SURGICAL PARADE

Urology Surgery Department

Saturday, March 20th 2021

Sarah Novita Rahayu, S.Ked

Ide Yudis Tiyo, S.Ked

Supervisor :
dr. Yudi Y. Ambeng, Sp.U

SECRETARIAT OF SURGICAL CLINIC

RSUD dr. DORIS SYLVANUS- FACULTY OF MEDICINE
UNIVERSITAS PALANGKA RAYA
PALANGKA RAYA
2021
Patient identity
Name : Mr. K
Age : 68 years
Birthday Date : 17/09/1952
Religion : Islam
Room : Dahlia
Hopitalized date : 15/3/2021
Address : Pulang Pisau
Profession : Farmer
Anamnesis Chief Complaint
Urinary Retention

Present Of Illness

Mr. K, A 68-years-old male was presented to the RSUD dr. Doris Sylvanus
Palangka Raya caused by experiencing of Urinary Retention since at least for the
last 4 months ago then The patient came to the health center for urinary catheter
placement because of the complaint.

Before the Chateter Placement, The Patients Complaints of Low Urinary Track
Syndrome were felt at least more then 1 years. Symptoms of LUTS that patients
experience include the patient had trouble starting urination. in addition, the
patient feels increased frequency of urin, The Incement was insideous in Onset
and Gradualy Progress even up to 2 hours and expirencing with nocthuria without
increasing the water intake. Another complaint that the patient feels is the frequent
dripping of urine. after urinating. And after finish urinating, the patients had
sensation of not emptying bladder complitly.
Anamnesis Present Of Illness

There is also a history of Poor stream which exaggreated on straining. It was

Sometimes followed by passage of few drops of urine his undergarments. there
was also history of inability to hold urine once the urge initiates on few occasions
he had soiled his clothes.

There was no history of hematuria, no Painful Urination (dysuria), No Abdominal

Pain, however, the patient feels slight pain or discomfort in the lower abdomen
when the urine does not pass, no trauma, or sugery of urinary tract. There No
History Of fever,reduced appetite or involuntary loss of weight. no history of stone
discharge from the urinary tract.

After few year of LUTS and few months with durg treatmen and urine cateter
placement, The patient then came and decided to come to the hospital because
the complaints were getting worse and felt uncomfortable and did not feel free to
use a urinary catheter every time.
Anamnesis International prostate symptomps score (IPSS)
 Past illness
Anamnesis The patient claimed to have a history of similar complaints since
the last 10 years, and was diagnosed with BPH (benign prostate
hypertrophy). The patient had to repeatedly use a catheter when
the complaint recurred. The patient said that he had taken the
drug for the prostate for ± 8 months and the complaints were
reduced after taking the drug.

History of disease:
• uric acid (-),
• Diabetes mellitus (-),
• Hipertension (-),
• Hipercholestrolemia (-)

Family History
• There’s no family who has this kind of complaint
• Uric acid (-)
• Hipertension (-)
• Diabetes Mellitus (-)
• Hipercholesterolemia (-)
Anamnesis Personal and Social History

The patient said he had a history of smoking since he was

young, likes foods such as offal, chicken, meat and green
vegetables.

Review of system
General : Tampak baik
Head, eyes, ears, nose, throat : no have complain
Neck : no have complain
Respiratory : no have complain
Cardiovascular : no have complain
Abdomen : Abdominal pain (-)
Urinary : Lower Urinary tract Symptomp (+), IPSS Score : 26
Extremities : no have complain
 Physical examination
General examination
General
General physical: Baik
examination
GCS: E4V5M6
VAS: 1

Vital sign
Tension : 137/72 mmHg
Pulsation : 58x/m
RR : 18x/m
Temp : 36,7°C
SpO2 : 98%
Head
Normocephal, white hair
Eyes: conjungtiva anemis (-/-), sclera ikterik (-/-)
Nose: deviation (-)
Neck
Trachea: simetris (+)
Lymph gland enlargement (-)
↑ JVP (-)
Thorax examination
Pulmo
Inspection
Simetris (+/+)
Retraction (-/-)

