121 OAK HILL RD STONEHAM MA 012345 Sample Patient Beth Israel Deaconess Medical Center Center for Clinical Computing Beth Israel Deaconess Medical Center 6401 Security Blvd Woodlawn MD 21235 Security AdministrationSocial Social Security Administration Beth Israel Deaconess Medical Center

Problem	Effective Dates	Problem Status	Provider	Comments
HEALTH MAINTENANCE - V70.0		Active	11-806 - Dr. JEANNETTE M. SHOREY	SEE COMPUTER SCREENING SHEET; PERIODIC EXAM IN WINTER
PANHYPOPITUITARISM	1982	Active	11-806 - Dr. JEANNETTE M. SHOREY	ON SYNTHROID, PREDNISONE, AND FOLATE
RESTR/OBSTRU. LUNG DIS		Active	11-806 - Dr. JEANNETTE M. SHOREY	NEVER SMOKED; LAST PFT'S 1981
CARDIAC - 429.2	1987	Active	11-806 - Dr. JEANNETTE M. SHOREY	Mild erxertional angina; RARELY USES NTG; Cardiac ECHO obtained 5/92 to assess murmurs: normal LV size with borderline hypertryphy and good systolic function; mildly thickened AV leaflets but no stenosis or regurgitation. MV mildly thickened with annular calcification, and mild MR. Echo 8/00 shows mild to moderate LVH with near obliteration of LV in systole, but no detected outflow obstruction.
PPD POSITIVE - 795.5	1982	Active	11-806 - Dr. JEANNETTE M. SHOREY	TREATED WITH INH FOR A YEAR IN 1982
S/P BUTTOCKS ABSCESS		Inactive	11-806 - Dr. JEANNETTE M. SHOREY	RESOLVED AFTER I&D
LT KNEE PAIN - 719.46	1990	Active	11-806 - Dr. JEANNETTE M. SHOREY	AFTER EXERCISE; BETTER WITH BUFFERIN AND ELASTIC SUPPORT
CATARACTS - 366.9	1989	Active	11-806 - Dr. JEANNETTE M. SHOREY	RE-REFERRED FOR CONSIDERATION OF EXTRACTION 12/90.
DRUG ALLERGIES - 995.2		Active	11-806 - Dr. JEANNETTE M. SHOREY	penicillin, sulfa
CLAUDICATION - 443.9	09/01/1992	Active	80-AGQ - Dr. DOREEN MUIR SIDDALL	Doppler 5/92 showed bilateral femoral artery obstruction. Referred to Dr. Kent. Saw Dr. Akbari 4/1/98 who will follow but recommended against surgery for now.
HYPERTENSION - 401.9	09/01/1992	Active	80-AGQ - Dr. DOREEN MUIR SIDDALL	Verapamil causing some constipation -- ? change or reduce dose.
PSYCHOSOCIAL - V62.9		Active	12-117 - Dr. DAVID M. Jones	Cost of meds is proving a problem for pt. Gave her Bill Werner's number.
CONSTIPATION - 564.0	7/93	Active	12-117 - Dr. DAVID M. Jones	Longstanding problem but worse x 6 mos.
TINNITUS - 388.30	09/21/1993	Active	12-117 - Dr. DAVID M. Jones	Left-sided. There is a lesion (? old scar) on the left TM.
COMPUTER DEMONSTRATIONS	09/29/1993	Active	12-117 - Dr. DAVID M. Jones	Pt. is willing to have her record shown for computer demonstration purposes.
PULMONARY - 519.9		Active
RESPIRATORY - 519.9		Active	12-117 - Dr. DAVID M. Jones	H/o restrictive/obstructive lung dz. NEVER SMOKED; LAST PFT'S 1981
GASTROINTESTINAL - 569.9	10/95	Active	12-117 - Dr. DAVID M. Jones	10/95 Presumed biliary sepsis --> ERCP showed ampullary diverticulum which may have led to ascending cholangitis.
HYPERCHOLESTEROLEMIA - 272.0	3/96	Active	12-117 - Dr. DAVID M. Jones	Would consider drug therapy but pt. cannot afford a "statin" at present.
WEIGHT LOSS - 783.2	1997	Active	12-117 - Dr. DAVID M. Jones
HEMATOLOGIC / ONCOLOGIC	6/97	Active	12-117 - Dr. DAVID M. Jones	Elevated WBC -- ? etiology.
OSTEOARTHRITIS - 715.90		Active	11-907 - Dr. ROBERT H. SHMERLING
DEMENTIA - 298.9	2/17	Active	26-321 - Dr. ROHN SAMUEL FRIEDMAN
DEPRESSION - 311	99	Active	26-316 - Dr. RANDALL H. PAULSEN	may account for wt loss. occurred once earlier
FALLS		Active	12-117 - Dr. DAVID M. Jones
BACK PAIN - 724.5		Active	12-117 - Dr. DAVID M. Jones	Compression fx L1.
ABC		Active
ORTHOSTATIC HYPOTENSION - 458.0	02/19/99	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
HYPOVOLEMIA - 276.5	02/19/99	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
HYPERTENSION NOS - 401.9	02/19/99	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
CHR AIRWAY OBSTRUCT NEC - 496	02/19/99	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
URIN TRACT INFECTION NOS - 599.0	02/19/99	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
PANHYPOPITUITARISM - 253.2	02/19/99	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
ANGINA PECTORIS NEC/NOS - 413.9	02/19/99	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
HYPERCHOLESTEROLEMIA - 272.0	02/19/99	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
INTERTROCHANTERIC FX-CL - 820.21	12/21/99	Active	20-128 - Dr. TOBIN N. GERHART	Inpatient discharge diagnosis
FALL ON LEVEL-TRIPPING - E885	12/21/99	Active	20-128 - Dr. TOBIN N. GERHART	Inpatient discharge diagnosis
ACCIDENT IN PLACE NOS - E849.9	12/21/99	Active	20-128 - Dr. TOBIN N. GERHART	Inpatient discharge diagnosis
ANGINA PECTORIS NEC/NOS - 413.9	12/21/99	Active	20-128 - Dr. TOBIN N. GERHART	Inpatient discharge diagnosis
ANT PITUIT HYPERFUNC NEC - 253.1	12/21/99	Active	20-128 - Dr. TOBIN N. GERHART	Inpatient discharge diagnosis
ATHEROSCLEROSIS EXT W/CLAUD - 440.21	12/21/99	Active	20-128 - Dr. TOBIN N. GERHART	Inpatient discharge diagnosis
CHRONIC BRONCHITIS W/COPD - 491.20	12/21/99	Active	20-128 - Dr. TOBIN N. GERHART	Inpatient discharge diagnosis
HYPERCHOLESTEROLEMIA - 272.0	12/21/99	Active	20-128 - Dr. TOBIN N. GERHART	Inpatient discharge diagnosis
ORGANIC BRAIN SYND NEC - 294.8	12/21/99	Active	20-128 - Dr. TOBIN N. GERHART	Inpatient discharge diagnosis
INTERTROCHANTERIC FX-CL - 820.21	01/12/00	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
FALL ON LEVEL-TRIPPING - E885	01/12/00	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
HYPERTENSION NOS - 401.9	01/12/00	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
ANT PITUIT HYPERFUNC NEC - 253.1	01/12/00	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
CHRONIC BRONCHITIS W/COPD - 491.20	01/12/00	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
HYPERCHOLESTEROLEMIA - 272.0	01/12/00	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
ORGANIC BRAIN SYND NEC - 294.8	01/12/00	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
ANGINA PECTORIS NEC/NOS - 413.9	01/12/00	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
ATHEROSCLEROSIS EXT W/CLAUD - 440.21	01/12/00	Active	12-117 - Dr. DAVID M. Jones	Inpatient discharge diagnosis
INTRACEREBRAL HEMORRHAGE - 431	10/23/00	Active	11-933 - Dr. ERIK GARPESTAD	Inpatient discharge diagnosis
MITRAL VALVE DISORDER - 424.0	10/23/00	Active	11-933 - Dr. ERIK GARPESTAD	Inpatient discharge diagnosis
TRICUSPID VALVE DISEASE - 397.0	10/23/00	Active	11-933 - Dr. ERIK GARPESTAD	Inpatient discharge diagnosis
PULMONARY HYPERTENSION - 416.0	10/23/00	Active	11-933 - Dr. ERIK GARPESTAD	Inpatient discharge diagnosis
CHR AIRWAY OBSTRUCT NEC - 496	10/23/00	Active	11-933 - Dr. ERIK GARPESTAD	Inpatient discharge diagnosis
PANHYPOPITUITARISM - 253.2	10/23/00	Active	11-933 - Dr. ERIK GARPESTAD	Inpatient discharge diagnosis
BRAIN CONDITIONS NEC - 348.8	10/23/00	Active	11-933 - Dr. ERIK GARPESTAD	Inpatient discharge diagnosis
HYPERTENSION NOS - 401.9	10/23/00	Active	11-933 - Dr. ERIK GARPESTAD	Inpatient discharge diagnosis
ANEMIA NOS - 285.9	10/23/00	Active	11-933 - Dr. ERIK GARPESTAD	Inpatient discharge diagnosis
ABNORMAL LOSS OF WEIGHT - 783.2	01/21/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
PNEUMONIA,ORGANISM UNSPECIFIED - 486	01/21/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
HYPERTENSION NOS - 401.9	01/21/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
HYPERTENSION NOS - 401.9	02/02/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
ENDOCRINE DISORDER NOS - 259.9	02/02/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
PULMONARY TB NOS-UNSPEC - 011.90	02/05/99	Active	11-889 - Dr. DIANE R. GOLD	Clinic visit diagnosis
PULMONARY TB NOS-UNSPEC - 011.90	02/08/99	Active		Clinic visit diagnosis
RECURR MAJ DEPRESSION-MOD - 296.32	02/11/99	Active	26-316 - Dr. RANDALL H. PAULSEN	Clinic visit diagnosis
HYPOVOLEMIA - 276.5	02/16/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
ENDOCRINE DISORDER NOS - 259.9	03/25/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
HYPERTENSION NOS - 401.9	03/25/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
HYPERTENSION NOS - 401.9	07/06/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
HYPERTENSION NOS - 401.9	09/22/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
ENDOCRINE DISORDER NOS - 259.9	09/22/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
HYPERTENSION NOS - 401.9	11/02/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
ENDOCRINE DISORDER NOS - 259.9	11/02/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
VACCIN FOR SINGL DIS NOS - V05.9	11/02/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
HYPERTENSION NOS - 401.9	12/02/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
HYPERLIPIDEMIA NEC/NOS - 272.4	12/02/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
PERIPH VASCULAR DIS NOS - 443.9	12/02/99	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
PERIPH VASCULAR DIS NOS - 443.9	02/22/00	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
HYPERTENSION NOS - 401.9	02/22/00	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
BACKACHE NOS - 724.5	02/22/00	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
BACKACHE NOS - 724.5	03/14/00	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
PAIN IN LIMB - 729.5	03/23/00	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
HYPERTENSION NOS - 401.9	03/23/00	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
ABNORMAL LOSS OF WEIGHT - 783.2	03/23/00	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
ABNORMAL LOSS OF WEIGHT - 783.2	04/12/00	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
DISORDER OF THYROID NOS - 246.9	04/12/00	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
HYPERTENSION NOS - 401.9	04/12/00	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
ABNORMAL LOSS OF WEIGHT - 783.2	04/26/00	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
HYPERTENSION NOS - 401.9	04/26/00	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
CARDIAC MURMURS NEC - 785.2	08/08/00	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis
HYPERTENSION NOS - 401.9	08/31/00	Active	12-117 - Dr. DAVID M. Jones	Clinic visit diagnosis

Dr. JEANNETTE M SHOREY Dr. JEANNETTE M SHOREY Dr. JEANNETTE M SHOREY Dr. JEANNETTE M SHOREY Dr. JEANNETTE M SHOREY Dr. JEANNETTE M SHOREY Dr. DOREEN MUIR SIDDALL Dr. DOREEN MUIR SIDDALL Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. ROBERT H SHMERLING Dr. ROHN SAMUEL FRIEDMAN Dr. RANDALL H PAULSEN Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. TOBIN N GERHART Dr. TOBIN N GERHART Dr. TOBIN N GERHART Dr. TOBIN N GERHART Dr. TOBIN N GERHART Dr. TOBIN N GERHART Dr. TOBIN N GERHART Dr. TOBIN N GERHART Dr. TOBIN N GERHART Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. ERIK GARPESTAD Dr. ERIK GARPESTAD Dr. ERIK GARPESTAD Dr. ERIK GARPESTAD Dr. ERIK GARPESTAD Dr. ERIK GARPESTAD Dr. ERIK GARPESTAD Dr. ERIK GARPESTAD Dr. ERIK GARPESTAD Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DIANE R GOLD Dr. RANDALL H PAULSEN Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones

Blood

Hematology
COMPLETE BLOOD COUNT	WBC	RBC	Hgb	Hct	MCV	MCH	MCHC	RDW	Plt Ct
23 Oct 2000 05:45AM	14.2*			32.4*
22 Oct 2000 07:10AM	15.1*	3.38*	10.7*	32.0*	95	31.6	33.4	15.3	144*
21 Oct 2000 07:30AM	15.2*	3.51*	11.0*	33.1*	94	31.3	33.2	15.2	147*
20 Oct 2000 06:10AM	14.1*	3.08*	9.7*	29.1*	95	31.6	33.4	15.3	123*
19 Oct 2000 10:00AM	19.7*	3.40*	10.8*	32.4*	95	31.9	33.5	15.2	149*
18 Oct 2000 06:38AM	16.2*	3.27*	10.4*	31.5*	96	31.8	33.1	14.8	145*
17 Oct 2000 06:39PM	19.3*#	3.62*	11.4*	34.7*	96	31.6	32.9	14.9	129*
12 Apr 2000 03:58PM	12.2*	4.06*#	12.1	37.6	93	29.7	32.1	15.4	200
20 Dec 99 09:00AM	18.6*	3.22*	9.9*	31.2*	97	30.9	31.8	15.6*	146*
19 Dec 99 07:45PM				33.5*
19 Dec 99 03:32PM	18.9*#	2.89*	9.0*	27.7*	96	31.1	32.4	15.3	141*
19 Dec 99 12:45PM	12.0*	2.84*	9.1*	27.0*	95	32.0	33.6	15.4	150
18 Dec 99 07:00PM	15.4*	3.56*	11.0*	33.4*	94	31.0	33.0	15.1	172
02 Dec 99 02:40PM	15.8*	4.12*	12.7	39.4	96	30.8	32.2	14.4	183
18 Feb 99 07:30AM	22.1*# DOUBLE CHECKED	3.95*	11.8*	38.0	96	29.8	31.0	15.1	142*
17 Feb 99 08:10AM	5.2	3.98*	12.3	37.7	95	31.0	32.6	14.8	144*
16 Feb 99 04:32PM	8.0	4.16*	12.9	38.8	93	31.1	33.4	14.7	155
Test added on to 603F-2/16 @1824 2/16/99
03 Feb 99 12:35PM	16.0*	4.34	13.5	38.7	89	31.2	35.0	16.2*	212# VERIFIED BY REPLICATE ANALYSIS
21 Jan 99 10:15AM	13.7*	3.51*	11.2*	32.9*	94	32.0	34.2	16.2*	128*

DIFFERENTIAL	Neuts	Bands	Lymphs	Monos	Eos	Baso	Atyps	Metas	Myelos
17 Oct 2000 06:39PM	82.3*		13.2*	3.5	0.7	0.3
12 Apr 2000 03:58PM	83.1*		12.6*	3.8	0.3	0.3
18 Dec 99 07:00PM	76.2*		18.1	4.8	0.5	0.3
02 Dec 99 02:40PM	75*	0	9*	9	0	0	4	3	0
16 Feb 99 04:32PM	65.7	0	23.4	9.6	.5	.8
Test added on to 603F-2/16 @1824 2/16/99
21 Jan 99 10:15AM	77.7	0	12.1	9.4	.5	.3

RED CELL MORPHOLOGY	Hypochr	Anisocy	Poiklo	Macrocy	Microcy	RBCFrag
17 Oct 2000 06:39PM	NORMAL	NORMAL	NORMAL	1+	NORMAL	NORMAL
12 Apr 2000 03:58PM	NORMAL	NORMAL	NORMAL	NORMAL	NORMAL	NORMAL
18 Dec 99 07:00PM	NORMAL	NORMAL	NORMAL	1+	NORMAL	NORMAL

