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{"id":64405,"date":"2023-01-25T06:01:20","date_gmt":"2023-01-25T06:01:20","guid":{"rendered":"https:\/\/nursingwritersbureau.com\/?p=64405"},"modified":"2023-01-25T06:01:20","modified_gmt":"2023-01-25T06:01:20","slug":"soap-note-1-acute-conditions-3","status":"publish","type":"post","link":"https:\/\/nursingwritersbureau.com\/soap-note-1-acute-conditions-3\/","title":{"rendered":"Soap Note 1 Acute Conditions"},"content":{"rendered":"Soap Note 1 Acute ConditionsSoap Note 1 Acute Conditions (15 Points) Due 06\/15\/2019Pick 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 PolicyAssignments 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 exceptionsFollow the MRU Soap Note Rubric as a guide:Grading RubricStudent______________________________________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 \u0093ok\u0094, \u0093clear\u0094, \u0093within normal limits\u0094, 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: __________________________________1 sample \u00a0SAMPLE Block format Soap Note Template.docxSOAP NOTE SAMPLE FORMAT FOR MRCName: \u00a0LPDate:Time: 1315Age: 30Sex: FSUBJECTIVECC:\u0093I am having vaginal itching and pain in \u00a0\u00a0my lower abdomen.\u0094HPI:Pt is a \u00a0\u00a030y\/o AA female, who is a new patient that has recently moved to Miami. She seeks treatment today after \u00a0\u00a0unsuccessful self-treatment of vaginal itching, burning upon urination, and \u00a0\u00a0lower abdominal pain. She is concerned \u00a0\u00a0for the presence of a vaginal or bladder infection, or an STD. Pt denies fever. She reports the itching and burning with \u00a0\u00a0urination has been present for 3 weeks, and the abdominal pain has been \u00a0\u00a0intermittent since months ago. Pt has \u00a0\u00a0tried OTC products for the itching, including Monistat and Vagisil. She denies any other urinary symptoms, \u00a0\u00a0including urgency or frequency. She \u00a0\u00a0describes the abdominal pain as either sharp or dull. The pain level goes as high as 8 out of 10 \u00a0\u00a0at times. 200mg of PO Advil PRN \u00a0\u00a0reduces the pain to a 7\/10. Pt denies \u00a0\u00a0any aggravating factors for the pain. Pt reports that she did start her menstrual cycle this morning, but \u00a0\u00a0denies any other discharge other that light bleeding beginning today. Pt denies douching or the use of any \u00a0\u00a0vaginal irritants. She reports that \u00a0\u00a0she is in a stable sexual relationship, and denies any new sexual partners in \u00a0\u00a0the last 90 days. She denies any \u00a0\u00a0recent or historic known exposure to STDs. She reports the use of condoms with every coital experience, as well \u00a0\u00a0as this being her only form of contraceptive. She reports normal monthly menstrual cycles that last 3-4 days. She reports dysmenorrhea, which she also \u00a0\u00a0takes Advil for. She reports her last \u00a0\u00a0PAP smear was in 7\/2016, was normal, and reports never having an abnormal PAP \u00a0\u00a0smear result. Pt denies any hx of \u00a0\u00a0pregnancies. Other medical hx includes \u00a0\u00a0GERD. She reports that she has an Rx \u00a0\u00a0for Protonix, but she does not take it every day. Her family hx includes the presence of DM \u00a0\u00a0and HTN.Current Medications:Protonix \u00a0\u00a040mg PO Daily for GERDMTV OTC \u00a0\u00a0PO DailyAdvil \u00a0\u00a0200mg OTC PO PRN for painPMHx:Allergies:NKA & NKDAMedication Intolerances:DeniesChronic Illnesses\/Major traumasGERDHospitalizations\/SurgeriesDeniesFamily HistoryFather- \u00a0\u00a0DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and paternal \u00a0\u00a0grandparents without known medical issues; 1 brother and 3 other sisters \u00a0\u00a0without known medical issues; No children.Social HistoryLives \u00a0\u00a0alone. Currently in a stable sexual \u00a0\u00a0relationship with one man. Works for \u00a0\u00a0DEFACS. Reports occasional alcohol \u00a0\u00a0use, but denies tobacco or illicit drug use.ROSGeneralDenies \u00a0\u00a0weight change, fatigue, fever, night sweatsCardiovascularDenies \u00a0\u00a0chest pain and edema. Reports rare palpitations that are relieved by drinking \u00a0\u00a0waterSkinDenies \u00a0\u00a0any wounds, rashes, bruising, bleeding or skin discolorations, any changes in \u00a0\u00a0lesionsRespiratoryDenies \u00a0\u00a0cough. Reports dyspnea that accompanies the rare palpitations and is also \u00a0\u00a0relieved by drinking waterEyesDenies corrective \u00a0\u00a0lenses, blurring, visual changes of any kindGastrointestinalAbdominal \u00a0\u00a0pain (see HPI) and Hx of GERD. Denies \u00a0\u00a0N\/V\/D, constipation, appetite changesEarsDenies \u00a0\u00a0Ear pain, hearing loss, ringing in earsGenitourinary\/GynecologicalReports \u00a0\u00a0burning with urination, but denies frequency or urgency. Contraceptive and STD prevention includes \u00a0\u00a0condoms with every coital event. Current stable sexual relationship with one man. Denies known historic or recent STD \u00a0\u00a0exposure. Last PAP was 7\/2016 and normal. Regular monthly menstrual cycle \u00a0\u00a0lasting 3-4 days.Nose\/Mouth\/ThroatDenies \u00a0\u00a0sinus problems, dysphagia, nose bleeds or dischargeMusculoskeletalDenies \u00a0\u00a0back pain, joint swelling, stiffness or painBreastDenies \u00a0\u00a0SBENeurologicalDenies syncope, \u00a0\u00a0seizures, paralysis, weaknessHeme\/Lymph\/EndoDenies \u00a0\u00a0bruising, night sweats, swollen glandsPsychiatricDenies \u00a0\u00a0depression, anxiety, sleeping difficultiesOBJECTIVEWeight \u00a0\u00a0140lbTemp -97.7BP 123\/82Height 5\u00924\u0094Pulse 74Respiration 18General AppearanceHealthy \u00a0\u00a0appearing adult female in no acute distress. Alert and oriented; answers \u00a0\u00a0questions appropriately.SkinSkin is \u00a0\u00a0normal color for ethnicity, warm, dry, clean and intact. No rashes or lesions \u00a0\u00a0noted.HEENTHead is \u00a0\u00a0norm cephalic, hair evenly distributed. Neck: Supple. Full ROM. Teeth are in \u00a0\u00a0good repair.CardiovascularS1, S2 \u00a0\u00a0with regular rate and rhythm. No extra heart sounds.RespiratorySymmetric \u00a0\u00a0chest walls. Respirations regular and easy; lungs clear to auscultation \u00a0\u00a0bilaterally.GastrointestinalAbdomen \u00a0\u00a0flat; BS active in all 4 quadrants. Abdomen soft, suprapubic \u00a0\u00a0tender. No hepatosplenomegaly.GenitourinarySuprapubic \u00a0\u00a0tenderness noted. Skin color normal \u00a0\u00a0for ethnicity. Irritation noted at \u00a0\u00a0labia majora, minora, and perineum. No ulcerated lesions noted. Lymph nodes \u00a0\u00a0not palpable. Vagina pink and moist \u00a0\u00a0without lesions. Discharge minimal, \u00a0\u00a0thick, dark red, no odor. Cervix pink \u00a0\u00a0without lesions. No CMT. Uterus normal size, shape, and consistency.MusculoskeletalFull \u00a0\u00a0ROM seen in all 4 extremities as patient moved about the exam room.NeurologicalSpeech \u00a0\u00a0clear. Good tone. Posture erect. Balance stable; gait normal.PsychiatricAlert \u00a0\u00a0and oriented. Dressed in clean clothes. Maintains eye contact. Answers \u00a0\u00a0questions appropriately.Lab TestsUrinalysis \u00a0\u00a0\u0096 blood noted (pt. on menstrual period), but results negative for infectionUrine \u00a0\u00a0culture testing unavailableWet \u00a0\u00a0prep – inconclusiveSTD \u00a0\u00a0testing pending for gonorrhea, chlamydia, syphilis, HIV, HSV 1 & 2, Hep B \u00a0\u00a0& CSpecial Tests- No ordered at this \u00a0\u00a0time.DiagnosisDifferential Diagnoses1-Bacterial Vaginosis (N76.0)2- Malignant neoplasm of female genital organ, \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0unspecified. (C57.9)3-Gonococcal infection, unspecified. (A54.9)Diagnosiso Urinary \u00a0\u00a0tract infection, site not specified. (N39.0) Candidiasis of vulva and vagina. \u00a0\u00a0(B37.3) secondary to presenting symptoms (Colgan & Williams, 2011) & (Hainer \u00a0\u00a0& Gibson, 2011).Plan\/TherapeuticsPlan:Medication \u0096\u00a7 Terconazole cream 1 vaginal application QHS for 7 days for \u00a0\u00a0Vulvovaginal Candidiasis;\u00a7 Sulfamethoxazole\/TMP DS 1 tablet PO twice daily for 3 days \u00a0\u00a0for UTI (Woo & Wynne, 2012)Education \u0096\u00a7 Medications prescribed.\u00a7 UTI and Candidiasis symptoms, causes, risks, treatment, \u00a0\u00a0prevention. Reasons to seek emergent care, including N\/V, fever, or back \u00a0\u00a0pain.\u00a7 STD risks and preventions.\u00a7 Ulcer prevention, including taking Protonix as prescribed, \u00a0\u00a0not exceeding the recommended dose limit of NSAIDs, and not taking NSAIDs on \u00a0\u00a0an empty stomach.Follow-up \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u00a0\u0096\u00a7 Pt will be contacted with results of STD studies.