DePaul Exh. 49A

~SSM
HEALTH - CARE
DePaul Health Center

Affidavit
2006 Missouri ; Quality Award Recipient
12303 DePaul Drive' St. Louis, MO 63044-2588' (314) 344 6000 phone' www.ssmdepaul.com
Before me, the undersigned authority, personally appeared Julie Leigh, RHIT, who, being me duly sworn, deposed as follows: My name is Julie Leigh, RHIT. I am of sound mind, capable of making this affidavit, and personally acquainted with the facts herein stated: I am custodian of the records of SSM DePaul Health Center. Attached hereto are
CtJ:;;
pages of records
frorrP~
/J7aJi.Lfu
These~ages
are kept by SSM DePaul Health Center in the regular course of business, and it was the regular course of business of SSM DePaul Health Center for an employee or representative of SSM DePaul Health Center with knowledge of the act, event, condition, opinion, or diagnosis recorded to make the record or to transmit information thereof to be included in such record; and the record was made at or near the time of act, event, condition, opinion, or diagnosis. The records attached hereto are the original:or exact duplicates of the original.
In witness whereof, I have hereunto subscribed my name and affixed my official , 2009. seal this ;)6 day of
mat
f&M 1dl flwm,(Signed) J /

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PLAINTIFF'S EXHIBIT
--. --. KAREN M. PAYNE Notary PubliC-Notary Seal State or Missouri, St louis County Commission # 05535024 My COmmlss~)es Aug 7, 2009
~
~
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'fA
GilI'
Missioll : THROUGH OUR EXCEPTIONAL HEALTH CARE SERVICES , WE REVEAL THE HEALING PRESENCE OF GOD .
DATESTARTED ,O.O<D. ZOO:} PREVIOUS 24 If0: Intake (Mpvt ISOLATION: 0 Special Conllict 0 Contact 0 Neutropenic 0 Airborne 0 Droplet 0 _ _ __ StAlE KEY: 0 Berl 0 Standing 0 W/ChaJr 0 Sling ornER PRECAUnONS: 0 Safety-Fall 0 Bleeding 0 Aspiration 0 Seiz.ure 0 YesterdBy'1 wI. _ _ _ KG T003,/,8 wi. KG (please reconcile welgllt difference II greatllt lfIan 2.5 kg.}
i Temp
: Pv~~ iRil>';,
24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD
/1J}er:
fP
24 HI
H'b"
i
'-'ft'
/ / //. / /
100
i
W/P
IBP
,0?J;11
v--" ~ft:11 >< >,/ / / ' / / /" i// 1//

'tOO
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V /
1 ,
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Irv
ff. ...
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// //
/ ' ../ ' , / / / /

Time
IOn,!Aat~
I02 dellvenog iWlil:e

-'
,i\
iLL\'
,
i
IBeosil.le glucose Dr 'PUL!E REaP TIME ,F"" J:i;M
Til!
mE
DP
'//'.'
Iflll.~
flU P ! Tfllf
lMf , lP
1/"-'
i/-:r
!
[PULSE HI 3P
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I.e",
~l'v.....",n"K~
" ."'''
v
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.r/-'
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DINNER
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S~TIC
111 IE
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I [TIME Dr
.,-rr"
~_/-
SealtUn,
i .-
()b$~rva1iD
0-
FII!I~Tlnn
,/-----
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LUNCH
/,/
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Oa&"ibe;
l~clllion.
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ORAL
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OTHER
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--' --
If
Amount
fWSfl
Amount
~.
AmellOl
Amlllillt
To Coon!
0700 OSOO 090 100 Jj lJ l1H r01)

I
i V' I
Amount
I\mwrn
ArT'.(Jlmt
AmLifl1lq,
Sedalll1n L
.. -
120
130
:?>IcD
''>
._,
1400
i
lSOO 1500
.,
1700
1300
i2 hi
SuI1 fotal;;
)fJO
,
i
---"
(Q,Cl) ... __
12 ~f
lot~1
12 hI Tot~1 P3fenwr1i _~ To COUllt 'I \}(15 1900 i

2(160 2101J 220(1
Z~OO
(i(al/!u(\c _ _
12
~I
Shift lMaxa
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--- --- - - - -
BEHAvt( AN ~ Ami i ~ Emo.

1= Ineff 11- 0_1
1{ h' :'iMl "Jili)'ll
INTERVE
1. R.aa&&u 2. R.Jt19(
3. Guldan
.01, C9~1J!
5. E!lablll
2406
0100
:
6. Enl:'{)Uf 7. Encour
0200
O~
IVO
Z;o
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0400
050D
0000
12hr Sub fQ!hl~
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:---
I? Ilr Toni
---------/7nrl
12 hi Shift Ol!1put
'~'"''-'."'
12 hr Shift Intake
FllItD QUlVflLEfflS: 10l .... , .. 30nL
4 02 (1/2 cup)
B til
. 120ml (3/4 cup) .. ,180ml
lwinfvloul hour lolal ~ 80z (1 cup) .. , .. , . ,240mt--"' . j 12 Ol (soda!

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PATIENT LABEL
D'-'1'-' br.1'V...
MARCH,PHlLLIP
072'1400691
~SSM
Ii E A l T
it
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Fo
~-

,-
DF:PAUL }lEJ'>.L'l'H CENTER
1101l1l1l1U11I11111
MED OS24-Ql
I/P
10/0')./07 0007~8298
._._..
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Iof t A L T
24 HOUR MEDICAL/SURGICAl.. PATIENT CARE RECQRD

DPM100Cl-071 (71;:007) PAGE 1 OF 6
MELKAV~RI,SONIA
10/02/1976 3lY
T1
DPM-l00C
DePaul Medical Records/Phillip H. March
000001
DATf STARTED
24
APP '" Aswrl~ I'illfl (Jf%ent

BCI1ilviol~
Sits I
Site
Timll
R311ng Scorn #
Site
#01
Soale USM 01
ObnfVallon
1'1
~.
Function 1;;0111 .'

DtS1;ribe:
Location,
lIellavior or API' Qualily
Frequ8flI;V
AlIlJlavirting Far:lof&
SellaliGn Level
IntBrnotion!s}
Initial,
BEHAVIOR I PSYCHOLOGICAL
BEHAVfOR{FIESPONSE;S;
A" - ArWouo
~
= I'ma,jl)m.j PiWeu
J ;::: IneffKtiVO f;~pins o = o.velopm<ml.llmpalrm9m
e - Conlinuo<lS Crying DE = Dopf04":5tun G = Gri&'1I1l1l

l = Lethar..,ic
Olh~'
~.
M " Mul1lple 1\"'1<;,,"1
u ~ Un,&.pOMlva
CO. Com"",",,,
Cf '" COl/nlli ... Impalrm9111 R = R"$1!a~
o - OVtitsUfTl1JlaledfOveMctive
Cf) - c"l'Ilusadlrnsori anl"d
O"P ..
Dklr~ptivo
Patmn1
H - HttlluCintlli!ln"J (}.lu~iiJn:J
W
~
OS - IhMupliYo
Dalibilralaly Withholding
Inlo
SigoHioanl OIn.r T - Thfeal6fling Plly,,,cal
1M Impulsiyo B - SJe!iplng
o ~ CalnVUui.,
A = Al!&flIlon S86;;""0
HamVCombal'v.
COP = COOp'316tt,.. LA - LeH AnXiOUs
INTEIWENTI',/iS:
2.
!5
"$di_V~n
1. Run",.r,. p.tle", I S;9,,~'eanl
9
\0
3. GuId.nee
4. CDnsfstMt FnY'konmol1t t Routine E..stahf~~h fll;>ltmninnd limofrBmns rm carti naMb:: ~Iloouragf) "erlJali.aiion
~~r.
1, 12
Off~f fr;>qUGnI brief CONGCI 14 Ptovfd-e in1ormetion to lnCf9S.stllevElJ .of Und9-1PtRndJng J5. Erx:ou-rag9 mmily t.o bring in fumHi<lf objocts 15 p",.ido ..laxation wHIT music. Im.~ry, deap bt/!lIthing. praY.f, m~di<>~lioll17. E,'OOur8(19 norma! s;ooo cyc,i& tfy usinG inalfoet 1'9/111"9 aflar oar. 1E.
RttOOOnl I RomolM>le I Re.,.ling fa,,!.

D-tll'entional acti. . . Hi~ Pro;:Jctiva mmtsurM
Reas.a.s! Reque.lion I SOOlI ctmllGation

t:.\abflsh boundariatl
6.
7. [';flCI)",ag;, paJitnl .,,111 ChlC;\f\;m milkinglQr
1J. OMll8n loom i Limitinlllollch f I'Ii9ds Qu<&l "9n 10 d.",...... p~lltnr. ret"Onn to sl1mvllltO"
11/. Pr<;><id" ,llIan.Na $o<:urily and 'oW mei....'ru \0 mintmlu OehlW!or.1 prob~"'~
~.
PA TlENT LABEl
~~~&!DPM"OOO~7'
o ".
DP~
24 HOU~ MEDICAL/SURGICAL PATIENT CARE RECORD

(7!2(07) PAGE 2 OF B
000002
24 HOUR MED'CAL/SURGICAL PATIENT CARE RECORD

AC
Po
26
Site #1
38 56
Site #2 Site #3
# 01 an&mpls for IV IOslart
I: ~
t fli NOT
Sf = Shnj!t (am-r-II
1fT
ill. -O'I'.IOIa~Q
lfr:_T!lpJi_~I/j,.~
lEFT
0
Sl f OL! TLC
~:I~T
w
x
JlrHil:alc Im;aflf)!l of
NMixwplOwdfi<i
R Lenglh _ _ cm
e z
::::J
9 I-
Irsflriion Dale
Dressing change date
w
Z
PATIENT LABEL
DEPJl.UL HEALTH CENTER
MARCH, PHILLIP
0727400691 24 HOUR MEDICA\"/sUAGICAL PATIENT CARE RECORD
11111111111111111111
MED 0524 -01
lip
10/02/1976 31Y M 10/02(07 MELKAVE!U, SONIA N 0007H12;l6
o " ..
DPM
DPY.1000-071 (712007) PAGE 3 OF B
000003

ACUITY LEVEL ACUITY TOTALS
Points 26-37 3855 56-70 Level 1 2 3 4 5
DATE STARTED
Patient Care ----,----------------------,--.--.

Subtotal Section ''fJ('
Record
to. fifo. :Z0!>.1-
Subtotal Section "8"

Subtotal Section TOTAL POINTS
-
"e"
71-83
8495
96120
ACUITY LEVEL
7 SItter 0 121+ + ReQUIRES FURTHER OOCUMIONTATION

NOTE; If more than onv Ifffl1 on
Ii
Iin8. circhJ the _"rvie<.> indica\"d.
~SSM
~ [" "
t
1 11
A ft ~ ...
DePaul Health Cellter
24 HOUR MEOICAI./SURGICAL PATtENT CARE RECORD

DPMl000-071 (7I2007) PAGE 4 OF B
000004
r:;j~~~.~~~,~AUSURGICAL
I
PATIENT CARE RECORD
DATE STARTED
24
KY
Aple
Abr~
?ertl
AA
w\
Motor r6spom e
(Ahnormaillfl(inn. Extension, Flaccid, LocaRzBS, None,
SPastic, Streng, Wt:ak,
5-S
D-I:
Cole
WD.Wilhdra'l's)
Safll
PED
TED
~
SC[;~
sec
AVI
Spec~y
abno,mal ilfeatll sounds on diagram.
Brut
(Absent, De! reaslNl, CRackles,

RlJO/lClli, Wt eezes, Cua.'Se)
Hen
eM Exit Ore:
POSTERIOR
AM
Atldl
80,,"
BillA Ab!
Last FlaIl
I StO!
~;. Ostc
StOl
~,
5101
NEe
~~
PATI~NT LAB~L
OS11
o
H
SSM DEPAUL HEALTH CENTER 24 HOUR ME01CALiSUROICAL PAnENT CARE. RECORD

DPMl000'(}71 (712007) PAGE 5 OF B
OP~
000005
OI\TE STARTED
/o/b A22/ I
24
Tim
AAbsent
WWeak S>SfrOllg
ftcl1
DDoppler
Color temp
re.~
liMe!
S9n~atinn
is pain
Ume!
Wit ltd fred Il\lI t CJI):
less man 3 !t 'lY<E;
Foot-s
skin 'l.y.}11!I wil!! h~l ~ ?m"~ tfOOtotooctl.OmJilO &wQfIDlll In nol~.
YOidi"
'Ull~ Alll10n
No,""
Freljlll
T " If'C~ 1 =, I
CSI (\I
~-!tD C(
Stira
Oraim
Hsk
Til

f7/2OO7J PAGE 6 OF 8
DEPAUL HEALTH CENTER
MARCH, PHILLIP
1111111111111111111101
t= o
" F
I/l.'
0727400691 ~mD 0524-01 .10/02/1976 31Y t.il 10/02/07 J'.1ELl"..AVERI, SONIA N ()00748296
DPI
000006
24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD

KEY; ,/ WN;.!B or
task compfetllQ
* '" Sue additional oommaols
DATE STARTED
2
F
0
In S:
A
Use botdad kay tatter rt indicated
0 G
A
A
ALTERO SKIN/WOlHlO KEY:

PU '" PlessLffc ulcer
A
D
= Abr~sion
~
I
L
= InCiSi~n
=lilcAl'atiM
, If preswre ulcer. lis1 Sta{je I. II. III. IV, Uftslaqeable

V N
BL - Blister BR = Bruise
E
R
T8
'" Rl.l3h
"lfoHT [VMOlIS sU.is, insuff:cieru;y) =Neumpa1t1!c vice (diabetic)
Va~.clilar
arlell~1
Denuded erythema
EX
H
== b;c!Jnat!oo = HRm;{IO!Th1
WA = Well appflJ)'imi!teu 0 = Other
= T~J1j! hum
[HesSing:
55 - Stell sltjp~
D
~ ll;rl))~t"'fllJ
C = GfMatiO<l B = SlnuQh
WOtlM BIIIUy:
E~char
:> Staples OTA ~ OI'""lu

I'!
DI
~
" Rl!1@Il!lon MlUftS Dry and intaci
il'
E =
Surrou1ldfn~ S~ln I = ~!l",,' Ii = [r'lm.lll. M = Ma.erllivfI

=
Key:
Drftlna~8
G S SS
= (;'-.Hi
=
'!\'Pe:
Drlllnsge Amc;unt:
~t;;
=);,an!
SOlan
Serl)lJS $ SWU'.''ll"''<)<JU. M
L
OIhtJ
C - f;Y"Jlol,iHall<
PU = PliflJl81lt
_____ 0
Other
D = Slwdy
Y
=MM1()ilmBI'I snaps =Otl!f _ _ __

YI H
= 'fRllrm
= MOOlifale - Lalge - CYjli!JIi~
o = OHm
= ClUsly
rIme
"e ,,0.
<!It.:-: ..~lJ~~r;;D:re:'.:ln:AT~w;;;OU;;;mI;Jrs;;;;~;;ri~~j;TA;;;~~Odiidao;rI-----~T:,"=a:lm=e=n~j------T//i;;In,dkablS
0""
Bini
No Chtng. TImi ,nd Inlllill
RelllSllument
~SSM.
ft I! ... \. T
~
. .: ... A

a
2,1 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

DPM-l001l-071 (712007) PAGE 7 OF
0727400691 MED 0524~Ol 10/02/1976 31Y M 10/02/07 MELKAVERI,SONtA N 000748298
111111111111111 MARCH,PHILLIP
rip
000007
Ass~s Ill' WlOliOflql w~u bel l1\!.

ark) s~te~f
comlor!
TO!L~Ung
0 iere~ esery 7
---------~>--+-4-~~.--~+_4__+~--~+__r_+~--+_4__r_+~r_+_4__r~~
!~ UmI!1! Awl!! Hnlrflnl

1 G()n1(lan; ;ruhl\l'SU1lID1~!<ir, 2 et>.;.'l1i <> ill""",\< 00ltffl!WUij It< {co..,.1 "'"" Ie. IV. If. ",'I: i
",(meAl HsPiun fin RCilfalll!

I ?IOIft! VI af\lil{.iI airwly ~,)':!i~r M\'\:tn *1<'I.rl (o9 ' fl1.1i(J1;-1in i'OOtI1r.Utl.lt'litlafMiM hiht:$)
patte:I1ts'
(iUff'&1t
!~
IiNlralUl frtUGiilltln (;wnelll ~m:: anll fe@'r~, (I.e OL wn:l1t ~~-e, etc.}
(.') '" oru;o1m bu, ..
lar~ ti'~,(:tffit.wl
3 &m1<OM ;r,ta! Mar,poillloos
{OW n",s~.
1;13',00> ~P!lt'~1
Il
o~119N .te I /leiitjO>!Oll\;ru!)lJ
M.toltn !IlmiVe '"~. ()i IIMl ~s~WIi<lI \() 100 liMlmllfil (]/ tile
CIJO;c1.lron (tI.g . &ula rourw I}f oolrikn
ill h)"I1,\lir~l}
m~:.ltft1B >\t1u\;mw.h<i!~JH
with li:"J(n~
",""la, fcllowlIlJ
TIIalHel!lilg I\eJ I Ur,Jlt>loc<>ooolct!m .. 2 CQnl to ~ul $I WIlts, in .., e{" J Admw mOllfll:it6; rist 01 fill"lUry
,.!y
!,kdl;l1i1 n "<l~"lioo
OiWS'Ofll !tlNAy (l\J(;~UOS. "Ioeo. W;l1~, OlJ,IC m.)
PiuitnVfirmy WtH;1i\ion
AbO birnl"lSl<in S\~tSfStJ1 ...~Ita$flQl>et
" Safety 01 p!liell! WI'lO are itl<:ap.11<liO from an mpry Of ""'>'0>1 prOCR<hll1 w-hi1 \'Yrnlld f,ufwJ lm:thp-j ~qw y J Hw,y 1"'lV6 e-l.l:tt'"f9"Ve mov>:mr.m I>cr",. it is rookalv "W'0llIlal<! {e g , <!X!lWIily
frac!U~1 !if 1'aSCi1!l' 3'J!l)~~'l
1 Rca-SUfI fUl u!':5\fm 2 A3y.!Smen! Oint f"m~~ J Tnal ,**t ~eG~"'Y 1 H!t~'tIor r8!f.it.~ f ferrmai
All",""",,,!~) _~dI~
S'J.\ife"
a~
(<lOperllflil .\1>1 ratU"nI ,,11:l<JVOd
01 harm to se~ Of w-ef! (let (Jen""",l\I

H8SlJ.!1mS}
BEHAVIORAL RI'STRNIITS'
{)\lief
rre<1U'ts I1llIf2Un OOI'Utnentau"'l
9 O\Iler
N t'f4CBO of!<! 10 rdllll.. inDical.,; 'I!3S"" hi.~ ,td\>.1!'J '@J~\r.d
AC11V1TY
sse" sC\t;;OC Commo')" KlY D = Oar'll1e C = Chay

A; Ambulate
B; 8eU
P{}SITIOIIING
KEY
~SSM
titAL'"'~ARt:
;!4 HOUR MEDICAUSURGICAL PATIENT CARE RECORD

DPM-l (I{lO-071 (712007) PAGE 8 OF 6
MARCH/PHILLIP 0727400691 MED 0524-01 10/02/1976 31Y M 10/02/07
1111111111111111111
1/ P
MELKAVERI/SONIA N 000748298
000008
~SSM
H E A l T H . CAR E"
DEPAUL HEALTH CENTER 12303 DEPAUL DR. BRIDGETON, MO 63044

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730.:WOSTEOMYElITfS NOS-UNSPEC
LA.;. A"'t1.SIQN DATE
LOCATION
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JlOMfTTRI<l P>{YSICIAN
RAHMAN,ANWER Z
1066 EXECUTIVE PKWY CREVE COEUR MO 6~14'
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SUITE 105
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(314)317-0600
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SUITE 105
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ZINSER,PHIUW 0 11125 DUNN ROAD JENNINGS MO

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3143170606
\3141366 7997
3143561471
fMrnnu,c't CARf f'HYSK";:IA"
SHAREO t:AAf PHYSICIAN:
SCHM10T,RICHARD U 12303 DEPAUL DRIVE MO 63Q44 BRIDGETON

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~
.<;>
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en
~
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tNSI)J~ftH~:'E
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!t~SUflItNCE
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L'Ji. S TLEPHoOJ>.tf f>.o't;.
lll'SUAANC.E
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t;.f
"C
OR'
fitil...INSVR~'
!'H~'UfU,
oro>
r;fw,
INSVRED,
lllSUR,IHiCE COMMENTS;
f'(IU
I"f]l ,
<lcr
CQt,1(MU.Il~
PHYSICIAN OFFJCE C9PY
10/02/2007 01 :58:3
000009
DISCHARGE SUMMARY
PAHENT: MARCH, PHILLIP MR#: 000748298 ADMIT DATE: 10/02/2007 ACCT#: 0727400691 DISCH DATE: \"t>\~ \ ,:n DaB: 10/0211976 PHYSICIAN: SONIA N. MElKA'{;;::E.:.-:R2I,~M.:..:..:.D=.:._ _ _ _ _ _ ._R.:..:..:O:...0,,-,M.:..:..:...:_05;..,;.2.:..:..:4_ _ _~
POSSIBLE DATE OF DISCHARGE: 10/05/2007.

DISCf lARGE DIAGNOSES: Lett mandible osteomyelitis. 2 Gram-negative bacteremia likely secondary 10 PIC line. 3 Hypertension.
PROCEDURES DONE DURING HOSPITAL COURSE: PIC Hne
pli'lCRrl1RI1t.
HOSPITAl. COURSE: The patient was a 3'I-year-old African Amffric81l rnale wiltl a past medical history of left mandible osteomyelitis after a stab injury to the jaw and hardwafe placement at Barnes Jewish Hospi1al The hardware that was placed in the mandible was removed at a later time due to infection complications and the patient was diagnosed with osteomyelitis of the jaw durin9 his last admission He was sent home on IV antibiotics However, the patient came back with increasing fevers and he \VRS found 10 have gram-negative bacteremia. It was likely secondary 10 a PIC line infection. So, the PIC line was removed and his antibiotics were changed 1o clindamycin and aztreonam per Dr. Zinser's recommendations. He was also given Neupogen since he had neutropenia likely drug-induced. His white count is now up to 15 likely secondary to the Neupogen effect.
We WIt! recheck a eBC and the patient has been afebrile although his white count is high. If patient has a repeat esc on Monday and the results wil! be faxed to Or. Zinser ane social work arranged tor home antibiotics. The patient will be discharged home with a repeat on Monday and the results to be followed up by Dr. Zinser. Also, the antibiotics 8ztreonam and clindamycm will be given until November 1,2007 and the patient is to follow up with Or. Zinser with In 2 weeks.
esc
DISCHARGE MEDICATIONS: 1 Pepcld 20 mg p.o. daily. 2 Norvasc 5 mg p.o. daily. :1 Altreonam 2 grams intravenous every 8 hours, 4 Ciindfunycln 900 mg Intravenous every 8 hours. Vicodin 5/500 one tablet every 6 hours as needed. 5
DISCHARGE ACTIVITY As tolerated.
FOLLOW UP INSTRUCTIONS: Repeat CBC on Monday with results to be faxed to Dr. Zinser. Follow up wHh Ek Zinser in ~ weeks DISPOSITION. The patient will be dIscharged pending arrangement of home antibiotics ADDENDUM: The patient's antibiotics hHve been changed to clindamycin and Meropenem per 10, Per social work. home antibiotics could not be arranged, since reportedly the patient has been noncompliant. However. Ihe patient denies noncompliance and states that he had been compliant with all of his IV medications. Social work is to arrange for horne antibiotics and if coverage for home anHbiotics Is arranged, the patient witl be discharged home today. It has been emphasized to the patient about being complaint wIth his antibiotics or the consequences mIght Incluoe even trismus and inability to lake p.o. The patient was advised to be compliant and he has been
MEDICALfSURGICAL DISCHARGE SUMMARYDP
, Page 1 of 2
000010

PATtENT: MARCH, PHILLIP
DISCHARGE SUMMARY
MR#: 000748298
-~----
emphasized on the impor1ance of cofnpliance. He will be discharged home today on Mflropenem and cllndarnycin till november i 1 if horne IV antibiotics can be arrcmged.
This document has been reviewed and signed by SONIA MELKA VERI
Sign
O~ternme:
10/10/2007 11 :58PM EST
SONIAN. MELKAVERI, MD SNM:256 - 2040469/253 D: 10105/2007 4 '48 PM T: 10/6/2007 11 :31 PM E:l 0111/200709:03 AM
cc:
SONIA N. MELKAVERI, M.D
MEDICAUSURG'CAL DISCHARGE SUMMARY-OP
- Page 2 of 2
000011
Patient Discharge Instructions

Flu Immunization Given, -';"";"'--:"=-i'If7-' Pneumonia Immunization Given '.' Discharge disposition: Home Care AgenCY:! " .~ __ U _'_-=--._......J..-I'_ _~_ _ _ _ _ -:=---_--'-:'::i,':-:-,::,:...-v_ (}';S - C l(,t,,;> PR~~CRfPTIONS; 0 None WiWritten t:l ~iven to Patient 0 Called to .p~armacy MEqrcA TlONS; See Discharg~ Home Medi~at;on List attach_ed _ _ _ _ _ _ _ __ WORK: 0 Return to. work in days OfO _ _ _ _,_ _ _ _ _~_ _ _ _ __ Activfty: . aintaj~ u~uaj physical activity, Pace activities and plan for rest periods, Restrictions Oi t: ~--------~------------------~-Discharge diagnosis:
(i , \' ,
~
o
CJ Modified Dlet _ _--=_____
Regular Diet
InstrUctions given by Dietician Smoking: Do not smoko/Avoid second hand smoke Smoking cessation Information provided and reviewed for patients who smoke. Worsening of symptoms - Call your physician if any of the following apply to you: A fever greater than 1000F or Chills Exce~sive redness Qf unusual dfainage at A worsening cough with sputum that is green surgical site or yellow or broody Excessive bleeding at surgical site * Worsening shortness of breath, with Of Unrelieved pain without activity NumbnessmnglinglChanges in color of Swollen ankles or hands affected area Weight Monitoring ;fyQu~ave;f:ieartQr Kidney failUre Weigh youfselfthe fficitnlng~ft~(yougethorne;-ai1~(f~ilyaftergoing to the bathroom and before breakfast. Notify yourdoctor,:of.welghtgaltJ of 3 ormotepoUhdsin ont;~day 0[5 pounds in 5 days, FOlLOWUP CARE: Bring alf mt\.dlcatlons with you 10 your appointment. Cal! for appointment with Dr.( \ i- lid? Phone # to be seen inJ.. weeks ,0 Call for aepoinfment with Dr.:;;;41vh,/t) Phone #, J '3;.;> to be seen in)JYw:.:::e..;:.ec..:.Ks::-_ ADD~TlONAL INSTRUCTJONS: . " 35~ 77ft7 C \ f'I 0.0, \'1'i c.. 1 I) \ V VlJ1 I \ IO"f _~
fT)e no
p ~ t") e
fY\
C~c.,/Cf'rlP
Physician Signature:
V l....ih. '\-\.t ('It t I)-:teVt'J'i 1Y1or-\6.~1 ~1 n:'..S1. d~ k0r2-()S:.<...(~-s(yT$cfJ(.rt\

\
J, \
l! \
Belongings returned: !D None
o Home medications o Other:
o Glasses
o No signature needed see orders Dentures o Hearing Aid(s) a Assistive device

Significant Other
to:
Actual time
pa~nature .L:::)' -\-~ < - . Date: /6'~, --y J tJ 'Home

0
Other
These instructions have been..te.l.!iewed with me and my questions have been an.swt'red. .
DI~harged
Mode
Of Discharge:
NurseDv")C.(I::d, ""'"
[J Phone # atrer diSCharge)) Escorted by;
;TI730
;'i:<ii;';''i.~'; ...J..~"t..:.~~'~ "
CJ we 0 Ambulatory
Q
Stretcher
"I-.:.:.U ~~.. :~ ;;-0,~.;i~':"~
DEPAUL HEJI.LTH CENTER

Patient Discharge Summa .
11/2005
,(
Make 2 COPieS oft/us/urm, Onglna/form to chart.
.,'
MARCH, PHTLL,IP 072' OC'r:;~Jl l'lED 0524 .. 01
IIIIIIIIIIIIIIRII
'.., 31 Y
lip
(101
M 10/02/07
'------------------------MEI--
. "':,SONIA N 0007<l829<1
000012
H
DePaul Health Center 123~3 DePaul Drive PAGE NOMBER: 1
ESTIMATED
DISCHARGE TIME:
Please circle: Discharge Mads or POEt-op Mads Bridgeton,MO 63044 Patient Active ~edication List {YES NO) Account Number, 0727400691
NURSE PHONE EXT:
Patient Name:
MARC~,PHILLIP
Room Nurobr: 0524-01
Date: 10/08/2007 Attending physician: MELKAVE~.SONIA N Patient Allergies: No Known Drug P.Jlergies Continue? Medication Generic Name(Brand Name) with Directions
, AM
DePaul Medical Records/Phillip H. March 000013
Noon
PH
Bedtime
Scheduled Medications
*.~*.
l~O l~O
23
FAMOTIDINE(PEPCID)20 MG BY MOUTH ONCE DAILY BEFORE A MEAL

AMLODIPINE(NORVASC)5 MG BY MOUTH Daily
GlVEN AS: (1)
GIVEN AS:
(1) 20 MG TABLET
x
X X
5 MG TABLET
7 YES VODIUM CHLORIDE BACT
o. 9't (BACTE:RIOSTATICl 3
ML INTRAVENOUS EVERY 8 HOURS
SNO
CLINDJ\.MYCIN(CLE:OCIN) (CLEOICIN) 900 MG INTRAVENOOS EVERY 8 HOURS
* * EVERY
HOURS
26 YES
r~ ~ SODtuM
CHLORIDE BACT 0.9% (EACTERIOSTATIC) 30 ML INTRAVENOOS EVERY
HOcrR.S
2@NO
MEROPENEM{MERREM) 1 GM INTRAVENOOS EVERY 8 HOURS

INTRAM:CJSCUW\.R PNEUMOCOCCAL VAt:;.
X
** EVERY 8 HOURS
12 YESVNEUMOCOCCAI. VACCINE POLYVALEN (GIVE) 1
....... ,.... As Needed Medications ........
>
PHYSICIAN SIGNATURE IS REQUIRED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST Medication Substituted per Hos~ital Approved Formulary Sub8titu~ion
pilot Form 4/2005
- . ".
~.
"f-
- ., '/-"
'F . .. -''- Cl, \,\:::-, L'I-<.)I l'.'Tl:l " . ~. '-;.:; . .:'. Y/;~'-.;
J
,r
.~-.-.--~_
i/,_IG
"'---7--!-T: J
-', : l~ ~""' . ~1t.: ___~ __
H
DePaul Health Center ~2303 DePaul Drive
PAGE NUMBER: 2
ESTIMATED DISCHARGE TIME:
NUBS E: PRONE EXT:
Please circle: Discharge Meds or
Po~t-op
Meds
Pat~ent
Bridgeton,MO 63044 Active Kedication List
(YES NO)
Account Number: 0727400691 Patient Name: MARCH,PHILLIP Room Number, 0524-01 Da~e: 10/08/2007 Attending physician: MELKAVERI,SONIA N patient Allergies: No Known Drug ~lergies
Continue? Medication Generic
~arne(Brand
Name) with Directions
r AM
J ~oon
PM
Bedtime
-~~-------------------------3~-----------------------------------.---.-------------------------------.-----------------8~O ACETAH:rnoPHEN(l'YLENO~ Bl'! MOUTH Everyftts pm GIVEN AS, (2) 325 MG TABL.ET I I I
27
----------
C/' FOR PAIN 29 YES~ZOLPIDEM{AMBIEN)10

INSOMNIA
~o
aYDROCODONE/APAP 5/SQOMG CVICODIN 5jSOOMG)
1 TAB BY MOUTII EVERY 6 HOURS
AS NEEDED
I
MG BY MOUTa AT BEDTIME AS NEEDED
GIVEN J;S;
(1)
10 MG TABLET
11
19
YE~DIPHENRYDRAHINE(BENADRYL)25
YE~ROMORPBONE
MG INTRAVENOUS EVERY 6 HOORS
AS NEEDED
HCL (DILJ\ODIDll .MIG INTRAVENOUS EVERY 4 HOURS AS NEEDED
*.*.* Held Scheduled Medications

10
~.*-*
YESG
>
-CLARIFY PENICILLI}f() 1 TJUlLET B MOmH *CLARIFY ADMINISTRATION FREQUENCY
,,*
9: 00 ! - *CLARIFY ADM]
= Medication
PHYSICIAN SIGNATURE IS REQOIRED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST substituted per Hospital Approved Formulary Substitution
pilot Form 4/2005
H
Depaul HealLh Center 12303 DePaul Drive
PAGE NlJMBER: 3
ESTIMATED DISCHARGE TIME: NURSE PHONE EXT:
Please circle: Discharge Meda or Post-op Weds Bridgeton,KO 63044 Patient Ac~ive Medication List (YES NO)
Account Number: 0727400691 Patient Name; MARCH,PHILLIP Room Number: 0524-01
Date: 10/08/2007 Attending Physician: MELKAVERI,SOHIA N Patient Allergies: No F~own Drug Allergies
Continue? Medication Generic Name(Brand Namel with Directions
------~-----------------------------------------------------
I
WIT~
AM
Noon
PM
Bedti~
14 YES
OXICILLIN-CLAVULANATE(AUGMENTIN)875 MG BY MOUTH TWICE DAY
----------------------._--------------------- ----------------------------.
MEALS GrvEN AS: (1) 875 MG TABLET
j
Additional arders
Ff~
f)y_
W\..
~2- UJ-e~
___________ C __ G_C_I_~~F
_~
--------------------------_.._..._._....- ....._.----._--------------Physician Signature:
6).\ _____
~
____ vate/Time
Nurse Signature:
.____ Date/Time
Readback Confirmed [ 1
PHYSICIAN SIGNATURE IS REQUI:RJID ONLY ON TIiE LAST PAGE OF THIS .MEDICATION LIST
> " Medication Substi tuted per Hos.pi tal. Approved FO:ntlulary Subst:i. tut i.on
Pilot Form 4/2005
H
DePaul Health Center 12303 DePaul Drive PAGE NUMBER: 1
ESTIMATED DISCHARGE
T~E:
Please circle: Discharge Meds or Post-op Mede Eridgeton,MO 63044 Patient Active Medication List {YES NO}
NORSE PHONE EXT:
Account Number: 0727400691 Patient Name: MARCH,PHILLIP

Room Number: 0524-01
Date, 10/05/2007 Attending Physician; MELKAVERI.SOHIA N Patient Allergies: No Known Drug ~lergie5
Continue? Medication Generic Name (Bramd 1;ramel with Directions
AM I Noon
PM
Bedtime
Scheduled Medications **.**
L3~O
7 YES
2:2
PAMO'In'NE""C'D)20 MO BY
MG BY
MOOTH
ONCE DAI.Y BEFORE A MRAL

Daily
GIVEN AS,
GIVEN AS, (1( TO
Me
TABLET
x x
x
X
X
l~O AMLODIPINE(~ORVASC)5
MOQT~
(1)
5 MG TABLET
@
;-. "
@
NO
SODIUM CHLORIDE BACT 0.9% (BACTHRIOSTATIC) 3 ML INTRAVENOOS EVERY 8 HOURS

AZ'rREONAM(AZACTAM) (AZACTMI.) 2 GM INTRAVENOUS EVERY 8 HOURS
+tQ.Q (( (0 \
.L
*.. EVERY a HOURS

(
2 3~O
CLINDAN'lCIN (CLEOCIN) [CLEOICIN) 9'00 JotG INTRAVENOUS 'E'\73RY 8 HOURS
I LXX...
Ill)
. {(
EVERY 8 HOURS
26 YES 00DIUM CHLORIDE BACT 0.9% (BACT'ERIOSTATICl 30 ML INTRAVENOOS EVERY

12 YESJ PNEUMOCOCCAL VACCINE POLYVALEN (GIVE) 1
~
HOURS
x
x
IN'l'RAMUSCULAR PNEUMOCOcCAL VAC

~.***
.. *.
As Needed Kedications
PHYSICIAN SIGNATURE IS REQUIRED ONI,Y ON THE LAST PAGE OF THIS MEDICATION LIST Medication Substituted per H05wital Approved Formulary SUbstitution
Pilot Form 4/2005
H
DePaul Heal~h Center 12303 DePaul Drive
PAGE NUMBER: 2
ESTnMATED DISCHARGE
NURSE PHONE EXT:
TI~E:
Please circle: Discharge
M~d8
or
Po~t-op
Mads Bridgeton,MO 63044 Patient Active Medication List (YES NO)
Account Number: Patient Name: ROom NUmber: Date: Attending Physician: Patient Allergies:
0727400691 MARCH, PHILLIP 0524-01 10/05/2007 MELKAVERI,SONIA N No Known Drug Allergies
Continue? Medication Generic Name (Braud Name) with Directions
AM
Noon
I p* I
Bedtime
8 YES NO
-~-------------------------------------------------------------------------------------------------------------------------------------1>CETAMlNOPHEN{TYLENOL}650 MG BY MOUTH Every 4hrs prn GIVEN AS: (2) 325 MG TABL:ET I Ii, I
YES NO lfYDROCODONE/APAP 5/500MGCVICOIJIN 5/50011(0) FOR PAIN 1 'l'M BY MOOTH EVERY 6 HOURS AS NE'ED:ED
I
j
11 YES
~IPHENHYDRAMlNE (BENADRYL) 25
MG INTRAVENOUS EVERY 6 HOURS
AS NEEDED
19
YES~ROMORPHONE
aCL{DlLAunID)l MG INTRAVENOUS EVERY 4 HOORS AS NEEDED

W
** Reld Scheduled Medications
1Q
YE~CLARIFY
PENICILLIN(ll TABLET BY MOUTS *CLARIFY
~NlSTRATION
FREQUENCY GIVEN AS. (I) 875 MG TABLET
.. w
9 :00 AM -
*CLl\RIFY ADMJ
14
YES~OXICILLIN-CLAVULANATE(ATIGMENTIN)87S
MG BY MOUTH TWICE DAY WITH MEALS
>
= Medication
PHYSICIAN SIGNATURE IS REQUIRED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST Substituted per Hospital Approved Formulary Substitution
Pilot Form 4/2005
H
DePaul Health Center 12303 DePa~l Drive
PAGE NUMBER: 3
BSTIMATED DISCHARGE TIME:
NURSE PHONE EXT:
Plea.se circle: Discharge Meds or post-op :Meds Bridgeton,MO 63044 Patient Active Medication List (YES NO)
Account Number: Patient Name: Room Number: Date: Attending Physician: Patient Allergies:
0727400691 MARCH. PHILLIP 0524-01 10/05/2007 MELKAVERI, SONIA. N No Known Drug Allergies
Continue? Medication Generic Nallle (Sran.d Name) wit.h Directions
AM
Noon
PM
Bedtime
Additional Orders
(!be
trw
.-~-
C/\i~ r ~r Or- - LM/LDe0 C~ ...............:::.......::......:.:::::...--------. -c ~.:_l:~...Y.~y._._~~__:z.._(_>e.e. __ h ___________

;I
---l~""'-'-'--"'-'-'--"'-:-"'-'-""""""-'
c0c
------_.._--Physician Signature: Nurse Signature:
v\.
M~~. ~
9<xv..rr
I {
ED fu ~;.ci2J
by clu~
~......-:=:
.
Date/Ti.e
Date/Time
t%$o-/o7
Readback Confirmed [ ]
>
PHYSICIAN SIGNATURE IS REQUI~D ONLY ~ THE LAST PAGE OF THIS MEDICATION LIST Medication Substituted per Hos:pit.al Approved Formulary Suh5tit~tion
Pilot Form 4/2005
,'M~
,.:f BE DISPENSED IN ACCOFIDANCE WITH THE
.-J\.
HERE "-Y
PHYSICIANtS ORDERS
.LERGIES
z,
PATIENT WEIGHT c::>
o
1. 'O~I!Y' in~ati of
'V"n~' in,1?~<i
AN<ay~
gl
'qo' y
5, 'Mon:hlne'lM1aad 01 'MS04'
1,1. 'Ml!9~Sium sultala' InSfila[J of 'MgS04'
3. No traillng W~ (1mg n011Jlmo)
4.
Kos 0 lobs
PATieNT
use leadlnillsros
7. 'Every oit1sr dl!}" m8ll!ad of '0.0.0: B. 'MeG' IMt4ad (lj "11ft
HEIGHT
{O. lmonoUmg}
9, 'InttrmtlonJl 00'15" IMtesd 01 'Ill"
ORDERS
~J'
.f
\.
J \ \
.\~f
--
~SSM
H E A L T H . CAR
SlM-1000Ofj5 4i2007
PATtENT LABEL
f~
)EPAUL HEALTH CI$NTEl{

''1ARC'l-f, PI1TLLH'
IUn81mrIIlIlUlJiflllfi
NED 052: 01
012740069J
PHYSICIAN'S ORDERS
TIP
10/02/1;176 J1Y
~"ELY.AVERI,SON1A
M ll'/02/0? N OOD74A798
000019
DRuG MAY BE DISPENSCD IN ACCORDANCE W1TH THF
.........
4FRE .....",
PHYSICIAN'S ORDERS
L 'OlEy' iMIMI! of "qd' 2, Un~~ in?l~arl ~ 'u' 3. tm n'aillno lams (lmg not I DmQl 4. AIw~,ys use leading Z8(oa ({J.lmg not .Irng)
5. 'IIJQfphino" ins!&ao or "MS04' 6. 'Mavn~slum suffate' Inst~iHJ 1II'MtfSD4' 1. 'Every other day" instead 01 "Q.O.O: 8. "MGG" in~wad Qf -"g' 9. "Inlernat-onal uni\$" insteal1 !If "IU'
PATfENT LABEL
'\."
PHYSICIAN'S ORDERS
SLM1000065 (4i20U7j
-'
'\ I,
,',
J'!~'!\~~~IUIIURU
072'1400691 MED
'JRPAUL HEALTH CENTER
I/P
0524 - 01
000'14 S298
i.'.)/02/1976 31 Y
RAH1>',AN I ,AN1'1RR Z
M 10/02/07
000020
DRUG MAY BE DISPS'{$I;I) IN ACCORDANCl: '/.1TH n-lE ,....J\. HOSPITAL HRE: '0/
PHYSICIAN'S ORDERS
, _ "Daily' instea<llJf 'qd' 2. \lops' instead of 'u' 3. tic lraifrng l$r08 (1 mg not l.Omg) 4. Always UU leaOIrQ zeros (0.1100 net .1 m{l)
5 'Mo!phfne' Inmid 01 'MSQ4' 6. 'Magneslum ttIlfLilu' Instead oj 'MqS04' 7. 'E~&ry alharday' instead oI'O.O.D.' 8. 'MeG' Instead of 'IlQ'
9. 'InlematiallHlun!ls'lniload of "IU'
~SSM
H E A L T H . CAR
SlM-l000065 (412D07)
DEPAUL HEALTH CENTER MARCH/PHILLIP
11I!llIIIIlIlIWIIIUDI
riP
O()O?48::!98
E~
0727400691 M~0 O~24-01 10/02/1976 31Y M 10/02/07
HAlINAN,ANWER Z
PHYSICIAN'S ORDERS
000021
DRUG MAY BE DISPENSfV IN ACCOflOANCE WIT'" THF
r-'>..
HOSPITAL FORMUlARY
M UNLESS CHECKED HERE ......",.
PHYSICIAN'S ORDERS
1. 'O;lily' instead 01 'qd' 2. "Units' insltad of V
a.
PATIENT kEIGHT
~
No tfailing
zeros (1mO MI1.0mil)
4. Alway, use leading l&1l&
rO.1mllIlOUmll)
5. 'MO!Jlhlne' instead of '1,1604' 6. 'M8jln8Slum $\I!tat~ in~teat! 61 "MgS04' 7. 'Every o\her oay' iMtead of 'QO D,' 6. 'MeG' instead 01 'jig' 9. "Internationll UfIlts' inswad 01 'IU'
000022
PHYSICIAN'S ORDERS
1. 'Oaily' Instead 01 '(!d'
2,
'!)f\!!~' i11~Qad
91 "u"
PATIENT 1tE1GHT Q
3 Nn tlallfngZ!f08 (imp noll.0m~) 4. Ah'lays use lea1!/ng ZtloS (O.lmg not.lmQ)
'MllIjlhil1e'lnste~d Qf 'MS04' 6. 'Magnssium sulfate' ins!l!l!d 01 "MqSD4" 7. "Every oU1er ,jay' \fl$\e<ld of "a.o.o." ~. 'MeG' imt~ad of '1J1J" 9. "International uhits' insleild Qf 'Ill'
5.
~SSM
SLM-1OOO-065 (4/2007)
PATIENT LABEL
H ~ A ~ T H e A R EO<
PHYSICIAN'S ORDERS
000023
PERIPHERALLY INSERTED CENTRAL CATHETER ORDERS

,..-----._.-----------,
Insert Pice line catheter by Vascular Access RN. Enter in HBOC under Department Consults,
AII~rgies.:
Assessment:
Obtain consenl for Peripherally Inserted Central Catheter If unable to place Pice hoe by Vascular Access Nurse, refer patient to Interventiona1 Radiology,
11.
Diagnostics:
a
..J-k::z.'l- /,,' "t"-..... _/ ~
Call Physician for INR 4,25 and lor platelet count < 25,000 . STAT one view portable chest x-ray post Pice insertion (tip verification in vena cava) Repeat STAT one view portable chest x-ray if PICC is repositioned Radiologist/Physician to confirm PIce placement prior to use.
III. Medications:
Use lidocaine Hydrochloride 1 % inject intraderrnally to produce wtleal to locally anesthetize site. Flush eaclliumen of Pice with 10 ml sterile NS IVP: before and after medication I solution administration before and after blood product administration every 8 hours (regardless of continuous tV infusion) when obtaininy blor.xi sample, discard small red tube, then obtain sample. Upon completion, pUlse ftush with 20 ml sterile NS IVP PRN to determine patency
N.
Treatment~
Place transparent tegaderm dressing and biopatch at time of line InsertJon. Change .' dreSSing after every 7 days and PRN If the integrity of the dressing is compromised. Document in progress notes and on flowsheet ).
NO BP OR NEEDLE STICK IN PIce ARM DO NOT USE ANY SYRINGE SMALLER THAN 10 ml WHEN lNJECTING IN PICC\~
/1) ;)
~
I agree with the above ordf:ni with fire exceptJon of those crossed through.
\jt
Date: _ _ _ _ _ Tlme:~_ _ __ Physltian_ _ _~~_ _ _ __
\pI
Tl100 noted_ __
RN__________~~_
~SSM
~f
1 t t 111 . t 1'1"
DEPAUL HEA.LTH CEN1'ER

MARCH, PHILLIP
1llllllilimmillUI
rip
PIce Orders 712007
0721400691 MED 0524-01 10/02(1976 31Y M 1.0/02/07 MELKAVERT,SONIA ~ 000748298
000024
ORVG MAY B DISPfNl)ED IN AGGOHUANGE WITH THE ...-'. HlORI; ....."..
PHYSICIAN'S ORDERS
1. 2. 3. 4. 'Daily' inst!1ad of "Qd' 'UnJts'lnsre.d or 'u'
No lli1ll1r1g zeros (lmO Tlol1.Om9J
5. 'MOfllhiW' umealj Of 'MS04'

6. 7. 8. 9. 'MaljlWS!UTll suNare' iflStead (If ''''9804' 'EVVIY otII6nlay" IlISttad Of '0.0.0." 'MeG' imttad o/'l1lJ' 'I/1tWlilllonal unils' Instead of 1U'
AlwJYs ua.lvading ~el1n (O.lmg not .1mo)
~SSM
H E A L T H . CAR
SlM1(l()(}.065 (412007)
PATIENT l.AEJEL
E~
OEPAUL HEALTH
0727400691
~fi~!~t~"}l~~lgU
10/02/1976 31Y
RARf<1Jl.N,AfMER Z
C~N1'ER
r/p
OODi48298
MED 05~4-01
M 10/02/07
PHVSICIAN'S ORDERS
000025
ORUG MA" BE Dl3I'ENSED IN ACCQROANCF WlTH THe
PHYSICIAN'S ORDERS
1. 'Dairy' l!13leao 01 -qrJ"
'Un~s'I!13lead
01 y
PATIENT HEIGhT
">
3. 110 tralHng !ero~ (1mg ~Oll,Omgl .1. AJ'.%ys use leading ~elOs (O.lmg flOt.ll1lQl
5. 'MQrphfm'lnstead Qf "MSO"6. 'Ma!/l1aslum sulf8lti' insl~iJl 01 -MqS04" 7. 'Ever; othe!~" in.!~ao 01 "00.0a. "MCG-Illstead of "iJIJ" 9. 'Intllfnational units" iIIslilall 1)1 'IU'
~SSM
H E A L T H . CAR
SLM-H)OO-065 (4/2(07)
PATIENT LABEL
E~
DEPAUL HEALTH CENTER MARCH,PHILLIP
IIDIIIIIIIIIIIIIIIIII
I/P
PHYSICIAN'S
O~OERS
0727400691 MBD 0524 .O~ , 10/02/197631Y N 10/~0;2f07r RAH~~,ANWER 3 OOO!482~~
000026
Emergency Department Admission Orders

Patient Name:
Ph; \\~p fvw-vL
a) j os--/u., ~.'.J--'f Diagnosis' _~__~_ _ _ _ _~

(}-'-I
-t~~~tl~~t -~d~ii ~o ;Eit1~di~i'

Physician: ();
OS-l;f~i~~i --0T ~I~~~t~ --03NO~h' (1~;t~'r~Gdl~;~ -leu) -. 0 leu

OSurgical 0 Telemetry
-.-- -- . --_--i .. -...... --... -.-.-.. ---.-.. .-.. --.,,--a o

Q
C,9de Status Full Resuscitation
Outpatient (Observation) admit to: 0 Medical
~ 't\"<-"''''.__ c.-,nsults:-f)r ~t""5~ U '.____
\:--.-1, .!.<[-'~ ::
rAne~le0~
DNR - Continue Madlcal Therapy
~~~~==~~~~==~~--~~
r,
II.
o o o o
13'"
ASSESSMENT 0 Obtain Previous Medical Records Vital signs every 5.=hours x ~ then routine [::J Oximetry 1&0 0 DAify Weights LJ Cardiac Monitoring
ADOITrON~L DIAGNOSTICS ~ ..~
a' esc~'
CMP
\'\
0
CXR
PT
PIT
EKG
E'l_ _ _ _ ..._ _
III.
g/ ~/ ___ --\
IV.
TREATMEN S
E1" (.I\"'n~~.,
Fingerstick Glucose U AC & HS n every ___ ._ hour:> MEDICATIONS CJ Initiate Sliding Scale Insulln Orders Continue Home Medications checked "Yes' on Home Medication SheeVOrders. c::( acetaminophen (Tylenol) 650 rng PO ovel)' 4 hours PRN mild pain or fever> 101.5F (J DVT prophylaxis:_... .. .--_ _~_ _
JA~_ (vf?~ ~ 1f!1~""'_~_
~:ty~} _illf.6.:;r t
OJ
'.
IVfluids _ _ erSnline Lock ~V: .. ' Oxygen at _ _ ... _~Iilertl per____ . _ _ _ _ Call physician if 02 SH! <~ 0/0 . !:l Foley 0 NG to ::>uclion Diat: 0 NPO id1fegular.~r 0 _ _ _ cafor:!9 ADA 0 _ _ . ____
Activity; 0 Bedrest 0 BRP f...

oSee Addlt'7al Physici~n Qrd~r~
Date:
0
.
sse
ErUp tJ(J lib 0

J_~.
I'"
/J cj) ttL Tirne:~_~PhYSiCian_f/~Yf~ WV?____

_ _ Time NoteJ: ____ . RN _____ -t?\~
Transcribed by:
________________________~fo~/~~~I-p--
Orders scanned to Pharmacy Date
\D/1;
~Vl
Time..Q.l..:~ Inilials,{:7 ~JJ ~~

DEPAUL HIP"'" TH
CENTER ~SSM DePaul Health Center II'BiI PHILP~"'I

HlHTII'~UI
MARCH,
07274QO~91
ERS
ERO
ED AdmissionOrder.-; 3-2005
10/02/1976 30Y ,
00748298
EMERGENCY PHYSICrMAolO/Ol/07
000027
HOME MEDICATION LIST ORDER SHEET
to latex? a No 0 UnSUr8 (NOIi:

Yes -Describe"""";';'_---:-_ _ _ _ _-:--_-:-_ _ _ _-:-------:Ch~c;k the box below if you have ever experienced runny nose, tearing, sneezing, or Itching aftar: a Denlall/ntemal exams 0 Contact with rubber gloves/products a blowing up bal/oons 0 Use of condoms or diaphragm Chl;lStl1Uts, kiwi
blood thinning products, oVBrthe-cOull ter medbatiOln.
risk)
Answering "yes" to any of these require initiatJon of Latex Allergy Protocol Chart labeled Allergy armband
Home Health Services being used? 0 Yes CI No If yes, Name Typ& _-:-~_ __ Sources of information: OPatien! 0 Medication Bot1!es 0 Patient's Family 0 Mad List 0 Doctor's Office o Pharmacy Name Pharmacy Number [J Old Chart 0 Other:
Route or topical site Frequency Last 00$(1
Comments
DYes DYes DYes DYes DYes

I
D Hold 0 Hold 0 Hold

FOR
~ss
These checked oroers will only become active when authorized by Physician.
Medicl'llions/h9rballvitimlm; will l;e dispenw(1 m accord/lfTca with tile hopil8i lormuiary Non-formula hetJlslvif!min:> mil be hold during hospital stay. Resume all'N ClIO
/7..
!-lome Med Usl \...R_e_c_Of_de_d_b-'-Y_ _+-___-'
Date:
I.J'
1-
Time:
(~
Physician:
...;;.~
dirt'it;1Br1lJy the physicil;l[l
Date: Time: Scanned to PhalT1lacy Date:
t~ l- 01
li~'"
Nurse: T;me:o 0/-' --,-n-iu-al-s-!).h;-T,f"" .+-:-------0 / -S
o Readback confirmed
Home Medication Orders 3/06
000028
PNEUMOCOCCAL VACCINE NURSING ASSESSMENTI PROTOCOL
. ./
It'?,) eq Tlme:O St.f.? Assessment completed by: l;x$~ flt.I . .~ DePaul Health Unter . rs~n~di;e~ -- Dilllliu.llitl
Date:
: Initials.
--I
ER
I MARCH t PHILLIP
IIp
- - - - - - - - - - - - - - ... 07.27400691
RAH~~/ANWER Z
MED 0524-01 10/0211976 31Y M 10/02/07
000748298
000029

HtSTORV AND PHYSICAL
PATIENT: MARCH, PHilLIP ADMIT DATE: 10/0212007 DOB: 10[02/1976 PHYSICIAN: SONIA N. MELKAVERI, MD.
MR#: 000748298 ACCT#: 0727400691 ROOM: 0524
CHIEF COMPLAINT: Fevers and Jaw pain. HISTORY OF PRESENT ILLNESS: The patient IS a 3'I-year-old, African American male with
past medical hi3tory Qf g 1;ltab injury in the jaw in April and had all internal fixation at Barnes In May that was complicated by infection of the hardware so the hardware was removed in July
The pallent has had prior visits to DePaul Hospital and he had IV antibiotics given and during the last admission was diagnosed with osteomyelitis of the jaw and was sent home on home antibiotics, I.e, Unasyn. The patient now returns back with complaints of increasing pain in the jaw and also fevers of 102 to 10'1. He denies any other complaints like cough. chest pain, shortness of breath, or nausea, vomiting, or abdomina! pflin. He did have ehnls and a high fAver and h was getting home heal1h visit him at home for IV antibiotiCS and for the Pice linf~ care. PAST MEDICAL HISTORY; Jaw injury, stalus post ORIF and removal of hardware, and osteomyelitis of the jaw on antibiotics.
ALlERGfES; No known drug allergies.

HOME MEDICATIONS: Unasyn.
SOCIAL HISTORY: He lives with his Mom. Denies any history of smoking, occasional alcohol.
no IV drugs.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: GENERAL: Fevers and chills present. RESPIRATORY: No cough, nn shortness of breath. CARDIOVASCULAR: No chest pain. no palpitations. GASTROINTESTINAL No nausea. no vomiting, no diarrhea. GENITOURINARY: No hematuria. no dysllna. ENDOCRINE: No history of diabetes. NEUROLOGICAL: No history of eVA. The rest of the review of systems are negative other than what has been in the HPI
PHYSICAL EXAMINATION: VITAL SIGNS: On admiSSion blood pressure 138/96, respirations 21. pulse 76, temperature 98.7, recorded temperatures of 101 he$ been seen in the ch'ni. GENERAL Well developed. well nourished, African American male In no acute distress. HEENT: Minimal jaw swelling preSnt. RESPIRATORY: Bileterallungs clear to auscultation. No craCl<les. CARDIOVASCULAR: S1 an9 $2 normal with regular rate and rhythm. ABDOMEN: Soit, nontender, non distended, normal bowel sounds. EXTREMITIES: Lower extremities no pedal edema. Strength 4-5/5 diffuse, LABORATORY DATA: On admission: chest x-ray shows no acute infiltrate. White count 6.5, hemoglobin 11.8, hematocrit 33.4. platelets 114. Blood cultures 2 out of Z positive for gram negative bacilli. UA is negative. Troponin less than 0.1 Sodium 138, potassIum 3.3, chloride 103, bicarbonale 27, BUN 13, creatinine 1 :1. Alkaline phosphatase 73. ALT 13, AST 24. INR 1. ASSESSMENT AND PLAN: 1 Possible sepsis secondary to gram negative bacilli likely from jaw osteomyelitis. Currently is on Unasyn. We will switch to Zosyn IV, repeat blood cultures, and consult Infectious Disease. 2 Jawosteomyelitls Start on Zosyn. 3 Pain control on morphine p.r.n.
MEDICAL/SURGICAL HISTORY AND PHYSICAL-DP
- Page 1 of 2
000030

PATIENT: MARCH. PHILLIP
4 5
HISTORY AND PHYSICAL MR#: 000748298
Hypertension. Restart on Norvasc. The patient apparently not taking Norvasc at home. Prophylaxis. Place sequential compression device and proton pump inhibitor.
This document has been reviewed and signed by SONIA MELKAVERI Sign DatelTime: 10/02/2007 10:34PM EST
SONIA N. MELKAVERI. M.D.

SNM: 168 - 2036802 0: 10/02/20072:24 PM T: 10/2/20074:02 PM E: 10/03/200709:13 AM
cc:
SONIA N. MELKAVERI. M.D.
MEDICAUSUROICAI- HISTORY AND PHYSICAL-DP
Page 2 of 2
000031
,
INTERDISCIPLINARY HISTORY AND PROGRESS NOTES
~ g
~----~----~--------------------------~------------~~~~~--------------
~SSM
H E A L T H . CAR
SLMl00U003 (612003) 02 FRONT
E~

W\RCH, PHILLIP D 0524-vl 0727400691 ME M lO/02/07 10/02/1976 31~ 00074829&
1111111111\1111111
Ip
INTERDISCIPLINARY HISTORY & PROGRESS NOTES
AAHMAN,ANWER
000032
~SSM
H E A L T H CAR

I/P 0727400691 MED 0524-01 lO/O~/1976 J]Y M 10/02/07 RAllM!\N,ANWER Z 000748298
~1ARCH, PHILLIP
E~
IIIIIIIIIIIII.,IIIIH
INTERDISCIPLINARY HISTORY PROGRESS NOTES
SlM-1000003 (Gi2003) 02 BACK
000033

Dill~
Time
NOTES MUST BE SiCNfD
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E A L T ..
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DEPAUL HEALT11 CEN1'ER
MARCH,PHILLIP
INTEADISCIPLINARY HISTORY & PROORESS NOTES
111111111111111111
lfP
f"llID 0')21\-01 172'/400691 LO/02/1976 31.Y M 10/02/07 000748298 ;{AHt-1AN,ANWER Z
SLM1000003 (612003) 02 FRONT
000034
~SSM
H E A L T H ' CAR EINTeRDISCIPLINARY HISTORY & PROGRESS NOTES
SLM1000a03 (B12003) 02 BACK
DEPA.UL HEALTH CENTER

l'!.i\l\CH, PHIl.LIP
RJ~MAN,PEW8R
1011111l1l1lllnlilB
Z
rip
000748298
0727400691 MED 0524-01 10/02/1976 31Y !vI 10/02/07
000035
P[RIPHERAlLY INSERTED r;:ENTRAl CATHFTEfl/MIDLlNE CATt1ETER INSERTION PROCEDURE NOTE
Insortion
--- ------- ---- ---Tile risks and benefits or the procedure were explained to patient. -*
Consent was obtained. .
A-~'J(. t..../
.1
2 Patient Identifiers and lime Out performed with

Midline Information
__ 2 e I t. u
~v "C> '. N1'f P'\.
Brand 13 t'-4- D ~....... E-L. v (/ "" "f>l-J-..>..- .....

Gauge/French 5' FnLUmens ~ lumen 0 Double lumen 0 Triple lumen
REF
7818508 RERE0772
Procedure:: The sltewas prepped and draped in a sterile fashion. Under sterile conditions per hospital policy, ~.'l,. ml 1% lidocaine was injected Intradermally to produce wheal. PIce placed using modified Seldinger
technique.
Site:
~ left
'@itsi!9)eln X
Cepl:lalis fe"", !nternallength
Blachibl
~eill
Catheter trimmed
Ye~Len9th tf~ ..... Mark

oe;5l.::.."""
~r- IO~ 4-t:t!----~
if?
Mark Externl;Jl
Mark
.. +,3. vC: -S t r-t.""
Arm Circumference RI Number of attempts: I
PIce tip verification by CXR and order for use needed prior to using PIce.
Patient tolerated procedure lit (Jar tfr.r P
p.,..
T7 C"'ft
12fJ?'H 60."'"~ ~ '-., .
Flush Protocol ~
Each lumen of th<lElCe'lMidline flu~ith 10ml NS IVP Positive blood return in aU lumens. ~ ~ No_ _ __
Comments:
"PII. :z.'NZ-E"-
f?t~ (!l~r ~{L
if?
~-vvtSvr
and staff oovcatoo on PICC care.
gc..
Patient Education: Patient receiveo Pice booKlet and card. PIce sign placed at head of bcd. Patient
Date: ro\c+loe(
~SSM ,.II
.. , , l
t ... ,"
~!I!~'J~l~I!III'I~
rip
Pice Procedure Note 8/007
')7271J00691 MED 0524 01 10/02/1976 31Y M 10/02/07

f-tl!:LKAVERI, SONIA N OOO'/48~q8
000036
Silicone Valved
Pice
I his f)..1!iellllvj,; a ~erGroshol'lg CaIMI'"

!m.urll]<;1Oft
by' _
~~f.c U/~ ....... -
_dlf/"~
_(ffaTO)
LolNo
r:;:::c:-d!!, ---==- ~.:!:_77:_

(1f>5lYbmIClN''Cii,,'narr''''i
When cleanln9 the exit ",it,:

120.
, VLlllil: lVl <S-C~(jff ttl1Q' lo I ;c;spitat rW'otO{',Q(
Naw Important Information:

\.onuad rneala $.ilf"-Itj b&wf'Ame-o III bodyftif11s,)l'rat{Jt~ pncr t~1 PQ\-"/Bf lllJfCtlQ'ff Wflrnmg F3w.xf. to \'ibnn r-C.(l.1f W Tf~a to [x,1..jy tftln~::'OtaUll~' prktf to Pflwe1 fI'IH('fl(;<." rf~Jy r~-sutI III eatfl&ll'f fa~<l<'
l/1<',JOH}ll5ty f~~l the Paw@rGro&OOngCdVv.>te.r (.jm~q a t{j Wf'011..1fW" Sylm\y.~ &nd ~hJ{'I!.e r(lfru:4 S''i'lhne pld)( to ,!fie lf1 rr.ntIEt(~ty h~mir.g l\iO comphiit.'O ("j( ptl'HP.i ""0.'1;t{;j)n sbrkE''.i '!tJo.~j ",i-1I111~F.tre thu ~M{["J;r:y (j~ Iix' PowerGrosflollQ Caltr"J!1)f (\.11Q flf'Am! (j;!fn.~9u (p the callclet: f/E:-:GlfJ.lf'Ce 1(; flo mog ;nn'1 If\<.jit.'''l1~ p:;vh;1l Of cnipwte call'ct1 QO.,il~%)
Ute cHarh"....,in\"'JlJ ~lj.x:()(l.nt$ aPf:1i~if p(l1,iltin~(r rodu!JJ to .;:!tt<.n U"'1t1 t'.1)f gl,e
."""' f1
the [;;llh@!Gr
A~.{]i.\> '.\11 ~kr<l!ur!>':f ~l~!I~alih&-t1j1-l<:S. to
ary l;~lf'npt~!"Hf{".. belom ,fppryiT10 l"e!:.';~'.>f'4J
C&theter Maintenance
.. ! ml flY'.sh . an'!1
r'.acl"; V:'tI-:
(II
Do not
d~'atel j
pt{)C~"d'
p!;{'>r
with O'<"YI.'E>r ~hm YtKh/lnW c01u3'j"Jf> h.ki teen W..mfng! r .aAUl/l to ef')<;'..,.t;f,! ,:..ah)fof:Y <}f (\'19 Pawertirosnoni
tv f',(t<.+..'ef lH~':'~'Or' '(,!ld~s
:>flo,: "
Csth('4t'%
m,lY !~~',A
lJ\
':-<1'I1"""ll'r 'aql,r~
week fU1'!'~e,rj~'I?J 1"..<8E-1!J.l3e;1; ,j(1-<.PlitiJ 10 ml flush att&i ;lrtN1t'"1.,] NO)-j, It hbO.(j 10; iii {~Ca!hr:llff, <.p ,tllEl vow,~ lfijl'r.t.\'II'l at ('(){j\f<if.# WJ:!"(}I.a (th(! r\o8i!rfi.;? fj{ :telJoi\ttw.s aaa-p!(,f j
D<,;nu! f'.cJ}6'1i tho?ln'::AlrtVJ1\a.ik~at(i 014 ft(\ljt, wa(nl~: f'O'..';T"i' lf1eGlill rrmch,r,w, DlB'$S!,Jm !tn)'Ni\j f.et1iUf(> 'nHy ,'1Q'~ preVi.mll"He-f ~:'H~''i:;'\tlli::a!iOf1 01 ,3l"1 {l'X},J.;.1io.d Citth::kl, whf,:n ~nay c,~c:,p
cathe1!:r fS!lViB
20 mt ftu-sh . pno;
iTO.1J}t!N
t,'
I V~t'",,'Xl ~.:.(\fll~li'4J
Warning: t)'cr.r:f.lvq tj)11 tTV':I,:rin1!l'l11 f~H" 11(1 ,)'" 'nJj'Se(" pt~jJ trl3UfJ PSI, may re;S';.Jl1 in ('stilet&! (nJfuH:' dnti/cr
rvW'!di.:' ,"~nt
(]I
ill ma:o::~n:Jrtl
Gi'1Uidf'f
nu
aJlf'( TPN (thto n6t'lflf? rlt;.:'t)k:u::~r.
Watnmg:ft'0Vl-erGroN1DngC;11hP..1.e1
tv.] 1"JSIT!t:.ll,(~1 for (QUline m.aittfrr'3,f.c..fI. A!nHY:S !}u'53~ ...lIth 10nnalsiul'j{'.

{;oJ(~"l,Ilt Ul'611t<;fflJcb(}p~>
for
lb~
DO Hen VS~ A S'I'RlGl' '-"MAlI.!;R THAN 1U M\'I
1f.7Q,J'OlrtiJ other care iUZ'.trv.:;tflbrJ,
1'l'l;\\I-;Bf11)n ft'l ~~ i-rriechalol t:.Ofltr.t'l'l mtsdill' imph:-'!~!he l:.iltt.<:!terS flu-t1I\' KI YtlifiS1ail.,i !lw ~:rOG~hJfF.' Qut (kNl3 N,J) nopty aDj.J{f.lOr~atetu~~ ct 11:1, ph)C;>~ twe tOf :J patt0,ubr pa~e"t A svrtahly lfMru:d c4o"",,,n '. ref4'''''sill'. (,:. """,..ting if',t.'
f).a~th ';IIHUS {~ a pa~if'lf as
Jt ow~.ams
to n pt'.m1~f ~',~CI'I'Oq p1OCwlU'e
Powvr InjectIon Procedure:

1 nB~ the U1~:Oic(I/.'1I':i '.d'telo&':', cap fro'" Jhe p.,lWi1fOrQshong G;-ilhefer ? Attacll;) 10 m~ IN talg1 :<i'finge (g:\e'j ""l\.1J,+}teri\e I'4J ffial s;,lff ::l A.~tuI.'dQ 11)( adtXl.I..fi\le tn)()d I~-tll(n lH'ld 'ril}<..<fCUS Y flUSh ttll) C6tn~ \.,>\lh the ifi'" 10 ff'>I u1 !(l.eft\o,) r!l. 'lrITU.\! S3wn~ Warning! r aihJfI! (Q ':Hlf,.lHe p.a~el',(, of It'i'H t.'SI/1o{,3t \yiCf ~) pD't'i'VI
T
6${f, ~A'\);Qm-..r.-,'Y' G(IIU\Q".,."" -
':"1"tI! V,,"t'(d rl
J\tIfYd-',dljt!"~,f7/1."{Pl:rP<Uiflt:{<;'~~'~i(fi~ft.A
fr,:{,,~w\:>~..,1,'1/1f1-):~~mf'ie
Snl'{1Qf dBlltf~l-o,
L'ljecfu.;tfl ~~'Jdli~: may [t~iUit if) c;ttt'miGr 1.'nh.IfO, 4 !)el""i> "I""'>./" " Allilch the 0<'- "';,"CI"," davit.'C 10 the """"'~/f'sI'!on"
f'T\a'''nui';tclOflit~; (OC..Oft'! I Et !nca1~ ~;
,"""'lsI r>3'
fi
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CONSULTATION REPORT PATIENT: MARCH, PHILLIP ADM'T DATE: 10/02/2007 CONSULT DATE; 10/02/2007 ATTENDING PHYS; SONIA N. MElKAVERI, M.D. CONSUL TlNG PHYSICIAN: PHILLIP G. ZINSER, M.D.
MR#: 000748298 ACCT#: 0727400691 DOB: 10/02/1976 ROOM: 0524
INfECTIOUS DISEASE CONSULTATION
REASON FOR CONSULTATION: Evaluation of fever.

SUBJECTIVE: This is a 31-year-old man with a history of hypertension. He had a stab wound to his left jaw earlier this year. He sustained a fracture to the left mandible. He had open reduction and internal fixation. He developed a hardware infection which had a partial response to antibiotics. The hardware was removed May 22, 2007at Barnes. At that time cultures grew strep anginosls, strap intermedills, and Eikenella corrodens. He returned to DePaul on September 19, 2007 with recurrence of swelling and pain in the same area. MRI of the jaw showed an osteomyelitis of his left mandible ramus. I consulted wi1h the surgeons at Barnes. He was discharged on IV Unasyn and was \0 follow-up with the surgeon at Barnes. He was discharged with a 6 weel< course of IV Unasyn through a PICC line. The patient is readmitted on October 2, 2007 with a 2 day history of increased pain in his jaw and fevers to 1Q2.7. He was admitted and switched from Unasyn to Zosyn. His fevers are improved and he feels much improved. His jaw pain improved on the previous hospltatization with the Unasyn. His swelling improved with Unasyn. His blood cultures are growing a Gram-negative bacteria at this lime. He reports that he did leave the Gap off of his Pice line. I suspect that the Pice line is infected at this point. He, however, teels improvei;l with the Z05yn. ALLERGIES: The patient's list of allergies reveals he has no known drug allergies. MEDICATIONS: His current list of medications includes: 1 Famotidine. 2 Acetaminophen. 3 Diphenhydramine. 4 Morphine, 5 Zosyn. PAST MEDICAL AND SURGICAL HISTORY; As above. SOCIAL HISTORY: He drinks alcohol. He does not lise tobacco or recreational street drugs. OBJECTIVE: VITAL SIGNS: The patient's T max is 102.7, pulse 92, respirations 21, blood pressure 152/91, saturating 100% on room air. Most recent temperature is 100.5. GENERAL: The patient is alert, awake, and orIented. H~ENT: Oropharynx is claar. Therr~ is no obviQu~ swelling in his face. HEART: Regular rate and rhythm. LUNGS: Clear to auscultation bilalerally. ABDOMEN' Soft, nontender, and nondislBnded. Normoacti'le bowel sounds. EXTREMITIES: The Pice in his left arm is without cording or signs of inflammation. LABORATORY DATA: The patient's white blood cell count is 7000 with 91% segments. 2% bands, hematocrit 33, platelets 114,000. Creatinine 1.1. Liver function tests normal. Urinalysis negative. Chest x-ray negative. CK 235 Blood cultures from 10/01f2007 are growing Gramnegative bacilli. ASSESSMENT:
MEDICAUSURGICAL CONSULTATION REPORT-DP
- Page 1 of 2
000048
OEPAUL HEALTH CENTER PATIENT: MARCH, PHILLIP
CONSULTATION REPORT MR#: 000748298
Left mandible osteomyelitis after stab wound. Cultures at Barnes grew streptococcus anginosis, streptococcus intermedius, and EikeneHa corrodens, Fever \Q 102.7 with left shift and increased pain and Gram-negative bacteremia. The peripherally inserted central catheter line 15 the lil<ely source as the patient left tile cap off the peripherally inserted central catheter line. He is feeling improved with the Zosyn.
RECOMMENDATIONS: 1 Discontinue Pice and culture tip. 2 Peripheral IV. 3 Follow-up blood cultures.
Of nole, Ihe patient also says th(:lt he has only missed 1 dose of Unasyn and that was yesterday. Thank you tor allowing me \0 participate
In
this patient's care.
This document has been nwiewed and signed by PHilLIP ZlNSER Sign Date/Time: 1Of03/2007 2:17PM EST
PHILLIP G. ZINSER,
M.D.
PGZ:356 - 20~7051
0: 10/02/20075:24 PM T: 10/2f2007 9:46 PM E: 10/03/200717:01 PM
cc:
SONIA N, MELKAVERI, M.D.
MEDlCAUSU RGICAL CONSULTATION REPORT ~DP
- Page 2 of 2
000049
SSM DEPAUL EMERGENCY FLOW SHEET RECORD Name: March, Phillip Age: 30Y MR: 000748298 Acet: 0727400691
VITAL SIGNS User DAGN CKEE DKIN
DateiTime 10/0200:08 10/0123:04

10/0121 :09
BP
152188 148/85
173/94
PULSE 80 93 104
RESP 16 26 20
TEMP 101.7 102.8 102.5
PA1N 3
8/1(}
02 SAT TIME 100 on ra 0008 99% on RA 2304 100% on RA 2107
Name: March, Phillip Age: 30Y MR: 000748298 Acct: 0727400691 Prepared: Tue Oct 2 01 :39:00 2007 by Dave ~ 1ew, Page: 1
000050
SSM DEPAUL EMERGENCY RECORD

Complaint: Chills
Triage TIme: Man Oct 01 200721 :09
Name: March, Phillip

Age: M30 Wt: 73.9 Kg (est.) MedRec:000748298 AcctNum: 0727400691
--------------TRIAGE DATA------------Age: 30 Male

Kg Weight: 73.9 (est) PhysIcians;
None Pcp Emergency Physicians WAITING
Source: Home
By: Car
Urgency: ESI3 Room:
(2107)
Paln;6/10
e~Sat: 1QO'%/RA
HPI BLANK (23:47 RSCH)

CHIEF COMPLAINT: Patient has ongoing history of complications apparently from the repair of 8 jaw
fracture. He has had a devlce apparently get Infec.md...replaced, and was Bdmitted late Septemb~r for apparently jaw qS~.!Q...myeJlti$. !iere tanightwith fever and int~ed pam.. --
HTSTORIAN: History obtained from patient.
TIME COURSE: Onset of symptoms reported as gradual. SEVERITY: Maximum severity is moderate. Currently symploms are moderate.
KNOWN ALLERGIES
No known drug allergies.
HISTORY
MEDICAL HISTORY (21 :35 JWHI): History of hY2]lrlensiOn, Pa1'ent is n'?r:'~~rnp.I~a.ntwith \re~ent,
Stabbed in left race April 26th, 2007. History of hypertension, Patient is noncompliant with treatment, ..
PSYCHIATRIC HISTORY (21:35 JWHI): No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. No previous psychiatric history... SURGICAL HISTORY (21 :35 JWHI):. Jaw Repair, plate left ja~. rag"l!.lrepair f?atient's previo\fs -
surgical history is not relevant tOJ.he ';:..!I.s~,.Jaw.Repair..~te ~ft Jaw. facial repair. PatJent'$ previous Surgical HlstoryTsnot relevant to the eaee.. ' SOCIAL HISTORY (21 :35 JWHI): Denies drug abuse, Lives al home with family, Denies alcohol abuse,
Denies tobacco ..
FAMILY HISTORY (21 :35 JWHI): Family history is not contributory to this case. Family history is not
contributory to this case. Family history is nQt contributory to this caS8 ..
NOTES (21 :35 JWHI): Agree with nursing records .

MEDICAL HISTORY (23:49 RSCH): History of hypertension, law osteomyelitis. SURGICAL HISTORY (23:49 RSCH): jaw fracture repairs. SOCIAL HISTORY (23:49 RSCH): Denies alcohol abuse, Denies tobac<:o abuse. FAMIL Y HISTORY (23:49 RSCH): Family history Is no1 contributory to this case. NOTES (23:49 RSCH): Nursing records reviewed.
ROS (23:48 RSCH) NOTES: see hpj.otherwise negative.

ALL SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above.
Prepared: Tue Oct 02 2001 01 :38 by D"fIvtl Agnew, Page: 1 of 9

SSM DePaul HtJIIlth Center
000051
11111 I! 11111 IlIlt 111111111111111111111111111111
III
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Name: March, PhilUp Age: M30 Wt 73.9 Kg (est) MedRec:000746298 Acc1Num: 0727400691

ADDITIONAL TRIAGE (Mon Oct 01 2007 21 :09 DKIN)
COMMENT (Man Oct 01 200721 :09 OKIN): Pt has PICC line to 1raat jaw infection. COMPLAINT (Man Oct 01 200721 :09 DKIN) PROVIDERS (Mon Oct 01 2007 21 ;09 DKIN): TRIAGE NURSE: Deborah King, BSN, CHARGE NURSE: Julie Sanchez, RN. ADMISSION (Man Oct 01 200721 :09 DKIN) PATIENT (Mon Oct 01 200721:09 DKIN): NAME: Phillip March, DOB: Sat OCl 02 1976, RACE: Black, Code: NO, Trauma: "NO, Work Comp.: NO, Heal Related: NO, SSN: 493788699, ZIP CODE: 63121, HEIGHT: 182cm, PHONE: 314522-8730, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0727400691, IBEX NUMBER: 20071001210950ADT. PREVIOUS VISIT ALLERGIES (Mon Oct 01 2007 21 :09 DKIN): No known drug allergies. VITAL SIGNS (Man Oct 01 200721 :09 DKIN) FALL RISK (21 :35 JWHI): TIME: 2133, Gender (Male), Get up and go test: Able to rise in a single movement. ASSESSMENT: (21:35 JWH1): The GCS total is 15, CIO FEVER AND CHILLS THAT ONSET TODAY, CIO LEFT JAW PAIN. RECIEVING IV ANTIBIOTICS VIA PIce LINE. IMMUNIZATIONS (21:35 JWHI): Last tetanus shot received less than 5 years ago. TB Screening (21 :35 JWHI): Denies T8 screening. Domestic Violence (21 :35 JWHI): Not Appiicable. TREATMENTS IN PROGRESS (21:35 JWHI): No treatment, Protocols: RIO Sepsis.
PHYSICAL EXAM (23:49 RSCH)

CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3, Patient is febrile. HEAD: Atraumatic, Normocephalic. EYES: Pupils equal and reactive to light, No discharge from eyes, Extraocular muscles intact. Sclera are normal, Conjunctiva are norma\. NECK: Normal ROM, No jugular venous distention, No meningeal signs, Cervical spine non-tender. RESPIRATORY/CHEST; Chest is n9n-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. ABDOMEN: Abdomen is non-tender, No masses, Bowel sounds normal, No distension, No peritoneal signs. BACK: There is no CVA Tenderness, There is no tenderness to palpation, Normal inspection. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, No calf tenderness, Normal range of motion, NEURO: GCS is 15. No focal motor deficits, No focal sensory deficits, No cerebellar defici1s. PSYCHIATRIC: Oriented X 3, Normal affect.
LAB INTERPRETATION (23:51 RSCH)

INTERPRETATION: Normal esc. Decreased PotaSSium, otherwise Chemistry normal, Normal Cardiac enzymes, Normal PT/PTT. Urinalysis is normal.
J2SAT INTERPRETATION (23:49 RSCH)

02SAT: 02 saturation reading 99%, 02 AMT: R.A., 02 Sat normal, Nona needed,
Pr~pared:
Tue Oct 02 2007 01:38 by Dave Agnew, Pay~; 2 of 9

SSM Of/Paul Heaith Center
000052

RESULTS
LAB (22:45 D '", LOOD GASES W/L YTES PANEL Oct 01 200722:09,

pH, Arteri .511 pH Units Ref Range (7.38-7.42), PCO Hg Ref Range (38-42), P02 98.9 mm Hg Ref Range (75-100), BE -1.1 mmol/L Ref Range (-2-2), 02 SaturatIon 98.1 % Ref Range (92-98.5}, Hgb 12.3 gmldl Ref Range (12-18), 02 Content 16.9 % Ref Range (15-23). Sodium, arterial bId 134.5 L mmoVL Ref Range (135-145), Potassfum, arterial blood 3.28 L mmollL Ref Range (3.3-5.3), Comment ER, HB0297.1 H % Ref Range (94.97), HBCO 0.6 %, Ref Range (0.01.5), MetHgb 0.4 % Ref Range (0.0-3.0),
Calclum.ionized 1.12 mmol/L Re1 Range (1.10-1.33),
Glu 95 mg/dl Ret Range {80-120), Hct 36 % Ref Range (36-54).

HHb 1.9 % Ref Range (0.0-5.0), HC03 20.7 L mmol/L Ref Range (22-29), Fi02 21,0, Site RB. tC02 21.5 L mmolfL Ref Range (23.027.0). (22:45 DAGN): esc WITH MANUAL OIFF OC1 01 200722:33. WBC 8.1 1000/mm3 Ref Range (4. 5-".0).
RBC 4.69l
,axe Ref Range (4.7-6.1).
Hgb 12.7 L gmldl Ref Range (13.0-18.0), .tict as.9 L % R~f Rgn9~ (~9.Q-!?4.0),
MeV 76.5 fl Ref Range (80.0-99.0), MCH 27.1 pg Ref Range (25.031.0), MCHC 35.4 gm/dl Ref Range (32.0-36.0). ROW 15.6 H % Ref Range (11.5-14.5), Platelets 159 1000/mm3 Ref Range (130.0-400.0). (22:45 DAGN): PT Oct 01 200722:39, PT 10.4 seconds Ref Range (9.711.1), 1NR 1.0 Ref Range (0.9-1.1), INR Therapeutic Range Conventional Anticoagulatlon:INR 2.0-3.0 INR Therapeutic Range Intensive Anticoagulation:lNR 2.53.5. (22:45 DAGN): PTT Oct 01 200722:39, APTT 22.5 l seconds Ref Range (23.0-34.0). (22:45 DAGN): CK Oct 01 200722:45, CK 235 H UlL Ref Range (55.0170.0). (22:50 RSCH): WITH MANUAL DIFF Oct 01 200722:47.
cse
Prepared: TUB Oct 02200701:38 by Dave Agnew, Page; 3 Qf 9 SSM OePaul Health Cenlef
000053

wec 8.1
1000/mm3 Ref Range (4.5-11.0),
RBC 4.69 L 10X6 Ref Range (4.7-6.1). Hgb 12.7 L gmldl Ref Range (13.0.18.0), Het 35.9 L % Ref Range (39.0-54.0),
MCV 76,5 fl Ref Range (80.0-99.0), MCH 27.1 pg Ref Range (25.0-31.0), MCHC 35.4 gm/dl Ref Range (32.0-36.0), RDW 15.6 H % Ref Range (11.5-14.5), Platelets 159 1000/mm3 Ref Range (130.0-400,0),

Age: M30 Wt: 73.9 Kg (est.) MedAec:000748298 AcctNum: 0727400691
Segs 91 H % Ref Range (40.070.0), Bands 2 % Ref Range (0.0-5.0), lymphs 5 L % Ref Range (22.0-40.0), Aty Lymphs 2 % Ref Range (0.0-9.0), RBC Morph 1+ Poikilocytosis. Pit Es1 Normal. (22:57 RSCH): COMPREHENSIVE M~TABOUC PANEL Oct 01200722:53, BUN 13 mg/dl Ref Range (9.0-20.0), Sodi IL Ref Range (137-145), Po ssl m 3.3 L Eqil Ref Range (3.6-5.0), Chlo . IL Ref Range (98.0-107.0). Glucose 94 mg/dl Ref Range (75-; 10), Creatinine 1.1 mg/dl Ref Range (0.81.5), AST/SGOT 24 U/L Ref Range (17.0-59.0). Alk Phos 73 U/L Ref Range (38,0126.0) I Calcium 8.8 mg/dl Ref Range (8.4-10.2), Bilirubin 0.8 mg/dl Ref Range (O.21.3), Albumin 4.7 gmJdl Ref Range (3.55.0). Prot Tolal7.1 gm/dl Ref Range (6.3-8.2),
~7 mEq/L Ref Range (22.0-30.0). AL T/SGPT 13 L. UfL Ret Range (21.0-72.0), GFR 101.1 m!lmin/1.73m2. (23:00 RSCH): TROPONIN-I Oct 01 2007 22:57, Troponin 1<.0.10 ng/ml Ret Aange (SEE BElOW). Normal <0.10
C02
Gray Zone 0.10-0.99 Positive >-1.00. (23:00 RSCH): CKMB Oct 01 200722:59, CKM8 <0.2 ng/ml Ref Range (0,0-0,0), In1erpretationCKMB An abrupt riselfall of CKMB over 24 hours is an acute injury Interpretation-CKMB pattern. (23:00 RSCH): UR1NALYSIS DIPST1CK AUTO Oct 01 2007 23:00, Color YELLOW 1 Turbidity CLEAR I Spec Graviiy 1.010 Ref Range (1 .005-1 .0300}.
Prepared: TUB Ocl 02 200701 :38 by Oaw Agnew. Page: 4 of 9 88M DePaul Hltalth Center
000054

pH 7.0 pH Units Ref Range (4.6-8.0), leukocyte neg lui Ref Range (Negative), Nitrite neg Ref Range (Negative). Protein. UA neg mg/dl Ref Range (Negative), Glucose,UA norm mgldl Ref Range (Normal). Klitone neg mg/dl Ref Range (Nega1ive), Urobilinogen norm Ehrlich Units Ref Range (Normal). Bili Qual neg mg/dl ReI Range (Negative), BloodfUA neg lui Ref Range (Negative).

Age: M30 WI: 73.9 Kg (est.) MedRec:00074B296 AcctNum: 0727400691
RADIOLOGY INTERPRETATION (23:51 RSCH) CHEST: Interpretation of chesl X-ray shows, chest x-ray negative, no infiltrates, no pneumothorax, no
hemothorax, no masses, no cardiomegaly, no CHF, no effusion, no free air.
DOCTOR NOTES (23:51 RSCH) TEXT: Admitting for iv abx and consultation ..
DNV: Discussed this case with Dr. Rahman, the on call physician. PATIENT ~LAN: The patient will be admi11ed to the hospital.
DIAGNOSIS (Tue Oct 02 2007 00;38 RSCH) FINAL: PRIMARY: Jaw osteomyelitis, ADDITIONAL: fever. DISPOSITION (Tue Oct 02 2007 00:38 RSCH)
PATIENT: X-RAY/CT Follow-up: NO, Critical Care: "None, Doctor ~rocadures: NO, Disposition: Admit Medical, Condition; Stable.
MEDICAT'ON SERVICE
Acetaminophen (21 :46 AMAJ): Order: Acetaminophen: 975 mg : By Mouth
Tim8: 2146
Notes: vo/rbo
Qrg~r~~: Mon Oct 01 200721 :46
Ordered by: Angela Majino. M.D. Entered by: Andra Kofahl, EMTP Mon Oct 01 200721 :46 Documented as given by: Andra Kofahl, EMT-P Mon Oct 0' 200721:47 MEDICATION, Time given: 2146, Given in amoun1 and via route as prescribed, Amount given: 975mg, Site: Medication administered P.O., Correct patient, time, rO~J1e, dose and medica1ion confirmed prior to administration, Patient advised of actions and side-effects prior 10 administration, Allergies confirmed and medications reviewed prior to administration. Benadryl (Tue Oct 02200700:13 RSCH): Order: Benadryl : 50mg : By Mouth Time: 0013 POTENTIAL MODERATE INTERACTION Morphine SuHate POTENTIAL MODERATE INTERACTION Neuronlin Notes: verbal order, read back Ordered: Tue Ocl 02 2007 00:13
Prepared: Tue Oct 022007 01 :38 by Dave Agnew, Page: 5 of 9
SSM DePaul Health Genter
000055
Name: March, PhiUip Age: M30 73.9 Kg (est) MedRec:000748298
wt:
AcctNum: 0727400691
Oroered by: Richard Schmidt, MD Entered by: Christine Keena, BSN Tue Oct 02 2007 00:13 Acknowledged by: Christine Keens, BSN Tue Oct 02200700;13 Documented as given by: Christine Keene. BSN Tue Oct 02 200700;14 MEDICATION, Time given: 0013, GiVen in amount and via route as prescribed, Amount given: SOmg. Site: Medication administered P.O., Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of aclions and side-eHeets prior to administratIon, Allergies conflrmM and medloations reviewed prior to administration, Administered by CMK, RN, Patient in position of comfort, . Cart in lowest position, Family at bedside. 3:46 RSCH): Order: Morphine Sulfate: 4 mg : IV Push Repeat: ever in utes PRN pain AL MODERATE INTERACTION Neurontln Ordered: Man Oct 01 2007 23:46 Ordered by: Richard Schmidt, MD Entered by: Richard Schmidt, MO Mon Oct 01 200723:46 Acknowledged by: Christine Keens, SSN Mon Oct 01 200723:47 Documented as given by: Andra Kofahl, EMTP Mon Oct 01 200723:56 MEDICATION, Time given: 2355, Given In amount and via route as prescribed, Amount given: 4mg, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medica1ion administralion, No swelling during administratlon, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies d and medications reviewed prior to administration. Unasyn :46 RSCH): Order: Unasyn : 3 grams: IV Piggy Back 00: Mon Oct 01 200723:46
Ordered by: Richard Schmidt, MD
Enterad by: Richard Schmidt, MD Mon Oct 01 2007 23:46 Acknowledged by: Christine Keene, BSN Man Oct 01 2007 23:47 DocumentfilQ as given by; .Angr9. KQtahl, EMT-P Tue Oct 02200700:1' MEDICATION, Time given: 0011, Given in amount and via route as prescribed, Amauni given: 3 grams,lV site 1. Medication administered into right wrist, Drfp/IVPB, Premixed, via pump tubing. at 200 ml/hr, Catheter placement confirmed via flush prior to admlnlstraiion, IV site without signs OF symptoms of infiltration during medicalion administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prio( 10 administration, Patient advised of actions and side'effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Administered by CMK. RN, Patieni in position of comfort, Side rails up, Cart in lowest pos\llon, Family at bedside.
PRESCRIPTION: No Documented Prescriptions NURSING ASSESSMENT: TUBES AND PORTS (22:08 DAGN)
TIME: PICC line noted. to Lefl arm, No signs/symptoms of Intection.
NURSING ASSESSMENT: SKIN (22:09 DAGN)

Prepared: TUB Ocl 02 2007 01 :38 by Dave Agnew, Page: 6 of 9
SSM DePaul Health C6nter
000056

TIME ASSESSED: Patianl was assessed at 2205.

Age; M30 WI: 73.9 Kg (est.) MedRec: 000748298 AcctNum: 0727400691
CONSTITUTIONAL: Patient arrives ambulatory with steady gait to treatment area, History obtain@d from patient, Pa1ient is cooperative, Patient Is alert and oriented x 3, Patient is well-groomed, Skin color is normal. Skin temperature is hot. SKIN; No rashes present, No Drainage. No obvious signs of skin trauma.
NURSING PRoceOURE; SEDSIOE RADIOLOGY (21:54 TMO)

TIME: Procedure was performed a1 2150. Portable x-ray pertormed of
chest
NURSING PROCEDURE: NURSE NOTES (21:54 AKOF)

TIME: Time: 2145. pl ambulates to Rm 2 c/o fever and chills. pt has not treated fever at home. pt demanding warm blanke1s, I explained to pt that we will get him a light cover aHer he changes into a gown, pt
non-compliant. . NURSING PROCEDURE: NURSE NOTES (21 :55 AKOF)

TIME: Time: 2155, x-ray at bedside tor CXR. pt still has noi changed
into gown ..
\JURSING PROCEDURE: NURSE NOTES (21 :58 AKOF)

TIME: Time: 2157, RT at bedside for ABG (per protocol).
NURSING PROCEDURE: IV (22:35 AKOF)

TIME: Procedure was performed at 2220,20 gauge catheter inserted. Into right Hand, with 2 attempts, Saline lock established, Labs drawn at time of placemlitnt, Blood cultures drawn al time of placement, After placement no swelling noted at site, no drainage noied at site, 2x3 ensure dressing applied.
NURSING PROCEDURE: ADDENDUM (22:42 DAGN)

TIME: Procedure was performed at 2205, Below is a reassessment, Pt skin assessment miSSing and saline lock attached a\ time of assessment
PIce Line had and cap
NURSING PROCEDURE: BEDPAN/URiNAL (22:51 DAGN)

TIME: Procedure was performed at 2250, Urinal used, Patient voided 300 ce, ml per bedpan/urinal, Urine specimen collected.
NURSING PROCEDURE: IV (23:00 CKEE) TIME: Procedure was performed at 2300, O.9NS 1 Liter hung, 1st bag hung, IV bolus of 1000 ml est~bllshed. at
1000 ml/hr, via primary tubing, via gravl1y tUbing, via pump tubing, After placement no swelling noted at site, no drainage noted at site,
SAFETY: Side rails
up, Cart in lowest positlon.
NURSING PROCEDURE: CARDIAC MONITOR (23:01 CKEE) TIME: Procedure was performed a\ 2300, Patient placed on cardiac monito" Patient placed on non-invasive blood
pressure monitor, Pulse Oximetry Multiple, Patient on cardiac monnor showing Normal Sinus, Strip charted, Disposable cuff, Rate: 96, Alarms set and on. SAFETY: Side rails up, Cart in lowes1 position.
Prepared: Tue Oct 02 ZOO? 01 :36 by Dave Agnew, Page: 7019
SSM DePaul Health Canter
000057

NURSING PROCEDURE: NURSE NOTES (23:02 CKEE)
TIME: Time: 2301, Dr, Schmidt at bedside to see pt.

Age: M30 W1: 73.9 Kg (est.) MedRec:000748298 AcctNum: 0727400691
NURSING PROCEDURE: NURSE NOTES (23:16 DAGN)

TIME: Time: 2316. IV infusing pI resting,
NURSING PROCEDURE: LAB DRAW (Tue Oct 022007 DAGN)

TIME: Procedure was performed at 2358, and labs sent from Left PICC line. with 1 attempt, Blood cultures senl, 10 ce blood draw for waste from Pice line, Then 10 cc blood draw for Be PICC line flushed with
10cc of NS then See of Heparin per Pt per horns care..
NURSING PROCEDURE: NURSE NOTES (Tue Oct 02 2007 00;09 DAGN)

TIME: Time: 0006, lVF dlc'd sl maintained Unasyn Infused through IV Pump.
NURSING PROCEDURE: NURSE NOTES (Tue Oct 02200700:10 DAGN)

TIME: Time: 0010, Patient is imprOVing, Patient in no apparent distress, Patient states decreased pain, Patient res1ing quietly, Familya1 bedside.
NURSING PROCEDURE: ADMISSION (Tue Oct 02 2007 01 :38 DAGN)

TIME: Bed assigned at 0104, Report called at 0125, Patient admitted at 0033, Pt admitted to room, 524, Patient Acuity Level Was NON-Urgent. Pa1iant admitted to mad-surg unit, Report called/faxed to 5 North 524, Parmedlc, Transported with personal belongings.
ADMIN
DIGITAL SIGNATURE (21 :47 AKOF): Kofahl, EMT-P, Andra. (21 :55 AKOF): Kofahl, EMT-P. Andra. (21 :58 AKOF): Kofahl, EMT-P, Andra.
(22;090AQN}: Agnew lI Dave,

(22:42 DAGN): Agnew" Dave. (22:51 DAGN): Agnew" Dave. (23:02 CKEE): Keene, BSN, Christine. (Tue Oct 022007 DAGN): Agnew" Dave. (Tue Oct 02 200700:10 DAGN): Agnew" Dave. (Tue Oct 02 2007 00:38 RSCH): Schmidt, MD, Ricllard. (Tue Oct 02 200701 :38 DAGN): Agnew" Dave. PATIENT DATA CHANGE (21:44): A08 67727831 by Inleriace, Payment 90, AdmiUing Doctor: Pcp None, Attending Doctor: Richard U Schmidt. (22:30): AOS 67728758 by Interface. Admitting Doctor: Pcp None, Attenoing Doctor: Richard U Schmidt. (22:43DAGN): Primary Nurse changed from (none} to Dave Agnew,. (22:49 RSCH): Attending changed from (none) to Richard Schmidt. MD. (23:02): AOa 67729397 by Interface, Admi11ing Doctor: Pcp None. Attending Doctor: Richard U Schmidt. (23:05): AOe 67729442 by (nterface, Admitting Doctor: Zinser Phillip G. Attending Doctor: Richard U Schmidt.
Prepaled: Tue Oct 02 2007 01 :36 by Dava Agnew, Paye: 8 of 9
SSM DePaul Health
C~n!ef
000058
Name: March, Phillip Age: M30 Wt: 73.9 Kg (est.) MedRec: 000748296 AcctNum: 0727400691
(23;06): AOS 67729481 by Interface. Admitting Doctor: Zinser Phillip G. Attending Doctor: Richard U Schmidt. (Tue Oct 02 2007 01 :05 JSAN): Admit Room: 524, Admit Area: full admIt, Payment: (none). KEY: AKOF:=Kofahl, EMT-P, Andra AMAJ;::MaJlno, M.D., Angela CKEE=Keene, BSN, Christine DAGN=Agnew" Dave DKIN=Kin9, BSN, Deborah JSAN=Sanchez, RN, Julie JWHI=White, RN, JeBl'lnet1e RSCH=Sehmidt. MDt Richard TMO=Ohlms, Tricia
Prepared:
TU9
Oct 02 2007 01 :38 by Dave Agnew, Page; 9 of \:1

SSM DePaul Health Center
000059
SSM DEPAUL CLINICAL SUMMARY RECORD

HPIBLANK
Name: March, Phillip Age: M30 Wt: 73.9 Kg (est.) AcctNum: 0727400691
MedRec:OQ0748298
CHIEF COMPLAINT: Patient has ongoing hIstory of complications apparently from the repair of II jaw fracture. He has had a device apparently get infected, replaced, and was admitted late September for apparently jaw osteomyelitis. Here tonight with fever and Increased paIn .. HISTORIAN: History obtained from patient. TIME COURSE: Onset of symptoms reported as gradual. SEVERITY: Maximum severIty IS moderate, Currently symptoms are moderate.
HISTORY MEDlCAL HISTORY: History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 26th, 2007. History of hypertension, Patient Is noncompliant with treatment, . PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. No prevIous psychiatric history... SURGICAL HISTORY: Jaw Repair, pillte left Jaw. f.cial repair. Patient's previous surgical history Is not relevant to the case. Jaw Aepalr, plate lett jaw. facial repair. Patient's previous surgical history Is
not relevant to the case. SOCIAL HISTORY: Denies drug abuse, Lives at home with family, Denies alcoho' abuse, Denies tobaGGO
FAMILY HISTORY: Family history is not contributory to this case. Family history Is not contributory to this case. Family hIstory is not contributory 10 this case .. NOTES: Agree with nursing records . MEDICAL HISTORY: History of hypertension, Jaw osteomyelitis. SURGICAL HISTORY: Jaw fracture repairs, SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse. FAMILY HISTORY: Family history is not contributory to this case. NOTES: Nursing records reviewed.
ROS
NOTES: see hpl.otherwlse negative. ALL SYSTEMS NEGATIVE: All syslems were reviewed and are nega11ve except as described above.
PHYSICAL EXAM CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3, Patient 115 febrile. HEAD: Atraumatic, Normooephalic. EYES: Pupils aqual and reactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal. Conjunctiva are normal. NECK: Normal ROM, No jugular venous distention, No meningeal signs, Cervical spine non-tender. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. ABDOMEN: Abdomen is non-tender. No masses, Bowel sounds normal, No dls1ension, No peritoneal signs. BACK: There is no CVA Tenderness, There is no tenderness to palpation, Normal inspection. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Inspection normal. No cyanosis/clubbing/edema, No calf tenderness, Normal range of
Prepared: Tue Oct 02 200701 :38 by Dave Agnew, Page: 1 of 3
SSM DePaul H&lIflh Clmter
000060
Name; March, Phillip

motion. NEURO: GCS is 15, No focal motor deficits, No focal sensory deficits, No cerebellar deficits. PSYCHIATRIC: Oriented X 3, Normal affect.
DOCTOR NOTES TEXT: Admitting for iv abx and consultation .. DNJ: Discussed this case with Dr. Rahman, the on call physician.
PATIENT PLAN: The patlent will be admined to the hospital.
DIAGNOSIS
FINAL: PRIMARY: Jaw osteomyelitis, ADDITIONAL: fever.
DISPOSITION
PATIENT: X-RAY/CT Followup: NO, Critical Care: 'None. Doctor Procedures: NO, Disposition: Admit Medical, Condition: Stable.
MEDICATION SERVICE
Acetaminophen: Order: Acetaminophen: 975 mg : By Mouth Time: 2146 Notes: vo/roo Ordered: Mon Oct 01 200721 :46 Ordered by: Angela Malina, M.D. Entered by: Andra Kofahl. EMT-P Mon Oct 01 200721:46 Documented as given by: Andra Kofahl, EMT -P Mon Oct 01 2007 21:47 MEDICATION, Time given: 2146, Given in amount and via route as prescribed, Amount given: 975mg, Site: Medication administered P.O., Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actIons and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration. B@nadryl: Order: Bsnadry! ; 50mg ; By Mouth Time: 0013 PQT!;;NTIAL MODERATE INTERACTION Morphine Sulfate POTENTIAL MODERATE INTERACTION Neurontin Notes: verbal order, read back Ordered: Tue Oct 02 200700;13 Ordered by: Richard Schmidt, MD Entered by; Christine Keene, BSN Tue Oct 022007 00:13 Acknowledged by: Christine Keene, BSN Tue OCt 02 2007 00:13 Documented as given by: Christine Keene, BSN Tue Oct 02 2007 00:14 MEDICATION, Time given: 0013, Given in amount and via route as prescribed, Amount given: 50mg, Site: Medication administered P.O., Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Administered by CMK, RN, Patient in position of comfort, Side rails up. Cart in lowest position, Family at bedside. Morphine Sulfate: Order: Morphine Sulfate: 4 mg : IV Push
Pmpared: Tue Oct 02 2007 01:38 by Dave Agnew. Page; 2. m 3
SSM OaPa1,J1 Health Center
000061
Ilitl 1111111111 11111 Illlt 111111111111'111111111111 I1111111t1
11m ~m Ifl~ lllllllijl" III Iml 11111 II ItIII III !IIII

Age: M30 Wt: 73.9 Kg (est.) MedAec:OOQ748298 AcctNum: 0727400691
Repeat: every 30 minutes PRN pain POTENTIAL MODERATE INTERACTION Neurontin Ordered: Mon Oct 01 200723:46 OrdereD by: Richard Schmidt, MD Entered by: Richard Schmidt, MD Mon Oct 01 2007 23;46 Acknowledged by: Christine Keene, BSN Man Oct 01 2007 23:47 Documented as given by: Andra Koiahi, EMT-P Mon Oct 01 200123:56 MEDICATION, Time given: 2355. Given In amount and via route as prescribed. Amount given: 4mg, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administralion. No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time. route, dose and medication confirmed prior 10 administration, Patient advised of actions and sida-Bffects prior to administration, Allergies confirmed and medications reviewed prior to administration. Unasyn: Order: Unasyn : 3 grams: IV Piggy Back Ordered: Mon Oct 01 2007 23:46 Ordered by: Richard Schmidt, MD Entered by: Richard Schmidt, MD Mon Oct 01 2007 23:46 Acknowledged by: Christine Keene, BSN Mon Oct 01 200723:47 Documented as given by: Andra Kotahl, EMT-P Tue Oct 02 200700:11 MEDICATION, Time given: 0011. Given in amount and via route as prescribed. Amount given: 3 grams, IV Site 1. Medication adminls1ered into right wrist, DrlpllVPB, Premixed. via pump tUbing, at 200 mllhf. Catheter placement confirmed via flush prior to administra1ion, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effec1s prior to administration, Allergies confirmed and medications reviewed prior to administration, Administered by CMK, RN, Patient in position ot comfort, Side rails up, Cart in lowest position, Family at bedside,
PRESCRIPTION: No Documented P~$criptlons
Prepared: Tue Oct 02 200701 :38 by Dav& Agnew, Page: 3 of:3

SSM DePaUl Health Center
000062
SSM DEPAUL RECORD
Name: March, Phl1lip

Age: M30 WI: 73.9 Kg (est.) MedRec:000748298 AcctNum: 0727400691
Prepared: TU8 Oct 02 2007 01 :38 by Dav1t AQf1ew, Page: 1 of , SSM DePaul Health Center
000063
Emergency'.'
t)$j,f,ifYJllOutnsion Protocol
I. ASseSSMeNT OlMln Piev/~'AIr.~~.t,.=~~~~~~~~;~'~~::~}f~:~ .. "."' . ~ .,...."" . fate greater than 100 ReeplratofY rate Notify p~dan for 181ften 36<'(98.8F). greater than 20. Tem~riltul'8 . Cardlao Monttortng, OXItnetlry, Notify phyaielen If dJ~I~;F;''':i;Wf~i;tl0
II.CIA N08TICS
~~~"x2~~~I~~:~~~~P~.~
~~tNt1llte
or 2 peripheral sites.
cae Wtth ~U'I dlf, eMl~Ol

1;1 phosphorus, mal~nelsl~~lli:lil~
s.er.um lactic. acid.
~putu~"'l,n &.
fY!... ,e;P'f.a?:1NR
)a
J..~ TSH&frOO:T4
[J Wound culture &it. $tool gU!e(l- rodel
1:3,' weC}ge8bJr ttran 10,000 or greater Ulan Notify phyelcf8n fo(:.c""dlnli~'a~l~~""'. 5% bande, pfelelebS '_than 100,;000d_4. 'i!lftUlHhlll"'"3i.urine output 1888 than :10 mllhour.
U'~CXR
tJ
III.
OROAN DY!!lFUI\lCT10N,:,:t:-<; i ;\!~i!f.',lA'~i4f~i::~f.:~",~~'t:
IV.
TREATMENTS Insert 2 peripheral Foley catheter. IV fluId, 11lter norlmalj&a'!lne'otA.!~)'11l1 liter of normal nllne. iEX"lljfdi.~s~ If SSP 1888 than 90 Qfl ~~J~
V860prftSOra & conUt1u'!id:~!~
than gO or MAP lese than 65 Infuae a second phySlclan for

pos8i~e
centraillne,
,\.
C Oxygen at --ooi-;....,..~ .,:

V. ME01CATIONS
vop.....OI"l SSP,. . ihtn to Of Ulilif UHa~

~~~~__"lcgJ'mln titrate to MAP greater
than 65 or
a dopamine 400 mgl2S('m!~'nottKiIJSlilJl
.';~~tiiit .ui~-:R~- .
"
j0727400691 ERS '110/02/1976 30Y M 10/01/07 :SMBRGENCY,PHYSICIA00074829B

I
000064
v.
MEDICATIONS: Antllmlc"'bJ~l * Af1 doses are based on crctt '>'::!l'~;:
of tnftotion
~~dtust
for renal function.
Patient's weight '''.''-'''''''~i!oI'
AJUt)UfI allagtntamldn par pharmacy
o
1:1
'and $Very hours Qba gentamlc4n per
,110","". otproftoxactn (Cipro) 400 mg
. per pna,nna<:y protocol (rounded to
and eVery 6hOura. , metronidazole (Flagyt)
L,'
,(rounded to fl4lilr6St 250 mg; max
o o
CJ Other: _ _-+...........
ff ..
lt'i::~'"."'~'1 MARCH / PHILLIpl.11

"
liUi.a-~;"m;~~/~976
0727400691 ERS _ ERQ
30Y
M 10/01/07
RNCY,PHYBICIAOQ074829S
000065
Emergency D,ediiltr"ff
\Itt. Ventilator Settings;
i:
Mode: _ _ ",..,'...----1
VNL ' .Additional Orde,.
'-,
I'
I have reviewed end ag~ \\ilth,tht ... "IPvru.'"" i ,~' '
7ffxCtlfPtfcm of those cros~ through.
DIIe:\9
{l.\;;r- T'mt;ii. ~
p'
Transcribed by',______........,...-.........~~,'~t:.,Orders scanned to har""1GY'<I;)lf!
RN .. "
In"I~~'
'.
'
,: /11
MARCH, PHILLIP
DEPAUL HEALTH CENTER ERQ
0727400691 BRS 10/02/1976 30Y 14 10/01/07 EMERGENCY,PHYSICIA000748298
: /. "~
000066
trRIAOe REtORD
.. "," ... >
SSMDIPAUL.
~: Maroh.PhlIIJp Aae: M30 Wt 73.~ Kg (e$t.) M""ecI~: 000748298 AtctNum: 0127400691
. tt~., .: E$I,.3..
( 8P:173194 \ __, : T:1'();~.6
. oom:
. No
Compllff\i:ChI.lIs ~_ Time: Mon 6c1 01 ~' .' ~Honi$ y; oar' '.
2007 .
..
'.
. .W~. ._ne: . .'4J

'.'Si'. R:20
...... 73.9 (Nt.)
. .' Em.rgen9Y PhySJclans
~ltai.,_.;: (2101)
KNOWN ALLE.AOIIS known drug aflergles.
PtYohf,itrlo n~gfY. No .tJ4)ujtj !SU'1Gtl~ UID,.....r.\i :~. n9JIItRlJ"p:tl
';SOCtAL HISTOAV;:hnIA drUg ' .
r not~.nt~t~Oi~"~.-"'''',; no.,,.~nt,o ~#~. .'
,-. J,N01es: Ag.... WIth nanlnt recc~.
fFAMILY HISTOij:'MtIffn",en'll;;
tt1_~.
.,
,.mliy:l\lltor;IAIIIMltlli6!
(Mqn lCOMMENT (Mon' oei Ol2001 ~ .1 rnbnkIPli\-",'

~COMPLAINT (Moo
I ~DDmONAL TRIAGE
Oct 01 2007 ~
'PROVIDeRS (Mon OCtQ12QQ1~1

, Julkt Sanohe.t, AN. . !ADMISSION (Man Oct 01 2007 'PATIENT (Moo OCt 01 200721 ; Code: NO, Trauma: -NO. HEiGHT: 182cm.-PHONe: 31452:2-8780.1 0727400691. ISEX NUM8ER: ~710tJ12' jPREVIOUS VISll Au.eA~~le$~(M~~ri 'VITAL SIGNS (MOn Oot 01' 'FALL RISK (21;3,5 JWHl): TIME.:'21:~i('.m
. \ movtment..
'.
rSSe'seMt:NT: (21 :SS'JWHII: f ONSET TOOAY. C/Q LEFT
000067
' ,/_:;-;{~tt:;:~~i:~~~t~~Y.,>"
" , ~"''<l'~,
,,~iiii;~~~;!;.!r.,~~> .
r::i~;:;':i~ "
,,' ,4f'1'..'~:k~\T~
i~t,';,
1IIIIIIm il~M IWI.IIIIIII. '~t~~,'~h!',.l1lllllllllmll

1,
Age: M,30 Wt; 73.9 Kg (est.) SSM DEPAUL : ' ~,,4f~ld~L l(E(}(}f:{:}~lI-:itI,W:l~:' '" MedRte: 000748298 t1~;~,<';J~!t;,:,-,:,:< ',:; : tRIAGE RECORD AcctNum: 0727400691 ~----------------~ ~~~ ~~--~~.-------------ilMMUNlZATlONS (21:36 JWHI): '~:.~~~~ r:~
T6 Screening (21:35 JWHJ): Domestic Vlolence (21 :36 JWHI): N011;AI:lIPI
':' :'6fh~,~'~'~('~;'i,{):}}\iiil' ,',
':, jJi~<),d:M~I~g, f.jd; ssf.i:?
'"ii.,', ,1\f!o!V!i'm!;),::ro;t;, ~::, .' ','
'
Nanw." March, Phillip
..
,"cn"",,,-,',;,-,,;--,,,,!!?,,,,
JTREA~ENTS
IN PROGReSS (21
PRESCRIPTION: No DocMn1tnttfd:,PlbjI
',_", i DKIN-Klng, aSH, Deb<>rah ,JW'H"~Wf.l
KEY:
,.
,~:';';!~:':
'
'
Ij,
';
',;)"r.;'iti.\ H,)I~~!gu: t-it.:}. ~~N,
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,att:~iy\1.';~~~r\f:~~J~~ '"':'"
<lr:::~{:f,.~L iIi~9}iliiNl.JBlt
, 'A~~)r
000068
No Patient Admitted
EXAM2
l~
PHILIPS
DePaul Health Csnter
Page 1 (last)
000069
No Patient AdmItted
EXAM2
PHILIPS
Page 1 (last)
000070
RHYTHM ANALYSIS MOUNT SHEET

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______________________________
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PATlI:NT L AHf-I
~SSM
H E A L T H e A R E-
RHYTHM ANALYSIS SHEET
0 7 27400691 ERS10/02/1976 30Y M 10/01/07
JlII.I II. CH,PHILLIP
D~PAUL HEALTH CENTER
ERQ
EMERGENCY,PHYSICIA00074829B
mt
uual a us,
111!1lln.
,a;
000071

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?R lnlsrvllll
~iqnab.He
LC.1M~ mH.t.fVt
I
Rhythm
I
1
PATINT LA8EL
~SSM
H E A L T H . CAR
I ,
E~
11I D\i s MARCH, PHiLLIP
R~TH
CENTER
ERO
0727400691 ER M 10/01/07 10/02/1976 ~;ICIA00074a29a
EMERGENCY, I>
000072
Patient Report Porfl1
0&1<- t) ~'-//e--f~'i
Htstory:
,L~- p,~
.i ~
+ ~
'Z,.~' ... ~<:!c-i'd?'
tJ-rnJ
Patient from:..wrHome o Nur5ing Home 0 Physeoian Otfioo o Hospital a Other: Home Med List
Med
ThrHl: aVes C No
No
DBPAUL HEALTH CENTER
MARCH,PHILLIP 0727400691 ERa10/02/1976 JOY
1111111
ERQ
M 10/01/07
EI>1ERGENC'i, I?HYS ICIAOO 07 48298
000073
o Muillple trauma o High risk OB

o
ReadmIssion within 30 days
II Abuse victim
t. Drug overdose A Substance abUS8 _ _ _ _ _ _ _ __

o History of substance abuse
o On 7 or more mlldlcallons d yYlQ ,

~ antibiotic or alimentation Tx o Dacumt~ ulcer o Ostomy patient
o Dehydralion/Malnutrition
df
o Admission within 1-3 months
o Progressive dlsMsa with impairment a Contagious disease
o Comatose condition
o
Mental status changell Dialysis patient at_ _ _ _ _ ~_ __
~ Pneumovac; Date: ~Iu Vacclne: Date:
-e- Q ca/'I1)../i P A
..J
Uvss alone andlor frail

Uves with spouse
o Liv611in: o , story home o Apartment

Number of stairs
Na~:
e
-
yV\ .0 \
-1-.~J., 1\
Family member dependent on you/ Nlleds arrangement for care _
11 06 under aoe'8
0 :2 story hom6
Over the age of 65 0 11 Suspected abuse and/or lleqlBcI

i1 Needs financial assistance
31
\4-'
o Occupation;
o
Umitations imposed by il/nBllll: Needs assistance in peiforming ADls:
to enter _ _ _ __
tl HOm6Ie$~
o Admission frQm(to nurSing home:

d Inadequate support:
o Clinic patient
Where;
a
A
-,-;:,
_________ _ __________
o V6teran-------~ ~ Family counseling needed f> -j - A-
0 Mobility 0 Feeding 0 Hygiene 0 Dressing 0 ToUeting 0 Transportation
'-' Previous Social Service Intervention

Ll. Financial assistance nsedM for medications
o Home Heal1h
Of iacifity:
0 Home IV Therapy
0 Home DME jiTranSPoIiatiOr]
Pl!ln_=--;;....;:;.;""--'--'-'---'-...::.j~_ _ _ _ _ _ _ _ _ __
0 Hospice
0 Hospital - Acute
Ho~ital
Psychiatric
0 Hospital. VA/Fe&ral
0 Nursing Home- Private Pay/Cus10dlal
o LTAC (long Term Acute Care Hospital) 0 Rehab o Resldential/Assisled Livingllntennediate Care Facility
0 SNF
0 Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
o Facility holding bed
0 PatienVFamlly confirms relurning to same taclll1y

~
Drnhsr________.___________________
____________________________________________
REFERRALS (REFER TO NURSING ASSESSMENT)
o Psycho~oci61 assessment request&d 0 Long term acute care ~_ _ _ _ _._ _ _ _ _ _ _ _ _ _~_ _ _~_ _ _ __ o Residential care _____________________
PAriENT LA8EL
~SSM
H E A l T H e ARE"
DEPAUL HEAliTH CENTER
MARCH, PHII.LIP
CASE MANAGEMENT SCREENINGIDISCHARGE PLANNING
llIIllllllUlllll
I/ P
000748298
0727'.1 00691 I-lED 0524 - 01 10/02/1976 31Y M 10/02/0"1

RAHMAN, AN1>1ER Z
000074
CASE MANAGEMENT SCREENING/DISCHARGE PLANNING
DISCHARGE DISPOSITION
Home
0 Hnme Health
0 Home IV Therapy 0 Hospital - Acute
[J Home DMl:
0 Transportation Plan
0 Hospital VNFederaI 0 SNF
Type of {acility:
0 Hospice
Hospital - Psychiatric
o LTAC (Long Term Mule Care Hospital} 0 Rtlhab o Rtlsidenlial/Assi&ted UvinyJin1ermediate Care Facility
0 Nursing Horne- Privata Pay/Custodial 0 Other _ _ _ _ _ _ _ _~_ _ _ _~_ _ _ _ __
, o Other_ _
o Facility holding bed
0 Patlertt/Family confirms returning \0 same facifity

PATIENT L48El.
~SSM
SlM8570-001 (12/2004) BACK
H E A I. T H CAR E~
CASE MANAGI:MENT SCREENINGIDISCHARGE PLANNtNG
. \0
000075
r;5
ADMISSION DATA BASE ------go p.::t.
IAdmiwion Oat! t O/-:'-{OT 0;.1.0
Patient has lhe following AdVance DireCtive:
0 See entity sp!>ciHc lorm (I.e., Essence, Intent) 0 See Progress Note~ Is inforffia1i",!1 ~\il! Yi!iQ? bl Yttli 0 No RlOqu&sleolO bring In copy? 0 Yes From whom _ _ _ _ _ _ _ _ _ _ _ _
o Copy in chan
0 Durable Power of Attorney for Healthcaffi 0 Health CalEl Directive
c _ _ _ _ _ __
HEALTH HISTORY (Check any that apply)

~--------------
BOLD SYMBOLS (* ,.
+ , ) IND/CATE REFERRAL NEEDED ON BACK PAGE

hx: 0 Heart attack VaSCular disease Pacemaker/DefiGrillalor Congestive Heart Faiture , o Heart mUfmurNalvular disease SLS: 0 Chest pain. Angina Frequency: Last episode: _ _ _ __
o AJzheimer's!Dementia
o Arthritis D Back/Hip/Knee
o Diabetes *
controlled by:
blli316eding problem DBlnod clol ~ Blood pressure problem Blood transfuSion Date: _______
o Breathing problem
~
o SUbcutaneous pump o Oral Hypoglycemic o Diel

Elevatl;td cholesterol
C insulin
o o o
o Chronic pain prior to ad mission ( _

Slle: _ _ _ _ _._ _ __
Chronic Pain Management D Pregnant/Lactating. If pregnant, due date: D Prostate problems o Reproductive problems
Last mens1rua! Wiod; 0
/10)
o Emotional problems
o Anxiety
o o ora. ~ o Wheezil19
OAsll1ma Bronchitis o COPDlEmphysema Sleep Apnea/CPAP
o Glaucoma o Heart dj~ease o Heart surgery

Dat.e:
o Depression o Suicidal thoughts/plan

o
o Palpitatlons
OEdema
Where:
N/A
o Sensory problem o Hearing 0 Vision
o Skin probfe1TI8 ...

DRash
D Cough/spulum production
o Shortness Of breath
o VRE
Frequency: _____ _ Hepaiitls Infectious/Communicable Disease.
o Skin fisK score 18 or l~lls + o Pressure ulcer Stage 3 or 4
0 MRSA 0 C, diff
When: ______ Locatlon:
o Cancer
Shol'lness of breath OCCUf5 at rest ___ wllh normal activity ___# of ftigtlts of stairs climbed ___# oj blocks walked Home oxygen
o Nonhealing wound ... o Other _ _ _

R(!ferral Orders.
o Unstageable wound
~.=-=,--.--
__
o Stone o Neurologica! problems o Seizures

o
FreQuency: ____~_ _ __ Last episode: Stroke/TIA frequency: _ __
o Kidney diseasa o Dialysis
o IV Davlce o:e::-port, Pice. etc.)
Contact physician for ET1Wound Nur
o Sexually transmitted disease

o Oslomy. Date last 8M; _ _ __ Thyroid problems Urinary problems
o Stomach/Sowel problems +
o GERD/Acid Rellux
D Chemo/Radiation o Chipped or loose teeth
o o
Re~fit exposure 10:
11 you cheGk any of the Hbovl, pl@,ui@d8Scribe: ____________._____________~_ _ __
o Other:
E Chicken pox 0 Hepatitis
Last episode:
Nauso<1/Vomi\ing
o Family problem1;i with am,~thesia

~mRcH(PHrLL!p
~SSM eH E A l T H . CAR
ADMISSION DATA BASE
1IIIIIIIIIIIIIIai
liP
0727400691 MED 0524-01 10/02/] 976 3lY M 10/02/07

RJ'iliMAN I ANh'ER Z O O 0 74 82 98
000076
ADMISSION DATA BASE
---'----i
tit Na fllferrll ind1c1\ed

{
Pttl&l\!r8qult'
. - - - - - - - - ;;;;;;;;;;;;;;;;;::::::;=~===-===:::..f 0
J~~!:!.~~~~~ 0
o 11!16!lguDf. Wfj~ll~
o SlIIge 3 or 4 PI~Uut. ulcer o NGn~.shna~unc
C11n(r.' NutrHton
Skln Rip SeOf~ (1118 Of I,n
o PI'flITI'1IfTF o I'nJllim (IlOt cleijyefill9) G/' Wtriflg o ~tlent nqutll
o o o o o
Rllllallail1fa ApptalWl o11111111ll1Ii1IotI lJIIpllftlled WI 5. 10 IbJ Of m~ltlhfttb Clmlge In appttita mQrt! 111111 6 dtyi If/V/tJ 3 days Of more IJ/ffiCllIIy c!Iewlng/1Wall1lwing
Live in' Who do
. 0 Apartment (J ResIdential howsin9 0 Nursing home Iive\';11h" . . ~"~ _ _ _ _ _ _ _ _ _ _ -_ _ _ _ _ __
o NfllolklwWo Olallellt 0111 o Majllf surveIl (0'1&1 15 Yelrs 016) o lfistory 01 bJnat/ll: lurgery
remnl imlifiitll1l
o Ikwly Dr Vllbetic
MID you al home now? f;<NO 0 Ye~ N\\rnesfAgencies _ ._ _ _ _ _- - - Difficulty wi actlvmes of dally lIVing? J~ No 0 vas Explain: _ _ _ _ _ _ _ _ _ _ _ _ _ __ Difficulty AmQulajing I Transf9mng1 No D Yos '" Explain: _ _ _ _ _ _ _~ _ _ _ _ __ if yes dua 10 paln, explaln: _ _ _ _- _ _ _ _ _ _ _ _ _ _ _ ~_ _ _ _ _ _ __
Do you plan to return to your home Irol1'1 the hospital? Transportation available? lives 0 No
%l. Vas
0 No. If fl'J. explain:
o IIlslory ~f MR&A.tVRE/C. am
o IV navlee (PoflI'ICC. tIc.)
InfAAlion ContIgl Potltive TB $(:I88nlnglSkin tnt
Does anyone
f51
o R~ttl1t eXf~wle
HD leWn! tndtClm4
'" ContKt pbysfclan for PT{OTISpeedl Referral Ordaf's
PSYCHOSOCIAL/ SPIRITUAL
Do you have any spet:;lal conCQrns aboul baing in the
. Do you Mve tiny spiritual canCI/Tn:;'? ~ No 0 vas +

Any special
O~er
Have you htld any lll"jO( chanr:les {job. move, dillerte, deal", ate.) In your life recently"
hospital'] ~ No 0 Yes. _ _......,._ __ ~ No 0 Ves ~ ____ _
r{!ngiOUS~C!tural factOfS~!9d 10 care? ~ No

None 0 DiffiGully falling ru!e;p ___
~4-
. _________
Sleeping problomt'..
DYes 0 Difficulty staying asleep
_____ .
_ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ___
bf'H~ refemlln(!lcl!led { -- TqbAm c.,.ation ..
o PSliaol fieQlIlIst o Spiritual Con"I'~'
o POGI PmgnOilt o Stlllms PIOCiduralSurll8fl o AgY1ln~e ()I,ecli~ A$$InaflCI
+ pntpral Cam + o AntlGilJll1811 CopinQ DI11Itllily
o Utellln !all 12 roonllli

Snntol
cOIl1rOIl/plO.l5odi(m do you or your partner use? _ _ __

yQ\J r!'!~!ly
did n9t want to? 0 No 0 Yes.
=~
_____
.-------1
SJryi$' _
o No
FORM COMPLETED BY (If other than RN)
DYes
o Elderly/frllY IIvlnv alooe

0 Home!lmlOi$placeo
o Pallenl Rtqullt
o Nwsioll Heme PlfClmtnl
o SlIfpeG!!<i AbuwNevlKl
Poulblf HQllI\I Aulslilltl!
~SSM
H E A L T H . CAR ADMISSION DATA BASE
SLM-l00G059 (3/2007) BACK
PATiENT !.PBEL

twlARCH, PHILLIP
E~
IUlIIIUIIIIIIIIIIU
liP
0727400691 MED 0524-01 10/02/1976 31Y M 10/0'2./07 000'748299 RAHMAN f AN'iTER Z
000077
ADMISSION ARRIVAL SHEET
for help to get up
smOking policy
~..mefgeney light 8R/shower ~lsitirT9 hours
ARRIVAI.INFOIfMATION COMPLETED
,If other than nllJ1le)

YGs No
Q
BY(22wk eke"f! L.Pnti

~N11PRE
LL patients the following questions:
--~-----------~==---==
I 0 ~;2 '0- 7
DATE
0/5
TIME"
(p
SUICIDE SeAEENINC
.iC Have you ever Inoo 10 harm yourself in the past'? Explain ._ _ _ ___
. Are you here because
you l11ed to harm yourself? Explain _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Q
In the PM! wee!<, have you bean haVing thoughts about harming yours&1f? ElCplalfl
Physician notifled
YOU EVER BEEN EMOTIONALLY. PHYSICALl.Y, OR SEXUALLY ABUSED?
rN0 EVfD(;NCE OF PHYSIGAL. SEXUAl. OR PSYCHOLOGICAL ABUS~ NOTED.

U EVIDENCE OF POTENTIAL ABUSE NOTED BUT NOT SUSPECTED.
SPECIFY EVIOENCE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ._ _ _ __
I.J Hotline called
specify: _ _ _ _ _ __
COMFORT STRATEGIES USED (PrIor 10 admission)
q'10'
PAIN FUNCTION GOAL
!
II pain present, complete Pain Assessment
~~tion
0'/0
1i!INFORMATIOff GIVEN ON RIGHTS AND RESPONS,efUTIES

OF PAIN MANAGEMENT
of PBtiBnI FIOW'Jf18Gt.
To be completed by an RN.
PLAN OF CARE
PATIENT/SIGNIFICANT OTHER INVOLVED IN THE CARE PLAN DEVELOPMENT. "t,i'VES :J NO explain: _ _ _ _ _ _ _ _ __
FORM COMPLETION INI=ORMATION

L.PH~
Form completed
Signature:f)-Lu J~<',.,........
l?t.-
Date; /0
(!
i!=( ~7
Time:
6/ 4- f
(If completed oy LPN, RN review and plan of care development required)
RN: u Form completed

Slgnature:J;fu
~)~\) pN
TIme:
Adm. data reviewed '-IPlan of care/Care pathway developed
Dare:rfJl ;).! 01
e}2.3L)~
~----
----,--- ------
------------~
PATIENT LABfl
-------'
rYl:iSSM
H E A L T H . CAR
ADMISSION ARRIVAL SHEeT
E~
Diiia 11
Mt(RCH PltILLIP
Q72740(}691
'1'H cSNTER
ERQ
ERS 10/01/07 10/02/ 1976 3H~~ICI~000748298 EMERGENCY,P
000078
Cardlovascularl Hematological
Reeptratory{ InffK:tlou~ Disease
JlfNo proDlem Identified
Musculoekeletal
fj Exception as below
Reprodudlve
U Exception as below Wour\d/Sklnl
.6No prODlem Identified

gfNo proh!am identified
~o problem identified o Exception as below
No problem identlfl&d
GliNutrltlon
6 No problem Identified a Exception as below

a EXC6plion as belOW
Mucous Membrllne PeycholSoctali Splrltuill
~o problem identified
Q Exwptlor. as below
Dale:
/0,10 zi-?
. Time:
tP/y r
PATIf-NT /..ABEL
~SSM e
H
SLM-\OOO-058 (7/2007) BACK
DEPAUL HahLTH CENTER

MARCH/PHILLIP
0727400691
A L T H . CAR E-
t11
ERS
ERQ
i~~~~~~:P~~~ICIAOQ074e29B
10/01/07
000079
INTERDISCIPLINARY CARE PATHWAYS@ GENERIC

MEDICAL H'~TORY
At ~r-Pe."',f
SPECIMENS TO BE COLLECTED
INITIAL DISCHARGE PLA.N
I,.,";
U,eiF t~
6-;l:-J:;L,rnt-if fiJ -
" t{{Y
Op,TE I~!.,l.,
piHome with stgllltlcMt other
o SNF/ACF o
o Other
DAILY LABS
Rehab
'~ u5{, L ""'....",,f' ~
OIHome Health
I
CONSULTS
PHYSICIANS
NAME
DEPARTMENTS f NURSING DATE NAME
/'-'
/' ~f'LoL.l' L
Admitted with
pressure ulcer? DYes 0 No
SPECIALTY EQUIPMENT
Date;
Type:
lsola1lon:
Pneumovax Yfitar: Flu vaccine year:
ttftW'W
t,\'\A
ld 't'jT~'7, .
D1AGNOSIS/PROCEDURl,
HT
5:..///
I-
Ost..Q.." mV 'tl J f. f.f JN" fr M.. r"
,
p'
~ VVJ;{~
t:
AI {..v'("'r I
,-
WT
Il~~ IbJ
DATE
'1 '//1(
ALLERGIES
CODE STATUS
..
I
I
-,1 FuJI resuscitation
o DNR medical management

D DNR comfort measures
---
IV KjJiJ
Advance directives? 0 Yes 0 No

Gopy in
chart?
EJ Yes 0 No
Is there anyone who should not receive general condition lnfonnation? DYes DNo Family/Significant other designated to receive medical information:
None
Name
o POA
Name
Phone
PATIENT LABEL.
POA
Phone
INTERDISCIPLINARY CARE PATHWAYS~ - GENERIC
o PM.. 1000-024 (;,{2Q06\ PAGE 1 OF 6
COPYRIGHT j997 8SM KEALTH CARE
000080
PLAN OF CARE
PROBLEMS I OUTCOMES I INTERVENTIONS
DATE I
INITIALS
Plac@ initials and oate that probhtma afe identified 11'1 left column. All identlfled problems mUlit be evaluated whether Outcome Is Met or Unmet at time of dlschar~e by placing Qillt IlI1Q initials In ~pprOprllllt Golumn, It Outcomg ia mtt prior to dlacharge. pinel:! datil And initialll in Met oo-Iumn. Place'" in bo)( by inferventions appropriate to patient. Write in addltlonal interventioN; dG needed In blank !ilpaces.
OOTCOMES
Met Unmel
P..obl.m: Alteration In Neurological Status

Age specifll; consideration in Elderly Adults: Dlminis/led muscle strength. Deg9norative lJone andlor joinl change$, DOCfCo.sed hearing. w/On and balar1l,;e.
Ovtcomw. The patient wUf exp.rlence a atabllIzatlon 01 neurolov1cal Impairment.
o Assess for Fall RIsk BID ' lni1iah~ Full Precautions for Fall Risk Score of 15 or higher. o Ass\}ss llilvel of cons<;:iOLJsnesS and motor junction livery shift and PAN, o Encourage achjevemen1 of ADL's as appropriate to the neurologieal impairment.
,
Age spqcific con.siderolion In Elderly Adults: Weakened T8Splrarory muscles, t;J~t;rw{l{#6d 1({IlQ tiS3U! BlaST/city. OU100m8: Re~tl'8topY tunctlcm will be within normaillmlt$ for patient. Intwlventfons; , POtlilion patient for maximum ventilation efficiency, Monitor VS I breath :lounds I oxirrwtry every shift and PRN, D Administer treatments I ol(ygen j ABGs as ordered, PrOVide fluid intake 10 liquify <lecrellons - Suction secretions as neceaslll)'.
Interventkms:
Problem! Alteratron In 0llYgenatlon / Respl..atory FunctIon
o o
Problem; AJI.,atlon In ComfortlPaJn Manag4tment
iO/~L
1f,-
Age specific consid~rat;on In Elderfy Adults: PossilJle Idiosyncratic effects f(vITI m~aica(irm~
l1ue 10 agsrelalfld cha~s
In i1ooorption. mmabolism Ilnd GXoretibfJ. Outcome, PaUent exhibIt. I state$ acfaquate rell.f of dl"omfort.
~~aen pallent'" polin level every 4 hours.
~voIve patient in cars by disC',IlIsing methods 01 pain reli",l. ~ate interventiol'lS (inclLlding non-pharmacologic) IIppropri<lte for pain/discomfort.
jnt~rventioni;
Assess pain level nnd rasponse within 60 minutes of intervention.
Problem: Alteration In NutrltJon
nut,ltlon8' Intake It I Outcome: Patlont'S 0 ,
Age sp8Gific consideration ill Elderly AduilJ; Diminished appetite, ponJt8lsis and digestive iuioes and denlltion changes. fliCeQrS thai ill8V jmprQv~ food InlakQ; Position patient upright - Offer smaller. more frequent nlt;lfl.is - Modifieri food consistency, i.e,. pureed / soft
.pproprl~te fOl
metabolIc ne9d$.
o o o
Interventions: Nutrition Consult enterea in HBOC, 0 Monitor hydrallon status Ass"'!3ll enteral fef/wng toleranGe A311~1l1l lor swallowing J chewing ditfieulty - Allsis! patient wllh meala as needed. Assess I Record dietary lottllle with each meal - Provide I record dietary supplenwnts I HS snacks. Record Dnily Weights - R@port une-xplained weIght changes >3 Kq from prayiOilll d;!y.
Problem: Alteration fn Cardiovascular Status

Ago specific con$ldcration in Elderly Adults: Drminish&d cardiac force I blo()d flow to brain.
Outcume: Pattent wlll "
o R&cord inlal<e and output every shift and PRN I Dally weighls and rapor1 ywiances. o Asus$ vital 8lgm, peripheral pulses and c-arplllary retill every shift and PRN.
D
Administer medlcaflons I blood products
<IS
tnttlrventions
hemodynamically stab'"
ordered WId monitor effects.
Problem: Alteration In Skin Int81iJrlty

Age specifiC cans/deration In Elderly Adults: Skin dry and less 8Jastic
Outcome; Patfent will maintain Or Improve skin Integrity.

