Week 2 SOAP Note

Name:  R.H.

Date: 07/22/2020

Time: 1:20 pm

Age: 72

Sex: Male

SUBJECTIVE

CC: 

“Follow Up: I have to use the bathroom a lot at night”. 

HPI: (Use OLDCART)

Patient has felt a strong need to go to the bathroom for the past 4 weeks. The urgency to go is relieved when he goes to pee. It is a strong urgency and he often has to stop what he is doing to go to the bathroom. He also reports that he only urinates a small amount whenever he goes. The urgency even occurs in the middle of the night. He goes to the bathroom over 10 times in one day and a few times at night. There is nothing that relieves his urgency. He began feeling this way 4 weeks ago. Labs were conducted in a previous visit where the patient stated the same complaint. We will review labs in this follow up visit.

Medications: (list with reason for med)

Lisinopril 10mg 1 po QD for HTN

Tylenol Arthritis 650mg 1 tab every 8 hours as needed for pain.

PMH

Allergies:   NKDA, denies food allergies

Medication Intolerances: Denies intolerances

Chronic Illnesses/Major traumas: Hypertension diagnosed in 2005

Hospitalizations/Surgeries: Denies any hospitalizations  

Family History

Father- deceased from natural causes at 89

Mother- deceased from natural causes at 92

Has 2 daughters and 1 son, and 5 grandchildren, all healthy with no medical problems.

Social History

General: Born in Cuba, and immigrated to Miami when he was 18 years old

Marital status: Married for 41 years

Living situation: Lives with his wife in a home in Miami, Fl. Has a caretaker paid for by his children.

Children: 2 daughters, and 1 son

Occupation: Retired, used to work as an electrician for a major electrical company for 51 years.

Leisure Patterns: Enjoys birdwatching in his backyards and playing online chess.

Social habits: Denies smoking or alcohol consumption. Does not exercise.

Spirituality: No religious ties.

Nutrition: States that his appetite is normal, and he eats whatever is cooked for him.

Sleep Patterns: Patient sleeps poorly due to having to get up to urinate at night at least 2 times. He sleeps less than 7 hours daily.

ROS

General

Complains of increased urinary urgency throughout the day and in the nighttime.

Head: Denies headache, head injury, dizziness, or lightheadedness.

Cardiovascular

Reports that he was diagnosed with hypertension around 15 years ago. He has been taking Lisinopril 10mg once a day. He reports that his BP is checked once weekly and is always under 130/80. Denies having chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or edema. Has never had EKG done.

Skin

Denies rashes, lumps, sores, itching, and changes in color. Denies changes in his nails or hair. Denies changes in size or color of moles.

Respiratory

Denies cough, sputum, hemoptysis, dyspnea, wheezing, or pleurisy. Has not had a Chest X Ray done. Denies having asthma, bronchitis, emphysema, pneumonia, or tuberculosis.

Eyes

Reports using glasses for the past 30 years. Last eye exam was 5 years ago. Denies any changes in vision or worsening vision. Denies any pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma or cataracts. 

Gastrointestinal

Denies trouble swallowing, heartburn, changes in appetite, or nausea. Denies pain or bleeding with defecation. No changes in bowel habits. Denies black or tarry stools, hemorrhoids, constipation, or diarrhea. Denies abdominal pain, food intolerance or excessive belching or passing gas. Denies jaundice, live, or gallbladder trouble.

Ears

Reports some hearing loss over the past 5 years but denies use of hearing aids. Denies tinnitus, vertigo, earaches, infection, or discharge

Genitourinary/Gynecological

Goes to the bathroom 7 to 10 times a day. Reports urinating a small amount. Reports urgency, and nocturia. Denies polyuria or burning or pain during urination. Denies hematuria, kidney or flank pain, kidney stones, urethral colic, suprapubic pain, or incontinence. Denies ever being diagnosed with urinary tract infection.

Currently not sexually active due to erectile dysfunction.

Nose/Mouth/Throat

Denies hay fever, nose bleeding, or sinus trouble. Throat: Denies use of dentures. Last dental examination 1 year ago. Denies sore tongue, frequent sore throats or hoarseness. Denies having dry mouth or excessive thirst.

Neck: Denies swollen glands, goiter, lumps, pain, or stiffness in the neck.

Musculoskeletal

Reports generalized weakness in the body. Denies paresthesia, loss of sensations, no severe or progressive neurological deficit in lower extremity. Positive for some pain in the knees. Reports taking Tylenol Arthritis 650mg as needed for pain. Denies stiffness, or hx of gout. Denies fever, chills, rash, anorexia, weight loss.

Breast

Non-Contributory

Neurological

Denies changes in mood, attention or speech. Denies changes in orientation, memory, insight, or judgment. Denies headaches, dizziness, vertigo, fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or pins and needles, tremors or other involuntary movements.

Heme/Lymph/Endo

Denies anemia, easy bruising or bleeding, and past transfusions. Denies excessive thirst and hunger. Denies thyroid trouble, heat or cold intolerance, excessive sweating, polyuria or changes in shoe size. Denies weight changes or fever.

Peripheral Vascular: Denies leg cramps, varicose veins, past clots in veins, swelling in calves, legs or feet. Denies any swelling or tenderness.

Psychiatric

Denies nervousness, tension, mood changes, depression, or memory changes.