BASIC COAGULATION (PT, PTT, PLT, INR)	PT	PTT	Plt Ct	INR(PT)	MPV
22 Oct 2000 07:10AM			144*
21 Oct 2000 07:30AM			147*
20 Oct 2000 06:10AM			123*
19 Oct 2000 10:00AM			149*
18 Oct 2000 06:38AM			145*
18 Oct 2000 06:38AM	16.1* NOTE NEW REFERENCE RANGE AS OF 9/28/00 AT 7:00 AM	28.8 NOTE NEW REFERENCE RANGE AS OF 9/28/00 AT 7:00 AM		1.7
17 Oct 2000 06:39PM			129*
17 Oct 2000 06:39PM	14.9* NOTE NEW REFERENCE RANGE AS OF 9/28/00 AT 7:00 AM	28.0 NOTE NEW REFERENCE RANGE AS OF 9/28/00 AT 7:00 AM		1.5
12 Apr 2000 03:58PM			200
10 Jan 2000 06:40AM	17.0*			1.7
04 Jan 2000 06:55AM	15.2*			1.4
03 Jan 2000 06:45AM	15.8*			1.5
29 Dec 99 01:45PM	16.5*			1.6
27 Dec 99 06:25AM	16.3*			1.6
26 Dec 99 06:45AM	15.9*			1.5
25 Dec 99 02:15PM	16.6*			1.6
24 Dec 99 07:00AM	19.2*			2.2
23 Dec 99 06:50AM	19.3*			2.2
22 Dec 99 06:45AM	19.7*			2.3
21 Dec 99 05:55AM	16.4*			1.6
20 Dec 99 09:00AM			146*		10.5*
20 Dec 99 09:00AM	15.7*			1.5
19 Dec 99 03:32PM			141*		8.4
19 Dec 99 03:32PM	16.4*	24.9		1.6
19 Dec 99 12:45PM			150		9.7*
18 Dec 99 07:00PM	14.4*	23.2		1.2
ADDED ON AT 10:40P
18 Dec 99 07:00PM			172		9.0
02 Dec 99 02:40PM			183		10.8*
18 Feb 99 07:30AM			142*
18 Feb 99 07:30AM	14.4*	24.8		1.2
17 Feb 99 08:10AM			144*
16 Feb 99 04:32PM			155
Test added on to 603F-2/16 @1824 2/16/99
03 Feb 99 12:35PM			212# VERIFIED BY REPLICATE ANALYSIS
03 Feb 99 12:35PM	14.4*	23.1		1.2
21 Jan 99 10:15AM			128*

Chemistry
RENAL & GLUCOSE	Glucose	UreaN	Creat	Na	K	Cl	HCO3	AnGap
22 Oct 2000 07:10AM	53*	20	1.0	144	4.3	110	25	13
21 Oct 2000 07:30AM	67*	20	0.9	143	4.0	113*	25	9
20 Oct 2000 06:10AM	65*	22*	0.9	149*	3.7	115*	24	14
19 Oct 2000 10:00AM	90	21*	1.0	149*	3.1*	113*	21	18
18 Oct 2000 06:38AM	151*	23*	1.0	143	4.0	109	22	16
17 Oct 2000 06:39PM	102	25*	1.0	146	4.0	110	25	15
12 Apr 2000 03:58PM	72	23*	1.2	140	3.7	106	21	17
19 Dec 99 03:32PM	131*	20	1.2	140	4.0	110	21	13
18 Dec 99 07:00PM	105	26*	1.6*	141	4.1 HEMOLYSIS FALSELY ELEVATES K	105	20*	20
SLIGHT HEMOLYSIS
02 Dec 99 02:40PM		21*	1.1	143	3.9	106	27	14
19 Feb 99 07:00AM					5.3
18 Feb 99 07:30AM		16	1.3	137	5.2	105	18*	19
17 Feb 99 08:10AM		13	1.2	137	4.4	108	17*	16
16 Feb 99 04:33PM	123*	16	1.5*	135	3.2*	99*	19*	20
CHEM 7 ADDED ON @1820 2/16/99. CA, MG, ALT, ALK, ALK AND FT4 ADDED ON @2116 2/16/99
21 Jan 99 10:15AM	92	17	1.2	140	3.9	106	24	14

ENZYMES & BILIRUBIN	ALT	AST	LD(LDH)	CK(CPK)	AlkPhos	Amylase	TotBili	DirBili
21 Oct 2000 07:30AM			284*
18 Oct 2000 06:38AM				33
17 Oct 2000 06:39PM	15	21			98		0.6
12 Apr 2000 03:58PM	9	11					0.4
02 Dec 99 02:40PM	13	12
16 Feb 99 04:33PM	17				66		0.5
CHEM 7 ADDED ON @1820 2/16/99. CA, MG, ALT, ALK, ALK AND FT4 ADDED ON @2116 2/16/99

CPK ISOENZYMES	CK-MB
18 Oct 2000 06:38AM	NotDone NotDone CK-MB NOT PERFORMED, TOTAL CK < 100

CHEMISTRY	TotProt	Albumin	Globuln	Calcium	Phos	Mg	UricAcd	Iron	Cholest
21 Oct 2000 07:30AM								66
18 Oct 2000 06:38AM						2.0
17 Oct 2000 06:39PM		3.4*		9.0	2.7	2.1
12 Apr 2000 03:58PM		3.4*
02 Dec 99 02:40PM									149
16 Feb 99 04:33PM				9.5		1.4*
CHEM 7 ADDED ON @1820 2/16/99. CA, MG, ALT, ALK, ALK AND FT4 ADDED ON @2116 2/16/99

HEMATOLOGIC	calTIBC	VitB12	Folate	Hapto	TRF
21 Oct 2000 07:30AM	254*	281	8.8	126	195
18 Feb 99 07:30AM		808

LIPID/CHOLESTEROL	Cholest	HDL	CHOL/HD
02 Dec 99 02:40PM	149	62	2.4

THYROID	Free T4
12 Apr 2000 03:58PM	1.1
02 Dec 99 02:40PM	1.0
16 Feb 99 04:33PM	1.3
CHEM 7 ADDED ON @1820 2/16/99. CA, MG, ALT, ALK, ALK AND FT4 ADDED ON @2116 2/16/99

NEUROPSYCHIATRIC	Phenyto
20 Oct 2000 06:10AM	18.3

LAB USE ONLY	EDTA Ho	HoldBLu	RedHold
18 Oct 2000 06:39AM			HOLD
12 Apr 2000 03:59PM			HOLD
18 Dec 99 07:00PM		HOLD HOLD DISCARD GREATER THAN 8 HOURS OLD
PT & PTT ADDED ON AT 10:40P
16 Feb 99 04:33PM			HOLD
CHEM 7 ADDED ON @1820 2/16/99. CA, MG, ALT, ALK, ALK AND FT4 ADDED ON @2116 2/16/99
16 Feb 99 04:32PM	HOLD HOLD DISCARD GREATER THAN 8 HOURS OLD
16 Feb 99 04:32PM		HOLD HOLD DISCARD GREATER THAN 8 HOURS OLD
16 Feb 99 04:32PM			HOLD

Urine

Hematology
GENERAL URINE INFORMATION	Type	Color	Appear	Sp Grav
18 Oct 2000 03:20AM		YELLOW	CLEAR	1.013
19 Dec 99 04:00AM		YELLOW	HAZY	1.016
18 Dec 99 10:30PM		YELLOW	CLEAR	1.017
18 Feb 99 09:00PM		YELLOW	CLEAR	1.016
16 Feb 99 07:07PM		AMBER	SLHAZY	1.014

DIPSTICK URINALYSIS	Blood	Nitrite	Protein	Glucose	Ketone	Bilirub	Urobiln	pH
18 Oct 2000 03:20AM	TR	NEG	NEG	NEG	NEG	NEG	.2	5.0
19 Dec 99 04:00AM	LG	NEG	TR	NEG	NEG	NEG	.2	5.5
18 Dec 99 10:30PM	NEG	NEG	NEG	NEG	TR	NEG	.2	6.0
18 Feb 99 09:00PM	NEG	NEG	NEG	NEG	TR	NEG	.2	5.5
16 Feb 99 07:07PM	NEG	NEG	NEG	NEG	TR	NEG	.2	5.5

MICROSCOPIC URINE EXAMINATION	RBC	WBC	Bacteri	Yeast	Epi	TransE	RenalEp
18 Oct 2000 03:20AM	4*	3	RARE	NONE	<1
19 Dec 99 04:00AM	475*	2	NONE	NONE	0
18 Dec 99 10:30PM	1	1	OCC	NONE	0
18 Feb 99 09:00PM	0	2	NONE	NONE	<1
16 Feb 99 07:07PM	3*	38*	FEW	NONE	7

URINE CRYSTALS	AmorphX
16 Feb 99 07:07PM	FEW

OTHER URINE FINDINGS	Mucous
18 Oct 2000 03:20AM	RARE

CSF

No Results for this Date Range

Other Fluid

No Results for this Date Range

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	CHEST (PA & LAT)	Study Date of 01/21/99 10:27 AM

Jones,DAVID M.	HCA		01/21/99 SCHED
CHEST (PA & LAT)
Reason: ? change in right upper lobe consolidation

UNDERLYING MEDICAL CONDITION:

88 year old woman with sob/fever and cough 12/27 with cxr showing RUL

consolidation. f/u film today

REASON FOR THIS EXAMINATION:

? change in right upper lobe consolidation

Final Report
HISTORY: SHORTNESS OF BREATH AND COUGH.
PRIOR STUDIES ARE NOT AVAILABLE FOR COMPARISON AT THIS TIME.
CORRELATION IS MADE WITH MOST RECENT REPORT.
CHEST, 2 VIEWS: THE HEART SIZE AND MEDIASTINAL CONTOUR ARE NORMAL.
AGAIN NOTED WITHIN THE RIGHT UPPER LUNG IS CONSOLIDATION WITH ASSOCIATED
VOLUME LOSS. THERE IS BIAPICAL PLEURAL THICKENING WHICH IS SIGNIFICANTLY
MORE PROMINENT ON THE RIGHT AS COMPARED TO THE LEFT. A COMPONENT OF THE
RIGHT UPPER LUNG CONSOLIDATION APPEARS MORE MASS-LIKE. THERE ARE NO PLEURAL
EFFUSIONS. THE OSSEOUS STRUCTURES ARE WITHIN NORMAL LIMITS. THERE IS NO
PNEUMOTHORAX.
IMPRESSION: PERSISTENT CONSOLIDATION WITHIN THE RIGHT UPPER LUNG WITH
CONTINUED ASYMMETRIC PLEURAL THICKENING AS COMPARED TO THE LEFT.
DIFFERENTIAL DIAGNOSIS, AS BEFORE, WOULD INCLUDE A FOCAL INFECTIOUS
PROCESS, TB, SCARRING RELATED TO PRIOR INFECTIOUS OR INFLAMMATORY PROCESS
AND MALIGNANCY. GIVEN THE PERSISTENCE OF THE CONSOLIDATION AS STATED A
PRIMARY LUNG MALIGNANCY CANNOT BE EXCLUDED. WE WILL CONTINUE TO ATTEMPT TO
OBTAIN THE PATIENT'S PRIOR RADIOGRAPHS. A FOLLOW UP PA AND LATERAL CHEST
X-RAY AFTER COMPLETION OF CURRENT THERAPY MAY BE HELPFUL IN ASSESSING FOR
RESOLUTION OF THE RIGHT UPPER LOBE PROCESS. A CT OF THE CHEST MAY BE
PERFORMED FOR FURTHER EVALUATION, AS CLINICALLY INDICATED.
DR. KIRT FREDERICKSON
DR. DAVID L. LEVIN
Approved: THU JAN 28,1999 7:57 AM

Patient,Sample

012-12-12

F 98 JUL 15,1910

Pulmonary Report	SPIROMETRY	Study Date of 02/03/99 10:03 AM

SPIROMETRY	10:03 AM		Pre drug			Post drug
		Actual	Pred	%Pred	Actual	%Pred	%chg
FVC		1.73	1.64	105
FEV1		1.38	1.02	135
MMF		1.21	1.50	81
FEV1/FVC		80	62	128

NOTES:
	Dx: COPD. Medications: Prednisone, Levaquin, Albuterol, Nitrostat, Pravachol,
	HCTZ, Levoxyl, Folic Acid, Pentoxifylline, ASA, Verapamil. No Albuterol used
	today. Good patient effort and test quality.
	Mechanics: FVC and MMEF are normal. FEV1 and FEV1/FVC ratio are increased.
	Flow-Volume Loop: Normal contour.
	Impression: Normal spirometry, with no evidence for an obstructive lung disease.
	Compared to the study from 10/26/95, there have been no significant
	changes in FVC and FEV1.
	Girish Subramanyan, HMS/ Carl O'Donnell, ScD/ Diane Gold, MD
(33-672F)

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	CT CHEST W/O CONTRAST	Study Date of 02/16/99 10:56 AM

GOLD,DIANE R.	OPT		02/16/99 SCHED
CT CHEST W/O CONTRAST
Reason: weight loss, RUL lung infiltrate ? TB or scar carcinoma. Pl

UNDERLYING MEDICAL CONDITION:

88 year old woman with see above

REASON FOR THIS EXAMINATION:

weight loss, RUL lung infiltrate ? TB or scar carcinoma. Please define anatomy

and look for nodes

Final Report
INDICATION: WEIGHT LOSS RIGHT UPPER LOBE INFILTRATE ? TB OR CARCINOMA.
TECHNIQUE: SPIRAL CT OF THE CHEST PERFORMED WITHOUT IV ENHANCEMENT PER
PROTOCOL.
CT OF THE CHEST: THERE IS NO SIGNIFICANT AXILLARY MEDIASTINAL NOR
HILAR ADENOPATHY. WITHIN THE RIGHT UPPER LOBE THERE IS PLEURAL THICKENING
AND FOCAL CONSOLIDATION WITH EVIDENCE OF BRONCHIECTASIS. THESE FINDINGS ARE
PRESENT TO A LESSER DEGREE IN THE LEFT UPPER LOBE. WITHIN THE LEFT LOWER
LOBE THERE IS LINEAR ATELECTASIS WITH BRONCHIECTASIS CONSISTENT WITH
SCARRING AS WELL. THESE AREAS OF SCARRING HAVE PREDOMINANTLY LINEAR AND
CONCAVE MARGINS HOWEVER THERE ARE A FEW AREAS WITH CONVEX MARGINS. A TINY
PERIPHERAL NODULE APPROXIMATELY 2 MM IS SEEN IN THE LEFT UPPER LOBE
LATERALLY. ANOTHER TINY NODULE IS SEEN IN THE RIGHT LOWER LOBE POSTERIORLY
THESE NODULES ARE NOT DEFINITELY CALCIFIED. IMAGES THROUGH THE UPPER
ABDOMEN REVEAL THE VISUALIZED PORTION OF THE LIVER ADRENALS AND PANCREAS TO
BE UNREMARKABLE. THERE IS A TINY CALCIFIED FOCUS IN THE SPLEEN LIKELY
REPRESENTING A CALCIFIED GRANULOMA.
CONCLUSION:
FINDINGS MOST CONSISTENT WITH SCARRING FROM PRIOR GRANULOMATOUS
INFECTION WITH SEVERAL NON-CALCIFIED GRANULOMAS. THE OCCASIONAL CONVEX
MARGIN AS DESCRIBED SUGGESTS NEOPLASM CANNOT BE ENTIRELY EXCLUDED.
DR. BRIAN J. DE MICHAELIS
DR. DAVID L. LEVIN
Approved: WED FEB 17,1999 5:04 PM

Patient,Sample

012-12-12

F 98 JUL 15,1910

Cardiology Report	ECG	Study Date of 02/16/99 3:21:00 PM

Sinus tachycardia. Left atrial abnormality. Probable left ventricular

hypertrophy. ST-T wave abnormalities beyond those of left ventricular

hypertrophy. Q-T interval prolongation. Since the previous tracing of 12-26-98

the ST-T wave abnormality pattern is somewhat different and the heart rate is

increased. Also, the rhythm is more obviously sinus.

Read by:	RASMUSSEN,CARL A.

		Intervals			Axes
Rate	PR	QRS	QT/QTc	P	QRS	T
95	168	88	404/465	64	20	189

(99-05554F)

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	CT HEAD W/O CONTRAST	Study Date of 02/17/99 4:42 PM

Jones,DAVID M.	MED	12R	02/17/99 SCHED
CT HEAD W/O CONTRAST
Reason: ms changes, new onset dementia

UNDERLYING MEDICAL CONDITION:

88 year old woman with h/o tb, pvd, panhypopit

REASON FOR THIS EXAMINATION:

ms changes, new onset dementia

Final Report
INDICATION: DEMENTIA.
TECHNIQUE: CT HEAD.
THE CSF SPACES ARE NORMAL. THERE IS NO SHIFT OF NORMAL MIDLINE
STRUCTURES, MASSES, OR INTRA OR EXTRA-AXIAL BLEEDS. THE WHITE MATTER
DEMONSTRATES SOME SMALL VESSEL DISEASE CHANGES BUT NO ABNORMALITIES IN THE
MAJOR VESSEL DISTRIBUTIONS ARE NOTED. THE ASSOCIATED OSSEOUS STRUCTURES ARE
NORMAL.
IMPRESSION: CT BRAIN NORMAL FOR PATIENT'S AGE; ?EMPTY SELLA.
DR. CARLOS A. CACERES
DR. JAMES N. SUOJANEN
Approved: THU FEB 18,1999 10:15 AM

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	CHEST (PRE-OP AP ONLY)	Study Date of 12/18/99 7:19 PM

BENZER,THEODORE	EU		12/18/99 SCHED
CHEST (PRE-OP AP ONLY)
Reason: PT WITH FALL RESULTIN IN FX/ REQUIRING EIF

Final Report
INDICATION: LEFT HIP FRACTURE
AP CHEST: NO PRIOR FILMS ARE AVAILABLE FOR COMPARISON. THE HEART SIZE
IS AT THE UPPER LIMITS OF NORMAL. THERE IS A GENERAL INCREASED INTERSTITAL
MARKINGS POSSIBLY RELATED TO CHRONIC LUNG CHANGES BUT CANNOT EXCLUDE A
COMPONENT OF FAILURE. THERE IS ALSO A RIGHT UPPER LOBE DENSITY WHICH WAS
EVALUATED ON 2/16/99 WHICH AGAIN RAISES THE QUESTION OF INFILTRATE VS MASS.
IMPRESSION: GENERAL INCREASE INTERSTITIAL MARKINGS POSSIBLY RELATED TO
CHRONIC INTERSTITIAL DISEASE. CANNOT R/O A COMPONENT OF FAILURE.
RIGHT UPPER LOBE INFILTRATE VS MASS.
DR. CARLOS A. CACERES
DR. EVAN ROCHMAN
DR. VASSILIOS RAPTOPOULOS
Approved: MON DEC 20,1999 1:16 AM

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	BILAT HIPS (AP,LAT & AP PELVIS) LEFT	Study Date of 12/18/99 7:12 PM

BENZER,THEODORE	EU		12/18/99 SCHED
BILAT HIPS (AP,LAT & AP PELVIS
Reason: r/o fx

UNDERLYING MEDICAL CONDITION:

89 year old woman with hx of fall onto left hip

REASON FOR THIS EXAMINATION:

r/o fx

Final Report
INDICATION: FALL. HIP PAIN
BILATERAL HIPS AP AND LATERAL AND AP PELVIS: THERE IS AN
INTERTROCHANTERIC FRACTURE ON THE LEFT FEMUR WITH SUBSEQUENT COXAVERA VERA
DEFORMITY. FINE BONE DETAIL IN THE PELVIS IS OBSCURED BUT NO GROSS PELVIC
FRACTURES ARE IDENTIFIED.
RIGHT FEMUR APPEARS INTACT.
IMPRESSION: LEFT INTERTROCHANTERIC FRACTURE WITH RESULTING COXAVERA
VERA DEFORMITY.
DR. CARLOS A. CACERES
DR. EVAN ROCHMAN
DR. VASSILIOS RAPTOPOULOS
Approved: MON DEC 20,1999 1:16 AM

Patient,Sample

012-12-12

F 98 JUL 15,1910

Cardiology Report	ECG	Study Date of 12/18/99 7:04:40 PM

Sinus rhythm. Left ventricular hypertrophy. Prior anteroseptal myocardial

infarction. Compared to the previous tracing of 2-16-99 there is less

prominent lateral ST segment depression and T wave inversion, and slight

slowing of the rate, suggesting resolution of prior inferolateral ischemia.

