




    *  1  *

    HISTORY AND PHYSICAL REPORT

    Date of Admission: October 3, 1993

    CHIEF COMPLAINT: Difficulty breathing.

    HISTORY OF PRESENT ILLNESS: The patient is a 32-year-old,
white,
    widowed woman who comes in to the hospital complaining of
dyspnea.
    She has been having these symptoms for over one month now. 
The
    patient was told in her childhood that she exhibited some
    asthmatic symptoms, although she has never been formally
treated
    for same.

    PAST HISTORY: She had a tonsillectomy and adenoidectomy at
age 12.

    SOCIAL HISTORY: She is widowed; her husband died two years
ago.

    FAMILY HISTORY: Noncontributory.

    REVIEW OF SYSTEMS: Head, eyes, ears, nose and throat:  She
has a
    history of having upper respiratory tract infections every
year.
    No throat pain.  Chest:  She has had no chest pain.
    Gastrointestinal: Negative.  Extremities: Negative.
    Neurologic: Negative

    PHYSICAL EXAMINATION: General: She is a well-developed, well-
    nourished, white female.  She is well dressed.  Vital signs:
    Temperature 36 degrees Celsius, respirations 24, pulse 78 and
    blood pressure 128/80.  She is 5'6" tall.  Her weight is 165
    pounds.  Head, eyes, ears, nose and throat: Normocephalic and
    atraumatic.  Pupils equal, round and reactive to light and
    accommodation.  right pinna: There is some minimal swelling
and
    edema around the ear lobe;  it is nontender.  Nose: Mild
rhinitis.
    The throat is clear.  Neck: Supple and nontender.  Abdomen:
Soft
    and nontender.  Active bowel sounds.  Musculoskeletal:
Negative
    Neurologic: Patellar reflexes are 2+.  Deep tendon reflexes
are 2+
    bilaterally. Normal motor and sensory exam.  Skin: Mucous
    membranes are moist.  There is good auxiliary sweat.


   IMPRESSIONS: 1. Dyspnea.  2. Asthma.

   PLAN: Admit the patient to the Stokes wing of the hospital. 
Place
   the patient on a bronchodilator.  Dr. John smith ,
pulmonologist,
   will consult in the morning.

                             John Doe, M.D.
                             Attending Physician

    *   2   *


    RADIOLOGY  REPORT

   PA & LATERAL CHEST                DATE: June 4, 1992

    The pulmonary vessels are clearly outlined and are not
distended.
    There are not any typical signs of redistribution.  A few
    increased interstitial markings persist, but there are no
typical
    acute Kerley B-lines.  Most of the pulmonary edema and
effusion
    has otherwise cleared.  The chest is not hyperexpanded. The
    thoracic vertebrae show spurring but no compression.
    IMPRESSION: 1. No signs of elevated pulmonary venous pressure
or
    frank failure at this time.  2. Residual pleural effusion is
seen
    in the costophrenic sinus and posterior gutters, either
residual
    or recent congestive failure.

    BILATERAL MAMMOGRAMS               Date:  March 6, 1992

    Bilateral xeromammograms were obtained in both the
mediolateral
    and craniocaudal projections.  There is no previous exam for
    comparison.  There is slight asymmetry of the ductal tissue
in the
    lower outer quadrant of the right breast.  There are no
dominant
    masses, clusters of microcalcifications or pathologic skin
changes
    identified.

   IMPRESSION:  Normal bilateral mammogram.

                                          Ruth Brown, M.D.
                                          Radiologist

    *   3   *


   CONSULTATION REPORT

   DATE OF CONSULTATION : March 6, 1993

   REASON FOR CONSULTATION: Dyspnea and asthma.

   CONSULTING PHYSICIAN: Fred Lopez, M.D. Pulmonology

   ATTENDING PHYSICIAN: John Doe, M.D.

    The chart and pertinent physical findings have been reviewed. 
A
    chest x-ray was taken the morning after admission and showed
a
    possible pulmonary embolus.  Examination under fluoroscopy
was
    performed, and it was positive for poor capillary filling and
    showed a plug that had been forced into a smaller one, this
    obstructing the circulation.  Pulmonary studies revealed the
    patient to have decreased lung capacity, a pulse oximetry of
88%
    and a high FEV to FVC ratio.  The probable diagnosis at this
time
    is acute asthma and pulmonary embolism, causing dyspnea and
poor
    pulmonary circulation.  My recommendation is for a pulmonary
    angiogram and placement of a catheter.  Thank you for your
    referral.  I will follow this patient with you.

