Patient List

No Identity Admission to ER Diagnosis Planning

2. Mr. Jailani/ 39 th/ 15th May 2019 at Clinical diagnosis: Treatment From ER
RMK 1-42-75-74 00.00 pm Urinary Retention • Percutaneus
Etiological diagnosis: Cystostomy
Susp. Panurethral stricture
Complication diagnosis:
Next plan: Bipolar Voiding
-
Other diagnosis: Cystourethrography
Susp. Urethrocutaneus fistule + (BVCUG)
Balanitis xerotica obliterans +
vitiligo + Anemia
 1. Mr. Dilham/ 45 y.o/admitted 15th May 2019 at 01.00 pm

Chief Complain : Can’t void

History taking :
patients came to hospitals complain that he cannot urinate for 1 day. initially the patient can
urinate but only dribbling and need to strain to void, the patient also complains of pain while
urinating, pain especially when starting urination. History of Bloody urethral discharge 2 months
ago after the patient was tride to be inserted folley catheter using mandrin by nurse nearby.
After that, he complain urine flow from his rectum, especially while voiding, while hold urinate,
urine didn’t flow through the fistule. No history of prolong cough/shortness of breath (-),
defecation (+) came out slightly, decreased appetite, history of weight loss (-).
History of family illness: Hypertension (-) DM (-)
History of family illness : No one in his family had the same symptom
Vital Sign

Compos mentis
BP : 110/70 mmHg
RR : 19 x/m
HR : 98 bpm
Tax : 37,1 ◦C
GCS : E4V5M6
SpO2 : 98% without O2 supplementary
 Physical Examination
• Head: Normal
Head/Neck • Eyes : anemic conjunctivae(-/-), icteric sclera(-/-),
• Neck: JVP enhancement(-), lymph enlargement (-)

• I: symmetric respiratory movement, retraction (-)

• P: symmetric VF
Chest • P :sonor at all lung fields
• A : symmetric VBS, no ronchi, no wheezing, crackles (-)

•I : distention (-) mass (-)

Abdomen •A : bowel sound (+) normal (8-9 x/m)
•P : tympanic
•P : H/L/M = nopalpable,tenderness(-),muscular rigidity(-)

• warm (+), edema (-),paralysis (-), hypopigmentation lessing on

Extremities extremities
Urology state
• CVA
- I : hematome (-) mass (-) • Suprapubic
- P : unpapable mass , tenderness (-) CVA (- - I : distended (+), mass cystic (+),
/-) Hematom (-), macula hypopigmentation
(+)
• Flank - P : tenderness (-) mass (-)
- I : hematome (-), swelling (-)
- P : unpapable mass tenderness (-) • Genitalia external:
-penis : edema (-) haematoma (-)
-Scrotum : Swelling (-), hyperemis (-) mass (-
) tenderness (-) hematom (-)
-Oue: bloody discharge (-), (+) at OUE
P: tenderness (-)
Digital Rectal Examination
•I : mass (-) hemoroid (-) •Prostat
laceration (-) mass (-) Nodule (-)
fistule at perineum (+)
palpable prostat
•P:
firm Consistency
Sphincter ani tonus in tenderness (-)
normal limit (+)
Regular surface
Recti mucous normal
Sulcus mediana
Ampula recti normal
Handscoon : faeces (+), blood
Tenderness (-) (-)
Clinical Pictures
Clinical Pictures
USG Abdomen 15/05/2019
USG Abdomen 15/05/2019
 Laboratory Finding
Examination Result Nilai Rujukan
Hemoglobin 9,2 12,00-16,00 g/dl
Leukosit 8,7 4,0-10,5 ribu/ul
Eritrosit 4,62 3,90-5,50 juta/ul
Hematokrit 30,3 37,00-47,00 vol%
Trombosit 300 150-450 ribu/ul
RDW-CV 17 11,5-14,7 %
MCV 65,6 81,0-99,0 fl
MCH 19,9 27-31pg
MCHC 30,4 33.0-37.0
Gran% 86,3 50-70%
Limfosit% 7,7 25-40%
MID% 5,4 4.0-11.0%
Gran# 7,48 2.50-7.00 thousand/ul
Limfosit# 0,67 1.25-4.0 thousand/ul
MID# 0,47
 Laboratory Finding

Pemeriksaan Hasil Nilai Rujukan

PT 11,3 9,9-13,5 detik
INR 1,05
APTT 27,2 22,2-37,0 detik
GDS 111 <200
SGOT 26 0-46 U/l
SGPT 17 0-45 U/l
Ureum 21 10-50 mg/dl
Creatinin 1,09 0,7-1,4 mg/dl
Natrium 141 135-146 mmol/l
Kalium 3,4 3,4-5,4 mmol/l
Chlorida 106 95-100 mmol/l
 Working Diagnosis
Clinical diagnosis:
Urinary Retention
Etiological diagnosis:
Susp. Panurethral stricture
Complication diagnosis:
-
Other diagnosis:
Susp. Urethrocutaneus fistule + Balanitis xerotica
obliterans + vitiligo + Anemia
 Management

Treatment From ER • Next: Pro BVCUG

• Percutaneus Cystostomy
Post Percutaneous Cystostomy