Posted: May 1st, 2022

Soap Note 2 Chronic Conditions

  
Cleansing cleaning soap Observe 2 Persistent Conditions
Cleansing cleaning soap Observe Persistent Conditions (15 Components)
Resolve any Persistent Sickness from Weeks 6-10
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SOAP NOTE SAMPLE FORMAT FOR MRC
  
Determine:  LP

Date: 

Time: 1315
 

Age: 30

Intercourse: F
 
SUBJECTIVE
 
CC:  
“I am having vaginal itching and ache in my lower abdomen.”
 
HPI:  
Pt is a 30y/o AA female, who’s   a model new affected individual that has simply currently moved to Miami. She seeks treatment as we communicate after   unsuccessful self-treatment of vaginal itching, burning upon urination, and   lower abdomen ache. She is anxious   for the presence of a vaginal or bladder an an infection, or an STD. Pt denies fever. She research the itching and burning with   urination has been present for Three weeks, and the abdomen ache has been   intermittent since months prior to now. Pt has   tried OTC merchandise for the itching, along with Monistat and Vagisil. She denies one other urinary indicators,   along with urgency or frequency. She   describes the abdomen ache as each sharp or boring. The ache stage goes as extreme as eight out of 10   at events. 200mg of PO Advil PRN reduces   the ache to a 7/10. Pt denies any   aggravating elements for the ache. Pt   research that she did start her menstrual cycle this morning, nonetheless denies any   totally different discharge totally different that delicate bleeding beginning as we communicate. Pt denies douching or the utilization of any vaginal   irritants. She research that she is in   a safe sexual relationship, and denies any new sexual companions throughout the closing   90 days. She denies any newest or   historic recognized publicity to STDs. She   research the utilization of condoms with every coital experience, along with this   being her solely sort of contraceptive. She research common month-to-month menstrual cycles that closing Three-4 days. She research dysmenorrhea, which she moreover   takes Advil for. She research her closing   PAP smear was in 7/2016, was common, and research on no account having an irregular PAP   smear consequence. Pt denies any hx of   pregnancies. Totally different medical hx consists of   GERD. She research that she has an Rx   for Protonix, nonetheless she does not take it every day. Her family hx consists of the presence of DM   and HTN. 
 
Current Medication: 
Protonix 40mg PO On daily basis for GERD
MTV OTC PO On daily basis
Advil 200mg OTC PO PRN for ache
 
PMHx:
Allergy signs:  
NKA & NKDA
Drugs Intolerances: 
Denies
Persistent Sicknesses/Important traumas
GERD
Hospitalizations/Surgical procedures
Denies
 
Family Historic previous
Father- DM & HTN; Mother-   HTN; Older sister- DM & HTN; Maternal and paternal grandparents with out   recognized medical factors; 1 brother and three totally different sisters with out recognized medical   factors; No youngsters.
 
Social Historic previous
Lives alone. For the time being in a safe sexual relationship   with one man. Works for DEFACS. Tales occasional alcohol use, nonetheless denies   tobacco or illicit drug use.
 
ROS
 
Widespread 
Denies weight change, fatigue,   fever, night sweats

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

Respiratory
Denies cough. Tales dyspnea   that accompanies the unusual palpitations and may also be relieved by consuming water
 
Eyes
Denies corrective lenses,   blurring, seen modifications of any kind

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

Genitourinary/Gynecological
Tales burning with urination,   nonetheless denies frequency or urgency. Contraceptive and STD prevention consists of condoms with every coital   event. Current safe sexual   relationship with one man. Denies   recognized historic or newest STD publicity. Ultimate PAP was 7/2016 and common.   Widespread month-to-month menstrual cycle lasting Three-4 days. 
 
Nostril/Mouth/Throat
Denies sinus points,   dysphagia, nostril bleeds or discharge

Musculoskeletal
Denies once more ache, joint   swelling, stiffness or ache
 
Breast
Denies SBE

Neurological
Denies syncope, seizures,   paralysis, weak level
 
Heme/Lymph/Endo
Denies bruising, night sweats,   swollen glands

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

Temp -97.7

BP 123/82
 
Peak 5’4”

Pulse 74

Respiration   18
 
Widespread Look
Healthful displaying grownup female   in no acute distress. Alert and oriented; options questions appropriately. 
 
Pores and pores and skin
Pores and pores and skin is common coloration for   ethnicity, warmth, dry, clear and intact. No rashes or lesions well-known.
 
HEENT
Head is norm cephalic, hair   evenly distributed. Neck: Supple. Full ROM. Tooth are in good restore.
 
Cardiovascular
S1, S2 with frequent value and   rhythm. No additional coronary coronary heart sounds. 
 
Respiratory
Symmetric chest partitions.   Respirations frequent and easy; lungs clear to auscultation bilaterally.
 
Gastrointestinal
Abdomen flat; BS full of life in all   4 quadrants. Abdomen clean, suprapubic tender. No hepatosplenomegaly.  
    
