Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint:
Document the patient’s main concern, typically severe, sudden onset scrotal pain.
History of Present Illness:
Onset and duration of scrotal pain (sudden onset is highly suggestive).
Severity and character of pain (sharp, constant, radiating to groin or lower abdomen).
Presence of nausea or vomiting.
Prior episodes of scrotal pain or testicular trauma.
Past Medical History:
Underlying medical conditions (e.g., inguinal hernia).
Past surgeries (inguinal hernia repair).
Medications:
List of current medications.
Social History:
Not typically relevant for testicular torsion.
Family History:
Family history of testicular torsion (uncommon).
Physical Exam:
Vital signs (may be elevated if testicular infarction has occurred).
General examination (assess for signs of nausea, vomiting, or discomfort).
Genitourinary examination:
Scrotal appearance (swelling, erythema).
Testicular palpation (affected testicle typically positioned higher in scrotum, may be firm and tender).
Cremasteric reflex (may be absent on the affected side).
**Diagnostic Tests (as indicated):
Scrotal Doppler ultrasound: Essential test to assess blood flow to the testicles. Absent or diminished flow is highly suggestive of torsion.
Nuclear scintigraphy: May be considered if ultrasound inconclusive.
Assessment:
Clinical suspicion of testicular torsion based on history and physical exam findings.
Confirmation of diagnosis with scrotal Doppler ultrasound.
Duration of symptoms (critical for determining testicular salvage potential).
Plan:
Emergency Surgery: Surgical exploration (orchiectomy or orchidopexy) is the definitive treatment for testicular torsion. The goal is to detorse the spermatic cord and restore blood flow to the testicle as soon as possible to maximize salvage potential.
Orchiectomy: Removal of the affected testicle if tissue infarction has occurred.
Orchidopexy: Detorse the spermatic cord and fix the other testicle to prevent future torsion. May be performed if torsion is identified early and testicular viability is likely.
Pain Management: Administer pain medication for symptom relief.
Testicular Prosthesis: Discuss the option of testicular prosthesis after orchiectomy (if applicable).
Follow-up: Schedule follow-up appointment within a week to assess recovery and discuss potential complications (e.g., infection, chronic pain).
Additional Notes:
Document the time from symptom onset to surgical intervention (critical for determining potential testicular salvage).
Document any informed consent discussions regarding treatment options and potential risks and benefits.
Consider referral to a urologist for definitive surgical management.
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. It is important to act promptly in suspected cases of testicular torsion to maximize the chance of testicular salvage