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146 Cards in this Set
- Front
- Back
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What sorts of things do you need to be mindful of when interviewing a patient with family members present? |
- Special attention to privacy and confidentiality while interviewing an adolescent in presence of a family member - May be ethical dilemmas involving confidentiality and privacy when family members are present with a patient of any age - Family members may have additional questions or concerns about the patient's health - There could be legal issues whenever a third party is involved to make financial and legal decisions for the patient, such as the mother of a child or the guardian of an adult who is impaired for has dementia |
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What are the benefits of having a family member present during an office visit? |
- Family members can be a valuable source of information and can help in the implementation of and compliance with a treatment plan - The presence of a family member strengthens the alliance between the physician and the patient without lengthening the office visit - Family involvement may have a positive influence on medical encounters |
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What are the methods of conducting an efficient and productive interview with family present? |
- Greet and build rapport - Identify each person's agenda - Check each person's perspective - Allow each person to speak - Recognize and acknowledge feelings - Avoid taking sides - Respect privacy and maintain confidentiality - Interview the patient separately, if needed - Evaluate agreement with the plan |
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What are the methods of advanced family interviewing skills that are useful in situations where the family exhibits ineffective communication due to conflict and intense emotions? |
- Guide communication - Manage conflict - Reach common ground - Consider referral for family therapy |
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What are the important features of the history for a patient in pain? |
LAQ CODIERS: - Location - Associated symptoms - Quality - Character - Onset - Duration - Intensity - Exacerbating factors - Relieving factors - other Symptoms |
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What is the mnemonic to use for general questions you should ask all adolescent patients? |
HEEADSSS: - Home - Education / Employment - Eating - Activities - Drugs - Sexuality - Suicide / Depression |
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What are some techniques for building rapport with adolescents? |
- Introduce yourself to the adolescent first, look him in the eye, shake his hand, and sit down during the interview - Acknowledge the adolescent as your primary patient by directing your questions primarily to him, rather than his parents - Use conversation icebreakers to allow time for adolescent to become more comfortable and get a sense of who you are - Allow the adolescent to remain dressed during the interview and sit in a chair rather than on the exam table - Ensure confidentiality and provide a safe environment for him to be honest |
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What are the components of the scrotal exam? |
- Inspection - Palpation - Transillumination - Cremasteric reflex - Blue dot sign - Prehn sign |
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What are you looking for on inspection of the scrotum? |
- Erythema - Swelling - Discoloration - Skin integrity - Position of testicle |
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What are you looking for on palpation of the scrotum? |
- Skin - edema, fluid collection, tenderness, subcutaneous emphysema - Testis - mobility - Spermatic cord --> to the superficial inguinal ring - Epididymis |
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What is the technique for palpating the testis? |
1. Gently grasp the testis between thumb and first two digits, testicle is examined from its inferior pole, superiorly 2. Then palpate the testicle for size, tenderness, (localized or diffuse), lie (high or low within scrotum), and axis (horizontal or vertical) |
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Which testicle is usually higher? |
The right testicle is higher |
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What is the technique for examining the epididymis? |
Should be palpable as a soft, smooth ridge posterolateral to the testis - Size - Position - Tenderness - Swelling |
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What do you evaluate for when examining the spermatic cord? |
Palpate to the superficial inguinal ring for tenderness or a "knot" which suggests testicular torsion, and any localized fluid collections (such as hydrocele or spermatocele) |
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What is the purpose of transillumination during the scrotal exam? |
Helps determine the etiology of the lesion - a light source should shine brightly through a hydrocele |
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How do you assess the cremasteric reflex? |
- Lightly stroke or pinch the superior medial aspect of the thigh - If intact, there is brisk ipsilateral testicular retraction - Absence of this reflex is sensitive but non-specific for testicular torsion - Should be done after inspection but before palpation |
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What is the utility of the cremasteric reflex? |
Sensitive but not specific for testicular torsion
(can be absent in normal testes) |
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What is the blue dot sign? |
- Small bluish discoloration may be visible through the skin in the upper pole - Virtually pathognomonic for appendiceal torsion when tenderness is also present |
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Tenderness in what area is suggestive of testicular torsion? |
Tenderness limited to the upper pole of the testis suggests torsion of a testicular appendage, especially when a hard, tender nodule is palpable in this region |
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What is Prehn sign? |
Physical lifting of the testicles relieves pain caused by epididymitis but not pain caused by testicular torsion
Positive Prehn sign = pain relieved by lifting testicle (helps distinguish epididymitis from testicular torsion) |
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How can you distinguish pain due to epididymitis from testicular torsion? |
Prehn sign = if pain is relieved by lifting the testicle it is most likely epididymitis; if pain is not relieved then it is likely torsion |
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Sexually active 17-yo male presents with 4-hr history of severe R groin pain w/ radiation to R scrotum and associated nausea, but no vomiting, fever, or urinary symptoms. He reports a similar episode 6-9 months ago that resolved spontaneously. Exam finds a swollen, erythematous R scrotum w/ exquisitely tender R testicle, no masses, a negative Prehn sign, an absent cremasteric reflex on the R, absent blue dot sign, and no transillumination of the scrotum.
