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Raymond E Rivera Vergara <[email protected]>

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Rivera-Vergara, Raymond <[email protected]> Sun, Jan 3, 2016 at 10:49 AMTo: [email protected]

LOCAL TITLE: H&P-MEDICAL SERVICE

STANDARD TITLE: INTERNAL MEDICINE H & P NOTE

DATE OF NOTE: DEC 30, 2015@20:55 ENTRY DATE: DEC 30, 2015@20:55:22

AUTHOR: MROUEH,GABRIELA EXP COSIGNER: URBINA-REYES,BRENDA Y

URGENCY: STATUS: COMPLETED

Internal Medicine Services History and Physical Examination

===========================================================

********** *** *** *** *** *** *******

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**** ********* ********* *** *** ****

**** *** *** ********* *** *******

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********** *** *** *** ** *** ***

CHIEF COMPLAINT:

===============

"Me transfirieron pero ya me siento mucho mejor"

HISTORY OF PRESENT ILLNESS:



==========================

Mr. DIAZ-MENDEZ, ULISES is a 85 year old MALE patient with the below mentioned

medical history who was in his usual state of health consisting of free

ambulation, self care, and total independence on activities of daily living

until approximately 1 week ago when patient began with nausea, ~4 episodes of

gastric content vomiting, watery diarrhea, dry cough, fever and general malaise.

He denied abdominal pain. Patient refers that he had been feeling well for a

while, but last Thursday patient felt worse than ever and his grandson decided

to call the ambulance to take patient to hospital. He also refered that his eyes

had become more yellow. He did not come to VAER because ambulance was not

allowed to come to VAER so he was taken to Hospital Buen Samaritano. There he

was hospitalized with the diagnosis of obstructive jaundice, suspected

cholangitis, pancreatitis and bronchial pneumonia. Studies available in chart

show that patient had abd/pelvic CT and abdominal sonogram done. CT abd/pelvic

remarkable for "cystic duct stone, biliary tract and common bile duct multiple

stones resulting in obstructive jaundice with intrahepatic biliary ductal

dilatation". Abdominal sonogram remarkable for "findings compatible with

intrahepatic and extrahepatic biliary ductal dilatation likely from biliary

tract obstruction secondary to choledocholitiasis...The common bile duct

measures 13mm in diameter...The pancreas demonstrates slight ill defined

echotexture that may represent early pancreatitis." Patient now refers feeling

marked improvement. Patient there was treated with Zosyn and Levaquin. He refers

not being evaluated by GI service. Patient transfered to our insitution for

further care and for evaluation by GI service for possible MRCP or ERCP.

COMORBIDITIES:

==============

- Diabetes Mellitus Type II

- Chronic Pancreatitis



>s/p pancreatic pseudocyst and exploratory laparotomy

- Depression

- Duodenal Ulcers

- Hypercholesterolemia

- Low back pain

- Diabetic Neuropathy

- Macular Degeneration

- Lumbar Radiculopathy

MEDICATIONS:

============

Admission Medication Reconciliation

Outpatient includes Prescriptions and Non-VA meds

Inpatient includes Unit Dose and IV

Medications Ordered for Both Outpatient and Inpatient

----------------------------------------------------------------

...None

Outpt Meds with No Corresponding Inpt Meds

--------------------------------------------------------------

Acetaminophen 325mg tab 650mg 2 tablets po q6h prn

Alcohol prep pad 1 pad misc qid

Atorvastatin calcium 80mg tab 40mg 0.5 tablet po at bedtime

Buspirone hcl 5mg tab 1 tablet po am-pm

Cholecalciferol (vit d3) 1,000unit tab 2000units po daily

Clotrimazole 1% top soln a small amount top bid

Freestyle lite (glucose) test strip 1 strip misc tid

Gabapentin 400mg cap 1 capsule po bid and at-bedtime

Insulin glargine,human 100 unt/ml inj 20 units sc at bedtime

Insulin syringe 1ml 30g 0.5in 1 syringe misc daily

Lancet,freestyle 1 lancet misc tid



Latanoprost 0.005% oph soln 1 drop ou at bedtime

Multivit/ophth areds2/lute/zeax cap/tab 1 capsule po bid

Omeprazole 20mg ec cap 1 capsule po daily

Pneumococcal 13-valent conjugate vaccine 0.5 milliliter im once

Trazodone hcl 50mg tab 1 tablet po at bedtime

Zolpidem tartrate 5mg tab 1 tablet po at bedtime

Inpt Meds Only (that are not on Outpt)

----------------------------------------------------------------

...None

CODE STATUS: FULL

============

PAST HISTORY:

============

Adult Illnesses: See COMORBIDITIES above.

----------------

DRUG SENSITIVITIES AND ALLERGIC REACTIONS:

------------------------------------------

Penicillin, Aspirin

IMMUNIZATIONS:

--------------

Immunization Series Date Facility Reaction

FLU C 10/14/2009 SAN JUAN V* NONE

C 11/03/2005 SAN JUAN V* NONE



FLU WHOLE 11/19/2003 SAN JUAN V*

10/23/2002 SAN JUAN V*

INFLUENZA 11/18/2010 SAN JUAN V*

10/14/2009 SAN JUAN V*

10/14/2009 Va SAN JUA*

Comments: ADMINISTERED BY

MS:NIEVES,MARIA-LPN.LEFT DELTOID

AREA-LOT-98446P1-EXP-JUN/2010--DATA ENTRY

ONLY

10/14/2009 Va SAN JUA*

10/01/2008 In HOSPITA*

10/01/2008 In HOSPITA*

10/15/2007 SAN JUAN V*

12/01/2006 SAN JUAN V* NONE

12/01/2006 SAN JUAN V*

11/03/2005 SAN JUAN V*

10/13/2004 SAN JUAN V* NONE

10/13/2004 SAN JUAN V*

B 11/19/2003 SAN JUAN V* NONE

PNEU PCV13 C 09/10/2015 SAN JUAN V*

PNEUMOVAX C 08/19/2003 SAN JUAN V*

TD-ADULT C 07/18/2006 SAN JUAN V* NONE

SURGERIES:

----------

MAR 14, 2016 Proc: PHACOEMULSIFICATION AND INTRAOCULAR LENS RIGHT EYE

SEP 11, 2015 Proc: AVASTIN INTRAVITREAL INJECTION LEFT EYE

JUL 16, 2015 Proc: INTRAVITREAL INJECTION OF AVASTIN LEFT EYE

MAY 19, 2015 Proc: LEFT EYE AVASTIN INTRAVITREAL INJECTION 1/3

FAMILY HISTORY:



===============

FATHER: DM

MOTHER: DM

SOCIAL HISTORY:

===============

HABITS:

-------

ALCOHOL: Drank for many years, quit 22 years ago

TOBACCO: smoked 1ppd for 30 years, quit 18 years ago

DRUGS:

REVIEW OF SYSTEMS:

