1. Soap Note 1 Acute Conditions
Soap Note 1 Acute ConditionsSoap Note 1 Acute Conditions (15 Points) Due
06/15/2019Pick 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
PolicyAssignments 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 RubricStudent______________________________________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
2. 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.docxSOAP NOTE SAMPLE FORMAT FOR
MRC Name: LPDate: Time: 1315 Age: 30Sex: 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 GERDMTV OTC PO DailyAdvil 200mg OTC PO
PRN for pain PMHx:Allergies: NKA & NKDAMedication Intolerances: DeniesChronic
Illnesses/Major traumasGERDHospitalizations/SurgeriesDenies Family HistoryFather- 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 HistoryLives 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
sweatsCardiovascularDenies chest pain and edema. Reports rare palpitations that are
relieved by drinking water SkinDenies any wounds, rashes, bruising, bleeding or skin
discolorations, any changes in lesionsRespiratoryDenies cough. Reports dyspnea that
accompanies the rare palpitations and is also relieved by drinking water EyesDenies
corrective lenses, blurring, visual changes of any kindGastrointestinalAbdominal pain (see
HPI) and Hx of GERD. Denies N/V/D, constipation, appetite changes EarsDenies Ear pain,
hearing loss, ringing in earsGenitourinary/GynecologicalReports burning with urination,
3. 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/ThroatDenies sinus problems, dysphagia,
nose bleeds or dischargeMusculoskeletalDenies back pain, joint swelling, stiffness or
pain BreastDenies SBENeurologicalDenies syncope, seizures, paralysis,
weakness Heme/Lymph/EndoDenies bruising, night sweats, swollen
glandsPsychiatricDenies depression, anxiety, sleeping
difficulties OBJECTIVE Weight 140lb Temp -97.7BP 123/82 Height 5’4”Pulse
74Respiration 18 General AppearanceHealthy appearing adult female in no acute distress.
Alert and oriented; answers questions appropriately. SkinSkin is normal color for
ethnicity, warm, dry, clean and intact. No rashes or lesions noted. HEENTHead is norm
cephalic, hair evenly distributed. Neck: Supple. Full ROM. Teeth are in good
repair. CardiovascularS1, S2 with regular rate and rhythm. No extra heart
sounds. RespiratorySymmetric chest walls. Respirations regular and easy; lungs clear to
auscultation bilaterally. GastrointestinalAbdomen flat; BS active in all 4 quadrants.
Abdomen soft, suprapubic tender. No
hepatosplenomegaly. GenitourinarySuprapubic 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. MusculoskeletalFull ROM seen in all 4 extremities as
patient moved about the exam room. Neurological Speech clear. Good tone. Posture erect.
Balance stable; gait normal. PsychiatricAlert and oriented. Dressed in clean clothes.
Maintains eye contact. Answers questions appropriately. Lab TestsUrinalysis – blood
noted (pt. on menstrual period), but results negative for infectionUrine culture testing
unavailableWet 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 Diagnoses1-Bacterial Vaginosis (N76.0)2- Malignant
neoplasm of female genital organ, unspecified. (C57.9)3-Gonococcal infection,
unspecified. (A54.9)Diagnosiso 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. ReferencesColgan, R. & Williams, M. (2011). Diagnosis and
Treatment of Acute Uncomplicated Cystitis. American Family Physician, 84(7), 771-
4. 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.docxPATIENT INFORMATIONName: Mr. W.S.Age: 65-
year-oldSex: MaleSource: PatientAllergies: NoneCurrent Medications: Atorvastatin tab 20
mg, 1-tab PO at bedtimePMH: HypercholesterolemiaImmunizations: 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, HTNDaughter-alive, 34 years old, healthySocial 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 agoSymptom 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
nocturnaldyspnea.Gastrointestinal: Denies abdominal pain or discomfort. Denies flatulence,
nausea, vomiting ordiarrhea.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 DataCONSTITUTIONAL: 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,
5. 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 palpationMusculoskeletal: 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)PlanDiagnosis 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· ElectrocardiogramØ
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 allFollow-
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.ReferencesDomino, 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
