Nursing Question

Description

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. The episodic SOAP note is to be written using the attached template below.

For all the SOAP note assignments, you will write a SOAP note about one of your patients and use the following acronym:

S = Subjective data: Patient’s Chief Complaint (CC).
O = Objective data: Including client behavior, physical assessment, vital signs, and meds.
A = Assessment: Diagnosis of the patient’s condition. Include differential diagnosis.
P = Plan: Treatment, diagnostic testing, and follow up

Submission Instructions:

Your SOAP note should be clear and concise and students will lose points for improper grammar, punctuation, and misspelling.
please use the template to avoid plagrasim

Unformatted Attachment Preview

SOAP Notes Rubric
Criteria
Ratings
Pts
Chief Complaint (Reason for seeking health care) – S
view longer description
4 pts
Distinguished
Includes a direct quote from
patient about presenting
problem
3 pts
Excellent
Includes a direct quote from
patient and other unrelated
information
2 pts
Fair
Includes information but
information is NOT a direct
quote
0 pts
Poor
Information is completely
missing
/ 4 pts
Demographics – S
view longer description
2 pts
Distinguished
Begins with patient initials, age,
race, ethnicity and gender (5
demographics)
1.5 pts
Excellent
Begins with 4 of the 5 patient
demographics (patient initials,
age, race, ethnicity and gender)
1 pts
Fair
Begins with 3 or less patient
demographics (patient initials,
age, race, ethnicity and gender)
0 pts
Poor
Information is completely
missing
/ 2 pts
SOAP Notes Rubric
Criteria
Ratings
Pts
History of the Present Illness (HPI) – S
view longer description
5 pts
Distinguished
Includes the presenting
problem and the 8 dimensions
of the problem PAIN
ASSESSMENT – Onset,
Location, Duration, Character,
Aggravating factors, Relieving
factors, Timing and Severity)
3 pts
Excellent
Includes the presenting
problem and 7 of the 8
dimensions of the problem
PAIN ASSESSMENT – Onset,
Location, Duration, Character,
Aggravating factors, Relieving
factors, Timing and Severity)
2 pts
Fair
Includes the presenting
problem and 6 of the 8
dimensions of the problem
(PAIN ASSESSMENT – Onset,
Location, Duration, Character,
Aggravating factors, Relieving
factors, Timing and Severity)
0 pts
Poor
Information is completely
missing
/ 5 pts
Allergies – S
view longer description
2 pts
Distinguished
Includes NKA (including =
Drug, Environemental, Food,
Herbal, and/or Latex or if
allergies are present (reports
/ 2 pts
SOAP Notes Rubric
Criteria
Ratings
Pts
for each severity of allergy
AND description of allergy)
1.5 pts
Excellent
If allergies are present,
students lists type Drug,
environemtal factor, herbal,
food, latex name and includes
severity of allergy OR
description of allergy
1 pts
Fair
If allergies are present,
students lists only the type of
allergy name
0 pts
Poor
Information is completely
missing
Review of Systems (ROS) – S
view longer description
12 pts
Distinguished
Includes a minimum of 3
assessments for each body
system and assesses at least 9
body systems directed to chief
complaint AND uses the words
“admits” and “denies”
6 pts
Excellent
Includes 3 or fewer
assessments for each body
system and assesses 5-8 body
systems directed to chief
complaint AND uses the words
“admits” and “denies”
3 pts
Fair
/ 12 pts
SOAP Notes Rubric
Criteria
Ratings
Pts
Includes 3 or fewer
assessments for each body
system and assesses less than 5
body systems directed to chief
complaint OR student does not
use the words “admits” and
“denies”
0 pts
Poor
Information is completely
missing
Vital Signs – O
view longer description
2 pts
Distinguished
Includes all 8 vital signs, (BP
(with patient position), HR, RR,
temperature (with Fahrenheit
or Celsius and route of
temperature collection),
weight, height, BMI (or
percentiles for pediatric
population) and pain.)
1.5 pts
Excellent
Includes 7 vital signs, (BP (with
patient position), HR, RR,
temperature (with Fahrenheit
or Celsius and route of
temperature collection),
weight, height, BMI (or
percentiles for pediatric
population) and pain.)
