Henry Levin, the 7th
is a 67 year old male referred for further asthma management. Onset of asthma in his twenties
teens. He was hospitalized twice last year, and already twice this year. He has not been able to be weaned off steroids for the past several months.
History of Present Illness
Past Medical History
- Asthma
- Hypertension (see HTN.cda for details)
- Osteoarthritis, right knee
Medications
- Theodur 200mg BID
- Proventil inhaler 2puffs QID PRN
- Prednisone 20mg qd
- HCTZ 25mg qd
Allergies and Adverse Reactions
- Penicillin - Hives
- Aspirin - Wheezing
- Codeine - Itching and nausea
Family history
- Father had fatal MI in his early 50's.
- No cancer or diabetes.
Social History
- Smoking :: 1 PPD between the ages of 20 and 55, and then he quit.
- Alcohol :: rare
Physical Examination
Vital Signs
| Date / Time | April 7, 2000 14:30 | April 7, 2000 15:30 |
|---|---|---|
| Height | 177 cm (69.7 in) | |
| Weight | 194.0 lbs (88.0 kg) | |
| BMI | 28.1 kg/m2 | |
| BSA | 2.05 m2 | |
| Temperature | 36.9 C (98.5 F) | 36.9 C (98.5 F) |
| Pulse | 86 / minute | 84 / minute |
| Rhythm | Regular | Regular |
| Respirations | 16 / minute, unlabored | 14 / minute |
| Systolic | 132 mmHg | 135 mmHg |
| Diastolic | 86 mmHg | 88 mmHg |
| Position / Cuff | Left Arm | Left Arm |
Skin Exam
Erythematous rash, palmar surface, left index finger.
Lungs
Clear with no wheeze. Good air flow.
Cardiac
RRR with no murmur, no S3, no S4.
Labs
- CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette, clear lungs.
- Peak Flow today: 260 l/m
In-office Procedures
- Suture removal, left forearm.
Assessment
- Asthma, with prior smoking history. Difficulty weaning off steroids. Will try gradual taper.
- Hypertension, well-controlled.
- Contact dermatitis on finger.
Plan
- Complete PFTs with lung volumes.
- Chem-7 tomorrow.
- Teach peak flow rate measurement.
- Decrease prednisone to 20qOD alternating with 18qOD.
- Hydrocortisone cream to finger BID.
- RTC 1 week.