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If you have completed case N, this is a review. Completion of this case will not be counted toward your assignment.
It is about 4:30pm and you are beginning to see the end of a long day as the acute care physician in your family medicine clinic. Just as you finish up with your last patient, you see that there is an "add on." You inquire as to the nature of the visit with the nurse who took the telephone call. She explains that the patient sounded like a male teenager, but that the patient did not wish to disclose the reason for his appointment.
As you are finishing up your final dictation, the patient arrives at the clinic. You gather your thoughts, pick up his chart, glance down to see the name, Warren T., knock, and then enter the room.
Upon entering the room, you find a 17 year old, somewhat distressed, young man named wearing a soccer jersey. He is seated on the examination table with an anxious look on his face. Upon your inquiry, Warren states:
"I have pain down there," pointing to his genitals.
Further tactful questioning reveals that Warren’s pain is in his scrotum, in particular, the right side.
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Continuing the clinical interview, you obtain the following information. Warren began to experience pain in his right testicle approximately three days ago. This discomfort has gradually worsened and he has noticed increasing redness and swelling of his scrotum. He further notes the presence of a yellowish discharge from his penis in the last day or so, and explains that he woke up last night sweating and felt that he probably had a fever. |
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Of
course, it is essential to obtain a thorough past medical history,
family and social history; medication and allergy, if this information
is not already available in the patient’s chart or if it is not up to
date.
HPI (con’d): Social Hx: PMHx: Medication: none Family Hx: Noncontributory Allergies: He has no known medication allergies ROS: |
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As
usual, vital signs are your first priority. If the vital signs are stable,
the physical exam in this patient should be directed to a thorough exam of
the genitals and surrounding structures. However, with STDs in the
differential, one should also examine the conjunctiva, oral cavity, skin
(for rashes/lesions), and joints despite the negative ROS from the patient
history.
**Professionalism is essential for the genital exam: It is important to prepare a systematic approach to the genital exam just as it is for any other region of the body. However, this is particularly important with the genital region, as this exam is usually embarrassing for the patient. It is essential that you be thorough, yet expedient, to minimize patient apprehensiveness. Remember, physicians do not "feel," they palpate. Try to use this medical terminology around the patient; it is more professional and lacks sexual connotation. As with any other part of the body, it is important to exam above and below the area of concern. In this patient, that would include an abdominal exam as well as an examination of the perineum, inguinal region and the upper portion of the lower extremities. Begin by examining above and below the genital region, saving that region for last. When treating adolescents, confidentiality should be maintained and discussed with the patients. Especially with sexually active teens, ensuring them that information will be disclosed only with their permission will foster trust and enhance the chances that the patients will be honest in giving an accurate history and discussing their concerns. |
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You
perform a directed physical exam on Warren, with the following results:
General appearance: The patient is an athletic-appearing, apprehensive seventeen year old who appears in mild distress. Vital signs: BP= 130/85, HR= 95, R =13, T= 100 F Abdominal exam: +bowel sounds, nontender/nondistended, no masses or hepatosplenomegaly Inguinal/upper thigh exam: no evidence of direct hernia, nontender, no redness or local skin changes, no evidence of femoral hernia Genital exam: you observe erythema of the right-sided scrotal skin, the skin is warm to the touch and the entire scrotum is tender and swollen, [rubor(redness), calor(warmth), dolor(pain/tenderness), tumor(swelling)], no evidence of other skin changes on scrotum or perineal skin, trace yellowish discharge from urethral meatus, testicles are normally descended, normal in size and shape, and are symmetrical and nontender, there are no masses palpated in the testicles, right epididymis is tender and enlarged, vas deferens are normal in size and shape bilaterally, and slightly tender on right side, elevation of the right testicle reduces patient pain (Prehn’s sign), cremasteric reflex present bilaterally, no hernia palpated through external ring |
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