IDENTITY

Name : Mr. AS
Age : 47 years old
Admission : August, 6th 2017
Doctor in Charge : dr. Muh. Jabir, Sp.U
HISTORY TAKING
Chief complaint : Suprapubic pain
Anamnesis : (autoanamnesis)
The patient referred from North Konawe Hospital came with complaint suprapubic pain.
It associated with sudden painful when urinating since a day ago. Patient admitted there
was somethings blocking when urinating. There were difficulty starting urination, blood
urine (+), sandy urine (+), dribbling at the end of urination, and always feel dissatisfied.
Patient also complained feeling full in night, so he waked up for urinate often >5x/night
since about 2 weeks ago. Before referred, patient was tried to pair the catheter and
suprapubic punction but it didnt work. Defecate was normally.
No history of trauma at the genitalia, stomach, hip, and spine area.
No history of urinary infections.
Patient likes to eat sea food.
PHYSICAL EXAMINATION

The patient was conscious with moderete ill

BP = 120/90 mmHg Pulse = 84x/m, strong lift

RR = 20x/m, regular Temperature = 36,8oC

GENERALIZED STATUS
Head : Normally Abdomen
Face : Normally Suprapubic distended (+)
Eyes : Normally
Extremity
Nose : Normally Superior : Normally
Mouth : Normally Inferior : Normally
Ears : Normally
Neck : Normally
Chest : Normally
LOCALIZED STATUS
Costovertebrae Genitalia
Inspection : Skin tone was same with Penis : Normally
around, inflammation signs (-) Scrotum : Normally
Palpation : Tenderness (-), mass (-), Perineum : Normally
renal ballottement (-)
Percussion: Tap pain (+)
Rectal Touche
Suprapubic Sphincter : Tight
Inspection : Distended (+) Mucosa : slick and smooth
Palpation : Tenderness (+), mass (-) Ampulla : Empty
Prostate : flattening, solid consistency,
tenderness (+)
Handscoen : Feces (-), Blood (-), Mucus (-)
CLINICAL FINDINGS
PLANNING
Routine Blood Test
Urinalysis
BNO Photo
USG Abdomen
DIAGNOSE

Susp. Nephrolithiasis
DD/ BPH
MANAGEMENT
IVFD
Antibiotic
Analgetic
H2R antagonis

Consult to Urology Surgeon

TERIMA
KASIH