axially artery treated last year at Hillcrest. He had an embolectomy and has been on Coumadin since. INR is significantly elevated at 16. None the less‚ because of the cavitary lesions that are seen in the right and left upper lobes‚ the possibility of tuberculosis has been raised. Ancillary history was been given by the wife‚ Nupaul‚ with the patient translating for her from the Indie language. PAST HISTORY: Tuberculosis is the past. Embolectomy at Hillcrest last year. SOCIAL HISTORY: Married
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pregnancy although she states she is sexually active and using no birth control. Gynecologic History: Patient is graved to par 1 abortus 1. her only child is a year old 15 year old daughter who lives in Texas that lives with her grandmother. PAST MEDICAL HISTORY: Positive for hepatitis B PAST SURGICAL HISTORY: Pilonidal cyst removed in the remote past‚ has plastic surgery on her ears child. SOCIAL HISTORY: Married‚ has 1 daughter‚ patient works as a substitute teacher‚ smokes 1 pack of cigarettes
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chance of pregnancy; although she states that she is sexually active and using no birth control. Gynecologic History: Patient is gravida 2‚ para1‚ abortus 1. Her only child is a 15 year-old daughter who lives in Texas with her grandmother. Past Medical History: Positive for Hepatitis B Past Surgical History: Pilodinal cyst removed in the remote past. Had plastic surgery on her ears as a child. Social History: Married‚ has one daughter. Patient works as a substitute teacher. Smokes one-pack
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RADIOLOGY REPORT Patient Name: Benjamin Engelhart Patient ID: 112592 DOB: 10/05/ Age: 46 Sex: M CT Scan No: 10-790031 Ordering Physician: Alex McClure‚ MD Procedure: CT scan of abdomen and pelvis without contrast. Date of Procedure: 11/14/2012 HISTORY: RLQ pain‚ no previous studies. ABDOMEN: The lung basis appeared unremarkable. The liver‚ spleen‚ gallbladder‚ adrenals‚ kidneys and pancreas and abdominal aorta appeared unremarkable. The bowels seen on the study appeared thickened
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HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Lydia Cruz Patient ID: DOB: Age: 40 Sex: F Hospital Number: 11723 Room No.: 425 Date of Admission/Date of Arrival: 05/26/2012 Admitting/Attending Physician: Tomas Burgos‚ MD Admitting Diagnosis: Questionable Herniated disk. Chief Complaint: Low back pain‚ right leg pain. HISTORY OF PRESENT ILLNESS: This 40-year-old black Latin female presents with complaints of low back and right
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past. D: She had left foot surgery in the remote past at Hillcrest by Dr. Smith‚ myself. E: She had right hip surgery 28 years ago. F: She had left hip surgery 26 years ago. G: 17 years ago she had a stage 2 left hip procedure completed 15 years ago. H: She had left hip revision 12 years ago. I: Nine years ago she had a mass on the bottom of her foot removed by Dr. Shelton of Podiatry . SOCIAL HISTORY: She works in the medical field. Enjoys a healthy social life‚ lives alone‚ is single
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OPERATIVE REPORT Patient Name: Putul Barua Patient ID: 135799 Room: CCU4 Date of Surgery: 01/08/2013 Admitting Physician: Dr. Simon Williams‚ MD Pulmonology Surgeon: Dr. Simon Williams‚ MD Pulmonology Preoperative Diagnosis: Recent onset hemoptysis‚ history of tuberculosis. Postoperative Diagnosis: No tuberculosis lesions seen. Operative Procedure: Bronchoscopy. Specimens Removed: Blood clots. Indications: Patient requires bronchoscopy because of recent onset hemoptysis and a
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axillary artery treated last year at Hillcrest. He had an embolectomy and has been on Coumadin since. INR is significantly elevated at 16. None the less‚ because of the cavitary lesions that are seen in the right and left upper lobes‚ the possibility of tuberculosis has been raised. Ancillary history was given by the patient’s wife Nupor‚ with the patient translating for her from the Hindi language. PAST HISTORY: Tuberculosis in the past. Embolectomy at Hillcrest last year. SOCIAL HISTORY: Married
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DEATH SUMMARY Patient Name: Putul Barua Patient ID: 135799 Room: CCU4 Date of Admission: 01/07/2013 Date of Death: 01/15/2013 at 00:41 hours. Admitting Physician: Simon Williams‚ MD Pulmonology Consultants: J.K. McClain‚ MD Cardiology. Trevor Jordan‚ MD Nephrology This 42 year old gentleman was admitted on January 7th‚ and expired on January 15. He was admitted with progressive tachycardia‚ hemoptysis and dyspnea. Please see his admission history and physical exam for details.
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OPERATIVE REPORT Patient Name: Olivia Carpenter DOB: 01/15 Sex: F Age: 40 Patient ID: 110901 Admitting Physician: Dr. Leon Medina‚ MD Internal Medicine Date of Admission: 11/12/13 Date of Procedure: 11/13/13 Surgeon: Dr. Bernard Kester Assistant: Jason Wagner PA-C Preoperative Diagnosis: 1) History of breast intertriginous skin irritations. 2) Abdominal wall contour irregularities. Postoperative Diagnosis: same. Operative procedures: 1) Bilateral Reduction mammoplasty
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