SOAP NOTE: Acute Gastritis.
\nMust use the sample template for your soap note, keep this template for when you start clinicals. Late Assignment Policy Assignments turned in late will have 1 point taken off for everyday assignment is late, after 7 days assignment will get grade of 0 (zero). No exceptions Follow the MRU Soap Note Rubric as a guide Use Help write my thesis – 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.
\n(Student Name)
\nMiami Regional University
\nDate of Encounter:
\nPreceptor\/Clinical Site:
\nClinical Instructor: MSN, APRN, FNP-C<\/p>\n
Soap Note # ____ Main Diagnosis ______________<\/p>\n
PATIENT INFORMATION
\nName:
\nAge:
\nGender at Birth:
\nGender Identity:
\nSource:
\nAllergies:
\nCurrent Medications:
\n\u2022
\nPMH:
\nImmunizations:
\nPreventive Care:
\nSurgical History:
\nFamily History:
\nSocial History:
\nSexual Orientation:
\nNutrition History:<\/p>\n
Subjective Data:
\nChief Complaint:
\nSymptom analysis\/HPI:
\nThe patient is \u2026<\/p>\n
Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states\u2026.. )
\nCONSTITUTIONAL:
\nNEUROLOGIC:
\nHEENT:
\nRESPIRATORY:
\nCARDIOVASCULAR:
\nGASTROINTESTINAL:
\nGENITOURINARY:
\nMUSCULOSKELETAL:
\nSKIN:<\/p>\n
Objective Data:
\nVITAL SIGNS:<\/p>\n
GENERAL APPREARANCE:
\nNEUROLOGIC:
\nHEENT:
\nCARDIOVASCULAR:
\nRESPIRATORY:
\nGASTROINTESTINAL:
\nMUSKULOSKELETAL:
\nINTEGUMENTARY:<\/p>\n
ASSESSMENT:
\n(In a paragraph please state \u201cyour encounter with your patient and your findings ( including subjective and objective data)
\nExample : \u201cPt came in to our clinic c\/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc\u2026 on examination I noted this and that etc.)
\nMain Diagnosis
\n(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference\/s as per Help write my thesis – APA style 6th or 7th Edition.
\nDifferential diagnosis (minimum 3)
\n–
\n–
\n–
\nPLAN:
\nLabs and Diagnostic Test to be ordered (if applicable)
\n\u2022\t–
\n\u2022\t–
\nPharmacological treatment:
\n–
\nNon-Pharmacologic treatment:
\nEducation (provide the most relevant ones tailored to your patient)<\/p>\n
Follow-ups\/Referrals
\nReferences (in Help write my thesis – APA Style)
\nExamples
\nCodina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).
\nISBN 978-0-8261-3424-0
\nDomino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010
\n(25th ed.). Print (The 5-Minute Consult Series).<\/p>\n
—
\nExample
\nStudent\u2019s Name
\nMiami Regional University
\nDate of Encounter: Mo\/day\/year
\nPreceptor\/Clinical Site: MSN5600L Class
\nClinical Instructor: Bidart MSN, APRN-IP, FNP-C
\nSoap Note # _____ Main Diagnosis: Dx: Herpes Zoster
\nPATIENT INFORMATION
\nName: Ms. GP
\nAge: 78
\nGender at Birth: Female
\nGender Identity: Female
\nSource: Patient
\nAllergies: Peanut. Iodine
\nCurrent Medications:
\n\uf0b7 Insulin Lantus 100 u\/ml 15 unit in the morning and at bedtime
\n\uf0b7 Metformin 500 mg 1 tablet PO once a day
\n\uf0b7 Atorvastatin 20 mg 1 tablet PO at bedtime
\nPMH:
\n\uf0b7 Diabetes mellitus type II
\n\uf0b7 Hyperlipidemia
\n\uf0b7 Varicella (Chickenpox) at the age of 20 year-old
\nImmunizations: Flu vaccine in 2020, Covid -19 (Pfizer) in 2021
\nPreventive Care: Wellness exam on 03\/2021
\nSurgical History: appendicectomy 20 years ago
\nFamily History: daughter 48 years old \/ hyperlipidemia
\nSocial History: Patient is widow, lives with her daughter. Catholic religion. No alcohol. No
\nsmoker. No history of drug used, sedentary lifestyle. Does not work.
\nSexual Orientation: Straight
\nNutrition History: Regular diet, low in carbohydrates and fat.
\nSubjective Data:
\nChief Complaint: I have been feeling itching and pain on my right lower back\u201d started 3 day
\nago.
\nSymptom analysis\/HPI: The patient is Ms. GP is 78-year-old Hispanic woman, who is
\ncomplaining about itching, pain or tingling on her right lower back. Patient stated that 3 days ago
\nshe started to feel an increase in burning sensation on the area taking all right lower back and
\ndon\u2019t relieve the pain with analgesic, she stated that wear any clothes that touch the area is very
\nuncomfortable. Denies any episodes of fever but she feels fatigue and chills and mild headache.
