Varicocele Presentation Finalbb
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XYLIA SAHARA E. TOCAO
MEDICAL CLERK
DAVAO MEDICAL SCHOOL FOUNDATION
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VG
18 years old
MaleLaverna Hills subdivision, Davaocity
October 29, 20137:05 AM
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SCROTAL PAIN
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6 months PTA
scrotal pain (left); 6/10
Lifting heavy objects
Not associated with fever, nausea, vomiting
No consultation and no medications taken
Tolerated the condition
1 month
PTA
1 month PTA-persistence of pain (10/10)
Consultation with AP
Sperm count done normal
Advised for surgery
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(-) Hypertension
(-) Diabetes Mellitus
(-) Bronchial asthma
(-) Previous hospitalization
(-) Surgical operation
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Maternal side :Hypertension and
DM
Paternal side: Bronchial asthma
(-) Cancer, Heart disease
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May 20, 1995
Laverna Hillssubdivision,Davao city
Freshman student
Gym -weight liftingexercises
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GENERAL (-) easy fatigability
ENDOCRINE SYSTEM (-) thyroid problems,(-) neck surgery,(-) heat and cold intolerance
SKIN (-) pruritus HEAD (-) dizziness, (-) headache EYE (-) pain,
(-) excessive lacrimation
EAR (-) tinnitus NOSE (-) persistent stuffiness,
(-) nasal congestion(-) postnasal drip
MOUTH (-) bleeding gums, (-) dyspnea
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THROAT (-) odynophagia,(-) hoarseness
NECK (-) neck surgery,
(-) nuchal rigidity,(-) limited motion
BREAST (-) breast pain,(-) abnormal discharge
CARDIAC (-) nocturnal dyspnea,(-) murmurs
PERIPHERAL VASCULAR (-) claudication GASTROINTESTINAL (-) change in bowel habits PULMONARY (-) hemoptysis, (-) asthma GENITO-URINARY (-) dysuria, (-) flank pain HEMATOPOIETIC (-) easy brusing
MUSCULAR (-) limited ROM NEUROLOGIC (-) change in orientation
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GENERAL:
awake, not in respiratory distress, oriented toperson,/ place and time.
VITAL SIGNS:
Temperature:36.3 oC Blood pressure:110/70mmHg
Pulse rate: 65 bpm Respiratory rate: 20 cpm
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SKIN: Inspection : no rash, lesions noted Palpation: good skin turgor,moist skin
HEAD: Inspection: normocephalic, no lice & nits
noted Palpation: (-) mass
EYES: Inspection: anicteric sclerae, pinkish palpebral
conjunctivae
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EARS:
Inspection: non erythematous, no cerumen
noted Palpation: mobile,firm, non tender
NOSE:
Inspection: nasal septum in midline position
Palpation: no sinus tenderness
THROAT: Inspection: no tonsillar enlargement, non
erythematous
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NECK:
Inspection: no thyromegaly
Palpation: (-) cervical lymphadenopathy
CHEST/LUNGS: Inspection: (-) use of accessory muscles for
breathing
Palpation: equal chest expansion
Percussion: resonant
Auscultation: clear breath sounds, nocrackles, wheezing
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HEART:
Inspection:adynamic precordium Palpation: no thrills /heaves
Auscultation: good S1 and S2, no murmurs noted
ABDOMEN: Inspection:flat
Auscultation: normoactive bowel sounds at 15 perminute
Percussion: tympanitic Palpation: non tender
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SCROTAL EXAM: Inspection: no lesions
Palpation: scrotal enlargement at the left sideafter bearing down
EXTREMITIES
INSPECTION: Full range of motion
Palpation: full pulses, CRT
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NEUROLOGIC EXAM:
GCS: 15
Eye opening: 4
Verbal response:5
Motor:6
awake, conscious, oriented to person , placeand time.
