Soap Note 2 Chronic Conditions

   Soap Note 2 Chronic Conditions Soap Note Chronic Conditions (15 Points) Pick any Chronic Disorder from Weeks 6-10 Soap notes get be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)  Follow the MRU Soap Note Rubric as a guide Turn it in Score must be close than 50% or get not be reliable for trustworthiness, must be your own labor and in your own expression. You can resubmit, Final yielding get be reliable if close than 50%. Copy paste from websites or textbooks get not be reliable or tolerated. Please see College Handbook delay regard to Academic Misconduct Statement SOAP NOTE SAMPLE FORMAT FOR MRC    Name:  LP Date:  Time: 1315   Age: 30 Sex: F   SUBJECTIVE   CC:   “I am having vaginal longing and suffering in my inferior abdomen.”   HPI:   Pt is a 30y/o AA womanish, who is   a new enduring that has novelly moved to Miami. She follows texture today following   unsuccessful self-texture of vaginal longing, persistent upon urination, and   inferior abdominal suffering. She is unquiet   for the influence of a vaginal or bladder corruption, or an STD. Pt denies passion. She descriptions the longing and persistent delay   urination has been confer-upon for 3 weeks, and the abdominal suffering has been   intermittent past months ago. Pt has   tried OTC products for the longing, including Monistat and Vagisil. She denies any other urinary symptoms,   including crisis or abundance. She   describes the abdominal suffering as either cutting or gloomy. The suffering raze goes as elevated as 8 out of 10   at spans. 200mg of PO Advil PRN reduces   the suffering to a 7/10. Pt denies any   aggravating factors for the suffering. Pt   reports that she did begin her menstrual cycle this morning, but denies any   other indemnify other that incompact bleeding initiation today. Pt denies douching or the use of any vaginal   irritants. She descriptions that she is in   a conclusiveing sexual homogeneity, and denies any new sexual partners in the conclusive   90 days. She denies any novel or   chronicled notorious snare to STDs. She   reports the use of condoms delay total coital proof, as polite-mannered-mannered as this   being her barely form of contraceptive. She descriptions natural monthly menstrual cycles that conclusive 3-4 days. She descriptions dysmenorrhea, which she besides   takes Advil for. She descriptions her conclusive   PAP varnish was in 7/2016, was natural, and descriptions never having an abnatural PAP   varnish upshot. Pt denies any hx of   pregnancies. Other medical hx includes   GERD. She descriptions that she has an Rx   for Protonix, but she does not charm it total day. Her rise hx includes the influence of DM   and HTN.    Current Medications:  Protonix 40mg PO Daily for GERD MTV OTC PO Daily Advil 200mg OTC PO PRN for suffering   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 heedful grandparents delayout   notorious medical issues; 1 fellow and 3 other sisters delayout notorious medical   issues; No children.   Social History Lives nondescript. Currently in a conclusiveing sexual homogeneity   delay one man. Works for DEFACS. Reports intermittent alcohol use, but denies   tobacco or illicit refuse use.   ROS   General  Denies influence vary, jade,   fever, misinterpretation sweats Cardiovascular Denies chest suffering and edema.   Reports expensive palpitations that are characteristic by drinking water   Skin Denies any wounds, rashes,   bruising, bleeding or peel discolorations, any varys in lesions Respiratory Denies cough. Reports dyspnea   that accompanies the expensive palpitations and is besides characteristic by drinking water   Eyes Denies restorative lenses,   blurring, visual varys of any kind Gastrointestinal Abdominal suffering (see HPI) and Hx   of GERD. Denies N/V/D, constipation,   appetite varys   Ears Denies Ear suffering, hearing forfeiture,   ringing in ears Genitourinary/Gynecological Reports persistent delay urination,   but denies abundance or crisis. Contraceptive and STD hinderance includes condoms delay total coital   event. Ordinary conclusiveing sexual   homogeneity delay one man. Denies   notorious chronicled or novel STD snare. Conclusive PAP was 7/2016 and natural.   Regular monthly menstrual cycle conclusiveing 3-4 days.    Nose/Mouth/Throat Denies sinus completions,   dysphagia, nose bleeds or indemnify Musculoskeletal Denies tail suffering, junction   swelling, cacophony or suffering   Breast Denies SBE Neurological Denies syncope, seizures,   paralysis, worthlessness   Heme/Lymph/Endo Denies bruising, misinterpretation sweats,   swollen glands Psychiatric Denies valley, heed,   sleeping difficulties   OBJECTIVE   Weight   140lb  Temp -97.7 BP 123/82   Height 5’4” Pulse 74 Respiration   18   General Appearance Healthy seeming adult womanish   in no intelligent annoy. Nimble and oriented; answers questions unexceptionably.    Skin Skin is natural hue for   ethnicity, animated, dry, unclouded and undented. No rashes or lesions famous.   HEENT Head is connectedness cephalic, hair   evenly arranged. Neck: Supple. Full ROM. Teeth are in amiable recover.   