Intervention\>; him patient every 2 hours - OVOid shearing - Keep skill dean and dry, Photograph and measure wounds on admission, every Monday, and on Qischarge, D Prollfeta wound \;1;\r& p~r Skin Car@ Plan {S.e !lag!! 8) 0 NutrHion Consult enlered
PrDb.bml Pot.nth,1 or Actual
rnfe~tlon
jO\J.\l;n
~
Age sp~"itic considuration in Eldor/y Adults; Decreasod renalll.lnction - nOIe /Bb vlllu8$ related to antibiotic dosing
~lize iSQlation precautions:
~9I'1tlon8:
Outoome: SIgna and symptoms of Infection are recognized. p,.cauUona are utllll,",.
0 CQntaGt 0 Special Respiratory AssenlReport signs and &ymptoms of infeclion every ~hrft and PRN,
D/oplat
PATtEN! LABEl.
~SSM
HE"" l 'H
(j
oil
I'{
e:-

0521-01 M 10/02/07
I./p
INTERDISCfPl..lNARY CARE PATHWAYS' GENERIC
000748296
DPMl00Q-024 (M'OOB) PAGe 2 OF II COPYRIGHT 1997 SSM HeALTH CARF
000081
PLAN OF CARE
PROBLEMS j OUTCOMES /INTERVENTIONS
PATEl INITIALS
Place initials and dote thaI problem!> are identified in lett column. All idllntified pn~bl~mll m~H,1 9~ evaluated whether Outcome Is Met or Umnet at time 01 dischorge by placing dale and initicds In appropriate column. If Outcome 1$ met prior to discharge. place date and initiwa itj Met ~otumn. Place y' in box by inlerventions appropriate to patient Write in addition a! interventions as needed in blank space~.
OUTCOMES
Mei Unmet
o o
Problem: Alteration In ElimInation Age specific consideratiun in Elderly Adul/s: Diminished pRristBlsis, kidllcy function. Outc;ome: Patient regains normal elimination patterns for age and disease process. Interventions; 0 D Offer tollallng every 2 houY$. Assess bowel sounds, abdominal distention andior dis.comfort every shift and PAN. D Record freque-ncy and chamcteristics of ~toc;>1. Repol1 if no stool tc;>r >3 days. Record intake and output "very shift and PRN I HejlQrt abnormal lab vt!lues, Problem: Knowledge Deficit
Ago ~pMifI{) eonsid9wuon in Eldsrly AdUlls: StlnoOf}' and CQgr!illw impairments, 0 1 \
"\0'1
ptr
Ou\,.:!)me; Patient and/or (Jignlflcant other Involved in plan of c::are ! demO'nstrate understanding O'f procedures / disease / medication. / and d'soharge inllti'uctlon5. ~tvenuons 0
~ssess baselin~ knowledge and preferred learning method of palian! I signlicant other, ~rovide educational material at patientl~ignificant other level olllllderstanding, ~!jsess patient;' signilicant other for under!1tandlng after leaching. Provide instruction on sate and effe.;;live use of mildlcal equipment.
Problem! Anxiety { Spiritual l1i'liturluIPl;c$

Age specific consideration in Elderly Adults: F;;Sf of loss of conlrol. decfinmg neallh and/or approachin,q death, changes in economIc St;ic(Jri~y I SOCial slaWS Outcome; Patienl/Slgnlflc;ant ottler demonstrates ability 10 (;ope and Identifies available re$ouroes, Interventions: 0 Fncourage verbalfz:ation 01 te<lfs elnd particlpation In <;>Ne. Decrease sensory tltin1uli - provide quiet I'!nvironmen1 ~ Dim Ihe hall'Mty lights alief 10 PM. Pustoral Care referral entered. Palli...tive eme referral entered.
o o
o
Problem: Qlyeemia Imbalance
Ago speclflc consideration in Elderly A(fl,l/ls: Dccre,'1BBd renal runction. metabolic rille.
Outoome: Patient'S blood glucose is within aceeptable range.
o Implement Hypoglycemia ProwCQI. o Implement Insulin Protocols as ordelBd.

o
Interventions'
-~
Monitor I Record fingerntici: glucose values \)~alwtes Educator Gon:lu!t enterad.
[1.$
ordered and PRN.
Problem; Alter~tion In Mobility / Activity Intolerance A90 specific consideration in Elderly Adults: Diminished muscle srrength, Degenerative bone andlor ioinf chEmges, DecreaSed hearing, vi:;ion .1nd tJ;llancEt. Outcomel Patient maintains or Improlles mobility I ac11vity level.
o AS$Ir.t patient 10 partiCipate in ADL's within limlts 01 impairment o Advance activity as ordered tolerated. o PT to assesS fun~tiona! <lbilily und provide appropriate adaptive dl/vices
j
Interventions;
Problem: Alteration in Safety Age (5{JftGifi9 CQn$id!!riilliprl ill Elderly Adults; SensQry and cognitlw Impairments, Outcome: Patient remain'll in a safe environment and frtlfl O'f phY$iejf 'iijuiV.
O~ o Aa~s$ fQr F!'II\ Hisk BID -Initiate Fall PrE>cGulions for F..lI Ri"k Soore or \5 or hi9h~r. o Provide appropriate satety equipment / deVIces und in&lrlJcHons Hue,
InterventiohS:
101
Implament plolecllVe status (VaV)
Problem: Oukome;
!ntervel'ltions:
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PLAN OF CARE POTENTIAL ALTERATION rN SKIN INTEGRITY
I DAn:: I
I '

Place initials and date that problems are identified in left column, All Identified prQblems must be evE\luated whether Outcome Is Mel or Unmet at time of discharge by placing (jate and initials in appropriate column. If Qt.l!t;;Qm~ 13 milt prior to dixtllUge, plac@ data anti inltia~ 1ft Met I1Qlumn. r:>lace Ii' in box by interventiwls appropriate to palienl Wrtte in additional Intervention::! as needed in blank spaces.
OUTCOMES
INITIALS
Met Un root
Owtc;ome Goals:
Skin Integrity is malntalned. Patients at risk are identllied and IntervelltiOlls inillated.
Prf1ChBCkBd items are initiated for all plflienls.
Skin Integrity ptan for all patients
0' Complete Braden Scale on admission, then daily.

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ASSWIS skin upon admission and every shift, especially bony prominences and skin fo/ds.
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E:! RccQrd any reOfl@!lS lhar dO!!i not di!lap~af Within 30 minutes
~ Reposi1iIJn at least every 2 hours.
any break in skin ihtegrity.
0' Apply 10110n Immecli~tely after bathing. Use moisturizing cream for dTy skm.
Avoid massaging over bony prominence!'; and discolomdlhyperemic areas.
ri1 Keep boo clean. dry. ana tree ot wrlnl-jes. Ii1 flamove antiembolism hose, sequential stockings, <lnd heel protectors every shih tor &> Imnutes to ass6sslegs. feel. and heels. 51 Minimize ;jilin 6xpasure 10 moisture from Inconfiflenc&, perspiralfon. or wound drainage. Ii1 E:otablish a bowel and bladder progrEUTl by assisting the patient to the balhfQom or bedskte commode every two hours, unless
contraindicatea.
~ Skin cleansing at time of Soiling with perineal cleanser with minimal friction and apply protective barrier cream.
0' Lhrrit usa of adhesive products on thin. fragile skin and apply skin sleeves PAN. 1!1' Float heels ott bed with pillows placed undar the length at thlO' lower legs. activate heel sl.Ispenslon On Tola! Care Bad {leU}, an<.fiOT
sflplico.tion of heel protectors.
~ Instruct patient and family on causes and prevention of skin breakdown. sources of pre~re, Iflclion. and shearing.
Record on
Patient Eduvalloll Form.
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o InitJate individualized IUtning schedule mInimum o/I1'rery 2 hours ill ~a {livelY 1 hour in chair. o Consider use ot pressure relieving cushion.
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Skin integrity plan for "At Risk" populations Braden SCOre ie or re$$ Place orange sign {PUPl on the door of room Imllcatlng patient Is high risk tar sl'.m breakdown.
PQsitlon pallen! in a 30 degree lateral position and avoid positionIng directly Oil trochanter. Consldar use of lifting devices 10 move and reposition pallent such as lift shet<1s. trapeze, and Air Pal to prevent frlctlon and strear. Maintain head
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o Use pillows/wedges 10 pad bony prominences from ctirecl pressure. especiaUy between kne~.
Consider use 01 urinary or tecal collection devlc'e to conlaln urlne or stoot. LImit use 01 diapers.
or bed <;It lhe lowest degree Qf elevallon consistent wffn medical cQndition.
SUpPQt1 surface per WOO N\JIse Specialist _ _ _ _ _ _ _ _ _ _~_ _ _ _ _ _ _ _ _ _~~_ _ _ __

Nut/ilion consult entered.
!v1edications: Use liQ~ln~ Hrdroctnotide 1 % inject intradermaUy to produce wheal to locally

anesthetize site. Flush each lumen of Pice with 10 ml sterile NS IVP: before and 8'ter medication I solution administration before and a :ter blood product administration every 8 hOUI!> (regardless of continuous IV infusion) when obtaliilng blood sample, discard small red tube, then obtam sample. Upon completion, oulse nush with 20 ml sterile NS IVP PRN to dete :mine patency
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LABEL
Treatment:
Place transparent tegaderrn dressing and blopatch at lime of !ine insertion. Change l./I? dressing after every 7 days and PRN if the integrity of the dressing is compromise~~/o12/07 Document in p'ogress notes and on flowsheet : )0748298 NO BP OR NEEDLE STICK IN PiCe ARM _ DO NOT USE ANY SYRINGE SMALLER THAN 10 mt WHEN INJECT1NG IN Plcq ~~>r_"'<_."'_
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o DNR madical management - - o DNR comfort measures

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Oopy in en9.r1? DYes
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medl~allnforma1ion:
Is ther.. anyone whC) should nol receive general condition in1orma1ion? [J Yss oNo
Family/Significan1 olher designated 10 receive

Name Phone
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Name Phone
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DSPAUL HEALTH CENTER
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INTERDfSCIPL1NARV CARE PATHWAY~ .. GENERIC
fl1ARCH,PHJLLIP I/P 0727400691 MED 0524-01 10/02/19"16 31Y M loio2/07 f-1ELKAVERI, SONIA N 000748298
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000088
PLAN OF CARE
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DATE!

Plae!'; Ini!iul~ und date thaI problems are identified In I$tt cofumn. Ail ,r/Qntifi"d problems musl be evaluated whether Outcome is M~t or Unmet af time 01 di'3<;;harge by pfacing date and imlifll3 In IIpproprlate colulnn. If Ouleo~e is met prior 10 discharge, place ciale and initials in Mel column. Ptal'e v In I:>ox by int~rvenliollJ appropriafe to pailenl Write iI1 addltlol'laf intervenlionll 115 needed in blank space:>.
OUTCOMES
INITIALS
Met
Unmet
Problem: Alteration
A.Qa "'IJtICitil~ CO/1:JlulN<llion in Elrferi'y Adults: Viminished muscle streng/II, OegenBl'fltlv(J bollO and/or joint changes, Decrc>osao' 11{;!IHm,q. Vi:~10n and billa(J{.;e.
'n Neurological Status
Outcome: The patl('nt will experience a stablH&lItion of neurofogical fmpalrment.

I I
I
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Intervention;;: [j , P.ss~sr, for Fall Hisk BID InitiRte Frill Pre<;;IIvtions for Fall Rink Scor~ of 15 or higher. Ihsess level of consdolwness and motor function every ahil1 and PAN Encourage achievement of ADL's as appropriate 10 the neurological irnp'lirment.
A't~r..tjon
Problem:
In Oxygenation I Re.splratory Function
Ago apecifia aonsirifw'Ition in Elderlv Adults: Weakened respiratory muscles, D?qr?.{j(;rJ IUHglf:iSU8
eJ8stiGity.
Outcome: Respiratory iunctlon will be within normallimft:s for patient.
o o U o
InW\,.;nliens; LJ , _ PositiOI1 p<ltienllor maximum vantil'llion effjci~ncy MOllItor VS ! breath wtmds i ol.imetry every shiff and PRN. Administer treatmento / oxygen J A8Gs a5 order~, IJrovi(;!e Iluici intake to liquify seem-nons Suction secrelions as necesaary.
Probl~m:
I~l
Alteration in Comfort/Pain Management
I1gc $1J~'iI," consirferation lil ElrJerly Adul/!'; Possibi<! Idic;syncralic effects from m~r;/i{;,/i.ti(}nli ttl Bosom/inn. moiabohsl1I lind excretion
due f'J (lglJ-f@la{flc1 changes
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IntElVUlllprls fJ ___ .________ ;\:;SIIS3 patient's pain level every .. hours Involv!! patient in ewe by discussing nll?tl'lods o! pain relief inil'a!~ inll'rVIO'nlion$ (i!"tcluding I)on pharmacologic) approprmte for painfdi&comfort Ar.[.J)oO pain level and respons", withm 60 mmules 01 ;ntJ?rv9I1tion.
Outeom~
Patient exhibits I states <ldequate relie' of discomfort.
I
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Problem: Alteration in Nutrition
I
I
Age sr>t?nili<: conf;ide/f;ttron in Eiderly"dulls. OlminishBrJ ilppetito. pf}(is1alsis and digestive juices and d8nffllon change!;. FiretO{$ 11121 {(jilV lmproVp. f09d ilJ/<lke: Position pfl/ient upright - Ofter smaller. more frequent mBals - Modifiod foor:! COl)s1:~tem:y I.e. pilmfh7 i soft,
Outc.oms! Plitientls nutritiona' Intake is appropriate for metabolic: n_ds.

Interventions
I o
o Nutrition Consult ent9red in H80C', [J Monitor hydrulion stalus o Ass&ss Imt"ral fesdlng tolerance o A!;sess lor sW.!Howing I chewing difficulty -A(l~ist patient with meals as neeQ\ld. o Assess i Record dietary !ntaka with each meal - Provide I record dietalY supplements f HS snacks.
n&cord naity Weights - neporl unexpluined weight changes ;-3 K9 from pr~vlous day.
! Outeome: Patient will be hemodynamically stable.

D
Problemf AlwrBllon In CardioYilseular Status

Interve!1lion~
Age specilia conSideratiOn III E/df:rly Adult."!.' Diminis/led carrifac force I blood flow to brain.
R,,,oord mlake and output every shift llnd PRN I Daily weights and report varmnces. I\$U"'~S vital signs, peripheral pulses and carpillary relill every $hifl and PRN. Administer medioltiom i blood prociuctr. il~ ord~red and monilOi effects.
Problem: Alteration In Skin Integrity

Age s{.,ecillc considRration 111 EI<./t!rly AduJt,~ Skin dfy ami /t;SS a/aS/ic.
o
o
Oulc<Jme: Patient wilt maintain Of' improve skIn Integrfty. Inlervenfiom' U Tum palient every 2 hours - avoid :;h9aring -I<cep skin cleB(] and dry.
Photograph and measuro wuunds on admission. every Monday. and on discharge. Pr"'1ide wound C3fO p!n Skin Car~ Pll'lfI (SM page 8) Nulr!ilon Consuii entered
\~W
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Probl&m; Potenticlll or Actual Infection
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Age 6pc'Clfic c()nslder.Qfion In Elci<!rly Adufls: Decrel'l.$cd lena! function ~ norc lab valuE'S related to antibiotic dosing Outcome: SI~S and symptoms of infeethm are r$cognized. PreGliullons are utilized. Il1lervention$' U Utilize iaolation precautionr. 0 C~ntact Special 0 HBspiratory 0 Dropl~t AG~\'3SHeporl sign~ and ~ymptoms 01 Infection evsry shift ll1d PRN,
Dil TlFNT
LABEL
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DEPAUL HEALTH CBNTRR
INTERDISCIPLINARY CARE PATHWAY~ GENERIC
0727400591 MED 0524'01 10/02/1976 31Y M 10/02/07 NBLKAVERI,SONIA N 000748298
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000089
PLAN OF CARE
DATEr
INITIALS
Plar,;e initials and date that problems are idefltifiedin left column. All idenlified problems mUl.!t be eV<llunled whether Outcomw is Met or Unmet at lime 01 discharge by placing date and initials in appropriate column. If Oulcome IS mel prior lo discharge, place date And initial~ in MGt column. Place ..... in box by interventions appropriate \0 patient Write in additional interventions as needed in blank sp(lces,
OUTCOMES
Met
Unmet
I
i
Problem: Altef'stiOf1 in Elimination

Age spr;lcific eonsi(ieriltion in EhJeriy Adults' Dimif1i!~hed per;sttlISls, kidney ftinction.
Pattent regaIns normal elimination pattel'nlf for ag9 and disease proee!50s. I Ou1eomel Il'1terven'ion~: 0 ___
D D
I
o Offer toiieling every 2 hOW3.
.. -
Ass,"sG bowel soundS. abdominal dl91entiQn and10r discomlort -:very shift and PRN.
lIecord !requeflcy and charactenstic5 of slool. Re-port If no stoellor "3 dnys Record Intake nnd outPUT every shill and PRN ! Report abnormal iab values.
Proble.ml Knowledge Defieit
I qO')
Io
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Age 5J]CGt'fiC ContiiaffUIfion in {;!(j(,lrly fldulIs: SMSOry and co9nilivo imptllrments Outcome: Patient and/or lilgntfieanl other Involved in plan of eare I demonstrate of proGedures I dlsea$e I medielilltions { and discharge instruotions. Interventions D ~__ . AaBN;s baslllin~ knowledge nf1d preferred learning method 01 patient f signtlcant other. D Provide edllcalional material at patIent/significant other level of :.md>Jrutanding. Assess pnlienli significant other tor l.lodemta/1ding after teachln9' Provide in3truction on safe and effective 1.l5e of mediC-'ll equipment.
underslandlng
Problem; Anxle" I Splf'itual Disturbances

Age apcoific consideration in E/uel/y Adults.' Fear of loss 0/ COIlIIOI. dodinmg htlalth in Bcono/me seGurity / social sill Ius,
and/or approaching death, cnanges
o o
o o
Oulcome: Patrent/Significant other demon$trates ability to cope and icfentlflell Bvallable rHources. Interven lion.s, 0 Encouragll verbullzation of fears and participation in care. Decrease sensory llllmuli - provide qui'" environment - Dim the hallway lights alter 10 PM, Pastoral eMil referral entered, Pallitltive Care referral entered
I I
Pt-oblem: Glyeemia Imbalance I Age speoific consideration frl Eldorly Ad!llt,~, Decreasel.i renal fllnetion, metabolic rille. Outcome: Pat14~nt's blood gluCO$e is within Bceeptabte range. Interventions: D. ImplemO'nt Hypo91ycemia ProtocoL Implement In1julin Protocols as ordered, Monitor I Record fingersti<:>k glliGose valuea aa order-:d and PRN. C Dial>ele!; Educator Consult ",nlered,
o o
o
o o o
Problem: Alteration in Mobility I Aetivity lntolerllnee Age specific cOnli/ueration in EldArly Adu!ls: Diminishod musc!fl strength, DegenerallVe bonA and/or fOlnt c;'flallge;;;. Decrea5ed hearing, viSIon and balance Outcome: Patient maintains or Improves mobiliiy I activity level. Intervention5: D_ Assist patient to participate in ADl's within limlt$ of impairment AdvanCe activity as ordered,' tolerated. PT to a3SeS$ functional abilily and provide appropriate adaptive device!';,
PrOblem! Alteralfon In Safety

Age specific (;onsideratioll Tn Elderly AdIJlrs: Sensory and cognitive impairments.
o o
Outcomet Pattent remaIns in a safe envIronment :ll\d freo 61 phllslea'lnJury. Interventions: 0 _ Assess lor rail Risk BID -Init,ate Fall rrecauti'~rl& for F~II Risk Score 011 b or higher. ProVide appropriate safeiy equipment ; devlce~ alia in(!!ructieM fe' UtQ, Implement protective status \VOV),
Problem: Outcome:
..
-
----
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I ABEL
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DEPAUL HEALTf! CENTER
INTERDISCIPLINARY CARE PATHWAYS"- GENEIRIC
MARCH r P!!lLLIP 1/ P 0727400691 MED 0524-01 07 lO/,CZ/1976 nY M lc/nl MELKAVERl,SONlA N 000748298
111111111111111111
000093
Of'M-l000-024 (512006) PAGE S OF 8 COPYRIGHT 1997 SSM HEALTIHCAAE

t1 ell .. 1'"
o Care Planning with PtlSO (Al

OCare Planning with PtlSO (P)
o Care Planning wi1l1 Pt'SO (A) o Care Planning with PtiSO (P)
OCare PlannUng with PtiSO (A) OCare Planning with PtiSO {P)
~SSM
~
(;
S ..

PAGE 7 OF II COPYRIGHT 1997 SSM HEJlltTH CARE.
DEPAUL
Copiedby _ _ _ __
RN Re\liew _ _ _ _ _ _
HE~TH
CENTER
I!?
M..ll.RCH, PHILLIP
0127400691
11I1.lllllIllftl
MED OS24-01
INTERDISCIPUNARY CARE PATHWAYS, GENERIC

r.1>..... ,M(l./l~t. f<;P!lOil\
~C/ :12/1976 31Y
M 10/02/07
MELKA\lERI., SON:i:A N 00074113298
PLAN OF CARE POTENTIAL ALTERATION IN SKIN INTEGRITY
I I
PROBLEMS I OUTCOMES { INTERVENTIONS

DATE I
INITfALS
Place initials and dal!;! that problems are identified in left column. Ailiderllifi&d problems musl be evaluated Whether Outcome Is Met or Unmel at time of discharge by placing date and initials in approprll\l$ corumn. If Outcome i3 ml't prior to discharge, plaM dale and inilials in Met column. PI.ace v in box by interventions approprIate to patient Write in additional intelVentions <G needed in blank spaces.
OUTCOMES
Mel
Unmet
Outcome 00al51
Skin Integrity is maintained . Patient$ at risk are Identified and Interventions initiated.
Prec:hBcked items <Ire mitiat8d for All pallfml-s.
Skin Integrity plan fer 1111 patients [if Complete Bradltn Scale on admission, 1f1en daily. !if Asse~ skin upon admission and every shift, especially bony prominences
and skin folds.
~ Record any reClnG(;-slhat M{!~ Mt disappear wlihin 30 minutes or any break in skin integrity,
[If Reposilion at least every 2 houts.
~ Apply IOlion Immedia1elf after bathing. Use moisturizing cream lor drl'skin.
I!?f Avoid massaging over bony promlf1ences and discolored/hyperemic areas,

/i1Keep bed clean, dry, and free of wrinkles.
It'!' Remove anliembolism t1Ose, seqlJential stockings, and heel plOtectors every sl1ift lor 30 minutes to I'IS:5ltSS legs, feel, and heels.
fi1 Minimize skin Elxposur~ to ffl!'JlstUl'e from incOhtinence, perspiration. or wound drainage,
!i1 EstabliSh a bowel and bladdel program by assisting the patient 10 the bat/lroom or bedside commode every two hours, unless
contrainctkaled.
Shill cleansing at time of soiling with perineal cleanser with mInlmai friction and apply protective barrier cream
fi5 limIt llOO of aQhesive products on thin, fmglle skin and apply skin sleeves PRN. !If FlOi'll heels oft bed with pillows placed under the length of the lowar legs, activate heel slispension on Total Care Bed (fCU), and/or
l
!
application of heel protectors
fi?f
Inst/utt patienl and family on causejj and prevention of skin breakdown, sources of pressure, friction, (lnd shearing. Recora on Pallenl EdUcation Form
Skin Integrity plan tor "At Ai$k" popillations. Brillden score 1U or less
o o
Place orange sign (PUP) on the door 01 room indicating patient j~ high risk tor skin breakdown.
Iniliate IndMdualize<l turning schedule minimum of every ~ hoUls In Wdl every I hour in chair. Consider llse of pressure relieving cushion.
o Position patienr in a 30 degree lateral pol.lltlon lind avoid positioning directly on trochanter. o Consider use of Ulting devices to move and reposition patient such as lilt sheets, trapeze. am:! Air Pal to preven( triction and shear.
Maintain he8d at bed at Ihe lowest degree at elevation consistent with Use pmows/wedges to
medical condition.
P"d bony prominences from direct presswe, especiaUy between knees.
o Consider use of urinary Qr fecal collection device to contain urine or stool. Limit use ot diapers, o Supportsurlace per woe NUlSe Specialist ___________________._________________ o NutrlUon consuff entered,
Other'nterventlons ________________________________________________________________
~------------------PATtENT LABEL
O~SSM
HI!AllH CliRi
DEPAUL HEALTH CENTER MARCH,PHlLLrp
1111111111111.
MED
INTEROISCIPUNARV CARE PATHWAYS" GENERIC
0727400691
0524~Ol
rip
10/02/1976 31Y
M 10/02/07
r-.fELMVERJ:, SONIA N 000'148298

DPM'100iJ-O~J4
(5!2000} PAGE B OF B COPYRIGHT 1997 SSM HEALTH CARE
000095
INTERDISCIPLINARY PATIENT/FAMILY EDUCATION RECORD

INITIAL. ASSESSMENT
.r:r None
~
Ph,.JSlea' BarrIers to Learning: CJ Vls!Qn CJ Hearing
0 Language
0 Difficutly Reading (explain) _, _ _ _ _ _ _ _ _ _ _ _ _ _ 0 Wri1ing {explain} _ _ _ _ _ _ _ _ _ _ __ 0 Development level requiring intelVention (explain) _ _ _ _ _ __
o Other
..E"rNone
Barriers 10 Learning: 0 Anxiety 0 Anger 0 Denia.l SIlWtual Barriers to Learning:
E~tfon8r
0 Depression
0 Olher
0 Confusion
0 Other _ _ _ _ _.
Grief
0 Guilt
0 Lack 01 hope
_~
_ _ _. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
0 Caregiver 0 Other _ _ _~_ _ _ _ __
Barriers to Compliance: None 0 Meal preparation 0 Transportation
0 Financial
Re'!iloU3 and/or Cultural Burrlers, to Learning:

..erNone
1.
0 Ye~ Explain _ _
Wh~ is the easiest way for you to learn? Reading 0 Listening ..erl)emonstratlon 0 Other _ _ _ _ _ _ _ _ _ _ _ __
0 Pictures
2. W~ are your learning needs at ~ time?
.tl Disease process
0 Diet Community resources 0 Rehabilitation Who should we involve in your teaching process?
o Use of equipment
nMedications
o Other __,_ _
o Pre/Post-op teaching
~1I0W-UP treatment
Ar:tivity/Exllrcis8
Admission Advanced dlrectjve~ Comm. (~sources {}Iagnostlc te$1$ Dmf/NPQ Disease managemerrl
Disease process
Disr.narge Information Dressings fall prevenhon Foflow-up c.are
Home care services

Incenliv!> spirometry Infant careifeedlng
Medications
Ml]nitors
Post JIllrtum teaching Pre-op teaching
SignSfSx Smoking Cessallon
Treatments
Wound (.are
IsolatiOn precautroos
IV~lnjr.r,tions
Mouth care Oulpatient programs
Pain fH1H120ement
Plan of oaTIl Post-op le3ciling
PSyCh!lsocial needs ReslIllfllls Risk ractors

Room orientation Safety
Social wvlce
Spiritual needs
Surgery
TCDIl Te(ls
Foley
FOrx!fDrug 1f1101acliofls
Labor mamlQemenl MDf
RtaCfin688: (1) S!ahl$ re-ady (.2) R&qlfflsIs delay (3) Conlulled (<ll Sedated (5) Cognitive inabilIty (6) Ll1l11rn.r: PT = PaMn! P = Parent F Fathat D = Daughter(s) 0 ~ Others M", MOlher SP '" SpoLJ~e S Son(s) MlJlllod: A _ Audicl'l>6uaJ D = Demonstration E = Explanation C Group ClasS H=H<lndoul T=TelephonelExplanatiOn
erIOSSM DePaul Health Center

He"LT"'~1\N"
DEl?AUI" H.I:;ALTH CENTER
r>iARCH, PHILLIP
IIUlllIHllffllflllllIB
I/f'
INTERDISCIPLINARY PATIENT/FAMLLY EDUCATION RECORD

OPM-10COQ60 (1212004) FRONT
RAHM.~, AN'I'lER Z
0727400691 MEO 0524-01 10/02/1976 3lY M 10/02/07

000'74829B
000096
INTERDISCIPUNARY PATIENT/FAMILY EDUCATION RECORD

POTENTIAL TEACHING TOPICS
ACllvity/fxflrclsf Admission Advanced dir&Ctlves Comm. resources Oiagnostic teslS DieVNPO Disea~ man.'I!)6menl Disease proc.8SS Discharge inlormation Dressings Fan prevenlion FOllow-lip care foley fOOdlDrll\llntaractions Home care SfJrvlCBS Incentivit liplrome")! Iman! can~lFeedlng Isolation precautions IV'slinjecliollS Labor mana'Jllment MOl Medications Monitors 1'ost parium teaching Pre-op teachiTllJ Psychosocial needs Restraints Risk factors Room onerllalkm Safety SignslSx Treatments
Mouth Cllre
Oulpatient programs Pain management Plan of care Postop teacl1ing
Date
SllI1lslure f Tille
,~
l:
Teacll!ng Content I DiSCharge Pans (May place slicker here)
D_
SOGi1!iaCfviGv
Spiritual needs Surgery TeDa
Smoking Cessalk1n
Woond ,are
Tens
Present? Yes or No
Family
OUTCOME -~~-f;
.!llll/Ill
_iva
IJJ-J
'r},.'l/ j
7/ 1/
A'lti..J / /
I
.&~..dN~ .JuL
Ir
Ip
VtJ
1-
r-----+-----------;--1-------------~--------------------------r__+--------~~----~----r_--_;,
Readin$s: (1) States ready (2) ReQUests delay (3) Confu~EKJ (4) Sedated (5) COgnitive Inability (H) Refused (7) Already knowledgtlahle leamer: PT" Patient P ~ Parent F", Father D" Daugtller(s} 0 = OIDers M = Mother SP = Spouse S = Son(s) Method: A = A\Jdlovi~l.I111 l)" Demoostratlon E = Explanation C" Group Clast; H=Handout T=TelephOnelExplanatlOn
~$~lrf-
DEPAUL HEAI,TH CENTER MARCH, PIUT,T.1P T/ P 0727400691 ~rnD 0524-01 10/02/1976 31 y l'1 10/02/0 'I
RAHt4AN.~iER
IWIIIIIIIIIIIIIII
Z
INTf:JmrSCJPLINARY PATLEN'I'lFAMlLY EDUCATION RECORD

DPM1000-060 (1212OC'4) BACK
000748298
000097
r----~---~~--------------------
1 - - - , - - - - - - - - - - - - - - - - - - - - - -special Instructions:
SCHEDULED MKDICATlON ORDERS

Fr@qu~ncy
...
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DOB: 10/02/76
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10/08/07 00:00 to 10/08/07 23:59
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Printed: 10/0'1/0'1 22:00
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0J~;'-e'::::r""-I>-Q-e-~eS-from:
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Medioation Administration Record

PrHttut:l: Hl/fl7/07 ~d:i}U
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bXXI)::;E'TON. HO
------------------------------
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~2:00
10/07/07 00: 00 to 10/07/07 23: 59
---------------------
Page: 1 (mQn mads follow ...
000101
,"
spvc1al-Instructions,
orrllJ'Ti:;t,an.
'<5 ..T. 1I1j(lq
1400
DC1UWULIID MEDICATION ORDBRS
(cont.)
k "
---------------01H = 15JO
1400
c,top
~~lejCOmm_en __ t_$_______+_F_r" __ :',JW~!WY

SODIUM C'IiW1UDE RACT 0.9'"
NURHlIL. SALINE
[IV)
0000-U7.10
lIGOO
1531 2)59
lNJE'.;I'lON
QIII{
FRENCH -
~ML
Q12HR6
5 FRbrlCH
5MT. QllliRS
MEDtCAT10~$
lOML APr8R
AND IVpaq TF
C01'll'lNUOV8 FLLI.lU Hi NOT RUNNING
---,-,
Codes
1JJ '" Lt. 0,0 RU _ Rt. U .0. l-iT RT
'='
Lt. 'Thl4h Rl ThirJh
RUle ., I<'t. Up""" Abd Wi\ .. 1,[ Upper A.bd.
"LA
we.
HLiI = HI
0524-01 MARCH, PHILLIP
l~lAA
Vel'jflerl lly'
f.,fiJi- K
1.)0El:
10/02/76
Age:
- - - ; - - - - 1 AOOO?'! 9290
31Y Sex: 14 Adm; 10/02/07 Dr, ~'1ELAAVERI, SOlHA N
Allergiesl m:A Medication

AdminiBtr~tion
19,_~/J 1 ::15 :~
DePa~l
Health Center
Record
PllnLf:-'lt rO/Of/o-, 2Z.rn)
10/07/07 00100 to 10/07/07 23:59
Fa~el
2 (more medB follow.,.
000102
r-- '-~----------~-ON-S-CH-KD-UL-ED-MRllICATION I-speci-;l-r truct ion~

OJ:! I
.-~-
ORDERS
(cont.)
" ...... .-
, Ordll -~IR
St.art. ' Stop

lo/o:!
GiGO
Drug/Do8e/Rout~/CommQnt~
-..
ACh'YAN1NOPHEN 325 to.J TADLIIT
,G
FLK
loose,
TYLENOL 325MG l'i\B!"!::'!'
650 MGf 2 TABLET
for /f,ild pain or fever gre.Jter
~,/
1:")11
{,.:A f3
than
lOl,~r'
._ ..
y.~iO,S ML
_.
I F'LK
--;;-:;-:;-1--('i 'J~J t"

2200
-B
10/02 OJ()O
InrBRN'HYOflAt1TNF: !N,TECTION BIlNADRYL S<JKG/1M[. VTA1, F.QlJTV
---\-\-,-f\.Lf~"---.-+----+-1 VOl? ~"Ol(~,D,)lj lH'if)R"-.,, r ' " "L MP _. ! D1LAIJ1HD It..r:;/lML
I
I i
I
I
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- ''''
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Do ! 25 !
I IH\ f)ROCOI~)!,~/f',PI\P
ic ~ (JOl>r~.v
1 1 Al;l .Ad.,bT
.,
.,
\JTr(1:i1/l1 "!~Om(f.i TlUl WUIV ase, 1 T~/l TABLET 't
{ORAL)
I" """
q6hprn
,'von,
I
ht~P
IJEC.'TIOH
P.QUTV
l Mg/l ML
I IV)
}\JI~L
I I
I 1
fi-..W
II
GTU,rrF: J{YOROMORPHf)HE 1101<:; IN
NOR.~1AL SALINE
I'VSH SLI.ML,'f OV",R 1 M!NlJ'l'll RE.i\BSESS IN 10-10, ~lHJ\lrl'S 10' M~J)TTTON"', [)()'~E IS NEEDED
Lt, (I,Q, LT Lt.. Thigh LV RU = Rt, [I.U. J<l - In.. Thi<;rh LLA - Lt Rill, = Rt. Uppe,' Abd.
~
S.Lt.t.: Code's
LA
RA
[,t
Ann
Rt , Arm
LUll = r,t
llpp" ,
/lId,
RLlI
LOwe I' IU)d
Rt, LO'o'e ( AbO,
I
- - - - - - - -... - J - - - + - _ . - - - - -
0524-01 SN MARCH,PHILLIP
DOB, ]0/0;>'/7(:'
i'\0727400691
/''f''';
IM;iJ(
v.-;rified bY,.)2,IJt.J\-,
~H J---""......,f"'\-.\-----
---11',000748298
31Y Sex: M Adm: 10/02/-07 Ill" t1l>~L.KAVERI, sarHA 1'1
\Q.;\op-l ,l!?:_~
BR IJX;t;T()N, W)
--l A~,le_r_q_i_e_ii_I_NKA
_ _ _ _ _ _ _ _ _-:-_ _ __
Covers Doses from:

10/07/07 00:00 t~ 10/07/07 23:59

Pr~nted:
1Q/06/07 22:00
<En~
page. 3
f MAR
000103
----------------------------10
.G
. . -.------------------------~----------------------------~ "'''* ft_ SCHEDULED ~IEDICATrON ORDERS w ......
i 10/02
0900
'CLARIFY PENICILLIN
TABLET
frequency IlOO[i-G7}IJ I Q7H-l~~'J l:;Jl;lJS? -----~~--------~----------------~I'------------------+--------------~

'C1J\K I'MO
[ ____ I
[OI\AL]
* . . "".~~.'* .... ~ ,."'.*
PATIENTS Oh'N'SUPPLY '"" ........ " .......... "".
r:}rtc,} y flOhf: ana f !P.qUt:':llCy
C.-:!;:::.=---T--1l.D--r.--!lT------------+D::cA-:I-:L-:Y=----+----------t--~900\"":).-~;..A -q-Q-!-b- t -j.-:-C"':/-:0-:-J-+----l-:-l\1:-:.1W:-::::D:-:I:-:P:-:IC":N--E-_::CAD Vf,r: (}!;l)U NJI'VASC ,)MG TAB SQUIll rO&lU.l
+TTT .. ++++++++++ ....... ++++
, r
Dase, !i MGll TABLIIT
oOli-"lOIo:)~---+J>,J,-M-O-X-:r-C-:r-LL-n-I .. -C-Ll\:-VULlIN1'I---T3--8-7-S-MC---T-iii.~
...
.. ..---:::--:---::--::::-:-+----------1 Order On Hold +t-+'t'+++++++++'i-+
CS
l'Llt
0700
10/04
1[100
AUGMBNTIN 875 TABUBT EQU

Dose, 675 He/I TABLIIT
11101
.3:'",
[OKU.1
---+-........,.~+--,----t-,------,----
oon
P!'\J.
AZTREONAN(AZACTAM) 2 GM
~U!.!WM CL
- -- .....
\l.9\c MIl+ 100 ML

M~outen
1000/).'-
Infuse Over. 30
F:efrigere.te 1 n! 04
lQnO
11/ O-:l-l'=C'LccclccNOcc':-IM-,Y-l-'l-t-H:-.C-'L-t,-Y)-C-l-Ncc)--,-f)-Ij-~-V.J-:-I'71b-:-'-~-"L-------t-:-=--------f--- ------If--:l-l-Q-Q------------+---1 '1,)0"'"

?1~~ SODlt.~i
CHWRIDE O.Y'
j(t
111>
--_ .... '''1t----II---,

oon
Jo/J~
t:!:)
,'L,Y,
')(;]0
._----J;])
-I11 rJjfl?
"':IOC
~::~('~~ !~7~ ~:L:;'l1V

IPNE!ll'fX\,;{:CfU, '!t\ccrN!! !'0LYVNA,N
1P;;HOTP)1IW
lnfu,,~
over: 30 ldnutea
:-'0
Kef:r19 8Jd t.e
W~
TA1H.if ------------t-----;--
...
1_ _ _ '
CAG
"'~A,\
Iooee:
GIVF. ON l)iI Y , OR
Nr nrSCHARGE
I'NliL\'YYlY)C(;A.L, VA(.'CINE HAS BElrl'l ORDERI>D 1'0 Ill'. GTVR ON D/IY 3 OR AT Vl;;L.'HAAU~ a'
/
0007 10/02
'..'oQ\'
[lEFOR!! DAY ). VACCINE OOS'I':S "'R1'l IN THR I1EDICATION RlZl'IUGllP.ATQR, PLEASE FILL ()(fl' '),Hb! CHAXGI$ SHEET WH8N GIVlil'/.
SODIUM C'HLOlIrng RAC1' 0, 9~

NORr-IAL SAL nH!I
Hl.TPr.TION
OBH
1400
I "ur
cr.G
ose,
zml NS EveLY II
/{Ol'n.
[Ivl
nul"""
MedL'>ato1l9 A<'e Given Then 2m1 Be Con' Md ;,iter' ~ledication Administration
Site
LU
~
codes
RA.
LLA Lt
--~I
LJ\ ..
~
I
i
0.0
RU - i~'C. U.t~. XI:A .. Rt Upp.. r
1.1' Lt. Tr,igh RT - Rt. -:!'t!lqh

Abd.
Lt. Al~fT\ HI. lU'[tI
WI,
L,t.
tipper A.t-d.
e:u . Xl:
L'Jwe r ATxl LOl1e. Abo.
0524-01
~~~----~~~--~MARCH,FHILLI?
5N
Aqe:
A0727400691
31'{
Sex, t1 }I.dm; 10/02/07 MKLK.AVE:RI,SONIA N
1l0H
1 O/O~</76
-----------------~A000748298
Dr,
,MAR V"",fl"d hy'
------------------.--1
Allergin; NKA
Coveru
Oo~e~
from:
Medioation Administration Record

l'rint~;
10/05/(17 "~,QO
m.~s
flRl00RTON, ['10
10(06/07 OOtOO to 10/06/07 23:59
page: 1 (more
follow ...
000104
r-------------~~~~~~~~~~~~~----.-
SCHEDOLlUl MEDICATION ORDBRS
... - - - - - - - - - - - - - - - - - - - ,
(cont:.) ... ",."
~--.--------~------------------------------~--------------------------------------~
Special Inatructions.
ordU Start
, O/()4
140{)
Stop
Drug!Doge./Routtl/commEmt!l
SODIll!<1 CHLORlm: BACT D _" ' N()ll~l"L flAl.TNP. lNJ!K'l'lt)N
[IV)
0000-073~~~_ 0731-1530
QllH
1 'i.ll-Tl;''1
2200
0600
1400
.. LK
luose:
J
~
+'ff
TP
lJ~
,'f(BN(;H
- oM!.. III ~hK::;

~ML
'RFN\'H =
C.;l~IT I
Q8HRS
ANn
rV]lIl~
DHL AF'rF.ll
Ml':!H(~""T(lH<:
Nl.!O'.'D
VLlHD IS NOT f(UNNINC
,
!
I I
. ..
_... -
.' .
Site Codes
LlJ f\U
=
~
Ll.
ll.Q.
J.T
Lt .
~I
Thigh
Thigh
LA ,
RA "
!.JC. Arm
Re. Arm
F;Ul\ -
Inie
Si9 Ild.t !J[t.'
l6Z~ !J.L
I
-~
/\
Signa cure
LUA
/.I.W.....
l/'
~rJ
RT = Rt. u.\). Re. Upper Abd Lt. uppel:' Abo.
I\b\j. LT-A - r.! . TAl RLA _ Rt. La"('r Alx1.
0524-01 5N MARCH,PHILLIP
A07 274()0691
Sl':'.,it : M Adm: .lll/O:!/O I t4i':LKAVERI ,SONIA N
1,H"R
verUied bi
~_~_.
\L1~t-~-+--Cen~er
~!
--
.- DOB:
10/02/76
Age;
31'/
Dr;
-_ ...
._ _ _ _ _
Covers Doses from.
AOO[J748298
_J J.
A_l.
1er 9. ie.9'
IDepaul Healtn
Medication Aaministration Record

23:5~
Printed'
BRIDJE'ION, NO
10/06/07 OOtOO to 10/05/07
i3ge: 2
(mo~e
la/oslO? ;;:;,M mads follow ..
000105
~P.ci"
O,.d~
"A
.........
tlNSCHEDUJ.1ID NEDIC,l\.TION ORDERS
(cont.l
fr." . . . .".
Instructiona:
BtaL'e
1!}fD2
010fl
Stop
DfUgi'Dl.jue!Ro\lrg/l'omm~mtg
\AC1ITIIHINOPHEN " 5 MI, TJ\BLE'l' nJ.. :;.'NOL 32 51>10 TABLSl' !bose: 650 Mel:! TJUlLBT
[Ol:
D t'J..K
(OAAL)
I 1M ,..,"
q4h
ifreCIUC'.Il_C_Y--+_ _1I_U_U_U_-_O_7_J_I1_
!
Onl.- ~~J~
l!i11-:!J!3Y
I
OVll CliO !'l,y,
JJ;')27
mild
p...1.in Of
1 P.II~'L'
greater
cha n 101.5"
::;~t
H/C4
~:iv'J
J),PHI': NHYDRI\HlIll!;
' - -...
_.....- - - - - - - - - ~NJECTlON
I .---+-~---!q6hPl'l1
lAS
tiem I.."1
BF.N "'OR'if. SWoG/IML VlAL EQU1V
Dose: 25 MC/O, 5 ML
[IV)
p "" "'o;-r ' '"!'SL
lH'fDRO 'CODON!::/ AI!Af' S/c'OOMS 1 T1I.B 'I'M\! ,RT V'fl'(lP1N <;/S110WJ '['Ai! b'QUIV
I~~6bpnl
Al.' N"'FI.rlt>ci
Q'jH
I
I
\3;; 7
.
-vY-
71')0
~V
'if
~.
FLK
DOse: 1 Tl<B/l TABLlIT
(ORA.t.)
~"
PAIN
h~";w
;'MORPliON~
INJECT1{)1:
----~----------~
/{p
,: tl.'O
[ITl .AlmlC lw.;/IHL AM\, IiQUlV
All N""dad
",K
iDose:
1 MG/l ML
(Iv1
I
I I
)1 ~,),.
1)1 ~)JTt:: HYDROMORPHONE IMC TN 1 fjf"L
~~
1750 Sf:'
NOllf.lhL S i\L W!'!

PUS H Sl,oWf.V OVER 1 MINU'J'b:
REASSllSS IN
l()
lS MHIIITES IE'
l\IDIJ1'J'LONAL OOSIl 1$ NEEDED_
I
I I
I
!
t---------. L1---"''''====
LU . Lt. V,O,
81 te Codes
LA Lt, Am LT ~ l.t.. Thigh AA~ Rt. Arm RU ~ Ht, D,O. RT RI:.. Thi4h RllA ~ Rt, uppel:' Abd. LLA Lt . T.o'n'er i\bd. RLlI . Rio, LOWCT A.bd. LUll ~ I,l.. lJpper Abct.
Init
0524-01
----------------~MARCH,PHILLI P
5N
Age:
A072740Q691
f-'-t-
iDepaUl Health Center
Mi\R
v!!rified Pi
YB:
~I
-1----1 -
008, 10/02/'{fi A0007'18298
31Y Sex.; I~ 1'..]11\, 10/02/0 7 Or: !1ELAAVERI, SONIA N
lDWrE:'C:OQ:iJ
Allerg:l.olJ: m<:A
~
._i_________~__
~ledl.ea.t1on
Covers Doses from:
Adml.nl.Btrat~on ReCO~d
Pr {J)ted: IV/\Y*.,,/07 ];t ,00
LU~ HX; -rc:'N ,_I-IC_v_ _ _ _ _ __
10/05/07 00:00 tQ 10/06/07 23:59
Pagel
(End of MAR
000106
ft"lt
1----:---::-- -- -Ordll 3ta rt
Spectal Instruetionst
Stop
- .--. - - . - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1
SCHEDULED I"..xIJICATION ORDERS
... "
I.
Drug
y-+___ Q IDo't;c:"/Routci Camlllcn t u ______-+I_f_f_e_. _tl_e_!l_c_ oo_o_fl_-_o_7_3_0_-+___ o_73_1_-_1_5_3_0 __

TABLET
IOlVW]
+-1_ _
1_5_1_1-_"_,1_5_9_-1
1_ _ _ 1
ICLAJ<Il'Y PENICILLIN
eLM l'RZO
! _ _ _l
! ___l
i!Dolle,
'X'JlBl..1n'
clarify dose and frequency
--+----j----+---------------- -- _._._- .AML0D1PINB 5 Me TABLE']'

NQRVASC
5~
TAD EQI.1IV
IDolle. & .U:C/l 'fAa4B'T

, ,
[OIW.I
BID W/HEAL 4'++H i-+ ......... +t .. ttt't Order On Hold
. .... -..- + - - - - j - - - - - - - - - - - - - - - - - - + - - - - - - . __ . _.- ._._-_._lIMOlCI CILL I n- CLJ\VU'L.1.NATl! 87 5 bIG TAELIST
E' I
0022
PSL
10/01
"'+.i--t-t't+t+tti-++
0700
'\
AUGxmrIN 815 'l'MlLl'l' HQU
,. 10/0'1 11/01 1800 : 2H9
!l\zTltEON.AJ.l-{iihCrNl)
SaDIUM CL
Q.9~
2 GH
Q8K
(IV)
~T
100 ML
\\l"'"
~).~<:I-:'>
I
0023
nSL
! 10/04
1900
llioi
2359
'"
II"fUIIO t>ver, 30 Mitlutea r:e(l'igerate

,.!
I
!
ICLINOAMYCHHCLEOCIN) 900 .ra/Ii /IlL

SODIUM CKLORTD3 O. H ,0 ML IIV)
----r~~~DC\
;.1
I
II
-,---~~----+~:--' 13 ___._1 1.'m. "tt\" ~ :)~}Ot.

~
j
C\\
~ I
I I
. ..- - - + - - - 1 - - - + - - - - - - - - - - - - - - - - - 1 - - - - - - 1 , - - - - - - - - + - - - - - - - - - - - - .
~()13
"
ilnfU." Ov"r, J 0 MilluteS

Relrlgerat2
eli
1
OD [J!1jEAL
%' I
l0/02
FilNOTlDINE 20 11 TJ>.J;lLlIT
1'J.;!'ClO 'J<JI1G TAl:l ;,;QULV
rs
I'LK
I
1
llIdO
"Dose:
20
Mell
TABLET
(ORAL]
OO::':i
CA.G '7T
10/0. nqOIl
l'Nf:OMQCOCCAL FDLYVALEN (JrVE ON Dl\Y 3 OR hT DISCHAJ{Gti
VACCINE
PNlW
I "ACT
lOGE
"i'I";
!~
__ l
IIlaue:
[lloS]
I
Q()07
'.,
,'Nt:'JI10(1JC(;AL VACClNE f'.AS BEEN QRDEREDj
:~:EG~~~ ~ll ~~~CiN~R C:;~E~';;:;"7;\'!:1

t~F.DTO"TT()N' RRpR1f:P.R"TOR.
-t----+----+---~
~~
I I
III
rr.FJI.RE F. ILLI 00'1' TlIE CHl<ll.GE SHEET WHEN C I VRJ'i
Iv/U:!
f'hOil
l>\)I>LUM CtiLOXIlJE BAC,,], (). 9\
.... - - - - - - - _ _ : _ - - - - - - + - - - - ----+--------1----------1--,-,-:-:---. -.-.. "...

IN,1EGTIOll OS!!
I _,
II'
DO::~W':'
O(;~J
f'
'qOO
S!\LINE
[IV]
at
?'\1~
I I I 1------+---+------. --~-----+-!
l\:n(l ,'\teel:
lflll /'IS !?very a Hew-s llnle.33 Hedi-cations Al.'e :Jiven Then .lm! be.f~t'"e.
~jedlcatlQn I\d"'~nl"t,.ation
------+,-------.-- ... "
__ l _______
-,~
__. ____________
U.Q
U. Q '
________________
Lt Thiqll - Rt. Thi'.lh
LLh
____
________
S:ee Codes
W~LL
LT
RT
I ....
~
1.1
AflH
Rf) _ R':.
RVI, - Rt,
Vppe l' Alxl.
LUf,
Lt.
vpper Abd.
!(Li1.
I..t..
RA l<t. hoOWer Abd.
AT'"
I<t.
Lower' At-d.
------4J~~~~~~~~~~----~MARCH,PHILLIP
0524-01
5N
A07?7400691
I
!)ex, 11
~1EL"AVERI,
DOS
10/02/76
Age. 3lY
Dr.
l-~------------jAOOU74 8298
Adm. lO!02/ O GONIi'. N
1-----+------------------------4
Allergiesl NKA
Covers Doses from,
________
~--------------~____________________
10/05/07 00:00 tQ 10/05/07
Prj "Cud' 1 a/01/r7 22: 1)0 23;S~ Page: 1_ _ (more rneds follow .. _ ______________ _____ _____ _____ _____ _ _J
000107
I 1,speCial
",
Instructions: ord~ sr.op I.n:ug/Do""'/HOvi,,~ !t;;9ffiffi_~_Il_t_Il~_ _ _ _ _ rl_t_"r_'f:_.r_ll_It'_nl~O~"O10l(i~ SOl.lLU~l CHLORTriF. lJAeT

NOll~IA1.
'
SCIJ:EDULIID MJ:i:UICATION ORDERS
-------07JJE}O
(COtlt _)
o,n
IN>JECT.iON
IORH
II
'060C'
HO(J
SI'.LINE (IV)
~
Pose,
J "R!:NCH
liM!, Q12HRS
~Mt..
S FRENCH -
Q8HRS
lOML l'If'T8R Ml!IJlt:ATIONS liND TVP1l5 Ir.

CONTlNIJOUS FLUTD TS NOT llUN?lING
"-+--I
-" . ----'---." ,~I___-
S.1lt.: Codes
r-- . _.,. IMi'.R V~r'ifi~d
i~ t.~ t+7"C..--.--~~==~-'-=-=-----------~--.~~:~-=1,~-,--S-l.;<J'-rl-<t_t.;.;~-re-:-~----~---+~----~-+I-o':::-~', "''''

..
-l
LlJ:
n,u
RIJA .
Lt U,C' P,t _ U, Q.
LT" Lt 'l'hlgl1 K'l' - Rt: _ Tt. j'll!
fA ~ f " , hrm RA R~ _ h,"lI\

V-1r
Kt.
lipps. Me:1
"'5N
Age;
1M
'u 31Y
"A:::'::'"
Adm: 10/02/07
Re~ord
L~,
Alxl,
,
J
~---~~-------+-."
1 MARCH,PHII~LIP
-----------1-by:
/
I I
,_
- - DOB: 10/02/76
11000740299
8;'1<: M
Dr, MBLY..AVERI, SONIA N
_ _ _ _ _ _ _ _ _-i"'lle,rgiea' NItA
DePaul Health Cent@r
Covers Doses from;
Medication Administration
l'Lint.od: 10/01/07 ?:l ,fin
10/05/07 00;00 tQ 1Q/05/07 23:59
page; 2 (more meda follow ...
000108
,--------------------_.--~s-p--e-c~i-a-l--I-n-B-t-r-~--c-t-i-o-n-B--:--------------Ordff
;3
,G ,'II.'
.~~
UNSCKKDULKD MaDICATION ORDERS (cont./

--~
------------------------------------,
*.~
------~--------------------------~
i
Start
lO/G2
!)l{)()
Stop
Ur-ug/Dose/RolltE!/Comm,mt_"
F! "~l\!<;fl'; Y
QQQQ OnQ
----
on.-l.~JO
f"'-'OO""~ ,., ~ ' ' ,. .

TYLENUL 3Z!'>w.; Ti\BV;-r
GB,
'11h
AB
[ORALI
I
tk~f.'(hx'
l~Jl-<lJ:i~
650 MC/2 TABLET
\
flO11 CAG
to~
ffllld pain Or fever
grell<;;e~-
than Iv1 . ~["
IC/O?
OJ(}C
jliTPHP;NHYf"lRAMlNE
n.x
0027
P;ilL yw<;
IN,JECTrON OENIIDIWL ;C(H-IG/lI-lL 'flU Eoury
qGhprnAs Needed
!IV)
q~hpr~
D1\;:)~
U~S
poee: 45 XQ/O.S ML
10/04 2209
1---JlYDlIOCOtlONlli/APhP
\
VI~QP~1l ~/~QQMG
DOSO:
CH
~~
--
S/SOOMG 1 TAB TABLB'l'
1M!
~~!1!Y
hi
[OUL)
!'Ino;l~
1 TAB/l TABLET FOR PI.TN
---_.
1)0.;1
PLK
10/0,
210/';'
H?
H'(Ul'/'iJXI'll'JNi> H1..'L Uhi \,;Cj'l ON DILIIUDIlJ LHG!L'lL mil ROUT'!
QIH
--~-9J
A.,; NtJ,-,"iL,tl
[IV]
I Cj;',
I:' ()
'-,
Dose: 1 I'.GIl ML
.- '5:6 - - - - ----------ll
at
I
O~Wl'"
HlI.W.oMOKI'H0Nl> lWJ IN H!l1L
NOFJ1i\L fil\l,IN?;
,'(i~ C\~
' \p '-\)
l\J'0rYlJ
~--~-~-- --
1---+--+--- + - - - - - - - - - - - - + - ;.nr>JTJONIU. OOSE IS NEEDED_
"11_'1-'.S ")W'l ,Y OVRll 1 "II N1ITE REASiE5. IN 10 15 1""!'h'l)'TE~ IF
(,
'!
+'
!
I
~---i----J-----~-------------------------~~------r_-LV
-------i-------------L-~--------._4 Sllf~ EodU!:;l O.Q. Lt, Thigh LT LA Lt. Arm KU ~ Kt_ v.U. p-; - Kt. A"f1', ringr, Iff = Rt i.l]\ "" Lr.. Lv.}'....''P.l ,I\.bd. RUi\ = He _ Upp"''- l\ixl RL.1>, ~ Rt _ [A''''':;) Al;>t;l LUll = L,t. r)pP';l' PM.
=
__
Lt.
5N
Age;
A07274006:Jl
MAR Verifiert by:
3lY Sex;~! Adm; 10/02/C'7 Dr; MELAAVER I, SON!'!>. N
D8Pa~1
Health Center 10/05(07 00:00 to 10/05/07 23:59
Medication AdminiBtration Record

i'Tinted, 10/04/07
no
Page; 3 (End of MAR
000109
SCHEDULED MEDICATION ORDERD
Sp';~ial Instrl,ll;tions:
Oraij r $ta.l:'t
w.o.0731.-15JO
.
[ - - -I
)
------1
lql-~~
Stop
D~l\-'J-:/-oo-ge--;iF.-,o-u-t-e-{7'/c-'o-,,-,n'!p.qtg.
'\~lO;O-2-+---j-'CL1UtIl"I'
;; 0900
Fre.quency
0000'013 o
PENICILLIN
TABLE'!'
TARL1!T
"c:x...'\R
lltAl.)
1'1lEQ
I- l ..
r_ _ _ l
.,.. ......... '"'" .. ,..0-
IDose 1
I OOiT'
1>015
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l"LK
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rf\'f
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+ ...
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;;r"'''
l'hTI E'N'l'S OWN SUPPl.t'l
""'" tency
DlIn.
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MOQ
10/03
NORV1I!1C' 5MG l'M BOVIV Dose I 5 MO/l 'l'Aa"1n'
(ORAL]
11>/03
CS
PU
0700
--+I\MO---X-I-C-Ij.-j.-I-H---C-I,AvtJLAW\'1'R 815 MQ l'MLl!:I' lI.UwmNTIN 875 TABLJIT !!QV

Dose, 8'15 MGil TAIII..IIT
M{J
itD W!MEAI..
.++++++++++++
C\f I t+++
I
I
Ortler 0.. Hold
... +t-t-t-+-++-t ++t++
1>
fORAL]
R/MEAL
. (Hill
I l')/U;':
~lSv
r ."
I
I
FAM01:IDINli: JIJ
TIIRT,F:T !ORl\L)
0630
%30
"lr
ijwJ
1'l>I'CID 20M(; TAB EQUIV Dose: 20 Nell TABI..ST
vl)l'J ", 10/0."]1(;('8 CS 11~or, 2)S)
iP1H;RACILL1N/TIIZO !'PO J 375 GMf~Q ~1L
I'
'(11;
~:
I 03G.
~I
LC
Itnfu.", ov.r;~~~ll,I.I;Ji:Il'---~t""--., ~ "efl.e
fez
IDO:~'~
I
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VACCINB P0LVI\LEN
,l 'll<
t
I
r" Ith
[fPI
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I
0600
i 01
I
I_ _ _1
LiOU
1900 235']-
CH
Oh r.A1
Ar
[)f!WHAIlCE
[UI!
, PNEU
I
I
I
I
f
I J~f ):':-:-;'0702l~l}lm"
I
i
.
Pl\'Elilt:x:nro.L VAO:nm RA!; HERN OlH>l"RED T', Ill': GIVE '.IN VAY J t'K 111' DT>;<:HARGE 1 F RFFDP" C,~y ). VA'}'.:lNE !X;SF'}; NUl IN THh Io1I:PIGl,110N I-!EFRH~"PlnOll Pr,W,SE nLL
)V! THO: CHMIel': SHITET WilEN
!
'
I
I
I
HOD
Ch1
I ('0,)0 I
"'LX
NOR.'l.~
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<J.n
nl.TF.r-r-TO-'N-~-tI-O-f.l-H----jl)~60w\l------lll
rJ:vl
IJ. VISN.
Dolle:
I'm i.
Nt;
EVer}~
a-
HOurs Un I t~HS
14cdica(ions Are (Jiven 'I'll!!" ~ml Detore l'Jld After Medicatil)1l Administration
KCI
]00
--<J-lo"-'.'-"",,--=_f_. I
L
Site Codes
: CH
U
I jtf,L/<:' I .,
Lt.
"''''"u,;- . - =--1 ('itt d~lt:\

----- ---~---~.
J
~ -'
\ I
'U '. Lt v.Q. LT R!), I)", 1rt' RUA kt. npl',:r N:x1
i".
Thi'Jb
Thlgb LLA Lt.
LA
ftc
Y.f>.
U:IWP.l
RI ..
At~d
p'nr
um - u
"p,e,-
'<'---':'~
Age;
J ,OWl.' r
Abd.
/7Jp.) MN/ verifie:!J by, ;;/'"
1= 1-.--------'--'---
0524 -01 5N - - " MARCH,PHILLIP

DOB: 10/02/76
AO'!:d740069l
J.IY Rp.x! M
A'JIn:
10/02/07
AO(l!)74B298
Dr:
/1hLKAVERI, SONIA N
Allergies! NKA
, DePaul Heal th Center
""<-=---";=-=--=--==--r'/W
.d!Mi3.;;'; ,./ ~.
Covers DQs;T"from:
----j
Medication Administratiort Record

Pr ;"ted, lr</OJ/O'l J:.I,UO
RRI[(;ETQN. NO
-------------------
10/04/07 00:00 to 10/04/07 23:59
Page: 1 (more meds follow,. ,
000110
~__~_~__________~______________________UN __S_CH __ED ____ ULED
MEDICATION ORDERS {coot.}
* 1H-2J9
~:-r~---,~--,-----~-'--~--~------
special Instructions: . 9nit S~"n St;\iP grugiIlo5e/tioutr./Cnmmr:llt:J
I
I
I frequency
[ORAL)
0000-07]0
10/02 0100
0,)11
10102
03'::V)
f
f
'~RTAHTNOPllRN
12~ ~l'} TAllLIIT
TYLW()L J15r~G TADLET 110: 650 KG/~ TAeLlIT
Iq4h
As Needed
tor If I I I rJ fk1 1 n thzm 101 511
01
(ever greilter
::;AG
!"LX
Iff.
DfPHENHWI'.AJ1.LNli WJh'GI'lDN tlt;NAllRYl.. 50HGilHL VIlIL f.QllTV Dose: 25 Me/o.5 ML
q6hFrn
As Heeded
(IV]
~T
12W)
/If! /lJ1?
Q4H
OOH
10/03
~100
Ml' YLK
KYOROMORPHONE MeL INJlSCTIOl'l DIWtUDID lMGilblli AMF IlQUIV

OOB&I
All N@f!d@d
(lit)
Cf.l
1 KG/l HI.
DJ-MJ
\::-{
\036
(11
m I i.IT!>
~/)RMAL
HYDROI'lOR?HONE IMC HI lOt4L
~jl ~/$b
SALIm;; PUSH SLQWI.t1 \NI>K 1 MINUTE Ry..,,<;SESS IN 10 -Pi MTNIITRS T I" AnnrTrONAL f'>..')SB IS NEEDED.
--~--------------~--------------+------------
Sit.e Codes
LU" Lt. U.Q. KV" l<t. V.Q.
RUI\ Rt. UPI""
Ul' RT I<l>d.
Lt. Thl';lh Rt. T!1i"h

LLA Lt.
l...'> = Lt
Ill'. - PI wYler hlJd
If-,[
_I-,-n_i-'-_t:~~~~~~~~:i_9~1"~
___ tU_l_'e __ - -_-_-_-_
---i-'::=C':-h"'T"--~-'-c=---~Jl:.L+'~~<Ci!~:i!~~---------l
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Lt. UPPN' AbcL
RLA
Rt. L.:l~I' i'JXl
0 5 2" _ 0 1
5N
A 07274006 91
-11
I MARCH, PHILLIP
-------j-C-----....J_
I
I
!
- . WlJ.l ve l' i f i ed by:
/lJttJ
DOB: lO/02/76 A000749298

NKA
Ay'~:
31Y Sex: t4 Adm: 10/02/0711 Dr; MELKAVCRI.SONIA N
___-,-______--; All&rgies,
IDePaul
[ tlkHXJt:iF.iN, NO
Medic~~iQn Admini8t~~tion Reco~d

Pnn~ed
10/0J /<)7
10/04/07 00:00 to 10/04/07 23;59
~age: 2 (End of MAR

. . -------
QO
000111
ft . . . . .
SCHEDULED MEDICATION ORDBRS

Frequ@ncy
Special Instructions:
0~dfl
'-..
'-"
gt~yt
~t~p
Drug/DuUfl./JlOutl'!/Comment
'.CLARlri
Dose I
I~
1{J/02
O!JOO
.G
.. -------~-+-----4-------+P!!nClt.t.:m TABLI'l' I - - -) I- - -) I
_ _ o.
JOOO=07)0
I
I
.-
0731-1530
{ 1
1 TAlII.Jrl'
[Ol'.ALl
".""Ji' .... ~ .... t .. *-. ......
I jPATIENTS
CMN SUPPl.Y
c::'cl1,Hy .;toss and I't'equency
-0-0-1-'- -1"O-/-O-1-+---!-~ir7CILLIN- CLAVULl\.tIA"'TE--5-7-5-MG-T-I\.il-Lln'---+jj-"-J;l-W-'(:-~-"--+"-"-+-+-"-"+~+-+-+-+-+-+-+.. -++-4+.-+... -.--o-r-=-de-r-o-,, 'Hold

C'S TLIC
0700
AUGMRNTTW 975 TABLP:'T EQU
P__50;
10/02
O~:jo
97 5
I'! ~(l TAllLll'l' _ _ _ _ _ _I_ORAL~_I_t_~:-----t:__._--_ri-.:.,r . _ _ _ _ _ ..

a
KG TAIIIJn'
OOD
CS
P'l\)IO'l'YD.'tNl!! J
on
l1(MEAL
P!N!'I'!i ! OW: 'I'M! P.el'JTV
()
ILl<:
10/02 1900
-t,D_'O_B_e_:_2_0_MG_I_l.,...-T._~_LlIT-:-_ _...,--,-_.,--{_O_RAL __ 1 +-:-----1-:---..

10/08
2J59
(IV)
PIPEl\AClLLm!T1u;o /B:lO J.J7S
~/sO
"t..,,"
XL
Q 6 HOlJRS
0600
Infu5e Ove!:' , )0 Minutes
tf
1200
----\----
1 RefrigeratE! ; - - - , - - - .....
0012
r-.NJ
K
PQn,
!
1
qIVE
on
DAY 'l OR AT D1:SClI.r.RGI!

(lMJ
i lNKO VJ\C i
(~~..... J
PNI'J.J110r.OCCIIL VI\CC1NJ,; HAS tlliliN OKUERED/ TO B8 C f VF. ON n~ Y 1 OR "T DISC'HJl.Ht;1:: BEFORE DAY }. VACC'NE OOSE'.5 P$J7, 11'1 THY-I MBt>l':A'l'lON x),;,',UGERATOR. F:'llA$!l I'lLLI "lIT nil': CHlU,GE SHEET hhL'N iJ!VU{.
Ifj
I
000'1 CliO
V'Ll(
---c-..l---isQ.~l\114 ~'HWRIDIl
I
NORMAL. SALINII
llA<'T O.
INJ1lC'l'ION
! QSH
,
LA = U
RA
r~t-
l'\ffH
f!~rm
Lt. In.~..E~gnatu[c
T--' .----...
.
w''''~r
1.1x\ .
Lower AtKl.
I
NAll Verified
SN
DOE; :;'0/02/,6 . - - - - - - 1 - - - - 4 - - - - - - - - - - - - - - - 1 ' l'.oon48 2 >lS
Aye:
A0727400691
by >;I
f"f~.JUW~
Ai
)lY Sex, M Adm, 10/02/07 Dr: NELKAVERI,SONTI\ N
L.-:i! ,
Allergies: NKA
IOI.3!~
BR1VGl!.TI.lH. ~KJ
Medication Administration Reoord

Printed: lu/u3/!)1 ;12,.)0
10/03/07 00:00 to 10/03/07 23:59
Fagel 1 (more meds follow ..
000112
Special
Ord#
,G
I'Ll':
""
.......
UNSCltEDULED MlWICATION ORDl!RS
(cent.)
Instructions;
9Eai:t
" lo/o2
Gto~_
D!'UlJ/Dos(l/I(Qut@fcomment!l
ACBTl\MINOPKEIl 32S KG T1.llLB'I'
,
FrequenGY
q"h
QO~Q'
on_ 0
!l7Jl-1510
1531 2359
,---
0100
TYLBNOL 32SMC TABLET 01;'" 650 MG!2 TABl.1rr

for fI\i H1 pa.l.O than 1~q ,,~
As needed
[ORAL)
0QiL
CAG
I'LX
~ 1-'10/02 0)00
or tever g:re.at er
q~bp=
Il'IlENHYPlWiIINIS
DOlle:
INJBCTii:m aBADRYL 50HG/lML VIAL SOOIV

35 IIC/!)'5 KL
[IV)
Ae.t:::tei!.:;,
,::\.,1 ,-lot)
All ~rl!l!d@d
~yto';
.0'--,
OoU-6
CAG
I'Ll(
E
I
'I
'OJ. 0 Ii
o.t'
~ ~
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,
v~
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"
.I
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(f/'"
{IV}
j", .;H)
~J..J#-
jty.
1PJ/d'It /h'd ///!j.
1;/
_u.
LIJ _ Lt, U, Q.
Site
codes
LA , Lt,
1\('"
LT - Lt. 'l'high
-+=-,'
IMM
VL'T' f I p.d by:
lnit
Signature
tnit
_
Sjgnatu_r_e_...-_ _ _-t-____
RV - Rt. U.O. RT = HI. Thigh RA = Rt, ~Jm RUi\ ~ Kt. upper Alxi, LLl> ~ Lt,. Lcr",er AbO. HJII ~ LL Upper 1IlxI. R!.II ~ Rt. 1,\""",r hbd.
_ _ _ _ _--j
~~''f''\...rJ-(
'\.
---+----cb'"t/-IT-
/,
!) -;-;- , .' - t" M --------
0524-0l
MARCH, PHILLIP
00&: 10/{)')/76
5N
Age: )lY
A072740069l
S,:",
Adm;
10/02/07
l;AWffill)j(1-'
-
i,iLL..
A0007482913
Dr; MELIC"NERI, SON III N
Allergi.e1\!; NKA
.1QjP7
10/03/07 00,00 to 10/03/07 23;59
1::,:~::",Healtn C~nter
! ARHX1ETON: ."10 _ _ _ _ _ _ _ _ __
000113
. . . . . 011
SCimDULBD MEOICl\TION ORDERS
Special Instructions: Ord# Otar1: Sr.<;>p Drug/DoseiRaule/comments
Freq"<;'n,,'y
"CLAR PRBQ !Ol!J\I.)
0000- Q7JO
G731-1530
[___1
l'i31-2J'3'.i
:0
.JO
10/02
.CLAJUl'Y Pl!NIcrLLYN
TABLET
I ogee
ue: 1 TAllLIIT
---
r- f_ _ _ !
1 - - -1
_ _ _I 1r* * ............ ~ .... ,,\y.
!_ _ _ I
PATTRNrS OWN SUPPLY ...................... it.;-j-'j.-':ti
clarify
QOO~
do~e
and h'equency
2TIH&S/DA~ +++~
CAG
I'Ll':
10/02 0900
lO/QS
235~
875 MG TABLBT AUGMBh'TIN 875 TABLET BQU

[OR1lLj
XLCILLIN-CLA~Ta
On HQld ++++
++++
On Hold
+++~
+~.+
on Rold +++
O(}(}S
CAG
10/02
0600
I Q 6 HOURS
I.
nOB~:
O~r
{IV)
.:'H>l
o~~
I
!
ltJ
-WC 2 m -
MI..~diC';:Ition.s
\O/~'~-+---+:.J..>
NS Ev.ety C iIOurs Vl1iess Are Ol.ven 'fnen ~ml Bf:Lll'''f\dmlI'IJ:;l j~lt
1-'"
And After Medication
10:;
---
----
ZJ.L'JI
------------+-~';,' f<::'(j) , .:LV "4)/r'r>
{(ji
1 to':':'r
')'1 ~\,
J'-
----------------f-----i
I I
l
UJ ... U .. 'I Q u1' Rl1 = Rt. U .0, RT [lUA - Rt. Uppe~' Alx\,
Sit_" CooeD - Lt,. Thigh

=
LA
Lt. Arm
An"
)<!:_
Tr.igl1
LLi\ ~ l.L
R/\. ql
Tuwcr A.bd,
l_n*-H. ..' _gJi;~t-\-tr-{!----~_---_-_-_-t- t-'~";:.7~;. , !~:. . .-_t- f="'~";: :!-'J,T<>~1;_q-". ....... na -11'Jt,,~_ ~
\
..
~LUI\ -
l.t,
Jppel J\lid
RI,A =:it
l/;l'<>'er i\Dj
0524 -01
SN
A0727400691
______~~~~~~~~~~~~v~ ______~
MARCH,PHILLIP
DOB, In/0%/76 Ag(;: 3lY Dr; Sex:
~______~/=~~/a='~iU}~~~_0PO_'._'~~~~~:~=====~__
PePaul Health Center Covers Doses from:
M~ VerHie~ l:iY(yl{\6~~ U .
'-~1\I'_
I I
.
..
~l
Adm:
10/02/01
1'\000748298
RAHM.lU~,ANWh!f( ~
AUel:'g1
.s: NKA

fl'inted; 10/01./01 lI,,:tJl
__________~
10(02/07 00: 00 to 10/02/07 23: 59
------~----------------~-
Page; l. (more mads foUQw ...
000114
~s
I
'---------------------------------.~.-.-*~t------~-----------------------------------------------------------------.
"e c ~a 1
UNSCHEDULED MEDICATION ORDERS
(cont.)
--111
urdJl
l'8 ,i'< FLf{
",. .-
Inetru.ctionB'
Start
iO/ .....1. OHl(\
i
Stop
Dr ugJD ogeJRout@(Comm@nr
'L "J25MU TNlL,,"r ITLBNO
Frequency
q4h
1'.:5 Nee.je<j
!OlU\Lj
0000= 07)0
07Jl=lS}O
1531,2355 ... -_. .. .~~. -.~
ACE' fAMHIOl>HEN 325 1<'13 TABL!:!'
Pos e: 65 () MG/2 TABLI':l'

f or mi 1d pain Oz' fever 'Jreacer tlltin 1 01.:;,
...
drtY
0006
CAG
10/07
0100
!Jill( !'HTNR
n.I'
flORPHI NE lOMe/1ML lIMPULE
PO.
l-\.)/-( 1'1'.IN
.: "
HLTRcrTON
I q.ji,----~ As rlUl..~il.'d
0:33.
l;tl
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I
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I I
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I I
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Sice Codes Lt.
RI
"'I
I
I
I
I
I
1
11
LV
91,.1 ""
~.~.
~~ : ~~ -:~~::~
TJA
p
Ilni't'"
Signature
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nt. Uppt'r Ai.>d . UJk - wt. Upper iWd

nUh
R1Jl
~:. ~:~,~.~: --~

A072'7400691
~ = ~~ : :
-_.
I I
~ ~t~ ..
--
l--_ _ _ _
('-"o-='~~/y
.~~
vt;,,-
l.MJhh~(L.
052401 5N MARCH/PHILLIP
--
OOB: 10/02/76
AOOI}74B2911
Age; 31Y
Dr,
5 '-'x, 1-1 Adm: lO/(l;</O'I PJlJ! I<!AN ,A...!i>-iER Z
Allergies: NXA
DePaul HeAlth Center

BRllJGE'l'UN. 1'1)
Covers Doses from,

10/02/07 00100 to 10/02/07 23:59
.. Medic&~ion Administr~tion
Record
Pdntcd' 10/0'/07 02,01 Pa9'e: ::I ('End 0 f MAR
000115
24 HOUn MEDICAL/SURGICAL PATIENT CARE RECORD
OCT 08 2007
DATE STARTED _ _ _ _ __
24 ..
PREVIOUS 24 110: Int~k~ Olltput ISOLARON: 0 Special Contact 0 Contact 0 NeutropenIC 0 Airborn!! 0 Droplet 0 _ _ __ SCALf KEY: 0 Bed 0 Slamliflg 0 W/C94i~\l ,P!f;IER PRECAUTIONS: 0 Salety-Fan 0 Bleeding 0 Aspiration 0 Seizure 0 _ _ _ _ _ __ Yuterday's WI. _ _ _ KG TOOlly'i ~ /NG (rinse recom:ile weight d1fftH&IICe IIqreater than 2.5 k~.~
Far.af;
IIPP"
BRos.de gitltose
-Rating S
61' il'Ul6E REV lffM!'
TIIIi~
Time
!III TIMf IE
fnttj ~
Dr
./~'
~,-,.,
rum .IIESP I ffMP
'IME
Bf
,/",f'
Il'1ll U IlIDITi !MJlA MTHD
//
"/,,
~-
/:.7
es~
" t.kL'II
TYPE
//"
--~
LUNCH I
//'/
a
U
DINNER
lIRlNE
Amount Amount
i TIME
BY
/.-"
~/,,,
TIM
P
STATIC
>~-
.--/
~.
Bf'
rDU~fib
~, OlllOlVa
Fun~jjDn
r--lllcalion Eltlla,lor
f--Uuailly
--'/
//
HlI ~ 'At!(
8HEM FAST
,,, Count i - _ - t - _ - - +_ _t-_A.m !-----------c+-_____ -; ,_ount-+---A--,-,-moun\,-\-A--'-'..ffiOun-,--+i_Am_ounJ f7

;
"""'" --
ORAIJTlIlJf ffEDINGS ORAl. TF FLUSH ..
OTllfR
r-aM
Fr&Qu&nt
'-----
I\moll~t
Amount
Alli~VI\1
Aml.!Frtlq.
Aggr3'1t1
~
""-
18:
S~d~lion
190
;00
110
:
i
I
-'
1230
1300
--~----~----+---r----1---_+---~----~----+--
Intervenl
In ruin
i--.
HOD 1500 1600

-
---
-.
'SfHAV
AN
~Ar
CiiMMi
1HO 18DO
.__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ..
--- --- --- --- --- ---j
Sub
12r"
r(}1aI~
1~ hr Tolal Parenler d .. ___

ToCO(Ini 1900 lOOO
21l1li
i Hr Tnlill i'lrai}iune _ __ .----~---l 12 hr Shilt Intake
1? hI SMt Output
E:= tme I .. h>ef!,
t1-o..,
----+_----~--~----_+----~----~----+_----~--_4-----
e----INTER~
2ZIl.o.
2, Aa<!lt a Guide
1. A~.."
2JCa
0100
C300 .64UU
--~---4----_+----~----4_----~--~~--_4----_+---~----+_----~--~----_+----_+----~----+_----r_
4,
{;gq~
5. E&lab
... --
6. Ene<
7. Ent<l4
~ .~
Patl~ntI
121lr
SuoT~\.lis
- - - - _ _ - - - - _ _ _ _ _ _ _ _ _ _ _ _ 1_
12
Interveo'
--- --- --- --- --- ---j
12m Ma!I'HI'l!!ielli _ _
nr Total OraHllba _ _
12 III ~jllH /IJldk~
r ---,n.",,- , , ... _, IOlal
;--.-
Respom
-
TWfnlyfllUf hour t~tal
FWID EQUIVAlE,rrS: 1 ar ...... 3CmL
4 oz (1/2 cuP) . 120mL (j oz (3/4 cup) " ,180mL
801
(1 GUP) . , 240ml 12 oz (5008-1 call) " 360ml
PATIENT LABEL
o IT't'SSM
H
I[
A \. f
tI}. 1t [.'
DEPAU1., HEALTH CENTER

DPM-1 QOO-()11 (W2007) PAGE 1 OF 6
fo1l\RCH, PHU,LIP II I? 0727400691 MED 0524-01 10/02/1976 31Y M 10/02/07 MELKAVRRI,SONIA N 000746298
IIIIIIIBIIIIIUIOIIIIUIII
~
DPM-100
ti t: ... L ] --<-j
.. ~
000116
17 ~pioo,"1 18 PeA 19 Preemptive
Na
~ Sit
Sit
Sit
/I
;,
APP", lI.Ssllrr.e
pain plC".,cn
Ikhavior>
Tlm~
20 Continuous annlge,slc !IlluSIOil 21 othaf'
~n'!YWI'
flallllll S(;ore.if
~V.f~ l1K~
gr
OllSll\'lIllon funtllon Goal #
Demille: location,
Bellavlor or A'P
Qustlfy
Fre~lIency
A\l\lravallrrl) FIctors
Sedalion bvel
Inlervenliarr(s I
Inili!!&
BEHAVIOR,'RESPONSES:
M
~
Muiliple Aequ ..t
AN =: Anxfoun E = Emo~"n.1
C ~ Conlinuow Crying
I-
DIOI190<; tnil~clivl' I) ~ D\IV;lQpln~n!~llmpa"m~nl
copin9
DE _ aOplon!?/> G ~ GrI!>Vfng
l LethaTQlr:
co. ComMo",
u - (ffln'i\>Q1l5;Ve
co -
CQn1\JuatDi.Qrtinlllll
OP - OillUPlillG
H~ l-/ailu(lI\atiOll./ Oeklli~.
W - Otlflb"!ltGly \VIIhlloldlng
A Mention Soaklflll
OS
"I
~
CI ~ Cognhlve ImpDlmteN R ~ Resile,., o Overstimu!ateofOvEt(&amive
= Oisrupliya
P~II1inl
1m"
Slgnmcant Ot!l~1
1M ImPlllij,'9 S = Sleeping Q R Calml(Mel

CO p
LA
1hrtanlng Physics! Harm/Comb<lU""
= las. An<lo\l.
~ C~p9'&1tv.
INTERVENTIONS: I, fI....urar~b P.t,em! Sf~nrll~~pl

AtOtftCliQ>' QulUlne. 4 ConSiflMI E~v!ronmonl J l1oU1;n~
~.
2~
Olh~'
6. II, 10. 11
12 e-a.1abUsh rn-eintAfned tfmt1'tfRmas for cafe need! 11 it E.ncouraQl+ vorbafil.aHof! 7. fnc-ouf~f' pa,lItJfll with tt-oc&i-o:-n makiHQ for cata naoob
1Ii, pr~yer, m.dicallon 17. Erco(lflll,}" no,rnal.l.ep cycl. by ".mglnlll,act Ilgl\lIog da'" 16. Dar'wn fOom { Umittng touch f 19 OU:ie1liiyn to owruafi6 paHtJltf6 rOOprntS6 to sUlnu.iallorl
Offer IreqlltfTI ~riaf ~ont.~l Prowe intormiluon ", m~f\I~'9 Ityel of un(/~r.tandlr~ EncoulI\l' t~jly 10 br,ng in '"miliar PrOVide feclllJ(alion with musIC. Im19"'Y, deep or.allllng,
1~,
A.orlan! I flamollval. i Ae.laltnij 'aol.

VMf<.lonal aeliviloe. Pr,,"otiV8 mUfuro. AU.~, II1t(julion I S k clari~cal"''' establish bo,,"d,,(i~ Provide if1t.ansiv9 MK!tlrily IInri sAfety fflflRF..UteS to m~fljmjz.lt Infhavloral pmulems
otj.",.
1~,
ott.,
PATIENT LABEL
~SSM :c
., ,
~
L- l' H
Ii Jt ! ..
10/02/1976
HELKAVERI
PI~!fl!"DUD 0727400691
MARClJ,
DEPAUL Hl<:AI 1' ~ H CENTER
111111111

DPMl00(}.()"1 (7i2007) PAGE 2 OF 8
s6NIA N M 10/02/07 00074829B

1Y
OPI
MED 05 24-01
lip
000117
24
ACU
Poin 26-3
38-5
Site #1
56-7 71-8 84-9
SKe #2
Sr.e #3
it 01 attempts hi IV rcstarl
96-1 121+ RE(

NOTE:
FRONT
RT
BACK RT
N ]
(~
.$1. -5iog.'Ik1fTll~
)
Ii
~:c=_r.;::~:;
f-----{-=S:":L=IQ=L=I=T=LC=+=-====+S'::'L-=/=D=L=j=TL=C+~===+~===j
P R
w
x
I rl
t~,\~
j//
insertion - Date _____ LenQlh _ _ em
Dressing change data ______
:z -w
>-
CS :r::
II
DEl'AUL .HEALTH CEN'rER
t-lARCH, PHTLLIP
JIIIIIIIIIIIIIIIIIOIL
liP
~SSM
iif'ALIU tARe

a
0727400691 MED 0~24-01 10/02/1976 ny M 10/02/07

f1.1ELKAVERI,SONIA N 000748298
~
H
24 HCtUR MEDICAl/SURGICAL PATIENT CARE RECORD

OPM'1000'{)71 (7/2007) PAGE 3 OF
DPM
000118

Patient Care Acuity Record
.-----.----.-------------------~.---.--.
DATE STARIJ~T
0 8 7007
ACUITY LEVEL
ACUITY TOTALS Subtotal SectIon "A"
Points
2637
Level
1
Meuicalivn~
as-55
56-70
7183
Subtotal Section "8" 2 ~--------------------~_+~ 3 Subtotal Section "e"
.MI
t
'FI us oolt Ie
L""" .vitlivu! Medicalivns

~
lirJ! ,.-'>l!,
Ql
..:"
Annrnorh""
[7 or more)
(~\
8495 96120
121+
4 TOTAL POINTS 5 r---------------------~_+~ 6 ACUITY LEVEL

7 Sitter 0
+ \lar in! IAltlcalMs
+ huIll!lle
\/PR'. anli IUP'"
+ on'I''''''
t
+
led
i.,-+-=R==EC=U=IR=E!;j-FU=RT=H-:!:e:-:;::-R-;:o::::COC==U=M=E=NT=A=TtC=N~-----'-' NOTE: If more than one item Qn " line, circle the ~..rvic.. indicated.
~ingle
+ MUl1lDle
EmI)llOR: ~)lIrt
~r~lce
1-1+u\Js
t
t
'e~{
/
hips
I ..
Dnerrtalton to Unit
10
Intake & : wllll meal!'S~ up tray . OuIDuI

..
fln( udes CaIe of tile tulle)
+ Emotfonal DIstress
+ OcvtiopmerrtaJ Impaimlent +-cQvnitlv~ Impalrment _ .....
. ............-... -.--------+-,!..::...-1f--.:.,:,~
Crying
il
I cnllre meill time Otal fe04: r....u 01 more meals
~Mtiple
e.aohmo Iutr ion
..
,ou
l
Care
+ + _ethil!uW 1+ 1+ 1+ 1+ 1+ 19UIlilf
I
. . . ---"-':':::0'-+---'-" o'--l
10 10 10 10
, tnt t sedated)
lIlO
If1\! Imormallon
I <t'
\JC
+
)then;
,en "'uno
Ball! with assist
I+
I: ~actl!lD
1
!tllarene
I
. i2 .t: ll.!e~[So=!JSi~ rooul~[()dl'-----+-.:;;--:'+"...;;-},....,

,
I+
ht~Rl~r
19.
~1I8nt
iel1ew lall of C re \\ til
Ino
no
+ Recelitive
!laths
.. - i----
1------ - - - - .
I I .. --~1----------------~1~----------__----~__--------__--__4
I I
PATIENT LABEL
~SSM
I'IEA1.Ttt
(AJl.I-

a
24 HOUR MEDICAL/SURGICAL PA.TIENT CA.RE RECORO

OPM-l000-071 (712007) PAGE 4 OF
MRD 05 lip 10/02/1976 31; 24-01 fIlRLKAVERI SON);' M 10/02/07 , A N 000148298
MARCH, 0727~00691
DlmBlllliTH PHTL~I!""'II
C8NTER
000119

KEY: .f WHt:$ or task completed
DATE STARTED _ _ _~~__
* = See addiUonal comments
Use bolded key letter if indicated
OCT 087007
Ii,
I'
Specify ahnormal breath sounds on diagrRm.

(A~ent. D~reaw~.
CRackles,
Rhonchi. Wheezes, coarse)
POSTERIOR
POSTERIOR
DEP~UL HEALTH CENTER

tJiARCH. PHILLIP
1ll1111111111"11I11
07274006~~ t-~D lO/02/197bS03~lA

MELKAVRI,
524~Ol ~ 10/07./07 N 000748299
Ip
SSM DEPAUL HEALTH CENTER 24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

OPM-1QOO-071 (7(2007) PAGE'- 5 OF 8
000120

KEY:
,I WNCs or task completed
24
= See additional cQmments
U~e
boltled key leiter If Indicated
Peripheral PUISf S
AAbSQflt
W-Weak
h&al
Ul1I1a,
'-Strong
I)-Doppler
ColQr temp sen laliar)
VlIi'_ - Ul, boo p., .. cap ~V~., ~ thifl :~ Ij.~'" U~tP..., , S>.ffl w.r"l VlJ\.~ lui te~il'
[N,nl II)
Is llaJr
Unne FouH
; oon I(i tw:h

9
YOW,
atJrC"mal n note~
~r-IOM
SUpra
AbMr Freq'J.
T = TracR 1 -1+
em (d lIeo (:{
1 - - - - - - - _ . _ . _ .. ---. _.
Sandbag _ _ Ills. Site: _ __
(Temp, perm) 5[6: _ __
Bilateral
13 '" removed
If Ski
~
~
---
~SSM
fi E A l. 1 11 ' ( A " i
~!!~J~'~RUI.tn

IIF
O!
...
24 HOUR MEDICAUSUROICAl PATIENT CARE RECORD

OPM-1000-071 (7!2007) PAGE 6 OF B
0727400691 ['tED 0524-01 1U/02/1976 31t M 10/02/07
MELKAVERI.SONIA N 000748299
DPM
000121

1(1: ,/ WNt i or lasl< complf.11ert
*=
DATE STARTED _ _ _ _ _ __
OCT 08 ?007
$00 addrtlonal comments
Use bolded key lanar " Indicated
Alit O,l
Gel
Adl
Adl
AAll
81j1l
TV
PI:
As
an.
fie Re
Flu
Tui
Re
------t-t-:-:::t--t--t--+-+-t---t--+--+--+-+---1f---t--++-+-+--I-l-+-++-l
Irs on' R I L
Bllat~al
AlIlI
I I
2 ( 3 !
I
4 I
5 I
AlTfllED SKIH/WOUIIO KEY:

PU - Pressure \l1r./ II pre.sure ulc~r, 1i,1 Siagli I. II. III. IV, UNSldQeilble V - VascuiRr ulcer (veoo~ sta$ls. ar lerial InwlilCiellcy) N = fleuropal'nic ulcer (diattetlc)
A = Abrasion ElL = Btisrer BlI - BrUiSC D = OarnidM E = Eryl!!tima IX = ~,r,(lri3fion H = Kem~1Dma

Surr~ufldln9
= Inctsllll1
- Liic6flItion
=
fi I
L R
TB
7 I
Tape oom WA '" 'Ilea approximated

-
Rash
9 1
Ret.
= Other
Drenlno:
55 D
~
Wound 5W Key:
Ii ..
t.~arHJ~Jbi'}r.
Sic" ';uiVo
Sla~';\",
= tntar1
Skin Key: OralnaOlll\'pe:

G
$
- Dsrm31JlinO
S
E
- Sl<lvgh
:::c
E - trWoem.
M -;:; M:Kt!n1ion
OTA = Open In air ft =' flelenUon 3uluftS

Df
= Ilry .lrnJ 101"_1
II
= ('JlWl = SflOUS
Or8inaQQ Amllvnl:
SC
Ro
Rn
A~
= ,,".,01
S
L
- Smal
= lllfQe
{tidl2.1
o -
88 = SeroS;tnlJ1'C<efHS III
= MM8(;l!a
- CfWI~"
G1haT
o-
C - CY3fiotleJDar1<
gUI~1
PU
pv!ul~m
Po'
I
Y
C;
- Woolly
- Yeiow
C;
Hi
Ca
0\1
M
o
=Monioomery 3lrap.
= Om!'r
o Treatmenl
= Cl""lr
O!htf _ _ _ __
Iinoieate, Rean8umsIJI No ChlflQe lima Ind IIlltlal1
BlI
TQ
Sit
10
All
O~
!sf
~SSM
H
. , 1 He -
-~--~-~------DEPAUL
HARCH, PHILL!P
11I1I1.UIUIII.!uI~
HEALTH CENTER
IIp
(!
HI
0727400691
24 HOUR MEDICAUSUROICAL PATIENT CARE RECORD

OPM-1QQO-l)71 (712007) PAGE 7 OF 8
MED 0524-01 10/02/1976 3lY Tv! 10/02/07 r-mLKAVERI,SONIA N 000748298
OF
000122
24 HOUR MEDICAL/SURGICAL PAT1ENT CARE RECORD
MEDICAL I SURGICAL RESTRAINT KEY

flIWICAL f\eawn Il!1 Rc!lmln!
e(~I)'lPlf::u}l1m?lSu~&OO
GI\o!liI' III I!1imll"~~ ~s_1l!< IrH\'ll, r.eeo fe' w, n, ,~,.) tITMU1ffi1lillaJ nWlIII'..mQrr~ (r~ar rww> ~HI'i'ln, sp<'m
,;:;! ~'l~. '~~j
"~l1fur-.ttITattO:l
P'I)i<lt'J'" a.11lW air'l<.y 0011'0' !l:<voeR O~ry (e.g., !O

m~ ul1dfJ1rJ.l..'lt;te~'fI:JI~tl~eJ
flU\[lflll ~911H1I? iJocu""n' trrM aMi !tame, (i.e,: 91..

P"tfUHf. ~;lt{tn!iil...
lIlal 6e"2Je Kex UrOO!t Til ~} lor s;My
lot!4%.)
atc..)
M~Ul,1ifi im.,il~ krr.,; if.~. t<MtoliillQ Ulf ttelw-Ill 01 t~~
(,(1 in OOi>:af.rm "'" imiG<!W" followtq

nm~
omRuf tnr,,1iH.l.1H (ft. 9., wto E{]Jil(..t me-cr~c~0::11d!lr1fli"!jl!dl;lJa I.J hyd,;tht'llil

~Jtlt:s")-'
of n;;trfWt),
di!MstG wrm i')Mner
2 Cent '" PIli '" Ilk.", .. '"'. "Ic ~ "Hr~ty \UI1l(!jU1IiIM !W; (,f relll\lrr
4 M~ IIJ rll"""" "''''''"\()'. J;; !i COCil6lll1iYe aM r~5tront r(f'OO)'w S Of hunll tlJ ';cH t~ iJlhl;::! s; (f..P.ll fiP.h:i'r1flJJ!
R!}str-a.fflSj
Otn~ !fNIUlTS mnati~r
~SQllfiif(~slr""l
e-Yavalion OiYU(ll)IIa\ mm,." (MClruP$, v~.~;. war.<s, mu,;" <Ie \
Me~{Jlioll
'i
nll''''.r{, wlm.Fa .. ~attalf(j Iroln an iIlNry Q1 S<JtQca! W(J('OVUI" who \'1m") "vlh)! iwlll8' ;,'py rt tt$Y haw ~'Num
"i!~ly
AS".65smant I!JM Iramas

T,;;d fJ;\a.,.. lmqtlllfa:;y
~1Ot rCQUifctl fur f-CimWill
M*"'' '
InCwmti1l a~'(lIf Ills nWk~( 'p;liop"n(<: (U U ' ",ben..,y
Ir "''foJfes Of ,OUlaJ' s"~rirll
o BEHAVIORAL nrSTllAltiT$:
d_tlt't!ure:ul.lltNl)
~I
~I
I
B
g
Bee = BMSUIA Cnmmooo
= 8~
PA TINT LABEL
POSITIONING
o-
= Am1JtdMfl = [fane
C~alr
KEY
DEPAUL BEAr,
~SSM
W I A. l 1 H . tAR , ..

.~~~~. --~~~-
MARCH, 07~7100691'
11111111111 CE1'lTER PHILLtpllll1

3~~D 0524-01
M
lip
24 HOUR MEDICAl.!SURGICAl PATIENT CARE RECORD

DPMl000071 (7/2007) PAGE B OF B
MELKJ\Vf>~JU SONI
,~
10/02/1976
A N 000748298
10 /02/07
'"
,---
----000123
24 HOUR MEDICAUSURGICAL PATIENT CARE RECORD DATESTARTED PREVIOUS 24 vo; Infaxe J70~ Output ~e...P ISOLAnON: 0 SpeCial Contact 0 Gonmct 0 NsutmpflniC 0 AlrbOme 0 Droplet [J SCALE J(F{; 0 Bed 0 Stooding 0 W/GhHIf 0 Sling OTHER PRECAUnOfiS: 0 Safety-Fall 0 Bleeding 0 Aspiralion 0 Seizure 0 Yesterday's 1111. _ _ _ KCl Today'$ wt. KG (PleBse llIl;ij/lCUe nlDbI dllfer&nc:e II grealer than 2.5 kg.)
T8~
PlJist
....
10 -J-07
_~_ _
24 H
lln~7)
irn~~
~"DJl!.m
1
iJ;_ _ _ _ _ __
:I(
Funclion I
DIIECriblJ:
loeatian.
O'OlVior
au.Hty OflAlITlIBf FEEnINGS TF fLUSH _~mQunt Arrnlh'11! Amount , URlKf
Amount Arnouril Amount
DTIIR
tyrE
To Gount
I-l.\f(f")
10m
11M
An1(J(lO!
AmD~nt
Amount
ArrdjFrsq
0700
11/JI
0900
O_8_00_-r---.-r----~--~--_;-~~~.\~--~
.01'""'\
1000 1200
1300
so
"'
l
\0-A J
.-
Sedallon I
'nferventh
1(,/ 1
~~bh~ota!s
To Count
_________
rr:t Q
12 hr Shiftlntakl:
'___
I_ _ _
pt!.AJ;J7~ ______
12 hI Stlll\ Outpul
1, hi TOlal Pilftll!erill _
12 hi Tnt!1 n,r:~:II,{f .:... ",,,h~PL-::-=::-;:'_ _ _~
~gOO
3 0ltO
.. _ -+---1----/-----+---1---+_-----r--~----+----r----~--~-!
-r----+-~--r_---+----~----+_-
~oo .22011
~
~: ____ -+:__~r___~--_+_ _~~_ _+i

---~~~~~----r_---+-----I-----+---
t;e>
:
I
-- -+-_<~0-t-~_+---t-_ _+---+_
0600
Pllr
StloTotals - - - ~----------~a'C1HCral
I<oil
--I---~
- - - ---- - - - - - - - - - - - -
12 hi lOla!
__
12 hr
Tol~f Or~VTuhe
_ __ 1,llr SMtln\akc r - - - - - i
12 hr Shift Ou!pul
.~U",,
"" .vv. ..u.
l.s~O
Twenty-IOUI hour lolal
FLUID EQUIVALENTS:
1 01
..
_ 30ITi
4 01 (112 cuP) . __ 120ml Boz (314 cup) .. 180ml
8 01 (1 CLIp) _. , _. _ _240mL
12 OZ (sooa-l can) _. 360ml

lip !>lARCH, PHTLLIl? 0727~00691 MED O~24-01 10/02/19 7 6 31Y M 10/02/07 t-tELKAVERI, SONIJ\ N 000748298
~SSM DePaul Health Center - - - - - ...-----------------}t
11111111111111.
e " L T n
C It J
e"
---:-t\J
!'~~
DPM;ooa

DPM-1000007; (7/:!OO7) PAGE 1 OF 8
000124
24 HOUR MEDICAL/SURGICAL PAT-=-I:::E=-N-=--:T_C=A~R~E~R=E~C-=O....:....R::..::D_---.:::.:.:.::..::..:.:.:.:..:.:~===:::::=::::::===;
17 Epidural
18 PCA
19 PTeemptlve
Jn~lge~Ha
UP", Issume
20 C{)IlDI1UQaS
r.JIn pr1!!.et\t
ana1gesic MluslOO 21 OIlier'
IIl;haV1OfS
11me
Scal~
li6C1 or
ObfflVll\lO'l
Det~ibe:
lD~i\l!ln.
B&llavior 0
Friqllincy
ABgrlVl1il\<J Factlln;
SOO3mm lll'lel
Ift1ervulloll(!)
fnttlals
BEHAVIOR/RESPONSES; AN .. AnxtIU'
E - EmotioNI
I ..
In~If&C' Ne
Oi.tr.~.
III = Multiple Rt<j\lU' C .. ContlnUOUg GIVing DE _ [}apmss!on

G., Grtaving
U .. V",osponlSM> CO .. COl!lt~l.
CI _ C<>3l\4JO& Impalrmen!
H ~ Ka~U~NltiM,r Delwiens W Os8b"lIt&1y Withhold1rl'J

Info A AIt'tot\Qn
co -
CcnllJ..<IILlI"orilmtad
DP DimUptiVD Patient
OS .. T
Dit.fllf}lI~b
1M - Impulalv& 8 - Stooping
Q ~ Calm/Ouial
Sil/nincant otll",
~ Thr&al~ing
coping D Davelt lpmental ~m palrm-ent
L = le\h,;'gio
Oth~r
R -R"""m'lS
o _ OV\Jr~t'lmutatedlO\+'BrBRcllve
Sft~lng
Physical HllrmlComlllli<9
CDI' CooJ.,,,,all.a ~ -l.lru!
An'''''J'
INTERVENTlONS:
j fleau,"al>C~' Patient f Sigl\1fteant 2, Rat1lr8cUan a l)uidaflllS 4. CO"";,,, m! Environrn.nt ! Routine
8. 9
1Q.
j
Oft~1 fril1!<I,ml brlilf oontact 14. Provid-i' information to incr-8aiB lewl of Und6>f6Iandi-ng 1!!I El1CO\Ira~$ fAmily 10 bring in familiar cbjects 15 Pro,to. '~IMallon wilh mv.k:, ima~.'Y. Ii""? br~;Uhing, praYilf. mvoicaUon 17
R.",tent i
R~I'I\Otlvote
! A9$!allng IMt.
I Sock ciRriflcolion
rneaS\ire~
Divlill'6kmal ae-tivltl00. Proaoli.... rna.suras

~8aSS9SS I R~qua.\ion
5.
7
ij, encoumg$
E!itabi~h mall1lulHa.ti Hma;ramos verVwiZaHon
iur cam
rmed~
'2, Enooura.ga normal ~Iwo -cycie by usIng In-d"1f.tt lf9hllng after datil.
13
D.a;kon room l Umning tOUGh l QUf&l slgn 10 dOOfe-aoo pahani':r ro~PQna.a to s1imufmfnrl
, 6 Esta;l)hstl oot.mdaris6
19
PrQV1=e int,"I1-5}\'i iecurity iinfJeafe.t)'

to mtl'\lrnlZe t-e-hlviOfi\J pfo-bfCJmSi
[nCQUfUge palfl.9nt Yir1h (;fi'CI$fOIi mahi.ng tor Qa/Q m~ud&
PATIENT LABEL
l
(
I
DEPAUL }!EALTH CEN'I''.!.R
~SSM
KEI'-Lri
(;I'-fl.('"
I IP MARCH,PHILLIP 0524-01 on74006:H M~D '1 10/02/07 MELK.J\VERI ,
111111111111111111110
2< HOUR MeDICAL/SURGICAL PATIENT CARE RECORD

DPM 1O{)(Hl71 {7i11007) PAGE 11 OF 8
lO/02/1976S;~ip. ~
000748298
c'
000125
HOUR MEDICAL/SURGICAL PATIENT CARE RECORD
24 H
ACUIT
POints 26-37 38-55
56-70~
Silel2
Site #3
71-83\ 84-95
96-i2C
121+ + ReaUI
NOTE; If
- ------------+-1-+--1
II 01 attempts lor IV (estal I
RT
(r--
, ),/,
I /
o
tq~
5
SL I DLITLC
u
v
Dr~sjno
w
x
trA:al1f;f) nf
RIGHT
p
!l~
f
N041int pr~i1fJf{1
lnseltlon Oat!l _ _ _ _ Len!]lh _ _ em
change date _ _ _ __
vlW!
PATIENT LABEL
~SSM
" i Ii t. J ti
<:"
Ii E-
MARCH, PHILLIP
0727400691
IRlIIIIIIlI1IUIIIIII~
NED Ob24-01
Tip
~
H
24 HOUR MEDICAUSURGICAL PATIENT CARE RECORD

! DPM-1OQCKl71 (712)07) PAGE 3 OF 8
10/02/1976 31Y
M 10/02/07
!>1ELKJ>.VERI,SONTA N 000746298
2'
000126

Patient Care
ACUIT'! LEVEL ACUITY TOTALS
A
P
Record
DATE STARTED
{O 0 -0-:3
Points
2637 38-55
L~vel
Subtotal SMti<)f1 ''N'

Subtotal Section "8" Subtotal Section "CO
7
1 2
E;V-t
B~
I
56-70
71-83
3 4
5
8495
TOTAL POINTS
96-120
121+
NOTE: If
6 ACUITY LEVEL 7 Sitter 0
+ REQUIRES FURTHER OOCI)MENTATIOtf more lhan one item on a line, c:irclo !he servfce Indicated,
..
11
DBl'AtJL HEALTH CEN'PER
~SSM
HIiA-"TK'CAh.E
---
, JIIHmi1l1J1fltfi1lf1111N .vtARCR, PHTLLIP

0727~00691
rip

OPM-l000"l71 (7/2007) PAGE 4 OF &
MED 0524-01 1,010 d /1 97 6 31 y ttl 1 0 / 0 2 I 0 7 ~'!F.L1CAV8RI, SONIA 1>1 000'74A298
000127

KEY: '" WN l:s 0( 1asl<. rompleled
DATE STARTE[l
0 ~J -6 2
* '" See
~dditiomll comments
Use bolded key letter if in\licated
Confllsed. Lethargic.
~
fr.
,\\
Ire
01
01
s
A
Specify abr ormaJ breath sounds on diagram. (Absent. Decreased, CRackles, RhonchI. V#lMieze$, Coarse)
B
H
C
A
A
,
L
B B
s.
[
Ii
T C
COmmiJnt,
PAT/HIT LABH
Time
Loclltion
WHlw ~~
C C
SSM DEPAUL HEALTH CENTER

DPM-10*J71
(7/~007)
PAGE 5 OF B
01
000128
24 ftOUR MEDICAL/SURGICAL PATIENT CARE RECORD

m. ,f WNl:s :If task cumpleted
* = Se'i! adrjltlonal comments
DATE STARTED
ID~
)'01-
USlJ
balded key latter if indicated
KEY:
24 I .I;
I
Pertpheral pulse';
A-Absent W-WBak
S.SlTong
D-Dnpplsr
UIiIl8 c~
isp~
FautH
Color temp sel1"ation

,"lel ~lIaIl>eUpI/lj;:C$ii "US ~S! 9ian J t<cl no, slM Wam'I 'k'l'ih M !i.e1S~
Urilla c(
'Wl-sn
Voit1ir<\l
M 10 tJlf.iI U.!mt.
itMnNHn r<>:.!!
Iliprap
AtmOfm FWllJat CAl {deJ
UIl1JCCII
D = f/{Jo. T - Tfece 1 = 14
Suprn P
SklOW1.'
Jnulldic
DIa~ MI.!OU~
Skin iflt1 Haslprr

Wwnd'
If skin'
OStomies; 0 lIe)s!o1llY 0 COlOstumy

Stoma red and
IT ois!
Appliance intact
~SSM e1-1 f A 1 , Joi '

!; ,
III:

DPM-H
24 HOliR MEDICAL/SURGICAL PATIENT CARE RECORD

OPM-l000'()71 (712007) PAGE 6 OF 8
000129
OATESTARTED
ID~-D7
24
AmflEP 8KINfWOUND kEY: PU - Pressure ulcer
= Allra~!on = OArllldw
8L
V
N
I{ p((:c~wrc UK'Jii. list SIalIC I, II, II" rv, UN.~tilgAable V'd3tul&/ ulet:! (VB/lUllS Slll>lS, i!llllIi~1
Gislsr BR .. Bruise
=N~uropathic ufter (diabelic)

G
i05ulliciantvl
E .. Erythema EX = FlI'corialion H = Hemalom~

I
- Rash TB = Tapa burn WA =- WeD ~ppr~xilf!al~J o = Qlhllf _ _ _ __

Dralniljj6 Amount:
I L R
= 1rn;ISIQn
Lacerallon
DremR\I: 1111 : "I.n <lI1r'"

D IS
Wound Sed Key: = t-=Jt .l:1111,~1IOn
Surroundl"u Skin Key: Drainage Type:
-~mtbond St~l)les
= Siougli
~
= lnlM;1
f-sct",
0'"
'" M
OpMloail
Rl,'1~TlliGlr YI~lt'
'" = PA;u;ernUI)f1
= Erythema
Olilln
G = GrAM 81: $ = Seroos $ 8$ = Serol'<IlrpiM1)1!t"
= SC,1nt
= Sma!
: Mru1"'''le
a
OIMI
o-
CranOlle<'Oari<
PU - Purularll
, , - LlIge
It
Y C
- 61l1'Jli,(
- W-Ilow = Ou,lv
C~~l!J\l~
Df
- Dry and intaGt

~
o
Wuund Bad
MU!ll'IV"""v .UaJ>
_ _ __
-Ol~E<
o -
Other _ _ _ __
/ Inrfioalel
Rta$$enmell1
No CIIllI9f Time amI Initials '
L-?-t~-L T-L"-$--~-ML-._-D---Le-R-"a---"uL-l-R--1-e-'a-l-tAL-'J-C---'-en-ter--'--.....-L---~~~~!~P~~~~~ 24
24 HOUR MEOICALJSURGICAL PATIeNT CARE RECORD
OPM,1000-071 (7{2oo7) PAGE 7 OF 8

01 I
IP
OJ
H I
1~/~2/1975 3l r1 10/0')/07 MELKAVER1, SONIA N 000748298

DPM-
000130
24 HOUR MEDICAL/SURGICAL PATtENT CARE RECORD
MEDICAl R"itD' 1m Rpstliilnt

1 r,(Jl'il$hAHionst'rl'"'&JOOf"'l5l(1l1
Gh~ i)l ~f ffi;t!.' -tt:fh:1~:mw!
""'fjY'! WURhn
Q
Trla[.IltlUE..ru
1 l.h:'ij)~ t~} uUH1r,y,,::1 io!
Crlwrnlm:wt.i
HllW'l~AJ~J.o-f,-'-'
R:t (r~f;~, nt.M 10r N. Tf ~t.i (rw..ar ~jr're~ '$tati!.t !to-ffiJi
1 ProIe>l an artlf,,1<! arway",ilio, (11,11<" dcllmv it fTulf>l,t-n r.Nli"JJ;}.dl.(ltlJbuctrucll!Joosl
!~
O!)tAnlli'l"It
6lJ1t ill1d !:ea1nfl'. {j.f" Pt.
lW~nt
IPause, etc.'
OOJ {tliJt.dl!S j(!g{JWi(PJ
,af-aty
,'"" I-J,I, ele
MaiO!aY\ invl6lV1 hn:az. 01 tooes P-h.-("",Rli{li-~d h. . Ijx.' tI '(Ultmcnt 'lf trw paitSoh.' (,-vrv~ a,riMiw \t! tl . :;l-,k' 'lwn;c of !'IutntUlfl,
fi,,"ci(;::",}i:lffl ;uk';ui!;u,AkHl r]f h'(il~liQn}
(.,If III eOJ,.,{4ti01l
CO"i I? wll at lUCKlS. 1m!. 81<;
iteM! a.ttu~~ "'nth \p,,)ilir.t

1 ~a.t'~)f' ffl'! (r;~;jlailll
Ad,it!
,1lJII11J~,tr3t~
OW 01 !e!~IJry
[1(,l~HJGn;V;l{
k\lly (tudJu1n, 't'1l.It:rx- wallis,
f1lIi$l>:,
etc,:
P~@.fl./tamti) 1~.hJf.,Ul:(it"
Silft/ 01 natWM; wt", "" Inr-'p,,;I"""; II"", <n inlWV Cl s~al 'l'ihu t'~~J-t.1 S1INcr f!Jrw mtJPJ ~ !ttc:j Mvt ~:tr.-e-s~.we "'\f'C" 00"1 helo'" ~ I> n1W1Cai', apfiIepriJ!l, {e.Q .. Bt1rOm~1
~~!.f.Il;f:U!JH:'
~ frame' ~ T,,$, 'W'.1\le ftellllfnCy 4 Oeh,\101 reqUlt.t fer .. moy.1

JrH~VllJl\Al
ki""",,,,,,m
4 A~ 10 n"OO',t <lre5WtQ5 WlU1.,. eK 5 Cflrti1~J;;fwl! ,J..d -rw.tra.ird flJmMG"O:
6 Of harm \Q i\!t !]I O(l!&;& 1 .... 1!.t"''''''~

f<es\l;iil!l';)
AM ttTIGtriSl m u"",,,,/\\el-,f:!e,,,,,'iI WI
0\",,01'
"iClIlft$ or 'Iasw., &lJ"It'flfSj

. eVA "'In
R!nRMHTS'
Other (~QWlel
n:llHti>~ dlltl'O"",IMil"')
ACllVln
KEY
a ~ Bad BSO [J~dSidP, Cammol1e A = Ambula!s
POSITIOHING
:-ll:!PAUl. HEALTH CENTER
e;;:; CI'2J(
D ; OafVJIe
KEY
" 1111 .1111111111111111 RH

I'tARCH. PHILLIP
riP
~SSM
It ~ " I.. 1 ti
R p""
0727400691
10/02/19'76 31Y t... 10/02/0'7 MELKAVEIU, SONI.A N 000'748298
MEW 0524-01

OPM-1000-071 (7f2Q07j PAGE B OF B
000131
24 HOUn MEDICAL/SURGICAL PATIENT CARE RECORD
DATE STARTED
/~ '01
PREVIOUS 24 110; lollike Output ISOLATION: 0 Special Contact 0 Contact 0 Neutropenic 0 Alrtorns 0 Droplet 0 _ _ __ SCALE KEY: 0 Bed 0 Standing 0 W/Chair 0 SUng OTHER PRECAUTIONS: 0 Safatt-FaH 0 Breeding 0 Aspiration 0 Seizure 0 _ _ _ _ _ __ Yesterday's wt. _ _ KG Today's wi. KG (Plalle reconcile weight differente If greater than 2.5 ~,l
Temp
PIII~e
Rasp
Bf'
"-----')T
6e!iverir'll dev;c~
<w"I"
~r ~
~
I
,,/
1X')
I<\.'~ V
b
'fJ
J
.~
/~
l,/ / / .,/ / ' ./-,,' Ail :~ ......./

1lJ)(
IZ
,/'
//" . / / ./,/
, / / ,/~ / /
/ . ,/"" / / l,/'
".-
102,at
IfJ2% I Rille
! 02
III ~
19(; ~
.nft ,v
'1>
n~~
Iq1c
Time
A.Ilf111 S
1V1'
'IME
51'
-,/-'
TIM I
SP
! ~~.,.
lum RUil TEMI
fiJI
.,r'~
,//'
IJ1UU
. ftnp ! Tfllf
j
j
IrUi
RlBf
EMP
OfITIIO Tim
STATIC
0-
SP
-,//-
TIM BP
_/'~'
Scale Ul P
Ohern
fllftclior 08scrihl
L'it8UOr
i,~'-
~,---/~~'
~,.,/
i _,_.".
-",,.,./'
6REAKFA~T
'L
~~/
/~
///
E~
.I~kM
U
Dlt/HER
~~/
YJ;n.. -ttl)!,
!
I
!J
.....
P+.f;!
()
Almvnl
LUNCII
ItS ItACK
t;;6%
URINE
Ka'\
../
BelIfviQ
Oll3lily
..
TYPE
ioCol/ot
OIlA JTOOE FffO !NBS ORAL IF fWSII

Amcunt
/"l r J.\
OntER
BM
Am'>mll
AffiQvnt
Amount
AnwulIl
Am.!Unl
Amwn!
AmQUflt
AmlJF,~q.
0700 0800 0900 i00n -'1100
.....
Vq1I
...-
S!iallm'
Intervcn
V()f
12fm
1300
1~OO
Lf!((j
f--
vdxl
Vel,x f
1600
1600
HOI! 18Cn
12111
Vd,d
------
Suo Tmals _ _ _
j
2 III Total PHlCII((, al _ _
Tn
Gourl! 1900 lOUD
12 hr IO\ai OraVTube _ _ 12 hI Shilt Intake
----------12 ,,, SItII Oulput
aSHA'
AN -fl
E
~
I~
Elf mel
II'LC'
2.l./0
r---..
D = Di
iNTER
I. R..a,
r-_~100
2700
__
2. Redl 3. Gulc
.",
23110
!---z,(Ill)
4. Con
5 E51a
6 Ene.
7. nCt
(/100
0<'00
03~~_ 04nO
G500
IMiDO
12 hi Sub Totals .-
tfoV
- - - - --- --1? nr TotJi
(1f~llTuna _
"_0-
12 111 lol;tl Parentml _ _
--- --- --- - - - - - - 12 hr Shift IMpiA
12 hi Siull Inlak
' .... ,f1"'U
''''Uf ""'''
FWID EQUIVAlENTS: loz ... .3JmL
402 (112 cup) . .1:?Omt 6 m (3/4 cup) .. 180ml
B ol(1 CUp) ... ..240ml 12 Ot (soda-1 can) .. 36QmL
Twentyltor !tour 10111

PAnENT LABEl
~SSM
Ii [" A l
"{
'J
R 1:-

a
DEPAUL, nKALT!I CENTER
MARCH. PIULLJP
-1lliliUlftlll111111D .
MED OtJ24-01_
I
I
24 HOUR M!:OlCAL/SLlROICAL PATIENT CARE RECORD

DPM10DO-071 17/2007) PAGE 1 OF
on'1401)691
10/0:</1976 31'1 tvt l%Llo? t-iELAAVERI. SON1A N 000748298

DPM-1(
000132
DATE STARTED
10 -5-0'
Kt
US
Aching
8untllQ
SA Sleep, easy to arouse

1 Awake .nd ~16ft
2 SliQltlly Of\lwsy. ca:.y ttl arw:.c 3 FrEqll~nlty drowsy. arousable. eyes drift CIoMd during r.onvarsation (woslOef reduclftQ oplolll dCl$1l) 4 SQmnQ~nl, dlfhWn \0 ilfOV~~
~~~~!~j CV Cramping I= Cru~illnD

APP '" lis::ull'.e pain Jl(eselll BAhavim); Dl'lI Gnawing
Heavy
P~~svre
1 MeOication 2 AmolilaMn
3 Rl:pv,ifion
4 Rl!lal<;!1illn
$ CWI1"liI Statements
ActiVity
PrOOl\lurt
O~
Re~
9 Heat 10l:nlrt 1 t Music 12 Touch tlJ Imager/
17 EpkJural
18 PCA
N~
19 Pii!emllbve
analgesia
anal!les~
!:g
Sf
20 CllflIinuous
6 PrayeriMeditatioo
7 Spirtlllal Cite
14 MaS$Hge 15 DistraCTiOn
16 Ed;.,eari<m
inlv.iQ(l
21 Olhu'
8 Oee,p
BI~Jlnil1g
Sr
TIme fll!lQO Score #

#
Stile Used or
ObserYall~n
h~CliQn
&oa' #
DescrIbe:
LovatiDB.
Bellaviar or I PI'
SIldatlon LUll
Inlervenlin!l:}
IfIilialt
COMMENT:i:
--------------------------------------------------------------------------------~
BtHAVIOR/RESPONSES: AN ~ An.lo"" E - Emn\lolBI Di.lr"".

I ;;:. InaffD-ctiv<) Coping
M - MuHipl. RoquMit
U - Unrpon."",
co
ConmsGdIOI&ori.nled
OP Oisfupiiv. Pollanl
1M ImpulSive
C - ConlmUO\l6 C'Ymg
DE ~ OGp!HilOO
00 - Comatou
CI ~ CQ~mHlW Imp;urm9nl
H-
HalllJ~lOllliQn&!
Deiusione
oS - Diarllptive
Si~ni1lcill\l
StlKipil19
GL
=:
O&/9bpmfmta-J tmp .')lrm8n1
(J "~v"'9 ~ l.e(fl.fQl~
R ~ Rnm.s.
0 O~'J1Im\lia~ct!Ovtfea~t"'e
INTERVENTIONS:
--------------------------e.
9,
W ~ D911beralGly Wlfl\hol<lil\~ Into A - Anentlon Snl<in<j
Othel
T - Thf9Jla","9 Pf'YSI"a'
'1almfComballve
Q - Calm/Qulit COP - CQOQ"a\!1I9 U\ ~ ~$S AnXlO\l$
1. RDftS"&um<lCo PntiDm! Significf}nt Ofhuf 2. Rudi,edlc,', l. (juro"n"" ~. Coruolil8rt Enwonmeml ROUim8 :>. E'tablish ma'nlalned Umeframes IQr ~afl ~. EncourSlIt v&m.lI~atlon
OHo-r troquont brlU! c:onhict 14 RoO'rtnnt I RemuUv.1.t0 1 RQmntJllg foo1r:; Provide iniormallon \0 inOr&869 ~a,,.ef of llPdil:n:01amJ!rY~ 16. DJvaf~wN11 8-eH-vl11otJ5 10. Encourags 1amiJy to bnn-Q m lamiUar oblOC1S '8 i"lr{lactlV9 rTt63sum.& 11, I'rQ'IiQe rela.\&IIOn ' ' 1111 muolc, Imag9f)1, g"~ b(~I~,lfI\l, prayer. meak;<lllon 17, R.aHe~. f Req'Je61ion I S ~ clarnioalion 12. E"ncDuflIge normal fleop cyele ~y USIng Indlrec! li9hti~ alt91 dark 1U. E"$la~h bVundal\as nHds 13. Darken foom I ~Jmkll\g IQUch I l~. P(Qvlae int@n$lvt ,"CU(rty and .. I&ty m~n",~. Olliat olgn to ooc,,,,,.e "",1<101'3 "'''PClM5 10 otlmul.Uon to mlnlml b.h.vlo",1 probl""'~ 7. enoourall" pRtl",,' wKI1 ooal.!on m.1<ln!l!or C"I'. na~M
PATlENr i..AfJL
L
IIp
~SSM e: \.
K
~
1 11
"A 1\ !:-
MARCH/PHILLIP
111111111111111111
0727400691 MED 0524-01 lo/02/1916 31Y M 10/02/07
24 IiOUR MEDICAll$URGICAl PATIENT CARE RECORO

OPM-1000-071 (7/2007) PAGE 2 OF B
MELKAVERI,SONIA N 000748298
OF.'
000133
fA(
rPa 26
38
56
71 84 96 12
NUT
+ RI
FRONT
/--
I)
;\ 1
~-l~~
,D): \
-',\
(
: /
LT
(}
I
-'~
~} II
I
,I
(twl "
) ~ C
J/
~l.W
I
! !
Ii r
I I
L
J
1"'( \ J,
K
I \
SL
= S~Jt; Lrr~1
UouhM !,:miN
Di. -
0
SUDllTLC
nc; JriplelvnlCf'
\1\
\
SL! OLi TlC

R
T
IU-V
I:)
E c::
/nIficJI' $QcaHOif t:J Ii liP k>f.) wortdfd
nJBIIT !
p
5 z
E\ \
i",
4~'I
Insertion - D~'e
Ann circumference
ern
LenQth _ _ cm
Orassing change date
\-------\.
--
---~-----
PATIENT LABEL
~SSM c.
}1 (" A. L T H
-A JI: I!'"
DEPAUL HEALTH CRNTBR

MARCH, PHILLIP
07274006~1
11l1l1!ll11l1l1~llmR
1/1'
...
1.1ED 052/1-01

DPM1000-{)71 (7/2007) PAGE 3 OF 6
10/02/1976 JIY 11 10/02/07 MELKAVERI,SON.[A N 000748298

DPM~
000134
24 HOUR MEDrCAWSURGICAL PATIENT CARE RECORD

A ACUITY LEVEL
Points
26-37
Level 1 2
DATE STARTED
Iii <; oJ
ACUITY TOTALS
Subtotal Section "A" Subtotal Section "8"
!;
38-55 5670
71-83
B4-95
'17
J~
i4{,
3 4
5
Subtotal Section
TOTAL POINTS ACUITY LEVEL
Silter 0
"e"
9S12n 121+
,~ -~
6
7
0-
RQ\JJ RES FUFlTHER OOCUMENTATION
NOTE: 11 more than ooe ilem on a line, clfOla lhe service indicated.
J
~EPAUL
~SSM
Hl"AlfH 1,6"..-
HEALTH CENTER
I/P
!'lARCH, PHTLLIP
ImllllllJlIl!HllUftlD
~4
HOUR MEO'CAUSURGICAL PATIENT CARE RECORD
077.7400691 M8D 0524-01 10/02/1876 31Y M 10/02/07 MEL KIWERI , SONIA N 00074B298
DPM10>lQ071 (712007) PAGE 4- OF II
000135
II'
DAlE STARTED
&.
Spaclfy abnormal brea1h sounds on diagram
(Absent, Ilecre ased, CRackles,

RhonGhL Wheezes, Coarse)
POSTERIOR
POSTERIOR
PATIENT LABEL
CfIIlliluS

072~400691
111111111111111010
rip
~
I (
(
D
I:,...,.
MED 0524-01 10/02/1976 3lY M 10/02/07

DPM-l00c-OT1 (712007) PAGE 5 OF8
f.fELKAVERIf SONIA N 000748298
000136
DATE STARTED
I () .<;;'OJ
24 HI
KEY: " WN
TIme
A-Absent W-Weak S-Slroog

!:I-Doppler
Fecal Man;
l100e cl~a( Is paInless. Urme CQiQrt
FOlll-.~millli
Color temp sensation

VrR - Ill;
t>!;C ",.:
cap
iP.tdl$~!h;1!l3~_tlf'i1 ....
Uln W3lm wI. IuI1 lens a(I\lll
II; !{IJd. Ol)1ilJ!! ii1m!)lmll1" nCla.,
Yolding, I
lUiirnpuon
IIMormaiu
2 ..
B = IInn~
Frequency.
elll {descril Roo coooUlI
T
1
Trw..t
3+
= 1+-
" 4+
Suprd9UiliI Oriliflllgtl (v
Skin warm
J;lllrufir.~
Diaphorebc
ML'COm Il1I Skin InIli<;t
He,:l procte
K~klfj wi~
{:
~
RJfr)
~SSM DePaul Health Center --------------------------------H A L T Jot

. C A ,
,-
M.lillCH I PHILLIP
1IIIIlfllBmIJIIUn
1/ P
0727400691
MED 0524-0J
M 10/02/07
DPM-1{)(J(

DPM-\OOO-071 (7(;1007) PAGE 6 OF!!
10/02/1976 31Y
MELKAVERI,SONIA N 000748298
000137

KEY: .( WNl:I Qr task completed
* - sea additional comments
DATE STARTED
10 c; .OJ
I),. bQJded key lettar it inctiollted
Syn
Me
Oil< Ger
Adr
Adr
M1i
Aitt
Ilfi-il
,
"
ALTERED Sl<lNtwOIlNO KEY: PI) ~ Pres,uT(' ~Ict( If pre~sute ulw, lis! St2ge I. It III, IV. UMstagellbie
V
~
A ElL 8R
I)
~ ~1~ISC
= B~Sl~r
'" AQr;;$tOO
VasGulJf ulcer (venOIiS ,tasK inStlffiCincy) = N<!ll'Walltc VICer (G.atlebc)
,rlenal
E
U
= ORtludM = Erytltema = hconallon

Hp.maloma
Q
$
= tn[.i~inn I = LacenWlJ1l L R '" Ras<~ T8 = Tall~ b~m
WA .. Well APf.tMm,11ao 0 Ollier

Dnrinagt Amount $0 = Stanl I I : Sman
M
~e
H
I
DrnsillO: .S ~ Steli slnps
= De",,,,buHt/
SlapiRs Open 10 lIir
Wound BIll Key: Q = Gram.r4ton ~ :w,"Oh

,. - EsChar
SUfloundlnv Skin lIey: DralnagD Type;
= Inl~('1
II ~ OTA R " DJ M
() = OIlleJ
H&llltlthJ!l MJ1IJ1ll~
ory and Intact

O1Mr~
o '" Om
E - [tyillema M ~ M'ter;~O<l C; = CyanOOciD'';
88
= brfM = S~'UlJ'J = S"rlSJngwofOus
PU - PlJnJiem Il = 11!\l9!1y Y - YellOw
I.
=La,9\'
-
- Mootnlle
CQpi9~~
p,
!<
_ M{Ii1l!)<lmery waps
____
= Giusti
~,
_________
o
s
,/ 1nII1~a1f1 R.-neumanl No ChJflie Time and Inillals
1
,.
~SSM
H I A \. T H . C A. it Fo.-
DePaul Health Center ._--------
DEPAUL HEAVfH CENTER
I"lARCH, PHILLIP
072 74 00691
IIUIllIIDIlIIIIIII'~
TIP
24 HOUR MEOICAL/$URGICAl PATIENT CARE RECORD

DPM1000071 (712007) PAGE 7 OF 8
MED 0524-01
lO/02/19'J6 31Y
M 10/02/07
D
ME.Ll<.AVERI, ,sONIA N 000718298
000138
I
I
Toilaling Off8f10 mAry Z>

RR~fl'1nr.R
---.--- ----- - -_.-.--- ---- ---1----+--+-+_.1---+--1---1-Ii! rRIAL RElEk'iE
ftJt.mJk!u Up1J1
tv "YRS H,Jlrfipl
Sla~Qn, ~~ial
"KAt. Hugo fpr R'furot

1 FTOIert an MiliCi,. 'irway y,M!! _ . dof,,,.ry (e.Q . to m~'I1Ia!" BfulOlJ2tlUtVIraa.aal(\Ib<Si
nul@lo! flImlf;m
(luw"wrrtli<,,,,,,.,d!cil"!C'.(ic Ill. pwert 1'1l'J1Il'~. etc.)
Df me
(,1j .. ed"<.u~n Ilo: "ale~ jo~~winv teMt &~~t'd wlfu It.\m!r. j f!I>",,"" ff< rnlr.!ia!
filalRelm; Key
, Unlble lO '.W.>tt lor ~.II.t'J
:> ()d b) tH.Jf1 ,11 !(dT(;"~. ~]~J. Wi
1 Cooman.onsl"'l;SuIlYI>I\J!l Z CiflIlGe Ij/;J, ....alI ~ R>. (l'H..at M~O tCli IV:]f. e%:.l
~ En\1roflfl1fltt I
"",.(lIlt. att
maNwlatlc{Jt (/ltar lilUlel
~'<Un im<aWe ton Iii tI.>bts emnTilllO \lJt 9~4tntfll !lit6nl>' ,urr~OI ~~tion (q" 1C.'~ ~QW'I~ Of rMtlbO!l.
) ActMty 1~~1!1f! rISk Of
rtllliWl'
R~;lit'! or~.t)M('
_.Iion .dmli,,,[ra(,,,' or "yd<i!loo)

3 Sal!1;' of J>~nts '11M flJ~ ID<:apac~~tll kNlI an "wry or nr7c~1
IJIltBdU'! 'liM "'Gall !.utlet IU'lh.. lIIjurt "
IHl)'tlt{l\ffrJ hai.QH:!"II \(; ~1~atr "'f~l:\,lf.~n1t:
4 l.jlef\fiI~ 10 "Jl""'~
5 Me1icaUQIl t IllJuaii(m " llt'itlS1~naf a _IMI tOdWOOS. ",J!;OS. WiJ!ICS. muSI!. tiC.)
thay hive ."'."'..

(e: U. ~Ihf!"nly
? A:'.!.~~"".tuV:l~ lilHtl fnltm;~ 3 Trial IP..IN$e lre<l'.lfIlCY 4 n~~"If rwui1ee 100lemovaJ
"""""1', M"O>l<. t:i<;

femore.l
(t.t:f\' Rt1!<'fr'1U1.;f
~.re
aoo
r~!lJ'a;nl
~!ht'.f(,
6 fl1 t,Mln lfi ttttf W
I 7 PaI,fw/fami' tdaCJ1iC11
lleiflJainl>l
1 01.",
run DM:,f&.i!\ s"",e~;Se1ire!e.sl1'9!i1l!
ffactums: or V.Imw sUIW:!OOs}
BEIIAVlORAl RUTIWIITS.
1W~..n !lcn""'~1
'11'", ;mif1:kil>C
L Ifttilied anu in
vla~~
u t/ul applicable
"CTlVlrY
Krf
D =OanwB C - Crnur
B ~ ~c(/ BSC = Bedside Commode A = Mmldate
POSITlOHlNS
KEY
S P
L = Lell
=
~
= Hignt = Rack
Self Proos
DEPAUL HEALTH
MARCH, PHILLIP 0727400691
~SSM r
" tAL y tt '
~- A ~
IlIIa.,IIII.RENTER IIR

OI'M 1000'171 (7/2007) PAGE B OF B
MED 0524-01 MELKAVERr6s~~IY M 10/02/07 I A N 00074829S
10/02/197
lip
000139
24 HOUR
MEDICAL/SU~GlCJ).L PATIENT CARE RECORD
._ __ SCALE KEY: 0 Bed 0 StaoojlllJ 0 ~WG~ir e1llrlg OTHER PRECAUTIONS: 0 SafelY-FaR 0 BleedjrJjj 0 Aspiration 0 Seizure 0 _ _ _ ___ Ynlerday's wi. , = = - KG Today'i wi. K.G (fl~ue rO~QnGlle Wlli9ht dlllrlrOD\l{J if greater Ihln l.~ kg.1
PflfV10US N 110: intake
111D
Outp\lt ~ ISIlLATlON: D Special Contact 0 Contact D NeutropenIc 0 Alrborn 0 Droplet 0
DATESTAATED
tol~! 16l
24
hM
APP
Time
RatllIg
Scalf l
Dbserv
funnlio
Onelit LotallG Behavl(
UA~
OlHEfI
~ ~. ~AiOOUnl
Anll fFt~Q
Fraque,
8M
1JflAl
TF
FLUSH
_Amourn
--+----1---'--'-" Amnum'--+----.!'----'fll0UIll
Am01~
AmQVnt
Sedafio
--+---~~---+-
Inltrver
lnilialt
.-
--+----+---4- --12 hI.
S~b T,~alO -'I.1L
11\1,
rrn"r- - - - 1'-Vp~
- - - - - - ---17 nr Shill Imokc
1- -- -
- - - __ _
12 hI 101.11 P3reolefli ~
To CUlint 19UO
12 hr rQt~1 Olii1fTvbe
r'
1i /J ()
._---
BEHA\
AN
~
Al
f:)}(..t'
12 hr Shift nlJt~ , - -
--------i
E; Em 1=Ir>.d
00""
INTERI
I Reu
n~o
--'-
.-
, Rodl, 3, Guid
4. COns
~. E..tat 6. !;IY.9\
2aUD
240-0
J"J-lJ
--olCO
IOu
I'IF:/)
--~----~-f-----l---_+_
IV
7.
En~O~
-~---+----+
~ ~ ~Ol
--!-----+----I---
- - - l - - - - l - - - - + - ---
,--
~Jr_--~~~---
~:;~otJIS --- d....,..:..~~7)_ - - - ---12hrToraIY;lrBnW;1 _ _ ltlTfTotaIOrill/Tulrli_....