=================

GENERAL BREASTS

(+) Fever (-) Lumps

(-) Night sweats (-) Pain/tendernes

(-) Excessive thirst (-) Nipple discharge

(-) Easy bruising (-) Gynecomastia

(-) Falls

(-) Itching

(-) Weakness

(-) Rash

ENT GASTROINTESTINAL

(-) Visual changes (-) Melena



(-) Double vision (-) Abdominal pain

(-) Eye pain (-) Rectal pain

(-) Hearing loss (-) Bowel incontinence

(-) Vertigo (+) Jaundice

(-) Ear infection (-) Changes in bowel habits

(-) Nose bleed (-) Constipation

(-) Nasal obstruction (-) Rectal bleeding

(-) Frequent sneezing (-) Hematemesis

(-) Nose running (+) Nausea

(-) Nocturia (-) Heartburn

(-) Tooth ache (-) Dysphagia

(-) Bleeding gums (+) Vomiting

(-) Loose teeth

RESPI/CARDIO GENITOURINARY

(-) Cough-productive (-) Polyuria

(+) Cough non-productive (-) Hematuria

(-) Hemoptysis (-) Urinary infection

(-) Shortness of breath (-) Stones

(-) PND (-) Venereal disease

(-) Orthopnea (-) Frequency or urgency

(-) Palpitations (-) Incontinence

(-) Murmur (-) Dysuria

(-) Edema (-) Hesitancy

(-) Claudication (-) Dribbling

(-) Thrombophlebitis

(-) Orthopnea

(-) Wheezing

(-) Chest pain

NEUROLOGICAL MUSCULOSKELETAL



(-) Seizures (-) Joint pain

(-) Weakness (-) Stiffness

(-) Pain (-) Joint swelling

(-) Difficulty speaking (-) Backache

(-) Tremor (-) Painful feet

(-) Gait problems

(-) Headaches

(-) Syncope

(-) Head trauma

(-) Hallucinations

(-) Delusions

(-) Loss of Consciousness

PHYSICAL EXAMINATION:

====================

VITAL SIGNS:

------------

VITAL SIGNS:

DATE/TIME TEMP PULSE RESP BP PAIN

12/30/15 @ 2021 98.2 69 18 124/70 6

1. GENERAL APPEARANCE: Active, alert, oriented to time, place, and person.

Cooperative. In no acute distress.

2. HEAD: Normocephalic, atraumatic.

3. NECK: No JVD at 45 degrees. No carotid bruits, masses, tracheal deviation.



4. EYES: Pupils equally round and reactive to light and accomodation.

Extraocular movements intact. No corneal lesions. Non-icteric,

non-erythematous sclerae.

7. MOUTH: Moist oral mucosa. No erythema or lesions. No tongue deviation.

8. THROAT: No erythema, purulent secretions or exudates.

9. CHEST: No trauma. No use of accessory muscles during breathing.

11. LUNGS: Clear to auscultation bilaterally. No rhonchi, wheezes, crackles.

12. HEART: Regular rhythm. Audible S1/S2. No S3/S4. No murmurs, rubs, gallops.

13. ABDOMEN: Bowel sounds positive throughout all quadrants. Soft, depressible,

non-distended, non-tender to superficial and deep palpation.

No guarding or rebound tenderness.

15. BACK: No gross deformities, no pain during examination.

16. EXTREMITIES: No cyanosis or edema. +2 peripheral pulses.

Adequate range of motion.

17. SKIN: No erythema, petechia, bruises, or generalized rash.

21. NEUROLOGICAL: No focal neurological deficits.

LABS:

====

No labs available on admission. They have been ordered.



IMAGING:

========

No imaging available on admission. Reports from CT and sonogram available in

physical chart in ward.

ECG:

====

- Normal Sinus Rhythm

- Vent Rate: 66bpm

- QTc: 423ms

INITIAL IMPRESSION:

==================

- Choledocholelitiasis

- s/p pancreatitis

ASSESSMENT & PLAN:

==================

Mr. DIAZ-MENDEZ, ULISES is a 85 year old MALE patient with the above mentioned

medical problems and comorbidities who was in his usual state of care until 1

week ago when he was hospitalized in Hospital Buen Samaritano for obstructive

jaundice, suspected cholangitis, pancreatitis and BKP. He was then transfered to

our institution for further care and for GI evaluation.

Patient was evaluated at bedside upon arrival at IM ward. He was alert, awake,

and oriented in all spheres. Currently patient afebrile, normotensive,



hemodynamically stable, with adequate vital signs. Physical exam findings

remarkable for the above mentioned findings. Lungs esentially clear. Normal

heart sounds. Benign abdominal exam. No focal neurological deficits.

Labs are not available on admission. New labs are ordered.

In view of above mentioned history and physical exam findings, most likely

diagnosis is choledocholelithiasis and s/p pancreatitis.

Patient with CT from Buen Samaritano showing cystic duct stone, billiary and

common bile duct tone with intrahepatic ductal dilation. Patient has been

previously followed by GI service due to chronic pancreatitis with pancreatic

pseudocyst, dilated extrahepatic ducts and H.pylori causing ulcer. Patient had

MRCP done in 2005 which showed "Atrophy of the distal pancreatic body and tail

with pancreatic ductal dilatation, but without obvious pancreatic head and/or

neck masses noted. Cholelithiasis." Patient was discharged from their clinics in

2009 due to stabilization of patient's conditions. An abdominal sonogram has

been ordered. A GI consult will be placed to evaluate for possible MRCP or ERCP

if stones are still present.

Patient had CT finding suggestive of beginnings of pancreatitis. He did not have

abdominal pain but he did have nausea, vomiting and diarrhea. Labs are not

available to determine Ranson criteniia or BISAP score. Nevertheless, patient

has improved clinically and abdominal exam is completely benign. Will hydrate

patient with Ringer's lactate.

Additional medication for patient's comorbidities were reconciliated. He

will be followed by inpatient primary care team who will follow daily with

labs and monitoring of clinical improvement; changes in management will be

made accordingly. Patient was oriented regarding above recommendations and

verbalized understanding. Time was allowed for questions and doubts were

clarified to the best of my ability.



DVT PROPHYLAXIS:

GI PROPHYLAXIS: Omeprazole

CODE STATUS: full code

PLAN:

=====

ADMIT TO: Medicine

DIAGNOSIS: As above

CONDITION: STABLE

PROGNOSIS: Guarded

VITALS: Q8h on chart

ACTIVITY: Bed rest

NURSING: Vitals as per protocol

DIET: See orders

IN/OUTS: Daily on chart

IV FLUIDS: See orders

LABS: See orders

IMAGINGS: See orders

CONSULTS: ID-done

/es/ GABRIELA MROUEH, MD

RESIDENT PHYSICIAN/MEDICAL SERV/INTERNAL MEDICINE

Signed: 12/31/2015 02:49

/es/ BRENDA Y URBINA-REYES, MD

Physician/Medical Service/Internal Medicine

Cosigned: 12/31/2015 07:23

LOCAL TITLE: INTERNAL MEDICINE OD NOTE



STANDARD TITLE: INTERNAL MEDICINE NOTE

DATE OF NOTE: DEC 31, 2015@00:02 ENTRY DATE: DEC 31, 2015@00:02:45

AUTHOR: BAHAMONDE,EMMANUEL EXP COSIGNER:

URGENCY: STATUS: COMPLETED

********* *** *** ******* *** *** ***

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----------------- PGY-2 RESIDENT ADMISSION NOTE -------------------

Last admission: DEC 30, 2015@20:13:26 DX: OBSTRUCTIVE JAUNDICE

Last discharge: JAN 28, 2009@16:58:35

*************************************************************************

Chief Complaint:

*************************************************************************

History of Present Illness:

*************************************************************************

Mr. DIAZ-MENDEZ,ULISES is a 85-year-old MAN with medical history

of DMII, chronic pancreatitis due to unknown etiology presenting with 5 days

hisotyr of nausea vomiting, diarrheas associated with fevers and dry cough.

