R’s 2 soap notes

2 soap notes

Patient 1

Age: 72

Race: Black

Gender: Female

Chief Complaint: Dizziness

HPI: The patient presents with intermittent dizziness over the past two weeks, primarily noted when

transitioning from sitting to standing positions. She denies syncope, chest pain, shortness of breath,

or visual disturbances. She reports adequate oral intake but admits to occasionally missing meals.

No recent medication changes.

CPT-9: 99213

CPT-10: 99214

ICD-9: 780.4

Medication: Lisinopril 10 mg daily

Education: Patient was educated on orthostatic precautions, hydration, slow position changes, and

when to seek urgent care.

Patient 10

Age: 78

Race: Black

Gender: Male

Chief Complaint: Leg swelling

HPI: Progressive bilateral edema worse in evenings. History of CHF.

CPT-9: 99214

CPT-10: 99215

ICD-9: 782.3

Medication: Furosemide 20 mg daily

Education: Sodium restriction and leg elevation discussed.