If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 2 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series.
This month’s stumper
A 55-year-old man comes to the urgent care clinic because of groin pain. He describes the pain as intense, constant and dull. He also thinks he noticed a new bulge in his groin. Past medical history is significant for hypertension. There is no surgical history.
His temperature is 38 ºC (100.4 ºF), pulse is 98 beats a minute, respirations are 16 breaths per minute, and blood pressure is 138/80 mm Hg. Examination of the groin shows mild right-sided erythema, and a mildly tender mass can be felt when the examiner's finger is placed in the internal inguinal ring. The size and presence of the mass are unaffected by cough or strain. The remainder of the examination is otherwise unremarkable.
Which of the following is the most appropriate next step in the management of this patient?
A. Elective surgical repair.
B. Emergent puncture and drainage of the inguinal abscess.
C. Emergent surgical repair.
D. Reassurance, ice compresses and rest.
E. Ultrasonography of the mass.
The correct answer is C.
Kaplan Medical explains why
This febrile patient with a bulge in the groin that is erythematous, tender and does not change with increased intraabdominal pressure likely has an incarcerated inguinal hernia. Given the potential for bowel necrosis if it is not repaired in a timely fashion, emergent surgery is required. Therefore, is the single best answer choice.
Why the other answers are wrong
Choice A: Elective surgical repair is appropriate for hernias that are not incarcerated (that is, are easily reducible) to reduce the likelihood of incarceration or strangulation. Once a hernia is incarcerated, however, immediate surgical repair is necessary since the reduction of the hernia is not possible.
Choice B: Emergent puncture and drainage of the inguinal mass would be of use if this was an abscess. The patient's presentation and low fever make the diagnosis of an incarcerated hernia more likely than an abscess.
Choice D: Reassurance, ice compresses and rest are inappropriate. An incarcerated hernia can progress to small bowel obstruction or necrosis. Emergency surgery is necessary.
Choice E: Ultrasonography of the mass is not necessary as the physical examination clearly points toward a diagnosis of an incarcerated hernia.
Tips to remember
- An incarcerated hernia is a surgical emergency.
- Emergent surgical repair is essential to save an entrapped loop of bowel and, if the bowel is already necrotic, to remove it.
- Elective surgical repair is appropriate for hernias that are not incarcerated (that is, are easily reducible) to reduce the likelihood of incarceration or strangulation.
For more prep questions on USMLE Steps 1, 2 and 3, view other posts in this series.
The AMA and Kaplan have teamed up to support you in reaching your goal of passing the USMLE® or COMLEX-USA®. If you're looking for additional resources, Kaplan provides free access to tools for pre-clinical studies, including Kaplan’s Lecture Notes series, Integrated Vignettes, Shelf Prep and more.