Case Report

1. Patient identityName : Mr. MS

Age : 60 years old

Sex : Male

Occupation : Civil Servant

Address : Bima

MR : 069748

Date of hospital admission : December 28th 2012

Date of examination : January 2nd 2013

II. Anamnesis

Chief Complaint:

The pain during of micturition

Present Ilness :

Patient have been consultating from Cardiologist with Chronic Heart

Disease OMI inferior. The patient confessed difficulty starting urination

since one month ago. The complaint getting severe and pain on the last

four day. He have complaint pain at the during of micturition (+), weak

urine stream (+), dribbling after urination (+). He confessed having a

straining whenever starting a voiding. An urge to urinate again soon after

urinating. The patient has confessed nokturia (+) in almost ten times a day.

The patient also confessed bloody urine (+) and stony urinate (+) while

right flank pain (-), suprapubic pain (-), mass (-), nausea (-), vomiting (-).

The patient confessed had not defecation in last of this day while flatus

(+). The appetite was good, weight loss (-). The patient also confessed that

he had been weakness for the left hand and feet for four days in lately.

Post Illness History:

Patient said that the history of stone urinate (+) and bloody urine (+).

History of heart disease (+), hypertension (-), DM (-), asthma (-).

Family Illness History:

No family member with the same complaint. History of bloody urine (-),

stony urine (-), hypertension (-), heart disease (-), DM (-), asthma (-).

Medication History:

Patient was consumting the medication relate for the heart disease and

have been ever taking care for the illness and hospitalized for one week in

last two month ago. He forget the drugs who were consumt.

Allergic History:

No history of allergy due to food or medication.

History of Sosial Life

Patient is a civil servant, exatly in foreshty. Due to the anamnesis he is an

active smoker, enjoying coffee and lack of caring for the healty life.

III. Physical Examination

a. Status Generalis:

General Condition: Moderate

Awareness/GCS : Compos Mentis/ E4V5M4

Blood Preassure : 100/60 mmHg

Pulse : 87 bpm

Respiration : 20 bpm

Temperature : 36,5 C

b. General Examination

Head And Neck

Head: Normochepali, symmetric, deformity (-)

Eye: Pale Conjunctiva(-), Icteric Sclera (-), Pupil Isocore, Reflex of pupil

(+/+), diameter 3/3 mm

Ear, Nose, throat : normal

Neck: Limph node enlargement (-)

Thorax-Cardiovaskular

Inspection : mass (-), lesion (-), chest wall movement simetric, retraction

(-)

Palpation : tenderness (-), vocal fremitus (+) normal, mass (-)

Percussion: sonor in both lung, percussion pain (-)

Auscultation : cor: S1S2 single, irregular, murmur (-), gallop(-)

Pulmo : vesicular in both lung (+/+), wheezing (-/-), rhonki (-/-)

Abdomen

Inspection : normal skin color, distention (-), mass (-), scar (-), sicatriks

(-), darm contour (-), darm steifung (-)

Auscultation : bowel sound (+) normal, borborygmus (-), metallic sound

(-)

Palpation : tenderness (-), defans muscular (-), ballotment (-), mass (-)

Percussion : tymphany (+) all regions

IV. Local Status

Uro-genital

Flank regions : bulging (-/-), inflammation sign (-/-), tenderness (-/-),

mass (-/-), ballottement (-/-), CVA tenderness (-/-)

Suprapubis regions :

- Inspection: normal skin color, mass (-), hyperemic (-), scar (-),

sistostomy (-)

- Palpation : bladder distention (-), mass (-), tenderness (-)

DRE

Normotonic sphincter ani, mucosal is smooth, prostate firm, nodule

(-), pressure pain (-), sulcus mediana unpalpable (+) dome shape, the

lateral sulci is narrow, superior pole unpalpable (+), gloves : mucus

(-), blood (-), fesses (-).

External genital

Scrotum: skin color normal, inflammatory sign (-), mass (-),

tenderness (-)

Penis : Patient used catheter with urin output 300 cc, varicochele

(-), preputium had been removed (+).

Upper and lower extremity axial

Edema -/-, deformity-/-, inguinal limph node enlargement -/-

Muscle strength :

5 3

5 3

V. Summary

Male, 60 years old, with chronic heart disease OMI inferior was

confessed difficulty starting urination since one month ago and severe in

the last four day. Pain at the during of micturition (+), weak urine stream

(+), dribbling after urination (+), nokturia (+), bloody urine (+), stony

urinate (+), right flank pain (-), suprapubic pain (-), mass (-), nausea (-),

vomiting (-), weight loss (-). Digital rectal examination: normotonic

sphincter ani, mucosal is smooth, prostate firm, nodule (-), pressure pain

(-), sulcus mediana unpalpable (+) dome shape, the lateral sulci is narrow,

superior pole unpalpable (+), gloves : mucus (+), blood (-), fesses (-).

VI. Working diagnosis

Urine Retension e.c Benign Prostate Hyperplasia

VII. Diferensial Diagnosis

- Susp. Vesica Urinary Carsinoma

VIII. Purposed Examination

Laboratorium : Complete blood test, PSA and complete urine test.

Radiologi : IVP.

Laboratorium findings

CBC (December 27th 2012) Urine electrolit

WBC : 6 K/uL

Hb : 21,1 g/dL

HCT : 64,9 %

PLT : 178 K/uL

Blood glucose : 113 mg%

SGOT/SGPT : 31 U/L, 40 U/L

SC : 1,1 mg%

Ureum : 55 mg%

Na+ : 126

Ka+ : 4-5

Cl - : 107

tPSA : 0,62 (Normal)

Abdominal USG result :

Interpretations:

Right kidney : hidronefrosis 0,8 cm

Left kidney, hepar, bladder, : Normal

Prostate : size 4,3x 4,3 volume 41 cc

ECG :

Interpretation:

Sinus beat in 85x/minutes, OMI inferior and anteroseptal + ischemic anterolateral

IX . Definitive Diagnosis

Benign Prostate Hyperplasia + Chronic Heart Disease OMI Inferior +

Hemiparese Sinistra

X. Planning

Medikamentosa :

- IVFD RL 20 tpm

- Fargoxin 1x1 tab

- Simvastatin 20 gram tab

- Aspilet 80 gram

- Furesemid ½ tab

- Neulin 500 / 12 hour

- Avodat 1x1 tab

- Harnal 1x0,9 tab

Operatif :

Pro TURP

Biopsy

XI. Prognosis

Dubia

CASE REPORT

BENIGN PROSTAT HYPERPLASIA

By

Name : Asrarudin

Nim : H1A005005

Supervisor

dr. Akhada Maulana, Sp.U

CONDUCTING FOR MIDDLE CLINICAL EDUCATION IN SURGERY

DEPARTEMENT OF MATARAM REFERRAL HOSPITAL/MEDICAL

FACULTY OF MATARAM UNIVERSITY

2013