Station 1 40 years old lady complaining of Para umbilical hernia,examine her abdomen?

1)Position. 2)Shape and size. 3)Surface and edge 1)Position . 2)Shape and size. 3)Surface and edge. The surface is smooth and edge easy to define, except when the patient’s abdominal wall is very fat. try to feel the upper border of the mass (to get above it):scrotal neck test* 4)Composition. The lump is firm as it usually contains omentum . If it contains bowel, it is soft and resonant to percussion.it will be reducible unless the contents are adherent to the sac or the defect is very narrow. also auscultate for bowel sounds. 5)Cough impulse. 2 times ex the cough impulsive first time with inspection ,and second with palpation

6)Relations to skin (overlying skin;red… 6)Relations to skin (overlying skin;red….) 7)Ask patient to reduce the mass herself 8)Perform deep ring test*: to differentiate indirect from direct. 9)General examination ( respiratory , cardiovascular, abdominal: masses, ascites, PR: for BPH)

*Scrotal neck test: thumb ant, index and middle post to scrotal base, try to feel the cord. If palpable>>it’s a scrotal mass, not palpable>>it’s an inguinoscrotal mass *Deep ring test: ask pnt to b supine and reduce mass him/herself, put ur finger 2cm above mid ing. ligament point*(point between ant. Sup. Ileac spine & pubic tubercle), keeping ur finger in place, ask pnt to stand up and cough.. If the mass did not appear (also u’ll feel cough impulse)>> it’s indirect.. If it appears>> it’s direct..

Station 2 What is your diagnosis and the management ? (the pic is not the same pic in the exam but this one shows Strangulated Hernia with Evisceration: Strangulated hernia with eviscerated small bowel seen in center ) What is your diagnosis and the management ?

Diagnosis : Strangulated hernia is incarcerated hernia with resulting ischemia management : emergent surgery (to check whether the intestinal tissue has died and to repair the hernia.)

NB:difference between types of hernia femoral hernia( the most type liable to be strangulated) indirect inguinal hernia commonest overall Direct inguinal hernia Umbilical hernia Para umbilical hernia Incision hernia Epigastric hernia

Bulges medial to the inferior epigastric artery Features Indirect Inguinal Hernia Direct Inguinal Hernia Femoral hernia Typical patient Young male Older male Old female Proportion of groin hernias 60% 25% 15% Anatomy Commence at deep ring, lateral to the inferior epigastric artery, and pass within the coverings of the spermatic cord. Bulges medial to the inferior epigastric artery Emerges from the femoral canal. Relationship to the Tubercle Start lateral to and above the tubercle,but passes superomedial to the tubercle into the scrotum. Lies above the tubercle Pass inferolateral to the tubercle Descent In to the scrotum Yes No Obstructs or strangulate Rarely yes

*The different between hernia & hydrocele: hernia (indirect inguinal) Hydrocele ( non- communicating type) cough impulse no cough impulse reducible Irreducible cannot get above it Can get above testis palpable Testis not palpable opaque translucent Contain bowel and fluid only fluid

Station 3 DDX: Inguinal hernia It is not the same pic but was Picture of swelling in inguinal region & scrotum DDX: Inguinal hernia

Station 4 34 years old man has a mass in the left loin, mention 5 important DDx:

DDx: LF renal tumours LF Pheochromocytoma massively enlarged spleen LF adrenal tumours LF Hydronephrosis LF adult polycystic kidney disease LF renal vein thrombosis LF acute tubular necrosis

N.B. : DDx of groin ( inguinal) swelling Hernia: inguinal, femoral. Lymphadenopathy Psoas abscess/cyst Femoral artery aneurysm Saphena varix Testis: ectopic/undescended Cord: lipoma/hydrocele NB: Hydrocele of the cord is a groin mass Non-communicating hydrocele is a scrotal mass Communicating hydrocele is an inguinoscrotal mass.