Patient denied sick contacts nevertheless was found by nephew acutely ill reason

why an ambulance was called. Ambulance could not bring him so took him to

another hospital in the area. Patient was found with elevated liver enzymes and

jaundiced for which a CT and echogram were performed with findings suggestive of

acute pancreatitis and choledocholelithiasis. Patient was started on Zosyn and

Levaquin to cover pneumonic process and abdomen. Patient was trasnferred for GI



evaluation for possible ERCP.

On evalaution patient was barely triaged in the ED. Medication reconciliation

was not done and labs not withdrawn. He was found in ed AAO x 3 in no acute

distress afebrile and hemodynamically stbale with Zosyn bag and IVF's. New labs

were requested andIVF's with RL were requested. Physical exam with benign

abdomen mildly hyperactive BS. Echogram noted on chart with evidence of

choledocholelithiasis. No jaundiced on physical exam noted yet liver enzymes

requested for evaluation as well as amylase and lipase. New echogram requested

to evaluated gallstone position. If choledochole found can consider MRCP.

patient without metal fragments for which checklist will be signed. GI consult

placed for recommendations. Diet has been tolerated in the meantime. No

antibiotics placed at the time. Primary team to rrevaluate need.

Patient was admitted to Internal Medicine Ward for further management.

*************************************************************************

Past medical history:

********************

Computerized Problem List is the source for the following:

- Diabetes Mellitus Type II or unspecified

- CONSTIPATION, unspecified

- Tobacco Use Disorder QUITED SMOKING FEB 14 2008

- Pancreatitis HX. OF RECURRENT

- Depression

- Duodenal Ulcers

- Drusen (Degenerative)



- Vertigo

- Hypercholesterolemia

- Intermittent Claudication

- Chronic Pancreatitis

- Unspecified gastritis and gastroduodenitis, without mention of hemorrhage

- Colonoscopy ARTERIOVENOUS MALFORMATION FOUND (AVM)

- Low Back Pain

- Polyneuropathy in diabetes

- Screening/Diab Retinopathy

- Lumbar Radiculopathy

- Neck Pain

HABITS:

=======

Denied

*********************************************************************

Outpatient medications:

*********************************************************************

Admission Medication Reconciliation

Outpatient includes Prescriptions and Non-VA meds

Inpatient includes Unit Dose and IV

Medications Ordered for Both Outpatient and Inpatient

----------------------------------------------------------------

OP: Atorvastatin calcium 80mg tab 40mg 0.5 tablet po at bedtime

IP: Atorvastatin calcium 40mg tab po at bedtime

OP: Buspirone hcl 5mg tab 1 tablet po am-pm

IP: Buspirone hcl 5mg tab po am-pm

OP: Gabapentin 400mg cap 1 capsule po bid and at-bedtime

IP: Gabapentin 400mg cap po bid and at-bedtime



OP: Insulin glargine,human 100 unt/ml inj 20 units sc at bedtime

IP: Insulin glargine,human 100 unt/ml inj 20 units sc at bedtime

OP: Multivit/ophth areds2/lute/zeax cap/tab 1 capsule po bid

IP: Multivit/ophth areds2/lute/zeax cap/tab 1 capsule po bid

OP: Omeprazole 20mg ec cap 1 capsule po daily

IP: Omeprazole 20mg ec cap po daily

OP: Trazodone hcl 50mg tab 1 tablet po at bedtime

IP: Trazodone hcl 50mg tab po at bedtime

OP: Zolpidem tartrate 5mg tab 1 tablet po at bedtime

IP: Zolpidem tartrate 5mg tab po at bedtime

Outpt Meds with No Corresponding Inpt Meds

--------------------------------------------------------------

Acetaminophen 325mg tab 650mg 2 tablets po q6h prn

Alcohol prep pad 1 pad misc qid

Cholecalciferol (vit d3) 1,000unit tab 2000units po daily

Clotrimazole 1% top soln a small amount top bid

Freestyle lite (glucose) test strip 1 strip misc tid

Insulin syringe 1ml 30g 0.5in 1 syringe misc daily

Lancet,freestyle 1 lancet misc tid

Latanoprost 0.005% oph soln 1 drop ou at bedtime

Pneumococcal 13-valent conjugate vaccine 0.5 milliliter im once

Inpt Meds Only (that are not on Outpt)

----------------------------------------------------------------

...None

*********************************************************************

Objective:

**********

Height: 66 in [167.6 cm] (09/11/2015 10:43)

Weight: 135.2 lb [61.5 kg] (12/30/2015 21:00)



Vital signs:

************

Blood pressure : 157/76 (12/30/2015 21:00)

Heart rate : 74 (12/30/2015 21:00)

Respiratory rate : 19 (12/30/2015 21:00)

Temperature : 98 F [36.7 C] (12/30/2015 21:00)

Pain : 0 (12/30/2015 21:00)

*********************************************************************

Physical exam:

*********************************************************************

General: Active, alert, oriented x 3. No acute distress

HEENT: PERRL, extra-ocular movements intact, moist oral mucosa, no JVD at 45

degrees.

Heart: Regular rate and rhythm, no murmurs, no gallops

Lungs: Clear to ausculation bilaterally

Abdomen: Bowel sounds positive, hyperactive, soft and non-tender, no guarding or

rebound

tenderness

Extremities: No cyanosis or edema, distal pulses present bilaterally +2.

Neurologic: No gross focal neurological deficits.

*********************************************************************

Laboratories:

