SAOP Note: Painful Bump in Left Groin

SAOP Note: Painful Bump in L Groin

Name: T. S Date: Time: 1:20 p.m
Age: 26 Sex: Female
Subjective
Chief complaint:

“I have a bump in my left groin.”

HPI:

 

T.S is a 26-year-old female, and she presents to the clinic complaining of a lump on the left groin region since yesterday. She denies experiencing fever, chills, chest pain, difficulty in breathing, sore throat, nausea, abdominal pain, diarrhea, swelling, difficulty in urination, skin changes, rashes or lesions, insect bites, and exposure to poisons ivy and oak, and any palpitations. She also denied having shortness of breath while resting. She denied a vaginal discharge.

Medications:

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The patient is not on any medications.

PMH

Allergies: No known drug allergies

Chronic Illnesses/Major traumas: none

Hospitalizations/Surgeries: Tonsillectomy.

Family History:

The patient was adopted.

Social history;

She does not smoke.

Occasionally takes alcohol in social events

She is sexually active.

Has no children

She is a waitress.

Review of the systems (ROS)
General;

No fever, chills, coughs, fatigue, loss of appetite, or weight loss.

Cardiovascular;

Denies chest pain, palpitations, fainting/passing out, shortness of breath during exercise or sleep, peripheral edema, and breathlessness in recumbent positions.

Skin

Denied skin rash, lesions, moles, dryness, or discoloration.

Respiratory:

Denied coughs, sputum, wheezing sounds, or history of respiratory illnesses such as tuberculosis.

Eyes:

Denies changes in vision, blurred vision, photophobia, irritation, or yellowing of the sclerae

Gastrointestinal:

Denies abdominal pain, constipation, abnormal bowel sounds and movements, ulcers, or nausea

Ears:

Denies loss of hearing, pain, or discharge.

Genitourinary

She is sexually active denies burning urination, changes in urine color, dysuria, and incontinence.

Nose/Mouth/Throat

Denies sore throat, dysphagia, dental discharges, nose bleeds, sinusitis, throat hoarseness, or pain.

Musculoskeletal

Denies joint and back pain, recent injuries, muscle pains, swelling, and stiffness.

Breast,

N/A

Neurological

Denies tremor, paralysis, ataxia, headaches, tingling in the hands or legs, or dizziness.

Heme/Lymph/Endo:

Denies bruising, bleeding, swelling in the extremities and lymph nodes, heat intolerance, increased hunger and thirst,

Psychiatric

Denies depression, suicidal ideation, hallucination and memory loss, or paranoia.

Objective
Weight: 142 BMI: 36.01 Temp: 98.3 BP: 154/99
Height: 65” Pulse: 83 Resp: 16
General Appearance

T.S is a 26-year-old female patient; she is well-groomed and appears pleasant. She is, however, a little worried about the bump in her groin region.

Skin:

The skin is warm, dry, pink, and intact; no bruising, tenderness, or rashes were observed.

HEENT

Head; is normocephalic, with no facial tenderness

Eyes; No blurred or double vision, no visual loss or yellowing of the sclerae.

Ears; nor hearing loss or pain.

Nose; no runny nose, sneezing, or congestion.

Mouth; no exudates, lesion, or enlargement of tonsils.

 

Throat/neck; no sore throat observed. The neck is supple, with no occipital nodes.

 

Cardiovascular;

Regular rhythms, no murmurs, no chest pain, edema, or other discomforts. Stage 1 blood pressure. Capillary refill 2 seconds.

Respiratory;

No shortness of breath or cough, no wheezing or tactile fremitus, respirations regular, Lungs clear to auscultation bilaterally.

Gastrointestinal;

Normal bowel sounds, No masses or abnormal bowel movements, no organomegaly, hernia, or distension.

Breast;

N/A

Genitourinary;

No bladder tenderness, vaginal discharge, or lesions, no suprapubic pain.

Musculoskeletal;

No joint stiffness or joint pain, no deformities or tenderness of upper or lower extremities

Neurological;

Steady gait with no ataxia, clear speech, normal sensation, and erect posture.

Psychiatric;

The patient is cooperative, appears calm, and has a normal affect.

Lab Tests:

Pelvic exam;

Urinary analysis; no leukocytes, nitrites, or bacteria.

Gonorrhea and Chlamydia culture gathered.

Special Tests: none
Diagnosis:

Cysts; are noncancerous growths that occur under the skin, including the groin area. They are usually harmless and painless, and most of the time, they resolve on their own without medical intervention. They can either be epidermoid or sebaceous cysts. Cysts are not infected and therefore not contagious; however, they are usually painful, contain pus, and redden when infected. The patient in this case only reported having a lump, and during the examination, she observed she denied any pain around the abdomen or groin areas, hence the cyst diagnosis (Beaux & Patel, 2018).

Differential diagnosis;

STDs; lumps around the groin region can also be caused by sexually transmitted diseases, including chlamydia, HIV, and gonorrhea. However, such infections are usually accompanied by other symptoms, including discharge from the vagina, painful lumps, odor from the vaginal, swollen lymph nodes, burning urination, and lower abdominal pain. The patient, in this case, denied experiencing all the other symptoms associated with STDs except the existence of lumps, and therefore it is unlikely that she has an STD infection.

Urinary tract infection; involves infection of any part of the urinary tract. It can also cause the appearance of lumps or swellings around the groin region. However, the possibility of the UTI is low since the associated symptoms such as burning and frequent urination and presence of WBC and cloudy urine were negative (Beaux & Patel, 2018).

Plan/Therapeutics
Plan: The care provider, in this case, should apply a wait and watch strategy; since the lumps are only one day old and they are not painful care provider should wait to see how they progress before initiating treatment. If they are cysts, they will resolve on their own without other symptoms.

However, the care provider should educate the patients on symptoms to look for and schedule a follow-up visit to assess their progress (Beaux & Patel, 2018).

 

References

Beaux, A. C. D., & Patel, D. (2018). Diagnosis of a Lump in the Adult Groin. In Management of Abdominal Hernias (pp. 195-207). Springer, Cham. https://link.springer.com/chapter/10.1007/978-3-319-63251-3_11