SOAP Note

Date: 4/24/2023
Time: 15:00

Guidelines: American Thyroid Association Task Force hypothyroidism Guidelines:

https://www-ncbi-nlm-nih-gov.husson.idm.oclc.org/pmc/articles/PMC4267409/
2021 AUA BPH guidelines:
https://www.auanet.org/guidelines-and-quality/guidelines/benign-prostatic-hyperplasia-
(bph)-guideline
2018 AUA ED Guidelines:
https://www.auanet.org/guidelines-and-quality/guidelines/benign-prostatic-hyperplasia-
(bph)-guideline
2017 AHA Blood Pressure Guideline:
https://www.ahajournals.org/doi/10.1161/HYP.0000000000000065

Subjective

Demographics: Dudley Snyder, a 69 year old male has come to follow-up by his PCP for a
recent diagnosis of BPH and erectile dysfunction

Chief Complaint: Problems with falling and dizziness after recent prescription changes

HPI: recently diagnosed with both BPH and ED about a week ago,

FH: N/A

SH: drinks 2-3 beers to relax daily

Medications
● Lisinopril 5 mg tablets - 1 tablet PO daily
● Levothyroxine sodium 50 mcg - 1 tablet PO daily
● Ibuprofen 600 mg - 1 tablet PO as needed every 4 hours
● Diphenhydramine HCl 25 mg - 1 tablet PO every 4 hours as needed
● Tadalafil 5 mg - 1 tablet PO daily
● Doxazosin 2 mg - D/C’ed
Objective

Allergies: sulfa allergy

PMH:

● previous Poison Ivy rash - has since cleared

● Hypothyroidism
● Hypertension

Physical Exam:

Vitals

Height 5’11”

Weight 90 kg

BP 154/89

HR 72 BPM

BMI 27.6

Labs

Labs Reference Ranges

BUN 17 mg/dL normal range: 8-20

SCr 1.0 mg/dL normal range: 0.6-1.2

Na 140 mEq/L normal range: 135-145

K 4.1 mEq/L normal range: 3.5-5.0

Cl 101 mEq/L normal range: 96-109

CO2 26 mmol/L normal range: 21-32

Glucose (random) 90 mg/dL normal range: 70-110

TSH 7.8 mIU/mL normal range: 0.4-4

 Total Cholesterol mg/dL normal range: 125-200

Triglycerides mg/dL normal range: < 150

HDL mg/dL normal range: > 40

LDL mg/dL normal range: < 100

Prostate specific Ag 5.4 ng/mL Normal range: <4

CrCl : 89 mL/min

Assessment

Problem 1:Benign Prostatic Hyperplasia

Goal(s) of Therapy: minimize symptoms of lower urinary tract symptoms, slow
down/prevent progression of BPH
Discussion of S/O:
● The main reason as to why the patient is having excessive falls is due to the medication
the patient is taking for their BPH: Doxazosin. One of the most important features to
alpha blockers is their very common adverse effects like orthostatic hypotension. The
patient was not put on the initial starting dose for doxazosin, which would have been 1
mg. Doxazosin is a non-selective alpha blocker, which could contribute to increased
incidence of falls and dizziness. The patient should be on a more selective alpha blocker
to minimize the risk of falls and fatigue. The patient is also a daily alcohol drinker, which
could also affect his blood pressure greatly and his risk of falls.

Treatment options:

Option 1: Switch to Tamsulosin 0.4 mg

● Rationale: tamsulosin is a “newer generation”, more selective alpha blocker that has less
incidence of hypotension compared to older generations of alpha blockers
● Dosing: 0.4 mg PO 30 mins after same meal every day
● Counseling points: do not take with alcohol or around the same time as alcohol, and do
not take the medication at the same time as PDE5 inhibitor, because it may cause
increased hypotensive effects and increase risk of a fall
Option 2: Decrease the dose to 1 mg until fully tolerable
● Rationale: the patient is already on Doxazosin, and has shown improvement of BPH the
past 10 days he was on the medication. The biggest problem for him about the
medication is the risk of falls, which can often be a counseling point to bring up with him,
and was not put on initial dosing
● Counseling points: DO NOT take with alcohol or with PDE5 inhibitors at the same time,
due to the increased risk of falls. Frequently monitor blood pressure. Encouraging the
D/C of daily alcohol should be done
Problem 2: Erectile dysfunction management
Goal(s) of therapy: restore sexual function, minimize Adverse events, improve QoL