12 hr Shift
-n.
.'I!fD-- -- flIl1J - - -"'t,t,e r~ ""--,'-i ...... l.'I'k~-l

, loti I
-- - - ---- 13: fl..!) a.1I1J

PATiENT L4BfL
12 fir ShiftOutpul
.~. ,-
Twuoly-four hB~r IlItll
flUID EQUIVAlEHrS:
4 oz (1/2 cup) ... 12(}ml
8 Ol (1 cup) . , .
240mL
lor. .. .
. 30ml
{\ oz (3/4 cup) . ' , '80mL
12 02 (sodal canl ' 360rnL
~SSM
HeAlTH'~"'~[

e
24 HOUff MEDICAL/SURGICAL PATIENT CARE RECORD

DPMl00G-071 (7:21)07) PAGE 1 OF
~mD OS21-01 10/02/1976 31Y M 10/02/07
~~~~'~p~1111I "
0727400691

lip
~
J;
All
RAHMAN,ANWER Z
000748298
DPM-100
000140
24 HOUR MEDICAl/SURGI CAL PATIENT C=-:A,-=-:R,-=-:E~R::-=E=-:C=---:O=-:R~D=----~----.:o=AT~:...:ES::.:.::TA::.:.:RT.:::ED======;
24
AclJing
Burning
A .... = AWlml pain present
B~hav:orG
1 Medlcalion
2 Amhulaliflll
Cg = Crus hin\) DuM

Gn~wing
Ct'~Olpi1l9
5<Ohtlv drowsy
e~,v to
Mouse
3 f,equ\.1'tlly UHJII'Sy.
alou~dble. ~y~,
drift closed during conve(~aoon

(tenlld.r rtaLKlng opiold dOle)
4 SomnOlsnr l1itticun to Jl'Olise
Heavy
pres$(Jre
3 4 II 6 7 B
HcpOSiUOIi
Relaxation
Calmmq Statements Prd)'l!liM<ditaihn Spiritual Care De&p Brea1l1mg
9 10 11 12
Heal C:nlrt
MUSIC
17 Epidural
18 PGA
19 Pret!mlJ\Nt
Toucll
an<lgaSi.
13 Imagery
14 Mir;sag~ , S DiStraction HI FctuCJtlVn
20 Continuous ana~~ic infusion 21 OI1!er'
Sits
Site;
'TIme
RlIIfRg Score #
# 01
Seale Used
Dr
Obrerva1fen
fllll~lioll
Goal #
FJI R1
Oemille;
\.&calIO!!,
Bel\avio I or API' Ilualily
Aggravating facton
8edation teyel
1!I1&l'VflllliDlI(&)
Inltlals
BEHAVIOR/RESPONSES; AN ~ Al\xiM
E ~ EmollonalrlilNi$
I", Inelf&<:U". Clpir>9
M ; MulflPl. Rtq ...ut C = COntll1UC\l$ Crying DE = o"PI'&"lon G '" Grlavlng

L
U ~ UnrwPl'nsiv;
CO = ComalGJi CI = Ct'gMm Impairment
CD ~ Con1u.~dJOj'Q(i.nl.d H - Hlitucilltti(!n41 Delu$lone

W ~ OtllberRlely WI1Mholtling
I) P
= Oisrupllws Patron!
[)j~fuptiv9 S~OIfI'.n1
1M -Impul:ij..~
tiS -
Ii: SI&llphlg
o;
Oev.lQpm~nl.IImP.r'm~nt
= Lclha'!JiG
o;
II.
j
R-
fleS119~S
O.",&!im"lale..1I0","eactNa
Inlo I< = /\I\&r'II<", Seeking
T ~ Th,,,aten,ng
OIlier
Phy~i"al
o - Ca\m!Quj~1
COP
~
Cooperative
An~io\l$
HaIQVCOmo.llV~
LA - Lan
INTERveNTIONS:
1, Rea..u.... "". -Val,,,nl! Sognifical'>\ 011> ...
2. Re<l!'8c1l0n
3. Guido"."
e.
4 C,,~sI"nI e.vlronm<m' f Roull"" ~, El!:tahiish m5i'llainod timehamJ;J.-S for care flOOds

EnWllra\l~
9. Provid& information to .nCn,ase I~ , ot und.r.\mdmg lQ. Encourlg" family to brIng In fAmIliar objects
OIIvr 'n.qwnt briiir OQIl(aot

PrQV1ct~
4 R(Jf)lhmll RemQCtvafe l RestnUnR (sots

DivBlsiaf1at acti... i1ios
15
I,
relaxation with m".iC, 1mA9~f' d""p br.alhln9, pr~y~r,
16 JIIrO-OOIi\I'Q Illsas.urez:t mwlcab<1O 17. KU$li1!e I fI~qw61/Qn I Sook cl.tl!"'a~o'l

m"'O$ur",~
v-f(QalkalIOll
j2 11
7. En_OIl,age pl<lient wilh QGCieiQn ",,,,I<lnll f<rr car. n<>ali.
QUill! stgn 10
Errooumgo no'm'" "O<IP cycl~ by tlslng fnalrect ftl/Iltino ..tt~r dark 18. ESlablrsh bound8ri8ll Dmkon r"om llimitmg louch l I S Provir.\e I"len.iv& l~~uri1y And .afety OOOfQ900 paUunt'.:I T85paflS[} to stimutntiol1 to mlnlmlu lh.."tor'" proMsm)
t ,
I
PATJEI\IT LAOEL
DEPAlTL ~EALTH CENTER
~SSM
H : .. l ,. l-i
.c.\ _ t"
DePatd Health Center

ij
24 HOUR MEOICAl/SURGICAL PATIENT CARE RECORD

OPM-1000-0n (712007\ PAGE l! OF
l'lARCH, PHILLll? OT27400B91 ,-lED 0524-01 07 tJ! 10/02/ 10/02/1976 3H 00074B298 i<AHl"'J\N ,ANWER 7.
1111111111111111111
IjP
0!1
" A
DPM-'
000141
Site #'2
SITe #3
I~
~
N(
# 01 attem:lts for IV restart
e ;::
t:
:II
~.
:2
II.
...
C >
:::c
PATIENT LABEL
~SSM
ttE"-tTH
C41\.

e

DPM-l000-071 (712007) PAGE 3 OF
HAReH, PHILL,IF lip 0727400691 MED 052l-01 :10/02/1976 3lY M 10/02/07 t{Aftf-W\f I .lI ..NWER zoe 0 74 8 2 9 8
IUIIIIIlIIIUOIIID
o
" f
ON
000142

Patient Care
A
DATE STARTED _ _ _-
__
Record
ACUITY LEVEL ACUITY TOTALS '----Points 26-37 38-55 56-70 71-B3 84-95 96-1211
Lwei
Subtotal Section
"Ai;
2 3
4
1 Subtotal Section "8"

Subtotal Section
i
"e"
!'Vi ~~
"
6 ACUITY L.eVeL
I
5'
TOTAL POINTS
I
)&' ?~
If
121+ 7 I Sitter 0 + REQUIRES FURTHER DOCUMENTATION

~:--
NOTE; If
n1Of&
than one irem on a line, cirele the service Indicated.
I
I
f
'!
:J
"
.i
PATIENT lABEL
~SSM
l1f.lTH C"R(

------

DPM-1(100-071 (7f2007) PAGE 4 OF 8
MARCH, ?HILLIP IIP 0727400691 HED 0524 -01 10/02/1976 J1Y Ell 10/02/07 HAHMAN, AN\,/BR Z 00074B~9S
IIIUWIIIIIIIIIDOBIU
000143
DATE STARTED _ _ _ __
24
i:~r~ "SHiii~iriiiiiiiiil~~
I.....
ZJml~=~l1Bt;
v . /
/
iLOe
n,
ConfuSed, Lethargic.
V
DHI;w~n $;k,rrAf1\
Speech (Apl1aslc,
!
Moves'"
r1.o\JJr response
,witil
ARM
t./
!R / ./
1/ L
(Abnormal OOXIOrl. Extension.
flaccid, LOf;il!lze~. None, SPa$tic, 81rong. W~aIi.
WDWithdraws)
'HAND
Size
fR"' V/ .~ W,' t.) L ,/
/" 175
/1// 1//
/1
[J
/ ii/ iii
;i
GRIPS
inemors
PUPIL SCAlE
B-flflsk
l~< j/' J/ //
// v/ /i i//1//1/ V/ /f / 1/." / 1,// ,/1// 1// // 1 ,/l ,/,iL/' 1// / 1// Vi 1/ c/ Ii 1//1/ 1// Vi ii' 1// 1./ 1/ /
:'
' .
/' /
/
/'
jl
.// //
'
./
I//i
1/
1//
1///
L// :/ / i// //
[,
$.StJC9ish
I nm In>''' :Jmm 4"""
ffl~d C-Sw,}l~rV
Clrmo IDysphagia
/iff."
e
flmm
I
lo'~/ 1// L/ I/o' l/" 1//" l./ 1// ~/ 1.// L
/".
//'
/ / [/' ~/
l// 1// l'/ .../' ~/' L,./L/'1,/1/' L/

:
ReacUon
1mm
!.~" // 1//
L
,// 1./,"'-
1// 1// 1.,/ // 1// 1//' 1'//t./ ~/ l.// 1/,,' l",'' ' [,./ 1// ,// ,,/ ,.././1//1/'1,/1I
+--'
Sa
Pa
la,oeDn' Ah.""tl
, TE
1Numbness Ilingllng
IOL''''UIINIi
R~
rv~w' 11'1
all lobes clear
~~
Abnormal b'eath sounds

Specify abmrmal breath sounds on diagram.
(Ab~~nt,
TIME
D lcr~a$ed,
CRackle~,
Rhonchi. Whe.nes. Coarse)
= --, A, ,nE\ t:==' r--:j

FfJ ~ JE ~ ~
TIME
TE
S(
lm1 tI ~ ~ ~
S(
r;=::j:
R
V-',
~/----..."
L
I'
4
~
CI E> Df
~
,..L
i
POSTERIOR
POSTERIOR
R86Pifalgry l1ffurt \lnlabor611

Abnormal mspJratory effort
OYSpr\l!3 (on Exertion, at Rest)
vi
At, Bi
Sf A
Cough-
1- .---
i Cough and deep breath
InGonliYe ~Jlrome1er It mL I fI reps

I Sputum
!
c'/~
.. /
I'."
.. -"
.,."r
,.,r ~.-""
~--" [-". [.,"
>'
1--/ I .. r ' i,"'"
.,'"
."J'
"J'
. ,...,
,
.,,- i,.,r' i."
L,
A
,.-
(dHSCribeamouflt colO!,
SI
C
N II
Suctiun (Nasal, Oral, Tracfl) TraeR care o Trach type _ _ _ Size o CPA? [) BIPA? S8IIlngs
Y1InllflllUI 9""II1I1J,
0 GMV 0 SIMV
11
" .. i~;;"wl .. " ...,,~
(ytlrilled per Qr\lcr)
o
S
Comments
..
lint:ll IUDtlI
PATIENT LABEL
o
a
TIme
LtlCatioll
Will~r Seal
&uctiun
Crepitus
Drainage
/'
,1/
L--l.- .
DEPAUL HEALTH CENTER HAReH,PHILLIP lip 0727'100691 MED 0524-01 10/02/1976 31Y M 10/02/07 R.l\,FiMl\N,ANWI::R Z 000748298
III 111111IIIIUIIIIII1
//
OPM-\OOO{)71 (7/2007) PAGE 5
OF 6
.!
D'
000144

Nfl:' I
WN~6 tlr task completed
* = See additional comments
24 t
,.,
TIm,
Un bolaed key letter II Indicated
PMfJMral pUlse,
AAbsam
W-Weak
FlulM
IJiinacll is pBinllJ
lhinu !;\:
Foul-Sir
IHtrung D-Doppler Colortgmp sans.ltion

WI' 1(,011...." u%!l r;w
~I!$HlYI3SI!:,rnlS
sUJ warm Vttil-;1tJij ~iS'"!
gC41llJ IOiJCU!tJIO!
JtmocJm.llfllmt;--s
Vuldiog juprap
AhflMm
II - None
Fr~Quer,
T '"
, 1:1:
Tlat~ 1i
eBi (ds!
Iliao cor\
&iPl3 !JI
Drainaoc
If skill,
~SSM
.... " " l T H
r; .. R E

t"1ARCH, PHILLIP
IIIDIIIIIBIIUIUIIIB
riP
24 HOUR MEDICALJSURGICAL PATIENT CARE RECORD

DPMIOOO-071 (7/2Q07) PAGE 6 OF B
0727400691 MED 0524-01 lO/OJ!/1.976 3lY M 10/02/07

ME!,KAVERl, SONIA N 000748298
000145
24
ALTEflfO SKIN.NKlUHD KEY:

PU
~
Pr&O'.wo ui<;1!1 If pressurR ulOSr list Stage I. II.
A = A/)rSSI<)" 81. ~ Bfisler
I
L
= Incision
III.
DR
IV. UN~\a'Jeable
V
N
Va~culilr llirer (venOL'5
sla3i:., arterinl
D i
= Denuolio
:: flyllK~ila
=Bru~e
=
~
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EX - [:.CM.lion H '"' HoHllltoma

I I:
; l;Jccralicl1 - RaSh = lavo bum WA ~ WAil ap/lIa<lnlillcd o '"' other
TB
Orvisfng:
I.e
"
Wound Bed
G -
5I<;rl >VlPS
K~y: Gt.i\,'lltl;lUOtl
Sutl'UUilding SkID = Intact
K~y:
[}rain~'
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; SIOUOh
= l'rylfi~I1H
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5
OTA
= (J!'<f,n 10 ail
~
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I: = rs(har
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and ,,111';1 Monl2Qfner'l sIn!>,
o -
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=\.liw _ _ __
Odor
Time
Sll~
He.
D,ell$ln:oTww~lIu~n~dTs;;;;;;;;;;;;ii;~~;
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AI
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H rAt. r "
I; "
R E
MARCH/PHILLIP
24 HOllR MEDICAl/SUf:lGICAL PATIENT CARE RECORD
DPM-1OOO-Ol1 (7/20Ql) PAGE 7 OF B
IIDlllllnmllllUn
MED
F
lip
0727400691
0524-01
DPM-l(
10/02/1.976 31Y M 10/02/07 ttlELKAVERI SONIA N 000748298
000146
MEDICAL flcs!on Ill!' He8!'BI!l!

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POSITIONING
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DEPAUL H
ef'I:;SSM DePaul Health Center

K E A l T 1 C A It
E~
liP tJiARCH, PHILLlP D 0524-01 '0727400691 3~~ H 10/02/ 07
\1111111..,
EAUTR CENTER 1ltllllllMl 11111\\
2' HOUR MEOICAL./SURGICAl. PATIENT CARf RfCORD

DPMl000071 (712007) PAGe B OF 8
lo/02/1~76
NIA N 000748~98
MEliIZAVBR1, SO
000147
24 HOUB MEDICAL/SURGICAL PATIENT CARE RECORD
DATE STARTED
/0 -3-07
24 ..
PREVIOUS 24 I/O: Inlake Oulput ISOLATION: 0 Spetia! Contact 0 Contact 0 Neutropenic 0 AlrtJOrns 0 Droplet 0 _ _ __ SCALE KEY; 0 e,d 0 Standmg 0 W!Crnm 0 Sling OTHER PRECAUTIONS: 0 Safely-Faft 0 Bleeding 0 Aspiflltion 0 Seizure 0 _ _ _ _ _ __ YestertlaY'$ wt. _ _ _ KG Today's wI. KG IPlealle reconcilo w&lght dl~(ence rr grllilter thlln Z.5 kg.)
Temp
1-1
J~ ~I :",'1 i" P:.....::..IlIi.A-----+--F.~II---+---+-+l-"'~+--+-!---+ru~-+--+-+--+-~~~i"--+--+---j -..
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ORAl./TUBE FEEDINGS Tf FLUSH P.rnDlJOI flmOUlll /lmount
imiNE
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.
Ftaquftnt
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Amount
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. Amount
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I WhC'\
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laW 1400
--
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~~ - - - 1 - - - - - - - - - - - - - -
urClv
....
~2 hr SMI
12 hi ShiM Oulptl!
f j ('\. '"'
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fLUID eIlUIVAlEflrS: 1 01 . . 30mL
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Ii 2..
Tw~nlylour
huur I~I~I
PATIENT LABEL
AIl,P~'
8 Ol (1 cup) . _...... 240Hll 12 or (sod~- i can) .. 360mL
~SSM DePaul Health Center r e -r"- - - - - - - - - - - - - - - - - - H A l ,. Ii

I< R
DEPAUL HEALTH CENTER I'lARCH, PHILLIP

0727400691
/11111111111111
f<]
lip
24 HOU:; MEDICAl/SURGICAL PATIENT CARE RECORD

DPIA-1000-071 (7f2007) PAGE 1 OF 8
MED 0524 -01
10/02/1976 _HY
1.0/02/07
RAHMAN,ANWER Z
000749298
000148
DAlE STARTED
A,hillg Buminn
SA Sl?ep. easy 10
IIroo,e
3IUUsaUIe.
ey~s
1 Medk'alion
:il
]~~!!i!~~
APP '" AS:,\JIIIC pain pre~~1 ct
1 Awake and .181'1

2 ShQhny drOWSy, easy to Mouse
CnlT1lling Cg '" CrUsI!lng

01111
GllilWllIg HA3Vy
:J
AclJvdy
Procedure ()(hgr'
Freq~tiflily dH1W~Y,
Rest
Behaviors
TIme Rlfing $cvr~ II
$~alv
drift closed during conversaboli (tllnsldar reDucing apicid dote)

4 SOf'MOlent. difficulllO arOll~.e
;, 4 II 6 7
8
Am!JlJ!alinr. RCPO$.loon Relax31iCfn Calmin9 StatemenlS Prayer/Mooilobull Splrltull Cars
9 Hl;al 10 Cold
11 MusIC
17 Epidmal
18 peA
19 Preemptive
12 Touch
13 Imagory
analgesia
70
Pr.,'$we
neep f\rathmg
14 Massage 15 Distraction
16 Edrw;!li,ln
anaJ(lCSi(: 21 Olher'
ConHnu~u~ i'~uSion
St
Sr
#
Und ~r
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Locaiion.
Behnier or ,.pp
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i I:
InitialS
L
L
!L
BEHAVIOR / PSYCHOLOGICAL
BEHAVIOR/RESPONSES: -E
I
D
"'" - AnKioll'
~
= EmQlioRll DisJross
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U - Unre5pon.ive
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[IE
O_p"-nion
CI .; CQgnitiva Impair",.nl
= D";."'fJ'l\90lallmpaJ(0\~'"
b,.lIooU., copffig
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w = Oolib&rlJolV WithhQId'''''
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DP - PltiNPliW
~ ~
pa~<mt
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Slttping
T ; Threattnlng Phvs!Cal
H"rmi'Coml:>alive
Q - Calm/Qui,!! COP" COOjlatiV& tA .. les. AnwlOll~
INTERVEN'UONS;
1. R9ifStnJr,sHce - Pannt I Signmesnt Olhb( 2. Redlreelicn 3. Gufdtnce 4. C9f1iifl,nt Ellvironm,jOll RIUJO", S. EJlabli.h 'flain1alned tlmslrame, for eare neeo, 6. EnOOlllftg. vBroa.llzallon 1 EflCQurng:l pnlien\ with (100t:'1ll;Jn mrurlng for C'.Jl~ naed-:J
11.
e. Olla, f'squall! hri.f co"lacl 14. Rooriaflt f Remotivate I Restating tu-ct-& ProvidE> inform.ilon to in<:rea." J&vlll of u,1<IoTGt,,"dil'lg 15. Divarsionai a-ot.vitias 10. Encourage lamrly 10 Mag In tammar objecTS 16. Proactive m&'i:liure,. 11. Provicl" r"faxiltion wflh rrome. un~g"ry, 11"9 1I,"lhmll, pfl.Yir. mildicali90 17. Rn$ns~ I RilQVUlion I (iNk clarifi<;~lion 12. ~CQ"".ge normalalefip cVC~ by using In<llrecl "ghtino aM! d.(k 1e. t:stabUsh boundari., 13. Oark.n room I LImning touch I 19 Provlde Inlen.l", S&CUrll and 3!l1My m&",",.,
Qulat '1igo to
d~etUI.e
p;,donl's
ra;lpo~
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MARCH,!'HILLIP
0727400691
IIIIIIIIII.D.
I'-tED 0524-01 1'-1 1.0/02/07 RAH?1AN r AIDIER Z 000748298
rIp
10/02/1976 31Y
C
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DPM1000-071 (712007) PAGE 2 OF
DP
000149
24
ACl.
Poir
26-3 38-5 56-7
8H
96-;
121
+
REI
71-~
NOTE
liTHER
FROWT
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SL.I DL.! TL.C

RIGHT
P
SLlDLlTlC
R T
S . ~tW~
Ins8l1lon Oats
length _~ r.rn
G
E
PATIENT LABEL
~SSM
l'tIAI.T""'AfLe"
Jf!~'A'PTtIIID 0727400691 MED 0524-01

10/02/1976 31Y
Rl\HMAN, A."N"WER Z
1"1
DEPAUL HEALrH C'ENr!?R
rip
0. H"
DPM

DPMl000-011 (712007) PAGE 3 Of 8
10/02/07
000749298
000150
~OUR MEDICALJSURGICAL PATIENT CARE RECORD Patient Care Acuity Record

,---_.
DATE STARTED
!b ,3 -07
ACUITY LEVEL
ACUITY TOTALS
Subtotal Section "8" - ....
-~
Points
26-S7
levDl Subtotal Section liN'

1
2 3 4
3855
56-70
Subtotal Section
TOTAL POINTS ACUITY lEVEL
He"
DV
~
'Ch
~~~~~
71-83
84-95
Sitter 0 ~ + REQUIA"ES FURTHER DOCUMENTATION

NOTE; II more than ona iTem on a line, circle the l18fVice indicated.
951.20
5 6 7
?,q
g-
DEP1\UL HEALTH CENTBR
~SSM
.. E" ...
l T I C A R.""
2~
MARCH/PHILLIP I/P 0127400691 MED 0524-01 10/02/1976 31Y M 10/02/07 RAHMk~,ANWER Z 000748298
1111111111111111111
DPM-1000471 (712007) PAGE 4 OF 8
000151
f5(

KEY: '"
WNI~$
OATE STARTEO
':3 .-01
f.t,
At
I)r ta$k complete<l
IAlert. nriAfllM~ tAlI""'" M,;'m.M"

f
~~:~DD~~~~~_~m~_~~~_
* '" See additional commen1s

V' Y
Use bolded key lener if indicated
IJI~~~ltI
ILOG ISpeech clear
Confused. Lethargic.
Pc
ISpeech (Aphasic. Delayed, $lurred)

IMoves iIIllfilf1lll11llttl>
Motor response
Iv
./
oJ
~
A w S p.
(Abnormal !laxion. Extension,

Flaccid, LQJ;altzes. Hono,
SPastic, StronQ, We~t

WD-Wrthdnws)
GRIPS
ITremor.
1S-!!rIsk
PUPIL SCAI.E
S.Slugylsh 1nm zmm
C-~~ll>'''. C!(Jsed
1m",
Hi'~
.
JIllIl1
e.
1mOl
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7rnm
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ARM LEG
1/ L
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Cc
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lDvspha{Jia iPrp'f'nl
i
Ah""nll
Numbness! TInglirlll.
R/L_
!
Posterior
alllooos clear
Abnormal breath sounds

Specify abo Jrmal breath sounds on diagram.
TIME
~ ~1m1m IE ~
a3D1
(Absent. D'lcreased. CRackles. Rhonchi, Wheeres. Coarse)
,~~:
L POSTERIOR
, gs
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TIME
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AI
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CI
POSTERIOR
I" I n~.II."IUlY ./lUI!
UIll~UIJI'U
Iv
Abnormal fE splratory effort Dyspna3 (Ou Exertion. a1 Rest)
i Cough ICouqh and ,Jeep breath

Incentive spirometer # mL I # reps
~ -,' .'
~B:
i"" i .."" .. I . "'" 1-"
1-'"
j ... , .- 1-" ..
. ;' " f""'- ~ .."-'. ~".,-- f,r" ~/'" I,,'.... 1-,'" I,,"" L,r-- I?,.. I"f" I,,"" I,.,'''' l" 1,/ 1
I Sputum {dalcrtoll amount. Golor, I Suction (Nasai, Oral, Tracn) I Trael1 care
~
FI
81
Be A
La
o Trach Iype.
1-----.. , . I VenUlator SeltlOOff: 0 eMV 0 SIMV

! Verrtilalar . 1-----"
___ Size CI CPAP Cl Sf PAP Settln9s
NI
.~
.,'
(verified per arder)
..... -
---
m
si
$1
N
Comment;
Time
Locallon
Water Seal
CHEST TUBES Suction ..'"
Crepitus
Drainage
DEPAUL
0727400691
PATIENT LABEL
01
01
j/ ,./'
--"
HEAJ~TH
C~NTER
MARCH,PHILLIP
1101111111111111.'11
!VlED 0524-01
liP 10/02/07
000748298
DF
SSM CEPAUL H!ALTH CENTER
--
... -
,.,/
24 HOUR MEDICAUSURGICAl PATIENT CARE RECORD

DPM1000-IJ71 (7f2007) PAGE 5 OF 8
10/02/1976 31Y IWIMAN,ANWER Z
000152

KEY: .I WNVs or task completed
= See additional comments Use bolded key letter if indicated
OATESTAflTEO
/0-3 '07
A-Absent
..Weak S-Stf(JIlV D-Doppfer Coloriemp sfnsalion
Will c 11;" l.e1 f"\' OJp !IMlt It!ll!\tn 3 ''ItlMl. sUn ~:JttTt wlh hi fiMSJ
~lalGiitlI ~1Im.a
amJOO1I~ m 11Ott:1
I! .. flu,,! T ~ Trw, 1 ~ 1+
II,
I.
I
~.
f
;)F;PAUL Hl:::ALTH CENTER

(7/2007) PAGE 8 OF 8
MARCH, PHILLIP
11I1I.fIfIlIIJlIIIII~D1
lip
0007'18298
0. "
DPI
0"/27400691 l'fED 0524 -01 10/02/1;176 JIY M J-Q/02/07

RAHMJ'IJiI,ANWER Z
000153

~Pjl\RI\W!(!I!'iI!ilnl
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7 ~ifatr; Y e~~itioJn JIM niMtr!~>lln ~'e~.,e;jlt'l="," h:lt
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3 To;,! rffi.l'" h,''l'''.''''''

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lTl(!.rmern l1olfole ~ is modcoll, dWWll,i"1'I (00. ',.ltfemJy
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~SSM
~ f
.... I. T J\
'V A k
.-
r1ARCH, PHILLIP
2t . HOUR MEDICAl/SURGICAL PATIENT CARE RECORD

DPMl000011 (1/2007) PAGE B OF B
I/F t)727400691 MED 0524-01 'L0/02/1976 31Y M 10/02/07 000748298 lUUH-1AN. 1\NWER Z
11111111111111111111
000154

PREVIOUS 24 1/1); Intake OU!j)vt _ _ _
DATE STARTED
/CJ . c9- '/)7
241
I!lOLAnOH: 0 Special Contact 0 Contact 0 Nevtropenic 0 AjrbOln6 0 Droplet 0 _ _ ._ _
YeJllmll,y's wI.!J
Temp , ?Wse
SCALE KEY: 0 BeQ 0 Sfandillg 0 W/ChaJr 0 Sling OTHER PRECAUTIONS: 0 Salety-Fall 0 Bleeding 0 Aspiration 0 Seizure 0 _ _ _ _ __ I g,~ Today'll wt. KG (pleillle reconcile wltlght difference if grealer IIntll 2.5 ~.)
(,?
10".(.:. q"l
.2\
I
Iq~
~I
~/
~
lW
Iii?
102%/ Rate
l,\5l.., l/r /"'- . / / V 1-,// / / v / V/ V
1/ / , / . /... v/ ~C,/ L/ k::: l / , / ' / /-- ~_/' 7
IWO
liP
_~_,,,,-,
-/
"
02 d~Ji\l1!flllj OOVfC"
Bedside glucoSfi
Rf
11[$1'
I !!!E. .,"~ II
......
--'~'
;
In!'''''
~UlU
ITEM,
11' ~E
BP
!i'Ulif
""p
110 / ______ 8P " " " " ....

.//'
-,---.,..----~AI(FAST
.-------,---~-'
...
~
n.PHiTI.'
$lmC
If
lei}
flatillll'
11M
p
Snl9U P
DfiS1HYl
,..-/
.~
~)
~//
~-------
----/
LUNCH
.~'
DINNEI\"
IE
,~/ H5 SNACK
.----/
__
BP
/"~
funcliOi
txP.{J. I;(f:
J
I PC1 L![J
htaiu:ll
"
mOl!NGS Tf FLUSH
. Amollnt
R p/A-IIJ rJ
V
Bellavlo OIIalily
PIR<II"".!
_f}RAVT~E
. URtHE
An~t
Jl!I!ER
IJM
Amrnmt
!\moun!
: .0.111000\
TYPf
~:~
"1
-
i
-
ORAl. Amovnt
AmOlJni
Arnllunr
AmCJOl
Am)Jfreq.
~
~~.
1200
1300
Se1l3litJI
~-{.Cr
\.'-"'
X\
()(~
IntrIVlIll
UP
<1 1",(
:~,..
Initiali COMMI
1406 1500
~OO 1700
,BJU/,
')(-_\ v
....,
'iV
,~
<;./
t...r
""""
rx\
1100
S\lb Totals ~ 11 hi 12 I1r Total f".u~lllef If

To Count 1900
.-
.E~-it- _ _ - - - - - - - 12111 Toti! Oranuoo _ _ t

1;> hr Shiln"lItke
---
--------12 hr :,hiftQtltput
.:.-.s00
>-
=~~
0100
W()
.-r----
'vJ.L!A,fA-
"
"
lJ
L
fI
OlOO
(
[
!J'
i~
I
ij
---~.
121lr
Suu Tlltllls
----~-
1? hi TotJI P.ucillefill _
1~ h. Tolal OrilllfubJ; _ _
17 hr Shill I<ltake
r~.four
--
~----
.---~--
--
f /" .tr"O
hour 111111
,,",
...,..
12 hr Shift OutPlrt
~~
....
, ".....
FW!D [QtIIVAlE~ T8:

10z ..... .30'TlL
4 Ol (1/2 cup) .. 120mL 6 oz (314 cup) ... 'llDml
B oz (1 cuP) ....
. 240mL 12 oz (soda-1 can) .. 31l0mL
.
MARCH I PRll,LIP
0'12740069l
PATIENT LABEL
~SSM
1'!EALlH
eA.RI!

- - .. - - - - ---
1 1I111111111110U II
. I/P
000',48298
tYA
H f
a, L l
Z4 HOUll MEDICAL/SURGiCAL PATIENT CARE RECORD

DPM100<Hln (7,2007) PAGE 1 OF a
MED 0524 - 01 10/02/1976 3lY M 10/02/07
RAHMAN 1 ANWRR Z
DPM-l00
000155
DATESTAATED
;tiJ~t)'/
241
APP
= A:l50ml
paIn pl~6nt
BRhavinrs
11m.
R8t1~Sme#
S~e "
# of,
SCilla Used ~r OllimallOll

hnCllon Goaf II DesCllbe:
FR, RT
location, Behavior nr APr

Quality
Frequ,ncy
AllflllIflllIng F"lm
Sedalion bYel
Inh:r'll1nthmhl
In~i31s
COMMENTS;
8EHAVIOR/RESPONSES,
III
~
Mulliplo R"'I"001
AN", Aru"'... E - Emo1lomd [,isIr~s

I '" I""lfucti,.., C'pm9 o '" OovBlopm&rial Im~.irrnllnj
C - Con1inuou~ Crying DE = O;lprntiQI'I

G
~
Grt....ing
I.; 1.$Ihf!rQi<;
U = Unnw"omJ"a CO= COmato" CI ~ C<;gnitr1i1'mpiirm91'1l R = R6SI!&"
co = ConfuwdlDiwri<>nl<td H = Haliveillation&i D ..lu$loml

W - D;I!lb."'1e1y WiUlnolclil1\l
Inl<> A ; A"""llOn S'vktnQ
Of'
= Di.,UpW9 Palienl
Slgnifi""nI Otl>er T_atlnlng Phys.eal
1M'" Imp",.ivo
OS = OisruptivG
T
10- Slttf)ir1g
0- C-'mlQ\!i9I
COP
o ~ OvImUmul'l~dfOvv",actlv.
Offo.r fraquont bria1 oon1m::1
HarmlC'XTttnllvi
f4 RotJtiunt
I.A
= L*n AnxiOUI
=Coo~r.1t~&
INTERVENTIONS:
1. Roooaumnc:u Jlalloni J S.lgniflcarn OIhDf
a-
I RamoHY1!to J "Rnstating faC1s
2. Realreotitm 3.. Ciuidanctr

~.
~.
9. ProlltdQ in1armation to h~(OOb'-D I{fllel o.f tJoderstanl1ing 10. Encou,al/" tamar 10 !>flOl/'" IannI , object.
15 16
DivnGtonal a-C:tivi1ie~ ProacUve. m9RtiUfQS
COOlilitllnt E<wlronm.n! I RoV1U1.
II, Provld& r.taxatlon wilh rnu~K. imitg9ly. deep Ilr9Wl\l/. pra\illr. m&(/IC11100 17.
I;
Elllbiish ma;m.inlldlimefrimps for care needs 12. Encourage norm&lsleep cycle Dy uSing Indlr"lilQh1in9 aflQl' dark E1WQLY~& vl"ballzmi(m 1S O"r'.~n room I Umfllng touch I 7. Enoourag1O pntilml wnh <lecl.ton ITlI\klnll for OOID noem. Q,jlet .111" to p~tl;>nf'. '""pon." 1<> .Umutation
0;1""'8.'"
Reasi~1 I RlK\Ue$llon l Se~k claril'l(;<lUcn 18. "5m1>1I5h boundllles HI Provide lot~n!lv. IIX'tJ'lIy and ,Moly "'989me$ 10 mlnimlr8 bat-a""",' prohfem3
PATIENT LABEL
~SSM
K
~ ~
L- T K " t. #I. R
~.
MARCH,PHILLIP
IIIUIIDII.IIIRII~
r/p
{2'
H A
24 H('UR MEDlCAUSURGICAl PAT(ENT CARE RECORD

DPM1000-071 (1/2007) PAGE 2 OF 8
072740069l MED 0524-01 10/02/1976 31Y M 10/02/0'/ 000748238 RAHJ'.1}:I.N I ANWER Z

OPM
000156
S~e
#3
Nt
# 01 attempts for IV rBstart
"~'
1,
I--
~, ",)
\ \
BACK
,M LT
t-!-(-:-:::-, -It/IJIJ-lum-:~_---t-0 _ _ _---t-0_______-!-s_ _---:---t-u....,

TLC-Tril!l</(JIllI!"
{, J
tjFilJ
, /,':fJ
\\1\
SLIDlfTlC
SLiDLITLC
Insertion Date _ _ _ _ Lenqlh _ _ em

Arm circumlerence
em
Dresslf1(l changs daIs _ _ _ __
,
I
i , I:
PATIENT LABEl
DEPl\UL HEALTH CENTER
~SSM a r
It
It \,
K ' (. /II "
r-
MARCH, PHILLIP
0727400691 lO/02/1~7&
RAH~~IANWER
IUIIIIIIIIIIIIIIIIII
I-IED 0524 - 01
II P
24 HOUR MEDICAl/SURGICAL PATlENT CARE RECORD

DPM-1()(){'~71
31Y Z
M 10/02/07 000746298
(712007) PAGE 3 OF 8
000157

Patient .Care
ACUIlY LEVEL
DATE STARTED
I() ';;., 'tJ I
Record
Points
2637
level Subtotal SMtlon ''A''

1
ACUfTY TOTALS .. -
C,
38-55
5670
7183
2
3 4 5
Subtotal Section
~Bn
~f
Subtotal Section "C"
1
I/O.
,'r!
! i
84-95 96-120
121+
TOTAL POINTS
Sitter 0
6 ACUiTY LEVEL
7
.;
f'ATlOlT LABL
! - -+ ReQUIRES fURTHER DOCUMENTATION
NOTE: If mom than OfleltefTl on a hne, circle thD sorvice indicated.
~SSM
H l " L. T H
'O),,,~ ..
IIII~IIIIIIIIIJIII'I' MARCH,PHILLIP
DBPAUL HEALTH
CENT~R
lip
24 HOUR MEDICAl/SURGICAL PATIE:NT CARE RECORD

DPM-1000-{;7' (7/2007) PAGE 4 OF 8
0727400691 MED 052{j-Ol 10/02/1976 31Y M 10/02/07 RAHMAN,ANWER Z 000748298
000158

KEY: ./ WNl:!. or task c()mpkJted
DATE STARTED
16 ;J-07
24
KE'I
*=
See additional comments
U5e bolded key let1ef if indiCalQ'd
},piC Abn
Peril
AA w-\
$S
D-[
Cole
VlNl It;JIIf
s~iO~
[illili
al>10
San
pac
T[
TEE
Se[
Se[
AV
SpllcHy abnormal breath sou nos 011 diagram (Absent, Decreased, CRackles, Rhonchi. Wt'6llZ11S, CQars6) Bru Her
CAl Exit Dre

L POSTERIOR
A
POSTEI'lIOR
Abnormal respirlilOlY effort

Dyspnea (on Elrertion. al Rest)
Ati~ AM
Bo~
Bov
Ab: r-
~
~
Las'
IBa
Tut ! , OS!
I Sto
rSlo
~
PAr/ENT LABEL
lOS!
DEPhUL HEALTH CENTER MARCH,PHILLIP rip 0727400691 MEn 0524-01 10/02/1.976 3lY M 10/02/07
IIIIIIIIDIIIIIIIYII
24 HOUR MEDICAL/SURGICAL PAT1~T CARE RECORD

DPM-l00().{l;'1 (1121)01) PAGE 5 OF 8
RAHMAN,AWnEg z
00074S29~
OP~
000159

KEY: .' WNls
Of
DATE STARTED
task complel6d
* = See additional comments
/0 'r:?: n
2l!
KEY;
Use balded key letter if indicated
...
Peripheral pu ses
A-Absent WWeak
S-Strong a-DopplHc
Urtr isp
llrir
FOl
Color temp s'lnsation

I'INl _ Nail bed
)~It.
tap
VQi IVI
Abr
pm
CBI
!leQ
Su~
Ora
11:
~SSM
MIA1.fK
(AIIt'-
DePaul Health Cerlter

MARCH, PHILLIP
rlnIDIIIYJIIIIIIIUII~
rip
000748298
o ",
DP
24 HOUR MEDICAlfSURGICAL ~AT1ENT CARE RECORD

DPM-l000-<l11 (712007) PAGE 6 OF 6
RAHMAN,ANi~ER Z
0727400691 MED 0524-01 10/02/1976 3lY M 10/02/07
000160
24 HOUR MEDICAL/SURGICAL PAT.ENT CARE RECORD

KEY: .; WNE:1I !;II luk compllttlld
'" SiMI Ilddltl!;lrn'll !;ommlmN Use bolded key leller if indiGated
DATE STARTED
10 OL '0 7
24 t
Urll1e CViClflClanly
BIQo\ly ClOt .sC\l!!ll,'Ilt

Arl\Jli~,
FOUIsmelling CI.GUIly Olner YQiQing,
FuJw.
Re!ef Oon,
IUMjiiJIlie ealll.
Abl1Dlmal urinaryvli6ing paltem' Inellntinenl,
FIl't[Jellty,
U!~Clll'"
Dysuria
AtTEflfD SKlNtWOUHO IIEY: PU ~ Pressure ulcer If jlTe,.,;ure ulcer. list Stage I. II, III.
'" 1it>r,1$JOn
ItL
. Blistar
L
R T8
= IncIsion
~
laceration
R;rsh
IV, UNstagtable V
N
55
'" Vasculaf ulcer (venous ,\\Isis, art~rial
=Neuropathic ulcer (diabetic) = STiIfi sr!!ps = Oermabood =i)laple<;

O~n
\m;lJfficiMcy)
SR ~ Brui~~ D - Denuded E '" EI ,'!hcm~ EX = Excoriafioo H = HemaloTllil

Sunournljl\~ I IrJaCl
Tape bum
o
= GrAAn
WA '" Well ~jljlI~;\imaIQd
=(IlMI _ _ __
Drainage Amount:
Oresslng: D
8
Wond Sad Key: Q = GrarwllliM S : Slough

E
e
E<dw
O'J~l
E II
= = ErytIlema
Sflln lay: D.alnage Typa:
o
S 88
liIe = St.
5
=:
M1r..e:abon
OTA -
to all
o -
= 59JO"fl()lllre!","
L
~
SelOUs
= Smilli
~ M01li!ram
R
DI
= R~!~lIligll ~U!IIfCO
C - Cyall!lWDark _ _ _ _ _ 
Drainage YIN
- Dry an-.J IfIlaCl
-Otner _ _ __
Y C
- '{flilow ~ C1u>ly - DtM, _ _ _ __

R~assenmefll
TillUl
Sit! .l~.
[)reulllfl
"
WDlmd
Bed
I}ralnage Amount ot Odor

Type
Tim e BAli Initials
ONR C{
eI~SSM
H II ,. L T
.joI , .; \
R ,"
IWlllllIlIlIIIOn MARCH/PHILLIP
DEPAUL
HEAL1~
CENTER
lip
.~
H E A I

DPMmOO-<l71 7/2007) PAGE 7 OF a
0727400691 MED 0524 -01 10/02/1976 JIY t1 10/02/07 RAHMAN,ANWER Z 000748298
DPM1
000161
~r:d
mAvgtA Rt2ifllru
MoDICA!. RlJ.iqft 101 Bw,atn\

I PrOk'{.1 all nftiftUa il..ir,'4ar OJH1!Qf a;(~n I!ehH'f {e.g.. 10
1 Cl)mpaJnQwm!l'~pe-IVis!OO
GocUIru!rtf
Rlt:trJlot fdU1fiUoo OntR aM1 i,:,o,;f(i!1

c(l')
IWI Hrtl!;nft KBy

(1.1\
pl
<
2 Cl/ir. '" tJ n"",1r 001>:,,,,,,,,, Rl: glcd, reed r." rV TF, eI: )
:\ Fflvi!{inmeort.,j H!Ull~tJ..JHf.1fl!J (ec::11 rvtS1!'j >Jt.tiIQJl,
'Jwxlal
moInIain en001RI<:In&i1tWh.'ltJ tutts) , ~t6flt.Wl ul'IJo;-lor-e HIt!.,: Of IJ.d.'(,"J C'3:SCilt41 to tht' trNtmcn1 01 {tJ!l
patkot"
OL"~!l1 "\)!l<ii<i~" (~.q.
V'f'",'I. ,~... tl'SC.
I
2
~
i)nai}ie
to cOlltract Ii.\!
saf~1
VI'" oWV~iWon OC'II'lllt<lH tG!oAng

atiN Oli(illl!O With
le.m~r
e..~. In p.al 3' h>h,.;. &n,,, It

An/firf {ltJT)<j/\WftC) (.Sh Of f!i1ljlllY
Co~m!1ve
cailt<llt eli 1
:\
5
Rr~.Jl~y Of~.'J
nrri:ls~\ll
f.Jtu.vI
$* $CV~~ of l'>'.arfuo.',
meOkil!lon B&nlllilt'alln 0' hydr.t,l)Jlj

{fUlj.,~llt~
1 RnS0l11O!(Wram\
'.I. As5a~J11!l1l YIfAA h,l!Tw':!\
M~'lk,'t~(Hl ..t;"AB;)lI{~
tr:1idy
0tltlif., w,1lk5
I!\:l!~l:
t:k)
~Mif:ntif,]m
iy oot:r-..310l
S"rcty p.r,:nts who arc inc'f'l,iIale" fr"", .n i!liulY (jf !uflliw IllQteQij," who \I'cuid svtkr (",lIltr.l i lnty t<AVt fXCt.<i'l mQ\,~leN. belm it Ii 1!ltO,.Il!y awo:m!le (e.o.. erut!l'll1y
frK..w8s or Ya-sttl~r S\Jf9'ftrif..~)
0'
,.,1IBrrtr'l m roo.,.,. <YWif'!}f.. ""\$.'. i<lr. eM re,l!2ln' WllO'fe<l

{~.Fp.
1 111\11 "'.,,"'" Im'l'!!',!!"" 4 eetlav!}. reqil~eO !(jf remM.1
B Uf rurm In !\Ait (jj ftft\P.{.~
R...t'~:>jH)f<l1
nestri!Mt$j
AN! UlildOl.' i~n sls,m''ilif.lreiilm\j tPil
OOtu.
4 PrI)le<t1he bfi\in ml\llY p;W<1 110<\1 1\Kt!W tnjUt)' [Il-Q eVA ""lh
pa'alyhlS
o nH"VlllMlIl'iSTlWNT1;
(t15 f(Jfl dl)t~nrr~ittUJH
or Man trdUfIU W!l1l.001....1 ~""'J
s"" .<lOiliolldllwwst'Ollt lill
iii, Sea
ACTIV TV
BSC= 6edsi<le Commoot

A = Ambulate
C = Cha1
D '" Olingill
, EY
POSITIONING KEY
R = Right L - Left
5 = Self P", PlUne
D - Back
~SSM
" " Ii t 1
C" R ['"'
MARCH,1?HTLLJP
DifliiilllilillCENTER 1111
MED 0

DPM1000071 (7/2007) PAGE 8 OF e
F.AHMAN~~E~l~
lO/02(
0727400691
524-01 Iv! 10/02/07
rip
000748298
000162
~!I~S~4~o~,n~ED'_CAL~::p~RGICALI~!!!~~S~r.:!~~ ~:~~~?upenjc Ail~~;~eS~R;!~!et ~o 'j -07

0
SCALf KEY: 0 B XI 0 Standing 0 W/Chair 0 Sltng OTHER PRECAUTIONS: 0 Slll!rty.fall 0 Bleeding 0 0 Seizure 0 _ _ _ _ _ __ Yetlerdar's WI. _ _ _ KG T~day'& wi, 16{d IB'S-mf (Please reGDnoile weight tiifleJeflce It greater tllan 2.5 kO.)
. T~mp
24 H
Aspiration
PuIsB
Re('p BP
02S2l
02%.!FM~
//
y/
/ / ' , / / / / r ,,/~
r'-"
IVL
'.
.....,"~
TlMI
'I,lm
RESP TEMI
----~
l// / / / / ./.,:: V l:7'" / / V
..--
----
?;?,
~
"11L
I//' l-/ / / , / f ~ ~/r [ / / / i/,/r V"
;;2.1
)riJ 'fJ./i
filii.
T1M!;
liP
'PilLS
RESP TiMP
TIME
BP
/"/
PU~E RE8f TEMPO
."" ""~!!. ""

11
~~ . . /.<
~r
r"r/
~
//
....-r'-,...-r"
....-~r
.~
D
...
Rating S
DfiTHO
STATIC
TIME
iTlME
BP
/,/
II!'
.-r""
....-/
"""
liS SNACK
~~
BREAI fAST
i
LUNCH
DINNER
!
I
I
takcl1
I
ORAVTIJBf FfEDIN(;S ORAl Tf fl.Ustl Amcun\ Amoun! Amount
QUlIIlI'(
URItIE
AlllW(ll
OTHER
TYP~
fuCOUll1
Frellnn
8M
A,'1(l\Jlll. Amount
_AnlUn1
Amnunj
AmnunI
Am1JFf6Q
"g;rava
Sellall~l
0700
0800
-
~~~~.
1100
-"I
I)
mil
1300
~oo
1\ !J ....
OV
,\
1'00
1600
1700
1800
Sub Totlf&
"
~
/'
I'
m I" ''/:..
,/'
.1
.0 rrvv .."....--
l.
---
..--'
.-
Inlu\'~~
lniliils
\2hr
_______
._ - -
1211r Total ParenTB al

10 (10<,1"1
12 I~ lolal Oralrrub~ _ _ 12 hI Shift Intake
----------_
12 hr Shift OUlnlll
~OO
ZODll
2100
INTE~ 1. liaR' 2 IWd
2200 1300
a.
Gul(
4. Con
2400
0100
.. -
ri. Eow
e,
En 7. Em:.
0200
0300
04UO
050(1
..
._._--12 hI 101<11
Or~\'Tiih
----~---
Benavl
0'00
12 hI S'Jr,TotaI5 _ _ _ _ _ _ ..
12 hr Tolal f'wenlu1!: _ _
.-
__
,
Pa1I8n ImerV8 Respo
12 h'
Sh'!lll1l~\~
12 fir Shift Output

.... "'1
lUUl
IWltllty-lllUJ llOullolal
"u'" tolal
PATIENT LABEL
fLUID EQUIVALE 1m:
10l
.. 3JmL
4 OZ (1/Z cup) . , 120mL 180mL 6 02 (3/4 cup)
8 (II (1 cup) , .. , '. . c40mL

12
Dl
(soda-I can) '. 360mL
.
D~PAUL
~SSM
N ! A L,. Ii C.
I/P 0727400691 MED 0524-01 lQ/Q2/1976 31Y M 10/02/0'/ L -_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ANVlER _ _ _ _Z ____ _ _ _ _ _ _ _ _ _ _ _ _ _~., 000748298 RAHMAN. OPM-1000-071 17/2007) PAGE 1 OF 8
24 HOllR MEDICA!..JSURGICAL PATIENT CARE RECORD
j
---
f:'"

.
HEALTH CENTER
.-
1IIIIIIlIIIUIBIIIIIDU MARCH,PHILLIP
OPMi1!i
000163
DATE STARTED
1 Medicabon 2 AmbulaMn SliVlllly (\Iowsy. ea'J{ to arouse

APP
9 Heat 10 Culd
11 MUSit
11 Fnldurol
t8 PGA
3
6
R~jlosltlOn
tS Preempd'll!
analq5'J
= .~S"'Jtl~
pam pre,ent BellavlOrs
A{,!j,ity
Re st
3 rrequently owwsy. arQvsab!e. eyes rtriH c1n;;Ro during f.OrwersatiGn

(consider re6uclnu oplQ!!I don)
4 Remtion II Calmtn9 StJI!<rnRn!~

PfaycliMc(i,t~wn
12 louch 13 imagery 14 Mm.3a~

15 [liSlI.Clr;'''
20 Continuous
anal~jC
infusiOn
PrGt8dur6 Other'
4 SVlIlllub)nt. olHiovff tv .J(ousa
e rHtap Br~alhrng
7 SplrttuaJ CalB
21 OtIwr'
16 E(!ucatron
Time
Rating SC:N' f1
S~BIf UiieiJ9r ObijrvaliQD Fun~tiDn
aDa/II
Ot6cribe: location.
B.havil)f er APr
!~
Quallly
frequ~cy
Sidalln Leval
IQwlYentk n{ s J
IFliUill~
. BEHAVIORlRE8PONSES:
r.I
AN Am lOllS
E. Emelle""IOililfasfi 1= Inol1",II." C<lping o ~ !l<I.il<>pmvnlol Impolrmer11
C .. Conllnl)Oua Crying
DE ; Dep",,,,,lon 0 Q Gri.v;n" l = L9tn"'9ic
=MU!\lpte fl8Qu.n
\J " Unrespons"'"
CO Comilt"ic
CI - C"9nil;v& Imp<lirnwnl R - Re.ilow 0 = OV~filim-.t~djOV'ilr8a~v"
r-------------------~------------------------IHTERVI;NTlONS:
1 R"""",,,..,,,,C6 Palillnll 2. Rediruotion
3, \3Yidatf(;&
SI~ni!lcanI
CD = Co"tu."dlOl."".nto<f H = HlllIIIQlnvtiQnlll "'~I~~I~M W - Oe~lXIfl>te!y Wrthholdin9 Info A ~ Allent,on S"lrlng
OJ>
o~
Oitruptivo Pallel1l DI.lUpl",. Signlilcant Olh .. , T = TtIPeBlenlng PI1yslcal
1M - ImpulWi.
S = SIplng
Q ~ C"lmiO",,,1
COP CODf"'ffliive LA = Le"" AmlolJ.
Re$!atin~
HArmfComhafj'iil
----------------------------------~
14. Reorien! f RemOlivate I
Div6fGIonai aClivitiOl
Proactive meN/ulet
OIMr
t;.
Offe, tt~quomt Met contRDI
lact$
4, Con&IHenl Environment I Rol.lllne
!>. ~~u.bish milnWMo Umif,limes to, eMi nood. e Enco",o.". wroaIJzaI!,,"

7, EncuUl'lIgll p;1tinnt with dOOiSior\ making. ror cars
n8ea~
9. Pro"I!Ie Inform~jlo" 10 I"""""", 1 ....1 of ""dDfGlandil1(j 15. 10. EnOOUf"l}" family '" bring in familist objoota lfi. II. Pruvi"" ,qI"""Uon w~" llruslc, imall"'Y. d.... p brealhlng, prllysr. meQlcAtion 17. 12. j;;;cuiilagi! ij(jll\\al ~lNp eytllllly uviflli/ ifl(!I~lli~lltll\g iIItil' !llIk HI 13. Oarluln roOm I Wmitlnglouch I 19,
QII191 s!9n to
Re&SlBI J AlIqtIe~ll<!n I Seek clartflc..Uon
dee.el>" rn.1!eon f6:lPOfl3e 1<> .!im,rt.tf<m
""I1!JIIJh 0001\{1ftI1!i PfQVtd9 Inlu051vu .ecurltv and rely mW6ur". lu rninimu.e bahaviora' f.'ro-ol .. m~
PATIENT LAill'L
O1!'t?SSM DePaul Health Center

H Ii ~ t. T
jo(
(A. R 1-
;~4
OPMI000'()71 (712007) PAGE 2 OF 8
000164
Site #1
Sfte#2 Site #3
# of atternpts lor IV restart
)".-.
-\
BACK LT
Sl. SlflfjtJ htWffll
()L~()~_
I Sll Dl ITlC
LcrT
0
S
Sll DL/TLC
j }
/'1 ( l
~'h'
l\
K
lie
iii
T'~I1h~ "WlPJf
Sl! DL/TLC
\\1\
.IIJJJ~
Itnm.':t}f(.' ~.:~."Y1f1JU ttl'
RlGlH
P A
IV flIl ,'<0$ (ffcwk<l.
l[i
J /
IE\ \\
V
Dresslo~
Insertion - Datil
Ann oireumfomnce
Length~. "
em
ChanQ& date
em
I._-L______~--________._---PATIENT LABEL
~SSM
H eo: 4. i.
1i
A. R -
DePaul Health Center ._----------------

V~CH,PHI~LTP
(4 HOUR MEDICALiSURGICAL PATIENT CARE RECORD

DPM100)'071 (7{2(07) PAGE 3 OF 8
07274006~1 MEP OS~IO/02/07 10/02/1916 31Y M 000748296 R.n.HI<1NI ,~WER Z
11111111111111111 ~.]
1/?
000165

Patient Care Record
PATE STARTED
I0- /o~
AcunYlEVEL _.'
Poin~
ACUITY TOTALS
C---
lev@1 Subtotal Seetion 'W'

1
26-37 38-55
56-70
2 3
4
Subtotal Section "S"

Subtotal Section "C"
TOTAL POINTS
{LS
71-8$
84-95
7
.1, 7
96-12U 121+
5 6
7
ACUITY LEVEL
Sitter 0
+ REQUIRES FURTHER DOCUMENTATION NOTE: If ilIora than on8 ilem on II line, circle 1M servico indicated.
PATiENT LAtJEL
~SSM
Ii [ ,\ l T If
----,,---
CAR" 1-
DEPAUL HEALTR CENTER

!'ffiRCIl, PHILLIP
072'140069:1.
1IIIIIIIIIRUILIal
lIP

OPM-1000Q71 (7/20071 PAGE 4 01' 8
MED 0524-01 10/02/:1.976 JlY 1'1 10/02/1)7 R~MAN,ANWRR Z 0007q8298
000166

KEY: I WNt:::; or tasK CQmpleted
DATE STARTED
!O L .c57
K
:=
See addl1lQnlll comments.
Use bold&Q key letter If indicat;)(j
~
r\
,
"
Motor re.'qIOHSB
(Aboormal flllxion, I!xtension, flar,eid, Ll)Calizes. MOfIC, SPastic, Strong, Weak,
Wo.Withcraws}
TIME
Specify aI. normal brealh sounds on dlagram.
(Absent, OecmaS(lo, CRackles. "hOllChi, 'Vflll6lBS. GQarse)
POSTERIOR
POSTERIOR
A~nurmal
respiratorj effort Oyspneu ,on Exertion, at Rest)
PATIENT LABEL

~rHIPHILLIl?
11U1I1I1111I1II1111
II p
SSM DEPAUL HEALTH CENTER 24 HOUR MEDlCAl,!SURGICAl PATIENT CARE RECORD DPM-l(l{O-{l71 (7/2007) PAGE 5 OF a
0727400691 MEO 0524-01 10/02/1976 31Y M 10102/07 RAH~,Am1ER Z 0007487.96
000167

KE't. .; WNLS or task completed
2
K
:=
See addi1\Qoltl comments
I~r:tl
I::~~:!:~rl.
LOC
Conll1Sed. Lellla[9ic.
, Speech (AJlIasic. Delayed. 6iurred)
i
r:; m III! lEI III m~ 1& _ _
USliI bolded key letter ii indicated
-~ V
Iv
~Ilrl
A
A
p
Mans all,,,,, Gil.'!*',., "i'..'1 equal strength

Motor reSrmlJl!B
ARM R,<
LEG
(A/l(lormal flexion. E!tlension. Flaccid, L')Calires. Hooo. SPastic. ;itrong, Weak,

WD.Wrthcraws)
Tremofll
V/
.i
/
/1/
;/
-.~/'~" 1/,/ /
GRIPS L
R/~ 1/'/ /
/
/
// 11/l,/I //
i'
//
//
// / ; / ,//
1//l/' V 1// [//[;/ l'~' l/ 1,/

;/
[.. /(
// 1/ 1// Ii // ~/ l/i VI .// ~(/ ~' ii/ i/i / / // // lL/ 11/ 1/' ,// / // L/ // 1//1// l'/" ~/' V/
,/1 /,1 // ,/ //
1,/ 1/'1//
1//
Iv
l-
f---
PUPil SCALE
B.firlsk
8-SI1190i~ I""" !!wm 3m'" 4mm
.
6mm
',fixed
C-SvroIleJII Close<! 5,,,m
ee
7"."
..
Size
l/~' ~,/ / / / / / ,/ // //
.L
IR Reaction l?~/
/"J'
1//1/'/ ~/ l//I//1.//~/ ~/I// 1.// ~/ ~/ //

~/ /
~>'/
I
I
1//' / /
,/ / / ' ./ ..... 1/,/l,,/ 1/' l/

//
1//
://
~I~ I
~
,f
."
/"'/
l/
,..// l///
1//1/l/' !.././ ,'//

- -
~(preSB!lI. AuSen!)
IirotlP
rv.,,,,,u,
Spec~v
~'Ti~
l i L _
,,~
am r;m 1m
Abnorl11al breath sounds
TIME
a\l1ormal oreath soundS on diagram,
(Absent, Decreased, CRackles, Rhonchi, Wf'.WlllS. Coarse)
:rl~~
L
~\
~ ~ ~RImID~ IB Btl m
~
Iv
""E
~;~ a~
"
5
~
(~
~~3
R
~4
POSTERIOR
POSTERIOR
,wV/'",",' ,
.unlaoored
.-V
Abnurmal respirator; "ffort

Dyspnea :on Exertion. at Rest)
i
Cough \.
. breath
t[\miiyg Sfji100WIN
ICough an'j
fI mL f /I reps
. color.
.",J
__,r-
.".' i ,r
1,,/' 1,.,,'/1,.,-' 1"'/ .,.-/ ~"'/ ~r/ ,,/
",/'
1,/'
.. , /
. - . - ' ,~~<
_/~
,/
.. - , /
J/
f/'" i
e /'
Sputum ."'"
E(iNaSal. Oral, TfllChi
Tmcli care
o Trach 1'pf< _ _
Size
V~/T1ilatol settlng {verllied per oroer)
o CPAP 0 BlPAP n. '0'""'''''" '''''''''Y~;
-'---
ICMV DSIMV
Comments
n;;;-
CHESTTUBS
PATIENT LABEL
Cf~
location
Waler Sl1al
Suction
.D~
/'
//
DI<.:PAUL HEALTH CBNTER

l-tARCH, PHILLIP 012H00691 lv\ZD 0524-01
111111111111111181
t,\
I/P
//

DPM-1{l(O-U7' (7/2007) PAGE: 5 OF a
]0(02/1976 31'1'
R.fI}lMAN, WiER Z
10/02/07 0OO748?98
000168

KEY: I WNL:s Qr tfik completlld
...
DATE STARTED
_-"-/'=0'--1/,-([2",,,,',-,,-_
24
TIr
= Sve additional commenbi
Use bolded key leiter if indicaled
Pelipheflll pub;s AAbscnt
WWeak
SStrong
D-O~ppler
Urifle
Is pal
Color t~mp sl;r.sa!lon

VlNl- NaltlOOllliLtlO
rr,M:t>;lts'!i!han
3~WIfB
$'.W".1111 w4J1 fiji *"Ia

ton to t""ch Dnn tt
<llillMmi," 001'$
Urirn: Fo"l Voldl JYjlf.

AllI10
FraQ\
CO! {I lleo c
SVJlft Orain
seDS
=on
0 := removed
DIALYSIS ACCESS
----~-
SIIJoI
"'au...
Diap: Muc(
Skin I Heet
WOOf
AV fisltJla/Grat Site:
BruWTtlltfl Hemo access
---~=;;;....j~..-*--*--;.J--4--;>+-*--;>I-+-J-*--+--;.J---+--;>I-,*--="-:.I-....,.t.--;.I-""!---;>I-+~--:l
CAPD calheier
II sk
-, I
l
E o
H ,
DEPAUL
~EALTH
r~CH,PHIL~IP
11101111111111[1111118
CENTER I/P
24 HOVR MEDlCAL'SURGICAL PATIENT CARE RECQRD

DPMl0000r (7/2007) PAGE B OF 8
MED 0524-01 M lO/02/CI7 RAHMAN,Am~ER Z 000748298 0727400691

10/02/1976 31Y
. j
DPM
000169

KEY: .' WNL:s or task completsd
DATE STARTED
La
i (J7
~ See additional comments
Use balded key leiter If indicated
II skin with airef8liOllS: IrnJlcale sites with numbers on ligures
ALTERED SKtNIWOUKD kEY: PU Pt~S:;UIa ulee! If r.ressure W;er, fiSt Stage I. II, III,
BL 8ft
V
N
= Vastular uker (venou~ slJsi;. ",ten.1
IV, Ultstageable
= NeuropaUlic ulcer (Oia~efic)

= Ot'tlna!Ju,,"
- Stoplas
insufficiency)
Dressing:
5$ - Sterl SWpl
WOllnd Bed Kty: a - uramn.lion

S
=
SIlIfOl.lll~lng
"
D I! = E,yUrema iiI ::0 FxtoRlfion = HemiJloma
- Abrasion Otister = llrviSC = DSlllIflRd
I
L
Te
,.,lncisMI = larlYalion : Rash % TaP'l bum
WA 0
= Well apPfo~jmared = Other

DrIIlnigt AmoWll:
IIC ~ SI.""I!
D
$
SI<WlIIi
OTA - OlWntlJalI
R
DI
M
o = OO,er _ _ __
Time SNe No. Omaing Wound SUJfIlundlng Oralnagl Anllllml III Odor I/e~ Skin Tvpe Ur8inallo YI H
Tt~lmenl
= Ri!lMtim ' 'Itiff'_' = iily and IfIlact = Monll)(llMfY Jraf'~
Ii = Es..-:hll () = OWr
J Ii
= Inlacl = Etythema
Ull1"
Skin lIer: DllIillllg' Typt: G = Gtaun
II
- Strous
M Macer.1oon
C - CyanotlclOa1\i
= CfU~1y o = Othflf
C
111 = S"w"illly"iIY_'JU1 lit PU - Punll!mt L B ; 61001!y C ., = Y6hw
= LM06
Small Mwer.te
= C<lJ;lous
.' IMI~alet
lIeo$$1i$$melll
ND GII1n9fl Time and Initials
~SSM
IoIfAt,.T--I,ARi
DEPAUL HEALTH CENTER MARCH,PHILLIP IIP 0727400691 MED 0524~Ol 10/02/1976 31Y f'l 10/02/07 000748298 RAHNAN,ANWER Z
1IIIIIIIIDWIIIlIIBU
III HOUR MEDtCAUSURG1CAL PATIENT CARE RECORD

DPM-1000.Q71 (7f2007) PAGE 7 OF 8
000170
24 HOUR MEDICAL/SURGICAL PATI ENT CARE RECORD
MEDICAL
~i.&d 19 Aypltt
BluhohD
MWlCAL 8 ..... t9r 6tlltl\1I1

I Pmtcr1 an artlf~ll flct!W{fy ur~<"r;! Ul)'~\ de!<\.iWf {e \J 11\
Rntralfti
EttU!@t1t1n
Hi;!! RehrJg!
tJ)-!Co~NfIl.Q
Key
!lt1tr~~ t;ftet..
1 4iJmparl'l'Jfi JT-p!;j~s;un
Ooc.menl tiro, 1110 Iwnw, (ie' ~l.

wetll.i~H,eI';;
~/l d1
i ,-h,hie to CCn\<lt! jo, ulety

2 Gcrtl lJ) ,ujjl .. " P.:1f.
2 Cnar.qf 0( IJ I1'inItl (>Ol1'""S{.q-~ ii' lfHI'J! OMi! 1Uf IV, 1r tIc,) 3 EMUorlll1e~laJ msn'9l'lat.iG<l1 IMa! W!H SlallCfl, 9PfC~j
elU 1;gIL Q! ;.)

'1 Rt<I~' ooe'~n
~.!lOnmmliln
DMls.II1Ai act","/ (!w.UijDS, vw.w, wall:s. muSIC, etc i

PaIl!l>tlfl!l1lye.l~~
AN billQeI,S\i)n ~1>MV"~1-rMa$"9 ~tt 0lh\'I;
man:w fl1OOlrfQla<'l,y,,,n.et ",1)<)11 2 t.hinhin ~WX':';NlJrlW'S vr bAre~>ttl;:'.Itilh.1j IfJ Ill"" tft',;~IM'\l otlt'.a Plll~\1' CVlTsnt cornll!iun (e ~. ~ Soti'CC vi rlJII)illil, 1T'~31iO" atministlalOO 01 hy(!ta~Q!1) 3 Sa1tty of p.al~':-lI!S ViM woe uiVlJJwMt"ll hon!.m I:1ljwy ()f fdJI~~jJ Ploceaure ...flo w~~1d wfW rWlll~1 "lv!)' 4 theY 00\', ~:":<'S>M: rnn\'1!l1l".J\! helOfe ~ 1J1IJ~i>aJy iI\1Pf~\1l{ (~"L ~remily 1m,"".,; (If \'aSCU!.:1i S'J'VO""S) 4 P~ltYv1 me ~I.in inivty Nlient limn f'JiU',M le.g,. eVA wl\lI flJ"l),,;it or hOld iflurna ...,111 .d("'Jon~ injuries}
,rouGtifrii bol' 1ld\{;lt!6
~"Hl"i d~5t"u~'~ i ~11lj ~Hnfr
)
.4
~r.\Nitr ~nsi.,.tes rtsKaf ru'l{ury

AIf~jmpi1u hI t~IIHW.llt~Mi\li,:. f;H~IM!"S. ..r.
t ReasOfJ fer rcstr-Dint 2 A!$tSWINlt time lranllH
3 Trtil rewa~s
fl~_1
5 (Mpe!illv>. aM
r<~rs",!
lelThlY<:Q
I,
4 EI.M;1VH)f fRQ:(JirlJO IOf f8lf'tllV.af
""I)'
BEHAVIORAL RESTRA.fIlTS:
AtTfllfT'l KEY
p(}SmON11I6
KEY
DEPAUL HEJU/1'H CENTER
~SSM.
HJ:A1.TH-"'AR~
MARCH,PHILLIP I/~ 0727400691 MED 0524-01 10/02/1976 31Y rot 10/02/07

RAHMAl~.
IIII~IIIIIIIDJI.~'DU
ANWER Z
24 HOUR MEDlCALJSUHGlCAL PATIENT CARE RECORD

DPM-'(J(){~07'
00074829B
(7/2001) PAGE B OF B
000171
12303 DEPAUL DR.

Tue Oct 09,
Di~~hat"g~
BRIDGETON, MO 63044 2007 06: 12 anl

HEr~TOLOGY-Page
Cumulative Trend Report from 10/01/07 2158 to 10/08/07 0415

MAR~,PHILLIP
Patient Name: Med Rec #:

Dis Date
000748298
10/0a/07
Adm, 10/02/07
Phys-Service:
979457 903572
NELKAVERI,SONIA N - HEDICAL I/P
BLOOD CELL COUNT/DIFFERENTIAL
Result: UnitB;
Low Refer: High Ref:
Platelet
Hgb
Ret
IOOO/mm3
130.0 400.0
gm(dl
13.0 1B.0
RBC 10:\6
MeV
~;i;~/~~-;~~~i---~~~-----I--~~~;----~I--~;~~----~I--~~~~----~I-----;~~~-------~I
10/07/07 10/06/07 10/05/07 10/05/07 , '04/07
39,0 54,0
4.'7 6.1
80.0 99.0
03401 03201 15451 04401 0510
03/07 04551 10/02/07 0614

10/01/07 22201
249 219 191 177 159 137 114

159
I I
I
I LI
1
11.B 12.7 12.1 12.3 12,0 11.4 11.8 12.7
L
LI Ll
LI
LI
L
LI
34.0 36.8 35.7 35.4 35.0 32.9 33.4 35.9
L L L
L
L
LI
LI LI
4.42 11.78 4.62 4.57 4.59 4.30 4.41 4.69
LI LI
L
76.9 77.0 77.3 77.5
LI
LI
L
L
L L L
Ll
76.3
76,5 75.7 76.5
LI
L
BLOOD CELL COUNT/DIFFERENTIAL.
Result;
Units: Lo\ol Refer: High Ref: 10/0a/07 10/07/07 10/06/07 10/05/07 10/05/07
MCR pg
25.0 31.0
._ft~-----
t<'lCHC
gm/dl 32.0 36,0
~
RDW
%
~lBC
Carr WBC
iOOO/mm3
11.5
____________
14.5 I 11. 0 _________ ______________________

~
iOOO/mm~
4.5
-------------------------
0415
0340 0320 1545
26.8 26,7
26.6
34.9
34.7
34,5
26.2
26.9 26.1. 26.5
33.9
34,7
Ool40 - - '04/07 0510
3'1.3
34,7
03/07 0455 10/02/07 0614 10/01/07 2220
26.8
27.1
35,3
35,4
lS.S 15.6 15.5 1S.7 IS.7 15.6 15.S 15.6 15.6
~I
HI
HI
8.6
12.0
14,
HI
15.1
~I
HI HI HI
HI
15.3 3.2
3,8 6,5
~I LI
8,1
ELOOD CELL COUNT/DIFFERENTIAL ..
R'ult: Units;
~~;~~~~~:~~!:\---~~:~---:j---~~:~--:~-I,---~~:~--:~il----~:~---~-II-------::~-------I
10/06/07 0320
L~w Refer:
I
I
I-
Gran
%
Lymph
%
40.0
22.0
Mono
%
I
I
Ega
%
I
1
Eal::l9
~~
0.0
2.0
I I
0.0
71
&HI
16
&L
&
&
MARCH,PHILLIP
000746298 (M-IO/02/76) Dr. MELKAVERI. SONIA N"
Alexander Babich, M.D. ** DO NOT DISCARD **

*Dischaz'ge Curnulative Trend Report
000172

12303 DEPAUL DR.
BRIDGETON, MO 63044 Tue Oct 09, 2007 06:12 am

HEM1>.TOLOGY-Page 2
Discharg@ Cumulativ@ Tr@nd R@port from 10/01/07 2158 to 10/08/07 0415

Patient Name: Med Rec #:
MARCH, PHILLIP
000748298
10/08/07
Adm: 10/02/07
I/P
Dis Date Phys-Service;
MELKAVERI,80NIA N - MEDICAL
BLOOD CELL COUNT/DIFFERENTIAL .. Result:

lJnit~i Lo ..... Refer;
(Cant)
Gran
~
Lympb
~
Nona
'l; 2.0
Bos 't
0.0
6.0
High Ref;
I ------------------------------------------------------------------------------,*0.0
40.0 70.0
22.0
Baso \
0.0
3.0
10.0
7.5
10/05/07 1545
73.9
H
&
10/05/07 0440 1 10/04/07 10/03/07 0455 10/02/07 06141 J'" ''11/07 22201
0511
62 26.9 56'.5
18.0 20 53.4 28.7
&L
H
96.5
91
HI
&HI
e.o
5
6 15.3 13.2
&
H H
0.4 2 2.5
0.2
&1
1.9 0.8
&Li
LI
5.2
0.8 0.0
0.3
BLOOD CELL COUNT/DIFFERENTIAL ...
Units: Low Refer:

High Ref:
1
Result:
Bands % 0.0
5.0
Met~s
0.0
1.0
'<1 y elo%8
I Promy;lO
~Q
Blas~s
~
II
0.0
1.0
I
I
0.0
0.0
0.0
0.0
~~~~i~~~-:~;~j---~~----.!il----~-----~-II-----------II-----------j-----------------I
10101/07 2220
&
BLOOD CELL COUNT/DIFFERENTIAL ....
P - 'ul t
::s:
Aty
Lyrnp
%
Plasma C
%
Othe..
%
0.0
NRI3C
/100 liBe
I I
j
Low Refer:
High Ref:
0.0
9.0
0.0
I I ~~/;~i;;-;;;;i----;-----~i-----------------------------------------------------1
0.0 0.0
f'l'LARCH
Ale~ander
PHILLIP
000748298
Babich, M,D.
*~
*k DO NOT DISCARD
(rt1-10/02/76)
*Discharge Cumulative Trend Report
Dr. MELKAVERI,SONIA N
000173
12303 DEPAUL DR.

Die~harge
BRIDGETON, MO
63044 HEMATOLOGY-Page 3 Adm: 10/02/07
Tue Oct 09, 2007 06:12 am
Cumulative Trend Report from 10/01/07 2158 to 10/08/07 0415

MARCH,
Patient Name: Med Rec #: Dis Date Phya-Service:

979157 903572
PHILLIP 000748298
10/08/07
MELKAVERI,SONIA N - MEDICAL r/p
BLOOD CELL COUNT/DIFFERENTIAL .....

Resu 1 t :
iInit:;};
Low Refer:
High Ref:
10/06/07 03201 Normal 10/05/07 0440 # 10/01/0722201 #
I I I ~;!;;/~;-~~~~-l-;~~~;~---~I-----------'-----------'-----------1-----------------1 10/07/07 0340 Normal &1 1 I I I

&.
I
I
RBC Morp
NBC Morp
I
I
PIt Est
- - - - - - 1 15/07 0440 CBC 10/01/07 2220 CBC - - - - - - - - 10/06/07 0320lcBC NITH HANUAL DIFF-Comment: Manual Differential correlates
Normal &1 I - - - - - - - Spec if i c Commen t. B - - - - - - - - - - - - - 1'1ITH MAl'IUAL DIFF-RBC Morp: Slight Microcyt;es *&.* WITH r~~AL DIFF-RBC Morp: 1+ Poikilocytosis *&* - - - - - - - General Comments - - - - - - - - - - - - - -
&1
&
I
-
-I
clinically with electronic differential provided. *&*
t1ARCH, PHILLIP
000748298
Alexander Babich, M.D. *~ DO NOT DISCARD **

"Discharge Cumulative Trend Report
(1<1-10/02/76 )
000174
12303 DEPAUL DR.
DePaul Health Center BRIDGETON, rotO 63044 Tue Oct 09, 2007 06:12 am COAGULATION-Page 4 Adm: 10/02/07 N - MEDICAL I!P
Disoharge CUmulative Trend Report from 10/01/07 2158 to 10/08/07 041S

Patient Name: Med Rec #: Dis Date Phys-Service:
979157 903572
MARCH,PHILLIP 000748298 10/08/07

MELY~VERI,SONIA
ROUTINE COAGULATION Result:
PT
I
10.8
INR
Units;
Low Refer;
High Ref:
A.PT!
1:ieGQnd1:i
Fibrinogen I
1.1
I 1
24.0
31.0
ms/dl
200
I
400
I
I
~~~~f~~~-~~~~I--~~~~-----f---~~;-----i--~~~~----~I-----------1-----------------1
- - - - - - - - - - - - - - - - General Comments - - - - - - - - - - - - - 10/01/07 2220 PT-INR Therapeutic Range: Conventional Anticoagulation: n~R :2.0-3.0 Intensive Anticoagulation:INR 2.5-3.5
-I
HARCH,PHILLIP 00074B298
Alexander Babich, M.D.
** DO NOT DrSCARP ** *Discharge C1.1m1.l1ative Trend Report
(M-IO/02!76) Dr. MELKAVERI,SONIA N
000175
DePaul Health Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Tue Oct 09, 2007 06;12 am
Discharge
Patient Name: Med Rae iI: Dis Date
Cumulativ~
Trend Report from 10/01/07 2158 to 10/08/07 0415

CHEMISTRY-Page 5 Adm: 10/02/07
MARCH, PHILLIP 000748298 10/08/07
Phys-Sarvice:
979457 903572
MELKAVERI, SONIA N - MEDICAL r/p
ROUTINE CHEl\tISTRY
Result:
Glucose
Unit5i
Low Refer;
High Ref; 10/06/07 10/05/07 0440 10/04/07 0511 10/03/07 0455
10/01/07 22201
m9/.jl
75 110
78 109
I I
I
Sodium
Potassium
Chloride
CO2
mSqjlo 22.0 30.0
29 31 26
28
mflq(L
137
145
137
mfiq(L
3.6 5.0
m1:iq!L
98.0 107.0
104
L
L L
I I
------------------------------------------------------ ----~-~--------------
0331
87
78 94
I
I
140
136 13B 138
LI
I
I
4.5
3.6 3.3
3.0 3.3
102 102 101

103
---II
H!
27
ROUTINE CHEMISTRY.
~~~:~~~~~, I :i~l
10/04/07 05101 10/03/070455\ 10/01/07 22201
7
~~iii
LI
I
l.l 1.3 1.1
C:ift~m I Ph~~1~n"
8.8 8.1 8.8
Ma~i1tum I
:g~g~:~~-~!~~i---~~------i---i:~---------:::-----i-----------------------------1
10 13
LI
I I
ROUTIUE CHEI-1ISTRY .. Result:
ts: Lvv.' Refer:

High Ref:
I
I
Tot Prot
Albumin
ALT/SGPT
grn/dl
6.3! 8.2 I
gm/dl
3.5 5.0
~~j~~~~;-:!!:j---;-~-----i---::~----------:-----~----i:------i------~~---------I
10/04/07 05101 10/03/07 04551 10/01/07 22201 6.6 6,9 7.1
11,
I I
U/L 21.0
72.0
I I
AST/SGOT U!L 17.0

59.0
Alk ph05
I I
V!L
38.0 126.0
I
I I
4.2
~,5
4.7
B H 13
L 1.1 L
17
l7 24
I
I
;is
73
59
I
I
rvtARCH, PHILLIP
000748298
Alexander Babich, M.D. ** DO NOT DISCARD ** *Discharge Cumulative Trend Report
(M-10/02/76) Dr. MELKAVERI,SONIA N
000176
12303
Die~harge
DePaul Health Center DEPAUL DR. BRIDGETON, MO 63044 Tue Oct 09, 2007 06:12 am
CUMulative Trend Repo?t f?om 10/01/07 2158 to 10/08/07 0415

MARCH,PHILLIP
000748298
Patient Name: I-ted Rec t1;

Dis Date
10/08/07
Fhya-Se:rvice:
979457 903572
MELKAVERI,SONIA N - MEDICAL lip
ROUTINE
CHEMIS~~Y
...
Result: Tot Bili Conjug Bil Uncon Bili Dir Bili GGT Unite; mg/dl mg/dl mg/dl mg/dl U/L Low Refer: 0.:;: 0.0 0.0 0.0 8.0 1.3 0.3 High Ref: l.1 0.4 78.0 1 ------------------------------------------------------------------------------10/06/07 10/05/07 10/04/07 10/03/07 10/01/07 03301 04401 0510 0455 2220\
0.2 <!O.l
<0.1 0.2 0.8
I
ROUTINE CHEMISTRy ....
Triglyc
Result:.: Units:
Low Refe.I':
Chol~st
mg/dl
120.0 200.0
mg/dl
0.0 250.0
High Ref:
10/01/07 2220j
LDH U/L 313.0 618.0
CK
Uric Acid
U/L
55.0 170.0
235
mg/dl
3.5 8.5
HI
CARDIAC TESTING. Result : Units:

Low Refer:
High Ref: 5:0 110.0 ____________________________________ ww. _______________ _________________________
CK-MB ng/ml
0 0
I
Myoglobi ng/ml
0 a
I
1
__ 0~/~7_2:2~1 _ _ _ _ _ _ 10/01/07
~O~2_
General
comm~nts
_ _ _ _ _ _ _
_ _____
2Z20ICKMB-Interpretation-CK~m: ~1 abrupt rise/fall
I I
of CKME over 24 hours is an acute injury pattern.
MARCH, PHILLIP 00074B298
Alexander Babich, M.D. ** DO NOT DISCARD ** *Discharge Cumulative Trend Report
(M-10/OZ/76) Dr. MELKAVERI,SONIA N
000177
DePaul Health Center 12303 DEPAUL DR. BRIDGETON, MD 63044 Tue Oct 09, 2007 06:12 am
Discharge Cumulative
Patient Name: Med ReC #: Dis Date Phys-Service:
T~end
Report from 10/01/07 2158 to 10/08/07 0415

MARCH,PHILLIP 000748298 10/08/07 MBLKAVERI,SONIA N - MEDICAL I/P
979457 903572 In: 10/01/07 2225 Out: 10/01/Q7 ~257 ColI Time: 10/01/07 2220 OI'der Phys: SCHMIDT, RICHARD U
Result Name
TROPONIN-I
Spec: Blood Heparin PST Techa; V-AK TLMURAT

(A0727400691/3861791)
*STAT*STAT*STAT*
Result
Reference Range
Troponin I(ng/ml):
<0.10
Normal Gray Zone Positive
<0.10 0.10-0.99 >=1.00

*Discharge CUmulative Trend Report
(M-IO/02/76)
Dr. MELKAVERI,SONTA N
000178
DePaul Health Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Tue Oct 09, 2007 06:12 am Discharge Cumulative Trend Report from 10/01/07 2158 to 10/09/07 0415 Patient Name: l<1ARCH, PHILLIP URINE ANALYSIS- Page 8 Med Ree if: 000748298 Adm: 10/02/07 Dis Date 10/03/07 Phys-Service: MELKAVERI, SONIA N - Jl.IED!CAL I/P 979457 997075 903572
URINALYSIS
Result:
Color ,
t
Clarity
Spec Grav
1,0005
pH
Units:
Low Refer:
pH UnitB
4.6
~~:~-~~:~----~--------------------------=~~~~~---!----~~~----!-----------------I 10/01/07 2250 I YELLOW CLEAR I 1. 010 I 7.0 I I

URINALYSIS.
P~sult:
Leukoc:yt
Nit.rite Negative
Prot.ein
Glucose
Ketone
.ls:
mg/dl
Negative
mg/dl
Negative
Ref Range:
Negative
neg
Normal
10/01/07 22501
neg
neg
norm
neg
URINALYSIS ..
Result:
urobilin
Bilirubin
Blood
Units:
Ref Range:
E~~~,~~~
norm
I
I
Ne:~~;e
neg
I Neg~~~ve I
I
neg
I
J
10/01/07 22501
-------------------------------------------------------------------------------1
I
MARCH/PHILLIP 000748298

(1'1-10/02/76) Dr. MELKAVERI,SONIA N
000179
DePaul Health Center 12303 DEPAUL DR. BRIDGETON, r>10 53044 Tue Oct 09, 2007 06:12 am Discharge Cumulative Trend Report from 10/01/07 215S to 10/08/07 o4is Patient Name: MARCH,PHILLIP MICROBIOLOGY-Page 9 000748298 r'led Rec #: Adm: 10/ 0 '2./ 07 Die Date 10/06/07 Phys-service: MELKAVERI/SONI~ N - MEDICAL rip
379457 997075 903572
CULTURE BLOOD
Source: Blood (Mi Coll. Time: 10/03/07 0455 In at: 10/03/07 0540 Order Phys: ZINSER/PHILLIP G Out at: 10/04/07 08tl Preliminary 1 (3863626J
Aeet #: A0727400691
Techs
V-NT Tech$!
T$MR
* * CULTURE * *
No Growth
Performed by: SSM Health Care Lab - SMHC
CULTURE BLOOD Source: Blood (M) Acct #; A0727400691
ColI. Time: 10/03/07 0455 In at: 10/03/07 0539 Order Phys: ZINSER,PHILLIP G
Teehs
V-NT
Techs: TSMR
Out at: 10/04/07 0841
Preliminary 1 [3863828]
* * CULTURE * *
No Growth
>~
CULTURE CATH TIP
~~
Sou ... ce~ Cath Tip ColI. Time; 10/02/07 1754 In at: 10/02/07 1754 Order Phys: MELKAVERI,SONIA N
~lt
Acct #: A0727400691
Techs VNUR
Techs: TSMH
at: 10/04/07 0805
Final
[3863380)
************CULTURE*****~******
No growth. Performed by; SSt'! Health Care Lab - SNHC
VJ\RCH, PHILLI? 000748298
Alexander Babich, M.D. ** DO NOT DISCARD ** *Discharge cumulative Trend Report
0>1-10/02/76 ) Dr. MELKAVERI,SONIA N
000180
DePaul Health Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Tue Oct 09, 2007 06:12 am
Dieehar9~
CUMulative Trend Report from 10/01/07 2158 to 10/08/07 0415

MARCH, PHILLIP 000749298 10/0a/07 MELKAVERI,SONIA N - MEDICAL I/P
Patient Name: Med Rec #: Dis Date Phys-service:
MICROBIOLOGY-Page 10 Adm: 10/02/07
979457 997075 903572
CULTURE BLOOD
Source: Blood (M) CoIl. Time: 10/01/07 2355 In at: 10/02/07 0001 Order Phys: scmHDT / RICHA.RD U
Acct #: A0727400691 Techs V-AK

Techs: TSMH
Out at: 10/05/07 1345
Final
[3861785)
CORRECTED - 10/08/07 1409 '/(
aerobic bottle time to detection 6.4hrs anaerobic bottle time to detection 6.9hr9
****~~******CULTURE************
*"'PANIC REPORT"''''
~~lled
toltime Grace 10/2/07 1110
(mls) rbr
KLEBSIELLA PNEUMONIAE (KL PNEUMONIA) Growth from 2 of 2 bottles two sets drawn
(MIC - ug/ml)
KL PNEUMONIA
R R S
T
Amp/Sulbact.am: Ampici 11 in:
>=32/16
>",}2
Aztnwnam:
Cefazolin: Ceftazidime: cipt"ofloxacin: Gentamicin: Imipenem: Levofloxacin: P;p/Tazobactam: .methop:r:im/Sulf:
c.=8 16
<",8
S S S S S R S
<;0.5
<~O.5
<=4
<=1 >=128
"",10
f-iARCH, PHILLIP 000748Z98
Alexander Babich, M,D. *'" DO NOT DISCARD "'* "'Discharge Cumulative Trend Report
Dr,
(1'1-10/02/76) MELKIWERI, SONIA N
000181
Depaul Health Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Tue Oct 09, 2007 06:12 am Discharge Cumulative Trend Report from 10/01/07 2159 to 10/Oa/07 0415 Patient Name: M.l\RCH, PHILLIP MICROBIOLOGY~Page 11 Med Ree tt: 000748298 Adm: 10/02/07 Dis Date 10/08/07
Phys~Service:
MELKAVERI,SONIA N - MEDICAL IIp
979457 997075 903572
CULTURE URINE
Coli. Time: 10/01/07 2250 Order Phys: SC~1IDT(RICHARD

O~t
Source; Urine (M) In at: 10/01/07 2255 U Final [3861788J
Acct #: A0727400691
Techs V-DJA
at:
10/04/07 1129
Techs; TSMH
1t '" ....
No growth.
* * * * * * * *"CULTURE* '" '" *" * * I d * *"

CULTURE BLOOD Source: Blood (M) Coll. Time: 10/01/07 2220 In at: 10/01/07 2225 ol."der Phys: SCHMIDT (RICHARD U
Acct #; A0727400691 Techs V-AK

Tachs: TSMH
Out at: 10/OS/07 0625
Final
[3861786J
"'''CULTURE'"'"
No Growth
MARCH,PHILLIP
000748298

(M-IO/02/76)
Dr. MELRAVERI,SONIA N
000182
DePaul Health Center 12303 DEPAUL DR, BRIDGETON, MO 63044 Tue Oct 09 , 2007 06:12 am
Discharge Cun\ulative Trei'l.d Report from 10/01/0'1 2158 to 10/c8/c7 0415

Patient Name:
r.1ed Ree #: Dis Date Phys-service:
MARCH, PHILLIP
000748298
BLOOD GAS ANALYS-Page 12

Adm; 10/02/07
10/08/07 MELKAVERI 1 SONIA N - f>1EDICAL lip
979457 997075 903572
ARTERIAL BLOOD GASES
Result:
ART PH
PC02
Units:
Low Refer:
pH Unit
High Ref:
------------------------------------------------------------------------------1
10/01/07 21581 7.511
7.38 7.42
I
HI
mm Hg
38
I
LI
P02
Base Exo
02 Satur
mm Hg
75 100
98.9
mmol!L
42
26.5
-2.0 2.0
-1.1
~ 92 98.5
98.1
I'
ARTERIAL BLOOD GASES.

R-
'ul t:
~s:
I
Hgb
gm/dl
02 Cant \
I
I
H802
%
HBCO
I
%
1
Met.hemoglobin %
1
~~~~~~;~~~ ___ l _____ ~; ____ l ____ ~~ _____ l ____ :~: ____ l ____ ~~~ ____ 1_______ ~~~ _______
10/01/07 215S1 12.3
1
16.9
97.1
HI
0.6
0.4
ARTERIAL BLOOD GASES ..
ARTERIAL BLOOD GASES ...

Reaul t.: RC03
Units: Low Refer:
mmol/L
1
22
mg/dl
80
Glu
HHb % 0.0
mmol/L 23.0
tC02
I
=
=
I
F
~~~~-~~~~----!---~~----!----~~~----!----~:~----!---~~:~----!-----------------1 10/01/07 21581 20.7 L! 95 I 1.9 I 21.5 LJI I

" -
= = = = = =
Gen@ral
Comm@nts
= = = =
=i
10/01/07 2l5SIBLOOD GASES W/LYTES PANEL-Comment: ER
MARCH,PHILLIP
000746298
Alexander Babich. M.D.

.+ DO NOT DISCARD *+ "'Discharge Cumulative Trend Report
(1'1-10/02/76) Dr. MELKAVERI,SONIA N
000183
DePaul Health Center 12303 DEPAUL DR. BRIDGETON, r40 63044 Tue Oct 09, 2007 06:12 am Die~h~rg~ CUmulative Trend Rep~?t from 10/01/07 2159 to 10/09/0? 0415 Patient Name: MARCH,PHILLIP BLOOD GAS ANALYS-Page 13 r-led Rec 1*: 00074829!3 Adm: 10/02/07 Dis Date 10/08/07 Phys-service: MELKAVERI,SONIA N - MEDICAL I/P 979457 997075 903572 ARTERIAL BLOOD GASES .... Resul t:
Units:
Temp.
~~;~~~!~~:---!-----------!-----------!-----------------------!-----------------I I I I I I
10/01/07 21581 21. RB
Fi02
Site
Resp Rat
CPAP
------------------------------1'" '07/07 0500
PENDING TEST
------------------------------Cancelled Patient discharged Cancelled DUPLICATE ORDER Partial Partial Cancelled ORDERED IN ERROR
CSC W AUTO DlFF
)4/07 10/03/07 10/03/07 10/02/07 10/02/07 10/02/07 10/01/07

i
0510 0455 0455

1645
eBC W AUTO DlFF

c..'UL'I'URE BLOOP CULTURE BLOOD CULTURE BLOOD
1643
1643
CULTURE ROUTINE
CULTURE BLOOD CULTURE SPUTUM
Cancelled Patient discharged

Cancelled ORDERED IN ERROR Cancelled Patient discharged
2146
!1P>RCH, PHILLIP 000748298
Alexander- Babich, 1-1. D.
**
DO NOT DISCARD ** kDischargB Cumulative
(l<1-10102/76 )
T~end
Report
000184
DePaul Health Center 12303 DEPAUL DR, BRIDGETON, MO 63044 Tue Oct 09, 2007 06:12 am
Discharge CUm Incomplete Work Listing from 10/01/0? 2158 to 10/08/07 0415
Patient Name: Med Rec #: Dis Date
Phys-Service:
MARCH, PHILLIP Page 14
000748298 10/0S/07
Adm: 10/02/07
N -
MELKAVERI,SONIA
MEDICAL r/p
979457 997075 903572
Accession
Number
Collection Test Name

CULTURE BLOOD
Spec Type Blood (Ml Blood (ttl)
Dace & Time

10/03/07 0455 10/03/07 0455
Status Partial
:3 863826
3863828
CULTURE BLOOD
Partial
End of Report ********************************************************************************
HARCH,PHILLIP
000748298

** DO NOT DISCARD ** *Discharge Cum Incomplete Nork Listing
(M-IO/02/76 )
000185
Depaul Health Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Tue Oct 09, 2007 06:12 am
Discharge Cumulative Trend Report from 10/01/07 2158 to 10/08/07 0415

Patient Name: Med Rec #: Dis Date Phys-Service:
979457 903572
~~CH,PHILLIP
000748298 10/08/07 1'1ELKAVERI,SONIA N - MEDICAL
Notification-page 15 Adm: 10/02/07

lip
LABORATORY CANCELLED AND SPECIMEN REJECTED TESTS

I.I.**SPECIMEN CANCELLED****
AGcn; J6656U Spec: Blood priority: ROUTINE

Test Name: CBC W AUTO DIFF Cancelled: 10/04/07 0550
Acct;
A07~74QQ9~l
COllected: 10/04/07 0510 Ord Phys: MELKAVERI,SONIA N
Cancellation Reason: DUPLICATE ORDER

End of Report
l\ll\RCH, PHILLIP 000748298
Alexander Babich, M.D. "'* PO NOT DISCARD ** "Discharge cumulative Trend Report
(lvf-10/02/76)
000186

12303 DEPAUL DR. BRIDGETON, MO 63044 Tue Oct 09[ 2007 06:12 am
Discharge CUm Incomplete Work Listing from 10/04/07 0800 to 10/07/07 0315
Patient Name:
I\ied Rec #:
MARCH, PHILLIP
Page 15
000748298
10/0a/07 MELKAVERI,SONIA N - MEDICAL I/P
~03572
Adm: 10/02/07
Dis Date
Phys-Service:
979457 977240
Accession Number
3863826
Test Name
Spec Type
Collection Date & Time

10/03/07 0455
10/03/07 0455
Status
Partial
3663828
CULTURE BLOOD CULTURE BLOOD
Blood (M)
Blood (Hl
Partial
End of Report
**~************************************************************************~****
r<IARCH, PHILLIP
00074.8298

DO NOT DISCARD
**
(1.1-10/02/76,
*Discharge Cum Incomplete Work Listing
Dr, MELKAVERI,SONTA N
000187
DePaul Health Center Wed Oct 10, 2007 06:09 am Post Discharge Work Report
Pat Name;
unit #/Acct #:
Dis Date Phys-Service:
979457 903572
MARCH/PHILLIP OOQ74829B/A0727400691 10/08/07

f,lfELKAVERI, SONTA N I"iEDIC.~L
Page:
I/P
CULTURE BLOOD Specimen; Blood {r,lfl Coll. Time: 10/03/07 0455 In at: 10/03/07 0540 Ordering Phys; ZINSER/PHILLIP G
Out at: 10/09/07 0730
F ina 1 ( 3 8 6 3 82 6]
Acct
Techs
j:I;
A0727400691
V-vlT
Techs: TSMH
* * CULTURE * *
No Growth Perfoxmed by: SSH Healt.h Care Lab - SMHC
CULTJRE BLOOD ~c specimen: Blood (f>') CoIl. Time: 10/0J/07 0455 In at; 10/03/07 0539 Acct #: A0727400691 Techs V-WT Ordering Phys: ZINSER/PHILLIP G
Out at: 10/09/07 0730
Final
[3863828 J
'J'echs: TSMH
* * CULTURE* *
NO Growth pe;t-formed by: SSM Health Care Lab - SNHC
End of Report - 10/10/07 06:09
MARCH/PHILLIP 000748298/A0727400691 Alexander Babich.

kpost
M.D.
I/P 10/08/07
U>l-lO/02/76) Dr. I'<1ELKAVERI,SONIA N
Discharge t'lork Report
000188
12303 DePaul Drive
DEPAUL HEALTH CENTER Bridgeton, HO 63044 DIAGNOSTIC Il-1AGING

Med Rec # A000748296 1'.CCT: A0727400691
Name:
J'-1.ARCH, PHTLLIP
DJB:
10/02/76 Age:
31Y
Sex: M
Pt Local-ion:
5N-0524~01
Date; 10(04 (07 1601
MELAVERI,SONIA N 1066 EXECUTTVE PARKWAY SUITE 105
CREVE COEUR
Exam Xl{ CHEST ONE VIEW PORTl\BLE
NO 63141
Check-In U
00010746
Ol-der Dia9no.siz Ord Diag: V67 _ 59-FOLLOV1-UP EXAM NEC
CHEST SINGLE VIEW
INDICATION; osteomyelitis, PIce line pl"cement.. FINDINGS: A single view pr..>ltable AP upright ex.:tminZltion of the chest, 1608 houl's, >hclWs oil PIce line has been placed via t:he right upper ext.remity. The distal end i:o direcl.ed into the .:tnticip.:tted location of the mid superior venoil cava.
NQ other changes .:tre :Jeen ,'!hen compared to the. pri or chest radiograph of
10/1/2003.
The lung fields are clear. The heart size is at the upper limits of
normal.
IMPRESSION
In.terval placement of a PICe 1ine, the tip of which is directed int.o the! anticipated location of the mid superior ven.:t CiJ.va. Read By- ANDRE !:i STR.3EI>1BOSZ H.D. Releaced By- l\NDRE S STl";;;EMBOSZ I'1.D. Released Date Time- 10/04/01 1611
Transcriptionist- BEM
ADM:
r-tF:J,"KAVERI, SONIA N
~rNSER,PHILLIP
ATT: Nl!:LKAVERI,SONIA N
CON: ZTNS'RR,PHILLIP G
REF;
~ep:
SCP:
FINAL
Page
000189
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, NO 63044 DIAGNOSTIC IMP~ING
Name: t1ARCH, PHILLIP DOB: 10/02/76 Age; 31Y Date; 10/01/07 2151
!l1ed Rec # A000748298
ACCT: A0727400691
,sex; M
Pt Loca.t.ion; 5N-0524-01
SCHNIDT,RICHARD IJ 12303 DEPAUL DRIVE Etl!ERGENCY DE PT BRIDGETON MO 63044
Exam
XR CHEST ONE VIEW PORT.lillLE
Check-In If
00010232
Ord Diag:
Order Diagnosis 786.50-ClIEST PJl..IN NOS
Chest one view portable. Indic'::'I.tion; Fever and chills and javi pain. Findings: A frontill view of the che<lt compared to prior of 9-24-07 shows tlie lungs to be well expanded and clear. The heart size is normal.
No change has occ;urre.d.
Impression: No acute infiltrate.

Re.J.d By - f1ATTHEW W STADN'iK M. D. Relea sed By- !l1ATTHEW W STADNYK M. D. ReleaDed Date Time- 10/02/07 1008 Transcriptionist- sTn~
A.DI'1;
REF:
RAHMAN / ANI-lEI<. Z
ATT:
RAHMAN, ANWER Z
PCP:
ZINSER/PHILLIP G
CON: SCP:
ZINSER/PHILLIP G
FINAL
Page
000190
"J?"~~!!:dt.Jr~
Consent to Medi(y.lJ and Related Health Cals; I request and consent to too medical cafe, diagnos1ic and treatmenl as determined necessary by mvphysiclanfs) Of hls/her assIstants. J acknowledge th~ care I receive while in this facility is under the <fJ(~ction o[my phYSician(s}. This facility is noTrespoilsftil1> for tho acts Or omissioos of my physician(s).
Mediga' and Allied Health Car~ Providers: I have boon informed and understand that the Physidan(sl providing to me in this facifity, such as my personal Physician{sJ, RadioIoglsls. Pathologists, Anesthesiologisl. Consulting PhY$lclans, Surgeons and other Allied Health Care Providers such as ~ntj.5ts and P3ychologists are independent contractors and ant not employoes or agents 01 this facility unless 0 erwisE/ specificalty identified.
$efVj~es
Teachfng Programs: I understand this facility may. from tima to tima. anter into greements with academic medical. nUI,sing and allied health programs. 8acau8o of the$6 agreaments, residents, Inter ,medical students, nun,iog students and various allred hI!Jallh plOfession students, may participate in my care. f agreo to participate in these programs, but have the right to limit my patticipation at any time. Re'!M! 91 Information; 'understand this facility will make l)very fJffort 10 treat my medical information as cl;mfidential; howeVQf, I realfz6 information must be shared with providars and/Of individuals involved tn my care or tn the payment of my cam, J undorstand this will inc Iud., information found in my medfeal record. I agree to the refease of information in my medical record, and to the actual medical record documents, to the extent necessary for the following purposes:
...} I have received the Nor.icf.! of Privacy Practices on this visitladmis$ion or previous one. I understand I can reque:rt another copy at any Hme.
8
b.J
to any medical and/or health care providers responsible for my care while in this fooilitY and
if transft-fred to another facility for care, to th!iltacifity and its carEl providers.
c.)
to those responsible fOf collecting and those resposibJe for the payment ot my care. Trns may include a person. government agen<:y, iostlf<lnce company, health plan or employer sponsored group plan. This is for the purpose of verifying insurance benefits for pr8certifiGiltion and axtfl/1ded stay review andlor the paymcllt of tha cost of my cere. to utilize for internal medical care studies and quality Implovemant a.ctivitie4. to compty with the Federal Safe M6dical Device Act 01 1990 and other requIred state and fader.:!1
d.) Cl.)
reporting.
Mcdicarp/ChamgusfTricilra Right!!.; rt oppticab-I&. I acknowledge receipt of tho Medicare/ChampusfTrictlfe Letter explaining my rights as a patient of this facility. I understand this includes my right to request a ravi(lw. Patient fUgb1:1: I acknowledga acces!l to the Patient Rights information explaining my rights as a pationt of this hcllity. Porsonal froper:\y; I have been informed and understand this facility will not be liable for any loss of unless it is irwl:fltoriod and pieced in a secured area maintained by !hls facility.
my
porsonal
property
fi.wmlU!:t fqr PhysicIan Services, Medical ,apd Relqted Care: Il)nd&(stand thaI all phYSician sarvicas ara billed separately from lOa facility chi.lrges. I 3l1ree to pay th$ charges incurred fOl Ih~ carO I receive as ordered by my phYiician(s) at this
facility. I guarante8 full payment 01 all charges unloss restrie-ted by Medicare, Medicaid or contractual arrangements botween my insuranco company and this facilitY.
~SSM
H E A L
H .
GAR E-
r.
"12303 DEP)\UL DR. BRIOG ETON. MO 63044
.\UL HEALTH CENTER
000191
Assiql)glAAtqt Be-efits: I hereby authorIZe and assign payment to this facility of aoy type of reimbursement or paymoo{ duu from Medicare, MedicaId, or any other third party payor, for llny and all cost incuued for my medical and rebned care at this facWty ond/or by the independent contractors providing services at this facility.
and t#lat would not change this agr~emant Of be coosklfod a discharge by Medicars. my agreement to the procediog al any timB by written notifieDtion to this fBcility.
I havo liar/any uno/e.ar Itcmt Bxplaln~d to me ond t.ll1derfitami its contents and accept its terms. , onaeritand that new account numbefs may bo issued for toUow up serv/Gas related to this admi.s.sionitfealment
I underStand I may wltildraw
AckHuwledgement of Under$tru\dlnq a~Gtli!:!t; {certify thai I have N}8d and understand the preceding agleement.
Patient's Signature
OR
Date
S1gna tu,elJl~latio~hip Do t e (Parent/legal GuarmanlResponsible Person/
Second Witness Signature

(If Or.vrelephonelP8tient Mark)
Date
Date ~
/E? /
f)?
DEPAUL HEALTH CENTE
MARCH I PIULLIP 0727400591 ERG

10/02/1976 30Y
,1
I.
_R
ERQ
EMFRGENCY/PHYSICIAOO~~~~~
M1
000192
PATiENT BELONGINGS VERIFICATION LOG
Page _ _ _ ot
07
SIGNATURE OF RECEIVING STAFF
DENTURES oe o Upper 0 Lower 0 Pariial U At
Date of Transfer: Date of Oischar e:

SiGNATURE OF TfIANSFERRlOO STAff
ROOM#:
Date of Transfer: Date of Discharge:

SIONATURE OF TRAN~FERR!NG $TAFF
MEMBER; -----::-::=-c-=--::-----I MEMBER: TIM!;: ROOM #TIME:

l1om~ -~-~r---------------------r-~----
MEMBER: _______~~~--__----TIME: ROOM

#~
DENTLIAES 0 None 0 Upper 0 Lower n Par1!::!) 0 At home
ono 0 With patient 0 At home
GLASSES 0 None U With Piltient 0 At home

CONTACTS 0 NOM 0 With patien1
HEARING AID
.----------~~~~-----------------
DENTURES 0 None 0 Upper 0 wHer U Partial 0 At home
GLASSES 0 None
one 0 With patient 0 At home 1--------HEp.RING AID U Left 0 Right 0 None
r----~~-----------------~-----
n With patient
0 AI home
n At home
CONTACTS 0 None 0 With palien! 0 At home

HEARING AID 0 Left 0 Right 0 None
~ome
_-r~I_ _ _ _ _ _+O_A_t_hO_m_e_______________
ORTHOPEDIC DEVICE 0 None 0 At home 0 cane LJ walker 0 prosthesis
JEWELRY (Description) 0 Watch
oR~W
LAft 0 Right 0 None
0 At home
ORTHOPEDIC DEVICE 0 None 0 cane n walker 0 prosthesis
JEWELRY (Description)
ORTHOPEDIC DEVICE one 0 At home cano 0 walker 0 proslhasis ne
JEWELRY (Description) o Watch
0 None
0 None
0 Walch
oru~~
o~gW
Other-
0 Other:
0 Other:
o Sent 10 5eGurHy
CLOTHING {MUST write description} n None Q Hat/Scarf o oa1/Sweater hoes (>16<.k. (l..~J) 4-t1"t,i sJ..,.~ Stockings/Socks SllppafsJAobe ~Iacks - JiJ t! ~ oI!..-"",'" S
o Sent 10 SflGurlty
CLOTHING (MUST write des(;riplion) o HatJ5cati o CoatlSwealer U Shoes o Stockings/Socks Slippers/Robe
Q $ent IQ l;jecurity
o None
o o
o
o o Pants/Slacks O~Blouse pv~l> ,!-T.,.,.,') nlt/ely..-", o Shirt/6louse
f6
CLOTHING (MUST write description) o HaVScarf Coat/Sweater Shoes o Stockings/Socks o Slippen./RQbe
o o
Underclothes
Underclothes
o Shirt/Blouse o UnderClothes
o PantslSlOlcks
J'cell phone
I
OTHER VALUABLES (D!!scnptionJ o Laptop computer oOthar
0 None
OTHEAVALUABlES
D Cell phone
(Description)
0 Non6
OTHt;;R VAl.VABlES (De~Qrip1iQn) U Cell phone
0 None
o Other _ _~_ _ _ _ __
Item(s) S611t homa _____
Laptop CompO!fir
o Laptop computer o o\her _ _ _ _
_ _ _ _ _ _ _ __
1------I 0 ilam(s) sent home ____________
o llern(s) sent home _______~__

U Sent horne with _____________
I-~--o Sent home with o Sent 10 Security

HC}ME MEDICATIONS
~ome 0 Pharmacy
o Sent home wilh _ _ _ _ _ _ __ o Sent to Security o None o Home

HOME MEDICATIONS 0 Pharmacy
o Senl 10 Security
HOME MEDICATIONS o Home 0 PhannaGY
None
0 None
amily as;;;umes final responsibility for belongings that are brought TO hospital
Ptjlamily 385umes final responsibilfty for belongings that Eire brought 10 hospital
o PtJlamily assumes final rasponsibility lor

belongings that are brooght 10 hospital SIGNATURE OF FATIENT / RESPONSIBLE PEASON UPON ARRIVAL:
SIGNATURE OF PATIENI / RESPONSIBLE

PERSON UPON ARRIVAL:
SIGNATURE OF PATIENT f RESPONSIBLE PERSON UPON ARRIVAL:
SIGNATURE OF RECEIVING STAFF MEMBER
SIGNATURE OF RECEIVING STAFF MEM6ER;
TIME: ____ RECEI.VING ROOM #:
.. _____ TIME: _ _ _ RECEIVING ROOM #!
TIME:
RECEIVING ROOM if:
~~SSM
COMPLETE A NEW FORM FOR TWO OR MORE TRANSFERS AND FILE WITH ORIGINAL. KEEP AT BEDSIDE AND PLACE IN DISCHARGE SECTION OF CHART. DEPAUL HBALTH CENTER
H E J. \. T H e A R e-
Ml'~~,!,!~nl. 0727400691 ERS _
PATIENT BELONGINGS VERIFICATION LOG

SLMl00QOTS (612007) FRONT
10/02/1975 30Y
ERQ M 10/01/07
EHERGENC,PRYSICIA00074829S
000193
TRANSFER CHECKLIST
INITIAL IN DATE COLUMN WHEN EA CH ITEM COMPLETED DATE DATE DATE
If Item Not Applicable} rec:o rd NtA In box.

'-
..
from Room # -....
TRANSFERRING DEPARTMENT
If transferring from Telemetry - Remove monitor

~nter transfer
into computer
Make sure that labels are place~ on all documents in the chart at time of transfer Communicate daily and pending labs
I Medication Reconciliation completed
-.-
Place MAR, Interdisciplinary Plan of Care/Care Path way, &Educa1ion Record in chart Place today's 24-hour record and all bedside flow sheets in chart Place Wound Tracking log in front of char!
-
-_.-
----r,
.~
Complete Patient Belongings Verification Log (on front) and place at bedside
I Take any old charts or thinned records wi1h patient to new room
I Place any Non-Pyxis mads and IV mads in plastiC bag and clip to chart
Notify Attending and Consulting Physicians of roo m change.
_.
-"
I
-
_._-----
INotlfy Family of new room number and print name

Name of Transporter:
0I family
.-
member in date column
----
..
RECEIVING OEPARTMENT
To Room #
--_..
Document date and time patient arrived in new department Document patient status on arrival to unit
_---.,._-
Place New Room Number on chart

'."-
Prinl new labels and place in front of chart

..
~
Ensure daily and pending labs are ordered

Label blank Physicians Orders & Progress Notes and place In proper sections altha chart
',--
SIGNATURE
..
/NIT
S/GNATURE
INIT
SIGNATURE
IN'T
-"_.-
~SSM
H E A L T H
PATIENT LABEL
C A. R E"
PATIENT BE:LONGINGS VERIFICATION lOG

SLM-l0DO-073 (6/2007) 8,A.CK
000194
PERIPHERALLY INSERTED CENTRAL CATHETER CONSENT
I,
2i'::t-- '- rr, hA,fo1ec-1, agree to have a penpherally inserted central cathnter (PICC) inserted, , "2 "''''P';f#f''Z-Kh'~~nd lor associate has ordered the I understand t~at my phys~cian, Dr.
tj
placement by a PICC certified RN. I understand that the insertion of a Pice is an invasive procedure, which is accompanied by possible risks, including, but not limited to: Insertion-associated: Unsuccessful catheter insertion; bleeding. swelling, or discomfort at venipuncture (insertion sits); catheter malposition or migmtiol"l: eardiac arrhythmias {irregular
pulse). Post insertion-associated: Phlebitis or venous thrombosis (clot), catheter occlusion, catheter or
insertion site infection, catheter breakage/rupture, The Pice certified RN win insert the specialize catheter into a specific vein under ultrasound guidance.
The benefits of and alternatives to Pice placement, as well as alternative methods of administration of the therapies of treatment have been explained to me, Including, but not limited to: Preservation of peripheral veins; longef (indefinite) dwell time of PICC; avoiding surgical catheter insertion; the therapy or treatment prescribed requires a central vein catheter. After the procedure and for the entire time my Pice is in place, I must report the follovling symptoms: Swelling, redness, soreness, wetness or drainage at the venipuncture (insertion site) or dressing, fever, chills, movement of the catheter in or out of my arm, shortness of breath, sounds of rushing of water in my ear on the same side of the catheter, exposure of the catheter outside of the sterile dressing andfor breakage of the catheter.
To reduce or eliminate the chance of the above risks from occurring, I agree to the care and maintenance instructions (no repe1itive motion of lifting weight [In excessive of 5Ibs.] of the PICC extremity); and to the prescribed schedule for therapy administration, catheter dressing changes, flushes, and cap changes, or catheter discontinuance. I also agree that I will not allow anyone to draw blood from above my Pice on the same arm, I have been informed of my right to ask questions or voice any concerns I have about the procedure and have received answers to my questions/concerns. I haye.(ead (or have'had read to me), and understand the consent.
( !
Patient's ~lgn.afufe
,,!Mle
OR
DatefTirnQ Signature/Relationship OatefTime
, _ too
h;J.J witnes~ed lhe pati~nt's signature on this lorm by which the patienl acl\llQwleQges that he/she has rec.erved adequ3te, infDnnatiol\ p"",d", 'f!"~("" phY""'"
., ' ' ',
/(/I11//~7 I?~
Da{emme Second Witness' Sig1lature DalelllfT1'i!
PJSSM DePaul Health Center

'II. ( J t t M
.(
DEPAUL HEALTH CENTER lip 0727400691 NED 0524-01 lO/02/1976 3lY r>1 10/02/07
I-1ELKAVERI, SONIA N OOU748298
r~RCH,PH1LLIP
l ,.
111111111111111111
PICC Consent 7/2007
000195
~SSM
"co",,, NO
I-
H E A L T H ' CAR E~
0902200197
r'M'f/iT NAME mo
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SOCSECNO
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TELEPHONE ~'Q,
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STATKtN
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055401
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ADMISSION RECORD
ec r ~AT T'f~l
liP
BY
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BS
000748298
HlfPHQfl(OO
AO~RE5S
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MARCH, PHILLIP H 8310 HAWJ(~SBURY DR SAINT lOUIS MO 63121-'005
(3141393-1241
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let MARCH,PHILLIP H
i
G\lAHAIHOH NAME AHll AODilESS
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SALEM,MOUNER
1066 ExeCUTIve PKWY CREVE coeUR MO 63141
Ole
(314l317~0600
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903693 SUITE 105
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MAJINO,ANGElA R 12303 DEPAUL DRIVE MO 63044 BRIDGETON

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EMERGENCY DEPT
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IN!l\JRAIICE COMMfHTS,
i I
01/22/2009 08;48:Ll
000196

DISCHARGE SUMMARY
PATIENT: MARCH, PHILLIP H ADMIT DATE: 01/22/2009 DISCH DATE: PHYSICIAN: MOUNER SALEM, M.D. MR#: 000748298 AceT#: 0902200197
DOB: 10102/1976
ROOM: 0564
PRIMARY DIAGNOSIS: Left facial cellulitis. SECONDARY DIAGNOSES: 1 Hypertension, untreated. 2 History of chronic parn of the left mandible. 3 History of osteomyelitis of the left mandible. 4 Status post open reduction and In1emal fixation from a stab injury complicated by hardware infection and removal. 5 History of liposuction. ALLERGIES: None. DISCHARGE MEDtCATIONS: 1 Neurontin 200 mg t.i.d. 2 Keflex 500 mg p.o. q.Ld. The patient Is supposed to be on a course for three weeks. 3 Pareoest 5/325 one to two tablets every 6 hours as needed. 4 Norvase 5 mg daily. SIGNIFICANT STUDIES: MRI of the face shmved no evidence of osteomyelitis. It was an otherwise unremarkable MRI of the face. There was no cystic or solid soft tissue mass at the area of Interest and no significant superfi9i~1 or deep soft tissue edema, There was normal bone marrow signal intensity withovt evidence of _ _ _ _ or bone marrow replacement. CONSULTANT:
Dr.
Zinser.
HOSPITAL COURSE: The patient is a 32-year-old gentleman admitted with increasing left facial pain and ~welling and had previous admissions for this for facial cellUlitiS, and has a previous history of osteomyelitis after infection of hardware that was placed after a stab Injury in the left face, The patient has not been on any of hfs medications incluoing his antihypertensive and he was apparently supposed to be Neurontin, which he stopped taking due to followup issues. The patient has not followed up wlth ENT at Barnes. He was evaluated for possible osteomyeliUs. Here his MRI was unremarkable. Clinically he was better. His white count was nomlal and he has been afebrile. Upon discussIon with infectious disease, we will switch him from Zosyn to Keflex to complete a three-week course. Follow up with ENT at Barnes was again emphasized to the patient. He is also to follow up with a primary care physician. He was given referral to the John C. Murphy Clinic and 30-day prescriptions for his Norvasc, Neurontin, with Pereoee! and Keflex for his cellulitis. Tile patient understands his followup instructions and agrees to comply.
All qU8stions answered.

DISCHARGE ACTrVITIES: As tolerated. The patient is not to drive or operate heavy machinery while taking Narcotic medications. D'SCHARGE DIET; Regular diet.
This document has been reviewed and signed by MOUNER SALEM Sign DatefTime: 01/27f2009 11 :22PM EST
MEDICAUSURG'CAL DISCHARGE SUMMARY-OP
- Page 1 of 2
000197

PATIENT: MARCH, PHILLIP
DISCHARGE SUMMARY
Ii
MR#; 000748200
MOUNER SALEM. M.D. MS:1-221 ,2468932 0: 1/26/2009 11:33 AM T; 1/2612000 12;07 PM E: 01/28/200909:01 AM
cc:
MOUNER SALEM. M.D.
MEDICAL/SURGICAL DfSCHARGE SUMMARY-DP
Page 2 of 2
000198
Patient Discharge Jnstructio'ns

Discharge diagno~ls: ,';
", ~_ "i \ \ . . ,.,.;......A.
f .....
'Ar t ' i"\ "

i_
<.
I -' j,'V '- I.- iI (''\ ~/' ,',
Discharge disposition:
I""'.t., .~", .. , \.
None O'Written
Flu Immunization Given ,\ j ,/ Pneumonia Immunization GiVel1) I ( / Home Care Agency:
PRESCRIPTIONS:
Cl
a Given to Patient
Q Call~d to pharmacy
,--
MEDICATIONS: See Discharge Home Mer:J=-ic::..:a:..:::ti::=:o.:.:.Il...::L"::::js:-:.t~a.:.:tta~c;;.;.h.;..;e:..=d'-r=---:--::;>"'r:-,,..,...-:-_ _ _ __ WORK: 0 Return to work in days or Ut(/\;)
a pt&" pWS(
Ilr' j;all for appointment with Dri~)a'l,.hO f~' i C1 [f'h~ne # Iir' Call for a ointment with 0 'inLt )1." Phone # />.'J.J..::r;/II{)
ADDITIONAL INSTRUCTIONS:
FOllOW.UP CARE: Bring all m~dicatlons with you to your appointment.

to be seen in _ _ _weeks to be seen in t..f weeks
IPhysician Signature:
o
o
I' , __ ~.i
o No Signature needed see orders
Dentures 0 Hearing Ald(s) 0 Assis1ive device Belongings returned; 0 None Cl Glas~~ !) lb' . -~ ,, __J.... Home medicltions tl Other: ~ [' \',\ <' These in$tructions have been reviewed wit me and my questions have been answered. Patient Si
......... ----.~
Di~charged to
Si njfjcant Other
Other --------------~~ Phone # after discharge':l;1':i . 1.)'// Escorted b ;
~ Home
Mode:
'i";
~mbulatory
Stretcher
I)EPAUL HEALTH CENT.b:R
,/ tr1is 1 fiarm. 0 r;ginalflorm to CIwr!. Copy (1902200197 Jt.1a ke 2 copies oJ _0/02/1976
~~CH,PHILLIP
liIIOftlillUllllIlI1 H
ERS
M
1/ p
1
32Y i;ALEt.,j, t-lOUNER
0554- Cl 01/22/09 000748:2 98
000199
PAGE:
J.

12303 DePaul Drive
Bridget.on. MO 63044 Fatient's Discharge Home Medication Liat

Account: Number: 0902200J.97
Patient Name: MARCH,PHILLIP B
Room Number: 0554-01 Date! 01j26j2CJ09 Attending Physician: SALEM,MOUNER
Patient Allergies: No Known Drug Allergies
l>1edication Generic Name [Br.and Name) with Di:rec.t.ioos
AM
Noon
PM " Bedtime
*.~.*
Scheduled Medications .-
AMLODIFINE(NORVASC)
5 MG BY MOUTH Daily
TAKE:
(1) 5 MG TABLET
TAKE. (2) 100 MG CAPSULE
~SOLE
I X
GABAPENTIN(NEORONTIN) 200 MG BY MOUTH 3. Times a Day
x
x
x
x
CEPHALEXIN{KEFLEX) 500 MG BY MOUTH 4 TIMES A DAY
TAKE: (11 500 MG

**~
-*.** As Needed Medications

OXYCODONE/ACET
5/325MG(PERCOCET-S) *1-:2 TABS BY MOU'I'H EVERY 6 HOURS AS NEEDED
AS NEEDED FOR FAIN
IF YOO HAVE ANY MEDICATIONS AT HOME WHICH DO NOT APPEAR ON THIS LIST.,
REMEMBER TO DISCARD OLD MEDICATIO:N LIS'TS AND UPDATB YOUR PHARMACY
PLEASE CHECK WITH OUR PRIMARY PlnlSrC!AN BEFORE RESONING THEM.
PAGE:
:<
DePaul Health Cen~er 12303 DePaul Drive

Bridgeton. MO 63044
patient's Discharge Home Medication List

Account Number: 0902200197 Patient Name; MARCH,PHILLIP Room Number: 0554-01 Date: 01/26/2009 Attending Physician: SALEM, MOONER
Patient Allergies: No Known Drug Allergies
Medication Generic Name (Brand Narr.e) with Directions
AM
Noon
EM
I Bedtime
Additional Orders
IF YOO HAVE ANY MEDICATIONS AT HOKE WHI:CH DO NOT APPEAR ON THIS LIST. PLEASE CHECK WITH YOUR PRIMARY PHYSICIAN BEFORE RESUMING THEM. REMEMBER TO DISCARD OLD MEDICATION LISTS AND UPDATE YOUR PHARMAcY
+
Please
H
DePaul Health Center 12303 DePaul Drive circle: Discharge
Meds or Post-op Mads PAGE NlJ!!!BER: 1
ESTIMATED DISCRARQE TIME:
Bridgeton,NO 63044 Patient Active Medication List (YES NO) Account Number: 0902200197 Patient Namel MARCR,PHILLIP EI
NURSE: PRONE EXT:
Room Number; 0554-01 Date: 01/26/2009

Attending Physician: SALEM, Momum.
patient Allergies: No Known Drug Allergies

Continue? Medication Generic Name (Brand Name) with Directions
AM
Noon
PM
Bedtime
**r.** Scheduled Medications ***.*
15~
NO
QABAFENTIN (NEURONTmll:O:C MG BY MOUTH :3 Times a Day

OOCUSATE SODIUM(COLACE)1ClIO MG BY MOUTH 2 Times a Day
ZDO
GIVEN AS:
tI) lOa MG CAPSULE

(1) 100 MG CAPSULE LF
x
x
x x
16 YES@
GIVEN AS:
DO NOT CRUSH - TASTE 7 YES
g;
PIPERACILLIN TAZOBACTAM (ZOlSYN) 4, 5 GM INTRAVENOIJS EVERY 6 HOURS
**
X
EVERY 6 HOURS
11 YES SODIUM CHLORIDE BACT O.9%(SODIUM)3 KL INTRAVENOUS EVERY B HOORS
**-,**
9 YES
OXYCODONE/ACET
As Needed
Medications ...... * ..
S/325MG(PERCOCET-SJ 2 TAB BY .MOlITH Every 4brs pm
FOR PAIN
PHYSICIAN SIGNATt1R.E IS REQOTRED ONLY ON 1'HE LAST PAGE: OF THIS MEDICATION LIST
>
pilot Form 4/2 aas
Medication Substituted per HOSlpital. Approved Formulary Substitution
H
Depaul Health Center 12303 DePaul Drive
PAGE :NUMBER: 2
EST~TED
DISCHARGE TIME:
Please circle: Discharge Meds or Pos.t-op .Meds
Bridgeton,MO 63044 Patient. Active Medication List (YES NO)

Account Number: 0902200197 Pat:ient Name. MARCH,PHILLIP H
NURSE PHONE EXT:
Room Number; 0554-01

Date: 01/26/2009
Attending Physician: SALEM,~OUNER Patient Allergies, No Known Drug A.llergies

Continue? Medication Generic Name {Bran.d Name) with Direct.ions
AM
Noon
PM
II
Bedtime
10 YES ~ ACETAMINOPHEN(TYLENOL)650 MG BY MOUTH EVE~Y 4 HOURS AS NEEDED 13 YES
_.. -- - - -?'f1- -- - -- - - ........ - - - _.. _.. -- -- - - - .. - _.. - - .. _.. - .... - ...... - .... _.... - _.. - - -- - _.. - _.. -- _.. "" .. - - - - - - - - - - -- - - - - - - _.. - - - - - ....... - _.. - - - - --- _.. - _.. - - - - - - - _.... - - - - - - -GIVEN AS; (2) 325 MG TABLET I i I I I
HYDROMORPHONE HCL(DlLAUDID) 1 M'G IWTRIWENOUS EVERY 4 HOURB AS NBEDED
BREAKTHROUGH PAIN
l.4 YES@ DIPHENHYDRAMINE (BENADRYLI 50 MG INTRAVENOUS EVERY 4 HOURS AS NEEDED
ITCHING Additional Orders
M. f1:r2--.C~h'r /ft-/t/~ _____.____ ~rVMt 5~ ,OfLd4.----------.
1<~:4 f'"
p&1wrd
Q)'b
--------"--_._--,',--,-----
5:!32-! /-Z-
--,-,--_._-,-----------------_._----_.
PHYSICIAN SIGNATURE IS :REQUIRED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST
>
pilot Form 4/2005
Medication Substituted per
Hos~ita1
Approved Formulary Substitution
H
DePaul Health Center 12303 DePaul Drive
PAGE lNUMBER; 3
ESTIMATED DISCHARGE TIME.

NORSE PHONE EXT:
Please circle: Discharge :Meds or Pos:t-op Meds Bridgeton,MO 63044 Patient Active Medication List (YES NO)
Account N\,UIlber:
09a2200~97
Patient Name: Room Number: Date: Attending Physician! Patient Allergies:
MARCH,PHILLIP H
0554-01 01.126/2009
SALEI4, MOUNER
No Known Drug Allergies
Name,(~~
4
--;~~:::~~-;:~~:~:~::-----~~~~-------~---------~:~:~~~~:---------------------------------------------------------------------NUrse Signature:
~.""_.._____. __Dat e/Time
1/
Name) with Directions
AM
Noon
PM
Bedtime
PHYSICIAN SIGNATURE IS REQUIRED ONLY ON "THE LAST PAGE OF THIS MEDICATION LIST
Pilot Form 4/2005
,.
Medication Substituted per Hos;pital. Approved Formulary Substitution

,--- ---------- --------I 0 No Known Allerg '.
j
~()I Jrr("o
('\f I"fr.. rr ... ., . -d;"v"l
Patient
o o
Medication Bottles Family/Significant Other Medication Lis! Physician's Office Pharmacy Name,_ _ __ Phone Num.:b.=e:.:r
ONo
AU Col
====_-.
over~th8.count8r.
h@mal s Innlofl'II"IRte
Dose
Route or tapir.al site
Frequency -.
cOlnDlletE~d
for each medication Including

last Dose
Date
Time
Continue?
[J
Drug Name
Yos
Hold
DYes
o t,ald
o
[J
Yes
Hold Hold
[J Yes
Cl Yes
[J
y~s
U Hold
Hold
DYes
o HOld
o Ho!d
U Hold
(J
o Yes
DYes
Q Yes Q Yes
\0~)
~\J~-' .
Hold
o Hold
U Hold
DYes
CJ VAS
o Hold
a
Hold
U Yes
Checked orders will only become active when authorized by Physician

MtJolcetion,Vherbdvvitaminfj will Of, di$pefWffd in BCGorriilnc@ wililltll;! l)oDit8i fMfflUIl'if)'
Home Med List
R@eon%tJ by:
Date
Dale
1/';Q,!tJ'I
Time t>} /:;

Time
.~I:._.?h..
Y_SiciavaCif . ./i.}C~'()--c9m
') :- }
: ..Nu~~e
0 Readback confirmed
-"..
'#
, 0 Scanned
~SSM DePaul Health Center

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DE:PAUL HEALTH cGENTR ~~~~'H~!PA.'II ERQ

0902200197
HOITlI:l Medication Orders 8/2008
10/02/1976 32Y
ERSM
01/22/09
BMERGENCY,PHYSICIA000748298
000205
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IMPORTANT
1, 'Dillly' IIlS(ijdU of
REMINDERS
"!!d'
;:, 'IInrt:i" 1II.1wll ul "It

3, Nu U.RIOg lerus (1 fIlV l1ul 1,Clug)
PATIl'NT \...EIGHT q
o K.,5
Cl Lbs
PATIENT HEiGHT q
4, IItvtays use leHdinu le'us (O,lmg not, lmgl
5, <MQIpf1tfro' IIlstcad 01 'MS04' a, "MagM.III!T! Ma\~' jlWt~~g Ql 'Mii~iJ4' r 'Every OIlier Ga',. ll1slcaQ Of -a,OD, 8, 'MGl;' ifl,lead 0/ '!JQ' 9, 'Inlelflabooa! ullils' inslood of 'IU"
1~IT"ll1rm:
mo 1lA&~ RJii ACOJIVC,
fO INOlcm T!lrpno.r c<lDm
ORDERS
~SSM
H E A L T H ' CAR E
W
nPl\UL HB7\J,l'H CENTER
- ImOlltllDlllllfllllUI PHLLLIP H
MAR~H
lip
PHYSICIAN'S ORDERS
SLM1000-005 (4/2007)
0902200197 ERS 0554-01 10;02(J 976 3ZY M 01/22/09

SALRM, 1"'.oU1~ER O(}U']" 8298
000208
,H.OSPITAl FOI1MUL~Y SYSTEM UNLESS CHECKEO HERE ....... ....,...
:.o,DR7'U;:-;;Qo;;:MA;;,;Y~BE:,::.:O::::.IS",",PE;..:.:NS..:;EP...::':..:.:N:;.;;ACC..::;;.;.;:Ofl;;;,.;OA:.::.N..::;'CE.;;;;V..;:..V'T.;:;;:H:;.;TH.;.:;e;.;.:::.."~p'-AllERGIES
__l'~J~tglAN 'S ORDE RS

IMPORTANT
REMINDERS
01 'Qd' 6, l,In~~< in.5\f?d r.f 'If 3, No lr.Ifting lAfru: (l mg not 1 Omg) ~, Always 1J38 laatll11g wos
PATIeNT WBariT r?
t 'Daily"
in~ao
o Kos
Cl Lbs
PATIENT HECHT q REAO

AC~ fQK
(O.lmg noumq)
5, 6 7 8, g,
'Morphllle' instead of 'MS04 wHale" Instead of 'M~S04' '('/ery olh!lf day' Instead 01 '0,0,0.' 'MeG' insteao cf '/lu' 'Imernationlil units" (n>l~ad (II 'IU'
't~eslUm
liill tAL U[f4: TO Uirr.C:ATf TRff'SOfff ~n-rli
IiC<;!iII'!;'f
ORDERS
ANTIBIOTIC ORDER RENEWAL

Accord\ng to Depaul Health Center's antibiotic stop order polioy, the follow1fig antibiotic ordem are schedy!~g to
elq)lre on \ \ ~~ \ ~
PsUent
~ W-lJr-
p,~ase revie",: your ,patle~t': cflnlcal response and renew, revisel or dISCOntinue ttl antibiotic orders accordingly, Thank You
~ '-..:: ".:.
f'
Room Numblr _ __
S!5.~
t:.t>~\4P
DP$-3901-991-819&
I.
__----~--------~<4Q~~~~----~b
H ' CAR E~
PATIENT LABEL
H " "
I\1ARCH,PHILLIP II
IlIIlIDlBlflllllflllllH
~RS
lip
0902200197
PHYSICIAN'S ORDERS
SLM-l000-OO!5 (4/2007)
0554-01
r.,
10/02/1976 37Y SALEM I MOUNEi<
0] /:I.:J.I09 0007 'J 8298
000209
HOSPITAL fORMUJ.AqySYSn;", VM.E$$ CHCCKCD HERE._""'~=_ _ _..:.-::.~-=..::..-=-:.:;.
DRUB MAY 6EDiSI'ENSfO IN ACCQRDANC5.WTTH lHE
,....l\.
PHYSICIAN'S ORDERS
IMPORTANT REMINOERS
5. "Murphine' h1slead vi "1.1$04' 6. 'MaVf16sium sulfalo" instead 01 'M9S0~' i. 'EYe!)' othu day' instead 01 'ODO:
ALLERGIES
1 2. 3 4.
f'IIfIEN I I'I1OIGHT
~
'Oaily' instead of 'q<j' 'Unhs' instead of 'u' No t:aihlJ leiOS (Hnq 1101 LOmQi AN,ays u~e Icooing WO,
(0 lmy Ilflt lmq)
IJ Kg. 0 Lb$
PATIENT HECHT
RiAn lAC' ra~ AC~\''f\,\C~
<>
u?,;vm
a 'MeG' Instaa<1 of '/Jq' 9. "IniHm300nallJntls" Instead 01 "!U'
l's'iltl't. HtRt
fQmo-lCJtJtT!Uf'llOH~
ORDERS
~SSM
SLM' 100{)'[166 (4/2007)
PA TfENT LABEL
H E A L T H . CAR E'"
DEPAUL HBAL'l:'H
PHYSICIAN'S ORDERS
S1\.LEM,MOUNER
CENTER MAl{CH f PHILLIP I"'" 0902200~97 ER" lip S 10/02/1976 32Y ~554-01
1IIIIlIIIIrIlilIfIlll
01/22/09 00(1'148298
000210
D QuaUtle$ for pneumococcal vaccine, Pneumococcal vaccine 0.5 milM will be administered on day 3 In AM or at disct1arg~ {when discharged betor~ day 3} per protocol unless countermanded by order of the physician with documented medIcal reason fever 101"F or for the vaccination.
*11 patient meets criteria for Pneumococcal vaccination but year of Il1lt PneumGOc;eal VlJl;ctne
Is not obtainable by Nursfng and/or Case Manager, vaccine should be given and recorded.
+CDC/AClP Recommendations MMWR 1012006
Yea
(j
Disqualifying Fadora (One or more Yes responses)

Already received flu vaccine this season
at 1:; 4
t:!:.I:
2~
I~
8---
AHergy to eggs, contact solution (thimerosal) or merthiolate

Patient Refusal Code Status: DNR: Comfort Measures Only
Q/ Allergic reaction to flu vaccine
U :l 'ii :- I
c~
Yea,;,
0
:','luaIU'jij'g;;lfiotors" (Oni:or':mora"'.Yssrssrioosss)..
50 years of age or older Heart Disease COPO/Asthma Diabetes
.........:.........
. ..
1:1
0
lJ
0
0
Renal Failure
Immunocompromised (i.e. on chronic steroids, chemotherapy)
:l_
Ei:
"," .f" ..;.; ...' .,i
Nursing Home or long Term Care Facility resident

Pregnant andlor newly delivered female Q 0088 not qualify for flu vaccine. D Qualifies for Influenza vaccine, Influenza vaccine 0,5 milM will be admlnlstere<l on day 3 In AM or at discharge (when discharged before day 3) per
;,;b:":",~t ..
':"~'
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essrDePaul Health Center r~.~~;';'tl~~~ ,,-. -, ~,11,1

Date:
D
HlIT~
'1.:l...,..
Time:
tJC1 00
Aneaament completed by: [J!tfL'-L/\

InitIals:
A.
A.
....,
HU
pneumocoo:allflu 91 2008
L ________.____
E- AUL HEALTH CENTER

1
0902200197 BRS 05~4-01 I. 10/02/1976 J2Y M 01/22/09
MARCH, PHILLIP H I D
SALEM, MOUNER
00074B298
000211
ASSESSMENT" ORDltS
(:
~-
DEPkUL HEALTH CENTER

'\,'... . .
..
'.:.'
MUIt\iTE~,. 8fl097
'0902200197 ERS 05S4-0~ , 10/02/19'16 32Y III 01/2'2/09

I SALEM, t-iOUNER 000748298
rv1ARCH I PHILLIP H
11111111111111.
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000212
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000213
EMERGENCY DEPARTMENT ADMISSION ORDERS
,~:_t!_~.~~. ~:.~~: . . . ~~.~n~_!.~.f..n._._~_~__:'~:~ .....n___ n. _____ n....................~~~.?~~~~~~..(1L~:.~:::(~_i_. __ ._.~::!I. ~.I' +i s

j Inpatient admit to: 0 Medical
. r . ' ~~_ r _ ... - --- -_. --. --
[) surgical
-" . __ 0_
0. _____ -
0 Telemetry [J 3 North (Intermediate leU) 0 Surgical
0 leu
<. _______ . . . . _ . . . . . . . . .
i Outpatient (Observation) admit to: )i(Medical i

Ph Sielan:
0 Telemetry
,t ................................ 1, ___ "
____
S~.ST~ r1' ... ,. _
"
". /
i' ,6.Fun ReSU5citation

o
Code Status
~ 10m ---_._-------------.,
.--._ _ _ _ co_n_s_u_lts_::..
~~_Z::.........:\:....!!V\...:...-".J>~e;r=---JL--::+-_ _ _ _ _ _ _ _.
Allergies:
o DNR - Continue Medical Therapy

DNR - Comfort Measures
Plac~on Care'pathwaY:D Acute Cardiac OCongeeiiveHeart Faflure' 0 Acute pu~onary
II.
~
.
!
SSESSMENT
Vita! signs every
0 Obtain Previous Medica' Records .-L hours x ~ then routine

0 Daily Weights
0 I&0
)!:( Oxime1ry o Cardiac Monitoring
ADDITIONAL DIAGNOSTICS
DCBC
OCXR
o CMP
OPT
o EKG
C _ _ _ _ _ _ ....._______
0 AC & HS 0 every _ _ hours
o PTT o Flngerstick Glucose

Ill. MEDICATIONS ~
Z" s '7 ~ .,. 5" j
-:r.
v'r '5
cp b
fvr~
o Imttate Sliding Scale Insulin Orders

)(continue Home Medications checked "Yes" on Horne Medic.'3tion She;;;t/Orders, )aacetamlnophen (Tylenol) 650 mg PO every 4 hours PRN mild pain or fever greater than 101.5F
);r .C (l '(\~ tY\ c..i n (.,o0:V .:! U PB Q '5 M- 5 'm Phrc<> c e,{ fL (5 2.J; if Ms PDQ i.{ b-rs pro pc. ij{)
IV. TREATMENTS
o DVT prophylaxis:
,,~
I I.
o IV fluids _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ '>tg Saline Lock

o Oxygen at
liters per_ _ _ _ _ _ CaH physician jf 02 Sat less than ~~%, 0 Regular 0 _ _ _ calorie ADA 0
Cl Foley 0 N13 to suction

0 NPO 0 Bedrest ~ SRP
~ I-t(.r).&c..:.. ..,.\.:...:(-...:::c~~-'-t---,-Su..o ..... f-J...+

0 _ _ _ _ _ _ _ __
if)
Activity:
sse
0 Up ad lib
'0 o See Additional PhYSician Orders

Date: Time: of;, So Physician: t~ Transcribed by: _ _ _ _ _ _ _ _ _ Time Noted:;:;P-
t{2-2-/0'1
~ -:~ ~
--'l
Orders scanned to Pharmacy. Date: _ _ _ _ _ TimB:
Inltlals: _ _ _ __
E A L T H e A. R t'"
~EPAOL
Jl~~'!!!AIJII 0902200197 ERS10/02/1976 32Y
HEALTH CENTER
S> EJ
ED ADMISSION ORDERS
M 01/22/09
EMERGENCY,PHYSICIA00074B298
DPM ..UOO-I~5 (tOl2007)
000214
DEPAUL HEAlTH CENTER

HISTORY AND PHYSICAl
PATIENT: MARCH, PHILLIP H ADMIT DATE: 01/22/2009 MR#: 0007462~98 ACCT#: 09022 7 ROOM: 0554
OOB: 10/0211976
PHYSICIAN: MOUNER SALEM, M.D.
REASON FOR ADMISSION: Left facial pain and swelling,
HISTORY OF PRESENT ILLNESS: This 15 a 32y~arold gentleman with a history of stab injury to the lfilft fflce in 2007 followed by fixation complicated by hardware infection requiring removal in July 2007. The patient has had a previous history of osteomyelitis. The patient hM also had problems wfth chronic pain. He states that the pain has gotten much worse. though, In the left
face along with the swelling. He denies fevers or chills. No drainage from his mouth or his nares. No ear drainage. He has not had any neck stiffness. No headache. His pain 1s primarily in the left face. He denies any radiation of this pain into the neck or shoulder. He denies any chest pain or shortness of breath, abdominal pain, nausea, or vomiting, No bloody stools or blackcolored stools, hematuria, dysuria, or frequency. REVIEW OF SYSTEMS: Otherwise negative, except as mentioned In the HPI. PAST MEDICAL HISTORY: Previous history of osteomyelitis of the left mandible, status post open reduction and internal fixation for a stab injury; hypertension; chronic pain since his facial injury; history of hardware removal; history of liposuction. ALLERGtES: None,
MEDICATIONS: The patisnt currently takea no medication accordIng to the medical records. He
states he is on Neurontin, however. ALLERGIES: None. SOCIAL HISTORY: He is a nonsmoker. He drinks alcohol primarily on weekends. He denies any illicit drug use. He works as a private investigator. PHYSICAL EXAMINATION: YITAL SIGNS: Temperature is 97,7. Pulse Is 68. Btood pressure is 1581108. Saturations are 100% on room air. GENERAL: He is well nourished. well developed. and in 110 apparent distress. He is sitting upright in bed. Every time he sn~ezeSt however, he does note a lot of pain In his left face. HEENT: ENT examination otherwise reveals anicteric sclerae. Extraocular movements are intact, Pupils are equal. round, and react to tight. Mucosa is moist. Oropharynx appears normal. No evidence of drainage, pus, or Significant dental deformities. NECK: Supple WIthout bruits or adenopathy. He has a wellhealed scar behind the left mandible. There is tenderness to palpation of the left race and left manoible. There is no crepltance noted or fluctuance. HEART: Regular rate and rhythm without any gallops. murmurs, or rubs. LUNGS: Clear to auseultation bilaterally without wheeze, ftJlee, Qf rhonchi. ABDOMEN: Soft, nontender, and nondistended. No organomegaly is noted. Bowel sounds are present. EXTREMIT1ES: Without cyanosis, clubbing or edema. The patient appears to be scratching his arms and legs and back since com ing up to the floor. LABORATORY DATA: Labs have been reviewed. ASSESSMENT AND PLAN: 1 This is a 32-year-Old gentleman who comes in with possible facial cellulitis. Preliminary report 6uggested celluliti$ However, the final CT report i& not Indicative of any acute changes. We will review with Radiology and Infectlol;s Diseases. Continue empiric
MEDICAUSURGlCAL HISTORY AND PHYS,CAl-DP
Page 1 of 2
000215

PATIENT! MARCH, PHILLIP H
HISTORY ANO PHYSICAL

MR#: OQQ74a2~6
antibiotic for nQW, He does appear to have some facial sweJling. however. An Infectious Diseases evaluation will be obtained. Pain control, He appears to have problems with pain CQntroi chronically with multiple emergency room visits to this hospital according to our records.
Ttlls document has been reviewed and signed by MOUNER SALEM
Sign OatefTime; 01/22/2009 11 :42 PM EST

MOUNER SALEM, M.D. MS:1-t862466880 D: 1/2212009 10:39 AM T: 1/22/200910:49 AM E: 01/231200909:01 AM
cc;
MOUNER SALEM, M.D.
MEDICAl/SURGICAL HISTORY AND PHYSICALDP
- Page 2 of 2
000216
I--~--~--------------~------~~~~------~SSM
H E A L T H . CAR E"
INTERDISCIPLINARY HISTORY & PAOGRESS NOTES
000217
~SSM eH E A L T H . CAR
INTERDISCIPLINARY
HtSTORY & PROGRESS NOTes
SLMl000-003 (6120031 02 BACK
000218
~SSM
H E A L T H . CAR E
Sl..M1000-00J (6/2003) 02 FRONT
DEPAUL HEALTH eEN'fER
INTERDISCIPLINARY HISTORY lit PROGRESS NOTES
--
r/p t,'[/\RCH, PHILLIP 11 0902200197 ERS 05~401 . LO/02/1976 32'l M 01/22/?09

$ALl::r.1, MOUNER Q00'{4{;l_98
!III0nlllltliRlIIJIIJI
000219
~SSM
SLMl O(){)-D03 (6f2003) 02 BACK
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090220Q19'l ERS 0554-01 . 1010211~n6 32Y fllf 01/22/09 SAT,EM, MOUNER OOOH8298
000220
f""te() 1. - ,2,<o..
OlTlme: ~
SSM DEPAUL PASTORAL CARE
OPM-6471-W2 (&LOOS}
~r-IRITUAL ASSESSMENT: ld1'fritial 0 Follow-up DJ~eterral 0 Trauma 0 Code 0 Death 0 _ _~-_______

DISTRESS; 0 Anger 0 Fear 0 ~us 0 _~jlty 0 Pain 0 Grief O _ _ _ _ _~____ - _ _ __ RESOURCES: 0 Gratitude Q1'fGst~ ~ ope .!d1'Ositive Image 01 Gad 0 Family/Friends 0 Church 0
SERV\CtS: 0 Sacraments
Notes:
~'<t T '\ {.- rb'i~;P-f~/I( S"f11'rt ----------------------------------------~ /~ _________ - ____ --____________ - _Chaplain: lC/Zt:f~ ~
A- {
.ayertG}SUpport 0 Literature 0 Suppor1 To FQmily P ~~==---------ADVANCE DlR CTIVES: _0 Yes !:iN0 Unkn wn b,&Patient 0 19<ippro~riat tAsk 0 ---/-"~---r-----'--~-~'7
J IJ fl , IJ
-
h----~----~------------------------~------------~~~T~~~NT~L~AB~E~L--------------
~SSM
DEPAUl, HEALTH CEJ-ITElI.
HfAL.TH-CARe
t'lARCH, PHILLIP H TIF 0902200197 ERS OS54-01 10/02/1976 32Y ~\ 01/22/09

SAL~M,MOUNER
tllJlIDUIDlllllflllllU
000746298
000221
~SSM
H E A L T H . CAR
SLM1000003 (6f2003) 02 BACK

r>1APCH 1 PHILLI P H TIp 09022~0l!J7 ERS 0554 -01 ]~O/02;l976. 3?Y M 01/22/09
SAl.EN, MOVNER 000'1 .. 82 98
E~
IUlIII0l1ll11ll1l1181
INTERDISCIPLINARY HISTORY 8. PROGRESS NOTES
000222

CONSULTATION REPORT
PATIENT:
MARCH, PHILLIP H
ADMIT DATE: 01/22/2009 CONSULT DATE: 01/23/2009

ATTENDING PHYS: MOUNER SALEM, M.D. CONSULTING PHYSICIAN: PHILLIP G. ZINSER, M.D.
MR#: 000748298 ACCT#: 0902200197

DOS: 10/02/1976 ROOM: 0554
REASON fOR CONSULTATION: Evaluation of left facial pain and swelling.

jaw in 2007,
SUBJECTIVE: This is a 32-year-old with a history ot hypertension. He had a stab wound to his He sustained 8 fracture to the left mandible. He had open reduction and internal fixatlon. He developed a hardware Infection. He had a partial response to antibiotics. The hardware was removed on 09/2212007 at Barnes. At that time, cultures grew strep ang/nosis, strap intermedius, and < >. He returned to DePaul on September 19,2007, with swelling. MRI showed osteomyelitis of his left mandible ramus. He was discharged on IV Unasyn to follow up at Barnes. He was readmitted in Octobef of 2007 with increased pain and fever. His blood cultures at that time grew Klebsiella. It was determined that he had a PIce line infection. The PIce line wa~ removed and he improved with Zosyn and has done well since that time. The patient has had chronic pain which he rates as a 6 out of 10 since that time.
The patient returns and was admitted on January 22, 2009, with a 2-day history of some increased swelling and Increas~ pain at the sits. He denies fevers, chills, sweats, nausea, vomiting, diarrhea. cough, phlegm, phlegm production, or he<:'ldache. He was admitted and started empirlCl3l1y on Zosyn and clindamycln. He feels unimproved at this point. He had a CT of the face without contrast which showed chronic bony changes but no acute changes or infection. His white blood carl count was normal. He has not had fevers.
ALLERGIes: The patient's list of allergies Includes that he has no known drug allergIes.
PAST MEDICAL AND SURGICAL HISTORY: The patient's past medical and surgical history are as above. In addition, he has history of VRE colonlzatJon. He also hal> history of liposuction.
HOME MEDICATIONS; He reports Neurontin.
His Ii$t of medications here tn the hospital Include1 Gabapentin. 2 Acetaminophen. 3 Diphenhydramine. 4 Hydromorphone. 5 Cfindamycin. 6 Zosyn.
SOCIAL HISTORY: He does not use tobacco. He drinks alcohol prlmarily on weekends, He denies any illicit dru~ use. HI;} wQrKS a~ a private investigator.
OBJECTIVE: VITAL SIGNS: The patient's temperature maximum is 97.8, The pulse Is 66. The respirations 18. The blood pressure Is 147/96. The saturation is 100% an room air, GENERAL: The patient is awake, alert, and oriented. The patient Is Sitting up in bad. HEAD: He has some chronic swefllng on the left side of his face from changes In the $hape of his mandible secondary to his previous history. He has a nodule on his left cheek where he evidently has a clip still in place from previous surgeries. This has been a site of problem~ previously. He has tenderness in that area. There Is no redness, warmth, induration, or bagginess. It is hard to know if there is any increased swelling from his baseline. The neck Is supple with a full range of motion. The pupils are equal, round, and reactiVe to light. The oropharynx is clear. The uvula rises midline. LUNGS: Tile lungs are clear to auscultation bilaterally with good ajr movement. HEART: The
MEOICAUSURGICAL CONSULTATION REPORT.DP
- Page 1 of 2
000223

PAT'ENT; MARCH, PHllUP H
CONSULTATtON REPORT
MRtI: 000748298
heart has a regular rate and rhythm. ABDOMEN; The abdomen is soft, nontender, and nondisten(jed. Normoactive bowel sounds. EXTREMITIES; There is no peripheral edema. There is no chording. There are no rashes. There is no decubiti.
LABORATORY DATA: The patient's white blood cell {;Qunt Is 7000 with 53% neutrophfls, and 37% lymphocytes. The hematocrit is 42. The platelets are 282,000. The creatinine: is 1.4. CT of the face shows no acute changes. Review of previous hospitalizations reveals history of VRE colonization and Klebsiella bacteremIa In 2007.
ASSESSMENT: 1 History of left facial stab wound with mandible osteal In the past treated and with hard removal in the past and with hardware removal in the past. A cUp remains. 2 Acute on chronic pain and swelling.
RECOMMENDATfONS; f MRf of the face with contrast.
3
4
Follow up with Barnes ENT. Oiscontlnue clindamyctfl for now. Continue Zosyn pendIng the results of the MRI.
Thank you for allowing me to participate in this patient's care.
This document has been reviewed and signed by PHILLIP ZINSER
Sign DatefTime: 01f25120098:20AM EST PHILLIP G. ZINSER, M.D. PGZ:1-190 ~ 2467787 0: 1/23/200912:32 PM T; 1/231200912:57 PM E: 01/25/200909:01 AM
cc:
MOUNER SALEM. M.D.
MEOJCAUSURGICAL CONSULTATION REPORT~DP
- Page 2 of 2
000224
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000225
E,m ergency .nepartme~t Or(],ers beneral Chlefcompla1t@,~<Jcui~_

Drugs must he dispensed in accorda1lce wilh tht: hospit1l1
AII.;::s
\1' \
tbl~ary system.
I.
Assessment: Notify physician if SDP < 90 or >; 95, or heart rate < 60 or > 120 1 or for oecrcas mental status PulHe oximetry (notify physician fN Sa02 <9211;;') and Temperature recorded Asses:'; women of childbearing age for pregnftUl.:'Y st~tu:; and perform urine beta 1 for any possibility of pregnancy
II.
o
III. Treatments:
o
TV. Medications:
-~--------
....... ~~--+--
V.
Tylenol 1 gram po for Temp> 1OQ.} or PRN pain
Nutrition:
VI.
NPO
AdditionaJ Oruen:
o
I have revIewed and agree with the above orders wilh {he f:};cqJtion of (hose crossed rhrough.
;),"e I Time: O() rIme llft;J=~ R.N.
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~
MARCH/PHILLIP H
0902200197
DEPAUL HEALTH CENTER 1
111.11
ERS-
ERQ
1.0/02/1976 32Y M 01/22/09 EMERGENCY, PHYS1ClAO0074SH8
000226
Name; March, Phillip H

Complaint: Swelling/Pain Of Jaw
Age: M32 Wt: 76,2 Kg (est.) MedRec:000748298 AcctN um: 0902200197
- - - - - - - - - - - - - - T R I A G E DATA----................- - - - - - Triage Time: Thu Jan 22200902:12 Source: By: Car Urgency: ESI3 Room: WTG-RM
Vital Signs: (0210) BP:128/85
Age: 32
Male
Kg Weight: 76,2 (est.) PhysIcians: None Pcp Emergency Physicians
P:72
T:98.9
Pain:?
Sat: 99/ra
R:20
HPI JAW PAIN (05:23 AMAJ) CHIEF COMPLAINT: Patient presents for the evaluation of Jaw pain. left,
HISTORIAN: History obtained from patient. TIME COURSE: Onsel of symptoms reported as gradual, Onset was 2 days ago, Patient currently has symptoms, Complaint Is worse, Complaint is constant. LOCATION: Pain most severe in left mandible, Posterior radiation. QUALITY; Pain is throbbing. No different from patient's previous epIsodes. EXACERBATED BY: Patient's condition exacerbated by chewing, speaking. RELIEVED BY: Patient's condition relieved by nothing. NOTES: Pt has hlo osteomyelitis of the jaw after an assault/stabbing In the area; feels/looks slmUar but he is without fever ..
KNOWN ALLERGIES Morphine, No known drug allergies, HISTORY

MEDICAL HISTORY (Thu Jan 22200902:12 DMH): Stabbed In left face April 28th, 2007. jaw osteomyelitis . $ee RN notes ..
PSYCHIATRIC HISTORY (Thu Jan 22 200902:12 DMF/): No previous pgyehistrie history. No previous
psychiatric history. No previous psychiatric history ...
200~ 02: 1~ OMHj; Jaw Repair, plute feft jaw. facial repair. Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left Jaw. facIal repair. Patient's previous surgical history Is not relevant to the case. Jaw fracture repairs. Jaw Repair, pla1e left Jaw. facial repair L Jaw surgery, harware removal, chronic osteomyefitls. see RN notes .. SOCIAL HJSTORY (Thu Jan 22 2009 02:12 DMH); Denies al~ohol abuse, Denies tobacco abuse, Denies drug abuse, Patient consumes alcohol socially, DenIes smoking, Patient consumes arcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco. Denies alcohol abuse, DenIes tobacco abuse. Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco. Denies alcohol abuse, Denies toba~co abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. Denies alcohol abuse, Denies tobacco abuse, Denie6 drug abuse . FAMILY HISTORY (Thu Jan 22 2009 02:12 DMH): Family history Is not contributory to this case, Family history is not contributory to this case. Family history Is not contributory to this case. Family hi8tory is
SURGICAL HISTORY (Thu Jan 22
Prepared: Thu Jan 22200907;43 by Charle BlaesIng, RN Page: 1 of 7

$$M DePaul Health Center
000227
Name: March, Phillip H

Age: M32 Wt: 76,2 Kg (est.) MedRec:000748298 AcctNum: 090Z200197
not contributory to this case, Family history is not contributory to this case, Family history is not contributory to this cass. Family history IS not contributory to this case .. NOTES (05:23 AMAJ): Nursing records reviewed, Agree with nursing records, Nursing notes reviewed at the time this note entered; any nursing or paramedic notes charted after that time not reviewable unfen directly
communicated to this M.D.,
ROS (05:23 AMAJ)

CONSTITUTIONAL: No fever, No chills. ENT: Historian reports otalgIa, No hearing changes, No sore throat, No dysphagia, No dysphonia, No drooling, No voice changes. RESPIRATORY: No SOB, GI: No abdominal paln, No nausea, No vomiting, ALLERGIC/IMMUNOLOGIC: No frequent Infections, No poor healing. ALL SYSTEMS NEGATIVE: All relevant systems reviewed and all negative excep1 for the above.
!\DDITIONAL TRIAG&; (Thu Jan 22200902:12 DMH)

COMPLAINT PROVIDERS: TRIAGE NURSE: Donna Hogan. ADMJSSION PATIENT: NAME; Phillip H March, DOB: Sat Oct 021976, RACE; Black, Code: NO, Trauma: "NO, Work Comp.: NO, Heat Related: NO, SSN: 493788699, ZIP CODE: 63121, HErGHT: , 82cm, PHONE: 314393-1241, MEDICAL RECORD NUMBER; 000748298, ACCOUNT NUMBER: 0902200197,lBEX NUMBER: 20090122021203ADT. PREVIOUS VISIT ALLERGIES: No known drug allergies, NOTES:Total score is: 0, Confusion (3), No Increased Risks patient, dh. ASSESSMENT: 8110, GCS Eye Opening: Spontaneously (4), GCS Verbal Response: Orientedlconversive (5), GCS Motor Response: Obeys comands(6), The GCS total is 15, pain in 11,* jaw with swelling and burning that started 2 days ago, Pf has hi{ of osteomyelItiS in left jaw, pt afebrile. IMMUNIZATIONS: Immunizations up 10 date, Last tetanus sho1 recaived less than 5 ye~r~ ggg, TB SCRtENING: Denies iB screening. DOMESTIC VIOLENCE: No domestic violence,
EDUCATIONAUCULTURAL BARRIERS: No educational/cultural barriers,

TREATMENTS IN PROGRESS: No treatment, Protocols: General Chief Complaint. VITAL SIGNS
PHYSICAL EXAM (05:25 AMAJ)

CONSTITUTIONAL: Vital signs reviewed, Alert and orian1ed X 3, Patient appears uncomfortable, HEAD: Atraumatic, Normocephalic. EYES: Sclera are normal, Conjunctiva are normal. ENT: External ear normal, no nasal deformity, No stridor, not injected, no pharyngeal swelling, no pharyngeal asymmetry. mucus membranes mOist, No drooling, Able to handl~ secretions. No tongue elevation, no abcess, no dental fractures, Sinuses non-1ander, No erythema, No swelling, Trismus present, edema over L mandibular body and angle, extending back to just anterior to ear; no induration or drainage, no r1uctuance. NECK: Normal ROM, No jugular venous dis1ention,
Prep!lred: Thu Jan 22 200907:43 by Cherie Biassing. RN Pagl1: 2 of 7 SSM DePeui Health Center
000228
Name; March. Phillip H
Age: M32 Wt: 76.2 Kg (est.)

