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    Laporan Jaga Urologi: IGD - 18 Maret 2018

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    Bayu Adhitya
    This document summarizes a urology night shift report from an emergency department on March 18, 2018. It describes a 45-year-old male patient who presented with pain in his scrotum that had been ongoing for 1 week. On examination, the patient was found to have a fistula in his perineum and infected scrotum. Laboratory tests were performed. The reported treatments included IV fluids, antibiotics, analgesics, and antacids.

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    Laporan Jaga Urologi: IGD - 18 Maret 2018

    Uploaded by

    Bayu Adhitya
    22 views13 pages
    This document summarizes a urology night shift report from an emergency department on March 18, 2018. It describes a 45-year-old male patient who presented with pain in his scrotum that had been ongoing for 1 week. On examination, the patient was found to have a fistula in his perineum and infected scrotum. Laboratory tests were performed. The reported treatments included IV fluids, antibiotics, analgesics, and antacids.

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    This document summarizes a urology night shift report from an emergency department on March 18, 2018. It describes a 45-year-old male patient who presented with pain in his scrotum that had been ongoing for 1 week. On examination, the patient was found to have a fistula in his perineum and infected scrotum. Laboratory tests were performed. The reported treatments included IV fluids, antibiotics, analgesics, and antacids.

    Copyright:

    © All Rights Reserved
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    Download as pptx, pdf, or txt
    22 views13 pages

    Laporan Jaga Urologi: IGD - 18 Maret 2018

    Uploaded by

    Bayu Adhitya
    This document summarizes a urology night shift report from an emergency department on March 18, 2018. It describes a 45-year-old male patient who presented with pain in his scrotum that had been ongoing for 1 week. On examination, the patient was found to have a fistula in his perineum and infected scrotum. Laboratory tests were performed. The reported treatments included IV fluids, antibiotics, analgesics, and antacids.

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    Laporan Jaga Urologi

    IGD - 18 Maret 2018


    IDENTITAS
     Nama : Tn. D
     Usia : 45 tahun
     Alamat : Jl. Pagar Alam Rawa Depok
     Agama : Kristen
     Status : Sudah menikah
     Pekerjaan : Pedagang
     Tanggal pemeriksaan : 18 Maret 2018

    Pasien datang ke IGD RSDP Serang pukul 19.40 WIB


    ANAMNESIS
     KU: Nyeri pada buah zakar
     RPS:
    Pasien datang ke IGD RS Dr. Dradjat Prawiranegara Serang dengan
    keluhan nyeri pada buah zakar (skrotum) yang dirasakan ± sejak 1 minggu
    SMRS. Pasien mengatakan jika awalnya terasa gatal kemudian pasien
    menggaruknya dan menjadi lecet, kemerahan dan terasa perih. Pasien juga
    mengatakan jika sejak 1 tahun yang lalu pasien BAK melalui dubur dan
    apabila akan BAK pasien harus mengedan. Riwayat BAK berpasir/batu (-),
    BAK bernanah (-), riwayat trauma pada saluran kencing (-), nyeri pinggang
    (-). Pasien mengatakan ± 6 bulan yang lalu pasien berobat ke RS Cibitung
    Bekasi dengan keluhan yang sama dan dicoba dipasang selang kencing
    tapi tidak bisa masuk. Pasien mengatakan selama ini hanya mengkonsumsi
    obat anti nyeri yang dibeli sendiri di apotek untuk meredakan nyerinya.
    Pasien mengatakan pada tahun 1991 pasien mengalami kecelakaan dan
    dilakukan operasi laparatomy.
    ANAMNESIS

     Riwayat penyakit terdahulu :


    Hipertensi (-), Diabetes mellitus (-)

     Riwayat penyakit keluarga :


    Hipertensi (-), Diabetes mellitus (-)
    PEMERIKSAAN FISIK

     KU : tampak sakit sedang


     KS : compos mentis (GCS : E4M6V5)
     TTV
     BP : 130/700 mmHg
     HR : 90 x/m
     RR : 21 x/m
     T: 37,1 °C
    STATUS GENERALIS

     Kepala dan wajah : bentuk normosefali, tanpa deformitas


     Mata : konjungtiva pucat (-/-), pupil isokor 2 mm, RCL +/+,
    RCTL +/+
     Telinga : bentuk normal
     Hidung : bentuk normal
    STATUS GENERALIS
     Thoraks :
     I : bentuk dan pergerakan simetris saat statis dan dinamis
     P: chest expansion simetris. Tactile vocal fremitus sama kanan
    dan kiri
     P: sonor di seluruh paru
     A: ronkhi (-/-), wheezing (-/-), murmur (-/-)
    STATUS GENERALIS
     Abdomen :
     I : bentuk datar
     A: BU (+)
     P: timpani di seluruh lapang abdomen, pekak hati (+)
     P: defans muskular (-), hepatosplenomegali (-)
    STATUS GENERALIS

     Ekstremitas atas :
    Akral hangat, CRT < 2 detik, edema (-/-)
     Ekstremitas bawah :
    Akral hangat, CRT < 2 detik, edema (-/-)
    STATUS UROLOGIS
    Regio Flank/CVA kanan kiri
     Tanda radang (-) (-)
     Ballotement (-) (-)
     Nyeri tekan (-) (-)
     Nyeri ketok (-) (-)
     Massa (-) (-)
     Jaringan parut/ bekas operasi (-) (-)

    Suprapubik : Bulging (+), hiperemis (-), bekas luka (-), massa (-), nyeri
    tekan (+)
    Genitalia : Sirkumsisi (-), letak OUE normal, darah (-), terpasang kateter (-),
    massa (-), skrotum tampak kemerahan, nyeri tekan (+), tampak fistula di
    perineum ± 0,5 cm.
    DIAGNOSIS

     DIAGNOSIS KERJA :
    Fistula regio perineum + infeksi skrotum

     DIAGNOSIS BANDING :
    -
    PEMERIKSAAN PENUNJANG

    Hasil Nilai Rujukan

    Hemoglobin 11,1 g/dL 12,00 – 15,30

    Hematokrit 31,6 % 35,00 – 47,00

    Trombosit 328.000 140.000 – 440.000

    Leukosit 6.800 4.400 – 11.300


    TATALAKSANA

     IVFD RL 20 tpm
     Inj. Ceftriaxone 2 x 1 g
     Inj. Ketorolac 3 x 1 amp.
     Inj. Ranitidine 2 x 1 amp.

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