Professional Documents
Culture Documents
1. Patient identity
Name : Mr. MS
Age : 60 years old
Sex : Male
Occupation : Civil Servant
Address : Bima
MR : 069748
Date of hospital admission : December 28th 2012
Date of examination : January 2nd 2013
II. Anamnesis
Chief Complaint:
Present Ilness :
Patient said that the history of stone urinate (+) and bloody urine (+).
History of heart disease (+), hypertension (-), DM (-), asthma (-).
No family member with the same complaint. History of bloody urine (-),
stony urine (-), hypertension (-), heart disease (-), DM (-), asthma (-).
Medication History:
Patient was consumting the medication relate for the heart disease and
have been ever taking care for the illness and hospitalized for one week in
last two month ago. He forget the drugs who were consumt.
Allergic History:
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
Uro-genital
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 (+).
Muscle strength :
5 3
5 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 (-).
Laboratorium findings
CBC (December 27th 2012) Urine electrolit
WBC : 6 K/uL Na+ : 126
Hb : 21,1 g/dL Ka+ : 4-5
HCT : 64,9 % Cl - : 107
SC : 1,1 mg%
Ureum : 55 mg%
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:
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
CASE REPORT
By
Name : Asrarudin
Nim : H1A005005
Supervisor
2013