11/23/98 00:49
Caldwell_Alexander
Problem: Abdominal pain.
Subjective: Crampy diffuse abdominal pain. Steady right lower quadrant pain. Has had diarrhea.
Objective: Weight: 140 Height: 65 BP 120/80 Temp: 98.6 Resp: 15
Tender right lower quadrant.
Assesment: RLQ pain, possible appendicitis.
Plan: Admit for further observation. CBC, panel 12, lipase, amylase.

Alexander Caldwell M.D.
11/23/98 00:49
Caldwell_Alexander
Problem: Abdominal pain.
Subjective: Crampy diffuse abdominal pain. Steady right lower quadrant pain. Has had diarrhea.
Objective: Weight: 140 Height: 65 BP 120/80 Temp: 98.6 Resp: 15
Tender right lower quadrant.
Assesment: RLQ pain, possible appendicitis.
Plan: Admit for further observation. CBC, panel 12, lipase, amylase.

Alexander Caldwell M.D.
11/23/98 00:49
Caldwell_Alexander
Problem: Abdominal pain.
Subjective: Crampy diffuse abdominal pain. Steady right lower quadrant pain. Has had diarrhea.
Objective: Weight: 140 Height: 65 BP 120/80 Temp: 98.6 Resp: 15
Tender right lower quadrant.
Assesment: RLQ pain, possible appendicitis.
Plan: Admit for further observation. CBC, panel 12, lipase, amylase.

Alexander Caldwell M.D.
11/23/98 00:49
Caldwell_Alexander
Problem: Abdominal pain.
Subjective: Crampy diffuse abdominal pain. Steady right lower quadrant pain. Has had diarrhea.
Objective: Weight: 140 Height: 65 BP 120/80 Temp: 98.6 Resp: 15
Tender right lower quadrant.
Assesment: RLQ pain, possible appendicitis.
Plan: Admit for further observation. CBC, panel 12, lipase, amylase.

Alexander Caldwell M.D.
12/29/98 17:57
Caldwell_Alexander
Problem: Cough.
Subjective: Cough x 3 days. Other family has had same symptoms. Allergies: sulfamethoxazole Problems : 1. constipation. 2. diarrhea. 3. impotence. 4. priapism. 5. depression. 6. mania. Past Medical Illnesses : Past Surgeries : 1. reduction of fractured left forearm - 1964. 2. lumbar laminectomy 1984. Family History : Mother alive age 73. Father alive healthy age 74. Sister alive age 49 healthy. daughter Laurel age 17 healthy. son Alex age 15 healthy. Social History : Occupation: physician. Smoker: no. Alcohol: no. Immunizations : Hepatitis B 1995 series of 3. Significant past procedures :
Objective: Weight: 140 Height: 65 BP 120/80 Temp: 98.6 Resp: 15
Lungs - No dullness to percussion. Bilateral moderate wheezing.
Assesment: Bronchitis.
Plan: doxycycline 100mg-bid No.-20

Alexander Caldwell M.D.
12/30/98 08:37
Caldwell_Alexander
Problem: Sore throat.
Subjective: The patient has not had signs of being toxic nor a very high fever. There has not been difficulty speaking or extreme throat pain. There is never-the-less a fairly sore throat. The patient is very tired and is a teenager.
Objective: Weight: 140 Height: 65 BP 120/80 Temp: 98.6 Resp: 15
There is an obvious exudate Rapid strep test checked and is negative. Mono spot test positive.
Assesment: Mononucleosis confirmed.
Plan: Patient and parents counseled about rest, fluids, avoiding contact sports.

