Good Health Clinic Procedure Note 17 Daws Rd. Blue Bell MA 02368 US Mr. Adam Frankie Everyman 17 Daws Rd. Blue Bell MA 02368 US Ralph Relative MA 02368 USA Good Health Clinic 21 North Ave Burlington MA 02368 USA 21 North Ave. Burlington MA 02368 USA Henry Seven 21 North Ave. Burlington MA 02368 USA Henry Seven Rose Everyman Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 USA Henry Seven Good Health Clinic Henry Seven Primary Care Provider Dr. Pseudo Physician-1 NIST HL7 Test Laboratory Primary Care Provider Dr. Pseudo Physician-3 HL7 Test Laboratory
Allergies, Adverse Reactions, Alerts
Substance Reaction Status
Penicillin Hives Active
Aspirin Wheezing Active
Codeine Nausea Active
Penicillin Aspirin Aspirin
Procedure Anesthesia Conscious sedation with propofol 200 mg IV 17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US Propofol 20mg/mL injection emulsion 50mL vial
ASSESSMENT Recurrent GI bleed of unknown etiology; hypotension perhaps secondary to this but as likely secondary to polypharmacy. Acute on chronic anemia secondary to #1. Azotemia, acute renal failure with volume loss secondary to #1. Hyperkalemia secondary to #3 and on ACE and K+ supplement. Other chronic diagnoses as noted above, currently stable.
REASON FOR VISIT/CHIEF COMPLAINT Dark stools.
Complications Asthmatic symptoms while under general anesthesia.
Family history Father (deceased)
Diagnosis Age At Onset
Myocardial Infarction (cause of death) 57
Diabetes 40
PAST MEDICAL HISTORY See History of Present Illness.
HISTORY OF PRESENT ILLNESS This patient was only recently discharged for a recurrent GI bleed as described below. He presented to the ER today c/o a dark stool yesterday but a normal brown stool today. On exam he was hypotensive in the 80?s resolved after .... .... .... Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes normal. H. pylori antibody pending. Admission hematocrit 16%, discharge hematocrit 29%. WBC 7300, platelet count 256,000. Urinalysis normal. Urine culture: No growth. INR 1.1, PTT 40. He was transfused with 6 units of packed red blood cells with .... .... .... GI evaluation 12 September: Colonoscopy showed single red clot in .... .... ....
MEDICAL (GENERAL) HISTORY Patient has had recent issue with acne that does not seem to be related to any particular cause. Previous concerns of oral cancer was actually irritated gums as a result of mild food allergy. Patient had recent weight gain due to sedentary lifestyle and new job.
MEDICATIONS
Medication Directions Start Date Status Indications Fill Instructions
Proventil 0.09 MG/ACTUAT inhalant solution 2 puffs QID PRN wheezing 2011-03-01 Active Bronchitis (32398004 SNOMED CT) Generic Substitition Allowed
0.09 MG/ACTUAT inhalant solution, 2 puffs QID PRN wheezing Good Health Clinic Diethylene Glycol label in spanish
PHYSICAL EXAMINATION HEENT: All normal to examination. Heart: RRR, no murmur. THORAX & LUNGS: Clear without rhonchi or wheeze. ABDOMEN: No distension, tenderness, or guarding, obese, pos bowel sounds. BACK: Normal to inspection and palpation, without tenderness; no presacral edema. EXTREMITIES: Doughy edema bilaterally, chronic stasis changes, no asymmetrical swelling.
Plan of Care
Planned Activity Planned Date
Colonoscopy April 21, 2000
Planned Procedure Colonoscopy
Postoperative Diagnosis Appendicitis with periappendiceal abscess
Preoperative Diagnosis Appendicitis
Postprocedure Diagnosis Sigmoid diverticulosis, moderate Internal hemorrhoids Colon polyp, 6mm, ascending colon
Procedure Description The patient was brought to the operating room, placed in the supine position, and general anesthesia was induced. A detailed technical narrative of a laparoscopic appendectomy from initial incision to placement of any dressings follows.
PROCEDURE DISPOSITION The patient was taken to the Endoscopy Recovery Unit in stable condition.
Procedure Estimated Blood Loss Minimal
Procedure Findings A 6 mm sessile polyp was found in the ascending colon and removed by snare, no cautery. Bleeding was controlled. Moderate diverticulosis and hemorrhoids were incidentally noted.
Procedure Implants No implants were placed.
Procedure Indications The procedure is performed for screening in a low risk individual.
Procedure Specimens Taken Ascending colon polyp
REVIEW OF SYSTEMS Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. One episode of melena. No recent headaches. Positive for osteoarthritis in hips, knees and hands.
Social History
Social History Element Description Effective Dates
smoking 1 pack per day 1947 - 1972
smoking None 1973 -
Alcohol consumption None 1973 -
1 pack per day None None
Surgical Drains Penrose drain placed