Docstoc

brown med files

Document Sample
brown med files Powered By Docstoc
					Account: Date:

DANIELMUWE DoB: K 03/10/2006

slr2lrg77

studentrD: sISH10413

Brown University Health Seruices providence,RI 02912 (4O1)863-39s3 Patient: DANIEL KAUWE K [31382] (808)382-6456 ft. Phone: pM NoteDate:031101200603:24 DOB:05/1211977 28) SSN: (Age

Summalyof note: sinus sx Allergies:(None) Current Medications:Buspirone 15mg Tablet,Rhinocort AquaNasal Spray, Sulfacet-R Lotion Intake:

Triage
Reasonfor visit: ha, sinus consestion Temperature:98.2 Pulse(Sitting): 73 Respiration: l2 (Sitting): I l5l58 Blood Pressure Pulse(Supine): Blood Pressure(Supine): Pulse(Standing): (Standing): Blood Pressure Height (Inches): Weight: Smoker: No LMP: PeakFlow (Actual / Expected): Visual Acuity Right: Visual Acuity Left: Additional Information: Signed Roberta by: Carlson, on Mar-10-2006 03:24pM MA at Locked by: Roberta Carlson, MA on Mar-IO-2OO6 at O3:24 pM

Subjective: Reports dailythiswk. Sometimes HA behind eyesandsometimes wholeheadis heavy.Sinuses feel But congested. no nasal or prurulent d/c sputum.Tooksudafed am- worksfor a litHe this whilebutnot pas neti pot this am but no mucus.Takes that helpful.Used clariitin dailyfor allergy. flonase,Seeing results CTscan-mayhaveturbinectomy, of chronic ENTawaiting of Hx sinusinf. Usually doeshave sinus or PND that. No asthma d/c hx. Hxof migraine doesn't likethat kindof HA. No W but feel swof glands' Wasusingrhinocort fen and stoppedsevdays ago.- Entered Laura by war4NponMar-10-2006
05:37 PM

Objective:

URl/Bronchitis/Otitis/Pharyngitis/Sinusitis ective Obj
General Appearance: Well appearing Ear - Left: Normal Ear - Right: Normal Abnormal Canal Described: Abnormal TItl Described: Nose: Edema, Erlthema

tof 2 Thisdocument beensigned has electronically.

Account: Date:

DANIEL KAUWE DOB: K 0311012006

5lLZl7977

StudentID: SISH10413

Throat: l. Normal Neck: Not Examined Lymph Nodes AC: Normal Lymph Nodes PC: Normal Lungs: Clearbilaterally Abnormal Lung Sound Described: Cardiac: Not Examined Abdomen: 1. Not Examined Abnormal Abdomen Described: Skin: Other PertinentFindings: Distal naresare friable- pt remembersblowing out some crustedmucus this am.

Assessment: Dx 1)Other TypeIn AddtInfo - X>x pressure congestion- evidence acutesinusitis. Sinus and no of w/u Undergoing for chronic sinusitis. WarQ onMar-10-2006 PM NP Entered Laura by 05:37 Plan: Office VisitEstPt 20 Minutes steroid nasal spray,Try mucinex sudafed.If not and dailyirrigation netipot. Resume Continue W on depending call andcheck CTscanresults.ENTmaywantto coverw/ antibiotic betterby 31L3, ENT by of sx. on result. ft agreedw/ plan. F/Uprn not sureof nextcourse actionor increased - Entered Laura
05:37 PM WarQNPon Mar-10-2006 05:37PM Ward, on Mar-10-2006 NP by: Signed Laura Locked by: Laura War4 IIP on Mar-70-2006 05:37 PM

Zof 2 electronically. has Thisdocument beensigned

Account: Date:

DANIEL KAUWE DOB: K 0310312006

5IL2II977

StudentID: SISH1O413

Brown University Health Services Providence,RI 02912 (4O1)863-3es3 Patient: DANIEL KAUWE K [31382] (808)382-6456 ft. Phone: NoteDate:03/031200611:18 AM DOB:0Slt2lI977 (Age28) SSN:

Summaryof note: Upper backpain. Allergies:(None) Current Medications:Buspirone 15mg Tablet,Rhinocort AquaNasal Spray, Sulfacet-R Lotion Intake:

Triage
Reasonfor visit: upper lt back pain ? from swimming Temperature: Pulse(Sitting): Respiration: l6 Blood Pressure(Sitting): Pulse(Supine): (Supine): Blood Pressure (Standing): Pulse Blood Pressure(Standing): Height (Inches): Weight: Smoker: No LMP: Peak Flow (Actual / Expected): Visual Acuify Right: Visual Acuity Left: Additional Information: lanni,MAon Mar-03-2006 11:18AM Signed Elyse by: at Locked by: Elyse fanni, MA on Mar-03-2006 at 7l:78 AM

