Up Four Times a Night and a Cold Pill in the Cabinet: An Episodic SOAP Note for Lower Urinary Tract Symptoms in a 68-Year-Old Man, Scored, Examined and Planned
[Student Name]
University of Phoenix
NRP/531: Advanced Health Assessment I
Week 7 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Subjective
Chief concern: "I'm up four times a night to pee."
History of present illness: Mr. R., a 68-year-old retired postal carrier, reports two years of gradually worsening urinary symptoms: a weak stream, hesitancy, a feeling of incomplete emptying and frequency every two hours during the day. Nocturia has increased from twice to four times nightly over the past three weeks, since he started a nonprescription cold and sinus tablet containing pseudoephedrine and chlorpheniramine for congestion. No dysuria, hematuria, fever, flank pain or back pain. No incontinence. He drinks two cups of coffee in the morning and a beer with dinner. International Prostate Symptom Score: 21 of 35. Quality of life score: 5, "unhappy."
Past medical history: hypertension, hyperlipidemia. No prior urological evaluation.
Medications: amlodipine 5 mg daily, atorvastatin 20 mg daily, the cold tablet twice daily for three weeks.
Allergies: none.
Family history: father had prostate cancer diagnosed at 78.
Social history: married, nonsmoker, walks daily.
Review of systems: no weight loss, bone pain, leg weakness or bowel changes.
Objective
Vital signs: blood pressure 142/84 mm Hg, pulse 76, temperature 36.8 °C, BMI 28.
Abdomen: soft, nontender; no suprapubic distension or dullness to percussion over the bladder.
Genitourinary: normal external genitalia, no meatal stenosis.
Digital rectal examination: normal sphincter tone; prostate symmetrically enlarged, estimated 40 g, smooth, rubbery, nontender, no nodules or induration.
Neurological: normal lower extremity strength, sensation and reflexes.
Urinalysis: negative for blood, leukocytes, nitrites, glucose and protein.
Bladder scan after voiding: 110 mL remaining.
Assessment
Lower urinary tract symptoms, severe by symptom score, attributed to benign prostatic hyperplasia, worsened by pseudoephedrine and chlorpheniramine. No signs of urinary retention, infection or neurological cause. Prostate cancer risk discussion indicated given family history.
Plan
Stop the cold tablet; use saline nasal irrigation and an intranasal corticosteroid for congestion. Reduce evening fluids and alcohol, and limit caffeine after noon. Start tamsulosin 0.4 mg nightly, with counseling about dizziness on standing and about informing eye surgeons before cataract surgery. Discussion of prostate-specific antigen testing: benefits, harms and his preferences; he chooses to be tested. Serum creatinine. Repeat the symptom score and post-void residual in six weeks.
The prostate had been growing for years; the cold tablet explained why the nights had changed in three weeks.
Why the Symptom Score
Barry et al. (1992) developed and validated the American Urological Association symptom index, which scores seven urinary symptoms, and showed it was reliable, valid and responsive to change. The International Prostate Symptom Score adds a quality of life question. Scores of 0 to 7 are mild, 8 to 19 moderate and 20 to 35 severe. Mr. R.'s score of 21 is severe, and repeating it after treatment will show whether the plan works.
Why Ask About Over-the-Counter Medicines
Pseudoephedrine stimulates alpha-adrenergic receptors in the bladder neck and prostate, increasing outlet resistance. Chlorpheniramine, a first-generation antihistamine, has anticholinergic effects that weaken bladder contraction. Together they can worsen obstruction and precipitate retention in a man with an enlarged prostate. The recent jump in nocturia aligns with starting the tablet. Age adds to the risk, since older adults are more sensitive to the effects of many drugs, including anticholinergic ones, and clear some of them more slowly (Mangoni & Jackson, 2004).
The Initial Evaluation
The American Urological Association guideline calls for a history, an examination that includes the rectal examination, a urinalysis and a validated symptom score when a man first presents with bothersome urinary symptoms from prostate enlargement, with post-void residual measurement and prostate-specific antigen testing considered in selected patients (Lerner et al., 2021). The urinalysis screens for infection and blood that would require other evaluation.
Why the Rectal Examination Findings Matter
A smooth, symmetric, rubbery gland suggests benign enlargement; a hard nodule or asymmetry would raise concern for cancer and prompt referral. The size estimate guides treatment, since 5-alpha reductase inhibitors are more effective in larger glands.
Why Tamsulosin
By relaxing the muscle tone of the prostatic urethra and bladder outlet, alpha blockers ease outflow, and the guideline lists them among first-line drugs for bothersome symptoms (Lerner et al., 2021). Tamsulosin is selective for receptors in the prostate and causes less blood pressure lowering than older alpha blockers, although dizziness on standing remains possible, particularly with his amlodipine. A 5-alpha reductase inhibitor could be added later if the prostate is large and symptoms persist.
