ATIENT: MICHAEL FLOURNOY
DOB: 10/27/1966
HISTORIAN: self
VISIT TYPE: Consult (Established Patient)
PROVIDER: Marney K. Sorenson MD
DATE OF SERVICE: 08/07/2012
CHART #: 002070837
SEX: male
AGE: 45 year old
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History of Present Illness
This 45 year old male presents with:
1. W/C right ING,hernia
Medication List Updated
Medication Name
Ambien CR 6.25 mg Tab
Pristiq 50 mg 24 hr Tab
hydrochlorothiazide 12.5 mg Tab
Bystolic 10 mg Tab
simvastatin 40 mg Tab
Allergies
Reviewed, no changes.
Allergen/Ingredient
Potassium Clavulanate
Amoxicillin Trihydrate
Sig Desc
take 1 Tablet (6.25MG) by oral route every day at bedtime
take 1 tablet (50MG) by oral route every day
take 1 tablet (12.5MG) by oral route every day
ONE PO QD
take 1 tablet (40MG) by oral route every day in the evening
Brand
Reaction:
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HISTORY OF PRESENT ILLNESS: Mr. Flournoy is a 45-year-old gentleman, works at Texas High, who
about 3 weeks ago was lifting a trailer and noticed a pain and burning in his right groin. He was seen by
Health Care Express and noted to have a right inguinal hernia. He says it causes him some pain and
discomfort but he denies any voiding problems or trouble with nausea, vomiting, obstructive-type
symptoms.
PAST MEDICAL HISTORY: Remarkable for hypertension.
PAST SURGICAL HISTORY: Remarkable for umbilical hernia repair.
ALLERGIES: Penicillin
MEDICATIONS: Bystolic and hydrochlorothiazide. Doses unknown. Flexeril 10 mg three times a day.
SOCIAL HISTORY: Without tobacco. No significant ETOH.
REVIEW OF SYSTEMS: He denies any angina, shortness of breath, dyspnea on exertion, or orthopnea.
PHYSICAL EXAMINATION:
GENERAL: Morbidly obese male, 6 feet 1 inch, 320 pounds with a BMI of 42.
HEENT: Negative.
CHEST: Clear.
HEART: Regular rate and rhythm.
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Patient: MICHAEL FLOURNOY
Encounter Date: 08/07/2012 8:18 AM Provider: Marney K. Sorenson MD
ABDOMEN: Soft, nontender, nondistended. Right groin – he has a reducible right inguinal hernia. Left
groin is negative.
GU: Testicular examination is negative.
EXTREMITIES: Palpable pedal pulses. No evidence of any edema.
NEUROLOGIC: He is alert and oriented x4. Sensory, motor examination is nonfocal.
ASSESSMENT: Patient with a right inguinal hernia.
PLAN: It is Workman’s Comp so once that is all situated we will schedule him for a robotic right inguinal
hernia repair. I have instructed him that he should not do any lifting more than about 25 pounds for about
3 weeks postoperatively.
Marney K. Sorenson, MD
MKS/md
dd: 08/07/12
dt: 08/07/12
Job: 1394975
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Patient: MICHAEL FLOURNOY
Encounter Date: 08/07/2012 8:18 AM Provider: Marney K. Sorenson MD