CREATE A SOAP NOTES OUT OF THIS CASE Chief Complaint “I just moved to town, and I’m here to see my new doctor for a check up. I’m just getting over a cold. Overall, I’m feeling fine, except for occasional headaches and some dizziness in the morning. My other doctor prescribed a low-salt diet for me, but I don’t like it!” HPI Sam Street is a 62-year-old African-American male who presents to his new family medicine physician for evaluation and follow-up of his medical problems. He generally has no complaints, except for occasional mild headaches and some dizziness after he takes his morning medications. He states that he is dissatisfied with being placed on a low sodium diet by his former primary care physician. He reports a “usual” chronic cough and shortness of breath, particularly when walking moderate distances (states, “I’m just out of shape”). PMH Hypertension × 15 years Type 1 diabetes mellitus Chronic obstructive pulmonary disease, Stage 2 (Moderate) Benign prostatic hyperplasia Chronic kidney disease FH Father died of acute MI at age 71. Mother died of lung cancer at age 64. Mother had both HTN and DM. SH Former smoker (quit 3 years ago; smoked 1 ppd × 28 years); reports moderate amount of alcohol intake. He admits he has been nonadherent to his low sodium diet (states, “I eat whatever I want.”) He does not exercise regularly and is limited somewhat functionally by his COPD. He is retired and lives alone. Meds Triamterene/hydrochlorothiazide 37.5 mg/25 mg po Q AM Insulin 70/30, 24 units Q AM, 12 units Q PM Doxazosin 2 mg po Q AM Albuterol INH 2 puffs Q 4–6 h PRN shortness of breath Tiotropium DPI 18 mcg 1 capsule INH daily Salmeterol DPI 1 INH BID Entex PSE 1 capsule Q 12 h PRN cough and cold symptoms Acetaminophen 325 mg po Q 6 h PRN headache All PCN—Rash ROS Patient states that overall he is doing well and just getting over a cold. He has noticed no major weight changes over the past few years. He complains of occasional headaches, which are usually relieved by acetaminophen, and he denies blurred vision and chest pain. He states that his shortness of breath is “usual” for him, and that his albuterol helps. He denies experiencing any hemoptysis or epistaxis; he also denies nausea, vomiting, abdominal pain, cramping, diarrhea, constipation, or blood in stool. He denies urinary frequency, but states that he used to have difficulty urinating until    his physician started him on doxazosin a few months ago. Physical Examination Gen WDWN, African-American male; moderately overweight; in no acute distress VS BP 168/92 mm Hg (sitting; repeat 170/90), HR 76 bpm (regular), RR 16 per min, T 37°C; Wt 95 kg, Ht 6'2'' HEENT TMs clear; mild sinus drainage; AV nicking noted; no hemorrhages, exudates, or papilledema Neck Supple without masses or bruits, no thyroid enlargement or lymphadenopathy Lungs Lung fields CTA bilaterally. Few basilar crackles, mild expiratory wheezing Heart RRR; normal S1 and S2. No S3 or S4 Abd Soft, NTND; no masses, bruits, or organomegaly. Normal BS. Genit/Rect Enlarged prostate; benign Ext No CCE Neuro No gross motor-sensory deficits present. CN II–XII intact. A & O × 3 Labs Na 142 mEq/L Ca 9.7 mg/dL Fasting Lipid Panel Spirometry (6 months ago) K 4.8 mEq/L Mg 2.3 mEq/L Cl 101 mEq/L HbA1C 6.2% Total Chol 169 mg/dL FVC 2.38 L (54% pred) CO2 27 mEq/L Alb 3.5 g/dL BUN 22 mg/dL Hgb 13 g/dL LDL 99 mg/dL FEV1 1.21 L (38% pred) SCr 1.6 mg/dL Hct 40% HDL 40 mg/dL Glucose 136 mg/dL WBC 9.0 × 103 /mm3 TG 151 mg/dL FEV1/FVC 51% Plts 189 × 103 /mm    UA Yellow, clear, SG 1.007, pH 5.5, (+) protein, (–) glucose, (–) ketones, (–) bilirubin, (–) blood, (–) nitrite, RBC 0/hpf, WBC 1–2/ hpf, neg bacteria, 1–5 epithelial cells ECG Normal sinus rhythm ECHO (6 months ago) Mild LVH, estimated EF 45%