HALAMAN PENGESAHAN

Judul

: Retention Urine and Inferior Paraplegia et causa Decompression Syndrome

Nama

: Ida Ayu Padmita Utami

NIM

: H1A008010

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, Desember 2013

Supervisor,

dr. Akhada Maulana, Sp.U

CASE REPORT

Retention Urine and Inferior Paraplegia et causa

Decompression Syndrome

By:
Ida Ayu Padmita Utami
H1A 008 010

Supervisor:
dr. Akhada Maulana, Sp.U

IN ORDER TO UNDERGO THE CLINICAL ORIENTATION /

CLERKSHIP AT THE SURGERY FUNCTIONAL MEDICAL STAFF
MEDICAL FACULTY OF MATARAM UNIVERSITY
NTB GENERAL HOSPITAL
2013
CASE REPORT

I. Patient Identitiy
Name
Age
Sex
Religion
Occupation
Address
Relationship status
Number of medical record
Date of hospital admission
Date of examination

: Mr. M
: 28 years old
: Man
: Moslem
: Diver
: Pujut, Lombok Tengah
: Married
: 524489
: October 14th 2013
: October 23rd 2013

II. Anamnesis
Main complaint : inability to move his leg and voiding
Present disease history :
Patient referred from Praya General Hospital with retention urine et causa susp.
Rupture uretra and paraplegi suspect guillen barre syndrome. Patient complained about his
inability to move his leg and void since three weeks ago. His work involved periodically
diving in the sea up to a depth of 2040 meters. Three weeks ago, he dived into the sea in
Makasar for searching some of sea cucumber (teripang) and returned to surface within a few
minutes. He dive down to 35 meters deep with complete diving equipment. While returning,
he experienced and weakness in both lower limbs, and marked muscle pain in all over the
body. After a few days , he unable to void and felt his lower stomach bulging. He try to
strain in order to urinate and manipulate his penis in order to get proper urination but he
unable to void. He can urinate properly after urinary catheter attached in Praya General
Hospital. Patient treated for 5 days in this hospital, but his complaint has not improved.
Patient also said that he had history of bloody urination (+) after urinary catheter
removed in Praya General Hospital, then nurse tried again but failed to attach urinary
catheter. After that patient were referred to NTB general hospital. Patient said that he unable
to feel the urge to urinate. He said that he doesnt feel pain , when his lower stomach bulging,
nausea (+), vomiting (-), dizzy (+). Patient drink about 1 L per day. Micturition pain (-),stone
urination (-), fever (-). Patient felt numbness in the groin and his limb. Defecation was
abnormal. Patient also said that he unable to feel the urge to defecate.
Past disease history :
The history of stone urination (-) and blood urination (-). The history of urinary tract
infection (-) .Diabetes mellitus (-), asthma (-). His work involved periodically diving in the
sea up to a depth of 3035 meters for searching sea cucumber. He was a chronic smoker. He
had no past history of deafness or neurological disease. Trauma history (-)

Family disease history :

No family member with the same complaint. Asthma (-), arthritis (-)
Social History :
Patient said many of his diver friend often experience similar complaint like limb weakness.
Drug allergy : (-)
History of treatment : . Patient treated for 5 days in this hospital, but his complaint has not
improved.
III. Physical Examination
General condition

: Moderate

Consciousness/GCS : compos mentis/E4V5M6

A. Vital Sign

Blood pressure
Heart rate
Respiration rate
Temperature

: 130/80 mmHg
: 84 bpm
: 20 rpm
: 36,4oC

B. General Status

Head and neck

o Head : normochepali, deformity (-)
o Eyes : anemic (-/-), icteric (-/-), pupil reflex (+/+) isocore
o Noise : deformity (-)
o Mouth : cyanotic (-)
o Neck : enlargement of lymphnode (-)
Thorax-Cardiovascular
o Inspection : mass (-), lesion (-), movement of chest wall simetric, retraction
(-)
o Palpation : movement of chest wall simetric, tenderness (-), vocal fremitus (+)

normal, mass (-)

o Percussion: sonor in both lung, percussion pain (-)
o Auscultation :
Pulmo : vesicular in both lung (+/+), rhonchi (-/-), 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 unpalpable, defans muscular (-), mass (-),

ballotement (-)
Upper and Lower extremity:
Deformity (-), edema (-).

