Testicle Torsion Consultation Sample Report
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CHIEF COMPLAINT: Left testicular torsion.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male who complains of sudden onset of left testicular pain. The pain progressively worsened and became less intermittent. The patient was brought to the emergency department by his parents.
The patient subsequently underwent a scrotal ultrasound, which initially revealed no flow to the left testicle and subsequently revealed some flow. The patient denies any trauma to the area. The patient denies any difficulty urinating.
PAST MEDICAL HISTORY: The patient’s past medical history is really unremarkable.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented, obviously somewhat uncomfortable.
VITAL SIGNS: He is afebrile. Temperature 97.8, pulse 76, blood pressure 128/68.
HEENT: Head is normocephalic. Eyes nonicteric.
ABDOMEN: Benign. There is no hernia.
GENITALIA: Normal-appearing external genitalia with an uncircumcised phallus without lesions or discharge. Scrotum is normally developed without lesions or slight fullness to the left hemiscrotum. The testicle itself is somewhat high-riding, much firmer and twice the size of the right testicle. The epididymis itself is extremely tender and indurated. However, the patient does state that the pain is actually improving. There is no significant cremasteric reflex on the left side.
EXTREMITIES: Without clubbing, cyanosis or edema.
NEUROLOGIC: The patient appears grossly intact.
LABORATORY DATA: The patient’s laboratory data revealed a hemoglobin of 15.4, hematocrit 45.2, and white blood cell count of 7.2.
ASSESSMENT: The patient has an acute torsion of the left testicle.
PLAN: At this point in time, the plan is to take the patient emergently to the operating room for left scrotal exploration, possible left orchiectomy, and possible left orchiopexy.
The procedure was discussed with both the patient and his parents in detail, who appeared to understand and agreed to proceed. The patient will be brought to the operating room emergently.
