THE CASE STUDY QUESTIONS TO ANSWER What

THE CASE STUDY QUESTIONS TO ANSWER What is your list of appropriate differential diagnoses and why? What is the final diagnosis, and what assessment findings serve to support this? Discuss normal versus abnormal findings. Describe the pathophysiology that may lead up to the final diagnoses. What pharmacology treatment would you recommend and why? CASE STUDY INFO You are working with Dr. Nayar at an inner-city office adjacent to a small hospital. He has asked you to see Andrew, a 17-year-old male with right scrotal pain, who was brought in by his mother. Dr. Nayar tells you, “Andrew is the third child of Ms. Deborah Hailey, a single mother who works as a home attendant and is also a patient of mine. Before you go into the room, let’s look at the chart to review his history. I have known him since his birth and have been seeing him regularly for health care maintenance. His last visit was more than a year ago for a sports preparticipation physical. He has been a good student but had behavioral issues during his early teenage years. His mother really struggled with this as Andrew is quite different from her other two children. I provided some counseling to the family to help them adjust to and manage Andrew’s issues.” You take a look at the problem list in Andrew’s medical chart. Problem list: Viral gastroenteritis at age 1 year Upper respiratory infection at age 5 years Appendectomy at age 12 years Behavioral concerns at age 14 years You enter the exam room and find Andrew lying down looking very uncomfortable on the exam table. His mother, Ms. Hailey, is sitting next to her son, visibly worried and anxious. You introduce yourself and say, “I understand you are not feeling well. Would it be okay if I get some information about how you’re feeling? First, I would like to talk with you and your mom; then I would like to talk to you by yourself for a bit.” Andrew nods assent and you ask, “Can you tell me more about your pain?” You note that Andrew has already told you the location, quality, character, onset, and duration of his pain. You still have a few more questions to ask: “Do you have other concerns, like nausea, sweating, chills, vomiting, or fever?” “I feel very nauseated but I don’t have a fever or vomiting.” “How bad is the pain? On a scale from 1-10, with 1 being the slightest pain and 10 being the worst pain you have ever felt?” Andrew grunts, “It is the worst pain I have ever had. I would give a score of 10.” “Does anything make it worse? What happens if you . . .?” Andrew is getting annoyed with these multiple questions and interrupts, “It is already worse.” You reply, “I am very sorry for bothering you with all these questions. I need this information to find out what is going on with you. “Has anything made it better?” “Nothing is relieving the pain.” Ms. Hailey interjects, “He had similar pain a few months ago and it was relieved without any treatment.” She looks worried, “I hope he didn’t hurt himself while playing.” Andrew does not have increased urinary frequency, dysuria, urethral discharge, abdominal pain, or vomiting. Ms. Hailey says, “Could you tell me what is going on with Andrew?” You respond, “Well, I have to ask Andrew a few more questions and then examine him before we could make a reasonable assessment. Can you please excuse us for now and I will call you back as soon as we are done.” After obtaining information about his pain you want to inquire whether he is sexually active. He tells you he has one partner and uses condoms most of the time. He has no penile discharge. You then excuse yourself while Andrew undresses for the physical exam. You ask him if he would like to have his mother in the room while he is being examined. He tells you he would appreciate her being there. Before Mrs. Hailey leaves the room, you reassure Andrew by saying, “What you and I talk about is confidential, which means that I am not going to tell your mother anything we talk about unless I am worried that you are hurting yourself, hurting someone else, or someone is hurting you.” Mrs. Hailey leaves the room, and you begin your conversation: “You must be in eleventh grade. How is school going?” Andrew responds, “My schoolwork is going pretty well. I am getting As and Bs. Next month I am going to take the SAT.” “Do you have a romantic or sexual relationship with anyone?” Andrew reports that he has been sexually active with a single female partner for the past year and uses condoms sometimes for protection. “Have you ever been pressured to do something sexually that you didn’t want to do?” Andrew says he has not been subjected to any kind of pressure. On further questioning, he reports no past history of sexually transmitted diseases, urological/surgical procedures (aside from the appendectomy), or congenital anomalies. You ask him about his diet and he tells you that he maintains a healthy diet and feels satisfied with his current weight and shape. He adds, “I have never experimented with dietary supplements or steroids, although I know of some kids on the football team who have tried them.” During the conversation, Andrew notes, “Several of my friends have begun