                                           Fred Lopez, M.D.
                                           Pulmonology Department


    *   4   *

DISCHARGE SUMMARY

December 1, 1994

PATIENT:Troy Wells    Hospital #55334

ADMITTED: November 21, 1994      DISCHARGED: November 30, 1994

CONSULTATION: Erin O'Brien, M. D.

SPECIAL PROCEDURES: None

SURGICAL PROCEDURES: Debride mall with application of Biobrane.

COMPLICATIONS: None

ADMITTING DIAGNOSIS: Burn trauma

DISCHARGE DIAGNOSIS: Partial thickness flame burn to the right
hand
and forearm.  Four percent total burn surface area.

HISTORY OF PRESENT ILLNESS: The patient is a 20 month old
caucasian
boy who was injured on November 21 when he fell into an open fire
pit
at home.  The patient was brought to Hillcrest Medical Center by
car
after receiving emergency treatment at Forest General Hospital
emergency room.  At that time he was given fluids p.o.,
resuscitation,
and debride mall.

HOSPITAL COURSE: The wounds appeared clean at the time of
admission
after debride mall with application of Biobrane.  Post Burn: The
boy
has done well with no true episodes of sepsis.  The wound has
remained
clean and the Biobrane has become completely adherent to the
burn surface.  The patient is discharged today to the care of his
parents.  The patient will be seen in my office for a wound check
December 5, and once again December 10.  He will be seen in the
plastic surgery burn clinic on December 15 by Erin O'Brien, M.D.

                                     Marie Morrison, M.D.


    *   5 *

    DISCHARGE SUMMARY

    This 3-year-old female was admitted with a three-day history
    of vomiting.  She was unable to hold anything down.  She was
    seen in the emergency room at another hospital one day prior
    to admission and was begun on Compazine suppositories without
    much help.  Exam on arrival at the emergency room revealed
    moist mucous membranes with tears present.  Her abdomen was
    soft with slight lower quadrant tenderness, right more than
    left.  There was no organomegaly or masses.  Bowel sounds
    initially hypoactive.  Surgical consult was obtained, and she
    was felt to not have a surgical abdomen.  Initial lab work
    revealed a CBC with hemoglobin of 14.8, hematocrit 44.6, WBC
   14,000 with 71% segs and 21% lymphs.  Blood sugar initially
   was 46 mg%.  Creatinine and BUN normal.  Urine specific
   gravity 1.030.  Initial electrolytes revealed sodium 130,
   chlorides 99, potassium 4, bicarb 12.  She was begun on IV
   fluids and kept n.p.o. except for sips of clear liquids over
   the next 48 hours.  She had no further emesis.  Her
   electrolytes improved with a slight rise in sodium and a rise
   in her bicarb to normal limits.  By the time of discharge she
   was tolerating p.o.  fluids well, was no longer lethargic, and
   had no further emesis.

   FINAL DIAGNOSIS: Acute gastroenteritis with mild to moderate
   hyponatremic dehydration.

   RECOMMENDATIONS: Advised mother to go very slowly in advancing
   diet from clear liquids to more solid foods.  Follow up p.r.n.


   *   6   *

   DISCHARGE SUMMARY

   ADMITTING DIAGNOSIS:
   1. Migraine.
   2. Cervical outlet syndrome with radiculitis.
   3.  Chronic anxiety.

    This 38-year-old man was admitted from the emergency room
    with a complaint of severe pain and numbness of the left
    face, left upper chest, and left shoulder.  The pain had been
   increasing in severity for the previous two or three days.
   Associated with this he had numbness of the left face and some
   blurring of vision in the left eye.  The patient had a severe
   headache with the present illness.  The patient had nausea but
   had not vomited with the present illness.  The patient has had
   similar spasmodic-type headaches in the past.  A chem panel
   was normal aside from a bilirubin of 1.9.  Sed rate was normal
   at 5.  A urinalysis was normal.  A CBC was normal.  X-rays of
   the cervical spine showed cervical spondylosis of mild degree
   with slight encroachment on the neural foramina of C5 and C6
   bilaterally.  A CT head scan was negative.  Chest x-ray was
   negative.  Paranasal sinus x-rays were normal.  The patient
   was advised that he probably has a variant migraine, and he
   was advised of the cervical spondylosis which could explain
   his history of neck pain with some radiation down the left
   arm, with numbness and tingling.  The day of discharge he was
   given Corgrad 40 mg daily to take for migraine.  He was
   advised that physiotherapy, neck traction, or neck collar
   could be used for his cervical spondylosis.

