You are on page 1of 11

(9:00) His blood pressure is well controlled. He has had no renal manifestations or cardiac manifestations of his hypertension.

His last cholesterol was found to be 226 with an LDL of 126. No chest pain or shortness of breath. No fever, chills, nausea, vomiting, or diarrhea. He does not smo e. O: !itals" #s above. $eneral" %leasant, white gentleman in no apparent distress. H&&N'" N()#'. '*s are clear. +ropharyn, is pin and moist. %&--L, &+*.. /undi clear, discs sharp. Nec " No adenopathy, thyromegaly, bruits or 0!D. Lungs" ('#1. Heart" --- without *-$. 1. 2. Hypertension, well controlled. Hypercholesterolemia.

A: P:

2e will chec (*% and /L% today. He will continue the lisinopril H('. . encouraged him to continue his diet and e,ercise regimen. #s long as his LDL is below 134, he will not be given a statin. He is to ta e his baby aspirin per day. 0L1"pae)(/014441514

0ohn L 1ur ard, 0r., *D

. +ropharyn. have given him 'ussione. !itals" #s above. one teaspoon every 12 hours. sore throat and cough. He does not smo e.without *-$. %&--L... who presents to the clinic today with a four day history of nasal congestion. or diarrhea. 0r. /undi clear.. Lungs" ('#1. chills. bruits or 0!D. No fevers. Nec " No adenopathy. H&&N'" N()#'. thyromegaly. is pin and moist. $eneral" %leasant blac gentleman. 9-. He is to drin plenty of fluids. in no apparent distress. *D . rest. which is nonproductive. and will follow up as needed. Heart" --. discs sharp. 0L1"pae)(/014441511 O: A: P: 0ohn L 1ur ard. '*s are clear. vomiting. nausea.Desmond Kennedy DOB: 06/26/77 CC: S: (ough. &+*. 2003961 12/16/13 *r. 6ennedy is a 378year8old blac gentleman.

*D . No evidence of in. He has been using Neosporin and #####(10:2$< seems to be getting larger. No fever. .ust above the right eye.ury to eye. nausea.ust below the right eyelid over the =ygomatic arch with some erythema that does blanch. !itals" #s above. >cratch over =ygomatic arch. 0L1"pae)(/014441512 0ohn L 1ur ard.t was . or diarrhea. He has noticed some redness at that area. vomiting. 'here is no evidence of infection. who was scratched by his dog over the wee end. . He reports no ocular pain. Despain is a :48year8old white demonstrates a small abrasion . Neosporin. possible reaction to O: A: P: . have given him wound care instructions and he will follow up with us as needed. $eneral" %leasant white gentleman. 0r. chills. He also has a scratch above the eye.. have as ed him to stop the Neosporin. 'he right facial e. in no apparent distress.Lance T Des a!n DOB: 0"/2"/73 CC: S: Dog scratch. 2010217 12/16/13 *r. He did not get the eye itself.

He is to use over8the8counter cold preparations. Nec " No adenopathy. %&--L.. 0r.. No hemoptysis. H&&N'" N()#'. 10$$2"$ 12/16/13 *r. &+*. 0L1"pae)(/014441513 O: A: P: 0ohn L 1ur ard. He no longer smo es. sore throat.. who presents to clinic today with several days history of nasal congestion. '*s are clear. drin plenty of fluids. !itals" #s above. +ropharyn. and will follow up if no better. bruits or 0!D. $eneral" %leasant white gentleman. Lungs" ('#1. /undi clear. *D . No nausea. thyromegaly. in no apparent distress. He reports little bit of shortness of breath.Te%%y D T&aye% S%'( DOB: 10/17/"3 CC: S: (ough. 'hayer is a 648year8old white gentleman. is pin and moist. discs sharp. and cough. 9-. or lightheadedness. diaphoresis.