Cardiovascular S1, S2 delay customary trounce and   rhythm. No extra nature probes.    Respiratory Symmetric chest walls.   Respirations customary and easy; lungs unclouded to auscultation bilaterally.   Gastrointestinal Abdomen flat; BS free in all   4 quadrants. Abdomen mild, suprapubic susceptible. No hepatosplenomegaly.        Genitourinary Suprapubic susceptibleness   noted. Peel hue natural for   ethnicity. Irritation famous at labia   majora, minora, and perineum. No ulcerated lesions famous. Lymph nodes not   palpable. Vagina pink and fresh   externally lesions. Indemnify minimal,   thick, ebon red, no perfume. Cervix pink   externally lesions. No CMT. Uterus natural extent, form, and compound.     Musculoskeletal Full ROM seen in all 4   extremities as enduring moved environing the exam margin.   Neurological  Speech unclouded. Amiable mood.   Posture elevate. Balance conclusiveing; degree natural.   Psychiatric Alert and oriented. Dressed in   unclouded clothes. Maintains eye apposition. Answers questions unexceptionably.   Lab Tests Urinalysis – lineage famous (pt.   on menstrual duration), but upshots disclaiming for corruption Urine refinement 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 span.   Diagnosis    Differential Diagnoses 1-Bacterial Vaginosis (N76.0) 2- Malignant neoplasm of womanish genital organ,         unspecified. (C57.9) 3-Gonococcal corruption, unspecified. (A54.9) Diagnosis o Urinary   tract corruption, predicament not determined. (N39.0) Candidiasis of vulva and vagina.   (B37.3) subordinate to confer-uponing symptoms (Colgan & Williams, 2011) &   (Hainer & Gibson, 2011).    Plan/Therapeutics   Plan:   Medication –  § Terconazole   cream 1 vaginal impression 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, sources, destroys, texture, hinderance. Reasons to follow   emergent heed, including N/V, passion, or tail suffering.  § STD destroys   and hinderances.  § Ulcer   prevention, including initiative Protonix as prescribed, not adequate the   recommended dose boundary of NSAIDs, and not initiative NSAIDs on an void   stomach.  Follow-up –  § Pt get be   contacted delay upshots of STD studies.  § Return to   clinic when haughty the duration for execute pap-varnish or if symptoms do not   resolve delay prescribed TX.              References Colgan, R. & Williams, M. (2011). Speciality and Texture of Intelligent Uncomplicated Cystitis. American Rise Physician, 84(7), 771-776 Hainer, B. & Gibson, M. (2011). Vaginitis: Speciality and Treatment. American Rise 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) 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 conclusive 2018-year, tetanus, and hepatitis A and B 4 years ago. Surgical History: Appendectomy 47 years ago. Family History: Father- died 81 does not description advice  Mother-alive, 88 years old, Diabetes Mellitus, HTN Daughter-alive, 34 years old, healthy Social Hx: No smoking narrative or illicit refuse use, intermittent alcoholic beverage decrease on gregarious celebrations. Retired, widow, he lives nondescript. SUBJECTIVE: Chief complain: “headaches” that begined two weeks ago Symptom analysis/HPI: The enduring is 65 years old hardy who complaining of episodes of guideaches and on 3 incongruous occasions lineage constraining was measured, which was elevated (159/100, 158/98 and 160/100 respectively). Enduring noticed the completion begined two weeks ago and casually it is accompanied by dizziness. He states that he has been underneathneath importance in his laborfix for the conclusive month. Patient denies chest suffering, palpitation, lack of expiration, sea-sickness or vomiting. ROS: CONSTITUTIONAL: Denies passion or chills. Denies worthlessness or influence forfeiture. NEUROLOGIC: Headache and dizziness as picture aggravate. Denies varys in LOC. Denies narrative of tremors or seizures.  HEENT: HEAD: Denies any guide waste, or vary in LOC. Eyes: Denies any varys in confidence, diplopia or blurred confidence. Ear: Denies suffering in the ears. Denies forfeiture of hearing or drainage. Nose: Denies nasal drainage, glomeration. THROAT: Denies throat or neck suffering, hoarseness, difficulty absorption. Respiratory: Enduring denies lack of expiration, cough or hemoptysis. Cardiovascular: No chest suffering, tachycardia. No orthopnea or paroxysmal nocturnal dyspnea. Gastrointestinal: Denies abdominal suffering or disagreeableness. Denies flatulence, sea-sickness, vomiting or diarrhea. Genitourinary: Denies hematuria, dysuria or vary in urinary abundance. Denies difficulty begining/stopping race of urine or dissoluteness. MUSCULOSKELETAL: Denies falls or suffering. Denies hearing a clicking or snapping probe. Skin: No vary of hueation 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 margin air, Ht- 6’4”, Wt 200 lb, BMI 25. Description suffering 0/10. General appearance: The enduring is nimble and oriented x 3. No intelligent annoy famous. NEUROLOGIC: Alert, CNII-XII grossly undented, oriented to individual, fix, and span. Sensation undented to bilateral exalteder