Alexander Caldwell M.D.
01/09/99 18:48
Alexander Caldwell
Problem or Chief Complaint: Bronchitis acute 466.0.
01/09/99 19:08
Alexander Caldwell

History and Physical

Problem or Chief Complaint: Bronchitis acute 466.0.
History of present Illness:
The patient is being admitted for a urinary tracti infection. Has history of dementia probably of the multi-infarct variety. General Health- Feeling pretty good lately. Seems to be picking up again last few days.
01/09/99 19:14
Alexander Caldwell

History and Physical

Problem or Chief Complaint: Bronchitis acute 466.0.
History of present Illness:
The patient is being admitted for pneumonia and also has acute bronchitis. General Health- No weight loss. Has no complaints. HEENT- No headaches. No loss of smell. Having migraines recently. Respiratory- Denies cough. Cardiovascular- Denies chest pain. Gastrointestinal- Has not had hematemesis. Genitourinary- Denies hematuria. Musculoskeletal- Has no pain in back recently. No pain that radiates to the legs. Neurological- Memory seems intact. Denies numbness or tingling anywhere. Cough x 3 days. Voice has been hoarse. Occaisionally coughs up some green looking phlegm.
01/09/99 19:17
Alexander Caldwell

History and Physical

Problem or Chief Complaint: Bronchitis acute 466.0.
History of present Illness:
The patient is being admitted for urinary tract infection. He also is demented. Review of Systems:
General Health- Seems to be picking up again last few days. Has no complaints. HEENT- Hearing is normal. No nasal discharge. No difficulty swallowing. Respiratory- Has had no hemoptysis. Denies wheezing. Increased sputum production. Cardiovascular- No dyspnea on exertion. Has not noticed edema of the ankles. Gastrointestinal- Has noticed no melena. There has been no hematochezia. Genitourinary- No urethral discharge. Musculoskeletal- No pain that radiates to the legs.
01/09/99 20:25
Alexander Caldwell

History and Physical

Problem or Chief Complaint: Bronchitis acute 466.0. Shortness of breath.
History of present Illness:
This patient is being admitted for pneumonia. He is really a mess. Voice has been hoarse. Other family has had same symptoms. Worried he could have asthma.
Review of Systems:
GENERAL- Has been improving. No weight loss.
HEENT- No headaches. No loss of smell. No changes in vision. LUNGS- Denies cough. There has been no shortness of breath. CARDIOVASCULAR- Denies chest pain.
Physical Exam: Weight: NA Height: NA BP NA/NA Temp: NA Resp: 15

GENERAL- Pleasant, cooperative. Well groomed. In no apparant distress.
HEENT- Head normal size and symmetry. Sclerae not icteric. Fundii reveal no exudates or hemorrhages. No papilledema. Ear canals clear bilaterally. No cervical or supraclavicular adenopathy. Carotids have no bruits. Thyroid not enlarged or nodular.
LUNGS- Lungs clear to auscultation and percussion. No rales. No rubs.
HEART- No murmers. No S3 gallop.
ABDOMEN- Bowel sounds normal. Abdomen flat, soft, non-tender.
GYNECOLOGICAL- Breasts examined carefully both sitting and lying.
MUSCULOSKELETAL- No atrophy. Reflexes intact. NEUROLOGICAL- Coordination intact. Mini mental status exam normal.
01/09/99 20:37
Alexander Caldwell

History and Physical

Problem or Chief Complaint: Bronchitis acute 466.0.
History of present Illness:
This patient is being admitted for pneumonia. He is a regular visitor to our E.R. Current Medications: antabuse dosage tylenol 500mg ginsing_root 2ft. prometh-codeine   TFP /root/drugs/accupril   TFP Longs Caldwell anabuse 250mg-qid actigall dosage lodine 0.1mg-q.day O.K. archie calendar Allergies: penicillin
Problems : 1. constipation. 2. diarrhea. 3. impotence. 4. priapism. 5. depression. 6. mania. Past Medical Illnesses : Past Surgeries : 1. reduction of fractured left forearm - 1964. 2. lumbar laminectomy 1984. Family History : Mother alive age 73. Father alive healthy age 74. Sister alive age 49 healthy. daughter Laurel age 17 healthy. son Alex age 15 healthy. Social History : Occupation: physician. Smoker: no. Alcohol: no.
Immunizations : Hepatitis B 1995 series of 3. Significant past procedures :
Review of Systems:
GENERAL- Feeling pretty good lately.
HEENT- No headaches. No changes in vision. No loss of smell. No difficulty swallowing.
CARDIOVASCULAR- No dyspnea on exertion. Chest pain.
PULMONARY- Has had no hemoptysis.
Physical Exam: Weight: NA Height: N/A BP NA/NA Temp: NA Resp: 15

