Identity (3)

Name : Mr. Mat Ikhsan

Sex : Male
Age : 63 y.o
Address : Surabaya
Registration number : 12456598

1
 Anamnesis
• Chief complain : could not void
• Patient could not void since 15 hours before admitted to
hospital. Patient complained of low flow of micturition since
a month ago. And getting smaller till could not void
• Patient complain flank pain S since 1 month ago
• Nausea (-), vomiting (-), fever (-)
• History of stone expulsion (-)
• History of haematuria (-)
• History of genital infection (-)
• Performed ESWL 1x 2006 at RS William Both
• Performed dorsal meatotomy 4 months ago at RSDS, e.c
anterior urethral stones
 Physical Examination
General Condition : Fair
• BP : 120/80 mmHg
• Pulse : 84 x/min
• RR : 18 x/min
• Temp : 36,6 oC axiler
• H/N : Anemia -
• Thorax : Cor : S1-2 int N, reg, murmur (-)
Pulmo : ves/ves, rh -/-, wh -/-
• Abdomen : Flat, soepel, BU + normal,
• Extremity : CRT < 2 second
Genitourinary examination
• Flank mass -/-
• CVA knocking pain : +/-
• Suprapubic :
Bladder palpated 2 fingers above suprapubic
• GE : Circumsized (+), testicle +/+ normal, MUE
stenotic (+)
Clinical Picture
Laboratory finding
Laboratorium 10/11/2015
Hb 14.7 g/dL
Leukosit 6610/uL
Trombosit 279.000/uL

SGOT/PT 24/16 U/L

Albumin 4.09 g/dL
RBS 138 mg/dL
BUN/SK 13/1.04 mg/dL

Na/K/Cl 148/3.8/111 mmol/L

PPT/APTT 11,3(11.9)/27.2(28,7)

HbsAg -
Thorax AP (10/11/15)

Cor n Pulmo wnl

 KUB (10/11/15)

Radiopaque shadow along at PVL 1-2 S,

Plain pelvic (10/11/15)

No Radioopaque shadow
 Uretrography (10/11/15)

Urethral stricture multiple pars pendulare

 USG (10/11/15)

Multiple Renal Stone S 2.45 x 2.0 cm

Local ectasis ren S at lower pole
USG (10/11/15)

Ren D wnl
USG (10/11/15)

VU full filled of urine

 Interdepartemen consultation

• Cardiology : CRI class II

• Anesthesiology : PS ASA II
 Assessment
• Working dx : Urinary retention
• Primary dx : Meatal stenotic + panurethral
stricture
• Secondary dx : Multiple Renal Stone S,
Complicating dx: -
 Planning
Tx :
 Pro trocart cystostomi