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

Aquifer assignment

Case Analysis Tool Worksheet

Student’s Name:                                                       Case ID: _AQ_27

1. 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

 

1. 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

 

1. 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

 

1. 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)

 

 

I have adhered to the honor system:  Yes

Student’s signature

 

 

 

 

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

 

The purpose of the Aquifer assignment is to teach you how to synthesize important patient information gathered during an office visit to select appropriate differentials and create subsequent diagnostic and treatment plans.

The Aquifer assignment is not a summarization of the Aquifer case, or an essay on the specific illness/disease presented.

The written portion of the Aquifer assignment should clearly outline your rationale for selecting your leading diagnosis and differentials, given the information collected for the patient presented.

While the write up needs to include an appropriately formatted title page per APA 7 guidelines, a formal introduction and conclusion are not needed.

An example outline of the written assignment should include would be as follows:

Leading Diagnosis
(this is the diagnosis for which diagnostic and treatment plan will be written)

The leading diagnosis for this patient is ****.  Leading diagnosis is supported  by patient’s presenting symptoms of ***** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). Supporting physical assessment findings include ****** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings).

Differential Diagnoses (must have 2 differentials)

Differential 1 (e.g. Influeza)

The first differential in this case is **** supported by patient presentation of *** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). The differential is further supported by physical exam findings of **** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). *** is less likely however due *(here you would present s/s, history physical exam findings that rule out differential)* (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings).

Differential 2 (e.g. Viral pharyngitis)

*** is the second possible differential in this case. Differential is supported by patient’s presenting symptoms of **** (citation). Patient’s physical assessment findings of *** further support the differential however, differential is less likely due to *** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings).

Diagnostics

Here you would outline your diagnostic plan including any pertinent diagnostic test(s) or exam(s) indicated for diagnosis (must include citation of a Clinical Practice Guideline unless not available. If no guideline is available may use a Problem Specific Peer Reviewed Reference). Brief statement regarding why test is being used, e.g. Positive RADT results are confirmatory for GAS in pediatric patients (Clinical Practice Guideline or Problem Specific Peer Reviewed Reference citation).

 

Treatment Plan

*** is the first line treatment for *** (must include citation of a Clinical Practice Guideline unless not available. If no guideline is available may use a Problem Specific Peer Reviewed Reference) Any medications should include name, route, dose, and duration (Clinical Practice Guideline or Problem Specific Peer Reviewed Reference citation). Supportive measures recommended, including ***** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings). Follow up **** (citation of a Clinical Practice Guideline or Problem Specific Peer Reviewed Reference supporting findings)

 

 

References (documented per APA 7 guidelines)

 

Must include an appropriate clinical practice guideline unless there is not a written guideline for diagnosis. In the case no guideline is available a peer reviewed article written on the specific diagnosis selected may be used.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Aquifer Case Study #18 Family Medicine: Migraine Headaches without Aura

 

Student

United States University

FNP 591: Common Illnesses Across the Lifespan

Professor Georgia Strong

June 01, 2022

 

 

 

 

 

 

 

 

 

 

Leading diagnosis

The leading diagnosis for S.P. is migraine headaches without aura. A diagnosis of migraine headaches without aura is supported by the patient’s report of unilateral and severe throbbing pain associated with nausea, photophobia, and hyperacusis occurring 2-3 times weekly (Cutrer, 2022).  S.P meets 5 of the ICHD-3 diagnostic criteria for migraine without aura, including 1) having 5 attacks 2) headache attacks that last 4-72 hours, 3) characteristics such as unilateral pulsating headache, 4) nausea, vomiting, and photophobia during headache, and 5) does not match other ICHD-3 diagnosis (Cutrer, 2022).

Differential Diagnoses

Differential diagnoses for this patient include cluster-type headaches and anxiety.

Cluster-Type Headaches

The first differential for S.P. is cluster-type headaches, supported by a debilitating unilateral and severe throbbing pain that’s associated with nausea, photophobia, and hyperacusis that occurs 2-3 times a week and results in the patient having to go home. However, this is ruled out due to lack of autonomic symptoms such as ptosis, miosis, lacrimation, conjunctival injection, sweating, and/or nasal congestion (May, 2022).
Anxiety

Another differential is headache due to anxiety supported by S.P. ‘s report of a stressful lifestyle with schooling, part time work, and recent breakup with a boyfriend who cheated. (Taylor, 2020). However, this is ruled out as the patient’s GAD-2 score was 2, testing negative (Taylor, 2020).

 

 

Diagnostics

Diagnostic testing of MRI for migraine isn’t needed in this patient given her age of under 50 or having cognitive changes (Ng & Hanna, 2021). The patient would not need other laboratory tests given the negative physical examination (Cutrer, 2022).

Treatment Plan

S.P. ‘s migraine can be treated with oral sumatriptan 100 mg PO as needed for headaches and can be repeated in 2 hours, but do not exceed over 200 mg in a 24-hour period (Ng & Hanna, 2021). The patient can also take a combo therapy of acetaminophen 250 mg, aspirin 250 mg, and caffeine 65 mg orally PRN for tension-type headaches (Taylor, 2020). The patient should reduce her caffeine intake from other sources if it’s a trigger for her headaches.

S.P. should have a follow up appointment in 2 weeks to see if the medication worked. The patient in the meantime should keep a journal of headache triggers and patterns and reduce stressors in her life that could contribute to the tension-type headaches. She can also exercise four times a week, use relaxation therapies, and improve sleep (Schwedt & Garza, 2022).

 

 

 

 

 

 

 

 

 

 

 

 

References

Cutrer, M. (2020). Pathophysiology, clinical manifestations, and diagnosis of migraine in adults. UpToDate. Retrieved June 12, 2022, from https://www.uptodate.com/contents/pathophysiology-clinical-manifestations-and-diagnosis-of-migraine-in-adults?search=migraine&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2

May, A. (2022). Cluster headache: Epidemiology, clinical features, and diagnosis. UpToDate. Retrieved June 12, 2022, from https://www.uptodate.com/contents/cluster-headache-epidemiology-clinical-features-and-diagnosis?search=cluster%20headache&source=search_result&selectedTitle=1~47&usage_type=default&display_rank=1#H6

Ng, J. Y., & Hanna, C. (2021). Headache and migraine clinical practice guidelines: A systematic review and assessment of Complementary and Alternative Medicine Recommendations. BMC Complementary Medicine and Therapies, 21(1). https://doi.org/10.1186/s12906-021-03401-3

Schwedt, T. & Garza, I. (2020). Acute treatment of migraine in adults. UpToDate. Retrieved June 12, 2022, from https://www.uptodate.com/contents/acute-treatment-of-migraine-in-adults?search=migraine%20treatment&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H7

Taylor, F. (2020). Tension-type headache in adults: Acute treatment. UpToDate. Retrieved June 12, 2022, from https://www.uptodate.com/contents/tension-type-headache-in-adults-acute-treatment?search=tension%20headache&topicRef=3357&source=see_link#H8