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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 pr ... essure 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 [Show More]
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