UNIVERSITY OF THE EAST

Ramon Magsaysay Memorial Medical Center

Aurora Blvd., Quezon City
Department of Surgery

Greg Mikhail B. Hubo August 27, 2021

2023-B
Preceptor: Dr. Napoleon Alcedo

I. Identifying Data
The patient is a 66-year-old Filipino male from IloIlo. He is married and is a member of Iglesia ni
Cristo.

II. Chief Complaint

Bulging mass in the right inguinal area of 2 years duration

III. History of Present Illness

Two (2) years of PTA, the patient noticed a mass (~2-3cm) on his abdomen at the right inguinal
area and at the right testicle that was reducible, associated with numbness. No pain, tenderness,
and redness were noted. The patient’s mass can be reduced when he attempts to push it back and
when applying ice on the area. Mass was aggravated when lifting heavy objects.
In the interim, the mass increased in size and numbness still persisted.
One (1) week PTA, a patient consulted at a clinic in Cavite and the physician requested blood
workup and testicular ultrasound. He was then advised by his physician to seek consultation with
a surgeon for his possible hernia. He was then referred by his relative to our institution.
On the day of consult, persistence of inguinal mass with the same characteristics but now
associated with pain and tenderness, with a pain scale of 5/10, relieved by paracetamol with no
noted decline in size when lying in supine position.
Pertinent positives: inguinal swelling, tenderness
Pertinent negatives: fever, weight loss
Recommendation: There should be better characterization of the mass. The texture, firmness or
softness? color of the mass? Ask for associated symptoms the patient might think is not related to
the mass. Ask for the results of the workup.
IV. Past Medical History
The patient has been diagnosed as hypertensive and dyslipidemic since 2013, with a usual BP of
150/80 and high BP of 160/90. He is maintained on metoprolol 100 mg OD and Simvastatin 20
mg OD with good compliance. He is also diagnosed with Benign Prostatic Hyperplasia (BPH)
with no maintenance medicine. She has no history of allergies, no previous accidents,
hospitalizations and surgeries.

V. Family History
No information elicited during interview
VI. Personal/Social History
The patient is a pepsi cola vendor with a 30 pack year history of smoking and is an occasional
alcoholic beverage drinker.
Recommendation: Ask about illicit drug use. Ask the type of alcohol he is drinking. How many
times per week? How many glasses per occasion? Ask about the sexual history of the patient due
to the proximity to and possible involvement of the genitals.
VII. Review of Systems
General survey  No anorexia, no fatigue, fever, weakness
Skin No jaundice, no skin dryness, itching, changes in hair and nails, rashes
HEENT  H: No headache, No head injury;
E: No redness, pain, inability to open eye
E: No hearing impairment, otalgia, discharge, swelling of structures
N: No Nose deformity, no colds, no epistaxis
T: No gum bleeding dental carries dysphagia odynophagia, hoarseness
Respiratory No hemoptysis, wheezing rales, crackles, exertional dyspnea, DOB
Cardiovascular  No chest pain, palpitations, dyspnea orthopnea, syncope
Gastrointestinal No constipation, indigestion, heartburn, fatty food intolerance
Urinary No pain in urination, UTI, hematuria, kidney or flank pain, suprapubic pain,
(+) increase in frequency, weak urinary stream, incomplete emptying,
polyuria, dribbling, hesitancy.
Extremities No joint pains, no edema clubbing cyanosis varicosity, claudication
Hematopoietic No excessive bleeding/bruising, PICA, anemia
Nervous No head trauma, sensory perversions, tremors, fainting spells, seizures,
trauma, dizziness
Musculoskeletal No pain on all extremities, swelling
Endocrine No heat/cold intolerance, neck surgery/irradiation, no polydipsia, no
polyphagia, no polyuria, no thyroid problems
Psychiatric No irritation, no agitation, anxiety, depression
IX. Physical Examination
General Survey The patient is awake, conversant, not in pain, not in
cardiorespiratory distress
Vital signs BP: 160/80
HR 89 bpm
RR 20 cpm
Temp 36.5C
O2 Sat 99% at RA

The patient’s blood pressure is elevated. This may need monitoring

since the patient is hypertensive.
HEENT anicteric sclerae, pink palpebral conjunctivae, moist lips and oral
mucosa, no tonsillopharyngeal congestion, no palpable cervical
lymphadenopathies
Chest and Lungs Equal chest expansion, clear breath sounds, equal tactile fremitus,
clear breath sounds
Cardiovascular Adynamic precordium, tachycardic, regular rhythm, distinct s1 &
s2, (-) murmurs

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Abdomen Flabby abdomen, non tympanitic, non-distended, normoactive, soft,
non-tender

