SURGICAL

PARADE
General Surgery
Saturday, March 20th
2021
Billy Pebrinatan, S.Ked
Ida Ayu Tungga Dewi, S.Ked

Supervisor :
dr. Darmo Sumitro, Sp.B

SECRETARIAT OF SURGICAL CLINIC

RSUD dr. DORIS SYLVANUS- FACULTY OF
MEDICINE UNIVERSITAS PALANGKA RAYA
PALANGKA RAYA
2021
Patient identity
Name : Mr. Emek
Age : 50 years old
Birthday Date : 14/03/1971
Religion : Islam
Room : Dahlia
Hopitalized date : 14/03/2021
Anamnesis Chief Complaint
a lump on the genitals

Present Of Illness
Pria berusia 50 tahun datang ke IGD RSDS
dengan keluhan terdapat benjolan di kemaluan,
nyeri dan berbau sejak 10 hari sebelum masuk
rumah sakit. Pasien mengkonsumsi obat anti nyeri
untuk mengurangi nyeri. Keluhan dirasakan
memberat sejak 2 hari sebelum masuk rumah
sakit, benjolan di kemaluan pecah, berisi nanah,
berbau dan nyeri terus menerus. pasien juga
mengeluh nyeri saat BAK dan BAB..
 Past illness
Anamnesis
• Hipertensi disangkal
• DM disangkal
• Alergi disangkal

Family History

• Hipertensi disangkal
• DM disangkal
 Personal and Social History
Anamnesis Patient rarely exercise or even doing physical
activity.

Review of system
Physical Examination
General Circumstances : Moderate
Pain Awareness : Composmentis
(E4V5M6)
VAS : 4
Vital Sign
Blood Pressure : 170/100 mmHg
Respiration Rate : 22 x /minute
Heart Rate : 80 bpm
SpO2 : 99 %
Temperature : 36,8⁰C
Physical Examination
Head : normocephal
Eye : Anemis conjunctiva (-), sclera ikterik
(-)
Neck : enlarged thyroid (-), mass (-),
enlarged lymph nodes(-), increased JVP (-)
Thorax examination
Pulmo
Inspectio
n (+/+)
Simetris
Retraction (-/-)
Palpation
Fremitus focal (+/+)
Chest expansion (+/+)
Percusion
Sonor (+/+)

Auscultatio
Vesicularn (+/+) , Rhonki (-/-) , Wheezing (-/-)
Thorax examination
Cardio
Inspection
Ictus cordis (-/-)

Palpatio
Ictusncordis palpation in intercostal
5 midclavicula sinistra
Percusion
Right bound: Ics 4 Parasternal Dekstra
Left bound: Ics 5 midclavicula Sinistra
Auscultation
S1 S2 single sound, murmur (-),gallop (-)
Abdomen examination
Abdomen
Inspection
Distension (-)

Auscultation
Bowl sound increased (+)

Palpation
Supel , Abdominal pain (-), defans
muscular (-)
Percusion
Timpani (+) in all region abdominal
Genital examination
Skrotum : Pain (+), Pus (+), Edema (+), Fistula (+), tissue necrosis (+)

Extremitas examination
Upper extremities warm (+/
+)

Lower extremities warm (+/+)

Upper extremities edema (-/-)

Lower extremities edema (-/-)

 Diagnostic

Clinical diagnostic
• Abses perianal
• Furunkel
Laboratory
examination
Haematology
Leukocyte : 12.640/uL
Haemoglobin : 12,7 g/dL
Haematocrit : 38,3%
Platelet : 775.000/uL

GDS : 124
Ureum : 41 mg/dL
Creatinin : 0,94 mg/dL

Na : 135 mmol/L
K : 4,8 mmol/L
Ca : 1,21 mmol/L
 Diagnostic
Working diagnose
• Abses Perianal
Operation
- Debridement
report
Therapy - Infus Nacl 0,96 -> 20 tetes permenit
- Ceftriaxone 2x1 g IV
- Ranitidine 2x50 mg IV
- Ketorolac 3 mg IV
- Cateter + urine bag
- Compress Nacl 0,96
 Thank You
Insert the Sub Title of Your Presentation