Soap Note 2 Chronic Conditions

Chronic Conditions (15 Points)

Pick any Chronic Disease from Weeks 6-10

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
 Follow the MRU Soap Note Rubric as a guide

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement

SOAP NOTE SAMPLE FORMAT FOR MRC

  

Name:  LP

Date: 

Time: 1315

 

Age: 30

Sex: F

 

SUBJECTIVE

 

CC:  

“I am having vaginal itching and pain in   my lower abdomen.”

 

HPI:  

Pt is a   30y/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after   unsuccessful self-treatment of vaginal itching, burning upon urination, and   lower abdominal pain. She is concerned   for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with   urination has been present for 3 weeks, and the abdominal pain has been   intermittent since months ago. Pt has   tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms,   including urgency or frequency. She   describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10   at times. 200mg of PO Advil PRN   reduces the pain to a 7/10. Pt denies   any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but   denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any   vaginal irritants. She reports that   she is in a stable sexual relationship, and denies any new sexual partners in   the last 90 days. She denies any   recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well   as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also   takes Advil for. She reports her last   PAP smear was in 7/2016, was normal, and reports never having an abnormal PAP   smear result. Pt denies any hx of   pregnancies. Other medical hx includes   GERD. She reports that she has an Rx   for Protonix, but she does not take it every day. Her family hx includes the presence of DM   and HTN. 

 

Current Medications: 

Protonix   40mg PO Daily for GERD

MTV OTC   PO Daily

Advil   200mg OTC PO PRN for pain

 

PMHx:

Allergies:  

NKA & NKDA

Medication Intolerances: 

Denies

Chronic Illnesses/Major traumas

GERD

Hospitalizations/Surgeries

Denies

 

Family History

Father-   DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal   grandparents without known medical issues; 1 brother and 3 other sisters   without known medical issues; No children.

 

Social History

Lives   alone. Currently in a stable sexual   relationship with one man. Works for   DEFACS. Reports occasional alcohol   use, but denies tobacco or illicit drug use.

 

ROS

 

General 

Denies   weight change, fatigue, fever, night sweats

Cardiovascular

Denies   chest pain and edema. Reports rare palpitations that are relieved by drinking   water

 

Skin

Denies   any wounds, rashes, bruising, bleeding or skin discolorations, any changes in   lesions

Respiratory

Denies   cough. Reports dyspnea that accompanies the rare palpitations and is also   relieved by drinking water

 

Eyes

Denies corrective   lenses, blurring, visual changes of any kind

Gastrointestinal

Abdominal   pain (see HPI) and Hx of GERD. Denies   N/V/D, constipation, appetite changes

 

Ears

Denies   Ear pain, hearing loss, ringing in ears

Genitourinary/Gynecological

Reports   burning with urination, but denies frequency or urgency. Contraceptive and STD prevention includes   condoms with every coital event. Current stable sexual relationship with one man. Denies known historic or recent STD   exposure. Last PAP was 7/2016 and normal. Regular monthly menstrual cycle   lasting 3-4 days. 

 

Nose/Mouth/Throat

Denies   sinus problems, dysphagia, nose bleeds or discharge

Musculoskeletal

Denies   back pain, joint swelling, stiffness or pain

 

Breast

Denies   SBE

Neurological

Denies   syncope, seizures, paralysis, weakness

 

Heme/Lymph/Endo

Denies   bruising, night sweats, swollen glands

Psychiatric

Denies   depression, anxiety, sleeping difficulties

 

OBJECTIVE

 

Weight   140lb 

Temp -97.7

BP 123/82

 

Height 5’4”

Pulse 74

Respiration 18

 

General Appearance

Healthy   appearing adult female in no acute distress. Alert and oriented; answers   questions appropriately. 

 

Skin

Skin is   normal color for ethnicity, warm, dry, clean and intact. No rashes or lesions   noted.

 

HEENT

Head is   norm cephalic, hair evenly distributed. Neck: Supple. Full ROM. Teeth are in   good repair.

 

Cardiovascular

S1, S2   with regular rate and rhythm. No extra heart sounds. 

 

Respiratory

Symmetric   chest walls. Respirations regular and easy; lungs clear to auscultation   bilaterally.

 

Gastrointestinal

Abdomen   flat; BS active in all 4 quadrants. Abdomen soft, suprapubic   tender. No hepatosplenomegaly.  

    

Genitourinary

Suprapubic   tenderness noted. Skin color normal   for ethnicity. Irritation noted at   labia majora, minora, and perineum. No ulcerated lesions noted. Lymph nodes   not palpable. Vagina pink and moist   without lesions. Discharge minimal,   thick, dark red, no odor. Cervix pink   without lesions. No CMT. Uterus normal size, shape, and consistency.  

 

Musculoskeletal

Full   ROM seen in all 4 extremities as patient moved about the exam room.

 

Neurological 

Speech   clear. Good tone. Posture erect. Balance stable; gait normal.

 

Psychiatric

Alert   and oriented. Dressed in clean clothes. Maintains eye contact. Answers   questions appropriately.

 

Lab Tests

Urinalysis   – blood noted (pt. on menstrual period), but results negative for infection

Urine   culture testing unavailable

Wet   prep – inconclusive 

STD   testing pending for gonorrhea, chlamydia, syphilis, HIV, HSV 1 & 2, Hep B   & C 

 

Special Tests- No ordered at this   time.

