Morning Report BPH

8/3/2019 Morning Report BPH

1/20

Morning report

Yanri puji haskoro


2/20

Patient P, Male, 78 years old, came topoliclinic of urology of AA Hospital with chief

complaint

Urine retention since 5 daysbefore admission.


3/20

Present Illness History:

Patient came to the policlinic of urologyto showed his plain films of chest andUSG examination result .

2 days before admission, he came to thepoliclinic to get some consultation on his

illness. He was asked to take anexamination of chest radiography andUSG.

.


4/20

3 days before admission, he came to theemergency unit of AA hospital complaining his

inability to urinate for the last 2 days. Hisbladder was full-filled and felt pain.

Then catheterization performed and his urinestreamed down to the urin bag about 750 mL.No blood and discharge seen.

The catheter remains attached for 3 days.


5/20

5 days before admission, he was taken by hisfamily to the emergency unit due to unable to

urinate at all. His bladder was full-filled andfelt pain. Incomplete emptying (+),intermittency (+), not satisfied after urinate(+), terminal dribbling (+), frequency (+),

nocturia (+), urgency (-), flank pain (-), fever (-), hematuria (-), severe abdomen pain (-),Traumatic history (-), surgery history in thegenitourinary system (-).


6/20

In the emergency unit, he got urinary

catheter. Then his urine immediatelyflowed through the catheter. Thevolume was about 500 mL.

After 3 hours observed, the catheter wasreleased and he was allowed to go home.


7/20

Notat

all

Less

than1

timein

5Less

than

halfthe

time

About

halfthe

time

More

than

halfthe

time

Almost

always

Patient

Score

Incomplete emptying

Over the past month, how often have you had

a sensation of not emptying your bladdercompletely after you finish urinating?

0 1 2 3 4 5

2

Frequency


to urinate again less than two hours after you

finished urinating?

0 1 2 3 4 53

Intermittency

Over the past month, how often have you

found you stopped and started again several

times when you urinated?

0 1 2 3 4 52

Urgency

Over the last month, how difficult have you

found it to postpone urination?

0 1 2 3 4 5 2

Weak stream


a weak urinary stream?

0 1 2 3 4 5 5

Straining

Over the past month, how often have you hadto push or strain to begin urination? 0 1 2 3 4 5 2


8/20

None

1time

2times

3times

4times

5times

or

more

Patien

tscore

NocturiaOver the past month, many times didyou most typically get up to urinate

from the time you went to bed until the

time you got up in the morning?

0 1 2 3 4 5 3


9/20

General Condition

Conciousness : Composmentis

Blood pressure: 150/90 mmHg

Pulse Rate : 86x/minuteRespiration Rate : 22x/minute

Body temperature: 36,5 C


10/20

Head and Neck : normally

Thorac : normally

Abdominal : normally

CVA : urologicus status Genitalia : urologicus status

Extremity : normally

Rectal toucher : urologicus status


11/20

CVA dextra sinistra

mass - -

sycatric - -

ballottement + -

Knock

pain/tenderness

+ -


12/20

Mass -

Tenderness -


13/20


14/20

Suspect Hyperplasia prostat suspect benign withurine retention with score IPSS 19 (mild).


15/20

Vesicolithyasis


16/20

Consult to internist

Urinalysis

Ureum and Creatinine

PSA BNO-IVP


17/20

WBC : 14.700 /l

HB : 12,2 g/dl

Hct : 39,8 %

Plt : 400.000 /l Ureum : 27,8 mg/dl

CR-S : 0,95 mg/dl

Uric : 4,4 mg/dl


18/20

Prostat hypertrophy

Right renal stone

Chest x rayNo cardiomegali


19/20

TUR Prostate

Ciproflocxacin tab. mg 500 2x1

Mefenamat acid tab. mg 500 if needed


20/20

THANK YOU

Morning Report BPH

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