9.1

A 15 year old boy presents with sudden onset of L) testicular pain whilst playing football. He is not sure if he was struck in the groin during play. The pain was initially severe but is resolving. He is nauseated but has not vomited. On examination his scrotum appears normal. The left testis is normal in size and position. It is moderately tender. The right testis is normal. You discuss the case with a fellow registrar who suggests getting a scrotal ultrasound to check for a traumatic haematoma. The ultrasound shows a normal testis with normal blood flow.

What is your management now?

This patient still requires urgent urology referral and possibly exploratory surgery to exclude testicular torsion. A normal ultrasound does not exclude this diagnosis. Most patients presenting with acute testicular pain should be discussed with a urologist. Testicular torsion is still the most likely cause of sudden testicular pain in this age group, and of course the most important to exclude. In this case it is possible the testis has torted transiently. The risk for further torsion remains and surgical exploration and orchidopexy may be indicated to prevent reoccurrence.

9.2

You are asked to see a 78 year old woman who has been triaged as ‘gastroenteritis’. You note from the ambulance sheet that she has profuse ‘faeculant’ vomiting.

What should you be thinking as you go to see her?

Faeculant vomiting (ie vomit that is offensive smelling, like faeces) indicates bacterial overgrowth in bowel content that has stagnated due to bowel obstruction. It is not at all characteristic of gastroenteritis.

When you see her you confirm the vomit is indeed offensive, her abdomen is distended and somewhat tender. An abdominal X-ray shows dilated small bowel with multiple fluid levels consistent with bowel obstruction. You refer her to the surgeons who subsequently operate on her and relieve an adhesion that was the cause of her obstructed bowel.