Patient Information Please see attachment for Rubrics and Soap T.docx

Patient Information
Please see attachment for Rubrics and Soap Template
Family Medicine 27: 17-year-old male with groin pain
User:
Beatriz Duque
Email:
[email protected]
Date:
September 5, 2020 11:01PM
Learning Objectives
The student should be able to:
Elicit focused history of patients presenting with scrotal pain.
Demonstrate the ability to perform proficient testicular
examination and to elicit signs specific to identify or exclude
testicular torsion.
Develop a differential diagnosis for adolescent male presenting
with scrotal pain.
Identify appropriate laboratory and radiological studies as it
relates to the differential diagnosis of scrotal pain. Outline the
algorithmic approach to testicular pain.
Discuss management of testicular torsion.

Recognize sexually transmitted infections as a cause of
testicular pain among adolescent males.
Discuss the importance of counseling to prevent sexually
transmitted infections.
Discuss epidemiology and USPSTF recommendations for
screening for common testicular cancers.
Knowledge
Important Features of the History for a Patient in Pain
The following acronym can be helpful:
LAQ CODIERS:
L
ocation
A
ssociated symptoms
Q
uality
C
haracter
O
nset
D
uration
I

ntensity
E
xacerbating factors
R
elieving factors other
S
ymptoms
HEEADSSS Adolescent Interview
Home
Education / Employment
Eating
Activities
Drugs
Sexuality
Suicide / Depression Safety / Violence
Scrotal Exam Findings
Cremasteric reflex
Cremasteric reflex can be assessed by lightly stroking or
pinching the superior medial aspect of the thigh. An intact
cremasteric reflex causes brisk ipsilateral testicular retraction.
Absence of the cremasteric reflex is a sensitive but nonspecific
finding for testicular torsion. It can be absent on physical exam
in normal testes. It should be assessed after inspection and
before palpation of the testicles.

Blue dot sign
Tenderness limited to the upper pole of the testis suggests
torsion of a testicular appendage, especially when a hard, tender
nodule is palpable in this region. A small bluish discoloration
known as the "blue dot sign", may be visible through the skin in
the upper pole. This sign is virtually pathognomonic for
appendiceal torsion when tenderness is also present.
Prehn sign
Prehn reported that physical lifting of the testicles relieves the
pain caused by epididymitis but not pain caused by testicular
torsion. A positive Prehn sign is pain that is relieved by lifting
of the testicle; if present this can help distinguish epididymitis
from testicular torsion.
Causes of Testicular Torsion
Congenital anomaly
A congenital anomaly that results in failure of normal posterior
anchoring of the gubernaculum, epididymis, and testis is called
a bell clapper deformity because it leaves the testis free to
swing and rotate within the tunica vaginalis of the scrotum
much like the gong (clapper) inside of a bell, causing an
intravaginal torsion. A large mesentery between the epididymis
and the testis can also predispose itself to torsion. Contraction
of the muscles shortens the spermatic cord and may initiate
testicular torsion.
Undescended testes
Although there is little solid evidence, the incidence of
testicular torsion is thought to be higher in undescended testes

than in normal scrotal testes. Torsion of an undescended testicle
often occurs with the development of a testicular tumor,
presumably caused by increased weight and distortion of the
normal dimensions of the organ.
Recent trauma or vigorous exercise
The patient's history often indicates recent trauma to the genital
area, hard physical work, or vigorous exercise
.
Testicular torsion can also occur without any apparent reason.
Complications of Testicular Torsion: Testicular Loss
The most significant complication of testicular torsion is loss of
the testis, which may lead to impaired fertility.
Common causes of testicular loss after torsion are:
delay in seeking medical attention (58%)
incorrect initial diagnosis (29%) delay in treatment at the
referral hospital (13%)
The viability of a testis depends on the duration of torsion and
pain:
Duration of scrotal pain
Percentage of testicular viability
6 hours
90%

more than 12 hours
50%
more than 24 hours
10%
Patient Centered Medical Home
Leading primary care physicians organizations* described the
characteristics of the Patient Centered Medical Home as
follows:
1.
Personal physician:
Each patient should have an ongoing relationship with one
personal physician. So when a patient needs medical attention,
they rely on a doctor they have established a long-term
relationship with who will help them get whatever care they
need.
2.
Physician directed medical practice:
The personal physician has assistance from the team of
individuals at the family practice clinic who collectively take
responsibility for ongoing care of patients.
3.
Whole person orientation:
The personal physician is responsible for providing all health
care needs at all stages of life. Including acute care, chronic
care, preventive services, and end of life care.

