6-1 Discussion To begin, review the Patient Record One PDF, Patient Record Two PDF, and Patient Record Three PDF documents. Then, in your initial post, add

6-1 Discussion To begin, review the Patient Record One PDF, Patient Record Two PDF, and Patient Record Three PDF documents. Then, in your initial post, add

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To begin, review the Patient Record One PDF, Patient Record Two PDF, and Patient Record Three PDF documents. Then, in your initial post, address the following:

  • Discuss your approach for reviewing the patient records. The final project directs you to specific sections of the patient records, but if it did not, what sections of the records would you review first? Why?
  • Which section of the report did you find most interesting? Why?
  • Now, review the Final Project Guidelines and Rubric PDF and Final Project Template Word Document Word documents. List any questions you have. If you do not have any questions, be sure to state this in your post.

Respond to at least two of your peers by comparing your approaches for reviewing the patient records. What insights can you provide your peers? Did you peers identify reasons that you found particularly insightful?

Note: You must submit your initial post before you can see your peers’ posts.

To complete this assignment, review the Discussion Rubric PDF  document.

Permission to reuse granted by Alfred State College and Michelle A. Green

Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
Hospital No. 999

INPATIENT FACE SHEET

Patient Name and Address Gender Race Marital Status Patient No.

LONG, BETH
4983 REED STREET
ALMOND, NY 14804

F W M IPCase001
Date of Birth Age Maiden

Name
Occupation

12/17/YYYY 30 Short Clerk

Admission Date Time Discharge Date Time Length of Stay Telephone Number

04/26/YYYY 1350 04/30/YYYY 1150 04 DAYS (607)555-3319
Guarantor Name and Address Next Of Kin Name and Address

LONG, BERNIE
4983 REED STREET
ALMOND, NY 14804

LONG, BERNIE
4983 REED STREET
ALMOND, NY 14804

Guarantor Telephone No. Relationship to Patient Next of Kin Telephone Number Relationship to Patient

(607)555-3319 Husband (607)555-3319 Husband
Admitting Physician Service Admit Type Room Number/Bed

John Black, MD 369
Attending Physician Admitting Diagnosis

John Black, MD Fever of undetermined origin
Primary Insurer Policy and Group Number Secondary Insurer Policy and Group Number

Diagnoses and Procedures ICD Code

Principal Diagnosis

Acute Pyelonephritis

Secondary Diagnoses

Dehydration

Principal Procedure

Secondary Procedures

Discharge Instructions
Activity: r Bed rest r Light r Usual r Unlimited r Other:
Diet: r Regular r Low Cholesterol r Low Salt r ADA r _____ Calorie

Follow-Up: x Call for appointment r Office appointment on r Other: To be seen for a follow up in
office in one week

Special Instructions: None
Attending Physician Authentication: Reviewed and Approved: John Black MD

ATP-B-S:02:1001261385: John Black MD
(Signed: 4/30/YYYY 2:20:44 PM EST)

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission:04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

CONSENT TO ADMISSION

I, Beth Long hereby consent to admission to the Global Care Medical Center (ASMC) , and I further consent to such
routine hospital care, diagnostic procedures, and medical treatment that the medical and professional staff of ASMC may
deem necessary or advisable. I authorize the use of medical information obtained about me as specified above and the
disclosure of such information to my referring physician(s). This form has been fully explained to me, and I understand its
contents. I further understand that no guarantees have been made to me as to the results of treatments or examinations done
at the ASMC.

