Staghorn

CASE ILLUSTRATION

Patients identity

Name
: Mrs. T
Age
: 55 years old
Address
: Pulo Gebang
Occupation
: housewife
Religion
: moslem

Alloanamnesis with patients

husband
Chief complaint
Loss of consciousness since 15 hours
before the admission.

History of present illness

Throbbing
headache
Fell into the floor
suddenly

15 hours
before
admission

After fell in
the
bathroom
Unable to walk
Slurred speech
Sudden right leg
and hand
weaknesses

Projectile vomiting
3X
Chocking (-)
Loss of
consciousness
(feeling sleepy
unable
to next 30
The
communicate)

minutes

(-)
Fever
chest pain
seizure
problems in
urinating and
defecating

History of past illness

Hypertension since 5 years ago and
received three different drugs (one of
them is Captopril)
Diabetes mellitus (-), heart disease (-),
previous stroke (-), history of trauma (-)
Family history
Sibling hypertension
Social history
Smoking and consuming alcohol were
denied.

Physical examination
General condition: Somnolent, moderately ill
Eye :Inferior palpebral is not anemic, conjunctiva is not
icteric
Neck :JVP 5-2 cmH2O, trachea is not deviated, enlarged
lymph node (-)
Heart :S1 and S2 regular, no gallop and murmur found
Lung :Symmetrical, expand together, vesicular at
both lobes, no ronchi, nor wheezing can be heard
Abdomen:flat, normal bowel movement, no
hepatomegaly
Extremities:edema (-) both extremities, warm
extremities

Vital sign
BP
230/130
mmHg

HR
90x/min

RR
22x/min

Temperature
37.50 C

Neurological examination
GCS: E3 V3 M6 = 12
Meningeal signs: Nuchal rigidity (+), Lasegue <700/<700, Kernig
<1350/<1350, Brudzinski I (+)
Pupil: round, 3mm/2mm, direct light reflex +/+, indirect light reflex
+/+
Cranial nerve: paralysis on N VI, N VII central, NXII dextra
Motoric: hemiparesis dextra
Physiological reflex:
00.45: +3/+2
+3/+2
11.30: +2 +2/+2 +2
0 0/+2 +2

Pathological reflex (Babinski): +/ Sensoric: could not be assessed

Autonom: urine catheter was used

Laboratory examination
Routine Haematology
Haemoglobin: 15.4 mg/dl
Leukocyte : 11.300/ul
Hematocrytes : 42.5%
Thrombocyte : 216.000/ul
PT (central) : 10.4 sec (11.8) 0.88x
APTT (central) : 32.1 sec (34.8) 0.92X
Electrolyte
Sodium : 141 mmol/L
Potassium : 3.7 mmol/L
Chloride : 102 mmol/L
Chemistry
SGOT : 19 U/L
SGPT : 24 U/L
Glucose Random : 128 mg/dl
Urea : 25.3 mg/dl
Creatinine : 1.13 mg/dl
Blood gas analysis
pH : 7.468
pCO2 : 32.1mmHg
pO2 : 159 mmHg
SatO2 : 99%
Base excess : 0.3 mEq/L
HCO3 : 23.4 mmol/L

Chest x-ray

Cardiomegaly

CT scan
Hiperdens
lesion in
ganglia basal
sinistra, volume
15 cc
Hiperdens
lesion in lateral
ventricle dextra
Middle shift
<0.5 cm

Diagnosis
Clinical
diagnosis

Topical
diagnosis

Etiologica
l
diagnosis

Pathologi
cal
diagnosis

Loss of
consciousn
ess

Thalamus
sinistra

Chronic
hypertensi
on

Thalamic
hemorrhag
e

Hemiparesi
s dextra
Paresis NVI,
NVII
central,
NXII dextra

Working diagnosis
Hemorrhagic
Stroke
(ICH thalamus
sinistra)

Emergency
hypertension

Reactive
leukocytosis
ddx/ infection

Management

Diagnostic
plan

Therapeutic
plan
CBC

Therapeutic plan
To prevent increased
intracranial pressure
Fluid
To control blood pressure
To prevent second episode
of stroke
To prevent stress ulcer

Therapeutic plan
To prevent increased intracranial pressure
Elevate head 300
O2 3 lpm nasal canule
Paracetamol 3X500 mg per oral
Laxadine 3X15 cc per oral

Fluid
IVFD NaCl 0.9 500 cc/ 12 hours

To control blood pressure

Nicardipine 0.5 mg/kgBW/ minute
BW: 90 kg
Nicardipine starts from 13.5 cc/ hour
MAP = [(2Xdiastolic) + systolic]/3 = 163.3
MAP target 20% from the first MAP = 20% X 163.3 = 32.66
MAP target = 163.3 -32.66 = 130.64 mmHg

To prevent second episode of stroke

Neurolex 2X1
Folic acid 2X5 g

To prevent stress ulcer

Omeprazole 1X40 mg

LITERATURE REVIEW

Statistics

How do the kidneys work?

Filtering units:
nephrons
Nephron
Glomerulus: Glomerular
filtration
(+) fluid and waste
(-) blood cells and large
molecules

Tubule: reabsorption
send needed minerals
back to the bloodstream,

Tubule: secretion
removes wastes

Urinary Formation

180L/day
(to control
the volume
and
composition
of body
fluid)

Renal handling
Examples
A. Creatinine
B. Typical for many
of the electrolytes
C. Amino acids and
glucose
D. Organic acids
and bases

Supersaturated Urine
1.Urinary pH
Morning acid
After meals: alkaline

2.Ionic strength
Relative concentration of monovalent ions
Rise in strength ~ decreased availability

3.Solute concentration
Unclear
Greater, higher chance to precipitate
Solubility product

4.Complexation
The availability of specific ions
If Na complexes w oxalate decreased free Na

Component
Crystal
Stones from the same
geographic location
Formation:
Nucleation
Growth
Aggregation

Matrix
Protein
Hexose and
hexosamine

Urinary Ions
Calcium
Oxalate
Phosphate
Uric Acid
Sodium
Inhibitors
Citrate
Magnesium
Sulfate
Other: GAG,
phyrophosphates,
uropontin

Types of Stone
Calcium calculi ~ increased calcium, uric acid,
and/or oxalate concentration in urine, with or
without concomittant decreased citrate
concentration.
Struvite: magnesium, ammonium, and
phosphate (MAP) ~ urea splitting organism
(proteus) staghorn calculi?
Uric acid ~ hyperuricemia, but not always
Cystine ~ inborn error of metabolism
Xantime ~ defective/deficient xanthine oxidase

Sign and Symptoms

Pain
Renal calyx
Renal pelvis
Upper and midureter
Distal ureter

Hematuria
Infection
Pyonephrosis
Xanthogranulomatous pyelonephritis

Fever
Nausea and vomiting

Signs and Symptoms