\nShe stated that today in the morning she feel worse and noted some redness in the area and
\ndecided to come to the clinic to PCP evaluation.
\nReview of Systems (ROS)
\nCONSTITUTIONAL: fatigue, chills, denies weakness, no thirsty, no loss of weight. No fever.
\nNEUROLOGIC: mild headache, no dizziness, no changes in LOC, no loss of strength or
\nweakness\/paresis\/paralysis on extremities, no Hx of tremors or seizures.
\nHEENT: denies any head injury, denies any pain
\n\uf0b7 Eyes: patient denies blurred vision, no diplopia, no wear glasses for reading
\n\uf0b7 Ears: patient denies tinnitus, ear pain, no ear drainage through ear canal.
\n\uf0b7 Nose: no presence of nasal obstruction, no nasal discharge, denies nasal bleeding. (No
\nepistaxis)
\n\uf0b7 Throat: no sore throat, no hoarse voice, no difficult to swallow
\nRESPIRATORY: patient denies shortness of breath, cough, expectoration, or hemoptysis.
\nCARDIOVASCULAR: patient denies chest pain, tachycardia. No orthopnea or paroxysmal
\nnocturnal dyspnea.
\nGASTROINTESTINAL: patient denies abdominal pain or discomfort. Denies flatulence,
\nnausea, vomiting or diarrhea. (BM pattern) every other day, last BM: today, no rectal bleeding
\nvisible for her.
\nGENITOURINARY: patient denies polyuria, no dysuria, no burning urination, no hematuria, no
\nlumbar pain, no urinary incontinence.
\nMUSCULOSKELETAL: denies falls or pain. Denies hearing a clicking or snapping sound
\nSKIN: patient states itching, pain, or tingling sensation on her right lower back.
\nHEMO\/LYMPH\/ENDOCRINE: glands swelling on groin, denies bruising or abnormal
\nbleeding.
\nPSYCHIATRIST: patient denies anxiety, depression, denies hallucinations or delusions, no
\nmood changes
\nObjective Data:
\nVITAL SIGNS:
\nTemperature: 98.4 \u00b0F, Pulse: 82x \u2018, BP: 122\/71 mm hg, RR 19, PO2-97% on room air, Ht- 5\u20193\u201d,
\nWt 164 lb, BMI 30.2. Report pain 6\/10.
\nGENERAL APPREARANCE: Adult, female. Alert and oriented x 3.
\nNEUROLOGIC: Alert, oriented to person, place, and time. Cranial nerves from I to XII intact.
\nSensation intact to bilateral upper and lower extremities. Bilateral UE\/LE strength 5\/5. Pupil
\nnormal in size and equal. Deep tendon reflex presents.
\nHEENT: Head: Normocephalic, atraumatic, symmetric, non-tender. Maxillary sinuses no
\ntenderness.
\n\uf0b7 Eyes: No conjunctival injection, no icterus, visual acuity, and extraocular eye movements
\nintact. No nystagmus noted. Wear glasses.
\n\uf0b7 Ears: BL external canal pattern, permeable, no redness, no drainage, tympanic membrane
\nintact, pearly gray with sharp cone of light. No pain or edema noted.
\n\uf0b7 Nose: Nasal mucosa normal. No irritations.
\n\uf0b7 Mouth: oral mucosa pink, tongue central, papillaes normal distributed, no lesions
\ndetected, present of upper and lower denture, fitting properly. Lips with no lesions.
\n\uf0b7 Neck: No lymphadenopathy noted. No jugular vein distention. No thyroid swelling or
\nmasses, no thrills on auscultation.
\nCARDIOVASCULAR: S1S2, regular rate and rhythm, no murmur or gallop noted. Capillary
\nrefill < 2 sec. Peripheral pulses present and symmetric. No edema on BLE.
\nRESPIRATORY: Lungs sounds clear. Chest wall symmetric and no deformities, no intercostal
\nretractions, patient no noticed dyspnea, no orthopnea. No egophony, no pectoriloquy, no fremitus
\nor sign of condensation tissue on palpation. Resonance equal in both hemithorax. Lungs: breath
\nsounds present and clear on auscultation, no rales, no wheezing, no rhonchi.
\nGASTROINTESTINAL: Abdomen soft and non-tender. Continent to BB. Bowel sounds
\npresent in all four quadrants; no bruits present over aortic or renal arteries. Last BM today.
\nGENITOURINARY: Costovertebral angles non-tenders, kidneys no palpable. External
\ngenitalia present, no enlargement, no tumors palpable. Groins area noted with redness.
\nMUSKULOSKELETAL: No pain to palpation. Active and passive ROM within normal limits,
\nno stiffness.
\nINTEGUMENTARY: painful redness rash, with crops of vesicles on an erythematous base
\nwith a few satellite lesions in linear distribution, do not cross midline, some of the blisters are
\nfilled with purulent fluids and other are crusted. Area is swollen and redness.
