No.

1
Name : Mr. F Sex : Male
Age : 21 years old No. Reg : 630382

Chief complaint : Udem and pain at penis

Condition : Suffered since 1 week before admitted to the hospital.
There was no event of fever. There was history used
kemiri oil injected to his penis.
Defecation : Normally
Micturation : Normally
General Status
Moderate illness / well nourish / conscious

Vital Sign
BP : 120/80 mmHg
HR : 100x/mnt, strong, reguler,
RR : 24x/mnt, symmetric L=R, thoracoabdominal type.
T(Ax) : 36,9C
Secondary Survey
Abdomen :
I: Seen flat, follow breath moving, wound (-),
hematoma (+)
A : Peristaltic (+) normal
P : Tenderness (-)
P : Tapping pain (-) tympani (+)
Perianal region :
I : Seen skin colour more darkness from vicinity, hematoma (-),
udema (-) , wound (-)
P : Tenderness (-)

Penis region :
I : Seen not circumsised yet, abcess (-), pus (+), udema (+)
P : Tenderness (-)
 Laboratory Result
WBC : 12,64 x 103 / L

RBC : 4,19 x 106 / L

HGB : 12,7 g/dL

HCT : 35,8 %

PLT : 415 x103/ L

CT / BT : 800/200

Blood Sugar : 97 mg/dl

Ureum : 17 mg/dl

Creatinin : 0,7 mg/dl

GOT / GPT : 23/33 /L

WORKING DIAGNOSIS : Siliconoma penis

MANAGEMENT : Medicaments
Report to senior plastic surgeon
advice: