Case Analysis Tool Worksheet

 

 

I. Epidemiology/Patient Profile

Andrew is a 17-year-old Caucasian male who has been seen routinely at the clinic since birth presents with his mother with severe right groin and scrotal pain that has persisted for the past four hours. He also complains of nausea but no fever or vomiting. He is currently sexually active.

Sharp and constant right groin pain x4 hours	Denies fever or vomiting
Radiating pain to right scrotum	Sexually active x1 year, uses condoms
Pain started after playing football	Denies dysuria, urethral discharge, frequency
Swollen, tender, erythematous right scrotum	Denies abdominal pain
10/10 pain scale	No steroids, dietary supplements, no smoking
No palpable mass to right scrotum	Nausea
No penile discharge, inguinal lymphadenopathy, or hernias	Nothing has relieved the pain
Negative Prehn sign, absent blue dot sign	Had similar pain a few months ago, relieved without any treatment
Absent cremasteric reflex on the right
No transillumination of the scrotum

 

II. Prioritized Cues from History and PE.

Tier 1 Tier 2 Tier 3

 

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

 

III. Problem Statement

 

IV. Differential Diagnosis

Leading dx: Testicular torsion (Kaplan, 2018)

History Finding(s) Physical Exam Finding(s)

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

 

 

Alternative dx: Acute Epididymitis (Singh, 2021)

 

History Finding(s) Physical Exam Finding(s)

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

 

Alternative dx: Hydrocele (Brenner & Ojo, 2020)

 

History Finding(s) Physical Exam Finding(s)

Physical discomfort	No palpable mass to right scrotum
	Swollen, tender, erythematous right scrotum

 

V. Explanation of Diagnostic Plan and Treatment Plan in prioritized order:

Diagnostic Plan Rationale

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

 

 

 

Treatment Plan Rationale

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

 

References

Brenner, J. S., & Ojo, A. (2020). Causes of painless scrotal swelling in children and adolescents (A. B. Middleman, G. R. Fleisher, L. S. Baskin, & J. F. Wiley, Eds.). UpToDate. https://www.uptodate.com/contents/causes-of-painless-scrotal-swelling-in-children-and-adolescents

Cash, J. C., Glass, C. A., & Mullen, J. (2020). Family practice guidelines. Springer Publishing Company. https://doi.org/10.1891/9780826153425.0018b

Domino, F. J., Baldor, R. A., Berry, K., Golding, J., & Stephens, M. B. (2021). The 5-minute

clinical consult 2022. Lippincott Williams & Wilkins.

Kaplan, G. (2018). Testicular torsion. Epocrates Web.

https://online.epocrates.com/diseases/50611/Testicular-torsion/Guidelines/Highlights-Basics

 

Ogunyemi, O. I. (2020). Testicular torsion medication. Medscape. https://emedicine.medscape.com/article/2036003-medication

Schick, M. A., & Sternard, B. T. (2020). Testicular Torsion. PubMed. https://www.ncbi.nlm.nih.gov/books/NBK448199/

Singh, A. (2021). Sexually Transmitted Infections Treatment Guidelines, 2021. MMWR Recomm Rep.

 

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

 

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