Professional Documents
Culture Documents
Indirect inguinal hernia is a type of hernia that is considered to be congenital lesion. The signs and symptoms are characterized by bulge, burning, pressure in the groin, pain, and discomfort when lifting or straining. It usually affects male and present during the first year of life, excessive straining and lifting of heavy objects, obesity, past history and familial history of hernia. According from the National Epidemiology center, from 2000 to 2010 Philippine health statistics, hernia incidence are likely to occur in older people 70 years and older with an average of 4.4 %.
II. Identifying data Name: Mr. ABC Patient ID: 107142 Age: 51 Gender: Male Nationality: Filipino Status: Married Address: Olongapo, City Religion: Roman Catholic Educational Status: High School Graduate Occupation: Farmer Date of Admission: 03/05/13 Time of Admission: 9:39 am Name of Hospital: James L. Gordon Memorial Hospital Diagnosis: Indirect Inguinal Right Hernia
A. Chief Complaint
Scrotal Bulging
B. History of Present Illness
Patient has intermittent pain in the groin area for the past 3 years especially during strenuous work that is relieved by mefenamic acid and rest.
D. Family Health History
Father Hypertension.
E. History of Medical Specialty
The client lives with his family in Camarines Sur. He used to chew nganga everyday since he was 36 years old; he drinks alcohol beverages once a month. He works on a farm and heavy lifting comes usually to his work. Their water resource is from a manual water pump.
F. Nutritional History
The client diet is consist of nutritional intake according to his satisfaction usually vegetables and fish.
A. General Appearance: Patient is lying flat on bed wearing patient gown afebrile with relax appearance. Cooperative and oriented with ongoing D5LR 1L at 700 ml inserted at the right cephalic vein regulated at 31 to 32 drops per minute. Infusing well. Weight: 59.5 kg Height: 159 cm BMI = 23.52 normal weight B. Vital signs: T: 36.5 c P: 72 bpm R: 20 cpm BP: 130/80 mmHg
BODY PART Skin TECHNIQUES Inspection BMI Categories: Underweight = <18.5 Normal weight = 18.524.9 Overweight = 2529.9 Obesity = BMI of 31 or greater
NORMAL FINDINGS The skin has minimum perspiration. -Free from lesions/rashe s
ACTUAL FINDINGS The skin has minimum perspiration. -Free from lesions/rashe s equal bilaterally, warm to touch No presence of tenderness Smooth, a certain amount of roughness can be normal. It returns to original contour immediately
INTERPRETATI ON Normal
Normal Normal
Palpation equal bilaterally, warm to touch No presence of tenderness Smooth, a certain amount of roughness can be normal. It should return to its original contour immediately.
Hair
Inspection
Hair varies from dark black to pale blonde. The body is covered by vellus hair and the terminal hair is evenly distributed. Hair may feel thin, straight, course, thick or curly.
Hair is black in color and evenly distributed The body is covered by vellus hair and the terminal hair is evenly distributed. Hair strands are thin, straight and shiny. Pinkish in color
Normal
Normal
Palpation
Normal
Nails
Inspection
Pink cast in light-skinned individuals, and brown in dark-skinned individuals. Smooth and slightly rounded or flat. Nail thickness should be uniform throughout Prompt return of pink or usual color should be 1-2 sec
Normal
Palpation
Head Size Symmetr y Inspection -Round, proportional to the size of the body -No areas of tenderness -Clean, free -Round, proportional to the size of the body -no areas of tenderness -Clean, free Normal
Palpation
Normal Normal
from masses, lumps, lice, nits, lesions but positive from dandruff
Hair Black Color Evenness of growth, thickness and thinness Scalp Inspection Inspection Thick and evenly distributed Black Normal Thick and evenly distributed Normal Palpation Smooth texture, no oiliness No areas of tenderness Face Skin color Facial movemen t Eyes Inspection Inspection Light to dark brown Symmetric facial features & movement -lids open and close symmetricall y and has frequently blinking reflex up to 20 times per minute Symmetrical in size, extension, hair texture and movement Dark brown Symmetric facial features & movement -lids open and close symmetricall y and has frequently blinking reflex up to 17 times per minute Symmetrical in size, extension, hair texture and movement Normal Normal Smooth scalp, no oiliness No areas of tenderness Normal Normal
