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Florida Medical Center Valrico Branch Square1_002 CLINIC NOTE: Date: November 1, 1999 Patient: S:
Chris Pace
Reevaluation SLE / possible severance. Some exposure over the weekend with increase fatigue and rash. Not able to work today. A gird / dysmotility. But still sick occasionally. No over heartburn. Nausea more of a problem. Worse in the morning. Currently taken propulsid before lunch, dinner and at bed time. He has had occasional diarrhea. Nothing prolong. Received amoxicillin surrounding recent dental procedures. His right shoulder has been doing better; he saw dermatology about the discriminative rash involving his scalp. Gives him unknown topical agent. He does not recall specific diagnosis. He relates symptoms of increase depression. This has been a problem for years. Current symptoms include sad in the mood thinking frequently about death. He denies suicidal aviation are intent. He is having difficulty with concentration and a motivation and relates intermittent careful episodes. He also describes symptoms anxiety but this is less of a problem currently. He has not noticed increased yellowish, unexplained fever, oral / nasal alterations are a change in his sickness symptoms. No pleurisy.
O:
Blood Pressure: 112/64, rash consistent with SCLE involving his neck and upper back. Error feminist annual elisions with peripheral desclamation. There is less desclamation apparent involving his scalp. The rash on his dorsal hands is unchanged. No nettle rash. Mild zero stony. Chest clear. Heart regular rhythm.
A:
1.
SLE – Flaring, I suspect this delay some exposure. He was giving additional information on where to buy some protective material for clothing. He has been on plaquenil sense 02/99. Will treat with topical and oral steroids. Yah, if he continues to have significant frequent flairs and more aggressive approach will be needed. 2. Sjogren's Syndrome – Resent dental work complete. Still considering saligenin. 3. Scalp, rash – ideology in the clear. Will request records. 4. Nausea/GERD – an improve is still a problem. He’s going to shifts Pulpulsive to the morning and take prevacid. Continue pulpusive before dinner and at bed time. He may require a boost QID therapy. 5. Right shoulder pain-improved with good range emotional exam. 6. Diarrhea –related to bacteria overgrowth. Antibiotic therapy reviewed. 7. Hashimoto's thyroiditis-U thyroid TSH in 08/99. 8. Depression-quite symptomatic. MSSRI such as Prozac seems to be the best choice giving his concurrent anxiety and fatigue. Sleeping underlying anxiety are a disorder will need to be watched as will his weight. 9. Fatigue – multi-bacteria. Suspect related to the Sjogren's/lupus/current flair and depression. P: 1. As outlined. 2. Prednisone 30 mg q.d. x 2 in taper by 5 mg q.d. and discontinued. _____________________________________________________________________________________ Office: 700 Main Street, Suite #700, Valrico, Florida 33569 Phone: 813-555-1212 Fax: 813-555-1111 Page 1 of 2
3. 4.
Records suppressive from “Dr. Smith.” Reevaluation in 4 to 6 weeks.
Copy to “Dr. Smith.” our fax is at 303-555-5555
John Hancock, M.D. JDH:
Chris Pace
Reevaluation SLE / possible severance. Some exposure over the weekend with increase fatigue and rash. Not able to work today. A gird / dysmotility. But still sick occasionally. No over heartburn. Nausea more of a problem. Worse in the morning. Currently taken propulsid before lunch, dinner and at bed time. He has had occasional diarrhea. Nothing prolong. Received amoxicillin surrounding recent dental procedures. His right shoulder has been doing better; he saw dermatology about the discriminative rash involving his scalp. Gives him unknown topical agent. He does not recall specific diagnosis. He relates symptoms of increase depression. This has been a problem for years. Current symptoms include sad in the mood thinking frequently about death. He denies suicidal aviation are intent. He is having difficulty with concentration and a motivation and relates intermittent careful episodes. He also describes symptoms anxiety but this is less of a problem currently. He has not noticed increased yellowish, unexplained fever, oral / nasal alterations are a change in his sickness symptoms. No pleurisy.
O:
Blood Pressure: 112/64, rash consistent with SCLE involving his neck and upper back. Error feminist annual elisions with peripheral desclamation. There is less desclamation apparent involving his scalp. The rash on his dorsal hands is unchanged. No nettle rash. Mild zero stony. Chest clear. Heart regular rhythm.
A:
1.
SLE – Flaring, I suspect this delay some exposure. He was giving additional information on where to buy some protective material for clothing. He has been on plaquenil sense 02/99. Will treat with topical and oral steroids. Yah, if he continues to have significant frequent flairs and more aggressive approach will be needed. 2. Sjogren's Syndrome – Resent dental work complete. Still considering saligenin. 3. Scalp, rash – ideology in the clear. Will request records. 4. Nausea/GERD – an improve is still a problem. He’s going to shifts Pulpulsive to the morning and take prevacid. Continue pulpusive before dinner and at bed time. He may require a boost QID therapy. 5. Right shoulder pain-improved with good range emotional exam. 6. Diarrhea –related to bacteria overgrowth. Antibiotic therapy reviewed. 7. Hashimoto's thyroiditis-U thyroid TSH in 08/99. 8. Depression-quite symptomatic. MSSRI such as Prozac seems to be the best choice giving his concurrent anxiety and fatigue. Sleeping underlying anxiety are a disorder will need to be watched as will his weight. 9. Fatigue – multi-bacteria. Suspect related to the Sjogren's/lupus/current flair and depression. P: 1. As outlined. 2. Prednisone 30 mg q.d. x 2 in taper by 5 mg q.d. and discontinued. _____________________________________________________________________________________ Office: 700 Main Street, Suite #700, Valrico, Florida 33569 Phone: 813-555-1212 Fax: 813-555-1111 Page 1 of 2
3. 4.
Records suppressive from “Dr. Smith.” Reevaluation in 4 to 6 weeks.
Copy to “Dr. Smith.” our fax is at 303-555-5555
John Hancock, M.D. JDH:
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