SOAP NOTE S. M. is a 72-year-old male, obese who came in wit

SOAP NOTE S. M. is a 72-year-old male, obese who came in with chief… SOAP NOTE S. M. is a 72-year-old male, obese who came in with chief complained of chest discomfort, described as burning sensation in the retrosternal area. Its very severe mostly after meals and experiences reflux of gastric contents especially when lying down after meals. Patient also a cigarette smoker. Diagnosis.   Gastro Esophageal Reflux Disease (GERD) PMHHypertension  Compose a SOAP NOTE on GERD base on the following Rubric  Rubric     Required Format & Expected Data CollectedPointsID, CC, HPI, ROS, PMH, Differential Diagnosis, Case Representation, Plan Each section clearly labeled & follows the format of the Model SOAP Note10HPI relates to CC and is fully developed with discriminating s from Symptom Attributes using Semantic Qualifiers & the other 6 DD Domains. Primary and alternative competing diagnoses being considered are clear.  (11) ROS: ROS selected to further investigate likely causes of CC w/ discriminating s from relevant Symptom Attributes using Semantic Qualifiers & the other 6 DD Domains. No redundancy or irrelevant information or systems. (7) PMH: All elements of PMH, PSH, Meds, Allergies, Women’s Health, Sexual History, Social & other as applicable are included and expand on the HPI/ROS without redundancy. Includes dates of onset of chronic medical problems. (7)25 Physical exam Relevant objective data collected for each appropriate system examined related to HPI/ROS/PMH (5) Exam well organized (5) specific/complete (5).15Differential Diagnoses in Rank Order (4)One-two sentences addressing Pathophysiology & one-two sentences addressing Epidemiology (3)Pertinent Positives (3) Pertinent Negatives (3) Case Representation (5)Analyzes, synthesizes, and draws conclusions about the patient’s condition in a narrative format, based on the data collected in the HPI/ROS/PMH & PE and ranking differential diagnosis in hierarchical order using clinical terminology and a deductive flow15Treatment plan: Correctly written prescriptions for every prescription (4)Patient (Medication) Education (2) Prevention & Supportive Care (2) Track & Monitor Symptoms (2) When to Seek ER Care (Other) (2) Disposition (2) Patient & Alternate Contact Info/Permission to Call & Discuss Case (1) 15Goals of Care5Evidence-based rationale for diagnostic testing (5) Evidence-based rationale for treatment (5) Studies supporting rationale for diagnostic testing, treatment & EBP reference (5)15Total100  Required TextbokGoroll, A. & Mulley, A. G. (2020). Primary care medicine: Office evaluation of the adult patient.(8th ed.). Philadelphia, PA: Wolters Kluwer/Lippincott. ISBN: 9781496398116 Uptodate is allowed  Health Science Science Nursing NURS 775

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