Soap Note 2 Chronic Conditions

  
Soap Note 2 Chronic Conditions
Soap Note Chronic Conditions (15 Points)
Pick any Chronic Disease from Weeks 6-10
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 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.
Sample Soap Note Template (2)
PATIENT INFORMATION
Name: Mr. W.S.
Age: 65-year-old
Sex: Male
Source: Patient
Allergies: None
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: 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 information
 Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking history or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain: “headaches” that started two weeks ago
Symptom 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 dizziness 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 nocturnal
dyspnea.
Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
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 Data
CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, 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 palpation
Musculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no stiffness.
Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.
Assessment 
Essential (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:
Ø Renal artery stenosis (ICD10 I70.1)
Ø Chronic kidney disease (ICD10 I12.9)
Ø Hyperthyroidism (ICD10 E05.90)
Plan
Diagnosis 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:
· CMP
· Complete blood count
· Lipid profile
· Thyroid-stimulating hormone
· Urinalysis
· Electrocardiogram
Ø Pharmacological treatment: 
The treatment of choice in this case would be:
Thiazide-like diuretic and/or a CCB
· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily. 
Ø Non-Pharmacologic treatment: 
· Weight loss
· 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
· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults
· Enhanced intake of dietary potassium
· Regular physical activity (Aerobic): 90–150 min/wk.
· Tobacco cessation
· Measures to release stress and effective coping mechanisms.
Education
· Provide with nutrition/dietary information.
· 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
· Instruction about medication intake compliance. 
· Education of possible complications such as stroke, heart attack, and other problems.
· 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 all
Follow-ups/Referrals
· Evaluation with PCP in 1 weeks for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn.
· No referrals needed at this time.
References
Domino, 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
 
Chronic Conditions:
  
Diseases   and Disorders of the Renal/GU System
· Acute Kidney Injury (AKI)
· Bladder Cancer
· Glomerulonephritis
· Hematuria
· Hydronephrosis
· Interstitial Cystitis
· Priapism
· Prostate Cancer
· Prostatic Hyperplasia, Benign (BPH)
· Prostatitis
· Pyelonephritis
· Testicular Torsion
· Urinary Tract Infection (UTI)
 
Diseases   and Disorders of the Endocrine System
· Addison Disease
· Cushing Syndrome
· Diabetes
· Graves Disease
· Hyper-, Hypoparathyroidism
· Hyper-, Hypothyroidism
· Myasthenia Gravis
· Syndrome of Inappropriate Antidiuretic Hormone Secretion
 
Diseases   and Disorders of the Gastrointestinal System
· Ascites
· Appendicitis
· Celiac Disease
· Cholelithiasis
· Cirrhosis
· Clostridium Difficile (C. Diff)
· Colitis
· Crohn’s Disease
· Constipation
· Diarrhea
· Diverticulitis
· Esophageal Varices
 
Diseases   and Disorders of the Gastrointestinal System
· Gastritis
· Gastroesophageal Reflux Disease
· Hemorrhoids 
· Hepatic Encephalopathy
· Hepatitis
· Irritable Bowel Syndrome (IBS)
· Pancreatic Cancer
· Pancreatitis
· PepticUlcerDisease (Zollinger-Ellison Syndrome)
· Salmonella Infection