DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Left testicle pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who presents with left-sided testicle pain for several months. The patient states that intermittently he has some right testicle pain, but the left testicle is more frequently and more severely painful.
The patient was seen here in the emergency department at the end of October and at that time was diagnosed with epididymitis. The patient was given Cipro and states that he has had no relief of his pain since then.
The patient complains of slight edema to his testicular area. The patient describes the pain as a burning pain that is fairly constant. He denies any dysuria, penile discharge, fevers or chills. He denies any abdominal pain, nausea or vomiting. The patient states he has been playing basketball and has not been wearing any type of athletic supporter.
PAST MEDICAL HISTORY: None.
MEDICATIONS:
1. Percocet.
2. Cipro.
ALLERGIES: None.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient denies tobacco, alcohol or illicit drug use.
REVIEW OF SYSTEMS: As above, otherwise negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 118/78, pulse 102, respirations 18, temperature 97.4, O2 sat is 97% on room air.
GENERAL: The patient is a well-developed, well-nourished male, in no acute distress.
HEART: Regular rate and rhythm. No murmurs, gallops, rubs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended. Bowel sounds x 4.
GENITOURINARY: The patient has normal external genitalia. There are no external genital lesions noted. The patient does have tenderness to palpation in the left epididymal area. He also has a slight tenderness to palpation in the anterior aspect of the left testicle. There is no scrotal edema or erythema. The testicles have normal lie. There is no relief of the pain with elevation of the testicles. There is no right-sided testicular tenderness to palpation. There is no inguinal lymphadenopathy.
EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING: The patient’s nursing notes were reviewed. At this time, the patient’s symptoms are consistent with epididymitis. This may be a traumatic epididymitis from his basketball playing. At this time, the patient states he does have a followup appointment scheduled with an urologist. We will encourage him to keep this appointment. At this time, we will treat the patient here with a dose of Rocephin and send him home with a prescription for ofloxacin as well as some pain medication. While in the emergency department, he did receive 250 mg of Rocephin IM.
DIAGNOSIS: Epididymitis.
PLAN:
1. The patient is given ofloxacin 400 mg b.i.d. x14 days.
2. The patient is given Percocet #20.
3. The patient is to wear scrotal support to help with scrotal elevation.
4. The patient is to avoid basketball playing until he follows up with his urologist.
5. The patient is to follow up with the urologist as scheduled.
6. The patient is to return to the ER for any increased pain, increased swelling, fevers or any other concerns.
DISPOSITION: The patient was discharged to home in good condition.
