Being judgmental right from the start will not be good in the long run Your

Being judgmental right from the start will not be

This preview shows page 160 - 162 out of 168 pages.

fell." Being judgmental right from the start will not be good in the long run. "Your husband does not hit you, does he?" (choice F) is a terrible question to ask her. It is leading, biased and she will try to give you the response that she thinks that you want to hear ("No, of course he doesn't hit me."). It is best to ask an open-ended question that allows her to tell you what happened. If this does not lead in the direction that you think is appropriate, you may ask, "does your husband ever hit you?", but this is not the best way to start out. A 31-year-old man undergoes an uneventful standard "open" repair of the hernia using "mesh plug" technique. As planned, he is discharged home on the same day of surgery. At his first postoperative visit, he complains of numbness over the upper aspect of his right thigh and the right side of the scrotum. Physical examination reveals an incision that is clean and dry without any evidence of infection. The right hemi-scrotum is moderately edematous and minimally tender, both testicles are normal to palpation. Motor sensation of his right lower extremity is completely intact. Sensory examination reveals decreased sensation to touch over the medial aspect of the thigh just below the inguinal ligament as well as over the right side of the scrotum. He is given instructions to observe this complaint and follow up in 2 weeks. The injured nerve is most likely the A. iliohypogastric B. ilioinguinal
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C. lateral femoral cutaneous D. obturator E. pudendal Explanation: The correct answer is B. Although it is now possible to perform inguinal hernia repairs laparoscopically, the traditional approach is through an incision over the inguinal canal. At the time of surgery, the inguinal canal is opened via sharp dissection through the external oblique aponeurosis, (the anterior wall of the inguinal canal). The ilioinguinal nerve is then encountered as it runs on the anterior aspect of the spermatic cord. If not properly identified at time of surgery, it is possible to transect the ilioinguinal nerve or to "trap" it during closure. If the ilioinguinal nerve is transected on "entrapped" in closure, the patient will complain of numbness over the nerve's distribution, (i.e. the upper medial aspect of the thigh and the anterior portion of the scrotum on the affected side). The iliohypogastric nerve (choice A) is derived from L1 (as is the ilioinguinal nerve), and runs with the ilioinguinal nerve as they both pierce the transversus abdominis muscle near the anterior superior iliac spine, and then pass through the internal and external oblique muscles to supply the skin of the suprapubic and inguinal regions and the abdominal musculature. The iliohypogastric sends a lateral branch to the skin of the gluteal region and then continues on , to pass through the superficial inguinal ring.
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