Downloaded 80 times
More Related Content
![[MBBS/MS/DNB] Sample EXAM Long Case on Breast Lump](https://cdn.slidesharecdn.com/ss_thumbnails/cccbreast-200518145117-thumbnail.jpg?width=640&height=640&fit=bounds)
Similar to Inguinal Hernia case presentation
![[MBBS/MS/DNB] Sample Long Case on Inguinal Hernia](https://cdn.slidesharecdn.com/ss_thumbnails/ccchernia-200501225130-thumbnail.jpg?width=640&height=640&fit=bounds)
Inguinal Hernia case presentation
- 1. Clinical Case discussion Dr.Loveleen Garg PG Resident, Deptt Of Surgery .
- 2. Case • A 76years old male, resident of Faridkot, Shopkeeper by occupation, presented with chief complaints of 1. Swelling in right lower abdomen X 1 month 2. Pain in swelling X 7 days
- 3. History of PresentIllness • HDBT 1 month back when patient was apparently well and noticed swelling in right lower abdomen, – insidous onset, – gradually increased in size, – Intermittent, – more prominent on standing/ coughing / sneezing – Completely disappears on lying down
- 4. Contd… • Swelling wasinitially painless, • Now c/o pain in swelling since 7 days, – Sudden onset, – Non pregressive, – Dullache, – Mild in intensity, doesn’t impair routine activities, – intermittent , – Resolves spontaneously.
- 5. Contd… • No H/Onausea & vomitings. • No H/O fever. • No H/O constipation. • No H/O any urinary complaints ( nocturia/ straining/ inreased frequency/ weak stream/ intermittency/ residual urine). • No H/O heavy weight lifting. • No H/O chronic cough.
- 6. Past history • NoH/O similar illness in past. • No H/O hypertension/ diabetes mellitus/ TB/ bronchial ashthma/ CAD/ thyroid illness. • No H/O any surgical intervention in past.
- 7. Personal history • Married,2 children • Vegetarian by diet, • Non alcoholic and non smoker • No H/O any substance abuse. • No H/O any drug allergy.
- 8. Family history • Norelevant family history.
- 9. Examination • GPE: – Ptwas calm/ conscious/ co-operative/ oreinted to time, place and person. – Comfortably sitting on bed. – Moderate built – No pallor/ icterus/ clubbing/ cyanosis/ LAP/ edema.
- 10. Contd… • Vitals: BP- 120/80mmHg, right arm, in supine position. PR- 70/min, regular, good volume, no R-R or R-F delay. RR- 16/ min, thoracoabdominal Temp- 98.8’F
- 11. Contd… • Head totoe examination: no significant finding except scoliosis. • Systemic examination: • CNS: E4V5M6, grossly intact • Chest: B/L NVBS present, No rhonchi/ crepts • CVS: S1S2 normal, No murmur
- 12. Contd… • Local examination: •Inspection: (In standing position) A swelling seen in right inguinal region, approx 4x3 cms in size, above the inguinal ligament, globular in shape, cough impulse present, overlying skin normal, no visible pulsations or visible peristalsis seen, reduces completely on lying down, external genitalia normal.
- 13. Contd… • Palpation: donein standing position A swelling seen in right inguinal region, 4x3 cms in size, above the inguinal ligament, globular in shape, non tender, smooth surface, smooth margins, soft & elastic in consistency, upper edge not palpable, cough impulse present, reducible with gurgling sounds, no local rise of temperature,
- 14. Contd… • Palpation contd… externalgenitalia normal, bilateral testes palpable in scrotal sac, Deep ring occlusion test- swelling disappeared Zieman’s 3 finger method- s/o indirect hernia Ring invagination test- impulse felt on tip of finger • Percussion: resonant over the swelling. • Auscultation: normal bowel sounds heard over the swelling.