Subjective: Painis in left upperback. Firstnotedabout2 wksagoand resolved. Started againyestam. Hadswam lapsthe day before.No specific precipitated. act Hurtswhenreaching or moving arm neck. Feels ok whenat rest-dilficult reador sit at computer.Sometimes to fleeting sharppainat B/10, Difficulty concentrating. started Just swimming abouta monthago. Mostly laps doesfreestyle- painmayhave but started breaststroke. w/ Can'ttakeNSAID because contraindicated Lithium.Tylenol veryeffective w/ not (?which for pt. Trieda muscle relaxant one)w/o muchrelief. Ice didn'thelp, Difficult localize to where to put ice. Painmovesaround.- Entered Laura by Ward, onMar-03-2006 pM NP 02:00 Objective: NAD. No pointtenderuponpalpation left upperbackandtrapezius shoulder. Nl Seated, of and of of excursion scapula,FullROM neckand UE's.- Entered Laura by War4 onMar-03-2006 pM NP 02:00 Assessment: l)BackPain- 724.5 Upperfeft backpainsecondary swimming, Entered Laura to by War4 onMar-03-2006 PM NP 02:00 I of 2 Thisdocument beensigned has electronically.

Account: Date:

K DANIEL KAUWE DOB: 03/03/2006

5lLZlL977

Student ID: SISH10413

Plan: VisitEstPt 20 Minutes Office for who referralto chiropractor alsodoesPTand exercise.Referral Koster. ft hasalready ft requests any relaxant thistime as it hasn'tbeen at to spoken themandfeelsit will be covered.ft declines muscle
by 02:00 PM hef pfuf . F/U prn no imp. - Entered LauraWard,NPon Mar-03-2006 02:00PM Ward, on Mar-03-2006 NP Signed Laura by: Locked by: Laura War4 NP on Mar-03-2O06 02:0O PM

2 of 2
electronically. has Thisdocument beensigned

Note Appended Account: DANIEL KAUWE DoB: K Date: 0I|LU2006

slL2lL977

student rD: sISH10413

Brown University Health Services Providence,RI 02912 (401)863-39s3 Patient: DANIEL KAUWE K [31382] (808)382-6456 ft. Phone: Summaryof note: Allergies:(None) Current Medications:(None) Intake: nasaUsinus congestion and/orpressure several for months nowandon andoff for a few yrs- hasnot responded trialsof Allegra, to Claritin Flonase, and NetiPothelps some;hasalsohadperiods frequent of oftentriggered hyper-sensitive reflexdry cough gag by "sometimes evenbrushmy teeth";no can't pA-c problem exercise, w/ runs30 min qod - Entered Tor by ctark, onJan-11-2006 AM 10:44 Subjective: throat-? increased but no grossPND cobblestoning red or whiteFBon R, resembles paintchip,did not flusheasily brieflavage ears-wnl except discreet a w/
fungs- clear to P+A - Entered TorClark, by PA-C Jan-l1-2006 on 10:44AM

NoteDate:OLltLlZOO6l0:35 AM DOB:05ll2l!977 (Age28) SSN:

Objective: Assessment: l)AllergicRhinitis 477.9 Z)Acne- 706.L by PA-C ? aflergic or other chronic sinus condition - Entered TorClark, onlan-l1-2006 t0:44AM Plan: Lotion Apply 1 Lotion2 Times per daily As DirectedQty 1. 6 Refills. RX,'Sulfacet-R by PA-C 10:44 refer to ENI referral list given, he will make own appt - Entered TorClarlg onJan-11-2006 AM on 10:43 by: Signed TorClar(PA-C Jan-11-2006 AM Lockedby: TorClark,PA-Con Jan-77-200670:43AM by on 10:44AM: APPENDED Tor Clark,PA-C Jan-11-2006 returned from I semester medical leave

1of 1 electronically. Thisdocument beensigned has

Account: Date:

DANIEL KAUWE DOB: K 04173/2006

5/12/1977

StudentID: SISH10413

Brown University Health Seruices Providence,RI 02912 (4O1)863-39s3 Patient:DANIEL KAUWE K [31382] (808)382-6456 ft. Phone:

NoteDate:041L312006 pM 02:09 DOB:0511211977 28) SSN: (Age

Summary of note: Allergies:(None) current Medications:Buspirone 15mg Tablet, Rhinocort AquaNasal spray,sulfacet-R Lotion Intake:

Triage
Reasonfor visit: mole check Temperature: Pulse(Sitting): Respiration: Blood Pressure(Sitting); Pulse(Supine): (Supine): Blood Pressure Pulse(Standing): Blood Pressure(Standing): Height (Inches): Weight: Smoker: LMP: Peak Flow (Acrual / Expected): Visual Acuity Right: Visual Acuify Left: Additional Information: Turner, on Apr-13-2006 02:09pM MA Signed Lisa by: at Locked by: Lisa Turner, MA on Apr-73-2006 at 02:09 pM

Subjective: Patient herefor check several of neviof neck.He hasnot notedany increase size, in shape, color.No of familyhistory skincancer patient neverhadany neviremoved. and has Patient concerned a also with small"flapof skin"on his neckthat is bothersome whena combbrushes against Patient it. usesRetin-A 0.1olo creamfor acneand wouldperhaps to try a differentretinoid,- Entered Nicote like by Grenier St Med
Training Apr-14-200609:33AM on

Apr-14-200609:33AM

Objective: Multiple darkbrownpapules scattered neckand back(approximately on 15-20) with symmetry no all and features. Rightlateralneckwith 2 mm skincolored concerning pedunculated papule. Thereis a 7 mm darkbrownsymmetrical raised nevus the left pectoral of area.Thereare multiple smallinflammatory papules closed and vcomedones cheek. Notruncal of acne. Thereis an approximatelycm ovallight 7 brownmaculeof L forearmwith a tiny blueblackdot within it. - Entered Nicole by Grenier StTraining Med on

Assessment: 1)Mole63L 2)Acne706.1
Iof 2 Thisdocument beensigned has electronically.

Account: Date:

DANIEL KAUWE DOB: K 041L312006

5lLZlI977

Student ID: SISH10413

3)OtherDxTypeIn AddtInfo - )0o< nevi 1. Benign 2. Acne 3. Cafeau fait maculewith incidentalblue nevus.- Entered Nicole by Grenier 5t Training Apr-14-2006 AM Med on 09:33 Plan: Office VisitNewPt 20 Minutes; Biopsy Skin,1 Lesion Of RX,'Tretinoin 0.1olo CreamApply1 Sparingly TimesperdayAs Directed 45. 5 Refills. l Qty Benzaclin Apply1 Sparingly timesper As Directed 50. No Refills. Gel 1 Qty
Signed Nicole by: Grenier StTraining Apr-13-2006 Med on 02:41PM Signed Tor Clar( PA-C Apr-14-2006 by: on 09:33 AM Locked by: Tor Clartg PA-C on Apr-14-2006 4):33 A|l

2of 2 electronically. has Thisdocument beensigned

0 $EP 4 200g
ffinrw
!...d;lr'.4

€€r1i.t:?

dM3

rMTIM BRO W } {
lii*;F#*

usf;;|ffi/ \[J-l
Section I Na me :

Health Services B ox 1928 P rovi dence, 029l2 RI 401 863-3953 Fax 401 863-7953

MEDICAL RECORD REQUEST/ RELEASE AUTHORIZATION ID#:

Dateof Birth:
Section 2

Ph o n e # :' l@

BrownUniversiry >iCf,"r"Uy authorize Health Services sendthe recordof my careto: to

t rl

authorizeBrown University Health Services requestthe recordof my carefrorn: to
r^A

Address:

les \"/
E Consultation E Treatment U Claim Settlement

D\-nx" Phone: '-t
Section 3 For the purpose of:

y

' o ff Ft-t Seglion4 - Pleuse checkoneoption below: > mentalhealtli,drug or alcfhol abuse, ,XRelease all infomation in my medicalrecord(includinginformationregarding sexually transmitted diseases, HIV related or information, includingtesting).

Re.orJ

E Release informationin my medicalrecord, all exceptfor: E mental health I drugor alcohol abuse D sexually transmitted diseases tr HIV related information, including testing E Release (stateillnessand/ or treatment only the following specificinformation suchrecords in and specifydates):

Section 5 I undcrsland thal my recordsare maintained accordance in with the Family Education Rightsand PrivacyAct and the General[.aws of Rhodelsland and cannotbe disclosedlvithout my rvrittenconsentexceptas otherrvise provided by larv. Anv information releascdor receivedas a result of this consentshall not be further relayed in an1'way to any other person.organization.entitl' or other without an additionalwritten consentfiom me. I mav withdraw this consentbv sivine writtcn notification vc pafty. at a.nytime prior to the disclosure rclease the information.ln the absence mv orior withdrawal. aftcr it is signed. or of of this conscnt will exnr I havcreadthis and consenlprior to signing and

