97%(119)115 out of 119 people found this document helpful
This preview shows page 32 - 35 out of 39 pages.
states the discoloration is of 4 weeks duration with no evidence of healing despite multiplehome remedies and overthe- counter treatments. Pt is a type 1 diabetic for 10 years.O:Wt: 146 lb, Ht: 5′5″ T: 98.6, BP: 131/58; HEENT: unremarkable. Dr. Prader notes premature graying of the right eyelashes and eyebrows and discoloration of the right lowereyelid. Ultraviolet light treatment and micropigmentation are discussed as treatment options.A:Type 1 diabetes; VitiligoP:RX: 0.1% Tacrolimus ointment, b.dPt to return in 2 weeks for follow-upE10.628 NOT E10.9: page 523: Diabetes>Type 1>with skin complicationsH02.732: page 596
PATIENT: FLOWERS, CATLYNNEACCOUNT/EHR #:FLOWCA001DATE: 09/16/18Attending Physician: Renee O. Bracker, MDS:Catlynne Flowers, a 22-year-old female, presents to the emergency room today with dyspnea and cough.O: Ht: 5’ 3”, Wt: 131 lb., R: 30, T: 101.2, BP: 110/67. Catlynne was diagnosed with sickle-cell disease 3 years ago. Patient appears to be in crisis. Chest x-ray confirms pulmonary infiltration. A broncho-alveolar lavage was performed; specimen was taken for culture, which confirmed the diagnosis.A:Sickle-cell/Hb-C crisis with acute chest syndrome ACSD57.211R50.81 NOT R91.8: Fever>conditions classified elsewherePATIENT: CROWDER, CHRISTOPHERACCOUNT/EHR #: CROWCH001DATE: 11/04/18Attending Physician:Oscar R. Prader, MDADMITTING DIAGNOSES:Deep venous thrombosis (DVT) left legUrinary tract infection (UTI)Parkinson’s diseaseFINAL DIAGNOSES:Acute DVT, leftUTIParkinson’s diseaseHOSPITAL COURSE:The patient presented to the office with left leg pain, and uneasiness as well as cloudy urine. He was evaluated, and Doppler studies of the leg confirmed DVT. Urinalysis reveals infection and the patient was started on Levaquin and Lovenox subcu 1 mg per kg twice a day; after 3 days patient asymptomatic for both with his urinary symptoms and calf pain. Patient’s vital signs are stable. He is afebrile. Lungs clear. Heart rhythm regular.Neurologic examination:Tremors and rigidity secondary to Parkinson’s disease. Rest is unremarkable. His Doppler studies were positive for left popliteal vein thrombosis and flow abnormalities in superficial femoral vein. The results of the pelvic sonogram reveal an enlarged prostate and questionable intraluminal. Right kidney, normal. Left kidney, cyst lower pole.