Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
Document the patient’s main concerns related to the inguinal hernia. This may include:
A bulge or mass in the groin area, often more noticeable with standing, coughing, or straining.
Pain or discomfort in the groin, which may be dull, aching, or sharp.
A dragging or pulling sensation in the groin.
Incarceration (inability to reduce the hernia back into the abdomen) – a more serious complication causing severe pain and requiring urgent medical attention.
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset and duration of symptoms.
Size and characteristics of the bulge (present all the time, appears with certain activities).
Severity of pain (constant, intermittent, worsens with certain activities).
Any history of incarceration episodes.
Aggravating and alleviating factors (e.g., coughing, straining, heavy lifting).
既往史 (jì wàng shǐ) Past Medical History:
Prior surgeries (especially abdominal surgeries) that may increase risk of hernia development.
Underlying medical conditions that can contribute to increased abdominal pressure (e.g., chronic obstructive pulmonary disease, chronic constipation).
History of heavy lifting or strenuous activity.
家族史 (jiā zú shǐ) Family History:
Family history of inguinal hernias (increases susceptibility).
社会史 (shè huì shǐ) Social History:
Occupation involving heavy lifting or straining.
查体 (chá tǐ) Physical Examination:
Inspect and palpate the groin area for:
Presence of a bulge (reducible or irreducible)
Tenderness
Size and consistency of the bulge
Cough impulse: Ask the patient to cough while palpating the groin to assess if the bulge increases in size (suggests patency of the hernia opening).
Hernial orifice size assessment (performed by a healthcare professional during a hernia reduction maneuver).
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Laboratory tests are not routinely used for diagnosing inguinal hernias.
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Imaging studies are not typically necessary for diagnosing a straightforward inguinal hernia.
Ultrasound of the groin (may be used in some cases to differentiate between a hernia and a lymph node).
诊断 (zhěn duàn) Diagnosis:
Inguinal hernia.
Specify the type of hernia (e.g., inguinal, femoral).
Indicate if the hernia is reducible or irreducible.
Incarceration (if present).
分期 (fēn qī) Staging (optional):
Some classification systems categorize inguinal hernias based on severity (e.g., incarcerated, strangulated).
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Elective surgical repair is the definitive treatment for inguinal hernias.
For incarcerated hernias, urgent surgical intervention is necessary.
A truss (supportive device) may be used for temporary symptom relief in some cases, but it does not cure the hernia.
预后 (yù hòu) Prognosis:
Inguinal hernia repair surgery is a generally successful procedure with minimal complications.
Discuss potential risks and complications of surgery.
Recovery time varies depending on the type of repair and the patient’s condition.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of following post-operative instructions for optimal healing.
Risk factors for hernia recurrence and how to minimize them (e.g., maintaining a healthy weight, avoiding heavy lifting).
Signs and symptoms to watch for that may necessitate a return visit (e.g., worsening pain, fever, inability to pass stool or gas).