EXPLANATION OF HISTORY PRESENTATION OR REPORTING FOR A PATIENT WITH INGUINAL HERNIA INCLUDING ALGORITHM IN RESPONSE TO THE QUESTION; EXAMINE THIS PATIENT S GROIN? In this article the trainee will find how to report a patient that has been clerked for inguinal hernia and the explanation for the statements that have been made by the presenter. When a patient has been clerked with a diagnosis of inguinal or femoral hernia, here are some of the questions that must have been answered after reporting your findings The trainee must prove that it is indeed a hernia The trainee should have linked the hernia to the cause The trainee will have stated clearly the progression of the hernia The trainee should attempt to give a hint of the content of the sac The trainee should have made it clear whether the hernia is symptomatic and need repair on the next operation day, as an urgent or an emergent case or as a case that may be delayed for a longer time The trainee should determine whether it is familial or sporadic On examination of short case of a groin swelling, the trainees should know how to separate abdominal mass that has gone into the scrotum from a primarily scrotal mass, he or she should be able to determine what method of 1
examination to progress with and how far to go. The algorithm that follows this discussion settles these questions whether or not the groin swelling swelling is immediately obvious. Now we start with the prototype history of a patient with hernia. The following were the positive finds Right groin swelling or protrusion of 9 months, first noticed will working on the farm, Attention was drawn to it by aching pain Reason for presenting: fear of loss of testis Has obstructive symptoms Pmhx= herniorraphy ten years earlier, hypertensive Family history in female child Social history: farmer, uses herbal concoctions, widower and has 7 children The history may be presented or reported as follows. Opening : Mypatient is Mr AA, a 63 year old male nonmechanized farmer who presented with a right sided growing swelling / protrusion of 9 months duration..( notice how the presenter started the discussion straight away without saying the patient was apparently, or in his usual state of health, he just cut to the chase straight away) 2
The swelling was notice for the first time after lifting heavy sacks in his farm.his attention was drawn to it by ache in the groin.. ( note here, that the presenter has immediately linked the problem to the likely cause. heavy weight lifting.this is the cause part of the 5cs method of presentation)..the swelling was initially a small bulge in his groin but progressively increased over the months and now grows into his right hemiscrotum so he presented because of fear of destruction of the testis. Since first notice..( note here that the presenter is tracing the course or progression of the disease).., the swelling always comes out when he is working in his farm, when he stands, lifts heavy objects or when he strains at defecation and disappears when he applies pressure over it or when he lies down..( this description of coming out during moments on increment in intraabdominal pressure or with gravity and disappearing during period of reduction or with gravity removed is classical for hernias and must always be present in any history presentation suggesting hernia).. He has aches locally when the swelling is present. He relieves the ache by pushing the swelling back. The swelling sometimes makes noise when coming out ( this line of reporting is going further to tell the listeners that not only is this hernia but that the hernia sac contains intestine-making noise suggests gurgling).. There is no change in the overlying skin and no discharge.(suggests the hernia is not inflamed and there is no fistula), There is no similar swelling in the other groin, no other swelling in any other part of the 3
body. There is periumbilical abdominal pain sometimes when the when the swelling remains persistent outside when swelling is outside.( this report segment is detailing the complications that are present. Local ache can occur when the hernia stretches the canal as it emerges but periumbilical or abdominal pain else were especially when the mass is outside suggests luminal obstruction. This suggests that the hernia is symptomatic and will definitely need to be repaired. Note that if there is protrusion is not noisy it does not rule out being and enterocoele but if it does it confirms it. If the patient has urinary symptoms when the swelling is prominent then the hernia may be a cystocoele ie containing the urinary bladder). He relieves the pain by forcing the swelling back in.( adding this statement here immediately links the hernia to the abdominal pain, this must be done any time there are complications due to a hernia, the presenter must find ways of linking the symptoms to the lesion),,,, no abdominal distension and no vomiting. There is no constipation, no diarrhea. Aside from this swelling in the lower abdomen, there is no abdominal mass, no alternating bowel habit, no anal protrusion and no tenesmus. There is no difficulty with swallowing, no jaundice, no weightloss and no anorexia.( this segment is trying to rule out other causes of increased intraabdominal pressure such as straining at constipation, intraabdominal mass etc) 4
