Comprehensive Case Study: 13-Year-Old Boy With Testicular Pain (CLASS 6512) | iHuman Case, Exams of Nursing

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CALEB MERTZ

WEEK#10 A 13YEAR-

OLD BOY:

TESTICULAR PAIN

IHUMAN CASE

STUDY LATEST 2024

-Nonsexually transmittied: Gram negative rods - E.coli and Klebsillea from UTIs and prostatitis; > 35 yrs

Symptoms of Epididymitis Gradual onset of pain Follows acute physical strain, trauma, or sexual activity One sided Leads to abrupt swelling, tenderness Irritative bladder symptoms: dysuria, frequency, urgency Associated: cystitis, urethritis, possible prostatitis Signs of Epididymitis Tenderness and induration of the epididymis Positive Phren Sign: transient relief of pain in recumbent position with scrotal elevation Diagnostic Studies for Epididymitis CBC: leukocytes with left shif DNA testing if G&C Gram stain: gram - intracellular diplococci (G) U/A: non sex will sho pyuria, bacteriuria, hematuria Urine cultures: diagnostic for pathogen Treatment of Sexually Trasmitted Epididymitis Ceftriaxone and doxycycline Treatment of Non Sexually Transmitted Epididymitis TMP/SMZ or floroquinolones Non Pharm Treatment of Epididymitis +/- sitz bath Analgesics

Bed rest (pain better when supine) Condom usage Testicular Torsion Etiology Most common 10-20 yrs or in older men following trauma/sporting injury - twisting of the spermatic cord History of athletic event, strenuous physical activity, or trauma Unilateral cremasteric muscle contractions Signs and Symptoms of Variocele Should always be performed in standing position Will present as a bag of worms that increases with standing/Valsalva and decreases in size when supine Treatment of Variocele Urologic referral for surgical repair (variocelectomy) if painful, bilateral or significant in size Untreated can result in atrophy or infertility Hydrocele Pathophysiolgy/Etiology Collection of serous fluid surrounding the testis between the two layers of the tunica vaginalis -During normal development, testicles descend down tube from abdomen into scrotum and it can remain open allowing fluid to build up Etiology; fluid or blod blockage in spermatic cord, inflammation or injury of testicle or epididymis, malignancy (< 10%) Signs and Symptoms of Hydrocele Painless, swollen testicle Diagnosis with transillumination - fluid will glow orange

*treatment only if embarrasing Spermatocele painless sperm containing cyst at the end of the epididymis Benign - rarely need treatment Spermatocele Signs/Symptoms Freely movable cysts located above and posterior to testes Sometimes tender Can confirm with US Testicular Trauma Direct blow to testes impinges it against symphysis is primary cause: rupture fills with blood vs contusion Penetrating injuries lead to hematocele (hydrocele with blood rather than fluid) Conservative Treatment of Testicular Trauma NSAIDs/opiates Ice Elevation Scrotal support Urology follow up Treatment of Severe Testicular Trauma Emergent urology consult Surgical exploration - evaculation of hematoceles, repair or testicular rupture Testicular salvage following penetrating trauma: 35%

Scrotal Hernia Bowel or other abdominal organ passes through internal inguinal ring lateral to the epigastric vessel INDIRECT HERNIAS Congenital defect - pass through continuity of the processus vaginalis (hydroceles also related to this) Clinical Presentation of Scrotal Hernia RIGHT SIDE Most often present as a bulge in the groin (due to increased intra-ab pressure Typically occurs after heavy lifting or coughing vigorously May also be associated with COPD, difficulty urinating, constipation PE for Scrotal Hernia Palpation of inguinal ring - best examined standing and straining under valsalva/cough Advancement of index finger through external inguinal ring Auscultation of scrotum + bowel sounds Types of Scrotal Hernia Reducible Incarcerated: contents of hernia cannot be reduced back into abdominal cavity Strangulated: identified by presence of skin erythema overlying the defect, elevated WBCs, and fever -Intense pain caused by ischemia and eventual necrosis of incarcerated segment Diagnosis of Scrotal Hernia U/S or CT can be used to diagnose occult hernia Treatment of Scrotal Hernia Watchful waiting: indicated for elderly patients with small, asymptomatic hernias Reduction: manual, can provide temporary management of inguinal hernias *NEVER attempt to reduce a strangulated hernia - can result in gangrenous segment of bowel

