Soap Hypertension and Depressive Disorder

   SOAP NOTE SAMPLE FORMAT FOR MRC    Name:  LP Date:  Time: 1315   Age: 30 Sex: F   SUBJECTIVE   CC:   “I am having vaginal lustful and affliction in   my inferior abdomen.”   HPI:   Pt is a   30y/o AA womanly, who is a new enduring that has of-late moved to Miami. She strives composition today behind   unsuccessful self-composition of vaginal lustful, enduring upon urination, and   inferior abdominal affliction. She is solicitudeful   for the influence of a vaginal or bladder contagion, or an STD. Pt denies broil. She reports the lustful and enduring after a while   urination has been confer-upon for 3 weeks, and the abdominal affliction has been   intermittent gone months ago. Pt has   tried OTC products for the lustful, including Monistat and Vagisil. She denies any other urinary symptoms,   including conjuncture or quantity. She   describes the abdominal affliction as either hard or dowdy. The affliction raze goes as exalted as 8 out of 10   at times. 200mg of PO Advil PRN   reduces the affliction to a 7/10. Pt denies   any irritant factors for the affliction. Pt reports that she did set-out her menstrual cycle this dawning, but   denies any other libeobjurgate other that not-difficult bleeding inauguration today. Pt denies douching or the use of any   vaginal irritants. She reports that   she is in a latesting sexual interconnection, and denies any new sexual partners in   the latest 90 days. She denies any   new-fangled or chronicled notorious charybdis to STDs. She reports the use of condoms after a while perfect coital trial, as polite   as this being her solely fashion of contraceptive. She reports typical monthly menstrual cycles that latest 3-4 days. She reports dysmenorrhea, which she as-well   takes Advil for. She reports her latest   PAP begrime was in 7/2016, was typical, and reports never having an abtypical PAP   begrime product. Pt denies any hx of   pregnancies. Other medical hx includes   GERD. She reports that she has an Rx   for Protonix, but she does not choose it perfect day. Her nativity hx includes the influence of DM   and HTN.    Current Medications:  Protonix   40mg PO Daily for GERD MTV OTC   PO Daily Advil   200mg OTC PO PRN for affliction   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 tender   grandparents after a whileout notorious medical issues; 1 tally and 3 other sisters   outside notorious medical issues; No offspring.   Social History Lives   alone. Currently in a latesting sexual   interconnection after a while one man. Works for   DEFACS. Reports interrupted alcohol   use, but denies tobacco or unfair garbage use.   ROS   General  Denies   weight vary, tire, broil, duskiness sweats Cardiovascular Denies   chest affliction and edema. Reports high palpitations that are characteristic by drinking   water   Skin Denies   any wounds, rashes, bruising, bleeding or bark discolorations, any varys in   lesions Respiratory Denies   cough. Reports dyspnea that accompanies the high palpitations and is as-well   characteristic by drinking water   Eyes Denies regulative   lenses, blurring, visual varys of any kind Gastrointestinal Abdominal   affliction (see HPI) and Hx of GERD. Denies   N/V/D, constipation, inclination varys   Ears Denies   Ear affliction, hearing detriment, unclouded in ears Genitourinary/Gynecological Reports   enduring after a while urination, but denies quantity or conjuncture. Contraceptive and STD obstruction includes   condoms after a while perfect coital occurrence. Current latesting sexual interconnection after a while one man. Denies notorious chronicled or new-fangled STD   exposure. Latest PAP was 7/2016 and typical. Ordinary monthly menstrual cycle   lasting 3-4 days.    Nose/Mouth/Throat Denies   sinus problems, dysphagia, nose bleeds or liberate Musculoskeletal Denies   end affliction, articulation swelling, stiffness or affliction   Breast Denies   SBE Neurological Denies   syncope, seizures, paralysis, weakness   Heme/Lymph/Endo Denies   bruising, duskiness sweats, stilted glands Psychiatric Denies   depression, apprehension, quiescent difficulties   OBJECTIVE   Weight   140lb  Temp -97.7 BP 123/82   Height 5’4” Pulse 74 Respiration 18   General Appearance Healthy   appearing adult womanly in no intelligent annoy. Alert and oriented; answers   questions well.    Skin Skin is   typical pretense for ethnicity, irascible, dry, pure and uncorrupted. No rashes or lesions   noted.   HEENT Head is   norm cephalic, hair evenly distributed. Neck: Supple. Full ROM. Teeth are in   good relit.   Cardiovascular S1, S2   after a while ordinary objurgate and rhythm. No extra character sounds.    Respiratory Symmetric   chest walls. Respirations ordinary and easy; lungs unclouded to auscultation   bilaterally.   Gastrointestinal Abdomen   flat; BS erratic in all 4 quadrants. Abdomen smooth, suprapubic   tender. No hepatosplenomegaly.        Genitourinary Suprapubic   tenderness illustrious. Bark pretense typical   for ethnicity. Irritation illustrious at   labia majora, minora, and perineum. No ulcerated lesions illustrious. Lymph nodes   not obvious. Vagina pink and lively   outside lesions. Libeobjurgate minimal,   thick, black red, no fragrance. Cervix pink   outside lesions. No CMT. Uterus typical largeness, pattern, and mass.     Musculoskeletal Full   ROM seen in all 4 extremities as enduring moved encircling the exam compass.   Neurological  Speech   clear. Good intonation. Posture build. Balance latesting; grade typical.   Psychiatric Alert   and oriented. Dressed in pure clothing. Maintains eye continuity. Answers   questions well.   Lab Tests Urinalysis   – blood illustrious (pt. on menstrual end), but products privative for contagion 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 womanly genital organ,         unspecified. (C57.9) 3-Gonococcal contagion, unspecified. (A54.9) Diagnosis o Urinary   tract contagion, locality not certain. (N39.0) Candidiasis of vulva and vagina.   (B37.3) unimportant to confer-uponing symptoms (Colgan & Williams, 2011) &   (Hainer & Gibson, 2011).    Plan/Therapeutics   Plan:   Medication –  § Terconazole gist 1 vaginal collision 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, composition,   prevention. Reasons to strive emergent solicitude, including N/V, broil, or end   pain.  § STD risks and obstructions.  § Ulcer obstruction, including commencement Protonix as prescribed,   not expanded the recommended dose article of NSAIDs, and not commencement NSAIDs on   an vacuity stomach.  Follow-up         –  § Pt gain be continuityed after a while products of STD studies.  § Return to clinic when high the end for perfashion   pap-begrime or if symptoms do not contravene after a while prescribed TX.