Morning report BPH

IDENTITY:
Patient H, male, 84 years old, came to the AA hospital on January 15rd 2014

No urine output in catheter since 1 day before admission AA Hospital

PRESENT ILLNESS HISTORY

Since 1 day before admission the patient complained no urine output in catheter and suffered from lower abdominal pain. Patient was taken to Dumai hospital, urine is removed by aspirated in the lower abdomen, according to the family the amount of urine output was about 500 mL. And then he was taken to the emergency unit AAs hospital and he was applied catheter, according to his family it was number 16 and the urine volume was about 500 mL.

Since 1 month before admission the patient began using a catheter, because the patient ever complained of could not voiding spontaneously and sufferd from lower abdominal pain for 1 day. He was taken to dumai hospital and he was applied catheter number 16 and the urine output volume was about 500mL. And then he was taken to AA hospital, patients had USG examination and diagnosed with an enlarged prostate, surgery is recommended by doctors but patients refused.

Before that complaint, he had never gotten any trauma, there is no complain about the benumbed feet or hand, no diabetes melitus history, no history of surgery.

since 4 months, he had difficulty in starting urination, Forced to urinate, decreased force of his urinary stream, stopped and started again several times when urinate, sensation of incomplete bladder emptying, having to urinate again soon after finishing, almost always difficult to postpone urination, he also complained that he had to getting up at night to urinate frequently (5 times/day). He had never complained any pain at the start, during or the end of urinate, no blood or stone in the urine, there was no split stream of

PAST ILLNESS HISTORY

hypertension (-) Spontaneous urinary passing stone (-)

Family illness history

Nothing is important and has no relation with patients condition

Incomplete emptying Over the past month, how often have you had a sensation of not emptying your bladder completely after you finish urinating? Frequency Over the past month, how often have you had to urinate again less than two hours after you finished urinating? Intermittency Over the past month, how often have you found you stopped and started again several times when you urinated? Urgency Over the last month, how difficult have you found it to postpone urination? Weak stream Over the past month, how often have you had a weak urinary stream? Straining Over the past month, how often have you had to push or strain to begin urination?

Not at all Less than 1 time in Less 5 than half the About time half the time More than the half Almost time always

Patient Score 5 5 3 3 4 4

2 times

3 times

4 times

Nocturia
Over the past month, many times did you most typically get up to urinate from the time you went to bed until the time you got up in the morning?

0 1 2 3 4 5

TOTAL SCORE : 25 (SEVERE)

5 times or Patien more t score

1 time

None

PHYSICAL EXAMINATION
Generalized condition : mild illness Conciousness : composmentis Vital sign : BP : 130/90mmHg RR : 24 x/minutes P : 68 x/minutes T : 36,0 C

PHYSICAL EXAM

Head and Neck : normal Chest : normal Abdomen : Localized Extremity : normal Limph node : normal Genitourinary : Localized Digital Rectal Examination : Localized

LOCALIZED STATE
Costovertebrae Angel CVA Inflammatory sign Scar Tenderness Knock Pain ballotemen Dextra Sinistra -

LOCALIZED STATE
Suprapubic I : Simetris, no distanded, no scar A : bowel sounds (+) P : no palpable mass/lump, tenderness (-) P : Tympani

LOCALIZED STATE
Genitalia externa OUE I : no lesions, edema, rashes or nodule, circumcised, the urethral meatus is centrally on the glans, no discharge, catheter applied no. 16 F P : no tenderness Genitalia externa scrotum I: no inflammatory sign (-) P: Testes freely movable feel oval, firm and rubbery, and smooth surface and equal bilaterally.

LOCALIZED STATE
Regio anorectal I : lump (-), ulcers(-), inflammation (-), rashes (-), excoriation (-), fistula (-), P: no palpable mass Digital Rectal Examination Sphincter tone is normal, Rectal mucosa: smooth Tenderness (-) prostate enlarge , consitency rubbery , no nodul or induration, smooth surface, no palpable medial sulcus and upper border of the prostat Handscoon: feses (-), no blood, no mucuse,

WORKING DIAGNOSIS Urinary retention et causa Bening Prostatic Hyperplasia

DIFFERENTIAL DIAGNOSIS
Posterior urethral stone Malignancy prostate enlargement

FURTHER EXAMINATION

Laboratory test Blood routin examination Blood chemistry examination Urinalysis

2

USG to examine of the size of the prostat, and to see the surface if are there any nodules

LABORATORY FINDINGS

Hb White blood cel Trombosit haematocryte Glu Creatinin- serum Ureum

: 13,5gr% : 10.100/ mm3 : 210.000 / mm3 : 41 % : 125 mg% : 1,26 mg% : 30,0 mg%

EXAMINATION FINDINGS

USG Prostat hiperplasia, diameter : 3,58x4,12 mm2 , smoot surface, no nodules

2

FINAL DIAGNOSIS

Benign prostate hyperplasia with retention urine

MANAGEMENT Surgical therapy Transurethral resection of the prostate (TURP)