CHIEF COMPLAINT: The patient states that he has testicular pain and hip pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with longstanding history of chronic back pain, status post lumbar fusion in the past, who comes in with left testicle pain of one day’s duration. He denies any swelling or trauma. He denies any dysuria, hematuria, and no penile drainage. He denies any headache, lightheadedness, dizziness, blurry vision, double vision, chest pain, shortness of breath, or difficulty breathing. He says that he is currently sexually active with one partner but has had previous partners in the past. He denies any constipation, no urinary frequency, no trouble starting his stream, no urinary hesitancy, no bowel or bladder retention or incontinence. He has not noticed any numbness or tingling in his fingers or toes, despite the fact that the nursing notes state that there was pain, numbness, and tingling in his left leg. He denies that to me and states that he just has some pain occasionally in his leg. He denies any falls.
PAST MEDICAL HISTORY:
1. Lower lumbar fusions.
2. Chronic back pain.
3. Hepatitis C.
MEDICATIONS: Morphine.
ALLERGIES: None.
SOCIAL HISTORY: The patient smokes a pack a day of tobacco. Does not drink alcohol or do drugs. He states that he also has hepatitis C as well, but he is unclear about the etiology or source for this.
REVIEW OF SYSTEMS: Otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 116/84, pulse 86, respiratory rate 18, temperature 98.2, and O2 sat is 95% on room air.
GENERAL: The patient is a well-appearing Hispanic gentleman in no acute distress.
HEENT: The pupils are equal, round, and reactive to light. The extraocular muscles are intact. TMs are clear bilaterally. No erythema or effusion. Nares are patent bilaterally. The oral mucosa is pink and moist. No oral lesions. No posterior pharynx erythema or exudate. Uvula is midline. No swelling or asymmetry.
NECK: Supple without lymphadenopathy or JVD.
LUNGS: Clear to auscultation bilaterally. No wheezes, rales or rhonchi.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended with good bowel sounds. No organomegaly. No masses palpated.
BACK: The patient had a scar over his midline in his lower lumbar area. He was nontender to palpation in the midline of the C-spine, T-spine or L-spine. He had some paraspinal musculature tenderness. He had a negative log roll to his hips bilaterally.
EXTREMITIES: The patient moves all four extremities in all directions. No cyanosis, no clubbing, no edema.
GENITOURINARY: Revealed normal circumcised male genitalia. There were no rashes or lesions noted to his phallus. He had no penile drainage noted. A swab was taken. His testicles were of equal size, shape, and consistency and normal lie. His testicle was minimally tender to palpation, and his epididymis was tender to palpation on the left. He did not have hernias to palpation bilaterally.
SKIN: Warm and dry without any rashes or lesions.
NEUROLOGIC: The patient is awake, alert, and oriented x3. Cranial nerves II through XII are checked and intact. Motor is 5/5 in the bilateral upper and lower extremities. Sensation is grossly intact to light touch. Reflexes; biceps, triceps, patellar, and Achilles tendons are 2+.
PSYCHIATRIC: The patient had normal affect, normal insight, and normal judgment.
EMERGENCY DEPARTMENT COURSE: The patient is brought back to the room. He was seen and evaluated. He was given 2 mg of Dilaudid IM for his pain. Given the large amounts of narcotics he takes on a regular basis, urinalysis was obtained as well that showed small bilirubin, trace blood, and 30 protein.
MEDICAL DECISION MAKING: We feel this patient is likely suffering from two processes, one being chronic back pain from his chronic back pain source of his lower lumbar fusion; however, we do not think that is causing the testicular pain and hip pain, and this is likely due to epididymitis. Given his age and risk factors, he certainly may be susceptible to prostate related versus sexually transmitted disease, and we will elect to treat him for both, and we explained this to both him and his significant other, who was present in the room. The patient was comfortable with this.
He was given a shot of Rocephin 250 mg IM and given a gram of azithromycin here and was given a prescription for ciprofloxacin and doxycycline. He was urged to follow up with his primary care physician and his spine physician for a repeat MRI, given the progression of his pain. He is to keep his scrotum elevated. He is to use ice packs as needed. The patient is to return for worsening scrotal pain, trouble urinating or defecating, trouble walking, numbness, tingling or weakness.
We do not think this is an acute cord compression, given his physical exam, and we do not think this is a testicular torsion based on his risk stratification and physical exam.
DIAGNOSES:
1. Epididymitis.
2. Back pain.
DISCHARGE CONDITION AND DISPOSITION: Stable, to home.