What are the three most likely diagnoses on the differential? |
- Testicular torsion - Epididymitis - Torsion of testicular appendages |
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Sexually active 17-yo male presents with 4-hr history of severe R groin pain w/ radiation to R scrotum and associated nausea, but no vomiting, fever, or urinary symptoms. He reports a similar episode 6-9 months ago that resolved spontaneously. Exam finds a swollen, erythematous R scrotum w/ exquisitely tender R testicle, no masses, a negative Prehn sign, an absent cremasteric reflex on the R, absent blue dot sign, and no transillumination of the scrotum.
Why is trauma a less likely diagnosis? |
- Trauma can cause acute pain and swelling of the scrotum and its contents - Severity may range from mild contusion to severe testicular fracture or vascular disruption - This pt has denied a history of trauma |
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Sexually active 17-yo male presents with 4-hr history of severe R groin pain w/ radiation to R scrotum and associated nausea, but no vomiting, fever, or urinary symptoms. He reports a similar episode 6-9 months ago that resolved spontaneously. Exam finds a swollen, erythematous R scrotum w/ exquisitely tender R testicle, no masses, a negative Prehn sign, an absent cremasteric reflex on the R, absent blue dot sign, and no transillumination of the scrotum.
Why is an inguinal hernia less likely to be the cause? |
An inguinal hernia is a PAINLESS swelling in the inguinal region, which can be enhanced by maneuvers that raise intra-abdominal pressure, such as cough or Valsalva
Swelling becomes PAINFUL when it is incarcerated
The pt's history of constant exquisite pain radiating to the scrotum does not fit with this diagnosis
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What are the characteristics of an indirect inguinal hernia? |
- Develops due to a persistent process vaginalis - Contents of an indirect hernia follow the inguinal canal down into the scrotal sac |
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Where does the inguinal canal run? |
- Begins in the intra-abdominal cavity at the internal inguinal ring (approx. midway between pubic symposia and anterior iliac spine) - Canal courses down along the inguinal ligament to the external ring, located medial to the inferior epigastric arteries, subcutaneously and slightly above the pubic tubercle |
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What are the characteristics of a direct inguinal hernia? |
- Usually occurs due to a defect or weakness in the transversalis fascia area of the Hesselbach triangle - Triangle is defined inferiorly by the inguinal ligament, laterally by the inferior epigastric arteries, and medially by the conjoint tendon |
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Sexually active 17-yo male presents with 4-hr history of severe R groin pain w/ radiation to R scrotum and associated nausea, but no vomiting, fever, or urinary symptoms. He reports a similar episode 6-9 months ago that resolved spontaneously. Exam finds a swollen, erythematous R scrotum w/ exquisitely tender R testicle, no masses, a negative Prehn sign, an absent cremasteric reflex on the R, absent blue dot sign, and no transillumination of the scrotum.
Why is a hydrocele less likely to be the cause? |
- Cystic painless scrotal fluid collection - Most common cause of PAINLESS scrotal swelling - Hydroceles are generally asymptomatic unless associated with trauma or infection, although patients may report a slowly growing mass that causes a pulling or dragging sensation
- Hydrocele is unlikely diagnosis as he is having acute tenderness and has no mass on exam |
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What is the most common cause of painless scrotal swelling? How do you diagnose? |
Hydrocele - light should be visible through the scrotum when it is transilluminated with a strong light source |
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Sexually active 17-yo male presents with 4-hr history of severe R groin pain w/ radiation to R scrotum and associated nausea, but no vomiting, fever, or urinary symptoms. He reports a similar episode 6-9 months ago that resolved spontaneously. Exam finds a swollen, erythematous R scrotum w/ exquisitely tender R testicle, no masses, a negative Prehn sign, an absent cremasteric reflex on the R, absent blue dot sign, and no transillumination of the scrotum.
Why is Henoch-Schönlein Purpura (HSP) less likely to be the cause? |
- HSP is characterized by non-thrombocytopenic purport, arthralgia, renal disease, abdominal pain, GI bleeding, and occasionally scrotal pain - Onset of scrotal pain may be acute or insidious
- Pt does not display any other symptoms of HSP, so this is unlikely |
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How can you distinguish HSP from testicular torsion? |
U/S |
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How do you treat HSP? |
Supportive care |
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Sexually active 17-yo male presents with 4-hr history of severe R groin pain w/ radiation to R scrotum and associated nausea, but no vomiting, fever, or urinary symptoms. He reports a similar episode 6-9 months ago that resolved spontaneously. Exam finds a swollen, erythematous R scrotum w/ exquisitely tender R testicle, no masses, a negative Prehn sign, an absent cremasteric reflex on the R, absent blue dot sign, and no transillumination of the scrotum.
Why is a testicular tumor less likely to be the cause? |
- Presents as a scrotal mass that is rarely accompanied by tenderness - Swelling is solid so should not transilluminate - Usually non-tender to palpation
- Important to consider in any adolescent male with a scrotal enlargement, it is unlikely to be the cause for his swelling because of the acuity of symptoms and absence of a mass |
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Sexually active 17-yo male presents with 4-hr history of severe R groin pain w/ radiation to R scrotum and associated nausea, but no vomiting, fever, or urinary symptoms. He reports a similar episode 6-9 months ago that resolved spontaneously. Exam finds a swollen, erythematous R scrotum w/ exquisitely tender R testicle, no masses, a negative Prehn sign, an absent cremasteric reflex on the R, absent blue dot sign, and no transillumination of the scrotum.
Why is a varicocele less likely to be the cause? |
- Collection of dilated and tortuous veins in the pampiniform plexus surrounding the spermatic cord in the scrotum - Seen more commonly in adult men but can be seen in adolescents; approximately 10-25% of adolescent boys have a varicocele - May be asymptomatic or may complain of a dull ache or fullness of the scrotum on standing - Mass-like and non-tender or mildly tender to palpation - This would not explain the patient's severe, acute pain
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On which side is a varicocele more common? |
Left side (85-95%) because the left spermatic vein enters the left renal vein at a 90 degree angle, whereas the right spermatic vein drains at a more obtuse angle directly into the IVC, facilitating more continuous flow |
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What are varicoceles associated with? |
Infertility, although the precise mechanism by which this occurs has been the subject of considerable research and is currently thought to be due to increased testicular temperature |
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Sexually active 17-yo male presents with 4-hr history of severe R groin pain w/ radiation to R scrotum and associated nausea, but no vomiting, fever, or urinary symptoms. He reports a similar episode 6-9 months ago that resolved spontaneously. Exam finds a swollen, erythematous R scrotum w/ exquisitely tender R testicle, no masses, a negative Prehn sign, an absent cremasteric reflex on the R, absent blue dot sign, and no transillumination of the scrotum.
Why is referred pain less likely to be the cause? |
- Boys who have acute onset of scrotal pain without local inflammatory signs or a mass on exam may be suffering from referred pain to the scrotum - Rectrocecal appendicitis is an important and rare cause of referred scrotal pain in children and adolescents
- Not a likely diagnosis since he has had a previous appendectomy and has no other systemic symptoms |
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What are the somatic nerves supplying the scrotum? |
- Genitofemoral nerve - Ilioinguinal nerve - Posterior scrotal nerve |
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Sexually active 17-yo male presents with 4-hr history of severe R groin pain w/ radiation to R scrotum and associated nausea, but no vomiting, fever, or urinary symptoms. He reports a similar episode 6-9 months ago that resolved spontaneously. Exam finds a swollen, erythematous R scrotum w/ exquisitely tender R testicle, no masses, a negative Prehn sign, an absent cremasteric reflex on the R, absent blue dot sign, and no transillumination of the scrotum.
What is the most serious condition under consideration? |
Testicular Torsion - the testicle rotates around its vascular supply
4-12 hours after onset of pain to save the testicle by untwisting the spermatic cord |
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In whom is testicular torsion most common? |
Neonates and post-pubertal boys - majority occur between ages 12-18 years |
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How common is testicular torsion? |
1 in 4000 men <25 years gets it |
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What are the symptoms of testicular torsion? |
- Scrotal, inguinal, or lower abdominal pain that begins abruptly - Pain is severe and pt appears uncomfortable - Can occur several hours after vigorous physical activity or minor testicular trauma - May cause nausea / vomiting - May be prior similar episodes that suggest intermittent testicular torsion |
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What are the physical findings of testicular torsion? |
- Swollen, tender scrotum - Cremasteric reflex is typically absent - Causes orientation of testis to change, causing a "transverse lie" although this may be difficult to assess due to swelling and tenderness |
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What happens in torsion of the testicular appendage? |
Appendix epididymis and appendix testis (testicular appendages) have torsion
The testicular appendix is a small vestigial structure (embryonic remnant of Mullein duct) located on the anterosuperior aspect of the testis |
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How does torsion of the testicular appendages present? |
- Typically between ages of 7-14 years - Abrupt onset of pain - Typically less severe than testicular torsion - Localized to region of the appendix testis without any tenderness in the remaining areas of the testes - Pt may be comfortable except when being examined |
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What signs on exam may indicate torsion of the testicular appendages? |
- Pt may be comfortable except when examined - Presence of a bluish discoloration in the scrotum at the upper pole of the testis (blue dot sign) is produced by testicular appendiceal torsion |
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Sexually active 17-yo male presents with 4-hr history of severe R groin pain w/ radiation to R scrotum and associated nausea, but no vomiting, fever, or urinary symptoms. He reports a similar episode 6-9 months ago that resolved spontaneously. Exam finds a swollen, erythematous R scrotum w/ exquisitely tender R testicle, no masses, a negative Prehn sign, an absent cremasteric reflex on the R, absent blue dot sign, and no transillumination of the scrotum.
