A 42-year-old male comes into the clinic stating that he has noticed a “lump” in one of his testicles. It is not painful. He says it is behind the right testicle and just slightly above it. His ROS is negative. He has no history of testicular cancer in the family. He has tried manipulating it to see if anything changes but it does not help. He tried ice but it did not go away. He says for a couple of days it hurt a little and he tried elevating the scrotum and that seemed to make the pain go away. He says, “it is kind of like I have a third testicle!”
Upon examination, his vital signs are stable and his assessment is unremarkable. You note a painless mass just superior and inferior to the right testicle. You are able to move it and it is freely movable.
Use the Focused SOAP Note Template to address the following:
· Subjective: What details are provided regarding the patient’s personal and medical history?
· Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical assessment findings. Describe whether the patient presented with any morbidities or psychosocial issues.
· Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
· Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
· Reflection notes: Describe your “aha!” moments from analyzing this case.
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