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Posted: January 31st, 2023

Soap Note 2 Chronic Conditions

  
Cleaning soap Observe 2 Persistent Situations
Cleaning soap Observe Persistent Situations (15 Factors)
Decide any Persistent Illness from Weeks 6-10
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SOAP NOTE SAMPLE FORMAT FOR MRC
  
Identify:  LP

Date: 

Time: 1315
 

Age: 30

Intercourse: F
 
SUBJECTIVE
 
CC:  
“I’m having vaginal itching and ache in my decrease stomach.”
 
HPI:  
Pt is a 30y/o AA feminine, who’s   a brand new affected person that has just lately moved to Miami. She seeks remedy as we speak after   unsuccessful self-treatment of vaginal itching, burning upon urination, and   decrease stomach ache. She is anxious   for the presence of a vaginal or bladder an infection, or an STD. Pt denies fever. She studies the itching and burning with   urination has been current for Three weeks, and the stomach ache has been   intermittent since months in the past. Pt has   tried OTC merchandise for the itching, together with Monistat and Vagisil. She denies another urinary signs,   together with urgency or frequency. She   describes the stomach ache as both sharp or boring. The ache stage goes as excessive as eight out of 10   at occasions. 200mg of PO Advil PRN reduces   the ache to a 7/10. Pt denies any   aggravating components for the ache. Pt   studies that she did begin her menstrual cycle this morning, however denies any   different discharge different that mild bleeding starting as we speak. Pt denies douching or the usage of any vaginal   irritants. She studies that she is in   a secure sexual relationship, and denies any new sexual companions within the final   90 days. She denies any latest or   historic identified publicity to STDs. She   studies the usage of condoms with each coital expertise, in addition to this   being her solely type of contraceptive. She studies regular month-to-month menstrual cycles that final Three-Four days. She studies dysmenorrhea, which she additionally   takes Advil for. She studies her final   PAP smear was in 7/2016, was regular, and studies by no means having an irregular PAP   smear consequence. Pt denies any hx of   pregnancies. Different medical hx consists of   GERD. She studies that she has an Rx   for Protonix, however she doesn’t take it each day. Her household hx consists of the presence of DM   and HTN. 
 
Present Drugs: 
Protonix 40mg PO Every day for GERD
MTV OTC PO Every day
Advil 200mg OTC PO PRN for ache
 
PMHx:
Allergy symptoms:  
NKA & NKDA
Medicine Intolerances: 
Denies
Persistent Sicknesses/Main traumas
GERD
Hospitalizations/Surgical procedures
Denies
 
Household Historical past
Father- DM & HTN; Mom-   HTN; Older sister- DM & HTN; Maternal and paternal grandparents with out   identified medical points; 1 brother and three different sisters with out identified medical   points; No kids.
 
Social Historical past
Lives alone. At the moment in a secure sexual relationship   with one man. Works for DEFACS. Stories occasional alcohol use, however denies   tobacco or illicit drug use.
 
ROS
 
Common 
Denies weight change, fatigue,   fever, evening sweats

Cardiovascular
Denies chest ache and edema.   Stories uncommon palpitations which can be relieved by consuming water
 
Pores and skin
Denies any wounds, rashes,   bruising, bleeding or pores and skin discolorations, any modifications in lesions

Respiratory
Denies cough. Stories dyspnea   that accompanies the uncommon palpitations and can also be relieved by consuming water
 
Eyes
Denies corrective lenses,   blurring, visible modifications of any form

Gastrointestinal
Stomach ache (see HPI) and Hx   of GERD. Denies N/V/D, constipation,   urge for food modifications
 
Ears
Denies Ear ache, listening to loss,   ringing in ears

Genitourinary/Gynecological
Stories burning with urination,   however denies frequency or urgency. Contraceptive and STD prevention consists of condoms with each coital   occasion. Present secure sexual   relationship with one man. Denies   identified historic or latest STD publicity. Final PAP was 7/2016 and regular.   Common month-to-month menstrual cycle lasting Three-Four days. 
 
