Patient List

No Identity Admission to ER Diagnosis Treatment

1. Mr. Ahmad Yani/Male/ February 27th 2020, HIL Dx Incarserated Treatment in ER :

31 yo/1 45 51 56 at 05.00 AM • RL Loading 500cc
• IVFD RL 20 tpm
• Inj. Ceftriaxone 1gr/12 hours
• Inj. Ranitidine 50mg/12 hours
• Inserted NGT decompression
• Inserted DC for fluid ballance

Consult to Digestive Surgery:

• Pro Hernia Repair  Spontaneus
Reduction  Hospitalized
 Mr. Ahmad Yani/Male/31 yo/1 45 51 56
Admitted February 27th 2020, at 05.00 AM

Chief Complained:
Lump in her scrotum

History of present illness:

He complained lump in the right scrotum which could not enter again since 1 o'clock this night. He complained that the
lump is larger than usual, initially like an egg but it is already bigger and cannot enter again. Vomiting (+), nausea (+), he
has not farted or defecated since last night.
Previously he had a history of lump in and out of the scrotum for 5 years, had never been seen by a doctor. He works as
a builder. Previously he worked as a freight worker at the company, but stopped working because he was no longer
strong.
He claimed to start feeling pain in the lump, there was no history of hard to defecation, Chronic cough (-), or Straining
when urinated.

History of past illness:

DM (-), HT (-), Allergy (-)
History of Family Illness : (-)
Vital Sign
• GCS E4V5M6
• BP 120/80 mmHg
•N 89 x/m
•T 36.9 oC
• RR 20 x/m
• SpO2 99 %
 • Eye : Sclera icteric (-/-), pale conjungtiva (-/-)
Head • Neck : Enlarge lymph node (-), increased jugular vein pressure (-)

• I : symmetric respiratory movement, retraction (-), bruise (-)

• Pal: FV symmetries, tenderness (-)
Chest • P : sonor at all lung fields
• A : symmetric VBS, rhonchi (-), wheezing (-)

• I : distension (-), lesion (-), hematoma (-)

• A : bowel sound (+) 6-8x/minute
Abdomen • P : soft, defense muscular (-) tenderness (-), liver/spleen/mass not palpable
• P : tympani at all region

• warm extremities (+)

• Scrotum mass (+)
Extremities / • I : mass size 2 fist, erythema (-),
Genitalia • Pa : hard, mobile
• Au : bowel sound (+) 6-8x/m
Clinical Pictures
 Diagnosis
HIL Dx Incarcerated
 Management

Treatment in ER : Consult to Digestive Surgery:

• RL Loading 500cc • Pro Hernia Repair  Spontaneus
• IVFD RL 20 tpm Reduction  Hospitalized, hernia
repair electively
• Inj. Ceftriaxone 1gr/12 hours
• Inj. Ranitidine 50mg/12 hours
• Inserted NGT decompression
• Inserted DC for fluid ballance