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Colic ren dextra

2. Mr. Syaifudin /60 years old


Oct 29th 2018 at 18.30 pm
Chief Complain : Abdominal Pain since 2 days ago
History taking :
Patient complained about the pain since 2 days before admission, sudden onset of pain, pain in the lower
abdomen and continuous. Pain appears from left to right side of abdomen. Patients also complained about
fever 1 day ago, vomiting 1 time consist of food, normal flatus and defecation.
History of Ilness:
Patient hospitalized in Anshari. S Hospital, 1 week ago with similar complain and out by permission after 3
days. Complain of the patient reappears 4 days ago and patient went to Siaga Hospital to control to
outpatient department and suggest to got ESWL in Ulin Hospital. Patient registered to Ulin, but
unfortunately the office was closed and patient refered to ER because his abdominal pain.
Vital Sign

Compos Mentis

BP : 100/70 mmHg

RR : 20 bpm

HR : 107 bpm

Tax : 37,5 ◦C

SpO2 : 98% without O2


Physical Examination
• Head:hematom(-)
Head/Neck • Eyes : anemic conjunctivae(-/-), icteric sclera(-/-),
• Neck: JVP enhancement(-), lymph enlargement (-)

• I: symmetric respiratory movement, retraction (-)


• P: symmetric VF
Chest • P :sonor at all lung fields
• A : symmetric VBS, no ronchi, no wheezing, crackles (-)

•I : distention (-) mass (-)


Abdomen •A : bowel sound (+) normal
•P : tympanic
•P : tenderness(+) at lower abdomen,muscular rigidity(-)

Extremities • warm (+), edema (-),parase (-)


Urology state
• CVA • Suprapubic
- I : hematome (-/-) - I : distended (-),
- P : unpapable mass , tenderness - P : tenderness (+) mass (-)
(+/-) CVA (-/-)
- Perkusition pain (+/-) • Genitalia external:
• Flank Area penis : swelling (-) tenderness (-)
- I : hematome (-/-), swelling (-/-) Scrotum
- P : tenderness (-/-) -I : edema (-), hyperemis (-) mass (-)
-P : tenderness (-)
Digital Rectal Examination
•I : mass (-) hemoroid (-) •Prostat
laceration (-) mass (-) Nodule (-)
•P: palpable prostat
Sphincter ani normal soft Consistency
Recti mucous normal Flat Sulcus Mediana
Ampula recti normal
Handscoon : faeces (+), blood
(-)
Clinical Pictures
Laboratory Finding
Examination Result Nilai Rujukan
Hemoglobin 7.4 12,00-16,00 g/dl
Leukosit 15.8 4,0-10,5 ribu/ul
Eritrosit 3.43 3,90-5,50 juta/ul
Hematokrit 23.9 37,00-47,00 vol%
Trombosit 643 150-450 ribu/ul
RDW-CV 14.5 11,5-14,7 %
MCV 69.7 81,0-99,0 fl
MCH 21.6 27-31pg
MCHC 31.0 33.0-37.0
Gran% 83.7 50-70%
Limfosit% 7.8 25-40%
MID% 8.5 4.0-11.0%
Gran# 13.30 2.50-7.00 thousand/ul
Limfosit# 1.20 1.25-4.0 thousand/ul
MID# 1.3
Laboratory Finding

Pemeriksaan Hasil Nilai Rujukan


PT 10.8 9,9-13,5 detik
INR 1.07
APTT 26.6 22,2-37,0 detik
GDS 117 <200
SGOT 21 0-46 U/l
SGPT 15 0-45 U/l
Ureum 46 10-50 mg/dl
Creatinin 1.66 0,7-1,4 mg/dl
Natrium 134 135-146 mmol/l
Kalium 3.9 3,4-5,4 mmol/l
Chlorida 102 95-100 mmol/l
USG Abdomen
Result :

- Hidronefrosis dextra
grade I
CT SCAN Abdomen

Result :
- Nefrolithiasis dextra diameter 0,82 cm
Working Diagnosis

Clinical diagnosis : Colic ren dextra

Etiological diagnosis : Nefrolithiasis dextra

Complication diagnosis : - Anemia


- Sepsis

Other diagnosis :-
Management

Treatment From ER Consult to Urology:


IVFD NS 20 tpm Po. Harnal Ocas 0-0-I
Inj. Ceftriaxone 2x1 gr Trf. PRC 2-3 kolf / day (Hb ≥ 10 mg/dl)
Inj. Antrain 3x1 gr
Inj. Kalnex 3x500mg

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