*********************************************************************

---- CBC PROFILE ----

BLOOD Dec 30 Reference

2015

22:20 Units Ranges

-------------------------------------------------------------------------------

WBC 12.6 H X10-3/ul 4.3 - 9.3



RBC 4.5 L X10-6/ul 4.7 - 6.1

HGB 12.9 g/dL 12.6 - 17.8

HCT 39.3 % 37.9 - 54.5

MCV 86.8 fL 81 - 102

MCH 28.5 pg 26 - 34

MCHC 32.8 g/dl 31 - 36.5

RDW 13.6 % 11 - 15

PLT 256.0 X10-3 155 - 371

MPV 9.9 fL 9 - 12.9

SEGS 65.2 % 34 - 74

LYMPHS 22.1 % 17 - 48

MONOS 8.3 % 2 - 12

EOSINO 4.0 % 0 - 7

BASO 0.4 % 0 - 1.4

---- COAG PROFILE ----

PLASMA Dec 30 Reference

2015

22:20 Units Ranges

-------------------------------------------------------------------------------

PT OLD1 Secs 10.6 - 12.6

INR 1.12

PT 13.8 Secs. 11.8 - 15

PTT 31.3 Secs. 22.4 - 38.3

---- CHEM PROFILE ----

SERUM Dec 30 Reference

2015

22:20 Units Ranges

-------------------------------------------------------------------------------



GLUCOSE 202 H mg/dL 70 - 99

BUN 14.9 mg/dL 10 - 26

CREA 0.9 MG/DL .7 - 1.5

NA+ 139 mEq/L 135 - 145

K+ 4.6 mEq/L 3.5 - 5

CL- 99 L mEq/l 100 - 110

CO2 27 mEq/l 24 - 32

SGPT 38 U/L 0 - 45

SGOT 24 U/L 0 - 40

EGFR 82 mL/min Ref: >=60

ALK PHO 323 H U/L 30 - 115

T BILI 1.4 H MG/DL .2 - 1.3

D BILI 0.8 H MG/DL 0 - .2

IBILI .62 MG/DL 0 - 1.3

CA++ 9.2 MG/DL 8.5 - 10.5

ALB 3.9 G/DL 2.6 - 5.2

TP 6.8 G/DL 6 - 8.5

CHOL EZ 174 MG/DL 140 - 200

HDL 49.5 MG/DL 39 - 60

NON HDL 124.1 mg/dL Ref: <=130

CHOL/HD 3.5 mg/dL Ref: <=5

LDL CHO 100.0 mg/dL Ref: <=100

VLDL 24.0 mg/dL Ref: <=30

TRIGLYC 119 MG/DL 25 - 150

---- MISC. CHEMISTRIES ----

SERUM ACID PH ACP PSA PSA AMYLASE

Ref range low 0 .02 0 0 25

Ref range high .8 1.26 4 4 115

U/L U/L ng/mL ng/mL U/L

-------------------------------------------------------------------------------



[b] Dec 30, 2015 22:20 69

===============================================================================

SERUM LIPASE FERRIT FOL V B12 2 HR PP AFP CEA

-

Ref range low 1 30 4.2 243 72 0 0

Ref range high 60 400 19.9 894 140 8.6 3

U/L. ng/mL. ng/mL. pg/mL. mg/dL ng/mL ng/mL.

-------------------------------------------------------------------------------

[b] Dec 30, 2015 22:20 33

*********************************************************************

Radiology:

*********************************************************************

On chart

*********************************************************************

ECG:

On chart

*********************************************************************

Consults:

PENDING CONSULTS - NONE FOUND

*********************************************************************

Diagnostic impression:

*********************************************************************

1. Suspected choledocholelithiasis

- s/p acute pancreatitis

2.

3.

*********************************************************************



Assessment and Plan:

*********************************************************************

Mr. DIAZ-MENDEZ is a 85-year-old MAN with medical

problems and physical findings mentioned above who was admitted to internal

medicine ward due to Suspected choledocholelithiasis

On evalaution patient was barely triaged in the ED. Medication reconciliation

was not done and labs not withdrawn. He was found in ed AAO x 3 in no acute

distress afebrile and hemodynamically stbale with Zosyn bag and IVF's. New labs

were requested andIVF's with RL were requested. Physical exam with benign

abdomen mildly hyperactive BS. Echogram noted on chart with evidence of

choledocholelithiasis. No jaundiced on physical exam noted yet liver enzymes

requested for evaluation as well as amylase and lipase. New echogram requested

to evaluated gallstone position. If choledochole found can consider MRCP.

patient without metal fragments for which checklist will be signed. GI consult

placed for recommendations. Diet has been tolerated in the meantime. No

antibiotics placed at the time. Primary team to rrevaluate need.

DVT PROPHYLAXIS:heparin

GI PROPHYLAXIS:omeprazole

CODE STATUS: full

*********************************************************************

Plan:

*********************************************************************

ADMIT TO: Medicine

DIAGNOSIS: As above

CONDITION: STABLE



PROGNOSIS: Guarded

VITALS: Q8h on chart

ACTIVITY: Bed rest

NURSING: Vitals as per protocol

DIET: See orders

IN/OUTS: Daily on chart

IV FLUIDS: See orders

LABS: See orders

IMAGINGS: See orders

CONSULTS: None

/es/ EMMANUEL I BAHAMONDE, MD

Resident Physician/Medical Serv/Internal Medicine

Signed: 12/31/2015 01:02


BLOOD Jan 02 Dec 30 Reference

2016 2015

08:24 22:20 Units Ranges

-------------------------------------------------------------------------------

WBC 10.1 H 12.6 H X10-3/ul 4.3 - 9.3

RBC 4.5 L 4.5 L X10-6/ul 4.7 - 6.1

HGB 12.7 12.9 g/dL 12.6 - 17.8

HCT 38.6 39.3 % 37.9 - 54.5

MCV 86.7 86.8 fL 81 - 102

MCH 28.5 28.5 pg 26 - 34

MCHC 32.9 32.8 g/dl 31 - 36.5

RDW 13.7 13.6 % 11 - 15

HDW g/dL

PLT 254.0 256.0 X10-3 155 - 371



MPV 9.7 9.9 fL 9 - 12.9

PLT CRT

BLASTS % Ref: 0

PROS % 0 - 0

MYELO % 0 - 0

META % 0 - 0

BANDS % 0 - 9

SEGS 62.1 65.2 % 34 - 74

LYMPHS 21.4 22.1 % 17 - 48

MONOS 9.9 8.3 % 2 - 12

EOSINO 6.1 4.0 % 0 - 7

BASO 0.5 0.4 % 0 - 1.4

SEGS# 6.28 8.2 H X10-3/ul 1.64 - 6.96

LYMPHS# 2.17 2.78 X 10-3 1 - 3.5

EOS# 0.62 H 0.50 H X10-3/ul 0 - .4

BASO# 0.05 0.05 X10-3/ul 0 - .1

MONOS# 1 1.04 H X10-3/ul .2 - 1

NRBC /100WBC 0 - .2

PLT.E Ref: Adq

TOXIC G "+" Ref: ABSENT

ANISO "+" Ref: <1+

MICROCY "+" Ref: <1+

MACRO "+" Ref: <1+

VAR "+"

HYPO "+" Ref: <1+

HYPER "+"

LUC

HPX

LI

MPXI

Comments: g u



g. Ordering Provider: Yashira E Veras-Vazquez MD

Report Released..: Jan 02, 2016@08:41

Reporting Lab....: SAN JUAN VA MEDICAL CENTER [CLIA# 40D0987710]

10 Casia St. One Veterans Plaza SAN JUAN, PR 00921-3200

Performing Lab...: SAN JUAN VA MEDICAL CENTER [CLIA# 40D0987710]


u. Ordering Provider: Gabriela Mroueh

Report Released..: Dec 31, 2015@00:40







2015

22:20 Units Ranges

-------------------------------------------------------------------------------

PT OLD1 Secs 10.6 - 12.6

INR 1.12

PTT#1 Secs 23.1 - 35.5

FIBRINO mg/dL 155 - 351

THROMBI Secs 5.9 - 10.7

PROTAMI DIL. Ref: NEGATIVE

FDP/fdp ug/ml Ref: < 5

PT OLD2 Secs 9.8 - 13

PTT#2 Secs 26.5 - 39



PT OLD3 Secs. 11.3 - 14.4

PT OLD4 Secs. 9.8 - 12.3

PTT#3 Secs. 24.7 - 36.7

PT 13.8 Secs. 11.8 - 15

PTT 31.3 Secs. 22.4 - 38.3

Comments: w

w. Evaluation for INR:

