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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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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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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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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ID: 135799 Room: CCU4 Date of Surgery: 01/08/2013 Page 2 DIAGNOSIS: Evidence of old hemorrhage. No new lesions seen. Recommend close follow up. ______________________________________ Dr. Simon Williams‚ MD Pulmonology SW/XX D: 1/8/2012 T:
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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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HISTORY AND PHYSICAL EXAMINATION Patient Name: Adela Torres Patient ID: 132463 Date of Admission: 6/22/2013 Admitting Physician: Leon Medina‚ MD‚ Internal Medicine Admitting Diagnoses: Stomatitis‚ possibly methotrexate related. Chief Complaint: Swelling of lips causing difficulty swallowing. HISTORY OF PRESENT ILLNESS: This patient is a 57-year-old Cuban woman with a long history of rheumatoid arthritis. She has received methotrexate on a weekly basis as an outpatient
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