Reviewed and Approved: Beth Long
ATP-B-S:02:1001261385: Beth Long
(Signed: 4/26/YYYY 2:12:05 PM EST)

Signature of Patient

Signature of Parent/Legal Guardian for Minor

Relationship to Minor
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 4/26/YYYY 2:12:05 PM EST

WITNESS: Global Care Medical Center Staff Member

CONSENT TO RELEASE INFORMATION FOR REIMBURSEMENT PURPOSES
In order to permit reimbursement, upon request, the Global Care Medical Center (ASMC) may disclose such treatment
information pertaining to my hospitalization to any corporation, organization, or agent thereof, which is, or may be liable
under contract to the ASMC or to me, or to any of my family members or other person, for payment of all or part of the
ASMC’s charges for services rendered to me (e.g. the patient’s health insurance carrier). I understand that the purpose of any
release of information is to facilitate reimbursement for services rendered. In addition, in the event that my health insurance
program includes utilization review of services provided during this admission, I authorize ASMC to release information as is
necessary to permit the review. This authorization will expire once the reimbursement for services rendered is complete.

Reviewed and Approved: Beth Long
ATP-B-S:02:1001261385: Beth Long
(Signed: 4/26/YYYY 2:14:17 PM EST)

Signature of Patient

Signature of Parent/Legal Guardian for Minor

Relationship to Minor
Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 4/26/YYYY 2:16:24 PM EST

WITNESS: Global Care Medical Center Staff Member

Permission to reuse granted by Alfred State College and Michelle A. Green

GLOBAL CARE MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

ADVANCE DIRECTIVE

Your answers to the following questions will assist your Physician and the Hospital to respect your wishes regarding your
medical care. This information will become a part of your medical record.

YES NO PATIENT’S INITIALS

1. Have you been provided with a copy of the information called
“Patient Rights Regarding Health Care Decision?”

X

2. Have you prepared a “Living Will?” If yes, please provide the
Hospital with a copy for your medical record.

X

3. Have you prepared a Durable Power of Attorney for Health
Care? If yes, please provide the Hospital with a copy for your
medical record.

X

4. Have you provided this facility with an Advance Directive on a
prior admission and is it still in effect? If yes, Admitting Office
to contact Medical Records to obtain a copy for the medical
record.

X

5. Do you desire to execute a Living Will/Durable Power of
Attorney? If yes, refer to in order:
a. Physician
b. Social Service
c. Volunteer Service

X

HOSPITAL STAFF DIRECTIONS: Check when each step is completed.

1. ü Verify the above questions where answered and actions taken where required.

2. ü If the “Patient Rights” information was provided to someone other than the patient, state reason:

Name of Individual Receiving Information Relationship to Patient

3. ü If information was provided in a language other than English, specify language and method.

4. ü Verify patient was advised on how to obtain additional information on Advance Directives.

5. ü Verify the Patient/Family Member/Legal Representative was asked to provide the Hospital with a copy of the
Advanced Directive which will be retained in the medical record.

File this form in the medical record, and give a copy to the patient.

Name of Patient Name of Individual giving information if different from Patient
Reviewed and Approved: Beth Long

ATP-B-S:02:1001261385: Beth Long
(Signed: 4/26/YYYY 2:35:05 PM EST)

Signature of Patient Date

Reviewed and Approved: Andrea Witteman
ATP-B-S:02:1001261385: Andrea Witteman
(Signed: 4/26/YYYY 2:35:47 PM EST

Permission to reuse granted by Alfred State College and Michelle A. Green

Signature of Hospital Representative Date

GLOBAL CARE MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234
LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

DISCHARGE SUMMARY

ADMISSION DATE: 04/26/YYYY DISCHARGE DATE: 04/30/YYYY

ADMISSION DIAGNOSIS: Fever of undetermined origin.

DISCHARGE DIAGNOSIS: Acute pyelonephritis.

SUMMARY: This 30 year old white female had high fever off and on for
several days prior to admission without any localizing signs or symptoms.
Preliminary studies done as an outpatient were unremarkable except to
indicate an infection some place. She was ultimately seen in the office,
temperature was 103 to 104. She was becoming dehydrated, washed out, weak,
tired, and she was admitted for further workup and evaluation.

Workup included a chest x-ray, which was normal. Intravenous pyelogram was
also normal. Blood culture report was normal. Urine culture grew out
Escherichia coli greater than 100,000 colonies. Throat culture was normal.
One blood culture did finally grow out an alpha strep viridans.

