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

2. 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

3. 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)

4. *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..

5. 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 ?

6. 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.)

7. 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

8. 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

9. *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

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

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

12. 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

13. 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.