SU_NSG6420_W2_A3_Taylor_A.docx - SOAP NOTE Name SY Date Age 69 Time 7:33 Sex M SUBJECTIVE CC \u201cSurgical follow\/up\u201d HPI Pt is a 69-year-old who

SU_NSG6420_W2_A3_Taylor_A.docx - SOAP NOTE Name SY Date Age...

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SOAP NOTE Name: SY Date: 11/8/18 Time: 7:33 Age: 69 Sex: M SUBJECTIVE CC: “Surgical follow/up” HPI: Pt is a 69-year-old who presents for f/u of an L3-L5 laminectomy on 10/31/18. Pt has a history of lumbar spinal stenosis with associated bilateral leg pain, numbness and tingling. Medications: Tylenol – PRN Pain Ultram – PRN Pain Lyrica – Neuropathy Elavil – Depression Lopressor – HTN Lipitor – Hypercholesterolemia Glucophage – DM Hydrodiuril – HTN Flomax – Chronic Prostatitis Lumigan – Glaucoma
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Alphagan P – Glaucoma ASA – Aortic Stenosis PMH Allergies: Levaquin Chronic Illnesses/Major traumas Aortic Stenosis, HTN, LVH, Eczema, Lumbar Radiculopathy, Lumbar Spinal Stenosis, Ulnar Nerve Compression, Chronic Prostatitis, OSA, Depression, DJD of Shoulder, Morbid Obesity, DM, Glaucoma, Squamous Cell Carcinoma, Hepatitis C Hospitalizations/Surgeries Artificial heart valve, Lumbar Laminectomy, Mohs Surgery, Cataract Removal, Wisdom Teeth removal, Right Hernia Repair, Tonsil and Adenoidectomy Family History
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  • Summer '16
  • ANDREWCLARK
  • Neurology, Spinal disc herniation, stenosis, Squamous cell carcinoma

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