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.

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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.

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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.

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FREQUENTLY ASKED QUESTIONS

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.

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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)

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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.

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FREQUENTLY ASKED QUESTIONS