HISTORY AND PHYSICAL EXAMINATION Patient Name: Fanny Copeland Patient ID: 115463 DOB: 10/26/- - - - Age: 58 Sex: Female Room No.: Hillcrest Memory Diagnostic Center Date of Admission/Date of Arrival: 04/26/- - - - Referring Physician: Lyndon F. Talcott‚ MD‚ Neurology Admitting Diagnosis: Memory loss. BACKGROUND: Ms. Copeland is a 58-year-old left handed white female who was referred to the Hillcrest memory Diagnostic Center by the emergency room physician for evaluation
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HISTORY AND PHYSICAL Patient Name: Patul Barua Patient ID: 135799 Room Number: CCU4 Date of Admission: 01/07/2010 Admitting Physician: Simon Williams‚ MD of Pulmonalogy Admitting Diagnosis 1: Rule out myocardial infarction 2: History of tuberculosis 3: Hemoptysis 4: Status post embolectomy Chief Complaint: Tightness in the chest‚ shortness of breath‚ fast heart rate. HISTORY OF PRESENT ILLINESS: Mr. Barua is a 42 year old gentleman from Bangladesh who presents with chest
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HISTORY AND PHYSICAL EXAMINATION Good morning this is Alex McClure‚ MD dictating PATIENT NAME: Brenda c. Seggerman PATIENT ID: 903321 Date of Admission: 3/27/2012 EMERGENCY ROOM Physical: Alex McClure. MD Admitting diagnosis: Egtopic pregnancy Chief Complain: The patient presents in the emergency this morning‚ complaining of lower abdominal pain. HISTORY OF PRESENT ILLNESS: the patient states that she has been having vaginal bleeding more like spotting over the past month
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HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Brenda C. Seggerman Patient ID: 903321 DOB: Age: 35 Sex: F Room No.: Date of Admission/Date of Arrival: 3/27---- Admitting /Attending Physician: Alex McClure M.D. Admitting Diagnosis: Ectopic Pregnancy Chief Complaint: The patient presents in the emergency room this morning‚ complaining of lower abdominal pain. History of Present Illness: The patient states that she has been having
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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. Dilated appendix
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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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HISTORY AND PHYSICAL Patient Name: Marilyn Sue Stone Patient ID: 116588 DOB: 01/24 Age: 50 Sex: F Room No.: 181A Date of Admission: 02/07/2012 Admitting Physician: Jessie D. Smith‚ MD of Orthopedics Admitting Diagnosis: Chronic Hip Pain HISTORY OF PRESENT ILLNESS: Patient is a candidate for a total right hip revision. She has 2 units of directed packed red blood cells. It is not autologous. She does had Hepatitis B. She has arthrogryposis. She had a right total hip replacement
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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 remote history of tuberculosis. PROCEDURE: Patient was routinely pre-medicated with 25mg of Demerol with 2mg of Versed also used. About
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HISTORY AND PHYSICAL EXAMINATION Patient Name: Putul Barua Patient ID: 135799 Room: CCU4 Age: 42 Sex: Male Admitting Physician: Dr. Simon Williams‚ MD Pulmonology Date of Admission: 01/07/2013 Admitting Diagnosis: 1) Rule out myocardial infarction 2) History of tuberculosis 3) hymoptesis 4) status: post embolectomy. Chief Complaint: tightness in chest‚ shortness of breath‚ fast heart rate. HISTORY OF PRESENT ILLNESS: Mr. Barua is a 42-year-old gentleman from Bangladesh who
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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. HOSPITAL COURSE: The patient’s hospital course was characterized by a progressively downhill course. He was initially hospitalized and found to be mildly hypoxic‚ which rapidly corrected with supplemental low flow oxygen
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