Soap Note 2 Chronic Conditions

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.

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

Urinalysis – blood noted (pt. on menstrual period), but results negative for infection

Urine culture testing unavailable

Wet 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 Diagnoses

1-Bacterial Vaginosis (N76.0)

2- Malignant neoplasm of female genital organ, unspecified. (C57.9)

3-Gonococcal infection, unspecified. (A54.9)

Diagnosis

o 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.

References

Colgan, R. & Williams, M. (2011). Diagnosis and Treatment of Acute Uncomplicated Cystitis. American Family Physician, 84(7), 771-776

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.

Sample Soap Note Template (2)

PATIENT INFORMATION

Name: Mr. W.S.

Age: 65-year-old

Sex: Male

Source: Patient

Allergies: None

Current Medications: Atorvastatin tab 20 mg, 1-tab PO at bedtime

PMH: Hypercholesterolemia

Immunizations: 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, HTN

Daughter-alive, 34 years old, healthy

Social 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 we

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helpasap

This is an open-book individual exam comprised of 5 questions.

Guidelines:

· Put your name in the exam.

· You should submit your exam to your assignment folder in WebTycho in a MS-Word (preferred), MS-RTF, PDF or ASCII file. Please scan your file against viruses before submitting.

· Please keep the full text of the question as part of your answering sheet.

· Be as clear and objective as you can in all questions and be sure you are answering what is asked.

· Justify all your numerical answers and answer all the questions using your own words. Show all your work, including how you found your answer (this is very important and essential to have your answer graded appropriately!).

· Post one file for the exam…do not include separate files!

Problem I – (55 points)

Steve Smith is a restaurant owner who wants to spend his $10,000 to modernize his restaurant by adapting it more closely to the preferences of his repeat customers. Keeping track of his customers’ likes and dislikes. Information such as where they like to sit, what they like to eat, when they normally arrive at the restaurant are all items of interest to him, since he believes that in this way he can better serve his customers. Steve has asked you to develop a system for him that will help make his customers happy while increasing his business.

You have heard what Steve had to say about his customers. There are certainly more preferences that he can keep track of.

Develop a problem definition for Steve…

Next define each area.

Be sure to include several possibilities and not just the minimum: (10pts. per section)

Problem Definition

Issues

Objectives

Requirements

Constraints

Problem II- (50 points)

Please label each question as either closed question or open-ended question.

1. How many personal computers do you have in this department?
2. How is this task performed?
3. Why do you perform the task that way?
4. How many hours of training does a clerk receive?
5. How many customers ordered products from the Web site last month?
6. What are users saying about the new system?
7. How are the checks reconciled?
8. What added features would you like to have in the new billing system?
9. Is the calculation procedure described in the manual?
10. Is there anything else you can tell me about this topic?

You are going to interview the local manager of LDI, a national tire retailer, who has asked you to work as a system analyst on a management information system to provide inventory information. (45pts…15pts. per pyramid, funnel & diamond shape)

Here are five questions you wrote to prepare for the meeting:

1. What are the five physical strengths and five limitations of the end users with respect to performing the national retail inventory processing on a daily basis?
2. What are the top ten high-level needs to make the new inventory system user-friendly, accurate, reliable, and secure?
3. Do you have year-to-date demand and supply metrics that were gathered in the last three months?
4. How often do you update your tire inventories?
5. How many retail stores do you currently have that carry your tire inventory?

List each above listed question in the proper sequence

(1) pyramid structure

(2) funnel structure, and

(3) diamond-shaped structure

C. You are a project manager at L & D Inc., specialized in information technology and network engineering. One of your junior systems analyst came to you for an advice of a technology to capture user information requirements. He described to you that he had talked with his client several times in the past week to define user information requirements. Each time he thought he had captured user information requirements, they’ve already changed. Finally, he thinks his clients do not even know what they want for their system.

Give your junior systems analyst an advice of several types of technology that he could use to capture user information requirements and explain to him how this technology can help him to better define users’ information requirements.

Problem III- (50 points)

1. What are six fact finding techniques and what are the advantages and disadvantages of each?
2. What are the types of facts a systems analyst is required to collect?
3. What is a fact-find strategy that will make the most of your time with end-users?
4. How do you develop an interview agenda and a questionnaire?
5. What is the role of ethics in the process of fact finding?

Problem IV – (50 points)

Perfect Pizza wants to install a system to record orders for pizza and chicken wings. When regular customers call Perfect Pizza on the phone, they are asked their phone number. When the number is typed into a computer, the name, address, and last order date is automatically brought up on the screen. Once the order is taken, the total, including tax and delivery, is calculated. Then the order is given to the cook. A receipt is printed. Occasionally, special offers (coupons) are printed so the customer can get a discount. Drivers who make deliveries give customers a copy of the receipt and a coupon (if any). Weekly totals are kept for comparison with last year’s performance. A summary of business activities for taking an order at Perfect Pizza is as follows:

1. Draw a context-level data flow diagram for Perfect Pizza using the following items. Explode the above context-level diagram by drawing the logical data flow diagram 0 showing all the major processes using the following items:

Process names:

(1) Find and display customer record

(2) Take customer order

(3) Send order to cook

(4) Print customer receipt

(5) Deliver customer order

(6) Print weekly totals

Data stores:

(1) Customer master

(2) Product file

(3) Coupons

(4) Sale history

Entities:

(1) Customer

(2) Management

(3) Cook

Problem V: (50 points)

In the following proposed DFD design, there are some typical errors among external entities (E), processes (P) and data stores (DS).

image1.png

1. Identify and explain errors in the above design. ( Use a narrative explanation )
2. Propose design modifications. (Use a narrative explanation)

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What kinds of benefits are these positions eligible for?

Instructions:

There are 10 positions that have become vacant due to the retirement of the University President. Your task is to recommend a salary range to post, list the benefits that will be provided for these positions, and include a list of perks that may be associated with these positions.

Complete the following table in a total of 525 to 700 words:

Position at the University

Recommend a target salary range for posting?

What kinds of benefits are these positions eligible for?

Will these positions have perks associated with it? (Describe)

University President

Special Assistant to the President

University IT Director

Department Finance Manager

Department HR Manager

HVAC Mechanic

Systems Administrator

Payroll Analyst

Administrative Assistant

Office Assistant

Explain in a total of 350 words how you determined the appropriate salary, benefits, and perks for each of these new roles.

References

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NEED THIS IN AN HOUR OR TWO

NEED HELP WITH THIS PLEASE-

https://bigg-shopp.myshopify.com/collections/all

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