Clinical correlation is suggested.

Read by:	MARKIS,JOHN EMANUEL

		Intervals			Axes
Rate	PR	QRS	QT/QTc	P	QRS	T
87	158	92	400/447	65	21	159

(99-44253F)

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST LEFT	Study Date of 12/19/99 1:50 PM

GERHART,TOBIN N.	ORTHO	8S	12/19/99 SCHED
LOWER EXTREMITY FLUORO WITHOUT
Reason: LT INTERTROCH FX FLOURO GUIDED RICHARDS PLACEMENT

Final Report
FLUOROSCOPY FOR ONE MINUTE, EIGHT SECONDS IN O.R. FOR PLACEMENT OF
RICHARD'S COMPRESSION SCREW IN PROXIMAL RIGHT FEMUR. THERE IS AN
INTERTROCHANTERIC FRACTURE IN GOOD ALIGNMENT.
DR. NORMAN JOFFE
Approved: TUE DEC 21,1999 8:45 AM

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	HIP 1 VIEW LEFT	Study Date of 12/21/99 9:12 AM

GERHART,TOBIN N.	ORTHO	8S	12/21/99 SCHED
HIP 1 VIEW LEFT
Reason: INTERTROCH FX NO NEW S/S

UNDERLYING MEDICAL CONDITION:

89 year old woman with hx of fall onto left hip

REASON FOR THIS EXAMINATION:

AP full length L femur

s/p ORIF L intertroch fx

Final Report
INDICATION: HISTORY OF ORIF OF FRACTURE.
LEFT FEMUR TWO VIEWS.
STATUS POST PLACEMENT OF RICHARDS TYPE COMPRESSION SCREW IN PROXIMAL
LEFT FEMUR FOR FIXATION OF INTERTROCHANTERIC FRACTURE. POSITION OF HARDWARE
AND ALIGNMENT APPEARS SATISFACTORY.
DR. NORMAN JOFFE
Approved: WED DEC 22,1999 9:18 AM

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	HIP UNILAT MIN 2 VIEWS LEFT	Study Date of 12/29/99 4:15 PM

Jones,DAVID M.	MED	TC11	12/29/99 SCHED
HIP UNILAT MIN 2 VIEWS LEFT
Reason: S/P HIP FX, PT. WITH SOME PAIN, NOW , TO EVALUATE LT. HIP REPAIR

Final Report
AP AND LATERAL HIP:
INDICATION: STATUS POST HIP FRACTURE WITH NEW PAIN.
AP AND LATERAL VIEWS OF THE LEFT HIP AND FEMUR REVEAL A DYNAMIC PLATE
AND SCREW DEVICE SECURING AN INTERTROCHANTERIC FRACTURE IN POSITION. THE
FEMORAL HEAD RESIDES WITHIN THE ACETABULUM. NO LOOSENING OR DISLOCATION HAS
OCCURRED. THE GREATER TROCHANTER HAS BEEN DISPLACED LATERALLY WITH NO
EVIDENCE FOR CALLUS FORMATION AT THIS TIME. ALL BONES ARE IN ANATOMIC
ALIGNMENT. THE REMAINING BONES OF THE PELVIS ARE UNREMARKABLE. EXTENSIVE
VASCULAR CALCIFICATIONS ARE NOTED.
IMPRESSION: SATISFACTORY ALIGNMENT OF ALL BONES IN LEFT HIP FOLLOWING
INTERNAL FIXATION OF INTERTROCHANTERIC FRACTURE LEFT HIP.
DR. JONATHAN B. KRUSKAL
Approved: THU DEC 30,1999 1:36 PM

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	VENOUS DUP EXT UNI (MAP) LEFT	Study Date of 01/05/00 1:20 PM

Jones,DAVID M.	MED	TC11	01/05/00 SCHED
VENOUS DUP EXT UNI (MAP) LEFT
Reason: ATTN LEFT LEG SWELLING

Final Report
HISTORY: SWOLLEN LEFT LOWER EXTREMITY.
FINDINGS: DUPLEX AND COLOR DOPPLER SHOWED NO DVT FROM THE COMMON
FEMORAL TO THE POPLITEAL VEINS ON THE LEFT. THE MORE PROXIMAL ASPECTS OF
THE PERONEAL, GREATER/LESSER SAPHENOUS VEINS, AND POSTERIOR TIBIAL VEIN ARE
ALSO WIDELY PATENT.
DR. ROBERT G. SHEIMAN
Approved: THU JAN 6,2000 8:06 AM

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	L-SPINE (AP & LAT)	Study Date of 03/14/00 10:58 AM

Jones,DAVID M.	HCA		03/14/00 SCHED
L-SPINE (AP & LAT); T-SPINE
Reason: BACK PAIN,R/O FX,BONY DISEASE.

UNDERLYING MEDICAL CONDITION:

89 year old woman s/p fall a few weeks ago, c/o back pain from mid thoracic to

sacral region. Please obtain thoracic and L/S spine films. Please "wet read"

and page 34095 with results.

REASON FOR THIS EXAMINATION:

R/o fx, bony disease.

Final Report
CLINICAL INDICATION: FALL. EVALUATE FOR FRACTURE.
TWO VIEWS OF THE THORACIC SPINE: THE BONES ARE DIFFUSELY OSTEOPENIC.
NO SIGNIFICANT DEGENERATIVE CHANGES ARE SEEN IN THE THORACIC SPINE. A
COMPRESSION FRACTURE IS SEEN IN THE FIRST NON-RIB BEARING VERTEBRAL BODY
WHICH WILL BE CALLED L1 FOR THIS DICTATION.
L-SPINE, 2 VIEWS: THE BONES ARE DIFFUSELY OSTEOPENIC. A WEDGE
COMPRESSION FRACTURE IS SEEN IN THE FIRST NON-RIB BEARING LUMBAR VERTEBRAL
BODY L1 FOR THIS DICTATION. AORTIC CALCIFICATION IS SEEN ANTERIOR TO THE
LUMBAR SPINE. SEVERE DEGENERATIVE CHANGES AND LOSS OF DISC SPACES IS SEEN
AT THE L5-S1 LEVEL.
IMPRESSION: 1) COMPRESSION OF THE FIRST NON-RIB BEARING VERTEBRAL BODY
IN THE LUMBAR SPINE. (THERE IS A TRANSITIONAL VERTEBRA IN THE LOWER LUMBAR
AND SACRAL SPINE).
2) SEVERE DEGENERATIVE CHANGES AT THE L5-S1 LEVEL.
3) VASCULAR CALCIFICATION.
DR. PETER J. KOUVELIOTES
DR. YVONNE CHEUNG
Approved: TUE MAR 14,2000 8:02 PM

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	T-SPINE	Study Date of 03/14/00 10:58 AM

Jones,DAVID M.	HCA		03/14/00 SCHED
L-SPINE (AP & LAT); T-SPINE
Reason: BACK PAIN,R/O FX,BONY DISEASE.

UNDERLYING MEDICAL CONDITION:

89 year old woman s/p fall a few weeks ago, c/o back pain from mid thoracic to

sacral region. Please obtain thoracic and L/S spine films. Please "wet read"

and page 34095 with results.

REASON FOR THIS EXAMINATION:

R/o fx, bony disease.

Final Report
CLINICAL INDICATION: FALL. EVALUATE FOR FRACTURE.
TWO VIEWS OF THE THORACIC SPINE: THE BONES ARE DIFFUSELY OSTEOPENIC.
NO SIGNIFICANT DEGENERATIVE CHANGES ARE SEEN IN THE THORACIC SPINE. A
COMPRESSION FRACTURE IS SEEN IN THE FIRST NON-RIB BEARING VERTEBRAL BODY
WHICH WILL BE CALLED L1 FOR THIS DICTATION.
L-SPINE, 2 VIEWS: THE BONES ARE DIFFUSELY OSTEOPENIC. A WEDGE
COMPRESSION FRACTURE IS SEEN IN THE FIRST NON-RIB BEARING LUMBAR VERTEBRAL
BODY L1 FOR THIS DICTATION. AORTIC CALCIFICATION IS SEEN ANTERIOR TO THE
LUMBAR SPINE. SEVERE DEGENERATIVE CHANGES AND LOSS OF DISC SPACES IS SEEN
AT THE L5-S1 LEVEL.
IMPRESSION: 1) COMPRESSION OF THE FIRST NON-RIB BEARING VERTEBRAL BODY
IN THE LUMBAR SPINE. (THERE IS A TRANSITIONAL VERTEBRA IN THE LOWER LUMBAR
AND SACRAL SPINE).
2) SEVERE DEGENERATIVE CHANGES AT THE L5-S1 LEVEL.
3) VASCULAR CALCIFICATION.
DR. PETER J. KOUVELIOTES
DR. YVONNE CHEUNG
Approved: TUE MAR 14,2000 8:02 PM

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	ANKLE (AP, LAT & OBLIQUE) LEFT	Study Date of 03/23/00 10:46 AM

Jones,DAVID M.	HCA		03/23/00 SCHED
ANKLE (AP, LAT & OBLIQUE) LEFT
Reason: r/o fx. WET READING. PLEASE PAGE DOREEN SPENCE BEEPER 32999

UNDERLYING MEDICAL CONDITION:

89 year old woman s/p fall 2 weeks ago, fell on back, now has pain on left

medial malleolus, very painful with walking.

REASON FOR THIS EXAMINATION:

r/o fx. WET READING. PLEASE PAGE DOREEN SPENCE BEEPER 32999

Pt waiting for result

Final Report
HISTORY: FALL 2 WEEKS AGO. CONTINUED PAIN.
THREE VIEWS OF THE LEFT ANKLE: THERE IS GENERALIZED SOFT TISSUE
SWELLING ABOUT THE ANKLE MOST PROMINENT OVER LATERAL MALLEOLUS. NO
FRACTURES IDENTIFIED. THE TALAR DOME IS CONGRUENT WITH THE MORTISE.
VASCULAR CALCIFICATIONS. LARGE POSTERIOR AND PLANTAR CALCANEAL SPURS.
IMPRESSION: NO FRACTURES.
DR. FERRIS M. HALL
Approved: TUE MAR 28,2000 8:58 AM

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	CHEST (PORTABLE AP)	Study Date of 10/17/00 10:05 PM

GARPESTAD,ERIK	MED	MICU	10/17/00 SCHED
CHEST (PORTABLE AP)
Reason: NEW BRAIN MASSES NOW LOOKING FOR LUNG MASSES;BLEEDING

Final Report
INDICATION: New brain masses, now looking for lung masses; bleeding.
Portable AP chest radiograph dated 10/17/00 is compared to previous chest
radiograph dated 12/18/99.
FINDINGS: A NG tube is seen coiled within the distal stomach, with the tip
visualized in the fundus. There is moderate left ventricular enlargement with
no radiographic evidence of failure. There is an area of increased opacity of
the right upper lobe, which most likely represents atelectasis/scarring, with
associated elevation of the minor fissure. Also noted are atelectatic changes
of the left lower lobe and left apex. Again, these may also represent areas
of scarring. There are no definite pulmonary nodules or suspicious lesions
visualized within the lung parenchyma. There are no definite pleural
effusions identified. The visualized soft tissue and osseous structures
appear unremarkable.
IMPRESSION: Atelectasis/scarring of right upper lobe. Areas of atelectasis
in the left lower lobe and left lung apex. No definite pulmonary nodules
identified on the present exam. These findings do not represent a significant
change from previous exam of 12/18/99.
The study and the report were reviewed by the staff radiologist.
DR. CHRISTOPHER TAYLOR
DR. MORRIS SIMON
Approved: WED OCT 18,2000 4:48 PM

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	CT HEAD W/O CONTRAST	Study Date of 10/17/00 7:32 PM

KRIVOPAL,MARK	EU		10/17/00 SCHED
CT HEAD W/O CONTRAST
Reason: 90yo woman with interparynchemal bleeds, likely secondary to

UNDERLYING MEDICAL CONDITION:

90 year old woman with abopve

REASON FOR THIS EXAMINATION:

90yo woman with interparynchemal bleeds, likely secondary to mets now with

progressive unresponsiveness and worsened MS

please, compare with CT scans from the OSH

Final Addendum
In terms of differential diagnosis of multiple hemorrhages, disorders of
coagulation could also be considered, with underlying ischemia and post-
traumatic causes being secondary possibilties.
DR. JONATHAN KLEEFIELD
Approved: WED OCT 18,2000 8:43 AM

KRIVOPAL,MARK	EU		10/17/00 SCHED
CT HEAD W/O CONTRAST
Reason: 90yo woman with interparynchemal bleeds, likely secondary to

UNDERLYING MEDICAL CONDITION:

90 year old woman with abopve

REASON FOR THIS EXAMINATION:

90yo woman with interparynchemal bleeds, likely secondary to mets now with

progressive unresponsiveness and worsened MS

please, compare with CT scans from the OSH

Final Report
CT HEAD 10/17/00.
INDICATION: Intraparenchymal hemorrhages likely secondary to metastases, now
with progressive unresponsiveness and worsened mental status.
TECHNIQUE: Axial images were obtained from the skull base to the vertex.
However, patient was unable to fully cooperate and there is motion artifact.
Thus patient was also scanned helically.
CT HEAD WITHOUT CONTRAST: There is an approximately 3.2 x 2.7 cm area of high
density at the left parietal lobe with surrounding low attenuation likely
representing hemorrhagic mass with surrounding edema. There is an additional
area of high density measuring approximately 1.6 x 1.3 cm at the left anterior
temporal lobe. A large area of high density is also seen at midline at corpus
callosum and measures approximately 1.9 x 2.7 cm. There is also high density
along the falx most likely representing hemorrhage. No midline shift or
hydrocephalus. The bony structures are intact. Note are made of hyperplastic
frontal sinuses. The visualized paranasal sinuses are clear.
IMPRESSION: High density areas at left parietal, left anterior temporal, and
corpus callosal regions most likely representing hemorrhagic masses from
metastatic disease; however, an alternative diagnosis could be amyloid
angiopathy. Also small amount of high density along the falx is likely
hemorrhage. These hemorrhages were also seen and are not significantly
changed from prior CT of same day from outside hospital.
The study and the report were reviewed by the staff radiologist.
DR. ERIC E. CHIANG
DR. JONATHAN KLEEFIELD
Approved: WED OCT 18,2000 8:41 AM

Patient,Sample

012-12-12

F 98 JUL 15,1910

Radiology Report	MR HEAD W & W/O CONTRAST	Study Date of 10/18/00 9:52 AM

GARPESTAD,ERIK	MED	MICU	10/18/00 SCHED
MR HEAD W & W/O CONTRAST
Reason: 90 YR OLD PATIENT WITH SEVERE CONFUSION AND CHANGE IN MENTAL STATUS, 3 HEMORRHAGES SEEN ON CT
Contrast: MAGNEVIST

UNDERLYING MEDICAL CONDITION:

