Executive Solution Overview
2 soap notes **Patient 1** Age: 72 Race: Black Gender: Female **Chief Complaint:** Dizziness **HPI:** The patient presents with intermittent dizziness over the past two weeks, primarily noted when transitioning from sitting to standing positions. She denies syncope, chest pain, shortness of breath, …
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2 soap notes
**Patient 1**
Age: 72
Race: Black
Gender: Female
**Chief Complaint:** Dizziness
**HPI:** The patient presents with intermittent dizziness over the past two weeks, primarily noted when
transitioning from sitting to standing positions. She denies syncope, chest pain, shortness of breath,
or visual disturbances. She reports adequate oral intake but admits to occasionally missing meals.
No recent medication changes.
**CPT-9:** 99213
**CPT-10:** 99214
**ICD-9:** 780.4
**Medication:** Lisinopril 10 mg daily
**Education:** Patient was educated on orthostatic precautions, hydration, slow position changes, and
when to seek urgent care.
**Patient 10**
Age: 78
Race: Black
Gender: Male
**Chief Complaint:** Leg swelling
**HPI:** Progressive bilateral edema worse in evenings. History of CHF.
**CPT-9:** 99214
**CPT-10:** 99215
**ICD-9:** 782.3
**Medication:** Furosemide 20 mg daily
**Education:** Sodium restriction and leg elevation discussed.
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