I want the soap note to be about a 65 year old female patient with a diagnosis of diverticulitis. I have attached a template with the required info for each section of the soap note to this posting. please keep in mind that this assignment is late already and I need it to be great so I do not get more points reduced. thanksName: Pt. Encounter Number:
Date: Age: Sex:
SUBJECTIVE
CC:
Reason given by the patient for seeking medical care “in quotes”
HPI:
Describe the course of the patient’s illness, including when it began, character of symptoms, location
where the symptoms began, aggravating or alleviating factors, pertinent positives and negatives, other
related diseases, past illnesses, and surgeries or past diagnostic testing related to the present illness.
Medications: (List with reason for med )
PMH
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas
Hospitalizations/Surgeries
“Have you ever been told that you have diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart
disease, cancer, TB, thyroid problems, kidney problems, or psychiatric diagnosis?”
Family History
Does your mother, father, or siblings have any medical or psychiatric illnesses? Is anyone diagnosed with:
lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease?
Social History
Education level, occupational history, current living situation/partner/marital status, substance use/abuse,
ETOH, tobacco, and marijuana. Safety status
ROS
General
Weight change, fatigue, fever, chills, night sweats,
and energy level
Cardiovascular
Chest pain, palpitations, PND, orthopnea, and
edema
Skin
Delayed healing, rashes, bruising, bleeding or skin
discolorations, and any changes in lesions or moles
Respiratory
Cough, wheezing, hemoptysis, dyspnea, pneumonia
hx, and TB
Eyes
Corrective lenses, blurring, and visual changes of
any kind
Gastrointestinal
Abdominal pain, N/V/D, constipation, hepatitis,
hemorrhoids, eating disorders, ulcers, and black,
tarry stools
Ears
Ear pain, hearing loss, ringing in ears, and
discharge
Genitourinary/Gynecological
Urgency, frequency burning, change in color of
urine.
Contraception, sexual activity, STDs
Female: last pap, breast, mammo, menstrual
complaints, vaginal discharge, pregnancy hx
Male: prostate, PSA, urinary complaints
Nose/Mouth/Throat
Sinus problems, dysphagia, nose bleeds or
discharge, dental disease, hoarseness, and throat
pain
Musculoskeletal
Back pain, joint swelling, stiffness or pain, fracture
hx, and osteoporosis
Breast
SBE, lumps, bumps, or changes
Neurological
Syncope, seizures, transient paralysis, weakness,
paresthesias, and black-out spells
Heme/Lymph/Endo
HIV status, bruising, blood transfusion hx, night
sweats, swollen glands, increase thirst, increase
hunger, and cold or heat intolerance
Psychiatric
Depression, anxiety, sleeping difficulties, suicidal
ideation/attempts, and previous dx
OBJECTIVE
Weight BMI Temp BP
Height Pulse Resp
General Appearance
Healthy-appearing adult female in no acute distress. Alert and oriented; answers questions appropriately.
Slightly somber affect at first and then brighter late
Why Choose Us
- 100% non-plagiarized Papers
- 24/7 /365 Service Available
- Affordable Prices
- Any Paper, Urgency, and Subject
- Will complete your papers in 6 hours
- On-time Delivery
- Money-back and Privacy guarantees
- Unlimited Amendments upon request
- Satisfaction guarantee
How it Works
- Click on the “Place Order” tab at the top menu or “Order Now” icon at the bottom and a new page will appear with an order form to be filled.
- Fill in your paper’s requirements in the "PAPER DETAILS" section.
- Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
- Click “CREATE ACCOUNT & SIGN IN” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
- From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.