You will write a soap note. You are an advanced nurse who conducted this assessment (all teh case information are provided below). Nw complet the soap note as directed. For the msising information you can come up with your own, but do not alter the primary diagnosis and do not add new diagnosis than was is provided in the case.
Case:
A 34-year-old black female reports to clinic with c/o chest pain and leg cramps.  The patient was seen by a GI specialist and was informed that she had hemorrhoids and was prescribed rectal suppositories for hemorrhoids.  The patient returned to the GI doctor, and he indicated that the rectal bleeding did not resolve.  The GI specialist performed a colonoscopy, and the patient was diagnosed with Crohn’s disease.  The patient was started on Remicade infusions for Crohn’s disease about 3 weeks ago.  The patient is currently in remission and reports no rectal bleeding.
Vital Signs:  B/P 148/94, Resp 20, Temperature 99.4, O2 sat 95%, Pulse 99
Cramps in legs can be painful at times with a current pain score of 2 today in office.
No known diagnostic allergies
SH:  Quit smoking 3 weeks ago after after starting Remicade.  The patient smoked 1 pack of cigarettes per day since age 20.
FH:  Mom passed away of a MI at age 40 years old.  Father is alive and is doing well.  Father has HTN controlled by Hydrochlorothiazide.  No family history of GI disorders.
The patient returns to your clinic after being hospitalized for 3 days in hospital.  The patient was ordered to follow up with their primary care provider post hospitalization.  The patient reports feeling better. The patient was started on an anti-hypertensive medication HCTZ 12.5 mg daily.  The patient’s cholesterol was 280 and the GI specialist recommended to follow up with primary care provider to start cholesterol medication.  The patient states that she is struggling with anxiety and depression because of her diagnosis of Crohn’s disease.  The patient has never taken medication for anxiety or depression but is requesting medication.  No suicidal ideation per patient.

Compelte these:

Patient Information: 
Initials, Age, Sex, Race
S.
CC (chief complaint): A brief statement identifying why the patient is here, stated in the patient’s own words (for instance "headache," not "bad headache for 3 days”). 
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products
Allergies: include medication, food, and environmental allergies separately (A description of what the allergy is, i.e., angioedema, anaphylaxis, etc. This will help determine a true reaction as opposed to intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more information is sometimes needed. 

Soc & Substance Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here, such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren, if pertinent.
Surgical Hx: prior surgical procedures
Mental Hx: diagnosis and treatment. Current concerns: Anxiety and/or depression.  History of self-harm practices and/or suicidal or homicidal ideation.   
Violence Hx: concern or issues about safety (personal, home, community, sexual . . . current & historical)
Reproductive Hx: menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse:  oral, anal, vaginal, other, any sexual concerns
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format, i.e., General: Head: EENT: etc. 
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines)