Content text HERNIA | TESTICULAR TUMOR
Topic: HERNIA LONG CASE AND SHORT CASE UITM NOTES- Groin swelling 1. HISTORY TAKING 1. 4C a. Complain i. Presence of groin/abdominal/inguinal/wound site/umbilical swelling 1. Where: Unilateral/Bilateral? 2. When : Intermittently? 3. Duration 4. How patient noticed 5. Size? Progression? 6. Any pain (painful-strangulated) 7. Reducible? 8. Ache?Dragging sensation 9. Symptoms of IO a. Vomiting,colicky abdominal pain, abdominal distention, no feces/flatus 10. Symptoms of complication a. Painful, tender, skin changes b. Incarcerated inguinal hernia→ pain +abdominal distention + nausea & vomiting b. Course i. Reducible become irreducible 1. When? 2. Why? 3. Any attempt to reduce? Seek for treatment (Medications or surgery before) c. Cause i. History of increase abdominal pressure (heavy lifting, obesity, chronic cough/COPD, pregnancy, constipation, micturition problem/straining, BOO, ascites d. Complications i. Irreducible hernia 1. Obstructed (due to kinking, intact blood supply) 2. Strangulated (loop of bowel is twisted, blood supply cut off)
3. Incarcerated (contents are fixed due to size and adhesion) 2. Systemic Review a. To rule out risk factor i. History of increase abdominal pressure (heavy lifting, obesity, chronic cough/COPD, pregnancy, constipation, micturition problem/straining, BOO, ascites b. Exclude complications i. Intestinal obstruction symptoms c. Exclude other diagnosis 3. Past Medical History a. Chronic Disease (rule out any chronic disease that can lead to risk factor -COPD, BPH, chronic constipation) i. Complaint ii. Current control or status iii. Complications of disease and treatment iv. Compliance 4. Past Surgical History a. Active Complaint b. Current control or status c. Complications of disease and surgery d. Compliance to Dr recommendations 5. Social History a. Acute i. Distance from home ii. Who take care of the patient iii. Knowledge of the disease b. Chronic i. Distance from home for multiple visit ii. Who take care of the patient and ensure compliance iii. How the disease affects patient lifestyle 5 Questions to Answer 1. Is this an inguinal-scrotal swelling or a groin lump? 2. Is this likely to be an inguinal hernia or a femoral hernia 3. Is the hernia reducible or irreducible 4. Is the hernia likely to be direct or an indirect hernia 5. Are there any predisposing factors
2. PHYSICAL EXAMINATION EXAMINATION OF AN INGUINAL HERNIA (may apply to other type of hernia or maybe not) Don gloves, introduce and explain your intention, expose the patient adequately, use clothes peg to hold shirt up STAND patient up, examine both sides 1. Mr X is a ___ who appears comfortable at rest. 2. I notice a groin / inguinoscrotal lump. Squat down and examine! ● Inspect as per a lump: (if unable to see, ask the patient) ○ Is the lump above or below the inguinal ligament? Any scrotal lump? ○ Estimate the dimensions of the lump ○ Any skin changes? Previous scars? (look hard, don’t miss a scar!) ○ Any lump on the other side? ○ Abdominal distension / visible abdominal mass? ○ Sir, could you turn your head to the left and cough? Look for visible cough impulse ○ Sir, is there any pain over the groin area? I am going to feel the lump. ● Palpate: ○ Can I get above the lump? ○ Can I feel testis? ○ Lump: consistency, fluctuant, size, temperature, any tenderness? ○ Landmark for the pubic tubercle (show that hernia is above and medial to the PT) ○ Landmark for ASIS and note the midpoint of the inguinal ligament (midpoint between ASIS & PT, 2 cm above midpoint = deep inguinal ring) ○ Sir, could you turn your head to the left and cough again? Feel for palpable cough ○ impulse (bilaterally?) ○ Sir, could you reduce the lump for me? ■ Reducible: The point of reduction is “above and medial to the PT” (superficial ring) ■ Incarcerated (irreducible): The patient is unable to reduce the lump. ● With patient standing: ○ Sir, could you turn your head to the left and cough? ○ If remains reduced – indirect hernia, ○ If not, direct hernia. (poor accuracy)
○ If hernia appears slightly and on removal of compression appear even more fully pantaloon hernia ○ Remove pressure & watch: hernia slide obliquely (indirect) or project forward (direct) ○ Percuss & auscultate for bowel sounds ● Lay the patient supine ○ Reduce the hernia if patient has not done so ○ Locate the Deep inguinal ring ■ Define pubic tubercle: umbilicus pubic symphysis 1st bony prominence laterally ■ Define anterior superior iliac spine (ASIS) ■ Define deep inguinal ring midpoint of inguinal ligament 2 cm above ○ Keep pressure on deep ring (use right hand for right sided hernia and left hand for left sided hernia), ask patient to sit up & support his pelvis, then swing over the bed and stand ● Examine other side Offer: ● Abdominal exam: scars, masses, ascites, ARU, constipation, IO ● DRE for BPH, impacted stools ● Respiratory exam for COPD ● Ask patient for history ● Smoking ● Chronic cough ● Heavy lifting (occupation) ● Difficulty passing stools (constipation) ● Difficulty passing urine (BPH)
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