Good Health Clinic Consultation Note Huisadres 1 1000AA Stad Henry Levin the 7th E.Novation B.V. Good Health Clinic
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History of Present Illness Henry Levin, the 7th is a 67 year old male referred for further asthma management. Onset of asthma in his twenties 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 Caption: list with specific style elements to test Asthma Hypertension (see HTN.cda for details) Osteoarthritis, right knee
Medications Theodur 200mg BID Proventil inhaler 2puffs QID PRN Prednisone 20mg qd HCTZ 25mg qd Theodur 200mg BID Proventil inhaler 2puffs QID PRN Prednisone 20mg qd HCTZ 25mg qd
Allergies and Adverse Reactions 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 Examination
Vital Signs
Date / Time April 7, 2000 14:30 April 7, 2000 15:30
Height 177 cm (69.7 in)
Weight 194.0 lbs (88.0 kg)
BMI 28.1 kg/m2
BSA 2.05 m2
Temperature 36.9 C (98.5 F) 36.9 C (98.5 F)
Pulse 86 / minute 84 / minute
Rhythm Regular Regular
Respirations 16 / minute, unlabored 14 / minute
Systolic 132 mmHg 135 mmHg
Diastolic 86 mmHg 88 mmHg
Position / Cuff Left Arm Left Arm
Skin Exam Erythematous rash, palmar surface, left index finger. R0lGODlhfgCRAPcAAAAAAIAAAACAAICAAAAAgIAAgACAgICAgMDAwP8AAAD/AP//AAAA//8A/wD/ /////wAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAMwAAZgAAmQAAzAAA/wAzAAAzMwAzZgAzmQAzzAAz/wBm AABmMwBmZgBmmQBmzABm/wCZAACZMwCZZgCZmQCZzACZ/wDMAADMMwDMZgDMmQDMzADM/wD/AAD/ MwD/ZgD/mQD/zAD//zMAADMAMzMAZjMAmTMAzDMA/zMzADMzMzMzZjMzmTMzzDMz/zNmADNmMzNm ZjNmmTNmzDNm/zOZADOZMzOZZjOZmTOZzDOZ/zPMADPMMzPMZjPMmTPMzDPM/zP/ADP/MzP/ZjP/ mTP/zDP//2YAAGYAM2YAZmYAmWYAzGYA/2YzAGYzM2YzZmYzmWYzzGYz/2ZmAGZmM2ZmZmZmmWZm zGZm/2aZAGaZM2aZZmaZmWaZzGaZ/2bMAGbMM2bMZmbMmWbMzGbM/2b/AGb/M2b/Zmb/mWb/zGb/ /5kAAJkAM5kAZpkAmZkAzJkA/5kzAJkzM5kzZpkzmZkzzJkz/5lmAJlmM5lmZplmmZlmzJlm/5mZ AJmZM5mZZpmZmZmZzJmZ/5nMAJnMM5nMZpnMmZnMzJnM/5n/AJn/M5n/Zpn/mZn/zJn//8wAAMwA M8wAZswAmcwAzMwA/8wzAMwzM8wzZswzmcwzzMwz/8xmAMxmM8xmZsxmmcxmzMxm/8yZAMyZM8yZ ZsyZmcyZzMyZ/8zMAMzMM8zMZszMmczMzMzM/8z/AMz/M8z/Zsz/mcz/zMz///8AAP8AM/8AZv8A mf8AzP8A//8zAP8zM/8zZv8zmf8zzP8z//9mAP9mM/9mZv9mmf9mzP9m//+ZAP+ZM/+ZZv+Zmf+Z zP+Z///MAP/MM//MZv/Mmf/MzP/M////AP//M///Zv//mf//zP///yH5BAEAABAALAAAAAB+AJEA QAj/AP8JHEiwoMGDCBMqXMiwocOHECNKnEixosWLGFHAckaN2jRnsKZhHEmy5EMU0+L5EseNG654 KEzKnGkShbN4uFq2xOWRps+fE5nEy6Wz5a+XQJMqTeisGdGiLuNRi7m0qlJn06iF7LhxKoqvX2Fp nRYSq1eBX62qRYhCKzWzZDeK3bqR7NSsb99uddZ2r1ZnINuanbrWp82tb8ly/Bjya1aOKOu+5ZgX ZFa7sARzBMl5a9rCJDl29ejxMuDKeb3mJYsSa93GIOW61QgWbEjQGStbrru7o2K3dkXjBUz242WU bj0u9vj1b2KquCn27Rq7I1+9nBkn7gySK/HBnFd3/y8bUizf6CM76s0qduxp0pvN23UrOnF7zB7n