8/13/2019 3rd Year Precept Pedia Case 4 Hydrocele

1/4

HEZER E. NECESITO July 29, 2013

MED 2015-B: Pedia Preceptorial Case 4

UERMMMCI HOSPITAL

University of the East Ramon Magsaysay Memorial Medical Center, Inc

College of Medicine

Date of Admission: July 25, 2013

Date of interview July 26, 2013.

PATIENTS PROFILE:

S.S . is a 5 y/o, Filipino male, a Roman Catholic by religion and live in Sta. Ana, Manila, was admitted this

July 25, 2013 as his first hospital admission.

Source and reliability:

The mother is the primary source of data and is deemed valid and with 90% reliability.

CHIEF COMPLAINT:

Enlargement of the right lateral side of scrotum of 2 months duaration.

HISTORY OF PRESENT ILLNESS:

2 months PTA, the mother noticed enlargement of pts .right scrotum, slightly firmand only with minimal

pain when manipulating. No signs of inflammation like redness, warmth and fever. Activities like playing, eating

and sleeping are not affected. No pain upon urination, or any change on urine quality and bowel movements.

Went to Sta. Ana Hospital, on which manual retraction was done by the doctor but only a little relief was

made. The next day, went to UERM for consult, manual manipulation was done by the doctor and UTZ was carried

out. Hydrocele was the diagnosis and advised them for a surgery (hydrocelectomy).1month PTA, the hydrocele was noticed to be smaller compared to previous size.

A day before admission the mother went to UERM hospital for the scheduling of surgery. Hence,

admission was done the next day.

Pertinent positives and negatives: enlargement of the right scrotum with remission the progressed

bilaterally, but more prominent to the right. Firm in consistency with pain on manipulation, redness and warmth

on site is not observed. No fever, change in bowel and urination, no affectation on daily activities.

TEMPORAL PROFILE

Size

Increasing

Hydrocele (right

scrotal sac)

decreasing

2 months PTA 1 month PTA 1 day PTA

8/13/2019 3rd Year Precept Pedia Case 4 Hydrocele

2/4

BIRTH HISTORY

Mother is a G3P1 (T0P1A2L1). Not drinking alcohol,smoking nor taking any elicit drugs. The

pregnancy was planned, however the mother didnt receive any immunizations or vitamins, o disease occurred

during pregnancy. T.Y. is 34 weeks AOG, with birth weight of 4 lbs., via CS delivery. Claimed to have no

complications during delivery. Length and APGAR score was unrecalled though claimed to have absence of bluish

or yellowish skin discoloration. Been incubated for a week in the hospital.

FEEDING HISTORY

Breast fed up to 3 moths only, the mother decided to stop due to pain felt while breastfeeding. Shifted to

formula milk (S26) up to present. Solid foods started by 6 months of age. And most of his diet consist of 2 glasses

of milk (250 + 2 scoops each) per day with usually 2 cups of rice and viand. Prefered foods consist of chicken,

vegetables, meat and fish. Currently taking multivitamins syrup (cherifer) and previously memo plus vitamins. No

food or medicine allergies. Urine claimed to be normal but with unrecalled frequency, usually defecate once a day

with formed brown stool.

DEVELOPMENTAL MILESTONES

Most of the data concerning development are unrecalled y the informant but what she remember was at his 1

year and four months old, he already can walk along. Presently on grade one school, with high grades on hissubjects, with good conduct inside the school, knows how to read and write and able to draw a complete human

face Including the feature of the face, he is right handed. Also able to dress self.

IMMUNIZATIONS:

Claimed by the informant to have completed though unable to name and described the vaccines given.

PAST DISEASES:

Had his first diarrhea at 9 months of age (unrecalled management) and the two episodes with unrecalled dates.

Contracted pneumonia at his 1 year and 6months of age. Diagnosed to have astigmatism + myopia at 4 years of

age and provided with glass, diopters of 100 OD 50 OS and astigmatism 170mmHg.

