Detailed Treatment Process
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An 82-year-old man was hospitalized for treatment of urinary retention caused by benign prostatic hyperplasia. The following is the discharge summary. Department: Urology (Prostate) Admission time: October 9, 14:14 Discharge time: October 18, 14:55 Admission status (including main symptoms and signs): An 82-year-old man was admitted because of difficulty urinating. Admission diagnosis: 1. Benign prostatic hyperplasia, 2. Urinary retention, 3. Diabetes mellitus Laboratory results (including main findings on admission and discharge and dates) (Note: Missing results reflect the original record) October 10, urine microalbumin panel (sample: urine): urine creatinine 6570.60 μmol/L, urine microalbumin 199.74 mg/L ↑, urine albumin/urine creatinine 268.78 μg/mg ↑; October 10, urinalysis (sample: urine): urine glucose NEGATIVE, urine protein 1+, urine bilirubin NEGATIVE, urine urobilinogen 3.2 μmol/L, urine pH 8.5, specific gravity 1.015, urine occult blood 2+, urine ketones -, urine nitrite +, urine color straw yellow, urine clarity clear, urine leukocyte esterase 1+, microscopic transparent casts -----/LP, microscopic mucus threads -----/HP, epithelial cells -----/HP, microscopic granular casts -----/LP, manual microscopic red blood cells -----/HP, manual microscopic white blood cells -----/HP; October 10, urine sediment quantification (sample: urine): others ----, pathologic casts (sediment) 1/μL, yeast-like fungi -, small round cells (sediment) 2.50/μL, mucus threads (sediment) -, red blood cell morphology information uniform red blood cells?, conductivity 21.70 mS/cm, red blood cells (sediment) 62.2/μL ↑, white blood cells (sediment) 93.5/μL ↑, epithelial cells (sediment) 16.5/μL, casts (sediment) 0.7/μL, bacteria (sediment) 21449/μL ↑, crystals (sediment) +; October 10, urine nuclear matrix protein (NMP22) assay (sample: urine): urine nuclear matrix protein (NMP22) positive (+); October 10, B-type natriuretic peptide precursor (PRO-BNP) assay (sample: blood): NT-proBNP 570.80; October 10, hepatitis C antibody assay (Anti-HCV) (sample: blood): hepatitis C antibody (Anti-HCV) S/CO; October 10, carbohydrate antigen assay (CA724) (sample: blood): carbohydrate antigen 724 IU/mL; October 10, carbohydrate antigen assay (CA199) (sample: blood): carbohydrate antigen 199 22.40 U/mL; October 10, carbohydrate antigen assay (CA153) (sample: blood): carbohydrate antigen 153 3.10 U/mL; October 10, carbohydrate antigen assay (CA-125) (sample: blood): carbohydrate antigen 125 4.90 U/mL; October 10, PSA prostate-specific antigen P/T (imported) (sample: blood): prostate-specific antigen (PSA) 0.900 ng/ml, free prostate-specific antigen (fPSA) 0.17, fPSA/PSA 18.889% ↓; October 10, lung cancer tumor marker panel (sample: blood): cytokeratin 19 fragment (CYFRA211) ng/ml, neuron-specific enolase (NSE) ng/ml, squamous cell carcinoma antigen (SCC) ng/ml; October 10, parathyroid hormone-related peptide PTH (sample: blood): PTH pg/ml; October 10, carcinoembryonic antigen assay (CEA) (sample: blood): carcinoembryonic antigen (CEA) 0.78 ng/ml; October 10, alpha-fetoprotein heterogeneity assay (sample: blood): alpha-fetoprotein heterogeneity (ratio) <10%; October 10, hepatitis B quantification (sample: blood): hepatitis B surface antigen (HBsAg) IU/mL, hepatitis B surface antibody (Anti-HBs) mIU/mL, hepatitis B core antibody (Anti-HBc) S/CO, hepatitis B core IgM antibody (Anti-HBcIgM) S/CO, hepatitis B e antigen (HBeAg) S/CO, hepatitis B virus pre-S1 antigen; October 10, alpha-fetoprotein assay (AFP) (sample: blood): alpha-fetoprotein (AFP) 5.84 ng/ml; October 10, cardiac injury markers (sample: blood): troponin I 0.01 ng/ml, CK-MB 1.10 ng/ml, myoglobin 27.7 ng/ml; October 10, erythropoietin assay (sample: blood): erythropoietin 10.19 mIU/ml; October 10, C-reactive protein assay (CRP) (sample: blood): high-sensitivity C-reactive protein 2.1 mg/L; October 10, complete blood count (five-part differential) (sample: blood): white blood cells 5.30 × 10⁹/L, red blood cells 4.02 × 10¹²/L ↓, neutrophil percentage 64.90%, hemoglobin 142.20 g/L, lymphocyte percentage 25.7%, hematocrit 40.1%, monocyte percentage 6.3%, mean corpuscular volume 100.0 fL ↑, eosinophil percentage 2.4%, mean corpuscular hemoglobin 35.4 pg ↑, basophil percentage 0.7%, neutrophils 3.44 × 10⁹/L, red cell distribution width 12.60%, lymphocytes 1.36 × 10⁹/L, platelets 90.00 × 10⁹/L, monocytes 0.33 × 10⁹/L, mean platelet volume 7.9 fL, eosinophils 0.13 × 10⁹/L, basophils 0.04 × 10⁹/L, plateletcrit 0.07% ↓, platelet distribution width 14.5%, mean corpuscular hemoglobin concentration 355 g/L; October 10, reticulocyte count (Ret) automated (sample: blood): reticulocyte percentage 2.28% ↑; October 10, plasma antithrombin activity assay (AT-A) (automated) (sample: blood): plasma antithrombin activity (AT-III) 72.00% ↓; October 10, fibrin (ogen) degradation products assay (FDP) (sample: blood): fibrin degradation products (FDP) 1.10 mg/L; October 10, coagulation panel (anticoagulated) (sample: blood): prothrombin time (PT) 12.30 s, activated partial thromboplastin time (APTT) 28.80 s, plasma fibrinogen (FBG) 1.800 g/L ↓, prothrombin time-INR 1.03, thrombin time (TT) 19.40 s; October 10, B-type natriuretic peptide (BNP) assay (sample: blood): B-type natriuretic peptide (BNP) 159.0 pg/ml ↑; October 10, RPR+TPPA (sample: blood): Treponema pallidum specific antibody negative, TRUST titer negative; October 10, human immunodeficiency virus antibody assay (Anti-HIV) (sample: blood): human immunodeficiency virus antibody (Anti-HIV) negative; October 10, hepatitis C antibody assay (Anti-HCV) (sample: blood): hepatitis C antibody (Anti-HCV) 0.65 (-) S/CO; October 10, carbohydrate antigen assay (CA724) (sample: blood): carbohydrate antigen 724 0.99 IU/mL; October 10, lung cancer tumor marker panel (sample: blood): neuron-specific enolase (NSE) 8.40 ng/ml, cytokeratin 19 fragment (CYFRA211) 1.97 ng/ml, squamous cell carcinoma antigen (SCC) 0.80 ng/ml; October 10, parathyroid hormone-related peptide PTH (sample: blood): PTH 26.74 pg/ml; October 10, hepatitis B quantification (sample: blood): hepatitis B core antibody (Anti-HBc) 0.08 (-) S/CO, hepatitis B e antibody (Anti-HBe) 1.89 (-) S/CO, hepatitis B core IgM antibody (Anti-HBcIgM) 0.06 (-) S/CO, hepatitis B surface antibody (Anti-HBs) 2.00 (-) mIU/mL, hepatitis B surface antigen (HBsAg) 0.00 (-) IU/mL, hepatitis B e antigen (HBeAg) 0.447 (-) S/CO, hepatitis B virus pre-S1 antigen negative; October 10, serum fructosamine assay (glycated albumin) (sample: blood): glycated albumin 20.4% ↑; October 10, routine biochemistry + lipids (sample: blood): creatinine 66.70 μmol/L, albumin 30.10 g/L ↓, serum alkaline phosphatase 50.80 