more cardio - unedited

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT: Precordial-type squeezing chest pain radiating to left shoulder and left arm, unrelieved for approximately 24 hours’ duration.

HISTORY OF PRESENT ILLNESS: This 68-year-old Caucasian male with a history of hypertension and congestive heart failure was apparently in good health, although he had failed to follow-up on his office appointments, and ran out of refills on probably his Lasix one week ago. The patient shortly thereafter had some slight precordial chest pain which resolved. The precordial chest pain returned again. Patient obtained good relief with nitro sublingual. The patient has also been on Calan and Micro-K, which he has continued to take. He has had no chills or fever, no nausea, emesis or diarrhea, no unusual color change. He had did complain of being somewhat diaphoretic and dizzy with the chest pain.

FAMILY HISTORY: No familial diseases known.

PERSONAL HISTORY: Patient is known to imbibe alcohol and perhaps to excess on occasion. He does not smoke.

PAST MEDICAL HISTORY: Patient has had appendectomy, tonsillectomy and umbilical herniorraphy.

REVIEW OF SYSTEMS: His system review essentially negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure, 160/110. Respiration is 20. Pulse, 87. Temperature, 98.
GENERAL APPEARANCE: A slightly obese, well-developed 68-year-old Caucasian male.
HEENT: Head, symmetrical. Pupils equal, react to light and accommodation. No scleral icterus. Ears, nose and throat clear. Mouth moist.
NECK: Supple. No masses. Normal anterior carotid pulsations bilaterally.
CHEST: Clear to P & A.
CARDIOVASCULAR: Distant heart tones. No murmurs. Good peripheral pulses including dorsalis pedis.
ABDOMEN: Protuberant. No masses. Active bowel sounds.
GENITALIA: Normal male.
RECTAL: Deferred.
EXTREMITIES: Negative x 4. No ankle edema.
NEUROLOGICAL: Physiologic.

IMPRESSION:
1. Probable angina pectoris.
2. Rule out MI.
3. Congestive heart failure, compensated.
4. Hypertension.
5. Arteriosclerotic heart disease.


_____________________________

CONSULTATION

The patient is a very pleasant 58-year-old white male. He is an extremely hyper type of personality who spends a great deal of time with his work. Basically, this patient has had hypertension for 30 years. He has been on just about every medication that has ever come out with variable results in management of his hypertension.

PRESENT MEDICATIONS: He is on Minipress 5 mg t.i.d, Catapres 1 mg b.i.d., Lopressor 100 mg t.i.d., Lasix 40 mg a day, Kay Ciel 10% 2 tablespoons b.i.d., Nitro-Bid Ointment 2 ½ inches b.i.d. He is also on a 4-gram-sodium-diet.

PHYSICAL EXAMINATION:
On physical examination, the patient’s pulse is 50 and regular. There is a sinus bradycardia. BP, 138/70 standing, and 140/70 lying. The fundi showed a very minimal AV nicking in each eye. There is a bruit noted in the right carotid area. There is an S4 noted. There is a very faint systolic ejection murmur along the left external border.

The ECG performed here in the office today shows a sinus bradycardia at a rate of 50 beats per minute. There are the changes consistent with the old inferior infarction. There is no evidence of an anterior infarction other than some reduction of the R waves across the precordium.

IMPRESSION:
1. Status post secured inferior wall infarction with residual sinus bradycardia, and associated symptoms of weakness and fatigue. This patient may need a pacemaker.
2. Long-term chronic hypertension which under current medication is
well-controlled at this point in time.

RECOMMENDATIONS:
1. We will do a PA and lateral chest x-ray and repeat the laboratory values.
2. We will perform resting nuclear ventricular function study to assess his ejection fraction and wall motion.
3. Next week, we will perform a submaximal treadmill stress test, and based on the study, we can plan his rehab program.

In eight weeks, we will do the full blown treadmill stress test and based on that, we will make the final modifications of his exercise program. We will, today perform a Holter monitor to determine just how much a problem his sinus bradycardia is, and if there are further drops in his rate until the 40s with symptoms, I would then at that point in time, consider atrial pacing studies, and whether or not there may be a need for a permanent atrial pacemaker.


__________________________________________

CHART NOTE

Has had occasional palpitations, and was told she has borderline hypertension, 162/85. This was not taken properly however.

Today 144/74, is on Diamox, Betagan eyedrops. Heart and lungs, okay. Pulse is regular, is on 1g of Euthroid, and continue Micro-K 2 capsules daily; sent for electrolyte today.

_____________________________

INITIAL OFFICE EVALUATION

She has complained shortness of breath.

HISTORY OF PRESENT ILLNESS: This elderly female was on Tonocard, Cardizem, Lasix, did Jackson, cardio set. She had no oxygen in home and there was no one to oversee her medications. She did quite well on Thursday and Friday, but yesterday begin getting more shorter breath. Her legs were swollen last night. She was short of breath and had sit up to breathe last night.

PHYSICAL EXAMINATION: On physical examination, she said that she is quite comfortable at the present time. Her neck veins are slightly distended. Her carotids are easily felt. There is no bruit. Her lungs are clear to percussion and auscultation. The heart is enlarged to the left. There is an apical impulse that is heaving. There is a grade IV systolic murmur at the apex, no diastolic component. The breasts are atrophic, no masses. The abdomen is soft. The liver is at the right costal margin. No other masses are felt. She has a good femoral pulse but I cannot feel the pulse in her feet. There is 2 to 3+ pitting edema in both legs, and a lot of superficial veins are present.

DIAGNOSIS: Diagnosis is hypertensive cardiovascular disease with left ventricular hypertrophy, mitral insufficiency, and congestive heart failure. She also has arteriosclerosis of bitter ends of the lower extremities.

She will be admitted to the hospital, started on oxygen, given intravenous diuretics. We will try to get the edema out of her body, and then she will either need to go to a nursing home or go home with oxygen in the house along with someone to care for her and make sure her meds are given regularly.

_________________________________________________

CONSULTATION

History reveals that this patient has a long sitting history of artherosclerotic and hypertensive heart disease. She has had chronic each of her vulation and has a pacemaker implanted. She has a chronic hypertension. She has an angina in the past. However no document history mark an infarction. She states that over the past two to three weeks, she has been having increase in shortness of breath. This appearly has been increasing and last night reached a P for suse mark of the short of breath and this week. She has an angina in the past but no document is to mark the infarction. No known history of valvular heart disease and no previous congestive heart failure.

MEDICATIONS: The Jacksons 125 mg daily, Inderal 10 mg b.i.d., Lasix, potassium, Codeine 2 mg daily because of her chronic each of her vulation, restoril, metamusol, voltaren, capeten. She is also in trands of nitro glycerin.

PHYSICAL EXAMINATION:
NECK: Both carotids are palpable. Poems used to be diminished particularly over the left. No definite bruit at this time. Jugular neck veins are distended to its three fingers.
BREAST: Above the stroll last of 30 degrees. No theramendular adenopathy.
LUNGS: Lungs should diminish breast sounds in both bases of perhaps greater in the right than the left. She does have by vascular rolstrum both lung feels. She does have a dorsal kyphosis.
HEART: Heart sounds are irregularly regular with a grade II to III/VI blowing systolic murmur. No other gallops or rubs. No diastolic rumble.

IMPRESSION:
1. Congestive heart failure, probably on the basis of comine atherosclerotic
anti-pretents of heart disease. Delta significant valvular heart disease.
2. Chronic age of fibrillation secondary to artherosclerotic and hypertensive heart disease.
3. Right side apleural effusion, most likely on the bases of congestive heart failure. Have her need to consider other inflammatory processes such as pneumonitis and perhaps also a possibility of neoplasm.

This patient will be admitted to the hospital and monitored.

Thank you very much for this consultation.

________________________________________

CONSULTATION

History reveals that this patient has a long sitting history of artherosclerotic and hypertensive heart disease. She has had chronic each of her vulation and has a pacemaker implanted. She has a chronic hypertension. She has an angina in the past. However no document history mark an infarction. She states that over the past two to three weeks, she has been having increase in shortness of breath. This appearly has been increasing and last night reached a P for suse mark of the short of breath and this week. She has an angina in the past but no document is to mark the infarction. No known history of valvular heart disease and no previous congestive heart failure.

MEDICATIONS: The Jacksons 125 mg daily, Inderal 10 mg b.i.d., Lasix, potassium, Codeine 2 mg daily because of her chronic each of her vulation, restoril, metamusol, voltaren, capeten. She is also in trands of nitro glycerin.

PHYSICAL EXAMINATION:
NECK: Both carotids are palpable. Poems used to be diminished particularly over the left. No definite bruit at this time. Jugular neck veins are distended to its three fingers.
BREAST: Above the stroll last of 30 degrees. No theramendular adenopathy.
LUNGS: Lungs should diminish breast sounds in both bases of perhaps greater in the right than the left. She does have by vascular rolstrum both lung feels. She does have a dorsal kyphosis.
HEART: Heart sounds are irregularly regular with a grade II to III/VI blowing systolic murmur. No other gallops or rubs. No diastolic rumble.

IMPRESSION:
1. Congestive heart failure, probably on the basis of comine atherosclerotic
anti-pretents of heart disease. Delta significant valvular heart disease.
2. Chronic age of fibrillation secondary to artherosclerotic and hypertensive heart disease.
3. Right side apleural effusion, most likely on the bases of congestive heart failure. Have her need to consider other inflammatory processes such as pneumonitis and perhaps also a possibility of neoplasm.

This patient will be admitted to the hospital and monitored.

Thank you very much for this consultation.

___________________________________________

CHART NOTE

Patient states she has had four to five episodes of left substernal burning chest pain which radiates to the left arm which is associated with type-free susnaby and shortness of breath. She states the pain usually comes out with exertion that has commonic rest on several occasions and is usually relieved by one or two sublingual nitro glycerin.

Additional ______________ reports dyspnea inversion, occasional orthopnea, and crescial PND were ______________, at night coughing several times. Patient states cough is not productive.

PHYSICAL EXAMINATION:
HEENT: HEENT exam was unremarkable. Neck exam: intravenous pressure was perfectly known cm. There is no adenopathy or bruit.
CARDIOVASCULAR EXAM: Heart is regular rate and rhythm, with a rate of 62 and positive S4, no murmur, no S3.
RESPIRATORY EXAM: Lungs are clear to auscultation and percussion.

MEDICATIONS: Medications include Tenex 1 mg p.o. q.h.s., Lasix 20 mg p.o. q.day, Chroneral 3 mg p.o. b.i.d., Coreg 100 mg p.o. b.i.d., Nitropatch 5 mg topically q. 24 hrs., Nitro glycerin 0.4 mg sublingually p.r.n. chest pain.

DIAGNOSIS: Unstable angina, hypertension, and congestive heart failure.

_______________________________

CHART NOTE

HISTORY: Patient was diagnosed to have new onset atrial fibrillation approximately eight weeks ago. He was placed on Anoxen followed by Conedeine therapy and several times were made medically to convert the rhythm to sinus without success.

Echocardiagram obtained at that time revealed dilated left atrium and right sided cardiac chambers. The decision now is to hospitalize the patient for elective cardioversion and to perform cardiac catheterization to rule out congenital heart disease.

His medications at the time of admission include Lenoxi cough syrup 0.3 mg daily and conedex 1 tablet q. 8 hour.

___________________________

CHART NOTE

A hypertensive male with a pacemaker placed, who is complaining tonight of a period of black-out that occurred approximately half hour before arrival here, and unheralded by any prior symptoms. He did not have chest pain, shortness of breath, or cough prior to his syncope. This happened once before, and resolved within the placement of a cardiac pacemaker.

He has in the past two weeks experienced several episodes of mild lightheadedness for which he is being treated with Antivert 25 mg t.i.d. He takes a blood pressure medicine that he cannot name. His pacemaker was checked for function this week, and found to be functioning satisfactorily.

PHYSICAL EXAMINATION:
A well-developed, well-nourished male in no apparent distress. His blood pressure, 120/84, pulse 88, respiratory rate 20, and temperature 99.6. He is alert and well-oriented and has normal pupils. There is no ataxia. The neck is nontender. The lungs are clear and the heart has a regular sinus rhythm without murmurs. The pacemaker is palpable in the left pectoral region. The abdomen is nontender, soft, and has normal pulse sounds. There is no pretibial edema.

LABORATORY FINDINGS:
The patient’s EKG was normal. The BUN was 18, and the CPK 67; the glucose was 156. His potassium was 5.0 and sodium 136; choroid was 102 and total CO2 27. The white count was 10,500 with 3% BUNs and 76% segs. The hematocrit was 50.

I was elected to admit the patient to the CCU for observation and for reevaluation of his pacemaker.

DIAGNOSIS:
1. Arterial hypertension.
2. Probable pacemaker malfunction.

_________________________________________

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT: Shortness of breath.

HISTORY OF PRESENT ILLNESS: This 60-year-old female has been in good health over life. Two months ago, she walked-in complaining of shortness of breath which had lasted all evening. She was told that she had suffered a myocardial infarction. The records are currently not available but are being sent for. The patient was observed for a period of seven days, and one within advice to have a temporary pacemaker followed by permanent ventricular pacemaker. Since that time the patient has been discharged and has done very well. She has had no recurrence of the shortness of breath. There has never been a chest pain described. The patient has been somewhat fatigued and has been remedied in work she can do, mainly because they were not advised what kind of activities were safe for her. She has also noted pain in her axilla from the permanent pacemaker side. She has had no recurrence of feeling short of breath similar to what brought her into the hospital in which ______.

PAST MEDICAL HISTORY: Illness is none. Surgery, none. Medications, Isordil 5mg q.i.d. Allergies, none known.

