SURGERY

Case Write Up No. ( 1 )

NAME: DIYANA FATIN ‘IZZATI BINTI

KAMARULZAMAN

LUC ID No: 1129120019494

Year: Y5B8

LECTURER: PROF. DR M. WALID HAMWI

A PROF. DR ALI CHYAD MARZOK

Date of submission: 2022 October 2022

PATIENT DATA:

Name : Harizan binti Abdullah

Age : 51 years old

Gender : Female

Race : Malay

Occupation : Housewife

Date of admission : 6/10/2022

Date of clerking : 13 / 10/ 2022

Ward : Ward 30

RN : HRPZ 827285

CHIEF COMPLAINT:

My patient, a 51 years old Malay lady, with a known case of breast cancer, presented with
painless breast lump on the right side of the breast since five years ago, was electively
admitted for mastectomy.

HISTORY OF PRESENTING ILLNESS:

My patient presented with sudden onset of painless breast lump on the right side of the breast
since five years ago in 2017 without history of trauma of laceration. Initially, the lump was
only about 2cm x 3cm in size which was described by the patient as big as 50 cents coin and
it gradually increased in size. But, she did not seek for any medication and treatment.

Since then, the condition of the breast was getting worse. The lump kept on increasing in size
and it was associated with redness around the surrounding skin and also an ulcer with
yellowish pus and bloody discharge. In 2020, which was three years later, the size of the
lump increased to about 5cm x 4 cm, or as big as tennis ball. My patient described that her
right breast felt hard with redness all around the breast. There was also an ulcer at the outer
upper quadrant of the breast that sized about 2cm x 3cm, with thick yellowish pus and also
bloody discharge that kept on increasing in amount. My patient then decided to come to the
hospital, and she was diagnosed with right breast invasive carcinoma (T4N2M0) after
mammogram and biopsy was done. Since then, she underwent chemotherapy treatment.

However, during her regular follow-up session last month on 25th September 2022, she was
told by the doctor that her CT TAP and mammogram showed right breast local infiltration
and also some axillary and supraclavicular nodal infiltrations, and mastectomy needed to be
done. In addition to that, her right breast was getting bigger and the lump increased to 7cm x
6cm. There was also redness and hardening of the surrounding area of breast. And, my
patient also noticed that that her nipple retracted inwards and there were blackening
discolorations around the edge of the ulceration. One week prior to admission, my patient
said that the discharge was getting worse and soaked one piece of her ‘kain sarong’ every
night.

My patient also claimed to lose weight about 8-9kg since 2020, together with loss of appetite
and feeling lethargic all the time. She claimed that she could not do her daily chores as before
such as cooking and washing dishes as she would feel tired easily.

Otherwise, there was no pain, no vomiting, no nausea, no

REVIEW OF SYSTEM:

General : Weakness, lethargy, weight and appetite loss. Otherwise, no

fever and no night sweats.

Cardiovascular system : No dyspnea, no palpitations, no orthopnea, no paroxysmal

nocturnal dyspnea, no chest pain, no ankle swelling and no
claudcation.

Respiratory system : No cough, no hemoptysis, no wheezing, no stridor, and no

hoarseness of voice.

Central nervous system : No muscle weakness, no numbness, no paralysis, no tremor,

no abnormal sensation and no loss of consciousness.

Gastrointestinal system : No constipation, no abdominal pain, no abdominal distension,

no dyspepsia, no flatulence, nausea and vomiting

Genitourinary system : No frequency, no urgency, no dysuria, no nocturia, no back

pain, no incontinence, and no changes in color and amount of
urine.

Musculoskeletal system : No muscle and bone pain, no joint pain and joint swelling.

PAST MEDICAL HISTORY:

My patient had no other known medical illness. No hypertension, and no diabetes mellitus.

SURGICAL HISTORY:

My patient underwent for chemoport insertion in 2020. Otherwise, no other surgical history.
DRUG HISTORY:

My patient was not on any drug prescription, except for her chemotherapy regime.

