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1. GROUND GROUND Urology Department DM Angel DM Bilton Consultant : dr. Made Tambunan Sp.U dr. Richman Patandung Sp.U

2. TOTAL PATIENTS OF dr. Made, SpU : 5 Kelimutu : 2 Asoka : 1 Anggrek : 1 Bougenvill : 1

3. PATIENT 1 Kelimutu

4. PATIENT IDENTITY Name : Mr. Soleman Boimau Sex : Man Age : 66 years Medical records : 587188 Date of Admission : 08/06/2024 Insurance : BPJS Kelimutu

5. ANAMNESIS S : Pain when urinating The patient was referred to urology with complaints of pain when urinating. The patient complained of pain since approximately 1 month ago. Patients also complain of not being able to hold urine, urinating continuously. The patient also complained that when urinating he had to strain and after urinating he felt that there was still urine remaining. The patient also complained of frequent urination >5 times at night.

6. Past medical history : Appendicitis (+) Family history of illness : - Medication history : - Operation history : Appendectomy (Mei 2024) in Atambua Allergic history : - ANAMNESIS

7. PHYSICAL EXAMINATION (17/06/2024) General Condition : GCS 15 Vital Signs BP : 120/60 mmHg HR : 92x/mins RR : 20x/ mins Temperature : 36 o C SpO2 : 99% (room air)

8. Secondary Survey Head : Normocephalic Eyes : anemic conjunctive (-/-), icteric sclera (-/-) Skin : pale (-), icteric (-) Neck : within normal limit Thorax : Symmetrical chest wall expansion, retraction (-) Pulmo : Vesicular (+/+), rhonchi (-), wheezing (-/-) Cor : S1S2, single, regular, murmur (-), gallop (-) Abdomen : supel , normal bowel sounds (+), no mass palpable, tenderness (+) in the left lumbar, left iliac, right lumbar, and right iliac and hypogastric regions Extremity : warm acral , CRT < 2”, edema lower extremities (-/-) PHYSICAL EXAMINATION (17/06/2024)

9. PHYSICAL EXAMINATION (17/06/2024) Urology statue : Flank : Bulging (-/-), mass (-/-), hematoma (-/-), scar (-/-), tenderness (-/-), CVA (+/+) Suprasimphysis : bulging (-), distension (-), mass (-), hematoma (-), scar (-), tenderness (+/+) Eksternal genitalia : bulging (-), mass (-), hematoma (-), scar (-), ulcus (-)

10. Laboratory Examination at RSUD Prof. Dr. W. Z. Johannes 11 /06/2024 Labs Result Reference value HB 12.7 g/dL 13.0 - 18.0 HCT 37.6 %  42.0 – 62.0 RBC 4.92 x 10 6 uL 3.70 - 6.10 WBC 10.40 x 10 3 uL  5.00 - 20.00 PLT 237.80 x 10 3 uL  150.00 - 400.00 Cr 1.97 mg/dL 0.00 - 1.40 Ur 15.20 mg/dL 6.00 - 20.00 Na 138 mmol/L 132 - 147 K 2.99 mmol/L 3.50 - 4.50 Cl 103 mmol/L 96 - 111 Ca 1.23 mmol/L 1.12 - 1.32 Tot Ca 2.63 mmol/L 2.20 - 2.55

11. USG Abdomen 13/06/2024

12. BON/KUB/BOF 12/06/2024 Clinical : abdominal pain BPH There is no visible abdominal distension, the preperitoneal fat line is firm ntestinal gas distribution was normal The liver and spleen shadows do not appear enlarged The contour of the right and left kidneys appears normal No radioopaque stones were seen in the urinary tract Psoas line right and left is normal The bones appear osteophyte on the lumbar CV Impression: No radiopaque stones were seen in the urinary tract Illeus doesn't appear Lumbar spondylitis

13. ASSESMENT LUTS ec susp BPH PLANNING Recommendation of urological ultrasound and repeat PVR for a second opinion Urief 2x4 mg (1-0-1) Avodart 1x0.5 mg (1-0-0)

14. PATIENT 2 kelimutu

15. PATIENT IDENTITY Kelimutu Name : Mr. Matheos Yunus Sex : Man Age : 68 years old Medical records : 587206 Insurance : BPJS

16. ANAMNESIS S/ : Pain in left hip The patient was consulted to urology with complaints of left lower back pain since 3 weeks before entering the hospital. Complaints of pain like being stabbed with 2-3 vases. Patients complain that the pain worsens when holding in urination, and the complaint does not improve with taking medication. Painless urination, cloudy urination (-), bloody urination (-), lower abdominal pain (-), LUTS (-).

