Family Medicine 27: 17 year old with 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

PATIENT NFORMATION

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:

1. Viral gastroenteritis at age 1 year

2. Upper respiratory infection at age 5 years

3. Appendectomy at age 12 years

4. Behavioral concerns 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.

You enter the exam room and find Andrew lying down on the exam table, looking very uncomfortable. 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?

Andrew says, “Yes.”

You then establish a general agenda for the appointment, “First, I would like to talk with you and your mother; then I would like to talk to you by yourself for a bit.”

Andrew nods assent and you ask,

“Can you tell me more about your pain?”

Andrew is having a hard time talking, but he states, “I have really bad pain in the right side of my groin. I was all right in the morning. It started suddenly about four hours ago while I was playing football. The pain started in my groin, and at first, it was off and on, but now it’s moved to the right side of my scrotum and it’s been sharp and constant for the last couple of hours.” He adds,” I don’t think I did anything strange in football practice.”

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:

“Have you experienced any nausea? Vomiting? Sweating? Fever? or Chills?”

“I feel very nauseated but no vomiting. No sweating. No Fever. No chills.”

“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’s the worst pain I’ve ever had. 10, more than a 10.”

“Does anything make it worse? What happens if you . . .?”

Andrew is 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?”

“No, nothing makes the pain go away!”

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.”

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.

Mrs. Hailey has left the room and 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.”

You begin the conversation. “May I ask you some questions about your sexual history that may be a little sensitive, but are important to help us figure out what is going on?”

Andrew agrees.

You knock on the door to ensure Andrew is ready, then enter the room to perform the physical examination.

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

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 and 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.

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.

You and Dr. Nayar return together to the exam room. Andrew has gotten dressed and his mother has rejoined him.

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?”

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, “I need to send you to the emergency room for further testing and to prepare you 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.

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.

The urologist, Dr. Greenburg, arrives quickly, examines Andrew, and confirms the diagnosis of testicular torsion based on 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 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 to help her to understand better about the condition.

After Andrew is taken to surgery, you and Dr. Nayar bid Ms. Hailey goodbye for now and head off toward 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, the emergency clinician, 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 clinicians and patients when providing quality care,” Dr. Nayar tells you.

Andrew has returned for his follow-up visit two weeks post surgery. 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 testis was untwisted. The testis was found to be viable (signs of a viable testis 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 testis 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 hear that Andrew is doing well, but needs to get a clearance letter from Dr. Nayar before he can return to school. He also has not had a wellness visit for a while, and you want to take the opportunity to check in with how he is doing overall.

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

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 that 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 non-contact 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.