Soap Note 1 Acute Condition

QUESTION

PATIENT INFORMATION

Name Mr W.S.

Age: 65-year-old

Sex: Male

Source: Patient

Allergies: None

Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime

PMH: Hypercholesterolemia

Immunizations: Influenza last 2018-year, tetanus, and hepatitis A and B 4 years ago.

Surgical History: Appendectomy 47 years ago.

Family History: Father- died 81 does not report information

Mother-alive, 88 years old, Diabetes Mellitus, HTN

Daughter-alive, 34 years old, healthy

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

 

 

SUBJECTIVE:

Chief complain: “headaches” that started two weeks ago

Symptom analysis/HPI:

The patient is 65 years old male who complaining of episodes of headaches and on 3 different occasions blood pressure was measured, which was high (159/100, 158/98 and 160/100 respectively). Patient noticed the problem started two weeks ago and sometimes it is accompanied by dizziness. He states that he has been under stress in his workplace for the last month.

Patient denies chest pain, palpitation, shortness of breath, nausea or vomiting.

ROS:

CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss. NEUROLOGIC: Headache and dizzeness as describe above. Denies changes in LOC. Denies history of tremors or seizures.

HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision, diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose: Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty swallowing.

Respiratory: Patient denies shortness of breath, cough or hemoptysis.

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

dyspnea.

Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence, nausea, vomiting or

diarrhea.

Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies difficulty starting/stopping stream of urine or incontinence.

MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.

Skin: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.

Objective Data

CONSTITUTIONAL: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI 25. Report pain 0/10.

General appearance: The patient is alert and oriented x 3. No acute distress noted. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to person, place, and time. Sensation intact to bilateral upper and lower extremities. Bilateral UE/LE strength 5/5.

HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements intact. No nystagmus noted. Ears: Bilateral canals patent without erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray with sharp cone of light. Maxillary sinuses no tenderness. Nasal mucosa moist without bleeding. Oral mucosa moist without lesions,.Lids non-remarkable and appropriate for race.

Neck: supple without cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or masses.

Cardiovascular: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary refill < 2 sec.

Respiratory: No dyspnea or use of accessory muscles observed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.

Gastrointestinal: No mass or hernia observed. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen soft non-tender, no guarding, no rebound no distention or organomegaly noted on palpation

Musculoskeletal: No pain to palpation. Active and passive ROM within normal limits, no stiffness.

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

Assessment

Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and high blood pressure (156/92 mmhg), classified as stage 2. Once the organic cause of hypertension has been ruled out, such as renal, adrenal or thyroid, this diagnosis is confirmed.

Differential diagnosis:

Ø Renal artery stenosis (ICD10 I70.1)

Ø Chronic kidney disease (ICD10 I12.9)

Ø Hyperthyroidism (ICD10 E05.90)

Plan

Diagnosis is based on the clinical evaluation through history, physical examination, and routine laboratory tests to assess risk factors, reveal identifiable causes and detect target-organ damage, including evidence of cardiovascular disease.

These basic laboratory tests are:

· CMP

· Complete blood count

· Lipid profile

· Thyroid-stimulating hormone

· Urinalysis

· Electrocardiogram

Ø Pharmacological treatment:

The treatment of choice in this case would be:

Thiazide-like diuretic and/or a CCB

· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally once daily.

Ø Non-Pharmacologic treatment:

· Weight loss

· Healthy diet (DASH dietary pattern): Diet rich in fruits, vegetables, whole grains, and low-fat dairy products with reduced content of saturated and trans l fat

· Reduced intake of dietary sodium: <1,500 mg/d is optimal goal but at least 1,000 mg/d reduction in most adults

· Enhanced intake of dietary potassium

· Regular physical activity (Aerobic): 90–150 min/wk

· Tobacco cessation

· Measures to release stress and effective coping mechanisms.

Education

· Provide with nutrition/dietary information.

· Daily blood pressure monitoring at home twice a day for 7 days, keep a record, bring the record on the next visit with her PCP

· Instruction about medication intake compliance.

· Education of possible complications such as stroke, heart attack, and other problems.

· Patient was educated on the course of hypertension, as well as warning signs and symptoms, which could indicate the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all

Follow-ups/Referrals

· Evaluation with PCP in 1 week to manage blood pressure and evaluate current hypotensive therapy. Urgent Care visit prn.

· No referrals are needed at this time.

References

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). Family Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0

QUESTION

Soap Note 1 Acute Condition

Soap Note 1 Acute Condition (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 it will not be accepted for credit, it must be your work and in your own words. You can resubmit; the 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 concerning Academic Misconduct Statement.

Late Assignment Policy

Assignments turned in late will have 1 point taken off for everyday assignment that is late; after 7 days assignment will get a 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 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’s complaint should be given in quotes. If the patient has more than one complaint, each complaint should be listed separately (1, 2, etc.) and 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, or 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 the sizes of things (like moles, and scars). Avoid using “ok”, “clear”, “within normal limits”, positive/ negative, and normal/abnormal to describe things. (5pts).

4) Assessment (___10pts.): Diagnoses should be listed and worded appropriately.

5) Plan (___15pts.): Be sure to include any teaching, health maintenance and counselling along with the pharmacological and non-pharmacological measures. If you have more than one diagnosis, it is helpful to have this section divided into separately 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 symptoms go with which complaints? The assessment/diagnosis should be consistent with the subjective section and 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, a new patient who 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 about 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 started her menstrual cycle this morning but denies any discharge other than light bleeding beginning today. Pt denies douching or the use of any vaginal irritants. She reports that she has 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 using condoms with every coital experience, which is her only contraceptive form. She reports regular 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, which was expected, and she 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 does not take it daily. 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 oedema. Reports rare palpitations that are relieved by drinking water

 

Skin

Denies any wounds, rashes, bruising, bleeding or skin discolourations, 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, and ringing in ears

 

Genitourinary/Gynecological

Reports burning with urination but deny frequency or urgency. Contraceptive and STD prevention includes condoms with every coital event. A current stable sexual relationship with one man. Denies known historical or recent STD exposure. The last PAP was on 7/2016 and was normal. A 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 the normal colour for ethnicity, warm, dry, clean and intact. No rashes or lesions were noted.

 

HEENT

The head is norm cephalic, and hair is evenly distributed. Neck: Supple. Full ROM. The teeth are in good repair.

 

Cardiovascular

S1, S2 with regular rate and rhythm. No extra heart sounds.

 

Respiratory

Symmetric chest walls. Respirations are 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 was noted. Skin colour is normal for ethnicity. Irritation was noted at the labia majora, minora, and perineum. No ulcerated lesions were noted. Lymph nodes are not palpable. Vagina pink and moist without lesions. Discharge minimal, thick, dark red, no odour. Cervix pink without lesions. No CMT. Uterus normal size, shape, and consistency.

 

Musculoskeletal

Full ROM saw in all 4 extremities as the 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 is unavailable

Wet prep – inconclusive

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

 

Special Tests- No order at this time.

 

Diagnosis

Differential Diagnoses

1-Bacterial Vaginosis (N76.0)
2- Malignant neoplasm of the 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, and 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 the results of STD studies.

§ Return to the clinic when finished the period for performing 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.

2 sample Sample Regular Soap Note Template.docx