1)  Submit 1 document per part

Part 1: Complete the file “Template Soap Note”  according to:
Name: NM
Gender: Male
Age: 77 years old
Diagnosis:  (L57.0) Actinic keratosis 
Chief complain:  scaly patches of skin 

Part 2: Complete the “Template Soap Note” taking into account the following information:

     Name: Rl
     Gender: Female
     Age: 67 years
     Diagnosis:  (I49.9) Cardiac arrhythmia, unspecied 
    Chief complain:  Rapid heartbeat and pounding in the chest

Part 3: Complete the “Sample Soap ” taking into account the following information:

Name: KY
    Gender: Female
    Age: 44
    Diagnosis:  (K64.9) Unspecied hemorrhoids  
    Chief complain:  Irritation and pain around the anus.

2)¨******APA norms, please use headers
          All paragraphs must be narrative and cited in the text- each paragraphs
          Bulleted responses are not accepted
          Dont write in the first person 
          Dont copy and pase the questions.
          Answer the question objectively, do not make introductions to your answers, answer it when you start the paragraph
         Submit 1 document per part

3) It will be verified by Turnitin and SafeAssign

4) Minimum 4 references per part not older than 5 yearsPatient Initials:

Pt. Encounter Number:

Date:

Age:

Sex:

Allergies: Advanced Directives:

SUBJECTIVE

CC:

HPI:
Describe the course of the patient’s illness:

Onset:

Location:

Duration:

Characteristics:

Aggravating Factors:

Relieving Factors:

Treatment:

Current Medications:

PMH

Medication Intolerances:

Chronic Illnesses/Major traumas:

Screening Hx/Immunizations Hx:

Hospitalizations/Surgeries:

Family History:

Social History:

ROS

General

Cardiovascular

Skin

Respiratory

Eyes

Gastrointestinal

Ears

Genitourinary/Gynecological

SOAP NOTE

Nose/Mouth/Throat

Musculoskeletal

Breast

Neurological

Heme/Lymph/Endo

Psychiatric

OBJECTIVE

Weight BMI

Temp

BP

Height

Pulse

Resp

PHYSICAL EXAMINATION

General Appearance

Skin

HEENT

Cardiovascular

Respiratory

Gastrointestinal

Breast

Genitourinary

Musculoskeletal

Neurological

Psychiatric

Lab Tests

Special Tests

Diagnosis

· Primary Diagnosis-
 Evidence for primary diagnosis should be documented in your Subjective and
Objective exams.

o Differential Diagnoses- Include three minimum diagnoses

PLAN including education

o Plan:
 Further testing
 Medication
 Education
 Non-medication treatments
· Referrals
 Follow-up visits

ReferencesPatient: Mr. H, male 54 years old
Hispanic, Spanish
Chief complaint: “I been in pain for the last 3 months with minimal or without relief.”
History of present illness: Mr. H 54 year’s old male came to the office c/o left shoulder pain 8/10 without reliefs since last 3 months. He been taking OTC analgesic without success.
Objective Information Allergies: NKDA.
Social History:
Patient 51 years old male denied smoking, alcohol intake or illicit drugs. Flu Vaccine 10/2019.
Past Medical History:
* Hypertension.
Medications:
* Lisinopril 25 mg PO daily.
Subjective:
Review of Systems:
Constitutional: Denies fever or distress.
Eyes: Denies any eye pain, redness, or tearing. Denies headache.
Ears, Nose, Mouth, and throat: Denies hearing loss or tinnitus or pain. No nasal congestion, drainage, redness, or swelling reported. Denies any throat pain.
Neck: Denies lumps or swollen glands, pain, or neck stiffness.
Cardiovascular: Denies chest pain, SOB or lightheadedness along with any palpitations at this time.
Respiratory: Denies any cough or shortness of breath.
Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation. Patient reports having daily bowl movements.
Genitourinary: Denies discharge. Denies urgency, dysuria, or hematuria.
Musculoskeletal: Denies joint pain, stiffness, swelling, or muscle pain, other than left shoulder pain for the past 3 months.
Skin: Denies rashes, dryness, color change. No abnormalities of hair or nails.
Neurological: Denies headaches, dizziness, or vertigo. Denies numbness, paresthesias, or tremors.
Mental Health: Denies Psychiatric disorder/ Patient reports good memory and concentration. • Endocrine: Denies endocrine disorder.
Hematologic/Lymphatic: Denies bruising or bleeding. No prior blood transfusions/ No intermittent claudication. Denies leg cramps.
Allergic/Immunologic: No known allergies.

Objective
Physical assessment:
Vital Signs: Temp: 98F B/P (left arm): 131/77 mmHg P: 86bpm R: 19rpm O2 sat: 100% RA Weight: 144lbs High: 5’5” BMI: 24kg/m2
General: Patient AAO x3, well nourished, no acute distress, also denies weight change, fatigue, fever, chills, or night sweats.
Skin:Warm and dry. Good turgor. No surgical scars.
HEENT: No sore throat or earache. No blurry vision or double vision.
Thorax & Lungs:Equal thoracic expansion. Breath sounds clear to auscultation bilaterally, unlabored respirations, no accessory muscle use or retractions. No rhonchi, wheezing, or rales. No tenderness on palpation or percussion of chest wall or spine. Upon percussion, there is tympani bilaterally and symmetrically.
Cardiovascular: No chest pain or palpitations.
Gastrointestinal: Denies abdominal pain, nausea, vomiting, diarrhea, or constipation. Patient reports having daily bowl movements.
Abdomen:Soft to palpation, non-distended. No rebound, guarding or tenderness. Bowel sounds present x four quadrants. No hepatic or spleen enlargement. No masses palpated.
Genitourinary: No hematuria or dysuria..
Nervous Syste




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.