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what are the icd-10-cm codes including an M code for this case: ADMISSION DATE DISCHARGE DATE 2/21/81 Weight loss, weakness, abdominal cremps of undetermined origin. ADMISSION DIAGNOSIS ICDA-8 DISCHARGE DIAGNOSIS_1- Hypopotassemia, correct# 2. Calcified fibroid uterus; 3. Cholelithiasis. OPERATION SURGEON ASSISTANT. DATE DISCHARGE SUMMARY: This 88 year old female has been living in the area with her son-in-law for some period of time. She has been feeling poorly for four to six weeks and she noticed recently that she had been losing a considerable amount of weight. She had anorexia, general fatigue, she wag seen in the office and it was felt that on the basis of her weight loss, anorexia, fatigue that she should be admitted for complete bowel study and further evaluation. Her work up has included a chest x-ray which revealed mild cardiomegaly; otherwise normal. Her barium.enema showed multiple diverticuli but otherwise was normal. Her IVP was normal, did show T 3 was 71, T 4 was 9.4. Oral cholecystogram showed no visualization of the gallbladder. Gallbladder ultrasound revealed probable cholelithiasis. Upper GI series was essentially normal. Her white count was 9,700, hemoglobin was 14.3, hematocrit 42.8, segs 89, lymphs 6, monos 4, eos l. Alkaline phosphatase 9.9, blood sugar 92, sodium 140, potassium 3.3, CO 2 36, chloride 88, cholesterol 223, SGO-T 16, LDH 134, creatinine 0.9, calcium 9.4, phosphorus 3.2, uric acid 5.6, bilirubin 0.8, total protein 7.4, albumin 4.2. Repeat potassium was 3.2, 3.7, 4.7, 4-1. Urine showed a specific gravity of 1.006, albumin and sugar were negative, WBC’s 3-5. Stools for occult blood were negative x 2. Urine culture no growth. Cardiogram was reported as abnormal showing minor myocardial changes of ischemia and/or Dig. effect. She was treated with bedrest, diet. Her studies were completed. As mentioned, her findings were those of #1 Hypopotassemia, corrected. #2 Calcified fibroid uterus. #3 Cholelithiasis. The patient was treated with potassium replacement, responded well to this. Discussed the simation in terms of her multiple gallstones and we both decided that because of her age and sofort it would be best to leave that situation alone. She is now up ambulatory, eating well, going to P.T. and having a good response there. She is being discharged at this time on a gallbladder type of diet, Theragran-M 1 b. i. d.- and will be seen in follow up in the office in two weeks. DICTATION DATE _2/20/81 TRANSCRIPTION DATE_3/2/81 BYjeb CC: BEWC SSMH – 263 – REVISED 10/74 DISCHARGE SUMMARY PATIENT NUMBER PATIENT NAME AND ADDRESS SEX |AGE |RACE RELIGION S. M. W. D. SEP. me |payne as bas BIRTH PoL DATE ey? | MO. DAY YEAR Fe Wee BIRTH PLACE MOTHER’S NAME OCCUPATION – PATIENT GUARANTOR NAME AND ADDRESS PLACE OFMPLOYMENT SOCIAL SECURITYPATION NUMBER. TELEPHO ADMISS!IO CIDENT REPORT 4 f r serkeos er Hoe Egham eae a be ES