I / M / 2mo

77.44.83
Chief complaint: lump at the right groin
It has been suffered by patient since 3 days before admitted to
the Adam Malik Hospital. Initially the lump came out when the
patient crying or screaming since 1 week ago and disappeared
while resting, but it persisted since yesterday. History of
vomitting (+), fever (+), defecation (-) since morning, micturition
(+) normal. History of curing traditonal massage (+)
Patient was the 2nd child. Patient was delivered normally by
midwife, immediately cried, aterm 38-40 weeks, birth body
weight 3300 gr, and length 50cm. History of drugs consumption
during pregnancy (-) and herbs during pregnancy (-). Patient's
mother had antenatal care evaluation the pregnancy into the
midwife. There is no history of the same illness in the another
child.
Patient was referred from district hospital
 PRESENT STATE
• Awareness : Alert
• Heart rate : 140x/minute
• Respiration rate : 34x/minute
• Temperature : 36,8oC
• Body Weight : 5000gr
 GENERAL STATE
• Head : no abnormality
• Neck : no abnormality
• Chest : no abnormality
• Abdomen : in localized state
• Genitalia : male, in localized state
• Extremity : no abnormality
Localized state:
Abdomen
– Inspection :
symmetrical, distention
(+), visible bowel
movement (-), visible
bowel countour (-)
– Auscultation :
Peristaltic (+) Increased
– Palpation :
soepel, muscular rigidity
(-)
– Percussion :
hypertymphani
• Right Groin :
lump size 3x1 cm, firm
consistency, erythema
(-), bowel sound (+),
translumination (-)
DRE :
• Perineum normal, Tight anal spinchter tone,
mucosa smooth, Ampulla recti collapse
• Gloves : stool (+), blood (-), mucous(-)
 Laboratory Findings:
Hb / Hct / WBC / PLT : 8.9/26/10850/480.000
Random Blood Glucose : 93
Na/K/Cl : 130/2.9/97
Ur/Cr : 64/0.58
Babygram
 Working Diagnosis:
(L) Incarcerated Lateral Inguinal Hernia
Treatment at the ER :

• Nil per mouth

• IVFD D5%, NaCl 0.225%, 20 micro drops/min
• Insertion OGT  greenish fluid 5cc
• Insertion Catheter  yellow clear 5cc/hours
• Inj. Analgetic  Inj. Paracetamol 30mg/8hours
• Attempt for hernia manual reduction
– Diazepam 0,3 mg/kgbb  1 mg iv
– Patient was positioned in a Trendelenberg position

• Plan :
• Herniotomy emergency