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.