Hernia Examination PDF

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Hernia Examination...

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HERNIA'EXAMINATION' Inguinal'anatomy:' - The%inguinal%canal%runs%along%the%inguinal%ligament,%from%the%internal%(deep)%ring%to%the% external%(superficial)%ring%% - The%inguinal%ligament%stretches%from%the%anterior%superior%iliac%spine%to%the%pubic%tubercle%% - The%internal%ring%lies%approximately%1.5cm%superior%to%the%femoral%pulse,%itself%in%the%midline%of% the%inguinal%ligament%% - The%external%ring%lies%immediately%superior%and%medial%to%the%pubic%tubercle%% - NAVY%—>%nerve,%artery%vein,%Y-fronts%

Internal inguinal ring

Inguinal ligament Muscle Nerve

External inguinal ring

Artery Vein Femoral hernia

Definition'of'a'hernia:' The%protrusion%of%an%organ%or%part%thereof%through%a%deficiency%in%the%wall%of%the%cavity%in%which%it% is%contained.%

Indirect hernia (through inguinal canal)

Direct hernia (through Hesselbach’s triangle)

Femoral hernia (below inguinal ligament)

% Table 12. Differential diagnosis of a lump in the groin Superior to the inguinal ligament

Inferior to the inguinal ligament

Before'starting:' - Introduce%yourself%% - Patient%name%and%DOB%% - Explain%examination%and%obtain%consent%% - Ask%for%chaperone%% - Ask%patient%to%lie%on%couch%and%to%expose%abdomen%from%umbilicus%knees% - EnsuSite,%re%patient%is%comfortable%% - Warm%up%hands%% - Ensure(patient’s(dignity(at(all(times( The'examination:' Inspection%and%palpation:% - Ask%patient%to%stand%(if%able)%or%lay%down%whilst%you%observe%% - Note%evidence%of%pain%(e.g.%stance/grimacing)% - Note%patient’s%overall%colour%(e.g.%pallor%secondary%to%anaemia%or%jaundice)% - Note%evidence%of%abdominal%distension%(may%suggest%bowel%obstruction,%possibly%due%to% incarcerated%hernia)% - Note%muscle%wasting%or%cachexia%suggestive%of%underlying%malignancy%% - Look%around%bed%for%evidence%of%vomit%bowls%or%medication%boxes%

- Inspect%for:%%

-

• Asymmetry% • Scars%on%abdomen%and%in%groin%(incisional%hernia0% • Obvious%lumps%protruding%from%abdomen%or%groin%% • Testicular%lumps%or%swellings%% Ask%patient%to%couch,%which%should%accentuate%any%hernia%that%is%present%% If%lump%visible%determine%location%in%relation%to%surrounding%anatomical%landmarks%and%also% determine%size,%shape,%site,%colour,%consistency,%%and%mobility%(is%it%tender%to%touch?%can%it%be% transilluminated?)% (A)

Assessing%a%lump:% - Site,%size,%shape%% • Multiple%lumps%more% suggestive%of%superficial% lymph%nodes,%superficial% lesions%e.g.%lipoma%or% dermatological%problems%% - Colour,%contour,%consistency%% - Tenderness,%temperature,% tethering% - Cough%impulse%% - Transillumination% - Bruit%%

(B) Indirect hernia

Direct hernia

Indirect hernia

- Lymphadenopathy% Cough%impulse%and%cough%tests:%% (The%patient%is%still%standing)% - Ask%patient%to%cough%and%look%again%% - Test%the%lump%for%a%cough%impulse%—>%place%two%fingers%over%the%lump%and%ask%patient%to%cough% once%more%% - If%you%are%satisfied%that%the%lump%is%an%inguinal%hernia,%ask%the%patient%to%reduce%the%lump,%and% once%it%is%fully%reduced%place%two%fingers%over%the%internal%ring%and%ask%patient%to%cough%% • If%lump%does%not%reappear%it%is%an%indirect%inguinal%hernia%—>%release%your%fingers%and%and% the%patient%to%cough%again%% • If%the%lump%reappears%medially%it%is%a%direct%inguinal%hernia%% - Once%again%ask%patient%to%reduce%the%lump,%this%time%place%two%fingers%over%the%external%ring% and%ask%patient%to%cough%% • If%the%lump%does%not%reappear%it%is%a%direct%inguinal%hernia%—>%release%fingers%and%ask%the% patient%to%cough%again%% • If%the%lump%reappears%laterally%it%is%an%indirect%inguinal%hernia%% - Percuss%the%lump%for%resonance%(bowel%involvement)%% - Auscultate%lump%for%bowel%sounds%(bowel%involvement)% After'the'examination:' - Indicate%that%you%would%also%examine%the%femoral%pulses,%inguinal%lymph%nodes%and%scrotum%% - cover%up%patient%% - Ensure%they%are%comfortable%% - Thank%patient%% - Summarise%findings%and%offer%differential%diagnosis%(apart%from%inguinal%and%femoral%hernias,% other%more%rare%types%are%epigastric%hernias%that%occur%in%the%epigastric%area%in%the%midline,% Spigelian%or%semilunar%hernias%that%occur%on%the%outer%border%of%the%rectus%muscles,%umbilical% and%paraumbilical%hernias%that%occur%at%or%around%the%navel%and%incisional%hernias%that%occur%at% the%site%of%an%old%surgical%incision)%% - Wash%your%hands%%...