SOAP NOTE for Benign Prostate Hyperplasia

ID: Mr. J.A. is a 60-year-old Hispanic male who presents to the clinic today with a chief complaint of frequent urination for the last 30 days.

S:

CC: “Frequent Urination"

HPI: Mr. J.A. is a 60-year-old Hispanic male who presented to the clinic today with a chief complaint of frequent urination. He reports that this started approximately 30 days ago, but he never took it seriously until he saw visible blood clots in his urine. He further reports experiencing an inability to hold the urge to urinate and a regular difficulty to start urination. He describes the urination as a weak stream that is on and off and that he takes a significantly longer time urinating despite having an escalated urge to urinate. He denies being involved in an accident that may have affected his reproductive system or diagnosed with urinary tract infection (UTI). However, he reports that at the yearly physical last week, his PSA came back slightly elevated. He reports unintentional weight loss in 30 days. He denies chills, penile pain, fever, abdominal pain, fatigue, confusion, flank pain, cloudy urine, or masses.