CHAPTER I CASE REPORT

1.1. Patient Identification Name Age Sex Address Nationality Religion Occupation : Mr. RS : 73 years old : Male : Harisan Jaya, Ogan Komering Ulu Timur : Indonesian : Moslem : Retirement (builder) : September 18th 2013

Medical Record : 754231 Admitted

1.2. Anamnesis (Autoanamnesis taken on September 21th 2013) Chief complaint: Unable to void one month before admitted to hospital.

History of present illness : 1 years before admission, 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 5 times at night (nocturia), difficult to postpone urination, and had sensation of incomplete bladder emptying. Bloody urination (-), stone in urin (-), defecate (+) normal, fever (-), and loss of body weight (-) 6 months before admission, patient complaints pain when urinating, uncomfortable when urinating, stopped and started again when urination with changed the position of the body. Patient also complaints pain in the lower abdomen that referred to the tip of the penis and the scrotum. There is no bloody urination, stone in urine (-).

2 month before admission, patient complaints pain when urinating and become more severe after urination, there is bloody urination, stone in urination (+). The patient has no fever and there is no decrease of body weight. 1 month before admission, patient complaint unable to void and bulging in suprapubic. He was admitted to Charitas Hospital and urethra catheter was fixed. Then he went to polyclinics Mohhamad Hoesin General Hospital Palembang to get more therapy.

History of past illness: No history of urinary tract infections. No history of using urethra catheter in long term use No history of prostate, bladder, penis, urethra operation No history of diabeties and CVD No history of postpone urination habit No history of trauma at the genitalia, stomach/ hip and back bone area. No history bone pain, paresthesias, weakness or spasticity of lower extremities and regional lymhadenopathy History of Family disease History with same complaint as the patient in family denied 1.3. Physical Examination (September 21th 2013) General Examination Appearance Consciousness Blood pressure Pulse rate Respiratory rate Temperature : good : compos mentis : 130/90 mmHg : 88 x/min : 20 x/min : 36,70C

Eyes

: conjunctiva palpebra anemic (-/-), sclera icteric (-/-), pupils isokor, light reflex (+/+)

Neck Inspection : normal Palpation : normal Thorax Shape Lung Inspection Palpation Percution Auscultation 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 (-) : statis, dinamis simetris dextra = sinistra : stremfremitus dextra = sinistra : sonor in both lung : vesiculer (+) normal, ronkhi (-), wheezing (-) : normal

Abdomen Genital

: refer to local examination : refer to local examination

Upper extremities : no abnormalities Lower extremities : no abnormalities

Local Examination Abdomen Inspection Palpation Percution Auscultation : flat : no tenderness : tympani : bowel sound (+) normal

CVA region Inspection : bulging Palpation : pain ballottement Percussion : pain

dextra (-) (-) (-) (-)

sinistra (-) (-) (-) (-)

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

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

Rectal toucher TSA good, enlargement of prostate, upper boarder of prostate unpalpable, ruberry consistency, flat surface, no tenderness, feces (+), blood (-).

1.4. Supportive Examination Laboratorium findings (07/09/13) Routine blood: Hemoglobin Hematocryte Leucocyte Thrombocyte LED Diff. Count Clinical Chemistry: BSS Ureum Creatinine : 99 mg/dL : 39 mg/dL : 1,04 mg/dL (N : 15-39mg/dL) (N : 0,9-1,3mg/dL) : 9,7 gr/dL : 29 vol% : 9.0/mm3 : 284.000 /mm3 : 120 mm/hour : 0/14/0/45/33/8 (N : 14-18g.dL) (N : 40-48vol%) (N : 5000-10000/mm3) (N : 200.000-500.000/mm3)

Uric Acid Na K+ Urine analysis: Epitel cell Leucocyte Erytrocyte Silinder Kristal
+

: 8,1 mg/dL : 140mmol/l : 4,3mmol/l

(N : < 8,4) (N : 135-155) (N : 3,6-5,5)

: Positive (+) : 20-25/ LPB : 80-100/ LPB : negatif : negatif (N : 0-5 / LPB) (N : 0-1 / LBP) (-) (-)

BNO

Result

: Multiple semi radioopaque stones in pelvic cavity (size 1,5-2 cm)

Interpretation : Susp. Vesicolithiasis multiple

USG

Result: Prostat : Widening of prostate, 50 x 54mm, Vesica urinary : multiple acoustic shadow on vesica urinary, multiple stones (+) Renal No abnormalities in right and left renal, no enlargement of kidney, pelvis calices not widening, no stone. Interpretation: Prostate enlargement Vesicolithiasis multiple

1.5. Differential Diagnose Urine Retention ec. Suspect Benign Prostate Hyperplasia + Vesicolithiasis Urine Retention ec. Suspect Prostate Cancer + Vesicolithiasis

1.6. Working Diagnose Urine Retention ec. Suspect Benign Prostate Hyperplasia +

Vesicolithiasis

1.7. Treatment Transurethral Resection of Prostate (TURP) Vesicolithotomy

1.8. Prognosis Quo ad vitam : bonam

Quo ad functionam : dubia ad bonam