Patient Identity Patient Initial: Mr. SGender : Male Date of Birth: December, 24th 1961Ae: !4 "ear#old Marital Stat$% : Marriae&eliion: I%lam Addre%%: 'l. Bano, (o. 19, &) **6+&, **6, -ilanda. 'ob: -on%tr$ction laborMedical &ecord : /4 02 11 Admi%%ion date : '$ne, 22th 2*1! Di%chare date : '$l" 2th 2*1!History Taking 3i%tor" ta.in 4a% done b" auto-anamnesison '$ne, 22th2*1! at 2*.** ,IB atBougenvillePa5ilion, Marinir Cilandak 3o%6ital 7&SM-8. Chief Complaint : 9$m6 in the riht %crotal reion 4hich de5elo6ed %ince 2 month% ao.Present Medical History A!4"ear#oldentleman, namedMr.S, came to-ilanda.Marine 3o%6ital 4iththe chiefcom6lainoffeelinal$m6inhi%riht %crotal reion4hichde5elo6ed%ince2month%ao.Aro$nd 2 month% ao, the %i:e of the l$m6 4a% a% bi a% marble% and there i% no tenderne%% on it.If he 4a% doin acti5itie% %$ch a% 4al.in or r$nnin, the l$m6 became bier. If he too. a re%t,the l$m6 4a% di%a66eared. Aro$nd 4 month% ao, the l$m6 became bier and radiated to the%crotal reion, the %i:e 4a% a% bi a% 6in#6on ball, he felt a bit na$%eo$% and 5omited /#4 time%a da", the con%i%tenc" of the 5omit i% food, and there 4a% no reeni%h %ecret. (o4, the l$m6 i% a%bia% olf#ball. )herei% neither redne%% nor 6aininthel$m6. )hel$m6i%not di%a66earaltho$hheta.e%are%t. )hel$m6become%bier4henhe4al.%, r$n%, orotheracti5itie%.)here i% no %"m6tom of 5omit, na$%ea, abdominal 6ain, die%ti5e 6roblem%, or $rinar" 6roblem%.Patient doe% not con%$me an" medicine to treat hi% com6laint. 1Past Medical History )here i% no e5idence% of aller" to an" food% or dr$%. Patient ha% not been admitted to ho%6italfor %inificant di%ea%e%. Family History )here i% no famil" member that ha% %imilar com6laint. Patient;% father ha% diabete% mellit$% t"6e2 and doe% ro$tine medical chec.$6 on clinic. Patient;% father con%$me% dr$% for treatin hi%di%ea%e. Daily Habitual History Patient 4or.% a% a con%tr$ction laborer. )hi% =amination : Abdominal reion: 9 : Attached bandae% on %$rical %ite, blood 7#8, 6$% 7#8, fl$id 7#8 G : )enderne%% 7@8, A: Po%t 3erniotom" and 3erniorrha6" 7D@18 P: Mobili:ation -eftria=one 2 = 1 r 7i58 Mefenamic acid / = !** m DateDoctor;% In%tr$ction '$l", 1%t2*1! 7*0.**8 S: (a$%ea 7#8, 5omit 7#8, flat$% 7@8, 6ain on %$rical %ite 9A: Moderatel" ill+-om6o% menti% 11*+0* mm3I 02 =+mI 16 =+mI /6 o- General >=amination : Abdomen : S$6el, Bo4el %o$nd 4 time% 6er min$te, tenderne%% 7@8 on %$rical %ite, t"m6ani 7@8 9ocali:ed >=amination : Abdominal reion: 9 : Attached bandae% on %$rical %ite, blood 7#8, 6$% 7#8, fl$id 7#8 G : )enderne%% 7@8, A: Po%t 3erniotom" and 3erniorrha6" 7D@18 P: Mobili:ation -eftria=one 2 = 1 r 7i58 Mefenamic acid / = !** m DateDoctor;% In%tr$ction 10'$l", 2th 2*1! 7*0.**8 S: (a$%ea 7#8, 5omit 7#8, flat$% 7@8, 6ain on %$rical %ite A: Moderatel" ill+-om6o% menti% 12*+2* mm3I 2* =+mI 12 =+mI /6 o- General >=amination : Abdomen : S$6el, Bo4el %o$nd 4 time% 6er min$te, tenderne%% 7@8 on %$rical %ite, t"m6ani 7@8 9ocali:ed >=amination : Abdominal reion: 9 : Attached bandae% on %$rical %ite, blood 7#8, 6$% 7#8, fl$id 7#8 G : )enderne%% 7@8, A: Po%t 3erniotom" and 3erniorrha6" 7D@18 P: Mobili:ation -efadro=il / = !** m Mefenamic acid / = !** m Sent home, control ! da"% on %$rer" o$t6atient% de6artment C"-E DI-C'--I+!11Patient;% Di%ea%e re5ie4 )e=tboo. &e5ie43i%tor" )a.in: Geelin a l$m6 on the roin Prore%%ion 7 in %i:e, and from red$ced#able to $n#red$ced#able8 Ara5atin factor : 4or. 7 hea5"liftin +%trainin 83i%tor" ta.in : Ma" be a%"m6tomatic Geelin of l$m6 (on#red$ced#able ,or. a% a ri%. factor : a 4or. that canincrea%e 6re%%$re in abdominal 4all &i%. factor : %trainin, 6rolonedco$h, hea5" e=erci%e% Ma" be 6ainle%% S"m6tom% mo%t commonl" occ$rred ifthe hernia become JincarceratedK : ile$%ob%tr$cti5e 6roblem 7 na$%ea, 5omitin,colic abdominal 6ain, ob%ti6ation8Ph"%ical e=amination: In%6ection : ro$nd#%ha6e ma%% in riht%crotal reion 4ith the %i:e of C ! = 4 =/ cm, no inflammation %in Pal6ation : )he con%i%tenc" i% %oft. )hema%% i% not tender. )here i% no 6$l%atilein the ma%% or fl$ct$ation. )he ede ofthema%%i%4ell#defined. )hema%%i%able to mobile to the %.in. )ran%#ill$mination )e%t 7#8Ph"%ical e=amination : 9$m6 in the roin 9$m6 can be felt 4hen %trainin on in%tandin 6o%ition 7 if re6onible8 Giner )e%t, Lieman )e%t, )h$mb te%t )ran% ill$mination te%t 7#8G$rther in5e%tiation : 9aborator" : Blood co$nt M#ra" )hora= Photo >-GG$rther in5e%tiation : NSG -)#ScanManaement: 3erniorha66" and 3erniotom" Manaement : )en%ion Gree techniO$e Bila"er %$t$re techniO$e In%ertion of Me%h Ba%%ini )echniO$e 9a6aro%co6ic1213