November 2, 2010
2
Consult Requests c\+^.{-,,^. JLdLL,LD. Last Action: Facility Activity COMPLETE COMPLETE/UPDATE Date/time / Zone Printed On Jan 06,2011 Responsible Person Entered By CPRS RELEASED ORDER 70/28/10 09:54 PRINTED ro MEDSSP20$pnr L0/28/10 09:54 SCHEDULED 10/28/70 10:31 LB PULM: ASAP Consul-t Appt . on It / 02 / L0 G 14 : INCOMPLETE RPT Note# 74910017 COMPLETE/UPDATE Note# L4970017 tt/02/r0 t6;42 tt/03/70 07:51 - - Note: TIME ZONE is local- if not inCicated LOCAL TITLE: PULMONARY /CCNSULT STANDARD TTTLE: PULMONARY CONSULT DATE OF NOTE: NOV 02, 2070G16:32 AUrHoRr- URGENCY: PATIENT NAME AND ADDRESS (Mechanical imprinting, if available) M]TCHELL, OLIVER PO BOX t9L2 LONG BEACH, CALTFORNTA 90801 ENTRY DATE: EXP COSIGNER: NCV 02,2010G15:33:21 STATUS: COMPLETED Pulmonary F/U note under supervision of Dr. - History of Present Illness: 39 year old AAM here for eval-uation of chronic productive cough. Pt states that since he was 20 and left the military, he's had episodes of coughing every year 2-3 times per year lasting up to three weeks. More recently his cough has l-asted for six weeks. He produces thick green sputum in the morning, which will fater turn to whitish froth. Usually these episodes resolve on their own, but this time it didn't so he went to his PCP. He was initially given a zpack, which dj-dn't improve his symptoms. Dr. Iprescribed him Doxycycfine, whi-ch has significantly improved his symptoms. No hemoptysis, fevers, chiIls, weight loss, or appetite changes. Past Medical Hi-story: 1) Dysuria * (ICD-9-CM 788.1) 2) Hemorrhoids * (ICD-9-CM 455.6) 3) Sleep Apnea (ICD-9-CM 780.51 /1 86.09) 4) Obesity VISTA Electronic Medical Documentation Printed at LONG BEACH VAMC Page 23
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On November 2, 2010 VA Physicians entered a medical note within Mitchell's VA medical record stating:No children (but has never tried to have children).
Transcript of November 2, 2010
Consult Requestsc\+^.{-,,^.JLdLL,LD.
Last Action:
FacilityActivity
COMPLETE
COMPLETE/UPDATE
Date/time / Zone
Printed On Jan 06,2011
Responsible Person Entered By
CPRS RELEASED ORDER 70/28/10 09:54PRINTED ro MEDSSP20$pnr L0/28/10 09:54SCHEDULED 10/28/70 10:31
LB PULM: ASAP Consul-t Appt . on It / 02 / L0 G 14 :
INCOMPLETE RPT
Note# 74910017COMPLETE/UPDATE
Note# L4970017
tt/02/r0 t6;42
tt/03/70 07:51
-
-
Note: TIME ZONE is local- if not inCicated
LOCAL TITLE: PULMONARY /CCNSULTSTANDARD TTTLE: PULMONARY CONSULTDATE OF NOTE: NOV 02, 2070G16:32
AUrHoRr-URGENCY:
PATIENT NAME AND ADDRESS (Mechanical imprinting, if available)
M]TCHELL, OLIVERPO BOX t9L2LONG BEACH, CALTFORNTA 90801
ENTRY DATE:EXP COSIGNER:
NCV 02,2010G15:33:21
STATUS: COMPLETED
Pulmonary F/U note under supervision of Dr.
-
History of Present Illness:39 year old AAM here for eval-uation of chronic productive cough. Pt states thatsince he was 20 and left the military, he's had episodes of coughing every year
2-3 times per year lasting up to three weeks. More recently his cough hasl-asted for six weeks. He produces thick green sputum in the morning, which willfater turn to whitish froth. Usually these episodes resolve on their own, butthis time it didn't so he went to his PCP. He was initially given a zpack,which dj-dn't improve his symptoms. Dr. Iprescribed him Doxycycfine, whi-chhas significantly improved his symptoms. No hemoptysis, fevers, chiIls, weightloss, or appetite changes.
Past Medical Hi-story:
1) Dysuria * (ICD-9-CM 788.1)2) Hemorrhoids * (ICD-9-CM 455.6)3) Sleep Apnea (ICD-9-CM 780.51 /1 86.09)4) Obesity
VISTA Electronic Medical Documentation
Printed at LONG BEACH VAMC
Page 23
Consult Requests5) Dysphagia, unspecified6) Syncope and collapse1) Anemia * (ICD-9-CM 285.9)B ) Blurred vision ( ICD-9-CM 368. B )
9) Cough (ICD-g-CM 186.2)
PSH:none
CLI .r-)11 .
Married, rro children (but has never tried to have children)quit smoking 5 months d9o, 10 pack year historyoccasional etohno illicit drug use
FH:no history of
Immunizations:
Immuni zationHEP B
INFLUENZATD-ADULT
Series Date Facility Reaction
Comments: Long
Allergy: Patient has answered NKA
Oupatient Medicati-ons :
Active Outpatient Medications (excluding Supplies) :
Issue DateLast FillExpiration
Printed On Jan 06,2011
lung disease
03/01 /2005 LONG BEACH*O9/02/2004 LONG BEACH*LO/22/2003 LONG BEACH*00/00/2005 No Site
Beach VA Hospltal
Active Outpatient MedicationsStatusRefills
AMLODIPINE BESYLATE 5MG TAB Qty: 90 for90 days Sig: TAKE ONE TABLET BY MOUTH
EVERY DAY FOR HTGH BLOOD PRESSURE
AZITHROMYCIN 250MG TAB Qty: 6 for 4
days Sig: TAKE TWO TABLETS BY MOUTH
EVERY DAY FOR 1 DAY, THEN TAKE ONE
TABLET EVERY DAY FOR 4 DAYS F"OR
INFECTIONCODEINE lOMG/GG lOOMG/5ML ORAL LIQUID
ACTIVERefills:
ACTIVERefills:
ACTIVE
VISTA Electronic Medical Documentation
Printed at LONG BEACH VAMC
Issu:10-28-L0Last:10-29-L0Expr: 01-26-77Issu:10-2L-L0Last:10-27-L0Expr:Ll-20-10
Issu:70*21-10
PATIENT NAME AND ADDRESS (Mechanical imprinting, if available)
MITCHELL, OLTVERPO BOX l9l2LONG BEACH, CALTFORNTA 90801
Page 24
