CASE REPORT FRIDAY, OCTOBER 18, 2013 54 AGE MAN PATIENT WITH WEAK URINARY STREAM

PRESENTED BY: AFIFAH NUR KARTIKASARI, 012.095.821

ADVISER : DR. BAMBANG S SP, BU

SULTAN AGUNG ISLAMIC MEDICAL UNIVERSITY SEMARANG 2013

PATIENTS IDENTITY
Name Age Sex Religion Occupation Adreess : Tn. Suharto : 54 tahun : Man : Moeslem : Farmer : Genuk, semarang

ANAMNESA
Main Problem Weak urinary stream
Historical Resend Disease

History Taking

Onset : weak urinary stream since 30 days ago, before hospital admission, these symptoms continuously increasing every day then there are no urinary at all. The patient had sensation of not emptying bladder less than half times a day. He always felt difficult to postpone urination and weak urinary stream before. In addition, weakened urinary shower , urine volume a little bit . Increased urinary frequency during the day from 3-4 times a day to be 7-8 times a day , accompanied by an increase in urine even today from 1 times every night to be achieved 10 times every evening . Patient distress when his bladder until urine dripping detained too long . No blood urine , pain when there is no urine , feel tenderness painful under of kidney or stomach

 For these patients only drink herbal remedy in the form of capsules ( nutrition for prostate disease ) , with the drug improved complaint but when more than 3 days to stop taking medication , the complaints came again.

Historical Symtoms History of similar illness:denied High Blood Pressure History: Denied Type 2 DM History :denied Gastritis History :denied

History of heart disease: Denied Allergy History : Denied Surgery History : Denied History of trauma : Denied History of long treatmant : Denied

Family History
In a family there who had similar complaints : Denied History High Blood Pressure : denied History type 2 DM :denied History allergy: Denied History Surgery : Denied History of trauma : Denied History long treatmant: Denied

Anamnesis
Main Probleme : Jaundice all of body Head : Headache (-), Dizziness (-), Eye : Blurred image (-), double image vision (-), Nose : rhinore (-), bleeding (-), obstruction (-), deviation septume (-) Ear : loss hearing (-), pain auricula (-), Out of fluid (-), blood (-). Mouth : Stomatitis (-), bleeding (-), dry mount (-). throat : throat discomfort (-), parau voice (-), itchy (-). Respiratory system: Deep Breathless (-), cough (-), paroxymal noctural dispeneu (-) Cardiovaskuler system: dispneu de effort (-), chest pain (-), heart beat(-) cold sweat(-)

Gastrointestinal tract system

: nause (-), vomiting (-), melena (-) abdominal pain (-), diarrhea (-), decreased appetite (-), loss weigh (-), pale faeces (- frequent, foul-smelling green faeces (+) had 1-2 times but not continuously, heartburn and burning in the throat (-) Muskcloskeletal system: muscle and join aches (-), Genitourinaria system: Frequent urination (-), pain during urination (-) gonorrhea (-), difficult urination start (-), clear yellow urine color, tea-colored (-). Extremitas: upper : parathesis (-), swelling (-), joint pain (-), edema (-), sweating (-), bump red (-) lower :parathesis (-), swelling (-), joint pain (-), edema (-/-), sweating (-), bump red (-) Neuropsikiatri system :Seizure (-), parastesis (-), Integumentum system :Pale (-), itching (-), red patches with vesicles (-), in the back, chest, right upper arm and left

General Status Looks a limp, awareness: compos mentis Nutrion Status Weigh: 50 kg Heigh: 163 cm BMI= 18.819 kg/m2 Analyzise : Normoweight Vital Sign Blood Pressure : 120/70 mmHg Heart rate : 80 x/minute, regulary, contents and sufficient voltage Respirasi : 16 x/minute temperature : 36,5 C (peraxiller)

