CASE REPORT Friday, July 5th 2013 Team of duty: dr. Maria Meildi dr.

Andria Saputra dr Nazir dr. Rynaldi Andriansya dr. Pinim dr. Lea dr. Zumirda dr. Sumrahadi dr. Fauzan dr. Raja dr. Ronasky I. Patient identity: Name : Buyung Age : 88 years old Sex : Male Address : Ds.Durung, Keb. Aceh besar MR : 0950267 HP : 082160834888 Chief complaint : Lump in the left scrotal region Presenting history : The patient was came to the emergency room with a chief complain lump in the left scrotal region for 5 hours ago. Previously, the lump is still intermittent, appeared during he moving and disappear when lying down since 1 year ago, but in 5 hours the lump settled, redness, painful. There was no history of vomiting. There was no abnormality in defecation and urinate. History of persistent cough (-). Physical examination: Vital Signs Blood pressure : 140/70 mmHg Pulse : 80 beats/min Respiratory rates : 22 breaths/min Rectal temperature : 37,7 oC L/S at the left scrotal region: I: There is a lump with a size of 7 cm, the skin color was redness P: The consistency is soft to rubbery, painfull (+), the margin of the lump is not clear at its base. The testicle is palpated (+)

II. III.

IV.

L/S at the abdominal region I : symmetrical, distension (-) A : bowel sound (+) decrease P : Muscular rigidity (-) P : Liver dullness (+) V. Digital rectal examination: Tonus sphincter ani : tight Rectal ampulla : empty Rectal mucous : smooth pain : (+) At glove : faeces (+), blood (-) Assessment: Incarcerated of the left scrotal hernia Management Stop oral intake IVFD RL 30 drips/min Inj. Ceftriaxone 1 gr Inj. Ketorolac 30 mg NGT decompression Urinary catheter, initially 60 cc Hours 19.00 20.00 21.00 22.00 23.00 24.00 01.00 Urine 100 cc 90 cc 110 cc 100 cc 90 cc 90 cc 100 cc

V. VI.

Laboratory examination Radiology examination

VII.

Laboratory results: Hb : 15,0 gr/dl WBC : 11.200 /ul Platelet : 158.000 /ul HT : 42 % CT : 7 minutes BT : 3 minutes Glucose ad random : 106 gr/dl Sodium : 139 mmol/L Potassium : 4,5 mmol/L Chloride : 107 mmol/L Diagnosed: Incarcerated of the left scrotal hernia (ICD 10 CM K40.3) Consult to digestive surgery division : Herniorraphy emergency Intraoperative Patient in supine position with spinal anesthesia Asepsis and antisepsis procedure Incision about 2 cm medial from SIAS to tuberculum pubicum Incision was deepened layer by layer, identified fascia Identified hernia sac and opened Content of hernia sac is one loop ileum viable Contents of hernia sac is inserted into the abdominal cavity Proximal hernia sac was separate from distal Proximal hernia sac was ligation Performed mesh graft Bleeding control Operation was closed by primary suture Diagnose post operative: Incarcerated of the left scrotal hernia (ICD 10 CM K40.3)

VIII. IX. X.

XI

X.

Follow up A General Incarcerated of Condition: good the left scrotal Blood presure hernia (ICD 10 130/70 mmhg CM K40.3) Pulse 86 beats/minute RR 20 breath/minute Temperature: 37,2 C At the left inguinal L: haematom (-) F : pain (-) O P Patient out of clinic

Date S 08/7/2013 Flatulence POD III (+) Defecation (+)