Soap Analysis-Testicular Mass on Ultrasound Example

Soap Analysis-Testicular Mass on Ultrasound Example

Introduction

This is a case analysis for a 42-year-old male who presents with a scrotal mass. It was painful on manipulation and had no other associated symptom. In his family, there is no history of testicular cancer. His vitals are within the normal range. On examination, the mass was non-tender and superior to the right testicle. Soap Analysis-Testicular Mass on Ultrasound Example

Subjective

Chief complaint: scrotal mass

HPI: patient reports a scrotal mass that was of gradual onset with no pain on palpation. The patient reports that the mass did not change in size upon exertion of pressure and it is irreducible despite manipulating it.  There is no history of dysuria, urethral discharge, swelling of the penile shaft, hematuria, and supra-pubic tenderness. Soap Analysis-Testicular Mass on Ultrasound Example

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Past Medical and Surgical History

The patient has no history of previous hospital admission, chronic illness, and blood transfusion. He reports that there is no known history of food and drug allergy. He has not undergone any minor or major surgical procedures.

Family Social Economic History

A patient is a businessman who is married and lives with his wife and two children. He denies taking alcohol and smoking tobacco. His parents and siblings are alive and healthy. There is no report of any chronic diseases in the family. No history of testicular carcinoma.

Review of Systems

The affected system is the genital-urinary system that presents with scrotal mass. There are no other associated symptoms. Other systems are not affected. Soap Analysis-Testicular Mass on Ultrasound Example

Objective

The patient walked in a normal gait, seems to be in a happy mood. He is in a fair general condition. No jaundice, no pallor, no cyanosis, no edema, no dehydration, and no lymphadenopathy. His vitals are; temperature 36.4 degrees Celsius, blood pressure 1120/78 mmHg, pulse rate of 78 beats per minute, and respiratory rate of 14 cycles per minute.

Scrotal examination entails inspection, palpation, and transillumination. The patient has normal external genitalia with normal skin color, obvious mass at the right testicle, and no therapeutic marks. The left testicle looks slightly bigger than the right one. On palpation, the testes feel smooth and firm. The mass superior to the right testes is 2cm by 1cm, firm, mobile, not fluctuant, and non-tender. The mass did not change in size and volume on exertion of pressure at the pelvic region and the size did not reduce on relaxation of the pelvic.

Diagnostic Test

Scrotal ultrasound shows a fluid-filled sac, transillumination test shows a clear fluid. Urine analysis was normal, beta-HCG levels were at the normal range, and the sperm count test was normal.

Assessment

The primary diagnosis is a spermatocele because the patient presents with a painless testicular mass superior to the right testicle. It feels like a testis that is non-tender on palpation. The transillumination test was positive. Differential diagnosis is hydrocele ICD code N43.3, inguinal hernia ICD code K40.90, and varicocele ICD code 186.1 (Harris & Tim 2016). A hydrocele presents with a painless scrotal swelling and shows clear fluid on the transillumination test. Matulewicz, & Meeks, (2016) an inguinal hernia is a painless scrotal mass that appears when pressure is applied at the pelvic region and has a negative transillumination test. Varicocele is a painless testicular mass at the left testicle with a negative transillumination test.

Plan 

Harris & Tim (2016), treatment modality for this patient is through surgical procedures, sclerotherapy, and spermatocelectomy. Sclerotherapy is the aspiration of the scrotum by the use of doxycycline and tetracyclines. Analgesics like paracetamol 1gm thrice a day is used to relieve pain. Spermatocelectomy is an extensive procedure to remove the spermatocele. This needs pre-operative care like counseling to alleviate patient from psychological pain post-operation (Moore, et al 2020).

Scrotal mass is commonly non-cancerous thus they do not pose a risk to the patient (Uglialoro, et al 2016). The most challenging moment during the examination and treatment was to convince the patient that the mass can not cause cancer.

Please remember to integrate your answers into your SOAP to avoid loosing points. Make sure appropriate items go into S, O, A and P. Any questions please let me know. A 42 year old male comes in to 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 exam 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. List three differentials for this mass. List your top differential first and give the reason why it is your top differential. When examining the patient, you examine the scrotum carefully. You note asymmetry with the left hemiscrotum lower than the right. This is typical. Typically, scrotal pain only affects one side and is not typically bilateral. When palpating, the normal epididymis is more firm than the testis. One of the things you can do is transilluminate the testis. For your top dd, will the testis typically transilluminate? For this patient, it is extremely important to get a semen analysis. Name 10 testicular disorders that are important when evaluating a testicular mass. If the patient is having no pain, what is the desired treatment? If the mass is painful, what is the preferred treatment? If a patient had to have an orchiectomy, why might counseling be an important intervention? How often should testicular self exam be performed Why is it best to perform the testicular self exam after a warm bath or shower? The differential diagnosis for any testicular disorder should first exclude the possibility of a ________________ Explain the difference between a spermatocele and a hydrocele. Testicular malignant neoplasms are very common in the general population. Testicular cancer is the most common form of cancer in men between the ages of: 15-34 years 35-45 years 46-60 years 61 years and older When documenting the results of the testicular exam, it should include: Any tenderness or pain Discoloration Edema All of the above Which of the following require immediate referral? Torsion of the spermatic cord Hydrocele Incarcerated scrotal hernia A and C A, B, and C Why can varicoceles cause infertility? If there is torsion of the spermatic cord, what are two things that can happen if treatment is delayed? Testicular tumors have been associated with scrotal trauma. Two things that can result from surgical intervention for testicular tumors are:____________ and _________________ Complete: 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 exam findings. Soap Analysis-Testicular Mass on Ultrasound Example

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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.

References

Harris &  Tim (2016). Benign testicular mass in a 55-year-old male. Urology case reports, 9, 41-42.

Matulewicz, & Meeks, (2016). Testicular Mass. Jama, 316(5), 557-557.

Moore, Lebel, & Bolduc, (2020). Testicular mass on ultrasound: no evidence on histology Report of two cases in teenagers. Canadian Urological Association Journal 14(3).

Uglialoro, Goltzman, Niazi, Lehman, Bjurlin, (2016). Asymptomatic testicular mass. Urology, 97, 1-4. Soap Analysis-Testicular Mass on Ultrasound Example