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Instructions: Read the Case Study carefully and pay attention to all elements of the SOAP Note provided. Identify key elements that must be included in a prescription. Suggest a professional prescription with the key elements applicable to your Rx. You can use WORD or similar for this task. * A template is not provided. Refer to your book or do some research. If you hand write it ensure that it is very, very legible. This can be an easy way to lose points. You may choose any medication from your assigned module chapters that meets the title of the assignment (see title). Your focus should always be patient safety and promoting adherence. On a second page include the following: Monitoring Parameters or key details regarding this med (i.e. black box warnings, state or federal regulations limiting quantity) Education that you would provide the patient. List references: What resource did you use for the prescription? If you include the textbook then you will need an additional reference Use a credible resource. There is a free version of the Epocrates App. (APA required) Sign and submit the script. Do not print your name. A signature is required. **Use a fictional name for the patient. CASE STUDY S.O.A.P. NOTE SUBJECTIVE C/C: “I have been here twice in the last three weeks and now I have a yeast infection and I am constipated” HPI: Ms. Argie is a 26 yr old female who presents for a follow up to the clinic with concerns of a yeast infection and constipation. She states that she took all of her antibiotics prescribed for her Acute Bacterial Sinus Infection and she was taking the pain medications for her headaches which did help. About two days before she completed her antibiotics she developed the yeast infection. She tried over the counter Monistat but it has not resolved the issue. She states that due to feeling ill and her headaches she forgot to mention that she is prone to yeast infections when taking antibiotics. ROS: General/Constitutional: +for chills, +fever, no dizziness or fatigue. HEENT: Positive for headache, no visual changes but does have eye drainage that is clear, ears feel muffled without pain, +nose congestion, + drainage, no sore throat Neck: no pain or restrictions in movement CV: no CP, palpitations Resp: denies SOB, cough, states she is much better. GI: + constipation, last bowel movement 3 days ago and had to strain GU: describes thick non odorous white clumpy discharge. Consistent with previous yeast infections Allergies: PCN (reaction- rash), NSAIDs PMH: Essential Hypertension (working on lifestyle modifications); Asthma; Migraine Headaches, Situational Anxiety PSH: Appendectomy Medications: Sprintec; albuterol inhaler, Sumatriptan 100mg, Acetaminophen 650mg Social History: Civil Engineer, Married, 2 kids, drinks 2-3 Mojitos every weekend. Exercises 5-6 days/week for approx. 45-60 minutes; eats healthy foods mostly veggies with some lean meats and fish. OBJECTIVE: Vitals: 124/72; HR 82, RR 16, O2 Sat 98%, Pain 0/10 headache Wt 127 lbs Ht. 60 inches General or Constitutional: appears well and is in no acute distress. She is well groomed and answers questions appropriately. Athletic thin build does not appear ill. Neck: Supple, FROM CV: RRR, S1 and S2, no presence of murmur, rubs or gallops. Pulse +2 throughout. No edema or cyanosis. Resp: occasional unproductive cough, Clear to auscultation x 4 apices/bases Anterior/Posterior; speech clear, appropriate, and effortless GI: normoactive bowel sounds, nontender to light or deep palpation, no organomegally GU: + mild vulvar and vaginal erythema, thick white non-odorous discharge. PLAN: Tx: What medication will you prescribe for this patient to help with their chief complain related to this specific assignment. Do not restrict your patient to one medication if there is a need for more; however, always think safety (See instructions).

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