\u00a7 Return to clinic when finished the period for perform \u00a0\u00a0pap-smear or if symptoms do not resolve with prescribed TX.ReferencesColgan, 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.2 sample Sample Regular Soap Note Template.docxPATIENT INFORMATIONName: Mr. W.S.Age: 65-year-oldSex: MaleSource: PatientAllergies: NoneCurrent Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtimePMH: HypercholesterolemiaImmunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.Surgical History: Appendectomy 47 years ago.Family History: Father- died 81 does not report informationMother-alive, 88 years old, Diabetes Mellitus, HTNDaughter-alive, 34 years old, healthySocial Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.SUBJECTIVE:Chief complain: \u0093headaches\u0094 that started two weeks agoSymptom analysis\/HPI:The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159\/100, 158\/98 and 160\/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month.Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.ROS:CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.Respiratory: Patient denies shortness of breath, cough or hemoptysis.Cardiovascular: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnaldyspnea.Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting ordiarrhea.Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting\/stopping stream of urine or incontinence.MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.Objective DataCONSTITUTIONAL: Vital signs: Temperature: 98.5 \u00b0F, Pulse: 87, BP: 159\/92 mmhg, RR 20, PO2-98% on room air, Ht- 6\u00924\u0094, Wt 200 lb, BMI 25. Report pain 0\/10.General appearance: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE\/LE strength 5\/5.HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,.Lids non-remarkable and appropriate for race.Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.Cardiovascular: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.Respiratory: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.Gastrointestinal: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpationMusculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no stiffness.Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.AssessmentEssential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156\/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed.Differential diagnosis:\u00d8 Renal artery stenosis (ICD10 I70.1)\u00d8 Chronic kidney disease (ICD10 I12.9)\u00d8 Hyperthyroidism (ICD10 E05.90)PlanDiagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease.These basic laboratory tests are:\u00b7 CMP\u00b7 Complete blood count\u00b7 Lipid profile\u00b7 Thyroid-stimulating hormone\u00b7 Urinalysis\u00b7 Electrocardiogram\u00d8 Pharmacological treatment:The treatment of choice in this case would be:Thiazide-like diuretic and\/or a CCB\u00b7 Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.\u00d8 Non-Pharmacologic treatment:\u00b7 Weight loss\u00b7 Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat\u00b7 Reduced intake of dietary sodium: <1,500 mg\/d is optimal goal but at least 1,000 mg\/d reduction in most adults\u00b7 Enhanced intake of dietary potassium\u00b7 Regular physical activity (Aerobic): 90\u0096150 min\/wk\u00b7 Tobacco cessation\u00b7 Measures to release stress and effective coping mechanisms.Education\u00b7 Provide with nutrition\/dietary information.\u00b7 Daily blood pressure monitoring at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP\u00b7 Instruction about medication intake compliance.\u00b7 Education of possible complications such as stroke, heart attack, and other problems.\u00b7 Patient was educated on course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R\/U.C. Answered all pt. questions\/concerns. Pt verbalizes understanding to allFollow-ups\/Referrals\u00b7 Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn.\u00b7 No referrals needed at this time.ReferencesDomino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute Consult Series).Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0\n<\/p>\n \n
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