Discussion:
● Another one of the patient’s main complaints, he is yet to see improvement in his sexual
function with the initial dose of tadalafil. The patient is only on the initial starting dose, so
there are potential options that the patient can get. He personally exclaimed he was
interested in sildenafil rather than tadalafil, but has not trialed a higher dose yet.
Counseling on how to use tadalafil to improve sexual function must be discussed once
again, and find potential problems as to why the medication is not affecting his ED

Treatment options:

Option 1: Titrate up the dose → Tadalafil 10 mg Daily

● Rationale: patient has not yet tried a titration of dosage, and has the eligibility to increase
the dosage to improve efficacy. It is best to titrate first, rather than assuming the entire
medication is ineffective and switching to another agent
● Counseling: Patient discussion about the efficacy of tadalafil and sildenafil should be
enforced, and the true differences between the medications and benefits tadalafil has for
his BPH as well. Patient should be taking this 30 minutes prior to sexual activity
● Closely monitor blood pressure → risk of hypotension
Option 2: Switch to Sildenafil 50 mg PO daily
● Rationale: while the patient is personally requesting Sildenafil, the patient would also
lose the benefits tadalafil has for patient with BPH as well as ED.
● Counseling: Discussion same as tadalafil. Patient should take this 1 hour before sexual
activity for better results. Taking this medication with a high-fat meal may decrease the
effectiveness of sildenafil.

Problem 3: hypothyroidism management

Goal(s) of therapy: achieve a euthyroid state, minimize symptoms of hypothyroidism,

avoid thyrotoxicosis

Discussion
● There is potential that the elevated TSH can be contributing to the risk of falls, as
uncontrolled hypothyroidism may cause fatigue. While the patient is not having major
issues with their thyroid, their thyroid replacement therapy is subtherapeutic and would
need a dosage increase.

Treatment option: Increase the Dose by 12-25 mcg → Levothyroxine 75 mcg

Problem 4: Hypertension

Goal(s) of therapy: achieve goal BP of <130/<90, improve symptoms, improve quality of

life, decrease risk of BP-related CV events

Discussion:
● While the patient is not complaining of any symptoms that may contribute to
hypertension, the patient is still not at BP goal. Getting the patient’s blood pressure at
goal can help improve the outcomes of the PDE5 and the alpha blocker in their
respective indications

Treatment options:

Option 1: increase Lisinopril to 10 mg

● Rationale: patient has not been controlled, and is at the lowest dose possible for their
blood pressure. Slow but sure titration of lisinopril is vital to prevent the risk of a
hypotensive emergency, especially with the concurrent medication the patient is on
●

Plan
Problem 1: BPH
START: Tamsulosin 0.4 mg PO daily
STOP: Doxazosin 2 mg
Monitor:
● Safety: cancer screening, urinalysis
● Efficacy: IPPS, improving signs and symptoms of LUTS
Counseling: may still cause dizziness/fatigue, inform your prescriber if any of this still occurs
Problem 2: ED
START: Tadalafil 10 mg PO daily
STOP:
Monitor:
● Safety:
● Efficacy
Counseling: do not take with alcohol or with alpha-blocker, take 30 mins prior to intercourse,
potentially discuss quitting alcohol intake to better improve sexual function
Problem 3: Hypothyroidism
INCREASE: Levothyroxine 50 mcg → 75 mcg PO daily
Monitor:
● Safety: HR, BP, worsening cardiac symptoms, bone mineral density
● Efficacy: TSH, free T3 and T4 levels
Counseling points: can potentially cause hair loss, take 30-60 mins before food
Problem 4: Hypertension
INCREASE: Lisinopril 5 mg → 10 mg PO daily
Monitor:
● Safety: blood pressure, renal function, potassium levels,
● Efficacy: blood pressure
Counseling: if dry, hacking cough occurs, this is a common adverse effect of lisinopril. Let your
doctor know if this too bothersome for you

Non-Pharmacological:
● Discussions about limiting or D/C the uses of alcohol
● Discussion of controlling blood pressure to increase sexual function
● Discussion of the similarities and differences of tadalafil and sildenafil
● Counsel on the potential benefits and risk of a vacuum constriction device

Follow-up with MD in another 10-14 days to address efficacy, safety, blood pressure, signs and
symptoms of worsening BPH or ED

Writer ID:
Dominic Pitre
Pharmacist Student
Phone: 207-423-9763