Paciente 3

LOCAL TITLE: EMERGENCY DEPARTMENT PHYSICIAN NOTE
STANDARD TITLE: PHYSICIAN EMERGENCY DEPT NOTE

DATE OF NOTE: JAN 04, 2016@07:50
ENTRY DATE: JAN 04, 2016@07:50:34
AUTHOR: RUIZ-RODRIGUEZ,DORC EXP COSIGNER:

URGENCY:
STATUS: COMPLETED
*** EMERGENCY DEPARTMENT PHYSICIAN NOTE Has ADDENDA ***
EMERGENCY DEPARTMENT PHYSICIAN NOTE
**********************************
*
Computerized Problem List *
**********************************
Computerized Problem List is the source for the following:
- Hypertension
- Hyperlipidemia
- Gout
- Esophageal Reflux
- Peptic ulcer of unspecified site, unspecified as acute or chronic, without m
- Exogenous Obesity
- Male erectile disorder
- Refraction Error
- Impotence of organic origin (ICD-9-CM 607.84)
- Diabetes Mellitus
- Arthritis
- OVERWEIGHT
- SENSORINEURAL HEARING LOSS, BILATERAL
- Presbyopia
- Astigmatism, NOS
- Myopia
- Blepharitis * (ICD-9-CM 373.00)
- Senile nuclear sclerosis (ICD-9-CM 366.16)
- Open angle with borderline glaucoma findings (ICD-9-CM 365.01)
- DM Type II, No Retinopathy
- Diabetic Neuropathies (ICD-9-CM 250.60/357.2)
- Coronary Artery Disease * (ICD-9-CM 414.9)
- Microscopic Hematuria (ICD-9-CM 599.72)
- Intermittent Claudication * (ICD-9-CM 443.9)
- Impacted cerumen * (ICD-9-CM 380.4)
- Joint pain
- Paronychia
- Family bereavement
- Onychomycosis of toenails
- Ingrowing toenail
**********************************
*
Active Medications
**********************************
Active Outpatient Medications (including Supplies):
Active Outpatient Medications
Status
==================================================
==================
1) ATORVASTATIN CALCIUM 40MG TAB TAKE ONE-HALF TABLET BY ACTIVE
MOUTH AT BEDTIME FOR CHOLESTEROL , AVOID GRAPEFRUIT
JUICE
2) CEPHALEXIN 500MG CAP TAKE ONE CAPSULE BY MOUTH EVERY ACTIVE
12 HOURS FOR INFECTION
3) CLOTRIMAZOLE 1% TOP SOLN APPLY A SMALL AMOUNT TO
ACTIVE
AFFECTED AREA EVERY DAY FOR FUNGI INFECTION

4) FREESTYLE LITE (GLUCOSE) TEST STRIP USE 1 STRIP FOR
TESTING
ACTIVE
THREE TIMES A WEEK FOR DIABETES
5) GABAPENTIN 400MG CAP TAKE ONE CAPSULE BY MOUTH TWO
ACTIVE
TIMES A DAY AND TAKE THREE CAPSULES AT BEDTIME

6) HYDROCHLOROTHIAZIDE 25MG TAB TAKE ONE-HALF TABLET BY ACTIVE
MOUTH EVERY DAY WITH FOOD , AVOID EXPOSURE TO
SUNLIGHT , FOR HIGH BLOOD PRESSURE
7) LANCET,FREESTYLE USE 1 LANCET
THREE TIMES A WEEK
ACTIVE
FOR DIABETES
8) LISINOPRIL 20MG TAB TAKE ONE-HALF TABLET BY MOUTH
ACTIVE
EVERY DAY FOR HEART OR FOR HIGH BLOOD PRESSURE

9) MELOXICAM 7.5MG TAB TAKE ONE TABLET BY MOUTH EVERY
ACTIVE
DAY AS NEEDED FOR PAIN

10) METFORMIN HCL 1000MG TAB TAKE ONE-HALF TABLET BY
ACTIVE
MOUTH EVERY DAY WITH FOOD , FOR DIABETES

11) MUPIROCIN 2% OINT APPLY A THIN FILM TO AFFECTED AREA ACTIVE
THREE TIMES A DAY FOR INFECTION

12) RANITIDINE HCL 150MG TAB TAKE ONE TABLET BY MOUTH AT ACTIVE
BEDTIME FOR STOMACH
13) TRAMADOL HCL 50MG TAB (CS-IV) TAKE ONE TABLET BY
ACTIVE
MOUTH TWO TIMES A DAY AND TAKE TWO TABLETS AT

BEDTIME FOR PAIN
Pending Outpatient Medications
Status
==================================================
==================
1) ALBUTEROL SO4 0.083% INHL 3ML USE 3 MILLILITERS IN
PENDING
NEBULIZER FOR INHALATION ONCE

2) ASPIRIN 81MG CHEW TAB CHEW AND SWALLOW TWO TABLETS
PENDING
NOW FOR HEART

3) MOXIFLOXACIN HCL 400MG TAB TAKE ONE TABLET BY MOUTH
PENDING
BY MOUTH
Active Non-VA Medications
Status
==================================================
==================
1) Non-VA ASPIRIN 81MG EC TAB 81MG MOUTH EVERY DAY
2) Non-VA NO NON-VA MEDICATIONS/HERBALS/OTC's
MISCELLANEOUS
18 Total Medications
**********************************
* Allergies/Adverse Reactions *
ACTIVE
ACTIVE
**********************************
Patient has answered NKA
**********************************
* HISTORY OF PRESENT ILLNESS *
**********************************
**Chief complaint: me dio falta de aire y dolor de pecho
patient with above mentioned dx problems and

mediocations presnets to VAEd with SOB and chest pain
that started yesterday at 10pm at the Casino, he
associate symptoms with recalling memories of his
wife who died 4 month ago, he went home and found
uncontrolled BP, above 200 systolis and took
Lisinopril 10mg x 3. Patient could not sleep due to
chest pressure, denied taking other meds to relieve
symptoms. Patient decided to visit VAED due to
persistance of symptoms of chest pressure at center
of chest, pressure, no irradiation, no n,v, no
abdominal pain, states recent URI symptoms which
produced a productive cough with sputum, unrecalls
color phlegm.
Suicidal ideas at this moment: Yes

Suicidal plan at this moment: Yes
**********************************
*
REVIEW OF SYSTEM
**********************************
refer to HPI
**********************************
*
PHYSICAL EXAM
**********************************
Vital Signs:
DATE/TIME
TEMP
PULSE
1/4/16 @ 0721
97.6
1/4/16 @ 0721
PULSE OXIMETRY: 94
52
RESP
16
BP
213/84
-General Appearance:
Fully awake and cooperative, oriented x 3, in no
apparent distress.
anxious and tearful
-Head and Neck:
PERRLA (pupils equal round, and reactive
PAIN
0
to light and accommodation), EOMI (extraocular movements intact),

well hydrated oral mucosa, no neck pain, no neck stiffness, no palpable
masses or adenopathy, no JVD.
-Lungs:
Wheezes: Right
Decreased breath sounds: Right
-Heart:
Regular rythm, no murmurs.
-Abdomen:
Normal bowel sounds, soft and depressible, non tender
to palpation, no palpable mass, no guarding, no rebound,
no evidence of trauma.
-Extremities:
No gross deformities, no cyanosis, no edema,
full range of motion of all extremities.
-Neurology:
No gross focal motor or sensory deficit.
**********************************
*
DIAGNOSTIC RESULTS
**********************************
---ECG Time done: 7:03

---ECG Time of interpretation: 7:05
---Interpretation: sinus bradycardia 51
**********************************
* IMPRESSION AND ASSESSMENT
**********************************
76 y/o male with SOB and chest pain with suicidal ideation
and plan.
**********************************
*
PLAN
**********************************
DAILY ORDER SUMMARY

Printed Jan 04, 2016@07:58
Ord'd
ST Item Ordered
Requestor Start
Stop
==================================================
==============================
MARTINEZ-RAMIREZ,WALTER 580-58-4562
01/04/16 p CHEST 2 VIEWS PA AND LAT STAT

07:46
DRR
RUIZ-ROD,D 01/04/16
PHYSICIAN
Typ:ELECTRONICALLY ENT Sgn:ELECTRONIC
01/04/16 p GRAM STAIN AND C&S SPUTUM WC ONCE LB
"
01/04/16
07:46
#1616372
DRR
"
01/04/16 dce ASPIRIN TAB,CHEWABLE 81MG

07:50
CHEW AND SWALLOW TWO TABLETS
"
01/04/16 02/03
NOW FOR
"
HEART STAT
Quantity: 1 Refills: 0
DRR
01/04/16 dce ALBUTEROL SOLN,INHL 0.083%

07:46
"
USE 3 MILLILITERS IN NEBULIZER FOR
01/04/16 02/03
"
INHALATION ONE TIME STAT TO BE

ADMINISTERED AT ER
DRR
01/04/16 dce MOXIFLOXACIN TAB 400MG

07:46
"
TAKE ONE TABLET BY MOUTH PO STAT TO BE
01/04/16 02/03
"
GIVEN AT ER
DRR
01/04/16 a >> Pulse Oximetry NOW .