MedRec: 000748298 AcctNlIm: 0902200197
RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. UPPER EXTREMITY: Inspection normal. No cyanosis/clubbing/edema, Normal rangs of motion.
LAB INTERPRETATrON (05;25 AMAJ)

INTERPRETATION: 1 reviewed the lab results, All labs normal.
02SAT INTERPRETATION (05:25 AMAJ)

02SAT: 02 satura1ion reading 99%, 02 AMT: R.A., 02 Sat normal, None needed.
RESULTS
LAB (04:50 AMAJ): CBC W AUTO DIFF Jan 22 2009 04:48, WBC 6.8 1000/mm3 Ref Range (4.511.0). Hgb 14.0 gm/dl Ref Range (13.0-18.0), Hct 41.5 % Ref Range (39.{)"S4.0),
PIa,1!ilI~ts
2821000/mm3 Ref Range {130.G-400.0).
(04:53 DAGN): CSC W AUTO DIFF Jan 22 2009 04:48, RBC 4.96 10X6 Ref Range (4.7-6.1), MeV 83.7 fl Ref Range (80.0-99.0}, MCH 28.2 pg Ref Range (25,O-31.0), MCHC 33.7 gm/dJ Ref Range (32.0-36.0), RDW 13.9 % Ref Range <1' .5-14.5), Gran 53.4 % Ref Range (40.0-70.0),
Lymph 37.1 % Ret Range (22.0-40.0),

Mono 8,4 % Ref Range (2.0-10.0), Eos 0.7'% Ref Range (O.O-S.O}, Baso 0.4 % Ref Range (0.0-3.0),
Manual DiH Not Indicated, Absolute Neutrophll3.62 1000/mm3 Ref Range (1.8-7.7}. (05:03 OAGN): BASIC MeTABOLIC PANEL jan 22200905:02, BUN 16 mg/dl Ref Range (9.0-20.0),
Sodium 140 mEq/L Ref Rang@ (137145),

Potassium 3.7 mEq/L Ref Range (3.6-5.0), Chloride 100 mEqlL Ref Range (98.0-107.0), C02 27 mEq/L Ref Range (22.0-30.0). Anion Gap 12.8, Glucose 74 L mg/d. Ref Range (75-110), CreatinIne 1.4 mg/df Ref Range (0.8-1.5), Calcium 9.5 mg/dl Ref Range (8.4-10.2), GFR 75.5 mVmin/1. 73m2.
RAOrOLOGY INTERPRETATION (06:49 AMAJ)

HEAD: Interpretation of the facial CT shows, c/w facial cellulitis. INTERPRETER: Preliminary review of CT by Radiologist.
Prepared; Thu Jan 22 2009 07:43 by Cherie Blaesing, RN Pag&; 3 of 7
SSM DePau! Health Center
000229
1I11! ijm
11'fllllllll/JIII~1111111I1" ~m mIt 11111

Age: M32 Wt: 76.2 Kg (est) MedRac:000748298 AcctNum: 0902200197

DOCTOR NOTES (06:50 AMAJ)
TEXT: Considering complicated hx with osteomyelitis and now cellufitis on CT, wUl admit for IV abx to IPC . INTERVENTIONS; Antibiotics administered:, Clindamycln, Antibiotics were given IV. DATA REVIEWED: Reviewed radiology films.
OTHER HISTORY: Other history obtained from: reviewed prior patient visil fscords.
PATIENT STATUS: Patient has stabllzed since admission.
DIW: Discussed this case with Dr. Salem, the on call physician.
PATrENT PLAN: The patient will be admitted to the hospital. Initial physician orders were written for patient as discussed with admitting physician.
DIAGNOSIS (07=25 AMAJ)

FINAL: PRIMARY: Factal CelluUtis, ADDfTIONAL: .
)ISPOSITION (07:25 AMAJ)

PATIENT: X-RAY leT Follow-up: YES, Critical Care: YNone, Doctor Procedures: NO. Disposition: Admit Medical. Condition: Stable.
MEDICATION SERVICE
8enadryl (05:43 AMAJ): Order: BenadryJ : 25 mg ; IV Push Time: 0320
Notes;
v~rb
Ordered: Thu Jan 22 2009 05:43 Ordered by: Angela Majino. M.D.
Entered by: Dave Agnew, RN Thu Jan 22200905:43 Documented as given by: Dave Agnew, RN Thu Jan 22 2009 05:43 MEDICATION, Time given: 0543, Given in amount and via route as prescribed, Amount given: 25mg, IVP. Rapidly, Caiheler plaoement confirmed via flush prior 10 administration, IV siie without signs or symptoms Of inflitration during medication adminisiratlon. No sW9111ng during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to adminis1ration, Patient advised of actions and slde-~Heet$ prior to administration, Allergies confirmed and medications reviewed prior to administration. Benadryl (03:23 AMAJ): Order: Benadryl : 25 mg : rv Push Time: 0320 POTENTIAL MODERATE INTERACTION Morphine Sulfate Notes: vorb Ordered: Thu Jan 22 200903:23 Ordered by: Angela Majino. M.D. Entered by; Dave Agnew, RN Thu Jan 22200903:23 Documented as given by: Dave Agnew, RN Thu Jan 22 2009 03:24 MEDICATION. Time given: 0320. Given in amount and via route as prescribed, Amount given: 25 mg, IV site 1, IVP, SlOWly, Catheter placement confirmed via flush prior to administration, IV sile without signs or symptoms of infiltraiion during medication administration, No swelling during administration, No drainage
Prepared: Thu Jan 22 200$ 07:43 by Ch~rie Blaesing, RN Page: 4 of 7 SSM DePaul Health Center
000230
IlItllllllllltJ II filiI "Ill fli filii II fJlll IIll11J111111111I1
11m 11m Iml II III Ifill I Jlllmlll IIlltllf II fill
~j
Name: March, Phillip H Age: M32 Wt: 76.2 Kg (est.) MedRec:000748298 AcctNum: 0902200197
during administration, IV flushed 'Ifter administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration. CJindamycin Phosphate {06:27 AMAJ}: Order: Gfindamycin Phosphate: 600 mg : IV Piggy Back Ordered: Thu Jan 22 2009 06:27 Ordered by; Angela Majino. M.D. Enter9d by: Angela Majina, M.D. Tl'lu Jan 22 200906:27 Documented as given by: Dave Agnew, RN Thu Jan 22 200906:35 MEDICATION, Time given: 0635. Given in amount and via route as prescribed. Amount given: 600mg. IV site 1, DripllVPB, Premixed, Catheter placement confirmed via flush prior 10 admlnistra1ion, IV site without signs or symptoms 01 infiltration during medication administration, No swelling during administration, No drainage during administratton, IV flushed atter administration, Corree;! patient, time, route. dose and medication confirmed prior to admInistration, Patient advised 01 actions and side-effects prior to administration, Anergies confirmed and medications reviewed prior to administration. Dilaudid (04: 16 AMAJ): Order: Dilaudid : 1 mg : IV Push POTENTIAL MODERATE INTERACTION Benadryl Ordered: Thu Jan 22 2009 04:16 Ordered by: Angela Majlno, M.D. Entered by: Angela Majino, M.D. Thu Jan 22 2009 04:16 Documented as given by: Dave Agnew, RN Thu Jan 222009 04:46 MEDICA liON, Time given: 0415. Amount given: 1 mg, IV site 1, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration dUring medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient. time, route, dose and medication confirmed prior to administration, Patrent advised of actions and side-effects prior to administration, Alierg'les confirmed and medications reviewed prior to administration. Morphine Sulfate (03:16 MOOR): Order: Morphine Sulfate: 4 mg : IV Push Time: 0310 Notes: vorb Ordered: ihu Jan 22 200903:16 Ordered by: Duane Moore, MD Entered by: Dave AgMw, RN Thu Jan 22200903:16 Documented as given by: Dave Agnew, RN Thu Jan 22200903:16 MEDICATION, Time given: 0310, Given in amount and via route as prescribed, Amount given; 4 mg, IV site
1.
: Follow Up (03:25 DAGN): Time: 0315, Attending physician aware. Dr. Majino, Pi complains of ilching after administration of IV morphine.
PRESCRIPTION: No Documented Prescriptions
NURSING ASSESSMENT: FOCUSED (03:14 DAGN)

NOTES: Pt has left taclal swelling, pt rates 10/10 pain . PAIN SCALE: left mandibular Jaw, swelfing and pain. EYES: Eyes are PERRL.
Prepared: Thu Jan 22200907:43 by Cherie 6mesing, RN Page: 5 01 7 SSM DePaul H"al1h Center
000231
SSM DEPAUL EMERGENCV RECORD
Name: March. Phillip H

Age: M32 Wt: 76.2 Kg ,est.) MedRec:000748298 AcctNum: 0902200197
NEURO: Orientation: Alert, Behavior: Cooperative, Coherent. GCS: GCS Eye Opening: Spontaneously (4), GGS Verbal Response: Orientedlconversive (5), GGB Motor Response: Obeys comands(6), The GCS total is 15. MUSCULOSKELETAL: Good ROM. SKIN: Skin is cool, Skin is dry.
NURSING ASSfSSMI:NT: NURSES NOTE (04:52 DAGN)

TIME ASSESSED: Time: 0430, Patient is improving, Patient in no apparent distress. Patient states decreased pain, Patient resting quietly.
NURSING ASSESSMENT: NURSES NOTE {05:43 DAGN}

TIME ASSESSED: Time: 0540, Pl comprains of i1ching.
NURSING ASSESSMENT: NURSES NOTE (06:36 DAGN)

TIME ASSESSED: Patient is improving, Patient in no apparent distress, Patient states decreased pain,
Patient resting quietly.

NURSING PROCEDURE: IV (03:15 DAGN)
TIME: Procedure was performed at 0305.20 gauge catheter inserted, into It~ft Forearm, with 1 attempt, Saline lock established.
NURSING PROCEDURE: TRANSPORT TO TESTS (05:22 DAGN)

TIME: Procedure was performed at 0520, Patient transported to CT scan, via ambula1ory, accompanied by Nurse.
NURSING PROCEDURE: 8LANK CHART (05:24 PENG)

TIME: Procedure was performed at 05:23, GT maxiHofacial completed by RK and ZE.
NURSING PROCEDURE: NURSE NOTES (07:10 CBlA)

TIME: Time: 0700, assumed pt care sleeping at present rasp even and nonli3bored no distress.
NURSING PROCEDURE: NURSE NOTES (07:31 CBlA) TIME: Time: 0730.

VITAL SIGNS: BP: 130, /90. Pulse: 72, Resp: 16.
NURSING PROCEDURE: INTAKE AND OUTPUT (07:42 CBLA)

TrME: Intake output performed, at 0740, PO Intake(ml): 240, IV IntaKe(ml): 100, Total IntaKe: 340, Taial Output: O.
NURSING PROCEDURE: ADMISSION (07:43 CBLA)

TIME: Bad assigned at 0730, Report called at 0740, Patient admitted at 074;~. 554, Patient Acuity Level Wa$ Urgent, Patient admitted to medsurg unlt, Report called/faxed to sheila, Patient transported via cart, Accompanied by transport, Transported with personal belongings.
ADMIN
Praparad: Thu Jan 22 20Q9 07;43 by Cherie Blaesing. AN Pa9~; 6 SSM DePaul Health Canter
01 7
000232
1111111111111111111111111 111111111111 flllllIl
"IfI1111111111
11111 'till 11m llflllilif 11111 1If1l1f11J
~lfI ""111111

DIGITAL SIGNATURE (03;14 DAGN); Agnew, RN, Dave. (03:15 DAGN): Agnew. RN, Dave. (03:25 DAGN): Agnew, RN, Dave.
Name: March, Phllflp H Age: M32 Wt: 76.2 Kg (est.)
MedRec:000748298
AcctNum: 0902200197
(04:53 DAGN): Agnew. RN. Dave.

(05:22 DAGN): Agnew. RN. Dave. (05:44 DAGN): Agnew, RN, Dave.
(06:36 DAGN): AgMw, RN, Dave.

(07:43 CBLA): Blaesing. RN. Cherie. PATIENT DATA CHANGE (03:47 AMAJ): A1tending changed from (none) to Angela Majino, M.D. (03:57): AOe 86231928 by Interface, Payment: 00, Admitting Doctor: Pcp None, Attending Doctor: Physicians Emergency. (04:02): A08 86232029 by Interlace, Admitting Doctor: Pcp None, Attending Doctor: Physicians Emergency. (07:36 HWE1): Admit Room: 554 r, Payment: (none).
KEY:
AMAJ=MaJlno, M.D., Angela C8LA=BlaQsing, RN, Cherie DAGN=Agnew, RN, Dave DMH=Hogen, Donna
HWE1=West, RN, Heather MOOR=Moore, MD, Duane PENG-Engleman, Paul
Prepared: Thu Jan 22 2009 07:43 by Cherie Blaesing, RN Page: 7 of 7 SSM DaPaul HMllh Canter
000233
1111111
m /I m '/111111111111111 lfl IIIJI 11 IfI IIIJI 11111 11111
IlJII1IfIJ ij IIIIIIfIII 1IIIIIIltI 11111111 11m 1 fill

Name: March, PhllUp H Age: M32 Wt; 76.2 Kg (est.) MedRec:000748298 AcctNum: 0902200197
~J

HPIJAW PAJN
CHIEF COMPLAINT; Patient presents for the evaluation of jaw pain, left. HISTORIAN: History obtained from pa1ient. TIME COURSE: Onset of symptoms reported as gradual, Onset was 2 daye ago , Patient currently has symptoms, Complaint i8 worse, Complaint Is constant.
LOCA nON: Pain most severe in lett mandlbfe, Posterior radiation.

QUALITY: Pain is throbbing, No different from patient's previous episodes. EXACERBATED BY: Pa1ient's condition exacerbated by chewing, speaking. RELIEVED BY: Patient's condition relieved by nothing. NOTES: Pt has hlo osteomyelitis of the jaw after an assault/stabbing in the area; feels/looks similar but he its without fever"
HISTORY
MEDICAL HISTORY; Stabbed in left face April 28th, 2007. jaw osteomyelitis. , see RN notes ..
PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No pf'evious

psychiatric history... SURGICAL HISTORY; Jaw Repair, pla~e left jaw. facial repair, Patient's previou5 surgical hIstory Is not rerevant to the case. Jaw Repair, plate left jaw. facial repair, Patient's previous surgical history is n01 relevant to the case. jaw fracture repairs. Jaw Repair, pfate left Jaw. facial repair . L jaw surgery, harware remova', chronic osteomyelitis. see RN notes .. SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse, Oenies drug abuse, Patient consumes alcohol socially, DenIes smoking, Patient consumes alcohol socially, Denies drug abuse, LIves at home with family, Denies alcohol abuse, Denies tobacco. Denies alcohol abuse, Denies tobacco abuse. Denies smoking, Patient consumes arcohol socially. Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco. Denies alcohol abuse, Denies tobacco abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. Denies alcohol abuse, Denies tobacco abuse, DenIes drug abuse .. FAMIL Y HISTORY; Family history is not contributory to this case, Family history is not contributory to this case. Family history Is not contributory to this case. Family history Is not contributory to this case. ~amily history Is not contributory to this case. Famfly history is not contributory to this case. Family history Is not contributory to this case .. NOTES: Nursing records revlewael, Agree with nursing records, NUrsing notes reviewed at the Ume this note entered; any nursing or paramedic notes charted after that time not reviewable unless directly communicated to this M.D..
ROS
CONSTITUTIONAL: No fever, No chills. ENT; Historian reports otalgia, No hearing changes, No sore throat, No dysphagia, No dysphonia, No drOOling, No voice changes. RESPIRATORY: No SOB.
GI: No abdominal pain, No nausea, No vomiting.

ALLERGIC/IMMUNOLOGIC: No frequent injections, No poor healing. ALL SYSTEMS NEGATIVE: An relevant systems reviewed and all negative except for the above.
Prepared; Thu Jan 22200907:43 by Chefie Btae!iioy, AN Page; 1 01 4 SSM DePaul Health CenlE/(
000234

PHYSICAL EXAM
Name: March. PhillIp H Age: M32 Wt; 76.2 Kg (est.)
MedRec:Q00748298
AcctNum: 0902200197
CONSTITUTIONAL: Vital signs reviewed. Alert and oriented X 3. Patient appears uncomfortable. HEAD: Atraumatic. Normocephalic. EYES: Sclera are normal, Conjunctiva are normal. ENT: External ear normal, no nasal deformity. No stridor, no1 Injected, no pharyngeal swelling, no phaIYngeal asymmetry. mucus membranes mois1, No drooling. Able to handle secretions, No tongue elevation. no abcess, no denIal fractures. Sinuses non"tsnder, No erythsma, No swelling, Trismus present, edema over L mandibular body and angle, extending back to Just anterior to ear; no Induration or drainage, no fluctuance. NECK: Normal ROM, No jugular venous distention. RESPIRATORY/CHEST: Chest is non-tender, 8reath sounds normal, No respira10ry distress. CARDIOVASCULAR: RRR, No murmurs. No rub, No gallop. UPPER EXTREMITY; Inspection normal, No cyanosis/clubbing/edema, Normal range of motion.
DOCTOR NOTES
TEXT: ConSidering compficafed hx with osteomyelitis and now cellulitis on eT, will admit for IV abx to
,PC..
INTERVENTIONS: Antibiotics administered:, Clindamycin, Antibiotics were given IV. DATA REVIEWED: Reviewed radiology films. OTHER HISTORY: 01her history obtained from: reviewed prior patient visit records. PATIENT STATUS: Patient has stablized since admission. Df\N: Discussed this case with Dr. Salem, the on call physician. PATIENT PLAN: The patient will be admitted to the hospital, InitiaJ phYSician orders were written for patient as discussed with admitting physician.
DtAGNOSrS FINAL: PRIMARY: Facial Cellulitis, ADDITIONAL: .
DISPOSITION
PATiENT: X-RAY/CT Follow-up: YES, Critical Care: None. Doctor Procedures: NO. Disposition: Admit
Medical, Condition: Stable.
M!;CICATION SERVICE
Benadryl: Order: Benadryl : 25 mg ; lV Push Time; 0320 Notes: vorb Ordered: Thu Jan 22 2009 05:43 Ordered by: Angela Majino, M.D. Entered by: Dave Agnew, AN Thu Jan 22 2009 05:43 Documented as given by: Dave Agnew, RN Thu Jan 22 2009 05:43 MEDICATION. TIme given: 0543, Given in amount and via route as prescribed, Amount given: 25mg, IVP. Rapidly, Catheter placement confirmed via flush prior to administration. IV site without signs or symptoms of infiltration during medication administration, No swefllng during administration, No drainage during administration, IV flushed after administration. Correct patient, time, route, dose and medication confirmed prior to adminlstra1ion, Patient advised of actions and sideettects prior to administration, Allergies
Prepared: Thu Jan 22 2009 07:43 by Cherie Blaesing, RN Page; 2 of 4 SSM DePaul Health Cenler
000235
Name: March. Phillip H
Age: M32 Wt: 76.2 Kg (est.) MedRec: 000748298 AcctNum: 0902200197
confirmed and medications reviewed prior to administration. Benadryl: Order: Benadry/ : 25 mg : IV Push Time: 0320 POTENTIAL MODERATE INTERACTION Morphine Sulfate No1es: vorb Ordered: Thu Jan 22 2Q09 03:23 Ordered by: AngeJa Majino, M.D. Entemd by: Dave Agnew, RN Thu Jan 22 200903:23 Documented as given by: Dave Agnew, RN Thu Jan 222009 03:24 MEDICATION, Time given: 0320, Given in amount and via route 85 prescribed, Amount given: 25 mg, IV site 1, IVP, Slowly. Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration. No swelling during administration, No drainage during administration, IV flushed atter administration, Correct patient, time, route, dose and medicaiion confirmed prior 10 administration, Patien1 advised of actions and sIde-effects prior to adminis1ration, Allergies confirmed and medications reviewed prior to administration. Clindamycin Phosphate: Order: Clindamycin Phosphate: 600 mg : rv Piggy Back Ordered: Thu Jan 22 200906:27 Ordered by: Angela Mallno, M.D. Entered by: Angela Majino, M.D. Thu Jan 22 2009 06:27 Documenled as given by: Dave Agnew, RN Thu Jan 22200906:35 MEDICA TlON Time given: 0635, Given in amount and via routEl as prescribed, Amount given: 600mg, IV site 1. Drip/lVP8, Premixed, Catheter placement confirmed via flusn prior to administration, IV site without signs or symptoms of Infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies con1irmed and m@dications reviewed prior to administration. Dilaudid: Order: Dilaudid : 1 mg : IV Push POTENTIAL MODERATE INTERACTION Benadryl Ordered: Thu Jan 22 200904:16 Ordered by; Angela Majino, M.D. Entered by; Angela Majino, M.D. Thu Jan 22 200904:16
Docummlad as given by: Dave AgMw, RN Thu Jan 22 2009 04;46

MEDICATION, Time given: 0415, Amount given: 1 mg. IV site 1, Catheter placement confirmed via flush prior to administration. IV site without signs or symptoms of inilttration during medication administration. No swelling during administration, No drainage during administration, IV flushed after administration, Corract patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Anergies confirmed and medioations reviewed prior to administration. Morphine Sulfate: Order: Morphine Sulfate: 4 mg : IV Push Time: 0310
Notes: vQrb
Order8d: Thu Jan 22 2009 03:16 Ordered by: Duane Moors, MD Entered by: Davs Agnew, RN Tl1u Jan 22 200903;16
Prepare<J: Thu Jan 22 2009 07:4:) by Cherie BII\~sjng. RN Page:.3 of 4 SSM DePaul Health Center
000236
11111 ,JltJ Ifill II m 1ff)1 IJIII 1\ tIl 11111
J/I~ Ifill
11111 1/11/ Name: March, Phillip H Age: M32 wt: 76.2 Kg (est.) MedRec: 000748298 AcctNum: 0902200197

f
Documented as given by: Dave Agnew. RN Thu Jan 22200903:16 MEDICATION Time given: 0310. Given in amount and via route as prescribed. Amount given: 4 mg, IV site
1.
: Follow Up: Time: 0315, Attending physician aware, Dr. Majino, Pt complains of itching after administration of IV morphine.
Prepared: Thu Jan 22 2009 07;43 by Cherie 6laesing, RN

Pag~;
4 of 4
000237
SSM DEPAUL RECORD
Name: March, Phillip H Age: M32 Wt: 76.2 Kg (est.) MedRac:000748298 AcctNum: 0902200197
Prepared; Thu Jan 22 200907:43 oy Cherie BIassing. RN Pugs: 1 Of 1
SSM DePa1.11 Health Cent&r
000238
VltC
1/22/2008 5:59 AM
PAGt
1. I
Fax !:)erver
DePaul Hospital (SSM)
Preliminary Radiology Report

Name: MARCH, PH!LLlP
~iA~~;: ..... .. . VIRTUAL RADIOLOGIC"

,
~
866-941-5695
Date: lf22f2009
Age: 32Years M
MRN: 000748298
Requesting Physician: Dr Majino
DOS:! Of2/1976
Number of Images
Procedure
CT SOFT TISSUE NECK
Accession
1226218K
159
Provided Clinical History: pi'lln In left jaw with swelling and burning that altllted 2 days ago Pt has hx of osteomyelitis in
left jaw
or of the neck with contrast;

History as provided: Pain in left jaw with swelling and burning that started 2 days ago. Pt has HX of osteomyelitis in left jaw ct maxillofacial wI contrast
Findings: There is mild soft tissue swelling along the left side facial soft tissues centered over the subcutaneous fat overlying the masseteric muscle. There are postsurgical clips adjacent to the left the carotid bifurcation. There js no identified focal collection or abscess. No bone erosion. There are some irregularIties and sclerotic change involving the left mandibular ang'e, The larynx and epiglottis are within normal limits. No evidence of tonsillar abscess. No airway shift or significant narrowing. No cetvicallymphadenopathy.
The visualized paranasal sinuses are aerated. Small polyp or mucous retention cyst left maxillary
sinus base. Improssion: Fundus compatible with remote left mandibular osteomyelitis.
There is no acute erosion or abscess identified. Nonspecific left-sided facial soft tissue swelling suggestive of cellulitis.
Thank you for allowing us to participate in the care of your patient.
If a slgn,flGupl is found between the preliminary .llnd final Interpretations of tlljs study. pleas", fax becK this rorm V>lth a :;01>1 of the officiai repc OJ contact VRe office so lhat
ap~opnate
o.l~crepancy
QUALITY ASSURANCE
action may be taken
Interpret alion;
Agree
Disagree
VRC dayt!lne arlrninls!nn,ve contact nun1bf'fs:

Fax 9521l35-255~ 1 el .. phone: 952-392~ 1100
Altered Plit/gnt Cara:
Yeo..
No
CONFIDENTIALITY STATEMENT
ThiS transltl/SSlon is confidentisl lind is mlendt:(f 10 be 8 priVileged ~'OmmlJnt~fltiO!1. It is intended only frx the USI'! Of 1h8llddre.~see. Ar:ces$ to //lis meSSif9t' by anyone else is unsuthonzed. tr you {Ire noi the intended rBcipitm/, any disc/owre. wP'tinr;. distribution IT any aelJOII l3iHITI, or omitted /0 btl fake/) in refisllce on II is prohibited find ffilIy be unlawftil If you feceivea (his cammonicatloll In error, please noli!>1 tiS by telepholle. 30 (hal return
of tfjs doculm'n/ to U~ csn b(l arranged
Pagfl1 of 2
000239
VRC
1/22/2009 5:59 AM
lJAGE
2 1 2
Fax Server
; .....:~~~ VlRrUAL RADIOLOGIC" -:.;;;:,"

...
866-941-5695
. ... .....'

Name: MARCH. PHILLIP
Age: 32Yc:ars M
Date: 1122/2009
DOS: 10/211976 Number of Images
Requesting Physician: Dr Ma)irlO

Procedure CT SOFT TISSUE NECK
MRN: 000748298
Accession 1226218K
159
Provided Clinical History: pain

left jaw
In
left jaw with swelling and burning that started 2 days ago Pt has hx of osteomyeiitis in
Dictated and Authenticated by: Boden, Tom, M.D.
112212009
5~57
AM Central Time
11 a Significant dlscr",pa flCY is found between the pr<;!fiminary and fin a! Interprelpiions of trJs study. please fax bllck this form ',~jth a copy of the official report qr contact VRe office so that apP'ooriate aclion may be taken
QUALITY ASSURANCE Interpretation: Agree
Ols<llIrn
VRC daytime administrative conlae! numbers'

FllX 952935-2551 Telephone: 952-392-1100
Altered Patient Care:
Yes
No
CONFIDENTIALITY STATEMENT
Tilis (HlIlsmi.Slon i! confidentl918JlQ IS Intended 10 be 8 privilege<! communication It is inlef)QeQ Qnly for the 11M! of thd 8ddl~ssec. Access 10 this Illessage by Iln>'one else is un(Ju!horize(J If )'011 are not 1M mtende<i (sc/pien/, any disclos\.ve, 'np),ing, distribution or any aclion taken, or oml!litd 70 L", titken in reiiance on if is prohibited lind may be unlawful If you r(!ceived fhM cOtnnl!illfre/JOfl i~ error, plt};)&o notify I/S Ily le/vpham:, so thai r~tllrn of !hI;; document /0 u,~ can be Olfl2ngoo
000240
11111 11111 /JIII/llfl II If lit I) rll11111 11 IIllflJI
~l
'II~ Iriff
mJlllltllltl1
~1tI ~m ijllf 1I1~ If 111 Ilfll rmlliffl

Age: M32 Wt: 76.2 Kg (est.) MedRec: 000748298 AcctNum: 0902200197
iiiiiiiiiiiio
SSM DEPAUL TRIAGE RECORD

--------------TRIAGE
Complaint: Swelling/Pain Of Jaw
Triage Time: Thu Jan 22 2009 02: 12 Source: By: Car Urgency: ESI-3 Room: WTG-RM Age: 32
DATA-----------.. . .
Male
Kg Weight: 76.2 (est)
Physicians:
None Pcp Emergency Physicians
Vital Signs: (0210)

BP:128f85
P:72 Pain:7
Sat:99/ra
R:20
T:98.9
KNOWN ALLERGIES
HISTORY (Thu Jan 22 2009 02;12 OM H) MEDICAL HISTORY: Stabbed in left face April 28th, 2007. jaw osteomyelitis . see RN notes.. PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous
psychiatrIc hIstory.. SURGICAL HISTORY; Jaw Repair, plate left Jaw. facial repair. Patienfs previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facia' repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. Jaw Repair, plate teft jaw. facIal repair . L Jaw 8urgery, harware removal, chronic osteomyeUtls. see RN notes . SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse, Den/ea drug abuse, Patlent consumes alcohol soclaJly, Denies smoking, Patient consumes alcohol socially, DenIes drug abuse, Lives at home with famjly, Denies alcohol abuse, Denies tobacco. Denies alcohol abuse, Denies tobacco abuse. DenIes smoking, Patient consumes alcohol socially, Denies drug abuse, lives a1 home with family, DenIes alcohol abuse, Denies tobacco. Denies alcohol abuse, Den;es tobacco abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. Denies alcohol abuse, Denies tobacco abue6, Denies drug abuse .. FAMIL Y HISTORY: Family history Is not contributory to this case, Family history is not contributory to this case. Family hl,t9ry I~ n9t contributory to thff) caGe, Family hiatory i3 not contributory to this case. Family history fs not contributory 10 this case. Family history is not contributory to this case. Family history is not contributory to this case ..
ADDITIONAL TRIAGE (ThU Jan 22 200902:12 DMH)

COMPLAiNT
PROVIDERS: TRIAGE NURSE: Donna Hogan.

ADMISSION PATIENT: NAME: Phillip H March, DOB: Sat Oc1 021976, RACE: Black, Code: NO, Trauma: 'NO, Work Comp.: NO, Heat Related: NO, SSN: 493788699, ZIP CODE: 63121. HEIGHT: 182cm, PHONE: 314393-1241, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0902200197, IBEX NUMBER: 20090 122021203ADT. PREVIOUS VISIT ALLERGIES: No known drug allergies. NOTES:Total score is: 0, Contusion (3), No Increased Risks patient, dh, ASSESSMENT: 8/10, GCS Eye Opening: Spontaneously (4), GCS Verbal Response: Oriented/conversive (5),
Prepared: Thu Jan 22 2009 02: 12 by Donna Hogan Paga-: 1 012 SSM DePaul Health Center
000241
11111 jlllllllil
IIIIIIIIIIIIIIIIIIIIIIIIIII'~ 11111 11111 1/111
IltrlllflJ IIJIIllm IIIJJ IIIIII'IIIIIIIIIIIIIIII~ mil

Name: Maroh, Phillip H Age: M32 Wt 76.2 Kg (est.)
AcclNum:
MedRec:00074B29B 0902200197
GCS Motor Response; Obeys comands(6), The GCS total is 15. pain in leit Jaw with swelling and
burning tha1 s1arted 2 days ago. P1 has hx 0# osteomyelitis in lett Jaw. pt afebrile. IMMUNIZATIONS: Immunizations up to date, Last tetanus shot received less than 5 years ago. TB SCREENING: Denies TB screening. DOMESTIC VIOLENCE: No domestic violence. EDUCATIONAUCUl TURAL BARRIERS: No educational/cultural barriers. TREATMENTS IN PROGRESS: No treatment, Protocols: General Chief C"mplaint. VITAL SIGNS
KEY:
DMH""Hogan, Donna
Prepared: TI1U Jan 222009 02: 12 by [)()nna Hogan Page: 2 of 2 SSM DePaul Health Center
000242
SSM DEPAUL EMERGENCY FLOW SHEET RECORD Name: March, Phfflip Age: 32:Y MIR: 000748298 Acct: 0902200197
VITAL SIGNS User
DatelTime
01/22 07:31 01/2202:12
BP
130/90
128/85
PULSE
RESP
TEMP
PAIN
7
02SAT
99 on ra
TIME
0210
CBlA
DMH
72 72
16 20
98.9

Name: March, Phillip Age: 32Y MR: ,000748298 Acc1: 0902200197 Prepared: Thu Jan 22 07:43:10 2009 Iby Cherie Blaesing, AN
Page; 1
UNIT ORIENTATION; Instruction ellplain<Jd ROOM ORIENTATION: Instructlan ftxp161ned

T
~pastoral servlceli
~ Aslong for help to gel up
CillIlIght nurse
Call hght pall'l
No smoking policy
qVisiting hour$
--t Sirlfl rails
Call IIghl - tu~eting
; Comlon Rounds ~ Telephone
. Tel(;l~.!___-;-U_8_8_0_'b_eO_c_O-:!lI,_fol_S ..........c--_,E"me_f_ge_n_C_Y_ligh_t.... B_Rl_S_ho_w_e_1_ __
ARRIVAL INFORMATION COMPLETED BY

(If otl1.r Illsn nurse)
S=IG=N=AT=lIR=~--.;;:::::;:::;.~f.\~S::.::OY\~_O:.::..~=p--=--....L1\....l..--
i~21d/O 7_====--=--=--=----l
Ask ALL palient,. the following Qll_e_SI_io_rllI_:_ _- -_ _ __ Y$S No

Q
CJ
Ll
l
.
Have you ellef tHed 10 harm yourse~ in the past? Explain _ _ Are YOIl here because you tried to harm yourself? Explain _ _ _ _ __ Y61:'C:,id:n;no=tm:8::d'-l In lhe past week. have you been having thought,. Elbout harming yourself? Explain .--:--========..:::.===--==-;:):...P.::h:
BEING EMOTIONALLY, PHYSICALLY OR SEXUALLY ABUSED?
:::J NO EVIDENCE OF PHYSICAl. SEXUAL, OR PSYCHOLOGICAL ABUSE NOi~O.

CI EVIDENCE OF POTENTIAL ABUSE NOTED BUT NOT SUSPECTED. SPECIFY EVIDENCE _ _ _ _ _ _ __
:J Hotline called
specify: _
RATIONALE _ _ _ ._ _ _ _ _-
_ _ _ _ _ _ _ _ _ _ __
PI\TIENT/FAMILY/SIGNIFICANT OTHER INVOLVED IN Tl"IE CI\RE PLAN DEVCI.OPMfNT. U
ves
LPN:
i.J
Form completed
Slgnnture:
Date:
Time:
(If completed by LPN, RN review and plan at care developmlmt required)
RN: efJU+l-l~!~tecttp+Mm data reviewed ~of
Signature:
Date: \ I
I
,
l_~~
' 7 ')
'2- -It
(
'(l
,______--.j\
care/Care
pathway developed
r<-----..../
Time:
c'~ . , \ U / C ~ ..,
PATIENT LABEl
~SSM
SLM1000050 (6/2008) FRONT
H E A l T H ' CAR EW
liP 0902200197 ERS 0554-01 '10/02/1976 32Y N 01/22/09

SALEf4, !40UNER 000748298
r1ARCH, PHILLIP H
IIIUIIIIIIIOIIIIIII
000244

SYSTEM REVIEW
Neurological CardloV8SGtJIBri HemalolOcgleal Resplraloryl Infectlous Ditleaae Gl/Nutrlllon
Q No problem idenlifiad
;:) No problem identified
..i Exception a:; be/ow

:.J E](ception
U Excep!Jofl
BS
au
Musculoskeletal Reproductive
Identified idantlli9d
identified
Q Exception
811
below
U Exception as I;Jljlow
Q E:Kception
below
below Wound/Stdn/ Mucous
as
oelow
o N'J problem identified

Q No problem identiliecl
<IS
IJ Exception liS below
o No problem i<lentffied o Exception as below

a ExceptIon as below
Sldn RIU Sooto: 18 or '"' petilfll I, Jl Q FellOw 8AJn C4re Protocol fo1 SCOIl1 0(
'8 Of less. (Post prolOCOl.it tMdsidft.) NlIlrfti()n;V oonwlt
(if nol previously obl&llllld.)
EENT
rt,,,
Protllam
Potonhal
problem
No apPiiIanl
prohlem
Tlma Score em Admission. twice daily. and with changes In condllion/actMty or assBSsed risk factors .
*'Score of 3 or gealef IndlCOItes ~~~~~~~~=-=-------'~-----'-=I ./C--+---""-d---i----l possible Fall RiSk. If nVllIing judgmtWlt
~
.------,;C-.-l---+---+
diffel'li from aeont obtained, dOCllment ._~_~ rel!.S()n code from list beIQw;
Date: ~bo<"'~...;..L.-- Time:
_l,,-,t...:..1_IL~//_
PATiENT LABEl.
~SSM
H E A L T H . CAR
ADMtSSION ARRIVAl.. SHEET
L._..-AUL J-I.EALTH CEI'lTER
E~
MARCH,PHILLIP H 090220019 7 ER8 0554-01

10/02/1976 32Y
SALE~t1,
1I1111111111111mllliR
t.l
MOUNER
rip
01/22/09 000748298
,LM 1000-058 {6f200a,; BACK
000245
0 Durable Pow of Attorney fur HeaItt1care 0 HRtIh Cant Olr&Ctlve 0 See tifl1ily sptlCifio form (I.e., Essence, Intent) 0 See Progre68 Notw \la.IIrI1OIrm!klnsIiU valid? a VI)& 0 No r~~~to blInQ In copy? 0 Yes From;Whom _ _......-_..........,_....-__--.-,.....,.,.,...-,-~..",_hu the fQllQwlng AdVance Ditectlve;
in chart
HEAl.TH HISTORY (Check any that apply)

BOLD SYMBOL.S
., + ,. _ ) INDICATE REFERRAL. NEEDED ON BACK

hx: 0 Hwrt attack
o BleedIng problem o Blood c!ot

o Blood tran$fusion
!l& 0
Asthma
o Arthritis 0 Ba<;k!Hip/Knee
o Blood pressure problem
Oate: _ _ __
o Alzheimer's/Dementla
o Diabetes * +
controlled by: insulin
o o Subcutaneous pump o Oral Hypoglycemic

DDiet
o Pacemaker/Defibrillator o Congestive Hearl Failure. o Heart murmurNalvular disease

~ 0 Chest
o Vascular disease
o Chronic pain prior to admission ( _

Site: _ _ _ _ _ _ _ __
110)
o Pregnant/Lactating.
o Chronic Pain Managtlmenl

If pregnant. due date: _ _ _ __
o Breathing problem
o Sleep ApnewCPAP
OT6. SiS; 0 Wheetlng
o Bronchitis o COPD/Emphysema
o Emotional problems o Anxiety o Depression

o HBart surgery
Date;
Elevated chQlesterol
pain. Angina Frequency: Last episode: ______ Palpitations
o Prostate problems o Reproductive problems

Lasl menstrual parlod:
0 N/A
o Sensory prOblem
o Glaucoma
o SUic1dalllloughts!p1an
OEdema Where:
Frequency:
o Heart disBase
o Cough/sputum production
o Hepalilis o InlectiousJCommunicuble Disease. o VRE 0 MRSA 0 C. dfff

When: Location:
o Hearing 0 Vision o Skin problems. + o Rash o Skin riSk soore 18 or isss

o Unstageable wound o Nonhealing wound o Other _ _ _ _ _ _ __
CJ Pressurl;! ulcer Stage 3 or 4
Shortness of breath Shortness of breath occurs at: rest _._ with normal activity _ _iF of flights of stairs climbed
o Chamo/Radialion
o Home oxygen o Cancer
# Of blocks walked
o Dialysis o Stone lJ Neurological problems o Seizures

o
Frequen"y: _ _ _ _ __ Last episode: Siroke/TIA Frequency: Last epIsode: ____~_ __
o Kidney disease.
o IV Devics (i.e .. POrt. PICe, ale.)
o o
o o
o Chipped or loose leeth
Contacl physician for ET/Wound Nunse Referral Orders Sexually transmitted disea~ Stomach/Bowel problems GERO/Acid Reflux Ostomy. Date \asl 8M: _ _ __ Thyroid problams UrInary problems
o o
Recent ex~ur8 to: 0 Chicken pox 0 Hepatitis
I:! O!fl~r; _--"""""'=~,===;-_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

If you check any of the above, please describe: _ _ _ _ _ _ _ _ _ __
o Naus<;;aNomiting
o Family problems with anl7slhasia

t4ARCH,PHILLIP H
~SSM e
H E A \. T H . CAR
W
1IIInlllll'I0011l11l1
rip
000748298
ADMISSION DATA BASE

SLMl000-059 (4{2008) FRONT
ERS 0554-01 10/02/1976 32Y I't 01/22/09

Si\L,EM, {v'lOT]NER
0902200197
000246
ADMISSION DATA BASE
~~~~~~9~!!!!~~~
---.,--,.,...---1 0 8/000 Sugar 1I1l11" G/l1lI 01161 300 ~~I DlAbelAA KWH "*
"* o N6 iIIofiHiirmg 01 bf9G!lll1glT
---+---1 0 Htwly Dr DialJelil:
------1----, 4lA'fo REFERRAL IlIDltATfD

o ltiltOl"l Of CHI'
- - - ; - - - - 1 0 Pallenlnqutd o tllJlfln pump
'" CtrdlAc Rehab "
O~etllf4f/uesj
~ RffERRAlIHDIGAlH)
o Slilgs 3 Of 4 jnuurtllfCer o Htn~II6aIInD woulld o UIl5t11l1lfble \IrOul!d o Sain RIsk SCOTt ot 18 or 1m

~~~::~~~~~~ 0 AIliJearanG'e 01 mllmrtrttlDn
CJJn!eJ1 Hytrlflon
o R811allallu"
o
Uapllllll14WT Q 101blOrllllffr'2-a
D DiffiGlflty GltnilngfiWlllowlng
o N/VID 3 ~ CI' mora

DPPHfWfIITl'
o Cllwn91 In JIIIletile m~ro OIan athf$
o Preonam (niillll!MrillQJ ar laota\fl!; o Pallenl requ~$l
Uve in:
Apartmant
Residential housing
Nursing home
Other.
Who do you livlo' wilt1?
(1ItIP '?e IF
0 Yes Narrms!Agencias _ _ _ __
0 No . . If no. explain: _ _ _ _ _ _ _ _ __
Do you pr,m to return TO your home from the nospil<ll? )il'Y65 Transportation 8vaifabk,'?,>:2J Yes 0 No Does anyone holp you at home now? ENo Diffic\.Ilty Ambulating f lrans1erring? .19'No
o Ullplllnllid majQt lW,gwy
o HoIIoIIawlltI1 {ljabttic (Jlel
o N8w1y Ox Dia~ic
011 -70 yearl old) o H lory of btrI11", tv/very
() REFtlIIW. INDiCATED
Inftet/Pn Ct)!!lro!
o I'omiYe T8 :lClUllqlSkin !Itt

IY
o HII!I1ry 01 MR3A/Vf1E1t, iliff
Difficulty wI actlvnles of rlilily lIVing? )g No 0 YQS
Yes
If
yes due to pain, explain; - ; ~;;;t;;;-;;Y;leI.;n _______
* Explain: _ _ _ _ __
Explain: _ _ _ _ _ _ _ _ _ _ __
~
o
v!tt (Pmf, PlCt;, fro.)

~
!;lint elj3ol1lre RfFfftRAL INtJrCATED
Do you have any specral concerns aboui being in the hospital?
13 No
YIt~
0 Yes
Hllve you had any major crr.l(jges (jOb, mova, dlvQrce, death, 61(;,) h) yuur life recently?;o No 0 Yes ~_ _ _ _ _ Do you have any ,piritual concem~'? ~o 0 Yes + ___~ _____________~ Any special religious/cullurEl factors reiateo 10 care? 0 No Sleeping oroqlems: Other (.'/f..1t,-<
t;J.Ro REfERRAL IIfOItATED + paslor@! Core +
o P91iem lIequttt o MalfiGaUon edu~11I1lI'I o CJJItq&m mQ1ls
_ _ _ _ _ _ __
rj1 Olfficulry falhng <lslt;!ep U Difficulty staying asIS,,!)
o AIlfu;jpated Cuplllg OIIIl&utty o PGIlr PfllflllCltlt o &eoout ProudurW8ufOiI)' o AOvJl1ee DUtCliYt A$3istinva o f'a11~nl Req ~"I
COII;erns IIffERML INDICATED
How do you get along with your family? Have you over hflQ ~x7 b]
;#
,<,,-3,
N'J ~lYes, hoW old Wlilrfl you Wh!lll yall 'Ir$! /lad 56X7---,''--':;;.z. _ _ __
0 No .K! Yes . A-" ))
o [friO In 1.,112 fflQnlIii
.. Job,"" C&s.;OOjnn ..
What kind 01 bi"" C'.Qnlrollp(Qtection do YI)U or your p!trtner U$f,1? _ Have you ",ver had 56' when you really tlid nol wan1 to?
if liV fi?h-,-'''''~/ _ __
o Ptlltm R'Qullst o NO flfFRIIA1IHnI~TfIJ
Have y6u
ever lei[ so sad thaI you trlought about killing yuurself?
.;0
No
0 Yes
[}-'I"tlysiCian Notified
COMPLETED BY (if other than_R_N..:..)_ __
-.----1 0
o P1fl.nt ReqllGsl o SiIMtyIil'lU 1Iw1~ alii ns

H4m~I\lJJt'OlspfJCtd
~unl!lo
!~
50cilj stN19Q ..
- - - - - - ..--.~-____t 0
5
o
Sl1l
IIDmtI Placemerll AhllwHaglec;t
oREffllRAlIHIlICATEIl
lillie liMit .m!stanoe
~SSM
H E A
~
DEPAUL
HEALTH CENTER
T H . CAR
E~
ADMISSION DATA BASE

SLMl00{)-059 14f2W8) [JACK
rIARC} .-
IllllnlUlIlllIIlll"l t PHILLIP H
r
I! L'
0 () 0 '{ 4 9 291;\
090220019 ~
10 I 02 ! 1 97 f>
ERS
SAl,Et'\. MOUNER
?2Y
"
055~ -01 1>1 01/22/09
000247

Primary Social Worker: lor Social Service intervention,
{j;; Tri9ger for Social Serv'ice i'nIterren'tiond
o Multiple trauma
o High risk 06 o Readmission within 30 days o Admission within t -3 monlhs o Progressive disease with impairment o Contagious disease
f:l Aouse
victim
l:J. Drug overdo;;e !'J. Substance abuse
o History of substance abuse

o
Comatose condition OMental stalu;J changes
o DehydrabonlMalnutritlon o On 7 or more medications o IV anlibiolic or alimentation Tx

o Decubitus ulcer
o Ostomy patIent
o Dialysis patient al _ _ _ _ "'

A
Family member dependent on Needs arrangement for care
o Flu Vaccine: Oate:

youl
A 06 under age t 8
Pneumovac: Date: --'-~ <~~~;rz::::::C1(
o l.ives e ; e; and/or ' frail

'Ith s
-f',\AI..IY6'S I
use or family ,
o O'ler the age 01 65

A Suspected abuse and/or neglsnt
{j Needs financial as:>istance
o Occupation:
o Limitations imposed by Illness.'
0 Mobility 0 Feeding 0 Hygiene 0 DresSing 0 Toil811ng 0 Tran:JPortallon
A Prevlou,> SOCial Ser.'lce Intervention A Financial asSistance needed for medlcallollS
~O Needs assistance in performing ADL5:
1 story home
0 2 story home
o Apartment
Number
or stairs to enter _ _ _ _ __
Homeless
o Admission from/to nursing home:

Name' /:. Inadequate support
o Clinic patieol
Whem:
/
~
o veteran-I'l Family counseling needed
=----__._ '
<....
o Equipment used: _ _ __
'~~;anspon.ation Plan ---~....s=7I'-.JL--'-'''''''''''~.....-::------0
Hospital VA/Feder, I Private PayiCustodi / 0 SNF 0 Other _ _ _ _ _ _ _ _ _ _ __
o Home IV Therapy
Type of fuc/lity:
0 Home DM!;;
HOSpice
Hospital Acute
Hospital' Psychiatric 0 Rehab
o LTAC (Long Term Acute Care HospitaQ

Patlan'tIF~lI'Y1lllv
o ResidentialfAssisted Ulling/lntermediate Care FaCIlity

cOllfirms retuming 10 same facUity
DEPAUL HEAL'l.'H CENTER
SALEM, MOONER
"lARCH, PHILLIP H rip 0902200197 ERS 055'1-01 10/02/1976 32Y 1'1 01/22/09
OO0?4829R
1111111111111111
000248

ADDITIONAL NOTES
f..-.-----~----
t--~----_-=----=----=-----~-~-----r-----i
i
~----------~~~~~--------~-------~
----1
I 0 Homf! 0 HQme H!H!l!h

Type of faciliry: 0 Hosplc!7
Q Home IV TMrapy
0 Hospital - Acute
bl Home QME
0 Rehab
0 TrlIn!iportatlon PIBn _ _ _ _ _ _ _ _ _ _~ _ _ _ _ _ __
0 Hospital- VAiFederal
0 Nursing Home- Private Pay/Custodial 0 SNF
0 Hospital - Psychiatric
o LTAC (Long Term Acute Care Hospital)

1 0 Facility hOlding bed
o Residential/Assisted Livmg/lntermediate Cars FaclUty

0 Patlent[Family confirms returning to aarTIct facUity
0 Other _ _ _ _ __
o Other
PATIENT LABEL
~SSM
H e A L T H . CAR
SlM~8570-OO1
E~
CASE MANAGEM!;NT SCREeN'NQ/OISCHARG~ PLANNING

(12/2004) BACK
000249
INTERDISCIPLINARY CARE PATHWAYS

MEDICAL HISTORY SPECIMENS
GENERIC
INtTIAl DISCHARGE PLAN
(Vt! n-!S~ tv {J(A. M
TO BE COLLEOTED
(i) IA c.L
Home with significant other
1------=-== _ _ _ _ _
, I ~l,
I - - , - - - - ---~
DAilY LABS
,'I
0 SNFIACF
0 Rehab
0 Other
o Home Health
_ _ _
,_~
CONSULTS DEPARTMENTS I NURSING
MRSA/VRE screen sent
"""ft.
c. diffioile sent
Results
/SOLATlON: Special Contact
f
o Airbome
o Droplet
PHYSICIANS
DATE
NAME
I'"
-,),,'1.-01 '
DJ-
'7' U "'" n,l",r"
l'
1(;
DATE
NA;;re--
<J I'
o o Contact
Pneumovax year:
Flu vaccine year:

AdmittBd with pressure ulcer? 0 Yes
SPECIALTY EQUIPMENT
Date:
Type:
/---.,-- - - - - - - - - - --l
___ _ ---.l _____

DIAGNO,SIS/PROCEDURE
_ __
:~O-~-:-~A-:U-S-_WT ~~
~n resuscitation
o ONR medical management o DNA com Ion mflasure~
Advance directives? 0 Yes
CJ?/Ik / III S (Il.....b/ F''!

N
/71
--I
--I
;;?"-
"1
I ALLERGMIES
i - - - - - - - -~- - - - - - - - - - - - - -~- - - - '
Copy in chart? 0 Yas 0 No

Is there anyone who should not receive general condition information? 0 Yes !l;M\Io
-----
Family/Significant other designated to receive medical information: Name

Phone
~~~
Name
Phone
0 POA
OPOA
~SSM
H A L T Ii
r. A R IE"

COPYRIGHT 1007 S:;>M HEALTH
DEPJl.l,JL HEALTH C!=:NTEH

r.tn.RC!{, Plllf..,LIP H
1~111f111J IBIIII ftiIIWII"
liP
fNTffiO,SCIPUNAAY CARE PATHWAYS- GENERIC

OPMlOOO024 (912007) PAGe 1 OF 8
CARE
SALEM', McmmR
09C2200197 ERS 0<;'<;'1,01 10'(' ~ I ; 970 3<!l' M Ol,'22!09 000748298
000250
-1 DATE! ' IN L
\
T----i
PLAN OF CARE
--PROBLEMS/OUTCOMES/INTERVENTIONS
IT/A S
place l!1itlals and dote th~ proble';'S are Identiflecf In l~ft cOlu~n. . AI( lutlntified problem must be evaluated whetne, Outcome 1$ Mal or Unmel at time of dillhruy6 by p~ d3te and imltats in appropriate column If Oulc.ome is mal pnor to di5charg~, place date and lnitlflls on Mit ooIumn. Place .( In bnx by I!1to;lfVomlion~ appropriate to palient. Wril& IT1 E!ddltkinallnle1Vt9ntlons as needed 10 blank spaces.
OUTCOMES
Met UnmQi
I Problem: Alteration In Neurologh::al StatU$
I I
Age~pcclfic cOllsideration
in Elderly Adutrs: Diminished muscla strength, degfilnsraUve l)on8 and/or jolnl changlJS, decreased hearing, vi!'.ion and balallce. Outcome: The patient will experlet1te a sta~lIIzatlon of n.vrol~lcat Impairment.
InlervQntions: 0 o Assess for Fall Risk BID . Initiate Fall p~(tcautions 101 Fall Risk Score 01 '\ 5 or higher: j 0 ASGass level of conscioLIsna5s and motor function every stHIt and pm. j U Encourage achievement 01 AOL's as appropriate to the neurologicallmpairment.
ProMem: Afterlltlon In OxygenatIon f RtsplUltOry F"n~to!'l Age specific consideration in Elderly Advlts: Waakened rasp/ratoIY musc{e$. d&creased lung tissue elaStiCity.
Outcome: Respiratory funct\on will be- within normaillmlts for patlent.

lrtervenlions: 0 o Pos1t1on paH~~j~an\!laljOf1 effiCIency. Mvnitor VS/breath sounds/oximetry every shift and prn. D Administer IrealmenI5/0);)lgen/A6G'$ as ordered. [1 Provide fluid intake to liquify secretions Suction secretions as necessary.
P,oblem~ Alteration In Comfon/Paln MDnagomant Age specific consideration In Elderly Adults: Possible idiosyncratio effects from medications due fa "garelatcd cilanges in absorption, metabolism, and excretion. Outcome: Patient exhibits/states adequate relief of dhu;omfot1. Interventions: 0 o Assess patienfs pain level q 4 h o U f S . - - Jnvoive patient in care by disOllSSing rne1hods of pain reliat Initiate intervenlions (including (lOn-pharmacologic) appropriate for pain/discomfort ASSe-ii"S pain level ancl response wilhin 60 minutes of intervention,
o
o o
I
I
Problem: Alteration In Nutrition Age speoilic cQllsideratlon In Efderfy AdUFU5; Oiminlshed appetite, peristalsis and digestive ;UiC8S ancJ danlilion changos, Facl.9(s t~DrDVB load IntaKe' Position patient uprighl- Offer smalJer, mors frequent mNls ModilifJd load cooslstency i.e., pureed/soft,
OutcQme: Patient nut,t11onal Intake Is appropriate for met.bone nods. Inter'lenlion:>. 0 U Nutrition Consult ef~HBOC 0 Monitor hydration status 0 Assess enteral feeding tolerance
o o
o
Assess fI~r swallowrng/chewing difficulty AsSist patient with meals as needed. Assess/Record di~\ary intake With each meal Provid6/record dietary supplemonts/HS snaCKs. Record DaHy Weights report unexplained weight changes greater than 3 kg from previous day.
Cardloya~\lle,
Problem: Alteration In
'f\I~rventJons.
Status
AgfJ specific cOllslderatiOfl in Elderly Adults: DU71Inishad cardiac force I blood floW Outcome: PAtIent will be hemotlynamh:ally stabt.
to bfEl;n.
'.J Record Intake i\I1d output every shiftand pm/daily weIghts ano report variances.
LJ Assess vil;>1 signs, peripheral pulses, and capillary r81ii1 every shift and pm
Administer medications/bloud products as ordered and monitor effects,
-------------1'
Age specific conSideration iff Elderly Adulls:

I ntBrventions: [J
,U, l I ~~ sk'{~ dry and less fJiastlc. Outeom&: Patlll"' will !n!!lntain or Improve skin Integnty.
o Tum pattent evr;'.fY 2 h~ld shearing - Keep skin clean Bnd dry. Photograph and mea~ure wounds on admission, every Monday, and on di'SCflarge. Provide wound care per Skin Care Protocol (see page 8) 0 Polential alteration in akin integrity
Problem~ AlteratIon in Skin Integrity
o o
1'\ 'II 'V
\\
_ _ _ _ _ _ _ _~
'V ~ Age SreC;ff,'C consideration In Eldeily AdU,ilS,; Decreased renal 'unction nClte lab values relatsd to antibiotic dosing.
Interventions: (y" l!,VMt'- h.,~J 11.-J--<' (U,~S'p; . 0 Utilize Isolation precautions: Cl Contac--'-t-o;:;....,~rp-a--'Cl:::.:'a::..I-D-R-=-e<i=--pj;::~ra::;.t-Jry'---":O.c"'D:..r-o-p-1et------------!
C Probtam: f'otentlal or Actual "tfactlon
Outcome: Signs ,n1l symptom~ of Infection are fe':9(Jnb:ed. Prel:&.UIlons
81'9
utJIIJ:IId.
Assesr.freport :>igns and symptoms of Infection every shift and pm.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~__
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~_ _ _ _~_ _ _ _J
~SSM
UEAl.Tti
'A~E:

COPYRIGHT 1997 SSM HEA,LTH CARE

MARCH, PHII,LIP H
11'111111811111
ERS 0554-01
M
0902200197
INTERDISCIPLINARY CARE PATHWAYS" G;NCRIC
DPMl000024 i9120(7) PAGE 2 OF 8
liP
10/02/1976 32Y
SfI.LEM, MOUNRR
01/22/09
000748298
000251
PLAN OF CARE
PROBLEMS/OUTCOMES/INTERVENTIONS DATE/ INITIALS
PI(tCe Initials and date (hal problcl!ls are idt<nlified in I~ cofumn. All identified problem must 1.>e evalu;lIed wtlether OutW'T1'i: i:l Mflll)( UnTIl@t 111 lime or digel'tafM by piacing date and '!'Iilials In appropriate column If Outcome is mot priol to dfr-charge, placE! dille fino initials on Met column. Place ". in box hy Interven!ion~ ~jJprUDriate 10 patient Writ" if) addlnonal inieJVentions as needed In bl;lnk spaces.
Prob'~m: Alteration In Elimination Age specific conSideration in Elderly Adults: Diminisheri pensli;ifsls, i<idnc.v function. Outcom~: PatIent re9111n~ normal elimination patterns for agl!l and dlsvase proceSlt. IntalYentions: 0
OUTCOMES
I-
Met
unmetl
I !
--
0
[J
Offer tolleling Avery 2 hours

Assess bower sounds, (;Ibdominal dist~ntion and/or discomfolt every shIft and prn. Record frequency and characteristic!; of stool. Report if no stool for more than 3 days, Record inlaklc! anel outpul every shift and pm. Report abnormal lao values.
St:ii~'Ory
0 0
\ .... ,""" .......... n..-"," Agll !Jp'cific (;onsider{l(/on in ldfJriy AduJis: and cognitive ~ Outcome, ....n' an. "' ~.n,"..n' .'ha, mvu'ved in p''" of ....I.~.nsVa .. n......n_ rv~i procedureS!di~ease/medlcafjon&/and discharge
ir.1pairments.
('
of
Instructions.
I
i
!
1
I
l
InlelYentlons: 0 0 Assess basellnc knowiedge and prefArred learning method ot palienl/significanl other. fJ Provide eell/cationa! material (ll J,Jatient/sign,ficant other lovel of under:;tandmg. Assess patiant/$Igmlicanl other for undArstandiog after te(lchrng. 0 PrOVide Instruction on sate and effective use of Inedical aqwpnwnt.
.---
I
I
I I I
I
I Probl.m: Anxiety/SpIritual Oisturban~e$

! changes In economic sec(I(ityls(){;la/ status
o
Age specific cOIlSlderation in E/de/ly Adults' Fl:flr of loss Qf control, dncimmg health iJ/ldlor approacllfng da~th.
I OutCQme: Patlent/slgnlrlcant othli!f dem o."strattl5 abmly to cope and l<hIntlfies available resources.
! Intervenljons: n ~_ n Encourage verbah.li;l!ion of tears (;Ind P?!rtlclpalion in care
______
I I __
Decrease sensory stimuli provide qUiet environment Dim 1/11;: Pastoral Care referral entered. [J Palliative Care rafeml! enterM GlyoomiB Imbalance
hallway IIgl1t:; alter
10 p.m.
Problem:
Age specific consiUefHtiolJ in Eidf;rly Adults, DeoreasAd ronal funclfOll, mMl;Joolic rate. CXItc0ftJ8: Patient's blood glueosa Is within a"~ptable range.
lntBlventions: 0 Implement Hypoglycemia Protocol. Implement Insulin Protocols <IS ordered, n Monitor/record fingerstick glucoSt! values as orderarf Md pm. Diabetes Edllcator Consult entered,
o o
------- ---------.------
Problem: Altli!ratlon in MobllUy/ActMty Intolerance

Age ,specific consideration in Elderly Adults: Diminisher.J muscle lJ/renglh, degenefativa bone am:J[or jaint chBngeB, decreased hearirJIJ, visi()n and Q<l/ance.
Outcome: Patient's malntaios or Improv&s mobillty/acllvlty level.

In!elYfmtJons; 0 Assist patilJntlo participate in ADLs within iimils of impillf~Advance actIvity as Ordered/tolerated. PT to assess function",! abHily and provide approplialc adaptive dellicl1s.
o o o
---------
PrOblem: Alteration in Safety , AgR .~per:lfic COflRidEifatiM ifj Elderly Aduils: SensolY (;Ind cognitrve impairments.
I,'
Outcome: Patient remains In a safe envIronment and free of physlcalln/ury.

0
!lnteIY9ntions: U
!
I
I I
J;i
CARE
! I0
i 0
_ _ _ _ _ __ AssfiSs lor F'cil Risk BiD hlltiate FilII Precautions for Fali Rif:'; Score of f 5 or higller, Provlde appropriatfl &afoty t>qulpmenlidwlc6s il'1d IP&Iri.!clions lor tJ,<! Implement prolective status (Victim of Violence)
Problem;
----- ._--- ------ -----
Outcome: -
L
HEAllJf
------ -----
int9I'1/ent_io_n_s._._-_-_-_-___ -__ _=___-_-_-,::-_-__ _-.:-_-_--_-~-__-_-_-_-_=__-_-:.. ____ -~::---
~SSM

e
COPYRIGHT 19E17 SSM HEALTH CARE
JP!I,I~1!'~JlI'111
0902200197
lO/02/B76 32Y
r.l P
000748298
ERS 0554-01
M 01/'22/09
INTERDISCIPLINARY CARE PATHWAYS' GENERIC

OPM-1QOO.024 (9/2007} PAGE 3 OF
SALEM, MOUNER
000252
f..V 5'
If-D
,~.j$
/2..,Dl\ rifle
J.~L-"
~I>
i:w~~
/)+0
DcW..~ pJ
_, _____L _ _ _ _,
~"t 5ei /f~0 l:)(L1
l
Insertion dale
Insertion date
I 0 TLC 0 PIce 0 Midline I 0 Other -.,..,-,:-;:--::----:c=---------~it=eri~f ~ 00ttgC~2l Insertion date 2.
At;;
d.e.f=
t1v..V
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4h/;,~1F1
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51-
S~L-
PATIENT LABEL
INTa!:DISCIPUNARY CARf' PAll-IWAVS- GElIERIC

Df>M-1000-024 (912007) PAGE 4 OF a COP'I'RIGHT 1991 SSM HEALTH CARE
gR{J
$f2-,r
73ll/::;
I~ /)
lie! ilk:)
o Care Planning with PtfSO (A) o Care Planning with PtlSO [Pi
J-L3
J-rt3
o Care Planning will1 PI/SO (Al

. 0 Care Planning with Pt'SO (I')
o Care PlaJln1nlg wit" PllSO (p)
o Care Planning witt1 ptl$O (A)
~SSM
.... f! A I.. T H . (
-A
ft
t'"

COPYRIGHT 1997 SSM HE.A.LlI'M CARE
Copied by _ _ _ _ __

MARCH, PlitT.LIP H
IIIBIIIIIIIRIII
ERS
IiF
0007'*8:298
INTERDISCIPLINARY CARE PArnWAYS" - GI;HERjC
09D2200197
DPM-tOOC-<l24 i9/2007) f'I:IGE 5 OF 8
10/02/1975 32Y SALEM,MOtlNER
055,",-0,M 0:;./22/09
~qu/
TLC 0 Pice 0 Midline DO~ __~~~--_=--_ _ _ _- - - - - - - - - o PerlphtlrallV (less than 12j Site Insertion date
f--JS "-'---w
o TLC 0 PICC 0 Midline DOther ____________

o
____________________
Peripheral IV (less than 72) I Sita __"C_ _ _ _c'~,_>_>_ _ _ Insertion elate
'SL
PATIENT LABEL
~SSM e
~
l4 L t
..
' C 1>. fl '"

e
COf"w'l'lIGHT 1997 SSM HEALTH CARE
000255
IHTEROISCIPUNARV CARE PATHWAYS . GENERIC

DPM-1000-024 (9/2007) PAGE B OF
1'::1
f. ()
W
o Care Planning wilh PI/SO (A) o Care Planning wjth Pt'SO (p)
,/', ,1
; ,I
;0.1
Clef
o Care Plao ning with P\.ISO (A) o Care Planning with P\.ISO (PJ
o Care Plannirng wrth ptjSO (A) o Care Plannil'lg with Pt/SO (P)
1'../ '-'
/,' r/ /1 :~Y.-; "/; '-
/,IJ
,/1
-RoY

Copied by
IN'rEROISCIPUNARY CARE PATHWAYS - GEN!;RIC
DPM-1QOO.(I24 (9}2007} PAGE 1 OF 8 COPYRIGH, 1991 SSM HEAlJ'H CARE
t'1F-.RCH, PHILLIP H
11111111111111.
32Y
]),1
liP
C1/22/0
9
'
0902200:9 7
~0/02!".J.976
HRS 0554-01
SALEM, MOUNER
aCQ748298
I I gAT~1
I
PROBL.EMS/OUTCOMESIlNTERVENTIONS
Place initials and date that problems lire identified in left column. Ali identl1ied problem mutt be evaJuutBd whilher Oulcome if> Mat Qf IJmn~t il,1 tim& of discharge by placing date and initials In appropriate column. 1f Outoot'lla it; met prior to discharge. place date and initill\$ on Met column. Place .; in bOl( by interventions appropriete to patient. Wrlte in additional interventions as needed in blank spaces.
OUTCOMES
INITIALS
Met
Unmet
Ou1eoma Goals: Skin integrity is maintained. Patients at risk aiEl idenlifiad and interventions initiated, Prochooked items are initiated tor all patients.
SkIn Integrfty plan for all patlent$
. i\ j
l' ~1i \,\- l I 0

't
0
621 Complete Braden Scale on admission. then daily. 0 AS$~sS skin upon admission and @verj shift 65pecially pony prominences and sllin folds. 0 Record any redness that doas not disappear withm 30 minU1es or Bny break in skin integrity,
Reposition
at IBaSI every :2 hours.
I0
i
Apply lotion immediately after bathing. Use moisturizing cream tor dry skin. Avoid massaging over bony prominences and
dlscolor~fhyperemic areas.
and heel protectors every shift for 30 minU1es 10 assess le\js. fast and hwls.
I
1
0 K(/ep bed clean, dry, and free of wrinkles. ~ Remove antiembQII~rn hose, sequential ~tockings,
0
i
II
Minimi..<:6 skin exposure to moisture from Incontinence, perspiration, or wounO drainage.
Establish a bowsl and bladder program by assisting the patient 10 the bathroom or bedside commode BvelY two hours, unless 1 contraindicated,
Ii] Skin cleansing at lime 0"1 soiling with perineal cleanser with minimal friction and apply protectlve barrier cream.
Dt ~
Limit use at adhwive proQucts on thin, fragile skin and apply skin slelilves PRN, Float heels off bed With pillows placed under the length of the lower legs. actlvatfi heel and/or application of heel protectors.
ttl
suspenslon on Total Care Bed (ICU).
III
Ins1ruct patient and family on causes and prevention 01 skin breakdown, sources 01 pressure, friction. and shearing, Record on
Patilmt Education Form.
o o o o o
Skin Inhtgrlly plan for "At Rl$k" populations - Braden score HI or lese
Place sign (PUP)
On the door of room
indicating patient is high (isk
tor skin oreakdown.
Initiate individualized turning schedule minimum 01 every 2. hourS In bed I every i hour in chair. Consider use of pressure radislribul!on equipment per orders/protoGol. Position proient in a 30 degree lateral position and avoId posi1ionlng direcUy on trochanter. Consider use of lifting devici;lS 10 move and reposilion patient
!Ouch as 11ft sheets. trapeze, and Air Pal to
pl'Bvent frtcUon and
sMar.
Maintain head 01 bed at the lowest degree of elevation consistent with medical condllioo. Use pll!ows/WQdges to pad bony prominences trom direct pressure. especially between knees, ConSider use 01 urinary or f{!Ca1 collection devi('.e to cont<lin urine or slool. Limit lise of diapers, Support 5uriace per
woe Nwsa and/of protocol
NulritiQn com,Ylt
!;'n\~red
Obtain bar\atrlc support surface per protocol.

I
Other Irtterventtons _ _ _ _ _ _ _ _~~ _ _ _ _ _ _ _____________._ _ _ _ __
l
Ii
----'-.
I------~-------------
~SSM
~
A L T H . C A
f-

COPYRIGHT 1997 SSM HEALTH CARE
ngpAUL HEALTH CENTER

NA.HeR, PHILLIP n
IIIIDIIiMINIIIUI
r/p
0902200197
INTEflD!SCIPUNARY CARe: PATHWAYS G"ENfRIC
OPM1000024 (912007) PAGE 6 OF 6
ERS 0554-01 ] O/O'2./l976 32Y M 01/22/09
SALEM, MOUNER
00074.8298
000257

1N1TIAL ASSESSMENT PhysIcal Barriers to learning;
,ti,None 0 Vision 0 Heanng 0 Language Dlfficutly - Reading (explain) _ _ _ _ _ _ _ _ _ _ _ _ __ o Writing (explain) _ _ _~__~________ Dsvelopmen11evei requiring intervention (explain) __________________________________ Other _____________________________________
o
o o
emotional Barriers to Learning:
? None
0 Anxiety
0 Anger
0 Denial
0 Depression
0 Confusion
0 Other _____________
Spiritual Barriers to Learning: ~None 0 Grief 0 Guill 0 Lack of hope
DOlher_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
0 Other -=~_ _ _ _ _ _ _ __
,D Nona 0
Home Barriers to Compliance:
Meal
prepar~tlon
0 Transportation 0 Finilnt;;!al bl Caregiver
Religious and/or Cultural Barriers to learning: DYes - Explain

Wl'Iat Is the easiest way for you to learn? !d11eading B-(Istenlng Q-Piclures o Demonstration 0 other ____________ Wha1 Bre your leaming needs at this time? o Disease process 0 Medlcations Follow-un treatment o Use of equipment 0 Disl PralPosl-Op teachinQ o Other Community resources
Who Should we invol~~~temlT11rnr:hil;1g
0i~8ase pTOGeS~
Discharge information
At1vanced \lireGllVCS
fl(A~Sin\lS
Home care services InccrrtJVe splwmatry

100Mt C3fl!/fetIQing
COffiro resources
Oiagnosbc tests
fan preventton Follow-up care

foley FoodjDrug
inletac~ons
llieliNP(I
OiSaasB fMnagem~nt
IS(llau(lfl pf!ICau!ions IV-sflnjeL11U1lS Labor managemp.nt MOl
M(lmto!$ Mouth care Outpaflent prOOf am~
Post pMtllfll teaching Ple-op teaChing Psychosocial neeo:; ReSlraints
SlqnslSx
Snllli<lno Cessahon
Social service !>\Jlfllual n~eds
SUtgRry
Pain mamtg~l\1cnl
Plan of care
RIgk factors
Room ori~ntalion Safety
TeDS
Teds
Post 'OD tea~1!iJ1y
"~~~Wa~:=:_!?~--C:!~~~~~~~P~a:!t~ie~n!.t~In~formation guide given information reviewed with
. . . -----++-f--
<;:fl)nldnn cessation
---'---'-----
A9adil1on: (1) Siaies ready (2) nequesl, (]olay i:J) Conlused (4) SUU<flfld (f>j Cognitive i,,!'L>ilily {fi} Retuseo (7) NrvwJ;l knnw\Mgeao\e Leame" 1'T = Palient P ~ Parent F ~ Father 0 = Daughteris) 0 = Others M,. MOU10t SP ~ 5pOU56 5,. Son(f.} Method; A' Audlovi"JIlI D .. C;"monSlration E,. E.<pl,'''''tiM C ~ Croup Cla% H=_H_atl_o_'O_U_l_T_=_"_el..,;ej)_h_O_M_fE_-xp_:_,_la_n3_tl_oo _ _ _ _ _ _ _ _ _ _ _---'
~SSM.
nEAl..THC.RE
DEPAUL HEALTH CENTER l'lARCH , PHILLIP H l!P 0902200197 ERS 0554-01 10/02!1976 3~Y M 01/22/09 SALRM.MOUNER 000748298
1111011111111111101
INTERDISCIPUNARY PATIENT/FAMILY EDUCATION RECORD

OpMl000-00Q (1Q12007) FRONT
000258
~'.
-r: ~/> C.>
'7-~)'
C';'
5
AcVvilyihercl'i!!
Admissl(lo Advanced directives Camm. resol/rces Diagnosnc tests D.4t(lNPO
INTERDISCIPLINARY PATIENT!FAMILY EDUCATION RECORD

O~VIl~tJ ~rnG!tss
Di5r,harg~
Intormation
~D>.
''>1"'-Y.pI8ce~r
..6
Dressings FBII prBYftntion Follow-up carll Foley
POTENTIAL TEACHING TOPICS Home car~ S8rv1G!X MedicaUuns Post parlurn l~aGhinll PrMp rgacnmg l(lcenliv(I spirometry Monitors Infant care/Feeding Moutl1 car~ Psychosocial needs
Isolation precautions
SignsfSx
Smoking Cessation Social service Spiritual need& Surgery TeDS
Tr~atments
Wound care
iV's/lnlecliQfls LebO! manl(jl1ment
Oulpalillnt proorams Pain man1fgement Plan ot care
Reslraints
Risk factof1 Room orientation
... 'n".:.' "'. . ..;;. i.: ." . <'''~''''~l:' . . . . . . "",)~

1Od' ....'._ ,:">;i\,."
'"
'~" . ' .c)'eSilr~.

",
II
~ Readln".:
(1) Stmcu ready (2) Rsque,;ls dul<lY (3) Confu:~oo (4) Sedatec (aj CogMlve i!lliJjty i6) Relus&1 (7) Already Leamer. PT = Paliel'lt P ~ Parenl F ~ Fathe. 0 ~ DBUQhler(s) 0". Omers M = Molher SF '" Spous~ S'~ SOCIis) Method: A '" AudIOvisual D '" Demonstration E = E'planat,on C - Gro,m Class H= Handout T= TOlephone/ExplanatiOn
knowledgA-~bIO
~SSM
H E It \. T "
C It R E-

r1AJl.CH, PHILLIP H lip 0902200197 ERS 0554-01 10/02/1976 32Y 1>1 01/22/09
iIBIIIIIl.JII.llnG
INTERDISCIPLINARY PATIENTfFAMILY EDUCATION RECORD

uPM,l00Q.060 (1012007) BACK
SALEM. MOUNER
000748298
000259
Special Instructions I
, -. .
SCHEDULRD M3DICATION ORDS:R.S

-----------
---------
\ Ordll
16
,{\./
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I
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I Start
01{2>,
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P)CUSATS SOUHl11 ),,00 W; CIU'SULE Ll' COLACE 1 OO~J (.'AP EQUIV
l.'reqUency
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15)1-21",':1
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I
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MARCH, PHILLlP H
DOB, 10/02/7b 11.000749298 Age, 32Y Si>X: N A<.im, Dr, SALSN,1-1Q(}NER
f1i(22j09
rD-e-p-a~u~l-Health
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Allergiesl NKA
"
Center
Covers Doses from:
M~di~&tion
23~59
Adminigtration
ReQQ~
--------------
01/26/09 00:00 to 01/26/09
-----------,-----------
P~inted, Ol/2S/o~ 22:00 :Page: 1. (more meds fol.low ...
000260
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ONSCHEIJi1LED MEDICATION OWERS
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0000- 073 (l
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01/22
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?OR 'l't;MP GREATER 'THAN 101.5
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INJECTION tlENADRYL 50MGjH1L VTAL EQUIV

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LlJ,o. Lt,
Alxl, Upper Abd,
LLI\ - Lt, Lo"e1" Filld, RLA - Rr. UJwe. i\bd,
0554.-01
------I
56
Age:
A0902200197
01/22/09
MAl<CH, PHILLIP 1I
32Y Sex: 14 Adm: Dr, SALFJM. MOUNER
DOl3: 10/02/76 --------;A00074S29B I.'IAP. Verified by:
,. ,~:J.:tL- I /24 [?f

p.!nl)G~T()N,
----------\
Alle.rqie!l: NKA
Covers Doses froml 01/26/09 00:00 to 01/26/09 23:59
Medication AdmlnietratiOr.
___________
------------------
.'10
~rinLed: Oi/2~/o9 22:0~J Pag... , 2 (End of MARl
R8eo~
000261
~ ~~tnBtructionsl
.......
SCHEDULE MEDICATION QlU)RRS
...... ,.
---------OOUO-07JO
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lG
Stet< t
St.op
Druy!Dose/Route!Comment.s
lCUANn: lK)DIUl-1 100 MG CAPSULE LI'
COLACE 1 n(}~;:; CAP EQU1V
I~
I
JAN
I I
>1'1 FLK
I
I
1
'1
861 100 Me/l

rD NUl CRUSH
CAPS~
LY
[ORALl
./
G~AP'l\pnL.LN
: 0900! ,
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1
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POTEMl'.lAL FALL lli
100 l",c
NrJJl101ITtN 100~1G CAP
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06/00 }',('RMAL SALlNE
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I
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t&
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med.icationg tin, glven then ~ml NS ooivre and aftcT "'f<dication adm ini st.rQ t i t)l1
,
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LA -
Site C'odt'ls
l{t,
RU LlT~ ~
tl.Q.
1'lliyll
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I.! . i\rm AA" Rt. A1III
Kt. upp<lr ;'I)e\.
Lt,
Upper Abd.
LUI KLA
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./'
0554-01
DOB: 10/02/7
AOOO748\1~8
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MAR.CH, PHIL LIP H
ss
J2Y
A09Q2200197
Sex, M AdM: 01/22/09
Agc~
Dr, SALEI-i. HOtJNEIl
--1
JAllergiea, NXA
!
Covers Doses f-r-o-m-:~-----
Medie&tion Administration ReCQ~~!

Prl['c"d;
----..;..--
01/25/09 00:00 to 01/25/09 23:59
Page: 1 (more medo
Dl/?4IC~
fOll~
22;00
000262
._ _ 1
.site
UJ ~ Lt. U.O.
Code~
T.T = Lt. Thigh
LA = Lt
"-,m
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RU h. U.I,.I. RT = ilt. Thigh RUA ~ RL. uppel' Abd. LLA - Lt.

WA _ Lt. Ilppel' AN. RLh
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------
-------
01/25/09 00:00 to 01/25/09 23:59
~agel
(Bnd of ~J
000263
~9peCial Instructione:
. 0t'd#
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ABW
; ---
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~S_CHED_ UI..BIl
MEDICA'l'ION ORDERS
.... U
----
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--------1
0554-01 56 MARCH. l'HILr,!~ H

Ag"': 32'{ Dr:
A.0902200197
10/02/76 1\000'141>:.198
SALE~t,~tOUNEP.
Se)<, M
AdlU, 01/22/09 II
{~I!-.{~~l~r741Iqj
DF.IDGF:~ON,
I'
di ;~
___~_
,___
Allerg ie8: NKA
Covers Doses froml
Medioation Administration
RecDrd
Print ..d: 01!23!V9 22:00
'-------
:-\0
---~--
------
01/24/09 00 I 00 to 01/24/09 23: S9
----
______ P_&_g_e! 1 (more
med~
follo~
000264
r ___.
_____
I
I
~_.~_"_UNSCH_Et>_UL_IID_ MlIDICATION
ORD __ B._R_S__ {_oo_nt ,_)_ _ __
9peCial InstructionSl O~'dH I StaIl I Stop 1 Dr_-U_-g-I-DO-s-e-l-p.u"te./cO;!lnlenLu.~=,It.}
j P~equenci'
ooeo07Ju
07:n-l~JO
01-12~
eel)
fU
i l)900 ,
}-
I , I
i
i \AC'f;1'l\H1NOPl1S'1 3 ~'\ 1"'", TiillLET 'I'YLF'NrnJ J25MQ TAP-LET iOO'UlI ~5D MG/2 T~Lr:T
iORAL]
I I
IQ4H
A.s NeEded
POl( MILD rA1N
OR
P{)P. Tl::MP Cl'.RA'l'ER Ti'.AN lQ 1 S
INJl!!CTJ:-O-N---
AllW YU
0014
:11
01/22
HOD
\no"",
r-
IDII'~lNB
&RNAnRVL ~OHa/lML VIAL KQUrV

50 MG/l ML I TCIHNG
I~_~--+--O-L~;H!)
(lV)
C;-~;
~_
I ~l~ iOXYCOL1(.lNE/ACir 5/31St>!G 09{)O I Pr.RC0Co.'T-5 TAB RQUl v I I'Ll( I i F61!&l J TJ.B/2 TABliJn' 1,1/ I' POI< P"TN I- --l.- - - '10') JU
J
I~
\
I I "' J ' I
0.(113
JAN
nr
I 110(;
I
/
_____
Dl/n
_'!Jll.olt,oRPIlDNE lK'L INJE{:nON D1LAVVIO lMC/1ML p~p EQUTV Dose I 1 MOil ML
BRltAKTHROOOH PA!N
'14!!
hE t;eeaeo
[Ivl
ot,!J~
C ..._/
1/
lHLV'l'E llYDnC-MQRPH'JNE Ill' ltMI.

IlflRMllL SALINE
PUGH ,sr.oWL'l OVEn 3 5 >UNUfES

1
"M-l'-.>Jj~L-ET~'--ii t!1-h---,
lltAL}
+'.
I'
I
\ I
A!5 NEeded
I
I
~-----t-
I !
"
I I
I I
l L
I -----(1 I ~ verif--ie-d~b-Y-'-'---------1/
I
"'..R
C;' , --l
:i.
._s~_.~at_ur:-
_ _ _ tl\1J
~Illi; I---g-l-g-n.-d-t\~r",e I.' J{,vJSJI -rV L-/\.-':J"---__
Site Codel:! LU Lt. V.Q, 1.1' Lt;.. l"hiqlt Rtf : P l U ,Q ' RT R Rt, 1'hir;h RUA ~ J,. Upper J\bO LLA - Lt. !/L!\ LUA - Lt. Upper Alx!. " t<:t.
d
.l_.
LA " Lt
<
A110
- H. Anli
Lower AJ:.d. Lower ,\bct,
-1
----+l-=t; I
-r---- ---1\ G\ vi. U ..l'{/-v I (1

to
-~--j
-1::~::::::~
---,
-j MARCH ~H:ILLIP H ~-'--j "''''''.' lO/02,i76 Ag,

I
UVD
0554-01
5S
A0902200197
NM
D~;
:!~'f
Sex,
Ad""
Gl/22/09
SALt:M,MOUNER
I ' - . . ---+-,!L\t;.Liu JjZ}j{;j 1i;~ . .
.____ .

FlRHlGE'lUU. Me
Covers poses from:

01/24/09 00;00 01/24/09 23:59
Medication Adrninistratiofi Reaord

printed 01/.3io')
I
I
I'
n,oo
~---------.---------.---------.---------~
hge:
(End of MAR
000265
~-~" -' Instru(!tiontJl

~Special
.
Medicacion ORDRRS
_~__
r:l,'d~
JOB CGO
IStdl~
101/21\
Drug/PODe/Route/C('jn'lments
____'
IlL
Frequency
QSK
I l
JW
l'1d(
I 01/22
HOO
i 23S~
CLINPAUYCUHCLBOCnll
600
ua/4
SOl)IOM C'lrt.ORIDi O. ~\ '>0 ML
I IV)
I''''fol '
G007 CCO
900
m
01/2B
....":::,:':::.
IOJlALJ
U'ltRACrLLIN-'r.A.ZOBAC'fAM'--"-,S-GM-/IOO HI. (IVI
01/:12 1200
Q 6 HQURS
GOOD 0600.
2359
tvJ 6J
!Ilao
/-tv'-
I
0011
eGD
In!U8@ Ovari }g
1<eh'iCj"n.te
Mi~~~~~
0600
Y
! ,
r
II!
!IODIUid GHWRLDIS
NOlUf,J. se
~g \I.~"
INJHC."l'ION
0600
s.u.nm
-~.t-- ~i'
Give 3ml every 8 '''}\H'e l'oedic6tianh are given then 3ml N$ befot'C iHtO after medJ..ca._lo:1
unl~:~1
yl
,'I:
I ~ ~ 31
' cr/4'r: ~
lad:~/r>!,i_:""'~,-'o _ll3-, "

1'.,)
l~
l
I-,
I
, ,I_~ __i
I
I
1J1 Dv
~.yv'"
j
1
I
~
I
I
J
I-J- U ,
, I
I I
I (
~- L_ I
------
I ,L-_
~R'~~.,_
,"
Site cod-esLT Lt. Th.l-.)b R'T ..; Rl. 'i'high

LA ~,
Lc"~<" c
E
'u'l.
i -'----r/ ,1'?:~
_Sign.ll"r~ _ _ .
--........-.-
'_-'.'.1 ---t- _-,-,_ . .~ - .. __ - ~_
_"" _ _
l--+-,---~
Verified by':
I-i.
-Wn-!J.t:.'.'FJ-I~..J2''jJ-;;;;/
'?Lt4 --
j----r'Ioil
-_.-----~.3l g 0dLllce
I ----i
.
,~.~. i"J ,,~U.':)

,:c,
Ll
{\nTh
- Rt. Aim
I\bd, i\bd
RtJl>.
LCl\
'JPP': 1 t\bd.
1.111 "
Lt. '.;pper Aid.
)'c.
RlP. _ Rt
L0Wt'T
0554-01 ~ v{)~Li-~"'J,~__ ~------' MARCH, PHILL!ll
-I-----"!,-
---
_=_'_~== __,' _-~.-,
5S
11.0902200197
DOB: 10/07./76 AU0074929B
Age: Dr: .l2'l SAL[':t4.MOUNER ElL'X, M Adm,
01/22/09
j~llergi.eBl
Covers Doses from:
t.o
NKA
_ _ _ ,_ _ _
Medication Administration Rlcord

Prlntw:
Dl/22/0~ ~2
nO
01/23/09 00:00 --------,
01/23/09 23:59
----- -----
Page;
1 (Il\or& mads follow ...
000266
Siee Codes
LU
RU
~ln~l~'t~___
I _.J
Th,yll
LA Lt, Arm 1'.A - RI. hl"m Lt,
Rt
.
E
1J'~ , Rt, V,Q,

)"
M;.
RT
RUA, = Rt: .
Rignature
WJI.
upper hb<J.
Upper Md.
Lt , Tlugh
Rt
"LA RLA =
Lower Ate
t "' ... er
-----
Ab:I.
0554-0l 58 MARCtt,PHI!.LIP H
DOB; lO/0:l!76 1\00074629B Age:
~\?'{
A0902200197
Sex: M Adm;
Ol/2?/D9
"R Verified by'
DL' 8ALErl, MOtJNEH
t----a_~_r-jl,-'......~_, /V'_I_/.2li=....=O",-'1
Depaul Health center
=---=--,-_L,
Allergies: NKA
Covers Doaea from;
~dication Administration Record

p, inted. (>1/"./09 ~2'l'O g_8_: 2 I End of MAR I _________ p_a_
01/23/09 00:00 to 01/23/09 23:59
000267
I 1 _ _-
_ _ _ __
!Spe~ial Instructions:
"rdl!
I
!
Start
Joe
CGD
I 1400
I 01/22[- 01/28
235~
I St~;p lDrug/PooE/Rouce/C(Jo~I
LIWAK1CLN(CLBOCllI)
6~O KG/. ML
-r
Itvl
Ke4ic~tion
ORDXRS
Y
.......
ouoo-ono
O?Jl-1S30
"'-ll-;'Quenc IOF
<>
BonIOM CHLORIDS 0.9\ ,0 ML

~O lo1in\1~es
:Iufuse Over,
I
Q 6 1I00ltS
Refrige[Le
0001 CGD 01/22 llOO
j l
(nne
2359
PIPE'RACIl.I.IN-TlIZOBA<:rM 4" S
cav 100
ML
lYV1
Yuf UJle OVer, 3 \) 16inutee
I OIiDO [
I I
I
01/22
-t- !
I
I '
I I r I I
Refl-ig,u'a t t'
MCT 0.9' UlJ1!C'l'ION
--+--ODIUM CHLORIDE
OOlt/'N.
~~P!!
~61
oal!
INJ
Q~y~ 3ml l}'I.:'p.ry a hOU1-~ D.nle-s9 ml'<lications un, given then ,",1 NS l~fore and ufte!" rnedL:atiol1 administral ion
1v~
.-~
I ------+-
I I
I
I
I
i
LJ
l;
~~. --- ---..L_._ i!~

w L~.
Site Codes
lJf Lt Tr,'gh
Thlqi. RT - Rt.
LA. Lt. RA 4 f}l.
].0'"."
l'
Arm Al'"ff(
D_C>
U.Q
Ii
41!
&-l-~-/)-S- ,?ture I "
rf(; ;/" - __
'\)<
I'_,it --~-j RUA = Rt vpper JIb!. e ' LUI< ~ LL. Upper Abd_
RU" Kt.
i<.~--_-I-' --+-!-~_~~---.__
+-_ _ 5~jLgl..:.:I<'lture
~ ~~~~~'ILLIP ~S
DOB: lo/02/7G ----lA00074B29H
Allargies: NKA
-\-.___
wu" - I.' k'-'A "nt
LOwer Abd. ADd.
_,
A090220019"Ol/n/09
Age,
Verified by:
32'1 Sex.: /<I Adm; Dr: gALEN, MOUN8R
!o8paUl Heal.th
----------------Covers Doses from I

00: 00 to 01/22/09 23! 59
Medication Adminisb-aHon Record
V.a Ol/22/Q~ tIll<IDGtt'TON. ----------------------------------
.------------------------------
l'ay.e: ~
Princed, {more meds follow
Olj~~/O~ O~,OO
000268
~pe~ia~
c=I'Ll!:
0r:dj!
I Start
Instructions:
Stop Drug/Done/\{ol.lte/Co",roents
CE'l'AMINOl'lmN 32~ MG T.AIILIn
ONSCHIIDULBD MlIDICATION ORDml5 (cont.)
~~o ~~~~2
I
I
\
,I
{O.R.U.I
----
Frequency
I
I
oooo-ono
Q41l
'I"lLlIOOL ~ 2 5 fiG 'rAB"'B1' se: 650 Maj2 'I'MU!T
A.a N&e~d
I -------------_. \
0731-1530
153i-2~
--+-----
I
i
'
I
\'
01/22
0900
'OOQ'9
-!
'caD
'~-'llhf7 ~~i:;~~';~ !Mj _:;~Yhr;

I
I
I
~'OR ~!lL1)
P"IN
OR !,OR TU>1.P GREAT!,;R TIIAN 101. 5-
l'
I Q4-b.---'
As Needed
IOXYCOOONl'l/ACBT
PKRCOCET-5 T1Il!
5/32SMC 1 TAiiTiBLET-
~~UIV
I! ! I i I
!
~i ~r{.i -jJ~/rv ~ut/;~ /f C~/~J.
\/~2-t-z7f
j
.
I
'
Iht--Qf IV-tM rV!'lln-.....

I ,
I l
I I
I
~
Sit.e Codes
I.!J
KU RUA.
I
LA -
~ I P;S~-_-'-r-..--,-+I_l~n" I
-~II
",='llie.
--
--
-==r:':::-~, "pe'AM,.
H
Dr:
LI,
Rt,
U.i,/.
LT
Lt. Thigh
L1A.
n.t n ,0.
RT - RL
l'pper Abd.
Tt,igl1 AA Rt, Arr.'. Lt. L"Wer At'(j
J..C, Arm
'
II,
'"' -
",:'::,7:'97 -i
Adm: 01/22/09
.w ,i
--~--...:..
--~=-- J MARCH/PHILLIP
AODO'I48299
DOB: 10/02/ 7 6
Age, 32Y
SALEM,IlOUNSR
Se",: M
W, /erified by:
AllergietH N1I:A
_________~J~/=-~-~
De~a~l
_ ___~_
Covers Doses from:
01/22/09 00:00 to 01/22/09 23:59
Medication Administration ~ecord
prIntEd, olta/o9 09,00 Page. 2 (Rnd. of MAR
gea1th Center
/>'10
~l<.i{X;ll'rON,
000269
~~-l'uI$t
PflEVf()US 24 VO: Intake Output Yesrerday's wi. KG Thdav's WI.
SCALE KEY: 0 Bed 0 Standing n W/Chalr 0 SUng KG !please reconcile weight dlfferenc:. It grealtr tbaft 7.5 ag.)
,(v
...............
IL1// ~/ ~/ 1//IL/'/1/1/ // L // ./ /~
PULSE
DATE STAHTEO
Ra.<;p
6P --" 02 sat
-'
02% i R.te
,-
/" l!t t / / !./ l~// l/~ //' .,//1 / Cl'7
:f ?
n
0, Urkltllll\l deVIce
~
i
If
lm1
~
Bl'llslOli gltlcose
TIME
T&MP
PUlSI
RUi>
8P
~i
SAT
Tille
TEMP
RUI'
IP
.//
/'
//
//
//
f)
'OUI ~
lIQ
DINNEIl
TIME
Jlt' l'
ITIME
,lIP
P
//
,//
,//-
U'"'-"'""''''''''~
, \~ laxe"
TYPE
D700
/'
LUNCH
I
/'
BIlEAKFtsT
N(
)
0/ \
ORAl /rUSE FEEDltlGS
,
I
t
./
HS.5ftACI(
UR NE VOID
~,
OTHER
Ilfl'fi
ORAL
TF
RUSH
8M
~:
( 0('1',\
'""-vv
JJr:.
I
1000
,-
I
-
~
13110 14(1) 1500
1600 J}OO
1300
12 Ill'
ilEHAVK
All- ,atJlI
Sub TotaJr.
12 hr total paremaral _ _
- -
--
12 hr \ol?J n'ol,'lIhe _ _ 12 ~r sh/11,m.1vl
--
-~
--- ----I
--
-~----
------12 hi shiH uulpul
,.
E ~ Elld I-~
O. Ovvti
1911:Q
2110n
ItlrelWI
1. At-..
~-~;~:
2JDC
2. Atdf
3 Guidon
~
6,
cniIl
Encwto
5. EaIobIiI
7,~
=:
~"~
02DO
oaoo
M!!!l
0500
1)600
12hr Sub Tutals
12 hi InIal flilrenteral _ _
-----12 hI Mal
:mllL
(}[~Vluoo
_ _ 12 hr shNtintake
'8VD" " " , ....
-- - -
----- ---I
I
---~
! 2 hr shltt output
~i Iota!
FLUID fQUIVALEt. TS:
1 Ol
.... ,
4 OZ IV, cup), 120rnL 60z (3/4 cup) _.. 1S0mL
B oz [1 cup) " . , .. , , 240ml 12 oz [sodi!-1 can) ,360ml
.
090220019"
"""~IH"l"'"
PATIENT LARFI
."", ......, I
tY/bSSM DePaul Health Center

II CAL
"f
DEPAUL HE&irfi CENTEt{ MARCH, ?HrLI,lP H

10/02/1976 3':), SJ>.Lr:l<\', t>10U1-lER
C ... R E"
IIiIDIDII1IUU.IIIIM
PRS 0554-01
I/f!

DPMl00Q-()71 (5,<'008, PAbE 1 OF B
M 01/22/09 0007LJ 8Z~~

DPM-10c0
000270
RGICAL PATIENT CARE RECORD
DATE
24
+
pam PH,S!>'l!
BehaviOrs Time
illSI' [}al,
Insl
Oa~
+
+
Haling SfOrt /I
Scale Usell er
O~ervatlon
Iflst ~I
PfJ
F1
Function Gild I II
Ducri~t:
R:
Locatiun, BtflMviar IIf ,\PP
Quality
Fn,quenev
fl~gr1!Yalino ';actor~
StllaUttnLml
tnrervcRlilln{ II
Inilial~
BeHAVIOR/REsponses:
AN
1r
AOljOU;
'" - MUlI.pI9 H"qutisl C - C<llltinUQU~ Crying
II
= vnra!ponsr/a
CD
W A
C<lIlM6(l/DiWi;tntgd
~lj -
Oliruplll1l
Siglilit;~nl Olh~
E =- Ernnfimtlf D;tifJP.-r.:~ I : IIletlet.ii-vH cUt.-Vty o - l.,,,,,.lop nentollmp",r~
OE ~ ~Pf~S$\"" CO ~ Orievlr>(>
l - t'lltlrugit.',
o Ove-'5iimvl~led;O<Jere-notivB
6,
~
CO - ComalQSe CI ; CoQni(i'~ ImpWimet>l R = R.~!le""
H .:. ttaIJu;;UlaliOml Dt'lusons
= Artention SI;-.ek\ng
= Oelloorately W]mllOl(!!ng lnlo
T = TNealenlng Phy";,,,,1
HRlmfCof'l'\tm~t,,-e
o " Ca!f1\'OWel
S - Sfeepmo
COP = Cooperative
DP ;;;: Os&ruptr....e PatiEmf
lM
'<:
Impu1.?J.... rR~oriEflt
LA '" les~ A.m:.ious ()o:-\"1.flr
IIIITERVENTIDNS:
1 AfraSSwat Ce . f'atfefi! 2. Hftdlr5{;tlu-1
f
';)iijnffit8r\1 OlhtJr
3 Qu,d/lr>
4. CoMslsten En1"<Jnmenll Rcut~

5~
Es(Qb\$h ll\a;"I';r\~Q 1;n\f!raillH I~, c.ere iiHas

En-cctJrag-11
veroflltZ"fl.t~oo
dl';1(;::i~mn
Vrr&llfeQIJ,wl briel cont.c1 PfO~tP~ inform~l!On to IO;fease ie''fel of understandin-J encourage family 10 "'ring in Jar",i1\! <'lY~. 11. PrOvi(le r~liI><atiM wnh mvsic, Imagery d~ ..p bl~alhing. pray~r. meQicl>non
10.
14 ~ 15,
1o,
I A~mW<ats i Rs.lating
lat;\~
~!vejsiGnat a-cuvttje~
PrOaet<,,~ meJ\SV(~$
17
ne&l1$l''l'l1 OI'QuesllQn ! Seek cla(lr.ea~on

~;lil)jl;;jfi Doliniiaf'"~ PfQV;rlO ininnr.hm ~.ncwity ami ~"lfnly IHI"!m~ln~'.
Iv fJWl!OJIL-e- I)ftff3'1lOfal prObhtiHS
1~ EnC6Uiaqe iiWfI8I91eep cycle by lising iiiii..ec! li{jlilifi!j atilt oM,

13 Darkan rcom : t fmfliniJ tOllch
I
to
~i)("fH.1!.dtnm
113
10
FnooV(<*gl p-UHp.nt \ ...".111
m.,t!lfl9 fm cam fl,flf'..!1;r;
QiI~~t ~;i!Jl\ 10 t1m.:re3~ fmh~Hr:; fI:"~:;4-Jur!::.'"H
~SSM
H
E" A L T M
ARE"

2<' HOUR MEDICAL/SURGICAL PATIENT CARE RECORD
rip MAACH,PHILLIP H 0902200197 ERS 0554-01 10/02/1976 32Y M 01/22/09

SALEM. ?40UNER
000748298
DP
111.UlDmllll~.IIIUI
DPM1QOO.071 (512008) PAGE 2 OF
000271
HOUR MEDfCAL/SURGtCAL PATIENT CARE RECORD
24
(nse<tioo Date:
["Irso Llill.;
Dr~_
+ Site #:1
!nse100lJ
Oalfl
FRONT
RT ('
[}alp.:
-"t
\
fRONT
LT
. BACK
I
BACK
/~-
RT
-\
j
I
LT
Q
~~ 'ti'
IJ
I
\v\
\ )~
~
"h;lj
/(
I .If
I)
\-\
I I
SLIDLlTLC
R
'u
! v ___ ---I
lnserllon Dale
Arm clrcumlcrcncc em
length _ _ cm
f----+--------------------------------------------------l
PATIENT LABEL
~SSM e
i4 A 1.. l' >4
~ '/to ~ (I""

MARCil, PHILLIP H rip 090220019" FRS 0554 -01 10/02/1976 32Y N 01/22/09
S;:''LF,101. MOUNER 00074l;j298
11111111111111
2" HOUR MEDICAUSUAGICAl PATIENT CARE RECORD
DPMl()(XH)71 (512008) PAGE 3 OF a
000272

Use bOidlfl1 Key letter" lr.dfca1ed
DATE STARTED
= See additional commEnts in NUr56S' NOles
!RQ\I~i
lR\luoos {ep, SNT i~}

B6dres1 Independen1 Positioning: R-AIgllt LLeft fI~ack S-Sell PProne
,.... lim
I,
:im
~
'P'
if\
IS
"'"'\
'-- ._. ,--- ,....
IH.n.B.
-i
n.
:H~a!soff
bM Chair Daollie SSG
~ Transfef assist
~ SB!\ x1 x2 x3 min mod
.~
J
.'
I,t:,
Self 'Assisl 2i\ssist device walksr C3n~
..
..
~II!Q~ WI' loth
,,,I,
(# Fset. Steps)
: A~"'"k.;, 1 comments
ROM . Ext IRA. LA, RL, LL All}
I~~h~n Asgist ~ml1let1! $Howe, r eell chanoed
i.::>
V
(q
J:~~a~~~:al
"arc
- - - - 1.
5
,
.. . _--
Den1l1re care
Self AssiSl Comolele A$~i$t Complete

Self Assist Complete
t~
I ShW9
~~ care
Self Assist Complete

Self Assist Compiete
lSi" bath
i
SlilgS I Splints I Cast RA, LA, RL, U
IK-Ilad / lee packs ICP''!l Set1ings

. . . . . f'.
Rt. Ilt.
I~"'o, "~,;,~, hip I knee

ITra:tk>n
Caliligrt 1 Phone in reach
~I I"Hlli
!I
,,u
and on
Weighl
wttllin reHch
~~
0/
../
,/
t/ ,/
.u,
Sld~
ral s: x2 x3 x3 PI.
~Qussted
)e X
'XI
-""
!
liP hano
i Ailergy
o Verified and ill place

~al1d
o Verified ant! in place

...
iDNR cede status bane
ilso/allo"
N'
"0
band
o Verified and in place o Verified and in place o Veliiled am!' piace

o Neutropenic
o Verified and in place

o Verlfied and 1n placs
0 Not applicable
__ ._--
0 Not applicable
0 Not appiicahie
--,--~-.-
o Vrifip.o and in piacR o No! applicable

,._.
ISOLAnON: 0 Special contact 0 Contact

.r-..
0 .l\i!uome Ll Urople\ 0
- .
.
"'--'--
OTHER PRECAUTIOtIS: 0 Satsty/fall 0 Bleeding 0 AspiratlUli 0 Sellure 0

'TI' I t: 'i SHIFT J l(J'ftALS I (~ ')\'t1 A )L,({!/.!t\) r/C--j
.... _._ .
INITIALS!
' TITLE / SHifT
INITIALS!
! TITLE ! SHIFT
f{'-.-\{
I
""'
J1f ~~\y\ (.:{-J 0.. l
.,.
~SSM
h (:
F, \.
T H
-C A R f"
.
Q902Z00197
tJAIf!::N( L4BEL

I'tARCH, PHILLIP H
24 HOUR MEDICAl./SURGICAl PATIENT CARE RECORD
I/P ERS 055401 10/02/1976 32'i M 01/22/09

000748298
1111111111111111
SALEH, t40mlEk
DPMlooo-071 (5/2006) PAGE 4 Of 8
000273
r:;!.~~~~,~:ICAUSURGICAL
I Speech
I Speech
PATIENT CARE RECORD
DATE STARTED
Apical hs:
Abnormal
Pacemakt clear
(Aphasic, Delayed, slurred)
.11
'1./
.J.
Periphera
I Moves
AAbsen1 W-We3k
WIIfl equal sfJIlnjJl/l
1/
S--Strong
D-Doppjt
Motor respons6
(Abnormal f\exlon. EXtenSion,
Color lelr
VIM - flal
,~f<!,
Flaccld,
Local!z8~,
None,
SPaSlie, &1rang, Weak,

WDW1t!ldrawsl
Tremors
ir>s In
~
!km warm
:tIR,i)tln.~
1i000Iotoocr
III
J3 '"
T
Sandbag
TEDS
... -+---i---j--!-4--l
TEDS
,UI~"""YI" (PreslMt. Absent)
Numbness I Tir)gH 19
seDs
SCDS
Atmormal breath! ou nds Specify abnormal breath soul1ds nn diagram
TIME
(Absent, Decrea>ell, CRackles. Rhonchi, Wheez( $, CoarSe)

AbIfnmsr
Abdnmto'
POSTERIOR
Re.ivS,,[)irllltDl,1V 7
Bowel s( Bowel sc
effort. IIflfabored
Absent
Last 8Mf
Abnormal reBpiratJrl effort Dyspnea {Oil Exertion, at Res1}

I
Cnuuh ,-
~,.
...- . -
Hilus f'i
Stool api
I Cough
and d8tP tfeaitl
Incentive splrome:.er tt ml/ # f1lllS

Sputum {tiescnbe amou!1I, color,
o GlUb
NG lube
Iilag! B
I Suction (Nasal, (lrai. Trllch)

Trach care
I
!
o Trach lype _ _ _ Size _~~~
~ GPIl.P
.""..........,,, ....\s: 0
I I I ii ! I ! IlWAP _S!tti~9S --~==--t--+-I-t--++-+-if-+-+-+-t-t-+-+-+~f-+-+-+--f-+-+-+--l

C~W
Tube fee Ostomle: Stoma rf

Stoma: I
.0 SIMV
,."motu! OOIl;"~ ~e~<ified
per order}
Necrotic Ostomy
Ostomy
Comments
PAHtN! LABEL
CHEST TUBES
TIma
Locallon
Wain S~1l1
Su~IIDn
Drainage
DE.\?AUL HEALTH CENTER

M.A.l\CH, PHILLIP H
1IIIIIIIIIIIIIlflD
rip
000748298
DPM-ioe
/
~4
0902200197 ERS 0554-01 10/02/19'16 32Y M 01/22/09

SALEM. Tv!OUNER
HOUR MEDICAUSURGICAL PATIENT CARE RECORD
DPMlOOO.{)71 (t/2OO8) PAGE 5 OF B
000274
MEDICAL/SURGICAL PATrENT CARE RECORD
DATE STARTED
24,..
Time
tYIJOSSM DePaul Health Center

If ! " 1. 1 H
I.
"
DEPAUL l-fEALTH CENTER

MARCri, PHILLIP H
111111111111111111111
ERS 0554-01
H
rip
01/22/09 000748298
0902200197
~
Ii i
A I. 1
10/02/19'16 32Y
S,l,LEl-l, MOUNER
2
DPM-l000-
!000-071 (512008) PAGE 6 OF 8
000275
DATE STARTED
oil
.J<i
'~1'.
--+--------------------------------~
Or.inage (vaginal, pa lilB)
SKIN RISK SCORE SUMMARY (Circle score In each area and total. Assessment frequency: once par day.) Actlvtty
Mobility
fmtlon i Sk
Skin Risk Score: 18 ur I..., plllf8nt Is at rISk n FQJIow SIcIn CIro ProtocfJf for scm of 18 or less, o MJ/J'itiQ(W OOI1S111/ (if not prevlQlJS/y ootaJlTtd.)
ALTERED SK.IN/WOUND KEY:

PU '" Pm.s\Ife uiceJ II pressure uli;Br, li~1 IV . UNsta!J1!abl~
St~!JIlI,
- Inc{SiQfl
BL
II. III,
an
o
- Laceration
" Ra:;11
TB = Tilf1e burn
V
N
S5
D
Vasc.lJlar ,ar.!)I' ivetlO'Js staSI!"', arlenal
lIIsuf!il;itncy) = t{;mmp;!tIliC ulcer (!iabebcl

~
D I! EX
SftrIOUR~IBU
WA = Wei! 3Pproxim8led = Dlhllr _ _ _ __
Dressln,,:
= Osrmlbond
~ St.~~es
~
SWi sHip.
n = Gr1!1101!U(Jl1
S E
~ ~
Wound Ra4 Key:

Slough
E$char
Frill,
,,'
\ i I , . , \ .
OTA " OPlln tn ~" R ~ ~1~on eulUllS
o = Othe.
Skin Key: Ofai~lIOe TvP1l: Q = GnlAn Ii: = E,yU.",,,. S = SSfOU9 M .- MacBr~Mn aa = Snrm'''"!lHli1\lOJU; C - Cyal1l1ticiOarx PU = Purulenl
"
Draina9i Amognt
SC:
$
~
- Intact
Scant
- Smafi
M L
C
MoOtrote - La/ge
_____ 0
~ Ollt~,
H!o\l<ly
~'elfJW
= Cupiuw
DI M
D,y and ..lad
y
o
Monicomerr ~trd~
~OIl1n
_ _ __
o '" Cru,i'j
- Olllar
TIme
N AU.,t<:! D ' Wound ISulTOUlaJlinvl !;Ir!!!"!!8!! Affi1!ygl qf !1!!gr S.. n8 (I, SilnlWuulll! Tonmg Bed' Type Dralnane YIN ('Sligt!
Tfei1iiienl
InlliulG6
RUDUllumcnl
No ChallilB Time and Initials
!.---+---~---r-----------------------------__+----~---------;
~
1 Ganp,3lHfl
2 ttw'llOf. 3 EnwOllml
CSfi
'QII1,
4 H6'airty Ofl
5 Mw,a\icl
6 Oi;'Er!iOn!
7 PlIienvfal
o O\hl;,
Rcltfill~t~l,I.
AIl<I!>Jn<l~
~SM
HfiAI.-T"'-CARIi
DEP~UL HEALTH CENTBR

I>'lARCH PHILLIP H
24 HOUR MEOICAL/SURG,CAL PATIENT CARE RECORD

DPM-looo-071 (5 /2008) PAGE 7 OF 6
1111111111111111111111
J,/P
090220019 7 1'0/02/ 1976
SALEI'L t40UNER
0554-01. ER5 t<1 01/22/09 32Y 00074829 8
000276
Nutrition
very puor Probably
Frl1::llon & Sh~lIr

Problem Potllntial I
Skin Rlik Scors: Is" Ihan H. plltlen( Is at risk o F(J!Iow Still Cafe Protocol for score l~ss
adequate Adaqu"te 3 Excellent 4
problem No appmonl problem
til.Jn H,. W()SI prototOl al bMLId? i Nutrttonal consult (iJ not pr&viOuS~' obtained.) ~CorC
SCOrfi of 9 or greatar indicates

.. - - t - - - poaafble Fall Risk, If nursing ;udgment
a Fall Pl'Ovol1ll<>n Infotm.lttion

snoot revlswed/relmorooo
---::;--------';--;--+---f--+-----, differs frum SCQfe obtaJrwd. docum&nt

reason code from list below:
o rllli rl'k ImlGlllllt In place
tAi~~~J;j;~:n;~I-----MMiiE!liiiltA~lUflJUGnIQr1ltl!!tlnl
1 Pm;"", OJ! aT ~fi<;ii<l airwiIY amIIm O'<\'!}On o.!iWlV (e.g., 10 malOlilin WOOlTStllolgl'VlCMel lU()fS)
Sl$lIJ1nt EgViatbp
Oocfll'lltrit iiHlf: <Hid !t+tIt\~.
( )
(11jc
TllaJ !Idem Mt'

1ft
~b210 (~ru)}
conlr1(t for safety

fil~,eit;
~mlfOmr<lilntaf mar~J 1113Mm (rw.J:( iitif,;.:f. stifitJ!I-. BfHtt;Jl
r:ilJlii(jhl till: I 1\J!'JI1ly orunt~!irnl

!'~tM
? M,iutJin l1ill<n,h-e line'J u; bAIt3 (,"'l!ieIliY.1l IT} k tr~atmf~ pal",,!>' em,wt tnf.oilJon (e.Q ,~\lOOlC~ oj rrut,alilA,
~m
~f the
~"lJrd, '1'<'110", cte.) ~i eQUc~llD', box l!\Oicalts fOio,,"n{I
2
4
10 rltAI.lIfUDe:;',
leffiS (Ii'IV.I~ ",il' le~m~.
3 AtlNty demonS1'ol1es
ri,~
01 ,eilljUry
miMu.uoo or l\yI1talronj
1 Keuoo 101 rest,.,nl

2' Astf.o&-eJ-nlll hm~ fl~f;l1a;; ~ Tlwt t~(lH! rrL'QlJt'~1c:Y 4 Behavior fe:QwetJ fO-! r~)VJ~
'tlt~fl4ltlj ~J li!i!~l.,..t dl1}~iH~.r~ 'J;i}:t;"u:~. Lt.
,vatwtJo,
~1it;'~'SeNrtle"Hll
tctl,it, 1)3(.1tobs, Y<00<>5, ",.'I<s maile . .tc.1 7 f'a';>..lI\'1i1IDil't ~~,~/('Qfl '

OWI~I\IJ
R.1Illly nll,,'!f<ll!:; wi", ive """'Piv;i!al1l tWIn an ni"'Y or ",*.!I sulk! 1111 \he! injury ~ 1Mi' tim m:tsse l1WIerr",nlllelore" is >m~oi1:ally tll'''t'llnillt (e~, e>Vmlitf
CO'~r4!lve
and restraint Itmo\'W

nr (!!t(:f!(f; if.~ RF.h<ivilU:ti
!!;tfr',ttf.if dm:url~(j1tldJ:!.\tl}
or=J.Jo", I'h. _
B Ut mfm to
IleWeiJlt~)
~a
5 ;Iix! DIMe;!S" 9 ()U;w'
1.'<11
1,.nm. Qrv<-s.vw ~,~ijuieil

4 Prowct!IIE /)1il. In}J1y pa!1ent 110m '",Ihe! ,"r-J'Y Ie g, eVA w,tll pm!)',;; CI h..ao l,aum. wllh .~$Mr'11 il\~)
SW "dimiur.al t!oVlm~ for

Q1~
BEKAVIOfW. RSlIWNTS:
7 f!tr:ffff i1liqtirW.
lli;1
N rme4mXlIO",J~rirlQi'aturea.son
r.~.,t f~\eO
Rctw"n drmoMl.ntioo 3, :M~r<al-eas-e
mn dlJl:>llmerua{)On
tYl':;SSM DePaul Health Center

HlAL1li
~ARI"

l't1A.RCH,PHILI,IP H
24 HOIJR MEDICAL/SURGICAL PATIENT CARE RECORD

DPM1000-071 r,.j2008) PAGE 8 OF 8
111111111111_
ERS 0554-01
t>1
l/f>
01/22/09
00074 B2 98
OQ0220Q197
10/02/1976 32Y
SAl<Et-1, NOUNER
000277

PflEV10US 241/0: Intake OutPjll
DATESTARTEO
JAN 2 S 2[109
24 I-
~~
Resp.
I-BP
E~.I,lh
SCALE KEY: 0 Sed 0 Standing 0 W/Chair 0 SYng
Ob"N31
Bed~.de
glucose
ITIME
~
~p
._'-p
Ve.crlb~
f"'/
loeatlGn
8e~lIvkJr
/
//"
Quality
HS SNACtI
frequent
IYPS
0700
1-0 =8(l{},-+_ _. _
ORAl.
O~=FEEDINlS TF FUlSH
VOIO
URINE r J-J"" [/
I
OTHER
1M
DiDO
1000 1100 1200 130()
.-
Initials
L~
i40()
150()
.&O~
'600
12 hr
t--.---~-----+----~----~~~+_----~--_4---~-~~ 1700 I&BJ IU) 1800

lOI~lS
Sub
&ei:J_
12 hr tolal ofaVblDe .
(
;tJ-5 V
-......
....,..,
1// ,.J.rJ
/:J 'rJ..;;>r>..
5I!!HAl,j AN ~ AI
12 111 \otdl parenteral
',Mr <lla~a
--------12 or gflit! outpul
E.;=:. E"rn(
I .. !11c.ff, D - \"'<r,
Illc9C:i
1900 20110
INTERI
~dl t;.
/U/
1 Rh~~ 2, H6dir ~r GY~Qi

.'j,
2300
5 c:..ac 6. EneD
CQ~
011'10
0200 0300 0400
J~
.-....
,'--::-'
j
7 FOJ,lI}
....
A('YtJ - ..
..
Wz....
t;7)[
FWID EOUIVAlENrS: 10z " .. > " 30nL
4 cz (1/2 cup) , . 120mL

T
801. (1 cup} ... , .... '240mL
PATIENT LABL
.,..,
6 nz (3/4 cup) .. 180ml
1201 (&Oda-1 can) .. 360ml

DBP~UL HEALTB C~NTER
II'J\RCH, PHILLIP ~
~ "
..
~SSM
H E ~ L '1 U C 0\. r:I
r"'
IIIiIllBIII1I1I1II~11
ERQ
1>1
liP
01/22/ 09 000'/48298
DPM-100
24 HOllR MEDICAL{SURGICAL PATIENT CARE RECORD

DPM-lUOO-071 [b!2OC'8} PAGE 1 OF 8
0902200197
05~'l-Ol
10/02/1976 nY
SALBM, I<lOUNER
000278
DATE STARTE& '
,.
2009
Kf
IJ~
1 Medir.\1tion 2 Aml!uJaUUlI 3 Reposition
17 Epidural 18 peA
+
N(
1m
t}a
19 Preemplr,e
analge~iJ
4 RelaY.aflOfl 5 Calming Statements

pain pl1lse 11
20
Con~I1\1M
Prayar!M~rnlation
analgesic intusiQo
21 Olflllr'
Bellaviors
e !}e~p BreHUliuy
7 Splrnual Care
Time
Rallllll S~Of8 #
Scale Used 0r Observation
+
1m Oa
+
In!
D~
tE
'.'F
Funtlhn Goal if
Duerib&:
location.
Behnior
01
IPP
Quality
FreQuenc}
Aggravating Facwrs
I
InlervenliDn("i
lrli\ial~
BI!MAVIOR/RESPONSES:
AN
I=
e. ::
=An.iO""
= MUlUPla R&q~;,l
~ D~reni<v>
c-.1ievin~
C - GiJnlmoous Cryin"
Of
EWUJt,(lH ft Dlliul:1':i-!. fnetf6LtfV-' I COPtHg
UnrespollSivil CO " Ccm~\05~ CI = Cognltke imp!llrmom

~
co - ConfureOJOlsotiented
os - ObrupWe
S
Oth~f
H ..
G ;:
~ ~ lie-\'~~:p
nental Imp',!3:rm'Ool
L - LeJhar}f.c
o ...
Aeatless O;''erQl1mu!;7d-erlJCrJN"C'm:tivo
W = Deliber1!lly WithholdlnQ Inlo A - Attennon Sl:'eking

P1iti.~t
HaJjuC!f1i1Uon~
Oe!vSiQn5
6IQniHcant
= S!eePIn\J
I)
= CelmfQule!
Coo""ra~v"
T = Thr "",inq Physical
OP '" Dmflln!;vt"}
j..{arm.lC.omhoHve fM = Impl,h;'1H
LA - t Crl-!t Am:ln~.m
O\t'tUf
COP -
fNTERVEN nONS: 1. Reat.U!".dIlCii" Falrent f :>hJrlllJCiln1 Ull1el

2. Rt:OfftC1fc,n
J,
G\>i(!~~t
RQ<.Alf)~
6. Oll~, fi~Q\.i.ni Q.-",! ,-OfIt,,\ 9. Prov:de lntorma\bn to incr-eas-e le'fe'. cf und-erstan-din"Q 10, Cnc{}Yr~. family 10 bilng in familiar obi~U ,, I~ 13 P,ovid9 i~lI>.a!iQt\ wit" m~~~.lma9~ry. (I~~p Nealhlng. preyer. moolCHtiDn ~il.;oofiVje Mirnm sleep t9aii by iiSiii~ ~ii~lJiiii ~ltiF <liii~ Dmkon room! lllTiiilng H:H~ J
14
1,
Reorient! RemottVale i RestatIng {acts

OiYertiOI'f$l ~~liv'~e$
r>tOtl~i;~
pjl1je~sli
4.. C:>I1;SIs-1e-nt (m-(lronme-nt !
E$t~i)I;$~ nt'nj,).;';e<jltmel,"MH 16, tiii~ MM. Enco:JfaQ 3 v8'b-aHzatorl FI"\{'~OHrn01 p.ni((;nf wah rW...r:-~l(H1 ma~mu kv. !'.;,JH IIlllid~,
,"cb'.el
17
\e
IB
'9
Reassess J Ra!lu&9tl.on j S-eev
"'e'w.,
{'lBrlfj~.atlon
no; ;ni'~'\noij
OU>H( ~.J.frl to i...htf.:It!-3he fkI.1~IH1r!3 fcspcns.!t \0 b\ij)\l1ial:otl
ID
PrtlYldn in\p.nKflH };ffr,'\Jjliy iiHd ~h;l, 1n&-a-Wri!5 !"Hn~ll\l& OOt"!3ViO(al probt&n\6
~SM
HE-ALTW'C"'1t1

S !>LEN, MOUNER
MARCB,PHILLIP H rip 0902200197 ERS 0554-01 10/02/1976 32Y M 01/22/09

00074B2~8
IllDlIJllllllllllllln
OPM'1000~l7i
(S/200e) PAGE 2 OF 8
000279
....--HOUR MEDICAL/SURGICAL PATIENT CARE RECORD
24 HC
!)rsg.
Date:
Dr~g
Dille
PIce
FRONT RT
(-
FRONT -~, LT
BACK
SL/OllTLC
if till!
jill 1/
IJ
\ \
\I
RT
!.,~'\
\~
~)
!J
411l
u
)(
~ wi
fu.e {JI(r.<..tled.
! \~ ~1I\t
Insertion Date
Arm Glrcumference
.___ Length _ _ em
Dressing change date _ _ _ __
em
PATIENT LABEL
~SSM.
k:51.\.1)t CIroRi
DEPAUlJ HEALTH CEUTER
~
II?
H E. It. I
24 HOUR MEOICALfSURGICAL PATIENT CARE RECORD
IIIIIIIIIIIIBIIIIU MARCH,PHILLIP H
0902200197 SALEM, NOUNER ERS
0554~Ol
10/02)1976 32Y
DPM-IOOO-D71
t'l
01/22/09
000748298
DPM-l0!
\:5 '2()J8) PAGE 3 OF 8
000280
24 HOUR MEnll"'AljSURGICAL PATIENT CARE RECORD

Use bolded key letter i/ inole8te4.
DATE STARTED
' r"lt
'.
"
"~"' ....., comments
in f'lUTS6S NOle$
ROIJIlds
; (CP, "OIT
_",.1.
.~~
V?
t
)
, Badrest
IV'
JSI
If''
rlJ' V
!~J
bd
I.,..
~~
"J
Wq
lW'
'A~
1----
IB-Back
I
"'..... '.'~.
(In
L-left
I:t"" Ir I-1:3
I't"'
~
H.O.B.
deoreesi
IHeels off bed

1130016
. IfilnSTer
LS
r; 5 ....::,
sse
.. _----
r-
1-<:
I;;;
1-0:::::
l> ~ -< r-
xl x2 x3 min moo 2-Asgisl
Cane
ICRutches
I m.bm-.
WI'
'M,
I a"'''UI<llIln
II # Feet. Steps) I,imbulaliofl comments IHOM Ext IRA. LA. Ill. LL AU)
IBatlY"il'lsslst GomDlte
I bed changed
11ikin care
IA
SHower
1.3
.
I-
'6
tn I [lentaVOrai
~
Denture cafe Self Assist Complete
j..::
--:
I;:~" =: :: ~:::
I f'eti/Caln care I !;Itz. bath
Self Assist Complote Sell Assist Comolete
I~ IC)
I~ilin!ls i Splims! Gast
RA, LA, ilL, LL

. . ...
I ~~oad lice Dacks It!ICPMSetlinQs I~ (:l"\'o(;u11 re-lced and on IIJJduC\(JrJll!low Ilolal hip i knee
11"'~ti""
,W.illht
Atilt
/
./
./
/'
! .......
./'
./'
~
"...,/
I'
I Calilioht J Phone in roach
.~
~::b;eLOW oostlion
ToDet ng offered
.... . ..
/'
/'
L
V'
v
v
~ L~ V //
/'
/!/
/
./
VVV
-..
~.
'/ V
v
ISide I ails:
110 hald
l2 x3 )(3 Pt. r!>Quested
K?
~,.
~:z..
~'L ....
in p!ace
~ ~..
Not applicalJle
. . , 4Y _--!. ". ,Vertffed

.
t ,-place . ./
V / 1/ / !/ / ' II( I)VX' I'l!,i""
;/
// /
/'
/
....
1 ADaruv baml
IOI~ ;_~~_>li!tus bafld. ______
iSO!allOn precauUons tland
in place
[j
o ,,,,,,,,,,, nit" in place
o Verified aMinplacp.
0 Not anniicabli:i 0 Not allDl,call1e
i 0 Verified and in piace 0 Not applicable
o Verified and If! place
ISOl4TION: 0 SOBclal contact 0 Contact 0 Neutropenlr. 0 AlrMrna 0 Drnplet 0 OTHER PRECAUTIONS! 0

p
Saf61wr~\I
0 BlftadinQ 0 ASpiration 0
S~12ure
0
TITlE!~Hlf!
INI~l~1
;I TIm / SHIfT
INITIALS I
Jt!I!!ALS I
!
-'
TITLE I SHlf~
II)' lI",I;1i;;.AICA ~,../ J..k C.i?7 f1 A/"J / ' ).r-'\.-.

'-j:.f///~~
/7
//
f.4--A.
/7
v," v.LI~ -l~.If.l'......
~SSM r
H I" A 1. H . , ARt
PATIENT LABE
DEPal.illllllll
sALEM.I<10uNER
H CENTER
LIP
J.'!CH, PHU,LlP H 0554 -01 0902200~.9:. ~RS M 01/22/09 lO/02/~97~ 3~Y 000748296
DP~J1000-071
(5!2008) PAGE 4 OF 8
000281
r-24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

KeY: WNls
Ia~k
DATE STARTED
241
KEY:
compieted
S2~ u"",l" "u, '"""" .. ,,. in
Nur;;!i,' N(lle~
US~
boWed key letler if indicated
,}.;1~~;t~::iCl
i.6.lerl nit.ml.,.J ~'l Follows .MMm2nrlo LOC (COmatme, Contused, LeUlargic,
~
mlllmDl_mllm~p:
I
V
:JUi!mUimJ.i~
I
I;
Apical
Abnon
Pacem
Periph'
A-Ahs WWe
i/
!
v'
Speech (Aphasic, Delayed, Slurred)
./
Moves all extreloi!ies wiIh ~qual strell\l1h

Motol response
(AboorJl1alll~on, E~tenslon,
v
/
II
ARM LEG
HAND GRIPS
,~< 1/
Flaccid. Locait:es, None.
SPastiC, Dong, Weak.

WIJ-WlllIdraw: I
_..
I~,< V/
,/' / / / / / / / ,/ /1 // /
1,,/
/
'1//1/
~,/ // .,,/'
// //' / /f 1./ Ii /
,:/ 1-,,>
SSlrc
/
)
j/ 1,//
iTremors
1/'1/ !// ,/'

.,,/
/.oJ
1/ 1,//
1//1//1//
/i
1,/
./f
// , / /1 ./ 1// /! // // :// //
/ / ,.1/
/
D-Oaf
Color I
WNl =
flJllV,,!';,11J!
// [// !//
//
,,/
sJon WII'
IOl(V!\
~m,
~SCALE .
a-ansk
'-Fitad
s~StuOOiS"h tmro 2mm Jmm 4mm
~SWcl1NV
CWsed
~mn'
e
6mrn
Size
// "// .// / / .,,/ l/l,/V 1/. . :/., / / / / /,/1//1/'

.,,./
i//' /,/ /,/ // /

[/" ~// /./ / / ,,../
!
1//
Salldb
Reaction
7mm
l"~: 'l
// .,/ / / /
1// /
,/
!// l//
!
,//
l//
!
l/'/
1/"
rEDS rEDS
SGDs
I f)v"nh~n'" 1---, .
L
fPr/,o.nt l!.h'Rnll
Ti!.llUfl'J
SGDs
A/L_
IPostefiof
all lObes clear
Abnormal Drealh sou nos Spetily abnormal breatll sounds 0/1 diaUfllm,
{Abgent Decmased, CRackles, Rlmnchl, Whulzes, coarse}
1m~ ~ ~~ ~ ~IIIEm~DJ Em lEa m
TIME
=
i{
m
-......
1
;(\ ~'
/POSTERIOR R
TIME 2
5,,-___
Hv '
4
--"r'..' ~,..
/
V---":;
~
~~
R
J
4
Abdon Abdorr
~
L
POSTERIOR
A6$j)lratory ~"JI \ UII'CW'MU

Atillormal resp ratory effort O),spnea (on exertion, at Resl)
.... _. __ .
(V
SowQt Bowel Abse. Last Bl

Flatus Stool
, CouUh
i
Nonproductive)
CouOh arid de~ p bre.ath ... _.. .. . Inwntive spirnneter # mll it reps
Sputum (d~scl'be amQunt tO~or.' co~s'sten~YL
"./
k'" ["./
~,.-'
I' -'
",/
1 .. / .. !"/I'
I
./
.-
OGt
./
/'
,/
,,'
"J"
/1,/"
!,./' ,"
NGlul
Bay /
~uctlon (Nas41. Oral. Trach)

Trach care o Trach type _ _ Size
TUGe I
Dston Storm
o CPAP
I
0 B PAP Settings
I
Slom.
N~tr(
Ventilator Set!illQ$: 0 CMV 0 SIMV

,1:n~,v, o~tti:.~
(verified per oroel')
Ostorr
Comments
Osrorr
.CHEST TUBES
Tlmil
LoraUlm
I'AlltN I Vlt'J;1.
! Wat&r Ssal
Su~tI(m
/'/
Crepitus
Oralnage
//
//
SSM DEPAUL HEALTH CENTER 24 HOUR MEDICAUSURGICAL PATiENT CARE RECORD
OPM-l(){)(}"()71 (S/ZOO8} PAGE 5 OF 8
0902200197 10/02/1976
~~~'~!Viki,ii'ER
3;~v 05 54-01
1'1
DEPAUL
o
tip
H ,
SALEM,MOUNER
01/22/09
0007"18298
DPM'
000282
....
-----------------------------------------------------------------~
OATESTARTfD
'1
24
A-Ab.~l!nl
W-Weak
$-511"00\] D-DOilplar
C~or
temp s( nsatlon
wm. - r,;ajI Iwa ~ "I: ""!'

r.w.I.!NIl w;vm w!e1 to r s..n)."
oon III lO')(jl "'" "*,,
Droll
o
w!
IU
~"
"'\

~~UR1atCJu..PATIENT CARE ReCORD
000283
24 I
A
~
Pressure UICllf
BL
8A
= 11CtSlOll = Llcllration
It ilIssure ulcer, list St~gA I, II, III,
= 8rui.e
o
"Hcm~loma
Or~jnloe T~;
Q
IV, UNstawallw
V N .- YlSCulal ulcer (v4lnous StaSIS, arterial inSlIfliCivilCY) .. Noorop3thic U!(,RI idi3heticj Wlund Oed Kay; = GranolailQll S = iilr.<luh
Q
= Ra>n
111 = T.lfIS bum WA = I'/eU appro;jmated
D Oenu1!ed EO E,yUI!IIrtU EX ~ EKconalion
'" ather _ _ _ __ Drllinllg1 Amllllllt:

ac "SC<1Il1 $ Smail M =Mvw, ..!v L - Largs ~ = Co~iqus
"
DruslRg:
I:l
sa = Sk,; sbij.,~
- DerflUtlimtl
~ SI~p1n
SurroUnding Skin Key: I - Inta,1

It ~ Erfjl"~lIll M . MacEr~ll()O C CY"lIJtirlOark 0 ~ OIhu
lr' \ { M - M91l!~~Y Wilill ~ - clum 1---"'1'""----,-----..----..-----. .._-.:\.~'-L:o~..::=:..'U:U:'1'~==;=:.....-----------~O~-== rP.hM Mired l'lUlrfl)UiildiflUI [IraIAaqe AmoUJII 01 Odor l"di~all6 R~~'~~"mtn! Dl'lulnll Wound 1 Trntmslll Tlmv lliluNlI; ~l.Il\'WUind No Ctrange Time and Inilis.ls ('S1aqe) Bed Typt [lralnllll6 "( I N
llfI.) ) I ' \ I
I, . f
\ : I
rrr"
-,
j { i I
I
j
'
~"I\
~Fn...
= E~th3r
= !.~M,
S
BS
: -.,~ I !,
OTA - Opan 10 air 0 R " Re1Bfltlon iUtulE5 CI nry an~ JnlaDI
PU ~ Purul~r,t "tiIoMy V '/e!',(lW
= Gf6~.n = SelOtJ's = ~pm"""iJ'w~,)iJS
!llJwmJ:
1 emfsll
~
2 Ctr1J!O l;:rrvuc
Gml<
4 lW3!t:
~SSM " e
A L T H C A A. ,.,.
DEPAUl, HE ltLTH C!SN'rER
/118111
24 HOUR MEDICALfSURGICAl PATIENT CARE RECORD

DPM10(1)-071 (512008) PAGE 7 OF 6
0902200197 10/02/1976
MARCH I
PH~!~I~.'.II w
32
RS
M
r/p
01/22/09
o .. ,
DPM,11
0554-01 000748298
SALEM, MOUNER -Y
000284
DATE
SCORE (Circle score in each area and total.)

