Good Morning! March 23, 2015

Transcription

1 Good Morning! March 23, 2015

2 Prep Question You are caring for an 8-year-old girl who was involved in a motor vehiclepedestrian crash. Despite maximal medical and surgical therapy, she developed intractable intracranial hypertension, and she now has fixed and dilated pupils as well as an absence of corneal, cough, and gag reflexes. Her temperature is 36C, HR is 90bmp, RR is 25 on the mechanical ventilator, blood pressure is 95/60, and oxygen saturation is 96%. She is in a cervical collar due to a suspected cervical spine injury, and her tympanic membranes are ruptured bilaterally. Results of the apnea test (absence of respiratory movements and a rise in PaCO2 after temporarily disconnecting the ventilator) are consistent with brain death. Of the following, the MOST commonly used ancillary test to support the diagnosis of brain death in this situation is A. Cerebral blood flow studies B. Electroencephalography C. Magnetic resonance imaging of the brain D. Somatosensory evoked potentials E. Transcranial Doppler ultrasonography

3 Our patient today: 10 year old male with groin pain

4 History PMH: Hypercalcuria ADHD Hereditary hearing impairment Meds: HCTZ, Vitamin D, Vyvance Immunizations: UTD Allergies: NKDA FHx: hearing impairment BHx: noncontributory

5 Differential Testicular torsion Torsion of appendix testis Epididymitis Inguinal hernia Henoch-Schonlein purpura Orchitis Referred pain Hydrocele Varicocele Spermatocele Cancer Nephrotic syndrome Cellulitis Trauma Sexual abuse

6 Important to the History Onset and severity Trauma Change in testicular or scrotal size Variation with time of day or positioning Sexual activity Difficulty with voiding Presence of flank pain or hematuria Abdominal pain with NV, decreased activity

7 Exam V: T99 P96 BP 114/76 R24 Wt 27.5kg Gen: appears uncomfortable HEENT: normal CV/Resp: normal EXT: normal Skin: normal, no rashes Abd: BS x4, soft, NTND GU: NEMG, no scrotal edema/erythema, sharp pain elicited on palpation of right testicle, testicle with normal orientation/no elevation, + cremasteric reflex, no discharge

8 Important to the Exam Include abdomen, inguinal region, genitalia Patient should be standing Palpation Inspection Notice any lesions, discharge, piercings, LAD Reflexes Cremasteric Phren

9 So, what are your picks? Testicular torsion Torsion of appendix testis Epididymitis Inguinal hernia Henoch-Schonlein purpura Orchitis Referred pain Hydrocele Varicoceles Spermatocele Cancer Nephrotic syndrome Cellulitis Trauma Sexual abuse

10 Work-up Options CBC UA/UCx STI evaluation Color Doppler Ultrasound Surgical Exploration

11 Testicular Torsion Torsion of Appendage Acute Epididymitis Incidence Perinatal, puberty Prepubertal <2 yrs, postpubertal Onset of pain Sudden Sudden Gradual Duration of pain <12 hours >12 hours >24 hours N/V Fever Hx of trauma? +/- - - Dysuria/Discharge Physical findings Bell clapper Blue dot None Cremasteric reflex Absent Present Present Tenderness? Testis -> diffuse Appendage -> testis Epididymis -> diffuse Erythema/edema >12 hours >12 hours >12 hours Pyuria Leukocytosis Doppler US Decreased Normal/Increased Normal/Increased

12 Twisting of spermatic cord blood supply compromised 4-8 hours before significant ischemic damage seen Major peak during puberty 65% between yo Described as extravaginal or *intravaginal Bell clapper deformity, usually bilateral

13 Sudden onset unilateral, severe pain** History of intermittent testicular pain Nausea/vomiting in 90% Involved testicle may be: higher, in transverse orientation, or see an anterior location of epididymis Absent cremasteric reflex Testicle tender to palpation Erythema and induration

14 Clinical!! UA- pyuria/bacteruria more likely in epididymitis High res US with color Doppler** Manual detorsion- medial to lateral rotation (2/3 of pts) Open book Sudden pain relief Urology for surgical exploration** Relieve torsion Testicle in warm/moist sponges Opposite scrotum explored CL testis is secured to scrotal wall IL testis reassessed

15 Boys between ages 7-12 years Prepubertal- hormonal stimulation increases mass of the structures, can then twist Appendix testis or appendix epididymis Also paradidymis-organ of Giraldes, superior and inferior vas aberrans of Haller Often misdiagnosed as epididymitis

16 Blue dot sign Appendage is focally tender to palpation (superior to testicle) Testicle nontender UA- usually normal US- Blood flow normal or increased** Self limited, 5-10 days Pain resolves as appendage infarcts and necroses NSAIDs, limited activity, warm compress

17 Most commonly in late adolescents** Predisposing factors: sexual activity, physical exertion, direct trauma Prepubertal boys and adolescents not sexually active** Structural anomalies of urinary tract Mycoplasma, enterovirus, adenovirus Bacterial etiology uncommon- 4% May be associated with UTI or urethritis

18 Pain slow in onset with swelling over days Usually no nausea, vomiting Dysuria, urethral discharge, +/- fever Affected testis in normal position Scrotum may appear erythematous and parchment-like Cremasteric reflex normal May have pain relief when elevate testis

19 Clinical UA/UCx Leukocytes Common urinary pathogens, Mycoplasma May also be viral STI workup if indicated Urethral swab or NAAT for Chlamydia and Gonorrhea Syphilis, HIV testing Imaging- renal/bladder US and VCUG after infection resolved Treat bacterial source with antibiotics**

20 Our patient US: minimal enlargement of right epididymis with associated mild increased flow within the epididymis. Underlying testicle is normal with normal Doppler flow. Ucx: no growth DC with Bactrim x10 days, Tylenol/motrin for pain relief

21 Painless Swelling Mass Palpation Transilluminates Increase with Valsalva Tumor Firm No No Varicocele Bag of worms No Yes Hydrocele noncommunicating Spermatocele Fluid-filled Yes No Small, soft, localized cyst Yes No

22 Have a Great Day Noon Conference: Dr Dal Corso, Outpatient Depression Screening (Location: Across the street!)

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