Morning Report

Dept. of Surgery
J-23

FAKULTAS KEDOKTERAN UNIVERSITAS MUHAMMADIYAH

MALANG
RUMAH SAKIT MUHAMMADIYAH LAMONGAN

Patient Identity

Name
: Mr. S
Age : 55 y.o
Address
: Lamongan
Occupation : Date of examination: February, 22nd,
2016

Chief complain
Cant urinate

Present History
Patient complaining cant urinate since 13 days ago. Before
that, patient can do urinate but feels hard, patient must
straining, and in the night patient can urinate for about
more than 5 times a night. When patient urinating, it feels
incomplete and the urine was dribbling. Then patient went
to RS Tuban and attatch catheter, and doesnt change till
patient examine now. Bloody urine (-) Come sand like from
urine (-) Nausea vomiting (-) fever (-) The doctor from
Tuban advice this patient to do operate his prostate.

Past History
DM (-) HT (-)
Same complaining before (-)

Social History
Alcohol (-) coffee (-)

Physical Examination
Vital sign:
TD: 140/75 mmHg
N: 72xm
RR: 20x/m
T: 36.7C
SpO2: 100% without O2 support
GCS 456
Primary Survey:
A : Gargling (-) snoring (-) pot. Obstruction (-)
B : Spontan, RR 20x/m, ves|ves, rh -|-, wh -|C : Extremity WRD, CRT <2, N 72x/m, TD 140/75
D: GCS 456

Physical Examination
Secondary Survey:
Head & neck: a-/- i -/- c -/d
Thorax:
Inspection:Sim, retraction
(-|-)
cor: s1 s2 single reg, m
(-), g (-)
pulmo: sonor|sonor, ves|
ve, rh -|-, wh -|Abdomen:
Flat, soefl, tympani,
bowel sound (+) within
normal limit
Extremity:

Urologic status
Flank: NKCVA -/VU: Kesan kosong, massa
(-)
Gen. Ext: MUE: discharge
(-)
skrotum simetris,
massa
(-) testis dbn
RT: TSA (+) mukosa licin
(+) mass (-) ampula
rectii tidak colaps.
Prostat konsistensi padat
kenyal, sulcus mediana
datar, lobus anterior
tidak teraba

Laboratory findings

Hb 14.7
Hct 44.5
Ery 5.11
Leu 8.3
Lymph 24.6
Moo 8.5
Bas 2.1
Eos 9.5
Plt 344
LED 1 :61/LED 2: 73
OT 52/PT 85
BUN 30/SC 1.0
GDA 129
HbsAg (-)

USG upper/lower
Ginjal ka/ki: Ukuran
normal, tak nampak
ektasis dari
pelvicocalics system,
intensitas
echoparenkim normal
VU: Terisi cukup fairan,
tak nampak penebalan
dinding, tak nampak
batu/massa
Prostat: Ukuran
membesar ukuran 40.7
ml, tak nampak
kalsifikasi

Clue and cue

Cant urinate
Frequency
Urgency
Nocturia
Straining
Incomplete urine
Weak stream
IPSS score
NCVA -/RT: Prostat konsistensi padat kenyal, sulcus mediana datar,
lobus anterior tidak teraba
USG upper/lower: Ukuran membesar ukuran 40.7 ml, tak
nampak kalsifikasi

Problem list
Benign prostate hyperplasia

Problem list
BPH gr. II

Therapy

Inf. Asering 1500cc/24j

Inj. Metamizole 3x1 gr
Inj. Ranitidin 2x50 mg
Consult urologist