Mol_lure
Constantly moist Very rnoisl
/JIEfIIGAL RmOl! lor RUf/tlnl

\ rroteet an arlJhrml a'4WUY i'I:f~Y~;\ f!f,,'JM'ofl'i;:'1t3f myqp;.,tltlOl:"""I& {nt-tr n!,lfS-eS ita-\1OIl SlJ~O&l
tI~/1JP-f1 r~.->f'f?f>'
fit q 10
maml',. e'to!(acn,e\fVacn~~l \I!~osl

<ill! Iig'<i
J~:
Ilntrtln! &1v;tlWr O'J-CUfrtf;ilt tinw ~r...Q ~{i'le I'''' puent $~OlJ${', I!H' '!
i
1
ma! BI!,u. !ty

~!I
1Jr..tltl! Iv r.l.l'1llt ..'ni !fir Mtft,
MamtEtrl /lTy,j,'i-;c hllt.l,~;"~ l\!hf.;-, ~9t.f..Jl.lv"tJ In !h;5 u&atmt'o! Of tM ptttN'S' r;vrrent roMnfll{,Q, SO!/..! sr,Hni~ ul !~'illiflifilJ
me4t'~blin ar:fl1iS!rabotl 01 nvQrav~nJ
I '" 1~.iCOli)n C"nfl<iiC Itt! lCliowI'9

wittl
~..a-tntf
R.~'~";{1I! h"1) (t:f.!IJ,'tlt
CvITI 10 0"' 1IlJQes. IrnlS,
e1C
!tij.'llS (hsclJS-&-j
Aattity f}<:JWYI~bMfJ,
M"'~t~o
(L'i~ rof fRtIl;Uf)'
10 lWIO\'e ~jnsilm. $11'",,,,,
ef.;
Ao;s:t'...smmll
Iflif. kllf~h
3 Safe.rv vl
6 Ut'i'&'SfiJl16 actl'ftly (b!c;;mIJS. '.1JeM. Vra.!1s. f!1l,.l-SU.!. ~tt i
Oif~rn\~ hilt i.t-Jf ~lf..1f"'1L~.1if'J1 fn};ll
an AIWj 0,- S-4..rg:-i1;a!

It-lye f...tf.-t:-;',fJYF:
Tli'l~
ltiease fre(}Jencv
Ctmp$j a11.11 100 fat1ra!M fifJln{t't~
ClOC-.!d'iJle 1'w11o. wo-uid suffer tu;thrr !.ltllify illjlt1
I Pritl1\lf~m'YWmll\l!l
i1lDwn;:n1 ("ltCf, rt is ,ne<1ic8tl _"a~ (e.q ..'1rorri~
4 O~1 reQweo for "~\1ii
Oillaffill leil 0' o~" (see 80M"""!

Ra-iJtti~ll1.)
lfact."s U1 vaSCltM ~"r9<flH) ~ P7Qlvet I.e tUiII "'Iary pall,rn from iU'!i1er injmy (e ~ eVA wi;' P3Illysil <,f M;;C lfJurna with aMffiGl1Ii1"jOI~ll
0 &EIiA~IORAL R~31RAfNTS: ilM nUlon,1 ftow<M<l1for

'<~"',",,I"IIrn.
7 Olhfl i(e~L;(tS "{frai1'''' GlW<IT>ernaliooj H P'e'.!:,,-d ttMt to ftfmOOr ioo!O;at6-S reUM tri.>!
"""Wr""lJ"'"
~SSM
~
i A l. T K t A 1\ ,-

OPM100 ),,071 (5/2008} PAGE 6 OF 6
000285
GICAL PATIENT CARE RECORD

SCALE KEY: 0 Bed 0 Standing 0 W/Chair 0 Sling
24 H
(Plllil>8 recondlB weillht difference if greater than 2.5 kg.1
lima
Raung Sc
Seale UU
OOUMII
Fvn~lIgn
D'nrl~9:
lll'JIlion, BebllvinT
Ilua!lly
Fr6qu8l1~~ ~lIravall
BEHAVI
AN -An: t ~ E>;,Q 1- inetf-e
12 h! lQt~1
olaV\vb~
De,,;
INTERV
1. Rean
2
~
r1<!";,e
GW,!a.
4 Coiii,
5 ""iahl
B, EI1U)U
7. tOC.UU
12 hr lotal parenreral
FLUID EOUlIIAlENlS: 1 oz ... . .. 30rqL
4 OZ (1/2 CUP). . 120mL 6 Ul (3(4 cup}. . 1 BOmL
DEPAUL HEALTH CBN~ER

Z4 HOUR MEOICAWSURGICAL PATIENT CARE RECORD
DPM-l000-o71 (5J:WOO) PAGE 1 OF 6
MARCH, PHILLIP H . riP 09QZ2001 97 ERS 055 4 -01 10/ 02 /19'76 32Y r4 01/.22/..r~ '~'UNER OOOI48~9B SALEM,l')v
1IIIIItlI1IIIIIIIO
DPM-10Q(
000286
24 HOUR MEDICAl/SURGICAL PATIENT CARE RECO~R~D=--_~oAT~E::'.!.:slA:!.!.!RT~Jf}~tf==-7-:=_O==09'=l
24
APP .. AsSUlli pain presenl
'r!Sfrt
Dei":
+.s
+
Behaviors
Time
Rallnv Scort Ii
S~Il18 Ut!d 01
Inw!
Oate
+ 51
Insert
~alR
O~1Y80on
I fu Rcllon lioal i'

D:ll$tflbe:
FRO
RT
Loctlion.
Behavior or APf'
Q~alily
frvqVfn~y
Aggrantlng fiClOrt
SedaJil/n Ulvol
Inlsrvenflonlsl
lniffllq
BEHAVIOR/RESPONSES:
flit ~,>\!.Jlhp!e:
R101 l"t'~N
U = UnrU90n.'''G
co HDP
CllnfWJP.-..d!OhO(l..eTIt"d
O~
" (I,>Nl>lwe
& ~ 51eelling
AN"' An'J(ll15
E = EmO!;O",,1 Diwes-;
C - OJntIflUOUE Cry"'tI DE - OeP1U!;lOfi

G _ G"""ing
CO .. Com.lI1!)Sa
CI == C..ognitiVR tmp.Rtfme-nt fit = R~t{Bmi o - O1t:l"blil'w..tl.:1iurVOvP,I-eactwe
Off~
Ha!lu(;iah.i.u.nr~.v
Oeh..t'3km5
SignikMl Ott""
T - Th,e~le"'f19 PhY' "'~! Hartn/CQl'noati'te
1M ... Impl.Jlsl'r'e
a = GiUm!O\.llel
COP:: Cf.NI(mr,,!lve> LoA - lss AOXHlU!i O\h$,
I IneHectl,.. Cvl"f19
o
=
W - D.hb", atafy Wi!hlmhlinfj tnlo A - AttiJ".'"'1tOn ~-ea~ing

~
Oe.-lI?fopmen:at Impannent
L - Lelhetgic
INTERVf NTIOnS:
t
3
--------------------------fr.e.q;Jent Mer c-ontaei 10
O<srupt<ve Pab9n!
Rea'S"St. rance- Pat:ent t Sigmtcanl Dlllel

L'ot~isfnnl
R<:rlin>cUo"
Glm.J.'1f'CC
'l.
FrrnrCl:flrneof j flo-vtloc
~. E!IIaBlI&I1 milillii"mil time/r.,,1e. lor til'. ft, Enco-ura--g& veb3.Ii.3Jinn 7 tocouraoe pa n~rn Wfth OOcmlf.Jfl m<lki"~ for
""ed.
cate r,e-e-(it
"L Heollejj(! Rrl:mQt;v"l1f f Aest8finy facts 1:' Orva-rfitonal.ic'{;vil.inr. 16, Pn~a-t.hve O1ras\..ile~ 11 P,nvlrie reiaxatjDTl with rnvs{{;, Ima\,liry. doop brE-athh~1J' pmyE'l. !T'2.dlc--dtkhl 17 Rea$~'H! "'~~Y.~'!9~~ ! ~f}~1h c.t~Jfifj991fGfi 12. EnccumUf! normal.s!eeo C',-..:;le by usino indiroict tHJhting aftel d",k 18 Estilly,ith b-ounOa-n~5 1:J_ Uark&fl fOom I Limitlrlg tmmh J i g Pm'>.'i.J:':Ie fntel'l~ive s.ecurity i1ld 'Sataty o"'.tJ'a~'..Jlti\i Ql,nel $lQil to d&cleasl;: patienf's response tQ ltmUiAttOl'l !\1 minimize behifv.oral pfCblems
Provide- b"\JO!mStionto lr<:r&$6e: le\'i)1 0' undtJHtlduiinq
FnCDurege family to br1nQ in famllfar Obj6'C1t.
fYl:;SSM. DePaul Health Center

H f .. t T
}oj . ': "
R E
DEPAUL HEAI,TH CENTEl{

24 HC'UR MEDICAL/SURGICAL PATIENT CARE RECORD
111111111111110 MARCH,PHILLIP H
~ "
rip
..
0902200197 ERS 0554-01 10/02/1976 32Y M 01/22/09 SALEM,MQUNER 000718298
DPM-l000-071 ()/2000) PAGE 2 OF 8
DPMl0(
000287
24 HOUR MEDICAL/SURGICAL PATJENT CARE RECORD
JAN 2 5
'.
241
BACK
RT
<')
S1 ;:;
!1fl;!)tP lJ)men
Lt> I
(1
i;<\
Dt - Vrobffl ~tJ/jrtlf
nc = frliJitl''''>e1I
IMitalt IoC~1l)I1 cJ
0 SLI DUTLe
SLi DLITlC
R T
'I ["IN h1ftr rli}'''~''fi
!liGHT
p
I(
Insertion Date Arm circulllhmmcl!
Lenglh _ _ cm em
DressioQ change !liil!!
PATIENT lABE"L
~SSM
M l A L. t lit' '
~
/, tI t

t;!.ARCH, PH!LLIP H
1IIIIIIlflliliDI
ERS 0554-01
M
I/'P
24
01/22/09
0007~8298
24 HOUR MEDICAL/SURGICAL. PATIENT CARE RECORD
0902200197 SALEM,MOUNER
10/02/1976 32Y
15l2OOa) PAGE 3 OF 8
D?M 1000-
000288

~SSM e.
)o!
A I. T H
'A
,-
24 HOUR MEDICAL/SURGICAl PATIENT CARE RECORD
000289
DPM-1{XJO-or (5/2008) PAGE 4 OF 8

PftEV I0US 24 liD; IntaKe Ynf.rday's wI. _ _ _ KG
JAN 2 4 2009
DATE STARTED
, I
24t-1
Output ____ SCALI: KEY; 0 Bed 0 Standing 0 W/C"air Cl Sling T~4ay'$ wt. KG (Plea$$ reClInl.lilll weigh1 ditferenl.le If grealerlhan 2.5 kg.)
~DI.-.q~_II.~ra
. Pvise
Rasp
.f::>
'I
~/
~1
J '}
~x
}
i8P
02 ~a!
9h
l:rl:~~
i
0h
/' ~/1///
~/
l// /1 .~ / /1,,/' / / 1// /1 ~ ~/ ..,/ / / 1/ / / / / qJ: ~ 91

Kif
bl~
..!., J
Timt
RIling S;
._-02 ooiivenng deviee 1---Oedside glutose
02% !Rale
I~'
ill
J>ULSE
"
Bti/eUil
011"1"1811
Fu~ct!OB
!~181
AESP
Bf
!OzJATi
n~
TfMP
RES!'
Sf'
D2 SiT
/"
//
//
~Diet-;; ,"M",U\I<: <0<""'11 IfF"

,taken
~;
//
//
L~N';H
I~ tiC?
DINNER
OIllHO
T1M~
II'
TIME
/ ../'
,,/
nt1 ,V"
... //
./ ,,/
l'
Ouc;rJl)a:
LooatlDn,
BehavIor
lIuality
,f~Lklruej{ I()~!!~ c.. ')'tuIt- !
'''''''''"
IVPB
/)
i8NACK
IV
{
mOl
, mlR..
/~O
URItIE
r 1.1.1'1
.c::
VOID
A.
,.1'./
~
()1pgjlt
ffEDIKGS
TYPE
il70fl OSOC
090n
ORAL
If
FUI8H
.I!t
Sedation
11T!8rv~nl
10IJO
Initials
IiJrTrt1 -It:
1100
not)
M..
noo
1400
150D
1(1:'0
29;)
/
\J~A
V. I
aEHAV
~1800
;,"'.:'
12 hr SUb TOlalS - - - - - -~-----12 hr tolal ofa\ituOt _ _ 12 hr shift intakA I 12 lir total PllrHniellil
XI
~t..i;:L
__ . ____
12 hr ~l!ift oulpul
t~i)
I
""'--'"
~~.~(
E - En-, 1= iniff'
--
iJ _ Oev
1900 21100 ?100
INTER.
.11. lL :j\ ~!V
4/1fJ I v
\.
R~~~
~I
2. Redin
J. Gut:)! 4 Co~1 5. E$IRI:>
22M
-}::~
01DO
I
I
6. F,,,,,,,
i)-f.)
7. Etl!..l"l1.
~~:
040C
_~~OO
SubTotals
>1UU
1)0
~
(teDO 12hr
_______
.~
. ,hll( i
'1~f.-1
r'/~--
111
12 hr total parenteral
_ 1? hr IOt.1i oraVlube
---= tl
- - - -
~---
I~~V
12 nr sfillt OUlpUt
T';'.".,,-.y., " total

FUIID EQI)IV~LENTS: 1 Ol .... 30 nL
LW()
4 oz (1/2 cup) .. 120mL

6 liZ (3/4 GUp) . . 180rnt
8 Ol (i cup) . .. .. . 240mL
'""~'"J''U'''
PATIENT LABEL
iIUIlrUllllt
I fA-':' I~
12 oz (soda -1 can) .. 360ml
~SSM
HEALT" CAtRC

D?M-WOOWl (512008) PAGE 1 OF 6
rip MARCH,PHILLiP H 0:102200197 ERS 0554-01 10/02/1976 32Y N 01/22/09 000748298 SALEr>1, MOUNER
D?Ml00
IIRIHIIIR11111tillill
000290
.!AN 2 4 2009 i42 .

DAlE STARTE,.O~-=======;
Aching
:J~~!!~~j Cg C"lImpin~ ~ Crushing

APP", Assume
~,~tn
Faces
Duming
DUll Gnawing
SA
S~ep.
eilSY to arou,e
1 Medication
17 Epidural
18 peA
t Awake and alef!
:2
vesem
Rssl
Betlal/i)IS
Hcavy
Pressure
2 S~htl'J Of1)Wsy, a~sy In ~rouse 3 FroquentlY dIVWSY, amusable, eyes drift closeQ during (XIIlVtlfSilliun (conEldar rellucln; oplol4 don)
3 4 Relaxation
Amb\ll~liun A6Posi~0Il
t 9 Prr.-cmpUve
analgesia
5 Calming S\aiem~nh
G Prayar/li.1!ditallnn 7 Spmrua! Care
11 Deep Bn.:alpjllg
20 Connnuous anal9!lSic ~lf\1$iOI1 2' Ol1\ar'
Tim8
S~'e
Usell vr
Obaemtlion
Functilll Goal #
Ol$crlh: Locallo I, BeltaviH or APP
QusJ1ty
Ffequellcy
Setlaliun level
Inlent IIIMls}
lp~il!s
BEHAVIOR f PSYCHOLOGICAL
BEHAV10R!R~SPONSES:
M; ,.1u"'plo Roqt.'I>sj
C ~ COnllflll{llJS (,'Yfl()
DE ;:::: f)-r:PWfll'if.lltt
G
AN - ,\r,,<iOl1~
i ... Eno\JonallJ4-stres;i I - Int: tfoct!'fe Copmg
co" C.ofll"lot;"
CI -
Unrrn;[lrv"'iv",
Co-~ostlY-a !rn.pa;rmEmt
CD - (JonIUE1>OfUlOOn&nfaa H ~ HshJon.I'JI151 DelUsfJfl5
05 -
Cwupwe
6ignnlcanlO\!la1
S = Slel>PinQ
Q GillmlQI,inl
= GntfV1fllJ R - H~Uttij5 A ;;: Atlentio.'l ~-e-e-kmO HrumlComhnii'i~: LA - LeW"d,HJI;IOU-6f-0_=_D'N __ elOpm __e_n_l"'__lm~p_a-I"_n~_n_l__~_=_L_"'_rta._,O_ .... __ _ _ _ _ O_~_Qy_.,__'b_mu_.'lated!Ovefe~:.. ~:::::t<':.:'~_...:D:::!'_-::..:Di::S~I\J:P:::tl</:::E..:p:.a=lie~-n~1_ _ _--.:IM::..:~:..:ln::tF=u"":.::'ff=___ _ _...:::U:'he:':,.,::;:=:::::====_l
INTEIWNTIONS;
1 Hal lji'8jJra.nCi P~tl9nl I S~nifjc-2.nt -~r
Roe<'loct~
W - OeH}era-tei'(\VithhO!(1ifl.g tn1c
T = ThreateninQ Phyrkal
COP
~ Gunpe~ali\'e
GUljance
Esobtfsn ms.in1Rined t;mefmmf7~ fm
f;\"Vt:
~f)
11
p-t!eli~
12
Em otlf'Elge "nrh",!iTalinn 7 En( mm'rr~ ~llhenl 'nith .atKf5!On makmg tOT ca."e n&ed-e:
13. O~k$n ty"m I Wm-itmg i--o~h t QI.Hit i"i"gn tv (1i'1&$$-e- pe.tienl's 11?SpOnSe to !;:(imul;lfinn
Of1er frf.l!Ql.a?nt hrifll cnnJani Providn infnrmab...lo to Increase level QI1Jm:::~H;tj.l1rJlnQ Ell{~UUH:iye laJ"(liiy to tHing Hl famcbtlf G-~~Ch Pro-vIde reil)c,a110n wrth OlUSH:i, ImI1l'981y, d~ b:(-eat"m-f~1, pf3'ler, me,oit:tation EOnvu.r"1I0 rtfl1'llli ~"P cycl. by V51n~ i"tJir~l ~gh\lnil ~I!l>r <lMk
14
Recnent (fiem-'Jlr(~1t'
Diverl~on-e.l ~}... Il!e:-s
n~'Mttlllg facts
15 15 17
HI
Proact-Ne measJJrE'-S Rp.a9~ie6S f Req.fG-stio-n I
S~dl d;l1lfl{~alIOH
13 J:'m'5!;Liii; fiiilimimiHr.
Pruvidl1 !(lhmSlVB wcunty an-d ~afety meaSvre-s,
'0 mu'tlrntla t}ehavlQ-fal problems
~SSM
M Ii l. l. t H 1; . . . . '"-

MARCH, P!-iILLIP H
IIIDnIIlIlIlIUIl.I~
riP
0902200197 ERS 0554-01 10/02/1976 32Y M 01/22/09 000749299 SALEM, t'lOUNER
DPM 1000-071 (5/2008) PAGE 2 OF 8
000291

IV ACCESS
Abs~nce 01 I1ilJ1WS5.
DATE STARTED
JAN: 2 4 200S
pain, drainage, swelling. l/lakilGB of noid and appropriarely secured,
= See adtJitional C<lmmell\S In Nurses' Notss
MY ~~r it irl'Ji~le~, ~ = TubillQ Chllll1l60 0 - Dmsfilna r.lW1il6G tatll sft. dt"umlnt; Lonatl~n Code I Type ot Fluids and Rate I SL=Sallne Look
On'g. Date
o 0 ~c-~L~;~~::::: I---+S-'l=}=DL=='==T=LCC+---==
P R
V
~
x
_ _ __
Inserlmn Dale _ _ _ _ LengttJ _ _ em Arm circuJlIfeHlllC8

em
Dressing chang8 date
Cal
OVl
Bel
Te>l
Sid
!Q.;
~
ON
Iso
IS[
OT
PATIENT LABEL
DPI
000292
- - -...
---------DATE STARTED'

Use balded key letter Kirnjfcated.
r.
JAN 2 .4 2009
<l Q
< -~
....
c,
,Ari."
. #1 Nurses' Notes
-"'l-L~fI
>Ie?, SNT iritlals)

Bedretil . Independent
Posili(lfling; R-Right
~
g
11
~
Itt-'
11'
5
IH.O.B, (in dtllTaasj IHaelsofl be(J .. IChaJr DamNS lise

~ ""'~'" assist ~ SBA ,xl x2 )(3 .mill mod
HI~siSl Z-fl~~iSl
I
IB-Sack
~~lltl'Prone
.n \J\
....
IvY
IIlV _. IV"
J"Kb
~ ([\~~("[\h
t'
5
f
~
1/r~
/tf
/
4-
-';>
'5
r-
,/'
-'
,.... ,,-. {
lV
Y ..--
~.
t I
fS
15
1.5
.5
S.
'3
AlllbulaUon(leViee
-~~
...
Caml
FEllt, stepS)
....
LA. HL. LL All) l:!l.IllIDtlm 5Kowtlf

[",
"nn.
S,/
ISkin care
n.
.;
I::~""
I I
: Peri/Cillo cart Sell Assist CompletA ' Sltz o2th Se(t Assist Complete Slings f SpHl1ts I Cast HI" LA, Ill. It .
!
:; ::: ~:::
.
. IWeigh! .
i
Dsntufa cue Self ASsist Complete
.s.:
~
5'
! !
.'\
~
,
- r--
K-pad I Ice packS
1"_
,ff
l:I CPM ~,fittinQS
.....
Rt I Lt.
I
re-iced and on
.lIow "'-"-""
ITola! tiP
IT, .
IGali Iighll PIlOIH; in reach

I~HJ"'U ,qUI':
,
;'
...
/
/
r
./
/
~
within reach
.'"'
. 1/
i-1
i"
Bed locksrll ToileUfl!l oiered
..'II
'"
i-Z
./
""
","'"
~ilS;. X2 x3 x3 P1. requested
!~l
~ "",
,;1...
in place
V,Z
Vz..,v
X~ :,....-
r:
<
,/ /
~.
'/ /' /
./
[Xtv
~band
!~ifiedllm i in place
tb
~
-
IAilergy Ilalld
!
o \lArifi~Ji ,nil in place

o Verified and in place 0 Not a~e
DNR code status band
o Verified and in place o Verified and in place

o Ventlad and in place
Cl No! appliGdtJle
IIsolation n"'~'''rti,,",
band
co~tacl
o Verified and in place 0 Nol HJlPlicllbie
0 Nol applicable
lSOLATIOII: 0 Special
0 Contact 0 Neutropenic 0 Airborne 0 Droplet 0
OTIiER PHECAUTIONS: 0 SBielyJFaIl 0 Bleeding 0 Asplra"on 0 Seilure 0
INiTIALS I
. / TITLE I SHIfT
INITIALS!
:/TITLE I SHIFT
INITIALS /
i.!ITLEJ SHIFT
----':K ~q~i".J {$J
0'1 ~ \ '"'
~
)GtJt.Qh~ 6
JJA III::N' LAlil::L
01!lJt)SSM DePaul Health Center

}lEAlfWc.\RE
DEPAUL HEALTH CENTER r"lARCH, PHILLTP H

O~O2200197
1IDIllfIIIII1IOIIBI
;!4 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD
1/1'
ERS 0554 ~Ol 10/02/1976 32Y t-1 01/22/09
SALEM , W~lUNER
OPM10(lO-071 (512008) PAGE 4 Or 8
r
0OO74R298
000293
124
I",
HOUR MEDICAWSURGICAl PATIENT CARE RECORD

WNCa or i."~
"mnnl~j~1
rHl
DATE STARTED
21 2009
Api
Abi
PHI
K~
,<> w
PI NUises' Noles
Use ooi(/ed key leiter il nnlicaled
~ Aliii't. O~filijd 12.

Follows comman<ls. contused, Lelllargic, I LOC
~"VY
l1~~J:I~~~[lEm_mllJ_mlBl j Iv l/ II
U
~~~J:%J[firm
,V'V
ISpa6th (A~haslc, Delayed, Slurred) IMoves all elptreml1les with equal strenglll
Motor resp( nse , ARM (Abnonnal flexion. Extension,
l/
Iv'
1/
r=
/'
Iv
/
Pel
A
W
Flaccid, Localizes. None, SPastiC, Strong. WeJK

wa-WrthdI3WS)
~ Tremors
LEG
GRIPS
PUPil SCAl.E
S-SlulI9ish
HAND i~/{
i;/( 1/
1/
1;/1/
'L
i,~ L Ii 1./'
V
1/
!
1/
:
<'
1/
Ii
./
L/ 1/ 1//
1/
1 ../
/
I
1// 1//
il/'
.,/
1/
1/ 1/
i/i
1/ 1/ [/ 1,/ 1// 1// 1/ 1// j/ 1/ i / / V

/1
,//
1/ If
II 1//1//1// 1.// 1// 1,//1//

/
sI:
/; / I'
1/ 1/ 1/ 1/ / 1/ l/ l//1//v//
l'// ",/' ,/'
1/
1/ 1/ 1/ 1/ \// 1//1/' 1/
1//
D-
Co
IVIi
,oN
.!all
lion
B-6Ii'lo.
101m 2mm 3ilm, 'fmlll
.
11m", 7m",
Ffir.ed
CSwoten/ CloSt''' ,min
ee
Size
1//
t." / / 1/" ;/'
Reaction
i/i. ,"" i.'
111
1// 1// Iv/ !/' 1.,/ 1//L/' t./' ,,/ 1// le/ l/ V/ / l./1/ t/i1//1/ l/ 1,,/ 1,,/ 1,,// 1/,/l/ 1/' I~// 1// l// l.. . 1//
,//
//
Sa
/ v''''
TE TE
IDysptlagia lPresem. Absenl)

INumbness, Tingling
I ~, ..b' oJ",,,
SC
II
n,/~"'"''''
Abnormal b'eath sounds
TIME
f!J I ~ tim EmIII~ ~ ~ ~m

5
SC
;3 t; ~
Specify abn)nnai brealfl sounds on diagram.
(Absent. D:creased. CRackles.

Rhonchi,
Wheel~s,
Coarse)
,(\fr L---~ ~~'

~-----.
L
TIME
~-"---"""-l
R
Ii
'~P' 9'
V----'"
l
"u;:"t:tt'\.'
= = =
Ab
~~ <l
R
Ab
80 Bo
POSTERIOR
IRespiratory effort I1l1lahorAri

Abnormal rt!spiratory effort Dyspnea {(}1 ExertIOn_ at Rest)
1/
I I
I
..;
At
La:
H~
1/,,,,,,...
y~.
ICough and deep breath

Incentive Sllirometer # mL / # reps
~,/
, Sti
o
1'/ ~,/ f,-' f'/
k"
~,/
k/ 1,'-' ~,/ ~,/ [0/ k"
~.,/
\ .. / k l.' l./ lr/ If
If f'
f'
k-"
III(
B,
ISputum (dliSCllhe amount, color,

I t:iiif.liiiii INu.l, Oral. Trath)
Trach cafe
fu
OE
o '!tach type _ _ _ Size

o CPA?
~]
BIPAP Senings
SI SI
N
...... ~.w, "'w .....\t

Comments
0 CMV 0 SIMV
'ord~r)
IVenlliator setting I'O;:!:OU v
Os 0,
liNt)1 rutltl:l
Tim.}
lOGalion
!Wal.r Seal
Suction
"l>'
Crepitu&
Drainage
.
I I
. PATlfNT LABfl.
CE.N'l'~R
DEPAlTL HEALTH
,,/
/
110111I1111111II.,li HARCH,PHTLLI? H
r!p
.. /
SSM DEPAUL HEALTH CENTER 24 HOUR MEOICAUSURGICAL PATIENT CARE RECORD

DPMl0001171 (5i2008) PAGE 5 OF B
0902200197 ERS 0554-01 10/02/1976 32Y IYl 01/22/09 SALEt-1,1-10UNER 000748298

OP
000294
HOUR MEDICAUSURGICAl PATIENT CARE RECORD
DATE STARTED
24
-H~
Fo1ey insert
Peripheral pulses
A-Absent
W-W~ak
S-StrolllJ
~bruir~
Fre~Jj(;y.i
I)-Doppler
Cotor temp sensation
1'.1'"
~
Gal (desertl
lieu eQildiJ~
IW bi pii!~.: <"I'
r#M illS thJJl ~ !~Qfldl
S'JPfil P'Jb~
Roo til tomn L'tr<ne

abii~flW
Drahage (v
in nob N",IV
B '"
T ,. flacc
1 " 1+
JJundiCf
Di~elk
Mucwlme
SldnlrPi:t,
!'.eel PfllCle
o Ar.r.u:ml o Othtr
W1)\IIIO vac
ill
o Pump used
Tlm8
~$~M.
DEPAPL HEALTH CENTER MARCH/PHILLIP H

0902200197 ERS
IIOUIIIIIIIIIIIIIII
055~-Ql
lip
01/22/09
00074 B290
lO/02/1976 32Y '::.r...LEN,I'40mlER
1'1
DPMiooo-o71 (51.:008) PAGE 6 OF
OPM100
000295
DATE STARTED . . '
f ~ III
? L1
':':-:"~~
L, ,
24
Skin
RIa~ S~re:
18 Dr 181a. patient ISlItrllk
o Follow SIrIn Clire Prolm:ol (or score of 18 or /e3s.

o NutJitionJl Cl)nsu/l (if not pm1lJ1Jsty Qbtiill~d.)
ALTBiED SKINJWDUHD KEY: PU = Pr8Sstlr~ uJr.6r * II pressure ulcer. list Stage . II. fII. IV, UNSIJge<lore
V
H
- Vascular ulw {venous stasis. artertal

11l5ufflciellcv}
- NeurOJ)athic ulcer (alallelic)

WQUll~
EX
H
SurrDundln~
..
.L DR
D
R TB '" Tape wm WA = WJj :lPProxim~lf.ri o '"' OUler _ _ _ __
Oruning;
lOa '" 5Ie,; ~"i;"
n
5
DI
= Siaule<;
oennat>on.j
OTA - Open 10 a~ fI = R~I""U~"i w(v'~'i
G Gral'.ilaliuu 51 - SlOugh E E,drd! o - Olher
= =
iJed Kev;
Skin Key: Drainage Tyjl~
D ra lnJge Amount:
I = illl.cI E - EfYll1em.
M ::;:
Ma~~"ah\.!fI
Cy~wot!C:O~fl'
G = Gr~~" SO - &e,m! I 59ro"; II Sm.lf S 8 = SerQS~ngunlW\JO M = Motrerate
=
0
= Ory.;rd ,"Mr!
Monl~Qmery
~
C ::::
=
PU
PI/flilAnl
i~iIiJ",
~ (.lD)1l
DIm,
B y
= Bloody
5
- Co;lIoV$
'"
,nils
G -
UIIW
o = Other
Cru~ty
! II~ Clt~noe Time amllnlllal,
!n~!~'w~
R~!m!m@n!
~SSM
HE" L 1 H C It. fl
e"

PAGE 7 OF
c ".
DPM

DPM-1000-()71
(~/2008)
000296
Cornp\uloly immobile Very limited

4 Slightly limited
Nutrition Very poor

Probal>ly
Frl~IrJn
& ShVIIT
Probll>m
POIBnlial
adilquata
Adequate
E"cellenl
prOOll1m No .'Ipparsnl
problem .3
SH:in Risk SCOTS! leslIlttllll 16 paUlin! 18 III (tak o Foliow $kto GJlfi Pru!O>~nI for score !es:; than , & (pOS1 /lfotocoi at OOoSII;'7)
Nolimililtk""
Nutritional CllHS1.dt (.1 n01 prevloH;;ly (!bta/ned ) Score
--------"'---+--1
--+--+----1
nScore of 3 or greater Indlcat9 possible FIlI1 Risk. If nursing judgment differs from scant obtained. document reason oode from !1st below:
o 1'1111 PrlOYflnllon Informallon

.\iheet revlaw.dfrelnforwd
o Fall risk bracele! In piau
~uont9[
BRiM'nl
fIg.bala! Educt!IM
C"lCIlIlWItllilr.. lild IoJlntI. i.LI pt.
1 l'ro!<ct
"'Biotalo iMctiaw<liM<arjt,<l illi>t>'

r.tri,-ftIVnenU!
Cli!~'ll.U;,j
ma~...on~
'0'" \#<:i;\! ""N.Y an!lio< Oc<ygM C~~'W'I \q .. I,)

cml)I~
(nNf nusSe>. staHoo
!~-;..tJ
Mllinti'li,) IHvasa !;i;nt5 Oi' 11.1te.s esst"ntiaJ to It\.c hl;3bljN~ rtf th"t;
panf<\\S'
c""nt... !l<Q,. stle s~"'Ct of nWiiion,
,HMlIt/{Ml\lJJlf\
~nontvilu".k"
meCiVltl!]n atlminhiufi-Ull m h}'dfdtro-m
1 Rf:a:;nn tor r6S1f~ 2 A~;Sli1OOl tt.1\it tfUrnlS
'''T6 d!s,"$,f/J "Hh tWM"
par!!>!. Sll'mr. vi<; l t }It\: e--iil..'CttiOii i>J)1 ir\d;attt:; fi,lffrMfHJ
J@I8MR1 (,ry 1 UMble \Q Cir.C1 It< saloly

7 fml, ID WI aI tu~\, tint!. e1~ AIlvIW i1#nCfis1.mte~ fffik oj r8~y
Nfffll\(IDJ Ii> rt'Wlr <!It!~1.
W'.uc>, "'"
IlmliiOMl KI!\;"ty (l)lclouiJ., ,idff , wall<S. llIl.'<i<:. dc, I

f1j,!tI\I"~ew-Alilm
lib<! \>I!I$>.1!ti<in .la:ver.-~ ,rolUS"O !ler.

I)!lu'
3 Salcty oJ tblliMt. "t,) on in>.ptOOU !rom 211 'ijIHY nr 51i1r-cal 3 TrtlJ ",1,,.,,,, Itffflancy pr()"..oo\lf~ woo ..'oul<l wnw hlflMl !lIu<y Dilley haw U'''OS~'<1! ileJ\l~jj)f reQ'J'cr! '1)1 lMvemuil bitm IT is n'"",""', ",~lt (t,g. tlCfrtmhv Iraduret Dr 'i1IstUal slIfqeliesJ .0 8fliAVIORAL RSTllAINTS, ~ PI_I \/;~ m.io !nlUIY (I,II''''lI trom I<Ji'th lnio/y (e~,. eVA 'IIiIh ~...ddlliMa! flowSllee1 !W ll~iS 01 11:"" lr.IUIT1il wiU, .'l!1<I1!i<maI IDjufl1!S) '11.'lll"in,_nt,w
too;>-erathtc
6
P~laiflt'l
~1JId Ie.,>::;lialn tiJ'liilfed
,,,,,,",,1
mhltm j<) ~t <)f Ol1l,rl Is'" Sd",Wtlf.ll
7 IJlhfj (rtquifn nartalrJt Coc\l!llCflcali""1 N r~cea noJ<! Itt "lI1me' irnl1t<1lw r~a!Q/l
~'~--'-''3!lel101cd
CI4?.)SSM DePaul Health Center

MIALTlI
[#",,,,1:
DEPAUL HEALTH CENTER l!P t4ARCH, PHILLIP 1'1 O~02200197 ERS 0554-0110/02/1976 3~'i M ol/Z2/o~
Shl.-Sf-1, tvl0UNER
11111111111111111
:iDI'M-1~71
000748298
(5J2003) PAOlO 8 OF B
000297
24 HOUR
Ye$terclllY', wi.
I\n ....
II(
~AI l~lIRGICAL
Outour.
PATIENT CARE RECORD
PREVIOUS 241,0: Intake
f-
~~~
~ r~
tlP
(l~
KG Today',
rI
fJ . KG
SCALE KEY: 0 Bed 0 Standing 0 'II/Chair 0 Sling (Plme ret:oncile wtigbllHlfartflce II greater than 2.5 kg.)
IResp,
I---
\~ F:? ~ 1,// 1/' 1/
.A
'ft'
sal
C ~
~
fJ2"t.[Hatc
P-t
Resp
SF
tL~ 1// I/)t t;H hA'/ -, 1//1/' 1// 1//L>l~(~~// 1//1/' c~
..- \-1'(
DATE STARTED
j 2009 JAN i. "
24 I
' 'C'9
,r.J\
IO? r.eIl.llflIlg aWOl

t Redside qlucosc
~
I
1/1.// / 1/1/l2
FvnCliGI
11m
1--
nM~
l1:MP , PULSE
Iat SAT
nME
TEMP
I'lIlSf
RiSI'
III'
IOl
t-----
I
I
~/ //
...a.
i~f1.1'\' 8\""I\,,"
//
SATI
ORlllO iTINlE
//
.///
:/'
/"'1
_LIIHCH
"'~\ "
i9
In.'oIV IV,::"_ ""'''''U
'1""
!},Iaken.
.l
ORA
~7.7
: fEE[ IHGlI
~('--LI\~
i1
I I
ltlJ' I U{/fl)
~/
By
0== n-q
STATIC
//
BP
tTIME
r
III'
p
Dtterlli<
l~fiu,
// //
///
~:,
,iI.
!
BehBYlo
HS SNACK
Quality
Frequllfl
mE
0100
~.
URiNE
VOID
IYPe
ORAl.
FLUSH
II
!
8M
OSoo
~.
1200 1300
..1400 1500 ,1600 1700
!
1\A.r '\
L...._
il
'-i..rIJ
'l'j.....
.--
~O(,..
'-
illOO
12 hr
BEI1A\
Sub Tola's
12 ilr tul~'
--::P2f1"Tj
-,~
I ()rffiitutl~
12 hI shl11 i n t i l x e . i - -
l-------
-~-----
12 hi sMt output
AN ~ AI f- ~ Bn 1- Illof[ D - (I~\
1ZlOO
.2300
llooo Lm.ll
.19110
INTER'
t
!
Ii/f)
If) Y()
r.
~/ 1i 'Llf }C
I
l.
2,
"
H~a.
Reei,
.=
3, Clvic.
.t
5 Ealae
I
eo".
A Fnco
.Mru!
.0100
7. ErW.,
. 0200
9300
I
'-liN
"~i)
~ oaoo
p~ttr Sub Ta1al~
121u tot~1 parenlera
-=- _
12111 1o1al UlavWl.I~ _
J-ti U ,~~ .{
nlJ
"'~'''r'1YW'
--
,lor shltt "l!U~O

"uul
I -I.e "h V - - - - -
. _ - - -12-slHlt -uulpU(
i"
Ii
UV
fLUID fOUIVALE,rrs:
401 (1/2 cup) .,. 120ml
10z ..... , 30mL
Ii m (3/4 cup) ... 1SOmL
lOUltl B 02 (1 cup) ....... 240mL 12 oz (~Dda-1 can) .. 360ml
'ft,,.,my"uu r lIIIur lolal

~I\
nr;M7 I
~Rl:J
DEPAUL. HEALTH CENTER
C4JC;SSM DePaul Health Center

lit t: It L f i t ,
A II; .-
HARCB, PHILLIP H 0902200197 BRoS 05'14-01
llillDflIIIIDfillftUII
I"
r!p
24 HOUR MEDICALJSURGICAL PATIENT CARE RECORD

DPM-l000071 (51200(1) PAGE 1 OF B
10/02/1976 32Y
SAT,Ej\1, MOUNER
01/22/09 OClO74ti298
Df'M-l00
000298
p3L~ IFe$eot Behavi,rs
lima
Raling Sr.or~
Observaton
/I
Scale Us-Hl or
FuacUOR Goal Ii
!)n~rlbe:
llIcatio1l,
Beh!vilH Qr
Qliailly Frequ8DI: I
3~dalion
.eJ1:1
BEHAVIOR/RESPONSES: AN - Am.1Du> Ii ~ EmO'lOflalUmUess I - '"a/f~AlY'i; Copmg o a Oeve-Jopmentallmpairmffit
R,,'lllOo' C - CoolltlUOuS CIY'1\j DE - D"IF~~'on
Q - GJ!8\'ing l letharg'BG
~ Mulh~'"
~ Ul1Te9p""'I,~
CO =Cum.tMe
CI ~ G<J<Jn~im Imra-wmant 1'1- Resli>iS&
CtI ~ Conlu8W1Dioo.ienled H " lIatluelnationti ()~lUsiQn& w ~ Oelibe,alely WiJhh?lding Info

/I.
os -
Olsr\'ptive
s~ Plly""""
S1etpmg
Si!l,,;f.mnl 01"",
T - nua"{fliflY 1M - ImPUI"''''
j
o - O.,.er~11t'f)u!aled!Oittr~a(jiv(:
=MentiOn Se<!k:mg
HarrrutJombalwe
Q ; CaimJOui~\ COP - Grope,alive LA =< l {Y.}:S AnXlOUS

0.1",.
f~t$
",. - OlSfuptlve ?alient
INTERVl:N110NS;
2 3
1 Rl'iIHII'i\fl<;e - t'.\Jan! I ::Il\lnih",,, ,I o.lll'! nedir&;l(On

G''';(!frio~
6
!}
j
Offer freCfJe-nt brief cont.a:-et ProvlOO Into,malll'" to i"Crease ,&Vel of IJn(f~.st>Ad1f19
Rem,,,,,1 / n~mO\lv"t.1 Re.Ilwr'9

DW'.;m;ional
Pffh.,.r,tiy{'
~OiNiti&3
m~aSUfe-9
1~
1ft
n E'lW'JIUI'lP. iafTlll'lIO Dr,,,," In familiar oiljecfs
4 Cons:!t tent E-rr':"oflment.' R~l.*"Q
., ~ijmi,;l1,1i malf\laIMalJiMI,W>\e. for car. ne~d, B Enc.:nu (lOr. v"am<1hZ-fHlcn

7 Encuu a~ fhl'h~nl
'Hidl n~n"Sif;m
ITlRkmg to.( cart
""""i
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tj Pm \<, ml.",tion Vl~h mu.II;, lm~gfff, d~ep txealhir>9. pra'iiL mroca!;oll 12. EnootHa&'e IJUfltlfl; ulrnp cyde by using lrvj~tllOhllno- a'l'1e-r Cark lJarken mom Ila-rminy k. 1./dl / Qll~t &.fgn ~o d-~faa6o patiflnl's (\;;'&PUfI:;if! tn ~timHJilfion
17. Rf'.a~tnSti I Rr.quruJMn f See-\! c.iaritC'.I1it)r'! 1l:l. EstabflSh Luutkladm;
l!/.
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to mm!ffia~ b~avlQHtf PfoblttrnB
~SSM
Ii' E' A L T H t~
II 11-

DEP.r...UL l-lEALTH CENTER
24 HOUR MEDICALISURGICAL PATIENT CARE RECORD
MARCH,PHILLTP H
IIllHllllllflllllll1II
Tip
0902200197 ERS D554-01 10/02/1976 321' r4 01/22/09 000748298 SALEf.1,MOUNER

DPM- tOO(}-071 (S{2000) PAGE g OF 8
000299
HOUR MEDICAl/SURGICAL PATIENT CARE RECORD
w
R
_ _ _ _ Langlh _ _ ell!
- ...
---~
... ---------~-----
~SSM e
'H ! A \ f H
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I
24 HOUR MEDICAL./SlIRQICAl PATIENT CARE RECORD
DPM\f 00-071 (5/2008) PAGE 3 OF' 6
000300
24 HOUR MEDIl"!AI
Use blllded key leJter " iOOICatell
1~IIRGICAl
PATIENT CARE RECORD

II
II
VAIl;
IIIKltV
JAN 2 q 2009 - "

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i
f.I Crvocuff re-l'Ald and on I_"~ "",ow '" p"" ITotal hip i knee Plecaullons
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.-
o Verified and in piace

I
0 Not applicable
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o Ven'tiert and in piac6 ....
tJ Verified and in piacB 0 NOl appilc.1~
ISOLATION: 0 Special Gont3r,j 0 Contllct 0 Nf.utmpenic 0 Airborne 0 Droplet 0 OTHER PRECAUTIONS: 0 SalHfyffali 0
INITIA~1 BlH~!lin!l
0 Aspiration 0 SHlzurH 0
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./ TITLE I SHIFT
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0902200197 10 /02/ ~976
~!AR~H, l?HILL I.I?
ENr JIIIIllIIl1rIlIIII P,R H lIE
3i~S
lip
SALE!>l,MOUNER
0554 01 M OJ/2.?/09 000748298
DPM-j'JOo-071 (S/ZOOS) PAGE 4 OF 8
30
,JAN, J 2009
DAlE STARTED
24
Peri
A-P W-1
'-S
(AbnonnallieKion, Extension, FlaccId, LOl:altzes, Nonp" Gok
\VIR
p-c
reiil!,
<lUn '
SPastic;, 51rong, W~IIk, WD-W'ilhdfllws)
tioot
~bn1)
Abnormal bn:ath sounds
TIME
Specify abnmTlal tneath sounds on dIagram, (Abserlt, Decreased, CRackles.
Rhoncnl, Wheazes, Coarssj
POSTERIOR
POSTERIOR
Abnormal re:;plratory eflDrt (}yspnea (on Ixeruall, at Res!)
o
"
DEPAUL HE}:>.LTH CENTER

~CH, PHILLIP H
1111111111111111
M
0902200197
1
HEALTH CENTER 24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

SSM DEPAUL
D?M,1000-071 (5/2Ow"8) PAGE 5 OF B
0 I n 2/1 9 7 6 32 y
ERS 055~-~~
I! P
0 0..1 .. ~ / 0 9,
GALEM,MOONER
000748298
DPM,
000302
DATE STARTED
241-l
--
A-Absent
W,W&af<
S-S1rong
D-Doppler
Color Wnp sansltlOI1

v.a fJ,;r 0.11 0*:
~ I$$$!l!i~
:'p
3 SOCOiId.: tat warm ",'lh ~ s:en'J.-J

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TIme
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TIP 0902200197 ERS 0554-01 10/02/1976 32Y M 01/22/09 SALRt-l, MOUNER 000748290
w. ,
DPM-100Q.{)71 [512008) PAGE \1 OF 6
000303
JAN ) 3 "LOOS
1 -
DATE STARTED
24 t
At.lHQIHI<II wioary Vllidino Ilatu:rn; InWlIin~IlL Frequencv, Retl1ntion, Urgency, DywrJa
If skin II>1\ll aJ!erah lOS iJ1,:licalB siles willl
nU~$
00 f'QUTes
ALTEIltD SKUI,lWOUNO KEY: PU = f're:;:;ull! ul(:", If preswre ulcer, liSt s~ I, II. In,
1\
11ft
BL = Blister
D E
EX
=AbraSion
Denuded - Erylilctlla
= BIUlsi;' = ~xcotiatinn
L
R
= InCiSIon = Laceration
=
Rash
IV, UNstageabla
v
H
= \I~scular
vlcer (VQIlOUS ,ta~"s,
altNi~1
= ileurQjlillhlC ulcc' (C1ab'~Uc)

Q "
Insutfldency)
TD - Tape bum WA - Well appfUxiHmle<J o = OthP.r

IJflIift~e Amu un!: IiC "SGaI\l
'" HClllllwma
SS
D
1,1f1-)
[fr.,,!
i
= Dr"'Mbotlll - Staples OTA = (li'l1' 10 ai, o R = Rlity,,{lOO SU!u;~S

s
DI
!lreHino: Sten slti~
WOUlId Bed K~I': Granulatkm

~ Olh~'
lkItroundlnll $iin Key; Draill,1Oe Type; I - In!aL! Q - Green

E = EfyO~,'I," '" - Myoel~n01\ C '" Cyaootic![mk
S
liS
S : SlouQit E - ESCMr
= SelO(Js
= SMOSJ!1(Jl1,nsOlit
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=Mor.tltalA
~ L.,~
Sm,ll
,I!,
U
TimB
o - om~r
= DIY ami inlacl = Mr'!1\gllf%fY ~~J~
o = OIhAt
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CD!>""'
o Yrntmllflt
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DEPAUL HEALTH CENTER MARCH, PHILLIP H

0902200197
10/02/1976 32Y
IIIIIIIIIIIIIOIIIIID
01
III>
O?M-l
" t .

DPM-1000-071 {5/2008} PAGE 7 OF 8
ERS 0554-01 M Qlln/o9 SALEM,MQUNER 000748298
000304
DATE
STARTEJAN L ~ 2009
Potential
prablM1
:>
No apparent 4 I prOblem 3
:"'",,+I-(}-r---t---+--j possible Fan Risk. If nursing judgment

differs from ~Ie ob1ained. document
IBason corle from Ilt below:
. ~"1f=~~~-l tt800m af S Dr gl'Gatar indiMiGfl
PtJSO EOllcatJor every 24' + pm
Uied 10 Avoltt /\e1l'RIM

C~n"Jns!lctMp~",~",
~
MEP'C!L Bruen fqr RtiWtinl I Pro~;:{'l an ~tif\C.jal iUWi.l'{ ilfal"W' O'ft'get1 !JcnltWV !e.g:.~ to
m$r~"t\
BJUJlW fUuFftU9!t
Q~..H1Y~1'::j 1m;; ..mi 1r.. ,rMf VZllfHl. >pot"". ole.)
Ida! RoJ,a! K,
(I ~
fA,
I iJn!lllla tQ CqntranlQf
~allty
\)",,,, ('( otb";nBIe I>o!til""",, fO' Ut.....1 r'ffi! I", iV, IU\c I
f-mln.lll.li~JqJ 1H'1niJ-~j~~bun" <<!Ii~Qhl.
IMolTatNeWlCUtllvlleS)
IIl:t:f.lJ rJljf'1t;':Il!.atil]o.
S~.{Xill
et<)
;iljl.-~q
R1;?ity(\"'J11~(jOl
2 f<.tllfi;J:n l'I'taSfi('"!r.es or ttlttr.s e-S~llb311!i It!e- tl'~.a!frwrn (l'fllw {llli"'" CW1t1( ,t\'lll~on (I.g . 10'.< S!laC1 c! J\lI!riMn. mea.tgtlOo a(lmln;S!BIioo OIl1fll'a~1)II1
SRf-d't u1 Pflknts will) GoT ~n;:8fac{atcd fm:n. an lruL1:l)' or shl!fc"i!l
p'~~4",e \I'M w00l4 lu"er 'I,l/t~ loy! II !!Ity naYe elteSSIV! {J\(t'ffiltn1 belCle i\ " meq,'~ll'i iliPlwn<.tt fe,g., Mil/lilt;
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1/1' MARCH, PHILLIP H 0902200191 ERS 0554"01 lO/02/1976 32Y 1-1 01/22/ 09 SALEM,1-10tn-lER ()0074B298
1IIIIIIIlUIIIIIIDft
24 HOUR MEDICAlJSURGICAL PATIENT CARE RECORD

OPM-1000-0n (512008) PAGE 8 OF 8
000305
DATE STARTED
1/t-1.) [J 1
24 H
Time
Rallng s( SCalt U"

ObUf'IB!
~edsiOe
glucose
ftll\~tiOn
nNE
TEf41'
I'UlSI
1181'
81'
02~AT
TI~
TEMP
PULSI
RE~P
8P
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/ /
I
L)Ul~1h
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LocatlOll,:
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.......
//
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....U\I
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~ __ ~_~_+ ____~/~O~i[~)~_~__~____~~~__ _ ~, J-..:l~40{)-+-_ _ -+'---------1i--_-!-\.).......-,-'{r)"--h_'if/-f1Lf-t.l-l----__ ..1500 .. _ -+----t---\-:;-o;:-r:~l-=(...A\'---'-''-t''-+---_-+_ _+-_-+-__ _ 1600 1;.....\( '\
1008 1100 ;~~
' '\l1J
1800
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BEHAV
AN - Ai'
E~{;l(){
fntlfE
D. De'.'
'900 2000
INTER'4
1.~1
2. R9illl;!
1100
1200 2300
010 02110
W"-I( )
3.
4.
G,ikll
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IJ / 1'I'V II , I ---4---~i--~~)~~V~--_+--~~U~~-A~/~__ 1
0600
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TwnenlY-IlIllr ho~lolill
- I- -...,.-0 U
~
I I I () 0
\
fW1D EQUIVALElrTS;
4 Ol (1/2 cup) , . , 120mL
1 02 , , , , ' , 3(lmL
6 ox (3/4 C\lPJ .... 18{)rnL
8 oz (1 cop) _, . , " ,240ml 12 Ol (s{)dlll can) , 360mL
DEPAUL HB:ALTH CENTER

W\RCH, !?HILLIP Ii
os ..
"
~SSM
H l A l 'f H . ( A " Ii-
1011.'111111110111110
ERS U554-01
M
IIP
01/~2/09
OOO-!482'1B
0902200197

DPM-l000-071 {!.!2000} PAGE 1 Of" a
10/02/1976 321' SAl,EM, MQUNER
000306
DATE STARTED
1 MedicJ.tiQn 2 AmbulilliQn
8 HB<l1
17 Epidmal
10 ~Id
f8 peA
3 Reposition
11 Music
12 Touch 13 IIIIU!J'lfY 14 Massage
, & OiSfr,1cti(l11
19 Preemptive
,1nal1l~J
APP'.
ASSltma pain Ilf6;8111
4 f\ol;,l)(ation 5 Ca\rni~ Statements I> Prny~r/MRdit~ticm

7 Spiritual Cale & Deep BreathinQ
20
CUllljmlUus
Bcllawurs
::u Other'
analgesic Infusion
HI Education
Time
Haling Sec fe #
8cale Used 0'

Obt8Mfluo
FuncUlln GQ~I #
Ouclios:
lOt31iM,
B~hpYiQr
or AI'P
StdallOll hve! Inlervention!$!
8El1AVIORjRI!SPONSI!S:
M -
MUil!p~ >l~ueSl
U == unrespOnsfv&
CD - Conluse!liVisone,.,;d
os In!c>
1M
Di+ruPliV1>
s -
5Ie"pjn~
AN", Am 0:'1;
e=
Ernulhma.l
D~;llH-.'i'l"i
C - Contm<iOU~ Crring DE ~ D,II~WC"

G ..
r..r4~",i,":g
CO - Comatose
CJ .. COQni'ir~i' Impuifmenl R = Re3~e5.'
H "" Halklcmallcmi OelVSl0l15
w=
!l;gn1f.cwl Olh~[
T = Thr{1&t(l'nlng Pnv-sk'al HEI:!m/C-omooH'r'e:=
o~n""re.'e''I WI!l>l>ol<!ln,~
Q i i CalmlO'MI COP = CooperaliYe

LA =(}fhr.-r
~ m~!lethCapng
Q - Vfl'l'~i Jpm1i.phtllmp~Hment
L - '..emarQ'('
o - Ovelsti-mt~ruoof-o;e:reocliye
Uff6f {la-quem
bn~l
A = Attention s...l<ing OP .. rr.Sf"'Plt~ P.n1<p.nt
le~"J An:tiQVS
!fT\p~t~ve
! ~.
INTERVE NTIONS: ~:~:~Il~~e. ?al>en{! ~:HV!ljb(-dnl o~rltH

10 11
contact
14
H~OMn\ i
ftamo1lVat. t R&Si~l'-<9 I'Cl~

f.>~ek
PrOlflO& ;nf-O-~lI<ahon 10 ;ncr~Me ~'1-et of
l.1nOen:tanOIfl9
;S. Oo"'an~e
4, Ccn-s-iYent En\'-irOM,ent f Rout!:ne S E)litblil,h rnwn!~ih~ I\me/rari\til IOi t~~ n~to; 6. EIlOOUHge Ye,t>1!li,,,,ion
7
FnOUl.ff~"l
1(>
13
EnoouraQ6 famlf't 10 wing in familiar objec~5 Provide relaxation .,nit 11\\1$"" im~~ry< d~~p b,eaihmq, prayer. mMicat",n Ei\6bi;;ge MifiitJ SiMP eyCle liy u!Wig IN!ifeCl ~ghfJijg fi~'j ,lfiik
Darn-an room i LlmHing 1CU{fll Oil~nt !;jun In ti'!l!fl~m pallnrlfH' r~~'lOnl{H hl ~;l.lI'nLilalJ(}Jl
1!J, tt; 17 1ij 1(1
Ol\teisicnat act\\iIttes
neassea, / neqvestQf' ! E.l.o 1i IiooMi\iI8
Pro-actNe Illeitsvr-es
!jo-ilication
pil1ienf with cWci-a;iOn milking fnr cnTn nnr:rls
Pr{llJldQ imen:!1lvo ~1}('.urny ~nrt ~nlcly mOO$~t'r.~ Iv HlU!IHI4-TH ut!lla\tiUfHI J-l,uillems
'.i 'j
~SSM
11 E Ai t T '" . ,
A R I'"

DEPAUL HEALTH CENTER MARCH,PHILLIP ~
090220019<{
Z4 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD
111111111111116 54-01
ERS
11 p
sALl{H. I>'lOUN1!:R
OPM100)-()71 (512000) PAce 2 OF a
lo/02/19~6 32Y
~S 01/22/09
Q00148298
000307
sc
24
OIsg.
Oat~
+ SIlo #3
I1\smo
DM~~
",l)} ~\.. -iOC~W_kIn~-oI. J-R_I!1_HT-, S_L

" I l-_fmJi_CilI_f
BACK
8ACK
_{ D .... L_'_TLC--l_ _ _---L_SL_I_D_L_'T_L.,.;:C-L-_ _ _..I..W _ _ _-I
I.J VU~,
.,
\\\
\~, \
WNlWIeDfDWd.d
T ___ V
In:;ertioll' Date _ _ _ _ Length _ _ em
Dressing change datll _ _ _ __
Arm circumference
em
PATIENT LABEL
~SSM
H E __ l - H G
R
f"
;!4 HOUR MEOICALISURGICAL. PATIENT CARE RECORD
~J!I~~~~"~~ll'1
0902200197
10/02/1976 32Y

ERS 0554-01
I/ P
M ul/n /09
SALEM, MOUNER
DPM-l000-071 (512006) PAGE 3 OF 6
000'148298
DI
000308
~SSM
H I< l T ... ~
A R
~.

~~CHfPHILL1P
H lip 0902200197 ERS OS~401 10/02/1976 32Y M 01/22/09

SALEM, MOUNER
OOQ7482~e
II I 1110111111 Imil IUml
DPM-1fOO-071 (512006) PAGE 4 OF 8
000309
~4 HOUR MEDICALISURGICAL PATIE~~.:!RE.~~:ORD

I
DATE STARTED
2.!
I,
Ap
Ab
Pal
Pel
A W'
5'
D
Co
WN f;!i
~ld~
ti"lfl
aM
Sa
TE
TE
SC
se
Abnormal b'ealh sounds
TIME
Specijy abnormal brea1h soon(/s on dia9[am.

(Absent, D ~croaSed,
CRac~jes,
Rhonchi. wheezes, Coarse)

~b
Abi
POSTERIOR
80 60 At
Lal
Fla
SI(
Nt
B!
Ttl
Os SI(
511
NI
Oll
Os

~~CH,PHrLLJP H lip 09 02200197 "'RS 0554 -01 10/02/1976 3 ~2v Sl\LEM,/I1UUNBR. M Ul/22/09 0007482;18
DPI
1111111111111111111
SSM DEPAUL HEALTH CENTER 24 HOUR MEOICAUSURGICAL PATI~NT CARE RECORD

DPM' 000-( 7'1 (5/2000) PAGE 5 OF 8
000310
DATE STARTED
241
lI1l!ec
lmlli
Urine c ,ouI-S)
Yll1dr\
SWfiI
Foie'y U
Abilolf
FrMuf
Cal (dl
Color temp seIHa\foo

WNl - /Iill toed pirl;; C;\lJ ~-l ~iS tMn" 3 j!}t ~~jll.t. stiIt...rot mfllull'ln..-
Ullal!i1.lI.O'.1cril'1
a'D~II\II'IIlct6,.
8 = NOlIe T = Trace
TIn
~SSM
M &: A
~ j
ti
A II IE"

I'IARCH I PHILLIP H
IlIlIUlIlIlIllIUlflllR
ERS 0554-01
rip
0007<18298
0902200197
BALm,!, fIlOUNER
10/02/1976 32Y
24 tlOUR MEDICAWSURGICAL PATIENT CARE RECORD
M 01/22/09
o
I
DPM10Q0.071 (512008) PAGE e OF 8
DPM
000311
L4_L_/~"IL RGICAL PATIENT CARE RECORD

..
DATE STARTED
FA
Ani
Hi\!
AlII
An. An' Alt. ~~

Dla
13\11
pal
YE>~
Ant
Bel
~LTERO
SKUf!W{)UNO kEY:
~wssur~
A
BL
pu- Pressure ulcer

11
V
~ ~
ulcc!.
~st ~\a,-e
I, It. III,
ar\eriai
IV, UNmgAilhlA Vasculat ulcer (v~nQU, imiufficiflncy)
SR D
sl;,!si~,
E
EX
= E"(t0fl31iOr.
= Hematoma
= 8li~ter = Bruise = f}enljd~rJ = E[)'f.1ema
A!Jr,lSIOf\
I
L
= IncIS"'''
R = Rash TB Tape hum WA = W~II aPliro~imHt.d
= L~r.9r~tinn
Allf
'" Other _ _ _ __
!JrlljnU\J~
Neumllillhic ulcer (di.b\!!ic)
f } \ , \ff-t ! i i
t,..:'
I):~
~)
nrl
'
i, "
DI1I~no: liS = SIan 5lrips
D
B
=Dernubood
ll"tenllQf' MUles .. Ory arnl ill!act
Mqnlll.~nllry
o = BfiUMJatmn
S = SlOugh E ~ i':'1..f'.n;:u
WDUlld !fEd Ite,(;
Surrounflao Skin Key; Oraiaag:e Type:

I = Inloct E - Erymema M = Ma(;erati(HJ
=lIUpI."
=
sc G = GmfJl $ $ - Sero\Il S . . . SNos:t.HQtHneous M

PU .. f>tIruiern B ~ 8!ouJy y = VilIlcw L C
Amuunt:
&-;JI)i
5m3Ji
~
Modc-ra\c
OTA=~to~r
0 - 0\I1e<
II DI
C - C\'a!101icJDari; Or Olh"r
- LalQE
;; Cwkl!JS
Wilil'
Other
o
T'Dlllmanl
G '" CruSl'j
~.
Olher
Flu
Time
Alt./Vd W d 1,1111 Nt!. UllllWeun6 DlGttm~ oun
(TSU9')
lied
IQ;ulYOullcllng IV
Odor
YIN
Indkates
Rmni~!!1'n!
Toi
No ChanlJe TIme an41nitlal,
~ \ (
2 (
~
! ,
4 I 5 r
6 i
7 I 8 , 9 ,
Fh.<i!
~SSM
If E .. I.- ,.
t4
C- A 1\ i
DEPAUL HRALTH CENTER

I"lARCH I PHTLLIP H IlP 09022001517 ERS 05::''4-01 10/02/1976 32Y f'l 01/22/09 SALEM I MOUNEK 000748296
IlllJIUllllflilDlJl1lI
24 HOUR MEDlCAUSVRGICAl PATIENT CARE RECORD

DPM" 1000-071 {5/200B) PAGE 7 OF 8
DP
000312
Skin AllSk .ijCOff<: 10.810 then 16 pllt!iIf}tl61lt risk Follow ~Kin Care Prmocol tor score I<!~; than 16. (Pust p,otocOl at CW,\oo.j NutllllOn31 conSlAt (if no! pr8vinus!y obtaln~d.j SCQr~
,...J;:;:::"'-+-":;;:'"'--oi HSOOftJ of 3 or greater indicat88

- - l - - - f - - - l po~lble Fall Risk. If nursing judgmarrt
~~------~--f..--l--+--4~--l
o fall Pr$vllBlIon information

III,et revl~wedllalnfQn;lXt
dlffers from score oblalnvQ. oocument -f---!----+--l----i reason code from fit;! below:
n Fall rIsk bractllelln placo
~J.lnf It Avgli RnlrJlnl 1 ~nonsMI'i$..,p~c,isi<m

C~rr~'vTW,t(JlJ;crw'lIj~lP"-tIJ1
Jr.",,,,,,, ..JItol fl""'~1i""~,

Ctlill1/,l. en:)
~.~! fjr!
,"""-'Io<fl. ItfllG.) VIR.v lHIr"as ">IUi. SIlI!cta!
'100" 6'1'90 l2! RHUlin! Ptotett u amffti9l a-lTway a-lldiur U.Kygf,'lI tkWi/j.lJ (e Q' to m.i"lain ~OOov;u:ha..'IlmI!alI!liIle~)
Maiillih IlWiWlIm.. "' lul,,'" """"".~ to Ii.. Ir"arm'" OlIn. pali~ ClJ(rn! cOOdiIi<ln Ie,} .. s~~ source 01 nu!,""!!.
rm<litallOn
a&n<lISV~ll'Jn ! n1Qml~)
Rmlmia' EducaJloo
mat BeJel" Ko,

1
UnilhJ~
DocumllflltinlCilfl'a""fIl' {i". pl..

(laIent ~OllSe. e\I;)
hI f:rmhar.t too sat;t'"!
\) in ed\KlI~{)fll)oJ; i~icales IQl1owi.oi

ltffi"n.\ dis.-rus56d ...... !#i !ell'Mt,
I Rr';;\WJi fru ut<;1f3-.ifd" '2 Assessment wne ft.W~~i
Z
3: 4
~\. to
pul a1 loOtl. ~ .."
~t,.
Artivil)' {~Il(ltM;d&;; f~ ~ ffi:llJiJri

Atwl~
10 rffi'lCHe ~res~1, stmlf." ck
-rt'?;Ju;*inn
Ur~"~M;tl a(Jr~-gy
{b.xn..t-s. wltos. waL~s. mu~~. de.}
Safety of p~tkJ'fii woo arc 1rn-.f.{J\wltrded IIMl an ii~Jlr'i or SUCij%li pro;;ell\!l~ ~1\(l WIl'Jld S\lfWf tu!l>1'1 inil'ry illhc,/I.JVf, ."',,;;"',.
J Tria! rtl.ase Irr;'!ucIl<Y

4
eell~',*
rj)a{l~iatl\-"B 2fid r~stn.int f6ffi{ive-o
reqwtd for femQwl
Of Mrm to setf Of o-lhe(o; {s.ct' BuoaV"tvr,li

Re;;lnil~')
P_'dfllily'<loc~iGf'
m<lI'M'.enl t~lIIe tt ~ mmaiy awoprtalB t~ .. ewerrvty

~
a IW flir,JilI!S;w ~lee,~t.'>eit'elt.t"1 be~ 9 ____________________

~~:
____
~a""m; III ,,,scular SlJrI"",a&) .\ ~f(itCltl;e trw ,"jUry pJl;t,llllom filI1li<I

jl.1falr<is '" Il8aO ItAIlIllJ
W IOf\S\l'lWn
!t~rtltan
"iPv 1M. eVA wlUI ".11\ Jddil~nZ1 ~Mlu)
0 nH~VIORAl A[STRAINU: ~.. '<l<l'",",iI""''Sh,'' 1o.
OUr,! (feqLil1ls namtN~ dl)<lJmcrlrrt;VIl)

N Pi;l<~f,-d
llP1J
to flUmtiw !l1OltatfS ttasOfl

"",i
~SSM
1'1
E A L. T tt .
I; ,.,
fi E"
DEPfl.UL HEfl.LTH CENTER

MARCH,PHILLIP H
09022Q0197
IIIIIIIDIIIOIIIIIII
ERS 0554"01
f>1
lip
Ol/:J~/09
24 HOUfi MEOICALJSURGICAL PATIENT CARE RECOfiD

DPMl(QO.071 (5/;:>008) PAGE B OF B
10/02/1976 32Y SALElvl, MOUl'lER
000748299
000313
DePaul Health Center 12303 DEPAUL DR, BRIDGETON, MO 63044 Tue Jan 27, 2009 05:47 am
Di9Chal'ge Cumulative Trend Report from 01/22/09 0300 to 01/23/09 1045

'ent Name; {'. Rec If: Dis Date Phys-Selvice:
p
MARCH/PHILLIP H 000148298 01/26/09 S~LEMJMO[rnER EMERGENCY
Ad~~
HEMATOLOGY-Page 1 01/22/09
903693 903572 917259 BLOOD CELL COUNT/DIFFERENTIAL

Result~
Platelet
Hgb
I
I I
Ii
Het
RBC
t1CV
; Low Refer: High Ref:

01/23/09 1045 01/22/09 0300
Unit~
lQOO/mmJ
130.0
400.0
gm/<J.l
13.0
1
39.0 54.0
lOXQ
4.7
t:l
80.0 99.0
211 282
18.0 I 6.1 I I --~------------------------------------------------I 13.4 14.0 40.6 41.5
4.77
4.96
i I
B5,1 83.7
BLOOD CELL COUNT/DIFFERENT!AL,
uui~!~:
01/23/09 10451
01/22/09 03001
~t~;
.J~
Low Refer: 25.0 High Ref: I 31.0 _____________________

28.1 28.2
32.0 11.5 I 4.5 I 36.0 14.5 I 11.0 ______________________________ _________________________
;~7~1
I
I I
RD~ -~l:o~~~m3 I
I I
5.3 6.8
I
I I
;~~~/:~~
l'
1
I !
33.0 33,7
14.4 13,9
BLOOD CELL COUNT/DIFFERENTIAL ..
~~~~;~;
L(lw Re fer: High Ref:
Gra~
40 ' 0 70,0
Lymi h
Mon~
I
2 .0 10,0
EO:
I
0 0 6:0
Bas~
I
I
I
22 " 0
qO.O
0 "0 3.0
-"------------~------------------------------------~--~--------------------I 01/23/09 1045 48,7 i 39,'1 . 9,3 I l.S i 0.8 I 0- ":,2/09 0300 53.4 I 37,1 8,'1 0.7 I 0,4 ,
"BLOOD CELL COUNT/DIFFERENTIAL . . . .
Result:
RRC Harp
I1BC Morp
plt Est
Aba
Neut
1.8 7.7
Ab Eos
units:
Low Refer:
lOOO/ntm3
1000/mm3
0.0 0.5
High
R~f;
------1
01/23/09 10451 01/22/09 0300
2.57 3.62
I I I I
!
t4ARCH, PHILLIP H 000748298

Alexander
k'
B~bich,
M.D.
""k
DO NOT DISCARD
,charge C1.1mulati ve Trend Report
Dr.
(N-IO/02/76l SALE1<T, r>10UNER
000314

12303 DEPAUL DR. BRIDGETON! tvlO
63044
Tue Jan 27, 2009 05:47 am
DiBchaz'ge Cumulative Trend Report from 01/22/08 0300 to 01/23/09 1045 MARCH, PHIL[,IP H 'ent Name: HE~~TOLOGY-Paqe 2 000'/48298 Ad'll: 01/22/09 11. Rec #: 01/26/09 Dis Date SALEM I 1,IOUNER - EMERGENCY Phys-Service;
p
Out:
903693 903572 ~1725~ In: 01/23/09 1138

01/23/09 1223
----------------------------------
SEDIMENTATION RATE,
I'IESTERGREN
Spec: Blood
Techs: V - if/T Tf'4VI LLD
ColI Time: 01/23/09 1045---------------------------------Order Phys: SALEM,MOUNER lA0902200197/4665606] Result Name Result Reference Range
Sed Rate. westergren (mm/Hrl :
NARCH,PHILLIP H 000748298 Alexander Babich, M.D.

ry~
NOT DISCARD
**
,charge Cumulative Trend Repol:"t
(1'1-10/02/76) Dr. SALEM I MQI,JNER
000315
DePaul Health
12303 DEP[\UL DR.
Centc~
Tue Jan 27, Di8ChJxgo Cumulative Tn~nd R@port from 01/22/09 O]OJ to 01/23/09 1045
r
',ent Name: MARCll, PHILLIP H
BRIDGETON, l'<IO 63044 2009 05:47 am
CHEMISTRy-p",ge 3
Rec #: Dis Date Phys-Service: 90369] 903572
000748298 01/26/09
SALEM,MOv~ER
91'!25~
Adm: 01/22/09 - EMERGENCY
.ROUTINE CHEMISTRY.
lPotassium IChloride C02 GPR I I mEq/L I mEq/L mEq/L ml/min/l .73m2 Lo..-, Refer: 75 ~37 1 3.6 I 98.0 22.0 110 115 I 5.0 I 107.0 30.0 I High Ref: -------------------------_._---------------------------------------------------,i Result:
lJn,i~~;
"Glucose m:l/gl
Sodium
mEq/L
I'
01/22/0903001
74
LI
140
3.7
100
27
75.5
ROUTINE CHEMISTRY.
l1e:
BUN
Creat
Calcium
Phosphorus
1. _ s: Low Refer: High Ref:
--------- ------------------------------------------------.--------------------1
16
mg/dl 9.0 20.0
mg/dl 0.8
1.:'
mg/dl 8.4 10.2 9.5
mg/d.1 2.5 4.5
I
I I
IYlagnesium
mg/dl 1.6 2.3
I I
i
01/22/09 03001
1.4
I !
ROUTINE CHEMISTRY .....

I ..
It ':'
Anion C.:\p
CA/ALB
Vnits:
Low Re[e:c:
High Ref:
I globulin I gm/dl
p../G Ratio
BUN/Creat
-------------------------.---------------------------- -------------------------1 01/22/0903001 12.8 I I I ! I

---------------------------PENDING TEST "-.----------------------------
End of Report
!'lARCH, PHILLIP H 000748298
Alexander Babich, N.D. ... DO NOT DISCARD ** Jcharge Cumulative Trend Report
(t'I-IOj02/76) Dr. SALE"'1, MOUNER
000316
DePaul Health Center 12303 DEPAUL DR. BRIDGETON, I-m
630014
Tue Jan 27, 2009 05:47 am
Disenat'ge Cum
:ent Name; Rec #:
Il'\~ompletp.
Work Listing from 01/22/09 0300 to 01/23/09 1045

Page 4 Adm: 01/22/0 9
MARCH, PHILLIP H
00074 8298
01/26/09 SALEt1, MOUNER E1>1ERGENCY
Dis D.;tte
Phys-Ser'vice:
903693
97~803
903572 917259
Collection
Ac(;t;ss.lon Number
Test Name
Spec Type
Da<;:e & Time
StatUG
A***".* ***************************W**************** **ttttt******************
All other lalJ work has been complet.ed Final reportl * **.*******************************.************.******** *********************
..
*****.*******~*~****.*
End of Report ********.***.***********************************'*******
MARCH,PHILLIP H
000748298
Alex~nder
Babich, M.D. ~O NOT DISCARD ** JChal-gc Cum Incomplete vlork T"istlng
(l'-l-lO/o2/76) Dr. SALEM, r10l,;'NER
000317
l'lARCH, PHILLIP H
Room:
O'-'fc:
58- 0554 - 01
EI>1ERGENCY
Phys; SALEM,MOilliER \-u;:sul t name

End
LABORATORY Pat #; A0902200197 Collected: 01/23/09 1045 Accessioned: 01/23/09 113B Completed: 01/23/09 1223 Result
of Report!
TEMP
Birch Date:
V-WT
[4665606)
10/02/76
TMVILLD
Spec. Type: Blood R.eference Range C-15
sed Rate, WS9tergren(mm/Hr: 1
*FINAL
~OJ69~ ~03577. ~17259
SEDTfIfENTATION RATE, 'ilESTERGREN
1/23/09 1223
He
000318
!llARCH 1 PHILLIP H
Room:
prvc:
53-0554-01
EMERGENCY Phys; SALF.M,MOUNER ~~dult name Result

WBC(1000/mm: RBC(10X6) : Hgb(gm/dl) ; Hct{%) :
5.3 4.77
LABORATORY TEMP Pat U; A0902200197 Birth Date: 10/02/76 TEVANCE Collected: 01/23/09 1045 V-WT Accessioned: 01/23/09 1138 14665606) Completed: 01/23/09 1152 Spec. Type: Blood Ref Range Result name Result Ref Range
4.5-11.0
Baso(t) ;
0.8
0,0-3.0
4.7-6.1
Manual DiEf:
Absolu(lOOO/mm:
Not Indicated
2.57 1.8-7.7
13.4
10.6 85.1 28.1
13.0-19.0
39.0-54.0 80.0-99.0 25.0-31.0 32.0-36.0
11.~-14.5
MCV(fl) ;
f.1CH(pg) :
MCHC (gm/dli :
RDW{%) ;
3].0 14.4
211
Platel(lOOO/mm:
Gran
(~)
130.0-400.
Lymph (%) : Mono (%) ;
48.7 .39.7 9.3

1.5
91725~
Eos (%) : *FINAL 903693 ~Q3572

~vom;
40.0-70.0 22.0-40.0 2.0-10.0 0.0-6.0

CBe 'tJ AUTO DIFF
01/23/09 1152
TEt,!P
rIC
LABORATORY
C'H,PHILLIP H
58-0554-01
EtvlERGENCY S rye:
Pat #: A0902200197 E!irth Date; 10/02/'16 CollecLed: 01/23/09 1045 V - vJT TEVANCE
Accessioned: 01/23/0'3 1138 (4565606]

Completed: 01/23/09 1152 E;pec. Type; Blood Ref Range Result name Hesult Ref Range
Ord Phys; SALEM,MOt~ER Result name Result
End of Repol.-t ~
~NAL
CBC W AUTO DIPF
01/23/09 1152
903693 903572 917259 HC
000319
Department of Radiology
INPATIENT MRI SAFETY FORM - PRE-SCAN METAL SCREENING

.... Contact MRI (314) 344-2778
Last
Nama:tJe<. V-L..--t"-'/ d
First Date ot Birth:
Today's Date:
~/O 1"
Nam.:~'J kl,\ if
/'0 -;) -
M.I. _ _ Height: _ _ __
Weight: Sex:
/t.
J"V'.:
This section is to be completed by the nurse.
No
~
Yes
1. Has the patient had an Invasive procedure since filling out this form?
2.
Does the patient have a pacemaker IICD?
",./
3. Does the patient have a sandbag?
1.
Have you ever had surgery or any similar invasive procedure? If yes, please list:
}[NO
__No
Yes
~pe: __------------------------------- Date: __

Type: _ _ __ 2.
Have you ever had any previous MRI Studies? If yes, please identity: Part Dale FaclillylLocation
--- ~ Gt3.
!y
_ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ _ _ _ __
v(.s
~ _ 'Je'CVl
\'
Of
J"V
__ No __ Yes
Have you ever worked with metal (grinding, fabricating, etc.) or ever had an injury to the eye involving a metallic object (metallic sliver, Shavings. foreign body)? If y~. please describe: _________________ ~_ _ _ _ _ __ Are you currently taking or have you recently takenany~Qjcatlon7 If yes, please list: ~ i--re...d .\" t ~
Do you have anemia or any disease that affects your blood, a history of renal disease or seizures? If yes, please describe: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Do you have any drug allergIes? If yes, please list: ______________
4.
5.
Yes
6.
JNO
~NO
Yes
7.
Have you ever had asthma, allergic reaction, respiratory disease, or other reaction describe: _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Yes
to a con1rast medium or dye used for a MRI or CT examination'? If yes, please
FEMALE PATIENTS
8. 9. Are you pregnant or experfenclng a late menstrual periOdl;d' _ _ _ Date 01 last menstrual period: ;/Ar/ro ast fSiJding? reatments?
No
Yes
No
Yes
Yes
10. Are you taking any type of fertility medication or h
WfetJUty
No
DEPAUL HEALTB C~NTER

l-tARCH,
INPATIENf MRI SAFETY fORM - PRE-SCAN METAL SCREENING
DPM-4201-001 (10!2005} FRONT
111111111111111111101 PHTLLIP H
liP
[OVER
0902200197 ERS 0554 01 lO/02/l976 32Y t.1 01/22/09 SALEM,I-10m~~R 000-/48295
000320
Some of the following items may be hazardous to your safety and some can interfere with the MRI examination. Please check the correct answer for each of the following:
_Yes Yes
~Yes
Yes Yes _Yes Yes
No No No No No No
No
No No No No No No No No No
_Yes __ Yes
_Yes
_Yes
~Yes
_Yes Yes Yes I_Yes
Cardiac pacemaker Implanted cardiac defibrillator Brain aneurysm clip(s) Carotid artery vascular clamp Neurostimulatof Insulin or infusion pump Implanted drug infusion device Bone growth/fusion stimulator Cochlear, otologic, or ear implant Any ~ype of prosthesis (eye, penile, etc,) Heart valve prosthesis Artificial limb or joint Electrodes (on body, head or brain) Intravascular sIems, filters or coils Shunt (spinal or intraventricular) Vascular access port and/or catheter
Please mark on the figure below, the location of any Implant or metal inside of or on your body.
Yes
No
SwanGanz catheter
Any implant held in place by a magnet Transdermal delivery system (Nitro) IUD or diaphragm Tattooed makeup (eyeliner. lips, etc,) Body piercing ';~~ Any metal f,agments Internal pacing wires Aortic clip Metal or wire mesh implants Wire sutures or surgical staples Harrington rods (spine) Meta! rods in bones Joint replacement BonelJoint pin, screw, nail, wire, plate Hearing aid (REMOVE BEFORE MRI) Dentures (REMOVE BEFORE MRI) Breathing disorder MOlion disorder Claustrophobia Anxiety
No Yes No Yes Yes No Yes ...i=-Yes =No No Yes Yes No Yes No Yas No Yes No No Yes Yes No Yes No No Yes Yes No No Yes Yes No Yes No Yes Yes
..v
Before your MRI, please remove all meta/He objects, including keys, hair pins, barrettes, jewelry, watch, safety pins, paperclips, money clip, credIt cards, coIns, pens, belt, metal buttons, cellular phones, beepers, pocket knife, and cfothing with meta/In the material.
Other:
Please explain:
during the MRI examination. __ Physician
~~~is
""'
are required 10 wear earplugs or earphones

~ Other
STAFF SIGNATURES:
-iltL{!t{t4'LLlLM&~~-;JJ"M
Nursa
jRadiologist (Metal Approved)

Extension it
~~~M-
PATIENT LABEL
INPATIENT MRI SAFETY FORM 1'~.sCA."'I METAl. SCREENING

OPM4201Q01 (1012005) BACK
000321
PATIENT BELONGINGS VERIFICATION LOG
Page _ _ _ of _ __
-~
ORTHOPEDIC DEVICE 0 None 0 At home Q oan~ CJ W'k~r Q pp~~!!W{!i
ORTHOPEDIC DEVICE 0 None 0 At homo Q Cww g W~!~~r g PfQl!t~!PjlJ
JEWELRY (DescriptIon)
o Watch
o Ring(s)
o Other:
o Watch o Ring{s)
o Other:
JEWELRY (Description)
0 None
JJ::WELRY (DescriptiOn) DWatch
0 None
o Ring(;I) o Other:
o Sant to Security
CLOTHING (MUST write description)
o SMt t~ Security
0 None
o Sanl to Saeurlty
0 None
o Hat/Scarf o Coat/Sweater
9 6liflperS/Ro~
~5fSIa(lk$
14 Shltftl?louse
d<Underc!othes
Stockings/Socks
o o o o o
CLOTHING (MUST write description) o HaV$cart Coal/Sweater Shoes Stockings/Socks CJ SlJpper<lfRobe o Pantl;lSlacks Shlrt/Blouse Underclothes
o Haf/Scarl o Coat/Sweater
CJ Shoes
CLOTHING {MUST write description)
0 Ncne
o Underclothes
o Slippers/Roba o Pants/Slacks o Shirt/Blous6
o Stockings/SOCkS
o
o
phon'! .J. Laptop computer Olher
VALUAIU.ES (Descriptinnj
o No 118
OTHER VALUABLES (Description)
o Cell phont! o laptop cnmputer o Other _ _ _ _ _ _~~
0 None
o Other
o Cell phone o Laptop computer
OTHER VALUABLES (Description)
0 NOM
ITEM (5) SENT HOME

-~---~-----~~----I --------~~-----
SENT HOME
_~~__
o Sent home with _ _ _ _ _ _ _ __ D Sent home \\f~h _ _ __ o Sent to Security _ _ _ _ _ _ _ __ o Sent to Security _ _ _ _ _ _ _ _ __
o
HOMEM
o None
HOMe MEDICATIONS
!J None
8ent home 0 Pha.rmacy
Sent home 0 Pharmacy
None
Sent home 0 Pharmacy
PtJ1amlly assumes final responsibility for belongings thai !lrB broughl 10 hospital
o PVfamily assomesnnal responsibility for

belongings Ihat are brought to hospital
!J PVlamily ~umes final responsibility fOf belongings that are brought to hospital
StGNATURE OF PATIENT / RESPONSIBLE PERSON UPON ARRIVAL I DISCHARGE:
SIGNATURE OF PATIENT f RESPONSIBLE
SIGNATURE OF PATIENT I RESPONSIBLE PERSON UPON ARRIVAL f DISCHARGE:

..,,,,,,,,"', vr,LO OF RECEIVING STAFF MEMBER;
SIGNATURE OF RECEIVING STAFF MEMBER:
TIME:
RECEIVING ROOM #.
TIME:
RECE1VING ROOM If'
COMPLETE A NEW FORM FOR TWO DR MORE TRANSFERS AND FILE WITH ORIGINAL KEEP AT BEDSIDE AND PLACE IN DISCHARGE SItTiON OF CHART.
PATIENT BELONGINGS VERIFICATION LOG SLM1000-073 (lV2007) FRONT
000322
TRANSFER CHECKLIST
INITIAL IN DATE COLUMN WHEN EACH ITEM COMPLETED If Item Not Appllcabfe, record NJA In box. DATE DATE
DATE
From Room II
If transferring from Telemetry Remove monitor Enter transfer Into computer Make sure that labels are placed on all documents in the chart at time of transfer Communicate daily and pending labs
i--------------------------t---~----------
t-M_e_Q_ica_tl_on_RQ_C_Qo_C_iliat_---'_Qn_C_Q_m_-P_'el_eQ _ _ _~---------+--------t-----t----------~
Place MAR, Interdisciplinary Plan Qr Care/Care Pathway, & Education Rei:ord in chart
f-------------~------------i--------l---------
I
i
!
I
-- - - - .~--+'----___j
f-------------------------------+----~-----+----
Place today's 24hour record and all bedside flowsheets in chart Place Wound Tracking log In front of chart
I----------------~----------+---.---------+:------
.-----------
(0(\ front) and place at bedside i I f - - - - - - - - - - - - - - - - - - - - - - - - - 1 - - - - - - ., ...- j - - - - - - - - j - - - - - - I
Complete Patient Belongings Verification LOQ
I-t_a_ke_a_n_y_O_ld_c_h_ar_ts_o_r_th_in_n_ed_r_e_co_rd_s_w_i_th_p_a_tie_n_tt_o_n_ew_ro_o_m _ _ _ _ _ _r--_._._._ ..__

Place any NonPyxis meds and IV mads in plastic bag and clip to chart
j - I '_ _ _ _
--j-_ _ _- - I
f - - - - - - - - - - - - - - - - - - - - - - - - - 1 - - - - - - - - - - - ------r---------j
Notify Attending and Consulting Physici(lns of room change.

-----.-----------~-~~-------_t_-----_+_----+---
.... - -
-- .. -
Notify Family of new room number and print name of family member in date column
-- - - - - - - - - - - - - - - - - - - - - - - - + - - - - - - t - - - - - - f - - - - - .-----
Name of Transporter:
--------------=R:---:-E--=C-=E--lV---.:-::N:-:G-D--E::-:P-'A-R-T-M-E-N-T----To-R-o-om-#--t--------t-~---t-------j
---------.:.::::..::.=::.:...:.:..:.=:..-=..::::..::..::.:..::..:::::=..:.:...----..:..:....:..:::.::.:...:.:..--4=====j=====9=====l Document date and time patient arrived in new department f----- - - - - - - - - - - - - - - - - - - - - - - - - - i - - - - - - + - - - -.... --t-----___j Document patient s1atus on arrival to unit
Place New Room Number on chart
t----
- - -------1
- - - - - - - - - - - - - - - - - - - - - J - - - - - - - - - - - i - - - - - ,.-.. - - l - - - - - - - j
Print new labels and place in front of chart

Ensure daily an~ pending labs are ordered
I - - - - _.. _---------------------f-------t-----+
Label blank Physicians Orders &Progress Notes and place in proper sections of the Ch~r! ~ _____------'_ _ _ _--'-_ _ _ _-'
~
--
SIGNATURE.
.. -
I/Nrrt
SJGNATURE
INfT
-" ... --SfGNATURE
INIT
--_ ....
I
~-
..
..
~SSM
SLM-'OOQ073 (12/2007) BACK

,,,,,,,--",CH, PHILLIP H 090 22(;0197 ERS 0554-01 Tip 101 02 11976 32Y 1-1 01/22109 SALE~1, f'10UNEF. 00 O'J 4 82 98
J",ltlllllllllill
H E A L T H ' CAR E-
PATIENT BELONGINGS VERIFICATION lOG
000323
CONDITIONS OF ADMISSION AGREEMENT

Consent to Admil;slon: I request end consI;'m to admission.
Con~Qnt
to Medical and Related Health Care: I request and consent to the medical care, diagnostic and treatment
procedures as determined necessary by my physician!s! or hisfher assistants. I acknowledge the care f rttG6jY6
while in this facility is under the direction of my physician(s). This tacility is not responsible for the acts or omissions of my physician(s). Medical and Allied Health Care Providers: I have been informed and understand that the Physician{:ll providing ~lilrvh;:~~ tQ me in this facility, 5uGh as my personal Physician(s), Radiologists, Pathologists, Anesthesiolosist, Consulting Physicians, Surgeons and other Allied Health Care Providers f;uch as Dentists and PsychologIsts are independent comrac~o(s and are not employees or agents of thIs facilIty unless otherwise specifically identified. Teaching Programs; I understand this facility may, from time to time, enter into agreements with academic medical, nursing and tlHied health programs. Because of these agreements, fcsiol:nts, interns, medical students, nursing ~tudents and various allied health profession students, may panicipate in my care. I agree to participate in these programs, but have the right to limit my participation at any time.
Release of Information: I understand tllis facility will makQ evory effon to treat my medical infofmation as confidential; however, I realize information must be shared with provider:;; andfor individuals involved in my care or in the payment of my care. I understand this will include information found in my medical record. I agree to the release of information in my medical record, and to the actual medical record documents, to the extl:nt necessary for the foUowing pvrposes:
a.)
I have received the Notice of Privacy Practices on this visitiadmission or a previous one, I under:H!md I can request BrJ<}ther copy at any time,
b.)
c.)
to any meoleal and/or health care providers responsible for my
CilfQ
whilo in this facility and
if transferred to another facility for care, to that facility and its care providers.
to those responsible for collecting and those resPQnsible for the payment of my care. This may include a person, government agency, insurance company, health plan or employer sponsored grOllp plan. This Is tor the purpose of verifying insurance benefits for precertification and extended stay review andlor the payment of the cost of my care, to utilize for internal medical care studies and quality imprOVement activities.
d.)
e,)
to comply with the Federal Safe Medical Device Act of 1990 <lnd other required state and federal
reporting.
MedlcarefChampuslTricarIJ Rights: If applicable, I acknowledge receipt of the Medicare/Ch!impuslTricare Lt:lter expJaining my rights as a patient of this facility. f understand this includes my right to request <I revIew.
Patient RighlS: I acknowledge acceS8 to the Patient Rights information explaining my rights as a patient of t his facility.
Personal Property: I have been informed and understand thi .. facility will not be liable lor any loss of property unless it is inventoried and placed in a secured area maintained by thi:;; faclilly.
mv personal
Payment for Physician Servlclt!t Medical Bnd Related Care: I understand that all pflysician services are billed separately from the facility charges. I agree to pay the charges incurred for the caffl I receive as ordered by my physiclan{sl at thIS facility. J guarantee full payment of all charges unless restricted by Medicare, Medicaid 01 c:ontrilctuill arrangements between my insurance company and this facility.
~SSM
H fr A L T 1-1
P{ftient Name; MARCH,PHILUP H
CAR E-
Mod/cill Rl,lcord If: 000748298

Aooount If: 0902200197
Typa ERa
Date of ServiC<t:

12303 DEPAUL DR,
01/22/09 02:00
BRIDGETON, MO 63044
Anendll'lg Physicilln;
EMERGENCY,PHYSIC1A
{Comlmmd -on reverso si!ffH
000324
D.ssignment of Benefits; I her&by authome end assign payment to this facility of any type of reimbursement r payment due from Medicare, Medicaid. or any other third party payor, for any and all cost incurred for my medical and related care at this facility and/or by the inrlepsndant contractors providing services at this facility. AcknowledaftfDent of Understanding ReceiPt; I c8rtJfy that I have read tmd understand the pretNJding agrf1fJment.
I have /tad any unc/qlJr items explained to me Imd understand its contents and sooept its terms. I understand that new account numbers mAY be Issued for follow up services related to this admission/treatment
and that would not change this agreement
QI
my agreement to the preceding
tit
any time by written notification to this
be considred a discharge by Medicare. facility.
I understand I may withdfaw
(~_I._~/_ _-------~~----
Patient-;; Signature
M~H.PHILLIP
~/.-...--:>
Date
000748298
."---
H 0902200197
Signa1Ure/Relationship
Date
(Parent/Legal Guardian/Responsible Person)
~cJr\ _____~_._
Second Witness Signature
(if OrallTelephone/Pati&nt Mark)
/1 dJ-b,'
I
Date
Date
Date
000325
12303 DEPAUL DR. ~SSM BRIDGETON, MO 63044 O;~~:~~;4S I ,~:~,:s~:~:Af;O:;; !~: 11~:~;;;;:: 13~: [: R':~ :$ r:::" I >rAl")';1 'm~No
H E"
~
L T H . CAR
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ADMISSION RECORD
ffi
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rCo~ IPA~;;~ I~~ 1000748298'1,

!
H.(}',/j
8310 HAWKESSURY DR SAINT l.OUIS MO 63121-1005
I
LillUJ
(3141393-1241
C;Ui\I\i\NTCfI EUPl.C'rrM
r-~~c~v~.r~~~';T~nR~N~.A7M7~'k~~D .. AOO~A~fnS~----------------~~~~--~ SfJCoFCIIO C/) XXX-XX-a69H 1 ~~ MARCH.PHllllP H c: W ~ 8310 HAWKESBURY DR THEP'<C.11 NO. > (314)393-1241 SAINT LOUIS MO 631Z1-10QS 0 \
~
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MARCH,K1MBERLY
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12774 eO~NKER LANE !.I BRIDGETON MO 63044 ~ ( H ' (314)291.7997 FAX 3147391471 I ATHNCi-NC FrfVStCI)S.N ~ ZINSER.PHILLIP (3 90~572
iE 1/~O~1J1T1NG Pj"'iYS\C'~"J'>J Z i ZINSER,PHILLIP G
-------------~------------r~,~1 l",,,,;;;,,,0?,;",;;;,,V.Yf"'11C=o,,,,,",,'j- - - - - . L_ _ _ _ _ _ _ _.L..._ _ __
10/15/07 23:59
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12774 BOENKER LA_N_E __________ BRIDGETON MO _ 63044 3147391471 OfC, i3141291-7997 '''', 3147391471 "-------------~---I-I..,~""HA=!\!''"D."C~A'''I\,'"'FH'''-''''',.''''.,""w""",-
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SELF PAY NO INSURAflCE
100150
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I
03/25/2009 15:32:30
000326

12303 D!!:PAUL DR.
Wed Mar 25,

P
BRIDGETON, MO 63044 2009 03:41 pm

Page~
Name: #/Acct #:
Outpatient Summaxy ~eport MARCH,PHILLIP H 00074B29B/A0728800245
Reg DaLe: 10/15/07
Loc:
O/P
ZINSER,PHILLIP G - INFUS:WN CENTER
Dis Date: 10/1S/07
Phys-Service:
903572
****** **~**~~~********~t.***t**4.*t**W*~*******************I****~**********
In: 10/15/07 1437 --------------------------------O\lt; 10/15/07 1458 I COl'lPREHENSIVE r<IETABOLIC PANEL I Coli Time: 10/15/07 1420--------------------------------OL'der Phys: ZINSF.R, PHILLIP G Spec; Blood
Teets; V-NM TLSCHWC
(AO'i28600245/3883092)
Result Name
nUN (mq/dl)
!
Result
9 139
ReferGm oe Range
9.0-20.( 137-145 3,6-5.0 98,0-10: .0 75-110 0.8-1.S 17.0-59.0 38.0-12E .0
8.4-10.~
Sodium (mEq/L)
potassium(mEg!L) ;
Chloride (mEq!L) ;
GluCO:;lC (rug/dl) : Creatinine(mg/dl) :

p
3.6 103 86 0.9

24
JSGOT(U/L) :
Phos (U/L) :
CCilcium(mg/dl} : Silirl-tbin (mg!dl) ; ,ZI,lbumin(gm!dl) : PJ:ot Tota1(gm/dl) ; CO2 (mEq!L) :
77 9.4
0,5
4.7 7.5 28
[U/L) :
ALT/SGf'T CFR \ml/min/ 1. 73m2) :
II L
0.2-1.3 3.5-5.0 6.3-g.2 22.0-30. 0 21.0-72. 0
126.6
Out.: 10/15/07 14:;5 esc i'1 hUTO DIFF I ColI Time; 10/15/07 1420 ----------.-------Ol:-der' Phys: ZUISER, PHILLIP G
ResulL N",me
io,/T"~{1000/mm:
In:
10/15/07 1437
-----~----------.-
Spec: Blood
Techs, V-m4 TLTALLEU
lAO"2 8 8002 4 5/ 3 BB3 092J Rel,ult

271;
Result 8.1 4.31 12.6
l~ef
Range
Result Name
Platel (IooO/mm: Gran(%) ! Lymph (%) :
t4ono (%-) : Eos {!I;} :
Basort) :
Ref Range 130.0-400,0
10X6) : rIgo (gm/ dl) : Bct (%) ;

1
4.5-11.0 4.7-6.1 13.0-18.0
77 9 H 16,9 L
5,1)
fY1CV (fl) ;
36.6 L 76.1 1,
39.0-54.0
80.0-99.0
o .'J
0.:1 No; 6 .~9
Mi;H (pg) :
r4CHC (gm!dl) :
Im~oJ(%) :
26.2 34.4 15.4 H
25.0-31.0
32.0-36.0
Manual DiU;
Abeolu (lOOO/mm:
40.0-70.0 22,0-40.0 2.0-10.0 0.0 6.0 0.0-3.0 Indi.cated
11.5-14.5
End of Report - 03/25/09 15;41
alp
.patient Summary Report
MARCH,PHILLIP -1 000748298/A0723B00245
n'1-10/02!76) Dr. ZlNSER,PHILLIP G
000327
~SSM eH E A
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12303 DEPAUL DR.
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ACUX;N' NO
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BRIDGETON, MO 63044
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DePaul Health ~enter 12303 DEPAUL DR. BRIDGETON, r,10 63044 Wed Mar 25, 2009 03:42 pm Outpatient Summacy Report MARCH,PHILLIP H OUOJ4829B!A0731000262 Reg Date
Page: 1 11/06(07
11/06/07
Loc:
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In: 11/06/07 1025 --------------------------------Out: 11/06/07 104B I COMPREHENSIVE METABOLIC PANEL! ColI Time: 11/06/07 1000--------------------------------Order Phys: ZINSER/PHILLIP G
Spec: Blood
Techr:;; V-Nt-1 TLPRETT
fAO"31000262/3917916)
Result Name
BUN
Result
12 136 L 3.9
102
(mg/dl) :
Sodium (mEq/T.) : PotassiumlmEq/LI: ChloridelmEq/L) : Glucose (ms/dl): Credtininclmg/dll

I"
1
9.0-20.0 137-145 3.6-5.0 98.0-10".0

75-110 0.8-1.5 17.0-59 0
78
1.0
'/SGOT ~U/ L) : Plios lui r..) :
Calcium(mg/dl) : BiliLubin (mgidl) : l,lbuml.n (gm/d1) : Prot Totallgm/dll:

C02 (mEq/L) :
27 75 9.1 1.0
'1.5
38.0-121>.0
8.4-10.:: 0.2-1.3 3.5-5.0
7.0
31 H
6.3-8.2 22.0-30 0
21.0-72 0
ALT/SGPT
GFR (ml/min/ 1. 73m2) :
(U!LI :
11 L
112.1
:n: 11/06/0~ 1025 Out: 11/06/07 1010 Coll Time: 11/06/07 1000
Order Phys! ZINSER, PHILLIP G
Result Name
\V" ..., ( 1000/ mm : 1 10X6) ;
------------- --
CDC W AUTO .cIFF
Sp@c; Blood
Techs: V-N!>1 TEViI,NCE
(AO'131000262/3917916]
-------------------
Result
4,1 L
4.80 13.1 37.3 L 77.7 L 27.3 15.1 ':'5.5 H
Ref Range
4.5-11.0 '1.7-6.1
13.0-18.0
Result Name
Re;,ult
Ref Range
130.0-400.0
Hgo(gm/dl) :
Hct (%) :
1;1CV (E1) :
39.0-54.0 BO.0-99.0
25.0-31. 0
Platel (lOOO/mm: Gran (%) : LYIT.ph ( 'l; l : Mono (%) :

Eos (%) :
Baso(%) :
17l
53.8 35.1
9. '7
40.0-70.0 22.0-40.0
2.0-10.0
D.7
O. 7 2.
0.0-6.0
0.0-3.0
NCH (pgl :
~/ICHC
(gm/dl) ;
rWW(*) ;
32.0-36.0 11.5-14.5
Manual Diff: AbE'olu{lODO/mm;
No: Indicated
End of Roport - 03/25/09 15:42
I>'IARCH I PHILLIP
alp
.patient Summary Report
0007'1S298!A073 L000262
(t1-10/02/76)
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03f2512009 15:32:45
000330
DEPAUL HEALTH CENl'l!;R

123J3
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Drive
Bridgeton, MO 61044
DIAGNOSTIC IMAGING
2:
MARCH, PHILLIP H
Sex:
Med Rec #
M
~000748~9R
ACCT; 1'.0731100362
D8D: 10/02/76 Age: 32Y

n~t~: 11/07/0~
Pt LOG'<ltior: *o/P
2119
ZINSER,PHILLIV (
12774 BOENKER BRIDGETON
LtN~
1>10 63044
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N08
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h~s
been reviewed and comp" re<'l
t.0
t.he
Tn r.()mparison to Lhc study of 9/19/2007 then~ iR interval :l.rlpI:0VemellL in Lhe bone marrow abnorma! ; ty within the LefL mandibLe .:.nd th~: abnormal signal wi th:i n the left iHo.S:';ctCI' muscle ,:>n the st.l.ldy of 11/7,2007. l1oweve.r !;li'3u1fic.:;mt cignal ab'101'mallty does perBi:;L wi(.hin (heGe GtJ.'uctures nn t.h~ study 11//(2007 wbLch is an unusual tinding given r.hR long Lime course cine;;- therapy 1!aR initiated aild L'6mail1:; worriGome (ur a persistent inflamm~tnry process,
or
Fi nc:lings discussed with Dr. ZinSel" on 11/12/200" at: 10: 50 J\ddendum Read By- NOANAl'J 1'1 ~Il)l),lQJ 1'1. D. )'>.ddp.ndum Released t3y. NOANAN \<1 SID:>IQI M.D. Addendum Releasp.ci Date Time- 11/l2/07 1053 l\ddenc:ltlm TranscL'lpLionist- NWS M.J. NWS M.D.
il
m.
r1RI f.:.\ce with ar.d w.1t-.hout eonLx:dst
11/7/2007
lndic 0 tion: Left m.:tndihlliar pain. History of prior trauma h \,.::.th Gurgie;': rF.pair ill. Mal' 2007. Infecthm. OsreornYf.'litis.
April 2007,
l,,::chnicjl.,e: The flelri-of"/:ie'd 1;; upLlmizcd u, evall.late the S'nlctl1r~8 of the tacp ,'lild nc;t t.he il11;:r<J.cl.'~mi-'ll ijtructures. Imaging in tll~ s<v;jitt.al, ."!xlal. and core,r."l plane vl.']S pf!rformed utlli.:.;ing both T1 pr~- and pcctcontrMi; Rna STIR iJllctgin9, Ihog 90r;;t;i;Qntrast;, 1'1 'R \'11' h~i;;-l2\'\p-p"<;:;;;$$Q as weJ.:e O\n o,xiCil ",nd corona 1 Tt precontrast :oequcnce. 16 CC ':;Jf Omniscan go.dc,lin~um con~:rilst \'IdS uLilizcd for the postconr.1'.;1S1"'. scan.
Findin'.:JG'
REVISION -
Arlct~ndLrn
X 1 DUPLICATE
Page
000331
DFPJl.m, HE.7;LTH Cmr::~ER L!30J L.leL'"ul Drive Bl"irigl'ton. DLZI,(;NOSTIC Il\IAGllIG
MO 63044
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ACCT: ;,0731100J62
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Pt Loco,tior.: "O/p ZlNSeR, PHILLI[l
Uat0: 11/07/07 2:19
c:
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There 1= marked edema and enhancement. wlthin the left 11lt1~;;;t;Ler muscle adj':\cE'l1t tCI the let!: manrlihular ramu~. Additionally. there :.;; R\lbcutaneou~ :;;vfL tissue ,-,welling and skin thif:ken1.ng of th(; left [<l(.;t;! in thic regIon. i\ci<iltlonallYI ill-det:in'Old infl",nllnLltorr chan;!", 1.S seen \vl t.hln tile dee;;; left; fuce near the caro': Id 6he.;!t.h. The flow vOlds o[ the jugul':ir 'I"ein and carotid are maintalned, TlJere is bonc mint-C'w edema and <"e'1h.'inr:F:ment wi thin tIll.:! 1t.:f',. I1k,ndiblll",y r~mus and neck "ri rh ilreas of c',;n;'tical in(\;.ctlw;:r:ness. 'The lnflammatocy findings arc glez-d'et' than '~ype("ted g~. \'en th~ remclLe HdLuL'e of the trClurna ,~nd surgery ,:tnd ; s
',,}orrisc)me {CL HkU'ldibul . ll.
C:Gte~:;mj"ell.tis
',lith
2t~~0r.iated
left
ma~!::H;::!tel
myositis and Thert: .:U"e

flO
reg'on~l
cellulitis.
foc.)l f hud collect.i ons r.o suggest Qu"cess,
Blooming iirtifact is seen in the region of the left mandibu .ar condyle compdLiblc I.d th retained met all i c fragm=nt.
No other fuel of <;,bnormal ::;ignal il3 8een I"ithin the face. There: is no other sitec of abnorma 1 Rignal within the mandible. There i l l no abnorma 1 sign.3i \"ithin the m~x.ill"". The par_"'pharyngeal 60ft t.issues dre unLemoOlrkClble. The tongue and peritonsill.~r cegions Llre nc.rm.ll in signal and m0rpr)Ology.
Impression: findings uTe '.'Iorricome for lett mandibular oHteufH'y'el.i.Lis invohrin9 the ram\IC and neck \.;j th an associated left masseter myositi, and regional cellulitia as dot~iled above.
Relea8",d By-
KC<ld By- NCAj,1.1;.,.'1 VI SIDDTQT t4.D. brO.!lj'IAN W SIDDiQI Ilf. D.
Reled~t.:d D~te
Time- 11;08/07 1?D?

Page 2
Tranc:.cl-iptionir;r.- SVN
RE,VI:3T01J - .l\ddenduill X 1 DUPLICATE
000332
DEPl\UL HEALTH CENTER

12303 Df.'P"1l1 Drive Brid<]et()l1, DIAGNOSTTC H1AGING
r"10 6]044
M.ll.RCH,PH1LLIP H
[lOB:
I1Clt.e:
lO!O:?/7C Age:
11/07/07 2}1'}
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Sex;
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ZINSER,PHILLIP G
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Code Summ.::lry
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PHYSICIAN OFFICE COpy
12/26/2007 21 :35: 1
000334

DISCHARGE SUMMARY
PATIENT: MARCH, PHILLIP H ADMIT DATE: 12/26/2007 DISCH DATE: 12/28/2007 PHYSICIAN: SONIA N. MELKA VERI, M.D. MR#: 000748298 ACCT#: 0736000302 DaB: 10/02/1976 ROOM: 0530
DISCHARGE DIAGNOSES: 1 Osteomyelitis of the mandible on the left side.
2 3 4
Hypertension.
Chronic pain. Impression narcotic-seeking.
PROCEDURES DONE DURING HOSPITAL COURSE; CT scan of the facial bones, CONSULTANTS; 1 Or. Kennedy with infectious diseases. 2 Dr, Gunapooti with pain management. HOSPITAL COURSE: The patient is a 31-year-old African American male with a past medical history of left mandible osteomyelitis after a stab Injury to the face and open reduction internal fixation with removal of the hardware. The patient was seen by Dr. Zinser as an outpatient and he has been on an extended course of antibiotics, Meropenem and clindamycin, The patient came in saying that he has had increased swelling and pain in the left side of the jaw. The patient insisted that he get intravenous BenadryJ and not p,o. Benadryt for itching from the pain medications and also insisted that he get intravenous Dilaudid. He used to take other p.o. medications. There was suspicion narcotic-seeking as well. Infectious disease was consulted and Dr. Kennedy that he continue the Meropenem and the cllndamycin for his osteomyelitis as per Dr. Zinser's orders. Home health care has already been set up and social work contacted them in his home. Infusion orders will be restarted and he will follow up with Dr. Zinser as an outpatient. He will be sent home on Vi cod in for his pain controL He has been asked to follow up with the John C. Murphy Clinic and the pain management clinic for his pain control. DISCHARGE MEDICATIONS: 1 Norvase 5 mg p.o. daily. 2 Meropenem 500 mg intravenous eVery 8 hours as per home infusion orders per Dr. Zinser. 3 Vicooin 5/500 2 tablets p.o. every 4 hours p.r.n. 4 CHndamycin 600 mg intravenous every 8 hours as per home infusion orders per Dr. Zinser, DISCHARGE DIET: A regular diet. DISCHARGE ACTfVlTY: As tolerated.
DISeHARGE INSTIWCiIONS: Follow up with Dr. Zinser. The patient is to call 291-7997 for an appointment in 1 to Z weeks. Follow up with John C Murphy Clinic in 1 week.
MEDICAL/SURGICAL DISCHARGE SUMMARY.Df'
- Page 1 of 2
000335

PAT!ENT: MARCH, PH!LLIP H MR#;
DISCHARGE SUMMARY
OQQ74~2ge
SONIA N. MElKAVERI, M.D. SNM:1-256 - 2118270
0: 12/28/2007 5: 12 PM T: 12/29/2007 7:15 PM E: 1212912007 22:00 PM
co:
IMRAN A. HANAFL M.D.
MEDICAUSURGICAL DISCHARGE SUMMARY-DP
.Page2of2
000336
)i? I;)
DISCHARGe SUMMARY
PATIENT= MARCH, PHILLIP H ADMIT DATE: 12f26/2007 DISCH DATE: 12/2812007 PHYSICIAN: SONIA N. MELKAVERI, M.D. MR#: 000748298 AceT#: 0736000302 DOB; 10/02/1976 ROOM: 0530
DISCHARGE DIAGNOSES: Osteomyelitis of the mandible on the left side. 1 2 Hypertension. 3 Chronic pain. 4 Impression narcotic-seeking. PROCEDURES DONE DURING HOSPITAL COURSE: CT scan of the facial bones.
CONSULTANTS; 1 Dr. Kennedy with infectious diseases. 2 Dr. Gunapooti with pam management. HOSPITAL COURSE: The patient is a 31-year-old African American male with a past medical history of left mandible osteomyelitis after a stab injury to the face and open reduction internal fixation wittl removal of the hardware. The patient was seen by Dr. Zinser as an outpatient and he has been on an extended course of antibiotics. Meropenem and clindamycin. The patient came In saying that he has had increased sweJling and pain in the left side of the jaw. The patient insisted that he get intravenous Benadryl and not p.o. Benadryl for itching from the pain medications and also Insisted lhat he get intravenous Dilaudid. He used to take other p.o.
medications. There was suspicion narcotlcseeking as well. Infectious disea36 wa~ consulted
and Dr. Kennedy that he continue the Meropenem and the clindamycin for his osteomyelitis as per Dr. Zinser's orders. Home health care has already been set IIp and social work contacted them in his home. Infusion orders will be restarted and he will follow up with Dr. Zinser as an outpatient He will be sent home on Vicodin for his pain control. He has been asked to foHow up with the John C. Murphy Clinic and the pain management clinic for hiS pain contro/. DISCHARGE MEDICATIONS: 1 Norvasc 5 mg p.o. daily. 2 Meropenem 500 mg intravenous every 8 hours as per home infusion orders per Dr. Zinser. 3 Vlcodin 51500:2 tablets p.o. every 4 hours p.r.n. 4 Cllndamycin 600 mg intravenous every 8 hours as per home infusion orders per Dr. Zinser.
DISCHARGE DIET: A regular diet.

DISCHARGE ACTIVITY: As tolerated.
DISCHARGE INSTRUCTIONS: Follow up with Dr. Zif"lSer. The patient is to ea1l291-7997 for an
. appointment in 1 to 2 weeks. Follow up with John C. Murphy Clinic in 1 week
This document has been reviewed and signed by SONIA MELKAVERI Sign DatelTime: 01/22/2008 10:56PM EST
MEDICAUSURGICAL DfSCHARGE SUMMARYDP
- Page 1 of 2
000337
OEPAUL HEALTH CENTER

PATIENT; MARCH, PHlll,.lP H
DISCHARGE SUMMARY
MR#: 000748298
SONIA N. MELKAVERI, MD. SNM:1-256 - 2118270 0: 12/28/20075:12 PM T: 12/29/20077;15 PM E; 01/23/2QOa Q9:03 AM
cc:
IMRAN A. HANAFI, M.D.
MED1CALlSURGICAL DISCHARGE $UMMARY-DP
- Page 2 of 2
000338
Patient Oi$Gh~rg~ In~tru~tk>ns

Discharge diag nosis: Discharge disposition
Flu Immunization Given _ _~_ Pneumonia Immunization Given ---~~=---~Home Care Agency:
~------.-
.. -.--.- ..
PRESCRIPTlON~.~__g.J"~me 0 Written 0 Given 10 Patient .~ Called to pha~~~_cy~_ _ MEDICA nONS: See Di~ch~r9.e Horne Medication List attached WORK: 0 Return to work in days or 0
Activity:
Maintain
usual Restrictions
physical activity Pac~ activities and plan for rest pgriods
rt~egUlar Diet Modified Diet _ _ _ _ _ _ _ _ _ __

o Instructions given by Dietician Smoking: Do not smoke/Avoid second hand smoke
Smoking cessation inforrwtion provided and
revIewed for patients who smoke .
. Worsening of symptoms - cart your physician if any of the fonowing apply to you: A fever greater than 100F or cnills Excessive redness or unusual drainage at
A worsening cough with sputum that is green or yellow or bloody Worsening shortness of breath, with or without activity Swolfen ankfes or hands
it
surgical site Excessive bleeding at surgical site
Unrelieved pain
NumbnessrnnglingfChanges in color Qf affected area
Weight Monitoring it you have H6art or Kidney Failure

Weigh yourself the morning after you get home and daily after going to the bathroom and before
breakfast. Notify your doctor of w~.!Rblg_ain of 3 or more pounds in one day or 5 pounds in 5 days.
LLOW.UP CARE; Bring all ~youto yourappointmenL I') Call for appointment with Dr. Phone # to be seen in ~weekS Call for a ointment with Or. Phontl # to be seen in weeks
CJf.liHigna Cite needed see orders.
Belon9ings returned: 0 None 0 Glasses 0 Denture~ 0 H~~ring Aid($) CJ Assistive dev!c~ o Home medications 0 Other: These instrucfcm~:. Jl~~.~\leRl'~iewed with me and my questions have been answered.
Patienf Si
'It;r~' ~
~
DiSCharged to
SI nificant Other
Home Other---------~~~,-----Phone # after discharge ____~_ Escorted b ;
Date:
C ~~-----
Actual time Of Discharge. _ _ _ __
Nurse
o o
Mode:
o I:l o
we
Ambulatory Stretcher
i11ii iili ikf~l=fj#:ie;lli~R~'IJi.ttlg:j=:;i,.\t.ft;ii'iUil~~fll!l'fiI~~Q~ ;!!7 ' ",.J!1I!.re JP:::====== DEPAUL
HEALTH CEN'I'BR
)
j
1/ P 0736000302 rilED 0530-01 10/02/1976 31Y M 12/26/07 ~------------------------------------------ HANAFI,IMRAN A 00074829~
.--..:..;;.=:..;;.;;==..::..=;~=-~===---------------~
Make 2 copies ofLhisf.or-m. Originalfonn to chart, Co .
11111f111UII.11I111 MARCil, PHILLIP H
000339
H
DePaul Health Center 12303 Depaul Drive
PAGE tmNBER: 1 ESTIMATED DISCHARGE TIME:
Please circle! Discharge Meds or post-op Meds Bridgeton,NO 63044 Patient Active Medication List (YES NO) Account Number: 0736000302 Patient Name: MARCH,PHILLIP H Room Number: 0530-01 Date: 12j2e/2007 Attending Physician: HANAFI.:tMRAN A Patient Allergies: No Y~own Drug Allergies
NURSE: PHONE EXT:
Continue? Medication Generic Name(Brand Narne) with Directions
I AM I Noon I PM I Bedtime I
Scheduled Medications **-
AMLODIPINE(NORVASC)5 MQ BY MOUTH Daily

11
GIVEN AS:
(1)
5 KG TABLET
SODIUM CHLORIDE
O.9%(NO~
SALINE} 1000 ML
INTRA~OUS
13
MEROPENEM(MERRBM)5DO MG INTRAVENOUS EVERY 8 HOURS
-o~
.-*.~
*.r*_ As Needed Medications

19@-0
HYDROCODONE/APAP 5/500MG{VICODIN 5/S00MGl
~~
FOv~
GIVEN AS: (1) 0.1 KG TABLET
* EVERy a HOURS
2 TAB BY MOUTH Every 4hrsprn
23
YES~ONIDlNE(CATAPRESiO.l
MG BY KOUTH EVERY 6 HOURS
AS NEEDED
B YES
~ROMORPHONE
MeL (DILAODIJ)) 0.5 MG INTRAVENOUS Every 4hrs pm
PHYSICIAN SIGNATURE IS REQUIRED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST
:>
Pilot Form 4/2005
= Medication Substituted per HOSlpital. Approved Formulary Substitut:ion
H
PAGE NUMBER: 2
ESTIMATED DISCHARGE TXME: NURSE PHONE EXT:
P1ease circle: Discharge Meds or Post-op Mads Bridgeton.MO 63044 Patient Active Medication List (YES NO) Account Number: Patient Name: Room Number: Date: Attending Physician: Patient Allergies: 0736000302 MARCH, PHILLIP H 0530-01 12/28/2007 HANAFI,IMRAN A No r~own Drug Allergies
Continue? Medication Generic Name (Brand Name) with Directions
I
AS NEEPED
AS NEEDED
.AM
Noon
PM
Bedtime
9 YES
10 YE
22 YE
ROME"l'HAZINE(PHENERGAN)12.5 MG INTRAVENOUS EVERY (; HOURS
E1'OROLAC (TORADOL) (TORADQL) 30 IMG INTRAVENOUS EVERY 6 HOURS IFHENHYDRAMr.NE(EENADRYL}25 KG INTRAVENOUS EVERY 6 HOURS
AS NEEDED
leW
:>
Held Scheduled Medications *****

CLINDAMYCIN(CLEOCIN} (CLEO'CIN) 600 KG INTRAVENOUS EVERY 8 HOURS
--i7 r~ ~a~
. . EVERY
HOURS
p-~
PHYSICIAN SIGNATURE IS REQUI.RED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST
Pilot Form 4/2005
Medication Substituted per Hos:pital Approved Formulary Substitution
H
DePaul Health Center 12303 D@Paul Drive
PAGE NUMBER: 3 ESTIMATED DISCHARGE TIME: NURSE PHONE EXT:
Please circle: DiBcharge Meds or
poet~op
!Meds
Patien~
Bridgeton,MO 63044 Active Medication Liat {YES Nol
Account Number: Patient Name: Room Number: Oate: Attending Physician: Patient Allergies:
0736000302 MARCH. PHILLIP H 0530-01 12/28/2D07 HANAFI.IMRAN A No Known Drug Allergies
Continue? Medication Generic Name (Bran,d Name) with Directions
I
~
AM
Noon
PM
Bedtime
Additional Orders
t.t
-..-.-.-.......-...---..- ... -------.........----.-.-.-----!-\.-.-...--.-.~-.--.

f0GJ-~
\)y _
___
2A i -lC{U
tJ\;aF1:~
~-~----------
------------..-...-----------
------..--.. ------------------_.
:fjA-~
Date/Time
(?{2>6[
7
Nurse Signature:
Date/Time _ _ _.
PHYSICIAN SIGNATURE IS JREQUIIRED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST Medication Substituted per Hospital Approved Formulary Substitution
pilot Form 4/2005
ORUGMAVBCDISPENSf:DINACCORDANC[.VfTHIHS PHVSfCfAN'S ORDERS ~~~~~~~~~~~ IMPORTANT
REMIND~RS
i 'Oaily' Instead til "qd'
'l, 'Unit5' instead of V

3 No trailing wros (lJTll1 noll.0mg) 4. Always HtAI&adiflg IQlVS (O.!rT1'J nat .1ma)
PAT/riNT HEIGHT c;>
5. 'Morphine' irlllftlad of "1.1804" 6. 'M3~nium ~UIta16' li\I,lbid of 'MgS04' 7. 'Every otllel oay' f0Sl9ad Of '0.0.0," a "MCG' in~toad oI'U'l 9. 'IntemmQrW umb" in,ltad 01 'Ill"
~SSM
H E A L T H . CAR E
PHYSICIAN'S ORDERS
SLM' OOO0fS5 (4/2007)
PA TlENT LABfL
DEPAUl. HE.AJ.,TH CENI'ER
MARCH, PHILLIP H
':lANAFT, INR.l\N A
IIIfBfiltllflmUlMlIJDH
lip
0736000302 MEV 0530-01 10/02/1976 3lY 1"1 12/26/07

a007'i8298
000343
DRUG MAY BE Di$PCNSfD IN ACC;<JROAN"F WHH TH
PHYSICIAN'S ORDERS
1. "Dally' InSlftad 01 'qO" 5. 'Morphil\9' instead 01 'MS04'
Z, "b'nlto IMIOOd ot V
3, No tralllng ~~IOS (1"'1/ nol 1.0rw) 4. Always usslRa(!inq leJ\lS
6. 'MJgJ1lIsium sulfate' insteoo of 'MgSO~'

7. 'EVftry O1Irer day' Insieau 01'0.0.0.' 6. 'MeG' insl~aa ot '119" 9.Inlemallonallllllts.lr.ste~dor.IV
(O,lmgr.ot.l mnl
~ss
SLMl000-0GS (41'2007)
H E A l T H ' CAR
000344
DRUO MAY tiE OfSPENS~~S~ ACCORDANCE WITH ~~RE
PHYSICrAN 7S ORDERS
1. 'Daily" Instead of "qd'
5, 'Morphine' Insli!ad of 'MS{J4"
Z, 'Uafif inattad of .~'

3, No fTailiCl\l zelos (lmq no! 1.0fngl 4. Always use leading lS/OS
PATIENT HEiGHT .:::>
6, 'Mauoolum wffJflf illsteJll ot "1,1\1504'

7. "EveT)' ather day" Instead of '0.00.' 8. 'MeG' instead III 'jig'
(O.lmg not.1mq}
DEPAIJ1, HRALTH CENTER
fvIMCH, PHTT,LIP H
1IIIUfIjlliDDUILUIll
,1
r /p
0736000302
PHYSICIAN'S ORDERS
SLMl000-065 (112007)
MED 0530-01
1')./26/07 OOO'/4879B
10/02/19""16 31Y HANAF 1. IMRAN A
000345
l'lRUC~I"'YOCD1SPt'I:;~i.J1NACCORD"N'~fwnHTHE DH~o~I<PErr~A~l~~~~'~~'~'~~G~H~F\'~'K~'E~o~H~ER~E~~==~______
PHYSICIAN'S ORDERS ----------1

1. "Dady"
m~tNd
IMPORTANT
REMIND
01 "Qd"
.'i "MOfphine" II1steatl 01 "M504'
? .~"'~" !n~t~i!d 3
V! y
fi "MaallmJm suJjijlE" rn3teSd 01 "MgS04"

7. "EVAry o~r day' ;I1$lcad ul "Q.O.o" B. "MeG" in>lBJ\1 01 "I1Y" 9. "International Units" ill~teall 01 "IU'
4.
PATIENT HEIGH: Q
__
, '-----.
~SSM e r
H A L
SLM1OOO065 (7!200fi)
PA TIENT LABEL
H . CAR E-
DRPAUL HEALTH CENTEH MARCH,PHILLIP H T/P 073(,000302 MED 0530-01 10/02/1976 31Y 1<1 12/26/07 HANAFl, IHFAl'J A 000748299
IIIIDUIJlDflJllllDl1I
PHYSICIAN'S OROERS
000346
DRUG MlW BE DlSr'CN(;J:D iN ACCOHUANCI' WiTH TH. HOSPITA~ FOAMln.ARY SYSTEM HEME
c~D
PHYSICIAN'S ORDERS
1. "Dally' instead of 'qd' (, "Unns" Instead of "\I' 3. No lrailiflllZSlllS (Img 1101 jOmg) 4. Nways use lea\lillQ l1Iro,
5. 'MOI]lhiflll' inslaad o/'MS04'
.'
G. 'MtQMlUm sulfata' In5ltl~d of 'Ml}5(W

7. 'EV~IY !!VJif dlly" Inst&ad of '0.0.0' a. 'MeG" iJlSteaQ 01 'w' 9, '!ntfmatloI1aI urJts Instead of 'fU'
.
PATIENll't'EIGHT
*
TIME;
o Kg>
Dlb~
""'~.~n
PATIENT HEIGHT 0;;'
(O.lmgno'1mg)
I.....
J~.~T~.
,,"M'
DERS
".........,"',
t)I':JJJ~.
f').
'j)
I
NURSING REfERRALS (based on nursing p$sessment/no physician order required) U
Diabetes
!\,~
kD
Q
Nur~~
Q
Pastoral
Care Allergies:
ET NulSB
Clinical Nutrition Infection Control
0 Social Service
PharmaQY /
d,
A '7 ~,..,6..1 ~'F/<-J ../),
I I
Height:
Code Status:
DPM'TM-(}~2
Weight:
Pneumovac year:
P
RN/LPN
Date;
(8/200.)
( j) Li,."jjl
t:~i) /.fi~ J
.~-r-
.t;.
('
1/ c?I--~
k ) ; . },.
. .~.-~
..
/:~ l(/;
,.I ~ ".- ;::--
//
'-
I'.
'\'"
"\,
" ".
,
~\
.\.
\.
\
\,
\
'\
'\
\\
\.
\.\,
'\
,"",
"
~SSM
H
~
!1 (12 4 007 l SL /.1-1000 1 00
PATIENT LABEL
A L T H . CAR E-
DEPAUL HEALTH CENTER ~0)~
PHYSICIAN'S ORDERS
ERQ MARCH, PHILLIP H 0736000302 ERS 10/02/1976 3lY M 12/26/07 EMERGENcy,PRYSICIAOOO748298
111111
000347
Vancomycin Dosing Protocol Physician Orders

The followmg standing orders shall be initialed by the pharmacist upon receipt of physIcian's order for vancomycin protocol. Vancomycin prolocol details and references are available in the pharmacy department.
Indication for vancomycin

Patient's Age: _3_1_
Actual Body Waight (A8W): Ideal Body Weight (18W):
Curren! serum crealinine:
-~C< (. \<...Q /J(J..LLJ CRJJ..JlJ.-JL ( h ~

M_ Height: Sex; __
71.0
inches
ABW
....L2:.L
~
Ibs:: kg
73.0
kg
_--,-,12=..:3~_ ml/mln
Calculated creatinine clearance (Clcr):
Medication Orders (derived for this patient from the tables befow): 1. Vancomycin 1250 mg IVPB Initial loading dose (infuse over 1.5 hours), THEN 2. Vancomycin 1000 mg IVPB every 12 hours (Infuse over 1 hours), ~~ beginning 12 hours after the loading dose. 3. Vancomycin trough levet to be drawn 30 min prIor to the AM dose on 1LJ!
Other orders'
'lnitialization Proiocol Dosing Table~ (see actual orders above)
Initial Dose
Mainl Doses
(-15rnqfk!)
Patient's
weiaht
(~20mgfkj'J)
.:.;M""a;.:;in~t""e:..;;na::..:n.:..::c:.:::e....::D::..:o""s:..::in=-.!QI-",n!-"te"-rv,-"a,,,I;_ _ _ _ _ _ _ _ _ _-if
ABW'( 45kg: ABW 46-.60kg: ABW 6O-76kg: ABW 7S-90kg: ABW> 90kg:
750 mg , 1000 mg , 1250 mg , 1500 mg 2000 mg
then then then Ihen then
500 mg 750 mg 1000 mg 1250 mg 1500 mg
Clcr> 50 mt/min and age <75: Q 12 hOUfS Clcr;:. 50 mlfmin and age :.",75: q 24 hours Cler 2050 ml/min: q 24 hours Clcr <20 mllmln; One time Initial dose. maint dose orders to follow
Pharmacist will evaluate laboratory data and provide writt8n orders for dose and/or interval adjustments with the goal to attain trough vancomycin levels within the target range of approximately 1520 meg/ml for hospital-acquired pneumonia anD 10-15 mcgfml for other indications, Pharmacist will provide written orders for appropriate laboratory monitoring pertaining to vancomycin dosing. Cancel serum levels If vancomycin IS disconiinued.
vancomycin
Duralion of therapy will be determined by th@ physician.
Deviations from protocol guidelines will be explained In the progress notes.
i Ordering Physician's &gnalure: _ _ _ _ _ _ _ _ _ __
~SSM 'NWMJil*.PU
H ~ A L l J1
.
e A R E'
March, Phillip 736000302 530
VANCOMYCIN DOSING PROTOCOl PHYSIC1AN ORDERS

SU,I....,< ... (02/05)
000348
EMERGENCY DEPARTMENT ADMISSION ORDERS

""ti."Name:
~f~ t p~"\\"~
Dlagnos~
(Pll.,tb
1---I-~p~ti;~t-;d~it-1~;--f.(M~di;~i-D-s~;~;~~i"o--T~j'~'~~~';;"'O-3"N~rt;'''{i;~t~';~~'d;;;~-i'c'v)'-''D'icu''_
!~~:::::"'_(~;1:~~;~_10' rJ~~i~.~I_~~::::~D_T~~~.~
Code Status
-~
10 DNR
I.
ull Resuscitation , 0 DNR - Continue Medical Therapy
. _f?. .
J ::1J
..1
_~~
r--AII.-rgi8s-,
~-+)-~-- . _ - -- - "-~------'l
- Comfort Measures
._
~
ASSESSMEN o 1& 0
o Acute Cardiac
0 C()1l9E1stive Heart Failure 0 Acute Pulmonary
~ital signs every ~ hours X _ _ then

. ADDITIONAL DfAGNOSTICS
~Obtain Prev;outj Mecficai Recorda

routine
0 Dally Weights
o Oximetry o Cardiac Monitoring
~
S
CSC
MP OPT
DCXR
0 EKG 0 _ _ _ _ _ _ _ _ __
0 AC & HS 0 every _ _ hours
DPTT
o Fingerstick Glucose
1fI. MEDJCATrONS
IV. TREATMEN
o IV ffUidS. _ _ _ 10_~---->@~---Jlu.,Z....:.c:'......;...:M=L,+j.I.Ll-,-r_ __
. _ _llters per
Saline Lock
o Oxygen at _
Call physician If 02 Sat less than ___%,
((E
~egUlar ~~,_.l_ ea!o,ie ADA 0 ~_ _ _ _ _ __ ktMty 0 Bedrest ~BRP 0 Sse 0 Up ad lib 0 _ _~_ _ _ __
. . 0 NPO
FO/@YONGtosuetlonf.!.-:V>
Date: 12Transcribed by: _ _ _ _ _ _ _ __
Physician
Time Noted: RN,_ _ _ _ _ _ _ __

Tima:, __ ' _ _ __
S&,. &~/
if"
',t.~,----....
Orders ,anned to Pharmacy - Date:
Initials: _ _ _ _~
/ :2115
~~MOPM2000-19S (10/2007)
'\~_ : .', ...r... '
t! ... '\)
ED ADMISSION OROERS
000349

I---C----------~---~----~-----~~~~-------
--------
p
-----------~~------------,_,
Other
rIsk) DYes -descflb"-,.-_...-.,.___________
Ch4!!Ck the bol( below it you have ever &xperlenced 'u~-n~y=n-o-s-e=.t=earing. sneezing, Of Itching after:
Dfmta/llntemal exams lJ Contact with rubber gloves/product'S U blowing up balloons Q Use 01 condoms or diaphragm
bal1Bn,as avclca<1os. water
Antlwering 'yeo' to any of
kiwi
o Allergy armband
supplements (list only wrrent mecJ~1
these require initiation of Lat~x Allergy Protocol Chart labeled
Homo H~'th Services being used? 0 y@!; 0 No ff yes, Name Ty~ -:-____~-Sources of information: CJPatltml U Mooicalion Bottles 0 PH!lent's Family CJ Med List U Doctor's Office o Pharmacy Name _ _ Pharmacy Number U 01<1 Chart U Other
La~t
Dose
Comments
H~meM
~'&Jictllionslltf)rbalivftJml"s lYIh b'!' di$psnsed in 8c;;Qfl:J~n(;tj Wil./I /hI! hap/t

Non-fQrmulary
These checked orders will only become active when authir tq by pnysiGldn
Record~d
315"
Dg!e~~
h8rb~l$/vifim;"s Tlme.zw!L ___

Time: ______
IVtll bi! h"k/ dUring, """'''
~ R.,~.
Physrclan
_~~
.""t~ hy'". ,h,.,,,"

ju/a '
__
Date _ _ __
Nurse' _ __
o Readback confirmed
10 Ph"",acy Dote' _ _ _Time': ____ 'nitia/s_ _
1111111.11111 MARCH/PHILLIP H
-.S3'A
ERQ
(/
0736000302 ERS10/02/1976 31Y M 12/26/07 EMERGERCY,PRYSICIA000748298
000350
\'
...
DEP~UL
HEALTH CENTER
IlfJllIllllIllllIl1II I\1ARCH, PHILLIP H

0736000302
: J!ANAl".l, IHRA.. N P.
rip
000'/48298
f\1ED 0530-01 10/02/1976 31Y 1'1 u/26jrn
000351

I,lARCH, PHILLIP H . 0736000302 MED I 10/02/1976 311:' I HANAFI, n'lRAN A
11111.111.1111111111
;"f',t~~:~~r
.
000352
UMOCOCCAL VACCINE NURSfNG ASSESSMENTI PROTOCOL
~r r~orded.
Is not obtainable by Nursing and/or Cas. Manager, vaCQine ehould be given and
+CDc/ACIP R9COmmlH1detlons MMWH 1012006
Flu VaCI[;lne Nun~lng Ass~ess:melr\t If)rot~()Col
[J . Qualifies for influenza vaccine. Influenza vaocine 0.5 mf 1M wilt be administered on day 3 in NIl or at discharge (When discharged before day 3) per protocol unlC'ts$ countennanded by order of the physlolan with documented.
medfcal reason (Le. fever 101"F or
forwlthttoldlng the vaccination.
Dat~;12b.(JQ
Time: tl2.Jt
j--
Ass&ssment completed by:
6[.u~d.Jv----
~~_,_. _______
ERQ
.q_
~~~~ DePaul Health Center i~n-~----~

Pneumococcal/flu
:1DiiI..~ ~
d073 (; 0 b03 ~2
'
AssessIlPro(o~1 9/2007
MARCfI~~n If
10/02/1976 31Y
ERS-
! EMERGSNCY,PHYSIClA00074S298
M ~2/26/07
TOBACCO USE INTERVENTION PROTOCOL ORDERS

AS1jJeSsment: (RN/lPN to fill in appropriate spaces) "l;a-- Has not use tobacco pwdlJcts. .0 ClgsleHes per day _"_~_ _ /0 SpiVsmokeless tobacco (can/pouch per day) _ Pipe/cigar (number per day) _ _ _ _ ~~_ _ Not currently uSing, date paUen! reported stopped tobacco USB: _-----;-_,,-_ _ __ fl' i '. ('. .",,/ II ,I. C'1. ' i _""(I 1 Assessment completed by; ':1 '\" ;"" \ l...-RN Date:./ I, i; " flme:~
I.
!;
r
\
II.
8ehaviorallntQrY{:ntign;
RN/LPN recommends ending tobacco use or continuing with abstinence. Provide smoking cessation patient education maferials
Excrusion Criteria for nicotine replacement therapy: (select all that apply) o Patient has known allergy to nicotine patch, o Patient is already on nicotine replacemen[ product.
Cl
Pafient refused nicotine replacement therapy
J)
Educational Consult Enter Respiratory Therapy Consult in HaDe for smoking oducation
1ft. Medication Intervention:

(PRESCRfBfNG A NICOTINE PATCH FOR PATieNTS UNDER THE AGE OF 18 Yf:ARS CONSTfTUTES AN OFF LABEL USE OF THE DRUG, PRESCRIBING THrS MEDICA nON WfLL BE LEFT TO THE DISCRETfON OF THE AITENDfNGPHYSrCfAN, IF USED. THE STRENGTH OF THE NICOTINE PATCH SHQULDNOTEXCEEO 21MG UNLESS' EXCEPTIONAL CfRGUMSTANCES DETERMINE OTHERWISE)
o
o o o
less than 20 cigarettes per day or less than olle can/pouch per week (pipe/spit/smokefess tobacco) nicoline patch (Nicoderm CO) 7 mg applied to skin every morning, remove old pafch. 20-30 cigarettes per day or 1 can/pouch per week {prpelspltlsmokeless tobacco) nicotine patch (Nicoderm CO) 14 mg applied to skin every morning, remove old patch. 31-40 cigarettes per day: or 2 cans/pouches per week (pipe/spit/smokeless tobacco) nicofine patch (Nlcoderm QVCQ) 21 mg applied (0 skin every morning, remove old patch. Consult pharmacy for other nicotine replavement options
#f nIcotine crmtrafndicated:
o o o
Other _ _ _ _ _ _ _ _ _~_ _ _ _ _ _ _ _~_ __
bupropion extended release 150 mg PO daily times 7 days, then 300 mg PO daily.
Cri~i~
!ntQrvention:
Acute agitation due to nicotine wjthdrawal

Other ____~_____________________________
alprazopam (Xanax) _
mg PO every 6 hours as needed for agitation,
I agree with the above orders with the exception or Ihose crossed through or NOT CHECKED
DATE:
TIME: _ _ _
PHYSICIAN:_~_ __
TRANSCRIBED BY:
Scanned to pharmacy
TIME NOTED:
~__
RN: _ _ _ _ _ _ __
Date: _ _ _ _ Time.' _ _ _ _ Initials _~~_
DEPAUL HEALTH CENT8R MJ\.RCH, PHILLIP H

TO-nACCO INTERVENHON PRfJTOCOL 11/2212006
0736000302
10/02/1976 31Y HANAFI, TMRAN A
IIIIIIIIIIIIIIIIIIBIO
MED 0530-01
III>
OOD'f4B298
M 12/26/UI
000354

HISTORY PATIENT: MARCH, PHILUP H
AND PHYSICAL
MR#: 000748298 ACCT#: 0736000302 ROOM: 0530
ADMIT DATE: 12126/2007 DOB: 10/02/1976

PHYSICIAN: SONIA N. MELKAVERI, M.D.
CHIEF COMPLAINT: Left law swelling and pain. HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old African American male with a past medical history of n9nCQmpiiance r left mandible osteomyelitis, and hypertension, who came into the emergency room with complaints of increasing swelling in the left jaw, associated with pain the last 2 days. The patient has a history of a stab injury to the left jaw. status post open reduction and internal fiJ<ation done at Barnes, which was infected and later had removal of the hardware. He was admitted to DePaul Hospital and diagnose<l with left mandible osteomyelitis and ha5 been on extended course of antibiotics, on Meropenem and Clindamycln. He was seen by Dr. Zinser as and outpatient. He Is currently on IV antibiotics and lie states that for the past 2 day~; his pain on the I~ft side of the Jaw has been increasing with increased swelling. He denies any fevers or chills. He has no chest pain. he has no shortness of breath. no nauSea OF vomiting. He has no abdominal pain, no diarrhea, no constipation. No other history. No other current complaints.
PAST MEDICAL HISTORY: 1 Left mandible osteomyelitis.
:2
Hyperten~ion.
ALLERGIES: No known drug aHergies. MEDICATIONS; 1 Clindamycin 600 mg IV Hd. 2 Merrern 300 mg IV t.i.d. SOCfAL HISTORY: He lives with hIs mother. No history of smoking, no alcohol. No drug abuse. FAMILY HISTORY; Noncontributory to the patient.
REVIEW OF SYSTEMS: As per HPI.

