CHAPTER I CASE REPORT

1.1. Patient Identification Name Age Sex Address Nationality Religion Occupation : Mr. HN : 67 years old : Male : kemudi I ilir timur, Palembang : Indonesian : Moslem : Entrepreneur : 21th of juni2013

Medical Record : 727933 Admitted

1.2. Anamnesis (Autoanamnesis taken on 23th of Juny 2013)

Chief complaint: Unable to void one week before admitted to hospital.

History of present illness : One month before admissions patient complaint of difficulty to void, had to push to begin urination, decreased force and caliber of stream, stopped and started again when urinated, post void dribbling. Voiding at night up to 8 times at night (nocturia), difficult to postpone urination, and had sensation of incomplete bladder emptying. Bloody urination (-), sandy urination (-), stone in urin (-), defecate (+) normal, fever (-), and loss of body weight (-)

One weeks before admission patient complaint unable to void and bulging in suprapubic. He was admitted to Siti Khodijah Hospital and

urethra catheter was fixed. Then he was reffered to Mohhamad Hoesin General Hospital Palembang to get more therapy

History of past illness:

History of using urethra catheter (+) six month ago No history of urinary infections, no history of piuria No history of prostate, bladder, penis, urethra operation No history of urinary stone, bloody urine (-) No history of diabeties and stroke No history of trauma at the genitalia, stomach, hip and backbone area No history bone pain, paresthesias, weakness or spasticity of lower extremities and regional lymhadenopathy.

History of Family disease History of disease in family with same complain (+) his father

Socioeconomic

1.3. Physical Examination General Examination ( 23th of Juni 2013) Appearance Consciousness Blood pressure Pulse rate Respiratory rate Temperature Eyes : good : compos mentis : 120/80 mmHg : 84 x/min : 20 x/min : 36,4 0C : conjunctiva palpebra anemic (-/-), sclera icteric (-/-), pupils isokor, light reflex (+/+) Neck

Inspection : normal Palpation : normal Thorax Shape Lung Inspection Palpation Percution Auscultation : statis, dinamis simetris dextra = sinistra : stremfremitus dextra = sinistra : sonor in both lung : vesiculer (+) normal, ronkhi (-), wheezing (-) Cor Inspection Palpation Percution : ictus cordis not visible : ictus cordis unpalpable : upper limit ICS II, right limit LPS dextra ICS IV, left limit LMS ICS V Auscultation : HR 84 x/minute, murmur (-), gallop (-) : normal

Abdomen Genital

: refer to local examination : refer to local examination

Upper extremities : no abnormalities Lower extremities : no abnormalities

Local Examination Abdomen Inspection : flat Palpation : no tenderness Percution : tympani Auscultation : bowel sound (+) normal CVA region Inspection : bulging Palpation : pain dextra (-) (-) sinistra (-) (-)

Ballottement

(-)

(-)

Suprapubic region Inspection : bulging (-) Palpation : tenderness (-)

External genitalia region Inspection :urethra catheter No. 16F fixed, urine clear, bloody discharge (-), circumcised.

Rectal toucher TSA good, bulbous cavernous reflex (+), ampulla not collapse, smooth mucosa, mass (-), enlargement of prostate, upper boarder of prostate unpalpable, ruberry consistency, flat surface, no tenderness, nodule (-), feces (+), blood (-).

1.4. Supportive Examination Laboratorium findings (11/05/13) Routine blood: Hemoglobin Hematocryte Leucocyte Thrombocyte LED Diff. Count Clinical Chemistry: BSS Ureum Creatinine : mg/dL : 39 mg/dL : 13 mg/dL (N : 15-39mg/dL) (N : 0,9-1,3mg/dL) : 11.3 gr/dL : 33 vol% : 7.8/mm3 : 315 /mm3 : 20 mm/hour : 0/6/0/57/32/5 (N : 14-18g.dL) (N : 40-48vol%) (N : 5000-10000/mm3) (N : 200.000-500.000/mm3)

Na+ K
+

: 144 mmol/l : 41 mmol/l

(N : 135-155) (N : 3,5-5,5)

Urine analysis: Epitel cell Leucocyte Erytrocyte Silinder Kristal : (-) : 90-104 / LPB : 0-1 / LPB : negatif : Negatif (N : 0-5 / LPB) (N : 0-1 / LBP) (-) (-)

USG

Result: Prostat : Widening of prostate, 50 x 53mm, no calsification, parencim homogeneous Vesica urinary : the wall is irregular, thickness of mucosa, no trace of stone or mass in bladder No abnormalities in right and left renal, no enlargement of kidney, sinus-renal parenchyma clear in appearance, pelvis calices not widening, no stone.

Interpretation: Prostate enlargement

1.5. Differential Diagnosis Urine retention due to suspect Benign Prostate Hyperplasia Urine retention due to suspect Prostate Cancer

1.6. Working Diagnosis Urine retention due to suspect Benign Prostate Hyperplasia

1.7. Treatment Transurethral Resection of Prostate (TURP)

1.8. Prognosis Quo ad vitam : bonam

Quo ad functionam : dubia ad bonam