Soap Note 1 Acute Conditions
Soap Note 1 Acute Conditions
Soap Note 1 Acute Conditions (15 Points) Due 06/15/2019
Pick any Acute Disease from Weeks 1-5 (see syllabus)
Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)
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.
Late Assignment Policy
Assignments turned in late will have 1 point taken off for every day assignment is late, after 7 days assignment will get grade of 0. No exceptions
Follow the MRU Soap Note Rubric as a guide:
Grading Rubric
Student______________________________________
This sheet is to help you understand what we are looking for, and what our margin remarks might be about on your write ups of patients. Since at all of the white-ups that you hand in are uniform, this represents what MUST be included in every write-up.
1) Identifying Data (___5pts): The opening list of the note. It contains age, sex, race, marital status, etc. The patient complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and each addressed in the subjective and under the appropriate number.
2) Subjective Data (___30pts.): This is the historical part of the note. It contains the following:
a) Symptom analysis/HPI(Location, quality , quantity or severity, timing, setting, factors that make it better or worse, and associate manifestations.(10pts)
b) Review of systems of associated systems, reporting all pertinent positives and negatives (10pts).
c) Any PMH, family hx, social hx, allergies, medications related to the complaint/problem (10pts). If more than one chief complaint, each should be written u in this manner.
3) Objective Data(__25pt.): Vital signs need to be present. Height and Weight should be included where appropriate.
a) Appropriate systems are examined, listed in the note and consistent with those identified in 2b.(10pts).
b) Pertinent positives and negatives must be documented for each relevant system.
c) Any abnormalities must be fully described. Measure and record sizes of things (likes moles, scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).
4) Assessment (___10pts.): Diagnoses should be clearly listed and worded appropriately.
5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counseling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separate numbered sections.
6) Subjective/ Objective, Assessment and Management and Consistent (___10pts.): Does the note support the appropriate differential diagnosis process? Is there evidence that you know what systems and what symptoms go with which complaints? The assessment/diagnoses should be consistent with the subjective section and then the assessment and plan. The management should be consistent with the assessment/ diagnoses identified.
7) Clarity of the Write-up(___5pts.): Is it literate, organized and complete?
Comments:
Total Score: ____________ Instructor: __________________________________
1 sample SAMPLE Block format Soap Note Template.docx
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.