OPERATIVE REPORT Patient: T.J. Moreno Patient ID: 110497 DOB: 02/15 Age: 44 Sex: M Date of Admission: 10/09/2013 Date of Procedure: 10/09/2013 Admitting Physician: Patrick Keathley‚ MD Endocrinology Surgeon : Dr. Max Hirsch‚ MD Orthopedics Assistant: Markus Leroy Johnson PAC (Surgical assistant was used for soft tissue protection and retraction and also for maintaining reduction during temporary and permanent fixation use of surgical assistant was medically necessary‚ and
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HISTORY AND PHYSICAL EXAM Patient: T.J. Moreno Patient ID: 110497 DOB: 02/15 Age: 44 Sex: M Room No.: 502 Date of Admission: 10/09/2013 Admitting Physician: Patrick Keathley‚ MD Endocrinology Chief Complaint: Left ankle pain. DETAILS OF PRESENT ILLNESS: This is a 44 year old Hispanic male who I was kindly asked to admit by Dr. Max Hirsch. The patient is status post arthrodesis of the left ankle and has newly diagnosed diabetes and hypertension. PAST MEDICAL HISTORY: Pre-op
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pain for the past week. Apparently got much worse last night‚ and by this morning wasn’t tolerable. She is also having some nausea and vomiting‚ denies hematemesis and mel?? She has had vaginal spotting over the past month with questionable vaginal discharge as well. denies the frequency‚ urgency and hematuria and denies arthralgia. Review of systems is otherwise essentially negative. PHYSICAL EXAM: Vital signs show temperature 97 degrees. pulse 53 respirations 22. blood pressure 108/60. GENERAL:
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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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that apparently got much worse last night and by this morning wasn’t tolerable. She is also having some nausea and vomiting. Denies Hematemesis‚ Hematochezia and Melena. She has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies Urinary frequency‚ Urgency and Hematuria. Denies Arthralgia. Review of systems is otherwise essentially negative. Physical Examination: Vital signs show T 97 degrees‚ P 53‚ R 22‚ BP 108/60. General Physical Exam reveals
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Hillcrest Medical Centre DISCHARGE SUMMARY Patient Name: Brenda C. Seggerman Hospital No: 903321 Date of Admission: 03/27/2014 Date of Discharge: 03/30/2014 Admitting Diagnosis: Ectopic pregnancy Surgical Procedures: Exploratory laparotomy‚ Partial salpingectomy‚ evacuation of hemoperitoneum‚ lysis of adhesions. Complications: blood loss requiring transfusion x2. History: This 35 year old white female‚ gravida 3‚ para 1-0-2-1. Had her last menstrual period in early January‚ prior menstrual
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DISCHARGE SUMMARY Patient Name: Deanna Martinez Patient ID: 117232 Date Admitted: 5/26/---- Date Discharged: 6/07/---- Surgeon: Shelia Goodman‚ MD‚ Neurosurgery Consultation: None. Procedure: Lumbar laminectomy. Complications: None. Admitting Diagnosis: Low back and right leg pain. Questionable herniated disk. BRIEF HISTORY: This 40-year-old Latin female was admitted for low back and right lower extremity symptoms. She had been suffering from intermittent low back pain dating back to an
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60 grams breast tissue to Pathology. 2) Left breast 68 grams breast tissue to Pathology. IV Fluids: 2700mL crystalloid‚ 500ml hespan. Blood Loss: 100mL. Urine Output: 1200mL. Complications: None. Sponge Count: Verified. Corrected end of case. Indications: The pleasant 40 year old female was seen and evaluated in the plastic surgery clinic. She had a significant weight loss via exercise. As a result‚ she had breastosis resulting in bilateral Intertriginous skin irritations. She never
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DISCHAGE SUMMARY Patient Name: Benjamin Engelhart Patient ID: 112592 DOB: 10/05/ Age: 46 Sex: M Date of Admission: 11/14/2012 Date of Discharge: 11/17/2012 Admitting Physician: Benard Kester‚ MD General Surgery Procedures Performed: Laparoscopic appendectomy with placement of RLQ drain on 11/14/2012 Complications: None. Discharge Diagnosis: Acute subapperative appendectomy perforated. DIAGNOSTIC/IMAGING LABS: Lab results at the time of admission showed a WBC count of 13.
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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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