GENERAL INFORMATION: Willie Belleh 58 year old male, Liberian presently residing at the St. Paul Bridge, Monrovia, Liberia. Patient sought consultation May 30, 2012. CHIEF COMPLAINT: For routine check up HISTORY OF PRESENT ILLNESS Patient came in for a routine check up. He claims to be under medication for hypertension and diabetes. He is presently taking Cozaar tablets 25mg 1 tablet once a day, Glipizide 15mg daily and Zocor 5 mg 1 tablet once daily PAST HISTORY: Underwent nephrectomy 1985 right kidney for inflammation in the UK. Diagnosed Diabetic 2005 and Hypertensive 2006. Underwent ultrasound kidneys 2002 results normal. PHYSICAL EXAMINATION: BP: 120/80 CR: 80/minute RR: 18/minute HEENT: Pale palebral conjunctiva, no tonisillo pharyngeal congestion CHEST/LUNGS: Clear breath sounds, No rales , No wheezes HEART: Normal rate regular rhythm no murmurs ABDOMEN: No organomegaly, normal bowel sounds, (-) kidney punch , Nephrectomy surgical scar right EXTREMITIES: No Edema noted MEDICATIONS: Cozaar (Losartan) 25 mg 1 tablet once a day Glucocontrol (Glipizide) 15 mg – 10mg AM and 5mg PM Zocor (Simvastatin) 5 mg 1 tablet once daily Aspirin Tablets 80mg 1 tablet once a day PERTINENT LABORATORY EXAMINATIONS: Chest X-ray: AP/Lateral June 1, 2012 . Complete Blood Count: HgB 12.9 g/dL Hct 35% RBC 4.5 x 106 WBC 10.5 x 103 Differential Count Segmenters 63 Band 0 Lymphocytes 35 Monocytes 0 Eosinophiles 2 Basophiles 0 URINALYSIS: Bilirubin 3umol/L Glucose Negative Ketone 4 mg/dL pH 5.9 Protein 99 mg/dL RBC’s 4 RBCs/HPF Specific Gravity 1.029 Urobilinogen 3.99 umol/L `IMMUNOLOGY: H. pylori test (-) March 20, 2014 Falciparum (-) March 15,2012 VDRL (-) September 19,2012 STOOL EXAMINATION: May 9,2012 Giardia lamblia cyst (+) . Peripheral Smear: May 30, 2012 Peripheral smear reveals microcytic hypochromic red blood cells with anisocytosis. White blood cells are normal with neutrophilic predominance. Platelets are adequate. No malarial parasites were noted on the examination of the smear. BLOOD CHEMISTRY APRIL 12 ,2012 Chemistry Test Results Reference Values Creatinine 1.4 mg/dl 0.5-1.1 mg/dl Blood Urea Nitrogen 45.8 mg/dl 14-45 mg/dl Blood Uric Acid 7.5 mg/dl 2.4-7.0 mg/dl Cholesterol 205 mg/dl <200 mg/dl HDL 31.7 mg/dl > 35 mg/dl LDL 98 mg/dl 1-150mg/dl Triglyceride 135 mg/dl 1-150mg /dl AST 23 U/L 5-38 U/L ALT 19 U/L 5-42 U/L Fasting Blood Sugar 98 mg/dl 75-115 mg/dl PSA: Positive > 4ng/dl WIDAL TEST: Non reactive MALARIAL SMEAR: No malarial parasites seen