FAMILY HISTORY: There is no family history of rare heart disease.

REVIEW OF SYSTEMS: Review of systems was essentially negative. The patient has had some cramping in her face and in her arms.

SOCIAL HISTORY: The patient does not drink or smoke.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 170/94 in the right arm and 140/90 in the left arm. The weight is 154.5 pounds with shoes off.
HEAD, EYES, EARS NOSE & THROAT: Unremarkable neck. No jugular venous distention. The carotids are 2+, without bruits. The thyroid is not enlarged.
CHEST: The chest is clear to percussion and auscultation.
HEART: The heart’s PMI is not palpable. The heart is without gallop or whatever murmur.
ABDOMEN: Abdomen is negative.
EXTREMITIES: Extremities are negative.

Put chest 4 reveals that the pacemakers’ side is over the left axilla which is causing some local discomfort in this region.

IMPRESSION:
1. Status post myocardial infarction.
2. Permanent ventricular pacing.

RECOMMENDATION: The patient was advised to undergo a chest x-ray and CBC and return for a treadmill stress test. At that time further recommendations as far as activity level will be made. The patient could probably benefit from abc consule or ab synchronize pacing. She could also benefit from a relocation of her pacemaker site out of the axilla. This will be discussed as time goes by.

____________________________________________________

CHART NOTE

Patient is diagnosed with PMI PTCA. He takes Persantine 75 mg three times a day, Cardizem 60 mg three times a day, stopped taking his aspirin. Aspirin have a no chest pain, no sureness of burnia. Last week, he developed some swelling in his left foot and in his left leg, and it is quite painful. This happened to him in the past this way.

On physical exam, his weight was 209, blood pressure 130/70, pulse rate 70, respiratory rate 80. Chest, clear. Cardiovascular, unremarkable. Examination of the left lower extremity reveal there will be 1+ to 2+ pretibial anpiladin. Dorsalis pedis and posterior tibial pulses were obtained with the doctor _______________. There was a negative hormones sign, no carotids were palpable.

IMPRESSION: Coronary artery disease, status post MI, status post PTCA, venous insufficiency of the lower extremities, rule out gout which I doubt, hypertension presently adequately controlled.

RECOMMENDATIONS AND DISCUSSION: Patient can stop taking his Persantine and we will take him off Cardizem taken 60 mg b.i.d. for three days, 60 mg a day for three days and then stop. He will be given a fresh bottle of nitroglycerin if there is any break through angina. He is to call or return soon p.r.n. Was also started on Ecotrin 5 mg every other day, is to use his dial link ted hose in his left lower extremity and to keep the extremity higher than the heart when he is not up in a bath, is to have a blood pressure check in one week along with blood drawn for CBCs sodium, potassium, BUN, creatinine, uric acid, pus, and blood sugar and pass to the lab with the labels. Return to clinic to see me in one month p.r.n.

abbreviation q-z

q. each; every
q.h.s. each bedtime; at hour of sleep
QNS quantity not sufficient
q.o.d. every other day
QS shunt fraction
QT total cardiac output
RA rheumatoid arthritis
RA right atrium
RAD Right atrial axis deviation
Rad radial
RAST radioallergosorbent test
RDW red cell distribution width
Rh blood group rhesus
RIA radioimmunoassay
RNA ribonucleic acid
ROM range of motion
ROS review of systems
RPG retrograde of pyelogram
RPR rapid plasma reagin (syphilis test)
RRA registered record administrator
RTA renal tubular acidosis
RU resin uptake
Rx prescription; take; treatment
S tach sinus tachycardia
SAA synthetic amino acid
SBE subacute bacterial endocarditis
SBFT small bowel follow through
SBS short bowel syndrome
SCr serum creatinine
Script prescription
sed rate sedimentation
segs segmented neurophils - same as polymorphonuclear leukolytes; polys, PMNs
SEM systolic ejection murmur
SGA small for gestational age
SGGT serum gamma-glutamyl transpeptisade
SGOT serum glutamic-oxalic transaminase
TURP transurethal resection of prostate
TVH Total vaginal hysterectomy
tw twice a week
Tx transplant; treatment
UAC uric acid
UP junction ureteropelvic
URI upper respiratory infection
US ultrasound
UTI urinary tract infection
UUN urinary urea nitrogen
UV junction ureterovesical
v fib ventricular fibrillation
VCUG voiding cystourethogram
VDRL Venereal Disease Research Laboratory
VHD valvular heart disease
Vis-a-vis as compared to
VMO vastus medialus obliquus
V/Q ventilation-perfusion
VSS vital signs stable
WB whole blood
WBC with diff white blood count with differential
WBC/hpf white blood cells per high-power field
WD well developed
WM white male
WNL within normal limits
WU work up
WPW Wolf-Parkinson-White syndrome
WF white female
XRT X-ray therapy
ZE Zollinger-Ellison
SGPT serum glutamic-pyruvic transaminase
SIADH syndrome of inappropriate antidiretic hormone
SIDS sudden infant death syndrome
SIMV synchronous intermittent mandatory ventilation
SL sublingual
SLE systemic lupus erythematosus
SMA Sequential Multiple Analyzer
SMA-6 6 different serum tests
SMAC Sequential Multiple Analyzer Computer
SMO slips made out
SOAP Subjective, Objective, Assessment, Plan
SR sustained release
SSB short spine board
stat immediately
subcu subcutaneous
SVT supraventicular tachycardia
T-1 thoracic vertebra with corresponding number
T3 triodothyronine
T4 thyroxine
T&A tonsillectomy & adenoidectomy
TAH total abdominal hysterectomy
TAH-BSO total abdominal hysterectomy, bilateral salpingo-oophorectomy
Td tetanus-diphtheria toxoid
TDI toluene diisocyanate
TENS transcutaneous electrical nerve stimulation
TIA transient ischemic attack
tic diverticulum
t.i.d. three times daily
TIG tetanus immune globulin
TLC total lung capacity
TMJ temporo mandibular joint
TNTC too numerous to count
TOPV trivalent oral polio vaccine
TPN total parenteral nutrition
TSH thyroid-stimulating hormone
TURBT TUR bladder tumors

abbreviations i-p

I&O intake and output
I.M. internal medicine
in. inch; use double quotation marks forinches in 5'8"
I.V. intravenous
ID identification/infectious disease
IDDM insulin-dependent diabetes mellitus
IgE immunoglobulin E
IG immunoglobulin
KVO keep vein open
km. kilometer
KOR keep open rate
L left/ liter
MA master of arts
MAST medical antishock trousers
MAP mean arterial pressure
MAO monoamine oxidase
MLE midiline episiotomy
MMR measles, mumps, rubella
MRI scan magnetic resonance imaging
MFT muscle function test
Monos monocytes
Mod moderate
mmHg millimeters of mercury
MS mitral stenosis/ morphine sulfate/ multiple sclerosis
MTP metatarsophalangeal
MCP meta carpophalangeal joint
Na+ sodium
NAD no active disease
NED no evidence of recurrent disease
NPO nothing by mouth
NIDDM non-insulin-dependent diabetes mellitus
NKA no known allergies
NRB non rebreathing mask
NSAID non-steroidal anti-inflammatory drug
NMR nuclear magnetic resonance
NGT nasogastric tube
G gravida/pregnant
GB gallbladder
GERD gastroesophageal reflux disease
GETT general by endotracheal tube
GI gastrointestinal
GU genitourinary
GXT graded exercise tolerance (Stress test)
GYN gynecology
H&H hematocrit and hemoglobin
H&P history and physical
HTN hypertension
I&D incision and drainage
neg negative
O2 oxygen
O: Objective
OB obstetrics
OCG oral cholecystogram
OD overdose
OCPs oral contraceptive pills
O.D. right eye
o.d. once a day; every day
OOB out of bed
O.U. both eyes/ each eye
O.S. left eye
OR operating room
OPV oral poliovirus vaccine
oz. ounce
P para/phosporus
P2 pulmonary valve closure
P&A percussion and auscultation
PERRLA pupils, equal, round, react to light and accommodation
PaO2 peripheral arterial oxygen content
PAP pulmonary artery pressure
para 3, 2-0-1-2 3 pregnancies; 2 term infants, 0 premature, 1 abortion, and 2 live births
PERRL pupils, equal, round, react to light
PED pediatric
PEEP positive end expiratory pressure
per os by mouth; p.o.
PE physical examination
PE pleural effusion
PE pulmonary embolus
PFK phosphofructokinase
PFTS pulmonary function tests
pH hydrogen ion concentration
pid pelvic inflammatory disease
PDA patent ductus arteriosus
PMH previous medical history
PNI peripheral nerve injury
PND paroxysmal nocturnal dyspnea
PND postnasal drainage
PR by rectum
LOC level of consciousness
LOC loss of consciousness
LP lumbar puncture
LE lupus erythematosus
LDH lactate dehydrogenase
LDL low-density lipoprotein
LBBB left bundle branch block
LOA leave of absence
LS lung sounds
LR lactated Ringer's
LUE left upper extremity
LVH left ventricular hypertrophy
PT physical therapy
PPD purified protein derivative
PS pulmonic stenosis
Px physical examination
pro time prothrombin time
PMS premenstrual syndrome
PVD peripheral vascular disease
PRBC packed red blood cells
Pt patient
postop postoperative
PP postprandial
PP pulpus paradoxus
PROM passive range of motion
POMR problem oriented medical record
polys polymorphonuclear leukocytes
INF intravenous nutritional fluid
IPPA inspection, palpation, percussion, auscultation
IPPB intermittent positive pressure breathing
IT interthecal
IU international unit
IUD intrauterine device - contraceptive
IVP intravenous pyelogram
JV jugular venous
JVD jugular venous distention
KUB kidneys, ureters and bladder
HA headache
HAA hepatitis B surface antigen
H2O water
HCG or hCG human chorionic gonadotropin
HgB hemoglobin
H/H hemoglobin/hematocrit
H/H henderson-hasselbach equation
HLA histocompatibility locus antigen
HOB Head of Bed
HR Heart rate
HPV human papillomavirus
PWB Partial weight bearing
Pap Smear Papanicolaou
Oriented x 3 oriented to person, place and time
Oriented x 4 oriented to person, place, time and future plans
Ortho orthopedics
P: Plan
GSW gun shot wound
P para/phosporus
P phosphorus
P pulse
NKDA no known drug allergies
NKA no known allergies
MVC motor vehicle crash
NT nasotracheal
nitro nitroglycerin
oh every hour

physical examination terms

General:
Apgar score (newborn)
Apgar score was 8 at one minute and 9 at five minutes
arousable
awake, alert and oriented
awake, alert and oriented X 3 (times 1, 2 or 3)
cachectic/cachexia
Cheyne-Stokes breathing
comatose
cushingoid
diaphoretic
dyspnea
dyspneic
lethargic
mask facies, masklike facies
no acute distress (NAD)
obese
obtunded
oriented to person, place and time
orthostatic changes
pallor
tachypnea
tachypneic
unresponsive
well-developed, well-nourished
Well-nourished, well-developed, white male in no apparent distress.


Vital signs:
Blood pressure: 120/80 mm Hg (millimeters of mercury)
Pulse rate: 80 (per minute) (see "Cardiac Exam" below)
Respiratory rate: 18 (per minute), labored/unlabored
Temperature: 98.6 degrees F. (sometimes T-max=temperature maximum)
afebrile/febrile
Pulse, 76, regular.
Respirations are normal.

Skin:
abrasions
complexion - flushed/pale/pallor/ruddy
decubital
decubitus ulcers (NOT decubiti)
ecchymosis, pl. ecchymoses
eczema
eczematoid
eczematous
edema
edematous
erythema
erythematous
eschar
herpes simplex
herpes zoster
herpetic lesion
lichenoid edema
maculopapules
maculopapular rash
pale
pallor
petechiae
plethoric
psoriasis/psoriatic
purpura
rash, petechiae, or purpura
scleredema
spider angiomata
stigmata of liver disease
tenting (skin/tissue)
turgor




Head, eyes, ears, nose and throat: (HEENT)
Head:
atraumatic
atraumatic, normocephalic (AT/NC)
Battle's sign (cap the "B" - named for Dr. William H. Battle)
flattening of the (left/right) nasolabial fold
fontanel (infant exam)
macrocephaly/macrocephalic
megacephaly/megacephalic
microcephaly/microcephalic
nasolabial fold
normocephalic
normocephalic, atraumatic (NC/AT)
raccoon eyes

Eyes: Pupils equal, round, and reactive to light and accommodation. (PERRLA)
Pupils equal, round, and reactive to light. (PERRL)
Pupils equal and reactive to light. (PERL)
(above may be dictated as PURL or PURL-LAH)
Pupils (fixed/dilated/pinpoint)
anicteric
arcus senilis
arterial pulsation
Battle's sign
best-corrected visual acuity
cataract
conjunctivae pink, not injected, clear, normal, muddy, no pallor
cornea clear/cloudy
corneal reflex intact
disk/disc margins well-delineated
disks/discs sharp
enucleated
extraocular movements (EOM) (may be dictated EE-OHM)
extraocular movements intact (EOMI) (may be dictated EE-OH-MEE)
fundi well-visualized/not well-visualized/not examined
funduscopic examination, funduscopy
homonymous hemianopsia
H or E (hemorrhage or exudate)
iridectomy
isocoria/isocoric (meaning the pupils are equal bilaterally)
lenticular opacification
macular degeneration
nystagmus
opacification
opacified
papilledema
ptosis (pronounced TOH-SIS)
raccoon
rapid eye movements (REM)
red reflex
retinopathy
sclerae anicteric/icteric
slit-lamp examination
strabismus
visual acuity
Physical exam was routine except for visualization by direct ophthalmoscope revealing numerous hard exudates and probable macular edema.
Exam with Pontocaine and flourescein reveals no corneal abrasion or ulceration.
No foreign bodies are noted on the palpebral conjunctiva or on the globe.
Pupil is round and reactive.
Ocular fundus is entirely normal.


