CHAPTER I CASE REPORT

1.1. Patient Identification Name Age Sex Address Nationality Religion Occupation Admitted Medical Record : Mr. Y : 62 years old : Male : Palembang : Indonesian : Moslem : Construction worker : 7th May 2013 : 718235

1.2. Anamnesis (Autoanamnesis taken on 24th May 2013) Chief Complaint: Left flank pain

History of Present Illness: 13 years before admission, patient complaints left flank pain, and the pain spreading to right buttock. The pain is intermitten but tends to settle. Voiding at night (nocturia) 2-3 times at night, there is no pain when urinating. Hesitancy at the beginning of urinary flow, decreased force and caliber of stream, and sensation of incomplete bladder emptying are denied. There is no bloody urination, no sandy urination, no stone in urine and the patient defecate as usual. The patient has no fever, vomitus , nausea, and there is no decrease of body weight. 2 years before admission, patient complaints left flank pain become more severe. The pain is intermitten and become more severe after works. There is bloody and sandy urination. Patient also complaint pain when

urinating and the pain become more severe after urination . Voiding at night (nocturia) up to 10 times at night and after that patient drink a lot of water. There is no stone in urine and the patient defecate as usual. Hesitancy at the beginning of urinary flow, decreased force and caliber of stream, and sensation of incomplete bladder emptying are denied.. The patient has no fever, vomitus , nausea, and there is no decrease of body weight. 1 months before admission, patient complaints difficult to void and pain when patients start to void. The patient also complaint increasing of urinary frequency and sensation of incomplete bladder emptying. Patient must straining when urination. There is no bloody urination, no sandy urination, no stone in urine. The patient has no fever, vomitus , nausea. 2 days before admission patient complaints unable to void. Patient also complaints abdominal bloating. And then patient admitted to Moehammad Hoesin General Hospital.

History of Past Illness:

No history of trauma at the genitalia, stomach/ hip and back bone area. No history of recurrent urinary tract infections. No history of surgery. No history of urinary stone and blood in urine. No history of diabetes. History of hypertension since 16 years ago Consuming 3-4 glass of water/ day Consuming 1 cup of tea and coffee/day History of postpone urination habit (+)

History of Family Illnesses History with same complaint as the patient in family denied

1.3. Physical Examination a) General Examination (On 24th May 2013) Appearance Consciousness Blood pressure Pulse rate : good : compos mentis : 170/100 mmHg : 82 x/min : 36,7 0C : conjunctiva palpebra anemic (-/-), sclera icteric (-/-), pupils isokor, light reflex (+/+) Neck : no abnormalities

Respiratory rate : 18 x/min Temperature Eyes

Thorax Lungs Inspection

: statis and dinamis simetris right and left, dynamic simetris right and

Palpation Percussion

: stem fremitus equals in both lungs. : sonor on both lungs

Auscultation : vesiculer (+) normal , ronkhi (-), wheezing (-).

Heart Inspection Palpation Percussion : Ictus cordis not visible : Ictus cordis not palpable : Upper boundary: left ICS III parasternal, Right boundary : right parasternal line ICS IV Left boundary: left axillaris anterior line ICS V.

Auscultation Abdomen Genital

: HR : 82 beats/minute, regular, murmur ( - ), gallop ( - ) : refer to local examination : refer to local examination

Upper extrimities : no abnormalities Lower extrimities: no abnormalities

b) Local Examination CVA Region Inspection : bulging Palpation : ballottement Percussion : percussion pain Right (-) (-) (-) Left (-) (-) (-)

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

External Genital Region Inspection : Urethra Catheter No. 16 F fixed, urine clear, bloody discharge (-)

Inguinal Region Inspection : no bulging

Rectal Toucher TSA good, no enlargement of the prostate, elastic consistency, no tenderness, nodule (-), feaces (+), blood (-).

