Case Report

1. Patient identityName : Mr. M

Age : 31 years old

Sex : Male

Occupation : Labour

Address : Kopang, Central Lombok

MR : 243791

Date of hospital admission : January 16th 2013

Date of examination : January 18th 2013

II. Anamnesis

Chief Complaint:

Difficulties during of micturition

Present Ilness :

The patient had been confessing difficulty during of micturition since two

years ago. It had been starting after got an accident, exatly a car accident

were took place in Malaysia. The pain during micturition (+) in almost of

it, the urinate had been done seven times a day. The pain in his male organ

(+) then discomfort during sexual activity (+). The confessed of weak of

urine stream (+). He confessed having a straining whenever starting a

voiding. Constipation during micturition (+). The patient also confessed of

nokturia (-), bloody urine (-) and stony urinate (-). Confessed of right flank

pain (-), suprapubic pain (+), mass (-), fever (-). Whenever the patient

urinate in almostly he confessed discharge (+) with the mainly colour is

yellow. History of used catheter mostly after sitostomi, but rightnow had

not. The appetite was good, weight loss (-). No diarrhea. History of unsafe

sexual activity does not clear.

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Post Illness History:

Patient said that he got an accident when he had working in Malaysia two

years ago. Got a therapy and hospitalized for few days. He also got a

therapy in Jakarta for two months. He got a sistotomi and off of it one year

ago.The history of stone urinate (+) and bloody urine (+). History of 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:

Patient sometimes go to Public Heatlty Care Center for his but he forget

the drugs which were consumt.

Allergic History:

No history of allergy due to food or medication.

History of Sosial Life

Patient is a labour. Due to the anamnesis he is not a moderate smoker,

sometimes drink of 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 : 130/80 mmHg

Pulse : 72 bpm

Respiration : 20 bpm

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Temperature : 36,8 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, rregular, 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

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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 has no used catheter , preputium had been removed

(+).

Upper and lower extremity axial

Edema -/-, deformity-/-, inguinal limph node enlargement -/-

V. Summary

Male, 31 years old. Confessed pain during micturition (+), pain in his male

organ (+). Weak of urine stream (+), straining whenever starting a voiding

(+). Constipation during micturition (+). Nokturia (-), bloody urine (-) and

stony urinate (-). Confessed of right flank pain (-), suprapubic pain (+),

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mass (-), fever (-).Whenever the patient urinate in almostly he confessed

discharge (+) with the mainly colour is yellow. The appetite was good,

weight loss (-) diarrhea (-), used catheter (-). History of unsafe sexual

activity does not clear. 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 Susp. Urethral Stricture

VII. Diferensial Diagnosis

- Urethritis

VIII. Purposed Examination

Laboratorium : Complete blood test, uroflometri, sistoscopy,

urinalisis test, kultur pus.

Radiologi : Urethrografi

Laboratorium findings

CBC (December 27th 2012) Urinalisis

WBC : 13,75 K/uL

Hb : 14,2 g/dL

HCT : 41,49 %

PLT : 460 K/uL

SGOT/SGPT : 18 U/L, 27 U/L

SC : 0,6 mg%

Ureum : 16 mg%

Urid Acid : 6,9 mg%

Leukosit : +3

Protein : +1

Blood : +3

Blood glucose : 107 mg%

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Urethrografi result :

Interpretations:

Subtotal urethral stricture pars bulbosa

Sinus (+) 3 cm x 2 cm to right lateral

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IX . Definitive Diagnosis

Subtotal urethral stricture pars bulbosa

X. Planning

Pro Antibiotic

Pro urethrotomy

XI. Prognosis

Dubia ad bonam

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CASE REPORT

SUBTOTAL URETHRAL STRICTURE PARS BULBOSA

By

Name : Asrarudin

Nim : H1A005005

Supervisor

dr. Akhada Maulana, Sp.U

CONDUCTING FOR MIDDLE CLINICAL EDUCATION IN SURGERY

DEPARTEMENT OF MATARAM REFERRAL HOSPITAL/MEDICAL

FACULTY OF MATARAM UNIVERSITY

2013

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