RESPONSI
Surgery Department, Haji Hospital
Medical Faculty of Hang Tuah University
Surabaya
Lecturer : dr. BambangArianto, Sp.B
By : Sandra Ayu Logista
Fitria Puspa Ekawati
SUBJECTIVE
I. PATIENT IDENTITY
Name : Naufal
Age : 6 years old
Sex : Male
Religion : Moslem
Ethnic : Java
Occupation : student
Education : primary school
Address : Pulo wonokromo
Medical Record :708509
Hospitalized : November, 18th 2014
Operation : November, 19th 2014
II. HISTORY TAKING
1. Main Complaint: a lump at the left groin
2. History of Disease:
Patient came to general surgery clinic in Haji General Hospital
Surabaya with complaint a lump at his left groin. Patient realized it
since 11 months ago. The lump first appeared when the patient swim
too long. The lump is becoming bigger day by day and now down to
the scrotum. The lump comes out while the patients playing and goes
in when the patient is resting. The lump is painless. There is no history
of chronic [Link] is no problem in the urinary and defecation.
3. Last history disease:-
4. Family history disease : -
III. OBJECTIVE
At November, 19th 2014
Primary Survey:
A: Free
B: Spontaneous, RR: 20tpm
C: warm, red, and dry acral, T:110/80 ,pulse: 90 bpm,
D: GCS 4-5-6
Secondary Survey:
General conditions: moderat illness
Awareness / GCS: Compos mentis / 4-5-6
Vital sign:
Tension: 110/80mmHg RR: 20tpm
Pulse : 90 bpm [Link]: 36,30C
BB : 20 kg
General Status:
Head / face: symmetric
Anemia / jaundice / cyanosis / dyspnea: - / - / - / -
Thorax:
Pulmo:
I : normochest, retraction (-)
P : symmetric breathing movement
P : sonor/sonor
A : vesicular/vesicular, rhonchi -/-, wheezing -/-
Cor:
I : ictus cordisnot seen
P : ictus cordis not palpable, thrill (-)
P : normal cor border
A : S1S2 single, murmur (-), gallop (-)
Abdomen:
I : flat, symmetric
A : bowel sound (+), normal
P : Soepel Soepel Soepel
Soepel Soepel Soepel
Soepel Soepel Soepel
tenderness: _ _ _
_ _ _
_ _ _
P : Tympani Tympani Tympani
Tympani Tympani Tympani
Tympani Tympani Tympani
Ekstrimitas: warm acral + +
+ +
Edema - -
- -
Local Status:
Regio: Inguinalis Sinistra
I: mass (+)
P: tenderness (-), warm (-)
AVN: normal
Finger test : (+) on the tip of the finger
Valsava Manuver: (+)
Zieman test : (+) on the index finger
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IV. ASSESSMENT
Working diagnose : Hernia
Primary diagnose : Hernia Inguinalis Lateralis Sinistra Reponible
Secondary diagnose :-
Complication diagnose :-
V. PLANNING
1. Planning diagnose :-
2. Planning therapy : Pro Herniotomy with high ligation of the sac
3. Planning management : infus D5 ½ NS 1500cc/24 hours
Inj Ceftriaxone 2x1g
fasting
Pro Op Herniotomy high ligation
4. Planning monitoring : wound conditionex op (dry or still wet)
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Follow up (November 19th 2014) post op
S : Pain post op, nausea and vomiting 3 times, flatus (-)
O : General condition: fatigue
Vital sign: BP: 110/70 Pulse : 96 times/minute
RR : 20 times/minute t : 36,4
Head / face: symmetric
Anemia / jaundice / cyanosis / dyspnea: - / - / - / -
Thorax:
Pulmo:
I : normochest, retraction (-)
P: symmetric breathing movement
P: sonor/sonor
A: vesicular/vesicular, rhonchi -/-, wheezing -/-
Cor:
I : ictus cordisnot seen
P: ictus cordis not palpable, thrill (-)
P: normal cor border
A: S1S2 single, murmur (-), gallop (-)
Abdomen:
I : flat, symmetric, wound dressing (+)
A: bowel sound (↓), normal
P :
Soepel Soepel Soepel
Soepel Soepel Soepel
Soepel Soepel SDE
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tenderness: _ _ _
_ _ _
_ _ +
P :
Tympani Tympani Tympani
Tympani Tympani Tympani
Tympani Tympani Tympani
Ekstrimities: warm acral + +
+ +
edema - -
- -
Local Status:
Regio Inguinalis Sinistra
I:wound dressing (+), blood (-)
P: tenderness (+), warm (+)
Regio genitalia
I: edema on scrotum S (+)
P: tenderness (-)
A : post herniotomy high ligation H-0
P : infus D5 ½ NS 1500cc/24hours
Inj Ceftriaxone 2x1g
Inj ketorolac 3x10mg
Inj metochlorpropamide 3x1/3 amp iv
Operation result:
Hernia sac (+)
Content of hernia sac (-)
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Follow up (november 20th 2014) post op
S : Pain post op, nausea (-) vomiting(-)
O : General condition: fatigue
Vital sign: BP: 120/70 Pulse : 96 times/minute
RR : 20 times/minute t : 36,6
Head / face: symmetric
Anemia / jaundice / cyanosis / dyspnea: - / - / - / -
Thorax:
Pulmo:
I : normochest, retraction (-)
P : symmetric breathing movement
P : sonor/sonor
A : vesicular/vesicular, rhonchi -/-, wheezing -/-
Cor:
I : ictus cordis not seen
P : ictus cordis not palpable, thrill (-)
P : normal cor border
A : S1 S2 single, murmur (-), gallop (-)
-Abdomen:
I : flat, symmetric, wound dressing (+)
A: bowel sound (+), normal
P : Soepel Soepel Soepel
Soepel Soepel Soepel
Soepel Soepel SDE
tenderness: _ _ _
_ _ _
_ _ sde
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P : Tympani Tympani Tympani
Tympani Tympani Tympani
Tympani Tympani Tympani
Ekstrimitas: warm acral + +
+ +
edema
- -
- -
Local Status:
Regio Inguinalis Sinistra
I: wound dressing (+), blood (-)
P: tenderness (+), warm (+)
Regio genitalia
I: edema on scrotum S (+)
P: tenderness (-)
A : post herniotomy high ligation H+1
P : infus D5 ½ NS 500cc/24hours
Inj santagesik 3x1 amp
Diet bubur halus
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