   * 7 *

   HISTORY AND PHYSICAL EXAMINATION

   CHIEF COMPLAINT: Hematemesis.

   HISTORY OF PRESENT ILLNESS: This 49-year-old white female is
   readmitted to this hospital with hematemesis.  The patient has
   a long history of abdominal pain which has been diagnosed as
   chronic pancreatitis in the past.  However, an ERCP revealed a
   normal pancreas.  She has continued to have abdominal pain,
   nausea, and vomiting, and a small bowel series two weeks prior
   to admission showed a terminal ileal stricture consistent with
   Crohn's disease.  The patient was begun on Azulfidine and then
   prednisone, but nausea, vomiting, and diarrhea persisted, but
   there has been no weight loss.  Bright red blood was brought
   up in yesterday's vomitus, and the patient was admitted.  The
   review of systems, family history, past medical history, and
   social history are available in the most recent record.

    PHYSICAL EXAMINATION: Reveals an alert white female in no
    obvious distress.  Her blood pressure is 112/70.  The eyes
    are nonicteric.  The conjunctivae are not pale.  The neck is
    supple.  The thyroid is not enlarged.  The carotids are
    equal.  There is no bruits.  The lungs are clear to
    auscultation and percussion.  The heart is not enlarged.
    There are no murmurs or gallops.  The breasts contain no
    masses.  The axillae are free of nodes.  The abdomen is soft.
    There is mild diffuse tenderness but no enlarged organs.
    Bowel sounds are normal.  Rectal is negative.  Extremities
    reveal no edema.

    IMPRESSION: Probable gastritis.

    * 8   *

    DISCHARGE SUMMARY

    FINAL DIAGNOSIS: Pneumonia

    HISTORY: This 56-year-old black male with insulin dependent
    diabetes and hypertension developed cough, chills, dyspnea,
    and fever in the 24 hours prior to admission.  He was seen
    initially at the (blank) and was found to be moderately
    hypoxic on arterial blood gases.  A chest x-ray done there
    showed a left lower lobe infiltrate.  He was admitted for
    treatment of pneumonia.

    PHYSICAL EXAMINATION: Examination on admission revealed the
    patient to be in mild respiratory distress with temperature
    of 102.4, blood pressure 182/92.  Examination was essentially
    negative except for the chest which disclosed rales in the
    left lower lobe with a few scattered rhonchi.

    LABORATORY DATA: Laboratory work while in the hospital
    included two negative blood cultures; a sputum culture
    growing normal flora; a sputum Gram stain showing many wbc's
    and epithelial cells, many gram-positive cocci and gram-
    positive rods, moderate gram-negative rods, and a few gram-
    negative diplococci.  A urinalysis disclosed 3+ albumin,
    otherwise negative.  Admission CBC showed a white blood count
    of 4.8 thousand with 58% segs, 7% bands, 24% lymphs, 8%
    monos, 1% eos, and 2% basos.  The hemoglobin was 13.6 and
    hematocrit 41.3.  Admission chemistry-12 was within normal
    limits except for a glucose of 128 and a CPK of 716.  Chest
    x-ray done in hospital showed extensive pneumonic infiltrate
    involving the right midlung and lower lung zones with mild
    cardiomegaly.  There was probable involvement of the superior
    segment of the left lower lobe as well.  Admission
    electrocardiogram suggested the possibility of inferior
    ischemia, and there were minimal criteria for anteroseptal
    infarction.  A followup electrocardiogram done the second
    hospital day was considered normal, with nonspecific ST and
    T-wave changes in the inferior leads.  Blood gas analysis
    done on room air showed a pO2 of 63, pH 7,.42, pCO2 44, and
    actual bicarbonate of 28.2.

    HOSPITAL COURSE:  The patient was hydrated with IV hydration,
    given Bronkosol via small-volume nebulizer, and started on
    erythromycin 1 gm q.6h intravenously.  He was maintained on
    his regular dose of insulin, and his diabetes remained in
    good control throughout the hospitalization.  Over the course
    of the hospitalization he developed no complications, his
    respiratory complaints gradually diminished, he was switched
    to oral erythromycin and was finally sent home in good
    condition on erythromycin 500 mg q.i.d., Theo-Dur 300 mg
    b.i.d., and Tenormin 50 mg q.d., with instructions to return
    in 10 days for an office visit.

