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hernia
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A CASE OF BILATERAL HERNIA
Robin 52 years male , Businessman from kerala
Presenting complaints 1. Swelling in the Right groin x 1 year2. Pain over the Left groin x for 2 months (7 months
back )3. Swelling in the Left Groin x 6 months
Patient had similar complaints in the past , was apparently normal 1 year back , developed swelling in the right groin . Noticed more while standing .with mild discomfort over the area and with no pain . He noticed that it’s size was more while coughing or lifting some weight. At fi rst it was small around 2x 2 cm . And now by one year it has reached around 5 x 5 cm . Swelling appeared in the midline fi rst and then towards midline , towards scrotum .it disappeared automatically on lying down position
7 months back he felt a dragging and aching type of pain over the left groin , mild in nature persisited through out the day . No aggrevating or releiving factirs . It was there for about 2 months . No h/o any radiation of pain . Now the pain is not there
H/O PRESENTING ILLNESS
Later the pain subsided and then he noticed a swelling in the left groin also initially small of aroun 2 x 2 cm size and now slightly larger No h/o colicky abdominal pain , vomiting , abdominal distension or absolute constipation No h/o persistent cough , urinary initiation diffi culty , unhealthy stream , feeling of incomplete evacuation of urine
12 years back he had a swelling in the left groin for which he had underwent some surgery. Details not known . Patient had appendicitis 2 years back which was managed conservatively
No h/o HTN , DM , BA, Seizure Ds, or other illness , sugeries in the past
PAST HISTORY
Not on any drugs No h/o allergy to any drugs
DRUG / ALLERGIC HISTORY
Mixed Diet Sleep and appetite normal Bowel and bladder habits normal Chronic smoker started at the age of 25 years . 1
packet of bidis per day NO h/o alcoholism
PERSONAL HISTORY
Father died due to old age Mother alive healthy Siblings healthy NO similar history in the family No h/o malignancy or TB in the family
FAMILY HISTORY
APL
SOCIOECONOMIC STATUS
Examination of groin Inspection On standing position Right side :- there is a single swelling in the right groin of 8 x 8 cm size , normal skin color , spherical in shape , surface appears smooth . Edge distinct . Skin over the swelling is normal . No scars dilated veins . No visible peristalsis There is expansile impulse on coughing . Shaft of penis shifted towards left side Swelling gets reduced in supine position
LOCAL EXAMINATION
Left side There is a single swelling in the laft groin 4 x 5 cm
size , normal skin colour , spherical in shape , smooth surface , edges distinct . Skin over the swelling is normal . Not extending into the scrotum
There is a scar above and parallel to the level of the inguinal ligament of about 12 cm in length. A well healed scar . No signs of infection ,
NO skin pigmentation , redness m NO dilated veins , sinus
There is expansile impulse on cough Swelling gets reduced in supine position
Palpation Right side No Local rise of Temoerature or tenderness Site , size shape confirmed .Surface smooth edge distinct Consistency doughy Cannot get above the swelling There is expansile impulse on cough Zieman’s technique – impulse on middle finger Reducible on lying down ,Ring occlusion test - swelling persisits on standing
with the occlude finger
Left side No local rise of temperature or tenderness Site size shape confi rmed Surface smooth Edge distinct Consistency doughy Cannot get above the swelling There is expansile impulse on coughing Zieman’s three fi nger technique . – impulse in the middle
fi nger Reducible on lying down . Invagination test not done Ring occlusion test – swelling present on standing with
occluded fi nger
Percussion Dull over both swellings
Auscultation
No Peristaltic sounds
Examination of Testis , spermatic cord , epididymis normal
1. In supine position – there is protrusion of the lower abdomen
2. when asked to raise the shoulder against resistance there is retraction of abdominal wall over flanks
Malgaigne’s bulges seen in the inguinal region 3. Finger is iuntroduced into the superficial inguinal
ring – when cough poor strength of pillars and sphincteric action of conjoint tendon felt
EXAMINATION OF ABDOMINAL MUSCLES
WNL
OTHER SYSTEMS
RIGHT SIDED DIRECT HERNIALEFT SIDED RECURRUNT HERNIA
DIAGNOSIS
Associated indirect sac or hernia
DD
Rectal examination to r/o prostatomegaly Urethral examination for stricturtes or thickening
OTHER EXAMINATIONS