COMPLETE HISTORY – RIGHT GROIN / TESTICULAR MASS 🧾 Identification * Name: Nik Adly Athiff * Age: 25 years * Sex: Male * Ethnicity: Malay * Occupation: Motorcycle repair worker * Address: Lallahat * Marital status: Unmarried ⸻ 🗣️ Chief Complaint * Swelling in the right groin/scrotal region for ~1 year ⸻ 📖 History of Present Illness The patient was apparently well until mid of last year, when he initially experienced a dull aching pain in the right groin region. * Pain was: * Sudden in onset * Dull aching in nature * Non-radiating * Lasted about 1 hour * Aggravated by movement * Pain score: ~5/10 Following this episode: * He noticed a swelling in the same region * Pain resolved and did not persist Progression: * Initially coin-sized * Gradually increased to about three-finger breadth over 1 year Characteristics of swelling: * Painless after initial episode * Progressively increasing in size * Irreducible * Persistent, no fluctuation in size There is no history of: * Fever * Nausea or vomiting * Abdominal pain * Urinary complaints * Trauma ⚠️ Patient presented late and is now evaluated in hospital for the first time. ⸻ 🚨 Associated Symptoms (Metastasis Screening) * No back pain * No cough or breathlessness * No bone pain * No loss of weight or appetite * No gynecomastia ⸻ ⚠️ Past History * No known chronic illnesses * No previous surgeries * No similar complaints in the past ⸻ 👶 Birth & Developmental History * Not born premature * Antenatal history significant for maternal Diabetes Mellitus ⸻ ⚠️ Testicular History (IMPORTANT) * History of undescended testis (cryptorchidism) * Side: to be confirmed * Orchidopexy history: to be asked ⸻ 👨👩👦 Family History * Mother has Diabetes Mellitus * No family history of malignancy ⸻ 🧬 Personal / Social History * Occupation: Motorcycle repair worker * Smoking history: * ~10 cigarettes/day since age 20 * Currently stopped * Appetite: Normal * Bowel & bladder habits: Normal ⸻ 🏥 Treatment History * Patient was evaluated for a suspected testicular tumor * He has been planned for right inguinal orchidectomy (surgery not yet performed) ⸻ 🧾 FINAL SUMMARY (EXAM VERSION) Nik Adly Athiff, a 25-year-old unmarried Malay gentleman, presented with a right groin/scrotal swelling of 1-year duration. The swelling was preceded by a brief episode of dull aching pain and has since been painless, progressive, and irreducible. There are no systemic or obstructive symptoms. He has a significant history of undescended testis, a known risk factor for testicular malignancy. He is currently planned for right inguinal orchidectomy for suspected testicular tumor. make it into proper history taking template and send me also dx and ddx and ix and mx
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HISTORY & PHYSICAL — RIGHT GROIN / TESTICULAR MASS
Patient ID: Nik Adly Athiff | Age: 25 years | Sex: Male
Ethnicity: Malay | Occupation: Motorcycle repair worker | Address: Lallahat
Marital Status: Unmarried | Date: 03 May 2026
1. BIODATA
| Name | Nik Adly Athiff |
| Age | 25 years |
| Sex | Male |
| Ethnicity | Malay |
| Religion | Islam (assumed) |
| Occupation | Motorcycle repair worker |
| Address | Lallahat |
| Marital status | Unmarried |
| Informant | Patient himself (reliable) |
2. CHIEF COMPLAINT
Right groin and scrotal swelling for approximately 1 year.
3. HISTORY OF PRESENTING ILLNESS
Nik Adly Athiff is a 25-year-old Malay gentleman who was apparently well until approximately mid of last year, when he first developed a sudden-onset dull aching pain in the right groin region.
Pain characteristics:
- Site: Right groin
- Onset: Sudden
- Character: Dull, aching
- Radiation: Non-radiating
- Duration: ~1 hour per episode
- Aggravating factor: Movement
- Relieving factors: None elicited
- Severity: 5/10 on pain scale
Following this pain episode, he noticed a swelling in the same region. The pain subsequently resolved and did not recur.
