Soap Note Week 4
Reason given by the patient for seeking medical care “in quotes”
The patient chief complaint is the disease Benign prostatic hyperplasia. This is because pf the major effects it has on the reproductive system thus having a needed for checking medical care due to its major effects to general body health.
Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.
The case of the patient illness disease maybe be due to several issues that include having kidney stones disease history, urinary tract infections, prostatitis issue, cancer disease of the bladder or even prostate and many more. This must have begun some few months ago before it happens to be having more adverse condition effects. Some of the symptoms include having difficulties in starting urination, urgent urination and inabilities to urinate due to the UTI problem. Other symptoms include inabilities on emptying bladder, blood in the urine, having dribbling kind of thing during end of urination and many more. The location at which the symptoms begins is on the urethra, the bladder, on the prostate, and even the kidney. The alleviating factors of this disease include the dietary factors such as having red meat intake, heart and the circulatory system disease, diabetes and more specific the type II diabetes, obesity related issues and the family history or the hereditary related issues. Some of the pertinent negatives include having the recurrent UTIs, increased urinary retention and also suffering from renal insufficiency. Some of the related illness of the chief complaint disease include having the kidney issues, urinary tract problems, bladder infection and malfunctioning, having chronic urinary retention and many more. Some of the past illness that might be contributing to the disease is the UTI and the kidney related infections/issues and many more. The pats diagnostic testing for this patient might include having the prostate gland assessment, urinary tract, bladder and the kidney functioning testing and many more.
Medications: (list with reason for med )
The medication to be used would include the alpha blocker such as the doxazosin, tamsulosin, alfuzosin etc., which help on relaxing the muscles located in the prostate and the bladder and thus easing excretory processes. There can also be used the 5-Alpha Reductase Inhibitors which helps the body of reducing the effect of increasing prostate through the help of hormones and thus having the urine flow improved and also reducing of other symptoms of BHP. The Phosphodiesterase-5 inhibitors are another type of medicine which would be used whereby it helps on reducing the erectile dysfunction issues, help easing the BHP symptoms and also the smoothening of the prostate and the bladder muscles.
Some of the allergies the patient has include the allergies to drugs, allergies to sensation that is why there is difficulty in breathing.
There are no medical intolerances which has been recorded.
Chronic Illnesses/Major traumas
The major chronic illness includes having the cardiovascular system disease, cancer of the prostate and the urinary tract infections.
The hospitalization for the disease may include having UTI control by the use of the drugs given by the healthcare profession, having the hospitalization of the kidney or balder related issues, and many more.
“Have you ever been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”
For the disease which has been stated the patient has ever been told of having kidney disease which might contribute to the infection which the patent is suffering from BHP.
Family History Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:
lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.
From the information provided the patent family has got a history of suffering from the disease whereby this might be contributing factor to his sickness due to the gene factor.
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, marijuana. Safety status
The patient is highly discouraged form having tobacco intake as it is contributing to the risk of cancer attack which can affect the male reproductive system. Also, the safety status has to be taken by having regular prostate screening and examination thus able to identify any abnormality in the organs and also any disease that might be developing.
Weight change, fatigue, fever, chills, night sweats, energy level
Chest pain, palpitations, PND, orthopnea, edema
Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles
Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB
Corrective lenses, blurring, visual changes of any kind
Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools
Ear pain, hearing loss, ringing in ears, discharge
Urgency, frequency burning, change in color of urine.
Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain
Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis
SBE, lumps, bumps or changes
Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells
HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance
Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx
General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.
Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.
Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.
Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.
Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.
Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.
Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.
Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable.
(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )
(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).
Full ROM seen in all 4 extremities as patient moved about the exam room.
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.
Urinalysis – pending
Urine culture – pending
Wet prep – pending
1- cancer disease 2- o urinary tract infections
Diagnosis of cardiovascular system
· Further testing
There needs to be done urine samples thus able to identify any issues which might be related to the kidney, prostate and the bladder. In that case urinalysis would be a better testing option.
The medication option for this patient would include having the combination of drug therapy, have the sue fop the alpha blockers, the 5-alpha reductase inhibitors and many more
Patient education for this case would be having a healthy lifestyle living procedures such as diets, having body exercises and many more. There also needs the avoidance of alcohol and smoking, avoiding caffeine and not drinking fluids during the bedtimes and also avoiding the intake of the antihistamines and decongestants at all.
· Non-medication treatments
The non-medication treatments would include having the pygeum, foods consideration, taking stinging nettle meals, use of beta-sistosterol and many more.
Evaluation of patient encounter
The patient evaluation would involve having the using of the questionnaire which has been validated thus helping on quantifying the various symptoms that the patient might be showing. There can also be used the digital rectal examination and also having the urinalysis processes test being done thus helping on screening the various urologic disorders which the patient might be having.
Free, A. H., & Free, H. M. (2018). Routine urinalysis. Urinalysis in Clinical Laboratory Practice, 205-210. https://doi.org/10.1201/9781351077460-36
Koshiba, K., Miki, M., Terachi, T., & Uchida, T. (2019). Treatment of benign prostatic hyperplasia. Springer Science & Business Media.
Mitchel, L. (2020). Benign prostatic hyperplasia: Clinical urology.
Stones, S. A. (2021). The fundamental guide to urinary tract infection: A handy guide on the causes and treatment of UTI. Independently Published.
Thiruchelvam, N. (2017). Benign prostatic hyperplasia. Oxford Medicine Online. https://doi.org/10.1093/med/9780199659579.003.0057