GYNAECOLOGICAL HISTORY:

She attained he menarche at 13 years old, regular menses, 28-29n days od menstrual
cycle with 11-13 dyas of menstruation with regular amount of flow and passage. Her
heaviest

ALLERGY HISTORY:

No known food and medication allergy.

FAMILY HISTORY:

Both of her parents had passed away, but she was unsure of their chronic illness.

She was the second child out of three siblings, with no similar malignancy noted in the family
however her eldest brother had brain tumor.

SOCIAL HISTORY:

She was a housewife, her husband works as food supplier. He is a non-smoker, non-alcoholic,
not drug abuser.

For her diet history, normally patient was taking approximately 2 meals per day with normal
diet full of protein and carbohydrates but apparently her appetite started to decrease since
2017 ; with only one meal per day. His height is 165 cm and weight is 76 kg, with BMI 27.9
kg/m2 slightly obese.

SUMMARY:

My patient, a 51 years old Malay lady, with a known history of breast cancer and had
underwent chemotherapy since 2020, presented with painless lump on the right side of the
breast that gradually increased in size since 5 years ago, and was also associated with
fungating ulcer, yellowish pus and bloody discharge, was electively admitted for mastectomy.
PHYSICAL EXAMINATION:

GENERAL INSPECTION:

On inspection, she looked well, alert and conscious, sitting comfortable, not in pain and not
in respiratory distress.

VITAL SIGN:

1. Pulse rate : 82 beat/minute, not tachycardic

2. Blood pressure : 108/75 mmHg, not hypertensive
3. Respiratory rate : 20/minute, not tachypneic
4. Temperature : 37°C, afebrile
5. SpO2 : 98% under room air, not hypoxic

GENERAL EXAMINATION AND SYSTEMIC EXAMINATION

Hand

Palms were pink and warm. Capillary refill time was less than 2 seconds. Otherwise, there
was no finger clubbing, peripheral cyanosis, koilonychia, leukonychia.

The radial pulse was regular, symmetrical with good volume. There was absent of collapsing
pulse, radio-radial delay and radio-femoral delay.

Head and Face

Upon the examination of eyes, the conjunctiva was pink and sclera was white. Otherwise,
there was no jaundice, no xanthelasma.

Upon the examination of mouth, good oral hygiene was good. Otherwise, no central cyanosis,
angular stomatitis noticed.

Upon the examination of face, there was no facial puffiness and no change in features.

Neck

There is no raised JVP, no cervical and supraclavicular lymphadenopathy and no tracheal

deviation. The carotid pulse is present with regular rhythm and good volume.

Chest

On inspection, there are no chest deformities and no surgical scars. The chest movement is
present and symmetrical.

On palpation, apex beat at 5th ICS at midclavicular line and absent of parasternal heave,
thrills. Patient presented with equal chest expansion bilaterally.
On percussion, normal resonant sound all over the chest.

On auscultation, the first and second heart sounds presents with no added sounds and no
murmur. Normal vesicular breath sound, there is no added sounds like inspiratory stridor,
rhonchi, crepitation, pleural rub. Vocal fremitus normal and equal in intensity.

Abdomen

On inspection, the abdomen is soft and not tender. There is visible transverse scar on right
iliac fossa from previous right hernioplasty measured 5-7 cm, well-healed, non-tender, not
hypertrophic and no keloid. There is also visible umbilical swelling measured 1cm x 2 cm,
non-tender, not warm and no skin changes. The umbilicus is centrally located and inverted
with the swelling surface is soft and smooth, not fixed to the skin with prominent margin and
positive cough impulse. Otherwise, there is no abdominal distension, abdominal masses and
visible pulsation.

On palpation, the abdomen is soft and non-tender. There is no hepatosplenomegaly. No

ballotable kidney.

Shifting dullness and fluid thrill is negative.

Bowel sounds is present.

