Discussion

June 5th, 2015

Bosniak Cyst

Identity

Name
: Mrs. Rekna Margini
Age : 51 years old
Sex : Female
Register
: 12.40.36.80
Address
: Jl. Sidotopo Lor 1/33 C Surabaya
Occupation
: Nurse
Insurrance : BPJS
Site of cancer
: Right Kidney
Identitiy number : 3578164610620002
Phone
: 081330371318
Referral
: General Hospital of Haji Surabaya
Ward : Out Department of Urology
Doctor
: Trisno Fajar Nursanto (FAJ)

KTP

Anamnesis
Px referred from General Hospital of Haji
Surabaya with right kidney cyst
Chief complaint : right flank pain
Right flank pain since 2 years ago, flank mass
since 1 years ago
Haematuria (-)
fever (-), nausea / vomit(-)
History of stone expulsion (-)
HT / DM (+)
History of smoking was denied
History of surgical procedure :
In June 1993 : Curetase e.c. Abortus Imminen, RSDS

Physical Examination
General Condition: Fair
GCS : 456
Karnoffsky score : 90%
Weight : 72 kg
height : 158 cm
Vital sign
: BP
: 140/90 mmHg
Pulse
: 88 x/mnt
RR
: 18 x/mnt
T.axi : 36,2oC
General State :
Head/Neck : a (-), i (-), c (-), d (-)
Thorax
: sim, ret (-), Cor normal Pulmo (ves/ves)
Abdomen
: defans (-), bowel sound (+) N, Soefel, mass (+) in
right upper
quadrant, size : 15 x 10 x 10 cm, mobile, cyst,
pain (+)
Extremity
: warm, dry

Physical Examination
Urological State :
Flank region
: mass (+) in right flank with size :
15 x 10 x 10 cm, mobile, cyst, pain (+)
CVA knoc pain : (+/-)
Suprapubic
: bladder empty
Ext Genital : Female, MUE (+) UP > 1500 2000 cc/24
hours, yellow, clear
VT : V/V fluor/flux -/-, portio within normal
limit,
mass in the AP S with size 3 cm, mobile
DRE
: TSA (+)N, smooth mucous, mass (-)

Clinical Picture

Laboratory Finding
Laboratoy May 26th, 2015
Hb

14,3 g/dL

Leu

7,68 .103/uL

Tromb

328 103/uL

FH

PPT

9,9 (9-12)

APTT

May 26th, 2015

pH

5,5

Erythrocy 0,77 /HPF

te

28,7 (23-33)

Leucocyt
e

5,78 /HPF

SGOT/PT

14/23 U/L

Epithelial

2,16 /HPF

Alb

4,1 g/dL

RBG

97 mg/dL

Urine
Culture

No growth of bacteria
aerob

HbA1C

11,9 %

BUN/SK

17/0,8 mg/dl

Na/K/Cl

141/3,8/107mm
ol/l

Ca/P

9,4/3,5 mg/dL

Thorax (March 23th, 2015)

Metastase (-)

BOF (April 7th,

2015)

Radioopaque shadow ( Metastase (-)

USG (September 25th, 2014)

Right kidney mass, cyst, hypovasculair

USG (September 25th, 2014)

Paraaorta lymph nodes enlargement or nodul at liver (-)

CT Scan
abdomen
(March 6th,
2015)

Right kidney cyst with size 16x11

cm, septa (+) with enhancement,
calcification (-), thickened irregular
walls

CT Scan
abdomen
(March 6th,
2015)

Simple cyst in the AP S with

size 3x2,2 cm

Interdepartment
consultation
Cardiology :
CRI class II + HT st I JNC VII

Internal medicine :
DM type 2
Tx. Lantus 12IU-0-0 sc ac, Metformin
3x500 mg

Obsgyn :
No pathological mass

ASSESMENT
Right kidney bosniak cyst III + DM
type 2 + HT st I JNC VII + simple cyst
in the AP S

Planning
Decision from out department of urology
discussion with dr. PAN / Prof.Dr.dr. SA,
SpU(K)
Right radical nefrectomy

Suggest to :
Right radical nefrectomy

Senior Decision
June 5nd, 2015
Prof. Dr. dr. Sunaryo, SpB, SpU(K)
Right radical nefrectomy