Benign prostatic hyperplasia SOAP note
This is a SOAP note
Primary diagnosis: benign prostatic hyperplasia
Differential diagnosis: UTI, urethral stricture, bladder calculi
references no older than 2 years.
Abnormal findings are placed in a bold and red tint.
no cover page
THE HISTORY AND PHYSICAL (H&P)
- Chief Complaint
“I have been experiencing extreme pain in my lower abdomen and in the urethra before, during, and after urination.”
- History of Present Illness (HPI)
D.S. is an 82-year-old white male patient who has come to the clinic accompanied by his son aged 47 years old. His chief complaint is extreme pain and discomfort in the lower abdomen and the urethra before, during, and after urination. According to D.S., he has trouble starting urination with a delay that is characterized by pain. He is also unable to stop urination completely as he usually has some urine still leaking out of the urethra after urination.
The patient denies a history of benign prostatic hyperplasia. He has type 2 diabetes and high blood pressure which he is currently managing effectively using medications. As reported by D.S., although he started to experience the named symptoms about two months ago, he has been reluctant to seek medication because he thought that they will disappear on their own. He lasted visited a doctor for a physical exam three years ago.
Location: Lower abdomen and the urethra.
Quality: Sharp pain.
Quantity or severity: Extreme pain. 8/10 on the pain scale.
Setting: Before, during, and after urination.
Aggravating or relieving factors: Urge to urinate aggravates the pain. The pain is relieved about 10 minutes after urination.
Associated manifestations: Dribbling or leaking urine after urination due to inability to stop the urine completely.
III. Past medical history (PHx)
- Childhood illnesses
D.S. cannot trace his childhood medical records. Again, he is unable to remember whether he had any childhood illnesses or not.
The patient does not know whether he received all his childhood medications or not. He lastly received tetanus booster 5 years ago. His last influenza vaccination occurred 3 months ago with his adulthood medical records indicating that he received High-dose inactivated influenza vaccine (HD-IIV). He has been fully vaccinated against COVID-19. He has taken two doses of Oxford/AstraZeneca vaccine 02/01/2022 and 01/03/2022.
- Adult Illnesses
D.S.’s son indicates that is father was hospitalized three years ago due to medical complications caused by both type 2 diabetes and high blood pressure. He was treated and discharged. Since then, D.S. has been managing these two conditions effectively at home without any other hospitalizations.
D.S. denies undergoing any surgery or medical operations before.
Denies food or drug allergies.
500 mg of metformin taken orally once a day to manage type 2 diabetes
100 mg of atenolol taken orally once a day to manage high blood pressure
- Complimentary treatments
D.S. uses meditation as a complementary treatment for his health problems.
- Family history
D.S.’s father died of ischemic attack 20 years ago at the age of 87 years. His mother died 32 years ago at the age of 75 years. His paternal and maternal grandparents died long time ago when he was still a young adult. He cannot remember their causes of death. D.S. is married to his lovely wife aged 74 years with whom they have stayed for more than 45 years. He has four children: two sons and two daughters. All his children are currently married and are staying with their families. He does not have any reports of his children and grandchildren being diagnosed with any serious medical conditions.
- Social history
D.S. is a retired engineer. He has a construction consultancy firm which is currently managed by his children. He is unable to manage the firm due to advanced age. D.S. lives with his wife, house help, and a gardener at home. He and his wife rarely leave their compound. Besides, they do not engage in any physical activities at home and in the community.
D.S. does not consume alcohol or cigarettes. He denies using illicit substances like cocaine and heroin. He does not consume processed foods, red meat, or beverages. His typical diet comprises green leafy vegetables, boiled bananas, porridge, and fruits.
- Review of Systems
General: Denies abnormal weight loss or weight gain. Reports fever and chills.
Skin: Does not report hair loss or thinning. Denies bruises, pruritus, redness, or rashes on the skin reported. Denies brittle nails or nail breakage.
Head: Denies a history of physical head injury. Denies a headache. Does not report redness and pain in the issues. No vision issues reported. Does not report a history of cataracts. Denies using contact glasses. Does not report double vision or excessive tearing. Denies ear pain, hearing loss, ear infection, or hearing in the ears. No nasal stuffiness reported. Does not report nasal discharge or obstruction. No recent changes in smell reported. Denies a history of nasal infections.
Mouth and throat: Denies soreness, bleeding gums, or pyorrhea. No mouth ulcers, pain, or dryness reported. Does not report hoarseness of the throat. No mouth or throat infections reported.
