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  • Identity and Medical History

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    Dyah Paramudita Raharjo
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    Mr. Abdul Hafid, a 46-year-old food seller, presented to the hospital with urinary retention, inability to void, and gangrene on his left foot. He had a history of diabetes for 16 years and urinary retention for 2 months managed with regular catheter changes. Physical examination found a palpable bladder to the umbilicus, bloody urethral discharge, and gangrene on his left foot. Imaging showed a partial rupture of the bulbous urethra and mild hydronephrosis. He was assessed with urinary retention secondary to urethral rupture, decubitus ulcer, uncontrolled diabetes, and gangrene. His treatment plan included trocar cystostomy and further

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    Duty Report 15-06-2017 Rupture Urethra Zdp

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    Mr. Abdul Hafid, a 46-year-old food seller, presented to the hospital with urinary retention, inability to void, and gangrene on his left foot. He had a history of diabetes for 16 years and urinary retention for 2 months managed with regular catheter changes. Physical examination found a palpable bladder to the umbilicus, bloody urethral discharge, and gangrene on his left foot. Imaging showed a partial rupture of the bulbous urethra and mild hydronephrosis. He was assessed with urinary retention secondary to urethral rupture, decubitus ulcer, uncontrolled diabetes, and gangrene. His treatment plan included trocar cystostomy and further

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    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    17 views18 pages

    Identity and Medical History

    Uploaded by

    Dyah Paramudita Raharjo
    Mr. Abdul Hafid, a 46-year-old food seller, presented to the hospital with urinary retention, inability to void, and gangrene on his left foot. He had a history of diabetes for 16 years and urinary retention for 2 months managed with regular catheter changes. Physical examination found a palpable bladder to the umbilicus, bloody urethral discharge, and gangrene on his left foot. Imaging showed a partial rupture of the bulbous urethra and mild hydronephrosis. He was assessed with urinary retention secondary to urethral rupture, decubitus ulcer, uncontrolled diabetes, and gangrene. His treatment plan included trocar cystostomy and further

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 18

    Identity

    Name : Mr. Abdul Hafid


    Sex : Male
    Age : 46 y.o
    Address : Gundul Soket Laok Tragah,
    Bangkalan
    Occupation : Food Seller
    Registration number : 12596359
    Ward : ER

    1
    Anamnesis
    Patient was refered from Bangkalan General Hospital (dr.Anugrah Sp.U)
    with Urinary retention ec Rupture Urethra Iatrogenik + Decubitic
    Ulcer + Gangrene Pedis S + DM type II
    Chief complain : could not void
    • Could not void since 1 day before admision after planned to change
    the catheter by midwife. Bloody discharge (+)  referred to
    hospital.
    • History of urinary retention since 2 months ago  chateterized at
    primary health care, and routinely changed by midwife every 2
    weeks
    • Patient with weakness in lower extremity and ulcus in his buttock
    and gangrene at left foot since 3 months ago.
    • Nausea (-), vomiting (-), fever (-)
    • History of stone expulsion (-),haematuria (-)
    • History of DM (+) since 16 years ago uncontrolled
    • History of family with DM (+), History of operation (-)
    Physical Examination
    General Condition : Fair
    • BP : 104/73 mmHg
    • Pulse : 98 x/min
    • RR : 16 x/min
    • Temp : 36,8 oC rectal

    • H/N : Anemia (+)


    • Thorax : Cor : S1-2 int N, reg, murmur (-)
    Pulmo : ves/ves, rh -/-, wh -/-
    • Abdomen : Flat, soepel, BU + normal,
    • Extremity : CRT < 2 second
    Genitourinary examination
    • Flank mass : -/-
    • Flank pain : -/-
    • CVA knocking pain : -/-
    • Suprapubic : Bladder palpated as high as umbilicus
    • GE : Circumsized (+), testicle +/+ normal,
    Bloody discharge (+)
    • RT : TSA (-), BCR(-) HS: feces (+), Blood (-)
    Clinical Picture
    Clinical Picture
    Clinical Picture
    Clinical Picture
    Laboratory finding
    Laboratorium 10/11/2015
    Hb 8,3 g/dL
    Leukosit 15.970 /uL
    Trombosit 390.000/uL

    SGOT/PT 15/15 U/L


    Albumin 2,61 g/dL
    RBS 210 mg/dL
    BUN/SK 17/0,76 mg/dL

    Na/K/Cl 133,1/4,02/95,9
    mmol/L
    PPT/APTT 11,9 / 33

    HbsAg Non reaktif


    KUB (10/11/15)

    No Radioopaque shadow
    Urethrography (14/06/2017)

    Partial Rupture Urethra


    pars Bulbosa grd III
    Urethrography (14/06/2017)

    Partial Rupture Urethra


    pars Bulbosa grd III
    USG (14/06/17)

    Mild HN D/S
    Bladder: debris (+), mass(-),
    USG (14/06/17)

    Mild HN D/S
    Bladder: mass(-), debris (+)
    Interdepartemen consultation
    • Internal Medicine :DM type 2 uncontrolled + ulcus
    decubitus + anemia + urinary retention + hypoalbumin
    Plan to take over patient, check GDP/GD2PP/HbA1c
    • Plastic Surgery : Ulcus Decubitus grd III
    Wound care with Autolytic Debridemant
    • Neurology : Poli Neuropathy Perifer Diabetes Mielitus
    (PNPDM)
    • BTKV: Gangrene Pedis S
    Wound care
    Assessment
    • Working dx : Urinary retention
    • Primary dx : Partial Rupture Urethra pars
    Bulbosa grd III Iatrogenic + susp
    neurogenic bladder
    • Secondary dx : - Gangrene pedis S
    - Decubitus Ulcer grd III
    - DM type II Uncontrolled
    • Complicating dx: - Anemia
    - Hipoalbumin
    Planning
    Tx :
    Pro trocart cystostomi

    • Report to dr. Lukman H Sp.U


    ACC for Trochart Cystostomi

    Trochart Cystotomy:
    Initial Urine ± 800ml yellow cloudy
    RT: TSA(-), BCR(-), Prostat dbn, massa (-)
    HS: Feces (+), darah (-)

    Next plan: BVCUG 2 weeks after trochart cystostomy


    Thank You

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