Transcript General Data

Objectives
To determine the proper approach to a
patient presenting with inguinal mass
 To determine possible differentials for
inguinal mass
 To determine the appropriate
management of an inguinal mass

Identifying Data

General Data
◦
◦
◦
◦
◦
◦

Gabaldon, Luis Arnel Beltran
16 years old
Male
Student
Roman Catholic
Pasay City
Chief complaint
◦ Bilateral inguinal mass
History of Present Illness
2 years PTC
Left inguinal mass
• Soft, smooth, “balloon-like”
• Well-circumscribed
• ~ 1-2cm in diameter
• Spontaneously appears and
disappears
• (-) pain or tenderness
• (-) fever, dysuria, hematuria
No consult
History of Present Illness
1 year PTC
Persistence of left inguinal mass
• Progression of mass to scrotal area
• Reducible
Right inguinoscrotal mass
• ~ 2-3cm in diameter
• More prominent on exertion,
straining, defecation
• Occasional pain, relieved by
wearing supporters
• Reducible
History of Present Illness
1 month PTC
Progressive enlargement of mass
• R: 4-5cm in diameter
• L: 2-3cm in diameter
Increase pain severity,VAS 5-6
Activity hindrance
Consult
• Advised surgery
Admission
Past Medical History

Childhood: febrile convulsions
◦ Multiple hospitalizations



Grade 2: chickenpox
(-) measles, mumps, primary complex
Claims to have complete childhood
vaccinations

Claims to have no sexual contact


(-) surgeries
(-) allergies to food or medications
Family History
Hypertension- father
 DM, inguinal mass???- mother
 (-) Cancer, lung diseases

Personal-Social History
Non- smoker
 Occasional alcohol drinker
 No illicit drug use
 1st year college student
 Dance and sports

Review of Systems

General: (+) fatigue, (-) fever, weight loss
or gain, weakness

Musculoskeletal/dermatologic: (-) lumps,
itching, muscle or joint pains, joint
swelling, changes in hair or nails
Review of Systems

HEENT: (-) dizziness, deafness, blurring of
vision, tinnitus, nosebleeds, hoarseness,
frequent colds, dry mouth, gum bleeding,
enlarged LNs

Respiratory: (+) cough, (-) dyspnea,
hemoptysis, wheezing
Review of Systems

Cardiovascular: (-) palpitations, chest
pains, syncope, orthopnea

GI: (-) nausea, vomiting, changes in bowel
habits, dysphagia, jaundice, rectal bleeding

GU: (-) nocturia, frequency
Review of Systems

Endocrine: (-) excess sweat or thirst, heat
or cold intolerance

Neuro: (-) seizures, loss of sensation
Physical Examination

General Survey
◦
◦
◦
◦
Alert, awake, coherent, ambulating
Not in cardio-respiratory distress
Height 170 cm, Weight 65 kg, BMI 22.5
BP 100/70 mmHg; HR 90 bpm; RR 14 bpm;
T 36.4 °C
◦ Pain scale 0/10

Integumentary
◦ Nails clean and properly trimmed; with good
color, reddish pink nail beds. No cyanosis or
clubbing noted

HEENT
◦ Head- No palpable and visible masses or
wounds.
◦ Eyes- eyelids normal. Visual fields full. Pink
conjunctiva. EOMs full and equal. (+) corneal
light reflex. (+) Direct and consensual
papillary reflex.
◦ Ears- No visible wounds, lumps or
deformities.

HEENT
◦ Nose- Nasal septum midline. Pink mucosa,
no exudate and swelling. No sinus
tenderness.
◦ Throat- Oral pale pink mucosa, no signs of
ulcerations and swelling. Tongue midline.
Symmetric elevation of soft palate; pink in
appearance
◦ Neck- (-) Lymphadenopathies over cervical,
post and pre auricular, and submental areas.
Trachea midline. Thyroid not palpable. No
goiter and nodules.

Pulmonary
◦ Normal shape. (-) lesions in anterior and
posterior thorax. (-) Areas of tenderness.
Resonant. Clear breath sounds, no crackles,
rales, wheeze.

Cardiovascular
◦ (-) Pallor, cyanosis. A dynamic precordium. No
palpable masses. PMI, 5th left ICS MCL. Heart
sounds normal rate and regular rhythm;
S1>S2 on the apex, S2>S1 on the base, S3
and S4 not heard. Absence of bruits, thrills
and murmurs.