Why is torsion of the testicular appendages less likely than testicular torsion? |
This patient's pain is not localized to the upper pole of the testis |
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What is the most frequent cause of sudden scrotal pain in adults? |
Epididymitis |
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What causes epididymitis? |
Bacterial infection of epididymis, typically from a UTI or STI |
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What are the symptoms of a patient with epididymitis? |
- Slowly progressive symptoms develop over several days (rather than abruptly) - Severe swelling and exquisite pain are present on involved side, often accompanied by high fever, rigors, and irritative voiding symptoms - Patients may have had preceding symptoms suggestive of a UTI or STI
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What are the physical exam findings of a patient with epididymitis? |
- Pt may be comfortable except when being examined - Scrotum is tender to palpation and edematous on involved side - Cremasteric reflex is usually present - Testis is in normal location and position |
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Sexually active 17-yo male presents with 4-hr history of severe R groin pain w/ radiation to R scrotum and associated nausea, but no vomiting, fever, or urinary symptoms. He reports a similar episode 6-9 months ago that resolved spontaneously. Exam finds a swollen, erythematous R scrotum w/ exquisitely tender R testicle, no masses, a negative Prehn sign, an absent cremasteric reflex on the R, absent blue dot sign, and no transillumination of the scrotum.
Why is epididymitis less likely than testicular torsion? |
Absence of a cremasteric reflex, Prehn sign, and lack of systemic signs of infection make epididymitis less likely |
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Sexually active 17-yo male presents with 4-hr history of severe R groin pain w/ radiation to R scrotum and associated nausea, but no vomiting, fever, or urinary symptoms. He reports a similar episode 6-9 months ago that resolved spontaneously. Exam finds a swollen, erythematous R scrotum w/ exquisitely tender R testicle, no masses, a negative Prehn sign, an absent cremasteric reflex on the R, absent blue dot sign, and no transillumination of the scrotum.
What should be done for this patient? |
Needs to be sent to ER to be seen immediately by urologist to have testicular torsion treated |
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What are the known causes of testicular torsion? |
- Congenital anomaly - Undescended testicle - Trauma - Exercise - Often unknown |
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How can a congenital anomaly lead to testicular torsion? |
A congenital anomaly that results in failure of normal posterior anchoring of the gubernaculum, epididymis, and testis is called a BELL CLAPPER DEFORMITY because it leaves the testis free to swing and rotate within the tunica vaginalis of the scrotum --> intravaginal torsion
A large mesentery between the epididymis and the testis can also predispose itself to torsion
Contraction of the muscles shortens the spermatic cord and may initiate testicular torsion |
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What is the relationship between undescended testicles and testicular torsion? |
Little solid evidence, but the incidence of testicular torsion is thought to be higher in undescended testes than in normal scrotal testes
Torsion of an undescended testicle often occurs with the development of a testicular tumor, presumably caused by increased weight and distortion of the normal dimensions of the organ |
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Besides congenital anomalies or undescended testes, what other things can increase the chance of testicular torsion? |
- Recent trauma to the genital area - Hard physical work - Vigorous exercise - Or without any apparent reason |
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How do you diagnose testicular torsion? |
- Color Doppler U/S - Radionuclide scintigraphy |
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What is the utility of a color Doppler U/S for diagnosing testicular torsion? |
Confirm testicular torsion if pain is less severe and the diagnosis is in question
If torsion is present, intra-testicular blood flow is either decreased or absent which appears as decreased echogenicity, as compared with the asymptomatic testis; in addition, the tossed testicle often appears enlarged |
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What is the utility of a radionuclide scintigraph for diagnosing testicular torsion? |
- Uses a radioisotope to visualize testicular blood flow - Pts with testicular torsion have decreased radio tracer in the ischemic testis, resulting in a photopenic lesion |
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How do the two imaging methods of diagnosis of testicular torsion compare? |
Radionuclide scintigraphy procedure has 100% sensitivity, whereas Doppler U/S only has 88% sensitivity and 90% specificity
Although scintigraphy may be more sensitive for testicular torsion, U/S is faster and more readily available |
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What is the most significant complication of testicular torsion? |
Loss of the testis, which may lead to impaired fertility |
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What are the common causes of testicular loss after torsion? |
- Delay in seeking medical attention (58%) - Incorrect initial diagnosis (29%) - Delay in treatment at the referral hospital (13%) |
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How does the viability of a testis with torsion differ depending on? |
Duration of torsion / pain: - 6 hours of pain --> 90% viability - >12 hours of pain --> 50% viability - >24 hours of pain --> 10% viability
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What are the two approaches to treating torsion of the testes? |
Non-surgical approach: - Manual detorsion of the tossed testes, but is usually difficult because of acute pain during manipulation - Not a substitute for surgical exploration - If this maneuver is successful, orchiopexy (surgical fixation of both testes to prevent re-torsion) must still be performed in the immediate future, preferably before leaving the hospital
