Progress Notes

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Turabo University

Calle Nuevo Leon

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

Ortiz Rodriguez, Junielys

Sex: Female, Date of Birth: 02-03-1980, Account No: INT01302
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. Diarrhea 787.91 Existing.
Cough 786.2 Existing. Streptococcal Sore Throat 034.0 Existing. Abdominal Pain, Generalized 789.07 Existing.
Surgical History
Leg Surgery : 01-22-2010 by Dr. Delgado at Hospital Oriente
Raspe de Prostata: 06-01-2010 by Dra. Solis at Hospital Ryder
Family History
Alcoholism: Uncle. Diabetes Type II: Sister. Heart Trouble: Father, Mother. Hypertension: Brother.
Social History
Use Of Drugs/Alcohol/Tobacco: Drinks alcohol occasionally. Reports drinking beer and other, 4 drinks per week. She
denies her alcohol consumption as being problem to self or family or others. She says she never indulges in 'binge' drinking.
Denies driving after drinking. She has quit smoking but was a light smoker. She 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. She has never used any illicit drugs. She denies using street drugs with a needle. Has used/ is using marijuana. She
has a sedentary lifestyle. Does not take any exercise. She reports doing mild exercise like climb stairs or walk 2-3 blocks.
She reports doing occasional vigorous exercise ( work or recreation). She does not do any regular vigorous exercise for
work or recreation.
Vaccination History
Vaccine
Hepatitis B
Hepatitis B

Dose
1
2

Age Range
0 - 1 Months
1 - 2 Months

Due Date
02-03-2005
03-03-2005

Diptheria, Tetanus Toxides, Acellular Pertusssis

2 - 2 Months

04-03-2005

Haemophilus Influenzae Type B

2 - 2 Months

04-03-2005

Inactivated Poliovirus
Pneumococcal

1
1

2 - 2 Months
2 - 2 Months

04-03-2005
04-03-2005

Rotavirus

2 - 2 Months

04-03-2005

Tetanus, Deptheria toxoids and acellular pertussis 1

Tetanus, Deptheria toxoids and acellular pertussis 2

2 - 2 Months
4 - 4 Months

04-03-2005
06-03-2005

Rotavirus
Pneumococcal
Inactivated Poliovirus

2
2
2

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

06-03-2005
06-03-2005
06-03-2005

Haemophilus Influenzae Type B

4 - 4 Months

06-03-2005

Diptheria, Tetanus Toxides, Acellular Pertusssis

4 - 4 Months

06-03-2005

Diptheria, Tetanus Toxides, Acellular Pertusssis

Hepatitis B

3
3

6 - 6 Months
6 - 18 Months

08-03-2005
08-03-2005

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Haemophilus Influenzae Type B

6 - 6 Months

08-03-2005

Influenza
Inactivated Poliovirus

1
3

6 - 12 Months
6 - 18 Months

08-03-2005
08-03-2005

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

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

08-03-2005
08-03-2005
08-03-2005

Measles, Mumps, Rubella

Pneumococcal

1
4

12 - 15 Months
12 - 15 Months

02-03-2006
02-03-2006

Haemophilus Influenzae Type B

12 - 15 Months

02-03-2006

Hepatitis A
Vericella

1
1

1 - 2 Years
12 - 15 Months

02-03-2006
02-03-2006

Diptheria, Tetanus Toxides, Acellular Pertusssis 4

Tetanus, Deptheria toxoids and acellular pertussis 4

15 - 18 Months
15 - 18 Months

05-03-2006
05-03-2006

Hepatitis A
Haemophilus Influenzae Type B
Influenza

2
5
2

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

08-03-2006
08-03-2006
08-03-2006

Pneumococcal
Pneumococcal Polysaccharide

5
1

24 - 37 Months
2 - 6 Years

02-03-2007
02-03-2007

Meningococcal Polysaccharide
Influenza
Influenza

1
3
4

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

02-03-2007
08-03-2007
08-03-2008

Diptheria, Tetanus Toxides, Acellular Pertusssis

Inactivated Poliovirus

5
4

4 - 6 Years
4 - 6 Years

02-03-2009
02-03-2009

Tetanus, Deptheria toxoids and acellular pertussis 5

Measles, Mumps, Rubella
2
Vericella
2

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

02-03-2009
02-03-2009
02-03-2009

Influenza
Influenza

5
6

4 - 4 Years
5 - 5 Years

08-03-2009
08-03-2010

Vericella
Vericella

3
4

7 - 12 Years
7 - 12 Years

02-03-2012
05-03-2012

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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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, shortness of breath, asthma and wheezing.
Gastrointestinal: The patient reports diarrhea.
Rheumatic fever
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, lipid panel, blood glucose, and urinalysis. In addition, blood and urine
cultures are are needed. Antibiotic therapy to be determined based on lab results. The patient was advised to take
analgesics to relieve 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, lipid panel, blood glucose, and urinalysis. In addition, blood and urine
cultures are are needed. Antibiotic therapy to be determined based on lab results. The patient was advised to take
analgesics to relieve 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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