Morning report

Yanri puji haskoro

Patient P, Male, 78 years old, came to policlinic of urology of AA Hospital with chief complaint

Urine retention since 5 days

before admission.

Present Illness History: Patient came to the policlinic of urology to showed his plain films of chest and USG examination result . 2 days before admission, he came to the policlinic to get some consultation on his illness. He was asked to take an examination of chest radiography and USG.

 3 days before admission, he came to the

emergency unit of AA hospital complaining his inability to urinate for the last 2 days. His bladder was full-filled and felt pain.

Then catheterization performed and his urine

streamed down to the urin bag about 750 mL. No blood and discharge seen. The catheter remains attached for 3 days.

5 days before admission, he was taken by his family to the emergency unit due to unable to urinate at all. His bladder was full-filled and felt pain. Incomplete emptying (+), intermittency (+), not satisfied after urinate (+), terminal dribbling (+), frequency (+), nocturia (+), urgency (-), flank pain (-), fever (), hematuria (-), severe abdomen pain (-), Traumatic history (-), surgery history in the genitourinary system (-).

In the emergency unit, he got urinary catheter. Then his urine immediately flowed through the catheter. The volume was about 500 mL. After 3 hours observed, the catheter was released and he was allowed to go home.

Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating? Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated? Urgency Over the last month, how difficult have you found it to postpone urination? Weak stream Over the past month, how often have you had a weak urinary stream? Straining Over the past month, how often have you had to push or strain to begin urination?

Not at all Less than 1 time in Less 5 than half the About time half the time More than half the Almost time always

Patient Score 2 3 2 2 5 2

2 times

3 times

4 times

Nocturia
Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?

0 1 2 3 4 5

5 times or Patien more t score

1 time

None

 General Condition

Conciousness : Composmentis Blood pressure: 150/90 mmHg Pulse Rate : 86x/minute Respiration Rate : 22x/minute Body temperature: 36,5 C

 Head and Neck Thorac CVA Abdominal Genitalia

Extremity

Rectal toucher

: normally : normally : normally : urologicus status : urologicus status : normally : urologicus status

CVA
mass sycatric ballottement

dextra
+

sinistra
-

Knock pain/tenderness

Mass

Tenderness

Anus was stable Tonus of sfingter ani adequate Smooth mucous Bulbocavernosus reflect (+) Prostat nodul (-) consistency was solid tenderness (-) medial Sulcus is not palpable Upper pole is not palpable Gloves : blood (-), feces (-), mucous (-)

 Suspect Hyperplasia prostat suspect benign with

urine retention with score IPSS 19 (mild).

 Vesicolithyasis

 Consult to internist

Urinalysis
Ureum and Creatinine PSA

BNO-IVP

 WBC : 14.700 /l

HB : 12,2 g/dl
Hct : 39,8 % Plt : 400.000 /l

Ureum : 27,8 mg/dl

CR-S : 0,95 mg/dl Uric : 4,4 mg/dl

 Prostat hypertrophy

Right renal stone

Chest x ray
No cardiomegali

TUR Prostate Ciproflocxacin tab. mg 500 2x1 Mefenamat acid tab. mg 500 if needed

THANK YOU