1a) Identify two (2) additional questions that were not asked in the case study and should have been?
The healthcare provider managed to address all questions related to the patient’s illness. However, a few concerns were not clearly addressed during the HEEADSSS assessment. The first question that could have identified activities and hobbies are “What do you and your friends do for fun?” The second question could have been about Andrew’s safety/violence. “Have you felt unsafe or experienced any incidences of violence at home or school?
1b) Explain your rationale for asking these two additional questions.
The two questions are part of the HEEADSSS assessment that is used to identify risk and protective factors for adolescents (Farrant & Hornung, 2019). During the assessment, asking about activities involves things adolescents do for fun and the amount of time spent in these activities. Apart from Andrew engaging in football activities, it could have been important to understand his friends’ influence on other pleasurable activities. The question about safety and violence could help identify if Andrew is involved in events that could risk his health and the health of others. For instance, his history of behavioral problems could be revealed by this question.
1c) Describe what the two (2) additional questions might reveal about the patient’s health.
Health is defined as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. These two questions could help reveal the psychological and emotional well-being of Andrew including his relationship with his friends. The questions will help the provider ascertain that the early behavioral problems observed are not present anymore and any further action like referral may be required upon treatment.
DOMAIN: PHYSICAL EXAM
For each system examined in this case;
2a) Explain the reason the provider examined each system.
During the assessment of Andrew, a head-to-toe examination was conducted alongside a focused scrotal exam. The head-to-toe approach to the patient’s assessment was used because the provider was not only focused on the chief complaint but also the overall well-being of Andrew as an adolescent. Secondly, examination of the body systems serves as a guide to help identify potential or underlying illnesses or disease states subjectively (Phillips et al., 2017). Through the review of the systems, the healthcare provider can prioritize care and systems to follow up in the objective assessment.
2b) Describe how the exam findings would be abnormal based on the information in this case. If it is a wellness visit, based on the patient’s age, describe what exam findings could be abnormal.
Andrew’s blood pressure was slightly high (130/82mmHg) probably because he was experiencing intense pain. Pain assessment revealed a score of 10/10 indicating that he was at the extreme end of pain. Abnormal findings during the assessment were observed in the genitourinary system. On inspection, a swollen and erythematous right scrotum was observed. The right testicle was exquisitely tender and swollen. The Prehn’s sign was negative while the Cremasteric reflex was present on the left side and absent on the right. These findings indicated that there was a problem in the right scrotum that could be revealed through additional diagnostic testing.
2c) Describe the normal findings for each system.
The vital signs for the patient were as follows: Temperature: 98.7 Fahrenheit, Heart rate: 90 beats/minute, Respiratory rate: 14 breaths/minute, Blood pressure: 130/82 mmHg, Weight: 145 lbs, Height: 5’ 9’’, Body Mass Index: 21. HEENT revealed no conjunctival icterus or pallor, Cardiac system revealed regular heart rate and normal heart sounds. The lungs were clear to auscultation bilaterally and the abdomen was not distended, non-tender, no masses, no hepatomegaly, and there were normal bowel sounds. At the back, there was no tenderness and the examination of the extremities revealed strong and equal pulses. Normal genitourinary findings included no scrotal masses, no scrotal transillumination, and there was no penile discharge, inguinal lymphadenopathy, or hernias. A rectal assessment revealed no tenderness and the stool was heme negative. These findings indicated that the patient only had health challenges in the right scrotum.
2d) Identify the various diagnostic instruments you would need to use to examine this patient.
Instruments for examination of the patient will include a blood pressure machine, stethoscope, thermometer, and weighing scale. For assessment of the scrotum, a penlight will be required to shine light from behind a scrotal lump.
DOMAIN: ASSESSMENT (Medical Diagnosis)
Discuss the pathophysiology of the:
3a) Diagnosis and,
The definitive diagnosis of the patient was testicular torsion. Accounting for roughly one-quarter of scrotal complaints that present to the ED, testicular torsion is caused by twisting of the blood supply and spermatic cord (Schick & Sternard, 2017). The condition is most common in neonates and post-pubertal boys and if not urgently treated it can lead to testicular loss. As the testicle twists around the spermatic cord, venous blood flow is cut off, leading to venous congestion and ischemia of the testicle (Schick & Sternard, 2017). The result is swelling, tenderness, and erythema. Further twisting can result in total cutting of blood supply leading to testicular ischemia and eventually necrosis.
3b) Each Differential Diagnosis
Differential diagnoses for the patient’s condition include testicular appendage torsion and epididymitis. Testicular appendage torsion is considered one of the causes of acute scrotal pain resulting from twisting of the appendix testis or appendix epididymis (Schick & Sternard, 2017). The twisting can be caused by trauma or prepubertal enlargement leading to an abrupt onset of pain localized in the region of the appendix testis without any tenderness in the rest of the testis.
Epididymitis is the most common cause of scrotal pain in adults (McConaghy & Panchal, 2016). The condition is caused by bacterial infection of the epididymis, typically from UTIs. Infection can also spread as a result of sexual intercourse that sees the bacteria migrate through the urinary tract to the epididymis (McConaghy & Panchal, 2016). Upon colonization by the bacteria, repetitive movements and the mobility of the scrotum and its contents result in inflammation of the epididymis.
DOMAIN: LABORATORY & DIAGNOSTIC TESTS
Discuss the following:
4a) What labs should be ordered in the case?
The patient will not be required to do any laboratory tests in this case. Laboratory tests are unlikely to be conclusive because no single test has high sensitivity or specificity for diagnosing the condition.
4b) Discuss what lab results would be abnormal.
No laboratory results will be abnormal in this case.
4c) Discuss what the abnormal lab values indicate.
No laboratory results will be abnormal in this case.
4d) Discuss what diagnostic procedures you might want to order based on the medical diagnosis.
I will want to order a Doppler ultrasound. This diagnostic test has approximately 93% sensitivity and 100% specificity when used to diagnose testicular torsion (Schick & Sternard, 2017). Power Doppler can be used to evaluate testicular blood flow and further indicate the severity of the torsion.
5A) Testicular cancer risk factors?
Testicular cancer is a relatively rare disease that affects men. Although the disease can affect young boys, it is common among individuals aged 15 to 44 years. Risk factors may include an undescended testicle, family history of the disease, and HIV infection (American Cancer Society, 2018). Additionally, individuals with a big body size and prior instances of testicular cancer can increase the chance of being affected.
5B) Signs and symptoms of testicular cancer?
The most common sign is a painless lump in the testicle which contributes to late diagnosis since most men do not seek early medical attention (American Cancer Society, 2018). Swelling of the testicle may be observed with or without pain and the testis becomes heavy. As the disease progresses, pain or a dull ache is observed in the testicle, scrotum, or groin and tenderness may be present in male breast tissue.
American Cancer Society. (2018). About testicular cancer. https://www.cancer.org/cancer/testicular-cancer/causes-risks-prevention/risk-factors.html
Farrant, B., & Hornung, R. (2019). Adolescent consultation and HEaADSSS assessment. https://starship.org.nz/guidelines/adolescent-consultation/
McConaghy, J. R., & Panchal, B. (2016). Epididymitis: An overview. American Family Physician, 94(9), 723-726. https://www.aafp.org/afp/2016/1101/p723.html
Phillips, A., Frank, A., Loftin, C., & Shepherd, S. (2017). A detailed review of systems: An educational feature. The Journal for Nurse Practitioners, 13(10), 681-686. https://doi.org/10.1016/j.nurpra.2017.08.012
Schick, M. A., & Sternard, B. T. (2017). Testicular torsion. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448199/
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