Chapter 1 and 3 Kak Udin

7/28/2019 Chapter 1 and 3 Kak Udin

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CHAPTER I

CASE REPORT

1.1.Patient IdentificationName : Mr. Y

Age : 62 years old

Sex : Male

Address : PalembangNationality : Indonesian

Religion : Moslem

Occupation : Construction worker

Admitted : 7th May 2013

Medical Record : 718235

1.2.Anamnesis (Autoanamnesis taken on 24th May 2013)Chief Complaint:

Left flank pain

History of Present Illness:

13 years before admission, patient complaints left flank pain, and the

pain spreading to right buttock. The pain is intermitten but tends to settle.

Voiding at night (nocturia) 2-3 times at night, there is no pain when urinating.

Hesitancy at the beginning of urinary flow, decreased force and caliber of

stream, and sensation of incomplete bladder emptying are denied. There is no

bloody urination, no sandy urination, no stone in urine and the patient

defecate as usual. The patient has no fever, vomitus , nausea, and there is no

decrease of body weight.

2 years before admission, patient complaints left flank pain become

more severe. The pain is intermitten and become more severe after works.

There is bloody and sandy urination. Patient also complaint pain when


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urinating and the pain become more severe after urination . Voiding at night

(nocturia) up to 10 times at night and after that patient drink a lot of water.

There is no stone in urine and the patient defecate as usual. Hesitancy at the

beginning of urinary flow, decreased force and caliber of stream, and

sensation of incomplete bladder emptying are denied.. The patient has no

fever, vomitus , nausea, and there is no decrease of body weight.

1 months before admission, patient complaints difficult to void and

pain when patients start to void. The patient also complaint increasing of

urinary frequency and sensation of incomplete bladder emptying. Patient

must straining when urination. There is no bloody urination, no sandy

urination, no stone in urine. The patient has no fever, vomitus , nausea.

2 days before admission patient complaints unable to void. Patient

also complaints abdominal bloating. And then patient admitted to

Moehammad Hoesin General Hospital.

History of Past Illness:

No history of trauma at the genitalia, stomach/ hip and back bone area. No history of recurrent urinary tract infections. No history of surgery. No history of urinary stone and blood in urine. No history of diabetes. History of hypertension since 16 years ago Consuming 3-4 glass of water/ day Consuming 1 cup of tea and coffee/day History of postpone urination habit (+)

History of Family Illnesses

History with same complaint as the patient in family denied


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1.3.Physical Examinationa) General Examination (On 24th May 2013)

Appearance : good

Consciousness : compos mentis

Blood pressure : 170/100 mmHg

Pulse rate : 82 x/min

Respiratory rate : 18 x/min

Temperature : 36,7 0C

Eyes : conjunctiva palpebra anemic (-/-), sclera icteric (-/-),

pupils isokor, light reflex (+/+)

Neck : no abnormalities

Thorax :

Lungs

Inspection : statis and dinamis simetris right and left, dynamic simetris right

and

Palpation : stem fremitus equals in both lungs.

Percussion : sonor on both lungs

Auscultation : vesiculer (+) normal , ronkhi (-), wheezing (-).

Heart

Inspection : Ictus cordis not visible

Palpation : Ictus cordis not palpable

Percussion : Upper boundary: left ICS III parasternal,

Right boundary : right parasternal line ICS IV

Left boundary: left axillaris anterior line ICS V.


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Auscultation : HR : 82 beats/minute, regular, murmur ( - ), gallop ( - )

Abdomen : refer to local examination

Genital : refer to local examination

Upper extrimities : no abnormalities

Lower extrimities: no abnormalities

b) Local Examination

CVA Region Right Left

Inspection : bulging (-) (-)

Palpation : ballottement (-) (-)

Percussion : percussion pain (-) (-)

Suprapubic Region

Inspection : bulging (-)

Palpation : tenderness (+)

External Genital Region

Inspection : Urethra Catheter No. 16 F fixed, urine clear, bloody discharge (-)

Inguinal Region

Inspection : no bulging

Rectal Toucher

TSA good, no enlargement of the prostate, elastic consistency, no tenderness,

nodule (-), feaces (+), blood (-).