Nostril/Mouth/Throat
Denies sinus issues,   dysphagia, nostril bleeds or discharge

Musculoskeletal
Denies again ache, joint   swelling, stiffness or ache
 
Breast
Denies SBE

Neurological
Denies syncope, seizures,   paralysis, weak point
 
Heme/Lymph/Endo
Denies bruising, evening sweats,   swollen glands

Psychiatric
Denies despair, nervousness,   sleeping difficulties
 
OBJECTIVE
 
Weight   140lb 

Temp -97.7

BP 123/82
 
Peak 5’Four”

Pulse 74

Respiration   18
 
Common Look
Wholesome showing grownup feminine   in no acute misery. Alert and oriented; solutions questions appropriately. 
 
Pores and skin
Pores and skin is regular coloration for   ethnicity, heat, dry, clear and intact. No rashes or lesions famous.
 
HEENT
Head is norm cephalic, hair   evenly distributed. Neck: Supple. Full ROM. Tooth are in good restore.
 
Cardiovascular
S1, S2 with common price and   rhythm. No further coronary heart sounds. 
 
Respiratory
Symmetric chest partitions.   Respirations common and simple; lungs clear to auscultation bilaterally.
 
Gastrointestinal
Stomach flat; BS lively in all   Four quadrants. Stomach smooth, suprapubic tender. No hepatosplenomegaly.  
    
Genitourinary
Suprapubic tenderness   famous. Pores and skin coloration regular for   ethnicity. Irritation famous at labia   majora, minora, and perineum. No ulcerated lesions famous. Lymph nodes not   palpable. Vagina pink and moist   with out lesions. Discharge minimal,   thick, darkish crimson, no odor. Cervix pink   with out lesions. No CMT. Uterus regular measurement, form, and consistency.  
 
Musculoskeletal
Full ROM seen in all Four   extremities as affected person moved in regards to the examination room.
 
Neurological 
Speech clear. Good tone.   Posture erect. Stability secure; gait regular.
 
Psychiatric
Alert and oriented. Wearing   clear garments. Maintains eye contact. Solutions questions appropriately.
 
Lab Exams
Urinalysis – blood famous (pt.   on menstrual interval), however outcomes damaging for an infection
Urine tradition testing   unavailable
Moist prep – inconclusive 
STD testing pending for   gonorrhea, chlamydia, syphilis, HIV, HSV 1 & 2, Hep B & C 
 
Particular Exams- No ordered at the moment.
 
Prognosis 
 
Differential Diagnoses

1-Bacterial Vaginosis (N76.Zero)
2- Malignant neoplasm of feminine genital organ,         unspecified. (C57.9)
Three-Gonococcal an infection, unspecified. (A54.9)

Prognosis
o Urinary   tract an infection, web site not specified. (N39.Zero) Candidiasis of vulva and vagina.   (B37.Three) secondary to presenting signs (Colgan & Williams, 2011) &   (Hainer & Gibson, 2011). 
 
Plan/Therapeutics
 

Plan:  

Medicine – 

§ Terconazole   cream 1 vaginal utility QHS for 7 days for Vulvovaginal Candidiasis; 
§ Sulfamethoxazole/TMP   DS 1 pill PO twice every day for Three days for UTI (Woo & Wynne, 2012)

Schooling – 

§ Drugs   prescribed. 
§ UTI and   Candidiasis signs, causes, dangers, remedy, prevention. Causes to hunt   emergent care, together with N/V, fever, or again ache. 
§ STD dangers   and preventions. 
§ Ulcer   prevention, together with taking Protonix as prescribed, not exceeding the   really useful dose restrict of NSAIDs, and never taking NSAIDs on an empty   abdomen. 

Observe-up – 

§ Pt will probably be   contacted with outcomes of STD research. 
§ Return to   clinic when completed the interval for carry out pap-smear or if signs don’t   resolve with prescribed TX.
            
