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DOE, RONALD 04/12/09
DOB: 12/09/44
HPI: Follow up
dyslipidemia, BPH, bilateral knee DJD. No significant complaints except for mild
medial knee pain on the L. Patient states he has continued to stay active and
golf on a regular basis. Using seat belts on a regular basis. Quit tobacco
approximately 26 years ago. Denies alcohol use. Minimal caffeine intake.
Adequate calcium intake per diet history. No change in stool or urine habits.
Denies any significant urinary obstructive symptoms. No blood in stool or urine.
No melena. Weight stable.
PMHX/ PSHX/ FMX/
SHX: See health maintenance form.
ROS: See progress
notes.
PX: Normal appearance. NAD. PERR. Normal
conjunctivae. EOMI. Ears clear. Nares clear. Oropharynx clear. Neck supple.
FROM. No stiffness. No lymphadenopathy. Thyroid nonenlarged and nontender. No
JVD or bruits. Lungs CTA without wheezes, decreased breath sounds, or rhonchi.
Normal percussion. Heart RRR. No clicks or rubs. Normal S1 and S2. Abdomen soft.
Positive BS. Nontender. Nondistended. No HSM. Rectal exam reveals slightly
enlarged prostate. No nodules. Lobes symmetrical. No tenderness. No rectal
masses or tenderness. No evidence of blood in stool. Extremities without CCE.
Skin reveals no rash. Normal DPs. Cap refill WNL.
A/P:
1.Dyslipidemia.
Will check FLP and ALT level today.
2.Benign prostatic
hypertrophy, stable.
3.Bilateral knee degenerative joint disease. Symptoms are mild at this time. Patient states this does not
limit him with his
daily activities.
4.Preventative health. Will obtain PSA for screening. Preventative health topics discussed. Will schedule
patient for a
screening flexible sigmoidoscopy.
FUN/ht:run
DOE, JULIE
04/12/09
DOB:
8/18/81
HPI: Complains of
persistent sore throat with chills with tender anterior and posterior cervical
lymphadenopathy. Denies any nasal congestion, drainage, or significant cough.
Allergic to penicillin. Has been on complete course of Z-pack, taking her last
tablet today. Denies abdominal symptoms. No emesis, diarrhea, or rash. No other
complaints or problems. No medication side
effects.
ROS: See progress
notes.
PX: Normal appearance. NAD. PERR. Normal
conjunctivae. Ears clear. Nares clear. Oropharynx shows tonsillar hypertrophy
with erythema. White exudates. No malodorous breath. Moist mucus membranes. Neck
reveals moderately swollen anterior and posterior lymphadenopathy, tender to
touch. Lungs CTA without wheezes, decreased breath sounds, or rhonchi. Normal
percussion. Heart RRR without murmurs, clicks, or rubs. Normal S1 and S2.
Abdomen reveals mild tenderness in the L upper quadrant, although spleen appears
normal in size. No hepatomegaly Abdomen otherwise soft. Extremities without CCE.
Skin reveals no rash.
A/P:
1. Acute tonsillitis. I feel that symptoms are most likely secondary to mononucleosis. Will continue with
Zithromax over the next couple of days. Samples given. Obtain throat culture today, along with Monospot.
Discussed
restrictions at this point until we know further results of the
testing.
FUN/ht:run
DOE, JOE
04/12/09
DOB:
10/05/27
HPI: Follow up GERD,
BPH, hiatal hernia. Patient seems to have intermittent dysphagia symptoms,
although states this is improved with taking the Axid 150 mg daily. Denies any
other complaints or problems. Using seat belts on a regular basis. Denies
tobacco or alcohol. No change in stool or urine habits. No significant urinary
obstructive symptoms. No blood in stool or urine. No melena. Denies complaints
or problems otherwise. Is taking Metamucil on a regular basis, along with one
aspirin daily.
PMHX/ PSHX/ FMX/
SHX: See health maintenance form.
ROS: See progress
notes.
PX: Normal appearance. NAD. PERR. Normal
conjunctivae. EOMI. Ears clear. Nares clear. Oropharynx negative. Neck supple.
FROM. No stiffness. No lymphadenopathy. Thyroid nonenlarged and nontender. No
JVD or bruits. Lungs CTA without wheezes, decreased breath sounds, or rhonchi.
Normal percussion. Heart RRR. No clicks or rubs. Normal S1 and S2. Abdomen soft.
Positive BS. Nontender. Nondistended. No HSM. Extremities without CCE. Skin
reveals no rash.
A/P:
1.Benign prostatic
hypertrophy, stable.
2.Gastroesophageal reflux disease. Intermittent dysphagia. Recommended upper endoscopy, although
patient states he
will consider this. Continue with Axid 150 mg q.h.s.
3.General screening. Occult blood test in office today was negative. Patient did have colonoscopy
approximately a year ago for blood in stool. This was unremarkable except for mild proctitis. Patient will
obtain wellness
testing at MGMC, consisting of fasting glucose, lipid panel, and PSA
test.
FUN/ht:run
DOE, DEANN
04/22/09
DOB:
9/11/37
HPI: Complains of
severe DJD L knee. Patient presents for joint injection today. Continues to have
pain in the knee. Also laxity and instability, although these are due to her
gait pattern. Problems are all secondary to MVA in 1972. Patient uses short
crutches for ambulation.
PX: Knee shows no evidence of joint deformity,
swelling or redness. Tenderness is over medial aspect of the knee. Patient has
had laxity noted in both knee joints in the past. Also crepitus.
PROCEDURE: Area was cleaned with Betadine. 2 cc
Marcaine, 0.5 cc Celestone, 1 cc Depo-Medrol is injected using sterile
technique. Area cleaned with alcohol and sterile bandage
applied.
A/P:
1.Degenerative joint disease, left knee. Injected as above. Patient education given on possible side
effects of the
injection, such as steroid flare, and how to treat this. Call if
problems.
FUN/ht:run
DOUGH,
KEN
04/12/09
DOB:
6/26/08
HPI: Follow up to
recheck ears. Mom states he has been doing well. No fevers. No emesis, diarrhea,
or rash. Normal appetite. Is having problems sleeping at night, although she
thinks this is due to the brace he is currently using for his club feet.
ROS: See progress
notes.
PX: Normal appearance. NAD. Both ears show dull
TMs. No significant redness. No drainage. Remaining HEENT grossly
normal.
A/P:
1.Bilateral serous otitis. Will start patient on prophylactic Gantrisin 500 mg / 5 mL, 1 teaspoon p.o. q.h.s.
Recheck in one
month. Call sooner or return if problems.
FUN/ht:run