Topic: Soap Note nursing case study

The SOAP note should be related to the content covered in this week, and the completed note should be submitted to the Submissions Area. When submitting your note, be sure to include the reference number from CORE.

SOAP Note #2

S

CC: 67-year-old Hispanic female is seen at the clinic today with symptoms of difficulty and pain when swallowing food, regurgitation of swallowed food and saliva. Patient smoke, denies alcohol use. Denies being sexually active.

O
VS: T: 99.2 F P: 72/bpm BP 130/72 Wt.: 167 HT: 5’05” BMI:

Patient looks alert and oriented. Physical exam is normal. CBC test sample collected. Gastrointestinal endoscopy scheduled.

A
Possible Esophageal cancer, Achalasia. Likely Gastroesophageal reflux disease, diverticulum. GI Endoscopy revealed diverticula in lower esophagus. CBC normal, hCG negative.

P
Patient is advised to make dietary changes, such as eating a bland diet, chewing food slowly and thoroughly and drinking plenty of water. Follow up appointment is scheduled in two weeks. Return sooner or go to nearest ER if symptoms worsen

Dx: Esophageal diverticula

For each final primary diagnoses you listed, you should have 3 differential diagnoses: for you should have 3 ddx for insomnia, OSA.

You also must have references.

Please be sure to check the rubric before submitting, as it is provided for your benefit.

Type of assignment: Academic paper writing
Type of assignment: Case study
Subject: Nursing
Pages/words: 1/275
Number of sources: 5
Academic level: Bachelor
Paper format: APA
Line spacing: Double
Language style: US English

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