No chest pain or shortness of breath. or diarrhea. &+*. . *D . encouraged him to continue his low8carb diet and e. thyromegaly.6 and we started him on metformin ?44 mg b. '*s are clear. .d. will see him bac in two months to chec an #1c. %&--L. He will continue the !ytorin and lisinopril H(' at the present dosages.i. He will see the diabetic educator ne. 0L1"pae)(/01444151: O: A: P: 0ohn L 1ur ard. poorly controlled. He chec ed one random blood sugar and was found to be 127.. No fever. in no apparent distress.. +ropharyn.ey DOB: 10/09/"9 CC: S: /ollowup.d. Nec " No adenopathy.ercise regimen. am going to increase his metformin to 1 g b.i. discs sharp. Heart" --. /undi clear. vomiting. $eneral" %leasant white gentleman. 0r. Lungs" ('#1. bruits or 0!D. is pin and moist. His vaccines are up8to8date. His blood pressure is under good control on lisinopril H(' 24)2? mg once daily. He has lost 7 pounds. His #1c was found to be 14.Da)!d * B%an+. .t month.without *-$. His cholesterol has been under decent control with his !ytorin ?)14 mg once daily and his last #1c was found to be 73. chills nausea. Diabetes. H&&N'" N()#'. !itals" #s above. He is following a low carb diet. 200"13$ 12/16/13 *r. 1rantley returns for followup today of his diabetes.

0ones returns for followup today of his diabetes and hypertension.ercise regimen. 3. Hypertension. He will follow up with us in two months for repeat #1c. in no apparent distress.nvo ana 344 mg once daily. He is doing well. . 0r. His blood sugars at home are fine. *D .nvo ana and #=or at the present doses. he will call.-ac&a%y P . 2hen we last saw him. !itals" #s above. Diabetes mellitus. 0L1"pae)(/01444151? 0ohn L 1ur ard. Heart" --. encouraged him to continue his diet and e. 201009" 12/16/13 *r. +verall. 2. Lungs" ('#1..ones DOB: 11/19/7" CC: S: /ollowup. He reports the .without *-$.f he has any problems before then. . 1.nvo ana has led to stomach upset. No polyuria or polydipsia. O: A: P: He was given the . white gentleman. we continued his #=or 14):4 mg once daily and stopped the 0anumet and switched him to . he reports that he is doing well. +besity. $eneral" %leasant morbidly obese.

1. . *onofilament test is negative. 0ohn L 1ur ard. . 2e will discuss this when he returns in two wee s to see if he needs (%#%.nvo ana 344 mg once daily. bruits or 0!D. and sleep apnea. He is on no medicines for his blood pressure. $eneral" %leasant.f he has any problems before then.d. . He went to sleep study on >aturday night.i. H&&N'" N()#'. +ropharyn.d. 2012371 12/16/13 *r. am going to add . :. . !itals" #s above. Heart" --. who returns to clinic today for followup. Nec " No adenopathy. 3. is pin and moist. Horton is a 278year8old blac gentleman with diabetes. last saw him. He was given a pneumococcal vaccination and flu vaccination in the office today. will await the results of his sleep study. /undi clear. as his #1c was found to be 1:. 0r. vomiting. . thyromegaly. hypertension. started him on metformin ?44 mg b. am going to rechec his blood pressure at ne. &levated blood pressure.t visit. or diarrhea. No chest pain or shortness of breath. blac gentleman. No fever. . encouraged him to continue his diet and e. . His cholesterol was 334 with an LDL of 2?1. discs sharp. have started him on atorvastatin :4 mg once daily.?. we will begin an #-1. 2e will schedule him with the diabetic educator. 2hen . am going to see him bac in two wee s@ time. am going to increase his metformin to 1 g b. . His microalbumin has been negative. ./%e0o%y *o%+on DOB: 07/02/16 CC: S: /ollowup. but does not now the results. in no apparent distress. he will call. He does not smo e.without *-$.. 'ype 2 diabetes mellitus. poorly controlled. morbidly obese. . nausea. and . *D . Hypercholesterolemia.i. >leep apnea.. 0L1"pae)(/014441516 O: A/P: 2. &+*. %&--L.ercise regimen. chills. Lungs" ('#1. '*s are clear. will rechec this in three months. 'hey did try (%#% on him suggesting that he did have in fact sleep apnea.f it remains elevated.

