R6 H&P

Rotation 6 - Ambulatory Care

Date & Time of Encounter: 7/5/24

Location of Encounter: Nao Williamsburg

Source of Information: Self

Chief Complaint: testicular pain x 2 wks

History of Present Illness: 

30YOM w/ no PMH presents for evaluation of intermittent perineal/testicular discomfort x 2 weeks. Pt describes intermittent, non-reproducible sharp sensation lasting ~1 second each, in various locations within the perineal and genital area. He reports that the sensation is most noticeable while driving, which is his occupation. It has not worsened in frequency or severity since onset. He denies recent trauma to the area. Denies severe pain, nausea/vomiting. Denies dysuria, difficulty with defecation, and bowel/bladder incontinence. Denies history of sexually transmitted diseases (STDs). He is sexually active with 2 female partners, always using condoms, but reports he was recently made aware one of his recent sexual partners tested positive for mycoplasma. Denies genital discharge, sores, or lesions; denies dysuria, hematuria, fever, chills, body aches, n/v/d or abdominal pain. Denies any difficulty urinating or defecating. Denies scrotal heaviness or palpable mass.

Past Medical History:

Present illnesses – Denies

Past medical illnesses – Denies

Childhood illnesses – Denies

Immunizations – Up to date, including annual covid and flu

Screening tests and results – Pt does not recall the last time he underwent STD screening

Past Surgical History:

Denies

Past injuries or transfusions

Denies

Medications:

Denies

Allergies:

NKDA

Family History:

Father: alive

Mother: alive

Siblings: alive

Denies known family history of diabetes, hypertension, or cancer

Social History:

Pt is a single man who lives alone. He works as an Uber driver.

He is a non-smoker. Reports alcohol intake socially, ~2-3 drinks per week.

Denies recent travel.

Reports a well-balanced diet with daily fruits and vegetables. 

Reports mostly sedentary lifestyle.

Reports sexual activity with multiple females, always using condoms. Pt has never undergone STD testing.

ROS:

  • General/Constitutional:
    • Denies fever, diminished appetite, fatigue.  
  • HEENT:
    • Denies ear pain, sinus congestion, sore throat. 
  • Respiratory:
    • Denies wheezing, cough, sputum, shortness of breath.
  • Genitourinary:
    • Reports intermittent testicular pain. Denies painful urination, frequent urination, penile discharge
  • Gastrointestinal:
    • Denies abdominal pain, constipation, diarrhea, nausea, vomiting. 
  • Skin:
    • Denies itching, rash
  • Cardiovascular:
    • Denies chest pain, dyspnea on exertion, palpitations 
  • Musculoskeletal:
    • Denies arthralgias, myalgias, back pain.
  • Neurologic:
    • Denies dizziness, headache. 
  • Psychiatric:
    • Denies anxiety or depressed mood.

Physical:

Vitals: 

Temp: 98.1

HR: 72

Oxygen sat %: 98

RR: 16

Ht: 5FT 5IN

Wt: 145

BP: 130/80

Pain scale: 5

BMI: 24.13

Exam:

General: 

alert, in no acute distress, well developed, well nourished. 

Skin:  

no suspicious lesions, warm and dry, moist, no rash. 

Eyes: 

B/L: PERRL, EOMI, sclera non-icteric, upper eyelids normal, lower eyelids normal. 

seen on L tonsil. Tonsils symmetric, uvula midline, no exudates.

Neck/Thyroid:

Trachea midline, FROM, supple

Cardiovascular:

regular rate and rhythm, S1, S2 normal without murmurs

Respiratory:  

clear to auscultation bilaterally, good air movement, no wheezes, rales, rhonchi. 

Gastrointestinal: 

soft, non-tender/non-distended, BS present, no guarding or rigidity, no masses palpable. 

GU:

Pt declines.

Neurologic Exam: 

nonfocal, alert and oriented; gait steady and normal, sensation intact, speech normal.

Extremities:  

no clubbing, cyanosis, or edema. 

Ddx:

  1. Epididymitis, Urethritis
  2. Inguinal Hernia
  3. Neuralgia
  4. Testicular Cancer
  5. Testicular Torsion

Assessment

30YOM w/ potential exposure to sexually transmitted mycoplasma presents with intermittent, sharp, perineal/testicular discomfort in various locations, lasting about 1 second each time, x 2 weeks total. He reports that the sensation is most noticeable while driving for long periods of time, which is his occupation. 

Plan:

  1. Perineal pain
  2. Possible exposure to mycoplasma genitalium
    1. STD Testing
      1. Mycoplasma/Ureaplasma PCR
      2. GC/CT Urine NAAT
      3. RPR 
      4. Hep B Antigen
      5. Hep C Antigen
      6. HIV 1/2 AG/AB
    2. Urinalysis
    3. Start doxycycline PO, 100 mg BID for 7 days
    4. Avoid sitting for extended periods of time, make an effort to sit with proper posture, consider purchasing lumbar support seat cushion
    5. RTC in 3 days for f/u and discussion of lab results