U/L, serum apolipoprotein A1 1.08 g/L, serum apolipoprotein B 0.70 g/L, serum apolipoprotein E 32.40 mg/L, serum direct bilirubin 4.80 μmol/L ↑, serum gamma-glutamyl transferase 26.31 U/L, glucose 4.82 mmol/L, potassium 3.56 mmol/L, serum lipoprotein(a) 38.41 mg/L, sodium 142.00 mmol/L, serum prealbumin 194.00 mg/L ↓, retinol-binding protein 24.70 mg/L ↓, serum total bile acids 5.30 μmol/L, serum total bilirubin 22.80 μmol/L ↑, serum triglycerides 0.97 mmol/L, total protein 49.25 g/L ↓, uric acid 344.80 μmol/L, urea 5.13 mmol/L, albumin/globulin ratio 1.57, globulin 19.2 g/L ↓, chloride 107.60 mmol/L, serum total cholesterol 4.12 mmol/L, high-density lipoprotein cholesterol 0.91 mmol/L ↓, low-density lipoprotein cholesterol 2.72 mmol/L; October 10, sex hormones panel (sample: blood): luteinizing hormone 13.09 IU/L ↑, follicle-stimulating hormone 15.71 ng/ml ↑, estradiol 45.00 pg/ml, progesterone 0.26 μg/L, testosterone 4.78 μg/L, prolactin 3.58 ng/ml ↑; October 10, anemia panel (sample: blood): vitamin B12 167.00 pg/ml ↓, folic acid 3.4 ng/ml, serum total iron-binding capacity 38.61 μmol/L ↓, ferritin 561.4 ng/ml ↑, transferrin 1.4 g/L ↓, iron 29.3 μmol/L, serum iron saturation 75.9%; October 10, serum free fatty acids assay (sample: blood): free fatty acids 0.38 mmol/L; October 10, cardiac enzymes (sample: blood): serum alanine aminotransferase 10.90 U/L, AST/ALT 1.0; October 10, plasma homocysteine assay (sample: blood): homocysteine 19.47 μmol/L ↑; October 10, cardiac function (sample: blood): serum aspartate aminotransferase 11.40 U/L ↓, serum creatine kinase 37.8 U/L ↓, lactate dehydrogenase 118.8 U/L ↓, serum creatine kinase-MB isoenzyme activity 9.00 U/L, serum indirect bilirubin 18.0 μmol/L ↑, estimated glomerular filtration rate (MDRD) 105 ml/min/1.73 m²; October 10, glycated hemoglobin assay (high-pressure liquid chromatography) (sample: blood): glycated hemoglobin 6.2% ↑; October 10, blood typing (ABO+RH) (gel) (sample: blood): ABO blood group O, Rh positive; October 10, blood type single-specificity antibody identification (sample: blood): antibody screen negative; October 10, thyroid-stimulating hormone assay (sample: blood): thyroid-stimulating hormone 3.63 μIU/ml; October 10, thyroid panel (sample: blood): thyroid-stimulating hormone 3.63 μIU/ml, thyroid peroxidase antibody <5.00 IU/ml ↓, reverse T3 0.94 nmol/L, thyroglobulin antibody 0.40 IU/L, thyroglobulin 4.57 ng/ml; October 10, thyroid panel (sample: blood): thyroid-stimulating hormone 3.63 μIU/ml; October 11, carbohydrate antigen assay (CA-50) (sample: blood): carbohydrate antigen CA50 15.62 IU/ml; October 11, HEV-Ab (sample: blood): hepatitis E antibody (Anti-HEV) IgM negative, hepatitis E antibody (Anti-HEV) IgG negative; October 11, carbohydrate antigen assay (CA24-2) (sample: blood): carbohydrate antigen 24-2 1.54; October 12, routine bacterial culture and identification (sample: urine): routine bacterial culture and identification Klebsiella oxytoca/(Raoultella planticola/Raoultella terrigena); October 12, urine culture with colony count (sample: urine): Klebsiella oxytoca/(Raoultella planticola/Raoultella terrigena) >100,000 cfu/ml ↑; October 14, (emergency) C-reactive protein assay (CRP) (sample: blood): high-sensitivity C-reactive protein 2.4 mg/L; October 14, complete blood count (five-part differential) (sample: blood): white blood cells 4.27 × 