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 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

 

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

 

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

 

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

 

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.

 

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.

 

Ears

No pain of the hear, denies hearing loss, no discharge

 

Genitourinary/Gynecological

Denies urgency, frequency, hesitancy, dysuria, hematuria, STDS. Admits being sexually active.

 

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

 

Breast

No changes, bumps, nor lumps.

 

Neurological

Denies weakness, numbness, syncope, seizure, transient paralysis, parenthesias, and the blackout spells

 

Heme/Lymph/Endo

HIV negative, denies history of blood transfusion, denies cold tolerance, no bruises, no night sweats, and no increased hunger or thirst.

 

Psychiatric

Denies depression, anxiety, sleeping difficulty, and any suicidal ideation or attempts

 

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.

 

Skin

Warm, dry, clean, and intact skin. No rashes or lesions

 

 a 17 year old male patient who experienced sudden onset of the severe pain in his left groin

HEENT

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.