SOAP NOTE

SOAP NOTE

Name: V.V.

Date: 9/9/2020

Time: 0900HRS

Age: 17 Years

Sex: Male

SUBJECTIVE

CC:
Severe left groin pain for 2 days

HPI: V.V is a 17 year old male patient who experienced sudden onset of the severe pain in his left groin. The pain is radiating to his testicles after carrying a heavy load three days ago. The pain is serious, constant, and is feeling like he is being torn inside. The patient is feeling nausea and vomited 4 hours before presenting to the facility. The patient denies dysuria, hematuria, and pain of the leg, diaphoresis, and the severe pain in his swollen left groin. His scrotum is swollen on the left with a normal size of the testicles an non-tender to palpitation.

Medications: Daily oral Lisinopril 10 mg

PMH

Allergies: NKDA

Medication Intolerances: No report of any history of medication intolerance.

Chronic Illnesses/Major traumas: No history of any major traumas or chronic illness

Hospitalizations/Surgeries: None

Family History
Father alive and has been diagnosed with high blood pressure and cardiac artery disease.
Mother: Alive and diagnosed with breast cancer and hypothyroidism

Social History
Single, stays with the parents, not using tobacco or alcohol, no history of narcotics. Sexually active with one girlfriend

ROS

General
Negative for fatigue, no reduced body weight, no fever nor chills, no night sweats, no change in the energy level

Cardiovascular
Denies chest pain, no palpitation, no edema, negative PND

Skin
Denies delayed healing, no rashes, no bruises, no bleeding or discoloration of the skin, no moles or lesions.

Respiratory
No wheezing, no cough, no dyspnea, no

Eyes
Denies the use of corrective lenses, no blurring, denies changes in the vision

Gastrointestinal
Denies pain in the abdomen, admit nausea, admit vomiting, denies constipation, and denies hepatitis, hemorrhoids, eating disorders, ulcers, and the black tarry stools.

Ears
No pain of the hear, denies hearing loss, no discharge

Genitourinary/Gynecological
Denies urgency, frequency, hesitancy, dysuria, hematuria, STDS. Admits being sexually active.

Nose/Mouth/Throat
No sinus issues, negative for dysphagia, nose bleeds or discharges, no dental disease, no hoarseness, and no throat pain.

Musculoskeletal
Denies back pain, denies swelling of the joints, admits pain

Breast
No changes, bumps, nor lumps.

Neurological
Denies weakness, numbness, syncope, seizure, transient paralysis, parenthesias, and the blackout spells

Heme/Lymph/Endo
HIV negative, denies history of blood transfusion, denies cold tolerance, no bruises, no night sweats, and no increased hunger or thirst.

Psychiatric
Denies depression, anxiety, sleeping difficulty, and any suicidal ideation or attempts

OBJECTIVE

Weight 55 kg BMI 20.2 kg/m2

Temp 97 (oral)

BP 120/80

Height 165 cm

Pulse 70

Resp

General Appearance
Healthy appearing adolescent male with no acute distress. The patient is well-groomed, alert and oriented ×4 and is responding to the questions by himself.

Skin
Warm, dry, clean, and intact skin. No rashes or lesions

HEENT

Normocephalic head, atraumatic and with no lesions. Evenly distributed hair. Eyes: PERRLA. Intact EOMs. There is no conjunctival or scleral injection. Ears: patent canals, bilateral TMs pearly grey with no positive light reflex; visualized landmarks. Nose: The nasal mucosa is pinkish with normal turbinates. No septal deviation. Neck: the neck is supple, full ROM, no presence of the cervical lymphadenopathy, no occipital nodes, no thyromegaly, no nodules. There is pink and moist oral mucosa. There is no erythematous and non-exudate pharynx. Teeth are in good repair.

Cardiovascular
Tachycardia, S1, S2 with regular rate and rhythm. No extra sounds, click, rubs, or murmurs. The capillary is refilled in 2 seconds. The pulses is 3+ throughout, no edema.

Respiratory
There is symmetric chest wall, regular and easy respiration, and clear

Gastrointestinal
Flat abdomen, BS is hyperactive in all the four quadrants. There is non-tender and soft abdomen. There is no hepatosplenomegaly.

Breast
No masses or tenderness, no discharge, no wrinkle, no discoloration of the skin

Genitourinary
Non-distended bladder with no CVA tenderness. The region of the left groin is swollen and indurated to palpitation. The right side is normal. The left inguinal canal is tender while the right is normal. There is swollen scrotum on the left side. The testicles appears normal in size and non-tender to palpitation. There is normal penile shaft with no lesions or discharge. The external genitalia is revealing coarse pubic hair with normal distribution. There is consistent skin color with the general pigmentation. There is no discharge in the urethra with appropriate rectal. There is no hemorrhoids, fissures, bleeding, and masses. There is smooth and non-tender prostate that is free from the nodules. The prostrate is having a normal size with a firm sphincter tone.

Musculoskeletal
There is full ROM in all the 4 extremities as the patient is able to move about in the examination room.

Neurological
There is clear speech, good tone, erected posture, stable balance, and the normal gait.

Psychiatric
The patient is alert and oriented person. He is dressed in shirt and trouser and is maintain the eye contact. He is having soft speech, clear, and normal rate and cadence. The patient is responding to the questions in appropriate manner.

Lab Tests

Urinalysis – light amber and clear urine with normal odor. Negative for bacteria and normal values for the biochemistry urine analysis.

Special Tests
Scrotal ultrasound reveals normal flow of the blood in each testicle, normal bilateral size of the testicle.

Diagnosis

Differential Diagnoses
Kidney stones: the pain in the left groin that radiates from the testicles
Epididymitis: the swelling and the tenderness of the scrotum on one side.
Testicular torsion: the sudden onset of the pain that is characterized with tenderness.
Diagnosis
o Hernia inguinal (ICD-10 Code Locjup)

Plan/Therapeutics

o Plan:
· Further testing: screening for cancer i.e. the prostate cancer
· Medication: surgical intervention when the patient is experiencing an onset of strangulation. Post-operative assessment for hernia in the future
· Education: patient advised to avoid smoking and encouraged to take part in the physical activities. Educating the patient to avoid heavy lifting
· Non-medication treatments: better nutrition choices and physical activities to improve fitness

Evaluation of patient encounter: The patient is evaluated for the possibilities of strangulation and this will required surgical process or post-operation assessment for hernia recurrences.

References

Fischbach, F. T., & Dunning , M. B. (2014). A manual of laboratory and diagnostic tests. Wolters Kluwer Health/Lippincott Williams & Wilkins.
Goolsby, M. J., & Grubbs, L. (2015). Advanced assessment: Interpreting findings and formulating differential diagnoses. F.A. Davis Company.