4.
Care is coordinated and/or integrated:
The personal physician doesn't have the expertise to take care
of every medical issue their patients may encounter, so the
personal physician needs to understand when to refer for
subspecialty care. The personal physician also needs to be able
to utilize all domains of the health care system, facilitated by
registries, information technology, health information exchange
and other means, in order to ensure that the patient gets the
indicated care where and when they need it. Furthermore, the
personal physician needs to be able to communicate health care
issues effectively to family members when appropriate.
Quality and safety are also hallmarks of the medical home.
*Leading primary care physicians organizations: American
Academy of Family Physicians (AAFP), American Academy of
Pediatrics (AAP), American College of Physicians (ACP),
American Osteopathic Association (AOA).
Discussing Sexual Risk Behaviors with Adolescents
Many young people engage in sexual risk behaviors that can
result in unintended health outcomes.
To reduce sexual risk behaviors and related health problems
among youth, physicians can help young people adopt lifelong
attitudes and behaviors that support their health and well-being-
including behaviors that reduce their risk for HIV, other STIs,
and unintended pregnancy.
Counsel youth that abstinence from vaginal, anal, and oral
intercourse is the only 100% effective way to prevent HIV,
other STIs, and pregnancy. The correct and consistent use of

male latex condoms can reduce the risk of STI transmission,
including HIV infection. However, no protective method is
100% effective, and condom use cannot guarantee absolute
protection against any STD or pregnancy.
In many states, minors can legally consent to certain types of
health care on their own—including STI and HIV testing.
Adolescent Health Clinical Recommendations and Guidelines
USPSTF Guidelines
Special Considerations
Depression
Adolescents age 12 to 18 should be screened for major
depressive disorder (MDD).
Chlamydia and gonorrhea
Screen all sexually active women age 24 years and younger.
HIV
Screen adolescents at age 15 years (USPSTF).
AAFP recommends starting at age 18.
CDC recommends starting at age 13.
Lipid
Disorders
Insufficient evidence to screen in children and adolescents 20

years and younger.
AAP recommend screening once between 9 and 11, and once
between 7 and 21 years of age.
Obesity
Children and adolescents 6 years and older should be screened
for obesity.
Syphilis
Screen in adolescents who are at increased risk for infection.
People at increased risk include men who have sex with men,
people with HIV, certain racial/ethnic groups, certain
geographic and metropolitan areas, history of incarceration,
history of commercial sex work, and being male younger than
29 years of age.
Sexually Transmitted Infection in Women
Women should have their first cervical cancer screening at age
21 and can be rescreened less frequently than previously
recommended, according to guidelines issued by the American
College of Obstetricians and Gynecologists (ACOG).
Moving the baseline cervical screening to age 21 is a
conservative approach to avoid unnecessary treatment of
adolescents, which can have economic, emotional, and future
childbearing implications. Although the rate of HPV infection is
high among sexually active adolescents, invasive cervical
cancer is very rare in women under age 21. The immune system
clears the HPV infection within one to two years among most
adolescent women. Because the adolescent cervix is immature,
there is a higher incidence of HPV-related precancerous lesions

(called dysplasia). However, the large majority of cervical
dysplasias in adolescents resolve on their own without
treatment.
See this chart
prepared by the CDC to compare HPV and cervical cancer
screening guidelines of the various professional organizations.
Sexually transmitted infection
Symptoms
Diagnosis
Chlamydia
Dysuria
Discharge (penile or vaginal)
Pain with sex
Abdominal or testicular pain
Nucleic acid amplification test of urine, endocervical sample, or
urethral sample
Breakthrough bleeding
May be asymptomatic
Gonorrhea
Dysuria
Discharge (penile or vaginal)

