np soap note hypertension and diabetes
70yr old african american (Ruthie) 3 month follow up for HTN, DM. Complaints of: wake up w/ HA x2 weeks (‘pressure ring’ around head), light headed, crazy dreams, stress, congestion x1day, nausea, productive cough, runny/stuffy nose, sore throat, 1+ ankle edema
tylenol helps w/ HA
vitals: 120/72, pulse 76, temp 98.5F, 5’7 286lbs A1C; 5.2 BMP no abnormalities
no social hx, no ETOH, non-smoker, depression no family hx
patient Hx: HA, reflux, memory loss (referred to neuro/hasn’t seen yet), back pain surgical hx: RTK, LTK, tubal ligation
medications: Benicar 40mg daily, Januvia 100 daily
negative for chest pain, SOB, vomiting, diarrhea, lungs clear, no wounds to feet
need: differential dx, action/plan for 3-6 months out
dx: sinusitis, recommend warm cloth over eyes/sinus, recommendations for stress relief, f/u with neuro
rx: flonase
(Add what you feel needed)
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