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PATIENT IDENTIFICATION DATA

Name

: TAI CHIN HOK

Registration number : N513305


IC number

: 590705-10-6351

Age

: 57

Sex

: MALE

Race

:CHINESE

Marital status

: SINGLE

Occupation

: RETIRED COOK

Religion

: CHRISTIAN

Date of admission

: 10/10/2016

Date of clerking

: 10/10/2016

Date of discharge

: 12/10/2016

CHIEF COMPLAINT
Mr. Tai Chin Hok, 57 years old Chinese gentleman complained of

left

inguinoscrotal swelling when standing for a long time associated with back pain and
vomiting for past 2 years.

HISTORY OF PRESENTING ILLNESS


He described the swelling as a painless swelling on the left side of the groin and
scrotum. It became painful when the swelling got bigger after standing or walking for
a long time and also after coughing. The pain was sharp in nature that radiates to the
flank and associated with vomiting.
Previously he had been admitted to emergency ward two times ( in Hospital Kuala
Lumpur and Hospital Teong Sin respectively) due to pain from the swelling. He
received injections to relieve the pain before being discharged. The doctor advised
him to reduce the swelling himself before it gets painful and it was uncomfortable for
him to do it in public.

He denied heavy lifting and chronic cough. He also denied altered bowel habit or
painful urination but sometimes he needed to strain during defecation.
He had no fever, abdominal pain and he could pass bowel output and flatus normally.
There was also no loss of appetite and loss of weight.
PAST SURGICAL HISTORY
He underwent cataract removal surgery on the left eye 4 years back and on the
right side 2 years ago.
PAST MEDICAL HISTORY
He is known to have sinusitis for 50 years and asthma for 42 years but has not
been prescribed any medication. He claimed that he has recovered from asthma. He
also has hypertension and dyslipidemia for 2 years on medication.
DRUG HISTORY
He is on Amlodipin 10 mg once daily (hypertension) and simvastatin 10 mg
twice a day (dyslipidaemia)
ALLERGY HISTORY
He has allergy to dust.
FAMILY HISTORY
His father died of heart attack at 68 years old while her mother died of old age
with underlying of heart problem at 70 years old.
There is no history of malignancy in his family.

SOCIAL HISTORY

He worked as a cook and has retired 10 years ago. He is not married.


Currently living alone in Pudu in a shop lot at third floor. He is not a smoker and does
not drink.
SUMMARY
Mr. Tai Chin Hok, 57 years old Chinese gentleman complained of left
inguinoscrotal swelling when standing for a long time associated with back pain and
vomiting for past 2 years is suggestive of inguinal hernia.

PHYSICAL EXAMINATION
GENERAL EXAMINATION
On general examination, the patient is lying comfortably on a bed. He is alert,
conscious, and communicative. He is not in respiratory distress, and is not in obvious
pain. Inguinoscrotal swelling on the left side were noted. The vital sign is as follow:
Pulse rate

: 60 beat per minutes with regular rhythm and good


volume

Blood pressure

: 127/87 mm Hg

Temperature

: 36.5o C

Respiratory rate

: 16 breaths per minutes

On the examination of the hand, there was no pallor of the hands, no


peripheral cyanosis, no muscle wasting and no nicotine stain. There were no stigmata
of chronic liver disease such as clubbing, koilonychias, leuconychia, Dupuytrens
contracture, palmar erythema and hepatic flap.
Next, the inspection of the eyes shows no yellowish discolouration of the
sclera and no pallor at conjunctiva. From the inspection of the mouth, the central
cyanosis is absent.
No pitting edema at medial malleolus for examination of the leg.
ABDOMINAL EXAMINATION

On abdominal inspection, the abdomen was moving with respiration. No


surgical scar seen. The abdomen was normal and not distended. There was absent of
obvious peristalsis that may suggest intestinal obstruction. There was no stigmata of
chronic liver disease noted such as caput medusae and spider naevi.
On palpation, the abdomen was soft and non-tender. There was no palpable
mass noted. There were no hepatomegaly, splenomegaly and the kidneys were not
ballotable. Murphy sign showed negative.
The percussion of the abdomen was normal. No ascites was detected as the
shifting dullness and fluid thrill were normal.
No any abnormal sound heard during auscultation.
HERNIAL EXAMINATION
On inspection, obvious left scrotal swelling was noted. There was no scar and no skin
changes over the swelling.
Upon palpation, the swelling on left scrotum was soft and non tender. It was partially
reducible and was unable to get above it. Positive cough impulse was noted on both
side of the inguinal region, above and medial to pubic tubercle suggesting bilateral
inguinal hernia. The bulging was more obvious on the left side.
Occlusion test was positive on the left side but negative on the right side suggesting
left indirect inguinal hernia and right direct inguinal hernia.
Transillumination test was done but the scrotum was not illuminated showing
negative sign for hydrocele.