fee tet e E Ee ADDRESS ADMITTED BY DOCTOR SERVICE E.R. ADM. ROOM NUMBER 2/1005 0h. > BE % OG67 CBS Ler 4s = REFERRED BY DOCTOR ADDRESS DISCHARGE DATE DAYS the = INSURANCEO. INSURANCE GROUP NO. Mats Pin DT CARE A GME G Mil TYPE OF PLAN EFF. DATE EXP. DATE DEDUCTIBLE M CRIBER POLICY NO./AGREE. NO. COMP/LIAB, CLAIM INSURANCE NO. GROUP NO. Oe ELLE GPStss Pri LADELPH EA [acai MEd TYPE OF PLAN EFF. DATE EXP. DATE DEDUCTIBLE M SUBSCRIBER COMP/LIAB. CLAIM INSURANCE NO. NAME OF INSURANCE “POLICY NO./AGREE. NOCOMP/LIAB CLAIM TYPE OF PLAN EFF. DATE EXP. DATE DEDUCTIBLE MET? SUBSCRIBER LAST DATE HOSPITALIZED NO. OF DAYS NAME OF HOSPITAL PHYSICIAN’S INSURANCE INFORMATION Pub RTS Ty gd yyey INFORMANT tf, “prop prea gg PRY Bees i ADMITTED BY ADMISSION DIAGNOSIS: Weight loss, weakness, abdominal cramps of undetermined origin. CHIEF COMPLAINT: Weakness, tremulousness and weight loss. HISTORY PRESENT ILLNESS: This is an 88 year old white female wholives here in the area. She lives with her son-in-law, helps to take care of her invalid daughter who has MS. She has not been feelin well probably for four to six weeks; although it has not been readily apparent until the last 1 to 2 weeks when she has had noticeable weight loss; anorexia, general i ome degree of tremulousness.e She was brought in by her son-in-law this morning, Pleasant lady, not in severe distress but she was seen and evaluated in the office and I think with an 18 lbs. weight loss that she has had in the last six weeks with some degree of bowel abnormality from what she was used to in the past she needs to be admitted for further investigation, evaluation and treatment. PAST MEDICAL HISTORY: She has had no major operations, injuries or illnesses. She has had an appendectomy. She has been on antihypertensive medication. She is not allergic to any medications. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: She is a retired widow who now lives with her daughter. She is a nondrinker, nonsmoker. Lives with her son-in-law here in town. SYSTEMIC REVIEW: She has had no particular cough, dyspnea or hemoptysis. Appetite has been poor the last three to four weeks. Her bowels have not been quite as regular as they were before, although she has had no diarrhea and she denies any urinary symptomatology. GENERAL: This is an elderly white female in no acute distress. VITAL SIGNS: Weight 152, blood pressure 140/78, temperature 97.6, SKIN: Warm and dry, color is a little bit pale. EENT: Ears are clear. Eyes: Pupils round, react and equal; extraocular muscles okay; sclera clear; no evidence of any jaundice. Nose and Throat: Unremarkable. NEG SUpple, no nodes or thyroid abnormalities. CHEST: Peripheral lung bases are clear. HEART: Heart sounds are good, no significant murmurs areh Signed .D. Dict. Trans. By DR. 367 HISTORY & PHYSICAL SSMH #201 (Rev. 6/77) Page 2 – Continuation BREASTS: Soft and free of masses. ABDOMEN: No palpable organomegaly, masses, no