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Pick any Chronic Disease from Weeks 6-10

Soap Note 2 Chronic Conditions
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 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.


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