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 med ...

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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.

10. 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)

11. 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)

12. 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

13. 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

14. 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 weeks ago
Symptom analysis/HPI:
The patient is 65 years old male who complaining of episodes of
headaches and on 3 different occasions blood pressure was
measured, which was high (159/100, 158/98 and 160/100
respectively). Patient noticed the problem started two weeks ago
and sometimes it is accompanied by dizziness. He states that he
has been under stress in his workplace for the last month.
Patient denies chest pain, palpitation, shortness of breath,
nausea or vomiting.
ROS:
CONSTITUTIONAL
: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC
: Headache and dizziness as describe above. Denies changes in
LOC. Denies history of tremors or seizures.
HEENT
: HEAD: Denies any head injury, or change in LOC. Eyes:
Denies any changes in vision, diplopia or blurred vision. Ear:
Denies pain in the ears. Denies loss of hearing or drainage.

15. Nose: Denies nasal drainage, congestion. THROAT: Denies
throat or neck pain, hoarseness, difficulty swallowing.
Respiratory
: Patient denies shortness of breath, cough or hemoptysis.
Cardiovascular
: No chest pain, tachycardia. No orthopnea or paroxysmal
nocturnal
dyspnea.
Gastrointestinal
: Denies abdominal pain or discomfort. Denies flatulence,
nausea, vomiting or
diarrhea.
Genitourinary
: Denies hematuria, dysuria or change in urinary frequency.
Denies difficulty starting/stopping stream of urine or
incontinence.
MUSCULOSKELETAL
: Denies falls or pain. Denies hearing a clicking or snapping
sound.
Skin
: No change of coloration such as cyanosis or jaundice, no
rashes or pruritus.
Objective Data
CONSTITUTIONAL
: Vital signs: Temperature: 98.5 °F, Pulse: 87, BP: 159/92
mmhg, RR 20, PO2-98% on room air, Ht- 6’4”, Wt 200 lb, BMI

16. 25. Report pain 0/10.
General appearance: The patient is alert and oriented x 3. No
acute distress noted.
NEUROLOGIC:
Alert, CNII-XII grossly intact, oriented to person, place, and
time
.
Sensation intact to bilateral upper and lower extremities.
Bilateral UE/LE strength 5/5.
HEENT:
Head: Normocephalic, atraumatic, symmetric, non-tender.
Maxillary sinuses no tenderness. Eyes: No conjunctival
injection, no icterus, visual acuity and extraocular eye
movements intact. No nystagmus noted. Ears: Bilateral canals
patent without erythema, edema, or exudate. Bilateral tympanic
membranes intact, pearly gray with sharp cone of light.
Maxillary sinuses no tenderness. Nasal mucosa moist without
bleeding. Oral mucosa moist without lesions,.Lids non-
remarkable and appropriate for race.
Neck: supple without cervical lymphadenopathy, no jugular vein
distention, no thyroid swelling or masses.
Cardiovascular:
S1S2, regular rate and rhythm, no murmur or gallop noted.
Capillary refill < 2 sec.
Respiratory:
No dyspnea or use of accessory muscles observed. No
egophony, whispered pectoriloquy or tactile fremitus on
palpation. Breath sounds presents and clear bilaterally on
auscultation.
Gastrointestinal:

17. No mass or hernia observed. Upon auscultation, bowel sounds
present in all four quadrants, no bruits over renal and aorta
arteries. Abdomen soft non-tender, no guarding, no rebound no
distention or organomegaly noted on palpation
Musculoskeletal:
No pain to palpation. Active and passive ROM within normal
limits, no stiffness.
Integumentary:
intact, no lesions or rashes, no cyanosis or jaundice.
Assessment
Essential (Primary) Hypertension (ICD10 I10): Given the
symptoms and high blood pressure (156/92 mmhg), classified as
stage 2. Once the organic cause of hypertension has been ruled
out, such as renal, adrenal or thyroid, this diagnosis is
confirmed.
Differential diagnosis:
Ø Renal artery stenosis (ICD10 I70.1)
Ø Chronic kidney disease (ICD10 I12.9)
Ø Hyperthyroidism (ICD10 E05.90)
Plan
Diagnosis is based on the clinical evaluation through history,
physical examination, and routine laboratory tests to assess risk
factors, reveal identifiable causes and detect target-organ
damage, including evidence of cardiovascular disease.

