Patient’s Information
Age: 50 years. Sex: Male.
Subjective
Chief Complaint
“Pain in the left groin radiating to testicles after moving a refrigerator 6 hours ago. The pain is severe, constant, and feels like something is tearing inside.”
History of the Present Illness
Mr. Baldwin experienced a sudden severe pain in his left groin 6 hours ago, after helping his friend to move a refrigerator. The pain radiated to his testicles, and it can be characterized as severe, acute, and constant. The intensity of the pain changed from 1/10 to 10/10. The left part of the groin area seems to be swelling. The pain worsens when standing up or bending. Nothing can alleviate the pain. The patient reports nausea and vomiting. He denies weakness, fever, changes in weight, dysuria, hematuria, and back or leg pain. No trauma is reported.
Medications
Lisinopril (hypertension).
The patient denies changing and taking new or herbal medications.
Past Medical History
Allergies
No drug allergies were diagnosed.
Medication Intolerances
No medication intolerances were diagnosed.
Chronic Illnesses/Major traumas
The history of hypertension and kidney stones (remission). No major traumas were determined.
Hospitalizations/Surgeries
No hospitalizations or surgeries in the past.
Family History
According to the information provided by the patient, his father suffered from hypertension, coronary artery disease, and prostate cancer.
The patient’s mother had breast cancer and hypothyroidism. No psychiatric illnesses, lung diseases, or kidney diseases were reported.
Social History
The patient works as a construction accountant. He reports consuming 1-2 drinks per day and smoking 1 pack per day for several years. The patient reports doing exercises and eating healthy food. The patient chooses safe sex.
Review of Systems (Only Symptoms)
General
The patient reports no weight changes, weakness, fatigue, fever, chills, or night sweats. The energy level is normal.
Cardiovascular
The patient is positive for tachycardia. He denies chest pain, any discomfort, palpitations, and edema.
Skin
The patient denies any delayed healing, bruising, rashes, or bleeding.
Respiratory
The patient denies shortness of breath, cough, wheezing, hemoptysis, pneumonia, dyspnea, or tuberculosis.
Eyes
The patient denies using corrective lenses and having any visual changes or blurring.
Gastrointestinal
The patient is positive for abdominal pain, nausea with vomiting, and constipation. He denies hepatitis, hemorrhoids, eating disorders, black tarry stools, or ulcers.
Ears
The patient denies ear pain or hearing loss. He does not have ringing in ears.
Genitourinary/Gynecological
The patient has severe pain in the left groin, this area is swollen. The patient does not feel pain when urinating. No changes in urgency and frequency, no changes in the color of urine. No blood is observed. Sexual activity is safe. No complaints related to his prostate.
Nose/Mouth/Throat
The patient denies sinus problems, nose bleeding or discharge, dysphagia, hoarseness, throat pain, and dental diseases.
Musculoskeletal
The patient denies back and leg pain, joint swelling, stiffness, osteoporosis.
Breast
No complaints/not related.
Neurological
The patient denies transient paralysis, syncope, seizures, paresthesias, weakness, and black out spells.
Heme/Lymph/Endo
The patient is positive for diaphoresis. He denies blood transfusion, night sweats, swollen glands, increased hunger or thirst, cold or heat intolerance. The patient’s HIV status is negative.
Psychiatric
The patient denies anxiety, depression, sleeping disorders, or suicidal ideations.
Objective
Weight 180 pounds. BMI 24.4. Temp 99.0 F (oral). BP 170/94 mmHg. Height 6′ 0″. Pulse 130 bpm (regular). Resp 18 bpm, SpO2: 98% on room air.
General Appearance
The healthy appearing adult male, no acute distress. He is alert and oriented and answers questions appropriately.
Skin
Skin is of normal color, warm, clean, and dry. No rashes or lesions are noted. Diaphoresis is observed.
HEENT
Head is normocephalic, atraumatic, without lesions. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral tympanic membranes – a positive light reflex, and landmarks are easily visualized. Nose: Nasal mucosa is of normal color, and turbinates are normal. No septal deviation. Neck is supple, and a full range of motion is observed. Lymph nodes are not enlarged or swelled. No thyromegaly is observed. Oral mucosa is of normal color, moist. Pharynx is nonerythematous. Teeth are good.
Cardiovascular
Tachycardia and hypertension are present. No extra sounds, rubs, or murmurs are observed. No edema.
Respiratory
The chest wall is symmetric. Respirations are regular and easy, and both lungs are clear to auscultation.
Gastrointestinal
The patient’s abdomen is soft and tender near the groin area. No hepatosplenomegaly.
Breast
No masses, tenderness, changes in skin color.
Genitourinary
Bladder is non-distended; no costovertebral angle tenderness is observed. Prostrate is smooth, free from nodules, and non-tender. Both testicles are palpable and normal in size, non-tender. An inguinal hernia is observed in the left groin area, the left inguinal canal is tender, and this area and scrotum are swollen. No evidence of hemorrhoids, fissures, or bleeding.
Musculoskeletal
A full range of motion is observed, but there are difficulties when standing up and bending caused by pain.
Neurological
Speech is clear and soft. The patient’s posture is erect, the balance is stable, and the gait is normal.
Psychiatric
The patient is alert and oriented, dressed neatly. He maintains eye contact and answers questions appropriately.
Lab Tests
Urinalysis – normal.
WBCs – 19,500 mm3.
Special Tests
CT abdomen/pelvis.
Scrotal ultrasound – the loop of bowel is in the left scrotum.
Diagnosis
Differential Diagnoses
- Inguinal hernia.
- Testicular torsion.
- Kidney calculi.
Diagnosis
- Inguinal hernia.
The careful assessment of the patient with the focus on laboratory tests has not supported the presence of testicular torsion or kidney calculi. An inguinal hernia is the main diagnosis for this case because of the presence of swelling of the left groin associated with a sudden and acute pain. The physical examination indicates the tender and indurated left groin mass with associated scrotal edema. In this case, scrotal ultrasound has revealed the following: the loop of bowel in the left scrotum; a normal blood flow in testicles; normal testicles’ sizes.
An inguinal hernia is the most common type of hernias in males, and it is a result of the increased abdominal pressure associated with lifting heavy things (Farrell, Coogan, Hibbeln, Millikan, & Benson, 2014; Ohene-Yeboah, Beard, Frimpong-Twumasi, Koranteng, & Mensah, 2016). An inguinal hernia observed in the patient is irreducible, and surgery is required (Khatib et al., 2014).
Plan/Therapeutics
Plan
- Further testing: CBC, BMP, and ultrasound.
- Medications: Paracetamol.
- Education: post-surgery activities.
- Non-medication treatments: open hernia repair.
This plan is oriented to treating an inguinal hernia. According to Roy, Mondal, and Maitra (2016), an inguinal hernia can be reducible and irreducible. In this case, it is possible to speak about an irreducible hernia which cannot be treated with the help of using a truss or manual procedures.
Further testing required for the case should include CBC, BMP, and ultrasound in order to control changes in the blood flow and sizes of testicles. Medications prescribed for the patient should include only Paracetamol which should be taken in the context of the post-surgery recovery plan. The non-medication treatment appropriate for the case includes surgery. Open hernia repair should be recommended for Mr. Baldwin’s case in contrast to laparoscopy in order to avoid using general anesthesia to conduct the required surgery (Li, Ji, & Li, 2014).
The recurrence rate after surgery is low (Huang, Zheng, & Ao, 2015). The patient should be educated regarding some aspects associated with consequences of open hernia repair: after the surgery, the patient should walk as soon as possible; the full recovery is observed in a week or two; the full recovery is guaranteed while following the postoperative care procedures (Bagshaw, Weller, Shaw, & Frampton, 2015).
The patient should also be educated regarding the use of a bandage and prevention of lifting heavy things. The patient should be informed that he will be able to return to work in two weeks after surgery. It is important to ask the patient to assess himself and determine the signs of infections. In this case, it is also important to educate the patient regarding approaches to controlling his hypertension with the help of a diet and healthy physical activities allowed for patients after surgery.
Evaluation of patient encounter (Self-Assessment)
This case has helped me learn about approaches to diagnosing and treating an inguinal hernia in contrast to testicular torsion and kidney calculi which can have similar symptoms. While working with male patients who have symptoms of an inguinal hernia, I should pay attention to the physical examination of the patient in order to determine causes of the experienced pain and focus on such related symptoms as diaphoresis and nausea with vomiting.
Furthermore, I should support my assumptions regarding the diagnosis by the results of the ultrasound and blood tests. I should focus on recommending the most appropriate treatment for the patient’s case and address such factors as age, the past history of diseases, hypertension, and his family history. The evaluation of all these aspects has helped me determine what plan to propose to the patient in order to improve his state and help him cope with possible pain during the post-surgery period.
References
Bagshaw, P., Weller, S., Shaw, C., & Frampton, C. (2015). Open inguinal hernia repair using polypropylene mesh: A patient reported survey of long-term outcomes. Journal of Current Surgery, 5(2), 165-170.
Farrell, M. R., Coogan, C., Hibbeln, J., Millikan, K., & Benson, J. (2014). Inguinal hernia containing a kidney with a duplicated system: An exceptionally rare case. International Journal of Urology, 21(3), 338-340.
Huang, G., Zheng, H., & Ao, Y. (2015). The study on perioperative nursing for the patients with inguinal hernia. Journal of Nursing, 4(2), 5-8.
Khatib, M., Hald, N., Brenton, H., Barakat, M. F., Sarker, S. K., Standfield, N.,… Bello, F. (2014). Validation of open inguinal hernia repair simulation model: A randomized controlled educational trial. The American Journal of Surgery, 208(2), 295-301.
Li, J., Ji, Z., & Li, Y. (2014). Comparison of laparoscopic versus open procedure in the treatment of recurrent inguinal hernia: A meta-analysis of the results. The American Journal of Surgery, 207(4), 602-612.
Ohene-Yeboah, M., Beard, J. H., Frimpong-Twumasi, B., Koranteng, A., & Mensah, S. (2016). Prevalence of inguinal hernia in adult men in the Ashanti region of Ghana. World Journal of Surgery, 40(4), 806-812.
Roy, S., Mondal, S. K., & Maitra, T. K. (2016). Laparoscopic repair of inguinal hernia: Early experience in a tertiary care hospital. Bangladesh Critical Care Journal, 4(1), 19-22.