A CASE OF BILATERAL HERNIA

Robin 52 years male , Businessman from kerala

Presenting complaints 1. Swelling in the Right groin x 1 year2. Pain over the Left groin x for 2 months (7 months

back )3. Swelling in the Left Groin x 6 months

Patient had similar complaints in the past , was apparently normal 1 year back , developed swelling in the right groin . Noticed more while standing .with mild discomfort over the area and with no pain . He noticed that it’s size was more while coughing or lifting some weight. At fi rst it was small around 2x 2 cm . And now by one year it has reached around 5 x 5 cm . Swelling appeared in the midline fi rst and then towards midline , towards scrotum .it disappeared automatically on lying down position

7 months back he felt a dragging and aching type of pain over the left groin , mild in nature persisited through out the day . No aggrevating or releiving factirs . It was there for about 2 months . No h/o any radiation of pain . Now the pain is not there

H/O PRESENTING ILLNESS

Later the pain subsided and then he noticed a swelling in the left groin also initially small of aroun 2 x 2 cm size and now slightly larger No h/o colicky abdominal pain , vomiting , abdominal distension or absolute constipation No h/o persistent cough , urinary initiation diffi culty , unhealthy stream , feeling of incomplete evacuation of urine

12 years back he had a swelling in the left groin for which he had underwent some surgery. Details not known . Patient had appendicitis 2 years back which was managed conservatively

No h/o HTN , DM , BA, Seizure Ds, or other illness , sugeries in the past

PAST HISTORY

Not on any drugs No h/o allergy to any drugs

DRUG / ALLERGIC HISTORY

Mixed Diet Sleep and appetite normal Bowel and bladder habits normal Chronic smoker started at the age of 25 years . 1

packet of bidis per day NO h/o alcoholism

PERSONAL HISTORY

Father died due to old age Mother alive healthy Siblings healthy NO similar history in the family No h/o malignancy or TB in the family

FAMILY HISTORY

APL

SOCIOECONOMIC STATUS

Examination of groin Inspection On standing position Right side :- there is a single swelling in the right groin of 8 x 8 cm size , normal skin color , spherical in shape , surface appears smooth . Edge distinct . Skin over the swelling is normal . No scars dilated veins . No visible peristalsis There is expansile impulse on coughing . Shaft of penis shifted towards left side Swelling gets reduced in supine position

LOCAL EXAMINATION

Left side There is a single swelling in the laft groin 4 x 5 cm

size , normal skin colour , spherical in shape , smooth surface , edges distinct . Skin over the swelling is normal . Not extending into the scrotum

There is a scar above and parallel to the level of the inguinal ligament of about 12 cm in length. A well healed scar . No signs of infection ,

NO skin pigmentation , redness m NO dilated veins , sinus

There is expansile impulse on cough Swelling gets reduced in supine position

Palpation Right side No Local rise of Temoerature or tenderness Site , size shape confirmed .Surface smooth edge distinct Consistency doughy Cannot get above the swelling There is expansile impulse on cough Zieman’s technique – impulse on middle finger Reducible on lying down ,Ring occlusion test - swelling persisits on standing

with the occlude finger

Left side No local rise of temperature or tenderness Site size shape confi rmed Surface smooth Edge distinct Consistency doughy Cannot get above the swelling There is expansile impulse on coughing Zieman’s three fi nger technique . – impulse in the middle

fi nger Reducible on lying down . Invagination test not done Ring occlusion test – swelling present on standing with

occluded fi nger

Percussion Dull over both swellings

Auscultation

No Peristaltic sounds

Examination of Testis , spermatic cord , epididymis normal

1. In supine position – there is protrusion of the lower abdomen

2. when asked to raise the shoulder against resistance there is retraction of abdominal wall over flanks

Malgaigne’s bulges seen in the inguinal region 3. Finger is iuntroduced into the superficial inguinal

ring – when cough poor strength of pillars and sphincteric action of conjoint tendon felt

EXAMINATION OF ABDOMINAL MUSCLES

WNL

OTHER SYSTEMS

RIGHT SIDED DIRECT HERNIALEFT SIDED RECURRUNT HERNIA

DIAGNOSIS

Associated indirect sac or hernia

DD

Rectal examination to r/o prostatomegaly Urethral examination for stricturtes or thickening

OTHER EXAMINATIONS