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    Course in The Wards Format

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    Jade Monreal
    The patient underwent a hernioplasty using the Lichtenstein technique to repair an indirect inguinal hernia on his right side. He tolerated the procedure well and had an unremarkable recovery. His vital signs remained stable, wound was healing properly, and pain was well controlled. He was discharged 4 days after admission with instructions to follow-up after 1 week and continue medications for a full course to prevent infection.

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    Course in The Wards Format

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    Jade Monreal
    584 views2 pages
    The patient underwent a hernioplasty using the Lichtenstein technique to repair an indirect inguinal hernia on his right side. He tolerated the procedure well and had an unremarkable recovery. His vital signs remained stable, wound was healing properly, and pain was well controlled. He was discharged 4 days after admission with instructions to follow-up after 1 week and continue medications for a full course to prevent infection.

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    The patient underwent a hernioplasty using the Lichtenstein technique to repair an indirect inguinal hernia on his right side. He tolerated the procedure well and had an unremarkable recovery. His vital signs remained stable, wound was healing properly, and pain was well controlled. He was discharged 4 days after admission with instructions to follow-up after 1 week and continue medications for a full course to prevent infection.

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    Download as docx, pdf, or txt
    584 views2 pages

    Course in The Wards Format

    Uploaded by

    Jade Monreal
    The patient underwent a hernioplasty using the Lichtenstein technique to repair an indirect inguinal hernia on his right side. He tolerated the procedure well and had an unremarkable recovery. His vital signs remained stable, wound was healing properly, and pain was well controlled. He was discharged 4 days after admission with instructions to follow-up after 1 week and continue medications for a full course to prevent infection.

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    of 2

    DEPARTMENT OF SURGERY

    ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE COMMAND


    VICTORIANO LUNA MEDICAL CENTER
    V. Luna Road, Quezon City

    Name: BAGAYAN, ALVIN CABUNOS


    Age/Sex/Rank: 34/M/SGT
    Registration Number: 199804
    Date Admitted: 13 OCTOBER 2019
    Date Discharged: 18 OCTOBER 2019
    Admitting Diagnosis: HERNIA, INGUINAL, INDIRECT, RIGHT, REDUCIBLE
    Final Diagnosis: HERNIA, INGUINAL, INDIRECT, RIGHT, REDUCIBLE
    OR done HERNIOPLASTY (LICHTENSTEIN TECHNIQUE), RIGHT (15 OCT 2019)

    NARRATIVE SUMMARY

    Chief Complaint: Inguinal pain


    History of Present Illness:
    One year prior to admission, patient noted intermittent inguinal pain, no skin changes, no bulge noted. Mo medications taken,
    no consult was done.
    In the interim, patient noted intermittency of inguinal pain, still no consult was done. No medications taken.
    Six months prior to admission, patient noted persistence of pain, now with associated inguinoscrotal bulge which spontaneously
    reduced by lying down. No skin color changes, vomiting or fever noted.
    Five months prior to admission, during physical examination for reenlistment, patient was noted to have inguinoscrotal bulge.
    Patient seek consult at a nearby hospital and was assessed to have Hernia. Patient came in for definitive management, hence this
    admission.

    PHYSICAL EXAMINATION

    General Survey: Awake, alert, not in distress


    Vital Signs: BP: 120/90 HR: 89 bpm RR: 19 cpm T: 36.8 O2sat: 96%
    HEENT: Anicteric sclera, pink palpebral conjunctiva, (-) nasoaural discharge, (-) cervical lymphadenopathy
    Chest and Lungs: Symmterical chest expansion, (-) retractions, clear breath sounds
    Heart: Adynamic precordium, normal rate, regular rhythm, (-) murmurs
    Abdomen: Flat, normoactive bowel sounds, soft, nontender
    Genitourinary: Bilaterally descended testis, negative transillumination test, internal inguinal ring defect
    approximately 1 cm, no bowel sounds noted
    DRE: No skin tags, no fissures, good sphincteric tone
    Extremities: Full equal pulses, no edema, no cyanosis

    DIAGNOSTICS

    12 L ECG (10 Oct 2019) Sinus Rhythm


    Chest Radiograph (13 Oct 2019) No significant chest findings
    Inguinoscrotal Ultrasound (14 Oct 2019) Inguinal hernia, right
    Epidermal head cyst, right
    Minimal hydrocele, left
    Negative ultrasound study of right testis, left epididymis, pampiniform plexuses
    and left inguinal area

    COMPLETE 13 Oct Urinalysis 13 Oct


    BLOOD COUNT Color Y
    Hemoglobin 155 Trans ST
    Hematocrit 0.43 Reaction 6.0
    RBC 5,14 SG 1.020
    WBC 8.85 Sugar Neg
    Segmenters 0.46 Protein Neg
    Lymphocytes 0.29 RBC 0-2
    Eosinophil 0.18 WBC 0-2
    Monocyte 0.06 Bact
    Basophil EC Rare
    Platelet Count 216 MT Mod
    AU Rare
    CLINICAL 13 Oct BLEEDING PARAMETERS 13 Oct
    CHEMISTRY PT 12.6
    Na 142.1 INR 1.04
    K 4.11 APTT 25.3
    Cl 100 %ACT 80.6
    iCa 1.20
    iMg 0.47

    COURSE IN THE WARDS

    Patient was admitted at W5C under the service of MAJ DE VEYRA/CPT JANANI and team. Consent for admission and
    management was secured. Patient was on diet as tolerated. Medications given were: Ascorbic Acid 500 mg tab once daily,
    Multivitamins tab once daily. Appropriate diagnostics were done. Patient was prepared for Hernioplasty, right.

    On the 2nd hospital day, patient underwent Hernioplasty (Lichtenstein Technique), Right. Patient tolerated the procedure
    well. Medications given were: Cefuroxime 500 mg tab 2 tab thrice daily, and pain medications care of Anesthesia Service. Post-
    operatively, the patient was afebrile with adequate pain control.

    On the 3rd hospital day, post operation day 1, patient was afebrile, comfortable with no inguinal pain, inguinal bulge and
    dysuria. Patient was put on diet as tolerated. Medications were: Cefuroxime 500 mg tab twice daily for 7 days, Ascorbic acid 500
    mg tab once daily, and Celecoxib 200 mg tab twice daily round the clock for 3 days. Patient was advised to maintain compressive
    dressing.

    During the interim, patient was afebrile, comfortable and had good pain control. Wound was dry and well coaptated.
    Daily wound care rendered.

    The rest of hospital stay was unremarkable. Patient was discharged, improved and stable, after 4 days of admission.

    Discharge Medications:
     Co-amoxiclav 625 mg cap, 1 cap twice daily to complete 7 days.
     Celecoxib 200 mg capsule, 1 capsule twice daily as needed for pain.

    Discharge Instruction:
     To come back at GS OPD on 22 October 2019
     Low fat diet

    CPT TUGANO MAJ SARIL CPT VELASCO CPT ADVINCULA CPT REYES
    CPT JANANI CPT MONTEJO CPT SASAM P2LT BERNALDEZ
    CPT TAGRA CPT REBUDAL
    P2LT SINCIOCO
    P2LT CAGUIOA
    Residents – In – Charge

    LTC DOMINADOR V ACOBA MC


    Chairman, Dept. of Surgery

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