Laporan kasus ruptur uretra

BAGIAN ILMU BEDAH FAKULT FAKULTAS KEDOKTERAN KEDOKTER AN

LAPORAN KASUS

UNIVERSITAS UNIVERS ITAS PATTIMURA

APRIL 2014

RUPTUR URETRA

Oleh: Muhammad Ali Samuda NIM. 2008-83-050

Pembimbi!: Dr. Ahmad Tuahuns, Sp.

DIBA"AKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK  BAGIAN ILMU BEDAH RUMAH SAKIT UMUM DAERAH DR# M# HAULUSS$ FAKULTAS AKULTAS KEDOKTERAN KEDOKTE RAN UNIVERSITAS UNIVERS ITAS PA PATTIMURA

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AMBON A I !AP"RAN #ASUS

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: T# L#

U&i%

: 41 '%h(

)ei& Kel%mi

: L%*i+l%*i

Al%m%'

: Be'e! K%,%!

S'%'(& Pe,*%-i%

: Mei*%h

Pe*e,.%%

: Pe*e,.% le/%&

A!%m%

: K,i&'e P,'e&'%

T%!!%l M%&(* RS

: 1  02  14

ANAMNESIS

Dil%*(*% %('%%me&i& /%3% '%!!%l 22 Feb,(%,i 2014

#$luhan U%ama

Pe,3%,%h% 3%,i &%l(,% *emih

Ri&a'a% P$n'a(i% S$(aran)

P%&ie 3%'%! 3e!% ,(.(*% 3%,i RSUD T(leh( Amb 3e!% *el(h% /e,3%,%h% 3%,i &%l(,% *emih &e.%* 1 h%,i SMRS# D%,%h *el(%, mee'e& be,-%,% me,%h &e!%, 'i3%* be,5%m/(, 3e!% (,i# P%&i P%&ie e me! me!%* %*( ( &%%' &%%' i!i i!i  BAK BAK 3i,% 3i,%&% &%*% *% 6e, 6e,i# i# BAK BAK *el( *el(%, %, &e3i &e3i*i *i'' 3% 3% be,5%m be,5%m/( /(,, 3%,% 3%,%h# h# Sebel(m6% Sebel(m6% /%&ie me!%l%mi *e5el%*%% &%%' *e,.% &%%' %i* 3i%'%& lem%,i ('(* me!e5%' 3i3i! 3e!% *e'i!!i% 2 me'e, *em(3i% /%&ie .%'(h /(bi&6% 'e,be'(, /e6%!!% *(,&i 7'e,b(%' 3%,i *%6(8 6%! be,%3% 'e/%' 3i b%-%h lem%,i *em(3i% 'e,.%'(h 3%,i *(,&i *el%'%i 3e!% be'(,% me!e%i /i!!%! *%%# Se'el%h .%'(h /%&ie &em/%' me,%&% 'i3%* 3%/%' b%!( &ehi!!% 3ib%'(

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 /%&ie *e RSU H%(l(&&6 ('(* me3%/%' /e%!%% l%.('%# P%&ie 3i ,(.(* 3e!% 3i%!&i& &eme' &eme'%,% %,% S(&/e5' S(&/e5' R(/'(,e R(/'(,e U,e', U,e',%# %# P%&ie P%&ie me!%*( me!%*( &%%' &%%' .%'(h .%'(h *e/%l% *e/%l% 'i3%* 'i3%* 'e,be' 'e,be'(, (, /i!&% /i!&%  3i&%!*%l m('%h 3i&%!*%l#

Ri&a'a% P$n'a(i% Dahulu

+

Ri&a'a% P$n'a(i% #$luar)a

+

PEMERI#SAAN *ISI#

Ke%3%% (m(m : '%m/%* &%*i' &e3%! Ke&%3%,%% : 9m/& me'i&

Tanda +i%al

Te*%% 3%,%h

: 120;0 mmH!

F,e*(ei %3i

: ;4 *%limei'

F,e*(e&i %/%&

: 24 *%limei'

S(h(

: ; ?9

STATUS ENERA!IS 

#$pala  N,m5he/%l De@,mi'%& 7+8



Ramu%  Hi'%m l(,(& 'e,&eb%, me,%'% 'i3%* m(3%h 3i5%b('#



Ma%a  K.(!'i% %emi& 7++8 &*le,% i*'e,i* 7++8 /(/il b(l%' i&*, 3i%me'e, < mm< mm

,e@le*& 5%h%6% l%!&(! 3% 'i3%* l%!&(! 78



hygiene b%i* Mulu%  M(*&% *e,i! 7+8 oral hygiene b%i*



&e,(me 7++8 6e,i 'e*% 7++8 6e,i '%,i* '%,i* 7++8 ',e 7+8 T$lin)a  N,m'i% &e*,e' 7++8 &e,(me

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

!$h$r  )VP C+2 5mH2O *ele.%, 'i,i3 3% *ele.%, !%'%h bei! 'i3%* 'e,%b% membe&%,



Paru 



I&/e*&i : Sime',i& &%%' &'%'i& m%(/( 3i%mi&



P%l/%&i : E*&/%&i 3%3% b%i* vocal fremi fremitus tus *i,i  *%%



Pe,*(&i : S, /%3% /%,( *i,i 3% *%%



A(&*(l'%&i : S(%,% %/%& e&i*(le, ,*hi ++ wheezing ++



1an%un) 



I&/e*&i : I*'(& *,3i& 'i3%* 'e,lih%'



P%l/%&i : I*'(& *,3i& 'e,%b% /%3% I9S V 1 .%,i me3i%l lie% mi3*l%i*(l% &ii&',%



Pe,*(&i : B%'%& .%'(! 3%l%m b%'%& ,m%l



A(&*(l'%&i : B(6i .%'(! I+II ,e!(le, m(,m(, 7+8 gallop 7+8 gallop 7+8



Adm$n 



I&/e*&i : D%'%, .e.%& 7+8



P%l/%&i : T(,!, b%i* defans muscular 7+8 6e,i 'e*% 78 /%3% ,e!i &(/,% /(bi& he/%, 3% lim/% 'i3%* 'e,%b% membe&%,



Pe,*(&i : Tim/%i /%3% &el(,(h %b3me



A(&*(l'%&i : Bi&i! (&(& 78 ,m%l



 E(s%r$mi%as : A*,%l h%!%'  e3em% ++++

STATUS UR"!"I 

Sudu% s% +$r%$ra$ 

I&/e*&i : m%&&% ++ .e.%& 

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

R$)i suprapuis 



I&/e*&i : m%&&% 7+8 .e.%& 7+8



P%l/%&i : b(li+b(li *&! 6e,i 'e*% 78



Pe,*(&i : ,e3(/



$ni%alia $(s%$rna



Hi/e,emi& 7+8 be!*%* 7+8 6e,i 7+8 &e*,e' 7+8 3%,%h OUE le'%* ,m%l



S*,'(m : be.l% 7+8 '%3% ,%3%! 7+8 'i3%* membe&%, 

PEMERI#SAAN PENUN1AN T%!!%l 1+02+2014   /EMAT"!"I Hem!lbi Hem%'*,i' Le(*&i' T,mb&i' E,i',&i'

#imia (lini( SGOT SGPT U,e(m 3%,%h K,e%'ii 3%,%h GDS

, 32 # 1C0 3.40

5 2< 83 .8 10=

!3l  ,ib((l ,ib((l  .('%(l

Ul Ul m!3l m!3l m!3l

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