Running Head: SOAP NOTE #7 1
PROSTATITIS
SOAP NOTE #7 – Month 9
Author’s Name
Course name
Instructor’s Name
Date
, PROSTATITIS 2
PROSTATITIS
CHIEF COMPLAINT (CC): “I have slight distress in my lower belly and I experience burning
sensation when urinate. At present I am facing problems related to fever.”
HISTORY OF PRESENT ILLNESS (HPI): A.R. is a polite, 39-year-old Caucasian male who
appeared to the clinic today (16/09/24) for symptoms of discomfort in his lower abdomen and
back and pain when peeing for the previous two days ago after a 20-mile bicycle ride in the hot
and humid weather. He had taken Acetaminophen and hydrated with cranberry juice and
Gatorade but symptoms increased and today felt chilly then broke out in a sweat. He tested his
temperature by mouth and it indicated 102 °. Pain in lower abdomen and lumbar region of his
back stated to be a dull pain on a scale of 5 out of 10, with no radiation and not alleviated with
OTC analgesics, Acetaminophen. He discloses no history of recent catheterizations or
operations, UTI’s, STI or HIV infection. His last sexual contact (vaginal) occurred with his wife
one week ago. He denies anal intercourse. He describes being in a monogamous relationship for
14 years or more.
MEDICAL HX (PMH): Occasional allergies, bilateral knee osteoarthritis (OA).
PAST SURGICAL HISTORY: Right Leg Knee Arthroscopy, August 2018.
Social History: He is an ardent biker and works full-time as a Pharmaceutical Representative for
Johnson & Johnson. He has been in a monogamous relationship with his wife, Tina, for 12 years.
They are currently married for the last 8 years and have 2 children, ages, 3 years old and 6 years
old. Denies any tobacco history. He drinks a few beers every week, 2-3 and sometimes more at
social situations. He denies the use of any illicit drug.
Medications: Allegra 60 mg for occasional allergies.
Immunizations: Up to date on all vaccines, including Tetanus (administered in
PROSTATITIS
SOAP NOTE #7 – Month 9
Author’s Name
Course name
Instructor’s Name
Date
, PROSTATITIS 2
PROSTATITIS
CHIEF COMPLAINT (CC): “I have slight distress in my lower belly and I experience burning
sensation when urinate. At present I am facing problems related to fever.”
HISTORY OF PRESENT ILLNESS (HPI): A.R. is a polite, 39-year-old Caucasian male who
appeared to the clinic today (16/09/24) for symptoms of discomfort in his lower abdomen and
back and pain when peeing for the previous two days ago after a 20-mile bicycle ride in the hot
and humid weather. He had taken Acetaminophen and hydrated with cranberry juice and
Gatorade but symptoms increased and today felt chilly then broke out in a sweat. He tested his
temperature by mouth and it indicated 102 °. Pain in lower abdomen and lumbar region of his
back stated to be a dull pain on a scale of 5 out of 10, with no radiation and not alleviated with
OTC analgesics, Acetaminophen. He discloses no history of recent catheterizations or
operations, UTI’s, STI or HIV infection. His last sexual contact (vaginal) occurred with his wife
one week ago. He denies anal intercourse. He describes being in a monogamous relationship for
14 years or more.
MEDICAL HX (PMH): Occasional allergies, bilateral knee osteoarthritis (OA).
PAST SURGICAL HISTORY: Right Leg Knee Arthroscopy, August 2018.
Social History: He is an ardent biker and works full-time as a Pharmaceutical Representative for
Johnson & Johnson. He has been in a monogamous relationship with his wife, Tina, for 12 years.
They are currently married for the last 8 years and have 2 children, ages, 3 years old and 6 years
old. Denies any tobacco history. He drinks a few beers every week, 2-3 and sometimes more at
social situations. He denies the use of any illicit drug.
Medications: Allegra 60 mg for occasional allergies.
Immunizations: Up to date on all vaccines, including Tetanus (administered in