90 year old woman with loss of conciousness, and 3 ICBs noted on head CT

REASON FOR THIS EXAMINATION:

r/o aneurysm, and better assess three paranchymal hemorrhages/lesions

Final Report
HISTORY: 90 y/o female with loss of consciousness and three foci of
intracranial hemorrhage on head CT. Evaluate for aneurysm or parenchymal
lesions.
TECHNIQUE: Multiplanar T1 and T2 weighted images of the brain were performed
both before and after Gadolinium enhancement. Comparison is made with a prior
head CT dated 10/17/00.
BRAIN MRI WITH AND WITHOUT CONTRAST: As seen on the recent head CT there are
three foci of intraparenchymal hemorrhage. These include a 3 cm hemorrhage in
the left parietal lobe, an approximately 1.5 cm hemorrhage in the left
anterior temporal lobe, and an approximate 3 X 2 cm hemorrhage centered in the
corpus callosum. Small amounts of intraventricular hemorrhage are also noted.
The exam is severely limited by motion throughout. None of these lesions
demonstrate definite enhancement. The lesions are predominantly hypointense
on T2 weighted images and isointense on T1 weighted images.
Moderate diffuse prominence of the ventricles and sulci is again seen. Mild
periventricular white matter signal abnormality is noted throughout. The
susceptibility sequence does not definite any additional definite areas of
hemorrhage. No areas of restricted diffusion are identified.
IMPRESSION:
1) Three focal areas of intraparenchymal hemorrhage involving the left
anterior temporal lobe, left parietal lobe, and corpus callosum. These have
not changed significantly from a head CT one day earlier.
2) No definite abnormal enhancement within the brain to suggest underlying
neoplastic lesions although the exam is significantly limited by motion.
The study and the report were reviewed by the staff radiologist.
DR. SALIM SAMUEL
DR. JONATHAN KLEEFIELD
Approved: FRI OCT 20,2000 3:05 PM

Procedure	Date	Provider	Comments
OPEN REDUC-INT FIX FEMUR - 79.35	12/21/99	20-128 - Dr. TOBIN N. GERHART	Inpatient Procedure
E & M, OFFICE OR OUTPATIENT VIST FOR ESTABLISHED PATIENT, LEVEL 3 CODE - 99213	01/21/99	12-117 - Dr. DAVID M. Jones	Clinic visit
ROUTINE VENIPUNCTURE FOR COLLECTION OF SPECIMEN(S) - 36415	01/21/99	12-117 - Dr. DAVID M. Jones	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	02/02/99	12-117 - Dr. DAVID M. Jones	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, THAT MAY NOT REQUIRE THE PRESENCE OF A PHYSICIAN NOT REQUIRE THE PRESENCE OF A PHYSICIAN - 99211	02/16/99	12-117 - Dr. DAVID M. Jones	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	03/25/99	12-117 - Dr. DAVID M. Jones	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	07/06/99	12-117 - Dr. DAVID M. Jones	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	09/22/99	12-117 - Dr. DAVID M. Jones	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	11/02/99	12-117 - Dr. DAVID M. Jones	Clinic visit
IMMUNIZATION ADMIN - 90471	11/02/99	12-117 - Dr. DAVID M. Jones	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	12/02/99	12-117 - Dr. DAVID M. Jones	Clinic visit
ROUTINE VENIPUNCTURE FOR COLLECTION OF SPECIMEN(S) - 36415	12/02/99	12-117 - Dr. DAVID M. Jones	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	02/22/00	12-117 - Dr. DAVID M. Jones	Clinic visit
E & M, OFFICE OR OUTPATIENT VIST FOR ESTABLISHED PATIENT, LEVEL 3 CODE - 99213	03/14/00	12-117 - Dr. DAVID M. Jones	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	03/23/00	12-117 - Dr. DAVID M. Jones	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	04/12/00	12-117 - Dr. DAVID M. Jones	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	04/26/00	12-117 - Dr. DAVID M. Jones	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	08/08/00	12-117 - Dr. DAVID M. Jones	Clinic visit
ROUTINE VENIPUNCTURE FOR COLLECTION OF SPECIMEN(S) - 36415	08/08/00	12-117 - Dr. DAVID M. Jones	Clinic visit
OFFICE OR OTHER OUTPATIENT VISIT FOR THE EVALUATION AND MANAGEMENT OF AN ESTABLISHED PATIENT, WHICH REUIRES AT LEAST TWO OF THE THREE KEY COMPONENTS AS LISTED IN CPT P. 19. - 99212	08/31/00	12-117 - Dr. DAVID M. Jones	Clinic visit

Dr. TOBIN N GERHART Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones Dr. DAVID M Jones

Telephone 01/07/99 Dr. BERYL R.N. CHAPMAN Service: General Med/Prim.Care
Date: 01/07/99
Signed by BERYL CHAPMAN, R.N. on 01/07/99
--Title: CONSTIPATION
Pt. home from hospital x 1 wk; unable to have BM. Has tried
metamucil, suppositories, incr. liquids. Hasn't yet tried Fleet.
Denies distention, n,v. Niece will attempt to give enema this
evening; pt. wcb tmrw. If results are not good, she will make
app't for episodic visit, as per PCP, Dr. Jones.

Telephone 01/12/99 Dr. DAVID Jones Service: General Med/Prim.Care
Date: 01/12/99
Signed by DAVID Jones, MD on 01/12/99
VNA called to report that pt.'s constipation has been better with
Fleets' enemas but that her BP has been running low with SBP of
100 going down to 90 with standing. I asked that they hold the
Dyazide and let me know how she is in 2 days when they see her
again.

Telephone 01/14/99 Dr. DAVID Jones Service: General Med/Prim.Care
Date: 01/14/99
Signed by DAVID Jones, MD on 01/14/99
VNA called to report that lightheadedness resolved and BP is
normal off Dyazide, but that pt. is still constipated. She has
had longstanding problems with constipation, but this seems
worse, and with her weight loss, this is concerning. I asked
that pt. make an appointment to see Dr. Lembo. She will likely
need colonoscopy.

Progress Note 01/21/99 Dr. DOREEN NP SIDDALL Service: General Med/Prim.Care
Date: 01/21/99
Signed by DOREEN SIDDALL, NP on 01/25/99
--------------- --------------- --------------- ---------------
Medications before January 21, 1999:
ALBUTEROL --2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth at bedtime
BISACODYL 10 MG--One suppository rectally as needed twice a day
DOCUSATE 100 MG--One capsule by mouth three times a day
FOLIC ACID 1 MG--One tablet by mouth every day
GUAIFENESIN DM --10 ml by mouth every 4 hours
IBUPROFEN 400 MG--One by mouth three times a day after meals as
needed
LEVOFLOXACIN 500 MG--One tablet by mouth every day
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
MAALOX --30ml by mouth as needed every 4 hours
MICRO-K 10 10 MEQ--One by mouth every day
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PENTOXIFYLLINE 400 MG--One tablet by mouth three times a day
POTASSIUM CHLORIDE 10 MEQ--One cap by mouth every day
PREDNISONE 2.5 MG--One tablet by mouth every evening
TRIAMTERENE & HCTZ 37.5MG/25MG--2 capsule by mouth every day
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on January 21, 1999.
No medications prescribed on January 21, 1999.
--------------- --------------- --------------- ---------------
VS: Wt. 117.6 lbs
S: Follow-up:
States that overall she feels "pretty good". She said she has
been trying to eat more.
She went to GI this morning but was told that she did not have an
app't with Dr. Lembo, and was not rescheduled.
HPT - she is off Dyazide.
Social - takes cabs to app'ts which is costly. Needs help at
home, may be one day a week.
O: BP 114/56
Lungs - clear
A/P; S/P Pneumonia
RLL consolidation 12/27. Follow-up CXR today.
Weight Loss/GI
I called GI to schedule pt's appt with Dr. Lembo.
They have the referral (so unclear why app't was not scheduled
when pt was there). App't scheduled for 3/15 at 4:20pm (first
available).
HPT
continue off of Dyazide.
Social
referred to Ms Regina McLean for help with
transporation and for homemaker.
Labs - CBC, chem-7

Progress Note 02/02/99 Dr. DOREEN NP SIDDALL Service: General Med/Prim.Care
Date: 02/02/99
Signed by DOREEN SIDDALL, NP on 02/03/99
--------------- --------------- --------------- ---------------
Medications before February 2, 1999:
ALBUTEROL --2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth at bedtime
BISACODYL 10 MG--One suppository rectally as needed twice a day
DOCUSATE 100 MG--One capsule by mouth three times a day
FOLIC ACID 1 MG--One tablet by mouth every day
GUAIFENESIN DM --10 ml by mouth every 4 hours
IBUPROFEN 400 MG--One by mouth three times a day after meals as
needed
LEVOFLOXACIN 500 MG--One tablet by mouth every day
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
MAALOX --30ml by mouth as needed every 4 hours
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PENTOXIFYLLINE 400 MG--One tablet by mouth three times a day
PREDNISONE 2.5 MG--One tablet by mouth every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on February 2, 1999.
Medications prescribed on February 2, 1999:
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
--------------- --------------- --------------- ---------------
VS: Wt. 110.0 lbs (with shoes)
S: FOllow-up. Ms Patient missed her Pulmonary app't b/c of the
snow, unable to get a cab. Recheduled for next week.
She said that she is feeling allright, but is concerned about her
weight loss. She said her appetite is good and she has no
problems sleeping. Her tenant has been bringing her breakfast
and supper and she eats as much as she can.
Meds - she is off of Dyazide and potassium, and is taking
Prednisone 2.5 mg 2 tabs in the morning and 1 tab in the evening
(not 2.5mg qd as per hospital discharge notation). She is
certain about this.
O: BP initially 120/80 sitting. answered that she is sometimes
lightheaded with change in position so checked postural sings:
BP 196/90 HR 80 reg. lying
104/60 HR 88 reg standing
Lungs - clear
weight down another 7#
A/P; Weight Loss
dsicussed with Dr. Jones. Pt will be seen in Pulmonary
next week, or sooner if possible. We will not make any med
changes today. She was asked to bring in all meds to next visit
to verify doses. Her tenants are helping her with meals.
Reginae McLean, CRS, is looking into help with transportation and
homemaker. I spoke with Ms McLean again today, and if need be,
she will arrange for taxi vouchers for upcoming app'ts.
RTC 2 weeks

Telephone 02/04/99 Dr. DAVID Jones Service: General Med/Prim.Care
Date: 02/04/99
Signed by DAVID Jones, MD on 02/04/99
I spoke with pt.'s niece, Debra Cox (436-6129), who asks to be
kept informed to assist pt. in understanding testing plans. She
reports that she does feel pt. is depressed after the loss of
her daughter, and that pt. may have had a similar episode after
a prior death of a relative. I will arrange for pt. to speak
with an HCA psychiatrist in the next few days, while continuing
plans for evaluation of other etiologies of weight loss.

Letter 02/04/99 Dr. DIANE R GOLD Service: Pulmonary
--Title: Dr. Jones
February 4, 1999
David Jones, M.D.
General Medicine-Y111
Beth Israel Deaconess Medical Center
Boston, MA 02215
RE: Sample Patient (012-12-12)
Dear Dr. Jones:
Thank you very much for asking us to evaluate Mrs. Sample Patient
for her right upper lobe infiltrate and loss of weight. As you
know, she is an 88-year-old woman who has had a right upper lobe
infilrate which is at least 20 years old. In 1980, she had a
bronchoscopy but cannot recall the results. In 1995, she was
reported to have converted to positive PPD status and was treated
for one year of INH. Induced sputa x 3 at that time were
negative. She was admitted to the Beth Israel Hospital between
12/26 and 12/29/98 for fever, shortness of breath, cough and a 15
pound weight loss. She was treated with Levofloxacin and felt
better after her course of antibiotics. However, she still does
not feel quite back to her baseline and continues with loss of
appetite and weight loss. She has at least two meals a day but
does not feel hungry and is unable to keep her weight steady.
She finds it more difficult to clean her seven room house and has
noted a decrease in her energy. She does not have a history of
night sweats or fever since her discharge in December of last
year. She has no report of shortness of breath, though I note
that she becomes somewhat short of breath walking on level ground
outside the pulmonary function laboratory. She says that she has
to stop after climbing nine stairs because her legs trouble her.
She lost her daughter in October 1998, though she says that she
is not depressed.
The review of symptoms is significant for hayfever in the spring,
"tired legs" but no pulmonary symptoms. She has been
intermittently constipated, she says, since she started
Verapamil. Flex sigmoidoscopy in 1993 was normal and she
reportedly has no occult blood in her stool.
Past medical history is significant for measles and whooping
cough as a child. She has been panhypopituitary for at least
seven years. She has peripheral vascular disease. On record,
she has angina but she denies any history of chest pain. In
1995, she was hospitalized for ascending colongitis. She has a
history of hypertension and hypercholesterolemia. She has a
history of baseline elevated white blood cell count.
Her medications include prednisone 5 mg. in the morning. 2.5 mg.
in the evening, Levoquin, albuterol, Nitrostat, Pravachol,
triamcinolone/hydrochlorothiazide, Levofloxin, pentoxofylline,
folate, aspirin and Verapamil. She is allergic to penicillin.
She lives alone. She is able to do her activities of daily
living. She has no history of exposure to asbestos. Her husband
smoked for 54 years but she has never actively smoked cigarettes.
Family history is significant for a father with asthma and a
mother with hypertension.
Social History:
The patient traveled extensively in the Caribbean when her
husband was living. Her last trip was one year ago to the
Bermudas.
On exam, she appears to be a very energetic, thin woman who is
very alert and is not in acute distress. She does become
breathless, however, when walking down the corridor at a slow
pace. Her blood pressure is 130/62, her heart rate 90, her
respirations 18 and unlabored. On examination of her HEENT, she
has no oral erythema or exudates. Her neck is supple. She ha
sno cervical or supraclavicular lymphadenopathy. She has no
thryomegaly. Her trachea is midline. On examination of her
lungs, she has normal lung excursion. Her lungs are resonant to
percussion. There is no egophony or whispered petroliloquy.
Lung sounds are normal. On cardiac exam, she has a regular rate
and rhythm, normal S1, S2 without murmurs, gallops or rubs. On
abdominal exam, her abdomen is soft, nontender without
hepatosplenomegaly. On examination of the extremities, there is
no clubbing, cyanosis or edema.
Laboratory values are positive for a hematrocrit which has slowly
dropped from 36 down to 32 on 1/21/99, a white blood count which
has varied between 24.5 on 12/28 and 13.1, with a differential
which is normal. On chest x-ray, the patient has consistently
had a right upper lobe, probably apical infiltrate, with no
obvious change in 1978. A recent sputum x 1 was negative for
AFB.
In summary, this is an 88-year-old wmoan who has had progressive
weight loss which, by report, has been rapid and who had a recent
episode of fever, shortness of breath and cough. While there is
no obvious change in the right upper lobe infiltrate, in the
setting of rapid weight loss, it is reasonable to rule out the
possiblity of either reactivated tuberculosis or a scar
carcinoma. We have ordered two incuded sputa for AFB and
cytology and a CT scan of the chest to further define the
abnormalities in the right upper lobe. On Wednesday of next
week, we have scheduled a bronchoscopy with transbronchial
biopsy.
It may, however, turn out that the source of the weight loss is
not related to the pulmonary infiltrate. If induced sputum and
bronchoscopy with washing and biopsy are unrevealing, then the
patient may need further evaluation either in relation to her
hematologic status, her GI tract or her depression. We will be
in touch regarding the results of her radiologic procedure and
her bronchoscopy.
Sincerely,
Diane Gold, M.D.
East Campus
/nb

Initial Note 02/05/99 Dr. JOAN DREVINS Service: Rehabilitative Services
Date: 02/05/99
Signed by JOAN DREVINS, PT, CCS, LIC #2692 on 02/05/99
--Title: SPUTUM INDUCTION
Time: 11:45-12:15 pm. "I don't know why I am here, It may have
something to do with being in the hospital after Christmas"
--------------- --------------- --------------- ---------------
Medications before February 5, 1999:
ALBUTEROL --2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth at bedtime
BISACODYL 10 MG--One suppository rectally as needed twice a day
DOCUSATE 100 MG--One capsule by mouth three times a day
FOLIC ACID 1 MG--One tablet by mouth every day
GUAIFENESIN DM --10 ml by mouth every 4 hours
IBUPROFEN 400 MG--One by mouth three times a day after meals as
needed
LEVOFLOXACIN 500 MG--One tablet by mouth every day
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
MAALOX --30ml by mouth as needed every 4 hours
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PENTOXIFYLLINE 400 MG--One tablet by mouth three times a day
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on February 5, 1999.
No medications prescribed on February 5, 1999.
--------------- --------------- --------------- ---------------
Pt is an 88 year old spry female who reports a history of fatigue
and weight loss since December.Pt was hospitalized from 12/26 to
12/29 secondary to fatigue, weight loss and anorexia. Pt has yet
to fully recover. Pt denies cough or night sweats.
Pt is referred to PT for sputum induction by Dr. Gold to r/o TB.
Pt Has had a RUL infiltrate for 20 years, and had a positive PPD
several years ago treated with INH. Pt does not recall her
medications, or if she is taking ABX, but apparently so, based
upon the OMR. Pt has never smoked.
ROS: Pt is alert and oriented, but not the most reliable of
historians. Pt was able to actively participate int he sputum
induction, and did produce a small amount of sputum., Cough is
fair, but generally nonproductive. VS at rest: BP 126/56, HR 101,
RR 24, SpO2 98%; VS following procedure: BP 120/60, HR 102, RR
20. SpO2 100%.
Intervention: USN delivered with 3% hypertonic solution for 10
minutes. One specimen was obtained, and sent for AFB smear and
culture. Pt had a previous sputum collected in another clinic.
This was her second AFB . The patient tolerated the session well.
Impairment:
1. AIrway clearance dysfunction
Outcome:
1. Obtain sputum specimen for diagnotic testing which were
obtained and carried to the lab. David Foote, Practice Assistant
was available to assist with today's session.

