CASE REPORT

Lateral inguinal
HERNIA
1

Presenter
• Choirina Qomariyah2013 2040
1011 113
• Fildzah Febriana I.
2012 1040
1011 042
• Prima Abdillah Akbar 2013 2040
1011 093

Preceptor :
Dr. dr. Bambang Arianto Sp.B FINACS
2

13 AM • Registry number : 6683725 3 .PATIENT IDENTITY • Name : Resky Andriayanto • Age : 11 Years Old • Address : Kedung Tarukan Wetan 15 Surabaya • Contact : 085232422705 • Job : Student • Lats education : Junior High School • MRS: 26th January 2014. 09.

Maksilofacial trauma (-). Crepitation(-).Primary Survey A B • Corpus alienium (-). symmetric. Whizing -/4 . deviated Trachea (-). Additional breath sounds (-). Gaps (-) • I : Normochest. retraction (-) • P: Movement of the chestwalls symmetric. Ronkhi -/-. widened ICS (-) • P : Sonor/Sonor • A : Vesicular +/+.

HR : 80x/mnt Blood pressure : 120/80mmHg Warm akral (+.+) CRT < 2 detik C • • • • D • GCS : 456 • Round pupil isokor 3mm/3mm • Pupil Reflex +/+ E • none 5 .+.+.

• It disappears when the patient is lying down. no more enlarged. and this lump may disappear arise by itself. nt HISTORY OF PRESENT ILLNESS : • Lump in the left scrotal sac has experienced since 5 months ago • Initially only a small lump as big as quail eggs • No pain. • It usually occurs when the patient is cough. Nausea (-). and straining. vomiting (-) 6 . after long stand.SECONDARY SURVEY Main complai Lump in the left scrotal sac.

nt HISTORY OF PRESENT ILLNESS : • No other complaints. and defecate and urinate normally. patient still has good appetite. • Patient was came to the general surgery department two days ago and was advised for get operation at Monday (27th January 2014) to overcome the lump. 7 .SECONDARY SURVEY Main complai Lump in the left scrotal sac.

HISTORY OF PAST ILLNESS: • Chronic caugh (-) • History of such illness is denied • History of any operation in abdomen is denied. SOCIAL HISTORY :ALLERGIES HISTORY : Denied 8 .

Wheezing -/9 . Crepitation (-). widened intercostals space (-) • P : sonor/sonor • A : Vesicular +/+.deviated trachea (-). symmetric.General state: Good Weight: 29 Kg Vital sign • • • • BP HR RR Tax :110/80 mmHg : 90 x/minute : 20x/ minute : 36.5 oC GENERAL STATUS Head/Neck Thorak • A-/I-/C-/D- • I : Normochest. Ronkhi -/-. retraction (-) • P : Movement of the chestwalls symmetric.

thrill (-) H/L/R no palpable • Cyanosis P: heart border • P: Meteorismus (-) normal • CRT < 2s (+) A: S1S2 single. • A: bowel sounds Gallop (-). akral. (+).Ekstremita s I: Ictus does not • I : Flat simetris • warm seem • P: Soepel. normal Murmur (-) COR • • • • Abdomen 10 . P: Ictus no tenderness (-). oedem (-) palpable.

thumb test: not performed – A : Bowel sounds (-) 11 . ziement test: (+) encouragement in digiti II. tenderness (-). swelling (-). finger tes: (+). translumination test (-) – P : palpable lump (+). hiperemi (-).LOCALIST STATUS Regio inguinal-scrotalis sinistra – I : Mass (+).

DIAGNOSIS Hernia inguinalis lateralis repponible sinistra 12 .

BUN.Planing diagnosi s • Thorax photo PA • Complete laboratory analysis for pre operation: DL. GDA. 13 . • Patient complaints. UL. SGOT. SGPT. SC. Planing terapi • Pro Herniotomy • Infusion RL 1700 cc/24 hours • Fasting Planing monitori ng • General state • Vital sign.

Fig. 2 Thorax Photo PA 14 .

