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Consultation
Active encounter — Juan Dela Cruz · Flow 1 doctor review
Diagnosis
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SOAP note
In progress
Subjective
Patient returns for laboratory review. Reports occasional fatigue. Compliant with Atorvastatin 20 mg nightly. Denies chest pain, dyspnea, or edema.
Objective
BP 128/82 · HR 76 · BMI 27.4 · Labs: LDL 148 mg/dL (↓ from 168), FBS 108, CBC WNL.
Assessment
Mixed dyslipidemia, improving. Prediabetes — lifestyle measures ongoing.
Plan
Continue statin. Reinforce low-saturated-fat diet. Recheck lipid panel in 3 months. Issue prescription refill. Schedule follow-up.
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Prescription
Encounter
JD
Juan Dela Cruz
42 · Male · O+
Allergy: Penicillin
HMO: Maxicare
History
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