PER RECTAL EXAMINATION


On inspection, there was no skin changes around the anus. There was also no
hemorrhoids or fissure noted.
Surface of the anal canal was smooth. There was no mass or ulcers. Soft faeces was
felt occupying the rectum . Prostate gland was not enlarged. External anal sphincter
tone was good. No mucus or blood noted on the glove.

CARDIOVASCULAR EXAMINATION
On inspection, the chest move symmetrically, no deformity, no scar and no
visible pulsation seen. The pulse is 60 beat per minutes with regular rhythm and good
volume.There was no radial-radial delay, no radial-femoral delay and the jugular vein
pressure is not raised. The blood pressure is mm Hg. The apex beat was palpable at
the left fifth intercostal space within midclavicular line. There was no thrill and
parasternal heave felt. On auscultation, first and second sounds were heard. The heart
is dual in rhytm with no additional sound or murmur.

RESPIRATORY EXAMINATION
On inspection, the chest wall moved symmetrically with respiration. There
were no skeletal deformities, any scars, dilated veins and use of accessory muscle
during respiration. The respiratory rate is 16 breaths per minutes which is normal
since the patient is not tachypnic because patient is not in obvious pain. On palpation,
the chest expansion was bilaterally symmetrical and there was no tracheal deviation.
Vocal resonance and tactile fremitus were equal in both side of the lung. On
percussion, there was resonance of both lung fields. On auscultation, normal
vesicular breath sounds were heard with no additional breath sound.

SUMMARY OF PHYSICAL EXAMINATION


A 57 year old Chinese gentleman has a left inguinoscrotal and right
inguinal swelling with positive cough impulse. The left inguinoscrotal swelling
was partially reducible and no overlying skin changes was noted.

PROVISIONAL DIAGNOSIS
Inguinal hernia

Points support:

Inguinoscrotal swelling

Positive cough impulse

Cannot get above mass

Reducible mass

Male is more likely to get inguinal

Point against:

This is not congenital problem as the


patient is a middle age man

No history of heavy lifting or chronic


cough

hernia compared to women.

DIFFERENTIAL DIAGNOSIS
1. Hydrocele
Points support:

Points against:

Scrotal swelling

Cannot get above the swelling

Painless swelling

Negative transillumination test

2. Testicular tumour
Points support:

Point against:

Testicular swelling

Cannot get above the swelling

Lower back pain

No symptoms of malignancy like loss


of weight or loss of appetite.

3. Testicular torsion
Points support:

Points against:

Testicular swelling

The pain is gradual rather than acute

Nausea and vomiting

No skin changes like erythema or

Radiation of pain to the back

ecchymosis.

INVESTIGATION
1) Full Blood Count (10/10/2016)

Indication: To assess his blood status that includes anaemia and thrombocytopenia
and any evidence of acute infection.

TEST
White Cell Count
Red cell count
Hemoglobin (Modified
Cyanmethaemoglobin)
Hematocrit
Mean Cell Volume
MCH
MCHC
RDW
Mean Platelet volume
Platelet
Neutrophils
Eosinophils
Basophils
Lymphocyte
Monocytes
Nucleated red blood cell

RESULTS
6.4
4.5

UNIT
x10^9/L
x10^12/L

RANGE
(4.1 11.4)
(4.5 6.0)

13.6

g/dL

(13.5 17.4)

40.5
89.4
30.0
33.6
13.1
9.9
253
4.0
0.1
0.1
1.8
0.5
0

%
ft
pg
g/dL
%
ft
x10^9/L
x10^9/L
x10^9/L
x10^9/L
x10^9/L
x10^9/L
x10^9/L

(40.1-50.6)
(80.6-95.5)
(26.9-32.3)
(31.9-35.3)
(12.0-14.8)
(8.9-11.9)
(142-350)
(3.9-7.1)
(0.0-0.8)
(0.0-0.1)
(1.8-4.8)
(0.4-1.1)
(0.0-0.0)

COMMENTS
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL

Impression:

Normal white cell count suggest that the paient is not having infection and
inflammation. Therefore patient did not have fever.

