morning report bph
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8/3/2019 Morning Report BPH
1/20
Morning report
Yanri puji haskoro
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8/3/2019 Morning Report BPH
2/20
Patient P, Male, 78 years old, came topoliclinic of urology of AA Hospital with chief
complaint
Urine retention since 5 daysbefore admission.
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8/3/2019 Morning Report BPH
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Present Illness History:
Patient came to the policlinic of urologyto showed his plain films of chest andUSG examination result .
2 days before admission, he came to thepoliclinic to get some consultation on his
illness. He was asked to take anexamination of chest radiography andUSG.
.
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8/3/2019 Morning Report BPH
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3 days before admission, he came to theemergency unit of AA hospital complaining his
inability to urinate for the last 2 days. Hisbladder was full-filled and felt pain.
Then catheterization performed and his urinestreamed down to the urin bag about 750 mL.No blood and discharge seen.
The catheter remains attached for 3 days.
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8/3/2019 Morning Report BPH
5/20
5 days before admission, he was taken by hisfamily to the emergency unit due to unable to
urinate at all. His bladder was full-filled andfelt pain. Incomplete emptying (+),intermittency (+), not satisfied after urinate(+), terminal dribbling (+), frequency (+),
nocturia (+), urgency (-), flank pain (-), fever (-), hematuria (-), severe abdomen pain (-),Traumatic history (-), surgery history in thegenitourinary system (-).
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8/3/2019 Morning Report BPH
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In the emergency unit, he got urinary
catheter. Then his urine immediatelyflowed through the catheter. Thevolume was about 500 mL.
After 3 hours observed, the catheter wasreleased and he was allowed to go home.
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8/3/2019 Morning Report BPH
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Notat
all
Less
than1
timein
5Less
than
halfthe
time
About
halfthe
time
More
than
halfthe
time
Almost
always
Patient
Score
Incomplete emptying
Over the past month, how often have you had
a sensation of not emptying your bladdercompletely after you finish urinating?
0 1 2 3 4 5
2
Frequency
Over the past month, how often have you had
to urinate again less than two hours after you
finished urinating?
0 1 2 3 4 53
Intermittency
Over the past month, how often have you
found you stopped and started again several
times when you urinated?
0 1 2 3 4 52
Urgency
Over the last month, how difficult have you
found it to postpone urination?
0 1 2 3 4 5 2
Weak stream
Over the past month, how often have you had
a weak urinary stream?
0 1 2 3 4 5 5
Straining
Over the past month, how often have you hadto push or strain to begin urination? 0 1 2 3 4 5 2
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8/3/2019 Morning Report BPH
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None
1time
2times
3times
4times
5times
or
more
Patien
tscore
NocturiaOver the past month, many times didyou 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 3
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8/3/2019 Morning Report BPH
9/20
General Condition
Conciousness : Composmentis
Blood pressure: 150/90 mmHg
Pulse Rate : 86x/minuteRespiration Rate : 22x/minute
Body temperature: 36,5 C
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8/3/2019 Morning Report BPH
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Head and Neck : normally
Thorac : normally
Abdominal : normally
CVA : urologicus status Genitalia : urologicus status
Extremity : normally
Rectal toucher : urologicus status
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8/3/2019 Morning Report BPH
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CVA dextra sinistra
mass - -
sycatric - -
ballottement + -
Knock
pain/tenderness
+ -
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8/3/2019 Morning Report BPH
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Mass -
Tenderness -
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8/3/2019 Morning Report BPH
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8/3/2019 Morning Report BPH
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Suspect Hyperplasia prostat suspect benign withurine retention with score IPSS 19 (mild).
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8/3/2019 Morning Report BPH
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Vesicolithyasis
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8/3/2019 Morning Report BPH
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Consult to internist
Urinalysis
Ureum and Creatinine
PSA BNO-IVP
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8/3/2019 Morning Report BPH
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WBC : 14.700 /l
HB : 12,2 g/dl
Hct : 39,8 %
Plt : 400.000 /l Ureum : 27,8 mg/dl
CR-S : 0,95 mg/dl
Uric : 4,4 mg/dl
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8/3/2019 Morning Report BPH
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Prostat hypertrophy
Right renal stone
Chest x rayNo cardiomegali
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8/3/2019 Morning Report BPH
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TUR Prostate
Ciproflocxacin tab. mg 500 2x1
Mefenamat acid tab. mg 500 if needed
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8/3/2019 Morning Report BPH
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THANK YOU
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