CVA tenderness or bruits, bowel sounds normally active. ” PELVIC AND RECTAL: Not done. EXTREMITIES: Warm, pulses good. NEUROLOGIC: AND ORTHOPEDIC EXAM: Okay. No pathologic reflexes elicited. ADMISSION DIAGNOSIS: Weight loss, anorexia of undetermined origin. Signed Dict – .2/9/81 Trans._ 2/10/81 By_ jeb a 74107 SSMH #201 (Rev. 6/77) gy Physicians use ___Date /) this margin ~ANCi _use this ary margin pesonnel 4 a ae a, Loom a ” 7 ” ” Lo foe 4 clasts Loa ee La, fo AS J Cs ff . 22 Le ‘ S a Ge Ly. 2D Sate Let. PILE. a this margin use this margin (Please skip one line between days) | 4 PROGRESS RECORD SSMH #205 (Rev. 10/77) Date y Physicians this margin use penct use this ary margin personnel (Please skip one line between days) | | dD —G 7 {Nay a “ht MY | PROGRESS RECORD SSMH #205 (Rev. 10/77) yy Physicians ue pnoaary personnel Date this margin use this margin (Please Skip one line between days} m —4 -t 1 PROGRESS RECOR! 205 (Rev. 10/77) ADMISSION PROGRESS NOTE Diagnosis: Confirmed Provisional Discharge Plan: —Home – No services needed —~ —_—_—_———. —ee Utilization Review Information Projected LOS days Initial Review Date __ Anticipated Discharge Date Refer to Patient Services for: Evaluation Home Care Management Transfer to appropriate facility Other , U.R. Coordinator ‘ee ADMISSION PROGRESS NOTE SSMH 205A M. D. CONSOLIDATED BUSINESS FORMS—LOCK HAVEN, PA 22309 DOCTOR’S ORDERS Patient Plate Area MEDICATION ORDERS WILL BE FILLED ACCORDING TO THE FORMULARY UNLESS CHECKED IN THE APPROPRIATE COLUMN. Tentative Diagnosis —_ | { | | | 601-03-120-1 DOCTOR’S ORDERS MEDICATION ORDERS WILL BE FILLED ACCORDING TO THE FORMULARY UNLESS CHECKED IN THE APPROPRIATE COLUMN. Tentative Diagnosis DOCTOR’S ORDERS Patient Plate Area Allergies ORDERED | NON — USE BALL POINT PEN- PHYSICIAN’S SIGNATUREQUIRED DATE FORM. /FOR EACH ORDER x ‘c “SSMH 206 4/75 DOCTOR’S ORDERS DOCTOR’S ORDERS – Patient Plate Area Soe @ MEDICATION ORDERS WILL BE FILLED py ACCORDING TO THE FORMULARY UNLESS we CHECKED IN THE APPROPRIATE COLUMN. 6 Tentative Diagnosis on ‘Allergies a 3 ORDERED| NON | USE BALL POINT PEN- PHYSICIAN’S SIGNATURE REQUIRED DATE FORM. | “sw FOR EACH ORDER : = _— | ) — f ___ —__________ ——— + —— a —— — — — — _ 601-03-120-1 DOCTOR’S ORDERS ao DOCTOR’S ORDERS Patient ide Aiea MEDICATIONRDERS WILL BE FILLED = | = ACCORDING TO THE FORMULARY UNLESS | f > CHECKED IN THE APPROPRIATE COLUMN. |* fy * Allergies ORDERED |NON USE BALL POINT PEN- PHYSICIAN’S SIGNATURE REQUIRED DATE – FOR EACH ORDER teney “SSMH 206 4/75 DOCTOR’S ORDERS aay CONSENT SHEET TQ LEI CONSENT TO RELEASE INFORMATION I hereby authorize the authorities o to provide my Insurance Company with informatior regarding the diagnosis, treatment patient or myself) during the present hospitalizatl ay be collected from the Insurance Company. \ Y . \ 1. ; ee CONSENT TO TREATMENT that I (or ) am (is) sufferfyg frorYa condition requiring I, (or hospital care do hereby voluntarily