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CHIEF COMPLAINT: Sore on scalp, earache in left ear, foot pain. Scaly patches on face.
HISTORY OF PRESENT ILLNESS: Established 56 year old male presents with prescription refills of amitriptyline, flunisolide, hyomax. Patient would like prescriptions called into Wal-Mart on 32nd. Patient has a sore on his head, left top close to back. Patient has been applying creams to sore for 3-4 months. He states there has been no difference. No pain. Bleeding only when he get a haircut. No change in size. Patient states it has a scab on it. He has had lesions on face for more than 6 months Onset: insidious. Denies: redness or itching. Patient states the last 3 weeks he has been getting an earache. He states it will come and go every couple of days. Patient has been using ear drops, and sinus medications, and it does not seem to clear it up. Denies: ear drainage or previous ear infections. Patient had a bone that was misplaced in his foot. Patient states that his shoes kind of worked the bone back up into place. He states that it feels like the bone has moved again, no pain. Denies: toe pain or swelling.
CURRENT MEDICATION: Hyoscyamine 0.37 5 mg 1 tab(s) Q12H, Flunisolide 29 ml 2 bid 3od - use two doses each nostril twice daily for 30 days, Amitriptyline Hydrochloride 25mg, take one tablet by mouth at bedtime once a day, Flunisolide nasal 29 mcg/inhale 2 puff(s) bid, Fluoxetine 20 mg 1 tab(s) once a day, Niaspan ER 500 mg 3 tabs once a day (at bedtime), Amitriptyline 10 mg 1 tab d/c.
MEDICAL HISTORY: Anxiety: Yes, Depression: Yes, Kidney Stones: Yes, arthritis: Yes, Colon polyps: Yes, Diarrhea: Yes, irritable bowel syndrome: Yes, Reflux: Yes.
ALLERGIES/INTOLERANCE: Penicillin swelling, allergic reaction.
SURGICAL HISTORY: vasectomy, dog bite –stitches.
HOSPITALIZATION: Denies Past Hospitalization.
FAMILY HISTORY: Father: deceased 86 yrs Alzheimer's dementia, Parkinson's disease. Mother: alive 90 yrs arthritis.
SOCIAL HISTORY: No Social History documented.
REVIEW OF SYSTEMS: DERMATOLOGY: No rash, no hives, no skin cancer, no eczema, no mole, no lumps, no hives. ENT: Ear pain left ear ache. No sore throat. No hoarseness. MUSCULOSKELETAL: No joint pain, no joint stiffness, no joint swelling, no back pain. 14 categories reviewed and the pertinent positives are listed.
EXAMINATION:
VITALS: Wt 72, BMI 26.58, Wt 196.0, BP 111/ 75, HR 70, Temp 98.0, SAO2 98, RR 14
DERMATOLOGY: Face-2 dry scaly lesions on erythematous base. GENERAL: Appearance: NAD, alert and oriented.
ASSESSMENT: Actinic keratosis, Depression with anxiety, Seasonal allergic rhinitis, Irritable bowel syndrome, and Hypercholesterolemia.
PLAN/TREATMENT: Actinic keratosis lesions treated with liquid nitrogen therapy (2). Depression with anxiety, Refill Amitriptyline Hydrochloride Tablet, 25, orally, 90, 1 tab, once a day, 90 day(s), Refills 3. Seasonal allergic rhinitis, refill Flunisolide Liquid, 29 ml, 3, 2 BID 3OD - use two doses each nostril twice daily for 30 days, bid, 90 day(s), Refills 3. Irritable bowel syndrome, refill hyoscyamine tablet, extended release, 0.375 mg, orally, 90, 1 tab(s), Q12H, 90 day(s), Refills 3. Stop amitriptyline tablet, 10 mg, orally, 1 tab(s), d/c. Stop fluoxetine tablet, 20 mg, orally, 1 tab(s), once a day.
LABS: CBC W/Diff, Comprehensive Metabolic Panel, Lipids, 1HbA1C.
PROCEDURES: Liquid Nitrogen Method: LN applied to affected area x 2.
NEXT APPOINTMENT: 4 Weeks