07:46
Special Instructions: Take Pulse
"
"
01/04/16 01/05
07:48 07:48
Oximetry Now and document

DRR
01/04/16 p BLOOD CULTURE BLOOD CULTURE BOTTLE TODAY

07:46
WC LB #1616369
DRR
"
SERUM STAT SP LB #1616366
DRR
"
"
07:48
"
DRR
01/04/16
#1616369
DRR
"
"
01/04/16
07:48
01/04/16 p TROPONIN-T BLOOD PLASMA STAT SP LB
DRR
"
07:48
01/04/16 p CBC & DIFF BLOOD STAT WC ONCE LB
07:48
01/04/16
07:48
01/04/16 p CPK-MB BLOOD SERUM STAT SP LB #1616366
07:46
01/04/16
07:48
01/04/16 p COMPREHENSIVE METABOLIC PANEL BLOOD

07:48
"
#1616366
"
"
01/04/16
07:48
==================================================
==============================
DAILY ORDER SUMMARY
JAN 30,1939 (76) Wt (lb): 192
Printed Jan 04, 2016@07:58

Ord'd
ST Item Ordered
Requestor Start
Stop
==================================================
==============================
MARTINEZ-RAMIREZ,WALTER 580-58-4562 (cont.)
01/04/16 p PRO-BNP BLOOD SERUM STAT SP LB #1616366

07:49
"
DRR
"
01/04/16
07:49
01/04/16 a >> Constant observation

07:58
RUIZ-ROD,D 01/04/16
PHYSICIAN
DRR
07:58

07:46
WC LB #1616370
DRR
"
WC LB #1616371
"
01/04/16
08:18
DRR
"
DRR
07:48
01/04/16
08:03

07:46
"
#1616367
"
"
01/04/16
15:48
"
01/04/16
07:48
#1616368
DRR
"
23:48
* END OF ORDERS *
==================================================
==============================
JAN 30,1939 (76) Wt (lb): 192
/es/ DORCAS L RUIZ-RODRIGUEZ, MD

PHYSICIAN, MEDICAL SERVICE, EMERGENCY ROOM
Signed: 01/04/2016 10:38
01/04/2016 ADDENDUM
STATUS: COMPLETED
Emergency Medicine F/U Note
MOST RECENT V/S:

DATE/TIME
1/4/16 @ 0721
TEMP
97.6
PULSE
52
RESP
16
BP
213/84
PAIN
0
OXYGEN SATURATION IN %: 94 (01/04/2016 07:21)
F/U: PAtient reevaluated and found with right lung pneumonia, labs with
leukocytosis and shifting with elevated pro BNP. PAtient was started on IV
antibiotics and oriented about lab findings, will consult IM for admission.
Patient also with depressive mood due to loss of wife and had suicidal ideation
with a plan. Patient and daughter were oriented about plan, understood and agree
with disposition.
ANCILLARY TROPONIN I: 0.11 H*

WBC: 10.0 H
RBC: 5.00
HGB: 15.3
HCT: 44.5
MCV: 89.0
MCH: 30.6
MCHC: 34.4
RDW: 13.1
PLT: 219
MPV: 12.9
SEGS: 81.2 H
LYMPHS: 10.8 L
MONOCYTES: 5.0
EOSINO: 2.8
BASO: 0.2
LYMPHS, ABSOLUTE: 1.08
MONOS, ABSOLUTE: 0.5
EOSINO, ABSOLUTE: 0.28
BASO, ABSOLUTE: 0.02
SEGS, ABSOLUTE: 8.09 H
GLUCOSE: 153 H
UREA NITROGEN: 17.3
CREATININE: 0.77
SODIUM: 141
POTASSIUM: 4.8
CHLORIDE: 103
CO2: 24
CALCIUM: 9.9
PROTEIN,TOTAL: 7.2
ALBUMIN: 4.1
BILIRUBIN,TOTAL: 0.79
ALKALINE PHOSPHATASE: 65
SGOT: 13
SGPT: 14
CK-MB 3/5/01: 5.38 H
pro-BNP 3/26/2003: 3202 H
EGFR 10/31/06: 98
TROPONIN-T: <0.01
*** Exam date: JAN 04, 2016@09:12
Proc: CHEST 2 VIEWS PA AND LAT ***
*** IMPRESSION TEXT: ***
Compared with prior study, interval bilateral effusions and more

confluent opacities in the perihilar regions are seen which may
represent mild atelectatic and interstitial changes. In the
appropriate clinical setting, mild decompensated heart failure
cannot be excluded however superimposed acute pneumonic process

cannot be excluded either. Follow-up is recommended.
*** REPORT TEXT: ***

Chest - PA and Lateral views:
Previous studies are available for comparison.
Lungs are hypoaerated. Cardiomediastinal structures appears

prominent without interval changes. The thoracic aorta looks
elongated ectatic and tortuous with atherosclerotic changes.
Compared with prior studies, more confluent opacities are seen

particularly in the perihilar and basal regions. There is
blunting of the costophrenic angles concerning for effusions.
Osteopenia and degenerative changes of the spine is seen.
EKG Interpretation:
/es/ DORCAS L RUIZ-RODRIGUEZ, MD

PHYSICIAN, MEDICAL SERVICE, EMERGENCY ROOM
Signed: 01/04/2016 10:43
LOCAL TITLE: INTERNAL MEDICINE ER CONSULT

STANDARD TITLE: INTERNAL MEDICINE CONSULT
ENTRY DATE: JAN 04, 2016@12:23:56
AUTHOR: SOTO-PILLICH,GLORIA EXP COSIGNER:

URGENCY:
STATUS: COMPLETED
==================================================
===========================
IM CONSULT
==================================================
===========================
Last discharge: OCT 09, 2011@12:34:99
Last admission: OCT 07, 2011@17:27:26
ALLERGIES:
Computerized Problem List is the source for the following:
- Hypertension
- Hyperlipidemia
- Gout
- Esophageal Reflux
- Exogenous Obesity
- Diabetes Mellitus
- Presbyopia
- Astigmatism, NOS
- Coronary Artery Disease * (ICD-9-CM 414.9)
- Intermittent Claudication * (ICD-9-CM 443.9)
MEDICATION RECONCILIATION:
Status
==================================================
==================
ACTIVE

ACTIVE
NOW FOR HEART

JUICE
ACTIVE

TESTING
ACTIVE
ACTIVE

THREE TIMES A WEEK
ACTIVE
FOR DIABETES
ACTIVE

ACTIVE

ACTIVE

ACTIVE
IMMEDIATELY
BEDTIME FOR STOMACH
16) TRAMADOL HCL 50MG TAB (CS-IV) TAKE ONE TABLET BY
ACTIVE
MOUTH TWO TIMES A DAY AND TAKE TWO TABLETS AT

BEDTIME FOR PAIN
Pending Outpatient Medications
Status
==================================================
==================
1) TRAMADOL HCL 50MG TAB (CS-IV) TAKE TWO TABLETS BY
PENDING
MOUTH NOW FOR PAIN
Status
==================================================
==================
ACTIVE
ACTIVE
MISCELLANEOUS
Service Branch
ARMY
Service #
50176263
Entered
Separated
NOV 04, 1964
SEP 09, 1966
Discharge
HONORABLE
IMMUNIZATIONS NOV 02, 2015 INFLUENZA, SEASONAL, INJECTABLE

SEP 02, 2015 TDAP
DEC 24, 2014 INFLUENZA, UNSPECIFIED FORMULATION
OCT 23, 2013 FLU,3 YRS (HISTORICAL)
OCT 23, 2013 INFLUENZA, UNSPECIFIED FORMULATION
VITAL SIGNS:
============
DATE/TIME
TEMP
1/4/16 @ 1155
1/4/16 @ 0721
12/22/15 @ 0730
PULSE
52
97.6
98.1
RESP
18
52
62
BP
138/60
16
18
PAIN
0
213/84
135/76
0
3
PHYSICAL EXAMINATION:
=====================
GENERAL: ALERT, ORIENTED X3, IN NO ACUTE DISTRESS
HEENT: MMM, PERRL, EOMI, + JVD AT 45 DEGREES
HEART: RRR, NO MURMMURS OR GALLOPS
LUNGS: DECREASED BREATH SOUNDS AT BOTH BASES, MILD SCATERRED
EXPIRATORY
WHEEZES.
ABDOMEN: GLOBOUS, BS+, S&D, NON TENDER TO PALPATION
EXT: +1 EDEMA, NO CYANOSIS, PULSES SYMMETRICALLY PRESENT
**LABS**
========
ANCILLARY TROPONIN I: 0.11 H*
WBC: 10.0 H
RBC: 5.00
HGB: 15.3
HCT: 44.5
MCV: 89.0
MCH: 30.6
MCHC: 34.4
RDW: 13.1
PLT: 219
MPV: 12.9
SEGS: 81.2 H
LYMPHS: 10.8 L
MONOCYTES: 5.0
EOSINO: 2.8
BASO: 0.2
LYMPHS, ABSOLUTE: 1.08
MONOS, ABSOLUTE: 0.5
EOSINO, ABSOLUTE: 0.28
BASO, ABSOLUTE: 0.02
SEGS, ABSOLUTE: 8.09 H
GLUCOSE: 153 H
UREA NITROGEN: 17.3
CREATININE: 0.77
SODIUM: 141
POTASSIUM: 4.8
CHLORIDE: 103
CO2: 24
CALCIUM: 9.9
PROTEIN,TOTAL: 7.2
ALBUMIN: 4.1
BILIRUBIN,TOTAL: 0.79
ALKALINE PHOSPHATASE: 65
SGOT: 13
SGPT: 14
CK-MB 3/5/01: 5.38 H
pro-BNP 3/26/2003: 3202 H
EGFR 10/31/06: 98
TROPONIN-T: <0.01
CHEST XRAY:
----------Impression:

**EKG**
SINUS BRADYCARDIA, RATE 51, LVH, NO ACUTE ISCHEMIC CHANGES.
__________________
INITIAL IMPRESSION:
DECOMPENSATED CONGESTIVE HEART FAILURE
COMMUNITY ACQUIRED PNEUMONIA
CURB 65-1
__________________
ASSESTMENT:
===========
76 Y/O MALE PATIENT WITH ABOVE MEDICAL CONDITIONS THAT CAME TO ER
COMPLAINING OF
SHORTNESS OF BREATH AND CHEST PAIN. PATIENT STATES THAT HE SINCE

YESTERDAY HE
HAS MILD SHORTNESS OF BREATH ON EXCERTION AND LAST NIGT DEVELOPED AN
EPISODE OF
CHEST TIGHTNESS AND SEVERE SHORTNESS OF BREATH THAT LASTED FOR 2-3
HOURS. THIS
MORNING AROUND 6AM HE HAS ANOTHER EPISODE OF SHORTNESS OF BREATH
AND DECIDED TO
CAME TO ER. PATIENT ALSO REPORTED NON-PRODUCTIVE COUGH OF 2-3 DAYS OF
EVOLUTION,
AND CHILLS. DENIES FEVER, NAUSEA, VOMITS, DIAPHORESIS, PALPITATIONS.
REFERS
SYMPTOMS IMPROVEMENT AFTER RESPIRATORY THERAPIES.
PATIENT WAS EVALUATED BEDSIDE AND WAS FOUND ALERT, ORIENTED X3, IN NO
DISTRESS.
DENIES RECURRANCE OF CHEST PAIN. PHYSICAL EXAM WITH RRR, LUNGS WITH
DECREASED
BREATH SOUNDS AT BOTH BASES, MILD SCATERRED EXPIRATORY WHEEZES, +BS,
NO
TENDERNESS TO PALPATION, +1 PITTING EDEMA.
D-CHF
-----EKG WITH LVH, NO ACUTE ISCHEMIC CHANGES. 2D ECHO WITH NO EVIDENCE OF
SYSTOLIC
DYSFUNCTION. CHEST XRAY IS SUGGESTIVE OF PULMONARY EDEMA AND THERE IS
ELEVATED
PRO-BMP LEVELS. NEW ECHOCARDIOGRAM REQUESTED.
CAP
-----LABS WITH MILD LEUKOCYTOSIS, WITH NEUTROPHILIC PREDOMINACE. CHEST XRAY

CAN NOT
EXCLUDE PNEUMONIC PROCESS. DUE TO HX OF CHILLS WILL PROVIDE THE BENEFOT
OF
ANTIBIOTIC THERAPY FOR CAP. BLOOD CULTURES GIVEN AT ER.
AT THE MOMENT PATIENT DENIES SUICIDAL OR HOMICIDAL IDEAS. HE STATED THAT

LAST
NIGHT HE HAD SELF HARM IDEAS AFTER HE HEARD A SONG THAT BROUGHT HIM
MEMORIES OF
HIS RECENTLY DECEASED WIFE. PSYCHIATRY CONSULT WILL BE PLACED FOR
RECOMMENDATIONS.
PLAN:
========================
ADMIT TO: MEDICINE WARD
SEE ORDERS
PATIENT WILL REMAIN AT ER PENDING BED AVAILABILITY.
/es/ GLORIA E SOTO-PILLICH, MD

Staff physician/Hospitalist/Medicine Service
Signed: 01/04/2016 15:30
LOCAL TITLE: INTERNAL MEDICINE OD NOTE

STANDARD TITLE: INTERNAL MEDICINE NOTE
ENTRY DATE: JAN 04, 2016@19:41:43
AUTHOR: BERTRAN-LOPEZ,JOVAN EXP COSIGNER:

URGENCY:
STATUS: COMPLETED
********* ***
***
*******
********* **** ****

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

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

JAN 04, 2016@19:34:31
Ward: 6J MED DX: DECOMPENSATED CHF
Last discharge: OCT 09, 2011@12:34:99

Last admission: JAN 04, 2016@19:34:30 DX: DECOMPENSATED CHF
*************************************************************************
Chief Complaint:
*************************************************************************
Vine porque desde que fui al casino me sentia mal
*************************************************************************
History of Present Illness:
*************************************************************************
Mr. MARTINEZ-RAMIREZ is a 76-year-old MALE with the below mentioned medical
conditions who was in his usual state of health which consists of self-care,
free ambulation and independence on activities of daily living until Sunday

night when he was at the casino as usual and suddenly he heard a song that
reminded him of his wife that passed away. When this happened he started to feel
down and extremely sad reason for which he decided to go home. He could not
sleep at home and was feeling anxious, he stated he felt he was going to die and
was feeling shortness of breath. On Monday morning he decided to take his blood
pressure that he said was high and he therefore took his medications. He was
feeling nervous and he said in a state of panic. Reason for which he visited the
VAER. At the ER due to shortness of breath history, CXR that could not rule out
edema and elevated probnp he was admitted with CHF vs CAP. He denied n/v,
fever/chills, chest pain, palpitations, cough, abd. pain, diarrhea, black or
bloody stools, and GU complaints.
*************************************************************************
Past medical history:
*************************************************************************
- Hypertension
- Hyperlipidemia
- Gout
- Esophageal Reflux
- Diabetes Mellitus type II
- Arthritis
- Sensorineural bilateral hearing loss
- Coronary Artery Disease
*************************************************************************
Medications:
*************************************************************************
Active Inpatient Medications (including Supplies):
Active Inpatient Medications
Status
==================================================
==================
1) ASPIRIN ENTERIC COATED TAB,EC 81MG PO DAILY
ACTIVE
2) ATORVASTATIN CALCIUM TAB 20MG PO AT BEDTIME
ACTIVE
3) DEXTROSE 40% GEL,ORAL 24 GRAMS 40% PO Q15MIN PRN If ACTIVE

CONSCIOUS and CBG IS 50- 80mg/dl ADMINISTER 24GM
GLUCOSE ORAL GEL every 15 minutes until CBG is
above 80mg/dl. See text nursing orders.
4) DEXTROSE 40% GEL,ORAL 48 GRAMS 40% PO Q15MIN PRN If ACTIVE
CONSCIOUS and CBG under 50mg/dl ADMINISTER 48GM
(TWO GLUCOSE GEL 24GM) GLUCOSE ORAL GEL every 15
minutes until CBG is above 80mg/dl. See text
nursing orders.
5) RANITIDINE TAB 150MG PO AT BEDTIME
Pending Inpatient Medications
ACTIVE
Status
==================================================
==================
1) 5% DEXTROSE/WATER,USP INJ,SOLN in 5% DEXTROSE/WATER
PENDING
INJ,USP 500 ML START AT 100 ml/hr@0 IV

2) 50% DEXTROSE INJ,SOLN 25 MLS IVP Q15MIN PRN
PENDING
3) 50% DEXTROSE INJ,SOLN 50 MLS IVP Q2MIN (D50W) PRN

4) FUROSEMIDE INJ,SOLN 10MG/1ML IVP DAILY
PENDING
PENDING
5) GLUCAGON EMERGENCY KIT INJ 1MG/1VIAL IM Q15MIN PRN

6) HEPARIN INJ,SOLN 5000UNIT/1ML SC Q8H
PENDING
PENDING
7) INSULIN REGULAR 100 UNT/ML INJ BEDTIME REGULAR
PENDING
INSULIN SCALE SC AT BEDTIME PRN

8) INSULIN REGULAR 100 UNT/ML INJ CONTINUOUS FEEDING
PENDING
REGULAR INSULIN SUPPLEMENTAL SCALE SC Q6H PRN

9) INSULIN REGULAR 100 UNT/ML INJ NPO REGULAR INSULIN
PENDING
SUPPLEMENTAL SCALE SC Q6H PRN

10) INSULIN REGULAR 100 UNT/ML INJ PRE-PRANDIAL
PENDING
SUPPLEMENTAL REGULAR INSULIN SCALE SC TID 1/2HR-AC

PRN
11) LISINOPRIL TAB 10MG PO DAILY
PENDING
12) METOPROLOL TARTRATE(LOPRESSOR) TAB 25MG PO Q8H
PENDING
Status
==================================================
==================
ACTIVE

ACTIVE
NOW FOR HEART


JUICE
ACTIVE

TESTING
ACTIVE
ACTIVE

THREE TIMES A WEEK
ACTIVE
FOR DIABETES
ACTIVE

ACTIVE

ACTIVE

ACTIVE
IMMEDIATELY
BEDTIME FOR STOMACH

16) TRAMADOL HCL 50MG TAB (CS-IV) TAKE TWO TABLETS BY
ACTIVE
MOUTH NOW FOR PAIN
Status
==================================================
==================
ACTIVE
ACTIVE
MISCELLANEOUS
*************************************************************************
Objective:
*************************************************************************
Vital signs:
------------Blood pressure
Heart rate
: 138/60 (01/04/2016 11:55)

: 52 (01/04/2016 11:55)
Respiratory rate
: 18 (01/04/2016 11:55)
Temperature
: 97.6 F [36.4 C] (01/04/2016 07:21)
Pain
: 0 (01/04/2016 11:55)
Height
: 68 in [172.7 cm] (11/02/2015 09:41)
Weight
: 192 lb [87.3 kg] (11/02/2015 09:41)
BMI
BODY MASS INDEX - 29.3 (NOV 02, 2015@09:41:55)
Physical exam:
-------------General: Active, alert, oriented x3. In no acute distress
HEENT: PERRL, EOMI, moist oral mucosa.
Neck: Supple. No JVD at 45 degrees.
Heart: Slow rate and rhythm. No murmurs, gallops, or rub.
Lungs: Left lower lung crackles.
Abdomen: Abdominal hernia. Bowel sounds positive, soft and depressible, no
tenderness to palpation. No involuntary guarding or rebound tenderness.
Extremities: No cyanosis or edema. Distal pulses present bilaterally +2.
Neurologic: No gross focal neurological deficits.
*********************************************************************
Laboratories:
*********************************************************************
---- CBC PROFILE ----
BLOOD
Jan 04
Dec 22
Sep 30
Jul 27
2016
2015
2015
2015
08:10
05:46
14:24
08:07
Units
Reference
Ranges
------------------------------------------------------------------------------WBC
10.0 H
RBC
5.0
6.7
5.0
5.8
5.0
6.1 X10-3/ul 4.3 - 9.3

