Question

A 65-year-old man presents with a bulge in his lower abdomen that has been present for 5-10 years. He can usually push this bulge back, but, about 4 hours earlier, it came out and could not be pushed back. There is an aching pain, but no nausea or vomiting. He admits to straining at the stool and getting up twice a night to urinate. He smokes 1 pack of cigarettes per day.

On physical examination, his vital signs are within normal limits; his pulse oxy is 91%. There is no jugular vein distention. Chest shows an increased A-P diameter, but breath sounds are good. Heart sounds are distant, and the rate and rhythm indicate normal sinus. There is an obvious bulge in the right lower quadrant extending into the right scrotal sac. The abdomen itself is soft, flat, and non-tender. Bowel sounds are slightly hyperactive; there are no rushes or tingling sounds. The bulge cannot be reduced and is tender. Bowel sounds are present within the mass. A somewhat enlarged, non-tender prostate is detected on rectal examination. Brown stool is obtained and is negative for blood. There is no abnormality on EKG. Chest x-ray shows some hyperinflation, but no infiltrates. An x-ray, flat and upright, of the abdomen shows some dilated small bowel extending into the right scrotal sac, but signs of obstruction are absent. Routine lab and urine studies are within normal limits. You start an intravenous line of 0.9 N/S to run at keep-open rate.

What would be the next logical course of action?

1 Order an immediate surgical consultation
2 Admit the patient to the observation unit for 4 hours and reassess
3 Sedate the patient well and attempt to manually reduce the mass
4 Pass an intestinal tube to reduce small bowel distention
5 Pass a Foley catheter to reduce bladder distention

Answer 1

The 65-year-old man's symptoms suggest he is experiencing an incarcerated hernia, thus the immediate course of action should be to order a surgical consultation.

Step-by-step explanation:

The 65-year-old man's clinical presentation is suggestive of an incarcerated hernia, given the history of a long-standing bulge in the lower abdomen that has suddenly become irreducible and is associated with tenderness, but no nausea, vomiting or signs of bowel obstruction. The presence of bowel sounds within the mass is indicative of entrapped bowel. The next logical course of action given this clinical scenario—of a hernia that cannot be reduced, is tender, but not obstructed—is to order an immediate surgical consultation (Option 1). Attempting manual reduction could lead to further complications if strangulation is present. The finding of an enlarged prostate on rectal examination may be indicative of benign prostatic hyperplasia (BPH), but it is less immediately concerning than the incarcerated hernia and does not necessitate immediate intervention in this context. The urgency of the hernia takes precedence over BPH or other findings at the moment.