01/09/99 20:48
Alexander Caldwell

History and Physical

Problem or Chief Complaint: Bronchitis acute 466.0.
History of present Illness:
Is being admitted today.
Review of Systems:
GENERAL- Feeling pretty good lately. Seems to be picking up again last few days.
HEENT- No headaches. No loss of smell.
Current Medications: antabuse dosage tylenol 500mg ginsing_root 2ft. prometh-codeine   TFP /root/drugs/accupril   TFP Longs Caldwell anabuse 250mg-qid actigall dosage lodine 0.1mg-q.day O.K. archie calendar
Problems : 1. constipation. 2. diarrhea. 3. impotence. 4. priapism. 5. depression. 6. mania. Past Medical Illnesses : Past Surgeries : 1. reduction of fractured left forearm - 1964. 2. lumbar laminectomy 1984. Family History : Mother alive age 73. Father alive healthy age 74. Sister alive age 49 healthy. daughter Laurel age 17 healthy. son Alex age 15 healthy. Social History : Occupation: physician. Smoker: no. Alcohol: no.
Immunizations : Hepatitis B 1995 series of 3. Significant past procedures :
Physical Exam: Weight: NA Height: NA BP NA/NA Temp: NA Resp: 15

01/09/99 21:09
Alexander Caldwell

History and Physical

Problem or Chief Complaint: Bronchitis acute 466.0.
History of present Illness:
Is in for a physical exam.
Current Medications: antabuse dosage tylenol 500mg ginsing_root 2ft. prometh-codeine   TFP /root/drugs/accupril   TFP Longs Caldwell anabuse 250mg-qid actigall dosage lodine 0.1mg-q.day O.K. archie calendar
Allergies: penicillin
Problems : 1. constipation. 2. diarrhea. 3. impotence. 4. priapism. 5. depression. 6. mania.
Past Medical Illnesses : Past Surgeries : 1. reduction of fractured left forearm - 1964. 2. lumbar laminectomy 1984.
Family History : Mother alive age 73. Father alive healthy age 74. Sister alive age 49 healthy. daughter Laurel age 17 healthy. son Alex age 15 healthy.
Social History :
Occupation: physician.
Smoker: no.
Alcohol: no.
Immunizations : Hepatitis B 1995 series of 3. Significant past procedures :
Review of Systems:
GENERAL- Feeling pretty good lately. No fever or chills.
HEENT- No changes in vision. No difficulty swallowing.
PULMONARY- Has had no hemoptysis.
Physical Exam: Weight: NA Height: NA BP NA/NA Temp: NA Resp: 15

GENERAL- Well developed. Well nourished.
HEENT- Head normal size and symmetry. Carotids have no bruits. No cervical or supraclavicular adenopathy. Thyroid not enlarged or nodular.
01/09/99 21:17
Alexander Caldwell

History and Physical

Problem or Chief Complaint: Back pain 724.2.
History of present Illness:
Is being admitted for back pain today.
Current Medications: antabuse dosage tylenol 500mg ginsing_root 2ft. prometh-codeine   TFP /root/drugs/accupril   TFP Longs Caldwell anabuse 250mg-qid actigall dosage lodine 0.1mg-q.day O.K. archie calendar
Allergies: penicillin
Problems : 1. constipation. 2. diarrhea. 3. impotence. 4. priapism. 5. depression. 6. mania.
Past Medical Illnesses : Past Surgeries : 1. reduction of fractured left forearm - 1964. 2. lumbar laminectomy 1984.
Family History : Mother alive age 73. Father alive healthy age 74. Sister alive age 49 healthy. daughter Laurel age 17 healthy. son Alex age 15 healthy.
Social History :
Occupation: physician.
Smoker: no.
Alcohol: no.
Immunizations : Hepatitis B 1995 series of 3.
Significant past procedures :
Review of Systems:
GENERAL- Feeling pretty good lately. Has been improving. Appetite has been good.
PULMONARY- Denies cough. Has had no hemoptysis. There has been no shortness of breath.
HEENT- No headaches. Hearing is normal.
CARDIOVASCULAR- Denies chest pain.
GASTROINTESTINAL- No difficulty swallowing. Not experiencing vomiting.
GENITOURINARY- No nocturia.
MUSCULOSKELETAL- Has no pain in back recently.
NEUROLOGICAL- Memory seems intact.
Physical Exam: Weight: NA Height: N/A BP NA/NA Temp: NA Resp: 15

