No.

Name : By. A Sex : Male

Age : 2 month old No. Reg : 713648

Chief complaint : Lump at scrotum

History taking : This condition had been apparent since 1 month ago. The
lump size would be bigger than before when he was
crying and would be smaller when he lied. The symptom
aggravates when before while his abdomen distended.
The lump along without pain and can reduce again.
Micturation : Normally

Defecation : Normally
General Status
Moderate illness / well nourish / conscious

Vital Sign
PR : 108x/mnt, strong, reguler,
RR : 30x/mnt, symmetric L=R, thoracoabdominal
type.
T(Ax) : 36,8°C
 Local Status
Abdominal
I : Flat, follow breath motion, skin color same with vicinity, bowel contour
(-), bowel motion (-)
A : Peristaltic (+) sound normal
P : Tenderness (-) ,Tumor mass (-)
P : Tympani
 Local Status
Scrotal region
I : Seen ovale lump from craniolateral to caudomedial until scrotum,skin
color reddish than vicinity
P : Palpable lump at right scrotum, soft consistency , tendernes(+),
palpable 2 testis normally
A : Peristaltic (-)
 Digital Rectal Examination
Sphincter tone was tight
Mucous was smooth
Ampulla filled with feces
Handscoen: blood (-), feces (+), slime (-)
 Laboratory Result
WBC : 6,77x 103 / μL

RBC : 3,18x 106 / μL

HGB : 9,9 g/dL

HCT : 27,9%

PLT : 256x103/ μL

PT/APTT : 5,30” / 3,30”

Blood Sugar : 111 mg/dl

Ureum : 13 mg/dl

Creatinin : 0,2 mg/dl

37/ 30 μ/L
GOT / GPT :
BNO X-Ray
Thorax X-Ray
WORKING DIAGNOSIS : • Hernia Inguinalis Lateral

MANAGEMENT : • IVFD
• Medicaments
• Report to senior Pediatric surgeon
advice : ?????????????????