soap notes

Care Date March 9, 2020 , PATIENT INITIAL: JS, AFRICA AMERICAN FEMALE

The diagnosis can be on any muscular skeleton, Please DO NOT make Arthris your primary diagnosis.

61year old African American female presents here today for Annual physical and medication review. Per patient she is completely blind in her right eye and slight impairment in left eye. She reports continues right hip and bilateral knees pain knees. She reports that her pain is intermittent, and she takes Tramadol. She reports that she needs a referral for a Gynecologist due to the calcification of her Ovary. She also wants to get back on the Niacin protocol to help lower her cholesterol. She also needs a prescription to refill her Tramadol. She also wants to see if she can get back on Felodipine 5 mg.

Diagnosis:

Hyperlipidemia

Hypertension

Vitamin D Deficiency

Arthritis

Medical History:

Uveitis

Blind in Right Eye

Osteoporosis

Anxiety

Visually impaired

CAD

SURGICAL HISTORY

Lumpectomy of Left Breast - 03/2012

C-section – UNKNOWN

SOCIAL HISTORY

Pass Smoker

VITAL SIGN

TEMP- 98.4, HEART RATE-72, BP- 124/80, RR- 18, OXYGEN- 98%

WEIGHT 283 LBS

HEIGHT- 64.5

BMI 47.84

MEDICATIONS

Simvastatin 10 mg 1 tablet daily in the evening for Hyperlipidemia Tramadol for Arthritis, Isosorbide mononitrate 30mg 1 tablet daily Cellcept 500 mg 2 tablet two times daily Lasix 20 mg 1 tablet daily Felodipine 5 mg 1 tablet daily