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SURGERY DEPARTMENT

CASE PRESENTATION
PATIENT HISTORY
GENERAL DATA:

NAME:PC.
AGE:50 ys old.
GENDER:Male.
OCCUPATION:chief officer(ship)
ADDRESS:Bacaca,Davao city.
MARITAL STATUS:married.
DATE OF ADMISSION:16/3/17,9.00AM.
INFORMANT:Patient.
RELIABILITY:85./.
CHEIF COMPLAINTS
:
Bulging in groin region.
HISTORY OF PRESENT ILLNESS
•3 months PTA,patient felt bulging near the scrotum in
the groin.bulging present on the left side
•Patient felt some irritation only during sneezing or
coughing.
•Patient does not allow to do physical examination,but
he reported 0.5cm size of his bulging.
•He doesn’t lift any heavy weight.He was having a
stressful work at the ship.
•Only 2 to 3 hrs of sleep only
• Patient returned from work on april and he is taking
rest until now.
•At present,the patient had an consultation and
diagnosed with inguinal hernia and advised to get
operated.
•Tomorrow morning will be the surgery.
PAST HISTORY
• No childhood illness.
• No history of measles,rubella,mumps,whooping
cough,dengue and rheumatic fever.
• MEDICAL: (-)asthma (-)diabetes (-)HTN
• (-)previous hospitalizations.
• SURGERY:none
• PSYCHIATRIC:none
• Complete immunizations.
• SCREENING TEST:(-)Colonoscopy (-)stool test for
occult blood (-)cholesterol test
FAMILY HISTORY
• Father passed away because of aneurysm.
• Mother alive 78 yrs old.
• No history of hernia in the family.
• No history of diabetes and hypertension in family
members
Personal and social history

• The patient is married and has two children-


boy(21yr old) girl(20 yr old)
• No allergy to food and medications.
• patient is an occassional alcoholic.
• The patient was a smoker but quitted before 20 yrs
ago.
• Patient prefers to exercise(running,jogging).
• OCCUPATION:patient is having a stressful work in
ship with omly 2 to 3 hrs of sleep.
SYSTEM SYMPTOMS
General (-)Weakness, (-) fatigue,(-)fever,(-)weight change

Skin (-)Itching,(-)dryness,(-)changes in colour of moles

Head,Eyes,Ears,Nose, (-)Headache,(-)head injury,(-)dizziness,reading glasses


Throat used.
(-)Excessive tearing,(-) blurred vision
(-)Tinnitus,(-) vertigo,(-) ear discharge

(-)Nasal discharge,(-)nose bleeds


(-)Bleeding gums,(-) false dentition,(-) dry mouth
Neck (-)Stiffness,(-) pain

Respiratory (-)Cough,(-) difficulty breathing

Cardiovascular (-)Chest pain,(-) palpitations


Gastro heartburn(-) vomiting(-) trouble swallowing(-) change in
REVIEW OF SYMPTOMS
intestinal bowel habits(-) abdominal pain(-) constipation(-) excessive
belching(-)

Urinary (-)polyuria,(-) nocturia,(-) hematuria,(-) UTI,(-)dribbling

Genital (-)tching,(-) sores,(+)bulging in the groin region.

Musculoskelet (-)Joint pain,(-) stiffness,(-) fractures,(-) edema


al

Psychiatric (-)changes,(-) depression

Neurologic (-)Loss of sensation,(-) seizures,(-) tremors

Hematologic (-)Past transfusion,(-) easy bruising


Endocrine (-)Excessive sweating,(-) heat/cold intolerance
Physical examination
• General :Patient is awake,
conscious and cooperative
• VITAL SIGNS
• Blood pressure: 120/85 mmhg
• Heart rate: 72bpm
• Respiratory rate:18cpm
• Temperature:36 c
• Height:5’8”
• Weight:81 kg
• BMI:25.9 OVERWEIGHT
PHYSICAL EXAMINATION

SKIN (-)lesions (-)pallor ,(-)cyanosis, (-)clubbing,


HEENT
•Head: Normocephalic, hair is thick
•Eyes : Anicteric sclera,EOM intact
•Ear : (-) auditory defect, ear drums intact
•Nose: midline septum
•Throat: trachea midline, (-) enlarged tonsils
•lungs:
symmetric chest exansion,no mass or tenderness,resonant on
both lung fields,
clear breath sounds.no wheezes or rales
• CVS:
Adynamic precordium (-) heaves, (-) thrills A : S1 S2
heard; (-) Murmurs.
• Abdomen:
Normoactive bowel sounds heard.
No pain during palpation.
Genitalia : not assessed
Rectum : not assessed.
• Musculoskeletal system:No mass,No spine
curvature,No bony swelling,(+)Limited range of
motion.
Neurological examination:
• Level of consciouness: GCS 15
• Cranial nerves:CN1 to CN12 intact,(+) good

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