CKD grade V et causa Hidronefrosis grade IV et causa ureterolithiasis dextraYovita Devi Kornelin

Case Report

I D E N T I T Y

Name : Mrs. AAge : 62 years oldSex : femaleAddress : Anjun Kanoman, Karawang BaratOccupation : housewifeReligion : IslamMarital status: married

Date of admission : 26th Nov 2012Taken from : Jatisari

A n a m n e s i sAutoanamnesis and alloanamnesis on Monday, November 26, 2012 at 6.00 a.m.

CLINICAL HISTORY

MAIN COMPLAINT

• Pain on the right side of waist since 4 months

ADDITIONAL COMPLAINT

• unable to sleep due to pain

HISTORY OF PRESENT ILLNESS

A patient came to RSUD Karawang ER with pain in the right side of the waist since 4 months before hospitalize. At first, the pain can be cured with medication, but one or two hours reappeared. But now, the pain doesn’t improve with treatment. Patients complain of unable to sleep because of the pain.

Urinating smoothly, yellow color, transparent, blood (-), and pain (-). Defecation every two days. Patients feel a little dizzy and weak. Fever, nausea, and vomiting are denied.

History of Past Illness

Hypertension -

Diabetes mellitus -

Surgery -

Allergies -

Two years ago had the same pain. And in the seven months before admission, urinating out the stone as large as papaya seeds.

FAMILY HISTORY

Same condition +• Patient’s father

had same condition, urinating out the stone as large as papaya seeds.

Diabetes mellitus -

Hypertension -

Asthma -

PERSONAL & SOCIAL HISTORY

Regular exersice

(-)

Smoking (-)

Alcohol consumption

(-)

Drug & medication

(-)

GENERAL CONDITION

General Appearance

•Moderately ill

Conciousness •Compos mentis

BB •50 kg

TB •165 cm

BMI •18,5 kg/cm2 normal

VITAL SIGN

Vital sign

•normochephalyHead•Conjunctiva anemic -/- , sclera ikterik -/-Eyes•Normotia, tragus pain -/-, auricular pain -/-, serumen -/-, sekret -/-, hiperemis -/-, membrane timpani intact +/+Ears•Septum deviasi -, konka hyperemic -/-, secret -/-, nostril breath-Nose•oral hygiene +, arkus faring hiperemis - , tonsil T1-T1 calmLip•lymph nodes and thyroid was not palpableNeck

PHYSICAL EXAMINATION

THORAX

INSPEKSI• Ictus cordis is invisible

PALPASI• Ictus cordis is palpable at 5th ICS LMCS

PERKUSI• The right border of the heart : ICS 3-4 LSD• The left border of the heart : ICS 5 1cm medial LMCS• The upper limit of the heart: ICS 3 LMCS

AUSKULTASI• Regular I - II heart sound, no murmur and gallop

Heart

THORAX

INSPEKSI• Symmetrical, intercostalis retraction (-)

PALPASI• Equal vocal fremitus

PERKUSI• Sonor in both lung

AUSKULTASI• Vesicular breath sound in both lung, Wh -/-, Rh

-/-

Pulmo

INSPEKSI• flat abdomen, caput medusa (-), smiling umbilicus (-)

PALPASI• Tenderness (-) , Liver and spleen are impalpable,

distension (-), undulation (-), pain present (+), CVA +/- , Ballotemen +/-

PERKUSI• Tympanic, Shifting dullness (-)

AUSKULTASI• Bowel sound (+) normal, arterial bruit (-), venous hum

(-)

ABDOMEN

Catheter inserted with 200cc/ 10 hours Normal (1cc/kgbb/jam)= 500cc

EXTREMITY

+ +

+ +

Warm Acrals

_ _

_ _

Oedem

Laboratory Findings26-11-2012

Tests Results Normal

Hb 9,3 gr/dl 12-17 g/dl

Ht 31 % 37-48 %

Trombocyte 348.000 150.000-450.000

Leucocyte 6400 5000-10.000

HBsAg - -

GDS 136 mg/dl 80-140 mg/dl

Ureum 236,3 mg/dl 10-45 mg/dL

Creatinin 11,05 mg/dl 0,4-1,5 mg/dL

Uric Acid 13,4 mg/dl < 6,5 mg/ dl

Laboratory Findings

TESTS RESULT NORMAL

COLOUR yellow

TURBIDITY transparent

pH 7,0

PROTEIN -

REDUKSI -

SEDIMEN

EPHITEL + Positif

LEUCOCYTE 1 - 2 0 – 5 / LPB

ERYTHROCYTE 0 - 1 0 – 5 /LPB

CRISTAL - Negatif

CILINDER - Negatif

BACTERY Negatif

27-11-2012

Plain Abdominal

BNO-IVP5 menit 15 menit

Hidronefrosis dextra grade 4 ec obstruction of opaq stone as high as L3-4

Impression :

GFR CALCULATION

• GFR CALCULATION

(140 – age) x weight x 0.85

72 x plasma creatinin

(140 – 62) x 50 x 0,85 = 5

72 x 11,05

CKD Stage V (GFR <15 or dialysis)

Anamnesis

• Pain on the right side of waist since 4 months

• Urine like tea color and little turbid

• Enable to sleep due to pain

Physical Examination

• Pain present in right lumbar

• CVA ++/+• Ballottement +/-

Adjuvant test

• Hb : 9,3 %• Ht : 31• Ureum : 236,3 mg/dl• Creatinin : 11,05

mg/dl• Uric acid : 13,4

mg/dl

RESUME

CKD et causa Hidronefrosis et causa ureterolithiasis dextra

CKD et causa Hidronefrosis et causa nephrolithiasis dextra

CKD et causa Hidronefrosis et causa stricture ureter dextra

DIFFERENTIAL DIAGNOSIS

WORKING DIAGNOSIS

CKD grade V et causa Hidronefrosis grade IV et causa ureterolithiasis

dextra

SUGGESTED EXAMINATION

USG

TREATMENT

Farmakologi • IVFD Nacl 0.9% 8 dpm• Ceftriaxone 2 mg x 1• Folic acid 3 x 1• Caco3 3 x 1• Ketopain 3 x 1

Non-farmakologi• Hemodialisis• Diet • Education

• Life style

Suggest : surgery treatment

PROGNOSIS

Ad vitam • Dubia ad

malam

Ad sanationam

• Dubia ad malam

Ad fungtionam• Dubia ad

malam