Date: [Date of encounter]
Patient: [Patient Name]
Chief Complaint:
Document the patient’s main concern related to testicular trauma, such as scrotal pain, swelling, bruising, or any other relevant symptoms.
History of Present Illness:
Onset and duration of symptoms.
Mechanism of injury (e.g., direct blow to the scrotum, straddle injury, sports injury).
Severity of the injury (blunt force vs. penetrating trauma).
Presence of nausea or vomiting.
Prior history of testicular trauma or surgery.
Past Medical History:
Underlying medical conditions (e.g., bleeding disorders).
Past surgeries (inguinal hernia repair).
Medications:
List of current medications.
Social History:
Not typically relevant for testicular trauma unless related to occupation or activity (e.g., contact sports).
Family History:
Family history of testicular torsion (uncommon).
Physical Exam:
Vital signs (may be elevated if bleeding has occurred).
General examination (assess for signs of nausea, vomiting, or discomfort).
Genitourinary examination:
Scrotal appearance (swelling, ecchymosis, hematoma).
Testicular palpation (assess for tenderness, swelling, presence of masses or crepitus).
Cremasteric reflex (may be absent on the affected side).
**Diagnostic Tests (as indicated):
Scrotal ultrasound: Essential test to assess for internal injuries like hematoma, testicular rupture, or epididymal injury.
Urinalysis: May reveal microscopic hematuria if there is internal bleeding.
Assessment:
Clinical suspicion of testicular trauma based on history and physical exam findings.
Severity of the injury (grade I – mild contusion, grade II – hematoma or tunica albuginea tear, grade III – testicular rupture).
Potential complications (e.g., infection, compartment syndrome, testicular atrophy).
Plan:
Non-surgical Management:
Bed rest with scrotal elevation for pain and swelling relief.
Ice pack application for initial inflammation (avoid prolonged use).
Scrotal support (wearing an athletic supporter).
Pain medication.
Antibiotics may be prescribed if there is a high risk of infection (e.g., penetrating trauma).
Surgical Management: May be necessary for:
Testicular rupture
Large hematoma causing compartment syndrome
Suspicion of testicular torsion
Follow-up: Schedule follow-up appointments within 24-48 hours for initial evaluation and then as needed to monitor for complications and healing.
Patient Education: Educate the patient about pain management strategies, signs and symptoms of complications to watch for, and the importance of follow-up care.
Testicular Prosthesis: Discuss the option of testicular prosthesis after orchiectomy (if applicable in severe cases).
Additional Notes:
Document the mechanism of injury in detail.
Note the severity of the injury based on physical exam and imaging findings.
Consider referral to a urologist for further evaluation and potential surgical intervention if indicated.
Disclaimer: This template is for informational purposes only and should be adapted to fit the specific needs of each patient. Prompt evaluation and management are crucial to minimize complications and optimize outcomes following testicular trauma