OSCE Scenario 1

Johnny M. is a 19 year old male with no significant PMHx c/o testicular pain x 3 hours

History elements:

Onset: 3 hours ago
Location: Left scrotum
Duration: Pain began abruptly 3 hours ago while patient was at the gym
Characteristics: Pain is sharp in nature
Aggregation/Alleviation: Pain slightly improves when lying down, worsens with movement
Radiation: States pain does not radiate
Timing: Pain is constant
Severity: Reports pain as “10/10”
No fever, body aches, chills
No dysuria, hematuria, pyuria, urinary urgency, urinary frequency
No abdominal pain
No penile discharge
Admits to nausea, no vomiting
OTC Tylenol 500 mg 1 hour ago, no relief of pain
Denies similar symptoms in the past
Sexual history: heterosexual, 1 female partner, patient admits to unprotected sex. No new partners. No history of STIs (last STI screening 2 months ago was negative)
No past medical history
Not on any medications or herbal supplements
No allergies to medications
No surgical history
No pertinent family history

Physical Exam:

Vital signs: BP 114/68, HR 110, RR 18, T 99.4, SpO2 99%
General: A/O x 3, patient appears in mild distress and pain
Heart: RRR, S1 & S2 distinct, no murmurs or gallops
Lung: Clear to auscultation B/L. No accessory muscle use noted.
Abdominal: Symmetrical, bowel sounds normoactive in all 4 quadrants. Soft and nontender to palpation. No guarding or rebound.
Male GU: circumcised male with no discharge noted. Mild swelling and slight erythema of left scrotum. Exquisite tenderness of left teste, no masses or lesions. No cremasteric reflex elicited on left side. Negative phren sign. No inguinal or femoral hernias noted.

Differential Diagnosis:

Testicular torsion: Testicular torsion presents with abrupt onset of severe testicular pain. It is also associated with nausea and vomiting. The age groups most commonly affected are neonates and males age 10-20. It is a urologic emergency and needs to be considered in males presenting with acute testicular or lower abdominal complaints. Loss of cremasteric reflex is suggestive of torsion.
Epididymitis: Epididymitis can also present with testicular pain and swelling. The patient had recent unprotected sexual encounters and the MC cause of epididymitis in men ages 15-35 is Chlamydia trachomatis. However, in epididymitis there is commonly a positive phren sign (relief of pain w/ scrotal elevation) and normal cremasteric reflex (elevation of testicle after stroking inner thigh). Nausea/vomiting is usually absent in epididymitis and there may be constitutional symptoms such as fever and chills.
Incarcerated inguinal hernia: Surgical emergency that is able to cause swelling and pain of scrotum. May also present with nausea and vomiting. Hernia will be irreducible.

Workup:

Treatment:

Patient Education:

Testicular torsion is a urologic surgical emergency
It is caused by twisting of the spermatic which leads to impaired blood flow to the testicle
Orchiopexy allows for prevention of the recurrence of torsion. The testicle will be attached to the scrotum with stitches. It will be performed on both sides to reduce the likelihood of torsion happening to the other testicle.
Invite questions, obtain consent for surgery and explain potential risks and complications.
- Typically can go home the same day
- Risk of bleeding, infection, pain
- Advise the patient that if the teste is not salvageable an orchiectomy (testicle removal) will be performed
  - If an orchiectomy is performed, will still remain fertile and able to have an erection
  - Typically within 6 hours of pain onset, the testicle can be saved 90% of the time; this percentage drops with the more time that goes by
Explain post-op recovery
- Incision site with ooze for a few days
- Pain medicine, rest and ice packs to relieve pain and swelling after surgery
  - Do not place ice packs directly on skin
- Rest at home
- Avoid strenuous activity for 1-2 weeks
- Typically may resume sexual activity 4-6 weeks after surgery

Sources:

https://www.ncbi.nlm.nih.gov/books/NBK448199/

Nia Grant – Portfolio