EllaC
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NOTE (Tuesday April 2, 2019 03:17 PM)
Chief Complaint: Three week recheck, feeling a little better from her sinus surgery.
History of Present Illness:
is now about 2 weeks status post her sinus surgery and has completed a postoperative course of
antibiotics. Her headaches are somewhat better but she is still having some headaches which are worse if
she bends over.
also complains of diffuse body pains, including low and upper back pain and pain in her hips and her
knees. She does have known arthritis in her knees, particularly the left one. The right knee is status post
replacement.
At the time of her hospital discharge was noted to have elevated liver tests. Apparently, she was told
by the hospitalist that this is caused by fatty liver disease. She has been having some abdominal pain and GI
upset since her hospitalization.
She has not had any lower extremity edema and is currently not on BUMEX. She has been coughing and is
requesting a refill on her HYCODAN.
Review of Systems:
GENERAL: Notes intermittent sweats, but ongoing issue, headaches as noted, sometimes lightheaded.
RESPIRATORY: Coughing as noted, occasional shortness of breath.
CARDIOVASCULAR: No chest pain, occasional heart racing.
GASTROINTESTINAL: Notes some reflux issues. No diarrhea or constipation.
GENITOURINARY: No urinary pain or frequency.
EXTREMITIES: No lower extremity edema.
SKIN: Notes bruising a bit lately as well.
Past Medical History:
1. Pulmonary hypertension, Dr. Ordal.
2. Fibrositis, and ill defined connective tissue disorder, Dr. Chamberland.
3. Chronic pain, fibromyalgia.
4. Essential hypertension.
5. GERD, esophagitis, IBS, Dr. Chow.
6. Osteoporosis.
7. Asthma.
8. History of renal stones.
9. History of angioedema, urticaria.
10. History of physical abuse, rape.
11. Depression / anxiety.
12. Sleep walking.
Past Surgical History:
Appendectomy, cholecystectomy, hysterectomy without BSO, rectal fissure surgery.
Family History:
CAD: Father, deceased at 56, myocardial infarction, cerebrovascular accident.
DM: Maternal grandfather.
CA: Mother, deceased at 72, liver cancer. Uncle and aunt, liver cancer.
OTHER: Mother, temporal arteritis, 20. Sister, Reiter syndrome. Two brothers, suicide.
Social History:
Married, 3 stepchildren, previous respiratory therapist now disabled.
[Tobacco: Former smoker (2 pk yrs / 38 yrs quit)
Start Date: 08/31/2018 End Date: 08/31/2018]
Allergies: penicillin, sulfa drug, codeine, aspirin, Ultram, AMITRIPTYLINE, MORPHINE, PAXIL,
TIGAN, METRONIDAZOLE, Bee Sting, hydromorphone, cephalexin, clindamycin
Medications: 1) Advair Diskus 250 mcg-50 mcg inhalation powder, 1 puff BID
2) albuterol 5 mg/mL (0.5%) inhalation solution, 1ml by nebulizer route q 6 hours prn SOB
3) albuterol CFC free 90 mcg/inh inhalation aerosol, 2 puffs QID PRN
4) amitriptyline 25 mg oral tablet, One tablet at night
5) amLODIPine 10 mg oral tablet, Take 1 tablet by mouth once daily
6) budesonide 180 mcg/actuation inhaler, 1 puff qd
7) bumetanide 2 mg oral tablet, 2 BID as needed
8) carvedilol 25 mg oral tablet, One tablet BID
9) clonazePAM 1 mg oral tablet, 1.5 tabs po qhs prn
10) Coumadin 5 mg oral tablet, One tablet daily or as directed
11) Cymbalta 60 mg oral delayed release capsule, One tablet in the morning
12) Dexilant 60 mg oral delayed release capsule, 1 BID
13) digoxin 125 mcg (0.125 mg) oral tablet, One tablet daily
14) EpiPen Auto-Injector 0.3 mg injectable kit, Use as directed
15) eplerenone 25 mg oral tablet, One tablet daily
16) fluticasone 50 mcg/inh nasal spray, 1-2 sprays each nostril daily
17) Hycodan oral syrup, 1 tsp PO qhs prn cough at night
18) Klor-Con 20 mEq oral powder for reconstitution, occas
19) Lidoderm 5% topical film, 1- 2 patches wear 12 hrs daily
20) Lomotil 2.5 mg-0.025 mg oral tablet, One tab QID PRN
