CHIEF COMPLAINT: Testicular pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gentleman who comes to the emergency department complaining of testicular pain times approximately 2 to 3 days. He describes the pain as a pressure pain. It is a 3/10 and it does not radiate. It is intermittent and occurs approximately 2 to 3 times a minute and lasts 2 to 3 seconds. He denies any dysuria. He denies any discharge. He states he has had intercourse with 3 different females. He also had intercourse with a dancer at a bachelor party recently. He states his condom broke, and he is concerned he has an infection.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
MEDICATIONS: No medications.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: No fever, chills, sweats. No cough, cold, congestion. No change in vision or hearing. No one-sided numbness, weakness, tingling. No blackouts, no seizures. All other review systems are negative.
SOCIAL HISTORY: Occasional tobacco, occasional ethanol. He denies any drug use. He does not work. He lives with his father.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 142/76, pulse 72, respirations 20, temperature 97.8, O2 saturation 97% on room air.
GENERAL: This is a well-developed, well-nourished 20-year-old Hispanic male in no apparent distress. He is awake, alert and oriented x4. He is appropriate throughout the exam.
HEENT: Pupils are equal, round, reactive to light. Extraocular motions intact. Sclerae white. Conjunctivae are pink. TMs clear bilaterally. Oral mucosa is moist and pink with no visible lesions.
NECK: Supple. No lymphadenopathy, no JVD, no carotid bruit.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended with positive bowel sounds.
EXTREMITIES: Without cyanosis, clubbing or edema. Pulses 3/4 throughout.
SKIN: Warm, dry and intact. There is no rash.
GENITOURINARY: He has normal external genitalia. He is a circumcised male. He has no lesions. He has no lymphadenopathy. There is no tenderness to palpation of either one of his testicles or either one of his epididymides.
EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING: The patient was evaluated. He felt his symptoms were most consistent with urethritis. He has no inguinal lymphadenopathy. He has no lesions. He has no constitutional signs or symptoms. He has normal vital signs. He does not have any testicular pain or pain in either one of his epididymides. Therefore, he received a medication regimen which consisted of 1 gram azithromycin, 2 grams Flagyl, 500 mg ciprofloxacin p.o. He was thereafter discharged home. He was advised to not have sex for 2 weeks. He was advised to have all of his sexual partners treated. He was offered EIP counseling; however, he states he was tested approximately 3 months ago for HIV and was negative at that point in time. He did not wish to repeat this. He had no further questions at discharge.
ASSESSMENT: A (XX)-year-old gentleman with urethritis.
PLAN: Discharge home.
