Presenting Complaint:

• Painful right groin swelling
  “I noticed this lump in my groin a few weeks ago, but it would come and go. Today it’s much bigger, and it’s really hurting. It won’t go back in like it did before.”

History of Presenting Complaint/Symptoms:

• Site: Right groin
  “It’s right here, in the crease where my thigh meets my body.”
• Onset: Initially intermittent swelling noted 3 weeks ago. Painful and irreducible since this morning.
  “It used to pop out when I coughed, but I could push it back in. Today, I woke up with it stuck out and painful.”
• Character: Sharp and pulling sensation
  “It feels like it’s tearing inside.”
• Radiation: Slightly to the right scrotum
  “Sometimes I feel it pull down into my testicle.”
• Associated Symptoms: Swelling, tenderness, nausea, no vomiting
  “I felt a bit sick earlier but haven’t actually vomited.”
• Timing: Constant pain for the past 6 hours.
• Aggravating Factors: Movement, standing, coughing.
  “When I cough or move around, it hurts more.”
• Relieving Factors: Tried lying down and pushing the lump in manually without success.
  “Usually lying down helps, but not this time.”
• Severity: 7/10
  “It’s quite bad now, about a seven out of ten.” 

• Impact on ADLs: Can’t walk comfortably or bend; pain is limiting mobility.
  “It’s difficult to walk normally or get in the car.”
• Impact on Work: Engineer, missed work today due to pain.

Systemic Symptoms:

• Nausea without vomiting
  “I felt sick earlier today but haven’t actually vomited.”
• No weight loss
• No abdominal distension
• No fever, night sweats or weight loss
• No urinary or bowel habit changes – no constipation, passing flatus
• No chest pain, SOB, palpitations, dizziness

Past Medical History:

• Appendicectomy age 15
  “Had my appendix out when I was a teenager.”
• Hypertension (diagnosed 6 years ago)
  “I take tablets for blood pressure.”

Drug History:

• Amlodipine 5 mg once daily
  “I’ve taken this for years. Never had any issues.”
• Occasional paracetamol for headaches

Allergies:

• Allergy to penicillin (rash and mild swelling)
  “I get a rash and a bit puffy if I take penicillin.”

Family History:

• Father: Hypertension and had surgery for an abdominal hernia in his 60s
  “Dad had something similar when he was older.”
• Mother: Type 2 diabetes
• No known cancers or connective tissue disorders in the family

Social History:

• Married, lives with wife and adult son
• Works as a mechanical engineer
• Independent of ADLs
• Non-smoker; ex-smoker (quit 10 years ago after 15 pack-years)
• Drinks 4–6 units of alcohol per week, mostly at weekends
  “I enjoy a few beers on Fridays.”
• No recent travel
• No recreational drug use

Ideas, Concerns, and Expectations:

Ideas:

• “I think it might be a hernia like my dad had.”

Concerns:

• “I’m worried it might burst or need emergency surgery.”
• “Is this dangerous? Could it damage my intestines?”

Expectations:

• “I want to know if I need surgery and how soon.”
• “Will I need to stay in hospital or go home today?”

Observations:

• Respirations: 18 breaths/min
• Oxygen Saturation: 98% on air
• Air or Oxygen: Air
• Blood Pressure: 146/88 mmHg
• Pulse: 94 beats/min
• Consciousness: Alert (A)
• Temperature: 37.5°C

NEWS Total Score: 1

General Inspection:

• Appears in moderate discomfort, holding right groin
• No obvious jaundice or pallor
• Alert and oriented
• Doesn’t appear systemically unwell

Abdomen + external genitalia and hernial orifices (patient lying flat, performed with chaperone present):

Author: IkeTheSloth. Public domain image. Wikimedia Commons.

Inspection:

• No distension
• Lanz scar seen in right iliac fossa from previous appendicectomy
• Right groin swelling visibly bulging

Palpation:

• Right inguinal region: firm, tender, non-reducible mass (~4 cm), found superior and medial to the pubic tubercle
• Cough impulse absent
• Localised tenderness with mild guarding
• No rebound tenderness or gross peritonism
• No organomegaly
• No other masses felt
• Abdomen otherwise soft

Percussion:

• Tympanic throughout
• No percussion tenderness
• No renal angle tenderness

Auscultation:

• Normal bowel sounds present
• No bruits

Other:

• No peripheral oedema
• Swelling doesn’t appear to extend into scrotum, testicular examination normal
• Femoral pulses present bilaterally

Choose EITHER viva questions OR patient communication questions:

Viva questions:

1. What is your working diagnosis and differentials?

• The most likely diagnosis here is incarcerated inguinal hernia. This is a groin lump found more commonly in men, located above and medial to the pubic tubercle. Because it is irreducible it is referred to as incarcerated. Incarcerated hernias may not have a cough impulse due to the neck becoming trapped, limiting communication with the abdominal cavity.
• A strangulated hernia tends to be more acute, painful with a more unwell patient. In this scenario, trapped contents within the hernia, such as bowel, become ischaemic and potentially necrotic. There may be signs of peritonism on examination.
• Femoral hernia is more common in women and located below and lateral to the pubic tubercle.
• Testicular torsion would typically present with extremely severe testicular pain and tenderness rather than a painful lump in the groin, along with absent cremasteric reflex.