21) LORazepam 0.5 mg oral tablet, 1/2 to 1 tab TID PRN
22) losartan 100 mg oral tablet, One tablet daily
23) Lyrica 100 mg oral capsule, 2 caps QAM, 1 cap QPM
24) magnesium citrate 100 mg oral tablet, One tablet daily
25) metOLazone 5 mg oral tablet, Take 1 tablet by mouth once daily as directed
26) nystatin 100,000 units/g topical cream, Apply TID to affected areas
27) ondansetron 8 mg oral tablet, disintegrating, 1 tab BID
28) Oxygen , 3 liters
29) Percocet 10/325 oral tablet, Take 1 tablet by mouth 2 times a Day
30) prochlorperazine 10 mg oral tablet, 1 tab Q 6 hrs PRN
31) promethazine 25 mg oral tablet, 1 tab Q 6 hrs PRN
32) sildenafil 20 mg oral tablet, One tablet TID
33) Soma 350 mg oral tablet, One tablet BID PRN
34) triamcinolone 0.1% topical cream, Apply BID
35) Vitamin B12 1000 mcg oral tablet, 1 po q AM
36) Vitamin D3 50,000 intl units oral capsule, 1 cap twice weekly
Physical Examination: Wt: 197.4 lb Ht/Ln: 65 in BMI: 32.8 BP: 153/98 Pulse: 102 Sat: 95
VITAL SIGNS: As noted, with weight down about 20 pounds from last visit here.
GENERAL: is smiling and pleasantly conversational. She is able to step up to the exam table with
some effort.
HEART: Regular, S1 and S2 are normal, without noted murmur.
LUNGS: Clear to auscultation throughout. No wheezes, rales or rhonchi.
ABDOMEN: Flanks are nontender to percussion. There is some tenderness over the lateral left flank area,
which is an area where hit when she fell recently. I do not see any bruising there, and the tenderness is
superficial to the ribs. Abdomen is soft and nondistended. There is mild tenderness to palpation in the
epigastric and right upper quadrant areas. No masses are felt.
EXTREMITIES: The lower extremities have no significant edema.
Labs from the hospital discharge summary show LFTs to be up in the mid-200s. originally had some
elevated liver tests about a month ago but subsequent labs had come back to normal.
Goals:
Health Concerns:
Assessment & Plan:
1. Chronic frontal sinusitis (J32.1): History of nasal sinus surgery (Z98.890): Status post FESS (functional
endoscopic sinus surgery), and completed antibiotics. is slowly improving but is still having headache
issues. Pain medicines are addressed below.
2. Liver function tests abnormal (R94.5): Unclear etiology, possibly related to medications while in the
hospital. Recheck CBC and CMP.
3. Pulmonary hypertension, unspecified (I27.20): Long-term (current) use of anticoagulants (Z79.01):
With previous edema that is currently resolved. is given a new prescription for HYCODAN, given her
chronic coughing. She had an INR last week that was 1.9, given the concern for bruising and abnormal liver
tests, recheck an INR through lab as well.
4. Chronic pain syndrome (G89.4): Long term (current) use of opiate analgesic (Z79.891): Including
headaches, upper and lower back pain, hip and knee pain. was asking for ongoing prescriptions for
OXYCODONE again today. We discussed that in the past she has abused this and become dependent. She
is aware of this, but believes she needs at least some level of OXYCODONE to keep herself functional.
Given that she is still recovering from her sinus surgery and has had significant issues there, I think
continuing some narcotic pain medicines is still reasonable. However, we will try to begin tapering this
down. She is given a prescription for PERCOCET 5 mg tabs, one t.i.d., #90. Follow up here pending labs,
or in one month.
PRESCRIBE: Percocet 5/325 oral tablet, 1 tab TID PRN, # 90 , RF: 0.
PRESCRIBE: Hycodan oral syrup, 1 tsp PO qhs prn cough at night, # 240, RF: 0.
DISCONTINUE: Percocet 10/325 oral tablet Take 1 tablet by mouth 2 times a Day, REASON: dose
change
Instructions:
Signed by:
Doc Doctor, MD
4/8/19 12:49 PM
Chief Complaint: Three week recheck, feeling a little better from her sinus surgery.