Ears:
auditory canal
cerumen
injected
myringotomy tubes
poor light reflex
TMs (tympanic membranes)
tympanic membranes intact - red/bulging/dull
Right ear, external canal is slightly irritated at the outer third, but the inner two-thirds is okay.
Tympanic membrane is intact and not inflamed.
Left ear is clear.
There is no cerumen on either side

Nose:
boggy turbinates
congested
flattening of the nasolabial fold
nasolabial fold
inferior turbinate
polyps
septal deviation
sinus
turbinate/turbinate hypertrophy
Airway is quite adequate.
Septum slightly deviated to the right.
No evidence of polyps or abnormal discharge.
Examination reveals the nasal septum to have somewhat of an S-shaped configuration with the midsection curved to the right of the mid-line in the caudal edged of the quadrilateral cartilage to the left of the mid-line.
There is marked obstruction of the right nasal passage.
She has some asymmetry to the dorsal nose as well.



Mouth and throat: (oral examination)
aphthae
aphthous ulcers
bifid
bifid uvula
buccal mucosa
cleft palate
dentition
edentulous
erythema
exudate
hard palate
mucous membranes moist/dry
palate
pharynx
protruded tongue midline
soft palate
temporomandibular joint
thrush
tongue well-papillated
uvula moves on phonation
uvula and tongue midline
Normal mucous membrane.
No evidence of inflammation.




Neck examination:
carotids 2+ and equal bilaterally
carotid bruit
cervical adenopathy
goiter
hepatojugular reflux (HJR)
jugular venous distention (JVD)
lymph nodes not palpable/palpable, hard, immobile, fixed, freely mobile
lymphadenopathy
multinodular goiter
pharynx
shotty lymph nodes [NOT shoddy]
stridor
supple
thyroid not palpable
thyromegaly
venous distention at 45 degrees
Neck is supple without masses.
Thyroid gland is not enlarged.
Carotid arterial pulsations are equal and full.
There are prominent, normal jugular venous pulsations with the patient in the supine position.
There is a venous hum on the left, which obliterates easily with minimal pressure on the neck.
Neck is supple.
There are no carotid bruits.
There is a soft bruit over the entire right carotid artery.
There is a soft bruit at the base of the left carotid artery.
There are no bruits over the subclavian arteries.
Supple, without jugular venous suspension, without carotid bruits.
No lympadenopathy is present.
No adenopathy.




Chest/Breast:
AP diameter (anterior-posterior diameter)
areola
atrophic
axilla ( No adenopathy or lymphadenopathy, no nodes felt.)
breasts atrophic (older women)
gynecomastia (men)
mastectomy
no nipple discharge
no lumps or masses
permanent pacemaker
status post mastectomy
sternum
sternotomy scar
Tanner
thoracic
thorax
The chest is symmetric with equal respiratory excursions.
There is no thoracic deformity or tenderness.
The breasts are normal and free of masses or tenderness.
Dry rales in both bases, without whizzing or rubs present.
Breath sounds are adequate.
Decreased breast sounds in the lower one third of left lung field with dullness to percussion and end-inspiratory wheezes on the left.



Lungs:
accessory muscles of respiration
adventitious sounds
AP diameter normal/increased
atelectasis
clear to auscultation and percussion (A and P/P and A)
coarse rales
costophrenic angles
crackles/crackling
crepitant rales
crepitation
crepitus
Cheyne-Stokes breathing
dullness to percussion
dyspnea
dyspnea on exertion
E to A changes (egophony) [patient says "EEEE" MD hears "AAAAA"]
egophony
end-expiratory wheeze
expiratory time normal/prolonged
expiratory wheeze
expiratory wheeze 1+, 2+, etc.
forced expiratory time
hyperresonant
hyperventilation
hypoventilation
moist rales
pleural rub
rales
rhonchi
rub
wheeze
Lungs are clear to auscultation and percussion.
Diaphragmatic motion appears normal.
Lungs are clear to percussion and auscultation.





Cardiac Examination:
A2 louder than P2
aortic click
aortic regurgitation
apical systolic murmur
arrhythmias
asystole
atrial fibrillation (often dictated Ay-Fib or AF)
atrial flutter
bradycardia
cardiomegaly
click
diastolic murmur
first heart sound (S1)
first and second heart sounds normal; no third or fourth heart sound
fourth heart sound
ejection murmur
ejection systolic murmur
gallop
grade 1/6, 2/6, 3/6, 4/6, 5/6*
grade I, grade II, grade III, grade IV, grade V, grade VI*
heart sound
heave
holosystolic murmur
intercostal space
irregularly irregular
knock
MAT (multifocal atrial tachycardia)
midclavicular line
mitral valve prolapse
mitral regurgitation
multifocal atrial tachycardia (MAT)
murmur
murmur radiating to the axilla or neck
normal sinus rhythm (NSR)
P2 louder than A2
parasternal border
pericardial knock
physiologically split
PMI - point of maximum impulse
point of maximum impulse (PMI) in fifth intercostal space
premature ventricular contractions (PVC)
prosthetic click/sound
PVC - premature ventricular contractions
regular sinus rhythm (RSR)
rapid ventricular response
rub
S1, S2, S3, S4
S1 equals S2
S1 and S2 normal, no S3 or S4
S3 gallop
second heart sound (S2)
supraventricular tachycardia (SVT)
systolic ejection murmur
tachycardia
third heart sound (S3)
thrill
tricuspid regurgitation
ventricular fibrillation (often dictated Vee-Fib)
ventricular tachycardia (often dictated Vee-Tak)
There is no visible or palpable precordial activity.
The first heart sound is normal in character and intensity.
The second heart sound is also normal in intensity, but I was unable to appreciate splitting of the second sound.
No third or fourth sound was present.
The cardiac rhythm is regular, and there is a grade 3/6 systolic ejection murmur that is loud at the second left intercostal space.
This murmur decreases in intensity markedly with Val Salva maneuver.
The murmur does not radiate to the neck.
PMI is not displaced.
PMI is in the fifth intercostal space.
No thrill, heave, gallop, rub or murmur.
No rub and no pathologic heart sounds
The PMI is in the fifth intercostal space at the MCL.
The left LV impulse is normal.
The rhythm is regular with no premature beats.
S1 and S2 are normal.
There was no S3, S4 or gallop.
There is a soft grade 2/6 systolic ejection murmur heard at the second right and left intercostal space, left sternal border, and cardiac apex.
There is no diastolic murmur.
Heart is regular rhythm.
Without murmur, gallop or rub.




Abdominal examination:
ascites
ballottable
bowel sounds normal (normoactive, hyperactive, hypoactive,
high-pitched, inaudible, tympanitic, decreased, diminished)
costovertebral angle tenderness (CVA tenderness/CVAT)[back exam]
distended, nondistended
exogenous obesity
fluid wave
guarding
liver and spleen
not palpable
1-2 fingerbreadths below right costal margin
hepatomegaly
hepatosplenomegaly
liver, spleen and kidneys not palpable/not felt
spleen enlarged/not enlarged/not felt
tender, nontender
McBurney's point (location to test for appendix)
morbid obesity
Murphy's sign
obese
organomegaly
palpable, nonpalpable
protuberant
rebound
rebound tenderness
scaphoid
scars of previous surgery
tender, nontender
visceromegaly
Soft, nontender.
Without organomegaly.

Landmarks:
axillary line
costophrenic angle
costovertebral angle
epigastric
inguinal
left costal margin
left lower quadrant
left upper quadrant
ligament of Treitz
McBurney's point
midclavicular line
Murphy's point
paramedian
parasternal border
right lower quadrant
right upper quadrant
right costal margin
subclavicular
suprapubic area
symphysis pubis
xiphoid to pubis
xiphoid process



Back:
C-spine
cervical spine
costovertebral angle tenderness (CVA tenderness/CVAT)
dorsal spine
kyphosis
kyphoscoliosis
lumbar
lumbosacral
palpation and percussion
paravertebral
point tenderness
radiation
referred pain
sacrum
sciatica
scoliosis


Extremities:
above-knee amputation (AKA)
arc of motion
below-knee amputation (BKA)
CCE (cyanosis, clubbing or edema)
calf tenderness
capillary refill
claudication
clubbing
cords
cyanosis
decubitus ulcer
Doppler
dorsalis pedis pulses
DP/PT - dorsalis pedis, posterior tibial (pulses)
edema
edema 1+ (2+, 3+)
edematous
femoral pulse
full range of motion
hip click (baby examination)
Heberden's nodes of osteoarthritis
Homans' sign
Lachman's sign (often pronounced "lock-man's")
mottling
pedal edema
peripheral pulses
pitting edema
popliteal pulse
posterior tibial pulse (PT)
pulses 2+ and equal bilaterally
range of motion
varicose veins
varicosities
The extremities are free of cyanosis, clubbing, or peripheral edema.
There are bilateral soft femoral bruits.
The left femoral artery has a 4+ pulsation, and the right femoral artery has only a 1+ pulsation.
The more distal pulses are normal and symmetric, including the popliteals, dorsalis pedis, posterior tibial pulses.
Without clubbing, cyanosis or edema.






Rectal examination:
ampulla
black tarry stool
bright red blood per rectum
guaiac-negative/positive
heme-positive (negative)
Hemoccult positive/negative
hemorrhoid - internal/external
hemorrhoidal plexus
maroon-colored
mass
prostate
prostate hard and nodular
prostate firm and 2+
prostate not enlarged
rectal ampulla
rectal examination refused by patient
rectal vault
stool guaiac-negative/positive
tarry stool
vault empty


Genitalia/Pelvic:
adnexa
Bartholin's gland
BUS (Bartholin's, urethral, Skene's) glands
chandelier sign
chordee
circumcised
epididymis (pl. epididymides)
epididymitis
glans
glans clitoridis
glans penis
hernia (direct/indirect/sliding)
herpes/herpetic lesions/herpes zoster
herpes simplex virus (HSV)
labia
labia majora
labia minora
lochia
menarche
normal for age
normal male/female genitalia
normal postmenopausal
parous
penis
perineal [NOT peroneal]
perineum [NOT peritoneum]
phimosis
scrotum
Skene's gland
status post orchiectomy
Tanner Developmental Scale
Tanner growth chart
Tanner stage I (II, III, etc.)
testes/testicles descended
testis (singular)
uncircumcised
undescended testicle
uterus
uterus anteverted/retroverted
uterus six weeks' size
vagina
vaginal discharge
venereal warts
verruca acuminatum (venereal wart)
vulva




Neurological examination:
ankle jerks
aphagia
aphasia
asymmetry
ataxia
ataxic gait
Babinski sign (negative/positive/withdrawal/equivocal)
Bell's palsy
cerebellar
confrontation
coordination
corneal reflex/response
cranial nerves II through XII grossly intact
deep tendon reflexes
doll's eye reflex/sign
dysarthria/dysarthric
extrapyramidal
face symmetric
facial droop
facial strength and sensation
festinating gait
finger-to-nose
flattening of the nasolabial fold
flexors downgoing
foot drop
gag reflex
gait - ataxic, athetotic, broad-based, dropfoot,
dystonic, equine, festinating
gait and station
gaze preference
heel-to-knee-to-shin test
hemiparesis
hemiplegia
homonymous field defect
homonymous hemianopsia
intention tremor
knee jerk
light touch
meningeal sign
Moro's sign or reflex
motor power
motor or sensory deficits
muscles of mastication
no meningeal sign
nonfocal
noxious stimulation
nystagmus
oculocephalic maneuver
paresthesias
pinprick
plantar flexion
plantar reflexes (downgoing/upgoing/equivocal/withdrawal)
plantars 2+ and equal bilaterally
position
posturing
proprioception
rapid alternating movements
Romberg's sign
suck and grasp
speech (fluent, dysarthric)
station
strength and sensation intact
straight leg raising positive (negative) at 45 degrees
tandem walk
temperature sense
titubation (head or trunk tremor)
tongue protrudes in the midline
vibratory sense
visual field
visual fields are full
withdrawal (on plantar or Babinski testing)


Mental Status:
affect
affective
alert and oriented x 3
alert and oriented to person, place and time
Axis I: Clinical disorders, syndromes and/or other areas of concern
Axis II: Personality disorders and mental retardation
Axis III: Medical conditions (which may impact emotions)
Axis IV: Psychosocial stressors (death, divorce, loss of job, etc.)
Axis V: Global assessment of functioning.
dangerous ideation
delusions
depression
flat affect
flight of ideas
grandiose/grandiosity
hallucinations
homicidal ideation
ideas of reference
ideation
insight and judgment
memory - immediate/recent and remote
pressured speech/pressure of speech
psychomotor agitation/retardation
psychosocial stressors
social judgment
stressors
suicidal ideation/suicidality
tangential/tangentiality

discharge summary

DISCHARGE SUMMARY

ADMITTING DIAGNOSIS: Large colloid goiter.

FINAL DIAGNOSIS: SameLarge colloid goiter.

PROCEDURE: Total thyroidectomy.

COMPLICATIONS: Bibasilar discoid atelectasis with probable pneumonitis.

HISTORY: This is a 68-year-old woman who was seen probably about three years ago, with pale a large colloid goiter. She was going to have surgery then but declined, and came back in more recently because of the increasing size of the goiter and the pressure symptoms in her neck and throat. Studies previously done showed this to be a non-toxic goiter. She was essentially euthyroid. Because of its increasing size, the possibility of malignancy had to be considered.

