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Good Health Clinic Consultation Note (April 7, 2000)

Good Health Clinic Consultation Note (April 7, 2000)
Patient Henry LEVIN the 7thDate of Birth:September 24, 1932(67yr)Gender:MPatient-ID: 12345 (2.16.840.1.113883.19.5)
Encounter ID:KPENC1332 (2.16.840.1.113883.19.6),Date/Time:at April 7, 2000Location:General internal medicine clinic
Author Robert DOLIN MD,Organization:Good Health Clinic,Authored On:April 7, 2000, 2PM
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Table of Contents ∇

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History of Present Illness

Henry Levin, the 7this 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.

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Past Medical History

  • Asthma
  • Hypertension (see HTN.cda for details)
  • Osteoarthritis,right knee

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Medications

  • Theodur 200mg BID
  • Proventil inhaler 2puffs QID PRN
  • Prednisone 20mg qd
  • HCTZ 25mg qd

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Allergies and Adverse Reactions

  • Penicillin - Hives
  • Aspirin - Wheezing
  • Codeine - Itching and nausea

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Family history

  • Father had fatal MI in his early 50's.
  • No cancer or diabetes.

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Social History

  • Smoking :: 1 PPD between the ages of 20 and 55, and then he quit.
  • Alcohol :: rare

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Physical Examination

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Vital Signs

  • Date / Time: Height
  • April 7, 2000 14:30: 177 cm (69.7 in)
  • Date / Time: Weight
  • April 7, 2000 14:30: 194.0 lbs (88.0 kg)
  • Date / Time: BMI
  • April 7, 2000 14:30: 28.1 kg/m2
  • Date / Time: BSA
  • April 7, 2000 14:30: 2.05 m2
  • Date / Time: Temperature
  • April 7, 2000 14:30: 36.9 C (98.5 F)
  • April 7, 2000 15:30: 36.9 C (98.5 F)
  • Date / Time: Pulse
  • April 7, 2000 14:30: 86 / minute
  • April 7, 2000 15:30: 84 / minute
  • Date / Time: Rhythm
  • April 7, 2000 14:30: Regular
  • April 7, 2000 15:30: Regular
  • Date / Time: Respirations
  • April 7, 2000 14:30: 16 / minute, unlabored
  • April 7, 2000 15:30: 14 / minute
  • Date / Time: Systolic
  • April 7, 2000 14:30: 132 mmHg
  • April 7, 2000 15:30: 135 mmHg
  • Date / Time: Diastolic
  • April 7, 2000 14:30: 86 mmHg
  • April 7, 2000 15:30: 88 mmHg
  • Date / Time: Position / Cuff
  • April 7, 2000 14:30: Left Arm
  • April 7, 2000 15:30: Left Arm

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Skin Exam

Erythematous rash, palmar surface, left index finger.

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Lungs

Clear with no wheeze. Good air flow.

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Cardiac

RRR with no murmur, no S3, no S4.

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Labs

  • CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette, clear lungs.
  • Peak Flow today: 260 l/m

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In-office Procedures

  • Suture removal, left forearm.

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Assessment

  • Asthma, with prior smoking history. Difficulty weaning off steroids. Will try gradual taper.
  • Hypertension, well-controlled.
  • Contact dermatitis on finger.

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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.
Document
:--- :---
ID c266 (2.16.840.1.113883.19.4)
Version 2
Set‑ID BB35 (2.16.840.1.113883.19.7)
Created On April 7, 2000
This document relates to document (replaces)
:--- :---
ID a123 (2.16.840.1.113883.19.4)
Version 1
Set‑ID BB35 (2.16.840.1.113883.19.7)
Custodian Good Health Clinic
Patient Henry LEVIN the 7th Contact Details
Date of Birth September 24, 1932 (67yr) Gender M
Patient-IDs 12345 (2.16.840.1.113883.19.5)
Provider Organization
:--- :---
ID 2.16.840.1.113883.19.5
Contact Details (Organization)
Encounter
:--- :---
ID KPENC1332 (2.16.840.1.113883.19.6)
Encounter Date at April 7, 2000
Encounter Location General internal medicine clinic
consultant (at April 7, 2000) Robert DOLIN MD
Author Robert DOLIN MD, Organization: Good Health Clinic
Legal Authenticator Robert DOLIN MD signed at April 8, 2000