Aquifer Groin Pain

Essay Elements:

One to three pages of scholarly writing in paragraph format, not counting the title page or reference page

Brief introduction of the case

Identification of the main diagnosis with supporting rationale

• Identification of at least two additional differential diagnoses with brief rationale for why these were ruled out

Diagnostic plan with supporting rationale or references

• A specific treatment plan supported by recent clinical guidelines

Please refer to the rubric for point value and requirements. In general, these elements must be covered as per the rubric.

• 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 year

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.

• “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 can 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 reports no penile discharge.

You ask him if he would like to have his mother in the room while he is being examined. He tells you that he is fine without her being there.

HPI:

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.

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

1. No transillumination of the scrotum
2. 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.

DIFFERENTIAL DIAGNOSIS:Trauma (H), testicular torsion (F), epididymitis (A), and torsion of the testicular appendages (G) 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.

• Diagnosing Testicular TorsionColor 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.

Treatment of Testicular TorsionThere are two approaches to treating torsion of the testis.Nonsurgical approachManual detorsion of the torsed testis 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 approachThe 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.