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A. GENERAL DATA
1. Patient’s Name: J.R.T
2. Address: La Paz Tarlac
3. Age: 3 months old
4. Sex: Male
5. Birth Date:08/29/09
6. Rank in the family:2nd child
7. Nationality: Filipino
8. Civil Status: Child
9. Date of Admission: 08/25/09
10.Order of Admission: N/A
11. Attending Physician: Dr. Jessie De Leon
HISTORY OF PRESENT ILLNESS: One day prior to admission, patient was confined because of having scrotal mass, nonreduceable accompanied
with fever. The patient sought consult to a private clinic and was diagnosed of Indirect Inguinal Hernia bilateral. Due to financial problem, patient
decided to transfer to TPH hence admitted.
F. SYSTEMS REVIEW- (Gordon’s 11 Functional Health Patterns Assessment, more patient’s more than 3 y/o)
3. ELIMINATION PATTERN
• Subjective:
Bowel habits: Usually he defecates 2x a day and doesn’t have any alteration upon defecation. According to his
mother, bowel is usually yellow cylindrical and soft.
• Color: brown
• Odor: pungent, affected by food type
• Consistency: soft form
• Laxative use if any: none
Bladder: She has no problem in urination. Patient usually urinate 4-6x a day
• Color: pale yellow
• Odor: mildly aromatic
• Alterations if any: none
Legend
0 – full care
I – requires use of equipment
II – requires assistance or supervision from others
II – requires assistance or supervision from another, and equipment and a device
IV – dependent; doesn’t participate
9. SEXUALITY-REPRODUCTIVE PATTERN
• Subjective: not active in sexual intercourse because he was only a child.
For both sexes
Contraception: none
Sexual activities: none
Special health reproductive problems: none
History of sex abuse: none
11.VALUE-BELIEF PATTERN
• Subjective: His mother stated that they don’t believe in any superstitious belief on health. And she also stated that it is
better to consult to a physician for early prevention of sickness. The patient’s religion is INC.
G. HEREDO-FAMILIAL ILLNESS
I-PHYSICAL ASSESSMENT
PEDIATRIC HISTORY
Maternal and Birth History
Date of birth: August 29,2009
Birth weight: cannot remember
Type of delivery: NSD
Condition after birth: no abnormalities
Hospital: Tarlac Provincial Hospital
b. Mother
Complications of delivery: none
Anesthesia: local anesthesia
Exposure to tetranogens: none
c. Neonates
Neonatal history: there was no abnormalities
Feeding history
Type of feeding: Breastfeeding and Bottle-feeding
IV. INTRODUCTION:
A HERNIA is a protrusion of an internal organ or part of an organ through a tear, hole or defect in the wall of a body cavity (ie the abdominal wall
muscle). A hernia may be likened to a failure in the sidewall of a pneumatic tire . The tire's inner tube behaves like the organ and the sidewall like the body
cavity wall providing the restraint.
Hernias may be present at birth, or be acquired later in life after repetitive heavy strain or injury to this abdominal wall muscle. Hernias may occur commonly
in such areas as the lower abdomen or groin areas (Inguinal Hernia), at the region around the navel (Umbilical Hernia), or even through a prior surgical
incision (Incisional Hernia). Hernias can re-occur in an area of a previous hernia repair (Recurrent Hernia). But Hernias can and do occur anywhere on the
abdominal wall, and are given other various names such Femoral, Epigastric, Spigelian or Sports Hernia. The basic problem remains the same, the muscle
container of the abdominal wall no longer holds the contents safely and securely in place. As pressure inside the abdomen pushes the abdominal contents
through this defect, a bulge is created, and pain, burning or aching are experienced. These symptoms gradually increase in intensity with time as the hernia
gradually enlarges, stretching surrounding tissue and irritating local nerve pain fibers.
Surgery is recommended to alleviate symptoms and prevent the hernia from becoming caught (Incarcerated) in the muscle tear or defect and having its blood
supply damaged (Strangulated).
Indirect inguinal hernia. Indirect inguinal hernias are congenital hernias and are much more common in males than females because of the
way males develop in the womb. In a male fetus, the spermatic cord and both testicles—starting from an intra-abdominal location—normally
descend through the inguinal canal into the scrotum, the sac that holds the testicles. Sometimes the entrance of the inguinal canal at the inguinal
ring does not close as it should just after birth, leaving a weakness in the abdominal wall. Fat or part of the small intestine slides through the
weakness into the inguinal canal, causing a hernia. In females, an indirect inguinal hernia is caused by the female organs or the small intestine
sliding into the groin through a weakness in the abdominal wall.
Direct inguinal hernia. Direct inguinal hernias are caused by connective tissue degeneration of the abdominal muscles, which causes weakening
of the muscles during the adult years. Direct inguinal hernias occur only in males. The hernia involves fat or the small intestine sliding through the
weak muscles into the groin. A direct hernia develops gradually because of continuous stress on the muscles. One or more of the following factors
can cause pressure on the abdominal muscles and may worsen the hernia:
• a small bulge in one or both sides of the groin that may increase in size and disappear when lying down; in males, it can present as a swollen or
enlarged scrotum
• discomfort or sharp pain—especially when straining, lifting, or exercising—that improves when resting
• a feeling of weakness or pressure in the groin
• a burning, gurgling, or aching feeling at the bulge
Case Study
Indirect Inguinal Hernia Bilateral
Submitted to:
Ms. Ruby-Ruth Pascual
Submitted by:
Vivien S. Pajela
BSN IV-A