References
Colgan, R. & Williams, M. (2011). Prognosis and Remedy of Acute Uncomplicated Cystitis. American Household Doctor, 84(7), 771-776
Hainer, B. & Gibson, M. (2011). Vaginitis: Prognosis and Remedy. American Household Doctor, 83(7), 807-815. 
Woo, T. M., & Wynne, A. L. (2012). Pharmacotherapeutics for Nurse Practitioner Prescribers (third ed.). Philadelphia, PA: F.A. Davis Firm.
Pattern Cleaning soap Observe Template (2)
PATIENT INFORMATION
Identify: Mr. W.S.
Age: 65-year-old
Intercourse: Male
Supply: Affected person
Allergy symptoms: None
Present Drugs: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza final 2018-year, tetanus, and hepatitis A and B Four years in the past.
Surgical Historical past: Appendectomy 47 years in the past.
Household Historical past: Father- died 81 doesn’t report data
 Mom-alive, 88 years outdated, Diabetes Mellitus, HTN
Daughter-alive, 34 years outdated, wholesome
Social Hx: No smoking historical past or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain: “complications” that began two weeks in the past
Symptom evaluation/HPI:
The affected person is 65 years outdated male who complaining of episodes of complications and on Three completely different events blood stress was measured, which was excessive (159/100, 158/98 and 160/100 respectively). Affected person seen the issue began two weeks in the past and typically it’s accompanied by dizziness. He states that he has been underneath stress in his office for the final month.
Affected person denies chest ache, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL: Denies fever or chills. Denies weak point or weight reduction. NEUROLOGIC: Headache and dizziness as describe above. Denies modifications in LOC. Denies historical past of tremors or seizures. 
HEENT: HEAD: Denies any head harm, or change in LOC. Eyes: Denies any modifications in imaginative and prescient, diplopia or blurred imaginative and prescient. Ear: Denies ache within the ears. Denies lack of listening to or drainage. Nostril: Denies nasal drainage, congestion. THROAT: Denies throat or neck ache, hoarseness, problem swallowing.
Respiratory: Affected person denies shortness of breath, cough or hemoptysis.
Cardiovascular: No chest ache, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal: Denies stomach ache or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies problem beginning/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or ache. Denies listening to a clicking or snapping sound.
Pores and skin: No change of coloration resembling cyanosis or jaundice, no rashes or pruritus.
Goal Knowledge
CONSTITUTIONAL: Important indicators: Temperature: 98.5 °F, Pulse: 87, BP: 159/92 mmhg, RR 20, PO2-98% on room air, Ht- 6’Four”, Wt 200 lb, BMI 25. Report ache Zero/10.
Common look: The affected person is alert and oriented x Three. No acute misery famous. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to individual, place, and time. Sensation intact to bilateral higher and decrease extremities. Bilateral UE/LE energy 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, visible acuity and extraocular eye actions intact. No nystagmus famous. Ears: Bilateral canals patent with out erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly grey with sharp cone of sunshine. Maxillary sinuses no tenderness. Nasal mucosa moist with out bleeding. Oral mucosa moist with out lesions,.Lids non-remarkable and acceptable for race.
Neck: supple with out cervical lymphadenopathy, no jugular vein distention, no thyroid swelling or lots.
Cardiovascular: S1S2, common price and rhythm, no murmur or gallop famous. Capillary refill < 2 sec.
Respiratory: No dyspnea or use of accent muscle tissues noticed. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
Gastrointestinal: No mass or hernia noticed. Upon auscultation, bowel sounds current in all 4 quadrants, no bruits over renal and aorta arteries. Stomach smooth non-tender, no guarding, no rebound no distention or organomegaly famous on palpation
Musculoskeletal: No ache to palpation. Lively and passive ROM inside regular limits, no stiffness.
Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.
Evaluation 
Important (Main) Hypertension (ICD10 I10): Given the signs and hypertension (156/92 mmhg), labeled as stage 2. As soon as the natural reason behind hypertension has been dominated out, resembling renal, adrenal or thyroid, this analysis is confirmed.
Differential analysis:
Ø Renal artery stenosis (ICD10 I70.1)
Ø Persistent kidney illness (ICD10 I12.9)
Ø Hyperthyroidism (ICD10 E05.90)
Plan
Prognosis relies on the scientific analysis via historical past, bodily examination, and routine laboratory checks to evaluate threat components, reveal identifiable causes and detect target-organ harm, together with proof of heart problems.
These primary laboratory checks are:
· CMP
· Full blood depend
· Lipid profile
· Thyroid-stimulating hormone
· Urinalysis
· Electrocardiogram
Ø Pharmacological remedy: 
The remedy of selection on this case can be:
Thiazide-like diuretic and/or a CCB
· Hydrochlorothiazide tab 25 mg, Preliminary dose: 25 mg orally as soon as every day. 
Ø Non-Pharmacologic remedy: 
· Weight reduction
· Nutritious diet (DASH dietary sample): Weight-reduction plan wealthy in fruits, greens, entire grains, and low-fat dairy merchandise with diminished content material of saturated and trans l fats
· Lowered consumption of dietary sodium: <1,500 mg/d is perfect purpose however not less than 1,000 mg/d discount in most adults
· Enhanced consumption of dietary potassium
· Common bodily exercise (Cardio): 90–150 min/wk.
· Tobacco cessation
· Measures to launch stress and efficient coping mechanisms.
Schooling
· Present with vitamin/dietary data.
· Every day blood stress monitoring at residence twice a day for 7 days, preserve a report, convey the report on the subsequent go to together with her PCP
· Instruction about remedy consumption compliance. 
· Schooling of doable problems resembling stroke, coronary heart assault, and different issues.
· Affected person was educated on the right track of hypertension, in addition to warning indicators and signs, which might point out the necessity to attend the E.R/U.C. Answered all pt. questions/considerations. Pt verbalizes understanding to all
Observe-ups/Referrals
· Analysis with PCP in 1 weeks for managing blood stress and to guage present hypotensive remedy. Pressing Care go to prn.
· No referrals wanted at the moment.
References
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Scientific Seek the advice of 2017 (25th ed.). Print (The 5-Minute Seek the advice of Sequence).
Codina Leik, M. T. (2014). Household Nurse Practitioner Certification Intensive Evaluation (2nd ed.). ISBN 978-Zero-8261-3424-Zero
 