C. Neurological Examination

Motoric Strength
55
11
Sensory nerve examination
NN
--

Physiologic Reflex
o B/T/P/A
Sx
: +/+/-/ Dx
: +/+/-/Pathologic reflex : Cranial nerve examination : normal
Meningeal sign (-)

D. Urogenitalia physical examination

Costo vertebrae angle (CVA) region:

o Inspection: color same as the surrounding skin, mass (-), inflammation (-), scar
(-), hematome (-), bulging (-/-)
o Palpation : tenderness (-/-), mass (-), ballottement (-)
o Percussion : pain (-/-)
Suprapubic region
o Inspection: color same as the surrounding skin, mass (-), inflammation (-),
scar (+), sistostomy (-).
o Palpation : bladder distention (+), mass (-),
Genitalia externa:
o Scrotum : enlargement (-), mass (-)
o Penis : circumsicated, scar (-), urethral discharge (-), urine catheter (+)

Rectal toucher examination :

-

Perianal : wound (-), mass (-), hemorrhoid (-), fistula (-)

TSA : weak, rectal mucosa surface was smooth, ampula recti was not colaps, mass

unpalpable,
Prostate : palpable, flattening of sulcus (-), pole superior unpalpable, nodul (-),

consistency was firm.

No blood and feces in handschund.

IV. Summary
Patient complained about his inability to move his leg and void since three weeks ago
suddenly after he dive down to 35 meters deep. He can urinate properly after urinary catheter

attached in Praya General Hospital. he had history of bloody urination (+) after urinary
catheter removed in Praya General Hospital. he unable to feel the urge to urinate. Suprapubic
pain (-), when his lower stomach bulging, nausea (+), vomiting (-), dizzy (+). Micturition
pain (-),stone urination (-), fever (-). Patient felt numbness in the groin and his limb.
Defecation was abnormal. Patient also said that he unable to feel the urge to defecate.
General

condition

General

condition

Moderate;

Consciousness/GCS

compos

mentis/E4V5M6, blood pressure 130/80 mm heart rate: 84 bpm, respiration rate : 20 rpm,
temperature 36,4oC . In the physical examination on Suprapubic region found in inspection:
color same as the surrounding skin, mass (-), inflammation (-), scar (+), sistostomy (-).
Palpation : bladder distention (+), mass (-). Weaken Motoric strength and physiologic reflx on
lower limb found in neurological examination . Rectal toucher examination were giving
results no wound and mass in perianal ; TSA weakene, rectal mucosa surface was smooth,
ampula recti was not colaps, unpalpable mass ; prostate : palpable, flattening of sulcus (-),
pole superior unpalpable, nodul (-), consistency was firm ; no blood and feses in
handschound.
V. Working diagnosis

Retention urine et causa susp decompression syndrome

Paraplegi inferior et causa decompression syndrome

VI. Differential diagnosis

Retention urine et causa susp stricture uretra

VII. Plan Examination

Routine blood examination,

Urinalysis
Uretrografi
Uroflowmetri

VIII. Laboratory Examination (October, 14th 2013)

Hb
: 12,3 g/dl
Rbc : 4,02.106 /ul
Hct
: 35,9 %
MCV : 89,3 fl
MCH : 30,6 pg
MCHC: 34,3 g/dl
Wbc : 10,96.103/ul
Plt
: 411.103/ul
GDS : 97 mg/dl
Creatinin : 0,7 mg/dl
Ureum : 38 mg/dl

SGOT : 87 mg/dl
SGPT : 56 mg/dl
IX. Uretrography (October, 19th 2013)

Total Stricture uretra pars bulbosa

X. Theraphy
Blast puction
IVFD 20 dpm
Inj. Ceftriakson 1gr/12 hours
Inj. dexamethason 1amp/12 hours
Tranexamat Acid 3 x 500 mg per oral
Bladder training
Physiotherapy