A 55-year-old male construction worker presented to the emergency department with pain in his groin, nausea, vomiting and fever. He reported a six-month history of a lump in his groin that was painful with exertion. On examination, he had an obvious, irreducible, firm lump above his inguinal ligament that was tender to touch and dusky in color, consistent with a strangulated inguinal hernia. His symptoms and examination findings indicated an urgent need for surgical referral and hernia repair.

1. Hernias
Samantha Harrison, MBBS 3, KCL

2. Mr S.H. (fictional patient)
55 year old construction worker
Presented to A&E reporting a pain in his groin. Looked sweaty and uncomfortable at
rest and had vomited into a kidney dish since being in A&E
HPC:
-Was lifting a heavy crate 6 months ago and since then has noticed a lump in his
groin
-Had felt nauseous since this afternoon
-Felt feverish from this morning
- Has been sick three times since this afternoon
-Pain: SOCRATES: left groin pain, started yesterday evening, is constant and aching
and getting worse, radiates down the groin, vomiting, nausea, fever, has been
painful for a while but only on exertion, gradual onset since yesterday evening, more
painful when lifting at work/during intercourse, severity: yesterday 5/10, today 7/10

3. PMH and Systemic Review
PMH:
• Type 2 diabetic – 6
years
• Hypertension – 10
years
• Central Obesity
• Previous MI 3 years ago
Systemic Review:
-No headaches or visual/hearing disturbances
-Joint pain in left knee
-No previous vomiting/nausea/dysphagia
-No change in bowel habit
-No contact with infectious individuals or recent
holiday
-No weight loss
-BMI – 27
Summary: 55 year old construction worker presented to A&E with a painful groin,
nausea, vomiting and fever with a six month history of a groin lump which is
painful on exertion. This patient is diabetic and hypertensive

4. Social Hx, Family Hx, Drug Hx
• Smoker – 20/day for forty years:
40 pack years
• Alcohol – 1 pint/day; 6 pints/day
on weekends
• Construction worker for 55 years,
stressful lately as considering
medical retirement due to his
knee pain.
FHx: Father and Uncle had
hernias.
Mother is still alive and a type
2 diabetic
Drug Hx:
-Metformin for 5 years
-Enalapril for 5 years
-Aspirin
-Allergic to penicillin – severe rash, struggles to breathe, had
penicillin as a child for tonsillectomy

5. Ddx and Examination
• Strangulated Inguinal
Hernia
• Obstructed Inguinal
Hernia
• Lymphogranuloma
Venereum
• Glandular fever
• Lymphoma
• Testicular Torsion
• Hydrocele
• General Examination: Feverish
and sweaty and in discomfort at
rest
• Obs: P:120, BP: 140/90, RR: 20,
Temp: 38.5C
• Cardiac Exam: HSI and II.
Unremarkable
• Resp Exam: Chest – clear,
• Abdo Exam: Insp: no scars,
Abdomen soft and non tender,
no organomegaly, no ascites, no
stigmata of chronic liver disease,
normal bowel sounds, no bruits

6. Examination contd.
• External genitalia exam: No
inguinal lymphadenopathy,
femoral pulse palpable, no
changes in scrotal
skin/scrotal swelling. Penis –
normal
• Hernial Orifices Exam:
Obvious left sided large lump
in above and medial to the
inguinal ligament that does
not extend into the scrotum
– Irreducible firm lump 2-3cm
diameter
– Dusky skin change on the
lump
– tenderness to touch
Investigations needed to clinch
diagnosis:
-Barium Swallow
Ix needed for management:
Mx:
Urgent surgical referral
Surgery – hernia repair often
requiring an area of bowel
resection
Further Management
Fluids, antibiotics following
surgery
Follow up appointments

7. DDx and Summary
• Strangulated inguinal
hernia
• Obstructed inguinal
hernia
Summary: 55 year old construction worker
presented to A&E with a painful groin, nausea,
vomiting and fever with a six month history of
a groin lump which is painful on exertion.
Groin lump is painful to touch and of dusky
colour. Abdominal examination was otherwise
unremarkable.