PHYSICAL EXAMINATION: Was Physical examination was not remarkable except the patient is being somewhat overweight and the large goiter which was visible and the right side being larger thatthan the left. The patient, because of religious customs would not allow pelvic or rectal examination.

Following surgery the patient had no problem speaking. He She is swallowing and eating solid food. Throat is sore. She did develop a temperature up to 101 and had some ronchirhonchi in both bases on auscultation.

Chest x-ray shows discoid atelectasis with probable pneumonitis. Her white count was elevated at a little over 12,000 with a left shift. Temperature this morning iswas 100 degrees. The wound is clean and dry. The drain has been removed, and ½one-half of the staples are removed. She will be continued on Tetracyclinetetracycline 500 mg q.i.d., and she iswas instructed to take her Lanoxin daily and her Dyazide as well. We are giving her Synthroid, and she is to take that every day. I have stressed the importance to her son of taking the Synthroid, as she should have no thyroid function. Her calcium was 8.6.

end of report

DISCHARGE SUMMARY

This was one of several admissions for the threethis nearly 3-year-old boy for bilateral inguinal hernia repairs. Impression for this nearly three-year-old boy for bilateral inguinal hernia repairs. Swelling in the left groin was noted several weeks prior toat admission. He has had pains in the groins on and off.

He is was found to have bilateral inguinal hernia repairs. The child is also followed because of congenital Addison’s disease. He is on Cortef and Florinef acetate. Acetate.

Because of the Addison’s disease, he iswas treated with cortisone acetate IM, 50 mg on admission, and
Solu-Cortef 50 mg IM one hour prior to surgery. A 50 mg of Solu-Cortef was ranrun during the surgery. Four hours after completion of the surgery, he received
12.5 mg of Solu-Cortef IM.

LABORATORY DATA: Hemoglobin 12.1. WBC 5,500. BUN 18 and electrolytes 140, 3.9, and 23.

DISCHARGE DIAGNOSIS:
1. Addison’s disease.
2. Bilateral inguinal hernias.

DISCHARGE MEDICATION: IncludedDischarge medication included only his usual medications for Addison’s disease.


end of report

DISCHARGE SUMMARY

ADMITTING DIAGNOSIS:
1. Diabetic Kioacidosisketoacidosis – mild to moderate in severity.
2.Type 1 Diabetes Mellitus.
2. Type 1 diabetes mellitus.
3. Bronchitis and gastroenteritis.
4. Mild dehydration.

DISCHARGE DIAGNOSIS:
1. Diabetic Kioacidosis – ketoacidosis –resolved.
2.Type 1 Diabetes Mellitus.
2. Type 1 diabetes mellitus.
3. Bronchitis and gastroenteritis.
4. Mild dehydration.

ADMITTING HISTORY AND PHYSICAL EXAMINATION: Physical findings - theFINDINGS: The patient is a 17-year-old white female, with eight 8-year history of type 1 diabetes, now on 14 units of old Proventil, Ultralente insulin and 13 units of regular Humulin q.a.m.,.; 12 unitunits of regular Humulin q. noon,; 14 units of old ProventilUltralente and 14 units of regular Humulin q. p.m. Who., who insists she is has been taking her insulin regularly andbut complains of two 2-to three weeks 3-week history of cough with yellow phlegm for two2 days and emesis and abdominal pain for the day prior to admission.

LABORATORY DATA: Atrial: Arterial blood gases ph: pH 7.2, APC 28, PCO2 29, PO2 85, bicarbonate 13, glucose. Glucose 626, urinalysis. Urinalysis unremarkable.

HOSPITAL COURSE: The patient was admitted to the medical floor and given I.V. insulin bolus of 10 units of regular and then placed on an insulin drip. Blood sugar rapidly normalized and her bicarbonate gradually rose to a level of 25. She was given IV fluid hydration with normal saline and potassium chloride initially. She received dietary counseling before discharge. She seemed to understand the instruction adequately. ForHer fasting blood sugar on the day of discharge and on her usual insulin dose was a 130. This was on a 2,000 -calorie ADA diet (patient states she had been taking a 2800 -calorie diet).

DISPOSITION: Discharge Discharged to home.

MEDICATIONS: Patient to continue the usual out-patient insulin dosage regimen. EpizoneAmpicillin 500 mg q.i.d. x 10 days. Patient was instructed to stop or minimize her smoking. She will see her endocrinologist in one week and will be seen by me in two2 weeks, as she has recently moved to this area. We wereShe was instructed to call upif blood sugarsugars run less than 80 or greater thatthan 300 –- she will be checking thisthese at home.


end of report

DISCHARGE SUMMARY

ADMITTING DIAGNOSIS: Cystocele with urinary incontinence.

FINAL DIAGNOSIS: Cystocele with urinary incontinence.

PROCEDURE: Anterior repair.

COMPLICATIONS: None.

HISTORY: This is a 65-year-old woman who had had a previous history of hysterectomy, who developed urinary incontinence, and was found to have a large cystocele.

Physical examination was unremarkable except for the cystocele.

Lab work, including a panel, CBC, EKG, and chest x-ray were, was essentially within normal limits.

Following surgery, the patient has done well. The vaginal pack iswas removed this date and a the Foley catheter. She will be checked for residual. If the residual is over 150 cc, the Foley will be replaced, and the patient taught to use athe catheter plug, and she will be discharged. She will be seen in the office in approximately one week for follow-up.


end of report

DISCHARGE SUMMARY

This patient was brought to the hospital outpatient ambulatory care center. The patient was brought to surgery, where she underwent arthroscopy of the right knee.

Arthroscopy of the right knee revealed the following problems. The patient was noted to have an acute hemarthrosis of the right knee. She was also found to have a partial tear of the anterior cruciate. An osteochondral fracture of the lateral femoral condyle was also present.

The patient did undergo a debridement of the right knee and also underwent an osteochondroplasty of the lateral femoral condyle.

The patient was then placed into a long leg immobilizer for the right leg.

The patient was fFurther mobilized with crutches when she awakened. She was able to be discharged from the hospital on the same day.

FINAL DIAGNOSIS:

1. Partial tear, anterior cruciate, right knee.
2. Osteochondral fracture, femoral condyle, right knee

The patient will require a healing period, as well as a rehabilitative exercise program for the right knee. A temporary total disability time of eight weeks is anticipated.

end of report

DISCHARGE SUMMARY

FINAL DISCHARGE DIAGNOSIS:
1. Cytomegalovirus retinitis, left eye
2. Molluscum contagiosum

HOSPITALIZATION: This 36-year-old white male with positive HIV antibody, acquired immune deficiency syndrome and prior Ppneumocystis carinii pneumonia was admitted to the hospital with progressive deterioration of vision in his left eye due to cytomegalovirus retinitis. After informed formal consent was obtained, the patient was started on antiviral therapy with gGanciclovir. At the time of initiation of therapy, the patient’s CBC showed hemoglobin of 11, hematocrit of 32.8, white blood cell count of 1600 with 41 6segs, one band, and platelets 158,000., Serum creatinine count was 1.0, and BUN was 8., Lliver function tests were normal.

Patient was given gGanciclovir 5mg/ per kg, twice a day. After two days of therapy, the patient’s WBC had dropped to 1600 with 28% segs 6,. Then again,and the gGanciclovir was held for 36 hours. Following this, his white blood cell count recovered well enough so that the Gganciclovir was re-started at the same dose. He received subsequent three days of gGanciclovir therapy in the hospital.

Prior to discharge, his final WBC was 1900 with 63% segs 6 and 2 bandsBUNs. Hhemoglobin was 11.9,. Hhematocrit, 35.6,. Pplatelets, 158,000.

Additional laboratory values showed negative serum RPR and negative tToxoplasma anti-body.

The patient was discharged to complete Gganciclovir therapy for two weeks at home.

DISCHARGE MEDICATION: Include Gganciclovir 300mg I.V. q.12h.rs for 14 days. pPentamidine aerosol 150 mg twice a month, Nizoral 200mg p.o. p.r.n.

I will see the patient back in the office in and follow-up in two weeks. Also, while the patient was in the hospital, he was seen in dermatology consultation and had cryotherapy to remove several lesions of molluscum contagiosum from the patient to affirm his face flies.


end of report

Cardiovascular

CHART NOTE

This 45-year-old woman went in four years ago because of a bad virus infection. At that time, serum cholesterol was 292. She was given niacin in doses of 2000 mg daily, and it dropped only to 262 with HDL of 62. Has a ten-year history of reactive hypoerglycemia, which has improved with diet and supplements. Has a six-month history of insomnia., Ggets “weepy” premenstrually.

ALLERGIES: Codeine.

REVIEW OF SYSTEMS: Has some bloating after meals and excess access flatus. Has urinary frequency, and has extremely cold extremities where she has to wear gloves in the house during the winter.

FAMILY HISTORY: Mother had valvular heart disease, colitis and gallstones. Father had heart attack and kidney stones. Brother has stomach problems. Mother has glutteon sensitivity.

HABITS: Drinks coffee and rare alcohol. Diet is balanced.

ASSESSMENT:
1. Borderline hypercholesterolemia with adequate HDL.
2. Reactive hypoerglycemia.
3. Insomnia.
4. Premenstrual syndrome.
5. Tinnitus related to diet.
6. Cold extremities and dry skin.
7. Seborrheic dermatitis.


end of report


September 10, 2005


Name
Address
Makati City 14344

Re: Pedro Cruz

Dear Sirs:

Mr. Pedro Cruz was admitted at 1700 hours after having had an episode of weakness following GI bleeding approximately three weeks earlier. He was seen by the ambulance people, and was in a rapid heart beat, . tThe exact nature which we do not know, but at any rate Xylocaine was started, and by the time he reached the emergency room, his heart rate was between 75 and 80 with a sinus rhythm. He had excellent ST segments and upright T waves.

When I saw him, his blood pressure was 166/88. Hhis pulse was 75 with a regular sinus rhythm. He had a good carotid pulse bilaterally. His lungs were clear. The heart was not enlarged. There were no murmurs.

He was started on cardiac monitor., Aa chemistry panel was drawn, and the only abnormal finding was a BUN of 22.4.

He was observed closely for any ST or T wave change, and there was none. He had no episode of hypotension. , and T there was no reason to do any cardiac enzyme studies. He did have a follow-up upper GI done because of his bleeding in late June, and this was reported as negative.

There was no further pain,. tThere was no further arrhythmia, and at no time were there any was ST or T wave changes present. I had no reason to do cardiac enzymes, and when I found that his GI track was stable, and that his upper GI did not reveal any new bleeding, and there was no drop in his hemogram, I discharged this patient to be followed by his regular physician.

I hope this information will be of help.

Sincerely,

end of report

INITIAL OFFICE EVALUATION

This 58-year-old female noted a sensation of “shortness of breath” in the high substernal region of the chest. She also describes this as a feeling of “heaviness” or “pressure.” I believe that this sensation is more consistent with angina than true air hunger. The sensation lasteds for about 20 minutes. The patient did not have any radiation of herreduced discomfort, and there were no associated symptoms, other that the shortness of breath as described.

PHYSICAL EXAMINATION:
NECK: The neck is supple without masses. The thyroid gland is not enlarged. The carotid arterial pulsations are equal and full. There are prominent, normal jugular venous pulsations with the patient in the supine position. There is a venous hum on the left, which obliterates easily with minimal pressure on the neck.
CHEST: The chest is symmetric with equal respiratory excursions. There is no thoracic deformity or tenderness. The breasts are normal and free of masses or tenderness.
HEART: There is no visible or palpable precordial activity. The first heart sound is normal in and character and in intensity. The second heart sound is also normal in intensity, but I was unable to appreciate splitting of the second sound. No third or fourth sound was present. The cardiac rhythm is regular, and there is a grade III/VI systolic ejection murmur that is loud at the second left intercostal space. This murmur decreases in intensity markedly with Val Salva maneuver. The murmur does not radiate to the neck.
LUNGS: The lungs are clear to auscultation and percussion, and diaphragmatic motion appears normal.
EXTREMITIES: The extremities are free of cyanosis, clubbing, or peripheral edema. There are bilateral soft femoral bruits. The left femoral artery has a 4+ pulsation, and the right femoral artery has only a 1+ pulsation. Nevertheless, the more distal pulses are normal and symmetric, including the popliteals, dorsalis pedis, posterior tibial pulses.

ELECTROCARDIOGRAM: The ECG reveals normal sinus rhythm. There are T wave inversions that are symmetric in leads V1 through- V3, and lead V4 has a very flat T wave. This pattern is consistent with anterior myocardial ischemia.

ASSESSMENT: This patient has a history which is consistent with angina pectoris. This is associated with an abnormal electrocardiogram that is apparently changed from a previous tracing. The ECG reveals T waves abnormalities consistent with anterior myocardial ischemia. I think that it would be appropriate to perform cardiac catheterization rather than stress testing, since the electrocardiogram has already shown us a signs of ischemic heart disease.

The patient also has a rather loud heart murmur which may be functional, but I have ordered an echo cardiogram to see if this can be further defined.

end of report


HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT: Pain in the chest.

HISTORY OF PRESENT ILLNESS: This is a 40-year-old gentleman referred to this office because of pain in the chest. He states that this pain has been present in the area for some time. The pain is radiating in nature, and the patient is worried about it.

PAST MEDICAL HISTORY: There is no diabetes or history of rheumatic fever in the past. The patient says, “I am really pretty healthy.”

SOCIAL HISTORY: He is a one-pack-a-day cigarette smoker. EtOH intake is negative.

