Vesikolithiasis+CystitisHadiyanto TionoFakulty of medical Krida wacana

Adviser : Dr. Sjaiful B. Sp.B

Patient Identity Name : Mr. USex : MaleAge : 17 years oldEducation : Senior High SchoolWork : Studentaddress : Kp bojong keji 4/3

ANAMNESISChief Complain: Pain during urination since 1 year ago

History of DiseasePatient came to complain of any pain during urination since a year ago, the pain is felt intermittent, urine is not smooth, the emission is Not strong, and feels hot, stone (-). The change Of position to make a smooth urination. blood (-). Fever (+), low back pain (-), normal defecation

History of pass illness (-)family history of disease (-)

Physical Examination General state: moderate illnessAwareness: compos mentisBP: 120/70 mmHgPulse: 76x/minuteTemperature: 38,9 CRR: 22 x/minute

Status localist a / r Abdomen

Inspection : flat, no visible lump / mass in the suprapubicPalpation: no palpable mass or lump in the suprapubic, suprapubic tenderness (+) Percusion : CVA -/-

Digital rectal examination Tonus sfingter Ani strong, Ampula not colaps normal limit mucosa, No palpable mass at the 12 oclockAt handscoen no visible feces or blood.Hipertrofi Prostate (-)

Differential DiagnosisVesikolithiasis + cystitisUTIStriktur uretraUretero lithiasis

*

URINALISISUSGSupport Examination

Working DIAGNOSIS

VESIKOLITHIASIS + Cystitis

URINALISISWarna : Kuning SedimenKerkeruhan : Agak keruh Eritrosit: 15-20Berat Jenis : 1,025 Lekosit : 5- 8Ph : 6,0 Silinder : -Leukosit : +++ Kristal : -Nitrit : + Bakteri: +Protein : ++ Jamur : - Glukosa : normalBenda keton : -Uronilinogen : normalBilirubin : -Eritrosit : ++++

TREATMENTPlanning operation

PROGNOSIS Ad Vitam : BonamAd Functionam : BonamAd Sanationam : dubia ad bonam

*