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focused soap noteMs. Donetz is a 73-year old Female who comes into your office with concerns of fatigue and dry skin. She is a retired Banker. She is AAOx4, ambulatory, and lives by herself. She does report increased fatigue no matter how much sleep she gets. She is also concerned that she may need to come off of one of her meds because her hair is thinning. She had labs done and also was informed they would review results at this visit. Other pertinent diagnoses include Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin D daily as prescribed. She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls or pain. (All other Review of System and Physical Exam findings are negative other than stated.) Vital Signs: BP 137/82, HR 89, RR 20, Temp 98.1 PMH: Hypertension, Hyperlipidemia, Vitamin D deficiency Allergies: I.V. Contrast – rash, ACE Inhibitors – cough
SCIENCE
HEALTH SCIENCE
NURSING

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