Follow the MRU Soap Note Rubric as a guide:Use APA format and must include minimum of 2 Scholarly Citations.Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)Tu
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Follow the MRU Soap Note Rubric as a guide:
Use APA format and must include minimum of 2 Scholarly Citations.
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.
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.
Follow the MRU Soap Note Rubric as a guide:Use APA format and must include minimum of 2 Scholarly Citations.Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)Tu
Chapter 9 Summary The Early History of Magazines The term magazine comes from a French word that means “storehouse.” Today, magazines are collections of articles, stories, and advertisements in a nondaily periodical not published in a newspaper style. The first magazines were published in European countries and often used for political commentary or persuasion. This form of publishing was imported to the American colonies, where the costs of production and delivery combined to keep industry growth slow for several decades. Most magazines were smaller local or regional publications, and many were devoted to certain categories of readers. As literacy increased and printing and transportation technology improved in the nineteenth century, a market was created for national magazines. One of the most famous examples is the Saturday Evening Post, which was launched in 1821 and became the longest–running magazine in U.S. history. In addition to the move to national circulation, there were two other important developments in magazine publishing at this time: magazines targeting a female audience, like Ladies’ Magazine and Godey’s Look Book; and the emergence of illustrations in magazines. The Development of Modern American Magazines The turn of the twentieth century saw faster growth in the industry as well as the rise of several major magazines as instruments for social reform. Muckrakers exposed unfair business practices and corruption in government. As muckraking journals became less popular after World War I, general–interest magazines, which often prominently featured photojournalism, rose to prominence. The Saturday Evening Post, Life, and Look were three of the most popular titles of the day, reaching millions of readers. Sadly, despite a large circulation and strong pass–along readership, competition from television and other factors meant many of these titles struggled and eventually folded in the 1950s and 1960s. Still, titles like TV Guide and People managed to use new business models and the public’s fascination with television to great success. In the last fifteen years, the newer electronic medium of the Internet is being embraced by the magazine industry. Publishing online eliminates the cost of printing and transportation, as well as space concerns. Major magazines typically offer online versions, which carry additional content like video, blogs, games, and other interactive components. Webzines(online–only magazines) like Slate and Salon have helped legitimize the Web as a site for breaking news and discussing culture and politics. Other Webzines are redefining the look, feel, and touch of the magazine. The Domination of Specialization While the history of specialization stretches back to the earliest days of magazines, the trend all but completely took over the industry starting in the 1950s, due largely to competition from television. Magazines today are first divided by advertiser type; there are consumer magazines (Cosmo), business or trade magazines (Advertising Age), and Chapter 9 Summary farm magazines (Dakota Farmer). Still others, such as Consumer Reports, fall into the noncommercial category, which relies completely on subscription and newsstand sales. Some categories of new specialized magazines include: men’s and women’s magazines; sports, entertainment, and leisure magazines; magazines for specific age groups; elite magazines; minority–targeted magazines; and supermarket tabloids. By focusing on niche audiences, the magazine industry continues to find readers. The Organization and Economics of Magazines Today a magazine can be a small one–person operation produced with computer–driven desktop publishing or an elaborate production operation with large staffs and multiple departments. Traditionally there are three parts of the magazine publishing business: (1) editorial and production staff that create the non–advertising content of the magazine; (2) advertising and sales staff that secure clients, arrange promotions, and place ads; and the (3) circulation and distribution department that monitors single–copy and subscription sales. The quest to make a profit means that major specialized magazines are trying to fit into even smaller niches by producing regional editions, split–run editions, and demographic editions. In general, magazines earn money from single–issue sales at places like newsstands and supermarkets, annual subscriptions, evergreen subscriptions that are set to renew automatically each year, and from selling ads. Publishers may also produce glossy high–end catalogs called magalogs for their customers. While the Internet has opened new inexpensive avenues for already–existing alternative publications (including zines), most of the popular magazine titles are still owned by a few large companies or chains. The largest of these in terms of circulation are Time Warner, Meredith Corporation, Hearst Corporation, Advance Publications, and Reader’s Digest Association. Magazines in a Democratic Society Historically, magazines have offered the flexibility to provide more analysis and insight into society than other media outlets. This has often been of great benefit to a democratic society. Unfortunately, the business needs of the magazine industry have also meant readers were viewed first as a commodity for advertisers, and second as members of society.
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