consent to such hospital care including routine diagnostic procedures and medical treatment by Dr. – , his assistants or his designees as is necessary in his jud explained to me and I certify that I understand its contents. “Sig nature ¢ Date _») 9 py witness oT | The patient is a minor, years of age. The patient is unable to consent because am i a Time pm __ _ 7 ___ Date __ witness Signature and relation to patient ITI. LEAVING HOSPITAL AGAINST MEDICAL ADVICE (am) (is) leaving the hospital against the advice of the attending pnysician and the hospital administration. Dr. explained to me my condition as and my refusal to continue treatment will result in and will seriously effect my life and chances for regaining normal health. The hospital authorities suggested that if treatment has not been satisfactory, it should be sought immediately at another institution. I hereby release the hospital, its nurses and employees, together with all physicians in any way connected with me as a patient from liability for any ill effects which may result from this action. I have read this form and understand its meaning. (In the event the patient, or the parent or guardian in the case of a minor patient, refuses to sign the form, this fact should be noted on the form and the form placed in the patient’s record.) witness Signature date relationship SSMH #214 (rev. 4/77) USEING THIS A SEPARATE TYPE OF MICRO-MOUNT MICRO-MOUNT FOR FOR CHEMISTRY, EACH TYPE OF HEMATOLOGY TEST. AND URINALYSIS REPORTS, (TOP GUIDE EDGE NE ReBI 9 ) AGE T.OR DOCTOR’S COPY — TECH. BACTERIOLOGY | /\\/O AND SENSITIVITY] DATE DONE / A\2 S/ BLOOD CULTURE FUNGUS CULTURE SPINAL FLUID CULTURE STOOL CULT. OTHER ROUTINE CULTURE AFB (TB) SOURCE: Lé2ReqweSENSITIVITY SMEAR (ONLY) f Y.0 Apa ot . DO 0A | t | : Q? co i [nar bit 2193] Lo. 60 Feo KEYSTONE BUSINESS FORMS (BOTTOM wo: = —_ | SENSITIVITY OF ORGANISM(S) *#)#)|# Renicillin Ampicillin Oxacillin Erthromycin Tetracycline Chlioromycetin Streptomycin Cephalothin Kanamycin Vancomycin Novobiocin Colistin Nitrofurantoin Gentamicin Nalidixic Acid Carbenicillin Lingomycin Sulfomtanide CALL TIME De aad) USING A SEPARATE 57¥ MICRO-MOUNT FOREACH TYPE (TOP OF GUIDE TEST. rms CHART OR. DOCTORS COPY cia Ze ge & B Wee < CHEMISTRY | [DATE DONE ee ok > KEYSTONE BUSINESS FORMS AGE ART £4 OR USING DOCTOR’S A SEPARATE MICRO-MOUNT COPY FOR -—EACH TYPE OF TEST. TECH. BACTERIOLOGY Wo BLOOD CULTURE FUNGUS CULTURE SPINAL FLUID . CULTURE STOOL CULT. OTHER ROUTINE CULTURE AFB (TB) SOURCE: (Ai ne SENSITIVITY “SMEAR (ONLY) =. nO | CUfTURE REPORT ir oO 5 w Das Q J â„¢N S so) |S O 2 TWO io % we: – ° Ho Orfos 5 fk SZ 5 coh FZOSd mabe * ae t Pee ue maaan PREGNESTICON _ GRAVINDEX _ BENCE JONES PROT. CREATININE: (OTHER TESTS) + SEMEN (SUNT 1 SEMEN ANALY. (COMPLETE) APPEAR VOLUME: couNT ‘®° (OTHER TESTS) % % CC} MOT. ABN. SPINAL FLUID APPEAR CELL COUNT SUSAR PROTEIN, CHLORIDE (OTHER\TESTS) WBC RBC STOOL OCCULT BLOOD O&P + — (OTHER TESTS) | ~ tite ek CHART OR DOCTOR’S COPY _O.Y 0 CBC w/o DIFF = pATE TOBE pone_o- f C1 Hab ORDERED BY __4 && Het | : : | URINE-SPINAL FLUID SEMEN ANAL-STOOL] TECH. No DATE DONE A~\lS/ ROUTINE . BILI LAB STIX ONLY _ – NORMAL | | SA OP CODES VALUES jo Routine C1 in pt. PH [x10 |wec “7a+3 |Ostat Gout Pt. SP. GR. ~ T M5.4+0.7 [CJ pre-op 0) er ALB. . x 10° RBC F 4.8+0.6 SUGAR – — Se o— —T 7 ——i TT Mares TP. 34 FEB 2 BILIRUBIN .. %® |Het |e goes Tgtoop m T: } — — CALLED TO: EPITH. _ BA TIME: _WBC SI CALLED BY: RBC pee iien COLLECT Fae aan — sine PREGNESTICON ‘ GRAVINDEX BENCE JONES PROT. C) DIFFERENTIAL % Cl setprate 9 ___ SF M s”0- 0 – 20 15 mm/hr. mm/h. CREATININE: LYMPH &, (OTHER TESTS) Ove. . ° MONO oe _ _ 0 retic UNCORRECTED SEMEN (COUNT ; NUC. RBC ‘Ww | W (OTHER TESTS) : COMMENTS: ; co n ~T . S g oO a © ec F 2 9 SPINAL FUID Sara = OUNT prec A Ary PROTEIN (OTHER TESTS) _ za ) = 6 ~ EE & O&P Du Fate (OTHER TESTS) Onrfkaos5 se cfcanrZ=odo s — Sow AdOO S.YOLOOGd HO LYVHO : mt : 2 DATE, T OR DOCTORS COPY u oO IRON BIND. CAP. Fe 9 « ALBUMIN { ww = 8 TOTAL PROTEIN oo 6fF 8 GLOBULIN __ wUe¢ ec a C5 D5 e = Oo | PROTEIN ELECTROPHORESIS 2 < < 6 g 5 LITHIUM r\ SN creoanwnereEO PROTEIN ELECTROPHORESIS CHECK [Vi FOR EXAM DESIRED CIRCLE RIGHT OR LEFT EXAM REQUESTED FOR DATE: od]\ 3| &i REASON FOR — .AM: (PLEASE INITIAL) _ SKULL PATIENT MAY TRAVEL: SINUSES Woe LCHAIR |ER L]mastoips STRETCHER ~ FACIAL BONES porTasie|>P NASAL BONES TECHNICAL DATA: (FOR X-RAY DEPT. USE.) MANDIBLE TM-JS CERVICAL HORACIC ——$ LUMBO-SACRAL eee SACRUM RADIOLOGIST’S CONSULTATION: COCCY. REPORT REGULAR CHEST RIBS (LOCALIZE) RL 2-13-81 UGI SERIES: A ‘ . CLAVICLE RL 5 em. incarcerated hiatal hernia was SCAPULA RL noted at fluoroscopy. The intra-abdominal portion of the stomach, STERNUM duodenal bulb and C loop are normal. MAMMOGRAM.__ Telepaque tablets, there is only very faint visualization of the PLAIN FILM – KUB IX) UPPER GISERIES SMALL BOWEL SERIES COLON (A.GALL BLADDER IV CHOLANGIOGRAM IvP HYPERTENSIVE IVP PELVIMETRY FETAL NUMBER OR POSITION SHOULDER R HUMERUS R ELBOW FOREARM WRIST. R R ee HAND R R R LD:hb FINGERS____ OS-CALCIS__ PELVIS HIP [-] FEMUR KNEE R R R LOWER LEG R R R R ANKLE FOOT. TOES REQUEST UNLISTED EXAMS: M.D., RADIOLOGIST X-RAY REQUEST anp REPORT RADIOLOGISTS PATIENT IDENTIFICATION (IF OUTPATIENT WRITE NAME, ADDRESS, AGE) SSMH-500 (REV. 11/77) EXAM REQUESTED FOR REASON FORL viz (PLEASE INITIAL) (CHECK [WJFOR EXAM DESIRED DATE: QQ -/Z=%/ BONE PATIENT MAY TRAVEL: BONE MARROW BRAIN REEL STRETCHER CHAIR ER T BRAIN ©/ FLOW OP CARDIAC BLOOD POOL TECHNICAL DATA: (FOR DEPT. USE.) MYOCARDIAL SCAN GALLIUM KIDNEY LIVER-SPLEEN LUNG PANCREAS SCANNING REPORT | . 