Write up the full SOAP note, including the final treatment plan for Michelle incorporating all the learning and guidance from faculty during the week as you would in clinic in SOAP format.
The treatment plan should include:
- Specific Diagnosis
- ICD 10 code
- Follow up
|Name: Michelle G.
|Pt. Encounter Number:
|CC: Shortness of breath and seasonal allergic reactions
|HPI: Michelle, a female-aged 40 years complains of shortness of breath especially when at work. However, the patient recalls no episodes of shortness of breath during the weekends. Few hours at work, Michelle feels like she cannot catch her breath, leaves work for an urgent care. Michelle is offered a “breathing treatment” and a take-away antibiotic. The patient’s overall health is good and denies experiencing any heartburn or sputum.
|Medications: The patient is currently under Zyrtec (an anti-histamine) and multivitamin
Allergies: Experiences seasonal allergies
Medication Intolerances: No known intolerances
Chronic Illnesses/Major traumas: Seasonal allergies
Hospitalizations/Surgeries/: Underwent Tonsillectomy and Cholecystectomy. Hospitalizations – Childbirth x3
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