A 54-year-old woman is brought to the emergency department by her husband due to confusion… — USMLE Step 2 CK

A $54$ -year-old woman is brought to the emergency department by her husband due to confusion, fever, and repeated episodes of vomiting over the last $12$ hours. She has a history of major depressive disorder treated with citalopram, and migraine headaches for which she recently started taking sumatriptan. Her husband notes she complained of some right-sided pelvic pain yesterday but thought it was a muscle strain. Temperature is $39.1^\circ\text{C}$ ( $102.4^\circ\text{F}$ ), pulse is $128/\text{min}$ , respirations are $24/\text{min}$ , and blood pressure is $86/50 \text{ mm Hg}$ . She is visibly diaphoretic and agitated. Neurologic examination reveals normal muscle tone without clonus. Abdominal examination reveals a non-distended, soft abdomen with normal bowel sounds. However, careful examination of the groin reveals a $3\text{-cm}$ , firm, exquisitely tender, and violaceous mass located inferior to the right inguinal ligament and medial to the femoral artery pulse. Laboratory results reveal:

Leukocyte count: $19,200/\text{mm}^3$
Serum lactate: $5.4 \text{ mmol/L}$
Serum bicarbonate: $12 \text{ mEq/L}$

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

A
Computed tomography of the abdomen and pelvis
B
Insertion of a nasogastric tube and serial abdominal examinations
C
Administration of intravenous cyproheptadine
Emergent surgical explorationAnswer
E
Arterial blood gas analysis to assess acid-base status

Answer

The correct answer is emergent surgical exploration.

This patient presents with signs of distributive shock (hypotension, tachycardia, fever, elevated lactate) and a firm, violaceous, exquisitely tender groin mass. The anatomical location—inferior to the inguinal ligament and medial to the femoral artery—is the hallmark of a femoral hernia. The violaceous color and extreme tenderness, coupled with systemic toxicity and lactic acidosis, indicate that the herniated bowel segment has become strangulated (ischemic and necrotic). Because only the antimesenteric border of the bowel may be trapped (Richter's hernia), patients can present with a soft abdomen and normal bowel sounds, making the groin examination critical. Strangulated hernias are absolute surgical emergencies. When a patient is hemodynamically unstable with a clear clinical diagnosis of an ischemic surgical abdomen, the definitive treatment is emergent surgical exploration. Delaying for imaging or attempting medical management drastically increases mortality.

Step-by-Step Solution

Evaluate the patient's hemodynamic status and synthesize physical examination findings.

The patient is in distributive shock (hypotensive, tachycardic, high lactate) and possesses a firm, violaceous, tender groin mass.

To determine the severity of the condition and distinguish between a medical toxidrome and a surgical emergency.

Identify the precise anatomical location and clinical significance of the mass.

The mass is located inferior to the inguinal ligament and medial to the femoral artery, identifying it as a femoral hernia. The violaceous color indicates strangulation and ischemia.

Femoral hernias have the highest rate of incarceration and strangulation among all hernias, often presenting without classic signs of small bowel obstruction if only a portion of the bowel wall is trapped (Richter's hernia).

Determine the appropriate intervention for a strangulated hernia in an unstable patient.

Immediate operative exploration is indicated.

Signs of transmural ischemia and hemodynamic instability mandate immediate surgical source control without delaying for imaging or medical therapy.

Key Concept

Strangulated femoral hernias present as painful, erythematous or violaceous masses inferior to the inguinal ligament and require emergent surgical exploration, even when confounding medical histories are present.

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