Craig Harris SOAP Note & Reflection on BPH Management nursing (002)2026/27 Update with complete solutions

Identifying Data First Name: Craig Last Name: Harris Age: 81 DOB: 02/01/1942 Gender: Male CC: The patient presents with a complaint of hesitancy starting the urine stream, decreased stream force, dribbling after urination, and left lower quadrant (LLQ) abdominal pain. HPI: An 81-year-old male residing in a nursing home presents to the office with a complaint of hesitancy starting the urinary stream, decreased stream of force of urine, dribbling after urination, nocturia, and left lower quadrant abdominal pain for the past month. The patient reports feeling like he doesn’t empty the bladder each time he urinates. No previous history of similar symptoms reported and has experienced the symptoms for the past month. The patient also reports constipation with the last bowel movement a week ago. The caregiver accompanying him asked if a MiraLAX would be appropriate to address constipation and only had a paper with medication from the nursing home. History Allergies (drugs and reactions): NKDA Current Medications: No current medications PMH: None reported Pertinent Family History: None reported Social History: Patient resides in a nursing home. No significant social history reported. Review of Systems (ROS) General: Denies weight changes, fever, or chills. Reports inability to sleep well at night due to nocturia. HEENT: Denies head injury, visual changes or hearing loss. Denies sinus pressure or nasal drainage. Denies sore throat Neck: denies neck pain, stiffness, or edema Respiratory: Denies SOB, wheezing, or coughing Cardiovascular (CV): No chest pain, discomfort, or palpitations reported. Page 2 of 9 Gastrointestinal (GI): Reports left lower quadrant abdominal pain and constipation. Denies nausea or vomiting. Urinary: Reports hesitancy starting the urine stream, decreased force of the stream, post-void dribbling, and nocturia. Reports failure to completely empty the bladder with each urination. Peripheral Vascular: No leg cramping, pain, or edema reported in the upper or lower extremities. Musculoskeletal (MSK): No muscle, back, or joint pain reported. Skin: No rashes, itching, or bruising reported. Neurological: No headache, weakness, numbness, or tingling reported. Psych: No history of depression or anxiety reported Objective Vital Signs HR: 74 RR: 16 Temp: 98 F Height: 72” Weight: 189 lb BMI: 25.6 Physical Exam General: Well developed and nourished. Alert and oriented and in no acute distress. HEENT: Head normocephalic. Eyes PERRLA, sclera white, conjunctiva pink without exudate. Tympanic membrane clear, hearing intact. Nasal mucosa pink and most, septum midline. Nares patent bilaterally. The oral buccal is pink and moist without lesions. Normal tonsils without exudate or swelling. Neck/Lymph: Neck is supple without lymphadenopathy. Trachea midline without lumps. Chest/Respiratory: Breath sounds clear; no wheezes, rales, or rhonchi noted. Resonance normal upon percussion without tenderness in all lung fields. Cardiovascular: Regular rate and rhythm, no murmurs, rubs or gallops noted. No cyanosis noted. Gastrointestinal/Abdominal: Abdomen symmetric without lesions. Soft and tender with light palpitation in the left lower quadrant. A palpable hard mass in the left lower quadrant. Genitourinary/Rectal: Weak sphincter tonal without perineal or rectal lesions. Prostate tender and enlarged. A 1x1 cm firm, hard, nodule on the left lateral lobe of the prostate on palpitation. Back: Spine normal without deformity.