### Good Health Clinic Consultation Note

RobertDolinMDRobertDolinMDGood Health ClinicRobertDolinMDHenryLevinthe 7th

#### History of Present Illness

Henry Levin, the 7th is a 67 year old male referred for further asthma management. Onset of asthma in his . He was hospitalized twice last year, and already twice this year. He has not been able to be weaned off steroids for the past several months.

#### Past Medical History

Asthma
Hypertension (see HTN.cda for details)
Osteoarthritis, right knee

#### Medications

Theodur 200mg BID
Proventil inhaler 2puffs QID PRN
Prednisone 20mg qd
HCTZ 25mg qd
Theodur 200mg BID
Proventil inhaler 2puffs QID PRN
Prednisone 20mg qd
HCTZ 25mg qd

#### Allergies and Adverse Reactions

Penicillin - Hives
Aspirin - Wheezing
Codeine – Itching and nausea

#### Family history

Father had fatal MI in his early 50’s.
No cancer or diabetes.

#### Social History

Smoking :: 1 PPD between the ages of 20 and 55, and then he quit.
Alcohol :: rare

#### Physical Examination

#### Vital Signs

Date / Time | April 7, 2000 14:30 | April 7, 2000 15:30
--- | --- | ---
Height | 177 cm (69.7 in)
Weight | 194.0 lbs (88.0 kg)
BMI | 28.1 kg/m2
BSA | 2.05 m2
Temperature | 36.9 C (98.5 F) | 36.9 C (98.5 F)
Pulse | 86 / minute | 84 / minute
Rhythm | Regular | Regular
Respirations | 16 / minute, unlabored | 14 / minute
Systolic | 132 mmHg | 135 mmHg
Diastolic | 86 mmHg | 88 mmHg
Position / Cuff | Left Arm | Left Arm

#### Skin

Erythematous rash, palmar surface, left index finger.

#### Lungs

Clear with no wheeze. Good air flow.

#### Cardiac

RRR with no murmur, no S3, no S4.

#### Labs

CXR 02/03/1999: Hyperinflated. Normal cardiac silhouette, clear lungs.
Peak Flow today: 260 l/m
normal cardiac silhouetteradiopacities

#### In-office Procedures

Suture removal, left forearm.

#### Assessment

Asthma, with prior smoking history. Difficulty weaning off steroids. Will try gradual taper.
Hypertension, well-controlled.
Contact dermatitis on finger.

#### Plan

Complete PFTs with lung volumes.
Chem-7 tomorrow.
Teach peak flow rate measurement.
Decrease prednisone to 20qOD alternating with 18qOD.
Hydrocortisone cream to finger BID.
RTC 1 week.
Complete PFTs with lung volumes.
Chem-7Chem-7 tomorrow
prednisone 20qOD alternating with 18qOD.
Hydrocortisone cream to finger BID.