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Interview Opening U [when ai
> HPI: Constitutional Complaints
How can | help you today? (previou
What has been happening since yo!
; > HPI: Other Complaints (1 - Z) = ef
> HPI: Other Compiaints (A - H)
> HPI: Pain Complaints (A - H) lt =
Do you have pain anywhere? If so, w
What symptom is the most distressint
Has anyone else you know developec
HPI: Sensation & Movement nl
Complaints Tell me how that makes you feel,
> Past Medical History (PMH) How does this affect your life?
> HPI: Pain Complaints (I - Z)
> HPI: Psychological Complaints
Family Medical History (FH) What is your name?
> Social Hx (SH)
Diet
> Review of Systems (ROS) _
Aggravating
Reliving
Timing/Treatments
@ Severity testicular pain?
PMH, FH, SH as Needed
@ Asked ® Not asked
Graded Approach Question
@ PMH ae re any prescription
e PMH ave youeeh been diagnosed
@ PMH Coumler or herbal modotions?
® PMH Do you have any allergies?
] SH fy is your family and family
@ SH Are you sexually active?
} FH Are there any diseases that run
in your family?
How severe (1-10 scale) is your
Maybe a 9? | have never had
anything like this before.
Information
Obtained Clinic
Notes
Response
No, | don't take any pills.
No, | don't think so.
No.
I'm pretty sure | don't.
Pretty good, | guess.
You're crazy. I'm a kid? That's a
weird question.
Dad takes something for his
blood pressure, but that's it.
Review of Systems (ROS)
Select the major body systems that have not been touched on during the interview process for the HPI.
@ Asked ® Not asked
P Information Obtained
Graded Question Response Clinic Notes
Have you noticed any bruising,
o bleeding gums, nose bleeds, or Nope.
other sites of increased bleeding?
Do you have problems with heat or
e cold intolerance, increased thirst, Nope.
increased sweating, frequent
urination, or change in appetite?
Do you have problems with
dizziness, fainting, spinning room,
seizures, weakness, numbness,
tingling, or tremor?
Nope.
Do you have any problems with an
itchy scalp, skin changes, moles, No, none of that stuff.
thinning hair, or brittle nails?
Do you have any problems with
nervousness, depression, lack of
interest, sadness, memory loss, or
mood changes, or ever hear voices
or see things that you know are not
there?
Nope.
Do you have any problems with
fatigue, difficulty sleeping, What does any of that have to do
unintentional weight loss or gain, with why my privates hurt?
fevers, or night sweats?
Do you have any problems with
headaches that don't go away with
aspirin or Tylenol (acetaminophen),
double or blurred vision, difficulty Kees
with night vision, problems hearing, Pe:
Do you experience chest pain
discomfort or pressure;
pain/pressure/dizziness with There's nothing wrong with my
exertion or getting angry; chest. That's not where it hurts!
palpitations; decreased exercise . °
tolerance; or blue/cold fingers and
toes?
Do you experience shortness of
breath, wheezing, difficulty catching No
your breath, chronic cough, or .
sputum production?
=xams
Skin, Hair, Nails - inspect skin overall
¢ Mildly diaphoretic, skin warm
e Acne noted on face and back
e« Norash
Exams
HEENT - inspect/palpate head
¢ Normocephalic, atraumatic
No deformities
Facial feature symmetric
Temporal arteries non-tender to palpation
Frontal and maxillary sinuses non-tender
MALE INGUINAL ANATOMY
direct hernia
Protrusion at the deep inguinal ring
ough the inguinal canat
fypically a congenital defect resulting
failure of the processus vaginalis
edial to the inferior
vessels through an acquired
in the abdominal wall
ach’s triangle). May occur in
Protrusion inferior to the inguinal
ligament through an acquired
eakness of the femoral.canal
‘common in women.
HERNIATION TYPES
Indirect inguinal Direct inguinal
« Abdomen lean, muscular, nondistended
¢ No visible herniation
Review the pathogenesis of the 3 demonstrated types of inguinal herniation:
¢ Indirect
¢ Direct
« Femoral
«ams
bdomen - palpate abdomen
¢ Soft, nontender to palpation
« No organomegaly; no abdominal or inguinal mass
Exams
Abdomen - percuss abdomen
« Abdomen normal to percussion
Exams
Extremities - visual inspection extremities
e There is no swelling or deformity.
¢ There is no cyanosis, clubbing or edema.
Exams
Lymphatic - palpate all lymph nodes
e No inguinal adenopathy
CREMASTERIC REFLEX
Lightly stroke the superior-medial region of the
thigh with the second and third fingers in an
upward or downward direction.
The normal response is an immediate contraction
of the cremaster muscle that results in
elevation of the ipsilateral testis.
Expert Feedback
Vitals Documentation:
@ Pulse: Good, all correct. (FYI actual rate: 120)
@ Respiration: Good, all correct. (FYI actual rate: 18)
x BP: Incorrect assessment, correct is normal. (FYI actual BP: 130/70)
@ Mental Status: Good, all correct.
Exam Documentation:
@ Lung Auscultation: Good, all correct.
®@ Cardiac Auscultation: Good, all correct.
@ Eyes - Pupils: Good, all correct.
Exams Performed:
@ Correct
Good job, you performed all appropriate :
1. Vitals: Temperature (provided)
2. Vitals: Skin (provided)
3. Vitals: Pulse
4. Vitals: BP
5. Chest Wall & Lungs: auscultate lungs
6. Heart: auscultate heart
7. Abdomen: auscultate abdomen
8. Abdomen: visual inspection abdomen
9. Abdomen: palpate abdomen
10. Abdomen: percuss abdomen
11. Lymphatic: palpate all lymph nodes
12. Genitourinary: genitourinary male exam
You also performed additional exams that were not required, but are never inappropriate.