Persistent Situations:
  
Ailments   and Problems of the Renal/GU System
· Acute Kidney Harm (AKI)
· Bladder Most cancers
· Glomerulonephritis
· Hematuria
· Hydronephrosis
· Interstitial Cystitis
· Priapism
· Prostate Most cancers
· Prostatic Hyperplasia, Benign (BPH)
· Prostatitis
· Pyelonephritis
· Testicular Torsion
· Urinary Tract An infection (UTI)
 
Ailments   and Problems of the Endocrine System
· Addison Illness
· Cushing Syndrome
· Diabetes
· Graves Illness
· Hyper-, Hypoparathyroidism
· Hyper-, Hypothyroidism
· Myasthenia Gravis
· Syndrome of Inappropriate Antidiuretic Hormone Secretion
 
Ailments   and Problems of the Gastrointestinal System
· Ascites
· Appendicitis
· Celiac Illness
· Cholelithiasis
· Cirrhosis
· Clostridium Difficile (C. Diff)
· Colitis
· Crohn’s Illness
· Constipation
· Diarrhea
· Diverticulitis
· Esophageal Varices
 
Ailments   and Problems of the Gastrointestinal System
· Gastritis
· Gastroesophageal Reflux Illness
· Hemorrhoids 
· Hepatic Encephalopathy
· Hepatitis
· Irritable Bowel Syndrome (IBS)
· Pancreatic Most cancers
· Pancreatitis
· PepticUlcerDisease (Zollinger-Ellison Syndrome)
· Salmonella An infection

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