MORNING

REPORT
 Name : Mr. SN
Age : 50 Years old
Sex : Male
Address : Solou Agung
Admission :
Doctor in charge : dr. Syamsul Rijal., Sp.B

IDENTITY
 Chief Complain : Cannot urinate
Anamnesis : (autoanamnesis)
Patient came to the Hospital with complain cannot
urinate since 2 days before came to the hospital. with
abdominal pain at the lower quadrant suffered since 2
days. Feaver (-), Nausea (-), vomitting (-).
History with same complain (+),
has a history of urinary retention and is treated with a
HISTORY catheter. complaints returned and patients had
treatment at the puskesmas. at the puskesmas the
TAKING patient received catheter therapy but failed and blood
came out of the urethra.
 General Condition : Moderate illness

Conciousness : Composmentis,

Vital Sign :
◦ BP : 130/80 mmHg

◦ RR : 23x/m

GENERAL ◦ HR : 86x/m

STATE ◦ T : 36,50c
Normally

Normally

Normally
Normally
Normally
State Localized
Normally
Normally Normally

Normally

Normally
 Abdomen
 INS : Distanded, follow the move of breath
AUS : Peristaltic was normally
PAL : Tenderness (+), Defans muscular (-).
PER : Tympani (+)

LOKALIZE
D STATE
 Rountine Blood

PLAN OF
DIAGNOSTIC

USG Abdomen
Laboratory Finding
Parameter Result
WBC 17.24
RBC 4.67
HGB 14.0
HCT 40.2
MCH 30.0
MCHC 34.8
PLT 336
NEUT 76.0%
Documentation
 Retensi
urin ec.
DIAGNOSE
Ruptur
urethra
 IVFD

Antibiotic

MANAGEMENT Consult Urology

Analgetic

H2RA
THANK YOU