IDENTITY

Name : Mr. A
Age : 19 years old
Sex : Male
Address : Budi Utomo
Admission : july, 14th 2017
DPJP : dr. M Jabir, Sp.U
 HISTORY TAKING
Chief complain : Swelling in the scrotum
Anamnesis :
Patient referrals from Lepo-lepo Medical Health Care with swelling in
the scrotum since 7 days ago. At first the swelling was small and then
enlarged. Patient also complain of pain that is felt to spread to the groin area.
Patient said the pain is like the burning pain. Another complaint is pain during
urination, urinate a little bit, there was not blood, there was not sandy urine.
Patient feel dissatisfied when urination. Pasient had to urinate 4-7x times a
day.
History of the disease (+) 1 month ago, History of higien (patient rarely
change panties, have sex more than one women), History of fever (+) 3 hour
ago, History of pain during recurrent urine (+). Defecated is normally. There
was complain malaise (+), dizzy (+), nausea (+), vomiting (+) 3x today.
Physical examination

The patient was composmentis with moderate ill.

BP = 120/80 mmHg
Pulse = 82x/m, regular, strong
RR = 20x/m, symmetric, thorakoabdominal type
Temperature = 37.0oC
 Generalized state

Head : Normally
Face : Normally Extremity
Eyes : Normally Superior : Noemally
Nose : Normally Inferior : Normally
Mouth : Normally
Ears : Normally .
Neck : Normally
Abd : Normally
 LOCALIZED STATE

Abdomen
INS : Flat, follow the motion of breath
AUS : Peristaltic was normally.
PER : tymphani, liver deaf (+)
PAL : Tenderness at inguinal dextra region
 LOCALIZED STATE

Genetalia
Inspection : Udem in the right scrotum like a apple with
size 8x6 cm, Red is scrutal color.
Palpation : Tenderness (+), sotf (+)
CLINICAL FINDING
Diagnoses
Orchitis
PLANNING
THERAPY
EXAMINATION
Complete Blood IVFD RL
Count Analgetik
USG Testis
Anti inflamasi
Urine catheter
H2 Reseptor Agonis
Consult Urology
LABORATORY FINDINGS
Chemist
Leukosit : positive ++
Protein : positive +
PH : 6,5
Blood : Moderate
Sedimen
Leukosit : positive +++
Erytrosit : positive +++
Epitel sel : positive +++
LABORATORY FINDINGS

WBC : 14,95 x 103/uL

HGB : 15,0 g/dL
PLT : 241 x 103/uL
 Thank You

BAGIAN ILMU
BEDAH