4. Mr. Bahriani/ 42 yo/ April 21th 2013 at 23.

30

Pain at the left flank area 2 days prior to admission, patient experienced pain at the left flank area. The pain came intermittent, moderate pain (+), the duration around 15 minutes every the pain came. Aggravating factors (-), relieving factors (-), radiation of pain (+) to the center of abdomen. Nausea (+), vomiting (-), anorexia (-), indigestion (-), jaundice (-), fever (-). History of consumption of traditional herbal drugs (-), NSID (-). History of epigastric pain (-). Previous similar pain (-), previous abdominal surgery (-). Bowels (N), micturition (+) N. Because the complaint, patient was brought to Ulin General Hospital.

Physical Examination
Alert Vital sign :
BP = 130/80 mmHg PR = 92 bpm RR = 22 bpm T = 37,2C

Physical Examination
Head/Neck
Eyes : No anemic conjunctivae, icteric sclerae (-), Nose : No epistaxis Mouth : Wet mucosa Neck : Lymph nodes enlargement (-), JVP enhancement (-) I : Simmetric respiratory movement, no retraction P : Simmetric VF P : Sonor at all lung fields A : Simmetric VBS, no rhonchi, no wheezing I : Distention (-) A : Bowel sound (+) P : Liver/spleen/kidney not palpable, mass not palpable, tenderness (+) P : Tymphani

Chest

Abdomen

Extremities

Warm, no oedema, no parese

Urologic Status
CVA

I : mass (-/-), hematoma (-/-) Pa : tenderness (-/-) Pe : pain (-/-)

Flank Area

I : mass (-/-), hematoma (-/-), Pa : tenderness (-/-)

SuprapubiC

I : mass (-), hematoma (-) Pa: tenderness (-)

Genitalia

OUE : bloody discharge (-) Penis: edema (-), hematoma (-) tenderness (-) Scrotum: mass (-), testis (+/+)

DRE
I : haemorrhoid (-), laceration (-) P:
sphincter ani muscle strong Smooth mucosa Ampulla wasnt collapse Mass (-) Tenderness (-) Prostat:
Touched, chewy consistence Nodule (-) Flat surface Mediana sulci unflattened Upper pole easy to touch Prostat + 20 gr Tenderness (-) BCR (+)

Handscon : feces (+), blood (-)

Laboratory Finding
Haematology Haemoglobin : 17.5g/dl RBC : 6.06 WBC : 15.5 Hematocrit : 51 Platelet : 298 Chemistry BSR : 145 PT / APTT : 11.6/ 30.8 OT / PT : 23 / 65 Ureum : 98 Creatinin : 2.3 Sodium : 144.0 Potassium : 4.6 Chloride : 109.4 Uric acid : 14.5

Urinalisa Color : Yellow BJ : 1.020 Ph : 6.0 Protein-Albumin : (+2) Occult Blood : (+2) Urobilinogen : 0.2 Leukosit : (+1)

Sedimen Leukosit : 8-10 Erythrosit : much Selinder : (-) Epithel : 1+ Bactery : (-) Crystal : (-)

Clinical Pictures

X-Ray

Working Diagnosis
Left kidney colic due to Left Nephrolithiasis 13x17 mm

Management
Co/ urology surgeon : Analgetic Control to polyclinic