Soap Note Chronic Conditions (15 Points)
Chronic Disease ( Gastritis)
Follow the 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 25% 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 25%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.
Please use the sample templates for you soap note, keep these templates for when you start clinicals.
The use of templates is ok with regards of Turn it in, but the Patient History, CC, HPI, The Assessment and Plan should be of your own work and individualized to your made up patient.
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SOAP note for a patient with chronic gastritis:
S: Subjective
Chief Complaint (CC): The patient is a 45-year-old male who presents with a chief complaint of epigastric pain for the past 6 months.
History of Present Illness (HPI): The patient reports a 6-month history of intermittent burning pain in the upper abdomen, approximately 2-3 times per week. The pain is usually mild but occasionally becomes moderate in severity. It is usually brought on by eating spicy or fatty foods. Antacids provide some relief. He denies any nausea, vomiting, diarrhea, or weight loss.
Past Medical History: Hypertension, hyperlipidemia, GERD
Past Surgical History: None
Family History: Mother with peptic ulcer disease
Social History: Married. Works as an accountant. Smokes 1/2 pack of cigarettes per day for 20 years. Drinks alcohol socially (2 drinks per week).
O: Objective
Vital Signs: BP 138/88, Pulse 80, Respirations 18, Temperature 98.6°F, O2 Saturation 98% on room air
Physical Exam: General: Well-developed, well-nourished in no acute distress. HEENT: Normocephalic, atraumatic. Neck: Supple, no lymphadenopathy. Cardiovascular: Regular rate and rhythm without murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally without wheezes, rhonchi, or rales. Abdomen: Soft, non-tender, non-distended. No hepatosplenomegaly. Normal bowel sounds. No rebound or guarding. Rectal: Hemoccult negative.
Laboratory Data: CBC, CMP, and EGD were performed last month and were normal.
A: Assessment
Chronic gastritis
GERD
Hypertension
Hyperlipidemia
P: Plan
Counsel patient on lifestyle modifications including smoking cessation, limiting fatty/spicy foods, weight control if overweight.
Prescribe proton pump inhibitor (PPI) daily for gastritis. Recommend omeprazole 20 mg by mouth daily for 8 weeks and follow up in 4-6 weeks.
Continue current medications for hypertension and hyperlipidemia: lisinopril 10 mg daily and atorvastatin 20 mg daily.
Recommend follow up in 4-6 weeks to assess response to treatment. May need endoscopy in future if symptoms persist.
References:
Fass, R. (2009). Management of gastritis and gastroesophageal reflux disease. Journal of Clinical Gastroenterology, 43(1), 35-43. https://doi.org/10.1097/MCG.0b013e31815c1c4c
Katz, P. O., Gerson, L. B., & Vela, M. F. (2013). Guidelines for the diagnosis and management of gastroesophageal reflux disease. The American Journal of Gastroenterology, 108(3), 308-28. https://doi.org/10.1038/ajg.2012.444
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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
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
o 1-Bacterial Vaginosis (N76.0)
o 2- Malignant neoplasm of female genital organ, unspecified. (C57.9)
o 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:
o 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)
o 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.
o 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.
