Acisclo M Marxuach, MD Evaluation and Management Service Patient Name: JUAN ADORNO ROSARIO EMR Record No: 180-5296 Visit Date: 26-Feb-2013 11:26:00AM Reference#: 60972 Center Record No:15306 Closing Date: 26-Feb-2013 2:28:48PM Visit Type: Regular Visit (New) Chief Complaint: 31 y/o male with HcvAb+ for the first time in Janb 18, 2013 and claims previous ones have been negative. Naive to any kind of Present Illness: IOVDU/Inhalation from age 15 up to Dec 2012, no tattoos, no sex with knopwn iomnfected persons and did have blood
transfusiosn inn Sep 201`2 at the time of GSW.
Sugerty for GSW with fractures in Sep 13, 2012 with metallic plaque in-place and a bullet in LLE. Claims recently with pain and limping due to the increase in weight of 10 lbs since event.
Claims Convulsive Seizures since 1998, pending Nuero visit in April first, currentlky on Dilantin 100 mg TID, Carbamazepin 100mg TID. Frequency of episodes are 5/month, last one last week.
History of HTN since 1998 and since then on Enalapril 20 mg QD and anothert unknown one HS, today found with 120/78.
Several broken nose episodes as a child, Lipoma removed from back of neck . Review of GENERAL: No weight loss, night sweats, fatigue. Systems: SKIN: No rash, itching, jaundice, psoriasis.
HEAD: No headaches, dizziness, or trauma. See HPI. EARS: No hearing loss, earaches, tinnitus, discharge. EYES: No difficulty seeing, inflammation, diplopia, lacrimation. NOSE: No epistaxis, discharge, sinusitis. See HPI. MOUTH: No sores, dysphagia, hoarseness, or any problems with teeth. NECK: No swelling, tenderness, stiffness, no thyroid enlargement. BREASTS: No masses, tenderness, discharge. Fat mass in R-breast. Recent Mammography, results not known yet. RESPIRATORY: No cough, expectoration, SOB, hemoptysis or chest pain. CARDIOVASCULAR: No chest pains, angina, SOB, PND, DOE, orthopnea, palpitations, or edema. GASTROINTESTINAL: Good appetite, No nausea, vomiting, diarrhea, constipation, hematemesis, melena, or change in stools. UROLOGIC: No difficulty or burning on urination, frequency, hematuria, discharge. Polyuria and nocturia x 5-6 since 12/2012. REPRODUCTIVE: No discharge or sexual dysfunction. MUSCULOSKELETAL: No pain, swelling, weakness, or joint pains. See HPI. HEMATOLOGIC: No bruises or bleeding disorder. NEUROPSYCH: No seizures, fainting, speech difficulty, gait problems, paralysis, memory problems or disorientation. Current Medications: Past Medical History Previous Illness:
(070.54) Chronic Hepatitis C Without Coma
Allergies/Intolerances: Social History: Patient Name: JUAN ADORNO ROSARIO EMR Record No: 180-5296 Visit Date: 26-Feb-2013 11:26:00AM Reference#: 60972 Center Record No:15306 Closing Date: 26-Feb-2013 2:28:48PM Visit Type: Regular Visit (New) Family History:
Mother is alive but not healthy. Reason: DM
Date: February 26, 2013 Physical Examination: Appearance: Alert, Active and oriented X3. Normal habitus. Head: Normocephalic, no masses. Eyes: PERLA. No exophthalmus. No lid lag. Nose: No discharge nor congestion. Throat: Moist oral mucosa. Pharynx not hyperhemic. Ears: Intact external canals. No discharge. Neck / Thyroid: Supple, normal thyroid. No nodules or adenopathies. Breast: No masses palpable, no galactorrea. Lungs / Chest: Clear to auscultation and percussion. Non-tender, fullness felt just below R-breast. Cardiovascular: RSR. No murmurs heard. No edema or fluid retention. Abdomen: Soft and depressible, LKS nor masses palpable. Genitourinary: Exam not done. Back: No CVA tenderness. No scoliosis. No kyphosis. Extremities / Musculoskeletal: Normal pulses. No varicose veins. Minimal limping with LLE due to bullet in L-heel. Rectal: Exam not done. Skin/Lymphatic: No Rashes. Tinea cruris not present. Neuro: No lateralizing signs. No sensory or motor deficit.
Adviused abnout Ab vs Loads and recent Ab+. Signature:
Electronically signed and approved by Acisclo M Marxuach, MD using Single-Form Authentication
Closing Date: 26-Feb-2013 2:28:48PM
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