17. Past medical history : Tumor paru sinistra Family history of illness : - Medication history : - Operation history : - Allergic history : - ANAMNESIS

18. PHYSICAL EXAMINATION (11/06/2024) General Condition : E4M6V5 Vital Signs BP : 120/60 mmHg HR : 89x/mins RR : 22x/mins Temperature : 36.2 o C SpO2 : 99% on NK 7 lpm

19. Secondary Survey Head : Normocephal Eyes : anemic conjunctive (-/-), icteric sclera (-/-) Skin : pale (-), icteric (-) Neck : within normal limit Thorax : Symmetrical chest wall expansion, retraction (-) Pulmo : Vesiculer (+/decreased), rhonci (-/-), wheezing (-/-) Cor : S1S2, single, regular, murmur (-), gallop (-) Abdomen : Distension, decreased bowel sound (+), no palpable mass, tenderness (+) in suprapubic region, left flank Extremity : warm acral, CRT < 2”, edema (+/+) PHYSICAL EXAMINATION (11/06/2024)

20. PHYSICAL EXAMINATION (11/06/2024) Urology statue : Flank : bulging (-/-), mass (-/-), hematoma (-/-), scar (-/-), tenderness (-/-), CVA (-/+) Suprasimphysis : bulging (-), distension (-), mass (-), hematoma (-), scar (-), tenderness (-) Eksternal genitalia : bulging (-), mass (-), hematoma (-), scar (-)

21. Laboratory Examination at RSUD Prof. Dr. W. Z. Johannes 09 /06/2024 Labs Result Reference value HB 10 g/dL 13.0 - 18.0 HCT 30 %  42.0 – 62.0 RBC 3.71 x 10 6 uL 3.70 - 6.10 WBC 23.55 x 10 3 uL  5.00 - 20.00 PLT 198.00 x 10 3 uL  150.00 - 400.00 Albumin 2.70 g/dL 3.40 – 5.20 Ur 7.00 mg/dL 6.00 - 20.00 Na 133 mmol/L 132 - 147 K 4.19 mmol/L 3.50 - 4.50

22. Urinalysis examination 12/06/2024 Crystal negative Urobilinogen negative Macroscopic Yellow color Clarity : clear Specific gravity : 1.020 pH : 6.0 Leukocyte esterase : negative Nitrite (-), protein (+2), glucose (-), Ketone (-), bilirubin (-), blood (+2) Sediment Erythrocytes 8-10/ lpb Leukocytes negative/ lpb Cylinders negative/ lpb Epithelial cells 5-7/ lpk Bacteria negative/ lpk

23. ASSESMENT Bilateral hydronephrosis ec susp bilateral ureteral stones dd/bilateral ureteral stenosis Right kidney stone PLANNING Recommendation for non-contrast CT urography to evaluate the lower abdomen (lower urinary tract) Surgery after the results of non-contrast CT urography

24. PATIENT 3 Asoka

25. PATIENT IDENTITY Name : Mr. Hasan Bai Atawani Sex : Male Age : 72 Years Old Medical records : 542652 Date of Admission : 16/06/2024 Insurance : BPJS Asoka

26. ANAMNESIS (17/06/2024) S/ : Bloody bowels The patient came with complaints of bloody urination since 2 days at SMRS. Since June 14 2024, patients have come to the ER at Ende Regional Hospital with complaints of not being able to urinate. The patient is then placed with a catheter. During monitoring, the patient's BAK was mixed with blood, making the urine color clear light yellow mixed with blood. Other complaints such as lower abdominal pain come and go (worse when the patient is going to urinate), pain in the genitals comes and goes (when going to urinate), urinating a little and feels incomplete. Fever (-), nausea (-), vomiting (-), weakness (-), eating and drinking normally. Normal bowel movements. BAK through the catheter, the amount of urine is 250 cc, dark red blood color.

