SOAP Note 2 Clinical Practice 2
S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx:
N.S., 70 year old male, reliable historian
DOB: 2/03/1955
Father: Deceased d/t
sepsis (84 yrs).
Assumed healthy
Mother: Deceased
d/t ischemic CVA (80
yrs). A-fib, CVA, HTN
Sister: Living (65
yrs). unknown
Brother: Living (72
yrs). A-fib
Personal/Social Hx:
Chief Complaint/RFE: -Lives in home with
“straining with urination, incomplete emptying of bladder, and weak stream” wife.
-Drinks socially 2x a
month
-Never smoker
-No illicit drug use
-Owner of
construction company
Hx Present Illness: (Variables of a symptom, also called symptom analysis)
N.S., a 70 year old male with history of benign prostate hypertrophy (BPH) presents to the clinic with a 4 week history of
straining with urination, incomplete emptying of bladder, and weak stream. He reports increased urination over night,
sometimes voiding 3-4 times a night. He reports he is adherent in taking his tamsulosin daily. He denies fever, fatigue, chills,
dysuria, or hematuria. He has tried decreasing night time fluids with minimal benefit. PSA level 6 months ago 1.2. No family
history of prostate cancer.
CURRENT HEALTH
Medications:
Tamsulosin 0.4mg 1 capsule by mouth daily
MOA: Tamsulosin is a selective alpha-1A blocker that works by relaxing the smooth muscle in the prostate and bladder neck, making it
easier to urinate. (Arcangelo et al., 2022).
Allergies: No known drug allergies
Last PE & Screenings: Physical exam: 1/2025, Colonoscopy: 10/2022 normal. Eye exam-done yearly. Dental exam-done yearly.
Immunization Status: Influenza 10/2024, Covid declines, Shingles-at age 55. PCV 20 at age 65. Tdap-greater than 10 years ago, declines.
LMP & Birth Control (if applicable) n/a
PMH
Illnesses & Trauma: none
, Hospitalizations/Surgeries: Cholecystectomy 2011, abdominal cyst removal 2017
OB Hx/Sexual Hx: Sexually active with wife
Emotional/Psy Hx: History of depression and previously treated. Denies at this time
REVIEW OF SYSTEMS
General Denies fever, fatigue, weakness, or unexpected weight loss
Nutrition deferred
Skin/Hair/Nails deferred
HEENT deferred
Breasts deferred
Respiratory Denies shortness of breath, wheezing, or cough
CV/peripheral vascular Denies chest pain, palpitations, or edema
GI Denies diarrhea, constipation, or abdominal pain
GU Reports nocturia, straining with urination, incomplete voiding, and weak stream. Denies CVA tenderness, dysuria, or bladder pain.
MSK deferred
Psych Denies depression or anxiety
Neuro Denies headaches
Lymph/Heme/Endocrine Referred
O/ Physical Exam: T: 98.4 P: 76 R: 14 BP: 120/72 HT: 5’10 WT: 185 BMI:26.5
General Pleasant, no acute distress
Skin Warm and dry. No rashes, lesions or wounds
Head Normocephalic
EENT deferred
Neck deferred
Breasts/Chest deferred
Lungs All lobes clear to auscultation, no cough
Heart/ perip vascular Regular rate and rhythm. S1, S2 heard, no S3,S4. No murmurs, gallops, or rubs. Peripheral pulses 2+, no edema
Abdomen Non-tender, no masses, or organomegaly
S/ Identifying Information: (initials, age/DOB, gender, reliability) Family Hx:
N.S., 70 year old male, reliable historian
DOB: 2/03/1955
Father: Deceased d/t
sepsis (84 yrs).
Assumed healthy
Mother: Deceased
d/t ischemic CVA (80
yrs). A-fib, CVA, HTN
Sister: Living (65
yrs). unknown
Brother: Living (72
yrs). A-fib
Personal/Social Hx:
Chief Complaint/RFE: -Lives in home with
“straining with urination, incomplete emptying of bladder, and weak stream” wife.
-Drinks socially 2x a
month
-Never smoker
-No illicit drug use
-Owner of
construction company
Hx Present Illness: (Variables of a symptom, also called symptom analysis)
N.S., a 70 year old male with history of benign prostate hypertrophy (BPH) presents to the clinic with a 4 week history of
straining with urination, incomplete emptying of bladder, and weak stream. He reports increased urination over night,
sometimes voiding 3-4 times a night. He reports he is adherent in taking his tamsulosin daily. He denies fever, fatigue, chills,
dysuria, or hematuria. He has tried decreasing night time fluids with minimal benefit. PSA level 6 months ago 1.2. No family
history of prostate cancer.
CURRENT HEALTH
Medications:
Tamsulosin 0.4mg 1 capsule by mouth daily
MOA: Tamsulosin is a selective alpha-1A blocker that works by relaxing the smooth muscle in the prostate and bladder neck, making it
easier to urinate. (Arcangelo et al., 2022).
Allergies: No known drug allergies
Last PE & Screenings: Physical exam: 1/2025, Colonoscopy: 10/2022 normal. Eye exam-done yearly. Dental exam-done yearly.
Immunization Status: Influenza 10/2024, Covid declines, Shingles-at age 55. PCV 20 at age 65. Tdap-greater than 10 years ago, declines.
LMP & Birth Control (if applicable) n/a
PMH
Illnesses & Trauma: none
, Hospitalizations/Surgeries: Cholecystectomy 2011, abdominal cyst removal 2017
OB Hx/Sexual Hx: Sexually active with wife
Emotional/Psy Hx: History of depression and previously treated. Denies at this time
REVIEW OF SYSTEMS
General Denies fever, fatigue, weakness, or unexpected weight loss
Nutrition deferred
Skin/Hair/Nails deferred
HEENT deferred
Breasts deferred
Respiratory Denies shortness of breath, wheezing, or cough
CV/peripheral vascular Denies chest pain, palpitations, or edema
GI Denies diarrhea, constipation, or abdominal pain
GU Reports nocturia, straining with urination, incomplete voiding, and weak stream. Denies CVA tenderness, dysuria, or bladder pain.
MSK deferred
Psych Denies depression or anxiety
Neuro Denies headaches
Lymph/Heme/Endocrine Referred
O/ Physical Exam: T: 98.4 P: 76 R: 14 BP: 120/72 HT: 5’10 WT: 185 BMI:26.5
General Pleasant, no acute distress
Skin Warm and dry. No rashes, lesions or wounds
Head Normocephalic
EENT deferred
Neck deferred
Breasts/Chest deferred
Lungs All lobes clear to auscultation, no cough
Heart/ perip vascular Regular rate and rhythm. S1, S2 heard, no S3,S4. No murmurs, gallops, or rubs. Peripheral pulses 2+, no edema
Abdomen Non-tender, no masses, or organomegaly
