Beruflich Dokumente
Kultur Dokumente
Name
: 590705-10-6351
Age
: 57
Sex
: MALE
Race
:CHINESE
Marital status
: SINGLE
Occupation
: RETIRED COOK
Religion
: CHRISTIAN
Date of admission
: 10/10/2016
Date of clerking
: 10/10/2016
Date of discharge
: 12/10/2016
CHIEF COMPLAINT
Mr. Tai Chin Hok, 57 years old Chinese gentleman complained of
left
inguinoscrotal swelling when standing for a long time associated with back pain and
vomiting for past 2 years.
He denied heavy lifting and chronic cough. He also denied altered bowel habit or
painful urination but sometimes he needed to strain during defecation.
He had no fever, abdominal pain and he could pass bowel output and flatus normally.
There was also no loss of appetite and loss of weight.
PAST SURGICAL HISTORY
He underwent cataract removal surgery on the left eye 4 years back and on the
right side 2 years ago.
PAST MEDICAL HISTORY
He is known to have sinusitis for 50 years and asthma for 42 years but has not
been prescribed any medication. He claimed that he has recovered from asthma. He
also has hypertension and dyslipidemia for 2 years on medication.
DRUG HISTORY
He is on Amlodipin 10 mg once daily (hypertension) and simvastatin 10 mg
twice a day (dyslipidaemia)
ALLERGY HISTORY
He has allergy to dust.
FAMILY HISTORY
His father died of heart attack at 68 years old while her mother died of old age
with underlying of heart problem at 70 years old.
There is no history of malignancy in his family.
SOCIAL HISTORY
PHYSICAL EXAMINATION
GENERAL EXAMINATION
On general examination, the patient is lying comfortably on a bed. He is alert,
conscious, and communicative. He is not in respiratory distress, and is not in obvious
pain. Inguinoscrotal swelling on the left side were noted. The vital sign is as follow:
Pulse rate
Blood pressure
: 127/87 mm Hg
Temperature
: 36.5o C
Respiratory rate
CARDIOVASCULAR EXAMINATION
On inspection, the chest move symmetrically, no deformity, no scar and no
visible pulsation seen. The pulse is 60 beat per minutes with regular rhythm and good
volume.There was no radial-radial delay, no radial-femoral delay and the jugular vein
pressure is not raised. The blood pressure is mm Hg. The apex beat was palpable at
the left fifth intercostal space within midclavicular line. There was no thrill and
parasternal heave felt. On auscultation, first and second sounds were heard. The heart
is dual in rhytm with no additional sound or murmur.
RESPIRATORY EXAMINATION
On inspection, the chest wall moved symmetrically with respiration. There
were no skeletal deformities, any scars, dilated veins and use of accessory muscle
during respiration. The respiratory rate is 16 breaths per minutes which is normal
since the patient is not tachypnic because patient is not in obvious pain. On palpation,
the chest expansion was bilaterally symmetrical and there was no tracheal deviation.
Vocal resonance and tactile fremitus were equal in both side of the lung. On
percussion, there was resonance of both lung fields. On auscultation, normal
vesicular breath sounds were heard with no additional breath sound.
PROVISIONAL DIAGNOSIS
Inguinal hernia
Points support:
Inguinoscrotal swelling
Reducible mass
Point against:
DIFFERENTIAL DIAGNOSIS
1. Hydrocele
Points support:
Points against:
Scrotal swelling
Painless swelling
2. Testicular tumour
Points support:
Point against:
Testicular swelling
3. Testicular torsion
Points support:
Points against:
Testicular swelling
ecchymosis.
INVESTIGATION
1) Full Blood Count (10/10/2016)
Indication: To assess his blood status that includes anaemia and thrombocytopenia
and any evidence of acute infection.
TEST
White Cell Count
Red cell count
Hemoglobin (Modified
Cyanmethaemoglobin)
Hematocrit
Mean Cell Volume
MCH
MCHC
RDW
Mean Platelet volume
Platelet
Neutrophils
Eosinophils
Basophils
Lymphocyte
Monocytes
Nucleated red blood cell
RESULTS
6.4
4.5
UNIT
x10^9/L
x10^12/L
RANGE
(4.1 11.4)
(4.5 6.0)
13.6
g/dL
(13.5 17.4)
40.5
89.4
30.0
33.6
13.1
9.9
253
4.0
0.1
0.1
1.8
0.5
0
%
ft
pg
g/dL
%
ft
x10^9/L
x10^9/L
x10^9/L
x10^9/L
x10^9/L
x10^9/L
x10^9/L
(40.1-50.6)
(80.6-95.5)
(26.9-32.3)
(31.9-35.3)
(12.0-14.8)
(8.9-11.9)
(142-350)
(3.9-7.1)
(0.0-0.8)
(0.0-0.1)
(1.8-4.8)
(0.4-1.1)
(0.0-0.0)
COMMENTS
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
Impression:
Normal white cell count suggest that the paient is not having infection and
inflammation. Therefore patient did not have fever.
