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Patient/Visit: MLPC15 HL0130.001
Document Type: Good Health Clinic Consultation note
Document Date: 04/08/2000
Gender: Male
DoB: 09/24/1932

ZZZ020 Consultation note .

Consultant : YYY011 .

Date : 04/07/2000 .

Patient : XPT-HL0130 . Medical Record Number : 12345 .

Sex : Male .

DOB : 09/24/1932 .

History of Present Illness . XPT-HL0130 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 . Albuterol inhaler 2 puffs QID PRN . Prednisone 20 mg qd . HCTZ 25 mg qd .

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

Family History . Father had fatal MI in his early 50's . No cancer or diabetes .

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

Physical Exam .

Vital Signs : BP 118 / 78 ; Wt 185 lb ; Resp 16 and unlabored ; T 98.6 F ; HR 86 and regular .

Skin : 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 .

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 . Provide educational material on inhaler usage and peak flow self-monitoring . Decrease prednisone to 20 qOD alternating with 18 qOD . Hydrocortisone cream to finger BID . RTC 1 week .

Signed by YYY011 04/08/2000 .