MORNING REPORT

PATIENT IDENTITY

Name :
Gender :
Age :
Occupation :
Address :
Ethnic :
Religion :
Marriage st. :

SUMMARY OF DATABASE
Chief of complaint:
Swelling or fullness at the hernia site
Aching sensation (radiating into the area
of the hernia)
No true pain or tenderness upon
examination
Enlargement with increasing intraabdominal pressure or standing

 History of present illness:

Hernias in older children and adults may be accompanied by a dull ache
or burning pain that often worsens with exercise or straining (eg,
coughing). Neuralgia of the ilioinguinal nerve may present with a sudden
stabbing pain in the distribution.
An incarcerated hernia may be associated with the following:
Painful enlargement of a previous hernia or defect
Inability to manipulate the hernia (either spontaneously or manually)
through the fascial defect
Nausea, vomiting, and symptoms of bowel obstruction (possible)
Symptomatic patients often present with groin pain, which can be severe.
Stretching or tearing of the tissue at and around the hernia defect can
lead to a burning, gurgling, or aching sensation in the groin. This usually
causes localized pain directly at the site of the hernia.
Pain may worsen with Valsalva maneuvers.

 Patients may experience a heavy or dragging

sensation in the groin, especially toward the end
of the day and after prolonged activity.
Activities
that
increase
intra-abdominal
pressure, such as coughing, lifting, or straining,
cause more abdominal contents to be pushed
through the hernia defect. As this occurs, the
bulge of the hernia gradually increases in size. If
the patient indicates that this bulge disappears
while he or she is in the supine position, clinical
suspicion of a hernia should be increased.

 Bulge in the groin, scrotum or abdominal

area that often increases in size with
coughing or straining
Mild pain or pressure at the hernia site
Numbness or irritation due to pressure on
the nerves around the hernia
Sharp abdominal pain and vomiting can
mean that the intestine has slipped
tyhrough the hernia sac and is strangulated

Incarserated hernia:
Nausea, vomiting or both
Fever
Rapid heart rate
Sudden pain that quickly intensifies
A hernia bulge that turns red, purple
or dark

 History of past illness:

Chronic cough, obesity/ excess weight, severe
lung damage, premature birth, pregnancy,

History of family illness:

Same complaint

History of social illness:

Bowel habit/ chronic constipation, urination habit
Patient occupation, having job that requires
standing for long periods, doing heavy physical
labor

PHYSICAL EXAMINATION
Vital Sign:
Blood Pressure : mmHg
Pulse Rate
: x/minutes
Respiration Rate : x/minutes
Temperature : 36.5 C

Generalis Examination:
Head/Neck: anemis -/-, jaundice -/-, cyanosis -/-,
dyspnoe -/ Chest:
Inspection: symmetrical, retraction -/-, gynecomasti (-)

Palpation: normal/ normal

Percussion: sonor/sonor
Auscultation: vesicular/vesicular, Rh -/-, Wh -/-

 Cor:
Inspection: Vussorue cardiac, Ictus cordis(-)
Palpation: ictus (-), thrill (-)
Percussion: the normal of heart
Auscultation: S1/S2 single murmur -, gallop
Abdomen:
Inspection: Flat, soepel, colateral vein (-), caput medusa (-), tenderness
(-)
Palpation: hepar and lien can not evaluated
Percussion: tymphani, shifting dullnes (-), undulasi (-)
Auscultation: bowel sound (+) Normal
Extrimity :

warm, dry, red, swollen (-), spider nervi (-), eritema palmaris (-)

CLUE AND CUE

PROBLEM LIST

PRIMARY ASSESSMENT

PLANNING DIAGNOSIS

Digital exam
Blood test
Urinalysis
ECG (px > 45th)
USG
CT Scan

LABORATORIUM

PLANNING THERAPY

EDUCATION
Maintain a healthy weight. Talk to your doctor about the best
exercise and diet plan for you.
Emphasize high-fiber foods. Fruits, vegetables and whole grains
contain fiber that can help prevent constipation and straining.
Lift heavy objects carefully or avoid heavy lifting altogether.
If you must lift something heavy, always bend from your knees not
your waist.
Stop smoking. Besides its role in many serious diseases, smoking
often causes a chronic cough that can lead to or aggravate an
inguinal hernia.
Avoid relying on a truss. Wearing a supportive garment designed
to keep hernias in place (hernia truss) doesn't correct the underlying
problem or help prevent complications. Your doctor might
recommend a hernia truss for a short time before surgery to help you
feel more comfortable, but the truss isn't a replacement for surgery