CASE REPORT

TOTAL STRICTURE URETRA PARS BULBOSA

Supervisor: dr. Akhada Maulana Sp.U

By: Lalu Karisma Aditya H1A 008 003

IN ORDER TO UNDERGO THE CLINICAL ORIENTATION / CLERKSHIP AT THE SURGERY FUNCTIONAL MEDICAL STAFF MEDICAL FACULTY OF MATARAM UNIVERSITY NTB GENERAL HOSPITAL 2013

HALAMAN PENGESAHAN
: Total Stricture Uretra Parsbulbosa : Lalu Karisma Aditya : H1A 008 003

Judul Nama NIM

Laporan kasus ini telah diterima sebagai salah satu syarat untuk mengikuti ujian kepaniteraan Klinik Madya pada Bagian/SMF Bedah Rumah Sakit Umum Provinsi Nusa Tenggara Barat / Fakultas Kedokteran Universitas Mataram.

Mataram, Oktober 2013 Pembimbing,

dr. Akhada Maulana Sp.U

CASE REPORT

I. Patient Identity Name Sex Age Address Religion Race Occupation Relationship status Date of hospital admission Date of examination : Mr. MK : Male : 79 years old : Jonggat, Central Lombok, West Nusa Tenggara : Muslim : Sasak : Farmer : Married : August 17th 2013 : August 21st 2013

II. Anamnesis The chief history : difficult to urinate Present disease history : Patient came to General Hospital Of West Nusa Tenggara Province complaining difficult to urinate since 1 month ago. This complaint worsen since 1 week. Patient often complains of hard to start urinating, frequent straining, frequent urinary dripping, and felt no satisfied on urinating. The frequency of urinating is more than 12 times / day, a little bit. In addition, sometimes patients also complains of pain when urinating, urinary dripping at the end (+), history of urinary bleeding (+), sandy urine or rock out (-), suprapubic pain (-). History of fever (-), nausea (-), vomiting (-). Patient drink about 2 L per day. Defecation was normal, once daily, concistency firm and brown. Past disease history: Patient often experiences the same complain for 1 month. Patient had a history of catheterization 2 months ago post peptic ulcers operation in General Hospital of West Nusa Tenggara. Patient said that he felt pain and blood came out during catheterization (+). A history of kidney stones (-), UTI (-), DM (-), HT (-), and Astmas (-).

Family disease history:

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No family member with the same complaint. Hypertension (-), Diabetes Mellitus (-), Uric acid (-) Drug allergy: Drug (-), Food Allergy (-) History of treatment: Patient was reffered from Praya General Hospital with Urine Retention et causa susp BPH. In Praya General Hospital, patient had been hospitalized for 7 days and had been treated with Antibiotic and analgetic.

Private and Social History: The patient worked as a farmer with 9 wives, 20 children, and 8 grandchildren, and 3 great-grandchildren. Patients often smoked 1 pack / day and regularly consuming 2 cups of coffee per day. History consume energy drinks (-), patients drank 1,5 L of water / day

III. Physical Examination General condition : Good

Consciousness/GCS : Compos mentis/E4V5M6 A. Vital Sign Blood Presure Heart rate Respiration rate Temperature : 150/80 mmHg : 88 bpm : 20 rpm : 36,5oC

B. General Status Head and neck o Head : normochepali, deformity (-) o Eyes : anemis (-/-), icteric (-/-), pupil isocore 3mm/3mm, pupil reflex (+/+) o Noise : deformity (- ) o Mouth : sianotic (-) o Neck : enlargement lymph node (-) Thorax o Inspection : chest wall shape and size simetric, mass (-), lesion (-), retraction (-), thoracoabdominal respiration (+). o Palpation : chest wall movement simetric, tenderness (-), vocal fremitus (+/+) normal, mass (-), crepitation (-).
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o Percussion: sonor in both lung, percussion pain (-). o Auscultation : Pulmo : vesicular in both lung (+/+), rhonki (-/-), wheezing (-/-) Cor: S1S2 single, regular, murmur (-), gallop(-) Abdomen o Inspection : distention (-), mass (-) o Auscultation : bowel sound (+) normal o Percussion : timpani in whole region o Palpation : tenderness (-), H/L/R not palpable, defans muscular (-), mass (-), ballotement (-)

Upper and Lower extremity: Warm acral (+/+/+/+), Deformity (-/-/-/-), oedem (-/-/-/-).

C. Urogenitalia Physical Examination Costo vertebrae angle (CVA) region: A. Inspection: color same as the surrounding skin, mass (-), inflammation (-), scar (-), hematome (-), bulging (-/-) B. Palpation : tenderness (-/-), mass (-), ballottement (-) C. Percussion : pain (-/-) Suprapubic region o Inspection: color same as the surrounding skin, mass (-), inflamation (-), scar (-), sistostomy (-) o Palpation : bladder distention (-), mass (-), tenderness (-) Genitalia externa: o mass (-)

D. Rectal Touche o Inspection: color same as the surrounding skin, mass (-), inflammation (-), scar (-), hematome (-), bulging (-). o Palpation : TSA is good, rectal mucosal is smooth, palpable prostate is not enlarge, palpable medial sulcus, palpable pole superior, pain (-), rubbery consistency.
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E. IPPS: 15 mild IIV. Summary Patients came to General Hospital of West Nusa Tenggara complaining difficult to urinate since 1 month ago. This complaint worsen since 1 week. Patient often complain of hard to start urinating, frequent straining, frequent urinary dripping, and felt no satisfied on urinating, frequency of urinating > 12 times / day, a little bit. Patient also complain of pain when urinating, urinary dripping at the end (+), history of urinary bleeding (+). Patient often experiences the same complain for 1 month. Patient had a history of catheterization 2 months ago post peptic ulcers operation in General Hospital of West Nusa Tenggara. Patient said that he felt pain and blood came out during catheterization (+). Patients drink about 1,5 L/day. Defecation was normal. On the physical examination, blood pressure 150/80 heart rate 88 bpm, respiration rate 20 rpm, temperature 36,8oC, there were no tenderness on the CVA region or suprapubic region, and no pain on the percussion.

V. Working diagnosis Suspect Stricture Ureter

VI. Differential diagnosis Susp. BPH

VII. Propose Examination CBC Uretrography

VIII. Laboratory Examination

Parameter August 16nd 2013 WBC RBC Hb HCT MCV MCH MCHC PLT BT CT GDS Creatinine Ureum 6,48.103/ul 3,91.106 /ul 8,8 g/dl 28,4 % 72,6 fl 22,5 pg 31 ,0 g/dl 397.103/ul 250 400 103 mg/dl 1,0 mg/dl 32 mg/dl

RANGE 4-11 4,5-5,5 13-18 37-50 82,0-92,0 27,0-31,0 32,0-37,0 150-400 <6 <15 <160 0,9-1,3 6-26

Uretrography result ( August 20nd 2013 )

Conclusion : Total Stricture Uretra Pars Bulbossa

VIII. Diagnosis Total Stricture Uretra

IX. Planning: Uretrotomi Interna (Sachse)

X. Prognosis: Quo ad vitam Quo ad functionam : Dubia ad bonam : Dubia ad bonam