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 / TimeApril 7, 2000 14:30April 7, 2000 15:30
Height177 cm (69.7 in)
Weight194.0 lbs (88.0 kg)
BMI28.1 kg/m2
BSA2.05 m2
Temperature36.9 C (98.5 F)36.9 C (98.5 F)
Pulse86 / minute84 / minute
RhythmRegularRegular
Respirations16 / minute, unlabored14 / minute
Systolic132 mmHg135 mmHg
Diastolic86 mmHg88 mmHg
Position / CuffLeft ArmLeft 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.