Anda di halaman 1dari 10

I.

Introduction
Inguinal hernia is a condition in which intra-abdominal fat and intestines pushes through a weak spot in a groin muscle. Indirect inguinal hernia is a type of hernia that is considered to be congenital in nature. The signs and symptoms are characterized by bulge, burning, pressure in the groin, pain, and discomfort when lifting or straining. It usually affects male and it is present at birth. Excessive straining, lifting of heavy objects, obesity, familial history of hernia are also the common risk factors of indirect inguinal hernia. According from the National Epidemiology center from 2000 to 2010 Philippine health statistics, hernia incidence are likely to occur at any age in either gender but mostly on older men 50-60 years old with an average of 4.4 %.

II. Identifying data


Name: Mr. ABC Patient ID: 107142 Age: 51 Gender: Male Nationality: Filipino Status: Married Address: Olongapo, City Religion: Roman Catholic Educational Status: High School Graduate Occupation: Farmer Date of Admission: 03/05/13 Time of Admission: 9:39 am Name of Hospital: James L. Gordon Memorial Hospital Diagnosis: Hernia, Inguinal, Indirect Complete Reducible Right

III. Patients History


A. Chief Complaint

Inguino-Scrotal Bulging
B. History of Present Illness

Inguino-Scrotal bulging noted since childhood. Prior to admission client noticed exacerbation of size cause by exertion at work usually relieved by rest. Adult for elective surgery. Hence admitted.
C. History of Past Illness

Patient experienced intermittent pain in the groin area and took self-medication such as cortal. He was admitted first at one of the hospital in Camarines Sur due to lack of specialty of surgeon to handle his case her mom decided to move his son here in James L. Gordon Memorial Hospital.
D. Family Health History

Father - Inguinal Hernia. - Hypertension.


E. Personal and Social History

The client lives with his wife and 5 children he described their house in Camarines sur as typical house in province build by bamboo and nipa, their water source comes from manual water pump and since he is the head he needs to carry bucket of water every day for his family. He always wakes up at 4 in the morning to do his work at home and also at the farm as a farmer. Since 1985 when he got married he started chewing nganga everyday and occasionally drinks liquor once a month amounting of 1-2 bottles of gin.

F. Nutritional History

The client diet is consist of nutritional intake according to his satisfaction usually vegetables and fish but he tends to drink coffee instead of water.

IV. Review of System

SYSTEM General

SIGNS & SYMPTOMS

DATE

CAUSE

-Hot to touch skin

Integumentary System

Masculo-skeletal System

-Small, red liquidfilled blisters -Small, touchable 2004 lump in midsternal area -redness with 2009 irregular break of skin in midscapula area -Muscle pain 1985 (5x) 2000(2x) 2010 -Dry nonproductive cough -Productive cough -Cough and colds 2002 (2x)

1992 1999 2004 1969

Fever Chicken Pox Cyst

Accidental laceration at work Due to strenuous work -Viral Cause

Respiratory System

2006 2003 and 2005 (3x) 1985 up to present

Genito Urinary System

-Aching, burning sensation in inguinal area

-Pulmonary tuberculosis -Bacterial Cause Inguinal Hernia

V. Physical Assessment
Date: March 6, 2013 Time: 10:00 am A. General Appearance: Patient is lying flat on bed wearing surgical gown afebrile with anxious appearance. Cooperative and oriented with ongoing 5% Dextrose in Lactated Ringer Solution 1L at 700 ml inserted at the right cephalic vein regulated at 31 to 32 drops per minute infusing well. Weight: 59.5 kg Height: 159 cm

BMI = 23.52 normal weight B. Vital signs: T: 36.5 c P: 100 bpm R: 20 cpm BP: 130/80 mmHg
BODY PART Skin TECHNIQUES Inspection NORMAL FINDINGS Uniform in color no presence of dry skin. ACTUAL FINDINGS -brown skin color with presence of dry skin. INTERPRETATION Abnormal