5.1 X10-6/ul 4.7 - 6.1
HGB
15.3
15.2
15.0
15.5
g/dL 12.6 - 17.8
HCT
44.5
44.2
43.8
45.5
MCV
89.0
88.6
88.0
90.1
fL 81 - 102
MCH
30.6
30.5
30.1
30.7
pg 26 - 34
37.9 - 54.5
MCHC
34.4
34.4
34.2
34.1
RDW
13.1
13.0
13.1
12.3
219.0
244.0
259.0
250.0
X10-3 155 - 371
MPV
12.9
12.3
11.7
12.2
fL 9 - 12.9
SEGS
81.2 H
PLT
57.7
63.4
29.0
g/dl 31 - 36.5
%
55.2
10.8 L
MONOS
5.0
7.6
9.0
7.0
2 - 12
EOSINO
2.8
5.1
4.7
5.7
0-7
BASO
0.2
SEGS#
8.09 H
3.85
3.68
1.08
1.94
1.3
LYMPHS#
EOS#
BASO#
0.28
0.34
0.02
MONOS#
0.5
0.3
1.94
17 - 48
0 - 1.4
X 10-3 1 - 3.5
0.35 X10-3/ul 0 - .4
0.03
0.51
3.37 X10-3/ul 1.64 - 6.96
0.27
0.04
0.5
31.8
34 - 74
LYMPHS
0.6
22.4
11 - 15
0.02 X10-3/ul 0 - .1
0.52
0.43 X10-3/ul .2 - 1
---- CHEM PROFILE ----
SERUM
Jan 04
Dec 22
Sep 30
Jul 27
2016
2015
2015
2015
08:10
05:46
14:24
08:07
Units
Reference
Ranges
------------------------------------------------------------------------------GLUCOSE
153 H
127 H
127 H
124 H mg/dL 70 - 99
BUN
17.3
23.9
22.0
CREA
0.8
0.8
0.8
NA+
141
144
K+
4.8
4.6
CL-
103
104
17.5
0.8
140
4.5
MG/DL .7 - 1.5
144
4.3
104
mEq/L 135 - 145
mEq/L 3.5 - 5
100
mEq/l 100 - 110
CO2
24
21 L
SGPT
14
24
20
U/L
0 - 45
SGOT
13
22
16
U/L
0 - 40
CK-MBEGFR
CA++
ALB
TP
CHOL EZ
HDL
NON HDL
CHOL/HD
LDL CHO
VLDL
TRIGLYC
25
5.38 H
98
ALK PHO
T BILI
21 L
mg/dL 10 - 26
ng/mL. 0 - 4.94
91
65
0.8
9.9
4.1
7.2
mEq/l 24 - 32
100
94
69
58
0.6
9.8
4.3
7.3
196
44.2
151.3 H
4.4
119.0 H
32.0 H
160 H
mL/min Ref: >=60
0.7
9.5
U/L 30 - 115
MG/DL .2 - 1.3
10.0
4.2
7.3
MG/DL 8.5 - 10.5

G/DL 2.6 - 5.2
G/DL 6 - 8.5
173
MG/DL 140 - 200
37.2 L MG/DL 39 - 60
135.8 H mg/dL Ref: <=130
4.7
99.0
mg/dL Ref: <=5

mg/dL Ref: <=100
37.0 H mg/dL Ref: <=30

186 H MG/DL 25 - 150
*********************************************************************
Radiology:
*********************************************************************
Chest X Ray Impression:

*********************************************************************
EKG:
*********************************************************************
Sinus rhythm with high degree AV block with junctional rhythm. Vent rate of
45bpm, QRS 90ms, QTc 394ms.
*********************************************************************
Diagnostic impression:
*********************************************************************
- Third degree AV block

- Panic attack
- Suicidal ideation
- Rule out of CHF or CAP
*********************************************************************
Assessment and Plan:
*********************************************************************
Mr. MARTINEZ-RAMIREZ is a 76-year-old MALE with hypertension, diabetes,

and gout, mentioned medical conditions who was in his usual state of health
which consists of self-care, free ambulation and independence on activities of
daily living until Sunday night when he was at the casino as usual and suddenly
he heard a song that reminded him of his wife that passed away. When this
happened he started to feel down and extremely sad reason for which he decided
to go home. He could not sleep at home and was feeling anxious, he stated he
felt he was going to die and was feeling shortness of breath. On Monday morning
he decided to take his blood pressure that he said was high and he therefore
took his medications. He was feeling nervous and he said in a state of panic.
Reason for which he visited the VAER. At the ER due to shortness of breath
history, CXR that could not rule out edema and elevated probnp he was admitted
with CHF vs CAP. He denied n/v, fever/chills, chest pain, palpitations, cough,
abd. pain, diarrhea, black or bloody stools, and GU complaints.
Upon arriving to the IM ward, patient was evaluated at bedside and was
found alert, awake, afebrile, hemodynamically stable and in no acute distress.
Vital signs evident of bradycardia. Physical exam left basilar crackles,
abdominal hernia, and benign rest of exam. ECG with high degree AV block,
negative chronotropism. Patient at the moment asymptomatic, referring he was
feeling better than when he arrived. Labs with leukocytosis, stable hemoglobin
and platelets. Chem profile with stable renal function and no major electrolyte
abnormalities. Probnp elevated at 3202. Due to AV block, patient was started on
telemetry, and bedside cardiac defibrillator on pacemaker mode placed.
Third degree AV block: Patient with fatigue and dyspnea that could be secondary
to this block. Patient's previous ECGs without AV block and heart rates over
60bpm. Patient at the moment of evaluation at IM ward referred no symptoms and
had stable vital signs despite bradycardia. Treatment for a complete AV block is
pacemaker placement. Therefore temporarily a bedside monitor in pacemaker
placed. Cardiology services called and consulted for further evaluation,
recommendations and if possible for placement of pacemaker. Patient had
metoprolol ordered at the ER, however never administered, it was quickly
discontinued.
Panic attack/bereavement: Patient with shortness of breath that started after

inciting event of his dead wife's memories. In association with extreme
nervousness, feeling of wanting to die, and lack of sleep. Patient's wife died 4
months ago, therefore bereavement, however based on panic symptoms also panic
attack on the differential. Patient's elevated blood pressure episode can be
related to emotional stressor, and is now resolved. Patient did express feeling
extremely sad and having ideas of killing himself by stepping up a stairway he
has at home and throwing himself down. Therefore patient started on constant
observation and psychiatry consulted.
Rule out of CHF vs CAP: Although patient was admitted with this rule out
diagnosis. I did not find the patient with signs of volume overload (JVD,
bilateral crackles, peripheral edema). Patient could lay down in his bed flat in
supine position. In addition patient denied cough, he has not had fever, does
present borderline high leukocytosis. CXR does not rule out any infectious or
effusion. Therefore I did not suspected CAP, reason for which he was not started
on antibiotic therapy. Echocardiogram ordered. Last echo from 2010 with
preserved diastolic and systolic function.
Patient clearly expressed wanting to be FULL CODE.
*********************************************************************
Admission orders:
*********************************************************************
ADMIT TO: Medicine
DIAGNOSIS: See above
CONDITION: Stable
PROGNOSIS: Guarded
VITALS: Q8H on chart
ACTIVITY: Bed rest
NURSING: See orders
DIET: See orders
IN/OUTS: Q8H on chart
IV FLUIDS: See orders
LABS: See orders
IMAGINGS: See orders
CONSULTS: None
Allergies: Patient has answered NKA
--------------------------------------------------------------------Medication Reconciliation
--------------------------------------------------------------------MEDICATIONRECONCILIATION
____Admission Medication Reconciliation

_x__Discharge Medication Reconciliation
____Transfer Medication Reconciliation
Inpatient 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: Aspirin 81mg chew tab 162mg 2 tablets chewable now
IP: Aspirin 81mg ec tab
po daily
OP: Aspirin 81mg ec tab (non-va) 81mg mouth every day

IP: Aspirin 81mg ec tab
po daily
OP: Atorvastatin calcium 40mg tab 20mg 0.5 tablet po at bedtime

IP: Atorvastatin calcium 20mg tab po at bedtime
OP: Lisinopril 20mg tab 10mg 0.5 tablet po daily

IP: Lisinopril 10mg tab po daily
OP: Ranitidine hcl 150mg tab 1 tablet po at bedtime

IP: Ranitidine hcl 150mg tab po at bedtime
Outpt Meds with No Corresponding Inpt Meds

-------------------------------------------------------------Albuterol so4 0.083% inhl 3ml 3 milliliters inhl once
Cephalexin 500mg cap 1 capsule po q12h
Clotrimazole 1% top soln a small amount top daily
Diphth/pertuss/tet (tdap) (boostrix) syr 0.5 milliliter im once
Dm 10/guaifenesin 100mg/5ml (alc-f) liq 2 teaspoonfuls po q6h
Fluticasone prop 50mcg 120d nasal inhl 1 spray inh nas daily
Freestyle lite (glucose) test strip 1 strip misc tiw
Gabapentin 400mg cap 1 capsule po bid
Hydrochlorothiazide 25mg tab 12.5mg 0.5 tablet po daily
Lancet,freestyle 1 lancet misc tiw
Loratadine 10mg tab 1 tablet po daily prn
Meloxicam 7.5mg tab 1 tablet po daily prn
Metformin hcl 1000mg tab 500mg 0.5 tablet po daily
Moxifloxacin hcl 400mg tab 1 tablet po stat
Mupirocin 2% oint a thin film top tid
Tramadol hcl 50mg tab (cs-iv) 100mg 2 tablets po now
Inpt Meds Only (that are not on Outpt)

---------------------------------------------------------------Dextrose 24gm/31gm squeeze tube 24 grams 40% po q15min prn
Dextrose 24gm/31gm squeeze tube 48 grams 40% po q15min prn

Dextrose 50% inj 25 mls ivp q15min prn
Dextrose 50% inj 50 mls ivp q2min (d50w) prn
Furosemide 10 mg/ml 4ml 10mg/1ml ivp daily
Glucagon 1mg/vil inj emergency kit 1mg/1vial im q15min prn
Heparin 5,000 u /ml vi 5000unit/1ml sc q8h
Insulin reg human 100 u/ml inj novolin r bedtime regular insulin scale sc at
bedtime prn
Insulin reg human 100 u/ml inj novolin r continuous feeding regular insulin
supplemental scale sc q6h prn
Insulin reg human 100 u/ml inj novolin r npo regular insulin supplemental
scale sc q6h prn
Insulin reg human 100 u/ml inj novolin r pre-prandial supplemental regular
insulin scale sc tid 1/2hr-ac prn
---------------------------------------------------------------------
/es/ JOVANNA BERTRAN-LOPEZ, MD

Resident Physician/Medical Serv/Internal Medicine
Signed: 01/05/2016 05:39
LOCAL TITLE: PSYCHIATRIC OD CONSULT

STANDARD TITLE: PSYCHIATRY CONSULT
ENTRY DATE: JAN 05, 2016@05:58:06
AUTHOR: ROQUE-SALDANA,ALEXA EXP COSIGNER: FEBLES-GORDIAN,INDRA

URGENCY:
STATUS: COMPLETED
*** PSYCHIATRIC OD CONSULT Has ADDENDA ***
****** ****** *
** ** **
* ****** **
** ** **
* **
**
**
* **
**
**
* * **
**
**
** ** **
****** ******
** **
********
**
**
** **
**
**
**
**
** **
**
**
**
**
**
**
**
**
******
**
**
**
****** **
**
HISTORY OF PRESENT ILLNESS:

Patient is Mr. MARTINEZ-RAMIREZ 76 year old MALE patient, 50% SERVICE
CONNECTED due to physical conditions, Vietnam Era veteran, WIDOWED, father of 2
adults, who is currently living in SAN JUAN, PR with daughter. Patient with past
psychiatric history of Unspecified Depressive Disorder, currently does not have
psychiatric follow up.
Patient admitted to Internal Medicine ward with working diagnosis of
Third Degree AV Block, and consulted to psychiatry service after verbalizing
suicidal ideas. Upon evaluation patient reported "ever since I have this
condition of neuropathy and pain in my legs, every time I get the pain it
changes my mood, and everytime that pain comes I think about killing myself,
jumping off the roof of my house". Patient reported that since his pain is not
well controlled he has this thought on an almost daily basis. Patient also
reported that 2 days ago he was at the casino, and a Trio was playing some "sad
songs" and he started to feel very sad because it reminded him of his wife.
Patient reported "after her death I am trying to carry on my life the same way,
I keep going to the casino, and to the horse tracks, I keep myself very active".
Patient reported that he has been feeling sad and depressed for "Some time now,
even before her death, I came to PIC many years ago for that too". Patient
denied difficulty sleeping or decreaed appetite. He reported good compliance
with medications. Denied active suicidal ideas, but reported that "I do not
control when the Ideas come, because they come with the pain". Patient denied
homicidal ideas, denied hearing or seeing things not perceived by others.
Patient denied feeling anxious, denied manic or hypomanic symptoms.
HEALTH or MEDICAL PROBLEMS:

- Hypertension
- Hyperlipidemia
- Gout
- Esophageal Reflux
- Peptic ulcer of unspecified site, unspecified as acute or chronic, without m
- Exogenous Obesity
- Male erectile disorder
- Refraction Error
- Impotence of organic origin
- Diabetes Mellitus
- Arthritis
- OVERWEIGHT
- Presbyopia
- Astigmatism, NOS
- Myopia
- Blepharitis
- Senile nuclear sclerosis
- Open angle with borderline glaucoma findings
- DM Type II, No Retinopathy
- Diabetic Neuropathies
- Coronary Artery Disease
- Microscopic Hematuria
- Intermittent Claudication
- Impacted cerumen
- Joint pain
- Paronychia
- Family bereavement
- Onychomycosis of toenails
- Ingrowing toenail
ALLERGIES:
OVER THE COUNTER MEDICATIONS OR HERBAL REMEDIES:

None reported
REVIEW OF SYSTEMS:
see H&P MEDICAL SERVICE NOTE dated 1/4/2016
SUBSTANCE HISTORY:
Patient denies active alcohol, nicotine or illicit drug use.
PAST PSYCHIATRIC HISTORY:

No past psychiatric admissions, no past suicide attempts or gestures.
PSYCHIATRIC MEDICATIONS:
None
HEAD TRAUMA/SEIZURES/LOST OF CONSCIOUSNESS:

Patient denies head trauma, seizure or loss of consciousness.
FAMILY PSYCHIATRIC HISTORY:

Father and grandfather with alcoholism. No family history of suicide.
SOCIAL HISTORY:
Patient denies legal problems, denies access to weapons or firearms.
VITALS:
DATE/TIME
TEMP
1/5/16 @ 0054
PULSE
45
RESP
BP
162/79
1/4/16 @ 2356
1/4/16 @ 2356
97.9
42
19
171/74
PAIN
1/4/16 @ 2003
96
1/4/16 @ 1155
46
52
20
18
148/68
138/60
0
0
MENTAL STATUS EXAMINATION
1)Appearance/behavior: Geriatric male, appears in accordance with age, fair

grooming and hygiene, dressed casual, good eye contact, cooperative.
2)Psychomotor: no psychomotor retardation/agitation, calm, no tics or

involuntary movements.
3)Speech: spontaneous, adequate volume and production, and fluent.
4) Mood: "better"
5)Affect: restricted
6)Thought process: coherent, circumstantial, logical, no

perseveration, no racing thoughts.
7)Thought content: on/off suicidal ideas with plan, no homicidal ideas, no

ideas of reference present, no obsessions nor compulsions, no phobias or
delusions.
8)Perceptual disturbances: not interacting with internal stimuli
9)Cognitive: awake, alert, and oriented in person, time, and place. Immediate,
recent, and remote memory intact.
10)Insight: poor
11)Judgment: poor
LETHALITY ASSESMENT:
RISK FACTORS (select yes or no when present)
1. Previous suicide attempts/gestures
2. Family history of suicide
no
no
3. Current substance abuse/dependence
no
4. Lack of social support/relationships
no
5. Increased situational stressors
yes
6. Recent or impending loss
yes
7. Worsening physical health
yes
8. Long psychiatric history
no
9. Evidence of alcohol/drug dependence
no
10. Diagnosis of Schizophrenia

11. Current suicidal ideation
12. Current suicidal plan
no
yes
yes
13. Recent suicidal attempt/gesture
no
14. Prominent feelings of hopelessness/helplessness no

15. Evidence of clinical depression
16. Evidence of psychosis at present
17. Increased energy level following severe
yes
no
Depression
no
CURRENT RISK LEVEL:

*High
(x)
(Several factors and at least 11, 12 or 13 is present)

**Moderate
()
(Several factors are present but no 11, 12 or 13)

***Low
()
(Few factors are presents but no 11, 12, or 13)

None
()
AIMS:
0 (zero) = normal
LABSORATORIES:
Specimen Collection Date: Dec 22, 2015@05:46
Test name
TSH
Result
4.550
units
Ref. range Site Code
uIU/mL
0.46 - 4.98
[672]
==================================================
=============================
Specimen Collection Date: Jan 05, 2016

Test name
Result
units
WBC
7.0
X10-3/ul 4.3 - 9.3
[672]
RBC
4.7
X10-6/ul 4.7 - 6.1
[672]
HGB
14.2
g/dL
HCT
42.2
12.6 - 17.8
37.9 - 54.5
[672]
[672]
MCV
89.8
fL
81 - 102
[672]
MCH
30.2
pg
26 - 34
[672]
MCHC
RDW-CV
33.6
31 - 36.5
[672]
11 - 15
[672]
155 - 371
[672]
13.0
PLT
232
MPV
11.8
SEGS%
g/dl
X10-3
fL
60.3
9.0 - 12.9
[672]
34 - 74
[672]
LYMPHS%
27.0
17 - 48
MONOS%
8.0
2 - 12
EOSINO%
4.6
0-7
[672]
0 - 1.4
[672]
BASO%
SEGS ABSOLUTE#
0.1
%
4.19
[672]
[672]
X10-3/ul 1.64 - 6.96
LYMPHS ABSOLUTE#
1.88
X 10-3
MONOS ABSOLUTE#
0.56
X10-3/ul 0.2 - 1.0
[672]
EOSINO ABSOLUTE#
0.32
X10-3/ul 0.0 - 0.4
[672]
BASO ABSOLUTE#
0.01
1.0 - 3.5
[672]
X10-3/ul 0.0 - 0.1
[672]
[672]
==================================================
=============================
ASSESSMENT:
Geriatric male patient with history of Unspecified Depressive Disorder
who is presenting on/off suicidal ideas with plan in the context of physical
health and pain. In addition, patient is experiencing changes in life style
after recent death of his wife. Patient, even though he is not actively
suicidal, he was unreliable at time of questioning about suicide ideas, since
this thoughts come on a regular basis to him. Therefore, we recommend to
continue Constant 1:1 observation. Patient with previous use of SSRI for
depressive symptoms, in which case, Sertraline may be started at dose of 25mg

daily. To aid in depressive symptoms as well, pain management and control would
be beneficial since this is one of his main stressors. In considering a change
in pain treatment, Tramadol is associated with risk of serotonergic syndrome
when used with serotonin reuptake inhibitor(SSRI's), for which other
alternatives for pain treatment should be considered.
DIAGNOSTIC IMPRESSION:
Unspecified Depressive Disorder
Bereavement
Global Assessment Functioning: 40
RECOMMENDATIONS:
=================
1. Ensure safety, keep in constant 1:1 observation
2. Falls precautions
3. Discard and treat medical causes contributing with depression

> Do Vitamin B12 and Folate levels
4. Medication:
START Sertraline 25mg oral in the morning with food
5. Catholic Chaplain consult
6. Ensure adequate pain management
7. Will follow. Contact Psychiatry service at Beeper #0878 on regular working

hours and after regular working hours call On duty psychiatrist Beeper #
0143. Thanks.
Patient discussed with attending psychiatrist Dr. Febeles, who agrees with
diagnosis, assessment and recommendations.
/es/ ALEXANDRA ROQUE-SALDANA, MD

RESIDENT PHYSICIAN/PSYCHIATRY SERVICE
Signed: 01/05/2016 06:29
/es/ INDRA FEBLES-GORDIAN,MD

Physician/Psychiatry Service/Psychiatrist
Cosigned: 01/05/2016 12:13
01/05/2016 ADDENDUM
STATUS: COMPLETED
Staff Psychiatrist Note:
I was the attending on call when resident evaluated this patient. This case was
discussed with me by phone during the call. I agree with resident's evaluation
and management of this case.
/es/ INDRA FEBLES-GORDIAN,MD

Physician/Psychiatry Service/Psychiatrist
Signed: 01/05/2016 12:14
LOCAL TITLE: CARDIOLOGY CONSULT

STANDARD TITLE: CARDIOLOGY CONSULT
ENTRY DATE: JAN 05, 2016@06:12:05
AUTHOR: RODRIGUEZ-MONSERRAT EXP COSIGNER: SUAREZ-GONZALEZ,JOSE M

URGENCY:
STATUS: COMPLETED
VA Cardiovascular Assessment, Reporting, and Tracking (CART) system
CARDIOVASCULAR PRE-PROCEDURE ASSESSMENT REPORT
Patient: MARTINEZ-RAMIREZ,WALTER SSN: 580584562 DOB: 01/30/1939 AGE: 76

Assessment Date:
1/5/2016
Assessed by: RODRIGUEZ-MONSERRATE,CARLA P

Attending: SUAREZ-GONZALEZ,JOSE M
PRESENTATION
MR.MARTINEZ IS A 76 Y/O MALE PAITENT WITH THE A MEDICAL HISOTRY OF

HYPERNTESION, DIABETES, ALCOHOL USE, WHO CAME TO ER AFTER HE SUFFERED
AN
EPSIDOE OF CHEST DISCOMFORT AND ASSOCIATED WITH SOB. HE WAS IN THE
CASINO,
WHEN HE HEARD THE MUSIC THAT REMEMBERS HIS WIFE THAT DIED 4 MONTHS
AGO. DENIED
OTHER PREVIOUS EPSIDOES OF CHEST DISCOMFORT. AT ER HE WAS FOUND WITH
TROP I IN
0.11, TROP T NEGATVIE X3 AND CPK MB IN 5. AT VAER HE WAS OFUND WITH AN
EKG
WITH HIGH DEGREE AV BLOCK . VITALS WERE FOUND STABLE,
ASYMPTOMATIC. BUT IN VIEW OF CURRENT FINDINGS HE WILL BE SCHEDULE FOR
PERMANENT PACEMAKER.
PRESENTATION SUMMARY
Other
NYHA Functional Class I
No cardiogenic shock
PRIOR CARDIAC HISTORY
No prior CHF, No prior MI, No prior CABG, No prior PCI, No prior Cardiac Cath,
No prior Valve Surgery, No prior Valve Treatment (TVT),
No prior Cardiac Transplant
CARDIAC RISK FACTORS

Diabetes, Hypertension, Dyslipidemia
No family history of CAD

No history of tobacco use
No history of alcohol abuse
No history of illicit drug use
COMORBID CONDITIONS
PVD
No PTSD, No Depression, No COPD, No OSA, No Renal Failure, No CVD
LVEF
Nuclear (2011) EF=55%, Normal systolic function, Normal wall motion
PHYSICAL EXAM
BP:
143/ 82 mm Hg (01/05/2016 08:06)
HR:
42 bpm
(01/05/2016 08:06)
Height: 68 inches
(11/02/2015 09:41)
Weight: 196.2 lbs

BSA:
1.9 m2
(01/04/2016 23:56)
(01/04/2016 23:56)
Neck:
Bilateral carotid bruits
Lungs:
No rales present
Cardiac:
No extra heart sound present
No murmur
Extremities:
No femoral bruits
Leg Pulses:
Normal left femoral pulse
Normal right femoral pulse
Normal left dorsalis pedis pulse
Normal right dorsalis pedis pulse
Normal left posterior tibial pulse
Normal right posterior tibial pulse
Arm Pulses:
Normal left radial pulse
Normal right radialpulse
Normal left brachial pulse
Normal right brachial pulse
LABS
BNP
: 3202
(01/04/2016 08:10)
Creatinine
: 0.77
(01/04/2016 08:10)
Potassium
: 4.8
(01/04/2016 08:10)
CK-MB
: 5.38
(01/04/2016 08:10)
Troponin T
: <0.01
(01/05/2016 05:34)
Hematocrit
: 42.2
(01/05/2016 03:15)
Platelets
: 232
(01/05/2016 03:15)
INR
: 1.18
(01/05/2016 08:3)
PTT
: 30.5
(01/05/2016 08:3)
WBC
: 7
(01/05/2016 03:15)
Cholesterol total
: 196
(12/22/2015 05:46)
LDL (calculated)
: 119
(12/22/2015 05:46)
HDL Cholesterol
Triglycerides
: 44.2
: 160
(12/22/2015 05:46)
(12/22/2015 05:46)
INPATIENT MEDICATIONS
HEPARIN INJ,SOLN expires: 01/11/2016
Give: 5000UNIT/1ML SC Q8H
ATORVASTATIN CALCIUM TAB expires: 01/25/2016

Give: 20MG PO AT BEDTIME
RANITIDINE TAB expires: 01/25/2016

Give: 150MG PO AT BEDTIME
*ASPIRIN ENTERIC COATED TAB,EC expires: 01/25/2016

Give: 81MG PO DAILY
*DEXTROSE 40% GEL,ORAL expires: 01/25/2016

Give: 24 GRAMS 40% PO Q15MIN PRN
*DEXTROSE 40% GEL,ORAL expires: 01/25/2016

Give: 48 GRAMS 40% PO Q15MIN PRN
*FUROSEMIDE INJ,SOLN expires: 01/25/2016

Give: 10MG/1ML IVP DAILY
LISINOPRIL TAB expires: 01/25/2016
Give: 10MG PO DAILY
*INSULIN REGULAR 100 UNT/ML INJ expires: 01/25/2016

Give: PRE-PRANDIAL SUPPLEMENTAL REGULAR INSULIN SCALE SC TID 1/2HR-AC
PRN

Give: BEDTIME REGULAR INSULIN SCALE SC AT BEDTIME PRN

Give: CONTINUOUS FEEDING REGULAR INSULIN SUPPLEMENTAL SCALE SC Q6H
PRN

Give: NPO REGULAR INSULIN SUPPLEMENTAL SCALE SC Q6H PRN
50% DEXTROSE INJ,SOLN expires: 01/25/2016

Give: 50 MLS IVP Q2MIN (D50W) PRN
50% DEXTROSE INJ,SOLN expires: 01/25/2016

Give: 25 MLS IVP Q15MIN PRN
GLUCAGON EMERGENCY KIT INJ expires: 01/25/2016

Give: 1MG/1VIAL IM Q15MIN PRN
in 5% DEXTROSE/WATER INJ,USP 500 ML expires: 01/25/2016

IV START AT 100 ml/hr@0
Instructions too long. See order details for full text.
SERTRALINE TAB expires: 01/26/2016

Give: 25MG PO DAILY
OUTPATIENT MEDICATIONS
VANCOMYCIN INJ Qty: 1
Sig: ADMINISTER 1GM INTRAVENOUS USE ONCE FOR INFECTION
ATORVASTATIN CALCIUM 40MG TAB Qty: 45 for 90 days

expires: 09/02/2016; last filled: 12/06/2015
Sig: TAKE ONE-HALF TABLET BY MOUTH AT BEDTIME FOR CHOLESTEROL ,
AVOID GRAPEFRUIT JUICE
CLOTRIMAZOLE 1% TOP SOLN Qty: 10 for 30 days

Sig: APPLY A SMALL AMOUNT TO AFFECTED AREA EVERY DAY FOR FUNGI
INFECTION
HYDROCHLOROTHIAZIDE 25MG TAB Qty: 45 for 90 days

Sig: TAKE ONE-HALF TABLET BY MOUTH EVERY DAY WITH FOOD ,
AVOID EXPOSURE TO SUNLIGHT , FOR HIGH BLOOD PRESSURE
LISINOPRIL 20MG TAB Qty: 45 for 90 days

Sig: TAKE ONE-HALF TABLET BY MOUTH EVERY DAY FOR HEART OR FOR HIGH
BLOOD
PRESSURE
METFORMIN HCL 1000MG TAB Qty: 45 for 90 days

Sig: TAKE ONE-HALF TABLET BY MOUTH EVERY DAY WITH FOOD , FOR DIABETES
FREESTYLE LITE (GLUCOSE) TEST STRIP Qty: 50 for 90 days

Sig: USE 1 STRIP FOR TESTING
LANCET,FREESTYLE Qty: 100 for 90 days

Sig: USE 1 LANCET
RANITIDINE HCL 150MG TAB Qty: 30 for 30 days

Sig: TAKE ONE TABLET BY MOUTH AT BEDTIME FOR STOMACH
MUPIROCIN 2% OINT Qty: 22 for 30 days

Sig: APPLY A THIN FILM TO AFFECTED AREA THREE TIMES A DAY FOR INFECTION
CEPHALEXIN 500MG CAP Qty: 14 for 7 days

Sig: TAKE ONE CAPSULE BY MOUTH EVERY 12 HOURS FOR INFECTION
*MELOXICAM 7.5MG TAB Qty: 14 for 14 days

Sig: TAKE ONE TABLET BY MOUTH EVERY DAY AS NEEDED FOR PAIN
Non-VA NO NON-VA MEDICATIONS/HERBALS/OTC's MISCELLANEOUS
Non-VA ASPIRIN 81MG EC TAB

81MG MOUTH EVERY DAY
ALLERGIES/ADVERSE REACTIONS
No known allergies
SEDATION/CONSENT
Planned sedation: Moderate
Mallampati Class 2: faucial pillars, soft palate visible
Mouth: Teeth
Airway: Normal
Jaw/Neck mobility: Normal
No difficulty with prior moderate sedation, analgesia, general anesthesia

and/or regional anesthesia.
Physical status assessment (ASA class):
3 - patient with severe systemic disease
NPO status for procedure was explained to patient/surrogate.
The risks, benefits, and alternatives of the procedure and sedation/analgesia

were explained to and discussed with the patient/surrogate in detail.
All questions have been answered and the patient/surrogate understands the
potential risks and benefits and consents to the procedure and the plan
for sedation.
SUMMARY
Planned Procedures: Permanent Pacemaker
/es/ CARLA P RODRIGUEZ-MONSERRATE, MD

Admitting Physician/MOD, Medical Service
Signed: 01/05/2016 10:29
/es/ JOSE M SUAREZ-GONZALEZ, MD

Physician/Medical Service/Cardiology
Cosigned: 01/05/2016 11:20
LOCAL TITLE: CARDIOTHORACIC CONSULT NOTE
STANDARD TITLE: CARDIOLOGY CONSULT

ENTRY DATE: JAN 05, 2016@10:14:40
AUTHOR: ONEILL-RIVERA,JOSE EXP COSIGNER:

URGENCY:
STATUS: COMPLETED
CT SURGERY
PLEASANT 76 YRS OLD PT. VERY ACTIVE ADMITTED WHITH
SYMTOMS OF CHF,SOB AND FOUND WHITH COMPLETE A/V BLOCK. THERE IS NO HX
OF MI OR
MEDICATIONS THAH COULD PRECITITATE HIS HEART BLOCK. PPM IMPLANT IS BEEN
ADVISED.PROECEDURE BENEFITS AND RISKS EXPLAINED HE UNDERTANDS AND
WANTS TO
PROCED.
/es/ ONEILL-RIVERA,JOSE G, MD
Physician,Surgical Service/Thoracic Surgery
Signed: 01/05/2016 10:22
LOCAL TITLE: POSTOPERATIVE SUPERVISION AND WOUND CLASSIFICATION

STANDARD TITLE: WOUND CARE NOTE
ENTRY DATE: JAN 05, 2016@12:09:59

URGENCY:
STATUS: COMPLETED
OPERATIVE SUPERVISION AND FINDINGS:COMPLETE A/V BLOCK

DATE OF OPERATION: JAN 05, 2016
OPERATIVE PROCEDURES:IMPLANT ENDOVENOUS PPM,DDD-R,FLUROSCOPY,
OPERATING TEAM:DR A CEDENO,DR J ONEILL
Levels of Involvement:
() Level A: Attending doing the operation: The staff practitioner
performs the case, but may be assisted by a resident.
(XX) Level B: Attending in OR, Scrubbed: The supervising practitioner is

physically present in the operative or procedural room and
directly involved in the procedure. The resident performs
major portions of the procedure.
() Level C: Attending in OR, Not Scrubbed: The supervising

practitioner is physically present in the operative
or procedural room. The supervising practitioner observes
and provides direction. The resident performs the
procedure.
() Level D: Attending in OR Suite, Immediately Available: The

supervising practitioner is physically present in the
operative or procedural suite and immediately available for
resident supervision or consultation as needed.
() Level E: Emergency Care: Immediate care is necessary to preserve

life or prevent serious impairment. The supervising
practitioner has been contacted.
() Level F: Non-OR Procedure: Routine bedside and clinic procedure

done in the OR. The supervising practitioner is identified.
SURGICAL WOUND CLASSIFICATION:

Check appropriate classification:
(X) Clean wound
() Clean-contaminated wound
() Contaminated wound
() Dirty and infected wound
SENSING PACING RESISTANCE
FINDINGS: ATRIUM
VENTRICLE
4.2mV
9.8 MV
.7V
.4V
715 oHMS
1,229 oHMS
ADDITIONAL COMMENTS:
() NO (X) YES, The key portion(s) of this procedure was (were) performed
in my presence.
Signed: 01/05/2016 12:15
LOCAL TITLE: SURGERY BRIEF POST OP NOTE

STANDARD TITLE: SURGERY POST OPERATIVE E & M NOTE
ENTRY DATE: JAN 05, 2016@12:15:51

URGENCY:
STATUS: COMPLETED
MARTINEZ-RAMIREZ,WALTER
DATE: JAN 05, 2016 12:15
PREOPERATIVE DIAGNOSIS: COMPLETE A/V BLOCK
POST OP DIAGNOSIS: COMPLETE A/V BLOCK
SURGEON: DR A CEDENO
ASSISTANT: DR J ONEILL
ANESTHESIA:GETA
PROCEDURE: IMPLANT PPM,DDD-R,
SURGICAL FINDINGS: SEE POSTOP NOTE,
SPECIMENS: NONE,
COMPLICATIONS: NONE,
ESTIMATED BLOOD LOSS: 50/CC
DRAINS:NONE,
CONDITION ON ARRIVE IN PACU: Stable
ATTENDING PHYSICIAN (responsible for Post-op care):
Signed: 01/05/2016 12:17
Reporting Lab: SAN JUAN VA MEDICAL CENTER [CLIA# 40D0987710]

10 Casia St. One Veterans Plaza SAN JUAN, PR 00921-3200
Report Released Date/Time: Jan 05, 2016@10:12

Provider: RODRIGUEZ-MONSERRATE,CARLA P
Specimen: PLASMA.
COAG 0105 147
Specimen Collection Date: Jan 05, 2016@08:30

Test name
INR
Result
1.18
Eval:
units

[672]
Eval: RECOMMENDED THERAPEUTIC RANGES FOR ORAL ANTICOAGULATION

THERAPY**
Eval:
Eval: INR 1.5:
Eval: a. Patients treated with OAC requiring ambulatory surgery
Eval:
Eval: INR 2.0-3.0:
Eval: a. Prophylaxix of venous thrombosis during high risk surgery
Eval: b. Treatment of venous thrombosis
Eval: c. Treatment of pulmonary embolism
Eval: d. Prevention of systemic embolism
Eval: (Tissue heart valves, AMI, Atrial fibrillation)
Eval:
Eval: INR 2.5-3.5:
Eval: a. Mecahnical prosthetic valves
Eval: b. Prevention of recurrent myocardial infarction
Eval:
Eval:
Eval: REF:
Eval: Oral Anticoagulants: Mechanism of Action, Clinical Effectiveness,
Eval: and Optimal Therapeutic Range. Sixth ACCP Consensus Conference on
Eval: Antithrombotic Therapy. 2001
PROTHROMBIN TIME
14.4
PARTIAL THROMBOPLASTIN TIME
Secs.
30.5
11.8 - 15.0
Secs.
[672]
22.4 - 38.3
[672]
==================================================
=============================


Provider: DE JESUS,FRANCISCO
Specimen: BLOOD,CAPILLARY. ANC 0105 314
Test name
Result
ANCILLARY GLUCOSE (NEW)
units
136

mg/dL
70 - 99
[672]
==================================================
=============================


Provider: DE JESUS,FRANCISCO
Specimen: BLOOD,CAPILLARY. ANC 0105 203
Test name
Result
ANCILLARY GLUCOSE (NEW)
units
161

mg/dL
70 - 99
[672]
==================================================
=============================


Provider: RUIZ-RODRIGUEZ,DORCAS L
Specimen: PLASMA.
CHEM 0105 269

Test name
TROPONIN-T
Result
units
<0.01
ng/mL.

0 - 0.1
[672]
Eval: Effective 3/9/09: For patients with new Troponin-T elevations greater
Eval: than 0.1 ng/ml (and clinical findings consistent with ACS), the provider
Eval: must document discussion with cardiology within 24 hours (include name
Eval: of cardiologist in note). Contact numbers:
Eval: Regular work shift ext: 31788 Off-regular work shift: 787-510-0614.
==================================================
=============================


Provider: SOTO-PILLICH,GLORIA E
Specimen: BLOOD.
HEM 0105 131

Test name
Result
units
WBC
7.0
X10-3/ul 4.3 - 9.3
[672]
RBC
4.7
X10-6/ul 4.7 - 6.1
[672]
HGB
14.2
g/dL
HCT
42.2
37.9 - 54.5
MCV
89.8
fL
81 - 102
[672]
MCH
30.2
pg
26 - 34
[672]
MCHC
RDW-CV
33.6
232
MPV
11.8
SEGS%
[672]
31 - 36.5
[672]
11 - 15
[672]
155 - 371
[672]
X10-3
fL
60.3
[672]
g/dl
13.0
PLT
12.6 - 17.8
9.0 - 12.9
[672]
34 - 74
[672]
LYMPHS%
27.0
17 - 48
MONOS%
8.0
2 - 12
EOSINO%
4.6
0-7
[672]
0 - 1.4
[672]
BASO%
SEGS ABSOLUTE#
0.1
%
4.19
[672]
[672]
X10-3/ul 1.64 - 6.96
LYMPHS ABSOLUTE#
1.88
X 10-3
MONOS ABSOLUTE#
0.56
X10-3/ul 0.2 - 1.0
[672]
EOSINO ABSOLUTE#
0.32
X10-3/ul 0.0 - 0.4
[672]
BASO ABSOLUTE#
0.01
1.0 - 3.5
[672]
X10-3/ul 0.0 - 0.1
[672]
[672]
==================================================
=============================


Provider: SOTO-PILLICH,GLORIA E
Specimen: SERUM.
CHEM 0105 194

Test name
Result
MAGNESIUM
PRO-BNP
units
1.73 L mg/dL
3.7
G/DL
CALCIUM
9.0
MG/DL
CREATININE
eGFR
SODIUM
1.8 - 2.4
1801 H pg/mL
ALBUMIN
PO4
3.9
0.72
106
142
Ref: <=450
2.6 - 5.2
2.5 - 4.5
MG/DL
[672]
mEq/L
135 - 145
[672]
[672]
3.5 - 5.0
CHLORIDE
103
mEq/l
100 - 110
UREA NITROGEN
[672]
Ref: >=60
mEq/L
GLUCOSE
[672]
mL/min
4.1
24
[672]
.7 - 1.5
POTASSIUM
CO2
[672]
[672]
8.5 - 10.5
mg/dL
[672]
mEq/l
24 - 32
136 H mg/dL
16.2
mg/dL
[672]
[672]
70 - 99
10 - 26
[672]
[672]
==================================================
=============================


Specimen: PLASMA.
CHEM 0104 1700

Test name
TROPONIN-T
Result
0.02
units
ng/mL.
0 - 0.1
[672]
==================================================
=============================


Specimen: BLOOD.
ANC 0104 271

Test name
Result
units
ANCILLARY TROPONIN I
0.11 H* ng/mL
0.00 - 0.079
[672]
Comment: MD Notified
==================================================
=============================
---- MICROBIOLOGY ---Accession [UID]: BC 16 112 [4616000112]
Received: Jan 04, 2016@08:53
Collection sample: BLOOD CULTURE BOTTLECollection date: Jan 04, 2016 08:25
Site/Specimen: BLOOD
Test(s) ordered: BLOOD CULTURE
==================================================
=============================


