Week 8 Soap Note
Sarah Sanchez
South University Online
Dr. Logsdon
NSG 6440
June 16, 2021
, SOAP NOTE
Name: W.Q Date: 06/10/21 Time: 1500
Age: 60 Sex: Male
SUBJECTIVE
CC: “annual”
HPI:
W.Q. is a 60-year-old, male, white patient. He is present today for his annual visit. He
reports difficulty when starting urine, decreased force, hesitancy, and dribbling after
voiding. He is also having trouble stop urine once started, along with urinary retention
and voiding multiple times. He has noticed increased urine at night. This has been
occurring for the past three months. The patient has a significant history for type 2
diabetes, hyperlipidemia, restless leg syndrome, essential hypertension, GERD. Chronic
diseases are management with medication, patient is at goal for chronic illness. He denies
painful discharge, dysuria, or pain.
Colonoscopy completed 6/2/21 WNL
Medications
Metformin 500mg po BID daily
Simvastatin 20mg po daily
Requip 2mg po at bedtime.
PMH
Allergies: N.K.D.A., denies food allergies
Medication Intolerances: Denies
Sarah Sanchez
South University Online
Dr. Logsdon
NSG 6440
June 16, 2021
, SOAP NOTE
Name: W.Q Date: 06/10/21 Time: 1500
Age: 60 Sex: Male
SUBJECTIVE
CC: “annual”
HPI:
W.Q. is a 60-year-old, male, white patient. He is present today for his annual visit. He
reports difficulty when starting urine, decreased force, hesitancy, and dribbling after
voiding. He is also having trouble stop urine once started, along with urinary retention
and voiding multiple times. He has noticed increased urine at night. This has been
occurring for the past three months. The patient has a significant history for type 2
diabetes, hyperlipidemia, restless leg syndrome, essential hypertension, GERD. Chronic
diseases are management with medication, patient is at goal for chronic illness. He denies
painful discharge, dysuria, or pain.
Colonoscopy completed 6/2/21 WNL
Medications
Metformin 500mg po BID daily
Simvastatin 20mg po daily
Requip 2mg po at bedtime.
PMH
Allergies: N.K.D.A., denies food allergies
Medication Intolerances: Denies