27. Past medical history : Ca bulli Family history of illness : - Medication history : Amlodipine 1x10 mg, gliquidone 1x30 mg, cefixime 2x10 mg, paracetamol 3x500 mg, valisanbe 1x1 tablet, tranexamic acid 3x500 mg Operation history : Laser (2018) Allergic history : Vitamin k ANAMNESIS (17/06/2024)

28. PHYSICAL EXAMINATION (17/06/2024) General Condition : E4V5M6 Vital Signs BP : 100/80 mmHg HR : 85x/mins RR : 19x/mins Temperature : 36.4 o C SpO2 : 97% RA

29. Secondary Survey Head : Normocephal Eyes : anemic conjunctive (+/+), icteric sclera (-/-) Skin : petechie in both lower limbs (+) Neck : within normal limit Thorax : Symmetrical chest wall expansion, retraction (-) Pulmo : Vesiculer (+/+), rhonci (-), wheezing (-/-) Cor : S1S2, single, regular, murmur (-), gallop (-) Abdomen : supel, distension (-), bowel sound (+), tenderness (-) Extremity : warm acral, CRT < 2”, edema (-/-) PHYSICAL EXAMINATION (17/06/2024)

30. PHYSICAL EXAMINATION (11/06/2024) Urology statue : Flank : bulging (-/-), mass (-/-), hematoma (-/-), scar (-/-), tenderness (-/-), CVA (-/-) Suprasimphysis : bulging (-), distension (-), mass (-), hematoma (-), scar (-), tenderness (+) Eksternal genitalia : bulging (-), mass (-), hematoma (-), scar (-), catheter inserted

31. Laboratory Examination at RSUD Prof. Dr. W. Z. Johannes 16 /06/2024 Labs Result Reference value HB 12.8 g/dL 13.0 - 18.0 HCT 47.1%  42.0 – 62.0 RBC 4.35 x 10 6 uL 3.70 - 6.10 WBC 8.44 x 10 3 uL  5.00 - 20.00 PLT 197.80 x 10 3 uL  150.00-400.00 Cr 1.70 mg/dL 0.00-1.40 Ur 13.0 mg/dL 6.00-20.00 Na 140 mmol/L 132-147 K 3.46 mmol/L 3.50-4.50 Cl 101 mmol/L 96-111 Ca 1.21 mmol/L 1.12-1.32 Tot Ca 2.56 mmol/L 2.20-2.55

32. ASSESMENT Working Diagnosis Infiltrasi urothelial carcinoma buli (ca bulli ) PLANNING IVFD nacl 0.9% 500 ml : futrolit 500 ml/24 hours Skin test for vitamin K, if there are no signs of allergy then add vitamin K 3X1 mg Ranitidine 2x50 mg IV Ketolorac 3x30 mg IV Contrast CT whole abdomen AP thorax photo/Lat view Recheck creatinine and urea

33. PATIENT 4 Anggrek

34. PATIENT IDENTITY Name : Mr. Markus Mita Sex : Male Age : 65 Years Old Medical records : 586875 Insurance : BPJS Cempaka

35. ANAMNESIS (17/06/2024) S/ Intermittent urination The patient was referred to urological surgery with a diagnosis of BPH and nephrolithiasis. Patients complain of intermittent urination and frequent urination. In a day the patient can urinate >10 times and claims to have no pain when urinating. The patient also said that when urinating, the stream was weak but there was no straining. Last night, the patient woke up to urinate 5 times. bloody urine (-), fever (-)

36. Past medical history : TBC (+) completed treatment, Mass in the left stomach since 5 years ago Family history of illness : - Medication history : - Operation history : - Allergic history : - ANAMNESIS (17/06/2024)

37. PHYSICAL EXAMINATION (17/06/2024) General Condition : E4V5M6 Vital Signs BP : 110/60 mmHg HR : 93x/mins RR : 20x/mins Temperature : 36 o C SpO2 : 96%

38. Secondary Survey Head : Normocephal Eyes : anemic conjunctive (-/-), icteric sclera (-/-) Skin : pale (-), icteric (-) Neck : within normal limit Thorax : Symmetrical chest wall expansion, retraction (-) Pulmo : Vesiculer (+/+), rhonci (-), wheezing (-/-) Cor : S1S2, single, regular, murmur (-), gallop (-) Abdomen : Distension, bowel sound (+) normal, mass in the left abdomen, tenderness (+) in the left region Extremity : warm acral, CRT < 2”, edema (-/-) PHYSICAL EXAMINATION (17/06/2024)

