ppt bph and vesikolithiasis.pptx
DESCRIPTION
ppt bph and vesikolithiasis.pptxTRANSCRIPT
By:Putri Dwi Kart ini
04114708080
Supervisor:Dr. Marta Hendry Sp.U
SURGERY DEPARTMENT MEDICAL FACULTY OF SRIWIJAYA
UNIVERSITY2013
Susp. Benign Prostate Hyperplasia and Vesicolithiasis
Case Report
IDENTIFICATION
Name : Mr. RSAge : 73 years oldSex : MaleAddress : Harisan Jaya, Ogan Komering
Ulu Timur
Nationality : IndonesianReligion : Moslem Occupation : Retirement (builder)Medical Record : 754231Admitted : September 18th 2013
ANAMNESIS
Autoanamnesis taken on September 21th 2013
Chief Complaint
• Unable to void 1 month before admitted to hospital.
History of present illness
1 year
• difficulty to void,
• had to push to begin urination
• decreased force and caliber of stream
• stopped and started again when urinated
• Voiding at night up to 5 times at night (nocturia),
• difficult to postpone urination
• had sensation of incomplete bladder emptying
• Bloody urination (-)
• Stone in urine (-)
• Defecate + normal
• Fever (-)• Loss body
weight (-)
6 months
• pain when urinating
• uncomfortable when urinating
• stopped and started again when urination with changed the position of the body
• pain the lower abdomen that referred to the tip of the penis and the scrotum.
• Bloody urination (-)
• Stone in urine (-)
2 months
• pain when urinating and become more severe after urination
• bloody urination
• stone in urination (+)
• Fever (-)• Decreas
e of body weight (-)
went to polyclinics Mohhamad Hoesin General Hospital Palembang to get more therapy.
Admitted at September 18th 2013
History of past illness
• No history of urinary tract infections.• No history of using urethra catheter in long term use• No history of prostate, bladder, penis, urethra operation • No history of diabeties and CVD • No history of postpone urination habit• No history of trauma at the genitalia, stomach/ hip and back bone area.• No history bone pain, paresthesias, weakness or spasticity of lower extremities
and regional lymhadenopathy
History of Family disease
• History with same complaint as the patient in family denied
PHYSICAL EXAMINATION
General Examination (September 21th 2013)
• Appearance : good• Consciousness : compos mentis• Blood pressure : 130/90 mmHg• Pulse rate : 88 x/min• Respiratory rate : 20 x/min• Temperature : 36,70C• Eyes : conjunctiva palpebra anemic (-/-), sclera icteric (-/-), pupils
isokor, light reflex (+/+)
•Neck : no abnormalities•Thorax
• Lung : no abnormalities • Cor : no abnormalities
•Abdomen : refer to local examination•Genital : refer to local examination•Upper extremities : no abnormalities•Lower extremities : no abnormalities
LOCAL EXAMINATION
Abdomen Inspection : flat Palpation : no tenderness Percution : tympani Auscultation : bowel sound (+) normal
CVA region dextra sinistra Inspection : bulging (-) (-) Palpation : pain (-) (-)
ballottement (-) (-) Percussion : pain (-) (-)
Suprapubic region Inspection : bulging (-) Palpation : tenderness (+)
External genitalia region
• Inspection :• urethra bloody discharge (-), circumcised, urethra catheter no.
16F fixed
Rectal toucher
• TSA good, enlargement of prostate, upper boarder of prostate unpalpable, ruberry consistency, flat surface, no tenderness, feces (+), blood (-).
SUPPORTIVE EXAMINATION
Laboratorium findings (07/09/13)
Routine blood
•Hemoglobin: 9,7 gr/dL (N : 14-18g.dL)•Hematocryte : 29 vol% (N : 40-48vol%)•Leucocyte : 9.0/mm3 (N : 5000-10000/mm3)•Thrombocyte : 284 /mm3 (N : 200.000-
500.000/mm3)•LED : 120 mm/hour•Diff. Count : 0/14/0/45/33/8
Clinical Chemistry:
• BSS : 99 mg/dL• Ureum : 39 mg/dL (N : 15-39mg/dL)• Creatinine : 1,04 mg/dL (N : 0,9-1,3mg/dL)• Uric Acid : 8,1 mg/dL (N : < 8,4)• Na+ : 140mmol/l (N : 135-155)• K+ : 4,3mmol/l (N : 3,6-5,5)
Urine analysis
• Epitel cell : Positive (+)• Leucocyte : 20-25/ LPB (N : 0-5 / LPB)• Erytrocyte : 80-100/ LPB (N : 0-1 / LBP)• Silinder : negatif (-)• Kristal : negatif (-)
BNO
Result Multiple semi
radioopaque stones in pelvic cavity (size 1,5-2 cm)
USG
No abnormalities in right and left kidney, no enlargement of kidney, pelvis calices not widening, no stone.
USG
Widening of prostate, 50 x 54mm,
USG
multiple acoustic shadow on vesica urinary, multiple stones (+)
DIFFERENTIAL DIAGNOSIS
Urine Retention ec. Suspect Benign Prostate Hyperplasia + Vesicolithiasis
Urine Retention ec. Suspect Prostate Cancer + Vesicolithiasis
WORKING DIAGNOSIS
Urine Retention ec. Suspect Benign Prostate Hyperplasia And
Vesicolithiasis
TREATMENT
Transurethral Resection of
Prostate (TURP)
Vesicolithotomy
PROGNOSIS
Quo ad vitam : bonamQuo ad functionam : dubia
ad bonam