Admission

No Identity/Age to ER Diagnose Treatment

1. Tn. Arnold Marbun/ admitted Clinical diagnosis : Treatment in ER:

48 th/ L/ RM PM, 7rd Urinary Retension IVFD NS 30 dpm
1231988 April 2019 Inj. Paracetamol 3 x 1 gr
Etiological diagnosis : Drip Ciprofloxacin 2 x 200 mg
Meatal Stricture Insertion of 6 FR Foley Catheter

Complication diagnosis : Consult to Urology surgery:

Urinary tract Infection Hospitalized
Other diagnosis :
Trombositopenia +
Penektomi a/i Tumor Penis
 Tn. Arnold Marbun/ 48
th/ L/ RM 1231988
Chief Complain: couldn’t urinate
History taking :
Patient Complaint Can’t Urinate 2 days before admission. In These 7 days He
urinate with little quantity and he awake frequently in the night only to urinate. In
last 2 days, he felt difficult to urinate and must strain when urinate but urin out
with dripping. Patients also complaints fever since 1 month ago the fever is felt
high and Intermittent. The patient is a sailor. Chills (+), high fever (+), sweating (+)
after fever. Patients consume Paracetamol medicine to stop fever. Nausea (-),
vomiting (-), shortness (-). It was only taken to the hospital because the patient
returned to sea 1 day ago. The patient had a history of penile tumors 2 years ago
and had surgery. The patient has undergone amputation due to ca penis 2 years
ago.
History of past illness : (-)
History of family illness : (-)
Vital Sign
BP : 97/72 mmHg
RR : 24 x tpm
HR: 140x bpm, (strong and regular pulse)
Temp : 39,6oC
VAS : 5/10
SpO2 : 98% without O2 supply
Physical Examination
• pale conjungtiva (-/-), sclera icteric (-/-)
Head/Neck • enlargement lymph node (-)

• I : symmetric respiratory movement, retraction (-), bruise (-)

Chest • P : sonor at all lung fields
• A : vesicular breath sound, rhonchi (-), wheezing (-)

• I : distension (-), mass (-), inguinal mass(-),

• A : bowel sound (+) 5x/minute
Abdomen • P : firm, tenderness (+) at suprapubic, H/L/M not palpable
• P : tympani (+)

Extremities • Warm extremities (-), parase (-), edem (-), pale extremity (-)
 Urologic Status
CVA :
• I : flat, lesion (-), hematom (-), mass (-)
• Pal : kidney not palpable, mass not palpable, tenderness (-/-)
• Per : knocked kidney pain : (-/-)
Flank area :
• I : flat, lesion (-), hematom (-), mass (-)
• P : tenderness (-/-), mass (-)
Suprapubic
• I : bulging (+), mass (-), scar (+), hematom (-)
• P : tenderness (+), mass (+) soft consistency, immobile (+)
• Per : dullness
Genitalia
• Penis : erythema (-), swelling (-), tenderness (-) penis (-)
• OUE : bloody discharge (+), pus (-), OUE at Perineum post
Digital Rectal Examination
• Mass (-), laceration(-), fistle (-), skin tag (-), anal cushion (-)
• spinchter ani tone : within normal limit
• ampulla recti was not collapse
• mucosa recti : smooth surface
• Prostate: symmetric, top pole palpable, sulcus mediana palpable,
nodule (-).
• BCR (+)
• Handscoon : feses (+), blood (-), mucus (-)
Clinical Picture
 Laboratory Finding
Pemeriksaan Hasil Nilai Rujukan

Hemoglobin 14,1 12,00-16,00 g/dl

Leukosit 9,2 4,0-10,5 ribu/ul

Eritrosit 4,87 3,90-5,50 juta/ul

Hematokrit 41,1 37,00-47,00 vol%

Trombosit 125 150-450 ribu/ul

RDW-CV 13,0 11,5-14,7 %

MCV 84,4 80,0-97,0 f

MCH 29,0 27,0-32,0 pg

MCHC 34,4 32,0- 38,0 %

Gran% 87,6 50.0-70.0

Limfosit% 11,0 25.0-40.0

MID% 1,1 4.0-11.0

 Laboratory Finding
Pemeriksaan Hasil Nilai Rujukan

GDS 173 <200

SGOT 25 0-46 U/l

SGPT 17 0-45 U/l

Ureum 31 10-50 mg/dl

Creatinin 1,46 0,7-1,4 mg/dl

Natrium 132 135-146 mmol/l

Kalium 3,9 3,4-5,4 mmol/l

Chlorida 100 95-100 mmol/l

 Urinalysis Laboratory (April 7rd 2019)
Examination Result Normal Value

Color - turbidity Clear-yellowish Clear-yellow

Density 1.015 1,005 -1,030
pH 7.0 5.0 -6.5
Ketone Negative Negative
Protein-Albumin Negative Negative
Glucose Negative Negative
Bilirubin Negative Negative
Blood 1+ Negative
Nitrit Negative Negative
Urobilinogen 2.0 0,1-1,0
Leucocyt 3+ Negative
Urinalysis Laboratory (April 7rd 2019)
Examination Result Normal Value

Lekosit Plentiful 0–3

Eritrosit 0–3 0–2
Epithel 1+ 1+
Crystal Negative Negative

Silinder Negative Negative

Bacteria 3+ Negative
Other Negative Negative
Diagnosis
Clinical diagnosis :
Urinary Retension

Etiological diagnosis :
Meatal Stricture

Complication diagnosis :
Urinary tract Infection

Other diagnosis :
Trombositopenia + Penektomi a/i Tumor Penis
Management

Treatment in ER Consult to urology surgery:

• IVFD NS 30 dpm • Hospitalized
• Inj. Paracetamol 3 x 1 gr
• Drip Ciprofloxacin 2 x 200 mg
• Insertion of 6 FR Foley Catheter