Problem Onset (Date) Problem Status
#
1 2015 Essential HTN Stable
2 2016 HLD Stable
3 2014 CKD stage 4 Stable
4 2018 Mitral valve regurgitation Stable
5 2015 Hyperparathyroidism Stable
6 2014 Arthritis Stable
7 2022 Anxiety Stable
8 2022 Major Depressive Disorder, mild Stable
9 2025 Pruritus New
Date: 07/02/25 Patient: LB Age: 80 Gender: Female
Race/Ethnicity: African American Source: LB who seems reliable
Insurance: Medicare
SUBJECTIVE:
CC: itching
HPI: Mrs. LB is an 80-year-old African American woman presenting today with complaints of
“itching all over”. She has a known history of HTN, HLD, CKD, MVR, anxiety, and MDD. She
was diagnosed with HTN at age 70 and HLD at age 51 and has been managing her HTN and
HLD with medication. She states that his blood pressure has been well-controlled at home, and
, he denies any recent headaches, dizziness, or vision changes. She reports that her Arthritis,
Depression, and Anxiety remain stable without current issue. She endorses feelings of
generalized “itching all over” that is mild (3/10), constant throughout the day, but more
noticeable at night. She states this started about 3 weeks ago, with no triggers known and has
remained stable in its severity. She has tried OTC cortisone cream with little relief. She denies
any additional rashes, fever, skin changes, or weight loss. She has been around no sick contacts
and has not recently traveled. She denies prior episodes of generalized pruritus. She continues to
take her medications as prescribed and has not started any new medications or supplements. She
has been to all of her specialist appointments (cardiology, nephrology).
PMH:
Allergies: Augmentin (severe nausea), Lortab (pruritus), Aspirin (Rectal bleeding)
Current Medications: Amlodipine 2.5 mg once daily, atorvastatin 10 mg once daily, bumetanide
1 mg once daily, carvedilol 25 mg BID, clopidogrel 75 mg once daily, hydralazine 50 mg BID,
Jardiance 10 once daily
Immunizations: Covid 2021, 2022, 2023, 2024; Influenza (annually form 2014-2024),
pneumococcal 2016; Tdap not listed; Shingrix not listed
Previous screening tests: PHQ-9 & GAD 7 done annually at check in, wnl; Breast cancer
screening not indicated as patient is over 74; Cervical cancer screening not indicated as patient is
over 65; Colonoscopy 2019; HCV was negative when tested, unsure of when lab was done; DXA
2020; Dental exam 2023; vision exam 2024
Chronic Illnesses: See problem list
#
1 2015 Essential HTN Stable
2 2016 HLD Stable
3 2014 CKD stage 4 Stable
4 2018 Mitral valve regurgitation Stable
5 2015 Hyperparathyroidism Stable
6 2014 Arthritis Stable
7 2022 Anxiety Stable
8 2022 Major Depressive Disorder, mild Stable
9 2025 Pruritus New
Date: 07/02/25 Patient: LB Age: 80 Gender: Female
Race/Ethnicity: African American Source: LB who seems reliable
Insurance: Medicare
SUBJECTIVE:
CC: itching
HPI: Mrs. LB is an 80-year-old African American woman presenting today with complaints of
“itching all over”. She has a known history of HTN, HLD, CKD, MVR, anxiety, and MDD. She
was diagnosed with HTN at age 70 and HLD at age 51 and has been managing her HTN and
HLD with medication. She states that his blood pressure has been well-controlled at home, and
, he denies any recent headaches, dizziness, or vision changes. She reports that her Arthritis,
Depression, and Anxiety remain stable without current issue. She endorses feelings of
generalized “itching all over” that is mild (3/10), constant throughout the day, but more
noticeable at night. She states this started about 3 weeks ago, with no triggers known and has
remained stable in its severity. She has tried OTC cortisone cream with little relief. She denies
any additional rashes, fever, skin changes, or weight loss. She has been around no sick contacts
and has not recently traveled. She denies prior episodes of generalized pruritus. She continues to
take her medications as prescribed and has not started any new medications or supplements. She
has been to all of her specialist appointments (cardiology, nephrology).
PMH:
Allergies: Augmentin (severe nausea), Lortab (pruritus), Aspirin (Rectal bleeding)
Current Medications: Amlodipine 2.5 mg once daily, atorvastatin 10 mg once daily, bumetanide
1 mg once daily, carvedilol 25 mg BID, clopidogrel 75 mg once daily, hydralazine 50 mg BID,
Jardiance 10 once daily
Immunizations: Covid 2021, 2022, 2023, 2024; Influenza (annually form 2014-2024),
pneumococcal 2016; Tdap not listed; Shingrix not listed
Previous screening tests: PHQ-9 & GAD 7 done annually at check in, wnl; Breast cancer
screening not indicated as patient is over 74; Cervical cancer screening not indicated as patient is
over 65; Colonoscopy 2019; HCV was negative when tested, unsure of when lab was done; DXA
2020; Dental exam 2023; vision exam 2024
Chronic Illnesses: See problem list
