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Hernia Hx & Exam - CE

Nov 02, 20247 min read

History

Framework

  1. Demographics (Name, Age, Gender, Nationality, Martial, Residency)
  2. Chief of complaint (Cause of hospitalization + days)
  3. HOPI (OPERATES NON PAIN | SOCRATES PAIN)
  4. B-Symptoms
  5. Systemic Review
  6. Past history (medical, surgical, medication, allergies, family, social)
  7. summary
  8. differential + justify differential
  9. investigations - appropriate
  10. treatment - suggestive

Introduction, explain, Permission, Assure privacy, chap. Greetings im Mohammed 5th year medical student; could you tell me your name..“amm ahmad”. im here to take your full history, may i proceed? =-

call nurse, assure privacy.

1) Demographics

Age

  • Young Age—indirect
  • Old Age—direct

Sex

  • Most common hernia in females—indirect inguinal hernia & obturator hernia
  • Most common hernia in males—indirect
  • Femoral hernia most common among—females
  • Direct hernia never occurs in females and children

Occupation: Most common in strenuous labor, Weight lifters.

residency, nationality, martial status


2) Chief of Complaint




3) HOPI

OPERATES OR SOCRATES

I- Site

  • From groin to scrotum (hernia)
  • From scrotum to groin (hydrocele and varicocele)

II- Onset/Progression

Duration Suddenly/gradually, When first noticed?

III- Character

IV- Radiation

V- Associated Symptoms

Associated with pain: Usually painless, Any other lump/ swelling

Pain in inguinal hernia is usually in the region of the umbilicus due to drag in the root of mesentery as bowel enters the sac

Para-umbilical associated with right inguinal hernia consistent with a generalised collagen disorder

VI- Timing/Episode

  • Does it disappear completely, does it become smaller/ larger?

VII- Relieving/ Exacerbating Factors

  • Aggravating factors:

    • On straining
    • On standing
    • On coughing

  • Relieving factors:

    • By lying down
    • Manually by himself

VIII- Severity

1-10 Grading with Limitations - cant walk, work, or think

4) B Symptoms




5) Systemic Review

  • Difficulty in micturition
  • Difficulty in defecation

6) Past Hx

Past medical / Surgical / Family

  • Chronic bronchitis/asthma/TB/DM/HTN/IHD/TB
  • Previous surgery
  • History of connective tissue disorders in family.

History of appendicectomy: Ilioinguinal or iliohypogastric nerve if damaged by grid iron incision or during keeping the drain; Direct Hernia Occurs

If ilioinguinal nerve is cut in the inguinal canal, direct hernia never occurs Because the nerve supplies the abdominal muscles before entering the cana

Medications / Allergies

Social im going to ask some specific question to reach to diagnosis, may i?

  • Occupation,

  • Travel,

  • kids,

  • smoking

    • ⇒ leads to chronic bronchitis = cough = prone hernia
    • Collagen deficiency occurs in smokers.

  • alcohol,

  • drugs,

  • sexual activity

7) Summary

8) Differential, Impression, most likely diagnosis

9) Investigations

I. Routine

  • Hemoglobin
  • Bleeding time/Clotting time
  • Total count, differential count, ESR
  • Urine—albumin, sugar deposits
  • Blood—urea, sugar
  • Blood grouping/typing—for irreducible hernia/huge hernia

II. Anesthetic Purpose

  • X-ray chest (Chronic TB, Asthma—precipitate hernia)
  • ECG all leads

III. USG Abdomen and Pelvis

  • In old age group—to find benign prostate hyperplasia calculate post-voidal residual urine. If >100 ml it is significant
  • To find any mas

10) Treatment Plan

A. Treat the precipitating cause of hernia first e.g.

  1. Benign prostate hypertrophy
  2. Tuberculosis
  3. Stop smoking

B. Conservative management is indicated only in cases of very old man with direct hernia; since there is no chance of obstruction.

C. Truss : is not curative for hernia.

SURGERIES FOR HERNIA

  • Indirect Hernia: Adult - Herniotomy + mesh repair, Children- Herniotomy
  • Direct Hernia: No sac excision, sac reduced

Examination

  • WIPER

    • Wash hands
    • Introduce
    • Right side of bed
    • Explain Procedure
    • Permission for examination
    • Position & Exposure

  • Preliminary examination

    • General Appearance (man, comfortable, comatose, connected device)
    • General examination (Vitals, hand/arm/axilla, hair, face, neck, chest, abd,leg)

  • Focused Examination + (correct technique)

    • Specific System Exam - IPPA
      • Inspection
      • Palpation
      • Percussion
      • Auscultation
    • Lesion/Swelling/Ulcer if present - SSSS TTEDC

