Presented by Brian Junnila, MD
Abdominal pain, nausea and vomiting
HISTORY OF PRESENT ILLNESS
14 year old male presents with acute onset of abdominal pain 3 hours duration which woke him up from sleep at 0300 this morning. Pt is accompanied by his mother and father who relate a history of being awakened by their son complaining of abdominal pain and crying inconsolably. Pain is located to the right lower quadrant radiating to the right inguinal region and scrotum. Pain is ranked 10/10, constant and stabbing in nature. Associated symptoms include nausea and vomiting, 2 episodes last 3 hours described as the contents of his dinner, no blood or greenish discoloration reported. Last oral intake was at 2000 last night and consisted of macaroni and cheese. Pt acknowledges multiple previous episodes of abdominal and scrotal pain over the last year which always spontaneously resolved in 1-2 hours and had never been this severe. Pt denies any recent dysuria, hesitancy, urgency or penile discharge. Pt denies any change in recent change in bowel pattern; last bowel movement was yesterday and normal in consistency. He denies any recent fever, sore throat, chest pain or shortness of breath.
REVIEW OF SYSTEMS
The following systems were reviewed: Constitutional, eyes, ears, nose, throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurologic, psychiatric, endocrine, lymphatic and immunologic. All review and negative except as document in history of present illness.
PAST MEDICAL HISTORY: Buckle fracture left radius
PAST SURGICAL HISTORY: Tonsillectomy at age 5
ALLERGIES: NKDA, peanuts cause swelling
FAMILY HISTORY: Father with HTN, DM type 2
SOCIAL HISTORY: Denies tobacco, alcohol, illicit drug use. In 9th grade, does well in school.
EXAMINATION OF ORGAN SYTEMS AND BODY AREAS
VITALS: BP 126/56, HR 112, RR 22, T 37.7˚C, Pulse ox 98% RA
CONSITUTIONAL: A&O x 3, in moderate distress, crying and uncomfortable
EYES: Injected conjunctiva, PERRLA, EOMI, sclera anicteric
EARS: TM good light reflex no bulging or erythema bilaterally
NOSE: Mucous membrane moist, clear rhino rhea
MOUTH: Mucous membranes moist, no intraoral lesions, no pharyngeal erythema
NECK: Supple, full ROM, no C-spine tenderness. No lymphadenopathy, no thyromegaly.
CARDIOVASCULAR: Tachycardia, regular rhythm. Normal S1 and S2. No M, R, G
RESPIRATORY: Good air movement bilaterally, CTAB, No wheezes, rhonchi, rales
ABDOMIN: Soft, discomfort to palpation of the right lower quadrant, no rebound, no guarding, ND, no masses. BS positive throughout.
BACK: No tenderness to palp of C,T L vertebrae. No CVA tenderness.
GENTIOURINARY: Uncircumcised. No external genital lesions, no urethral discharge, no inguinal lymphadenopathy. Loss of the cremasteric reflex on right. Left cremasteric reflex intact. Scrotal edema. Right testicle firm and tender to palpation.
MUSCULOSKELETAL: Full range of motion in all 4 extremities with strength 5/5 both proximally and distally. No joint effusions.
SKIN: Warm dry and normal color, no rash, no ecchymosis, no petechiae.
CBC w/diff: 6.7>13.9/4.2<281
Urinalysis: Clear, yellow, glucose negative, bilirubin negative, ketones negative, specific gravity 1.029, blood negative, pH 5.5, protein negative, urobilinogen negative, nitrite negative, leukocytes esterase negative, RBC < 2, WBC < 5, epithelial cells < 5, casts none, mucous negative, bacteria none, sperm none, trichomonas none
Bilateral transverse color Doppler ultrasound
Right testicle Left testicle
1. What is the first step in management of patients with this condition?
a. Color-flow duplex Doppler ultrasound
b. Manual detorsion
c. Radionuclide scintigraphy
d. Systemic intravenous analgesia
e. Urologic consultation
2. After what time from symptom onset will the salvage rate for the affected testes drop below 90%?
a. 3 hours
b. 6 hours
c. 9 hours
d. 12 hours
e. 24 hours
3. What is the correct procedure for manual detorsion of the right testis?
a. 180˚ clockwise rotation
b. 180˚ counterclockwise rotation
c. 360˚ clockwise rotation
d. 360˚ counterclockwise rotation
e. 540˚ clockwise rotation
f. 540˚ counterclockwise rotation
4. Which physical exam finding is present in nearly 100% of all adolescent patients with our patient’s condition?
a. Tender firm testicle
b. High position of affected testicle
c. Loss of the ipsilateral cremasteric reflex
d. Prehn sign
e. Transverse orientation of affected testicle
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