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CASE REPORT
TOTAL STRICTURE URETRA PARS BULBOSA
Supervisor:
dr. Akhada Maulana Sp.U
By:
Lalu Karisma Aditya
H1A 008 003
IN ORDER TO UNDERGO THE CLINICAL ORIENTATION /
CLERKSHIP AT THE SURGERY FUNCTIONAL MEDICAL STAFF
MEDICAL FACULTY OF MATARAM UNIVERSITY
NTB GENERAL HOSPITAL
2013
HALAMAN PENGESAHAN
Judul : Total Stricture Uretra Parsbulbosa
Nama : Lalu Karisma Aditya
NIM : H1A 008 003
Laporan kasus ini telah diterima sebagai salah satu syarat untuk mengikuti ujian kepaniteraan Klinik
Madya pada Bagian/SMF Bedah Rumah Sakit Umum Provinsi Nusa Tenggara Barat / Fakultas
Kedokteran Universitas Mataram.
Mataram, Oktober 2013
Pembimbing,
dr. Akhada Maulana Sp.U
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CASE REPORT
I. Patient Identity
Name : Mr. MK
Sex : Male
Age : 79 years old
Address : Jonggat, Central Lombok, West Nusa Tenggara
Religion : Muslim
Race : Sasak
Occupation : Farmer
Relationship status : Married
Date of hospital admission : August 17th 2013
Date of examination : August 21st 2013
II. Anamnesis
The chief history : difficult to urinate
Present disease history :
Patient came to General Hospital Of West Nusa Tenggara Province complaining
difficult to urinate since 1 month ago. This complaint worsen since 1 week. Patient often
complains of hard to start urinating, frequent straining, frequent urinary dripping, and felt no
satisfied on urinating. The frequency of urinating is more than 12 times / day, a little bit. In
addition, sometimes patients also complains of pain when urinating, urinary dripping at the
end (+), history of urinary bleeding (+), sandy urine or rock out (-), suprapubic pain (-).
History of fever (-), nausea (-), vomiting (-). Patient drink about 2 L per day.
Defecation was normal, once daily, concistency firm and brown.
Past disease history:
Patient often experiences the same complain for 1 month. Patient had a history of
catheterization 2 months ago post peptic ulcers operation in General Hospital of West Nusa
Tenggara. Patient said that he felt pain and blood came out during catheterization (+). A
history of kidney stones (-), UTI (-), DM (-), HT (-), and Astmas (-).
Family disease history:
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No family member with the same complaint. Hypertension (-), Diabetes Mellitus (-),
Uric acid (-)
Drug allergy: Drug (-), Food Allergy (-)
History of treatment:
Patient was reffered from Praya General Hospital with Urine Retention et causa susp
BPH. In Praya General Hospital, patient had been hospitalized for 7 days and had been
treated with Antibiotic and analgetic.
Private and Social History:
The patient worked as a farmer with 9 wives, 20 children, and 8 grandchildren, and 3
great-grandchildren. Patients often smoked 1 pack / day and regularly consuming 2 cups of
coffee per day. History consume energy drinks (-), patients drank 1,5 L of water / day
III. Physical Examination
General condition : Good
Consciousness/GCS : Compos mentis/E4V5M6
A. Vital Sign
Blood Presure : 150/80 mmHg
Heart rate : 88 bpm
Respiration rate : 20 rpm
Temperature : 36,5oC
B. General Status
Head and neck
o Head : normochepali, deformity (-)
o Eyes : anemis (-/-), icteric (-/-), pupil isocore 3mm/3mm, pupil reflex (+/+)
o Noise : deformity (- )
o Mouth : sianotic (-)
o Neck : enlargement lymph node (-)
Thorax
o Inspection : chest wall shape and size simetric, mass (-), lesion (-), retraction
(-), thoracoabdominal respiration (+).
o Palpation : chest wall movement simetric, tenderness (-), vocal fremitus (+/+)
normal, mass (-), crepitation (-).
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o Percussion: sonor in both lung, percussion pain (-).
o Auscultation :
Pulmo : vesicular in both lung (+/+), rhonki (-/-), wheezing (-/-)
Cor: S1S2 single, regular, murmur (-), gallop(-)
Abdomen
o Inspection : distention (-), mass (-)
o Auscultation : bowel sound (+) normal
o Percussion : timpani in whole region
o Palpation : tenderness (-), H/L/R not palpable, defans muscular (-), mass (-),
ballotement (-)
Upper and Lower extremity:
Warm acral (+/+/+/+), Deformity (-/-/-/-), oedem (-/-/-/-).
C. Urogenitalia Physical Examination
Costo vertebrae angle (CVA) region:
A. Inspection: color same as the surrounding skin, mass (-), inflammation (-), scar
(-), hematome (-), bulging (-/-)
B. Palpation : tenderness (-/-), mass (-), ballottement (-)
C. Percussion : pain (-/-)
Suprapubic region
o Inspection: color same as the surrounding skin, mass (-), inflamation (-), scar
(-), sistostomy (-)
o Palpation : bladder distention (-), mass (-), tenderness (-)
Genitalia externa:
o mass (-)
D. Rectal Touche
o Inspection: color same as the surrounding skin, mass (-), inflammation (-), scar
(-), hematome (-), bulging (-).
o Palpation : TSA is good, rectal mucosal is smooth, palpable prostate is not
enlarge, palpable medial sulcus, palpable pole superior, pain (-), rubbery
consistency.
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E. IPPS: 15 mild
IIV. Summary
Patients came to General Hospital of West Nusa Tenggara complaining difficult to
urinate since 1 month ago. This complaint worsen since 1 week. Patient often complain of
hard to start urinating, frequent straining, frequent urinary dripping, and felt no satisfied on
urinating, frequency of urinating > 12 times / day, a little bit. Patient also complain of pain
when urinating, urinary dripping at the end (+), history of urinary bleeding (+). Patient often
experiences the same complain for 1 month. Patient had a history of catheterization 2 months
ago post peptic ulcers operation in General Hospital of West Nusa Tenggara. Patient said that
he felt pain and blood came out during catheterization (+). Patients drink about 1,5 L/day.
Defecation was normal. On the physical examination, blood pressure 150/80 heart rate 88
bpm, respiration rate 20 rpm, temperature 36,8oC, there were no tenderness on the CVA
region or suprapubic region, and no pain on the percussion.
V. Working diagnosis
Suspect Stricture Ureter
VI. Differential diagnosis
Susp. BPH
VII. Propose Examination
CBC
Uretrography
VIII. Laboratory Examination
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Parameter August 16nd 2013 RANGE
WBC 6,48.103/ul 4-11
RBC 3,91.106 /ul 4,5-5,5
Hb 8,8 g/dl 13-18
HCT 28,4 % 37-50
MCV 72,6 fl 82,0-92,0
MCH 22,5 pg 27,0-31,0
MCHC 31 ,0 g/dl 32,0-37,0
PLT 397.103/ul 150-400
BT 2’50” <6”
CT 4’00” <15”
GDS 103 mg/dl <160
Creatinine 1,0 mg/dl 0,9-1,3
Ureum 32 mg/dl 6-26
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Uretrography result ( August 20nd 2013 )
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Conclusion :
Total Stricture Uretra Pars Bulbossa
VIII. Diagnosis
Total Stricture Uretra
IX. Planning:
Uretrotomi Interna (Sachse)
X. Prognosis:
Quo ad vitam : Dubia ad bonam
Quo ad functionam : Dubia ad bonam
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