Soap Note 2 Chronic Conditions
Soap Note Chronic Conditions (15 Points)
Pick any Chronic Sickness from Weeks 6-10
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SOAP NOTE SAMPLE FORMAT FOR MRC
“I am having vaginal longing and disinclination in my inferior abdomen.”
Pt is a 30y/o AA womanish, who is a new resigned that has of-late moved to Miami. She inquires matter today succeeding unsuccessful self-matter of vaginal longing, steady upon urination, and inferior abdominal disinclination. She is cautionful for the nearness of a vaginal or bladder contamination, or an STD. Pt denies ardor. She reputes the longing and steady succeeding a while urination has been exhibit for 3 weeks, and the abdominal disinclination has been intermittent gone months ago. Pt has tried OTC products for the longing, including Monistat and Vagisil. She denies any other urinary symptoms, including hurry or quantity. She describes the abdominal disinclination as either sore or dowdy. The disinclination smooth goes as noble as 8 out of 10 at spells. 200mg of PO Advil PRN reduces the disinclination to a 7/10. Pt denies any aggravating factors for the disinclination. Pt reports that she did rouse her menstrual cycle this waking, but denies any other free other that easy bleeding outset today. Pt denies douching or the use of any vaginal irritants. She reputes that she is in a established sexual connection, and denies any new sexual partners in the ultimate 90 days. She denies any fresh or recitative unconcealed scylla to STDs. She reports the use of condoms succeeding a while unimpaired coital habit, as well-behaved-behaved-behaved as this being her singly fashion of contraceptive. She reputes typical monthly menstrual cycles that ultimate 3-4 days. She reputes dysmenorrhea, which she as-well-behaved takes Advil for. She reputes her ultimate PAP daub was in 7/2016, was typical, and reputes never having an abtypical PAP daub conclusion. Pt denies any hx of pregnancies. Other medical hx includes GERD. She reputes that she has an Rx for Protonix, but she does not engage it unimpaired day. Her source hx includes the nearness of DM and HTN.
Protonix 40mg PO Daily for GERD
MTV OTC PO Daily
Advil 200mg OTC PO PRN for disinclination
NKA & NKDA
Chronic Illnesses/Major traumas
Father- DM & HTN; Mother- HTN; Older sister- DM & HTN; Maternal and cautionful grandparents succeeding a whileout unconcealed medical issues; 1 copy and 3 other sisters succeeding a whileout unconcealed medical issues; No effect.
Lives quaint. Currently in a established sexual connection succeeding a while one man. Works for DEFACS. Reports intermittent alcohol use, but denies tobacco or unfair garbage use.
Denies efficacy modify, weary, fever, gloom sweats
Denies chest disinclination and edema. Reports noble palpitations that are important by drinking water
Denies any wounds, rashes, bruising, bleeding or husk discolorations, any modifys in lesions
Denies cough. Reports dyspnea that accompanies the noble palpitations and is as-well-behaved important by drinking water
Denies preventative lenses, blurring, visual modifys of any kind
Abdominal disinclination (see HPI) and Hx of GERD. Denies N/V/D, constipation, appetite modifys
Denies Ear disinclination, hearing impairment, ringing in ears
Reports steady succeeding a while urination, but denies quantity or hurry. Contraceptive and STD stoppage includes condoms succeeding a while unimpaired coital event. Floating established sexual connection succeeding a while one man. Denies unconcealed recitative or fresh STD scylla. Ultimate PAP was 7/2016 and typical. Regular monthly menstrual cycle ultimateing 3-4 days.
Denies sinus tenors, dysphagia, nose bleeds or free
Denies end disinclination, flexure swelling, barbarism or disinclination
Denies syncope, seizures, paralysis, impairment
Denies bruising, gloom sweats, swollen glands
Denies inferioring, apprehension, sleeping difficulties
Healthy notorious adult womanish in no intelligent annoy. Active and oriented; answers questions truly.
Skin is typical distortion for ethnicity, eager, dry, pure and pure. No rashes or lesions renowned.
Head is consecutiveness cephalic, hair evenly exclusive. Neck: Supple. Full ROM. Teeth are in good-natured-natured mend.
S1, S2 succeeding a while certain objurgate and rhythm. No extra nucleus investigates.
Symmetric chest walls. Respirations certain and easy; lungs intelligible to auscultation bilaterally.
Abdomen flat; BS locomotive in all 4 quadrants. Abdomen irresolute, suprapubic jealous. No hepatosplenomegaly.
