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  1. AAFP Journal Review Nov 15th, 2008 Dr. Meenakshi Aggarwal PGY3 Emory Family Medicine

  2. Topics • Evaluation Of Scrotal Masses • Fatigue: An Overview • Pressure Ulcers: Management

  3. Evaluation Of Scrotal Masses • Anatomy • Causes • Diagnostic Evaluation: History Physical Exam Imaging

  4. Q. Which one of the following findings is the most consistent with testicular torsion? • A. Elevation of testes may aggravate pain. • B. "Bag of worms" consistency. • C. Transilluminates. • D. A normal cremasteric reflex. Answer: A

  5. Overview

  6. Diagnosing Scrotal Masses

  7. CREMASTERIC REFLEX • Stroke or pinch the medial thigh • Stimulus usually causes cremasteric muscle contraction • Observe for rise of the testicle on same side • Normal: Cremasteric reflex present (testicle rises) • Seen in Epididymitis • Abnormal: Cremasteric reflex absent (no Testicle rise) • Suggests Testicular Torsion • Also absent in 50% of boys under age 30 months • Efficacy Test Sensitivity for Testicular Torsion: 99%

  8. IMAGING Doppler Ultrasonography MRI CT Radionucleotide Imaging

  9. Figure 3. Ultrasound images of a patient with mixed germ cell tumor of the right testis. Longitudinal views of the testes show (A) the heterogeneous nature of the tumor parenchyma on the right compared with (B) the normal parenchyma on the left. Color Doppler images show normal blood flow on (C) the right longitudinal and (D) left transverse views.

  10. Q. Which one of the following statements about the management of the patient with suspected testicular torsion is correct? • A. Surgical referral should await confirmation of torsion with ultrasonography. • B. Radionuclide imaging is not an accurate test to confirm the presence of torsion. • C. All patients should be emergently referred for evaluation by a urologist. • D. Elevation of testes may relieve pain. Answer: C

  11. Fatigue Condition characterized by a lessened capacity for work and reduced efficiency of accomplishment, usually accompanied by a feeling of weariness and tiredness.

  12. Etiology • No etiology in 1/3rd cases • Common causes: Overexertion Depression Viral illness URTI Anemia Medications Cancer

  13. Sleepiness • Impairment of the normal arousal mechanism and is characterized by a tendency to fall asleep.

  14. Classification • Physiologic: Imbalance in the routine and is relieved with rest. • Secondary: Caused by underlying medical condition. Lasts >1 month<6 months. • Chronic: Lasts longer than six months and is not relieved with rest.

  15. Management • Physiologic Fatigue: Adequate sleep, good sleep hygiene, stimulants (caffeine, Modafinil), exercise • Secondary Fatigue: Correcting anemia, discontinuing medications causing fatigue, yoga, stress management, SSRI’s • Chronic Fatigue: Moderate aerobic exercise, cognitive behavior therapy, antidepressants, NSAIDs. REGULAR VISITS

  16. Q. Which one of the following are patients with chronic fatigue usually seeking from their physicians during an office visit? • Medication. • Diagnostic testing. • Reassurance. • Referral. ANSWER: C

  17. Pressure Ulcers • Localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of unrelieved pressure. • Predisposing factors: Intrinsic and extrinsic • Prevention: Identifying at risk persons, assessing nutrition, using pressure reducing surfaces.