GROUP 8: PATIENT CASE

History of Present Illness

L.A. is a 29-year-old white male who presented to his PCP because he recently felt a “heavy sensation”
in his scrotum and subsequently discovered a small, but distinct, lump on the surface of his right testicle.
He is accompanied by his wife, who appears to be very supportive.

Past Medical History

• Appendicitis, 18 years ago

• Asthma, since age 5 years

• Vasectomy, 5 years ago

• Last PE was 5 years ago

Social History
• Works full-time as a janitor in a home for the mentally disabled

• Before that served 3 years in the U.S. Army

• Has been married for 7 years and has twin daughters, age 8

• Smoked 1 ⁄2 pack cigarettes/day for 8 years but quit 5 months ago

• Denies alcohol consumption and IV drug use

• Has used cocaine several times in the past year

Medications
Albuterol inhaler PRN

Allergies
• Aspirin causes swelling in the face and tongue

• Latex causes a rash

• Sulfa drugs cause a rash

Review of Systems
 swelling or abnormal lumps  coughing up of blood,
 fatigue  abdominal or chest pain
 headaches,  difficulty breathing,
 changes in vision  seizures,
 dizziness  difficulty swallowing
 cough  back pain.
PE and Lab Tests
General

Thin, alert but anxious, healthy-looking, young, white male in NAD

Abdomen

• Soft, NT/ND

• Normoactive BS

• No HSM, masses, or bruits

Genit/Rec

• External genitalia normal with no enlarged inguinal lymph nodes

• Uncircumcised male

• No rectal/prostate exam conducted

Clinical Course

Ultrasound of the right testicle revealed a 2-cm solid, non-cystic mass. A chest x-ray and CT scans of the
chest and abdomen were negative. An orchiectomy was performed of the right testicle. Microscopic
analysis of the tumor revealed a mixed population of malignant cells that had not invaded the tunica
albuginea, epididymis, or spermatic cord, but was confined exclusively to the testicle.

--Nothing follows--
B. Anatomy and Physiology

I. Testes

Testes or testicles are paired oval glands in the scrotum that develop near the kidneys, in the
posterior portion of the abdomen. They usually begin their descent into the scrotum through the
inguinal canals. The tunica vaginalis is a serous membrane that is formed during the descent of testes
and will serve as the partial cover of the testes. Hydrocele is the term for the collection of serous fluid in
the tunica vaginalis that is caused by the inflammation of epididymis or injury to the testes.

In the internal part of tunica vaginalis, there is a white fibrous capsule composed of dense
irregular connective tissue called tunica albuginea. It extends inward and forms a septa that will divide
the testis into a series of internal compartments called lobules. Each of these lobules contains 1-4
seminiferous tubules which will produce the sperm or is the site of spermatogenesis.

The seminiferous tubules contain two types of cells namely, Spermatogenic cells, where 95% of
testicular cancers arise and the sustentacular cells (Sertoli cells). These are sperm-forming cells that
forms gametes and will mature into sperm. They serve as support in spermatogenesis. Stem cells called
spermatogonia develop from primordial germ cells that arise from the yolk sac and enter the testes
during the fifth week of development. Sustentacular cells act as protection and support to the
spermatogenic cells (where it is embedded). It also nourishes the spermatocytes, spermatids, sperm and
also produce fluid for the transport of sperm, secrete the hormone inhibin, and regulate the effects of
testosterone and FSH (follicle-stimulating hormone).

III. Lungs

The lungs are a paired organ located in the thoracic cavity and is separated by mediastinum. Each lung is
covered and protected by pleural membrane, a double layered serous membrane. The wall of thoracic
cavity is lined by superficial parietal pleura while the deep visceral pleura lines the lungs themselves. The
small space found in between the visceral and parietal pleurae is called pleural cavity. It contains
lubricating fluid which acts to reduce friction between membranes allowing them to slide over another
when breathing and when the pleural membrane is inflamed, it will cause pleuritis that leads to fluid
accumulation in the pleural space, a condition known as pleural effusion.

The lungs almost fill the thorax. The apex, which is a narrow superior portion of the lungs lies is
the only area that can be palpated. Smaller units of the lungs are called lobes which are separated by
fissures. The right lung consists of the superior, the middle and inferior lobes. The left lung on the other
hand houses only two: the inferior and superior lobes. Each lobe contains various bronchopulmonary
segments, which receives gas from and blood from individual tertiary bronchus and arteries,
respectively. In cases of diseases, these individual segments can be removed without affecting
neighboring segments. A subdivision is formed as a bronchi branch into bronchioles, called a lobule.
Lobules are separated by an interlobular septum composed of connective tissues. The pulmonary artery
carries the deoxygenated arterial blood to the alveoli. This artery becomes smaller in diameter as it
nears the alveoli, termed as an arteriole accompanied by a venule supply and one pulmonary lobule.
These arteries then become the pulmonary capillaries as they become smaller vessels with thin walls
without smooth muscle fibers. These capillaries link to the alveoli which are microscopic air sacs where
oxygen is absorbed into the lungs and then into the blood. Carbon dioxide travels from the blood as
waste to the alveoli where it is exhaled. Oxygenated blood exits the lungs through the hilum. Bordering
these sacs are thin cell layers called interstitium containing blood vessels and other cells that nurture the
alveoli. The lung root formed at the entrance of the nerves of the hilum are called the pulmonary plexus.

III