- 15. Differential diagnosis 1.Inguinal hernia(clinical diagnosis) 2.Undescended testis • Clinical- Groin mass, children, underdeveloped hemiscrotum with absent testis on the affected side • Tests- USG, CT, MRI 3. Lymphadenopathy • Clinical- enlarged mass which is firm tender and non reducible (d/d femoral hernia), associated H/O trauma, infection or malignancy • Tests- USG
- 16. Differential diagnosis 4.Femoral hernia •Clinical- common in slender, older female, more prone to strangulation, located below the inguinal ligament, neck below and lateral to pubic tubercle (inguinal hernia- above and medial to pubic tubercle) • Tests- USG, CT 5.Femoral aneurysm • Clinical- Pulsatile mass • Tests- Duplex ultrasound scan 6.Psoas abscess • Clinical- back pain and fever, chronic cough, weight loss and night sweats, h/o contact, fixed flexion deformity • Tests- MRI, CT scan
- 17. Differential diagnosis 7.Saphena varix •Clinical- Dilated great saphenous veins close to saphenofemoral junction because of incompetent saphenofemoral valve. There are signs of varicosity elsewhere. It is soft, compressible and disappears on lying down. Trendelenberg test +ve • Test- Duplex ultrasound scan 8.Hydrocele • Clinical- Transillumination, can reach above the swelling and testis not separately felt • Test- USG 9. Encysted hydrocele of the spermatic cord • Clinical- Traction test • Test- USG
- 18. Differential diagnosis 10. Lipomaof the spermatic cord • Clinical- no cough impulse • Test- USG -echogenic mass, CT- fat in inguinal canal 11. Spermatocele • Clinical- cyst attached to the head of the epididymis, can get above the swelling, transillumination, testis separately felt 12. Hydrocele of canal of nuck
- 28. DD scrotal swelling •Skin- boil, sebaceous cyst, papillomas, warts • Subcut tissues - Filariasis lymphscrotum • Tunica vaginalis- Hydrocele, hematocele, pyocele • Testis- orchitis, torsion, neoplasm • Epididymis- cyst, infection • Spermatic cord- Varicocele, lymph varix
- 29. DD Inguinal swelling •Inguinal hernia • Lymph nodes • Encysted hydrocele of cord • Undescended testis
- 30. DD of inguinoscrotalswelling • Inguinal hernia • Hydrocele- infantile, congenital, hydrocele of hernia sac • Spermatic cord- Varicocele, lipoma of the cord, • Testis- Undescended testis, ectopic
- 31. DD of femoralswelling • Femoral hernia • Lymph nodes • Saphena varix • Ectopic testis • Psoas abscess
- 32. DD of inguinofemoralswelling • Inguinal lymph nodes • Distended psoas bursa • Effusion in the hip joint
- 41. Approach algorithm • Groinmass- reducible, cough impulse, can’t reach above the swelling- Groin hernia( Inguinal, femoral) • Check right, left or bilateral • Zieman’s test, relation of hernia sac to pubic tubercle - Ring finger, Below and lateral to pubic tubercle, below inguinal ligament, (elderly, slender female),commonly strangulated - Femoral hernia - Index or middle finger, above and medial to pubic tubercle, above inguinal ligament- Inguinal hernia
- 42. Approach algorithm • Inguinalhernia- Finger invagination test, ring occlusion test - Direct / Indirect inguinal hernia • Reducible / irreducible / complicated • Incomplete or complete • Content - Enterocele: Soft, with gurgling sensation, resonant on percussion, auscultation- bowel sound, first part is difficult for reduction - Omentocele: Doughy, last part is difficult for reduction due to adhesion of sac with omentum
- 43. Approach algorithm • Canreach above the swelling, transillumination + - Testis not separately felt: Hydrocele (Vaginal) - Testis felt separately: Spermatocele • Scrotum not developed and testis absent - undescended testis • Scrotum developed and testis absent - Ectopic/Retractile testis • Pulsatile( expansile) and compressible - Femoral aneurysm • Evidence of varicose vein- Saphena varix
- 44. Final Diagnosis: • 76years old male with right sided reducible, incomplete, indirect inguinal hernia with enterocele.