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

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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 timeSensation 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

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