Urology Morning Report

Thursday, November 26th 2020

Consultant in Charge :
Dr. Bambang S. Noegroho, dr., SpB, SpU(K)

Residents On Duty :
Adit / Andrey / Ruli
 Mr. Nurdin / 44 y.o /1877992 / EMG Department
DPJP : Dr. dr. Bambang S Noegroho, SpB. SpU(K)
Admission time : 04.15
Decision time : 04.30

Chief complaint: Swelling at scrotal region

Patient complained of swelling at scrotal region since 10 days prior to admission.
Previously the swelling was small swelling then enlarged to sized 8x8 cm. The
complaint was accompanied by pain and redness in scrotal region. Patien also
complained of intermitent fever since 1 weeks ago.
History of cloudy urine was admitted 3 weeks ago. History of reddish, sandy, and
passing stone in urine were denied. There were no histories of difficulty to urinate,
small urine stream, and pain when urinate. There were no history of trauma at
external genitalia region. History of silicone injection was denied. There were no
histories diabetes melitus, hypertension, and hemodialysis. Previous urology surgery
was admitted (nephrolitotomy, 2016 Dustira Hospital). Daily urine production was
1500ml/24hrs, yellowish.
 PHYSICAL EXAMINATION
General State:
Alert
BP : 140/93 mmHg RR : 21 x/min
HR : 84 x/min Temp : 37,2 0C

Urological State:
At right and left flank region : no ballotement, no tenderness, no tenderness on CVA percussion At
suprapubic region : bladder was empty, no tenderness
At external genitalia region : meatal stenosis (-)
At scrotal region : edema (+/+), hyperemis (+/+), tenderness (+/+), crepitation (+/+), fluctuation
(+/+), testis intact (+/+)
DRE: Anal spinchter tone (+), smooth mucousal surface, ampulla was not collapse, prostate
palpated 20 gr, symmetric, soft no nodule, BCR(+) normal
 LABORATORIUM
Parameter 27/11/20 Urinalysis 27/11/20

Hb/ Ht 14,1/40,5 Specific gravity 1.015

Leukocyte/ pH 6.0
Thrombocyte 21.160/414.000
Erytrosit 20-29
BUN/Cr 40,2/1,3
Na/potassium 139/3,6 Leukocyte >50

GDS 99

Protein/ Albumin 7,8/2,4

PT/ aPTT/ INR 12,10/26,70/1,10

Clinical picture
We diagnose this patient with
Scrotal abscess + Hypoalbuminemia + History of Left nephrolithotomy
(2016, Dustira Hospital)

Plan
Drainage incision + necrotomy debridement
LAPORAN
LAPORANOPERASI
OPERASI
26
26November
November2020
2020
 OK
OK407
407
1. Tn. E. O. Saprudin / 74 thn / Fresia 3 / dr. Sawkar Vijay Pramod, SpU(K)
Dk/ CKD ec obstruktif uropathy ec infiltrating urothelial Ca Buli T4bN3M0 + Riwayat TURBT (tidak habis)
(November 2019, RS Al Islam) + Riwayat nefrostomi sinistra (Januari 2020, RSHS) + Riwayat kemoterapi
neoadjuvant 12x
Th/ Paliatif cystectomy + UCN bilateral
OK
OK407
407
 OK
OKERCP
ERCP
1. Tn. Suripto/ 64 thn / ODS / dr. Kuncoro Adi, SpU(K) / dr. Gugum
Dk/ Retensi urine ec striktur uretra pars pendulare + BNC + Riwayat cystostomy perkutan (September 2020,
RSHS) + Riwayat TURP (2015, RS Salamun)
Th/ Urethrosistografi bipolar
 OK
OKERCP
ERCP

Plain Full bladder Miksi

Post miksi
 OK
OK401
401
1. Tn. Abdullah/ 26 thn/ Fresia 1/ dr. Ricky Adriansjah, SpU(K)
Dk/ Infertilitas primer ec Varicocele bilateral grade II + Teratozoospermia
Th/ Ligasi varicocele bilateral
Terima kasih