Soap Note 1 Acute Conditions

Soap Note 1 Acute Conditions (15 Factors) Due 06/15/2019

Decide any Acute Illness from Weeks 1-5 (see syllabus)

Soap notes will probably be uploaded to Moodle and put by means of TURN-It-In (anti-Plagiarism program)

Flip it in Rating have to be lower than 50% or is not going to be accepted for credit score, have to be your personal work and in your personal phrases. You’ll be able to resubmit, Remaining submission will probably be accepted if lower than 50%. Copy paste from web sites or textbooks is not going to be accepted or tolerated. Please see School Handbook on the subject of Educational Misconduct Assertion. Soap Note 1 Acute Conditions

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Late Project Coverage

Assignments turned in late may have 1 level taken off for day-after-day project is late, after 7 days project will get grade of zero. No exceptions

Comply with the MRU Soap Note Rubric as a information:

Grading Rubric

Student______________________________________

This sheet is that can Help you perceive what we’re searching for, and what our margin remarks could be about in your write ups of sufferers. Since at the entire white-ups that you simply hand in are uniform, this represents what MUST be included in each write-up.

1) Figuring out Information (___5pts): The opening listing of the be aware. It incorporates age, intercourse, race, marital standing, and so forth. The affected person grievance must be given in quotes. If the affected person has multiple grievance, every grievance must be listed individually (1, 2, and so forth.) and every addressed within the subjective and underneath the suitable quantity. Soap Note 1 Acute Conditions

2) Subjective Information (___30pts.): That is the historic a part of the be aware. It incorporates the next:

a) Symptom Assessment/HPI(Location, high quality , amount or severity, timing, setting, elements that make it higher or worse, and affiliate manifestations.(10pts)

b) Assessment of methods of related methods, reporting all pertinent positives and negatives (10pts).

c) Any PMH, household hx, social hx, allergic reactions, medicines associated to the grievance/drawback (10pts). If multiple chief grievance, every must be written u on this method.

Three) Goal Information(__25pt.): Very important indicators should be current. Top and Weight must be included the place applicable.

a) Acceptable methods are examined, listed within the be aware and in step with these recognized in 2b.(10pts).

b) Pertinent positives and negatives have to be documented for every related system.

c) Any abnormalities have to be absolutely described. Measure and report sizes of issues (likes moles, scars). Keep away from utilizing “okay”, “clear”, “inside regular limits”, optimistic/ detrimental, and regular/irregular to explain issues. (5pts).

Four) Assessment (___10pts.): Diagnoses must be clearly listed and worded appropriately.

5) Plan (___15pts.): Make sure you embrace any instructing, well being upkeep and counseling together with the pharmacological and non-pharmacological measures. When you have multiple analysis, it’s useful to have this part divided into separate numbered sections.

6) Subjective/ Goal, Assessment and Administration and Constant (___10pts.): Does the be aware Help the suitable differential analysis course of? Is there proof that you recognize what methods and what signs go together with which complaints? The Assessment/diagnoses must be in step with the subjective part after which the Assessment and plan. The administration must be in step with the Assessment/ diagnoses recognized. Soap Note 1 Acute Conditions

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

Feedback:

Whole Rating: ____________ Teacher: __________________________________

1 pattern SAMPLE Block format Soap Note Template.docx

SOAP NOTE SAMPLE FORMAT FOR MRC

Title: LP

Date:

Time: 1315

Age: 30

Intercourse: F

SUBJECTIVE

CC:

“I’m having vaginal itching and ache in my decrease stomach.”

HPI:

Pt is a 30y/o AA feminine, who’s a brand new affected person that has lately moved to Miami. She seeks remedy as we speak after unsuccessful self-treatment of vaginal itching, burning upon urination, and decrease stomach ache. She is anxious for the presence of a vaginal or bladder an infection, or an STD. Pt denies fever. She experiences the itching and burning with urination has been current for Three weeks, and the stomach ache has been intermittent since months in the past. Pt has tried OTC merchandise for the itching, together with Monistat and Vagisil. She denies another urinary signs, together with urgency or frequency. She describes the stomach ache as both sharp or uninteresting. The ache degree goes as excessive as eight out of 10 at occasions. 200mg of PO Advil PRN reduces the ache to a 7/10. Pt denies any aggravating elements for the ache. Pt experiences that she did begin her menstrual cycle this morning, however denies another discharge different that gentle bleeding starting as we speak. Pt denies douching or using any vaginal irritants. She experiences that she is in a secure sexual relationship, and denies any new sexual companions in the final 90 days. She denies any current or historic identified publicity to STDs. She experiences using condoms with each coital expertise, as properly as this being her solely type of contraceptive. She experiences regular month-to-month menstrual cycles that final Three-Four days. She experiences dysmenorrhea, which she additionally takes Advil for. She experiences her final PAP smear was in 7/2016, was regular, and experiences by no means having an irregular PAP smear outcome. Pt denies any hx of pregnancies. Different medical hx consists of GERD. She experiences that she has an Rx for Protonix, however she doesn’t take it day-after-day. Her household hx consists of the presence of DM and HTN. Soap Note 1 Acute Conditions

Present Medicines:

Protonix 40mg PO Each day for GERD

MTV OTC PO Each day

Advil 200mg OTC PO PRN for ache

PMHx:

Allergic reactions:

NKA & NKDA

Treatment Intolerances:

Denies

Power Sicknesses/Main traumas

GERD

Hospitalizations/Surgical procedures

Denies

Household Historical past

Father- DM & HTN; Mom- HTN; Older sister- DM & HTN; Maternal and paternal grandparents with out identified medical points; 1 brother and three different sisters with out identified medical points; No youngsters.

Social Historical past

Lives alone. At the moment in a secure sexual relationship with one man. Works for DEFACS. Stories occasional alcohol use, however denies tobacco or illicit drug use.

ROS

Normal

Denies weight change, fatigue, fever, night time sweats

Cardiovascular

Denies chest ache and edema. Stories uncommon palpitations which can be relieved by ingesting water Soap Note 1 Acute Conditions

Pores and skin

Denies any wounds, rashes, bruising, bleeding or pores and skin discolorations, any modifications in lesions

Respiratory

Denies cough. Stories dyspnea that accompanies the uncommon palpitations and can be relieved by ingesting water

Eyes

Denies corrective lenses, blurring, visible modifications of any type

Gastrointestinal

Belly ache (see HPI) and Hx of GERD. Denies N/V/D, constipation, urge for food modifications

Ears

Denies Ear ache, listening to loss, ringing in ears

Genitourinary/Gynecological

Stories burning with urination, however denies frequency or urgency. Contraceptive and STD prevention consists of condoms with each coital occasion. Present secure sexual relationship with one man. Denies identified historic or current STD publicity. Final PAP was 7/2016 and regular. Common month-to-month menstrual cycle lasting Three-Four days.

Nostril/Mouth/Throat

Denies sinus issues, dysphagia, nostril bleeds or discharge

Musculoskeletal

Denies again ache, joint swelling, stiffness or ache

Breast

Denies SBE

Neurological

Denies syncope, seizures, paralysis, weak spot

Heme/Lymph/Endo

Denies bruising, night time sweats, swollen glands

Psychiatric

Denies despair, anxiousness, sleeping difficulties Soap Note 1 Acute Conditions

OBJECTIVE

Weight 140lb

Temp -97.7

BP 123/82

Top 5’Four”

Pulse 74

Respiration 18

Normal Look

Wholesome showing grownup feminine in no acute misery. Alert and oriented; solutions questions appropriately.

Pores and skin

Pores and skin is regular shade for ethnicity, heat, dry, clear and intact. No rashes or lesions famous.

HEENT

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

Cardiovascular

S1, S2 with common fee and rhythm. No further coronary heart sounds.

Respiratory

Symmetric chest partitions. Respirations common and straightforward; lungs clear to auscultation bilaterally.

Gastrointestinal

Stomach flat; BS lively in all Four quadrants. Stomach delicate, suprapubic tender. No hepatosplenomegaly.

Genitourinary

Suprapubic tenderness famous. Pores and skin shade regular for ethnicity. Irritation famous at labia majora, minora, and perineum. No ulcerated lesions famous. Lymph nodes not palpable. Vagina pink and moist with out lesions. Discharge minimal, thick, darkish crimson, no odor. Cervix pink with out lesions. No CMT. Uterus regular measurement, form, and consistency.