I talked to Dr. Burke about this and we decided on the basis of her
clinical condition and the fact that this did not grow on all bottles it
was more likely a contaminate. Urine showed a specific gravity of 1.010,
albumin 1+, sugar and acetone were negative, white blood cells 6 to 8, and
red blood cells 1 to 2. White count 13,100, Hemoglobin 12, hematocrit 35.1,
segmental cells 81, lymphocytes 11, monocytes 5, eosinophils 1, bands 2.
Mononucleosis test was negative. Alkaline phosphatase 127, blood sugar 125,
sodium 142, potassium 4.7, carbon dioxide 30, chloride 104, cholesterol
119, Serum glutamic oxaloacetic transaminase 41, lactate dehydrogenase 151,
creatinine 0.9, calcium 9.8, phosphorus 3.3, bilirubin 0.6, total protein
6.8, albumin 4.0, uric acid 6.5. Electrocardiogram was reported as normal.

She was started on intravenous fluids, intravenous Keflex, her temperature
remained elevated for approximately 48 hours and now has been normal for
the last 48 to 72 hours. She feels better, hydration is better, eating
better, no urinary symptoms. She’s being discharged at this time on Keflex
500 four times per day, increased fluid intake. To be seen in follow up in
the office in 1 week.

DD: 04/30/YYYY Reviewed and Approved: John Black MD

ATP-B-S:02:1001261385: John Black MD
(Signed: 5/1/YYYY 2:24:44 PM EST)

DT: 05/01/YYYY Physician Authentication

Permission to reuse granted by Alfred State College and Michelle A. Green

GLOBAL CARE MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

HISTORY & PHYSICAL EXAM

ADMISSION DIAGNOSIS: Fever undetermined etiology, pyelonephritis, dehydration, and
possible urinary tract infection.

CHIEF COMPLAINT: Chills and fever, and just feels lousy for the last 5 days.

HISTORY OF PRESENT ILLNESS: The patient began to run a temperature on Sunday, had no other
complaints whatsoever. She has not felt like eating for the past 5 days and only taking in
fluids and Aspirin. She was seen in the office on 4/24 with 98 degree temperature but she
had just taken Aspirin. At that time physical exam was negative but she had an 18,300
white count. The white count was repeated the next day and found to be 13,400 with
temperature elevated at 102-103 unless she was taking Aspirin. She was seen in the office
again today, continues to feel lousy and now she has some pain in the left upper flank
area posteriorly, she is being admitted to the hospital for a workup with a temperature of
103.

FAMILY HISTORY: Negative for cancer, tuberculosis, diabetes, she has a brother with mild
epilepsy.

PAST HISTORY: She has only been admitted for delivery of her 2 children, otherwise she has
always been in excellent health without any problems. She smokes 15-20 cigarettes a day
and has done so for the last 15 years. She doesn’t drink. She uses no other drugs.

SOCIAL HISTORY: She lives at home with her husband and 2 children. There are no apparent
problems.

REVIEW OF SYSTEMS: Normal except for the history of the present problem.

GENERAL: Shows a cooperative young lady. She shows no pain. She is 30 years old. WEIGHT:
113 lb. TEMPERATURE: 103 oral PULSE: 102 RESPIRATIONS: 18

SKIN: Pink, warm, dry, no evidence of rash or jaundice.

HEENT: Head symmetrical. No masses or abnormalities. Eyes react to light and
accommodation. Extraocular movements are normal. Sclera is clear. Ears, tympanic membranes
are not injected. Mouth and throat are negative. NECK: Supple. No lymph notes felt. No
thyromegaly.

CHEST: Clear to percussion and auscultation. HEART: Normal sinus rhythm. Not enlarged.

ABDOMEN: Soft. She is tender under the left costal margin with no enlargement of any
organs. She has pain to percussion in left upper flank area.

