45192771-Vesicolithiasis.pptx

Laporan Kasus
VESICOLITHIASIS
Indah Permata
54061001037
Pembimbing: dr. Marta Hendry, SpU
Fakultas Kedokteran Universitas Sriwijaya
Departemen Bedah RSMH Palembang
Identitas Pasien
Nama : Tn. S
Umur : 79 tahun
Jenis Kelamin : Laki-laki
Status : Menikah
Agama : Islam
Bangsa : Indonesia
Alamat : Lawang Agung
Pekerjaan : Petani
MRS : 14 September 2010
ANAMNESIS
Keluhan Utama:
Nyeri saat BAK
Riwayat Perjalanan Penyakit:
± 5 bulan yang lalu penderita mengeluh nyeri saat BAK, BAK merah (-
), kencing menetes (+), kencing berhenti mendadak (+) dan lancar
kembali pada perubahan posisi kencing, BAK lebih sering dari
biasanya (+), kencing tidak lampias (+), mengedan saat kencing (+),
riwayat BAK berpasir (-), BAK keluar batu (-), demam (-).
Riwayat Penyakit Dahulu:
– Riwayat pemasangan kateter (+)
– Riwayat penyakit kencing manis (-)
– Riwayat operasi (-)
Riwayat Penyakit dalam Keluarga:
Riwayat penyakit yang sama dalam keluarga disangkal
PEMERIKSAAN FISIK
• Status Generalis
• Kesadaran : Compos Mentis
• Tekanan Darah : 120/80 mmHg
• RR : 20x/ menit
• HR : 72x/menit
• Suhu : 36,8 0C
• Kepala : konjungtiva pucat (-), sclera ikterik (-/-)
• Leher : Tidak ada kelainan
• Pupil : Isokor/ Reflek Cahaya +/+
• KGB : Tidak ada kelainan
• Thorax : Tidak ada kelainan
• Abdomen : Lihat status lokalis
• Genitalia Eksterna : Lihat status lokalis
• Ekstremitas atas : Tidak ada kelainan
• Ekstremitas bawah : Tidak ada kelainan
PEMERIKSAAN FISIK
Status Lokalis
• Regio Costo Vertebrae Angle (CVA) dextra:
– Inspeksi : Bulging (-)
– Palpasi : Nyeri tekan (-)
Ballotement (-)
Nyeri ketok (-)
• Regio Costo Vertebrae Angle (CVA) sinistra:
– Inspeksi : Bulging (-)
– Palpasi : Nyeri tekan (-)
Ballotement (-)
Nyeri ketok (-)
PEMERIKSAAN FISIK
• Regio Suprapubik:
– Inspeksi : Bulging (-)
– Palpasi : Nyeri tekan (-)
• Regio Genitalia Eksterna :
MUE normal, tersunat, bloody discharge (-).
• Rectal Toucher:
TSA baik, mukosa licin, prostat teraba tidak membesar.
PEMERIKSAAN LABORATORIUM
• Pemeriksaan Darah Rutin nilai normal
• Hb : 12,1 g/dl (L: 14-18 g/dl)
• Ht : 35 vol% (L: 40-48 vol%)
• Leukosit : 9.800/mm3 (L: 5000-10.000/mm3)
• LED : 20 mm/jam
• Trombosit : 318.000/mm3 (L: 200.000-500.000/mm3)
• Hitung jenis
– Basofil : 0
– Eosinofil : 4
– Batang : 2
– Segmen : 63
– Limfosit : 24
– Monosit : 7
PEMERIKSAAN LABORATORIUM
• Kimia Klinik
• BSS : 92 mg/dl
• Ureum : 43 mg/dl (15-39 mg/dl)
• Creatinin : 1,1 mg/dl (L:0,9-1,3 mg/dl )
• Natrium : 136 mmol/l (135-155 mmol/l)
• Kalium : 4,8 mmol/l (3,5-5,5 mmol/l)
• Urinalisa:
• Sel epitel (+) negatif
• Leukosit (+) 50/LPB (0-5/LPB)
• Eritrosit 0-2 (0-1/LPB)
• Silinder (-)
• Protein (+)
• Glukose (-)
PEMERIKSAAN RADIOLOGI: BNO
• Tampak gambaran
radioopak pada vesika
urinaria ukuran 3x2 cm,
dan 1,7x1,1 cm.
PEMERIKSAAN RADIOLOGI: USG
• DIAGNOSIS KERJA:
VESICOLITHIASIS
Diagnosis banding:
BPH
PENATALAKSANAAN
VESICOLITHOTOMI
PROGNOSIS
• Quo ad vitam : Dubia ad Bonam
• Quo ad functionam : Dubia ad Bonam
TERIMAKASIH.
1 sur 14

