Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case

Week 8 Assignment: Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case

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Complete only the History, Physical Exam, and Assessment sections of the Aquifer virtual case: Family Medicine 27: 17-year-old male with groin pain.

Discussion Question 1

Based on your performance and the expert feedback in your HISTORY collection, describe two missed questions and your understanding of why they were important to collect for this case history. Use specific references from your text to explain.

Discussion Question 2

Based on your performance and the expert feedback in your PHYSICAL EXAM collection, describe two errors in your exam performance or documentation. Use specific references from your text to explain the importance of these findings in correct assessment of this client.

Discussion Question 3

Based on your performance on the PHYSICAL EXAM collection, describe one key finding that you included in your list and describe a specific physical exam that you can perform at the point-of-care to further evaluate the finding. Use specific references from your text.

Discussion Question 4

Based on your performance and the expert feedback in your ASSESSMENT identification of problem categories, choose one missed/incorrect category and use specific references from your text to explain the importance of this category in arriving at correct differential diagnoses for this client.

Discussion Question 5

Based on your performance and the expert feedback in your ASSESSMENT of differential diagnoses, describe one incorrect/missed differential diagnosis and use specific references from your text to support the inclusion of the diagnosis for this client.

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 in 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:

1. Viral gastroenteritis at age 1 year

2. Upper respiratory infection at age 5 years

3. Appendectomy at age 12 years

4. Behavior problems at age 14 years

When you have finished looking at the chart, you and Dr. Nayar discuss some issues that might come up during an interview with family members present.

TEACHING POINT

Interviewing with Family Members Present

· Special attention should be given to privacy and confidentiality while interviewing an adolescent in the presence of a family member.

· There may be ethical dilemmas involving confidentiality and privacy when family members are present with a patient of any age.

· Family members might have additional questions or concerns about the patient’s health. The physician must make sure they avoid a potential breach of HIPPA: Patient should agree and not object to their relevant health care information being disclosed.

· The patient should have time to communicate privately with the physician at some point during the visit.

· There could be legal issues whenever a third party is involved to make financial and legal decisions for the patient, such as the mother of a child or the guardian of an adult who is impaired or has dementia.

Core and Advanced Skills of Family Interviewing

· Family members can be a valuable source of information and can help in the implementation of a treatment plan, which can result in better patient outcomes.

· The presence of a family member strengthens the alliance between the physician and the patient without lengthening the office visit.

· Family involvement may have a positive influence on medical encounters.

Core family interviewing skills are used routinely during interviews in which another person accompanies the patient. Core skills are sufficient when family members communicate effectively and when the differences between the family members, patient, and physician are minimal. Using these skills, the physician can conduct an efficient and productive interview that involves everyone present. They include:

· Greet and build rapport

· Identify each person’s agenda

· Check each person’s perspective

· Allow each person to speak

· Recognize and acknowledge feelings

· Avoid taking sides

· Respect privacy and maintain confidentiality

· Interview the patient separately, if needed

· Evaluate agreement with the plan

Advanced family interviewing skills are useful in situations where the family exhibits ineffective communication, as a result of a conflict and intense emotions. The advanced family interviewing skills will help the family in communicating or managing conflicts to address the immediate patient care issues; however, unlike therapy, the use of these skills is not intended to create a permanent change in the family’s interaction patterns. The physician may use the following skills:

· Guide communication

· Manage conflict

· Reach common ground

· Consider referral for family therapy

All students can be expected to learn and practice the core skills. The advanced skills are generally learned during residency training and are described in more detail in the article by Lang, et al., listed in the References section, below.

You enter the exam room and find Andrew lying down in an uncomfortable position on the exam table. His mother, Ms. Hailey, is sitting next to her son visibly worried and anxious.

You introduce yourself and explain, “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.”

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?”

TEACHING POINT

Important Features of the History for a Patient in Pain

The following acronym can be helpful: LAQ CODIERS:

· Location

· Associated symptoms

· Quality

· Character

· Onset

· Duration

· Intensity

· Exacerbating factors

· Relieving factors

· other Symptoms

· You have a few more questions:

· “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 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 few months ago and it was relieved without any treatment.” She looks worried, “I hope he didn’t hurt himself while playing.”