The haemoglobin of the patient is within the normal range and this indicates
patient is not anaemic.

The platelet level also is within the normal range which means this patient has
no bleeding tendencies.

2) C-reactive protein test (10/10/2016)


Indication:
High level of Creatinine Reactive Protein is caused by infections and many long term
disease. But a CRP test cannot show where the inflammation is located or what is the
causing of it.

TEST
C-reactive

RESULT
0.05

UNITS
mg/dl

RANGE
(<0.5)

COMMENT
NORMAL

protein

IMPRESSION:
C-reactive protein was normal in this patient. This indicate that the patient had no
inflammation.
3) Renal Profile (10/10/2016)
Indication: To assess for his electrolyte imbalance and hydrational status as well as renal
function.
TEST
Sodium (Ion Selective
Electrode Indirect (diluted))
Potassium (Ion Selective
Electrode Indirect (diluted))
Urea (urease)
Creatinine

RESULTS

UNIT

RANGE

140

mmol/L

(135 - 150)

4.4

mmol/L

(3.5 - 5.0)

4.1
72.7

mmol/L
umol/L

(2.5-6.4)
(62-106)

COMMENTS
NORMAL
NORMAL
NORMAL
NORMAL

Impression:
-

Electrolytes are all in normal range.

Urea and creatinine level is also normal which indicates no renal problem in this
patient.

The hydration of the patient is well.

4) Liver Function Test (10/10/2016)


Indication: To test and detect if there is any derangement in liver function by assessing the
liver enzymes.
TEST
Albumin
Total protein

RESULT
41
71

UNITS
g/L
g/L

RANGE
(35-50)
(67-88)

COMMENT
NORMAL
NORMAL
8

Total bilirubin
Alanine

9.7
27

Umol/L
U/L

(3.4-20.5)
(0-55)

NORMAL
NORMAL

81

U/L

(40-150)

NORMAL

Aminotransferase
(ALT)
Alkaline
Phosphatase (ALP)
IMPRESSION:

All tests were normal which indicate normal liver function.

5) Coagulation profile (10/10/201)


Indication: Coagulation profile is a screening test for abnormal blood clotting because
it examines the factors most often associated with the bleeding problem. Besides, it
will be done to confirm normal clotting function before a procedure which may cause
bleeding.

Result:
TEST
PT (patient)
PT (control)
INR
APTT (patient)
APTT (control)
APTT (ratio)

%
12.5

RESULT
12.8
0.97

29.3
38.7
0.76

UNITS
seconds
seconds
ratio
seconds
seconds
ratio

RANGE
(11.6-14.1)

(30.16-44.29)
(0.89-1.32)

IMPRESSION:
Coagulation profile showed APTT with slightly faster time of clotting where else PT
was normal indicating normal blood clotting ability and this patient was eligible to
undergo a surgery.
6) Chest X-ray (5/4/2016)

Indication: Chest X-ray stratify risk, direct anesthetic choices, and guide postoperative
management. Patient with lung problems should be stabilized before operation.
Result: No picture obtained
IMPRESSION:
No focal lung lesion
No consolidation/ cavitation
Both costophrenic angles are sharp
Heart is normal size
FINAL DIAGNOSIS
Bilateral inguinal hernia

MANAGEMENT AND PROGRESSION OF PATIENT


DATE

10 October 2016 ( 1st day of admission )

PATIENTS

o He was admitted to ward surgery 1

CONDITION

o The patient was alert and conscious


o He was not pale, septic looking and hydration is fair
o His vital signs are stable with blood pressure: 124/80
mmHg, pulse rate is 74bpm and temperature was 37C .
o Abdomen is soft and non-tender
o Positive strong cough impulse on the left inguinal region
and weak cough impulse on the right inguinal region
o Positive deep occlusion test, scrotal is enlarged.

MANAGEMENT

o Nil by mouth at 2 am

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o Allow clear fluid till 6 am


o Trace blood result
o Trace cardiac studies
o Continue old medications
o Serve medications with sips of clear fluid
o Start 4 Ounce Intravenous Drip once Nil by mouth
o Anaesthesia reviewed continuous plan
o Cefubid and Flegyll to Operation Theather
o Intravenous Augmentin 1.2 gram to Operation Theather
for laparoscopic transabdominal preperitoneal hernia
repair

DATE

11 October 2016 ( 2nd day of admission )

PATIENTS

o He was alert, stable and afebrile

CONDITION

o His vital sign was normal with blood pressure of 112/80


mmHg and pulse rate of 58 bpm. Temperature of 37 C
o Patient is comfortable, no URTI and UTI symptoms, no
fever
o The abdomen is soft and non tender
o No scrotal hematoma

MANAGEMENT

o
o
o
o

For operation as planned


Antibiotic to operation theater
Continue vital sign monitoring
Continue intravenous drip 4 Ounce ( 2 normal saline/ 2
dextrose)

INTRAOPERATIVE
FINDINGS

o Transabdominal Preperitoneal inguinal hernia repair is


done
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o It confirmed left indirect inguinal hernia, containing


omentum. Sac is adhered but able to release.
o Atrium mesh is placed and secured with taking device in
place.
PATIENTS
CONDITION

o Right very small direct hernia is not repaired.


o 3 hours post operative
o He was alert, stable and afebrile of temperature of 37C.
o His blood pressure was of 118/74 mmHg and pulse rate of
64 bpm.
o Patient is comfortable with no acute complaint
o The abdomen is soft and non tender
o No scrotal hematoma

MANAGEMENT

o Start IV Tramal 50 mg TDS


o Allow orally (Clear fluid tolerating to allow full diet)
o Off intravenous drip once oral intake is good.
o Off NPO2

DATE

12 October 2016( 3rd day of admission )

PATIENTS

o Post operative day 1

CONDITION

o He was alert, stable and afebrile of temperature of 37C.


o His blood pressure was of 124/50 mmHg and pulse rate of
102 bpm.
o Patient is conscious, alert and not pale.
o Left inguinoscrotal swelling while standing after
operation, painful reduction, irreducible, has not pass
flatus yet, no nausea/ vomitting, no bowel output yet,

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painful urination, no haematuria and no hematoma.


o Upon examination, noted on the left side was 5x3 cm
inguinoscrotal mass, irreducible, no pulse on cough, non
tender, testes palpable, non erythematous, not warm.
o 1x1 cm reducible inguinal mass on the right side, non
tender, non erythematous, testes palpable and not warm.
o Lungs are clear, air entry bilaterally.
MANAGEMENT

o Explained to patient, content of hernia reduced, mass on


left side only residual. Right side will only be repaired
when it becomes larger. Painful urination will go by time.
o Keep nil by mouth for now with intravenous 4 Ounce
o Continue observation
o Continue medications T. Amlodipin 10 mg OD, T. Zocor
20 mg ON
o Off intravenous drip
o To avoid heavy lifting
o Tight underwear to support scrotal part
o To come again 3/12 to Upper GI clinic
o T. PCM 1gm QID & Tramal PRN.

There was no complication develops after post-operation. His post- operative


medication are T. Amlodipin 10 mg once daily and Zocor 20 mg on night which are his
old medications for hypertension and dyslipidaemia. He was also prescribed with T.
Paracetamol 1gm four times a day and C. Tramal 50 mg as needed for pain reliever.
Syrup lactulose 15 mls on night also given to soften his stool to avoid straining during
defecation. He was discharged well on 12 October 2016.

