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Turabo University
Inostroza, Jayden
Sex: Male, Date of Birth: 05-15-1980, Account No: INT01304
Attending Provider: Marcus . Welby, M.D.
Encounter Date: 07-01-2015
Chief Complaint:
Other Complaints:
Past Medical History
Fever Unspecified 780.60 Existing. Vomiting Alone 787.03 Existing. Chest Pain 786.50 Existing. Cough 786.2 Existing.
Streptococcal Sore Throat 034.0 Existing. Diarrhea 787.91 Existing. Abdominal Pain, Generalized 789.07 Existing.
Surgical History
Leg Surgery : 05-25-2010 by Dr. delgado at hima san pablo humacao
Raspe de Prostata: 07-22-2010 by Dr. Oquendo at rydel memorial
Family History
Alcoholism: Uncle. Diabetes Type II: Sister. Heart Trouble: Father, Mother. Hypertension: Brother.
Social History
Work History: He is employed.
Use Of Drugs/Alcohol/Tobacco: Drinks alcohol occasionally. Reports drinking beer and other, 4 drinks per week. He
denies his alcohol consumption as being problem to self or family or others. Denies ever experiencing blackouts. He says he
never indulges in 'binge' drinking. Denies driving after drinking. He has quit smoking but was a light smoker. He consumes
0. Number of chews per day: 0. No. Of pipes smoked per day: 0. Cigars smoked per day: 0. Reports consuming caffeine or
caffeinated drinks 3-5 cups a day. He has never used any illicit drugs. He denies using street drugs with a needle. Has used/
is using marijuana. He has a sedentary lifestyle. Does not take any exercise. He reports doing mild exercise like climb stairs
or walk 2-3 blocks. He reports doing occasional vigorous exercise ( work or recreation). He does not do any regular vigorous
exercise for work or recreation.
Vaccination History
Vaccine
Hepatitis B
Dose
1
Age Range
0 - 1 Months
Due Date
06-26-2005
Hepatitis B
Diptheria, Tetanus Toxides, Acellular Pertusssis
2
1
1 - 2 Months
2 - 2 Months
07-26-2005
08-26-2005
2 - 2 Months
08-26-2005
Inactivated Poliovirus
Pneumococcal
1
1
2 - 2 Months
2 - 2 Months
08-26-2005
08-26-2005
Rotavirus
2 - 2 Months
08-26-2005
2 - 2 Months
08-26-2005
4 - 4 Months
4 - 4 Months
4 - 4 Months
10-26-2005
10-26-2005
10-26-2005
Inactivated Poliovirus
Haemophilus Influenzae Type B
2
2
4 - 4 Months
4 - 4 Months
10-26-2005
10-26-2005
4 - 4 Months
10-26-2005
3
3
6 - 6 Months
6 - 18 Months
12-26-2005
12-26-2005
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7/6/2015
Progress Notes
Page 2 of 4
6 - 6 Months
12-26-2005
Influenza
Inactivated Poliovirus
1
3
6 - 12 Months
6 - 18 Months
12-26-2005
12-26-2005
Pneumococcal
3
Rotavirus
3
Tetanus, Deptheria toxoids and acellular pertussis 3
6 - 6 Months
6 - 6 Months
6 - 6 Months
12-26-2005
12-26-2005
12-26-2005
1
4
12 - 15 Months
12 - 15 Months
06-26-2006
06-26-2006
12 - 15 Months
06-26-2006
Hepatitis A
Vericella
1
1
1 - 2 Years
12 - 15 Months
06-26-2006
06-26-2006
15 - 18 Months
15 - 18 Months
09-26-2006
09-26-2006
Hepatitis A
Haemophilus Influenzae Type B
Influenza
2
5
2
1 - 2 Years
18 - 37 Months
1 - 1 Years
12-26-2006
12-26-2006
12-26-2006
Pneumococcal
Pneumococcal Polysaccharide
5
1
24 - 37 Months
2 - 6 Years
06-26-2007
06-26-2007
Meningococcal Polysaccharide
Influenza
Influenza
1
3
4
2 - 10 Years
2 - 2 Years
3 - 3 Years
06-26-2007
12-26-2007
12-26-2008
5
4
4 - 6 Years
4 - 6 Years
06-26-2009
06-26-2009
4 - 6 Years
4 - 6 Years
4 - 6 Years
06-26-2009
06-26-2009
06-26-2009
Influenza
Influenza
5
6
4 - 4 Years
5 - 5 Years
12-26-2009
12-26-2010
Vericella
Vericella
3
4
7 - 12 Years
7 - 12 Years
06-26-2012
09-26-2012
Health Maintenance
Type
Test
LB
AMYLASE,SERUM
Status
Due
LB
Cardiac Panel
Due
07-01-2015
LB
LB
Due
Due
07-01-2015
07-01-2015
LB
LB
LB
Due
Due
Due
07-01-2015
07-01-2015
07-01-2015
LB
Microalbumin
Due
07-01-2015
LB
STOOL GUAIAC
Due
07-01-2015
RL
RL
RL
Echocardiogram
Chest x-ray PA and Lat
Abdomen (2 view)
Due
Due
Due
07-01-2015
07-01-2015
07-01-2015
RL
Abdomen
Due
07-01-2015
Last Result
Review of Systems
Constitutional Symptoms: The patient reports fever and chills.
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7/6/2015
Progress Notes
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Physical Examination
Obtain following labs today: CBC with differential, lip panel, bloos glucose, and urinalysis. In addition, blood and urine
cultures are needed. Antibiotic therapy to be determined based on lab results. The patient was advised to take analgesics to
relive symptoms until results confirm or rule out sepsis and causative agent. He is to call tomorrow to let me know how he
feels, and seek immediate treatment if his fever reaches 103.5 degrees.
Obtain following labs today: CBC with differential, lip panel, bloos glucose, and urinalysis. In addition, blood and urine
cultures are needed. Antibiotic therapy to be determined based on lab results. The patient was advised to take analgesics to
relive symptoms until results confirm or rule out sepsis and causative agent. He is to call tomorrow to let me know how he
feels, and seek immediate treatment if his fever reaches 103.5 degrees.
Lab Order
Radiology Order
Consults Ordered
Labs Reviewed
Radiology Reviewed
No Follow Up
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7/6/2015
Progress Notes
Page 4 of 4
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7/6/2015