Longitudinal Patient

Visit
1 & 2 SOAP Notes
Leah Double Team Leader
Amanda Serio
Amanda Lipps
Patient Information
SK is a 62 year old married male
College Educated
Employed
Chief Complaints:
Hypertension
Osteoarthritic associated pain
Subjective
Religious beliefs: Presbyterian
Overcomes challenges through faith
Denies any life or health stressors
Denies any domestic violence concerns
Reports pain associated with arthritis
4/10 on pain scale
Reports prior neck surgery
Denies smoking
Claims regular eating habits
Consumes four 8 oz cups of coffee per day

Objective
Medications







PRN medication: APAP Extra Strength 500mg - arthritis
Level of Consciousness: 10
Cooperative and appropriate affect
Appeared knowledgeable regarding medications and health conditions
Wears glasses
Up to date on Immunizations (Influenza, Tetanus, Pneumococcal)
Medication Time Dose Pt Understanding Date/Time Last Taken
Atenolol 25mg QHS 12.5mg HBP 2/5 pm
Pravastatin 20mg 1 QHS 20mg TC 2/5 pm
Lansoprazole 30mg 1 QHS 30mg GERD 2/5 pm
HCTZ 25mg 1 QHS 25mg HBP 2/5 pm
Finasteride 5mg 1 QHS 5mg BPH 2/5 pm
Assessment Family History
Lymphoma
Sister
Non-Hodgkins Lymphoma
Sister deceased age 50
Hypertension
Mother
Father deceased MI
Heart Disease
Father
Uncle - paternal
Assessment Personal History
GERD
Arthritis
Controlled Depression
High Blood Pressure
High Cholesterol
BPH
Recovering Alcoholic
Prior Exposure to Varicella
Previous Surgeries:
Cervical Spine
Tonsillectomy
Cataract
Plan
Patient will continue Lansoprazole for GERD and remain asymptomatic
Patient will continue PRN use of APAP to keep pain at a tolerable level
Patient will remain free of symptoms associated with depression
Patient will continue Atenolol and HTCZ as prescribed for HBP
Patient will continue Pravastatin as prescribed for high cholesterol
Patient will continue Finasteride as prescribed for BPH
Patient will continue to refrain from alcohol use
Educate patient regarding Shingles and vaccination for prevention
Patient will keep all laboratory and office visits, and report any signs or symptoms to his
physician