\nASSESSMENT:
\nPatient Ms. GP is 78-year-old Hispanic woman with Hx of DM Type II and Hyperlipidemia,
\ncame into our clinic today complaining about itching, pain and tingling on her right lower back
\nstarting 3 days ago. During the physical exam was noted painful redness rash, with crops of
\nvesicles on an erythematous base with a few satellite lesions in linear distribution, which do not
\ncross midline. Diagnosis is based on the clinical evaluation through history and physical
\nexamination. According to patient presentation, signs and symptoms patient is diagnosed with
\nherpes zoster. Patients falls into the high risk group based on Buttaro (2017). Herpes zoster is
\nviral infection that occurs with reactivation of the varicella-zoster virus and the patient referred
\nhas history of Chickenpox when she was 20 years old.
\nMain Diagnosis
\nHerpes Zoster (ICD10 B02.9): Herpes zoster is infection that results when varicella-zoster virus
\nreactivates from its latent state in a posterior dorsal root ganglion. Symptoms usually begin with
\npain along the affected dermatome, followed within 2 to 3 days by a vesicular eruption that is
\nusually diagnostic. (Domino, Baldor, Golding, &Stephens,2017).
\nOther diagnosis:
\nDiabetes mellitus type II. (ICD-10 E11.9)
\nHyperlipidemia. (ICD-10 E78.5)
\nDifferential diagnosis
\n\uf0b7 Irritant contact dermatitis (ICD10 L24)
\n\uf0b7 Impetigo. (ICD10 L01.0)
\n\uf0b7 Varicella. (ICD 10 B01)
\n\uf0b7 Dermatitis herpetiformis. (ICD10 L13.0)
\nPLAN:
\nLabs and Diagnostic Test to be ordered (if applicable)
\n\uf0b7 Viral culture, polymerase chain reaction for VZV
\nPharmacological treatment:
\n\uf0b7 Valtrex 1 gm TID x 7 days ideally during the prodrome, and is less likely to be effective if
\ngiven > 72 hours after skin lesions appear,
\n\uf0b7 VZV vaccine
\n\uf0b7 Pain-reliever NSAIDs
\n\uf0b7 Management of post herpetic neuralgia (Treatments include gabapentin, pregabalin)
\nContinue with current medication for chronic condition:
\n\uf0b7 Insulin Lantus 100 u\/ml 15 unit in the morning and at bedtime
\n\uf0b7 Metformin 500 mg 1 tablet PO once a day
\n\uf0b7 Atorvastatin 20 mg 1 tablet PO at bedtime
\nNon-Pharmacologic treatment:
\n\uf0b7 Do not scratch the area with dirty hands. Use lotion like calamine to refresh the area.
\n\uf0b7 Keep the area clean and dry.
\nEducation
\n\uf0b7 Isolation precaution \u2013 Type Contact
\n\uf0b7 Avoid contact with susceptible person like pregnancy woman, kids and
\nImmunocompromised patient.
\n\uf0b7 Education about hand washing.
\n\uf0b7 Avoid ABT cream.
\nFollow-ups\/Referrals
\nFollow up appointment 2 weeks \/ No referral needed at this time
\nCall if the symptoms are worse or you noticed any adverse reaction.
\nReferences
\nButtaro, T. M., Trybulski, J. A., Polgar-Bailey, P., & Sandberg-Cook, J. (2017). Primary care: a
\ncollaborative practice. St. Louis, MO: Elsevier.
\nDomino, F., Baldor, R., Golding, J., Stephens, M. (2017). The 5-Minute Clinical Consult 2017
\n(25th ed.). Print (The 5-Minute Consult Series).
\nMcCance, K. L., & Huether, S. E. (2019). Pathophysiology: the biologic basis for disease in
\nadults and children. St. Louis, MO: Elsevier.<\/p>\n","protected":false},"excerpt":{"rendered":"
SOAP NOTE: Acute Gastritis. Must use the sample template for your soap note, keep this template for when you start clinicals. Late Assignment Policy Assignments turned in late will have 1 point taken off for everyday assignment is late, after 7 days assignment will get grade of 0 (zero). No exceptions Follow the MRU Soap […]<\/p>\n","protected":false},"author":4,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1738,2474,2482,1563,2516,2499],"tags":[2501,2518,2477,2519,2520],"class_list":["post-9951","post","type-post","status-publish","format-standard","hentry","category-help-me-with-social-psychology-assignment","category-psyc-essays","category-psyc-paper-writing-service","category-psychology-case-study-examples","category-sociology-essays","category-write-my-psychology-papers","tag-psy-papers","tag-psych-research-paper-sample","tag-psychology-assignment","tag-psychology-dissertation-writing","tag-psychology-research-paper"],"_links":{"self":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts\/9951","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/comments?post=9951"}],"version-history":[{"count":0,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/posts\/9951\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/media?parent=9951"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/categories?post=9951"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.colapapers.com\/nursing\/wp-json\/wp\/v2\/tags?post=9951"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}