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Morning report

June 9, 2012

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Patient N, male, 49 years old, came to theEmergency Unit of Arifin Ahmad General

Hospital on June 7, 2012

Couldnt urinate since a day before admitted

to the hospital.

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Since 1 day before came to hospital,

patient couldnt urinate, Patient felt

pain on lower abdominal, looked

bigger, strain palpable.

Patient admitted to Duris hospital and

he was applied catheter urin, but it

didnt work. The catheter couldntenter the urethra. blood in orifice of

penis (-).

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1 week before admitted to AAs

general hospital, patient complained

of difficulty in passing urin. Pain

during urination (+), diffuculty startingurination (+), dribbling (+), starting

and stopping often (-), felt

unsatisfied. Waking to urinate duringnight(-), frequency urination was 5

times a day, split urination stream (+),

weak and small.

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Patient then admitted to Emergency

Unit of AAs General Hospital. The

catheter also couldnt enter the

urethra. Then he was applied

cystostomi suprapubic. Initial of urine

output was about 2000 mL with

yellow color, blood in urin(-)

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Bloody urine (-), no stones and sand

came out from urethra

Felt pain at flank (-), no referred pain.

Painful and discomfort at lower

abdominal area (+), sometimes

referred to penis. Fever (-), vomitus (-

)

3 years before admission to hospital

there was stone comes out from

uretra, small, the size about a grain

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No history of genitourinary trauma

No history of Diabetic disease

Gouty artritis (+)

Hypertension (+)

Post Hernia surgery 1 years ago

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Alcoholic (+)

Not sufficient of drink (+)

Consumed of giblets and bean

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Generalized condition : mild illness

Conciousness : composmentisVital sign :

Blood Pressure : 160/100mmHgRespiration Rate : 20 x/minutes

Pulse : 84 x/minutesTemperature : 36,5 C

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Head and Neck : Conjuntiva anemic (-/-)

Sclera icteric (-/-)

Chest : Normal

Abdomen : Normal

Extremity : Tophi at dorsal pedis(+), Warm

Capillary Refilling Time

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CVA Right Left

Inflammatory sign - -

Scar - -

Ballottement - -

Tenderness - -

Knock pain - -

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Suprapubic

Inspection : inflamation sign (-), cystostomy

suprapupic (+) applied with IV Catheter,volume of urine bag was

100 ml/3hours with yellow color,bloody urin (-)

Palpation : no palpable mass, tenderness(+)

External GenitaliaPenis : Inflamation sign (-), no

discharge, no masspalpable

Scrotum : Inflammation sign (-), testiss mmetric +/+ rubber

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Digital Rectal Examination

Inspection : Anal and perineum normal

Palpation :

- Sphincter ani tone was normal

- Rectal mucosa was smooth

- Tenderness (-)

- Prostate : rubbery consitency, flat surface,

no nodul, interlobe sulcus not palpable,upper pool not palpable

- Gloves : faeces (-), mucous (-), blood(-)

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Urinary retention due to suspect Urethral

stricture + Bladder stone

Urinary retention due to suspect BenignProstatic Hyperplasia

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UrinalysisBlood Routine examination

Blood Chemical examination

BNOUSG of kidney, Ureter, Bladder

Urethrogram bipolar

TRUS

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Hb : 11,5 gr%White blood cel : 12.500/ L

Trombosit : 234.000 /L

Haematocryte : 33,6 %

Glu : 89 mg/dl

Creatinin- serum : 6,2 mg/dl

Ureum : 128,4mg/dl

URIC : 17,2 mg/dl

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IVFD RL 20 gtt/ minute

Ceftriaxone 2 x 1 gr

Ketorolac 2x1 amp (IV)

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