The haemoglobin of the patient is within the normal range and this indicates
patient is not anaemic.
The platelet level also is within the normal range which means this patient has
no bleeding tendencies.
TEST
C-reactive
RESULT
0.05
UNITS
mg/dl
RANGE
(<0.5)
COMMENT
NORMAL
protein
IMPRESSION:
C-reactive protein was normal in this patient. This indicate that the patient had no
inflammation.
3) Renal Profile (10/10/2016)
Indication: To assess for his electrolyte imbalance and hydrational status as well as renal
function.
TEST
Sodium (Ion Selective
Electrode Indirect (diluted))
Potassium (Ion Selective
Electrode Indirect (diluted))
Urea (urease)
Creatinine
RESULTS
UNIT
RANGE
140
mmol/L
(135 - 150)
4.4
mmol/L
(3.5 - 5.0)
4.1
72.7
mmol/L
umol/L
(2.5-6.4)
(62-106)
COMMENTS
NORMAL
NORMAL
NORMAL
NORMAL
Impression:
-
Urea and creatinine level is also normal which indicates no renal problem in this
patient.
RESULT
41
71
UNITS
g/L
g/L
RANGE
(35-50)
(67-88)
COMMENT
NORMAL
NORMAL
8
Total bilirubin
Alanine
9.7
27
Umol/L
U/L
(3.4-20.5)
(0-55)
NORMAL
NORMAL
81
U/L
(40-150)
NORMAL
Aminotransferase
(ALT)
Alkaline
Phosphatase (ALP)
IMPRESSION:
Result:
TEST
PT (patient)
PT (control)
INR
APTT (patient)
APTT (control)
APTT (ratio)
%
12.5
RESULT
12.8
0.97
29.3
38.7
0.76
UNITS
seconds
seconds
ratio
seconds
seconds
ratio
RANGE
(11.6-14.1)
(30.16-44.29)
(0.89-1.32)
IMPRESSION:
Coagulation profile showed APTT with slightly faster time of clotting where else PT
was normal indicating normal blood clotting ability and this patient was eligible to
undergo a surgery.
6) Chest X-ray (5/4/2016)
Indication: Chest X-ray stratify risk, direct anesthetic choices, and guide postoperative
management. Patient with lung problems should be stabilized before operation.
Result: No picture obtained
IMPRESSION:
No focal lung lesion
No consolidation/ cavitation
Both costophrenic angles are sharp
Heart is normal size
FINAL DIAGNOSIS
Bilateral inguinal hernia
PATIENTS
CONDITION
MANAGEMENT
o Nil by mouth at 2 am
10
DATE
PATIENTS
CONDITION
MANAGEMENT
o
o
o
o
INTRAOPERATIVE
FINDINGS
MANAGEMENT
DATE
PATIENTS
CONDITION
12
13
DISCUSSION
A hernia is the bulging of part of the contents of the abdominal cavity through a
weakness in the abdominal wall.
The most common types of hernia are inguinal (inner groin), incisional (resulting
from an incision), femoral (outer groin), umbilical (belly button), and hiatal (upper
stomach).
Types of hernia by complexity
Occult not detectable clinically; may cause severe pain
Reducible a swelling which appears and disappears
Irreducible a swelling which cannot be replaced in the abdomen, high risk of
complications
Strangulated painful swelling with vascular compromise, requires urgent surgery
Infarcted when contents of the hernia have become gangrenous, high mortality
Inguinal hernia
An inguinal hernia happens when contents of the abdomenusually fat or part of the
small intestinebulge through a weak area in the lower abdominal wall. The
abdomen is the area between the chest and the hips. The area of the lower abdominal
wall is also called the inguinal or groin region.
