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NBME 24 Answers

nbme24/Block 4/Question#13 (27.5 difficulty score)
A 90-year-old man has a 1-week history of ...
Incarcerated inguinal herniaπŸ”

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sattanki  So as far as I understand, you don’t really get a bulging, defined abdominal mass with fecal impaction. Much more likely to see this with a hernia. +6  
xxabi  Fecal impaction can be palpated in the abdomen, since it'd be accumulating in the rectum and colon, not the groin. Hope that helps! +11  
pseudorosette  a little late but they also mention that the mass had bowel sounds hence it was an incarcerated bowel! :) +5  
waterloo  question said right groin, so idk, didn't think fecal impaction would be that low. + the bowel sounds made me think there is something at the groin that can make bowel sounds? --> Hernia. +  
thisshouldbefree  think in 3D. mass in right groin. in my head thats very low down below the belt line. i thought if its fecal impaction it would be on the left groin. next they hear bowel sounds over this mass in the right; if it was impaction right there i dont think youll be hearing anything, therefore the bowel loop is over there and is not impacted and thats what they hear. +  

 +1  upvote downvote
submitted by hungrybox(771),

(D) Fecal impaction: While this patient presents with some signs consistent with fecal impaction (inability to defecate for days or weeks, distended/tympanitic abdomen), fecal impaction typically presents with hard, impacted stools distending the rectum. Since the rectum is left sided, it's unlikely to present with a right-groin mass.

That's the explanation I came up with after reading the Amboss wiki

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submitted by yotsubato(778),
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yotsubato  Incarcerated hernia. If the contents of the hernia become trapped in the weak point in the abdominal wall, it can obstruct the bowel, leading to severe pain, nausea, vomiting, and the inability to have a bowel movement or pass gas. Like really? Why is he not in pain? +1  
medschul  I thought that inguinal hernias were reducible? +  
fahmed14  could be a femoral hernia as they are more likely to cause incarceration. They do, however, present more often in females. (FA 2019- 364) +1  
wowo  incarcerated, not strangulated, thus no pain as there's no serious tissue damage/ischemia. Incarcerated hernias may progress to strangulated in which case he would have pain Under section, "complications" +5