Diagnosing, and Treating Special Populations

Week 9 SOAP NOTE

 

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 y
• our 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.

 

 Use the following case to complete a focused SOAP note. Incorporate answers to the questions into your SOAP write up. Please include a detailed history. If elements that you would include if you were interviewing the patient are not included in this case study, acknowledge with language such as would include if ” patient is a veteran without permanent disability”, “occupation would be of importance here” etc.

 

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. 

 

1.  List three differentials for this mass. List your top differential first and explain why it is your top differential. 
2.  
3. When examining the patient, you examine the scrotum carefully. You note asymmetry with the left hemiscrotum lower than the right. Is this typical? 
4.  
5. Typically, scrotal pain only affects one side and is not typically bilateral. True or false?
6.  
7. When palpating, the normal epididymis is more firm than the testis. True or false?
8.  
9. One of the things you can do is transilluminate the testis. For your top dd, will the testis typically transilluminate? 
10.  
11. For this patient, is it extremely important to get a semen analysis?
12.  
13. Name 10 testicular disorders that are important to consider when evaluating a testicular mass. 
14.  
15. If the patient is having no pain, what is the desired treatment?
16.  
17. If the mass is painful, what is the preferred treatment? 
18.  
19. If a patient had to have an orchiectomy, why might counseling be an important intervention?
20.  
21. How often should testicular self-exam be performed? 
22.  
23. Why is it best to perform the testicular self-exam after a warm bath or shower? 
24.  
25. The differential diagnosis for any testicular disorder should first exclude the possibility of a ________________.
26.  
27. Explain the difference between a spermatocele and a hydrocele. 
28.  
29. Testicular malignant neoplasms are very common in the general population. 
30.  
31. Testicular cancer is the most common form of cancer in men between the ages of _______.
32.  
33. When documenting the results of the testicular exam, what should it include?
34.  
35.  Which of the following require immediate referral?
36.  Torsion of the spermatic cord
37. Hydrocele
38. Incarcerated scrotal hernia
39.  
40. Why can varicoceles cause infertility? 
41.  
42. If there is torsion of the spermatic cord, what are two things that can happen if treatment is delayed? 
43.  
44. Testicular tumors have been associated with scrotal trauma. True or false?
45.  
46. What are two things that can result from surgical intervention for testicular tumors?
47.  

Use the following case to complete a focused SOAP note. Incorporate answers to the questions into your SOAP write up.