Pain with sex
Abdominal or testicular pain
Breakthrough bleeding May be asymptomatic
Nucleic acid amplification test of urine, endocervical sample, or
urethral sample
Gonococcal culture of rectal or pharyngeal specimens
Trichomonas
Vaginal discharge with odor or itching
May be asymptomatic
Saline wet mount rapid antigen testing Trichomonas culture
HIV screening is recommended for patients in all health-care
settings after the patient is notified that testing will be
performed unless the patient declines (opt-out screening).
Persons at high risk for HIV infection should be screened for
HIV at least annually. Separate written consent for HIV testing
should not be required; general consent for medical care should
be considered sufficient to encompass consent for HIV testing.
Testicular Cancer: Prevalence, Presentation, & Screening
Recommendations
Testicular cancer is the most common malignancy affecting
males between the ages 15 and 35, although it accounts for only
one percent of all cancers in men.
These tumors could present as a nodule or as a painless swelling

of the testicle, 30-40% may present with dull ache or heavy
sensation in the lower abdomen, perianal area, or scrotum areas.
Acute pain is the presenting symptom in ten percent of cases.
There is no evidence to support routine screening for testicular
cancer in asymptomatic adolescents and young adults.
Testicular Tumor Risk Factors
The most common testicular tumor is germ cell tumor. The
specific cause of germ cell tumors is unknown, but various
factors have been associated with the increased risk.
Genetics
play a role in testicular cancer risk. Klinefelter's syndrome
(47xxy) is associated with a higher incidence of germ cell
tumors. For first degree relatives of individuals affected there is
approximately six to ten- fold increased risk for germ cell
tumors. Other conditions such as Down syndrome, testicular
feminizing syndrome, true hermaphrodites, persistent mullerian
syndrome, and cutaneous ichthyosis are at higher risk for
developing germ cell tumors.
Family history
also plays an important role in testicular cancer risk. There
have been reports of six-fold increased risk among male
offspring of a patient with testicular cancer.
Patients with
cryptorchidism
have 20 to 40-fold increased risk compared with their normal
counterparts. Cryptorchidism is the absence of one or both
testes from the scrotum, usually as the result of an undescended
testis.Orchipexy, even at an early age, appears to reduce the
incidence of germ cell tumor only slightly.

Numerous
environmental
hazards, such as industrial occupations and drug exposures
have been implicated in the development of testicular cancer.
They include DES, Agent Orange, and solvents used to clean
jets and ochratoxin A.
One to two percent of patients with
testicular cancer
will develop a second primary cancer in the contralateral
testicle. This represents a 500-fold increase in risk compared
with normal population.
Prior trauma, elevated scrotal temperature, and recurrent
activities, such as horseback riding and motorcycle riding do
not appear to be related to the development of testicular tumors.
(NSGCT)
Yolk sac tumors (also known as endodermal sinus tumors) are
the most common prepubertal GCTs. They may be benign but
are most often malignant. Most affected patients require surgery
and chemotherapy because of the aggressive nature of the
tumors, but the overall prognosis is excellent.
Choriocarcinoma is the most lethal but least common NSGCT
(1%)
1. Non-germ cell tumors
Non-germ cell tumors (Leydig cell tumors and Sertoli cell
tumors) constitute the remaining 5% of primary testicular
tumors; these are rare tumors that are malignant in only about
10% of the cases.
1. Extragonadal

Lymphoma, leukemia, and melanoma are the most common
malignancies that metastasize to the testicle (extragonadal
tumors).
Clinical Skills
Interviewing with Family Members Present
Special attention should be given to privacy and confidentiality
while interviewing an adolescent in the presence of a family
member.
There may be ethical dilemmas involving confidentiality and
privacy when family members are present with a patient of any
age.
Family members might have additional questions or concerns
about the patient's health. The physician must make sure they
avoid a potential breach of HIPPA: Patient should agree and not
object to their relevant health care information being disclosed.
The patient should have time to communicate privately with the
physician at some point during the visit.
There could be legal issues whenever a third party is involved
to make financial and legal decisions for the patient, such as the
mother of a child or the guardian of an adult who is impaired or
has dementia.
Family Interviewing Skills
Make sure you gather data by asking open-ended questions, by
prompting facilitation, identifying and exploring clues,
responding empathetically, and by reaching common ground.

