A) Please fallow instruction. I need you to make up a soap note for a female patient with diagnoses of Pelvic Inflammatory disease (PID) Please fill out the template. I include the soap note template you must plug the information, the rubric to follow in separate attachments. I need you to provide the following: APA format with references at least no older than 5 years.
Chief complaint: Lower abdominal pain and vaginal di
1) The Diagnosis ICD 10 code
2) 3 differential diagnoses with ICD 10 code.
3) Vital sign, BMI
4) Complete Chief patient compliant
5) Subjective Information
6) PMH, PSH, FH, ROS completed. Provide complete and concise summary of pertinent information.
7) Complete Objective Information
8) Lab Tests
9) Allergies
10) Complete physical exam with critical elements related to subjective data.
11 )Perform Assessment
12) Minimum of 3 differentials supported by S + O data. Final diagnosis noted and optimal and thorough subjective and objective assessment is presented for final diagnosis.
13) Create a Plan
14) Plan includes pharmacologic and nonpharmacologic treatments as well as education provided. The plan is supported by evidence/guidelines, and the follow-up plans are noted.
15) Self-Assessment & Clinical Guidelines
16) Analyze quality and relevance of S + O data and the evidence for diagnosis. Use of clinical evidence based reasoning and literature in designing plan of care, compare to plan of care.
Weight: 96 kgs need this in LBS
Height : 1.7 m need in cm
BMI: 33.22
Expert Solution Preview
Introduction:
In this assignment, we will be creating a SOAP note for a female patient with a diagnosis of Pelvic Inflammatory Disease (PID). The SOAP note will include all the necessary information, such as the patient’s medical history, vital signs, subjective and objective information, lab tests, allergies, differential diagnoses, and a plan of care. The SOAP note must follow the given rubric and be written in APA format with references no older than 5 years.
Answer:
1) The Diagnosis ICD 10 code for Pelvic Inflammatory Disease (PID) is N70.
2) Three differential diagnoses with ICD 10 codes for lower abdominal pain and vaginal discharge:
a) Ectopic pregnancy: O00.9
b) Endometriosis: N80.0
c) Ovarian cyst: N83.20
3) Vital signs:
Weight: 211.64 lbs
Height: 66.93 inches (169 cm)
BMI: 33.22
4) Complete chief patient complaint: The patient presents with the complaints of lower abdominal pain and vaginal discharge.
5) Subjective information: The patient reports experiencing persistent pain in the lower abdomen for several days. She also states that the pain intensifies with sexual intercourse and urination. The patient complains of a yellowish-green vaginal discharge with an unpleasant odor.
6) PMH, PSH, FH, ROS completed. Pertinent information summarized below:
Past Medical History (PMH) – Hypertension, Type 2 Diabetes Mellitus, Obesity
Past Surgical History (PSH) – Cholecystectomy
Family History (FH) – No significant family history of any disease
Review of Systems (ROS) – Negative for fever, chills, nausea, vomiting. Positive for lower abdominal pain, vaginal discharge, pain during urination or intercourse.
7) Complete Objective information: Inspection reveals diffuse tenderness in the lower abdomen with positive tenderness over bilateral adnexal regions. No masses palpated. Speculum exam shows a yellowish-green frothy discharge. Cervix is erythematous and easily friable.
8) Lab Tests:
Complete Blood Count (CBC) – Negative for leukocytosis
Pregnancy Test – Negative
Chlamydia and Gonorrhea PCR Tests – Positive for both
9) Allergies – No known allergies
10) Complete physical exam with critical elements related to subjective data:
Inspection of abdomen and adnexal areas, pelvic exam, speculum exam
11) Assessment: PID with chlamydia and gonorrhea infection.
12) Differential diagnoses supported by S + O data:
a) Ectopic Pregnancy (O00.9)
b) Endometriosis (N80.0)
c) Ovarian cyst (N83.20)
Final Diagnosis: PID with chlamydia and gonorrhea infection.
Thorough subjective and objective assessment presented for the final diagnosis.
13) Plan:
Pharmacologic treatments:
a) Ceftriaxone IM 250mg
b) Azithromycin PO 1g
c) Analgesics – ibuprofen 800 mg PRN for pain
Non-pharmacologic treatments:
a) Abstain from sexual intercourse for at least 7 days.
b) Sexual partners should be treated and encouraged to get tested.
c) Educate the patient about the importance of sexual safety and prevention of sexually transmitted infections.
14) The plan is supported by evidence/guidelines, and the follow-up plans are noted. The patient will follow up in 7 days. Test for chlamydia and gonorrhea in 7 days. Encourage the patient to follow up on her diabetes and hypertension management with her primary care provider.
15) Self-Assessment and Clinical Guidelines – The S+O data was consistent with a diagnosis of PID, and the treatment plan was based on the clinical guidelines. The differential diagnoses were weighed based on the available information, and the final diagnosis was supported by S+O data.
16) Analyze the quality and relevance of S + O data and evidence for diagnosis. The use of clinical evidence-based reasoning and literature in designing the plan of care was compared to the plan of care.
Conclusion:
In this assignment, we designed a SOAP note for a female patient with PID. The SOAP note included all necessary information, such as the patient’s medical history, vital signs, subjective and objective information, lab tests, allergies, differential diagnoses, and a plan of care. The patient was diagnosed with PID and Chlamydia and Gonorrhea infections, and the treatment plan followed clinical guidelines and evidence-based reasoning.
