A 19-year-old male college student returns from spring break in Fort Lauderdale, Florida, with complaints of acute pain and swelling of the scrotum. Physical examination reveals an exquisitely tender, swollen right testis that is rather hard to examine. The cremasteric reflex is absent, but there is no swelling in the inguinal area. The rest of his genitourinary examination appears to be normal. A urine dip is negative for red and white blood cells. Which of the following is the appropriate next step in management?
a. Administration of antibiotics after culture of urethra for chlamydia and gonorrhea
c. Intravenous fluid administration, pain medications, and straining of all voids
d. Ultrasound of the scrotum
e. Laproscopic exploration of both inguinal regions
the answer is below…
The United States Medical Licensing Examination, or USMLE for short, is a three-part licensing examination that is required in order to receive a license to practice medicine within the United States.
The USMLE assesses a physician’s ability to apply knowledge, concepts, and principles, and to determine fundamental patient-centered skills that are important in health and disease and that constitute the basis of safe and effective patient care.Examination committees composed of medical educators and clinicians from across the United States and its territories prepare the examination materials each year.
This exam is designed by the Federation of State Medical Boards and the National Board of Medical Examiners to determine whether or not an individual understands and can apply the knowledge necessary to practice medicine safely and intelligently.
The USMLE is actually comprised of three different exams that are referred to as steps, which examine the individual’s knowledge of specific topics related to the field of medicine such as basic science, medical knowledge, medical skills, clinical science, and the application of all of these skills and areas of knowledge in the medical field.
All three steps of the USMLE include a series of computerized multiple-choice questions, but the format of the exam and the information covered in each multiple-choice section is different for each step of the USMLE. The USMLE Step II also has a clinical skills portion that examines an individual’s ability to work with real patients and the USMLE Step III has a computerized patient simulation portion in addition to the multiple-choice section of the exam. In order for an individual to receive a license to practice medicine, the individual must pass all three steps of the USMLE.
The correct answer is d; Ultrasound of the scrotum.
The patient in the question may have a torsion of his testis that requires immediate attention. Another possibility would be epididymitis, especially if there is a possible antecedent history of sexual activity or urinary tract infection. Prehn’s sign, although not totally reliable, is elicited by gently lifting the scrotum toward the symphysis. Relief of the pain points to epididymitis; its worsening, to torsion. Doppler ultrasound (or surgical consultation) is a logical first step in this man’s evaluation, demonstrating absence of flow in torsion and increased flow in epididymitis. Alternatively, a radionuclide scan will show diminished uptake in torsion and increased uptake in epididymitis. Treatment for torsion is surgical exploration and detorsion and scrotal orchiopexy. Causative organisms for epididymitis include Neisseria gonorrhoeae, Chlamydia trachomatis, and other bacteria. Treatment with appropriate antibiotics and rest is indicated. However, treating this patient with antibiotics without first excluding testicular torsion is ill-advised; loss of the testis can be expected after 4 to 6 h of absent blood flow if the testis has torsioned. Strangulated hernia is associated with evidence of intestinal obstruction.