· You complete the history. Andrew denies any increased urinary frequency, dysuria, urethral discharge, abdominal pain, or vomiting.

· Ms. Hailey wants to know, “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 I could tell you anything. 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 about his sexual history.

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 denies being subjected to any kind of pressure.

On further questioning, he denies 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 that 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.”

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.

While waiting for Andrew to undress, you quickly go to Dr. Nayar to update him on the case so far.

Question

Dr. Nayar asks you, “What are some of the techniques for establishing rapport with adolescents?” Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Introduce yourself to the adolescent first, look him in the eye, shake hands and sit down during the interview.

· B. Ask an adolescent about sexual activity in front of a parent.

· C. Acknowledge the adolescent as your primary patient by directing your questions primarily to him rather than his parents.

· D. Use conversation icebreakers to allow time for the adolescent to become more comfortable and get a sense of who you are.

· E. Ensure confidentiality and provide a safe environment for him to be honest.

SUBMIT

Answer Comment

The correct answers are A, C, D, E. See Teaching Point below on why these are correct/incorrect.

TEACHING POINT

Building Rapport with Adolescents

Building rapport is the most important skill a provider needs in taking care of adolescent patients. A few simple techniques may help reassure the adolescent that his provider is trustworthy:

· Introduce yourself to the adolescent first, look him in the eye, shake his hand and sit down during the interview.

· Acknowledge the adolescent as your primary patient by directing your questions primarily to him, rather than his parents.

· Use conversation icebreakers to allow time for the adolescent to become more comfortable and get a sense of who you are.

· Allow the adolescent to remain dressed during the interview and sit in a chair rather than on the examination table.

· Ensure confidentiality and provide a safe environment for him to be honest.

· Practicing reflective listening and take time to listen to what the adolescent is saying and not saying.

· Facilitating a comfortable experience for the adolescent by providing adolescent-friendly and easy-to-access office and staff.

· Interviewing the adolescent without his family present for sensitive questions. Don’t ask an adolescent about sexual activity in front of parents.

InspectionOn inspection, look for erythema, swelling, discoloration, skin integrity, and position of the testicle.
PalpationThe skin of the scrotum should be palpated for edema, fluid collection, tenderness, and subcutaneous emphysema. Begin palpation of scrotal contents with the unaffected side.

The normal testis is mobile, and the spermatic cord and epididymis are palpable posteriorly.

1. By gently grasping the testis between the thumb and first two digits, the testicle is examined from its inferior pole, superiorly.

2. Then palpate the testicle for size, tenderness, (localized or diffuse), lie (high or low within scrotum-the left testicle normally sits slightly lower than the right), and axis (horizontal or vertical).

The epididymis should be examined for size, position, tenderness, and swelling. The epididymis should be palpable as a soft, smooth ridge posterolateral to the testis.

To complete the intra-scrotal evaluation, palpation of all scrotal contents should occur. This includes examination of the spermatic cord to the superficial inguinal ring for tenderness or a “knot” which suggests testicular torsion and any localized fluid collections, such as a hydrocele or spermatocele.

TransilluminationTransillumination may help you determine the etiology of a lesion. For example, a light source shines brightly through a hydrocele.

Scrotal Exam Findings

Cremasteric reflexCremasteric 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 signTenderness 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 signPrehn reported that physical lifting of the testicles relieves the pain caused by epididymitis but not pain caused by testicular torsion. A positive Prehn sign is pain that is relieved by lifting of the testicle; if present this can help distinguish epididymitis from testicular torsion.

You knock on the door to ensure Andrew is ready, then enter the room to perform the physical examination. Andrew’s mother is seated in the corner because he has requested her presence.

Dr. Nayar greets Andrew and his mother, and expresses concern about Andrew’s pain, then proceeds to perform a physical exam with you.

