CareLink - Patient Record: WEISS, M

Surgical & Major Medical History

Date	Condition/Procedure	Physician	Notes
Jan 15, 2018	Dermatology Consult	Dr. P. Chen	Evaluation of benign mole on left shoulder. Biopsy negative.
Mar 22, 2015	Ophthalmology Routine	Dr. L. Vance	Prescription updated. Slight astigmatism noted OD.
Nov 12, 2012	Gastroenterology Consult	Dr. S. Cohen	Diagnosed severe lactose intolerance. Patient reports acute cramping/emesis after dairy intake. Dietary restriction advised.
Jun 10, 2010	Tonsillectomy	Dr. R. Miller	Elective removal due to recurrent strep. No complications.
May 04, 2005	Appendectomy (Laparoscopic)	Dr. K. Lee	Emergency procedure. Routine recovery. Scar noted at McBurney's point.
Dec 02, 2001	Dental Surgery	Dr. T. White	Removal of 4 impacted wisdom teeth.
Aug 10, 1998	Fracture (Left Radius)	Dr. B. Smith	Cast applied for 6 weeks. Fully healed.

Recorded Allergies

Penicillin (Mild Hives)
Lactose (Severe Intolerance) - Dietary management required.
Sulfa Drugs (Hives)

Active & Historical Prescriptions

Date Prescribed	Medication	Dosage	Status
Oct 10, 2018	Zolpidem (Ambien)	5mg PO QHS PRN	Active (Refillable)
Jan 15, 2018	Triamcinolone Cream	0.1% Topical	Archived
Jun 10, 2010	Oxycodone/APAP	5/325mg PO q4h PRN	Discontinued

Laboratory Results

Most Recent Panel (Jan 15, 2018)

WBC 5.8 k/cumm

RBC 4.50 m/cumm

Hemoglobin 13.2 g/dL

Hematocrit 39.5 %

Platelets 250 k/cumm

Glucose 85 mg/dL

Provider Note - 01/15/2018: Patient presents for routine follow-up. Reports elevated stress due to upcoming book deadline. Sleep hygiene discussed. Refilled sleep aid as requested.

Provider Note - 11/12/2012: GI Consult summary reviewed. Patient educated on checking food labels for milk proteins/whey. Patient expressed frustration with lifestyle changes.