and inferior extremities. Bilateral UE/LE force 5/5. HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no susceptibleness. Eyes: No conjunctival injection, no icterus, visual acuity and extraocular eye movements undented. No nystagmus famous. Ears: Bilateral canals indisputable delayout erythema, edema, or exudate. Bilateral tympanic membranes undented, pearly silvery delay cutting cone of incompact. Maxillary sinuses no susceptibleness. Nasal mucosa fresh delayout bleeding. Oral mucosa fresh delayout lesions,.Lids non-remarkable and after a whilehold for pursuit. Neck: limber delayout cervical lymphadenopathy, no jugular temper distention, no thyroid protuberance or magnitudees. Cardiovascular: S1S2, customary trounce and rhythm, no reverberation or gallop famous. Capillary engenerous < 2 sec. Respiratory: No dyspnea or use of abettor muscles observed. No egophony, whispered pectoriloquy or real fremitus on palpation. Expiration probes confer-upons and unclouded bilaterally on auscultation. Gastrointestinal: No magnitude or hernia observed. Upon auscultation, bowel probes confer-upon in all four quadrants, no bruits aggravate renal and aorta arteries. Abdomen mild non-tender, no protecting, no reverberate no distention or organomegaly famous on palpation Musculoskeletal: No suffering to palpation. Free and enduring ROM delayin natural boundarys, no cacophony. Integumentary: undented, no lesions or rashes, no cyanosis or jaundice. Assessment  Essential (Primary) Hypertension (ICD10 I10): Given the symptoms and elevated lineage constraining (156/92 mmhg), classified as station 2. Unintermittently the constitutional source of hypertension has been ruled out, such as renal, adrenal or thyroid, this speciality is confirmed. Differential speciality: Ø Renal artery stenosis (ICD10 I70.1) Ø Chronic offspring disorder (ICD10 I12.9) Ø Hyperthyroidism (ICD10 E05.90) Plan Diagnosis is inveterate on the clinical evaluation through narrative, visible testimony, and uniformity laboratory tests to assess destroy factors, disclose identifiable sources and unmask target-organ hurt, including proof of cardiovascular disorder. These basic laboratory tests are: · CMP · Complete lineage count · Lipid profile · Thyroid-stimulating hormone · Urinalysis · Electrocardiogram Ø Pharmacological texture:  The texture of select in this instance would be: Thiazide-like diuretic and/or a CCB · Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally unintermittently daily.  Ø Non-Pharmacologic texture:  · Influence forfeiture · Healthy viands (DASH viandsary model): Viands generous in enrichment, vegetables, undivided grains, and low-fat dairy products delay poor satisfied of saturated and trans l fat · Poor incharm of viandsary sodium: <1,500 mg/d is optimal aim but at lowest 1,000 mg/d diminution in most adults · Enhanced incharm of viandsary potassium · Customary visible breath (Aerobic): 90–150 min/wk. · Tobacco cessation · Measures to indemnify importance and cogent coping mechanisms. Education · Provide delay nutrition/dietary advice. · Daily lineage constraining monitoring at settlement twice a day for 7 days, haunt a chronicles, adduce the chronicles on the next scrutinize delay her PCP · Instruction environing medication incharm consent.  · Education of feasible complications such as clap, nature invasion, and other completions. · Enduring was educated on race of hypertension, as polite-mannered-mannered as caution signs and symptoms, which could betoken the need to heed the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes underneathstanding to all Follow-ups/Referrals · Evaluation delay PCP in 1 weeks for managing lineage constraining and to evaluate ordinary hypotensive therapy. Urgent Heed scrutinize prn. · No referrals needed at this span. 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). Rise Nurse Practitioner Certification Intensive Review (2nd ed.). ISBN 978-0-8261-3424-0   Chronic Conditions:    Diseases   and Disorders of the Renal/GU System · Intelligent Offspring Waste (AKI) · Bladder Cancer · Glomerulonephritis · Hematuria · Hydronephrosis · Interstitial Cystitis · Priapism · Prostate Cancer · Prostatic Hyperplasia, Benign (BPH) · Prostatitis · Pyelonephritis · Testicular Torsion · Urinary Tract Corruption (UTI)   Diseases   and Disorders of the Endocrine System · Addison Disease · Cushing Syndrome · Diabetes · Graves Disease · Hyper-, Hypoparathyroidism · Hyper-, Hypothyroidism · Myasthenia Gravis · Syndrome of Inwithhold Antidiuretic Hormone Secretion   Diseases   and Disorders of the Gastrointestinal System · Ascites · Appendicitis · Celiac Disease · Cholelithiasis · Cirrhosis · Clostridium Difficile (C. Diff) · Colitis · Crohn’s Disease · Constipation · Diarrhea · Diverticulitis · Esophageal Varices   Diseases   and Disorders of the Gastrointestinal System · Gastritis · Gastroesophageal Reflux Disease · Hemorrhoids  · Hepatic Encephalopathy · Hepatitis · Irritable Bowel Syndrome (IBS) · Pancreatic Cancer · Pancreatitis · PepticUlcerDisease (Zollinger-Ellison Syndrome) · Salmonella Infection