Inspection
Normal
Eyebrows
Inspection
Normal
Eyelashes
Inspection
Normal
Eyelids Conjuncti va
Inspection Inspection
Distributed evenly and curved upward Same color as the skin Pinkish palpebral and bulbar conjunctiva no lesion or drainage present Smooth, symmetric with same color as the face
Distributed evenly and curved upward Same color as the skin Pale palpebral and bulbar conjunctiva no lesion or drainage present Smooth, symmetric with same color as the face
Normal Abnormal
Ears
Inspection
Normal
Nose
Inspection
Normal
Mouth Lips Buccal mucosa Gums Inspection Inspection Inspection Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface 32 adult teeth Firmly set, white and shiny Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface 30 adult teeth Brown and black discoloration of the enamel Pink, moist symmetric Pink, soft, moist Dark, moist, symmetric Pink, soft, moist Abnormal Abnormal Normal
Tongue
Inspection
Normal
Teeth
Inspection
Abnormal
Neck
Inspection
Proportional to the size of the body and head No palpable lumps or areas of tenderness Free from lesions and scars Chest symmetric, spine vertically aligned. Full and symmetric expansion.
Proportional to the size of the body and head No palpable lumps or areas of tenderness Presence of 3cm scars on left midscapular line Chest symmetric, spine vertically aligned. Full and symmetric expansion. Percussion notes resonate except over the scapula. Excursion is 3-5cm bilaterally. Vesicular and bronchovesic ular breathe sounds. Presence of 2 cm scar on midsternal line Symmetrical chest movement
Normal
Palpation
Normal
Posterior Thorax
Inspection
Abnormal
Palpation
Normal
Percussion
Normal
Normal
Auscultation
Percussion notes resonate except over the scapula. Excursion is 3-5cm bilaterally. Vesicular and bronchovesic ular breathe sounds.
Normal Normal
Anterior Thorax
Inspection
Abnormal
Normal Normal
Auscultation
Respiratory rate within normal range [16 20 cpm] Trachea is bronchial and tubular in sound Abdomen Inspection Skin color same as the body, symmetric movement Clicks or gurgling sounds occur irregularly and range from 5-35 per minute Percussion Tympany over stomach and gas-filled bowels; dullness over the liver and spleen or full bladder No tenderness, relaxed abdomen Liver may not be palpable, no tenderness, boarders feels smooth Tenderness may be
Respiratory rate of 25 cpm Normal Trachea is bronchial and tubular in sound Skin color same as the body, symmetric movement Gurgling sounds occurred irregularly 30 times per minute Normal There is tympany over stomach and gas-filled bowels Normal No tenderness, relaxed abdomen Palpable liver, no tenderness, boarders feels smooth Presence of tenderness near xiphoid Normal
Normal
Bowel sounds
Auscultation
Normal
Palpation (Light)
Normal
Palpation (Deep)
Normal
Normal
present near xiphoid process or sigmoid colon Bladder not palpable Genitals Pubic hair Inspection Penis Inspection Penile skin intact slightly wrinkled and same color as the body skin Smooth and semifirm Scrotum Inspection Scrotal skin is loose and darker in color. Scrotum appears asymmetric Palpation Testicles are rubbery and smooth. Triangular distribution
Triangular distribution
Normal
Penile skin intact slightly wrinkled and same color as the body skin Smooth and semifirm
Normal
Palpation
Normal
Scrotal skin is loose and darker in color. Marked asymmetry in size of right scrotum (right scrotum is larger) Testicles are rubbery and smooth.
Abnormal
Normal
Inguinal Area
No swelling or bulges Extremiti es Inspection Upper Extremiti es -skin color same as the whole body, free from lesions and scars
bulges while client is bearing down -skin color is same as the whole body, Presence of tattoo on right deltoid region -free from masses, warm to touch no presence of edema and varicosities -free from masses, warm to touch Abnormal
Palpation -free from masses, warm to touch no presence of edema and varicosities Free from masses, warm to touch
Normal
Normal
Palpation
Normal