GENERAL- Well developed. Well nourished.
HEENT- Carotids have no bruits. No cervical or supraclavicular adenopathy. Thyroid not enlarged or nodular.
LUNGS- Lungs clear to auscultation and percussion. No dullness to percussion. No rales.
HEART- Rhythm regular. No murmers.
ABDOMEN- Abdomen flat, soft, non-tender. Bowel sounds normal. Liver, spleen, kidneys not enlarged.
MUSCULOSKELETAL- Negative straight leg raising. No atrophy. Good femoral, popliteal and dorsalis pedis pulses bilaterally.
01/09/99 21:45
Alexander Caldwell

History and Physical

Problem or Chief Complaint: Bronchitis acute 466.0.
History of present Illness:
This patient is being admitted for acute bronchitis. I know it isn't usually done, but he is a V.I.P. and is essentially coming in for an extended rest. I may be critisized for admitting him this way but I feel we should do what makes us feel good whether it is against the rules or not.
Current Medications: antabuse dosage tylenol 500mg ginsing_root 2ft. prometh-codeine   TFP /root/drugs/accupril   TFP Longs Caldwell anabuse 250mg-qid actigall dosage lodine 0.1mg-q.day O.K. archie calendar
Allergies: penicillin
Problems : 1. constipation. 2. diarrhea. 3. impotence. 4. priapism. 5. depression. 6. mania.
Past Medical Illnesses : Past Surgeries : 1. reduction of fractured left forearm - 1964. 2. lumbar laminectomy 1984.
Family History : Mother alive age 73. Father alive healthy age 74. Sister alive age 49 healthy. daughter Laurel age 17 healthy. son Alex age 15 healthy.
Social History :
Occupation: physician.
Smoker: no.
Alcohol: no.
Immunizations : Hepatitis B 1995 series of 3.
Significant past procedures :
Review of Systems:
GENERAL- Feeling pretty good lately. Seems to be picking up again last few days.
HEENT- No headaches. No changes in vision. Hearing is normal.
PULMONARY- Denies cough. Has had no hemoptysis.
CARDIOVASCULAR- Denies chest pain. Has not noticed edema of the ankles.
GASTROINTESTINAL- No difficulty swallowing. Denies nausea. Has not had hematemesis.
GENITOURINARY- Wanted to get prostate exam. Denies dysuria.
MUSCULOSKELETAL- Has no pain in back recently. No numbness or tingling in the legs. GYNECOLOGIC- No problems with dysmenorrhea. Periods have been regular.
NEUROLOGICAL- Hearing seems normal.
Physical Exam: Weight: 145 Height: 65 BP 120/69 Temp: 98.6 Resp: 15

GENERAL- Well developed. Well groomed.
HEENT- Head normal size and symmetry. Conjunctivae clear. Cornea clear. No papilledema. Tympanic membranes pink and translucent. Nasal mucosa normal. No cervical or supraclavicular adenopathy. No cervical or supraclavicular adenopathy. Thyroid not enlarged or nodular. Carotids have no bruits.
LUNGS- Lungs clear to auscultation and percussion. No dullness to percussion.
HEART- Rhythm regular. No murmers. S1 and S2 normal. No S3 gallop.
GENITOURINARY- No varicocele. No hydrocele. No inguinal heria. No CVA tenderness. Phallus normal. No urethral discharge. Rectal exam normal. Hemoccult test negative. Testicles normal size. NEUROLOGICAL- Coordination intact. Deep tendon reflexes intact. Romberg normal.
Assesment/Diagnosis: Bronchitis, acute 466.0. Impending pneumonia.
Plan: EES 400mg qid with food x 10 days. Claritin D 12 hour 1 p.o. b.i.d. x 10 days.

Alexander Caldwell M.D.
01/10/99 23:09
Alexander Caldwell
Date of Birth - 09/05/1948 Age - 50

History and Physical

Problem or Chief Complaint: Bronchitis acute 466.0.