P 15 .S.A.O.

hiperemi (-). swelling (-)  P : Tenderness (+)  A: Bowel sounds (-) Assesment HIL sinistra (pro-surgery today) Planning Planning diagnosis: Planning therapy:  Infusion RL 1700 cc/24 hours  Fasting  Pre operation: Injection Claneksi 1 g iv drip in NS 100 cc Planning monitoring :  General state  Vital sign  Complaints 16 .3C  Head/Neck: A/I/C/D (-)  Thorax: cor/pulmo: normal  Abdomen:flat . symmetric. this day of fasting pre-op no other complaints defecate (-) urination: normal Objective General state: enough  VS: Blood pressure : 110/70mmHg HR:92x/m RR:22x/m Tax:36. H/L/R no palpable. tympani.Date  27/1/14     Subjective No pain in the lump in the scrotum sac. tenderness (-) . bowel sounds (+) N  Ext: normal Status lokalis: Regio inguinal-skrotalis sinistra  I: mass (+).

skrotalis sinistra HIL sinistra (post herniotomy 1st day)   L: herniotomy wound (+). mass (-).Date 27/1/14 Subjective      Pain at the incision Not defecate today difficult urination Nausea No appettite Objective Assesment General state: enough Vital Sign: Blood pressure :110/80mmHg HR:89x/m RR 23x/m Tax: 36.8 C Head/Neck: A/I/C/D Thorax: Cor/pulmo: normal Abdomen: flat. bleeding seeps from the gauze (-) F: tenderness (+) 17 Planning Planning diagnosis: Planning therapy:  Infus Ka-en 3B: PAG (1000 cc : 500 cc/24 hours)  Injection Claneksi 1 g iv drip  Injection Cedantron 3 x 2 mg iv  Injection Novaldo 3 x 500 mg iv  Injection Ketopain 3 x 10 mg iv Planning monitoring :  General state  Vital sign  Complaints  Urination  Defecation  Herniotomy wound .. there herniotomy wound. soepel. tenderness .--+ -++ Tympani Bowel sounds (+) N Extrimity: normal Localys status : Regio inguinalis . hyperemia (-) swelling (-).

mass (-).--+ -++ Tympani Bowel sounds (+) N Extrimity: normal Localys status : Regio inguinalis . bleeding seeps from the gauze (-) F: tenderness (+) 18 .2 C Head/Neck: A/I/C/D Thorax: Cor/pulmo: normal Abdomen: flat.skrotalis sinistra   Assesment Planning HIL sinistra(post Planning diagnosis: herniotomy 2nd day) Planning therapy:  Infus D5 ½ NS 500cc/ 24 hour.Date 28/1/14 Subjective      Pain at the incision Not defecate today difficult urination Nausea No appettite Objective General state: enough Vital Sign: Blood pressure :110/70mmHg HR:88x/m RR 24x/m Tax: 36. soepel.. hyperemia (-) swelling (-). there herniotomy wound. tenderness .  Injection Antrain 3x1/2 amp iv Planning monitoring :  General state  Vital sign  Complaints  Urination  Defecation  Herniotomy wound L: herniotomy wound (+).

skrotalis sinistra   Assesment HIL sinistra (post herniotomy 3rd day) L: herniotomy wound (+). herniotomy wound (+). bleeding seeps from the gauze (-) F: tenderness (+) 19 Planning Outpatient:  Infus D5 ½ NS 500cc/ 24 hourstopaff infusion  Injection Antrain 3x1/2 amp ivMefenamic acid 3x500 mg per oral .6 C Head/Neck: A/I/C/D Tho: C/p normally Abdomen: flat.. but still difficult defecation Nausea (-) No appetite Objective General state: enough Vital Sign: Blood pressure :100/70mmHg HR:105x/m RR 21x/m Tax: 36. soepel.Date 29/1/14 Subjective     Pain at the incision is still felt. mass (-). hyperemia (-) swelling (-). tenderness . especially when moving no difficult urination.--+ -++ tympani Bowel sounds (+) N Ext: normally Localys status : Regio inguinalis .

THANK YOU FOR YOUR ATENTION 20 .