SOAP NOTE: diagnosis of Scleroderma

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%
(Student Name)

Miami Regional University

Date of Encounter:

Preceptor/Clinical Site:

Clinical Instructor: Patricio Bidart MSN, APRN, FNP-C

Soap Note # ____ Main Diagnosis ______________

PATIENT INFORMATION

Name:

Age:

Gender at Birth:

Gender Identity:

Source:

Allergies:

Current Medications:

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PMH:

Immunizations:

Preventive Care:

Surgical History:

Family History:

Social History:

Sexual Orientation:

Nutrition History:

Subjective Data:

Chief Complaint:

Symptom analysis/HPI:

The patient is …

Review of Systems (ROS) (This section is what the patient says, therefore should state Pt denies, or Pt states….. )

CONSTITUTIONAL:

NEUROLOGIC:

HEENT:

RESPIRATORY:

CARDIOVASCULAR:

GASTROINTESTINAL:

GENITOURINARY:

MUSCULOSKELETAL:

SKIN:

Objective Data:

VITAL SIGNS:

GENERAL APPREARANCE:

NEUROLOGIC:

HEENT:

CARDIOVASCULAR:

RESPIRATORY:

GASTROINTESTINAL:

MUSKULOSKELETAL:

INTEGUMENTARY:

ASSESSMENT:

(In a paragraph please state “your encounter with your patient and your findings ( including subjective and objective data)

Example : “Pt came in to our clinic c/o of ear pain. Pt states that the pain started 3 days ago after swimming. Pt denies discharge etc… on examination I noted this and that etc.)

Main Diagnosis

(Include the name of your Main Diagnosis along with its ICD10 I10. (Look at PDF example provided) Include the in-text reference/s as per APA style 6th or 7th Edition.

Differential diagnosis (minimum 3)

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PLAN:

Labs and Diagnostic Test to be ordered (if applicable)

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Pharmacological treatment:

–

Non-Pharmacologic treatment:

Education (provide the most relevant ones tailored to your patient)

Follow-ups/Referrals

References (in APA Style)

Examples

Codina Leik, M. T. (2014). Family Nurse Practitioner Certification Intensive Review (2nd ed.).

ISBN 978-0-8261-3424-0

Domino, F., Baldor, R., Golding, J., Stephens, M. (2010). The 5-Minute Clinical Consult 2010

(25th ed.). Print (The 5-Minute Consult Series).