Identifying Info
Full name: M.P.
DOB: 02/19/1987
Date & Time: 9/23/2019 @ 4:30 PM
Location: Rego Park
Source of Info: patient
Reliability: Reliable

CC:“testicular pain” x 2 days

History of Present Illness:
32 year old male with a past medical history of gout presents with complaints of left greater than right testicular swelling, redness and urinary frequency x 2 days. Patient states the pain is intermittent and described as dull and achy, rated a 3/10 on pain scale (10 is the worst). Patient states the pain is non-radiating and  is worse during and after riding his motorcycle. Patient also states he was rough housing with friends last week and got punched in the groin. He has not done anything to alleviate the pain. Patient is sexually active with two new partners and states he always uses condoms. Denies every having an STD. Patient denies fever, chills, night sweats, nausea, vomiting, abdominal pain, burning or pain with urination, urinary urgency, penile discharge, or hematuria.

Past Medical History
Gout Left ankle and foot

Past Surgical History
Tonsillectomy 2000

Family History:
Mother: alive 57 years old with allergic rhinitis, otherwise healthy
Father: alive, 67 years old with medically controlled HTN
Siblings: two sisters aged 30 and 27, healthy.
Paternal grandfather: deceased lymphoma in 80s
Paternal grandmother: deceased, breast cancer in 80s
Maternal grandfather: deceased – heart attack 40-50s
Maternal grandmother: decreased – lung cancer 50-60s.

Social History
Mr. M.P is a single bartender residing in Queens New York. He enjoys riding his motorcycle and hanging out with friends. He eats mainly fast food and exercises 4 days a week. He smokes cannabis almost every night and drinks two beers a day. He is sexually active with two new partners who are women, he uses condoms and has never gotten an STD. Denies tobacco smoking and  illicit drug use.

Medications
St. John’s Wort – 1 capsule orally once a day
Colchicine 0.6 mg – 1 tablet orally twice a day

Allergies
No known drug, food or environmental allergies

Review of Systems:
Constitutional: Denies fever, chills, night sweats, fatigue, recent weight loss or gain, nausea or vomiting, diaphoresis, loss of appetite, generalized weakness.
Skin, hair, nails: Denies changes in texture, excessive dryness/sweating, discoloration, pigmentations, moles/rashes, or changes in hair distribution
Head: Denies headaches, vertigo or head trauma
Eyes: denies lacrimation, visual disturbances, photophobia, diplopia, discharge.
Ears: Denies ear pain, pruritus, discharge, deafness, tinnitus, hearing aids.
Nose/Sinuses: denies discharge, obstruction or epistaxis
Mouth & Throat: denies bleeding gums, sore throat/tongue, mouth ulcers, voice changes
Neck: denies localized swelling/lumps or stiffness/decreased range of motion
Breast: Denies lumps, nipple discharge, pain.
Pulmonary system: Denies shortness of breath, dyspnea, wheezing, hemoptysis, cyanosis, orthopnea, PND.
Cardiovascular System: Denies chest pain, syncope, known heart murmurs.
GI: Denies food intolerance, vomiting, dysphagia, unusual flatulence, diarrhea, constipation, jaundice, hemorrhoids, rectal bleeding or blood in stool.
GU: Admits to urinary frequency. Admits to L>R testicular swelling, redness and pain. Denies nocturia, urgency, oliguria, polyuria, dysuria, incontinence. Denies penile discharge, erythema
Nervous: Denies seizures, LOC, sensory disturbances, ataxia
MSK: Denies swelling/edema, joint or muscle pain, deformity, redness, arthritis.
Peripheral vascular: Denies intermittent claudication, denies edema, coldness of trophic changes, varicose veins, color change.
Hematologic system: denies anemia, easy bruising/bleeding, lymph node enlargement, blood transfusions.
Endocrine: denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism or goiter.
Psychiatric: Denies feelings of hopelessness, sadness or depression. Denies ever seeing a mental health professional.

Physical Exam:

Vital Signs:BP: 118/72 mmHg RR: 16 breaths/min unlabored P: 78 bmp, regular T: 98.7 F SpO2: 99% RA Height: 6’2 Weight: 233 lbs BMI: 30.12

General: Alert and oriented x3. Pleasant male with large build and tattoos down both arms, sitting comfortably in chair and in no acute distress.
Skin: Warm and dry.
Head: NCAT. No lesions and masses noted
Eyes: symmetrical, PERRL, EOMI, conjunctiva clear. No nystagmus
Respiratory: lungs are clear to auscultation. No wheezing, rales, rhonchi.
Cardiac: S1 and S2 present. RRR. No murmurs, rubs, gallops, JVD. Pulses 2+ bilaterally.
Gastrointestinal: soft nontender, no distention, bowel sounds present. No rigidity or guarding.
GU: normal external genitalia. Bilateral testes descended. Right testes and epididymis non tender. Left testes nontender to palpation, L epididymis tender to palpation and erythematous. Cremasteric reflex intact. Positive Prehn’s sign.
Extremities: no pedal edema. No muscle or joint tenderness.
Neurological: alert and oriented x3. No focal deficits. No motor or sensory deficits. Speech coherent.
Psychiatric: normal mood and affect.
UA: increased WBCs.

Assessment:
32 year old male with past medical history of gout presents with 2 day history of L>R testicular pain with urinary frequency worsening during and after motorcycling. Patient has two new sexual partners and uses condoms. Patient denies fever, chills, night sweats, n/v, abdominal pain, burning or pain with urination, urinary urgency, penile discharge, or hematuria. Physical Exam findings are consistent with epididymis. Labs are pending results.

Plan – Epididymis

• Start Doxycycline Monohydrate Capsule 100 mg, 1 capsule orally twice day for 7 days.
• Start Ceftriaxone Sodium Solution Reconstited, 250 mg injection.
• Patient will start doxy and return with ceftriaxone tomorrow
• No sexual activity for 2 weeks
• Labs
  • CBC (leukocytosis)
  • Urine Culture
  • STD testing: Chlamydia & Gonorrhea
  • HIV testing (HIV combo 4^thgen HIV I/II
  • RPR

Patient is counseled on reducing HIV risk, specific risk reduction steps may include; keeping in mind that alcohol can affect decision making abilities, avoid risky behavior, avoid sharing materials such as razors and needles, condom use.

DDx

• Epididymitis: most likely diagnosis due to symptoms and physical examination. + Prehn’s sign.
• Testicular torsion: possible due to symptoms of testicular pain, however cremasteric reflex present and findings more consistent with epididymitis.
• Orchitis: usually similar to epididymis with viral cause. (MCC mumps)
• Testicular mass – usually painless but can be dull and achy, can present w acute pain however uncommon. No mass palpated on examination.
• Varicocele – possible due to dull achy pain worsening with activity.

Notes:
Epididymitis

• Usually bacterial infection
• Men <35 years Chlamydia*, N.Gonorrhea MCC
• Men >35 years & children: Enteric organism MCC*, E.coli, Klebsiella.
• Dx: Scrotal US reveals INCREASED testicular blood flow.

 

Nora Ennab PA-S