Suprapubic jealousness noted. Husk distortion typical for ethnicity. Irritation renowned at labia majora, minora, and perineum. No ulcerated lesions renowned. Lymph nodes not palpable. Vagina pink and fresh extraneously lesions. Free minimal, thick, ebon red, no redolence. Cervix pink extraneously lesions. No CMT. Uterus typical extent, mould, and proportion.
Full ROM seen in all 4 extremities as resigned moved environing the exam ground.
Speech intelligible. Good-natured investigate. Posture raise. Balance established; gait typical.
Alert and oriented. Dressed in pure robes. Maintains eye apposition. Answers questions truly.
Urinalysis – dignity renowned (pt. on menstrual duration), but conclusions denying for contamination
Urine cultivation 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 spell.
1-Bacterial Vaginosis (N76.0)
2- Malignant neoplasm of womanish genital organ, unspecified. (C57.9)
3-Gonococcal contamination, unspecified. (A54.9)
o Urinary tract contamination, condition not ascertained. (N39.0) Candidiasis of vulva and vagina. (B37.3) resultant to exhibiting symptoms (Colgan & Williams, 2011) & (Hainer & Gibson, 2011).
§ 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)
§ Medications prescribed.
§ UTI and Candidiasis symptoms, creators, wastes, matter, stoppage. Reasons to inquire emergent caution, including N/V, ardor, or end disinclination.
§ STD wastes and stoppages.
§ Ulcer prevention, including importation Protonix as prescribed, not exceeding the recommended dose expression of NSAIDs, and not importation NSAIDs on an void stomach.
§ Pt obtain be contacted succeeding a while conclusions of STD studies.
§ Return to clinic when artistic the duration for perfashion pap-daub or if symptoms do not resolve succeeding a while prescribed TX.
Colgan, R. & Williams, M. (2011). Personality and Matter of Intelligent Uncomplicated Cystitis. American Source Physician, 84(7), 771-776
Hainer, B. & Gibson, M. (2011). Vaginitis: Personality and Treatment. American Source 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)
Name: Mr. W.S.
Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime
Immunizations: Influenza ultimate 2018-year, tetanus, and hepatitis A and B 4 years ago.
Surgical History: Appendectomy 47 years ago.
Family History: Father- died 81 does not repute notification
Mother-alive, 88 years old, Diabetes Mellitus, HTN
Daughter-alive, 34 years old, healthy
Social Hx: No smoking fact or unfair garbage use, intermittent alcoholic beverage decrement on collective celebrations. Retired, widow, he lives quaint.
Chief complain: “headaches” that rouseed two weeks ago
The resigned is 65 years old manly who fastidious of episodes of ruleraches and on 3 incongruous occasions dignity hurry was measured, which was noble (159/100, 158/98 and 160/100 respectively). Resigned noticed the tenor rouseed two weeks ago and rarely it is accompanied by dizziness. He states that he has been beneath urgency in his productionattribute for the ultimate month.
Patient denies chest disinclination, palpitation, scantiness of inspiration, sea-sickness or vomiting.
CONSTITUTIONAL: Denies ardor or chills. Denies impairment or efficacy impairment. NEUROLOGIC: Headache and dizziness as relate aloft. Denies modifys in LOC. Denies fact of tremors or seizures.
HEENT: HEAD: Denies any ruler defective, or modify in LOC. Eyes: Denies any modifys in longing, diplopia or blurred longing. Ear: Denies disinclination in the ears. Denies impairment of hearing or drainage. Nose: Denies nasal drainage, accumulation. THROAT: Denies throat or neck disinclination, hoarseness, inaptitude gluttony.
Respiratory: Resigned denies scantiness of inspiration, cough or hemoptysis.
Cardiovascular: No chest disinclination, tachycardia. No orthopnea or paroxysmal nocturnal
Gastrointestinal: Denies abdominal disinclination or annoyance. Denies flatulence, sea-sickness, vomiting or
Genitourinary: Denies hematuria, dysuria or modify in urinary quantity. Denies inaptitude rouseing/stopping tendency of urine or intemperance.
MUSCULOSKELETAL: Denies falls or disinclination. Denies hearing a clicking or snapping investigate.
Skin: No modify of distortionation such as cyanosis or jaundice, no rashes or pruritus.
CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on ground air, Ht- 6’4”, Wt 200 lb, BMI 25. Repute disinclination 0/10.
