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Patient: Joseph Jones Record number Jones J005 Date: 11/17/18

History of Present Illness: this patient is a

48-year-old white male complaining of a history of petechial lesions on the bilateral lower extremities and a 2 week history of swelling and pain in the right ankle. He denies any history of trauma, bites, tick exposure, or new medications.

Additional findings are significant for submucosal hemorrhage of the oral mucosa gingival hypertrophy with bleeding gums.


Past Medical History: Noncontributory


Social History: significant for heavy alcohol consumption of approximately 12 beers per day Medications: patient denies any medications. Patient denies using recreational drugs.

Laboratory Data: significant for anemia (hemoglobin - 11.6, hematocrit - 34.1) and leukocytopenia (WBC 2.1). CMP panel was within normal limits,


Procedure results:

ECG - Within normal limits GTT - Within normal limits


Diagnosis: Scurvy


Plan: Supplementation with vitamin C, 100 mg 3-5x/day until a total of 4 g is reached then 100 mg qid. Patient is counseled to have a diet rich in fruits and vegetables such as grapefruit, lemons, broccoli, green peppers, tomatoes and cabbage.


Does the documentation in the chart support the medical necessity of the tests/procedures performed? Yes No

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