Soap Note 1 Acute Conditions
Soap Note 1 Acute Conditions (15 Factors) Due 06/15/2019
Choose any Acute Illness from Weeks 1-5 (see syllabus)
Soap notes might be uploaded to Moodle and put by 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 individual work and in your individual phrases. You possibly can resubmit, Remaining submission might 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 as regards to 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 daily project is late, after 7 days project will get grade of zero. No exceptions
Observe the MRU Soap Note Rubric as a information:
Grading Rubric
Student______________________________________
This sheet is that can Help you perceive what we’re in search of, and what our margin remarks is perhaps 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 checklist of the notice. It accommodates age, intercourse, race, marital standing, and so on. The affected person grievance needs to be given in quotes. If the affected person has a couple of grievance, every grievance needs to be listed individually (1, 2, and so on.) and every addressed within the subjective and below the suitable quantity. Soap Note 1 Acute Conditions
2) Subjective Information (___30pts.): That is the historic a part of the notice. It accommodates the next:
a) Symptom Assessment/HPI(Location, high quality , amount or severity, timing, setting, components that make it higher or worse, and affiliate manifestations.(10pts)
b) Evaluate of techniques of related techniques, reporting all pertinent positives and negatives (10pts).
c) Any PMH, household hx, social hx, allergic reactions, drugs associated to the grievance/downside (10pts). If a couple of chief grievance, every needs to be written u on this method.
Three) Goal Information(__25pt.): Important indicators must be current. Peak and Weight needs to be included the place acceptable.
a) Applicable techniques are examined, listed within the notice 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 totally described. Measure and file sizes of issues (likes moles, scars). Keep away from utilizing “okay”, “clear”, “inside regular limits”, constructive/ adverse, and regular/irregular to explain issues. (5pts).
Four) Assessment (___10pts.): Diagnoses needs to be clearly listed and worded appropriately.
5) Plan (___15pts.): You should definitely embrace any instructing, well being upkeep and counseling together with the pharmacological and non-pharmacological measures. You probably have a couple of analysis, it’s useful to have this part divided into separate numbered sections.
6) Subjective/ Goal, Assessment and Administration and Constant (___10pts.): Does the notice help the suitable differential analysis course of? Is there proof that you recognize what techniques and what signs go along with which complaints? The Assessment/diagnoses needs to be in step with the subjective part after which the Assessment and plan. The administration needs to 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 not too long ago moved to Miami. She seeks remedy immediately after unsuccessful self-treatment of vaginal itching, burning upon urination, and decrease belly ache. She is worried 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 belly 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 belly ache as both sharp or boring. The ache degree goes as excessive as eight out of 10 at instances. 200mg of PO Advil PRN reduces the ache to a 7/10. Pt denies any aggravating components for the ache. Pt experiences that she did begin her menstrual cycle this morning, however denies another discharge different that gentle bleeding starting immediately. Pt denies douching or using any vaginal irritants. She experiences that she is in a steady sexual relationship, and denies any new sexual companions in the final 90 days. She denies any current or historic recognized publicity to STDs. She experiences using condoms with each coital expertise, as nicely 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 end result. Pt denies any hx of pregnancies. Different medical hx contains GERD. She experiences that she has an Rx for Protonix, however she doesn’t take it daily. Her household hx contains the presence of DM and HTN. Soap Note 1 Acute Conditions
Present Drugs:
Protonix 40mg PO Each day for GERD
MTV OTC PO Each day
Advil 200mg OTC PO PRN for ache
PMHx:
Allergy symptoms:
NKA & NKDA
Medicine Intolerances:
Denies
Persistent 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 recognized medical points; 1 brother and three different sisters with out recognized medical points; No youngsters.
Social Historical past
Lives alone. At the moment in a steady sexual relationship with one man. Works for DEFACS. Experiences occasional alcohol use, however denies tobacco or illicit drug use.
ROS
Normal
Denies weight change, fatigue, fever, evening sweats
Cardiovascular
Denies chest ache and edema. Experiences uncommon palpitations which can be relieved by consuming 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. Experiences dyspnea that accompanies the uncommon palpitations and can be relieved by consuming water
Eyes
Denies corrective lenses, blurring, visible modifications of any sort
Gastrointestinal
Stomach 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
Experiences burning with urination, however denies frequency or urgency. Contraceptive and STD prevention contains condoms with each coital occasion. Present steady sexual relationship with one man. Denies recognized 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 point
Heme/Lymph/Endo
Denies bruising, evening sweats, swollen glands
Psychiatric
Denies melancholy, anxiousness, sleeping difficulties Soap Note 1 Acute Conditions
OBJECTIVE
Weight 140lb
Temp -97.7
BP 123/82
Peak 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 coloration for ethnicity, heat, dry, clear and intact. No rashes or lesions famous.
