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Assignment: Case Study of a Patient with Pain in the Right Scrotum

Assignment: Case Study of a Patient with Pain in the Right Scrotum

 

The case study is of D.G, a 34-year old male patient who presents with complaints of pain in the right scrotum in the last 24 hours, which he rates as 7. He described the pain as constant and nagging. He has no history of STIs or urinary problems but reports a history of rash at the groin area in the past months, which he applies OTC cream to relieve the itch. He is sexually active but does not use condoms and is also allergic to penicillin. He has a family history of hypertension, hyperlipidemia, and COPD, and reports taking ten drinks per week. Vital signs include, Temp-98.4 F; Pulse-74; Resp-16; BP-110/74 and BMI-26. Physical exam findings include: red right testis, tender and swollen twice the normal size, decreased pain with raising the testes and positive cremasteric reflex. The left testis is not red, tender, or swollen. There is also a dull, faint red rash in the left and right groin area with scaly plaques and distinct margins covering a small area of the groin.

Potential Differentials

Testicular torsion: Testicular torsion is a sudden twisting of the spermatic cord structures within the scrotum that causes loss of blood supply to the testicle (Jordan, Ann Kroger-Jarvis & Gillespie, 2016). Positive pertinent findings of Testicular torsion include worsening unilateral testicular pain, scrotal erythema, and swelling. A positive Phrehn’s sign rules out Testicular torsion as the primary diagnosis. A positive Prehn’s sign is considered when there is pain relief with lifting the affected testicle (Jordan, Ann Kroger-Jarvis & Gillespie, 2016). Testicular torsion presents with increased pain when the testicles are elevated. Cremasteric reflex is usually absent in Testicular Torsion, and a positive cremasteric reflex rules out testicular torsion as a primary diagnosis (Jordan, Ann Kroger-Jarvis & Gillespie, 2016). Other negative findings include nausea, vomiting, high-riding testis, and an abnormal transverse lie.

Orchitis: Orchitis is an acute inflammation of the testes secondary to an infection. Physical findings on testicular examination in Orchitis include testicular enlargement, tenderness, erythematous scrotal skin, edematous scrotum, induration of the testes, and an enlarged epididymis (Bonkat et al., 2017). Orchitis also manifests with systemic symptoms such as fatigue, myalgia, fever, malaise, nausea, and headache (Bonkat et al., 2017). Pertinent positive findings of Orchitis include scrotal pain, testicular tenderness and enlargement, and an erythematous scrotal skin. Pertinent negative findings include systemic symptoms, including fever, malaise, nausea, headache, and myalgia.

Primary Diagnosis

Acute Epididymitis: Epididymitis is the inflammation of the epididymis. Subjective data that points to Epididymitis include gradual onset of scrotal pain and swelling (McCONAGHY & Panchal, 2016) (McCONAGHY & Panchal, 2016). Positive pertinent findings include scrotal swelling, tenderness, and erythema; positive Prehn’s sign, as evidenced by relief of pain by raising the testes and a positive cremasteric reflex (McCONAGHY & Panchal, 2016). Besides, Epididymitis manifests with unilateral testicular pain that points to the affected epididymis, which is the case with the patient’s presentation of a red, tender, and swollen right testis with a normal left testis.

Secondary Diagnosis

Tinea Cruris: A superficial fungal infection affecting the groin and the adjacent skin. Symptoms of Tinea Cruris include pruritus and rash. Physical exam findings include erythematous rash in the groin, large patches of erythema, sharply demarcated scales at the periphery (Bishnoi & Mahajan, 2018). The penis and scrotum are usually spared. Pertinent positive findings include a history of chronic rash in the groin and erythematous scaly plaques with distinct margins. The patient has a history of ointment use, which suppressed the itching, and this resulted in a chronic Tinea Cruris infection.

Treatment Plan

Medications: The CDC recommends initiating treatment and basing treatment choice on the risk of gonorrhea and chlamydia to prevent complications and spread of gonorrhea and chlamydia (CDC, 2015). As per the CDC guidelines, the treatment will include:

  1. Ceftriaxone 250 mg I.M STAT dose, no refills.
  2. Doxycycline 100 mg per oral, take two tablets in a day for 10 days.
  • Ibuprofen 400 mg thrice a day to relieve pain and inflammation.

Terbinafine 250 mg oral dose, take one tablet per daily for 4 weeks. Terbinafine will be the drug of choice for Tinea Cruris since the patient has a chronic infection (Bishnoi & Mahajan, 2018).