2-12-81 GALL BLADDER ULTRASOUND: CONCLUSION: Possible cholaithiasis. no reveals lumen On LD:bls” two acoustic of views, rather the shadowing gall there poorbladder visualization are defects sveral suggestive are tiny ofpresent Multiple the of echoes stones, gall to within confirm B bladder. mode however the scans thi. PLACENTA ROSE BENGAL-LIVER THYROID UPTAKE AND SCAN (I 13!) THYROID UPTAKE ONLY THYROID SCAN (TECHNETIUM) LIVER-LUNG (R/O ABSESS) LAB EXAMS T-3RIA T-4RIA TSH DIGOXIN ULTRA SOUND THYROID BREAST LIVER GALL BLADDER KIDNEY PANCREAS SPLEEN RESULTS THYROID UPTAKE ) | T-3RIA | DIGOXIN ( ( ( TSH ( T ( ( (04 ng/ml – 2.7 ng/ml ) ( 0-10 ulU/ml RETROPERITONEAL URINARY BLADDER FETAL AGE 10% – 40% ) PLACENTA | PREG. COMP. SERIES 80 -220 ng% ) PELVIC MASS 4.5 – 13.0 ug% ) ) REQUEST UNLISTED EXAMS: (IF OUT PATIENT PATIENT – TYPE NAME, IDENTIFICATION ADDRESS, 412/93 3.) AGE, DOCTOR) B7Y RADIOLOGISTS EXAM REQUESTED FOR DATE: o- /d- &/ PATIENT MAY TRAVEL: REASON FOR & EXAM: (PLEASE INITIAL) | CHECK [v¥] FOR EXAM DESIRED CIRCLE RIGHT OR LEFT SINUSES STRETCHER PORTABLE MASTOIDS FACIAL BONES NASAL BONES TECHNICAL DTA: (FOR X-RAY DEPT. USE.) L]JMANDIBLE TM-JS CERVICAL THORACIC LUMBO-SACRAL $$$ $$ SACRUM RADIOLOGIST’S M9°H2-81 bladder. contrast CONSULTATION: medium, ORAL The patient CHOLECYSTOGRAM: there has isbeen no visualization of the gall COCCY. REGULAR CHEST RIBS (LOCALIZE). ORR LL Following ingestion of 4 . CLAVICLE RL given 3 additional telepaque SCAPULA RL epeated tomorrow. . STERNUM MAMMOGRAM___R L ABDOMEN PLAIN FILM – KUB ABDOMINAL SERIES ESOPHAGUS Sf UPPER GI SERIES SMALL BOWEL SERIES COLON IV CHOLANGIOGRAM IvP HYPERTENSIVE IVP PELVIMETRY FETAL NUMBER OR POSITION SHOULDER R – HUMERUS R ELBOW FOREARM WRIST. HAND FINGERS____ OS-CALCIS__ R R R R R R PELVIS HIP (] FEMUR KNEE R R R LOWER LEG R R R R [] ANKLE FOOT ad ¥/ _ _ TOES REQUEST UNLISTED EXAMS: M.D., RADIOLOGIST SSMH-500 (REV. 11/77) (IF OUTPATIENT -~ PATIENT WRITE IDENTIFICATIO NAME, ADDRESS, AGE) X-RAY REQUEST ano REPORT RADIOLOGISTS EXAM REQUESTED FOR pate: D- //-¥ / PATIENT MAY TRAVEL: REASON FOR E. i: (PLEASE INITIAL) WHEELCHAIR ER STRETCHER OP TECHNICAL DTA: (FOR DEPT. USE.) ‘ _ SCANNING REPORT THYROID UPTAKE ( ) __ ( 10% – 40% DIGOXIN ( ) — TSH ( i ( 0-10 ulU/mI RESULTS ISOOPE LAB RESULTS ( 0.4 ng/ml NORMAL – 2.7 ng/ml . M.D., ) RADIOLOGIST | Tq BONE BONE MARROW BRAIN CARDIAC BRAIN ©/ FLOW BLOOD POOL MYOCARDIAL SCAN GALLIUM KIDNEY LIVER-SPLEEN LUNG PANCREAS THYROID THYROID LIVER-LUNG PLACENTA ROSE BENGAL-LIVER ek SCAN UPTAKE (R/O wea (TECHNETIUM) ABSESS) AND ONLY SCAN (1!3!) | T-3RIA T-4RIA TSH DIGOXIN THYROID BREAST LIVER GALL BLADDER KIDNEY PANCREAS SPLEEN ABD. AORTA RETROPERITONEAL URINARY BLADDER FETAL AGE PLACENTA PREG. COMP. SERIES PELVIC – ULTRA MASS SOUND REQUEST UNLISTED EXAMS: CHECK [7 FOR EXAM DESIRED REASON FOr AM: (PLEASE INITIAL) CIRCLE RIGHT OR LEFT . ( BD / aoe EXAM REQUESTED FOR DATE: c / PAJIENT MAY TRAVEL: SINUSES \AJ WHEELCHAIR ER MASTOIDS FACIAL BONES STRETCHER OP PORTABLE . NASAL BONES TECHNICAL DATA: (FOR X-RAY DEPT. USE.) [_]MANDIBLE , CERVICAL THORACIC [JLUMBO-SACRAL SACRUM RADIOLOGIST’S CONSULTATION: []coccy. REPO REGULAR CHEST CLAVICLE____—ORR LL 2-11-81 BARIUM ENEMA: Barium filled the entire colon and outlined SCAPULA RL the cecum. There is a small amount of reflux into the terminal STERNUM ileum. There were numerous diverticula scattered throughout the MAMMOGRAM___R EL entire colon. I could not detect any radiographic evidence of diverticulitis. PLAIN FILM- KUB ABDOMINAL SERIES ~~ IVP: A plain film of the abdomen shows a 3 cm. calcified ESOPHAGUS fibroid in the left side of the pelvis. There is also rather UPPER Gi SERIES significant degenerative disease of the lumbar spine. SMALL BOWEL SERIES Following the IV injection of contrast material, serial JX COLON GALL BLADDER films including tomograms show that both kidneys are normal in H, CP LANGIOGRAM ureters are unremarkable. The bladder is well visualized on a PELVIMETRY delayed film and is normal. A post voiding film shows complete FETAL NUMBER OPOSITION evacuation. Conclusion; | SHOULDER RL Normal IVP. HUMERUS RL Calcified fibroid of the uterus. ELBOW RL [_] FOREARM RL . . WRIST. RL “s— CERVICAL SPINE: Multiple views of the cervical spine HAND RL show significant degenerative changes involving the facet joints FINGERS Re at all levels of the cervical spine. There is also narrowing of OS-CALCIS_R L the C4 -CS intervertebral disc space. There is rather extensive ote RL spine. All of these changes are due to degenerative osteoarthrit KNEE RL and degenerative di LOWER LEG RL ANKLE RL . FOOT. RL MCD:hb TOES RL REQUEST UNLISTED EXAMS: .D., RADIOLOGIST = X-RAY REQUEST AND REPORT SSMH-500 (REV. 11/77) – — ~ B7Y Ps st EXAM REQUESTED FOR DATE: J-9-§ 1 REASON FOR. .M: (PLEASE INITIAL). CHECK [v] FOR EXAM DESIRED CIRCLE RIGHT OR LEFT SKULL PATIENT MAY TRAVEL: | _ SINUSES Miwieercuain [ER MASTOIDS STRETCHER FACIAL BONES PORTABLE |> (I NASAL BONES TECHNICAL DATA: (FOR X-RAY DEPT. USE.) MANDIBLE TM-JS THORACIC RADIOLOGIST’S CONSULTATION: REPORT 2-9-81 CHEST: PA and lateral views reveals the chest to be essentially normal and unchanged from the study of 12-1-80, The heart is slightly enlarged. LD:hb M.D., RADIOLOGIST [JLUMBO-SACRAL SACRUM []coccy. REGULAR CHEST RIBS (LOCALIZE) RL CLAVICLE RL SCAPULA RL STERNUM MAMMOGRAM___RL ABDOMEN PLAIN FILM – KUB ABDOMINAL SERIES ESOPHAGUS UPPER G! SERIES SMALL BOWEL SERIES COLON | GALL BLADDER IV CHOLANGIOGRAM IVP HYPERTENSIVE IVP PELVIMETRY FETAL NUMBER OR POSITION SHOULDER RL HUMERUS RL ELBOW RL FOREARM RL WRIST. RL HAND RL [1 FINGERS_._ RL OS-CALCIS_R L [] PELVIS HIP RL FEMUR RL KNEE RL LOWER LEG RL ANKLE RL [|] FooT. RL _|TOES RL REQUEST UNLISTED EXAMS: | ka 367 2 49/34 (IF OUTPATIENT WRITE NAME, ADDRESS, AGE) SSMH-500 (REV. 11/77) REPORT 7AV9I7 (12/93 87Y mi GRAPHIC CHART yy “y a os ‘Days after Adm. 2. 3 ; 7 G “OD f eg Oevs after Oper, _A.M.| P.M. A.M.| P.M.| A.M.| P.M.| A.M.| P.M.1 A.M.| P.M.1 A.M.| P.M.| A.M.| P.M.|[A.M.| P.M.] A.M.| P.M.| A.M.| P.M.[ A.M.) P.M.| A.M. | P.M.| A.M.