Snapshot
- PMH: Atrial Fibrillation (on coumadin), Diabetes Type 2 (well-controlled), COPD/Emphysema (not on home O2), Hypertension, Prior MI (with stenting), Coronary Artery Disease, Hypercholesterolemia, Congestive Heart Failure (EF 45% on last echo), Paronychia, Spinal Stenosis, History of Colles's Fracture
- PSH: Appendectomy (2005), Cardiac Cath (2007), L4 Laminectomy (2001), ACL Repair, Right Knee (1994)
- Psych: Anxiety
- Social: Daily alcoholic, no illicits, tobacco smoker (40 pack-year), lives alone, not sexually active
- Meds: Aspirin, Atenolol (Recent Dose Increase), Lipitor, Azithromycin, Diltiazem, Furosemide, Ibuprofen, Levothyroxine, Lisinopril, Nicotine Patch, Omeprazole, Oxycodone, Warfarin
- Encounters: Admission for CHF (11/20/2012), Office Visit for CHF (11/18/2012), Office Visit for COPD (11/1/2012)
Problems
| Condition | Category | Date Diagnosed |
|---|---|---|
| Type 2 Diabetes Mellitus | Medical - Endocrine | 6/1/2001 |
| Atrial Fibrillation |
Medical - Cardiac | 6/1/2001 |
| COPD | Medical - Respiratory | 7/6/1995 |
| Hypertension | Medical - Cardiac | 7/6/1995 |
| History of Myocardial Infarction | Medical - Cardiac | 2/4/1998 |
| Congestive Heart Failure | Medical - Cardiac | 2/4/1998 |
| Hyperlipidemia | Medical - Cardiac | 7/6/1995 |
| Paronychia of Toe | Medical - Musculoskeletal | 11/2/2012 |
| Spinal Stenosis | Medical - Musculoskeletal | 12/12/2009 |
| Distal Radius Fracture | Medical - Musculoskeletal | 2/12/2009 |
| Appendectomy | Surgical - GI | 1/1/1976 |
| Cardiac Catheterization | Surgical - Cardiac | 2/4/1998 |
| Laminectomy, L4-S1 | Surgical - Musculoskeletal | 12/12/2010 |
| ACL Repair, Right Knee | Surgical - Musculoskeletal | 10/19/1984 |
| Anxiety Disorder | Psychiatric | 10/9/1987 |
Medications
| Common Name | Dosage | System | Instructions |
|---|---|---|---|
| Aspirin | 81mg daily | Cardiac | Take 1 pill every day |
| Atenolol | 50mg BID | Cardiac | Take 1 pill 2 times a day |
| Lipitor | 20mg daily | Cardiac | Take 1 pill every day |
| Azithromycin | 500mg daily | Infection | Take 1 pill every day for 3 days |
| Diltiazem | 30mg BID | Cardiac | Take 1 pill 2 times a day |
| Lasix | 80mg TID | Cardiac, Respiratory, Musculoskeletal | Take 1 pill 3 times a day |
| Ibuprofen | 400mg TID | Musculoskeletal | Take 1 pill 3 times a day as needed for pain |
| Synthroid | 125mcg daily | Endocrine | Take 1 pill every day |
| Lisinopril | 20mg daily | Cardiac | Take 1 pill every day |
| Nicotine Patch | 50mg daily | Overall Health | Put one patch on your shoulder every day and take off the old one |
| Omeprazole | 20mg daily | GI | Take 1 pill every day |
| Oxycodone | 5mg QID | Musculoskeletal | Take 1 pill every 6 hours as needed for pain |
| Coumadin | 5mg daily | Cardiac, Neurological | Take 1 pill every day |
Labs
Click on the first lab image to display a table with a full trending of a lab value.
Creatinine 11/2/2012
Today10/30/2012
3 days ago10/4/2012
1 month ago9/1/2012
2 months ago1/31/2012
10 months ago8/27/2011
>1 Year Ago1.2 1.8 1.2 1.1 1.0 2.6 
Imaging/Studies
- Chest X-Ray: No infiltrate, cardiomegaly, pneumothorax, or widened mediastinum.
- Echocardiogram: No wall motion abnormalities, EF 45%, no pericardial effusion.
Visits
- Admission (11/1/2012 - 11/9/2012) Diagnosis: CHF
- Office Visit (10/25/2012) Diagnosis: CHF
- Office Visit (9/25/2012) Diagnosis: COPD Exacerbation
- Office Visit (9/14/2012) Diagnosis: Pneumonia
- Office Visit (9/1/2012) Diagnosis: Diabetes, Hyperglycemia