CASE REPORT

Stag-horn Nephrolithiasis

By:

Zulkifli Salim

H1A 212 065

Supervisor:

dr. H. Akhada Maulana, Sp. U

IN ORDER TO UNDERGO THE CLINICAL ROTATION IN SURGERY

DEPARTMENT MEDICAL FACULTY OF MATARAM UNIVERSITY
RSUD PROVINSI NUSA TENGGARA BARAT
2017
 CASE REPORT
I. Identity
Name : Mr. IKD
Sex : Male
Age : 62 years old
Address : Gebang, Mataram
Religion : Hindu
Occupation : Entrepeneur
Marital status : Married
Number of medical record : 57 83 13
Date of hospital admission : Mei, 4th 2017
Date of examination : Mei, 6th 2017

II. Clinical history

Main complaint: Right flank pain
Present history of disease:
Patients are referred from Bayangkara hospital in east Lombok to urology poly in
RSUP NTB complained right flank pain since 2 weeks ago Patient describe the pain as blunt,
intermittent, and not triggered by body position, He felt pain periodically and disturb his
activities. Patient also complained pain to urinate since 1 months ago. The complaint worsen
for the past 2 weeks, and sometimes saw the urine combined with blood, patient also
complained frequent and sudden felt the urge to urinate, and urinate in small volume 6-7
times a day. Waking up at night because of the urge to urinate (+) more than two times, there
is no complain of feeling unsatisfied after urinating (-), terminal dribbling (-). History of
fever (-), nausea (-), vomiting (-). Patient only eat small amount of food for 3 times a day.
Drink about 1.5 L per day, doesnt drink coffee. Defecation was normal, once daily,
consistency firm and brown.

Past disease history:

Patients had the same symptoms about 3 times in several years ago, had 3 times
history of urinary tract stones (+), and the stones were all operated, HT (+), DM (-), Astma
(-). The first one was 7 years ago in 2010 patient had right kidney stone and got ESWL
treatment, the second one was 4 years ago in 2013 had left kidney stone, the third one was
last year in November 2016 also left kidney stone, both had an open surgery removal, in
December the patient also had a stroke and was hospitalized.
Family disease history:
His father had suffered a similar illness.
History of allergy:
Drugs (-), foods (-).
History of treatment:
Patient were taken to the bayangkara hospital. After that, he was referred to NTB
general hospital urolology department.

