Progress Notes

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Turabo University

Calle Nuevo Leon

Albany, NY 29978 - 0000
Tel: 212 876-8768
Fax:

Vazquez Vazquez, Anastacio

Sex: Male, Date of Birth: 09-26-1950, Account No: INT01337
Attending Provider: Marcus . Welby, M.D.
Encounter Date: 07-13-2015
Chief Complaint:
Other Complaints:
Family History
Cancer: Father.
Social History
Use Of Drugs/Alcohol/Tobacco: Drinks alcohol once a week. Reports drinking beer, 1 drink per week. He denies his
alcohol consumption as being problem to self or family or others. He says he never indulges in 'binge' drinking. Denies
driving after drinking. He has never smoked tobacco. He consumes 0. Number of chews per day: 0. No. Of pipes smoked
per day: 0. Cigars smoked per day: 0. Reports consuming caffeine or caffeinated drinks 3-5 cups a day. He has never used
any illicit drugs. He denies using street drugs with a needle. Has used/ is using marijuana. He has a sedentary lifestyle.
Does not take any exercise. He reports doing mild exercise like climb stairs or walk 2-3 blocks. He reports doing occasional
vigorous exercise ( work or recreation). He does regular vigorous exercise for work / recreation.
Current Medication
Vitamin B-6 50 mg capsule 1 Capsule Every Morning for 30 Days , Dispense 30 Capsule
Allergy
PENICILLINS Moderate .
Health Maintenance
Type
Test

Status

Due Date

LB
LB
LB

ANA Panel
Complete Metabolic Panel
Lipid Panel

Due
Due
Due

07-13-2015
07-13-2015
07-13-2015

LB
LB

CBC w/auto diff

Renal Function Panel

Due
Due

07-13-2015
07-13-2015

LB
LB
LB

Thyroid Antibody Panel

Hemoglobin A1c
Microalbumin

Due
Due
Due

07-13-2015
07-13-2015
07-13-2015

LB
LB

Urinalysis, Complete W/Microscopic Due

STOOL GUAIAC
Due

07-13-2015
07-13-2015

Last Done Last Result

Review of Systems
Constitutional Symptoms: He has normal appearance. He denies having any kind of disability for any reason whatsoever.
The patient denies fever, chills, malaise/fatigue or night sweats. He denies any recent unintended weight gain or loss in the
last 12 months.
Eyes: The patient denies blurred vision, double vision, photophobia, visual changes, discharge, glaucoma, itching,
lacrimation, pain or redness of eyes.
Ears/Nose/Mouth/Throat: The patient denies hearing loss, ear pain, tinnitus, nasal congestion, nasal discharge, abnormal
sneezing, bleeding from nose, postnasal drip, oral ulcers, oro-dental problems, Hoarseness or sore throat.
Cardiovascular: The patient denies chest pain, murmur, palpitation, dyspnea, orthopnea or edema.
Respiratory: The patient denies cough, shortness of breath, chest tightness, hemoptysis, asthma or wheezing.
Gastrointestinal: The patient denies nausea/vomiting, change in bowel habits, diarrhea, constipation, abdominal pain,

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Progress Notes

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difficulty with swallowing, blood in stools or hemorrhoids.

Genitourinary: The patient denies blood in urine, painful urination, excessive night time urination, urinary frequency,
hesitancy, urinary urgency, dribbling, burning or itching. Force of stream is normal.
Male GU: The patient denies lumps/pain in testicles or difficulty with erection/ejaculation.
ntegumentary: The patient denies change in skin color, change in hair/nails, itching or rashes.
Neurological: The patient denies weakness, convulsions/seizures, migraine headache, numbness, decrease in cognitive
skills, loss of balance, head injury or tremors. Denies any symptoms of paralysis.
sychiatric: The patient denies difficulty concentrating, insomnia, changes in socializing, irritability/mood changes, suicidal
thoughts/attempts, anxiety, depression, forgetfulness or nervousness.
Endocrine: The patient denies heat/cold intolerance, excessive urination, changes in hat/glove size, nocturia or
glandular/hormone problem.
Hematologic/Lymphatic: Denies getting bruises or bleeding easily. The patient denies malaise/fatigue, night sweats or
tenderness in the nodes of neck/groin area.
asic ADL: No bladder incontinence. No bladder incontinence. No bowel incontinence. Independent toileting. Independent
feeding. Independent dressing. Independent bathing. Ambulation: self.
ADL: He does not require any help in preparing the meals. He can do medication management without assistance. He can
manage money matters on his own. He can do light work independently. He can do heavy work independently. He does not
require transportation assistance.
Vitals
eight: 160.00 lbs. Height: 70.00 inches. M : 23. ulse: 60 per min. Respiration: 17 breaths per min. BP Systolic: 70
mm Hg.
Diastolic: 80 mmHg.

hysical E amination

Assessment and lan

Office/outpatient Visit New (99204)
Diabetes - First Visit
Diabetes - Followup Abdomen: Abdomen is tight. The abdomen is soft to touch. The abdominal appearance is
unremarkable. Abdomen is
nontender. There is no rebound tenderness. Bowel sounds/Auscultation are within normal limits. The abdomen is mildly
tender. No abdominal masses. Percussion of the abdomen in within normal limits: . No Hernia.
Female Genitalia: Adnexal masses are None. Adnexal texture is noted to be normal. PAP/ ECB done: 2 degrees. Speculum
exam - Cervix shows cervix normal. Uterus is WNL. Vaginal mucosa is atrophic.
Lymphatic: There is no lymphadenopathy. The lymph nodes are shotty.
Diabetes - Followup
Abdomen: Abdomen is tight. The abdomen is soft to touch. The abdominal appearance is unremarkable. Abdomen is
nontender. There is no rebound tenderness. Bowel sounds/Auscultation are within normal limits. The abdomen is mildly
tender. No abdominal masses. Percussion of the abdomen in within normal limits: . No Hernia.
Female Genitalia: Adnexal masses are None. Adnexal texture is noted to be normal. PAP/ ECB done: 2 degrees. Speculum
exam - Cervix shows cervix normal. Uterus is WNL. Vaginal mucosa is atrophic.
Lymphatic: There is no lymphadenopathy. The lymph nodes are shotty.
Lab Order
Order No: LA
Dated:
Lab: Any Lab
HL ADHOC: Complete Metabolic Panel
lood Test: Urinalysis, Complete W/Microscopic

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Progress Notes

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HL ADHOC: ANA Panel, Lipid Panel, CBC w/auto diff, Renal Function Panel, Thyroid Antibody Panel, Hemoglobin A1c,
Microalbumin, STOOL GUAIAC
Radiology Order
Consults Ordered

Labs Reviewed
Radiology Reviewed
rescription
metformin 1,000 mg tablet 1 Every Morning PRN, Dispense 1 Tablet
List of education material given
Follow up: No Follow Up

Marcus Welby, M.D.

This has been electronically signed on 07-13-2015

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