PELVIC & RECTAL: Deferred.

EXTREMITIES: Normal. Peripheral pulses are normal.

DD: 04/26/YYYY Reviewed and Approved: John Black MD

ATP-B-S:02:1001261385: John Black MD
(Signed: 4/26/YYYY 2:24:44 PM EST)

DT: 04/26/YYYY Physician Authentication

GLOBAL CARE MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

PROGRESS NOTES

Date Time Physician’s signature required for each order. (Please skip one line between dates.)

04/27/YYYY 1450 Chief complaint: left flank pain; fever.

Diagnosis: (1)Inflammation of the kidney and renal
pelvis; (2)the loss or deprivation of water from the
body; rule out (3)kidney stones

Plan of Treatment: Admit. Hydration with intravenous
Ancef.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 4/27/YYYY 2:50:55 PM EST)

04/28/YYYY 1110 Bacteria in the (4)blood culture. Alpha strep, not
viridans, clinically.

Improving. Has (5)genital and urinary infection; urinary
tract infection.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 4/28/YYYY 11:14:07 AM EST)

04/29/YYYY 1140 Patient feels better; still complains of left flank and

back pain.

SUBJECTIVE: Patient without (6)fever vital signs.

OBJECTIVE: HEAD/EYES/EARS/NOSE/THROAT: (7)Eardrum of left
ear somewhat dull yellowish.

Throat: slight redness of the (8)skin.

Heart: regular rate and rhythm, without murmur.

Back: positive left costovertebral angle tenderness.

Abdomen: mild left upper quadrant.

ASSESSMENT/PLAN: 1) Probable left pyelonephritis. Rule
out stone. 2) Positive streptococcal bacteremia. Possibly
secondary to pyelonephritis. Possible other source?
(9)Localized collection of pus which could occur in any
part of the body – doubt.

(10)X-ray record of kidney, renal pelvis, ureters, and
bladder is okay.

Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 4/29/YYYY 11:40:32 AM EST)

Permission to reuse granted by Alfred State College and Michelle A. Green

GLOBAL MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

DOCTORS ORDERS

Date Time Physician’s signature required for each order. (Please skip one line between
dates.)

04/26/YYYY 1400 Complete blood count and mononucleosis test. Urinalysis.
Urine for culture and sensitivity. Throat culture.
Blood culture every one-half hour times two until next
temperature increases to 101 degrees. Chest x-ray done as
outpatient. Electrocardiogram. SCG #2. Electrolytes.
Full liquids as tolerated. Intravenous fluids, 50-100
cubic centimeters per hour. Tylenol 2 tabs every 4 to 6
hours as needed for elevated temperature. Ancef 500
milligrams intravenous every 6 hours (after cultures are
obtained. History and physical examination report
dictated.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 4/26/YYYY 2:04:00 PM EST)

Permission to reuse granted by Alfred State College and Michelle A. Green

04/27/YYYY 1110 Please schedule for intravenous pyelogram, Monday morning.
Soft diet as tolerated. Strain urine.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 4/27/YYYY 11:24:52 AM EST)

04/29/YYYY 1515 Discontinue intravenous fluids in morning. Discontinue

Ancef in morning. Start on Keflex, 500 milligrams four
times per day in morning on April 30.
Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 4/29/YYYY 3:24:00 PM EST)

04/30/YYYY 1315 Discharge to home.

