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Morning Report

Departement of Surgery
Identity

Name : Mr. M
Age : 72 years old
Occupation : Farmer
Address : Gempolpalding RT2 RW 1
Admission : February 2 nd, 2017 at 20:26 PM
Patient ID : 72.17.65
Anamnesis

Chief Complain:
mass in scrotum
Present History:
The patient felt a mass inside the scrotum since 2 months ago. The mass appear
when he doing some activity at home (sweep floor, wash clothes, etc.) and disappear
when he rest. 12 hours before admission, He felt the mass appears again in the left
side of scrotum when he was washing clothes. he never go to doctor to cure his
illness. Pain (+), nausea and vomiting (-), loss of appetide (-), history of accident (-),
defecation and urination within normal limit
Past Illness History:
HT (-), DM (-), never felt same complain
Family History:
HT (-), DM (-), his son also suffering hernia
Social History:
Work as a farmer and often lift a heavy burden, did not smoke and drink
alcohol
Vital Signs

BP
140/70 mmHg
Pulse
78 x/min, strong, rreguler
Temp
36.7 C
RR
22x/min
Primary Survey

A: clear, gargling (-), snoring (-), speak fluently (+), potential obstruction (-)
B: spontaneous, RR 22x/min, ves / ves, rh -/-, wh -/-, SaO2 100% without O2
support.
C: extremity WDR, CRT <2, N 78x/min, BP 140/70 mmHg
D: GCS 456, lat -, PBI 3mm/ 3mm, LP +/+
E: temp 36.7 C
GENERAL STATUS

General condition : well


Awareness : compos mentis
GCS : 456
H/N : a -/i-/c-/d -
lymph node enlargement at neck (-)

JVP within normal limit


Thorax
Inspection
Symmetrical, retraction -
Palpation
Thrill (-), fremitus WNL
Percussion
Lungs: sonor / sonor
Cor: N
Auscultation
Lungs: ves /ves, rh -/-, wh -/-
Cor: S1S2 single, M -, gallop -
Abdomen
Inspection
flat
Auscultation
Met -, bowel sound WNL
Palpation
Pain (-)
Liver/Spleen within normal limit
Percussion
Tymphany
Extremities
Inspection
Clubbing fingers (-), icteric (-), cyanosis (-), edema (-)
Palpation
Cold and wet, CRT <2

Genitalia
Inspection
Wound (-), Inflamation (-), discharge(-), mass at left
scrotum
Palpation
Pain (+), the mass get bigger when the patient
cough, thumb test (+)
CLUE AND CUE

Male, 72 years old


Mass at left scrotum
Reponible
Thumb test +
Initial Diagnose
Hernia Scrotalis S

Planning diagnose
DL
USG
Planning Therapy

IVFD Asering 1.500cc/24 hours


Inj. Na. Metamizole 3x1gr iv
Inj. Ranitidine 2x50mg iv
Consul surgeon
PLANNING MONITORING

Vital Signs
Patients complaint
Adverse effect
PLANNING EDUCATION

Explain to the patient and his family about the


disease, cause, complication, intervention of
the therapy and prognosis.