18. These basic laboratory tests are:
· CMP
· Complete blood count
· Lipid profile
· Thyroid-stimulating hormone
· Urinalysis
· Electrocardiogram
Ø
Pharmacological treatment:
The treatment of choice in this case would be:
Thiazide-like diuretic and/or a CCB
· Hydrochlorothiazide tab 25 mg, Initial dose: 25 mg orally
once daily.
Ø
Non-Pharmacologic treatment
:
· Weight loss
· Healthy diet (DASH dietary pattern): Diet rich in fruits,
vegetables, whole grains, and low-fat dairy products with
reduced content of saturated and trans l fat
· Reduced intake of dietary sodium: <1,500 mg/d is optimal
goal but at least 1,000 mg/d reduction in most adults

19. · Enhanced intake of dietary potassium
· Regular physical activity (Aerobic): 90–150 min/wk.
· Tobacco cessation
· Measures to release stress and effective coping mechanisms.
Education
· Provide with nutrition/dietary information.
· Daily blood pressure monitoring at home twice a day for 7
days, keep a record, bring the record on the next visit with her
PCP
· Instruction about medication intake compliance.
· Education of possible complications such as stroke, heart
attack, and other problems.
· Patient was educated on course of hypertension, as well as
warning signs and symptoms, which could indicate the need to
attend the E.R/U.C. Answered all pt. questions/concerns. Pt
verbalizes understanding to all
Follow-ups/Referrals
· Evaluation with PCP in 1 weeks for managing blood pressure
and to evaluate current hypotensive therapy. Urgent Care visit
prn.
· No referrals needed at this time.
References

20. Domino, F., Baldor, R., Golding, J., Stephens, M. (2017). The
5-Minute Clinical Consult 2017 (25th ed.). Print (The 5-Minute
Consult Series).
Codina Leik, M. T. (2014). Family Nurse Practitioner
Certification Intensive Review (2nd ed.). ISBN 978-0-8261-
3424-0
Chronic Conditions:
Diseases and Disorders of the Renal/GU System
· Acute Kidney Injury (AKI)
· Bladder Cancer
· Glomerulonephritis
· Hematuria
· Hydronephrosis
· Interstitial Cystitis
· Priapism
· Prostate Cancer
· Prostatic Hyperplasia, Benign (BPH)
· Prostatitis

21. · Pyelonephritis
· Testicular Torsion
· Urinary Tract Infection (UTI)
Diseases and Disorders of the Endocrine System
· Addison Disease
· Cushing Syndrome
· Diabetes
· Graves Disease
· Hyper-, Hypoparathyroidism
· Hyper-, Hypothyroidism
· Myasthenia Gravis
· Syndrome of Inappropriate Antidiuretic Hormone Secretion
Diseases and Disorders of the Gastrointestinal System
· Ascites
· Appendicitis
· Celiac Disease

22. · Cholelithiasis
· Cirrhosis
· Clostridium Difficile (C. Diff)
· Colitis
· Crohn’s Disease
· Constipation
· Diarrhea
· Diverticulitis
· Esophageal Varices
Diseases and Disorders of the Gastrointestinal System
· Gastritis
· Gastroesophageal Reflux Disease
· Hemorrhoids
· Hepatic Encephalopathy
· Hepatitis
· Irritable Bowel Syndrome (IBS)
· Pancreatic Cancer

23. · Pancreatitis
· PepticUlcerDisease (Zollinger-Ellison Syndrome)
· Salmonella Infection