Sixth Case : No Picture to Confuse

Today, you were in particularly bad mood due to my trickery in the last case and in office at your usual job, you really wanted to make some real show of brains . Cases were coming but none gave you the margin to show your talents. That's exactly when a 16-year-old boy presented to to you complaining of suprapubic pain radiating to the right testicle, dysuria, urgency and frequency for eight days. The patient was seen one week prior to this visit by his primary care provider (PCP), at which time he described the previous complaints as well as subjective fevers. At that time, the patient’s temperature was 99.2 F (37.3 C). He was noted to be well appearing and in no acute discomfort. The abdominal examination revealed mild suprapubic tenderness to palpation but without the presence of rebound or guarding, there was no costovertebral angle tenderness (CVAT) and his genitourinary (GU) examination was normal. A urinalysis was negative for infection and the patient was diagnosed with a viral syndrome. Three days prior to today's visit, the patient reported a temperature of 103 F (39.4 C) and severe suprapubic pain. The following day, the intensity of his pain diminshed some what and hisf ever resolved.In the ED,thepatient continued to complain of crampy abdominal pain at a level of 6 (on a scale of 0 to 10), with associated dysuria, urgency and frequency. He denied nausea,vomiting,diarrhea,constipation orpenile discharge, and was tolerating oral liquids.As is becoming your second nature now , you did the PE and found :

GENERAL APPEARANCE: lying supine on the gurney, appeared comfortable and in no acute discomfort.

VITAL SIGNS
Temperature 98.7 F(37.1 C)
Pulse 88 beats/minute
Blood pressure 120/80 mmHg
Respirations 20 breaths /minute
Oxygen saturation 100% on room air
Head , Eyes & ENT: PERRL, EOMI, oropharynx moist and rest unremarkable.

NECK: Supple.no abnormality whatsoever

CARDIOVASCULAR: Regular rate and rhythm without rubs,murmurs or gallops.

LUNGS: Clear to auscultation bilaterally.

ABDOMEN: Soft, nondistended; suprapubic, periumbilical and right lowerquadrant tenderness to palpation without rebound or guarding . No CVAT.

RECTAL: Normal tone, brown stool,hemoccult negative.

GENITOURINARY: Circumcised, no penile discharge, testes descended bilaterally, no testicular swelling or tenderness, no hernias.

EXTREMITIES: No clubbing,cyanosis or edema.

NEUROLOGIC: Nonfocal.

A peripheral intravenous line was placed by you, and blood was drawn and sent for laboratory testing. Laboratory tests revealed a leukocyte count of 16 K/µL with 84% neutrophils ; electrolytes, creatinine, glucose and urinalysis were within normal imits.

This is what you've got . . now you have to work out differentials , declare one as your suggested diagnosis and confirm it by minimum further investigations and then to treat the peatient considering your suggested diagnosis is right