Laporan Jaga

Jumat, 6 Januari 2017

Residen Bedah: Andre Setiawan,

M.D.
Koass: Agnes, Anne, Nada, Yuvi.

Patient's Resume
Outpatient 0
Inpatient 1
Operation 0

Mr. NY, 47 tahun( 845062)

Keluhan Utama:
Nyeri pada pangkal paha kanan dan skrotum

Riwayat penyakit sekarang:

The patient had history of decreased passing his waters
since 2 weeks ago. It had been associated with swelling of
both lower extremities. It was not associated with pain nor
rednes. The swelling resolved whenever herise his lowerextremities higher than his body
1 minggu yang lalu, perut pasien membesar, semakin
bertambah setiap harinya, pasien menjadi tidak dapat
bergerak dan selalu di tempat tidur
5 hari yang lalu, pasien nyeri saat BAK. Dimana terdapat
demam, tanpa adanya mual maupun muntah.
Tiga hari yang lalu, pasien mengeluh nyeri pada kedua
skrotum, dan semakin membrat, pada bagian skrotum
menjadi bengkak, memerah dan nyeri. Pasien juga
mengeluhkan nyeri pada bagian perut kanan atas sejak 3

Mr. NY, 47 years old

( 845062)

History of past illnesses:

Gangguan ginjal sejak 2 minggu yang lalu

DM (-). Gastritis (-), HT (-), Riwayat operasi (-),

General findings
Fully alert
TD 130/90 mmHg, HR : 85x/m , RR 22x/m, t 37,8o C

Kepala: normocephalic,
Mata : Konjungtiva anemis (-/-), sklera ikterik(-/-)
Paru : versikular (+), rhonki (-/-), wheezing (-/-)
Jantung : BJ 1 2 Normal, gallop(-) murmur (-)
Abdomen :

I
A
P
P

:
:
:
:

cembung
bising usus normal
supel, nyeri pada perut kanan atas
tympani

Extremities:
Edema
deformitas, CRT < 2

(+/+)

pitting,

tidak

ada

Local findings
Regio inguinal kanan dan skrotum
Bengkak, merah, dan nyeri...
Swollen, reddish and tender, no fluctuation,
no lump on the right inguinal and the scrotum
Both testicles were normal, same in size

Rectal toucherl : TSA was good, the ampula

was not collapsing, pain at 12 oclock
position, no mass, smooth mucous lining,
glove: feces (+), blood (-), mucine (-)

Urologic findings
Flanks
: CVA tenderness -/ Supra symphysis : pain on palpation with no
palpable
mass, the bladder was
empty.
EUO
: no stenosis at EOU,
discharge
(-) ,

Laboratory
results
TBC
Electrolytes

12,2(g/dL)/(Ht)35(%)/(Leu) 2.880(mL)/(tro)232.000 (mL)

(Hb)

135(mmol/L)/(K)3,5(mmol/L)/(Cl)116(mmol/L)

(Na)

PT/APTT

1.1x/1x

Blood sugar

136(mg/dL)

SGOT/SGPT
Ur / Cr
Urinalysis

31(U/L)(alt)35(U/L)

(ast)

91mg/dL)/(Cr)3,0

(Ur)

(mg/dL)

Color : yelowish/ clarity : cloudy/ Spesific

grafity : 1,025/ pH 5,5/ protein (-) /
glucose (-)/ ketones (-) / blood (+++) /
Bilirubin (-)/ urobilinogen (-) / nitrit
(-)/ leucocyte esterase (-)/ bacteria
(+)

Abdominal sonography
Sonographic findings
Bilateral renal cysts
Right renal cysts :
2,4x2,5cm
Left renal cysts : 2x2,5cm

Thickness of gall
bladder, no stone, no
sludge appearance
An ascites was noted

Working diagnosis
Right inguinal and scrotal cellulitis
Urinary tract infection
Bilateral renal cysts
Cholecystitis
Chronic kidney disease

Management
Observe the vital signs
Antibiotic
Analgesic
To be admitted

Todays condition

Thank you for your

attention