1.4. Supportive Examination Laboratorium findings (16/5/13) Routine blood:

Hemoglobin Hematocryte Leucocyte Thrombocyte

: 15,7 gr/dL : 43 vol% : 125.00/mm3 : 408.000/mm3

(N : 14-18g.dL) (N : 40-48vol%) (N : 5000-10000/mm3) (N : 200.000-500.000/mm3)

Diff. count : 0/2/4/52/32/8

Clinical Chemistry: BSS Ureum Creatinine Na+ K+ : 82 mg/dL : 30 mg/dL : 0,94 mg/dL : 142 mmol/l : 4,2 mmol/l (N : 15-39mg/dL) (N : 0,9-1,3mg/dL) (N : 135-155) (N : 3,5-5,5)

Urine analysis: Epitel cell Leucocyte Erytrocyte Silinder Crystal : 0,1/LPB : 0,1 / LPB : 0,1 / LPB : (-) : (-) (N : 0-5 / LPB) (N : 0-1 / LBP) (N : Negative ) (N : Negative )

Sensitivity test and gram culture Microscopic result : Gram (+) coccus (+) Culture result : Streptococcus bovis

USG

No enlargement of prostate Vesica urinaria stone (+) , diameters = 3,5 cm

BNO

Radio opaque appearance in vesicae urinaria , size 3,5 cm x 2,5 cm

X-ray Thorax AP/lateral : no abnormalities

1.5. Differential Diagnosis Vesicolithiasis + Hypertension grade II

1.6. Working Diagnosis Prostate Carcinoma

1.7. Treatment 1.8. Prognosis Quo ad vitam Quo ad functionam : dubia ad bonam : dubia ad bonam Opening vesicolitotomi Anti Hypertension + restriction natrium diet

CHAPTER III CASE ANALYSIS Mr. Y, 62 years old man, admitted to Mohammad Hoesin General Hospital Palembang with chief complaint left flank pain. From the anamnesis, 13 years before admission, patient complaints left flank pain, and the pain spreading to right buttock. The pain is intermitten but tends to settle. Voiding at night (nocturia) 2-3 times at night, there is no pain when urinating. Hesitancy at the beginning of urinary flow, decreased force and caliber of stream, and sensation of incomplete bladder emptying are denied. There is no bloody urination, no sandy urination, no stone in urine and the patient defecate as usual. The patient has no fever, vomitus , nausea, and there is no decrease of body weight. 2 years before admission, patient complaints left flank pain become more severe. The pain is intermitten and become more severe after works. There is bloody and sandy urination. Patient also complaint pain when urinating and the pain become more severe after urination . Voiding at night (nocturia) up to 10 times at night and after that patient drink a lot of water. There is no stone in urine and the patient defecate as usual. Hesitancy at the beginning of urinary flow, decreased force and caliber of stream, and sensation of incomplete bladder emptying are denied.. The patient has no fever, vomitus , nausea, and there is no decrease of body weight. 1 months before admission, patient complaints difficult to void and pain when patients start to void. The patient also complaint increasing of urinary frequency and sensation of incomplete bladder emptying. Patient must straining when urination. There is no bloody urination, no sandy urination, no stone in urine. The patient has no fever, vomitus , nausea. 2 days before admission patient complaints unable to void. Patient also complaints abdominal bloating. And then patient admitted to Moehammad Hoesin General Hospital.

From physical examination, on general examination, patients blood pressure is 170/100 (hypertension grade II). On local examination, there is tenderness on suprapubic regio. From laboratory examination, there is slightly increasing of leucocyte. And from gram culture there is gram (+) streptococcus, Streptococcus Bovis. From BNO examination, there is radioopaque appearance in vesicae urinaria , size 3,5 cm x 2,5 cm. From USG examination , there is no abnormalities in prostate and there is stone in vesica urinaria with diameters = 3,5 cm. From anamnesis, physical examination, laboratory,BNO and USG finding this patients diagnosed as vesicolithiasis and hypertension grade II. Treatment for this patient is, opening vesicolitotomi, antihypertension and restriction natrium diet. Quo ad vitam prognosis is dubia ad bonam and quo ad functionam prognosis is dubia ad bonam.