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Morning report
June 9, 2012
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Patient N, male, 49 years old, came to theEmergency Unit of Arifin Ahmad General
Hospital on June 7, 2012
Couldnt urinate since a day before admitted
to the hospital.
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Since 1 day before came to hospital,
patient couldnt urinate, Patient felt
pain on lower abdominal, looked
bigger, strain palpable.
Patient admitted to Duris hospital and
he was applied catheter urin, but it
didnt work. The catheter couldntenter the urethra. blood in orifice of
penis (-).
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1 week before admitted to AAs
general hospital, patient complained
of difficulty in passing urin. Pain
during urination (+), diffuculty startingurination (+), dribbling (+), starting
and stopping often (-), felt
unsatisfied. Waking to urinate duringnight(-), frequency urination was 5
times a day, split urination stream (+),
weak and small.
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Patient then admitted to Emergency
Unit of AAs General Hospital. The
catheter also couldnt enter the
urethra. Then he was applied
cystostomi suprapubic. Initial of urine
output was about 2000 mL with
yellow color, blood in urin(-)
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Bloody urine (-), no stones and sand
came out from urethra
Felt pain at flank (-), no referred pain.
Painful and discomfort at lower
abdominal area (+), sometimes
referred to penis. Fever (-), vomitus (-
)
3 years before admission to hospital
there was stone comes out from
uretra, small, the size about a grain
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No history of genitourinary trauma
No history of Diabetic disease
Gouty artritis (+)
Hypertension (+)
Post Hernia surgery 1 years ago
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Alcoholic (+)
Not sufficient of drink (+)
Consumed of giblets and bean
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Generalized condition : mild illness
Conciousness : composmentisVital sign :
Blood Pressure : 160/100mmHgRespiration Rate : 20 x/minutes
Pulse : 84 x/minutesTemperature : 36,5 C
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Head and Neck : Conjuntiva anemic (-/-)
Sclera icteric (-/-)
Chest : Normal
Abdomen : Normal
Extremity : Tophi at dorsal pedis(+), Warm
Capillary Refilling Time
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CVA Right Left
Inflammatory sign - -
Scar - -
Ballottement - -
Tenderness - -
Knock pain - -
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Suprapubic
Inspection : inflamation sign (-), cystostomy
suprapupic (+) applied with IV Catheter,volume of urine bag was
100 ml/3hours with yellow color,bloody urin (-)
Palpation : no palpable mass, tenderness(+)
External GenitaliaPenis : Inflamation sign (-), no
discharge, no masspalpable
Scrotum : Inflammation sign (-), testiss mmetric +/+ rubber
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Digital Rectal Examination
Inspection : Anal and perineum normal
Palpation :
- Sphincter ani tone was normal
- Rectal mucosa was smooth
- Tenderness (-)
- Prostate : rubbery consitency, flat surface,
no nodul, interlobe sulcus not palpable,upper pool not palpable
- Gloves : faeces (-), mucous (-), blood(-)
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Urinary retention due to suspect Urethral
stricture + Bladder stone
Urinary retention due to suspect BenignProstatic Hyperplasia
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UrinalysisBlood Routine examination
Blood Chemical examination
BNOUSG of kidney, Ureter, Bladder
Urethrogram bipolar
TRUS
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Hb : 11,5 gr%White blood cel : 12.500/ L
Trombosit : 234.000 /L
Haematocryte : 33,6 %
Glu : 89 mg/dl
Creatinin- serum : 6,2 mg/dl
Ureum : 128,4mg/dl
URIC : 17,2 mg/dl
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IVFD RL 20 gtt/ minute
Ceftriaxone 2 x 1 gr
Ketorolac 2x1 amp (IV)
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