FAMILY HISTORY: His parents both died as a result of strokes. There is no known family history of heart disease.

PHYSICAL EXAMINATION:
NECK: The neck is supple. There are no carotid bruits.
CHEST: Lungs are clear to percussion and auscultation.
HEART: PMI is not displaced. PMI is in the fifth intercostal space. There is no thrill, heaves, gallop, rub or murmur.

LABORATORY DATA: The electrocardiogram is within normal limits.

The patient was subjected to a treadmill stress test. Using the protocol of Ellestad, he reached a maximum pulse rate of 150, which was 93% of his maximum predicted heart rate. There were no abnormalities noted before the exam, there were no abnormalities noted during the exam, nor after the exam. He had a good response to all phases of this testing.

DIAGNOSIS:
1. Chest pains, not on a cardiac basis.
2. Possible musculoligamentous sprain in the costal area.
3. Some risk factors for cardio vascular disease, including heavy cigarette smoking.

DISCUSSION: I find no frank evidence of cardiac problems in this gentleman; however, I believe with some modification of his lifestyle, including the discontinuation from smoking and loosing several pounds of weight, he can enjoy good health for many years. As noted above, his treadmill stress test was interpreted as being completely normal. The patient’s present episode of chest pains are probably only on a musculoskeletal basis and are to be treated with oral analgesics, such as aspirin or perhaps Parafon Forte.


end of report

CHART NOTE

This 19-year-old male presented with an acute onset of left- sided of chest pain. His electrocardiogram done in the office today is entirely within normal limits, and there is no suggestion of pericarditis on the EKG.

The physical exam shows no rub and no pathologic heart sounds.

I would suspect that he has no organic heart disease.

I have recommended that he takes the a rest, a week off from work, and return for follow-up treadmill stress test. If this is normal and he is symptom-free, he may return to work.

IMPRESSION: Chest pain probably musculoskeletal in origin.

end of report

CONSULTATION

It was my pleasure to see this very pleasant 58-year-old white male for evaluation of chest tightness. He has had the symptoms of tightness across the anterior chest which occasionally radiates into both the right and left pectoralis areas and into the shoulders.

The patient does have multiple risk factors for a coronary artery disease. He was told eight years ago that he had elevated blood pressure, and he was advised to start a low-fat and low-salt-diet at that time. He did not go back to his doctor for follow-up blood pressure measurements. He also recalls having an elevated cholesterol at that time.

More rRecently, he had a B/P of 168/96 when he was seen at your office for treadmill exercise test. He smoked two-pack-a-day for some 30 years, but stopped six years ago upon his retirement. A recent cholesterol was 268.

I did review the treadmill exercise test from your office. IWe agreed that the patient had a positive treadmill exercise test with symptoms of typical angina pectoris starting at stage two of the exercise test, and 1mm horizontal ST segment depression in and lead V5 at stage three of the exercise test.

PAST MEDICAL HISTORY: The patient has had probable hypertension and hypercholesterolemia of 8 years’ duration. He was told that he hads some narrowing of the carotid arteries several years ago when he was initially seen by you.

This patient has no previous surgery.

PHYSICAL EXAMINATION:
VITAL SIGNS: B/P, 174/94. Pulse, 76,. rRegular. Rrespirations are normal.
NECK: There is a sSoft bruits over the entire right carotid artery, and a soft bruit at the base of the left carotid artery. There areis no bruits over the subclavian arteriesy.
CHEST: Clear to percussion and auscultation.
CARDIOVASCULAR SYSTEM: The PMI is in the fifth intercostal space at the MCL. The left LV impulse is normal. The rhythm is regular with no premature beats. S1 and S2 are normal. There was is no S3, S4 or gallop. There is a soft grade II/VI systolic ejection murmur heard at the second right and left intercostal space, left stexternal border, and cardiac apex. There is no diastolic murmur.

ASSESSMENT: The patient is a 58-year-old white male who has a stable angina pectoris for 3 years’ duration. His symptoms of are substernal tightness which but ocrecurs with exertion, and which is relieved promptly by rest, this typical of angina pectoris. This is confirmed by your treadmill exercise test, which shows a definite ST segment abnormalitiesy consistent with myocardial ischemia at stage 3 of the exercise test. In addition, the patient has a multiple risk factors including hypertension, hypercholesterolemia and past history of smoking.

I believe the patient should be given a trial of medical therapy for angina pectoris. Anticipate that the patient will have a good response to medical therapy, and that he has a relatively good prognosis. I have started the patient on Cardizem 60mg p.o. tp.i.d which may be increased to a higher dose if he is able to tolerate the medications. This would be helpful for treatment of both in angina pectoris and hypertension. The patient is already taking aspirin three times a week when he plays golf, and this wshould be sufficient. It may be necessary to add other anti-hypertensive medications for better control of his blood pressure. I have asked the patient to return to my office in two weeks to assess the patient’s tolerance to the medication, and to see if he is having adequate antianginal response.

If the patient continues tends to have symptoms of grave exertional angina pectoris on good antianginal medical therapy, then I would be much more concerned that if the patient has significant high-grade stenosis, and he should undergo a coronary angiography study at that time.

FINAL IMPRESSION:
1. Stable angina pectoris.
2. Hypertension.
3. Atherosclerotic peripheral vascular disease.

Again, thank you for asking me to see this patient in for consultation.

end of report

CHART NOTE

The patient is a 67-year-old female who speaks a small amount of English. Patient was seen in my office for her scheduled office treadmill stress test.

However, on examining the patient, and getting the history through an interpreter, we found that the patient has a two-hour chest pressure two days prior to the stress test, and EKG was done in the office which showed new T wave inversions in the inferior anterior leads. The patient has had T wave inversions in the anterior- lateral leads in the past, but the new inferior wall T wave inversions were new. It was felt since patient had two-hour chest pain with new EKG changes, she should not have the a treadmill.

Patient has been on Inderal 10 mg p.o. b.i.d. for a prior her history of hypertension. She denies any shortness of breath, diaphoresis, PND or orthopnea. There is no history of occult bleeding. No history of anemia.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 140/90. Pulse, 60 and regular. Respiratory rate, 20, unlabored. Temperature, afebrile.
HEENT: Was within normal limits.
NECK: Supple, without jugular venous suspension, without carotid bruits, and Nno lympadenopathy is present.
CHEST: Dry rales in both bases, without whizzing or rubs . Ppresent. Bbreath sounds are adequate.
HEART: Heart is regular rhythm without murmur, gallop or rub.
ABDOMEN: Soft, nontender, without organomegaly.
EXTREMITIES: Without No clubbing, cyanosis or edema.

ELECTROCARDIOGRAM: Electrocardiogram shows a regular sinus rhythm with
ST- T waves changes consistent with ischemia versus over subendocardial MI.

IMPRESSIONS:
1. Atherosclerotic Arteriosclerotic coronary artery disease.
2. Unstable angina, and rule out MI.


end of report

SAMPLE REPORTS

07/27/04
William Seal #436383

S: Mr. Seal is a 57 y/o who presents with discomfort in his groin and right testicle. He has had pressure in his groin for 5 days. No bulging in the area. No urinary symptoms. No fever. He has had dizziness when he took Cipro in the past. He has been eating well. No nausea or vomiting. Overall, his red eyes have been improving. He has not had any injury to the area.
O: Vital signs as noted. In general, Mr. Seal is pleasant, overweight and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally with normal respiratory effort. Extremities no edema. No testicular mass or hernia. He has tenderness to palpation over the epididymis on the right. There is no mass on the testicles. Rectal exam: Reveals boggy, tender prostate with no mass. Normal tone.
UA is negative.
A/P: Probable prostatitis: Given his Cipro allergy, we will use Septra DS 1 p.o. b.i.d. for 2 weeks. This will also cover for epididymitis, given his tenderness in the area. We talked about the normal course of these illnesses. He knows to call if not improving.


07/27/04
Paul Dyson #52785

S: Mr. Dyson is a 46 y/o who presents for f/u of diabetes. Overall, he has been feeling much better. He has been following a reduced carbohydrate diet and his insulin requirements for sliding scale have dropped dramatically. His blood sugars have been running well. He is under 400 lbs. for the first time in a long time. His energy level has increased. He is taking the stairs at work more often. He has not gotten on a regular exercise program. He is tolerating Pravachol 40 mg q.h.s., while Dr. Tilley is following both his INR on Coumadin, and his liver, and cholesterol testing. He has had rare symptomatic hypoglycemia. He has not checked his blood pressure outside of the office. He started Lamisil for onychomycosis but stopped it when he was hospitalized for the PE.
O: Vital signs as noted. In general, Mr. Dyson is pleasant, obese and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally, normal respiratory effort. He has thickened toenails bilaterally. Trace edema in the lower extremities. Normal sensation to light touch except for the right great toe.
A/P:
1. Diabetes mellitus, type II with improved control: We will check a hemoglobin A1c and a BMET today. And f/u with him regarding the results. He will continue Actos 45 mg q.d., Glucophage 1000 mg b.i.d., Lantus 50 mg q.h.s. with sliding scale Humalog.
2. Onychomycosis: I refilled Lamisil and he is going to restart this. I checked to make sure there are no interactions with Coumadin.


07/27/04
Gloria Green # 41495

S: Ms. Green is a 43 y/o who presents to f/u abdominal pain with nausea for greater than 6 months. She has had difficulty eating due to nausea. She has had burning stomach pain. She is on chronic narcotics due to intractable migraine headaches. Her pain has been in the upper and lower abdomen. She uses 50 mg Phenergan approximately 4 times a day. She has difficulty holding her medicines down. Her pain is worse when she eats. She was seen 6 days ago and given Protonix and a GI referral. The appointment is for August 23rd. She has been taking Protonix daily. No fever. She has had decreased appetite with weight loss. No blood in the stool.
O: Vital signs as noted. In general, Ms. Green is pleasant and in no acute distress. She is tearful during the interview. Mucous membranes moist. Conjunctivae are clear. Heart RRR, no murmur. Lungs CTA bilaterally, normal respiratory effort. Extremities no edema. Abdomen soft, positive bowel sounds with tenderness in the epigastric region to deep palpation. She also has tenderness in the bilateral lower quadrants with no rebound or guarding.
A/P: Greater than 6 months of abdominal pain and nausea with recent weight loss: An injection of Phenergan 50 mg was given in the office today. We will have her take Protonix b.i.d. She has also been having a lot of burning in the chest area, which is consistent with reflux. I gave her Carafate 10 cc p.o. q.i.d. p.r.n. We will try to move up her GI appointment. Also, Levsin 0.125 mg 1-2 sublingual q. 6h. p.r.n. for symptomatic relief. For abdominal pain, we will check a CBC with diff and a C-MET today. She knows to call for signs of worsening or unresolved illness.

06/17/04
David Brandon # 57279
S: Mr. Brandon is a 43 y/o who presents to establish care and for a complete physical exam. He has some skin lesions on his chest which he wanted to get checked out. They have been there for several years. He has not noticed them growing. He takes no regular medication. He has no known drug allergies.
PMH: Broken arm, kidney stone x2 , nystagmus.
SURGICAL HISTORY: None.
SOCIAL HISTORY: He is an applications engineer. He has two children. He is married. He drinks rare alcohol. No smoking.
FAMILY HISTORY: His dad died at age 76 with heart disease. His mom is living at 69. He has a family history of heart disease. No family history of colon or prostate cancer.
ROS: He began working out regularly in November and this has helped his overall well being. He was dealing with some anxiety which resolved once he started exercising. He eats fastfoods a lot and has not been focusing on his diet much. He has had some difficulty obtaining and maintaining erection. Otherwise, 12-point review of system is as above otherwise unremarkable.
O: Vital signs as noted. In general, Mr. Brandon is pleasant and in no acute distress. He has horizontal nystagmus. Funduscopic exam normal. Tympanic membranes normal bilaterally. Oropharynx clear without exudate. Heart RRR, no murmur. Lungs CTA bilaterally, normal respiratory effort. Abdomen soft, nontender, positive bowel sounds, no organomegaly, no mass. Extremities: No clubbing, cyanosis or edema. Cranial nerves II-XII are intact. He has a benign appearing hemangioma. He has a skin tag on the left chest. Normal male external genitalia. No testicular mass or hernia. Normal strength and sensation to light touch, pulses and reflexes in the upper and lower extremities bilaterally.
A/P:
1. Complete physical exam: I encouraged focusing on heart healthy diet. I encouraged continued regular exercise. I reassured him about the benign appearing moles on his chest. We will check a CBC with diff, C-MET, lipid panel today.
2. Erectile dysfunction: We will check a free and total testosterone. I gave him samples of Viagra 50 mg to be used one tablet 30 minutes to one hour prior intercourse.
3. Nystagmus with recent visual changes: I recommended evaluation at Southeastern Eye Center.
Greg Perry, M.D


06/18/04
Robert Franklin # 15833
S: Mr. Franklin is a 52 y/o who presents to f/u hypercholesterolemia and to discuss erectile dysfunction. He has a history of SVT, a beta-blocker was recommended. Ablation was offered. He uses Xanax p.r.n. for symptoms and this seems to do well but he does not take Xanax frequently. He takes Prilosec on a regular basis. His GERD symptoms returned when he tried to go off of the Prilosec. He has had some recent problems obtaining and maintaining an erection. This problem seemed to start around the time he started Lipitor, so he is wondering if this could be related. He does not take nitroglycerin but he does report having a mildly abnormal stress test in the past. He smokes cigars. He has been better with exercise recently. He tried the Atkins diet.
O: Vital signs as noted. In general, Mr. Franklin is pleasant, overweight and no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally, normal respiratory effort. Extremities no edema.
A/P:
1. Hyperlipidemia: We will check a fasting statin panel today. We will continue Lipitor 20 mg q.h.s., a prescription was provided.
2. GERD, well controlled: Continue Prilosec.
3. Erectile dysfunction: We will check a free and total testosterone today. We will find out more about his cardiac workup prior to using a medicine like Viagra, although, this would be a rare side effect; the symptoms started when he started the Lipitor. We could consider a trial off of Lipitor.