Core and Advanced Skills of Family Interviewing
Family members can be a valuable source of information and
can help in the implementation of a treatment plan, which can
result in better patient outcomes.
The presence of a family member strengthens the alliance
between the physician and the patient without lengthening the
office visit.
Family involvement may have a positive influence on medical
encounters.
Core family interviewing skills
are used routinely during interviews in which another person
accompanies the patient. Core skills are sufficient when family
members communicate effectively and when the differences
between the family members, patient, and physician are
minimal. Using these skills, the physician can conduct an
efficient and productive interview that involves everyone
present. They include:
Greet and build rapport
Identify each person's agenda
Check each person's perspective
Allow each person to speak
Recognize and acknowledge feelings
Avoid taking sides
Respect privacy and maintain confidentiality

Interview the patient separately, if needed
Evaluate agreement with the plan
Advanced family interviewing skills
are useful in situations where the family exhibits ineffective
communication, as a result of a conflict and intense emotions.
The advanced family interviewing skills will help the family in
communicating or managing conflicts to address the immediate
patient care issues; however, unlike therapy, the use of these
skills is not intended to create a permanent change in the
family's interaction patterns. The physician may use the
following skills:
Guide communication
Manage conflict
Reach common ground
Consider referral for family therapy
All students can be expected to learn and practice the core
skills. The advanced skills are generally learned during
residency training and are described in more detail in the article
by Lang, et al., listed in the References section, below.
Building Rapport with Adolescents
Building rapport is the most important skill a provider needs in
taking care of adolescent patients. A few simple techniques may
help reassure the adolescent that his provider is trustworthy:
Introduce yourself to the adolescent first, look him in the eye,
shake his hand and sit down during the interview.

Acknowledge the adolescent as your primary patient by
directing your questions primarily to him, rather than his
parents.
Use conversation icebreakers to allow time for the adolescent to
become more comfortable and get a sense of who you are.
Allow the adolescent to remain dressed during the interview and
sit in a chair rather than on the examination table.
Ensure confidentiality and provide a safe environment for him
to be honest.
Practicing reflective listening and take time to listen to what the
adolescent is saying and not saying.
Facilitating a comfortable experience for the adolescent by
providing adolescent-friendly and easy-to-access office and
staff. Interviewing the adolescent without his family present for
sensitive questions. Don't ask an adolescent about sexual
activity in front of parents.
Scrotal Exam Techniques
Inspection
On inspection, look for erythema, swelling, discoloration, skin
integrity, and position of the testicle.
Palpation
The skin of the
scrotum
should be palpated for edema, fluid collection, tenderness, and
subcutaneous emphysema. Begin palpation of scrotal contents
with the unaffected side.

The normal
testis
is mobile, and the spermatic cord and epididymis are palpable
posteriorly.
1. By gently grasping the testis between the thumb and first
two digits, the testicle is examined from its inferior pole,
superiorly.
2. Then palpate the testicle for size, tenderness, (localized or
diffuse), lie (high or low within scrotum-the left testicle
normally sits slightly lower than the right), and axis (horizontal
or vertical).
The
epididymis
should be examined for size, position, tenderness, and swelling.
The epididymis should be palpable as a soft, smooth ridge
posterolateral to the testis.
To complete the intra-scrotal evaluation, palpation of all scrotal
contents should occur. This includes examination of the
spermatic cord
to the superficial inguinal ring for tenderness or a "knot" which
suggests testicular torsion and any localized fluid collections,
such as a hydrocele or spermatocele.
Transillumination
Transillumination may help you determine the etiology of a
lesion. For example, a light source shines brightly through a
hydrocele.
Management
Treatment of Testicular Torsion

