A Case of M.C.

PATIENT PROFILE
M.C. is a:
32 year old
Filipino
Roman Catholic
married
Male
From Borbon, Cebu
CC: Inguinal pain and reducible mass, right

PAST MEDICAL HISTORY

No prior hospitalizations or surgeries
Not a known hypertensive, diabetic or
asthmatic
No maintenance medications
No known food or drug allergies

PERSONAL AND SOCIAL

HISTORY
7.5 pack year smoker
Previously an alcoholic beverage drinker
of 1-2 bottles beer 1-2x per month
History of methamphetamine use, last
use back in 2012
Incarcerated since ____ in CPDRC

PERSONAL AND SOCIAL

HISTORY
No particular food preference or
restrictions
No recent bowel or bladder problems
Previously worked as a construction
worker for 3 years
Exercises regularly while in incarceration
including lifting free weights

FAMILY HISTORY
Birth rank of 3/5, siblings apparently well
Eldest brother died
Known heredofamilial diseases include:
Hypertension both sides
Diabetes paternal
Asthma maternal

HISTORY OF PRESENT
ILLNESS
Years PTA:
Recurrent inguinal mass associated
with inguinal pain of 4-6/10, dull with
radiations to right iliac region
No consult made, self-medicates with
pain relievers with some relief
Patient sometimes perform taxis of
mass without associated adverse
effects
(-) blood or dark colored stools, (-)
constipation

HISTORY OF PRESENT
ILLNESS
1 month PTA:
Noted recurrence of same inguinal mass still
associated with inguinal pain now with PS
10/10, dull with radiation to right iliac region
No medications taken
(-) fever, (-) constipation, (-) bloody or darkcolored stools
This prompted consult with VSMMC-OPD.
Patient was advised operative management.

HISTORY OF PRESENT
ILLNESS
Patient was told to have laboratories
taken and to come back for scheduling.
Day of admission:
Patient came in with lab results and
subsequently scheduled thus this
admission

PHYSICAL EXAMINATION
GENERAL: Awake, conscious, coherent,
afebrile patient not in respiratory
distress
VITAL SIGNS:
BP 110/70mmHg
RR 21 cpm
PR 85 bpm
T 36.7C
HEENT: anicteric sclerae, pink palpebrae,
moist oral mucosae
NECK: supple, no lymphadenopathies

PHYSICAL EXAMINATION
CHEST/LUNGS: equal chest expansion,
clear breath sounds bilaterally, (-)
crackles
CVS: adynamic precordium, distinct S1
and S2,
(-) murmurs
ABDOMEN: flabby, normoactive bowel
sounds, soft, nontender, no
organomegaly
GUT: grossly male, enlarged right

PHYSICAL EXAMINATION
DRE: no skin tags, tight sphincter tone,
smooth rectal wall, empty rectal vault,
rubbery nontender smooth prostate,
no fecal material or blood on examining
finger
EXT: strong peripheral pulses, CRT<2secs
CNS: within normal limits

IMPRESSION

Indirect inguinal hernia, right, reducible

Hydrocele, right

LABORATORIES
HBsAg
nonreactive
Ultrasound
hydrocele formation, right
1.4 x 2.5 x 2.6 cm, complex focus.
Consider inguinal hernia right.
normal sized and appearance of both
testicles
Chest x-ray, PA view
- Normal chest

LABORATORIES
CBC
WBC

10.29 x 109L

4.8 10.8

HGB

167 g/L

140 180

HCT

0.46

0.42 0.52

PLT

339 x 109L

150 400

NEU

65.30 %

40 74

LYM

28.50 %

19 48

MON

3.80 %

39

EOS

2.20 %

07

BAS

0.20 %

02

Diff Count

LABORATORIES
UA
Color

Yellow

Transparency

Clear

Specific gravity

1.020

pH

6.0

Glucose

Negative

Protein

Negative

RBC

0-1/hpf

WBC

0-1/hpf

Squamous E. cells

Rare

Bacteria

Rare

LABORATORIES
Prothrombin Time
Patient
% activity
INR
Control

12.8 secs
115.8%
0.93
13.3 secs

Control % Act

105%

Control INR

0.975

LABORATORIES
Chemistries
Creatinine
Sodium
Potassium
Chloride

1.02 mg/dl
143.5 mmol/L
3.56 mmol/L
101.4 mmol/L