Fix - Laporan Kasus Vesikolitiasis

7/23/2019 Fix - Laporan Kasus Vesikolitiasis

1/11

CASE REPORT

Vesicolithiasis + Retensio Urine ec Suspect Ca Proatat

By

Heri Satryawan, S.e!

H"A ##$ ##%

Super&isor

!r. A'ha!a (aulana, Sp.U

)* ORER TO U*ERO THE C-)*)CA- OR)E*TAT)O*

C-ERSH)P AT THE SURER/ 0U*CT)O*A- (E)CA- STA00

(E)CA- 0ACU-T/ O0 (ATARA( U*)VERS)T/

*TB E*ERA- HOSP)TA-

1#"2


2/11

CASE REPORT

). Patient )!entity

Name : Mr. J

Age : 82 years oldSex : Male

Religion : Moeslem

Race : Samawa

Occupation : -

Relationsip status : Married

Address : !ung"a# Sum$awa

Num$er o% medical record : &' 22 ()

*ate o% ospital admission : June# +(t 2,+&

*ate o% examination : June# 2,t 2,+&

)). Su34ecti&e

The chie5 history 6 *i%%icult urinate

Present !isease history 6

!atient re%erred %rom Sum$awa eneral ospital wit recurrent urinary retention post re-open

cistostomy + year ago / $ladder stones. !atient con%ess tat e could not urinate since %our days ago.

e also con%ess %luid lea"ed out %rom is operati0e scar in lower a$domen and wen urinating patient

does not %eel pain.

1e urine color was red# di%%icult to start urinating /3# unsatis%ied sensation a%ter urinate /3#

pain%ul wen urinate -3# sandy sensation wen urinate -3. Malaise /3# good appetite and weigt loss

-3# eadace and di44iness -3# %e0er -3# nausea and 0omiting -3. Normal de%ecation + time a day. 1e

stool is $rownis-colored.

Past !isease history 6

!atient ad complaint o% similiar $e%ore. istory o% 0esica urinary stone /3# istory o%

operati0e 0esica urinary stone wen 2,+) and 2,+5. istory o% $loody urinate -3# astma -3#dia$etes mellitus -3# ypertension -3 and cardiology disease -3.

0a7ily !isease history 6

1ere is no %amily mem$ers ad te same complaint wit patient. Astma -3# dia$etes

mellitus -3# ypertension -3. *rug or %ood allergies -3

1


3/11

History o5 treat7ent 6

!atient e0er try treat is pro$lem to medical clinic.

Ha3itually history 6

6o%%e-drin"ing a$itual /3# alcoolic -3# acti0e smo"er -3. Soda-drin"ing a$itual

-3. !atients drin" wen tirsty te amount o% drin"ing water is uncertain.

.

))). Physical E8a7ination

A. Present Status

eneral state : Moderate

6onsciousness76S : 6ompos mentis 7 59&M'

Vital si9n lood !ressure : +',7+,, mmg

eart rate : 85 $pm

Respiration rate : 22 times per minute.

1emperature : )'#5 o6

B.eneral Status

Hea! an! nec'

ead : normocepaly# $lac" air# allopecia -3

yes : anemic con;ungti0al -7-3# icteric sclera -7-3# pupil re%lex /7/3 isocor

) mm7) mm.

Nose : rinorrea -3# de%ormity -3

ar : otorrea -3# sape and si4e normal

Mout : dry lips -3# cyanotic -3

Nec" : enlargement o% lympnodes -3

Thora8:Car!io&ascular


4/11

!ercussion : sonor at $ot lungs# pain -3

Sonor Sonor

Sonor Sonor

Sonor Sonor

Auscultation :

!ulmo : 0essicular in $ot lungs /7/3# ronci -7-3# wee4ing -7-3

6or : S+S2# single# regular# murmur -3# gallop -3

A3!o7en


5/11

Anal perianal

Mass -3# %istula -3# erytema -3# pain -3# emorroid -3

Rectal touce : strong ani spincter tone# ampula rectum doesn=t collapse#

slippery mucosal# pain -3# palpa$le enlarge prostate# ard consistency# median

sulcus palpa$le con0ex# unpalpa$le posterior pole# prostat 0olume a$out ', cc.

)V. Su77ary

Male# 82 years old re%erred %rom eneral ospital o% Sum$awa wit recurrent urinary

retention post re-open cistostomy + year ago wit $ladder stones. !atient could not urinate

suddenly and di%%icult urination since %our days ago# %luid out %rom te operati0e scar in te

lower stomac and wen urinating patient does not %eel pain# urine is redness /3# di%%icult to

start urinating /3# unsatis%ied sensation a%ter urinate /3. !atient ad complaint o% similiar$e%ore. istory o% 0esica urinary stone /3# istory o% operati0e 0esica urinary stone wen

2,+) and 2,+5. !atients drin" wen tirsty te amount o% drin"ing water is uncertain# co%%e-

drin"ing a$itual /3.

eneral condition is moderate# consciousness is compos mentis. Brom examination

$lood pressure +',7+,, mmg# supra pu$ic inspection: scar post cystostomy /3# palpation:

mass /3# num$er o% mass is + at ipogastric region# si4e & x 5 cm# immo$ile# smoot su%ace#

clear $oundaries# pain -3. enitalia inspection: cateteri4ed /3. Rectal touce : strong ani

spincter tone# ampula rectum doesn=t collapse# slippery mucosal# pain -3# palpa$le enlarge

prostate# ard cosistency# median sulcus palpa$le con0ex# unpalpa$le posterior pole# prostat

0olume a$out ', cc.

V. ;or'in9 !ia9nosis

Retensio urine ec suspect !

V). i55erential !ia9nosis

6a prostat

V)). Plannin9 !ia9nostic

A$dominal ultrasonograpy

OB

!SA

Routine $lood examination

Routine urine examination

4


6/11

Non contrast a$dominal 61 C Scan

Drinelisys

iopsy

V))). Supportin9 E8a7ination

". Laboratory

Para7eter Result

"2#


7/11

1. Imaging

a? BO0 @"$


8/11

Result:

- iperplasia prostat wit 0olume )8+ cc

- Stone 2#)' cm

- Mild ectasis S!6 ren sinistra

- 6onclusion: 9esicolitiasis / ! susp. malignansi

c? CT Scan A3!o7en @1$


9/11

8


10/11

9


11/11

Result:

- iperplasia prostat wit 6alsi%i0ation 0olume 2)) cm)3

- 9esicolitiasis 2.+ x ,.( cm

- Mild idrone%rosis and idroureter dextra et sinistra

). ia9nosis !e5initi5

9esicolitiasis / suspect ca prostat

. Plannin9 therapy O$ser0ation

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Fix - Laporan Kasus Vesikolitiasis