Reviewed and Approved: John Black MD
ATP-B-S:02:1001261385: John Black MD
(Signed: 4/30/YYYY 1:16:32 PM EST)

GLOBAL CARE MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234

LONG, BETH

IPCase001
DR. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY
ROOM: 369

LABORATORY DATA

SPECIMEN COLLECTED: 04/26/YYYY SPECIMEN RECEIVED: 04/26/YYYY

TEST RESULT FLAG REFERENCE

URINALYSIS

DIPSTICK ONLY

COLOR YELLOW

SPECIFIC GRAVITY 1.010 ≤ 1.030

GLUCOSE NEGATIVE ≤ 125 mg/dl

BILIRUBIN NEGATIVE ≤ 0.8 mg/dl

KETONE TRACE ≤ 10 mg/dl

BLOOD TRACE 0.06 mg/dl hgb

Permission to reuse granted by Alfred State College and Michelle A. Green

PH 6.5 5-8.0

PROTEIN NORMAL ≤ 30 mg/dl

UROBILINOGEN NORMAL ≤ -1 mg/dl

NITRITES NEGATIVE NEG

LEUKOCYTE NEGATIVE ≤ 15 WBC/hpf

WHITE BLOOD CELLS 6-8/hpf **H** ≤ 5/hpf

RED BLOOD CELLS 1-2/hpf ≤ 5/hpf

BACTERIA MANY **H** 1+(≤ 20/hpf)

URINE PREGNANCY TEST Negative

≤ = less than or equal to

≥ = greater than or equal to

mg/dl = milligrams per deciliter

hgb = hemoglobin

/hpf = per high power field

***End of Report***

GLOBAL MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369
LABORATORY DATA

Permission to reuse granted by Alfred State College and Michelle A. Green

SPECIMEN COLLECTED: 04/26/YYYY 1450 SPECIMEN RECEIVED: 04/29/YYYY 1814

TEST RESULT

BACTERIOLOGY OTHER ROUTINE CULTURES

SOURCE: Blood Cultures

SMEAR ONLY:

CULTURE

1st PRELIMINARY No bacteria seen at 24 hours.

2nd PRELIMINARY

FINAL REPORT Strep viridans

SENSITIVITIES 1. S AMIKACIN NITROFURANTOIN

R = Resistant AMPICILLIN 1. R PENICILLIN G

S = Sensitive CARBENICILLIN POLYMYXIN B

CEFAMANDOLE SULFISOXAZOLE

CEFOXITIN 1. S TETRACYCLINE

1. R CEPHALOTHIN TRIMETHOPRIM

1. S CHLORAMPHENICOL 1. S VANCOMYCIN

1. S CLINDAMYCIN

1. S ERYTHROMYCIN

1. S GENTAMICIN

KANAMYCIN

1. S METHICILLIN

NALIDIXIC ACID

GLOBAL CARE MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369
LABORATORY DATA

SPECIMEN COLLECTED: 04/26/YYYY 1504 SPECIMEN RECEIVED: 04/29/YYYY 1814

TEST RESULT

BACTERIOLOGY OTHER ROUTINE CULTURES

SOURCE: Blood culture

SMEAR ONLY:

CULTURE

1st PRELIMINARY No bacteria seen at 24 hours

2nd PRELIMINARY No growth seen on 24 hour subculture

FINAL REPORT

***End of Report***

GLOBAL CARE MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369
LABORATORY DATA

