SOAP Note Scleroderm

Instructions:

You must use the template provided.- If any part of the Soap Note is missing the Soap Note will be taken as invalid- do not change or modify in any matter the format of the template provided.

This soap note Main Diagnoses is: Scleroderm

All vaccinations are up to date including 2 COVID19 vaccines and a 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. Non-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 had a PMH of Asthma since childhood, hypothyroidism, and arthritis since 2010. Current Medications; Levothyroxine 25mcg every morning, with an 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 weak and almost impossible to come to the consultation today. He has lost 15 kilos in the last three months. She is 1.5 mt in height and weighs 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.

The rubric is as follows:

Subjective: 10%

Objective: 20%

Assessment: 25%

Planning: 25%

Correct APA format and References: 10%

Use APA format and must include a minimum of 2 Scholarly Citations.

Must be your own work and in your own words. Copy-paste from websites or textbooks will not be accepted or tolerated.

The use of templates is ok, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient.