Good Health Clinic Consultation Note
RobertDolinMDRobertDolinMDGood Health ClinicRobertDolinMDHenryLevinthe 7thHistory 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 silhouetteradiopacitiesIn-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.