Progress Notes

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Turabo University

Calle Nuevo Leon

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

Inostroza, Jayden
Sex: Male, Date of Birth: 05-15-1980, Account No: INT01304
Attending Provider: Marcus . Welby, M.D.
Encounter Date: 07-01-2015
Chief Complaint:
Other Complaints:
Past Medical History
Fever Unspecified 780.60 Existing. Vomiting Alone 787.03 Existing. Chest Pain 786.50 Existing. Cough 786.2 Existing.
Streptococcal Sore Throat 034.0 Existing. Diarrhea 787.91 Existing. Abdominal Pain, Generalized 789.07 Existing.
Surgical History
Leg Surgery : 05-25-2010 by Dr. delgado at hima san pablo humacao
Raspe de Prostata: 07-22-2010 by Dr. Oquendo at rydel memorial
Family History
Alcoholism: Uncle. Diabetes Type II: Sister. Heart Trouble: Father, Mother. Hypertension: Brother.
Social History
Work History: He is employed.
Use Of Drugs/Alcohol/Tobacco: Drinks alcohol occasionally. Reports drinking beer and other, 4 drinks per week. He
denies his alcohol consumption as being problem to self or family or others. Denies ever experiencing blackouts. He says he
never indulges in 'binge' drinking. Denies driving after drinking. He has quit smoking but was a light smoker. He 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. 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.
Vaccination History
Vaccine
Hepatitis B

Dose
1

Age Range
0 - 1 Months

Due Date
06-26-2005

Hepatitis B
Diptheria, Tetanus Toxides, Acellular Pertusssis

2
1

1 - 2 Months
2 - 2 Months

07-26-2005
08-26-2005

Haemophilus Influenzae Type B

2 - 2 Months

08-26-2005

Inactivated Poliovirus
Pneumococcal

1
1

2 - 2 Months
2 - 2 Months

08-26-2005
08-26-2005

Rotavirus

2 - 2 Months

08-26-2005

Tetanus, Deptheria toxoids and acellular pertussis 1

2 - 2 Months

08-26-2005

Tetanus, Deptheria toxoids and acellular pertussis 2

Rotavirus
2
Pneumococcal
2

4 - 4 Months
4 - 4 Months
4 - 4 Months

10-26-2005
10-26-2005
10-26-2005

Inactivated Poliovirus
Haemophilus Influenzae Type B

2
2

4 - 4 Months
4 - 4 Months

10-26-2005
10-26-2005

Diptheria, Tetanus Toxides, Acellular Pertusssis

4 - 4 Months

10-26-2005

Diptheria, Tetanus Toxides, Acellular Pertusssis

Hepatitis B

3
3

6 - 6 Months
6 - 18 Months

12-26-2005
12-26-2005

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Progress Notes

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Haemophilus Influenzae Type B

6 - 6 Months

12-26-2005

Influenza
Inactivated Poliovirus

1
3

6 - 12 Months
6 - 18 Months

12-26-2005
12-26-2005

Pneumococcal
3
Rotavirus
3
Tetanus, Deptheria toxoids and acellular pertussis 3

6 - 6 Months
6 - 6 Months
6 - 6 Months

12-26-2005
12-26-2005
12-26-2005

Measles, Mumps, Rubella

Pneumococcal

1
4

12 - 15 Months
12 - 15 Months

06-26-2006
06-26-2006

Haemophilus Influenzae Type B

12 - 15 Months

06-26-2006

Hepatitis A
Vericella

1
1

1 - 2 Years
12 - 15 Months

06-26-2006
06-26-2006

Diptheria, Tetanus Toxides, Acellular Pertusssis 4

Tetanus, Deptheria toxoids and acellular pertussis 4

15 - 18 Months
15 - 18 Months

09-26-2006
09-26-2006

Hepatitis A
Haemophilus Influenzae Type B
Influenza

2
5
2

1 - 2 Years
18 - 37 Months
1 - 1 Years

12-26-2006
12-26-2006
12-26-2006

Pneumococcal
Pneumococcal Polysaccharide

5
1

24 - 37 Months
2 - 6 Years

06-26-2007
06-26-2007

Meningococcal Polysaccharide
Influenza
Influenza

1
3
4

2 - 10 Years
2 - 2 Years
3 - 3 Years

06-26-2007
12-26-2007
12-26-2008

Diptheria, Tetanus Toxides, Acellular Pertusssis

Inactivated Poliovirus

5
4

4 - 6 Years
4 - 6 Years

06-26-2009
06-26-2009

Tetanus, Deptheria toxoids and acellular pertussis 5

Measles, Mumps, Rubella
2
Vericella
2

4 - 6 Years
4 - 6 Years
4 - 6 Years

06-26-2009
06-26-2009
06-26-2009

Influenza
Influenza

5
6

4 - 4 Years
5 - 5 Years

12-26-2009
12-26-2010

Vericella
Vericella

3
4

7 - 12 Years
7 - 12 Years

06-26-2012
09-26-2012

Health Maintenance
Type
Test
LB
AMYLASE,SERUM

Status
Due

Due Date Last Done

07-01-2015

LB

Cardiac Panel

Due

07-01-2015

LB
LB

Complete Metabolic Panel

Lipid Panel

Due
Due

07-01-2015
07-01-2015

LB
LB
LB

CBC w/auto diff

Thyroid Antibody Panel
Hemoglobin A1c

Due
Due
Due

07-01-2015
07-01-2015
07-01-2015

LB

Microalbumin

Due

07-01-2015

LB

STOOL GUAIAC

Due

07-01-2015

RL
RL
RL

Echocardiogram
Chest x-ray PA and Lat
Abdomen (2 view)

Due
Due
Due

07-01-2015
07-01-2015
07-01-2015

RL

Abdomen

Due

07-01-2015

Last Result

Review of Systems
Constitutional Symptoms: The patient reports fever and chills.

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Progress Notes

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Eyes: The patient reports visual changes.

Cardiovascular: The patient reports chest pain, murmur and palpitation. Previous EKG: 07-01-2015.
Respiratory: The patient reports cough, asthma and wheezing.
Gastrointestinal: The patient reports diarrhea.
Vitals
Weight: 220.00 lbs. Height: 511.00 inches. BMI: 1. Pulse: 90 per min. Respiration: 20 breaths per min. BP Systolic: 170
mm Hg. BP Diastolic: 90 mmHg.

Physical Examination

Assessment and Plan

Obtain following labs today: CBC with differential, lip panel, bloos glucose, and urinalysis. In addition, blood and urine
cultures are needed. Antibiotic therapy to be determined based on lab results. The patient was advised to take analgesics to
relive symptoms until results confirm or rule out sepsis and causative agent. He is to call tomorrow to let me know how he
feels, and seek immediate treatment if his fever reaches 103.5 degrees.
Obtain following labs today: CBC with differential, lip panel, bloos glucose, and urinalysis. In addition, blood and urine
cultures are needed. Antibiotic therapy to be determined based on lab results. The patient was advised to take analgesics to
relive symptoms until results confirm or rule out sepsis and causative agent. He is to call tomorrow to let me know how he
feels, and seek immediate treatment if his fever reaches 103.5 degrees.
Lab Order
Radiology Order
Consults Ordered

Labs Reviewed
Radiology Reviewed

List of education material given

Follow up:

No Follow Up

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Progress Notes

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Marcus Welby, M.D.

This has been electronically signed on 07-01-2015

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