Episodic SOAP Note and Reflection: Craig Harris
, Episodic SOAP Note and Reflection: Craig Harris
First Name: Craig
Last Name: Harris
Gender: Male
Age: 81
Race: African American
Source of history: Patient- Mr. Craig Harris and his nursing home caregiver
Subjective Data:
Chief Complaint (CC):
Hesitancy in starting urinary stream, decreased force of the urinary
stream, post-voiding dribbling, nocturia, and LLQ pain.
History of Present Illness (HPI):
Mr. Harris is an 81-year-old African American presenting to the clinic
from a nursing home with complaints of LLQ abdominal pain x1 month,
hesitancy in starting urinary stream, decreased force of the urinary stream,
post-void dribbling and nocturia.
Mr. Harris reports that he doesn’t feel like he empties his bladder with
each urination and has had problems with constipation. States his last bowel
movement was one week ago. Denies fever. Staff reports they aren’t sure if
Mr. Harris is sexually active but it does occur at the nursing home.
Allergies:
No Known Drug Allergies (NKDA) reported
, Episodic SOAP Note and Reflection: Craig Harris
First Name: Craig
Last Name: Harris
Gender: Male
Age: 81
Race: African American
Source of history: Patient- Mr. Craig Harris and his nursing home caregiver
Subjective Data:
Chief Complaint (CC):
Hesitancy in starting urinary stream, decreased force of the urinary
stream, post-voiding dribbling, nocturia, and LLQ pain.
History of Present Illness (HPI):
Mr. Harris is an 81-year-old African American presenting to the clinic
from a nursing home with complaints of LLQ abdominal pain x1 month,
hesitancy in starting urinary stream, decreased force of the urinary stream,
post-void dribbling and nocturia.
Mr. Harris reports that he doesn’t feel like he empties his bladder with
each urination and has had problems with constipation. States his last bowel
movement was one week ago. Denies fever. Staff reports they aren’t sure if
Mr. Harris is sexually active but it does occur at the nursing home.
Allergies:
No Known Drug Allergies (NKDA) reported
