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 ab

Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

S.

CC (chief complaint): A brief statement identifying why the patient is here, stated in the patient’s own words (for instance "headache," not "bad headache for 3 days”).

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:

Location: Head

Onset: 3 days ago

Character: Pounding, pressure around the eyes and temples

Associated signs and symptoms: Nausea, vomiting, photophobia, phonophobia

Timing: After being on the computer all day at work

Exacerbating/relieving factors: Light bothers eyes; Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: Include dosage, frequency, length of time used, and reason for use; also include OTC or homeopathic products.

Allergies: Include medication, food, and environmental allergies separately. Include a description of what the allergy is (e.g., angioedema, anaphylaxis, etc.). This will help determine a true reaction vs. intolerance.

PMHx: Include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed. Soc & Substance Hx: Include occupation and major hobbies, family status, tobacco, and alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: Identify illnesses with possible genetic predisposition, and contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

Surgical Hx: Prior surgical procedures.

Mental Hx: Diagnosis and treatment. Current concerns: (Anxiety and/or depression). History of self-harm practices and/or suicidal or homicidal ideation.

Violence Hx: Concern or issues about safety (personal, home, community, sexual (current & historical)

Reproductive Hx: Menstrual history (date of LMP), pregnant (yes or no), nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns

ROS: Cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period (MM/DD/YYYY).

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O.

Physical exam: From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format (i.e.) General: Head: EENT: etc.

Diagnostic results: Include any labs, X-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines)

A .

Differential Diagnoses: You must have at least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.

P.

Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.

Also included in this section is the reflection. Reflect on this case and discuss whether or not you agree with your preceptor’s treatment of the patient and why or why not. What did you learn from this case? What would you do differently?

Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (such as age, ethnic group, etc.), PMH, and other risk factors (e.g., socioeconomic, cultural background, etc.).

References

You are required to include at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines which relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.

© 2020 Walden University 1

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Two Parts:

Case Study

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. 

Part 1-

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 your 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.

Part 2-

Review question below and answer them

1. List three differentials for this mass. List your top differential first and explain why it is your top differential. 

2. When examining the patient, you examine the scrotum carefully. You note asymmetry with the left hemiscrotum lower than the right. Is this typical?

3. Typically, scrotal pain only affects one side and is not typically bilateral. True or false?

4. When palpating, the normal epididymis is more firm than the testis. True or false?

5. One of the things you can do is transilluminate the testis. For your top dd, will the testis typically transilluminate?

6. For this patient, is it extremely important to get a semen analysis?

7. Name 10 testicular disorders that are important to consider 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 _______.

17. When documenting the results of the testicular exam, what should it include?

 

18. Which of the following require immediate referral?

Torsion of the spermatic cord

Hydrocele

Incarcerated scrotal hernia

18. Why can varicoceles cause infertility?

19. If there is torsion of the spermatic cord, what are two things that can happen if treatment is delayed?

20. Testicular tumors have been associated with scrotal trauma. True or false?

 

21. What are two things that can result from surgical intervention for testicular tumors?

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