Genitourinary
Suprapubic tenderness   well-known. Pores and pores and skin coloration common for   ethnicity. Irritation well-known at labia   majora, minora, and perineum. No ulcerated lesions well-known. 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 common measurement, kind, and consistency.  
 
Musculoskeletal
Full ROM seen in all 4   extremities as affected particular person moved regarding the examination room.
 
Neurological 
Speech clear. Good tone.   Posture erect. Stability safe; gait common.
 
Psychiatric
Alert and oriented. Sporting   clear clothes. Maintains eye contact. Options questions appropriately.
 
Lab Exams
Urinalysis – blood well-known (pt.   on menstrual interval), nonetheless outcomes damaging for an an infection
Urine custom testing   unavailable
Moist prep – inconclusive 
STD testing pending for   gonorrhea, chlamydia, syphilis, HIV, HSV 1 & 2, Hep B & C 
 
Explicit Exams- No ordered in the meanwhile.
 
Prognosis 
 
Differential Diagnoses

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

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

Plan:  

Drugs – 

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

Education – 

§ Medication   prescribed. 
§ UTI and   Candidiasis indicators, causes, risks, treatment, prevention. Causes to hunt   emergent care, along with N/V, fever, or once more ache. 
§ STD risks   and preventions. 
§ Ulcer   prevention, along with taking Protonix as prescribed, not exceeding the   actually helpful dose prohibit of NSAIDs, and by no means taking NSAIDs on an empty   stomach. 

Observe-up – 

§ Pt will most likely be   contacted with outcomes of STD analysis. 
§ Return to   clinic when accomplished the interval for perform pap-smear or if indicators do not   resolve with prescribed TX.
            
References
Colgan, R. & Williams, M. (2011). Prognosis and Treatment of Acute Uncomplicated Cystitis. American Family Physician, 84(7), 771-776
Hainer, B. & Gibson, M. (2011). Vaginitis: Prognosis and Treatment. American Family Physician, 83(7), 807-815. 
Woo, T. M., & Wynne, A. L. (2012). Pharmacotherapeutics for Nurse Practitioner Prescribers (third ed.). Philadelphia, PA: F.A. Davis Agency.
Sample Cleansing cleaning soap Observe Template (2)
PATIENT INFORMATION
Determine: Mr. W.S.
Age: 65-year-old
Intercourse: Male
Provide: Affected particular person
Allergy signs: None
Current Medication: Atorvastatin tab 20 mg, 1-tab PO at bedtime
PMH: Hypercholesterolemia
Immunizations: Influenza closing 2018-year, tetanus, and hepatitis A and B 4 years prior to now.
Surgical Historic previous: Appendectomy 47 years prior to now.
Family Historic previous: Father- died 81 does not report knowledge
 Mother-alive, 88 years outdated, Diabetes Mellitus, HTN
Daughter-alive, 34 years outdated, healthful
Social Hx: No smoking historic previous or illicit drug use, occasional alcoholic beverage consumption on social celebrations. Retired, widow, he lives alone.
SUBJECTIVE:
Chief complain: “issues” that started two weeks prior to now
Symptom analysis/HPI:
The affected particular person is 65 years outdated male who complaining of episodes of issues and on Three utterly totally different occasions blood stress was measured, which was extreme (159/100, 158/98 and 160/100 respectively). Affected particular person seen the difficulty started two weeks prior to now and usually it is accompanied by dizziness. He states that he has been beneath stress in his workplace for the ultimate month.
Affected particular person denies chest ache, palpitation, shortness of breath, nausea or vomiting.
ROS:
CONSTITUTIONAL: Denies fever or chills. Denies weak level or weight discount. NEUROLOGIC: Headache and dizziness as describe above. Denies modifications in LOC. Denies historic previous of tremors or seizures. 
HEENT: HEAD: Denies any head hurt, or change in LOC. Eyes: Denies any modifications in imaginative and prescient, diplopia or blurred imaginative and prescient. Ear: Denies ache throughout the ears. Denies lack of listening to or drainage. Nostril: Denies nasal drainage, congestion. THROAT: Denies throat or neck ache, hoarseness, downside swallowing.
Respiratory: Affected particular person denies shortness of breath, cough or hemoptysis.
Cardiovascular: No chest ache, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
Gastrointestinal: Denies abdomen ache or discomfort. Denies flatulence, nausea, vomiting or
diarrhea.
Genitourinary: Denies hematuria, dysuria or change in urinary frequency. Denies downside starting/stopping stream of urine or incontinence.
MUSCULOSKELETAL: Denies falls or ache. Denies listening to a clicking or snapping sound.
Pores and pores and skin: No change of coloration resembling cyanosis or jaundice, no rashes or pruritus.
Objective Information
CONSTITUTIONAL: Necessary indicators: 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 ache Zero/10.
Widespread look: The affected particular person is alert and oriented x Three. No acute distress well-known. NEUROLOGIC: Alert, CNII-XII grossly intact, oriented to particular person, place, and time. Sensation intact to bilateral larger and reduce extremities. Bilateral UE/LE power 5/5.
HEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no tenderness. Eyes: No conjunctival injection, no icterus, seen acuity and extraocular eye actions intact. No nystagmus well-known. Ears: Bilateral canals patent with out erythema, edema, or exudate. Bilateral tympanic membranes intact, pearly gray 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 heaps.
Cardiovascular: S1S2, frequent value and rhythm, no murmur or gallop well-known. Capillary refill < 2 sec.
Respiratory: No dyspnea or use of accent muscle tissues seen. No egophony, whispered pectoriloquy or tactile fremitus on palpation. Breath sounds presents and clear bilaterally on auscultation.
Gastrointestinal: No mass or hernia seen. Upon auscultation, bowel sounds present in all four quadrants, no bruits over renal and aorta arteries. Abdomen clean non-tender, no guarding, no rebound no distention or organomegaly well-known on palpation
Musculoskeletal: No ache to palpation. Full of life and passive ROM inside common limits, no stiffness.
Integumentary: intact, no lesions or rashes, no cyanosis or jaundice.
Analysis 
Necessary (Important) Hypertension (ICD10 I10): Given the indicators and hypertension (156/92 mmhg), labeled as stage 2. As quickly because the pure purpose behind hypertension has been dominated out, resembling renal, adrenal or thyroid, this Assessment is confirmed.
Differential Assessment:
Ø Renal artery stenosis (ICD10 I70.1)
Ø Persistent kidney sickness (ICD10 I12.9)
Ø Hyperthyroidism (ICD10 E05.90)
Plan
Prognosis depends on the scientific Assessment by way of historic previous, bodily examination, and routine laboratory checks to judge menace elements, reveal identifiable causes and detect target-organ hurt, along with proof of coronary heart issues.
These main laboratory checks are:
· CMP
· Full blood rely
· Lipid profile
· Thyroid-stimulating hormone
· Urinalysis
· Electrocardiogram
Ø Pharmacological treatment: 
The treatment of choice on this case could be:
Thiazide-like diuretic and/or a CCB
· Hydrochlorothiazide tab 25 mg, Preliminary dose: 25 mg orally as quickly as each day. 
Ø Non-Pharmacologic treatment: 
· Weight discount
· Nutritious eating regimen (DASH dietary pattern): Weight-reduction plan rich in fruits, greens, total grains, and low-fat dairy merchandise with diminished content material materials of saturated and trans l fat
· Lowered consumption of dietary sodium: <1,500 mg/d is ideal function nonetheless not lower than 1,000 mg/d low cost in most adults
· Enhanced consumption of dietary potassium
· Widespread bodily train (Cardio): 90–150 min/wk.
· Tobacco cessation
· Measures to launch stress and environment friendly coping mechanisms.
Education
· Current with vitamin/dietary knowledge.
· On daily basis blood stress monitoring at residence twice a day for 7 days, protect a report, convey the report on the next go to collectively along with her PCP
· Instruction about treatment consumption compliance. 
· Education of doable issues resembling stroke, coronary coronary heart assault, and totally different points.
· Affected particular person was educated heading in the right direction of hypertension, along with warning indicators and indicators, which could level out the need to attend the E.R/U.C. Answered all pt. questions/concerns. Pt verbalizes understanding to all
Observe-ups/Referrals
· Assessment with PCP in 1 weeks for managing blood stress and to guage current hypotensive treatment. Urgent Care go to prn.
· No referrals wished in the meanwhile.
References
Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Scientific Search the recommendation of 2017 (25th ed.). Print (The 5-Minute Search the recommendation of Sequence).
Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Analysis (2nd ed.). ISBN 978-Zero-8261-3424-Zero
 
