💢C Circulation

▪︎Check the patient’s heart rate & blood pressure

▪︎Assess temperature:
•the hands should be symmetrically warm, indicating adequate perfusion.

•Cool hands indicate poor peripheral perfusion (e.g. hypovolaemic shock).

•Pallor or mottled skin: commonly associated with hypovolaemic shock (e.g. haemorrhage)

▪︎Measure capillary refill time (CRT):
•should return to its normal colour in less than two seconds

▪︎Assess the patient’s radial and brachial pulse to assess rate, rhythm, volume and character

▪︎Auscultate the patient’s precordium to assess heart sounds, listening for evidence of murmurs.

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💢D Disability

▪︎Assess the patient’s level of consciousness by using the Glasgow Coma Scale (GCS).


▪︎Assess if the patient is orientated to person, place and time.


▪︎Assess the patient’s pupils:

•Assess the size and shape of the patient’s pupils.

•A normal pupil diameter ranges from two to five millimetres.

•Assess the pupils for both direct and consensual response to light using a pen torch.

•An oval-shaped pupil, sluggish reaction to light, “blown pupil” or deviated pupil suggests raised ICP or herniation.

•Bilaterally small or “pinpoint” pupils may be due to opioid toxicity.


▪︎Perform a neurological examination in patients who are able to follow commands, assessing:

•Cranial nerves

•Power in each limb

•Sensation in each limb

•Cerebellar function

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❇️Clinical features of raised ICP

▪︎Headache

▪︎Nausea and vomiting

▪︎Restlessness, agitation or drowsiness

▪︎Slow slurred speech

▪︎Papilloedema

▪︎Ipsilateral sluggish dilated pupil which then becomes fixed (“blown pupil”)

▪︎Cranial nerve palsy (e.g. CN III palsy with ‘down and out’ pupil)

▪︎Seizures

▪︎Reduced GCS

▪︎Abnormal respiratory pattern

▪︎Abnormal posturing, initially decorticate and then decerebrate

▪︎hypertension

▪︎bradycardia

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❇️Signs of skull fractures

▪︎CSF (clear fluid) leaking from nose or ear

▪︎Raccoon (Panda) eyes: bruising around the eyes (Fracture of the base of the skull)

▪︎Battle sign: bruising behind the ear over the mastoid process (Fracture in the posterior Cranial Fossa)

▪︎Haemotympanum: blood noted behind the tympanic membrane on otoscopy

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DDX Of Herina/Lump in the Groin

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■ General Causes & Features of Hernia

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Herina Examination (P1) ■

▪︎Assessing the groin lump to determine if it is a hernia or other pathology (e.g. testicular mass, lipoma, abscess, lymph node).

▪︎You should always assess both sides of the groin to avoid missing pathology.


▪︎Hernias of the groin typically present with the following clinical features:

•Single lump in the inguinal region

•Positive cough impulse (unless incarcerated)

•Soft on palpation

•Reducible (unless incarcerated)

•Unable to get above the lump during palpation

•Painless (unless incarcerated)

•Bowel sounds on auscultation (may be absent if incarcerated)



▪︎Not Herina :

•Multiple lumps (e.g.lymphadenopathy)

•Hard or nodular consistency (e.g. malignancy)

•Able to get above the lump during palpation (e.g. scrotal mass)

•Transillumination (hydrocoele)

•Bruit on auscultation (e.g. arteriovenous malformation)

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Herina Examination (P2) ■

🔹Hernia Should first be examined like any mass by

▪︎Inspection For
Site/Size/Shape/Over Skin/Surrounding Skin/Symmetry/Number

▪︎Palpation
•Superficial ➡️ Hotness/Tenderness
•Deep ➡️ Mobility/Reducibility/Consistency/Edge/Lobules

▪︎Cough Impulse
▪︎Occlusion Tests
▪︎3 Finger Test
▪︎Invagination Test
▪︎Trans illumination Test


▪︎While the patient is standing upright. Inspect the inguinal and femoral canals and the scrotum for any lumps or bulges.


▪︎Ask the patient to cough; look for an impulse over the femoral or inguinal canals and scrotum.


▪︎Inguinal hernias : located above and medial to the pubic tubercle (Direct/Indirect).


▪︎Femoral hernias : located below and lateral to the pubic tubercle.


■ Is it Direct or indirect inguinal Hernia ? (Ring occlusion test)👇

1.Ask the patient To lie Down

2.Locate the deep inguinal ring (midway between the anterior superior iliac spine and pubic tubercle).

3. Manually reduce the patient’s hernia by compressing it towards the deep inguinal ring starting at the inferior aspect of the hernia.

4. Once the hernia is reduced, apply pressure over the deep inguinal ring (close it) and ask the patient to cough.

• If reappears: Direct inguinal hernia 

• if not reappears : indirect inguinal hernia


▪︎Inguinal hernias can extend into the scrotum (indirect). So If a testicular swelling is noted or there is suspicion of an inguinal hernia, palpation of the scrotum should be performed : 👇

•When palpating an inguinal hernia in the scrotum you will not be able to get above the mass.


■Comparison

●Direct inguinal hernias:

•Mostly Occurs in adult males.

•caused by a weakness in the muscles of the abdominal wall (develops over time, or are due to straining or heavy lifting).

•Reappears after deep ring occlusion

•Not enter the Scrotum

•Reducible (Wide Neck)


●Indirect inguinal hernias:

•In children (Present at birth).

•caused by a birth defect in the abdominal wall (congenital).

•Enter the Scrotum (Pass with spermatic cord).

•Not reappears when close the deep ring

•Reducible (Wide Neck)


●Femoral Herina:

•weakness in the lower groin

•Mostly in females

•more prone than inguinal hernias to develop incarceration or strangulation

•Mostly not reducible (Narrow Neck)

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