A 36-year-old woman is brought to the emergency department 20 minutes after being involved in a high-speed motor vehicle collision. On arrival, she is unconscious. Her pulse is 140/min, respirations are 12/min and shallow, and blood pressure is 76/55 mm Hg. 0.9% saline infusion is begun. A focused assessment with sonography shows blood in the left upper quadrant of the abdomen. Her hemoglobin concentration is 7.6 g/dL and hematocrit is 22%. The surgeon decided to move the patient to the operating room for an emergent explorative laparotomy. Packed red blood cell transfusion is ordered prior to surgery. However, a friend of the patient asks for the transfusion to be held as the patient is a Jehovah's Witness. The patient has no advance directive and there is no documentation showing her refusal of blood transfusions. The patient's husband and children cannot be contacted. Which of the following is the most appropriate next best step in management?

Transfusion of packed red blood cells

Consult hospital ethics committee

Administer high-dose iron dextran

A 67-year-old woman is brought to the emergency department by her husband because of a 1-hour history of severe groin pain, nausea, and vomiting. She has had a groin swelling that worsens with standing, coughing, and straining for the past 3 months. Her pulse is 120/min. Examination shows pallor; there is swelling, erythema, and tenderness to palpation of the right groin that is centered below the inguinal ligament. The most likely cause of this patient's condition is entrapment of an organ between which of the following structures?

Lacunar ligament and femoral vein

Inferior epigastric artery and rectus sheath

Medial and median umbilical ligaments

Conjoint tendon and inguinal ligament

A 22-year-old man is brought to the emergency department by his friends 30 minutes after falling down a flight of stairs. His friends report that they were at a college party, where he drank large amounts of alcohol. He is aggressive and restless. Examination shows tenderness to palpation and swelling of his right lower leg. An x-ray of the right leg shows a lower tibial shaft fracture. The physician recommends overnight observation and surgery the following morning. The patient refuses the suggested treatment and requests immediate discharge. Otherwise, he says, he will call his lawyer and sue the entire medical staff involved in his care. Which of the following is the most appropriate response by the physician?

I understand that you want to go home, but I'll have to keep you here as long as you are intoxicated.

You can leave the hospital after signing a self-discharge against medical advice form.

If you don't consent to treatment, I'll be forced to obtain consent from your parents.

Have you ever felt you should cut down on your drinking?

I can't force you to stay here, but I'll have to inform your dean of this incident.

A 63-year-old man comes to the emergency department because of pain in his left groin for the past hour. The pain began soon after he returned from a walk. He describes it as 8 out of 10 in intensity and vomited once on the way to the hospital. He has had a swelling of the left groin for the past 2 months. He has chronic obstructive pulmonary disease and hypertension. Current medications include amlodipine, albuterol inhaler, and a salmeterol-fluticasone inhaler. He appears uncomfortable. His temperature is 37.4°C (99.3°F), pulse is 101/min, and blood pressure is 126/84 mm Hg. Examination shows a tender bulge on the left side above the inguinal ligament that extends into the left scrotum; lying down or applying external force does not reduce the swelling. Coughing does not make the swelling bulge further. There is no erythema. The abdomen is distended. Bowel sounds are hyperactive. Scattered rhonchi are heard throughout both lung fields. Which of the following is the most appropriate next step in management?

Surgical exploration of the testicle

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

"Can you tell me more about the symptoms you have been experiencing?"

"Does the diarrhea typically precede the constipation, or vice-versa?"

"Is the diarrhea foul-smelling?"

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

"Are the symptoms worse in the morning or at night?"

A 52-year-old man, with a history of alcoholism, presents with loss of appetite, abdominal pain, and fever for the past 24 hours. He says he consumed 12 beers and a bottle of vodka 2 days ago. He reports a 19-year history of alcoholism. His blood pressure is 100/70 mm Hg, pulse is 100/min, respirations are 20/min, and oxygen saturation is 99% on room air. Laboratory findings are significant for the following: Sodium 137 mEq/L Potassium 3.4 mEq/L Alanine aminotransferase (ALT) 230 U/L Aspartate aminotransferase (AST) 470 U/L Which of the following histopathologic findings would most likely be found on a liver biopsy of this patient?

Cytoplasmic inclusion bodies with keratin

Positive periodic acid-Schiff stain

Hernia complications for USMLE Step 2 CK: High-Yield Pathology Lessons

Hernia Complications - The Stuck & Squeezed Gut

Incarceration: Trapped hernia contents; non-reducible. Can cause bowel obstruction.
- Presents with pain, tenderness, and a firm mass.
- Symptoms: Nausea, vomiting, constipation.
Strangulation: Surgical emergency! Incarceration compromises blood flow, leading to ischemia and necrosis.
- Presents with severe, constant pain, erythema, and systemic signs (fever, tachycardia).
- Labs may show leukocytosis and ↑ lactate.

⭐ Femoral hernias have the highest risk of strangulation due to their narrow and rigid neck (the femoral ring).

Clinical Clues - Red Flags & Alarms

Incarceration: An acute, painful, and tender irreducible mass.
- Often accompanied by nausea, vomiting, and symptoms of bowel obstruction (abdominal distension, absolute constipation).
Strangulation (⚠️ Surgical Emergency): Features of incarceration plus signs of ischemia and systemic toxicity.
- Severe, persistent pain, often disproportionate to exam findings.
- Systemic signs: Fever (>38°C), tachycardia, hypotension.
- Overlying skin may show erythema, warmth, or edema.
- Peritoneal signs (rebound tenderness, guarding) suggest bowel perforation.

Common Types of Hernias and Anatomy

⭐ Femoral hernias carry the highest risk of strangulation. They present as a small bulge below the inguinal ligament and are more common in women.

Management - Code Red Intervention

Immediate surgical exploration is mandatory for suspected strangulation to prevent bowel necrosis and sepsis.
Pre-operative stabilization is critical:
- IV fluid resuscitation
- Broad-spectrum IV antibiotics (cover gram-negatives & anaerobes)
- NPO (Nil Per Os)
Gentle manual reduction may be attempted for incarceration without signs of strangulation. If unsuccessful, proceed to urgent surgery.

⭐ Femoral hernias have the highest rate of strangulation due to their narrow and rigid femoral ring.

High‑Yield Points - ⚡ Biggest Takeaways

Incarceration is an irreducible hernia without vascular compromise, often preceding strangulation.

Strangulation is a surgical emergency with compromised blood flow, leading to infarction and necrosis.

Small bowel obstruction is the most frequent complication, causing nausea, vomiting, and abdominal distension.

Femoral hernias carry the highest risk of strangulation due to their narrow, rigid femoral ring.

Vomiting, fever, and leukocytosis suggest a strangulated hernia requiring immediate surgery.

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