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2
Chief complain : Swelling on the scrotum
Present history of disease :
Patient came to ER and complaint about his scrotum which become swelling since
three days ago. The patient says that the swelling is suddenly appear when the
patient take a rest. The complaint start with pain on his scrotum which appear
suddenly too. The pain appear intermittently and than become more painful when
the patient walked. After swelling, patient feel shiver, but now fell better. Pup and
pee is normal.
Past history of disease : Hemoroid (-), HT (-), chronic cough (-), mumps disease (-)
Family history of disease : (-)
Social history : Patient is unemployment, daily just doing mild activity, sexual activity
is deny
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Blood Preasure : 100/60
Heart Rate : 117 times per minute
Respiratory Rate : 20 times per minute
Temperature : 37,8 ˚C
SpO2 : 99%
General state : Moderate illness
GCS : E4V5M6
Head : Normocephal
Eye : anemic conjungtive(-/-), icteric sclera(-/-)
Ear : otorhagia (-/-)
Nose : Rhinorea (-/-)
Mouth : pale (-) ,cyanosis (-)
Neck : palpable lymph node (-)
Cor : S1/2 Single, reguler, Murmur (-), Gallop (-)
Pulmo
– Inspection : symmetrical chest expansion
– Palpation : crepitation (-) tenderness (-)
– Perkusi : Sonor (+/+)
– Auskultation : Vesikuler (+/+) , Ronchi (-/-), Wheezing (-/-)
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Abdomen:
Inspection : flat
Ausculation : bowel sound (+) normal
Palpation : Supel, tenderness (-)
Percussion : Tympanic
Genitalia :
a/r scrotum (D)
Inspection : Redness (+), swelling (+), lesion (-)
Palpation : tenderness (-), warm (+), Phren test (-), consistency semi hard
Auscultation : Bowel sound (-)
Extremities:
Warm
edema (-/-)
CRT < 2 sec
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a/r scrotum (D)
Inspection : Redness (+), swelling (+), lesion (-)
Palpation : tenderness (-), warm (+), Phren test (-), consistency middle hard
Auscultation : Bowel sound (-)
Hemoglobin 15,00 g/dL 13,00-18,00
eritrosit 6,22 x10^6/uL 4,50-6,20
hematokrit 54,0 % 40,0 – 54,0
MCV 86,7 fl 81,0-96,0
MCH 24,2 pg 27,0 -36,0
MCHC 27,9 g/dL 31,0 -37,0
Leukosit 29,01 x 10^3 /uL 11,0-16,0
Neutrofil 25,58 x 10^3 /uL 1,50-7,00
Monosit 2,04 x 10^3 /uL 0.00-0,70
Trombosit 236 x 10^3 150-400
PT 11,6 detik 10,8 – 14,4
APTT 40,00 detik 26,4 -37,6
Glukosa 109 mg/dL 70-150
BUN 8,0 mg/dL <48
Cr 0,90 mg/dL 0,7 -1,3
Orchitis dd Epididimitis
10
UL
USG
11
Mefenamic acid 3x500 mg (PO)
Cotrimoxazole 2x960 mg (PO)
Paracetamol 3x500 mg (PO)
THANK YOU
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