Progress Note 02/08/99 Dr. CLAUDIA LEVENSON Service: Rehabilitative Services
Date: 02/08/99
Signed by CLAUDIA LEVENSON, PT, CCS on 02/08/99
--Title: SPUTUM INDUCTION #2
Subjective:
Time 11:15-11:45am
--------------- --------------- --------------- ---------------
Medications before February 8, 1999:
ALBUTEROL --2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth at bedtime
BISACODYL 10 MG--One suppository rectally as needed twice a day
DOCUSATE 100 MG--One capsule by mouth three times a day
FOLIC ACID 1 MG--One tablet by mouth every day
GUAIFENESIN DM --10 ml by mouth every 4 hours
IBUPROFEN 400 MG--One by mouth three times a day after meals as
needed
LEVOFLOXACIN 500 MG--One tablet by mouth every day
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
MAALOX --30ml by mouth as needed every 4 hours
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PENTOXIFYLLINE 400 MG--One tablet by mouth three times a day
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on February 8, 1999.
No medications prescribed on February 8, 1999.
--------------- --------------- --------------- ---------------
"I just don't feel to great. I'm a little dizzy today."
Objective:
VS: HR 104 BP 130/66 RR 16 SpO2 100%
Breath sounds clear bilaterally to bases.
Patient reprots "dizziness" getting out of bed today and when she
stands up. It seems to resolve when she is sitting or lying down.
Measured orthostatic signs and HR 110 and BP dropped 80/50 with 1
minute of standing and did not return to normal after several
minutes. Patient did report dizziness with standing during these
measurements.
Instructed patient to drink plenty of fluids which she reported
she did not usually do.
She was able to tolerate a sputum induction with 3 % hypertonic
saline via ultrasonic nebulizer for 15-20 minutes. Cough
productive of thick clear sputum sent for AFB #3 and cytology x1.
Post session patient reported feeling the same as when she
arrived and VS post session were: HR 95 BP 118/58 RR 16 SpO2
100%
Breath sounds clear bilaterally
Assessment:
Tolerated procedure well but only one cytology spec has been sent
and patient did not wish return again. I have told her to call
her MD if the dizziness does not resolve or worsens.
Plan:
No further treatment at thsi time.
Assisted by David Foote.

Progress Note 02/11/99 Dr. RANDALL PAULSEN Service: Psychiatry
Date: 02/11/99
Signed by RANDALL PAULSEN, MD on 02/25/99
--------------- --------------- --------------- ---------------
Medications before February 11, 1999:
ALBUTEROL --2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth at bedtime
BISACODYL 10 MG--One suppository rectally as needed twice a day
DOCUSATE 100 MG--One capsule by mouth three times a day
FOLIC ACID 1 MG--One tablet by mouth every day
GUAIFENESIN DM --10 ml by mouth every 4 hours
IBUPROFEN 400 MG--One by mouth three times a day after meals as
needed
LEVOFLOXACIN 500 MG--One tablet by mouth every day
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
MAALOX --30ml by mouth as needed every 4 hours
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PENTOXIFYLLINE 400 MG--One tablet by mouth three times a day
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
Medications DC'd on February 11, 1999:
GUAIFENESIN DM --
LEVOFLOXACIN 500 MG--
PENTOXIFYLLINE 400 MG--
No medications prescribed on February 11, 1999.
--------------- --------------- --------------- ---------------
Patient referred by Dr. David Jones. She is an 88-year-old woman
with marked weight loss over the past 3 months since the death of
her daughter. She had a previous depression like this, according
to a niece, and so far the medical work up has been negative in
terms of looking for medically related causes. Patient has
agreed to an empiric trial of low dose prozac, given a
prescription of 10 mg q.d. Return visit for 3/4/99.

Progress Note 02/16/99 Dr. DOREEN NP SIDDALL Service: General Med/Prim.Care
Date: 02/16/99
Signed by DOREEN SIDDALL, NP on 02/16/99
--Title: DEHYDRATION
--------------- --------------- --------------- ---------------
Medications before February 16, 1999:
ALBUTEROL --2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth at bedtime
BISACODYL 10 MG--One suppository rectally as needed twice a day
DOCUSATE 100 MG--One capsule by mouth three times a day
FOLIC ACID 1 MG--One tablet by mouth every day
IBUPROFEN 400 MG--One by mouth three times a day after meals as
needed
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
MAALOX --30ml by mouth as needed every 4 hours
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on February 16, 1999.
No medications prescribed on February 16, 1999.
--------------- --------------- --------------- ---------------
VS: Wt. 109.8 lbs (with shoes)
S: Ms Patient is here for follo-wup after chest CT. Her niece
called me this morning re: her concerns. Pt has been staying
with the niece since Christmas and acc to the niece, pt has been
eating bery little, her balance is poor, and she wonders if Ms
Patient is mixing up her meds and/or doubling them.
Ms Patient said she is not feeling well, balance is not good, but
cannot say how else she is not feeling well.
O: weight 110 (same as 2/9).
looks dry, weak
BP 120/72 HR 100 reg lying
90/70 sitting
unable to palpate when standing
A/P; 88 YO woman with panhypopit, HPT, weight loss, ? depression,
now dehydrated and not able to eat or drink. Brief visit today.
Pt seen with Dr. Jones. Referred to the EW for hydration and
probable admission. Taken to the EW by transportation via
wheelchair, also accompanied by son.

Initial Note 02/17/99 Dr. ROHN S FRIEDMAN Service: Psychiatry
Date: 02/17/99
Signed by ROHN S FRIEDMAN, MD on 02/17/99
(Monitored)
Psychiatry Staff consultation:
Asked to see this 88 yo wbf with hx of panhypopituitarism,
cataracts, htn, copd, oa, cad, pvd, admitted for N, v,
hypotension, dehydration, to evaluate ?depression. Patient seen,
chart reviewed.
HPI: Patient reports she lives in and takes care of her own
house, is active in New Hope church, has many friends, prepares
her own meals, has a son, and grandchildren and great
grandchildren though she cannot recall how many. She reports
that her daughter died in October, though she cannot tell me what
daughter died of and only repeats that daughter never did what
she was told and never took care of herself but always did things
her way. She has felt depressed since, and has had little
appetite and has lost 15 pounds. However she has slept well,
denies anhedonia, hopelessness, helplessness, guilt, loss of
interests, difficulties with concentration or memory. she
reports being unable to walk for a few weeks and hence not going
out of house.
Past psych hx: patient denies any hx, but OMR reflects visit
2/11 with dr. Paulsen who suggested Prozac 10 mg.
Family psych hx: denies.
Substance abuse hx: denies.
Social hx: as above.
ROS: psych as above. Neuro: denies ha, sz, change in vision,
sensation, hearing; c/o overall weakness and fatigue. GI: c/o
constipation. Other systems neg.
Labs, meds, xr reviewed. Note cxr with RUL consolidation 1/21.
chest ct reading pending; TSH pending. On synthroid, solumedrol
Exam: 99.4, 10, 24, 136/68
Neuro: slow unsteady gait, normal stance; good tone; no
abnormal movements noted, eom full without nystagmus.
appearance: elderly black woman in bed. Affect: "depressed"
but shows broad range, including describing pleasure she gets
from church, family and friends. Behavior: slowed, calm,
cooperative, appropriate. Cognition: Ox winter 1990's, BI;
unable to give month, date, or year beyond decade. Attention: 5
digits forward. Memory: registers 3 items, recalls 0
spontaneously, recognizes 0 from list. Clock:
circled positions of digits rather than
drawing them in, perseverated on that when asked to draw hands,
and again when asked to write a sentence. Speech: normal rate,
articulation, prosody. Language: word-finding difficulty,
difficulty describing situations (eg unable to give any
substantial description of how daughter died); but comprehension
good, follows simple commands, repetition good, spontaneous
speech good. Thought process: circumstantial and at times loses
thread of conversation and perseverates on her last thought.
Thought content: no hallucinations,delusions, homicidal or
suicidal ideation. Judgment and insight: limited.
Impression:
1. dementia, severe, with impairments of memory, language,
constructions. Phenomenology is most consistent with DAT, but
also history of vascular disease and panhypopituitarism suggests
other possible contributors. Pulmonary process and endocrine
abnormalities, high dose steroids may all further exacerbate and
compromise her cognitive functioning.
2. adjustment disorder with depressed mood, mild. Patient has
some appropriate sad feeling relating to daughter's death, but
she shows a continued good range of affect and the only other
possible symptom of depression is loss of appetite. In this
context, I strongly suspect that her weight loss is more related
to her inability to prepare meals and care for self than a simple
anorexia.
Suggest:
1. OT safety and functional assessment. Patient recognizes that
she needs more services at home, but she is reluctant to consider
nursing home.
2. Await TSH and medical workup.
3. B12, folate, RPR.
4. Consider neuroimaging, though I suspect it would be very low
yield
5. As above information is developed, it would make sense to
have a family meeting to discuss disposition.
6. fine to continue Prozac, but would also refer to HCA social
work or community services/visiting psychiatric nurse to talk
about loss of daughter. Patient reports she has many friends but
has been reluctant to burden them with talk about her loss.

BETH ISRAEL DEACONESS MEDICAL CENTER
PATIENT DISCHARGE PLAN

PATIENT INFORMATION
Patient Name	Sample Patient
MRN#:	0121212
Case#:	1600732 0
DOB:	JUL 15,1910
Patient Status:	Admitted FEB 16,1999
Reason for Admission:	DEHYDRATION;ORTHOSTASIS
Discharged to:
Attending Physician:

DISCHARGE INSTRUCTIONS
FINAL DIAGNOSIS
RECOMMENDED FOLLOW-UP
MAJOR SURGICAL OR INVASIVE PROCEDURES
CONDITION AT DISCHARGE

Disch Sum 02/19/99 Dr. David M. Jones
DISCHARGE SUMMARY
Jones,DAVID M.
Signed Electronically by Jones,DAVID on TUE MAR 2,1999 7:15 PM
Name: Patient, Sample Unit No.: 0121212
Admission Date: 02/16/99 Discharge Date: 02/19/99
Date of Birth: 07/15/10 Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is an 88-year-old
female with a complex medical history including coronary
artery disease, peptic ulcer disease, panhypopituitarism and
hypertension, who was very functional and independent until
approximately three months ago, when her daughter passed away.
In December of 1998, she was admitted for a question of
pneumonia, and since then the patient has been losing weight
over the last couple of months. Over the past six weeks, she
has noticed increased weight loss, became less independent,
has had increased confusion and complained of anorexia. Her
niece reported a similar episode in the past over the death of
another relative. A recent follow-up chest x-ray showed an
increasing right upper quadrant infiltrate. A CT and
bronchoscopy were planned as an outpatient. The patient was
noted to be PPD positive in 1996, and was status post INH
treatment. Two induced sputums as an outpatient were AFB
negative. Today in Radiology, when the patient presented for
her CT scan, she was noted to be very dry looking and
orthostatic, with symptoms. She then was sent to the
emergency room. She reported a two day history of nausea and
vomiting. No abdominal pain, diarrhea, melena or
hematochezia. The patient denied any chest pain or shortness
of breath. No loss of consciousness, no night sweats.
ALLERGIES: PENICILLIN AND SULFA.
MEDICATIONS ON ADMISSION:
1. Verapamil SR 240 mg p.o. q.d.
2. Synthroid 50 mcg q.d.
3. Folate 1 mg q.d.
4. Prednisone 5 mg alternating with 2.5 mg q.d.
5. Aspirin 325 mg p.o. q.d.
6. Albuterol metered dose inhaler 2 puffs q.i.d. p.r.n.
7. Prozac 10 mg p.o. q.d.
8. Nitroglycerin p.r.n.
9. Maalox p.r.n.
10. Ibuprofen 400 mg t.i.d. p.r.n.
11. Colace 100 mg p.o. t.i.d.
12. Dulcolax suppository b.i.d. p.r.n.
13. Atorvastatin 10 mg q.d.
PAST MEDICAL HISTORY:
1. Exertional angina.
2. History of PPD positive, treated with INH x1 year.
3. Cataracts.
4. Peripheral vascular disease and claudication.
5. Hypertension.
6. Tinnitus.
7. Hypercholesterolemia.
8. Panhypopituitarism, etiology unclear.
SOCIAL HISTORY: She denied tobacco or alcohol use. She lives
alone. Her daughter passed away recently.
PHYSICAL EXAMINATION: In general, she was a very pleasant,
elderly female in no acute distress. Blood pressure 136/68,
respirations 20, heart rate 100, temperature 99.4. HEENT:
Pupils equal, round and reactive to light and accommodation,
extraocular muscles intact, anicteric sclerae. Dry mucous
membranes. Neck: Supple, no bruits, no lymphadenopathy.
Pulmonary: Decreased breath sounds at both apices, dull to
percussion at the apices. Cardiovascular: 3/6 systolic
ejection murmur at the right upper sternal border. Abdomen:
Diffusely mild tenderness, no masses, no rebound or guarding,
normoactive bowel sounds, no costovertebral angle tenderness.
Extremities: 2+ dorsalis pedis and posterior tibial
bilaterally, no peripheral edema. Neurologic: Alert and
oriented x3. Cranial nerves II through XII grossly intact.
Reflexes 2+ and equal throughout. Babinskis down going
bilaterally. Strength 5/5 and symmetric.
LABORATORY: White count 8.0, hematocrit 38.8, platelets 155.
Potassium 3.2, bicarbonate 19. Urinalysis with 38 white blood
cells, 7 epithelial cells and few bacteria. Her PTT on
February 3 was 1.2. Her sputum from February 8 and February
2 was negative for AFB, and cytology on February 9 was
negative. Chest x-ray with right upper lobe consolidation
with decreased volume, biapical pleural thickening, - right
greater than left. EKG with sinus rhythm at 100, normal axis,
left ventricular hypertrophy by aVL, strain pattern, normal
intervals.
HOSPITAL COURSE:
1. The patient was admitted for orthostatic hypotension. It
was thought that it most likely was due to a decreased p.o.
intake and nausea and vomiting over the last couple of days.
It also was thought possibly because the patient was not
taking her p.o. prednisone. The patient was hydrated with
normal saline, and also given stress dose steroids. By
hospital day #3, her orthostatic symptoms had resolved.
2. Pulmonary: The patient had a chronic right upper lobe
opacity. It was being evaluated as an outpatient by Pulmonary
for TB. The patient had a history of being PPD positive and
was treated in 1995 with INH. Due to her recent weight loss,
it was thought that this possibly could represent a
reactivation of prior disease. A third sputum was sent for
AFB. Due to her stress-dose steroids, the patient became more
confused, making an inpatient bronchoscopy difficult. She
will be tapered down off her high-dose steroids and will be
scheduled for an outpatient bronchoscopy.
3. Panhypopituitarism: The etiology of the patient's
hypopituitarism was unknown. Her free T4 was within normal
limits. She initially was given stress-dose steroids, and was
tapered back down to prednisone, 10 mg p.o. q.d., and
eventually will resume 5 mg alternating with 2.5 mg q.d.
4. Psychiatry: The patient was noted to be depressed with a
decreased p.o. intake since the loss of her daughter. Many of
her symptoms could be attributed to this depression.
Psychiatry was consulted and found the patient to be severely
demented, with impairments in memory, language and
constructions. There was also thought likely to be an element
of a mild adjustment disorder. A head CT was obtained which
revealed some small vessel disease, thought consistent with
her age.
5. Cardiovascular: The patient remained orthostatic
throughout hospital days #1 and #2. She was hydrated
adequately, and diltiazem was decreased to 120 mg p.o. q.d.
By hospital day #3, her orthostatic symptoms had resolved.
The patient on initial exam also was noted to have a new
murmur. A cardiac echo was performed which revealed an
ejection fraction of 55% with normal systolic function, a
moderately thickened aortic valve, moderate mitral
regurgitation and increased left ventricular hypertrophy from
her prior study.
6. Infectious Disease: On admission the patient was noted to
have pyuria, with a question of it being sterile. Cultures
remained negative. She was treated with three days of Cipro,
250 mg p.o. b.i.d. Urine also was sent for AFB.
7. Disposition: A long family meeting was held with her
niece, who is her legal guardian, to discuss outpatient
support for the patient. It was felt that with extensive VNA
and a home health aide that she would be able to provide home
health care.
DISCHARGE MEDICATIONS:
1. Synthroid 50 mcg p.o.q.d.
2. Folate 1 mg p.o. q.d.
3. Colace 100 mg p.o. t.i.d..
4. Verapamil SR 120 mg p.o. q.d.
5. Atorvastatin 10 mg p.o. q.d.
6. Prozac 10 mg oropharynx q.d.
7. Albuterol metered dose inhaler 2 puffs q.i.d. p.r.n.
8. Nitroglycerin 0.4 mg sublingual p.r.n.
9. Prednisone 10 mg q.d. x3 days, then alternate 5 mg and
2.5 mg q.d.
10. Dulcolax suppository b.i.d. p.r.n.
DISCHARGE DIAGNOSES:
1. Orthostatic hypotension.
2. Resolved nausea and vomiting.
3. Panhypopituitarism.
4. Right upper lobe opacity, chronic.
DAVID M. Jones 12-117
Dictated by: JEFF ZWICKER, M.D.
DR/JZ/mem/LPSI-bos
D: 02/19/99
T: 02/20/99
Job#: 0879

Telephone 03/11/99 Dr. DAVID Jones Service: General Med/Prim.Care
Date: 03/11/99
Signed by DAVID Jones, MD on 03/11/99
VNA called today to report SBPs in 160 range. I told them that
that was okay. They report that she is taking care of all ADLs
and is full alert and functional, and are discharging her from
care. I spoke with pt.'s niece a few days ago who also reports
pt. is doing extremely well. I asked that she schedule pt. to
see me and Nurse Spence.