 

Diagnosis 

 

Differential Diagnoses

• 1-Bacterial Vaginosis (N76.0)
• 2- Malignant neoplasm of female genital organ,         unspecified. (C57.9)
• 3-Gonococcal infection, unspecified. (A54.9)

Diagnosis

o Urinary   tract infection, site not specified. (N39.0) Candidiasis of vulva and vagina.   (B37.3) secondary to presenting symptoms (Colgan & Williams, 2011) &   (Hainer & Gibson, 2011). 

 

Plan/Therapeutics

 

• Plan:  
  • Medication – 

§ Terconazole cream 1 vaginal application QHS for 7 days for   Vulvovaginal Candidiasis; 

§ Sulfamethoxazole/TMP DS 1 tablet PO twice daily for 3 days   for UTI (Woo & Wynne, 2012)

• Education – 

§ Medications prescribed. 

§ UTI and Candidiasis symptoms, causes, risks, treatment,   prevention. Reasons to seek emergent care, including N/V, fever, or back   pain. 

§ STD risks and preventions. 

§ Ulcer prevention, including taking Protonix as prescribed,   not exceeding the recommended dose limit of NSAIDs, and not taking NSAIDs on   an empty stomach. 

• Follow-up         – 

§ Pt will be contacted with results of STD studies. 

§ Return to clinic when finished the period for perform   pap-smear or if symptoms do not resolve with prescribed TX.

            

References

Colgan, R. & Williams, M. (2011). Diagnosis and Treatment of Acute Uncomplicated Cystitis. American Family Physician, 84(7), 771-776.

Hainer, B. & Gibson, M. (2011). Vaginitis: Diagnosis and Treatment. American Family Physician, 83(7), 807-815. 

Woo, T. M., & Wynne, A. L. (2012). Pharmacotherapeutics for Nurse Practitioner Prescribers (3rd ed.). Philadelphia, PA: F.A. Davis Company.

 

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Soap Note 1 Acute Conditions Due 10/12/2019

Soap Note 1 Acute Conditions (15 Points) 

Pick any Acute Disease from Weeks 1-5 (see syllabus)

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

Late Assignment Policy

Assignments turned in late will have 1 point taken off for every day assignment is late, after 7 days assignment will get grade of 0. No exceptions 

Follow the MRU Soap Note Rubric as a guide:

Grading Rubric

Student______________________________________

This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.

1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.

2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:

a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts).

b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).

c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.

3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.

a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).

b) Pertinent positives and negatives must be documented for each relevant system.

c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4) Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.

5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.

6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.

7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?

Comments:

Total Score: ____________ Instructor: __________________________________

 

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In this assignment, you will consider case studies that describe abnormal findings in patients seen in a clinical setting.

In this assignment, you will analyze a SOAP note case study that describes abnormal findings in patients seen in a clinical setting. You will consider what history should be collected from the patients, as well as which physical exams and diagnostic tests should be conducted. You will also formulate a differential diagnosis with several possible conditions.

GENITALIA ASSESSMENT

Subjective:

• CC: “I have bumps on my bottom that I want to have checked out.”
• HPI: AB, a 21-year-old WF college student reports to your clinic with external bumps on her genital area. She states the bumps are painless and feel rough. She states she is sexually active and has had more than one partner over the past year. Her initial sexual contact occurred at age 18. She reports no abnormal vaginal discharge. She is unsure how long the bumps have been there but noticed them about a week ago. Her last Pap smear exam was 3 years ago, and no dysplasia was found; the exam results were normal. She reports one sexually transmitted infection (chlamydia) about 2 years ago. She completed the treatment for chlamydia as prescribed.
• PMH: Asthma
• Medications: Symbicort 160/4.5mcg
• Allergies: NKDA
• FH: No hx of breast or cervical cancer, Father hx HTN, Mother hx HTN, GERD
• Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

• VS: Temp 98.6; BP 120/86; RR 16; P 92; HT 5’10”; WT 169lbs
• Heart: RRR, no murmurs
• Lungs: CTA, chest wall symmetrical
• Genital: Normal female hair pattern distribution; no masses or swelling. Urethral meatus intact without erythema or discharge. Perineum intact with a healed episiotomy scar present. Vaginal mucosa pink and moist with rugae present, pos for firm, round, small, painless ulcer noted on external labia
• Abd: soft, normoactive bowel sounds, neg rebound, neg murphy’s, neg McBurney
• Diagnostics: HSV specimen obtained

Assessment:

• Chancre
• PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

To prepare:

With regard to the SOAP note case study provided:

• Review this week’s Learning Resources, and consider the insights they provide about the case study.
• Consider what history would be necessary to collect from the patient in the case study.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

To complete:

Refer to Chapter 5 of the Sullivan text. Analyze the SOAP note case study.  Using evidence based resources, answer the following questions and support your answers using current evidence from the literature.

• Analyze the subjective portion of the note. List additional information that should be included in the documentation.
• Analyze the objective portion of the note. List additional information that should be included in the documentation.
• Is the assessment supported by the subjective and objective information? Why or Why not?
• Would diagnostics be appropriate for this case and how would the results be used to make a diagnosis?
• Would you reject/accept the current diagnosis? Why or why not? Identify three possible conditions that may be considered as a differential diagnosis for this patient. Explain your reasoning using at least 3 different references from current evidence based literature.

 

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