IDENTITY

Name : Mr. N
Age : 76 years old
Address : Lantari Jaya Village
Admission : April, 27th, 2016
DPJP : dr. Faruly Wijaya S Limba, Sp. B
 HISTORY TAKING
Chief Complain : bulge at right lower quadrant
abdomen
Suffered since 2 weeks ago before admitted to the
hospital refference from Bombana Hospital. The
bulge was intermittent, appear when coughing or .
The patient also complaint pain at right lower
quadrant, intermittent. There was no nause and
vomit, no anorexia. The patient complaint to hard to
defecate since 2 weeks ago, urinary was normally.
The history of vomit and diarrhea before the bulge
appear. The history of abdominal surgery (-)
 PHYSICAL EXAMINATION
The patient was conscious with moderate ill

BP = 180/100 mmHg
Pulse = 100 x/m, regular, strong
RR = 20 x/m, regular
Temperature = 36.8oC
General state
Head : Normal
Eyes : Normal
Nose : Normal
Ears : Normal
Mouth : Normal
Neck : Normal
Chest : Normal
Extremity : Normal
Abdomen I : flat, follow the breath, there
is bulge at right illiaca region
when Valsava manuever and a
few minutes the bulge missing,
no eritem,
A : peristaltic was normal
P : tenderness at right illiaca
region, there is mass, consistency
was soft, reguler, mobile when
P : tympani, liver was deaf
 Rectal
touche Mass (-)
Anal spinchter : weak
Ampulla filled by
feces
Feces (+), blood (-) at
handscoen
Laboratory finding
WBC : 6,00
RBC : 3,66
HGB : 10,1
PLT : 658
NEUT : 79,6
 DIAGNOSE
Susp. Spiegheli Hernia

Planning diagnostic

USG Abdomen
Planning of therapy
IVFD
Analgetic
Antibiotic
Consult a surgeon