Surgical approach: - Testis must be unwound at operation and inspected for viability - If unviable, it should be removed - If viable, then orchiopexy should be performed to prevent recurrence - Whether affected testis is removed or conserved, the contralateral one should undergo orchiopexy as the risk of recurrence on other side is high |
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What are the characteristics of a patient centered medical home? |
- Personal physician (each patient should have an ongoing relationship with one personal physician; when they need medical attention, they rely on a doctor who will help them get the care they need) - Physician directed medical care (personal physician has assistance from team of individuals at family practice clinic who take responsibility for ongoing care) - Whole person orientation (personal physician is responsible for providing all health care needs at all stages of life, including acute care, chronic care, preventive services, and end of life care) - Care is coordinated and/or integrated (personal physician needs to know when to refer for sub-specialty care and needs to be able to utilize all domains of health care system; also need to be able to communicate health care issues effectively to family members) |
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What is an example of the "personal physician" component of the Patient Centered Medical Home? |
The doctor has taken care of the mother and her family for 18 years. He provided prenatal care when the mother was pregnant with the patient. He has taken care of all the family's health care needs since. This allows a solid, long-term relationship which maximizes the doctor's ability to assist the family in all health care issues. |
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What is an example of the "physician directed medical practice" component of the Patient Centered Medical Home? |
The nurse who obtained the patient's chief complaint and vitals assists in the patient's care by maximizing how the doctor spends their time with the patient. The NP may have seen the pt for a URI a few years ago and only needed to utilize the doctor's expertise if needed. There are other healthcare workers who coordinate diabetes care and other complex chronic health issues. |
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What is an example of the "whole person orientation" component of the Patient Centered Medical Home? |
When the pt came in with acute scrotal pain, they addressed the issue, but also used the opportunity to tackle other issues that are important in taking care of him as a whole person, such as quickly addressing some other lifestyle factors besides sexual activity, including drugs and smoking. |
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What is an example of the "care is coordinated and/or integrated" component of the Patient Centered Medical Home? |
In this pt's case, they recognized he likely had testicular torsion which required immediate intervention. They effectively coordinated not only his ER visit, but his urology care as well. Furthermore, they kept the channels of communication open with the pt's mother allowing her information and reassurance she needed. |
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What are the signs of a viable testis? |
- Return of color - Return of Doppler flow - Arterial bleeding after incision of tunica albuginea |
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How do you prevent subsequent torsion? |
Gonads are fixed to scrotal wall with non-absorbable sutures |
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What are the recommended immunizations for kids 7-10 years? |
- Tdap ^ Meningococcal conjugate vaccine (MCV4)
* Influenza (yearly) ^ Pneumococcal -/^ Hep A series - Hep B series - Inactivated Polio series - MMR series - Varicella series
* Ideal time - If catching up ^ If certain health conditions |
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What are the recommended immunizations for kids 11-12 years? |
* Tdap * HPV (3 doses) * Meningococcal conjugate vaccine (MCV4)
* Influenza (yearly) ^ Pneumococcal -/^ Hep A series - Hep B series - Inactivated Polio series - MMR series - Varicella series
* Ideal time - If catching up ^ If certain health conditions |
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What are the recommended immunizations for kids 13-18 years? |
- Tdap - HPV - Meningococcal conjugate vaccine (MCV4), * Booster MCV4 at age 16
* Influenza (yearly) ^ Pneumococcal -/^ Hep A series - Hep B series - Inactivated Polio series - MMR series - Varicella series
* Ideal time - If catching up ^ If certain health conditions |
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What topics or health conditions are addressed by the Guidelines for Adolescent Preventive Services (GAPS)? |
- Prevent HTN - Prevent HLD - Promote safety and injury prevention - Promote physical fitness - Promote parents' ability to respond to healthcare needs of their adolescents - Prevent use of tobacco products, alcohol, and other drugs - Prevent severe or recurrent depression / suicide - Prevent physical, sexual, and emotional abuse - Prevent learning problems - Prevent infectious disease - Promote adjustment to puberty and adolescence - Promote healthy dietary habits and prevent eating disorders and obesity - Promote healthy psychosexual adjustment and preventing the negative health consequences of sexual behaviors |
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What diabetes screening should be done in adolescents? |
- USPSTF has not addressed screening youths for dabietes - AMA recommends checking fasting plasma glucose levels q2 years in high-risk children and adolescents, beginning at age 10 years |
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What are the screening recommendations for sexually active adolescents? |
- Chlamydia - Gonorrhea - HIV - Hep B vaccination, if not already immunized
- Syphilis if high risk |
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How do patients with chlamydia present? |
- Dysuria - Discharge (penile or vaginal) - Pain with sex - Abdominal or testicular pain - Breakthrough bleeding - Asymptomatic |
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How do you diagnose chlamydia? |
Nucleic acid amplification test of urine, endocervical sample, or urethral sample |
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How do patients with gonorrhea present? |
