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Patient/Visit: MLPC15 HL0131.001
Gender: Male
Document Type: Good Health Clinic Consultation note
Document Date: 04/08/2000

ZZZ020 Consultation note .

Consultant : YYY011 .

Date : 04/07/2000 .

Patient : XPT-HL0131 . Medical Record Number : 12345 .

Sex : Male .

DOB : 09/24/1932 .

History of Present Illness . XPT-HL0131 is a 67 year old male referred for further asthma management . Onset of asthma in his teens . He was hospitalized twice last year , and already twice this year . He has not been able to be weaned off steroids for the past several months .

Past Medical History . Asthma . Hypertension . Osteoarthritis , right knee .

Medications . Theodur 200 mg BID . Proventil inhaler 2 puffs QID PRN . Prednisone 20 mg qd . HCTZ 25 mg qd .

Allergies and Adverse Reactions . Penicillin - Hives . Aspirin - Wheezing . Codeine - Itching and nausea .

Social History . Smoking : 1 PPD between the ages of 20 and 55 , and then he quit . Alcohol : Rare .

Physical Examination .

Vital Signs . Height : 177 cm ( 69.7 in ) 04/07/2000 14:30 . Weight : 194.0 lbs ( 88.0 kg ) 04/07/2000 14:30 . BMI : 28.1 kg / m2 , 04/07/2000 14:30 . BSA : 2.05 m2 , 04/07/2000 14:30 . Temperature : 36.9 C ( 98.5 F ) , 04/07/2000 14:30 ; 36.9 C ( 98.5 F ) , 04/07/2000 15:30 . Pulse : 86 / minute , 04/07/2000 14:30 ; 84 / minute , 04/07/2000 15:30 . Rhythm : regular , 04/07/2000 14:30 ; regular , 04/07/2000 15:30 . Respirations : 16 / minute , unlabored , 04/07/2000 14:30 ; 14 / minute , 04/07/2000 15:30 . Systolic : 132 mmHg , 04/07/2000 14:30 ; 135 mmHg , 04/07/2000 15:30 . Diastolic : 86 mmHg , 04/07/2000 14:30 ; 88 mmHg , 04/07/2000 15:30 . Position / Cuff : Left Arm , 04/07/2000 14:30 ; Left Arm , 04/07/2000 15:30 .

Skin Exam : Erythematous rash , palmar surface , left index finger .

Lungs : Clear with no wheeze . Good air flow .

Cardiac : RRR with no murmur , no S3 , no S4 .

Labs . CXR 02/03/1999 : Hyperinflated . Normal cardiac silhouette , clear lungs . Peak Flow today : 260 l / m .

In-office Procedures . Suture removal , left forearm .

Assessment . Asthma , with prior smoking history . Difficulty weaning off steroids . Will try gradual taper . Hypertension , well-controlled . Contact dermatitis on finger .

Plan . Complete PFTs with lung volumes . Chem-7 tomorrow . Teach peak flow rate measurement . Decrease prednisone to 20 qOD alternating with 18 qOD . Hydrocortisone cream to finger BID . RTC 1 week .

Signed by YYY011 04/08/2000 .