HEENT
Head is norm cephalic, hair evenly distributed. Neck: Supple. Full ROM. Tooth are in good restore.
Cardiovascular
S1, S2 with common price and rhythm. No further coronary heart sounds.
Respiratory
Symmetric chest partitions. Respirations common and simple; lungs clear to auscultation bilaterally.
Gastrointestinal
Stomach flat; BS lively in all Four quadrants. Stomach gentle, suprapubic tender. No hepatosplenomegaly.
Genitourinary
Suprapubic tenderness famous. Pores and skin coloration 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 purple, no odor. Cervix pink with out lesions. No CMT. Uterus regular dimension, form, and consistency.
Musculoskeletal
Full ROM seen in all Four extremities as affected person moved concerning the examination room.
Neurological
Speech clear. Good tone. Posture erect. Stability steady; 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 adverse 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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Prognosis
Differential Diagnoses
1-Bacterial Vaginosis (N76.zero)
2- Malignant neoplasm of feminine genital organ, unspecified. (C57.9)
Three-Gonococcal an infection, unspecified. (A54.9)
Prognosis
o Urinary tract an infection, web site not specified. (N39.zero) Candidiasis of vulva and vagina. (B37.Three) secondary to presenting signs (Colgan & Williams, 2011) & (Hainer & Gibson, 2011).
Plan/Therapeutics
Plan:
Medicine –
§ Terconazole cream 1 vaginal software QHS for 7 days for Vulvovaginal Candidiasis;
§ Sulfamethoxazole/TMP DS 1 pill PO twice every day for Three days for UTI (Woo & Wynne, 2012)
Training –
§ Drugs 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 really useful dose restrict of NSAIDs, and never taking NSAIDs on an empty abdomen.
Observe-up –
§ Pt might 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). Prognosis and Therapy of Acute Uncomplicated Cystitis. American Household Doctor, 84(7), 771-776.
Hainer, B. & Gibson, M. (2011). Vaginitis: Prognosis and Therapy. 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
Allergy symptoms: None
Present Drugs: 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 info
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 observed the issue began two weeks in the past and generally it’s accompanied by dizziness. He states that he has been below 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 point 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 damage, 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, problem swallowing.
Respiratory: Affected person denies shortness of breath, cough or hemoptysis.
Cardiovascular: No chest ache, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal: Denies belly ache or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies problem 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 similar to cyanosis or jaundice, no rashes or pruritus.
Goal Information
CONSTITUTIONAL: 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 power 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 acceptable for race.
Neck: supple with out cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or lots.
Cardiovascular: S1S2, common price 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 gentle non-tender, no guarding, no rebound no distention or organomegaly famous on palpation
Musculoskeletal: No ache to palpation. Lively and passive ROM inside regular limits, no stiffness.
Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.
Assessment
Important (Major) Hypertension (ICD10 I10): Given the signs and hypertension (156/92 mmhg), categorized as stage 2. As soon as the natural reason behind hypertension has been dominated out, similar to renal, adrenal or thyroid, this analysis is confirmed.
Differential analysis:
Ø Renal artery stenosis (ICD10 I70.1)
Ø Persistent kidney illness (ICD10 I12.9)
Ø Hyperthyroidism (ICD10 E05.90)
Plan
Prognosis relies on the scientific analysis by historical past, bodily examination, and routine laboratory checks to evaluate danger components, reveal identifiable causes and detect target-organ injury, together with proof of heart problems.
These fundamental laboratory checks are:
· CMP
· Full blood rely
· Lipid profile
· Thyroid-stimulating hormone Soap Note 1 Acute Conditions
· Urinalysis
· Electrocardiogram
Ø Pharmacological remedy:
The remedy of alternative on this case could be:
Thiazide-like diuretic and/or a CCB
· Hydrochlorothiazide tab 25 mg, Preliminary dose: 25 mg orally as soon as every day.
Ø Non-Pharmacologic remedy:
· Weight reduction
· Nutritious diet (DASH dietary sample): Weight loss program wealthy in fruits, greens, complete grains, and low-fat dairy merchandise with diminished content material of saturated and trans l fats
· Lowered consumption of dietary sodium: <1,500 mg/d is perfect aim however at the least 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 diet/dietary info.
· Each day blood strain monitoring at house twice a day for 7 days, maintain a file, carry the file on the following go to along with her PCP
· Instruction about treatment consumption compliance. Soap Note 1 Acute Conditions
· Training of potential problems similar to stroke, coronary heart assault, and different issues.
· Affected person was educated on the right track of hypertension, in addition to warning indicators and signs, which might point out the necessity to attend the E.R/U.C. Answered all pt. questions/issues. Pt verbalizes understanding to all
Observe-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 right now. Soap Note 1 Acute Conditions
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