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
- 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 |
- 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
- 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 |
- 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
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