SOAP Note
Chief Complaint
“My blood pressure has been staying high.”
SUBJECTIVE:
History of Present Illness
LW is a 76 y/o male patient established at the clinic. Pt reports that his blood pressure has been
staying
...
SOAP Note
Chief Complaint
“My blood pressure has been staying high.”
SUBJECTIVE:
History of Present Illness
LW is a 76 y/o male patient established at the clinic. Pt reports that his blood pressure has been
staying high since last week. Pt reports that he went to a physician who prescribed him
phentermine for weight loss which he took last week. He reports taking OTC weight loss pills
since Christmas as well. Patient reports associated symptoms of reflux and chronic back pain
which are familiar to him but denies any other additional complaints.
Past Medical History
Medical History: T2DM, HTN, HLD, obesity
Surgical History: No surgical history
Social History
Patient lives in an adjacent town and lives on a small farm. He is married and has grown
children but does not elaborate further on his family life. He is a former smoker (quit 30 years
ago) and denies history of drug or alcohol abuse.
Family History
Biological Mother; alive; no history
Biological Father; alive; tobacco dependence/ETOH abuse
Allergies
Codeine, Sulfa; NKFA
Medications
OTC Medications/Herbal Prescription Medications
Unknown weight loss drug: 1 tab PO QD Albuterol MDI: 2 puffs INH Q4 Hr PRN
Motrin 800mg PO TID PRN Glipizide 5mg PO BID
Omeprazole 40mg PO QD PRN Lisinopril/HCTZ 20/12.5: 1 tab PO BID
Ranitidine: 150mg PO BID Metformin: 1,000mg PO BID
Pravastatin: 40mg PO QPM
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