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CASE STUDY

L.D. has come for an evaluation of a firm nodule he noticed about 6


months ago attached to his testicles. He states he had not been
concerned because he was hit in the testicles with a baseball shortly
before he noticed the nodule.

PRESENTING COMPLAINT
A firm nodule attached to patients testicles. Nodule first noted about 6
months ago.

COMPREHENSIVE HEALTH HISTORY

SUBJECTIVE DATA:
BIOGRAPHICAL DATA: AGE: 30 SEX: M MARITAL STATUS: Married
OCCUPATION:

MALE GENITALS (REVIEW SYSTEM R\T PRESENTING COMPLAINT)

EXAMINAMINOR ASKS:

•How are you feeling today?

•Did you discover this firm lump on your testicle during a testicular
self-examination?

•Do you do testicular self-examinations regularly?

•has the lump changed in size, shape or firmness since you first noticed it?

• any pain associated with the lump?( frequency, severity , area it radiates
from and to, how long it presist, is it intermittent or during attivity and
is it relieved through the use of pain medication)

•note any change in the size of your scotum? (swelling or heavy,dragging


feeling)

•any problems with your penis? (pain,lesions or discharge)

•any change in your sexual activity and contraceptive use? (ability to have
an erection, sexual satification for you and your partner)
•any problems with urination? (frequency, urgency, waking at night to
urinate, burning upon urination, hesitancy or straining, difficulty
controlling your urine , cloudy, foul-smelling or blood tinged urine )

•have you had any STI contact? (when, did you become infected, how was
it treated and do you use condoms)

•are you currantly taking any prescribed or over-the -counter


medications?

OBJECTIVE DATA
GENERAL SURVEY: the examiner makes a visual assessment of the patient
during the interview noting (appears stated age, level of consciousness,
skin colour, nutritional status, posture, mobility and gait, facial expression,
mood and effect, speech, hearing and personal hygiene)

VITAL SIGNS: pulse, respirations,blood pressure ,temperature

MALE GENITALIA:

•inspect and palpate the penis

•inspect and palpate the srcotum

•tranilluminate hard node on testicle

•palpate for an inguinal hernia

•palpate inguinal lymph nodes

DOCUMENTATION OF THE PHYSICAL


EXAM
GENERAL SURVEY: L.D. is a 30 year old male, well norished and
developed, appears stated age, he is alert and orientated,behavior and
speech appropriate,ambulates without difficultly and is in no distress.

VITAL SIGNS: within normal limits.

MALE GENITALIA : penis - no lesions, no inflamation or discharge,


scrotum - testes descended, symmetrical, found upon examination
-Palpation- small hard nodule ,free moving, lying between testies, denies
pain, "I,m not concerned, i t happened 6 months ago, when I was hit
with a baseball", no hernias.
NURSING DIAGNOSIS & HEALTH
PROMOTION
At risk for Testicular Cancer due to testicular mass .

At risk for Testicular Cancer due to age (most common cancer in young
men 15 and 35 years old)

HEALTH PROMOTION - arrange a biopsy of testicular hard nodule.

Pain due to testicular mass

HEALTH PROMOTION - educate the patient to the possibility of pain and


the availabilities of pain medication and the importance of informing his
health team of changes in his condition.

Anxiety due to biopsy R\T testicular mass

HEALTH PROMOTION - reassure patient that the biopsy procedure is


simple and quickly preformed by professionals. follow-up pain medication
available if necessary

Risk for wellness due to deficient knowledge -skill R|T testicular hard
nodule

HEALTH PROMOTION - educate patient to self examine his testicles


monthly while in the shower. Check for changes and report them
immediately.