History of Present Illness:
is now about 2 weeks status post her sinus surgery and has completed a postoperative course of
antibiotics. Her headaches are somewhat better but she is still having some headaches which are worse if
she bends over.
also complains of diffuse body pains, including low and upper back pain and pain in her hips and her
knees. She does have known arthritis in her knees, particularly the left one. The right knee is status post
replacement.
At the time of her hospital discharge was noted to have elevated liver tests. Apparently, she was told
by the hospitalist that this is caused by fatty liver disease. She has been having some abdominal pain and GI
upset since her hospitalization.
She has not had any lower extremity edema and is currently not on BUMEX. She has been coughing and is
requesting a refill on her HYCODAN.
Review of Systems:
GENERAL: Notes intermittent sweats, but ongoing issue, headaches as noted, sometimes lightheaded.
RESPIRATORY: Coughing as noted, occasional shortness of breath.
CARDIOVASCULAR: No chest pain, occasional heart racing.
GASTROINTESTINAL: Notes some reflux issues. No diarrhea or constipation.
GENITOURINARY: No urinary pain or frequency.
EXTREMITIES: No lower extremity edema.
SKIN: Notes bruising a bit lately as well.
Past Medical History:
1. Pulmonary hypertension, Dr. Ordal.
2. Fibrositis, and ill defined connective tissue disorder, Dr. Chamberland.
3. Chronic pain, fibromyalgia.
4. Essential hypertension.
5. GERD, esophagitis, IBS, Dr. Chow.
6. Osteoporosis.
7. Asthma.
8. History of renal stones.
9. History of angioedema, urticaria.
10. History of physical abuse, rape.
11. Depression / anxiety.
12. Sleep walking.
Past Surgical History:
Appendectomy, cholecystectomy, hysterectomy without BSO, rectal fissure surgery.
Family History:
CAD: Father, deceased at 56, myocardial infarction, cerebrovascular accident.
DM: Maternal grandfather.
CA: Mother, deceased at 72, liver cancer. Uncle and aunt, liver cancer.
OTHER: Mother, temporal arteritis, 20. Sister, Reiter syndrome. Two brothers, suicide.
Social History:
Married, 3 stepchildren, previous respiratory therapist now disabled.
[Tobacco: Former smoker (2 pk yrs / 38 yrs quit)
Start Date: 08/31/2018 End Date: 08/31/2018]
Allergies: penicillin, sulfa drug, codeine, aspirin, Ultram, AMITRIPTYLINE, MORPHINE, PAXIL,
TIGAN, METRONIDAZOLE, Bee Sting, hydromorphone, cephalexin, clindamycin
Medications: 1) Advair Diskus 250 mcg-50 mcg inhalation powder, 1 puff BID
2) albuterol 5 mg/mL (0.5%) inhalation solution, 1ml by nebulizer route q 6 hours prn SOB
3) albuterol CFC free 90 mcg/inh inhalation aerosol, 2 puffs QID PRN
4) amitriptyline 25 mg oral tablet, One tablet at night
5) amLODIPine 10 mg oral tablet, Take 1 tablet by mouth once daily
6) budesonide 180 mcg/actuation inhaler, 1 puff qd
7) bumetanide 2 mg oral tablet, 2 BID as needed
8) carvedilol 25 mg oral tablet, One tablet BID
9) clonazePAM 1 mg oral tablet, 1.5 tabs po qhs prn
10) Coumadin 5 mg oral tablet, One tablet daily or as directed
11) Cymbalta 60 mg oral delayed release capsule, One tablet in the morning
12) Dexilant 60 mg oral delayed release capsule, 1 BID
13) digoxin 125 mcg (0.125 mg) oral tablet, One tablet daily
14) EpiPen Auto-Injector 0.3 mg injectable kit, Use as directed
15) eplerenone 25 mg oral tablet, One tablet daily
16) fluticasone 50 mcg/inh nasal spray, 1-2 sprays each nostril daily
17) Hycodan oral syrup, 1 tsp PO qhs prn cough at night
18) Klor-Con 20 mEq oral powder for reconstitution, occas
19) Lidoderm 5% topical film, 1- 2 patches wear 12 hrs daily
20) Lomotil 2.5 mg-0.025 mg oral tablet, One tab QID PRN
21) LORazepam 0.5 mg oral tablet, 1/2 to 1 tab TID PRN
