varicocele presentation finalbb

8/14/2019 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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varicocele presentation finalbb

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