    *  9  *

    DISCHARGE SUMMARY

    FINAL DIAGNOSES: 1. Abdominal pain secondary to acute
    cystitis.  2.  Organic brain syndrome.  3.  Pernicious
    anemia.  4. History of seizure.

   ADMISSION HISTORY AND PHYSICAL: See hospital notes.  Briefly,
   this 78-year old white female was just discharged from this
   hospital after treatment for weakness with urinary tract
   infection, and a fractured clavicle after falling from an
   apparent seizure.  She was admitted because of two nights of
   lower abdominal pain, On exam she was afebrile, with organic
   brain syndrome, which was her usual.  A significant abdominal
   exam revealed some tenderness in the lower abdomen without
   rebound.

    LABORATORY DATA AND HOSPITAL COURSE:  The patient remained
    afebrile throughout the admission, and her abdominal pain
    subsided and stayed resolved.  Her white count was normal at
    9,800, hemoglobin 12.8, hematocrit 37.7.  Urine culture grew
    E.  coli sensitive to all antibiotics.  Her chemistry
    profiles were unremarkable with the exception of some
    borderline hypokalemia.  She did have a markedly elevated
    alkaline phosphatase, which was felt to be secondary to her
    recent clavicle fracture, and borderline elevated GGTP at 66
    and 67.  Her amylase was normal at 65..  Abdominal series was
    unremarkable except for apparent gallstones.  Because of
    clinical improvement after observation and initiation of
    antibiotics for the urinary tract infection, the patient and
    son both desired to have her go home and be followed as an
    outpatient.  DISCHARGE PLANS: Discharged home on Keflex for
    another week.  She was on no other regular medications.  She
    is to follow up in my office in approximately a week.

    *  10 *

    DISCHARGE SUMMARY

    FINAL DIAGNOSES: Intrauterine pregnancy at six weeks.
    Hyperemesis gravidarum.

    CONDITION ON DISCHARGE: Improved.

    DISPOSITION: The patient is to return to my office in two
    weeks for followup examination.  She is given 12 Thorazine 25
    mg suppositories to be used one or two q.6h.  p.r.m.

    SUMMARY: The patient is a 32-year-old Eurasian female,
    gravida 3, para 1, ab 1.  The patient was seen by me
    complaining of epigastric distress, worse after meals,
    unassociated with nausea.  During the ensuing 10 days the
    patient developed nausea and vomiting and was unable to eat
    or even drink fluids.  This was not controlled by the use of
    routine medications.  Outpatient electrolytes and CBC were
    obtained; these were within normal limits.  The patient was
    treated with Compazine suppositories without success.
    Because of this it was felt that she should be admitted for
    control of the vomiting and hydration.  After admission to
    the hospital, the patient was treated with electrolyte
    solutions and vitamins, as well as Thorazine suppositories.
    These suppositories seemed to control the vomiting, and the
    patient was able to consume liquids and some small amounts of
    food.  All blood studies while in the hospital were within
    normal limits.  Seemingly under control, the patient was
    discharged on the third hospital day.

     *  11 *

     Discharge Summary:

     This is a 63 year old female who was admitted
    because of a recent fall sustaining head injury.  She was
    seen by Dr.  consultation, who felt that she had post-
    traumatic vertigo.  A CAT scan was done and showed no
    evidence of subdural hematoma.  The patient had a large
    hematoma of the left eyelid.  Other laboratory evaluation
    revealed a negative rib series, negative IVP, normal upper GI
    Series and cholecystogram.  Barium Enema showed mild
    diverticulosis of the sigmoid colon without evidence of
    diverticulitis.  Hemoglobin 13.4. White Count 6,300.
    Urinalysis 3 to 5 white cells per high-power fields. SMA 17
    was within normal limits.

    IMPRESSION; 1.HEAD INJURY 2. Soft tissue injury with hematoma
    to left eyelid 3. Post traumatic vertigo 4.  Abdominal and
    flank pain, etiology undetermined.


