Soap Note 2 Chronic Conditions Assignment

Soap Note 2 Chronic Conditions Assignment

Soap Note Chronic Conditions (15 Points)

Pick any Chronic Disease from Weeks 6-10

Soap notes will 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 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

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.