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Case Studies

1- Knee Injury 

A 15-year-old gymnast has noted knee pain that has become progressively worse during the past several months of intensive training for a statewide meet. Her physical examination indicated swelling in and around the left knee. She had some decreased range of motion and a clicking sound on flexion of the knee. The knee was otherwise stable.

Studies and Results:

Routine laboratory values: Within normal limits (WNL)

Long bone (femur, fibula, and tibia) X-ray: No fracture

Arthrocentesis with synovial fluid analysis

Appearance: Bloody (normal: clear and straw-colored)

Mucin clot: Good (normal: good)

Fibrin clot: Small (normal: none)

White blood cells (WBCs) <200 WBC/mm3 (normal: <200 WBC/mm3)

Neutrophils <25% (WNL)

Glucose 100 mg/dL (normal: within 10 mg/dL of serum glucose level)

Magnetic resonance imaging (MRI) of the knee Blood in the joint space. Tear in the posterior aspect of the medial meniscus. No cruciate or other ligament tears

Arthroscopy Tear in posterior aspect of medial meniscus

Diagnostic Analysis

The radiographic studies of the long bones eliminated any possibility of fracture. Arthrocentesis indicated a bloody effusion, which was probably a result of trauma. The fibrin clot was further evidence of bleeding within the joint. Arthrography indicated a tear of the medial meniscus of the knee, a common injury for gymnasts. Arthroscopy corroborated that finding. Transarthroscopic medial meniscectomy was performed. Her postoperative course was uneventful.

Critical Thinking Questions

1. One of the potential complications of arthroscopy is infection. What signs and symptoms of joint infection would you emphasize in your patient teaching?

2. Why is glucose evaluated in the synovial fluid analysis?

3. What are special tests used to differentiate type of Tendon tears in the knee ? Explain how they are performed (Always on boards)

2-Testicular Cancer 

A 21-year-old male noted pain in his right testicle while studying hard for his midterm college examinations. On self-examination, he noted a “grape sized” mass in the right testicle. This finding was corroborated by his healthcare provider. This young man had a history of delayed descent of his right testicle until the age of 1 year old.

Studies and Results

Routine laboratory studies: Within normal limits (WNL)

Ultrasound the testicle: Solid mass, right testicle associated with calcifications

HCG (human chorionic gonadotropin): 550mIU/mL (normal: <5)

CT scan of the abdomen: Enlarged retroperitoneal lymph nodes

CT scan of the chest: Multiple pulmonary nodules

Diagnostic Analysis

At semester break, this young man underwent right orchiectomy. Pathology was compatible with embryonal cell carcinoma. CT directed biopsy of the most prominent pulmonary nodule indicated embryonal cell carcinoma, compatible with metastatic testicular carcinoma. During a leave of absence from college, and after banking his sperm, this young man underwent aggressive chemotherapy. Repeat testing 12 weeks after chemotherapy showed complete resolution of the pulmonary nodules and enlarged retroperitoneal lymph nodes.

Critical Thinking Questions

1. What impact did an undescended testicle have on this young man’s risk for developing testicular cancer?

2. What might be the side effects of cytotoxic chemotherapy?

3. What was the purpose of preserving his sperm before chemotherapy?

4. Is this young man’s age typical for the development of testicular carcinoma?