Neck: D.S. denies pain in the neck region. Denies swollen lymph nodes. Does not report goiter or lumps in the neck region.
Lymphatics: Denies axillae or swollen lymph nodes in the neck region.
Breasts: Denies abnormal enlargement of breasts. Does not report pain or discharge in the nipple. No masses or lumps on the breasts.
Pulmonary: Does not report difficulty breathing. Denies a cough. No hemoptysis reported. Denies pleuritic chest pain, wheezing, or blue discoloration of nailbeds or lips. Denies a history of exposure to TB. Does not report a history of recurrent pneumonia or tuberculosis. Reports a history of environmental exposure, especially at the construction sites before retirement.
Cardiovascular: Denies chest pain, shortness of breath, irregular heartbeat, or heart murmurs. Denies a history of cardiovascular disease such as ischemic attack. D.S. has never been diagnosed with high blood pressure before. He denies a history of abnormal electrocardiogram.
Gastrointestinal: Reports sharp pain in the lower abdomen. Denies constipation or diarrhea. Does not report dysphagia or trouble swallowing, or heartburn. Does not report vomiting or nausea. No changes in bowel movements. Denies excessive belching or a history of gallbladder problems. Denies abnormal changes in appetite or indigestion.
Urinary: Reports hematuria or presence of blood in urine. Reports pain during urination. Reports an abnormal increase in urination frequency of more than 8 times a day, especially at night (nocturia). Reports increased urinary urgency or inability to delay urination. Reports trouble starting urination or difficulty initiating a urine stream, reports dribbling or persistent leaking of urine at the end of urination. Reports pain before, during, after urination. Urine has an abnormal red color. D.S. denies a history of urinary tract infections. Denies a history of kidney stones.
Genital tract (male): Denies abnormal penile discharge, penile lesions, or a history of sexually transmitted disease. Reports intermittent urine leakage after urination. Reports mild testicular pain. Denies visible testicular swelling. Reports increased scrotal mass. Denies impotence or infertility. Reports sexual difficulties. Denies hernias.
Musculoskeletal: Reports joint stiffness. Denies joint pains, joint swelling, or joint tenderness. Does not report backache or a history of fractures. Reports reduced physical mobility.
Neurologic: Denies fainting, seizures, tingling, tremors, or numbness of limbs. Does not report local weakness or local paralysis. Denies headaches, muscle atrophy, dizziness, or memory changes.
Psychiatric: Denies nightmares, nervousness, or depression. Denies insomnia, anxiety, or irritability. Denies phobia, suicidal ideation, or suicide attempt.
Endocrine: Denies heat or cold intolerance. Does not report trouble with thyroid. Denies excessive thirst, abnormal sweating, or excessive hunger. Reports increased urination urgency and frequency.
Hematologic: D.S. denies uncontrolled bleeding or easy bruising. Denies anemia or past reactions to blood transfusion. Denies having other blood-related disorders such as sickle cell disease or an autoimmune disease.
VII. Physical examination
Vital signs: Blood pressure; 142/95, temperature; 97.9 Degree Fahrenheit, pulse; 93 beats per minute, respiratory rate; 18 breaths per minute, weight; 171.8 pounds.
General appearance: D.S. is properly oriented to time, place, and person. He appears comfortable and maintains eye contact. He is responding to questions asked throughout the interview.
Skin: Skin is without rashes, sores or lesions. It is warm, intact, and dry. No cyanosis observed on the nail beds.
Head: The head is normocephalic and without trauma. It lacks evidence of palpable masses, scarring, or depressions. Hair is evenly distributed on the scalp and of normal texture.
Eyes: No evidence of discharge. Eyelids are normal in appearance without swelling or lesions. Cornea is not opacified. Conjunctivae are clear without exudates or hemorrhage. Sclerae is non-icteric. Visual acuity is 20/20.
Ears: The external ear and ear canal are non-tender without edema. The ear canal is clear without discharge. No signs of ear blockage. The tympanic membrane is pale grey in color in both ears.
Nose: No evidence of enlarged turbinates. Nasal mucosa is pink, hairy, and moist. No evidence of nasal tenderness. The nasal septum is positioned midline.
Throat: Oral mucosa is without sores, lesions, or ulcers. It is pink and moist with good dentition. Throat is non-erythematous. The pharynx is pink in appearance. No evidence of tonsillar exudates, edema, or pharyngeal injection.
