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Name:  TC Date: 2/6/2017 Time:
Age: 36 Sex: Male
CC:  TC reaches the outpatient department groaning in pain. He says, “my testes are swollen, and they are painful. I cannot even walk faster.”
HPI:  TC was well until six months ago when he started having painful urination. He says that the urine had an unusual color by that time, so he went to the hospital to receive treatment. The doctor prescribed him medicines that he does not remember. However, TC says that he travels extensively, and he did not have enough time to complete the dose due to his demanding work as a pilot. The symptoms disappeared. However, seven days ago, he started feeling pain in the scrotum. The following day, he noticed that his urine had an unusual smell, and his scrotum started to swell. TC says that yesterday evening, he was unable to walk well due to the pain he experienced when he tried to walk. He has thus come for the treatment of the symptoms.
Medications: Not using any medication currently.

Allergies: No current food allergies.

Drug Intolerances: No history of medication intolerances.

Chronic Diseases or Traumas: No cases of injuries or chronic diseases identified.

Hospitalizations/Surgeries: PS has never been hospitalized and has never undergone any surgery.

Family History: Two parents who are alive and do not suffer from any chronic disease. TC is the second born child, and his three sisters are in a satisfactory state of health.
Social History: TC is married, but he says that he has two girlfriends. He has sex with them without any protection. TC neither drinks alcohol nor smokes tobacco. However, he likes spending time with his friends twice a week having dinner. He works as a pilot.
General: Positive for fever and malaise. Cardiovascular: No claudication or any experiences of PND or orthopnea.
Skin: Denies any experiences of delayed healing of wounds, moles, or rashes. Respiratory: No chest pain, denies coughing or any experiences of hemoptysis or TB.
Eyes: No retinal hemorrhage or blurring. Gastrointestinal: Denies loss of appetite, abdominal tenderness, or vomiting.
Ears: No tinnitus or hearing loss. Genitourinary/Gynecological: Positive for dysuria, foul-smelling urine, and swollen testes. Positive for previous history of gonorrhea six months ago. Did not complete the previous dosage regimen. In addition, positive for pain in the scrotum. The prostate exam was done two years ago, and the results turned negative.
Nose/Mouth/Throat: No experiences of a sore throat or epistaxis. Musculoskeletal: Denies joint stiffness or any joint pains. Further denies calf-muscle cramps and back pains.
Breast: No breast lumps ever noted. Neurological: No seizures.
Heme/Endo/Lymph: No endocrine, blood, or lymph abnormalities. Psychiatric: No depression or suicidal thoughts.
Weight: 155lbs      

BMI: 21.0kg/m2

Temp: 100.4F BP: 122/80mmHg
Height: 6’0” Pulse: 78bpm Resp: 18bpm
General Appearance: Young and looks healthy.
Skin: Brown, warm, and intact.

Head: Normocephalic, atraumatic, short hair.

Eyes:  PERRLA.

Ears: Clearly visible landmarks, patent canals.

Nose: Mucosa pink and moist, no septal deviation.

Neck: Supple.

Mouth and Throat: Moist mouth, no throat abnormalities.

Cardiovascular: Regular heartbeat, no edema of extremities identified.
Respiratory: Regular respirations identified, lungs clear.
Gastrointestinal: Active bowel sounds heard, no abdominal obesity.
Breast: No lumps identified.
Genitourinary: Swollen and tender scrotum. Genitals have an unusual smell.
Musculoskeletal: Full ROM in all joints of the lower limbs. No fractures noted.
Neurological: Speaks clearly, and cranial nerves are intact.
Psychiatric: Oriented to the environment and dressed in clean clothes that are well ironed.
Lab Tests: The nurse took the urine to the lab for testing. The results are available, and they show that the urine is cloudy. According to Assimacopoulos, Johnston, Clabots, and Johnson (2012), cloudy urine shows an infection of the urinary system.
Special Tests: The nurse also requested an ultrasound, and the results show that TC does not have testicular torsion. However, they further confirm that the blood flow is slower than normal. According to K?hn, Scortegagna, Nowitzki, and Kim (2016), slower blood flow in the testes indicates an abnormality. In this case, TC has pain, thus indicating that he has inflammation of the testes.
Differential Diagnoses

The subjective and objective data might indicate the presence of three diagnoses. They include:

· Hernia due to its ability to cause swelling of the scrotum as seen in the objective patient data.

· Acute epididymitis due to its capacity to cause pain. TC has pain, which he experiences as the testes swell.

· Hydrocele due to its ability to cause swelling. TC has a scrotal swelling according to the subjective data.

Final Diagnosis

· Epididymo-Orchitis. According to the subjective data, TC confirms that he experiences testicular pain and swelling. The objective data show that he has a fever and cloudy urine. Furthermore, the ultrasound results show that TC has slow blood movement in the testes. According to K?hn et al. (2016), swollen testes accompanied by a slow blood flow indicate a positive diagnosis of orchitis. Assimacopoulos et al. (2012) further argue that the presence of fever and abnormal color of urine in the swollen testes indicate an abnormality of the epididymis. Consequently, the TC has epididymitis and orchitis, which, when combined, form a positive diagnosis of epididymal-orchitis.


Further Testing: The nurse should recommend further STI screening because TC confirms that he underwent treatment for gonorrhea six months ago, but he failed to complete the dose due to traveling. According to Taylor (2015), STIs are the major causes of epididymal-orchitis. TC does not attribute any cause to the current symptoms since he says that they started suddenly. Thus, the treatment could have been ineffective, thereby resulting in the current diagnosis of epididymal-orchitis. Consequently, there is a need to conduct STI screening.

Medication: The presence of fever indicates that TC has an infection. Therefore, the nurse should consider the previous drugs he used to manage the STIs and prescribe them afresh. In this case, TC does not know the previous dosage and thus, the nurse can give a single injection of Gentamicin 240 mg and then administer a single dose of Azithromycin 2g by mouth. According to Kyle (2015), a combination of these drugs is effective in treating uncomplicated epidydymo-orchitis, which TC has. Additionally, the nurse can use pain relievers to manage pain and increase the patient’s comfort. In this case, the nurse can prescribe Naproxen 500mg by mouth twice per day to be taken for five days.

Non-Medication Treatment: The non-medication treatment can focus on increasing TC’s comfort. The subjective data show that TC experiences discomfort when he walks and when the environment is warm. Therefore, the nurse can help him with the application of cold packs to the scrotum. According to Kyle (2015), cold packs reduce temperature, thus increasing the comfort.

Education: The nurse can advise TC to use cold packs at home to reduce his pain and increase his comfort. Additionally, the nurse can tell the patient to elevate the scrotum every time he goes to sleep to lower the temperature, which will increase his comfort. Kyle (2015) argues that scrotal elevation can increase comfort in patients with epididymitis. Finally, the nurse can advise TC to be faithful in his marriage or use condoms when engaging in sexual intercourse with his two girlfriends. Then, he should bring his wife for treatment as she might also be infected with the bacteria.

Referral and Follow-Up: Referral is unnecessary now because TC has mild symptoms of epididymo-orchitis. Therefore, the nurse can focus on the treatment and ask him to adhere to the symptom-relieving measures. Then, the nurse can tell TC to come back after four days to assess his recovery. His status by then will determine the need for referral and further treatments.

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