Progress Note 03/25/99 Dr. DOREEN NP SIDDALL Service: General Med/Prim.Care
Date: 03/25/99
Signed by DOREEN SIDDALL, NP on 03/30/99
--------------- --------------- --------------- ---------------
Medications before March 25, 1999:
ALBUTEROL --2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth every day
BISACODYL 10 MG--One suppository rectally as needed twice a day
DOCUSATE 100 MG--One capsule by mouth three times a day
FLUOXETINE 10 MG--One by mouth every day
FOLIC ACID 1 MG--One tablet by mouth every day
IBUPROFEN 400 MG--One by mouth three times a day after meals as
needed
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
MAALOX --30ml by mouth as needed every 4 hours
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on March 25, 1999.
No medications prescribed on March 25, 1999.
--------------- --------------- --------------- ---------------
VS: Wt. 115.2 lbs
S: Mrs. Patient, an 88 yo woman, s/p recent admission for
dehydration and confusion, returns for f/u. She states she is
"back to normal", back in her own home, remembers some of the
hospitalization and knows that she was confused. She stayed with
her niece for a while after discharge, with VNA services which
have since been discontinued. She said that her appetite is very
good. Her neighbor brings her hot breakfast every morning, she
has fruit and milk for lunhc, meal-on-wheels for dinner, and said
she snacks throughout the day. She has been out alone yet.
She is now feeling stronger, walking more at home. Her niece
prefills her meds weekly, and visits frequently.
Discussed needs at home, and acknowledged that she needs
homemaking services esp to help with housecleaning and to go with
her to the store. Also needs help with transportation - takes
cabs to app'ts which is expensive.
Meds - knows the names and doses (as listed in OMR) incl new med,
Prozac.
O: well groomed, appropriate, cheerful and talkative. oriented
to date (mo/yr, day off by one), address, birthdate, place,
(president - immediately talked of recent events regarding the
president, but took a couple of minutes to remember the name)
BP 120/80 HR 64 reg.
Lungs - clear
Ext - no edema
weight up 6#
A/P: Confusion
seem back to baseline. managing at home with help of
family and friends, but does need additional services (see
below). Her niece is prefilling the meds.
HPT
BP stable
Panhypopit.
she is back on usual dose of Prednisone
Home Services
needs homemaker and transportation. refer to
Roanna Forman, CRS.
Pt wil RTC 1 month to see Dr. Jones.

Progress Note 07/06/99 Dr. DAVID Jones Service: General Med/Prim.Care
Date: 07/06/99
Signed by DAVID Jones, MD on 07/09/99
--------------- --------------- --------------- ---------------
Medications before July 6, 1999:
ALBUTEROL --2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth every day
BISACODYL 10 MG--One suppository rectally as needed twice a day
DOCUSATE 100 MG--One capsule by mouth three times a day
FLUOXETINE 10 MG--One by mouth every day
FOLIC ACID 1 MG--One tablet by mouth every day
IBUPROFEN 400 MG--One by mouth three times a day after meals as
needed
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
MAALOX --30ml by mouth as needed every 4 hours
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on July 6, 1999.
No medications prescribed on July 6, 1999.
--------------- --------------- --------------- ---------------
VS: Wt. 124.0 lbs BP 138/66
Subjective: Ms. Patient returns today for follow-up. This is the
first time I have seen her since her hospitalization in February
with confusion. At that time, we had sent her home with a lot of
services concerned that she would not be able to make it at home
even with these services. Since then she has improved markedly,
has no problems with confusion, is getting around on her own and
taking care of herself. She reports to me that her appetite is
improved.
Objective:
VS: Wt: 124 lbs. BP: 138/66
General: In no acute distress.
Neuro: Mental status - alert and oriented x3 (thought date
was 7/8). Knew the President of the U.S. w/o any
difficulty.
Assessment/Plan:
1) PSYCHOSOCIAL
I think at this point that it is almost certain that Ms. Patient's
symptoms in February were mainly related to depression. She
remains on Prozac and with this has had an improved appetite and
weight gain. She seems to be doing extremely well.
2) HYPERTENSION
Ms. Patient's blood pressure is in good control today.
3) HEALTH MAINTENANCE
Ms. Patient will return to see Nurse Spence in 2 months and me in 5
months.

Progress Note 09/22/99 Dr. DOREEN NP SIDDALL Service: General Med/Prim.Care
Date: 09/22/99
Signed by DOREEN SIDDALL, NP on 09/23/99
--------------- --------------- --------------- ---------------
Medications before September 22, 1999:
ALBUTEROL --2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth every day
BISACODYL 10 MG--One suppository rectally as needed twice a day
DOCUSATE 100 MG--One capsule by mouth three times a day
FLUOXETINE 10 MG--One by mouth every day
FOLIC ACID 1 MG--One tablet by mouth every day
IBUPROFEN 400 MG--One by mouth three times a day after meals as
needed
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
MAALOX --30ml by mouth as needed every 4 hours
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on September 22, 1999.
No medications prescribed on September 22, 1999.
--------------- --------------- --------------- ---------------
VS: Wt. 121.4 lbs
S; Follow-up: states she feels "terrific" except that she again
has leg cramps with walking which go away right away when she
stops to rest. She loves to walk and has been trying to go out
more. She would like to take the medication again. She thinks
it helped a little in the past, although our notes indicate that
it didn't make much difference.
Appetite is fine.
Soc - has a homemaker 1 hr once/week for housework
gorceries are delivered and son comes from NH q 1-2 weeks
to take her to do a big shopping
O: looks great
BP 126/60 HR 76
Lungs - clear
A/P; Leg Cramps
Disc with Dr. Jones. Will try Pentoxifylline again.
Pt said she has a supply at home and declined a new script today.
She will call to report how this is working and if it does not,
there is a new medication we may try.
Hypertension
BP stable
Psychosocial
Doing very well. Managing at home with present
services.
RTC early November, flu shot then.

Progress Note 11/02/99 Dr. DOREEN NP SIDDALL Service: General Med/Prim.Care
Date: 11/02/99
Signed by DOREEN SIDDALL, NP on 11/05/99
--------------- --------------- --------------- ---------------
Medications before November 2, 1999:
ALBUTEROL --2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth every day
BISACODYL 10 MG--One suppository rectally as needed twice a day
DOCUSATE 100 MG--One capsule by mouth three times a day
FLUOXETINE 10 MG--One by mouth every day
FOLIC ACID 1 MG--One tablet by mouth every day
IBUPROFEN 400 MG--One by mouth three times a day after meals as
needed
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
MAALOX --30ml by mouth as needed every 4 hours
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on November 2, 1999.
No medications prescribed on November 2, 1999.
--------------- --------------- --------------- ---------------
VS: Wt. 122 lbs
S: Ms Patient returns for follow-up: She states she feels "great,
I'm enjoying life". Sleeping well, appetite is "pretty good",
she has 2 meals a a day. She goes out with neighbors and
otherwise keeps busy at home.
The medication helped her leg cramps a little. She ran out but
said that the cramps have not been too bad and she doesn't really
want to take anything else right now, but if the cramps get worse
again she wants to try the new medication.
O: looks well, alert, oriented, made 2 confusing statements which
may just have been when she was thinking of someone else.
BP 130/60 HR 64
Lungs - clear
Ext - no edema
A/P; Hypertension
Bp well controlled
HM
flu vaccine 0.5cc given. See OMR for details.
Claudication
Prefers to be off of medication just now, but if sx
increase again wants to try the new medication.
Psychosocial
stable. managing at home.
RTC 1 month Dr. Jones

Progress Note 12/02/99 Dr. DAVID Jones Service: General Med/Prim.Care
Date: 12/02/99
Signed by DAVID Jones, MD on 01/03/00
--------------- --------------- --------------- ---------------
Medications before December 2, 1999:
ALBUTEROL --2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth every day
BISACODYL 10 MG--One suppository rectally as needed twice a day
DOCUSATE 100 MG--One capsule by mouth three times a day
FLUOXETINE 10 MG--One by mouth every day
FOLIC ACID 1 MG--One tablet by mouth every day
IBUPROFEN 400 MG--One by mouth three times a day after meals as
needed
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
MAALOX --30ml by mouth as needed every 4 hours
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on December 2, 1999.
Medications prescribed on December 2, 1999:
CILOSTAZOL 100MG--One by mouth twice a day for leg claudication
-- take on an empty stomach
--------------- --------------- --------------- ---------------
VS: Wt. 122.0 lbs (with shoes) BP 132/54
Subjective: Ms. Patient returns today for f/u. She tells me that
she is feeing fine; although, she continues to have some L knee
pain at times. She also continues to have intermittent
claudication and is interested in trying a new medication for
this. She did not get a lot of relief with Trental.
Objective:
VS: Wt: 122 lbs, BP: 132/54.
General: No acute distress.
Breasts: No axillary lympnadenopathy. No masses or
discharge.
Assessment and Plan:
1) CLAUDICATION: Ms. Patient is interested in trying medication
for this, and so I prescribed her cillostazol to see of this is
helpful. People generally are supposed to get benefit in 2-4
weeks. I will have her see Nurse Spence in 6 weeks to see how
she is doing with this. I asked her to call me if she notices
any side effects from the medication.
2) HYPERTENSION: Ms. Patient's BP is in excellent control.
3) HYPERCHOLESTEROLEMIA: I am checking a cholesterol, HDL, and
LFTs today.
4) PANHYPOPITUITARISM: I am checking a free T4 today.
5) HEMATOLOGIC: Ms. Patient has had an elevated white blood count
in the past. I am rechecking a CBC with differential today.
6) HEALTH MAINTENANCE: I ordered a mammogram today. Ms. Patient
is to return to see Nurse Spence in 6 weeks and me in 4 months.

Op Report 12/19/99 Dr. Tobin N. Gerhart
OPERATIVE REPORT
GERHART,TOBIN N.
Signed Electronically by GERHART,TOBIN on TUE DEC 28,1999 2:44 PM
Name: Patient, Sample Unit No.: 0121212
Service: Date: 12/19/1999
Date of Birth: 07/15/1910 Sex: F
Surgeon: TOBIN N. GERHART, M.D. 20-128
First Asst.: CONRAD WANG, M.D.
PREOPERATIVE DIAGNOSIS: Left intertrochanteric hip
fracture.
POSTOPERATIVE DIAGNOSIS: Left intertrochanteric hip
fracture.
OPERATION: Open reduction and internal
fixation, left intertrochanteric
hip fracture, using a Richards
compression screw and a 3-hole,
130 degree angle side-plate.
ANESTHESIA: General endotracheal anesthesia.
PROCEDURE IN DETAIL: The patient was given satisfactory
general endotracheal anesthesia, placed on a CHICK fracture
table and prepped and draped in the sterile fashion. The
fracture was reduced with longitudinal traction and internal
rotation. A 5 inch incision was made starting at the greater
trochanter, this was extended distally and was brought to the
skin and subcutaneous tissue, fascia lata and vastus
lateralis, to expose the proximal femur. A threaded K-wire
was drilled at a 130 degree angle centrally into the femoral
head on AP and lateral views. This was reamed to 95
millimeters, a 95 millimeter lag screw was inserted. A 130
degree side plate fixed to the lag screw and secured to the
proximal femoral shaft, using three self-tapping cortical
screws. The wound was irrigated with antibiotic saline
solution and closed using #1 Vicryl for the fascial layers, 2-
0 Vicryl subcutaneous and skin staples.
I certify that I was present in compliance with HCFA regulations.
TOBIN N. GERHART, M.D. 20-128
TNG/mbt/LPSI-bos
D: 12/21/1999
T: 12/27/1999
Job#: 10518

BETH ISRAEL DEACONESS MEDICAL CENTER
PATIENT DISCHARGE PLAN

PATIENT INFORMATION
Patient Name	Sample Patient
MRN#:	0121212
Case#:	0207834 7
DOB:	JUL 15,1910
Patient Status:	Admitted DEC 18,1999
Reason for Admission:	(L) HIP FRACTURE
Discharged to:
Attending Physician:

DISCHARGE INSTRUCTIONS
FINAL DIAGNOSIS
RECOMMENDED FOLLOW-UP
MAJOR SURGICAL OR INVASIVE PROCEDURES
CONDITION AT DISCHARGE

Disch Sum 12/21/99 Dr. Tobin N. Gerhart
DISCHARGE SUMMARY
GERHART,TOBIN N.
Signed Electronically by GERHART,TOBIN on WED DEC 22,1999 4:03 PM
Name: Patient, Sample Unit No.: 0121212
Admission Date: 12/18/99 Discharge Date: 12.21.99
Date of Birth: Sex: F
Service: ORTHOPEDIC
PRIMARY DIAGNOSIS:
1. Left intertrochanteric hip fracture.
HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old
female status post fall on the day of admission, and presented
with left hip pain. She denied any other injury and denied
any chest pain, shortness of breath or palpitations, and head
or neck injury or loss of consciousness. She was unable to
bear weight on her left lower extremity and x-rays were
notable for a left-sided intertrochanteric hip fracture. Pre-
injury she ambulated with occasional pain.
PAST MEDICAL HISTORY: Notable for:
1. Pan hyperpituitarism.
2. History of angina.
3. Hypertension with left ventricular hypertrophy. Echo in
2/99 was notable for an ejection fraction of 55%.
4. PPD positive.
5. Bilateral lower extremity claudications.
6. Left deep venous thrombosis.
7. History of chronic obstructive pulmonary disease.
8. Hypercholesterolemia.
9. Dementia/depression.
MEDICATIONS ON ADMISSION:
1. Albuterol and Atrovent prn.
2. Enteric coated aspirin, 325 milligrams PO q.d.
3. Lipitor, 10 milligrams PO q.d.
4. Colace.
5. Veloscazol, 100 milligrams PO b.i.d.
6. __________ 10 milligrams PO b.i.d.
7. Sublingual Nitroglycerin prn.
8. Synthroid, 50 micrograms q.d.
9. Prednisone, 5 milligrams PO q.a.m., 2.5 milligrams PO
q.p.m.
10. Verapamil, 240 milligrams SR q.d.
ALLERGIES: PENICILLIN, SULFA.
PHYSICAL EXAMINATION: Examination on admission was notable
for full range of motion at the neck. Bilateral upper
extremities were with full range of motion with no tenderness.
Lungs were clear. Heart was regular. Right lower extremity
was with full range of motion, nontender on exam. Left lower
extremity was shortened, externally rotated. Motor strength
was 5/5, gastric and tibialis anterior, extensor hallucis
longus and flexor hallucis longus. She had normal sensation
to light touch over the left lower extremity. She had
bilateral 2+ edema.
LABORATORY:
HOSPITAL COURSE: The patient was therefore admitted to the
surgical service. The medical consult service was contacted
for preoperative clearance. Their recommendations were for no
additional testing, to continue antihypertensive and cardiac
medications and use stress dose steroids. The patient was
therefore taken to the Operating Room on 12/19/99, for open
reduction and internal fixation of the left intertrochanteric
hip fracture by Doctor Tobin Gerhart. Please see that
operative note for details. Postoperatively the patient was
admitted to the surgical floor. She remained hemodynamically
stable with a postoperative crit that was adequate. The left
lower extremity was neurovascularly intact to exam. She
mobilized out of bed on postoperative day #1 with physical
therapy. She was initially maintained on IV pain medications.
She was subsequently weaned to PO pain medication without
difficulty. All of her drains were discontinued at the
appropriate time without complications. She was able to
tolerate a regular diet and void spontaneously without
significant difficulty. Physical therapy was consulted. She
will be weight-bearing as tolerated on the left lower
extremity with a walker. She was started on Coumadin
postoperatively for a target INR of 1.5 to 2 for 6 weeks
postoperative for deep venous thrombosis prophylaxis.
She will be discharged to rehabilitation when a bed is
available. She will be weight-bearing as tolerated on her
left lower extremity with physical therapy for gait training
and range of motion and strengthening exercises.
FOLLOW-UP: She should follow-up with Doctor Gerhart in 1-2
weeks time for postoperative check.
MEDICATIONS ON DISCHARGE:
1. Albuterol and Atrovent prn.
2. Enteric coated aspirin, 325 milligrams PO q.d.
3. Lipitor, 10 milligrams PO q.d.
4. Colace.
5. Veloscazol, 100 milligrams PO b.i.d.
6. __________ 10 milligrams PO b.i.d.
7. Sublingual Nitroglycerin prn.
8. Synthroid, 50 micrograms q.d.
9. Prednisone, 5 milligrams PO q.a.m., 2.5 milligrams PO
q.p.m.
10. Verapamil, 240 milligrams SR q.d.
11. Percocet, 1-2 tabs PO q 4 hours prn pain.
12. Coumadin, dose to be determined q.d. for a target INR of
1.5 to 2, for a total of 6 weeks postoperatively.
13. She is also to resume her PO Prednisone, 5 milligrams PO
q.a.m. and 2.5 milligrams PO q.p.m.
TOBIN N. GERHART, M.D. 20-128
Dictated by: CONRAD WONG, M.D.
TNG/CW/mbt/LPSI-bos
D: 12/21/99
T: 12/21/99
Job#: 10172

