Paul’s Complete Physical Exam 01/17/2013 ( Passed 32 days later)

I don’t have a scanner to scan these pages but I will put insert from his physical exam.

 

My Son’s Paul G. Victorian Jr

Complete Physical Exam January 17, 2013

By Dr. Michael Moshier Sutter Health Care, Fairfield, Ca

                

       (Parts of My son’s PAUL VICTORIAN JR Complete Physical Exam)

 

The Patient is here today for a general physical exam and follows up of the following medical problems: Patients present with: Complete physical exam

Health Maintenance-flu shot

Medication reconciliation- 2 antidepressants- names unknown

Notes;

 

No abnormal labs in the past 12 months

Past medical history:

Review of patient’s past surgical history indicates

HX No Significant past Surg Hist

 

SOCIAL HISTORY:

Tobacco Use: Never

Alcohol Use: No

Drug Use: No

 

FAMILY HISTORY:

Family history included No Sig Fam PMH in his father or mother

 

MEDICATION:

No current prescription on file (Was included later on report)

 

ALLERGIES:

Review of patient’s allergies indicates no known allergies.

 REVIEW OF SYSTEM:

*      GENERAL: No weight loss, fever or fatigue

*      EYES: No Visual disturbances, no diplopia

*      ENT: no earaches, bleeding gums, or epistaxis

*      GI: Denies any nausea, vomiting, diarrhea, abdominal pain, no hepatitis, no blood in stool

*      CV: NO heart Disease, chest pain, palpitation, syncope, or edema

*       RESP: No cough,asthma or wheezing.

*      NEURO: No headaches, dizziness, vertigo, or tremors.

*      GU: No dysuria, frequency, no prostate problems, or hematuria

*      HEME: No easy bruising, or lymph node sweeling

*      ENDO: No Polyuria

 

PHYSICAL EXAMINATION:

 

  • GENERAL: The patient is a healthy-appearing male who is alert and oriented
  • EYES: Pupilas are equal, round, regular and reactive to light and accommodation. Fundi: retina are normal without lesions, exudates, or papilledema
  • ENT: Ears are normal. Mouth and pharynx are normal. Nasal mucosa normal
  • NECK: Carotids are without bruits. Thyroid is normal to palpation.
  • CHEST: Clear to percussion, and auscultation. No ralse or wheezes are heard.
  • HEART: Heart: S1, S2 normal, no murmur, rub or gallop, regular rate and rhythm.
  • ABDOMEN: Soft and non-tender. Bowels sounds are active, No hepatosplenomegaly present.
  • GENITALIA: Normal no hernia no masses testes normal and descended
  • RECTAL: Deferred
  • EXTREMETIES: No edema, Pulses are intact
  • LYMPH: No cervical axillary or groin adenopathy
  • NEUROLOGIC: Cranial nerves intact. No motor sensory defect, reflexes are equal, Gait normal

 

 

IMPRESSION PLAN:

V70.0 Routine General medical examination at a health care facility (Primary encounter diagnosis)

 796.2 elevated blood pressure reading without diagnosis of hypertension

 Plan: Basic Metabolic Panel

LIPID PROFILE- Future

CBC WITH AUTOMATED DIFFERENTIAL-Future

URINALYSIS WITH MICROSCOPE-Future

 V04.81  Need for prophylactic vaccination and inoculation against influenza

Plan: INFLUENZA VAC PRES FREE (FLU CLINIC) 3 YO (V04.81) W/MD

 300.00 Anxiety state, unspecified

 299.00L Autistic Disorder

 Low salt diet rechecks in 2 months

 

Michael Moshier, MD

Family Medicine

Sutter Regional Medical

Please note that this was a complete physical exam and they did complete lab work as well. My son did not have Heart Disease, he did not have Hypertension, he did however have a normal heart, his chest was clear, etc. My husband took him because his medication was increased and he was having these drastic changes, weight was the primary concern becasue he gained 132lb since he started the medication and his negligent doctor never address our concerns are monitorted our son, And to add insult to injury the doctor who prescribed this antiposychotic medication  dropped my son as a patient for no apparent reason all of a sudden. He abanonded my son treatment when he prescribed this medication, he did not monitor my son while on this medication, he did not do current lab work when he increased his dosage twice in March 29, 2012 he increased his dosage to 20mg, Then in November 26, 2012 it ws increased to 30mg. When it states on the website from the manufacture of Ability(we researched after our son’s death) it states on their website: play close attention to any changes, especially sudden changes in mood, behavior, its states this is very important when an antipedressant medicine is started or when a DOSE is changed. My son’s was changed twice. It states that Abilify may cause heart failure, sudden death, or pneumonia in older adults with dementia-related conditions. ( Note Autism is a degenerative brain disorder family). It also states that Patients need to be warned about the risk and educated about how to identify early signs. It states that the patient should still regularly see a therapist or doctor, to keep track of symptoms and keep them at bay. That didn’t happen in our case, His doctor gave us a prescription with 3 refills on them, and when he was low the doctor would call in another prescription. But we always talk about Pauls weight it was a big concern but the psychartist who prescribed this didn’t do anything, He never told us any information about abilify or the risk nothing, He just switched my son Paul from on antipsychotic RISPERDAL to another ABILIFY. He did tell us about Risperdal, only that it might cause his chest to lactate like a lady. That was a concern to use but he was the professional and we trusted him. My son grew breast from Ridperdal but was switch to Abilify in 2011.    

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