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.

            

THIS IS A RESPONSE TO DISCUSSION BELOW, PLEASE USE APA & IN-TEXT CITATIONS. NO MORE THAN 200 WORDS.

  I was always taught in nursing school that pain is what the patient says that it is. We cannot feel what the patient is feeling, so we have to believe the patient and what they are telling us. “McCaffery defined pain as ‘whatever the experiencing person says it is, existing whenever he says it does’” (Huether &McCance, 2017, p.336). Pain effects each and every person differently. There are many different types of pain caused by many different diagnoses and issues. “Acute pain is transient, usually lasting seconds to days, sometimes up to 3 months. It begins suddenly and is relieved after the chemical mediators that stimulate pain receptors are removed” (Huether & McCance, 2017, p.340). When I think of acute pain, I think of getting a shot. A shot hurts while we are receiving the shot but is quickly relieved once the shot is over. “Visceral pain often radiates (spreads away from the actual site of the pain) or is referred. Referred pain is felt in an area removed or distant from its point of origin- the area of referred pain is supplied by the same spinal segment as the actual site of pain” (Huether & McCance, 2017, p.340). An example of referred pain would be left arm pain during a heart attack. Pain that is radiating away from the actual site of where the hurt is. “Chronic or persistent pain has been defined as lasting for more than 3 to 6 months and is pain lasting well beyond the expected healing time”(Huether & McCance, 2017, p.340). We hear of a lot of people struggling with chronic back pain. 

Pain can feel throbbing, stabbing, aching, burning, cramping, squeezing, etc. There are different factors that affect pain as well. “There are important age and sex differences in the clinical presentations of chronic pain patients. Some older patients present with unique clinical profiles that may reflect cohort differences, and/or physiological or psychological adjustment processes. There appears to be a greater number of distinct chronic pain presentations among females” (Cook & Chastain, 2001, para.5). Age and gender are just 2 factors that can affect pain and the way it is perceived. “In general, the prevalence of chronic pain has been found to be 50% or more among people aged 65 years or older” (Karjalainen, Saltevo, Tiihonen, Haanpää, Kautiainen, & Mäntyselkä, 2018, p.6). Different diseases that patients have can cause patients to have pain. Ethnicity can also be a factor of pain. If we think about sickle cell patients, it occurs more in African Americans and can cause pain during a sickle cell crisis. Age does not affect who can get sickle cell but can affect pain. Sickle cell presents at birth but usually patients do not have any issues until the age of 5 or 6. Another example would be having a tonsillectomy. Everyone states that the pain and recovery is so much easier on young children than in adults. These examples just go to show that everyone perceives pain differently depending on different factors like age, gender, ethnicity, and diseases. 

References

Cook, A. J., & Chastain, D. C. (2001). The Classification of Patients with Chronic Pain: Age and 

Sex Differences. Pain Research and Management, (3), 142. https://doi-org.ezp.waldenulibrary.org/10.1155/2001/376352

Huether, S. E., & McCance, K. L. (2017). Understanding pathophysiology (6th ed.). St. Louis, 

MO: Mosby.

Karjalainen, M., Saltevo, J., Tiihonen, M., Haanpää, M., Kautiainen, H., & Mäntyselkä, P. 

(2018). Frequent pain in older people with and without diabetes – Finnish community-based study. BMC Geriatrics, 18(1), 73. https://doi-org.ezp.waldenulibrary.org/10.1186/s12877-018-0762-y

 Contact one professional association or organization in the state of Florida that deals with some aspect of elderly care. Submit a two-page summary of information obtained including: Method of contact, ease of obtaining this information and any other supporting information or discoveries.  

 

course textbook:

ISBN: 978-0-13-295631-4 

Tabloski, P. (2014). Gerontological Nursing (3rd Ed). Upper Saddle River, NJ: Pearson Health Science.

APA is required.

Please, follow grading criteria attached below.

Identify your MSN Specialty Track

Describe the practice concern/problem.

Why is this concern/problem important to nursing and healthcare?

What is the scope of the concern?

What evidence is there for the need for change?

Include a minimum of two scholarly sources.

Define each element of your PICOT question

P-Population and problem – What is the nursing practice concern or problem and whom does it affect?

I-Intervention – What evidence-based solution for the problem would you like to apply?

C-Comparison – what is another solution for the problem? Note that this is typically the current practice, no intervention at all, or an alternative solutions.

O-Outcome – Very specifically, how will you know that the intervention worked? Think about how you will measure the outcome.

T-Time frame – For the purpose of the EBP project, keep the timeframe within 6-8 weeks.

Write your PICOT question in the standard PICOT question format

Identify the key search terms and phrases for your literature search.

Identify a theoretical framework/nursing theory that will guide your EBP project.

Describe one internal and one external method for the disseminationof your EBP project results. For example, an internal method may bethe hospital board, and an external method may be a professionalnursing organization. Discuss why it is important to report yourresults to both of these groups. How will your communicationstrategies change for each group? My EBP is on hand washing