PHYSICAL EXAMINATION: VITAL SIGNS: On admission - blood pressure 136/90, pulse 64, temperature 98, respirations'S. Pulse oximetry 100% on room air. GENERAL: Well developed, well nourished, African American male, in no acute distress. HEENT: Cervical lymphadenopathy I}resent. No redness appreciated on the left mg\nglbls. LUNGS: Bilateral lungs clear to auscultation. No crackles. CARDIOVASCULAR: 51. S2 normal, regular rate and rhythm. A6DOMEN: Soft, nontender. Nondistended. Normal bowel sounds. EXTREMITIES: Lower extremities no pedal edema. LABORATORY DATA: On admission, sodium 138, potassium 3.9, chloride 103, bicarb 31, BUN 12, creatinine 1. Glucose 77. AST 125 1 alki3l1ne phosphatase 60. AL T 48. White count 4.9, hemoglobin 12.3, hematocrit 35.2, platelet count 214,000. CT of the facial bones shOWS no evidence of acute injury and i6 unchanged from the previous study. Blood cultures shOwed no growth. ASSESSMENT AND PLAN: 1 Jaw pain, history of left Jaw osteomyelitis. Continue current antibiotics. Vancomycin has been added. CT maxillofacial bones dId not show any change. Infectious disease has been consulted. Question if needs MRI of the mandible/facial bones.
MEDICAU5URGICAL HISTORY AND PHYSICALDP
- Page 1 of:2
000355
OEPAUl HEALTH CENTER

PATIENT: MARCH, PHILLIP H
2
3
HISTORY AND PHYSICAL
MR.#:
000748298
Hypertension. The patient is really noncompliant with medications. Continue to monitor blood pressure and add Norvasc. Pain control. Will start on Vicodin. Consult pain management. Prophylaxis. Place sequential compression devises.
SONIA N. MELKAVERI, M.D. SNM:1-327 - 2116784 D: 12/27/200712:33 PM
T: 12/27/20071:09 PM E: 12/271200714:02 PM
cc:
IMRAN A. HANAFI. M.D.
MEOICAUSURGICAL HISTORY ANO PHYSICALOP
Page2of2
000356
OEPAULHEALTHCENTE~
HISiORY AND PHYSICAL
PATIENT: MARCH, PHILLIP H ADMIT DATE: 12f26f2007 DOB: 10/02/1976 PHYSICIAN: SONIA N. MELKAVERI, M.D.
ata,8
MR#: 000748298 ACCT#: 0736000302
ROOM: 0530
CHIEF COMPLAINT: Left jaw swelling and pain. HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old African American male with a past medical hi~tory Qf nQn<;;ornpliance, left mandible osteomyelitis, and hypertension, who came into the emergency room with complaints of increasing swelling in the left jaw, associated with pain the last 2 days. The patient has a history of a stab injury to the left jaw. status post open reduction and internal fixation done at Barnes, which was infected and later had removal of the hardware. He was admitted to DePaul Hospital and diagnosed with left mandible osteomyelitis and has been on extended course of antibiotics, on Merapenem and Clindamycin He was seen by Dr. Zinser as and outpatient. He is currerttly on IV antibiotics and he states that for the past 2 days, his pain on the left side of the jaw has been increasing with increased swelling. He denies any fevers or chills. He has no chest pain, he has no shortness of breath, no nausea or vomiting. He has no abdominal pain, no diarrhea, no constipation. No other history. No other current complaints.
PAST MEDICAL HISTORY: 1 Left mandible osteomyelitis. 2 Hypertension.

ALLERGIES: No known drug allergies.
MEDICATIONS: 1 Cfindamycin 600 mg IV U.d 2 Merrem 300 mg IV t.i.d.

SOCIAL HISTORY: He lives with his mother No history of smokmg, drinks alcohol over the weekends. No drug abuse.
FAMtL Y HISTORY: NonGontributory to the patient.

REV!EW OF SYSTEMS: As per HPI.
PHYSICAL EXAMINATION: VITAL SIGNS: On admission - blood pressure 136/90, pulse 64. temperature 98, respirations 18. Pulse oximetry 100% on room air. GENERAL: Well developed, well nourished, African American male, in nQ \:lCUtB distress. HEENT: Cervical lymphadenopathy present. No redness appreciated on the left mandible. LUNGS: Bilateral lungs clear to aY~C\lltation. No crackles. CARDIOVASCULAR: S1, S2 nomlal, regular rate and rhythm. ABDOMEN: Soft, nontender. Nondistended. Normal bowel Munds. EXTR~M1T1ES: Lower extremities no pedal edema.
LABORATORY DATA: On admission, sodium 136, potassium 3.9, chloride 1Q3. bicarb 31, BUN 12, creatinine 1, Glucose 77. AST 125, alkaline phosphatase 60, ALT 48. White count 4.9, hemoglobin 12.3, hematocrit 35,2, platelet count 214,000. CT of the facial bones shows no evidence of acute injury and is unchanged from the previous study. Blood cultures showed no growth,
ASSESSMENT AND PLAN:
MEDICAL/SURGICAl HISTORY AND PHYSICAl-DP
- Page 1 of 2
000357
HI$TORY AND PHYSICAL
PATlENT! MARCH, PHILLIP H
MR#; 000748298
2 3
4
Jaw pain, history of left jaw osteomyelitis. Continue current antibiotics. Vancomy<:in has been added. CT maxillofacial bones did not show any change. Infectious disease has been consulted. Question if needs MRI of the mandible/facial bones. Hypertension. The patient Is really noncompliant with medications. Continue to monitor blood pressure and add Norvasc. Pain control. Will start on Vlcodin. Consult pain management. Prophylaxis. Place sequential compression devises.
This docurnen1 has been reviewed and signed by SONIA MElKAVERI Sign DatefTime: 01f2212008 10:57PM EST SONIA N MELKAVERI, M.D.
SNM:1-327 2116784 0: 12/27/2007 12:33 PM

T: 12/27/20071:09 PM E: 01/23/200809:05 AM
cc:
IMRAN A. HANAFl. M.D.
MEOICAUSURGICAL HISTORY AND PHYSICAL-DP
- Page 2 of 2
000358
INTERDISCIPLINARY HtSTORY AND PROGRESS NOTES

Dale
Time
I NOTES MUST BE S/CiNI:O
z3
~----~----~----------------------~------------~~~~-------------
~SSM
H e A l T H . CAR
E~
DEP~UL
HEALTH CRNTBR
INTERDISC1PLINARY HISTORY &. PROGRESS NOTES
1111111111111111111 t-'IARCH, PHILLIP H
rip
0736000302 !I!ED 0530-01 10/02/197631Y M 12/26/0'1 HANAF'I, U1RAN A 000'148299
SLM\OOO-003 (6/2003j <l2 FRONT
000359

Date
Tillie
I NOTES !.iUST BE SIGNED
_ Date: \ ;...
-TI l?7 Time: ~
SSM DEPAUL PA TORAl CARE
NOles:~~~~.~"~~.~Q~~'d~\ ~;~( - ~.~~~~~~~~,~,~~~~~.~,~~~~~i~~~,:{~~l~~/~~~~;~:~~:~r __ fl" 1(; 1> 4 fl\~' :';1 .:~/ ~ ~2

f
SPIRITUAL ASSESSMENT: 01n1tial 0 Follow-up Referral 0 Trauma 0 Code 0 Death 0 _~_ _ _ _ _ _ __ - DISTRESS: 0 Anger 0 Fear 0 Anxious 0 lonely 0 Guilty 0 Pain 0 Grjef D _ _ _ _ _ _ _ _~______ ~ RESOURCES; 0 Gratitude 0 Tr~ Ho . Po~itive Image of God ~mi!y/FriendS 0 Church 0 ~=_ _=~_ _ SERVICES; 0 Saeram~nts ~yers.., Support 0 Literature 0 Support To Family 0 _ _ _ _ _ _._ _ _ _ _ __ - ADVANC DIRECTIVES: 0 Va No 0 Unknown by Patient 0 Inappropriafe to Ask 0_-,------,_ _, _ _ _----:-_ __
(.'-=-i--.d-_
,Cl
C;
iii'!
;, \""
cl4Cil""
Chaplain:
~,1
:I V
SI.M1 OOQ-003 (6f2G03) 02 BACK
000360
~ ----~----~----------------------~------------~~~~~------~~---
~SSM
H E A L T H . CAR
SLM1000-003 (612003) 02 FRONT
E~
DEPAUT, HEALTH C'RNTEP.

MAl~CH, PHILLIP H
r
liP OJ36000302 MED 0530-01 lO/02/lY I6 3lY 1'1 12/26/0"

000"148298
1IlIIlff111111BIlftilltl
l1J\l'1Af'I, TMRAN A
000361
~SSM
H E A L r H . CAR
SLM1000003 (Ot20()3t 02 BACK
E~
000362

Dilte
Time
\ NOTES MUST BE SIGNED
I ~----~----~----------------------T-------------~~~LA~B~R-------------~SSM
H E A L T H . CAR

MARCH PHILLIP H
~-
IHlUIUlIlIIlltlllUlil1
INTERCISC1PLlNARV HISTOFIYa. PROGRESS NOTES
07J60~0302 MED OS30-0J_ 10 / 02/J9763lY M 12/26/ 01 HAi~AF11 .LHRAN 1\ OOO'l4B29ll
1;-' L
000363

Dale
TUlle
INOTES MUSf Bt SI(iNED
PA 71ENT LABEL
~SSM
HEALTH
DEPAUL H5ALTH C&NTER
CAR
E~
INTERDISCIPI.INARY HISTORY & PROGRESS NOTES
rip MARCH/PHILLIP H MED 0530-01 0736000302 10/02/1976 3lY r,l 12/26/07

HANAFI, lMR1\N A
1IIIIIIIIUlDl.III~U
000748298
SLMl00o.003 (612003) 02 BACK
000364

CONSULTATION REPORT
PATIENT: MARCH, PHILLIP H ADMIT DATE: 12126/2007 CONSULT DATE: 12/27/2007 ATTENDING PHYS: IMRAN A. HANAFI. M,O. CONSULTING PHYSICIAN: MICHAEL J. KENNEDY, M.D. MR#: 000748298 ACCT#: 0736000302 DOB: 10/02/1976 ROOM: 0530
REASON FOR CONSULTATION:
Evaluate patient with chronic left mandibular osteomyelitis.
SOURC E: The patient's current Inpatient medical record and old infectious disease consult note and the patient himself
HtSTORY OF PRESENT ILLNESS: A 31-year-old African Am eriean male with a history of hypertension and stab injury to his left face/jaw reQuiring surgery with hardware placement at Barnes Jewish Hospital. The patient subsequently developed infection and had the hardware removed and has since had a chronic left mandibular osteomyelitis. He Is currently being treated with IV clindamycin and meropenem until mid January for his osteomyelitis and has a Pice line in his right upper arm. The patient frequently presents to emergency rooms complaining of increased left jaw pain and swelling. He presented to DePaul Hospital Emergency Room yesterday with complaints of two days of increased left facial pain and swelling but no other systemic symptoms, He was continued on his current IV antibiotics and vancomycin was added. He was admitted for further evaluation and treatment and I was asked to see him for antibiotic management. A CT scan of the face was unchanged from prior and did not reveal any new sign of infection. He has been afebrile with a normal white cell count and cultures from the blood have been negative. The patient denies fevers. chills, sweats, nausea, vomiting, diarrhea, constipaUon, chest pain, shortness of breath, productive cough, sinusitis, otitis, pharyngitis, abdominal pain, dysuria, blood in his urinH or stool, rashes, headache, visual changes, oral lesions Of thrush. arthralgias, myalgias, back pain or problems with his PICC line site He recently had a gram ne9stive rod bacteremia secondary to P1CC line infection so his PICC line was removed and he was put on his current antibiotics.
Al.LERGIES: No known medica! allergies,
MEDICATIONS: At home, Clindamycin. 2 Meropenem.
CUrrent Inpatient medications include 1 Clindamycin. 2 Meropenem. J VancQmyv in .
PAST MEDICAL HlSTORY: As per HPI. He denies other medical problems Of surgical history.
SOCIAL HISTORY: He is single, has four children, he works as a bounty hunter. He denies tobacco, drinks occasional alcohol. He denies recreational drug use. He denies TB exposure. He has one tattoo.
REVIEW OF SYSTEMS: As per HPI, otherwise negative. PHYSICAL EXAMINATION; GENERAL: Well-developed, well-nourished young AfricanAmerican male In no apparent distress. VITAL SIGNS: Temperature 98.4 degrees, pulse 57, respirations 18, blood pressure 162/115, Sa02 98% on room air. SHEE NT: Skin is warm and
MEOICAU5URGICAL CONSULTATION REPORTOP
- Page 1 of 2
000365

PATIENT: MARCH, PHILLIP H
CONSULTATtON REPORT MR#: 000746298
dry. No lymphadenopathy. Head IS normocephalic and atraumatlc except for some mild to
moderate left facial swelling. There is no overlying erythema or fluctuance. Eyes - pupils were equal, round, and reactive to light and accommodation. Extraocular muscles are intact. Sclerae and conjunctivae are anIcteric. Oropharynx Is clear. No orallesion~ or thrush He has good dentltlon. NECK: Supple, soft, flO lymphadenopathy, no JVO, no bn.ritti, no thyromegaly, no meningismus. LUNGS: Clear to auscultation. HEART: RegUlar rate and rhythm with a soft systolic murmur. Pulses +2/4. ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. No appreciable hspatosplenomegaly. EXTREMITIES; No clubbing, cyanosis or edema. No evidence of peripheral emboli or an active synovitis. The right upper extremity PICC line site is benign. There is no inguinal or A)(illary Iyml'hadenopathy. BACK: No costovertebral angle or
spinal tenderness.
LABORATORY AND XRAY DATA: White blood cell count 4.9,43% neutrophils, hemoglobin and hematocri112.3 and 35.2, MeV 80, plateletcoun1214,OOO. Sodium 136, potassium 3.9, chloride 103, C02 31, BUN 12, creatinine 1, glucose 77, AST 125. Blood cultures x2 are negatIve. CT scan of the face is unchanged from prior with no new evidence of infection.
IMPRESSION: 1 ChroniC left mandibular osteomyelitis, status post hardware removal. Prior cultures at Barnes grew Streptococcus anginosis, StreptococC\ls intermedius and Eikenella corrodens. He is currently on IV clindamycin and IV meropenem until mid January. 2 Chronic left jaw pain/suspect narcotic-seeking behavior. 3 Hypertension.
RECOMMENDATIONS: Would discontinue vancomycin. 2 Continue cllndamyein and meropenem IV as directed by Dr. Zinser with hoTTie health therapy. 3 Would use ice or heat to the left face PJ.n. for swelling. At this time, it 15 okay to discharge him home with his current home IV antibiotics as previously ordered and to follow up with Dr. Zinser as an outpatient when he returns from vacation. I will sign off. Thank you for allowing me to participate in the care of your patlent. At this time, ! will sign off but please feel free to call me with any questions.
MICHAE!'" J, KENNEDY, M.D.

MJK:418-2117298 0: 12/27/20078:04 PM T: 12127/20079:24 PM E: 12/27/200722:01 PM
cc:
IMRAN A. HANAF1, M.D.
MEOICAUSURGICAL CONSULTATION REPORT-DP
- Page 2 of 2
000366

CONSULTATION REPORT PATIENT! MARCH, PHILLIP H AOM'T DATE: 12/26/2007 CONSULT DATE: 1212712007 ATIENDING PHYS: IMRAN A. HANAFI, M.D. CONSULTING PHYSICIAN: MICHAEL J. KENNEDY, M.D.
MR#: 000748298
ACCT#: 0736000302 DOS: 10/02/1976
ROOM: 0530
REASON FOR CONSULTATION: Evaluate a patient with chronic left mandibular osteomyelitis.
SOURCE: The
patlent'~ current inpaUent medical record, an old Infectious disease consult note
and the patient himself. HISTORY OF PRESENT ILLNESS: A 31-year-Old African American male with a history of hypertenSion and stab Injury to his left face/jaw requiring surgery with hardware placement at Barnes Jewish Hospital. The patient subsequently developed infection and had the hardware removed and has since had a chronic left mandibular osteomyelitis. He Is currently being treated with IV clindamycln and meropenem until mid January for his osteomyelitis and has a PICC line in his right upper arm. The patient frequently presents to emer99ncy (ooms complaining of Increased left jaw pain and sweHlng. He presented to DePaul Hospital Emergency Room yesterday with complaints of two days of increased left facial pain and swelling but no other systemic symptoms. He was continued on his current IV antibiotics and vancomycin was added. He was admitted for further evaluation and treatment and I was asked to see him for antibiotic management. A CT scan of the face was unchanged from prior and did not reveal any new sign of infection. He has been afebrile with a normal white cell count and cultures from the blood nave been negative. The patient denies fevers, chills, sweats, nausea, vomiting, diarrhea. constipation, chest pain, shortness of breath, productive cough, Sinusitis, otitis, pharyngitis, abdominal pain. dysuria, blood in his urine Dr stool, raahes, headache, visual f.,ilsnges. oral lesions or thrush, arthralgias, myalgias, back pain or problems with his Pice line site. He recently had a gram negative rod bacteremia secondary to Pice line InfectIon so his PICC tine was removed/replaced and he was put on his current antibiotics by Dr. Zinser. ALLERGIES: No known medical allergies. MEDICATIONS: At home, 1 Cllndamycin. 2 Meropenem. Current Inpatient medications include 1 Cllndamycin. 2 Meropenem.
:3
Vancomycin.
PAST MEDICAL HISTORY: As per HPI. He denies other medical problems or surgical history. FAMIL Y HISTORY: Noncontributory.
SOCIAL HISTORY: He is Single, has four children, he works as a bounty hunter. He denies tobacco and drinks occasional alcohol. He denies recreational drug use. He dentes T8 exposure. He has one tattoo. REVIEW OF SYSTEMS: As per HP1, othef'INise negative.
PHYSICAL EXAMINATION: GENERAL: Well-developed, well-nourished young AfricanAmerican male in no apparent di$l(ess. VITAL SIGNS: Temperature 98.4 degrees, pulse 57. respirations 18, blood pressure 162/115, Sa02 98% on room air- SHEENT: Skin is warm and
MEP1CAU5URGICAL CONSULTATION REPORT-OP
- Page 1 of 2
000367

PATIENT~
CONSULTATION REPORT
MARCH, PHILLIP !1.-'--__________ M_R_#_:..:.-00:-0_74_8_2..:.-98 ___~....__~
dry, No ~ymphadenopathy, Head is normocephalic and atraumatic except for some mild to moderate left facial swelling. There is no overlying erythema or fluctuance. Eyes - pupils were equal, round, and reactive to Ilght and accommodation. Extraocular muscles are intact. Sclerae and conjunctivae are anicteric. Oropharynx Is clear, No oral lesions or thrush. He has good dentition. NECK: Supple, soft, no lymphadenopathy, no JVD t no bruit~, no thyromegaly, no meningismus. LUNGS; Clear to auscultation. HEART: Regular rate and rhythm with a soft systolic murmur. Pulses '1-2/4. ABDOMEN: Soft, nontender, nondistended, normoactive bowel sounds. No appreciable hepatosplenomegaly. EXTREMITIES: No clubbing, cyanosis or edema. No evidence of peripheral emboli or an active synovitis, The right upper extremity Pice line sIte is benign. There is no Inguinal or axillary lymphadenopathy, BACK: No G05tovertebra! angle Qr
spinal tenderness.
LABORATORY AND X-RAY DATA: White blood cell count 4.9, 43% neutrophils, hemoglobin and hematocrit 12.3 and 35,2, MeV 80, platelet count 214,000. Sodium 136, potassium 3.9, chloride 103, C02 31, BUN 12, creatinine 1, glucose 77. AST 125, Blood cultures x2 are negative. CT scan of the face is unchanged from prior with no new evidence of infection. IMPRESSION: 1 Chronic left mandibular osteomyelitis. status post hardware removal. Prior cultures at Barnes grew Stftlptococcus sanginosis. Streptococcus intermedius and Eikenel\a corrodens. He is currently on IV cllndamycin and IV meropenem until mid January. 2 Chronic left jaw painfsuspect narcotic-seeking behavior. 3 Hypertension.
RECOMMENDAT~ONS;
1
2
Would discontinue vancomycin.

Continue cUnoamycin and meropenem IV as directed by Dr. Zinser with home health therapy. Would use ice or heat to the left face p.r.n. for swelling. At this time. it is okay to ct\sch~rge him home with his current home IV antibiotics as previously ordered and to follow up with Dr. Zinser as an outpatient when he retums from vacation. Thank you for allowing me to participate in the care of your patient. At this time. I wi\! sign off but please feel tree to call me with any questions.
This document has been reviewed and signed by MICHAEL KENNEDY Sign Datemme: 0111112008 3:58PM EST
MICHAEL J. KENNt;DY M.D.

j
MJK:418 - 2117298 0: 12/27/20078:04 PM T: 1Zf27/2007 9:24 PM E: 01111/200817:01 PM cc: tMRAN A. HANAFI. M.D.
MEDICAL/SURGICAL CONSULTATION REPORT -DP
- Page 2 of 2
000368
~~. .~_ _~8tI: 49'2 "81,,$,

RUIGNif'OA _.tiNa 1Qtlliil"GENCY ROOM TODAY:
.AQc"'It.~""""~~=-+=H~..;......&___ CltyIZlP:
CLOCK IN
HERE
,10 'al,2'
~
.".. ~a.r...L::..J"JL.A.s.-- Dam. of Birth: 10
., 6
000369
SSM DEPAUL. EMERGENCY FLOW SHEET RECORD Name: March, Phillip Age: 31 Y MR: 000748298 Acct: 0736000302
VITAL SIGNS
User MEE CBLA
DateiTime
12/2618:53 121'2615:47
BP 159/105 1 50198
PULSE 63 65
RESP 20 16
TEMP 98.4 98.4
PAIN 9 9
02 SAT TIME 100 on ra 1845 100 on ra 1544
Name: March, Phillip Age:: 31Y MR: 000748298 Acct: 0736000302 Prepared: Wed Dec 26 21 :25:29 2007 by Julie "''lInchez, RN
Page: 1
000370
--------------TR'AGE DATA----""""""'-------Complaint: Facial Swelling And Pain

Triage Time: Wed Dec 26 2007 15:47
Name: March, Phittip H Age: M31 wt: 73.5 Kg
MedRec:00074629a
AcctNum: 0736000302
Room;
Source: By: Carried Urgency; ESI-3
Age: 31
Male
Kg Weight: 73.5 Physicians:

Phillip G Zinser Emergency Physicians
WAITING
Vital Signs: (1544) BP;150198

T:98.4
Paln:9
P:65
Sat: 1OOlra
R:16
KNOWN ALLERGIES
HISTORY (Wed Dec 262007 15:47 CBLA) MEDICAL HISTORY: Hlstory of hypertenoion, Patieflt is noncompliant with treatment, Stabbed In left face
April 28th..L20QZ History of hypertension, Patient is noncompliant with treatment, History of h~n8ion, jaw oeteomyentls. HAS Pice LINE FOR IV ANTIBIOTIC. History of hypertension, Patient's noncompllant witlHr~fment, Stabbed-InlelHace April 28th; 2001. History of hypertension, Patient is noncompliant with treatment, ' History of hypertension, Jaw osteomyelitis. HAS Pice LINE
FOR IV ANTIBIOTIC.. PSYCHIATRIC HISTORY; No previous psychiatric history. No previous psychiatric history. No previous
history~revlous
psychlatric history. No previous psychiatric
psychiatric history.
SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is
not relevant to the case. Jaw Repair, plate left jaw faCial repaIr. Patient's prevloutlYr9ical history Is not relevant to the case. iawJracture repairs. Jaw Repair, plate left Jaw. fac'al repair .... SOe1A1.HISTORY: Denies smoking, PatIent Consumes lllcohol soclaUy, oen'eg~buse, LIves at home with family, Denies alcohol abuse, Denies tobacco, Denies alcohol abuse, Denies tobacco abuse. Denies smokIng, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco. Denies alcohol Bbua&, Dentes tobacco abuse. FAMILY HISTORY: Family history i1S not contributory to this case. Family hlstory is not contributory to this case. Family history is not contributory to this caee. F@ffiJly history Is not contributory to this case . NOTES; Nursing records reviewed, Agree with nursing records, Nursing records revlewed 1 Agree with nursing records, Agree wit" nursing records. Nursing records reviewed. Nur&ing records reviewed..
ADDIT10NAL TRIAGE (Wed Dec 26 200715:47 CBLA)

COMPLAINT
PROVIDERS: TRIAGE NURSE: Cherie Blaesing, RN.
ADMISSlON PATIENT: NAME: Phillip H March, DaB: Sat Oct 021976, RACE: Black, Code; NO, Trauma; "NO, Work Comp.: NO, Heat Related: NO, SSN: 493788699, ZIP CODE: 63121, HEIGHT: i82cm, PHONE:
314387-8122, MEDICAL
RECORD NUMBER: 000748298,
ACCOUNT NUMBER: 0736000302, IBEX NUMBER:
20071226154742ADT,
Prepared; Wed Dec 26 2007 15:46 by Cherie 6Ia&slng. RN Page: , SSM DePaul Health Center
of 2
000371
11m liitl 11111 tl!1l IIII! Itfll
~IIJ ~1If IIffl !lItllf!ll 11111

Agf1: M31
MsdRec:000746298 AcctNum: 0736000302
wt: 73.5 Kg
PREVIOUS VISIT ALLERGIES: No known drug allergies. FALL RISK: TIME: 1544, Gender (Male), Score: 1. ASSESSMENT: 9, GCS Eye Opening: Spontaneously (4), GCS Verbal Response: Oriented/conversive (5), GCS Motor Response: Obeys comands(6). The GCS total is 15, GO It side facial swelling for a while states has been stabbed and got infection and1.akes iv an1ibiotics at home pi has pice line. TB SCREENING: Denies TB screening . .-~ DOMESTIC VIOLENCE: The presence of domestic vIolence is unknown. EDUCATIONAUCULTURAL BARRIERS; NQ educational/cultural barriers. TREATMENTS IN PROGRESS: No trealment VITAL SIGNS
KEY:
CBLA=Blaeslng, RN, Cherie
Prepared; Wed Dec 26 2007 15:48 by Cherie Bla~!iling, AN Page;;1 of 2 SSM DePaul Health Canler
000372

Complaint: Facial Swelling And Pain
Triage Time: Wed Dec 26 2007 15:47 Source:
BV; Carried
Name: March, PhI/lip H

Age: M31
Wt: 73.5 Kg MedReG: 000748298
AcctNum: 0736000302
--------------------------~TRIAGEDATA---------------------------
Age: 31
Male
Kg Weight: 73.5 Physicians:

Phillip G Zinser
Urgency: ESI-3 Room: Vital Signs: (1544) BP:t50f98 T:98.4
Emergency Phys icians

WAITING
P:65
R:16
Sat:100/ra
Paln:9
HPI BLANK (19:26 AMAR)

CHIEF COMPLAINT:
The patient pr~sents with worsening left sided jaw pains. He reports having a history
of a broken iaw with sev~ral s.urgeries for repairs. He reports a history Of bone infections and Is currently
undergoing antibiotic t-herapy via PICG line leyeralifmeSdany: He reportscurrently taking clindamycln and merrem. He reports that the swe~ In hl~ law is worsening, and that the pain is Increasing., HISTORIAN; History obtaIned from p a t i e n t . -----------. TIME COURSE: Onset of symptoms reported liS gradual, Complaint is worse, Complaint is persistent. SEVERITY Maximum severity is moderate, Currently symptoms are moderate,
KNOWN ALLERGIES No Known drug allergies.
HISTORY
MEDICAL HISTORY (Wed Dec 26 2007 '5:47 CBLA): History of hypertenslon, Patient Is noncompliant with
treatment, Stabbed In left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, . History of hypertension, Jaw osteomyelitis. HAS Pice LINE FOR IV ANTlBIOTIC. History of hypertension, Patient is noncompliant with treatment, Stabbed In left f~~~ April 28th, 2007. HIstory of hypertension, Patient Is noncompliant with treatment, . History of hypertension, law
ost6omy~lltis. HAS LINE FOR IV ANTIBIOTIC .. PSYCHIATRIC HISTORY (Wed Dec 26200715:47 CBLA): No previous psychiatric history. No previous
PIce
psvchlatric history, No previous psychiatric history. No previous psychiatric history .. No previous psychi9tric htstory .. SURGICAL HISTORY (WAd Dec 26 200715:47 CBLA): Jaw Repair, e!me __1ett iaY'l...J~!!l!.r~..pair. Patient's previous surgical history is not relevant to the cast[:;'~wJlepair, plate letUaw~1 repair. Patient's prevlou& suf'gical hislciryTi not relevant to the case. Jaw fracture repairs. Jaw Repair, plate lett law. facial repair':":_----. .-_. - --' .. SOCIAL HISTORY (Wed Oec 26 2007 15:47 CBLA): Oenles smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse. Denies tobacco. Denies alcohol abuse, Denies tobacco abuse. Denies smokIng, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco. Denies alcohol abuse, Denies tobacco abuse.. FAMIL Y HISTORY (Weo Oec 26 2007 15:47 CBLA): Family history is not contributory to this case. Family
Prepared: Wed Dec 26 2007 <:1 :25 by Julie Sanchez, RN Page: 1 of 7

SSM CJePaul Health Cenler
000373
11m 11II! Imt IlIllIllll 1/lJIIl fIlII III 11111 lllll 1111111111
Name: March, Phillip H Age: M31 WI: 73.5 Kg MedRec:000748298 AcctNum; 0736000302
history is not contributory to this case. Family history is not contributory 10 this case Family hlSlOry is n01 contrib\Jtory to this case .. NOTES (Wed Dec 26 2007 15:47 CBLA): Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. Nursing records reviewed .. (19;ZG AMAR): Nursin~ records reviewed, Agree with nursing records.
ROS (19:26 AMAR)

ALL SYSTEMS NEGATIVE; All systems were reviewed and are negative except as described above.
ADDITIONAL TRIAGE (Wed Dec 26 2007 15:47 CBLA)

COMPLAINT PROVIDERS; TRIAGE NURSE: Cherie 8Iaes[ng. RN. ADMISSION PATIENT: NAME: Phillip H March. DOB: Sat Ocl 021976. RACE: Black, Code: NO, Trauma: -NO, WorK Comp.: NO, Heat Related: NO, SSN: 4937B8699, ZIP CODE: 83121, HEIGHT: 1B2cm, PHONE: 314387-8122, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0736000302, IBEX NUMBER: 20071226154742ADT. PREVIOUS VISIT ALLERGIES: No known drug allergies. FALL RISK: TIME: 1544. Gender (Male), Score: 1. ASSESSMENT: 9, GCS Eye Opening: Spontaneously (4). GCS Verba! Response: Oriented/conversiv8 (5), GCS Motor Response: Obeys Gomands(6). The GCS total is 15, co It side facial swelling for a while states has been stabbed and got infectIon and takes iv antibiotics at horne pI has pice hne. TB SCREENING: Danies TB screening. DOMESTIC VIOLENCE: The presence of domestic violence is unknown. EDUCATIONAUCULTURAL BARRIERS: No educational/cultural barriers. TREATMENTS IN PROGRESS: No treatment VITAL SIGNS
PHYSICAL EXAM (19:27 AMAR)

CONSTITUTIONAL: Vita! signs reviewed, Comfortable, Alert and oriented X 3, Hypertensive. HEAD: Atraumatic, Normocephalic. EYES: Pupils equal and reactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal, Conjunctiva are normal. ENT: tender over left posterior lower molars. Swellin9 and tenderness present over the angle of the mancH~le. ~);VTcMa<len6patny~t.. NECK: Normal ROM, No meningeal signs. RESPIRATORY/CHEST: Chest is non lender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. ABDOMEN: Abdomen is non1ender, No masses, BowE:'l1 sounds normal, No distension, No peritoneal signs. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Inspection normal, No cyanosis/clubbingJedema, No calf tenderness, Normal range of molion.
Preparso: Wed Dec 26 2007 21 :25 by Julie Sanchez, RN Page: 2017
SSM DePaul Health Cantor
000374
lllllllllf ItIII tflllll ~lllIlIlllflllllllf III 11111 It Ilf '11f!

LAB INTERPRETATION (19:27 AMAR)
INTERPRETATION: I reviewed the lab results.

Age: M31 Wt: 73.5 Kg MedRec:000748298 AcctNum: 0736000302
NEURO: GCS is 15, No focal motor deficils. No tocal sensory deficits, No cerebel19r deficits.
RESULT5 (19:04 AMAR)

LAB: CBC W AUTO DIFF Dec 26 2007 16:25, WBC 5.3 1000/mm3 Ref Range (4,5-11.0), RBC 4,75 TOX6 Ref Range (4,7-6,1). Hgb 13.2 gmJdl Ref Range (13.0-16.0), Hot 37.7 L % Ref Range (39.0-54.0),
MeV 79.4 L 11 Ref Range (80.0-99,0),

MCH 27.8 pg Ref Range (25.0-31.0), MCHC 35.0 gm/dl Ref Range (32.0-36.0), ROW 14.5 % Ref Range (11.5-14.5), Platelets 220 1000/mm3 Ref Range (130,0-400.0), Gran 66.0 % Ref Range (40.0-70.0),
Lymph 20.2 % Rei Range (22.0-40.0),

Mono 7.2 % Ref Range (2.0-10.0), Eos 0.2 % Ref Range (0.0-6.0), Baso 0.4 % Rei Range (0.0-3.0), Manual Diff Not Indicated. Absolute Neutrophil 3.48 1000/mm3. : COMPREHENSIVE METABOLIC PANEL Dec 26 200716:41, BUN 11 mg/dl Rei Range (9.0-20.0), Sodium 137 mEqfL Ref Range (137-145). Potassium 4.1 mEq/L Ref Range (3.6-5.0), Chloride 103 mEq/L Ref Range (98.0-107.0),
Glucose 73 L mg/dl Ref Rang~ (7$-110),

Creatinine 0.9 mg/dl Ref Range (0.8'1,5), AST/$GOT 174 H Ufl. Ref Range (17.0-59.0), Alk Phos 68 U/L Ret Range (38.0-126.0). Calcium 8,B mg/dl Ref Range (8.4-10.2), Billrubin 0.5 mg/dl ReI Range (0,2-1.3). Albumin 4.4 gm/dl R~f Range (3.5-5.0), Prot Tolal 6.8 gm/dl Ref Range (6.3-8.2),
C02 32 H mEqll Ref Range (22.0-30.0),

AL T/SGPT 71 U/L Ref Range (21.0-72.0), GFR 126.6 mllmin/1.73m2. : CBC W AUTO DIFF Dec 26 200716:25, wac 5.3 'OOO/mm3 Ret Range (4.5-11.0), RBC 4.7510X6 Rei Range (4.7-6.1), Hgb 13.2 gm/dl Ref Range (13.0-18.0). Hct 37.7 L % Ref Range (39.0-54.0),
Prepared: Wed Dec 26 2007 4:1 ;25 by JUlie Sanchoz, RN Page: 3 of 7
SSM DePaul Health Cer11er
J7S
[11fI11 11111111 mllltil tl fflllllllllll mil 11 III If lit IIJll

Mev 79.4 L fl Ret Range (80.0-99.0). MCH 27.8 pg Ref Range (25.0-31.0). MCHC 35.0 gm/dl Ref Range (32.0-36.0), RDW 14.5 % Ref Range (11.5-14.5), Platelets 220 10001mm3 Ref Range {130.0-400.0}, Gran 66.0 % Ref Range (40.0-70.0), Lymph 26.2 % Ref Range (22.0-40.0), Mono 7.2 % Ref Range (2.0-10.0), Eos 0.2 % Ref Range (0.0-6.0), Baso 0.4 % Ref Range (0.0-3.0),
Manual Diff Not Indicated,

Age: M31 W1: 73.5 Kg MedRec:000748298 AcctNum: 0736000302
Absolute Neutrophil 3.48 1000/rnm3,

: COMPREHENSIVE METABOLIC PANEL Dec 26 200716:41, BUN 1i mg/dl Ref Range (9,020.0), Sodium 137 mEq/l Ref Range (137-145), Potassium 4.1 mEq/L Ref Range (3.6-5.0), Chloride 103 mEq/L Ref Range (98.0-107.0),
Glucose 73 L mgldl Ref Range (75-110),

Creatinine 0.9 mg/dl Ref Range (0.8-1.5).
AST/SGOT 174 H Ull Ref Range (17.0-59.0).

Aik Phos 68 U/L Ref Range (38.()'126.0), Calcium 8.8 mg/dl Ref Range (8.4-10.2). Bilirubin 0.5 m\1/dl Ret Range {D.2-1.3}. Albumin 4.4 gm/dl Ref Range (3,55,0), Prot Tolal 6,8 gm/dl Ref Range (6.3-8.2), C02 32 H mEq/l Ref Range (22.0-3Q.0), ALTiSGPT 71 U/L Ref Range ,21.0-72.0), GFR 126.6 mllmin/1.73m2.
DOCTOR NOTES (20;15 AMAR) TEXT: D/w Dr. Siddiqui from 10 and will admit to IPC ..
PATIENT PLAN: The patienl
wm be admitted to the hospital.
DIAGNOSIS (20:04 AMAR) FINAL: PRIMARY: Cellulitis, ADDITIONAL: Facial Swelling, DISPOSITION (20:04 AMAR)
PATIENT: X-RAY/CT Follow-up: YES, Critical Care~ 'None. Doctor ProcedUres: NO, Disposition: AdmIt Medical, Condition: Improved.
MEDICATION SERVICE
Banadryl (21 :05 AMAR): Order: Banadryl : 25mg : IV Push POTENTIAL MODERATE INTERACTION Diiaudid POTENTIAL MODERATE INTERACTION Phenergan
Prepared: Wed Dec 26200721 :25 by Julie Sanchez, RN Page: 40t 7 SSM DePaul Heallh CentEr
370
000376
Name; March, Phillip H

Age: M31 Wt: 73.5 Kg MedRec: 000748298 AcctNum: 0736000302
Ordered: Wed Dec 26 2007 21 :05 Ordered by: Alan Martin, MD Entered by: Julie Sanchez, RN Wed Dec 26 2007 21 :05 Documented as given by: Julie Sanchez. RN Wed Dec 26200721 :06 MEDICA nON. Time given: 1935. Given in amount and via route as prescribed. Catheter placement confIrmed via flush prior to administration. IV site without signs or symptoms of infiltration during medication administration. No swelling during administration. No drainage during administration, IV flushed ",fter administration. Correct patient, tIme, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration. Clonldine (21 :17 AMAR): Order: C!onidine : 0.1 mg : By Mouth POTENTIAL MODERATE INTERACTION Senadry\ POTENTIAL MODERATE INTERACTION Dilaudid POTENTIAL MODERATE INTERACTION Phenergan Ordered: Wed Dec 26 2007 21 :17 Ordered by: Alan Manin, MD Entered by: Julie Sanchez, RN Wed Dec 26 2007 21 :17, Dilaudld (19:28 AMAR): Order: Dilaudld: 1 mg: IV Pust) Ordered: Wed Dec 26 2007 19:28 Ordered by: Alan Manin, MD Entered by: Alan Martin, MD Wed Dec 26 2007 19:28 Documented as given by: Julie Sanchez. RN Wed Dec 26 2007 19:35 MEDICATION. Time given: 1930, Given in amount and via route as prescribed, Catheter placement confirmf;Jd via flush prior to administration. IV site wi1hout signs or symploms of infiltration during medica1ion administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient. time, route, dose and medication confirmed prIor to administration, PaUent advised of actions and side-effects pnor to administration. Allergies confirmed and medications reviewed prior to administration. Phenergan (19:28 AMAR); OrQ~r: Phenergan: 12.5 mg : IV Push POTENTIAL MODERATE INTERACTION Dilaudid Ordered: Wed Dec 26 2007 19:28 Ordered by: Alan Marlin, MD Entered by: Alan Martin, MD Wed Dec 26 200719:28 Documented as given by: Julie Sanchez, RN Wed Dec 26 2007 19:36 MEDICATION, Tima given: 1930, Given in amount and via rOt,lte as prescribed. Catheter placement con1irmed via Hush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during adrninistration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and sideef1ects prior to administration. Allergies confirmed and medications reViewed prior to administration. Vancomycin Hydochloride (20:05 AMAR): Order: VancomYCin Hydochloride : 1 gm : IV Piggy B~ck Ordered: Wed Dec 26 2007 20:05 Ordered by: Alan Martin, MD Entered by: Alan Martin, MD Wed Dec 26 2007 20;05 .
Prepared: Wed Dec 26 2007 2125 by Julie Sanchez. RN page: 5 of 7 SSM DePaul Health Center
000377
IlllI/lltl ijllll1lt1lltl1 ~I~ ttllt IJ~lll~1 mIl 11m

NURSING ASSESSMENT: NURSES NOTE (18:48 MEE)
TIME ASSESSED: Time: 1830, ambulatory to rm 6,

Age: M31 WI: 73,5 Kg MedRec: 000748298 AcctNum: 0736000302
NURSING ASSESSMENT: FOCuSED (18:53 MEE)
pt states he had stab wound on upperleft upper cheek with repeated bone Infections and treatment with IV antibIotics via pic line at home. pt states despite this treatment he continues to have pain in left side of face and have intermittent episodes of swelling. this time the $welling began yesterday. currently pain at 9/10. NURSING DIAGNOSIS: left face pain and swelling.
NOTES: TIME ASSESSED: Patient was assessed at 1845. PAIN SCALE: On 21 scale 0-10 patient rates pain as 9, Quahly 01 pain is pressure, achIng. VITAL SIGNS: BP: 159,/105, Pulse: 63. Rasp: 20, Temp: 96.4, Pain: 9, 02 sat: 100. ra, Time: ~845. EYES: Eyes are PERRL. NEURO: Orientation: Alert, Orientel.i. Behavior: Cooperative, No weakness present, No numbness present, Coherent. GCS: GCS Eye Opening: Sponlaneously (4), GCS Verbal Response: Oriented/conl/arsive (5). GCS Motor Response: Obeys comands(6), The GCS total is '5. RESPIRATORY: Breath sounds:, Brealh sounds are clear. blla1erally. ABDOMEN: Abdomsn is non-tender, Abdomen is soft, Abdomen is flat, Bowel sounds present. MUSCUL.OSKELET AL: Good ROM, Normal pulses, SKIN: Skin is warm, Skin is dry, Skin color is normal. SAFETY: Side rails up, Cart in lowest position, Call light Within reach.
NURSING ASSESSMENT: NURSES NOTE (19:52 JSAN) TIME ASSESSED: Time: 1925. Assumed care of pI. Pl in no distress but is c/o fascial swelling and pain on right jawline into neck i'HlB. Pt is NQ x 3 1 h~art tones regular, lun~$ clear. SIP elevated at this time.
pain rx ordered.
NURSING PROCEDURE: LAB DRAW (16:09 eSLA)

TIME: Procedure was performed at 1609, Blood obtained from PICC labs sent, with 1 attempt, Blood cultures sent.
NURSING PROCEDURE: ADMISSION (21 :25 JSAN)

TIME: Report called at 2120, PI. admitted to room, 530, Patient admitted to med-surg unit, Report called/faxed to JudY,RN, Patient transported wheelchair.
ADMIN
DIGITAL SIGNATURE (16:10 CBLA): Blaesing, RN, Cherie. i21 :25 JSAN): Sanchez, RN. Julie. PATIENT DATA CHANGE (18:31): A08 70912600 by Interface. Payment: 90, Admitting Doctor: Zinser PhllHp G, AUending Doctor: Physicians Emergency,
Prepared: Wed Dec 25 2007 21 :25 by Julie Sancho'll, RN Puge: 6 of 7
SSM DePaUl lil'tlllt'l Center
000378
Illfll! (fIllllt 1111111
~lllllllj III 11111 It/If fIlII 11111 Illfl

Name: March, Phillip H Age: M31 Wt: 73.5 Kg MedRec:000748298 AcctNum: 0736000302

Emergency.
(19:04 AMAR): Attending changed from (none) to Alan Martin, MD. (21 :08 JSAN): Admit Room: 530, Admit Area: full admit, Payment: (none).
(18:36): Aoa 70912659 by Interface, Admitting Doctor: Zinser Phillip G, Attending Doctor: Physicians
KEY:
AMAR:::Martln, MD, Alan CBLA=Blae$lng, AN, Cherie
JSAN=Sanonez, RN, Julie MEE=Etherldge, RN; Marilyn
Prepared: Wed Dec 26 2007 2125 by Julie Sunvhe7, RN Page: 7017

SSM DePaul Heal\l1 Center
000379
111111111111 ttl If
~IIJ ({lllllllllllli tfl It11111filIIIlIlltll
mtll! tIl Imf 11111 II lit Ill/I filiI
~III 111I1111If lIIIl

HPIBLANK
Name: March, Phillip H Age: M31 Wt: 73.5 Kg MedRec: 000748298 AcctNum: 0736000302
CHIEF COMPLAINT: The patient pres~mts with worsening left sided jaw pains. He reports having a history of a broken jaw with several surgeries for repairs. He reports a. history of bone Infections and is currently undergoing antIbiotic therapy via PIce line severa' times daily. tie reports currently taking clindamycin and merrem. He reports that the swetHng In his jaw is worsening, and that the pain is Increasing.. HISTORIAN: History obtained from patient. TIME COURSE: Onset of symptoms reported as gradual, Complaint Is worse, Complaint is persistent. SEVERITY: Maximum severity is moderate, Currently symptoms are moderate.
HISTORY
MEDICAL HISTORY: HIstory of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant wIth treatment,. History of hypertension, jaw osteomyelitis. HAS Pice LINE FOR IV ANTIBIOTIC. History of hypertension, Patient Is noncompliant with treatment, Stabbed in left face April 28th, 2007. HIstory of hypertension, Patient Is noncompliant with treatment, . History of hypertension, jaw osteomyelitIs. HAS Pice LINE
FOR IV ANTIBIOTIC..
PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. No previous psychiatric history .. No previous psychiatriC history.. SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history Is not relevant to the case. Jaw Repair, plate left law. facial repair. Patient's previous surgical history Is not relevant to the case. jaw fracture repairs. Jaw Repair, plate left taw. facial repair ... SOCIAL HISTORY: Denies smoking. Patient consumes alcohol socially, Denies drug abuse, Lives at home with famlty, DenIes alcohol abuse, Oenles tobacco. Denies alcohol abuse. Denies tobacco abuse. Denies smoking, Patient consumes alcohol SOCIally, Denies drug abuse, Lives at home with famIly, Denies alcohol abuse, Dentes tobacco. Denies alcohol abuse, Denies tobacco abuse .. FAMILY HISTORY: family hi$t9ry j~ not contributory to this case. Family history is not contributory to this case. Family history is not contributory to thIs case. Family history is not contributory to this
C{J$~ .
NOTES: Nursing records reviewed, Agree with nursing records, Nursing records reViewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. NUfsing records reviewed .. ; Nursing records reviewed, Agree with nursing records.
ROS
ALL SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above.
PHYSICAL EXAM
CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3, Hypertensive. HEAD: Atraumatic, Normocephalic. EYES: Pupils equal and (EJactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal, Conjunciiva are normal. ENT: tender over left posterior lower molars.
Prepared: Wed Dec 26 2007 21 :25 by Julie Sanchez:, RN Page: 1 oj 3
SSM D!tP~ul Health CantaT
000380
Ilft/tlllllllll tlllllltllliJIlllfJI111J1 tlllllltllllllllllJI

Swelling and tenderness presenl over the angle at the mandible. Cervical adenopathy present.. NECK: Normal ROM, No meningeal signs. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs. No rUb, No gallop. ABDOM~N; Abdomen is non-tendi:n, No masses, Bowel sounds normal, No distension, No peritoneai signs. UPPER EXTREMITY; Inspection normal, No cyanosIs/clubbing/edema. Normal range of motion. LOWER EXTREMITY: Inspec1ion normal, No cyanosis/clubbing/edema, No calf tenderness. Normal range of motion. NEURO: GCS is 15. No focal motor delicits, No local sensory de1icits, No cerebellar deficits.
DOCTOR NOTES
TEXT: O/w Dr. Siddiqui from ID and will admit to IPC .. PATIENT PLAN: The patient will be admitted to the hospital.
DIAGNOSIS
FINAL: PRIMARY: Cellulitis. ADDITIONAL: Facial Swelling.
DISPOSITION
PATIENT: X-RAY/CT Follow-up: YES. Critical Care: 'None. Doctor Procedures: NO. Disposition: Admit Medical, Condition: Improved.
MEDICATION SERViCE
Benadryl: Order: Benadryl : 25mg : IV Push POTENTIAL MODERATE INTERACTION Dilaudid POTENTIAL MODERATE INTERACTION Phenergan Ordered: Wed Dec 262007 21 :05 Ordered by: Alan Martin, MD Ent8red by: Julie Sanche~. RN WftQ b)E;lG 26 2007 21 :05 Documented as given by: Julie Sanchez, RN Wed Dec 26 2007 21 :06 MEOICATION ! Time given: 1935. Given in amoun1 and via route as prescribed, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiHraUon during medication administration, No swelling during administration, No drainage during administration. IV flushed after administrahofl. Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior 10 administration. AllergIes confirmed and medications reviewed prior to administration. Clonidine: Order: Clonldine : 0.1 mg : By Mouth POTENTIAL MODERATE INTERACT10N Banadryl POTENTIAL MODERATE INTERACTION Di!audid POTENTIAL MODERATE INTERACTION Phenergan Ordered: Wed Dec 26 2007 21: 17 Ordered by: Alan Martin, MD Entered by: JUlie Sanchez, RN Wed Dec 26 2007 21 :17 , Dilaudid: Order: Di!audid: 1 mg: IV Push
Prepared' Wed Dec 26 2007 21 :25 by Juli~ SMchBZ, RN Page' 2 of 3 SSM DeP~ul Heollh Center
000381
llltlllllll! III rIllllltll1l Jl! 1111111 JJ/ tlill 11111 II lIt IIIll

Ordered: Wed Dec 26 200719:28 Ordered by: Alan Martin, MD Entered by: Alan Maf1in. MD Wed Dec 262007 19:28 Documented as given by: Julie Sanchez. RN Wed Dec 26 2007 19:35 MEDICATION, Time given: 1930. Given in amount and via route as prescribed. Catheter placement confirmed via flt,Jsh prior to administration, IV site without signs or symptoms of infiltration during medication adminislration. No swelling during administration. No drainage during administration, IV 11ushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies coniirmed and medications reviewed prior to adminlstration. Phenergan: Order: Phenergan : 12,5 mg : IV Push POTENTIAL MODERATE INTERACTION O\laudid Ordered: Wed Dec 26 200719:28 Ordered by: Alan Martin, MD Entered by: Alan Martin, MD Wed Dec 26 200719:28 Documenled as gIVen by: Julie Sanchez, RN Wed Dec 26 200719:36 MEDICATION, Time given: 1930, Given in amount and via route as prescribe(.l, Catheter placement confirmed via flush prior to administra1ion, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration. IV flushed after administration, Correct patient, time, roule. dose and medication confirmed prior to administration, Patient advised of actions and Side-effects prior to administration, Allergies confirmed and medications reVlf:lwed prior to administration, Vancomycin Hydochloride: Order: Vancomycin Hydochloride ; 1 gm ; IV Piggy Back Ordered: Wed Dec 262007 20:05 Ordered by: Alan Martin, MD Entered by: Alan Martin, MD Wed Dec 26 2007 20:05 .
Pr9par~u:
Wed Dec 262007 212G by Julie Sa,ncheT, RN Page: 3 of .3

SSM DePaul Hlffil1h Conter
000382
IIIII 11111
lillt 111111111111 til IItJllllll 111/1 1/111 11111 f!1I!

Name: March, Phillip H Age: M31 WI: 73,5 Kg MedRec: 000748298 AcctNum: 0736000302
SSM DEPAUL RECORD
Prepar9d: Wed Dec 262007 Z1 :25 by Julie SBnch~z, RN Page:

SSM DePaul Haanl1 Center
1 of
000383
Emergency Department Orders General Chief Complaint

Drugs must be
disp~nsed
Allergies:
in accordance ,.. ith the hospitnj formulnry sys(e>m.
1.
Assessment: Nutify physician if SBP <: 90 or> 195, or heart rate < 60 or> 120, or for decreas Inentru stalus Pulse oximetry (notify physician for Sa02 <92%) and Temperature recorded Assess women ofchiIdberuing age for pregnancy status and perform urine beta Ifor any possibility of pregnancy
II.
III.
VI.
Additional Orders:
DEPAlJL HEAL'l'H CEN1'ER
MJl,RCH PHILLIP H
0736000302 10/02/ 1976 sRS
\111".111
~
ERQ
Et-mRGENCY,P
3H;~ICIA00074B298
12/26/07
000384
pi\tient Report Form
POA
Social History:
Cardiac Rhythm:
~----!...:...-~---';o--r-I-----~--~':"'--Fo-J"..oC.--------IASA
Current PaIn Score:

Abnormal Assessment Findings:
Last Med given:
Acute MI given @ Beta Blocker;
f1U1j
~'Qt)v"g/Lv;-..s:.',
Pertinenl/AbnormallablX-ray Results CKlCKM8
Next Draw
". Isolation:O None 0 Airborne D roplst 0 Contact {J Spacial Contact VRE C dif MRSAlVRE Screen date: - sDIts: MRSA
Troponin
Next Draw
IV Type
Size:
Intake:
a Peripheral 0
TL
ICC
tart Date:
Site:
Rate:
Fluids runnin : . . . /
PT/INR
ABG's
PH
Cl Rectal tube/FMS
OCAPD
o other;
Site:
Thrill: DYes U No
DYes U No Old Records? OYes D No Department: Question call #;
leted? UYes
No
-SSM DePaul,Health Center

.(HI',
tA~f
Jf~~!~!P~I"1 0736000302 SRS-

>
ERQ
Patient Roport Form 920Q7
10/02/1976' 31y M 12/26/07 EMERGENCy,PHYSICrA0007482~8
000385
ADMISSION DATA BASE

Name
_____ B_OLD SYMBOLS (*
o Alzheimer'slOementia
o o Blo{)d clot
o
(J Arlhritis . 0 Back!Hip/Knee Bleeding problem
o Diabetes *
CQntrofled by:
+ - -)
!JA;
INDIC~TE REFERRAL NEEDED ON BACK PAGE. --~-----l
Blood pressure problem 1-Blood transfusIon Dale; _ _ _ __ Breathing problem hx: 0 Asthma Bronchitis o COPD/Emphysema Q Sleep ApnealCPAP
o Emotional problems
o Diet o Elevated cholesterol o Anxiety
o Insulin o SubCU1aneous pump o Oral Hypoglycemic

~
o Vascular disease o Pacemaker/Dafibrillator o Congestive Heart Failure' o Heart mllfml,lrNalvular disease

0 Chest pain, Angina
Frequency: _ _ _ _ __ Last episode> _______ D Palpitations OEdema Where: _ _ __ Frequency: HepatItis Infectious/Communicable Disease.
0 Heart attack
o Chronic pain prior to admiSSion ( _

Site: _ _ _ _ _~_
flO)
o ChrOi'lic Pam Management

o
OTB. S.; 0 Wheezing
o Cough/spulum productiOli
o Shortness of breath
o Glaucoma o Heart disease o Heart surgery

Date!
o Depression o SUicidal thoughls{plafl
o o Sensory problem
PregnanVLactaling If pregnant. due date: _ _ _ __ Prostate problems Reproductive problems Last menstrual period: 0 N/A
o H~ring 0 Vision o Skin problems
o o
o VRE
When:
o Rash o Skin risk 5C<lre \ 8 or IMS o Pressure ulcer Stage 3 or 4
0 MRSA 0 C. diff
(J I)nstageable wound o Nonhealing wound
Shortness 01 breath occurs al: r6$t ~_ ,-6th normal actNity _ _ If of II\ghts 01 slalrs dimbed
~_ #
Location: _ _---,'""""~..._
~N
Device (i.e.,
Contat physicIan
Referral Ordvfs
o Other - - - - = - c c : - - - : fOT
ETtWound Nur$e
D Kidney disease.
of tlloGks walked
o Chipped or loose teeth

Rllcent exposure 10: 0 Chicken pox 0 Hepatills
o ChemolRadiailon
o Canc~r
Home oxygen
o Neurologic.al prOblems o Seizures

Frequency: _ _ _ _ _ _ __
o DialySis o Slone
o Sexually transmitted disease o SlomachiBowei problems.

o
GERD/Acid Reflux
C Ostomy.
Date last 8M: _ _ __
Last episode: [) StrokelllA

Frequency:~---.
o ThyrOId problems
o Urinary problems
Last episode:
------..,...-c-~--....,....---~ If you check anyof1he above, please describe: ]lL~7 "S.L.i,L",. /0, j>col- .J.. ; c
IT
~
o Other: ==~_ _ _ -----~~rc
---,--_---.,._-.,_ "7---~:__~
F!.J
,J
ji
Ci,:,jr
I
{'J
JI1U
I: Ie,;
1/" "o NausQa,Nomlling o Family problvms with llneslhesia

Q
j
~~., 1v\ ~..
o KOPTiQf
~SSM
ADMISSION DATA BASE
I MARCH,l?HILLIP H
ERQ
0736000302 ERS10/0-;./1976:UY M 12/26/07
EMERGENCY,PHYSlCIA00074S298
000386
ADMrSSION DATA BASE
" Cardiac BIMb '#

o ffltlGry ofCHF
-_._--''--.., 0 l'lIlient r'q1IflU
n.CI..Jv,________ ____ _____"r .____

~
No Muml Indlclllll ellola! Nytrltlon 0 SIJ!l13 nr 4 1Ir8S$UnI ulter 0 Nonheallltl 'IiIOUlIJ!
[I Unsl30ealJltJ \Wund
o Persi3lent cough ~ 3 wesks and suspiciouS chest x-ray + 2 the following: o Coughing up blood 0 Past T8 e~posure o Night sweats 0 Unsxplained weight loss
Type _._.
13~1 use
-:s~~~~~~~ 0 R8~Jlliif!Jfe
o Skin IUsk S~ore DIll or IIISS

o Uf19l1nttd WT 6 fO Iblllf mDrtl2 won;
o ~nranct 01 malnutrltloll
o N/Y/D 3
o ChlllGlI m&\lpefil8 IIlOru Jbin eclays
~.
AmountlFreq. -= )', (,...,
'< \ ~
I Cigar.
10
Tobacco? 'm f-lo 0 Yas '.. crgar~tte. Pipe. Chew (circle one) Cunei'll UfiRr (wlin IMl 1201(>$') 0 Former u~ef
Last use
i Street Drugs? i TYPR _ _ _ _ _~

'AmounVFreq. _. ___ _
o Prtgn3ll1 (flot dlllvwinQl or I.Icta1h1g o /'alienI reque;!

o Newly DJ Dllbftlc o Major mgery !uv8r 75 yeDJ1 old)
e IllfeqHon Control.
o Hillar; lit bJrlalIil: IUlVflry [J No relel1al imll~BII!d
._ _ i AmOllntlFreq
, La:n use
==:::-_=........--= o "01 1011owi1\i Dt.blIlIi: Olaf
llvo in:
INITIAL DISCHARGE PLANNING I HOME ENVIRONMENT I FUNCTIONAL SCREENING 0 HQ\lsll '\rApartmenl 0 Re3idential housing 0 Nvrslng home- 0 Other _ _ _ _ _ __
Do you plan TO roturn to your home frmn'the hospital? ~es 0 N01llt If no, explain: _ Trilnspor1illic.n 1;lvailable? !Sl. Ves 0 No . Does anyone help you at hOme now? . ~o 0 V",s Names/AgenCies Difficulty wi activities 01 daily hYing? ijf'No 0 Yes Explain: _ __~_ _ _ _ _ __ Difficulty .to.mbulalJllg I Transferring? No 0 YtiS Explain: _~_ _ _ _ __ if yf'lS 00", tv pain, expla!n. ____~____
Who do you live wirh? ... C\
Lc-.,.""
~--~
o PlISltlve T8 sJ;f'eaIllncr"3k1n t811

o
Hi~vrv
0'1 MRSA/IlHE/C. dill
';tI
o III O'>Ylce (""rt, Nee, ct,,) o fitCllIl1 npDWJll

relerrallmUClled
... Contact Pfilfslc:!an
o Chllfilt In mIdI
Do YOL! hav'.' any special concerns about being in the h05pilf!l?
o I'tliMl R,qml o liIafftatirm taucallon

No refel1l1l
ill1li~.ted
EIlIImml
Have you had ;my major Changes tiob, ~"ve. divoroo, dealh,
Do you have any spiritual concerns?
~o 0
Yes
+ ,
~o
.
0
Yas _ _ _ _ _ __
I Any special religious!cullural factors related to care?
Sleep,ng problems: ~pne 0 Difficulty faHing asleop Other _ _ _ _ _ _ _ _~_ _ _ _ __
Difficulty staying asleep
Paslorsl Csrt + AnUcfpal1f Coping Difficulty rOOr fro!lllosb Serious ProoedmiSurvery OlrllGtlve .\tsltlallCf
ADOLESCENT INTERVIEW (14-17 years old)
o Splrttu., COltEern1
l'lIU~nl
RtqIIltsl
IHev';!
j How do
What
get-~lung with your fa

ha
<;>x?
o Nil fe1errlll lfl1iil:J18d

.. Tobaceg CeHition ...
'.
'>
Qil !lV!!f
0 No
Y8, how &.1 wartlyou when you
K!nd oj birth ontrollprOle Ion do you or

''JX
Hav you ever had 'I Hav you ever felt
o Physician Notit!(ld
o PatlMt
0
when y}lu really did not w 'n! to? [J No 9'~'m" {lad ~ you thought aboui ~ Ii~g y,~~~!;llf1 0 No 0 Yas
Y~rp"nner use? --.L-.
Il~ex'l ~
"
o Ute!! In IMI12 IDGlllbs .~ o PaUenl Rtlqunl ' __ ~ r6felfill iMlcaled '=9\;===-=~~/':'---- ~illl tfilej \ _~_ __ o Pali~nl Reqlieil
o Ehlerlylfrail fi'liRIl alolle
.-.-----i 0 HOID!les$/nispliClid
-----~---I
tit
------FORM C<?MPlETEO BY {If other tha_"_R_N.....;>'--_ _ __

Hospital
Staff 0
Other
o SUiptteled ADm/Neglect
[)
Ponlbl~ H~mt
0 NUlling Home Placement

Hl) relerra! ill4llealtd
ASilstanca
SIOUA1URE
~SSM
ADMISSION DATA BASE
SlM.10c0-OS9 {!I/2007) BACK

1 MAACH,PHII..I..IP H
0736000302
EMERGEN ......
0 11
ERS -
H E A L T H CAR E"
ERQ
12/26/07
lO/02/1~6p'H3yl~IC~AOOQ748298
000387
--,~'=;;--T'-"'-'--'-'"'-'~------1.
In&trotfOn flxpiflfned
FROM 0 Home U ED :.J PACU Q DIs. office

'oJ ACUl8
i MODE
IRES~ (~
care
;:) Other:
IS? 79Z,-:;~
ILr=~::l;St:.:.:..:re::.:lc::.:h&::.r-':;:":";:;~:::::=t=TI=~==-1
IOTIiER
.;;) Vile
UNIT OFflENTATION Mf>~r(11 s~fVlCes l.,.I-Cillllghl' nurse oetilrh!;lhl pam ~Ilighl . \oi!&tlng ~king for help 10 g",I up smoking policy ~~ 1~lIs ,JJ-Wlephone ~JeVISjon conlrol ~:LU8e of bed controls u.-Em6lgenGy light BRfshowllr ~ng hOUfll U'fomlort Rounds
ARRlVAL INFORMATION
(If other tnen nurse)
COMPLE1ED-By-JJ~' -)'-/1-(-',-. 6-C-/"-7-/-/

-.
SIGNATURE
t.{s
/;? 90tn dl5t:;~

DATE TIME
SUICIDE SCREENING
Viol!S ~
I..J
~==~----====~------
Ask ALL patiHnts the following questions:
.{;J, Have you over tried 10 harm YOUfself in tht! p(l~t? Explain _ _ _ _ __ Are YOLi hers bllClluse you tried to harm yOU($&1I'? Explain _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~_ _ _ _ _ _ _ _ _~_
In the past w1;Jek, have you been havinA thoughts about
..
harming,,-y'.'o=u=rs=<U~I'!~Ex=p::la:ln__ =-=-=-=-=-:..:=====-====~~==:"::==-.j HAVE YOU EVER BEEN EMOTIONALLY. PHYSICALLY, OR SEXUALLY ABUSED?
Q Hotline called specify: _ _ _ _ _ _ _ __
~ NO EVIDENCE OF PHYSICAL, SEXUAL, OR PSYCHOLOGICAL ABUSE NOTED.
EVIDENCE' OF POTENTIAL ABUSE NOTED BUT NOT SUSPECTED, SPECIFY EVIDENCE _ _ _~_ _ _ _ ___
RATIONALE
Q
ABUSE SUSPECTED, COMMENTS:
o Soc,al SeNiee notified

PAIN MANAGEMENT
P N SCALEjOBSEAVATlON .t:!umeric 0 Behavior o Faces rating 0 Assume pain present
Ol~r
PAJNLEVEL
COMFORT STRATEGIES OSEO (Prior to admi3slon)
ATPR~~
PAIN FUNCTION
GOAL,)
Q INFORMATION GIVEN
_________________
ON RfGHTS AND
RESPONSIBILITIES
OF PAIN MANAGEMENT
If pain plOsem, comp/1JiS Pain Assessment Se~lioll of Patient Flowl'Jh&et.
To be completed by all RN.
PLAN OF .CARE
>
PATIENT/SIGNIFICANT OTHER INVOLVED IN THE CARE PLAN DEVELOPMENT. J'PfES 0 NO explain: _ _ _ _ _ _ _ _ _ _ _ __
FORM COMPLETION INfORMATION

: ~ Form Ii/eFfll9letet1 1'.;,f"...,J..,I{
Signature:
{,Lu;:.,.... .;:(:,":. ',',,--
\),j..l
Date: ) JL. j. ) Time: :2./ I ;f~' (If completed by LPN, RN review and plan of elfre development required)
, RN:
):6
~,' Signature: ________"\.'

,
Form
comp'et~<1 \iA~m ?ata reviewed
~'4.i,--'..j1.)!-ll"i'>:":\"',-,_.,_c....;;._~_ _ _ _ _~_ _
!7i
Q Plan of care/Care pathway developed
Date:'
1;~L
Jr"
, Time:
L-.
'
PATlI;NT LABEL
~SSM
SU.l1000-OSB (7!2007) FRONT

MARCH,PHILLIP H ERQ 0736000302 ERS10/02/1976 31Y M 12/26/07 EMERGENCY,PHYSICIAOOQ748298
11.111111
H E A L T H e A R E-
000388

.
NeurOlogical CardiovIl9CuillTI
SYSTEM REVIEW
No probh.m identified
Q Exception as below Q Excention as below Q Exception as below Q Exception as below
au
Musculoskeletal
Repro(:luCllve
o No problem Identffled o ExoopUon as b(llow

Q No pro~lem Identlfled
I,J Exception as below
Hematologloal
Respiratoryl
Infectious Disease
::::l No problem identified
Q No probt<m1 idl/ntlfied
Q ExceptIon as below
o No proolem identified
Q No prOblem identified
GIJNutrltioll
EENT
Wound/Sldn} Mucou, Membrane
o No problem identified o Exception 6$ below
PsyehOfSoclal1
Spiritual
Compll;!tefy
limil~d
t
,.3
",",-'
CCnSlantly moist
Bedtas!
Very poor
PrOIlaIJly
PrOblem
VlJry ilffliloo
Slightty limile6
No
I .....pmrmen!
2 VtJry mo!!)!
(4.,
Oc~u&i<.Jna!ly moist (~
2 Cnalrfll8t
WalK$ OCCaSionally
Walks frequelllly
4
adequate .e"
Adequate (3
ExcaJienf 4
Rarely mois!
r'rtctlon & ShUT I Silfl Rille Sc<lre: 18 (J( IMa Jl'IIEInt I. at n$l( 1 I Q Fallow SJdn Ca~ Pr%coI for ~ of Potential HI or IllSl. IPM pr%(;01 Mi bedsIde.) problem Nutrltktn<il consult No apparent (II nor P'f1Violl~ty obts/ned.)
problem
Score~
T1me
L2.t
a::
HENDRICH II FALL RISK SCORE' Score on adlllls",,,,,, IWI"" d<uly, and WIth changes III conal!lon actl~ll\I OJ """,..",,('.1 "sl< meto,s.
II)
RIsk Factor
1---"""---+--"""----1 0 Fall risk brllcekliin place ~or. of 5 or greater"" Fall RIsJ(
o FilII Prevention information Sh!l@1
Signature: _________
-+'~_'__~_;VJ...t._;_\_".....::::-".._ _ _ _ _ _
)
Date:
TIme:
~_-,>.l _ _ __
2.{I'r-
PATIENT LABEL
~SSM
H E A L T H ' CAR
AOMISSION ARRIVAL SHE!:T
SLM1000{)58 (7/2007) BACK
E~
MARCH, PHILLIP
0736000302 ERS10/02/1976 3lY M 12/26/07 EMERGgNCY,PHYSICIA000746298
/1111-11 H ~ERQ
000389
INTERDISCIPLINARY CARE PATHWAYS~ - GENERIC

~.
'nJ MEDICAL HISTORY

<.(Vt",
( ~'r 'S-\'(." " ~'( (" . (,1'
/.',ltJi:,' ~Ck .' ~,tll-t:'t ii<' '1 {'\
f:'- {,', ( . I)
-1?C;C{
1
,
i
INITIAL DISCHARGE PLAN
o Home with significant other

o SNF/ACF o Rehab
free - (R' fA'-'vr1~'
DAILY lABS
o Other
o Home Health
MRSAIVAc screen sent

Results C. difficila sent
Results
PHYSICIANS
DATE
NAME
CONSULTS DEPARTMENTS I NURSING DATE NAME ...'1'r-- :f/'1
/1-/t&'
o Droplet o Airborne t if>"
lJ!f,.
])/
~~
o Spacial Contac1 o Contact
D)z(:"
/v~fn;~>1
::ifllJ
(a
t) /l(~
(h::'in 7L
(' <")
,'e 117
Pneumovax year: Flu vaccine year:
Admitt~Q Mih pressure Ulcer1~ Yes~o

SPECIALTY EQUIPMENT Date:
Type:
;
I I
DIAGNOSIS/PROCEDURE { ;
I
e--I/glt 1IS (} p jaJ
t,
HT
(,;
0" wr
'rS' ,>(~
DATE
C*TATUS
Full resuscitation
ALLERGIES
tV ,<b;r
o DNA com/ort measures

Advance directives? [J Yes 0 No Copy in chart? 0 Yas 0 No Is there anyone who should not receive general condition Information? 0 Yes 0 No FamllY/Signlfilin1 Otherd8si~~ted to ,)OOlve madical information: 0 None Name
Phone
t~, ,~:,~"", ; -V"". ',,>(i 4 ) (ff' - ,f' 1 ~ t.!. t .7
0 POA
Name Phone
OPOA
pRPAUr. }l.EALT}l Cl:::N'fEtI.
et'I'C;SSM DePaul Health Center

HE.lT"'CA~E
~~CH,FHILLIP
111111161111118 H _
MED 0530-01
liP
.
0736000302
INTEROISCIPLINARY CARE PATHWAYS' GcNI:RIC

DFMl000~4
10/02/1 976 31 Y Hl>.NAFT, H1RAN A
M 12 /2 G!~o J 000148 L 98
(912007) PAGE 1 OF 6
COPYRIGHT 1997 SSM HEALTH eMt:!
000390
..
PLAN OF CARE
PROBLEMS/OUTCOMES/INTERVENTIONS OUTCOMES
DATE!
INITIALS
Place initials and data Ihal problems (Iff; identlfltfd In left co4umn. All idGntlliil'Q prQb!~m multt bu Ilva!uated wh~lh8r Oulcomi II M@t or Unmet al time of CIlIWI'I!
hy placing dale and

Met Unmat
initials in appropriate column. " OUlcomw is met prior to discharge. philcv dllte and Initials on Ahtl)(Jf\lmn. Place ./ in box by Int&Nsntions appropriate to patient. Write in additional Int8MJ!1tlons as nmed in bl8nk spaces.
I
I
I
I I
I
Problttll1! Alteration In NeurofagJcal Status Age specific conslderatkm in fdefl'y Adults: Diminished muscle strength, degenerative ~ end/Of joim changetl, der:rellsad /'tearing. vision and balllncB. Outcome: The patient will expBl'lene. a stabilization af neurologIcal fmpatrment. Interventions: 0 Assess for Fall Risk BID Initiale Fall Pracautl1Jna for Fall Risk Score of 15 or hlgh!)r. 0 Assess level 01 consciousness and motor function every shift snd pm. i 0 Encourage achievement 01 ADL's as appropriate to the neurologleallmpalmlant.
I Age specific conSiderB!lon In Eld()rty Adults: WeaKened msp;rotory muscles, d&ctMsBd lUng tiS$/JIJ ~luticity.
Outcome: Respiratory functIon will be within nannaJ .'ml1s for patlenL
0 o Position patlant for maximum ventilation ~fficiency. Monitor VS/breath ~o\lnds/oxlmetry every shift and prn. D Administer treatments/oxygen/AOO's as ord~red. Provide Ouid intake to liquify secretions Suction tWcretions as necessary.
) Problem! AlteraUnn '" Oxygenation I Rttsplratory Function
I
l
! In!9NenlionG: 0
o
\,!;\
-..:-
I\
I
I
C!>/ .
~'\ff'
%}
~;
Problem: AUerallon In ComfQrt/f'flln Managent9nt Age specific consideration in Elderly Adults: PossIble idiosyncratic effects from mOOicalJons due to ag&-relateci changes ill flbsorption, metabolism, and excretion. Outcome: Patient exfllblts/stlltes adequatll relIef of discomfort. Interventions: 0 AS6eSS patient's pain lavel q 4 hours. 0 Involve patient in care by dlscvssing methods of paIn relief. 0 Initiate interventions {including nOn'Pharmacofogic) appropriate for pain/discomfort. Assess pain leve! and response within 60 minutes of intsNantion.
o o
I
'l \ ~.
Problem: AHwatJon In NutrHlon

Age speGitic consideration in Elderly Adufts: Diminished apputits, perlsf4l$;s and digestive jufces line! d8ntitJon changes. FactDrs that may improye food intaktt" Position patient upright Offer smaller, more ff8qUf1nt meals Modified food consistency l.fJ., pureed/soft. Outcome: Patient nutrfUonal .ntake Is approprIate for ~Ifc ,*",s.. Interventions: 0 Nutrition Consult enlsrad in HBOC !:l Monitor hydration sta1l,.1$ D As!e$s enteral feeding tolerance o ASS&5S tor swallowing/chewing difficulty Assist patIent with me\IIil as needed. 0 Assess/Record dietary intake with each meal Provide/record dietary JlupptementslHS linacl{i. o Record Daily Weights. rsport unexplained weight changes greater than 3 kg from previous day.
r~o'7
,
Probfem: Alteration In Cardiovascular Statu$ Age specifiC consideration in Elderly Adl.Jlfs: Diminished GtJrdlac force I blood /Jow to bt&ln. Outoomit: Patl.nt will be hemodynamically stablv. Interventions: 0 0 Record Intake and output every shift and pm/daily weignts and report variances, Assess vital signs, peripheral pulses, and capillary refill every shift and pm. Administer rnedicatlol'lil/blood P!oducts as ordered and monitor eff8cts.
o o
Problem: AfteraUon In Skin fntegrlty Age specifio consideration in Elderly Adults: Skin dry and 18;$ efastic. Outcome: Patient wfJI maintain or fmprove skin Integrity. Int~!V!!nt!on; Cl Turn patIent every 2 hours avoid shearing Keep skin clesn and dry. o Photograph and measure wounds on admiSSion, every Monday. and on dlsChBfg&. 0 Provide wound care per Skin CarB Protocol (s~ page B) o Potential aitaralionin .ktn inteQrfty
~VJ-'<;_y
.'JzX
~
PrOblerm Potentl.' or Actua' Infection

Age speCific consideration In Elderly AdfJlts~ Decreased renal function nota lab valUfi rvlBl8d to antibJofic do!iiflfl. Outcome: Slgnll and $ymptoms of Infection are recoqnlzed. Pl'4tCautlon$ eN vttltUd. ~arventions: 0 Utiliz& isolation precautIons: [') Contact 0 Spada! 0 RaspiratOf}' 0 Droplet ASM5s/report signs and symptoms of infection every shift and pm.
-("..I
'a'
~SSM
HEALTH,t;:ARE"

a
DEPAUL HEAL'H CENTER
INTERDISCIPLINARY CARE PATHWAYS" . GENERIC

OPM1~024 (9/2007) PAGE 2 OF
HARCH,PHILLIP H 0736000302 MED 0530-01

lo/0Z/l9763lY RANAFI,IMRAN A 1'1
11II11111I.llllnl
rip
12/26/07
000748298
000391
PLAN OF CARE
PROBLEMS/OUTCOMES/INTERVENTIONS
Placo initi(!ls and date thaI problems are identified in lett column. All iti9f1liliod probl!lm musi b!e !evaluated Whathllf Ou\wrn9 !$ MAt or Unmel at lirne of discl1arge by placing <;late ann initial:, in o.pproprlate column. II OutCome Is mel prp:!! 10 Olscnarq8. place date and initials on Met column PI"r,e ./ In box by interventions appropriate to paliAnt, Write in aUClit\,)nal intBrvenlions a, needed in blank spaces.
DATE! ilNITIALS
OUTCOMES Met Unmet
Problem: Alteration In Elimination

1 Age specific considertllion ill Elderly Adults: OlrlllTllshed peris/alsis, krc1ney function. , Outcome: Patlant regains norm,,1 elimination patterns for liSe and disease process. IIlWIY~nllons' 0 o Offer loilating every 2 hours. U AsSess bowel sOl.inds, abdominal distention ana/or rtiscomlort evelY shift a"d pm
Record frequency and characteristiCS of stool. Report if no stool for more than 3 day:> RQcord j"take and output every shift and pm Report abnormal lab values.
!0
I0
I Problem: Knowledge Oet\clt Age specifiG con$ide~<!ltiDn in Elderly Adults: SfIflsOry am.! cognitive JmpBirment;;. Outcome: Patient and or $Ignlflcant othtlf Involved in plan of care/demonstrate unclen,wndlng of procedures/dls9I1se/medlcatlons/and discharge Instructions.
Interventions:
o o o
U Assess baseline knowledge and prtlferred leQming method 01 patient/significant other.

Provide educational material al palient/signil!<;wt other level 01 understandinq. Assess patient/significant other for understandinq after teaching. Provide instruction on sate and effeoti::'!l._u_s_e_O_f_m_tl_d_I_Ca_l_e_q.;..u-,ip:...m_B_n_t________________--4_ _ _ ----l
Problem: Anxiety/Spiritual Dlsturban(l8s

Age :spf;loific consldaratlon if) Elderly Adults: FeBr of 10$s of control. declining hearth andlor approaching death, chtirlgas in economic secUlity!soclaJ status.
I
;..1
Outcome: Patient/signlfleant oth.r demonstrates ability to cope and Identifies available resources. Interventions: 0 o Encourage verbalization of lears amJ participation in care. o [lecreafitl sensory stimuli - provlde quiet onvironmem . Dim lhe hallway lights after 10 p.m
o o
Pastoral Care relerral entered. Palilative Care referral entered,
Pr(lblem: Glycemia Imbalance Age speciric consideration in Elderly Adu/ls: Decreased renal function, metaoo(;c rate. Outcome; Patient's blood glucose Is withIn acceptable ranga. Interventions: 0
o o
, I I
Implement HYflog1ycemia Protocol Implement Insuhn Protocols as oroared. [J Monitor/rer,ord fingerstlck glucose value<i as ordered "nd pm Diabetes Educator COi'lSull entered.
I I
Problem: AJt91Oltiofl In Mobility/Activity Intolerance Age speciltc r;onsJOeri.ltion in Eidetly Adults' Diminished muscle strength, degellerilf!Ve bone and/or fOill! changes, decrMMd hearing, VISion and balance,
Outc:ome: Patient's main1ains

!ntervemionG: 0 U
Of improves
mobilltyfacttvlty level.
0 __
_ _ _ _ _ __
Assist patient to participate in ADLs Within IlnHS of impairment. Adll,mca aclivlty as ordcred;toIArnled. ,OPT to Clssess functional ability and provide appropriate adaptive devices.
--II
i
I
Prob!tm; A,,~ratlon in Safety

Age spectfic Qonsideralion in Eldef(Y Adults: Sensory tifld cognltlve impairments.
Out.:ome; PlItient remains in a safe envIronment and free of physIcal Injl.lry.
lntervgntions: 0 _-,-__
o Assess lor Fall RiSK BID - Iniliale Fan Prsr:autions for Fall Risk Score of 15 or higher. f1 Provide appropriate safety l;>quipmenf/devices and instructions for use. f] Implement protective status (Victim of Violence).
Problem;
Outcome:
L -_ _ _ _ _ _ _ _
Intervention~~~~-=---~~~~::__-_-_-_-_----_-_-_-____-_-_-_-_---==~~~__====~-------- ------________
i:~
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-I
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H !: .. l ! H ' (: A R

INTERDISCIPl.fNAlW CARE PATHWAYS GENERIC

DPM1OOO02-4 19j2GQ7j PAGe; 3 OF 8
HJ\NAF 1 , I NRAN A
0736000302 MED OS30-01 10/02/1976 31Y M 12/2G/07
JJ!~'J~~~J!B~IB
DEPAUL HEALTH CENT!::H
rip
000'1'18298
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-v
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o TLC 0 Pice 0 Midline
o o ather Paripheral IV {less than 72<)

Site
.---~---
//
..- -
-------Insertion date
I0
TLe 0 "CO 0 Midli'"
0 Other C Peripheral IV {less Site
lhan-721------------___ Insertion date
I ~
0 TLC
.-J
--:-':':"7'"::--:-:--=:----0 Peripheral IV ~ess than 72'') Site Insertion date
tl.c~)~0----.-----------------t-----....
) i v
C.8 Cj
Ctnt?
.Jc:
J /
----1
.~-.
:;:J
DEPAUL HE.~Ll'H CENTER
~SSM
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COPVAIGKT 1997 SSM HEALTH CARE
MARCH, PHILLIP H
111111111111111011111
IfP
INTERDISCIPUNAflY CARE PATHWAYS~ - GENERIC
073;::000302 1'1ED C530 -01 10./ ';:)2/19 7 6 31 Y t'l :2/26 / o~ HANAFI,IMR.llli A oDe 74 8298
000393
OPM-1000-024 (9/2007) PAGE 4 OF 8
-h:-r; lv1/S
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tl-f
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o Care Planning with PtlSO (A) o Care Planning with PI/SO (P)
D Care Ptannrng with PtJSO {A) o Care Plaf1ning with PtlSO{pl
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~SM
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COPYRlGKT 1997' SSM HEJI\LTH CARE
~.!J'.RC}l ,PHILIJIP
Copied by__
RN Review
______ _
INTERDISCIPLINARY CARE PATHWAYS - GENERIC OPM-1000024 (912007) PAGE 5 OF 8
1/ P 0" %O()03 02 MED J~:.30 - 01 :'Jj02/l.9763lY 1'112!26!C'7 HANAFI, IMRAN A Q00748298
111111111111111118 H
o Other o Peripheral 117"11955 than 72;)

Site In56rtion date
TLC 0
Pice 0
Midline
o Other o P&ripheraliV (lesS lhan 72")

Site
o TLC
0 PICC 0 Midline
o
Insertion date
o Other o Peripheral IV (iessthaii~----Insertion date
TLC 0
Pice 0
Midline
Site

IfHERDISC1PLlHARV CARE F'AniWAYS. GEIllERIC
DPM-1ooo-004 (912007) PAGE 6 OF 8
nr\pp,\Jj..itl,"" Yl!~~?li1,!:1~B~ OS30~?l

0'1;,6 CCC ;-O.io
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o Care Planning with PtlSO ~A) o Care Planning with Pt'SO ~P)
o Care Planning \'11th ?llSO (AJ o Care Planning with PI/SO (P)
DEPAUL HEALTl-1 CENTER
erD:;;SSM DePaul Health Center

11 t! '" 1. 'I H
CAR:
rr-
Copied bV
RN Review
INTERDISCIPLINARY CARE f>ATHWAYS' - GENERIC
MARCH, !?lHLLI P H 0-: 3 60 003 G::" l>1ED <) :3 ]. 0 - 01 1 1:1/02/19 76 31Y i'1 12/26/0 HANAFl. IMR.."/;N A 00074:8298
11I1111I11111IB
III."
OPM-1(XIO024 (9.'20071 PAGE 7 OF 8
COPYRIGHT 1997SS~1 HEALTK CARE

PROBLEMS/OUTCOMES/INTERVENTIONS DATE/
INITIALS
Place initials and date thaI problems /lfe identified in teft column. AI! identified prOblflm mum be flvailllltfld whether OutGome ia Met or Unmet at time of discharge by ploolng datfl find
Initials in
Ilpproprht1~
OUTCOMES
Place'; In box by interventJons appropnate 10 pabem. Wnte in aooitionOJI
column It Oulc.:ome IS met prior to discharge. placlJ datlJ and initial,. on Met column. ImerventiQn~ a~ nwded in blank ~pacw.
~~Met
Unmet
I Outcome Goals:
I !
Skin integrity is maintained. Patients at risk are identified and interventions lnllialed .
?rechecked items are initiated for all patients.
ISkin IntegrIty plan for all patients

o
o Complete Braden Scale on admission. then daily. Assess skin upon ~dmls~iQn ~n.;l r;v~ry $hift, \l$pI?Ci~lIy QQny p'rQmln~n~$ ~nQ $kin fQlgs.
0 Record any redness that does nOI disappear within 30 minutes or any break in skin integrity. 0 Reposition at least every 2 hours.
It.! It'! 0' 0'
Apply Iolion immediately after bathing. Use Keep bed clean, dry, and free of wrinkles.
moistori~jng
cream for dry skin
Avoid massagIng over bony prominences and discolored/hyperemic areas. Remove antjemboHsm hose. sequential stockings, and heel protectors every shift for 30 minutes to assess le9s, feet. and heels.
Of wound drainage.
0 MiOimize skin exposure to moisture from incontinence, perspiration,

contraindicated.
0 Establish a bowel and bladder program by assisting the patient to the bathroom Of bedside commode every two hours. unless
0 Skin cfeansing at time of soiling with penneal cleanser with mlnimallriction and apply protactive barriar craam. 0 L.imll use of adhesive products on.thin, fragile skin and apply skin sleeves PAN. Itl FlOat heels off bed With pillows placed under Ihe length of the lowar legs, activate heel suspension on Total Care Bad (leU},
10' Instrvct patient and family on causes and prevention of !OKm breakdown. sources of pressure, Inction, and shearing. Record on
and/or application of heel protectors, Patient Education Form.
I Skin Intogrlty pian for "At RI$k" population5 Breden score 18 or less
o
PiaN sign (PUP) on the dOOr of (001'1' indicating patient is high risk for skin breakdown. Initiate Individualized turnln9 schedule minimum of avery 2 hourS in bed f avery 1 houl in chair. Consider use of pressure redistribution equipment per orders/protocol. Position patianl in a 30 degree lateral pOSition and avoid positioning directly on trochanter. Consider use allifting devices to move and repOSition patient such as 11ft sheets, trapez.e, and Air Pal to prevent friction and shear. Maintain head of bed at the lowesl degree of elevation consistent .,.lith medIcal condition.
Use pillows/wedges to pad bony prominences from direct pressure, especially between knees.
0 0 0 0 0 0 0 0 0 0
Consider use of urinary or fecal collection device to contain urine or stool. Limit use of diapers. Support surface per WOC Nurse and/or protocol Nutrition consult entered, Obtain bariatrlc support suliace per protocol.
... ,..
Othar Interventions
.~
,.,
.~
- ....-.
~SSM e eH A L T H
~
A R:

COPYRIClHT i 007 SSM HEAl.TH CARE
INTERDISCIPLINARY CAR!: PATHWAYS. GEr-lERIC

OPM 1000024 {9/2007l PAGE 8 01" 8
000397

INITIAL ASSESSMENT
ti None 0 Vision 0 Hearlng Cl Language [) Difficulty - Reading (explain) _~_ _ _ _ _ _ _ __ o Writing (explain) o Development levi;l1 rsquiring intervention (explain) _ _ _ _ _~ o Other
Plwslcal Barriers to Learning:
r:
rp Nons
otlonSI Barriers to Learning: None CJ Anxiety 0 Anger 0 Denial ~Irl.ual Barriers to Learrnng:
0 Grief 0 Guilt 0 Lack of hope
0 Depression
0 Confusion
o Olher
o Other
D Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ._ _ _ _ __ 0 Financial 0 Caregiver
Home BarrIers to Compliance: p/None 0 Meal preparation 0 Transportation Rldlgloufi andfor Cultural Barriers to learnIng:
It1 None
o
0 Yes - Explain
What is the eas/es1 way lor you to learn? Piclures Reading Listening Demonstrallon 0 Other _ _ _ __ What are your learning needs at this time? ~isease process tl-Medications )5Follow-up treatment US@ 01 equipment )B'LJlel D PreJPQst-QP teaching Other _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Community resourCes "0 Rehabilitation Who should we involve In your teaching process?
1
o
Activlty/Exercis~
Admission Advanced direGtlYes Comm. resources
Disease process DiSChsrC\l intormation Dresslngs

Fall prevention Follow-up cafe Foley FoodlDrug interactions
Diagnostic OOSIS
DieVNPO
Home cars sl)rvictS Incentive spirometry Infant care/feeOi!1O IsolatiOn precautions IV's!1njechons Labor mana~ement
Medlciltions Monitors Mouth care Outpatient programs
Post parium teaching Pre-o!) te,ach!ng Psychosocial needs
SI1JllsJSx
Smoking Ces'>ation
Social ssrvic:e Spiritual needs Surgery
Treatments
Wound Cafe
Restrainls
Pain m3m10emanl
Plan of care
RiSk factors
Room orlsn13110n Sa1et'l
TGOB
Teds
Olsaa$l!
man~em\1nl
MOl
PO$t-op teactnflll
R dlnen: (t) States ready (2) ReQI.JIlSls delay (3) CDt1tused (4) S&oated (5) Cognitive inability (OJ Re!u"oo (7) Alraady ktoOWledQeable Leemer: PT .. ~alt9nl P = Parent F = Falller 0 = Daughter(!!) 0 Others M '" Moliter Sp" SpoWG S. son(s) Metht)d: A = AudiOVIsual 0 Dilmonsiralfon E = EX]l\sl\2!1on C = GIOllP GlaSS H=HMdoU! T~TelephonelExplanalion
aJJCSSM DePaul Health Center

HE""H'''''Rt
DEPAUL H1i:ALTH CENTER
~6~O~~~LIiR:
10/02/1976 31Y
11,1111.1.1.1
rlJ
ll\'TERD1SCII'LINARY PATlENT/FAMfi.Y EDUCATION RECORD

DPM-l0000eo ('212004) FRONT
EMERGENCy,PHYSICI~000748298
_) ERQ M 12/7.6/07
000398

POTENTIAL TEACHING TOPICS
Actr/ily/Exercis6 Adml"lon
Advanced directive, Comm. resources

Diagnostic tests Diet/NPO
Disease management
Disease process Dls/)harl76 inlorrnalion Uressings
FaU preWlltion Follow- up care Foley

FooQ/Or uy interactions
Homo cara services Ineenlive spirometry Inlanl eare/F6~dina fsolallon PI eC8utions IV'sjlnjection, labor management
Medications
MQnllQr~
Post partum teactlitlll
SlgnslSx
Treatments
Pre-up tff1l1!hlrlO
PsychoSOCial flBans Restraints Riskfac:tors
Room orientation Safety
Smoking C8ssalion
Social SBlVice Spiritual nec(ls
Surgery
T605
WOund Cllre
MDi
Mouth care Outpatient pro(lrams Pain management Ptan of cars Post-op !eactllflG
Date
Slgllalure! Tltls
Teaehlng CUn18nt I Discharge Plans (May place sUcker here)
-v::r
TeOS
Family
IUTCOME
Present?
Yes or No
~f
:'~~.
R&adJnu,: (1l Stales reudy (2) Requests delay (3) Confused (4) S8\latacl (5) Cognitiva Inability (6) Refined (7) Alrsady knowledgeable Learner: PT = Patian! P = Parent F: Fathef 0 = Daughter(s) O. Others M = MothAr SP" S~'QtiW S = Sones)
Method: A = Audiovisual D = DemOllstraTlon e = c;o;p1llnallon C '" Group Clan H"Handouf T= TelaphoneiExplanallM
trIOSSM. DePaul Health Center

HEAlrH'CA~1
INTERDfSCIPUNARY PATIENT/FAMll.Y EDUCATION RECORD

OPM-1000.Q60 (1212004) BACK
0736000302 ERSlO/02!l.97Q 3lY M 12/26/07 EMERGENCY,PHYSTCIA00074S298
Diil'IIP.mit MARCH/PH~!~IP
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31'l Sex: N AdlF! 12/2(./0" Dr: HANAFI I IMRAN A
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Allergies:
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12/2.8/07 00:00 to 12/28/07 23:59 page: 1 (more meds fOllow,,,j ----------------~------
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Recordji
------------------
12/28/07 00:00 to 12/28/07 23:59
<'Lince'.}: L"4127/07 ~2:00 pagel 2 {End of MAR
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UNSCHEDULED MBDlCAT1:0N ORDl!:M (cont.)
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00:00 to 12/27/07 2_3_;_5_9_ _ _ _ _ _ .___ p_a_ge~~
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000403
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----
000404
000405
0 Airborne 0 Droplet 0 _ __ SCALE KEY 0 Bed 0 Standing 0 'Mehalf 0 Sling OTHER PRECAUTIONS: 0 Safety FaR 0 Bleeding 0 Aspiration 0 Seizure 0 ~__-=-~_ __ Ylliterday's III. -==- KG TDday'~ WI, KG (r1!~8 reco~ejll! w!lllJ/I! d~rellce il greater Illan 2.5 kg.)
Temp
PREVrOUS 74 r,J; 'ntak~
24 HOl'R MEDICAL/SURGICAL PATtENT CARE RECORD 31.% O'JtrllJt J3~ ISOLATION: 0 Special Contact 0 Contact 0 ~reutropemc
DATESTARTED/:l-(2r~o7
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rBWsida'nl"C(l'~
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12 hi lot,!! O{i!(.'TlIba _ _ _
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12 tv Shiftbllakf- , - - - - - - - 1
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17 nrShil1~ui
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u<w _._-4_ _ _ +-----ie.- ----11--- -+----t - - - t - - - - - t - - - - r - - - 1 - - - - ; - - - - l - - - - . / - . i ~o-=+-{I_.--+ _--,-_ --!-_ _-I - - - - f - - _-+-1_ _ f - - - - f - - - - - i - - _t~-+- - - - 4 - - -+----1
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----~-
SuD Tolals _ _ _ _ _ _
I?
_ _ . _ _ _ ._ _ _ _ _.1_ __ 2 or Tol.1 Or~IiTuoa _ _ 12 hi $h(fllntaJ<~ r - - - - \
II! lOlal Parente,," _ _
-------
12 hr Shill OuliJUl
'''_''''r~u,
TWllnlyfour hour folElI

FI,UID EQUIVALENTS:
'''"' ""'.
PATIENT UBa
4 oz O!2 cup) .. ,120mL

6 0: (3/4 cup) . 180mL
8 oz (1
cup) .
., . 240mL
1 Ol , ... ' . 30mL
1~ 02 (soda-l can)
. 360rnL
D1i:FtAUL HB"
~SSM.
KEAlTH
C~,(f-
24 HOUF: MEDICAl/SURGICAL PATIENT CARE RECORD

DPM1000~71
]o/O~I
G
~7 CH, PH1'~R'!JI1l1l 3600030~

X
N
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111111.11 ~~TH
CBNTER
~ MED OSJQ 1 P 1976 51 -01

l2/26/07 000748298
HANi\F'l, If'fIUW
(1/lOO7I PAGE 1 OF B
000406
24 HOUR MEDICAL/SURGICAL PAT) ENT C~~A.~R~E~RiE:..=C-=O~R=D=--_..::.DA:.:.::.JE=SJA~RT.:::Eo-===~
2 S'qhtly drowsY,
3
~ft'QUCl1lly
P,ilSY to afOll~a
Heat 10 Cllill 11 Muslt

12 10llch
l'
Epiri!fral
18 PGA
Rest
,j, ousao!C. cfee; Orilt closed dumO comers.tion (consider redUting oplold dose)
I:lJQWSY.
161 Preemptive aoa i9esia

20 Conlinuous 3%tgeSit inlusion
13 imagery
14 M'R~l(jfi
4 SornoNilnf, dirfir."ll In
lrnH~R
UI (MtrJcllOn Hi Edu:;.t,Ull
:n
OIDe,'
Stat! Usal or
Obmvatillij
Oes&ribe'
Loelli~n.
SIh&Ylar It! APP Quulity

FrtllUe~cy
Aggravalln DFadllu
Sedalioolml
M - Multipla Requa., AN ~ Anx Ou~ C ~ Col\lirdJo\J8 Cr{in9 E ~ Emo~on~1 DI~tr& DE - D.p,n~jon I ~ In&ff9f \1,,& C<>pl"9 '" = \>(19"tn.. f-D_a_D_"'_''',.o_p_m_an_'_"I_lm-,-p''_i,_ma_"1__L .. _-. LetnMgJc
8EHAVIOR/RESPONSES:
Unrooponsivv
CO - Coma1Qst
CD ~ Conl1l'<ldI IlI$ori<loIQd Ii - H~lIlteil\.ljQl\tf DolvsioM

W
DP
Disruptive pali.n!
o ~ OVQrlUmollll*dIOve'l>ac,',a
CI = CogMive Impairm9n! R - Retlles,
=Ofliberat61y
W~hhOl(fll\g
OS: OitNptN9 slgnl1lcant O!hol

T : Threo'lnif1g Physical HUTm,/Combf.Hhu
Into
A w Anontlon Saaklng
COP _ C(>l)I'"ratlvc LA = LO-:'i'3 ArudOU:i !

~.I~ting
1M = ImplIl?lve 5", sllIllplnll o : Calml'O",,1
INTERVt'NTIONS:
1 fll5" ran"" . !'!!tlenl i SIgnificant Other 2. R_~I""
3 Gukiarcfl 4. COrl.I"",,,1 Envlwmn.nll !loutin"
B. OffDf (roquDol bri6f uOnla<..1 9. PrcNioo Information 10 m-ere-aGe. ffivsl ot undan.-landinij 10, Enc""ra~. family 10 brinQ in familIar Ob/&C1S
14. R;,crienll
Remoli"~te
ram
15. OfV'9I'ilona! a-etNtties
16. Proactive m,.awre~ 11. Provltte relll\ation with m\l~iI: .......gllry. """Il braalhin\j, pr"yat. m.doealk>n 17. ReU$~3 f R.qUI''51!OO I S".k clarffica!lon 5. E-stabU,h mai-ntalnsd t!m-8frim8S f-or Cart n~s 12. Enc<>l.I~ge nc'm~I.I"p cycl' ~y oSin9lnCllriICt lighting ett., dark 16 E31RbU.h tH't",darl.w 13. D.<1<." room I Umltlng !Ouoh I i$ Pro.ido intan:!Jivo. ~(jt.ltity ilnd 5i&I1' Ui-.&3fiiUt&6 ij. Ef1~9"'it91l v9rb~iz"lion Quiet .stgn to 06-f'".f8fl3'e pnl~nf3 fosponsu to .siimulation \'0 minimi:;Z:Q Ixtha.vioral probl9nli 7. Enl;Ol.lllg. p*ti9nt w~n (te(1'lon making for eor. nee<!.
~SSM
H f: A \. 1 tf C " II
e'"

OF 8
24 HOllR MEDICAL/SURGICAL PATIENT CARE RECORD

OPM-1DOIHl71 (7/2007) PAGE 2
000407
24
ACI
POil
26:
SIta #2
S~e
#3
01 attempt! lor IV restall
~
96S1.
=S.ir~?lt"m.'Tl
-l
56-' 71-l
B4-~
121
Non
+ RE
IlL - /JooIJ!el1lmoo T1 C = rll!Jii1 lumen
s
SL/OllTlC
SL.! DL./TLC
p
Insertion Data _ _ _ _ Length _ _ em

Arm circumfenmce em
DressIng change (Jute _________
f-----------
---------------------------------------------------------~
PATfE,VT LABEL
~SSM
H: f
A L T 11
(,
~.
DEP,I,\UL HEALTH C~NTF.:R
t~CH,PHrLLIP H Tip 0736000302 MED 0530-01
IlnlUIUllllIflllJllft .
o ".
DPI
24" OUR MEDICALJSURGICAL ~ATIENT CA.RE RECORD

OPM.l000-071 (712007) PAGE 3 OF 8
rlANA~l,lMR.~ A
10/02/1976 ]lY
M 12/2~/07 000748298
000408

Patient Care
ACUITY LEVEL
Poln~
Record
ACUITY TOTALS
.......-~
Level Subtotal Section ''P:,'

1
26-37
1,15
-V/f t- ~
!
if-
138-55 56-70
7183 84-95
2
3
4
Subtotal Section "8" Subtotal Section "C"
~/
5
6
9&-120 121+ 7 Sitter 0 + REQUIAES I'URTt-IER DOCUMENTATION
IACUITY LEVEL
1----~--~-
TOTAL POINTS
<-; ti-~
~SSM. e ....
l-! I! "
t. f
H '
I!
DEPAUL HEALTH CENTER MARCH,PHILLIP H IIp 0736000302 MED 0530-01 10/02/1976 31Y M ) 2/26/07 '{lI.NAFI,IMRAN A 000748298
1 1IIIIU8 11111 III IJOIII 011
24 HOUR MEDlCAlISURGICAl PATIENT CARE RECORD

DPM100()'{)71 (712007) PAGE 4 OF 8
000409

KEY;
,I WN!;ij Of task completed
DATE STARTED
I :A"';J..~ -
01
24
ApIc<
Abno
... = See additional comments
U66
bolded key letter if indicated
Perfp
A-At
w-v.
5SII
DOr
Color
(Abnormallia:<inr, E1I16nslon, Flaccid, LOCH Iles, None,
WIlL
laMs I
~kJnw
SPastic, 5trong. Weak,

WD-Wltildral1s)
boo to
AbiWn
PUPil StAlE
B-Biisk
F-fhM
S.Slu~giSh 1m" ?mm 3m'" 4mm
_
lmm
Size
C-SWUOCN . . . Cloml Sm" Gmhl
Sand
~ace
I TED~
TED~
SeD! SGD!
Specify abnormal breath sounds on diagram.

(Absent, Del:lease(j, CRackll:ls,
Rhonchi, Whl'llles, Coars8)
s
l. POSTERIOR R
'D ~
AV,fj,
Bruit
Hem
C.M'r Exit (
Ores:
R
POSTERIOR
Atldo
BOWl
BOWl
AbS(
laS! I
Flatu
Stool
OG
NGtl
~
I Ston'
Tube i Ostc
Isrorr
Oslo
Oslo
Ne(,1
PATIENT LABEL
DEPAU~ HEALTH CENTER

F---t----t-7 _____
i__ ~____~____ r~CH,PHILLIP
111111111111111 II
r/p
24 HOUR MEDICAIJSURGICAL PATIENT CARE RECORD

DPMWOO071 (7/2007) PAGE 5 OF 8
073600 0 }Q2 MED 0530-01 10/02/1976 3lY jvl 12/26/07 '{1\NA!"I t TlvtRAN A 000'/482:18
OJ!
" E
DPM
000410

KFe ./ WNDI or t1uk completed
DATE STARTED
LJ. -;;i5f" 0 1
24 f
KEY;,f ,
... = See audllional comments
Use bolded key letter it indicaled
Time
Fltal M
UJir<lCH i. palnle
Ul1lle c,
Color temp sens dien

WIot
~
NaJ teo P'r~
ClJ)
~ les~ tnYl3 5>::0 j~S
Foulso
1lu,,~mw'1nM;a'u
fIlA \3 W'J(l.i
[l(;.cm)1
II
=1f~~B
T=
'rar.
1 ::: 1 +
IG81 (de,
I Veo con
iVC!~
tu~p
AfilJolm
FIf<Quer
I-wpra P
Sldn wa
.Jammll
Diaplio
MUClJU! Sl<inin\ Heel on
Wound
I"~I
I~
, I
I (
k
i
T,lmf
!~.-
~ ~
~
0530-01. 1'1 12/26107 000748298
...
lip
DPM'
000411
24 HOUR MEDICAL/SURGICAL PATtENT CARE RECORD
DATESTARTEO
{ ~J</-o1
24 t
I ..reQueocv.
:
illJnormal urinsry \'~din{j pattern IN:on01lni.

Retenlinn UrQency. Dvsum
A!ImJ1li
t COIDl'l
2 Ch_ :J fm-in.1I
c<illliq , AmM'1
5 Mf:;l1u:;
ALlER EO ,IlK1N/WOU/iD f(fY: PU = Pr~~:rure ulcer
= AhrasiM
I
L R
= IIlcistoo
=
fi O;"'f.fS
V
N
= IJ"urwatilt\; vice,
II praswre ulcer, I,;! Snge I, II. III IV. UHs!agfab!e - VJ$tul~r u!rer (venous slam, arterial insufficIency)
(01ilt",Ud
ilL = Sli.ler .R = Brwte D - Denuded I! = Erythema EX Excoriation H = Hiillr31ullra

I E
La,er.ticn
Well apptWimaiC>J
P<~i~YI
'" RJsh
=
H AWl>
TO - Tape bum
9DNr
WA
Return O~
- Otr.er
Drcstill\l:
55 - SWi Wills P --= Ot.~Hnt1t!QIKI
I StlP:>!S OTA = O~n to air
Wounll Sell Key:

Q
S
E
Grafl\)!awn SliJuyll
[ScriM
SUlfounding Sllin I(ey: Drainage Type: Q - lota,1 - Green Elylh. . 'fll<! S ;:::: 5NOUS
M 0
"
PI
= Mnntgi)rTer~ 1.1r::ffl:f.
- Other
= Hjjlij'lllr,n ~ul\lT~~ - Dry i!J~i ill1aCI
= Oltler
M C
. =
=
~
018 inage Amount:
Ie
S M
L
~
- SCMlI
= SIJf~~
=MMml~
MOC",llJOn
Cyaoouc/Dl!rk
IlWff
,
Y
1111 ;::
=
SAt(1~,l"JJliI,}~1U~
PU
= i'urulenl
iilg<llfy
= Larse
~ Cqp~\!\l
c:
- Yelo'"
:;:; Grll!,iy
- Other
Tlma
Wound
1!~11
YIN
OIlGr
Trealment
Reauenmenl Time an d Iniliall!
.. - .... -...... -. ------------+_--_t_----__ ._----~---_+--~~--~--~--_+--~--+_---------------+_--_t_----__I
~SSM e ,\
If ~ .t l
'I' '"
-E-
-------------.-------------------
24 HOliR MEDICAL/SURGICAL PATIENT CARE RECORD

DPM1000-071 ,712007) PAGE 7 OF 6
000412
MEnttAl tlfM1lD Wr Rftlraird
Rltlr.ln1 EJSuqUqn
IrtalRaJpauKey
j
, ?iOltt! ,In M1ifu':iaJ :i.t'lmy ,Ultt'VJ O--1't'J(";fl tk..-4t'i{.'f't (e li ' W m3h>iaj" o_tr""lIact'll.rh~ tw.:l)
1 En~in"JlUlli:!r ,tt 1r>,."ll,v,mbtY.ifif. inP" ...ll 1lI1~'f,;S !Jilhull ''l.MXll cui~.~jl )
M~1c~j"n 1<v.1i'J::-,J,H)r, !<J,~;nt~it) IDi/;1'!>iW
UOCIll1len! t1r.1l ~"4 IBltnSl. (I.e p1..

parAl'J. ~<l1fll)!;'R. illr:)
U,"",tct)) ,ooJBctl", ",fcty
!in;;'S fit luM','_
~t';,";f1 ~fnl It! Ib~ (rt<;t!Hlt'.Hl
ur tk
(.,II
In l<UIJGat~Gn
tVJX IDIJV.:,aICS Idkrw~
~l3th;r;{~' ORRlll fUf1iJ.'1kin {(' g., '-;I)~ lO:!.HC<:
oJ
!Hj~nHon<
~vns UljCUjW) AS$t~~mel\!
WIln ielmer
1 GM! pili a1 t,,>US .I~$. He ;3 AJ:-111ily ~j\moo::Jtf1tI,;S nsk C't rf;mFffr
m;etirf.ooon adm;ms~rtl!jl)ft (If hydrtttc-N