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45192771-Vesicolithiasis.pptx

  • 1. Laporan Kasus VESICOLITHIASIS Indah Permata 54061001037 Pembimbing: dr. Marta Hendry, SpU Fakultas Kedokteran Universitas Sriwijaya Departemen Bedah RSMH Palembang
  • 2. Identitas Pasien Nama : Tn. S Umur : 79 tahun Jenis Kelamin : Laki-laki Status : Menikah Agama : Islam Bangsa : Indonesia Alamat : Lawang Agung Pekerjaan : Petani MRS : 14 September 2010
  • 3. ANAMNESIS Keluhan Utama: Nyeri saat BAK Riwayat Perjalanan Penyakit: ± 5 bulan yang lalu penderita mengeluh nyeri saat BAK, BAK merah (- ), kencing menetes (+), kencing berhenti mendadak (+) dan lancar kembali pada perubahan posisi kencing, BAK lebih sering dari biasanya (+), kencing tidak lampias (+), mengedan saat kencing (+), riwayat BAK berpasir (-), BAK keluar batu (-), demam (-). Riwayat Penyakit Dahulu: – Riwayat pemasangan kateter (+) – Riwayat penyakit kencing manis (-) – Riwayat operasi (-) Riwayat Penyakit dalam Keluarga: Riwayat penyakit yang sama dalam keluarga disangkal
  • 4. PEMERIKSAAN FISIK • Status Generalis • Kesadaran : Compos Mentis • Tekanan Darah : 120/80 mmHg • RR : 20x/ menit • HR : 72x/menit • Suhu : 36,8 0C • Kepala : konjungtiva pucat (-), sclera ikterik (-/-) • Leher : Tidak ada kelainan • Pupil : Isokor/ Reflek Cahaya +/+ • KGB : Tidak ada kelainan • Thorax : Tidak ada kelainan • Abdomen : Lihat status lokalis • Genitalia Eksterna : Lihat status lokalis • Ekstremitas atas : Tidak ada kelainan • Ekstremitas bawah : Tidak ada kelainan
  • 5. PEMERIKSAAN FISIK Status Lokalis • Regio Costo Vertebrae Angle (CVA) dextra: – Inspeksi : Bulging (-) – Palpasi : Nyeri tekan (-) Ballotement (-) Nyeri ketok (-) • Regio Costo Vertebrae Angle (CVA) sinistra: – Inspeksi : Bulging (-) – Palpasi : Nyeri tekan (-) Ballotement (-) Nyeri ketok (-)
  • 6. PEMERIKSAAN FISIK • Regio Suprapubik: – Inspeksi : Bulging (-) – Palpasi : Nyeri tekan (-) • Regio Genitalia Eksterna : MUE normal, tersunat, bloody discharge (-). • Rectal Toucher: TSA baik, mukosa licin, prostat teraba tidak membesar.
  • 7. PEMERIKSAAN LABORATORIUM • Pemeriksaan Darah Rutin nilai normal • Hb : 12,1 g/dl (L: 14-18 g/dl) • Ht : 35 vol% (L: 40-48 vol%) • Leukosit : 9.800/mm3 (L: 5000-10.000/mm3) • LED : 20 mm/jam • Trombosit : 318.000/mm3 (L: 200.000-500.000/mm3) • Hitung jenis – Basofil : 0 – Eosinofil : 4 – Batang : 2 – Segmen : 63 – Limfosit : 24 – Monosit : 7
  • 8. PEMERIKSAAN LABORATORIUM • Kimia Klinik • BSS : 92 mg/dl • Ureum : 43 mg/dl (15-39 mg/dl) • Creatinin : 1,1 mg/dl (L:0,9-1,3 mg/dl ) • Natrium : 136 mmol/l (135-155 mmol/l) • Kalium : 4,8 mmol/l (3,5-5,5 mmol/l) • Urinalisa: • Sel epitel (+) negatif • Leukosit (+) 50/LPB (0-5/LPB) • Eritrosit 0-2 (0-1/LPB) • Silinder (-) • Protein (+) • Glukose (-)
  • 9. PEMERIKSAAN RADIOLOGI: BNO • Tampak gambaran radioopak pada vesika urinaria ukuran 3x2 cm, dan 1,7x1,1 cm.
  • 13. PROGNOSIS • Quo ad vitam : Dubia ad Bonam • Quo ad functionam : Dubia ad Bonam