Umbilical hernia

Case Presentation

1. By BASIL WILSON 13Q0408 PHARM D IV th yr UMBILICAL HERNIA CASE PRESENTATION ON

2. Definition An umbilical hernia is a health condition where the abdominal wall behind the navel is damaged. It may cause the navel to bulge outwards — the bulge consisting of abdominal fat from the greater omentum or occasionally parts of the small intestine. The increased pressure near the umbilicus causes the umbilical hernia to bulge out.

3. Etiology There are three causes of umbilical hernia. Congenital Congenital umbilical hernia is a congenital malformation of the navel (umbilicus). Among adults, it is three times more common in women than in men. Acquired An acquired umbilical hernia directly results from increased intra-abdominal pressure caused by obesity, heavy lifting, a long history of coughing, or multiple pregnancies . Para umbilical Importantly this type of hernia must be distinguished from a para umbilical hernia, which occurs in adults and involves a defect in the midline near to the umbilicus .

4. Pathophysiology A hernia refers to when an internal body part pushes through a weak area of muscle or the surrounding tissue wall. Hernias often do not cause any symptoms, although a swelling may appear in the abdomen or groin. An umbilical hernia forms when part of the intestine or fatty tissue protrudes through an opening in the abdominal muscles near to the naval, causing the belly button to swell. This hernia can affect adults, possibly due to repeated abdominal strain. umbilical hernia rarely causes complications, although complications can occur if protruding abdominal tissue becomes trapped and is not possible to push back into the abdominal cavity. This “incarcerated” tissue receives a reduced supply of blood which can lead to tissue damage and umbilical pain. If the trapped tissue receives no blood supply at all (strangulation) gangrene may occur and infection may spread throughout the abdomen, which can be life threatening.

5. Signs and Symptoms The most common symptoms are: ● Bulge in the abdominal area that often increases with coughing or straining ● Pain or pressure at the hernia site ● Increasing sharp abdominal pain and vomiting

6. Demographic Details Name : ABC Age : 32 Sex : F I.P No : 27438 Dept. : Surgery Unit : B D.O.A : 09/08/2016 D.O.D : 21/08/2016

7. Reason For Admission c/o swelling over umbilical region -1.5 months Past Medical History H/o Lap Tubectomy 6 years back

8. Pt. was app alright 1.5 months back, then she developed swelling over umbilical region,insidious in onset,progressive in nature,initially of peanut size now progressive to present size of 2*2 cm.Swelling increase in size on coughing,straining and reducing partially on lying down on rest. H/o pain over abdomen H/o vomiting Expansile cough impulse positive,partially reduces on its own Scars of lap Tubectomy positive. History Of Present Illness

9. Family History Diet : Mixed Sleep : Not Disturbed Appetite : Good Habits : Nil

10. General Physical Examination Patient is moderately built and nourished PR : 72 bpm BP : 110/7 0 Afebrile

11. Systemic Examination CVS : S1S2 + , no murmur RS : NVBS + ,No added sounds CNS : Intact P/A : Everted,centrally placed 2*2 sized spherical shape

12. Laboratory Data RBC : 11.9 (12.0-16.0) WBC : 9200 (4500-10500cells/ uL ) Lymphocytes : 35 (20-40%) RBC : 4.01 (4.2-5.4 million/ uL ) Platelet : 248000 (150000 -450000 cells/cubic mm) Sodium : 137(135-147 mEq /L) Potassium : 4.3(3.5-5.2 mEq /L) Chlorides : 104(95-107 mEq /L) Sr. Urea: 21(10-50mg%) Sr.Creatinine: 0.9(0.6-1.2mg/dl) BT :3 mints(1-6 mins ) CT: 5 mins (5-10 mins )

13. Provisional Diagnosis : UMBILICAL HERNIA

14. TREATMENT CHART BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DAY 8 DAY 9 DAY10 DAY 11 INJ. ZONOMAX CEFOPERAZONE + SULBACTAM 1.5 GM IV 1-0-1 √ √ √ √ √ INJ.JUSTIN DICLOFENAC SODIUM 1 amp IV 1-0-1 √ √ √ √ √ √ INJ. EMSET ONDANSETRON 4 MG IV S-0-S √ √ √ √ √ TAB. PAN PANTOPRAZOLE 40 MG P/O 1-0-0 √ √ √ √ √ √ √ √ √ √ √ IVF 1 PINT RL 1 PINT DNS IV 70 ml/ Hr √ √ √ √ √ √ INJ.AMICIN AMIKACIN SULPHATE 1 GM IV 1-0-0 √ √ √ √

15. BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 DAY 6 DAY 7 DAY 8 DAY 9 DAY10 DAY 11 TAB . DOLO PARACETAMOL 650 MG P/O S-O-S √ √ √ √ √ √ TAB. LINCEF CEFIXIME + LINEZOLID 600 MG P/O 1-0-1 √ √ √ √ √ √ TAB. DOLWIN FORTE PARACETAMOL+ ACECLOFENAC+ SERRATIO PEPTIDASE 500 MG P/O 1-0-1 √ √ √ TAB. XYZAL LEVOCETIRIZINE 5 MG P/O 0-0-1 √

