Outpatient Office Visit
Patient Case Number: OPOV64-Dunbar, June
Patient Name: June Dunbar | DOB: 11-15-72 | Sex: F
Date of Service: 05-15-XX | Physician: Freddy Smith, MD

# History of Present Illness:

Ms. Dunbar is here today for a follow-up recheck visit for ulcerative colitis, she states that she is “feeling good” and “in maintain mode” at this point.

# Medical History: Ulcerative colitis

# Medication:

Imuran 50 Mg Tablet SIG: take 2 q d

Folic Acid 1 Mg Tablet SIG: Take 1 tablet daily Remicade 100 Mg Vial SIG: q 8 weeks

Depo-provera 150 Mg/ml Vial SIG: Birth control Loratadine 10 Mg Tablet SIG: As needed for allergies Vitamin D 2,000 Unit Tablet SIG: Take 1 daily

# Social History:

June has never smoked or used tobacco products. Currently drinks. She has been drinking occasionally on a social basis. She denies recreational drug use. Patient is single.

# Surgical History: Colonoscopy-which revealed ulcerative proctosigmoiditis, Sigmoidoscopy

# Vitals

Temperature | 98.7
Height | 5’5
Weight | 150
Respirations | 18
Pulse | 72

BMI | 25.0
BP | 130/60

# Physical Examination:

# General Appearance: The patient is well-developed, well-nourished, and in no cardiorespiratory distress. She is alert and oriented to time, place, and person. The patient ambulates to the examination room without assistance. She is able to sit comfortably on the examination table without difficulty or evidence of pain. Head is normal. Eye conjunctiva is pink. Sclera is not jaundiced. Mucous membranes are moist. Neck is supple. Heart is regular. Lungs are clear. Abdomen is soft and non-tender. No palpable mass.

# Impression/Plan:

1. Ulcerative colitis: All the results were discussed with the patient and questions answered to her satisfaction. The patient’s complaint and associated medical conditions were explained to her in detail. I discussed treatment options for diet and exercise with the patient. Doing very well on meds. Continue on meds.

# Electronically Signed By: Freddy Smith, MD

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