  • Describe correct physical findings

1) WIPER

Exposure | position | privacy | Ask for vitals 

  • W ash hands (before and after)
  • I ntroduce yourself to the patient and seek his or her consent
  • P osition the patient correctly.
  • E xpose the patient as needed (e.g. ‘Please take off your shirt for me now, if that is all right’)
  • R ight side of the bed

Position & Exposure Mid chest to mid thigh

Position standing at first, then supine - examine both sides

Intro

Greet, Introduce (5th year med), assure privacy (curtain, nurse), explain procedure, position (mention good position - supine semisitting) & exposure (from midchest to midthigh - cover genatelia)

2) General Appearance

  • Conscious and alert
  • features
  • connected devices

elderly male with good build lying comfortable to be - connected to cannula - not connected oxygen. (note general exam findings)

“Now i will do focused examination after general apperance, should i do general examination?“

3) General Examination

dont touch patient until needed

  • Hand: organized explaination from distal to proximal

    • Clubbing -
    • Capillary refill
    • Pulse:
    • water hammer pulse

  • Vital signs 

  • Face & Neck: 

  • Abdomen:

    • Mass abdomen
    • Malgaigne’s bulgings
    • Ascites

  • Lower Limb: Edema - thumb

4) Focused Examination

Hernia Focused Examination

Inspection

Standing position

  • Groin swellings:
    • Does it extend down to scrotum?—Inguinoscrotal
    • Is testis separate from swelling?
  • Site:
    • Femoral—below and lateral to pubic tubercle
    • Inguinal—above and medial to pubic tubercle
  • Size
  • Shape:
    • Pyriform—indirect
    • Hemispherical—direct
    • Retort—femoral
  • Extent
  • Surface
  • Skin over the swelling
  • Visible peristalsis
  • Cough impulse
  • Draining lymph nodes
  • Penis
  • Urethral meatus
  • Opposite scrotum

Palpation

Ask patient if there is any pain before proceeding.

  1. Temperature
  2. Tenderness
  3. Site
  4. Size
  5. Shape
  6. Extent
  7. Surface
  8. Skin over
  9. Get above the swelling: (hernia vs scrotal swelling)
    • Is testis separate from swelling?
    • Get above the swelling is a classical feature of hydrocele
  10. Cough impulse
  11. Consistency:
    • Soft elastic—intestine
    • Doughy granular—omentum
  12. Reducibility:
    • a. Intestine: Last part is easy to reduce; Initial part is difficult to reduce; gets reduced with gurgling sound.
    • b. Omentum: First part easy to reduce, last part is difficult because omentum adheres to fundus of sac.
  13. Direction of reduction of hernia
    • Direct hernia—directly backwards
    • Indirect—goes upwards, backwards and laterally
  14. Ring invagination test
    • Only test in hernia; done in lying position.
    • Prerequisite:
      • ––Swelling should be reducible
      • ––Lax of skin should be there for invaginating (so this test could not be done in females)
    • Procedure
      1. Reduce the swelling.
      2. For right side, invaginate with right little finger into the superficial ring.
      3. Rotate the little finger medially so that the pulp faces medially.
      4. Note the direction of entry and site of impulse.
    • Look for:
      • Strength of superficial ring: Normal ring admits only the tip
      • Site of impulse:
        • Pulp—direct
        • Tip—indirect
  15. Deep ring occlusion test: (only after complete reduction of hernia)
    • After reducing the contents, patient in standing position, occlude the deep ring with thumb. Ask the patient to cough.
    • If swelling appears - Direct
    • Does not appear – Indirect
    • Fallacy of deep ring occlusion test (When will you get the swelling even though it is an indirect hernia by deep ring occlusion test?)
      • A. Pantaloon hernia
      • B. Wide deep ring (Occlude in such cases with index and middle finger together)

Ring invagination test

Deep ring occlusion test

Percussion

  • Enterocele: Resonant
  • Omentum: Dull

Auscultation

Peristaltic sounds occasionally heard.

5) Complete examination with

  1. Testis: ‘Traction Test’ to find whether the inguinal swelling is an Encysted Hydrocele of Cord.

  2. Epididymis.

  3. Penis:

    • Phimosis
    • Penile strictures
    • Pinhole meatus

  4. Regional nodes.

  5. Opposite groin.

  6. Per-rectal Examination To Rule out:

    1. Benign Prostate hypertrophy—micturition difficulty
    2. Malignant obstruction
    3. Chronic fissure—constipation

6) Summarize Findings, Thank patient




Other

Each type can be:

  • Reducible: may result in adhesion resulting in irreducible (longstanding)
  • Irreducible/ incarcerated;
  • Complicated: Obstructed; bowel & strangulated; artery veins

Complications of Hernia

  • Incarcerated: Hernia contents are irreducible due to adhesion. May obstruct or strangulate.
  • Obstructed: Irreducible hernia presenting with intestinal obstruction.
  • Strangulated: When blood supply to the contents is jeopardized in an irreducible hernia.

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