NRNP 6531 SOAP NOTE 1(Patient initials:RB)

NRNP 6531 SOAP NOTE 1(Patient initials:RB) Patient Initials: RB. Age: 75 Gender: Male SUBJECTIVE DATA: Chief Complaint (CC): "I'm here for my follow-up" History of Present Illness (HPI): RB. is a young-appearing 75-year-old Caucasian male presenting to the clinic for follow-up on his HTN, hyperlipidemia, recently (4-20-2020) diagnosed T2DM, and morbid obesity. His last visit was one month ago. Glycemic control has been achieved with diet and exercise. His Ale was initially 5.7 % and will be rechecked in 3 months . He denies the s/sx of polyuria, polyphagia and polyuria present in T2DM. He is moderately exercising and watching his diet to maintain glycemic control. He denies mood changes or irritability, fatigue/weakness or extreme hunger. He denies being depressed. Has had normal hair loss for his age, skin in thin, warm, and dry with normal turgor and is not sensitive to heat or cold. Hid blood pressure is controlled with Lisinopril and Atenolol. Denies recent stress. Denies any memory loss, confusion or poor concentration. Chronic shoulder pain is controlled with Meloxicam and Tramadol. Continues with moderate respiratory distress, probably caused by morbid obesity, treated with ProAir inhaler PRN. Medications: 1. ASA 81 mg one (1] tablet every day via oral route 2. Atenolol 25 mg one (1] tablet daily via oral route 3. Flomax 0.4 mg one [l] capsule every day via oral route 4. Lisinopril 20 mg one [I] tablet every day via oral route 5. Meloxicam 15 mg one (l] tablet every day via oral route, with food 6. ProAir HFA 90 mcg/actuation aerosol inhaler, two (2] puffs every four hours via inhalation route. 7. Tramadol 50 mg tablet, one (1] every six hours as needed via oral route Allergies: NKA Past Medical History (PMH): 1. T2DM - Onset: 04/30/20 2. Essential HTN - Onset 10/31/2019 3. Hyperlipidemia- Onset 10/31/2019 4. Morbid Obesity- Onset 10/31/2019 5. OSA Syndrome - Onset: 11/13/2019 6. BPH (Benign Prostatic Hypertrophy)- Onset "can't remember" 7. Erectile Dysfunction - Same "can't remember" 8. Sebaceous Cyst of skin- Onset 10/31/2019 9. Long-Term drug therapy: Onset 10/31/2019 10. Abdominal Aortic Aneurysm, incidental finding, stable - Onset 10/31/2019 11. Rheumatoid arthritis - Onset unknown -last reviewed 12/03/2019 12. MVA - Onset 04/28/2020 This study source was downloaded by from CourseH on :47:20 GMT -06:00 Past Surgical History (SHx):