D117 Task 3 Male Genitourinary SOAP Note

D117 Task 3 Male Genitourinary SOAP Note

Student Name

Western Governors University

D117 Advanced Health Assessment for the Advanced Practice Nurse

Prof. Name:

Date

Male Genitourinary SOAP Note Form

Date: 
Patient Name: 
DOB: 01/01/XXXX

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Subjective

Chief Complaint

What symptoms is the patient experiencing?
The patient reports urinary hesitancy and post-urination dribbling, which have progressively worsened over the past two months. Additionally, he experiences nocturnal voiding three to four times per night, despite reducing fluid and caffeine intake before bedtime.

Does the patient report any changes in urine characteristics or pain?
The patient denies any changes in urine color or odor, dysuria (painful urination), or discharge.

History of Present Illness

What is known about the patient’s current condition?
The patient mentions that he was previously informed about having an enlarged prostate.

Review of Systems

What other symptoms or complaints does the patient have?

System	Symptoms/Findings
General	No acute distress reported.
HEENT	No vision/hearing changes, nasal discharge, congestion, sore throat, or swallowing difficulties.
Cardiac	No chest pain or palpitations.
Pulmonary	No shortness of breath, cough, or recent respiratory infections.
Gastrointestinal (GI)	No abdominal pain, nausea, vomiting, diarrhea, constipation, or stool changes.
Genitourinary (GU)	Urinary hesitancy with post-urination dribbling worsening over two months. No pain, burning, or discharge.
Musculoskeletal	No muscle weakness or joint pain.
Skin	No itching, rashes, or lesions.
Breast	No pain or lumps reported.
Neurologic	No numbness, tingling, or loss of consciousness.
Psychiatric	Denies mood changes, anxiety, or depression. Patient reports transient sadness after job loss, now resolved.
Endocrine	Denies heat or cold intolerance.
Hematologic	No easy bruising.

Allergies and Immunizations

Does the patient have any known allergies?
The patient has 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

Screenings

When was the last colonoscopy performed?
The patient had a colonoscopy on 01/01/2018.

Medications and Supplements

What medications and supplements does the patient use?

Medication	Dose and Frequency
Lisinopril	20 mg daily
Simvastatin	20 mg daily
Acetaminophen (OTC)	As needed

Supplement	Purpose
Turmeric	Arthritis support
Chondroitin	Arthritis support

Past Medical and Surgical History

What medical conditions and surgeries has the patient experienced?

Condition	Details
Hypertension	Present
Hypercholesterolemia	Present
Osteoarthritis	Multiple joints affected

Surgery	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, retired from a career as a high school teacher, has never smoked, denies alcohol or drug use, and exercises irregularly.

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Objective

Physical Examination

Parameter	Measurement/Findings
Blood Pressure (BP)	134/82 mmHg
Heart Rate (HR)	88 bpm
Respiratory Rate (RR)	18 breaths/min
Temperature (T)	97.9°F
Height (Ht)	5’11”
Weight (Wt)	92.1 kg (203 lbs)
BMI	28.3 kg/m²

General Appearance

The patient appears well-nourished, well-developed, and is in no acute distress.

Skin

No rashes or lesions noted.

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

Normocephalic head shape, white sclera with no conjunctival injection, pupils equal, round, reactive to light and accommodation (PERRLA). Tympanic membranes are pearly gray bilaterally. Nasal septum is midline, no discharge. Throat is clear with moist mucous membranes and no lesions or exudates. Dentition is clean.

Neck

Trachea is midline. The thyroid gland is symmetrical with no enlargement or nodules detected on palpation.

Cardiovascular

Regular rate and rhythm, S1 and S2 heart sounds present. No murmurs, gallops, or rubs auscultated.

Pulmonary

Chest movement is symmetric with clear breath sounds bilaterally. No wheezing, rhonchi, or rales.

Gastrointestinal

Active bowel sounds in all four quadrants. Abdomen is soft, non-tender, non-distended, and mildly obese. No palpable organ enlargement.

Genitourinary

• External genitalia: Normal hair distribution, no lesions, discharge, or erythema. Epididymis is non-tender.

• Urethral meatus: Midline.

• Prepuce: Type IV redundant prepuce covering the penile tip and extending beyond.

• Scrotum/Testes: No masses or discoloration. Testes descended bilaterally with no palpable masses. Cremasteric reflex intact.

• Hernias: No inguinal or femoral hernias detected.

• Anal/Rectal exam: Normal external anatomy, sphincter tone intact, stool appearance normal.

• Prostate: Palpable 3 cm protrusion, smooth, symmetrical, rubbery, boggy, and mobile.

Extremities

No deformities observed. Patient ambulates without weakness. No varicosities, cyanosis, or edema.

Neurological

Alert and oriented to person, place, and time (AAO ×3). Pleasant affect noted.

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Procedure Note

The patient was appropriately prepared for the male genital examination. A male chaperone was present, and the patient gave verbal consent. Inspection and palpation included the pubic area, scrotum, penis, testes, epididymis, and urethra. Cremasteric reflex was tested, and inguinal/femoral regions were examined for hernias. The anal, rectal, and prostate examinations were also conducted.

D117 Task 3 Male Genitourinary SOAP Note

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References

• American Urological Association. (2021). Benign Prostatic Hyperplasia (BPH) Guidelines.

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

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