Loading...

Messages

Proposals

Stuck in your homework and missing deadline? Get urgent help in $10/Page with 24 hours deadline

Get Urgent Writing Help In Your Essays, Assignments, Homeworks, Dissertation, Thesis Or Coursework & Achieve A+ Grades.

Privacy Guaranteed - 100% Plagiarism Free Writing - Free Turnitin Report - Professional And Experienced Writers - 24/7 Online Support

Sample soap note for abdominal pain

03/11/2021 Client: muhammad11 Deadline: 2 Day

Soap Note Gastritis

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.

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

· 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.

Homework is Completed By:

Writer Writer Name Amount Client Comments & Rating
Instant Homework Helper

ONLINE

Instant Homework Helper

$36

She helped me in last minute in a very reasonable price. She is a lifesaver, I got A+ grade in my homework, I will surely hire her again for my next assignments, Thumbs Up!

Order & Get This Solution Within 3 Hours in $25/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 3 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 6 Hours in $20/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 6 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

Order & Get This Solution Within 12 Hours in $15/Page

Custom Original Solution And Get A+ Grades

  • 100% Plagiarism Free
  • Proper APA/MLA/Harvard Referencing
  • Delivery in 12 Hours After Placing Order
  • Free Turnitin Report
  • Unlimited Revisions
  • Privacy Guaranteed

6 writers have sent their proposals to do this homework:

Homework Tutor
Top Class Engineers
Engineering Solutions
Assignment Solver
ECFX Market
Top Rated Expert
Writer Writer Name Offer Chat
Homework Tutor

ONLINE

Homework Tutor

I am an experienced researcher here with master education. After reading your posting, I feel, you need an expert research writer to complete your project.Thank You

$21 Chat With Writer
Top Class Engineers

ONLINE

Top Class Engineers

I have read your project description carefully and you will get plagiarism free writing according to your requirements. Thank You

$19 Chat With Writer
Engineering Solutions

ONLINE

Engineering Solutions

I am a professional and experienced writer and I have written research reports, proposals, essays, thesis and dissertations on a variety of topics.

$31 Chat With Writer
Assignment Solver

ONLINE

Assignment Solver

I am a PhD writer with 10 years of experience. I will be delivering high-quality, plagiarism-free work to you in the minimum amount of time. Waiting for your message.

$30 Chat With Writer
ECFX Market

ONLINE

ECFX Market

I find your project quite stimulating and related to my profession. I can surely contribute you with your project.

$23 Chat With Writer
Top Rated Expert

ONLINE

Top Rated Expert

After reading your project details, I feel myself as the best option for you to fulfill this project with 100 percent perfection.

$22 Chat With Writer

Let our expert academic writers to help you in achieving a+ grades in your homework, assignment, quiz or exam.

Similar Homework Questions

How values affect choices - Student integrity - Hydraulic grade line formula - ART APPRECIATION - Discussion-8 MM - Relationship between certainty and doubt - Nebosh igc element 1 foundations in health and safety notes - Egan's 3 stage model - Monkey on my back management book - Why you should donate blood speech outline - 300 words - Chipping sodbury tennis club - Simulation everest harvard - Georgia military college honor code - Lost wax technique dentistry - Black wattle bay high school - Operational plan of coca cola company - Should mobile phones be banned - Advantages of one way anova - Notre dame advanced standing - Suppose that a monopolistically competitive restaurant - Semantic feature analysis words - Binary to gray code table - Https www law2 byu edu career_services jobbank - Hius 221 quiz 2 - Flue gas analysis ppt - Information Governance discussion 2 - What is the basic building block of society - Unit 5 Assignment - Workplace Safety Program - Bahrain garden of eden - Summary of 500 words - The retained earnings statement shows - Square number word problems - How to use navy dive tables - Master of economics uq - Fate vs free will macbeth - Paper - Findit@au - 13 ft lbs to nm - Aquatap plumbing point cook - Thesis statement on the drafting of the us constitution - Private peaceful last chapter - Betta grower mt waverley - Spell spirit of the wilderness raglan - Garden city management pte ltd - Grp products ltd bolton - Oars acer pat test - The four lenses of wellness - Cascaded amplifier gain formula - Para swimming classification masterlist - Sex offender registry mn watchdog - Judgmental and mechanical methods - Glitz green 2l cleaning vinegar - Describe conduction convection and radiation - Virtual water quality lab - Human population growth most closely resembles - A girl pushes a kg lawn mower - A soft drink machine is regulated so that - Traffic control uniform victoria - Discussion(TM) - Assignment - Critically examines the relationship between crisis management - How to find vce in a transistor - Slot machine java - María sergio, ¿quieres hacer diligencias ahora o por la tarde? - Business Management- Assign 2- Power Point - IT Information Dashboards Essay - 3 Pages - Due 3rd Oct - Technical Writing in Criminal Justice - Chapter 4 - Jane elliott blue eyed video - Electrogas welding advantages and disadvantages - Equal Protection and Public Education Essay - How does the oxygen cycle work - Cola Wars Continue: Coke and Pepsi in 2010 - Selkirk townhomes kicking horse - Containment level 2 checklist - Cell division and cancer review worksheet - How to measure current on a breadboard - Cash disbursement journal template - Business continuity and disaster recovery plan - What does mrs gren stand for - Ab inbev investor presentation - Creative Solutions - De facto definition centrelink - Mission vision and objectives of coca cola company - Statistics chapter 4 practice finding outliers - When the weather reflects the mood - 12500 in standard form - According to economy from walden what happened before the framing - Article analysis by 10/16 /2020 at 6:00 pm please add references - Southwark council bulky waste - Chemistry acid base titration lab report - Evaluating polynomial functions worksheet pdf - The little prince journal - 200 kva transformer load capacity - Managerial accounting - Bibical Faith Papper - Red bull wall to wall production - Battery spill containment requirements - PSY 8 - 1908 sir donald bradman 20 cent coin worth - South african national fish galjoen