IDENTITY

Name : Mr. HS
Age : 62 years old
Admission : August, 11th 2017
DPJP : dr. Muh. Jabir, Sp.U
HISTORY TAKING
Main complaint : poor urination
Anamnesis :
The patient was reffered from kolaka hospital with poor urination since 2
day ago. Patients also feel discontinuous urination and poor stream.
the patient felt pain in lower abdomen, especially during urination. Each
time urinating the patient have to wait a long time every time urine out,
have to push and feel dissatisfied when urinating. Patients wake up to
urinate often> 5x times. Defecate was normally.
There was no history of previous disease, history of family, trauma.
PHYSICAL EXAMINATION

General State :
Moderate ill, conscious
Vital Sign :
BP : 150/100mmHg
RR : 20x/m
HR : 80x/m
T : 370c
 GENERALIZED STATUS

Head : Normally Extremity

Face : Normally Superior : Normally
Eyes : Normally Inferior : Normally
Nose : Normally
Mouth : Normally
Ears : Normally
Neck : Normally
Chest : Normally
Abdomen : Normally
 LOCALIZED STATUS
Regio costovertebralis dextra
Inspection : skin colored was same with around, Regio suprapubic
Inflammatory sign (-) hematom (-) Inspection : flattening, mass (-), hematom (-)
Palpasi : mass (-) ballotemen test (-) tenderness (- Palpation : tenderness (+)
)
Perkusi : tap pain(-)
Regio costovertebralis sinistra
Inspection : skin colored was same with around,
Inflammatory sign (-) hematom (-)
Palpation : mass (-) ballotemen test (-) tenderness
(-)
Perkusi : tap pain(-)
 LOCALIZED STATUS
Regio genitalia eksterna
Penis inspection : Penis is circumcised, OUE on the tip of the penis
palpation : tenderness (-)
Scrotum inspection : skin colored was same with around
palpation : tenderness (-)
Perineum inspection : skin colored was same with around, tumor mass (-)
palpation : tenderness (-) Striktur uretra (-)
Rectal toucher > Sphincter : tight
Mocosa : slick and smooth
Ampulla : empty
Prostat : Prostate palpable 3 cm at 12 o'clock direction Soft consistency, slippery surface
tenderness (-)
Handscoen : feses (+) mucus (-) blood (-)
PLANNING

Urinalysis
 LABORATORY FINDINGS

ROUTINE BLOOD TEST PARAMETER RESULT

August 11th 2017 WBC

RBC
14,77x 103/Ul
5,91x 106/uL
HB 11,1g/dL
PLT 2205x 103/uL

PARAMETER RESULT
BLOOD CHEMISTRY TEST GDS 95 mg/dl
August 11th 2017 Ureum 27 mg/dl
Creatinine 0,8g/dl
SGOT/AST 17/L
SGPT/ALT 15gr/dl
 RADIOLOGY FINDINGS

KESAN : hepar, GB, lien, pankreas, kedua ginjal dan VU dbn Hipertrofi prostat dengan volume 30 ml, calsifikasi (+)
DIAGNOSIS

BPH
MANAGEMENT
IVFD
Antibiotic
Analgetic
H2R antagonis
Consult a urologi Surgeon