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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OPERATIVE REPORT Patient Name: Deanna Martinez Patient ID: 117232 Date of Surgery: 05/27/---- Admitting Physician: Sheila Goodman‚ MD‚ Neurosurgery Surgeon: Sheila Goodman‚ MD Assistant: Markus LeRoy Johnson‚ PA-C Preoperative Diagnosis: Lateral recess syndrome at L5-S1‚ right. Postoperative Diagnosis: Herniated disk at L5-S1‚ right. Operative Procedure: Lumbar laminectomy and excision of disk at L5-S1 on the right. Anesthesia: General endotracheal plus Marcaine with
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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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HISTORY AND PHYSICAL EXAMINATION (H&P) Patient Name: Deanna Martinez ID No.: 117232 Room No.: 425 Date of Admission: 05/26/---- Admitting Physician: Sheila Goodman‚ MD Neurosurgery Admitting Diagnosis: Questionable herniated disk Chief Complaint: low back pain‚ right leg pain. HISOTRY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain she said that she hurt her back in a motor vehicle accident three years ago
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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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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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