CASE REPORT

By: Izacha Hatma Panganugraha

(NIM 201510401011016)
Preceptor : Dr. dr. Bambang Arianto, Sp.B, FINACS
A. PATIENT IDENTITY
Name
Age
Address
Job
Last education
Coming to polyclinic

: Mr. AS
: 26 Years Old
: Surabaya
: Employee of Superindo
: Senior High School
: 31 May 2016, 12.00

B. SUBJECTIVE
PRIMARY SURVEY
Airway :
Corpus alenium (-)
Maksilofacial trauma (-)
Additional breath sounds (-)
Gaps (-)
Breathing :

I : Normochest, symmetric, retraction (-), RR: 20x/minute

P: Movement of the chestwalls symmetric, crepitation (-),
deviated trachea (-),widened ICS (-)
P : sonor/ sonor
A : breath sound vesicular +/+, Ronchi -/-, Wheezing -/-

Circulatiom : HR : 90x/mnt
Blood pressure : 120/80mmHg
Warm akral (+,+,+,+)
CRT < 2 detik
Disability :
Exposure :

GCS : 456
Round pupil isokor 3mm/3mm
(-)

SECONDARY SURVEY
Main complaint :
Lump in the right scrotal sac.
HISTORY OF PRESENT ILLNESS :
Patient come to the Surgeon Polyclinic General Hospital of Haji
Surabaya with complaint lump in the right scrotal sac has experienced
1

since 1 years ago and this is a painless lump. Initially only a small
lump as big as guava, and more enlarged until now. For the first time,
this lump can in and out, it usually occurs when the patient is cough,
after long stand, and straining. It disappears when the patient is lying
down. But now the lump is stagnant especially for 2 weeks. Nausea (-),
vomiting (-), no other complaints, eat and drink as usual, defecate and

urinate are normally, flatus (+).

HISTORY OF PAST ILLNESS:
Chronic cough (-). history of such illness is denied, history of any

operation in abdomen is denied.

SOCIAL HISTORY :
The patient is an employee in superindo. His work is lifting goods in

the company
ALLERGIES HISTORY : Denied
C. GENERAL STATUS :
General state : Good enough, Weight: + 55 kg
Blood pressure :120/80 mmHg
HR
: 90 x/minute
RR
: 20x/ minute
Tax
: 36,5 oC
Head/Neck : A-/I-/C-/DThorak s
I

: Normochest, symmetric, retraction (-)

: Movement of the chestwalls symmetric, crepitation (-),

deviated trachea (-), widened intercostals space (-)

: sonor/ sonor

: breath sounds vesicular +/+, Ronchi -/-, Wheezing -/-

: Ictus does not seem

: Ictus no palpable, thrill (-)

: heart border normal

: S1S2 single, Gallop (-), Murmur (-)

COR

Abdomen
I

: Flat simetris

: Soepel , tenderness (-), H/L/R no palpable,

: Meteorismus (+)

: bowel sounds (+) normal

Ekstremitas

o Warm akral
+
+

+
+

o Oedema
o Cyanosis

o CRT < 2 dtk

D. LOCALIST STATUS
Regio inguinal-scrotalis dextra
o I : Mass (+), hiperemi (-), swelling (-), translumination test (-)
o P : palpable lump (+), mass (+) solid, supple, mobile, clear boundaries,
tenderness (-)
finger tes, ziement test, and tumb test: not performed
o A : Bowel sounds (+)
E. DIAGNOSIS
Hernia inguinalis lateralis irreponible dextra
F. PLANNING DIAGNOSIS: - Thorax photo PA
- Complete laboratory analysis for pre operation: DL, UL, SGOT, SGPT,
BUN, SC
G. PLANNING THERAPY
- Pro Herniotomy, consult to surgeon
- Infusion RL 2200 cc/24 hours
- Fasting
H. PLANNING MONITORING
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General state
Vital sign.
Patient complaints.

The picture of patient: