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SETMA I - 2929 Calder, Suite 100
SETMA II - 3570 College, Suite 200
SETMA West - 2010 Dowlen
(409) 833-9797
www.setma.com
Discharge Summary
Memorial Hermann Baptist
Patient
Sex Male
Date of Birth
Admit Date 03/25/2010
Discharge Date 03/26/2010
Admitting Assessment Status
Pneumonia Pneumonitis Acute
Hyperten Benign Essential Untreated
Discharge Assessment Status
Pneumonia Pneumonitis Very - Mild
Hyperten Benign Essential Chronic
CAD Unspecified Vesse Chronic
Discharge Chronic Conditions Status
1. Hyperten Benign Essential
2. CAD Unspecified Vesse
Histories
Social History
Ethnicity - Caucasian
Sexuality - heterosexual
Marital Status - divorced
Past Medical History
Hospital
Pneumonia Pneumonitis, 2010
Surgical
hiatal hernia repair
L inguinal hernia repair
Family History
CBC - 03/26/2010
Chemistry - 03/26/2010
Chest X-Ray - 03/26/2010
Flu Shot - 03/26/2010
Pneumovax - 03/26/2010
Review of Systems
Source of Information
Patient
Family member
Allergies
Description Onset
No Known Allergies 03/26/2010
Constitutional
Patient Denies
Malaise, Fatigue, Fever, Chills, Headache, Weakness, Syncope, Vertigo, Shortness of breath, Flu-like symptoms, Diaphoresis, Night sweats, Lethargy,
Eyes
Patient Denies
Redness, Swollen lids, Purulent discharge, Crusting/Matting,
Head/Neck
Patient Denies
Headache,
Nose
Patient Confirms
Nasal congestion, Post-nasal drip, Rhinorrhea,
Patient Denies
Sneezing,
Oropharnyx
Patient Confirms
Sore throat, Dry mouth, Loose/Missing teeth,
Cardiac
Patient Denies
Chest pain at rest, Chest pain with exertion, Chest pressure, Palpitations, Tachycardia, Irregular heart beat, Heart murmurs, Diaphoresis, Nausea, Fatigue, Cough, Syncope, Peripheral edema,
Respiratory
Patient Confirms
Post-nasal drip, Pleuritic chest pain, Rhinorrhea,
Patient Denies
Cough, Chest pain, Fever, Peripheral edema, Shortness of breath, Sneezing,
Gastrointestinal
Patient Denies
Nausea, Vomiting, Diarrhea, Abdominal pain,
Male Genitourinary
Patient Denies
Nocturia, Urinary incontinence,
Integumentary
Patient Confirms
Intact, Warm/Dry
Neurologic
Patient Denies
Convulsions, Clumsiness, Headache, Syncope,
Hematologic
Patient Confirms
Anemia,
Physical Exam
Vital Signs
Blood Pressure
Trial 1 - 153 / 80 mmHg
Mid-Arm Circumference - .0 inches
Temperature - 98.40 *F
Pulse - 70.00/min
Resp Rate - 20/min
Weight - 152.68 pounds
Protein Requirement - 83 grams/day
Constitutional
Level of Consciousness - Normal
Orientation - Normal
Level of Distress - Normal
Overall Appearance - Normal
Head/Face
Hair and Scalp - Normal
Skull - Normal
Facial Features - Normal
Eyes
General
Right - Normal
Left - Normal
External
Right - Normal
Left - Normal
Neck
Inspection - Normal
Palpation - Normal
Lymph Nodes - Normal
Thyroid Gland - Normal
Auscultation
Carotid
Quality - 2+ expected
Finding - no bruit
Respiratory
Inspection - Normal
Auscultation - Normal
Palpation - Normal
Cough - productive
Cardiovascular
Auscultation - Normal
Murmurs - Absent
Palpation - Normal
Bruit - Absent
Peripheral Edema - No
Cardio Intima Media Thickening Left Right
Thickening (mm)
Blockage Present
Perecnt Blocked 0 % 0 %
Abdomen
Inspection - Normal
Auscultation - Normal
Palpation - Normal
Abdominal Reflexes - Normal
Costovertebral Percussion - Normal
Liver
Normal
Spleen
Normal
Neurological
Mental Status
Cognitive Abilities - Normal
Emotional Stability - Normal
Integumentary
Inspection - Normal
Palpation - Normal
Radiology
Chest
Comments
CHEST TWO VIEWS
IMPRESSION
Increased lung markings have appeared at the left base suspicious for a developing left lower lobe pneumonia when compared to 18 June 2007. There has been no other interval change.
Laboratory
CBC
Admission Discharge
WBC 13.8 8.3
Hgb 12.4 11.4
MCV 97.3 97.7
Plate 164 139
Bands
CMP
Admission Discharge
Na 138.0
K 3.9
BUN 9
Creat .8
Ca 8.3
Alp
Ast
Bil
Glucose 90.0
Chloride 104.0
ALT
ALP
Protein
Other
B12 150
FERR 218
Folate 13.7
BNP - 69
PSA - 1.4
CK - 44
HDL - 46
FT4 - 0.8
TSH - 0.7
FLU A & B - Negative
Follow-Up Instructions
Hospital Discharge Instructions
Discussed condition, medications, and follow-up care with patient and/or family
Give patient a copy of discharge summary
Ensure patient understands follow-up instructions
Review all follow-up instructions with patient
Review medications with patient before discharge
Post Hospital Follow-Up Instructions
Bring ALL medications to next office appointment
Continue medications per Post Hospital Follow-up Instructions document
Diet:2000low salt
Follow-Up
Please make an appointment to see Dr. Holly on 03/29/2010.
Please make an appointment to see Dr. .
Please make an appointment to see Dr. .
Comments - SEE Dr Holly Moday at 730 am Fasting for Labs
Guidelines
Follow-Up Locations
The physician recommended the following location(s) for additional care if needed:
City of Beaumont Public Health
950 Washington Blvd.
Beaumont, Texas 77705
(409) 832-4000
Continue Medications as Listed
Start Date Brand Dose Sig Code Sig Desc
03/26/2010 Levaquin 500mg 1 tab po daily 1 tab po every day
03/26/2010 Ventolin Hfa 90mcg 1 puff po bid Inhale one time by mouth twice per day
The patient was stable upon release from the hospital.
The patient's prognosis is good.
At least thirty-one minutes were required to complete the discharge process.
Hospital Course Summary
Admission
Patient was admitted through the emergency room, For the treatment of Fever Cough.
Treatment
The patient was treated with the following fluids and antibiotics intravenously: NS, Levofloxacin, .
The patient received the following medications intravenously: .
Therapy
Breathing treatments of Albuterol + Atrovent unit dose
Diagnostics
Chest x-ray and physical exam of the lungs show improvement. Appropriate cultures were obtained and reviewed. Appropriate lab tests were obtained and reviewed. Appropriate diagnostic tests were obtained and reviewed.
Complications
The hospital course was uneventful. Gradual improvement took place.
Discharge Condition
The patient has improved.
Patient is ambulatory.
Reason for Discharge
Patient is stable
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Approved By James L. Holly MD 03/26/2010 7:50 AM
Southeast Texas Medical Associates
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