| P.M. A.M.! P.M HOUR}) 4[shal4[ehal 4[ehai 4[ah2} 4[shal 4[eh2) 4]shal 4[sltal 4[ehal 4jeh2|4|shal4[shal4/anal4jen fl i 7 | 106/11 | 105||—-14 ; Litt I 10 ++ + _ | 10 +t —- r 170 + 4 rr 16 4 + { . ~ 14 T T T | 130 |_| ; 120 14 11 } 1 4+ 4o| 4 | | | 30 t + 4 | | 10 T ‘| L Oral Le” – ww wv ue vA a cer } yo Le A a – a 7] ee Intra- a ~ venous Proctoclysis Subcu- — taneous Urine we uv v ra uw L ee 4 “| “oe WA = – | Emesis ; | Bile or Sputum T, C.C IN ~ | Fe . ‘ 5 ; ly | “gn ! } on } + lo Weight Wal isi h*lisce lisae lisait-|pa’b [/s3’blflo3h- 15.37 53 Wi | OY Blood Pressur 7A tA ya tl pelo ley ip fs elud 177k. 1 | | Form SSMH 207 GRAPHIC CHART Pome a T { i NAME caseNo. PED I /8C ROOM NO. ay: DIAGNOSES: Enter Here IN PENCIL Number of Forms in Use J ALLERGIC TO: (Record in Red) DIET: OR DATE |EXP.DATE DATES GIVEN ME DICATION-DOSAGE -FREQUENCY-RT. OF ADM. INITIALS TIME 4) fp ge. ty. Ty 7 Af ; — ~ Ph 1) Single Orders + Pre-Operatives ENTER HERE IN PENCIL NO. OF FORMS IN USE OR DATE TO BE GIVEN MEDICATION-DOSAGE-RT. OF ADM. NURSE MEDICATION TO BE GIVEN NURSE -DOSAGE-RT. OF ADM. INITIALS DATE TIME INITIAL Binitiacs DATE TIME INITIAL ee GARE STECTATI ay a Cuarct nice 2-~/2 CLS of tPA SAL. An DATE/TIME ADMITTED aa Date 2 /-f/ eh DISCHARGE STATUS SUMMARY a. Health é b. Activity f Y c. Pt. Knowledge : d. Instructions e. Mode of discharge £. Other (specify) a , Mes 1. Afebrile _ Vp?. bH- [55 2. Diet GB. duke – jaskiichcor3 Gt Ot. J. Scheu Cc £4 ¢ c/ – 3 ° Wound IV OAM 4. Medication Qy tees Theis os 1) G jules) & 2p Leviat e 5. Pain Free 44, Yes g 6. Activity ; ad Lh | 7. Instructions | (pt. and/or family) VO KOC & De Céel CK te Adspt Aikd 2 FF ¢ 8. Pt’s Knowledge 9. Discharge v ; —_ / ii ly & priv? & ck ri Ue PYLE vr, CCL SS a. How b. Where 10. Other (specify) . VIVE TI € SSMH 823 acmenenenres seni: 2 DE: Ambulatory. we U% Stretcher AoA 7 lYes No[Comment | \SON FOR ADMISSION __ Co key Gre |8: ELIMINATION-BLADDER Ft i coe N ormal , Rn OS7’-§F-GO. Be Frequency/Urgenc al | _ . | Burning lert/Oriented ae ; Catheter __ prehensive ie __ Drugs __ semicomatose u | Other ‘omatose S| | | uf a | TO. HEALTH ALDS ther nm Dentures OMMUNICATTI ON Glasses Speaks English | Cone Lenses fo Hearing Aid | | cL. Aphasic Other _ KIN CONDITION Reddened_ Decubiti_ Areas +—| CL | _—_____ moe Pt Ly | Crutches . Burns | . | Rash/Scaling _ rp 13. (FEMALE ONLY) Cold-Clamm\ BC/TUD | Color-Pale [4. CHRONIC CONDITION _CU Lk Average Cyanotic ELIMINATLON-BOWEL Regular Diarrhea Constipation __ eee DEY Sg Zhe Lax/Enema _ | —T TT Came w/patient Lash incontinence rt _ Colostom TT Disposition DATE OF LAST SOSPITAL ADMISSION – Reason Lit Lome: for Unit — Call Light__~ Bathroom __. Visiting Hours — PATIENT ORTENTATION: NURSE’S OBSERVATION AND ASSESSMENT: . NURSING ADMISSION C BECK LIST SSMH #802 (Rev. 4/77) ~ CLOTHING AND VALUABLES SHEET (addre ssograph) | 1. Tunderstand that while the hospital will be responsible for items deposited in the safe, I must be responsible iNantures kept at the bedside will be labeled, : end nannot He