PLEASE WRITE SOAP NOTE ON ATTACHED PATIENT USING THE SOAP NOTR TEMPLATE ATTACHED
CM is 36 yo female with history of hypertension and seizures. Pt follows a neurologist but has no seen the neurologist in two years since her last seizure. Gall bladder removal 9/2008. Pt works at a Pizzeria in the day and security at night. She had a history of bariatric surgery on 10/2023 and is not following the recommended diet. Pt lost 150lbs since surgery but has gained back 70lbs for the last 3 months. Pt is now requesting ozempic to help medically manage her eating.
Allergies: PCN, Amoxicillin. Denies smoking, drinking or drugs
PHQ9 is 9
Intermittent sharp pain 8 – right lower quadrant
Screenings: Refuses flu vaccines yearly, Covid vaccine x2, no other vaccines
Does not take any medicine
Vital signs: BP130/85 HR74 T 97.9 Wt65.25 kg
ROS
GENERAL: no fever, no chills +obese
CARDIOLOGY: no chest pain, palpitations or edema
LUNG: no cough, no sob, no wheezing
GI: no nausea/vomiting, diarrhea, constipation, abdomen soft and tenders
GU: no urinary frequency, no urgency, no dysuria
MUSCULOSKELETAL: normal gait, no joint tenderness
PLEASE WRITE SOAP NOTE ON ATTACHED PATIENT USING THE SOAP NOTR TEMPLATE ATTACHE
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