D117 Task 3 Male Genitourinary SOAP Note

Student Name

Western Governors University

D117 Advanced Health Assessment for the Advanced Practice Nurse

Prof. Name

Date

Male Genitourinary SOAP Note Form

Subjective

Chief Complaint
What symptoms is the patient experiencing?
The patient presents with progressively worsening lower urinary tract symptoms over the last two months. He describes difficulty starting urination, followed by ongoing dribbling after voiding. Additionally, he experiences nocturia, waking three to four times nightly to urinate, despite efforts to reduce evening fluid and caffeine intake.

Does the patient report any changes in urine characteristics or pain?
He denies experiencing pain during urination (dysuria), blood in urine (hematuria), changes in urine color or smell, or any urethral discharge. There are no reports of suprapubic or flank pain, which suggests no acute infection or kidney involvement.

History of Present Illness
What is known about the patient’s current condition?
The patient recalls a prior diagnosis of an enlarged prostate from a healthcare professional. His symptoms have become more severe recently, negatively affecting his sleep and overall well-being. He has no history of urinary retention, catheter use, or prostate surgeries.

Review of Systems
What additional symptoms or complaints are present?

System	Symptoms/Findings
General	Denies fever, fatigue, weight loss; appears in no acute distress.
HEENT	No visual, auditory, nasal, throat, or swallowing complaints.
Cardiac	No chest pain, palpitations, or arrhythmia history.
Pulmonary	No shortness of breath, cough, wheezing, or infections.
Gastrointestinal	No abdominal pain, nausea, vomiting, diarrhea, or bowel changes.
Genitourinary	Reports increased urinary hesitancy, nocturia, and post-void dribbling; denies pain or bleeding.
Musculoskeletal	Denies swelling or weakness; has chronic osteoarthritis discomfort.
Skin	No rashes, itching, or lesions.
Breast	No pain, tenderness, or masses.
Neurologic	No dizziness, numbness, headaches, or loss of consciousness.
Psychiatric	No anxiety or depression; mild situational sadness after job loss, now resolved.
Endocrine	No intolerance to heat/cold, excessive thirst, or unrelated urination issues.
Hematologic	No easy bruising or bleeding.

Allergies and Immunizations
Does the patient have any allergies?
The patient reports no known drug allergies (NKDA).

What immunizations has the patient received?

Vaccine	Date Administered
DTaP	01/01/2015
PCV 13	01/01/2010
PPSV 23	01/01/2011
Influenza	01/01/2019, 01/01/2020

Screenings
When was the last colonoscopy performed?
A screening colonoscopy was done on 01/01/2018 without any complications or abnormal findings.

Medications and Supplements
What medications and supplements is the patient currently taking?

Medication	Dose and Frequency
Lisinopril	20 mg orally once daily
Simvastatin	20 mg orally once daily
Acetaminophen (OTC)	As needed for pain

Supplement	Purpose
Turmeric	To reduce joint inflammation
Chondroitin	Supports joint health and arthritis

Past Medical and Surgical History
What previous medical conditions and surgeries does the patient have?

Condition	Details
Hypertension	Chronic, managed medically
Hypercholesterolemia	Managed with statins
Osteoarthritis	Multiple joints affected

Surgery	Date
Knee Arthroplasty	1998

Family and Social History
What is relevant in the family medical history?

Family Member	Health Conditions	Status
Mother	Hypertension, Breast Cancer	Alive
Father	Hypertension	Alive
Grandparents	Unknown	—

What are the patient’s lifestyle habits?
The patient is married and retired from a long career as a high school teacher. He has never smoked and denies alcohol or illicit drug use. Physical activity is inconsistent, possibly contributing to his elevated BMI and chronic joint pain.

Objective

Physical Examination

Parameter	Measurement/Findings
Blood Pressure	134/82 mmHg
Heart Rate	88 beats per minute
Respiratory Rate	18 breaths per minute
Temperature	97.9°F
Height	5’11”
Weight	92.1 kg (203 lbs)
BMI	28.3 kg/m²

General Appearance
The patient appears well-nourished and developed, with good hygiene and no acute distress.

Skin
Skin integrity is intact with normal turgor; no rashes or discolorations observed.

Head, Eyes, Ears, Nose, Throat (HEENT)
Head is normal shape without trauma. Eyes show clear sclerae and reactive pupils. Ear canals and tympanic membranes are normal. Nasal septum is centered without discharge. Oral mucosa is moist and healthy; throat is clear without redness or exudate.

Neck
The trachea is midline. The thyroid gland is symmetrical, non-tender, and without nodules.

Cardiovascular
Heart sounds S1 and S2 are normal and rhythmic; no murmurs or abnormal sounds detected.

Pulmonary
Symmetric chest expansion. Lungs are clear without wheezes or crackles.

Gastrointestinal
Abdomen is soft and non-tender, with active bowel sounds. No masses or organ enlargement palpated.

Genitourinary
External genitalia have normal hair distribution, with no lesions or discharge. Epididymis is non-tender, and the urethral meatus is midline. A redundant type IV prepuce extends beyond the glans. The scrotum is intact; testes are descended, smooth, and without masses. Cremasteric reflex is intact. No hernias are present.

Rectal examination shows normal anatomy and good sphincter tone. Stool is normal. The prostate is enlarged (approximately 3 cm), smooth, symmetrical, rubbery, mildly boggy, mobile, and non-tender—consistent with benign prostatic hyperplasia.

Extremities
No deformities, swelling, or vascular abnormalities. The patient walks independently without weakness.

Neurological
The patient is alert, oriented, and demonstrates appropriate mood and affect.

Procedure Note
The male genitourinary examination was performed with proper preparation and verbal consent. A male chaperone was present throughout. Inspection and palpation included the pubic region, penis, scrotum, testes, epididymis, and urethra. The cremasteric reflex was assessed, and the inguinal and femoral areas were checked for hernias. A digital rectal exam with prostate assessment was completed without incident.

References

American Urological Association. (2021). Benign prostatic hyperplasia (BPH) guidelines.

National Institute of Diabetes and Digestive and Kidney Diseases. (2023). Prostate enlargement. https://www.niddk.nih.gov/health-information/urologic-diseases/prostate-enlargement

D117 Task 3 Male Genitourinary SOAP Note

Wein, A. J., Kavoussi, L. R., Partin, A. W., & Peters, C. A. (Eds.). (2020). Campbell-Walsh urology (12th ed.). Elsevier.