CHAPTER I CASE REPORT

1.1. Patient Identification Name Age Sex Status Address Nationality Religion $%%u&ation Medi%al Re%ord Admitted : Mr. T : 73 years old : Male : Married : Gantwarno RT 03 RW 01 elura!an "elitang ### : #ndonesian : Moslem : 'a(or : 737)*+ : 11t! o, No-em(er .013

1... Anamnesis /Autoanamnesis ta0en on 1*t! o, No-em(er .0131 2!ie, %om&laint: 3na(le to urinate one day (e,ore admitted to !os&ital. 4istory o, &resent illness : T!ree years (e,ore admission &atient %om&lained di,,i%ulty o, urinate !ad to &us! to (egin urinate5 slow urine stream5 sto&&ed and started again w!en urinated5 &ost -oid dri((ling5 sensation o, in%om&lete (ladder em&tying.. 6atient ,re7uent urination es&e%ially at nig!t (ut it was still le,t o-er /not satis,ied1. 6atien also o,ten straining w!en urinating5 (loody urination /815 sandy urination /815 ,e-er /815 (a%0 &ain /815 nausea /815 -omited /815 a !istory o, trauma /81. 6atient got medi%ation ,rom a general &ra%titioner5 redu%ed %om&laints t!en rea&&ear.

Se-en mont!s (e,ore admission &atient %om&lained o, &ain a%%om&anied urinate es&e%ially at t!e (eginning o, urin ate. "loody urination /815 sandy urination /815 stone in urin /815 de,e%ation /91 normal5 ,e-er /815 nausea /81 and loss o, (ody weig!t /81. 6atient went to t!e "elitang 4os&ital and got inserted urinary %at!eter &ro%edure in !is uret!ra. T!e %om&laint was not redu%ed5 &atient %om&lained o, &ain during insertion o, %at!eter in !is uret!ra. 2at!eter was remo-ed a,ter ,i-e days inserted and t!en &atient got %at!eter uret!ra insertion &ro%edure at t!e se%ond time (ut it was ,ailed. 2at!eter %an:t inserted. 6atient got under a(dominal insertion %at!eter &ro%edure /%ystostomy su&ra&u(i%1. $ne day (e,ore admission &atient %om&lained una(le to urinate normally. 4e was admitted to "elitang 4os&ital. T!en !e was re,,ered to Mo!ammad 4oesin general !os&ital to !a-e t!e next &ro%edure. 4istory o, &ast illness: 4istory o, using any instrument inserted to t!e uret!ra 4istory o, %y%tostomy su&ra&u(i% &ro%edur at "elitang 4os&ital No !istory o, urinary in,e%tions5 no !istory o, &iuria No !istory o, &rostate5 (ladder5 &enis5 uret!ra o&eration No !istory o, urinary stone No !istory o, dia(eti% and stro0e No !istory o, straddling in;ury No !istory (one &ain5 &arest!esias5 wea0ness or s&asti%ity o, lower extremities and regional lym!adeno&at!y. 4istory o, <amily disease No !istory o, disease in ,amily wit! same %om&lain

So%ioe%onomi%
.

6atient is a ,armer. 4e !as one wi,e and six %!ildren.

1.3. Physical Examination General Examination A&&earan%e 2ons%iousness "lood &ressure 6ulse rate Res&iratory rate Tem&erature @yes Ne%0 #ns&e%tion : normal 6al&ation : normal T!orax S!a&e 'ung #ns&e%tion 6al&ation 6er%ution Aus%ultation 2or #ns&e%tion 6al&ation 6er%ution Aus%ultation A(domen : i%tus %ordis not -isi(le : i%tus %ordis un&al&a(le : u&&er limit #2S ##5 rig!t limit '6S dextra #2S #C5 le,t limit 'MS #2S C : murmur /815 gallo& /81 : statis5 dinamis simetris dextra A sinistra : strem,remitus dextra A sinistra : sonor in (ot! lung : -esi%uler /91 normal5ron0!i /815w!eeBing/81 : normal : good : %om&os mentis : 1.0=>0 mm4g : >? x=min : .0 x=min : 3?5> 02 : %on;un%ti-a &al&e(ra anemi% /8=815 s%lera i%teri% /8=815 &u&ils iso0or5 lig!t re,lex /9=91

: re,er to lo%al examination

3

Genital 3&&er extremities 'ower extremities Local Examination A(domen

: re,er to lo%al examination : no a(normalities : no a(normalities

#ns&e%tion : ,lat 6al&ation : no tenderness 6er%ution : tym&ani Aus%ultation : (owel sound /91 normal 2CA region #ns&e%tion : (ulging 6al&ation : 6ain "allottement dextra /81 /81 /81 sinistra /81 /81 /81

Su&ra&u(i% region #ns&e%tion 6al&ation : "ulging /815 %ystostomy su&ra&u(i% wit! uret!ra %at!eter No. .0< is ,ixed5 urine %lear. : 6ain /81

@xternal genitalia region #ns&e%tion 6al&ation : "loody dis%!arge /815 eryt!ema /815 nodule /815 ul%eration /81 5%ir%um%ised. : 4ardness on t!e undersur,a%e o, t!e &enis %an:t (e &al&ated Digital Rectal Examination TSA is good5 am&ulla is not %olla&se5 smoot! mu%osa5 mass /815 enlargement o, &rostate5 ,lat sur,a%e5 no tenderness5 nodule /815,e%es /915 (lood /81.
)

1.4. Su

o!ti"e Examination

Laboratorium findings Routine (lood: 4emoglo(in 4emato%ryte 'eu%o%yte T!rom(o%yte "leeding time 2lotting time 2lini%al 2!emistry: "SS 3reum 2reatinine Na9
9

: : : : : :

1.5? 37 ?5? 171 . +

/N : 13..817.3=d'1 /N : )38)+D1 /N : )*00811000=mm31 /N : 1*0.0008)*0.000=mm31 /N :183 minutes1 /N : +81* minutes1

: : : : :

117 .? 05?? 1)3 35* /N : 1*83+mg=d'1 /N : 057815.mg=d'1 /N : 13*81** mmol='1 /N : 35*8*5* mmol='1

3ret!rogram

Result : 6lain &!oto &el-is and uret!ra are normal 2ontrast %an enter t!e (ladder Cisi(le indetation at t!e (ase o, t!e (ladder (y enlarged o, &rostate /"enign 6rostate 4y&er&la&sia1 @xtra-asation o, %ontrast a&&ears in t!e (order (etween &ars &rostati% uret!ra wit! &ars mem(ranous 1.#. $o!%in& 'ia&nosis 3rine retention due to uret!ral stri%ture &ars mem(ranasea and "enign 6rostate 4y&er&lasia 1.(. T!eatment #nternal 3ret!rotomy T3R86 1.). P!o&nosis

Euo ad -itam

: (onam

Euo ad ,ungtionam : du(ia ad (onam

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