Case Report

1. Patient identity Name : Mr. M Age Sex Occupation Address MR : 31 years old : Male : Labour : Kopang, Central Lombok : 243791 : January 18th 2013

Date of hospital admission : January 16th 2013 Date of examination II. Anamnesis Chief Complaint: Difficulties during of micturition Present Ilness : The patient had been confessing difficulty during of micturition since two years ago. It had been starting after got an accident, exatly a car accident were took place in Malaysia. The pain during micturition (+) in almost of it, the urinate had been done seven times a day. The pain in his male organ (+) then discomfort during sexual activity (+). The confessed of weak of urine stream (+). He confessed having a straining whenever starting a voiding. Constipation during micturition (+). The patient also confessed of nokturia (-), bloody urine (-) and stony urinate (-). Confessed of right flank pain (-), suprapubic pain (+), mass (-), fever (-). Whenever the patient urinate in almostly he confessed discharge (+) with the mainly colour is yellow. History of used catheter mostly after sitostomi, but rightnow had not. The appetite was good, weight loss (-). No diarrhea. History of unsafe sexual activity does not clear.

Post Illness History: Patient said that he got an accident when he had working in Malaysia two years ago. Got a therapy and hospitalized for few days. He also got a therapy in Jakarta for two months. He got a sistotomi and off of it one year ago.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 sometimes go to Public Heatlty Care Center for his but he forget the drugs which were consumt. Allergic History: No history of allergy due to food or medication. History of Sosial Life Patient is a labour. Due to the anamnesis he is not a moderate smoker, sometimes drink of 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 : 130/80 mmHg : 72 bpm : 20 bpm

 Temperature b. General Examination Head And Neck

: 36,8 C

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, rregular, 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 has no used catheter , preputium had been removed (+). Palpation : bladder distention (-), mass (-), tenderness (-)

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

V. Summary Male, 31 years old. Confessed pain during micturition (+), pain in his male organ (+). Weak of urine stream (+), straining whenever starting a voiding

(+). Constipation during micturition (+). Nokturia (-), bloody urine (-) and stony urinate (-). Confessed of right flank pain (-), suprapubic pain (+), mass (-), fever (-).Whenever the patient urinate in almostly he confessed discharge (+) with the mainly colour is yellow. The appetite was good, weight loss (-) diarrhea (-), used catheter (-). History of unsafe sexual activity does not clear. 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 Susp. Urethral Stricture VII. Diferensial Diagnosis Urethritis

VIII. Purposed Examination Laboratorium : Complete blood test, uroflometri, sistoscopy,

urinalisis test, kultur pus. Radiologi : Urethrografi

Laboratorium findings CBC (December 27th 2012) WBC Hb HCT PLT SGOT/SGPT SC : 13,75 K/uL : 14,2 g/dL : 41,49 % : 460 K/uL : 18 U/L, 27 U/L : 0,6 mg% Urinalisis Leukosit : +3 Protein : +1 Blood : +3 Blood glucose : 107 mg%

Ureum Urid Acid

: 16 mg% : 6,9 mg%

Urethrografi result :

Interpretations: Subtotal urethral stricture pars bulbosa Sinus (+) 3 cm x 2 cm to right lateral

IX . Definitive Diagnosis Subtotal urethral stricture pars bulbosa

X. Planning Pro Antibiotic Pro urethrotomy XI. Prognosis Dubia ad bonam

CASE REPORT

SUBTOTAL URETHRAL STRICTURE PARS BULBOSA

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