 Skin Ikterik (+), petekie (-), decrease of turgor , hiperpigmentasi (-), dry skin (+), hiperemis (-) Head Mesocephal shape, Blacks hair (+), hair fall (-),massa (-) Face Simetris, moon face (-) Eyes Pale Conjungtiva (+/+), ikteric sclera (+/+), sunken eyes(-/-), subkonjungtiva bleeding (-/-), isokor pupilary (3mm/3mm), light reflex (+/+) normal, arcus senilis (-/-), cataract (-/-) Ear Secret (-/-), bleeding (-/-), mastoid painess (-/-), sensory hearing loss (-/-) Nose Nostril breath ( -/- ), secret (-/-), epistaxsis (-/-), good smelling fungtion(-/-) Mouth Sianosis (-), dry lips (-), Pursed lips breathing (-), stomatitis (-), bleeding (-), dirty tongue (-), hiperemis (-), tremor tongue (-)
Throat

Simetris, trachea deviation (-), lymph node enlargement (-), enlarge thyroidea(-), pain (-), muscle of respiration (-).

Chest Examination-Lung ANTERIOR

EXAMINATION

POSTERIOR

Inspeksi Static Dinamic

RR : 24x/min, thoracal breathing,Hyperpigmentatio n (-), spider nevi (-), atrofi M. Pectoralis (-), Hemithoraks D=S, ICS Normal, Diameter AP < LL Up and down of hemitoraks D=S ,muscle retraction of breathing (-), retraction ICS (-) Palpation pain (-), mass (-), Arcus costae angle < 900, enlargemnet of ICS (-), Sterm fremitus D=S Sonor (+) Vesicular (+), Whezzing (-), Ronchi (-)
Normal

RR : 24x/min, thoracal breathing, Hiperpigmentasi (-), spider nevi (-), Hemithoraks D=S, ICS Normal, Diameter AP < LL Up and down of hemitoraks D=S, muscle retraction of breathing (-), retraction ICS (-) Palpation pain (-), mass (-), Sterm fremitus D=S

Palpation

Percution Auskultation
Interpretation

Sonor (+) Vesicular (+), Whezzing (-), Ronchi (-)

CARDIAC
Inspection : Ictus cordis seen at ICS V linea 2 cmmed mid clavicula sinistra Palpation : Ictus cordis is palpable at ICS linea 2cm med mid clavicula sinistra , thrill (-), pulsus epigastrium (-), pulsus parasternal (-), sternal lift (-). Percussion : dull sound Upper borderline of heart Waist of heart

: ICS II linea sternalis sinistra : ICS III linea parasternalis sinistra Lower right borderline of heart : ICS V linea sternalis dextra Lower left borderline of heart : ICS V linea mid clavicula sinistra 2 cm medial

Interpretation : Normal Cor

Abdoment
Back bone Kifosis (-), lordosis (-), skoliosis (-),tenderness of costovertebra (-) Abdomen Inspection : spider nevi (-), sikatrics (-), striae (-) Auscultation : peristaltic (+) increase, Noise of gut (+) Increase Percussion : thympani all of field abdoment except upper righ abdoment is deaf(+),Liver span dextra 10 cm, liver span sinistra 8 cm Palpation : defens muscular (-), distension gland bladder, unpalpble spleen, murphy sign (-)

Interpretation : Normal

Genitourinaria Ulcus (-), secret (-), sign of inflamtion(-) Lhymp Node unenlargement Ekstremities Cold upper ektremities (-/-), cold lower ektremitas (+/+) Oedem upper ektremities (-/-) oedem lower extremities (+/-)

LABORATORY TEST

Suggest 1. Urinalysis 2. Urine culture 3. PSA test 4. Rectal grading 5. Clinical grading 6. Intra-uretal grading 7. Intravesical grading

USG ABDOMEN

IMAGING A. USG (ULTRASONOGRAPHY) B. PSA DENSITY

RECTAL EXAMINATION

Diagnosis
3-4 cm palpable prostate Firm to soft nodules regularities, equal lobes There are no Induration Smooth of surface prostate

Treatment
1. WATCHFUL WAITING

2.MEDICATION
Cateter Reseptor adrenergict - : PRAZOSIN 2 TIMES A DAY

Finasterid and dutaseride : lower levels of hormone produced

by the prostate, reduce the size of the prostate gland, i

Antibiotic

3. Surgery
TURP TUIP

THANK YOU