Identity

Name Age Sex Address : Mr. DS : 38 years old : Male : Amarasi

Anamnesis
Chief Complaint : Pain on the scrotum. The patient came to ER because he continuous pain on the scrotum since 3 day ago. Its begin from the scrotum, then the pain in the lower right abdomen too. The patient also complaint about swelling of the scrotum since 3 day ago, and the swelling is not change due toe change of position. Fever (+), history of intermitten swelling of the scrotum(-), pain during urination (+) no blood, history of STD (+) , history of same complaint (-)

Physical Examination
GCS : E4 V5 M6 Vital Sign:
RR BP Pulse Temp : 22 times per minute : 100/80 mmHg : 92 times per minute : 37,10C

 Eye (-/-) Ear Nose Throat

: anemic (-/-), light reflex (+/+), icteric : Normal : Normal : Normal

Thorax
Inspection : chest development simetrics, reguler, abdominothoracal respiration Palpation : vocal fremitus R=D Percusion : sonor (+/+) Auscultation : vesicular (+/+), ronchie (-/-), wheezing (-/-)

Abdomen
Inspection : flat, distended (-), mass (-) Auscultation : peristaltics + normal Palpation : tenderness pain (+) on the lower right quadrant , mass (-) Percusion : timpany sound (+)

Genitalia
Inspection : swelling of the scrotum dextra and sinistra, simetris, hiperemis. Palpation : left testis is felt, right testis hard to be evaluated. Tenderness pain (+),

Extremity
Look normal Feel normal Move
ROM : normal

Assesment
Susp. Orchitis

Planning diagnostic
Urinalysis CBC

Laboratorium
CBC WBC RBC HGB HCT MCV MCH MCHC PLT

: 22.25x 103/uL : 6.18 x 106/uL : 16.8 g/dL : 48.4 % : 78.3 fL : 22.8 pg : 29.1 pg : 390 x 103/ul

Working Diagnosis
Orchitis

Treatment
IVFD RL 20 dpm Ceftriaxon 2x1 gram IV (ST) KTC 3x1 amp iv

TERIMA KASIH