Persistent Conditions:
  
Illnesses   and Issues of the Renal/GU System
· Acute Kidney Hurt (AKI)
· Bladder Most cancers
· Glomerulonephritis
· Hematuria
· Hydronephrosis
· Interstitial Cystitis
· Priapism
· Prostate Most cancers
· Prostatic Hyperplasia, Benign (BPH)
· Prostatitis
· Pyelonephritis
· Testicular Torsion
· Urinary Tract An an infection (UTI)
 
Illnesses   and Issues of the Endocrine System
· Addison Sickness
· Cushing Syndrome
· Diabetes
· Graves Sickness
· Hyper-, Hypoparathyroidism
· Hyper-, Hypothyroidism
· Myasthenia Gravis
· Syndrome of Inappropriate Antidiuretic Hormone Secretion
 
Illnesses   and Issues of the Gastrointestinal System
· Ascites
· Appendicitis
· Celiac Sickness
· Cholelithiasis
· Cirrhosis
· Clostridium Difficile (C. Diff)
· Colitis
· Crohn’s Sickness
· Constipation
· Diarrhea
· Diverticulitis
· Esophageal Varices
 
Illnesses   and Issues of the Gastrointestinal System
· Gastritis
· Gastroesophageal Reflux Sickness
· Hemorrhoids 
· Hepatic Encephalopathy
· Hepatitis
· Irritable Bowel Syndrome (IBS)
· Pancreatic Most cancers
· Pancreatitis
· PepticUlcerDisease (Zollinger-Ellison Syndrome)
· Salmonella An an infection

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