D117 Task 3 Male Genitourinary SOAP Note

Male Genitourinary SOAP Note Form

Subjective

Chief Complaint

What symptoms is the patient experiencing?
The patient describes a progressive worsening of lower urinary tract symptoms over the last two months. He reports difficulty initiating urination followed by persistent dribbling after voiding. Additionally, he experiences nocturia, waking up three to four times nightly to urinate, despite consciously reducing fluid intake and caffeine consumption in the evening.

Are there any changes in urine characteristics or associated pain?
The patient denies experiencing any pain during urination (dysuria), blood in the urine (hematuria), or alterations in urine color or odor. There is no urethral discharge or discomfort in the suprapubic or flank regions, suggesting no signs of an acute urinary tract infection or kidney involvement.

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History of Present Illness

What is known about the patient’s current condition?
The patient recalls being previously informed by a healthcare professional that he has an enlarged prostate. His urinary symptoms have become more bothersome lately, significantly affecting his sleep and overall daily comfort. He reports no history of urinary retention, catheter use, or previous surgeries related to the prostate.

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Review of Systems

Are there any other symptoms or health concerns?

System	Symptoms/Findings
General	No fever, fatigue, or unexplained weight loss; appears in no acute distress.
HEENT	No vision or hearing changes, nasal congestion, sore throat, swallowing difficulties, or sinus pain.
Cardiac	No chest pain, palpitations, or known arrhythmias.
Pulmonary	No shortness of breath, cough, wheezing, or recent respiratory infections.
Gastrointestinal	No abdominal pain, nausea, vomiting, diarrhea, constipation, or bowel habit changes.
Genitourinary	Increased urinary hesitancy, nocturia, post-void dribbling; no pain, blood, or discharge.
Musculoskeletal	No joint swelling or muscle weakness; chronic joint pain due to osteoarthritis.
Skin	No rashes, itching, lesions, or pigmentation abnormalities.
Breast	No pain, tenderness, or masses.
Neurologic	No dizziness, numbness, tingling, headaches, or loss of consciousness.
Psychiatric	No ongoing anxiety or depression; brief situational sadness related to job loss has resolved.
Endocrine	No intolerance to heat/cold, excessive thirst, or polyuria aside from urinary symptoms.
Hematologic	No bleeding tendencies or easy bruising.

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Allergies and Immunizations

Does the patient have any known allergies?
The patient reports no known drug allergies (NKDA).

What immunizations has the patient received?

Vaccine	Date Administered
DTaP	01/01/2015
PCV 13	01/01/2010
PPSV 23	01/01/2011
Influenza	01/01/2019, 01/01/2020

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Screenings

When was the last colonoscopy performed?
The patient had a screening colonoscopy on January 1, 2018. The procedure was uneventful, and no abnormalities were reported.

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Medications and Supplements

What medications and supplements does the patient currently take?

Medication	Dose and Frequency
Lisinopril	20 mg orally once daily
Simvastatin	20 mg orally once daily
Acetaminophen (OTC)	As needed for pain

Supplement	Purpose
Turmeric	Supports joint inflammation and arthritis
Chondroitin	Supports joint health and osteoarthritis

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Past Medical and Surgical History

What are the patient’s previous medical conditions and surgeries?

Condition	Details
Hypertension	Chronic, medically controlled
Hypercholesterolemia	Managed with statins
Osteoarthritis	Affects multiple joints

Surgery	Date
Knee Arthroplasty	1998

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Family and Social History

What is the patient’s relevant family history?

Family Member	Health Conditions	Status
Mother	Hypertension, Breast Cancer	Alive
Father	Hypertension	Alive
Grandparents	Unknown	—

What are the patient’s lifestyle habits?
The patient is married and retired, having worked as a high school teacher. He has never smoked and denies alcohol or illicit drug use. Physical activity is irregular, possibly contributing to his elevated body mass index (BMI) and chronic joint pain.

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Objective

Physical Examination

Parameter	Measurement / Findings
Blood Pressure	134/82 mmHg
Heart Rate	88 beats per minute
Respiratory Rate	18 breaths per minute
Temperature	97.9°F
Height	5’11”
Weight	92.1 kg (203 lbs)
BMI	28.3 kg/m²

The patient appears well-nourished and appropriately groomed, showing no signs of acute distress. Skin examination reveals intact texture with normal elasticity, free from rashes, lesions, or discolorations.

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Head, Eyes, Ears, Nose, Throat (HEENT)

The head is normocephalic and without trauma. Eyes have clear sclera with pupils equal, round, and reactive to light and accommodation. Ears are normal with intact tympanic membranes. Nasal septum is centered and dry. Oral mucosa is moist, dentition intact, and oropharynx clear.

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Neck

The trachea is midline. The thyroid gland is symmetrical, non-tender, without enlargement or nodules.

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Cardiovascular System

Heart sounds (S1, S2) are normal with regular rhythm and no abnormal murmurs, rubs, or gallops.

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Pulmonary System

Chest expansion is symmetrical; lungs are clear with no abnormal breath sounds.

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Gastrointestinal System

The abdomen is soft, non-tender, non-distended, and bowel sounds are active throughout all quadrants. No palpable masses or organ enlargement.

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Genitourinary System

External genitalia show normal male hair distribution with no lesions, redness, or discharge. The epididymis is non-tender, and the urethral opening is midline. The prepuce is redundant (type IV), extending beyond the glans. Scrotum is intact with no discoloration; testes are descended bilaterally, smooth, and without masses. Cremasteric reflex is intact. There are no inguinal or femoral hernias.

On digital rectal exam, the prostate measures about 3 cm, is smooth, symmetrical, rubbery, mildly boggy, mobile, and non-tender—consistent with benign prostatic hyperplasia (BPH).

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Extremities

No deformities, swelling, cyanosis, or varicosities noted. The patient moves independently without weakness.

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Neurological

The patient is alert and oriented to person, place, and time. Mood and affect are appropriate and stable.

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Procedure Note

The male genitourinary exam was performed after obtaining verbal consent and proper patient preparation. A male chaperone was present throughout. The exam included inspection and palpation of the pubic region, penis, scrotum, testes, epididymis, and urethra. Reflexes and inguinal/femoral areas were examined for hernias. A digital rectal exam including prostate assessment was conducted without complications.

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References

American Urological Association. (2021). Benign prostatic hyperplasia (BPH) guidelines.

National Institute of Diabetes and Digestive and Kidney Diseases. (2023). Prostate enlargement. https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-enlargement

D117 Task 3 Male Genitourinary SOAP Note

Wein, A. J., Kavoussi, L. R., Partin, A. W., & Peters, C. A. (Eds.). (2020). Campbell-Walsh urology (12th ed.). Elsevier.