CASE REPORT SUSPECT BLADDER TUMOR

By: Dyah Mayang Ramadhani H1A 007 015

Supe !i"# : d $ A%hada Mau&ana' Sp$U

() ORDER TO U)DER*O THE CL()(CAL OR(E)TAT(O) + CLER,SH(P AT THE SUR*ER- .U)CT(O)AL MED(CAL STA.. MED(CAL .ACULT- O. MATARAM U)(/ERS(T)TB *E)ERAL HOSP(TAL

0011 CASE REPORT ($ Pa2ien2 (den2i2iy Name Age Sex Religion Occupation Address Relations!ip status Num"er o# medical record 'ate o# !ospital admission 'ate o# examination (($ Anamne"i" Main 3#mp&ain2 : di44i3u&2y 2# u ina2e P e"en2 di"ea"e hi"2# y : *atient complained a"out !is di##iculty to urinate since % +eeks ago. *atient said t!e complaint "een +orsening #or t!e past ( +eek and !e !ad #e,er as +ell. 'ripping urination -./ !e !ad to strain to urinate and manipulate !is penis in order to get proper urination. Micturition pain -./ !istory o# "loody urination -./ #rom t!e start until t!e end o# urination stone urination --/ "ut patient said t!at !e !ad sandy urination % +eeks ago. *atient said t!at !e al+ays #eels satis#ied a#ter urination. Suprapu"ic pain -./ nausea -./ ,omiting --/ di00y -./. *atient drink a"out ) 1 per day. 'e#ecation +as normal once daily concistency #irm and "ro+n. Pa"2 di"ea"e hi"2# y : 2!e !istory o# stone urination --/ and "lood urination --/. 2!e !istory o# urinary tract in#ection -./ % mont!s ago -at 3e"ruary )0(%/. 'ia"etes mellitus --/ ast!ma --/. 2!e !istory o# appendectomy % years ago. .ami&y di"ea"e hi"2# y : No #amily mem"er +it! t!e same complaint. Ast!ma --/ art!ritis --/ D ug a&&e gy : --/
2

: Mr. K : 50 years old : Man : Moslem :: Karang Kelok Selaparang Mataram : Married : 50$0%& : () Mei )0(% : ($ Mei )0(%

Hi"2# y #4 2 ea2men2 : --/ ((($ Phy"i3a& E5amina2i#n 4eneral condition A. 9ital Sign :lood pressure <eart rate Respiration rate 2emperature : ((06;0 mm<g : &8 "pm : )0 tpm : %$ 8o5 : Moderate 5onsciousness645S : compos mentis67895M$

:. 4eneral Status <ead and neck o <ead : normoc!epali de#ormity --/ o 7yes : anemic --6-/ icteric --6-/ pupil re#lex -.6./ isocore

o Noise : de#ormity --/ o Mout! : cyanotic --/ o Neck : enlargement o# lymp!node --/ 2!orax-5ardio,ascular o =nspection : mass --/ lesion --/ mo,ement o# c!est +all simetric retraction --/ o *alpation : mo,ement o# c!est +all simetric tenderness --/ ,ocal #remitus -./ normal mass --/ o *ercussion: sonor in "ot! lung percussion pain --/ o Auscultation : *ulmo : ,esicular in "ot! lung -.6./ r!onc!i --6-/ +!ee0ing --6-/ 5or: S(S) single regular murmur --/ gallop--/ A"domen o =nspection : distention --/ mass --/ o Auscultation : "o+el sound -./ normal
3

o *ercussion : timpani in +!ole region o *alpation : tenderness --/ <616R unpalpa"le de#ans muscular --/ mass --/ "allotement --/ >pper and 1o+er extremity: 'e#ormity --/ edema --/. 5$ >rogenitalia p!ysical examination 5osto ,erte"rae angle -59A/ region: o =nspection: color same as t!e surrounding skin mass --/ in#lammation --/ scar --/ !ematome --/ "ulging --6-/ o *alpation : tenderness --6-/ mass --/ "allottement --/ o *ercussion : pain --6-/ Suprapu"ic region o =nspection: color same as t!e surrounding skin mass --/ in#lammation --/ scar --/ sistostomy --/ o *alpation : "ladder distention --/ mass --/ tenderness -./ 4enitalia externa: o Scrotum : enlargement --/ mass --/ o *enis : circumsicated scar --/ uret!ral disc!arge --/ Rectal touc!er examination : *erianal : +ound --/ mass --/. 2SA : ade?uate rectal mucosa sur#ace +as smoot! ampula recti +as not colaps mass unpalpa"le. *rostate : palpa"le #lattening o# sulcus --/ pole superior unpalpa"le nodul --/ consistency +as #irm. No "lood and #eses in !andsc!ound.

(/$ Summa y

*atient complained a"out !is di##iculty to urinate since % +eeks ago. 2!e complaint "een +orsening #or t!e past ( +eek. 3e,er -./. 'ripping urination -./ !e !ad to strain to urinate and manipulate !is penis in order to get proper urination. Micturition pain -./ !istory o# "loody urination -./ #rom t!e start until t!e end o# urination stone urination --/ sandy urination -./ % +eeks ago. *atient said t!at !e al+ays #eels satis#ied a#ter urination. Suprapu"ic pain -./ nausea -./ ,omiting --/ di00y -./.

=n t!e p!ysical examination +as #ound suprapu"ic tenderness -./ and rectal touc!er examination +ere gi,ing results no +ound and mass in perianal @ 2SA ade?uate rectal mucosa sur#ace +as smoot! ampula recti +as not colaps mass unpalpa"le @ prostate : palpa"le #lattening o# sulcus --/ pole superior unpalpa"le nodul --/ consistency +as #irm @ no "lood and #eses in !andsc!ound.

/$ 6# %ing diagn#"i" Suspect "ladder tumor /($ Di44e en2ia& diagn#"i" 5!ronic cystitis :enign prostate !yperplasia

/(($ P&an E5amina2i#n Routine "lood examination R32 132 K>: A"dominal >S4

/((($ La7# a2# y E5amina2i#n -Aune (8t! )0(%/ <" : (8 % g6dl

5

R"c <ct

: 5 )0.(0$ 6ul : 8% 8 B

M59 : &% 5 #l M5< : ); 5 pg M5<5: %) C g6dl D"c *lt 4'S : (( $;.(0%6ul : )$$.(0%6ul : (0C mg6dl

5reatinin : ( ( mg6dl >reum : %& mg6dl S4O2 : )8 mg6dl S4*2 : %0 mg6dl 2!orax roentgen

2!ere +as no a"normalities. >S4

2!ere +as no a"normalities.

2!ere +as no a"normalities.

2!ickening o# "ladderEs +all.