- Asymptomatic - Dysuria - Discharge (penile or vaginal) - Pain with sex - Abdominal or testicular pain - Breakthrough bleeding |
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How do you diagnose gonorrhea? |
- Nucleic acid amplification test of urine, endocervical sample, or urethral sample - Gonococcal culture for rectal or pharyngeal specimens |
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How do patients with trichonomonas present? |
- Vaginal discharge with odor or itching - Asymptomatic |
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Who should be tested for trichomonas? |
- Women with concern for vaginal discharge - Screen in those at high risk for infection, such as women who have new or multiple partners, history of STIs, exchange sex for payment, or use injection drugs |
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How do you diagnose trichomonas? |
- Saline wet mount - Rapid antigen testing - Trichomonas culture |
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Who should be tested for HIV? |
Patients in all health-care settings after the patient is notified that testing will be performed unless they decline (opt-out screening)
Persons at high risk for HIV should be screened for HIV at least annually |
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What consent is needed for HIV testing? |
Separate written consent for HIV testing should not be required; general consent for medical care should be considered sufficient to encompass consent for HIV testing |
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What is the most common malignancy affecting males between ages 15-35? |
Testicular cancer |
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How common is testicular cancer? |
Only 1% of all cancers in men
Most common in African Americans, with a frequency of 1.6 per 100,000 |
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How does testicular cancer present? |
- Nodule or painless swelling of testicle - 30-40% may present with dull ache or heavy sensation in lower abdomen, perianal area, or scrotum - Acute pain is the presenting symptom in 10% of cases |
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What are the risk factors for testicular tumors? |
- Genetics - Family history - Cryptorchidism - Environment - Prior testicular cancer |
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What genetic condition increases the risk for testicular cancer? |
- Klinefelter's syndrome (47xxy) --> increased risk for germ cell tumors - First degree relatives of individuals affected --> 6-10 fold increased risk for germ cell tumors - Down syndrome, testicular feminizing syndrome, true hermaphrodites, persistent mullein syndrome, and cutaneous ichthyosis --> higher risk for germ cell tumors |
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How does family history of testicular cancer affect your risk? |
Reports of 6-fold increased risk among male offspring of a patient with testicular cancer |
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How does cryptorchidism affect risk for testicular cancer? |
20-40 fold increased risk compared with normal counterparts
Cryptorchidism = absence of one or both testes from scrotum, usually as the result of an undescended testis. Orchipexy even at early age appears to reduce incidence of germ cell tumor only slightly. |
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What environmental factors affect risk for testicular cancer? |
- Industrial occupations - Drug exposure - DES, Agent Orange, solvents used to clean jets, and ochratoxin A |
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How does a history of testicular cancer affect risk for testicular cancer? |
1-2% will develop a second primary cancer in contralateral testicle; this is a 500-fold increase in risk compared to normal population |
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What are the types of testicular tumors? |
1. Germ cell tumors - seminomatous, 45% (SGCT) and non-seminomatous, 50% (NSGCT)
2. Non-germ cell tumors
3. Extragonadal tumors |
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What is the most common type of testicular tumor? |
Germ cell tumors - 95% of primary testicular tumors |
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What are the types of non-seminomatous germ cell tumors? |
- Embryonal cell tumor, classic pure-cell NSGCT (20%) - Mixed GCTs (40%) - Teratomas and teratocarcinomas (30%) - Yolk sac tumors - Choriocarcinoma (1%) |
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What are the most common pre-pubertal germ cell tumors? |
Yolk sac tumors aka endodermal sinus tumors (non-seminomatous germ cell tumor) - May be benign but are most often malignant - Most require surgery and chemotherapy because of the aggressive nature - Overall prognosis is excellent |
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What is the most lethal but least common testicular tumor? |
Choriocarcinoma (type of non-seminomatous germ cell tumor) |
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What are the types of non-germ cell tumors? |
- Leydig cell tumors - Sertoli cell tumors |
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How common are non-germ cell tumors? Malignancy? |
- 5% of primary testicular tumors - Rarely malignant, only about 10% |
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What are the types of extragonadal testicular tumors? |
- Lymphoma - Leukemia - Melanoma |
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Case: A healthy 16-yo adolescent female presents for a routine checkup and sports pre-participation physical exam. She is noted incidentally to have a heart murmur.
What are the recommended immunizations? |
- Tdap booster - Meningococcal vaccination - Consider starting HPV vaccine series |
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Case: A healthy 16-yo adolescent female presents for a routine checkup and sports pre-participation physical exam. She is noted incidentally to have a heart murmur.
What is the recommended age to start routine Pap smears? |
ACOG recommends initial Pap smear be at age 21. Only <21y if patient has significant gynecologic symptoms that warrant further investigation, is immunocompromised, or is pregnant. |
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Case: A healthy 16-yo adolescent female presents for a routine checkup and sports pre-participation physical exam. She is noted incidentally to have a heart murmur.