RECOMMENDED THERAPEUTIC RANGES FOR ORAL ANTICOAGULATION THERAPY**

INR 1.5:

a. Patients treated with OAC requiring ambulatory surgery

INR 2.0-3.0:

a. Prophylaxix of venous thrombosis during high risk surgery

b. Treatment of venous thrombosis

c. Treatment of pulmonary embolism

d. Prevention of systemic embolism

(Tissue heart valves, AMI, Atrial fibrillation)

INR 2.5-3.5:

a. Mecahnical prosthetic valves

b. Prevention of recurrent myocardial infarction

REF:

Oral Anticoagulants: Mechanism of Action, Clinical Effectiveness,

and Optimal Therapeutic Range. Sixth ACCP Consensus Conference on

Antithrombotic Therapy. 2001

Ordering Provider: Gabriela Mroueh









SERUM Jan 02 Dec 31 Dec 30 Reference

2016 2015 2015


-------------------------------------------------------------------------------

GLUCOSE 272 H 202 H mg/dL 70 - 99

BUN 7.6 L 14.9 mg/dL 10 - 26

CREA 0.8 0.9 MG/DL .7 - 1.5

NA+ 139 139 mEq/L 135 - 145

K+ 4.0 4.6 mEq/L 3.5 - 5

CL- 100 99 L mEq/l 100 - 110

CO2 25 27 mEq/l 24 - 32

SGPT 28 38 U/L 0 - 45

SGOT 22 24 U/L 0 - 40

LDH 141 U/L 60 - 200

CPK U/L 5 - 169

CK-MB- ng/mL. 0 - 4.94

EGFR 96 82 mL/min Ref: >=60

ALK PHO 266 H 323 H U/L 30 - 115

T BILI 1.3 H 1.4 H MG/DL .2 - 1.3


IBILI .62 MG/DL 0 - 1.3



G-GT U/L 0 - 60

UA mg/dL 2.7 - 9

ING PHO 2.2 L mg/dL 2.5 - 4.5

CA++ 8.9 9.2 MG/DL 8.5 - 10.5

MG 1.6 L mg/dL 1.8 - 2.4

ALB 3.6 3.9 G/DL 2.6 - 5.2

TP 6.3 6.8 G/DL 6 - 8.5

CHOL EZ 174 MG/DL 140 - 200

HDL 49.5 MG/DL 39 - 60




D-LDL mg/dL Ref: <=100



TIBC ug/dL 260 - 400

GLOB G/DL 1.5 - 3.5

FE ug/dL 40 - 150

A/G 1.1 - 2.2

OSMOLAL MOSM/L 275 - 295

ADJ CA 8.5 - 10.5

AN GAP 0 - 12

BUN/CRE 11 - 21

CA*IN P 22 - 47

ACETONE Ref: NEG

Comments: f t v

f. Ordering Provider: Yashira E Veras-Vazquez MD








t. Ordering Provider: Gabriela Mroueh






v. Ordering Provider: Gabriela Mroueh











-------------------------------------------------------------------------------

[v] Dec 30, 2015 22:20 69

===============================================================================


-

Ref range low 1 30 4.2 243 72 0 0



Ref range high 60 400 19.9 894 140 8.6 3


-------------------------------------------------------------------------------

[v] Dec 30, 2015 22:20 33

===============================================================================

SERUM PROLAC B-12 TESTOST FOLIC VIT-B12

Ref range low 1.98 200 3 1.1 197

Ref range high 19.86 978 12 12.6 871

ng/mL pg/mL ng/mL ng/mL pg/mL

-------------------------------------------------------------------------------







---- POINT OF CARE GLUCOSE ----

BLOOD,CAPILLA Jan 03 Jan 02 Jan 02 Jan 02 Reference

2016 2016 2016 2016

06:17 21:16 16:49 16:35 Units Ranges

-------------------------------------------------------------------------------

POC-GLU 286.0 277.0 384.0 366.0 mg/dl 70 - 99

Comments: a b c d

a. For Glucose:Reg. Insulin Subcutaneous

Ordering Provider: Francisco De Jesus








b. For Glucose:Reg. Insulin Subcutaneous







c. For Glucose:Reg. Insulin Subcutaneous







d. For Glucose:Reg. Insulin Subcutaneous










2016 2016 2016 2016

11:36 06:50 21:35 20:49 Units Ranges

-------------------------------------------------------------------------------

POC-GLU 216.0 310.0 109.0 70.0 mg/dl 70 - 99

Comments: e h i j

e. For Glucose:Reg. Insulin Subcutaneous







h. For Glucose:Reg. Insulin Subcutaneous

Ordering Provider: Yashira E Veras-Vazquez MD






i. Ordering Provider: Yashira E Veras-Vazquez MD








j. For Glucose:Juice given







BLOOD,CAPILLA Jan 01 Jan 01 Jan 01 Dec 31 Reference

2016 2016 2016 2015

16:37 11:55 06:48 23:02 Units Ranges

-------------------------------------------------------------------------------

POC-GLU 363.0 157.0 213.0 281.0 mg/dl 70 - 99

Comments: k l m n

k. For Glucose:Reg. Insulin Subcutaneous







l. For Glucose:Reg. Insulin Subcutaneous









m. For Glucose:Reg. Insulin Subcutaneous







n. For Glucose:Patient Rn Notified







BLOOD,CAPILLA Dec 31 Dec 31 Dec 31 Dec 31 Reference

2015 2015 2015 2015

20:46 20:23 15:51 12:11 Units Ranges

-------------------------------------------------------------------------------

POC-GLU 229.0 48.0 L* 259.0 182.0 mg/dl 70 - 99

Comments: o p q r



o. For Glucose:Patient Rn Notified







p. For Glucose:Patient Rn Notified







q. For Glucose:Reg. Insulin Subcutaneous







r. Ordering Provider: Yashira E Veras-Vazquez MD








BLOOD,CAPILLA Dec 31 Reference

2015

08:25 Units Ranges

-------------------------------------------------------------------------------

POC-GLU 177.0 mg/dl 70 - 99

Comments: s

s. For Glucose:Patient Rn Notified







---- MRSA Surveillance DNA ----

NARES MrsaPCR

Ref range low NEGATIVE

Ref range high

-------------------------------------------------------------------------------

[x] Dec 30, 2015 22:02 NEGATIVE

x. NEGATIVE: No MRSA detected, MRSA Nasal colonization unlikely.



Ordering Provider: Brenda Y Urbina-Reyes MD






---- BLOOD BANK ----

*** [LEGACY VISTA BLOOD BANK REPORT] ***

The following historical information comes from the Legacy VISTA Blood Bank System

It represents data collected prior to the installation of VBECS. Some of the information

in this report may have been duplicated in the VBECS report above (if available).