39. PHYSICAL EXAMINATION (11/06/2024) Urology statue : Flank : bulging (-/-), mass (-/-), hematoma (-/-), scar (-/-), tenderness (+/+) Suprasimphysis : bulging (-), distension (-), mass (-), hematoma (-), scar (-), tenderness (-/+) Eksternal genitalia : bulging (-), mass (-), hematoma (-), scar (-)

40. Laboratory Examination at RSUD Prof. Dr. W. Z. Johannes Labs Result Reference value HB 10.6 g/dL 13.0 - 18.0 HCT 41.0 %  42.0 – 62.0 RBC 3.56 x 10 6 uL 3.70 - 6.10 WBC 11.39 x 10 3 uL  5.00 - 20.00 PLT 287.10 x 10 3 uL  150.00-400.00 Cr 9.16 mg/dL 0.00-1.40 Ur 109 mg/dL 6.00-20.00

41. Urinalysis examination 15/06/2024 Crystal negative Urobilinogen negative Macroscopic Yellow color Clarity : clear Specific gravity : 1.010 pH : 6.0 Leukocyte esterase : negative Nitrite (-), protein (-), glucose (-), Ketone (-), bilirubin (-), blood (+2) Sediment Erythrocytes negative/ lpb Leukocytes negative/ lpb Cylinders negative/ lpb Epithelial cells 10-20/ lpk Bacteria negative/ lpk

42. CT SCAN ABDOMEN 14/06/2024 Heterogeneous multilobulated solid mass with suspicion of central necrosis in the peritoneal cavity where the boundary with the intestinal system and aorta does not appear clearly, dd/: 1. Lymphoma 2. Extralumen mass (GIST) Illeus does not appear Bilateral severe hydronephrosis accompanied by bilateral proximal ureteral dilatation, ec susp of mass filtration into the ureter Right nephrolithiasis Prostate hypertrophy Ascites Obsv single right lung nodule scanned, suspected pulmonary metastases Bilateral pleural effusion

43. ASSESMENT PLANNING Tumor abdomen Malnutrisi AKI dd ACKD BPH Hidronefrolitiasis Kidmin 14 tpm Furosemide 20-0-0 Pantoprazole 1x40 mg Metoklopramid 1x40 mg Asam folat 2x2 tab Liv b plex 2x1 tab Lactulosa 2xC1 Vip albumin 3x1 PO Ketorolac 2x1 k/p Harnal 0.4 0-0-1 PO

44. PATIENT 5 Bougenville 1

45. PATIENT IDENTITY Name : Mrs. Wattrina Lomi Sex : Female Age : 68 Years Old Medical records : 212410 Insurance : BPJS IGD

46. ANAMNESIS (17/06/2024) S/ Pain when urinating and burning sensation in the stomach The patient complained of weakness when he finished HD and the patient experienced a loss of consciousness. Patients also complain of pain when urinating accompanied by low back pain, bleeding (-), cloudy urine (-). Complaints are also accompanied by no chapter since yesterday, the last chapter was mixed with blood. The patient was taken by the family to the emergency room with complaints of weakness and was unconscious.

47. Past medical history : - Family history of illness : - Medication history : Left kidney stone laser and DJ stent installation (April 2024), CDL installation (May 2024) Operation history : - Allergic history : - ANAMNESIS (17/06/2024)

48. PHYSICAL EXAMINATION (17/06/2024) General Condition : E1V1M1 Vital Signs BP : 90/60 mmHg HR : 69x/mins RR : 18x/mins Temperature : 35.7 o C SpO2 : 99% on RA

49. Secondary Survey Head : Normocephal Eyes : anemic conjunctive (-/-), icteric sclera (-/-) Skin : pale (-), icteric (-) Neck : within normal limit Thorax : Symmetrical chest wall expansion, retraction (-) Pulmo : Vesiculer (+/+), rhonci (-), wheezing (-/-) Cor : S1S2, single, regular, murmur (-), gallop (-) Abdomen : supel , distension (-), bowel sound (+), tenderness (-) Extremity : warm acral, CRT < 2”, edema (-/-) PHYSICAL EXAMINATION (17/06/2024)

