John Davis, MD
Family and General Medicine
1600 Creekside Dr., Suite 3300
Folsom, CA 95630
voice (916) 983-7200
fax (916) 983-8591
Dr.
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re: Adams, John dob 10/01/1923 79 & 4/12 y/o 2-26-03
000-0000 ---
subject: Medical Record
Dear Sir or Madam,
John Adams's medical record summary follows. If further specific information is desired,
please let us know so that we can selectively copy it and send it to you.
Sincerely,
John Davis, MD
_______________next page________________________________________
Adams, John dob 10/01/1923 79 & 4/12 y/o 2-26-03
000-0000 ---
Patient Medical Record Summary
prepared for Dr.
Note:
this table usually adds some information at each visit http: //coremedicalconcepts.com PMH: long tobacco habit,
hypoxemia, PVD w/ bypass, HBP, asthma, RLL pneumonia 1995, chol/HDL 215-61 7/96; O2 sat on RA
at rest 82 and 76 w/ accurate pulse pick up, w/o gross dyspnea; left carotid?
Surgery ‘70’s w/ subsequent chronic left frontalis muscle non-function and
left angle of mouth weakness; visual field loss x 2/98; COPD; aspiration
pneumonia 3’98, prior chronic severe
hypoxemia: sat 76-82% on RA 1/98 w/o gross dyspnea; but 96% O2 sat on RA since off tobacco x 1/98 10/14/98 |
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FH: f cancer ? type, m HBP |
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Problem Progress List |
02/16/01 |
02/13/01 |
02/07/01 |
12/14/00 |
04/18/00 |
7/6/98 |
|
|
Cholesterol - HDL
|
|
|
|
191-55 |
207-79 |
150-- |
|
|
LDL -- trigly |
|
|
|
124-88 |
119-45 |
|
|
|
weight
and/or height ® |
|
135 |
|
|
|
124 |
|
|
BUN-creatinine K+
|
47-2.4 wnl |
59-2.7 6.5 |
76-3.4 6.3 |
|
|
1.9-54 |
|
|
RBS
or FBS |
560® 266 |
283 |
|
|
|
|
|
|
Ongoing Meds |
Past meds used & notes
about them below: |
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Lisinopril stopped |
x
~ 02/09/01; previously, 10 mg 4 qd x before ‘12’98 |
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glucotrol
5 mg 1/2 qd |
x
02/20/01; previously, qd started x 2/14/01 |
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Atrovent
neb qid prn |
resumed
6/5/98 |
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Atrovent
500 m vial nebulized qid prn |
|
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Lasix
stopped |
x
02/14/01; previously, 40 mg qd x 7/6/98; before that, bid x 6/29/98 |
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K+ stopped |
x ~
02/09/01; previously, 8 meq qd w/ H2O, 10 meq x 01/12/99 ok qs 6 mos;
previously, 10 meq qd w/ h20 x 6/98, D to base formulary |
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Albuterol
nebulizer 0.5 cc 3 cc NS qid prn |
1998
abx prophylaxis cefzil 500 mg qd x 6/22/9810/26/00 |
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Guaituss
AC 1-2 t q 4-6 hr prn 8 oz mr2 |
X
10/26/00 |
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azmacort
2 p qid prn |
|
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humabid
600 bid |
|
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Quinine
sulfate 325 mg q hs prn |
qs
6 months 9/28/00 X 10/26/00; before that x 9/2/98 before that, lower dose x 8/11/98 R quadriceps cramps |
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Biaxin
250 mg bid pc |
X
11/00 |
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Pravachol
20 mg q hs |
#
90 x 11/29/00 |
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selected test results: Dr. Pecha; CXR increase in infiltrate and slight increase in CM
5/29/98; EKG LAE, Incomplete RBBB, RVH, AS MI 7/8/98; PSA 0.5 and urine
C&S wnl 10/16/98; CXR severe chronic interstitial lung dz scarring bullae
and pul HBP 05/99; urine C&S neg 11/99; 02sat RA w/ walking 85%; resting
w/ O2 96% 2/3/2000; XR ileus &
possible gall stones 3 way abd with US gall stones w/o appendicitis, pnacreas
obscured wnl CT abd but for severe lung bullae inferiorly 11/00; renal
failure w/ wbc & hgb both 10.7, RBS 59
2/7/01 |
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ADR: ativan 7/6/98; benadryl muscle twitches; cough syrup insomnia
3’99; Immunizations: pnvax ‘94;
flu 11/12/99 , flu ~11/7//00 |
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Office visit
record: ... ct’d ... ct’d 02/13/01
renal failure 02/14/01
new DM, dehyration, renal failure, chronic pneumonia, COPD, K+ |
02/16/01
new onset DM w/ dehydration & renal failure, lisinopril & lasix
stopped, pneumonia, hyperkalemia, COPD 02/20/01
hypoglycemia, chronic pneumonia & chronic DOE |
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John Smith, MD 2-26-03
Remote office visit record:
3/6/98 CVA, left lateral visual field loss & paresis of left lateral gaze paresis, [no MRI nor CT] dysphagia, LL pneumonia, probable aspiration etiology x 2/98; peg tube x ~2/25/98
3/31/98 seasonal allergic rhinitis; vision loss post stroke
5/6/98 HBP; CVA sequelae; aspiration pneumonia.