BLOOD Jan 02 Dec 30 Reference

2016 2015


-------------------------------------------------------------------------------

WBC 10.1 H 12.6 H X10-3/ul 4.3 - 9.3

RBC 4.5 L 4.5 L X10-6/ul 4.7 - 6.1

HGB 12.7 12.9 g/dL 12.6 - 17.8

HCT 38.6 39.3 % 37.9 - 54.5



MCV 86.7 86.8 fL 81 - 102

MCH 28.5 28.5 pg 26 - 34

MCHC 32.9 32.8 g/dl 31 - 36.5

RDW 13.7 13.6 % 11 - 15

HDW g/dL

PLT 254.0 256.0 X10-3 155 - 371

MPV 9.7 9.9 fL 9 - 12.9

PLT CRT

BLASTS % Ref: 0

PROS % 0 - 0

MYELO % 0 - 0

META % 0 - 0

BANDS % 0 - 9

SEGS 62.1 65.2 % 34 - 74

LYMPHS 21.4 22.1 % 17 - 48

MONOS 9.9 8.3 % 2 - 12

EOSINO 6.1 4.0 % 0 - 7

BASO 0.5 0.4 % 0 - 1.4

SEGS# 6.28 8.2 H X10-3/ul 1.64 - 6.96

LYMPHS# 2.17 2.78 X 10-3 1 - 3.5

EOS# 0.62 H 0.50 H X10-3/ul 0 - .4

BASO# 0.05 0.05 X10-3/ul 0 - .1

MONOS# 1 1.04 H X10-3/ul .2 - 1

NRBC /100WBC 0 - .2

PLT.E Ref: Adq

TOXIC G "+" Ref: ABSENT

ANISO "+" Ref: <1+

MICROCY "+" Ref: <1+

MACRO "+" Ref: <1+

VAR "+"



HYPO "+" Ref: <1+

HYPER "+"

LUC

HPX

LI

MPXI

Comments: g u

g. Ordering Provider: Yashira E Veras-Vazquez MD






u. Ordering Provider: Gabriela Mroueh








2015

22:20 Units Ranges

-------------------------------------------------------------------------------



PT OLD1 Secs 10.6 - 12.6

INR 1.12

PTT#1 Secs 23.1 - 35.5

FIBRINO mg/dL 155 - 351

THROMBI Secs 5.9 - 10.7

PROTAMI DIL. Ref: NEGATIVE

FDP/fdp ug/ml Ref: < 5

PT OLD2 Secs 9.8 - 13

PTT#2 Secs 26.5 - 39

PT OLD3 Secs. 11.3 - 14.4

PT OLD4 Secs. 9.8 - 12.3

PTT#3 Secs. 24.7 - 36.7

PT 13.8 Secs. 11.8 - 15

PTT 31.3 Secs. 22.4 - 38.3

Comments: w

w. Evaluation for INR:

RECOMMENDED THERAPEUTIC RANGES FOR ORAL ANTICOAGULATION THERAPY**

INR 1.5:

a. Patients treated with OAC requiring ambulatory surgery

INR 2.0-3.0:

a. Prophylaxix of venous thrombosis during high risk surgery

b. Treatment of venous thrombosis

c. Treatment of pulmonary embolism

d. Prevention of systemic embolism

(Tissue heart valves, AMI, Atrial fibrillation)

INR 2.5-3.5:



a. Mecahnical prosthetic valves

b. Prevention of recurrent myocardial infarction

REF:

Oral Anticoagulants: Mechanism of Action, Clinical Effectiveness,

and Optimal Therapeutic Range. Sixth ACCP Consensus Conference on

Antithrombotic Therapy. 2001

Ordering Provider: Gabriela Mroueh







SERUM Jan 02 Dec 31 Dec 30 Reference

2016 2015 2015


-------------------------------------------------------------------------------

GLUCOSE 272 H 202 H mg/dL 70 - 99

BUN 7.6 L 14.9 mg/dL 10 - 26

CREA 0.8 0.9 MG/DL .7 - 1.5

NA+ 139 139 mEq/L 135 - 145

K+ 4.0 4.6 mEq/L 3.5 - 5



CL- 100 99 L mEq/l 100 - 110

CO2 25 27 mEq/l 24 - 32

SGPT 28 38 U/L 0 - 45

SGOT 22 24 U/L 0 - 40

LDH 141 U/L 60 - 200

CPK U/L 5 - 169

CK-MB- ng/mL. 0 - 4.94

EGFR 96 82 mL/min Ref: >=60

ALK PHO 266 H 323 H U/L 30 - 115

T BILI 1.3 H 1.4 H MG/DL .2 - 1.3


IBILI .62 MG/DL 0 - 1.3

G-GT U/L 0 - 60

UA mg/dL 2.7 - 9

ING PHO 2.2 L mg/dL 2.5 - 4.5

CA++ 8.9 9.2 MG/DL 8.5 - 10.5

MG 1.6 L mg/dL 1.8 - 2.4

ALB 3.6 3.9 G/DL 2.6 - 5.2

TP 6.3 6.8 G/DL 6 - 8.5

CHOL EZ 174 MG/DL 140 - 200

HDL 49.5 MG/DL 39 - 60




D-LDL mg/dL Ref: <=100



TIBC ug/dL 260 - 400

GLOB G/DL 1.5 - 3.5

FE ug/dL 40 - 150



A/G 1.1 - 2.2

OSMOLAL MOSM/L 275 - 295

ADJ CA 8.5 - 10.5

AN GAP 0 - 12

BUN/CRE 11 - 21

CA*IN P 22 - 47

ACETONE Ref: NEG

Comments: f t v

f. Ordering Provider: Yashira E Veras-Vazquez MD






t. Ordering Provider: Gabriela Mroueh



















-------------------------------------------------------------------------------

[v] Dec 30, 2015 22:20 69

===============================================================================


-

Ref range low 1 30 4.2 243 72 0 0

Ref range high 60 400 19.9 894 140 8.6 3


-------------------------------------------------------------------------------

[v] Dec 30, 2015 22:20 33

===============================================================================

SERUM PROLAC B-12 TESTOST FOLIC VIT-B12

Ref range low 1.98 200 3 1.1 197

Ref range high 19.86 978 12 12.6 871

ng/mL pg/mL ng/mL ng/mL pg/mL

-------------------------------------------------------------------------------









---- POINT OF CARE GLUCOSE ----


2016 2016 2016 2016

06:17 21:16 16:49 16:35 Units Ranges

-------------------------------------------------------------------------------

POC-GLU 286.0 277.0 384.0 366.0 mg/dl 70 - 99

Comments: a b c d

a. For Glucose:Reg. Insulin Subcutaneous







b. For Glucose:Reg. Insulin Subcutaneous









c. For Glucose:Reg. Insulin Subcutaneous







d. For Glucose:Reg. Insulin Subcutaneous








2016 2016 2016 2016

11:36 06:50 21:35 20:49 Units Ranges

-------------------------------------------------------------------------------

POC-GLU 216.0 310.0 109.0 70.0 mg/dl 70 - 99

Comments: e h i j

e. For Glucose:Reg. Insulin Subcutaneous









h. For Glucose:Reg. Insulin Subcutaneous







i. Ordering Provider: Yashira E Veras-Vazquez MD






j. For Glucose:Juice given









BLOOD,CAPILLA Jan 01 Jan 01 Jan 01 Dec 31 Reference

2016 2016 2016 2015

16:37 11:55 06:48 23:02 Units Ranges

-------------------------------------------------------------------------------

POC-GLU 363.0 157.0 213.0 281.0 mg/dl 70 - 99

Comments: k l m n

k. For Glucose:Reg. Insulin Subcutaneous







l. For Glucose:Reg. Insulin Subcutaneous







m. For Glucose:Reg. Insulin Subcutaneous









n. For Glucose:Patient Rn Notified







BLOOD,CAPILLA Dec 31 Dec 31 Dec 31 Dec 31 Reference

2015 2015 2015 2015

20:46 20:23 15:51 12:11 Units Ranges

-------------------------------------------------------------------------------

POC-GLU 229.0 48.0 L* 259.0 182.0 mg/dl 70 - 99

Comments: o p q r

o. For Glucose:Patient Rn Notified









p. For Glucose:Patient Rn Notified







q. For Glucose:Reg. Insulin Subcutaneous







r. Ordering Provider: Yashira E Veras-Vazquez MD






BLOOD,CAPILLA Dec 31 Reference

2015



08:25 Units Ranges

-------------------------------------------------------------------------------

POC-GLU 177.0 mg/dl 70 - 99

Comments: s

s. For Glucose:Patient Rn Notified







---- MRSA Surveillance DNA ----

NARES MrsaPCR

Ref range low NEGATIVE

Ref range high

-------------------------------------------------------------------------------

[x] Dec 30, 2015 22:02 NEGATIVE

x. NEGATIVE: No MRSA detected, MRSA Nasal colonization unlikely.

Ordering Provider: Brenda Y Urbina-Reyes MD








---- BLOOD BANK ----

*** [LEGACY VISTA BLOOD BANK REPORT] ***

The following historical information comes from the Legacy VISTA Blood Bank System

It represents data collected prior to the installation of VBECS. Some of the information

in this report may have been duplicated in the VBECS report above (if available).

MRI ABDOMEN WITH AND W/OUT CONT

Proc Ord: MRCP

Exm Date: DEC 31, 2015@10:24

Req Phys: VERAS-VAZQUEZ,YASHIRA E Pat Loc: 6J MED/01-03-2016@10:38

Img Loc: MAGNETIC RESONANCE IMAGING

Service: MEDICAL

*** THIS IS AN AMENDED REPORT ***

(Case 18154 COMPLETE)MRI ABDOMEN WITH AND W/OUT CONT (MRI Detailed) CPT:74183

Contrast Media : Gadolinium



Reason for Study: Evaluation of choledocolithiasis/cholangitis

(Case 18155 COMPLETE)MRI 3D RENDERING W/POSTPROCESS (MRI Detailed) CPT:76377

Clinical History:

Report Status: Verified Date Reported: DEC 31, 2015

Date Verified: DEC 31, 2015

Verifier E-Sig:/ES/CARLA M BLANCO-URRUTIA

Report:

MRI of the abdomen and MRCP December 31, 2015:

Multi planar T2-weighted images were acquired throughout the

upper abdomen and reviewed at the workstation. Oblique, thick

slab cholangiographic images performed. Study done using a 1.5

Tesla magnet. 6 cc of gadavist administered IV. No comparison is

available.

The exam is remarkable for severe intra-and extrahepatic biliary

dilatation with common bile duct full of filling defects felt to

represent calculi. These are noted from the proximal common bile

duct to the distal intrapancreatic common bile duct level. The

proximal common bile duct measures roughly 2 cm in diameter.

There seems to be narrowing of the distal common bile duct, which

is difficult to evaluate given some motion blurring and presence

of endoluminal calculi/filling defects. The ampullary region and

the duodenum are suboptimally evaluated in this exam.

Postcontrast images show enhancement of the common bile duct and

cystic duct which is most conspicuous at the distal common bile

duct and may represent cholangitis.



Currently, the gallbladder is free of calculi. No pericholecystic

fluid collections.

The largest choledochal calculus which is the most proximal one

measures 1.8 cm craniocaudal x 1.5 cm AP x 2 cm transverse.

There is no discrete mass lesion in the liver or spleen. Adrenal

glands are grossly within normal limits. Small renal cystic

lesions present. No hydronephroses. No free fluid or fluid

collections. No abnormal lymphadenopathy by size. The portal vein

is patent.

There is a cluster of T2 hyperintense/cystic structures at the

level of the pancreatic body likely representing incidental

intrapancreatic mucin producing tumor. Possible involvement of

the main pancreatic duct. Lesion at the level of the pancreatic

body measures approximately 2.2 cm craniocaudal x 3.3 cm

transverse x 1.9 cm AP at its widest.

Impression:

Extensive choledocholithiasis accounting for biliary obstruction.

Enhancement of the common bile duct walls may represent

cholangitis in the proper clinical scenario.

Incidental intrapancreatic mucin producing tumor/cluster of

cystic structures (pancreatic body) with possible involvement of



the main duct.

Addendum: Addendum:

Multi planar T1 and T2-weighted images were acquired. Axial

T1-weighted fat-saturated gradient echo, dynamic images acquired

for the contrast-enhanced portion of the exam.

Impression:

See addendum.

Primary Diagnostic Code: SIGNIFICANT ABNORMALITY, ATTN NEEDED

Primary Interpreting Staff:

CARLA M BLANCO-URRUTIA, Radiologist, Radiology Service (Verifier)

/CBU

Select an imaging exam...

Note: Listing displays limited data, view details for more information.

