SOCIAL HISTORY: He drinks alcohol moderately, is a nonsmoker. FAMILY HISTORY, RE
ID: 175064 • Letter: S
Question
SOCIAL HISTORY: He drinks alcohol moderately, is a nonsmoker. FAMILY HISTORY, REVIEW OF SYMPTOMS: Entirely negative. PHYSICAL EXAMINATION: GU: Penis, normal phallus without lesions. Testes, descended bilaterally. The left testicle is entirely normal in consistency and size. The right testicle is approximately 2x the sire of the left. It is hard, without any areas of fluctuance. It is only mildly tender. The epididymis does not feet enlarged. There is no hydrocele. There is no groin adenopathy. A scrotal ultrasound was done the day before yesterday which revealed an inhomogenous right testicular mass consistent with tumor versus possible abscess. IMPRESSIONS: Rule out right testicular mass versus possible abscess. PLAN: Admit the patient this evening for right inguinal exploration with possible radical orchiectomy. We also plan to proceed with chest x-ray and preoperative lab work, including alpha-fetoprotein and beta HCG. INFORMED CONSENT: The patient is scheduled for the above surgery on 10/13/2014. The indications, risks and alternatives of the procedure were explained in detail to him and his parents. The risks include bleeding, infection and testicular loss. He understands the above, has no further questions and agrees to proceed with surgery. What were the patient's initial symptoms? What was he initially treated for? Did he have a urethral discharge? What did the scrotal ultrasound reveal?Explanation / Answer
1. The patient showed non consistent mass in the right testis.
2. He was initially treated for testicular pain. This has been proved from the medication that was administered to him, i.e penetrax and ibuprofen (both being painkillers).
3. The above report does not show any point where he has any case of urethral discharge.
4. The scrotal ultrasound revealed that the left testicle was normal in consistency of mass and the size. But, the right testis showed enlargement of its size of around twice the normal size. This abnormality in size was suspected either as a tumoral mass or an abscess.
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