Soap Note 1 Acute Conditions Soap Note 1 Acute Conditions (15 Po

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. 2 sample Sample Regular Soap Note Template.docx 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 or 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 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 weeks for managing blood pressure and to evaluate current hypotensive therapy. Urgent Care visit prn. · No referrals 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

Online Custom Essay

Cost of your order

Pages
{{total || ""}}

Why Choose Us

Top Quality and Well-Researched Papers

We always make sure that writers follow all your instructions precisely. You can choose your academic level: high school, college/university or professional, and we will assign a writer who has a respective degree.

Professional and Experienced Academic Writers

We have a team of professional writers with experience in academic and business writing. Many are native speakers and able to perform any task for which you need help.

Free Unlimited Revisions

If you think we missed something, send your order for a free revision. You have 10 days to submit the order for review after you have received the final document. You can do this yourself after logging into your personal account or by contacting our support.

Prompt Delivery and 100% Money-Back-Guarantee

All papers are always delivered on time. In case we need more time to master your paper, we may contact you regarding the deadline extension. In case you cannot provide us with more time, a 100% refund is guaranteed.

Original & Confidential

We use several writing tools checks to ensure that all documents you receive are free from plagiarism. Our editors carefully review all quotations in the text. We also promise maximum confidentiality in all of our services.

Customer Support 24/7

Our support agents are available 24 hours a day 7 days a week and committed to providing you with the best customer experience. Get in touch whenever you need any assistance.

Our Services

No need to work on your paper at night. Sleep tight, we will cover your back. We offer all kinds of writing services.

Essays

Essay Writing Services

No matter what kind of academic paper you need and how urgent you need it, you are welcome to choose your academic level and the type of your paper at an affordable price. We take care of all your paper needs and give a 24/7 customer care support system.

Admissions

Admission and Business Papers

An admission essay is an essay or other written statement by a candidate, often a potential student enrolling in a college, university, or graduate school. You can be rest assurred that through our service we will write the best admission essay for you.

Editing

Editing and Proofreading

Our academic writers and editors make the necessary changes to your paper so that it is polished. We also format your document by correctly quoting the sources and creating reference lists in the formats APA, Harvard, MLA, Chicago / Turabian.

Coursework

Revision Support

If you think your paper could be improved, you can request a review. In this case, your paper will be checked by the writer or assigned to an editor. You can use this option as many times as you see fit. This is free because we want you to be completely satisfied with the service offered.

eskort eskişehir - adana eskort - escort - izmit eskort - mersin eskorteskort eskişehir - adana eskort - escort - izmit eskort - mersin eskort