Benign prostatic hyperplasia.



SOAP NOTE

Name:

Date:

Time:

Age:

Sex:

SUBJECTIVE

CC:

Reason given by the patient for seeking medical care “in quotes”

The patient chief complaint is the disease Benign prostatic hyperplasia. This is because pf the major effects it has on the reproductive system thus having a needed for checking medical care due to its major effects to general body health.

HPI:

Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness.

The case of the patient illness disease maybe be due to several issues that include having kidney stones disease history, urinary tract infections, prostatitis issue, cancer disease of the bladder or even prostate and many more. This must have begun some few months ago before it happens to be having more adverse condition effects. Some of the symptoms include having difficulties in starting urination, urgent urination and inabilities to urinate due to the UTI problem. Other symptoms include inabilities on emptying bladder, blood in the urine, having dribbling kind of thing during end of urination and many more. The location at which the symptoms begins is on the urethra, the bladder, on the prostate, and even the kidney. The alleviating factors of this disease include the dietary factors such as having red meat intake, heart and the circulatory system disease, diabetes and more specific the type II diabetes, obesity related issues and the family history or the hereditary related issues. Some of the pertinent negatives include having the recurrent UTIs, increased urinary retention and also suffering from renal insufficiency. Some of the related illness of the chief complaint disease include having the kidney issues, urinary tract problems, bladder infection and malfunctioning, having chronic urinary retention and many more. Some of the past illness that might be contributing to the disease is the UTI and the kidney related infections/issues and many more. The pats diagnostic testing for this patient might include having the prostate gland assessment, urinary tract, bladder and the kidney functioning testing and many more.

Medications: (list with reason for med )

The medication to be used would include the alpha blocker such as the doxazosin, tamsulosin, alfuzosin etc., which help on relaxing the muscles located in the prostate and the bladder and thus easing excretory processes. There can also be used the 5-Alpha Reductase Inhibitors which helps the body of reducing the effect of increasing prostate through the help of hormones and thus having the urine flow improved and also reducing of other symptoms of BHP. The Phosphodiesterase-5 inhibitors are another type of medicine which would be used whereby it helps on reducing the erectile dysfunction issues, help easing the BHP symptoms and also the smoothening of the prostate and the bladder muscles.

PMH

Allergies:

Some of the allergies the patient has include the allergies to drugs, allergies to sensation that is why there is difficulty in breathing.

Medication Intolerances:

There are no medical intolerances which has been recorded.

Chronic Illnesses/Major traumas

The major chronic illness includes having the cardiovascular system disease, cancer of the prostate and the urinary tract infections.

Hospitalizations/Surgeries

The hospitalization for the disease may include having UTI control by the use of the drugs given by the healthcare profession, having the hospitalization of the kidney or balder related issues, and many more.

“Have you ever been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.”

For the disease which has been stated the patient has ever been told of having kidney disease which might contribute to the infection which the patent is suffering from BHP.

Family History Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with:

lung disease, heart disease, htn, cancer, TB, DM, or kidney disease.

From the information provided the patent family has got a history of suffering from the disease whereby this might be contributing factor to his sickness due to the gene factor.

66hSocial History

Education level, occupational history, current living situation/partner/marital status, substance use/abuse,

ETOH, tobacco, marijuana. Safety status

The patient is highly discouraged form having tobacco intake as it is contributing to the risk of cancer attack which can affect the male reproductive system. Also, the safety status has to be taken by having regular prostate screening and examination thus able to identify any abnormality in the organs and also any disease that might be developing.

ROS

General

Weight change, fatigue, fever, chills, night sweats, energy level

Cardiovascular

Chest pain, palpitations, PND, orthopnea, edema

Skin

Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles

Respiratory

Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB

Eyes

Corrective lenses, blurring, visual changes of any kind

Gastrointestinal

Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools

Ears

Ear pain, hearing loss, ringing in ears, discharge

Genitourinary/Gynecological

Urgency, frequency burning, change in color of urine.

Contraception, sexual activity, STDS Fe: last pap, breast, mammo, menstrual complaints, vaginal discharge, pregnancy hx

Male: prostate, PSA, urinary complaints

Nose/Mouth/Throat

Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain

Musculoskeletal

Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis

Breast

SBE, lumps, bumps or changes

Neurological

Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells

Heme/Lymph/Endo

HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance

Psychiatric

Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx

OBJECTIVE

Weight BMI

Temp

BP

Height

Pulse

Resp

General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later.

Skin

Skin is brown, warm, dry, clean and intact. No rashes or lesions noted.

HEENT

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation.

Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules.

Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair.

Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.

Breast

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.

Genitourinary

Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT.

Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable.

(Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. )

(Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm).

Musculoskeletal

Full ROM seen in all 4 extremities as patient moved about the exam room.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.

Lab Tests

Urinalysis – pending

Urine culture – pending

Wet prep – pending

Special Tests

Diagnosis

Differential Diagnoses

1- cancer disease 2- o urinary tract infections

3-

Diagnosis of cardiovascular system

Plan/Therapeutics

o Plan:

· Further testing

There needs to be done urine samples thus able to identify any issues which might be related to the kidney, prostate and the bladder. In that case urinalysis would be a better testing option.

· Medication

The medication option for this patient would include having the combination of drug therapy, have the sue fop the alpha blockers, the 5-alpha reductase inhibitors and many more

· Education

Patient education for this case would be having a healthy lifestyle living procedures such as diets, having body exercises and many more. There also needs the avoidance of alcohol and smoking, avoiding caffeine and not drinking fluids during the bedtimes and also avoiding the intake of the antihistamines and decongestants at all.

· Non-medication treatments

The non-medication treatments would include having the pygeum, foods consideration, taking stinging nettle meals, use of beta-sistosterol and many more.

Evaluation of patient encounter

The patient evaluation would involve having the using of the questionnaire which has been validated thus helping on quantifying the various symptoms that the patient might be showing. There can also be used the digital rectal examination and also having the urinalysis processes test being done thus helping on screening the various urologic disorders which the patient might be having.

References

Free, A. H., & Free, H. M. (2018). Routine urinalysis. Urinalysis in Clinical Laboratory Practice, 205-210. https://doi.org/10.1201/9781351077460-36

Koshiba, K., Miki, M., Terachi, T., & Uchida, T. (2019). Treatment of benign prostatic hyperplasia. Springer Science & Business Media.

Mitchel, L. (2020). Benign prostatic hyperplasia: Clinical urology.

Stones, S. A. (2021). The fundamental guide to urinary tract infection: A handy guide on the causes and treatment of UTI. Independently Published.

Thiruchelvam, N. (2017). Benign prostatic hyperplasia. Oxford Medicine Online. https://doi.org/10.1093/med/9780199659579.003.0057


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