Greg Perry, M.D.

07/27/04
Ernestine Edmondson # 17796

S: Ms. Edmondson is a 55 y/o who presents with a burn on her right hand. She burned her hand on a coffee pot late last week. She called the on-call doctor over the weekend and he called in Silvadene 1% cream, which she has been using twice a day. She has been using gauze on the area. She has had decreased drainage recently. She has throbbing pain, which has not improved with the Lorcet that she takes for her chronic back pain. She has difficulty sleeping due to the pain.
O: Vital signs as noted. In general, Ms. Edmondson is pleasant, overweight and in no acute distress. She has a second-degree burn on the dorsal aspect of the right hand with erythema and warmth of the burn and the surrounding tissue. Normal grip strength. There is mild edema in the right hand.
A/P: Second-degree burn with cellulitis: We will use Keflex 500 mg t.i.d. for one week. Also,
oxycodone 5/325 one p.o. b.i.d. p.r.n. for breakthrough pain #12 no refills. She will f/u with Dr. Harris in one week, sooner as needed.


Greg Perry, M.D.
08/13/04
Lisa Killen #38752
S: Ms. Killen is a 38 y/o who presents to discuss cough with shortness of breath. She started coughing yesterday. Three days ago, her left ear had some drainage. She has a history of tympanic membrane perforation on both side. No ear pain. She used an old albuterol, which she had at home which did seem to help some of her symptoms. The left side of her throat was sore yesterday, but it is somewhat better today. She feels irritation in the right side of her chest. No known drug allergies. No fever. She slept sitting up last night. She continues to smoke.
O: Vital signs as noted. In general, Ms. Killen is pleasant, obese and in no acute distress. Tympanic membrane is normal. Oropharynx is mildly erythematous without exudate. Neck is supple with shotty cervical lymphadenopathy. Heart RRR, no murmur. Lungs are CTA bilaterally. Extremities no edema.
Rapid strep is negative.
Chest x-ray shows possible early pneumonia in the left upper lobe of the lungs.
A/P: Cough with shortness of breath: Given her abnormal chest x-ray, will cover for pneumonia with Tequin 400 mg p.o. q.d. x 10 days. Also prescribed Hycodan one tsp p.o. q6h p.r.n. and albuterol 2 puffs t.i.d. p.r.n. She knows to call if not improving.


Greg Perry, M.D.
08/13/04
William Hege #56679
S: Mr. Hege is a 69 y/o who presents to discuss an ulcer on his leg, as well as leg swelling. He has a history of chronic venostasis in the left lower extremity. He noticed increased swelling recently. He takes the Demadex only occasionally. His wife put some pressure dressing on the leg, which seemed to help some. There is a blister on the leg that puffed and has caused an ulcer that began five days ago. It seems to be getting bigger, no pus drainage or surrounding warmth or erythema. No fever.
O: Vital sign as noted. In general, Mr. Hege is pleasant, obese and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally. There is significant pitting edema in the left lower extremity with chronic venostasis changes. There is an approximately one and a half cm well-circumscribed superficial ulceration in the left lateral calf with no pus drainage or surrounding warmth or erythema.
A/P: Left lower extremity edema with chronic venous stasis and new ulceration. An Unna boot was applied today. I encouraged him to take the Demadex each day as prescribed. He will f/u in one week with Dr. Harris sooner as needed.


Greg Perry, M.D.

06/15/04
Vikram Kapil # 50060
S: Mr. Kapil is a 41 y/o who presents for a complete physical examination, as well as to discuss left ankle pain and indigestion. For several months, he has had indigestion. His stomach feels full, it is worse with spicy food. He does have frequent burning sensation in his chest. He has felt full earlier than usual for approximately one year. He has not tried any medicines with this. Three days ago, he rolled his ankle when he was walking. He has continued to have pain and swelling. He takes no regular medicines. He has intolerance to guaifenesin.
SURGICAL HISTORY: Ingrown toenail.
SOCIAL HISTORY: He exercises about once a week. He has begun to focus more on eating a healthy diet. He works as a lawyer. He is a public defender. He is married with two children. No smoking. No alcohol.
FAMILY HISTORY: His dad has heart disease and diabetes. His maternal grandfather had a CVA. Mom with gout. No family history of prostate cancer or colon cancer.
ROS: 12-point review of system is as above otherwise unremarkable.
O: Vital signs as noted. In general, Mr. Kapil is pleasant, overweight in no acute distress. Conjunctivae are clear. Funduscopic exam is normal. Tympanic membranes normal bilaterally. Oropharynx is clear without exudate. Neck supple without lymphadenopathy or thyromegaly. Heart RRR, no murmur. Lungs CTA bilaterally with normal respiratory effort. Extremities no clubbing, cyanosis or edema. Except for edema of the left ankle, he is tender to palpation above the lateral malleolus. Left, no ankle ligamentous laxity. Abdomen overweight, soft, nontender, positive bowel sounds, no organomegaly, no mass. Skin: No suspicious lesions or rashes. Cranial nerves II-XII are intact. Normal strength and sensation to light touch. Pulses and reflexes in the upper and lower extremities bilaterally. Normal male external genitalia. No testicular mass or hernia.
A/P:
1. Complete physical exam: We discussed the need for weight loss. I gave him the AFP handout about weight control. Encouraged increase frequency of regular exercise and heart healthy diet. I reviewed his lab work with him.
2. Probable GERD: We will use Protonix 40 mg q.d., samples and a prescription were given. If he has complete resolution of symptoms, he can give a trial off of the medicine in 8 weeks. If his early satiety does not improve, we can consider gastroenterology referral.
3. Left ankle injury: Given his bony tenderness, we will obtain x-rays to rule out fracture. If this is normal, we will fit him for lace of ankle brace. Encourage rest, ice and anti-inflammatories as needed.


Greg Perry, M.D


John Sheets # 34963
S: Mr. Sheets is a 71 y/o who presents to discuss back and leg pain and f/u diabetes and hypercholesterolemia. He takes Amaryl 2 mg 1/2 tablet each AM. He takes 1/2 tablet of Pravachol each day. His blood sugars have been in the 90s in the morning until recently when they have been higher. He has not checked his blood sugar later in the day. He is not fasting today. He has had right lower back pain for approximately two weeks. For several years, he has had pain in the left mid back with spasm after standing for a prolonged period of time. He has had continued abdominal pain and requests referral back to Dr. Buccini for further evaluation. He did not have any particular trauma or injury to the right lower back. He has pain that goes down his leg on the right. He did have a similar problem several years back.
O: Vital signs as noted. In general, Mr. Sheets is pleasant but uncomfortable appearing. Heart RRR, no murmur. Lungs CTA bilaterally with normal respiratory effort. He has tenderness to palpation in the lumbar musculature on the right. He walks with a limp. Normal strength sensation to light touch and pulses in the lower extremities bilaterally. Straight leg test is positive.
A/P:
1. Diabetes mellitus, Type II: Hemoglobin A1c today is 8.8. I encouraged focus on diabetic diet. We will increase Amaryl to 4 mg 1/2 tablet each AM. He will go to a full tablet if his sugars have not improved to within goal within a couple of weeks. I encouraged him to call us with his sugars in 2-3 weeks. I encouraged him to check his sugars several times during the day, rather than just his fasting sugar.
2. Hypercholesterolemia: We will check a fasting statin panel at his convenience. Continue Pravachol 80 mg 1/2 q.d. for now.
3. Acute right low back pain with greater one year of left-sided pain and spasm with prolonged standing: We will obtain a lumbar spine film given the chronicity of the left-sided back pain. We will treat symptomatically with Celebrex 400 mg x1 then 200 mg p.o. q.d. to b.i.d., samples were given. Also, Flexeril 10 mg p.o. t.i.d. p.r.n. and Vicodin 5 mg 1 p.o. q6h p.r.n. #15 no refills. He will use a heating pad to the area. He will avoid heavy bending, lifting or twisting and slowly advance his activity as tolerated. Given his symptoms, nerve root irritation is a possibility. Lumbar strain is highest on the differential. He knows that if worse or not improving, we need to consider further evaluation such as MRI.
4. Continued abdominal pain: We will arrange GI referral at his request.


Greg Perry, M.D

08/13/04
Lourdes Williams #13527
S: Ms. Williams is a 44 y/o who presents to discuss burning with urination and nausea. Her symptoms began yesterday. She has had chills, no blood in the urine, no vomiting. She has had urinary frequency. No known drug allergies.
O: Vital signs as noted. In general, Ms. Williams is pleasant and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally with normal respiratory effort. No costovertebral angle tenderness. Abdomen soft, nontender, positive bowel sounds.
UA is 2+ leukocyte, 1+ nitrite, trace protein with 1+ blood.
A/P: UTI: Given for upper tract symptoms, we will cover with Levaquin 250 mg p.o. q.d. for 7 days. Also Phenergan 25 mg 1/2-1 p.o. q6h p.r.n. She will push fluids and rest and let us know if not improving.

07/27/04
Sue Daughtry # 3365

S: Ms. Daughtry is a 50 y/o who presents with right eye redness and drainage that began yesterday am. She used some leftover Bleph-10 drops that she had at home and has not noticed any improvement. She has kept her contacts out. Her right eye was matted shut this morning. She had a little bit of left eye redness but this has improved. She has been a little bit hoarse today. No nasal congestion. No cough. She has recently been dealing with some right-sided pelvic pain, which her gynecologist feels is a ruptured ovarian cyst. She is allergic to amoxicillin. She is not sure whether she has had fever.
O: Vital signs as noted. In general, Ms. Daughtry is pleasant, well appearing and in no acute distress. Left conjunctivae are clear. Right conjunctivae are injected diffusely. Funduscopic exam is normal. PERRLA. Heart RRR, no murmur. Lungs CTA bilaterally. Oropharynx clear.
A/P: Right eye conjunctivitis: Given the unilateral location and severity, we will cover with Ocuflox
2 drops q4h for 2 days then q6h for a total course of 7 days. She knows to call if not improving. She will keep her contacts out until completely resolved.

Greg Perry, M.D.
07/27/04
Carrie Charles # 36888

S: Ms. Charles is a 36 y/o who presents to discuss possible allergic reaction to Zoloft. She was placed on Zoloft yesterday during the afternoon. She developed dizziness with burning and tingling in her arms and legs. She felt sweaty and clammy that her symptoms did not go away for several hours. She was seen at an urgent care and told to hold the Zoloft. She has had depressed mood with anxiety over the last several months. She has a history of hyperthyroidism. She is now up to 100 mg of Toprol XL, which has also helped her hypertension. She has been under lots of stress. She feels fatigued. She has difficulty sleeping. She takes Xanax 0.5 mg b.i.d. She has been on Zoloft, and Paxil, and Lexapro in the past. She remembers not tolerating them well but does not remember the particular side effects. She has tried Ambien in the past without relief of her insomnia. She finds that her mood symptoms are worse around the time of her menses.
O: Vital signs as noted. In general, Ms. Charles is pleasant, overweight and in no acute distress. No thyroid mass. Heart RRR, no murmur. Lungs CTA bilaterally, normal respiratory effort. Extremities no edema.
A/P: Anxiety with depressed mood and intolerance to multiple SSRIs: We will refer for counseling. I refilled her Xanax 0.5 mg b.i.d. #60 no refills. We will also use Restoril 30 mg p.o. q.h.s. p.r.n. for sleep. She will let us know if not improving. If she does not start to feel better with the above plan, we can arrange psychiatry referral and we did discuss this today.

Greg Perry, M.D.
08/13/04
Je'nai Ge'saussure #47841
S: Je'nai is a 4 y/o who presents with two weeks of deep congested cough. She has also had nasal congestion. Originally, mom thought she was dealing with allergies. She has not had any fever. She has complained of left ear pain. She started to get better and them became worse over the past couple of days. Her PO intake has been normal. No known drug allergies. Positive sick contacts.
O: Vital signs as noted. In general, Je'nai is pleasant and coughing occasionally. Tympanic membranes are normal. Oropharynx is clear. Neck is supple without lymphadenopathy. Heart RRR, no murmur. Lungs CTA bilaterally with normal respiratory effort. Extremities no edema.
A/P: Acute bronchitis: Given the duration of this illness, we will cover with antibiotics. Zithromax 245 cc
1 tsp p.o. x 1 then 1/2 tsp p.o. q.d. days 2-5. Also samples of Levall were given, 1/4 tsp p.o. q6h p.r.n. We talked about the normal course of these illnesses. Mom knows to call if not improving.