4/15/98 aspiration pneumonia; COPD hx
5/29/98 chronic bronchitis; COPD O2 sat 86% on 2-3 L
6/8/98 recurrent pneumonia; COPD +/- aspiration; dry mouth; 81% sat on 3 L 6/15/98 pneumonia; hx aspiration and stroke; [microhematuria] ® hospital pneumonia pyelonephritis 6/24/98
6/29/98 marked edema both legs
7/6/98 edema; COPD
7/15/98 new onset CHF resolved, COPD; oximetry 99% on RA; ABG pCO2 39.4, p02 64, O2 calc 93%
8/11/98 COPD, leg cramps, K+ frustrations w/ pharmacy
9/14/98 COPD, stroke vision loss, PVD
10/14/98 prostatic enlargement [PSA wnl]; prostatitis element; COPD; [urine C&S wnl]
11/13/98 COPD
12/28/98 COPD, bronchitis
02/03/99 bradycardia
02/17/99 uri post cataract repair yesterday
03/01/99 bronchitis, bradycardia (atenolol dc’d)
03/23/99 bronchitis
04/05/99 GERD
05/17/99 bronchitis
05/24/99 chest wall pain, myalgia vs cracked rib
09/21/99 BPH, cataracts
09/23/99 authorization to treat to MFH ER
10/04/99 COPD, BPH
10/26/99 bronchitis, COPD, pneumonia sequelae
11/05/99 suspect pyelonephritis, responded to cipro
11/12/99 COPD, flu shot
12/21/99 ophth referral, cataracts
12/28/99 multi-medicine multi-month rx
01/7/00 hospitalized MFH, COPD, viral syndrome, pneumonia
01/18/00 resolved pneumonia
02/08/00 pneumonia f/u, COPD
04/12/00 pneumonia, hypoxemia, ST-T wave D‘s
04/14/00 pneumonia
05/03/00 bronchitis
10/26/00 leg cramps, bronchitis
11/13/00 recurrent bronchitis
11/16/00 MFH admit: RUL & RLL pneumonia w/ new L frontal stroke
11/29/00 stroke®increased visual loss, nocturnal leg cramps, pneumonia better
02/05/01 suspect pneumonia
John Smith, MD 2/14/01
Problem Progress List |
04/18/00 |
7/6/98 |
4/15/98 |
3/31/98 |
3/6/98 |
7/96 |
12/95 |
Cholesterol -
HDL |
207-79 |
150-- |
|
|
|
215-61 |
210-47 |
LDL -- trigly |
119-45 |
|
|
|
|
|
|
Dysphagia
p CVA 2’98 |
|
|
|
B80% |
|
|
|
Creatinine-BUN |
|
1.9-54 |
|
|
|
|
1.1-23 |
HBP |
|
|
|
|
|
|
|
weight 127#
7/15/98 |
|
124 |
144 |
131# |
|
139 |
|