Lower Limb

Pedal edema absent.

There is right inguinoscrotal swelling with probably bowel content as there is active
movement within the swelling. The swelling measured approximately 8cm x 8cm, dark-
purplish in color and non-tender, not warm. The swelling surface is irregular, smooth, not
fixed to the skin with prominent margin and positive cough impulse. It is reducible and able
to separate from testis. The transillumination test is negative. On the deep ring occlusion test,
the swelling did not reappear which occlusion test positive, suggest of indirect inguinal
hernia.
SPECIFIC EXAMINATION

Breast examination

On inspection, the breast looked asymmetrical, the right side of the breast appeared larger,
with an obvious lump at the outer lower quadrant of the breast, with size about 7cm x 8cm.
There was a fungating ulcer, sized 2cm x 3cm, at upper outer quadrant of the breast with
gangrenous discoloration around the ulceration border and also purulent yellowish and
bloody discharge. There were also erythematous discoloration all around the breast, skin
retraction, peau d’ orange and nipple retraction was noted. Otherwise, no nipple discharge
was seen.

On palpation, the breast was firm, warm, with palpable lump, size 7cm x 8 cm, at the lower
outer quadrant of the right breast.
SUMMARY:

My patient, a 56 years old Malay gentleman, underlying hypertension and end stage renal
failure on regular hemodialysis, with history of right hernioplasty for right inguinal hernia 25
years ago presented with left inguinoscrotal hernia for 2 years and umbilical hernia for 1 year
prior to admission which associated with intermittent groin tension pain, constipation,
abdominal pain and mild abdominal distension.

On physical examination, there is soft and smooth umbilical hernia measured 1cm x 2cm; and
reducible inguinoscrotal hernia measured 8cm x 8 cm with dark purplish in color associated
with positive deep occlusion test.

DIFFERENTIAL DIAGNOSIS:

Differential Diagnosis Points towards Points against

Femoral Hernia  Groin swelling with  Common in women than

tension pain men
 Exacerbated by  The hernia appears
coughing, strenuous below (below inguinal
physical activity ligament ) and lateral to
 If abdomen content is the pubic tubercle and
within hernia sac, will lies in upper leg
present with
 obstruction signs and  Zieman’s technique
symptoms like nausea bulging on saphenous
and vomiting, opening during cough
abdominal pain and impulse
distension

Varicocele  Scrotal swelling  Not exacerbated by

 Complaint of pain or coughing, strenuous
heaviness physical activity
 O/E the scrotum of  Cough impulse negative
affected side hangs but sometimes can be
lower than normal positive
 Has the feel of ‘a bag of
worms’

Epididymo-orchitis  Scrotal swelling  Sometimes with history

 Gradual onset of of UTI or STD s/s like
scrotal and groin pain dysuria, urethral
discharge, pyrexia
 Tenderness & induration
localized to epididymis
& spermatic cord
 Prehn’s sign +
 Not exacerbated by
coughing, strenuous
physical activity
 Cough impulse negative

PROVISIONAL DIAGNOSIS:

Left indirect inguinal hernia and umbilical hernia

INVESTIGATION:

The diagnosis of inguinal hernia is based on clinical history and physical examination and
patient often know their diagnosis because it is so common.

Umbilical Hernia

1. History and Physical Examination

Clinical manifestations include:

  The bulge is typically slightly to one side of the umbilical depression, creating a
crescent-shaped appearance to umbilicus
 Complaint of pain due to tissue tension or symptoms of intermittent bowel obstruction
 Cough impulse +

Inguinal Hernia

1. History and Physical Examination

Clinical manifestations include:

 A bulge in groin area which some will complain of pain that gets worse with
coughing and physical activity
 Burning or pinching sensation in groin; feeling of pressure and a pulling sensation
 Sometimes sensation radiate into scrotum or down the leg
 Sometimes present with obstructive symptoms caused by strangulation of hernia sac
contents such as abdominal pain, abdominal distension and constipation
 Usually reducible presenting as intermittent swelling, often reduce on lying and
reappear on standing