Treat current conditions which can increase intra-abdominal pressure Surgery Testicular Cancer Epidemiology Most common tumor in men 15-35 y/o More common on right side than left (parallels incidence of cryptorchidism) Signs and Symptoms of Testicular Cancer Enlargement of testes without pain "Heavy" feeling of testicle; only 1/3 present with pain Symptoms related to metastatic disease (10%): back pain, cough, lower extremity edema (IVC obstruction) Labs for Testicular Cancer Elevated hCG (nonseminous higher than seminous) Alpha fetoprotein (elevated in nonseminous) LDH: can be elevated LFT (to r/o metastases) Scrotal U/S Treatment for Testicular Cancer Radical orchiectomy Seminous: radiation treatment, advanced may need chemo Nonseminous: more likely to present with advanced disease - retroperitoneal lymph node dissection and chemo

Diagnosis of Testicular Torsion intense pain caused by ischemia and eventual necrosis of incarcerated segment sentinel lymph node bx inguinal node dissection CT or MRI tx of penile cancer supportive care / counseling surgery

• laser, cryo
• circumcision
• mohs surgery
• penectomy/lymph node dissection radiation chemo testicular cancer epidemiology most common tumor in 15-35 year old men estimated lifetime risk = 0.2% alpha fetoprotein - testicular CA never going to be elevated in seminomas Shock Reduction of systemic perfusion Tissue Perfusion

Delivery of oxygen and nutrients to tissues Brainpower Read More Hypovolemic Shock Caused by blood or fluid loss Cardiogenic Shock Caused by heart failure Obstructive Shock Caused by physical obstruction to blood flow Beck's Triad Cardiac tamponade symptoms: low BP, low heart sounds, high JVP Septic Shock Caused by systemic vascular dilation and leaky blood vessels Neurogenic Shock Due to loss of sympathetic vascular stimulation leading to vasodilation and bradycardia Anaphylactic Shock Resulting from severe allergic reaction Multiple Organ Dysfunction Syndrome (MODS) Failure of multiple organs due to shock

Cremaster Reflex Test for testicular torsion: stroke inner thigh, testicle should retract Epididymitis Inflammation of the epididymis, often due to infection Testicular Torsion Emergency condition of twisted testicle cutting off blood flow Orchitis Inflammation of the testicle, commonly seen with viral infections Varicocele Dilated veins in the scrotum Hydrocele Accumulation of fluid around the testis Spermatocele Cyst containing sperm above or behind the testes Testicular Trauma Injury to the testicle from direct impact

Scrotal Hernia Bowel protrudes through the inguinal ring into the scrotum Penile Cancer Cancer affecting the penis, often associated with HPV Testicular Carcinoma Most common tumor in young males, often unilateral Renal Diagnostic Studies Tests to assess kidney function and health Urinalysis Biochemistry Analysis of urine composition for diagnostic purposes Urinalysis Microscopy Microscopic examination of urine for cells and particles Renal Function Tests Blood tests to evaluate kidney function Casts Structures formed in the kidney tubules, indicative of various conditions

Radionuclide Kidney Clearance Scanning Gold standard test for assessing kidney function HTN Hypertension indicates poor prognosis. Cr Clearance More accurate than BUN + Cr for assessment. Protein electrophoresis Identifies light-chain immunoglobulins in Multiple Myeloma. Protein selectivity index Used for diagnosing minimal change glomerular disease. Edema Pathophysiology Involves filtration, capillary permeability, reabsorption, and protein synthesis. High protein loss Associated with CKD allowing protein into filtration. Lymphatic Obstruction Caused by tumors, node resection, or lymphoma.

