No.

Name : Mr. J Sex : Male

Age : 65 years No. Reg : 655405

Chief complaint : Bloody urinate

History taking : The condition had been apparent since 3 months
admitted to the hospital and aggravates in the last 1
week. The condition accompanied by pain. Prior
medical care at Takalar hospital
Symptom & sign : Pain, bloody urinate
Examination : Physical examination, laboratory examination, USG
abdominal, chest x-ray
Physical Examination
Right abdomen :
I: Seen flat, follow breath moving, wound (-) ,
hematoma (+), skin colour same with vicinity
A : Peristaltic (+) normal
P : Tenderness (+) at the whole abdomen,
defance (+)
P : Tympani (+)
Urologycal states

Costovertebra region :
I : skin colour same with vicinity, allignment normal,
gibbus (-) , edema (-), hematoma ()
P : Tenderness (-)

Suprapubic region :
I : bulging (-), wound (-), skin colour same with
vicinity,
P : Tenderness (-)
Genitalia external region

Perianal region :
I : Seen skin colour more darkness from vicinity,
hematoma (-), udema (-) , wound (-)
P : Tenderness (-)
Penis region :
I : Seen circumed, OUE normal, hematoma (-), udema (-),
meatal bleeding (-)
P : Tenderness (-)
 Digital Rectal Examination
Sphincter was tight
Mucous was smooth
Ampulla was empty, mass tumour (-)

Gloves : blood (-), feces (+), slime (-)

 Laboratory Result
WBC : 21,6 x 103 / μL

RBC : 2,98 x 106 / μL

HGB : 8,4 g/dL

HCT : 25,2 %

PLT : 284 x103/ μL

CT / BT : 7‘00” / 3’00”

Blood Sugar : 96 mg/dl

Ureum : 17 mg/dl

Creatinin : 0,8 mg/dl

GOT / GPT : 251/223 μ/L

 Urinalisis
Colour : red lecosit sediment : full

pH : 7,0 eritrosit sediment : full

Bj : 1,020

glucose : negative

urobilinogen : Normal

bilirubin : Negative

keton : +1/5

nitrit : Positive

Blood : +5/250

Lekosit : +3/500
Chest X-ray
Pelvis X-ray
Abdominal CT Scan
Abdominal USG