Soap Note 2 Chronic Conditions

24 Aug Soap Note 2 Chronic Conditions

Soap Note 2 Chronic Conditions

Soap Note Chronic Conditions (15 Points)

Pick any Chronic Disease from Weeks 6-10

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Follow the MRU Soap Note Rubric as a guide

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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