Referral Note for IRVIN, PAULINA 06/13/1948 (74yo F) #24781107

E#24781107
This document (1 of 1) was received from [email protected] on 09/06/2022 through Direct Message along with the following message bod
Please see attachment.

Ordering Provider , Performing facility AHMAD FAROOQ MD

Reported Date Accession ID

Performed Date

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Referral Note for Paulina Irvin

Encounter Details
Ahmad Farooq: Ph. tel: (713) 756-8700

Table of Contents
Demographics
Care Team Members
Reason for Referral
Reason for Visit
Assessment
Plan of Treatment
Results
Problems
Procedures
Medical Equipment
Allergies
Medications
History of Present Illness
Physical Exam
Review of Systems
Vitals
Social History
Functional Status
Mental Status
Family History
Medical History
Immunizations
Past Encounters
Goals Section
Health Concerns Section
Notes

Demographics
Sex: Female Ethnicity: Information not available
DOB: 06/13/1948 Race: Information not available
Preferred language: English Marital status: Information not available
Previous Name:

Contact: 2602 ROSEWOOD ST, APT 2, 2602 ROSEWOOD ST, APT 2, HOUSTON, TX 77004-3053, USA, Ph. tel:+1-(713) 444-3567 (Primary Home) tel:+1-(713) 444-3567 (Mobile)

Care Team Members

Reason for Referral

Reason for Visit

Assessment
No assessment recorded.

Plan of Treatment
Reminders Order Date Submit Date Provider
Appointments Endoscopy 30 09/06/2022 10:30AM Ahmad Farooq, MD

Lab None recorded.

Referral general surgeon referral - **PLEASE CALL PATIENT TO SCHEDULE** 09/06/2022 09/06/2022 Daniel L Howell MD, 7105 Lawndale St, Houston, TX, 77023, Ph (832) 942-835

Procedures None recorded.

Surgeries None recorded.

Imaging None recorded.

Medication Orders None recorded.

Patient Targets No targets recorded.

Results

None recorded.

Problems
Name Status Onset Date
Hypertensive disorder Active 08/16/2022
Referral Note for IRVIN, PAULINA 06/13/1948 (74yo F) #24781107
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Hypertensive disorder Active 08/16/2022

Anemia Active 08/16/2022

Vitamin D deficiency Active 08/16/2022

Problem Notes

None recorded.

Procedures
Surgical History

None recorded.

Imaging Results

None recorded.

Procedure Notes

None recorded.

Medical Equipment
None Reported.

Allergies
No known drug allergies - True

Medications
Name Sig Start Date Stop Date
lisinopril 20 mg-hydrochlorothiazide 12.5 mg tablet TAKE 1 TABLET BY MOUTH EVERY DAY

fluocinonide 0.05 % topical ointment APPLY TO AFFECTED AREA TWICE A DAY

hydrocortisone acetate 25 mg rectal suppository Insert 1 suppository twice a day by rectal route for 10 days. 08/16/2022

lisinopril 10 mg tablet TAKE 1 TABLET BY MOUTH EVERY DAY

ergocalciferol (vitamin D2) 1,250 mcg (50,000 unit) capsule TAKE 1 CAPSULE BY ORAL ROUTE WEEKLY FOR 3 MONTHS

GaviLyte-G 236 gram-22.74 gram-6.74 gram-5.86 gram oral solution Take 4000 mL by oral route as directed.

BinaxNOW COVID-19 Ag Self Test kit REFER TO MANUFACTURER INSTRUCTIONS INCLUDED IN PACKAGING

History of Present Illness

Physical Exam

Notes: None recorded.

Review of Systems
None recorded.

Vitals
Date Recorded Body height Body mass index (BMI) Body weight Heart rate Body temperature Systolic blood pressure Diastolic blood pressure
08/16/2022 162.56 cm 20.1 kg/m2 53070.31 g 87 /min 98.1 [degF] 127 mm[Hg] 84 mm[Hg]

Social History
Smoking Status Never Smoker
Birth Sex Female

Functional Status
None recorded.

Mental Status
None recorded.

Family History
Relationship Description Onset Age Died of this Age Resolved Age
Father No current problems or disability

Mother No current problems or disability

Medical History
No medical history recorded.

Gynecological History No gynecological history recorded.

Obstetrics History

GPAL:
G0P0000

Immunizations
None recorded.
Referral Note for IRVIN, PAULINA 06/13/1948 (74yo F) #24781107
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Past Encounters
Encounter ID Performer Location Encounter date Diagnosis/Indication
1846428 Ahmad Farooq SJMC_St. Joseph Gastroenterology 08/16/2022 Screening for malignant neoplasm of colon
Hemorrhoids
1315 St Joseph Parkway Suite 1210 Iron deficiency anemia
Constipation
HOUSTON, TX 77002-8232
1883136 Olga Fernandez SJMC_St. Joseph Gastroenterology 09/06/2022 Mass of colon

1315 St Joseph Parkway Suite 1210

HOUSTON, TX 77002-8232

Goals Section
Goal Description Status Start Date Updated by Updated on
None Recorded

Health Concerns Section

Notes
Date Note Note
Type
08/16/2022 text/html HPI Notes: This is a 74-year-old female past medical history of anemia, hypertension vitamin-D deficiency. Patient tells me she has complained of rectal bleeding, she has issues with hemorrhoid
noted to have anemia, she has been on iron supplementation. Patient denies any abdominal pain, melena, family history of colon cancer. Patient denies family history of IBD She does not take an
thinners next she denies using any NSAIDs It appears patient had rectal bleeding in the context of hemorrhoids. She was noted to have iron deficiency anemia. I will proceed with EGD and colon
out peptic ulcer disease, small bowel enteropathy, malignancy. She is due for colon cancer screening, colonoscopy as noted above. Regarding her hemorrhoids, I will start her on hydrocortisone
b.i.d. for 10 days. She does have underlying constipation. I discussed dietary changes lifestyle modification.