SOAP / Chart / Progress Notes
Sample Name: Sexual Dysfunction - Chart Note
Description: A 33-year-old black male with main complaint of sexual dysfunction, would like to try Cialis.
(Medical Transcription Sample Report)
SUBJECTIVE: The patient is a 33-year-old black male who comes in to the office today main complaint of sexual dysfunction. Patient reports that he would like to try Cialis to see if it will improve his erectile performance. Patient states that he did a quiz on-line at the Cialis web site and did not score in the normal range, so he thought he should come in. Patient states that perhaps his desire has been slightly decreased, but that has not been the primary problem. In discussing with me directly, patient primarily expresses that he would like to have his erections last longer. However, looking at the quiz as he filled it out, he reported that much less than half the time was he able to get erections during sexual activity and only about half of the time he was able to maintain his erection after penetration. However, he only reports that it is slightly difficult to maintain the erection until completion of intercourse. Patient has no significant past medical history. He has never had any previous testicular infections. He denies any history of injuries to the groin and he has never been told that he has a hernia.
CURRENT MEDICATIONS: None.
ALLERGIES: No drug allergies.
SOCIAL: Only occasionally drinks alcohol and he is a nonsmoker. He currently is working as a nurse aid, second shift, at a nursing home. He states that he did not enroll in Wichita State this semester. Stating he just was tired and wanted to take some time off. He states he is in a relationship with one partner and denies any specific stress in the relationship.
General: He appears in no distress.
Lungs: Clear to auscultation.
Cardiovascular: Normal S1-S2 without murmur.
Abdomen: Soft, nontender. Femoral pulses are 2+.
GU: Testicles descended bilaterally. No evidence of masses. No evidence of inguinal hernias.
ASSESSMENT: Sexual dysfunction.
PLAN: We will check a free and total testosterone level as he does note some diminished desire. He was given a sample of Cialis 10 mg with instructions on usage and a prescription for that if that is successful. He will follow up here p.r.n. Lastly, I did give him a blood pressure recording card, as his blood pressure is borderline today. He will have that checked weekly at his workplace and follow up if they remain elevated.
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