Swelling characteristics:
- Initial size: Coin-sized
- Progression: Gradual increase over 1 year to approximately three-finger breadths
- Nature: Painless after initial episode
- Reducibility: Irreducible
- Fluctuation: No fluctuation in size
- Transilluminability: Not documented (to be examined)
- Skin over swelling: No erythema or warmth reported
Systemic enquiry (negative):
- No fever, rigors, or chills
- No nausea or vomiting
- No abdominal pain
- No urinary symptoms (dysuria, haematuria, frequency, hesitancy)
- No bowel changes
- No history of trauma
Metastasis screening (all negative):
- No back pain
- No cough or breathlessness
- No bone pain
- No loss of weight or loss of appetite
- No gynecomastia
Patient presented late — first hospital attendance despite 1-year symptom duration.
4. PAST MEDICAL HISTORY
- No known chronic illnesses (hypertension, diabetes mellitus, bronchial asthma)
- No previous hospitalisations
- No previous surgeries
- No similar complaints in the past
5. BIRTH & DEVELOPMENTAL HISTORY
- Not born premature
- Antenatal history: Mother had Diabetes Mellitus during pregnancy (significant — maternal DM is a recognised risk factor for cryptorchidism/testicular dysgenesis)
- Developmental milestones: Not contributory
6. TESTICULAR HISTORY (CRITICAL — to be elicited)
| Question | Answer |
|---|---|
| History of undescended testis (cryptorchidism)? | Yes — side to be confirmed |
| Age at which cryptorchidism was noted | To be clarified |
| Orchidopexy performed? | To be clarified |
| Age at orchidopexy (if done)? | To be clarified |
| Any previous testicular trauma or infection (orchitis, epididymo-orchitis)? | Not reported |
| Any infertility concerns? | Not applicable (unmarried) |
Clinical significance: Cryptorchidism is a well-established risk factor for testicular germ cell tumour (TGCT). Orchidopexy before puberty reduces but does not eliminate this risk. — Robbins & Cotran Pathologic Basis of Disease
7. FAMILY HISTORY
| Condition | Relative |
|---|---|
| Diabetes Mellitus | Mother |
| Testicular cancer / other malignancy | Denied |
8. SOCIAL HISTORY
| Occupation | Motorcycle repair worker (exposure to chemical hydrocarbons — possible environmental risk) |
| Smoking | ~10 cigarettes/day from age 20; currently stopped |
| Alcohol | Not documented (likely non-consumer per religion) |
| Substance use | Not documented |
| Exercise / activity | Not documented |
| Diet / appetite | Normal |
| Bowel habits | Normal |
| Bladder habits | Normal |
| Sexual history | Unmarried; not documented |
9. DRUG HISTORY & ALLERGIES
- No regular medications
- No known drug allergies
- No herbal or traditional medicine use documented
10. SYSTEMIC REVIEW (Summary)
| System | Findings |
|---|---|
| General | No fever, no weight loss, no night sweats |
| CVS | No chest pain, no palpitations |
| Respiratory | No cough, no breathlessness, no haemoptysis |
| GIT | No abdominal pain, no nausea/vomiting, normal bowel habits |
| GUS | No LUTS, no haematuria, no scrotal pain currently |
| MSS | No bone pain, no joint swelling |
| Neurological | No headache, no focal deficits |
| Endocrine | No gynecomastia, no galactorrhoea |
11. PHYSICAL EXAMINATION (To be completed)
General:
- Conscious, alert, cooperative
- No pallor, jaundice, cyanosis, clubbing, lymphadenopathy
- BMI: To be documented
Vital signs: HR, BP, RR, SpO₂, temperature
Local Examination — Scrotum/Groin:
| Feature | Findings |
|---|---|
| Inspection | Swelling in right groin/scrotal region, skin appearance normal/abnormal |
| Size | Approximately three-finger breadths |
| Surface | Smooth or lobulated — to document |
| Consistency | Firm/hard (suggest malignancy) — to document |
| Tenderness | Non-tender |
| Transillumination | Negative (expected in solid tumour) |
| Reducibility | Irreducible |
| Get above the swelling | To determine if scrotal or inguino-scrotal |
| Epididymis | Palpable separately or not |
| Cough impulse | Absent |
| Left testis | Normal |