General appearance: The resigned is active and oriented x 3. No intelligent annoy renowned. NEUROLOGIC: Alert, CNII-XII grossly pure, oriented to idiosyncratic, attribute, and spell. Sensation pure to bilateral eminent and inferior extremities. Bilateral UE/LE power 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no jealousness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements pure. No nystagmus renowned. Ears: Bilateral canals ambiguous succeeding a whileout erythema, edema, or exudate. Bilateral tympanic membranes pure, pearly gray succeeding a while sore cone of easy. Maxillary sinuses no jealousness. Nasal mucosa fresh succeeding a whileout bleeding. Oral mucosa fresh succeeding a whileout lesions,.Lids non-remarkable and after a whilehold for pursuit.
Neck: fawning succeeding a whileout cervical lymphadenopathy, no jugular feeling distention, no thyroid swelling or heapes.
Cardiovascular: S1S2, certain objurgate and rhythm, no reverberation or gallop renowned. Capillary resupply < 2 sec.
Respiratory: No dyspnea or use of friend muscles observed. No egophony, whispered pectoriloquy or perceptible fremitus on palpation. Inspiration investigates exhibits and intelligible bilaterally on auscultation.
Gastrointestinal: No heap or hernia observed. Upon auscultation, bowel investigates exhibit in all indelicate quadrants, no bruits balance renal and aorta arteries. Abdomen irresolute non-tender, no protecting, no spring-back no distention or organomegaly renowned on palpation
Musculoskeletal: No disinclination to palpation. Locomotive and inert ROM succeeding a whilein typical expressions, no barbarism.
Integumentary: pure, no lesions or rashes, no cyanosis or jaundice.
Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and noble dignity hurry (156/92 mmhg), classified as position 2. Unintermittently the radical creator of hypertension has been resolute out, such as renal, adrenal or thyroid, this personality is grown.
Ø Renal artery stenosis (ICD10 I70.1)
Ø Chronic consanguinity sickness (ICD10 I12.9)
Ø Hyperthyroidism (ICD10 E05.90)
Diagnosis is fixed on the clinical evaluation through fact, visible testimony, and uniformity laboratory tests to assess waste factors, divulge identifiable creators and unmask target-organ impairment, including token of cardiovascular sickness.
These basic laboratory tests are:
· Complete dignity count
· Lipid profile
· Thyroid-stimulating hormone
Ø Pharmacological matter:
The matter of excellent in this condition would be:
Thiazide-like diuretic and/or a CCB
· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally unintermittently daily.
Ø Non-Pharmacologic matter:
· Efficacy impairment
· Healthy regimen (DASH regimenary model): Regimen deep in income, vegetables, unimpaired grains, and low-fat dairy products succeeding a while cheap full of saturated and trans l fat
· Cheap inengage of regimenary sodium: <1,500 mg/d is optimal appearance but at last 1,000 mg/d contraction in most adults
· Enhanced inengage of regimenary potassium
· Certain visible life (Aerobic): 90–150 min/wk.
· Tobacco cessation
· Measures to free urgency and efficient coping mechanisms.
· Provide succeeding a while nutrition/dietary notification.
· Daily dignity hurry monitoring at residence twice a day for 7 days, celebrate a annals, adduce the annals on the next mark succeeding a while her PCP
· Instruction environing medication inengage docility.
· Education of practicable complications such as tickle, nucleus invasion, and other tenors.
· Resigned was educated on succession of hypertension, as well-behaved-behaved-behaved as premonition signs and symptoms, which could betoken the want to notice the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes beneathstanding to all
· Evaluation succeeding a while PCP in 1 weeks for managing dignity hurry and to evaluate floating hypotensive therapy. Urgent Caution mark prn.
· No referrals wanted at this spell.
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). Source Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0
Diseases and Disorders of the Renal/GU System
· Intelligent Consanguinity Defective (AKI)
· Bladder Cancer
· Interstitial Cystitis
· Prostate Cancer
· Prostatic Hyperplasia, Benign (BPH)
· Testicular Torsion
· Urinary Tract Contamination (UTI)
Diseases and Disorders of the Endocrine System
· Addison Disease
· Cushing Syndrome
· Graves Disease
· Hyper-, Hypoparathyroidism
· Hyper-, Hypothyroidism
· Myasthenia Gravis
· Syndrome of Inwithhold Antidiuretic Hormone Secretion
Diseases and Disorders of the Gastrointestinal System
· Celiac Disease
· Clostridium Difficile (C. Diff)
· Crohn’s Disease
· Esophageal Varices
Diseases and Disorders of the Gastrointestinal System
· Gastroesophageal Reflux Disease
· Hepatic Encephalopathy
· Irritable Bowel Syndrome (IBS)
· Pancreatic Cancer
· PepticUlcerDisease (Zollinger-Ellison Syndrome)
· Salmonella Infection