22) losartan 100 mg oral tablet, One tablet daily
23) Lyrica 100 mg oral capsule, 2 caps QAM, 1 cap QPM
24) magnesium citrate 100 mg oral tablet, One tablet daily
25) metOLazone 5 mg oral tablet, Take 1 tablet by mouth once daily as directed
26) nystatin 100,000 units/g topical cream, Apply TID to affected areas
27) ondansetron 8 mg oral tablet, disintegrating, 1 tab BID
28) Oxygen , 3 liters
29) Percocet 10/325 oral tablet, Take 1 tablet by mouth 2 times a Day
30) prochlorperazine 10 mg oral tablet, 1 tab Q 6 hrs PRN
31) promethazine 25 mg oral tablet, 1 tab Q 6 hrs PRN
32) sildenafil 20 mg oral tablet, One tablet TID
33) Soma 350 mg oral tablet, One tablet BID PRN
34) triamcinolone 0.1% topical cream, Apply BID
35) Vitamin B12 1000 mcg oral tablet, 1 po q AM
36) Vitamin D3 50,000 intl units oral capsule, 1 cap twice weekly
Physical Examination: Wt: 197.4 lb Ht/Ln: 65 in BMI: 32.8 BP: 153/98 Pulse: 102 Sat: 95
VITAL SIGNS: As noted, with weight down about 20 pounds from last visit here.
GENERAL: is smiling and pleasantly conversational. She is able to step up to the exam table with
some effort.
HEART: Regular, S1 and S2 are normal, without noted murmur.
LUNGS: Clear to auscultation throughout. No wheezes, rales or rhonchi.
ABDOMEN: Flanks are nontender to percussion. There is some tenderness over the lateral left flank area,
which is an area where hit when she fell recently. I do not see any bruising there, and the tenderness is
superficial to the ribs. Abdomen is soft and nondistended. There is mild tenderness to palpation in the
epigastric and right upper quadrant areas. No masses are felt.
EXTREMITIES: The lower extremities have no significant edema.
Labs from the hospital discharge summary show LFTs to be up in the mid-200s. originally had some
elevated liver tests about a month ago but subsequent labs had come back to normal.
Goals:
Health Concerns:
Assessment & Plan:
1. Chronic frontal sinusitis (J32.1): History of nasal sinus surgery (Z98.890): Status post FESS (functional
endoscopic sinus surgery), and completed antibiotics. is slowly improving but is still having headache
issues. Pain medicines are addressed below.
2. Liver function tests abnormal (R94.5): Unclear etiology, possibly related to medications while in the
hospital. Recheck CBC and CMP.
3. Pulmonary hypertension, unspecified (I27.20): Long-term (current) use of anticoagulants (Z79.01):
With previous edema that is currently resolved. is given a new prescription for HYCODAN, given her
chronic coughing. She had an INR last week that was 1.9, given the concern for bruising and abnormal liver
tests, recheck an INR through lab as well.
4. Chronic pain syndrome (G89.4): Long term (current) use of opiate analgesic (Z79.891): Including
headaches, upper and lower back pain, hip and knee pain. was asking for ongoing prescriptions for
OXYCODONE again today. We discussed that in the past she has abused this and become dependent. She
is aware of this, but believes she needs at least some level of OXYCODONE to keep herself functional.
Given that she is still recovering from her sinus surgery and has had significant issues there, I think
continuing some narcotic pain medicines is still reasonable. However, we will try to begin tapering this
down. She is given a prescription for PERCOCET 5 mg tabs, one t.i.d., #90. Follow up here pending labs,
or in one month.
PRESCRIBE: Percocet 5/325 oral tablet, 1 tab TID PRN, # 90 , RF: 0.
PRESCRIBE: Hycodan oral syrup, 1 tsp PO qhs prn cough at night, # 240, RF: 0.
DISCONTINUE: Percocet 10/325 oral tablet Take 1 tablet by mouth 2 times a Day, REASON: dose
change
Instructions:
Signed by:
Doc Doctor, MD
4/8/19 12:49 PM