What is the most common cause of sudden cardiac death in young athletes? |
Hypertrophic cardiomyopathy (HCM) |
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What should you focus on during a sports physical? |
History: - Conditions that can lead to sudden cardiac death, which are usually cardiovascular, most commonly hypertrophic cardiomyopathy - Marfan syndrome is associated with aortic root dilation or dissection |
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What is the signature physical exam finding in a patient with hypertrophic cardiomyopathy? |
Systolic murmur: - Decreases in intensity with the athlete in the supine position (increased ventricular filling, decreased obstruction) - Increases with Valsalva (decreased ventricular filling, increased obstruction) |
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How does lying supine affect the murmur in a patient with HCM? Why? |
Decreases murmur intensity due to increased ventricular filling --> decreased obstruction |
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How does Valsalva affect the murmur in a patient with HCM? Why? |
Increases murmur intensity due to decreased ventricular filling --> increased obstruction
Note that most murmurs decrease in intensity and duration with Valsalva |
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What physical exam finding would make you hold an athlete from participating in sports? What should you do for them? |
- Systolic murmur with an intensity of 3/6 or greater - Diastolic murmur - Holosystolic murmur - Continuous murmur - Any other murmur that the examiner finds suspicious or worrisome (e.g., worsening with Valsalva)
- Should refer to a cardiologist for evaluation |
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What are the "GAPS"? |
Guidelines for Adolescent Preventive Services - Series of recommendations regarding the delivery of health services, promotion of well-being, screening for common conditions, and provision of immunizations for adolescents and young adults between the ages of 11-21 years |
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What does the HPV vaccine protect against? |
Immunization against the four high-risk strains of HPV - 6 and 11 (prevents venereal warts) and 16 and 18 (prevent large fraction of cervical dysplasia/cancer)
Series of three injections over 6 months that has been shown to be efficacious at reducing the incidence of genital warts and cervical cancer |
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Who is recommended to get the HPV vaccine? |
Adolescent girls and young women |
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When does the GAPS recommend complete physical exams? |
At least 3 complete physical exams: - During early adolescence (11-14) - During middle adolescence (15-17) - During late adolescence (18-21) |
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The GAPS recommends what kind of counseling to parents of adolescents? |
- Provide guidance to parents on normal physical, sexual, and emotional development - Teach signs of physical and emotional problems - Teach parenting behaviors to promote health - Teach methods to help their child avoid harmful behaviors |
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What should adolescent patients receive counseling on according to the GAPS guidelines? |
Annually: - On their growth and development - Injury prevention - Healthy diet - Exercise - Avoidance of harmful substances (alcohol, tobacco, drugs, anabolic steroids) - Responsible sexual behaviors, including abstinence and contraception, to reduce the risks of STDs and pregnancy |
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According to the GAPS guidelines, what routine screening should be done for adolescents? |
- HTN (further evaluation/treatment for pts whose BP is >90% for gender/age) - Eating disorders / obesity - Use of tobacco (cigarettes and smokeless tobacco), alcohol, and other abusable substances - Lipid screening (if at above-average risk) - TB skin testing (if at high-risk) - Sexual behaviors - Depression / risk of suicide |
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When is BP screening significant in an adolescent? |
If >90 percentile for age/gender |
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What adolescents should get lipid screening? |
Pts at above-average risk based on a personal history of comorbid conditions or a family history of hyperlipidemia, CAD, or other vascular diseases |
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What adolescents should get TB skin test screening? |
For pts at high risk: - Lived (or living) in a homeless shelter - Lived (or living) in an area with a high prevalence of TB - Having been (or being) incarcerated - Having been exposed to active TB - Working in a health-care setting |
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What questions about sexual behavior should all adolescents be asked? |
- Sexual orientation - Use of contraception - Number of sexual partners - History of pregnancy or STDs
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What adolescents should be screened for STDs? Which ones? |
Sexually active, symptomatic, and high risk females and males: - Gonorrhea and Chlamydia by urine nucleic acid amplification - Should be offered confidential testing for HIV
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What screening about mental health should be done for adolescents? |
- Screen for depression and risk of suicide - Screen for emotional, physical, or sexual abuse - Screen for problems at school or with learning |
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What are the guidelines about abuse of minors? |
Every state mandates reporting of suspected abuse of minors to the designated child welfare agency or child protective service |
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What are the recommendations regarding the Tdap/Td immunizations in adolescents? |
- In those who have received the recommended primary series, a Td booster is recommended at age 11-12y and then q10y - Tdap is recommended in place of one Td booster for adolescents and adults |
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What are the recommendations regarding the Varicella immunization in adolescents? |
Should be offered to those who have not been vaccinated and who do not have a history of chickenpox |
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What are the recommendations regarding the MMR immunization in adolescents? |
MMR booster should be given if the patient did not receive a booster at ages 4-6 years |
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What are the recommendations regarding the Hepatitis B immunization in adolescents? |
Should be given to any adolescent who has not been previously immunized |
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What are the recommendations regarding the Hepatitis A immunization in adolescents? |