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CRANIAL NERVES:
I not assessed II isocoric
III, IV,VI pupils equally round and reactive to light andaccommodation
V (+) corneal reflex, able to distinguish sharp andblunt stimuli
VII able to perform facial expressions like smilingand frowning
VIII able to hear soft and loud spoken words
IX (+) gag reflex
X (-) difficulty of swallowing
XI able to raise shoulders against resistance
XII able to protrude tongue and move it up, downand side
MOTOR
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MOTOR:
R 5/5 5/5 L
5/5 5/5
REFLEX:
R ++ ++ L
++ ++
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SENSORY100% 100%
100% 100%
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Varicocele , left
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POST OPERATIVE DIAGNOSIS: Varicocele , left
OPERATION PERFORMED: varicocelectomy
OPERATIVE TECHNIQUE: Operation started: 2:17 pm Operation ended: 3: 10 pm Skin preparation and draping done Aseptic technique Left inguinal incision done
Left internal spermatic vein ligated Closure of incision in layers Bleeders cauterized Dressing applied
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Seen and examined Venoclysis started with D5LR I liter at
100cc /hour
Medications started
Omeprazole 40 mg 1 amp IVTT now may havebreakfast now then NPO
Laboratory test done:
10/29/13
hemoglobin: 156 PT: 12.3 sechematocrit: 0.45 APTT: 30.5 sec
platelet count : 245
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Chest x-ray: normal findings
Varicocelectomy , L at 1 pm
10/30/13
May go home
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SALIENT FEATURES 18 years old, male
Scrotal pain
Gym weight lifting exercises
Pertinent physical exam finding
includes scrotal swelling on theleft side after bearing down
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SwellingDragging /aching pain in the groin
and scrotum bag of worms feeling
Scrotum on the affected side hangsdown
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Male and female reproductive systemsdevelop from similar embryonic tissue.
First few weeks of development, male andfemale embryos are indistinguishable.
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Ovoid structures about5 cm long and 3 cmwide.
Located within thescrotal sac (scrotum)
During fetaldevelopment they arenear the kidneys andslowly move inferiorly
in the abdominal cavity. During the 7thmonth
they descend throughthe inguinal canals
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Sac of skin and superficial fascia thathangs outside the abdominopelvic cavityat the root of the penis
Contains paired testicles separated by amidline septum
Its external positioning keeps the testes3C lower than core body temperature
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In the dermis, there isa thin layer of smoothmuscle known as thedartos muscle.Contractions of this
muscle causeswrinkling of the skin. The cremaster muscle
is a thicker layer ofskeletal muscle that
lowers and raises thetestes based ontemperature.
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Each testes isenclosed by thetunicavaginalis, acontinuation of the
peritoneum that linesthe abdominopelviccavity.
A fibrous capsule
covers each testiscalled the tunicaalbuginea.
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The tunica albugineagives rise to septa(partitions) thatdivide the testis intolobules (about 250)
Each lobule contains3 or 4 highly coiledseminiferous tubules
These converge to
become rete testiswhich transportsperm to theepididymis
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Contains thestructures runningfrom the testicles tothe pelvic cavity. Passes through the
inguinal canal
Contents: Vas Deferens
Nerves Blood Vessels
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Lie on the posterior wall of the bladder andsecrete 60% of the volume of semen Seminal fluid:
Fructose: provides energy for the sperm. Fibrinogen: helps turn semen into a bolus that can
be readily propelled into the vagina.
Prostaglandins: decrease cervical mucus viscosityand stimulate reverse peristalsis of the uterus.
Join the ductus deferens to form theejaculatory duct
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Doughnut-shaped gland that encirclespart of the urethra inferior to the bladder
Plays a role in the activation of sperm
Enters the prostatic urethra duringejaculation
Prostatic secretions include:
Citrate: is a food source (TCA cycle)
Proteolytic enzymes:acts to "decoagulate" the
semen that was coagulated by seminal vesicle
secretions, which helps the sperm begin their
journey once inside the vagina
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Pea-sized glandsinferior to the prostate
Produce alkaline
mucus prior toejaculation thatneutralizes traces ofacidic urine in theurethra
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Epididymis: Storage and maturation area forsperm
Its head joins the efferent ductules and capsthe superior aspect of the testis
The duct of the epididymis has stereociliathat: Absorb testicular fluid Pass nutrients to the sperm
Nonmotile sperm enter, pass through itstubes and become motile (propelled byperistalsis)
Upon ejaculation the epididymis contracts,
expelling sperm into the ductus deferens 47
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Produced: Seminiferous tubules Stored:Epididymis Transported through epididymis by rhythmic
peristaltic contractions as they mature
EpididymisVas DeferensEjaculatory duct(ampulla of vas deferens fuses with duct ofseminal vesicle ejaculatory duct) prostateprostatic urethra(then passes thebulbourethral gland)membranous urethrapenile urethra
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Cornerstone in Male Infertility
May vary in the same individual over time,may repeated if abnormal
2 3 samples, months apart may benecessary (3 month cycles)
Unless azospermic, the predictive value of
subnormal semen variables is limited; nofunctional test to predict sperm capacity
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20% chance of recurrence
5% chance of hydrocele
Damage to testicular artery
Infection
hematoma
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