Testicular Pain Sample Patient Note

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HPI

32 YO M C/O PAIN AT THE TOP OF THE RIGHT TESTICLE (6/10, ACHING, NON-RADIATING, BEGAN 2 DAYS AGO); PAIN IS GETTING WORSE WITH TIME; NO PAST EPISODES; PAIN BEGAN SUDDENLY AND IS CONTINUOUS; PAIN IS ACCOMPANIED BY URETHRAL DISCHARGE (YELLOW, 1 TEASPOON, NO BLOOD, CREAMY, FOUL ODOR, BEGAN 2 DAYS AGO) AND BURNING ON URINATION (THROUGHOUT URINATION, NO BLOOD IN URINE, BEGAN 2 DAYS AGO). NOTHING MAKES THE PATIENT'S CONDITION BETTER OR WORSE. PATIENT DENIES URINARY FREQUENCY, URGENCY, NOCTURIA, INFECTIONS, FATIGUE, FEVER, CHILLS, PAIN ON URINATION, FEELING OF INCOMPLETE BLADDER EMPTYING, WEAK URINARY STREAM, PAST HX OF RENAL STONES, STDS, OR URINARY INCONTINENCE.

ROS- NO BURNING, NUMBNESS, WEAKNESS, NIGHT SWEATS, NO CHANGES IN BOWEL HABITS, NO JOINT PAIN, RASH, INFECTIONS.

PMH/PSH- NOT CONTRIBUTORY

NKDA

MEDICATIONS/HOSPITALIZATIONS- NONE

MULTIPLE SEXUAL PARTNERS/INCONSISTENT CONDOM USE/NO SMOKING/DRINKING/DRUGS/MARRIED

FH- NOT CONTRIBUTORY

PHYSICAL EXAM

GA- PATIENT IN MILD DISTRESS

HEENT- NC/NT, PINK CONJUNCTIVA, PINK PHARYNX

NECK- NO LUMPS, NO THYROMEGALY

ABDOMEN- NO SCARS, NO DEFORMITIES, SOFT, NT/ND, BS+, TYMPANIC 4X, PSOAS-, MURPHY-, REBOUND-, CVA TENDERNESS-.

DIFFERENTIAL DX

ORCHIEPIDIDYMITIS

HISTORY PHYSICAL EXAM
RIGHT TESTICULAR PAIN
BEGAN 2 DAYS AGO
BURNING ON URINATION
URETHRAL DISCHARGE
NOTHING MAKES IT BETTER OR WORSE
SEXUALLY ACTIVE
MULTIPLE SEXUAL PARTNERS
INCONSISTENT CONDOM USE
NO FEVER
NO CHILLS
NO WEAK URINARY STREAM
NO FREQUENCY
NO NOCTURIA
NO FEELING OF INCOMPLETE BLADDER EMPTYING
NO WEAK URINARY STREAM

GONOCOCCAL URETHRITIS

HISTORY PHYSICAL EXAM
RIGHT TESTICULAR PAIN
BEGAN 2 DAYS AGO
BURNING ON URINATION
URETHRAL DISCHARGE
NOTHING MAKES IT BETTER OR WORSE
SEXUALLY ACTIVE
MULTIPLE SEXUAL PARTNERS
INCONSISTENT CONDOM USE
NO FEVER
NO CHILLS
NO WEAK URINARY STREAM
NO FREQUENCY
NO NOCTURIA
NO FEELING OF INCOMPLETE BLADDER EMPTYING
NO WEAK URINARY STREAM

TESTS

GENITAL EXAM

TESTICULAR U/S

URETHRAL CULTURE

UA

CBC

ELECTROLYTES

KUB

Additional Readings:

USMLE CS Sample Patient Notes

1. Testicular Pain
2. Mid-Epigastric Pain
3. Back Pain

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