There are two approaches to treating torsion of the testes.
Nonsurgical approach
Manual detorsion of the torsed testes, may be attempted, but it
is usually difficult because of acute pain during the
manipulation. This nonoperative distorsion is not a substitute
for surgical exploration.
If the maneuver is successful, orchiopexy (surgical fixation of
both testes to prevent retorsion) must still be performed. This
should be done in the immediate future, preferably before the
patient leaves the hospital.
If full manual reduction of torsion cannot be performed or if
there is doubt about the diagnosis and reason to suspect torsion,
the scrotum must be explored.
Surgical approach
The testis must be unwound at operation and inspected for
viability. If it is not viable, it should be removed. If the testis is
viable
then orchiopexy should be performed to prevent recurrence.
Whether the affected testis is removed or conserved, the
contralateral one should undergo orchiopexy as the risk of
recurrence on the other side is otherwise high.
Studies
Diagnosing Testicular Torsion
Color Doppler ultrasonography
can confirm testicular torsion if pain is less severe and the
diagnosis is in question. If testicular torsion is present,

intratesticular blood flow is either decreased or absent which
appears as decreased echogenicity, as compared with the
asymptomatic testis. In addition, the torsed testicle often
appears enlarged.
Radionuclide scintigraphy
is a diagnostic test that uses a radioisotope to visualize
testicular blood flow. Patients with testicular torsion have
decreased radiotracer in the ischemic testis, resulting in a
photopenic lesion.
Radionuclide scintigraphy vs color doppler ultrasonography:
Radionuclide scintigraphy procedure has 100% sensitivity,
whereas Doppler ultrasonography only has a sensitivity of 88%
and a specificity of 98% in detecting testicular torsion.
Although scintigraphy may be more sensitive for testicular
torsion, ultrasonography is faster and more readily available.
This is a critical consideration in a condition that warrants a
rapid diagnosis.
Color Doppler ultrasonography and scintigraphy demonstrate no
statistically significant difference in ability to demonstrate
testicular torsion in boys with acute scrotal symptoms and
indeterminate clinical presentations.
Clinical Reasoning
Differential of Groin Pain in an Adolescent
Trauma
Trauma can cause acute pain and swelling of the scrotum and its
contents.

Severity may range from mild contusion to severe testicular
fracture or vascular disruption.
Testicular torsion
Testicular torsion, in which the testicle rotates around its
vascular supply, is the most serious condition under
consideration.
Surgical emergency with a limited window of four to 12 hours
(optimally within four to six hours) after the onset of pain to
save the testicle by untwisting the spermatic cord. Timely
diagnosis and treatment are vital for survival of the testis.
Most common in neonates and post pubertal boys, with the
majority of cases of testicular torsion occurring between the
ages of 12-18 years.
Relatively uncommon condition. Each year one in 4,000 men
younger than 25 years gets it.
Symptoms: scrotal, inguinal, or lower abdominal pain which
usually begins abruptly. The pain is severe, and the patient
appears uncomfortable. It can occur several hours after vigorous
physical activity or minor testicular trauma and there may be
associated nausea and vomiting. There may be prior similar
episodes that might suggest intermittent testicular torsion.
Symptoms: scrotal, inguinal, or lower abdominal pain which
usually begins abruptly. The pain is severe, and the patient
appears uncomfortable. It can occur several hours after vigorous
physical activity or minor testicular trauma and there may be
associated nausea and vomiting. There may be prior similar
episodes that might suggest intermittent testicular torsion.
Torsion of the testicular

appendages
Torsion of the testicular appendages (appendix epididymis and
appendix testis) occurs less commonly and is
associated with less morbidity than torsion of the testis.
Appendix testis is a small vestigial structure (embryonic
remnant of Mullerian duct) located on the anterosuperior aspect
of the testis.
Typically occurs in younger patients with most cases occurring
between the ages of seven and 14 years. Presents with abrupt
onset of pain that is typically less severe than in testicular
torsion and is localized to the region of the appendix testis
without any tenderness in the remaining areas of the testes.
As in epididymitis, the patient may appear comfortable except
when examined.
Presence of a bluish discoloration in the scrotum at the upper
pole of the testis (blue dot sign) is produced by testicular
appendiceal torsion.
Epididymitis
Epididymitis is the most frequent cause of sudden scrotal pain
in adults.
Symptoms are typically slowly progressive over several days
rather than abrupt.
It is caused by bacterial infection of the epididymis, typically
from a urinary tract or sexually-transmitted infection.
The patient may appear comfortable except when examined.

