Summary NRP 571 Craig Harris Episodic SOAP Note and Reflection Latest Update with complete solution

Episodic SOAP Note and Reflection: Craig Harris First Name: Episodic SOAP Note and Reflection: Craig Harris Craig Last Name: Gender: Age: Race: Source of history: Subjective Data: Harris Male 81 African American Patient- Mr. Craig Harris and his nursing home caregiver 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 Current Medications: List from caregiver (medications not disclosed in scenario) History: Past Medical History (PMH): Inguinal hernia Surgical History (SH): Not disclosed but possibly inguinal hernia Childhood illnesses: Not disclosed in the scenario Immunization History: Not disclosed in the scenario Family History (FH): Mother- Breast cancer BRCA Father- Colon cancer Social History: 10th grade education Retired military Smoker of 20 years Recent Exam/Tests: N/A Review of Systems: (ROS) General health: Thin elderly male HEENT: Normal: Denies the following: