Case Report

“HERNIA INGUINAL LATERALIS IRREPONIBLE DEXTRA”

By:
M. F. Hanif
M. F. Satriadi
Rio Chairul Anam 

Supervisor :
dr M. Bob Muharly Rambe, M. Ked (Surg), Sp. Surgery
Patient Informations
Name : M. Dedi Gunawan
DOB : July 06, 1995
Age : 26 years old
Sex : Male
Address : Rawa Street, No.89 Medan city
Occupation : Student
Religion : Islam
Room : Jabal Rahma Room
MR : 368791
DOE : September 30, 2021
HERNIA INGUINAL LATERALIS
IRREPONIBLE DEXTRA
 Case Presentation

A 26 year old man came to the Surgical Department of

the Medan Haji General Hospital with a complaint of a
lump in the right scrotum, smooth consistency, flat
surface, mobile, well-defined, negative tenderness with a
size of 7 cm x 4 cm. entered when pushed but since two
weeks ago the lump has persisted, negative nausea,
negative vomiting, no problems urinating and defecating
 DiagnosticPhysical
Diagnostic PhysicalExamination
Examination

General condition : Looks moderately sick

Awareness : Compos mentis

Blood pressure : 130/70 mmHg

Pulse : 111 bpm

Temperature : 36,4 ⁰C

Respiration : 22 bpm

SPO2 : 90% ROOM AIR

Diagnostic Physical Examination

11 Head : Normocephali

22 Eyes : CA -/-, SI -/- , Isochoric pupils +/+

33 Thorax : Rh -/-, Wh -/-

44 Abdomen: Soepel (+), Symetric (+), tenderness (-)

55
Extremity : CRT < 2, oedem (-)
 Diagnostic Physical Examination
LocalizationState
Localization State: Abdomen
: Abdomen(Right)
(Right)

Inspection : The right scrotum looks enlarged, the color looks

the same as the surrounding skin
Palpation : palpable lump in right scrotum, chewy consistency,
flat surface,mobile, well demarcated, tenderness, size 7cm
x 4cm
 Chlinical Laboratory
Complete Blood Count
Complete Blood Count
Name Test Result Referral value
Blood
Hemoglobin 13,4 g/dL 13 – 18
Hematocrit 40,3 Vol % 40 – 50
Erythrocytes 3,6 million/uL 4.5 – 5.5
Leukocytes 4,8 thousand/mm3 4 – 11
Platelets 302 thousand/mm3 150 – 440
Index Eritrosit
MCV 111 fL 80 – 100
MCH 37 pg 26 – 34
MCHC 33 g/dL 32 – 36
Immunoserology Result Referral value
HIV Reactive Non-Reactive
 Rontgen Thorax

Result :
Sinus Costophrenicus & Diafragma : Normal
Cor : Normal Shape
Lungs : Normal bronchovascular pattern, no specific
and pathological active abnormalities seen

Image : Cor/Pulmo normal.

 Resume
A 26 year old man came to the Surgical Department of the Medan Haji General
Hospital with a complaint of a lump in the right scrotum, smooth consistency, flat
surface, mobile, well-defined, negative tenderness with a size of 7 cm x 4 cm.
entered when pushed but since two weeks ago the lump has persisted, negative
nausea, negative vomiting, no problems urinating and defecating

The inspection had found The right scrotum looks enlarged, the color looks the same
as the surrounding skin ,The palpation had found palpable lump in right scrotum,
chewy consistency, flat surface,mobile, well demarcated, tenderness, size 7cm x
4cm
 Diagnosis

Hernia inguinalis lateralis irreponible

TREATMENT

11 Surgical Treatment
 Hernioraphy
TREATMENT

22 Medical Treatment
 IVFD RL 20 gtt/min
 Inj. cefriaxon 1 gr/12 hours
 Inj. keterolac 30 mg/ 8 hours
 Inj. ranitidine 10 mg/ 12 hours
Documentation
Thank You