I picked Doppler US because I thought it was a torsion and wanted to see if there would be absent blood flow. Now that I read the question again, it sounds more like an inguinal hernina - distended abdomen, decreased bowel sounds, diffuse tenderness to palpation, and superior scrotal swelling.

Initially I thought this was torsion but it is clearly talking about an incarcerated hernia as the boy is having significant abdominal pain. His bowel likely descended through the inguinal canal into the scrotum.

This sounds most likely to be a strangulated inguinal hernia. Perhaps it is made intentionally vague on torsion vs strangulated hernia so that we just say send them to the OR. However, wouldn't valsalva help differentiate between the two and be EXTREMELY quick and easy to perform? Why would you not take 5 seconds to do valsalva and then operate? If it said "surgical consult" then okay that's reasonable, but why would you do a procedure before this simple step? What am I missing here?

"When strangulation exists, the patient may present with bowel obstruction symptoms, including nausea, vomiting, and obstipation. If bowel ischemia is present, the patient will have severe pain and may present with sepsis (hypotension, tachycardia). Before palpating the abdominal wall, it is important to inspect the skin overlying the hernia visually. Any appearance of erythematous or dusky skin is a concern for a possible strangulated hernia. An emergent surgical consult should be obtained if skin changes are noted before attempting to reduce the hernia. When evaluating a patient for a hernia, it is essential to ask the patient to increase abdominal pressure via a Valsalva maneuver." https://www.ncbi.nlm.nih.gov/books/NBK555972/

I answered doppler u/s as that is how you diagnose testicular torsion. going straight to OR also makes sense

• Young child presenting with acute unilateral scrotal pain, nausea/vomiting, abdominal pain with involuntary guarding and a discolored, swollen hemiscrotum prompting concern for testicular torsion which should be taken directly to OR!
• Key idea: Surgical correction should be performed within 6 hours in order to salvage the affected testicle and importantly torsion often occurs in the setting of an inherited defect in the attachment of the testicle within the scrotum that will affect both testicles, so an orchiopexy should be performed both on the affected and unaffected side

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