Greg Perry, MD


08/13/04
Jimmy Thompson #3889
S: Mr. Thompson is a 56 y/o who presents to discuss an abnormal sensation in his upper abdomen and chest over the past couple of months. He has a history of reflux and still similar to him, he used Zantac with good success in the past. He has a history of hypercholesterolemia and is due for a lipid panel today. His symptoms in his chest are worse as the day progresses. He feels like there is some congestion and he has had some cough. No shortness of breath. He had a negative cardiac workup in the fall of 2003. No fever. He has not had much postnasal drip. He does have an abnormal taste in his mouth and his symptoms seem to be worse after meals. He has tried some Tums, which does seem to help some.
O: Vital signs as noted. In general, Mr. Thompson is pleasant, well appearing and in no acute distress. Oropharynx is clear. Neck is supple without lymphadenopathy. Heart RRR, no murmur. Lungs CTA bilaterally with normal respiratory effort. Extremities no edema. Abdomen is soft, nontender, positive bowel sounds, no organomegaly, no masses.
A/P:
1. GERD: I gave samples of Aciphex 30 mg q.d. If this is working well for him he can fill up a prescription that I gave to him for Protonix. Protonix is a lower tier on his insurance but we did not have samples of Protonix today. I stressed to him the importance of letting us know if not improving, so that we can pursue further evaluation such as a chest x-ray or an empiric trial antibiotics. We did talk about continuing the proton pump inhibitor for approximately two months and then giving a trial off with the medicine.
2. History of hypercholesterolemia: He was doing really good with diet and exercise for a couple of months and then has slacked off as of late. We will check a lipid panel today.


Greg Perry, MD

08/13/04
Sherry Phillips #38605
S: Ms. Phillips is a 33 y/o who presents with cough that started approximately nine days ago and has gotten worse this week. She has fits of coughing especially at night. No fever. She feels drainage in the back of her throat. She has had ear pain. Her cough is occasionally productive. No shortness of breath, no smoking, no sick contacts. She works as a chemist. She has not tried any medicines. No body aches. No foreign travel. She is allergic to penicillin and amoxicillin.
O: Vital signs as noted. In general, Ms. Phillips is pleasant, overweight and in no acute distress. Oropharynx is clear with several postnasal drip. Tympanic membranes normal. Nasal mucosa is mildly erythematous. Neck is supple without lymphadenopathy. Heart RRR, no murmur. Lungs CTA bilaterally with normal respiratory effort. Extremities no edema.
A/P: URI, likely viral: We discussed the normal course of these illnesses. We will treat with Hycodan 1 tsp 1 p.o. q6h p.r.n. for cough. Potential side effects were discussed. If she is going to dose this only at night, we can use Mucinex 2 p.o. b.i.d. p.r.n. during the day. Also albuterol 2 puffs t.i.d. p.r.n. Prescription given and samples of Zyrtec 10 mg q.h.s. She knows to call if her signs are worsening or unresolved illness.


Greg Perry, M. D.


08/13/04
Velma Newsom #28111
S: Ms. Newsom is a 46 y/o who presents for f/u of hyperthyroidism. She was previously on Synthroid
75 mcg each day. She has been out for over a month due to insurance reasons. She is now back on the insurance and will be able to afford medication. She was diagnosed approximately 3-4 years ago. No history of thyroid surgery. She has been very tired for the last month but was tired even before she was off the medicine. She has not been getting much exercise but she does have a gym membership. No shortness of breath, no fever, no smoking, no known drug allergies.
O: Vital signs as noted. In general, Ms. Newsom is pleasant, overweight and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally with normal respiratory effort. Neck is supple without lymphadenopathy or thyromegaly.
A/P: Hyperthyroidism: We will resume Synthroid 75 mcg q.d., samples and a prescription were given. We will plan on checking a TSH with a lab visit in two months. I encouraged her to resume regular exercise, which can be helpful for her overall energy level and she knows to f/u if not improving.


Greg Perry, M. D.

08/13/04
Lisa Killen #38752
S: Ms. Killen is a 38 y/o who presents to discuss cough with shortness of breath. She started coughing yesterday. Three days ago, her left ear had some drainage. She has a history of tympanic membrane perforation on both side. No ear pain. She used an old albuterol, which she had at home which did seem to help some of her symptoms. The left side of her throat was sore yesterday but it is somewhat better today. She feels irritation in the right side of her chest. No known drug allergies. No fever. She slept sitting up last night. She continues to smoke.
O: Vital signs are noted. In general, Ms. Killen is pleasant, obese and in no acute distress. Tympanic membrane is normal. Oropharynx is mildly erythematous without exudate. Neck is supple with shotty cervical lymphadenopathy. Heart RRR, no murmur. Lungs are CTA bilaterally. Extremities no edema.
Rapid strep is negative.
Chest x-ray shows possible early pneumonia in the left upper lobe of the lungs.
A/P: Cough with shortness of breath: Given her abnormal chest x-ray will cover for pneumonia with Tequin 400 mg p.o. q.d. x 10 days. Also prescribed Hycodan one tsp p.o. q6h p.r.n. and albuterol 2 puffs t.i.d. p.r.n. She knows to call if not improving.


Greg Perry, M.D.


08/13/04
William Hege #56679
S: Mr. Hege is a 69 y/o who presents to discuss an ulcer on his leg as well as leg swelling. He has a history of chronic venous stasis in the left lower extremity. He noticed increase swelling recently. He takes the Demadex only occasionally. His wife put some pressure dressing on the leg, which seem to help some. There is a blister on the leg that puffed and has caused an ulcer that began five days ago. It seems to be getting bigger, no pus drainage or surrounding warmth or erythema. No fever.
O: Vital sign as noted. In general, Mr. Hege is pleasant, obese and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally. There is significant pitting edema in the left lower extremity with chronic venous stasis changes. There is an approximately one and a half cm well-circumscribe superficial ulceration in the left lateral calf with no pus drainage or surrounding warmth or erythema.
A/P: Left lower extremity edema with chronic venous stasis and new ulceration: An Unna boot was applied today. I encouraged him to take the Demadex each day as prescribed. He will f/u in one week with Dr. Harris sooner as needed.


Greg Perry, M.D.

08/13/04
Vincent Price #25890
S: Mr. Price is a 39 y/o who presents with two to three weeks of cough. He will have fits of coughing. He has tried Sudafed. He does wake up sometimes at night with coughing. No fever. He does not feel bad. No smoking. No regular medication. He has not had a lot of postnasal drip. No sick contacts. No GERD symptoms. He does occasionally have burp after coughing. No known drug allergies. No smoking. No nasal congestion.
O: Vital signs as noted. In general, Mr. Price is pleasant, well-appearing and in no acute distress. Oropharynx clear. Tympanic membranes normal. Conjunctivae clear. Neck supple without lymphadenopathy. Heart RRR, with no murmur. Lungs CTA bilaterally with normal respiratory effort. Extremities no edema.
A/P: Probable acute bronchitis, suspect mycoplasma. Given the duration of his illness, we will cover with Z-pak. Also Hycodan 1 tsp. p.o. q6h p.r.n. for cough. He knows to call for signs of worsening or unresolved illness. We can consider chest x-ray if not improving.


Greg Perry, M.D.


08/13/04
Cindy Cage #0845
S: Ms.Cage is a 45 y/o who presents to discuss an ulcer on her tongue, knots on her leg, as well as pain on her hand. She has noticed an area on her palm for the last couple of months that hurts to press. She changed the mouse that she was using with her computer thinking that this would help but did not notice any difference. It seems like it was getting larger. She had an ulcer on her tongue for 2 1/2 months it does not seems to heal well. She has used Magic mouthwash without good relief. She is not sure whether she is biting or sucking on it at night. She has noticed knots skin on her left thigh and on her bilateral lower extremities over the past eight weeks. No change in size. It does seem like they will get red when she is in the shower. She takes Parnate for treatment-resistant depression. Her lower extremity edema has continued to improve on the Lasix.
O: Vital signs as noted. In general, Ms. Cage is pleasant, overweight and in no acute distress. She has a firm protuberance over the first metacarpal head on the right hand with no overlying skin changes. Normal sensation to light touch in the upper extremities bilaterally. There is ulceration on the right side of the tongue. Otherwise, oropharynx is clear with small ulceration. She has multiple well-defined subcutaneous masses in her bilateral upper extremities, the largest of which is in her left thigh. No overlying skin changes.
A/P:
1. Right tongue ulceration: Given the chronicity of this lesion, we will refer for ENT evaluation.
2. Right hand pain with firm protuberance over the first metacarpal head: We will obtain x-ray and f/u with her regarding the results. We can consider a hand specialist referral.
3. Probable lipomas: We discussed that these are benign and she will watch for any growth or unusual changes in the areas and let us know.
4. Chronic use of medication: Given her overall symptom complex and her Parnate use, we will check a CBC with diff, C-MET and a sed rate today.


Greg Perry, M.D.
08/13/04
Stephanie Franklin #56264
S: Ms. Franklin is a 49 y/o who presents with one week of fatigue and feeling poorly. She has been sleeping more than usual. She has sores in her mouth. She has had joint pain and chills. She noticed a rash on her leg this morning. She has had decreased appetite. She has had a dull headache that comes and goes. No nausea, vomiting or diarrhea. She leaves in the country but has not noticed any tics. No foreign travel. She drinks free water. No sick contacts. She takes Protonix on a regular basis. No smoking. No known drug allergies. No cough or congestion. She has had some mild sore throat.
O: Vital signs as noted. In general, Ms. Franklin is pleasant and in no acute distress. Oropharynx is mildly erythematous. Neck supple, shotty cervical lymphadenopathy. Tympanic membrane is normal. Heart RRR, no murmur. Lungs CTA bilaterally normal respiratory effort. There is normal neck range of motion. Abdomen soft, nontender, positive bowel sound, no organomegaly, no mass. Extremities no edema. She has a patch of erythematous papules on her right thigh. No bulls eye lesions.
Rapid strep is negative.
A/P: Probable viral syndrome: Given the duration and severity of her illness, we will check a CBC with diff and C-MET today and f/u with her regarding the results. We will also check a monotest. We will treat symptomatically with Mobic 7.5 mg 1 p.o. q.d. to b.i.d. She will rest and push fluids and still remains with her activities as tolerated. She knows to call if worsen or not improving.


Greg Perry, M.D.

08/13/04
Brandy Spence #28767
S: Brandy is 24 y/o who presents to f/u abnormal ANA, fibromyalgia and vaginal discharge. For approximately one week, she has had a white vaginal discharge with some vaginal itching. She is sexually active and uses condoms for protection. No history of STDs. She did have bacterial vaginosis approximately two months ago. She has recently been improving from a flare of her fibromyalgias. She was recently started back on Wellbutrin XL and overall this seems to be helping her symptoms. She uses Flexeril as needed. She has been sleeping well and exercise regularly. She had blood drawn on 08/04/04 and had a 1:640 ANA titer. She was concerned about this and wanted to know what this means for her. She has been having more flares of pain within the past couple of months. She is having some difficulty, because she was not able to take off very many days of work. Lately, she seems to have more pain in her knees all goes in feet. She was diagnosed with fibromyalgia approximately three to four years ago. No smoking.
O: Vital signs as noted. In general, Brandy is pleasant, well-appearing and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally with normal respiratory effort. Extremities no edema. There is no joint effusion, erythema or ligamentous laxity.
Wet prep shows many clue cells, no trich, no yeast.
A/P:
1. Flare-up fibromyalgia symptoms, improving with history of positive ANA: She was evaluated by Baptist Hospital Rheumatology in 2001 for her positive ANA. She was not felt to have any other connective tissue diseases. I did not really know that it was not usual for the ANA to stay positive like this. She will let us know if she continues to have more flares of her joint pains or if she has a change in the carried-over pain, so we can consider further evaluation. Assessments f/u with the rheumatology group at Baptist.
2. Bacterial vaginosis: Flagyl 500 mg 1 p.o. b.i.d. for 7 days. If she continues to have vaginal itching, she can fill up a prescription I gave her for Diflucan 150 mg p.o. times one. Call if not improving.


Greg Perry, M.D.

