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You are an FY1 doing a placement in a GP surgery. Mr Ation, 81 year old man who presents to your surgery with pain in his groin. He has had COPD for the last 20 years. He also has hearing difficulties. He manages to care for himself and his wife without any help. Please take a history and perform the examination you feel is appropriate. Ensure that you address his concerns regarding this presentation.

You are Sid Ation, 81 year old gentleman who is very active for his age. You love to go walking and manage all the jobs at home with no problems. You care for your wife full time. She had a stroke 5 years ago. You don’t mind caring for her as it gives you something to do with your days. You don’t have any of your own children but your wife has 3 sons from her first marriage. One of them, Tom, lives nearby and visits daily. He is the one who made you come to the GP today. You are very hard of hearing and really struggle to hear the doctor. If the doctor asks you please tell them that the best way for them to make you hear is to look at you while they talk. If they do this then don’t make it too difficult for them. If they don’t look at you while talking to you then make it difficult as you cannot hear what the doctor is saying.

HPC: You have had a lump in your groin for many many years, possibly as many as 10. It has never bothered you before. You always used to be able to push the lump back in and it has never been painful. Over the last few weeks you have not been able to push the lump back in but you have not had any pain until yesterday evening. The pain has gradually got worse, you did not sleep very well and this morning the pain was so bad you could not help your wife get dressed. That’s when your step-son popped in with the morning paper and said you had to come to the GP. The pain is in your lower left abdomen, around the groin area. It’s starting to become a ‘stabby’ pain now and it’s rather painful to walk. The pain doesn’t really go anywhere else. You tried some paracetamol and a hot water bottle to make it better but it hasn’t really helped. If asked, you would give it an 8/10 now. You feel sick and have vomited once today, you think this is just from the pain. The vomit had food in it, no blood, you haven’t eaten all day. Opened bowels this morning. Normal bowel movement.

ICE: You would like some pain killers and reassurance. You could not possibly go into hospital and you don’t expect you would need to. If you went into hospital there would be no one to look after your wife.

PMH: COPD Arthritis, the wear and tear one.. seems to be in most joints these days
Diabetes, for what must be about 20 years now!

DH: No known drug allergies A blue inhaler, a brown inhaler and a purple one… you take them how you are meant to, you think Metformin

SH: You live with your wife, as her full time carer. You used to work in the pits (mines) and then you were a labourer, lots of heavy lifting on those building sites! You much preferred the pits and tried to stop them closing but there was nothing you could do! You have never smoked. If they ask, say you have been told the COPD is from working at the coal face. You drink a ‘totty’ of whiskey a night to help you get to sleep. You don’t have any pets. You have a flight of stairs in your house and 4 stair up to the front door. Your wife can’t get out now and you have had to move the bedroom downstairs where you have a shower and toilet. It’s a bit cramped in the front room with the bed, but not to worry, as long as you can stay together.

Please observe the student taking the history and performing the examination. Use the mark sheets below to help you see what they have done well and what they need to improve. They should perform a hernia examination. Please ask the student to briefly summarise the case, then list their differentials. Discussion topics: - Please define a hernia - What different types of hernia do you know - How would you initially investigate and manage this patient - What are the risk factors for hernias forming - How would you tell the difference between a direct and indirect hernia - What are the risks and potential complications of a hernia - What are the common complications of a hernia repair