Painful scrotum and racing heart

[DartmouthDave]

Hello,

You are dispatched to a suburban residence for a complaint of a painful scrotum and weakness.

On arrival, you find an obese (110 kg) 52 year-old male sitting in a large chair. He looks pale with slightly laboured respiratory rate. He is shifting uncomfortably in his chair.

The pain started a day ago and has been getting worse. It feels like a burning sensation. He hasn't been able to sleep or eat or drink due to the pain that her rates a 10/10. The pain dose not radiate and is localized to his scrotum.

He past medical history includes HTN, DM, Asthma, GERD, High Cholesterol, Smoker (1 pack a day for 10 years), ETOH (3-6 a day), Depression, rapid heart beats and Sleep Apnea.

His current medications are ASA 80mg OD, Ramipril 10mg OD, HCTZ 25mg OD, Metformin 500mg TID, Losec 20mg OD, Zantac 150mg PRN, Tly #3 PRN, Tyl PRN, Advil PRN, Crestor OD, Ventolin PRN, Digoxin OD and Tums PRN.

You initial assessment shows:

GCS 15

PEARL @ 4mm

Strong x4

Lungs: wheezing all lobes

Rate: 32

SpO2 90%

HR 100-120 iregular

Skin: hot and sweaty

Temp 39

Abd soft and non-tender

No jaundice

No N+V

Voding no problem but 10/10 pain that won't go away

Cheers...

[Dustdevil]

Scrotum, or scrotal contents? Specific localisation? Exacerbation? Onset? The whole PQRST thing.

How was the temperature taken? It may or may not be particularly significant, depending on route. But if you got that off someone's TM or forehead, that's a doozie. And it may or may not be related to the pain. There's no law against having pneumonia and Testicular Torsion both on the same day. The dirty lungs may be indicative of the origin of the fever, irrespective of the source of the pain. Regardless, I'm pretty surprised to see an assessment in the field that includes a temp, but not a BP. Tachyness can be related to the fever, the lungs, or the Ventolin, so while significant, it's not particularly contributory to ruling anything out.

Top three, off the top of my head, in order of suspicion at this point:

1. Epididymitis - Fever puts this at the top.

2. Testicular Torsion - Always a concern with 10/10 pain, and a true emergency.

3. Inguinal Hernia - Often exacerbated by coughing, which he most likely is doing with the Asthma and junky smoker's lungs.

All three rate a trip to the hospital right now for proper work-up.

Edited March 26, 2010 by Dustdevil

[Chief1C]

First (the victim) couldn't breathe or pee, now it's (the victims) boys and heart. Is this a pattern, or does (the victim) secretly need to see Dr. Drew? Clearly (the victim) is being kicked in the groin, maced and tazed. Maybe (the victim) needs to try a different approach?

Edited March 26, 2010 by 4c6

[DartmouthDave]

Hello,

LOL. No, there isn't a need for psychotherapy here. There just have been a few odd cases as of late around here that seem to focus on problems down South.

Dust,

I was typing quickly on a coffee break and neglected to include it. The BP is 110/30. The temp was taken in the patients ear.

There is no history of assault or anything that the patient can recall that might be casing this pain. The patient describes quality of the pain as an aching sensation inside his scrotum and scores it as 10/10. The pain started 24 hours ago and has been getting worse. Nothing seems to make it better or worse.

Cheers

[Dustdevil]

TM temps are notoriously inaccurate. But if one says the patient has a fever, you can bet that he does. And it's probably greater than the reading, so this patient definitely has some septic process going on. That jibes with the elevated heart rate, despite dig. The BP is a wild card because of the pre-existing HTN and concurrent antihypertensive therapy.

This scenario is an excellent learning opportunity! Patients with multiple pre-existing issues going on always complicate the picture. Sure, you can just transport them all and let the ER sort them out. That's what the vast majority of EMS personnel will do, and that's a shame. But to me, the most exciting part of medical practice is the diagnostic process. And considering that probably 90 percent of all runs you make will not be snot-slinging trauma runs or full-arrests, if you don't also enjoy the challenge of the so-called "routine:" patients, you're going to burn out really quick.

[tniuqs]

Top three, off the top of my head, in order of suspicion at this point:

1. Epididymitis - Fever puts this at the top.

2. Testicular Torsion - Always a concern with 10/10 pain, and a true emergency.

3. Inguinal Hernia - Often exacerbated by coughing, which he most likely is doing with the Asthma and junky smoker's lungs.

All three rate a trip to the hospital right now for proper work-up.

Priority tx for myself: I certainly would treat the wheeze and mild laboured breathing and sats of 90% (a tad low) asap with s/s Ventolin.

Is he producing Sputum and what colour and volume is it ?

Ok a 52 year old male and only 10 pack years, so did he only start smoking @ 42 y/o ? Odd.

4- Diff Dx : spermatocele or epididimal cyst ?

Must agree with dust's input, and Testicular Torsion is a true emergency, inguinal hernia too can lead to very serious complications and in remote settings sometimes can be reduced .I would agree from the scenario presented that an infectious disease process is at the top of the list for scrotal pain based on rapid onset of 24 hours.

Perhaps rounds of cipro if one is in a remote or clinic setting, post doppler ultrasound (if available) CBC not a bad idea either.

I believe although meds are listed is patient compliant with meds ?

Like just how many T#3s has he had in last 24 hours ?

Is he on any herbal or naturo-pathetic rx as he is on digoxin and this rx frequently is affected by self prescribed herbal remedies, speaking of "herbal" any recreational drug usage .. You are in BC bud country.

cheers and agreed its too bad the scenario setting is just a quick flip into ER.

Edited March 26, 2010 by tniuqs

[Kaisu]

Did you examine the scrotum? What does it look like?

[Dustdevil]

Did you examine the scrotum? What does it look like?

Pics or GTFO!

[DartmouthDave]

Hello,

Here is some answers to the various questions. A solid list of Dx so far.

Smoking: He started 10 years ago after getting a divorced.

Sputum: He has a non-productive cough. However, he has been having chills, myalgia, and fatigue.

Tyl & Tly#3: He has been taking more than usual. Not so much at the start but more as the pain has escalated. He has been taking around 12 Tyl #3 in the past 12 hours. Around the same number of Advil (200mg) and Plain Tyl (325mg). Usually, He takes his medications as prescribe.

HTN: He says his BP is normally very high even with the medications. Last check was around 155/95 at the Drug Store. His GP was going to increase his medications.

Hernia: No hernias are noted in the abd

Alternative Medicines: No odd herbal stuff. Pt says he smokes weed to relax. Once or twice a week.

ETOH: A regular drinker (daily). Unable to drink for around 24 hours now. "I'm too sick to drink!!!"

More of the story:

A IV is started and a Ventolin neb is given. The patient is assisted to the cot. He is very weak and trembling weakly when standing. Your partner (lucky) is delegated to assess the scrotum. A vile odour is noted. The scrotum (sorry no picture Dust) appears ashen in general. Also, when lift gently (due to pain) the perineal area is black with purlent drainage. The surrounding tissues is indurated with a red and waxy appearance.

A second set of VS are taken (HR 110-120 Ireg BP 100/28 Temp 39.5 BGL 22 SpO2 92 with treatment thus far). A 12-lead is done. I will add that later. Time to go to sleep now. Night shift is fast approaching. =(

Also, feel free to play with the scenario. It is based on a case that came through the ICU. The main goal is brain gym.

Cheers

[Dustdevil]

Scrotal abscess progressed to that level is bad news. Potentially fatal. The guy's pre-existing conditions are going to seriously complicate his treatment and recovery. At least he was admitted before circulatory collapse, which is the only good news here. He's still facing a long road in the ICU.