Subjective:

Chief Complaint: Groin bulge/pain.

History of Present Illness:

2 days prior to consultation, the patient had abdominal bloatedness, and vague abdominal/inguinal
pain on the right. He also reported mild nausea and a lack of bowel movement.

Past Medical History: The patient was diagnosed with hydrocele at the age of 2, surgery was advised but
the patient refused.

Family Medical History: His two cousins were diagnosed with groin hernias during childhood.

Review Of System:

General: Usual weight, recent weight change; weakness, fatigue, or fever.

Skin: No Rashes, No lumps
HEENT : No Headache, No dizziness
Respiratory: No Cough, No wheezing
Cardiovascular: no palpitations, no shortness of breath
Gastrointestinal: Presence of vague Abdominal pain and abdominal bloatedness with flatus, mild nausea
Peripheral Vascular: No swelling with redness or tenderness.
Genital : presence of groin bulge/ pain, No bowel movement for 2 days
Musculoskeletal: No Muscle or joint pain, No low back pain
Psychiatric:No depression, No memory
Neurologic: No dizziness, No seizures.
Hematologic: no Anemia, no easy bruising or bleeding.
Endocrine: No Heat or cold intolerance, No excessive sweating

Objective:

Physical Examination: Upon examination an irreducible bulge was observed in the right inguinoscrotal
region, indicating the presence of an inguinal hernia. The abdomen was slightly distended, and bowel
sounds were normal. There was a vague bulge noted on the left side of the inguinal region when the
patient strained, and a cough impulse was felt on the tip of the examining finger, suggesting a potential
bilateral hernia or a predisposition to hernia formation on the left side.

Assessment:

Differential Diagnosis:

1. Inguinal Hernia: Suspected based on the patient's presentation of a groin bulge/pain, along with
a positive cough impulse.

2. Constipation: Considered due to the patient's complaint of no bowel movement for 2 days,
abdominal bloatedness, and vague abdominal pain.

Final Diagnosis: Based on the history and physical examination findings, the final diagnosis is an inguinal
hernia.
Plan:

1. Diagnostic Workup:
a. Further evaluation with imaging studies such as ultrasound may be considered to
confirm the diagnosis and assess the extent of the hernia.
2. Management:
a. Surgical consultation for repair of the inguinal hernia.
b. Symptomatic treatment for constipation if confirmed.
3. Patient Education:
a. Educate the patient and family about the diagnosis, treatment options, and the
importance of surgical intervention for inguinal hernia repair.
b. Advise on measures to prevent constipation, such as dietary modifications and adequate
fluid intake.
4. Follow-up:
a. Schedule a follow-up appointment to monitor the patient's progress post-surgery and
assess for any complications.