objectives to determine the proper approach to a patient presenting with inguinal mass to determine...
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ObjectivesTo 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
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Identifying DataGeneral Data
◦Gabaldon, Luis Arnel Beltran◦16 years old◦Male ◦Student◦Roman Catholic◦Pasay City
Chief complaint◦Bilateral inguinal mass
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History of Present Illness2 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
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History of Present Illness1 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
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History of Present Illness1 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
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Past Medical HistoryChildhood: febrile convulsions
◦Multiple hospitalizationsGrade 2: chickenpox(-) measles, mumps, primary complexClaims to have complete childhood
vaccinations
Claims to have no sexual contact
(-) surgeries(-) allergies to food or medications
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Family HistoryHypertension- fatherDM, inguinal mass???- mother(-) Cancer, lung diseases
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Personal-Social HistoryNon- smokerOccasional alcohol drinkerNo illicit drug use1st year college studentDance and sports
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Review of SystemsGeneral: (+) fatigue, (-) fever,
weight loss or gain, weakness
Musculoskeletal/dermatologic: (-) lumps, itching, muscle or joint pains, joint swelling, changes in hair or nails
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Review of SystemsHEENT: (-) dizziness, deafness,
blurring of vision, tinnitus, nosebleeds, hoarseness, frequent colds, dry mouth, gum bleeding, enlarged LNs
Respiratory: (+) cough, (-) dyspnea, hemoptysis, wheezing
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Review of SystemsCardiovascular: (-) palpitations,
chest pains, syncope, orthopnea
GI: (-) nausea, vomiting, changes in bowel habits, dysphagia, jaundice, rectal bleeding
GU: (-) nocturia, frequency
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Review of SystemsEndocrine: (-) excess sweat or
thirst, heat or cold intolerance
Neuro: (-) seizures, loss of sensation
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Physical ExaminationGeneral 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
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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.
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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.
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Pulmonary◦Normal shape. (-) lesions in anterior
and posterior thorax. (-) Areas of tenderness. Resonant. Clear breath sounds, no crackles, rales, wheeze.
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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.
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Gastrointestinal◦Flat. (-) Lesions. Normoactive bowel
sounds. (-) Tenderness. (-) Organomegaly. Tympanitic in all quadrants. Traube’s space empty. (-) CVA tenderness.
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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
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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
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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.
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Salient Features
Subjective2 year history of L and R
inguinoscrotal massReducible(+) Pain relieved by wearing
supporters(+) Activity hindrance
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Salient Features
ObjectiveBilaterally descended testesR: 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
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Salient Features
ObjectiveL: no palpable mass; L external ring
~ 1 cm in diameter; (-) transillumination test
Normal DRE
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Impression R hydrocoele, communicating L indirect inguinal hernia,
complete
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DifferentialsRule 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, malignancyChronic 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
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ManagementBilateral 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
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Procedure Done/ Intra-op findingsBilateral 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
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Inguinal herniaProtrusion 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.
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Indirect inguinal herniaPatent processus vaginalisReducible
◦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
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Risk factorsMaleFamily historyChronic cough, constipationObesityPregnancy PrematurityPrevious history of hernia
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TreatmentSupporters, bindingsSurgery
◦Herniotomy, herniorrhaphy◦Laparoscopy
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PrognosisTreatableRisk of strangulation (7%)
◦Recurrence, urinary retention, wound infection, hydrocoele, scrotal hematoma
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HydrocoeleBuildup 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
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TreatmentWait and seeHerniotomyContralateral exploration