Patient Identity

Patient Initial : Mr. S

Gender

: Male

Date of Birth : December, 24th 1961

Age

: 54 year-old

Marital Status : Marriage

Religion

: Islam

Address

: Jl. Bango, No. 19, RT 006/RW 006, Cilandak

Job

: Construction labor

Medical Record : 34 72 **
Admission date : June, 28th 2015
Discharge date : July 2th 2015
History Taking
History taking was done by auto-anamnesis on June, 28th 2015 at 20.00 WIB at Bougenville
Pavilion, Marinir Cilandak Hospital (RSMC).
Chief Complaint : Lump in the right scrotal region which developed since 8 months ago.
Present Medical History
A 54 year-old gentleman, named Mr.S, came to Cilandak Marine Hospital with the chief
complain of feeling a lump in his right scrotal region which developed since 8 months ago.
Around 8 months ago, the size of the lump was as big as marbles and there is no tenderness on it.
If he was doing activities such as walking or running, the lump became bigger. If he took a rest,
the lump was disappeared. Around 4 months ago, the lump became bigger and radiated to the
scrotal region, the size was as big as ping-pong ball, he felt a bit nauseous and vomited 3-4 times
a day, the consistency of the vomit is food, and there was no greenish secret. Now, the lump is as
big as golf-ball. There is neither redness nor pain in the lump. The lump is not disappear
although he takes a rest. The lump becomes bigger when he walks, runs, or other activities.
There is no symptom of vomit, nausea, abdominal pain, digestive problems, or urinary problems.
Patient does not consume any medicine to treat his complaint.

Past Medical History

There is no evidences of allergy to any foods or drugs. Patient has not been admitted to hospital
for significant diseases.
Family History
There is no family member that has similar complaint. Patients father has diabetes mellitus type
2 and does routine medical checkup on clinic. Patients father consumes drugs for treating his
disease.
Daily Habitual History
Patient works as a construction laborer. This job may be related with the illness since he has to
do some heavy-lifting jobs which relates to the increase in abdominal wall pressure.
Physical Examination
The physical examination was done at Bougenville Pavilion, Marinir Cilandak Hospital (RSMC)
on June, 27th 2015.
General Examination
General condition : Mild ill
Consciousness : Compos Mentis, GCS E4M6V5

Vital Signs :

Blood pressure : 120/70 mmHg

Respiratory rate : 18 breaths/minute
Pulse : 88 beats/minute
Temperature : 36.5 degree celcius
Head
Eyes

Normocephalic
Anemic conjunctiva -/Icteric sclera -/Pupil round, isochoric, diameter 3 mm / 3
mm
Direct and indirect light reflex +/+,

Ears

Visus OD/OS: normal

Normal and symmetrical ear shape,

Nose

deformities (-), blood and secrete (-)

Normal and symmetrical nose shape,

Mouth and Throat

septum deviation (-)

No ulcer, moist mucosa, teeth normal.
Hyperemic pharynx (-), tonsil T1/T1

Neck

No lymph node enlargement in the sub

Thorax

mental, submandibular or cervical region.

Symmetric chest wall at static and
dynamic state, retraction (-), use of

Cardio

additional respiratory muscle (-)

Inspection : Ictus cordis pulsation is not
seen
Palpation : Ictus cordis is palpated at fifth
intercostal space left midclavicular line
Percussion : Right border of cor is at third
intercostal space right parasternal line,
left border of cor is at 2 cm medial from
fifth intercostal space left midclavicular
line, waist of the cor is at third intercostal
space left parasternal line
Auscultation : S1S2 regular, murmur (-),

Pulmo

gallop (-)
Inspection : Symmetric chest wall
movement at static and dynamic state,
retraction (-), use of additional respiratory
muscle (-)
Palpation : Vocal fremitus is same on both
lung fields
Percussion : Sonor on both lung fields
Auscultation : Vesicular breath sound +/+,
rhonchi -/-, wheezing -/-

Abdomen

Inspection : Abdomen is flat, distension

(-), scar (-)
Auscultation : Bowel sound (+)
Palpation : Tenderness (-)
Percussion : Tympani (+)
3

Extremity

Cyanosis (-), edema (-), warm acrals,

capillary refill time < 2 seconds

Localized status
Region : Genital
Look :
There is round-shape mass in right scrotal region with the size of 5 x 4 x 3 cm. There is
no redness, pain, and other inflammation signs. There is no scar and has a smooth
surface. Trans-illumination test was negative.
Palpation :
Palpable mass in right scrotal region with the size of 5 x 4 x 3 cm. The temperature of
the mass is same as its region around. The consistency is soft. The mass is not tender.
There is no pulsatile in the mass or fluctuation. The edge of the mass is well-defined. The
mass is able to mobile to the skin.