    *  12  *

    DISCHARGE SUMMARY

    The patient is a 57-year-old white married female who was
    admitted to the hospital because of dyspnea, weakness, and a
    five-pound weight gain over the previous 24 hours.  Initial
    laboratory workup at the time of admission revealed a
    potassium of 2.9, sodium 135, chlorides 100, CO2 24.
    Urinalysis was negative except for 8-10 WBCs.  There were
    only occasional bacteria.  The arterial gases showed a pO2 of
    75, PCO2 of 35, pH7.45, bicarb 24.9.  The CBC revealed a
    hemoglobin of 13.5 gm, white blood count 8600, with a normal
    differential.  The chem panel showed a cholesterol of 257,
    triglycerides 224, a fasting alkaline phosphatase elevated to
    355.  The phosphorus was up to 5.2, BUN 30, creatinine 1.4,
    and the potassium on the chem panel was 3.2 on the morning
    after admission,  The chem panel was otherwise normal.
    Ventilation profusion lung scan showed a low probability for
    pulmonary emboli and was compatible with mild COPD and
    cardiomegaly.  The chest x-ray showed no evidence of
    active parenchymal disease and was essentially unchanged from
    previous x-rays.  The patient's weight decreased from 53.7 kg
    to 51.9 kg during this hospitalization.  Her blood pressure
    has remained essentially normal.  She was initially treated
    with nasal oxygen for the dyspnea, but toe oxygen was
    discontinued yesterday and she has had no further dyspnea.
    She had one brief episode of anginal chest pain yesterday
    which was relieved by nitroglycerin.  At that time, she
    developed PVCs intermittently.  Last night and this morning
    she has had essentially no PVCs and has been comfortable and
    without recurrence of chest pain.  EKG showed no acute
    changes.  Some workup for primary hyperaldosteronism has been
    initiated, including baseline recumbent plasma renin.  This
    is being done because the hypokalemia does not appear
    adequately explained at this point, although the history of
    renal damage is considered.

    DISCHARGE DIAGNOSES: 1.  Arteriosclerotic heart disease with
    angina pectoris and dyspnea, probably secondary to mild
    congestive heart failure, resolved.  2.  Hypokalemia,
    etiology uncertain, rule out primary hyperaldosteronism, rule
    out renal potassium-losing state.

    DISCHARGE PLAN: The patient will be discharged on her current
    regimen, including Norpace 150 mg q.6h., Procardia 20 mg
    q.6h., 20% KCI 15 cc q.i.d., digoxin 0.125 mg q.a.m.,
    nitroglycerin paste 1 1/2 inches q.6h., Surmontil 25 mg
    t.i.d., and nitroglycerin 0.4 mg sublingual p.r.n., Benadryl
    50 mg q.5-6h. p.r.n.

    *  13 *

    DISCHARGE SUMMARY

    ADMITTING DIAGNOSIS: Severe rash due to penicillin allergy.

    DISCHARGE DIAGNOSIS: Severe rash due to penicillin allergy.

    This patient was admitted with a severe generalized rash
    which had occurred as a result of use of oral penicillin
    tablets.  In addition to the rash, she was seen in the
    emergency room the night before admission with diarrhea, with
    associated tarry stools.  The penicillin had been given for a
    felon with cellulitis of the finger, from which 3 cc of pus
    had been drained.  The rash had progressed for 36 hours
    before admission,  She had been treated with Decadron 2 mg
    daily by mouth for 24 hours before admission, but this had
    not provided relief from the severe itching and discomfort.
    Within 24 hours after admission the patient had improved
    considerably, and the rash was 50% better.  Forty-eight hours
    after admission the rash had cleared completely and she was
    discharged.  The mature felon of the thumb had improved
    considerably also by that time.  A chem panel showed a high
    phosphorus of 1.1, high BUN at 27.  Serum albumin was low at
    3.2, serum protein low at 5.9.  Otherwise the chem panel was
    normal.  The CBC showed a white count of 15,800, with 82%
    polys, including 19% bands.  Her urinalysis was normal. She
    was treated with Benadryl 50 mg every 8 hours, and morphine
    was given for itching and discomfort.  She had no diarrhea
    while she was in the hospital.  Her temperature, pulse, and
    blood pressure remained normal in the hospital.  She was
    discharged without further treatment.