Musculoskeletal

Full ROM seen in all Four extremities as affected person moved in regards to the examination room.

Neurological

Speech clear. Good tone. Posture erect. Stability secure; gait regular.

Psychiatric

Alert and oriented. Wearing clear garments. Maintains eye contact. Solutions questions appropriately. Soap Note 1 Acute Conditions

Lab Checks

Urinalysis – blood famous (pt. on menstrual interval), however outcomes detrimental for an infection

Urine tradition testing unavailable

Moist prep – inconclusive

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

Particular Checks- No ordered at this time.

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Analysis

Differential Diagnoses

1-Bacterial Vaginosis (N76.zero)
2- Malignant neoplasm of feminine genital organ, unspecified. (C57.9)
Three-Gonococcal an infection, unspecified. (A54.9)
Analysis

o Urinary tract an infection, website not specified. (N39.zero) Candidiasis of vulva and vagina. (B37.Three) secondary to presenting signs (Colgan & Williams, 2011) & (Hainer & Gibson, 2011).

Plan/Therapeutics

Plan:
Treatment –
§ Terconazole cream 1 vaginal utility QHS for 7 days for Vulvovaginal Candidiasis;

§ Sulfamethoxazole/TMP DS 1 pill PO twice day by day for Three days for UTI (Woo & Wynne, 2012)

Training –
§ Medicines prescribed.

§ UTI and Candidiasis signs, causes, dangers, remedy, prevention. Causes to hunt emergent care, together with N/V, fever, or again ache. Soap Note 1 Acute Conditions

§ STD dangers and preventions.

§ Ulcer prevention, together with taking Protonix as prescribed, not exceeding the advisable dose restrict of NSAIDs, and never taking NSAIDs on an empty abdomen.

Comply with-up –
§ Pt will probably be contacted with outcomes of STD research.

§ Return to clinic when completed the interval for carry out pap-smear or if signs don’t resolve with prescribed TX.

References

Colgan, R. & Williams, M. (2011). Analysis and Remedy of Acute Uncomplicated Cystitis. American Household Doctor, 84(7), 771-776.

Hainer, B. & Gibson, M. (2011). Vaginitis: Analysis and Remedy. American Household Doctor, 83(7), 807-815.

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

2 pattern Pattern Common Soap Note Template.docx

PATIENT INFORMATION

Title: Mr. W.S.

Age: 65-year-old

Intercourse: Male

Supply: Affected person

Allergic reactions: None

Present Medicines: Atorvastatin tab 20 mg, 1-tab PO at bedtime

PMH: Hypercholesterolemia

Immunizations: Influenza final 2018-year, tetanus, and hepatitis A and B Four years in the past.

Surgical Historical past: Appendectomy 47 years in the past.

Household Historical past: Father- died 81 doesn’t report data

Mom-alive, 88 years outdated, Diabetes Mellitus, HTN

Daughter-alive, 34 years outdated, wholesome

Social Hx: No smoking historical past or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.

SUBJECTIVE:

Chief complain: “complications” that began two weeks in the past

Symptom Assessment/HPI:

The affected person is 65 years outdated male who complaining of episodes of complications and on Three totally different events blood strain was measured, which was excessive (159/100, 158/98 and 160/100 respectively). Affected person seen the issue began two weeks in the past and generally it’s accompanied by dizziness. He states that he has been underneath stress in his office for the final month. Soap Note 1 Acute Conditions

Affected person denies chest ache, palpitation, shortness of breath, nausea or vomiting.

ROS:

CONSTITUTIONAL: Denies fever or chills. Denies weak spot or weight reduction. NEUROLOGIC: Headache and dizzeness as describe above. Denies modifications in LOC. Denies historical past of tremors or seizures.

HEENT: HEAD: Denies any head harm, or change in LOC. Eyes: Denies any modifications in imaginative and prescient, diplopia or blurred imaginative and prescient. Ear: Denies ache within the ears. Denies lack of listening to or drainage. Nostril: Denies nasal drainage, congestion. THROAT: Denies throat or neck ache, hoarseness, issue swallowing.

Respiratory: Affected person denies shortness of breath, cough or hemoptysis.

