Mr. Nurdin, Male, 44 y.

o (11/08/1976)
1877992/BPJS
Consultant dr. Ali Sundoro, SpBP-RE(K)
Admitted 26/11/2020 Consult 04/12/2020

Diagnosis:
Plastic Reconstructive and Aesthetic Surgery
• Defek regio scrotalis ec post ND ec abses scrotalis; Post orchidopexy + tutup defek dengan
STSG POD 5

Surgery History:
• History of necrotomy debdidement due to scrotal abscess ( 10/12/2020, Hasan Sadikin Hospital)
• History of Left nephrolithotomy (2016, Dustira Hospital)
• History of Necrotomy debridement (26/11/2020, Hasan Sadikin Hospital)

General Status
• GCS E4M6V5, TD: 126/65 HR 90 x/minutes, RR 20 x/minutes (SpO2 99% room air). S 37 oC
 Mr. Nurdin, Male, 44 y.o (11/08/1976)
1877992/BPJS
Consultant dr. Ali Sundoro, SpBP-RE(K)
Admitted 26/11/2020 Consult 04/12/2020

Clinical Pictures 04/12/20

 Mr. Nurdin, Male, 44 y.o (11/08/1976)
1877992/BPJS
Consultant dr. Ali Sundoro, SpBP-RE(K)
Admitted 26/11/2020 Consult 04/12/2020

Clinical Pictures 05/12/20

 Mr. Nurdin, Male, 44 y.o (11/08/1976)
1877992/BPJS
Consultant dr. Ali Sundoro, SpBP-RE(K)
Admitted 26/11/2020 Consult 04/12/2020

Clinical Pictures 06/12/20

 Mr. Nurdin, Male, 44 y.o (11/08/1976)
1877992/BPJS
Consultant dr. Ali Sundoro, SpBP-RE(K)
Admitted 26/11/2020 Consult 04/12/2020

Clinical Pictures 07/12/20

 Mr. Nurdin, Male, 44 y.o (11/08/1976)
1877992/BPJS
Consultant dr. Ali Sundoro, SpBP-RE(K)
Admitted 26/11/2020 Consult 04/12/2020

Pre OP 10/12/20
 Mr. Nurdin, Male, 44 y.o (11/08/1976)
1877992/BPJS
Consultant dr. Ali Sundoro, SpBP-RE(K)
Admitted 26/11/2020 Consult 04/12/2020

Intra Op 10/12/20
 Mr. Nurdin, Male, 44 y.o (11/08/1976)
1877992/BPJS
Consultant dr. Ali Sundoro, SpBP-RE(K)
Admitted 26/11/2020 Consult 04/12/2020

Post Op 10/12/20
 Mr. Nurdin, Male, 44 y.o (11/08/1976)
1877992/BPJS
Consultant dr. Ali Sundoro, SpBP-RE(K)
Admitted 26/11/2020 Consult 04/12/2020

Clinical Picture 13/12/20

 Mr. Nurdin, Male, 44 y.o (11/08/1976)
1877992/BPJS
Consultant dr. Ali Sundoro, SpBP-RE(K)
Admitted 26/11/2020 Consult 04/12/2020
Laboratory Result
Complete Blood Count
No. Parameter Normal 27/11/20 02/12/20
1 Hemoglobin 10.5-13.5 14.1 11.9
2 Hematocrit 33-39 40.5 34.0
3 Leukocyte 6000-17000 21.160 13.110
4 Platelet 150000-450000 414.000 521.000
5 Natrium 135-145 139 -
6 Potassium 3.5-5.1 3.6 -
7 Calcium Ion 4.5 – 5.6 - -
8 Albumin 3.5-5.0 2.37 1.96
9 Ureum/Creatinin 15.0-39/0.80-1.30 40.2/1.31 -
10 SGOT/SGPT 15-37/16-63 - -
11 GDS <140 99 -
12 Anti SARS-CoV-2 Non-reactive Non-reactive -
13 PCR SARS-COV 2 Non-reactive - -
 Mr. Nurdin, Male, 44 y.o (11/08/1976)
1877992/BPJS
Consultant dr. Ali Sundoro, SpBP-RE(K)
Admitted 26/11/2020 Consult 04/12/2020
Complete Blood Count Laboratory Result
No
Parameter Normal 03/12/20 07/12/20 13/12/20
.
1 Hemoglobin 10.5-13.5 - - 9.7
2 Hematocrit 33-39 - - 29.2
3 Leukocyte 6000-17000 - - 7690
4 Platelet 150000-450000 - - 629000
5 Natrium 135-145 132 - 136
6 Potassium 3.5-5.1 4.1 - 3,9
7 Calcium Ion 4.5 – 5.6 - -
8 Albumin 3.5-5.0 2.57 - 1,87
9 Ureum/Creatinin 15.0-39/0.80-1.30 39.0/0.91 - 42,2/1,03
10 SGOT/SGPT 15-37/16-63 - - 26/107
11 GDS <140 109 -
Anti SARS-CoV-
12 Non-reactive - -
2
PCR SARS-
13 Non-reactive - Non-reactive
COV 2
 Mr. Nurdin, Male, 44 y.o (11/08/1976)
1877992/BPJS
Consultant dr. Ali Sundoro, SpBP-RE(K)
Admitted 26/11/2020 Consult 04/12/2020

Pus Culture 27/11/20

 Mr. Nurdin, Male, 44 y.o (11/08/1976)
1877992/BPJS
Consultant dr. Ali Sundoro, SpBP-RE(K)
Admitted 26/11/2020 Consult 04/12/2020
X-RAY Thorax PA
RSHS, 27/11/2020
 Mr. Nurdin, Male, 44 y.o (11/08/1976)
1877992/BPJS
Consultant dr. Ali Sundoro, SpBP-RE(K)
Admitted 26/11/2020 Consult 04/12/2020
Management
Plastic Reconstructive and Aesthetic Surgery • Metronidazole 3 x 500 mg IV
• Wound toilet with nacl 0,9 % and • Omeprazole 2 x 40 mg IV
chlorhexidine , wound care with gause • Paracetamol 3 x 500 mg PO
fluffy , tie over , and hypafix • Albumin 20 % 100 cc
• Diet 1500 kkal with extra eggs • VIP Albumin 3x1
• IVFD NaCl 0.9% 1500cc/24 jam
• Cefepime 3 x 1 g IV