Palpation
Fremitus focal (+/+)
Chest expansion (+/+)

Percusion
Sonor (+/+)

Auscultation
Vesicular (+/+)
Rhonki (-/-)
Wheezing (-/-)
Thorax examination
Cardio
Inspection
Ictus cordis (-/-)

Palpation
Ictus cordis palpation in intercostal 5
midclavicula sinistra

Percusion
Right bound: Ics 4 Parasternal Dekstra
Left bound: Ics 5 midclavicula Sinistra
Auscultation
S1 S2 single sound, murmur (-), gallop (-)
Abdomen examiantion
Abdomen
Inspection
Flat (+), Ascites (-), Tumor (-), Scars (-)

Auscultation
Bowl sound (+) normal

Palpation
Abdominal pain (-) in all region, massa (-),
ballottement (-), Splenomegaly (-),
Hematomegaly (-)

Percusion
Timpani, all region abdominal
CVA Tenderdess (-)
Extremitas examination

Upper extremities warm (+/+)

Lower extremities warm (+/+)

Upper extremities edema (-/-)

Lower extremities edema (-/-)

Urology examiantion
Urology
Inspection
Gland penis normalsecret (-), testis (+)
Palpation
Bulbocavernosus reflex (+)
Rectal Tusce: spincter ani externa (+)
menjepit, rectal mucosa licin, haemorrhoid
(-),Prostat (+) membesar batas atas tidak
dapat teraba, konsistensi kenyal, nodul (-),
nyeri palpasi (-). Darah (-), fases (+)
Digital rectal exam (DRE)
Inspections
• No Hemoroid
• No Fistule
• No Lesion
• No Abcess
• No Bleeding
• No Rashes

• Palpation
• Anal Tone : Normal
• Size Of Prostate : Enlarge
• Surface : Smooth, Rounded
• Consistency : Firm, Rubery
• Medial Sulcus : Obliterated
• Other rectal Mass : Absent
• Upper Limit : Can Not be reached

• Normal Feces
• No Blood
 List of problems
• Low Urinary Track Syndrome (LUTS)
• High IPSS Scoring (Score :26)
• Prostat Enlargement
 Diagnostic
Clinical diagnostic
• Benign Hipertrophy Prostat

Differential Diagnostic
• Urolithiasis
• Prostat Cancer

Examination suggest:
• Complete Blood Count
• Urinalysis
• Plain Thorax and abdominal radiography
 Laboratory
examination
Haematology
• Leukocyte : 7.270/uL
• Haemoglobin :13,1 g/dL
• Haematocrit : 41%
• Platelet : 263.000/uL
• LED : 20 mm

• Ureum : 42 mg/dL
• Creatinin : 1,54 mg/dL
• HbsAg : positif

• Na : 136 mmol/L
• K : 3,7 mmol/L
• Ca : 1,11 mmol/L
 Laboratory Urologi
•
examination Kimia Urin
• Warna : Kuning
• Kejernihan : Keruh
• Glukosa : Normal
• Billirubin : Neg
• Keton : Neg
• Berat Jenis : 1030
• Blood : Neg
• pH : 5,0
• Protein : Neg
• Leukosit : 125 Leu/ul
• Hemoglobin :

• Sedimen Urin
• Epitel Squamos : Pos
• Leukosit : 8 - 10 / Lp 40x
• Eritrosit :Neg
• Jamur : Neg
• Bakteri : (+) 1
• Kristal non patologis :Neg
• Kristal Patologis : Neg
• Silinder Hialin : Neg
• Silinder Butir : Neg
Radiology
 Diagnostic
Working diagnose
• Benign hypertrophy prostat
• Urinary Retention
 • Infus RL 20 Drip per second
Therapy • Catheter + Urine bag
• Pro Operation TURB (Transurethral resectrion of prostat)
Thank You