Inguinal Hernia
How to take history from a patient with suspected hernia or inguinal swelling?
Patient with inguinal hernia usually present with:
-swelling in the groin.
-or swelling in the inguino-scrotal region.
-or pain in the groin.
History:
1) Personal data:
Name, age, sex, nationality, from where the patient was admitted (E.R, OPD) and for how long he is in the hospital.
2) Chief complaint:
including the duration.Ex. C/O Rt. Groin swelling for 6 months
3) History of the present illness:
A) If the patient present with a swelling:
- How he observes it.
- When he observes it.
- Any changes in the size.
- Any associated symptoms as pain, fever, vomiting, constipation abdominal pain or distention….
- Any other swelling.
B) If the patient present with pain:
Site, duration, character, aggravating and relieving factors, radiation, associated symptoms as fever, swelling…
c) You have to ask about symptoms of the complication as symptoms of intestinal obstruction (vomiting, abdominal pain, constipation)..
D) You have to ask about the predisposing factors for the hernia as:
- Lifting heavy object.
- Chronic cough.
- Chronic constipation.
- Difficulty in passing urine.
In Incision hernia
same questions plus:- Wound infection post operative.
- Use of steroid.
- Jaundice.
4) Systemic review.
5) Past medical and surgical history.
6) Drug history.
7) Social history.
8) Allergy.
9) Summary of the history.
EXAMINATION
How to examine a patient with suspected inguinal hernia?
Position: you have to examine the patient in supine position and standing.
Exposure: from the upper abdomen to the mid thigh.
After general examination and vital signs, examine the groin.
The aim of the examination of the groin is:
1) To confirm it is hernia or not (by cough impulse).
2) To determine it is inguinal hernia or femoral hernia (by the relationship of the hernia to the pubic tubercle).
3) If it is inguinal hernia, which type, direct or indirect hernia( by deep inguinal ring test) 4) To determine it is simple hernia or complicated hernia as strangulated hernia…( by
the presence or absence of the signs of complication).
A) Inspection:
- Comment on any swelling ( if present, site and shape), and ask the patient to cough, if the swelling appears or increases by the cough, it is hernia,
- Comment on any skin changes as redness…
- Comment on any scar.
B) Palpation:
1- Put your palm of the right hand on the swelling and ask the patient to cough again, if there is cough impulse, it is confirmed that the swelling is a hernia.
2- Identify the pubic tubercle, put your index finger on it, and ask the patient to cough again, if the swelling appears below and lateral, it is femoral hernia, if it appears above and medial to the pubic tubercle, it is inguinal hernia.
How to identify pubic tubercle?
A) Flex the hip joint of the patient, and abduct it, put your hand in the medial aspect of the knee, ask the patient to adduct his hip joint against resistance (against your hand), feel the medial aspect of the thigh, you will feel a cord like tendon of the adductor longus muscle, follow this tendon proximally, it will be inserted in the pubic bone.
B) Palpate the lower abdomen of the patient with the medial aspect of your left hand, go down ward until you feel the symphisis pubis, then palpate lateral. The pubic tubercle will be the outer most, outer lateral bony prominence.
3- Identify the deep inguinal ring (make a line between the anterior superior iliac spine and the symphisis pubis, the deep inguinal ring will be one finger breadth above the midpoint of this line).
Do the deep inguinal ring test:
- Ask the patient to reduce the hernia, or you reduce it, put the tip of your index finger on the deep inguinal ring, asks the patient to cough. If the hernia appears, it is direct inguinal hernia. If it did not, it is indirect inguinal hernia.
- The direct inguinal hernia comes from Hasselbach`s triangle, which is boundered by, inferiorly by inguinal ligament, medially by lateral boarder of the rectus muscle, and laterally by the inferior epigastric blood vessels.
c-
Auscultation: auscultate the hernia to know the content of it. If there is bowel sound or no.4-Examine for the signs of complications as:
- Signs of strangulation: the hernia will be tender and tens, with absences of cough impulse. In late stages, skin changes as redness may be present.
- Signs of intestinal obstruction, as abdominal distention…
5- Examine other systems as GIT, Respiratory, C.V.S. …
