Comprehensive SOAP Note for J.L. 1
Date: 07/14/2025
Patient Name/DOB: J.L. / 03/05/1980
Subjective:
Chief Complaint (CC):
"It burns to urinate."
History of Present Illness (HPI):
J.L. is a 44-year-old African American male presenting with a 2-day history of
dysuria, characterized by burning on urination, urinary hesitancy, urgency,
and minimal cloudy urine output. He also reports mild suprapubic pain but
denies general abdominal pain, back pain, penile discharge, rashes, scrotal/
testicular pain, or tenderness. The patient notes that he recently had unpro-
tected vaginal intercourse with a female partner. He reports that his fever is
relieved by acetaminophen but recurs when the medication wears off after
approximately four hours.
Past Medical History (PMH):
The patient's past medical history is significant for hypertension. He also has
a history of gonorrhea, which was treated in 2015.
Social History:
J.L. is a full-time accountant who is unmarried and without children. He de-
nies smoking, illicit drug use, and marijuana use but consumes two glasses
of wine on Saturday evenings with dinner.
Sexual History:
J.L. intermittently uses condoms during intercourse with female partners. He
reports insertive vaginal intercourse and receptive oral sex. He has a history
of gonorrhea treated in 2015 and was tested for gonorrhea, HIV, syphilis, and
chlamydia in 2016, all of which were negative.
Medications:
The patient takes Norvasc 10 mg PO daily for hypertension.
Immunizations:
His immunization history includes Hepatitis B vaccines (2020), Tdap (2019),
and the influenza vaccine (October 2023).
Allergies:
The patient is allergic to sulfa drugs, which cause hives.
Family History:
The patient's mother is alive and has a history of diabetes mellitus, hyperten-
sion, and chronic obstructive pulmonary disease (COPD). His father, who is
, Comprehensive SOAP Note for J.L. 2
deceased, had a history of cerebrovascular accident (CVA), hypertension,
and depression.
Health Care Maintenance:
The patient had his last dental and vision examination in March 2024.
Review of Systems (ROS):
• General: The patient reports fever, chills, and weakness.
• HEENT: The patient denies headaches, dizziness, vision changes, and
hearing loss.
• Cardiovascular: The patient denies chest pain, peripheral edema, or
palpitations.
• Respiratory: The patient denies pain on inspiration and shortness of
breath.
• Gastrointestinal: The patient complains of lower abdominal pain. He
denies difficulty swallowing, nausea, vomiting, diarrhea, constipation,
or rectal pain.
• Genitourinary: The patient denies penile discharge, hematuria,
polyuria, or incontinence. He complains of burning on urination, urinary
hesitancy, urgency, and dysuria. He denies testicular pain or swelling,
scrotal swelling, or pain. He also denies rashes to the genitalia.
• Musculoskeletal: The patient denies flank pain, joint pain, muscle
pain, and decreased range of motion.
• Neurological: The patient denies dizziness or headaches.
• Integumentary: The patient denies lesions, rashes, itching, excoria-
tion, or bruising.
• Psychiatric: The patient denies feeling depressed or anxious.
Objective:
Vital Signs:
• BP: 124/76 mmHg
• HR: 92 bpm
• Temp: 100.9°F
• Pulse Oximetry: 99% on room air
• Respirations: 22 per minute
• Height: 5 feet 10 inches
• Weight: 215 pounds
• BMI: 30.8 kg/m²
Physical Exam:
Date: 07/14/2025
Patient Name/DOB: J.L. / 03/05/1980
Subjective:
Chief Complaint (CC):
"It burns to urinate."
History of Present Illness (HPI):
J.L. is a 44-year-old African American male presenting with a 2-day history of
dysuria, characterized by burning on urination, urinary hesitancy, urgency,
and minimal cloudy urine output. He also reports mild suprapubic pain but
denies general abdominal pain, back pain, penile discharge, rashes, scrotal/
testicular pain, or tenderness. The patient notes that he recently had unpro-
tected vaginal intercourse with a female partner. He reports that his fever is
relieved by acetaminophen but recurs when the medication wears off after
approximately four hours.
Past Medical History (PMH):
The patient's past medical history is significant for hypertension. He also has
a history of gonorrhea, which was treated in 2015.
Social History:
J.L. is a full-time accountant who is unmarried and without children. He de-
nies smoking, illicit drug use, and marijuana use but consumes two glasses
of wine on Saturday evenings with dinner.
Sexual History:
J.L. intermittently uses condoms during intercourse with female partners. He
reports insertive vaginal intercourse and receptive oral sex. He has a history
of gonorrhea treated in 2015 and was tested for gonorrhea, HIV, syphilis, and
chlamydia in 2016, all of which were negative.
Medications:
The patient takes Norvasc 10 mg PO daily for hypertension.
Immunizations:
His immunization history includes Hepatitis B vaccines (2020), Tdap (2019),
and the influenza vaccine (October 2023).
Allergies:
The patient is allergic to sulfa drugs, which cause hives.
Family History:
The patient's mother is alive and has a history of diabetes mellitus, hyperten-
sion, and chronic obstructive pulmonary disease (COPD). His father, who is
, Comprehensive SOAP Note for J.L. 2
deceased, had a history of cerebrovascular accident (CVA), hypertension,
and depression.
Health Care Maintenance:
The patient had his last dental and vision examination in March 2024.
Review of Systems (ROS):
• General: The patient reports fever, chills, and weakness.
• HEENT: The patient denies headaches, dizziness, vision changes, and
hearing loss.
• Cardiovascular: The patient denies chest pain, peripheral edema, or
palpitations.
• Respiratory: The patient denies pain on inspiration and shortness of
breath.
• Gastrointestinal: The patient complains of lower abdominal pain. He
denies difficulty swallowing, nausea, vomiting, diarrhea, constipation,
or rectal pain.
• Genitourinary: The patient denies penile discharge, hematuria,
polyuria, or incontinence. He complains of burning on urination, urinary
hesitancy, urgency, and dysuria. He denies testicular pain or swelling,
scrotal swelling, or pain. He also denies rashes to the genitalia.
• Musculoskeletal: The patient denies flank pain, joint pain, muscle
pain, and decreased range of motion.
• Neurological: The patient denies dizziness or headaches.
• Integumentary: The patient denies lesions, rashes, itching, excoria-
tion, or bruising.
• Psychiatric: The patient denies feeling depressed or anxious.
Objective:
Vital Signs:
• BP: 124/76 mmHg
• HR: 92 bpm
• Temp: 100.9°F
• Pulse Oximetry: 99% on room air
• Respirations: 22 per minute
• Height: 5 feet 10 inches
• Weight: 215 pounds
• BMI: 30.8 kg/m²
Physical Exam:
