MORNING REPORT SURGERY DEPARTMENT DM E-17

28th

January 2013

Patients Identity
Name : Mr. F Age : 25 year Sex : man ID : 637888 Religion : moslem Address : Jipo RT3 RW2 kepohbaru Bojonegoro

Summary of Database
Chief complaint : mass in left crotch Present illness history: Patient complained mass in left crotch. Mass in left crotch appeared 1 year ago. The mass was missing and arising. It arised when patient cough and straining. It could disappeared by it self. It was painless Past illness history: (-)

Patients Status
Vital signs General appearence, awareness, GCS good , CM, 456

Blood Pressure
Pulse Rate Temperature Respiratory Rate

145/72 mmHg
85x/mnt 36,0 C 20X/mnt

Phisical Examination
Head : An -/- ; Ict -/- ; Cya -/- ; Dysp Thorax
Symmetric -, retraction Pulmo : RR: 20x/m, Ves/ves, Rh-/-, Whz-/ Cor : HR: 85x/m, reg (+) S1S2 tunggal, M-

 Abdomen
Inspection Palpation Auskultation Perkution : flat : soefl, pain (-), H/L just palpable : BU (+) N : met (-)

Extremity : acral warm and dry Inguinal:

Tonus of spinchter ani: good Mucosa: slick Painless The content of ampula recti was blank Feses (-), blood (-), slime (-)

LABORATORY FINDING
Diffcount Hct Hb Leukosit Trombosit Bleeding time Clothing time SGOT SGPT Urea Serum creatinin RBG : 3/0/71/22/4 : 48,7 % : 15.8 mg/dl : 5.100 : 242.000 : 2 00 : 8 30 : 15 : 25 : 29 : 0,8 : 95

Clue and cue

Man , 25 years Mass in left crotch: - mising and rising - painless

Problem List
Mass in left crotch

Initial Diagnose
Hernia Inguinalis Lateralis Sinistra Reponibilis

Planning of therapy
Pro op herniotomy IVFD RL 1500 cc/ 24 hour Inj ceftriaxon 1 gr

Monitoring
Vital signs Patients complain

Prognosis
Dubia ad bonam