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A lump which arises from the groin/inguinal region and it may be due to various diseases or disorders
Epididymitis
Femoral aneurysm or pseudoaneurysm
Cyst
Femoral Hernia
Clinical Grading
Reduction Grade reponible irreponible incarceration + colic + pain Obstruction toxic
strangulation
steady increase
++
leucocytosis
History taking:
Introduction:
Greet the patient, and develop a warm and helpful environment
Introduce yourself to the patient
History taking:
Patient Identity
Ask the patient politely concerning his/her:
Name
Age
Female:
Number of children parity
History taking:
Chief complaint:
Ask the patient regarding why the patient comes to you. Lump on the groin:
Location: unilateral/bilateral
History taking:
The nature of the lump:
Intermittent?
If yes, what are the aggravating factors? Or relieving factors?
Persistent?
If yes, determine the lump progression
Accompanying pain: continuous? Intermittent? Colicky abdominal pain?
History taking:
Other related symptoms:
Ask the patient concerning related/concomitant symptoms of :
Gastro-intestinal function:
Nausea.
Vomiting
Bowel habit: obstipation?
History taking:
Urinary function:
Micturition: amount of urine,
Lower urinary tract symptoms: obstructive and irritative symptoms.
History taking:
Fever:
Onset of fever: before or after the appearance of the lump? Type of fever:
Continuous?
Intermittent?
History taking:
Previous history of :
Previous similar lump Previous hernia surgery
Stethoscope
Explain the procedure and its goals to the patient.
General Examination:
General appearance:
Consciousness
Mood: distressed? Anxious? Immobile Colour: Pallor? Flushing?
If the patients general condition looks normal, the patient is asked to stand up in front of you. Ask the patient politely to expose his/her inguinal region.
If there is no lump, you ask the patient to perform Valsava manoeuvre: Ask the patients head to turn one side. Ask the patient to cover his/her mouth with one of hands, and blow air through the mouth. While doing this, allow the patient to strain and watch for any visible lump from both inguinal and femoral regions, and scrotal regions for male patients.
Groin Examination
Position Temperature Pain Size Shape Tensile strength Composition (solid, gas, liquid) Changes with cough
Try to reduce the lump manually by using your fingers, starting from the external ring or the most lower part of the lump, going up to internal ring (Anatomical landmark: Anterior Superior Iliac Spine, pubic tubercle). If it fails, do not continue. The success procedure is indicated when the lump disappears with or without gurgle sounds.
Put your right index finger above the inguinal canal or place your right/left fingers on the external ring and the opposite fingers on the internal ring or on top of any noticeable lump. Ask the patient to repeat the valsava manoeuvre, watch if there is lump coming out from the rings. Determine the position of the lump in relation with inguinal ligament:
Finger test
Differential Diagnosis
Indirect inguinal hernia (no lump, if the fingers compression released, the lump will reappear).
If a scrotal lump presents, grasp the swelling between fingers and thumb, and ascertain whether it is possible to get above the swelling. Determine its continuity with the inguinal canal. Using flash light, determine whether there is any trans-illumination.
Ask the patient to lie down on the couch in supine position. Examine the vital signs:
Temperature Pulse rate Blood Pressure Respiratory rate
Ask the patient politely to expose his/her abdomen and inguinal region.
Abdominal Examination:
Inspection : Inspect the movement:
Respiratory movement
Visible bowel peristaltis
Abdominal Examination:
Palpation:
Using the palmar surface of your fingers, gently palpate the abdomen. While palpating, look to the face expression of the patient, and look for any signs of :
Tenderness Rebound tenderness Muscle guarding Rigidity Hernial orifices
Abdominal Examination:
Percussion: Place the palmar aspect of your left hand on the abdomen, and gently percuss its dorsal aspect with the tip of the middle finger of the right hand, moving all around the abdominal region:
Is it tymphanitic? Is it Dull ? Is there any shifting dullness? Site of liver dullness ? and is it disappeared ?
Abdominal Examination:
Auscultation Using stethoscope, and place it gently on the abdomen, listen to the bowel sounds and bruit at least for a minute:
Normal Absent?
Groin Examination:
Perform the groin examination as you perform on standing position.
Auscultation on top of a hernia may allow the detection of bowel sounds, which can be useful information if you are unsure as to the nature of an inguinal bulge.
Write up
Write up all significant findings in the medical record.
Conclude your diagnosis and differential diagnosis, and order any necessary special investigations
Demonstration:Video