1 pts
Fair
Includes 6 or less vital signs,
(BP (with patient position), HR,
RR, temperature (with
Fahrenheit or Celsius and
route of temperature
/ 2 pts
SOAP Notes Rubric
Criteria
Ratings
Pts
collection), weight, height, BMI
(or percentiles for pediatric
population) and pain.)
0 pts
Poor
Information is completely
missing
Labs – O
view longer description
3 pts
Distinguished
Includes a list of the labs
reviewed at the visit, values of
lab results and highlights
abnormal values OR
acknowledges no
labs/diagnostic tests were
reviewed.
2 pts
Excellent
Includes a list of the labs
reviewed at the visit, values of
lab results but does not
highlight abnormal values.
1 pts
Fair
Includes a list of the labs
reviewed at the visit but does
not include the values of lab
results or highlight abnormal
values.
0 pts
Poor
Information is completely
missing
/ 3 pts
Medications – O
view longer description
4 pts
Distinguished
Includes a list of all of the
patient reported medications
/ 4 pts
SOAP Notes Rubric
Criteria
Ratings
Pts
and the medical diagnosis for
the medication (including
name, dose, route, frequency)
2 pts
Excellent
Includes a list of all of the
patient reported medications
and the medical diagnosis for
the medication (including 3 of
the 4: name, dose, medications
route, frequency)
1 pts
Fair
Includes a list of all of the
patient reported medications
(including 2 of the 4: name,
dose, route, frequency)
0 pts
Poor
Information is completely
missing
Screenings – O
INCLUDE MULTIPLE SCREENINGS
3 pts
Distinguished
Includes an assessment of at
least 5 screening tests
2 pts
Excellent
Includes an assessment of at
least 4 screening tests
1 pts
Fair
Includes an assessment of at
least 3 screening tests
0 pts
Poor
Information is completely
missing
/ 3 pts
SOAP Notes Rubric
Criteria
Ratings
Pts
Past Medical History – O
view longer description
3 pts
Distinguished
Includes (Major/Chronic,
Trauma, Hospitalizations), for
each medical diagnosis, year of
diagnosis and whether the
diagnosis is active or current
2 pts
Excellent
Includes (Major/Chronic,
Trauma, Hospitalizations), for
each medical diagnosis, either
year of diagnosis OR whether
the diagnosis is active or
current
1 pts
Fair
Includes each medical
diagnosis but does not include
year of diagnosis or whether
the diagnosis is active or
current
0 pts
Poor
Information is completely
missing
/ 3 pts
Past Surgical History – O
view longer description
3 pts
Distinguished
Includes, for each surgical
procedure, the year of
procedure and the indication
for the procedure
2 pts
Excellent
Includes, for each surgical
procedure, the year of
procedure OR indication of the
procedure
/ 3 pts
SOAP Notes Rubric
Criteria
Ratings
Pts
1 pts
Fair
Includes, for each surgical
procedure but not the year of
procedure or indication of the
procedure
0 pts
Poor
Information is completely
missing
Family History – O
view longer description
3 pts
Distinguished
Includes an assessment of at
least 4 family members
regarding, at a minimum,
genetic disorders, diabetes,
heart disease and cancer.
2 pts
Excellent
Includes an assessment of at
least 3 family members
regarding, at a minimum,
genetic disorders, diabetes,
heart disease and cancer.
1 pts
Fair
Includes an assessment of at
least 2 family members
regarding, at a minimum,
genetic disorders, diabetes,
heart disease and cancer.
0 pts
Poor
Information is completely
missing
/ 3 pts
Social History – O
view longer description
3 pts
Distinguished
/ 3 pts
SOAP Notes Rubric
Criteria
Ratings
Pts
Includes all 11 of the following:
tobacco use, drug use, alcohol
use, marital status,
employment status, current
and previous occupation,
sexual orientation, sexually
active, contraceptive use, and
living situation.
2 pts
Excellent
Includes 10 of the 11 following:
tobacco use, drug use, alcohol
use, marital status,
employment status, current
and previous occupation,
sexual orientation, sexually
active, contraceptive use, and
living situation.
1 pts
Fair
Includes 9 or less of the
following: tobacco use, drug
use, alcohol use, marital status,
employment status, current
and previous occupation,
sexual orientation, sexually
active, contraceptive use, and
living situation.
