History of Present Illness
Review of Systems
Past Medical History
Physical Examination
Essential Differential Diagnoses
Relevant Testing
Test Results
Diagnosis
Treatment Orders
Question 1
Question 2
Question 3
About the Case
Scrotal pain in a 21 yo male
Physical Examination
General appearance
: Appears nontoxic but seems uncomfortable on the examination table
Vital signs
:
Temperature: 37° C
Pulse: 80 beats/min
Respirations: 16/min
BP: 110/55 mm Hg
Height: 6'0"
Weight: 180 lb
BMI: 24.4
Skin
: Warm and dry to the touch.
HEENT
: Oropharynx is normal without erythema or exudate.
Pulmonary
: Breath sounds present and equal bilaterally. No stridor, rales, or wheezing.
Cardiovascular
: Regular heart rate and rhythm without murmurs; radial pulses present and equal bilaterally.
Gastrointestinal
: Abdomen overall is soft and nontender to light and deep palpation. Normal bowel sounds. No guarding, no ecchymosis.
Genitourinary
: Circumcised phallus with visible swelling of the right hemiscrotum. Discomfort on palpation of the right testis and epididymis; left testis has normal texture and no pain on palpation. No tenderness or fullness over the inguinal canals. Cremasteric reflexes present bilaterally. No obvious urethral discharge.
Musculoskeletal
: No costovertebral angle tenderness
Neurologic
: Unremarkable
Mental status
: Alert and oriented to person, place, time, and event.
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