Gastrointestinal
◦ Flat. (-) Lesions. Normoactive bowel sounds.
(-) Tenderness. (-) Organomegaly.
Tympanitic in all quadrants. Traube’s space
empty. (-) CVA tenderness.

Inguinal/ Genitalia
◦
◦
◦
◦
◦
Tanner stage 5
Bilaterally descended testes
(-) phimosis, hypospadia
Skin normal looking
L: no palpable mass; L external ring ~ 1 cm in
diameter; (-) transillumination test

Inguinal/ Genitalia
◦ R: palpable mass ~ 4cm over inguinal to upper
scrotal area; soft, smooth, non-tender, well
demarcated; mass pressing against the tip of
the examining finger in the R inguinal canal;
mass irreducible with taxis; R external ring ~
2cm in diameter; (+) transillumination test

DRE
◦ (-) lesions, masses in the perianal; (-) masses,
fissures, hemorrhoids, pararectal tenderness;
intact external anal sphincter; (-) blood on
examining finger

Extremities
◦ (-) cyanosis and edema. Pulses full and equal.
Good turgor.
Salient Features
Subjective
 2 year history of L and R inguinoscrotal mass
 Reducible
 (+) Pain relieved by wearing supporters
 (+) Activity hindrance
Salient Features
Objective
 Bilaterally descended testes
 R: palpable mass ~ 4cm over inguinal to upper
scrotal area; soft, smooth, non-tender, well
demarcated; mass pressing against the tip of
the examining finger in the R inguinal canal;
mass irreducible with taxis; R external ring ~
2cm in diameter; (+) transillumination test
Salient Features
Objective
 L: no palpable mass; L external ring ~ 1 cm in
diameter; (-) transillumination test
 Normal DRE
Impression
R hydrocoele, communicating
 L indirect inguinal hernia, complete

Differentials
Rule in
Rule out
Inguinal hernia
(+) inguinoscrotal mass more
prominent with straining
Hydrocoele
(+) transillumination test
Varicocoele
(+) scrotal mass
(-) veins palpated
(-) feeling of heaviness in the
testicle
(-) atrophy of testicle
Lymphadenopathy
(+) inguinal mass
(-) history of trauma, infection,
malignancy
Chronic case
Epididymitis
(+) scrotal pain
(-) acute scrotal pain
(-) fever
(-) warm/ red scrotum
Testicular torsion
(+) inguinoscrotal mass
(-) acute testicular pain
Undescended testes
(+) inguinal mass
(+) testes palpated in the
scrotum
Management
Bilateral herniotomy
 Pre op

◦ CBC: unremarkable
 Hbg 141, Hct 0.43, WBC 6.6, Plt 266
◦
◦
◦
◦
CT: 2-4 mins.
BT: 2-4 mins.
UA: unremarkable
CXR: unremarkable
Procedure Done/ Intra-op findings

Bilateral herniotomy
◦ R: internal ring measures 1 cm in diameter,
floor not attenuated
◦ L: internal ring measures 0.5cm in diameter,
floor not attenuated

Post op
◦ Tramadol 50mg/ mL q 8o  50 mg/tab q 8o
◦ Mefenamic acid 500mg/ tab
Inguinal hernia
Protrusion of abdominal-cavity contents
through the inguinal canal
 75% of all abdominal wall hernias occur in
the groin
 Indirect hernias vs. direct hernias- 2:1,
 Right > L
 Male vs. female- 7:1.

Indirect inguinal hernia
Patent processus vaginalis
 Reducible

◦ Inguinal mass that increases in size with
straining, coughing; non-tender

Irreducible
◦ Occasional pain; incarcerated

Strangulated
◦ Pain; fever, skin changes, s/sx of bowel
obstruction
Risk factors
Male
 Family history
 Chronic cough, constipation
 Obesity
 Pregnancy
 Prematurity
 Previous history of hernia

Treatment
Supporters, bindings
 Surgery

◦ Herniotomy, herniorrhaphy
◦ Laparoscopy
Prognosis
Treatable
 Risk of strangulation (7%)

◦ Recurrence, urinary retention, wound
infection, hydrocoele, scrotal hematoma
Hydrocoele

Buildup of fluid between the two layers of
the tunica vaginalis
◦ Can lead to either a communicating hydrocele
or an indirect inguinal hernia
Inguinal/ scrotal mass
 (+) Transillumination
 Risk factors similar to indirect inguinal
hernia

Treatment
Wait and see
 Herniotomy
 Contralateral exploration