Permission to reuse granted by Alfred State College and Michelle A. Green

SPECIMEN COLLECTED: 04/26/YYYY 1450 SPECIMEN RECEIVED: 04/26/YYYY 1746

BLOOD CHEMISTRY

TEST REFERENCE RESULT
ACID PHOSPHATASE 0.0-0.8 U/I

ALKALINE PHOSPHATASE 50-136 U/I 127

AMYLASE 23-85 U/I

LIPASE 4-24 U/I

GLUCOSE FASTING 70-110 mg/dl

GLUCOSE Time collected 125

BUN 7-22 mg/dl

SODIUM 136-147 mEq/1 142

POTASSIUM 3.7-5.1 mEq/l 4.7

CARBON DIOXIDE 24-32 mEq/l 30

CHLORIDE 98-108 mEq/l 104

CHOLESTEROL 120-280 mg/dl 119

SERUM GLUTAMATE PYRUVATE
TRANSAMINASE

3-36 U/I

SERUM GLUTAMIC
OXALOCETIC TRANSAMINASE

M-27-47 U/I F-22-37 U/I 41

CREATININE KINASE M-35-232 U/I F-21-215 U/I

LACTATE DEHYDROGENASE 100-190 U/I 151

CREATININE M-0.8-1.3 mg/dl F-0.6-1.0 mg/dl 0.9

CALCIUM 8.7-10.2 mg/dl 9.8

PHOSPHORUS 2.5-4.9 mg/dl 3.3

BILIRUBIN-DIRECT 0.0-0.4 mg/dl

BILIRUBIN-TOTAL Less than 1.5 mg/dl 0.6

TOTAL PROTEIN 6.4-8.2 g/dl 6.8

ALBUMIN 3.4-5.0 g/dl 4.0

URIC ACID M-3.8-7.1 mg/dl F-2.6-5.6 mg/dl 6.5

TRIGLYCERIDE 30-200 mg/dl

U/I = International Units
g/dl = grams per deciliter
mEq = millequivalent per deciliter
mg/dl = milligrams per deciliter

GLOBAL CARE MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369
LABORATORY DATA

Permission to reuse granted by Alfred State College and Michelle A. Green

SPECIMEN COLLECTED: 04/26/YYYY 1505 SPECIMEN RECEIVED: 04/28/YYYY 1957

TEST RESULT

BACTERIOLOGY OTHER ROUTINE CULTURES

SOURCE: Urine

SMEAR ONLY: 1+ white blood cells, 4+ gram negative rods

CULTURE

1st PRELIMINARY 1. CC = >100,000 Escherichia coli

2nd PRELIMINARY

FINAL REPORT 1. CC = >100,000 Escherichia coli

SENSITIVITIES 1. S AMIKACIN 1. S NITROFURANTOIN

R = Resistant 1. R AMPICILLIN PENICILLIN G

S = Sensitive 1. R CARBENICILLIN POLYMYXIN B

› = greater than 1. S CEFAMANDOLE 1. R SULFISOXAZOLE

1. S CEFOXITIN 1. R TETRACYCLINE

1. S CEPHALOTHIN 1. S TRIMETHOPRIM

1. R CHLORAMPHENICOL VANCOMYCIN

CLINDAMYCIN

ERYTHROMYCIN

1. S GENTAMICIN

KANAMYCIN

METHICILLIN

NALIDIXIC ACID

GLOBAL CARE MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

LABORATORY DATA

Permission to reuse granted by Alfred State College and Michelle A. Green

TIME IN: 04/26/YYYY 1450 TIME OUT: 04/26/YYYY 1746

COMPLETE BLOOD COUNTS DIFFERENTIAL

TEST RESULT FLAG REFERENCE

WHITE BLOOD CELL 13.1 4.5-11.0 thou/ul

RED BLOOD CELL 3.99 5.2-5.4 milliliter/ upper
limit

HEMOGLOBIN 12.0 11.7-16.1 grams per
deciliter

HEMATOCRIT 35.1 35.0-47.0 %
MEAN CORPUSCULAR VOLUME 87.9 85-99 factor level
MEAN CORPUSCULAR HEMOGLOBIN 30.2
MEAN CORPUSCULAR HEMOGLOBIN
CONCENTRATION

34.3 33-37

RED CELL DISTRIBUTION WIDTH 11.4-14.5
PLATELETS 355 130-400 thou/ul

SEGMENTED CELLS % 81
LYMPHOCYTES % 11 20.5-51.1
MONOCYTES % 5 1.7-9.3
EOSINOPHILS % 1

BAND CELLS % 2

Thou/ul= thousand upper limit

***End of Report***

GLOBAL CARE MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

RADIOLOGY REPORT

Date of X-ray: 04/29/YYYY

REASON: Fever of unknown origin.

TECHNICAL DATA: No known allergies. 100 milliliter infusion through
intravenous – no reaction noted.

