James, Patricia            dob 02/01/1926           77 & 0/12 y/o              2-26-03

941-0000                     000-0000  

 

Patient Pocket SummaryTM

 

Patient to sign here for receipt of this private

information.____________________________     2-26-03

 

Note: this table usually adds some information at each visit  http: //coremedicalconcepts.com

PMH: gyn hx infra, appy ~ 15 y/o; Crohn's; urinary incontinence but no fistula, just loss of angle per urology; seizure disorder, DJD neck, HH, COPD, recurrent UTI, monilial angular stomatitis, partial small bowel obstruction resection 1970, 1988; B12 injection need; no tobacco x ‘85; TIA ~’75, stroke? per Dr Goldstein hx

FH: no breast ca

Problem Progress List

03/14/01 

3/00

4/1997

 

 

 

 

 

 

Cholesterol  -  HDL

195-106

195-106

226-118

 

 

 

 

 

 

LDL  -- trigly

69-100

69-100

 

 

 

 

 

 

 

  ‘ “          weight ® 

106

90#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ongoing Meds

Past meds used & notes about them below:

 

Dilantin 100 mg tid

x ‘85 for seizure

 

Estropipate 0.625 qd

(=ogen=orthoest); previously on premarin 2/98; TAH BSO ‘70, bladder suspension, wnl mammogram 9’98

 

Hcthz 25 mg q AM

x 02/00; previously, hcthz 25 mg q AM or dyazide x ‘95

 

K+ 8 meq qd

X 8/4/00

 

Stopped

x 02/00; previously, lorazepam 0.5 mg 1-2 tid prn x ‘96; # 60 mr2 03/08/99

 

Prednisone 5 mg qd

x 1970

 

Pentasa 250 mg 4 qid

x 1/00; previously, azulfidine 500 mg 1-2 qid x 2/98; stopped 2/98; hx asacol 400 mg 2 tid ‘96; occl prednisone x 10 yrs; vit B12 injections 09/08/99

 

Quinine SO4 325 mg hs prn

x before ‘94; B12 q several months

 

Monthly B12 injection

stopped lomotil 1-2 qid if needed x years; #240 mr6  03/29/99

 

Darvocet N 100 1 q 4-6 hr prn pain max #30/mo

zantac 150 mg hs x ‘93; bentyl prn; occl lomotil; B12 1000 mg  IM 06/18/99

 

vicodin 5 mg q 4-6 hr prn pain max #30/mo

for neck pain, see MFH ER visit 05'01

 

Selected test results: cardiac w/u ETT + 8’95, echo heart Normal 7’95; gi Dr. Schneiderman 4/1/98; colon wnl except diverticulosis 5/12/98; wnl EKG and CXR ‘97; CBC sgot alk phos lipase wnl but UA and C&S + 03/99; urine C&S neg 03/29/99; CXR probable old histoplasmosis 06/99; R hip post-op pelvic changes noted, w/ diffuse osteopenia w/o advanced arthropathy 12/99; CBC ESR K+ giardia Ag stool O&P  C- difficile wnl 2'00; neck XR trace anterolisthesis C4 on 5, minimal DDD neck 8/00;  CBC CMP UA lipids ESR SPE & TSH wnl except ¯ K+ 3.3, FBS ­ 159 [Hgb A1C 5.6], & UTI sensitive to sulfa 8/00; wnl CXR neck XR & EKG MFH ER 05'01; XR L5-S1 DDD 10'01

 

ADR:  penicillin rash, macrobid & motrin gastritis    Immunizations: pneumovax & Td 5’95; flu 11/6/99 & 10/29/01

 

Office visit record:  ... ct’d

10/1/01 chronic LBP x '97 fall, psoas myalgia?, seborrheic keratosis L preauricular region, pointed L malar red papule

10/29/01 seborrheic keratosis, facial papule, flu & B12 shot

12/10/01 labyrinthitis, neck myalgia

1/2/02 Crohn’s

 

 

John Smith, MD                 2-26-03