Patient List

No Identity Admission to Diagnosis Treatment

E.R.
3. Mr. Mahyuni April 24th Post sectio alta due Urine VS Obs
retention due to Prostate IVFD RL
41yo/1-14 -86-65 2015 at 20.30
WITA
hyperplasia + HIL dextra Inj antibiotic
reponible Inj analgesic
Inj H2Blocker

Complete blood count

Consult to Urology surgeon:

USG Urology
PSA
Consult to Digestive
department
Hospitalized

Consult to digestive surgeon:

Treat the HIL first
Planing herniotomy +
hernioraphy

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3. Mr. Mahyuni 41yo/1-14 -86-65
April 24th 2015 at 20.30 WITA
Chief Complain :
Post Operation
History :
1x24 hours before admission, the patient was underwent surgery due to his
prostate enlargement which caused him unable to miction. They were planned to
put permanent cable to him, but according to his family and the nurses, the
surgery was unsuccessful due to adhesion. The patient got referred shortly
afterwards.
The patient has history of unsatisfying miction since a year ago. It was frequent and
usually painful. The patient often awoken at night to urinate. He also have to
push to put it out. 1 day before admission, the patient was unable to urinate at all.
He got catheter installment at Buntok Hospital before got referred to Ulin
Hospital. Patient has history lump on right groin for last 5 years. The lump came
out when the patient stand and release if patient lay down. There no history of
bloody stool, no history of abdominal distention, there no history of nausea and
vomitus.
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ECG
Vital Sign
BP : 120/80 mmHg
PR : 90 bpm
RR : 20 tpm
T : 36,7oC

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General Status

5 5 + +

5 5 + +
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Rectal Touche
Anal sphincter tone (strong)
Mucous membrane sleek and smooth
Ampulla recti was not collapsed
Mass was not palpable
Tenderness (-)
BCR (+)
Faeces (+) yellow, Blood (-)
Clinical Pictures

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Local Status

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Laboratory Result April 24th 2015
Items Result Normal Value Unit
Hemoglobine 13,44 14.00 - 18.00 g/dl

Leukocyte 12,2 4.0 10.5 thousand/ul

Eritrocyte 4,48 4.50 6.00 million/ul

Hematocrit 41,3 32.00 44.00 Vol%

Thrombocyte 385 150 450 Ribu/ul

RDW-CV 12,5 11.5 14.7 %

MCV 92,4 80.0 97.0 Fl

MCH 29,9 27.0 32.0 Pg

MCHC 32,4 32.0 38.0 %

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 Items Result Normal Value Unit

Gran% 80,3 50.0-70.0 %

Lymphosite% 14,6 25.0-40.0 %

MID% 5,1 4.00-11.00 million/ul

Gran# 9,8 2.50-7.00 Billion/ul

Limfosit # 1,8 1.25-4.0 Billion/ul

MID# 0,6 Billion/ul

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 Items Result Normal Value Unit
GDS 159 <200 Mg/dL

PT 10,8 9,9-13,5 Second

APTT 24,7 22,2-37,0 Second

INR 0,95

SGOT 47 0-46 U/l

SGPT 47 0-45 U/l

Ureum 54 10-50 mg/dL

Creatinin 1,2 0,7-1,4 mg/dL

Natrium 134,9 135-146 mmol/L

Kalium 4,1 3,4-5,4 mmol/L

Chloride 99,8 95-100 mmol/L

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Thorax X-Ray April 24th 2015

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BNO X-Ray April 23rd 2015 at Buntok Hospital
Impression:
Suspect Uretrhrolithiasis
DD Prostate calcification

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Copy of ECG on April 23rd 2015 at Buntok Hospital

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Working Diagnosis
ICH a/r cerebri dextra 9cc + IVH dextra +
Hydrochepalus+ Hemiparese sinistra

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Management
VS Obs
IVFD RL
Inj antibiotic
Inj analgesic
Inj H2Blocker

Complete blood count

Consult to Urology surgeon:

USG Urology
PSA
Consult to Digestive department
Hospitalised

Consult to digestive surgeon:

Treat the HIL first
Planing ------ Herniotomy elective
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ECG