08/13/04
Ruth Burnell #9797
S: Ms. Burnell is a 45 y/o who presents to f/u after was seen on 08/03/2004 with an acute anxiety reaction. Overall, she has not had any more severe episodes. She is continued to have some occasional chest tightness. She has a history of asthma, which has been more controlled when she uses albuterol rarely. She takes Advair consistently. Her gynecologist prescribed fluoxetine 10 mg q.d. for irritability and low mood that she has meeting a premenstrual cycle. She has not yet had this filled. She has had occasional difficulty with early morning wakening. She notices that when she wakes up in the middle of the night her legs will feel numb below the knees, which eases off within a few hours.
O: Vital signs as noted. In general, Mr. Burnell is pleasant and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally, normal respiratory effort. Extremities no edema.
A/P: 45 y/o with premenstrual dysphoric disorder and recent acute anxiety reaction. I encouraged her to begin fluoxetine 10 mg p.o. q.d. on days 15-28 of her cycle as well as on the first day of her menses. We talked about possible transient side effects. She will let us know if not improving. I refilled her albuterol inhaler today. I wrote for trazodone 50 mg 1-2 p.o. q.h.s. p.r.n. for sleep. She knows to call if not improving. Of note: During her episode on 08/13, she had lab shown, which showed a glucose of 140. I repeat non fasting glucose today, is 103.
Greg Perry, M.D.
08/13/04
Belvin Overman #33653
S: Mr. Overman is a 50 y/o who presents for f/u of diabetes as well as to discuss numbness in his arms and swelling of his testicles. For the past three weeks, he has had numbness in his entire arms that lasts about 10 minutes, no pain. His hands have been numb on both sides for 4-5 months. He has chronic foot numbness bilaterally. He has cut down on smoking but he continues to smoke. He has not been checking his blood sugars because he has been out of his test strips. He was hospitalized with acute coronary syndrome in July of 2004. He had some transient neck pain prior to his arm numbness beginning but has not had pain since. He has felt a lump in his scrotum that started two years ago and it will usually go down on its own but has been flared up for three weeks with pain and without getting better. His Lipitor has been increased to 40 mg b.i.d. His current medications are reviewed and updated in the medical record.
O: Vital signs as noted. In general, Mr. Overman is pleasant and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally. He has decreased sensation to light touch in the upper and lower extremities. Normal pulses in the upper and lower extremities bilaterally. Normal neck range of motion. The typical musculature is nontender. He has fullness with tenderness to palpation above the testicles bilaterally. No definite testicular mass.
A/P:
1. Bilateral upper extremity numbness: This maybe diabetic neuropathy. We will obtain nerve conduction studies and f/u with him regarding the results. We can consider use of amitriptyline or Neurontin.
2. Diabetes mellitus, Type 2: I refilled his Glycoside sustain release and Actos as well as his test strips. And I encouraged him to check his sugars more frequently. His last hemoglobin A1c was within a good range.
3. Scrotal fullness with pain: We will obtain a testicular ultrasound and f/u with him regarding the results.
4. Hyperlipidemia: Continue Lipitor 80 mg a day. We will plan C-MET with lipid panel in 3 weeks.
5. Tobacco dependence: I strongly encouraged smoking cessation.
Greg Perry, M.D.
Aug.13, 2004
Re: Cassie Myers
DOB: 10-16-40
To whom it may concern:
Cassie Myers is a patient of mine at Eagle Family Medicine at Triad. I am writing to ask you to excuse her from jury duty. She is scheduled for jury duty on 09/14/04. Due to her sleep apnea, she is unable to stay awake for a long period time if she sits in the same place. In the same, she has a history of asthma and obesity and has shortness of breath with exertion. Finally, she gets numbness in her legs if she sits in one place for an extended period of time.
Thank you for your consideration. Please do not hesitate to contact me if I can be of any further assistance.
Sincerely,
Greg Perry, M.D.
08/13/04
Jacob Goad #35925
S: Jacob is a 21 y/o who recently returned from three months in Peru. He is feeling well until two days ago, when he developed liquid stools and he has noticed 1-2 cm worm-like structures. No blood in the stool, no fever, no rectal itching. No vomiting or diarrhea. Otherwise, he feels fine. Vermox has worked for similar infections in the past.
O: Vital signs as noted. In general, Jacob is pleasant, well appearing and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally. Normal respiratory effort. Abdomen: Soft, nontender, positive to bowel sound; no organomegaly, no mass. Extremities, no edema.
A/P: Probable intestinal parasite infection from recent stay in Peru: We will treat empirically with mebendazole 100 mg p.o. b.i.d. for five days. This should cover for most potential intestinal parasites. He knows to call if not improving so we can arrange formal stool testing.


Greg Perry, M.D.


08/13/04
Tina Hutcherson #57441
S: Ms. Hutcherson is a 23 y/o who presented for blood pressure check on a nurse schedule today. She has a recent diagnosis of renal insufficiency. She was found to have evidence of chronic kidney disease on her renal ultrasound. Her blood pressure today is 180/120. She has had some headaches but is currently without headache or other problems. When she was seen last week with increased blood pressure, she was prescribed atenolol/chlorthalidone 50/25 1 p.o. q.d. She did not get this filled due to financial reasons. I spoke with Dr. Powell at Care Line and Kidney Associates. We will arrange for her to have a 24-hour urine for protein and creatinine clearance, as well as a urinalysis, HIV, ANA, C3 and C4 for further evaluation. We will arrange for her to be seen at Care Line and Kidney Associates. In the meantime, I have placed her on furosemide 80 mg p.o. q.d. as well as atenolol 100 mg p.o. q.d. We talked about possible side effects. Samples of atenolol were given.


Greg Perry, MD
08/13/04
Melissa Bocci #29745
S: Ms. Bocci is a 46 y/o who presents with a rash on her chest for four days. She has had a raised, red rash in the medial aspect of her breasts. It seems to be spreading. No history of similar problems. There has been some itching; she had some swelling in the left side of her neck two days ago and this has gotten better. No new exposures to soaps, detergents or foods. No fever, no history of similar problems. No new medication.
O: Vital signs as noted. In general, Ms. Bocci is pleasant, and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally. Oropharynx clear. Neck is supple without lymphadenopathy. She has raised patches of erythema in the medial aspect of both breasts with no warmth or drainage.
A/P: Probable tinea infection on the chest: We will treat with Nystatin powder b.i.d. until resolution. We talked about keeping these areas as clean and dry as possible. She knows to call if not improving.


Greg Perry, MD


08/13/04
Michael Hopper #25469
S: Mr. Hopper is a 27 y/o who presents to discuss ear discomfort. Last week his left ear began feeling abnormal and felt stopped up and he is having difficulty hearing. He has also developed ear pain. Over the past couple of days, he has developed right ear discomfort, he had some clear drainage in the right ear today. He has also had some headache. He has had elevated blood pressure, but in the past but has never been on blood pressure medication. No cough. No known drug allergies. Current medications are reviewed in the medical record. No nasal congestion.
O: Vital signs as noted. In general, Mr. Hooper is pleasant, overweight and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally. Oropharynx clear. Neck supple without lymphadenopathy. The right ear canal is erythematous and edematous with white drainage. The left ear canal contains a significant amount of cerumen, after the cerumen was irrigated; the tympanic membrane was visualized and normal.
A/P: Cerumen impaction and right side otitis externa: The ears were irrigated successfully today. We will use Cortisporin Otic 4 drops in the right ear q.i.d. for ten days. He knows to call for signs of worsening or unresolved illness.


Greg Perry, MD

08/13/04
Gail Hopkins #47933
S: Ms. Hopkins is a 25 y/o who presents with one week of urinary frequency. She does drink a lot of water, but this has not changed for her. She feels urinary urgency and has occasionally had symptoms of urge incontinence. No fever. No back pain. She has not seen blood in the urine. She has had occasional nausea without vomiting. No known drug allergies. She takes oral contraceptives and Singulair.
O: Vital signs as noted. In general, Ms. Hopkins is pleasant, well appearing and in no acute distress. Conjunctivae are clear. Tympanic membranes are moist. Heart RRR, no murmur. Lungs CTA bilaterally. No costovertebral angle tenderness. Abdomen soft, nontender, positive bowel sounds. Extremities no edema.
Urinalysis, there is trace protein, trace blood and microscopy is negative.
A/P: Urinary urgency and frequency: We will send the urine for culture to rule out infection and f/u with her regarding the results. If the culture is normal, we can give her trial of Detrol LA 4 mg p.o. q.d., samples were given. She knows to call if this helps, so that we can call in a prescription for her. F/u if not improving.


Greg Perry, MD


08/13/04
John Taylor #56032
S: John is an almost 12 m/o who presents with mom because of increased thirst. She has noticed that he drinks more fluids including water, milk and juice. They have a family history of diabetes and mom was worried about the onset of diabetes. He seems to be urinating more than usual. No fever. He has been acting well and eating well. He had some issues of poor weight gain earlier in life but has been gaining weight well over the last 12 months. He is developing normally. He does seem to be sleeping more than usual.
O: Vital signs as noted. In general, John is alert and well-appearing, in no acute distress. Heart RRR with a somewhat harsh 2 out of 6 systolic murmur heard best at the left lower external border. Lungs CTA bilaterally, normal respiratory effort. Abdomen soft, nontender; positive bowel sound. Mucus membrane is moist. Tympanic membrane is normal.
Finger stick glucose is 98.
A/P: Family history of diabetes with recent increased thirst: I reassured mom about his normal exam and normal glucose. She will continue to feed and give drinks ad lib and call if with further problems. Of note: The systolic murmur heard on exam today has not been heard on previous exams. He has a 12-month well-child check coming up and Dr. Harris can listen and decide about need for further evaluation.


Greg Perry, M.D.

08/13/04
Jennifer Catania #42013
S: Ms. Catania is a 30 y/o who presents to discuss itching and rash that began five days ago. She started with itching in her axillary and pubic area. Two days ago, she noticed raised red spots in various aspects of her body. She has had itching on the palms and soles of her feet. She lives with her sister who does not have a rash but she has been doing some recent traveling. No new exposures to foods, soaps, detergents or medications. There has been no drainage on the areas. She has no known drug allergy and no history of similar problems.
O: Vital signs as noted. In general, Ms. Catania is pleasant and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally. She has occasional small raised erythematous papules in various aspects of the body including the ankles, hands and one of her legs.
A/P: Probable scabies: We will treat it with Permethrin 5% to be applied chin to toes and then washed off 8-10 hours later with a repeat application in one week. A handout was given regarding treatment and prevention. She will wash her clothes and linens in hot water. She did take a veterinary dose of ivermectin earlier this week. She knows to call if not improving.


Greg Perry, M.D.
08/13/04
__ Rapp #11995
S: Mr. Rapp is a 39 y/o who presents with nasal congestion and body aches for three months. In the spring, he dealt with body aches, nasal congestion and drainage. It was originally thought to be due to allergies, he was then given antibiotics and he eventually got better after prednisone. He had been feeling well until approximately three to four days going when he developed thick nasal drainage with a slight sore throat right greater than left. He has also had nasal congestion and a mildly elevated temperature along with generalized body aches. No facial pain. He has been out of his Allegra recently but
has been taking loratadine. He has been taking his Nasacort and Astelin. He has had some fatigue over the past couple of days. In addition, he has poison ivy on his right arm and right leg, for approximately six days, this has been slow to get better. Finally, he has right foot pain that is chronic. He has seen Murphy Wainer who recommended a surgery, he requests a second opinion. He has had allergies over the last five years.
O: Vital signs as noted. In general, Mr. Rapp is pleasant, and in no acute distress. No sinus tenderness to percussion. Nasal mucosa is very erythematous and edematous with purulent drainage. Tympanic membranes normal. Oropharynx is clear without exudate. There is some postnasal drip. Neck supple without lymphadenopathy. Heart RRR, no murmurs. Lungs CTA bilaterally. Extremities no edema. On exam, the skin reveals a patch of erythema with some scaling on the right arm and right leg.
A/P:
1. Allergic rhinitis with overlying viral URI, possibly acute sinusitis: I gave him samples and a prescription for Allegra 180 mg q.d. which he had been on chronically. Also Maxifed 1-1½ p.o. b.i.d. p.r.n. for congestion. Given his significant breakthrough symptoms, we will add Singulair 10 mg p.o. q.d., samples and a prescription were given. We can consider allergist referral for allergy testing. If he is worse or not improving, he will fill a prescription for Augmentin 875 mg 1 p.o. b.i.d. for ten days. I wrote on the prescription that it should not be filled after September 13th, 2004. He knows to call if not improving.
2. Continued foot pain: He is going to call Dr. Graves for a second opinion. He will let us know if he needs assistance with the referral.
3. Poison ivy dermatitis: Triamcinolone 0.1% cream b.i.d. until resolution.


Greg Perry, MD

08/13/04
Brooke Nemchin #54412
S: Brooke is a 22 m/o who presents with mom because she has been crying when she wets her diaper. She has not had fever. This morning she seemed to be clinging more, but otherwise has been acting normally this afternoon. No history of UTI. No vomiting or diarrhea. No regular medications. Her immunizations are up-to-date. No known drug allergies. She has had a diaper rash in the vaginal area today. Her urine looks darker than usual to mom.
O: Vital signs as noted. In general, Brooke is well appearing and in no acute distress. Tympanic membranes are normal. Mucous membranes moist. Conjunctivae are clear. Heart RRR, no murmur. Lungs CTA bilaterally with normal respiratory effort. Extremities no edema. The external vaginal area is erythematous, with no satellite lesions. Normal capillary refill.
A/P: Crying with urination: This maybe due to the irritated diaper area. We need to rule out UTI. A sterile bag was given to mom and she will bring back any urinalysis for UA and culture and we can treat it positive. Otherwise she will treat the diaper rash with OTC preparations. If not improving, she can consider treating for yeast. She will call sooner if for fever or other signs of worsening illness.


Greg Perry, MD


08/13/04
Frankie Wilmoth #33495
S: Mr. Wilmoth presents with blood in his urine that started today. He has not been feeling well for the last couple of days. He has had some burning with urination. No history of kidney stones, no history of UTI. He has chronic pain in his lower back but he has some sharp pains that feel different recently. No history of prostatitis. He is allergic to prednisone.
No fever.
O: Vital signs noted. In general, Mr. Wilmoth is pleasant, overweight and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally. Abdomen soft, nontender, positive bowel sounds, no organomegaly, no mass. Normal testicular exam. No hernia. No penile discharge. Prostate exam: Reveals a mildly tender prostate, no mass, normal tone. UA shows 1+ leukocytes, 30 protein, 3+ blood. Microscopy shows occasional WBC with two numerous count RBC/HPF.
A/P: Gross hematuria: We will send urine for culture and treat empirically with Levaquin 500 mg p.o. q.d. 2-14 days, samples and a prescription given. This will cover for the possibility of prostatitis as well. He knows to call if worsen or not improving. If his culture would comes back negative, we will need to arrange further evaluation including urology referral.


Greg Perry, M.D.

08/13/04
Lourdes Williams #13527
S: Ms. Williams is a 44 y/o who presents to discuss burning with urination and nausea. Her symptoms began yesterday. She has had chills, no blood in the urine, no vomiting. She has had urinary frequency. No known drug allergies.
O: Vital signs as noted. In general, Ms. Williams is pleasant and in no acute distress. Heart RRR, no murmur. Lungs CTA bilaterally with normal respiratory effort. No costovertebral angle tenderness. Abdomen soft, nontender, positive bowel sounds.
UA is 2+ leukocyte, 1+ nitrite, trace protein with 1+ blood.
A/P: UTI: Given for upper tract symptoms, we will cover with Levaquin 250 mg p.o. q.d. for 7 days. Also Phenergan 25 mg 1/2-1 p.o. q6h p.r.n. She will push fluids and rest and let us know if not improving.


Greg Perry M.D.