By:Putri Dwi Kart ini

04114708080

Supervisor:Dr. Marta Hendry Sp.U

SURGERY DEPARTMENT MEDICAL FACULTY OF SRIWIJAYA

UNIVERSITY2013

Susp. Benign Prostate Hyperplasia and Vesicolithiasis

Case Report

IDENTIFICATION

Name : Mr. RSAge : 73 years oldSex : MaleAddress : Harisan Jaya, Ogan Komering

Ulu Timur

Nationality : IndonesianReligion : Moslem Occupation : Retirement (builder)Medical Record : 754231Admitted : September 18th 2013

ANAMNESIS

Autoanamnesis taken on September 21th 2013

Chief Complaint

• Unable to void 1 month before admitted to hospital.

History of present illness

1 year

• difficulty to void,

• had to push to begin urination

• decreased force and caliber of stream

• stopped and started again when urinated

• Voiding at night up to 5 times at night (nocturia),

• difficult to postpone urination

• had sensation of incomplete bladder emptying

• Bloody urination (-)

• Stone in urine (-)

• Defecate + normal

• Fever (-)• Loss body

weight (-)

6 months

• pain when urinating

• uncomfortable when urinating

• stopped and started again when urination with changed the position of the body

• pain the lower abdomen that referred to the tip of the penis and the scrotum.

• Bloody urination (-)

• Stone in urine (-)

2 months

• pain when urinating and become more severe after urination

• bloody urination

• stone in urination (+)

• Fever (-)• Decreas

e of body weight (-)

went to polyclinics Mohhamad Hoesin General Hospital Palembang to get more therapy.

Admitted at September 18th 2013

History of past illness

• No history of urinary tract infections.• No history of using urethra catheter in long term use• No history of prostate, bladder, penis, urethra operation • No history of diabeties and CVD • No history of postpone urination habit• No history of trauma at the genitalia, stomach/ hip and back bone area.• No history bone pain, paresthesias, weakness or spasticity of lower extremities

and regional lymhadenopathy

History of Family disease

• History with same complaint as the patient in family denied

PHYSICAL EXAMINATION

General Examination (September 21th 2013)

• Appearance : good• Consciousness : compos mentis• Blood pressure : 130/90 mmHg• Pulse rate : 88 x/min• Respiratory rate : 20 x/min• Temperature : 36,70C• Eyes : conjunctiva palpebra anemic (-/-), sclera icteric (-/-), pupils

isokor, light reflex (+/+)

•Neck : no abnormalities•Thorax

• Lung : no abnormalities • Cor : no abnormalities

•Abdomen : refer to local examination•Genital : refer to local examination•Upper extremities : no abnormalities•Lower extremities : no abnormalities

LOCAL EXAMINATION

Abdomen Inspection : flat Palpation : no tenderness Percution : tympani Auscultation : bowel sound (+) normal

CVA region dextra sinistra Inspection : bulging (-) (-) Palpation : pain (-) (-)

ballottement (-) (-) Percussion : pain (-) (-)

Suprapubic region Inspection : bulging (-) Palpation : tenderness (+)

External genitalia region

• Inspection :• urethra bloody discharge (-), circumcised, urethra catheter no.

16F fixed

Rectal toucher

• TSA good, enlargement of prostate, upper boarder of prostate unpalpable, ruberry consistency, flat surface, no tenderness, feces (+), blood (-).

SUPPORTIVE EXAMINATION

Laboratorium findings (07/09/13)

Routine blood

•Hemoglobin: 9,7 gr/dL (N : 14-18g.dL)•Hematocryte : 29 vol% (N : 40-48vol%)•Leucocyte : 9.0/mm3 (N : 5000-10000/mm3)•Thrombocyte : 284 /mm3 (N : 200.000-

500.000/mm3)•LED : 120 mm/hour•Diff. Count : 0/14/0/45/33/8

Clinical Chemistry:

• BSS : 99 mg/dL• Ureum : 39 mg/dL (N : 15-39mg/dL)• Creatinine : 1,04 mg/dL (N : 0,9-1,3mg/dL)• Uric Acid : 8,1 mg/dL (N : < 8,4)• Na+ : 140mmol/l (N : 135-155)• K+ : 4,3mmol/l (N : 3,6-5,5)

Urine analysis

• Epitel cell : Positive (+)• Leucocyte : 20-25/ LPB (N : 0-5 / LPB)• Erytrocyte : 80-100/ LPB (N : 0-1 / LBP)• Silinder : negatif (-)• Kristal : negatif (-)

BNO

Result Multiple semi

radioopaque stones in pelvic cavity (size 1,5-2 cm)

USG

No abnormalities in right and left kidney, no enlargement of kidney, pelvis calices not widening, no stone.

USG

Widening of prostate, 50 x 54mm,

USG

multiple acoustic shadow on vesica urinary, multiple stones (+)

DIFFERENTIAL DIAGNOSIS

Urine Retention ec. Suspect Benign Prostate Hyperplasia + Vesicolithiasis

Urine Retention ec. Suspect Prostate Cancer + Vesicolithiasis

WORKING DIAGNOSIS

Urine Retention ec. Suspect Benign Prostate Hyperplasia And

Vesicolithiasis

TREATMENT

Transurethral Resection of

Prostate (TURP)

Vesicolithotomy

PROGNOSIS

Quo ad vitam : bonamQuo ad functionam : dubia

ad bonam