neidacaroboone-editingM-19
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School
Valencia College *
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Course
1611C
Subject
Medicine
Date
Dec 6, 2023
Type
docx
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Uploaded by BrigadierFang12455
Internal Medicine Clinic Note
Patient Name
: Jack T. Lampe, PhD
PCP
: Sherman Loyd, MD
Date of Exam
: 09/30/----
Age/Sex
: 76/M
ID#
: M-19
CHIEF COMPLAINT
: This 76-year-old white male is here for follow up
medical care.
HISTORY
: The patient describes being Dr. Ramirez's patient, describes
appreciation for his thoroughness. He goes on to note that he needs no
medications renewed but has had a hard time getting into our clinic and
hopes that in the next few months he would be able to reestablish care.
PAST MEDICAL HISTORY
1. Dyslipidemia.
2.
One’s a smoker, discontinued 3 years ago.
3.
Sensorineural hearing loss.
4.
Chronic ischemic heart disease, apparently.
5.
Symptomatic bradycardia. He had a pacemaker placed 8 years ago.
6.
Chronic atrial fibrillation.
7.
Anticoagulation, chronic, and this for #6 above.
8.
Slow urinary stream.
9.
Pulmonary tuberculosis left kidney focused. This was found when
presented with recurrent urinary tract infections. Multiple urinary samples
done at different medical facilities found the culprit organism, with a
diagnosis eventually made.
10. Cataracts, both eyes. There is a question as to whether or not
amiodarone is involved. (The sternal deposits are called verticillata.)
PAST SURGICAL HISTORY
1.
He had a coronary arteriogram and a permanent pacer placed 8 years ago
in January.
2.
Left kidney revision by Dr. Green in the remote past.
3.
Rectal melanoma excision 10 years ago.
4.
Tympanoplasty and mastoidectomy 20 years ago.
5.
Right cataract surgery 7 years ago.
ALLERGIES
: STREPTOMYCIN and ALDOMET. Manifestations unknown.
Internal Medicine Clinic Note
Patient Name: Jack T. Lampe, PhD
Date of Exam: 09/30/----
ID#: M-19
Page 2
MEDICATIONS
(mg p.o. daily unless otherwise noted)
1.
Warfarin 223 as of today.
2.
Tamsulosin 0.4 mg b.i.d.
3.
Simvastatin 20.
4.
Potassium chloride 10.
5.
Omeprazole 20.
6.
Metoprolol 200.
7.
Lisinopril 40.
8.
Hydrochlorothiazide 25.
9.
Finasteride 5.
FAMILY HISTORY
: Patient describes his mother dying of tuberculosis 8 to 9
months after he was born. A sister succumbed to cancer as an adult. He
thinks it was lymphoma.
SOCIAL HISTORY
: Patient lives locally with his wife. He has been seeking
medical care from Quali-Care Internal Medicine Clinic for some time. He once
smoked and he rarely drinks. History of being a pipe smoker.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Patient has gained approximately
8 pounds in the last year. There has been no weakness.
NEUROLOGIC: Denies headaches, seizures. There have been no falls.
HEENT: Denies description of sore throat, vision, or hearing change. He
admits to being hard of hearing. ENDOCRINE: He has had no diabetes or
thyroid problems. He has had hypertension. CARDIAC: There has been no
heart attack or heart failure. He has had no rapid heart race. PULMONARY: No
known pulmonary disease. He has no cough or wheeze. There has been no
pulmonary embolism. GASTROINTESTINAL: He denies description of
odynophagia, dysphagia, bleeding ulcers, or epigastric pain. He describes an
empty feeling that led him to seek medical attention. A diagnosis of what
sounds like GERD was made. Prilosec started. His chief complaint was 100%
resolved. He has had no liver disease. No change in stool color, caliber, or
consistency. He thinks his last colonoscopy was 3 years ago in our facility.
RENAL: He has had the renal disease as described above. His kidneys are
now functional from his point of view. Denies dysuria or kidney stones.
HEMATOLOGIC: No bleeding or clotting abnormalities. No transfusions.
SKIN: No skin color changes. No new lumps or bumps.
Internal Medicine Clinic Note
Patient Name: Jack T. Lampe, PhD
Date of Exam: 09/30/----
ID#: M-19
Page 3
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RHEUMATOLOGIC: Denies muscle pains or join aches.
PHYSICAL EXAMINATION:
VITALS: Blood pressure 129/86, pulse 91,
respirations 16, temperature 98.7, height 5 feet 10 inches, weight 171
pounds. Generally, he is a white male of medium build, very careful with his
speech, in no apparent respiratory distress. Has minimal upper body
segment obesity.
HEENT: No dominant skin lesions. Mouth and nose clear.
Eyes without arcus senilis. No injection. Ears clear bilaterally.
NECK: Without
cervical lymphadenopathy, thyromegaly, or nodules. There are no carotid
bruits or murmurs.
PULMONARY: Lungs are clear to auscultation. HEART:
Regular. S1 and S2 are both S1 and S2 are normal.
ABDOMEN: Soft,
nontender, with bowel sounds present.
EXTREMITIES: Without cyanosis,
clubbing, or edema.
ANCILLARY DATA: Cardiac catheterization from 8 years ago showed normal
coronaries with injection fraction of 45%. Eight years ago, his pulmonary
function tests showed FEV1 of 86% of predicted, FVC 106%, DLCO—an
adjusted value, namely D/VA—103% of predicted. Plethysmography showed
vital capacity 81% of predicted. Spirometry showed normal inspiratory and
expiratory flow volume lids. Three years ago he had a transthoracic echo
that showed an ejection fraction of 60% and normal left ventricular size and
function. The valves were unremarkable. Last January (9 months ago) his LDL
and HDL were within normal limits. Creatinine was 1.3 and slowly increasing,
when viewing the trend. Total bilirubin increased and decreased.
ASSESSMENT
1.
Hypertension, controlled on medical therapy.
2.
Extrapulmonary tuberculosis, eventuating in an undocumented surgery.
3.
Symptomatic bradycardia, now with paste in place. Normal left ventricular
function.
4.
Vacillating total bilirubin.
5.
Chronic atrial fibrillation, now anticoagulated.
6.
Slow creatinine rise, etiology unclear. Patient clinically stable.
Internal Medicine Clinic Note
Patient Name: Jack T. Lampe, PhD
Date of Exam: 09/30/----
ID#: M-19
Page 4
PLAN
1.
I have reviewed patient's medical record, which dates back approximately
8 years. I see no evidence of colonoscopy.
2.
I would like to see him back in 6 months.
3.
Patient clinically stable. No medications to review.
____________________________________
Jean W. Mooney, PA, Internal Medicine
JWM:ncb
T: 09/30/----
D: 10/01/----
c:
Sherman Loyd, MD, Pulmonology, Saul Thompson, MD, Cardiology