16. Daily Assesment Day 1 Afebrile PR : 80 bpm B.P : 120/80 mmHg No fresh complaints Pre operative Orders NBM from 10 PM Xylocaine test dose Take informed consent Inform OT staff Inj.TT 1 amp IM Shift to OT at 8:30 am Inj.zostum 1.5 gm IV Inj.Pan 40 mg IV Inj.Emset 4 mg IV

17. Post Operative Orders Foot end evaluation Inj.Zonomax 1.5 gm IV BD Tab. Pan 40 mg OD Inj.Justin IM BD Inj.Emset 4 mg IV SOS IVF 1 pint RL 1 pint DNS @70cc/ hr

18. Day 2 C/o pain over Sx site Afebrile B.P : 120/80 mmHg P.R : 72 bpm Dressing Intact Tenderness and Guarding around Sx site positive TREATMENT ADVICE Continue same treatment ADD- Inj.Amicin 1 gm IV

19. Day 3 No Fresh Complaints Continue Same Treatment Pain over Sx site Afebrile B.P : 110/70 P.R : 80 bpm Tenderness and Guarding around Sx site Day 4 No Fresh Complaints Continue Same Treatment Afebrile B.P : 110/80 P.R : 72 bpm Day 5 Continue Same Treatment No Fresh Complaints Afebrile B.P : 110/80 P.R : 72bpm

20. DAY 6 TREATMENT ADVICE C/o chills and rigors Dressings intact Inj.Justin 1 amp IM BD No soakage Tab.Pan 40 mg OD IVF Tab.Dolo 650 mg SOS Tab.Lincef 600mg BD DAY 7 No fresh complaints STOP-IVF Dressings intact Inj.Justin No soakage DAY 8 Continue Same Treatment No fresh complaints Dressings intact No soakage B.P -120/80 PR – 80 bpm

21. DAY 9 No fresh complaints Continue Same Treatment Dressings intact No soakage ADD- Tab.Dolowin forte BD B.P -120/80 PR – 80 bpm DAY 10 No fresh complaints Continue Same Treatment Surgical site healthy NO discharge B.P -120/80 PR – 80 bpm DAY 11 No fresh complaints Continue Same Treatment Surgical site healthy NO discharge ADD- Tab.Xyzal 5mg OD B.P -120/80 PR – 80 bpm

22. FINAL DIAGNOSIS UMBILICAL HERNIA

23. BRAND NAME GENERIC NAME DOSE ROUTE FREQUENCY DURATION T.Xyzal LEVOCETRIZINE 5 mg p/o 0-0-1 10 tabs T.PAN PANTOPRAZOLE 40 mg P/O 1-0-0 10 days Fudic BNF cream BECLOMETHASONE+ FUSIDIC ACID 20 mg L/A 1-o-1 10 days T. A-Z MULTIVITAMIN + FOLIC ACID p/o OD 10 tabs T.Dolowin Forte PARACETAMOL+ ACECLOFENAC+ SERRATIOPEPTIDASE 500mg p/o 1-0-1 10 days Discharge Medication Review after 10 days to OPD

24. PHARMACEUTICAL CARE PLAN Subjective Evidence c/o swelling over umbilical region since 1.5 months c/o pain over abdomen Expansile cough impulse positive Objective Evidence Hb : 11.9 (12-16) RBC : 4.01 (4.2-5.4million/ uL ) WBC :9200(4500-10500 cells /UL)

25. Assesment Based on the Subjective and Objective evidences , it is assessed that the patient is suffering from UMBILICAL HERNIA

26. Plan Treatment Goals To reduce swelling over umbilical region To perform the surgery successfully To improve patients health status To prevent post-operative infections To reduce abdominal pain To stop vomiting

27. Surgery done successfully Reduced abdominal pain Vomiting stops

28. No drug related problems identified in this case.

29. Patient Counselling About disease An umbilical hernia is a health condition where the abdominal wall behind the navel is damaged. It may cause the navel to bulge outwards — the bulge consisting of abdominal fat from the greater omentum or occasionally parts of the small intestine.

30. About Drugs Pantoprazole should be taken 1 hour before meals.Swallow whole,do not chew/crush. Cefoperazone is given to prevent the surgical infections that can be occur post surgery.

31. Life Style Modification Getting regular exercise is an important safeguard as muscles that are well toned and strong are less likely to rupture. Maintain a healthy weight. Being overweight strains the body and can also dangerously stretch the peritoneum - the abdominal lining and is a risk factor for developing hernias and many other physical problems. Don't strain your muscles. Weight lifters, football players, and golfers frequently strain and can tear the muscles making them more prone to hernias. If you play any such sports ensure that adequate warm up is practised before starting the game.

32. Be careful when lifting heavy objects. Lift with your knees rather than your back, and don't attempt to move anything too heavy for one person to manage. Quit smoking . Smokers often are prone to persistent cough, which can increase the risk for herniation .. In addition it increases the risk for serious diseases such as cancer, emphysema and heart disease. Get plenty of fibre . Regular bowel movements will prevent undue straining. Fresh fruits and vegetables and whole grains are good for overall health. They're also packed with fibre that can help prevent constipation.

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