Specimen: BLOOD.
HEM 0104 499

Test name
Result
units
WBC
10.0 H X10-3/ul 4.3 - 9.3
RBC
5.0
HGB
15.3
g/dL
HCT
44.5
37.9 - 54.5
MCV
89.0
fL
81 - 102
[672]
MCH
30.6
pg
26 - 34
[672]
MCHC
X10-6/ul 4.7 - 6.1
34.4
RDW-CV
219
MPV
12.9
SEGS%
[672]
[672]
31 - 36.5
[672]
11 - 15
[672]
155 - 371
[672]
X10-3
fL
9.0 - 12.9
81.2 H %
LYMPHS%
[672]
g/dl
13.1
PLT
12.6 - 17.8
[672]
10.8 L %
[672]
34 - 74
17 - 48
[672]
[672]
MONOS%
5.0
2 - 12
EOSINO%
2.8
0-7
[672]
0 - 1.4
[672]
BASO%
0.2
SEGS ABSOLUTE#
8.09 H X10-3/ul 1.64 - 6.96
LYMPHS ABSOLUTE#
1.08
MONOS ABSOLUTE#
EOSINO ABSOLUTE#
BASO ABSOLUTE#
[672]
1.0 - 3.5
[672]
0.5
X10-3/ul 0.2 - 1.0
[672]
0.28
X10-3/ul 0.0 - 0.4
[672]
0.02
X 10-3
[672]
X10-3/ul 0.0 - 0.1
[672]
==================================================
=============================


Specimen: SERUM.
CHEM 0104 1191

Test name
CPK-MB
PRO-BNP
Result
units
5.38 H ng/mL.
0 - 4.94
3202 H pg/mL
PROTEIN,TOTAL
7.2
4.1
G/DL
CALCIUM
9.9
MG/DL
CREATININE
0.77
98
BILIRUBIN,TOTAL
65
[672]
8.5 - 10.5
[672]
.7 - 1.5
[672]
Ref: >=60
[672]
MG/DL
ALKALINE PHOSPHATASE
[672]
2.6 - 5.2
mL/min
[672]
6.0 - 8.5
MG/DL
0.79
[672]
Ref: <=450
G/DL
ALBUMIN
eGFR
.2 - 1.3
U/L
[672]
30 - 115
[672]
SGOT
13
U/L
0 - 40
[672]
SGPT
14
U/L
0 - 45
[672]
SODIUM
141
mEq/L
135 - 145
[672]
[672]
POTASSIUM
4.8
mEq/L
3.5 - 5.0
CHLORIDE
103
mEq/l
100 - 110
CO2
GLUCOSE
UREA NITROGEN
24
mEq/l
24 - 32
153 H mg/dL
17.3
mg/dL
[672]
[672]
70 - 99
10 - 26
[672]
[672]
==================================================
=============================


Specimen: PLASMA.
CHEM 0104 1190

Test name
Result
TROPONIN-T
units
<0.01
ng/mL.
0 - 0.1
[672]
==================================================
=============================
---- MICROBIOLOGY ---Accession [UID]: BC 16 111 [4616000111]
Received: Jan 04, 2016@08:53
Collection sample: BLOOD CULTURE BOTTLECollection date: Jan 04, 2016 08:10
Site/Specimen: BLOOD
Test(s) ordered: BLOOD CULTURE
==================================================
=============================
Performing Lab Sites

[672] SAN JUAN VA MEDICAL CENTER [CLIA# 40D0987710]
==================================================
=============================
CHEST 2 VIEWS PA AND LAT
Exm Date: JAN 04, 2016@09:12

Req Phys: RUIZ-RODRIGUEZ,DORCAS L
Pat Loc: 6J MED/01-05-2016@14:28
Img Loc: GDR(GEN. DIAGNOSTIC RADIOLOGY)

Service: Unknown
(Case 5505 COMPLETE) CHEST 2 VIEWS PA AND LAT
(RAD Detailed) CPT:71020
Reason for Study: sob
Clinical History:
76 y/o male with sob, cough and chest pressure that worsened
yesterday
Report Status: Verified
Date Reported: JAN 04, 2016

Date Verified: JAN 04, 2016
Verifier E-Sig:/ES/EDNA M RUIZ-QUIJANO
Report:
Chest - PA and Lateral views:
Previous studies are available for comparison.
Lungs are hypoaerated. Cardiomediastinal structures appears

prominent without interval changes. The thoracic aorta looks
elongated ectatic and tortuous with atherosclerotic changes.
Compared with prior studies, more confluent opacities are seen

particularly in the perihilar and basal regions. There is
blunting of the costophrenic angles concerning for effusions.
Osteopenia and degenerative changes of the spine is seen.
Impression:


Primary Diagnostic Code: SIGNIFICANT ABNORMALITY, ATTN NEEDED
Primary Interpreting Staff:

EDNA M RUIZ-QUIJANO, Radiologist, Radiology Service (Verifier)
/EMR
CHEST PORTABLE (1 VIEW)
Exm Date: JAN 05, 2016@12:28

Req Phys: RODRIGUEZ-MONSERRATE,CARLA P Pat Loc: 6J MED/01-05-2016@14:28
Img Loc: GDR(GEN. DIAGNOSTIC RADIOLOGY)
Service: MEDICAL
(Case 15045 COMPLETE)CHEST PORTABLE (1 VIEW)

Proc Modifiers : CHEST
Reason for Study: S/P PACEMAKER PLACEMENT
Clinical History:
(RAD Detailed) CPT:71010
Report Status: Verified
Date Reported: JAN 05, 2016

Date Verified: JAN 05, 2016
Verifier E-Sig:/ES/JOSE E RIVERA-RODRIGUEZ, MD
Report:
Portable chest on 1/5/2016 at 1234 hours, compared to examination
dated 1/4/2016.
Findings:
As compared to prior study, there has been interval placement of

a dual lead permanent pacemaker, with adequate positioning of the
atrial and ventricular leads. The lungs are well-expanded and
grossly clear. Cardiac silhouette is magnified by technique with
ectasia and atherosclerotic disease to the thoracic aorta. Chest
wall is unremarkable.
Impression:
Interval placement of a permanent pacemaker as noted. No
complications are observed.
Primary Diagnostic Code: NO ALERT REQUIRED
Primary Interpreting Staff:
JOSE E RIVERA-RODRIGUEZ, , STAFF RADIOLOGIST, RADIOLOGY SVC (Verifier)

/JER

Paciente 3

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Paciente 3

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LOCAL TITLE: EMERGENCY DEPARTMENT PHYSICIAN NOTE

STANDARD TITLE: PHYSICIAN EMERGENCY DEPT NOTE

ENTRY DATE: JAN 04, 2016@07:50:34

AUTHOR: RUIZ-RODRIGUEZ,DORC EXP COSIGNER:

*** EMERGENCY DEPARTMENT PHYSICIAN NOTE Has ADDENDA ***

EMERGENCY DEPARTMENT PHYSICIAN NOTE

Computerized Problem List *

Computerized Problem List is the source for the following:

Active Outpatient Medications (including Supplies):

Active Outpatient Medications

AFFECTED AREA EVERY DAY FOR FUNGI INFECTION

THREE TIMES A WEEK FOR DIABETES

5) GABAPENTIN 400MG CAP TAKE ONE CAPSULE BY MOUTH TWO

TIMES A DAY AND TAKE THREE CAPSULES AT BEDTIME

THREE TIMES A WEEK

EVERY DAY FOR HEART OR FOR HIGH BLOOD PRESSURE

DAY AS NEEDED FOR PAIN

MOUTH EVERY DAY WITH FOOD , FOR DIABETES

THREE TIMES A DAY FOR INFECTION

MOUTH TWO TIMES A DAY AND TAKE TWO TABLETS AT

Pending Outpatient Medications

NEBULIZER FOR INHALATION ONCE

NOW FOR HEART

Active Non-VA Medications

Patient has answered NKA

**Chief complaint: me dio falta de aire y dolor de pecho

patient with above mentioned dx problems and

Suicidal ideas at this moment: Yes

to light and accommodation), EOMI (extraocular movements intact),

---ECG Time done: 7:03

DAILY ORDER SUMMARY

01/04/16 p CHEST 2 VIEWS PA AND LAT STAT

01/04/16 p GRAM STAIN AND C&S SPUTUM WC ONCE LB

01/04/16 dce ASPIRIN TAB,CHEWABLE 81MG

CHEW AND SWALLOW TWO TABLETS

Typ:ELECTRONICALLY ENT Sgn:ELECTRONIC

01/04/16 dce ALBUTEROL SOLN,INHL 0.083%

USE 3 MILLILITERS IN NEBULIZER FOR

INHALATION ONE TIME STAT TO BE

Typ:ELECTRONICALLY ENT Sgn:ELECTRONIC

01/04/16 dce MOXIFLOXACIN TAB 400MG

TAKE ONE TABLET BY MOUTH PO STAT TO BE

Typ:ELECTRONICALLY ENT Sgn:ELECTRONIC

01/04/16 a >> Pulse Oximetry NOW .

Special Instructions: Take Pulse

Oximetry Now and document

Typ:ELECTRONICALLY ENT Sgn:ELECTRONIC

01/04/16 p BLOOD CULTURE BLOOD CULTURE BOTTLE TODAY

Typ:ELECTRONICALLY ENT Sgn:ELECTRONIC

SERUM STAT SP LB #1616366

Typ:ELECTRONICALLY ENT Sgn:ELECTRONIC

Typ:ELECTRONICALLY ENT Sgn:ELECTRONIC

Typ:ELECTRONICALLY ENT Sgn:ELECTRONIC

01/04/16 p TROPONIN-T BLOOD PLASMA STAT SP LB

01/04/16 p CBC & DIFF BLOOD STAT WC ONCE LB

01/04/16 p CPK-MB BLOOD SERUM STAT SP LB #1616366

01/04/16 p COMPREHENSIVE METABOLIC PANEL BLOOD

Typ:ELECTRONICALLY ENT Sgn:ELECTRONIC

DAILY ORDER SUMMARY

JAN 30,1939 (76) Wt (lb): 192

Printed Jan 04, 2016@07:58

01/04/16 p PRO-BNP BLOOD SERUM STAT SP LB #1616366

Typ:ELECTRONICALLY ENT Sgn:ELECTRONIC

* EMERGENCY DEPARTMENT PHYSICIAN NOTE Has ADDENDA *

* IMPRESSION TEXT: *

* REPORT TEXT: *

*****

* * * * *** *

* * ***

* * ****

**PGY-2 RESIDENT ADMISSION NOTE*