D117 Task 3 Male Genitourinary SOAP Note

Grace J.
January 3, 2026January 3, 2026
D117, MSN, Western Governors University

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 reports progressive lower urinary tract symptoms characterized by difficulty initiating urination and persistent dribbling following voiding. These symptoms have gradually intensified over the past two months. He also reports nocturia, requiring him to awaken approximately three to four times each night to urinate, despite conscious efforts to limit fluid and caffeine consumption in the evening.

Does the patient report any changes in urine characteristics or pain?
The patient denies dysuria, hematuria, changes in urine color or odor, and urethral discharge. He does not report suprapubic pain or flank discomfort, suggesting the absence of acute urinary tract infection or renal involvement.

History of Present Illness

What is known about the patient’s current condition?
The patient states that he has previously been informed by a healthcare provider that he has an enlarged prostate. He notes that his urinary symptoms have become more noticeable recently, impacting sleep quality and overall comfort. There is no history of urinary retention, catheterization, or prior prostate-related surgical interventions.

Review of Systems

What other symptoms or complaints does the patient have?

System	Symptoms/Findings
General	Denies fever, fatigue, or unintended weight loss; no acute distress noted.
HEENT	Denies visual or auditory changes, nasal congestion, sore throat, dysphagia, or sinus pain.
Cardiac	Denies chest pain, palpitations, or history of arrhythmias.
Pulmonary	Denies dyspnea, cough, wheezing, or recent respiratory infections.
Gastrointestinal	Denies abdominal pain, nausea, vomiting, diarrhea, constipation, or changes in bowel habits.
Genitourinary	Reports worsening urinary hesitancy, nocturia, and post-void dribbling; denies dysuria, hematuria, or discharge.
Musculoskeletal	Denies joint swelling or muscle weakness; reports chronic joint discomfort related to osteoarthritis.
Skin	Denies rashes, pruritus, lesions, or abnormal pigmentation.
Breast	Denies pain, tenderness, or palpable masses.
Neurologic	Denies dizziness, numbness, tingling, headaches, or loss of consciousness.
Psychiatric	Denies anxiety or depression; reports brief situational sadness following job loss, now resolved.
Endocrine	Denies heat or cold intolerance, excessive thirst, or polyuria unrelated to urinary symptoms.
Hematologic	Denies easy bruising or bleeding tendencies.

Allergies and Immunizations

Does the patient have any known 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?
The patient underwent a screening colonoscopy on 01/01/2018, with no reported complications or abnormal findings.

Medications and Supplements

What medications and supplements does the patient use?

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	Joint inflammation and arthritis support
Chondroitin	Joint health and osteoarthritis management

Past Medical and Surgical History

What medical conditions and surgeries has the patient experienced?

Condition	Details
Hypertension	Chronic, medically managed
Hypercholesterolemia	Chronic, managed with statin therapy
Osteoarthritis	Affects multiple joints

Surgery	Date
Knee Arthroplasty	1998

Family and Social History

What is the family history relevant to this patient?

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

What about the patient’s lifestyle and habits?
The patient is married and retired after a long career as a high school teacher. He has never smoked and denies alcohol or illicit drug use. Physical activity is reported as inconsistent, which may contribute to his elevated BMI and chronic joint discomfort.

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 well-developed, with appropriate hygiene and no signs of acute distress.

Skin

Skin is intact with normal turgor; no rashes, lesions, or discoloration observed.

Head, Eyes, Ears, Nose, Throat (HEENT)

Head is normocephalic and atraumatic. Sclerae are white without conjunctival injection. Pupils are equal, round, and reactive to light and accommodation. Tympanic membranes are intact and pearly gray bilaterally. Nasal septum is midline without discharge. Oral mucosa is moist, dentition is clean, and oropharynx is clear without erythema or exudate.

Neck

Trachea is midline. Thyroid gland is symmetrical, non-tender, and without palpable nodules or enlargement.

Cardiovascular

Heart sounds S1 and S2 are present with regular rate and rhythm. No murmurs, rubs, or gallops auscultated.

Pulmonary

Thoracic expansion is symmetric. Lung fields are clear to auscultation bilaterally with no adventitious sounds.

Gastrointestinal

Abdomen is soft, non-tender, and non-distended with active bowel sounds in all quadrants. No hepatosplenomegaly or palpable masses detected.

Genitourinary

External genitalia demonstrate normal male hair distribution without lesions, erythema, or discharge. Epididymis is non-tender. Urethral meatus is midline. A redundant type IV prepuce is noted, extending beyond the glans. Scrotum is intact without discoloration; testes are descended bilaterally, smooth, and without masses. Cremasteric reflex is intact. No inguinal or femoral hernias are present.

Anal and rectal examination reveals normal external anatomy and intact sphincter tone. Stool appears normal. Prostate examination reveals an approximately 3 cm enlargement; the gland is smooth, symmetrical, rubbery, mildly boggy, mobile, and non-tender—findings consistent with benign prostatic hyperplasia.

Extremities

No deformities, edema, cyanosis, or varicosities noted. The patient ambulates independently without weakness.

Neurological

The patient is alert and oriented to person, place, and time. Mood and affect are appropriate.

Procedure Note

The male genitourinary examination was conducted following appropriate patient preparation and verbal consent. A male chaperone was present throughout the examination. Inspection and palpation included the pubic region, penis, scrotum, testes, epididymis, and urethra. The cremasteric reflex was assessed, and inguinal and femoral regions were examined for hernias. A digital rectal examination, including prostate assessment, was completed without complications.