Sie sind auf Seite 1von 10

Case Report

1. Patient identity Name : Mr. MS Age Sex Occupation Address MR : 60 years old : Male : Civil Servant : Bima : 069748 : January 2nd 2013

Date of hospital admission : December 28th 2012 Date of examination II. Anamnesis Chief Complaint: The pain during of micturition Present Ilness : Patient have been consultating from Cardiologist with Chronic Heart Disease OMI inferior. The patient confessed difficulty starting urination since one month ago. The complaint getting severe and pain on the last four day. He have complaint pain at the during of micturition (+), weak urine stream (+), dribbling after urination (+). He confessed having a straining whenever starting a voiding. An urge to urinate again soon after urinating. The patient has confessed nokturia (+) in almost ten times a day. The patient also confessed bloody urine (+) and stony urinate (+) while right flank pain (-), suprapubic pain (-), mass (-), nausea (-), vomiting (-). The patient confessed had not defecation in last of this day while flatus (+). The appetite was good, weight loss (-). The patient also confessed that he had been weakness for the left hand and feet for four days in lately.

Post Illness History: Patient said that the history of stone urinate (+) and bloody urine (+). History of heart disease (+), hypertension (-), DM (-), asthma (-). Family Illness History: No family member with the same complaint. History of bloody urine (-), stony urine (-), hypertension (-), heart disease (-), DM (-), asthma (-). Medication History: Patient was consumting the medication relate for the heart disease and have been ever taking care for the illness and hospitalized for one week in last two month ago. He forget the drugs who were consumt. Allergic History: No history of allergy due to food or medication.

History of Sosial Life Patient is a civil servant, exatly in foreshty. Due to the anamnesis he is an active smoker, enjoying coffee and lack of caring for the healty life.

III. Physical Examination a. Status Generalis: General Condition: Moderate Awareness/GCS : Compos Mentis/ E4V5M4 Blood Preassure Pulse Respiration Temperature : 100/60 mmHg : 87 bpm : 20 bpm : 36,5 C

b. General Examination Head And Neck Head: Normochepali, symmetric, deformity (-) Eye: Pale Conjunctiva(-), Icteric Sclera (-), Pupil Isocore, Reflex of pupil (+/+), diameter 3/3 mm Ear, Nose, throat : normal Neck: Limph node enlargement (-) Thorax-Cardiovaskular Inspection : mass (-), lesion (-), chest wall movement simetric, retraction (-) Palpation : tenderness (-), vocal fremitus (+) normal, mass (-) Percussion: sonor in both lung, percussion pain (-) Auscultation : cor: S1S2 single, irregular, murmur (-), gallop(-) Pulmo : vesicular in both lung (+/+), wheezing (-/-), rhonki (-/-)

Abdomen Inspection : normal skin color, distention (-), mass (-), scar (-), sicatriks (-), darm contour (-), darm steifung (-) Auscultation : bowel sound (+) normal, borborygmus (-), metallic sound (-) Palpation : tenderness (-), defans muscular (-), ballotment (-), mass (-) Percussion : tymphany (+) all regions

IV. Local Status Uro-genital Flank regions : bulging (-/-), inflammation sign (-/-), tenderness (-/-), mass (-/-), ballottement (-/-), CVA tenderness (-/-)

Suprapubis regions : Inspection: normal skin color, mass (-), hyperemic (-), scar (-), sistostomy (-) DRE Normotonic sphincter ani, mucosal is smooth, prostate firm, nodule (-), pressure pain (-), sulcus mediana unpalpable (+) dome shape, the lateral sulci is narrow, superior pole unpalpable (+), gloves : mucus (-), blood (-), fesses (-). External genital Scrotum: skin color normal, inflammatory sign (-), mass (-), tenderness (-) Penis : Patient used catheter with urin output 300 cc, varicochele (-), preputium had been removed (+). Palpation : bladder distention (-), mass (-), tenderness (-)

Upper and lower extremity axial Edema -/-, deformity-/-, inguinal limph node enlargement -/-

Muscle strength : 5 5 3 3

V. Summary Male, 60 years old, with chronic heart disease OMI inferior was confessed difficulty starting urination since one month ago and severe in the last four day. Pain at the during of micturition (+), weak urine stream (+), dribbling after urination (+), nokturia (+), bloody urine (+), stony

urinate (+), right flank pain (-), suprapubic pain (-), mass (-), nausea (-), vomiting (-), weight loss (-). Digital rectal examination: normotonic sphincter ani, mucosal is smooth, prostate firm, nodule (-), pressure pain (-), sulcus mediana unpalpable (+) dome shape, the lateral sulci is narrow, superior pole unpalpable (+), gloves : mucus (+), blood (-), fesses (-).

VI. Working diagnosis Urine Retension e.c Benign Prostate Hyperplasia VII. Diferensial Diagnosis Susp. Vesica Urinary Carsinoma

VIII. Purposed Examination Laboratorium Radiologi : Complete blood test, PSA and complete urine test. : IVP.

Laboratorium findings CBC (December 27th 2012) WBC Hb HCT PLT : 6 K/uL : 21,1 g/dL : 64,9 % : 178 K/uL tPSA : 0,62 (Normal) Urine electrolit Na+ : 126 Ka+ : 4-5 Cl - : 107

Blood glucose : 113 mg% SGOT/SGPT SC Ureum : 31 U/L, 40 U/L : 1,1 mg% : 55 mg%

Abdominal USG result :

Interpretations: Right kidney : hidronefrosis 0,8 cm Left kidney, hepar, bladder, : Normal Prostate : size 4,3x 4,3 volume 41 cc

ECG :

Interpretation: Sinus beat in 85x/minutes, OMI inferior and anteroseptal + ischemic anterolateral

IX . Definitive Diagnosis Benign Prostate Hyperplasia + Chronic Heart Disease OMI Inferior + Hemiparese Sinistra

X. Planning Medikamentosa : IVFD RL 20 tpm Fargoxin 1x1 tab Simvastatin 20 gram tab Aspilet 80 gram Furesemid tab Neulin 500 / 12 hour Avodat 1x1 tab Harnal 1x0,9 tab

Operatif : Pro TURP Biopsy

XI. Prognosis Dubia

CASE REPORT

BENIGN PROSTAT HYPERPLASIA

By Name : Asrarudin Nim : H1A005005

Supervisor dr. Akhada Maulana, Sp.U

CONDUCTING FOR MIDDLE CLINICAL EDUCATION IN SURGERY DEPARTEMENT OF MATARAM REFERRAL HOSPITAL/MEDICAL FACULTY OF MATARAM UNIVERSITY 2013