Department of SurgeryFebruary, 02 2015

DAFTAR OBMr M huseinHIM bilateral

Name: Mr HAge: 76 y.oSex: maleAddress: LamonganDate examination: february 02, 2015

ANAMNESISChief complaint Pain In the groinPresent IllnessThe patient complained of pain in the groin suddenly 2 hours before admission. There is a lump in the groin left and right since 2 years ago. Initially little later enlarge. The patient also complained of flatulence. Patients say the pain begins as patients exhaustion.defecation and miction within a normal limit.

History illness HT+ since > 5 years uncontrolled, The patient had been a hernia operation 3 times, the last in 2010Family illness :(-)Social history : (-)

PHYSICAL EXAMINATION VITAL SIGN :GCS: 456BP: 230/120 mmHgPULSE RATE: 76 x/minutesTEMP: 36oCRR: 20 x / minutes

Airway and spine control : clear (+), snorring (-), gargling (-), potensial obstruction (-)Breathing : spontan, simetric (+), RR 20x/minutes, ves/ves, rh-/-, wh-/-, Sp02 100% Circulation : PR 76x/minutes, acral warm dry red, CRT < 2, BP 230/120 mmhgDisability : GCS 456, Light reflex +/+, isocor pupil 3mm/3mm, lateralisasi-Exposure : temp 36CPRIMARY SURVEY

Head and neck : anemic (-), icteric (-), cyanosis (-), dyspneu (-). Thorax : simetric (-), retraction (-)Pulmo : ves/ves, rh-/-, wh-/-Cor : S1S2 single, murmur (-), gallop (-), lession -Abdomen : soepel, distended (-), tympani (+), liver and spleen were not palpable, bowel sound (+), lession-Extremities : acral warm, dry, red, lession-

lump in the groin dextra and sinistra

Clue and cueMale, 76 y.o Pain in the groin Lump in the groinHistory of hernia and had been operation 3 times, the last in 2010

Early AssesmentHernia Inguinalis Medialis dbilateralHernia inguinalis Lateralis Dextra rponibilisHernia inguinalis Sinistra ireponibilis

CBCCT-BTGDA Thorax AP

CBCDiff 0/0/74/23/3Hct 44,6Hb 14,2LED 1/16Lekosit 8.200Trombosit 246.000SGOT 16SGPT 13Urea 42Serum Creatinin 2,1BT 200CT 800

AssesmentHernia Inguinalis Medialis dbilateralHernia inguinalis Lateralis Dextra rponibilisHernia inguinalis Sinistra ireponibilisHypertension emergency

IVFD Assering 1500 cc/24 hoursInj Remopain 3x1 ampNicardipine IV 5 mg/hours

Subjective complaintVital sign

Explain to the patients family about the diagnosis, etiology, intervention of therapy, complication, and prognosis.

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