Station 24 Hernia examination 63
Table 12. Differential diagnosis of a lump in the groin
Superior to the inguinal ligament Inferior to the inguinal ligament
• Indirect or direct inguinal hernia.
• Scrotal mass (see Station 27).
• Introduce yourself to the patient.
• Explain the examination and obtain consent.
• Ask the patient to lie on the couch and to expose his abdomen from the umbilicus to the knees.
• Ensure that he is comfortable.
Ensure the patient’s dignity at all times.
• Inspect the groins(both sides!) for an obviouslump. If a lump is visible, determine itslocation in
of a superficial mass and of lymph nodes.)
• Look for old surgical scars (incisional hernia).
• Ask the patient to stand up and look again.
(The patient is still standing.)
• Ask the patient to cough and look again.
• Test the lump for a cough impulse. Place two fingers over the lump and ask the patient to
• If you are satisfied that the lump is an inguinal hernia, ask the patient to reduce the lump. Once
the lump is fully reduced, place two fingers over the internal ring and ask the patient to cough.
– if the lump does not reappear it is an indirect inguinal hernia. Release your fingers and ask
– if the lump reappears medially it is a direct inguinal hernia
• Once again ask the patient to reduce the lump. This time place two fingers over the external
ring and ask the patient to cough.
64 Station 24 Hernia examination
– if the lump does not reappear it is a direct inguinal hernia. Release your fingers and ask the
– if the lump reappears laterally it is an indirect inguinal hernia
• Percuss the lump for resonance (bowel involvement).
• Auscultate the lump for bowel sounds (bowel involvement).
• Indicate that you would also examine the femoral pulses, inguinal lymph nodes, and scrotum.
• Ensure that he is comfortable.
• Summarise your findings and offer a differential diagnosis. Don’t fret over your diagnosis as
even experienced surgeons are notoriously poor at differentiating between indirect and direct
inguinal hernias. Apart from inguinal and femoral hernias, other (more rare) types of hernia are
that occur at or around the navel, and incisional hernias that occur at the site of an old surgical
Indirect hernia Direct hernia Indirect hernia
Specifications: A mannequin in lieu of a patient.
Nasogastric (NG or Ryle’s) tubes can be used for feeding or drug administration, to decompress the
or greater is required. If not, a fine bore tube should be preferred.
• A pair of non-sterile gloves • Tape
• An NG tube of appropriate size • Stethoscope
• K-Y/lubricant jelly • A 20 ml syringe and some pH paper
• Xylocaine spray • A spigot or catheter bag
• A glass of water with a straw • A vomit bowl
• Introduce yourself to the patient.
• Explain the need for an NG tube and the procedure for inserting it, and ensure consent.
• Position the patient upright and ask about nostril preference/examine the nostrils.
• Ensure that the patient is comfortable.
• Wash your hands and don the gloves.
• Measure the length of NG tube to be inserted by placing the tip of the tube at the nostril and
extending the tube behind the ear and then to two fingerbreadths above the umbilicus.
• Lubricate the tip of the NG tube with K-Y jelly.
• Spray the preferred nostril with xylocaine or indicate that you would do so.
• Insert the NG tube into the preferred nostril and slide it along the floor of the nose into the
nasopharynx (aim straight back towards the occiput).
time the patient swallows, advance the tube a little bit further.
• If the patient coughs or gags, slightly withdraw the tube and leave him some time to recover.
• Insert the tube to the required length.
• Ensure that the tip of the tube is in the stomach.
– inject 20 ml of air into the tube and listen over the epigastrium with your stethoscope
– pull back on the plunger to aspirate stomach contents. Test the aspirate with pH paper to
confirm its acidity (pH < 6). If a fine-bore tube has been inserted, it may not be possible to
– request a chest X-ray or indicate that you would do so
• Tape the tube to the nose and to the side of the face.
• Attach a spigot or catheter bag to the NG tube.
66 Station 25 Nasogastric intubation
• Ask the patient if he has any questions or concerns.
• Ensure that he is comfortable.
