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May 16
th
2014
Name : Mr. EO
Age : 34 years old
Sex : Male
Address : Bakunase
Job : -



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IDENTITY
Chief Complaint :
Swelling at the left scrotum
MOI :
The patient came to ER complained of pain and swelling at the left
scrotum realized since 2 day ago. The swelling and pain persist. The pain
especially when his walk. Nausea (-), vomiting (-), defecation (+),
urination pain (+). Fever (+) history of lifting heavy weights (-).
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ANAMNESIS
GCS : E4V5 M6
Vital sign : BP 120/70 mmHg, Pulse 100 x/mnt, temp
37,5
o
C, RR 20x/mnt
Eye : anemic (-), light reflex (+/+), icteric (-)
Ear : In normal limit
Nose : In normal limit
Throat : Normal

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physical examination
THORAX
Inspection : chest development simetrics, reguler,
abdominothoracal
Palpation : vocal fremitus R=D
Percusion : sonor (+/+)
Auscultation : vesicular (+/+), ronchi (-/-),
wheezing(-/-)


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ABDOMEN
Inspection : distended, mass (-), scar (-)
Auscultation : peristaltic (+) normal , metallic
sound (-)
Palpation : tenderness pain (-) , mass (-)
Percussion : timpanic sound (+)


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Local State
Inspection : mass (+), perisltaltic movement (-)
translumation test (-), inflammation (-), scar (-)
Auscultation : peristaltics sound (-)
Palpation : tenderness pain (+), bowel
mass (+), testicle (+/+)


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EXTREMITY

Look
normal
Feel
normal
Move
ROM : normal


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Planning Diagnostic
UL, DL
USG scrotum

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Orchitis
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ASSESSMENT
Ketorolac 1% 1 amp/iv
Ciprofloxacin tab 2x1


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THERAPY