10⁹/L, basophils 0.01 × 10⁹/L, basophil percentage 0.3%, neutrophils 3.16 × 10⁹/L, neutrophil percentage 73.90% ↑, eosinophils 0.09 × 10⁹/L, eosinophil percentage 2.1%, lymphocytes 0.81 × 10⁹/L, lymphocyte percentage 18.9% ↓, monocytes 0.20 × 10⁹/L, monocyte percentage 4.8%, red blood cells 4.26 × 10¹²/L, hemoglobin 144.00 g/L, mean corpuscular volume 99.8 fL ↑, mean corpuscular hemoglobin 33.7 pg, mean corpuscular hemoglobin concentration 338 g/L, red cell distribution width 14.10%, hematocrit 42.6%, platelets 85.00 × 10⁹/L, mean platelet volume 7.0 fL ↓, platelet distribution width 15.7%, plateletcrit 0.06% ↓; October 14, plasma D-dimer assay (sample: blood): D-dimer 2.86 mg/L ↑; October 14, (emergency) amylase assay (sample: blood): amylase (dry chemistry) 77.00 U/L; October 14, emergency cardiac function (sample: blood): creatine kinase isoenzyme (dry chemistry) 30.00 U/L ↑; October 14, emergency biochemistry + electrolytes (dry chemistry) (sample: blood): magnesium (dry chemistry) 0.88 mmol/L, aspartate aminotransferase (dry chemistry) 15.00 U/L ↓, creatinine (dry chemistry) 54.5 μmol/L ↓, lactate dehydrogenase (dry chemistry) 270.00 U/L ↓, uric acid (dry chemistry) 296 μmol/L, total protein (dry chemistry) 52.50 g/L ↓, calcium (dry chemistry) 1.95 mmol/L ↓, albumin (dry chemistry) 30.80 g/L ↓, creatine kinase (dry chemistry) 46.00 U/L ↓, chloride (dry chemistry) 105.00 mmol/L, potassium (dry chemistry) 3.49 mmol/L ↓, gamma-glutamyl transpeptidase (dry chemistry) 28.00 U/L, phosphorus (dry chemistry) 1.14 mmol/L, blood glucose (dry chemistry) 6.8 mmol/L ↑, total bilirubin (dry chemistry) 23.70 μmol/L ↑, alanine aminotransferase (dry chemistry) 20.00 U/L ↓, urea (dry chemistry) 3.53 mmol/L, albumin/globulin ratio (dry chemistry) 1.42, globulin (dry chemistry) 21.70 g/L ↓; October 14, B-type natriuretic peptide (BNP) assay (sample: blood): B-type natriuretic peptide (BNP) 200.0 pg/ml ↑; October 15, cardiac injury markers (sample: blood): myoglobin (strip) 55.2 ng/ml, troponin I (strip) <0.05 ng/ml, CK-MB (strip) 1.90 ng/ml; October 15, (emergency) C-reactive protein assay (CRP) (sample: blood): high-sensitivity C-reactive protein 2.6 mg/L; October 15, complete blood count (five-part differential) (sample: blood): white blood cells 7.16 × 10⁹/L, basophils 0.01 × 10⁹/L, basophil percentage 0.1%, neutrophils 6.77 × 10⁹/L, neutrophil percentage 94.60% ↑, eosinophils 0.01 × 10⁹/L ↓, eosinophil percentage 0.1% ↓, lymphocytes 0.30 × 10⁹/L ↓, lymphocyte percentage 4.2% ↓, monocytes 0.07 × 10⁹/L ↓, monocyte percentage 1.0% ↓, red blood cells 4.20 × 10¹²/L, hemoglobin 144.00 g/L, mean corpuscular volume 98.3 fL, mean corpuscular hemoglobin 34.4 pg ↑, mean corpuscular hemoglobin concentration 350 g/L, red cell distribution width 13.80%, hematocrit 41.3%, platelets 96.00 × 10⁹/L, mean platelet volume 7.2 fL ↓, platelet distribution width 15.7%, plateletcrit 0.07% ↓; October 15, B-type natriuretic peptide (BNP) assay (sample: blood): B-type natriuretic peptide (BNP) 294.0 pg/ml ↑; October 15, (emergency) amylase assay (sample: blood): amylase (dry chemistry) 107.00 U/L; October 15, emergency cardiac function (sample: blood): creatine kinase isoenzyme (dry chemistry) <3.00 U/L; October 15, emergency biochemistry + electrolytes (dry chemistry) (sample: blood): blood glucose (dry chemistry) 13.1 mmol/L ↑, magnesium (dry chemistry) 1.19 mmol/L ↑, total