MORNING REPORT

IDENTITY

Name : Ch. H
Age : 14 years old
Address : Andonohu
Admission Date : January, 14th 2019
 HISTORY TAKING

 Chief Complain : a lump on the right thigh crease

Anamnesis :
 The patient admitted to hospital with a complain of a lump appeared on the
right thigh crease since 3 years ago. The lump appeared when patient
stand and disappear when patient lie. Other complaints such as fever (-),
nausea (-), vomitting (-). Defecate and urinate was normally.
History :
 There was no history of the same disease
 There was family history of lump on thigh crease
 There was no previous medication
 PHYSICAL EXAMINATION

General Condition : Mild illness

Composmentis (GCS 15 E4V5M6)

Vital Sign
BP : 110/70 mmHg
HR : 84x/minutes
RR : 20x/minutes
T : 36,5◦C/axillary
 GENERALIZED STATE

Head : within normal limit Upper limb : Within normal limit

Face : within normal limit Lower limb : within normal limit
Eyes : within normal limit
Nose : within normal limit
Mouth : within normal limit
Ears : within normal limit
Neck : within normal limit
Chest : within normal limit
Abdomen : localized state
LOCALIZED STATE

Abdomen
Inspection : flat, follow breath movement. Lump at
inguinal dextra region (-), eritema (-)
There was a lump at inguinal dextra region
when patient straining like when defecate and
disapper after patient stop
Auscultation : Peristaltic sound (+) within normal limit
Percussion : Tympanic (+)
Palpation : Tenderness (-)
Digital Rectal Examination
 Sphincter: tone strangle
 Mucosa: smooth
 Ampulla: collaps (-)
 Handscoen: blood (-), feces (-)
CLINICAL FINDINGS
 PLANNING

 Routine Blood Test

 USG Abdomen
Laboratory findings

Routine Blood
Parameter Result Unit Reference value
WBC 10.51 10^3/uL 4.00-10.00
HGB 12.9 g/dL 12-16
PLT 334 10^3/uL 150-400
 DIAGNOSE

Hernia Inguinal Lateralis Dextra

Reponibilis
MANAGEMENT

 Non Pharmacotherapy  Pharmacoterapy

 Rest  IVFD
 Analgesic if feel pain
THANK YOU