to smoke cigarettes, but I don’t like the taste of them.” While waiting for Andrew to undress, you quickly go to Dr. Nayar to update him on the case so far. Scrotal Exam Findings Cremasteric reflex Cremasteric reflex can be assessed by lightly stroking or pinching the superior medial aspect of the thigh. An intact cremasteric reflex causes brisk ipsilateral testicular retraction. Absence of the cremasteric reflex is a sensitive but nonspecific finding for testicular torsion. It can be absent on physical exam in normal testes. It should be assessed after inspection and before palpation of the testicles. Blue dot sign Tenderness limited to the upper pole of the testis suggests torsion of a testicular appendage, especially when a hard, tender nodule is palpable in this region. A small bluish discoloration known as the “blue dot sign”, may be visible through the skin in the upper pole. This sign is virtually pathognomonic for appendiceal torsion when tenderness is also present. Prehn sign A positive Prehn sign is pain that is relieved by the lifting of the testicle. If positive, it is more likely epididymitis than testicular torsion. Physical Exam Vital signs: Temperature is 37 °C (98.7 °F) Pulse is 90 beats/minute Respiratory rate is 14 breaths/minute Blood pressure is 130/82 mmHg Weight is 65.8 kg (145 lbs) Height is 175 cm (69 in) Body Mass Index is 21 kg/m2 Pain score is 10/10 General: 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; 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: 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. After completing the examination, you and Dr. Nayar excuse yourselves from the room in order to give Andrew a chance to put his clothes back on. Andrew is a 17-year-old male, sexually active with one female partner, 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. STATEMENT FINDINGS The ideal summary statement concisely highlights the most pertinent features without omitting any significant points. The summary statement above includes: Epidemiology and risk factors: 17-year-old well male, sexually active with a female partner Key clinical findings about the present illness using qualifying adjectives and descriptive language: Acute onset four hours ago 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 DIFFERENTIAL DIAGNOSES Epididymitis Testicular torsion Torsion of the testicular appendages Trauma Tumor Varicocele Hydrocele Inguinal hernia Differential of Groin Pain in an Adolescent Trauma Trauma can cause acute pain and swelling of the scrotum and its contents. Severity may range from mild contusion to severe testicular fracture or vascular disruption. Testicular torsion Testicular torsion, in which the testicle rotates around its vascular supply, is the most serious condition under consideration. Surgical emergency with a limited window of four to 12 hours (optimally within four to six hours) after the onset of pain to save the testicle by untwisting the spermatic cord. Timely diagnosis and treatment are vital for survival of the testis. Most common in neonates and post pubertal boys, with the majority of cases of testicular torsion occurring between the ages of 12-18 years. Relatively uncommon condition. Each year one in 4,000 men younger than 25 years gets it. Symptoms: scrotal, inguinal, or lower abdominal pain which usually begins abruptly. The pain is severe, and the patient appears uncomfortable. It can occur several hours after vigorous physical activity or minor testicular trauma and there may be associated nausea and vomiting. There may be prior similar episodes that might suggest intermittent testicular torsion. Symptoms: scrotal, inguinal, or lower abdominal pain which usually begins abruptly. The pain is severe, and the patient appears uncomfortable. It can occur several hours after vigorous physical activity or minor testicular trauma and there may be associated nausea and vomiting. There may be prior similar episodes that might suggest intermittent testicular torsion. Torsion of the testicular appendages Torsion of the testicular appendages (appendix epididymis and appendix testis) occurs less commonly and is associated with less morbidity than torsion of the testis. Appendix testis is a small vestigial structure (embryonic remnant of Mullerian duct) located on the anterosuperior aspect of the testis. Typically occurs in younger patients with most cases occurring between the ages of seven and 14 years. Presents with abrupt onset of pain that is typically less severe than in testicular torsion and is localized to the region of the appendix testis without any tenderness in the remaining areas of the testes. As in epididymitis, the patient may appear comfortable except when examined. Presence of a bluish discoloration in the scrotum at the upper pole of the testis (blue dot sign) is produced by testicular appendiceal torsion. Epididymitis Epididymitis is the most frequent cause of sudden scrotal pain in adults. Symptoms are typically slowly progressive over several days rather than abrupt. It is caused by bacterial infection of the epididymis, typically from a urinary tract or sexually-transmitted infection. The patient may appear