    *  14  *

    DISCHARGE SUMMARY

    The patient is a 30-year-old male alcoholic who has been
    consuming approximately three bottles of wine per day for the
    past five years, who was admitted for detoxification from
    alcohol.  He had no history of active hallucinations.  He did
    complain of nausea and vomiting for two days prior to
    admission, with upper abdominal pain radiating through to the
    midback.  The patient's past history was not remarkable from
    a medical standpoint, with the exception of a fractured left
    ankle.  On examination he appeared very anxious, with a mild
    gross tremor.  He was alert, oriented, and cooperative.
    Examination revealed epigastric tenderness.  There were no
    abdominal masses.  His liver was not clinically enlarged.  A
    liver edge was just palpable in the right upper quadrant and
    mildly tender.  There was a diffuse pharyngitis of the
    throat.  Chest was clear to percussion and auscultation.
    Examination of the cardiovascular system was unremarkable.
    Pulse was 100 and regular, blood pressure 130/70.
    Neurological examination revealed hyperactive but symmetrical
    deep tendon reflexes.  Treatment consisted of intravenous
    fluids, Tagamet, Valium orally and IV, thiamine IM, and
    vitamin B complex per os.

    HOSPITAL COURSE was uneventful, with gradual improvement in
    the patient's symptoms.  At the time of discharge he was
    consuming a normal diet, his abdominal pains had subsided,
    and his back pain had disappeared.  He stated that he felt
    quite anxious but was sleeping well.

    DISCHARGE PLANNING: The patient will be discharged today.  He
    has agreed to become involved in an ongoing program.  He will
    be discharged home on Valium 15 mg q.i.d. x 2 days, reducing
    to 10 mg q.i.d. x 3 days, finally 5 mg q.i.d.  In addition he
    will be continued on Tagamet 300 mg q.i.d. and Theragram-M
    multiple vitamin capsule t.i.d.  He will be seen in followup
    in family practice in three days' time.

    *  15 *

    CONSULTATION REPORT

    CHIEF COMPLAINT, HISTORY OF PRESENT ILLNESS: This 54-year-old
    Caucasian female was referred by her daughter to our office
    for evaluation.  The patient complains of a one- to two-year
    history of decreasing energy levels and associated
    depression.  The patient feels like she can hardly get
    through the day.  Although she sleeps fairly well, she feels
    tired on awakening.  The patient feels her mental acuity and
    her memory are reasonable.  There is no constipation, but
    there are skin changes and cold intolerance noted.  The
    patient states that she was told that she had a questionable
    "low thyroid" many years ago and took pills for this.
    Presently she takes no medications for this particular
    problem.  The patient denies at any time any pain or
    tenderness in the neck, no dysphagia, hoarseness, or
    enlargement of the thyroid gland.  With regard to the
    patient's stamina, she feels that she has no excessive
    shortness of breath with minimal exercise, nor chest pain,
    claudication, or ankle swelling, nor associated breathing
    disturbances at night.  The patient's last menstrual period
    was at age 50 or 51, and presently the patient denies hot
    flashes or urinary symptoms but does have dyspareunia.  PAST
    MEDICAL HISTORY: Serious illnesses, allergies, operations are
    denied.  Medications taken are Tylenol with codeine and an
    occasional Flexeril for fairly chronic low back pain (without
    neurological referral).

    REVIEW OF SYSTEMS: The patient's review of systems refers
    essentially to history of present illness.

    FAMILY HISTORY: Noncontributory.

    SOCIAL HISTORY: The patient smokes about a pack a day.  She
    drinks probably more than the normal amount of alcohol.  The
    patient gets a minimal amount of exercise but does work out
    at a gym two times a week and plays occasional tennis.  The
    patient is a housewife.

    PHYSICAL EXAMINATION: Physical exam reveals a pleasant,
    cooperative 54-year-0ld Caucasian female in no acute
    distress.  Blood pressure is 158/78 in the right arm lying,
    pulse is 108.  Skin is warm, smooth, with palmer sweating.
    HEENT: Not much dental work is noted; teeth in fair repair.
    EOMs are full.  PERRL.  Fundi benign.  Ears, nose, and throat
    are otherwise normal.  Neck is supple, nontender.  Carotids
    symmetrical without bruit.  A palpable right lobe is noted;
    no tissue is palpable on the left.  There is no bruit or
    venous hum noted.  Chest is clear.  Heart reveals a regular
    rhythm without murmur or gallop.  Rate is 100. Abdomen is
    soft, otherwise unremarkable.  Extremities: Pulses are
    present.  No clubbing, cyanosis, or edema appreciated.
    Neurological exam: Deep tendon reflexes 2+/4+ with brisk
    return phase.  No gross motor or sensory deficits
    appreciated.  Breast exam reveals no discrete masses or
    abnormalities.

    DATA BASE: No recent data base is available to this
    physician.