OBJECTIVE

Weight 142lbs      BMI 20.4

Temp 98.3 F

BP 130/78

Height 70”

Pulse 65

Resp 18

General Appearance

Skin warm and dry w/o discoloration or pallor, A/O x 3, appropriate responses, cooperative, appears concerned w/o signs of acute distress.

Skin

Skin is warm, pink and supple, no lesions noted.

HEENT

Normocephalic, PERRLA, EOMs intact, fundoscopic: red reflex present, no nicking or hemorrhage. TM intact bilaterally, pearly with + light reflex. Nares patent, neck supple. Pharynx: swallows w/o difficulty, no erythema; Neck: thyroid non palpable, no carotid bruits. No adenopathy.

Cardiovascular

Carotid upstrokes are brisk, w/o bruits. The PMI is tapping, 7cm lateral to the midsternal line in the 5th intercostal space. S1 louder than S2 on auscultation. No murmurs or extra sounds. Extremities are warm and w/o edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial pulses are 2+, brisk, and symmetric.

Respiratory

Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes, or rhonchi.

Gastrointestinal

Abdomen is flat with active bowel sounds in all four quadrants. It is soft and non-tender; no masses or hepatosplenomegaly. No CVA tenderness.

Breast

Deferred

Genitourinary

Suprapubic region examined for bladder distention, none found. Bladder is non-distended. No abnormal penile lesion.

Digital Rectal Exam Performed: Prostate is enlarged on examination; surface is smooth with no distinct nodules present. Mass is approximately 50g.

Musculoskeletal

No joint deformities. Positive ROM in hands, wrists, elbows, shoulders, knees and ankles. Gait/Posture: Heel and toe walking intact. Spinal column: No kyphosis, scoliosis or lordosis. Lateral movement: bilaterally to 20º. No noted major motor weakness on knee extension, ankle plantar flexors, evertors, dorsiflexors. No CVA Tenderness.

Neurological

Cranial nerves II to XII intact. Good muscle bulk and tone. Strength 4/5 throughout. Rapid alternating movements and point to point movements are intact. Gait stable. Pinprick, light touch, position sense, vibration, and stereognosis intact, Romberg negative. Reflexes 2 + and symmetric with plantar reflexes down going.

Psychiatric

Alert relaxed and cooperative. Thought process is coherent. Oriented to person, place and time.

Lab Tests

Labs conducted 07/17/2020

Significant Findings

PSA: 5.7 ng per mL

Urinalysis: blood (-), nitrites (-), leukocyte esterase (-), glucose (-), bacteria (-), SG 1.015, pH 5.5

Special Tests

 None ordered today.

 Diagnosis

 Diagnosis:

1. Benign Prostatic Hyperplasia (N40): The patient likely has BPH. He has an enlarged prostate with the presence of lower-urinary tract symptoms. His PSA is elevated without any nodules. The patient also has a risk factor of erectile dysfunction (Chughtai, et al., 2016)

Differentials:

1. Prostatitis (N41.0): Patient has an enlarged prostate and an abnormal PSA level. This may indicate prostatitis. However, the patient is lacking symptoms that are associated with prostatitis including fever, back pain, or suprapubic pain. Patient also lacks pain on urination or any signs of bacterial infection (Prostatitis: Inflammation of the Prostate , n.d.).

2. Malignant Neoplasm of Prostate (C61): Patient has characteristics of prostate cancer, such as urgency and nocturia. However, on the digital rectal examination, the prostate was not found to be rough or nodular. The prostate was found to be smooth. Patient also has few risk factors for cancer as no one in his family has it. Other signs of prostate cancer such as pain or discomfort in the pelvic area are missing from this case (Prostate Cancer, 2019).

3. Male Erectile Dysfunction, unspecified (N52.9): Patient reports having erectile dysfunction; however, this dysfunction would not be the cause of the enlarged prostate or elevated PSA levels, rather it could be a result of the BPH.

Plan/Therapeutics

Plan: 

Diagnostic: No tests needed at this time

Therapeutic: Pharmacological:

Tamsulosin (generic Flomax): Start treatment with 0.4mg of Tamsulosin taken once daily.

Non-pharmacological/ Patient Education

1. Reduce fluid intake before sleeping or leaving the home to reduce the need to use the bathroom

2. Reduce the use of alcohol or caffeinated beverages as they are diuretics and can cause increased urination

3. Avoid the use of common decongestants for cold and flu symptoms as they can cause side effects associate with urinary retention.

Follow Up:

We will follow up with the patient in 1 month. Symptoms will usually go away within 3-4 days of pharmacologic treatment with Tamsulosin 0.4mg (Chughtai, et al., 2016). If symptoms worsen, we will increase to 0.8mg daily. If symptoms keep worsening, we will refer the patient to a urologist for specialized treatment.

 Evaluation of patient encounter:

In this case I treated the patient almost exclusively with some guidance from my preceptor except for the Digital Rectal Examination (DRE). For the DRE, the preceptor conducted this exam in a private room for the privacy of the patient.

Weaknesses: This patient was established in this clinic and I wanted to make him more comfortable with me, as I was not his usual provider.

Strengths: I conducted this entire case in 40 minutes or less and have increased my skills in history taking and the physical examination.

Reflection: I have improved greatly when It comes to time management, and this patient was treated quickly and efficiently.