1.4.Supportive ExaminationLaborator ium fi ndings (16/5/13)

Routine blood:


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Hemoglobin : 15,7 gr/dL (N : 14-18g.dL)

Hematocryte : 43 vol% (N : 40-48vol%)

Leucocyte : 125.00/mm3 (N : 5000-10000/mm3)

Thrombocyte : 408.000/mm3 (N : 200.000-500.000/mm3)

Diff. count : 0/2/4/52/32/8

Clinical Chemistry:

BSS : 82 mg/dL

Ureum : 30 mg/dL (N : 15-39mg/dL)

Creatinine : 0,94 mg/dL (N : 0,9-1,3mg/dL)

Na+ : 142 mmol/l (N : 135-155)

K+ : 4,2 mmol/l (N : 3,5-5,5)

Urine analysis:

Epitel cell : 0,1/LPB

Leucocyte : 0,1 / LPB (N : 0-5 / LPB)Erytrocyte : 0,1 / LPB (N : 0-1 / LBP)

Silinder : (-) (N : Negative )

Crystal : (-) (N : Negative )

Sensitivity test and gram culture

Microscopic result : Gram (+) coccus (+) Culture result : Streptococcus bovis

USG


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- No enlargement of prostate- Vesica urinaria stone (+) , diameters = 3,5 cm

BNO

- Radio opaque appearance in vesicae urinaria , size 3,5 cm x 2,5cm

X-ray Thorax AP/lateral : no abnormalities


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1.5.Differential DiagnosisVesicolithiasis + Hypertension grade II

1.6.Working DiagnosisProstate Carcinoma

1.7.Treatment- Opening vesicolitotomi- Anti Hypertension + restriction natrium diet

1.8.PrognosisQuo ad vitam : dubia ad bonam

Quo ad functionam : dubia ad bonam


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CHAPTER III

CASE ANALYSIS

Mr. Y, 62 years old man, admitted to Mohammad Hoesin General

Hospital Palembang with chief complaint left flank pain. From the

anamnesis, 13 years before admission, patient complaints left flank pain, and

the pain spreading to right buttock. The pain is intermitten but tends to settle.

Voiding at night (nocturia) 2-3 times at night, there is no pain when urinating.

Hesitancy at the beginning of urinary flow, decreased force and caliber of

stream, and sensation of incomplete bladder emptying are denied. There is no

bloody urination, no sandy urination, no stone in urine and the patient

defecate as usual. The patient has no fever, vomitus , nausea, and there is no

decrease of body weight.

2 years before admission, patient complaints left flank pain become

more severe. The pain is intermitten and become more severe after works.

There is bloody and sandy urination. Patient also complaint pain when

urinating and the pain become more severe after urination . Voiding at night

(nocturia) up to 10 times at night and after that patient drink a lot of water.

There is no stone in urine and the patient defecate as usual. Hesitancy at the

beginning of urinary flow, decreased force and caliber of stream, and

sensation of incomplete bladder emptying are denied.. The patient has no

fever, vomitus , nausea, and there is no decrease of body weight.

1 months before admission, patient complaints difficult to void and

pain when patients start to void. The patient also complaint increasing of

urinary frequency and sensation of incomplete bladder emptying. Patient

must straining when urination. There is no bloody urination, no sandy

urination, no stone in urine. The patient has no fever, vomitus , nausea.

2 days before admission patient complaints unable to void. Patient

also complaints abdominal bloating. And then patient admitted to

Moehammad Hoesin General Hospital.


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From physical examination, on general examination, patients blood

pressure is 170/100 (hypertension grade II). On local examination, there is

tenderness on suprapubic regio.

From laboratory examination, there is slightly increasing of leucocyte.

And from gram culture there is gram (+) streptococcus, Streptococcus Bovis.

From BNO examination, there is radioopaque appearance in vesicae urinaria ,

size 3,5 cm x 2,5 cm. From USG examination , there is no abnormalities in

prostate and there is stone in vesica urinaria with diameters = 3,5 cm.

From anamnesis, physical examination, laboratory,BNO and USG

finding this patients diagnosed as vesicolithiasis and hypertension grade II.

Treatment for this patient is, opening vesicolitotomi, antihypertension and

restriction natrium diet. Quo ad vitam prognosis is dubia ad bonam and quo

ad functionam prognosis is dubia ad bonam.

Chapter 1 and 3 Kak Udin

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