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IDENTITY

Name : Mr. L
Age : 67 years old
Admission : November, 28th 2017
DPJP : dr. Syamsul Rijal, Sp. B
HISTORY TAKING

Main complaint : difficult to urination


Anamnesis :
Patient reffered from bombana hospital with complain difficult to urinatio since
4 days ago. Patients also feel discontinuous urination and poor stream.
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 > 10x times. Defecate was normally.
There was no the same history (-)
PHYSICAL EXAMINATION

General State :

Moderate ill

Vital Sign :
 BP : 130/80mmHg

 HR : 80x/m

 RR : 20x/m

 T : 36,50c
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 • Regio suprapubic


Inspection : skin colored was same with around, Inspection : flattening, mass (-), hematom (-)
Inflammatory sign (-) hematom (-) Palpation : tenderness (+)
Palpasi : mass (-) ballotemen test (-) tenderness (-)
Perkusi : tap pain(-)
• Regio costovertebralis sinistra
Inspection : skin colored was same with around,
Inflammatory sign (-) hematoma (-)
Palpation : mass (-) ballotemen test (-) tenderness
(-)
Percusion : 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 touch –> Sphincter : tight
Mocosa : slick and smooth
Ampulla : empty
Prostat : Prostate palpable 2 cm at 12 o'clock direction Soft consistency
Handscoen : feses (+) mucus (-) blood (-)
PLANNING

 Blood rutin test


 Urinalysis
KESAN : Hipertrofi prostat dan kista ginjal kanan
DIAGNOSIS

BPH
MANAGEMENT

Apply urine catheter


IVFD
Analgetic
H2R antagonist
Consult General Surgeon

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