결석 총론 stone

목차

1.STONE 총론
1. Mechanism
2. Cause
3. Symptoms & Physical examination
4. Diagnosis
5. Treatment

2.Renal stone
1.Symptoms
2.Diagnosis
3. Differential diagnosis
4. Complications
5. Treatment
...

본문내용

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Present Ilness : 상기 환자는 10년전 ureter stone으로 경희대에서 ESWL 1차 시행한 Hx 있는 환자로 그 후 별 pain 없이 지내다 내원 2개월 전부터 갑자기 상기주소 있어 본원 ER & OPD 방문하여 IVP 시행후 OP위해 내원
Past History : DM, Tbc, HTN, hepatitis - all denial
operation history - ureter stone 으로 10년전에 ESWL시행
Familial History : N-S
Social History
tabacco - 1pack/day
alcohol - beer 2bottle/week
Review Of System
fever/chill(-/-)
cough/sputum(-/-)
chest pain(-)
abdominal pain(-)
flank pain(+) Rt.
Anorexia/Nausea/Vomitting(+/+/+)
Diarrhea/Constipation(-/-)
voiding symptoms(-)
hematuria(-)
Physical Examination
Vital sign : 120/80-70-20-36.5℃
HEENT : no anemic conjunctiva
anicteric sclera
Chest : CBS without rale
RHB without murmur
Abdomen : soft & flat
normoactive bowel sound
no tender point
Back/ Extremities : CVAT(+) Rt.
no pitting edema
Initial Laboratory finding
CBC : 15.9 - 45.6 - 5890 - 19700
Electrolyte : 140.0 - 4.2 - 102.5
BUN/Cr : 17/0.9
GOT/GPT : 30/43
Urine analysis : RBC - many, WBC - 1∼4
Radiologic finding

Rt. kidney에 5×5mm radiopaque density
Lt. kidney에 1.5×3.5mm radiopaque density
Pelvic space내에 3×3mm radiopaque density

Pelvic space내의 radiopaque density는 ureter밖에 있는 것으 로 phlebolith등으로 추정됨
Impression
1. Rt. renal stone
2. Lt. staghorn stone
Treatment Plan
1. Lt. kidney → OP(nephrolithotomy)
2. Rt. kidney → ESWL
Brief OP Note
Post OP Dx : Lt. staghorn renal stone
OP name : nephrolithotomy
OP finding
1)Lt. flank incision(10cm 가량)
2)Ext. & inf. oblique & transverse abdominal m. incision
3)peritoneum을 앞으로 젖히고 Gerota's fascia열어 perirenal fat 관찰 됨
4)perirenal fat을 박리하여 kidney lower pole 관찰됨
5)kidney 전체를 아래로 내리고 ureter에 u-tape를 suspending 함
6)kidney lower pole에 심한 adhesion 관찰되어 dissection
7)renal pedicle을 renal a.로부터 박리함
8)renal pedicle 근처 v.에 injury 받았으나 ligation함
9)sono로 renal stone위치 파악한 후 lower pole에서 4cm 가량 incision하고 kelly로 stone remove
10)sono상 mid. pole에 remnant stone 관찰되었으나 bleeding으로 remove 못하고, incision site를 suture
11)renal fossa에 2개의 penrose drain insertion
12)Gerota's fascia를 덮고 transverse abdominois m.과 int. & ext. oblique abdominous m.을 layer 별로 suture

location - middle lower pole
size - 3.5×1.5mm
shape - irregular margin & dark brown color
Progress Note
10/29/99
S : flank pain(-)
O : CBC (14.8 - 43.1 - 5860 - 15800)
Electrolyte (140.8 - 4.4 - 96.7)
protein/albumin : 6.5/4.1
wound site : clear(wound pad까지 젖음)
A : renal stone Lt. POD#1
P : ABR
10/30/99
S : flank pain(-)
O : Bowel sound - normoactive
diet - start
urine color - clear
A : POD#2
P : ABR
10/31/99
S : nausea(-) - soft diet 한 후
O : Bowel sound - normoactive
wound site - clear(wound pad 까지 젖음)
urine color - clear
A : POD#3
P : conservative Tx
11/1/99
S : nausea(-) - soft diet 한 후
O : Bowel sound - normoactive
wound site - clear(wound pad 안만 젖은 정도)
A : POD#4
P : ABR
11/2/99
S : nausea(-)
O : wound site - clear(4×4 5장 정도 젖음)
A : POD#5
P : 1. conservative Tx
2. foley remove
11/3/99
S : nausea(-)
O : wound site : clear
urine color - red (foley remove 후)
A : POD#6
P : conservative Tx

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