Severe swelling and exquisite pain are present on the involved
side, often accompanied by high fever, rigors, and irritative
voiding symptoms.
Patients may have had preceding symptoms suggestive of a
urinary tract infection or sexually transmitted disease.
On exam, the scrotum is tender to palpation and edematous on
the involved side. The cremasteric reflex is usually present, and
the testis is in its normal location and position.
Less Likely Diagnoses
Inguinal hernia
An inguinal hernia is a painless swelling in the inguinal region,
which can be enhanced by maneuvers that raise intraabdominal
pressure, such as cough or Valsalva maneuver. The swelling
becomes painful and tender when it is incarcerated.
Indirect hernia:
An indirect inguinal hernia develops as a result of a persistent
process vaginalis. The inguinal canal begins in the intra-
abdominal cavity at the internal inguinal ring, located
approximately midway between the pubic symphysis and the
anterior iliac spine. The canal courses down along the inguinal
ligament to the external ring, located medial to the inferior
epigastric arteries, subcutaneously and slightly above the pubic
tubercle. Contents of this hernia then follow the tract of the
testicle down into the scrotal sac.
Direct hernia:
A direct inguinal hernia usually occurs due to a defect or
weakness in the transversalis fascia area of the Hesselbach
triangle. The triangle is defined inferiorly by the inguinal

ligament, laterally by the inferior epigastric arteries, and
medially by the conjoint tendon.
Hydrocele
A hydrocele is a cystic painless scrotal fluid collection and is
the most common cause of painless scrotal swelling.
Light should be visible through the scrotum when it is
illuminated with a strong light source (positive
transillumination).
Hydroceles are generally asymptomatic unless associated with
trauma or infection, although patients may report a slowly
growing mass that causes a pulling or dragging sensation.
HenochSchönlein purpura (HSP)
Henoch-Schönlein purpura (HSP) is characterized by
nonthrombocytopenic purpura, arthralgia, renal disease,
abdominal pain, gastrointestinal bleeding, and occasionally
scrotal pain.
The onset of scrotal pain may be acute or insidious.
In boys who lack other characteristic findings of HSP,
sonography can usually distinguish HSP from testicular torsion.
Treatment of HSP is supportive.
Testicular tumor
Testicular tumor presents as scrotal mass that is rarely
accompanied by tenderness. The swelling is solid so should not
transilluminate.

Varicocele
A varicocele is a collection of dilated and tortuous veins in the
pampiniform plexus surrounding the spermatic cord in the
scrotum.
Varicoceles occur more commonly on the left side (85-95
percent) because the left spermatic vein enters the left renal
vein at a 90 degree angle, whereas the right spermatic vein
drains at a more obtuse angle directly into the inferior vena
cava, facilitating more continuous flow.
Varicocele is seen commonly in adult men but can be seen in
adolescents; approximately 10-25 percent of adolescent boys
have a varicocele.
One-third of all males presenting to an infertility clinic have a
varicocele.
Varicocele is associated with infertility, although the precise
mechanism by which this occurs has been the subject of
considerable research and is currently thought to be due to
increased testicular temperature.
Patients with varicocele can be asymptomatic or may complain
of a dull ache or fullness of the scrotum upon standing.
A varicocele is mass-like and nontender or mildly tender to
palpation on exam.
Referred pain
Boys who have the acute onset of scrotal pain without local
inflammatory signs or a mass on examination may be suffering
from referred pain to the scrotum.

The scrotal pain is caused by three somatic nerves that travel to
the scrotum: the genitofemoral, ilioinguinal, and posterior
scrotal nerves.
Retrocecal appendicitis is an important and a rare cause of
referred scrotal pain in children and adolescents.
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