Physical Exam

Vital signs:

· Temperature: 98.7 Fahrenheit

· Heart rate: 90 beats/minute

· Respiratory rate: 14 breaths/minute

· Blood pressure: 130/82 mmHg

· Weight: 145 lbs

· Height: 5′ 9″

· Body Mass Index: 21 kg/m2

· Pain score: 10/10

General: Well-built male 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; No abdominal bruits. 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: Inspection of his genitals reveals a 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.

Rectal: Nontender. Stool medium brown, heme negative. Prostate gland normal size, smooth and nontender.

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.

Answer Comment

Andrew is a sexually active 17-year-old male 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:

1. Epidemiology and risk factors: 17-year-old well male, sexually active

2. Key clinical findings about the present illness using qualifying adjectives and transformative 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.

Dr. Nayar asks you to consider the differential diagnosis of unilateral scrotal pain in this patient.

Question

Which of the following conditions are the four most likely diagnoses on your differential at this point?

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Trauma

· B. Testicular torsion

· C. Epididymitis

· D. Inguinal hernia

· E. Hydrocele

· F. Henoch-schönlein purpura

· G. Torsion of the testicular appendages

· H. Tumor

· I. Varicocele

· J. Referred pain

SUBMIT

Answer Comment

The correct answers are A, B, C, G.

Trauma (A), testicular torsion (B), epididymitis (C), 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.

Less Likely Diagnoses for Andrew’s Groin Pain:

· Inguinal hernia (D): Andrew’s history of constant exquisite pain radiating to the scrotum does not fit with a diagnosis of inguinal hernia.

· Hydrocele (E): A hydrocele is an unlikely diagnosis for Andrew as he is having acute tenderness and has no mass on exam.

· Henoch-Schönlein purpura (HSP) (F): Andrew does not display any other symptoms of HSP, so this is an unlikely diagnosis for him at this point.

· Testicular tumor (H): Although important to consider in any adolescent male with a scrotal enlargement, it is unlikely to be the cause for Andrew’s scrotal swelling because of the acuity of his symptoms and the absence of a mass.

· Varicocele (I): This does not explain Andrew’s history of severe, acute pain.

· Referred pain (J): This is not a likely diagnosis for Andrew at this time, since he has had a previous appendectomy and has no other systemic symptoms.

TEACHING POINT

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.

Inguinal herniaAn 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.

Less Likely Diagnoses

You and Dr. Nayar return together to the exam room.

He sits down in a chair and explains, “Andrew has a condition called testicular torsion.”

Ms. Hailey asks,

“What do you mean by testicular torsion?”

Dr. Nayar takes a paper and pen and draws a diagram of a normal testicle and its blood supply and explains, “Here is a picture of the blood supply to the testicle. In testicular torsion, a testicle gets twisted and the blood supply to the stalk is blocked.”

“How did Andrew get this?”

“The cause of testicular torsion usually is not clear.”

Andrew interjects,

“How can you tell that I have testicular torsion?”

“You have severe pain in your scrotum. Your right testicle is swollen and is higher in the scrotum than the other testicle. Infection, cancer, or an injury also can cause pain in the scrotum. However based on your history and physical findings we strongly suspect testicular torsion,” Dr. Nayar answers.

Dr. Nayar continues, “I know this is a lot to process, but it can be treated. You will need immediate surgery to untwist the testicle. I will call the urologist who will be performing the surgery and they will make sure the testicle does not twist again. They also will make sure the other testicle doesn’t twist.”

Dr. Nayar hurriedly says, “Now if you don’t have any further questions I need to send you to the emergency room for further testing and to prepare Andrew for surgery.”

He reassures them that he will come to the emergency room to follow up on the tests and to further explain the management plan.

Question

Dr. Nayar tells you, “Ms. Hailey asked why Andrew’s testis has torsed, and as I told her, the cause isn’t usually clear. However, there are some causes we do know of for testicular torsion.” Which of the following are causes of testicular torsion? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Congenital anomaly

· B. Undescended testicle

· C. Trauma

· D. Exercise

SUBMIT

Answer Comment

There is no single correct answer. All options are possibilities. See Teaching Point below for details.

