Case Report
1. Patient identity
Name
: Mr. S
Age
: 64 years old
Sex
: Male
Occupation
: Farmer
Address
:Bima
MR
:551332
Date of hospital admission :December10th2014
Date of examination
:December18th2014
II. Anamnesis
Chief Complaint:
Urine out of the scrotal sac.
Present Ilness :
patients complain of urine out of the scrotal sac since 2 months before
admission. Initially the patient complained of urine less satisfied since 2
years ago after insertion of a catheter for a month due to illness stroke.
since that time the patient complained of pain when urinating and urinate
as much as seven times a day. he admitted weak urinary stream. he
claimed to be straining to begin urination. Then arise boil for a week in the
scrotal sac accompanied by urinary suspended for 2 days, and fever. after
it boils broke and eventually urine out of the scrotal sac. since that time the
urine is always out scrotal sac with pain then dripped through the penis.
History of trauma (-). Now patients urine is yellowish, clear, with a
frequency of urinate of 3-4 times a day. The patient also confessed of
nokturia (-), bloody urine (-) and stone urinate(-). Confessed of right flank
pain (-), suprapubic pain (-), mass (-), flank pain (-). Normal defecation
with frequency of 1 times a day. The stool colour is brownish.
1
Post Illness History:
Patients aid he had experienced stroke and catheter during month.The history of
stone urinate (-) and bloody urine (-). Patient had operation tumor uretral 2
day before admission. History ofheart disease (-),hypertension (+), DM (-),
asthma (-).
Family Illness History:
No family member with the same complaint. History of bloody urine (-),
stony urine (-),hypertension (-), heart disease (-), DM (-), asthma (-).
Medication History:
Patients had admitted to PKU Muhammadiyah hospital and diagnosed
tumors urethral and fistula uretrocutan.
Allergic History:
No history of allergy due to food or medication.
History of Sosial Life
Patient is a farmer. Due to the anamnesis he is not a moderate smoker,
sometimes drink of coffee.
III. Physical Examination
a. Status Generalis:
General Condition: Moderate
Awareness/GCS : Compos Mentis/ E4V5M4
Blood Preassure : 140/80 mmHg
Pulse :72 bpm
Respiration: 20 bpm
Temperature: 36,8 C
b. General Examination
Head And Neck
Head: Normochepali, symmetric, deformity (-)
Eye: Pale Conjunctiva(-), Icteric Sclera (-), Pupil Isocore, Reflex of pupil
(+/+), diameter 3/3 mm
Ear, Nose, Throat : normal
Neck: Limph node enlargement (-)
Thorax-Cardiovaskular
Inspection : mass (-), lesion (-), chest wall movement simetric, retraction
(-)
Palpation : tenderness (-), vocal fremitus (+) normal, mass (-)
Percussion: sonor in both lung, percussion pain (-)
Auscultation : cor: S1S2 single, rregular, murmur (-), gallop(-)
Pulmo : vesicular in both lung (+/+), wheezing (-/-), rhonki (-/-)
Abdomen
Inspection : normal skin color, distention (-), mass (-), scar (-), sicatriks
(-), darm contour (-), darm steifung (-)
Auscultation : bowel sound (+) normal, borborygmus (-), metallic sound
(-)
Palpation : tenderness (-), defans muscular (-), ballotment (-), mass (-)
Percussion : tymphany (+) all regions
IV. Local Status
Uro-genital
Flank regions : bulging (-/-), inflammation sign (-/-),tenderness (-/-),
mass (-/-), ballottement (-/-), CVA tenderness (-/-)
Suprapubis regions :
-
Inspection: normal skin color, mass (-), hyperemic (-), scar (-),
sistostomy(-)
Palpation : bladder distention (-), mass (-), tenderness (-)
DRE
Normotonic sphincter ani, mucosal is smooth, mass (-), ampula recti
not
collapse,
prostatepalpable
size
finger,
flat
surface,symmetric,chewy consistency, sulcus mediana palpable,
superior pole palpable, nodule (-), gloves : mucus (-), blood (-), feses
(+)
External genital
Scrotum: skin color normal, inflammatory sign (-), mass (-),
tenderness (-), fistula (+)
Penis : Patient has no used catheter , preputium had been removed
(+). Mass (-)
Upper and lower extremity axial
Edema -/-, deformity-/-, inguinal limph node enlargement -/-
V. Summary
Male, 64 years old.Complain of urine out of the scrotal sac since 2
months before admission. History catheter insertion (+),urine less satisfied
since 2 years after insertion of a catheter (+). since that time the patient
complained of pain when urinating (+). weak urinary stream (+). straining
to begin urination (+). Then arise boil for a week in the scrotal sac
accompanied by urinary suspended for 2 days, and fever. after it boils
broke and eventually urine out of the scrotal sac. since that time the urine
is always out scrotal sac with pain then dripped through the penis. nokturia
(-), bloody urine (-) and stony urinate(-). right flank pain (-), suprapubic
pain (-), mass (-).
General condition is moderate, Consciousness is compos mentis,
Blood Pressure: 140/80 mmHg, Heart rate: 72 bpm, Respiration rate: 20
times/minute, Temperature 36,8oC.
Digital rectal examination :
Normotonic sphincter ani, mucosal is smooth, mass (-), ampula recti not
collapse, prostate palpable size 1 finger, flat surface, symmetric, chewy
consistency, sulcus mediana palpable, superior pole palpable, nodule (-),
gloves : mucus (-), blood (-), feses (+)
VI. Working diagnosis
1. Fistula uretrokutan
2. Susp. Urethral Stricture
VII. Diferensial Diagnosis
1. Uretra stone
VIII. Supporting Examination
Laboratorium
: Complete blood test, urine examination.
Radiologi : Urethrografi
Laboratorium findings
CBC (December10th 2014)
WBC
: 10,43 K/uL
Hb
: 11,5 g/dL
HCT
: 35,2 %
PLT
: 373 K/uL
GDS
: 89 mgl/dl
SGOT/SGPT
: 24 U/L, 10,5 U/L
Kreatinin
: 1,0 mg%
Ureum
:21 mg%
Urid Acid
: 6,9 mg%
Urethrografi result :
Interpretations:
Subtotal urethral stricture pars membranacea
Fistula uretrocutan/scrotal
IX . Definitive Diagnosis
Fistula uretrocutan/scrotal ec subtotal urethral stricture pars membranacea
X. Planning
Pro Sistostomi
Pro urethrotomy interna
XI.Prognosis
Dubia ad bonam
CASE REPORT
FISTULA URETROCUTAN ec SUBTOTAL
URETHRAL STRICTURE PARS MEMBRANACEA
By
Name : Andy Kumara
Nim : 08.06.0045
Supervisor
dr. Akhada Maulana, Sp.U
CONDUCTING FOR MIDDLE CLINICAL EDUCATION IN SURGERY
DEPARTEMENT OF MATARAM REFERRAL HOSPITAL/MEDICAL
FACULTY OF AL-AZHAR MATARAM UNIVERSITY
2014
