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Apr 3, 2024

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Family Medicine 27: 17-year-old male with groin pain . DOMAIN: HISTORY 1a) Do you have any history of STI/STDs? Have you ever had any testicular trauma or any injuries in the past? 1b) These additional questions would be asked in order to learn more about the patient's condition. The patient takes pleasure in playing a range of sports. He is therefore more likely to experience trauma-related disorders when playing. A player may sustain trauma if they fall, get struck by something, or come into touch with another player. Furthermore, I would like to know if he has ever suffered a testicular injury, regardless of whether it was connected to sports. One of the many things that could cause groin pain is damage to the testicles. People who play sports run the risk of suffering from a variety of injuries. Male athletes are susceptible not just to musculoskeletal issues but also to testicular injuries. These problems might vary from indolent testicular tumors to an immediate emergency like testicular torsion (Horiike et al., 2021) . On the other hand, epididymitis may manifest gradually. Given that STIs may cause the patient pain, I would ask about their existence or any prior history of them. Some STIs or STDs can be asymptomatic until they worsen and start affecting the patient. 1c) These extra questions might help determine the underlying cause of the patient's symptoms. These questions can help rule out other possible explanations for the patient's symptoms. DOMAIN: PHYSICAL EXAM For each system examined in this case; 2a) The physician verified that everything was operating as it should. Investigating the patient's problems further is another goal of the evaluation. The examination may also reveal disease processes and provide an explanation for the patient's symptoms. The assessment went as followed: Vital signs: · Heart rate: 90 beats/minute Temperature: 98.7 Fahrenheit · Respiratory rate: 14 breaths/minute · Blood pressure: 130/82 mmHg · Pain index 10/10 General: Strong male experiencing moderate to severe pain.

Head, ears, eyes, nose, and throat (HEENT): No conjunctival pallor or icterus. Cardiac: No murmurs, gallops, or pleural rubs. Normal S1 and S2, Regular. Lungs: Bilaterally clear to auscultation. Abdomen: No bloating. Constant rumblings of the gut. There is no sensitivity on rebound. No masses or hepatomegaly can be felt. Back: No spine tenderness or costovertebral angle. Extremities: Pedal and Femoral pulses are equal and strong. Genitourinary: His genitals inspection reveals an erythematous and swollen right scrotum. There are no palpable lumps in his right testicle, which is enlarged and incredibly sensitive. There is no decrease in pain upon elevating the testis (negative Prehn sign). Both the testicles and the left scrotum are healthy. The contents of the scrotum and the epididymis were normal. There is no transillumination of the scrotum. The left side has a cremasteric reflex, while the right side does not. Hernias, inguinal lymphadenopathy, or penile discharge are absent. 2b) During the examination, abnormalities in the patient's genitourinary system were found. On his right side, the patient had a big, erythematous scrotum. He had an edematous, painful right testicle with no evidence of malignancy. Furthermore, there was no right cremasteric reflex. 2c) Aside from the genitourinary abnormalities, patient was was normotensive with no other abnormalities in any other system. 2d) A penlight, gloves, sphygmomanometer, ophthalmoscope, scale, and thermometer will be utilized as diagnostic tools. DOMAIN: ASSESSMENT (Medical Diagnosis) Discuss the pathophysiology of the: 3a) N44.0 Torsion of testis: A serious ailment brought on by the spermatic cord twisting, which contains the blood arteries supplying the testis and its surrounding tissues. Acute testicular discomfort is the presenting symptom. Testicular necrosis and tissue loss will result if prompt medical attention is not given. the spermatic cord twisting as a result of anatomical anomaly that caused the testis to hang freely in the scrotum (Schick, S. M.,2023). Obstruction of venous return is the first symptom of testicular torsion. Testicular symptoms can vary in severity and length, ranging from edema to testicular pain and stopped arterial flow. If there is no blood supply to the testis for four to six hours, spermatogenesis can be lost forever (Sajjad et al., 2019). 3b) N45.1 Epididymitis : Inflammation of the epididymis, a structure that resembles a convoluted cord that is connected to the testis' posterior region. Inflammation of the penile organ (Sajjad et al., 2019). Clinical signs and symptoms include fever, pyuria, discomfort, enlarged epididymis, and swollen scrotum. It is typically associated with urinary tract infections, which most likely traveled to the epididymis via the spermatic cord lymphatics or the vas deferens. N44.03 Torsion of appendix testis: Compared to torsion of the testis, torsion of the testicular appendages, the appendix epididymis and appendix testis, occurs less frequently and is linked to lower morbidity. Located on the anterosuperior part of the testis, the appendix testis is a small

vestigial structure that is the embryonic remnant of the Müllerian duct (Horiike et al., 2021). usually affects younger patients, with the majority of cases happening in the seven to fourteen age range. Appears suddenly, is localized to the area of the appendix testis, and is accompanied by no tenderness in the other testicular regions. The pain is usually less intense than in testicular torsion. N45.2 Orchitis: An irritation of the testicles. It exhibits many of the symptoms of epididymitis, including fever, pyuria, discomfort, and enlarged scrotum (Horiike et al., 2021). It is typically associated with urinary tract infections, which most likely traveled through the vas deferens or the spermatic cord lymphatics to the epididymis and ultimately the testis. 3c) 'Not Applicable' DOMAIN: LABORATORY & DIAGNOSTIC TESTS Discuss the following: 4a) Complete Blood Count and Urinalysis with cultures 4b) Leukocytes and WBCs high levels in urine. 4c) The abnormal lab values would indicate that the patient has a bacterial infection. 4d) Based on the medical diagnosis, I would want an ultrasound to confirm the diagnosis. After a physical examination, ultrasound is the main diagnostic tool for this diagnosis. Testicular torsion ultrasound has a sensitivity of about 93% and a specificity of 100% (Schick, S. M.,2023). References Horiike, M., Yokoyama, S., Yokoyama, K., & Yoshida, A. (2021). Testicular appendage torsion resulting in testicular ischemia and necrosis in a child. Journal of Pediatric Surgery Case Reports, 74, 102024. https://doi.org/10.1016/j.epsc.2021.102024 Sajjad, A., Akhtar, M. A., & Sajjad, Y. (2019). Pathologies of the male reproductive tract. Clinical Reproductive Science, 159- 176. https://doi.org/10.1002/9781118977231.ch13 Schick, S. M. (2023, June 12). Testicular torsion. National Center for Biotechnology Information. https://pubmed.ncbi.nlm.nih.gov/28846325/

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