Two Parts:

Case Study

A 42-year-old male comes into the clinic stating that he has noticed a “lump” in one of his testicles. It is not painful. He says it is behind the right testicle and just slightly above it. His ROS is negative. He has no history of testicular cancer in the family. He has tried manipulating it to see if anything changes but it does not help. He tried ice but it did not go away. He says for a couple of days it hurt a little and he tried elevating the scrotum and that seemed to make the pain go away. He says, “it is kind of like I have a third testicle!”
 

Upon examination, his vital signs are stable and his assessment is unremarkable. You note a painless mass just superior and inferior to the right testicle. You are able to move it and it is freely movable.

 

Part 1- 

Use the Focused SOAP Note Template to address the following:

· Subjective: What details are provided regarding the patient’s personal and medical history?

· Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical assessment findings. Describe whether the patient presented with any morbidities or psychosocial issues.

· Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?

· Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.

· Reflection notes: Describe your “aha!” moments from analyzing this case.

Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race


S.

CC (chief complaint): A brief statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” not “bad headache for 3 days”).

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: Head

Onset: 3 days ago

Character: Pounding, pressure around the eyes and temples

Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia

Timing: After being on the computer all day at work

Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use; also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Include a description of what the allergy is (e.g., angioedema, anaphylaxis, etc.). This will help determine a true reaction vs. intolerance.

PMHx: Include immunization status (note date of
last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed.

Soc & Substance Hx: Include occupation and major hobbies, family status, tobacco, and alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: Identify illnesses with possible genetic predisposition, and contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Two Parts:

Case Study

A 42-year-old male comes into the clinic stating that he has noticed a “lump” in one of his testicles. It is not painful. He says it is behind the right testicle and just slightly above it. His ROS is negative. He has no history of testicular cancer in the family. He has tried manipulating it to see if anything changes but it does not help. He tried ice but it did not go away. He says for a couple of days it hurt a little and he tried elevating the scrotum and that seemed to make the pain go away. He says, “it is kind of like I have a third testicle!”
 

Upon examination, his vital signs are stable and his exam is unremarkable. You note a painless mass just superior and inferior to the right testicle. You are able to move it and it is freely movable. 

Part 1-

Use the Focused SOAP Note Template to address the following:

· Subjective: What details are provided regarding the patient’s personal and medical history?

· Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.

· Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?

· Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.

· Reflection notes: Describe your “aha!” moments from analyzing this case.

Part 2-

Review question below and answer them

1. List three differentials for this mass. List your top differential first and explain why it is your top differential. 

2. When examining the patient, you examine the scrotum carefully. You note asymmetry with the left hemiscrotum lower than the right. Is this typical?

3. Typically, scrotal pain only affects one side and is not typically bilateral. True or false?

4. When palpating, the normal epididymis is more firm than the testis. True or false?

5. One of the things you can do is transilluminate the testis. For your top dd, will the testis typically transilluminate?

6. For this patient, is it extremely important to get a semen analysis?

7. Name 10 testicular disorders that are important to consider when evaluating a testicular mass.

8. If the patient is having no pain, what is the desired treatment?

9. If the mass is painful, what is the preferred treatment?
 

10. If a patient had to have an orchiectomy, why might counseling be an important intervention?