neidacaroboone-editingM-19

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Valencia College *

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1611C

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Medicine

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Dec 6, 2023

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docx

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Uploaded by BrigadierFang12455

Internal Medicine Clinic Note Patient Name : Jack T. Lampe, PhD PCP : Sherman Loyd, MD Date of Exam : 09/30/---- Age/Sex : 76/M ID# : M-19 CHIEF COMPLAINT : This 76-year-old white male is here for follow up medical care. HISTORY : The patient describes being Dr. Ramirez's patient, describes appreciation for his thoroughness. He goes on to note that he needs no medications renewed but has had a hard time getting into our clinic and hopes that in the next few months he would be able to reestablish care. PAST MEDICAL HISTORY 1. Dyslipidemia. 2. One’s a smoker, discontinued 3 years ago. 3. Sensorineural hearing loss. 4. Chronic ischemic heart disease, apparently. 5. Symptomatic bradycardia. He had a pacemaker placed 8 years ago. 6. Chronic atrial fibrillation. 7. Anticoagulation, chronic, and this for #6 above. 8. Slow urinary stream. 9. Pulmonary tuberculosis left kidney focused. This was found when presented with recurrent urinary tract infections. Multiple urinary samples done at different medical facilities found the culprit organism, with a diagnosis eventually made. 10. Cataracts, both eyes. There is a question as to whether or not amiodarone is involved. (The sternal deposits are called verticillata.) PAST SURGICAL HISTORY

1. He had a coronary arteriogram and a permanent pacer placed 8 years ago in January. 2. Left kidney revision by Dr. Green in the remote past. 3. Rectal melanoma excision 10 years ago. 4. Tympanoplasty and mastoidectomy 20 years ago. 5. Right cataract surgery 7 years ago. ALLERGIES : STREPTOMYCIN and ALDOMET. Manifestations unknown. Internal Medicine Clinic Note Patient Name: Jack T. Lampe, PhD Date of Exam: 09/30/---- ID#: M-19 Page 2 MEDICATIONS (mg p.o. daily unless otherwise noted) 1. Warfarin 223 as of today. 2. Tamsulosin 0.4 mg b.i.d. 3. Simvastatin 20. 4. Potassium chloride 10. 5. Omeprazole 20. 6. Metoprolol 200. 7. Lisinopril 40. 8. Hydrochlorothiazide 25.

9. Finasteride 5. FAMILY HISTORY : Patient describes his mother dying of tuberculosis 8 to 9 months after he was born. A sister succumbed to cancer as an adult. He thinks it was lymphoma. SOCIAL HISTORY : Patient lives locally with his wife. He has been seeking medical care from Quali-Care Internal Medicine Clinic for some time. He once smoked and he rarely drinks. History of being a pipe smoker. REVIEW OF SYSTEMS: CONSTITUTIONAL: Patient has gained approximately 8 pounds in the last year. There has been no weakness. NEUROLOGIC: Denies headaches, seizures. There have been no falls. HEENT: Denies description of sore throat, vision, or hearing change. He admits to being hard of hearing. ENDOCRINE: He has had no diabetes or thyroid problems. He has had hypertension. CARDIAC: There has been no heart attack or heart failure. He has had no rapid heart race. PULMONARY: No known pulmonary disease. He has no cough or wheeze. There has been no pulmonary embolism. GASTROINTESTINAL: He denies description of odynophagia, dysphagia, bleeding ulcers, or epigastric pain. He describes an empty feeling that led him to seek medical attention. A diagnosis of what sounds like GERD was made. Prilosec started. His chief complaint was 100% resolved. He has had no liver disease. No change in stool color, caliber, or consistency. He thinks his last colonoscopy was 3 years ago in our facility. RENAL: He has had the renal disease as described above. His kidneys are now functional from his point of view. Denies dysuria or kidney stones. HEMATOLOGIC: No bleeding or clotting abnormalities. No transfusions. SKIN: No skin color changes. No new lumps or bumps. Internal Medicine Clinic Note Patient Name: Jack T. Lampe, PhD Date of Exam: 09/30/---- ID#: M-19 Page 3

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