Disch Sum 12/21/99 Dr. Tobin N. Gerhart
DISCHARGE SUMMARY
GERHART,TOBIN N.
Signed Electronically by GERHART,TOBIN on WED DEC 22,1999 4:03 PM
Name: Patient, Sample Unit No.: 0121212
Admission Date: 12/18/99 Discharge Date:
Date of Birth: Sex: F
Service: ORTHOPEDIC
PRIMARY DIAGNOSIS:
1. Left intertrochanteric hip fracture.
HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old
female status post fall on the day of admission, and presented
with left hip pain. She denied any other injury and denied
any chest pain, shortness of breath or palpitations, and head
or neck injury or loss of consciousness. She was unable to
bear weight on her left lower extremity and x-rays were
notable for a left-sided intertrochanteric hip fracture. Pre-
injury she ambulated with occasional pain.
PAST MEDICAL HISTORY: Notable for:
1. Pan hyperpituitarism.
2. History of angina.
3. Hypertension with left ventricular hypertrophy. Echo in
2/99 was notable for an ejection fraction of 55%.
4. PPD positive.
5. Bilateral lower extremity claudications.
6. Left deep venous thrombosis.
7. History of chronic obstructive pulmonary disease.
8. Hypercholesterolemia.
9. Dementia/depression.
MEDICATIONS ON ADMISSION:
1. Albuterol and Atrovent prn.
2. Enteric coated aspirin, 325 milligrams PO q.d.
3. Lipitor, 10 milligrams PO q.d.
4. Colace.
5. Veloscazol, 100 milligrams PO b.i.d.
6. __________ 10 milligrams PO b.i.d.
7. Sublingual Nitroglycerin prn.
8. Synthroid, 50 micrograms q.d.
9. Prednisone, 5 milligrams PO q.a.m., 2.5 milligrams PO
q.p.m.
10. Verapamil, 240 milligrams SR q.d.
ALLERGIES: PENICILLIN, SULFA.
PHYSICAL EXAMINATION: Examination on admission was notable
for full range of motion at the neck. Bilateral upper
extremities were with full range of motion with no tenderness.
Lungs were clear. Heart was regular. Right lower extremity
was with full range of motion, nontender on exam. Left lower
extremity was shortened, externally rotated. Motor strength
was 5/5, gastric and tibialis anterior, extensor hallucis
longus and flexor hallucis longus. She had normal sensation
to light touch over the left lower extremity. She had
bilateral 2+ edema.
LABORATORY:
HOSPITAL COURSE: The patient was therefore admitted to the
surgical service. The medical consult service was contacted
for preoperative clearance. Their recommendations were for no
additional testing, to continue antihypertensive and cardiac
medications and use stress dose steroids. The patient was
therefore taken to the Operating Room on 12/19/99, for open
reduction and internal fixation of the left intertrochanteric
hip fracture by Doctor Tobin Gerhart. Please see that
operative note for details. Postoperatively the patient was
admitted to the surgical floor. She remained hemodynamically
stable with a postoperative crit that was adequate. The left
lower extremity was neurovascularly intact to exam. She
mobilized out of bed on postoperative day #1 with physical
therapy. She was initially maintained on IV pain medications.
She was subsequently weaned to PO pain medication without
difficulty. All of her drains were discontinued at the
appropriate time without complications. She was able to
tolerate a regular diet and void spontaneously without
significant difficulty. Physical therapy was consulted. She
will be weight-bearing as tolerated on the left lower
extremity with a walker. She was started on Coumadin
postoperatively for a target INR of 1.5 to 2 for 6 weeks
postoperative for deep venous thrombosis prophylaxis.
She will be discharged to rehabilitation when a bed is
available. She will be weight-bearing as tolerated on her
left lower extremity with physical therapy for gait training
and range of motion and strengthening exercises.
FOLLOW-UP: She should follow-up with Doctor Gerhart in 1-2
weeks time for postoperative check.
MEDICATIONS ON DISCHARGE:
1. Albuterol and Atrovent prn.
2. Enteric coated aspirin, 325 milligrams PO q.d.
3. Lipitor, 10 milligrams PO q.d.
4. Colace.
5. Veloscazol, 100 milligrams PO b.i.d.
6. __________ 10 milligrams PO b.i.d.
7. Sublingual Nitroglycerin prn.
8. Synthroid, 50 micrograms q.d.
9. Prednisone, 5 milligrams PO q.a.m., 2.5 milligrams PO
q.p.m.
10. Verapamil, 240 milligrams SR q.d.
11. Percocet, 1-2 tabs PO q 4 hours prn pain.
12. Coumadin, dose to be determined q.d. for a target INR of
1.5 to 2, for a total of 6 weeks postoperatively.
13. She is also to resume her PO Prednisone, 5 milligrams PO
q.a.m. and 2.5 milligrams PO q.p.m.
TOBIN N. GERHART, M.D. 20-128
Dictated by: CONRAD WONG, M.D.
TNG/CW/mbt/LPSI-bos
D: 12/21/99
T: 12/21/99
Job#: 10172

BETH ISRAEL DEACONESS MEDICAL CENTER
PATIENT DISCHARGE PLAN

PATIENT INFORMATION
Patient Name	Sample Patient
MRN#:	0121212
Case#:	0207963 5
DOB:	JUL 15,1910
Patient Status:	Admitted DEC 21,1999
Reason for Admission:	S/P HIP FRACTURE
Discharged to:
Attending Physician:

DISCHARGE INSTRUCTIONS
FINAL DIAGNOSIS
RECOMMENDED FOLLOW-UP
MAJOR SURGICAL OR INVASIVE PROCEDURES
CONDITION AT DISCHARGE

Progress Note 02/22/2000 Dr. DAVID Jones Service: General Med/Prim.Care
Date: 02/22/00
Signed by DAVID Jones, MD on 02/28/00
--------------- --------------- --------------- ---------------
Medications before February 22, 2000:
ALBUTEROL --2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth every day
CILOSTAZOL 100MG--One by mouth twice a day for leg claudication
-- take on an empty stomach
FLUOXETINE 10 MG--One by mouth every day
FOLIC ACID 1 MG--One tablet by mouth every day
IBUPROFEN 400 MG--One by mouth three times a day after meals as
needed
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
Medications DC'd on February 22, 2000:
ALBUTEROL --
Medications prescribed on February 22, 2000:
ALBUTEROL 17 GM--2 puffs inh as needed four times a day
IBUPROFEN 400 MG--One by mouth three times a day as needed --
take with food
--------------- --------------- --------------- ---------------
VS: Wt. 125.4 lbs (with shoes) BP 128/40
Subjective: Ms. Patient returns today for f/u. She was admitted
from 12/18/99 through 1/12/00 with a left hip fracture, that
required open reduction internal fixation. She tells me that
last week while walking into her front hall, she placed her cane
on some snow and fell again, banging her back and back of her
head. She has been having some back pain in the mid-back since
then. Other than that, she has actually been doing reasonably
well. She tells me that she is very scared now of walking around
when there is ice.
Objective:
General: in no acute distress, ambuling well with a cane
VS: WT: 125.4 lbs., BP: 128/40
HEENT: there is a small bump on the left occiput, that is
minimally tender
Back: there is mild spine tenderness at about T10/11
Assessment and Plan:
1) FALLS
Ms. Patient has now had a couple of falls, with injuries. I do not
think anything needs to be done for her current back pain, except
I gave her some ibuprofen today. I am concerned though about her
home situation. She is having rails installed in the front hall
and in other areas, but I also wonder whether she would benefit
from having a door that could be unlocked with a buzzer from
upstairs, so that she does not have to go down to the front hall
so often. She will be seeing Nurse Spence in 1 month, and at
that visit, we can check how Ms. Patient is doing with the rails in
the hall.
2) HYPERTENSION
Ms. Patient's BP is in good control, although her diastolic BP is
quite low. If she gets any dizziness, we should think about
backing off on her BP medication.
3) CLAUDICATION
Ms. Patient was interested in resuming cilostazol, which she felt
had been helping previously. I gave her a new prescription for
this today.
4) HEALTH MAINTENANCE
As above, Ms. Patient is to return to see Nurse Spence in 1 month.

Telephone 03/13/2000 Dr. MAUREEN RN LOONEY Service: General Med/Prim.Care
Date: 03/13/00
Signed by MAUREEN LOONEY, RN on 03/13/00
--Title: TRIAGE/ BACK PAIN
Pt reports she is having increasing back pain for the past 2
weeks since her fall. She denies numbness and tingling in her
legs but states pain has not been relieved by ibuprofen. Epi apt
tomorrow w/ Dr Jones.

Progress Note 03/14/2000 Dr. ROANNA FORMAN Service: General Med/Prim.Care
Date: 03/14/00
Signed by ROANNA FORMAN on 01/26/01
Called cab company to pick up patient after epi appt.

Progress Note 03/14/2000 Dr. DAVID Jones Service: General Med/Prim.Care
Date: 03/14/00
Signed by DAVID Jones, MD on 03/14/00
Subjective:
--------------- --------------- --------------- ---------------
Medications before March 14, 2000:
ALBUTEROL 17 GM--2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth every day
CILOSTAZOL 100MG--One by mouth twice a day for leg claudication
-- take on an empty stomach
FLUOXETINE 10 MG--One by mouth every day
FOLIC ACID 1 MG--One tablet by mouth every day
IBUPROFEN 400 MG--One by mouth three times a day as needed --
take with food
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on March 14, 2000.
Medications prescribed on March 14, 2000:
MIACALCIN 200U/DOSE--One spray in nostril every day -- alternate
nostrils daily
--------------- --------------- --------------- ---------------
Pt. comes in today for an episodic visit for back pain. She had
fallen several weeks ago and has had continued pain just in the
back, with no radiation, weakness, numbness, or bowel or bladder
sx's. Pt. was scheduled for an 8am appointment but her ride did
not come and she was waiting in the front hall of her building
for about 90 minutes after getting very little sleep last night.
Objective:
Gen: Appears tired.
Back: Difficult exam, but point of maximal tenderness seems to be
at about T12.
Neuro: Pt. is having trouble finding words as happened in the
past in the hospital, but was oriented x 3. Appears sleepy.
Back films: Compression fx of indeterminate age at L1.
Assessment & Plan:
--Title: BACK PAIN
Pt. has a compression fx at about the level where she is having
pain, and this probably occurred with the fall that occurred
about 3-4 weeks ago. She is not getting adequate pain control at
present. I am very hesitant to give her any narcotic medications
for pain as she could end up falling more or getting very
confused. I prescribed nasal calcitonin for her to try. She is
to let me know in a couple of days if she is not improving or has
any worsening. She is already scheduled to see Nurse Spence in a
few weeks.
--Title: PSYCHOSOCIAL
Pt. was having some problems finding words today, but she felt
strongly that she was able to get home without assistance. We
got her a cab voucher and ride and I paged her niece who called
after pt. had left and said she would check in and assist pt.
with medication.

Telephone 03/21/2000 Dr. DAVID Jones Service: General Med/Prim.Care
Date: 03/21/00
Signed by DAVID Jones, MD on 03/21/00
Pt. and pt.'s niece called. Back pain still present but more
tolerable. Now having left ankle pain with walking. Pt. is
seeing Nurse Spence in 2 days and can have ankle evaluated then.

Progress Note 03/23/2000 Dr. DOREEN NP SIDDALL Service: General Med/Prim.Care
Date: 03/23/00
Signed by DOREEN SIDDALL, NP on 03/24/00
--Title: LEFT ANKLE PAIN
--------------- --------------- --------------- ---------------
Medications before March 23, 2000:
ALBUTEROL 17 GM--2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth every day
CILOSTAZOL 100MG--One by mouth twice a day for leg claudication
-- take on an empty stomach
FLUOXETINE 10 MG--One by mouth every day
FOLIC ACID 1 MG--One tablet by mouth every day
IBUPROFEN 400 MG--One by mouth three times a day as needed --
take with food
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
MIACALCIN 200U/DOSE--One spray in nostril every day -- alternate
nostrils daily
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on March 23, 2000.
No medications prescribed on March 23, 2000.
--------------- --------------- --------------- ---------------
VS: Wt. 115.4 lbs (with shoes)
S: 89 YO pt s/p fall a few weeks ago, now with left foot pain.
She said her back is much better, and in fact has no back pain
now, but for the past few days she has had left ankle pain with
walking. The pain is particularly over the bone on the inner
part of her ankle. She has not fallen again. The fall was on her
back, not foot. She uses a cane for walking.
She has been staying with her niece until able to be on her own
again. She was surprised when I pointed out that she has lost
10# and said that since being with her niece she has been eating
more.."my niece makes sure I eat". She denies feeling
depressed.
She is accompanied by her niece's dgt today.
O: older woman having difficulty walkingb/c of foot pain, with
obvious weight loss
BP 108/60
Left foot - pain over medial malleolus; mild swelling; FROM
A/P; Left Ankle Pain
Most likely due to change in walking b/c of the back
pain, but given pain over the bone need to r/o fx. Pt sent for
x-ray with wet reading whcih was read as being negative with no
fx. Pt was given an ace and instructions to continue her pain
medication and elevate her legs when sitting. Instructions
reviewed with her niece incl to call/come in if pain increases or
any other changes.
Weight loss
F/U 2 weeks to check weight. She is now staying with
her niece, so intake will hopefully better. Discussed with Dr.
Jones.

Telephone 04/06/2000 Dr. DOREEN NP SIDDALL Service: General Med/Prim.Care
Date: 04/06/00
Signed by DOREEN SIDDALL, NP on 04/06/00
--Title: MISSED APP'T
Call to pt b/c she missed her app't today. She thought her app't
was tomorrow, but not able to keep anyway b/c her niece is out of
town.
We rescheduled for next week.
States that her ankle pain is gone, but her back is sitll
bothering her. SHe is back in her own home and has a homemaker
twice a week. She said that her niece is away only for a day and
otherwise "keeps an eye on me".

Progress Note 04/12/2000 Dr. DOREEN NP SIDDALL Service: General Med/Prim.Care
Date: 04/12/00
Signed by DOREEN SIDDALL, NP on 04/17/00
--------------- --------------- --------------- ---------------
Medications before April 12, 2000:
ALBUTEROL 17 GM--2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth every day
CILOSTAZOL 100MG--One by mouth twice a day for leg claudication
-- take on an empty stomach
FLUOXETINE 10 MG--One by mouth every day
FOLIC ACID 1 MG--One tablet by mouth every day
IBUPROFEN 400 MG--One by mouth three times a day as needed --
take with food
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
MIACALCIN 200U/DOSE--One spray in nostril every day -- alternate
nostrils daily
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on April 12, 2000.
No medications prescribed on April 12, 2000.
--------------- --------------- --------------- ---------------
S: Return visit for this 89 yo pt whom Dr. Jones and I follow.
Ms Patient states that the ankle pain is resolved and her back is
much better.
She said her appetite is good. She has Meals-on-Wheels once a
day and eats most of the meal. 24 hr recall: bkft juice,
cornbread, tea; lunch pork chop, collard greens, fruit; dinner -
meals-on-wheels.
Has a homemaker twice a week. Her son does her shopping every
1-2 weeks. She hasn't heard from her niece for a few days and
thinks she is out of town.
O: BP 106/70
Lungs - clear
oriented to address, birthdate, month and year (not day), niece's
name, place, MD's name.
A/P; Weight Loss
weight was not recorded today, but as I recall she
has lost another 4#. discussed with Dr. Jones. WIll cehck the
following labs: CBC/diff, LFTs, Alb, chem-7, Free T4. Pt asked
to RTC 2 weeks adn to bring in all of her medications, to make
sure she is taking the Prozac. Suggested that she ask her son ot
buy supplements such as Carnation Instant Bkft or Boost.
Falls
no further falls. back and ankle improving.
RTC 2 weeks

Progress Note 04/26/2000 Dr. DOREEN NP SIDDALL Service: General Med/Prim.Care
Date: 04/26/00
Signed by DOREEN SIDDALL, NP on 04/27/00
--------------- --------------- --------------- ---------------
Medications before April 26, 2000:
ALBUTEROL 17 GM--2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth every day
CILOSTAZOL 100MG--One by mouth twice a day for leg claudication
-- take on an empty stomach
FLUOXETINE 10 MG--One by mouth every day
FOLIC ACID 1 MG--One tablet by mouth every day
IBUPROFEN 400 MG--One by mouth three times a day as needed --
take with food
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on April 26, 2000.
No medications prescribed on April 26, 2000.
--------------- --------------- --------------- ---------------
VS: Wt. 113.4 lbs (with shoes)
S: 89 YO woman returns for follow-up:
"Most of the pain is gone." Still has some back pain after lying
down a while which she said goea away once she has been up for a
while.
- she started having Boost dietary supplemtent 3 cans/day and
states she also has 3 meals a day. Her son and niece bought the
supplements and neighbors also bring cooked food to her.
- she brought her med bottles today as I had asked last visit.
She knows the correct doses and said she is taking the Prozac,
although the bottle is empty. She said she took the last pill
today and was planning to call for a refill today as well as
another she needs to have refilled.
She said her niece prefills her meds every 2 weeks.
O: BP 112/60 HR 64
Lungs - clear
weight down another 2#, total 13# since 2/00.
A/P; Weight Loss
Labs from last visit unrevealing.
She was advised to continue the dietary supplements
and her app't with Dr. Jones was moved up to early May.
Need to check next visit to see that she did refill
the Prozac.

