SOAP NOTE

SOAP NOTE Name: F.N. Date: 9/27/2018 Time: 10:00 Age: 52 Sex: Male SUBJECTIVE CC: Pt presents today for follow up and medication refill for my blood pressure and diabetes and has a new complaint of erectile dysfunction. HPI: F.N. is a 52-year-old male had a right CVA on 7/6/18. He has been attending occupational and physical therapy 3x a week since 7/10/18. He gets around with the use of a cane and has very little neurological deficit. Complaining of erectile dysfunction. Medications: • aspirin 81mg PO daily, • amlodipine 10mg PO daily, • atorvastatin 10mg PO daily in the evening, • clopidorgel 75mg PO daily, • gabapentin 300mg PO TID, • lisinopril 20mg-hydrochlorothiazied 12.5mg PO BID, • omeprazole 40mg PO daily, • zolpidem 10mg PO daily @ HS, • lantus U-100 insulin 100 unit/mL inject 24 units sub Q @ HS, • metformin 1000mg PO BID PMH Allergies: NKDA Medication Intolerances: Denies Chronic Illnesses/Major traumas: Right CVA 7/2018 Hospitalizations/Surgeries: Hospitalization 7/2108 Family History: Mother: Alive, healthy. Father: No information available. Sister: Alive, HTN. Paternal Grandfather: Deceased at age 84, septic wound infection. Paternal Grandmother: Alive, Alzhiemers. Maternal Grandfather: Deceased at age 66, MI. Maternal Grandmother: Deceased at age 89, Cardiac disease, ROS