Soap Note
- Submitted by: cindyquynh84
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- Category: Other
- Date Submitted: 12/16/2010 10:42 PM
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Patient: Zelda N. Milkyway
MRN: 56781234
DOB: 2/12/45
Date: September 3, 2010
PCP: Dr. Casey Starburst, Family Medicine Group
ZM is a 65 year old CF who presents to the Family Medicine office with c/c of always having a headache after taking HCTZ. Last visit was 3 months ago for elevated BP in which she started HCTZ 25 mg daily. She states she is compliant with all of her medications (except for 1-2x per week she skips HCTZ).
HPI: Her headaches are happening daily and she rates her pain 5-6 out of 10; which she describes as dull, constant pain. ZM never had headaches until starting HCTZ therapy, on days where she does not take HCTZ she experiences no headaches.
PMHx: Depression x 30 yrs, HTN x 3 months
SHx: Diet: she states she has been trying to avoid salt most days of the week
Exercise: she states she walks 2-3 times/week on a treadmill
EtOH- neg, Tob- pos 1ppd, no illicit drug use
FHx: Mother: ↓colon cancer, DM 2, HTN
Father: ↓ HTN, hypothyroid
2 sons: ↑↑ healthy
ROS: HTN: headache with HCTZ use, some dizziness in the afternoon in which she need to lay down when this happens. She has not D/C’d HCTZ use
Depression: states she feels depressed moods about 3-4x/week and improves when she gets to play with her grandchildren. She regularly takes lexapro daily, currently following with a psychiatrist.
Vitals: BP 138/86 (last visit 156/92), P 86, RR 18, temp 98.6 Height: 5’5”; weight: 160 lbs (last visit 166 lbs); BMI 26.6
Labs: FLP: TC 207 TG 187 HDL 50 LDL 120 (7/10)
BMP: Na 136 Cl 99 BUN 15 Gluc 92 K 5 CO2 25 SrCr 0.8
Microalbumin: not collected , Hgb 10.1 Hct 31 WBC 5.4 Plt 206
PE: Gen: no acute distress, well nourished, well developed.
Neuro: She is alert and oriented to person, place and thing; and cranial and nerve function are intact.
HEENT: Clear to auscultation and percussion
Heart: no murmurs, rubs or gallops
Lungs: clear to auscultation, equally bilateral, no CVA tenderness
GI: bowel sounds...
MRN: 56781234
DOB: 2/12/45
Date: September 3, 2010
PCP: Dr. Casey Starburst, Family Medicine Group
ZM is a 65 year old CF who presents to the Family Medicine office with c/c of always having a headache after taking HCTZ. Last visit was 3 months ago for elevated BP in which she started HCTZ 25 mg daily. She states she is compliant with all of her medications (except for 1-2x per week she skips HCTZ).
HPI: Her headaches are happening daily and she rates her pain 5-6 out of 10; which she describes as dull, constant pain. ZM never had headaches until starting HCTZ therapy, on days where she does not take HCTZ she experiences no headaches.
PMHx: Depression x 30 yrs, HTN x 3 months
SHx: Diet: she states she has been trying to avoid salt most days of the week
Exercise: she states she walks 2-3 times/week on a treadmill
EtOH- neg, Tob- pos 1ppd, no illicit drug use
FHx: Mother: ↓colon cancer, DM 2, HTN
Father: ↓ HTN, hypothyroid
2 sons: ↑↑ healthy
ROS: HTN: headache with HCTZ use, some dizziness in the afternoon in which she need to lay down when this happens. She has not D/C’d HCTZ use
Depression: states she feels depressed moods about 3-4x/week and improves when she gets to play with her grandchildren. She regularly takes lexapro daily, currently following with a psychiatrist.
Vitals: BP 138/86 (last visit 156/92), P 86, RR 18, temp 98.6 Height: 5’5”; weight: 160 lbs (last visit 166 lbs); BMI 26.6
Labs: FLP: TC 207 TG 187 HDL 50 LDL 120 (7/10)
BMP: Na 136 Cl 99 BUN 15 Gluc 92 K 5 CO2 25 SrCr 0.8
Microalbumin: not collected , Hgb 10.1 Hct 31 WBC 5.4 Plt 206
PE: Gen: no acute distress, well nourished, well developed.
Neuro: She is alert and oriented to person, place and thing; and cranial and nerve function are intact.
HEENT: Clear to auscultation and percussion
Heart: no murmurs, rubs or gallops
Lungs: clear to auscultation, equally bilateral, no CVA tenderness
GI: bowel sounds...