You are on page 1of 17

Indra Destia

12100113043

Preceptor :
Dr. Liza N., Sp.B.,M.Kes.,FinaCS

Surgical Department
Faculty of Medicine
Universitas Islam Bandung
RS Al-Islam Bandung


Patients Identity
Name : AF
Sex : Boy
Age : 8 years old
Address : Buah Batu, Bandung
Occupation : Student
Religion : Moeslem
Date of Admission : April 16
th
2014
Date of examination : April 16
th
2014
Anamnesis
Chief Complaint : Lump at right groin
Present of Illness :
Patient comes to the hospital with complaint
lump at right groin. According to his parents, the
lump appeared since one year ago. Lump appear
suddenly, the measuring about 3 cm, and it
enlarged from the initial complaint.
The lump seen when patient doing activity,
straining, coughing, and disappear when the
patient was sleeping. The lump can be entered into
the abdominal cavity without help.
The lump is not painful, and was not
accompanied by abdominal distended, nausea,
vomiting, or difficult in bowel habit. Complaints
are not accompanied by redness of the skin over
the lump, or body heat.
No history of previous trauma, patients have
not been treating this complaint, and no family
history of similar complaints.
Physical Examination
General Status
Consciousness : Composmentis
General appearance : mild illness
Vital Sign
- BP : 120/80 mmHg
- PR : 80 x/minute
- RR : 22 x/minute
- Temperatur : 36,8
o
C
Head : Normochepal
- Eye : Conjunctiva anemis (-/-)
Sclera icteric (-/-)
Pupil Reflex +/+, isochor
- Nose : septum deviation (-), secret -/-
- Mouth : moist mucosa
- Neck : no enlarged of lymph node


Thorax : Symmetrical movement
Lung : Retraction -/-, VBS +/+, Ronchi
-/-. Wheezing -/-
Heart : Ictus cordis (-), border at ICS IV
midclaviculari line, heart
sound (1&2) regular.
Gallop (-), Murmur (-)
Abdomen : Flat, tenderrness (-), no
palpable enlargement of the
liver, and spleen. Tymphani (+),
Bowel sound (+) normal


Extremities:
Superior : Edema -/-, cyanosis -/-, deformity -/-,
Warm acral, CRT <2 seconds
Inferior : Edema -/-, cyanosis -/-, deformity -/-,
Warm acral, CRT <2 seconds
Localized Status :
a/r inguinalis dextra
hiperemis (-), edema (-), tenderness (-), valsava
test (+), finger test (+) lump at fingertip

Resume
A boy 8 years old came to the hospital, with
complaints lump at right groin. The lump
appeared since one year ago. Lump appear
suddenly, measuring about 3 cm, and enlarged
from the initial complaint.
The lump seen when patient doing activity,
straining, coughing, and disappear when the
patient was sleeping. The lump is reponible.
The lump is not painful, nausea (-), vomiting
(-), difficult bowel habit(-), redness of the skin over
the lump (-), body heat (-).
From physical examination, generalis status
within normal limits. Localize status obtained
from the a/r inguinal dextra, valsava test (+), finger
test (+) lump at fingertip.


Differential diagnosis
Hernia Inguinalis Lateralis Dextra Reponible
Lymphadenopathy

Diagnostic examination
Routine hematology
USG abdomen

Work Diagnosis
Hernia Inguinalis Lateralis Dextra Reponible

Management
Herniotomy
Prognosis
Ad vitam : ad bonam
Ad functionam : ad bonam
Ad sanationam : ad bonam

THANK YOU