In the review of systems, central nervous system; there is no persistent headache, no change in personality no change in sleep pattern. In the respiratory system, there is no cough, no chest pain and no difficulty with breathing. In the cardiovascular system there is no palpitation, or pedal swelling no paroxysmal nocturnal dyspnea and no orthopnoea. In the urogenital system, there is no frequency of micturition, no straining at micturition and no hesitancy or poor stream. In the endocrine there is no nocturia, no polyuria, no excessive sweating and no fever. In the musculoskeletal system, there is no bone pains, joint pains, no back pains and no deformities. In the integument there is no pruritus, no rashes and no easy bruising.. ( please note that all other systems aside from gastrointestinal systems have been included including hematologic which was checked by rashes and easy bruising. The gastrointestinal system is the region where the main symptom emanates hence it has been well reviewed in the history of presenting complaint) Past medical history: he has a similar illness about 10 years ago for which he had herniorraphy under local anesthersia. He was discharged on the day of surgery The perioperative period was not adversely eventful and the wound healed within 1 week. ( the circumstance surrounding the previous surgery is dissected to give an idea of how the patient reacts to anesthesia and how he tolerates surgical intervention and to determine whether there is a need to be 5
wary of certain anesthetic agents etc )...He is a known hypertensive diagnosed 15 years ago he has been regular on moduretic and aldomet. He has not used aspirin ( the presenter has presented details of the drugs being taken by the patient because of interaction with anesthetics and with surgery eg here aspirin may cause pleading from impaired platelet function. The aspirin needs to be stopped for at least 7-10 days for the platelet functions to normalize.) There is no history suggestive of diabetes, sickle cell disease, peptic ulcer disease. There is no history suggestive of blood transfusion or hospital admission. There is no history of trauma to the groin or abdominal or groin surgery.( this suggests the cause is not traumatic rupture of muscle nor is it incisional or recurrence nor is it due to nerve injury eg injury of iliohypogastric or ilioinguinal nerve during open appendectomy with muscle weakness leading to direct inguinal hernia) In the drug and allergy history, aside for moduretic and aldomet there are other routine medications and there is no history suggestive of allergies. ( for a multiparous female: who has had several spontaneous vertex deliveries. The presentation should be reported as follows; in the obstetrics and gynecologic history. She is a multiparous; para7+0 5 alive. She lost 2 children to childhood febrile illness. All were spontaneous vertex delivery. She is 9 years postmenopausal. there is no history of use of oral contraceptives ) 6
In the social history; he is a farmer, not mechanized. He takes regular African Yoruba diet.. He is a widower, he has 3 male children and 4 females. There is a history of similar illness in one of his female children who is a hairdresser.( mentioning the child s occupation here suggests that the hernia in that child may not be due to the occupation because we know that hernia can occur in families from connective tissue deficiency or if they perform the same occupation, this suggests in this patient that the occurrence in the father and child may be a genetic or familial occurrence and not just sporadic chance occurrence because they have both had the problem yet they have not been exposed to the same environmental conditions)... There is no history of cigarette smoking or intake of alcohol. He takes herbal concoction made from bitter leafs and other items which he does not know ( Family history: there is a similar history of same illness in his father who was also a farmer ( this links the relationship to occupational risk even though there is a possibility of genetic undertone also) next is an algorithm for determining how to examine a groin swelling. this algorithm answers the questions is there a swelling at all is it groin or is it inguinoscrotal or is it a scrotal swelling is a hernia or is it something else is it a primary scrotal mass is it the testis or is it something else in the scrotum 7
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