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Histories

Inguinal Hernia History Station | MRCS Part B OSCE Revision

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Clinical Scenario

A 60-year-old man presents with a groin bulge that has been present for several months, appearing more prominent on standing or straining. He has come in now because it has started to ache enough to stop him finishing a shift at work.

Take a focused history from this patient and answer his and the examiners questions.

Related Differentials · Same Topic
The examiner could set this station around a different diagnosis within the same presenting complaint. Know how each would change the history.
Differential What would point to it in the history Management in brief
Inguinal hernia (this case)Reducible lump above and medial to the pubic tubercle, appears on standing or straining, positive cough impulse, dragging acheConservative: watchful waiting if small and minimally symptomatic; treat cough, constipation and weight; truss only if unfit. Surgical: open Lichtenstein mesh repair, or laparoscopic TEP/TAPP if bilateral or recurrent
Femoral herniaBelow and lateral to the pubic tubercle; higher strangulation riskSurgical: repair promptly even if asymptomatic because of the narrow, rigid neck — low (Lockwood) approach electively, high (McEvedy) if bowel may need resection
Groin abscessHot, red, tender, fluctuant, systemically unwellConservative: analgesia and antibiotics after cultures. Surgical: incision and drainage — but image first if there is any pulsatility, to avoid opening a pseudoaneurysm
Inguinal lymphadenopathyFirm discrete nodes, may have a source of infection/malignancy elsewhereConservative: find and treat the source — examine leg, perineum, anal canal and genitalia. Surgical: excision biopsy if persistent or suspicious of lymphoma or metastasis
Femoral pseudoaneurysmPulsatile, history of vascular access/injection, may have distal ischaemic signsNever incise. Duplex ultrasound and urgent vascular referral → ultrasound-guided compression or thrombin injection; open repair if infected, expanding or bleeding
Saphena varixSoft, disappears lying flat, cough impulse, associated varicose veinsConservative: reassurance and compression hosiery. Surgical: treat the underlying saphenofemoral incompetence — endovenous ablation or ligation

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