Urinary Retention SOAP Note Medical Transcription Sample Report
CHIEF COMPLAINT: Urinary retention.
SUBJECTIVE: The patient is a (XX)-year-old gentleman who presented approximately a week ago in urinary retention. He, at that time, had a Foley catheter placed and was discharged to home with the Foley bag to gravity drainage. He returns today for a voiding trial and was found to have a postvoid residual of approximately 830 mL. The patient has had a prior episode of urinary retention in the past, approximately four years ago, and was placed on Cardura at that time.
In addition, the patient states that his PSA, approximately four years ago, was in the level of around 4 or so; however, the patient never had his PSA followed up. He does report that he, in addition, has some difficulty with his urinary stream. He has nocturia approximately only one time per night and he does have occasional incontinence on doing heavy activity or stressful work. The patient denies any urinary tract infection or gross hematuria. His prior episode of urinary retention, four years ago, involved nearly 48 hours without voiding. Actually, the patient did have a prostate biopsy approximately four years ago, which was reportedly negative.
PAST MEDICAL HISTORY: The patient’s past medical history is remarkable for smoking and reactive airways disease requiring an inhaler. The patient has had a right inguinal hernia repair.
MEDICATIONS: Include generic Cardura 8 mg p.o. daily as well as albuterol inhaler, which he uses daily.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Remarkable for approximately anywhere from 2-4 drinks per day as well as approximately one-half pack per day. He has over a 40-pack-year history of smoking.
FAMILY HISTORY: No significant family history.
OBJECTIVE: On physical exam, he is a pleasant male in no acute distress. Lungs are clear. Heart is regular. Abdomen is soft, nontender and nondistended. He has a well-healed scar in the right groin. His GU exam reveals a circumcised phallus, which is unremarkable. He has bilateral descended testicles, which are also unremarkable and no palpable masses and they are nontender. Rectal exam reveals a 2-3+ prostate.
ASSESSMENT AND PLAN: This is a (XX)-year-old gentleman with a history of urinary retention and benign prostatic hypertrophy who now presents with a failed voiding trial. The plan is to discharge this patient to home again with the Foley catheter, which will remain indwelling until the time of his surgery. He will be, today, scheduled for a TURP since his benign prostatic hypertrophy has resulted in urinary retention refractory to medical therapy. His urinalysis and urine culture, which were checked when he had his Foley catheter placed, were negative. He will, today, undergo a PSA test as well as any preoperative blood work that may be required. He will return and we will see him in the next several weeks for his operation.
