Progress Notes

Page 1 of 3

Turabo University

Calle Nuevo Leon

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

Laboy, Nashaly
Sex: Female, Date of Birth: 12-23-1950, Account No: INT01241
Attending Provider: Marcus . Welby, M.D.
Encounter Date: 07-15-2015
Chief Complaint:
Other Complaints:
Family History
Cancer: Father.
Social History
Use Of Drugs/Alcohol/Tobacco: Never drinks any alcohol. Reports drinking beer, 1 drink per week. She denies her
alcohol consumption as being problem to self or family or others. She says she never indulges in 'binge' drinking. Denies
driving after drinking. She has never smoked tobacco. She 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. She has never used
any illicit drugs. She denies using street drugs with a needle. Has used/ is using marijuana. She exercises on a regular
basis. She reports doing mild exercise like climb stairs or walk 2-3 blocks. She denies doing any vigorous exercise
( work or recreation). She does not do any regular vigorous exercise for work or recreation.
Current Medication
Vitamin B-6
Allergy
PENICILLINS Moderate .
Health Maintenance
Type
Test
LB
ANA Panel
LB
Complete Metabolic Panel

Status
Due
Due

Due Date Last Done Last Result

06-24-2015
06-24-2015

LB
LB

Lipid Panel
CBC w/auto diff

Due
Due

06-24-2015
06-24-2015

LB
LB

Obstetric Panel
Renal Function Panel

Due
Due

06-24-2015
06-24-2015

LB

Thyroid Antibody Panel

Due

06-24-2015

LB
LB

Pap smear
Hemoglobin A1c

Due
Due

06-24-2015
06-24-2015

LB
LB
LB

Microalbumin
Due
Urinalysis, Complete W/Microscopic Due
STOOL GUAIAC
Due

06-24-2015
06-24-2015
06-24-2015

RL

Mammo diagnostic

06-24-2015

Due

Review of Systems
Constitutional Symptoms: She has normal appearance. She denies having any kind of disability for any reason
whatsoever. The patient denies fever, chills, malaise/fatigue or night sweats. She reports recent unintended weight 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

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Progress Notes

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sneezing, bleeding from nose, postnasal drip, oral ulcers, oro -dental problems, Hoarseness, sore throat or sensation of a
lump in the 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.
astrointestinal: The patient denies nausea/vomiting, change in bowel habits, diarrhea, constipation, abdominal pain,
difficulty with swallowing, blood in stools or hemorrhoids.
enitourinary: The patient denies blood in urine, painful urination, excessive night time urination, urinary frequency,
hesitancy, urinary urgency, dribbling, burning or itching.
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 or head injury. 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. She denies any sleep-related problems. Reports
adequate and sound sleep.
Endocrine: The patient denies heat/cold intolerance, excessive urination, changes in hat/glove size, nocturia or
glandular/hormone problem.
Hematologic/Lymphatic: The patient denies malaise/fatigue, night sweats or tenderness in the nodes of neck/groin area.
There is no history of transfusion.
asic ADL: No bladder incontinence. No bladder incontinence. No bowel incontinence. Independent dressing. Independent
bathing. Ambulation: self.
ADL: She does not require any help in preparing the meals. She can go shopping alone. She can do medication
management without assistance. She can manage money matters on her own. She can do light work independently. She
can do heavy work independently.
itals
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

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.

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Progress Notes

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Lab Order
Order No: LA
Dated:
Lab: Any Lab
HL ADHOC: ANA Panel, Complete Metabolic Panel, Lipid Panel, CBC w/auto diff, Renal Function Panel, Hemoglobin A1c,
Microalbumin
lood Test: Urinalysis, Complete W/Microscopic
HL ADHOC: 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 07-15-2015

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