CASE REPORT

By: Izacha Hatma Panganugraha
(NIM 201510401011016)
Preceptor : Dr. dr. Bambang Arianto, Sp.B, FINACS
A. PATIENT IDENTITY
 Name
 Age
 Address
 Job
 Last education
 Coming to polyclinic

: Mr. AS
: 26 Years Old
: Surabaya
: Employee of Superindo
: Senior High School
: 31 May 2016, 12.00

B. SUBJECTIVE
PRIMARY SURVEY
Airway :
Corpus alenium (-)
Maksilofacial trauma (-)
Additional breath sounds (-)
Gaps (-)
Breathing :

I : Normochest, symmetric, retraction (-), RR: 20x/minute
P: Movement of the chestwalls symmetric, crepitation (-),
deviated trachea (-),widened ICS (-)
P : sonor/ sonor
A : breath sound vesicular +/+, Ronchi -/-, Wheezing -/-

Circulatiom : HR : 90x/mnt
Blood pressure : 120/80mmHg
Warm akral (+,+,+,+)
CRT < 2 detik
Disability :
Exposure :

GCS : 456
Round pupil isokor 3mm/3mm
(-)

SECONDARY SURVEY
 Main complaint :
Lump in the right scrotal sac.
 HISTORY OF PRESENT ILLNESS :
Patient come to the Surgeon Polyclinic General Hospital of Haji
Surabaya with complaint lump in the right scrotal sac has experienced
1

It disappears when the patient is lying down. Initially only a small lump as big as guava. Nausea (-). GENERAL STATUS : General state : Good enough. retraction (-) P : Movement of the chestwalls symmetric. SOCIAL HISTORY : The patient is an employee in superindo. symmetric. For the first time. history of any  operation in abdomen is denied. after long stand. His work is lifting goods in the company  ALLERGIES HISTORY : Denied C. this lump can in and out. Gallop (-). and more enlarged until now. crepitation (-). widened intercostals space (-) P : sonor/ sonor A : breath sounds vesicular +/+. Ronchi -/-. no other complaints. HISTORY OF PAST ILLNESS: Chronic cough (-). Weight: + 55 kg Blood pressure :120/80 mmHg HR : 90 x/minute RR : 20x/ minute Tax : 36. Murmur (-) COR 2 .5 oC Head/Neck : A-/I-/C-/DThorak s I : Normochest. defecate and  urinate are normally. vomiting (-). eat and drink as usual. and straining. it usually occurs when the patient is cough. flatus (+).since 1 years ago and this is a painless lump. Wheezing -/- I : Ictus does not seem P : Ictus no palpable. history of such illness is denied. thrill (-) P : heart border normal A : S1S2 single. deviated trachea (-). But now the lump is stagnant especially for 2 weeks.

hiperemi (-). SGPT.Fasting H. translumination test (-) o P : palpable lump (+). consult to surgeon . ziement test.Abdomen I : Flat simetris P : Soepel .Infusion RL 2200 cc/24 hours . mobile.Thorax photo PA . tenderness (-) finger tes. UL. P : Meteorismus (+) A : bowel sounds (+) normal Ekstremitas : o Warm akral + + + + o Oedema o Cyanosis - o CRT < 2 dtk D. BUN. H/L/R no palpable. swelling (-). mass (+) solid. supple. DIAGNOSIS Hernia inguinalis lateralis irreponible dextra F. SC G. clear boundaries. tenderness (-). PLANNING THERAPY . LOCALIST STATUS Regio inguinal-scrotalis dextra o I : Mass (+). and tumb test: not performed o A : Bowel sounds (+) E.Complete laboratory analysis for pre operation: DL. PLANNING MONITORING 3 .Pro Herniotomy. SGOT. PLANNING DIAGNOSIS: .

Patient complaints.- General state Vital sign. The picture of patient: 4 .