PEM Case of the Week

By: Boris Khodorkovsky, MD

History

20 yo M who came in with RLQ pain x1day.  No other signs of appendicitis – no vomiting/anorexia/fever.  No pain migration.  No trauma. No sore throat. No testicular pain. No urinary symptoms.

Exam:

VSS. Afebrile, MMM, pink conj, anicteric, lungs clear, abdomen soft, non tender, no distension, no peritoneal signs. No McBurney’s. 

GU exam (the look below): L testicular enlargement x3 size of the R one.  Hard to palpation.  No tenderness.

Further history regarding L testicular swelling: Pt stated that he noticed it about 2 weeks ago, but it did not bother him.  No trauma.

Plan:

Labs, UA, US, +/- CT

Imaging:

US = L testicular multiple masses.  No torsion.

CT = no acute surg pathology, multiple para-aortic lymph nodes, multiple pulmonary nodules

Dispo:

                GU consultation. Cancer markers. Discharge with close follow up.

Testicular Tumors:

• most common malignancy in young men

• presentation:

• scrotal/testicular enlargement

• Lower abdominal pain

• Diff Dx:

• Epididymitis

• Torsion

• Hydrocele

• Hernia.

• ED Work up:

• US testicular

• UA

• CT rarely helpful unless pt has other related complaints

• Tumor markers (LDH, AFP, hCG) – only with GU on board.

• Management:

• GU referral – communicate with GU prior to dispo

• Outpatient

• Careful documentation and follow-up are crucial.

BK1 Pearls:

• Always complete your exam prior to any workup decisions.

• Abdominal pain = GU exam.  Don’t skip the testicular exam.

• The initial complaint may not be the actual reason why patient is in the ED.

• Expand your differential diagnosis