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  • Amaury Ruiz Sanchez

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    He has never used any illicit drugs. He denies using street drugs with a needle. Has used / is using marijuana. He exercises on a regular basis. He reports doing mild exercise like climb stairs or walk 2-3 blocks. He does not do any regular vigorous exercise for work or recreation.

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    amaury ruiz sanchez

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    He has never used any illicit drugs. He denies using street drugs with a needle. Has used / is using marijuana. He exercises on a regular basis. He reports doing mild exercise like climb stairs or walk 2-3 blocks. He does not do any regular vigorous exercise for work or recreation.

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    © All Rights Reserved
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    26 views2 pages

    Amaury Ruiz Sanchez

    Uploaded by

    api-281279790
    He has never used any illicit drugs. He denies using street drugs with a needle. Has used / is using marijuana. He exercises on a regular basis. He reports doing mild exercise like climb stairs or walk 2-3 blocks. He does not do any regular vigorous exercise for work or recreation.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    of 2

    Progress Notes

    Page 1 of 2

    Turabo University

    Calle Nuevo Leon


    Albany, NY 29978 - 0000
    Tel: 212 876-8768
    Fax:

    Ruiz Sanchez, Amaury


    Sex: Male, Date of Birth: 06-04-1950, Account No: INT01217
    Attending Provider: Marcus . Welby, M.D.
    Encounter Date: 07-13-2015
    Chief Complaint:
    Other Complaints:
    Surgical History
    apendice: 06-17-1998 by Dr. Rivera at Rydel humacao
    vesicula: 04-15-2010 by Dr. Delgado at Hima Humacao
    Family History
    Arthritis: Mother. Cancer: Father. Diabetes: Mother. Heart Attack: Brother, Father. Hyperthyroidism: Mother. Osteoporosis:
    Mother.
    Social History
    Use Of Drugs/Alcohol/Tobacco: Drinks alcohol once a week. Reports drinking beer, 4 drinks and 6 drinks per week. He
    denies his alcohol consumption as being problem to self or family or others. He says he never indulges in 'binge' drinking.
    Denies driving after drinking. He has never smoked tobacco. 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 1-2 cups a day. He has
    never used any illicit drugs. He denies using street drugs with a needle. Has used/ is using marijuana. He exercises on a
    regular basis. 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.
    Current Medication
    Mapap (acetaminophen) 32 mg/mL oral syringe 1tableta cada 4 a 6 horassi es necesario for 30 Days , Dispense 30 Tablet
    nortriptyline 50 mg capsule 1 Capsule Every Morning for 30 Days , Dispense 30 Capsule
    hydroxyzine pamoate 25 mg capsule 1 Capsula al acostarse for 30 Days , Dispense 30 Capsule
    amlodipine 10 mg tablet 1 Tablet Every Morning for 30 Days , Dispense 30 Tablet
    Allergy
    Acetaminophen causes nauseas Moderate . GRASS POLLEN-KENTUCKY BLUE, STANDARD sneezing Moderate . MILK
    THISTLE causes rash Moderate . PENICILLINS causes rash Moderate . SHELLFISH Moderate .
    Health Maintenance
    Type
    Test
    LB
    ANA Panel

    Status
    Due

    Due Date Last Done Last Result


    06-24-2015

    LB
    LB
    LB

    Complete Metabolic Panel


    Lipid Panel
    CBC w/auto diff

    Due
    Due
    Due

    06-24-2015
    06-24-2015
    06-24-2015

    LB

    Renal Function Panel

    Due

    06-24-2015

    LB

    Thyroid Antibody Panel

    Due

    06-24-2015

    LB
    LB
    LB

    Hemoglobin A1c
    Due
    Microalbumin
    Due
    Urinalysis, Complete W/Microscopic Due

    06-24-2015
    06-24-2015
    06-24-2015

    LB

    STOOL GUAIAC

    06-24-2015

    Due

    Vitals
    Weight: 100.00 lbs. Height: 56.00 inches. BMI: 22. Pulse: 10 per min. Respiration: 20 breaths per min. BP Systolic: 180

    https://ut.prognocis.com/prognocis/scrPrint.jsp?id=4459&mode=default&tmpid=2&output... 7/22/2015

    Progress Notes

    Page 2 of 2

    mm Hg. BP Diastolic: 98 mmHg.

    Physical Examination

    Assessment and Plan

    Closed fracture of multiple sites of Metacarpus (815.09) Office/outpatient Visit Est (99214
    Lap Order: LAB00111 07/13/15
    Closed fracture of multiple sites of Metacarpus (815.09) Office/outpatient Visit Est (99214
    Lap Order: LAB00111 07/13/15
    Lab Order
    Radiology Order
    Consults Ordered

    Labs Reviewed
    Radiology Reviewed

    List of education material given


    Follow up:

    No Follow Up

    Marcus Welby, M.D.

    This has been electronically signed on 07-13-2015

    https://ut.prognocis.com/prognocis/scrPrint.jsp?id=4459&mode=default&tmpid=2&output... 7/22/2015

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