Description
I’m working on a nursing case study and need guidance to help me learn.Please use template provided. Soap note should be based on a patient complain that would be seen at a family practice, based on the below weekly reading. I also included a guide/sample.week, we will cover the male genitalia and also the male genitourinary system. The male genitalia include the reproductive and the genitourinary system. The male genitalia includes the penis, scrotum, testis, epididymis, and vas deferens. The prostate, seminal vesicles, and bulbourethral glands will be included in the discussion as well.
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CONPH NSG6020 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name:
Patient Name: (Initials ONLY)
Ethnicity:
Date:
Age:
SUBJECTIVE (must complete this section)
Course:
Time:
Sex:
CC:
HPI:
Medications:
Previous Medical History:
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas:
Hospitalizations/Surgeries:
FAMILY HISTORY (must complete this section)
M:
MGM:
MGF:
F:
PGM:
PGF:
Social History:
General:
Skin:
Eyes:
Ears:
Nose/Mouth/Throat:
Breast:
Heme/Lymph/Endo:
Weight:
Height:
General Appearance:
Skin:
HEENT:
Cardiovascular:
Respiratory:
Gastrointestinal:
Breast:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Lab Tests:
Special Tests:
REVIEW OF SYSTEMS (must complete this section)
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary/Gynecological:
Musculoskeletal:
Neurological:
Psychiatric:
OBJECTIVE (Document PERTINENT systems only. Minimum 3)
BMI:
BP:
Temp:
Pulse:
Differential Diagnoses
• 1- Diagnosis, (ICD 10 code):
• 1- Diagnosis, (ICD 10 code):
Plan/Therapeutics:
Diagnostics:
Education:
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DIAGNOSIS
Diagnosis
•
Resp:
1- Presumptive diagnosis (ICD 10 code):
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CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes Guide
THIS GUIDE IN NOT ALL INCLUSIVE. ALWAYS USE SOUND CLINICAL JUDGEMENT
Student Name:
Patient Name: (Initials ONLY)
Ethnicity:
Date:
Age:
SUBJECTIVE (must complete this section)
Course:
Time:
Sex:
CC:
What brings patient in for visit?
HPI:
Describe your symptoms in detail. When did they start and how long have they been going on?
What is the severity of your symptoms and what makes them better or worse?
What is your medical and mental health history?
What other health-related issues are you experiencing?
What medications are you taking?
Medications:
Ask details related to all medications to include prescribed, OTC, and non-traditional. Don’t forget dosage and frequency.
Previous Medical History:
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas:
Hospitalizations/Surgeries:
Ask have they ever received medical care? If so, what problems/issues were addressed? Don’t exclude obstetrical related matters.
Was the care continuous (i.e. provided on a regular basis by a single person) or episodic? Have they ever undergone any
procedures, X-Rays, CAT scans, MRIs or other special testing? Ever been hospitalized? If so, for what? Were they ever operated
on, even as a child? What year did this occur? Were there any complications? If they don’t know the name of the operation, try to at
least determine why it was performed. Do they participate in intercourse? With persons of the same or opposite sex? Are they
involved in a stable relationship? Do they use condoms or other means of birth control? Married? Health of spouse? Divorced? Past
sexually transmitted diseases? Do they have children? If so, are they healthy? Do they live with the patient? Have they experienced
any adverse reactions to medications? The exact nature of the reaction should be clearly identified as it can have important clinical
implications.
FAMILY HISTORY (must complete this section)
M:
MGM:
MGF:
F:
PGM:
PGF:
In particular, you are searching for heritable illnesses among first- or second-degree relatives. Most common, at least in America,
are coronary artery disease, diabetes and certain malignancies. Patients should be as specific as possible. “Heart disease,” for
example, includes valvular disorders, coronary artery disease and congenital abnormalities, of which only coronary disease has
genetic implications. Find out the age of onset of the illnesses, as this has prognostic importance for the patient. For example, a
father who had an MI at age 70 is not a marker of genetic predisposition while one who had a similar event at age 40 certainly
would be. Also ask about any unusual illnesses among relatives, perhaps revealing evidence for rare genetic conditions.
Social History:
What sort of work does the patient do? Have they always done the same thing? Do they enjoy it? If retired, what do they do to stay
busy? If not employed, are they a student. Inquire about grades, school, bullying (if primary education) Any hobbies? Participation
in sports or other physical activity? Where are they from originally?
Have they ever smoked cigarettes? If so, how many packs per day and for how many years? If they quit, when did this occur? Do
they drink alcohol? If so, how much per day and what type of drink? Any drug use, past or present, should be noted. Get in the
habit of asking all your patients these questions as it can be surprisingly difficult to accurately determine who is at risk strictly on
the basis of appearance. Remind them that these questions are not meant to judge but rather to assist you in identifying risk factors
for particular illnesses (e.g. HIV, hepatitis).
REVIEW OF SYSTEMS (must complete this section)
General:
Cardiovascular:
Weight change, fatigue, fever, chills, night sweats,
Chest pain, palpitations, PND, orthopnea, edema
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CONPH Subjective, Objective, Assessment, Plan (SOAP) Notes Guide
THIS GUIDE IN NOT ALL INCLUSIVE. ALWAYS USE SOUND CLINICAL JUDGEMENT
energy level
Skin:
Delayed healing, rashes, bruising, bleeding or skin
discolorations, any changes in lesions or moles
Eyes:
Corrective lenses, blurring, visual changes of any
kind
Ears:
Ear pain, hearing loss, ringing in ears, discharge
Nose/Mouth/Throat:
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, throat pain
Breast:
SBE, lumps, bumps or changes
Respiratory:
Cough, wheezing, hemoptysis, dyspnea, pneumonia
hx, TB
Gastrointestinal:
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, black tarry
stools
Genitourinary/Gynecological:
Urgency, frequency burning, change in color of urine.
Contraception, sexual activity, STDS Fe: last pap, breast,
mammo, menstrual complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Musculoskeletal:
Back pain, joint swelling, stiffness or pain, fracture
hx, osteoporosis
Neurological:
Syncope, seizures, transient paralysis, weakness,
parenthesis, black out spells
Psychiatric:
Depression, anxiety, sleeping difficulties, suicidal
ideation/attempts, previous dx
Heme/Lymph/Endo:
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst, increase
hunger, cold or heat intolerance
OBJECTIVE (Document PERTINENT systems only. Minimum 3)
Describe what you see, instead of WNL (within normal limits) or another acronym, be descriptive with your assessment findings.
Support your diagnoses solidly.)
Weight:
Height:
BMI:
BP:
Temp:
Pulse:
Resp:
General Appearance:
Skin:
HEENT:
Head and scalp normocephalic, normal hair distribution. EOM intact, red reflex visualized, PERRLA, no cataracts noted b/l,
eyelids without redness or swelling. No tenderness on palpation of tragus, no erythema or effusion. Tympanic membrane
translucent in bilateral ears. pearly grey with positive light reflex; landmarks easily visualized. No erythema or swelling of
turbinates, no discharge and crusting seen in bilateral nares No Pharyngeal erythema and uvula midline. No ulcers noted. No foul
odor from mouth, no tonsillar enlargement without exudates. Teeth are in good repair. Neck is supple without tender cervical nodes,
no nuchal rigidity and thyroid tissue firm pliable and non-tender.
Cardiovascular:
HR NSR, S1, S2 with regular rate and rhythm, no murmur noted. No extra sounds, clicks, rubs or murmurs. Pulses 3+ throughout.
No edema. Cap refill 100.4) go to the emergency room.
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