Posted: November 28th, 2022

Andrew is a 17-year-old Caucasian male

Case Analysis Tool Worksheet
Student’s Name: Case ID: _AQ_27
I. Epidemiology/Patient Profile
Andrew is a 17-year-old Caucasian male who has been seen routinely at the clinic since birth presents with his mother with severe right groin and scrotal pain that has persisted for the past four hours. He also complains of nausea but no fever or vomiting. He is currently sexually active.
Sharp and constant right groin pain x4 hours Denies fever or vomiting
Radiating pain to right scrotum Sexually active x1 year, uses condoms
Pain started after playing football Denies dysuria, urethral discharge, frequency
Swollen, tender, erythematous right scrotum Denies abdominal pain
10/10 pain scale No steroids, dietary supplements, no smoking
No palpable mass to right scrotum Nausea
No penile discharge, inguinal lymphadenopathy, or hernias Nothing has relieved the pain
Negative Prehn sign, absent blue dot sign Had similar pain a few months ago, relieved without any treatment
Absent cremasteric reflex on the right
No transillumination of the scrotum

II. Prioritized Cues from History and PE.
Tier 1 Tier 2 Tier 3

Andrew is a 17-year-old Caucasian sexually active male with a history of viral gastroenteritis, upper respiratory infection, appendectomy, and behavioral problems. Four hours ago, while playing football, he experienced a sudden onset of severe right groin pain radiating to the right scrotum, for which he now seeks medical attention. He reports that the pain was intermittent at initially but has been consistent and severe over the past couple of hours. On a scale from 0 to 10, he rates the pain as a 10 out of 10. Six to nine months ago, the patient experienced a similar incident that spontaneously resolved. He has accompanying nausea, although he denies vomiting and fever. or for which he is now seeking medical attention. He claims that the pain was intermittent at first but has become consistent and severe in the last few hours. He rates the pain as a 10 out of 10 on a scale of 0 to 10. Six to nine months ago, the patient had a similar incident that resolved spontaneously. He has nausea and vomiting, but he denies having a fever.
III. Problem Statement

IV. Differential Diagnosis
Leading dx: Testicular torsion (Kaplan, 2018)
History Finding(s) Physical Exam Finding(s)
Severe groin and scrotal pain Swollen, tender, erythematous right scrotum
Acute onset of severe pain Swollen, tender, right testicle without mass
Occurred after playing football 10/10 pain scale
Pain radiating from right groin to right scrotum Negative Prehn sign, absent blue dot sign
Nothing alleviates the pain Absent cremasteric reflex on the right
No past trauma to groin area No transillumination of the scrotum
Prior episode, resolved on its own No palpable mass to right scrotum
Sexually active male No penile discharge, inguinal lymphadenopathy, or hernias

Alternative dx: Acute Epididymitis (Singh, 2021)

History Finding(s) Physical Exam Finding(s)
Severe groin and scrotal pain Swollen, tender, erythematous right scrotum
Pain radiating from right groin to right scrotum Swollen, tender, right testicle without mass
Occurred after playing football 10/10 pain scale
Prior episode, resolved on its own Negative Prehn sign, absent blue dot sign
Nothing alleviates the pain Absent cremasteric reflex on the right
No past trauma to groin area No transillumination of the scrotum
Sexually active male No palpable mass to right scrotum
No penile discharge, inguinal lymphadenopathy, or hernias

Alternative dx: Hydrocele (Brenner & Ojo, 2020)

History Finding(s) Physical Exam Finding(s)
Physical discomfort No palpable mass to right scrotum
Swollen, tender, erythematous right scrotum

V. Explanation of Diagnostic Plan and Treatment Plan in prioritized order:
Diagnostic Plan Rationale
Doppler ultrasonography Ultrasonography for blood flow and scrotal imaging (Cash et al., 2020). If the diagnosis is uncertain and the pain is less severe, this test can confirm testicular torsion. If testicular torsion is present, intratesticular blood flow is diminished or absent, resulting in lower echogenicity relative to asymptomatic testis (Kaplan, 2018).
History and physical A history and physical examination suggestive of testicular torsion may necessitate rapid surgical exploration without further diagnostic tests (Kaplan, 2021). In this case, only a medical history and physical examination are necessary to confirm the diagnosis.
Urinalysis Normal in 90% of testicular torsion cases (Cash et al., 2020). If abnormal, it indicates another diagnosis (such as epididymitis or orchitis) (Kaplan, 2018).
Urine Culture
To rule out urinary tract infection and epididymitis as the cause of the scrotal symptoms (Schick & Sternard, 2020).

Treatment Plan Rationale
Surgical Intervention Urgent referral to urologist or emergency room. Torsion of the testis is a urologic emergency necessitating surgery (Cash et al., 2020). Testicular necrosis may develop if symptoms linger longer than four to six hours (Domino et al., 2020).
Monitoring Patients should be monitored for postoperative complications, including infection, and delayed complications such as testicular atrophy and infertility (Kaplan, 2018).
Follow-Up Follow- up with urologist as recommended post procedure (Cash et al., 2020)

I have adhered to the honor system: Yes
Student’s signature

References
Brenner, J. S., & Ojo, A. (2020). Causes of painless scrotal swelling in children and adolescents (A. B. Middleman, G. R. Fleisher, L. S. Baskin, & J. F. Wiley, Eds.). UpToDate. https://www.uptodate.com/contents/causes-of-painless-scrotal-swelling-in-children-and-adolescents
Cash, J. C., Glass, C. A., & Mullen, J. (2020). Family practice guidelines. Springer Publishing Company. https://doi.org/10.1891/9780826153425.0018b
Domino, F. J., Baldor, R. A., Berry, K., Golding, J., & Stephens, M. B. (2021). The 5-minute
clinical consult 2022. Lippincott Williams & Wilkins.
Kaplan, G. (2018). Testicular torsion. Epocrates Web.
https://online.epocrates.com/diseases/50611/Testicular-torsion/Guidelines/Highlights-Basics

Ogunyemi, O. I. (2020). Testicular torsion medication. Medscape. https://emedicine.medscape.com/article/2036003-medication
Schick, M. A., & Sternard, B. T. (2020). Testicular Torsion. PubMed. https://www.ncbi.nlm.nih.gov/books/NBK448199/
Singh, A. (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep.

70(4);1-187.https://online.epocrates.com/guidelines/586/Epididymitis-in-Adults-

Adolescents-2021-CDC-STI-Guidelines-epocrates-Guideline-Synopsis