Male Genitalia Assessment
S:
CC: “I feel a lump in my testicle”
HPI: Patient is a 28-year-old male c/o of a lump in his right testicle.
Patient states he is unsure of when the lump appeared, denies pain or
tenderness when he touches the lump. Patient denies that the lump
has changed in shape or size since he has noticed it 2 weeks ago.
Patient denies any testicular trauma that may have caused the lump.
Patient states he is currently sexually active with his wife. Patient
denies any history of sexually transmitted infections. Patient denies
condom use. Patient denies frequency, burning, or urgency with
urination. Patient denies penile discharge or difficulty in having and
maintaining an erection. Patient denies history of lesions, lumps or
swelling on his penis or testes.
PMH: Patient has a past medical history of chicken pox, and tonsillitis
and underwent a tonsillectomy in 2015. Patient currently does not take
any prescription medications, over the counter drugs, vitamins, or
supplements. Patient has no known allergies.
FH: Patient’s father has a history of heart disease, high blood pressure,
and high cholesterol. Patient’s mother has a history of hypothyroidism
and gestational diabetes. Patient denies any family history of
reproductive cancers, sexual dysfunction, testicular anomalies or
sexual disorders. Patient is unaware of familial history of DES or
impotence.
SH: Patient is a nonsmoker, nondrug user, and consumes 1-2 beers per
week. Patient participates in a regular exercise regimen 3-4 days per
week. Patient is married and is sexually active. Patient denies changes
in sleep habits or diet.
ROS:
General: Pt denies any recent weight changes, weakness,
fatigue or
fevers.
Skin, hair, nails: Pt denies any instances of rash, lumps, sores,
itching,
dryness, or color changes. Pt denies any changes to his hair or
nails
Head: Pt denies headache, head injury, or dizziness.
Eyes: Pt wears corrective lenses daily. Pt last eye exam was in
April 2015.
S:
CC: “I feel a lump in my testicle”
HPI: Patient is a 28-year-old male c/o of a lump in his right testicle.
Patient states he is unsure of when the lump appeared, denies pain or
tenderness when he touches the lump. Patient denies that the lump
has changed in shape or size since he has noticed it 2 weeks ago.
Patient denies any testicular trauma that may have caused the lump.
Patient states he is currently sexually active with his wife. Patient
denies any history of sexually transmitted infections. Patient denies
condom use. Patient denies frequency, burning, or urgency with
urination. Patient denies penile discharge or difficulty in having and
maintaining an erection. Patient denies history of lesions, lumps or
swelling on his penis or testes.
PMH: Patient has a past medical history of chicken pox, and tonsillitis
and underwent a tonsillectomy in 2015. Patient currently does not take
any prescription medications, over the counter drugs, vitamins, or
supplements. Patient has no known allergies.
FH: Patient’s father has a history of heart disease, high blood pressure,
and high cholesterol. Patient’s mother has a history of hypothyroidism
and gestational diabetes. Patient denies any family history of
reproductive cancers, sexual dysfunction, testicular anomalies or
sexual disorders. Patient is unaware of familial history of DES or
impotence.
SH: Patient is a nonsmoker, nondrug user, and consumes 1-2 beers per
week. Patient participates in a regular exercise regimen 3-4 days per
week. Patient is married and is sexually active. Patient denies changes
in sleep habits or diet.
ROS:
General: Pt denies any recent weight changes, weakness,
fatigue or
fevers.
Skin, hair, nails: Pt denies any instances of rash, lumps, sores,
itching,
dryness, or color changes. Pt denies any changes to his hair or
nails
Head: Pt denies headache, head injury, or dizziness.
Eyes: Pt wears corrective lenses daily. Pt last eye exam was in
April 2015.
