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SOAP Note week 8
Patient: John Doe
Age: 60 years
Subjective:
Chief Complaint
SOAP Note week 8
Patient: John Doe
Age: 60 years
Subjective:
Chief Complaint: Difficulty urinating, increased frequency, and nocturia.
History of Present Illness:
Onset: Symptoms began approximately six months ago and have progressively
worsened.
Duration: Symptoms are persistent.
Characteristics: Reports weak urine stream, difficulty starting
urination, dribbling at the end of urination, and a sensation of incomplete
bladder emptying.
Aggravating Factors: Symptoms worsen at night, causing frequent
awakenings (nocturia).
Relieving Factors: None reported.
Associated Symptoms: No fever, chills, or weight loss. No hematuria or
dysuria was reported.
Past Medical History:
– Hypertension
– Diabetes Mellitus
– Hyperlipidemia
– Anemia
Medications:
– Lisinopril 20 mg daily
– Metformin 1000 mg twice daily
– Atorvastatin 20 mg daily
– Iron supplements as needed
Allergies: No known drug allergies.
Social History:
– Smoking: Never smoked.
– Alcohol: Occasional use, 1-2 drinks per week.
– Occupation: Retired.
Family History: No family history of prostate cancer.
-Father had a History of Hypertension and diabetes.
-Mother had a History of Hypothyroidism
Objective:
– Vital Signs:
– BP: 130/85 mmHg
– HR: 78 bpm
– RR: 16 breaths/min
– Temp: 98.6°F
– SpO2: 98% on room air
General Appearance: Well-nourished, alert, and oriented x3.
– HEENT: Normocephalic, atraumatic. PERRLA, EOMI.
– Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.
– Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or
rhonchi.
– Abdomen: Soft, non-tender, no masses or organomegaly.
– Genitourinary: Digital rectal exam
(DRE): Prostate enlarged, smooth, non-tender. weak urine stream, difficulty
starting urination, dribbling at the end of urination, and a sensation of
incomplete bladder emptying.
-Extremities: No edema, pulses 2+ bilaterally.
Laboratory Results:
– CBC: Hemoglobin 12.5 g/dL, Hematocrit 37%, WBC 7.0 x 10^3/uL
– CMP: Within normal limits
– Lipid Panel: Total cholesterol 180 mg/dL, LDL 100 mg/dL, HDL 45 mg/dL,
Triglycerides 150 mg/dL
– PSA: Awaiting results
Assessment:
1. Benign Prostatic Hyperplasia (BPH)
2. Hypertension – well controlled
3. Diabetes Mellitus – Type 2
4. Hyperlipidemia – well controlled
5. Anemia – stable
Plan:
1. BPH Management:
– Start Tamsulosin 0.4 mg daily.
– Schedule follow-up in 4 weeks to assess symptom improvement.
– Educate patient on potential side effects of Tamsulosin
(dizziness, orthostatic hypotension).
2. Hypertension:
– Continue current medication (Lisinopril 20 mg daily).
– Monitor blood pressure at home and record readings.
3. Diabetes Mellitus:
– Continue current medication (Metformin 1000 mg twice daily).
– Advise patient to monitor blood glucose levels regularly.
– Schedule HbA1c test in 3 months.
4. Hyperlipidemia:
– Continue current medication (Atorvastatin 20 mg daily).
– Encourage heart-healthy diet and regular exercise.
5. Anemia:
– Continue iron supplements as needed.
– Monitor hemoglobin and hematocrit levels regularly.
6. Patient Education:
– Discuss lifestyle modifications to manage BPH symptoms (limit
caffeine and alcohol, avoid drinking fluids before bedtime).
– Educate on signs and symptoms that would require immediate
medical attention (e.g., inability to urinate, severe pain).
7. Follow-Up:
– Return to clinic in 4 weeks for BPH symptom evaluation and review
of PSA results.
– Routine follow-up in 3 months for chronic condition management.
Differential Diagnosis for Benign Prostatic Hyperplasia (BPH)
1. Prostatitis:
– Inflammation or infection of the prostate gland, often
accompanied by fever, chills, and pelvic pain. Symptoms may include painful
urination and frequent need to urinate.
2. Prostate Cancer:
– Malignant growth within the prostate. Symptoms can overlap with
BPH, such as urinary frequency, urgency, and weak stream, but may also include
hematuria and unexplained weight loss. Elevated PSA levels and abnormal
findings on digital rectal exam (DRE) are often indicative.
3. Bladder Outlet Obstruction:
– Blockage at the base or neck of the bladder, which can be caused
by BPH, bladder stones, urethral stricture, or tumors. Symptoms include
difficulty urinating and a weak urine stream.
4. Urethral Stricture:
– Narrowing of the urethra due to scar tissue, often caused by
infection, injury, or previous surgeries. Symptoms include reduced urine flow,
difficulty starting urination, and frequent urination.
5. Urinary Tract Infection (UTI):
– Infection of the urinary tract causing inflammation and symptoms
such as frequent urination, urgency, burning sensation during urination, and
suprapubic pain.
6. Medications:
– Certain medications (e.g., antihistamines, decongestants)
can affect urinary function, leading to symptoms that mimic BPH.
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