| Vas deferens | Palpable bilaterally |
Abdominal examination:
- Inspect for distension
- Palpate for para-aortic lymphadenopathy (epigastric/retroperitoneal mass)
- Liver assessment (metastasis)
Lymph nodes:
- Supraclavicular (Virchow's node) — important in testicular tumour staging
- Inguinal nodes
DIAGNOSIS & DIFFERENTIALS
PROVISIONAL DIAGNOSIS
Right testicular germ cell tumour (TGCT) — likely seminoma
Rationale:
- 25-year-old male (peak incidence for testicular cancer is age 20–40)
- Painless, progressive, irreducible right scrotal mass
- History of cryptorchidism (3–5× increased risk of TGCT)
- Maternal DM antenatally (testicular dysgenesis syndrome association)
- No systemic symptoms (suggests localised disease)
- Presentation consistent with textbook description: "the most common presenting complaint in males with testicular cancer is a painless testicular mass" — Sabiston Textbook of Surgery
Germ cell tumours account for 95% of all testicular neoplasms, divided approximately equally between:
- Seminoma (~50%): Classic seminoma most common in the 4th decade, radiosensitive
- NSGCT (~50%): Embryonal carcinoma, yolk sac tumour, choriocarcinoma, teratoma, mixed
DIFFERENTIAL DIAGNOSES
| # | Diagnosis | Supporting Features | Against |
|---|---|---|---|
| 1 | Testicular seminoma (most likely) | Age 20–40, painless mass, cryptorchidism Hx | Confirmation requires histology |
| 2 | NSGCT (embryonal / mixed GCT) | Same age group, painless mass | Typically faster-growing, earlier metastasis |
| 3 | Epididymo-orchitis | Scrotal swelling | No fever, no urinary Sx, no tenderness, 1-year duration makes infection unlikely |
| 4 | Indirect inguinal hernia | Right groin swelling, irreducible | Cannot get above swelling?, no bowel sounds in sac, no cough impulse |
| 5 | Hydrocele | Scrotal swelling in young male | Irreducible + no transillumination effectively rules this out |
| 6 | Varicocele | Scrotal swelling | Typically left-sided, bag-of-worms texture, reducible when supine |
| 7 | Spermatocele / epididymal cyst | Scrotal swelling | Usually separate from testis, transilluminates |
| 8 | Lymphoma of testis | Testicular mass | Most common testicular tumour in males >60; patient is 25 |
| 9 | Leydig / Sertoli cell tumour | Non-GCT testicular mass | No endocrine features (no gynaecomastia, no precocious puberty) |
INVESTIGATIONS
A. URGENT (First-line)
| Investigation | Rationale |
|---|---|
| Scrotal ultrasonography (USS) | Diagnostic study of choice for suspected testicular mass — distinguishes solid from cystic, intra- from extra-testicular. High sensitivity and specificity for malignancy. |
| Serum tumour markers: α-fetoprotein (AFP), β-hCG, LDH | Critical for diagnosis, staging, and post-orchidectomy surveillance. AFP elevated in yolk sac tumours/NSGCT; β-hCG elevated in choriocarcinoma and ~15% seminomas; LDH is a non-specific prognostic marker. — Smith & Tanagho's General Urology; Sabiston |
| FBC, BUSE/Creatinine, LFT | Baseline bloods; LFT for hepatic metastasis screening |
| Blood group & cross-match | Pre-operatively for planned orchidectomy |
B. STAGING (Post-diagnosis, Pre/Post-orchidectomy)
| Investigation | Rationale |
|---|---|
| CT chest, abdomen, pelvis (contrast-enhanced) | Retroperitoneal lymphadenopathy (primary metastatic site in >70% of metastatic testicular cancer, right-sided drains to infrarenal interaortocaval/paracaval/para-aortic nodes); lung metastases |
| Chest X-ray | Pulmonary metastases (use in low-risk; CT chest for high-risk) |
| Post-orchidectomy tumour markers | β-hCG t½ = 24–36 h; AFP t½ = 5–7 days. Failure to normalise indicates residual/metastatic disease. |
C. INTRAOPERATIVE
| Investigation | Rationale |
|---|---|
| Radical inguinal orchidectomy + histopathology | Definitive diagnosis. Scrotal biopsy is contraindicated — violating scrotal tissue planes alters lymphatic drainage and can change staging/treatment. |
D. ADJUNCTIVE
| Investigation | Rationale |
|---|---|