• Make an entry in the patient’s notes confirming that the NG tube has been successfully placed.
[Note] The principal complications of NG tube insertion are aspiration and tissue trauma.
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain that you are going to ask him some questions to uncover the nature of his urological
complaint, and obtain consent.
• Ensure that he is comfortable.
Presenting complaint and history of presenting complaint
• Ask about the main presenting complaint. Ask open questions.
• Elicit the patient’s ideas, concerns, and expectations.
• Determine the time course of events and the severity of the problem.
– pain: for any pain, ask about site, onset, character, radiation, associated factors, timing
(duration), exacerbating and relieving factors, and severity
– frequency: “Are you passing water more often than usual?”
– nocturia: “Do you find yourself waking up in the middle of the night to pass water?” “How often?”
– urgency: “When you need to pass water, how long can you wait?”
– incontinence: “Are there times when it can no longer wait and you end up going there and then?”
– dysuria: “When you pass water, is there any pain or burning?”
– haematuria: “When you pass water, is there any blood in your urine? Does it colour all of your
– hesitancy, poorstream and terminal dribbling (if male): “When you are standing at the toilet do
you have to wait before you are able to pass water? Is the jet as strong as it ever was? What about
after, does urine continue to trickle out?”
– back pain, leg weakness, fatigue, weight loss, nausea, anorexia, itching
– vaginal/urethral discharge, genital sores
– testicular masses, testicular pain
• Ask specifically about UTI, renal colic, diabetes mellitus, hypertension and vascular disease, and
• Current, past, and childhood illnesses.
• Prescribed medication including anticholinergics and anticoagulants.
• Over-the-counter medication.
68 Station 26 Urological history
• Parents, siblings, and children. In particular, has anyone in the family had a similar problem?
• Ask specifically about polycystic kidney disease and bladder cancer.
• Employment. Has the patient ever worked with chemicals or dyes?
• Ask the patient if there is anything he might add that you have forgotten to ask about.
• Summarise your findings and offer a differential diagnosis.
Conditions most likely to come up in a urological history station
• Most common in young females.
• Common symptoms are frequency, urgency,
dysuria, haematuria, and a pressure above the
• If the infection is above the bladder, there
may be fever, nausea, and back pain.
• There may be a history of recent sexual
• Most common in elderly males.
• Common symptoms are frequency, nocturia,
urgency, incontinence, hesitancy, poor stream
and intermittency, and terminal dribbling.
• Most common in elderly males.
• Symptoms, when present, are similar to those
seen in benign prostatic hypertrophy with
the possible addition of dysuria, haematuria,
sexual dysfunction, weight loss, and bone
• There may be a family history.
• Three to four times more common in males
• Painless haematuria is characteristic, but
there may also be dysuria and/or frequency.
• Associated with smoking and occupational
exposure to chemicals and dyes.
• More common in males than in females.
• Severe pain in the loin that radiates to the
• the pain is often colicky but it may be
• The pain may be associated with nausea and
• Haematuria is a common finding.
• Dehydration is a common predisposing factor.
Specifications: You may be asked to examine the male genitalia on a real patient or, more likely, on
• Introduce yourself to the patient.
• Confirm his name and date of birth.
• Explain the examination and obtain consent.
• Ask the patient to lie on the couch and expose his groin area.
• Ensure that he is comfortable.
Ensure the patient’s comfort and dignity at all times.
• From the end of the couch observe the patient’s general appearance. The patient’s age can give
you an indication of the most likely pathology.
• In particular, note the distribution of facial, axillary, and pubic hair.
Inspection and examination of the male genitalia
• Inspect the penis for lesions and ulcers.
• Retract the foreskin and examine the glans penis and the external urethral meatus for red
patches and vesicles. Is there a discharge? Can a discharge be expressed? If there is a discharge,
indicate that you would swab it for microscopy and culture. Remember to replace the foreskin.
may have been surgically removed.
• Be conscious of the patient’s face in case of pain, and palpate:
impulse (see Station 24). Determine the size, shape and consistency of the mass.
are almost invariably left-sided.
No comments:
Post a Comment