WiaMXuZhvGJNoxhjpr3G3WMfJfdbgtD1p1RbxgkHX3uUbeYbdli5dp6DHHbo4YcghijiiCSWeJJG rJloIkoqPeXLNA2q+GFHm+yUSzzxiCQjiG3hVFQuN+74IQry4JSTTjfCImSHyE1TyS9I+iJPZkv2 1ySE+bE31VTjhZfZfhm2V+VJXLH3WH70MfZVeKfF9Z1inv3mXldjEiTYmX9tpVhkXrW1JpfX6bVd nosh19xGINVpk3JydafYZjC6RhqMNlHa11u0aQbjl/mVJaB1McrY16eSSeYle2AmqGp5wIl1KVxj +f8WIDV1/iOYVote5lt4eZUn6WsI+kZgp6iVxV+tAs064aqUebdraW55GqZ2AiIWKrIHQahfo3bB eaZ5zq1q17XYMoQleQt+Jxt56jXrarnwxivvvPTWa++9TJYlGrn4+kdNPJv4kksz92zY709ExqPJ kbncw+/BI9mEDy4Mx+MMxD/9+xQ3m+RIK8Yz2STPkS11s8nFIMvEhDw1FoVLxynLdI9KR+bUMMox R+yML1BxIyWMOY+0kTxQuizVw0E3hOJjBTe9UYO1fZZ0Qlga59hYvgLX3W7GWo20vLWV5uqjlHZU aVcDbukuZVTe29poqNYnZ2ZzrdbV0hRmdZh9dX3/raKv5MknG19YVojmVPIJmtlwhBpXbq4V6trd 1VhV6t5jfM6XWWVzaRmZ3yO+3WaAi3XGFZfP2vRnYogLp+tec4Ee4qLZ3dfV3XXpHanZMHJVd6Ws ucprXJiOyaZ+iaH60aJ1JxirRoCF5WdmfnqlJ9uUVdma1m7CvTe74mHWLSyNgft6nmaDNSZy5o1m HvPWadW+aN9luVxglpnVeXF6Kxr/88MhX3wcJZsBuS81uDpc+5KDM0VBr3SlAQx1LBSSy1AHT2iS S1u2E6DYwUtbGTQOacj3mPGg6TeSEZBrWAUnyMzrbVk6XVyKsxgCwW0/62GMhVKErw12S1D5S018 5RQnn8XQxYUx45NyNOe87gCRPubZj+xeaB+smIl+yllirChoxKmhxExoK1Cv0BSftAVmamhMoxrX yMY2uvGNcIyjHOeoxkXBh44OOZdn8Ggu+DiPjwtJ2CZyUomCTRGOKJFHLljiEnkc8o0Sy0U3WpIL oAGSLf9qmc86ckmE/MtHOfEFVjp5EGfc40jieAlgSFmQL27sF/GQx8dYiRaP8EwnL9ERLW1lS5L5 whfxyMcubaWworVEHIX0xzBRcI9NMBJJ9xgmMTW5E19QQ5m0tAlOjOkzeeiSlcwcJFSAeSxSomRj uDT/2y6ncQ9fkMwozMkmVhRWlFTGk5T5sAlgaCawjjWjnJcEYoYWRJU/CUdqbQSXbNYEGRQZjj63 0qAXO7MmRJ3pOq65DOOiBaqghaVya4sUcrKYn+ugay+PXFJzgiOesGWISx3sFfRoaEHCqY9ePmzU pCoTnN5JyobF8lx9zJJSEZlqWNK6D0artaDWsY4zOV2NVj5olq2VVIvCQ1GsjKURBSnnbCJkFbzi hxdSqYc1MAyhZZBDPwZ1sKygKiqTHsOqPGFOL8JrX7cgxBmiYk2LagKo9uQ3LKv2zjGcMlbsVLUv I2YRUf+Z5fq2GqzRqO04Z2POlyo4m7KGB3oXsmSd/2Llps7Mh6mVK84FtQW9qllnccLJkFythBgU yo2FAlzTgMIyqECVDkZltSgSB6unZ8Vwc9jZHKUIJ8Ll8YkvkmLUa3koJPaFdoGeK2Ln9KI6S4GF VMsDV31eM1vQqPZT+uMpcJYY2/V89y9+0tuoKuqp8mhvfKnx7NNI95fiCIpx1Nmchrj1VbaWtzAO dSLr6MLX+5VHPx+BVIVQdLuXKk8v2pMg69wzFodez0x/Fa+37tQ4CcbnwAge6Icbg9Ww6gpAALLr Xer20mKhuDDGoWlg/Aveq8InizQsjwq7GkQEEVVRsWHQYYIYQ+cFK00G4o1webxWZEEIsVAEznmH 6N1Y4eiUNJaLaRex9UVfwWlSJCRhr+AiZElZsYZoi5xg12eqp3buNEJm3LRQBcTeSZUx8/pLdk53 w9p6CYKE/p+J83NjJuUPeemq71bbqrjTkTEvjfaQDyFFnXbJr1lshqIKnaja4uHrtWEa4beqRZpJ pXcvy3kaxhxD6U/NqaQ0xCr6jJhpFUlYPVl01HrsI8JYPSdpoCXhEG2YUVzrqT2mzpkSKVRAG955 u3SJdhITZ766KosyNjQOnZAt6F3d7oQJ+inaJNPrHUXt3fCOt7ylSe962/ve+M63vvkYEAA7
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 normal cardiac silhouette radiopacities
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 20qOD alternating with 18qOD. Hydrocortisone cream to finger BID. RTC 1 week. Complete PFTs with lung volumes. Chem-7 Chem-7 tomorrow prednisone 20qOD alternating with 18qOD. Hydrocortisone cream to finger BID.