Nails

Inspection

Pink cast in light-skinned individuals, and brown in darkskinned individuals. Smooth and slightly rounded or flat. Nail thickness should be uniform throughout Prompt return of pink or usual color should be 1-2 sec

Pinkish in color

Normal

Palpation

Rough, slightly rounded and thick

Abnormal

Capillary refill time of 4

seconds

Abnormal

Conjunctiva Inspection

Pinkish palpebral and bulbar conjunctiva

Pale palpebral and bulbar conjunctiva

Abnormal

Mouth Pink, moist symmetric Inspection Pink, soft, moist Dark, dry, symmetric Abnormal

Lips

Buccal mucosa

Inspection

Slightly pink color, moist and tightly fit against each tooth Moist, slightly rough on dorsal surface 32 adult teeth Firmly set, white and shiny

Dark brown, soft, moist

Abnormal

Gums Inspection

Dark Brown, moist and tightly fit against each tooth

Abnormal

Tongue Inspection

Moist, slightly rough on dorsal surface

Normal

30 adult teeth Teeth Brown and black

Inspection

discoloration of the enamel

Abnormal

Posterior Thorax

Inspection

Free from lesions and scars

Presence of 3cm scars on left midscapular line

Abnormal

Anterior Thorax

Inspection

Free from lesions and scars

Presence of 2 cm scar on midsternal line

Abnormal

Genitals

Pubic hair Triangular distribution Inspection Hairless (shaved) Penile skin intact slightly wrinkled and same color as the body skin Smooth and semifirm Penile skin intact slightly wrinkled and same color as the body skin Normal Normal

Penis

Inspection

Scrotal skin is loose and darker in color.

Palpation

Scrotum appears asymmetric

Smooth and semifirm

Normal

Scrotum Testicles are rubbery and smooth. Inspection Testes is about 2 x 4 cm Scrotal skin is loose and darker in color Normal

No swelling or bulges

Marked asymmetry in size of right scrotum (right scrotum is larger)

Abnormal

Palpation

No tenderness

Presence of hardened testicles

Abnormal

Right testes is 4 x 6 cm Inguinal Area Inspection Presence of bulges while client is bearing down Presence of tenderness in the right inguinal area

Abnormal

Abnormal

Palpation

Abnormal

VI. Laboratory Result


Hematology Report

Date: (03/05/13)
PARAMETER Hemoglobin Hematocrit White Blood Cells Neutrophils Lymphocytes Eosinophil Platelet Count NORMAL FINDINGS 14.0-18.0 g/dL 40-50 5,000-10,000/mm 0.55-0.70% 0.20-0.40% 0.01-0.08 150,000-450,000/mm ACTUAL FINDINGS 10.5 g/dL 32g/dl 7,460/mm 0.60% 0.27% 0.05 328,000/mm INTERPRETATION Decreased Decreased Normal Normal Normal Normal Normal

Radiographic Report

Date: (03/05/13) Chest X-Ray Non cavitary Pulmonary Tuberculosis both upper lobes Normal cardiac size Diaphragm and soft tissues unremarkable

VII. Pathophysiology
NON MODIFIABLE FACTORS -Male -Age (51 years old) -Congenital -Hereditary MODIFIABLE FACTORS -Occupation (Farmer) -Lifestyle (lifting heavy object)

Intra-abdominal wall of inguinal canal into the scrotum becomes weakened Increased pressure in the abdominal compartments Intra abdominal fat / part of small intestine slides through the weakened abdominal muscle Slides into the inguinal canal Bulge at the right side of the groin Feeling of heaviness or pressure in the groin S/Sx: Aching, burning sensation during strenuous activities

S/Sx: Increasingly more uncomfortable and tender to touch

Hernia increase in size Pressure in the groin exacerbated by exertion Stretching surrounding tissures Swelling of tissue of scrotum / Enlarged right scrotum

Stimulation of pain receptor

S/Sx:Pain (Presence of tenderness upon palpation)

INDIRECT INGUINAL RIGHT HERNIA

Anda mungkin juga menyukai