Surgery Case Report

September 1st 2020

Case 1: Hernia Scrotalis Sinistra Irreponibilis w/
Multiple Abdominal Tumor dd Nodules
•Name : Mr. NR
•Age : 20 years old
•Address : Tangerang
•Religion : Islam
•Occupation : Construction Worker
•Medical Record : 0899xx
•Admission Date : 30th August 2020
Anamnesis
A 20 year old male came to the ER with the presence of a lump in his left scrotum since 1
month ago. The complaint is also accompanied with difficulty of defecating (2-3 times per
week). There are no complaints of lump tenderness, nausea, and vomiting. Fever (-) cough
and sneeze (-). The lump cannot be pushed inward.

The scrotal lesion was being massaged by traditional therapist 2 weeks ago. After being
massaged, the lesion became very painful and the patient felt nauseous and vomited
frequently

History of hypertension and diabetes mellitus (-)

There are lumps that located in entire stomache with a big lump in the right region of abdomen
since he was born.

Family history (+) tumor

Physical Examination
•General appearance : Moderately ill
•Consciousness : Compos mentis (GCS: E4M6V5)
•Vital Sign:
❖ Blood Pressure : 110/80 mmHg
❖ Heart Rate : 88 beats/mins
❖ Respiratory Rate : 20 beats/mins
❖ Temperature : 36.8oC
Physical Examination
● Head & face : Normocephalic, deformity (-)
● Eye : CA -/-, SI -/-, isokor 3 mm, eye reflex (+/+)
● Neck : Lymph gland not palpable
● Thorax
○ I : Symmetrical chest expansion, no delayed movement
○ P : Symmetrical chest expansion, symmetrical tactile vocal fremitus, ictus cordis palpable in
SIC 5 LMCS
○ P : Sonor
○ A : VBS +/+, rhonchi (-/-), wheezing (-/-), S1 S2 reguler, murmur (-), gallop (-)
Physical Examination
● Abdomen
○ I: Flat, darm steifung (-), darm contour (-)
■ Multiple lumps throughout abdominal field, immobile, well demarcated
■ Single giant lump in upper right quadrant, hyperpigmented
■ Hyperpigmented skin scattered throughout abdominal field
○ A: Bowel sounds (+) normal
○ P: Tymphanic throughout all abdominal field
○ P: Supple, with slight tenderness in lower left quadrant, muscular defense (-)
● Extremity
○ Warm (+/+), edema (-/-), CRT <2secs
Physical Examination
Local Examination

● Lump in left scrotum

● Transillumination test (-)
● Bowel sounds in scrotum (+)
● Finger Test (+) teraba di ujung jari
● Tenderness in left scrotum (+)
Laboratory Result
August, 30th 2020 Result Reference
Result Reference Range
Range
Differential Count
Full Blood Count
Basophil 0 0-1
Hemoglobin 13.3 14.0-18.0
Eosinophil 0 1-3
Hematocrit 38 40-54

Erythrocyte 4.75 4.6-6.0 Neutrophil 83 50-70

Leukocyte 18300 4500-11500 Lymphocyte 9 20-40

Thrombocyte 568 150-450
Monocyte 8 2-8
MCV 80 80-94
Platelet Count 1647 1000-4000
MCH 28 26-32

MCHC 35 32-36 NLR 9.22 <3.13

Diagnosis
Hernia Scrotalis Sinistra Irreponibilis

Multiple abdominal tumor dd nodules

Plan
● IV line access + IVFD RL 20 dpm
● Consult to General Surgeon Specialist
● inj. ranitidin 2 x 1
● inj. ondansetron 3 x 1
● inj. ketorolac 3 x 30 mg
● inj. ceftriaxon 1 x 2 g
● USG testis
 CASE 2 : Obstructive Ileus
•Name : Mr. YA
•Age : 28 years old
•Address : Tangerang
•Religion : Islam
•Occupation : Cashier
•Admission Date : 22nd August 2020
PATIENT HISTORY
A 28 year-old male came to the ER, complained about abdominal pain since 1 day
before the admission. The abdominal pain initially started from the umbilical area
down to the lower side of the abdomen, the pain characteristically explained as
cramp around the lower area VAS 7-8 accompanied with abdominal distention.
There was no history of abdominal trauma.

