Good Health Clinic Consultation Note Good Health Clinic
History of Present Illness 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.
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 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 normal cardiac silhouette radiopacities
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. Complete PFTs with lung volumes. Chem-7 Chem-7 tomorrow prednisone 20qOD alternating with 18qOD. Hydrocortisone cream to finger BID.