TEACHING POINT

Causes of Testicular Torsion

Congenital anomalyA congenital anomaly that results in failure of normal posterior anchoring of the gubernaculum, epididymis, and testis is called a bell clapper deformity because it leaves the testis free to swing and rotate within the tunica vaginalis of the scrotum much like the gong (clapper) inside of a bell, causing an intravaginal torsion. A large mesentery between the epididymis and the testis can also predispose itself to torsion. Contraction of the muscles shortens the spermatic cord and may initiate testicular torsion.
Undescended testesAlthough there is little solid evidence, the incidence of testicular torsion is thought to be higher in undescended testes than in normal scrotal testes. Torsion of an undescended testicle often occurs with the development of a testicular tumor, presumably caused by increased weight and distortion of the normal dimensions of the organ.
Recent trauma or vigorous exerciseThe patient’s history often indicates recent trauma to the genital area, hard physical work, or vigorous exercise.

Testicular torsion can also occur without any apparent reason.

You accompany Andrew to the emergency department. The attending, Dr. D’Souza, quickly places him in one of the adolescent rooms and begins to evaluate him. Intravenous access is established. She sends blood and urine samples for further testing, and pages the urologist.

By now, Andrew’s pain has become much more intense and he asks for pain medication. Dr. D’Souza gives him 2 milligrams of intravenous morphine, which provides some relief. You wait patiently for the results to come back, while at the same time, you are trying to reassure Ms. Hailey.

TEACHING POINT

Diagnosing Testicular Torsion

Color 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.

Radionuclide scintigraphy is a diagnostic test that uses a radioisotope to visualize testicular blood flow. Patients with testicular torsion have decreased radiotracer in the ischemic testis, resulting in a photopenic lesion.

Radionuclide scintigraphy vs color doppler ultrasonography:

Radionuclide scintigraphy procedure has 100% sensitivity, whereas Doppler ultrasonography only has a sensitivity of 88% and a specificity of 98% in detecting testicular torsion.

Although scintigraphy may be more sensitive for testicular torsion, ultrasonography is faster and more readily available. This is a critical consideration in a condition that warrants a rapid diagnosis.

Color Doppler ultrasonography and scintigraphy demonstrate no statistically significant difference in ability to demonstrate testicular torsion in boys with acute scrotal symptoms and indeterminate clinical presentations.

The urologist, Dr. Greenburg, arrives quickly, examines Andrew, and confirms the diagnosis of testicular torsion based on a history and physical findings. He then discusses the results of the tests and a management plan with Andrew and Ms. Hailey.

“Andrew, your complete blood count (CBC) is normal. Your urine analysis is also normal. However, we ordered urine tests for infection that will not be back for a couple of days. At this point, we do not suspect an infection as a cause for your symptoms.” Dr. Greenberg explains the risks and benefits of surgical intervention and general anesthesia, obtains informed consent from Ms. Hailey and prepares for immediate surgical exploration.

You also give Mrs. Hailey  patient information on testicular torsion  to help her to understand better about the condition.

After Dr. Greenburg has finished his preparations, while he awaits the anesthesiologist, he reviews the procedure with you.

TEACHING POINT

Complications of Testicular Torsion: Testicular Loss

The most significant complication of testicular torsion is loss of the testis, which may lead to impaired fertility.

Common causes of testicular loss after torsion are:

· delay in seeking medical attention (58%)

· incorrect initial diagnosis (29%)

· delay in treatment at the referral hospital (13%)

The viability of a testis depends on the duration of torsion and pain:

Duration of scrotal painPercentage of testicular viability
6 hours90%
more than 12 hours50%
more than 24 hours10%

TEACHING POINT

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 distorsion 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.