Signed
Signalureof il' u n d cr l8 )

Date:
(*Rclationship Patient) to

Wi tn e s s :

Date:

FctrIleulth Services Olficeuseonly: E Faxed E Mailed tr Picked Up
RcvisedBt'. Medical RecordsCommittee.March 20011

Date:

Initials:

""i,

*q I inr*cttn

"t

rc: 2?r34 * f :"*m te

* {*1 *r33 ?S33 p?14

-rl i , Hnspirar 3:d% Rrr*de rsrand ""''-- Separtment of Pathology "

{'rn* ;;;,;,,;;;.;,;;. hlfftr?.ii:1ffi:,T;;,'ffi:"--"' ; Rhode tsla*d llospitai $93 Fddy streel Proviri*nc*. Rl StSg
trirecior af $erm*lep*tlr+legy: l-eslit &cbtRsgtt'Boat$lt,fH"*. M**i{:slSrre:t*: iileilttel$lc$'li Cr-lA.# 4i*SSi]?$$6 {$.1}. C|lsri*$ d4a*cnald. tr*x: 4$'1444"s#4 Fhcrie: {*i "d4'4'f*1€

S&etl..l]et-1 it#:*e!rie: A:c*g$i*ri:*: it*it*r:*{ l:,e|}iil!nt i"$i3

Rflss4t$3
4rt 3J?{g}S 4r14#*.*$ 4ri 3itf.*s l"J*tjfi :- frf ft *flvl:!'Cir 3rl:

Pstie,llr
t4*d**i r*$orti* il+EijNgs,sex. l*rrrlic$q1isnlr

**s*li# f: 0SA{S0$*12 tri?r1 ?IiA*sr tsi M I f,:PfrtJ *hnde|tian#i{*sn:tai

KAUWE, il4fi{}81_

ilfirl?Si3fti!fi

0ennat*pafhologY RePori FinalOiagnesis
sdils L$l: i' f{J*rsFitr, pul{cfi Elcfi$Y AL 3l :{:11 f,i[ *ANof vTc$ i$ , Tf"til Lts'ilN rx"t[t".tu5 Tc GI"JE #Ai?SlrJ LA;UQALSL.fiGAfi&L ^ $ili: C$tutt*Filr,

S*n1cfie.{rls
S*ctr*rs x*r:w **avi:y Sj$rr,efite* de*{ir}tio r}si*n{F:$eg and cr*ie*sp*fr*en **ars*iy ais+*l:*g itl l**.i*rml\, *lt}st $f{}|nrflrirt *i+**r! a.*wx*l $trutltrjre$ The d!g.*ge,tti# ril**nfi{iis i*clude s 6*ilj*{rp*fli *i * spe*kie* t*#i*in$'.Js *srr"tx. b,*e rfl#ir-qsr $*:rYl*i d eildr f b r${i#rlssyte h831*efil}a. *l ilt?s*ic*r'*laltotl ;5 1gs6ry,gtgrri*d

*o'Re$eit [l*elr*n*ally
'#sr$$.i17i?frfl:l ?r* allen$ng +aiEulegid 6.itc$* $rgjlsiijfs *ilpears *f t:ris rei{if li:e iilla! *;a**+tlt,

{J $:Sfted *y L*$ie &*hi***st-{***i${T. fn'l *"*
i es$f q sh:*ss i!-ti+**:t. iJ!.i) *iliJ h6$ i*vi**t

:!*$ rs,vi*!ted ll}* c*$e $$*r!&lt

ClinicafHirt*ry
;r;g1 I)14$aJgt'!

Prel0peratlve0iagn+sig
.*luennruu-.fffh Sai*ier.ilait flrft"*r:i€ P$$t Opeffitiss &i*g*esi*
3rllt*1

Grsss ilascri$ti$n
i.a*eie*, ''Lelt F'xearrrr". fi**eived:n i*sr::aii:: it a grey Fun*S bi*pgy v*easugi*$ *.! *ryt il iiai*:+t*r irrd C ] rry: lflJii$ Sir*rr.f!** r:' t*$$sli{r "&.:" j* ery#<Jtf.r2$*6 A.s{i ,tonaid\{*vr 3$r{. lt&il^!.

,/p?

rffn*
Prye'l i nf

*Ai'ligt'{AltWC, sfi$100$$J8ssss5!

RB!64t9e ft*sds ls{afldLs$paw

pfr|liedtAftsre

;:,.Q"t]

J&46

i$i 5j:

{it*/

i). ffil


				
DOCUMENT INFO
Shared By:
Tags:
Stats:
views:9
posted:10/11/2009
language:English
pages:9