Duty report

th
Friday, January 6
2016
Surgical resident : Andre Setiawan,
M.D.
Surgical interns : Agnes, Anne,
Nada, Yuvi.

Attending surgeons in
charge
Pediatric surgery
Digestive surgery
Sp. BD
Orthopedic surgery

: Irhami, M.D., Sp. B, Sp. BA

: Boediono Soehendro, M.D.,
: Jursal Harun, M.D., Sp. Ot

Plastic surgery
: Anastasia Dessy Harsono,
M.D., Sp.Bp-RE
Neurologic surgery: Handrianto Setiajaya, M.D., Sp. BS
Oncologic surgery : Agus Sutarman, M.D.,Sp.B(K) Onk
TCV surgery
Urologic surgery

: Deddy A. Zaelani, M.D., Sp. BV

: Robert Prasetyo, M.D., Sp. U

Patient's Resume
Outpatient 0
Inpatient 1
Operation 0

Mr. NY, 47 years old

( 845062)

Chief Complaint:

Pain on the right groin and the scrotum

History of present illness:

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 week ago, his abdomen distended, slightly increased by
the time. The patient became immobilised and bed ridden.
5 days ago, the patient had pain when urinating. It was
associated with fever without nausea nor vomitus
3 days ago patient had a bilateral scrotal pain. Within 1
day, the pain had spread. His scrotum and his right groin
became swollen, reddish, and tender. He also had a right
upper abdominal pain on since 3 days ago which wasnt
persistent but precipitated by greasy food

Mr. NY, 47 years old

( 845062)

History of past illnesses:

renal disease since 2 weeks ago.

DM (-). Gastritis (-), HT (-), previous surgery (-),

General findings
Fully alert
ABP 130/90 mmHg, HR : 85x/m , RR 22x/m, t 37,8o C
Head: normocephalic,
Eye: Pale eye-lids (-/-), icteric sclera (-/-)
Chest : Vesicular breathing sounds on both lungs,
rales (-/-), wheezing (-/-)
Heart : Normal heart sounds, no galloping rhythm,
nor murmur
Abdomen :
I
: distended
A : normal bowel sounds
P : supple, tenderness on upper right abdomen, no
muscle rigidity

Local findings
The right inguinal region and the scrotum
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