Date/ Subjective Objective Assessment Plan

time
July 21, This is a case of Patient is awake, Hypertension 81 II For repeat RBS,
2016 / MH, 70y/o female conscious, controlled crea after 2
2:15pm last seen on July coherent, DM type 2 weeks, for repeat
16, 2016, came in ambulatory, not in Obese class I cholest rig, lipid
for the follow up cardiorespiratory Hypercholesteromelia profile after, 6
with no subjective stress, w/ the ff weeks till awaits
complaints and vital signs: fo 12 L ECG
with the following official result
lab results BP 130/70 mmhg Start:
PR 78 bpm 1 . Sitagliptin +
Cxr: RR 18 cpm Metformin
Except for the T – 36o C 50mg/500mg
calcified aortic Skin is brown no BID\(after
knob, messes. No breakfast and
cardiopulmonary lessions, soft, after dinner
findings are capillary refill 2 . Metformin
unremarkable time < 2 sec 500mg. 1 tab OD
(-) headache Anicteric Sclerae, before bedtime
(-) dizziness pink palpebral 3. atorvastatin
(-) nausea conjuctiva, no 20mg 1 tab OD
(-) dysuria nesocural (AM)
(-) dyspnea discharge, no 4 . amlodipine
(-) chest pain tonsillapharyngeal 10mg 1 tab OD
(-) cough congestion 5 . Vitamin B
Symmetrical chest Complex 1 tab
expansion, no OD
retractors, equal Therapeutic
vocal, and tactile lifestyle changes
For daily bp
 fructose clear For referral to
breath sounds dietary for DM
Adynamic diet
Procordium For referral to
normal rate, optha for
regular rhythm, fundoscopy
PMI at 5th ICS *on next follow
LMCL. Globular, ip (w/
normoactive, soft, companion)TCB
non-tender, pan after 2 months
light and deep
palpitation
Grossly normal
extermities

Blood Chem:

Urea 2.69
3.7 2.9 Uric acid 272.46
143 Cholesterol 5.62
9.51 357
0.422
Triglycerides 1.73
47.8 HDL 1.24
44.2 SGOT 20.51
SGPT 14.67
Crea 122.92
Giu 15.10
LDL 3.60
Vldl 0.79

Date/ Subjective Objective Assessment Plan

time
8-5-16 / This is a case of MW, Conscious, HTN SA II For 2d echo
12:25p 70 y/o, femaile last coherent, not in Controlled Still for 12c
m seen on July 16, 2016 DM type 2 ECG
and was diagnosed of cardiorespiratory Obese Class I Still for cbal
Hypertension Stage II, distress Hypocholesterolemi lip profile after
controlled, DM Type BP 130/70 mmhg a 1 month
2, Obese class I, and PR 83 bpm Continue:
Hypercholesterolemia RR 20 cpm 1. Sitapiptin +
. Came in today for T – 37.3 metformin
follow up with the ff. O2 96% 50mg/50m
lab results and Weight 57kg g BD
subjective complaints Height 150cm (after
(+) Calf pain, both BMI Obese I breakfast
legs Skin is brown, no and after
(+)numbness, both masses, no dinner)
hands lesions, soft, 2. Metformin
warm to touch. 500mg/tab
Anicteric Sclerae, 1 tab after
pink palpebral lunch
conjuctiva, no 3. Atovastin
nesocural 20mg/tab 1
discharge, no tabs ODAS
tonsillapharyngea 4. Amlodipine
l congestion, no 10mg/tab
cervical 1tab OD
lymphacenopathy (AM)
, symmetrical 5. Vit B.
chest expansion. Complex 1
No retractions, no tab OD
logging, clear Therapeutic
breath sounds lifestyle
Adynamic changes for
procordium daily BP
monitoring for
 normal rate, referral to
regular rhythm, no Ophtha for
mermer, flabby, fundoscopy
soft, nontender, one with
normoactive, composion
bowel sounds, TLB after 1
generally normal month advised
extremities, no
edema, no
cyanosis

CN I: can identify odor of perfume

II: wears correctional glasses
II, III: presence of direct and consensual light reflex on both eyes
III, IV, VI: full EOM movements
V: able to feel pinprick, light touch, dull pain, temp
V, VII – correal reflex intact
VII: no facial asymmetry
VIII: hears rubbing of fingers on both ears
IX, X: gag reflex intact, uvula at midline
XI: Shugs shoulders against resistance
XII: Tongue at midline