Unit 10 DB Template Tana Smith SOAP Note: S: O: A: P: Educational
Information/To
Unit 10 DB TemplateTana Smith SOAP Note:S:O:A:P:Educational Information/Toxic Shock
Syndrome:What is toxic shock syndrome:How did you develop toxic shock
syndrome:Options for preventing toxic shock syndrome:Citation template: Author or
publisher. (year of publication). Title of article. URLUnit 10 Quiz Study Guide:Chapter
11:https://highered.mheducation.com/sites/dl/premium/1259638162/instructor/11061
83/Jon38162_ch11_CR1_CR10_onlinecontent.pdfChapter 12:
https://highered.mheducation.com/sites/dl/premium/1259638162/instructor/1106183/
Jon38162_ch12_CR1_CR8_onlinecontent.pdfChapter
13:https://highered.mheducation.com/sites/dl/premium/1259638162/instructor/11061
83/Jon38162_ch13_CR1_CR8_onlinecontent.pdfYou are to respond by composing a SOAP
note. Write your SOAP note in layman’s terms, which means you will need to decipher the
medical information in the progress note. You will need to include at least two items from
each of the areas: History, Objective Findings, and Assessment.In addition, you need to
include a follow-up treatment plan after discharge to educate the patient on the diagnosis of
toxic shock syndrome by explaining what toxic shock syndrome is, how she developed toxic
shock syndrome , and how she can prevent getting toxic shock syndrome again.PROGRESS
NOTEMain Street Medical Center6000 North Tree Street – Branch PA 12345 Phone: (555)
123-4567PATIENT NAME: Tana Smith MEDICAL RECORD: 8888888DATE OF BIRTH:
12/10/1988 DATE OF VISIT: 1/15/2015HISTORY: The patient is a 28-year-old female, who
has a history of IUD placement in 2012. May of 2014, patient seen by a gynecologist for
dysmenorrhea and menometrorrhagia. Upon examination a hysterosalpingogram was
performed. Patient diagnosed with oophoritis and hematosalpinx with multiple myoma. In
June of 2014, the patient was scheduled for a salpingostomy laparoscopically. A
hysteroscopy was performed with visualization of two myoma of the uterus on the lower
left wall approximately 3 cm and 2.5 cm in diameter. At the junction of the fundus and left
salpingo, a 4 cm myoma was noted. A myomectomy was performed on the smaller myoma
without incidence. A D and C was performed. Due to complications during the procedure, a
left salpingo-oophorectomy was performed. Patient presents to the ER today with c/o
myalgia, episodes of syncope, fever, rash of the face and chest, N and V x 2 days, and
leukorrhea. Patient states she experienced dysmenorrhea for the last 5 days and diarrhea
started today.OBJECTIVE FINDINGS:Vitals: BP 105/62, T: 100.7, R: 22, P: 96, Weight: 155,

Height: 5’6.”Skin: Facial erythroderma, warm, clammy.Resp: Lungs are clear to auscultation
and percussion.Cardio: S1, S2 within normal limits, without gallops or murmurs.Gastro:
abdominopelvic tender to palpation in lower right iliac region, without organomegaly
mass.Neuro: LOC – Alert and oriented to person, but confused to time and place. Grips,
flexion, extension weak but equal bilaterally. PERRL.Urinary: 100 ml cloudy, amber urine.
No dysuria, polyuria, or tenderness with voiding reported. No bladder distention
reported.Lab: CBC, WBC, Creatinine, BUN, UA, Vaginal, Throat, and Urine
cultures.ASSESSMENT: Patient posture is slightly bent; gait is slow. Examination conducted.
Patient disoriented when asked questions, agitated and grimacing upon palpation of RLQ
and posterior left lumbar region. Lower abdominopelvic region tender to palpation. No
ascites noted. UA performed. Patient placed in lithotomy position to obtain vaginal cultures.
Lab results show elevated WBCs – specific to elevated T Cells, anemia, albuminuria, and
vaginal culture positive for staphylococci. This raises the suspicion of TSS and
ARF.TREATMENT SUMMARY: Patient admitted and transferred to the Intensive Care Unit,
started on normal saline and Clindamycin 700 mg IV q 8h. Dopamine started IV. Indwelling
Foley catheter inserted via urethra to monitor hourly output. Peri-pads used to replace
tampons for menorrhea. VS taken q 2h. Day 2, patient responding well to intravenous
infusion of dopamine and antibiotic therapy. Cultures obtained. Upon day 3, patient afebrile,
blood pressure is within normal limits, cultures negative for Staph, BUN and liver function
tests are within normal limits. Discharge orders written.