Soap Note 2 Chronic Conditions

Soap Note 2 Chronic ConditionsChronic Conditions (15 Points)Pick any Chronic Disease from Weeks 6-10Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)Follow the MRU Soap Note Rubric as a guideTurn 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 StatementSOAP NOTE SAMPLE FORMAT FOR MRCName:  LPDate:Time: 1315Age: 30Sex: FSUBJECTIVECC:“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 GERDMTV OTC   PO DailyAdvil   200mg OTC PO PRN for painPMHx:Allergies:NKA & NKDAMedication Intolerances:DeniesChronic Illnesses/Major traumasGERDHospitalizations/SurgeriesDeniesFamily HistoryFather-   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 HistoryLives   alone. Currently in a stable sexual   relationship with one man. Works for   DEFACS. Reports occasional alcohol   use, but denies tobacco or illicit drug use.ROSGeneralDenies   weight change, fatigue, fever, night sweatsCardiovascularDenies   chest pain and edema. Reports rare palpitations that are relieved by drinking   waterSkinDenies   any wounds, rashes, bruising, bleeding or skin discolorations, any changes in   lesionsRespiratoryDenies   cough. Reports dyspnea that accompanies the rare palpitations and is also   relieved by drinking waterEyesDenies corrective   lenses, blurring, visual changes of any kindGastrointestinalAbdominal   pain (see HPI) and Hx of GERD. Denies   N/V/D, constipation, appetite changesEarsDenies   Ear pain, hearing loss, ringing in earsGenitourinary/GynecologicalReports   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/ThroatDenies   sinus problems, dysphagia, nose bleeds or dischargeMusculoskeletalDenies   back pain, joint swelling, stiffness or painBreastDenies   SBENeurologicalDenies   syncope, seizures, paralysis, weaknessHeme/Lymph/EndoDenies   bruising, night sweats, swollen glandsPsychiatricDenies   depression, anxiety, sleeping difficultiesOBJECTIVEWeight   140lbTemp -97.7BP 123/82Height 5’4”Pulse 74Respiration 18General AppearanceHealthy   appearing adult female in no acute distress. Alert and oriented; answers   questions appropriately.SkinSkin is   normal color for ethnicity, warm, dry, clean and intact. No rashes or lesions   noted.HEENTHead is   norm cephalic, hair evenly distributed. Neck: Supple. Full ROM. Teeth are in   good repair.CardiovascularS1, S2   with regular rate and rhythm. No extra heart sounds.RespiratorySymmetric   chest walls. Respirations regular and easy; lungs clear to auscultation   bilaterally.GastrointestinalAbdomen   flat; BS active in all 4 quadrants. Abdomen soft, suprapubic   tender. No hepatosplenomegaly.GenitourinarySuprapubic   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.MusculoskeletalFull   ROM seen in all 4 extremities as patient moved about the exam room.NeurologicalSpeech   clear. Good tone. Posture erect. Balance stable; gait normal.PsychiatricAlert   and oriented. Dressed in clean clothes. Maintains eye contact. Answers   questions appropriately.Lab TestsUrinalysis   – blood noted (pt. on menstrual period), but results negative for infectionUrine   culture testing unavailableWet   prep – inconclusiveSTD   testing pending for gonorrhea, chlamydia, syphilis, HIV, HSV 1 & 2, Hep B   & CSpecial Tests- No ordered at this   time.DiagnosisDifferential Diagnoses1-Bacterial Vaginosis (N76.0)2- Malignant neoplasm of female genital organ,         unspecified. (C57.9)3-Gonococcal infection, unspecified. (A54.9)Diagnosiso 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/TherapeuticsPlan: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.ReferencesColgan, 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.

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