Soap Note

Name:   J. B
Date:

Time:  1145

Age:  50 years

Sex:  M

SUBJECTIVE

CC:   “I am here due to left groin and testicle pain.”

HPI: 

The patient is a 50-year old male who visited the clinic after experiencing a sudden onset of severe pain in the left groin. The patient noted that the pain is radiating to the testicles. The patient has been experiencing the pain for 6 hours. This pain started after moving a refrigerator. He rates the pain at 5/10 and becomes severe when he bends.

Medications:

Lisinopril 20mg bid for hypertension

PMH

Allergies: NKDA

Medication Intolerances: none

Chronic Illnesses: high blood pressure

Hospitalizations/Surgeries: no history of hospitalizations

Family History

Father has prostate cancer coronary heart disease and hypertension

Mother has hypothyroid and breast cancer

Social History

The patient does not take alcohol and does not have a history of cigarette smoking. He also states that he has never abused illicit substances. The patient rarely participates in physical exercises though he enjoys walking for at least thirty minutes per day.

ROS

General

The patient appears the stated age. He is distressed by the pain in the groin. He denies the loss of appetite and weight loss. He has not experienced fever, chills and extreme fatigue

Cardiovascular

The patient denies painful sensation in the chest as well as incidences of shortness of breath

 

Skin

He denies abnormal skin conditions

 

Respiratory

He denies a persistent cough and wheezing as well as dyspnea. He also denies excessive sputum secretion

 

Eyes

He does not wear lenses and spectacles

He denies excessive tearing, pain, and burning sensation in the eyes.

He reports that his vision has decreased slightly and he attributes this to age.

Gastrointestinal

The patient does not report abdominal pain. He, however states that he feels nauseated and has vomited once. He does not suffer from diarrhea and constipation

Ears

The patient does not report pain and ringing in the ears.

He does not have abnormal discharge in the ears.

Genitourinary/Gynecological

The patient reports severe pain in the groin, together with pain in the testicles which he rates at 5/10. The patient reported that his testicles were hard and swollen

 

He denies decreased urinary output and hematuria

 

Nose/Mouth/Throat

The patient denies nose, mouth and throat related conditions including hoarseness, a sore throat and inflamed sinuses.

 

Musculoskeletal

The patient does not experience muscular weakness, pain in the joints and a decreased range of motion. He also denies edematous conditions

Heme/Lymph/Endo

The patient has not experienced heat and cold intolerance incidences, excessive thirst and hunger as well as lymph glands inflammation

Neurological

The patient denies weakness and numbness on any side of the body. He does not suffer from dizziness, severe headaches, and back pain.

 

Psychiatric

The patient denies mental symptoms such as depression, anxiety and stress.

 

OBJECTIVE

Weight        180 lbs BMI

Temp 99.0

BP  195/90

Height:  6’0

Pulse  130bpn

Resp 18      Osat 98%.

General Appearance

The patient appears distressed. He is well developed and properly groomed. He does not show signs of extreme weight loss.

Skin

The skin color is brown. No signs of skin ulcers, rashes and moles detected.

HEENT

Head: there are no signs of major blows to the head. The patient is slightly bald. The head shape is normal

Eyes: no pupillary infections detected. No signs of inflammation or excessive tearing observed.

Ears: the ear canals are patent with no detectable signs of abnormal discharge or inflammation

Nose: the nasal mucosal does not show signs of dryness or excessive secretion.

Neck: no thyromegaly or cervical lymphadenopathy signs reported, he does not have a decreased range of neck motion

Throat: The sinuses are not inflamed

Cardiovascular

s/1 and s/2 present and normal. No bruits, clicks and gallops noted. Pulses+3

Respiratory

Auscultation of the lungs does not identify abnormal sounds and the chest wall is bilaterally symmetrical

Gastrointestinal

The patient does not show signs of spleen enlargement; the bowel sounds are normal and detectable in all quadrants.

The abdomen is non-tender and non-distended and does not show signs of injury of abdominal obesity

 

Genitourinary

The left inguinal canal is slightly tender and the left scrotum is swollen

Palpitation of testicles reveals they are normal sized and non-tender.

 

Musculoskeletal

The patient has bilateral lower extremities +2 edema, but no decreased range of motion. The joints are not inflamed or reddened

Neurological

The patient does not have neurological disorder. The cranial nerves are intact. He has a normal posture and an upright gait.

Psychiatric

The patient is slightly distressed. His tone is audible and he listens attentively besides responding accurately to interview questions. He is alert and oriented x3.

Lab Tests

Normal urinalysis: pH- 5.1

CBC

Special Tests

Scrotal ultrasound reveals the following:

• Loop of bowel in the left scrotum

• Normal blood flow to each testicle

• Normal testicular size bilaterally

 Diagnosis

Primary diagnosis

Incarcerated left inguinal hernia: The main symptoms of this condition include severe pain and aching sensation in the bulge. The patient presents with severe pain and discomfort in the groin. The pain becomes severe when the patient bends, coughs or lifts a heavy weight. The patient also experiences pressure, weakness and a dragging sensation in the groin. The risk factors for this condition include family history, being male and advanced age which leads to weakening of muscles (Mayo Clinic, 2018).

 

Differential Diagnoses

Acute epididymitis: the symptoms of acute epididymis include chills, low grade fever, and intense pressure in the testicles. Other symptoms include inflammation, redness and warmth in the scrotum. The lymph nodes become enlarged and the patient experiences pain in the pelvic area (Rodger, 2016).

 

Testicular torsion: Testicular torsion symptoms include Severe abdominal pain, swelling in the scrotum, and painful sensation during urination. The patient also experiences nausea and vomiting fevers and severe pain in the scrotum. The testicles appear to have changed the normal position and angle (Mayo Clinic, 2017). .

 

Plan/Therapeutics

                  o    Plan:

§  Further testing

CT scan – to generate 3-D images of internal structures to identify issues contributing to the symptoms.

MRI –

Abdominal Ultrasound – sound waves to generate comprehensive images of blood vessels around the groin (Mayo Clinic, 2018).

§  Medication

Patient to continue with Lisinopril 20mg bid for hypertension

 

§  Education

Patient advised to reduce and maintain a healthy weight through exercises and proper diet.

Patient to consume fruits and vegetables as well as other foods with high fiber content.

The patient should stay away from cigarette smoking and avoid lighting heavy objects.

 

§  Non-medication treatments

Proper nutrition and drinking sufficient amount of water

Surgical operation to relieve pain and discomfort besides preventing complications.

 Evaluation of  patient encounter

The Patient is cooperative and responds positively to interview questions

The patient verbalized the prevention strategies for hernia.

 

 

References:

Mayo Clinic. (2017). Testicular Torsion. Retrieved from https://www.mayoclinic.org/diseases-conditions/testicular-torsion/symptoms-causes/syc-20378270

Mayo Clinic (2018). Inguinal Hernia. Retrieved from https://www.mayoclinic.org/diseases-conditions/inguinal-hernia/symptoms-causes/syc-20351547

Rodgers, G., (2016). Epididymitis. Retrieved from https://www.healthline.com/health/epididymitis

The post Assessment/ SOAP NOTE FORMAT appeared first on Custom Writing Service.