Progress Notes

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Turabo University

Calle Nuevo Leon

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

Correa, Abner
Sex: Male, Date of Birth: 09-14-1975, Account No: INT01333
Attending Provider: Marcus . Welby, M.D.
Encounter Date: 07-13-2015
Chief Complaint:
Other Complaints:
Surgical History
apendice: 05-27-1998 by Dra. Solis at Hima San Pablo
vesicula: 07-01-2010 by Dr. Delgado at Ryder
Family History
Arthritis: Mother. Cancer: Father. Diabetes: Mother. Heart Attack: Brother, Father. Hyperthyroidism: Mother. Osteoporosis:
Father.
Social History
Use Of Drugs/Alcohol/Tobacco: Drinks alcohol once or twice 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. Does not drink caffeinated beverages. 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 not do any regular vigorous exercise for work or recreation.
Current Medication
nortriptyline
hydroxyzine pamoate
amlodipine
Mapap (acetaminophen)
Allergy
Latex rash Moderate . Milk rash Moderate . acetaminophen (bulk) 100 % powder nauseas Moderate . BEE POLLENS
sneezing Moderate . PENICILLINS rash Moderate . SHELLFISH Moderate .
Vitals
Weight: 100.00 lbs. Height: 5.60 inches. BMI: 2,242. Pulse: 10 per min. Respiration: 20 breaths per min. BP Systolic:
180 mm Hg. BP Diastolic: 98 mmHg.

Physical Examination

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Progress Notes

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Assessment and Plan

ICD: Closed Fracture Of Multiple Sites Of Metacarpus (815.09)

Office/outpatient Visit Est (99214)
Order No: LAB 00111 DATED: 7-14-2014 Lab:Any Lab HL7ADHOC : Basic Metabolic Panel
Radiology order: Consults Ordered, Labs Reviewed, Radiology reviewed
ICD: Closed Fracture Of Multiple Sites Of Metacarpus (815.09)
Office/outpatient Visit Est (99214)
Order No: LAB 00111 DATED: 7-14-2014 Lab:Any Lab HL7ADHOC : Basic Metabolic Panel
Radiology order: Consults Ordered, Labs Reviewed, Radiology reviewed
Lab Order
Radiology Order
Consults Ordered

Labs Reviewed
Radiology Reviewed
Prescription
ibuprofen 400 mg/4 mL (100 mg/mL) intravenous solution 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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