Progress Note 17 Daws Rd. Blue Bell MA 02368 US Mr. Adam Frankie Everyman 17 Daws Rd. Blue Bell MA 02368 US Ralph Relative MA 02368 USA Good Health Clinic 21 North Ave Burlington MA 02368 USA 21 North Ave. Burlington MA 02368 USA Henry Seven 21 North Ave. Burlington MA 02368 USA Henry Seven Rose Everyman Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 USA Henry Seven Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 USA Mrs. Abigail Ruth Primary Care Provider Dr. Pseudo Physician-1 NIST HL7 Test Laboratory Primary Care Provider Dr. Pseudo Physician-3 HL7 Test Laboratory
ALLERGIES
Substance Reaction Status
Penicillin Hives Active
Aspirin Wheezing Active
Codeine Nausea Active
Penicillin Aspirin Aspirin
ASSESSMENT Recurrent GI bleed of unknown etiology; hypotension perhaps secondary to this but as likely secondary to polypharmacy. Acute on chronic anemia secondary to #1. Azotemia, acute renal failure with volume loss secondary to #1. Hyperkalemia secondary to #3 and on ACE and K+ supplement. Other chronic diagnoses as noted above, currently stable.
REASON FOR VISIT/CHIEF COMPLAINT Dark stools.
MEDICATIONS
Medication Directions Start Date Status Indications Fill Instructions
Proventil 0.09 MG/ACTUAT inhalant solution 2 puffs QID PRN wheezing 2011-03-01 Active Bronchitis (32398004 SNOMED CT) Generic Substitition Allowed
0.09 MG/ACTUAT inhalant solution, 2 puffs QID PRN wheezing Good Health Clinic Diethylene Glycol label in spanish
OBJECTIVE DATA Chest: clear to ausc. No rales, normal breath sounds Heart: RR, PMI in normal location and no heave or evidence of cardiomegaly,normal heart sounds, no murm or gallop
PHYSICAL EXAMINATION HEENT: All normal to examination. Heart: RRR, no murmur. THORAX & LUNGS: Clear without rhonchi or wheeze. ABDOMEN: No distension, tenderness, or guarding, obese, pos bowel sounds. BACK: Normal to inspection and palpation, without tenderness; no presacral edema. EXTREMITIES: Doughy edema bilaterally, chronic stasis changes, no asymmetrical swelling.
PLAN OF CARE
Planned Activity Planned Date
Colonoscopy April 21, 2000
PROBLEMS Pneumonia: Resolved in March 1998 ...
RESULTS
LABORATORY INFORMATION
Chemistries and drug levels
HGB (M 13-18 g/dl; F 12-16 g/dl) 13.2
WBC (4.3-10.8 10+3/ul) 6.7
PLT (135-145 meq/l) 123 (L)
Liver Functions and Other Laboratory Values
ALT (SGPT) 31.0
AST (SGOT) 18.0
GGT 28.0 Alk
Phos 86.0
Total Bili 0.1
Albumin 3.2
Blood Count
White Count 7.7
Platelets 187.0
Hematocrit 23.7
Hemoglobin 8.1
ELECTROCARDIOGRAM (EKG) INFORMATION
EKG Sinus rhythm without acute changes
M 13-18 g/dl; F 12-16 g/dl
REVIEW OF SYSTEMS Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. One episode of melena. No recent headaches. Positive for osteoarthritis in hips, knees and hands.
SUBJECTIVE DATA Complaints of rectal bleeding, fatigue and a change in bowel patterns. Has several days of constipation alternating with diarrhea.
VITAL SIGNS
Date / Time: Nov 14, 1999 April 7, 2000
Height 177 cm 177 cm
Weight 86 kg 88 kg
Blood Pressure 132/86 mmHg 145/88 mmHg