Inguinal Hernia (OSCE Guide)

1/03/2020

Inguinal Hernia (OSCE Guide)

Examination of an inguinal hernia is a vital part of surgical examination methods. It is one of the most basics skills that every medical student and doctor should be aware of.

More importantly, differentiating between a femoral and inguinal hernia plays a major role here.

Firstly, introduce yourself and get consent before you proceed to examine the patient.


INGUINAL HERNIA EXAMINATION

You will be asked to examine the groin area of a patient who is lying supine, but always remember to examine the patient in the erect position as well, at some point in your examination.

  1. Get the Consent, cover the area and expose adequately.
  2. Look carefully for surgical scars in the groin (Recurrent hernia?).
  3. See the shape of the lump in the groin. A direct inguinal hernia is usually globular in shape and an indirect one may be sausage-shaped (inguinoscrotal swellings).
  4. Ask the patient to cough,
    • To elicit expansile cough impulse.
    • Inorder to visualize a hernia that cannot be seen.
    • To see the full extent of an already visible hernia.
  5. ONLY IF the hernia still cannot be seen, ask the patient where the lump is (It may be a scrotal swelling!!) and ask him to stand up at this point & look for a bulge appearing on the groin area on coughing (Very rare to give invisible ones in an exam setting).
  6. Once the hernia is visible, demonstrate the palpable expansile cough impulse.
  7. ONLY IF there is no past surgical scar indicating a previous repair, differentiate whether it is direct or indirect hernia.
    • Ask the patient himself to reduce the hernia fully for you.
    • If the patient is unable to do so, ask the examiner whether you may try to reduce it (DO NOT try to reduce without the consent of the examiner)
    • ONLY IF the hernia is reduced,
      1. Locate the deep inguinal ring (2methods can be used).
        • 1 cm above the femoral pulse (Easy way).
        • 1 cm above the mid inguinal point (midpoint between the anterior superior iliac spine and pubic tubercle).
      2. Ask to cough while you are applying firm pressure on deep inguinal ring with your index finger.
      3. If the lump can be controlled by digital pressure over the deep ring, it is an “Indirect inguinal hernia”, if not it is a “Direct inguinal hernia”.
  8. Examine the external genitalia to exclude phimosis and coexisting scrotal lump which is very common.
  9. If the patient was supine throughout your examination, ask him to stand up before you finish and look for,
    • A coexisting small hernia on the other groin.
    • A coexisting varicocele.

PRESENTATION

This patient has got a globular shaped lump in the right groin region. It has visible and expansile cough impulse. The hernia can be completely reduced and cannot be controlled by applying firm pressure over the deep inguinal ring. He has got no phimosis and there are no coexisting scrotal lumps. The contralateral groin is normal. So my probable diagnosis is uncomplicated right-sided direct inguinal hernia and I would like to offer him inguinal hernia repair under spinal anesthesia.



FREQUENTLY ASKED QUESTIONS

1. How do you locate the deep inguinal ring?

Method One – 1 cm above the femoral pulse (Easy way).
Method Two – 1 cm above the mid inguinal point (midpoint between the anterior superior iliac spine and pubic symphysis).

2. If you see a scar of a previous repair, do you still want to locate the deep inguinal ring?

No. Once a hernia is repaired, its anatomy is disturbed. So a recurrence of a hernia arises from the weakest part of it. Hence it is neither direct nor indirect.

3. If you cannot control the hernia by applying firm pressure over the deep inguinal ring, can it still be an indirect hernia? Why?

Yes, it can be.
1. Not enough pressure applied.
2. Finger is not on the deep inguinal ring.
Anyway, this method is just for crude assessment. The direct or indirect nature of a hernia is best identified during the surgery.

4. From where does an indirect inguinal hernia appear?

It comes from deep inguinal ring, passes obliquely through the inguinal canal and may continue through the superficial inguinal ring to the scrotum. It arises lateral to the inferior epigastric artery. Commonly due to persistent processes vaginalis.

5. From where does a direct inguinal hernia appear?

It occurs as a result of weakened posterior wall of the inguinal canal and arise medial to the inferior epigastric artery. So a direct inguinal hernia is not within the spermatic code. It may descend to the scrotum though.

6. What is the importance of differentiating direct and indirect inguinal hernia?

No importance! Management is the same for both.

7. What is the landmark to differentiate direct from indirect inguinal hernia during the surgery?

Inferior epigastric artery.

8. At what age, inguinal hernia are operated on children?

As early as possible due to the high risk of strangulation.

9. What are the treatment options?

1. Mesh repair (Gold standard).
2. Darning repair.
3. Bassini repair.
4. Shouldice repair.

10. What is the difference in surgical steps of managing inguinal herniae?

Indirect inguinal herniae require both herniotomy (excision of the hernia sac) & herniorrhaphy (hernial repair) while direct inguinal herniae usually only necessitate herniorrhaphy.

