1. Objectives To determine the proper approach to a patient presenting with inguinal mass To determine possible differentials for inguinal mass To determine the appropriate management of an inguinal mass

2. Identifying Data General Data ◦ Gabaldon, Luis Arnel Beltran ◦ 16 years old ◦ Male ◦ Student ◦ Roman Catholic ◦ Pasay City Chief complaint ◦ Bilateral inguinal mass

3. History of Present Illness 2 years PTCLeft inguinal mass Soft, smooth, “balloon-like” Well-circumscribed ~ 1-2cm in diameter Spontaneously appears and disappears (-) pain or tenderness (-) fever, dysuria, hematuria No consult

4. History of Present Illness 1 year PTC Persistence of left inguinal mass Occasional migration to scrotal area Mass with similar characteristics Spontaneously revolves Sometimes with manual compression Right inguinal mass Occasional migration to scrotal area ~ 2-3cm in diameter Exertion, straining, defecation Occasional pain Manual compression

5. History of Present Illness 1 month PTCPersistence of symptoms Mass appeared to enlarge, 4-5cm in diameter on R; 2-3cm on L Increase pain severity, VAS 5-6 Activity hindrance Consult Advised surgery Supporters but only minimal relief Admission

6. Past Medical History Childhood: febrile convulsions ◦ Multiple hospitalizations Grade 2: chickenpox (-) measles, mumps, primary complex Claims to have complete childhood vaccinations (-) Sexual contact (-) surgeries (-) allergies to food or medications

7. Family History Hypertension- father DM, inguinal mass???- mother (-) cancer, lung diseases

8. Personal-Social History Non- smoker Occasional alcohol drinker No illicit drug use 1 st year college student Dance and sports

9. Review of Systems General: (+) fatigue, (-) fever, weight loss or gain, weakness Musculoskeletal/dermatologic: (-) lumps, itching, muscle or joint pains, joint swelling, changes in hair or nails HEENT: (-) dizziness, deafness, blurring of vision, tinnitus, nosebleeds, hoarseness, frequent colds, dry mouth, gum bleeding, enlarged LNs Respiratory: (+) cough, (-) dyspnea, hemoptysis, wheezing Cardiovascular: (-) palpitations, chest pains, syncope, orthopnea GI: (-) nausea, vomiting, changes in bowel habits, dysphagia, jaundice, rectal bleeding GU: (-) nocturia, frequency Endocrine: (-) excess sweat or thirst, heat or cold intolerance Neuro: (-) seizures, loss of sensation

10. Physical Examination General Survey ◦ Alert, awake, coherent, ambulating ◦ Not in cardio-respiratory distress ◦ Height 170 cm, Weight 65 kg, BMI 22.5 Vital Signs ◦ BP 100/70 mmHg; HR 90 bpm; RR 14 bpm; T 36.4 °C ◦ Pain scale 0/10 Integumentary ◦ Nails clean and properly trimmed; with good color, reddish pink nail beds. No cyanosis or clubbing noted HEENT ◦ Head- No palpable and visible masses or wounds. ◦ Eyes- eyelids normal. Visual fields full. Pink conjunctiva. EOMs full and equal. (+) corneal light reflex. (+) Direct and consensual papillary reflex. ◦ Ears- No visible wounds, lumps or deformities.

11. HEENT ◦ Nose- Nasal septum midline. Pink mucosa, no exudate and swelling. No sinus tenderness. ◦ Throat- Oral pale pink mucosa, no signs of ulcerations and swelling. Tongue midline. Symmetric elevation of soft palate; pink in appearance Neck ◦ (-) Lymphadenopathies over cervical, post and pre auricular, and submental areas. Trachea midline. Thyroid not palpable. No goiter and nodules. Pulmonary ◦ Normal shape. (-) lesions in anterior and posterior thorax. (-) Areas of tenderness. Resonant. Clear breath sounds, no crackles, rales, wheeze. Cardiovascular ◦ (-) Pallor, cyanosis. A dynamic precordium. No palpable masses. PMI, 5 th left ICS MCL. Heart sounds normal rate and regular rhythm; S1>S2 on the apex, S2>S1 on the base, S3 and S4 not heard. Absence of bruits, thrills and murmurs. Gastrointestinal ◦ Flat. (-) Lesions. Normoactive bowel sounds. (-) Tenderness. (-) Organomegaly. Tympanitic in all quadrants. Traube’s space empty. (-) CVA tenderness.

12. Inguinal/ Genitalia ◦ Tanner stage 5 ◦ Bilaterally descended testes ◦ (-) phimosis, hypospadia ◦ R: palpable mass ~ 4cm over inguinal to upper scrotal area; soft, smooth, non-tender, well demarcated; mass felt at the tip of the finger in the inguinal canal; mass irreducible with taxis; (+) transillumination test ◦ L: no palpable mass ◦ Skin normal looking DRE ◦ (-) lesions, masses in the perianal; (-) masses, fissures, hemorrhoids, pararectal tenderness; intact external anal sphincter; (-) blood on examining finger Extremities ◦ (-) cyanosis and edema. Pulses full and equal. Good turgor. Neuro exam ◦ GCS 15 (4E, 5V, 6M). Muscle strength 5/5. Sensation 100%.

13. Salient Features 2 year history of L and R inguinal mass, slowly migrating to scrotum Spontaneously or manual compression (+) pain, activity hindrance Bilaterally descended testes R: palpable mass ~ 4cm over inguinal to upper scrotal area; soft, smooth, non-tender, well demarcated; mass felt at the tip of the finger in the inguinal canal; mass irreducible with taxis; (+) transillumination test L: no palpable mass Normal DRE

14. Impression Bilateral indirect inguinal hernia, complete

15. Differentials Rule inRule out Inguinal hernia(+) inguinoscrotal mass more prominent with straining Hydrocoele(+) transillumination test(-) painless enlarged scrotum Varicocoele(+) scrotal mass(-) veins palpated (-) feeling of heaviness in the testicle (-) atrophy of testicle Lympphadenopathy(+) inguinal mass(-) history of trauma, infection, malignancy Chronic case Epididymitis(+) scrotal pain(-) acute scrotal pain (-) fever (-) warm/ red scrotum Testicular torsion(+) inguinoscrotal mass(-) acute testicular pain Undescended testes(+) inguinal mass(+) testes palpated in the scrotum

16. Management Bilateral herniotomy Pre op ◦ CBC: unremarkable  Hbg 141, Hct 0.43, WBC 6.6, Plt 266 ◦ CT: 2-4 mins. ◦ BT: 2-4 mins. ◦ UA: unremarkable ◦ CXR: unremarkable ◦ Antibiotics: Cefuroxime 1.5g IV

17. Procedure Done Bilateral herniotomy ◦ R: internal ring measures 1 cm in diameter, floor not attenuated ◦ L: internal ring measures 0.5cm in diameter, floor not attenuated Post op ◦ Cefuroxime 1.5g/ IV TID ◦ Tramadol 50mg/ mL q 8 o  50 mg/tab q 8 o ◦ Mefenamic acid 500mg/ tab