    ASSESSMENT: 1. A 54-year-old Caucasian female presenting
    without acute problems but with a long history of tiredness
    and depression.  The patient does have a past history of
    treatment for some form of thyroid problem.  However, at this
    time, if anything the patient appears to be somewhat
    clinically hyperthyroid with a pulse of 108 at rest and
    somewhat smooth, moist skin, and with a palpable right lobe
    of the thyroid gland.  Physical examination is otherwise
    unremarkable, and clearly the level of thyroid function will
    need to be tested with appropriate laboratory work.  2. The
    patient is clearly postmenopausal and apparently having some
    dyspareunia.  The patient also has a very reasonable dairy
    product intake, but we will discuss the importance of calcium
    supplementation in this postmenopausal state.  PLAN: Baseline
    laboratory data will be drawn to include chemistry panel, CBC
    with differential, thyroid function tests, and urinalysis.

    * 16 *

    DISCHARGE SUMMARY

    This 58-year-old white female was admitted to the hospital
    because of acute diarrhea, mausea, vomiting, abdominal pain,
    vertigo, and fever.  Cultures of her stool isolated
    Campylobacter jejuni.  She was treated with IV fluids,
    control of electrolytes, and initially on admission,
    cephalosporins; however, this was changed to erythromycin on
    discharge.  The patient was also noted to have a urinary
    tract infection, and this was treated also.  Her white count
    on admission was 10,000, with a shift to the left on the
    differential count.  The patient brought in some fish sticks
    which she felt were the cause of her infection, but these
    failed to culture out Campylobacter, and Enterococcus was the
    only organism found.  Chemistry studies showed a blood sugar
    of 114, and they were otherwise normal.  Other medications in
    the hospital included Desyrel and Lomotil.  She will be
    discharged to home with Tagamet, Tylenol, and erythromycin.


    * 17 *

    DISCHARGE SUMMARY

    REASON FOR ADMISSION: Increasing cough and breathlessness,
    with sputum production and high fever.

    HISTORY PRIOR TO ADMISSION: This is a 79-year-old white male
    with a long history of known diagnoses including (1) chronic
    silicosis; (2) status post left thoracotomy for removal of
    multiple cocci nodules; (3) arteriosclerotic cardiovascular
    disease, status post aortocoronary bypass with permanent
    pacemaker implantation; (4) mild chronic seizure disorder
    controlled with Dilantin and phenobarbital.  He has a history
    of daily cough with minimal sputum production over the last
    few years and has mild recurrent episodes of increasing
    breathlessness with purulent sputum.  In the few days prior
    to his admission he had been on a fishing trip where he began
    to have increasing cough, purulent sputum production, and
    daily fevers.  He was followed as an outpatient with what
    should have been appropriate medications; however, he did not
    improve substantially.  He was admitted because he continued
    to have temperatures to 101 or 102 daily.  Chest x-ray on
    admission did not verify acute pneumonia.  However, sputum
    was noted to be purulent, and the presumed diagnosis was that
    of acute bronchitis.  Admission laboratory work showed a
    white count of 131,100 with 59 segs, 13 bands, 17
    lymphocytes, 10 monocytes, and 1 basophil.  Hemoglobin was
    13.6, hematocrit 42.0.  Urinalysis was not remarkable.
    Gran's stain of the sputum showed many white cells, many
    gram-positive cocci, a moderate number of gram-negative rods
    and a few gram-positive rods, and gram-negative diplococci.
    Subsequent sputum culture revealed normal flora and
    Hemophilus influenzae.  Profile-1 was within normal limits
    with the exception of a minimally elevated glucose at 127,
    this drawn in a nonfasting state.  Electrocardiogram was
    essentially changed from its previous state in that now there
    is patient overriding the pacemaker.  No acute or disturbing
    changes were noted.

    HOSPITAL COURSE:  Mr. (  ) was started on oral
    bronchodilators and oral antibiotics and respiratory therapy
    treatments.  He defervesced over the next 36 hours and has
    had minimal temperature spikes to approximately 100 for the
    past 24 hours.  He states that he is back to his baseline,
    feeling as well as he has in a number of months.  For that
    reason he is ready to be released at this time, significantly
    improved from his admission condition.

    INSTRUCTION ON DISCHARGE include the following.  Medications:
    (1) Theo-Dur 200 mg twice daily, (2) Ceclor 250 mg 3 times
    daily for five days, (3) Nitro-Bid 6.5 mg twice daily, (4)
    nitroglycerin as necessary, (5) Dilantin with phenobarbital
    prior to sleeping at night.  He is to be on no particular
    diet.  He is to gradually increase his physical activity
    until he is back to normal.

