October 05, 2010

USMLE 1 Question 5

A 25 year old body builder presents to his physician with a swelling in the groin.He has never been to see a doctor before. On examination,the patient is afebrile, the mass is 3cm x 3cm. It can be reduced on gentle palpation. When asked to cough,an impulse is felt by the physician and a mass appears inferomedial to the external ring in the inguinal region.

The most likely diagnosis is

a) enlarged lymph node
b) ectopic testes
c) indirect inguinal hernia
d) saphena varix
e) direct inguinal hernia

The correct answer is E


Heavy lifting is more likely to result in a DIRECT hernia. Direct inguinal hernias are secondary to a developed weakness of the transversalis fascia in the floor of Hesselbach's triangle.

The sac is usually composed of a single layer, the peritoneum. It passes through or around the conjoint tendon to reach the superficial inguinal ring; thus it does not pass through the deep inguinal ring.

Some have suggested that these hernias are related to heriditary or acquired defects in collagen synthesis or turnover. Hernia and saphena varix can give a cough impulse, however the incidence of hernia is higher.

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