Carson Meyer Ihuman Case Study

Testicular pain in men can be attributed to different causes. Below is a case study on Carson based on the Testicular pain that he has been having. The context is based on his experience over the past 2 hours.

Patient Information: Carson Meyer, 13-year-old, Caucasian, Male

Subjective:

CC (chief complaint): Testicular pain

HPI: Carson is a 13-year-old white male who presents today with complaints of left testicular pain that began 2 hours ago while playing basketball. He reports the pain is constant and rates it a 9/10. He states that it feels like her "got punched". There is mild swelling to the left testes.

Denies headache, dizziness, lightheadedness, or fever. He does report one episode of emesis on the way to the clinic, denies blood in emesis. Denies difficulty urinating or blood in urine. He denies injury and stated that the pain just started. He has not taken any medications or tried anything for pain relief. Denies abdominal pain or rectal pain.

Current meds: None

Allergies: NKDA

Pertinent PMHx: Carson is in general good health. Tympanostomy tubes as a young child otherwise no pertinent past medical history noted. He is up to date on immunizations and has regular check-ups.

Immunizations: Up to date for age.

Social hx: Lives in a single family home with his sister and both parents.

Fam Hx:

1. Mother, 48-years-old, healthy
2. Father, 49-years-old, HTN
3. Sister, 9-years-old, healthy

History Questions Asked:

1. How can I help you today?
2. Do you have any other symptoms or concerns we should discuss?
3. Do you have pain anywhere? If so, where?
4. What happened?
5. Have you been having fevers?
6. Have you noticed any swelling in any part of your body?
7. Where more precisely is the swelling?
8. When did the swelling start?
9. How severe is your swelling?
10. Do you have any difficulty urinating?
11. Do you have any pain in your genitals?
12. When did your genital pain start?
13. Do you have any pain/discomfort when you are at rest?
14. What does your genital pain feel like?
15. Where more precisely is your genital pain?
16. Is your genital pain superficial (on the surface)or deep inside?
17. Do you have testicular pain?
18. When did your testicular pain start?
19. What are the events surrounding the start of your testicular pain?
20. Does anything make your testicular pain better or worse?
21. Does your testicular pain vary with changes in position?
22. What does your testicular pain feel like?
23. Where more precisely is the pain in your testicles?
24. Is your testicular pain superficial (on the surface) or deep?
25. Does your testicular pain radiate some place else? Where?
26. How severe (1-10 scale) is your testicular pain?
27. Any change in your testicular pain since it began?
28. Does your testicular pain come and go?
29. Have you had any trauma to your genitals?
30. Do you have any pain in your groin?
31. Do you have any allergies?
32. Are you taking any prescription medications?
33. Are you taking any over-the-counter or herbal medications?
34. Can you swallow pills?
35. What childhood illnesses have you had?
36. When did you last urinate?
37. Do you have any pain in your abdomen?
38. Do you have any pain in your flanks?
39. Do you have nausea and/or vomiting?
40. What does your vomit look like?
41. When did your nausea and/or vomiting start?

ROS:

GENERAL: Alert and oriented.

HEENT: No runny nose, eye or ear discharge. No reports of conjunctivitis.

SKIN: No rashes, bruising or petechiae.
CARDIOVASCULAR: No history of murmurs, gallops or rubs. 

RESPIRATORY: Denies any SOB, cough, wheezing or difficulty breathing. 

GASTROINTESTINAL: Nausea and vomiting x1 within the last 2 hours.

GENITOURINARY: Denies any burning or trouble urinating. Denies incontinence or penile discharge.

NEUROLOGICAL: No history of seizures or headaches. 

MUSCULOSKELETAL: No recent trauma, weakness, or limping.

LYMPHATICS: Denies any lymph node enlargement.

HEMATOLOGIC: Denies anemia, unexplained bruising or bleeding.

PSYCHIATRIC: Denies any abnormal mental health issues.

ENDOCRINOLOGIC: Denies excessive sweating, thirst, or urination. Denies heat or cold intolerance.

ALLERGIES: Denies frequent or re-occurring infections or hives. Up to date on immunizations.

Physical exam:

Vital signs: P 87 and regular, T 97.6, Orally;RR 18 non-labored, 100% on room air; Wt: 120 lbs; Ht: 5’5”; BMI: 20.0

General: A/Ox4 well groomed, dressed appropriately, uncomfortable. Affect and behavior are appropriate.

HEENT: PERRLA, normal conjunctivae, mucous membranes pink and moist.

Chest/Lungs: Clear to auscultation in all lung fields.

Cardiovascular: Regular rate and rhythm. No murmur, rub, or gallops noted.
Differential Diagnoses:

1. Torsion of testicular appendage – It is the twisting of a small piece of tissue above a testicle.

The appendage does not have a function in the body, however it can become twisted and cause painband swelling that gets worse over time. The pain is generally gradualbonset. A positive blue dot sign, which is a tender nodule with blue discoloration on the upper pole of the testis, is often an indicator of torsion of the testicular appendage (Pomajzl & Leslie, 2021).

1. Epididymitis - Inflammation or infection of the epididymis. Pain and swelling typically develops gradually over the course of a few days, unlike testicular torsion, which is usually of sudden onset.
2. Urolithiasis - It is calculior stones that form the urinary tract. They are likely related to diet.

