I-HUMAN CASE STUDY FOR A 75 YEARS OLD male WITh
inability to urinate and lower abdominal pain for the past 12
hours — WEEK 10 FOR WALDEN UNIVERSITY LOCATION
:OUTPATIENT CLINIC WITH X-RAY, ECG, AND LABORATORY
CAPABILITIES FULL CASE STUDY WITH A SOAP NOTE
History of Present Illness (HPI)
James Wilson is a 75-year-old male who presents to the Emergency Department with inability to
urinate and lower abdominal pain for the past 12 hours. He reports a progressive decrease in
urinary stream over several months, with increased hesitancy, weak stream, dribbling, and
nocturia (3–4 times nightly). Since last night, he has been unable to void at all, despite strong
urge to urinate.
He describes the abdominal pain as dull, constant, and pressure-like, located in the
suprapubic region, rated 7/10, and worsening over time. He reports abdominal fullness and
,distention. He denies dysuria, hematuria, fever, chills, flank pain, nausea, vomiting, or recent
trauma. No recent medication changes.
This is his first episode of complete urinary retention. He has not previously required
catheterization.
Review of Systems (ROS)
Constitutional:
• Denies fever, chills, weight loss, or fatigue
Cardiovascular:
• Denies chest pain, palpitations, edema
Respiratory:
• Denies shortness of breath, cough, wheezing
Gastrointestinal:
• Reports suprapubic abdominal pain and fullness
• Denies nausea, vomiting, diarrhea, constipation
Genitourinary:
• Positive for urinary retention, hesitancy, weak stream, nocturia
• Denies dysuria, hematuria, penile discharge
Musculoskeletal:
• Denies back pain, joint pain
Neurologic:
• Denies weakness, numbness, saddle anesthesia
Endocrine:
• Denies polyuria, polydipsia
Integumentary:
, • Denies rash, skin changes
Past Medical History
• Benign Prostatic Hyperplasia (suspected, not formally diagnosed)
• Hypertension
• Hyperlipidemia
Past Surgical History
• Appendectomy (remote)
Medications
• Amlodipine 10 mg daily
• Atorvastatin 20 mg nightly
• No alpha-blockers or 5-alpha reductase inhibitors
Allergies
• No known drug allergies (NKDA)
Family History
• Father: Prostate enlargement in later life
• Mother: Hypertension
• No family history of prostate cancer
Social History
• Retired accountant
inability to urinate and lower abdominal pain for the past 12
hours — WEEK 10 FOR WALDEN UNIVERSITY LOCATION
:OUTPATIENT CLINIC WITH X-RAY, ECG, AND LABORATORY
CAPABILITIES FULL CASE STUDY WITH A SOAP NOTE
History of Present Illness (HPI)
James Wilson is a 75-year-old male who presents to the Emergency Department with inability to
urinate and lower abdominal pain for the past 12 hours. He reports a progressive decrease in
urinary stream over several months, with increased hesitancy, weak stream, dribbling, and
nocturia (3–4 times nightly). Since last night, he has been unable to void at all, despite strong
urge to urinate.
He describes the abdominal pain as dull, constant, and pressure-like, located in the
suprapubic region, rated 7/10, and worsening over time. He reports abdominal fullness and
,distention. He denies dysuria, hematuria, fever, chills, flank pain, nausea, vomiting, or recent
trauma. No recent medication changes.
This is his first episode of complete urinary retention. He has not previously required
catheterization.
Review of Systems (ROS)
Constitutional:
• Denies fever, chills, weight loss, or fatigue
Cardiovascular:
• Denies chest pain, palpitations, edema
Respiratory:
• Denies shortness of breath, cough, wheezing
Gastrointestinal:
• Reports suprapubic abdominal pain and fullness
• Denies nausea, vomiting, diarrhea, constipation
Genitourinary:
• Positive for urinary retention, hesitancy, weak stream, nocturia
• Denies dysuria, hematuria, penile discharge
Musculoskeletal:
• Denies back pain, joint pain
Neurologic:
• Denies weakness, numbness, saddle anesthesia
Endocrine:
• Denies polyuria, polydipsia
Integumentary:
, • Denies rash, skin changes
Past Medical History
• Benign Prostatic Hyperplasia (suspected, not formally diagnosed)
• Hypertension
• Hyperlipidemia
Past Surgical History
• Appendectomy (remote)
Medications
• Amlodipine 10 mg daily
• Atorvastatin 20 mg nightly
• No alpha-blockers or 5-alpha reductase inhibitors
Allergies
• No known drug allergies (NKDA)
Family History
• Father: Prostate enlargement in later life
• Mother: Hypertension
• No family history of prostate cancer
Social History
• Retired accountant