13

DISCUSSION
A hernia is the bulging of part of the contents of the abdominal cavity through a
weakness in the abdominal wall.
The most common types of hernia are inguinal (inner groin), incisional (resulting
from an incision), femoral (outer groin), umbilical (belly button), and hiatal (upper
stomach).
Types of hernia by complexity
Occult not detectable clinically; may cause severe pain
Reducible a swelling which appears and disappears
Irreducible a swelling which cannot be replaced in the abdomen, high risk of
complications
Strangulated painful swelling with vascular compromise, requires urgent surgery
Infarcted when contents of the hernia have become gangrenous, high mortality
Inguinal hernia
An inguinal hernia happens when contents of the abdomenusually fat or part of the
small intestinebulge through a weak area in the lower abdominal wall. The
abdomen is the area between the chest and the hips. The area of the lower abdominal
wall is also called the inguinal or groin region.
This patient has indirect inguinal hernia on the left side where the hernial sac
protrudes through the deep inguinal ring and passes down to the inguinal canal and
extend as far as the upper pole of testis. The risk of developing indirect hernia can be
congenital in which are more common in premature infants due to incomplete
obliteration of the processus vaginalis or can be acquired due to old age or increased
in intra-abdominal pressure such as in heavy lifting or carrying, chronic coughing,
constipation, benign prostate hyperplasia and obesity
He also has direct hernia on the right side where it protrudes directly through
the abdominal, in the area known as the Hasselbachs triangle which is bound
laterally by inferior epigastric artery, medially by lateral border of rectus muscle and
inferiorly by inguinal ligament.
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CLINICAL MANIFESTATION
The first sign of an inguinal hernia is a small bulge on one or, rarely, on both sides of
the grointhe area just above the groin crease between the lower abdomen and the
thigh. The bulge may increase in size over time and usually disappears when lying
down.
Patient might feel discomfort or pain in the groin especially when straining, lifting,
coughing, or exercising that improves when resting.
There are also feelings such as weakness, heaviness, burning, or aching in the groin
Patient will present with a swollen or an enlarged scrotum.

INVESTIGATIONS
Medical and family history.
Taking a medical and family history may help to diagnose an inguinal hernia. Often
the symptoms that the patient describes will be signs of an inguinal hernia (reducible,
bulge after coughing)
Physical exam.
A physical exam may help diagnose an inguinal hernia. During a physical exam, ask
the patient to stand and cough or strain to feel for a bulge caused by the hernia as it
moves into the groin or scrotum and gently try to massage the hernia back into its
proper position in the abdomen (reducibility).
Cough impulse and occlusion test: In the absence of a visible or easily palpable
bulge, a cough impulse may be demonstrated by palpation at the external ring
(midpoint of inguinal ligament-between pubic tubercle and anterior superior iliad
spine) after invaginating the upper scrotum (in men) and asking the patient to cough
or perform a Valsalva manoeuvre. An indirect hernia may theoretically be controlled
by applying occlusive pressure at the mid-point of the inguinal ligament, whereas a
direct hernia is not affected by this manoeuvre. However, discrimination between
direct and indirect inguinal hernia by physical examination is not very accurate.

15

Imaging tests.
Hernia cases do not usually use imaging tests, including x rays, to diagnose an
inguinal hernia unless to diagnose a strangulation or an incarceration which cannot be
felt during physical exam, especially in patients who are overweight is uncertain if
the hernia or another condition is causing the swelling in the groin or other
symptoms.
TREATMENT AND MANAGEMENT
Repair of an inguinal hernia via surgery is the only treatment for inguinal hernias and
can prevent incarceration and strangulation. Surgery is recommended for most people
with inguinal hernias and especially for people with hernias that cause symptoms.
Research suggests that men with hernias that cause few or no symptoms may be able
to safely delay surgery until their symptoms increase.
Hernia surgery is also called herniorrhaphy. The two main types of surgery for
hernias are:
Open hernia repair: During an open hernia repair, the surgeon makes an incision in
the groin, moves the hernia back into the abdomen, and reinforces the abdominal wall
with stitches. Usually the surgeon also reinforces the weak area with a synthetic mesh
or screen to provide additional support.
Laparoscopic hernia repair: A surgeon performs laparoscopic hernia repair with the
patient under general anesthesia. The surgeon makes several small, half-inch
incisions in the lower abdomen and inserts a laparoscopea thin tube with a tiny
video camera attached. The camera sends a magnified image from inside the body to
a video monitor, giving the surgeon a close-up view of the hernia and surrounding
tissue. While watching the monitor, the surgeon repairs the hernia using synthetic
mesh or screen.
People who undergo laparoscopic hernia repair generally experience a shorter
recovery time than those who have an open hernia repair. However, the surgeon may
determine that laparoscopy is not the best option if the hernia is large or if the person
has had previous pelvic surgery.

