Ospital ng Maynila Medical Center
Quirino Avenue corner Roxas Boulevard Manila, Philippines
Ospital ng Maynila Medical Center
Department of Surgery
Hospital No. 1937309 Ward: Surgery Ward
Name: Tuyay, Mark Lorence Age/Sex: 2/M Address: 165 Cupang, Muntinlupa City Date Admitted: 8 Jan 2009 Admitting Diagnosis: Indirect Inguinal Hernia, Left, Incarcerated Residents-in-charge: Dr. Cruz / Gonzales / Malabanan / Lucero / Caravana Clerks-in-charge: JI Anicete / Baluyot / Barnes / Bautista / Belandres / Boado / Bognot 24 hour History This is a case of a 40 year old, male, who came in due to inguinoscrotal mass.
History of Present Illness: 18 months PTA, patient mother noted enlargement of the left inguinoscrotal area aggravated by crying. One day PTA, parents noted progression of enlargement of left scrotal mass. It was associated with high grade fever and tenderness on the affected area. No vomiting, diarrhea, and convulsion were noted. Hours PTA, they seek consult at another government hospital but was advised to transfer, hence seek consult at this institution. Past Medical History (-) HPN, BA, allergies (-) previous hospitalization/ operation Family History Denies heredofamilial disease Personal and Social History (+) fully immunized 3 DPT, 3 Hepa B, 3 OPV, BCG, Measles (+) Breastfed with Alaska powder 1:2 dilution Review of Systems No chills, no weight loss No cough, no colds, no difficulty of breathing No dysuria, no hematuria, no oliguria No polyphagia, no polydypsia, no polyuria No seizure, no weakness, no loss of consciousness Physical Examination Patient is awake, irritable, NICRD CR= 140 RR= 24 T= 37.8 Wt= 11 kg HEENT: Anicteric sclerae, pink palpebral conjunctiva, no nasoaural discharge, no tonsillopharyngeal congestion, no cervical lymphadenopathy, Chest and Lungs: symmetric chest expansion, no retraction, clear breath sounds, no wheezes, no crackles Heart: adynamic precordium, normal rate regular rhythm, no murmur Abdomen: flabby, soft, normoactive bowel sounds, non-tender GU: (+) 5x2 inches scrotal mass, left with tenderness upon palpation Extremities: no gross deformity, FEP Assessment: Indirect Inguinal Hernia, left Incarcerated Plan: for admission
On the 1 HD, patient was admitted under the service of Drs. Troncales/ Cruz/ Gonzales/ Malabanan/ Jawali/ Caravana. Consent for admission was secured and service consultant was informed of this admission. Patient was put on NPO and IV Fluid of D5 o.3 NaCl at 64-65 ugtts/min was hooked. Patient was booked for ‘E’ herniotomy and was directed immediately to OR. Patient was also referred to Pediatrics Department for co-management. Foley catheter and OGT was inserted and Output was monitored every hour. Medications prescribed were Metronidazole 100 mg TIV q8 and Cefuroxime 250 mg TIV q8. Patient was asked for serum Na, and K, and post-op Chest X-ray APL.
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