Question of the Week # 1

Question of the Week – July 29th 2010

1. A 15 year old boy presents to emergency room with severe lower abdominal pain that awoke him from sleep about 5 hours ago. The pain is sharp and radiating to the left thigh. While in the emergency room, the patient has one episode of vomiting. He denied any fever, dysuria or chills. Physical examination reveals normal vitals with blood pressure 100/60 and temperature of 98.6F. Abdominal examination is relatively benign. Scrotal examination reveals an elevated left testis that is diffusely tender to palpation. Cremasteric reflex is present on the right but absent on the left. Most important next step in managing this patient :
a. CT scan Abdomen and Pevlis
b. Testicular Ultrasound
c. Surgical Exploration
d. Intravenos Antibiotics
e. Plain X-Ray KUB

Answer will be posted with in 3 days. You may submit your responses and analysis as a comment to this post.

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27 Responses

  1. c

    • surgery consultation
      Dx test torsion emergency medical cond
      no epidymitis, no infection

    • c

    • its b) patient has testicular torsion in the left probably. Confirm with testicular ultrasound.

    • Surgical exploration.
      Torsion of Testis is likely

    • C

    • c surgical exploration, Dx: testicular torsion

    • b) positive cremasteric reflex (no elevation with stimulation) “suggest testicular torsion need to confirm with testicular ultrasound first and if positive next step is surgery

    • Testicular us

  2. c

  3. Ans. C

    ( For extensive discussion on several similar highyield Step 3 topics, visit Archer USMLE Step 3 Review)

    Congratulations! Most of you got this Q right. Testicular ultrasound is a very close distractor in this Question but one should know when to do a tesicular ultrasound as opposed to surgical exploration in a suspected testicular torsion case.

    Recognize that clinical probability of testicular ultrasound can be estimated by history and physical examination ( see the predictive clinical score below). Ultrasound should only be done if the clinical diagnosis is uncertain and if the performance of imaging does not significatntly delay the treatment. Doing color doppler in this patient is not necessary since the diagnosis is clinically clear and imaging will further delay surgical intervention ( it is already 5 hrs since onset of pain)

    Rapid diagnosis is important in order to salvage a viable testis with prompt surgery. The testicular salvage rate is more than 80% if surgery is performed within 6 hours, but the rate decreases to approximately 20% if surgery is done after 12 hours after the onset of symptoms.

    Testicular Torsion: Clinical features include acute onset pain, absence of cremasteric reflex, negative prehn’s sign, tender testicle on palpation and a an elevated or horizontal lie of testis ( changed position of testis). Absent cremasteric reflex is the most sensitive physical finding for diagnosing testicular torsion. Three features in the history can serve as predictors of pre-test clinical probability of Testicular Torsion: 1. Onset of pain less than six hours 2. Absence of Cremasteric reflex 3. Diffuse Testicular Tenderness. Presence of all the three features ( score:3) is assocaited with 87% probability (high probability) of having Testicular Torsion as per a large study. These patients should undergo direct surgical exploration. A score of 1 or 2 indicates moderate to low clinical probabilty and should first undergo diagnostic ultrasound. A score of 0 favors an alternative diagnosis for acute scrotum rather than Testicular Torsion.

    Key Concept : Recognize “Testicular Torsion” clinical score and determine the next step as follows : : 1. Onset of pain less than six hours 2. Absence of Cremasteric reflex 3. Diffuse Testicular Tenderness. Presence of all the three features ( score:3) is assocaited high probability of having Testicular Torsion as per a large study –> Next step, direct surgical exploration. A score of 1 or 2 indicates moderate to low clinical probabilty –> next step, diagnostic ultrasound. A score of 0 favors an alternative diagnosis for acute scrotum rather than Testicular Torsion.

  4. hello

  5. c

  6. TESTICULAR TORSION

  7. This is also a ccs case

  8. surgical exploration

  9. The on set of pain is only from 5 hours ,so we can assume that it is an acute on set which may be an indication for emergency surgical intervention. here local tenderness, swelling of the scrotum concerned with age it is due to torsion of the testis.

  10. c

  11. C

  12. c

  13. c

  14. testicular ultrasound

  15. Testicular ultrasound to rule out testicular torsion

  16. B

  17. For this patient it better to do scrotal elivation test to differentiate testicular torsion from epididymiorchitis.
    If we are sure that it is not epididymiorchitis, it is better to do surgical exploration to avoid unnecessary delay which might cause loss of the testis. If we wait more than 6hr , we may not get viable testis

  18. Testicular ultrasound

  19. Surgical exploration

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