After Andrew is taken to surgery, you and Dr. Nayar bid Ms. Hailey goodbye for now and head off towards the family medicine clinic. On the way back, Dr. Nayar praises you, “You did a nice job today. Andrew’s mother told me she was relieved to have your assistance. I am impressed with how well you facilitated effective communication between the family and the emergency physician, and the urologist. You made what could have been an extremely overwhelming situation for Andrew and his mother into an opportunity to forge a strong partnership with them.”

You thank Dr. Nayar for his kind words and say, “I’m really glad I got to come over. I enjoyed helping to coordinate Andrew’s care.”

“You’ve demonstrated a firm grasp on an important premise in family medicine that can be difficult to teach, as it has not been articulated all that well until a couple of years ago. I’m talking about The Patient Centered Medical Home, an approach to primary care that really emphasizes the value of relationships between physicians and patients when providing quality care,” Dr. Nayar tells you.

Dr. Nayar tells you how the principles of the Patient Centered Medical Home apply in Andrew’s case:

1. Personal physician: “For example, I have been taking care of Deborah and her family for the past 18 years. I provided prenatal care when Deborah was pregnant with Andrew. And I have taken care of all the family’s health care needs since. This allows a solid, long term relationship which maximizes my ability to assist the family in all health care issues.”

2. Physician directed medical practice: “For example, the nurse who obtained Andrew’s chief concern and vitals assists in Andrew’s care by maximizing how I spend my time with him. The nurse practitioner at the clinic who saw Andrew for his upper respiratory infection a few years ago, assisted with that aspect of his care — but I was available if my expertise had been needed. We have people at our clinic who help coordinate diabetes care and other complex chronic health issues.”

3. Whole person orientation: “In other words, when Andrew came in with acute scrotal pain, we addressed this issue, but we also used the opportunity to tackle other issues that are important in taking care of Andrew’s whole person, such as quickly assessing some other lifestyle factors besides sexual activity, including drugs and smoking.”

4. Care is coordinated and/or integrated: “In Andrew’s case, we recognized he likely had testicular torsion which required immediate intervention. We effectively coordinated not only his visit to the emergency room, but his urology care as well. Furthermore, we kept the channels of communication open with Andrew’s mother, allowing her the information and reassurance she needed.”

TEACHING POINT

Patient Centered Medical Home

Leading primary care physicians organizations* described the characteristics of the Patient Centered Medical Home as follows:

1. Personal physician: Each patient should have an ongoing relationship with one personal physician. So when a patient needs medical attention, they rely on a doctor they have established a long-term relationship with who will help them get whatever care they need.

2. Physician directed medical practice: The personal physician has assistance from the team of individuals at the family practice clinic who collectively take responsibility for ongoing care of patients.

3. Whole person orientation: The personal physician is responsible for providing all health care needs at all stages of life. Including acute care, chronic care, preventive services, and end of life care.

4. Care is coordinated and/or integrated: The personal physician doesn’t have the expertise to take care of every medical issue their patients may encounter, so the personal physician needs to understand when to refer for subspecialty care. The personal physician also needs to be able to utilize all domains of the health care system, facilitated by registries, information technology, health information exchange and other means, in order to ensure that the patient gets the indicated care where and when they need it. Furthermore, the personal physician needs to be able to communicate health care issues effectively to family members when appropriate.

Quality and safety are also hallmarks of the medical home.

*Leading primary care physicians organizations: American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA).

Andrew has returned for his follow-up visit. You review his inpatient records including the operative and post operative course using his electronic medical record (EMR).

EMR review reveals that Andrew had surgical exploration of the scrotum through the midline scrotal raphe. The ipsilateral scrotal compartment was entered and the testes was untwisted. The testes was found to be viable (Signs of a viable testes after detorsion include, a return of color, return of Doppler flow, and arterial bleeding after incision of tunica albuginea). To prevent subsequent torsion, the gonads were fixed to the scrotal wall with nonabsorbable sutures. The contra lateral testes was explored and anchored through the same incision. The post-operative period was uneventful. Andrew was discharged from the hospital 48 hours after the surgery. He also had a follow-up visit with Dr. Greenburg a week later.

