Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: Briefly describe the patient’s main reason for this visit. This could include:
Increased scrotal swelling on one or both sides
Discomfort or pain in the scrotum (may be dull or achy)
Feeling of heaviness in the scrotum
No concerns (if incidental finding on physical exam)
History of Present Illness:
Onset and duration of scrotal swelling
Severity and character of any pain (constant, intermittent)
Changes in size or appearance of the swelling
Any recent scrotal trauma or injury
Prior surgeries or procedures in the groin or scrotum
Past Medical History:
History of inguinal hernia or hernia repair
History of sexually transmitted infections (STIs)
History of testicular infections or inflammation (epididymitis, orchitis)
Prior surgeries (any)
Family History:
Not typically relevant for hydrocele, but inquire about a family history of inguinal hernias (may be a risk factor)
Social History:
Occupation (strenuous activity may increase risk)
Physical Examination:
General appearance (discomfort, distress)
Scrotum exam:
Size and symmetry of both testicles
Transillumination test (may be helpful to differentiate hydrocele from solid mass)
Feeling for tenderness or lumps
Laboratory Tests:
Not typically needed for diagnosis of hydrocele unless infection is suspected.
Complete blood count (CBC) and urinalysis may be ordered if fever or urinary symptoms are present.
Imaging Studies:
Ultrasound of the scrotum: Most reliable test to confirm hydrocele and differentiate it from other causes of scrotal swelling.
Diagnosis:
Hydrocele (specify unilateral or bilateral)
Suspected inguinal hernia (if transillumination inconclusive)
Epididymitis or orchitis (if tenderness or inflammation present)
Treatment Plan:
Observation (may be recommended for small, asymptomatic hydroceles)
Scrotal aspiration (removal of fluid with a needle) – temporary relief only
Hydrocelectomy (surgical removal of the fluid sac) – definitive treatment
Prognosis:
Discuss the outlook based on the type and severity of hydrocele.
Hydrocele recurrence is possible after surgery.
Patient Education:
Explanation of hydrocele and its causes
Importance of good scrotal hygiene
Warning signs of infection (fever, redness, increased pain)
Benefits and risks of treatment options (observation, aspiration, surgery)
Next Follow-up:
Schedule for the next appointment depends on the treatment plan.
Earlier follow-up if signs of infection develop.
Follow-up after surgery to monitor healing and check for recurrence.