The patient also complained about nausea and vomiting around 3 times since 12
hours before the admission, containing processed food and fluid without blood.
The patient also experienced dark stool yesterday. Watery stool (-)

The patient complained about experiencing prolonged micturition, incomplete

bladder emptying, and urinating discomfort such as burning and stinging
sensation 1 day before admission. The urine was explained as yellow and clear.
Bloody urine (-), cloudy urine (-), urinary hesitancy (-), fever (-)
History of Past Illness
•2016: Exploratory Laparotomy ec Appendicitis Perforative
•5 months before admission until now:
• New Case of Lung TB on medication
PHYSICAL EXAMINATION
•General appearance : Moderately ill
• Consciousness : Compos mentis (GCS: E4M6V5)
•Vital Sign:
•Blood Pressure : 120/80 mmHg
•Heart Rate : 80 beats/mins
•Respiratory Rate : 18 beats/mins
•Temperature : 36.5oC
Status Generalis

•Head & face : Normocephalic, deformity (-)

•Eye : CA -, SI -, pupil isokor 3 mm, RCL +/+, RCTL +/+

•Ear : deformity (-), blood (-)

•Nose : deformity (-), blood (-), mucus (-)

•Neck : Lymph gland not palpable

General Examination
•Thorax :
• I : symmetrical chest expansion, the movement of the chest static
and dynamic
• P : symmetrical chest expansion, symmetrical tactile vocal fremitus
• P : Dull on the base of right lung, sonor on other area
• A : VBS +/+, diminished lung sound on the base of right lung,
rhonchi (-/-), wheezing (-/-), S1 S2 reguler, murmur (-), gallop (-)
 General Examination
• Abdomen : +
• I : convex, distended
• A : increased bowel sounds (+)
+
• P : tympanic throughout the abdominal field, costophrenic angle pain (-/-) + + +
• P : Tense, epigastric tenderness (+), umbilical, iliaca dextra, suprapubic,
iliaca sinistra tenderness (+), ballotement (-/-)

• Local Examination :

a/r suprapubic revealed a vertical hyperthrophic scar approximately 8x1 cm in

size, clear edge, regular shaped, coloured same as the surrounding areas,
without erythema and discharge. Local rise in temperature (-)
 Laboratory Result (22/08/20)
Result Reference Range
Full Blood Count
Hemoglobin 17.2 14.0-18.0
Hematocrit 49.0 40.0-54.0
Thrombocyte 440000 150-450
White blood cell 11000 4.500-11.500
Differential Count
Basophil 0 0-1
Eosinophil 1 1-3
Neutrophil 83 H 50-70
Lymphocyte 12 L 25-40
Monocyte 6 2-8
NLR 6.93 H <3.13
 Laboratory Result (25/08/20)
Urinalysis
Macro
Color Dark Yellow
Turbidity Slightly cloudy
pH 6
Fluid density 1030
Glucose (-)
Protein +1
Blood (-)
Leucocyte Esterase +
Nitrite (-)
Bilirubin (-)
Keton urine (-)
 Laboratory Result (25/08/20)
Urinalysis
Micro
Erytrocyte 1-2
Leucocyte 2-4
Epithelial Cells +
Crystals (-)
Cylinder (-)
Bacteria +
Others (-)
 Rontgen
Abdomen 3
Position
(25/08/20)
DIAGNOSIS
• Small bowel obstructive ileus ec susp. Bowel adhesion
dd/ GI Tuberculosis
PLAN
• IV line access + IVFD RL 500 cc/12 jam
• Cefazolin injection 1x2 gr
• Omeprazole injection 1x40mg
• Ketorolac injection 3x30 mg
• Nasogastric Tube (fasting)
• Consult to General Surgeon Specialist for operative decompression (LE)
• Consult to Lung Specialist for lung TB
• Consult to Internal Medicine Specialist for lower urinary tract infection
CASE 3 : Diabetic Ulcer

