ANSWER FOR CASE 1

A 57-year-old male patient presented to surgical cold OPD with a

reducible swelling on his right groin of 01 year duration which was
initially small in size
but progressively increased to attain the current size. He was
diagnosed to have tuberculosis prior to the onset of swelling and has
been treated.

Upon physical examination, he has 4x5 cm reducible mass on his

right groin which is soft and felt by the index finger upon three finger
(Zieman’s) test with positive cough impulse.

Laboratory investigations are non-revealing.

1. What are the possible differential diagnoses? (List the

differential diagnoses based on patient’s chief compliant).
The possible differential diagnosis are:
 Lymphadenopathy.
 Ectopic testis
 Femoral hernia
 Femoral aneurysm
 Psoas abscess
 Epididymitis
 Retroperitoneal sarcoma
 Metastasis of tumor from any part of the body
 Saphena varix
 Encysted hydrocele of spermatid cord
 Spermatocele
 Inguinal hernia
 Testicular tumor
2. Considering your differential diagnoses, which important histories
would you
like to ask in this particular patient?
History of present illness
Ask the following

 Position and duration of pain duration

 If present locate area of the tender

 Ask for constipation or diarrhea

 Ask for nausea and vomiting

 Ask for Abdominal distention

 Any weight Weight loss

 Chronic cough, asthma and COPD

 Any history of ascites or abdominal swelling

 Any weight lifting

 Straining at micturation

 If there is history of abdominal surgery

 History of swelling at other sites(lymphadenopathies)

 Wether fever is present

 If there is any hereditary disease in the family

Review of system
 HEENT
If there is head ache
Sore throat
neck swelling
lymph glandular
axillary swelling

GASRTOINTESTINAL
Splenomegaly
vomiting

RESPIRATORY
 Sputum production
 cough
CARDIOVASCULAR
 Palpitation
 dypnea
 Weakness
 Body swelling
 Ortopenia
 PND
GENITOURINARY
 Urethral discharge
 Urine color change
 STI
 Dysuria
 Urine frequency
 Lesion around the genitalia
CENTRAL NERVOUS SYSTEM
 Dizziness
 Vertigo
3. Discuss briefly on the proper examination of groin mass (swelling)
including
the different techniques to differentiate groin masses (swellings).
Physical Examination
Inspection
should be done in the standing position and both sides should be
checked.
Location, size, shape and border of the mass

 Check for symmetry

check for expansile impulse on coughing

Peristalsis
which may give a hint for an enterocoele.
Surgical scar:
indicate recurrent hernia
Ragged scar
which indicate an infection
Palpation
 Palpate the skin to check for tenderness, temperature

 Check for border around the swelling

 check for size, shape, consistency of the swelling

 Differentiate inguinoscrotal from scrotal swelling

 Ask the patient to cough feel the expansile impulse at the root of
scrotum

 Check for Reducibility

Special tests for inguinal hernias
External ring invagination test
At the root of the scrotum, skin is gathered and lifted up with the little
finger. It is then invaginated into the external ring. On asking the
patient to cough, the impulse touches the pulp of the finger in direct
hernia and the tip in indirect hernia.
Internal (deep) ring occlusion test
This test can be done with the patient standing or in supine position.
First, reduce the swelling. Then locate the deep ring above the
midpoint between anterior superior iliac spine and symphysis pubis.
Occlude the deep ring with the thumb and ask the patient to cough.
If impulse and the swelling are seen, it is a direct hernia
If the swelling is not seen, it is an indirect hernia.
Leg raising test or head raising test
Weakness of the oblique muscles is manifested by Malgaigne's
bulging above the medial half of inguinal ligament. It is an absolute
indication for hernioplasty.
Zieman's (three fingers) method
Keep index finger at the deep ring, middle finger on the posterior wall
(above and lateral to the external ring) and the ring finger at femoral
ring. Now ask the patient to cough. Depending upon the type of
hernia, impulse is felt. It is not necessary to perform this test in
incomplete or complete indirect hernias. After performing the special
tests, you should also do abdominal and respiratory examinations.
This may pick abdominal masses or respiratory diseases.
4. What is the most likely diagnosis? (Please verify your reason)
Right inguinal hernia
Manifestations of this can be seen in elderly patients in whom an
indirect hernia can be triggered by some factors which increase intra-
abdominal pressure. This patient has a history of chronic coughing
(He was diagnosed to have tuberculosis prior to the onset of swelling)
and cough is one of the risk factors that increases intra-abdominal
pressure and also may be due to weakening of inguinoscrotal
ligament.
On physical examination (Zieman’s test three finger test)index finger
over the deep ring and If impulse touches the index finger it’s
indicates indirect inguinal hernia which is consistent with our
diagnosis.
The mass is reducible and in right groin area which verify that it is
inguinal hernia.

5. Discuss briefly on the pathophysiology of patient’s clinical

presentation.
Inguinal hernia is the most common form of hernia and refers to when
bowel or fatty tissue protrudes into the groin. This type of hernia
mainly occurs in men. A painful dragging sensation may be felt, as
well as pain and swelling in the scrotum and testicles.
In cases of inguinal hernia, a loop of intestine protrudes through a
hole in the abdominal wall into the inguinal canal, which contains the
spermatic cord. The weakness that occurs in the abdominal wall may
be present at birth or may develop later on in life.

Indirect hernia occurs due to persistent processusvaginalis sac. It is

the most common type of hernia in the body. The preformed sac
passes through the deep ring, traverses the inguinal canal and may
extend into the scrotum through the external ring. As it comes into the
inguinal canal, it is invested by the following coverings:
1. External spermatic fascia derived from external oblique
aponeurosis.
2. Cremasteric fascia derived from internal oblique.
3. Internal spermatic fascia from fascia transversalis.
Direct hernias are acquired rather than congenital and usually occur in
people aged 25 or older. This hernia occurs due to degeneration and
fatty changes in the inguinal floor or posterior wall in an area called
the Hesselbach triangle. The majority of direct hernias do not have a
true peritoneal lining and do not contain intestine; they mainly contain
preperitoneal fat and occasionally bladder. A long-standing direct
hernia that has become large may extend into the scrotum and may
also contain abdominal content or intestine.

6. What are the risk factors and possible complications of patient’s

clinical
presentation?
Risk factors
 Congenital a persistent processusvaginalis sac is chief cause of
indirect inguinal hernia
Collagen fiber disorders
 Congenital: Prune-belly disorder
 Acquired collagen deficiency:
 Smoking, that results in weakening of collagen
 Obesity
 Chronic cough
 Chronic constipation
 Straining at micturition
Those 3 listed above increase intra abdominal pressure
 Ascites
 Weakness of conjoined tendon/rupture of a few fibers
 Lifting heavy weight
 Post-appendectomy (injury to ilioinguinal nerve)
 Chronic debilitating disease causing transversalis fascia
weakness in the Hesselbach's area.
 Increased age
 Being a Male
  Familial history of hernia
Generally those result in progressive weakening of inguinal
rings,musculature
Complications of hernia
 Irreducibility:
 Obstruction:
is an irreducible hernia with obstruction to the
lumen of the gut.
 Strangulation:
is an obstructed hernia with impairement of blood he
intestine.
 Incarceration:
is when the hernia can’t be pushed back in and is
trapped in the abdominal wall, due to obstruction by
focal inflammation.
 Inflamed hernia:
 occurs when the contents of hernia get
inflamed. Examples include appendicitis or a
Meckel's diverticulitis occurring in hernial sac.

There may be infection,hematoma and bleeding after surgery is done