Soap Nota Assignment
Patient Information
Please see attachment for Rubrics and Soap Template
Family Medicine 27: 17-year-old male with groin pain
User: Beatriz Duque
Email: bettyd2382@stu.southuniversity.edu Date: September 5, 2020 11:01PM
Learning Objectives
The student should be able to:
Elicit focused history of patients presenting with scrotal pain.
Demonstrate the ability to perform proficient testicular examination and to elicit signs specific to identify or exclude testicular torsion.
Develop a differential diagnosis for adolescent male presenting with scrotal pain.
Identify appropriate laboratory and radiological studies as it relates to the differential diagnosis of scrotal pain. Outline the algorithmic approach to testicular pain.
Discuss management of testicular torsion.
Recognize sexually transmitted infections as a cause of testicular pain among adolescent males.
Discuss the importance of counseling to prevent sexually transmitted infections.
Discuss epidemiology and USPSTF recommendations for screening for common testicular cancers.
Knowledge
Important Features of the History for a Patient in Pain
The following acronym can be helpful: LAQ CODIERS:
Location
Associated symptoms
Quality
Character
Onset
Duration
Intensity
Exacerbating factors Relieving factors other Symptoms
HEEADSSS Adolescent Interview
Home
Education / Employment
Eating
Activities
Drugs
Sexuality
Suicide / Depression Safety / Violence
Scrotal Exam Findings
Cremasteric reflex
Cremasteric reflex can be assessed by lightly stroking or pinching the superior medial aspect of the thigh. An intact cremasteric reflex causes brisk ipsilateral testicular retraction. Absence of the cremasteric reflex is a sensitive but nonspecific finding for testicular torsion. It can be absent on physical exam in normal testes. It should be assessed after inspection and before palpation of the testicles.
Blue dot sign
Tenderness limited to the upper pole of the testis suggests torsion of a testicular appendage, especially when a hard, tender nodule is palpable in this region. A small bluish discoloration known as the “blue dot sign”, may be visible through the skin in the upper pole. This sign is virtually pathognomonic for appendiceal torsion when tenderness is also present.
Prehn sign
Prehn reported that physical lifting of the testicles relieves the pain caused by epididymitis but not pain caused by testicular torsion. A positive Prehn sign is pain that is relieved by lifting of the testicle; if present this can help distinguish epididymitis from testicular torsion.
Causes of Testicular Torsion
Congenital anomaly
A congenital anomaly that results in failure of normal posterior anchoring of the gubernaculum, epididymis, and testis is called a bell clapper deformity because it leaves the testis free to swing and rotate within the tunica vaginalis of the scrotum much like the gong (clapper) inside of a bell, causing an intravaginal torsion. A large mesentery between the epididymis and the testis can also predispose itself to torsion. Contraction of the muscles shortens the spermatic cord and may initiate testicular torsion.
Undescended testes
Although there is little solid evidence, the incidence of testicular torsion is thought to be higher in undescended testes than in normal scrotal testes. Torsion of an undescended testicle often occurs with the development of a testicular tumor, presumably caused by increased weight and distortion of the normal dimensions of the organ.
Recent trauma or vigorous exercise
The patient’s history often indicates recent trauma to the genital area, hard physical work, or vigorous exercise.
Testicular torsion can also occur without any apparent reason.
Complications of Testicular Torsion: Testicular Loss
The most significant complication of testicular torsion is loss of the testis, which may lead to impaired fertility.
Common causes of testicular loss after torsion are:
delay in seeking medical attention (58%)
incorrect initial diagnosis (29%) delay in treatment at the referral hospital (13%)
The viability of a testis depends on the duration of torsion and pain:
Duration of scrotal pain
Percentage of testicular viability
6 hours
90%
more than 12 hours
50%
more than 24 hours
10%
Patient Centered Medical Home
Leading primary care physicians organizations* described the characteristics of the Patient Centered Medical Home as follows:
1. Personal physician: Each patient should have an ongoing relationship with one personal physician. So when a patient needs medical attention, they rely on a doctor they have established a long-term relationship with who will help them get whatever care they need.
2. Physician directed medical practice: The personal physician has assistance from the team of individuals at the family practice clinic who collectively take responsibility for ongoing care of patients.
3. Whole person orientation: The personal physician is responsible for providing all health care needs at all stages of life. Including acute care, chronic care, preventive services, and end of life care.
4. Care is coordinated and/or integrated: The personal physician doesn’t have the expertise to take care of every medical issue their patients may encounter, so the personal physician needs to understand when to refer for subspecialty care. The personal physician also needs to be able to utilize all domains of the health care system, facilitated by registries, information technology, health information exchange and other means, in order to ensure that the patient gets the indicated care where and when they need it. Furthermore, the personal physician needs to be able to communicate health care issues effectively to family members when appropriate.
Quality and safety are also hallmarks of the medical home.
*Leading primary care physicians organizations: American Academy of Family Physicians (AAFP), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Osteopathic Association (AOA).
Discussing Sexual Risk Behaviors with Adolescents
Many young people engage in sexual risk behaviors that can result in unintended health outcomes.
To reduce sexual risk behaviors and related health problems among youth, physicians can help young people adopt lifelong attitudes and behaviors that support their health and well-being-including behaviors that reduce their risk for HIV, other STIs, and unintended pregnancy.
Counsel youth that abstinence from vaginal, anal, and oral intercourse is the only 100% effective way to prevent HIV, other STIs, and pregnancy. The correct and consistent use of male latex condoms can reduce the risk of STI transmission, including HIV infection. However, no protective method is 100% effective, and condom use cannot guarantee absolute protection against any STD or pregnancy.
In many states, minors can legally consent to certain types of health care on their own—including STI and HIV testing.
Adolescent Health Clinical Recommendations and Guidelines
USPSTF Guidelines
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