16

Patient can keep inguinal hernias from getting worse or keep inguinal hernias from
recurring after surgery by:

avoiding heavy lifting


using the legs, not the back, when lifting objects
preventing constipation and straining during bowel movements
maintaining a healthy weight
not smoking

PREVENTION AND COMMUNITY HEALTH


Patient who develops a hernia may be born with a defect or weak spot in the
abdominal wall, or an inguinal canal that is not closed as much as it should be as
what has been discussed above.
Risk of developing hernia can be decreased by reducing the pressure inside of the
abdominal cavity that may push the abdominal contents out of a weak spot in the
abdominal wall. We sshould lift things properly, reduce straining, quit smoking and
lose weight for obese people
During heavy lifting, it is important to keep the spine straight and use the leg muscles
to provide the lifting power. When someone bend the back when lifting, they are not
only placing themselves at risk for back injuries, but may also be increasing the risk
of developing a hernia as well. It may be helpful to stretch before lifting something
heavy so that there are less likely to pull a muscle.
Constipation can cause high abdominal pressure that can exacerbate hernia formation.
Person with chronic constipation should try to increase amount of fiber in the diet and
drink plenty of water. There are over-the-counter laxatives to help with constipation.
People who smoke are advised to quit smoking for many medical reasons, but a
smoker with a chronic cough is risky to develop a hernia. This is because coughing
can increase the abdominal pressure by straining the abdominal muscle.

REFERENCES:

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1. Browse, Black, Burband, Thomas (2005). Browses Introduction To


Symptoms and Signs of Surgical Disease (fourth edition). Hodder
Arnold.
2. Williams, Bulstrode, OConnell (2012). Bailey and Love's Short
Practice of Surgery; 26th edition
3. https://www.niddk.nih.gov/health-information/health-topics/digestivediseases/inguinal-hernia/Pages/facts.aspx

DISCHARGE SUMMARY

DISCHARGE SUMMARY
Pusat Perubatan Universiti Kebangsaan Malaysia
Jalan Yaacob Latif
Bandar Tun Razak
Kuala Lumpur, Malaysia
PATIENT INFORMATION: TAI CHIN HOCK @ TAI AH HOCK
MRN

N513305

VISIT ID

201610102894

NRIC

590705106351

AGE

57

GENDER

MALE

RACE

CINA

ADMISSION DATE

10/10/2016

ADMISSION TIME

10:48

DISCHARGE DATE

11/10/2016

DISCHARGE TIME

17.28

DISCHARGE TYPE

DISCHARGE HOME

DISCHARGE

(5H) SURGERY 7:

LOCATION

ENT/PLASTIC/MAX
ILOFACIAL

SPECIALIST

NAME

18

Mr Tai Chin Hock a 57 years old Chinese gentleman post bilateral Laparoscopic
Transabdominal Preperitoneal Hernia Repair with underlying hypertension and dyslipidaemia
for the past 2 years on Amlodipine and Zocor respectively with complain of bilateral
inguinoscrotal hernia for 2 years duration
HISTORY OF PRESENTING ILLNESS
Patient feels inguinoscrotal swelling when he was standing for a long time for the past two
years associated with vomiting and back pain. Otherwise, no other active complains such as
fever, loss of weight, loss of appetite, chest pain or shortness of breath. He was electively
admitted on 10/10/2016. During pre-operation, patient is doing well.
INTRA-OP FINDINGS (11/10/2016)
Transabdominal Preperitoneal inguinal hernia repair is done. It confirmed left indirect inguinal
hernia, containing omentum. Sac is adhered but able to release.
Atrium mesh is placed and secured with taking device in place.
Right very small direct hernia is not repaired.
POST-OP
Patient complained of swelling reappear on the left inguinoscrotal region upon standing and
dysuria. He was told that the hernia is reduced with mass on the left side is only residual and
dysuria will disappear by time. Hernia on the right side is not repaired as it is too small. It will
be repaired when it comes bigger or develop complication symptoms. Patient understood.
Upon discharge, patient is well and vitally stable.
ALLERGIES
- He is allergic to dust
Medication

Plan of Care/ Treatment/Care Plan

T. AMLODIPINE 10 MDG OD

1. Allow discharge

T. ZOCOR 20 MG ON

2. To come again to Surgery Clinic 3/12

T. PCM 1GM QID

3. Wear tight underwear for scrotal support


4. Modify lifestyle by avoiding heavy lifting

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C. TRAMAL 50 MG PRN

and long standing

SYRUP LACTULOSE 15 MLS ON

Prepared by

,
Dr. Amelia Akmar binti Ramli
Medical Officer of Surgery
Wad 5B SURGERY 1
Pusat Perubatan UKM

