Make up soap note 1 opened: saturday, february 19, 2022, 12:00 amdue:

 

MAKE UP SOAP NOTE 1

Opened: Saturday, February 19, 2022, 12:00 AMDue: Saturday, March 5, 2022, 11:59 PM

You must used the template provided in this class under Course Document – If any part of the Soap Note is missing the Soap Note will be taken as invalid and the previous grade will prevail ( No Exception) – do not change or modify in any matter the format of the Template provided (attached)

This soap note Main Diagnoses is: Scleroderm

All vaccinations up to date including 2 COVID19 vaccines and booster. 

65 years old female patient, who lives alone in a one bedroom efficiency in Miami, with the minimum pension. Pt reports that a cousin supports her monetary at times. No Smoker, No Drinker.

The patient brought her last laboratories results that show: Severe dehydration, malnutrition and anemia. (include in your SOAP note the names of the labs that show these results.

Pt has a PMH of Asthma since childhood, hypothyroidism and arthritis since 2010. Current Medications; Levothyroxine 25mcg every morning, with empty stomach. Albuterol PRN Today she presented with swollen hands bilaterally complaining of pain and impossible to do the activities of daily living. In the last 3 months she has been having problems swallowing and passing food, but it was getting worse to swallow. During the last weeks, she was not able to tolerate any solid food and barely drink water.. Pt states feeling very week and almost impossible to come to the consultation today.. He has lost 15 kilos in the last three months. She is 1.5 mt height and weights : 51 kilos.

Note: You must use the information above to create your SOAP NOTE however you cannot copy and paste this information. You have to use your own words to create your case.

Due date: March 05, 2022 at 23:59

Rubric as follows:

Subjective: 10%

Objective: 20&

Assessment: 25%

Planning: 25%

Correct APA format and References: 10%

Maximum score: 90%







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