Progress Note 08/08/2000 Dr. DAVID Jones Service: General Med/Prim.Care
Date: 08/08/00
Signed by DAVID Jones, MD on 08/14/00
--------------- --------------- --------------- ---------------
Medications before August 8, 2000:
ALBUTEROL 17 GM--2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth every day
CILOSTAZOL 100MG--One by mouth twice a day for leg claudication
-- take on an empty stomach
FLUOXETINE 10 MG--One by mouth every day
FOLIC ACID 1 MG--One tablet by mouth every day
IBUPROFEN 400 MG--One by mouth three times a day as needed --
take with food
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on August 8, 2000.
No medications prescribed on August 8, 2000.
--------------- --------------- --------------- ---------------
VS: Wt. 119.8 lbs BP 108/44
Subjective: Ms. Patient returns today for f/u. She tells me that
she is having some discomfort in her left thigh or knee, but
overall feels like she is doing quite well. Her back pain has
resolved.
Objective:
VS: WT: 119.8 lbs., BP: 108/44
General: walking with a cane, but looking much improved
from last visit
Extr: left knee with full range of motion and
no tenderness, no erythema or effusions
Heart: RRR, III/VI systolic ejection murmur, with ? very
soft diastolic murmur
Assessment and Plan:
1) WEIGHT LOSS
Ms. Patient's weight is up 6 lbs. from her visit in April. This is
very reassuring. She looks much improved.
2) CARDIAC
Ms. Patient last had an echo about a year and a half ago. I am
rechecking this just to make sure that she has had no progression
of valvular disease. Her BP is low and she has a wide pulse
pressure. I would wonder about decreasing her Verapamil dose to
improve her BP, but this could potentially worsen her angina.
3) LEFT KNEE PAIN
This is a longstanding problem for Ms. Patient. I am somewhat
hesitant to have her take ibuprofen. I asked her to have her
niece, Debbie, give me a call so that we can discuss costs of
meds. I would prescribe Ms. Patient a COX-2 inhibitor, but I am not
sure whether the co-pay would be a significant financial burden.
4) HEALTH MAINTENANCE
Ms. Patient is to return to see Nurse Spence in 2 months, and me in
4 months.

Progress Note 08/31/2000 Dr. DOREEN NP SIDDALL Service: General Med/Prim.Care
Date: 08/31/00
Signed by DOREEN SIDDALL, NP on 09/05/00
--------------- --------------- --------------- ---------------
Medications before August 31, 2000:
ALBUTEROL 17 GM--2 puffs inh as needed four times a day
ASPIRIN E.C. 325 MG--One tablet by mouth every day
ATORVASTATIN CALCIUM 10 MG--One tablet by mouth every day
CILOSTAZOL 100MG--One by mouth twice a day for leg claudication
-- take on an empty stomach
FLUOXETINE 10 MG--One by mouth every day
FOLIC ACID 1 MG--One tablet by mouth every day
IBUPROFEN 400 MG--One by mouth three times a day as needed --
take with food
LEVOTHYROXINE 50 MCG--One tablet by mouth every day
NITROGLYCERIN 400 MCG (1/150 GR)--One under the tongue as needed
for chest pain, may repeat every 5 minutes x 2, then got to er
if pain persists
PREDNISONE 2.5 MG--2 by mouth every morning and one by mouth
every evening
VERAPAMIL SR 240 MG--One tablet by mouth every day
No medications DC'd on August 31, 2000.
No medications prescribed on August 31, 2000.
--------------- --------------- --------------- ---------------
VS: Wt. 117 lbs
S: 90 YO pt returns for follow-up stating that she feels
"wonderful". Her moved has moved in with her to help her so she
said she is now eating regularly, 3 meals plus snacks. She
enjoys his company and help but it is an adjustment from living
alone. She spends time on her porch and goes shopping with her
son 2-3 times/week. He is to start a new job this week.
She said she has no problems with sleeping. The left hip pain
occurs "only when I lie on the left side all night".
Denies lightheadedness or dizziness.
Needs dental work. asking if there is a dentist at BI.
Meds reviewed - knows the correct names and doses of all meds
except Proxac which did not sound familiar. She said that a new
medication was sent with the recent refills (has mail order)
which is one a day, but she doesn;t know the name.
O: BP 118/50 HR 68 reg
Lungs - clear
A/P; Weight Loss
Her weight is down over 2# since last visit, although
with son now living with her and preparing the meals, weight will
hopefully stablilze. WIll needs to watch closely.
Hypertension
BP stable. No sx of low BP.
Medications
Unfamiliar medication sent to pt with recent
refills. Asked pt to bring in all meds to next visit and to
also call me with the name of the new medication.
HM
referred to the Dental Clinic
F/U: plan per last note was to see me in 2 months and Dr Jones in
4 months, but for some reason this app' was scheduled early and
she was also given an app't to see Dr Jones next week. PA was
asked to cancel that app't and reschedule for 6 weeks (sooner in
order to check weight).

BETH ISRAEL DEACONESS MEDICAL CENTER
PATIENT DISCHARGE PLAN

PATIENT INFORMATION
Patient Name	Sample Patient
MRN#:	0121212
Case#:	0222280 4
DOB:	JUL 15,1910
Patient Status:	Admitted OCT 17,2000
Reason for Admission:	INTRAPARENCHYMAL BLEED
Discharged to:	:Coolidge House - Brookline 617-734-2377
Attending Physician:

DISCHARGE INSTRUCTIONS
FINAL DIAGNOSIS
RECOMMENDED FOLLOW-UP
MAJOR SURGICAL OR INVASIVE PROCEDURES
CONDITION AT DISCHARGE

Disch Sum 10/23/2000 Dr. David M. Jones
DISCHARGE SUMMARY
Jones,DAVID M.
Signed Electronically by Jones,DAVID on MON NOV 20,2000 3:39 PM
Name: Patient, Sample Unit No: 0121212
Admission Date: 10/17/2000 Discharge Date: 10/23/2000
Date of Birth: 07/15/1910 Sex: F
Service:
DISCHARGE DIAGNOSIS:
1. Hemorrhagic brain lesion
CHIEF COMPLAINT: Syncope
was in her usual state of health until the day of admission,
on 10/17/00, when she had a sudden loss of consciousness. We
don't know much about this event, as the patient can't give a
history. She went to Lawrence General Hospital, and regained
consciousness in the ambulance. She was noted to have
garbled speech and decreased movement on the left side. CT
of the head showed three areas of intraparenchymal
Medical Center for further evaluation.
In the Emergency Room, the patient was at first conversant,
and then somnolent. In the Emergency Room, the patient got
Dilantin, labetalol, and was seen by neurosurgery. The
patient stabilized in the unit. She was seen by neurology,
who advised head of bed 30 degrees, isotonic fluid only, SBP
to 160, continue Dilantin, get electroencephalogram, get MRI,
and increase prednisone. The patient denied pain, but
otherwise not answering many questions.
PAST MEDICAL HISTORY: Hypertension, left ventricular
hypertrophy, mitral regurgitation, status post left hip
fracture, panhypopituitarism of unclear etiology, chronic
obstructive pulmonary disease, hyperlipidemia, peripheral
vascular disease, claudication, history of deep venous
thrombosis, depression, history of dementia.
ALLERGIES: Penicillin, sulfa
MEDICATIONS ON ADMISSION: Aspirin 325 mg once daily,
albuterol metered dose inhaler, Lipitor 10 mg once daily,
________________ 100 mg twice a day, Verapamil 240 mg once
daily, prednisone 2.5 mg once daily, folate 1 mg by mouth
once daily, Prozac 10 mg by mouth once daily, Synthroid 50
mcg once daily, as needed ibuprofen.
Social history and family history were unobtainable.
PHYSICAL EXAMINATION: On admission to the Intensive Care
Unit, blood pressure was 170/59, pulse 73, respiratory rate
20, oxygen saturation 95% on 2 liters. Neurologic Glasgow
coma scale was 5/15, opens eyes to voice, vocalizes to pain,
and incomprehensible sound. Brain stem reflex intact except
had left gaze preference. Pupils bilaterally were 3 on
right, 2 on left, persistent clonus, withdrew to pain x 4,
but decreased response on the right. Deep tendon reflexes
were 3 in the right upper extremity, 2 in the left upper
extremity, 2 in the right lower extremity, 3 in the left
lower extremity, downgoing Babinskis bilaterally. Cardiac:
Rapid, regular, II/VI holosystolic murmur, loudest at the
apex. The lungs were clear to auscultation anteriorly. The
abdomen was soft, nontender, nondistended, normal bowel
sounds, guaiac negative brown stool. The extremities were
cool, with positive pulses faintly, no edema.
LABORATORY DATA: On admission, white count 19.3,
neutrophils 82, lymphs 13. Hematocrit 34.7, platelet count
129,000. Sodium 146, potassium 4.0, chloride 110,
bicarbonate 25, BUN 25, creatinine 1.0, glucose 102. INR
1.4, PTT 28. Electrocardiogram was normal sinus rhythm, left
ventricular hypertrophy, early R wave progression, flat T
wave in II, III and F.
HOSPITAL COURSE: This is a 90-year-old woman with an
episode of syncope.
1. Neurologic. The patient was stabilized in the Intensive
Care Unit. Her prednisone was increased to 80 mg once daily.
She was tapered down to 60 mg once daily, and is on a
prednisone taper now, to bring her back down to her usual
dose of 2.5 mg once daily. The patient was started on
Dilantin at 125 mg three times a day, with Dilantin levels in
the therapeutic range. The patient did not have an
electroencephalogram, however, the Dilantin was continued to
prevent seizures/convulsions. The patient may not need to be
on Dilantin long-term, especially as its long-term use has
complications such as osteogenesis, that could be critical in
an elderly patient. The patient had an MRI of her head on
10/18/00, showing three focal areas of intraparenchymal
hemorrhage involving the left anterior temporal lobe, left
parietal lobe, and callosum. These have not changed
significantly from a head CT one day earlier. No definite
abnormal enhancement was in the brain to suggest underlying
neoplastic lesions, although the examination was
significantly limited by motion. The patient had a CT of her
head without contrast on 10/17/00, showing high density areas
of left parietal, left anterior temporal, and corpus callosum
regions, less likely representing hemorrhagic masses from
metastatic disease, however, an alternative diagnosis could
be amyloid angiopathy. Also a small amount of high density
along the faults, likely hemorrhage. These hemorrhages were
also seen and are not significantly changed from prior CT of
same day from outside hospital.
After a long discussion with the family, the patient was made
Do Not Resuscitate/Do Not Intubate on 10/17/00. The etiology
of these hemorrhagic lesions in the brain included hemorrhage
vs. metastatic lesion. A metastatic workup, including lumbar
puncture and abdominal CT were suggested to the family. They
felt that, regardless of the etiology, they would not pursue
treatment if it was metastatic, i.e., they would not pursue
chemotherapy or even XRT, because they did not want to expose
their mother and aunt to frequent hospital visits, so no
further workup was done.
The patient was seen by the physical therapist in
consultation, who felt that acute rehabilitation would be the
best.
2. Cardiovascular. The patient has been hemodynamically
stable throughout her stay. She was restarted on Verapamil
240 mg by mouth once daily. She was continued on her
Lipitor. She was not restarted on her aspirin due to the
intracerebral bleeding.
3. Pulmonary. The patient had a chest film done on
10/17/00, showing moderate left ventricular enlargement with
no radiographic evidence of failure in area of increased
opacity of the right upper lobe, which most likely represents
atelectasis or scarring with associated elevation of the
minor fissure. Also noted atelectatic changes of the left
lower lobe and left apex. Again, these may represent areas
of scarring. No definite pulmonary nodules or suspicious
lesions visualized within the lung parenchyma. No definite
pleural effusions identified. The visualized soft tissue and
osseous structures are unremarkable. The patient maintained
her oxygen saturations on room air.
4. Gastrointestinal. The patient was kept nothing by mouth.
She had a nasogastric tube in place, which was
self-discontinued by the patient. The patient had a bedside
swallow done by nursing. She was able to tolerate thickened
and pureed foods without problems, and she eventually
advanced to a regular diet.
5. Hematology. Patient with elevated INR to 1.4. She
received vitamin K subcutaneously x 3. Patient with history
of anemia. Iron studies were sent showing LDH of 284, iron
of 66, total iron binding capacity of 254, B12 of 281, folate
of 8.8, haptoglobin is pending, and TRF 195.
DISCHARGE MEDICATIONS: Prednisone taper 20 mg by mouth x
two days on 10/23 and 10/24, then 10 mg by mouth x two days
on 10/25 and 10/26, 5 mg by mouth x two days on 10/27 and
10/28, then 2.5 mg by mouth once daily. Verapamil SR 240 mg
by mouth once daily and hold for systolic blood pressure of
less than 110, Lipitor 10 mg by mouth daily at bedtime,
Prozac 10 mg by mouth once daily, folate 1 mg by mouth once
daily, _______________ 10 mg by mouth twice a day to take on
an empty stomach, Synthroid 60 mcg by mouth once daily,
Dilantin 125 mg by mouth three times a day, albuterol two
puffs every four hours as needed.
FOLLOW UP: The patient should follow up with Dr. David Jones,
667-9600, within two weeks of discharge. The patient should
also follow up in the neurology clinic with Dr. David Anschel
in two weeks.
Jones,DAVID M.D.12.117
73-449
Dictated By: LISA SPROAT, M.D.
MEDQUIST36
D: 10/22/2000 23:14
T: 10/23/2000 00:27
JOB#: 03072

Letter 10/30/2000 Dr. MICHAEL RONTHAL Service: Neurology
--Title: Dr. Copello
October 30, 2000
Maria Copello, M.D.
Urban Medical Group
545a Centre Street
Jamaica Plain, MA 02130
RE: Sample Patient (012-12-12)
Dear Dr. Copello:
We had the opportunity to see Sample Patient in our Neurology Clinic
following her recent admission from 10/17/00-10/23/00.
She is a 90 year old woman with multiple medical problems and has
a history of dementia. She was admitted secondary to loss of
consciousness and decreased movement on her left side. She also
had incomprehensible speech but it is not clear whether this was
her baseline language function. Head CT and then subsequent MRI
of the brain with and without contrast revealed three
intraparenchymal hemorrhages. There was a 3 cm hemorrhage in the
left parietal lobe, a 1.5 cm hemorrhage in the left anterior
temporal lobe, and a 3 x 2 cm hemorrhage in the corpus callosum.
There was also some intraventricular blood as well and the
lesions did not enhance with gadolinium. Ms. Patient was started on
dilantin presumably for seizure prophylaxis and the family
apparently decided not to pursue further work-up as to the
etiology of the underlying hemorrhages as they felt that they
would not pursue treatment options and did not want to burden her
with multiple hospital visits.
She was subsequently discharged to Coolidge House on October 23
and presents today in follow up. Unfortunately, she is not
accompanied by any caretakes or family members and was brought to
the clinic by the EMT service. I attempted to call a niece but I
was not able to reach her. The nurse at the the Coolidge House
states that there has been no decline in her condition and she
was brought to the clinic for routine follow-up. Ms. Patient has
apparently had a decreased appetite. The rest of her history was
obtained from the discharge summary from her recent
hospitalization.
PMHX: hypertension, s/p left hip fracture, panhypopituitarism,
COPD, hyperlipidemia, peripheral vascular disease, h/o DVT,
depression, dementia
ALL: sulfa
MEDS: verapamil, lipitor, prozac, folate, synthroid, dilantin 125
mg po tid, albuterol prednisone taper to 2.5 mg po qd, colace,
promod.
Soc HX: Currently at Coolidge House but apparently lived with her
niece prior to her hospitalization. I am not able to obtain
history pertaining to her prior functional status.
PE: BP=142/82 P=72
Gen: Alert somewhat agitated lying on stretcher but in NAD
HEENT: Neck supple
Chest: CTA B
CV: RRR
Ext: no edema
Neuro: She is alert and moaning with no intelligible speech
production. She is able to follow some simple commands such as
moving her limbs. She has bliateral grasp reflexes. On cranial
nerve testing, her pupils are equal and reactive to light,
extraocular movements are intact, she has very mild left facial
weakness, and palate and tongue are midline. On motor
examination, she was not able to cooperate with formal strength
testing but she was able to move all four extremities with very
mild weakness of the right arm. Her sensation is grossly intact
to painful stimuli in all four extremities and her reflexes are
2+ and symmetrical in the upper extremities and 1+ and
symmetrical at both knees with absent ankle jerks and toes were
mute.
Impression:
Ms. Patient is a 90 yo woman with multiple medical problems and a
history of dementia who was recently admitted with multiple
intraparenchymal cerebral lesions of unclear etiology ? amyloid
angioparcy. Her exam now appears mainly unchanged from the time
of her admission except that she is perhaps moving her left side
better now. She continues to be confused and appears
encephalopathic. I am unclear as to how close she is to her
baseline at this time but suspect that once the hemorrhages are
completely resorbed that she may show some improvement in her
current exam. This may take a couple of months.
Given that the family does not want to pursue a work-up for the
etiology of the hemorrhage there is not much else that we can
offer unless her conditon were to change. I would recommend that
the dilantin be discontinued as she apparently has not had a
seizure and dilantin can have side effects.
Please do not hesitate to call us if you have any questions or
concerns.
Sincerely,
John Croom, MD,PHD
Patient was seen with Dr. Ronthal

Telephone 11/07/2000 Dr. DAVID Jones Service: General Med/Prim.Care
Date: 11/07/00
Signed by DAVID Jones, MD on 11/07/00
--Title: DEATH NOTE
Family called to report that Ms. Patient had died.