Week 10 Aquifer Study

Instructions

Week 10 Aquifer Study details and requirements.

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:

Viral gastroenteritis at age 1 year
Upper respiratory infection at age 5 years
Appendectomy at age 12 years
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.

Consider family interviewing skills while preparing to see Andrew and his mother.

You enter the exam room and find Andrew lying down looking very uncomfortable on the exam table. 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? First, I would like to talk with you and your mom; 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 unusual in the 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:

“Do you have other concerns, like nausea, sweating, chills, vomiting, or fever?”

“I feel very nauseated but I don’t have a fever or vomiting.”

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 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?”

“Nothing is relieving the pain.”

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 could make a reasonable assessment. 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 whether he is sexually active. He tells you he has one partner and uses condoms most of the time. He has no penile discharge.

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.

He tells you he would appreciate her being there.

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 says he has not been subjected to any kind of pressure.

On further questioning, he reports no 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 who 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.”

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

After you have discussed the differential diagnosis, Dr. Nayar tells you, “Before we go back in to see Andrew, let’s review the basics of the scrotal exam. This exam will help us narrow the differential.”

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.

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 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, 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.

In the hallway, Dr. Nayar asks you to summarize the information you have gathered about Andrew so far.

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

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. Epididymitis
F. Testicular torsion
G. Torsion of the testicular appendages
H. Trauma
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, “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 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.

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.

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 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 contralateral 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, “By 4 weeks after surgery if you are not having any pain or discomfort. The most important thing to remember once you are having sex again to reduce your risk of getting an STI is to use a condom every time you are sexually active. Do you know how to use a condom correctly?”

“Um, yeah I do.”

You reply: “Well, I’d still like to review it with you. 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. Pinch the tip of the condom, and then roll it down over the whole penis. Make sure to remove the condom while the penis is still erect, and hold the base of the condom when taking it off. 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.

Dr. Nayar asks you to refer to the USPSTF Guidelines and the American Academy of Family Physicians’ Adolescent Health Clinical Recommendations & Guidelines to better understand the various health and behavioral issues specific to adolescents.

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 the 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 Chlamydia and Gonorrhea screening, and HIV 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.

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 on time, 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 swelling or 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 avoiding contact sports for another month is best, 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.

QUESTION

After completing your Aquifer case study, answer the following questions:

What is your list of appropriate differential diagnoses and why?
What is the final diagnosis, and what assessment findings serve to support this? Discuss normal versus abnormal findings.
Describe the pathophysiology that may lead up to the final diagnoses.
What pharmacology treatment would you recommend and why?