50. PHYSICAL EXAMINATION (17/06/2024) Urology statue : Flank : bulging (-/-), mass (-/-), hematoma (-/-), scar (-/-), tenderness (-/-) Suprasimphysis : bulging (-), distension (-), mass (-), hematoma (-), scar (-), tenderness (-) Eksternal genitalia : bulging (-), mass (-), hematoma (-), scar (-)

51. Laboratory Examination at RSUD Prof. Dr. W. Z. Johannes 13/06/2024 Labs Result Reference value HB 9.6 g/dL 13.0 - 18.0 HCT 27.6 %  42.0 – 62.0 RBC 3.58 x 10 6 uL 3.70 - 6.10 WBC 14.44 x 10 3 uL  5.00 - 20.00 GDS 168 mg/dL 70.00-150.00 Cr 0.96 mg/dL 0.00-1.40 Ur 10.30 mg/dL 6.00-20.00 Na 128 mmol/L 132-147 K 5.07 mmol/L 3.50-4.50 Cl 100 mmol/L 96-111 Ca 1.61 mmol/L 1.12-1.32 Tot Ca 3.32 mmol/L 2.20-2.55

52. ASSESMENT Grade IV right hydronephrosis ec susp total ureteral stenosis + DJ left stent in situ + CKD + Genitourinary TB on OAT PLANNING Pro URS + right DJ stent insertion k/p right nephrostomy Aff left DJ stent k/p replace left DJ Stent

53. TOTAL PATIENTS OF dr. Richman, SpU : 1 Teratai : 1

54. PATIENT 1 Teratai

55. PATIENT IDENTITY Name : Mr. Petrus Muda Sex : Male Age : 73 years old Medical records : 565195 Date of Admission : June 12, 2024 Insurance : BPJS

56. ANAMNESIS (10/06/2024) Chief complaint : Difficult to Urinating The patient came to the Hospital with complaint difficult to urinating and looks like there is a blood in the urine. The Complaints have appeared since 3 days before came to the Hospital. At first it felt like urinating was incomplete so the patient had to urinate several times a day. One day before came to the hospital the patient’s urinating was dripping. The other Complaint: Patient said that the color of the Urine looks like Bloody, Nausea(-), Vomitting (-), Fever(-)

57. Past medical history : CKD on HD, HT(+) Family history of illness : - Medication history : - Operation history : - Allergic history : - ANAMNESIS (10/06/2024)

58. PHYSICAL EXAMINATION (1/06/2024) General Condition : GCS 15 Vital Signs BP : 140/70 mmHg HR : 67x/mins RR : 21x/mins Temperature : 36.8 o C SpO2 : 98% (room air)

59. Secondary Survey Head : Normocephal Eyes : anemic conjunctive (-/-), icteric sclera (-/-) Skin : pale (-), icteric (-) Neck : within normal limit Thorax : Symmetrical chest wall expansion, retraction (-) Pulmo : Vesiculer (+/+), rhonci (-), wheezing (-) Cor : S1S2, single, regular, murmur (-), gallop (-) Abdomen : supel, distension (-), bowel sound (+), tenderness (-), tympani Extremity : warm acral, CRT < 2”, edema (-/-) PHYSICAL EXAMINATION ( 12 /06/2024)

60. PHYSICAL EXAMINATION (11/06/2024) Urology statue : Flank : bulging (-/-), mass (-/-), hematoma (-/-), scar (-/-), tenderness (-/-), CVA (-/-) Suprasimphysis : bulging (-), distension (-), mass (-), hematoma (-), scar (-), tenderness (-), Pressure Pain(+) Eksternal genitalia : bulging (-), mass (-), hematoma (-), scar (-)

61. LABORATORIUM CHECK (11/05/2024) Hb 9,3 g/dL 12 – 16 RBC 3,05 x 10^6/ uL 4.20 – 5.40 Hct 25 .1 % 37 – 47 WBC 7,55 x 10^3/ uL 4 – 10 Plt 127,5 x 10^3/ uL 150 – 400 Ur 43,7 6.00-20.00 Cr 8,73 0.00-1.40

62. ASSESMENT Working Diagnosis Hematuria ec Ca Bladder + CKD PLANNING Urology Planning Transurethral Resection of Bladder Tumor X-Ray Thorax Internist Hemodialysis

63. THANK YOU