Please write soap note on case attached. Please use soap note template attached
EN is a 63-year-old male presented today for acute pain. Pt has a history of essential hypertension, Diabetes Mellitus and and Cervicalgia, Peripheral vascular disease. Pt s/p CVA 11/2023 and recently discharged for rehabilitation in 3/2024. Lives independently by himself.
Pt has NKDA
Heavy Smoker, Drinks socially, Denies drugs.
Pain is primarily in shoulder and legs and patient describe it as throbbing
ROS
Musculoskeletal – walks with a cane
Current medications:
Aspirin 81mg po daily
Baclofen 10mg po daily
Tramadol 50mg
Magnesium oxide
Metformin 500mg bid
Gabapentin 300 tid
Ibuprofen 800 prn as needed
Famotidine 40mg daily
Jardiance 25mg
Diclofenac prn
Clopidrogrel 75mg daily po
Cilostazol 50mg po daily
Capsaicin
