SOAPNote

Name:  J B

Date:11/1/20

Age: 50

Sex:M

SUBJECTIVE

CC: GROING PAIN

HPI: Patient is a 50-year-old male, present with a complaint of left groin pain and left testicle pain, patient stated the pain started after he was helping his friend to move. Patient refers the pain as a 10 out of 10 that make him nauseated.

Medications:

Lisinopril

PMH: Hypertension, previous kidney stone

Allergies:   NKDA

Medication Intolerances: NKDA

Chronic Illnesses/Major traumas: Normal childhood illness, hypertension and kidney stones

Hospitalizations/Surgeries:

Immunizations: Up to date.

Family History:

Dad: hypertension and coronary artery disease and prostate cancer

Mom: Hypothyroidism and breast cancer

Social History:

Marital status: Married for 20 years

Denies smoking

Alcohol intake one or two drinks daily, usually beer or whiskey

Caffeine intake: none.

ROS

General

Patient looks healthy and in his normal weight, he is in obvious pain and pale.

Cardiovascular

 Patient denies any cardiovascular distress, chest pain or syncope

Skin 

Pale and diaphoretic

Respiratory

Patient denies cough congestion or sputum production. Patient denies shortness of breath or dyspnea.

Eyes

Denies blurry vision eye pain or drainage

Gastrointestinal Denies nausea vomiting diarrhea, melena.

Ears

Patient denies pain or drainage

Genitourinary/Gynecological

Patient denies urinary symptoms. Patient report scrotal pain and edema and left groin pain

Nose/Mouth/Throat

Patient denies sore throat, loss of taste or difficulty swallowing

Musculoskeletal

Denies imbalance or weakness

Breast

Denies any symptoms

Neurological

Alert and oriented responding question appropriately

Heme/Lymph/Endo

No complaints at this point.

Psychiatric

Adequate mood

OBJECTIVE

Weight: 180

BMI 24.4

Temp:99.0

BP: 170/90

Height: 6’0

Pulse: 96

Resp:19

General Appearance

Patient appear to be in pain, awake alert and oriented answering questions appropriately.

Skin: Pale and diaphoretic, afebrile. Skin warm and dry to touch

HEENT: Head is normocephalic atraumatic with no deformities, facial feature symmetric. Frontal and maxillary sinuses non tender.

Cardiovascular

The chest is symmetrical and the anterior and posterior AP diameter is normal.

Respiratory

The anterior lung field are resonant, lungs are clear to auscultation, the rest of the lung field are resonant and no hyper resonant.

Gastrointestinal

Abdomen lean and non distended, bowel sound present in all four quadrants visible swelling in the left groin with extension into the scrotum.

Breast

Normal

Genitourinary

Left groin area is swollen and indurated to palpation. Tenderness in the left inguinal canal, right side is normal. The scrotum is swollen in the left side no abnormal penile discharge. No flank tenderness to percussion.

Musculoskeletal

No swelling or deformities, no cyanosis. Move all extremities walks with no assistive device.

Neurological

Cranial nerves are intact, normal gait and posture no rigidity. Strenght is 5/5 bilaterally.

Psychiatric

Normal mood and affect, active and alert. Good judgement.

Lab Tests

Complete blood count

Ct abdomen and pelvis

Basic metabolic panel

Scrotal ultrasound

Urinalysis

Special Tests

·

  Diagnosis

Testicular torsion

Nephrolithiasis, kidney calculi

Epidymitis

Incarcerated hernia

Plan &Education:

· Pain control (Morphine 2mg q4 hours prn for pain control

· Nausea control (Zofran 4mg q8 hours prn)

· Surgical consultation for emergency reduction of the incarcerated small bowel and herniorrhaphy.

· Teach the patient that he may need to remain in the hospital after surgery to achieve complete recovery

· Provide reinforcement to the patient in reference to this procedure. Pain control

While some hernias can be reduced in the ED under adequate sedation and pain control, this is not a definitive repair — only a temporary fix.

Traditionally almost all inguinal hernias are referred for surgical treatment following diagnosis. Progression of a hernia by time is natural and most surgeons prefer repairing all inguinal hernias as soon as possible.