Morning report BPH

IDENTITY:Patient H, male, 84 years old, came to the AA hospital on January 15rd 2014

No urine output in catheter since 1 day before admission AA Hospital

PRESENT ILLNESS HISTORY

Since 1 day before admission the patient complained no urine output in catheter and suffered from lower abdominal pain. Patient was taken to Dumai hospital, urine is removed by aspirated in the lower abdomen, according to the family the amount of urine output was about 500 mL. And then he was taken to the emergency unit AA’s hospital and he was applied catheter, according to his family it was number 16 and the urine volume was about 500 mL.

Since 1 month before admission the patient began using a catheter, because the patient ever complained of could not voiding spontaneously and sufferd from lower abdominal pain for 1 day. He was taken to dumai hospital and he was applied catheter number 16 and the urine output volume was about 500mL. And then he was taken to AA hospital, patients had USG examination and diagnosed with an enlarged prostate, surgery is recommended by doctors but patients refused.

Before that complaint, he had never gotten any trauma, there is no complain about the benumbed feet or hand, no diabetes melitus history, no history of surgery.

since 4 months, he had difficulty in starting urination, Forced to urinate, decreased force of his urinary stream, stopped and started again several times when urinate, sensation of incomplete bladder emptying, having to urinate again soon after finishing, almost always difficult to postpone urination, he also complained that he had to getting up at night to urinate frequently (±5 times/day). He had never complained any pain at the start, during or the end of urinate, no blood or stone in the urine, there was no split stream of urination, no fever, no complained pain at the waist.

PAST ILLNESS HISTORY hypertension (-) Spontaneous urinary passing stone (-)

Family illness history Nothing is important and has no relation with patient’s

condition

TOTAL SCORE : 25 (SEVERE)

PHYSICAL EXAMINATION

Generalized condition: mild illnessConciousness : composmentisVital sign :

BP : 130/90mmHgRR : 24 x/minutesP : 68 x/minutesT : 36,0 C ͦ

PHYSICAL EXAM• Head and Neck: normal• Chest : normal• Abdomen : Localized• Extremity : normal• Limph node : normal• Genitourinary : Localized• Digital Rectal Examination : Localized

LOCALIZED STATE Costovertebrae Angel

CVA Dextra SinistraInflammatory

sign- -

Scar - -Tenderness - -Knock Pain - -ballotemen - -

LOCALIZED STATESuprapubicI : Simetris, no distanded, no scarA : bowel sounds (+)P : no palpable mass/lump,

tenderness (-)P : Tympani

LOCALIZED STATEGenitalia externa OUEI : no lesions, edema, rashes or nodule,

circumcised, the urethral meatus is centrally on the glans, no discharge, catheter applied no. 16 F

P : no tenderness

Genitalia externa scrotumI: no inflammatory sign (-)P: Testes freely movable feel oval, firm

and rubbery, and smooth surface and equal bilaterally.

LOCALIZED STATERegio anorectalI : lump (-), ulcers(-), inflammation (-), rashes

(-), excoriation (-), fistula (-), P: no palpable mass

Digital Rectal ExaminationSphincter tone is normal, Rectal mucosa: smoothTenderness (-)prostate enlarge , consitency rubbery , no

nodul or induration, smooth surface, no palpable medial sulcus and upper border of the prostat

Handscoon: feses (-), no blood, no mucuse,

WORKING DIAGNOSIS Urinary retention et causa Bening

Prostatic Hyperplasia

DIFFERENTIAL DIAGNOSIS

Posterior urethral stone Malignancy prostate enlargement

FURTHER EXAMINATION

• Laboratory test Blood routin examinationBlood chemistry examinationUrinalysis

• USG to examine of the size of the prostat, and to see the surface if are there any nodules

2

LABORATORY FINDINGS • Hb : 13,5gr%• White blood cel : 10.100/

mm3

• Trombosit : 210.000 / mm3

• haematocryte : 41 %• Glu : 125 mg%• Creatinin- serum : 1,26 mg%• Ureum : 30,0 mg%

EXAMINATION FINDINGS• USG Prostat hiperplasia,

diameter : 3,58x4,12 mm2 , smoot surface, no nodules

2

FINAL DIAGNOSIS Benign prostate hyperplasia with retention

urine

MANAGEMENTSurgical therapy Transurethral

resection of the prostate (TURP)