case history wid topic of discussion.

1. Case presentation:-
Intern :- Amrit Pokhrel
GMCTH,Pokhara

2. Personal details:-
A 49 yrs female residing on Baglung, Housewife by occupation
presented at Surgery-OPD with
Chief complaints:-
 Swelling on right inguinal region since 4 yrs.
 Pain for 15 days

3. History of present illness:-
Swelling on rt.inguinal region:-
 Since 4 yrs.
 Develops spontaneously.
 Associated with pain.
 Grows slowly.
 Not a/w fever, ulceration, loss of body weight and
swelling is single.

4. Pain:-
 At rt.inguinal region.
 Insidious onset.
 Pin pricking.
 Radiates toward thigh.
 Aggravated by standing & weight lifting.
 Relief by rest on supine position.
 Pain is mild.

5. Past history:-
 No significant past medical ( like:- chronic cough, constipation
and retention of urine ) and surgical history in past.
Personal history:-
 Patient is non-alcoholic, non-smoker, non-vegetarian diet.
Family history:-
 No significant family history.
 Eight member family with five kids.

6. General physical examination:-
 General condition – fair
 Jaundice
 Anemia
 Cyanosis
 Clubbing
 Lymph adenopathy
 Edema
 Well hydrated
Vital signs:-
 B.P. - 110/70 mm of Hg.
 Pulse – 76 beats/minute – regular.
 Temperature – 98.F
 RR – 18 breathe / minute
 Spo2 – 98 %
Not found

7. Systemic examination:-
Chest:- normal vesicular breathe sound present.
CVS :- S1 + S2 + Mo
CNS:- grossly intact.
Per abdomen:-
 Inspection:-
 Scaphoid shape.
 Umbilicus inverted and centrally located
 All quadrants moves equally with respiration.
 Visible pulsation and peristalsis are absent.
 Protrusion from right sided saphenous opening.

8.  On palpation:-
 On percussion:-
 Tympanic sound found.
On Auscultation:-
 Bowel sound present – 3/ minute.
 No localize rise of
temperature.
 No tenderness.
 No organomegaly
detected.

9. Local examination:-
On standing position:-
 Inspection:- single swelling
- at upper – medial thigh.
- cough impulse present.
- similar to skin color.
- globular.
- 2.5 x 2.5 cm
- well defined edge.
- no pulsation & peristalsis.
- no move with respiration.
- skin over swelling normal.
On supine position:-
 There is no alteration of
shape and size of the
swelling i.e. similar to
standing position.

10.  Palpation:-
- No localize rise of temperature.
- No tenderness.
- Size 2.5 x 2.5 cm, globular.
- Smooth surface.
- Cough impulse present.
- Distinct edge but not palpable upper edge.
- Firm consistency.
- Non fluctuating.
- No fluid thrill.
- Non translucent.
- Non reducible.
- Compressible.
- Non pulsatile and not fixed to overlying skin.

11.  on percussion:-
- Dull on percussion.
 On Auscultation:-
- No bruits.
- No gurgling and bowel sound.

12. Laboratory findings:-
 TLC – 8200 Hb – 13.5 ESR – 10
 RBS – 80 Urea – 31 Creatinine – 1.0
 Na+ - 145 K+ - 4.1
 BT – 2’ 15” CT – 7’ 30” PT/INR – 13”/1.0
 Serology – negative
 Urine R/E – Pus cell – 12 to 14
- Epithelial cell – 1 to 3
- RBC – nil
 USG abdomen and pelvis.
- Right Femoral Hernia.

13. Provisional diagnosis:-
- Irreducible Right Femoral Hernia ( Non – obstructed ).
Differential diagnosis:-
 Rt.inguinal hernia.
 Rt.inguinal lymph node.
 Lipoma.
 Psoas abscess.
 Femoral Artery Aneurysm.

14. Surgical treatment:-
 Open surgery – LOCKWOOD approach under Spinal
Anesthesia.
 Intra operative findings are:- Rt.femoral hernia with peritoneal
fluids approx. amount 20 ml

15. Topic of Discussion:-

16. Anatomy:-
Boundary of femoral canal:-
 Supero-anteriorly :-
Inguinal ligament.
 Infero-posteriorly:-
Iliopectineal ligament
(cooper)
 Medially:- Lacunar ligament
( Gimbernats ligament ).
 Laterally:- femoral vein

18. Hernia:-

19. Femoral hernia :-

21. Clinical presentation:-

22. Clinical features:-
 Usually presents with pain or discomfort in groin.
 Groin lump.
 Usually not reducible.
 Mild pain exacerbated by bending or lifting.
 Mild tenderness.
In case of obstruction:-
 Colicky abdominal pain.
 Vomiting, constipation
 Abdominal distension.
 Lump irreducible and tender.

23. In case of strangulation:-
 Lump is very tender.
 Skin over the lump red and hot.
 Features of shock.

24. Diagnosis:-
History and Clinical examination.
Ultrasonography – abdomen and pelvis.

25. Differential diagnosis:-
Inguinal hernia.
Saphena varix.
Lipoma.
Femoral artery aneurysm.
Psoas abscess.
Ectopic testis.

28. Treatment:-