It’s going to be one of those shifts. You just sent a 29- year-old male to the cardiac cath lab for a bona-fide ST elevation MI. Your patient with a chief complaint of “eye pain” ended up having metastatic cancer within his right orbit, and your seemingly straight-forward post-partum woman with a headache had an MR venogram showing a dural vein thrombosis. Although these are awesome teaching cases for your residents and medical students, you wonder out loud, “Where did the ankle sprains go?”

For your next case, your resident presents a 32-year-old male who drove himself to the ED because of right testicular pain. He notes the pain came on gradually over the past week, and it is “achy” and “heavy” in nature. On review of systems, he denies any fevers, chills, abdominal pain, dysuria, penile discharge, or recent trauma. He is sexually active with multiple partners, but has never had a sexually transmitted infection before. He notes he was on antibiotics recently for an “infected bug bite” on his arm, but is otherwise healthy and does not take any medications.

Other than being slightly tachycardic, the patient’s vital signs are within normal limits, and except for his testicles, the remainder of the physical examination is normal. Both testicles had a normal lie and there were no obvious external abnormalities. The epididymis felt normal bilaterally, but there was a rather odd palpable mass within the scrotal sac that your resident is concerned about. He wants you to help him figure out what it could be. For that matter, so does the patient.

Your astute resident rattles off his differential diagnosis for the patient’s testicular pain. He doesn’t think the patient has testicular torsion, torsion of the testicular appendage, epididymitis, orchitis, a hernia, or Fournier’s gangrene.

At the bedside, your stoic 32 year-old patient appears rather pleased that your resident is getting a “second opinion” and is happy his IV pain medications are finally kicking in. You take the opportunity to teach your resident about transillumination, the cremasteric reflex, and Prehn’s sign. On exam, you note that the right testicle does indeed feel more full along the inferior, posterior border. The area does not transilluminate, and it is definitely more tender to palpation than the surrounding tissue and contralateral testis.

Like a well-trained mind-reader, your resident excuses himself to grab the ED ultrasound machine, as you explain to the patient that you are going to do a focused bedside testicular scan to gather some more information about what could be going on.

To begin your scan, you obtain a transverse image of both testicles side-by-side. By convention, the orientation marker is facing the patient’s right side (Top). What do you see? You zoom in on the abnormality and scan through the region of interest (B).




What should you be concerned about? Conclusion on next page.


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