Male Genitourinary SOAP Note Form
Subjective
Chief Complaint
What symptoms is the patient experiencing?
The patient presents with progressively worsening lower urinary tract symptoms (LUTS), primarily characterized by difficulty initiating urination, weak urinary stream, and persistent post-void dribbling. These concerns have developed gradually and intensified over the past two months. He also reports significant nocturia, awakening three to four times nightly to urinate, despite actively reducing evening fluid and caffeine intake. These symptoms have begun to interfere with sleep quality and daily functioning.
Does the patient report any changes in urine characteristics or pain?
The patient denies painful urination, blood in the urine, foul odor, abnormal coloration, or urethral discharge. He also denies suprapubic pressure or flank pain, reducing suspicion for acute urinary tract infection, nephrolithiasis, or renal pathology.
History of Present Illness
What is known about the patient’s current condition?
The patient reports a prior diagnosis of prostate enlargement communicated by a healthcare provider in the past. He notes a gradual progression of urinary symptoms without episodes of acute urinary retention. There is no history of catheter use, prostate biopsy, or surgical intervention involving the prostate. The worsening nocturia and hesitancy have prompted evaluation due to their impact on quality of life and sleep patterns.
Review of Systems
What other symptoms or complaints does the patient have?
| System | Symptoms / Findings |
|---|---|
| General | Denies fever, chills, fatigue, or unintentional weight loss |
| HEENT | Denies vision or hearing changes, nasal congestion, sore throat, or sinus discomfort |
| Cardiovascular | Denies chest pain, palpitations, or known arrhythmias |
| Pulmonary | Denies shortness of breath, cough, wheezing, or recent infections |
| Gastrointestinal | Denies abdominal pain, nausea, vomiting, diarrhea, constipation, or bowel changes |
| Genitourinary | Reports urinary hesitancy, nocturia, weak stream, and post-void dribbling; denies dysuria, hematuria, or discharge |
| Musculoskeletal | Reports chronic joint pain associated with osteoarthritis; denies acute swelling or weakness |
| Skin | Denies rashes, lesions, itching, or pigmentation changes |
| Breast | Denies masses, tenderness, or nipple discharge |
| Neurologic | Denies dizziness, headaches, numbness, tingling, or syncope |
| Psychiatric | Denies anxiety or depression; reports resolved situational sadness related to prior job loss |
| Endocrine | Denies temperature intolerance, excessive thirst, or unexplained polyuria |
| Hematologic | Denies abnormal bruising or bleeding |
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 |
| PCV13 | 01/01/2010 |
| PPSV23 | 01/01/2011 |
| Influenza | 01/01/2019, 01/01/2020 |
Screenings
When was the last colonoscopy performed?
The patient underwent a routine screening colonoscopy on 01/01/2018. Results were unremarkable, and no complications were reported.
Medications and Supplements
What medications and supplements does the patient use?
| Medication | Dose and Frequency |
|---|---|
| Lisinopril | 20 mg orally once daily |
| Simvastatin | 20 mg orally once daily |
| Acetaminophen (OTC) | As needed for pain |
| Supplement | Intended Purpose |
|---|---|
| Turmeric | Anti-inflammatory support for joint pain |
| Chondroitin | Joint health and osteoarthritis management |
Past Medical and Surgical History
What medical conditions and surgeries has the patient experienced?
| Condition | Details |
|---|---|
| Hypertension | Long-standing, controlled with medication |
| Hypercholesterolemia | Managed with statin therapy |
| Osteoarthritis | Involving multiple joints |
| Surgical Procedure | Date |
|---|---|
| Knee Arthroplasty | 1998 |
Family and Social History
What is the family history relevant to this patient?
| Family Member | Health Conditions | Status |
|---|---|---|
| Mother | Hypertension, breast cancer | Alive |
| Father | Hypertension | Alive |
| Grandparents | Unknown | — |
What about the patient’s lifestyle and habits?
The patient is married and retired, having previously worked as a high school educator. He denies tobacco use, alcohol consumption, and illicit drug use. Physical activity is inconsistent, which may contribute to his elevated body mass index and persistent musculoskeletal discomfort.
Objective
Physical Examination
| Parameter | Measurement |
|---|---|
| Blood Pressure | 134/82 mmHg |
| Heart Rate | 88 bpm |
| Respiratory Rate | 18 breaths/min |
| Temperature | 97.9°F |
| Height | 5’11” |
| Weight | 92.1 kg (203 lbs) |
| BMI | 28.3 kg/m² |
General Appearance
The patient appears well-nourished, appropriately groomed, and in no acute distress.
Skin
Skin is warm, intact, and well hydrated without lesions or discoloration.
Head, Eyes, Ears, Nose, and Throat
Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Sclerae are non-icteric. Tympanic membranes are intact bilaterally. Nasal passages are patent, and oral mucosa is moist without lesions.
Neck
Neck is supple with the trachea midline. Thyroid gland is non-tender, symmetrical, and without palpable nodules.
Cardiovascular
Regular rate and rhythm with normal S1 and S2 sounds. No murmurs, rubs, or gallops detected.
Pulmonary
Lungs are clear to auscultation bilaterally with symmetrical chest expansion.
Gastrointestinal
Abdomen is soft, non-tender, and non-distended. Bowel sounds are present in all quadrants with no organomegaly.
Genitourinary
External genitalia are normal in appearance with appropriate hair distribution and no lesions or discharge. A redundant type IV foreskin is noted. Testes are descended bilaterally, smooth, and non-tender. No inguinal or femoral hernias are detected.
Digital rectal examination reveals a moderately enlarged prostate measuring approximately 3 cm. The gland is smooth, symmetrical, rubbery in consistency, mobile, and non-tender—findings consistent with benign prostatic hyperplasia rather than malignancy.
Extremities
No edema, cyanosis, or deformities noted. Gait is steady, and the patient ambulates independently.
Neurological
The patient is alert and fully oriented. Cranial nerves appear intact, and mood and affect are appropriate.
Procedure Note
A comprehensive male genitourinary examination was performed following informed verbal consent. A male chaperone was present throughout the assessment. Inspection and palpation included the penis, scrotum, testes, epididymis, urethral meatus, and inguinal regions. Digital rectal examination and prostate assessment were completed without complications.
D117 Task 3 Male Genitourinary SOAP Note
References
American Urological Association. (2021). Guideline on the management of benign prostatic hyperplasia.
National Institute of Diabetes and Digestive and Kidney Diseases. (2023). Prostate enlargement (benign prostatic hyperplasia). https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-enlargement
Wein, A. J., Kavoussi, L. R., Partin, A. W., & Peters, C. A. (Eds.). (2020). Campbell-Walsh urology (12th ed.). Elsevier.