Morning report

June 9, 2012

Patient N, male, 49 years old, came to the Emergency Unit of Arifin Ahmad General Hospital on June 7, 2012

Couldnt urinate since a day before admitted to the hospital.

Since 1 day before came to hospital, patient couldnt urinate, Patient felt pain on lower abdominal, looked bigger, strain palpable.

Patient admitted to Duris hospital and he was applied catheter urin, but it didnt work. The catheter couldnt enter the urethra. blood in orifice of penis (-).

week before admitted to AAs general hospital, patient complained of difficulty in passing urin. Pain during urination (+), diffuculty starting urination (+), dribbling (+), starting and stopping often (-), felt unsatisfied. Waking to urinate during night(-), frequency urination was 5 times a day, split urination stream (+), weak and small.

Patient

then admitted to Emergency Unit of AAs General Hospital. The catheter also couldnt enter the urethra. Then he was applied cystostomi suprapubic. Initial of urine output was about 2000 mL with yellow color, blood in urin(-)

Bloody urine (-), no stones and sand came out from urethra Felt pain at flank (-), no referred pain. Painful and discomfort at lower abdominal area (+), sometimes referred to penis. Fever (-), vomitus () 3 years before admission to hospital there was stone comes out from uretra, small, the size about a grain

 No

history of genitourinary trauma No history of Diabetic disease Gouty artritis (+) Hypertension (+) Post Hernia surgery 1 years ago

 Alcoholic

(+) Not sufficient of drink (+) Consumed of giblets and bean

Generalized condition : mild illness Conciousness : composmentis Vital sign : Blood Pressure : 160/100mmHg Respiration Rate : 20 x/minutes Pulse : 84 x/minutes Temperature : 36,5 C

 Head

and Neck : Conjuntiva anemic (-/-) Sclera icteric (-/-) Chest : Normal Abdomen : Normal Extremity : Tophi at dorsal pedis (+), Warm Capillary Refilling Time <3 minute Genitourinary : Urologic state

CVA Inflammatory sign Scar Ballottement Tenderness Knock pain

Right -

Left -

Suprapubic Inspection : inflamation sign (-), cystostomy suprapupic (+) applied with IV Catheter, volume of urine bag was 100 ml/3hours with yellow color, bloody urin (-) Palpation : no palpable mass, tenderness (+)
External Genitalia Penis : Inflamation sign (-), no discharge, no mass palpable Scrotum : Inflammation sign (-), testis symmetric (+/+) rubbery

Digital Rectal Examination

Inspection

: Anal and perineum normal

Palpation

: - Sphincter ani tone was normal - Rectal mucosa was smooth - Tenderness (-) - Prostate : rubbery consitency, flat surface, no nodul, interlobe sulcus not palpable, upper pool not palpable - Gloves : faeces (-), mucous (-), blood(-)

Urinary retention due to suspect Urethral stricture + Bladder stone

Urinary retention due to suspect Benign Prostatic Hyperplasia

 Urinalysis Blood

Routine examination Blood Chemical examination BNO USG of kidney, Ureter, Bladder Urethrogram bipolar TRUS

 Hb White

blood cel Trombosit Haematocryte

: 11,5 gr% : 12.500/ L : 234.000 /L : 33,6 % : 89 mg/dl : 6,2 mg/dl : 128,4mg/dl : 17,2 mg/dl

Glu Creatinin- serum Ureum URIC

IVFD RL 20 gtt/ minute Ceftriaxone 2 x 1 gr Ketorolac 2x1 amp (IV)