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SOAP NOTEName:BLDate:11/26/18Time: 12:30Age:62Sex:FSUBJECTIVECC: “Left leg pain, nausea, SOB, lethargic, weight loss”HPI: 64-year-old patient with a long hx of mental illness comes in with complaints of Lt leg pain that stems from a piece of the ceiling falling on her leg during a hospital visit. Pt states that the pain is a 10/10 and has continuously worsened over the last 3 weeks. The pain is throbbing in nature and is constant with any movement aggravating the symptoms. The patient states at the time of the incident, the hospital did an x-ray of her left leg and treated her with medication and she was discharged. Medications:Trazodone 50 mg po – SleepMethotrexate 2.5mg po – RACarafate 100mg po – UlcerFolic Acid 1 mg po – supplementMaxzide 37.5/25mg po – HTNZofran 4mg po – nauseaNorvasc 10mg po – HTNPlaquenil 200mg po – SLE
Amitiza 24 mcg po – IBSAmbien 10 mg po – sleepTramadol 50 mg po – painProair HF 90 mcg inhaler – asthmaSymbicort 160- 4.5 mcg inhaler – asthma