1. Vitals: SpO2 (provided)
2. Vitals: SpCO (provided)
3. Vitals: eTCO2 (provided)
4. Vitals: Respiration
X Incorrect
You performed 16 exams not required by expert.
1. Vitals: Mental Status
2. HEENT: examine pupils
3. Neck: auscultate carotid arteries
4. Abdomen: auscultate abdominal/femoral arteries
Exam Performance:
XIncorrect
You made 2 errors performing some exams:
1. Did not auscultate the anterior in the correct order.
2. Did not auscultate the posterior in the correct order.
Ramindar:
Gloria Problem Statement A 13-years-old male child has sudden onset of left testicular pain 2 hours ago. The pain started during the basketball match. He is also experiencing nausea and had one episode of vomiting. During physical assessment swelling is observed in let testicle and left cremasteric reflex is absent. Patient has tachycardia and diaphoresis.
Test/Diagnosis Association
Association of test with diagnosis:
@ Correct X Incorrect ® Missing
Other Tests
testicular torsion
X scrotal ultrasound
®@ scrotal ultrasound, doppler
hernia, inguinal
X abdomen CT
@ CT abdomen/pelvis without contrast
X CT abdomen/pelvis with IV contrast
torsion of testicular appendage
Association of test with diagnosis:
@ Correct X Incorrect ® Missing
@ scrotal ultrasound, doppler
X scrotal ultrasound
appendicitis
@ complete blood count (CBC)
@ CT abdomen/pelvis without contrast
X urinalysis (UA)
urolithiasis
@ urinalysis (UA)
@ CT abdomen/pelvis without contrast
epididymitis
epididymitis
@ urinalysis (UA)
X scrotal ultrasound, doppler
1 of 1
Index of Tests Exercises
Which of the following statements are true regarding the utility of ultrasound in cases of suspected
epididymitis? Select all that apply.
@ Correct ® Missing X Incorrect
Yours Graded Choice
oOo
Oo
Oo
u@
oOo
x
Ultrasound may be normal
Ultrasound may show increased blood flow
Ultrasound may show decreased blood flow
Ultrasound is necessary to make the diagnosis
None of the above
Scoring: Your score will be 0 if you select more than the number of correct choices.
Diagnosis
| of6 Index of Diagnosis Exercises
What is the correct diagnosis ‘or this patient?
@ Coroct @ Missing X Incorract Discussion
Yours Graded Choice
ooe000
Definitive diagnosis: Testicular torsion
appendicitis ‘The sudden onset of testicular pain, along with physical findings of scrotal
epididymitis erytnemayswelling and elevated testicle are highly suggestive of testicular
hem i torsion. The absent cremasteric reflex is highly predictive of this diagnosis;
me, nguinal and, the absent blood flow to the affectad testicle on ultrasound Doppler
testicular torsion evaluation confirms the diagnosis. If history and physica’ excm alone are
suspicious for testicular torsion, urgent urology consultation shauld not bo
lorsion of lesliculer appendage delayad for imaging studies,
urolithiasis
Expert's Feedback
“The tunica vaginalis isa fascial structure that ensheathes the testis (other than the posterior border), the
‘epididymis, andthe spermate-cord structures. has bath an inner visooral layer and an outer parietal layer.
“Testicular torsion may occur within the tunica vaginalis (inravagina), o exterior to — and inclusive of —
the tunica vaginalis (extravaginan.
+ xtravaginal testicular torsion mast commonly presents in neonates.
* Iriavaginal testicular torsion most commanly occurs in adolosconts, but can be seen in
Inwhat age groupe are these types of testicular torsion most common? (Short answer) ‘any age group,
Testicular torsion commonly occurs among neonates and adolescents (12-18 years of age.
Discussion
Plan Initially, medications for pain management will be given to the patient. Manual reduction can be considered as an initial management. As testicular torsion is a medical emergency, the patient will be referred to urologist for surgical correction. Pain and edema management after surgical procedure can be done. pLan Gloria Pain management will be the initial step. Nothing from mouth will be given to the patient. IV morphine can be given. Testicular torsion is a medical emergency therefore, the patient will be immediately referred to urologist. manual reduction and surgical correction are two processes. Manual reduction can be done however, surgical detorsion is required to prevent future testicular torsion. 1of4 Index of Plan Exercises
Salvage rates for testicles in cases of testicular torsion drop off after how many hours?
@ Correct ® Missing X Incorrect
Yours Graded Choice
oO @ 6 hours
© x 12 hours
© 24 hours
oO 48 hours
aod Expert's Feedback
sion shou be cone byutasound prio tkng apt othe OR? Secon
© correct @ MsingX Incoret idesunsian
Yours Graded Choice
ee ine Apter who ha a lasso presentation of estar trsion shoud go ot OR for exploration of he
° @ false ‘scrotum, as re-establishment of perfusion to the testicle may be delayed by obtaining an ultrasound. In.
‘equivocal cases o inthe situation in which the ultrasound can be obtained quickly while wating forthe
Urologist to are, obtaining an ultrasound may be appropriate
4of4 Index of Plan Exercises
At this point in the case, what is the most appropriate choice of analgesics?
@ Correct ® Missing X Incorrect
Yours Graded Choice
Acetaminophen
Oral oxycodone
IV morphine
Ibuprofen
oOo0e00
e@
Analgesics may mask symptoms and should be avoided