Clinical case: Andrew, a 17-year-old male with right scrotal pain who was brought in by his mother

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Clinical case: Andrew, a 17-year-old male with right scrotal pain who was brought in by his mother

Clinical case:

Andrew, a 17-year-old male with right scrotal pain, who was brought in by his mother.

Andrew is a sexually active 17-year-old male who presents with a four-hour history of severe right groin pain with radiation to the right scrotum and associated nausea but no vomiting, fever, or urinary symptom. The patient reports a similar episode six to nine months ago that resolved spontaneously. Physical exam finds a swollen, erythematous right scrotum with an exquisitely tender right testicle, no masses, a negative Prehn sign, an absent cremasteric reflex on the right, absent blue dot sign, and no transillumination of the scrotum. The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes:

  1. Epidemiology and risk factors: 17-year-old well male, sexually active
  2. Key clinical findings about the present illness using qualifying adjectives and transformative language: acute onset four hours ago
  3. severe right groin pain with radiation to right scrotum
  • associated nausea but no vomiting, fever, or urinary symptoms
  • previous similar episode that resolved spontaneously
  • sexually active
  • swollen, erythematous right scrotum
  • exquisitely tender right testicle
  • no masses
  • negative Prehn sign
  • absent cremasteric reflex on the right
  • absent blue dot sign
  • no transillumination of the scrotum.

Problem list:

  1. Viral gastroenteritis at age 1 year
  2. Upper respiratory infection at age 5 years
  3. Appendectomy at age 12 years
  4. Behavior problems at age 14 year                                                                                                                                                   His mother said that He had similar pain few months ago and it was relieved without any treatment.

Physical Exam

Vital signs:

  • Temperature: 98.7 Fahrenheit
  • Heart rate: 90 beats/minute
  • Respiratory rate: 14 breaths/minute
  • Blood pressure: 130/82 mmHg
  • Weight: 145 lbs
  • Height: 5′ 9″
  • Body Mass Index: 21 kg/m2
  • Pain score: 10/10

General: Well-built male in moderate to severe discomfort.

Head, eyes, ears, nose and throat (HEENT): No conjunctival icterus or pallor.

Cardiac: Regular, Normal S1 and S2. No pleural rubs, murmurs, or gallops.

Lungs: Clear to auscultation bilaterally.

Abdomen: No distension. Active bowel sounds; No abdominal bruits. There is no guarding or rebound tenderness. No rigidity. No palpable masses or hepatosplenomegaly.

Back: No costovertebral angle or spine tenderness.

Extremities: Femoral and pedal pulses are strong and equal.

Genitourinary: Inspection of his genitals reveals a swollen and erythematous right scrotum. His right testicle is exquisitely tender, swollen and has no palpable masses. Elevation of the testis results in no reduction in pain (negative Prehn sign). The left scrotum and the testicle are normal. Epididymis and other scrotal contents were within normal limits. The scrotum does not transilluminate. Cremasteric reflex is present on the left side but absent on the right. There is no penile discharge, inguinal lymphadenopathy, or hernias.

Rectal: Nontender. Stool medium brown, heme negative. Prostate gland normal size, smooth and nontender.

The correct answers are A, B, C, G.

 

 

Main diagnosis are: Trauma, testicular torsion , epididymitis , and torsion of the testicular appendages are the four most likely diagnoses at this point.

Causes of groin pain:

  • Andrew displays all the classic physical findings for testicular torsion.
  • Andrew’s tenderness is not localized to the upper pole of the testis, making torsion of the testicular appendages less likely.
  • Absence of a cremasteric reflex, Prehn sign, and the lack of systemic signs of infection makes epididymitis unlikely in Andrew’s case.

Less Likely Diagnoses for Andrew’s Groin Pain:

  • Inguinal hernia (D): Andrew’s history of constant exquisite pain radiating to the scrotum does not fit with a diagnosis of inguinal hernia.
  • Hydrocele (E): A hydrocele is an unlikely diagnosis for Andrew as he is having acute tenderness and has no mass on exam.
  • Henoch-Schönlein purpura (HSP) (F): Andrew does not display any other symptoms of HSP, so this is an unlikely diagnosis for him at this point.
  • Testicular tumor (H): Although important to consider in any adolescent male with a scrotal enlargement, it is unlikely to be the cause for Andrew’s scrotal swelling because of the acuity of his symptoms and the absence of a mass.
  • Varicocele (I): This does not explain Andrew’s history of severe, acute pain.
  • Referred pain (J): This is not a likely diagnosis for Andrew at this time, since he has had a previous appendectomy and has no other systemic symptom.                                                                                                                                      Diagnosing Testicular Torsion: color Doppler ultrasonography can confirm testicular torsion if pain is less severe and the diagnosis is in question. If testicular torsion is present, intratesticular blood flow is either decreased or absent which appears as decreased echogenicity, as compared with the asymptomatic testis. In addition, the torsed testicle often appears enlarged.
  • Radionuclide scintigraphy is a diagnostic test that uses a radioisotope to visualize testicular blood flow. Patients with testicular torsion have decreased radiotracer in the ischemic testis, resulting in a photopenic lesion. Radionuclide scintigraphy vs color doppler ultrasonography: radionuclide scintigraphy procedure has 100% sensitivity, whereas Doppler ultrasonography only has a sensitivity of 88% and a specificity of 98% in detecting testicular torsion.Although scintigraphy may be more sensitive for testicular torsion, ultrasonography is faster and more readily available. This is a critical consideration in a condition that warrants a rapid diagnosis. Color Doppler ultrasonography and scintigraphy demonstrate no statistically significant difference in ability to demonstrate testicular torsion in boys with acute scrotal symptoms and indeterminate clinical presentations.                                                                                                                          Questions:

DOMAIN: HISTORY
1a) Identify two (2) additional questions that were not asked in the case study and should have been?
1b) Explain your rationale for asking these two additional questions.
1c) Describe what the two (2) additional questions might reveal about the patient’s health.

DOMAIN: PHYSICAL EXAM
For each system examined in this case;
2a) Explain the reason the provider examined each system.
2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal.
2c) Describe the normal findings for each system.
2d) Identify the various diagnostic instruments you would need to use to examine this patient.

DOMAIN: ASSESSMENT (Medical Diagnosis)
Discuss the pathophysiology of the:
3a) Diagnosis and,
3b) Each Differential Diagnosis
3c) If it is a Wellness, type ‘Not Applicable’

DOMAIN: LABORATORY & DIAGNOSTIC TESTS
Discuss the following:
4a) What labs should be ordered in the case?
4b) Discuss what lab results would be abnormal.
4c) Discuss what the abnormal lab values indicate.
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.