11. What are the aetiological factors?

1. Chronic cough.
2. Constipation.
3. Cigarette smoking.
4. Bladder outflow obstruction (BOO)

12. What are the complications of inguinal herniae?

1. Irreducibility.
2. Obstruction.
3. Strangulation.
4. Incarceration

13. What are the complications of the surgery?

1. Acute urine retention.
2. Hematoma formation.
3. Pain.
4. Infection.
5. Ischemic orchitis.
6. Recurrence.

14. What is the risk of recurrence after a Mesh repair?

Less than 1%.

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Ulcer Examination (OSCE Guide)

1/03/2020

Ulcer Examination (OSCE Guide)

Ulcer Examination is a basic short case OSCE skill for all doctors and medical students.

Firstly, introduce yourself and get consent before you proceed to examine the patient. Examination of an ulcer is more or less similar to an examination of a lump. But some additional features have to be kept in mind.


ULCER EXAMINATION

Inspection
1. Site.
2. Size (Extent).
3. Margin (Shape) – Regular? Irregular?
4. Edge – Sloping? Punched-out? Undermined? Rolled-out? Everted?
5. Floor – Healthy? Granulation tissue? Slough?
6. Discharge? – Serous? Serosanguinous? Purulent? Amount and smell?

Palpation (With a gloved hand)
1. Palpate the margin and edge.
2. Palpate the base – Muscle? Bone?

Palpation (Without gloves) – depending on the type of suspected ulcer from above
1. Temperature of the surrounding skin.
2. Regional lymphadenopathy.
3. Peripheral pulses.
4. Peripheral sensation and joint position sensations (JPS)


PRESENTATION

Venous Ulcer
There is an ulcer over the right ankle just above the medial malleolus (Gaiter’s area). It is oval in shape, approximately 2cm x 3cm in size. Its margin is irregular, edge is sloping and the floor contains healthy granulation tissue. There is a serous discharge from the ulcer. The ulcer is superficial and the base contains subcutaneous tissue. The surrounding skin is warmer, pigmented and thickened. There are associated varicose veins. Peripheral pulses and sensation are normal and there is no inguinal lymphadenopathy.

Neuropathic Ulcer
There is an ulcer over the sole of the right foot which is oval in shape, approximately 3cm x 4cm in size. Its margin is regular, edge is punched-out and floor contains healthy granulation tissue. There is no discharge from the ulcer. Ulcer is painless, the base contains flexor tendons of toes, surrounding skin and peripheral pulses are normal. Peripheral sensation to pain is absent up to ankles and joint position sensation is impaired.

Ischemic Ulcer
There is an ulcer over the tip of the 2nd toe of the right foot which is round in shape, approximately 1cm x 1cm in size. Its margin is irregular, edge is punched out and floor contains slough. There is a purulent discharge from the ulcer. The base contains bone of the distal phalanx. The surrounding skin is colder and blackish in colour. Dorsalis pedis and posterior tibial pulses are absent and the femoral pulse is weak on the right side. The peripheral sensations are normal and there is no inguinal lymphadenopathy.

Malignant Ulcer
There is an ulcer over the dorsum of the right foot which is irregular in shape, with a maximum diameter of 6cm. There is a purulent discharge from the ulcer. Its margin is irregular, the edge is raised & everted. Floor is reddish-brown and contains slough. There is hard inguinal lymphadenopathy on the right side. Peripheral pulses and sensation are normal.



FREQUENTLY ASKED QUESTIONS

1. What is an ulcer?

It is a break in the continuity of an epithelial surface.

2. Explain the terms margin, floor, edge and base of an ulcer.

1. Margin – The line of demarcation between normal and affected tissue.
2. Floor – Exposed bottom of the ulcer.
3. Edge – It connects the margin to the floor.
4. Base – The area in which the ulcer rests.

3. What are the types of edges and examples for each one?

1. Sloping – Venous ulcer.
2. Punched-out – Ischemic ulcer.
3. Undermined – Tuberculous ulcer.
4. Rolled-out – Basal cell CA.
5. Everted – Squamous cell CA.

4. What are the common causes of leg ulceration?

1. Peripheral vascular disease.
2. Varicose veins.
3. Peripheral neuropathy.
4. Squamous cell carcinoma.
5. Sickle cell disease.
6. Syphilis.
7. Tuberculosis

5. What are the causes for neuropathic ulcers?

1. Uncontrolled diabetes.
2. Chronic alcoholism.
3. Vitamin B12 deficiency.
4. Leprosy.
5. Vasculitis

6. How do you differentiate a neuropathic ulcer from an ischemic ulcer?

1. Painless ulcers.
2. Associated glove & stocking type of sensory loss.
3. Normal surrounding skin.

7. What are the risk factors in diabetics for foot ulceration?

1. Peripheral neuropathy.
2. Peripheral vascular disease.
3. Immunodeficiency.

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