•Name : Mrs. H
•Age : 54 years old
•Address : Tangerang
•Religion : Islam
•Occupation : Housewife
•Admission Date: 29th August 2020
 PATIENT HISTORY
A 54 year-old female came to the ER, complained about nausea and vomitus
since 1 day before admission. She also came with open wound, some parts
were covered in pus, on her right toe.
The patient claimed to have history of dyspepsia and type 2 diabetes since 8
years ago. She has been routinely consuming glimepiride and insulin to control
her blood glucose level.
rd
The patient underwent debridement surgery on August 23 due to ulcer that
developed from laceration at her right toe after stepping on glass shards.
The patient was advised to undergo amputation after getting her debridement
surgery.
History of Past Illness
rd
•23 August 2020: Debridement surgery on her right toe
•Type 2 diabetes
PHYSICAL EXAMINATION
•General appearance : Moderately ill
•Consciousness : Compos mentis (GCS: E M V )
4 6 5
•Vital Sign:
•Blood Pressure : 110/70 mmHg
•Heart Rate : 80 beats/mins
•Respiratory Rate : 18 /mins
o
•Temperature : 37 C
Status Generalis

•Head & face : Normocephalic, deformity (-)

•Eye : CA -, SI -, pupil isochor 3 mm, RCL +/+, RCTL +/+

•Ear : deformity (-), blood (-)

•Nose : deformity (-), blood (-), mucus (-)

•Neck : Lymph gland not palpable

General Examination
Thorax
•I : symmetrical chest expansion, the movement of the chest static
and dynamic
•P : symmetrical chest expansion, symmetrical tactile vocal fremitus
•P : Sonor
•A : VBS +/+, rhonchi (-/-), wheezing (-/-), S1 S2 reguler, murmur (-),
gallop (-)
Local Examination
a/r Pedis Dextra
Look: There was an ulcer under the right toe, sized approximately 4 cm
x 3 cm, some parts were covered in soufra tulle, there were purrulent
discharge from the ulcer.
Feel: Warm extremities, CRT <2 seconds, mild tenderness, local rise in
temperature (-)
Move: Passive and active movement of the right toe was limited due
to the pain.
 Result Reference Range

Full Blood Count 14.0-18.0

Hemoglobin 9.9 40.0-54.0

Hematocrit 28 4.60-6.00

Erythrocyte 3.61 4.500-11.500

White blood cell 32.100

Differential Count

Basophil 0 0-1

Eosinophil 1 1-3

Neutrophil 83 2-6

Lymphocyte 15 25-40
Monocyte 1 2-8

Platelet count 485.000 150.000-450.000

NLR

MCV 77 82 – 92 FL

MCH 27 26 – 32 pg

MCHC 36 32 – 36 g/dL
Blood Glucose Level 110
 Result Reference Range

Creatinine 4.5 0,5 – 1,1 mg/dL

Elektrolyte

Sodium (Na) 120 137 – 145 mEq/It

Potassium (K) 4.5 3,6 – 5 mEq/It

Chloride (Cl) 91 98 – 107 mmol/L

Diagnosis

•Diabetic foot ulcer

• Dyspepsia
Plan
•IV line access + IVFD RL 500 cc/12 jam
•Ceftriaxone injection 1x2 gr
•Ranitidine injection 2x50 mg
•Ondansentron injection 3x8 mg
•Ketorolac injection 3x30 mg
•Wound irrigation with saline water and wound dressing
•Consult to General Surgeon Specialist for amputation procedure
•Consult to Internal Medicine Specialist for dyspepsia, type 2 DM, and
high creatinine level