Good Health Discharge Summary 17 Daws Rd. Blue Bell MA 02368 US Mr. Adam Frankie Everyman 17 Daws Rd. Blue Bell MA 02368 US Ralph Relative MA 02368 US Good Health Clinic 21 North Ave Burlington MA 02368 US 21 North Ave. Burlington MA 02368 US Henry Seven 21 North Ave. Burlington MA 02368 US Henry Seven Rose Everyman Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US Henry Seven Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US Mrs. Martha Mum
ALLERGIES, ADVERSE REACTIONS, ALERTS
Substance Reaction Status
Penicillin Hives Active
Aspirin Wheezing Active
Codeine Nausea Active
Penicillin Aspirin Aspirin
REASON FOR VISIT/CHIEF COMPLAINT Dark stools.
DISCHARGE DIET No solid food for 2 days. Follow the B.R.A.T. diet for 2 days after that. Regular diet may be resumed 4 days after discharge.
FAMILY HISTORY Father (deceased)
Diagnosis Age At Onset
Myocardial Infarction (cause of death) 57
Diabetes 40
FUNCTIONAL STATUS
Functional Condition Effective Dates Condition Status
Dependence on cane 1999 Active
Memory impairment 1998 Active
M 13-18 g/dl; F 12-16 g/dl
PAST MEDICAL HISTORY See History of Present Illness.
HISTORY OF PRESENT ILLNESS This patient was only recently discharged for a recurrent GI bleed as described below. He presented to the ER today c/o a dark stool yesterday but a normal brown stool today. On exam he was hypotensive in the 80?s resolved after .... .... .... Lab at discharge: Glucose 112, BUN 16, creatinine 1.1, electrolytes normal. H. pylori antibody pending. Admission hematocrit 16%, discharge hematocrit 29%. WBC 7300, platelet count 256,000. Urinalysis normal. Urine culture: No growth. INR 1.1, PTT 40. He was transfused with 6 units of packed red blood cells with .... .... .... GI evaluation 12 September: Colonoscopy showed single red clot in .... .... ....
HOSPITAL ADMISSION DIAGNOSIS Appendicitis
HOSPITAL COURSE Following a colonoscopy, the patient was admitted and started on Lovenox and nitroglycerin paste. The patient had serial cardiac enzymes and was ruled out for myocardial infarction. The patient underwent a dual isotope stress test. There was no evidence of reversible ischemia on the Cardiolite scan. The patient has been ambulated. The patient had a Holter monitor placed but the report is not available at this time. The patient has remained hemodynamically stable. Will discharge.
HOSPITAL DISCHARGE DIAGNOSIS Diverticula of intestine
HOSPITAL DISCHARGE MEDICATIONS
Medication Directions Start Date Status Indications Fill Instructions
Proventil 0.09 MG/ACTUAT inhalant solution 2 puffs QID PRN wheezing 2011-03-01 Active Bronchitis (32398004 SNOMED CT) Generic Substitition Allowed
0.09 MG/ACTUAT inhalant solution, 2 puffs QID PRN wheezing Medication Factory Inc. Good Health Clinic Normal Saline Medication Factory Inc. 21 North Ave. Burlington MA 02368 US label in spanish Medication Factory Inc.
HOSPITAL DISCHARGE PHYSICAL GENERAL: Well-developed, slightly obese man.
NECK: Supple, with no jugular venous distension.
HEART: Intermittent tachycardia without murmurs or gallops.
PULMONARY: Decreased breath sounds, but no clear-cut rales or wheezes.
EXTREMITIES: Free of edema.
HOSPITAL DISCHARGE STUDIES SUMMARY
Laboratory Information Chemistries and drug levels
Potasium 4.0
NA (135-145meq/l) 140

Other Tests Results
EKG Sinus rhythm without acute changes.
IMMUNIZATIONS
Vaccine Date Status
Influenza virus vaccine, IM Nov 1999 Completed
Influenza virus vaccine, IM Dec 1998 Completed
Pneumococcal polysaccharide vaccine, IM Dec 1998 Completed
Tetanus and diphtheria toxoids, IM 1997 Refused
Influenza virus vaccine Possible flu-like symptoms for three days. Influenza virus vaccine Possible flu-like symptoms for three days. Influenza virus vaccine Possible flu-like symptoms for three days. Tetanus and diphtheria toxoids - preservative free Possible flu-like symptoms for three days.
PLAN OF CARE
Planned Activity Planned Date
Colonoscopy April 21, 2000
PROBLEMS Pneumonia: Resolved in March 1998 ...
PROCEDURES
Procedure Date
Colonic polypectomy 1998
17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US 17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic 17 Daws Rd. Blue Bell MA 02368 US Good Health Clinic
REVIEW OF SYSTEMS Patient denies recent history of fever or malaise. Positive for weakness and shortness of breath. One episode of melena. No recent headaches. Positive for osteoarthritis in hips, knees and hands.
SOCIAL HISTORY
Social History Element Description Effective Dates
smoking 1 pack per day 1947 - 1972
smoking None 1973 -
Alcohol consumption None 1973 -
1 pack per day None None
VITAL SIGNS
Date / Time: Nov 14, 1999 April 7, 2000
Height 177 cm 177 cm
Weight 86 kg 88 kg
Blood Pressure 132/86 mmHg 145/88 mmHg
HOSPITAL CONSULTATIONS Gastroenterology Cardiology Dietitian
HOSPITAL DISCHARGE INSTRUCTIONS Take all of your prescription medication as directed. Make an appointment with your doctor to be seen two weeks from the date of your procedure. You may feel slightly bloated after the procedure because of air that was introduced during the examination. Call your physician if you notice:
Bleeding or black stools.
Abdominal pain.
Fever or chills.
Nausea or vomiting.
Any unusual pain or problem.
Pain or redness at the site where the intravenous needle was placed.
 Do not drink alcohol for 24 hours. Alcohol amplifies the effect of the sedatives given. Do not drive or operate machinery for 24 hours.