III. Physical Examination

A. Present Status
General state : Moderate
Consciousness/GCS : Compos mentis / E4V5M6
Vital sign
Blood Pressure : 140/70 mmHg
Heart rate : 71 bpm
Respiration rate : 23 times per minute.
Temperature : 36.6 oC
SpO2 : 99%
B. General Status
Head and neck
Head : normocephaly, deformity (-),
Eyes : anemic conjungtiva (-/-), icteric sclera (-/-), pupil reflex (+/+), isocor
3 mm/3 mm
Nose : discharge (-), rhinorrhea (-), deformity (-)
Ear : otorrhea (-), shape and size normal
Mouth : dry lips (-), cyanotic (-)
Neck : enlargement of lymphnodes (-)
Thorax-Cardiovascular
Inspection : mass (-), lesion (-), simetric movement of chest wall (+)
Palpation : simetric chest wall movement (+), tenderness (-), mass (-), pain (-)
vocal fremitus
+ +
+ +
+ +
Percussion :
Sonor Sonor
Sonor Sonor
Sonor Sonor
 Auscultation :
Pulmo : vessicular in both lungs (+/+), ronchi (-/-), wheezing (-/-)
Cor : S1S2, single, regular, murmur (-), gallop (-), ictus cordis in ICS VI
Abdomen
Inspection : distention (-), mass (-) on suprapubic area, color same as the
surrounding skin, normal umbilical
Auscultation : normal bowel sound
Percussion : tympanic (+), pain (-)
Palpation : unpalpable liver and spleen, pain (-), defans muscular (-)
Upper and Lower Limbs
Warm acral
- -
- -
Edema
- -
- -
Deformity
+ +
+ +
C. Urogenitalia physical examination
Flank-Costo Vertebrae Angle (CVA) region
Inspection : color same as the surrounding skin, mass (-), sign of inflammation
(-), scar (-), bulging (-/-)
Palpation : tenderness (+/+), mass (-), ballotment (-/-)
Percussion: CVA flank (+/+)
Suprapubic region
Inspection : color same as the surrounding skin, distention (-), mass (-), sign of
inflammation (-), scar (-),
Palpation : full bladder (-), bladder distention (-), pain (-). mass (-),
External genitalia
Mass (-), erythema (-), fistula (-), hemorage or discharge (-)
Anal perianal
Mass (-), fistula (-), erythema (-), hemorrhoid (-), pain (-)
Rectal touche
Anal sphincter tone: strong
The mucosa of the rectum: slick
Ampulla recti: not collapse
Rectal Toucher : normal prostate impression, chewy consistency.
Gloves: stool (-), blood (-), mucus (-)
IV. Summary
 Patients are referred from hospitals in east lombok to urology poly in RSUP NTB
complained difficult to urinate since 1 months ago. The complaint worsen for the past 2
weeks, Patient also complained right flank pain since 2 weeks ago Patient describe the pain as
blunt, intermittent, and not triggered by body position, He felt pain periodically and disturb
his activities. Patient also complained pain felt during urination, and sometimes saw the urine
combined with blood, frequency 6-7 times a day. Patients has a history of the same symptoms
about several years ago and had 4 bladder stone operated. On the physical examination, there
were tenderness on the CVA region, and pain on the percussion.
V. Working Diagnosis
Susp. Nephrolithiasis Sinistra + susp. Cystitis

VI. Differential diagnosis

1. Ureterolithiasis sinistra
VII. a. Diagnostic Planning
CBC
Urinalysis
USG Urology
CT Scan Urology

b. Therapy planning
Medicamentosa
IVFD RL 20 dpm
Paracetamol 500 mmg 3x1
Ciprofloxacin 250 mg twice per day for three days
Surgery: Nephrolitotomy Sinistra
VIII. Supporting Examination
1. Laboratory
Parameter April 29th 2017 RANGE

WBC 9,39.103/ul 4-11

RBC 4,66.106 /ul 4,5-5,5

Hb 11,6 g/dl 13-18

HCT 35,8 % 37-50

MCV 95,3 fl 82,0-92,0

 MCH 30,5 pg 27,0-31,0

MCHC 32,0 g/dl 32,0-37,0

PLT 451.103/ul 150-400

BT 200 <6

CT 530 <15

GDS 85 mg/dl <160

Creatinin 3,8 mg/dl 0,9-1,3

Ureum 43 mg/dl 6-26

SGOT 20 mg/dl <40

SGPT 21 mg/dl <41

Na 135 135-146

Ka 5,5 3,4-5,4

Cl 105 95-108

Urinalysis result (April 29th 2017)

pH : <5,5
color : yellow
leukosit :-
nitrogen :N
protein : +2
glukosa :-
urobilinogen : N
keton :-
bilirubin :-
eritrosit : +3
Neutrophil : +3

2. Imaging
 a) Abdominal USG (05/05/2017)

Interpretation
Mulitple Renal stone (Biggest at pyelum measuring 3,5 cm), Inferior (0,53cm),
median (0,47cm)
cystitis
Left renal seems atropic
b) CT Scan (06/05/2017)
 Renal stone in left kidney size: 4,28cm x 2,24 cm
Right kidney and vesica urinaria is in normal range
Conclusion: Staghorn renal stone sinistra
X. Diagnose
Staghorn Nephrolhitiasis Sinistra + Cystitis
XI. Planning Therapy
Extended pyelolithotomy
XII. Prognosis
Qou ad vitam : dubia ad bonam
Quo ad functionam : dubia ad bonam