ASRARUDINH1A005005

Case ReportSubtotal urethral stricture pars

bulbosa

Patient identity

Name : Mr. MAge : 31 years oldSex : MaleOccupation : LabourAddress : Kopang, Central LombokMR : 243791Date of hospital admission : January 16th 2013Date of examination : January 18th 2013

II. Anamnesis

Chief Complaint: Difficulties during of micturition

Present Ilness :- Difficulty during of micturition (+), since 2 years ago- Got an accident (+)- Pain during micturition (+), urinate 7 times a day.- Few days ago pain in male organ (+), disconform during sexual

activity (+)- Pain at the during of micturition (+)- Constipation during micturition (+)- Weak urine stream (+)- Nokturia (-) , bloody urine (-), stony urinate (-) - Right flank pain (-), suprapubic pain (-), mass (-), nausea (-),

vomiting (-), fever (-), catherer (-)

Con’t

- Appetite was good, weight loss (-). - Discharge (+) with the mainly colour is yellow. - Diarrhea (-), history of unsafe sexual activity does

not clear.

Post Illness History:Accident/trauma (+), stone urinate (-), bloody urine (-). 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 Social 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 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

IV. Local StatusUro-genitalFlank 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 (+), 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 diagnosisUrine 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 findingsCBC (December 27th 2012) WBC : 13,75 K/uL Hb : 14,2 g/dL HCT : 41,49 % PLT : 460 K/uL Blood glucose : 107 mg% SGOT/SGPT : 18 U/L, 27 U/L SC : 0,6 mg% Ureum : 16 mg% Urid acid : 6,9 mg%

Urinalisis : Leukosit : +3 Protein : +1 Blood : +3  

Urethrografi result :

Interpretations: Subtotal urethral stricture pars bulbosaSinus (+) 3 cm x 2 cm to right lateral

IX . Definitive Diagnosis Subtotal urethral stricture pars bulbosa

X. Planning Pro Antibiotic Pro urethrotomy

XI. PrognosisDubia ad bonam