Progress Notes

Page 1 of 2

Turabo University

Calle Nuevo Leon

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

Amil, Nydia
Sex: Female, Date of Birth: 12-30-1948, Account No: INT01219
Attending Provider: Marcus . Welby, M.D.
Encounter Date: 06-29-2015
Chief Complaint:
Other Complaints:
Past Medical History
Abdominal Pain Other Specified Site 789.09 Existing.
Surgical History
apendice: 03-12-2012 by Dra. Solis at Hospital Ryder
Gastric Bypass : 06-02-2014 by Dr. Vergara at Hospital Oriente
Family History
Alzheimer's: Maternal Grandmother. Back pain: Cousin. Cancer: Sister. Hipertension: Father.
Social History
Use Of Drugs/Alcohol/Tobacco: Drinks alcohol occasionally. Reports drinking beer and mixed drinks, 3 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 never smoked tobacco. She consumes 0. Number of chews per day: 0. No.
Of pipes smoked per day: 0. Cigars smoked per day: 0. Does not drink caffeinated beverages. 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 does not do even mild exercise. She reports doing occasional vigorous exercise ( work or
recreation). She does not do any regular vigorous exercise for work or recreation.
Current Medication
prednisone 5 mg tablet,delayed release 1 Tablet Every Morning for 30 Days , Dispense 30 Tablet
Claritin 5 mg/5 mL oral solution 1 Tablet Every Morning for 25 Days , Dispense 25 Tablet
Allergy
Peanuts Mild . Yodo Moderate . Acetaminophen Moderate . Aspirin Moderate . Seafood Moderate to severe .
Health Maintenance
Type
Test
LB
ANA Panel
LB
Complete Metabolic Panel

Status
Due
Due

Due Date Last Done Last Result

06-24-2015
06-24-2015

LB
LB

Lipid Panel
CBC w/auto diff

Due
Due

06-24-2015
06-24-2015

LB

Obstetric Panel

Due

06-24-2015

LB
LB

Renal Function Panel

Thyroid Antibody Panel

Due
Due

06-24-2015
06-24-2015

LB

Pap smear

Due

06-24-2015

LB

Hemoglobin A1c

Due

06-24-2015

LB
LB
LB

Microalbumin
Due
Urinalysis, Complete W/Microscopic Due
STOOL GUAIAC
Due

06-24-2015
06-24-2015
06-24-2015

RL

Mammo diagnostic

06-24-2015

Due

https://ut.prognocis.com/prognocis/scrPrint.jsp?id=4244&mode=default&tmpid=2&output... 7/22/2015

Progress Notes

Page 2 of 2

LB

AMYLASE,SERUM

Due

06-29-2015

RL
RL

Abdomen (2 view)
Abdomen

Due
Due

06-29-2015
06-29-2015

Review of Systems
Integumentary: The patient denies change in skin color, change in hair/nails, itching or rashes. She does not have varicose
veins.
Physical Examination

Lab Order
Radiology Order
Consults Ordered

Labs Reviewed
Radiology Reviewed

List of education material given

Follow up:
Marcus Welby, M.D.

This has been electronically signed on 06-29-2015

https://ut.prognocis.com/prognocis/scrPrint.jsp?id=4244&mode=default&tmpid=2&output... 7/22/2015