REFERRAL TO DOCTOR FOR


CONTINUED MANAGEMENT
Pusat Perubatan Universiti Kebangsaan Malaysia
Jalan Yaacob Latif
Bandar Tun Razak
Kuala Lumpur, Malaysia

Name: TAI CHIN HOCK @ TAI AH HOCK


MRN: N513305
Age: 57
Race: CHINESE
Gender: MALE
To: Surgery Clinic,
Pusat Perubatan Universiti Kebangsaan Malaysia.
Dear attending doctor,
Thank you for seeing this patient, Mr Tai Chin Hock with background history
of hypertension and dyslipidaemia came with the chief complaint of left
inguinoscrotal swelling.
He has been diagnosed with bilateral inguinal hernia and transabdominal

20

preperitoneal inguinal hernia repair is done. It confirmed left indirect inguinal hernia,
containing omentum. Right very small direct hernia is not repaired.
He was discharged well recently from the ward on 12/10/2016. Upon
discharge, his condition was good and vital signs were stable.
I would like ask for your kindness to help me to assess the progression of his
health and continue monitoring the patient 3 weeks after his discharge.
Thank you.

Yours truly,

........
(Dr. AMELIA AKMAR BINTI RAMLI)
House officer of Surgery Ward 1,
PPUKM

PRESCRIPTION LETTER
Pusat Perubatan Universiti Kebangsaan Malaysia
Jalan Yaacob Latif
Bandar Tun Razak
Kuala Lumpur, Malaysia
PATIENT INFORMATION: TAI CHIN HOCK @ TAI AH HOCK
MRN

N513305

VISIT ID

201610102894

NRIC

590705106351

AGE

57

GENDER

MALE

RACE

CHINESE

Medication
T. AMLODIPINE 10 MDG OD
T. ZOCOR 20 MG ON
T. PCM 1GM QID
C. TRAMAL 50 MG PRN
SYRUP LACTULOSE 15 MLS ON
21

Prepared by:

........
(DR. AMELIA AKMAR BINTI RAMLI)
House officer of Surgery Ward 1,
PPUKM

PPD COMPONENT
Communication issues
Communication is the key how to build a rapport with our patients. How we speak to
them affects how they will cooperate in giving information to us. Eventhough this
patient does not share the same race with me, but I still managed to talk well with
him in English or even Malay. I tried to sound concern as much as I could to show
my empathy in his condition. He was also consistent with his symptoms and made it
easy for me to reorganise all the informations.
Ethical issues
Medical ethic consist of 4 components; non-maleficience, beneficience,
autonomy and justice. In my case of situation, my clerking and examination on this
patient are for his beneficience. I am trying to find out what is the real diagnosis to
come out with the right treatment and management and this patient also choose to
undergo the surgery for his own benefits and before everything becomes complicated
and harm him (non-maleficience). In this situation, this patient used his autonomy
correctly.

Critical thinking
Critical thinking is so important when seeing patients because all questions that we
asked must have its own reason. We cannot simply throw any questions while hoping
some of it will be right. To come up with the provisional diagnosis, we must exclude
all the possible differential diagnosis before coming to the conclusion. All history,
examination and investigation are important to decide on treatment regime for the
patient.

Reflection and life long learning

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I am very thankful to this patient because he was so cooperative. I never have


problems clerking and examining him. He never refuses my request that I learned so
much things from him. This was my first time performing per rectal and hernial
examination on real patient this semester. These were all possible because he allowed
me to. But what concerns me is this time it might comes easily, but how do I deal
with difficult patient in the future? Do I just give up?
This is also my first time following patients progression from admission until his
dischargement. I also attended the operation theatre to observe laparoscopic surgery
for the first time in my life. Attending this patient has taught me a lot of things more
than my 2 weeks previously in this posting. Now I understand why many doctors
urged the students to take responsibility to know patients progression from
admission until they are discharged.
This experience also taught me how big responsibility of a doctor towards their
patients. All decisions we are making would affect the patient. Every mistakes we
made will also affect them first. We cannot afford to even make one small error
because there are lives on our hands.

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