Hernias: Clinical

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Hernias: Clinical

USMLE® Step 2 questions

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USMLE® Step 2 style questions USMLE

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 A 32-year-old man comes to the office because of painless scrotal swelling for two months. He states that he first noticed the swelling in the shower, but thought that it would go away. There is no history of testicular trauma. Examination shows a hard nodule inseparable from the right testicle. A scrotal ultrasound shows a 3 cm (1.2 in) homogeneous hypoechoic mass arising within the right testicle as well. The left testicle shows no abnormalities. Laboratory studies show:

Which of the following is the most appropriate next step in management?


A hernia is when an organ protrudes or bulges out through the body wall that normally contains it.

So an abdominal wall hernia is when an organ protrudes through the abdominal wall, which is made up of a few layers.

The deepest layer is the visceral peritoneum, which covers many of the abdominal organs, and lines the peritoneal space.

That layer wraps around to form the parietal peritoneum.

Then moving outwards, there’s the extraperitoneal fat, the transversalis fascia, the muscle layer with the internal and external oblique and transversus abdominis aponeurosis, and a layer of fascia, which has different names in different regions.

Anything that increases the pressure of the abdominal cavity may result in a sac that forms in the abdominal wall through which organs may protrude.

The organ that’s usually involved in a hernia is the gastrointestinal tract, but it can also involve other organs like the omentum, the bladder, and even the ovary.

Abdominal hernias vary in size and location.

Small hernias can be asymptomatic or they can cause pain and create a small bulge that can worsen with increased abdominal pressure from coughing or straining.

Over time, hernias can grow and lead to bowel obstruction, causing severe pain, nausea, vomiting, or constipation.

Larger hernias can put pressure on the overlying skin, causing erythema and ulceration.

Generally speaking, there are four types of abdominal wall hernias - groin, ventral, pelvic, and flank hernias.


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