This soap note Main Diagnoses is: Scleroderm

All vaccinations up to date including 2 COVID19 vaccines and booster. 

65 years old female patient, who lives alone in a one bedroom efficiency in Miami, with the minimum pension. 

Pt reports that a cousin supports her monetary at times. No Smoker, No Drinker.

The patient brought her last laboratories results that show: Severe dehydration, malnutrition and anemia. (include in your SOAP note the names of the labs that show these results.

Pt has a PMH of Asthma since childhood, hypothyroidism and arthritis since 2010. Current Medications; Levothyroxine 25mcg every morning, with empty stomach. Albuterol PRN Today she presented with swollen hands bilaterally complaining of pain and impossible to do the activities of daily living. In the last 3 months she has been having problems swallowing and passing food, but it was getting worse to swallow. During the last weeks, she was not able to tolerate any solid food and barely drink water.. Pt states feeling very week and almost impossible to come to the consultation today.. He has lost 15 kilos in the last three months. She is 1.5 mt height and weights : 51 kilos.

Note: You must use the information above to create your SOAP NOTE however you cannot copy and paste this information. You have to use your own words to create your case. 

Sources between 2018 and 2022. No more than 15 %plagiarism. and you have tu use the tamplate aatached  here. 

Thank you