bilirubin (dry chemistry) 22.20 μmol/L ↑, alanine aminotransferase (dry chemistry) 16.00 U/L ↓, urea (dry chemistry) 2.93 mmol/L, phosphorus (dry chemistry) 0.89 mmol/L, aspartate aminotransferase (dry chemistry) 12.00 U/L ↓, creatinine (dry chemistry) 51.6 μmol/L ↓, lactate dehydrogenase (dry chemistry) 272.00 U/L ↓, uric acid (dry chemistry) 236 μmol/L, total protein (dry chemistry) 52.40 g/L ↓, alkaline phosphatase (dry chemistry) 51.00 U/L, creatine kinase (dry chemistry) 23.00 U/L ↓, calcium (dry chemistry) 1.91 mmol/L ↓, albumin (dry chemistry) 29.70 g/L ↓, gamma-glutamyl transpeptidase (dry chemistry) 26.00 U/L, chloride (dry chemistry) 100.00 mmol/L, potassium (dry chemistry) 3.96 mmol/L, sodium (dry chemistry) 132.00 mmol/L ↓, albumin/globulin ratio (dry chemistry) 1.31, globulin (dry chemistry) 22.70 g/L ↓; October 15, plasma D-dimer assay (sample: blood): D-dimer 1.13 mg/L ↑; October 15, anti-insulin antibody assay (sample: blood): insulin autoantibody 12.06 RU/ml Special examinations (including X-ray, electrocardiogram, endoscopy, isotope scans, etc., and dates) October 10, ultrasound: hepatic cyst; bilateral carotid artery atherosclerosis. October 10, chest CT plain scan: nodular lesion in the posterior basal segment of the left lower lobe, inflammatory nodule? Small subpleural nodules in both lungs, follow-up recommended. Small pericardial effusion, aortic atherosclerosis. Treatment course (including surgery and dates) After admission, the patient completed relevant auxiliary examinations. On October 14, transurethral holmium laser prostatectomy was performed under general anesthesia. The operation went smoothly. Postoperatively, the patient received urinary catheter drainage, nutritional support, monitoring, anti-infection treatment, and other supportive care. The patient recovered well and was discharged after review by the attending physician. Pathology diagnosis: pending Discharge diagnosis: 1. Benign prostatic hyperplasia, 2. Urinary retention, 3. Diabetes mellitus Discharge status (including main symptoms and signs): The patient had a normal diet and sleep, no abdominal pain or distension after eating, no cough, and clear urine. Physical examination: vital signs stable, heart and lungs normal. Abdomen without abnormal signs. No redness or stenosis at the urethral meatus. Discharge instructions: 1. Rest adequately, maintain good nutrition, engage in appropriate activity, and drink plenty of water. 2. Keep stools soft and regular; avoid strenuous exercise and cycling for 3 months. 3. Follow-up urinary system ultrasound and PSA regularly. 4. Return to the urology outpatient clinic for follow-up. 5. If difficulty urinating recurs or the urine stream becomes thin, seek medical attention promptly for appropriate management. 6. Bladder function is currently poor; perform clamp training on the catheter for 2 weeks after discharge and then monitor urination. The patient requires follow-up. Follow-up physician: not specified. The patient has pending pathology results (please return to the hospital within one month after discharge to inquire about the pathology report). The above is the discharge summary. After discharge, the patient never regained the ability to urinate. In other words, the surgery did not achieve its intended purpose, and the patient has since relied on an indwelling urinary catheter for bladder drainage.