CASE REPORT

Saturday, Sept 12th 2015

Team on duty
dr. Fahrul Razi
dr. Maria Meildi
dr. Aviecena Gatot
dr. Andrian
dr. Herdi Gunanta S
dr. Ahmad Muhtadi
dr. Syahmardani Ibnu
dr. Sanwinata Badiri
dr. M.IFani
dr. Moh. Iskandar
Patient identity
Name
Age
Sex
Address
CM
HP
Came at

(Jaga 1)
(Jaga 2)
(Jaga 5)
(Jaga 5)
(Jaga 5)
(jaga 5)
(Jaga 6)
(Jaga 6)
(Jaga 6)
(Jaga 6)

: Syamsyarif
: 77 years old
: Male
: Beurawe, Banda Aceh
: 1062826
: 081360606161
: 20.30

Date/h Examinati Laboratory

Radiology
Hour of
our
on hour
Examination Examination Diagno
patien
stics
t came
Sen Result Send Result
to ER
d
Sept,
12th,
2015
20.30

20.30

Chief complaint

20.40 21.50

20.45 21.00 21.00

Date/ho DPJP
ur
patient
out
from ER
Dr.
Jufriady
Ismy SpU

necrotic penile and cannot urinate

Patient illnes history
The patient came to Zainoel Abidin emergency room with chief complain necrotic
penile since 2 weeks. Initially, 1 weeks before patient urinated with bottle,
suddenly his penile trap with the bottle,after the bottle release his refuse medical
advice, now he came again to emergency room with necrotic penile and cannot
urinate. Patient was with speech impaired.
.
Physical examination
Primary Survey :
A: Clear
B: Spontaneous, RR = 18 breaths/minute
C: BP 120/70 mmHg, Pulse : 90 beats/minute
D: GCS = E4M6V5
E:L/S at the supra pubic:
L: distention (+)
F:Pain (+)
E:L/S at the penile:
L: necrotic wound (+), swelling (+), lacerated wound (-). Pinprick test (-)
F:Pain (+)
Secondary survey :
Head and neck
: In normal limit
Thorax
: In normal limit
Abdominal
: In normal limit
Upper extremity
: In normal limit
Lower extremity
: In normal limit
E:L/S at the supra pubic:
L: distention (+)
F:Pain (-)
L/S at the penile:
L: necrotic wound (+), swelling (+), lacerated wound (-), pinprick test (-)
F:Pain (+)
Digital Rectal examination:
TSA
: tight
Mucous
: smooth
rectal ampula : feses
Pain
: Prostat
: (+) volume 20-40 gram
Glove
: faeces (+), blood (-)

VAS : Moderate

Radiology result
Thorak :
In normal limit
Usg Doppler :
????
Assessments:
-Gangrene penile due to entrapment bottle
-CKD due to obstruction uropaty due chronic urine retention due to band at the penile
-Susp. BPH
-+ speech impaired
Management
IVFD RL 20 gtt/mnt
Inj. Ceftriaxon 1 gr/12 jam
Inj. Keterolac 1amp/8 jam
Inj. Ranitidin 1amp/12 jam
Laboratory examination
Radiology examination

Laboratory examination

HB
: 10,4 g/dl
HT
: 30 %
WBC
: 9.500 u/l
Platelet
: 395.000 u/l
CT/BT
: 7/2
Glucose ad random : 146 mg/dl
Ureum
: 234 mg/dl
Creatinin
: 8,58mg/dl

Diagnose
-Gangrene penile due to entrapment bottle (ICD 10 CM N48.89)
-CKD due to obstruction uropaty due chronic urine retention due to band at the penile
(ICD 10 CM M18.9)
-Susp. BPH (ICD 10 N40.1)
-Speech impaired
Consult to Urology surgery division:
Cystostomy emergency
Hospitalize
Total penectomy elective
Consult to interna medicine division:
Team wise with urology surgery division
Operative Report Urology Surgery
Incision 2 cm above umbilical
Perform cystostomy percutan initial 600 cc purulent
Post Operative Diagnose
Urine Retension
Susp BPH
Necrotic penis ec mekanical iskemic
Akut on CKD ec retensio kronis
Bilateral hydronefrosis
Speech impaired

Follow up

Date
14-09-15
AD 2

O
Pain ( - )

Vital sign
Blood Pressure :
120/80 mmhg
Pulse : 82 beats/mnt
RR : 20 breaths/mnt
E:L/S at the supra pubic:
L: distention (-)
F:Pain (-)
L/S at the penile:
L: necrotic wound (+),
swelling (+), lacerated
wound (-), F:Pain (+)
Urine : 50 cc / h
(cystostomy)

Urine Retension
Susp BPH
Necrotic penis ec
mekanical iskemic
Akut on CKD ec
retensio kronis
Bilateral
hydronefrosis
Speech impaired
Post
cystostomy

IVFD NaCl 0,9 %

20
drips/minutesInj.
Cefaforazon 1
gr/12hour
drip. metronidazol
500mg/8hour
Inj.Keterolac 3%
1amp/12hr(K/P)
Inj ranitidin
1amp/12jam (k/P)
Kalnex
500mg/8jam
Hospitalize
prepare for Total
Penectomy
elective