Comprehensive Soap note.
Remember that this is a mock patient. You will make up the history and exam findings as if you have interviewed this patient and performed an exam. You are required to use a SOAP note template with citations and references in APA format. You will include three ddx with supportive documentation, citations, and references! Please be aware Turnitin similarity should be less than 20%
If the information was not provided in the case study, be creative and ask yourself what would be important for me to ask this patient if he were in my office. All systems should be included in the ROS and for the Physical Exam
Use the following case to complete a focused SOAP note:
Use the following case to complete a focused SOAP note. There are questions associated with the case study. Please write out the question and provide answers to the questions in number format.
A 42-year-old male comes in to 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.
1. List three differentials for this mass. List your top differential first and give the reason why it is your top differential. 2. When examining the patient, you examine the scrotum carefully. You note asymmetry with the left hemi scrotum lower than the right. This is typical———————– 3. Typically, scrotal pain only affects one side and is not typically bilateral. 4. When palpating, the normal epididymis is firmer than the testis. 5. One of the things you can do is trans illuminate the testis. For your top dd, will the testis typically trans illuminate? 6. For this patient, it is extremely important to get a semen analysis. TRUE/FALSE 7. Name 10 testicular disorders that are important 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? 11. How often should testicular self-exam be performed? 12. Why is it best to perform the testicular self-exam after a warm bath or shower? 13. The differential diagnosis for any testicular disorder should first exclude the possibility of a ________________ 14. Explain the difference between a spermatocele and a hydrocele. 15. Testicular malignant neoplasms are very common in the general population. 16. Testicular cancer is the most common form of cancer in men between the ages of: a. 15-34 years b. 35-45 years c. 46-60 years d. 61 years and older 17. When documenting the results of the testicular exam, it should include: a. Any tenderness or pain b. Discoloration c. Edema d. All of the above 18. Which of the following require immediate referral? a. Torsion of the spermatic cord b. Hydrocele c. Incarcerated scrotal hernia d. A and C
e. A, B, and C 19. Why can varicoceles cause infertility? 20. If there is torsion of the spermatic cord, what are two things that can happen if treatment is delayed? 21. Testicular tumors have been associated with scrotal trauma. 22. Two things that can result from surgical intervention for testicular tumors are:____________ and _________________