SOCIAL/ ENVIRONMENT HISTORY

Live in Sta Ana Manila at his grandmothers house (maternal side). The house is two storey on wh ich there are ten

residents including his family and closed relatives. They stayed at the 2nd

floor on two rooms made of wood and

cement. Their comfort room had flush, and with good source of water at nawasa and current at Meralco.

The environment are claimed to be crowded but peaceful, the barangay is located near Pasig river though their

house is a little bit far from the river. Their garbage had been collected twice a week.

Two of his house mates are smoking cigarettes including his mother, uncle and grand father.

His father was already away for 2 years as an OFW in Bahrain. Working as salad maker earning P70,000/month

but then only P10,000 had been remitted to his wife (reasons was unknown). The money as claimed is insufficient

for their needs and so some monetary help had been provided by his aunt (his fathers sister).

His mother (the informant), 33 years old, BS psych graduate and currently without job. A full pledged home maker.

ROS (REVIEW OF SYSTEM)

Theresno pertinent positives and negatives except those that are already presented in past medical history

(diarrhea, pneumonia, and visual impairment) which was managed and his current health situation.

Physical Examination

a. General Survey

8/13/2019 3rd Year Precept Pedia Case 4 Hydrocele

3/4

Patient is awake, alert, conscious, coherent, cooperative, and playful without signs of

cardiorespiratory distress. He is oriented to place, person, and time.

b. Vital Signs

Vital Signs

BP: not assessed

PR: regular 101bpm

HR: regular 106 (using stethoscope)

RR: 22 cpm

Temperature: 36.2 deg Celsius (axillary)Anthropometrics

Weight: 24kg

Height: 111.5cm

BMI: 19.83 Normal

b. Skin and Appendages

Skin is fair, without scars or lesions, moist, warm to touch and with good turgor.

Hair is black, coarse, and evenly distributed without infestations.

Nailbeds are pink without signs of clubbing and a capillary refill time of

8/13/2019 3rd Year Precept Pedia Case 4 Hydrocele

4/4

No gait and stance abnormalities noted with full range of motions in big and small joints.

m. Extremities

No gross deformities and edema on upper and lower extremities. Peripheral pulses are regular

and full.

II. Neurologic Examination

a. MMSI

Patient is awake, alert, conscious, coherent, and cooperative. He is oriented to places, people,

and time and is able to talk fluently with good articulation and vocabulary. He can name objects and withgood immediate, recent, and remote memory.

b. Cranial Nerves

CN I not tested; no complaints of loss of appetite was noted.

CN II (GUI, ANO VISUAL ACUITY NYO?); No cuts in visual fields were noted. Both

pupils are 3-4mm in diameter, reactive to light with direct and consensual

pupillary reflexes. Both eyes have ROR.

CN III, IV, VI Primary gaze at center without strabismus. EOMs are full in all directions

without complaints of double vision.

CN VII Facial features are symmetrical.

CN VIII Patient is able to hear spoken words. No lateralization noted with AC>BC.

CN IX, X Uvula at midline with intact gag reflex.

CN XI Patient is able to shrug shoulders against resistance and full range of motionwas observed on left and right SCM muscles.

CN XII Togue at midline without atrophy and fasciculations.

c. Motor and Sensory

Patient has 5/5 motor strength on all extremities and is able to appreciate pain and light touch

sensations over dermatomal levels.

d. Cerebellar Exam

No abnormalities in the gait and stance of patient were observed. He is able to do simultaneous

supination and pronation of hands and negative nose to finger, heel to shin, and Rombergs tests.

e. Deep Tendon Reflexes

Tendons Grade

Biceps +2

Triceps +2

Brachioradialis +1

Patellar +2

Ankle +2

PLANNING:

Ultrasound to confirm the diagnosis and to rule out other possible cause of the enlargement..

INTERVENTION:

Surgical intervention: Hydrocelectomy to remove the hydrocele. Provide prophylactic antibiotic for one

week to prevent infection and anti-inflammatory drugs to hasten healing and relieving of pain. Also advice patient

and parents to carefully assessed and clean the wounds, and report immediately if signs of infection or any

bleeding are observed. Also advised to protect the wound to avoid contamination and to increased intake of

vitamin C and proteins to hasten healing process.