Neck: The trachea is positioned midline-positioned. Absence of unusual masses or pulsations. No jugular venous distention. Thyroid is palpable.
Nodes: No swelling of the inguinal, axillary, or epitrochlear nodes.
Breasts: Palpation and inspection of both breasts does not reveal tenderness, discharge, or masses.
Chest: No evidence of deformities on inspection. Normal breath sounds, wheezes, crackles, rubs, or rhonchi on auscultation. No fremitus detected on palpation.
Heart: Visible PMI on inspection. Normal heart rate, S1, S2, without galloping, murmurs, or rubbing. Normal heart rhythm, no heaves, lifts, or excitement. No evidence of edema on the periphery. Varied bilateral peripheral pulses, capillary refill less than 3 seconds.
Abdomen: No bowel sounds heard. No scars. Absence of abdominal tenderness. No evidence of bloating or abdominal distention.
Back/spine: No mobility challenges. No evidence of deformities on the neck and back. No curvature. No CVA tenderness.
Extremities, including exam of pulses: No tremor, deformities, or swellings in upper and lower extremities. No evidence of joint tenderness or effusion.
Genitalia/Rectal (male): Absence of lesion sin the external genitalia. Evenly distributed public hair. Slight discharge of urine from the urethra. Tender and enlarged lymph nodes in the groin. Evidence of tender and enlarged scrotum. Rectal examination or physical exam of the prostate revealed enlarged and tender prostate glands.
Mental status: D.S. is able to concentrate and he is attentive. He has normal speech. Although he does not present with any signs of memory loss, D.S. cannot remember some of the things that happened in his life during childhood and early adulthood due to memory lapse.
Cranial nerves: Crania nerves II-IX have full EOM’s. They are intact with evidence of visual fields.
Motor: Muscle rigidity present. Normal gait and good balance. Muscle strength on joints is 4/5.
Sensory: Reflexes are 2+. Light touch/pricking has revealed sensitivity in lower and upper limbs.
VIII. Problem list
D.S. is an 82-year-old white male who has reported to the clinic complaining of extreme pain in his lower abdomen and in the urethra before, during, and after urination. As reported by D.S., he has trouble starting urination with a delay that is characterized by extreme pain in the lower abdomen. He is also unable to stop urination completely as he usually experiences dribbling after urination.
These symptoms have lasted for about two months. The urge to urinate aggravates the pain. The pain is relieved about 10 minutes after urination. The problematic symptoms that should guide the clinician when making a decision regarding the patient’s diagnosis include; extreme pain in my lower abdomen and in the urethra before, during, and after urination, fever, chills, and hematuria or presence of blood in urine.
D.S. also reports an abnormal increase in urination frequency of more than 8 times a day, especially at night (nocturia). He further reports increased urinary urgency or inability to delay urination, trouble starting urination or difficulty initiating a urine stream, dribbling or persistent leaking of urine at the end of urination, and abnormal red color in urine. The patient further reports mild testicular pain, reports increased scrotal mass as well as sexual difficulties.
Risk factors to consider include lack of physical exercise and the presence of type 2 diabetes and a cardiovascular disease, particularly high blood pressure. From physical exam, there is evidence of dribbling with tender and enlarged lymph nodes in the groin. There is also evidence of tender and enlarged scrotum. Rectal examination or physical exam of the prostate revealed enlarged and tender prostate glands.
- Differential diagnosis
- Benign prostatic hyperplasia
- Urinary tract infection
- Urethral stricture
- Bladder calculi
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.
Foo K. T. (2019). What is a disease? What is the disease clinical benign prostatic hyperplasia (BPH)?. World Journal of Urology, 37(7), 1293–1296. https://doi.org/10.1007/s00345-019-02691-0
Langan, R. C. (2021). Men’s health: Benign prostatic hyperplasia. FP Essentials, 503, 18-22. PMID: 33856179.
National Institute of Diabetes and Digestive and Kidney Diseases. (2022). Prostate enlargement: Benign prostatic hyperplasia. https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-problems/prostate-enlargement-benign-prostatic-hyperplasia
Rachna, J. & Yogesh, J. (2021). The importance of physical examination in primary health care provided by NPHW is being threatened in COVID19 times. Journal of Family Medicine and Primary Care, 10(1), 19-21 doi: 10.4103/jfmpc.jfmpc_1932_20
Roehrborn C. G. (2005). Benign prostatic hyperplasia: an overview. Reviews in Urology, 7 Suppl 9(Suppl 9), S3–S14.