comfortable except when examined. Severe swelling and exquisite pain are present on the involved side, often accompanied by high fever, rigors, and irritative voiding symptoms. Patients may have had preceding symptoms suggestive of a urinary tract infection or sexually transmitted disease. On exam, the scrotum is tender to palpation and edematous on the involved side. The cremasteric reflex is usually present, and the testis is in its normal location and position. Less Likely Diagnoses Inguinal hernia An inguinal hernia is a painless swelling in the inguinal region, which can be enhanced by maneuvers that raise intra-abdominal pressure, such as cough or Valsalva maneuver. The swelling becomes painful and tender when it is incarcerated. Indirect hernia: An indirect inguinal hernia develops as a result of a persistent process vaginalis. The inguinal canal begins in the intra-abdominal cavity at the internal inguinal ring, located approximately midway between the pubic symphysis and the anterior iliac spine. The canal courses down along the inguinal ligament to the external ring, located medial to the inferior epigastric arteries, subcutaneously, and slightly above the pubic tubercle. Contents of this hernia then follow the tract of the testicle down into the scrotal sac. Direct hernia: A direct inguinal hernia usually occurs due to a defect or weakness in the transversalis fascia area of the Hesselbach triangle. The triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoint tendon. Hydrocele A hydrocele is a cystic painless scrotal fluid collection and is the most common cause of painless scrotal swelling. Light should be visible through the scrotum when it is illuminated with a strong light source (positive transillumination). Hydroceles are generally asymptomatic unless associated with trauma or infection, although patients may report a slowly growing mass that causes a pulling or dragging sensation. Henoch-Schönlein purpura (HSP) Henoch-Schönlein purpura (HSP) is characterized by nonthrombocytopenic purpura, arthralgia, renal disease, abdominal pain, gastrointestinal bleeding, and occasionally scrotal pain. The onset of scrotal pain may be acute or insidious. In boys who lack other characteristic findings of HSP, sonography can usually distinguish HSP from testicular torsion. Treatment of HSP is supportive. Testicular tumor Testicular tumor presents as scrotal mass that is rarely accompanied by tenderness. The swelling is solid so should not transilluminate. Varicocele A varicocele is a collection of dilated and tortuous veins in the pampiniform plexus surrounding the spermatic cord in the scrotum. Varicoceles occur more commonly on the left side (85-95 percent) because the left spermatic vein enters the left renal vein at a 90-degree angle, whereas the right spermatic vein drains at a more obtuse angle directly into the inferior vena cava, facilitating more continuous flow. Varicocele is seen commonly in adult men but can be seen in adolescents; approximately 10-25 percent of adolescent boys have a varicocele. One-third of all males presenting to an infertility clinic have a varicocele. Varicocele is associated with infertility, although the precise mechanism by which this occurs has been the subject of considerable research and is currently thought to be due to increased testicular temperature. Patients with varicocele can be asymptomatic or may complain of a dull ache or fullness of the scrotum upon standing. A varicocele is mass-like and nontender or mildly tender to palpation on exam. Referred pain Boys who have the acute onset of scrotal pain without local inflammatory signs or a mass on examination may be suffering from referred pain to the scrotum. The scrotal pain is caused by three somatic nerves that travel to the scrotum: the genitofemoral, ilioinguinal, and posterior scrotal nerves. Retrocecal appendicitis is an important and a rare cause of referred scrotal pain in children and adolescents. Testicular torsion is final diagnosis Treatment of Testicular Torsion There are two approaches to treating torsion of the testes. Nonsurgical approach Manual detorsion of the torsed testes may be attempted, but it is usually difficult because of acute pain during the manipulation. This nonoperative distortion is not a substitute for surgical exploration. If the maneuver is successful, orchiopexy (surgical fixation of both testes to prevent retorsion) must still be performed. This should be done in the immediate future, preferably before the patient leaves the hospital. If full manual reduction of torsion cannot be performed or if there is doubt about the diagnosis and reason to suspect torsion, the scrotum must be explored. Surgical approach The testis must be unwound at operation and inspected for viability. If it is not viable, it should be removed. If the testis is viable then orchiopexy should be performed to prevent recurrence. Whether the affected testis is removed or conserved, the contralateral one should undergo orchiopexy as the risk of recurrence on the other side is otherwise high. SCIENCE HEALTH SCIENCE NURSING NURSING NSG 6023

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