Date Range: All Results

Selected Items from 04/14/02 to 01/03/16

Lab Tests

Alkaline Phosphatase (serum) 95 U/L 30 - 115 04/15/02 07:49





Alkaline Phosphatase (serum) 323 H U/L 30 - 115 12/30/15 22:20

Alkaline Phosphatase (serum) 266 H U/L 30 - 115 01/02/16 08:24




Lab Tests

Amylase (serum) 106 U/L 25 - 115 04/15/02 07:49

Amylase (serum) 77 U/L 25 - 115 04/14/05 10:07

Amylase (serum) 105 U/L 25 - 115 05/14/08 19:24

Amylase (serum) 108 U/L 25 - 115 10/07/08 07:25

Amylase (serum) 81 U/L 25 - 115 01/25/09 09:42

Amylase (serum) 103 U/L 25 - 115 03/07/09 15:00

Amylase (serum) 113 U/L 25 - 115 03/09/09 08:52

Amylase (serum) 102 U/L 25 - 115 05/26/09 10:42

Amylase (serum) 96 U/L 25 - 115 11/04/09 09:09

Amylase (serum) 69 U/L 25 - 115 12/30/15 22:20




Lab Tests

Bilirubin,Direct (serum) 0.2 MG/DL 0 - 0.2 04/14/05 10:07

Bilirubin,Direct (serum) 0.78 H MG/DL 0 - 0.2 12/30/15 22:20






Lab Tests

Bilirubin,Total (serum) 1.0 MG/DL .2 - 1.3 11/22/04 09:00


































Bilirubin,Total (serum) 1.40 H MG/DL .2 - 1.3 12/30/15 22:20

Bilirubin,Total (serum) 1.32 H MG/DL .2 - 1.3 01/02/16 08:24




Lab Tests

Calcium (serum) 10.2 MG/DL 8.5 - 10.5 04/15/02 07:49











Calcium (serum) 10.6 H MG/DL 8.5 - 10.5 08/22/06 07:32



















Calcium (serum) 8.4 L MG/DL 8.5 - 10.5 01/28/09 04:15




































Date Range: One Week


Lab Tests

Chloride (serum) 99 L mEq/l 100 - 110 12/30/15 22:20

Chloride (serum) 100 mEq/l 100 - 110 01/02/16 08:24






Lab Tests

Chol/Hdl (serum) 3.5 mg/dL - 5.0 12/30/15 22:20




Lab Tests

Cholesterol (serum) 174 MG/DL 140 - 200 12/30/15 22:20




Lab Tests

Co2 (serum) 27 mEq/l 24 - 32 12/30/15 22:20

Co2 (serum) 25 mEq/l 24 - 32 01/02/16 08:24




Lab Tests

Creatinine (serum) 0.88 MG/DL .7 - 1.5 12/30/15 22:20

Creatinine (serum) 0.77 MG/DL .7 - 1.5 01/02/16 08:24






Lab Tests

Egfr (serum) 82 mL/min 60 - 12/30/15 22:20

Egfr (serum) 96 mL/min 60 - 01/02/16 08:24




Lab Tests

Eosino Absolute# [0.0-0.4] (blood) 0.5 H X10-3/ul 0.0 - 0.4 12/30/15 22:20

Eosino Absolute# [0.0-0.4] (blood) 0.62 H X10-3/ul 0.0 - 0.4 01/02/16 08:24




Lab Tests

Eosino% [0-7] (blood) 4.0 % 0 - 7 12/30/15 22:20

Eosino% [0-7] (blood) 6.1 % 0 - 7 01/02/16 08:24

CHEST PORTABLE (1 VIEW)

Exm Date: DEC 31, 2015@05:24

Req Phys: MROUEH,GABRIELA Pat Loc: 6J MED/01-03-2016@10:45

Img Loc: GDR(GEN. DIAGNOSTIC RADIOLOGY)



Service: MEDICAL

(Case 17652 COMPLETE)CHEST PORTABLE (1 VIEW) (RAD Detailed) CPT:71010

Reason for Study: HX OF BKP

Clinical History:

please evaluate for infectious process. thanks!



Verifier E-Sig:/ES/EDNA M RUIZ-QUIJANO

Report:

Chest AP portable view:

Lungs are mildly hyperexpanded. Ill-defined reticulonodular

pattern is noted. Linear opacities suggesting thickened

interlobular septa and interstitial changes are also noted. The

costophrenic angles are clear. No acute segmental opacities are

lobar consolidations are seen. The costophrenic angles appears

clear.

Small asthenic heart and tortuous aorta with mild atherosclerotic

changes is observed.

Impression:



Mild hyperexpansion and increased pulmonary markings suggesting

obstructive and interstitial lung disease. Compare with prior, no

significant acute radiographic changes are noted.

Primary Diagnostic Code: NO ALERT REQUIRED


EDNA M RUIZ-QUIJANO, Radiologist, Radiology Service (Verifier)

/EMR

MRI 3D RENDERING W/POSTPROCESS

Proc Ord: MRCP

Exm Date: DEC 31, 2015@10:24



Service: MEDICAL






Clinical History:






Report:






available.














fluid collections.









is patent.







Impression:






the main duct.

Addendum: Addendum:






Impression:

See addendum.




/CBU


Proc Ord: MRCP

Exm Date: DEC 31, 2015@10:24



Service: MEDICAL








Clinical History:




Report:






available.














fluid collections.









is patent.







Impression:






the main duct.

Addendum: Addendum:






Impression:

See addendum.




/CBU


Proc Ord: MRCP

Exm Date: DEC 31, 2015@10:24



Service: MEDICAL








Clinical History:




Report:






available.
















fluid collections.







is patent.







Impression:






the main duct.



Addendum: Addendum:




Impression:

See addendum.




/CBU

JAN 03, 2016 (10:46) Cumulative Vitals/Measurements Report Page 1

------------------------------------------------------------------------------

01/03/16

08:57

T: 97.7 F (36.5 C)

P: 69

R: 18

B/P: 135/64

Pulse Oximetry: 97%



Pain: 0 - No pain

00:53

T: 98.2 F (36.8 C)

P: 68

R: 19

B/P: 125/60*

Pulse Oximetry: 97%

Pain: 0 - No pain

01/02/16

16:40

T: 98.1 F (36.7 C)

P: 75

R: 17

B/P: 127/65

Pulse Oximetry: 97%

Pain: 0 - No pain

09:31

T: 97.7 F (36.5 C)

P: 75

R: 20

B/P: 148/68

Pain: 0 - No pain

01:23

T: 97.6 F (36.4 C)

P: 80

R: 19

B/P: 108/64

Pulse Oximetry: 95%

Pain: 0 - No pain

01/01/16

09:38



T: 98.0 F (36.7 C)

P: 67

R: 18

B/P: 121/65

Pulse Oximetry: 94%

Pain: 0 - No pain

00:23

T: 97.8 F (36.6 C)

P: 75

R: 18

B/P: 145/71

Pulse Oximetry: 95%

Pain: 0 - No pain

12/31/15

15:49

*** (E) - Error entry

DIAZ-MENDEZ,ULI 1838 NOV 24,1930 85 YRS MALE VAF 10-7987j

Unit: 6J MED Room: J6650-B-1

Division: SAN JUAN VA MEDICAL CENTER

JAN 03, 2016 (10:46) Cumulative Vitals/Measurements Report Page 2

------------------------------------------------------------------------------

12/31/15 (continued)

T: 98.1 F (36.7 C)

P: 55*



R: 20

B/P: 133/64

Pulse Oximetry: 97%

Pain: 0 - No pain

15:00

P: 75

B/P: 121/64

08:50

T: 97.9 F (36.6 C)

P: 58*

R: 18

B/P: 135/67

Pain: 0 - No pain

00:40

T: 97.9 F (36.6 C)

P: 75

R: 16

B/P: 160/79

Pulse Oximetry: 98%

Pain: 0 - No pain

12/30/15

21:00

T: 98.0 F (36.7 C)

P: 74

R: 19

B/P: 157/76

Wt: 135.20 lb (61.45 kg)

Body Mass Index: 22

Pulse Oximetry: 98%

Pain: 0 - No pain

20:21



T: 98.2 F (36.8 C) (ORAL)

P: 69

R: 18

B/P: 124/70

Pulse Oximetry: 95%

via ROOM AIR

Pain: 6

*** (E) - Error entry

DIAZ-MENDEZ,ULI 1838 NOV 24,1930 85 YRS MALE VAF 10-7987j

Unit: 6J MED Room: J6650-B-1

Division: SAN JUAN VA MEDICAL CENTER

universidad de puerto rico mail - (no subject)

Documents