You and Dr. Nayar visit with Ms. Hailey and Andrew. You discover that Andrew is doing well, but needs to get a clearance letter from Dr. Nayar before he can return to school.

Dr. Nayar asks Ms. Hailey to leave the room so that he can perform the physical examination.

After she leaves, you examine Andrew. He shyly asks you,

“Can I have sex again now? Do I need to take any precautions?”

Your answer is, “The surest way to prevent contracting a sexually transmitted infection (STI) is to abstain from any type of sexual activity. However, if you are sexually active, the most important thing to remember to reduce your risk of getting an STI is to use a condom every single time you are sexually active. Do you know how to use a condom correctly?”

“Um, yeah I do.”

You hesitate to pursue the matter further, as Andrew is not indicating any need for further advice, but you understand that he may be too embarrassed to ask for help in this arena so you reply: “Well, it is still something I like to review. It is much more likely for the condom to break if it is used incorrectly. It is important to put the condom on when the penis is erect and to make sure to pinch the tip, and then roll down the condom over the whole penis. Make sure to hold the base of the condom when taking the condom off, and to take it off while the penis is still erect. Do you have any questions about any of that?”

“Well, sort of. Should I wear a condom for any type of sex?”

“That’s a really good question,” you assure him, “To protect yourself from STIs, you should wear a condom for every sexual act – oral, anal, or vaginal sex.”

“Feel free to come back any time to discuss these issues with me.” reassures Dr. Nayar.

TEACHING POINT

Discussing Sexual Risk Behaviors with Adolescents

Many young people engage in sexual risk behaviors that can result in unintended health outcomes.

To reduce sexual risk behaviors and related health problems among youth, physicians can help young people adopt lifelong attitudes and behaviors that support their health and well-being-including behaviors that reduce their risk for HIV, other STIs, and unintended pregnancy.

Counsel youth that abstinence from vaginal, anal, and oral intercourse is the only 100% effective way to prevent HIV, other STIs, and pregnancy. The correct and consistent use of male latex condoms can reduce the risk of STI transmission, including HIV infection. However, no protective method is 100% effective, and condom use cannot guarantee absolute protection against any STD or pregnancy.

In many states, minors can legally consent to certain types of health care on their own—including STI and HIV testing.

Dr. Nayar asks you to refer to the USPSTF Guidelines and  Monograph American Academy of Family Physicians Adolescent Health Clinical Recommendations and Guidelines  to have a better understanding of the various health and behavioral issues that are specific to adolescents.

Question

Which of the following are topics or health conditions related to adolescents addressed by The American Academy of Family Physicians? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Preventing diabetes mellitus

· B. Screening for depression

· C. Screening for obesity

· D. Screening sexually active men for gonorrhea and chlamydia

· E. Promoting physical fitness

SUBMIT

Answer Comment

The correct answers are B, C, E. A is incorrect because it is not recommended by the AAFP. D is incorrect because AAFP and USPSTF endorse screening sexually active women for gonorrhea and chlamydia, and not men (USPSTF recommendation) . See Teaching Point below for details.

TEACHING POINT

Adolescent Health Clinical Recommendations and Guidelines

USPSTF Guidelines Special Considerations
DepressionAdolescents age 12 to 18 should be screened for major depressive disorder (MDD).
Chlamydia and gonorrheaScreen all sexually active women age 24 years and younger.
HIVScreen adolescents at age 15 years (USPSTF).AAFP recommends starting at age 18.

CDC recommends starting at age 13.

Lipid DisordersInsufficient evidence to screen in children and adolescents 20 years and younger.AAP recommend screening once between 9 and 11, and once between 7 and 21 years of age.
ObesityChildren and adolescents 6 years and older should be screened for obesity.
SyphilisScreen in adolescents who are at increased risk for infection.People at increased risk include men who have sex with men, people with HIV, certain racial/ethnic groups, certain geographic and metropolitan areas, history of incarceration, history of commercial sex work, and being male younger than 29 years of age.

