Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for chronic bacterial prostatitis (CBP), evaluation of worsening symptoms, or medication management.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the severity, frequency, and location of current urinary symptoms:
Urinary frequency and urgency
Dysuria (burning with urination)
Incomplete bladder emptying
Nocturia (waking up at night to urinate)
Pelvic pain or perineal discomfort
Lower urinary tract symptoms (LUTS) suggestive of irritative voiding.
Ask about any recent changes in symptoms, sexual activity, or risk factors (new sexual partners, unprotected sex).
Inquire about response to previous treatments (antibiotics, lifestyle modifications).
Past Medical History:
Briefly summarize relevant past medical history, including:
Date of CBP diagnosis
Number of prior urinary tract infections (UTIs)
Previous antibiotic regimens and duration of treatment
Comorbid conditions that might influence treatment (e.g., urinary retention, neurologic conditions)
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Genital Exam (if indicated):
Perform a digital rectal exam (DRE) to assess for:
Prostate tenderness or enlargement
Boggy consistency (soft and fluctuant)
Note: DRE may be uncomfortable for the patient and should be performed with discretion.
Laboratory Tests (review recent results):
Urinalysis and Urine Culture:
Evaluate for signs of infection (leukocytes, nitrites) and confirm presence of bacteria on culture with appropriate sensitivity testing.
If negative, consider alternative diagnoses.
Prostatic Specific Antigen (PSA) (if indicated):
May be checked to rule out prostate cancer, although PSA levels can be elevated in prostatitis.
Assessment (A):
Severity of CBP:
Assess the severity of CBP based on symptom frequency, impact on quality of life, and response to treatment.
Treatment Response (if applicable):
Evaluate the response to previous antibiotic treatment based on symptom improvement and urine culture results.
Antibiotic Resistance (if applicable):
Consider the possibility of antibiotic resistance if prior treatments were ineffective and based on culture and sensitivity results.
Plan (P):
Treatment Plan:
Develop a treatment plan based on culture results and sensitivity testing, considering:
Antibiotics: Select an appropriate antibiotic based on sensitivity testing for a sufficient duration (usually 4-6 weeks).
Alpha-blockers: May be helpful to relax the prostate muscles and improve urinary flow (consider for patients with bothersome LUTS).
Anti-inflammatory medications (NSAIDs): May help manage pain and inflammation.
Supportive Measures:
Encourage increased fluid intake and voiding every 2-3 hours.
Discuss potential benefits of lifestyle modifications like stress management and avoiding bladder irritants (caffeine, alcohol).
Follow-up:
Schedule follow-up visits to monitor symptom improvement, repeat urine culture after treatment completion, and assess for recurrence. Define the frequency of follow-up based on treatment response and severity of symptoms.
Patient Education:
Educate the patient about CBP, risk factors, importance of completing the entire antibiotic course, and potential side effects of medications.
Discuss the importance of practicing safe sex to prevent recurrent UTIs.
Provide resources for further information on prostatitis and healthy urinary habits.