Comprehensive New Patient Consultation

Thank you for referring the patient, who was seen today, 24 October 2023, for consultation.

Reason for Visit

45yo M presenting with a symptomatic right inguinal bulge.

History of Present Illness

Pt reports a 6-month Hx of a R groin bulge and intermittent dull ache (4/10 severity). Onset noticed after heavy lifting at work. Exacerbated by prolonged standing, heavy lifting, and straining; relieved by supine positioning and manual reduction. Denies N/V, obstipation, fever, or irreducible episodes. Tried supportive undergarments with minimal relief. Goal is definitive surgical repair to return to full work duties without discomfort.

Medical/Surgical History

• Essential HTN
• GERD
• Laparoscopic appendectomy (2012), uncomplicated
• ORIF left distal radius fracture (2018), uncomplicated

Medications

• Perindopril (Coversyl®) 4 mg PO daily (confirmed via Netcare)
• Pantoprazole (Pantoloc®) 40 mg PO daily
• Ibuprofen (Advil®) 400 mg PO PRN for groin discomfort

Allergies

• Penicillin (maculopapular rash)
• Latex: None

Social/Occupational History and Functional Inquiry

• Warehouse supervisor; requires regular lifting up to 25 kg. Enjoys recreational cycling.
• EtOH: 2–3 standard drinks/week. Tobacco: ex-smoker (quit 2015, 10 pack-year Hx). Recreational drugs: none.

Physical Examination

• BP 128/82 mmHg, HR 74 bpm, Temp 36.8 °C, BMI 26.4 kg/m²
• Abdomen soft, non-tender, non-distended. Well-healed laparoscopic scars. Easily reducible 3 x 3 cm right indirect inguinal hernia palpable above the inguinal ligament with positive cough impulse. No left-sided hernia or femoral hernia detected. Normal gait and hip ROM bilaterally.
• Distal neurovascular status intact; femoral pulses 2+ bilaterally, normal sensation in ilioinguinal and genitofemoral nerve distributions.

Investigations

• Groin US (10/10/2023): Fat-containing right inguinal hernia measuring 2.8 cm at the neck, reducible, no bowel loops identified.
• Labs (10/10/2023): Hb 148 g/L, WBC 6.2 x 10^9/L, Plt 240 x 10^9/L, Cr 82 µmol/L, eGFR > 60 mL/min.

Assessment & Plan

45yo M with a symptomatic, reducible right inguinal hernia. Differential of inguinal lymphadenopathy or femoral hernia excluded on exam and US. Booked for outpatient laparoscopic transabdominal preperitoneal (TAPP) right inguinal hernia repair with mesh fixation. Postop multimodal analgesia to include paracetamol (acetaminophen, Tylenol®) 1,000 mg PO QID, ibuprofen (Advil®) 400 mg PO TID, and tramadol (Ultram®) 50 mg PO q6h PRN. Advised to avoid heavy lifting (> 5 kg) prior to and for 4 weeks following surgery. Pre-admission clinic referral not required given low anaesthetic risk. Thank you for involving me in his care.

Additional Notes

Discussed natural history of inguinal hernias, including red-flag symptoms of incarceration/strangulation (severe pain, irreducibility, N/V, skin changes) warranting urgent ED presentation. Reviewed operative risks (bleeding, infection, seroma/hematoma, chronic groin pain, recurrence, visceral/vascular/cord structure injury, conversion to open); informed consent obtained and signed. Chaperone (RN Sarah Jenkins) present for the inguinal and genital examination.