Physical examination:

 Inspection best is during standing, there is asymmetrical in groin or scrotum

 Palpation to detect the presence of hernia and reduce the hernia. Usually reducible,
lying above and lateral to pubic tubercle with positive cough impulse
 Deep ring occlusion test
a) Lie down and ask the patient to reduce the swelling.
b) Locate the deep inguinal ring and identify the pubic tubercle (from umbilicus
go vertically downwards to locate pubic symphysis, the first bony prominence
lateral to pubic symphysis is the pubic tubercle)
c) Locate the midpoint of inguinal ligament (between ASIS and pubic tubercle).
The deep inguinal ring is located 1 cm above this point. OR the deep inguinal
ring is at the mid-inguinal point (between ASIS and pubic symphysis).
d) Occlude the deep inguinal ring with one finger then ask patient to cough.
Inspect and feel whether the swelling reappears.
e) If reappears medial to this point: direct inguinal hernia
f) If not: indirect inguinal hernia
g) Examine the opposite side
 Zieman’s test
a) Place index finger on deep inguinal ring; Middle finger on superficial inguinal
ring; Ring finger above saphenous opening
b) Cough
c) Indirect hernia: impulse felt on index finger
d) Direct hernia: no impulse felt or impulse felt on middle finger
e) Femoral hernia: impulse felt on ring finger
 2. Other investigations
Most cases require no diagnostic tests but ultrasonography, CT and MRI occasionally
used. A herniogram involves the injection of contrast into peritoneal cavity followed
by screening which shows the presence of a sac or asymmetrical bulging of inguinal
anatomy

FINAL DIAGNOSIS:

Left indirect inguinal hernia and umbilical hernia

MANAGEMENT:

The idea of hernia repair: open the inguinal canal → free the hernia sac from spermatic cord
→reduce its contents → excise the hernia sac → transfix the neck of hernia. There are few
important terms:

a) Herniotomy
- Transfixation of deep inguinal ring (DIR) + excision of excessive hernia sac
- Treatment of choice for children or infants (<15 years old)
b) Herniorrhaphy (Open Suture Repair)
- 15-35 years old
- Repair of posterior wall
- Can be done by Bassini or shouldice method
- Modified Bassini method: involves approximation of conjoined tendon with
inguinal ligament using non-absorbable suture
- Shouldice: involves transverse division of fascia transversalis with double
breasting of the loose fascia in two layers + repair of conjoined tendon in two
layers
- Indications of herniorrhaphy: used during emergency when hernia has
strangulated → mesh (hernioplasty) is contraindicated due to high risk of
contamination (in view of dead bowel)
c) Hernioplasty (Open Flat Mesh Repair)
- >35 years old
- Repair of the posterior wall by mesh, behind spermatic cord, and is split to wrap
around the spermatic cord at the deep inguinal ring. Loose sutures hold the mesh
to the inguinal ligament and conjoint tendon.
- Lichtenstein tension-free repair, simple, flat polypropylene mesh repair
d) Laparoscopic Inguinal Hernia Repair
- Totally extraperitoneal (TEP) and Transabdominal Preperitoneal (TAPP)
- In both, aim is to reduce the hernia & hernia sac within abdomen, and place a
mesh just deep to the abdominal wall, extending across midline into retropubic
 space and 5cm lateral to the deep inguinal ring. The mesh covers Hasselbach’s
triangle, the deep inguinal ring and femoral canal.
- In TEP, able to create space just deep to the abdominal muscles without entering
the peritoneal cavity.
- In TAPP, need to enter the peritoneal cavity then incises the peritoneum above the
hernia defects, and reflects it away from the muscles, essentially entering the same
space as in TEP. Once the hernia has been reduced, an identical mesh is inserted
and the peritoneum closed over the mesh.

DISCUSSION: