Hello I need you to fill out the template below by make up a SOAP NOTE for a male patient with any disease of the Reproductive and Urinary Systems. (You can choose any you fill comfortable with)
I send the the soap note template, do not use exatly the same words.
I needs you to come up with the following:
Chief complain
History of present illness
History of past meical history
Family history
Social history
Objective
Subjective
Vital sign
BMI
AGE
Full head to toes assessment with findings
Review of system
Differential Dignosis
Dignosis
ICD 1O CODE
Treatment plan
APA style 4 References no older than 5 years old
SOAP NOTE
|
Name: |
Date: |
Time: |
||
|
Age: |
Sex: |
|||
|
SUBJECTIVE |
||||
|
CC: Reason given by the patient for seeking medical care “in quotes” |
||||
|
HPI: Describe the course of the patient’s illness, including when it began, character of symptoms, location where the symptoms began, aggravating or alleviating factors; pertinent positives and negatives, other related diseases, past illnesses, surgeries or past diagnostic testing related to present illness. |
||||
|
Medications: (list with reason for med ) |
||||
|
PMH Allergies: Medication Intolerances: Chronic Illnesses/Major traumas Hospitalizations/Surgeries “Have you ever been told that you have: Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems or kidney disease or psychiatric diagnosis.” |
||||
|
Family History: Does your mother, father or siblings have any medical or psychiatric illnesses? Anyone diagnosed with: lung disease, heart disease, htn, cancer, TB, DM, or kidney disease. |
||||
|
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, marijuana. Safety status |
||||
|
ROS |
||||
|
General Weight change, fatigue, fever, chills, night sweats, energy level |
Cardiovascular Chest pain, palpitations, PND, orthopnea, edema |
|||
|
Skin Delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles |
Respiratory Cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB |
|||
|
Eyes Corrective lenses, blurring, visual changes of any kind |
Gastrointestinal Abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools |
|||
|
Ears Ear pain, hearing loss, ringing in ears, discharge |
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 |
|||
|
Nose/Mouth/Throat Sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain |
Musculoskeletal Back pain, joint swelling, stiffness or pain, fracture hx, osteoporosis |
|||
|
Breast SBE, lumps, bumps or changes |
Neurological Syncope, seizures, transient paralysis, weakness, paresthesias, black out spells |
|||
|
Heme/Lymph/Endo HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance |
Psychiatric Depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dx |
|||
|
OBJECTIVE |
||||
|
Weight BMI |
Temp |
BP |
||
|
Height |
Pulse |
Resp |
||
|
General Appearance Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Slightly somber affect at first, then brighter later. |
||||
|
Skin Skin is brown, warm, dry, clean and intact. No rashes or lesions noted. |
||||
|
HEENT Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. Pharynx is nonerythematous and without exudate. Teeth are in good repair. |
||||
|
Cardiovascular S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema. |
||||
|
Respiratory Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally. |
||||
|
Gastrointestinal Abdomen obese; BS active in all 4 quadrants. Abdomen soft, non-tender. No hepatosplenomegaly. |
||||
|
Breast Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin. |
||||
|
Genitourinary Bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. Cervix is pink and nulliparous. Scant clear to cloudy drainage present. On bimanual exam, cervix is firm. No CMT. Uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable. (Male: both testes palpable, no masses or lesions, no hernia, no uretheral discharge. ) (Rectal as appropriate: no evidence of hemorrhoids, fissures, bleeding or masses—Males: prostrate is smooth, non-tender and free from nodules, is of normal size, sphincter tone is firm). |
||||
|
Musculoskeletal Full ROM seen in all 4 extremities as patient moved about the exam room. |
||||
|
Neurological Speech clear. Good tone. Posture erect. Balance stable; gait normal. |
||||
|
Psychiatric Alert and oriented. Dressed in clean slacks, shirt and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately. |
||||
|
Lab Tests Urinalysis – pending Urine culture – pending Wet prep – pending |
||||
|
Special Tests |
||||
|
Diagnosis |
||||
|
Differential Diagnoses
Diagnosis
|
||||
|
Plan/Therapeutics |
||||
|
||||
|
Evaluation of patient encounter |
||||
How to solve
Soap Note Reproductive and Urinary Systems, health and medicine homework help Nursing Assignment Help
SOAP NOTE Name: John Doe
Date: 10/15/20
Time: 10:00 AM
Age: 45
Sex: Male
SUBJECTIVE
CC: “I have been experiencing frequent urination and pain while urinating for the past week.”
HPI: The patient reports a one-week history of increased frequency of urination and dysuria. The symptoms started spontaneously and have been progressively worsening. He denies any hematuria, flank pain, fevers, or chills. No previous episode of such symptoms has occurred. The patient denies any recent sexual activity or history of sexually transmitted infections.
Medications: No current medications.
PMH: No history of chronic illnesses, major traumas, or surgeries.
Allergies: No known drug allergies.
Medication Intolerances: None reported.
Family History: The patient’s mother has a history of hypertension. No other significant medical or psychiatric illnesses reported in the family.
Social History: The patient is married and works as an accountant. He denies tobacco, marijuana, or illicit drug use. He drinks alcohol occasionally, approximately 2-3 times a month.
ROS:
General: No recent weight changes, fatigue, fever, chills, or night sweats. The patient reports normal energy levels.
Cardiovascular: No chest pain, palpitations, paroxysmal nocturnal dyspnea (PND), orthopnea, or edema.
Skin: No delayed healing, rashes, bruising, bleeding, or skin discolorations. No changes in lesions or moles reported.
Respiratory: No cough, wheezing, hemoptysis, dyspnea, pneumonia history, or tuberculosis history.
Eyes: No corrective lenses, blurring, or visual changes reported.
Gastrointestinal: No abdominal pain, nausea, vomiting, diarrhea, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, or black tarry stools.
Ears: No ear pain, hearing loss, ringing in ears, or discharge.
Genitourinary: Increased urgency and frequency, dysuria reported. No change in color of urine. No history of contraception, sexual activity or sexually transmitted diseases.
Nose/Mouth/Throat: No sinus problems, dysphagia, nosebleeds, dental disease, hoarseness, or throat pain.
Musculoskeletal: No back pain, joint swelling, stiffness, or fracture history.
Breast: No breast complaints reported.
Neurological: No syncope, seizures, transient paralysis, weakness, paresthesias, or blackouts reported.
Heme/Lymph/Endo: No HIV status, bruises, blood transfusions, night sweats, swollen glands, increased thirst, increased hunger, cold or heat intolerance reported.
Psychiatric: No history of depression, anxiety, sleeping difficulties, or suicidal ideation/attempts.
OBJECTIVE
Weight: 180 lbs
BMI: 27.5 (overweight)
Temp: 98.6°F
BP: 120/80 mmHg
Height: 5’10”
Pulse: 76 bpm
Resp: 16 breaths per minute
General: The patient appears healthy, well-groomed, and in no acute distress. He is alert and oriented, answering questions appropriately. The patient’s affect starts somber but brightens later during the encounter.
Skin: The skin is brown, warm, dry, clean, and intact. No rashes or lesions are noted.
HEENT: The head is normocephalic, atraumatic, and without lesions. Hair is evenly distributed. Eyes display PERRLA (pupils equal, round, reactive to light, and accommodation). Extraocular movements are intact, and there is no conjunctival or scleral injection. Ears reveal patent canals, pearly gray tympanic membranes with positive light reflex, and easily visualized landmarks. Nose shows pink nasal mucosa with normal turbinates and no septal deviation. Neck is supple with full range of motion, no cervical lymphadenopathy, no occipital nodes, and no thyromegaly or nodules. Oral mucosa is pink and moist. Pharynx appears nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular: Heart sounds S1 and S2 are heard with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs are noted. Capillary refill is 2 seconds, and pulses are 3+ throughout. No edema is observed.
Respiratory: Chest wall is symmetric. Respirations are regular and easy with clear lung sounds bilaterally.
Gastrointestinal: Abdomen is obese but soft and non-tender. Bowel sounds are active in all four quadrants. No hepatosplenomegaly is observed.
Genitourinary: External genitalia reveals normal distribution of coarse pubic hair and consistent skin color. No vulvar lesions are noted. A small speculum is inserted, and vaginal walls appear pink and well-rugated with no lesions. Cervix is pink and nulliparous. Scant clear to cloudy drainage is present. On bimanual exam, cervix is firm, with no cervical motion tenderness. Uterus is anteverted and positioned behind a slightly distended bladder, with no fullness, masses, or tenderness. No adnexal masses or tenderness is detected.
Musculoskeletal: Full range of motion is seen in all four extremities as the patient moves about the exam room.
Neurological: Speech is clear. Good tone is observed, along with erect posture and normal gait.
Psychiatric: The patient is alert and oriented. He is dressed in clean attire and maintains eye contact. Speech is soft but clear and of normal rate and cadence.
Lab Tests: Urinalysis, urine culture, and wet prep pending.
Diagnosis
Differential Diagnoses:
1. Urinary tract infection
2. Prostatitis
3. Sexually transmitted infection
Plan/Therapeutics
Plan:
1. Complete urinalysis, urine culture, and wet prep.
2. Start empirical antibiotic therapy for urinary tract infection and prostatitis.
3. Encourage increased fluid intake and hygiene measures.
4. Provide patient education on the importance of completing the full course of antibiotics, maintaining proper hygiene, and safe sexual practices.
Evaluation of patient encounter: The patient’s presenting symptoms and physical examination findings are consistent with a possible urinary tract infection or prostatitis. Further diagnostic tests and empirical antibiotic therapy have been initiated. Patient education regarding hygiene and safe practices has been provided. Follow-up will be scheduled to monitor treatment response and assess for resolution of symptoms.
APA Style References:
1. National Institute of Diabetes and Digestive and Kidney Diseases. (2019). Urinary tract infection (UTI) in men. Retrieved from https://www.niddk.nih.gov/health-information/urologic-diseases/urinary-tract-infections-men
2. Ferrero, D., Peyronnet, B., Mathieu, R., Bruyant, R., Houé, T., Verhoest, G., … & Thomas, C. (2018). Prostatitis: Diagnosis and Management. European Urology Focus, 4(3), 337-339.
3. Workowski, K. A., & Bolan, G. A. (2015). Sexually transmitted diseases treatment guidelines. MMWR Recommendations and Reports, 64(RR-03), 1-137.
4. Gupta, K., Hooton, T. M., Naber, K. G., Wullt, B., Colgan, R., Miller, L. G., … & Raz, R. (2011). International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clinical Infectious Diseases, 52(5), e103-e120.