Generally, presents with abdominal and flank pain with UA often showing blood in the urine (Maaks, et al., 2020).

1. Appendicitis - Is the obstruction of the lumen of the appendix is the main cause of acute appendicitis. It typically occurs in adolescence or early adulthood and presents with RLQ pain, anorexia, diminished bowel sounds, fever, nausea, tachycardia, and a positive Rovsing, psoas, and obturator signs (Jones, Lopez, & Deppen,2021).
2. Inguinal hernia - Often there is a history of heavy lifting or previous surgery. There may detect a mass in the inguinal canal that may be nonreducible. Physical exam may be a normal lie and a normal cremasteric reflex (Tiemstra,& Kapoor,2008).

Additional laboratory and diagnostic tests: Scrotal Ultrasound – A scrotal US should be ordered as soon as possible. The hallmark sign of testicular torsion on ultrasonography is absence of testicular blood flow or whirlpool sign which is the twisting of the spermatic cord(Keays & Rosenberg, 2019). He should also have a urinalysis, CBC, CMP, and UA.

Consults: STAT Urology consult and STAT Surgical consult. - If surgery is not available within two hours, an attempt to de-torse the testicle manually will be made by urology. Surgery will still be warranted, however, manual detorsion can relieve pain and provide for a higher testicular salvage.

Therapeutic Modalities: patient will need to be made NPO.

Pharmacological – Initially analgesics will not be used because pain is a dependent symptom, and pain relief can mask the torsion or a worsening condition. Further, the sign of a successful manual detorsion is a painless scrotum. If the pain becomes severe IV morphine may be given. Post procedures - The patient will be educated to use ibuprofen 600mg every 6 to 8 hours for inflammation and pain control, not to exceed 3200mg in a 24-hour period.

Nonpharmacological management - After the successful detorsion urology and surgery may choose a bilateral orchiopexy to be performed on the patient to prevent future testicular torsions. This is a procedure that fixates the testicle to the inner scrotal wall, therefore avoiding the testicle's risk of becoming torsioned in the future. Additionally, external scrotal colling will be ordered to reduce the severity of injury while awaiting surgery (Feher& Bajory, 2016).

Health Promotion: The patient should be educated on the significance of being familiar with his anatomy, including his scrotum and testicles, so he will be prudent in knowing what is normal and not normal. He should be given information on how to properly do self-testicular exams. (Green, et al., 2020).

Patient education: He will need to avoid vigorous activities such as jogging, sports, PE class, or riding his bike for 1-2 weeks, as instructed by surgery. Additionally, the patient and parent will be educated to look for fever >101.4, redness, warmth, and white/yellow drainage coming from the surgical incision as this may be a sign of infection. They should follow wound care instructions given by surgery which may include that the incision is to be covered with a non- adhesive bandage and to apply antibiotic ointment 2-3 times daily. The patient will be instructed by the surgeon or urology when he can return to school following surgery, if he feels well. The patient and caregivers will be educated on the importance of being aware of testicular torsion and testicular pain and understanding the urgency of addressing it. They will be educated on the importance of time, and the potential harm should care be delayed (George, et al., 2017).

Disposition/follow-up instructions:

Disposition for this patient is good. He will be discharged after meeting the surgical discharge criteria and advised to follow up with his primary care provider within 5 days. The patient will also be scheduled for a follow-up check with his surgeon in 7-10 days. The patient and his caregivers will be advised to seek immediate medical attention at the emergency department if he develops a fever of 101.4, has increased pain, nausea, vomiting, diarrhea, or constipation that is not improving (George,et al., 2017). 

References

Feher, A. &Bajory, Z. (2016).A review of main controversial aspects of acute testiculartorsion.

Journal of Acute Disease, 5(1), 1–8. https://doi.org/10.1016/j.joad.2015.06.017 George, A., Koka, R., Gan, J., Jelin, E., Boss, F., Strockbine, V., Hobson, D., Wick, C., & Wu,

L. (2017). Review of the enhanced recovery pathway for children: Perioperative anesthetic considerations. Canadian Journal of Anesthesia, 65(5), 569–577. https://doi.org/10.1007/s12630-017-1042-6

Green, C., Stubbs, V., & Green, J. (2020). Public health education initiatives for testicular torsion. Trendsin Urology &Men's Health, 11(6), 14–16. https://doi.org/10.1002/tre.775

Jones MW, Lopez RA, Deppen JG. (2021, February 8). Appendicitis. StatPearls [Internet].

Treasure Island(FL): StatPearls Publishing; Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK493193/

Keays, M., & Rosenberg, H. (2019). Testicular torsion. CMAJ: CanadianMedical Association Journal, 191(28), E792. http://doi.org/10.1503/cmaj.190158

Maaks, D. G., Starr,N., Brady, M., Gaylord, N. Driessnack, M., & Duderstadt, K. (Eds.). (2020).

Burns’ pediatricprimary care(7th ed.). Elsevier.

Tiemstra,& Kapoor.(2008, November 15). Evaluation of scrotal masses.American Family Physician.;78(10):1165-70.

Pomajzl AJ, Leslie SW. (2021, February 10). Appendix Testes Torsion. Treasure Island (FL): StatPearls     Publishing;      2021     Jan-.     Available      from: https://www.ncbi.nlm. nih.gov/books/NBK546994/

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