| MRI scrotum | If USS equivocal |
| PET-CT | Used post-chemotherapy in seminoma to assess residual mass viability |
| Bone scan | If bone pain is present (not currently indicated) |
| Semen analysis / sperm banking | Pre-treatment fertility counselling (important in 25-year-old) |
MANAGEMENT
A. IMMEDIATE
- Refer to urology urgently (already planned — right inguinal orchidectomy)
- Obtain tumour markers before surgery (AFP, β-hCG, LDH)
- Pre-operative workup: FBC, BUSE, coagulation studies, CXR, ECG, anaesthetic assessment
- Sperm banking discussion — patient is 25 and unmarried; fertility preservation must be offered prior to any treatment
- IV access, NBM, consent for procedure
B. SURGICAL
Right Radical Inguinal Orchidectomy
- Approach: Inguinal incision (NOT scrotal)
- The testis and spermatic cord are removed at the level of the internal inguinal ring
- Scrotal or transscrotal approach is absolutely contraindicated (alters lymphatic drainage → changes staging)
- Surgical findings determine histological type → guides further management
C. POST-ORCHIDECTOMY MANAGEMENT (Guided by histology + staging)
If Seminoma — Stage I (localised):
| Option | Details |
|---|---|
| Active surveillance | Preferred in low-risk Stage IA; requires regular CT + tumour markers |
| Adjuvant carboplatin (×1 cycle) | Reduces relapse risk |
| Adjuvant para-aortic radiotherapy | 20 Gy to para-aortic nodes; less preferred now due to long-term toxicity |
If Seminoma — Stage II:
- Stage IIA/IIB: Retroperitoneal radiotherapy ± RPLND
- Stage IIC/III: Platinum-based chemotherapy (BEP: Bleomycin, Etoposide, Cisplatin)
If NSGCT — Stage I:
- Options: Surveillance, primary RPLND, or cisplatin-based chemotherapy
If NSGCT — Stage IIA/IIB:
- Primary RPLND (if tumour markers normal) or 3–4 cycles BEP chemotherapy
If NSGCT — Stage III:
- 3–4 cycles BEP chemotherapy
D. LONG-TERM FOLLOW-UP
| Tumour marker surveillance | AFP, β-hCG, LDH at each visit |
| Imaging | CT abdomen/pelvis at intervals per staging protocol |
| Contralateral testis | Counsel about ~2–5% risk of metachronous TGCT; teach self-examination |
| Fertility | Review sperm banking; counsel on long-term fertility impacts of chemotherapy/radiotherapy |
| Smoking cessation | Patient has already stopped — reinforce |
| Psychological support | Diagnosis at age 25; multidisciplinary team involvement |
| Oncology referral | Medical oncology for chemotherapy planning if indicated |
E. PATIENT EDUCATION
- Explain diagnosis clearly in language the patient understands
- Explain that testicular cancer has an excellent prognosis with survival rates >95% for stage I disease
- Stress importance of compliance with follow-up
- Explain surgical procedure, risks, and expected recovery
- Address concerns about masculinity, sexual function, and fertility
FINAL SUMMARY
Nik Adly Athiff, a 25-year-old unmarried Malay gentleman, presented with a right groin/scrotal swelling of 1-year duration, preceded by a single episode of self-limiting dull aching pain. The swelling has since been painless, progressively enlarging, and irreducible, with no systemic features of metastatic disease. He has a significant past history of cryptorchidism — a well-established risk factor for testicular germ cell tumour. The most likely diagnosis is a right testicular germ cell tumour (seminoma vs. NSGCT), which is the most common solid malignancy in males aged 20–40. He requires urgent tumour markers, scrotal ultrasound, and staging CT before proceeding to right radical inguinal orchidectomy, with further management tailored by histology and stage. Prognosis is excellent with early intervention and appropriate post-operative management.
Sources: Smith & Tanagho's General Urology (19th Ed.); Sabiston Textbook of Surgery; Robbins & Cotran Pathologic Basis of Disease; Textbook of Family Medicine (9th Ed.). Recent guidelines: SEOM 2023 (PMID 38958901); French AFU 2024 (PMID 39581663).
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