Further invsetigation

Investigation
Hemoglobin
Hematocrit
Leukocyte
Thrombocyte
Clotting time
Bleeding time
Random Blood

Result
15
44
8.5
366
4
2
97

Unit
g/dL
%
103/L
103/L
minute
minute
mg/dL

Normal Range
13 17
37 54
5 10
150 400
26
13
< 200

Glucose

Thorax x-ray photo

Result : Cor and Pulmonum in the normal condition, bone and soft tissue intact.
EKG investigation : on the normal range
Resume
A 54 years old man, named Mr.M, presents with chief complain of feeling a lump on his right
scrotal region. This complains has been presented since 8 months ago. The lump just got bigger
from a marble size to a golf ball sized. There is no tenderness, and pain around the lump, there is
no inflammatory signs like redness, and swelling around the lump. Around 8 months ago, the
patient said when he took a rest the lump just disappeared, but now it is not. Further investigation
reports that there is no abnormality in his laboratory result, thorax x-ray result, and his EKG
result.
Diagnosis
Hernia Scrotalis Dextra Irreponible
Management
Herniotomy and Herniorrhapy on june, 29th 2015.

DURANTE OPERATION PHOTO

FOLLOW UP
Date
June 30th 2015

Doctors Instruction
S: Nausea (-), vomit (-), flatus (+),

(07.00)

pain on surgical site

O: Moderately ill/Compos mentis

120/80 mmHg; 88 x/m; 22 x/m; 36.4
oC
General Examination :
Abdomen : Supel, Bowel sound 4
times per minute, tenderness (+) on
surgical site, tympani (+)
Localized Examination :
Abdominal region:
L : Attached bandages on surgical
site, blood (-), pus (-), fluid (-)
F : Tenderness (+),
A: Post Herniotomy and
Herniorrhapy (D+1)
P: Mobilization
Ceftriaxone 2 x 1 gr (iv)
Mefenamic acid 3 x 500 mg

Date
July, 1st 2015

Doctors Instruction
S: Nausea (-), vomit (-), flatus (+),

(07.00)

pain on surgical site

O: Moderately ill/Compos mentis

110/70 mmHg; 78 x/m; 16 x/m; 36
oC
General Examination :
Abdomen : Supel, Bowel sound 4
times per minute, tenderness (+) on
surgical site, tympani (+)
Localized Examination :
Abdominal region:
L : Attached bandages on surgical
site, blood (-), pus (-), fluid (-)
F : Tenderness (+),
A: Post Herniotomy and
Herniorrhapy (D+1)
P: Mobilization
Ceftriaxone 2 x 1 gr (iv)
Mefenamic acid 3 x 500 mg

Date

Doctors Instruction

10

July, 2th 2015

S: Nausea (-), vomit (-), flatus (+),

(07.00)

pain on surgical site

O: Moderately ill/Compos mentis
120/80 mmHg; 80 x/m; 18 x/m; 36
oC
General Examination :
Abdomen : Supel, Bowel sound 4
times per minute, tenderness (+) on
surgical site, tympani (+)
Localized Examination :
Abdominal region:
L : Attached bandages on surgical
site, blood (-), pus (-), fluid (-)
F : Tenderness (+),
A: Post Herniotomy and
Herniorrhapy (D+1)
P: Mobilization
Cefadroxil 3 x 500 mg
Mefenamic acid 3 x 500 mg
Sent home, control 5 days on surgery
outpatients department

CASE DISCUSSION

11

Patients Disease review

History Taking:

Feeling a lump on the groin

Progression ( in size, and from reduced-

able to un-reduced-able)
Aggravating factor : work ( heavy
lifting / straining )

Textbook Review
History taking :

May be asymptomatic
Feeling of lump
Non-reduced-able
Work as a risk factor : a work that can

increase pressure in abdominal wall

Risk factor : straining, prolonged

cough, heavy exercises

May be painless
Symptoms most commonly occurred if
the hernia become incarcerated : ileus
obstructive problem ( nausea, vomiting,

Physical examination:

Inspection : round-shape mass in right

scrotal region with the size of 5 x 4 x
3 cm, no inflammation sign

Palpation : The consistency is soft. The

colic abdominal pain, obstipation)

Physical examination :

Lump in the groin

Lump can be felt when straining on in

standing position ( if reponible)

Finger Test, Zieman Test, Thumb test
Trans illumination test (-)

mass is not tender. There is no pulsatile

in the mass or fluctuation. The edge of
the mass is well-defined. The mass is
able to mobile to the skin.
Trans-illumination Test (-)
Further investigation :

Laboratory : Blood count

X-ray Thorax Photo
ECG

Management:

Herniorhappy and Herniotomy

Further investigation :

USG
CT-Scan

Management :

Tension Free technique

Bilayer suture technique
Insertion of Mesh
Bassini Technique
Laparoscopic
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