This patient has indirect inguinal hernia on the left side where the hernial sac
protrudes through the deep inguinal ring and passes down to the inguinal canal and
extend as far as the upper pole of testis. The risk of developing indirect hernia can be
congenital in which are more common in premature infants due to incomplete
obliteration of the processus vaginalis or can be acquired due to old age or increased
in intra-abdominal pressure such as in heavy lifting or carrying, chronic coughing,
constipation, benign prostate hyperplasia and obesity
He also has direct hernia on the right side where it protrudes directly through
the abdominal, in the area known as the Hasselbachs triangle which is bound
laterally by inferior epigastric artery, medially by lateral border of rectus muscle and
inferiorly by inguinal ligament.
14
CLINICAL MANIFESTATION
The first sign of an inguinal hernia is a small bulge on one or, rarely, on both sides of
the grointhe area just above the groin crease between the lower abdomen and the
thigh. The bulge may increase in size over time and usually disappears when lying
down.
Patient might feel discomfort or pain in the groin especially when straining, lifting,
coughing, or exercising that improves when resting.
There are also feelings such as weakness, heaviness, burning, or aching in the groin
Patient will present with a swollen or an enlarged scrotum.
INVESTIGATIONS
Medical and family history.
Taking a medical and family history may help to diagnose an inguinal hernia. Often
the symptoms that the patient describes will be signs of an inguinal hernia (reducible,
bulge after coughing)
Physical exam.
A physical exam may help diagnose an inguinal hernia. During a physical exam, ask
the patient to stand and cough or strain to feel for a bulge caused by the hernia as it
moves into the groin or scrotum and gently try to massage the hernia back into its
proper position in the abdomen (reducibility).
Cough impulse and occlusion test: In the absence of a visible or easily palpable
bulge, a cough impulse may be demonstrated by palpation at the external ring
(midpoint of inguinal ligament-between pubic tubercle and anterior superior iliad
spine) after invaginating the upper scrotum (in men) and asking the patient to cough
or perform a Valsalva manoeuvre. An indirect hernia may theoretically be controlled
by applying occlusive pressure at the mid-point of the inguinal ligament, whereas a
direct hernia is not affected by this manoeuvre. However, discrimination between
direct and indirect inguinal hernia by physical examination is not very accurate.
15
Imaging tests.
Hernia cases do not usually use imaging tests, including x rays, to diagnose an
inguinal hernia unless to diagnose a strangulation or an incarceration which cannot be
felt during physical exam, especially in patients who are overweight is uncertain if
the hernia or another condition is causing the swelling in the groin or other
symptoms.
TREATMENT AND MANAGEMENT
Repair of an inguinal hernia via surgery is the only treatment for inguinal hernias and
can prevent incarceration and strangulation. Surgery is recommended for most people
with inguinal hernias and especially for people with hernias that cause symptoms.
Research suggests that men with hernias that cause few or no symptoms may be able
to safely delay surgery until their symptoms increase.
Hernia surgery is also called herniorrhaphy. The two main types of surgery for
hernias are:
Open hernia repair: During an open hernia repair, the surgeon makes an incision in
the groin, moves the hernia back into the abdomen, and reinforces the abdominal wall
with stitches. Usually the surgeon also reinforces the weak area with a synthetic mesh
or screen to provide additional support.
Laparoscopic hernia repair: A surgeon performs laparoscopic hernia repair with the
patient under general anesthesia. The surgeon makes several small, half-inch
incisions in the lower abdomen and inserts a laparoscopea thin tube with a tiny
video camera attached. The camera sends a magnified image from inside the body to
a video monitor, giving the surgeon a close-up view of the hernia and surrounding
tissue. While watching the monitor, the surgeon repairs the hernia using synthetic
mesh or screen.
People who undergo laparoscopic hernia repair generally experience a shorter
recovery time than those who have an open hernia repair. However, the surgeon may
determine that laparoscopy is not the best option if the hernia is large or if the person
has had previous pelvic surgery.