0 pts
Poor
Information is completely
missing
Physical Examination – O
view longer description
12 pts
Distinguished
Includes a minimum of 4
assessments for each body
system and assesses at least 5
/ 12 pts
SOAP Notes Rubric
Criteria
Ratings
Pts
body systems directed to chief
complaint
6 pts
Excellent
Includes a minimum of 3
assessments for each body
system and assesses at least 4
body systems directed to chief
complaint
3 pts
Fair
Includes a minimum of 2
assessments for each body
system and assesses at least 4
body systems directed to chief
complaint
0 pts
Poor
Information is completely
missing
Diagnosis – A
view longer description
5 pts
Distinguished
Includes a clear outline of the
accurate principal diagnosis
AND lists the remaining
diagnoses addressed at the
visit (in descending priority)
3 pts
Excellent
Includes a clear outline of the
accurate diagnoses addressed
at the visit but does not list the
diagnoses in descending order
of priority
2 pts
Fair
/ 5 pts
SOAP Notes Rubric
Criteria
Ratings
Pts
Includes an inaccurate
diagnosis as the principal
diagnosis
0 pts
Poor
Information is completely
missing
Differential Diagnosis – A
view longer description
5 pts
Distinguished
Includes at least 3 differential
diagnoses for the principal
diagnosis
3 pts
Excellent
Includes 2 differential
diagnoses for the principal
diagnosis
2 pts
Fair
Includes 1 differential
diagnosis for the principal
diagnosis
0 pts
Poor
Information is completely
missing
/ 5 pts
Pharmacologic treatment plan – P
view longer description
5 pts
Distinguished
Includes a detailed
pharmacologic treatment plan
for each of the diagnoses listed
under “assessment”. The plan
includes ALL of the following:
drug name, dose, route,
frequency, duration and cost as
well as education related to
pharmacologic agent. If the
/ 5 pts
SOAP Notes Rubric
Criteria
Ratings
diagnosis is a chronic problem,
student includes instructions
on currently prescribed
medications as above.
3 pts
Excellent
Includes a detailed
pharmacologic treatment plan
for each of the diagnoses listed
under “assessment”. The plan
includes 4 of the following 7:
the drug name, dose, route,
frequency, duration and cost as
well as education related to
pharmacologic agent. If the
diagnosis is a chronic problem,
student includes instructions
on currently prescribed
medications as above.
2 pts
Fair
Includes a detailed
pharmacologic treatment plan
for each of the diagnoses listed
under “assessment”. The plan
includes less than 4 of the
following: the drug name, dose,
route, frequency, duration and
cost as well as education
related to pharmacologic
agent. If the diagnosis is a
chronic problem, student
includes instructions on
currently prescribed
medications as above.
0 pts
Poor
Information is completely
missing
Pts
SOAP Notes Rubric
Criteria
Ratings
Pts
Diagnostic/Lab Testing – P
view longer description
5 pts
Distinguished
Includes appropriate
diagnostic/lab testing 100% of
the time OR acknowledges “no
diagnostic testing clinically
required at this time”
3 pts
Excellent
Includes appropriate
diagnostic/lab testing 50% of
the time OR acknowledges “no
diagnostic testing clinically
required at this time”
2 pts
Fair
Includes appropriate
diagnostic testing less than
50% of the time.
0 pts
Poor
Information is completely
missing
/ 5 pts
Education – P
view longer description
5 pts
Distinguished
Includes at least 3 strategies to
promote and develop skills for
managing their illness and at
least 3 self-management
methods on how to incorporate
healthy behaviors into their
lives.
3 pts
Excellent
Includes at least 2 strategies to
promote and develop skills for
managing their illness and at
least 2 self-management
/ 5 pts
SOAP Notes Rubric
Criteria
Ratings
Pts
methods on how to incorporate
healthy behaviors into their
lives.
2 pts
Fair
Includes at least 1 strategies to
promote and develop skills for
managing their illness and at
least 1 self-management
methods on how to incorporate
healthy behaviors into their
lives.
0 pts
Poor
Information is completely
missing
Anticipatory Guidance – P
view longer description
4 pts
Distinguished
Includes at least 3 primary
prevention strategies (related
to age/condition (i.e.
immunizations, pediatric and
pre-natal milestone
anticipatory guidance)) and at
least 2 secondary prevention
strategies (related to
age/condition (i.e. screening))
2 pts
Excellent
Includes at least 2 primary
prevention strategies (related
to age/condition (i.e.
immunizations, pediatric and
pre-natal milestone
anticipatory guidance)) and at
least 2 secondary prevention
strategies (related to
age/condition (i.e. screening))
/ 4 pts
SOAP Notes Rubric
Criteria
Ratings
Pts
1 pts
Fair
Includes at least 1 primary
prevention strategies (related
to age/condition (i.e.
immunizations, pediatric and
pre-natal milestone
anticipatory guidance)) and at
least 1 secondary prevention
strategies (related to
age/condition (i.e. screening))
0 pts
Poor
Information is completely
missing
Follow up plan – P
view longer description
4 pts
Distinguished
Includes recommendation for
follow up, including time frame
(i.e. x # of days/weeks/months)
2 pts
Excellent
Includes recommendation for
follow up, but does not include
time frame (i.e. x # of
days/weeks/months)
0 pts
Poor
Does not include follow up plan
/ 4 pts
References
view longer description
3 pts
Distinguished
High level of APA precision
2 pts
Excellent
Moderate level of APA
precision
1 pts
/ 3 pts
SOAP Notes Rubric
Criteria
Ratings
Pts
Fair
Incorrect APA style
0 pts
Poor
Information is completely
missing
Grammar
view longer description
3 pts
Distinguished
Free of grammar and spelling
errors
2 pts
Excellent
Writing mechanics need more
precision and attention to
detail
0 pts
Poor
Writing mechanics need
serious attention
/ 3 pts
SOAP Note Template
Encounter date: ________________________
Patient Initials: ______ Gender: M/F/Transgender ____ Age: _____ Race: _____ Ethnicity ____
Reason for Seeking Health Care: ______________________________________________
HPI:_________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): ___________________________________
Current perception of Health:
Excellent
Good
Fair Poor
Past Medical History
• Major/Chronic Illnesses____________________________________________________
• Trauma/Injury ___________________________________________________________
• Hospitalizations __________________________________________________________
Past Surgical History___________________________________________________________
Medications: __________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Family History: ____________________________________________________________
Copyright © MVJ 2018
Social history:
Lives: Single family House/Condo/ with stairs: ___________ Marital Status:________
Employment Status: ______ Current/Previous occupation type: _________________
Exposure to: ___Smoke____ ETOH ____Recreational Drug Use: __________________
Sexual orientation: _______ Sexual Activity: ____ Contraception Use: ____________
Family Composition: Family/Mother/Father/Alone: _____________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc _____
Exposures:
Immunization HX:
Review of Systems:
General:
HEENT:
Neck:
Lungs:
Cardiovascular:
Breast:
GI:
Male/female genital:
Copyright © MVJ 2018
GU:
Neuro:
Musculoskeletal:
Activity & Exercise:
Psychosocial:
Derm:
Nutrition:
Sleep/Rest:
LMP:
STI Hx:
Physical Exam
BP________TPR_____ HR: _____ RR: ____Ht. _____ Wt. ______ BMI (percentile) _____
General:
HEENT:
Neck:
Pulmonary:
Cardiovascular:
Breast:
Copyright © MVJ 2018
GI:
Male/female genital:
GU:
Neuro:
Musculoskeletal:
Derm:
Psychosocial:
Misc.
Significant Data/Contributing
Dx/Labs/Misc.
Plan:
Differential Diagnoses
1.
2.
3.
Principal Diagnoses
1.
Copyright © MVJ 2018
2.
Plan
Diagnosis
Diagnostic Testing:
Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Diagnosis
Diagnostic Testing:
Pharmacological Treatment:
Education:
Referrals:
Follow-up:
Anticipatory Guidance:
Copyright © MVJ 2018
Signature (with appropriate credentials): __________________________________________
Cite current evidenced based guideline(s) used to guide care (Mandatory)_______________
DEA#: 101010101
STU Clinic
LIC# 10000000
Tel: (000) 555-1234
FAX: (000) 555-12222
Patient Name: (Initials)______________________________
Age ___________
Date: _______________
RX ______________________________________
SIG:
Dispense: ___________
Refill: _________________
No Substitution
Signature: ____________________________________________________________
Copyright © MVJ 2018
Copyright © MVJ 2018
SOAP Note Template
Encounter date: ________10/8/23________________
Patient Initials: ___I.F___ Gender: F Transgender ____ Age: __18___ Race: _White____ Ethnicity
__Hispanic __
Reason for Seeking Health Care: “I’ve had vaginal itching, burning, and discharge with foul odor for the
past 3 days and also having diarrhea for 5 days. I’m still dealing with throat pain, nasal congestion, and ear
pain for 7 days after taking amoxicillin for a week, I still have 3 more days of medication but I don’t feel
better, I feel worse. Im taking advil every once in a while, but my throat still hurts. I’m also taking pepto
bismol and that seems to help me for a day and half or so but then the diarrhea comes back.”
HPI:_I.F.is an 18 year old female who is complaining of vaginal itching, burning, and thick
white/yellow discharge. Patient reports that the discharge has a strong foul odor. She denies
being sexually active. Patient states that she has intense itching and burning with urination.
Denies nausea or vomiting. She said she tried an over-the-counter yeast infection medication but
it did not help. I.F also states that she has been having liquidy,loose stools ever since taking the
antibiotic that was prescribed to her at the urgent care. She states she initially went to the urgent
care because she was having trouble swallowing due to pain, nasal congestion, fever, and pain in
her ear that hasn’t improved.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________
Allergies(Drug/Food/Latex/Environmental/Herbal): __Cats
_________________________________
Current perception of Health:
Past Medical History
Copyright © MVJ 2018
Poor
•
•
•
Major/Chronic Illnesses: None reported
__________________________________________
Trauma/Injury: None reported______________________________________________
Hospitalizations: Broken left tibia and fibula at age 10
(2015)__________________________________
Past Surgical History:___repaired tibia and fibula at age 10
(2015)____________________________________________________
Medications:_
Currently taking amoxicillin 500mg PO Q12H for 10 days, currently on day 7.
Monistat (miconazole nitrate 1200mg) vaginal insert one time dose, taken two days ago
Pepto Bismol (bismuth subsalicylate) 30mL, the patient states normally in afternoon
Advil (ibuprofen) 400mg, patient states she takes it once or twice a day
Lo Loestrin FE 1m/10mcg and 10mcg(norethindrone acetate and ethinyl estradiol, ethinyl
estradiol and ferrous fumarate) 1 tab daily for 28 days.
Family History:
Father: no pertinent history, alive and well
Mother: no pertinent history, alive and well
Maternal grandmother: hx of ovarian cancer, alive and well
Maternal grandfather: deceased in motor vehicular accident
Paternal grandmother: no pertinent history, alive and well
Paternal grandfather: deceased due to COVID-19 complications
_________________________________________________________
Social history:
Lives: Single family House/Condo/ with stairs: Single family home, without stairs
Marital Status: Single
Employment Status: ___Student___
Copyright © MVJ 2018
Current/Previous occupation type: __Student _____
Exposure to: ___Smoke__denies__ ETOH _denies___Recreational Drug Use:
____denies_
Sexual orientation: __Straight_____ Sexual Activity: __Denies ever having
intercourse__ Contraception Use: __________currently taking OCP__
Family Composition: Family/Mother/Father/Alone: _live at home with mother and
sister__________________________
Health Maintenance
Screening Tests: Mammogram, PSA, Colonoscopy, Pap Smear, Etc: None _____
Exposures: None
Immunization HX: Denies flu and Covid vaccine
Review of Systems:
General: intermittent chills, denies fever, denies weight loss
HEENT: denied changes in vision, denies eye pain, discharge, states her right ear feels clogged
Neck: denies stiffness and pain
Lungs: no shortness of breath, denies cough and difficulty breathing
Cardiovascular: denies palpitations, chest pain,
Breast: denies any masses, lumps, or pain
GI: intermittent abdominal pain, decreased appetite, loose and liquidy stools 4-5x daily for 5
days, denies nausea or vomiting
Copyright © MVJ 2018
Female genital: vaginal itching, white thick foul smelling discharge, no pelvic pain, denies
dysmenorrhea
GU: burning with urination, no changes in urine noted, no frequency
Neuro: denies weakness, denies changes in sensation
Musculoskeletal: denies myalgia and joint pain
Activity & Exercise: reports missing class the past 3 days, and not going to the gym for a week
Psychosocial: denies mood changes, depression, changes in sleep habits, suicidal thoughts
Derm: no pruritus, no lesions or rash, no hyperpigmentation
Nutrition: decreased appetite, reports she is trying to eat healthy
Sleep/Rest: sleeps 8 hours/night
LMP: September 19th
STI Hx: Not applicable.
Physical Exam
BP___113/72_____TPR_____ HR: 75_____ RR: 16____Ht. ___5’0_(60 inches)_ Wt.
_140lbs_____ BMI (percentile) _27.3 (overweight) ____
General: awake, alert, and oriented. Looks tired, well nourished, in no distress. Normal mood,
ambulating with no difficulty.
HEENT:
Copyright © MVJ 2018
head: normocephalic, atraumatic, no visible or palpable masses, depressions, or scaring, normal
hair distribution
eyes: bilateral eyes, visual acuity intact, conjunctiva clear, sclera non-icteric, EOM intact
bilaterally. Normal convergence, PERRL, fundi have normal optic discs and vessels, no exudates
or hemorrhages. Left eye: 20/20, right eye 20/20
ears: left, tympanic membrane translucent, pearly gray and intact, hearing intact. right, tympanic
membrane red and bulging, hearing intact.
nose: septum midline, no external lesion, mucosa erythematous and red. No pain with palpation
of frontal or maxillary sinuses
mouth: mucus membranes moist, no mucosal lesions, adequate dental hygiene
pharynx: pharyngeal erythema, palatal petechiae, tonsillar hypertrophy with white exudates,
uvula midline but swollen, posterior pharynx with mild cobble stoning
neck: supple, without lesions, bruits. Mild adenopathy noted in the cervical area. thyroid nonenlarged and non-tender, trachea midline. Carotid pulses 2+. Jaw with no clicks, full range of
motion.
Pulmonary: Lung sounds clear to auscultation without wheezes, crackles, or cough. Chest
symmetrical
Cardiovascular: Regular rate and rhythm. S1 and s2 present. No murmurs, rubs, gallops,
precordial movements. Pulses 2+ and equal bilaterally in upper and lower extremities without
trills. No bruits. No JVD. Capillary refill < 3 seconds. No peripheral edema. Copyright © MVJ 2018 Breast: No nipple abnormalities, masses, tenderness to palpation, axillary or supraclavicular adenopathy. Symmetric in shape and size GI: soft and protuberant without any scars or lesions. Bowel sounds present in all 4 quadrants tenderness in lower left quadrant, no tenderness in LRQ, RUQ, or LUQ. Tympanic throughout. Female genitalia: normally developed genitalia with no external lesions or eruptions. Vagina shows mild inflammation, erythema , and irritation. No lesions. White, thick discharge noted. Cervix shows no lesions, inflammation, erythema. Neuro: CN 2-12 normal. Sensation to pain, touch, and proprioception normal. DTR’s normal in upper and lower extremities. No pathologic reflexes. Musculoskeletal: Normal gait and station. No misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions, decreased range of motion, instability, atrophy or abnormal strength or tone in the head, neck, spine, ribs, pelvis or extremities. Derm: no skin lesions, discoloration, or bruising. Good skin turgor. Nails: normal color, no deformities noted Psychosocial: normal behavior, acts age appropriately. Misc. Copyright © MVJ 2018 Significant Data/Contributing : Patient is on day 7 of 10 of amoxicillin, no improvements. Dx/Labs/Misc.: Patient had positive rapid strep test at urgent care 7 days ago. Streptococcal culture came back positive 5 days ago. Plan: Discontinue amoxicillin, start I.F on Augmentin (amoxicillin clavulanate potassium) 875mg Q12h for 10 days. Start I.F on fluconazole 150mg PO single dose and advise to monitor for improvement of symptoms, if not better in 7 days to come back to the office for a recheck. Advise I.F to start taking probiotics to assist with diarrhea and yeast infection symptoms. Educate on the importance of fluid intake with diarrhea to prevent dehydration. Educate I.F on importance of not skipping any antibiotic dose and to complete full treatment. Educate I.F on taking antibiotic with meals to minimize GI symptoms. Educate I.F to avoid dairy, fatty and spicy foods while symptoms are still present. Differential Diagnoses 1. epiglottitis 2. bacterial vaginosis 3. clostridium difficile secondary to antibiotic administration Principal Diagnoses 1. streptococcal pharyngitis 2. vaginal candidiasis secondary to antibiotic administration Copyright © MVJ 2018 3. diarrhea secondary to antibiotic administration Plan Diagnosis: streptococcal pharyngitis Diagnostic Testing: rapid antigen detection test (rapid strep test), throat culture Pharmacological Treatment: Augmentin (amoxicillin clavulanate potassium) 875mg Q12h for 10 days Education: complete full treatment of antibiotic, do not skip a dose. Take medication with meal to reduce GI intolerance symptoms. Maintain adequate fluid intake. Eat soft foods while throat pain is present to avoid more pain. Referrals: refer to ENT if symptoms to do not improve after antibiotic course, or if recurrent strep infections occur. Follow-up: call the office if not feeling better after 48 hours of taking antibiotic. Anticipatory Guidance: acetaminophen or ibuprofen can be taken for discomfort or fever while antibiotic begins to take effect. Diagnosis: vaginal candidiasis secondary to antibiotic administration Diagnostic Testing: vaginal wet prep, pH testing, Whiff test Pharmacological Treatment: fluconazole 150mg PO single dose Copyright © MVJ 2018 Education: Advise patient that a yeast infection may develop if taking antibiotics. Probiotics may help relieve symptoms while antifungal begins to take effect. Maintaining a healthy diet and a a diet low in sugar will help prevent yeast infections. Referrals: if patient doesn’t respond to therapy, an OBGYN referral may be needed. Follow-up: follow up in 7 days if symptoms do not go away. Anticipatory Guidance: Advise patient against intravaginal yogurt therapy, intravaginal garlic, or douching as this can cause further infection or complication. Educate patient to advise all providers of risk of yeast infection before taking antibiotic for any future antibiotic treatment. Oral contraception use makes I.F more susceptible to yeast infection, discuss other contraception methods especially if patient is not sexually active. Diagnosis: diarrhea secondary to antibiotic administration Diagnostic Testing: stool culture to rule out c.difficile infection , BMP Pharmacological Treatment: fluid and electrolyte replacement such as Pedialyte or Gatorade. Possible IV rehydration if necessary. Education: Educate I.F eating foods low in fiber to harden stools. Educate on BRAT diet, bananas, toast, oatmeal, white rice, applesauce, and soup/broth as its easier to tolerate. Avoid fatty and spicy foods, as well as dairy until symptoms improve. Wash hands thoroughly to avoid cross contamination. Referrals: refer to gastroenterologist if symptoms do not improve post antibiotic treatment. Copyright © MVJ 2018 Follow-up: call office if diarrhea persists following completion of antibiotic treatment (10 days) Anticipatory Guidance: Advise on probiotics supplements to reduce severity and duration of symptoms while taking any antibiotics. Advise on importance of following up to prevent complications. Advise on maintaining a healthy balanced diet to avoid recurrent diarrhea episodes. Signature (with appropriate credentials): _ X Cite current evidenced based guideline(s) used to guide care (Mandatory) Ashurst, J. V., & Edgerley-Gibb, L. (2023). Streptococcal Pharyngitis. In StatPearls. StatPearls Publishing. Jeanmonod, R., & Jeanmonod, D. (2023). Vaginal Candidiasis. In StatPearls. StatPearls Publishing. Mada, P. K., & Alam, M. U. (2023). Clostridioides difficile Infection. In StatPearls. StatPearls Publishing. Nemeth, V., & Pfleghaar, N. (2022). Diarrhea. In StatPearls. StatPearls Publishing. Copyright © MVJ 2018 DEA#: 101010101 STU Clinic LIC# 10000000 Tel: (000) 555-1234 FAX: (000) 555-12222 Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution Signature: ____________________________________________________________ Copyright © MVJ 2018 Copyright © MVJ 2018 Purchase answer to see full attachment