1 Sftt!'!i) ~)l !~I~tnh~ tt1,(): ;;l~ 'lll~itP~Vh'k-d
ll(,hH
Ileosoo !Q{ Ie.\u.ml

lime lI"OWS
Ti!/i1 ff'Jf<..:..V;B !If!~VI;-Ji;ry
M~m~t"'110 (Mlilt~
Wl i;l~\l{'f ~ll !:'\)(Q~;ai
~ GtlfY,Jr:.fIJtivc
Ot<SSInIjS. scwre, It wd fr:S!Juinf rr.mD'lfcd
liNN!W13'
.iiiiivt.}
~b-:rt(:~h... -"ti$, itdM>i1o \,;j-;ti<:S (;1.:6;(,_ fM;)
jjrrx:.edJjf~ 'rmo WQI'.Jd ~urle' furRt Jnr.)!} if the, taft t!~~tS$h-t mement Il<I00e ~ '; ""'~'~lIy a>'V~ll'iall .9. e:.weffiIlr
4 8~ha'HJ{ rcQtJlll>j fo! r~mrNal
(}I
haml !G s':l 01 r;if!,ll! (100 8<l1a.""a,
q..tfiliot,)
lfJtliJrts 'l V,!;Stl.l(.a{ .fA,tc-~6fiaSt
ACTIV TV HY
A ~ Ambu\iite D = DlIllgle C '" Gh3h-
DSC
II
Bed
= 6e!J,ii!~ CcmffiQQe
POSITIONING
KEY
DEPAUL /iRALT'"
MARCH,
~~~M- DePaul Health Center

24 HOUR MEOICAUSURGICAL PATIENT CARE RE;CORD
DPMl000Q71 (7/2007) PAGE
lO/OVJ 976 Jl~ f-iANAPI, IT>lRAN A
PHr'~I!""1 07 36000302 MED

"I
1111111
CENTBR
0530-01
lip
a OF a
12/26/07 OO()748298
000413
24 HOUR
PflEVIOUS Z41fl1: I' :ake S Output >?fCc-t f>1<Zf ISOLAlION: (] SpecIal Contact 0 Contact 0 Neutropenic 0 Airborne 0 Droplet 0 _ _ __ SCAlf KEY 0 3e(; O,-Standjng 0 W/Ghair 0 6fing OTHER PRECAUTIONS: 0 Safety-Fall 0 Blsedlnll 0 Aspiration 0 Saizura 0 _ _ _ _ _~_ Yellterday's Wl. _~ KG Tooay's wt. KG {Please ",Gom:H& welghl difl8rencil if grAtar than 2.5 kg.}
~V1EDtq~/SURGIC~l PATIENT CARE RECORD

(.s, /..,
DATESTARTED
i2/2-;rfIYl
241
Time
RtUn;
Sulill
Obsorv
ftlRclio
llfwit
LocatiQ
H. UA
jl&A
Jiym
o
"Aim nil,
__~O~~~~~ . .~~~. ._ _
O!W./TUBE fEEDINGS URINE jJ'fHER
8tllavh
II .. / '
Quality freque
"Vgr8Y
S.~~II!
~l
'14(,
1200
1300
5W
.-
12hr Sut TOlals!.

j
ill/' '1(;1) (.{1,.f7"1 'l-- ,~-__ ~6...L/'A7J)I- - ......!..'i..k:-/12 hr Toia! (hlfTuue ~WJl..!
.,'
~
---, - -
---
-~-
._--
8HJ:
2 he Tot.l f'arenllfal
191)0
AN.
, E" EI
12 hr 8M; O>J\put
v
.2 I <:,6
, I ~ kif
O~O
i' __~~~~~4-__~____~,_---~----+---~----r_--_+----+_--~----_r----+---_+----4_----1
~:
INTEl
1. Rei 2, R~ a, Gy 4, CQ 5, "'~,
6,
7
en,
Em
0'
0200
0400
I'
I
,--
11111
D~O
,,"V
-A
12hrTol31PamUeral
~:;'OI~\S --~ -ar- - - - - :1J&

..;"JU12 III TU!lIl
,IJC
12
'SMII~ftrg
-/;JV
I~-----'17C
TWinty-lour 11m total
"5g ~
nU11J EIlUIVALfNTIi; 1 oz " ., ,lOmL
4 QZ (1/2 cup) , , . 1ZOrn!. 6 OZ (3/4 cUDj, . 180mL
8 oz (1 CUp), "
. ,24OmL 12 0, (sooa- t can) 360mL
PATIENT LABEl
~SSM
.,. E '" " l' H (A ~
~ ..

,
DEPAUL HEALTH Cl!;NTER

l'>lARCH, PHILLIP H.
073600030~
....
-~------~-
1Illlllllllilltl1l
II?
00074829
24 HOUR
MEDICAl/SU~GICAl
PATIENT CARE RECORD
l'>ffiD 0530-01 10/02/197631Y J'112/26/07

HANAFI JtJlRAN A
OPM1
OPM-IOOO-071 (7120071 PAGE 1 OF 8
000414
DAlE STARTED
It
l
1 Medication
2 Amblli;l!il)o
9 He.t
10 Cold
11 Mu~rc
APP", A,llJlllt pain prest nl
Slightly drowsy, ea'>Y to aroUG;; FreQoenrtv drowsy. lIro~able, eyt"
Ilril! closed ounng conversalion

{cnn&id&r redllcing opioid ItDtS}
4 Somnolent. difficult to arouse
BeMviors
3 Reposition " RelaxaVon !I Calming StJlements > P!ilyeriMedi!~tlllH 7 Spiritual Care 8 Deep Breathing
12 Touch
13 Im.'\OAry
14
MilS~~yC
15 Distr;.ttion 16 Ecillr:alilln
analQesv; 21 Otfrer'
lIliv;.on
TIme
Rallng SeDI<! (I
Scale Used II Observalinn
Fun~tJ/)n
GOII II
Describe:
lIIcaflon. BilbBv!Qr QI APP
Sedation La I!I
Inl~nenIlGD!I)
6EHAVIO>tjRt:SPOlll5E5:
M
~
Multiple Req" ...t
UnfBspo-nswe
AN ..
A.~xlous
C - ConllrWOUti Crying
E - E-motlollal Oislf&SS
I e fnDfk:u:U!{D CopIng o = DaJ'-elopu\ttot&:llmpaltman(
l. = Lelhaf9ic
G ~ G';DVII19
PEi
OwreH/"n
CO ~ GOmalOSS CI ~ CQ9I1it;"l> Imp~irm901

R
co ~ Contllt9<l!Dl~or",n!ed H ~ Hallucli,1!tIOnsi 09lUilOoi

W - Dffilb*r.t.'y Wi1hl1QlQ",~
UP '" OlSllJpliv..
"au",,'
1M '" Impul.we
5
~
OS " Ol5ruptiY8
Othit! T " ThreatenIng Ph)'1kal Ho'",;Comballv$
S'9"i~anl
SIeij)in9
Coop~rljve
Q - Calm/Quilil
o-
Ae.Ueu
Ovel'$llmula\~Ovetel\{1lYe
Into A _ AmomIon $nking
COP "
LA ~ L&~* Am<loln
tNTERVEHTIONS:
L 2. 3. 4, ~,
~
Ra-assur,mc-a PatfOflt / SigoHk:anl Olnar RadlreG[ on
Guidanc.
CO(\~I&II
~.i8bli~j, ma,nioJr,od i,m.fAime. !or ""A nNdo
n1 F.n"ronmint! Rovt;,\~
s. Off.! Iroqufml briel ""nlDGI 14, Ra,,,jltnt I Ramo!;""," 1 Ra.taliflQ flY;;l. 9, ProVide Informal.on to in",,"ase '"".1 "I undar.tanoilV. 15, O~Ver6KJnal ac(Ntbuu 10. .nNurll.Qe fam.1y IQ b(mg in IbmJl;,,; ollje>;t. 1e. Proactive meuur$$ 11. Prollld9 relaxat,on Wllh "Wfi~, imilS/eIY. de~p \>reathi"l!. 1'''')'91. miOiC.lie>n 17. Rea5$'1H I R9QuistiQn ! Sn~ clari1icatiQn
Hi.
13
bO"U"9~ nOlmel.,"p crtl. by Darkan room i ~lmllln~ touch I
QuIst sign
u.ing Indlrecl RllMtins alt., dark

stimulOlti(m
19,
19
~.t"br..h
tt;l
bOvndMt.
EnCQu'A.i v6,\>.lIz"llo"
Provtde In:len.s-Wa 8soeur+ty and S"Rf-e'IY m-eMln-o"'l

mln'i:mizQ bllhavioml prohtgms
7, Enc1}ura-,]G paUant with ctafJ~~Ofl malftng for
caf9 naan.$
to MCfa3:W pahnn1's
r~.p.)TlS-910
DEPAUL HEA~TH CENTER
~SSM.
HiA\."J.io
'CAR~
DePaul Health -Center
MARCH, PHILLIP H
0736000302 MED 0~30-01 10/02/1976 31Y fv1 12/26/079 HANAFI,tMRAN A 00074829
IIIHIItMlIlBlllllDMI .
11 p

DPMl000Q71 \lf200?) PAGE 2 OF 8
000415
.24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD
..
J:.
,.
SIte #2
SiIe#3
+
I
of aliem~1s for IV restart

BACK
BACK
RT
f~
~J
/,.
I'! l
I)
L
.~
K\ \. \
'-T
M
rv.
5l.=;
SJ."1JIe. /!.iffifn "IIF!lortb/('.bilt''il
LH-l
0
s
Sll Dl I TlC
'IV
r,, ~ T'ipI~ kJil'fR

RIGHT
Sl/Dl f TlC
./I J
1\ '
t ') \
.v Ql! Ime !X(J\'0'e<J.
hWtcale !caM" 01
T- - - Y
5L
l!J~~
insortlon - Date
.linn circumference
kength _ _ cm
Dressing chilngt Qate
em
!i
\
PATIENT LAeEL

V~CH/PHILLIP
1111181110111111 H
MED 0530-01
1<1
lip
12/26/07 000748298
24 HOUR MEOICAUSUROICAL PATlENT CARE RECORD DPMfOOG-071 (712007) PAGE 3 OF e
07J6000302
10/02/1976 31i1 HANA.FI I IMRAN A
000416
DATE STARTED
~
ffi
--_. UITY LEVEL

jots
1
2
Pat;ent Care
ACUJTY TOTALS
..
Record
1{:r-tCo ;;r
A
<:;;
Level Subtotal SeetlOf'1 f'fJi'

f
126 37 i3& 55 :56 70
Subtotal Section "8"
! 71 83 184 95 !96 120 1+
6 ACUITY LEVEL
7
,=",_.
3 4 5
!Subtotal Section "e"

TOTAL POINTS
----~
iZii
Iq
Iu'~
I~~
Sitter 0
..,
NOTt:: If mora than ane ilam on a Hne, circle the service IndlcBlsd.
+ AI:OUIRES FURTHeR OOCIJMENTATION
--
~SSM
tt E H L T i l e " If
...
r-
-----~
24 HOUR MEDICALJSURGICAL IlATlENT CARE RECORD

OPM-l00Q-Q71 (7f~007) PAGE 4 Of f1
000417
DATE STARTED
24 H
KEf;,i W
nmr
flcal MI
Urina co!;
Fou!~smt
Y'li(fiil{j,
1tJpnp<!
<brtQrnlJi in 'ID!!.
A.bnormai
PfI}qfjenc
B ~ /<lone T = Trace
CSI
((.eS(
1 = t-t
Feo WIld Swapui

Dr~lfIa9a
! SkiOillall
"aunme,
IJraphilr!
M~el)lJ~1
IWCllodv
Sl:!n lntal I Htel pille
~;:!::
k:
I~~
tf f
Time!
~~M-
.~
"
t=
L
111111111111 r"'Jl,RCH, PHILLIP H

07~Q000302
III'
24 HOUR MED1CAL,iSURQICAL PATIENT CARE RECORD

DPM-100Q.(171 (7/2007) PAGE 6 OF 6
M~D OS}O-Ol
10/02/1976 31Y
HANAFI,IMRAN A
M 12/26/07 0007<18298
DPM-f(
000418
DATE STARTED
,12/a.7,ioZ
24 H
lInne tOlol/ct;li!ty:
Foulsmel~ng
IJIOOUf Clot 5romtl1!
CLJ,uay
Abnormal u(;nary VI i:Mg pattern' Inoont1neJl1,

Freqwllcy. RijlelillUlI. Ulyc>HCY.
[)l's~!ill
ALTEREO nl~OuNO kEY:

PU = Pr~ssure ulcer II pfB~,urB ulcer.
!i~t
A = Abrasion BL = 81islef
Stage I. II. III,
8R
I L
R
= InCiSIon
= Lac~riliiQn
= BruISe
. Denude.d = Erylhema
= Rash
IV, UNstageatlle
D
E
TB - Ta~.e burn
V
N
Vascvl vIce.
(VCllQV; sta~IS.r!(:t>al
= tieUfOPlltilic uleet (dlabellc) = =DermanQl1iJ =I\t"l'\<'''

O~~ 10
h$liffidenr.yl
EX - Exco.iz!ion
H
= lieHllIimlla
CI 5
o
- G<oen
WA =W~II 3ppW(lmJIQ
Other
IJrBnillll: SS Sl6f1 SlOpS

D
Wound Bed Key: Granulallon S ~ Sl00lJ11

Q -
SUlfoUlldlnll Skin Kev:

I - inta~l E : ;: t;ythl.!lrn.
Dr~inalle Ty~c:
DraInage Amount:
lie - Scam S = ~Jfl~ij
M L
~
Rl}unrj~ I
Rounds
I!I OTA -
Ii
R
DI
M
RIl\~I~gil
aIr ,\!Ivrt;
= H(il~
= Other
= S~:1tJl:f3
.. = Mat..'iflIIOO C = CYioobciOzrl<
Q
~ W!~f
SISI
PU
= Purulent'
Hhl!l!!Y - Yellow
=
= S;,toSlnQ~ln..,u~
e'lIf,ty
= Mllderal&
= llilg~
~
Activity
P05!t\llil(j
- Drl anQ irllact

;;;; MUIl\\I"on1{'JY ~.tf;'l)S
I Y
C
!;,1'i"!I"
HOI!
{~
Olhel _ _ __
Oll~r
o - QU,er
_ _ _~~
C.IlIiQhl
Tune
Si1t1 NG.
Dr6uln" Wound Slirtoonding Drainage "!led Sldn Type
YiN
RlIlIummont TIme RRd lolllal$
O\'rtJd [leo loct.

Toil'iling
:lirrRr~i~
10 bono;
i\IlCI(Iy b
ONR (.fl(
Isolalion
ftC
OfF?SSM DePaul Health Center

HIAllt\C:hR!
DEPAUl, HEALTH CENT.E:R

DPMl00{).{J71 17f20(1) PAGE 7 OF B
MARCH/PHILLIP H
07 36()003 02
111I11I1I1Il1ll1l1ll11la.
r-n::D 05]O-U1.
I/P
12/26/07 00074B298
lO/02/197r- 31Y
Hf,-NAFI ,.eMRAN A
"1
DPMjQ
000419
"~L.r1i
MEDICAL/SURGICAL PATIENT CARE RECORD
MWItAl Bum Iw flHlr.lnj

to~n-p,lrIOaihiplSu-r.ervt!J--on
RultJlnlgstuHoA
DW!lm~u' hfflP. ~rtd laalf',,!l (ie:,; P'!!1fl1, "l'O"'t. <'") Vi in t~)tlll\Ql1ll(1, "".,,"" fofl)"'1"9 iltrTl! OlitlinW WM teMm!
j
Trfat Retp'!: Key
Cr,anyN lIiTiJTall ~:olIMwne R. ~.<vJ I'll! "" IV, n: ".c)

~tjjoo [II'"r~l1t t'Ii~g~~tionJ {[l:t'W fUlI'.jt"':.
1 PtOfUl an znn!ct!l air""v""""m u''I\)!\l' !lI{hill'Y (8.9 to mll1Uin fJlOOlsarlUW\r!chOfI \tJ!les)
ct.
r.t;Jl!rll't
~al
...l!~h.el<;.l
M~iola1n I"~li'''' in", '" ~...,.! p,l(1ents' cwrtftt c~ (it.!l.,
",,,. .,,VaI 10 tn. h..

S{ljc
'tmMt ti th~ wmt!!: 01 rH/hiho(l.
unable 10 (~nl~tl lot ~:tfIY 2 Cool to olin ill II'''' iil"', ffic 3 AChitl <en1<lflWal~S risk 0I1l''''i"''1
4
~
A!lrnwt.~~J tlJ f\-'fit)'#. ruf$~~. 51.~'t$..
R~amy
.<1I!l!il'<oo
MffiC!1 ~n falU3tl~n
QvefUMilwlit'( (bamc""
,""""
,,,lll< mil.". alt.)
m.d<Gatloo aClJ1~ni31''';o" 0< hy~,.~} Salet\' 01 ~8\t~'lt~ WilD '"" '''''''!JaJ;i!;Il"j Iff." M1I!\Ury m 'lJfqk;~ ~ \'ino woo\6 !.JlIerIllfWJ)I hl\lJ ~ t11<-y haw (U1;!JfSW.
lIIv",m"-lIIlllIDfO ~ IS rne<liCaJly apj)1it~1Ia1e !f.q" f.<l!\'ll1fty
traC'ttH(~ 0'1 Vi~;t~ 5U1WJ:fS)
IW.SCIl lOt mllm

k"~mMI!!mo
tramtls
J TlBl rtlcii,c I,",.I<''''"'Y 4 fWtllliOt reQWed 10'- 1<UW\'i11
etc.. CIY4iErali1< ",,><I restraillt ''''-'1,.d 01 hilm. 10 ,';1 (0 Illt"" ("" e.ta'll1lr.Ii
f'alitnt'amlrr ~{bcal~lf)
HistfdlfU!
1 Othw (re.{luit'!;) 1"6.l1f..ID"lt lmtutMob-fton) H
P''''lKllll. Ilf&n iI1Iurl p;l1i<n1IIO.'1l fOItr.-er "'jUlY (q . eVA w~h jWhlfi"J (>( iw.1d liau"", 'II<ln lodl\iool1 koiVieS)
v""' .... nan \0 AliffiWr mtlitales le,lon
B= fl;;rl
A;TlYITY
Sse ~
KEY
A -
D =
Ambulate
{)al1Ql~
~dsidB C{)mmlJd~
PATI~Nr L4BEL
POSITIONING
KEY
o ~ Chait
~SSM
" E A I l H . t
DEPAUL HEALTH CEwrER
A " E~
24 HOUR MEDICAU5URGICAL PATIENT CARE RECORD

DPM1000-071 (712007) PAGE 8 OF 8
rip MARCH,?HILLIP H 0736000302 HED 0530-01 10/02/1976 :nY t-1 12/26/07 0007462:18 HANAFI ,rMRAN A
111!Un1lOllllllUall
000420

PREVIOUS 24 1/(; Intake Output SCALE kEY: 0 Boo 0 Standing 0 W/Ch'!1L- pSfino YllztllnlllY'S wt , "KG Today', wt,
t.. ) ,f'
DATE STARTED ISOLATION: 0 Specilll GOlltllCt 0 Contact 0 Neutropemc 0 Airborne 0 Drllplet 0 _ _ __ OT~ PRECAtJTIONS: 0 Safety-FaU 0 Bleeding 0 Aspiration 0 Seizure 0 _ _ _ _~_ _ ~}Please rooorwife willght difference If greater !IIan 2,5 kg,J
IResp_
I~p
Ip~se
02 S31 O?% I R,]tP
I Temp
--
I
!
"-;,1'
I...;:
,il
v/ v/
l.,r-/ l,../ l.,r-/ L,/ , / , / "V
/,,,/
1,../' i.,,'/ / / V' V'''' l/l
,-r
//
~.I; -' /'.:
V/
'LX )
~
I'
,~.,
1 ..../ 1_/'
Time
~~Y~II,g lJtiV'~'
!ledsld glucose
,
RES!'
12_ff
~pl--
Rating
Scali l Ob1VrY
. . lIME
\ill' rum
//'
ITEMr
TIM!:
t;,M
h!!L
r
F.IiI
---",.
7'
//"
rum REsr !TfMI'
llM~
81'
,/"
Irum HE81'
,/-'
",.-""
,~.
~I
D
IliNNER
STAll!:
CRTHO iTiME
0BP ,.,-,-
ITIM
SP
,//
-,' ",-
,./-'
~.-/
BRAI:FAST i
~
,//
--".....
./.-'"
O~,cril
lUNCIl
tiS SNACK
LocaUI
geb&vl
%!a~M
ORAl
URINE
OlHER
TYPf
.
TOCo'J~
ORAL Amvuft\
n
. Amount
fWSI1
Ammmt
8M
Amoun!
i1moufl!
llmo"nl
Arr'-IlI/l1
Amo,m\
Amount
010
--
A.mtJfreQ.
Obu
~
I--
SMa!"
i
1111
1100
,
Inlllili
-f2lJO
1300
,
I
12 flr
1400
1500
COM'
..
1600
nil!)
noo
Sub TOlals __
_._-
--- - -
----(jr.l~'TlIba _ _
12 II Total Paren!"ral _ _
Tn Count
12 h(To!~1
- - - - - - --------"_.
1? hr Shill Outpul
i 2 hI ShiH Intake
'19DO
lOUO
C--"
- W)(i
~100
1l.1 ( ... (
i/L-Sr:;
(6".)
~y.,
me
2400
j"'.(
I'-Y;'
H/\,.
I
I
--
0100
0200
'fH(r
i
i
0300
o~oo
-i"K ['po
-il
I
,
~SOQ
1%
~/}(;t'
0000
12 hr .
1'1-<-
SubTotliS _ ~ ______ ~ 121, Io\~ P~Hm frai"~ 17 or Total OIaHIIOA _ _

12 t. <i1lil1 IIdakc
p..(~
,rr>
.'. IV'-
<!.L'"'>.
)'Ii,.. '--
-----------12 Ilr Shift OUTput

'Or
,..... " -'w,

fLUID EQUIVAl ENTS: . _ lOmL lor.
4 oz (1/2 cup) . _. 120mL
6 01 (3/4 cup) .. lBOml
"v~.
'V'.'
I~~~
........
8 or (\ GUp)
-- . 240ml 12 or (soda-' can) . 360ml
~+ ~ +-]")I<J
PATIENT LASEL
~$M DePaul He.,!lth Center

24 He UR MEOICAUS\JROICAL PATIENT CARE RECORD
DPM1000~71
MARCIl, PHILI.TP H
07360003~2 ~mD
D'BllilJilllll1lHllii
hH
10/02/1976 31Y
(7/2007) PAGE 1 OF e
IIp 0530-01 1'1 12/26/07
HANAF'I,IMItAN A
000748298
DPM
000421
24
Ar.hlng
A,;d,,)MQ
Burning
SA SI< ep, easy 10 ~rou>c
~:]~!!!i~;L~
APP"" ASSlme r,~m pro.'RnI
S9:'laVI()fl',
CrJrnpil1Q
~
ShllfP Slailblr;ll
tnwmmenr
Awak~ "n(j
alert
RR~y In .m'ISi!
.. M"llicotion 2 Amllulatmfl
:I RepaSl1ion
to eoid
K~~t
Crushing
tender
Throbl>~IY
:2 Sllglitly drow~y.
ActiVity
Procedure Oloer'
ftj!S!
11 Musil;
Dvij
Qnawing
Ht~dvy
PrR~RHffi
T1
T9
= TIOht
c
3 Frequently drowsy, arou~at.le. eyes <inn I;loo~d UUI1f1q cunversation

(~o"'lde,
4 f1e!axsrion
5 t..1mino SI.Ii!m~1115
.. 2 Tovch
13 ImaORIY 14 Ma~SJgc
i f Epi(Jul31 is peA 1~ PreemptIVe analgesia

20 Contil1l)(l11S
om".--
nngling
reduclnll oplold dose)

3m!!!;!!
e PrayCl/MCOitaliOn
7 S;W1lUal em
8 DRRp BrRiith\!ln
Hi Distraction
16 Edcatloo
aJ Iah)cSif: IlIlusioll 21 I)lht'f"
4 Somnolent, dillirul! \0
Site
Time
8itt
/t
Ralino Score
S~19
# (
Used &1
OtSemtioR
Funeliln GClal Describe:
~
LotBlilm.
8ebyjor Qr Af P
Quality
Fr&quancy
Aggrayali~~
F. ~IOfS
Sedation Level
Inlervenlkln(&)
In1ll811
BEHAVIOR J PSYCHOLOGICAL
6EHAVIOR/RESPONSES;
!IN
Anxious
ImpalrlT'.enl
M = Multip/s R.tf....l C = C(lnllnU(lU$ Crying

DE = oeprMslon G -Gr!\!Yino
IJ = CI
UnrO$PQn,iv~
CD
~ CQhfll'~()~Oti$nlll<l
DP ; OiorupUw PaI,,,nl
E ~ EmotiOlli DlttNlU
CO = COIlltIOal! = CognltlVe Impalrmllnl
I = tn&f/t!cllve Cop,"9
I) _ Oe'.eIOPll'~l1\J.1
L = lUlhatyk
o =o-"",.!imu!alad/Overwvti\la
11.
9
10,
Off~I
R ~ Reslles.!!
w = O~flb.ra!al:r Witl1holliin9
Info A ~ Ahen!lun Soeklng
H ~ Hllluein1l.tionl' OIu~ion6
DS
1
Disruptive
Si9nifi<:an! 0111$/ Th,eatenl1\9 PhysIcal HalllliComba1l'le
Calm/Oul<>' COP ~ Co()peraUv$ LA ~ ~ An>elOil.
a~
9 = Sleeping
1M - iMpulsi,,'"
INTERVENTIONS:
t, R... nu'on.... P.li~nll Stgnfficant 0'.119r 2, R&:f!rectlC<, 3, GuloAm6
'r.q""nt blivl contact
H. Roo,iDn! j R9mOa"'li" j Ao<'1l111ng fact~

Diversion," SL1iviU""
4 ('.on.islsnl I"n"lronmen! J Rc,nina
e.
5.
E5-labii'S"h rrJaintainuti timijframas for CRre OEURts

En~o'1jra~\l
'terbBfi;tBHoi'
7. Er.c<>\Jra~$
tnl"lnt >'IiIh <l1I'4I.,on m.... 'fl5I 10' car. n".".
! 5. ! 5. i 1 i>toy,~ filMatlo" wtlh mu~ie, imagery, de.p b",alhin~. prayvr, m~i~a\IDn 17. 12. Enoo"'''1l5 normal .Ieep cy~le by u~ln9Inolf$cll!omlng aftar daTi( 1&. 13 Darkon TGom (Lmrtiog t('uuh I lS. Quist siQn to daofoosB J}atillnrs rtmport:m Jo nfimw.af!on
E;n"ouf"9~
provide 11i10RnaMI\ to locrea.6 16\'61 of Ufloorolandiog
family 10 bring In familiar ooj9CtS
PrQacl'''B maa.uras R~ilU6U f R&q\l~~lion I Seek clarine.lion
ESlabUth
bOI/"da~ m8~~:ure5
P1Qvtde Intew,ive $&cutrty t.nd e:~lety to mlnlmlze b.eh~v;afl,j pf-obJti:m5
PATIENT LABEL
~.;;SSM
HEALTH
.t!AJI;E

DPM-1000-1)71 (7/2007) PAGE 2: OF 8
ttJARCH, PHILLIP H rip 0736000302 MED 0530-01 10/02/1976 31Y ttl 12/26/0'1
KANAf'l, H1RAN A
000748298
11111111111111111101011
o
" E
DP~
000422
24
ACt
Pair
2S-~
38~~
SIle#l
Site #2
sa.i
7H
64'~
961
121
REI NOTE
T
Site #3
# of altampts for IV restart
FRONT
RT
'\
FRONT IT
:' ! -
.-I
LT 1 - - - - - - 1 lEFT
SL = Smqil:kJmcn at - UOilOlf. iUmen
T[(' =
. {
) I
I; {
a
SLf DL ITLC
RIGHI
p
u
ITLC
rr:pl/;' MIJCfI
tGCJll1;.Ji Of
In':Jrcft?~
fI/ 1\(1 bn)J {J;trr..'l~1fW
} ./ J
-~UJvr
/(f
!n5~rt!on
Oatil _ _ _ _ Langtn _ _ em
DressIng Cha!){)8 ~a!a _ _ _ __
-. j'
- -------------------------------------------1
G
E
1 - - - - - + - - - - - - - - - - - - - - -- ..
1-----1 - - - - - - - - - -
PATIENT LABEL
DI::.PAUL HEALTH CENTER
~SSM.
.IA'o.TK,~
... ft:f:
T'lARCH, PHILLIP If HAN.!'.FI,

INPA~
111910111110111118
A
rip
000748298
24 HOUR MEDlCALJSURGlCAl PATIENT CARE RECORD

DPM100().()7- (7/2007) PAGE 3 OF B
0736Q00302 MED 0530-01 10/02/1976 31Y M 12/26/07
o
H
OPt.'
000423
DATE STARTED
IACUITY LEVEL
26-37 38-55 56-70 71-83 8495
1
Patient Care
ACUITY TOTALS
Record
{l. /k' /01-
I A
Point"
,1
Level
2
Subtolal Section "AU 1 Subtotal Section uB"
-1G
jd~'~
3 Subtotal Section "C" 4 I TOTAL POINTS
96-120 1121 +
1-
~ ~LEVE~
Sitter 0
'1- '
REQUIRES FURTHER DOCUMENTATION NOTE: Jj more lhan one tttlm on a line, circle the 5ervice indlcaNd.
, , .
~
j
~SSM
HE'" l l' H
C.
~
FI r
24 HOUR MEDICALJ5URGICAL PATIENT CARE RECORD

DPMl00Q071 (712007) PAGE 4 OF IS
000424

KEY; ? WNt:s or talSk complated
/-;. f1(; {D 1~mama
24
* '" See additional comments
Use bolded key letter if indicated
AiMt
rniR!a!
Con1used. Lethargic.
D~~~~E
__ ~~m~~~
/~
IJI
Follows eM~ nMds

LOG
Ann
Peril
AA
Speech clear
Speech (Aphasic, Delayed, 8lurred)
/'
w-\
$S IIH
S,astie. Str\1l'l(l. Wtak.

WI)-Wit/1draHs)
Moyes an "'""u''',...." withe~I.stlngtll Motor response ARM (Abnormal flnxion. EXtension. Flaccid, Loc;lijles. NOrle. LEG HAND
GRIPS
.~/~
/f
/1/
// 1;/1//
,~/{ j' 1//' 1// 1/'/1;'/!/,/ i/.lii/ '// ,/1 // // // j( l;/ 1,/ ./' 1,/ 1,// >/ ./ .,// // .//l// /! I/! 1/'
1 . ./
[/ 1// i//
I
/ / / //!
//
1//
1;/
,// V/ .//
1// .// 1/1//1//1// .,/ // /i// .;,/ ;/ / 11/1//1// ./ //

!
//
/~
~
l-<JnI
WIlt . ffilW.
liim!'
abr~
// ! / / e/
/
/1/ i,/ // l,1
Tremors PUPIL SCALE

B-l:SnSl<
S-Sluggish
In'/ll 2m", Jmm 1'Mn
i
SIll!
F-Ftxed
C~WQ1enl
I;l":'"d
;;, '1m
e
IJmm
I
; l//
l
,,/
.,/'!//
1// 1/
;
/
1"/ .,,'
//' ,// 1//

./
l// 1/// /
./
/ / "//
",/
/'
1'/' l / / ./' / / [//
. R~ac\!on
H.
l
//
7mm
./ i
!
'
,-'
...-
.,/
1//
// //
./
l// l/ / / l/
/"c'
San
Pac
TEe
Dysphagia
is)''''''nl Ah.wnll
Numbness! ringling
FacialdfOOJi.R/L _
Postel1or
aU lobes clear
~ am 1m ~
TIME 2
Aboormal bl1"alh sounds Specify abnormal breath sounds on diagram. (Absent DIl ;reased. Cflackles, Rhonchi. Wheezes, Coarse)
1m
1m IE l!l
TIME
~
,,'
Em mI
= =
1
TEe
SC[
~ tim t:=
SC[
AV I
BTU
~
L
fti;
CAf Exit
~re
~"'~
~4
R
V--"""
5
1r~3
~
l
V--,,R
POSTERIOR
POSTERIOR
""0f'"O.V, J' effort un/aborad

Abnormal relpiratofy effol1 Dyspnea (on &xertion, at Rest)
I Cough
Abt
,-
."
ICough and
Incentive spi! omeler # rnL / # reps
Sputum
(ru.o.;h
.f'
ra; reo; lAb

.,,~- Y'~ -"'~
AM
"", ..,' " .,"" ~.," "

.
i-"'" i"' " l.,'/ I,,, .. " " . J
.,
...... ........
..,C"
f/'" !-" ... 1-'" " 1""''- ,/,.>,
~ y"
i"---
LasFlal
'~n"n',
color,
, Suciicn {Nar:ai, Orai, 'flach)
Trach care o Trach tyPI; _ _ _ Size o CftAP 0 BIPAP Settings 1~.1mG.", fklli'.YA. 0 CMV 0 SIMV
1 I !
!
I
I
I
, ,
,r--i
I
rn
NG
Sto
Da
Tut OSI
ro."" ",
'~11"'!1
(vp.rified per order)
Comments
~ Stc,
~.
tiHElST TUI.IEl:i
TIme
localion
WlItrStal
Suction
Crepitus
Drainage
PATIEN) LABEL
OSI OSI
/
//
,//
SSM DEPAUL HEA.lTH ceNTER
DEPAUL HEALTH CENTER HARCH,PHILLIP H MED 0530-01 0736000302

10/02/1976 31't' HANAFI I INKAN 1\
t<1
11I61n I'WIOIIIIUft II
rIp
o
H
D/2G/07
00Q'/46t98
OPt

OPM10000i 1 (7/2007) PAGE 5 OF a
000425
DATE SlAR1ED _--'_ __--'-f'_1_ /
)(wfo"
24 He
KEY: " WN
Tlmli
/'fill MaBI
Ui1ntcl$!r,
Co!or toolp sensatic fl

I'ml - t~!J1 tl!!d ptrJ<: rA~ rehfu. ~1;: !}1<1a 1 flli:'i:wd.... ~.jn ""Ill\ willi !l# I!osa
i:illlliri1lSS, Ur"lC cCIGri Foul.sme!ih
roD IV YJxb
S
=
01':&0 ill!
~,.,ilImlli.""W,.
Y!fX!it,g, I I!JP~ Abnormal u

freQlIIJncy.
C61 (de>1;ril
Non.
T Trace 1 - 1+
ISwra
lfa()cOll<luit
IfJblC
Drainage (\'
Sldo WiITn
JauMICl!
Dia?hOrclic
MuCOll! IllI
SlI;'rIlRtact '
~Plu~e
WI}!i!ldvac
IfSl'slwilt
~SSM
Kill. I. 1 '" C A ,
E-

PAGE 6 OF 8
r.!~~'H"~~.'11 0736000302 MED 0530-01

10/02/1976 31Y HANAFI,IMRAN A
I/P
2

DPM100IH171
(7l~007}
M 12/26/07 OQ0748'-99
000426
Urineciear, Is painless, ~fllnlll'r ""In;n1llm

Urine color/clatil'{: 8loady Clot 5a(fJlllenl
FOUl-smelling (:I.oudy Olller
VGiJli:Jq, Foley,
SDllfiPDb!~
AbmHln~
Anuri<',
cBlh.
winijlY ,Qidlng ~l\C(fl' "1~OI1MMt. FrR1jllanr.y, Ratalltioll, UrgMcy, DySUria
AllunIlJI
I C(}rn',l 2 C-NilQ 3 Efi'~hv
calIf<
4 Rpi-llit!
ALTEl\fD &KINJWOUIfD KEY;

PU - Pressure t~Gp.r If ptes,ure vicel, frst 5la~e I. II. III, IV, UfiStaQeable V Vascular ulc{!:r ('lfJnous s1as~s, arterial InwHlCiern;YI
N
A ~ AOf;)sioll II L ; mistsr BR - BIUise D = flae,ulod E = Erythema

KX
= Excoriation
liem2toma
o
= f~",n
I = InCISIon L - LJGeratlon R - Rash 'TB = TapAbllm WA = Well eppmximaleu
'1m'" g 0.",'-'
~
lin<! ~ Y 01 .,:
RetUll1~
%011181 _ _ __
Drainage ArnDt/fit
SC
N~lIroJlalhit
IIIf.Rr (!iiilbetc)
H
I
IE
Dressing: 55 = >~iJJ" D ~ O~rmJbood
S\e,'
Wound Bed !ley:

G ;:;: Granulati~.JJ) $ " SlmlQiI
SurlGundlRg Skin KIlY: PrJ!nllie Type:

; hltat'l
[1y1hemi
G
=S.-""t
8
ft
DI
= S'~!1Jn = 11IYilmlinl,lfl
=
belJUf
OT.I.. (Jjl!!nla""
Iletentlon Slltufe3
o = Otner
o '"
~ MacefJ:Jiuu C = Cyanf)\iGlV3r1<
S - Serous $ ; SIlblII 55 ~ Se;o&'1i1j)Ui,,"lU. M = Moo"'"I~

PU - ?uru!ent
Dlh!ll
J
Y
..
o
... ". Sed Typll r---+---~~~+---+----~----~-
; omar
M[jnl~omery ~tr.IlS
o = Olhal
" ,
= Yelow = ,n,r,!y
SiWlly
L L31\lij ~ - C\IIIIiIII'J
_ _ _ __
I~Ti=I~S~it=-~M=-r:J~~J;;[I:r.:OO:j~:,,:T-;W;l);;;un~~~;;;;;;;ru;;~Dc.r;aj~n~aw~e1AA;m;;O~IIll;;11Ofl~oo;lI~a~r!----------~TtoatmoQI
me e "Q,
llfail1ftge Y / N
I / 1It1l~\lln Reau~ssment
No Cungt TIma Ind Inillall
.-+--------------------------r----~----~
~SSIA
HF101.1H
C}"AE.
----.-- - - - - - - - - -
DEPAUL HEALTH CENTER t<LI>.RCH, PHTLLIP H

HANAf'I, IM~AN A
,Qd
I
1lUIIIIIIIIIIIlllllllfti
24 HO'JR MEDICAL/SURGICAL PATIENT CARE RECORD

01'1.11000-<171 (7/2007) PAGE 7 OF 8
IP
"
..
0736000302 MED 053Q-01 10/02/1976 31Y M 12/26/07

000748290
DPM1
000427
MEDICAL / SURGICAL RESTRAINT

AH"JOOim L/ff' '9 Aypjd ,Rotrl.!!ll
;
C<lmp~lIi<~i
K~;~~~_ _ _ _ _ _ _ _ _ __
mWlvAL Rmll" IU Iliijlfilll

1 Pi<.Jtr;:1 an afbJ~aJ :atrwty ~'or vxy~n dehai"'1 t!.q , to .1!a'ntaln ,l1liU/la,Hrahati 1"'"'01
MilH"", 'wa,ilf liI1?l ~l \1, eUtnt'ili w!i~ Ifeilmllfl alit", PM'ent,: G\i'1re.n1 <:-O!1(J(IV-n {e,~" Mt.t to'lHGt- UI rt."tnmlil,
me.1iCiloo 4"tirtwtlEtr4-tl-J).1 Cf tt)<j;,alwH}
f:ltCty Qi ~att:lis
IfSuvilIm","
(fltll
"2 ~t ~ fWTht{:te merww~ K.~ {Je-r-":;Jt l~l JlI f'I If ('n: 1
!lel\(~ D\>.1.tf\tIlt liff.. arullfe.Hlef (r" I~ PJftnt, ~.{JfIHf;e eli: J
Tri81 Brim!! Kyy

1 Unat-e to ~"1tTa{-t for s,31,,4y t [,on{ ID put a.1li~~, W1e~ etc
E"rttfOMnfntal ;H;!11O!1ialions cfIIll!. ef(. I d nul()' omm~l on

ONW~~llJa! It:;\
rurs!!$. !I~.tf,{j, f;llt-t~~
(,1,,00;1';,"""
,
A~smer~
oo<lIldlcales t()jlOt,'fl~
iom, cisw~std ",OJ) I... ",ner

1 Rea;<lJllw feW..11
~w.(y
dtJl'.onro.ca, ,IS> ffi ""~"i1

romow "e~sirujs. Mns. <It
I~'~ O~lmillraJ
utr (~'JWs.
YiCP';')S. w;i!J..& ill!"~'d" f.;tr J
F-aUE'nt{fam~'( !01Jta{!:O!1
~I'tJ
MOg.'S" , 1!ee'f'1.'Seil,gta""'II~
proc-tdtlf~. wno wctJl(! ;utl!f fl1J1titr Ji'I.tJ")' !f U~~' !j4't'i; l';"\t.:J2:;-Si't f mOf'M'-Afll t-alt1""8 t g !r>p.rt:[,A~I' '}l-1-uu.;,'!r.J.Jt {l: Q.. f:k11effiJW trac:hIrn-;;; rtr '1;r.".t:M;v. ~~Jlqem');
T
wM are rnt~9acitatoo from In: t!llUr, (sf !;l~);;-:;)j
Irnfi !fJif!B;;,
1!l;d(f:fl";,lU;fjtJ.f..K~-Y
4 :;
A'~"ij.:mo i.
C~$we anC ((!;strdHl! fel1rtvelf
Rt""'" r6q'if0'4 lor 1emt>1aJ
, C'J 'aim Ie >ell 01 omm

Ra~trMI!j
Cl
BrtlAVIOHA~
RUfAAlNTS;
) O1hlJi
(lW~h~
narra'Jl't <lcWnl<mI'Mr,j
o Not appliCable
ACTIVITY
KEY
POSITIONING
KEY
DRPAUL HEAl.rTH CEN1'RR
~SSM.
H!;t.LT"C"Ri

DPM-1000Q71 (712007) PAGE 8 OF \I
0736000302 MED 0530-01 lJp lO/02!B76 3lY HANAFI,IMRAN A M 12/20/07
IvlARCH, P1HLI.,IP H
IIIUIIIIIIIIIIIIII.i '"
00074829B
000428
DePaul Healch Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Sat Dec 29, 2007 07:06 am Discharge Cumulative Trend Report from 1')./'2.G/07 1610 to 12/28/07 0430 t4ARCH, PHILLIP H HEMATOLOGY-Page 1 000748298 Med Rec #: Adm: 12/26/07 Dis Date 12/28/07 Phys-Service: HANAFI.IMRAN A - MEDICAL r/p
Patient Name:
977103 979457 973630

Result:
Units: Low Refer: High Ref: 12/28/0'7 0430/ 12/27/07 0430 12/26/07 16101
Platelet
Hgb
lCdC/mm3
130.0
gm/dl
13.0 18.0
12.9
Hct :t
39.0
REe
Mev
80.0
10[(6
4.7
400.0 239
214
54.0
6.1
4.62
220
12.3 13 .2
~l
--------.------80.5 79.5 79.4
99.0
I
'
I
I I
!
37.2
35.2
37.7
4.43
4.75
Ll
L\
'i
BLOOD CELL COU}IT/DIFFERENTIAL.
Ref:lult;
Units; Low Refer; HIgh Ref:
________
~
!
I
!I-1CH
_______________
pg 25.0 31.0
!
-_.
MeHC
Rm1
'fmc
__________________
gm/dl 32,0 36.0
12/28/07 04301
27.9
12/27/07 0430) 12/26/07 1610
27.$
27,8
34.7
34.9 35.0
I i I
I
% 11.5 14.5
I
! I
I
________
lOOO/mm3 4.5 11.0

4.3
I
LI I I
Corr WEC 1000/mm3

_____
~ ~ ~ ~
________________
I 1 I I
'
14.4
14.4 14.5
4.9 5,3
BLOOD CELL COma/DIFFERENTIAL, .
Result:
Gran
% 40.0
Lymph
%
Units:
Lolo" Refer: High Hef:
Mono %
2.0 1Q.O
Eos
% 0.0 6.0
70.0 35.7 43.2 66.0
22.0 40.0
51. 9
015.4
Baso % 0.0 3.0 0.7 0.6 0.4
I
-!
1 'S/07 0430! 1~,27/01 04301
8.9
9,4
12/26/07 16101
26.2
7.2
2,8 1.1 0.2
I
I
NARCH, PHILLIP H
00074S298
Alexande~
Babich, M.D. ** DO NOT DISCARD ** "Discharge Cumulative Trend Reporc
(M-10/02/76)
Dr. HANAFI, H1RAN A
000429
DePaul Health
12303 DEPAUL DR.
Cen~er
BRIDGETON, 1>10
63044
Sat Dec 29, 2007 07:06 am Discharge Cumulative Trend Report from 12/26/07 1610 to 12/28/07 0430 I>1ARCH, PHILLIP H CHEl'HSTRY-Page 2 Patient Name: Med Rec tI; 000748298 Adm: 12/26/07 12/28/07 Dis Date l?hys-Service; HANAFI,IMRAN A - MEDICAL I/P
977103 979457 979630

ROtTTINE CHEMISTRY
Result;
Units:
Low Refer: High Ref:
j
Glucose mg/dl
75
110 77 77 73
Sodium
mEq/L
12/28/07 04301 12/27/07 04301 12/26/07 1610
------------------------------------------------------------------------------1
13 7
145 137
I
.
Potassium
mBq/L
3.6
5.0 4.2 3.9 4.1 I
Chloride mEq/l.!
C02
n. 0 107.0
103
mEq/L
22 . 0
30.0 32
I
HI
I L>I
I
I
I
i
136
137
Ll
I I I
101
10]
31
32
HI
HI
ROUTINE CHEMISTRY.
Re<lult: BUN
Creat
mg/dl
units:
H~gh Re~~
L~W Ret:r:
mg/dl 9.0 20.0

12 12
I
I
0.8
1.5 1.0 LO
I
I I
I
Calc1.um mg/dl
10.~
i
1
8.~
Phosphorus mg/dl
2.5 4.5
I I
I
I I
I
f'.tagnesium mg/dl
l.~ 2.3
I
-----1
------~--------------------------.-----------------------------------
12/28/07 04301
J.2/27/Q7 04301
I I
I
12/26/0716101
11
0.9
8.5 8.2 8.8
LI
I I
I
Result;
Units;
~~;~:~~~~;~;;I---6:~~----!---~;;g-----I'---~~:~----i---~~:~---~i------~~6:~------1 HI'
L,27/0704301 12/26/07 1610\ 5.8 6.8
Tot Prot
gm/dl
I
LI
1
ROUTINE CHEMISTRY .. Albumin
gm/dl
ALT/SGPT
AST/SGOT
U/L
U/L
Alk phos U/L
I
I
I
3.7 4.4
4B 71
I
i
125
60
174
68
ROUTINE CHElvlISTRY ...
Result: units: Low Refer: High Ref;
Tot Bili iConjug gil mg/dl! mg/til

0.2
I
Uncon Bi1il Oir Bili mg/dl I mg/dl

0.0
I
I',
1.3
0.0 0.3
0.0
1.1
,0.4
GGT U/L
8.0 78.0
1
~~~~~~~~-~:~~i--~~:~----~[-----------I-----------I-----------i-----------------I
MARCH/PHILLIP H
00074B2~S
Alexander Babich, M.D. ~* DO NOT DISCARD ** *Discharge Cumulative Trend Report
(fYI-lO/02/76)
DL'.
HANAFI, IMRAN A
000430
Depaul Health Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Sat Dec 29, 2007 07,06 am Discharge cumulative Trend Report from 12/26)07 1610 t~ 12/28/07 0430
l'>1ed
patient Name: Ree #:
t1ARCH ( PHI LLI P H
MICROBIOLOGy-page 3
Adm: 12/26/07
Dis Date Phys-Service;
000748298 12/26/07 HANAFI,IMRAN A - MEDICAL I/P

CULTURE BLOOD c.c. Source; Blood (M)-2 In at: 12/26/Q7 1619
977103 979457 978630 ColI. Time: 12/26/07 1610 Order Phys; TENG,MARCUS S
Acet
#~
A0736000302
Techs
V-LB
Techs: TSMH
Out at: 12/27/07 0925

**CULTURE** No Growth
Preliminary 1 [3999222J
Performed by; SSM Health Care Lab - SMHC
Co~l. Time: 12/26/07 1610 Order Phys; TENG,HARCUS S
CULTURE BLOOD ~c. Source: Blood {M} In at: 12/26/07 1619
Acct #; A0736000302
Techs
v- LB
Ou t a t ;
12/27/07 0925
Preliminary 1
[39992231
Techs: TSIt1H
*~CULTURE~*
No Growth
Perfo:l."med by; ss!<r Health Care Lab - SMHC
--------------------------.---12/28/07 0930 12/26/07 1610 12/26/07 1610 VANCOMYCIN TROUGH CULTURE BLOOD CULTURE BLOOD
PENDING TEST
------------------------------Cancelled Patient diacharged Partial
Par1;ial
End of Report
MARCH,PHILLIP H
000746298
Alexander Babich, M.D. ** DO NOT DISC~RD **

*Discharge cumulative Trend Report
(t<l-lO!02/76)
Dr. HANAFI,IMRAN A
000431
DePaul Health Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Sat Dec 29, 2007 07:06 am Discharge Cum Incomplete I-Iork Listing hom 12/2G/07 1610 1:0 12/28/07 0430 Patient Name: MARCH PHI LLI P H Page 'I 000748298 Adm; 12/26/07 Med Rec #: Dis Date 12/'28/07 HANAFI,IMRAN A - MEDICAL I/? Phys-Service:
I
977103 978730 979457 978630
Accession Number
Test Name
CULTURE BLOOP CULTURE ELOOD
Spec Type
Collection Date & Time

12/26/07 1610 12/26/07 1610
Stat~ls
3999222 3999223
Blood (f>t) Blood (M)
Partial Partial
End of Report
****T*+***.***w~*w*********************T*~***T*+***********~**~*~*~Y.**********k
MARCH/PHILLIP H
000748298
*" DO NOT DISCARD * *
(!v1-10/02/76 )
"'Discharge Cum Incomplete I'lork Listing
Dr.
HANAFI,IM~~
000432
Depaul Health Center

12303 DEPAUL DR. BRIDGETON, fl[O G3044
Sat Dec 29. 2007 07:06 am
Discharge Cum Incomplete Work

Patient Name: Med Ree #: Dis Date
Lieting from 12/25/07 2324 to 12/28/07 0410

page 21 Adm: 12/26/07
MARCH, PHILLIP H 000748298 12/28/07

HANAFI,IM~~N
Phys-service:
A - MEDICAL lip
977103 975892 979457 978630
Accession
Number Test Name Spec Type
Collection
Date & Time Status
3999222
3999223
CULTURE BLOOD
CULTURE BLOOD
Blood (14) Blood (1,'0
12/26/07 1610 12/26(07 1610
Partial Partial
End of Report ***** * ********~*.*********.***********w*****.************* ****************
HARCH,PHILLIP H 000745298
Alexande~
Babich, M.D.
(M-IO/02/76 )
** DO NOT DISCARD **
Dr.
H~~AFl,IMRAN
000433
A Member of SSM Health Care
~SSM " E ALT H .

Effective Date: April 14, 2003
CAR E~
The document immediately following is our Notice of Privacy Practices. We have prepared this summary to assist you in understanding the notice. For the full and complete description of our practices, please read the full notice. What is a Notice of Privacy Practices? * It is a formal document that describes how your medical information is used by our staff and disclosed by others. It also describes your privacy rights.
Why was I provided this document?
'*
We take ijreat care in treating you and your medical information with respect Clnd confidentiality. A Federal law now requires us to notify you 01 our privacy practices in a more structured format.
How IS my medical information used? *" To plan and carry out your treatment . .. To submit claims to your insurance . .. To enable us to carry out our health care operations.
Are there circumstances where my information is used without my prior permission?

... Public health and other safety issues. ... Requirements by State, Federal and loca! law. ... Law {:nforcement . ... Certain types of research. What are *" To .. To * To * To .;:. To * To ... To * To
my rights described in the notice? review or copy your medical records . request an amendment to your medical information. receive an accounting of disclosures of your medical information. request restriction in how we disclose your medical information . have us communicate with you in a certain way or at a certain location. opt out of the hospital directory . make a complaint aboul privacy issues. authorize other releases of your medical information.
Who will follow this notice?
*" Our employees, volunteers, students and trainees.

... Other health care and service providers that provide care or services at this entity. Who doesn/t this notice cover?
* Independent physician practices or operations of health care and service providers that provide services independent of this entity.
What if I have ill!8stions about it later?
* Please contact the admission/registration department of this entity.
Through our exceptional health care services, we reveal the healing presence of God
000434
We may deny your request for an amendment it it is not in writing or does not include a reason to support the fequns\. In addition, we may d~ny yoo.;.r request if you Rsk us to amend information that: Was not created by us, unless the person or ttntity that created the information is no longer available to make the amendmen I; - Is not part of the medical information kept by or for the Hospital: - Is nol part of the informati<Jn which you would be Porfl'litted to inspect and copy; or
"
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS: You have the right to request we communicate wdh you about medical matters in a certain way or at a certBin location. For example, you can ask that we only contact you at work or by mail.
Please advise the Registration Repr6ssntDtive how or where you wish to be contact17d_ We will n{Jt ask you the reason for your request, We will accommodate all rBllsonable requests,
.. RIGHT TO A PAPER COpy OF THIS NOTICE: You have the right to a paper copy of this Notice. You may ask us to give you a copy of this NQtk:e at tiny time by requesting Il copy trom any member ot our Hospital personnel.
- Is accurate and complete.

i<
RIGHT TO AN ACCOUNTING OF DISCLOSURES: You have the right to reqI,Jest an 'accounting of disclosures'. This is a list of the disclosures we made of medical informalion obout you to others except for purposes of treatment, pByment and opcr(;ltiQns i<lemified abovo. and other exceptions under federal and sttlte law.
CHANGES TO THIS NOTICE:

.. We reserve the right to change thiS Notice. We reserve the right to miike the revlsEld or changed Notice effecttve for medical information we already have about you as well 8S any information we receive in the future. We will post 0 copy of 1ho curren! Notice in the Hospital. The NOlice will contain on the first page 1 in the !Of) righthand Gornor , the effective date. In addition, each time you register at or arc admitted to the hospital for treatment or health care services as <if) if)patient or outpatient, you have the right to request a copy of the current Notice in eHect.
To request this list of disclosures, you must submit your request in writing to the Director ot Medical Records_ Your request must state a time period which may f)ot be \c.>nger than six years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list {tor example. on paper or electronically}. The first list you request within a 12-month period will be free. For additional lists. we may charge you for the costs of providing the list. We will notify you ot the cost involved and YOll may choose to withdraw or modify your request at that time before any co:;ts Dre incurred .
.. RIGHT TO REQUEST RESTRICTIONS: You have the right to request a restriction or limitation on the medical intormati<)!1 we use or disclose about you tor treatment. paymef)t or he{lith care operations. You !:lIsa have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not u:;Je or gisclQs~ information about a surgery pertormed.
QUESTIONS AND COMPLAINTS;

If y!)U have questions Of believe your privacy rights have been violated, you may contact or submit your compl<lin in writing to the CRP Conlact 314344-6000. It we cannot resolve your concern you also have the right to tile a written complaint with the SecreTary of the Deportment of Health and HumEm Serviccs
f
THE QUALITY OF YOUR CARE WILL NOT BE JEOPARDIZED NOR WILL YOU BE PENALIZED FOR
FlUNG A COMPLAINT.
OTHER USES OF MEOfCAL INFORMA TfON:
Other uses tmd disclosures ot medical intormation not covered by this Notice or the laws thai apply to us will be mad!;! only with your written permission. If you prav'lde us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission I we will no longer use or disclose medical information about you for the reasons covered by your written 8uthorin,tion. You understand that we are unable to take back any c!lsclosures we have already made with your permission, and that we are required to retain our records of the care that wa provided to you,
- We are not reqvired to agree 10 your rlquest, If

we do agree, we will comply with your reque8t unless the intormation is needed to provide you emergency treatment.
- To request restriction8, you must make your request in writing to the Director of Medical Records. In your request. YOLI must tell us (1) what in formation you want to limit; (2) whether you want to limit aUf use, disclosure or both; and (3) to whom you want the limits to apply. tor example f disclosures to your spouse.
Page 4 of 4
000435
to review our treatment and services and to evaillate the performance of our staff in caring for you. We, or our designee, may send you a patient ~ati{!i~ction survey. We may also combine medical intormation about many Hospital atients to decide what additional services the Hospital .,hould offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, health care studtmts, anQ other hospital personnel for review and learning purposes. We may also combine the medical information we have with medical information from other hospitals to compare how we arc doing and sea where we CBn make improvements in the Gare and services we Qtt~r, We may remove information that identifies you fmrn this set of medical intormotion so others may use it to study health care and health care delivery without learning who the speciiic patients are.
In addition, we may disclose medical information to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location. .. INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT fOR YOUR CARE: We may release medical information about YOll to a care giv6T who may be a friend or family member. We may also give information to someone who helps pay for your care.
C~rHlh' circumstances, WC may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who rec6ived one medica1ion to those who received another, for the same condition. All research proj~cts, however. are subject to a spacial approval process. We will almost alwtlYs ask tor your specitlc permiSSion it the researcher will have access 10 your name. t1ddrcss or other information that reveals who you are, or will tJfl involved In your care at the hospital.
RE5EARCH: UndtH
it
APPOINTMENT REMINDERS; We ml:lY use and disclose medical information to contact you as a reminder that you have an apPointment for treatment or medical care at the Hospital.
" TREATMENT ALTERNATIVE:S: We may use and disclose medicBI information to tell YOl) abo~1t or recommend possible treatment options or alternatives that may be of interest to you.
" HEALTH-RELATED BENEFITS AND SERVICES: We

may use and disclose medical information to tel! you about heal~h related benefits, services I or medical education classes that may be of interest to yOll.
AS REQUIRED BY LAW: We will disclose medical information about you when required to do so by federal. state or local law,
SPECIAL SITUA TrONS .. ORGAN AND TISSUE DONATION; If you are an organ donor, we may release medical information to organizations that handle organ prouurement or organ, eye or tiSS\..16 transplantation or 10 an organ donation bank as nscessnry to fHcilitate organ or tissue donation and transplantation.
I
FUNDRAISING ACTIVITIES; We may usc information about you to contact you in an cffort to raise money tor 'he Hospital and its operotiQns. We may disclose information to Cl foundation related to the Hospital so that the foundation may contaC"t you in raising rT'oney tor the Hospital, We would only rels8se contact informatIon. such as your name, address and phone number and the dates you reCeiVIJd tre~nment or services at the Ho!;pital. It you do not want the Hospital to contact you tor fundraising eHorts, you must notify our C R P
Contact (Privacy Ofticsr) in writing.

.. HOSPITAL DIRECTORY: Unless you advise the Registration !=Iepresentativc otherwise, we may inclUDe certain limited information about you in the Hospital directory while you are a patient at the Hospital. This information may include your name, location in the hopsital, your general condition ( e. g. I good. fair, etc.) and your religious affiliation. The dlrsctory information, except for your religious affiliation I may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as R priest or rebbi, even if they don't ask tor you by name. This is so your family, friends and Clergy can visit you in the hospital and gonerally know how you are doing.
MIUT ARY : If you are a member of 1he urmed forces, we mr:ry release medical intormation about yo\.! !:IS required by mHllary command authorities. Wf5 may ~ISQ rel~g~~ mmlical inlormation about toreign military personnel to the appropriate foreign military 8uthority.
" WORKERS' COMPENSATION: We m<;lY release medical information about you tor workerstcompensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
PUBLIC HEALTH RISKS ! HEALTH AND SAFETY TO YOU AND / OR OTHERS) : We may disclose medical information about you tor public health activities. We may use and disclOse modical Information l:lbout you to ogencies when necessary to prevent a serious threat to your hetllth and safety or the health and safety tor the public or another person. These activities generHlly include the following:
Page 2 of 4
000436

A Member of SSM Hoalth CST!!
~SSM
Effective Date: April 74, 2003
H " A L T H CAR eO<
.vOTlCE OF PRIVACY PRACVCES
THIS NOTICE DESCRtBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE REVIEW IT CAREfULLY.
If you have any questions about this Notice, please ask a Registration Representative.
HOW WE MA Y USE AND DISCLOSE MEDICAL

fNFORMA nON ABOUT YOU,'
The following categoriss describe diffQrent ways that we use imd disclose medica! \nformafiOfl. For each category of uses or disclosures, we will explain what we meDn and try to give some examples. Not every use or disclosure in a category wlll be listed. However, all of the ways we EIre permitted to use and disclose information will fall within one of the categories,
WHO WILL FOLLOW THIS NOTICE:

This Notice of Privacy Practices applies to the Hospital and its employees, volunteers, students and trainees. This Notice also applies to other health care and service providers that provide care or services at the Hospital. or for its patients, in that, \:IS a condition to providing services at the HospitRI, such providers must agree to comply with II Hospital policies, including its plJlicics relating to ,atient privacy, This Notice. however, only details the privacy policies of the Hospital and does I'\ot govern the independent practices or operations of health care and service providers, for services provided independent of the Hospital. This notice will also be followed by other affiliated entities within SSM HSftllh Care With whom we share information.
OUR PLEDGE REGARDING MEDICAL INFORMA nON:

We understand that medical information abOll1 you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the Hospital. We need this record to provide you with quality care and to comply With ':6rtain legal requirements. This Notice applies to all of the ecords of YOllr cafe generated by the Hospital, whether ,nade by Hospital personnel or your personal doctor or other prElctitionElrs involved in your care. Your personal dO. ctor m. <ly have different policies or notices regarding the 90ctor's use and diSClosure ot your medical information created In the doc~or's office Of clinic,
FOR TREATMENT: We may use medical Information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses. technicians, heaith care students, Clergy, or others who are involved in your care, For example, a doctor treating you tor a broken leg 'nay need to know if you have diabetes so that Wf'; con arranye fOT appropriate meals. Ditferenl departments of the Hospital also may shore medical information about you in order to coordinate the different things you net:!d such as prescriptions, lab work and xrays. We also may disclose medical information about you \0 people outside the Hospital who may be involved in your medical care after you leave the Hospital. such as long term care tacilities or others your physician or we use to provide 8ervices that aro part of your cara,
I
I,
.. fOR PAYMENT: We may use and disclose medical

infOfmation about yOU so that the treatment and services you receive at the Hospital may be billed to and payment may be collected tram you, an imn.HllflQe company or a thiro party. For example, we may need to give your health plan intormation about surgery you receiv~d at the Hospital so your health pion will pay \is qr reimburse you for the surgery, We may also lall your health plan about a treatment you are going to receive to obtain prior approval Of to determine whether your plan Will cover the tre!l!lllont.
~
This Notic8 will tell you tlomlt 1!"Hl ways in which we may use and disclose medic(ll information about you, We also describe your rights and certain obligations we have regardin9 the use and disclosure ot medical information.
We are required by law to: make SLire that medical Information thai identifies you is kept private; " give you this Notice of our leg a! duties and privacy practices with respect to medicol information about you; and follow the lerms of the Notice that is currently in effect.
FOR HEALTH CARE OPERATIONS: We may use and disclose medical information about yOL! for Hospital operations, These uses and disclosures are necessary to run the Hospital and nlake sure that all of our patients receive quality care, For exomple, we may use medical information
Page 1 of 4
000437
CONDITIONS OF ADMISSION AGREEMENT

Consont to I\dmi:rsi9n: t rlHll18s1 llnd consent fo llull1is5ion.
Conseot to Mudi~tlf and Heloteo H9l\f~h Care: I request and CUll:iCnt to the medicol enro, diagnostic and treatmont procedures (lS d8termincd nocessary by my phYS1CiutlIs) Of his-thor assistants. I aCknowledge (/)(l core t receive while in this facility iI:; under the direction 01 my physicliln(s). This facility is not respunsible for the acts or omis .. iol\s of my physir.ian(s>.
M.!Q!.~lllJJ!.Allieu Hc?fth Cer_eProyidcrs: J have beon informed lind un<.lorstand thlll the Physician(s) providing ser"iDQS (0 mo in this facility, slich as my porson",1 rhyslcien(s), Radlolo{;lists, Pothologists. Anesthesiologist, Consulting Physicians, SUfgeoru and other Allied Health Care Providers such as D~ntist::l Md Psychologists are independent contractors and aro not t'mploYl:16S or ogents ot this facility unless othcfwi$e $pocitically identified. Tct!~t;hln9 PTQ}jnllll~
I understand this facUity may. from lime to eimo, onter Into agreements with academic medical.
and \'lIlian health programs. Because of these lIgrcemcnts, residents, Interns, medical stl/dents, nursing students and various alliod health profession students, may partiolpate in my care. I agree to participate in these programs, but have tho right to limit my participation at OilY tima.
Relea9 of InformatIon: r understand thi8 facifity will make BV61yofton to treat my medical information as confIdentIal; how6ver, I realize information must be shared wIth providers and}or Individuals IMQlvcd in my care or In the payment of my care. I ulfdorstand this will fnclude IntormBtiofl found In my mediC<l' record. I agreQ tD the ralease of information in my medjCilI r"c<)rd, end to the actual medical reeorrt documents, to (he 8xtent necessary for the following puq)Qses:
a,1 I have received the Notico of Privacy PrDctices on this visitladmission or a previous one. I unc!orstand I can requost another copy at ill'lY time. to any mt:dkal and/or health care rroviders responsible for my care While in this fa(;ililY and it transferred to IHlOlhcr facility for care. to that facility and its CAfe providers.
ro those responsible for colle;;;tlng and thoso rosp0\1.sibla for the payment of my care. This may illcll.1dc a porson, government aqoncy, insurance company. health plan or employor sponsored group plan. Thi8 i:; for the PUlPOS\i of verifying inslllanco benatit8 tor pro-certiflGation and extcndc<:l stay review unci/or the payment of the cost ot my Gara,
n\Jr~ing
b.l
c.)
d.)
to utifize
tOt
internal medicol care swdies ilnu quality imprOyement acttvtHes.
e.}
10 comply with the Federal Sa1e Medicol D6Vic6 Act of
1990 ahd other required state (lnd roderal
reporting.
MediQarllfChllmpu~lTricare
Fiights: If flppliGable, I acknowledge receipt at the MeQicare/Champus/Tricare Lettar
Qxplaln;ng my rights as a patient 01 this facHity. r understand this includes my dght to requasr a review.
PatJent/uMts: ! acknowlaclge accoss to the Pationt Rights information explaining my rights \I~ a patient of this facillly. Per.sonaJ Prop&r1y: J have bt1en informed and understand this facility will not be- liabfe for any 10S$ 01 my parsonlll property unles!> it Is inventoried Dnd placed in a secured areii mffintuincd by this facilfty. Paymant fur Physician Servjce~t M"dicat aM Rehrt~d Cgre: I understand that all physiciefl servie&s are bitted separately from th& faiUty charges. I agree to pay th~ charges incurred for the car" I receive as ordered by my physician(st 31 this facUlty. f guarantee full paymant of aHchargss unless restricted lJy Medicare. M$dicaid Ofcorltractual arrangements between my inswanc6 cornpany and thts faciltty.
HeA.~THr;
'IEPAUl HEALTH CENTER

12303 DEPAUL DR BRIDGETON, MO 63044
000438
I hereby authori16 and a!>$ign p~ymBrlt to this faGllity of any type of reimbursam6At p3We.nt rut: from M&droa~. Medicaid, or any other HlIrd party payor, lor any and atl cost incurred for my medical and l&tated care at this faclIlty and/or hy the independent con~ractors providing servlcos at this facility.
01
ASign~~.w,m@:
OR
Data
Signature/Relationship Date (Parent/Legal GURrdlan/RespoosibJe Person)
~s Signature
-lhC!~ a.(~
tlato
Second Witness Slynature

(if Qral/T!7lephooo/Patiflta Mark)
Data
Data
Please Print Name
000439
- to prevent or con trol disease, injury or disability; - to report births and deaths; to report child abuse or negtcc~; - to report reactions to medit;ations or problems with prooucts; - to notify people of recalls of products they may be usiny; - to notify a person who may have been exposed to a dlseaso or may be at risk tor Gontracting or spreading a disease or condi'ion; . to notitv the appropriele government authority if we believe a palient has been the victim of abuse, neglect or domestic violence. We will only make- this disclosure when required or authorized by law.
+
.. NATIONAL
SECURITY AND INTELLIGENCE We may release medical information about you to euthori;z.ed federal offiCIals for Intelligence, coUI'\UH - intolligence, and oth{}f national security activities authorized by law,
ACTlV~TIES:
PROTECTIVE SERVICES fOR THE PRESIDENT AND OTHERS: We may disclose medical information about you to 6uthori;z.ed tederal otticiahs so they may provide protection to lhe President, other authorized persons or foreign heads of state or conduct special investigations. .. INMATES: If you are an inmate of a correctional institution or Und\H tM Cl,lstody ot a law enforcement official, we may release medical intormation about you to the correctional institution or law enforcement official. This release would be necessary ( , ) for the institution to provide you With health care; ( 2 ) to protect your hedlth and safety or Ihe health and safety of others: or ( 3 ) for the satety and security ot the conectional institution.
HEAlTH OVERSIGHT ACTIVITIES: We may disclose medical information to 8 health oversight agem";)' for activities authpriled by law. These oversight activities include, for example, audits, investigations, inspectIons I fmd licensure. These activities [Ire necessflry for the government to monitor lhe health !;aTe system, government programs and compliance with civil rights laws.
.. LAWSUITS AND DISPUTES: If you are involvd in a lawsuit or 0 dispute I we may disclose medical intormation about you in response to a court or administrative order. We may also disclose medical information about you in response ttl a subpoena I discovmy request. or oth~r lawful process by someone else involved in the disDute_ " LAW ENFORCEMENT: We may release medical information it asked to do 50 by a law enforcement official: - In response to a court order, subpoena, warrant, summons or similar process; To idenHfy or locate a suspect, tugitive, material Witness, or missing person; About the victim of 8 crime if, under certain limited circumstancos, we are unable to obtain the person's agreement; - Aboul I death we believe may be the result of criminal conduct; AbQU1 criminal conduct at the Hospital; and In emergency circumstDnces tu report a crime: the IncEltion of the crime or victims; or the identity, description or IOCe1tion of the person who committed the crime,
YOUR RIGHTS REGARDING MEDICAL INFORMA TlON ABOUT YOU:

-II
RIGHT TO INSPECT AND COpy;
have the following rights regarding medical irrforma'tion we maintain about you: . To inspect and copy medical information that may be used to make decisions about your cQre - To inspect find copy medical information that may be used to make decisions about yO\.l , you must submit this request in writing to the Medical Records Department. It you request a copy of information. we will c!large a fee for the costs of copying. mailing or other supplies associated with your request. - We may deny your request to inspect and copy in certain very limited circumstances. If yuu are denied access to medit;al information, you m{lY request that the denial be reviewed. Another licensed heal1h care professional chosen by the hospital will review your request and the del't!aL The person conducting the review will not be tho person who denied olJr re\jye~H, We will comply with the {Jutcome of the r.eview.
YOll
.. RIGHT TO information
* CORONERS, MEDICAL EXAMINERS AND FUNERAL

DIRECTORS: We may release medical information to a coroner or medical examiner. This may be necessary, tor example, to identify a deceased person or to determine the {~BUSO of death. We mtlY also release medical information about patients ot the Hospital to funeral diredors as necessary to carryon their duties.
AMEND; If you feel tFlat msdical we have about you is incorrect or incomplete, you may ask us to amend the information You h~ve the right to reqLltlst an amendment for 88 long as the information is kept by or tor the Hospital.
To request an amondment, your request must be mad in writlng and submitted to the Director of Medical Records. In addition, you m 1.1 st provide a reason that supports your request-
Page 3 of 4
000440
~SSM
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06/16/2007 12:48:23
000441
,J~~"EmGATJONS:
S~e Discharge Home Medication
list attached
Jawed with me and my questions have been answered. Si nificant Other

Discharged to:
CJ' Ofuer____~_____________
Ph
~ Home
c::tItJSSM DePaul Health Center

, I . l
DEPAUL HI-;ALTH CENTER
MARCH, PHILLIP I/P 0715100477 MED 0546-01 Make 2 copies o/this/orm. Original form to chart. ( SRlRAM,VISSA 10/02/1976 30Y M 000748298 OG/Ol/07 ________________________________________
Pati(lntOlschar e Summa
1112005
fIUIU.BlllfOIfIl
000442
DePaul Health Center 12303 DePaul Drive Bridgeton, MO 63044 Patient's Discharge Home Medication List 07151Q0477 Name: MARCH,PHILLIP Roan Nu..-nher, 0546-'01 Dace: 06/06/2007 Attending Physician: SRlRAM,VISSA
Acco'unt Nwnber:
Pat~ent
Patient Allergies: No
~own
Drug
Aller~ies
Medication GeneLic Name(Brand Name) with Directions
l
.**.~
.AMI I
Noon
PM
Bedt.
.~*
MAGIC MOUTHWASH(MAGIC) 5 ML BY MOUTH J Times a Day AMLODIPINE(NORVASC) 5 MG BY

~orrTH
x
5 MG TABLET (1) 20 MG TABLET
Daily
TAKE:
(1)
FAMOTIDINE(PEPCID) 20 KG BY MOUTH 2 Ticres a Day
TAKE:
...... ,. As Needed Medications
,o . . . . . . .
OXVCODONEjACET lO/325MG(PERCOCET) 1 TABLET BY MOUTH EVERY 6 HODRS

IBUPROFEN (MOTRIN) 400 MIG BY MOUTH 3
AS NEEDED (1) 400 MG TABLET
'rimes a Pay }.S N'EEDED
TAKE:
GIVE WITH FOlOD OR St-l"AClt
~F
yoa
~ffiVE
ANY MEDICATIONS AT HOME WHICH DO NOT APPEAR ON TRIS L!ST, PLEASE CHECK WITH: YOUR PRIMARY PHYSICIAN BdFoRE RESUMING THEM.
000443
PAGE!
DePaul Health Center 12303 DePaul Drive Bridgeton, MO 63044 Patient's Discharge Home Medication List Account Number: Patient Name' Room Number: Date: Attending Physician:
0715100477 MARCH. PHILLIP 0545-01 06/0612007 SRIRAM,VISSA

Kn~wn
Patient Allergies: No
Drug Allergies
Na~e(Br~d
Medication Gerre=ic
Name> with Directions
iJ.2ol
Noon ! PM
Bedt:
Additional Orders
- - - - - - - - - - - - - - - - ---------
------------------------------------------
I:F YOO HAVE ANY !'..EDlCATIONS AT HOME WHICH DO NOT APPEAR ON TRIS LIST,
----------
PLEASE
CHECK
WITH YOUR
PRIMARY
PHYSICIAN
alORE
RESUMING THEM.
000444
PAGE,
.....
.......
....
;;..--
Com.
..1(ounds
RespOMlble Staff
1. P.... maklll;S1ft tbUyou trtDp and , .. your p.tlnt everv hour. 2. ~IUhbln r4'om. owr bed table. wlndOWlliIi and batlhroom as well
cords
a.
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1:El?A,UL HE
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- - - - -
............-.
loIII...
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Comforr-rtounds
Responsible Staff
DEP~UL
1. Please make sure !'!at you s.!OP a.ntl see your:..~t1elrrt every hour._ _ _ _ _ _
2. Straighten room, over bed table, windowsill a.nd bathroom as well as detangle cords. _____.________ ~ _ .___..__._____ ._._. _ _ _ _ _._._. _. __ .__ 3. Em.P.!>' ove~~~!~ _ _. _ _ _ .~ _ _ _ _ _ _ _.._ _ _.
14. Offer snacks, drinks and ta..ke out old food a.nd food !!!Y~ ______.....__
l-11>.RC'rl, PHILl.IP
111111111HIIIIllilI
~
HEALTH CEN7ER
:/p
Initials I
15. Offet" b~.ro0f!!..!'~ and repO$ltion ~tlent.
_________ ..___.-.-..-.----1 6. Remember to ask about pain level a.nd report to nurse right away.
Q71!'>10C'I77 MED 0546-01 10/02/1916 30Y M 0I5!Ol/G7 ~~~p~,~~ER Z 000148298

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Time
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TIfl1(l
0:00
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eaCh='~--' --~=-~===~_====~~=~==="_=.=-~==---:-~~~~=~~
Coonfc\1 RoondS Form if, nat a part <II tho .,...,."anellll1)OOOj Return 10 Cliolco1l O~c( upon <llodlalge,
_ _ _ __ __~ -_~ ~._--~-~~- ------ - -- -
Wd Juo 06,
~007
05:28 am
5TH F'OOR RN WORKSHEET (W/LINES)

Page 1
DEPAUL Hl!:ALTH CENTER 06/06/07 Shift 1 thru 06/06/07 Shift

O~46-01
MAFCH,PHILLIP
682'9-CE~ITW NQ.().
Vent
02
NC
Mack
OT
10/O<!/l97f'i 301' r/p Ob/Ol/07 5 0715100477 MH#;00074B298
1-.-.,
6'0,0"
N~ R~GULAR
tc-\~ i"lu Vaccine: No 182,gem 1571bs /'Il. 01 Kg
Pncumovax; No
Smoker? NO
SRlRAM,VIS5A
DAVIS, SHELDON 1.
PD FULL RESUS
/\.. ZTNSEll.. PHTLLIP G ~~~ AV G~/Quinton

f.~
Resl.:raints
('..... TLC,~/I"'id1in<;;\..J.)fA'HL/ IV I'J~) (cJ[) JP/C'T'
NG/GT/JT/TF
f'ffiSA/VRE/
Bath; <.:ompll":te/AGt;;ist"./Setup Activity;.--f!J. P____
Adm.! t from:
lioley Ci;l.lh on Adllllt ER
Home- Nurr;;ing
02 SatB"'
R_ _ _
PT/OT Consull.: Yes I No VC to - Home - NUl:ci119 lIome
IIQlne (Name) =-~.=--_ I NH / Foley Cath Place by Fluor - DCid D;-te

--(Name of r,H) _ _ _ .
-Vitals
T
Signs&
?
B/P
SAT_ _
R
R
n/l'---' SAT
B/P~~ SAT _ _
Pain L';;tin _ __
Pain~
T P One Touche!:
__
01
11
15
21
If/.. ~Sfo.-kJ}:uL:l1 -'1

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c ( ('" C L
000447
'ed Jun OG,
;':007
02:'12 pm
2N RN NORKSHEET D1:::21\o1. HEALTH CENTJ:::K
(NITH LINE5) Page 1
OS/06/07 Shift 1 thru 06/U1/07 Shift 2

aS46-01
~~CH,PHILLIP
Vent
()2
NC
OT
10/02/1970 30Y M 06/01/07 5 071.5100477

,..,RI!; 0007'}B298 SIURAM, VISSA
lip 682. 9-CEI.LULITIS NOS
Pneumovax: No
Flu Vaccine; No
Ib71hs /71.4kg
6'0.0 1 182.9cm NKA
Smoker? NO
REGULAR PD
FULL t{ESUS
Re.8tralnts
DAVIS, SHELDON L ZINSER,PH1LLIP G l\V Graft/Quinlon TLC/PICcjr'11dline

HT./IV
Neul"o
Heart Pul Be!: /Rdma---.-_~. __
Abd/L.~zt
JP/CT NG/GT/JT/TF NRSA/VRE/ Bilth: r:omplete7A~sEt / Setup

l\ct_lvicy: _ _ _ _ _~ __
Skin- .-
void/Foley --=..~=-~ Drsg
Llmgs _ _ _ _ _ _ . ,_ _- Rt<!
__
000448
PAGh.
DePaul Health Center 12303 DePaul Drive Bridgeton, Me 63044 Patient's Discharge Bo~e Medication List Account Nurrber! Patient Name! ReOID NumbEr: Date: Attending Physician, 0715100477 MARCH,PHILLIP
0546-0~
06/05/2007 SRlRAM,VISSA
Al~ergi.es
Patient. Allergies: No K.nown Drug
Medication Generic Narne(Brand Name) with Directions
1 AM I Noon 1 PM
Bedtime \
**~-.
SCheduled Medications
MAGIC MOUTHWASH(MAGIC} 5 ML BY MOUTH 3 Times a Day AMLODIPINE(NORVASCl 5 MG BY MOOTH Daily FAMOTIDINE(PEPCID) 20 MG BY MOUTH 2
Ti~es
x
5 MG TABLET
TAKE:
(1)
x
~ABLET
a Day
TAKE:
(1) 20 MG
',~~~
. . . . . . . . . . .' .
v_
-~".-.
______ . _
TAKE: {SO) 3.315 GM INJ IVPB FROZEN
. . EVERY 6 HOURS
P!PERAClLLIN/TAZO !H20 (ZOS"lN} 3.37.5 GM: 1:NTRAVENOrrS EVERY 6 ROORS

***-*
AS Needed Medications .****
OXYCODONE!ACE'l' l0j3:25MG (PERCOCET)
1 TlilllLET BY MOOTH EVERY
HOURS
TAKE:
AS NEEDED
(Ll 400 MG TABLET
IBOPROFEN(MOTR!N) 400 MG BY MOUTH 3 Times a Day AS NEEDED GIVE WITH FOOD OR SNACX
IF YOU HAVE ANY MEDICATIONS AT HOME
----------_._--_.__
WH~CH
...
DO NOT APPEAR ON THIS LIST, PLEASE CHECK WITH
YO~
PRIMARY paYSICIAN BEFORE RESUMINU THEM.
000450
~}h' REG.NO.~.~.~____~~~~~~___
PhysiCian Offica Phone. Number _ _........_ _ _ _ _ _ _ __

OPS-:WO"999 (10!2001)
SEE REVERSE SlOE FOR AODITIONAl DOCIJMENT SECURITY
..
_
..
LJ<;>'
"
..',...../ ..~::~
0IP?~cu:n;;,TlA-..;tt.1o"u:llb~f-612303 [J~~~~I<gr:f~;;~l
~". lJl!llii,.R
for~ 0'7l~l00477
LiP
10/02/1976
Jur
h
MED Q~46 01
06/01/0~
,,:.:~7~~OlI~::JJ.l1] f
.~~.
Addi'e~ RAHMAN, AlMER
00 i) i '18 298
p~~ ~~~ (4
I\J~~(
/ ..' . "
(Sr"
0 (;:.
~ ~> ('~ ~.~
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';." ".:\{
~~.
S(J8SrrTUT10N PEflMITTEO
'>
.'
"
...
Physician.Qff~ Phone Number _",;;,;;,..,., ..,.:.,"'-'---'-__~-";""___~_ _

Of'S-39Q1-999 t1Qf2(01)
..... " l
000451
PAGh.
:6
Bridgeton. MO 63044
Patient's Discharge Horne Medication List

Account Number: 0715100477 Patient Name: MARCH. PHILLIP Room Number: 0546-01 Oa~e: 06(05/20Q7 Attending Physician: SRIRAM,VJSSA Patient Allergies: No Known Drug AllergLes
Medication Generic Na~e(Brand Name) with Oirectiona
AM ' Noon
PM I Bedtime
Additional Orders
--""-------------------------
~'---
IF YOU HAVE Am{ MEDICATIONS AT ROMIE WHICH
,-------------------------------,-------------------------------no NOT APPEAR ON THIS LIST. PLEASE CHECK WITH YOUR PRIMARY PHYSICIAN BEFORE RESUMING THEM.
+
Please
H
DePaul Health ce~ter 12303 DePaul Drive
c~rcle:
PAGE NUJMBER: 1
ESTIMATEDDISCHARGE TIME:
NURSE PHONE EXT:
Discharge Mads or Fost-op Meds

Bridge~on.~O Patie~t
63044
Active Medication List (YES NO)
Account Number: Patient Name: Rooll". N1..l.Jnber: Date' Attending Physician: Patient Allergies:
0115100477
MARCH,PHILLIP
054 -01
06/06/2007
SRlRAM,VISSA
No Known Drug
Gener~c
1>~.lergi.es
Continue? Medication
NameCBrand Name) with Directions
AM
Noon
PM
Bedtime
*_*6. Scheduled Medications

1 @ NO
_* .. w
x
x
MAGIC MOOTHWlUlH (MAGIC) 5 NlL BY IMOU'I'H 3 Times a Day AMLOD:IPINE (NORVASC) 5 MG B'Y M01JTH Daily
GIVEN AS: (1) 5 MG TlIBLET
)~:
1~ NO
20~~O
13
FAMOTIDINE(PEPCID)20 MG BY MOUTH 2 Times a Day

SODIUM CFWORIDE 0 ~ 9'" (NORMAL SALINE)
GIVEN
tl) 20 MG TABLET
ns @:
1000 ML INTRAVENOOS EVERY 8 HOURS ....

EVER~
27 Y E @ CLINnAMYCIN{CLEOCIN) {CLEOIClN) 600 MG INTRAVENOUS EVERY 8 HOURS
~PIPERAC!LLIN/TAZO ia20 (ZOSW) 3,375 GM INTRAVENO'C'S EVERY 6 HOURS

****- AS Needed Medications
**~*~
6 HOURS
PHYSICIAN
> =
Medica~ion
SlGN~TURE IS REQOIRED ONLY ON THE LAST PAGE OF THISMEDXCA~ION L!ST' Substituted per Hospital Approved Form~lary Substitution
Pilot Forro 4/2005
.d
DePaul Health Cente~ 12303 DePaul Drive Please circle: Discharge Meds or Post-op Meds Bridgeton,MO 63044 Patient Active Medication List (YES NO) Account Number: 07~Sl00477 Patient Name: MARCH,PHILLIP Room Numb~r: 0546-0~ Date: 06/06/2007 Attending Physician: SRIRAM,VISSA Patient Allergies: No KnO'WIl Drug Allergi.es Continue? Medication Generic
NaE~CBrand
PAGE NUMBER: 2 ESTINATEDDISCHARGE NURSE PHONE EXT:
TIME:
Name) w1th Directions
AM
I NOQU
PM
Bedtime
19~NO
--~~-~---------------------------------------~---------------~-------------------------------------
OxYCOnONEjACET
~Oj325MG(PERCOCBT)1
--~--~ -----~---~-----~--------
--------
TABLET BY MOOTH EVERY 6 HOURS
AS NEEDED
(l)
:nNQ
IBUPROFEN(MOTRIN)400 MG BY MOU'lrH 3 Tir.les a Day AS NEEDED GIVE WITH FOOD OR SNACK
GIVEN AS:
400 MG: TJ'.BLET
23 215
Y~; ACETAMINOPHEN ('1'YLENOLl550
MG BY MOUTH EVERY 4 HOURS AS NEEDED AS NEEDED
GIVEN AS:
(2)
32'S MG TABLET
(1)
YE~'
DIPHENHYDRAMINE (BENAPRYL) 25 MG BY MOUTH EVERY 6 HOURS
GIVEN AS:
25 MG CAPSULE
FOR ITCHING ON HIS FACE 24 YES~ EYDROMORPRONE HCL(DILAUDID)1 MG INT~.VENOUS Every 4hre pm POTENTIAL FALL RISK #4
25 YES
--" @J
PROMEl'HAZINE(PHENERG~) 25i MG :rnTRAVENOUS EVERY 4 HOURS AS NEEDED
PHYSICIAN SIGNATURE IS REQUIRED ONLY ON THE LAST PAGE OF THISMEDICATION LIST > = Medication Substituted per H05pita~ Approved Formulary Substitution
Pilot Form 4/2005
H,
.....
H
DePaul Health Center 12303 DePaul Drive PAGE NUMBER: 3 ESTlMATEDDISCHARGE TIME: Bridgeton,MO 63044 Patient Active Medication List (YES NO)
Please circle: Discharge Meds or post-op MedB
NURSE FHONE EXT:
Account Number: Patient Name: Room ~umher: Date: Attending Physician: Patient Allergies:
0715100477 MARCH,PHILLIP 0546-01 06/06/2007 SRIRAM,vISSA No Rnown Drug Al.lergi.es
Continue? Medication Generic Name{Brand Name) with Directions
I AM
Noon
PM
Bedtime
Additional Orders
------------_..__
__..----_..
_-----------_.
-------------------------
----------------_._------------------
hysici=
.i"""'ur"
./1
Nurse Signaturey-"
~~~
./1
~ C~. 1'II'D--__
I
1K.----.
o? r;
Date/Time
._ _ _._ _ _ _ _ Date/Titr.e
~/fr.,/O?.
(l
7~~_
Readback Confirmed
V(J
> :
PHYSICIAN SIGNATURE IS REQUIRED ONLY ON THE LAST PAGB of THISNEDlCATION LIST Medication Substituted per Hospital Approved Formulary Substitution
P!lot Form 4/2005
PATIENT TRANSPORTATION HAll PASS

Nurse assigned to patient: _..I.r-,~~ e~J,-,-i....;:L::..I1..I-.l~""::"'-~_ __ DatelTime:
ti
1-(
0
GIlII for
Qy~stions
Nurse Phone #:
(p ( '6b
0085 this patient have a PCA or epidural (pain medicine pump)? Can patient speak? Is patient deaf or HOH?
DYes
I;H'fo
DNo
Patient alert and oriented x 3 If no, please describe
0 0 No
~s
DYeS~
~s 0 No
Is patient on active seizure precautions?
DYes
Is patient on Isolation? What type? f i U1 Isolation armband on? ~
.B1e$~
6,..
Gan this patient speak English? If "no" what language does patil:tnl speak? _ _ _ _ _ _ _ _ _ __
Can this patient ambulate/1ransfer independently'? List assis1ive devices patient would need to ambulat~ or transfer:
oYes~
OYes~ o Yas p110 OYes~
0 Yes
S
';
~ 0 No
Is this patIent on telemetry? Tele box remains on patient? Does the patient require a Nursing staff member to accompany them?
C
k
:~
C)
.5 (It
Z
:J
(See olf-uni' monitoring criteria at bottom of the paglJ)
Medications rscsived in the last hour that could aHeet patient alertness? (This includes narcotiCS, PSYCh drugs) If "Yes", list the medications:
~%
Puhie oximetsr measurement when patient left the division
Is patient on 0 2 70 Yes,P-Ho- If Yes, what \s the rate and

mode of delivery l./minute i.e, NC 4LJmln
_ _ _ _ _ _ _~_ Dose _ _ _ Time given _

_ _ _ _ _ _ _ _ _ Dose _ _ _ Time given _ _ _ Dose _ TIme given
If this drops to ~%, notify nurse immediale!yl
0 lCP in chart
o No change in pattent condition from above upon return to room.
o Change in patient condition from above upon retl.lm to room. See Nurse's Notes.
Telemetry box returned with patient. 0 Yes 0 NA
Return Time
Nurse Signature
Patients Who meet the following criteria will accompanied by a Nuralng Staff member for nurstng observation and/or off unit cardiac monitoring unless otherw\ae ordered by the patient's physIcIan. Ii the patient requires a NurSing Staff member to accompany them, the nUfse can investigate whethl,ff tbe test can be dons portable in the patient's room, Criteria Ural require! a Nursing Staff mambAr to iJccpwpany a patient; Must have RNlLPNlCP
Is using greater than or equal to 6Vminute of O 2, non rebraather mask or requires continuous monitoring of oxygen saturation R~yjrii!S close observation or assessment more frequently than every 2 hours - Is restrained Patients Who transfer to Sl. Vincent'g tRNfIJlNJCPfS6GUrity) - Patient experienced a seizure In past 24 hours
be
Must haye 8N/LPN ~ Has an IV cardiacNasopressor drip - Requires temporary pacemaker
- Maintenance of Arterial LIM or otlier invasive line!! - Has 2nd degree type II or 3rd degree Heart Block
- Requiroo alfWay maintenance and ytintilmQry support

- Is medically unstable
- Having chest pain in the last 24 hours needs physician approval prior to leaving the unit for test
If your patient requires cardiac monitoring ~ Be sure to resume monitoring and/or change their location on the central monitors. 8& they INve/return to the nursing areal
Patients who 00 NOT require a Hallpass would be from PACU, OR, ER or already accompanied by a nurse. Areas who document aSS9ssments throughout test need only to indicate on tne Hallpasa to see treatment or procedure notes, i.e. Cardiac Gath Lab, DialYSis, elc,
~SSM
HIAl.T~
eARf
_,DEPAUL HEALTH CI!;t-ll'ER
14ARCH,PHTLLIP
071510047~
1I1~~MIIJlI!flUBlBnlJ3J1UII
riP
FATIENT TRANSPORTATION HALL PASS

DPM8611.o18 (412006) FRONT
MBD 0546-01 10/Q2/1976 30'1 M 00/01/07

SHIRAY." VIS SA 000718298
000456
PATIENT TRANSPORTATION HALL PASS

Oestinationrrest #1
Any change rn patient condition during te$t!procedure? If "Yes". list name of nurse you notified Was test / procedure completed? If not, why? "fiYes 0 No
1vf--
IJ.-""';'f.
Arrival TIme
Name
DYes cVNo
Pulse Time
oXi~Neasuremen1 a1 and of test ~ %

0
ear probe
~ger probe 0
TIME left TESTING site
forehead
Name of nurse notified

Q)
Anclflary Signature
L 5i.t=JI..-;
== en
TESTING SITE and NURSING DIVISlON, CALLED TO NOTIFY OF PATIENT TRANSPORT TO NEXT DESTINATION DYes 0 No
en c :;:
r
to
:s
r;t.
Destination/T9st 112
Any change in patient condition during test/procedure? If wYes", list name oj nurse you
Arrival Time
DYes ONo
Name
m ( I)
Pulse oximeter measurement at and or test Time
--
notified
Was test/procedure completed?
[J Yes 0
o
No
ear probe 0 finger probe 0 forehead
TfME latt TESTING site
If not, why?
Name or nurse notifi@{j
AncillaIY Signature
TESTING SITE and NURSING DIVISION, CAllED TO NOTIFY OF PATIENT TRANSPORT TO NexT DESTINATION DYes 0 No
OVER FOR NURSING DIVISION COMPLETION
~SSM
H!ALTH,CAR"
PATIENT LABEL
PATIENT TRANSPORTATION HAU PASS

DPM661j019 (4/Z006) BACK
000457
Non Jun 04,
2007 02:09 pm
PREPS &. SPECIAL INSTRUCTIONS NOTICE
PAT lENT
TF.ST
ORDERING
977280
PHYSICT~~
0546-01 HARCH, PHILLIP TJnit U1Rl # 000748298

~(,
0-/15100477 CDR: 10/02/76
SRIRAM,VISSA
INSERT PICe PEE WO SQ P'l' S+YRS
06/04 14: 04
ROUTINE
l'atient needs consent: form.
o
o
Patient may eat
nOIm~lly.
Check if Qutient is alle-r'':lic to J.ooine dye.
I[ you need additional 'information, go t.o the Intranet DePaul Home page click un "Nursing" link on ri.ghL :;;ide of page. Then click on "Radiology Te::lt...:J -and Procedure::;" on left Qide 0.( page and thBn choose app.copri ate t.est.
II
If Cro~tinlne 1.4 or l~ce'l a:.:' Creatifline Clearance >(iOml/n1in. Omnipaque 300 IV. If Crei:ltinine gl-eater c.han 1.4 or Cr.eaLinine ClcOlrance <.GOml/rnin, no cont.rast.
****SCl>.N TO DPHC PHARl>1ACY PRIOR TO
TES1'*~'''*
000458
HEALTH CENTER
PATIENT: MARCH, PHILLIP ADMIT DATE: 06/01/2007 DISCH DATE: 06/06/2007 PHYSICIAN: VISSA SRI MR#: 000748298 ACCT#: 0715100477 DOB: 10/02/1976 ROOM:
PRIMARY DIAGNOSIS AT DISCHARGE: Left facia! cellulitis, possible hardware infection. SECONDARY DIAGNOSIS: HypertenSion. CONSULTS DURING HOSPITAL STAY: Dr. PhillIp Zinser, Infectious Disease; Dr. Sheldon Davis, Otolaryngology.
STUDIES DURING HOSPITAL STAY: CT of the face shows no discrete abscess, soft tissue thickening. angioedema suggestive of cellulitis.
NOTE ON HOSP1TAL ST AY: The patient is a 30-year-old African American male who had a stab wound injury and a mandibular fracture, which was repaired at the Barnes Hospital. The patient has been following up closely at Barnes and was prescrlbe<1 multiple courses of oral clindamycin, however. he continued to notice severe swelling, induration and insbllity to open his rnouth wide enough to eat any kind of food. Hence, he presented to DePaul Emergency Room. The patient was afebrile on admission. had a norma! white count. He was empirically started on IV antibIotics With this he had a s1eady improvement The patient was seen by lnfectlous Diseases. It was felt that patient may possibly have a hardware infection. Hence, he has been set up for horne IV antibiotics for four weeks and follow lip with ENT as an outpatient.
DISPOSITION AT DISCHARGE: Stable.
DIET AT DtSCHARGE: Regular as tolerated. ACTIVITY AT DISCHARGE: Regular as tolerated. MEDICATIONS AT DISCHARGE: 1 Zosyn 3.375 gm IV Q.6 hours until June 12, 2007. 2 Norvasc 5 mg p.o. once daily, 3 Percocet 10/325 mg one tablet p.o. q.6 hours p.r.n. 4 Motrin 400 mg p.o. t.i.d. p.r.n. 5 Pepcid 20 rng p.o. b.i.d. This document has been reviewed and signed by VISSA SRIRAM Sign DatelTime: 06/1212Q07 2:22PM EST VISSA SRIRAM, M.D. VS:123/QA/Z3 - 1924986 0: 6/05/2007 11'.17 AM T: 6iSf2007 7:24 AM E: 06/12/200717:06 PM
CG:
PHILLlP G. ZINSER. M.D. SHELDON L DAVIS, M.D. BARNES JEWISH HOSPITAL ENT DEPARTMENT
MEDICAL/SURGICAL DISCHARGE SUMMARY-PP
- Page 1 of 1
000459
H
PAGE NlJM.BER: 1 ESTIMATEDDISCHARGE TIME:

NURSE FHONE EXT:
Please circle: Discharge Meds or Post-op
M~ds
Bridgetorl,MO 63044Patient Active Medication List (YES NO)
Account NUPber: Patient Name: Room NUmber: Date: Attending Physician: Patient Allergies:
0715100477 JffiCR,PHILLIP 0546-01 06/05/2007 SRlRAM,VISSA No Known Drug
~
Allerg~es
Continue? Medication Generic NameCBrand Name) with Directions
1 )<::::) <:9
?:O~
I
1J!1.
Noon
PM
'
Bedtime
*W
Scheduled Medications ***
14
15
~~ NO
MAGIC MDUTHWASH(MAGIC) 5 ML BY MOUTH 3 Times a Day

OXYCODONE STRENGTH () BY MOUTH 3 Times a Day
x
x
YES~~' "'CLARIFY
x
x
x
x
16 YES \O' III
r,
NO
"CLARIFY CLINDAHYCIN {)
BY MOrrrlH 3 TL'1Ies a :Jay
(6s
J
1u~ODIPINB (NORVASC) 5
MG HY MOU'TH Daily
GIVEN AS, (1) 5 MG TABLET GrvEN AS: (1)

GIVEN AS:
~O
2{]
fi..-~~
NO
FAMOTIDlNE(PEPCID) 20 MG BY MOUTH 2 Times a Day

IBUPROFEN(MOTRIN)400 MG B,Y MOUTTH 3 TL"lles a Day
NG TABLET
x
x
x
x
x
21~
NO
GIVE WITH FOOD OR SNACK
~~
{1) 400 MG TABLET
>
M~dication
PHYSICIAN SIGNATURE IS REQUIRED ONLY ON THE LAST PAGE OF THISMEDICATION LIST substituted pe~ Hospita~ Approved Formulary Substitution
Pilo,t Form 4/2005
H
DePau~
Health Center 12303 DePaul Drive
PAGE NUMBER: 2
ESTlMA~EDDISCHARGE
TIME:
Please circle: Discharge Meds or Post-op Meds Bridgeton,MO 63044 Patient Active Medication List (YES NO) hCCOunt Number: Patient Name: Room Number: Date: httending Physicianf Patient Allergies:
0715100471 MARCH,PHILLIP 0546-01
NURSE PHONE EXl':
06/05/2007 SRlRAM.VlSSA No Known Drug Allergies

Name~Brand
Name) with
~irectiona
AM
NOOn
pM
Bedtime \
9 13G Nb
)..0 YES
--------~------------------------------------------------------------------------------
CLINDAMYCIN (CLEOCI:N) (CLEOCIN) 600 MG INTRAVENOUS EVERY 8 flOURS SODIUM CHLORIDE 0.9%{NO:ruo..L SAlLlNE} 1000 M1., INTRAVENOUS PIPERACILLIN!TAZO IE20 (ZOS'YN) _375 GM INTRAVENOUS EVERY 6 HOURS
*'*~.
---------------------------------------------------.... EVIilRY 8 flOORS
NO
+rAj -; /
a /~
(1) 25 MG CAPSULE
**
EVERY
HOUR.S
As Needed Medications ****.

AS NEEDED
17 YES(NO) DIPHENHYORAMINE(BENADRYL125 MG BY MOUTH gvgay 6 HOURS 1..-/' FOR lTCHING ON HIS FACE
GIVEN AS:
l~~
,~
NO
OXYCODONE/ACET 10/325MG(P'ERCOC8T)1 TABLET BY MOUTH EVERY 6 HOURS
AS NEEDED
(2) 325 MG TABLET
YES~ ACETAMINOPHEN(TYLENOL)1550 MG BY MOUTH EVERY 4 HOURS AS NEEDED
GIVEN AS:
PHYSICIAN SIGNATORE IS REQOlRED ONLY ON THE LAST PAGE OF THISlolBDlCATION LIST Medication Substituted per Hospita~ Approved Formulary Substit~tioD
Pilot Form 4/2005
H
DePaul Health Cent~z 12303 DePaul Drive
PAGE N1UMBER: 3
ESTrMA~EDDISCHARGE
TIME:
Please circle: Discharge Meds or Post-oJ:> MIeds Bridgeton.MO 63044 Patient Active Medication [.iEt {YES N<ll
NURSE PHONE EXT:
Account NuQber: Patient Name; Room W~~er: Date: Attending Physician:
0715100477 MARCH, PHILLIP

OS4~-Ol
06/05/2007 SRIRAM,VISSA Patient Allergies: No Known Drug
A~lergies
Continue? Medication Generic Name(Brand Name) w1th Directions
AM
Noon
PM
Bedtime
-----.. 0. ------- ----- . -------------- ----- ------------ ---"" -------- ----- . ----. --------.. ---- ---.- ---. ------ ------------------.. --- ------.. ---1.1
YES~
HYDROMORPHONE HeL (DILAUDIIJ) 1 }1G INTRAVENOUS Every 4hrs pro POTENTIAL PALL RISg #4
12 YE6 PROMETHAZINE: (PHEI:l'ERGAN) 2 5 MG
n~RAVENOUS
EVERY 4 HOORS AS NEEDED
Additional Orders
-----------------_ _................_-- .._._-.....

.. _ _ _ _ ._ " ' _ ' ___" m _ " _ '
PhysiCian Signature: Nurse Signature:
JI!~_~
...- ....
__
....... ......
_.-_......_-----------------
Oate/Ti_
Date/Time Readback Confirmed [ 1
> :
PHYSICIAN SIGNATURE IS REQDIRED ONLY ON THE LAST PAGE OF TRISMEDICATION LIST Medication Substituted per Hospital Approved Formulary Substitution
Pi1.~t
Form 4/2005
paUent meets for Pneumococcal year of teat Is not obtainable by HURling and/or case Managar, vac:cln. should be given and recorded.
000463
000464
DRUC MAY BE DISPENSl"1'l ,N ACCOHDNICE Wfl H
lH~
HOSPITAL FORMUlARV SYSTEM UNLt:iS CliECKEO HERE
PHYSICIAN'S ORDERS
1 'UJIly' IIlSINd nJ "!)d'
AI.I.ERGIES
IN,tead oj V iI. 1J0 Immo larO! (lmg Mil ama)
2.
'Umt~'"
5. '/,{mphine' in~ead 01 'MS04' 6. "MagnesIUm sull~tc' ~'$\eJd .)j 'Mo.S04'

7 . EvelY olliel aay' IfISleJo of "Q
0 fl.'
4. Always use leading mos

I PAnPlT
e. 'Mel,. "i:;teaii 01
'~/Q'
()!
wlG.... r c;,
U Kg. 0 lOS
P,o,TlEN1 IKJCHT
(0 1mg no! .1mg)
9. 'Int~tn,lUonal unit!.' io;ta~~
"IU'
Iv
,~'?-~~~
"'''' . 1 HHI
Tu "'''',.,,
ORD
~f 11 t/ J
l
(J
"'--'
1J1e
(Il
CU,..
~tb-.
6flCQ
V
cJJ
/j\ ')
l1.A./\
.J...PO 't')11
'-'
P..1
An
crbo<
(\
,......
~ ~iL~ l.-, VI \11"/"- {
\
~] V7.!!l I
I(
~
\ ,... iVVA.J.j
,
Y'-' <-- .-
Yl
l~v
A
r\
.1
~
'C
"-f
"-
oud.f
~
f)./'~ "'-/~J
.....
CJ
"~
'7
--r J ~ -~F ~;;:;c j
(.?Xj"... , r_.
f
[J (/
~Jl
~~ c..-
OA
r
/1;7.
/ (/;.1. (ft j' f'--.--' 8-. J .f- ,.A.42 TL. L

.\
\\
f--
\
flUA
IIIJ,I
-a.
~SSM
HEALTH
SLM1QOOC65 (712006)
PATIENT LABEL
CAR E-
D8PAU;, HEALTH CEN'fER
IViARCH,PHILLIP
O'Il~1()04'!7
IIUHUmlllUlllllnnallftllll1
HElD 05,1601
"<1
I/P
06/01/CU
PHYSICIAN'S ORDERS
10/02/1976 30Y JW1MAN, ANWER Z
OOO"J4fl29fl
000465
DRUG MAY Ht UISPNSEfJ IN ~aOnDANCE 'MTH rOlf'
""""
HUSl'llAL fORMULARY SYS'TEM
CHFCKEO
.........
PHYSICIAN'S ORDERS
1. "Dab'y' in~teBtj oj 'Q\1' 2 "Unrts' ill~tcil1J 01 V 3. tf1.l Itailo!(j zeros ilmo not 1.0mg)
4. Alway; lIse
I~.dino 2~!OS
5 "Mmphine' instead of "MS04' "Mal)lleSlum wHale' inslead 01 "h\gS04' 7. "fiery ethel day' insl~aLl 01 'U.oO ' 6 'MeG' ~15te!ld ul "Jig' 9. "Inltrnational units' inste;!tJ 01 -m"
(j
~SSM
SLMl000-065 (7lZOC'.)
PATIENT LABEL
H E A L T H . cAR e-
PHYSICIAN'S ORDERS
000466
DRUU MAY .
~~
UISf'ENSED IN ACCORDANCE WITH THE ~ SY51"EM HERE '-Y
PHYSICIAN'S ORDERS
1. 'Oailv" inSleM nf "~1I'
2.. "Units" inslaad 0/ "JI" ~. No trailing llllllS l1mg flO! I,Omg) 4. Always use lea/ltng zelOs
S, "Morpl\lIle" instead ul "MS04"

6, "Ir\aaneslum ~ulfalg' ilt~tcad of "MgS04' 7. "Every \liliar day" ~Islcad 01 '0.0 D: 8. "MeG" In~1cad of 'J1Q"
(01mgml.1mg)
9. "Intern.wHal ullas' instead oj "\U"
~SSM
SLM\ mKI{Jn~ (1/2006)
PATIENT U\BEL
H E A l T H ' CAR EM
DEPAUL HEhLTH CENTER
MARCIl, PlUU',lP
07J5100477
PHYSICIAN'S ORDERS
1I1f1ll11lllmiItIUlnf~!lnJ
M
TIp
06/01/0'1
MED 0546 01
()0074a298
10/02/1976 :!oUr-
RhHl>1AN,ANWRR Z
000467
RADIOLOGY: Pice GUIDELINES (Peripherally-inserted Central Catheters)
POST-PROCEDURE ORDERS FOR SINGLE LUMEN (5 FR) & DOUBLE LUMEN (5 FR) Pice INSERTION
Change ctre66ing in 24 hr; then change every 7 days or PRN if it becomes loose or sQiled,
Change intermilterlt infusion plug every 7 days or PRN if leakage occurs, Cleanse site with Chloraprep at each dressing change and use transparent occlusive dressing. Pulse flush with normal saline 10 rnl every 8 hrs (regardless of continuous IV infusion), Pulse flush with normal saline 10 ml before and after administration of medication. When obtaining blood sample, discard first tube, then obtain the sample. Upon completion, pulse flush with 20 ml norma.! saline,
DO NOT USE VACUTAINER TO OBTAIN BLOOD SAMPLE OR BLOOD CULTURE.

NO BP OR NEEDLE STICK IN Pice ARM.
00 NOT USE ANY SYRINGE SMALLER THAN 10 ml WHEN INJECTING IN PICC.
ADDITIONAL ORDERS:
VV\ou-;
l..{S..t...
fl C c..
~--
(; 1-
cO~~
I(J~
7
Physician Signature: ----'I---t--------~
Dale: _-+-~--=------'--__ Time: _ _
6(/~ 7
t:( /1(
NurM Signature! _ _ _ _ _ _ _ _ _ _ _ __
Date: _ _ _ _ _ _ _ TimG:
~SSM
'lllr.~
r"
DEPhUL HEALTH CRNTER

t>lARCH, PHILLIP
U71S100~71
RADIOLOGY DEPARTMENT IVR PICC GUIDELINES 4{2006
Tip MED 0~46-01 10/nj197G 30'1' M 06/01/07

00074U;~98
IDJMllllBSlltMmIrHlli1
SR1RAN:, VISSA
000468
DRUG MAY Ill=
I)ISP~NSEt)
IN ACCORDANCE WlTIl nIL
SYSTEM UNLeSS
PHYSICIAN'S ORDERS
t, "Daily" instead 01 "qd' 2, "Und5" instead oJ "u" 3, No lTaWng lfrUS Omg flul 1,OlllQ)
J Alway~ u'illl~auUlg lelOS
" "Morptllre" IIl5!p.ad of "MS04'
6, 'MugMsium Sulfal~' ~~t6art of "MI}S04' 7, "i:very other aay' !!ISlMII of "0,0.0 " 3 "MeG- Instead 01")10' 9 "'lnternattor\ai ur\f~" int{A.1d of ""IV'"
ANTIBIOTIC ORDER RENEWAL

According to DePaul Health Center's antibiotic stop O(der policy. the foJlowing antibiotlc orders are scheduled to
expire on C Please ranew your palienes clinical response and renew, revise. or discontinue the Thank You antibiotic orders accordinp'
Patient
.f
f"'\
b-.. r
t.-......... " , , '
Room Number
t ,
ti.f!r
PAT/EN1 LABEL
Dh:PAUL Hlc:Al.TH CENTi!:R

1
i"'J\RCH I PHILLIP
PHYSICIAN'S ORDERS
SU.!IO(}()~5
li11M11111111I1B111 "
rip
0'/151004/ 7 MED 0:::'46-,01 I ' 7 1 1)/01/J.9 76 30Y (>1 06;.1',, '"~' ANI"ER Z OQU 148 . 9fl Ri-\!l !'lfi-l', r
(712006)
000469
DRUB MAY I>~ DISPENSeD IN ACCORDl'NeE W!Tl-I il-lE
PHYSICIAN'S ORDERS
1 'Daily' instead 01 "qd' 2, 'Unlts'ln$lead o! V 3, ~lo t'~l1iny L!O, (1mgIl(!11.0mg}
5 I> 7 R
-MJJrphlnt" lIlsread of "M504" "MagneSium w~at~' instead uf 'MqS04" "EWlIY Olhtf claf Instead 01 '0,0,0 ' 'MeA' inStead oj 'JiQ' 9, '!nl&maUonal units' !nslead vI 'IU'
~SSM
H E A L T H ' CAR
SLM! 000-065 (7120OBi
PA DENT LAl3EL
E~
f)F;PAUL HEALTH CENTER

MARCH, PHILLIp I/P 0715100477 MED 0546-01
imllllnR~I:mllla!lnU~II~
z.
M
PHYSICIAN'S ORDERS
10/02/1976 JOI P.A.4M.ll.N I AffivER
06/U1/0 I
000 -, Ii 8 2 9 8
000470
UHuCi MA'/ B( DiSpeNSED IN A0C.OMANGc "liTH THE
UNLESS CHE.C~.c()
r-". '-V
PHYSICIAN'S ORDERS
\. "Oady' tostead 01 "qrt" 2 'Unils' m~83d 01 "u' 3 No ftailing WI>S (1 mg nol L~mg)
~
S. 'MQrphine"
IIlS~d 01
'MS04'
6. 'MaYllcswal sulfate' b1,laarl I}f 'MgS(W 7. 'E~ery other (!.ly' lostAUI (Jf "0.0.0. '
8. 'MCG' ,nstll.1d 01 'Jl(( 9 "I01hrn,11inr.~1 unrts' tnslaad 01 'IU'
Alwil'{S use leading

(O.lm~
leros
no\ ling)
OfIOSS'jliWERS rAll"'4111
H , A L T H
J;-'
ABOVE SCAN "'YXiS COl NECT 8Y:......J,L.....~_-+ \lATE, TIME,
; rJflJT
MlJ~(,H( PH.lLLIP
LABEL
DEPAUL HEALTH C::E?JTE)(
l~flUI~~Ufilml!illlml~I~~
t1
JrQf",-.i.C.AN'S ORDERS
SLMl000065 {7/2006j
liP
0715100477
MBD 0546-01
06/01/07
OOO'J<] I}:! 98
j 0/02/1.9"6 30Y ~
D(-
S'~lv-I\~
000471
Emergency Department Admission Orders

Diagnosis:
Ft;.4......e
ViM~~""-'-'--~_
Inpatient admit to: ~dical
DSurgica!
0 Telemetry 03 North (Intermediate ICU} DICU DSurglcal 0 Telemetry
Outpatient (Observation) admit to: 0 Medical
..... I:o,.l~=.:.. _ _ _ _ Consults: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Physician: ----It2'-""""*.IoqC..v:

Full Resuscitation
DNR ~ Continue MedicHI Therapy
~Iace on Care Pathway:
~~~~~~~~~~====~~
DNR - Comfor! MtlHsures
I Nk:
Nlergi
M A-
A~U~~C;;dJ~~~:~O"'C~~~~;t;~~c-~~~~~;iid~\-{JA.cut~';Pdlffl.~tie~---!
> ~~~~~:~: ev:~~::~;:;:;~::~::~:~;;;;;~~ ~~i~~t~ o

I&.O 0 Daily Weights
[J Cardiac Monitoring
II.
\
III. IV.
o C8C CMP 0 CXR o PT 0 EKG o PTT 0 AT1 o Fingerstick Glucose 0 AC &-H-S--D-e-ve-f)!_:~~Ju!s MEDICATIONS o Initiale Sliding Scaie Insulin Orders
o
~ntinue
Home Medications checked "Yes"
ADDITIONAL DIAGNOSTICS
.;
on Home Medication Sheet/Orders.
S--acetamlnoptH:m (Tylenol) 650 mg PO every 4 hours PRN mild pain or fever> 101.5F
c..../~IV f1uids_
U
TRENMENTS
r~~$d;r:tf~~,. __ <C~ ~:;J ~ebJ

(9
N>:
1M- lo,,~ ) Jv.. ~
, \
0 SaUna Lock
Activity: U Becires.Vff1iBP ,n c~ S~O AddltlO.nal Physician Orders
Oxygen at _ _ Foley Diet: [] ~JrO
__liters per_ _ _ _ _ _ _ Call physician if 02 Sat <--% .... 0 NG to suction fr -, 0 ReQular 0 calorie ADA ~ .. d 1.6 .._~_1' '-"
---d
/"
sse
Delle:
G_ , II
Tlme:CJ-,O
Physician
0 Up ad lib 0 _ _ _ _ _
'--r __
~~ ~
RN
f""<"'
Tran~cri/.)ed
by;
______Time Noted:
Ord~rs SCanned
to PhJrmZlcy Date _ _ _ _ _~ Time _____ . _ Iniliuls _ _ _ _ __
~SSM
tI , I. i f
II {.
A JI:
~iiDBPAlTL
HEALTH CENTER
:.. J,IIIDIIIIIIIIIII ") / "~CHt PHILLIP
0715100477 BRS 10/02/1976 30Y M 05/31/07
ERQ
E1I1ERGENCY,PHYSrCIA00074B298
000472
HOME MEDICATION LIST ORDER SHEET Name:

Weigh1 _ _ 0 Kg (J lbs Is Patient Lactating? Cl N/A 0 Yes 0
No
Flu Vaccine 0 No 0 Yes 0
AHergytreaction to latex? 0 No 0 Unsure (Note: History
.... - .. - - .. ---.:-----=:--=--:-c-----==-+~--_;:__:__c____:_~----'-~-:::__L-~~-'---- .._r-~---'--------____l
asthma may increase
ri$k) g
y~{\ -Q~$vrl!;le~~_ _ _ _ _ _..,.-_-:-_ _ _ _ _-:-_.....
Check the box below if you have ever experienced runny nose, tearing,
Answering "yes" to any of these require initiation of
sneezing, or itching aft~r: o Dental/Internal eXams 0 Contact with rubber gloves/products
o blowing up balloons 0
bana
Use of condoms or diaphragm kiwi avocados water
o Ci1anlabeled
Latex Allergy Protocol
U Allergy armband
Include blood thinning products, over-the-counter medication. herbal supplements ( list only current meds) Home Health Services being used? Q Yes 0 No If yes, Name Type _ _ _ _ __ Sources of Information: OPatlent CI Medication Bottles CI Patient's Family 0 Med Lisl U Doctor's Offioo o Pharmacy Name Pharmacy Number 0 Old Chart 0 Other:
Continua?
Drug Name
Dose
topical sito frequency
RQute or
LB5t Dose
Comments
('
1-----1------+---.--.------.----. -.. ,,-- - ....
. I
These checked orders will only become active when 8uthmized b~P ysician.
M!:i.JiCfJliOllsihefballvfllmiflS will be dispollsod in oeco/dOllce
Home Mad LiS~ Recorded b Y : - - o

l<ylll~fltl'y$I~iilll.
Non-formulary hrgrba/viliminli will IJft twIrl ~lJrtrl~ fl"$/iilul :lIar. R:ilJfM <III
Date: Date: Time: Time: _ _ __
with Uw hopital form .'
.
a(g~ lJ(/lft~~ !J1!l)~(
Physician: _......,.---ly....::;,.",::..;.2..-'-~<-_ _...L
Nurse: _ _ _ _ _ _ _ _ _ _ _ __
Readback confirmed
Scanned to Pharmacy Date: _ _ _Time:: _ _ _~!n!tiats._ _ _ __
~SSM
~
f .. t I . .
(I 4
DePaul Hetllth Center
eH, PHILLIP 07~Sl00477 ERS ERQ 10/02/1976 3 EMERGENCY, PH~~ICM 05/31/07 1A000748299
JJIIIIDIII;i
OEPAUL liE
TER
000473

HISTORY ANO PHYSICAL
PATIENT: MARCH, PHILLIP ADMIT DATE: 06101/2007 MR#: 000748298 ACCT#: 0715100477 ROOM: 0546
008: 10/02/1976
PHYSICIAN: VISSA SRI RAM, M.D.
CHIEF COMPLAINT: Pain and swelling In the left side of Ihe jaw. HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old African American male who was stabbed in his left face in an attempted burglary around M~rch 8, 2007. The palient was admitted to Barnes Hospital and states that he had a mandible fracture, which was fixed with a plale He subsequentty was discharged home on oral clindamycin. However, the patient has obviously been having pain and swelling of the left jaw. He has been twice back to his same surgeon and was prescribed other another course of clindamycin and was discllarged home. The patient states that the pam has become unbearable. and this time it has even spread furlher. He also noted some hardening at the superior aspect of the incision of the left jaw area. The patient states that he has lost about ten pounds of weight because of Inability to open his mouth or chew any food. The pain is unrelenting and severe, radiating up to his left ear. There has been no fever or chills, rigors, no cough with expectoration, diarrhea or constipation. No dysuria. hematuria, or frequency of micturilion No double vision, no blurred viSion. no diplopia. no tinnitus. no otorrhea, nO rhinorrhea
Today upon my Interview, the patient is awake, alert, sitting in bed. He continues to complain of
inability to open his mouth, and severe pain In the left side of hIS jaw PAST MEDICAL HISTORY: NegatIve for hypertension, diabetes or bronchial asthma.
PAST SURGICAL HISTORY: As above.

MEDICATIONS: 1 Clindamycin 300 mg p.o, Ud. 2 Oxycodone one tablet p.o. Ud. 3 Magic Wash mouthwash 5 ml p.o. U.d. ALLERGIES; No known drug allergies. SOCIAL HISTORY: He works CIS a bounty hunter. He denies smoking. He consumes alcohol on the weekend. No drug abuse. FAMILY HISTORY: No history of premature heart disease. REVIEW OF SYSTEMS: Unremarkable as above in the current history. PHYSICAL ExAMINATION: GEN~RAL: The patient is an alert. awake. male sitting in bed in moderate discomfort. VITAL SIGNS: Blood pressure 99/59, pulse oximetry 99% on room air. Respira1ions 16, heart rate 64, temperature 97.6. SKIN: Warm. NECK: No JVO. No carotid bruils. Trachea central. No thyromegaly. CHEST: 6t1ater~1 clear to auscultation. CVS: 81,82, regular rate and rhythm. ABDOMEN: Soft, nontender. No organomegaly. Bowel sounds are present eNS: Alerl, awake, and oriented to time, place and person. Crania! nerves II-XU grossly normaL Power and lone are grossly normal. HEENT: Tri$mus. The patlent is unable to open his mouth to a wide angle. The patient also has hardening and induration along ttl8 len subrnandibular angle. There is a well opposed incision With no drainage at thiS time. However, EO notes mentioned some purulent drainage from the superior aspect of his incision.
MEDICAWSURGICAl HISTORY AND
PHYSICAL-D~
- Page 1 of 2
000474

PATIENT; MARCH, PHILLIP
HISTORY AND PHYSICAL
MRlI;
00074az~a
LABORATORY DATA: BUN 14, sodium 139, potassium 3.8, chloride 100, glucose 93. creatinine 1. WBC 7.2, hemoglobin 11.9. hema10crit 35.8, platelet count 341. No bands. Granulocytes 63.4%.
IMPRESSION: Left facial cellulitis following a recent surgical repair. The patient has been started on IV Zosyn and clindamycin, which should be continued. The patient is afebrile. He has normal white count on admission. ENT consultation will be placed. The pa1ient will continue to follow in
the hospital for pain conlrol and oral intake. If the patient remains afebrile for another 24 hours, ans shows improvement in IV antibiotics, he could be switched to p.o. Augmentin and possibly be
discharged home. Ideally, the patient should follow up with his own surgeon for close monitoring
and foUowup.
DISPOSITION: Curre()lIy stable.
This document has basn nWI@wf:lrJ and sign@d by VISSA SRIRAM

SIgn Dalerrime: 06/04/2007 7:25AM EST
VISSA SRIRAM. M.o. VS:221 1922615
D: 6/01/2007 1:31 PM
T: 6/1/20072:14 PM E: 06104/2007 09:0J AM
cc:
VISSA SRIRAM, M.D. BARNES JEWISH HOSPITAL CLINIC
MEOICALISURGICAL HISTORY AND PHYSICALOP
- Page 2 of 2
000475
~----~----~------------------------'--------------'P.~~TruIE~N~T~~--------------
~SSM e
H A L T H . C A
ft
E~
JII!~~J~~~PJJnn~m
071 cJI00477 lo/o2/J 976
i~MAN, ANHER Z
1/ P MIW 051\6-01 30Y M On/Ol/07
OOOH 8798
SLM-l000-003 (6/2U03) 02 FRONT
000476
SlM 1000003 (fif2003) 02 BACK
000477
1v7?J
h _ _ _ _~--~_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _._----------~~~~-------------
~SSM
SlM- \ 000-003 (6r.'OO3) 02 FRONT
H E A L T H - CAR E~
INTERDiSCIPLINARY H1STORY 8< PROGRESS NOTES
000478
\ ~~~~~Af-
SlMl00001)3 (6l2003) 02 BACK
000479
~ ----~----~------------------------~------------~~~~~--------------
~-----+-----r--------------------------------------------------------------
~SSM
H E A l T H - CAR
SlM1OOQ003 (612003) 02 FRONT
Dh:PAUL HEALTH CENTER

MARCH,l'HILL1P l/P 071S100~77 MBD 054601 l.0/02/1976 30Y M 06/01/0'1 U;HMAN, ANWBR Z 00074B7.98
E~
IllMllIllllHIllIlUlmlHll1IfI
INTEROISCIPLINARY HISTORY & PROGRESS NOTES
000480
~SSM
SLM,'oOO-003 (6120(13) (12 BACK
INTEROI$ClPlINARY HISTORY & PROGRESS NOTES
rjp~'~!t~'~P}IItIlU
I/l'
000746298
Q71S10lH 77 MED 0546 -01 10/02/1976 30Y M 06/01/07
Ri\HMAN,ANI"ER Z
000481

Date Time
NOTES MUST BE SIGNED
0(Lt!7
:r~
'7
b-I
.S"
fYl:;SSM
H E A L T H . CAR

!'lARCH, PHILLIP I/!;1 071S100477 MEV 0546-01 J.0/02/1976 30Y M 0&/01/07 RAJ/MAN, ANvlER 7, 000 'l'lq:,: ;.U
E~
111111111111111110111
INTeROISCIPLINARY HISTORY & PROGRESS NOTES
000482

Dille
TUllC
I NOTES Ut)ST BE SIGNED
I
I
--"
PATIENT LA8EL
~SSM
SLM-loo0-003 (612003) 02 BACK
H E A L T H ' CAR E~
] 5100 177 10/02/19'16

RARMJ
1llllllIIlii.m CBH:t'F;I~ ~1:~.RCR, PHI!,l,IP 1f11I18

MED
lOY
'.7
DEPAUL llRAJ
054 6-01
M -
II . P
UV,A1"WER
06 101107
000748'-98
,
;
000483

Ddt" TUlle
I NOTES Musr B SIGNeD

PERrPHERALL y
tNSERTED
CENTRAL VENOUS CATHETER Placement Information
CATHETER:
LOT#;
gx,~~~~
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DATE OF PlACEMENT:
VEIN USED: R
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CATHETER UTILIZATION:
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000484

HEALTH
NARCH, PHILLIP Tip 0715]00477 MED U~46-01 ~O/0:.1/19?6 30Y I't 06/01/0'/
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INTERDISCIPUNARY HISTORY AND PROGRESS NOTES
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MARCH,PHIGLIP rip 0715100477 Ml<:l) 0546-01

10/0'-/19)6 JOY RAHMAN, AN1vBR Z M 06/01/0'1 OO()74!l7.c,i}
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INTERDISCIPLINARY
HISTORY & PROGRESS NOTES
SlM1000003 (6/2003) 02 FRONT
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INTERDISCIPLINARY
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SlM10QO003 (&2003) 02 BACK
000487

MARCH, PHILl,IP
INTERDISCIPLINARY
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rNTERDISCIPLINARY HISTORY AND PROGRESS NOTES
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MARCH,PHILLIP rip 0715100477 MED 0546-01 ~O/02/1976 JOY t>'f 06/0]/07 ~RIR~~ VlSSA OOd748298
11111111111111111
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000489

CONSULTATION REPORT
PATIENT: MARCH, PHilLIP ADMIT DATE: 06/01/2007 CONSULT DATE: 0610112007 ATTENDING PHYS: VISSA SRIRAM, M.D. CONSULTING PHYSICIAN: PHILLIP G. ZINSER, M.D, MR#: 000748298 ACCT#: 0715100477 DOB: 10102/1976 ROOM: 0546
REASON FOR CONSULTATION; Evaluation of left jaw infection, SUBJ ECTIVE: This is a 30-year-old man without sIgnificant past medical history. He sustaIned a stab wound to his left face on sbout April 24. He also sustained a fracture to his left Jaw and face at that time, He had surgery to stabilize the fracture on about May 5. Since that time. he has had pain and swelling in his left face. This has been Llnchanged since the surgery date. He has been on clindamycin since the surgery date. Last week. he had some serosanguineous drainage out of an incision at the angle of his left jaw. He complains of bwning pain in his left face. Apparently, a nerve was cui al sOllle point He was admitted on 06/01/2007 with pain in his left face so that he was unable to open his mouth. He feels improved with pain medications. He denies fevers. He dOBS report chills In the last 2 weeks. He says that these are bad chills, He denies any night sweats. He denies cough, phlegm, shor1ness of breath, nausea, vomiting. diarrhea, or abdominal pain. The patient was admitted and started on Zosyn and clindamycin empirically, They consulted me and ENT. They ordered a CT scan of the left face, which is pending. ALLERGIES: No klJown drug allergies.
CURRENT MEDICATIONS: 1 Promethazine. 2 Clindamycin.

3
Zosyn. Hydromorphone.
PAST MEDICAL AND SURGICAL HISTORY: Otherwise negative SOCIAL HISTORY: He drinks alcohol. He does not use tobacco or recreational street drugs. OBJECTIVE: VITAL SIGNS: T-max is 98,7, Blood pressure Is 113/76. Pulse is 62. Respirations are 16 Saturation is 100% on room air. GENERAL: Patient is alert and oriented. Oropharynx is clear. He is able to open his jaw somewhat now with the pain medications His left jmv and face are swollen and indurated up to his cheekbone. There is some swelling at the angle Qf the jaw, The area is tender, There is a s{{ar belQw his left ~heekpQne, There i~ nQ fluctuance. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender. Normoactive bowel sounds. EXTREMITIES: There are no red, warm, or swollen extremities. No rashes. LABORATORY DATA: The patient's white blood cell count is 7200, hematocrit 36, platelets
341.000, creatinine 1. liver function tests are normal. Blood cultures are penCling. CT scan of
the face is pending. ASSESSMENT: Status post trauma and stab wound to left jaw with fracture and hardware fixation, now with perSistent swelling and increasing pain and chills concerning for the possibility of osteomyelitis or Infected hardware. RECOMMENDATIONS: 1 CT scan of the face
IS
pending.
MEDICAL/SURGICAL CONSULTATION REPORT wOP
- Page 1 of 2
000490

PATIENT: MARCH, PHilLIP
2 3 4
CONSULTATION REPORT
MRf1; 000748298
ENT consult is pending. We will screen for methicillin-resistant Staphylococcus aureus and check sedimentation rale. Continue current antibiotics for now.
Thank you for allowing me to participate in this patient's care.
This document has been reviewed and Signed by PHILLIP ZINSER Sign Daternme: 06103/2007 5:43PM EST
PHILLIP G. ZINSER, MD
PGZ:186 - 1922996 D: 6/0t/2007 7:56 PM T: 6/2/20073:30 PM E: 06/04/200709:01 AM
CC:
VISSA SRIRAM, M,D,
MEDICAL/SURGICAL CONSULTATION REPORTDP
- Page 2 of 2
000491

CONSULTATION REPORT
PATtENT: MARCH. PHilLIP ADMIT DATE: 06/01/2007 CONSULT DATE: 06/0212007 ATTENDING PHYS: VISSA SRIRAM. M.D. CONSULTING PHYSICIAN: SHELDON L. DAVIS, M.D.
MR#: 000748298
ACCT#: 0715100477
DOB: 10/02/1976 ROOM: 0546
SERVICE OF CONSULTATION: Otolaryngology PRIMARY CARE PHYSICIAN: Dr. Anwer Rahman
CHIEF COMPLAINT: Left facial swelling.

HISTORY OF PRESENT ILLNESS: This 30-year-old male was assaulted on 4/24/2007. The detail of the assault is unk.nown to the patient as he was unconscious for a short period of time, He was taken to Barnes Hospital where stab WOUJld to the left side of the face was treated and an apparent pumping artery was conlroUed. The diagnosis of jaw fracture was made and he was seen several days later by the otolaryngology department for this fracture, He ultimately underwenl open reduction. Internal fixation of the jaw fracture on 5/8/2007. Sillce that time anc\ flven predating the fracture reduction, he has had a severe burning in the posterior part of his throat supenorly, This has preventing hIm from eating very well. He has also developed swelling over the left malar and jaw region and mild to moderate trismus He has had multiple revislts to the emergency room at Barnes as well as several readmisSions, He did not feel his Clinical progress was improving enough and therefore presented to the emergency room at DePaul on
6/1/2003.
Since admission, he has been on Zosyn; clindamYGin and Dileudid and has had improvement not
only in his trismus but in his pain. He is now able 10 eat and is feeling much better.
PHYSICAL EXAMINATION: Reveals obvious left-sided fadal edema. It involves the malar area inferiorly to the inFerior portion of the left mandible. The incision for the open reduction is a horizontal incision under the jaw, approximately 3 em and extends to the postaurlcular area and curves upward and anteriorly \0 the area of the leFt earlobe. All of the edema is confined to above the incision. The area below the incision has JlO edema and no adenopathy is present. Normal landmarks are also palpated in and around the larynx, Again, the oral caVity is only open to approximately 12 mm. The tongue is mobile and has full range of motion, The palate appears symmetric and raises in the midline. Facial nerve func1ion is intact There is a healed stab wound in the lateral malar region and also another healed area just inferior and posterior to the open reduction incision consistent with the postop drain.
IMPRESSION: Left facial celluHhs, status post stab wound and open reduction for mandibular fracture, Rule out abscess.
PLAN: Since the patient is iinprovli"lt) clif'llcatly on this presMt regimen of Zosyn. elindamycin
and Oilaudid, we wili continue him as is and add a K-pad. His p.O. intake has markedly improved. We will review CT scan. If the scan shows an abscess, we will need to transfer the patient's to Barnes, since I no longer head and neck abscess drainages or facial fractures (it is possible that someone else on staff at DePaul still does).
SLD:370 - 1923146
MEDICAL/SURGICAL CONSULTATION REPORT-DP
- Page 1 of 2
000492
CONSULTATION REPORT
PATIENT; MARCH; PHIL..;::cL.I-'-P_ _ _ _ _ _ _ _ _.-..;.;.M;..;..;R#;;.:..:-. ..;..;OOO~74;..:..6::..;2~;..:..e_ _ __

0: 6/02/20079:27 AM T: 5f2f2007 10:50 PM E: OB/03/2007 00:01 AM
cc: VISSA SRIRAM, M,D.

ANWER Z. RAHMAN, M.D. PHILLIP G. ZINSER, M.D,
MEDICAL/SURGICAL CONSULTATtON REPORTDP
- Page 2 of 2
000493
IlIlllmlll/11
IlIlllllllllllf 111111111111111111111111111111
111111111111111
~fIIl1lf1l1llllmlllllllllll 'llfIlll~
Age: M30 WI: 68.0 Kg

- - - - - - - - - - - - - - T R I A G E DATA-Complaint: Pain In Lft Jaw (4wks)
Tria98 Time: Thu May 31 2007 23:56 Source: Home Age: 30 Male
MedRec:000748298
AcctNum: 0715100477
iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii...............iiiiiiliiiii_ _ _ __
By; Car
Urgency: ESI-3
Kg Weight: 68.0 PhY5icians:

Room:
Vital Signs: (2355)
BP:152/104
WAITING
P:83
Pain:10
Sa1:S6/RA
R:18
T:98.7
HPI BLANK (Fri Jun 01 2007 06:49 RSMI) CHIEF COMPLAINT: pt to ed with co I face swelling warmth and de sp stab wound I face.
HISTORIAN: History obtaine{j trom patient. TIME COURSE: Onset of symptoms reported as $udden, Onset was 1 months ago, Patient currently
has symp'Qm:?, Complaint is constant.

SEVERITY: Maximum severity is moderate, Currently symptoms are moderate.
KNOWN ALLERGIES
HISTORY
MEDICAL HISTORY (Thu May 31 200723:56 MEK): which is not being treated, Stabbed in lett face
April 24th, 2007 ..

PSYCHIATRIC HISTORY (Thu May 31 200723:56 MEK): No previous psychiatric history. SURGICAL HISTORY (Thu May 31 200723:56 MEK); Jaw Repair, plate left jaw. SOCIAL HJSTORY (Thu May 31 200723:56 MEK): Denies alcohol abuse. Denies tobacco abuse, Denies drug abusI, Livas alone, Denies smoking, Lives at home alone. FAMilY HISTORY (Thu May 31 200723:56 MEK): Family history is not contributory to this case. NOTES (Thu May 31 200723:56 MEK): Stabbed In left face April 24th, 2007_ Underwent surgery the week
following .
MEDICAL HISTORY (Fri Jun 01 ZOQ7 Q6;51 RSMI}:
H'~1Qry 01 hyp~mt:n~iQn, Patient is nonc:omplfant with treatment, s1ab wound I face 4\24\07. PSYCHIATRIC HISTORY (Fri Jun 01 200706:51 RSMI): No previous psychiatric history. SURGICAL HISTORY (Fri Jun 01 200706:51 RSMI): facial repaIr. SOCIAL HISTORY (Frf Jun 01 200706:51 RSMI): Denies alcohol abuse. Oenies tobacco abuse, Denies drug
abuse. Lives alone. FAMILY HISTORY (Fri Jun 01 200706:61 RSMI): Family history is not contributory 10 this case. NOTES (Fri Jun 01 200706:51 RSMI): Nursing records reviewed, Agree with nursing records.
ROS (Fri Jun 01 2007 06:50 RSMI)

CONSTITUTIONAl: Negative constitutional review at systems. EYES: Negative eye review of systems. ENT: Negative ENT review of systems.
Pr~pared;
Fn Jun 01 200708:19 by Anne Al1draws,AN Page: 1 017

SSM DeP<lul Health Center
000494
1IIIIIIIIIIIItl III 1111111111111111111111111111111111111111
lilli/III/11m 1111111111 11m 11111 IIIJI 11111 11m 11111

Name: March, Phillip Age: M30 Wt 68.0 Kg MedRec:000748298 AcctNum: 0715100477

CARDIOVASCULAR: Negative cardiovascular review of systems. RESPIRATORY: Negative respiratory review 01 sys1ems. GI: Negative gastrointestinal review of systems. GENITOURINARY MALE: Negative genitourinary review of systems.
MUSCULOSKELETAL: Negative musculoSKeletal review of systems. SKIN: Nega1ive skin review of systems. NEUROLOGIC: Negative neurologic review of systems. ENDOCRINE: Negative endocrine review of systems. HEMO/LYMPHATIC: Negative hemo/lymphatic review of systems. ALLERGICIIMMUNOLOGIC: Negative Allergic review of systems, PSYCHIATRIC: Negaiive psychiatric review of systems, ALL SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above.
ADDITIONAL TRIAGE (Thu May 31 200723:56 MEK)

COMPLAINT
PROVIDERS: TRIAGE NURSE: Mary Beth Kelly, RN, ADMISSION PATIENT: NAME: Phillip March, DaB: Sat OGt 021976, RACE; Black, Code; NO, Trauma: "NO, Work Comp.: NO. Hypothermia: NO, SSN: 493788699, ZIP CODE: 63121, HEIGHT: 182cm, PHONE: 314521-0600, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0715100477, IBEX NUMBER: 20070531235602AOT, FALL RISK: TIME: 2350. Gender (Male), Get up and go test: Able to rise in a single movement, Score: 1. ASSESSMENT:The GCS to1al is 15, Lef1 jaw pain with burning sensation with eating. Surgery @ Barnes one month ago. FlU with surgeon for pain no diagnoses made. Pt reports was told nothing is wrong. Pain persists uncontrolled with Oxycodone, Left face swollen. , IMMUNIZATIONS; Immunizations up to dale, Last tetanus shot received less than 5 years ago. TB SCREENING: Denies TB screening. DOMESTIC VIOLENCE: No domestic violence, EDUCATIONAL/CULTURAL BARRIERS: No educational/cultural barriers. TREATMENTS IN PROGRESS; No treatment. VITAL SIGNS PHYSICAL EXAM (Fri Jun 01 2007 06:53 RSMI)
CONSTITUTIONAL: Vital signs reviewed, Alert and oriented X 3, Hypertensive, Patient appears
uncomfortable, Patient ap~ar$ to be In pain. HEAD: Normocephalic. I facial swelling with serosanguinous de unable to open mouth. EYES: Pupils equal and reac1lve to light. No discharge from eyes, Extraocular muscles intact, Sclera ara normal. Conjunctiva are normal. ENT: Ears normal to inspection, Nose examination normal, Oropharynx normal, Mouth normal to inspection. NECK: Normal ROM, No jugular venous distention, No meningeal slgns, Cervical spine non-tender, RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress.
CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. ABDOMEN: Abdomen is non-tender. No masses. Bowel sounds normal, No distension, No peritoneal signs. BACK: There is no eVA Tenderness, There is no tenderness 10 palpation, Normal inspection.
Prepared: Fri Jun 01 200708:19 by Anne Andr~ws.RN Page: 2 017 SSM DePaul Health Center
000495
11111 II III 11111 111111111111111111 tllllIlllllf 11111 "/1111111

Age: M30 Wt; 68.0 Kg MedRec:000748298 AcctNum: 0715100477
UPPER EXTREMITY: Inspection normal. No cyanosis/clubbing/edema. NQrmal range of motion. LOWER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, No calf tenderness. Normal range of
mo1ion. NEURO: GCS is 15, No focal motor deficits, No focal sensory deficits, No cerebellar deficits. SKIN: Skin is warm and dry, No rash or induration. LYMPHATIC: No adenopathy in neck, No adenopathy In axillae, No adenopathy in groin. PSYCHiATRIC: Oriented X 3, Normal affecf.
LAB INTERPRETATION (Frl Jun 01 200706:53 RSMJ)

INTERPRETATION: I reviewed 1he lab results.
02SAT INTERPRETATION (Fri Jun 01 200706:53 RSMI)

02SAT: 02 saturation reading 99%.02 AMT: R.A., 02 Sat normal, None needed, Continuous Pulse Ox.
RESULTS (Fri Jun 01 200706:33 RSMI)
LAB: eBC W AUTO DIFF Jun 01 200704:25.

WBC 7.2 1000/mm3 Ref Range (4.5-11.0), RBe 4.37 L 10X6 Ref Range (4.7-6.1). Hgb 11.9 L gm/dl Ref Range (13.0-18.0), Hct 35.8 L % Ref Range (39.054.0), MeV 81.9 fI Ref Range (BO.0-99.0), MCH 27.2 pg Ref Range (25.0-31.0), MCHC 33.2 gm/dl Ref Range (32.0-3B.0),
ROW 14.1 % Ref Range (11.5-14.5),

Platelets 341 1000/mm3 Ref Range (130.0-400.0), Gran 63.4 % Ret Range (40.0-70.0), Lymph 27.3 % Ref Range (22.0-40.0). Mono 8.6 % Ref Range (2.0-10.0), Eos 0.3 % Ref Ran~e (0.O-6.0), Baso 0.4 % Ref Range (0.03.0). Manual Diff Not Indicated,
Absolute Neutrophil 4.56 1000/mm3.

: COMPREHENSIVE METABOLIC PANEL Jun 01 200704:42. BUN 14 mg/dl Ret Range (9.0-20.0), Sodium 139 mEq/L Ref Range (137-145), Potassium 3.8 mEq/L Rei Range (3.6-5.0), Chloride 100 mEqlL Ref Range (98.0-107.0), Glucose 93 mg/dl Ref Range (75-110), Creatinine 1.0 mg/dl Ref Range (O.B1.5), AST/SGOT 18 u/L Ref Range (17.059.0),
Alk Phos 84 UlL Ref Range (38.0-126.0),

Calcium 10.0 mg/dl Ref Range {8.4-1 O.2}, Bilirubin 0.3 mg/dl Ret Range (0.2-1.3), Albumin 4.8 gm/dl Ref Range (3.5-5.0"
Prepared: Frl Jun 01200708:19 by Anne Andrl>w$.RN Page: 3 of 7 SSM DePaul Health Center
000496
IItll 11II1 11111 mil 11111 mil II III It 11111111111111111111111
11111 11111111111111111111111 1111111111111111111111111

Name; March, Phillip Age: M30 68.0 Kg

Prot Total 8.5 H gm/dl Ref Range (6.3~8,2). C02 28 mEqJL Ref Range (22.0-30.0), AL T/SGPT 23 U/L Ref Range (21.0-72.0), GFR 1 '2.8 mVmln/1.73m2.
MedRec:000748298
wt:
AcctNum: 0715100477
RADIOLOGY INTERPRETATION (Fri Jun 01 200706:54 RSMI) HEAD: Interpretation Of the faCial CT shows. eellulitis I face. INTERPRETER: Preliminary review Of CT by Radiologist. DOCTOR NOTES (Fri Jun 01 2007 06:54 RSMI) TEXT: pt stable abx started will admit for iv abx and pain meds.
PATIENT STATUS: Patient has improved since admission. D!W: Discussed this case with Dr. rahman. PATIENT PLAN: The patient wi!! be admitted to the hospital.
DIAGNOSIS (Fri Jun 01 2007 06:56 RSMI)

FINAL: PRIMARY; facial cellulitis, ADDITIONAL: .
DISPOSITION
PATIENT (Fri Jun 01 200706:56 RSMI): X-RAY/CT Follow-up: YES, Critical Care: 'None, Doctor Procedures: NO, Disposition: Admit Medical, Condition: Improved. (Fri Jun 01 200707:24 HHAW): Discharge Transport Stretcher. NOTES (Fri Jun 01 200706:56 RSMI): Patient admitted.
MEDICATION SERVICE
Calapres (Fri Jun 01 200704:06 RSMI): Order: Catapres : 0,1 mg : By Mouth POTENTIAL MODERATE INTERACTION Oxycodone Hydrochloride No1es: verba! order read back Ordered: Frl Jun 01 2007 04:06 Ordered by: Robert Smith, MD Entered by: Jennifer Gremmlnger, RI'J Fri Jun 01 2007 04;06
Acknowledged
I)y~
Jennifer Gmmminger, RN
~rj
Jun 01 2007 04:07
Documented as given by: Jenniier Gremminger, RN Fn Jun 01 200704:23 MEDICATION. Time given: 0415, Correct patient. time. route, dose and medication confirmed prior to aoministra\ion, Patient advised of actions and side-effects prior to administratton, Allergies Goniirmed and medications reviewed prior to administration. Patient in position of comfort, Side rails up, Cart in lowest position, Family at bedside. Catapres (Fri Jun 01 2007 04:50 RSMI): Order: Catapres : 0.1 mg : By Mouth Notes: verbal order read back Ordered: Fri Jun 01 200704:50 Ordered by: Robert Smith, MD Entered by: Janet Hackmann, MSN Fri Jun 01 2007 04:50 Documented as given by: Janet Hackmann, MSN Fri Jun 01 200704:53 MEDICATION.
Preparod: Frl Jun 01 200708: 19 by Anna Andrews,RN Page: 4 of 7 SSM DePaul Health Center
000497
11111 "11111111111111111111 III 1111111111 1IIIIIIIIlIIIII 11111
1111111111111111111111111 1IIIIlif lit 111111111111111

Name: March, Phillip Age: M30 W1: 68.0 Kg MedRec:Q00748298 AcctNum: 0715100477

Dilaudid (Fri Jun 01 200704:51 RSMI): Order: Dilaudid : 1MG : IV Push
POTENTIAL MODERATE INTERACTION Catapres Ordered: Fri Jun 01 200704:51 Ordered by: Robart Smith, MD Entered by: Janet Hackmann, M8N Fri Jun 01 200704:51 Documented as given by: Janet Hackmann, MSN Fri Jun 01 200704:52 MEDICATION, Dilaudid (Fri Jvn 01 2007 07:47 RSMI): Order: Dilavdid : 1MG : 1V Push Time: 0747 Ordered: Fri Jun 01 2007 07:47 Ordered by: Robert Smith. MD Entered by: Anne Andrews,RN Fri Jun 01 200707:47 Documented as given by: Anne Andrews,RN Fri Jun 01 2007 07:48 MEDICATION Time given: 0747, Given in amount and via roU1e as preSCribed, Catheter placement confirmed via flush prior to administration, IV site without signs or symp10ms of infiltration during medIcation adminislration, No swelling during administration, No drainage dUring admmistration, IV flushed after administration, Correct patient, time, roule, dos8 and medication confirmed prior to administration, Patient adVIsed 01 actions and sideeffects prior to administration. Allergies confirmed and me<llca1ions reviewed prior to administration, Phenargan (Fri Jun 01 2007 04:52 RSMI): Order: Phenergan ; 25MG : IV Push POTENTiAL MODERATE INTERACTION Caiapres POTENTIAL MODERATE INTERACTION Dilaudld POTENTIAL MODERATE INTERACTION Oxycodone Hydrochloride Ordered: Fri Jun 01 200704:52 Ordered by: Robert Smith, MD Entered by: Janet Hackmann, MSN Fri Jun 01 200704:52 Documented as given by: Janet Hackmann, MSN Frl Jun 01 2007 04:52 MEDICATION, ~9~yn (Fri Jun 01 200704:51 RSMI); Order: Zosyn : 30375 : IV Piggy BacK Ordered: Fri Jun 01 200704:51 Ordered by: Robert Smith, MD Entered by; Janet Hackmann, MSN !=ri Jun 01 2OC704:51 LJocumented as given by: Janet Hackmann, MSN Fri Jun 01 2007 04:52 MEDICATION.
I
PRESCRIPTION: No Documented Prescrip1ions NURSING ASSESSMENT: FOCUSED (Fri Jun 01 200704:03 JGRE) NOTES: Received report from Jeanette, RN, pt resting quletlv on stretcher CC of burning left law pain, Pt has significant swelling to left side of face and along jaw inCision line. CIO burning pain when eating and coughing. Pt sts was stabbed In lett side of face approx one month ago and had artery c8uterizaton and plate placement for broken jaw. Pt ats jaw line incision opened and was draining appro)( 2 weeks ago, sts incision was packed, pI unsure if packing was removed, .
TIME ASSESSED: Patient was assessed at 0350.
Prepared: Fri Jun 01 200708:19 by Anne Andrews,RN Page: S Qrl SSM DePaul Health Center
000498
lllll/III/1111t II IlIlIllI 1111111111111'11111111111 1111111111
111111111111111111111111111111 t11111111111111111fllllll
Name: March, Phillip Age: M30 Wt: 68.0 Kg MedRec: 000748298 AcctNum: 0715100477
PAIN SCALE: 6110 with swanowing 10110 with coughing, On a scale 010 patient rates pain as 10. VITAL SIGNS; BP: 155, /108, Pulse: 68, Resp: 20, Temp: 98.1 t Pain: 10,02 sat: 97, ra, Time: 0355. NEURO: Orientation: Alert, Behavior: Cooperative, No facial droop, No weakness present, No numbness present, Coherent. GCS: GeS Eye Opening: Spontaneously (4), GCS Verbal Response: Oriented/conversive (5), GeS Motor Response: Obeys comands(6), The GCS total is 15. MUSCULOSKELETAL: Good ROM. SKIN: SKin IS warm, Skin is dry, Skin color is normal. SAFETY: Side rails up, Cart in lowest position, Cal! light within reach.
NURSING PROCEOURE: IV (Fri Jun 01 200704:13 JBOR)

TIME: 20 gauge catheter inserted, into right AC. with' attempt, Saline lock established, After placement no swelling noted at site, no drainage noted at site, Sterile dressing applied.
NURSING PROCEDURE: LAB DRAW (Fri Jun 01 200704:13 JBOR)

TIME: Venipuncture performseVlabs sent, Blood obtained from right AC and labs sent, wilh 1 attempt.
NURSING PROCEDURE; NURSE NOTES (Fri Jun 01 200704:23 JGRE)

TIME: Time: 0405. Pt c/o pain 10/10 on verbal scale pt appears uncomfortable. Requested pain medication order from physiCian, phyaician declined 10 give med order. Awaiting eval by physician,
NURSING PROCEDURE: NURSE NOTES (Fri Jun 01 2007 04:40 JGRE) TIME; Time: 0435, Or. Smith at bedside to eval pI. NURSING PROCEDURE: TRANSPORT TO TESTS (Fr. Jun 01 2007 05:33 JGRE)
TIME: Procedure was performed at 0525, Patlen1 transported to CT scan, via cart, accompanied by Paramedic.
NURSING PROCEDURE: NURSE NOTES (Fri Jun 01 200705:38 JGRE)

TIME: Time: 0537, Pt retumed from CT.
NURSING PROCEDURE; NUASE NOTES (Fri Jun 01 2007 06:06 JGRE)

TIME: Time: 0605, Pt resling quietly on stretcher, sleeping. No apparent distress.
NURSING PROCEDURE: NURSE NOTES (Frt Jun 01 200707:22 AAND)

TIME: Time: 0721, Pt resting on stretcher with eyes closed, appears in no distress, vss.
NURSING PROCEDURE: ADMfSSION (Fri Jun 01 200708:19 AANO)

TIME: Bed assigned at 0742, Report called at 0807, Pt. admitted to room, 546, Patient Acuity level Was NON-Urgent, Patien1 adrnlt1ed to med-surg unit, Admission orders received and complete, Report caHed/faxed 10 5 south.
ADMIN
DIGITAL SIGNATURE (Fri Jun 01 200706:56 RSMI): Smi1h, MD. Robert.
Prepareu; FriJun 012007 00:19 by Anile Andrews,RN Page: 6 01 7 SSM DePaul Healltl Cenl1?r
000499
1111111 til 1111111111 III
~ fll~ 11111111111111) 111111111111111
1111111111111111111111111 UIIIIIIIII [1111 m t11l111111

Age: M30 Wt: 68.0 Kg MadRec:000748298 AcctNum: 0715100477
(Fri JUIl 01 200707:01 JGRE): Gremrninger, RN, Jennifer. (Frl Jun 01 2007 08:'9 AAND): Andrews,RN, Anne, PATIENT DATA CHANGE (Fri Jun 01 200703:39): AD8 63106670 by Interface, Payment 90, AdmHting Doctor: Pcp None, Allending Doctor: Physicians Emergency, (Fri Jun 01200703:41 JGRE): Primary Nurse changed from (none) 10 Jennifer Gremminger, RN. (Fri Jun 01 200704:02): A08 63107023 by Interlace, Payment: 95, Admilting Doctor: Pcp None. AMending Doctor: Physicians Emergency. (Fri Jun 01 200704:33 RSMI): Att&liding changed from (none) to Robert Smith. MD. (Fri Jun 01 200705:59): AOa 63109611 by Interface, Admitting Doctor: Pcp None, Attending Doctor: Robert B Smi1h. (Fri Jun 01 200707:24 HHAW): Admit Area: full, Payment: (none).
KEY:
AANO;Andrews,RN, Anne HHAW=Hawkins, RN, Heather JBOR=Borho, EMT-P, Jeffrey JGRE=Gremmlnger, RN, J MEK=Kelty, RN, Mary Beth RSMI=Smith, MD, Robert
Prepared: Fri Jun 01200708:19 by Anne Andrews,RN Page: 7 of 7 SSM DePaul Health Center
000500

HPI BLANK
Name: March, Phillip Age: M30 Wt: 68.0 Kg MedRec: 000748298 AcctNum: 0715100477
CHIEF COMPLAINT: pt to ad with co I face swelling warmth and de $P stab wO\lnd I face. HISTORIAN: History obtained from patient. TIME COIJRSE: Onset of symptoms reported as sudden, Onset was 1 months ago, Patient currently has symptoms, Complaint is constant. SEVERITY: Maximum severity is moderate, Currently symptoms are moderate.
HISTORY
MEDICAL HISTORY: which Is not being treated, Stabbed in left face April 24th, 2007 .. PSYCHIATRIC HISTORY: No previous psychiatric history. SURGICAL HISTORY: Jaw Repair, plate left Jaw .. SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives alone, Denies smoking, LivBs al home alone. FAMIL Y HISTORY: Family history is not con1ributory to this case. NOT~S; Slabbed in left face April 24th, 2007. Underwent surgery the week following .. MEDICAL HISTORY: History of hypertension, Patient is noncompliant with treatment. stab wound I
face 4\24\07.
PSYCHIATRIC HISTORY: No previous psychiatric history. SURGICAL HISTORY: facial repair. SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse. Denies drug abuse, Lives alone. FAMILY HISTORY: Family history is nol contributory 10 this case. NOTES: Nursing records reviewed, Agree with nursing records.
~OS
CONSTITUTIONAL: Negative constitutional review of systems. EYES: Negative eye review of systems. ENT: Negative ENT review of systems. CARDIOVASCULAR: Negative carciiovascular review of systems. RESPIRATORY: Negative respiratory review of systems. Gl: Negative gastrOintestinal review of systems. GENITOURINARY MALE: Negative genitourinary review of systems. MUSCULO$KELETAL: Negative musculoskeletal review of systems. SKIN: Negative skin review of systems. NEUROLOGIC: Negative neurologic review of systems ENDOCRINE: Negative endocrine review of systems. HEMO/L YMPHATIC: Negative hemo/lymphalic review of systems. ALLERGICIIMMUNOLOGIC: Negative Allergic review of systems. PSYCHIATRIC: Negative psychiatric review of systems. ALL SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above.
PHYSICAL EXAM
CONSTITUTIONAL: Vital signs reviewed, Alert and oriented X 3, Hypertensive. Patient appears uncomfortable, Patient appears to be In pain.
Prepared: Fri Jun 01 200708:19 by Anne Andrews,RN Page: 1 of 3 SSM DePaul Health Genter
000501
1II1111ll/ !III11I/lllllIllllIt 111111111\ 11111 Illllllltl 11111
' '"IIIIIIIII/11Il1111l11l1lt tlllllllllllill tlllllllil

HEAD: Normocephalic. I facial swelling with serosanguinous de unable to open mQuth. EYES: Pupils equal and reactive to tight, No discharge from E7YSS, Extraocular muscles intact, Sclera are normal, Conjunctiva are normal. ENT: Ears normal to inspection, Nose examination normal, Oropharynx normal, Mouth normal 10 inspection. NECK: Normal ROM, No jugular venous distention, No meningeal $igns, CSlVical spine non-tender. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respira10ry distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. ABDOMEN: Abdomen is non-lender. No masses, Bowel sounds normal, No distension, No periioneal signs. BACK: There is no CVA Tenderness, There is no tenderness to palpation, Norma! inspection. UPPER EXTRErv1lTY: Inspection normal, No cyanosis/clubbing/edema. Normal range of motion, LOWER EXTREMITY: Inspec1ion normal, No cyanosisiclubbing/edema. No calf lenejernes$, Normal range of motion, NEURO: GCS is 15, No focal motor detieils, No focal sensory deficits, No cerebellar deficits. SKIN: Skin is warm and dry, No rash or induration. LYMPHATIC: No adenopathy in neck, No adenopathy in axillae, No adenopathy in groin, PSYCHIATRIC: Oriented X 3, Normal affec!.
DOCTOR NOTES
TEXT: pt stable abx started will admit for iv abx and pain meds. PATIENT STATUS: Patient has improved since admission, DIW: Discussed this case with Dr. rahman, PATIENT PLAN: The patient will be admitted to the hospital.
DIAGNOSIS
FINAL: PRIMARY: fa<:lal cellulitis, ADDITIONAL: .
DISPOSfTlON
PATIENT: X-RAY/CT Follow-up: YES, Critical Care: None, Doctor Procedures: NO, Disposition: Admit Mli<;Hcal, Condition: Improved. : Discharge Transport: Stretcher. NOTES: Patient admitted.
MEDICATION SERVICE
Catapres: Order: Catapres : 0.1 mg : By Mouth POTENTIAL MODERATE INTERACTION Oxycodone Hydrochloride Notes: verbal order read back Ordered; Fri Jun 01 2007 04:06 Ordered by: Robert Smith, MD Entered by: Jennlter Gremminger, RN Fri Jun 01 200704:06 Acknowledged by: Jennifer Gremminger, RN Fri Jun 01 200704:07 Documented as given by: Jennifer Gremminger, RN Fri Jun 01 2007 04:23 MEDICATION, Time given: Q415, Correct patient, time, route, dose and medication confirmed prior to adminls1ration, Patient advised ot actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient in posItion of comforl, Side rails up, Cart in lowest
Prep<lred. Fri Jun Oi 200708:19 by Anne Andr9'#$,RN Page: 2 of 3 SSM O~Paul Health Center
000502
1111111 IIIlmt 111111111111 III 1lllllllll/llllllllf 11m 11111
IIlt1 11111 11111 Ill"
~111111" 1111111111 llltllllllllill

Name: March, Phillip Age: M30 Wt 68,0 Kg MedRec: 000748298 AcctNum: 0715100477

position, Family at bedside, Catapres: Order: Catapres : 0.1 mg : By Mouth Notes: verbal order read back Ordered: Fri Jun 01 200704:50 Ordered by: Robert Smith, MO Entered by: Janet Hackmann, MSN Frl Jun 01 200704:50 Documented as given by: Janet Hackmann, MSN Frj Jun 01 200704:53
MEDICATION. Dileudid; Order: Dilaudid : 1MG : IV Push POTENTIAL MODERATE INTERACTION Catapres Ordered: Fri Jun 01 200704:51 Ordered by: Robert Smith, MD Entered by: Janet Hackmann, MSN Fri Jun 01 200704:51 Documented as given by: Janet HaCkmann, MSN Fn Jun 01 200704:52 MEDICATION. Dilaudid: Order: Dilaudid : 1MG : IV Push Time: 0747 Ordered: Fn Jun 01 2007 07:47 Ordered by: Robert Smith, MD Entered by: Anne Andrews,RN FYi Jun 01 200707:47 Documented as given by: Anne Andrew8,RN Fri Jun 01 2007 07;48 MEDICATION, Time given: 0747, Given in amount and via route as prescribed, Catheter placement oonfirmad via flush prior to administration, IV sIte without signs or symptoms of infiltration during medicaHon administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and sids-effects prior to administration, Allergies confirmed and medications revieweQ prior to administration. Phenergan: Order: Phenergan : 25MG : IV Push POTENTIAL, MQQt;RATE INTERACTION Catapres POTENTIAL MODERATE INTERACTION Dilaudid POTENTIAL MODERATE INTERACTION Oxycodone Hydrochloride Ordered: Fri Jun 01 2007 04:52 Ordered by: Robert Smith, MD Entered by: Janet Hackmann, MSN Fri Jun 01 2007 04:52Documented as given by: Janet Hackmann, MSN Frl Jun 01 200704;52 MEDICATION. Zosyn: Order: Zosyn : 30375 : IV Piggy Back Ordered: Fri Jun 01 200704:51 OrderM by: Robert Smitll, MD EntereD by: Janet Hackmann, MSN Fri Jun 01 200704:51 Documented as given by: Janet Hackmann, MSN Fri JUI"i 01 200704:52 MEDICATION,
PRESCRIPTION; No Documented Prescriptions

Prepared: Frl Jun 01 200706:19 by Anne Andrews,AN Page; 3 of 3
SSM DElPaul Health Center
000503
mJllltIllfllf 1lllllfflllll~ IJIIf If IfIIfill JIm llfll

SSM DEPAUL RECORD
Name; March, Phillip Age: M30 66.0 Kg MedRec:000748298 AcctNum: 0715100477
wt:
Prepared: Fri JUIl 01 200708:19 by Anne Andrews,RN pag",~ 1 of 1 SSM DePaul Health Canlaf
000504
SSM DEPAUL EMERGENCY FLOW SHEET RECORD
Name: March, Phillip Age: 30Y MR: 000748298 Acct: 0715100477

VITAL SIGNS User MEK DateITime 05/31 23:56 BP 1521104 PULSE 83 RESP 18 TEMP 98.7 PAIN 10 02 SAT 980nRA TIME 2355

Name: March, Phillip Age: 30Y MR: 000748298 Acct: 0715100477 Prepared: Fri Jun 1 08:19:262007 by Anne Andrews,RN Page: 1
Emergency Department Orders

General Chief Complaint
AUerde:
Drugs must be dispensed in accordlitlCe \"iththe hosJ:lital fotmulery syst~m.
I.
Assessment;
Notify physician if SBP <: 90 or ~ 195, or heart rate < 60 or> 120, or for deere as mental status Pulse oximetry (notify physician for Sa02 <92%) and Temperature recorded Assess women of childbearing age for pregnancy status and perform urine beta 1 for any possibility of pregnancy
e regnancy for females.::;...~>...:1...:.4..;;;an:;.:.=-d_<..;;5,:.::.:::.::...:;...::~~
----
III.
IV.
Medicatton~:
Tylenol 1 gram po for Temp;> 100.3 or PRN pain
v.
Vl.
o
'S.'l jr~ ~
~.~.
----------~---------~p~~b=o_~~i~
ed lhrclUgh.
PJ~.l.J t,~.
l/rave reviewed and agree wlrlt the abcve orders with the exception of (hose en
Time Noted: O';:;:,? ~
Dat~;
1)l_ID~: ~~ !?2C~L:_-4-~~~~=-- ""f'

R.N.~~f'--'
000506
VRC
8/1/2007 8:25:54 AM
PAGE
1/003
Fax Server

Name: MARCH, PHILIP
Requesting Physician: Dr. Smith
ii.;:1: ... It._ VIRTUAL RADIOLOGICI
..
866-9415695
Dlte: 6/1 t2 007
OOB: 1012/1976
Number of Images
Age: 30 M
MRN: 748298
Accession
Procedure CT SOFT TISSUE NECK CT FACE WITH MANDIBLE:
97'1739
57
135
Provided Clinical History: left sided jaw pain y,;!h swelling
CT OFTHE FACIAL BONES

Provid_d CUnlcal History:
left sided jaw pain ~th swelling stabbed in Icftjaw April 27, 2007, jaw repairlm May,2007; pain and swelling in left jaw since surgery. Male,30 Years.
Comparisons:
None.
Technique:
Multiple thin cut axial images were obtained through the facial bones. Two dimensional reconstructions were conducted in the coronal plane.
Findings:
Status post metallic fixation of left mandibular fracture. Healing of comminuted fracture of left mandible is appreciated. Stranding within subcutilneous 50ft tissues of the left face compatible with inflammatory change. The paranasal sinuses arc free from air fluid levels. Minimal mucosal thickening within the left maxillary and sphenoid sinus. The globes are of smooth contour and symmetric bilaterally. The orbital soft tissues are unrcm.:ukable.
No foreign bodies are Identified.