DRE: smooth, rectal mucosa, no masses palpable, no blood on

examining finger, good sphincter tone

A DRE is a must for patients within this age group because the
likelihood of BPH/Prostate cancer is high. Also, BPH may
contribute to the hernia that the patient is currently concerned
about.
Extremities Full equal pulses, no edema, no cyanosis, CRT <2 seconds
Other Bulging mass on right inguinal area up to the right scrotum
~4x6cm, (+) bowel sounds, firm irreducible, no erythema, no
tenderness, not warm to touch
Pertinent Subjective Pertinent Objective
Patient Profile BP: 160/80 mmHg
• 66 years old, male Temp: 36.5oC
Chief Complaint RR: 20cpm
• Bulging mass in the HR: 89bpm
right inguinal area
Personal/Social History: Inguinal Examination
• 30 pack year Smoker ● Bulging mass on right inguinal area up to the right
• Occasional alcohol drinker scrotum ~4x6cm, (+) bowel sounds, firm irreducible,
History of Present Illness no erythema, no tenderness, not warm to touch
• 2 years PTA,
• mass on abdomen at right
inguinal area and right
testicle
• no pain and mass was
reducible.
• aggravated by lifting
heavy object
• Interim- increase in size
• 1 week PTA,
• blood work up and
testicular ultrasound was
requested.
• advised to seek consult for
possible hernia
• Day of Consult
• inguinal mass with same
characteristics
• pain and tenderness 5/10
PS
• pain relief with
paracetamol
• no decline when lying in
supine position

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 Initial Assessment
Primary Impression: Incarcerated Indirect Inguinal Hernia

Herniation is the protrusion of the abdominal contents through a weakened abdominal wall
because of weakening of fibromuscular tissue. It is more common in men and has a median age
of presentation of 50-69 years old. Since the patient is a 66 year old male, the likelihood of the
condition is considered. Other risk factors for developing hernia would include history or prior
repair of hernia, caucasian race, obesity, chronic cough, chronic constipation, genitourinary
obstruction abdominal wall injury, and family history of hernia.

Most common sign of hernia in adults is bulging in the groin or body wall, which was
present in the patient. The patient had a reducible mass 2 years PTA and an irreducible mass
during the day of consultation. Bulging isn’t always visible in other cases and may require
maneuvers such as Valsalva or performing a cough for the bulge to be appreciated. In the case of
the patient, the bulging reached the scrotal area and was irreducible which makes it more likely to
be an indirect inguinal hernia. An indirect inguinal hernia is one that passes through the inguinal
ring and down to the inguinal canal. This predisposes it to cases of incarceration, where the
hernia becomes trapped and reducing it back to the anatomical site is impossible. If not given
attention to, it may lead to strangulation where blood flow is compromised leading to edema,
ischemia, and necrosis of the hernia contents which is a medical emergency.

Differential Diagnosis
Differential Rule in Rule Out
Testicular Tumor ● Bulging mass in ● (-) anorexia
the inguinal area ● (-) malaise
up to scrotum ● (-)weight loss
● Chronic and with
increase in size
● Painless mass that
became painful
with increase in
size

Epididymo-orchitis ● Scrotal Mass ● history of sexual contact

● (-) fever

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 Diagnostic Workup:
● The existing gold standard for diagnosing inguinal hernia remains
to be a complete and comprehensive history and a thorough
physical examination. Imaging and other diagnostic tests may be
warranted to confirm factors that contribute to the hernia or if
there is suspicion of complication. Imaging can also be requested
for absolute certainty.
● If suspected to be due to benign prostatic hyperplasia and COPD
would include:
Diagnostic tests 4,7,8 o Urinalysis – possible urinary tract infection
o PSA – elevated in BPH patients
o Ultrasound – to determine residual volume upon voiding
for assessing severity of urethral compression if present
o Chest x-ray – for visualization of lung fields and to
exclude other diagnoses that may cause chronic cough
o Spirometry – for diagnosis of COPD (decreased FEV1,
FEC1/FVC ratio)
o Pulse oximetry – to assess presence of hypoxemia

Assessment
Final Diagnosis: Incarcerated Indirect Inguinal hernia

With the available history and PE findings, final diagnosis would be an acquired indirect
inguinal hernia that is classified as incarcerated based on symptoms. The patient fits the common
clinical picture of patients with hernia including male, age between 50-69 years old. In
classifying the type of hernia, it is an indirect hernia. An indirect hernia occurs more often on the
right, which is presented in the case of the patient. This is believed to be attributed to the slower
closure of a patent processus vaginalis on the right side compared to the left. An indirect hernia is
a type of hernia that traverses the internal inguinal ring down to the inguinal canal extending into
the scrotum. This type of hernia is associated with incarceration or strangulation. In this case, the
hernia of the patient was irreducible even in supine position that is why it is classified as
incarcerated. Strangulation is usually associated with necrosis, fever, and severe pain which are
not present in this case.

Management
Initial management Supportive care:
● Alleviate the symptoms of the patient:
● Give weak pain relievers such as NSAIDs to alleviate acute pain
felt by the patient.
Elective Surgery:
● Surgical repair is the standard treatment for inguinal hernia. The
patient is old and presenting with incarcerated inguinal hernia
Definitive Plan 4,,6 which may be treated via open elective surgery. Elective surgery
may also be beneficial to the patient to prevent complications
such as strangulation and intestinal obstruction
● If not managed urgently, incarcerated hernia may progress to
strangulated hernia that can cause necrosis of hernial contents.
Small bowel obstruction is also a common complication

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 Activity:
● Fatigue is common for the first week after surgery.
Post-operative Plan ● Limit physical activity and prioritize rest as needed.
● Avoid heavy lifting or any activity that will increase abdominal
pressure for the first 4 weeks.
● Persistent groin pain and postoperative neuralgia is a common side
effect after groin hernia surgery and varies overtime. Nerve block
may be offered if pain lasts for more than three months with no other
relatable causes.

ALGORITHM:

Figure 1: Diagnosing Inguinal hernia from History and Physical Examination

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