1. Case Discussion
R1 吳宗祐
VS 邱元佑
2016/12/07

2. Patient Profile Name: 葉X佑 Chart number: 177621xx Age: 4-month old
Gender: Male
Date of admission: 2016/11/28~12/02
Informant: Parents and medical records

3. Chief Complaints
Right scrotal swelling and local redness

4. Present Illness 4 days before admission Odorous and yellowish urine
Mild decrease of urine output
1 day before admission
LMD:
U/A revealed OB(1+), WBC(-)

5. Present Illness
2016/11/28
Right scrotum swelling, erythematous change, local heat
No fever, No irritable crying, No painful expression during palpation
No upper airway symptoms
No nausea/vomit, no diarrhea, no constipation
Good activity and appetite
Denied TOCC history
Transfer to NCKU ER from LMD

6. Past History Birth Hx: Feeding: Medical Hx: Allergic history: Nil
G2P2, GA 38+1wks, NSD, BBW: 3390g
Apgar score 8  9
Feeding:
Formula ml Q4H
Medical Hx:
ASD, PFO(closed), f/u at our OPD
Allergic history: Nil
Growth and development:
BL: 67 cm = 50-85th percentile
BW: 7.8 kg = 50-85th percentile

7. PE General appearance: fair
HEENT: conjunctiva: not pale, sclera: anicteric
Throat: not injected, Tonsil: no swelling, no pus
Neck: supple, no JVE, no LAP
Chest: symmetric expansion, bilateral clear breath sounds, crackle(-), wheezing(-)
Heart: regular heart beat, diastolic murmur(+),
Abdomen: flat and soft, normoactive bowel sound, tenderness (-), rebound tenderness (-), muscle guarding (-), flank pain(-)
Extremities: warm, pitting edema (-)
Skin: no edema, petechiae or ecchymosis
Right scrotum: local heat(+), swelling(+), eythematous change(+), No irritable crying or painful expression during palpation, Cremester reflex(+)

8. PE

9. Lab

10. Lab

11. Image

12. Image

13. Initial Impression Urinary Tract Infection Epididymo-orchitis Plan
Admitted 4C
Empirical Abx Cefazolin + Gentamycin
Arrange Renal Sonography

14. Treatment course
2016/11/29-12/02
No fever
Good activity and appetite

15. 11/29
11/30
12/01
12/02

16. Renal Echo Relative enlarged kidney, nonspecific
Thicken bladder wall, suspect cystitis like

17. Treatment course 2016/11/29-12/02 In 4C
Discharge on 12/02 with oral Abx and arrange OPD follow up

18. Final Diagnosis
Urinary Tract Infection
Epididymo-orchitis

19. Discussion -- Epididymitis

20. Epididymitis Postpuberty (More frequent) Prepuberty
Sexual activity, heavy physical exertion, and direct trauma
Chlamydia > N. gonorrhea, E.coli, viruses
Others: Ureaplasma, Mycobacterium, CMV, Cryptococcus in HIV patients
Prepuberty
Associated with structural anomalies of urinary tract
Mycoplasma pneumoniae, enteroviruses, adenoviruses

21. Epididymitis – Clinical presentation
History
Acute or subacute onset of pain and swelling
Frequency, dysurea, urethral discharge, and/or fever PE
Local redness, swelling
Normal cremaster reflex
Prehn sign: pain relief with elevation of the testis

22. Epididymitis – Diagnosis
Clinical diagnosis
Doppler ultrasonography or nuclear scan
Urinalysis & urine culture
The US CDC recommendation: if sexually transmitted epididymitis
Gram-stained smear & culture of urethral exudates or intra-urethral swab
Nucleic acid amplification of N. gonorrhea & C. trachomatis
Suphilis and HIV testing

23. Epididymitis – Treatment
Abx, analgesics, scrotal support, bed rest
Sexual partner gets treatment if susp. STD
Susp. chlamydia/gonorrhea
Ceftriaxone 250mg IM in 1 dose
Doxycycline 100mg POBID for 7 days
Susp. enteric organisms
Ofloxacin or levofloxacin
Prepubertal boys: treat as UTI if pyuria(+)

24. Thank you for your attention