Dr. Nayar continues, “These practice guidelines explain the AAFP position on adolescent preventive services. Take a moment to also look over the CDC’s recommended immunization schedule for persons ages 7 through 18 years in the United States on your computer.”

You review the article and recognize that in addition to addressing the acute problem, you could use this opportunity to ensure provision of comprehensive and continuity of care.

You then review his immunization record and find that Andrew is up to date with immunizations.

While in the exam room with Andrew, Dr. Nayar discusses  recommendations for STI screening .

Based on your conversation with Dr. Nayar, you recommend that Andrew have a hepatitis B vaccination, if not immunized. Since he is not at high risk for syphilis, you do not need to recommend syphilis screening.

Question

Dr. Nayar asks you, “I know Andrew is a boy, but let’s consider which of the following should NOT be screened in a sexually active adolescent female who initiated sexual activity one week ago?” Choose the single best answer.

The best option is indicated below. Your selections are indicated by the shaded boxes.

· A. Chlamydia

· B. Gonorrhea

· C. Trichomonas

· D. Pap test for cervical cancer

· E. HIV

SUBMIT

Answer Comment

The correct answer is D.

TEACHING POINT

Sexually Transmitted Infection in Women

Women should have their first cervical cancer screening at age 21 and can be rescreened less frequently than previously recommended, according to guidelines issued by the American College of Obstetricians and Gynecologists (ACOG).

Moving the baseline cervical screening to age 21 is a conservative approach to avoid unnecessary treatment of adolescents, which can have economic, emotional, and future childbearing implications. Although the rate of HPV infection is high among sexually active adolescents, invasive cervical cancer is very rare in women under age 21. The immune system clears the HPV infection within one to two years among most adolescent women. Because the adolescent cervix is immature, there is a higher incidence of HPV-related precancerous lesions (called dysplasia). However, the large majority of cervical dysplasias in adolescents resolve on their own without treatment.

See this chart  prepared by the CDC to compare HPV and cervical cancer screening guidelines of the various professional organizations.

Sexually transmitted infectionSymptomsDiagnosis
Chlamydia· Dysuria

· Discharge (penile or vaginal)

· Pain with sex

· Abdominal or testicular pain

· Breakthrough bleeding

· May be asymptomatic

· Nucleic acid amplification test of urine, endocervical sample, or urethral sample
Gonorrhea· Dysuria

· Discharge (penile or vaginal)

· Pain with sex

· Abdominal or testicular pain

· Breakthrough bleeding

· May be asymptomatic

· Nucleic acid amplification test of urine, endocervical sample, or urethral sample

· Gonococcal culture of rectal or pharyngeal specimens

Trichomonas· Vaginal discharge with odor or itching

· May be asymptomatic

· Saline wet mount

· rapid antigen testing

· Trichomonas culture

· HIV screening is recommended for patients in all health-care settings after the patient is notified that testing will be performed unless the patient declines (opt-out screening). Persons at high risk for HIV infection should be screened for HIV at least annually. Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing.

After completing the physical examination, you call Ms. Hailey back to the room and continue the conversation.

“Andrew’s surgical wound has healed well,” Dr. Nayar explains to Ms. Hailey, “and he is ready to go back to school.”

She looks relieved and asks, “What are the other testicular disorders we need to worry about?”

Dr. Nayar attempts to set Ms. Hailey’s mind at ease by telling her that since he received treatment in a timely manner, Andrew has escaped the most dangerous complication of testicular torsion, which is losing a testicle. He explains, “There are other conditions such as testicular tumors, torsion of the appendix epididymis, epididymitis, and trauma could cause similar pain and these conditions should be treated as soon as possible. But,” he assures them, “Andrew is at no greater risk of these testicular conditions now than he was before he had a torsed testicle.”

You and Dr. Nayar tell Mrs. Hailey that if there is any swelling or any pain occurs or recurs, you need to seek medical attention immediately.

Andrew wants to know if he can participate in the upcoming football game. Dr. Nayar counsels that it is best to avoid contact sports for another month, but he can participate in noncontact drills. You help Dr. Nayar complete the medical clearance form to return to school.