INTRAVENOUS PYELOGRAM: A plain film taken prior to the intravenous
pyelogram shows no shadows of urological significance.

Following the intravenous injection of contrast material, serial films
including anterior-posterior and oblique views show that both kidneys are
normal in size and configuration. The right kidney is slightly ptotic and
there is some buckling of the right proximal ureter. However, I do not
think that this finding is clinically significant. The visualized course
of the distal ureters are both normal. The bladder is well visualized on a
delayed film and is within normal limits. There is a small amount of
urinary residual on the post voiding film.

CONCLUSION: Essentially normal intravenous pyelogram.

DD: 04/29/YYYY Reviewed and Approved: Randall Cunningham MD
ATP-B-S:02:1001261385: Randall Cunningham MD
(Signed:4/29/YYYY 2:24:44 PM EST)

DT: 04/29/YYYY

GLOBAL CARE MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

EKG REPORT

Date of Electrocardiogram: 04/26/YYYY Time of Electrocardiogram: 1600

Rate 90

Sinus rhythm normal. PR

.12

QRSD .68

QT .32

QTC

— Axis —

P

QRS

T

Reviewed and Approved: Dr. Steven J. Chambers,
M.D.
ATP-B-S:02:1001261385: Dr. Steven J. Chambers,
M.D. (Signed:4/29/YYYY 2:24:44 PM EST)

GLOBAL CARE MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

GRAPHIC CHART

DAY IN HOSPITAL 1 2 3 4
DATE 04/26/YYYY 04/27/YYYY 04/28/YYYY 04/29/YYYY

PULSE
(•)

TEMP
(X) 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400

140 106

130 105

120 104

110 103

100 102 X X

90 101 • • X • • X • • •
80 100 X • • • • • X X • • • • •
70 99 X X X • • X
60 98.6 • X X X X X X X X

50 98 X

40 97

30 96

20 95

RESPIRATION 20 20 16 20 20 18 16 20 20 20 20 18 16 16 20 18 16 20 18 18

BLOOD PRESSURE
0800

1600

110/65
0800

110/70
1600

112/68
0800

100/70
1600

110/70
0800

108/68
1600

1200
102/60

2000
90/60

1200
90/65

2000
110/69

1200
110/70

2000
105/68

1200
95/72

2000

WEIGHT 5’8” 141#

DIET Full liquid Full liquid Soft Soft

APPETITE 50% 50% 100% 100% 30% 90% 75% 100% 100% 100% 80%

BATH Self Self Self Self

INTAKE/OUTPUT 7-3 3-11 11-7 7-3 3-11 11-7 7-3 3-11 11-7 7-3 3-11 11-7

IN
TA

K
E

ORAL FLUIDS 600 100 650 1350 200 600 1170 100 850 440

IV FLUIDS 500 600 600 850 550 650 650 1050 700 600

BLOOD

8-HOUR TOTAL 1100 700 1250 2200 750 1250 1820 1150 1550 1040

24-HOUR TOTAL 1800 4200 4220 2590

O
U

TP
U

T

URINE 800 600 1100 750 650 700 1175 700 1000 900

STOOL 2 loose

EMESIS

NASOGASTRIC

8-HOUR TOTAL 800 600 1100 750 650 700 1175 700 1000 900

24-HOUR TOTAL 1400 2500 2575 1900

GLOBAL MEDICAL CENTER n 100 MAIN ST, ALFRED NY 14802 n (607) 555-1234

Permission to reuse granted by Alfred State College and Michelle A. Green

LONG, BETH

IPCase001

Dr. BLACK

Admission: 04/26/YYYY

DOB: 12/17/YYYY

ROOM: 369

GRAPHIC CHART

DAY IN HOSPITAL 5
DATE 04/30/YYYY

PULSE
(•)

TEMP
(X) 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000 2400 0400 0800 1200 1600 2000

2400

140 106

130 105

120 104

110 103

100 102

90 101
80 100 X
70 99
60 98.

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