Station - Instructions for candidate
You are a final-year medical student in a surgical outpatient clinic at Royal Perth Hospital.
Nathan Adeyemi is a 29-year-old FIFO drill rigger attending the surgical outpatient clinic three weeks after starting doxycycline for presumed epididymo-orchitis. His right hemiscrotum remains larger than previously, and he reports a nagging lower back ache. The patient has been informed that the current diagnosis is a right testicular germ-cell tumour and wants you to explain what this means and what happens next.
| Referral information | Name: Nathan Adeyemi. Age: 29 years. He was started on doxycycline three weeks ago for presumed epididymo-orchitis. |
|---|
Results provided:
Scrotal ultrasound
| Item | Value | Reference range |
|---|---|---|
| Right testis | 4.2 cm solid vascular mass replacing most of the right testis | - |
| Left testis | Normal | - |
| Testicular blood flow | No torsion | - |
| Scrotal fluid | Small right hydrocele | - |
The report states: The right testis is enlarged and largely replaced by a heterogeneous solid vascular mass measuring 4.2 cm. The left testis is normal. There is no evidence of torsion. A small right hydrocele is present. No inguinal hernia is seen.
imaging other - read aloud by the examiner
The right testis is enlarged and mostly replaced by an irregular solid mass. The mass contains areas of mixed echogenicity and shows increased internal blood flow on Doppler. The left testis appears normal. There is a small fluid collection around the right testis.
Look up an example image: Radiopaedia testicular tumour ultrasound
Serum tumour markers
| Item | Value | Reference range |
|---|---|---|
| Beta-hCG | 86 IU/L | <5 IU/L |
| Alpha-fetoprotein | 6 kIU/L | <10 kIU/L |
| Lactate dehydrogenase | 312 U/L | 100-250 U/L |
Serum beta-hCG is mildly elevated. Alpha-fetoprotein is normal and LDH is mildly elevated.
CT staging
| Item | Value | Reference range |
|---|---|---|
| Abdomen and pelvis | Right para-aortic lymph nodes up to 2.1 cm | - |
| Chest | No pulmonary metastases | - |
| Abdomen | No liver lesions | - |
CT of the chest, abdomen and pelvis shows enlarged right para-aortic lymph nodes up to 2.1 cm. There are no lung metastases and no liver lesions.
imaging other - read aloud by the examiner
There are several enlarged lymph nodes beside the abdominal aorta on the right, the largest measuring 2.1 cm. The lungs are clear of focal metastatic deposits. No liver lesions are identified.
Look up an example image: Radiopaedia testicular cancer retroperitoneal nodes CT
Baseline blood tests
| Item | Value | Reference range |
|---|---|---|
| Haemoglobin | 146 g/L | 130-170 g/L |
| White cell count | 7.4 x 10^9/L | 4.0-11.0 x 10^9/L |
| Platelets | 268 x 10^9/L | 150-400 x 10^9/L |
| Creatinine | 82 umol/L | 60-110 umol/L |
| eGFR | 98 mL/min/1.73 m2 | >60 mL/min/1.73 m2 |
Full blood count, electrolytes and renal function are within the stated reference ranges.
Your tasks are to:
- Take a focused history of the presenting problem and relevant background.
- Perform a focused scrotal and groin examination, first standing and then supine. Describe what you would look for and do; the relevant findings will be provided by the examiner.
- Request appropriate investigations; results will be provided when appropriately indicated.
- State the most likely diagnosis and two to four differentials, with brief justification.
- Outline the initial management plan, including urgent referral, treatment considerations and safety-netting.
- Explain the diagnosis and agreed plan to the patient in plain language, including its implications for fertility and work.
- You do NOT need to summarise your findings to the examiner.
- You are not required to examine systems other than the scrotum and groin, or to perform an internal examination.
- You do not need to write prescriptions or complete referral paperwork; verbalise your initial plan and explanation to the patient.
This is a 15-minute station, with 2 minutes of reading time.