Vsmmc-or Case Study 2009

UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION Salinas Drive, Lahug, Cebu City COLLEGE OF NURSING

CASE STUDY PATIENT PROFILE: •

Name: Jonel Capuyan

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Age: 5y2m19d

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Sex: male

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Status: child

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Address: Poblacion, Carmen, Cebu

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Name of Hospital: Vicente Sotto Memorial Medical Center

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Date of Admission: Aug. 23, 2009

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Ward & Bed No. : Ward VI/ Bed no. PS4

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Case No. : 65538

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Chief Complaint: pain at the lower left inguinal

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Medical diagnosis: Hernia, Inguinal Indirect left meducible

- An indirect inguinal hernia is an inguinal hernia that results from the failure of embryonic closure of the internal inguinal ring after the testicle has passed through it. Like other inguinal hernias, it protrudes through the inguinal ring. It is the most common cause of groin hernia.

History of Past Illness: Patient delivered full term, normal spontaneous vaginal delivery, home delivery by Trained Barangay Assistant, BCG, DPT, OPV, (-) Hepa, (-) meales.

History of Present Illness: Condition noted immediately after birth, patient 7 months old recommended surgery aonsult at the Local Health Center, consult for obstructive prevention of condition with accompanied pain prompted patient’s mother and sought consult.

Genogram: Cecilio Cole (HPN, Hernia)

Lourdes Cole (DM)

Antonio Capuyan

Anita Capuyan

Ranilo Capuyan

Judelyn Cole

Vincent

Male

Female

Diagnostic test and Laboratory:

Mariann e

Jonel (Hernia)

CBC Result Exam

Result

Normal value

RBC

5.03

4.20-5.40 ml/mn

Hemoglobin

0.426

0.37-0.47 L/L

MCV

85

81.00-99.00 gl

MCM

28

27.00-31.00 pg

WBC

9.2

4.80-10.80 10^g/L

MCHC

332

330.00-370.00 fl

RDW

10.3

11.00-16.00 fl

MPV

7.3

7.20-11.10 fl

Platelet count

444

150.00-400.00 10^g/L

Neutrophil

41.2

40.00-74.00 %

Lymphocyte

35.8

19.00-48.00 %

Monocyte

8.4

3.40-9.00 %

Eosinophil

13.5

0.00-7.00 %

Basophil

1.1

0.00-1.50 %

Blood type: A+

Urinalysis Color: yellow

RBC cells: 0-1/hpf

Transparency: clear

Pus cells: 0-2/hpf

Reaction: 6.0 Specific Gravity: 1.030

Sugar: negative Protein: negative

Abnormal crystals:

Normal crystals:

Tyrosine:

Calcium oxalate:

Cystine:

Amorphous Urates: few

Leucine:

Uric acid:

Ultrasound Scrotal area Findings: The right testicle measures 1.5x0.8x0.7cm while the left testicleis displaced inferomedially and measures 1.8x0.5x0.7cm. both exhibit a homogeneous echo pattern. There are loops of bowels with peristalsis noted within the scrptal sac.

Conclusion: Scrotal hernia Normal size and appearance of both testicles.

Pathophysiology: Host:

Etiology:

Males 90%

-congenital -heredofamilial

Canal begins in the intraabdominal cavity at the internal ring (located lateral to the inferior epigastric arteries, approximately midway between the pubic symphysis and anterior iliac spine)

canal courses down along the inguinal ligament.

External ring of the canal is located medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic tubercle.

Contents of this hernia then follow the tract of the testicle down into the scrotal sac. Signs & Symptoms: Textbook-based -aymptomatic -lump or swelling in the groin -a sudden pain into the scrotum -abdominal discomfort -heavy feeling in the groin -pain in the groin while standing or moving

Patient’s Manifestation

Interpretation