'*s are clear. *D . +ropharyn.2)a 3 Sna DOB: 0$/16/79 CC: S: /ollowup sinusitis. rest and will follow up as needed. in no apparent distress. Lungs" ('#1. chills. &+*. H&&N'" N()#'. 0r. and cough. discs sharp. Nec " No adenopathy. nausea. $eneral" %leasant white female. nasal discharge. %&--L. bruits or 0!D. No fevers. 2e will place her on (efdinir 644 mg once daily for 14 days.without *-$. >he does not smo e. >he is to drin plenty of fluids. >inusitis. who presents to clinic today with a two8wee history of facial pain and pressure. vomiting. Heart" --. thyromegaly.. >napp is a 3:8year8old white female. !itals" #s above.. 0L1"pae)(/014441517 O: A: P: 0ohn L 1ur ard. or diarrhea. 110"3"7 12/16/13 *s. is pin and moist. /undi clear.

months. in no apparent distress.Kenne+& 4a% DOB: 03/20/69 CC: S: /ollowup gout. $out. He has no complaints. . months for uric acid level. 2003""9 12/16/13 *r. *ar returns for followup today of his gout. &. 0r. he will call.tremities" Lower e. 0L1"pae)(/01444151A O: A: P: 0ohn L 1ur ard. He reports he is doing well with it. !itals" #s above. . He will follow up with me in si. He is presently ta ing 9loric A4 mg once daily. refilled his 9loric A4 mg once daily.amination reveals no erythema. stable.. His last uric acid level was ?.f he has any problems.tremity e. No gouty arthritis for the past si. *D . $eneral" %leasant white gentleman.

>ensation is intact throughout. 0L1"pae)(/01444151B O: A: P: 0ohn L 1ur ard. D'-s are 2C throughout. >trength is ?)? throughout. No trauma. white gentleman. He reports he has had nec pain since he was in a car accident in 1BB4s. who wo e up this morning with nec pain.t hurts to turn his nec to left. (ervical strain. 1asso is a :28year8old white gentleman. placed him on Naprosyn and Norfle. *D . He is to put heat to the affected area.ona+&an K Basso DOB: 0"/01/71 CC: S: Nec pain. He will follow up with us if no better. .. No numbness in his hands. $eneral" %leasant. Nec " &. 1033016 12/16/13 *r. ... in no apparent distress. 0r.amination has full range of motion. !itals" #s above.

nontender. Lungs" ('#1. He reports no relation to eating with this pain. %ain is not reproduced by palpation on the left side. no masses or H>*. . %robable thoracic strain. .8ray was negative.. He is to put heat where it hurts. He will follow up with us if no better. >hah is a :48year8old #sian gentleman. 'hey recommended a cholecystectomy. and nondistended. #bdomen" >oft. . 10371"3 12/16/13 *r... !itals" #s above. have placed him on Naprosyn and Norfle. 0L1"pae)(/014441524 O: A: P: 0ohn L 1ur ard. *D . .t was not bad enough that he went to the emergency room.t seems to get worse when he wa es up in the morning. in no apparent distress. (hest . No rash. 9pper endoscopy was completely negative and they did a right upper Duadrant ultrasound even though the pain was on the left and found no gallstones. 0r.without *-$. $eneral" %leasant. No cough or hemoptysis.A5!dan P S&a& DOB: 10/13/73 CC: S: Left8sided pain. 'hey thought it could be some #####(16:"2< to $. No rebound or guarding. who presents to clinic today stating that since >eptember when he went out #####(16:$2< pain in his left side. #sian gentleman. Heart" --.t seems to be constant.