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S.M. is a 62-year-old White female who presents to the clinic with complaints of SOB, bilateral feet dependent edema and pain, and weight gain of 3 Ib in the past week. Patient alert and oriented x3, Normocephalic; denies headaches, + PERRL; TMs gray/pearly; oral mucosa is moist and intact; oropharynx is clear, Lung CTA, crackles heard on heart sound, Abdomen soft and non-tender, Active ROM, Peripheral pulses present, +3 edema on bil feet. PMH of morbid obesity, DVT, CKD, Hypertension, CHF, Hypothyroidism, Anxiety. BP 133/77, P 78, R 18, T 97.8, Wt. 315, Pox 94% on RM Air.Calculate BMI? Current Medication: Bumex 2mg, Lipitor 40mg, Aspirin 81mg, Oxycodone 10mg, Amlodipine 10mg, levothyroxine 25mcg, Escitalopram 20mg, and famotidine 40mg.
Complete a comprehensive SOAP note.
Subjective: What details did the patient provide regarding the personal and medical history?
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities and psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
Add information where necessary to complete your Comprehensive soap note.
Support your SOAP note with 6 APA citation using articles with nursing background within the last 5 years.
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