Week 2- SOAP Note and Case Presentation

CC: Erectile dysfunction

S) HPI: SC is a 75-year old male presents to the clinic with erectile dysfunction. The patient came to the clinic
today to address his erectile dysfunction. He states that he used to take Viagra but it does not seem to be
working any longer. The last 3 times he tried Viagra he was not successful at getting an erection. Last used this
weekend. He is allergic to aspirin, as it gives him swelling and mass lump in his head and neck.
PMH: Hx of DM2, HTN, Asthma, Gastritis, Chronic kidney disease- stage 3, essential tremor, hyperlipidemia,
male erection dysfunction, sleep apnea. Past surgeries include vasectomy and cataract extraction.
Meds:
 Advair Diskus 250mcg/50mcg powder; inhalation 1 puff twice daily
 Lipitor 10mg 1 tablet PO daily
 Lisinopril 10mg- 1 tablet PO daily
 Refresh solution; 1-2 drops in the affected eyes as needed
 Levocetirizine 5mg 1 tablet PO at bedtime
 Amlodipine 5mg 1 tablet daily
 Januvia 25mg 1 tablet daily
 Omeprazole 20mg 1 capsule daily
 Uloric 40mg 1 tablet daily
 Patanol 0.1% ophthalmic solution 1 drop on the affected eyes 2x a day 6-8hours apart
FH: Both parents are deceased. Has no siblings. Family history of lung cancer, asthma, arthritis and HTN.
SH: Married, has children. Enjoys playing golf. Former smoker. Stopped smoking about 20 years ago.
ROS: Gen: No recent wt loss or wt gain; no change in general level of energy. Denies fatigue and fever.
HEENT: denies dizziness, headache, pain in throat, runny nose, dry eyes
Neck: denies neck stiffness or enlarged lymph nodes.
Resp: hx of asthma, no SOB, cough or wheezing now.
Cardiac: denies chest pain or palpitations.
GI: denies n/v, heartburn, constipation, diarrhea or blood in stools
GU: reports impotence, denies burning on pain on urination, or frequent urination.
Skin: denies rash or open wounds
Musk: denies stiffness, joint immobility or pain

O) V/S: BP 117/73 HR 67 RR 18 HT 65.0 inch WT 165.8lb BMI 27.6

HEENT: PEERLA, pink conjunctiva, TMs intact bilaterally, mucous membranes are pink and moist.
Neck: midline, no palpable lymph nodes
Resp: Lungs clear to auscultation bilaterally
Cardiac: regular rate, rhythm
GI: abdomen soft and non-tender, normal bowel sounds
GU: bladder non-tender, scrotum without lesions/ cysts/ masses, testes symmetrical and normal in size
without masses, urethral meatus is normal in size without lesions or discharge, penis without lesions
masses or scarring.
Skin: no edema or cyanosis, no rashes
Musk: ROM, motor and sensory WNL
Psych: Mood and affect appropriate for situation
Neuro: CN I-XII WNL

A) Erectile dysfunction

P) Dx: male erection dysfunction

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 Rx: Cialis 10mg 1 tablet PO PRN before sexual activity. Do not exceed 20mg in a 24-hour period.
Pt. Ed: Cialis may be taken with or without food. Drinking alcohol after taking Cialis may lower BP and
decrease sexual performance. Eating grapefruit or grapefruit products while taking Cialis is not
recommended. Call your PCP immediately if you experience dizziness or feel nauseous during sexual
activity, or develop pain, numbness, tingling in your chest, arms, neck, or jaw. Certain lifestyle and
psychological factors, such as smoking, drinking, and stress, can impact on ED. Taking Cialis does not
protect you from sexually transmitted diseases.
F/U: RTC if Cialis does not help with Erectile Dysfunction. Seek urgent medical advice if an allergic
reaction, sudden vision loss or painful erections lasting more than four hours occur.

Oral Case Presentation:

SC is a 75-year old male presents to the clinic with erectile dysfunction. The patient came to the clinic today to
address his erectile dysfunction. He states that he used to take Viagra but it does not seem to be working any
longer. The last 3 times he tried Viagra he was not successful at getting an erection. Last used this weekend. He
is allergic to aspirin, as it gives him swelling and mass lump in his head and neck. Has a history of DM2, HTN,
Asthma, Gastritis, Chronic kidney disease- stage 3, essential tremor, hyperlipidemia, male erection dysfunction,
sleep apnea. Past surgeries include vasectomy and cataract extraction. He takes multiple medications for all his
conditions, including Advair inhaler, Lipitor, Lisinopril, Amlodipine, Januvia, Omeprazole and Patanol. He is also
a former smoker whom stopped smoking about 20 years ago. Vitals are WNL BP 117/73 HR 67 RR 18 HT
65.0-inch WT 165.8lb BMI 27.6- overweight. His physical assessment was WNL, no finding noted. Based on
my assessment, my diagnosis is Male Erection dysfunction. For which I will prescribe Cialis 10mg 1 tablet PO
PRN before sexual activity, not to exceed 20mg in a 24-hour period. I’d educate the patient to ensure that Cialis
may be taken with or without food. Drinking alcohol after taking Cialis may lower BP and decrease sexual
performance. Eating grapefruit or grapefruit products while taking Cialis is not recommended. Call your PCP
immediately if you experience dizziness or feel nauseous during sexual activity, or develop pain, numbness,
tingling in your chest, arms, neck, or jaw. Certain lifestyle and psychological factors, such as smoking, drinking,
and stress, can impact on ED. Taking Cialis does not protect you from sexually transmitted diseases. The patient
shall return to clinic if Cialis does not help with Erectile Dysfunction. Seek urgent medical advice if an allergic
reaction, sudden vision loss or painful erections lasting more than four hours occur.

This study source was downloaded by 100000885835965 from CourseHero.com on 06-04-2024 14:24:25 GMT -05:00

https://www.coursehero.com/file/59810762/Week-2-SOAP-Note-and-Case-Presentationdocx/
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