Reference no: EM133657857
66 y/o African American male presents to your clinic for the first time for his health visit and reports he has been feeling fatigued lately which he attributes to waking up most nights to urinate.
He denies any fevers, chills, unexplained weight loss, SOB, polyuria, polydipsia, dysuria, hematuria, urethral discharge, urinary urgency , frequency, or incontinence. He denies taking any prescription or over-the-counter medications and denies any dietary, social, or environmental changes in his life since his last visit a year ago. He states he generally feels well, exercises 3 times a week for about 30 minutes a day , eats healthy organic foods as much as possible. He denies any known drug, food, or environmental allergies; drinks 1-2 beers per week since age 20 and an average of 3 cups of coffee a day. Denies any history of smoking cigarettes or marijuana or any illicit drug use.
He has been a body builder since his 30's and works out with weights about 3 x a week and walks about 2 miles most mornings with his husband. He and his husband have been in a monogamous sexual relationship since they got married. He reports it is the 1st marriage for both him and his husband. He engages in both insertive and receptive anal sex 2-3 a week. A screen for STIs prior to their marriage 10 years ago was negative for gonorrhea, chlamydia, syphilis, hepatitis B, hepatitis C and HIV. He reports his father died of prostate cancer at age 68.
Physical exam findings:
Vitals: T 37.0 C (98.6F), P =76; R -14, BP 122/80 mmHg, HT 183cm Wt 82 kg, BM = 24.5
General: Well-developed, well-nourished male in no acute distress
Abdomen: Bowel sounds normal, abdomen soft, non-tender, nondistended, no masses palpable
Genital/Rectal: Uncircumcised, no discharge/lesions, no scrotal or testicular masses; soft non-tender symmetrical boggy 2+ enlarged prostate; loss of median sulcus; no palpable prostate nodules.
Musculoskeletal: No tenderness, full range of motion on bilaterally upper and lower extremities
Discussion questions:
1. Based on the patient's chief complaint and HPI provided, what are the most significant 3-5 questions you need to ask and why?
2. Discuss what other systems you need to include in your physical exam?
3. Discuss and provide your rationale for the type of SOAP note that is needed based on the information in the HPI.