Ms. Hailey once again thanks both you and Dr. Nayar for all the assistance in taking care of Andrew’s health and for coordinating his care. She makes the follow-up appointment to see Dr. Nayar in six months, and she and Andrew leave the office looking content.

TEACHING POINT

Testicular Cancer: Prevalence, Presentation, & Screening Recommendations

Testicular cancer is the most common malignancy affecting males between the ages 15 and 35, although it accounts for only one percent of all cancers in men.

These tumors could present as a nodule or as a painless swelling of the testicle, 30-40% may present with dull ache or heavy sensation in the lower abdomen, perianal area, or scrotum areas. Acute pain is the presenting symptom in ten percent of cases.

There is no evidence to support routine screening for testicular cancer in asymptomatic adolescents and young adults.

Question

What are the risk factors for testicular tumors? Select all that apply.

The best options are indicated below. Your selections are indicated by the shaded boxes.

· A. Genetics

· B. Family history

· C. Cryptorchidism

· D. Environment

· E. Prior testicular cancer

SUBMIT

Answer Comment

There is no single correct answer. All options are possibilities. See Teaching Point below for details.

TEACHING POINT

Testicular Tumor Risk Factors

The most common testicular tumor is germ cell tumor. The specific cause of germ cell tumors is unknown, but various factors have been associated with the increased risk.

Genetics play a role in testicular cancer risk. Klinefelter’s syndrome (47xxy) is associated with a higher incidence of germ cell tumors. For first degree relatives of individuals affected there is approximately six to ten- fold increased risk for germ cell tumors. Other conditions such as Down syndrome, testicular feminizing syndrome, true hermaphrodites, persistent mullerian syndrome, and cutaneous ichthyosis are at higher risk for developing germ cell tumors.

Family history also plays an important role in testicular cancer risk. There have been reports of six-fold increased risk among male offspring of a patient with testicular cancer.

Patients with cryptorchidism have 20 to 40-fold increased risk compared with their normal counterparts. Cryptorchidism is the absence of one or both testes from the scrotum, usually as the result of an undescended testis.Orchipexy, even at an early age, appears to reduce the incidence of germ cell tumor only slightly.

Numerous environmental hazards, such as industrial occupations and drug exposures have been implicated in the development of testicular cancer. They include DES, Agent Orange, and solvents used to clean jets and ochratoxin A.

One to two percent of patients with testicular cancer will develop a second primary cancer in the contralateral testicle. This represents a 500-fold increase in risk compared with normal population.

Prior trauma, elevated scrotal temperature, and recurrent activities, such as horseback riding and motorcycle riding do not appear to be related to the development of testicular tumors.

TEACHING POINT

Three Types of Testicular Tumors

1. Germ cell tumor (GCT)

· Seminomatous (SGCT)

· Nonseminomatous (NSGCT)

Germ cell tumors (GCTs) are the most common-accounting for (95%) of primary testicular tumors-and are classified as either seminomas (45%) or others (50%), called nonseminomatous germ cell tumors, or NSGCT, based on histology.

Distribution of nonseminomatous germ cell tumors (NSGCTs):

· Embryonal cell tumor, the classic pure-cell NSGCT (20%)

· Mixed GCTs (40%)

· Teratomas and teratocarcinomas (30%)

· Yolk sac tumors (also known as endodermal sinus tumors) are the most common prepubertal GCTs. They may be benign but are most often malignant. Most affected patients require surgery and chemotherapy because of the aggressive nature of the tumors, but the overall prognosis is excellent.

· Choriocarcinoma is the most lethal but least common NSGCT (1%)

1. Non-germ cell tumorsNon-germ cell tumors (Leydig cell tumors and Sertoli cell tumors) constitute the remaining 5% of primary testicular tumors; these are rare tumors that are malignant in only about 10% of the cases.
1. ExtragonadalLymphoma, leukemia, and melanoma are the most common malignancies that metastasize to the testicle (extragonadal tumors).

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