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The patient will be advised to have bed rest and reduce physical activity to avoid worsening the pain. The scrotum will be elevated

Assignment Case Study of a Patient with Pain in the Right Scrotum

Assignment Case Study of a Patient with Pain in the Right Scrotum

Scrotal with a jockstrap when the patient is upright to reduce repetitive, minor bumps, and relieve pain (McCONAGHY & Panchal, 2016). I will also instruct the patient to use ice packs on the scrotum to help in alleviating pain.

Education on medication adherence, especially Griseofulvin, to prevent relapse of the infection. The patient will also be educated on safe sex practices such as using condoms to avoid reinfection. Obese patients with tinea cruris are recommended to lose weight to reduce chafing and sweating, which result in reinfection (Bishnoi & Mahajan, 2018). I will advise the patient to limit alcohol intake, take a healthy diet, and engage in physical exercise to promote weight loss.

Additional diagnostic tests: Nucleic acid amplification test (NAAT) to rule out a sexually transmitted infection with Neisseria gonorrhoeae and Chlamydia trachomatis. NAAT should be performed for sexually active patients below 35 years or those who have a new sex partner, to detect N. gonorrhoeae and C. trachomatis (CDC, 2015).

Referral: Referral to a urologist if the symptoms worsen or do not resolve with treatment to review the patient and treatment plan.

Follow-up: The patient will be scheduled for a follow up in the outpatient setting after one week to assess for clinical response to prescribed treatment.

CC: “I am having pain in my right scrotum.”
HPI: D.G. is a 34-year-old male who presents with c/o pain in the right scrotum for the past 24 hours. Reports that pain has been “getting worse” and rates as 7 on pain scale. Reports that the pain is constant and nagging. He denies trauma to the area, penile discharge or burning. He denies any h/o UTI, prostatitis or kidney stones. He is sexually active with a new female partner for the past 2 ½ months and does not use condoms.
PMH: Last physical 1 year ago. UTD on immunizations.
Medication: None
Allergies: Penicillin – causes rash
PSH: Denies
SH: Divorced for 2 years. Has 3 children. Works as an electrical engineer. Nonsmoker. Denies illicit drug use. Drinks 10 drinks per week.
FH: Mother – deceased
Father – HTN and Hyperlipidemia
Sister – Alive and well
Brother – COPD
Review of Systems:
Cardiovascular: Denies chest pain, dyspnea or edema.
Respiratory: Denies SOB, wheezing, cough, allergies.
Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, constipation or change in bowel pattern.
Genitourinary: Denies h/o STI or undescended testicles; denies h/o of kidney or urinary problems; reports rash to the groin area for the past several months; applies OTC cream when it begins to itch and stops when the itch goes away.
Physical examination:
VS: 98.4-74-16-110/74; BMI:26
General: A&OX3; NAD
Heart – RRR with murmur, gallops, rubs
Lungs: CTA bilaterally
Abdominal: soft, flat, non-distended with ABSX4; no HSM; no CVA or suprapubic tenderness; no inguinal nodes or lymphadenopathy noted
Genitourinary: Right testis red, tender and swollen twice the normal size; raising the testes decreases the pain; positive cremasteric reflex; negative to transillumination; no varicocele, hydrocele, epididymal cyst or spermatocele noted. Left testis is not red, tender or swollen. No inguinal or femoral hernias. Dull, faint red rash noted in the left and right groin area with scaly plaques and distinct margins covering a small area of the groin.
Lower extremities: no lesions or rashes.
Assignment:
For the assessment portion of the assignment:
1. identify potential differentials and specify the subjective and/or objective data that rules the differential out as the primary diagnosis
2. identify primary diagnoses and specify the subjective and/or objective data that confirms the diagnoses
3. identify secondary diagnoses and specify the subjective and/or objective data that confirms the diagnoses.
For the treatment plan portion of the assignment:
1. identify appropriate medications based on evidence-based guidelines for each diagnosis (primary and secondary) and list the medication as if you were writing a prescription or escribing (medication name, dose, how to take, number to dispense and if refills will be provided)
2. identify appropriate non-pharmacological therapies and patient education based on evidence-based guidelines
3. identify if additional diagnostic testing or referrals are warranted and justify why the labs and or is warranted
4. identify when the patient is to return for follow-up
*If you feel that the patient needs to be referred for the diagnosis, develop the treatment plan based on evidence-based pharmacological and non-pharmacological therapies that would be utilized by the specialist.
*Remember to list the evidence-based guidelines that you utilized to develop the treatment plan on a reference page.

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