Offer to those who: - Live in areas with high infection rates - Travel to high-risk areas - Have chronic liver disease - Inject IV drugs - MSM |
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What are the recommendations regarding the Meningococcal immunization in adolescents? |
Meningococcal vaccination with a tetravalent polysaccharide-protein conjugate vaccine (MCV4): - Routine vaccination is recommended at ages 11-12 years - If not previously vaccinated, it should be given before high school - Also recommended for college freshman living in dorms and for others at increased risk, such as military recruits, travelers to endemic areas, or the functionally / anatomic asplenic |
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What are the recommendations regarding the HPV immunization in adolescents? |
Gardasil and Cervarix work against high-risk strains of HPV - recommended for adolescent girls and young women (can start as early as 9y but routinely recommended at 11-12y, but put o 26y)
Gardasil has been approved for use (but not yet routinely recommended) in adolescent boys
Series of 3 injections over 6 months |
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What is the purpose of a pre-participation exam? |
Identify conditions that may place a young athlete at risk during athletic participation - primarily cardiac and orthopedic
These exams also allow physician to provide comprehensive health maintenance, including counseling, anticipatory guidance, screening, and vaccination, recommended in the GAPS guidelines |
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What is the most common etiology of sudden cardiac death in athletes? |
Congenital cardiac anomalies (most common) - Hypertrophic cardiomyopathy (1/3) - Anomalous coronary arteries (1/5) |
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What history should you be assessing for in a pre-sports physical to assess for risk of sudden cardiac death? |
Personal history: - Exertional chest pain - Dyspnea - Syncope - History of heart murmurs - History of asthma - History of other pulmonary disorders - History of orthopedic injuries - History of heat-related illness - Absence of one of a paired organ (e.g., single kidney, testicle, ovary, etc)
Family history: - Hypertrophic cardiomyopathy - Other congenital cardiac abnormalities - Premature cardiac death |
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What about a student athletes weight should you screen for during a pre-sports physical? |
- Eating disorders - Desire to change body weight (either for body image or athletic purposes)
- Ask females about menstrual irregularities, as amenorrhea could signal anorexia and amenorrheic female athletes could be at risk for osteoporosis |
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What features of the physical exam are most important in a pre-sports physical? |
- BP - General appearance (signs of Marfan syndrome) - Listen to heart in both lying and standing position |
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What are the signs of Marfan syndrome? |
- Arachnodactyly - Arm span > height - Pectus excavatum - Tall-thin body habitus - High-arched palate - Ocular lens subluxation |
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Why is it important to diagnose Marfan syndrome in a patient who wants to participate in sports? |
They may have aortic abnormalities that may predispose to rupture during sports
They need referral to cardiologist before clearing! |
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The murmur of hypertrophic cardiomyopathy is best heard where? |
Along left sternal border (but not always present) - Accentuates with activities that decrease preload and end-diastolic volume of the LV - Standing or straining with Valsalva would INCREASE murmur - Squatting would DECREASE murmur |
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What is the study of choice for diagnosing hypertrophic cardiomyopathy? |
Echo |
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What may cause delay of clearance for participation in sports? |
- Further evaluation of a suspected condition - Rehab of an injury - Recovery from an acute illness |
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A high school student is being seen for a sports physical exam. Which of the following should prompt a referral to a cardiologist prior to clearance to participate in HS sports? a) grade 2/6 systolic murmur in asymptomatic 16yo girl b) grade 1/6 diastolic murmur at apex of 17yo girl c) grade 2/6 systolic murmur in 17yo boy that is heard lying down and gets softer when standing d) asymptomatic 16yo whose grandpa died of MI at 72y |
B - grade 1/6 diastolic murmur at apex
Any patient with a diastolic murmur, grade 3/6 or louder systolic murmur, murmur suggestive of hypertrophic cardiomyopathy, or signs of Marfan syndrome should be evaluated by a cardiologist prior to clearance for athletics. The murmur of hypertrophic cardiomyopathy typically gets louder with maneuvers that reduce preload (Valsalva and when standing). |
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A 15yo girl is brought in by her mother for a wellness clearance for sports participation in school. She would like to discuss the addition of birth control. When the mother leaves the room you learn the girl is not sexually active but wants to start OCPs because she has heard they may help with acne and her friends have seen improvement. She does not drink alcohol or some and is in honors classes in 9th grade. She plays on the JV softball team and eats most days in school cafeteria. Which of the following is recommended routinely in GAPS and should be performed at this time? a) annual complete physical exam between ages 11-21y b) periodic screening for drug use w/ urine toxicology screen c) cholesterol testing d) annual screening for HTN |
D - Annual screening for HTN
GAPS recommends annual screening for HTN by BP in all adolescents. Complete physical exam is advised routinely, once during early adolescence, once in middle adolescence, and once in late adolescence, as well as more often when indicated. Lipid screening should be targeted to those who are at high risk based on personal or family history. Routine toxicology screening is not recommended. |
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A 17yo adolescent boy reports he has been sexually active with two female partners in past year. He has used condoms "sometimes, but not always." He is asymptomatic and has a normal physical exam. Which of the following tests would be recommended to screen him for G/C? a) urethral swab b) serum antibodies to G/C c) urine for nucleic acid amplification d) no screening |
C - Urine for nucleic acid amplification
This method is recommended as screening for presumptive G/C in sexually active males. A urethral swab is only appropriate for diagnostic testing in a male who has urethral discharge. |
