a 17 year old male patient who experienced sudden onset of the severe pain in his left groin
a 17 year old male patient who experienced sudden onset of the severe pain in his left groin
Name: V.V. | Date: 9/9/2020 | Time: 0900HRS |
Age: 17 Years | Sex: Male | |
SUBJECTIVE | ||
CC:
Severe left groin pain for 2 days
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HPI: V.V is a 17 year old male patient who experienced sudden onset of the severe pain in his left groin. The pain is radiating to his testicles after carrying a heavy load three days ago. The pain is serious, constant, and is feeling like he is being torn inside. The patient is feeling nausea and vomited 4 hours before presenting to the facility. The patient denies dysuria, hematuria, and pain of the leg, diaphoresis, and the severe pain in his swollen left groin. His scrotum is swollen on the left with a normal size of the testicles an non-tender to palpitation. | ||
Medications: Daily oral Lisinopril 10 mg
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PMH
Allergies: NKDA
Medication Intolerances: No report of any history of medication intolerance.
Chronic Illnesses/Major traumas: No history of any major traumas or chronic illness
Hospitalizations/Surgeries: None
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Family History
Father alive and has been diagnosed with high blood pressure and cardiac artery disease. Mother: Alive and diagnosed with breast cancer and hypothyroidism
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Social History
Single, stays with the parents, not using tobacco or alcohol, no history of narcotics. Sexually active with one girlfriend |
a 17 year old male patient who experienced sudden onset of the severe pain in his left groin
ROS | |
General
Negative for fatigue, no reduced body weight, no fever nor chills, no night sweats, no change in the energy level |
Cardiovascular
Denies chest pain, no palpitation, no edema, negative PND |
Skin
Denies delayed healing, no rashes, no bruises, no bleeding or discoloration of the skin, no moles or lesions.
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Respiratory
No wheezing, no cough, no dyspnea, no |
Eyes
Denies the use of corrective lenses, no blurring, denies changes in the vision |
Gastrointestinal
Denies pain in the abdomen, admit nausea, admit vomiting, denies constipation, and denies hepatitis, hemorrhoids, eating disorders, ulcers, and the black tarry stools.
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Ears
No pain of the hear, denies hearing loss, no discharge
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Genitourinary/Gynecological
Denies urgency, frequency, hesitancy, dysuria, hematuria, STDS. Admits being sexually active.
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Nose/Mouth/Throat
No sinus issues, negative for dysphagia, nose bleeds or discharges, no dental disease, no hoarseness, and no throat pain. |
Musculoskeletal
Denies back pain, denies swelling of the joints, admits pain
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Breast
No changes, bumps, nor lumps.
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Neurological
Denies weakness, numbness, syncope, seizure, transient paralysis, parenthesias, and the blackout spells
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Heme/Lymph/Endo
HIV negative, denies history of blood transfusion, denies cold tolerance, no bruises, no night sweats, and no increased hunger or thirst.
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Psychiatric
Denies depression, anxiety, sleeping difficulty, and any suicidal ideation or attempts
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OBJECTIVE |
Weight 55 kg BMI 20.2 kg/m2 | Temp 97 (oral) | BP 120/80 |
Height 165 cm | Pulse 70 | Resp |
General Appearance
Healthy appearing adolescent male with no acute distress. The patient is well-groomed, alert and oriented ×4 and is responding to the questions by himself.
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Skin
Warm, dry, clean, and intact skin. No rashes or lesions
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a 17 year old male patient who experienced sudden onset of the severe pain in his left groinHEENT Normocephalic head, atraumatic and with no lesions. Evenly distributed hair. Eyes: PERRLA. Intact EOMs. There is no conjunctival or scleral injection. Ears: patent canals, bilateral TMs pearly grey with no positive light reflex; visualized landmarks. Nose: The nasal mucosa is pinkish with normal turbinates. No septal deviation. Neck: the neck is supple, full ROM, no presence of the cervical lymphadenopathy, no occipital nodes, no thyromegaly, no nodules. There is pink and moist oral mucosa. There is no erythematous and non-exudate pharynx. Teeth are in good repair. |