Cardiovascular: No chest ache, tachycardia. No orthopnea or paroxysmal nocturnal

dyspnea.

Gastrointestinal: Denies stomach ache or discomfort. Denies flatulence, nausea, vomiting or

diarrhea.

Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies issue beginning/stopping stream of urine or incontinence. Soap Note 1 Acute Conditions

MUSCULOSKELETAL: Denies falls or ache. Denies listening to a clicking or snapping sound.

Pores and skin: No change of coloration comparable to cyanosis or jaundice, no rashes or pruritus.

Goal Information

CONSTITUTIONAL: Very important indicators: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’Four”, Wt 200 lb, BMI 25. Report ache zero/10.

Normal look: The affected person is alert and oriented x Three. No acute misery famous. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to individual, place, and time. Sensation intact to bilateral higher and decrease extremities. Bilateral UE/LE energy 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visible acuity and extraocular eye actions intact. No nystagmus famous. Ears: Bilateral canals patent with out erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly grey with sharp cone of sunshine. Maxillary sinuses no tenderness. Nasal mucosa moist with out bleeding. Oral mucosa moist with out lesions,.Lids non-remarkable and applicable for race.

Neck: supple with out cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or plenty.

Cardiovascular: S1S2, common fee and rhythm, no murmur or gallop famous. Capillary refill < 2 sec.

Respiratory: No dyspnea or use of accent muscle tissues noticed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation. Soap Note 1 Acute Conditions

Gastrointestinal: No mass or hernia noticed. Upon auscultation, bowel sounds current in all 4 quadrants, no bruits over renal and aorta arteries. Stomach delicate non-tender, no guarding, no rebound no distention or organomegaly famous on palpation

Musculoskeletal: No ache to palpation. Energetic and passive ROM inside regular limits, no stiffness.

Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.

Assessment

Important (Main) Hypertension (ICD10 I10): Given the signs and hypertension (156/92 mmhg), labeled as stage 2. As soon as the natural reason for hypertension has been dominated out, comparable to renal, adrenal or thyroid, this analysis is confirmed.

Differential analysis:

Ø Renal artery stenosis (ICD10 I70.1)

Ø Power kidney illness (ICD10 I12.9)

Ø Hyperthyroidism (ICD10 E05.90)

Plan

Analysis is predicated on the scientific analysis by means of historical past, bodily examination, and routine laboratory checks to evaluate threat elements, reveal identifiable causes and detect target-organ harm, together with proof of heart problems.

These fundamental laboratory checks are:

· CMP

· Full blood depend

· Lipid profile

· Thyroid-stimulating hormone Soap Note 1 Acute Conditions

· Urinalysis

· Electrocardiogram

Ø Pharmacological remedy:

The remedy of selection on this case could be:

Thiazide-like diuretic and/or a CCB

· Hydrochlorothiazide tab 25 mg, Preliminary dose: 25 mg orally as soon as day by day.

Ø Non-Pharmacologic remedy:

· Weight reduction

· Nutritious diet (DASH dietary sample): Eating regimen wealthy in fruits, greens, complete grains, and low-fat dairy merchandise with lowered content material of saturated and trans l fats

· Lowered consumption of dietary sodium: <1,500 mg/d is perfect objective however not less than 1,000 mg/d discount in most adults

· Enhanced consumption of dietary potassium

· Common bodily exercise (Cardio): 90–150 min/wk

· Tobacco cessation

· Measures to launch stress and efficient coping mechanisms.

Training

· Present with vitamin/dietary data.

· Each day blood strain monitoring at house twice a day for 7 days, hold a report, carry the report on the subsequent go to together with her PCP

· Instruction about medicine consumption compliance. Soap Note 1 Acute Conditions

· Training of doable problems comparable to stroke, coronary heart assault, and different issues.

· Affected person was educated heading in the right direction of hypertension, in addition to warning indicators and signs, which may point out the necessity to attend the E.R/U.C. Answered all pt. questions/issues. Pt verbalizes understanding to all

Comply with-ups/Referrals

· Analysis with PCP in 1 weeks for managing blood strain and to guage present hypotensive remedy. Pressing Care go to prn.

· No referrals wanted at the moment. Soap Note 1 Acute Conditions

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