MORNING REPORT

IDENTITY

Name : Mr. L
Age : 53 years old
Sex : male
Address : tomia
Doctor in charge : dr. Syamsul Rijal, Sp.B
Admission : September 23 2018
Chief complain : difficult urination
Anamnesis :
Patient come with complaints of difficulty urinating since 7 days ago. Initially
the patient complained of urinating a little. Urinate more than 8 times a day.
The patient also feels dissatisfed when urinating and when urinating must push
first. Frequent urination at night, when urinating the urine is sometimes weak.
Clear yellow urine color, defecate within normal limits.
History of the same complaint before : (+) often hold urine
History of some disease in the family (-)
History of other diseases (+) HT , DM, stone urine history 4 years ago.
History of medication (+) the drug is unknown to the patient, there is a
history of consumption of cold medicine, history of tea and coffee
consumption
PHYSICAL EXAMINATION

General state :
minor illness, good nourish,
composmentis
Vital sign :
BP = 140/90 mmHg
HR = 80x/m, regular, strong
RR = 18x/m, regular
Temperature = 36.6oC
 STATUS PRESENT

Head : Within Normal Limit

Face : Within Normal Limit
Eye : Within Normal Limit
Nose : Within Normal Limit
Ear : Within Normal Limit
Neck : Within Normal Limit
Chest : Within Normal Limit
Abdomen : localized state
Extremity
Superior : Within Normal Limit
Inferior : Within Normal Limit
 LOCALIZED STATE

ABDOMEN
I : convex,follows the breath motion. Suprapubic bulging (-) ec. Catheter installed
A : Peristaltic (+) normally
P : Suprapubic Tenderness (-) the bladder is not palpable (-), mass (-)
P : thympani (+)

Rectal toucher :
- Sphincter ani : strangulate
- Mucosa : slippery
- Ampulla : blank
-Prostat : palpable mass at 11 to 1 o’clock, protrusion is approximately 1 to 2 cm, consistency of solid
boundaries, slippery surface, tenderness (-).
-Handschoen : feces (-), blood (-), mucus (-)
CLINICAL FINDINGS
CLINICAL FINDINGS
 PLANNING

• Routine Blood
• Abdominal USG
 Laboratory Findings

• WBC : 10.76
• HB : 15.0
• PLT : 251
• GDS : 406
• CREATININ :0.9
• ALBUMIN : 4.1

Routine Blood (/09/2018)

Ultrasound results

(19/09/2018)
Impression : currently liver, glade bladder,
spleen, the right kidney, bladder don’t appear
abnormalities
 DIAGNOSIS

Benign prostat hypertropy + urine retention

Management
Pharmacology
• IVFD
• Analgetic inj. (ketorolac)
• 5⍺ reduktase (finarterid)
• ⍺-blocker
Non-Pharmacology
• Education
Consult to general
surgeon/urology surgeon
 Thank You

BAGIAN ILMU
BEDAH