Generalized Edema Approach includes assessing renal, myxedema, liver disease, and allergies. Regional Edema Approach varies for upper and lower extremity edema. Compartment syndrome A condition leading to acute lower extremity edema. Reflex Sympathetic Syndrome Causes burning pain, muscle spasm, and DTR after trauma. Venous stasis Manifests as brown skin changes in the lower extremities. Cellulitis, Gout, Erythema Nodosum Causes red skin changes in the lower extremities. Chronic venous insufficiency Unilateral edema resolves with elevation. Superior Vena Cava Syndrome Leads to sudden onset edema in the upper body and neck.

Filariasis Caused by parasites transmitted by flies and mosquitos. Nephrotic Syndrome Characterized by severe proteinuria, edema, and hypoalbuminemia. Hypercoagulable state Leads to thrombi formation and requires monitoring with PT/PTT. Fatty casts Found in the urine analysis of certain conditions. Preload/EDV Pressure generated by blood volume against ventricle walls. Afterload/ESV Resistance against blood ejection from the ventricle. Contractility (inotropy) Directly affects ESV and is regulated by the Frank-Sterling Law. Myocardial hypertrophy Thickening of ventricular walls leading to increased oxygen consumption. Neurohormonal mechanism

Involves RAAS, ADH, and vasoconstriction in HF. Right-Sided HF Caused by pulmonary POSTcapillary HTN. Dilated Cardiomyopathy Characterized by ventricle dilation and systolic dysfunction. Hypertrophic Cardiomyopathy Involves thickening of ventricle walls and diastolic dysfunction. Restrictive Cardiomyopathy Results in stiff ventricles without thickening. Aortic Stenosis Manifests with a crescendo-decrescendo murmur and narrow pulse pressure. Hypertrophic Cardiomyopathy (HOCM) Causes a systolic ejection murmur that intensifies with Valsalva maneuver. Aortic Regurgitation Shows early diastolic decrescendo murmur and bounding pulse. Mitral Stenosis Leads to early-mid click diastolic murmur and enlarged left atrium.

Mitral Regurgitation Presents with holosystolic blowing murmur and enlarged left atrium. Elastic arteries First to carry blood away from the heart and can stretch. Muscular arteries Medium-sized vessels that can constrict and relax. Capillaries Fragile vessels where capillary exchange occurs. Arterial end Where blood pressure exceeds oncotic pressure, leading to fluid outflow. Venous end Where oncotic pressure exceeds blood pressure, causing fluid influx. Hydrostatic vs. Osmotic Pressure Opposing forces affecting fluid movement in capillaries. Control of Blood Flow Involves intrinsic and extrinsic factors regulating vessel diameter.

Baroreceptors Detect changes in blood pressure and trigger immediate responses. RAAS Activated by low blood pressure to regulate sodium and water balance. Aldosterone Hormone that promotes sodium and water retention in response to low blood pressure. ADH Antidiuretic hormone that conserves water in response to low blood pressure. Athero- (vs.) Arterio- Sclerosis Distinguishes between lipid accumulation and vessel wall thickening. Peripheral Arterial Disease (PAD) Causes intermittent claudication and ulcers in extremities. Chronic Venous Insufficiency Leads to dermatitis, pigmentation, and varicose veins in the legs. Thromboembolism Formation of emboli from fragmented thrombi in the bloodstream. LDH - testicular CA may be elevated in either type

LFT - testicular CA to rule out metastasis scrotal US - testicular CA readily makes diagnosis tx of testicular CA refer to urology radical orchiectomy

• high rates of cure when tx with retroperitoneal irradiation seminomas tx 60-65% of all germ cell tumors require only radiation tx advanced disease = platinum based chemo