Student Instructions
You are a junior doctor working in the urology clinic. Mr Albert Clower is a new patient who has come to you today with a lump in his left scrotum. He is rather embarrassed about this and would prefer to see a male doctor but will settle for a female doctor if there isn’t anyone else around.
Please take a complete medical history for Mr Clower regarding this new lump.
After 7 minutes the examiner will stop you to ask you a few questions.
Patient Instructions
Name: Albert Clower
Age: 37 years old
Job: Internet entrepreneur
PC- left scrotal lump
Whilst in the shower a week ago you noticed that one of your testicles seemed bigger than the other. You weren’t quite sure if they had always been like this, so you asked your girlfriend who is a qualified nurse to examine you. She was concerned and told you to go to the GP.
The lump is not painful, but you have noticed a kind of dragging sensation.
The overlying skin feels normal. You remember that a couple of weeks ago you were kicked in the groin whilst playing rugby and are unsure of this is what started it. You think you might have put on a bit of weight recently as your girlfriend has been making fun of your man breasts.
You are not having any sexual problems. You have not experienced any abdominal pain or other gastrointestinal symptoms or urinary symptoms. You feel well in yourself.
PMH
As a child you had an operation to correct an undescended left testicle. As a teenager you were treated for attention hyperactivity disorder (ADHD).
DH
Nil
NKDA
SH
You smoke socially about 20 per week. You indulge in binge drinking at weekends but would rather not tell the doctor exactly how much because you are embarrassed you will get told off. You live with your girlfriend of two years and your relationship is going well.
FH
Your father suffered with type one diabetes and your mother had breast cancer.
ICE
You don't really think it is anything but want to avoid being pestered by your girlfriend and so will go along with whatever investigations are necessary.
Questions
What is the likely diagnosis?
Testicular tumour- seminoma
Differentials
Other testicular tumour- lymphoma, non-germ cell testicular tumours
Hydrocele
Epididymal cyst
Infection- epididymo-orchitis, TB, syphilis, mumps
Torsion
What investigations and possible management would you do?
Ultrasound scan to confirm diagnosis.
Staging scan by CT of the chest, abdomen and pelvis.
Tumour markers: beta-HCG may be raised (AFP is not normally raised in seminomas but may be raised for non-germ cell tumours)
Surgical management: orchidectomy via an inguinal approach to avoid tumour seeding
Radiotherapy and chemotherapy are indicated for certain stages of cancers
Overall testicular tumours (seminomas) if found early have a very good prognosis. It is estimated that over 95% of testicular tumours in young men will be seminomas.