Prostate-Specific Antigen Testing
Testing is a shared decision because it can find cancers that would never cause harm and lead to biopsies and treatment with side effects, while finding some cancers early. His father's diagnosis raises his risk somewhat. After discussion, he chose testing, and the note documents the conversation.
Why the Bladder Scan
A post-void residual volume helps judge how well the bladder empties. Mr. R.'s 110 mL shows incomplete emptying but not retention. A much larger volume, often several hundred milliliters, would raise concern about chronic retention, back pressure on the kidneys and the safety of drugs such as anticholinergics, and would prompt urological referral. The serum creatinine checks for kidney effects of long-standing obstruction.
Nocturia Has More Than One Cause
Nocturia may reflect not only the prostate but also nighttime urine production, which can rise with evening fluids and alcohol, sleep apnea, heart failure or poorly controlled diabetes. A frequency-volume chart for three days, recording each void's time and volume, would show whether he produces a large share of his urine at night. If so, reducing evening fluids and screening for sleep apnea would matter as much as the alpha blocker. I will ask him to complete the chart before the follow-up visit.
Reviewing His Other Medications
Amlodipine, his blood pressure drug, can cause ankle swelling that shifts fluid back into the circulation when he lies down, adding to nighttime urine. If nocturia persists despite treatment, a change in his antihypertensive could be considered. Combining tamsulosin with amlodipine also increases the chance of lightheadedness on standing, so I advised him to rise slowly at night.
Safety Net
He should seek care urgently for inability to urinate, fever with urinary symptoms or blood in the urine.
Follow-Up Plan
At six weeks, a fall in his symptom score of three points or more would suggest a meaningful response. If symptoms persist, options include adding a 5-alpha reductase inhibitor, referral for urodynamic testing or discussion of procedures. He will bring his frequency-volume chart and a week of home blood pressure readings to that visit, so that both his urinary and his cardiovascular plans can be reviewed together.
Conclusion
Mr. R.'s severe lower urinary tract symptoms, benign prostate examination, normal urinalysis and moderate post-void residual point to benign prostatic hyperplasia made worse by a decongestant and antihistamine. Stopping the cold tablet, adjusting fluids and starting tamsulosin address both causes, and repeating the validated symptom score will measure the response.
References
Barry, M. J., Fowler, F. J., Jr., O'Leary, M. P., Bruskewitz, R. C., Holtgrewe, H. L., Mebust, W. K., & Cockett, A. T. K. (1992). The American Urological Association symptom index for benign prostatic hyperplasia. Journal of Urology, 148(5), 1549-1557. https://doi.org/10.1016/S0022-5347(17)36966-5
Lerner, L. B., McVary, K. T., Barry, M. J., Bixler, B. R., Dahm, P., Das, A. K., Gandhi, M. C., Kaplan, S. A., Kohler, T. S., Martin, L., Parsons, J. K., Roehrborn, C. G., Stoffel, J. T., Welliver, C., & Wilt, T. J. (2021). Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline part I: Initial work-up and medical management. Journal of Urology, 206(4), 806-817. https://doi.org/10.1097/JU.0000000000002183
Mangoni, A. A., & Jackson, S. H. D. (2004). Age-related changes in pharmacokinetics and pharmacodynamics: Basic principles and practical applications. British Journal of Clinical Pharmacology, 57(1), 6-14. https://doi.org/10.1046/j.1365-2125.2003.02007.x
How this NRP 531 Week 7 example is structured
The NRP/531 Week 7 work usually asks for an episodic SOAP note from a patient visit scenario. This paper writes a complete note, then explains the reasoning behind the history questions, the examination, the assessment and each part of the plan, citing the guideline and the validated symptom index. Students search this week as NRP 531 Week 7, NRP531 Wk 7 or NRP/531 Wk 7; all three are the same assignment.
NRP/531 Week 7 questions, answered
What does NRP/531 Week 7 usually ask for?
Many sections ask students to write an episodic SOAP note from a visit scenario using a structured template, with a justified assessment and plan.
What is the International Prostate Symptom Score?
A validated questionnaire, developed from the American Urological Association symptom index, scoring seven urinary symptoms from 0 to 35 to grade severity as mild, moderate or severe, with a quality of life question.
Why ask about cold medicines in a man with urinary symptoms?
Decongestants and antihistamines can worsen urinary retention and obstructive symptoms by tightening the bladder neck or weakening bladder contraction.
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