Consultation Note 17 Daws Rd. Blue Bell MA 02368 US Mr. Adam Frankie Everyman 17 Daws Rd. Blue Bell MA 02368 US Ralph Relative MA 02368 USA Good Health Clinic 21 North Ave Burlington MA 02368 USA 21 North Ave. Burlington MA 02368 USA Henry Seven 21 North Ave. Burlington MA 02368 USA Henry Seven Rose Everyman Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 USA Henry Seven Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 USA Mrs. Abigail Ruth
Allergies, Adverse Reactions, Alerts
Substance Reaction Status
Penicillin Hives Active
Aspirin Wheezing Active
Codeine Nausea Active
Penicillin Aspirin Aspirin
ASSESSMENT Recurrent GI bleed of unknown etiology; hypotension perhaps secondary to this but as likely secondary to polypharmacy. Acute on chronic anemia secondary to #1. Azotemia, acute renal failure with volume loss secondary to #1. Hyperkalemia secondary to #3 and on ACE and K+ supplement. Other chronic diagnoses as noted above, currently stable.
REASON FOR VISIT/CHIEF COMPLAINT Dark stools.
Family history Father (deceased)
Diagnosis Age At Onset
Myocardial Infarction (cause of death) 57
Diabetes 40
GENERAL STATUS Alert and in good spirits, no acute distress.
PAST MEDICAL HISTORY See History of Present Illness.
HISTORY OF PRESENT ILLNESS This patient was only recently discharged for a recurrent GI bleed as described below. He presented to the ER today c/o a dark stool yesterday but a normal brown stool today. On exam he was hypotensive in the 80?s resolved after .... .... .... Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes normal. H. pylori antibody pending. Admission hematocrit 16%, discharge hematocrit 29%. WBC 7300, platelet count 256,000. Urinalysis normal. Urine culture: No growth. INR 1.1, PTT 40. He was transfused with 6 units of packed red blood cells with .... .... .... GI evaluation 12 September: Colonoscopy showed single red clot in .... .... ....
Immunizations
Vaccine Date Status
Influenza virus vaccine, IM Nov 1999 Completed
Influenza virus vaccine, IM Dec 1998 Completed
Pneumococcal polysaccharide vaccine, IM Dec 1998 Completed
Tetanus and diphtheria toxoids, IM 1997 Refused
Influenza virus vaccine Possible flu-like symptoms for three days. Influenza virus vaccine Possible flu-like symptoms for three days. Influenza virus vaccine Possible flu-like symptoms for three days. Tetanus and diphtheria toxoids - preservative free Possible flu-like symptoms for three days.
MEDICATIONS
Medication Directions Start Date Status Indications Fill Instructions
Proventil 0.09 MG/ACTUAT inhalant solution 2 puffs QID PRN wheezing 2011-03-01 Active Bronchitis (32398004 SNOMED CT) Generic Substitition Allowed
0.09 MG/ACTUAT inhalant solution, 2 puffs QID PRN wheezing Good Health Clinic Diethylene Glycol label in spanish
PHYSICAL EXAMINATION HEENT: All normal to examination. Heart: RRR, no murmur. THORAX & LUNGS: Clear without rhonchi or wheeze. ABDOMEN: No distension, tenderness, or guarding, obese, pos bowel sounds. BACK: Normal to inspection and palpation, without tenderness; no presacral edema. EXTREMITIES: Doughy edema bilaterally, chronic stasis changes, no asymmetrical swelling.
Plan of Care
Planned Activity Planned Date
Colonoscopy April 21, 2000
PROBLEMS Pneumonia: Resolved in March 1998 ...
Procedures
Procedure Date
Colonic polypectomy 1998
17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US 17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic
REASON FOR REFERRAL Colonoscopy due to rectal bleeding.
Results
LABORATORY INFORMATION
Chemistries and drug levels
HGB (M 13-18 g/dl; F 12-16 g/dl) 13.2
WBC (4.3-10.8 10+3/ul) 6.7
PLT (135-145 meq/l) 123 (L)
Liver Functions and Other Laboratory Values
ALT (SGPT) 31.0
AST (SGOT) 18.0
GGT 28.0 Alk
Phos 86.0
Total Bili 0.1
Albumin 3.2
Blood Count
White Count 7.7
Platelets 187.0
Hematocrit 23.7
Hemoglobin 8.1
ELECTROCARDIOGRAM (EKG) INFORMATION
EKG Sinus rhythm without acute changes
M 13-18 g/dl; F 12-16 g/dl
REVIEW OF SYSTEMS Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. One episode of melena. No recent headaches. Positive for osteoarthritis in hips, knees and hands.
Social History
Social History Element Description Effective Dates
smoking 1 pack per day 1947 - 1972
smoking None 1973 -
Alcohol consumption None 1973 -
1 pack per day None None
Vital Signs
Date / Time: Nov 14, 1999 April 7, 2000
Height 177 cm 177 cm
Weight 86 kg 88 kg
Blood Pressure 132/86 mmHg 145/88 mmHg