Other differentials are listed below:

2. What is an inguinal hernia, and how does it differ from a femoral hernia?

• An inguinal hernia is a protrusion of abdominal contents through the inguinal canal, usually presenting as a lump in the groin, superior and medial to the pubic tubercle. It may be direct (through the posterior wall of the canal) or indirect (through the deep ring). Direct is more common in elderly men, whereas indirect is more common in paediatric populations due to a patent processus vaginalis.
• Risk factors include: Male sex, increasing age, increased abdominal pressure (chronic cough, heavy weightlifting, obesity), family history, connective tissue disorder (e.g. Ehlers-Danlos, Marfan).
• A femoral hernia occurs below the inguinal ligament, through the femoral canal. It is more common in women, and has a higher risk of strangulation due to the narrow neck of the femoral canal. It presents as a lump in the groin inferior and lateral to the pubic tubercle.

Inguinal hernia diagram. Author: National Institutes of Health. Public domain. Wikimedia Commons.

Sites of direct and indirect inguinal hernias and femoral hernias. Author: Dennis M. DePace, PhD. CC BY-SA 4.0. Wikimedia Commons.

Common hernia sites. Author: BruceBlaus. CC BY-SA 4.0. Wikimedia Commons.

3. What is a strangulated hernia and what are the clinical signs you would expect to see?

A strangulated hernia occurs when the trapped contents of the hernia, such as bowel or omentum, are compressed such that the blood supply is compromised, leading to ischaemia and eventually necrosis. This is a surgical emergency and needs CT imaging if the patient is stable, then urgent surgical exploration.

Features include:

• Severe, continuous pain over the hernia site out of proportion to clinical features
• Tender, irreducible mass
• Systemic features: fever, tachycardia, hypotension
• Skin changes overlying the hernia (redness, oedema)
• Possibly signs of bowel obstruction (vomiting, abdominal distension, constipation)
• Absent bowel sounds or peritonism in advanced cases with progressing ischaemia or perforation 

Strangulation is a surgical emergency due to the risk of ischaemia and necrosis of bowel.

4. What is the immediate management of an incarcerated inguinal hernia in the Emergency Department?

• Initial A-E assessment
• Attempt gentle reduction of the hernia initially, however avoid forceful reduction if challenging
• Keep nil by mouth (NBM), consider NG tube if vomiting profusely or obstructed
• IV access and fluids
• Analgesia and antiemetics
• Urgent surgical referral
• Baseline investigations: FBC, U&Es, CRP, LFTs, clotting, G&S, VBG for lactate
• Imaging (usually USS or CT if diagnosis uncertain), consider erect CXR if suspicion of perforation
• Prophylactic antibiotics may be required in accordance with local guidelines
• List and consent for possible emergency hernia repair due to risk of strangulation

5. How do NICE and CKS guidelines recommend managing asymptomatic versus symptomatic inguinal hernias?

Asymptomatic or minimally symptomatic hernias:

• Watchful waiting is reasonable in low-risk patients
• Elective repair can be offered if symptoms develop or patient prefers

Symptomatic hernias (pain, discomfort, affecting activities):

• Elective surgical repair (open or laparoscopic) is recommended 

Femoral or strangulated hernias:

• Urgent surgical repair required regardless of symptoms

Patient communication questions:

1. “Doctor, what exactly is a hernia, and how did I get it?”

Example Answer:
“A hernia is when part of your internal organs or tissue — often part of the bowel or fatty tissue — pushes through a weak spot in the abdominal wall, creating a lump. In your case, this is an inguinal hernia, which occurs in the groin area. It’s quite common and can happen due to things like straining, heavy lifting, chronic coughing, or even just ageing, as the abdominal muscles naturally weaken over time. Sometimes there’s no obvious cause.”

2. “Do I really need surgery, or can I just leave it alone?”

Example Answer:
“That’s a very reasonable question. In some cases, especially if the hernia is small and not causing symptoms, we can take a watchful waiting approach. But surgery is the only way to fix the hernia definitively. We usually recommend surgery if it’s causing pain, limiting your activities, or if there’s a risk of complications like strangulation — where the blood supply to the bowel is cut off. In your case, we can’t seem to put the hernia back in place (reduce), and because it is trapped there is a risk it will become strangulated, which would make you very unwell. I’d be happy to discuss the pros and cons of an operation with you so we can decide together what’s best in your case.”

(NICE and CKS both highlight the importance of shared decision-making based on risk, age, and patient preference.)

3. “What will the operation involve, and are there any risks I should know about?”

Example Answer:
“The operation is usually straightforward and involves pushing the hernia back in and reinforcing the abdominal wall — often using a mesh. It can be done via open surgery or keyhole (laparoscopic) surgery, depending on various factors. Like any operation, there are some risks, such as bleeding, infection, pain, or recurrence of the hernia. With mesh repairs, some people also report discomfort or a feeling of tightness, but serious complications are rare. I’ll make sure you’re fully informed before deciding.”

4. “How long will it take me to recover? I’m worried about missing work. Have you got any medical advice to help with this?”

Example Answer:
“That’s completely understandable. Most people recover well within 1–2 weeks after surgery and can return to light duties fairly quickly. If your job involves heavy lifting or strenuous activity, you might need to take 4–6 weeks off to avoid straining the repair. I’ll work with you to plan your recovery so it fits your lifestyle and job requirements.”

“In terms of the wound, you should keep it clean and dry, and come back to get it looked at if you think it is getting infected or becoming red and painful. Also, although the risk of recurrence is low with the repair, you should keep an eye out for any new lumps or pain, especially on straining. To minimise the risk of further hernias, it’s a good idea to maintain a healthy weight, and avoid smoking and straining where possible. You shouldn’t drive until you can perform an emergency stop, which may take a week or two after surgery.”