16
Patient can keep inguinal hernias from getting worse or keep inguinal hernias from
recurring after surgery by:
REFERENCES:
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DISCHARGE SUMMARY
DISCHARGE SUMMARY
Pusat Perubatan Universiti Kebangsaan Malaysia
Jalan Yaacob Latif
Bandar Tun Razak
Kuala Lumpur, Malaysia
PATIENT INFORMATION: TAI CHIN HOCK @ TAI AH HOCK
MRN
N513305
VISIT ID
201610102894
NRIC
590705106351
AGE
57
GENDER
MALE
RACE
CINA
ADMISSION DATE
10/10/2016
ADMISSION TIME
10:48
DISCHARGE DATE
11/10/2016
DISCHARGE TIME
17.28
DISCHARGE TYPE
DISCHARGE HOME
DISCHARGE
(5H) SURGERY 7:
LOCATION
ENT/PLASTIC/MAX
ILOFACIAL
SPECIALIST
NAME
18
Mr Tai Chin Hock a 57 years old Chinese gentleman post bilateral Laparoscopic
Transabdominal Preperitoneal Hernia Repair with underlying hypertension and dyslipidaemia
for the past 2 years on Amlodipine and Zocor respectively with complain of bilateral
inguinoscrotal hernia for 2 years duration
HISTORY OF PRESENTING ILLNESS
Patient feels inguinoscrotal swelling when he was standing for a long time for the past two
years associated with vomiting and back pain. Otherwise, no other active complains such as
fever, loss of weight, loss of appetite, chest pain or shortness of breath. He was electively
admitted on 10/10/2016. During pre-operation, patient is doing well.
INTRA-OP FINDINGS (11/10/2016)
Transabdominal Preperitoneal inguinal hernia repair is done. It confirmed left indirect inguinal
hernia, containing omentum. Sac is adhered but able to release.
Atrium mesh is placed and secured with taking device in place.
Right very small direct hernia is not repaired.
POST-OP
Patient complained of swelling reappear on the left inguinoscrotal region upon standing and
dysuria. He was told that the hernia is reduced with mass on the left side is only residual and
dysuria will disappear by time. Hernia on the right side is not repaired as it is too small. It will
be repaired when it comes bigger or develop complication symptoms. Patient understood.
Upon discharge, patient is well and vitally stable.
ALLERGIES
- He is allergic to dust
Medication
T. AMLODIPINE 10 MDG OD
1. Allow discharge
T. ZOCOR 20 MG ON
19
C. TRAMAL 50 MG PRN
Prepared by
,
Dr. Amelia Akmar binti Ramli
Medical Officer of Surgery
Wad 5B SURGERY 1
Pusat Perubatan UKM
20
preperitoneal inguinal hernia repair is done. It confirmed left indirect inguinal hernia,
containing omentum. Right very small direct hernia is not repaired.
He was discharged well recently from the ward on 12/10/2016. Upon
discharge, his condition was good and vital signs were stable.
I would like ask for your kindness to help me to assess the progression of his
health and continue monitoring the patient 3 weeks after his discharge.
Thank you.
Yours truly,
........
(Dr. AMELIA AKMAR BINTI RAMLI)
House officer of Surgery Ward 1,
PPUKM
PRESCRIPTION LETTER
Pusat Perubatan Universiti Kebangsaan Malaysia
Jalan Yaacob Latif
Bandar Tun Razak
Kuala Lumpur, Malaysia
PATIENT INFORMATION: TAI CHIN HOCK @ TAI AH HOCK
MRN
N513305
VISIT ID
201610102894
NRIC
590705106351
AGE
57
GENDER
MALE
RACE
CHINESE
Medication
T. AMLODIPINE 10 MDG OD
T. ZOCOR 20 MG ON
T. PCM 1GM QID
C. TRAMAL 50 MG PRN
SYRUP LACTULOSE 15 MLS ON
21
Prepared by:
........
(DR. AMELIA AKMAR BINTI RAMLI)
House officer of Surgery Ward 1,
PPUKM
PPD COMPONENT
Communication issues
Communication is the key how to build a rapport with our patients. How we speak to
them affects how they will cooperate in giving information to us. Eventhough this
patient does not share the same race with me, but I still managed to talk well with
him in English or even Malay. I tried to sound concern as much as I could to show
my empathy in his condition. He was also consistent with his symptoms and made it
easy for me to reorganise all the informations.
Ethical issues
Medical ethic consist of 4 components; non-maleficience, beneficience,
autonomy and justice. In my case of situation, my clerking and examination on this
patient are for his beneficience. I am trying to find out what is the real diagnosis to
come out with the right treatment and management and this patient also choose to
undergo the surgery for his own benefits and before everything becomes complicated
and harm him (non-maleficience). In this situation, this patient used his autonomy
correctly.
Critical thinking
Critical thinking is so important when seeing patients because all questions that we
asked must have its own reason. We cannot simply throw any questions while hoping
some of it will be right. To come up with the provisional diagnosis, we must exclude
all the possible differential diagnosis before coming to the conclusion. All history,
examination and investigation are important to decide on treatment regime for the
patient.
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