Case Report Benign Prostat Hiperplasia

ASRARUDIN H1A005005

Patient identity
Name

: Mr. MS Age : 60 years old Sex : Male Occupation : Civil Servant Address : Mataram MR : 069748 Date of hospital admission : December 28th 2012 Date of examination : January 2nd 2013

II. Anamnesis
Chief Complaint: The pain during of micturition Present Ilness : - Consultating from Cardiologist : Chronic Heart Disease OMI inferior. - Difficulty starting urination 1 month ago. Severe in 4 days lately. - Pain at the during of micturition (+) - Weak urine stream (+), dribbling after urination (+). Straining whenever starting a voiding. - Urge to urinate (+), nokturia (+) 10x/ day. - Bloody urine (+), stony urinate (+) - Right flank pain (-), suprapubic pain (-), mass (-), nausea (-), vomiting (-).

Cont

- Defecation (-) today, flatus (+). - Appetite was good, weight loss (-). - Had been weakness for the left hand and feet for four days

in lately.

Post Illness History: Stone urinate (+), bloody urine (+). Heart disease (+), hypertension (-), DM (-), asthma (-). Family Illness History: No family member with the same complaint. History of bloody urine (-), stony urine (-), hypertension (-), heart disease (-), DM (-), asthma (-). Medication History: Have been consumting the medication relate for the heart disease hospitalized (+) 1 week in last 2 month ago. He forget the drugs. Allergic History: No history of allergy due to food or medication. History of Social Life A civil servant, exatly in foreshty. Active smoker (+), enjoying coffee and lack of caring for the healty life.

III. Physical Examination

a. Status Generalis:

General Condition: Moderate Awareness/GCS : Compos Mentis/ E4V5M4 Blood Preassure : 100/60 mmHg Pulse : 87 bpm Respiration : 20 bpm Temperature : 36,5 C

b. General Examination
Head And Neck

Head: Normochepali, symmetric, deformity (-) Eye: Pale Conjunctiva(-), Icteric Sclera (-), Pupil Isocore, Reflex of pupil (+/+), diameter 3/3 mm Ear, Nose, throat : normal Neck: Limph node enlargement (-)

Thorax-Cardiovaskular Inspection : mass (-), lesion (-), chest wall movement simetric, retraction (-) Palpation : tenderness (-), vocal fremitus (+) normal, mass (-) Percussion: sonor in both lung, percussion pain (-) Auscultation : cor: S1S2 single, irregular, murmur (-), gallop(-) Pulmo : vesicular in both lung (+/+), wheezing (-/-), rhonki (-/-)

Abdomen Inspection : normal skin color, distention (-), mass (-), scar (-), sicatriks (-), darm contour (-), darm steifung (-) Auscultation : bowel sound (+) normal, borborygmus (-), metallic sound (-) Palpation : tenderness (-), defans muscular (-), ballotment (-), mass (-) Percussion : tymphany (+) all regions IV. Local Status Uro-genital Flank regions : Bulging (-/-), inflammation sign (-/-), tenderness (-/-), mass (-/-), ballottement (-/-), CVA tenderness (-/-)

Suprapubis regions : Inspection: normal skin color, mass (-), hyperemic (-), scar (-), sistostomy (-) Palpation : bladder distention (-), mass (-), tenderness (-) DRE Normotonic sphincter ani, mucosal is smooth, prostate firm, nodule (-), pressure pain (-), sulcus mediana unpalpable (+) dome shape, the lateral sulci is narrow, superior pole unpalpable (+), gloves : mucus (-), blood (-), fesses (-). External genital Scrotum: skin color normal, inflammatory sign (-), mass (-), tenderness (-) Penis : Patient used catheter with urin output 300 cc, varicochele (), preputium had been removed (+).

Upper and lower extremity axial

Edema -/-, deformity-/-, inguinal limph node enlargement -/Muscle strength :

5 5

3 3

V. Summary
Male, 60 years old, with chronic heart disease OMI inferior was confessed difficulty starting urination since one month ago and severe in the last four day. Pain at the during of micturition (+), weak urine stream (+), dribbling after urination (+), nokturia (+), bloody urine (+), stony urinate (+), right flank pain (-), suprapubic pain (-), mass (-), nausea (-), vomiting (-), weight loss (-). Digital rectal examination: normotonic sphincter ani, mucosal is smooth, prostate firm, nodule (-), pressure pain (-), sulcus mediana unpalpable (+) dome shape, the lateral sulci is narrow, superior pole unpalpable (+), gloves : mucus (+), blood (-), fesses (-).

VI. Working diagnosis Urine Retension e.c Benign Prostate Hyperplasia VII. Diferensial Diagnosis Susp. Vesica Urinary Carsinoma VIII. Purposed Examination Laboratorium : Complete blood test, PSA and complete urine test. Radiologi : IVP.

Laboratorium findings CBC (December 27th 2012) WBC : 6 K/uL Hb : 21,1 g/dL HCT : 64,9 % PLT : 178 K/uL Blood glucose : 113 mg% SGOT/SGPT : 31 U/L, 40 U/L SC : 1,1 mg% Ureum : 55 mg% Urine electrolit Na+ : 126 Ka+ : 4-5 Cl - : 107

tPSA : 0,62 (Normal)

 Abdominal USG result :

Interpretations: Right kidney : hidronefrosis 0,8 cm Left kidney, hepar, bladder, : Normal Prostate : size 4,3x 4,3 volume 41 cc

 ECG :

Interpretation: Sinus beat in 85x/minutes, OMI inferior and anteroseptal + ischemic anterolateral

IX . Definitive Diagnosis Benign Prostate Hyperplasia + Chronic Heart Disease OMI Inferior + Hemiparese Sinistra

X. Planning Medikamentosa : IVFD RL 20 tpm Fargoxin 1x1 tab Simvastatin 20 gram tab Aspilet 80 gram Furesemid tab Neulin 500 / 12 hour Avodat 1x1 tab Harnal 1x0,9 tab

Operatif : Pro TURP Biopsy

XI. Prognosis Dubia