    FINAL DISCHARGE: 1. Acute bronchitis 2.  Probable moderate
    chronic obstructive pulmonary disease.  3.  Biopsy-proven
    silicosis.  4.  Status post left thoracotomy for removal of
    coccidioidomycosis nodules.  5.  Status post aortocoronary
    bypass with implantation of permanent pacemaker.  6. History
    of ulcer surgery in the past.  7.  History of cervical spine
    surgery.

    CONDITION ON DISCHARGE: Improved.

    NOSOCOMIAL INFECTIONS: None.

    CONSULTATIONS: None.

    COMPLICATIONS: None.

    *  18  *

    DISCHARGE SUMMARY

    This 72 year old lady was admitted to the hospital with a
    stroke causing aphasia and during the hospital stay, because
    of auricular fibrillation being the possible source of
    vascular aneurysm of the central nervous system, it was
    elected to start her on anticoagulant therapy. She is now on
    a effective dose of Coumadin and will be maintained on the
    same dose. There is no other real significant peripheral
    neurological loss and she is now being moved for supportive
    care for the next several weeks and then will be transferred
    from there back to her summertime residence.  The speech
    therapy will be continued in the extended nursing care
    facility.

    *  19 *

    DISCHARGE SUMMARY

    DIAGNOSIS: Severe Arthritis

    SUMMARY OF HOSPITALIZATION: This is a 75-year-old white
    female admitted with history of arthritis.  However, pain is
    greatly increased in both knees, left greater than right, and
    she is experiencing night sweats.  Admitted to hospital for
    relief of symptoms and evaluation from orthopedist.  The
    patient was seen in consultation, which was suggestive of
    degenerative arthritis, left knee, with increasing inability
    with cope with usual functional daily demands of living. The
    patient was put on physical therapy, deep heat, and
    ultrasound, to continue her ambulatory status using walker as
    necessary.  Patient given Decadron prior to admission
    intramuscularly, and therefore intra-articular injection
    deferred at present time.  Suggestion of social service
    consult taken.  SED RATE noted to be 18. Admitting CBC 8,900
    with 82 SEGS and 10 BANDS, 6 LYMPHS, HMG and HCT 12.4 and
    36.8.  URINE Negative. CHEM PROFILE essentially normal with
    slightly elevated glucose of 120.  The patient was on
    Prednisone 5mg one BID., Lasix, Ducolax, Restroil.  Motrin
    started, 600 mg p.o. TID.  Bowel care of choice.  Ativan 1mg
    begun.

    DISCHARGE: To continue Motrin 600mg tid, and Ativan 1mg at
    bedtime for sleep as needed.  Increase activity as tolerated.
    Social Service helpful regarding fear of returning to home
    and inability to cope.

    FINAL DIAGNOSIS: Arthritis Anxiety Depression

    *  20  *

     DISCHARGE SUMMARY

     This 77-year-old housewife entered with acute faintness and
     rapid heart action.  She had been taking multiple Anacins
     and Excedrins for headache and was severely constipated,
     complaining of acute fluttering in the chest.  When seen she
     did not present with audible paroxysmal tachycardia, but in
     view of her history and description of the event, this
     appears most likely.  On laboratory examination, her urine
     was essentially normal as was her hemogram except for
    predominance of lymphocytes and some reactive lymphs.  Her
    sodium was depleted to 130; she had taken some diuretics.
    Uric acid was low at 3, and her blood gases showed oxygen
    tension of 75, slightly reduced, with CO2 of 42, pH of 7.4,
    tending to rule out hyperventilation syndrome as the cause of
    her basic problem.  Her chest x-ray was likewise normal.
    Because of chronic headache, sinus films were obtained, which
    showed lack of pneumatization of the frontal sinuses, and x-
    ray of the cervical spine showed extensive degenerative
    narrowing of C5 through T1.  Her cranial CT scan showed
    diffuse atrophy and no localizing abnormalities.  She had, in
    a previous tracing in the hospital, Q-waves and other EKG
    changes which had disappeared completely, and her
    electrocardiogram was considered normal during this admission
    although she had, on monitoring, periodic episodes of
    bigeminy.  An exercise tolerance test was negative for
    myocardial ischemia and showed a normal work capacity for a
    patient of her age.

    * END  *
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