History of present Illness:
Has had a cough for 4-5 days. Has been coughing up green phlegm. Has had a fever.
Review of Systems:
GENERAL- Also having chills. Has had feeling of malaise.
HEENT- No changes in vision. No loss of smell.
PULMONARY- Denies cough. There has been no shortness of breath.
CARDIOVASCULAR- Denies chest pain. No orhopnea.
GASTROINTESTINAL- No difficulty swallowing. Has not had hematemesis.
GENITOURINARY- No nocturia. No urethral discharge. Having flank pain. Having decreased libido.
MUSCULOSKELETAL- No numbness or tingling in the legs. No pain in joints of the hands or swelling.
NEUROLOGICAL- Hearing seems normal. CURRENT MEDICATIONS: antabuse dosage anabuse 250mg-qid actigall dosage lodine 0.1mg-q.day accupril 10mg-q-day erythromycin 250mg-qid hismanal 10mg-q.day atrovent 2-puffs-qid atrovent   Longs antabuse   Longs penicillin 250mg-p.o.-qid
Problems : 1. constipation. 2. diarrhea. 3. impotence. 4. priapism. 5. depression. 6. mania.
Past Medical Illnesses : Past Surgeries : 1. reduction of fractured left forearm - 1964. 2. lumbar laminectomy 1984.
Family History : Mother alive age 73. Father alive healthy age 74. Sister alive age 49 healthy. daughter Laurel age 17 healthy. son Alex age 15 healthy.
Social History :
Occupation: physician.
Smoker: no.
Alcohol: no.
Immunizations : Hepatitis B 1995 series of 3.
Significant past procedures :

PHYSICAL EXAM: Weight: 140 Height: 65 BP 120/80 Temp: 98.6 Resp: 15


GENERAL- Pleasant, cooperative. Well dressed.
HEENT- Head normal size and symmetry. Pharynx not inflammed.
HEART- Rhythm regular. No murmers. S1 and S2 normal.
LUNGS- Breath sounds are equal on both sides. No dullness to percussion. No wheezing.
GENITOURINARY- No varicocele. No CVA tenderness. No urethral discharge.
NEUROLOGICAL- Coordination intact.

ASSESMENT/DIAGNOSIS: Bronchitis, acute 466.0.

PLAN: EES 400mg qid with food x 10 days. Phenergan with codeine one tsp q. 4h prn.

Alexander Caldwell M.D.
03/02/99 17:56
Caldwell_Alexander
Problem: Acne 706.1.
Subjective:
Objective: Weight: NA Height: NA BP NA/NA Temp: NA Resp: 15 Pulse: NA

Assesment: Acne 706.1.
Plan:

Alexander Caldwell M.D.

03/02/99 17:57
Caldwell_Alexander
Problem: Acne 706.1.
Subjective:
Objective: Weight: NA Height: NA BP NA/NA Temp: NA Resp: 15 Pulse: NA

Assesment: Acne 706.1.
Plan:

Alexander Caldwell M.D.


03/02/99 18:18
Caldwell_Alexander
Problem: Anorexia 783.0.
Subjective:
Objective: Weight: NA Height: NA BP NA/NA Temp: NA Resp: 15 Pulse: NA

Assesment: Anorexia 783.0.
Plan:

Alexander Caldwell M.D.


03/02/99 18:18
Caldwell_Alexander
Problem: Bronchitis acute 466.0.
Subjective:
Objective: Weight: NA Height: N/A BP NA/NA Temp: NA Resp: 15 Pulse: NA

Assesment: Bronchitis acute 466.0.
Plan:

Alexander Caldwell M.D.


03/02/99 18:42
Caldwell_Alexander
Problem: Asthma 493.0.
Subjective:
Objective: Weight: NA Height: NA BP NA/NA Temp: NA Resp: 15 Pulse: NA

Assesment: Asthma 493.0.
Plan: Get a life

Alexander Caldwell M.D.


03/02/99 18:42
Caldwell_Alexander
Problem: Bronchitis chronic 491.2.
Subjective:
Objective: Weight: NA Height: N/A BP NA/NA Temp: NA Resp: 15 Pulse: NA

Assesment: Bronchitis chronic 491.2.
Plan: Get a life II.

Alexander Caldwell M.D.