Station - Instructions for candidate
You are an intern in the Emergency Department at Fiona Stanley Hospital.
Jayden Nikolaidis is a 17-year-old apprentice electrician who has self-presented to the Emergency Department four hours after being woken at 4 am by sudden severe left scrotal pain with two episodes of vomiting. He reports mild stinging when passing urine and has been triaged as haemodynamically stable and afebrile. The patient has already been told that the clinical findings suggest a twisted testicle and wants you to explain what this means and what will happen next.
| Triage observations | Triage observations: HR 104 regular, BP 132/78 mmHg, RR 20, SpO2 99% on room air, temperature 36.8 degrees C, pain score 9/10. |
|---|---|
| Nursing handover | You have been asked to assess Jayden before the next available surgical review. |
Results provided:
Urinalysis
| Item | Value | Reference range |
|---|---|---|
| Leucocytes | Negative | Negative |
| Nitrites | Negative | Negative |
| Protein | Negative | Negative |
| Blood | Negative | Negative |
| Glucose | Negative | Negative |
| Ketones | Negative | Negative |
| pH | 6.0 | 5.0-8.0 |
| Specific gravity | 1.015 | 1.005-1.030 |
Sexual health NAAT
| Item | Value | Reference range |
|---|---|---|
| Chlamydia trachomatis NAAT | Negative | Negative |
| Neisseria gonorrhoeae NAAT | Negative | Negative |
Urine NAAT for chlamydia and gonorrhoea is negative.
Blood tests
| Item | Value | Reference range |
|---|---|---|
| Haemoglobin | 154 g/L | 130-175 g/L |
| White cell count | 10.8 x 10^9/L | 4.0-11.0 x 10^9/L |
| Platelets | 278 x 10^9/L | 150-400 x 10^9/L |
| CRP | 3 mg/L | <5 mg/L |
| Potassium | 4.3 mmol/L | 3.5-5.2 mmol/L |
| Creatinine | 76 umol/L | 60-110 umol/L |
FBC, CRP and UEC are not significantly abnormal.
Scrotal ultrasound
| Item | Value | Reference range |
|---|---|---|
| Left intratesticular blood flow | Reduced or absent flow | Present and symmetrical |
| Right intratesticular blood flow | Normal flow | Present and symmetrical |
| Left testicular lie | High and horizontal | Vertical lie |
Doppler ultrasound shows reduced or absent intratesticular blood flow in the left testis compared with the right, with abnormal lie of the left testis.
imaging other - read aloud by the examiner
The left testis lies higher than the right and has markedly reduced internal colour flow compared with the right testis. The right testis has preserved internal flow.
Look up an example image: Radiopaedia testicular torsion ultrasound
Your tasks are to:
- Take a focused history, including relevant medical, medication, allergy, sexual and social history.
- Perform a focused examination of the scrotum and groin, first standing and then supine. Describe what you would examine to the examiner; findings will be provided.
- Request appropriate investigations. Results will be provided by the examiner when appropriately indicated.
- State the most likely diagnosis and two to four differentials, with brief justification.
- Outline your initial management plan, including analgesia, escalation, referral and safety-netting.
- Explain the diagnosis and agreed management plan to the patient in plain language.
- You do NOT need to summarise your history and examination findings to the examiner.
- Please verbalise your examination to the examiner; findings will be provided when you request the relevant step.
- You do not need to write medication orders or operative consent forms.
- The patient knows the diagnosis and you are required to explain it and agree on the immediate plan.
This is a 15-minute station, with 2 minutes of reading time.