INTERN REVIEW
Mr. John Doe, a 50-year-old nondiabetic male, hailing from Chawkbazar, CTG, presented to our ward on 3rd August 2024,
with the chief complaints of a Right sided groin and scrotal swelling for 1 year and a Left groin swelling for the past 3-4
months.
According to his statement he was relatively well until 1 year ago when he first noticed this swelling on the right
inguinoscrotal region which was initially smaller in size but later gradually increased In size over the months, and initially
spontaneously goes back to flat when he lies down but later on after it extended into the scrotal cavity, that he has to
manually reduce it inside. Much later on just 3-4 month back he also noticed another swelling, on the left groin confined
to inguinal region, which does not extend to the scrotum, which is smaller in size compared to the right side, which goes
back spontaneously when he lies flat. Both of these swellings were more prominent when he does strenuous activity or
when he lifts heavy. He denies any history of pain associated with it, or any history of it getting stuck, vomitus or
constipation, and bowel and bladder habit has been generally normal. He ignored these complaints for many months and
finally in July he decided to consult his local doctor who advised admission to CMCH for surgical intervention.
He has a 3-4 year history of smoking, 4 sticks per day on average, but claims he stopped it 1 year back. Patient denies any
history of chronic cough, weight loss or fever. Patient denies any previous history of surgeries. His profession often
involves heavy lifting and his family history is unremarkable.
On general examination, he is healthy looking, body build and nutritional status looks average, he is non-palor, non-
edematic, non-icteric, non-cyanotic and well hydrated. Onto his vital signs, at presentation, his blood pressure was 150/90
mmHg, which we observed for next 2 days or so, which remained elevated at 150-160 systolic and 90-100 diastolic, thus
we added Tab. Losartan 50 mg, OD, and alas BP reduced and maintained at 120-130 systolic and 80-90 diastolic. All his
other vitals remained within normal physiological limits at presentation till now. No accessible lymph nodes were palpable.
On local examination, on right inguinoscrotal region, a swelling is visualized extending into the bottom of the scrotum,
pyriform in shape, approximately 10x12 cm in size. On inspection, no skin changes were seen over the swelling and no
scar marks were seen. Visible expansile cough impulse was present. On palpation, local temperature of skin over swelling
is not raised, and it was soft and non-tender to touch. On palpation of scrotum, testes were palpable, normal in shape,
size and consistency. I could not get over the swelling, palpable expansile cough impulse was present, contents were
manually reducible and deep ring occlusion test was positive on right side. On left side, another swelling was seen, which
does not extend to scrotum, globular in shape, smaller compared to right sided swelling, approximately 6x8 cm in size. On
inspection, no skin changes were seen over the swelling and no scar marks were seen. Visible expansile cough impulse
was present. On palpation, local temperature of skin over swelling is not raised, and it was soft and non-tender to touch.
Palpable expansile cough impulse is present, there is no extension of swelling into scrotum, testes were palpable
separately and was normal in shape, size and consistency. Swelling reduces spontaneously when lying down and deep ring
occlusion test is negative on left side.
Per abdominal examination, abdomen is not distended, umbilicus centrally placed and inverted, no visible scar marks and
no other skin changes. On palpation, abdomen soft and non-tender, no guarding or rebound tenderness and no
organomegaly felt. Bowel sound is heard and normal in all quadrants.
Per digital rectal examination, no skin tags, fissures or hemorrhoids visualized. Anal tone is normal, no anal growths felt.
Prostate may be mildly enlarged in size. On withdrawal of the finger, it was stained with fecal matter and no blood was
seen.
Other evaluation of the systems revealed no abnormalities.
USG of Whole abdomen with attention to KUB region was done, which showed protrusion of abdominal contents with
enterocele thru right side, and protrusion with omentocele on left side seen. Mildly enlarged prostate was seen at 37 cc
but PVRV was 8 ml.
So my clinical diagnosis for this patient is, this is cases of:
