CASE REPORT

TOTAL STRICTURE URETRA PARS BULBOSA

Supervisor:

dr. Akhada Maulana Sp.U

By:

Lalu Karisma Aditya

H1A 008 003

IN ORDER TO UNDERGO THE CLINICAL ORIENTATION /

CLERKSHIP AT THE SURGERY FUNCTIONAL MEDICAL STAFF

MEDICAL FACULTY OF MATARAM UNIVERSITY

NTB GENERAL HOSPITAL

2013

HALAMAN PENGESAHAN

Judul : Total Stricture Uretra Parsbulbosa

Nama : Lalu Karisma Aditya

NIM : H1A 008 003

Laporan kasus ini telah diterima sebagai salah satu syarat untuk mengikuti ujian kepaniteraan Klinik

Madya pada Bagian/SMF Bedah Rumah Sakit Umum Provinsi Nusa Tenggara Barat / Fakultas

Kedokteran Universitas Mataram.

Mataram, Oktober 2013

Pembimbing,

dr. Akhada Maulana Sp.U

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CASE REPORT

I. Patient Identity

Name : Mr. MK

Sex : Male

Age : 79 years old

Address : Jonggat, Central Lombok, West Nusa Tenggara

Religion : Muslim

Race : Sasak

Occupation : Farmer

Relationship status : Married

Date of hospital admission : August 17th 2013

Date of examination : August 21st 2013

II. Anamnesis

The chief history : difficult to urinate

Present disease history :

Patient came to General Hospital Of West Nusa Tenggara Province complaining

difficult to urinate since 1 month ago. This complaint worsen since 1 week. Patient often

complains of hard to start urinating, frequent straining, frequent urinary dripping, and felt no

satisfied on urinating. The frequency of urinating is more than 12 times / day, a little bit. In

addition, sometimes patients also complains of pain when urinating, urinary dripping at the

end (+), history of urinary bleeding (+), sandy urine or rock out (-), suprapubic pain (-).

History of fever (-), nausea (-), vomiting (-). Patient drink about 2 L per day.

Defecation was normal, once daily, concistency firm and brown.

Past disease history:

Patient often experiences the same complain for 1 month. Patient had a history of

catheterization 2 months ago post peptic ulcers operation in General Hospital of West Nusa

Tenggara. Patient said that he felt pain and blood came out during catheterization (+). A

history of kidney stones (-), UTI (-), DM (-), HT (-), and Astmas (-).

Family disease history:

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No family member with the same complaint. Hypertension (-), Diabetes Mellitus (-),

Uric acid (-)

Drug allergy: Drug (-), Food Allergy (-)

History of treatment:

Patient was reffered from Praya General Hospital with Urine Retention et causa susp

BPH. In Praya General Hospital, patient had been hospitalized for 7 days and had been

treated with Antibiotic and analgetic.

Private and Social History:

The patient worked as a farmer with 9 wives, 20 children, and 8 grandchildren, and 3

great-grandchildren. Patients often smoked 1 pack / day and regularly consuming 2 cups of

coffee per day. History consume energy drinks (-), patients drank 1,5 L of water / day

III. Physical Examination

General condition : Good

Consciousness/GCS : Compos mentis/E4V5M6

A. Vital Sign

Blood Presure : 150/80 mmHg

Heart rate : 88 bpm

Respiration rate : 20 rpm

Temperature : 36,5oC

B. General Status

Head and neck

o Head : normochepali, deformity (-)

o Eyes : anemis (-/-), icteric (-/-), pupil isocore 3mm/3mm, pupil reflex (+/+)

o Noise : deformity (- )

o Mouth : sianotic (-)

o Neck : enlargement lymph node (-)

Thorax

o Inspection : chest wall shape and size simetric, mass (-), lesion (-), retraction

(-), thoracoabdominal respiration (+).

o Palpation : chest wall movement simetric, tenderness (-), vocal fremitus (+/+)

normal, mass (-), crepitation (-).

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o Percussion: sonor in both lung, percussion pain (-).

o Auscultation :

Pulmo : vesicular in both lung (+/+), rhonki (-/-), wheezing (-/-)

Cor: S1S2 single, regular, murmur (-), gallop(-)

Abdomen

o Inspection : distention (-), mass (-)

o Auscultation : bowel sound (+) normal

o Percussion : timpani in whole region

o Palpation : tenderness (-), H/L/R not palpable, defans muscular (-), mass (-),

ballotement (-)

Upper and Lower extremity:

Warm acral (+/+/+/+), Deformity (-/-/-/-), oedem (-/-/-/-).

C. Urogenitalia Physical Examination

Costo vertebrae angle (CVA) region:

A. Inspection: color same as the surrounding skin, mass (-), inflammation (-), scar

(-), hematome (-), bulging (-/-)

B. Palpation : tenderness (-/-), mass (-), ballottement (-)

C. Percussion : pain (-/-)

Suprapubic region

o Inspection: color same as the surrounding skin, mass (-), inflamation (-), scar

(-), sistostomy (-)

o Palpation : bladder distention (-), mass (-), tenderness (-)

Genitalia externa:

o mass (-)

D. Rectal Touche

o Inspection: color same as the surrounding skin, mass (-), inflammation (-), scar

(-), hematome (-), bulging (-).

o Palpation : TSA is good, rectal mucosal is smooth, palpable prostate is not

enlarge, palpable medial sulcus, palpable pole superior, pain (-), rubbery

consistency.

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E. IPPS: 15 mild

IIV. Summary

Patients came to General Hospital of West Nusa Tenggara complaining difficult to

urinate since 1 month ago. This complaint worsen since 1 week. Patient often complain of

hard to start urinating, frequent straining, frequent urinary dripping, and felt no satisfied on

urinating, frequency of urinating > 12 times / day, a little bit. Patient also complain of pain

when urinating, urinary dripping at the end (+), history of urinary bleeding (+). Patient often

experiences the same complain for 1 month. Patient had a history of catheterization 2 months

ago post peptic ulcers operation in General Hospital of West Nusa Tenggara. Patient said that

he felt pain and blood came out during catheterization (+). Patients drink about 1,5 L/day.

Defecation was normal. On the physical examination, blood pressure 150/80 heart rate 88

bpm, respiration rate 20 rpm, temperature 36,8oC, there were no tenderness on the CVA

region or suprapubic region, and no pain on the percussion.

V. Working diagnosis

Suspect Stricture Ureter

VI. Differential diagnosis

Susp. BPH

VII. Propose Examination

CBC

Uretrography

VIII. Laboratory Examination

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Parameter August 16nd 2013 RANGE

WBC 6,48.103/ul 4-11

RBC 3,91.106 /ul 4,5-5,5

Hb 8,8 g/dl 13-18

HCT 28,4 % 37-50

MCV 72,6 fl 82,0-92,0

MCH 22,5 pg 27,0-31,0

MCHC 31 ,0 g/dl 32,0-37,0

PLT 397.103/ul 150-400

BT 2’50” <6”

CT 4’00” <15”

GDS 103 mg/dl <160

Creatinine 1,0 mg/dl 0,9-1,3

Ureum 32 mg/dl 6-26

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Uretrography result ( August 20nd 2013 )

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Conclusion :

Total Stricture Uretra Pars Bulbossa

VIII. Diagnosis

Total Stricture Uretra

IX. Planning:

Uretrotomi Interna (Sachse)

X. Prognosis:

Quo ad vitam : Dubia ad bonam

Quo ad functionam : Dubia ad bonam

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