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Objectives

Objectives. To 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. Identifying Data. General Data Gabaldon , Luis Arnel Beltran 16 years old Male

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Objectives

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  1. Objectives • To 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

  2. Identifying Data • General Data • Gabaldon, Luis Arnel Beltran • 16 years old • Male • Student • Roman Catholic • Pasay City • Chief complaint • Bilateral inguinal mass

  3. History of Present Illness 2 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

  4. History of Present Illness 1 year PTC • Persistence of left inguinal mass • Occasional migration to scrotal area • Mass with similar characteristics • Spontaneously revolves • Sometimes with manual compression • Right inguinal mass • Occasional migration to scrotal area • ~ 2-3cm in diameter • Exertion, straining, defecation • Occasional pain • Manual compression

  5. History of Present Illness 1 month PTC • Persistence of symptoms • Mass appeared to enlarge, 4-5cm in diameter on R; 2-3cm on L • Increase pain severity, VAS 5-6 • Activity hindrance • Consult • Advised surgery • Supporters but only minimal relief Admission

  6. Past Medical History • Childhood: febrile convulsions • Multiple hospitalizations • Grade 2: chickenpox • (-) measles, mumps, primary complex • Claims to have complete childhood vaccinations • (-) Sexual contact • (-) surgeries • (-) allergies to food or medications

  7. Family History • Hypertension- father • DM, inguinal mass???- mother • (-) cancer, lung diseases

  8. Personal-Social History • Non- smoker • Occasional alcohol drinker • No illicit drug use • 1st year college student • Dance and sports

  9. Review of Systems • General: (+) fatigue, (-) fever, weight loss or gain, weakness • Musculoskeletal/dermatologic: (-) lumps, itching, muscle or joint pains, joint swelling, changes in hair or nails • HEENT: (-) dizziness, deafness, blurring of vision, tinnitus, nosebleeds, hoarseness, frequent colds, dry mouth, gum bleeding, enlarged LNs • Respiratory: (+) cough, (-) dyspnea, hemoptysis, wheezing • Cardiovascular: (-) palpitations, chest pains, syncope, orthopnea • GI: (-) nausea, vomiting, changes in bowel habits, dysphagia, jaundice, rectal bleeding • GU: (-) nocturia, frequency • Endocrine: (-) excess sweat or thirst, heat or cold intolerance • Neuro: (-) seizures, loss of sensation

  10. Physical Examination • General Survey • Alert, awake, coherent, ambulating • Not in cardio-respiratory distress • Height 170 cm, Weight 65 kg, BMI 22.5 • Vital Signs • 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 • 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.

  11. 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. • Pulmonary • Normal shape. (-) lesions in anterior and posterior thorax. (-) Areas of tenderness. Resonant. Clear breath sounds, no crackles, rales, wheeze. • 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. • Gastrointestinal • Flat. (-) Lesions. Normoactive bowel sounds. (-) Tenderness. (-) Organomegaly. Tympanitic in all quadrants. Traube’s space empty. (-) CVA tenderness.

  12. Inguinal/ Genitalia • Tanner stage 5 • Bilaterally descended testes • (-) phimosis, hypospadia • R: palpable mass ~ 4cm over inguinal to upper scrotal area; soft, smooth, non-tender, well demarcated; mass felt at the tip of the finger in the inguinal canal; mass irreducible with taxis; (+) transillumination test • L: no palpable mass • Skin normal looking • 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. • Neuro exam • GCS 15 (4E, 5V, 6M). Muscle strength 5/5. Sensation 100%.

  13. Salient Features • 2 year history of L and R inguinal mass, slowly migrating to scrotum • Spontaneously or manual compression • (+) pain, activity hindrance • Bilaterally descended testes • R: palpable mass ~ 4cm over inguinal to upper scrotal area; soft, smooth, non-tender, well demarcated; mass felt at the tip of the finger in the inguinal canal; mass irreducible with taxis; (+) transillumination test • L: no palpable mass • Normal DRE

  14. Impression • Bilateral indirect inguinal hernia, complete

  15. Differentials

  16. Management • Bilateral herniotomy • Pre op • CBC: unremarkable • Hbg 141, Hct0.43, WBC 6.6, Plt 266 • CT: 2-4 mins. • BT: 2-4 mins. • UA: unremarkable • CXR: unremarkable • Antibiotics: Cefuroxime 1.5g IV

  17. Procedure Done • Bilateral 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 • Cefuroxime 1.5g/ IV TID • Tramadol 50mg/ mL q 8o 50 mg/tab q 8o • Mefenamic acid 500mg/ tab

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