To prepare: (MAKE SURE NO PLAGIARISM,WE USE SAFEASSIGN TO CHECK )
Mrs. L., a 68-year-old woman, presents to your office today with a complaint of feeling tired all the time and now, more recently, feeling weak and like “I can’t catch my breath sometimes.”
HPI: She has been healthy except for high cholesterol, managed by Lipitor. Her husband died 9 months ago, and she has attributed her fatigue to dealing with his death but realizes that she is feeling worse and not better as time passes.
No known drug allergies.
Medications: Takes only Lipitor.
Past surgical history: Appendectomy in childhood; hysterectomy for uterine myoma 10 years ago.
No significant medical history. Has two daughters living nearby.
Blood pressure (BP) 106/70 mm Hg, heart rate (HR) 98 beats/min and regular, respiratory rate 18 breaths/min and afebrile, body mass index (BMI) 22 (10-pound weight loss since death of husband).
Slender, quiet-spoken older woman appearing tired.
PE: Conjunctiva pale, mucous membranes moist. No lymphadenopathy of neck or femoral area.
Heart tachyarrhythmia with regular rate, soft midsystolic murmur. Chest (CTA), good air movement.
Abdomen soft, bowel sounds × 4.
Urine dipstick negative.
The results of a colonoscopy show a neoplasm in the colon.
Address the following in your SOAP note:
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