The mandibular condyles <He ~thin the mandibular fossa tilaterally.
If a dgnitClnl di)c~""ncyl$ found OOtwellfl Ihg pmllmlnary and linal interpretati<Jnsofthis
study, pI&lIU fill< ~cl< Ihl:; follTl IMth a ccpy o11t\p ofllcl,J1 f9port or CClnwct VRC office 'l(J !!lsi
QUAJ.ITY ASSURANCe:
In1llrpl'lltailon:
f/q:e9
IIppropnllw
~ctiQf1
may
t)! t~\ln.
Dbilgrw
VRC dllytJme IIdmlnhjtrll~v~ cont,,! numbef';>

Fax 952.935-2551
TeleJ*lon~:
9523921 100
CONfIDENTIALITY STATCMfNT
This tlTJ(1sm/s,s(m Is conl1d8nlial umi IS intended to be a privilegttd commlJnication. II i$ imflmifKf oo/y let' (ilfl USfi of the a(j(/ro$$8fi. Atc&ts kl this m~ssage by anyon&IIJfllls CIf1l1!111Joriz9d. If you Bra not the Intended recl,:ient fIf1Y diwrur&. (;opyirrg, ci;stlfl;tUtiOl1 or &1y acl10n tairM, or omitted ta Of! taktliJ in r8liMce on I/ls prohibitftd anti mPY be U11luwftJ. If you receiv~ IJ!is ccmmunlClition in efTQf. pease n otily us oy telephone, so th&t mum of lhis riocumflnl 10 us Cl! bit WTqBd.
Pllg~
1 ofJ
000507
VRC
6/1/2007 6:25:54 AM
PAGE
21003
Fax Server
, r

Name: MARCH, PHILIP
Requesting Physician: Dr Smith
:i::;:~: VIRTUAL RADIOLOGIC" ...

-." t
866-941-5695
Date: 6/1 n. 00 7
oOB: 1012/1976
Number of Images
Age: 30 M MRN: 748298

Aecession
Procedure
CT SOFT TISSUE NECK

CT FACE WrTH MANDIBLE
97'1739
67
135
Provided Clinical Histot)': left sided ja w p..'lin with swelling
Minimally visualized intracranial
contents are unremari<able.
Impression:
1. Negative for acute fracture. 2. Stranding within the subcutaneous soft tissues of left face compatible with inflammatory change.
3. Remainder offtndings as described above.
CT OF THE NECK WrTH CONTRAST
Provided Clinical History:

left sided jaw pain v.1th swelling stabbed in left jaw April 27, 2007, ji1W repair 1m May.2007; pain and swelling in left jaw since surgery. Male,30 Years .
Comparisons:
None
Technique:
Postcontrast images were obtained from the level of the orbits through the lung apices.
Findings:
Postsurgical change involving left neck and angle of mandible. Prominence of left muscles of
If ~ signiteahl dlscr&lllllcyiJ foullcl belWMn tnt' preliminary and lIna! inlerp~tstiOlls of 61ls
"tlldy. f;lf;!~!\e lax back Ihis10lTTl v.ith ~ CQpy of tho oflici,.,1 reportorconl6el VRC oflicello that approprl~tl! ~ctiOl'l mlly be taken. VRC c1~yfime aaninlstraHve contact number=; FJX 952-93~2551 Tclcj:tlOl'le' !H,2-392-11UO
QUAUTY ASSURANCE Inwrpf&tatlon:

Yell
No
'CONFIDENTIALITY STATI:MfNT
TflIs tr&'1 smlsslOllls ccn"cientiBi iIfId i~ intflflded 10 bfi a ptilli/9(jw communlca~an. It is in/fnd'ld IXIly fQF fh9 (.IS(l of the lftfr'eliSOO, ACC9.U to tft!.: meSl1f;gt1 by anYOO9 elsli IS unau/hoti400 If you Elf8 not the inlfmded red/ient MY esQWUIV. c;opyrng. disurovtiOll (Y I1Y 8G/iM ta"-en. oromitli 10 0.. taken ill rlillil'lflce on ills prohlbll8d ana may be IJI1lewM. If you roceive13
000508
VRC
6/1/2007 8:25:54 AM
PAGE
3/003
Fax server

Nam.: MARCH. PHIUP
Requesting Physlt:hm: Dr, Smifrl
... i~!~~: ... VIRTUAl RADIOLOGIC

Date: 6/112Q07
DOB: 1012/1976
Number of Images
866-941-5695
Age: 30 M
MRN: 748298
Accession
Procedure
CT SOFT TISSUE NECK CT FACE WrTH MANDrEll.E
971739
67
135
Provided Clinical History: left sided jaW pain '1Ji!h swelling
mastication with peripheral stranding compatible with inflammatory change, No abscess,

Sm~1I bilateral cervical lymph nodes. Largest nodes are noted within the left level 1 region. Mucosal surfaces are smooth and relatively symmetric, Visualized portion of the orbits is unremarkable. Minimal mucosal thickening as described above in facial bone report. Thyroid gland shows normal enhancement character and is within normal limits of size. Visualized intracranial contents are unremarkable. Healing 160ft mandible fracture \\lith internal fixation. Visualiz.ed lung Apices arc clear, Vas~ular structllres are unrematkable.
Impression: 1, Softnssue swelling and stranding involving left muscles of mastication and ~urroundin9 soft ti ssues, No abscess, 2. Remainder of findings discussed above.
Thank you for allowing us to partidpate in the care of your patient.
Dictated and Authentic(lted by: Gapinski, Connie, M.D, 5/1/2007 ();24 AM Centr(ll Time
lfa $Ignlfie'"tdltc~PI'/ley i!l fllund belwllsn !he preliminary and finalinlcrptemti01'l~of1h15 stvdy. pIt'H r!lX bPd< thl" form v.ith a copy of the oftieilll repqrt orOOl1limf VRC office so that IIppro~/)te lIetion mBY be taken.
VRC daytime adminlslr'tiv~ contllctrwmbers: FlU 952-935-2551 Telephone: 951-:.\92-1100
QUAl-lrY A$$IJRANCE
lmerprvtatlon:
Yu No
CONfiDeNTIALITY STATEMENT
m.,nagv by anycnelilislil is unsuthOlized, If )'DU a~ ntX II1/iI intendeJy dI~o.sulll,
1/ i~ IntMd/Jd only fOf fie U$1iI ortne ElddJ8!f.~ee AocliISS to this ~pyin", cislrlbulion "r &'1y action taken, or om/ttlld to be mken in (fJ/iance on illS prohibited and may be unlfJNfuI. lfyourecElived this r;ommull/csf/on in eilW. JitHI36 notify us by f8iefYJona. so thaI retum of thIs doclKl7/ffl1 /0 US em 06 ElTfIIlged.
II pml1!1geO communication.
ThIs tfllfJsmi3lir:n i~ cr:nfjd~!ti81 fIIld i~ intMded to be
Page 3 of 3
000509
11111
--------------TRIAGE
Complaint: Pain In Lft Jaw (4wks) Triage Time: Thu May 31 2007 23:56 Source: Home By: Car Urgency: ESI-3 Room: WAITING
Vital Signs: (2355)
BP~1521104
m~ Imlllm ~m ~I~ ~m 1111111111 Iml lit

Name: March, PhllUp
DATA------------Male
Age: 30
Kg Weight: 68.0
PhysIcians!
P:83
Paln:10
R:18
T:00.7
Sat:9SIRA
KNOWN ALLERGIES No known drug allergies. HISTORY (Thu May 31 2007 23;56 MEK)
MEDICAL HISTORY: whli;nl, not bel"g treated, Stabbed In left face April 24th, 2007..
PSYCHIATRIC HISTORY; No previous psychiatric history. SURGICAL HISTORY; Jaw Repair, plate left law.. SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives alone, Denies smoking. Lives at home alone. FAMILY HISTORY: Family history is not contributory to this case. NOTES: Stabbed In left face April 24th, 2007. UndelWent surgery the week following
ADDITIONAL TRIAGE (Thu May 31 2007 23:56 MEK)

COMPLAINT PROVIDERS: TRIAGE NURSE: Mary Beth Kelly, RN. ADMISSION PATIENT: NAME: PhiHip March, DaB: Sat Oct 021976, RACE: Black, Code: NO. Trauma; *NO, Work Comp.: NO, Hypothermia: NO. SSN: 493788699, ZIP CODE: 63121, HEIGHT: 182cm, PHONE: 3'4521-0800, MEDICAL RECORD NUMBER: 000746298, ACCOUNT NUMBER: 07151004n J 16EX NUM6ER; 20070531235602ADT. fALL RISK; TIME: 2~50, Gender (Ma!~)! ~et YP ~mt go test: Able to rise in a single movement, Score: 1. ASSESSMENT:The GCS total is 15, Left jaw pain wflh burning sensation with eatlng. Surgery @ Barnes one month ago. FlU with surgeon for pain - no diagnoses made. Pt reports was told nothing is wrong. Pain persists uncontrolled with Oxycodone. Left face swollen . IMMUNIZATIONS: Immuni~ations up to date, Last tetanus shot received less (han 5 year~ ago. TB SCREENING: Denies T8 screening. DOMESTIC VIOLENCE: No domestic violence. EDUCATIONAUCULTURAL BARRIERS: No educatlonaVcultural barriers. TREATMENTS IN PROGRESS: No treatment. VITAL SIGNS

KEY:
Pr~pafed: Thu
May 31 200723:57 by Mary Beth Kelly. AN Page:' of 2

000510

MEK=Kelly. RN, Mary Beth
Name! March, PhUlip

Age: MaO Wt: 68.0 Kg MedAec:000748298 AcctNum: 0715100477
Prepared: Thu May 31 200723:57 by Mary Beth Kelly. RN Paga: 2 of 2 SSM DePaul Health Center
000511
CAl5EAlVIAINA(3EI\~~IT
SCREEI\lING/DISCHARGE PLANNING
Social Workor:
o Readmisaion within 30 days o Admission within 1-3 months o Progressive disease with impailment
o Contagious Qisoas~
o Multiple trauma o High riskOB
6 Abuse victim
~
Drug overdose
A Substance abuse o History of substance abuse
o ComatO$(l condition
o Dialysis patient al _ _ _ _ _ _ _ __
OMental atatull changes
o Dehydration/Malnutrition o On 7 or more medications o IV antibiotic or alimentation Tx o Decubitus ulcer o Ostomy patient \" A " ') o Pneumovac: Date: "--P' ___ f....-C-/ _____ o Ru Vaccine; Date; _ _ _ _ _ _ __
.6 DB under age 18
ra ' nd . / o r e - !:l. Family member dependent on youf Blone Needs arrangement for care with spouse family o Over the age 01 65 In:
o Occupation:
o Limitations imposed by Illness:
NeedS assistance In pflrformlng ADLs:
o 1 story homa
C Apartment
0 2 story horne
Suspected abuse andlor neglect
A Needs financial assistance
NVll1ber of stairs to enter
II Homeless
o Admission from/lo nursing home:

Name: _ _ _ __
o Clinic patient
Where: _
i\ Family counseling needed
'" Inadequate suppen!
o Veteran - - - - - - - - -........ --=
d.
---
o MobUity
0 Feeding
Hygiene
0 Dressmg 0 Toileting 0 Transportation
6. PreviolJs Social SelVice Intervention
II fInancial aSsistance needed for medications
IV Therapy
0 Home DME
0 Tranllponatioll Plan _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
o HospltBl Psychiatric 0 o Rehab 0 SNF
Hospital- VAlFaderal
0 NUlsing Home- Private Pay/Custodia!
Ornher _____________________-
______________
PATIENT LABEL
R tip 071b1004n M~D 0546-01 10/02/1976 30Y RAHMP,N, ANWER Z vi 06/01/07
IJfJJt~It~~rRtIllHlI't
D~PAU4 HEALTH CENTE
000748?98
000512
bJ Home
(;;l Home HBillth
0 Homs IV Therapy 0 Hospital - Acute
0 Hom!! DME 0 Rehab
0 Transportatin Plan ____________________ 0 Hospital - VNFederal 0 Nursing Home- Private Pay/Custodial 0 SNF
Type 01 facility:
0 Hospice
0 Hospital - Psychiatric
[J LTAC (Long Term Arule Cars Hospital)
o Rssidantial/Assisted I1vlngJlnlerm~iala Car\!! Facility
0 Other ~_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
o Facility holding bed o Other
Patient/Family confirms returning to same tacllity
PATIENT LAl3n
~SSM
SlM-8570 001 (12/2004) BACK
000513
ADVANCE DIRECTIVES
0 See ~mlity specific form (ttl., Essence, Intent) Is Information still valld1 El Yes El No
Petittnt hal; the following Advance Directivl;l:
o Copy in chart
0 Durable Power
of Attorney for Healthcwe
0 See Progr~ss Noles
Health
,'i
Care If),
Directive
Rvqu~s\ed to bring in copy? 0 Y8SmFf!om!w~h:Olmmiiimliiiiiiiiiiiiiiiii

____ BOLD SYMBOLS (*
+ ,,. .) INDICATE REFERRAL NEEDED ON BACK

M; 0 Heart attack Vascular disease D Pacemaker'O~ibralatot Congestive Heart Heart rnurml.lrNalvular disease ~ 0 Chest pain, Angina
o Blood pre~ure problem o Blood transfusion Dale; _ _ _ __ o Bre..~thing problem

hx: 0 Asthma Bronchitis o COPO/Emphysema
o Blood clot
o Arth rHis -0 Back/Hlp/Knee o Bleeding problsm
o A/zhEilmer's/Demenlia
o Diabe1es *
controlled by: Insulin
o Oral Hypoglyc~mic
o Subcutaneous pump
o
Diet
o Chronic pain prior to admiSSIon ( _

Site' _ _ _ _ _ _ _ __
110)
o o
Faitufe
o Chronic Pain Managemsnt

o PregnantJLactaling +
o Elevatsd cholesterol o Emotional problems o Anxiety
Frequency:
_~
_____
o Prostate problem!; o Reproductive problems

o Sensory problem
o Hearing
Last menstrual period:
It pregnant. due date: _ _ __
l.a~
episode: _ _ _~
o Sleep APMalCPAP
OTS.
Ml; 0 Wheezing
o Heart disease
Dale;
o Glaucoma
o SUicidal thoughtslptan
o Depression
o Palpitations
OEdema Where: _ _ _ _ _ __
0 N/A
o Skin problems
0 Vision
o Shortness of breath
o Cough{Sputum produclion
o Heart surgsry
o Hepatilis o InfectiousJCommunic.able DIsease.

o VRE 0 MRSA 0 C, \lifI When: _ _ _ _ __
Location: _ _ _ _ _ __
Frequency: _
o Cancer o ChemOiRadiation o Chipped or ioose teeth
Shortness of breath occurs at: rest _ _ with normal activity _ _ # of flights of stairn climbed _ _II 01 blocks walked Home oxygen
o Nonheafing wOUnd o Olher _ _ _ _ _ _ __

o
o Rash o Skin risk score 1(j or lass. o Pressure ulcer Slage 3 or 4 o Unstageable wound
o tV Device (i.e., port, PiCe, etc.) o Kidney disease

o Neurological problems
o Stone
o Dialysis
Contact physician for ET;Wound Nurse Referral Orders. o SeJ(ually transmitted disease Stomach/Bowel problems +
o Seizufss
o GERD/Acid Rellux
o
Ostomy.
Frequency: _ _ _ _ _ _ __ Last episode: _ _- _ _ __ Stroke/TlA FrequencY' _ _ _~_ __
o Urinary problems
Date las! 8M: _ _ __ o Thyroid problems
! Recent e}\p<l$ure to: 0

Other:
Chlck~ pox 0 Hepatitis
Last episode: _ _ _,,_,-+(_0_ _ _ _ _ __
If you check any OhM above, please describe.
o None o Family prOblams wllh aneslhesia

DR~AUL HEALTH CENTER
0 r-to prIor
~SSM
H : A
JfPJ!~!~~~Jlflllflllll
~~02/1976
0715100477
30Y I".AN,ANNER Z
t.
T Ii . CAR E~
MBD 0546-01 I!p M 06/01/0'1

000748298
ADMISSION DATA BASE

SLM-10(l0.059 (3/2007) FRONT
000514
ADMISSfON DATA BASE
----~---
~~!!ef!~R~~~~~!!~!!!!~~[~ADMrr *
o
--'---------._----1 0 o
CONSULTS/REFERRALS
Diabetes NurD
b! B!a~d $\Igftr ~Mu eq 9r mr aDO !lIII41

No monllnrll1g of blood $ugar
----+-----t 0 Insulin pom.p
o Newly DI Olibell~ o PalieDt re~uefl
- - - - - t - - - - i 0 No leterrallnOttllld ., Cnd1ac RehAb If
Q Hntllfy utt;JoiF
Patllnlll1qll$$f Kg reI'''11 Inllltallld Clinical Nutrition
o Stagt 3 ~f 4 prf$Wre ulwl o Nonhll!In~ W\II!OO o Ullitt'"'/! WOUld ;;;;;;.;;;;;;;.;;;;;;;.;;;;;;;.;;;;;::;:::;:::========:::...1 0 Slin Risk SClI!, 011 e~Iltin
~~~~~~J Q
RUllal failure
o Ap~ttr'III:' of mJIIJlJ!filioo o Unplrnntd wr t, 10 Ibi or II'~~ " . ,

o Change in ippellle mor1f thin 6 dayl
o I'PN(TPN,m'
o N;VIII 3 fays or mUT" o Difficulty Cl!tWln;thlllllowlllO
o Palientl'llQuut o Newly DI D18.11B11e o N!)t fOllOWing Diabetic [lie! o Majilr Sfll'\1Cry jover 75 ,nti WI) o Hillilry of barlatt!c wrgery o No refemllndfcated
Who do you live Do you pfWl to return (0
o Prevnrnt (not lftlivetlnol ur um!i1lV
Y'~~;;;ho~m~8~fr~om;:;~t~';;il;;?~tv.;-rD=ifN~o;-;_;-lrlr-;;n;;;o:-.e;'x;':;plam.
0
Yes NilmeslAgencies . . _ _ __
Intvctlon CgntrRl
_ _ _ _ _ _ _ __
Transportalion available? ~Ve5 D~ Does anyone help you at home !low? No
o J>o6i1in T8 streeninlllSlln fnl o IIlslory nf MRSArVR~'C. dlff
Difficulty wI ilC1ivltJes ot lli:nty I'v,ng? Difficulty Al'lbulaltng ! Transferring?
'
No 0 Yes 0 0 Y~s
* Expla'll _ _ __ * bp1a,n' __
0
o Recent e:qJosun o Nt. r61wal iadisiled

o Patiell! Rvquesl
o I\' Oni~ (Port. PICe, lIe.)
If yes due to pam, explain: .J~:;;~;;--;;~~~~
PT/OiriS;;;;';R;;;;;:;:;;;(;;;;;;;-;;Yes
f.IWIllw
00 yoo have any special concerns about being in lhe hOspital? .
My $p\lCial religiou,:'i?lfural taclors related to care? ~NO 0 Yes _ _ _ _ _ _ _ __

Sleeping problljm~\N-None
H.ave you hao any mejor changes U;:'b,:F.ove, divorCt;). ueath. etc.) in your Ilfa rece.n1i Y ? ~NO Do you have any spiritual concernS\)'4NO 0 Yes + ___________
o No reltrrallMlcaled
o MedlnallQn educallon o Cb~"g& In lI\eds

+ PilMA! e.W +
Difficulty falling asleep
Oiftlculty Slaying asleep
Other
How do you get along with your f.~mily'7 _ _ _ _ __
o Pecr PrognOilS o kllolls I'roCfdura}Scfljlll)' o Mvanc~ Dimllvt Anllllnttl o PatiSf)j Reqlllm o Spllllual CDnefms
o
No rp(flrll'ndICftld
.. TQbnppo CepstIpn ....
o Anticlpalt\l CoptH\llllffl\lulIy
, Have you ever had sex?
What kind of birth control/ploteclion do you or your partner lise? _ _ _ _ _ _ __ Have you ever had sex when you reaUy did no! wanl to? 0 No 0 Yes. _ _ _ _ _ _ _ _ __
0 rlliul Rtqllut 110 ,elenal indi~~d .. &wIlli 5mJct .. Have YOti tWar fel! so sad thai you thought aboul killing you/sell? 0 No 0 Yes _ _ _ _ __ I'aIlnl R&qu$S1 Physx;ian Notified o E!d~rly!fraR living . - - - - - - - - - . - - 1 0 Itmne!~nllll$jIlJU:~ COMPLETED BY (If other Ihan __ R_N.;....}_ _ _ _ _ __ o Nllrnnu HOOle P!aemem Other o bJptcltd 1It!J!c$ilieolect o POi~jblij ItWle Anlsltllca
"19
0 Yeg, Mw old W{tfIJ YOY wh~n you first had !lX~ _ _ _ _ _ _ _ _ _ __
o US1d in lasli2 monlhs

-
--------
.'MB
~SSM e
H
DEPAUL HEALTH CENTER.

MARCH, PIULLTP
11ll111l1lllll1l1811
MED 05,\16-01 Ill? M 06/01/07
A L T H ' CAR E-
0"/15100477
ACMISSION DATA BASE

&1.1-1000-059 (312007) BA.CK
10/02/1976 JOY RAHMAN. Am....ER Z
000"149298
000515
patient CI SecuritylMmitllng .J With family
(Signature 1<
of/am/ly)
(SigfJ(lturo X
of family)
------------il~w-w~ith patient
---,--+----------MED1G~naNS ! .Il.J'N'ONE ;J 1-------"-'".
:J With patient ..... Security/Admitting ':J With lamfly

C,j Sec\!ritylMrnitling ,:J With family
{Slgnll,Jfe!
L11 family}
bSj'r,;':::luy'"e X X
full1.1Bm1&
~ojl'lm!y
~-----j~---------------
------------~~~~~/---I~ilf.i"ar/Jf" of fam1iY.J
Wlih palil1ni 1.1 Phgrrr1!lVY W Socurity

~
:oJ With family \J Othar
ASSISTNE DEWeES
UNONE
A!hQ""~ y~
at"JI"lj)hJf{l!Q-!t~j,
ASSISTfIIE DEVfCES
IJ Walker
Alr.omo
Wl\t\~
..i
U
IJ
:J
0
.J
:J
D
U
X
J(
QCane ;:] CrutcheS

CI Contact Lenses
fj
J ;J
:J
0
I.J
)I )(
)I
U Own wheelcnair
0
Q
.J prosthetlcs
:J Braceg
Q Dentunt3
LJ
/I.
U
..i
X
if.
Right CI Left
:J
0
U
;:]
)(
U
'J
'..iGlasses
..i uppers Ll Lowers
o Hearing aiel(s)
U Right ..i Left
IJ
-J Bridgework
I.)
IJ
)I
o Other
u:Galilight toileting \f8ide rails
~Iephone
II
l11CpIIJlne<f.
UHIT ORIENTATION 7PaF>1oral services ~Cal! ~ght . nurse ::J.CsU light - pain In.structlon y: or
Television control
r -
')tAsking for help \0 get up
se of bed controls
,,'Emergency light BR/show,.r
------~----------~
ARRNAL. INFORMATION COMPlETED BY
(If olhllf 'han
nUfll9)
~S~IG~N~A_T~U~R~E_~_ _ _ ___
HAY~
DATE
YOU EVER BEEN EMOTIONALLY, PHYSICALLY. OR SEXUALLY ABUSED?
I.J
o NO EVIDENCE OF PHYSICAL. SEXUAL, OR PSYCHOLOGICAL ABUSE NOTED,

o EVIDENCE OF POTENTIAL ABUSE NOTED 6VT NOT SV$PECTED.
SPECI~'~DENCE
d Hotline caliE'.d
_______________
specify: _ _ _ __
RATIONALE ______
PATIENT/SIGNIFICANT OTHER INVOLVED IN THE CARE PiAN DEVELOPMENT, Cl YES
Q NO explain;
Form Completion Information: LPN: 0 Form completed
Signature:
(ff completed by LPN, RN review and plan of
Date: ________.
Time:
RN:
care development required}

Date:
Signature:
~,
Form completed
:J Adm,.data reviewed ':i Plan of care/Care pathway developed
.~ 4\tv ) . ~! &. \V~/C

-i
ILl
L -0 l'-::::.
/' JJJ DEPAO~ ~ Tjm~: I 05 .~~~==~---\
~SSM
ADMISSION ARRIVAl SHEET SLM-iOOO058 (312008) FRONT
H E A L T H ' CAR EW
1 0/02/1976 T1ED 05.16 I/F' Rl\..[l .1 0)' >, - 01 1'1AN, JWwg}(? ,iT 06/0 1 . 000 107 , 74829B
071~~10'oPHTLr.IP' ... - ,177
w!!f1J1IN"lq'IICEI~ilm ill
HR
000516

SYSTEM REVIEW
Neurolol1lcal CardloY1IlIcufari
o Nn probli?m identified
:::l Exception as below

U Exceptiun as below U Exception as Delow
GU
MU6(:uloskelolal
::J No problem identi1ied

:l No problem identified
:l Excspfion liS below :l Excepfion as below
Hematofoglcal
o No problem idenliiled
R$productlve
o No problem identifieD o Exception as below

W No problem id\lntified
Respirat<>ryl
Infectious Disease
o No problem identified
U
NQ problem identified
Woundj$klnf Mucous Membrane
CJ Exception as helow
GI/Nlltrltlon
EENT
Sensory ptoTcepllon
C<:ropl9!ely flf11ited
d EJlception as below
o No problem Identified
MIII,II".
ConstanUy moi.! Very mClsl 2 {Xcaslonally moist
Plycho/Soclal!
Spiritual
Exception as below
No prOblem iclentified
:J E;xceplion as below
Actlvlty
Mobility
Cornpl"!,,ly
irnmobile
Nutrition
Badlas!
ChJiri.-=teJ WalkS oGcasionaliy
Vary lifniled
S!,ghUy limae<!
NoimpMmenl
Rarely mo.sl
Walks frequently
Ver'llim.{e(/ SiigNiy filf1f!"'"!

No IImIHHon5
Very P\lOf Probably adequate

AdcqlJat~
Fricrtion & Shear Skin RIsk Score: Ie or It" patient 1& 81 rlst ..i Follow Skjn Cve PralODQllor s('o{(' 01 Problam
PnI?J1tia.
18 QI" Jru,. (Pos! pwtoc{li iit i.w.I'ikie)
:'
flfob/e",
No apparent
OIobJ~m
E<<:-ellent
Nutrilional consult (Ii not previolJMy nblMrlM.) Svore _ _~_ Tlmlt

'..J
DAIE'TlME
~=- - -"---f-----------I
}---
-,---------
Signature: _______
Date:
Time: ____
PATIENT LABCL
~SSM
~
E A L T H . CAR E-

SLM100005S (3!2(}(JfI) BACK
000517
TOBACCO USE INTERVENTION PROTOCOL ORDERS

I, Assessment: (RNfLPN to till in appropriate spaces) Q Has not use tobacco prodvc1s. CJ Cigareltes per day _ _ _ _ _ _ __ CJ SpiUsmokefess tobacco (can/pouch per day) Pips/cigar (number par day) _ _ _ _ _ _ _ __ Not currently using, date patient reported s~ped tobacco usa;
Pt-- Joe (yt:
()wVJ'\(~ ,
Assessment completed by:

(I.
&~~
(f;o i"l~!JRN
Date:
i;,t~ im.:~
Behavioral fnterventlon: RN/LPN recommends ending tobacco use or continuing with abstinence. Provide smoking cessation patient education materials.
Excfu6fon Crit&ria for nicotine replacement therapy: (serect aU that apply) Patient has known allergy to nicotine patch.
o
)
Patient is already on nicotin~ (&pla~m&nt product.

Patient refused nicotine replacement therapy.
Educational Consult
Enter Respiratory Therapy COllsult in HaOC for smoking education
fit MedIcation Intervention:

(PRESCRIBING A NICOTINE PATCH FOR PA TlENTS UNDER THE AGE OF 18 YEARS CONSTITUTES AN OFF LABEL USE o,c THE DRUG. PRESCRIBING THIS MEDICATION WfU 8E LEFT TO THE DISCRETION OF THE ATTENDING PHYSICIAN. IF USED, THE STRENGTH OF THE NICOTINE PATCH SHOULD NOT EXCEED 21MG UN~SS eXCEPTIONAL CIRCUMSTANCES DETERMINE OTHERWISE)
.'
less than 20 cigarettes per day or less than ona can/pouch per week (pipe/spit/smokeless
tobacco) nicotine patch (Nicoderm CO) 7 mg applied to skin every morning. remove old
a o a
patch . 20-30 cigarettes per day or 1 can/pouch per week (pipe/spiUsmokejess tobacco) nicotine patch (Nlcoderm CQ ) 14 ",'g. applied to skin every morning. remove old patch. 31-40 cigarettes per day; or 2 cans/pouches per week (pipe/spit/smokeless tobacco) nJcotine patch (Nicoderm CO ) 21 mg applied to skin every morning, remove old patch. Consult pharmacy for other nicotine replacement options
If IlfcotJne contraIndicated:
o o
bupropion extended release 150 mg PO daily times 7 days, then 300 mg PO daily. Other _ _ _ _ _ _ _ _ _ _ _~_ _ _ _ _ _ _ _ _ _ __
Critsls Intervention:
Acute agitation due to nicotine withdrawal
Cl o
Othef ________________________________
alpral:opam (Xanax)
.. mg PO every 6 hours as needed tor agItation.
DATE; _ _ _ _ TIME; _ _~ PHYSICIAN:
t fig"" -with the above orders with the oxc:ept/on of those Cl ossed II ifOug" or NOT CHECKEa._~_ _ _ _ _ _ _ _ _ _ __
TRANSCRIBED BY: _ _ _ _ _ _TtME NOTED: _ _ _ RN; _ _ _ _ _ _ __ Scanned to pharmacy
Date: _ ......_,.... Time: _ _ __

Lip {"lED 0546-0] ~O/02/1976 30Y M 06/01/07
~Af.
DePaulHealth Cenu!r
f>1ARCH I PH'" ..I.LLIP

0715100477
1111111111111111 . ill
RAHMAN,Ah~lER Z
000748298
000518
INTERDISCIPLINARY CARE PATHWAYS@ GENERIC

,MEDICAL HISTORY
BIl COLL.EPTE00 10-Ilf ~tftSJi'l tJ fAe boifNI - . fY

TO.
SPECIMENS
INITIAL [)ISCHARGE PLAN
101--'
o Home with significant other o SNF/ACF 0 Rehab
o other
o
Home Heal1l1
~------------------~C-O-N~S-U-LT-S------------------~
DATE PHYSICIANS NAME DEPARTMENTS I NURSING
DATE NAME
Admitted with pressure ulcer? 0 Yes \

SPECIALTY EOUIPMENT
No
Date:
Type:
Isolation:
Pn8lJmOVaX year:
Di.'\GNOS1S!PROCEDVRE
Flu vaccine year:
WT
CODe STATUS
~! resusdta1ion
o DNR comfort measures

Advance directives?
0 Yes 0 No
Copy in chart?
Yes 0 No
Is there anyone who $hould not receive general condition information? 0 Yes 0 No
o
Phone
None
POA
Nam8~~WU~W4__~~LW~r-____
Phone r: \
PATIf"MT I
4~1
~SSM
KfA.lTtf CA.RIf"
DEPAUL IIEAL'fH
CEN1.'Er~
INTERDISCIPL/lliARYCARE PATHWAYS"' GENERIC
MARCH, PHILLIP lip 071510U477 MED 0546-01 10/02!E/7630Y M 06/.:,1/0'1

HAHM]\N,
1~'l'lER
:1111111 mil1l. II IIHfllU IJRb

i:
0007!,13298
DPM-l000-024 (512006) PAGE 1 OF 8 COPYRIGHT 1997 &9MHEALTII CAnE
000519
PLAN OF CARE
DATE I INITIALS
PROBLEMS / OUTCOMES /INTERVENTfONS Place initials anti date Ihat problem~ are idenfltledln left column.
All identifIed probiems must be evaluated whether Outcome is Met or Unmel al time of dischlllrgi! by placlnQ date and inilit;lh in appropriate column. It OUMame ii; met prior 10 discharge. place date anti initials In Met column. PlaclJ V" in boll' by intervention~ appropriate to patient. Wrllllir additionallntervenlions as needed in blank iJPaces.
OUTCOMES
Met
Unmet
Problem: Alteration In Neuro'ogioa' Status
I
I
I I o o Io
Age Splilctli(; consideration in Elderly Adul/s: DiminisheO musc/I;! strengrh, Oegenerarive Done lind1o! faint changes. D.;'Cretlsed hearino. vision and balance
Outcome: The patient wfll 8xperie"ce a stabilizatIon of neurologlesl Impairment.

Inlerventlono: 0 ASI,lf:-SS far rail Risk BID - Initisl\< Fall Precautions lor Fall Als/<. Score of 15 or higher. Assess level of consolO'll/ness and motor function i1Vilry shit! and PRN. Encourage achievement of ADL's as appropriate to th& neurologic...' impairment.
Problem; Alleration in Oxygenation I Respiratory function

Age specific consideration in Elderly Adults: Weakened
respiratory muso/'ili, Omft,mui Iling tissue fllcrslic:Jty.
o POGition pati&nt for maximum ventilation efficiency_ o Monitor VS I breath sounds/ oximetry every shift and PRN. o Administer tr"'[Ilmenls I oxygen i ABGs ali ordered, o Provide fluid intake to liquify secretions - ~uction secreliono us necessary.
Problem: Alteration In Comfort/Pain Management
Outcome: Respiratory function wlR be within norma. limits for putlant. Interventions: 0
bldV}=
~
Age specific considerallon in Elderf,;, Adulls.- Possi/)/e idiosyncratic effects from m~dication$
due II) ag-reIBtf!d changes
[J
in [jfJsorption, metabolism and 8!(Cretion. Outeome; Patient exhfbits I stOltes adllquate relief of diseomfort.
J.(
I
o A!>i&SS patient's puin levi11 every 4 hours. o !twolve patient in care by dlscussillg methr,Jds of pain relief_ D Initiate Interventions {including nonph~vmacologic) appropliate tor painfdlscomiaf1 o Assess pain level and re(lpon'3e within 60 minutes of intervilntiOIl
Problem: Alter8110n in Nutrition
Age specific cOlJ9idfJralion in Elder~y Adulll:i Oimln/sfled ,~ppetlle. peristalsiS and digestive juices and dBntJtkJn changes. Improve lOad im8iW Position patient upnghl- Offer Ilmllffer. more frequent meals - fllfodiflGd food conSistency. I.e" pureed Isoll. outcom.~ PatielttJs ftutritionallntake is approprIate for metabolic needs. intervention&. 0 Nutrition Consult Mtered in HBO(;, Monitor hydration status Ass(!ss .. nhmillllleding tolerance I\!lSe~5 for swallowing! chewing difficulty - AGSISI patient with meals os need_d. A:/SeSs f Record dietary intake with each meal - Provide I record dietary supplements I HS snackl/, fh!tord Daily Weights - Report unexplained weight changes ;>3 Kg trom previous day.
F,~ctor5 lhal @lV
Interventions~
At110rl
I
LI)<
)......./
V--j o
!
o o
I I
0hl~
Yv
Pl'obl~m:
Alteratlon In cardiovascular Status
Age specific considoratiorl in Elderly Ad!llts: Diminished cardiac force / Dk'CKi ffow ta brain.
Outcome: Patient win be hemodynamically stabfe.
o R(!cord intake and OUlput every shift and PRN I Daily weights and repoll Yariunces.
o Assess vital signs. peripheral pulses and carpilfwy relill every 5hift and PRN.
o
Administer meoications , blood products as ordered and monitor effects.
Interventions
ProbJem: Afteratlon in SJdn Integrity

Age specific consideration ill Elderly Ad(llts' Skin dry and less flfastic.
Outcome: Patient wilt m.rntarn or Improve skin Integrity.
o Turn pl1l1ient evary 2 hours - avcid $hearing - Keep skin clean and dry. o Photograph and meaGlI1e wounds on acimiso.ion. i1very Mortday, and on diachlilrge, o PHnid@ wound car! ptlr ~kin CAl!! Plllfj (.st'~ ptige B) 0 Nutrition Consult entered
Probfeml Po1entla' or Actual Infection
Age spel.:iflc consideration m lderiy Adults: Decro<lsed renal function - note 1,#) VIi/U9S felated 10 ~nlibioflc dosing Outcome: $I~S and symptoms of infection are recognl&lJd. Pre~lIutlon9 are utfllzlld.
Intemmllona.
I ~ldVf
V-
o Utilizli isolation precaution o Contact o Special o Respiratory o Droplet o A!)sl1:nlReporf slgn5 and ~ymploms. of Infection e'lrvry shiH ahd PRN.
(I;
Interventions:
PATIENT LAB~L
~SSM
HEALTH
CARE'
DEPAUL HEALTH
C~NTER
INTERDISCIPLINARY CARE PATHWAYS* GENERIC
T jp 071S10047) MED 0546- 01 10/02/1976 JOY M 06/01/0'1 l{AHMlU~ ,Al'lWER Z O O 0 74 0 2 98
I1III1IIIII111 ZVlll.RCH. l'HILI. I P
DPM I 000-024 (iiJ:>1J08j PACE 2 OF B GOfJYRIGHT 1997 SSM HFALI H CAnE
000520
PLAN OF CARE
PROBLEMS I OUTCOMES /INTERVENTIONS
DATE I
INITIALS
Place iniMln and date that problems ilfC idenlifif1d In left cO!\lml1. All identified problems must be evaluated whether OUtcome I~ Met or Umnet at lime of disch~rge by pladng date and initials in appropriate column If OlJtcome is mei prior 10 di~chl;ltge. place elate and initial!! in Mot eolumo. Place"" ill box by Interventions appropnat to patien!. Write in additional interventions as needed in blank spaces.
OUTCOMES
Met Unmet
Problem: Alteration In Elimination Age specific consideration ill Elderly Adulth. Diminished peristalsIs. kidmW function. Outcome: Patient regBin$ normal elimination patterns for age and disease proees:i.
o Offer toilstiog every 2 hours.

o
o
Interventions:
0 _
I I
o ilecord intElke and output ~vefy ahif! and PRN f Report abnormal lab vailies.
Assess bowel sounds. abdominal disle1)tion andior di$comfort every .shit! and PRN. R<;>oord frequency and charactE',i$tics of stool. Report iloo :;1001 fot >;J days.
Problem: Knowledgl1 Deficit Age specific Gon.'iirit:rl:ltfrJn tr1 &(gr;rly Adul/s. Sensory and ~'''~nilive ImpairmBnis. Outcome: Patient andlor slgnllieant other Involved In plan of care I demonsb'ale understanding of procedure$ I dhsease J medications! and discharge instruG1ions.
o ASSeoll baseline knowledge and preferred learning method of patient i signticant other. o Provide educational material at patienlfGignifJcant other l@vel 01 undel3!unding o Assess patient i significant other for understanding oftsr teaching, o Provide instruction on safe and efiectiv9 use o! m<;>olCol equipment.
Problem; Anxiety / SplrituMI Pf,turbances
Age specific C{.",sid~r{ltion in EldBrly Adulls: Fear of 105S of (;Ontrol, df:'C/ining he,llth andlor approaching in economic security / social $tMlIS.
Int~rl/entiQns
_.
_..
dealh,
changas
Outcom&; Patient/Signtttcant ather demonstrates ability to cope end identifies ilvallable resources.
o o
Interventions: D_ Fncourage vwrbahzntion of 1earr. and participation in care, Decreal';& sensQry stimuli - provide qutet environmenl- Dim the hallway iight:; <lfter 10 PM. PaslClrel Care "~ferrar entered. Palliative Cara referral entered.
I
I
PrOblem: Glycemia Imbiltance
Age speCific considfHliHion in Elderly Adulls: DIO(Jreascd renal function,
me/abolic rate
Outcome: Patient's blood glucose is within acceptable range.
o Impl<lment Hypo9!ycen.la Protocol.

o o o
Implement Insufin Protocols as ordered. Monitor I Record tingerstiok o;)lw:.oue valLes as ord"red .'.ne! PRN. Diabele~ EdlJcator Consult entered.
Interventions:
Problem: Alteration in Mobility I A<:tjvfty Intole-ranee Age speoific conRidBrafion In Elderly Adults' Diminished m(Jscie strength, Degeneratwe bone andlor 100nt cnangt;!s. Decre6sed hc,ving. \/i,~ion and Odl<"r)ce. Outcome: patient maintains or improves mobility I ilGtMty revel.
I
I
!
o o o
lntarventiona: 0 . ASSist patient 10 participl;lte in ADL'" within limits oj impElmnenl. Advance activity as ordered! tolerated PT to asnsa funcl/ont'l! ability and provide ~pproprtale adaptive deVices.
I I
!
Probleml Alt.rBtion In Safety

Age speCific consideration in Idelly Adults: Sansory and cOlJnltive impairments. Outcome: Patient remains In a safe environment iU'id fre~ of physical injury. Intervention9. 0 _ .' Assess for I-all Risk BID -Initlate FaUl-'recavtionn for Fall Risk Score of 15 or higher. Provide appropriate 9ately equipment I oevite$ ana irw1ruetit'lllc fer us@. Implement protective stalu~ (VOV).
o o o
Problem: Outcome:
Intervention~;
PATfENT LABEL
~SSM
H E'
~ ~
T H . r- A
I{
fir

PATHWAY5~-
DEPAUL HEALTH CENTRR
MARCH,PHILLIP
INTERDISCIPLINARY CARE GENERIC
,"gUIDtIUIIIIIIIIJI.~nOI[1
TiP
t1ED 0';46-01 10/02/19'/G 30Y M 00/01/07 RAlW,AN, AN\~EH ~ 000'1'18298
0) l~H,,)4 77
DPMl000 024 (~1200G) PAGe 3 OF 8 COPYRIGHT! 9'37 SSM HEAL! H CARE
000521
vi::, f yhr;.
o
)L L
&
nJ,'u-
f-VS pUJ
~"jfIV(s) as.<>essed and in place less fhan 96
IV(s) assessed and in place less than 96
o IV(s) assessed and in place less than 96"
f0r {)(~If::~DePaul Medical Records/Phillip H. March 000522
~gvJul-
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DPMl000-024 (5."2006) PAGE 6 OF 8 COPYRIGHT H197 SSM HEALTH CARE
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M,r..RClH, PHILLIP
INTERDISCIPUNAAY CARE PATHWAYS" GENIERIC
DPM100Q.()24 (512006) PAGE '7 OF 8 COPYRIGHT 1997 SSM HEAILTH CARE
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MED 1}546-Cl
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DATE I INITIALS "Iace initials and date that problems are identified In lett column, AU ldentllted problems mtJ$t be evaluated whether Outcome is Mel or Unmet at tlme 01 discharge by placlng date I;\nd lnrna/a In appropriate column. If Outcome IS Illgt prior to di!ehart1, place date and initials In Met column Place \I' In box by interventions appropliate 10 patient. Write In additional interventions as needed in blank spaces,
Outc~me
OUTCOMES
Met Un met
Goals!
Skin Integrity Is maintElined, Patients Ell lisk are identll1ed and Interventions initiated,
Prer;h'ilt;;ked items are initialed for ttli pBti9ntS

Skin
l"t~9rfty
plan for aU patlenh
[iif
COmpltltfl Braden Scale on admission, then daily Assess skin up9n admission and every shit!, especially bany promkwl1ces and skin folds.
Ii'!'
fi?f RecOId IIny redness ihai dof,ls not disappear within 30 minutes or any break In skin integrity,
~ Reposition alleast ewrj2 hours,
&1 Apply lolion immedlat&ly after bathing. Use moisturII z ng cream for dry skin.
I!f Avoid massaging over bony promineflC8s and discolQrecfhyperemic areas.
Io I li1
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li1 Keep bed clean, dry. and tree 01 wrinkles,

Remove antiembolism hese. sequential slockings, and heel protectors every shift for 30 minutes 10 assess legs, feet, and he{!ls, moisture from Inconllnence, perspiration, or wound drainage,
~ Minimize skin exposure to
Eslabhsh a bowel and bladdsr program by ussistmg the patient 10 tile bathroom or bfJdskle commode every two hours. unlE'.ss contraindicated,
o application Float heela off bed with pillows pI\.lced underlhelength of the lower fegs, activate heel susp!.lllsion on Total Care Bed (ICU), and/Of of heel protectors.
!Jif Instruct patient and family on causes and prevention ot skin breakdown, souroo~ 01 pressurl'!, friction, and strearing. Record on
Patlanl Education Form. Skin Integrity plan for "At Risk" populations. Brilden Beare 18 or JeS5
fi?f Skin cl<!ansing a1 time of SQlHng wilh perinsal deanser with minima! Irictlon and apply protective barrier cream, li1 Limit use of adhesive products on thin, fragile skin and apply e.kln sleeves PRN,
o
o o
Place orange si9n (PUP) on tne door of room indit;llting patfenl is high risk, for skin breakdown
Initiat~ individualized turning schedule minimum of lIVery 2 hours In bed I avery 1 hOUf in chair.
o Consider usa 01 prsS$ure relieving cushion.

PositIon patient in a 30 degree [aleral position Wld avoid positioning directly on trochanter, Consiaer we of Ilfting devices \0 move and reposition palienl !>uch as lilt sheets, trap<!ze, and Air Pal to prevem friction and shear,
Use piIJow$lwedges to pad bony prominences from direct pressure, eiipeciaUy between knees.
Of
o Maintain head at bed at the lowest degree of elwaliQn c<msistent with medical condition
o
o
o Consider use 01 urtnary or fecal colle<;lion device 10 contain urirlB o Support surface per WOC Nurse Specialist
o
Nufritlon consult entered, Other IntelV&ntfons
stool. limit use of diapers,
--
PAT/ENT LABEL
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DEPAUL HEJ\LTH CBN'l'ER
fNTERDISCIPLINARY CARE PATHWAVS" GENERIC
!'1N;CH, PHILLIP Yip 0'11:'100'*'/7 NED o ')'16 -OJ. ':'0/02/1976 30Y M 06/0 )/01 Rru-lW\N, ArTWER Z 000/48298
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000526
INTERDISCIPLINARY CARE PATHWAYS@- GENERIC

MEDICAL HISTORV SPECIMENS TO BE COLLECTED INITIAL DISCHARGE PLAN
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Home with significant other Rehab
Mil:t..r(
o SNF/ACF o o Other
Home Healff'l
DAILY LABS
CONSULTS
PHYSICIANS
DATE
,~(
DEPARTMENTS I NURSING
NAME
DATE
NAME
I:. .~IJ~ , -/~o7 k9-.Z~
Admitted with pressure ulcer? DYes SPECIALTY EQUIPMENT
No
Date:
Type:
Isolation:
I
i~ ~tee;
I
I
(lI/a
-Q'
~
DIAGNOSISJPAOCEOURl::
Pneumovax year:
Flu vaccine year:
HT
&'0
resuscitation
WT
Lt.! iL L<~
DAT[
AURGIE$
CODE STATUS
?II
---
I
tVKI1
o DNR medical management o DNR comfort measures

Advance directives? 0 Yes
--'Vl No
Copy Iii chart?
0 Yes 0 No
Is there anyone who should not recaive general condition information? DYes oNo
FClmily/SIgnifican1 other designated to fscelve medical Information:
o NQne
Name
Namell..Jm~ InM'1v C.;,..4v

Phone
o POA
o
PATIENT LABEl.
POA
Phone
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10/02/1976 SRIRN", \l'15S1>.
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DPM1001J~024
t5/2006} PAGE 1 O~ 8 COPYRIGt IT 1997 SSM HEAlTH CAR[
000527
PLAN OF CARE
I
I f
DATE/ INmALS
I I
------------~PR-O-B-L-EM--s-I-O-u-Tc--O-M-E-s-f-'N-T-E-R-v-E-NT-I-O-N-S-------------------.I,o-U-T-C--O-M-ES~ Place initials and date thaI probf~rm are identifisdin left column. AiI,denlitied problemn rnll~t be evaluated whether Oulcom .. tS Mel or Unmet at time of d~cMarge by placin~ dale aoo in!li,.lt in appropriate eolumn. il Outcome ;5 met pdor io dIscharge. piac", date and initIals in Met column. Met IJnmet Place"" i,) box by Interventions appropllale to patient Write in addiiional int~rventions as needed in blank ~pace&,
Problem: Alteration In Neul'ologies' Status

Age specifirl Gl~nsidomtjorl in Eld&rfy Arfults: Dimil1ls/led muscle strength, Degeneratiwi bone and/or Joint chMges, Of/creased ilcarmg, .'is/on anrf ha/.ance. Outcome: The patient wilt experience a stabilization of neurologleallmpall'menL Int'!fvel1lions: D_ Assess tor Fall Risk BID Initiate fall PreCC\ution~ for f-aJl Risk Score 01 15 Of higher. AsoeGs level oj consciousness and motor function every shUt and PRN. [J EnCQurage achievement of ADl's us approprial& to the neurologioal impairment.
Problem: Alteration in Oxygenation I Respiratory Function Agfl specific colls!(/efl1lion in Elderly Adults: WeiJkrJn8d respiratory m~ql?~J Q~~rlJl'llftJd lung Uti5U6 6laslicity. Outcome: RespIratory function will be withIn normal IhnUs for patient,
o !'oslllon patient tor maximum ventilation efficiency. o Monitor VS f breath sounds! OXimetry every shit! and PRN.
o
D Adminiater treatments! mygen ,. fl6Ga as ordered.
Provide fluid intake to liquify ,eCr4itlons Suction secretions
all
Interventions:
necessary,
Problem: Alteration in Comfort/Pain Management Agl1 specific CDTlsJ(ll:!ralion in Elderly Advlts: Possible idiosyncratic ~ff~tli {rQm medications due (" age-fe/flied changes
in absorption
Out~ome:
intelv~ntion!';:
meI8bnl!~,m i'lnd cxctE'iion.
Patient elfhlblt$/ states adequate relh~f of dIscomfort.
o AsseaD p<,!lenl's pain level every 4 hours o Invulve patient in care by diGcll~$in9 methods ot pain relief. U Imliate intervention .. (includmg non-pharmacologic) <lppropriate tor pain/discomfort, o Assess pain lellel !.\T1d response within flO minutes 01 IntervQnHon.
Problem; Altel"lltion In Nutrition
Age $/.'e(,'''I~' considl'!ffltiOf1 in Elderly Aoufts: DimInished appellte. peristBlsis .'lnd digestive Juice;; Bnd dentition changes. &'{O(S thaI mllv imQrovc food rntake: Po.~i/ion patient uprighl- Offer smaller, mo(r;; frequent me~/s - Modified food conS!,~tRncv i.o. ptHf;f;!c/! soft.
0 ______---,-.,--_
Outcomel Patient's nutritional intake Is appropriate for metabolic needs.
o Nutrition Consult entered in HBOC 0 Monilor ilydration status 0 Assess (lntliral teeding tolerance n I\S~l'!st for Gwa.lJowing i chewing difficult>, ~ Assl~1 patl~t with menb a'3 ne~~d. o Record dl9tary intdke with euch m~aI- Provid", / record dietary supplr.ments I HS snacks. o Re<:ord Oa.ily Weights - Report unexplained weight changes :>3 Kg trom prevloua day,
ASf,8l>t. I
Intt)(verrlions:
li
Pf"oblem: Alteration in CardlovasQufar Status

AtJp. .specific con;;ideralion in t=lder/y Adults. DJflJiflished cardiac {orc'",! D/ood !fow to brain.
o o o
OUtcome: Patient will be hemodynamfcClUy stable. Inlerven1ions 0 I lecord intake Dnd o~lput every shift and PRI~ ! Daily weights and report vari'!!nces, Assess Vitill signs, peripheral pUlses tlOd o<\rpillary refill every shift and PRN. Administer m~jcatiDns j blood plodvcts as ordered and monitor effects.
I
'.! ,:
PToblem: AlteraUon In Skin Integrity

Agp. ~pe('ific cOllsiueralion in Elderly Adults. Skin dry and less ef01stic.
O"lcom~l Patient Illtf'1 venlions:
I
'jl
10
will maintain or Improve skin integrity.
Iwn patient everyzhours - avoid shearing -. Keep skin clean and dry. Photogmph and measure wr.tlflldc on admi:;siol1, every Monday. and on discharge Ptoviui3 wound CMlllflf Skil, Cafe Plan (S~ page 8) 0 Nuiritiol1 Consul! entered
Problem: PotentJal or Aetu;l1 Jnfection

Age S(JRcific conSideration in Eklerly /Idv/rs. Decreased rnn.'ll {unction - note lab vaiu(Js re!atod tQ antibiotic dosing
Outcome I Signs and symptoms of InrtKttQO are rec:ogniHd. PreGAutlons are utilized.
'Jtiifze isoiation pr~C<lutions: D Conlad 0 Special 0 RespIratory ~ssess'R'3POll a.gns and syrnptom~ of Inll/chon every shift and PRN,
inl\?'venlions
Droplet
~SSM
Hrlr.\..TH CARt;

W'''M.''.~.._,>
INTERDISCIPLINARY CARE PATHWAYS~ GENERIC
OPMHX1U O~4 ($/20061 PAGE:; Of {\ COf'YI1IGHT 199f S8M HEALTH CARe
,
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000528
PLAN OF CARE
PROBLEMS / OUTCOMES f INTERVENTIONS DATE I INITIALS
All i~ntill~d pr<;>1?Ielm
initluls and date that probl'lms arc idemified In left column. tI'lUst be eValuated whether Outcome is Me! of Unmet at lime 01 dischmsv by placing date and iniliai:J !f1 appropriate column. !f Outcome is met prior to discharge. place dale and initials in Met colUmn. Place V in box by interventions appropriate to pali",n!. Write in additional int~rventions as need8d in blank spuces,
Elimin~tion
Dimini.~hed perisial~is,
P!w;~
OUTCOMES
Met (unmet
Problem: Alteration In
Age specific consideration in Eldtnly Adults,
kldnoy funcfinn.
I
I
o o o
Interventions: 0 _~__ . Offer toi!~ling avory 2 hOUf9 AS$ssS bowel ~o\inds, abdominal dietentioll [ndlor discomfort every shift and PRN Record trequency (lild characteristics ot slool, Report 11 no stool tor .>3 days. D Record .ntake and output every r;hifl and t-'RN ! Report abnormal lab value5,
Outcomel Patient regains normal elimination patterns for age and disease proces$.
Probleml Knowledge Deflt;it
A{J CfJfWiflC ,'OilSldoranon in Elderly Mulls' Senso/)' and r,gqnitiye im(.lir lll?(1I$
Outcome, P.tient and/or significant other involved In pilln of OMe / demonstrate under$tandlng of procedures I disease I medications I Bnd discharge IntltructioJi$.
Interventions 0 A:l5eaa bt1seline knowledge tlnd preferred learning mllthod of p~tje-nt I signfleant other. Provide educational malerial at patient/significant other level of underGlanding, Aaseu patient I significant other for understanding after leaching. Provide instruction on all!e and effective use oj medical equipment
gl5turban~ea
o o o o
I
I
Problem: Anxiety I Spirituel
Age specific considerat.On in Elderly Adult:;;: Fear of !.1SS at COn/H)I. oecllning health and/or approaching death. changes in MOnomic sec-urity .I SOCI<1! stalos
Outoome; Patient/Significant other demon.strates ability to cope ilnd identifles available resouree$.
o o o o
Interventions: D, Encourage verbalizntion of tears and participation )n care, D~Grease sensory stimwli - provide quiet environment Dim the. hallway lights after 10 PM, Pa~toral Care raferral entered, Palliative Cnre relerral entered.
Problem; Glycemia Imbalance

Age specifIC cortifdflra!ion in {;I~erly Adults. D"creased renal ftJllcriOn. metabolic raie.
Outcome! Patient's blood gIYeose is wHhin acceptable range.

Implement Hypogly<;emie Praioeo!. Io o Impl<;>ml;ln! Insulin Protocols as ordered o Monitor I Record flngerslick glUCOSli values as ordered and PRN. o Diabetes I::dueator Consult entered, !ntervenlions:
I I
I
DegefJerEllive bone and'or JOint chBnges.
Problem; AHeration In Mobility / Activity IntDleran~e ! Age specific consideration In Etc/edt' AdUlts.' DimlnlsheO muscle strength,
Decrfll1sed IJC;lrlng. vis/on afJd O/:Jiance.
o o
Interventions: 0 AnGiet pallent to parilcipate III AOl's within limit~ of impairment D Advanc.a {lc1ivity as ordered i lolerntad, PT to aness funclional ability and provide oppropriat~ adaplivlI deviceg,
OutcDme; Patient main'alna or improves mobility I Betlvity level.
Problem; AUeration in Safety

Ag $pecific consideration in Elderly Adults; Sensory a.nd "ognilive imp!lirmBn/s.
Interv",o\lons; 0 Assess for Fall Risk BIU - Initiate Fall Precaution5 tor F~II Rink Score of 15 or higher, Provide appropriale safety equipmli'ni! devices and instrucilons for use, D Implement protective 3lr1llW (VOV),
Outcome; Patient remain. In a safe environment and free of physical Injury.
Problem; OQt~ome:
lnterv enlions'
~SSM
HiAI.TH-C.A.Rf

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COPYRIGHT 1997 SSM HIOALTH Cf\HE
INTERDISCIPLINARY CARE PATHWAVsa GENERIC
DPMl000-024 (5120\115) PAGE 3
000529
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IV(s) assessed and in place less than 96'
o !V(s) assessed and in plac-e less than 96"
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000530
DPM-l000-024 (512000] PAGE 4 OF B COPYRIGHT 1997 SSM HEALTH CARE
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Deara Planning with PtlSO (A)
Deare Planning with pt/SO lA}
o Care Plarming with PtlSO (P)
o care Planning with PtfSO (P)
o Care Planning with PlISO (A)
o Care Planning wl1h PtlSO (P)
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Copied by ._ _ _ , RN Aeview _ _ _ _ __
MA.RCH, PHILLIP
1111111111111111111
lip
0715100477
INTERDISCIPLINARY CARE PATHWAYS"'. GENERIC
OPt.1-100Q.024 (5120(0) PAGE 5 OF S COPYRIGHT 1997 :SSM HEAtJH CARE
MED 05';6-01 2.("/02/1976 3CY 1-1 06/(H/07

C;:'07-18233
SRIRA11, VISSA
IV(s) assessed and in place less 1ha.n 96
DIVIs} assessed and In place less Ihan 96'
o IV(s) assessed and in pJace less 1han 96'"

DE~~UL HK~TH
11811111116111100 MARCH, PlULLIP

INTEROfSCIPUNARY CARe PATHWAYS"' GENERIC
CENTER
.Ii P
0715100477 MED OS46-Cl 10/02/1976 30Y 111 06/01/07
SRrRAM,VISSA
000748298
000532
OPM-10Q0024 (5/2006) PAGE 6 OF 8 COPYRIGHT 1997 SSM HEAlTH CAAE
OGare Planning with PtJSO (AJ OCara Planning with PtlSO (P)
o Care Planning wi1l1 PtlSO (A)

OGara Planning wi1h PtISO (P)
Oeare Planniing with PtlSO (A) Care Planning with pt/SO (P)
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INTEflDISCIPLINARY CARE
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071510047" l'ffiD 0546-01 10/02/1975 3QY M OE/Ol/07 SRI::t..l>.."'1, VISSA 000748298
DPMIOOQ024 {S;2(06) PAGE] OF 8 COPYRIGHT 1937 SSM HEAIlTH C/I.RE
PLAN OF CARE POTENTIAL ALTERATION IN SKrN INTEGRrTY

DATE I INITIALS
Place inilials and date Itlat problems are identified in left column, All idenlifil;'Q problems must be ~vlIJuated whether Outcome Is Mel or Unmel at time of d,scharg<i1 by placing date and initials In ilpprQpriali IfQlumn. if OutCOn1 i3 m~t prior to di9CtJa,g~, ~laM clare and Initials in Met coiumn. Place in box by intervenllons appropriate to patient Write in additiona/lnterventions as needed in blank spaces.
OUTCOMES
Met Unmet
Outcome Goals:
Skin integrity Is maintained . Patients at risk are jaenlified and interventions initiated
PrBChec/',ed tlems 8r8 in/riat",,, for a/l patients.
o
ri?f
Skin Integrity plan for an pallenta ~ Complete Btaden Scale on admission, then daily.
Assess skin upon admission and every shift, especially bony prominences and skin folds,
Ii1 Reoord any rllMMs that dQ~3 not disappear withtn 30 minutes or any break In s~jn InteQrily, Ii1 RepositIon At least every ;;> nQurs.
1!1 Apply lolion immediately aller balhlng. Use moisturizing cream for dry $in.
Avoid massaging over bony prominences {\fld discolorsd!hyperemic areas,
1!1 Keep bed clean. dry. and free 01 wrinkles. Ii1 Remove llntlembOlism hose, sequential stockings. and heel pfOlectors every shift for 30 minutes to assess legs. feet. <lnd heels.
Ii1 Minimize skin exposlIft'l to moisture from Inoontinence, perspiration, or wound drainage.
~
~ Limit use of adhesive products on thin. frElglle skin and apply skin sleeves PRN. [if float heels off bed with pillows plee"d under the length of the lower legs, aclivale heel suspension on
Establish a bowel and bladder program by assisting the patient to the bafhroom 01 bedside commode every two hours, unless contraindicated. Skin cleaming af lime 01 soiling wtlh perineal cleanser with minImal friclion and apply protective barner cream.
Total Care Sed (leU), and/or
application of heel prolectors instruct pallen! and !Elmily on causes uno prevention of skin breakdown. sources of pressure, friction. ;;tno shsarlng. Racoroon Patient EdUcation Form.
le~6
o PI;;tce orange sign (PUP) on the door 01 room Indicating jX\tient i:. high rls!-, for skin breakdown.
I
Skin Inteor1ty plan for "At Risk" populations Braden $core 18 or
o Io
D
o Initiate indiVidualized ftlrning schedule minimum of every 2 hours In bed I every' 1 hour in chair. o Consider use of pressure refjev/ng cusllioll.
Position patient in a 30 degree lateral posllion and avoid positioning directly on trochanter. Maintain head of bed at the lowest degree 01 elevation consistent
Consider use of lifting devices to move and reposilhm patient slIch as lift sheets, trapeze, and Air Pal to prevent Iriction and shear.
with medical condition,
o Support surface per woe Nurse Speciali~1 o Nutrition consult entered

Other Intenlentlons
o Use plliowsJwedges to pad bony prominences from direct pressure, especially between kne",~, o Consider l.I$ ot urinary or !ecal coll8c110n device 10 contain urine or stool, limit use of dia,pers.
1
~--.--
I
I
PA TlENT LABEL
I
~"A1.lH
~SSM
Cf\,R~
INTERDISCIPLINARY CARE PATHWAYS& GENERIC
[}PM1QOO02415120n6) PAGE 6 OF 8 COPYRIGHT 1997 SSM HEALTH CARE
000534

INITIAL ASSESSMENT
Physical Barriers to Learning:
________ 0 Writing {explain) _ _ _ _ _ _ _ __ D Development level requiring Intervention (explain) _ _ _ _ _ _ _ _ _~_ _ _ _ _ _ _ _ _ _ _ _ _ __ Drnher ___________ ___________________________________________________
~
~ None 0 VisUm 0 Hearing D .. Language o Difficulty Reading (explain) _____ .
~one 0 Anxisty 0 Angsr 0 Denial 0 Depression 0 Confusion o Other ___ _ Spiritual BarrIers to Learning: &;hNone 0 Grief 0 Guilt 0 Lack of hope 0 Other __________________
EmoUonal Barriers to Learning:
"9 None
140me Barriers to Compliance: 0 Meal preparation 0 Transportalion

None
0 Finanaal
0 Caregiver
OOther _ _ _~_________
~ellgiou$ and/or eultural BarrIers to LearnIng:
DYes Explain.
___ . ____ _
What is the ea~iest \\-ay for you to learn?!J Reading 0 Listening D Picture~, ' 1\.(' o DemonstratJon ~Other A'-L !.-'<., ..l;;I\\.,t.. <.)l~ LL1h(',r 1;"1 cXJ.~ ... ) What are your learning needs at this time? /.:Jj U o Disease process 0 Medications 0 Follow-up treatment I:J Use of equipment I:J Diet I:J Pr~/PQs1-Qp t~9,ching o Community resources 0 Rehabilitation 0 9ther
iJ
Who should we involve in your teaching process'?
N~
Activity/exercise .I\ormssion
Disease process Dischan;re IIlformarj(jn
Home care services Incentive splromclly
Medications
MOnitors Moulh care
Advanced directives
Gomm. resources
Drtfsstngs
fall preventIOn
lntant caratFe8rling
Isolallon precautions
PORt partum IBaching Preop teaclling PsyChosocial needS

R~slrainls
Oulpalisni Proll rams
!)lgns/5x Smoktng Cessalloll Social 5Drvice Spiritual nseds
Trfliltlrn!nts
Wound c-alt,
Diaynosllc Ie's!';
DiWNPO Disease manauemellt
FollOw-up care
foley
FoudiDrug mlerBctruns
!V'sJi!ljccllOns Lauer m.'magemenl MDI
Pain managenwnt
Plan of car~. Post "up tf8Chlng
RISk !aclors
Room orientation Salety
Surgery
TeDB
Ted.
Date
Signature / Tille
T;TelepnonefExplanation
DEPi\UL HEALTH CENTER
~SSM
~t.LfH'<;"'.e
INTERDISCIPLINARY PATIENT/FAMILY EDUCATION RE.CORO

DPM,100o-000 (1212004) FRONT
RAHrW~, ANvlER Z
I>1ARCH, PHILLIP T/P 07151 0 I) '< "! 7 HED 0546 - 0 1 l0/02/1976 JOY r'l U6/01!07
000'/48298
IfSmnUIIUrtIUIrtllHlfi
000535

AclivilylExercise
Disease process
POTENTIAL TEACHING TOPICS Post partum teaching Medications Home care services
Inc-entiVe &plrom@lry
Infan! G3reiFeedillg Isolation precavtlOilS IV's!!n jections labor management
MOOifor~
SiOllslSx
Treatments
Admission
Advanr.l'.G direr,livlIs Camln, resources Diagnostic lelils DiP.tIt/PO
Diseas~
Discharge information Dressings

Fall prevention
Pre-aD teachiog
Psycha~/)()fal
Follow-up care
roley FoooiOrug interattions
management
Mo!
Moult! care Outpatient programs Pain managem8nl Plan of care Post-ap teaching
needs
Smoking Ciss~Uon Social ~Ivice

Splritval needs
Surgery TGDS
Wound emf
Restraints RIsk factors Room ollenlalio!1 Safety
Oat~
Si~natLlr9 111lla
: !I
ae
Teaching
f. :
onten11 Distharge ans (May plate slicker here)
PI
Dm_
Presenl?
Teds
Family
Yes or Ho
Pr::~f:e R.~
OUTCOME
tWBfbalila.
p:rJ.
.!IlIum I
~::;'
! ,
I~
Readiness: (1) States ready (2) ReqU9t;IS dalay (3) Confuwd Learner; PT '" Patient P = Palenl F
Method: A", AUDioviaual
[) =
= Father D Oaughter(sj 0 = OIh".s M Mother SP Spouse S", Soots) DSlY\nstralion e " Explanatl(ln C = Group Class H=Handout T=Telephon<o/E"planahon
(4) Sooa/at:!
(5) Cognitive inabi(1)I (6) RefuBd
(7) Already knOWledgeable
~SSM r
" A I. H ' C
1\
R Ii"

r<lARCH,PHILLTP lIP 0715100477 l'1ED Ob46-01 10/02/19'16 30Y 1-1 06/01/07
IlilWlIIllJUllIlllI1
fNTERDISCIPLIN .... Ry PATIENTfFA....HLy Ef}UCATION RECORD

DPM-l000-0ao (12/2004) BACK
RAHMAN,ANWER Z
000748298
000536
SCHEDULED MEDICATrON OKDEIlS
Special Instructions, ~I"d# !ita 1"1: 81:0 --P-i!'-u",';'-J-cV-o-s-e-;:C:Rc-o-U-1:-e-c/:--Cc-6-m~iii-e-ri-t-s- - Ub!(H 0900
1531-2J59
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NOR VAse
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TABLET
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0546-01 58 MARCHrPHILLIP
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Veri fied by I
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Dr, SRIRN1,VISSA
AlleJ;gieB: Nl(A
~----~~~~==-~~~~~~
L -_ _ _ _ _ _ _ _____________________ _________ _ ___ I RII'r';noN, ~~,~ 06/06/07 00: 00
Covers Doses from:
~edication
Administration Record
to 06/06/07 23! 59
t>rinted; 06/05/07 22 :'JO Page t 1 (more made follow:...:....:..J
000537
~._w~
UNSCHEDULED MlIDICATION ORDBRS
(cont.1
-spe~i~-l-Instructions
Ordli .;
Gtii;;t-~-Stop
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AOOO74829B
DL : SRIRAN,VISSA
Alle:L"giea: NM
!Oepaul Health Center

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!lJR: CGETON,
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06/05/07 00:00 to 06/06/07 23:59
Printed, Ub!U~!U'1 n uu Page: 2 (End of MAR ,
000538
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LU ~ LI:. IJ .Q. KU-Kt..V.Q.
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I,T _ Lt. Thl"h t<'r-Rt.1'high

AJ:xj.
LA
Lt _
."n"
RA_Rt.Arm
J<t.
vpper
I..LA -
-.-~- --'-
- "-r . .__ .__

I
I
[rl~tl __ ~~'a1!a..~~~__~___+.::..:..c =-~
Gc:-'~<--":---:;------
--
Hl-" ~ T.I
lip!>"" Tlb,l.
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---I-~=+BlJ~/J...<"""'''''''.LJt.-::_c_--
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A0715100 /j 77
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Cover~
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06/01i07
1'.000"'748:298 Dc SRIRAI>!, VISSA
Allar.' . . ,
.-1._ _
N~
_ _ _ __
Doses from:

Printed: Ob/U4!UI 2J:UV
06/05/07 00:00 to 06/05/07 23:59
Fage: ) (End of MAR'
000541
~ :Special
_ Drug/Do&@/l<out!!/commQl][C,
8CHEVU~ED MEDIChTION ORDBRS
Inst-r-u-c--t~i-o-n-B-;-----------------------------I
----------------------
r-ordU 13tar-t'Stop
,,; 1'J;;:-O 1
09CO
cr..AR ;~;~Ll NL1M~\UN

Oin:!:
; ... - - - - - - - -
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0015
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("l.ARTi'Y OXYC'ODONE STRUNGTH
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2100
oue:
.... ..,...... 1",,""" "'"

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SUPPLY
0010
/liW/
06/01
l<JCO
06/0 7
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CL!NJ)fWYCmlCLBQCIN~
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t-1NVAiX 11IUlN) 1.jrJl:('A1NE :fi V!~COU$
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CO_N_s_r_D_RR __
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___ .. ____~I . I ~ ~.~'--_-~_~-_-5t~_~ __-~_~--i~~~~~HILLIP

,,- 1.{j({k; '.--=-----------1 DOB:
10/02/76
AOllO'I-1H~l"8
aWl
l;Ower Abd.
'inlt!
SHr,ctl'HL'
VIA" Lt. Upper- Abo.
xLII - Rt. lower i\bd,
SS
AO-llbl00477
,---
r.ga:
JOY Sex: l'l hun" Dr: SRIRAM. VlS~1'.
06/01/07
______-{AllergielJ: NM
DePaul Health
Covers Doses from:

06/04/07 00.00 to 06/04/07 23:59
Printc~d~
~ecord
~------------------------------------------
Pagel 1 (more meds fOllOW_ ~ ----------~------------------------------~-
06/03/(17 22:00
000542
.".
UNSCHEDULED MBDlCATJ:ON OlW"RS (CQut. l
special InstructionSl
-Q~d~r~af~I~~~1_~t"',l9}DoseIRouee!Cofiifjjerif.S
~W
ii'LY )6
I
i
h-aquency
1l00t1-n'nO
06/01 HJ(JU
i I
I,;:CE'TANLNOI-'HEN ;\2." MG '!AJ;ll.>t::l TYl,t::N')l, j 0<"M(; TAllLIIT 650 Ma/2 TML!';'I'
I
I i
jue,
M~
(ORAL)
Q'lH
N"'''''i',(1
fOR MILD "fdN

FDR 1'P.MP (;REA1'ER Tl1AN 101 .5
~
As Needed
0r'l'I-I-O-C-.,C""'1-1-t----tO-I-"-IlI';Nli-.iD-R-AM-U<E
ruM "LX 180G IlI:;N<1!.1K1L
[<"Be, 25 KG/l CAPSlILJ!:

FDR l1'eHHIG (IN HT':; PArR
roml'rTllU- FALL iUSK "1
2~MI;
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CIH':';Vl,t; I:.\lUJV
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I
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loon
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",,, ""
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OOGe: 1
Mall
/oIL
I ~.
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rOTENTIAL~
rnLIITR
H':;~R(}I40RPHmm
1MG
;
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IPROMETHAZINE
P~~LQ;"'~[~~'ER ~
MUM'E
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IDo:~~N~~[~~~/~'>~
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I I
PGTRNTJ:1'.l. f"ALl, RISK
~11
~l'{ . ~~J I~ ... ot~ r4
'I
-I
~--~~---
I l
---------------~--r:~-t.--~------~----------i
Site Codes
hT
"
U.Q.
_~ ~~A ~ R~(
I
t -
RT Upper Abd LUA .. Lt. UpFET Abd.

H.O.
Lr., nngh 1'iliQ!1 RI LLI\ - Lt. Ii'.r......~ - Rt
LA " Lt. '\t"fU I1r\ = HI .. Arrn Lower- ~Jyj
L,o ....er
"bd.
--j 0545 -Ol

.- -loOB:
i MARCH, PHILLIP
10/02/76
5S
A0715100477
t:::!J~~~~~~L----_1A00074829!l
A~c:
30\" S<.!x: M "dm: 0;;-/01/07 Dr; SRIRAN. VISSA
_~j .~/.fJ-- .0. ,'fJ2 f------+~.~--~.. - - - - - - - - _ j All~rgiea,

DePaul Health center covers Doses from:
liKA
---c-------'-----------,---c----.---- -
Meuication Administration Record
L-.._ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~_ _ _ _ _ _ _ _ _ _ _ .
06/04/07 00:00 to 06/04/07
23~59
P\'~~c;:; ;Glt~~~7:r~J _. . .. 1
000543
r .
SCHRDUL50 MEDICATION ORD5RS
Special tnstructions: [
01: dlf ! Sf. La t

lG
..lW
I eoUOl
JSL-;-p-'I-f}-r-",-g-;'C:r,:C-n-,,-,e-.,-c, O-,-,-t-e-:;-e'--,,-m-mp.-.n-t-.a------'I,-P-l-"-,!,-.l-e-~l-'~~-. y-!---.---~ o=u=o=U=-=O='='I=U===::=====o="=:l=l=-=i=.,:J=Il===::====1=.,:3=''=1=-'=~:J=., :9==-1
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f'IlRIPIlERALL'l "ND KCL CONCENTRATION

IS ,A;;::;::; TUAN 40 r'll!Q/lJITIlR,
I'
I
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II
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fA = J,e,
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RU
r--............. ,
SiyndLure.
RA _ Ht. 1U<l' RT - Rt, '!'h1')h kVA - kt, upper Abd , LLA - Lot. Lower Abd.
~
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r_'m I
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0546-01 58 MARCH,PHILLIP
7\0715100'] 77
, +1-------
1
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(gj ~! fy1il, _a.(:plr-----jl~------__L_._, ___,.__

Pe~aul
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DDS:
10/02/76
a~!gH
Age:
. l\OOO !-1
30Y Sex;~! Adm, Ill': :';l<llV""1, VISSA
06/01/07
jAllersries: NKA
.
PI'int-ed; U6/t.JJ/(j'1
Health Center
Covers DOses from.
Medication Administration Reoordl

~~; (JV
06/03/07 00:00 to 06/03/07 23:59
Page: 1 (more meds follow ... '
000544
UNSCItIWVLBD MBDICATION ORDERS ....
SpeCial Instructl.~o,--n_s_:_:--_-:-___ .,-_ _ _ _ _ _ _ _ _-.-_ _ _._.--;_ _ _ _ _ _ _--,_ _-:--~:__--.-ordilj SL,,,l Drug!lJoee!R6ut.e!Cornmeilts ._+pl'~<"l\,Hmey _ _ _ _-+__ 0_0_0_0_,0_7_:1_0_-1. ___ . .07]1 lJO
---... _-_.(cont.) ---------c:;

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LUA ~
r.t.
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----+--=:....IO.:.;q-J,i-~~~...d:L..\4""'~--l
0546-01 5S MARCH, PHlt.LIP

00[3; 10/02/76 A000746298
A9C: 30Y
A0715100477
Sex,
~l
Adm:
06/01/07
Dr: SRrRAM,VISSA
Alle:t'giee. HKA
DePaul
Center
Covers
D05&S
from:
~rlf1ted
Ot .tUl!,"
22 -O-J-'
L -________________________ ~_ _ _ _ _ _ _ _ _ BR I DGll'TVN . 1\0
06/03/07 00:00 to 06/03/07 23:59
page: 2 (Rod of
000545
1 - "
SCHBDULED MEDICATION ORDBRS
!Special !natructions;
!---()):tj,'-~-i! _::,'~~-~-+_~'~I~ 6 O~/Ol i

J''f/
TOi\JqjnOflp./ROUle/COlll!11l!!lllJ
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01100
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06/01 0900
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. . . . . . . . . . . . . . . . . PhTIENTD OWN SUF.PLV!.U h
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06/01 1000
06/07
2359
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Ob/Ql'~- SODIUM CHWIUDE 0.3\

0932
1000 ML
{IVj
1.................
~lt
Rate: 100 lill/hr

UJNt;lO};R USING l\ DTM.-l\- FUJW !lEVTeR "r TV F[):lIn IS BEING ADMINISTERCD I'!lHINnlRALL't AND i:C.I., CONCCNTRATION 1 G [,1155 THAN -to ~jEO/['ITEl':.
,I
I
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KU/\ Kt..
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L'r
RT
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u; . Thigrl RI;. Thigh
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Lt.. Arm Kt..

AI'. 1
,.\l-m
upper Atd.
Signature
LU1, LI , Upp... , 1I1d.
LLA RIA
r.t _
~
l.nWf'f
Rt
Lower Alxl,
MARCH, PHILLIP
1----'----'cn~/r..-A-':-:-::-J()""": /m=-i-,--";-e~~~711--..-----f+,,..t:--+---ri i\O 00'148298
.. ,~ Verihcd by'
05H-0J.
5S
30Y
A07151Q0477
S"",,;: M Adm, 06/01/07
I DOH:
10/02/76
A9'-"
Df.0.,.tt-(..;fUL-1tAli
Dr;
NKA
SEIP~,VISSA
[} ..tfl)
_~
______-; Allergies,
f0:!Y:--'-.-' _
i-D-e-p-a-u-=-l-H-ea--cl=-t-:Ch-""'-CC-enter
Covers Doses froml
Medication
~dministration
Record
L,__________________________________ 06/02/07 I
BR1DGETGN. Me
00;00 to 06/02/07 23:59
_ ______________ ________________________________ Pagel 1 (mor:e mads follow

~
P,inl."j, 0";/1)1/1)7 22,M'
000546
,--------------
,~
-,-
-"
rpatryct~opa:
ONSCHlWULED"MEOICATION ORDERS
--------------------------------, (oout.)
--,---------------_._--I
j--'--O-O-O-O-O-7-3-0---rI---O-,-3-1-.-1-S-J-O---'-'jr---1-S-)-1-.-2-)-59---1
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06/01 1600
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Q6hprn?:O ho Needed
/tu~~ ~~~~ ~~~E
OLliHlmlIWRAMUIE 25 m CAPSULE SENl\DRYI. 2SHe CAPJroLE EQUIV

FACB
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1
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A0715100477
30Y Sex: N f>.dm:
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I DOE;
10/Q2/76
Age:
06/0l/WI
Ill-: 1:nURNI. V ISSA
I - - - - - t - - - - - - - - - - - - - - ; Al1ers!e:~; liKA
Covers Doses from:
Pa~el
~ecord
Pnnte-d, 0,,/01/07 ;'? I nn
06/02/07 00:00 to 06/02/07 23:59
2 {Rnd of MAR
000547
r ----------------------------------------------------------------------------------.-..
SCHEDULm> MBDICATION ORDBRS ~s-p--e-c~i-a-l--I-n-~--t-r-u-c-t~i-o-n-~--:------------~---------------------- .. ., ......
._----------------------,
_l
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'flO
{ORAL]
-. -.- --.---=-:-:-::--:-=:-c:---,----:---:---~,-,---""T"----_:__-,...,__:___\
09"00 1300 2100
06/01 0900
'CLARITY CLINDlIMYCI!l'
conc.inue hc,,1."1e med or IV ordet"s Wl,."itten
-1.l-0-1-Q- fI-Q-~-/-o-l-+12359 (l-6-I-O-7-+~-:-:-~-'

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06/01
0900
I
I
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II
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(IV]
IQ
6 HQURS
1--------------- I
1100
1700
noo
lJ'I
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I
I
I
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(?
I "013 ~;~~l I
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h
KL
frY1
+++++++++++~++~++ ++; ~~ Time.

'l'-i
+++[++++++++++++++++4
"K
Ratel 100 Illl/hr

CONSIDIIR
DlM.-;"-V'!.J)I~
Dl'lvrCE:
I
I.!:I
-+-----, ---- I - - - - - - - - - - - i - - f - - - - - - - + - - - - +-
j
I
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----1
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!
I
:
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I
Site Codes
LU ~ Lt. U. Q. Rl.l _ RI. fl.Q_
RU~
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t-,- -S-i-g-n-a- t.- u~:~- -~ -~~~ --l--.----~--,~-.--_a~~---~

---_._--_.- _. ---- -------
LT ~ Lt, Th~9h llT Re_. TJliljlJ
LT\ Ill'<
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~
Lt" 111.-'0
ll~.
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LUA
- Rt. upper Aba, - Lt, upper Alx1,
LLA - Lt.
i(1-J\ -
~ower At~.
Kt. l,Q\'ler
Alx1,
----+----------------------t-"~-"+.-1<=-:=------.:-==--'---==-___j
0 5 46 ~ 01
- - - - - - - - - - - r t +........I-\;:/-H+t7i-.~A__:1--:----_i MARCH, PHILLIP
58
A0715100477
Sex, M Adm, 06/01/07
Age, JOr
Dr: RAHI1AN. hlTffER Z
Allergie~:
NJtA
DePaul Health center
Covers Doses from:
Medieatian Admini$tration Record

!'l'inte<l; %/Ql/v, ,,>; J& Page: 1 (more meds follow ...
06/01/07 OO~OO to 06/01/07 23:59
-------------------------------------------------~
000548
'ONSCIil!:Di;JLSP NEDJ:CAl'ION ORD8RS
(cant.)
f'requency
uS
olW
llfiiHI- 0'1'1 n
00/01
~OOO
Cl!'I'AlUNOPHKN 32~ m 'J'Ml1.!U r~L l25KG 'I'ABLET

QS~'
Q-lU As N....ded
J'LK
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FQJ( 111LI) PAlN

OR
FOR TRMf'
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00:1-1
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Ae Needed
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0546 - 01
MARCH, PHILI.IP
DOE, 10/03/76 I---...L-------------l-.-t--t-+-I-Irl-f---t~ffrrl_.M..t..'--__l AOOO? .. B 2 9 a "'\!l VerififO\i by:
58
A-;,e;
A0715100477
30Y Sex: If Adm:
06/01/07
Dr:
HAHMI\N, I\NW";K Z
Allergie .. , NKA
r _____~-=.:../=-e.:./~__==---='-'-_---'_________
IDe Ul lth Centor
tlf{W;;!ITON. ~1(1
Covers Do from,
Medication Admdnistration ReCord!

Printed, OG!Ol(07
~9,Jo
.... _ - - . - - - - - - - - - - - - 1
06/01/07 00: 00 to 06/01/07 23; 59
page: 2 (and of MAR
000549
HOUR DATE STARTED PREVIOtlS 24 I/O Inlllke Oulput ~ISOLATlON; 0 Special Contact 0 Contacl 0 t4etltropenic 0 Airborne 0 Droplet SCALE KEY: 0 tied 0 S!alloioy 0 W/Chair 0 Slin!) OTHER PRECAUTlOtlS: 0 Safety-Fa!! 0 Bleeding 0 Aspiration 0 Seizure 0 _ _ _ _ _ __ Yesterday's wt ... _ KG Today's WI. KG (Plene reconcile wel9hl differen!;! if gruter lhlln 2.5 kg.)
Temp Poise
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MEDICAL/SURGICAL PATIENT CARE RECORD &2 q(jJ-j
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12 tor Tolal Parml,!d; _ _
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fWID EQUIVALENTS:
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. :IOml
4 oz (1/2 cupj .. 120ml 6 oz (3/4 c-uP) 180ml
1;\ 02 (1
240ml 12 oz (soda \ c,an) . 360ml
cup) .
PATIENT LABEL
~SSM r ..
fl
DEPAUL HEALTH :;;,;NTEP.
t T H
C A If F'"

PATIENT CARE RECORD
TIF NJU{CH, FHTLT->IP 071510041'1 !-U::D OS46-01

10/0.!/19 7 6 30Y SRTRA!>1, VISSA
Ilai~ll1lllnDID!18~IH
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OIJ
H t. It l
24 HOUR
ME[)ICALfSUR~ICAI.
06/0J/07
000749298
DPM 100
DPM-lOOo-071 .4i200S} PACE 1 OF 8
000550

pcrformcctlintcrvcntfon
* '" SiQnificant fmomg OocUmenled mNurses Notes. Use tJoldeil key leller if iIlOic81e!i.
DATE STARTED ==l="+~~
241
~
3
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10
I
W(H~I
rx~~iep;'!'n
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#
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RT
aEHAVIOfl/"':ESPONSES:
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c
U =Unrespoosfve
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G G,ie .,II1
T
c.:; CoonitUt'~ !rnpavment

R =-
CO _ Ct.lmruCise
R~~{i!..I:~""
11 H<llbc;mllM!ding Inlo
os _ C'slOpllVe
T
S _ Sleep11\<]
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Hifrrn.r'GomoalivE
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a - G.lmlQUf;!l
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.=.
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9:
~o
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to
incr~ase 19\;1elIJt ~iafl14ilJ

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EnC6:iJ.r8ge fa-mity to btltl9 in
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11
f?
is
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17 IB 10
Proa-;;uve m-ea30frS n~g~~{H I n'i~~1i9n l $~~i; ~ij"I'~ti>ln E~Hi.~~5h bounrjane3 PrnVy.f", ~fllullnivn rinr:mny :mn !.nklly m('!t}r,IHf'''
(Jute;l61gn to
ct6\;r9'a:~.e pal~ts iaS{.!Ol16~
to stimv!ah-.)t)
to miniiT)~l~
t':t;!h~'1'D(.il1 J.m)u~llI~
PATIENT LABEL
~SSM
H!At.Tli
C4Jll'

DPM- 1000-07' (412006) PACE 2 OF 8
IIp MARCH, PH1LLIP 071S100477 MEV 0546 01 10/0;l!1976 JOY M C5/01/0'i SRIRAM,Y1S!;!A 000748298
IllRJmnlllllllDBIIHllIll1
0:
H
J,
DPM-1
000551

A(
~c
26
38
56
71
84
96
Site #3
1/ 01 ails/rots for IV ff1start
12
,
\
L
+R N01
FORT
1'1I,t;
Sll DLlTlC
r410LlNE
f
/'1 f
J
M
Jw:!h.:'.a!C bxa(wn c1
N 0.1 JOB OWUff1Jd
K \ "\
1\ \
E\ \
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Inset!iM [hie _ _~_
:z
IoU
~ :r
LL/
.. -------------------------------~
1 - - - + - - - - - - - - - - - - - - - -...
PATlfNT L48L
DEPAUL HEAI.TH CENTER
fYl:>SSM DePaul Health Center

ttl"LTt, CARE
MARCH, PHIT,LIP
11Il1ll1~llilII1Ill1I1IUII
Tip
0715100477
24 HOUR MEDICAUSUfiGICAL PATIENT CARE RECORD
OPM-1~07\
MED 0516-0]
M 06/01/07
10/02/1976 30Y
SRIRl~,VT5S~
00074R?90
lll-'
(412{)Oll) PAGE [i OF 8
000552

-----ACUITY LEVEL ACUITY TOTALS Points 26-37
3855
r 56-70
1 7 1-83
DATE STARTED
Patient Care
A
Record
Level
1
Subiota! Section "A"

Subtotal Section "8" Subtotal Section "C"
~.
2 3 4
'''7
"Y
I
i 84-95
198-120
1121 +
'---
TOTAL POINTS
.J~
6
7
i ACUITY LEVEL
i Sliter i
0
'" REQUI,'1ES FURTHER DOCUMENTATION
7
11 11
UE;PAIJL HEALTH CENTER
~SSM
H Ii' I<. L T'" 1;:" ~
~.,
MARCH, PHILLIP
IJIBlllllffllftllflilii
l/P
2 ~ HOUR ME01CAlJSUAGICAL PArrENT CARE RECORD

OPM100H-071 (4/2006) PAGE 4 OF 6
10/0~!/19'lh SRlfI-AI'1. VlSSA
0715100,177
MED 0546 - 0] 30Y Iv! 06/01/07
000748298
000553

KEY: v' WNL'!
0(
24
KFI
Apj(
task completed
of<
= See additional comments
Use bolded key letter it indicated
Abo
Peri
A-'
W.'
S~
D-l
Coil
WN[
LEG IH
. HAND R
GRII'S
Size
Pac
m.
TErI
SCr SCI
Abnormal breath sounds
Specify abno 'rnal breath sounds on di3gram
TIME TIMF
AV Bru
Her
(Absent, Decreased, CRackles.

Rhonchi. Wheezes, Coarse)
!cAl
I Ole
POSTERIOR
IExit
PORTER!OR
PATIENT LABEL
DEPAUL HEALTH CE;L\jTER

OPM-10l0Tl (412006) PAGE 5 OF
MARC,PRILLIP rip 0715100477 ~mD 0546-01 10/02/1976 .lOY M 06/rJl/07 SRIRAM,VISSA 00074$29a
DP~
'UIIIIIIIIIIIIIII
000554
24 HOtJR MEDICAL/SURGICAL PATIENT CARE RECORD

KEY: /WNl'S or task completed
* = See additional r.omments
DATE S T A R T E D .
24
KEY;,
Use holded kfTY letter if indicated
..
Til
AAbsent
WWB2K
SS!rUfltl
DDopp!~r
Color romp
~en&atQn
I~
Urlna p.
Unne
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Foul
IW!t)
Fr~q
It_M11}11S
r--
1 8t111r
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T 1
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= Tra;e
=
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IT
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-
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h E
I--DEPAUL HEJ\L'fH CENTER
I I ,
I~
II
B
0
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0715100477
UIU.IIIIIUllllllUlllnl~
MED 0546-01
lip
10/02/1976 ,OY SEIRAJ>1,VISSA
M 06/0~ /07 000748298
oPt.
000555

KEY: ,I WNL '8
:f1
.)( tat~
DATI STAHTEO
wmplBted
f,,.
= See additional comments 0 NA
Use IJOIded key leller It Indicated
4tj(PI/(f]
1
24 t
Tfmll
Typt
Lq~If!i~"
1~9mprem~
Qt~vilY
I
i
!
~li!mptl!!
f'at~lIt
I'!!tf}rm!tt~1
I
I
CQn!inY!H!~
i
;
1-- I
Feul Managemelft System
AM
~ . . jinlj
-.~.-
PM /-D;;:i-;;B"'I.=';ck-';I'-:nd;;'lc-'c~t"'orc.;li:::-ne:':':v-;-ls:;;:ib-;-ie----------; RetenllOl1 baUoon ~ ftiij jiij iii!i ~ ji!iiiii Retentii)11 b'E'1Ioon amOlml: . ! 'f' al' ~"'IIIi.iUiliUil~~' .~jr~ ~ I~
o Black maleator 11M \1slole
o 1r.~3jed and deflatert
n Inf!at~d alii! nellilted
is painless, 3{) rtilJllf millimum 'IllltIme.
Uliflll ~a(, yelk/H to amlnr. odOOe~; urin~ Row
iJrine cnlor/clam;: BlOOity ClOt Sediment Fuu'smtll~19 r.:1.01ItJ;.. OUWf
v ........ -.-..-----f--f--t--'4--+---+--l--f--I--+---+--l-+--+-+--+-I--+--+--t--'-+--I--+--+--i
I )
J
I\bnormai urinal!' voiding pattern: InllIlti!JPIIL FrBlwency, RIl'MliO', UrlJMCY, DYSiirt~
/-C:-8,,-t.::{OO;.;.S,,-r,,-rit,,-~,:-)_--,-,-,-_ _ _ _ _ _ _ _
--
+ _______________.__ . _._ ...... .
Deo cun:luit
(de,~ribe)
SKIN RISK SCORE SUMMARY (Circle score in each area and t01al. Assessment frequency: once per day.)
moist
: Hffi R (L 6itllerfll
\~
Al!nW
! CUi-l\l,
'Wlluno vaG
'!
tl1.4f"'~i
tnvfm
C~i;'
.mm'11
foam
A
!ilJ
fiLTER"') SKlNi\VOUN(I KEY. PU ~ Pressure ulcer II preSSUIl! ulcer, list Slaqe " II. III, IV, UNstageallle
SL D
e EX H
en - 8rulS&
= An'asian = SUster = tlyth~l1la = henri.llnn = Hemaluma

Q -
= Inci~ion
4 H.-,ity , MID" 8 rnvls!!i

f
I.
R
= laceration
P'\J.!HI.
~.oo b;'
- [}enutled
= V~)Cufili vlcer
insHIlir.ifI(Jr.y)
(\'tJ)OUS 81asis. arlCfi(ll
- R,h TS ~ Tape bum WA ~ Wtll Jpproxlll}lted
&
= Neuropathic ulcer (ulltl1;Ocl

o
- Other
[lressinq: 55 = SIGn 5Inj'o~ D = Derl1'AloOliO

8 = St.3p1o$ OTA DIlen to ait
Wound 8M Key' = Gr.lllulaboo

~.
SurrouMlng Skin Key: Drainage fl'lle:

I = Intact E = Eryt!rema M = Mar.",""" C - Cyanotit.'Dartl
Green
Drainage Amounl'
lie - $c!m $ = Sm;llJ
5
&
Slough
~ ~sCh>f
R DI
M
= rnniY ____
Treatmeftl
=Rdenj... ""lUll'S - Dry and muel =t.luflly".II"'Y"!TaVS
o-
OIMr
0= [jill(;!
S "Serous $1iI = SIlrOf~fl9lijMM'; M PU - Purl;lenl L j - illOlXly C Y Yellow
= Mr.d~ra!;;
=larqe
=
GOIiirn'"
C "emslv
9 - Olnu
Time
WOUQd
Bad
jSurroun,olng I Drainage ~moull' at Odor Skin Type Drainage YIN
" Indicate,
ReasseSimenl 110 Cntn~e Time ana Inllisls
UNR
C"J
Isol.rkil
A
---.-~------.~--------~
~SSM
h f A L T ti
- '" ;... R t-
DEPAUL HEALTH C,t;NTER
24 Hf)UR MEDlCAUSURG1CAl PATIENT CARE RECORD

OPM-IOOO-071 (4f200S) PAGE 7 OF 8
rJ'!~'~'~~pllllllll 0715100477 MED 0546-01

10/02/1976 30Y SRlRAM,VTSSA
M
~'
If
It., .
iI P
DPM1
06/01/Q'/
000748298
000556
MEDICAl.. f SURGICAL RESTRAINT KEY
AlImllid i..\!in I~ ~V~!~ RUlli!!!

1 CMlP/IO on)i1,;l!';;;'~vr,1Qn
MfDJeA! Rfim 1m 8t$'r.,lq1

"'''" "', t{, TF. ct<)
I!Ulralnt fnUt:aIUln
flfltll!11ffi! timo a!Y.Ilal!'oi<, (Lij, Cl ..
Tlj8111~
2 Ctw>qr' I e:;mm.re ~"'" R.< (n;,,-vli

J
EnW~nrlfNal morop!1atllM
1 Pml..! ao M!d!<JJllirway aM'>l!' O"l'~ \!o'~'erl' (ego, to 111~)jt~ilf r:!IIh~l:n~b~Vt,.lt.ltjl') hba.\}

MmlllllllWlSm W1 OlltlD!$ m~j\ 10 !I'd! rn:mlltn! 01 trt II.Mia-'1s' (:U((P.I~ r.filidhon {s Q", 5[)/j &I)'Jrtt 01 !\utr'tHiit
'0i1.'l1l. SOUJ'iU. cIt: I
111l~b*
to wntrJct Irn
Uf~ty
(1llll1
!IIj"a~. ;I,IIWI, ',,"";;~
r.r lin e~uCilllli" 1m>' >rnI('.a!es lo!"''''r,"

v.ems if,,,;o,,,sj wlln ltarlltL 1 H.llOO fOC restrnnt
J
"\",~~"O:;filfrl f~n811;t116S
"Hlqm alt,! A?1lITi (WltlllQn

MW!t$i~ Dlvl'l;~ ae1Mly
rJlI:dbttiDn tfjmm~ll;.Wtf<1 llllrylk.tl'JM}
2 Cott, l~ ""I III lobes, Im\, ~IC 1 Ad;,I1 rlil,n1m~rl:~ fISt of f!HIU'r 4 ~Oil to fI(lI{fR Crmlr.q;. S\f\..... ell'
5f).f-f'!(lF'f,llrW. and t9Str:a-mllB'fll,T-id:d
l'i1i?n~1am!'"
Ii.
"li",<ati""
tp."krub, id<'IJ'. ,/.,l'5. """"', .~: }
C1lur,O"..,
~"I.ly al P>~ln1> who M& ncapMtated l(~m i\tl1~Url or H~~I procedure wrm WiJUW ;.,uft~ hx !1Ift( l!~u:ry If !hey halfi: ;~C-f.sg...e I'rnmmel1l b.!Qre Ill~ "",dic.~ ap;>rapliak (e.g., "",,"nitl IntllitCS or m~\I1", .uryeries)
3 lrUlr<\)il'Jc hcqx'ncy
4 Dflla'/ior I"""ITel.! 101 rtllliw<I u

n~YIORAl
Of tWm to ~, Or rAhm (ne Ilch~I'icf.1

R~'lr."\';l
flfSTR1.JNTS:
OllIe. (<eQU~tl n.,.,ah" Occo~~l!liOOl
Int:
A(J\\IITY
B= tied DSC = Bedside Commode A - Ambulate D = [)~nglR C ~ eMir
PI;}SITIONING KEY
~SSM
" I' ~ I 1 H . ,
II P; l
DePtlUI Health Center
24 HOUR MEDICAWSUROICAL PATIENT CARE RECORD

OPM-1)CO-{)71 (412006) PAGE 8 OF 8
000557
A Y~~ltrQlly'~ WI, ,~y TOlfay'i WI, 15, '21

I{mp
24 OATESTARTEO PREVIOUS 24 lfi!;. Intake Output ~ ISOLATION: 0 Special Contact 0 Contact 0 Neutropenic 0 AIrborne [J Droplet 0 _ _ __ SCALE KEY ~e~ I S~ng 0 'NIChair 0 Slmg OTHER PRECAUTI014S: 0 Safely-Fall 0 Bleeding 0 A!>piration 0 Seizure 0 _ _ _ _
Kli (PlOi.e reGIIRGilc weiutJl dmenmcil If gntilltr than 2.5 kOJ
HOUR Mn9lf;LlSU']f}C..o\L PATIENT CARE RECORD
<R ('>to)
~:
~1E~~~~~!~.~~~~~B~~m~~~
(~
R~~
OP
P!oIs~
~~
::.. 'J
1'7
'~i"~~-+--+-~~--+--r~--~~
~7..
flATlN( SCALE!
iCw~t-tl.'\ :;.f~'J':\:
~/vvmV~V~VLVV~
!ct Ilc'(
~///VVVVV~
}(Y')
b.';'-1)OOGr,
INTER'
zj
~
1-
ITIME
P Of
p
. TYPE
Tl\Gount
JJ(
--
ORAl.,I1UBE FEDINGS
URINE
OTH~R
076D IJ~)
080D
0900
]to
1--_10--+1)0_._+=1 S=:=--,Q-"--+_ _-t- ___ _ 1100 <;\)

12DO
1400
1500 1600
~
1100 1600
S"lJ.
#tI '\. - - - - - -
L1~2~IlI!::To~lal~P~~lti~lIi.::"d:':::;~ ~~";t.:.-,t!f'~~",'A',~,':).t'~'....,...E12..'::hr~To~tal Oral-1ube _ _ .---_ _--1

ToCOUnl
~---
12 hr . "7 ~ A..tJV Sub Totals --- ' - .....-.----.-"'lr-;-:--
---t--~ - - - - - - - - - 12 hr Sr,ilt Output
BEHA"
AN. II"
,,~
12 hrShift IlImi'
Em,
t;; Irl6ffl!
1900 , 20Ull 21aO I 2200 f-rr=~9==~==l=~~===1==+==l=.' , 2300

_741]\"
0- fJ<>y
INTER\
<_ RtOi,
1.
H"".
ESlar
3. GUidi
4. eon3
I
;
--
r-_~10D
U100
1\_ ~rl1::t1 7_ Enw
oaon
~OO ~SOO
D600
--"-----+-----~----+_--~----_+----4_----r_--~----~----+_--~r_---
lln, SubTolaiS _ _ _ _ _ _ _ _ _ _~ _ _
12 hr Tolal
Or3Hub~ _
----y.;~t--
l(hVj?
____ _
j 2 hr
---Shit! Output
..-----i
TW~flly-four
hOur lOla!
Twenty.lour hour lolai I
fL\JUHQUIVAl:KTS; 1 or . , . , ... :\Oml
4 oz (1/2 cup) ,,' 120mL 6 o3i4 cup) ,180mL
80l
(1 cupl ' ,240mL 12 Ol (sooa-l can) ,. 360mL
~SSM
J1 E' A t f H
C It R "
~
HE" L
24 HOUR MEDICAL/SURGICAL PATIENT CARe RE.CORD

DPM-1{)()<}-071 [4r.!O(6) PAGE 1 OF 8
DPMIO(
000558
DATE STARTED
24 I
Burning, CHronic, COnstant, CRilmpiflfj, CS - Cn~sh'ng, aJI.tlr. THrobbing, Other: __
HOHVy,
Intel/nitta"t, NV
PAIN
RATING
Velbal
Non-vo,b,1i
2
:l 'I
,
~~~::, ~
'<.llt4-.;,~~..'ff':
b"Ut)ilfl
.
I
I
'I
!!
10
--------J
---f--
N<"'
f"fU~'
o
4 - fW/;,>allU>
10
" !.'I-i*~~;
~r ..In-'
I
t.'oa/ll~
I
fu: $t~" "11::
w;vwrmll
CQr'$\j,"lt rnv..r~r<q WIv'i13ff~
Site #
INTERVENTIONS:
1 - M-v:i!&a1hHI
,~
5
6
=.
5~1t.'lirn,"q
Sl&tmefl~
AmbuloliJr'
{- IltilIWi' 6 - a.,e;:. br"~"'"Q
SEDATION
L.EVEL.
30;; Fft'quenUy U(l1Wf.y
S -III"
Touch
!;omnolent. Iiffic.ultlO j'W$-~
# of a
BEHAVIOR/RESPONSES;
AN = An,ious E \;;fThJl.......al t: "t",y'> I 1~lfiC"''' C- lpmg
D - D6Ijel~1'lW11'31ImpairmoEi'l1!
M - Mulllp\t R~w'SI C - Continuous '>,.ing DE - Oei>",.,ion

C - Gti.',inS
L
0::
U Vn<"bDOflOP/" CO ~ Comalos~ CI - C"~niliv~ imp<>itment

R - I'I%Ue..
0 ~ Ove-{'itimu:late-~tQvar-ei:tlfvi}
CD ~ Conlu;WiDiro,."te<J tl = Ha\luunalillnsl Delusion; VI ~ O.hb"raltily WI1l>holdlnglnlQ

A - Attention Seekir<q
DP - OfSwp~tvG Patient
os ~ Di~.,upfiv(J
SiIJ!lffif.f.ilttl Ctti{!f
s ~ "lnnrJil1,1
Q:(;"I",/<::,,;/,I COP .. CU\JPt~!~i1i'ln
l::
Ihreatt3nt-ng Pr')'ica!
HarrnlCQ!nba{iv~
LA
=-ltl~;& AII)itlUb
f-----------------------------------------------INTERVENTIONS:
,. H-ea-Hyran(,11 Pah&nt
2,
RE<ftfe.(t~n
(~Igf)iticant
L&lhalqic-
1M - Impul$l\'9
0t"'" ,
UlheI
8,
J.
G\.li.a~rl:\,.~
4 con,iSlenl C 'WOllf'f'l.,~nt I RovUM: 5 E~fSbijsh rna ntsiMO tffrIei18mM !ot c-afe news 6 Enr.:UIJmGfl 'It :mn117ntinn 7, Efl{;tJUrdy~ p1:h~lI ,'lilh dt."Gh.mH SlInking hH I~il!f! f\:i"';CrlS
p, 10 l' 12
1,3
Qift::l 11I:i:quunl Lmj! I.'t!fllm:t Pr{]Vde inh:mnati-on to In(..n,:m!;~ 1t!II'l:l u! UHtbn,t;;1H!JiIiO
14 \5
Ae:Of!efl! I RemOl.WBle f ne!iHH~ (BC19

nI.".r:1~U}t)-al
j)('..1Jvi~i43s
10 oung Wi lanuliaj-' obtav1& Prov.qe r~pK"~lqn Wl\h m\l"~, ~'T!~Db g~\lP ~g~Wlr!ijl r!l!f1;!>l't r{t~{ff";:~~!! Cn:CV\ll_ge IlIJ."Plftlsle-.ap cycfe by USing lndjr&Cll~ghlSf"'J9 aiiljt' cf~(... Dtvwen r/l4.Y'n " Umiliog tOUCh I
~IlC{"f1.lfage lamlfy
16
i1
l':t
P'0ir:,Ii'''''' mcmllll~'!' Rg:Hi.li1f~! f Rytl!l!~H~ll! f}nt* dm!j{f;qt~~!
HI'. t;S!ftDlt5h boundallw

PrC"Jide intenS-h'-i" e~.ul'lty ~nd i;!f~ty to minmiz~ behaVIOral PToolem'J:
1T'<9~$\lI\l-!i
OH1r.f 'linn 10 rifT.ra--D':..-e palh;mfs r:Sponse to stimulation
PI1T1FNT i IIRFI
DEPAUL HEALTH
~SSM J" :
H ..... \. A R
1IIIIIIIIIIi, CJS!'/TRR
'
Ii~

OPM10C{)-071 {4!2006} PAGE 2 OF 8
MARCH, 0715100477 lip 10/02/1976 3 MEO 0546-01 RABMAN, ANWE~ 0: r1 06/01/07
PIiILLIP'IIIII
000718298
DPM-1'
000559
24 t
ACUI
Pom!;
26-3r
38-5:
567e
71-8~
Site #2
SitE #:\
# 01 attempts Ie r IV restart
84ge
961~
121+
.. REal
NOTE'I
FRONT
RT
(/
H\
I'
.........\
I
LT
j, \
II
! U ' ttw
I. )I(/c
Lt\j~
\I
\
G
A
;
vtwi
;'"
I
~.
'\
St;; Singklt.llfl('fl
I"f !/ J /(
I K II \
OL - OwUelU/llf<l
ll.C ~ rf';pIck."IJl:"
('l!iH:a(~ ~filriJ)n
I !\ \
~ )
01
RIGHT
P
WflJtli. ift lHtN1fiki.l.
\I,A~~
\.
Insertion -Oale
Arm r.ircnmterf,nCfl em
Length
em
Dressing change date _ _ _ __
r= :
C
t
:E....
t
~~
+
r+
GUI
EVe!
DEllAl.IL l-I8A.LTH CENTER MARCH,l'H1LLIP
IBJIIIIIIJIIIIIIIDU
lip

(4I2OOB) PAGE 3 OF 8
0715100477 MED 0546-01 10/02/1976 .'lOy N 06/01/07 KAHMAN,ANWER Z 000748298
OPMil
000560
24 HOUR MEDICAWSURGICAL PATIENT CARE RECORD

--------
DATE STMTED
_te""-'>.-1_, . .1_,,'-'-..
ACUITY LEVEL ACUITY TOTALS Points Level Subtolal Section "Au

26-37
IA
':Sf
,"
'I
38-55
56-70 7183
84-95
1 2
Sub/olal Section "B# Subtotal Section "C"
",)1
+ REQUIRES FURTHER DOCUMENTATION
~=-
96120
____?J_S~IT~~ 0
3 4 5 6
TOTAL POINTS
ACUITY LEVEL
.~
DEPAUL HEALTH CEN'l'BR
~SSM.
hE"A .. Tt
\iI\R~
f4ARCH, PHILLIlO'
IOfHillinIIIII nu HI til 1111
l/lJ
0715100477
lO/o2/19~6
MRD 0516-01 Jor M 06/01/07

OCO'/4!l293
24 HOUR MEDICAL/SURCICAL PATIENT CARE RECORD

DPM-1000'071 (4i200QJ PAGE 4 OF 8
RAHMNJ, ,l\NYfER Z
000561
..------'---------------------------------_.
KEY: ./ WN _'s or task completed
,.. See additional comments
------.

Use balded key lener if indicated
nATE STAmEn
U 1(1(n
2
K
~nM~~
u-....
LOC
Spuch clatr
m~~~~mmmm~~mmmB~m~~~m~
"/
r;;
All
.J.
Ab
confused, Lalhargic,
__ _
I: ./
/
i Sp9llch (Ap~ie, Delayer!, Slurred)
w
5
;i ./ ,. / /' ./.' ,/ ,. / .' ./
IMoves all ettre-mf!l&<; wfttt equal strength

Motor response
iAbflormalHexion, Extension,
I
/ /../
,I
I /
ARM ' R / /
./ L
i . / / ,/ ./
/ /
i
, ( (
.. /
i /
./
f //
.,//,
." //
>'
/
Flaccid, LI),allw" NOM.

SPastic, $'rorg, Weak,
~EG
GRIPS.
H/
/.
/
.. /
//
..
/l
/'
'
L / 1,-,'
,/'/
//
/'
/' /'
/
,/
1/
/'
./
;'. /
/.'
,i
/
:i
1./
/
1/
/ ,..
WD-Wllhdnws)
Tremors
8-Brisx &-.S!u-ggl'-sn
PUPIL SCA1,E
''It!l1' 2mm Jmm
C-Swilf,HV
[.m.?eO
liJr-m
Ff~ed
4...
4mm
HAND R
L R
/
/
;'
i,
,/
','
!/
!
Ii
Ii
//
Size
,
i
./
,/
:-
_.
,
.// / '
S p -
R Reaction'
L
/1
Bmm
?mm
// /
.'
DysptlaQla (Present, Absent) Numtrness i ,Ingling
T S
S -
Abnormal breath sounos
TIME
I:
Specify abn)rmal breath sounds on diagram.

(Ab$~nt
I).;crcased, CftacMC$,
Rhonchi, Wheezes, Coarse)
-Bf H c Ex
D,
POSTERIOR
AI
Respiratory 1'1I1}11 IJ"'~W' OV Abnormal nsplralory effort

Dyspnea (on Exertion. at Rest)
Cough
IDrnnfll'.tivp,
, Ab
~
-A
~
~
Be
Cough and1eeo
In~6fll1Y6
breafn
18
~;!,
&J irom6tcr H mL lit mps
l Suction (~l!;al. Oral. Trach)

,raw care
St, ttf---
FI~
o Trach IY!l8 _ _ _ Size _ __

o CPAP QJ BIPAP
Settings
0 CMV 0 SIMV
"fillialUf 11111111111.6..
Nl
B: Tu
i VentilatOl
satllnll (verH16d per order)
PATIENT LABEL
/
SSM DEP4UI. HE4LTH CENTER
"VYVV'
~ ~
DP
:0;
{412000} PAGE 6 OF 8
000562

KEY: I
'NN!.'& or task completed
DATE STARTED
* = See addi\lonal comments
_-""C. .(..:..f"_It..'-01",--_ ..
24
KFf:
lise holded key k}tter if indicated
AAbsent W-W8ak 5,Slrong DOoppler
Color temp s3nsation

\'ttr.
~ ~lU
Urlfle iHai
Uline
IJW oink
~~p
ret&!; l<~' INn 3 ,",,,<lQs,
Foul
VOidi lupr. Almo
FIlM CBt (, iltn G
SuPf~
s,in "<om \'i;1l1lul

Allfcrmtl
(l;
~nSi!
ocmtnlfi'XO Of:f,f:OOli
n'C{t t
Draln
:~ II'iwt'
I Skin'
Jaun
I N~ilT
Sflgl1f
m
Diillrl
Mut<: Skin I
Hefl
WOOf
If sk
1
I
I ,
~:
DEPAVL HEALTH CEln'ER MARCH, PHILLIP
IIIIIVIIIIIIIIIIIIIII
I/P
o
K
0715100477 MEV 0546-01 10/02/1976 30Y M 06/01/07
RAHMAN,ANWER Z
\<\12006) PAGE () OF 8
000748298
DPN
000563
~------------------------------------------------------------------------------------------
24 HOUR MEDJCAL/SURGICAL PATIENT CARE RECORD
DATE STARTED _ _ _ _ _ __
In.,
24
Voiding, Suprapubic
Strai9h! calli, Anum;,
ii&JComiuii
Abnormal urin3ry voiding pallern: Incentineo!, Frequfm;y, I'MerrtiulI, Urgelll'Y. Dy.ulia
Tnil1\t
I /
I
Sldn Intac! .. ",,"u. ~~.auv"o
If skin with a feratlOflS: indical siles with flUmbel~ on figures
ALfERED Sl(mIWOUND Kf'I: PU = Pressure ulcer II pressurf ulcer, kst Slaq I, II, III,
IV.
UN~I.ge"i)le
A
0
BL = Blister BA -- ilruise
= Abrasion
L
WA
... Dtnuded
- Rath R TB .. TapcuuiU
= LaC'l:rJllon =W~II arWnx1mM.1i

--
Im:ision
V
N
V~Scul2r
ulcer (vennus
S!a.~iS,
aneriai
insijlht;rdnty)
= Nel)(op11ltiC
= Erythp.nu EX = E:<wrialiun
= OIlier
Drainaga Amount;
SO ~ $canl iii = om,~1 I.
uk:er (dI<10e1ir,)
- Hemaloma
S~jn
Drusln;:
WoUM
G
S
B~d
Kay:
S5
o
= n",m.hnmj
=
51",!i stnps
$la~
= C-nnulabon = illrnlflh
~ ou~x
SurrDunding J = iO!1
E
Kay; Drainaga Twa:

Q
=
~
= Guen
~ 'ytN<lllil
iii
PU
= ~ellJ'J&
S DJ
M
OTA ~ Ope" III iii! R = RGtllllUIlli SUlUfBt
I! - [schar
M - Mawatioo
C l:'(ilHO\it;!O",'.
$S - Serosanguineous M
o = 0111'21
= PL<oj':Hl
8100lly Olher
- MO<ierille = UYg<!
Ii
Y
C
o -
Dry alld i,~_.l:! - Moo!\fomery straps
= YeitlJw
- Crusty
= Coptou~
00',
Trelllme~1
Time
Wound
Be\!
Skin
Drainage I~mQ.unl 01 OdDr Typ e Jraimrqe Y f N
Iinditalts
RltaSSIl5Smll~!
I/o C~~nQe Time and initials
1---+----+---+-----1----- ------ --
-- --
-- .. ----1~---t----+---+__-_+--_t_-+----
1------+'- ---+---1---+---+----+---1---+--+---------------.----- ---t-------{-----------!
.
~SSM
fi E: A "- T H . CAR E"-
~JIl!~'H~!~ltIlIlIID
0715100477
10/02/1976 30Y RAHMAN,ANWER Z M
l/ P
0007~8298
o
000564
H l ,
24 110UR MEDICAL/SURGICAL PATIENT CARE RECORD

DPM,1000'(7i \4/2(06) PAGE 7 or 6
MED 054 Eo - 01
06/01/07
DPM.
6l!e1M1iXlUllfO IU AYOIO flelllBim

1
cr:t~ar i{l.nsf\~'"5i..>{:ter~s}Qo
l! ~MmJU ~Xt~Stlmij
MfDltAl Rmqn In' Rulrp!n!

f\'
tmlillll~
rrill Rllnn 11.,/

.l.a-maf
ft.!J' .01"
2 CMJ'Vjt
fh p:-C'fi"L ntJ;.ol) 10
r. 1;/1..'.!
1 P:t1t.aC! a.<} ilft1v:.4.l ill:1'14t 100/(1:( Oti9~n

l1yinl.lfl1'Hl"hh idtlJ4.<' .:\-I;h..18 !.m,I!~1
d-eiiv-ery
t~9 ' W
1)(~etim~.f4 !~r!la .,j
i I k"nhff 1(1 f:fnlrrilf1lfrf saf.ety
,.IJ >gl1 ,ftc)
~rr~11-r;1".,r,;;frt.a1
rrunpl.Hat1Vffl j/.:'.a!"
!'JH1f;;J. :;,t~!HI 'p~I:t,~1
Mdil1!dfl IiWMft~ lifl'~ Qf M'<s N>tnll~ I~ Il'~ Vlilmfrn QI \1".(

!'dl'lY.ljffj nflf ..,-U {,liH\l~h1n (a.ij. ~.fie S.OOff;ti 01 rm:1lltOl1, mtJI.HCillim ${kl!~~~Nt~}l1 i}1 "Y!!H\J.fil}
Vifrnt. s-POOSt, elf) !,/! m <:d!J~:j*HI bell
ln4!{'"~~s fl}luwm~
lel1\\ dluvmo ~jlh IUIW

J
rli:!lllt ,ien!all~"
Mt-tJ:t-;:too fVl~}3U:YI
j 6 okerskflil.adf'lit{ ~ar~TtJtvJ. ~~d~y;. w;.:. lf~Jt.I;. ph:.)
7 P"a.1:e1lt: "amly {'dOC1.ftk..lfl
R,lely 01 p3Mots wCD .,. .."aNClU'ad bom an iI1IUfy IX m9'ci pmt'twrl' wh!) ,l,J,mkf "-,<)fill! Iljltll:~ qmy J- tOif}, h,\,ti! f.:rU;;;@lJit movement ~e1or~ ~ i, me~k.lv 'W'opmjr (r 4 ' r,imnty
l1<tlUfel f!f
1 Hdsontor I13YJiH,"li Asr.f.!.t.!m(l\ lit/I.f f(~tM't~';. Tna! fclws~ freq.t.(f";ucy [JehifJ"lll-r te-CfJ1t~d fOt lemOV3!
B~HAVlOlIIIl
2 Cool 10 ~uf> 11Io}es, j,'t~, -.t~ A!;liray ,lm~~;J.JI,'Iil!i ITf.> ill l6i,IHY 4 ,~_JPilil?to I?lfIV'1! a/mirV,s, IVV~I,~
, GmolptntlYff a!Hl J"Bif<:ilni
I~fl.lmw.j
Ol Olin', ~ ut Of CIlia"
(tel: Bna\'i~nj
'8 AM U<IJ .\.riSf;" ;M,,,,,,;s.,li ,d-.","l hili

9 OHlf.'.1
'/i,"" sJ;r~~''''j
CVA,.i!).
RESTRAt.'ITS;
Ott", lrequrl!
Br~tfaiAG'1
~mati,e
dowmwl:nlQn)
I:l
B\)ll
ACTIVITY KeY
BSC = aMtid~ CMlI'Mlie A = IIrnr,lIlatR
D = Oanwe C Chall
POSITIOIIINB KEY
DEPAUL HEALTH
MJl..RCH I PHILLIE'
C~NTER
~SSM
fiS;I\LlM
!;".i
111111111111111118111110
Tip

DPMl(100071 (412006) PAGE 8 OF 8
0715100477 HED 054&-01 10/02/1976 30Y f.1 06/01/U7 F--AH1<IAN, AmqER Z 000748298
000565
24 HOUR M~~LlSURGICAL PATIENT CARE RECORD PREVIOUS 24 ItO: Intake Output 1'2.1)'() ISOLATION: 0 Sp~cilll Coalac! 0 Contact 0 Neutropenic
0 Airborne 0 orople-I-O-~~~~==_ StALf KEY. 0 81:0 0 Stan log 0 W/Chair 0 Sling OTHER PRECAUTIONS; U Safety, fall 0 Bleeding 0 Aspiration 0 Seizure 0 _ _ _ _ _ __ Yesterday's wt _ _ I(G Today'! wi. KG (Mellie feConcile weighl difference if greater than Z.S kg.)
"T"llIAl,"
JUN 032001
24
H~
TVP4
DISCOMI
I
T"np
Ill!
//'.
Pulse
R~sp
~..
02 sal
02% iRate
02 deh~wiY Iklit~
lIN-- ")1
1-'~ ~\/
1-'\
100 if.t
1t1~ f!,o
,_
I
X~
,,// / / '
PAIN RATING SCALES

iC~d"'I)VlI
tl1'S<~Il~
,~/
,/,/ l,//
./ ~
~'
11'f1 ~
~um
i
! ,
.~
J~ V,
[,,// /~ / / ' ,/,,,- //~ , / , / / / / / v''''

i
//' ,//
,.,/,r
,//
'.\
INTERve
'
I
6f
///
IE'
~
TYPE
]0 COUll!
lIm;> O~ ~
.f
TIME
l\l
IItsP TiMI
TIME
liP
."'-//
Iruu
RESf'
'nMr lME
iru~ fifSf'
EMPH
/J
.--' ,..--"
~rrr"
//"
//"
.noD
UI
aRTHa
UloTIC
TlMt
BP
/~//
/-/
TIM
p
BP
..-~..--'
",/'-
BREAKFAST
J'I
LUtitH
t~;takfJi1
fllA' U
IDUI
[0,,-
\nn},
"..-/
URINE
Amount
Q.I)
~'
,.,"'-/ .
."_....
l
()
f-..,PiZ.J
DINNER
HS SHACK
"'" i'
Am~
I
OTHffi
N.,g
I(Ft.1I
"'.
ORAL
ORA' JTUBE FEEOIHGS TF fillS"

Amount
'f'\
1
1M
i
AmOlmt
~I~q.
~nl
IVnwllt
AmQunt
. Amoont
Amovnt
Q7(Jl\
080.
09110
I J5 SO
,Jftr V"'1\.'J
.~~li
'-/V'
--jJ) U
hUX}
"-
/ ' ;1
100
10(10
1100
i}
I () ~J 1200 I~(
1300
50
I.
f,
C)
I/)rH)
"...
1400
1600
If
Cl
(~
....
.-
'/OQ'/Ol;!)
1600 1700
laC:
!S'O.
""'I
c~
4."'"'0
~OV
1600 /[JcJ
Suh Tatals/:1O cL ~ 121r Total Parelllolal _ _
12hl
tJ ~~l)
12 hr TOla! OraVTutle .-/) 12 hi SinH In\il~e
To Count
f--
1900 lUOO ZlOD
)UllI(
.~
4 Dv- ~----U~
12 ~I Slull Outrrul
'AI \-VJ
, BEHAvi . AN -Anx
E ~ Em;'1 1=IMffe(
D - Oeve
~1nO
rQ /" J
.INT5RV
'.)-'tU
! I. R.aH
Redlre
CCflsi~
Z4C11
non r 1>"'-'. 9'D 'l~~
9'(.2
3 C"IOa>
1 /0 ()
_.
4
~
6
F~Wb'
EO(,"TilJ
~100
llZOO
OJllD
(J'I)!)
, Ill/\""
7. EllCOU
c-
!l5Dn I)MU
~~
'
S'TI
12 hiTot"ls SilO
----kUtV 1S'
_
r';JA...
hV
.---~11 hI Tntal ilrRI/Tube _ _ . 12 hr Shitllntali
j
-n
12 hi Toto! ParentEla) _ _
._-----12 hr ShiH Output

""''''T'IVOI IWU I
I~'"
I. a'1 U
.~
Twenty,faul hour total

FLUID EQUIVALf IITS:
+'7
1;..) Ic-r
/'l
.....
1i){Lf-'
~\.)
1 01
30mL
[, oz (3/4
4 02 (1/2 cup) .
Clip) .
12Dml
180lllL
8oz(lCUp)
12 Ol (SOd~l
.. 240rnL can) .
.
!,1ARCH I PHILLIP 07J5100477 MED
C1:CU
PAr lEN [ UifJFL
~SSM r
I-i
L , W
c:
Ito
R EO.

~~
1 at HllDllMJIIUlIIlllUtHUU
rip
-01
:)~46
24 HOllR MEDfCAL.iSURaICAL PATIENT CARE RECORD

DPMl0CO071 1412006jl'l\bF 1 OF R
10/02/1976 30Y
r:AHr1AN I ANWER Z
M 06/01/07 000'/16296
DP"HO(
-.
000566
D~JE STARTED JUN 0 3 2001
24
Burning. CHronic. COnstant CRamplng. Cs Crushing. Dvli. H~avy. Intermittent HV NauseaNQmlllng, 'ressure, Radlallng.lharp,
THrobbing, Other: ______.' _
PAIN
RATING
SCALES
(C~d,ll'),..a vf~4;,.~vm
---l---W__ -L_l.. __ .-
(;
7
Slw~.JI
C~H
S
-,,~
OO'....NC"i"l
"1.'\.V!.Wth',
'1"'po"tl.">ih~pain
HI
<". GsJlBitl:nlj
I.
I
.............
tJV'd'J'~HY
Site
Site
R~~'l>~
'o.\">'ftllntffifIP"1I.
'f(!iI~~r~ul
inTERVENTIONS:
{ - fiHaxali<m ~ - [dc;ll.m"U
7 - !m~Otfl
staternems
6 = TOl1{'h
s ~Hwt
Deep biNillg-'i
R :i;k:r.p 1.A.,,1 2 :;; O\X.;J$iol *dily illOW:-iY

easy to amUS9
Site
#
f1) -= G.tl!ll
09 10 11
., .
1
.!'
'II
ex:
,
'f
:~:
BEHAVlOH/RESPONSES:
AN AtlKioo~ i: .. lmohon 11
I t"$~,;C1'" , Ct-!"\) o - Oefe~Tioenral jmtHtff11~i'll
~NTERVE~
M - MvH'Plf n9q"~~t
U :: Urvesp:on,tve
CD ~ C""jlls<IlDlgQrl<>nled
os
DI,mpH".
~,q",jtO.'\n1
5" SleePlnQ
C'
l);strSS-6
ClJI\tlnuou~ CIY'''Q DE ;;;;. O~prF-;3ton G:;;; (lriC'Anq
ct
CO
l:;l
~Gomruose
H"
HaIIVt'lnM~J D{>IUSlOn~
Other
GopP.fk.'B Imp.:urml'nt
R('~;!k:',n
R =-
W ~ n{'fi~rrrrclv ~Yflhhmrlinn Inln A =: AUf:nHwl Sn(}I\JIIJJ

OP ;;; D\~".Jf..i'Jfv~ ?.Jh~.litl
~ ll~lhl'ry~~
o ~ O,(llf~.kp\.Jl~ih'U./O'I:Il~~~!..tI"li
T =- ThmalnniPl] Phy~\.l{;;:~1 MamU'CuHllMl*Vf:
o =C~lm(()U!OI
COP LA ;;;
~
Cnnpt!nItNl!
llrr~., hl)l.f,.,'U~;
1M;;
llllp,,)t.<Vd
~h$t
nONS;
~~H,r,t l St~rvk'ant Ol~{
1, Ki'.,i'iS"'foi n,~
2. Hemroct"' ....., 3, Guxlanc~

4. (;!iSfsteH: E<i'lverw.'nl
j
Offer f~li:ent bf~~1 ...:ontaet Provide mformaliort t~ I'~fi"a'it! l~y~j 01 vnder:(.andtllg
1J
Ri-'(-{rent i Remr-tt.... ii;:t~ f
nestallng
f~ct<;;
15
16
Dh:-ersicn.ftt
a('.\Mti~s
10
n0utme
1i l;t
En>:.our89.f:o 1am.i1v Ie 1:tIinog In t-aml!iar OOieCt3

PfD\'k1e te~xatlOI1 Wttn RlH-5It'. 1fl1Rqeri, i.1e1J'P breathmq. pr(\;'(. mE-(t:c~wor. Fncollf~ nnnn>11 ~ir..np r-yI;lC' hy tl.'~flD iod-iJf::f"'; !~bljn!l ilttf:f dWlI O<:it~,i. .'H loot1l / LimJl;'\I to'.Jt:b I
Ou~l sIgn
E'S.tsbhsh rn8:lnlamed lane1fames tOl car~ neett.;' (; E-nc:ourti5 c vmhav-.l.'unn 7 _ Enruu'''1i e J'd"",rt ..mil doc"""" """IIV 101 C3ru lW6ds
17 I A:
PrOtlrlj'l. fltEtSWe-';7: R~1..3$e'3.'3 f Re.qu("l..sh,"')f1:1 $rr,-k r,1:uih.-,..,!inn
E\tabfihh fmuf!llw 1t1~i
13
HI
Plo...ids:
,{lttn~y'B
6eGtlnty and 8te-ty
lTIoa~\}r~:5
to Q9{;re.as'G pailGn.I'o nnpon6-O- to sUmvlaflQn
to- mmmllz..e beha<nQf.)! problem$:
PATIENT LABEL
DEPAUL HRALTH CENTER
~SSM
HIAt.')
(AtI;lE"'
24 HOUR MED1CALlSURGICAL PATIENT CARE RECORD

DPM-l00{))71 (412006) PAGe 2 or 0
lip i-1ARCH, PHILLIP orll51D0477 MED 0'>46-01 ttl 06/01/07 10/02/1976 JOY 00074.82;18 RAHI'lAN ,1\N'I>lER Z
IIIIIIIIIUIIIIIIIIII
c ",
000567
24 ..
ACUF
Point!
26-37 38-55 56-70
71-83
84-95
96-12
121+
FRONT RT
81
= .<;":<;'<B fuIlH!ll
llipl"
M_ru~eMmn~-+~~==~~~'---I~-=====~~==~-+~~==~
111: =
full".
lj"~""'Ni<."")Jitl" '" IV ()(/ hr~ pto.ide1.
InSHrlion Date
PA TiENT LAD'L
~SSM
k l 1\ ""
1 t4 . ,
1\
R ,..-
DEPAUL HEALTH CENTER MARCH,PHILLIP I/l? 0715100477 MED 0546-01 10/02/1976 30Y M 06/01/0'1 RAHMAN,ANWP.R Z 000748298
lHUIMBlllIUIHIUIUJlIU81
(2
"

DPMl000'()71 (412006) PAGE 3 OF 8
DPM
000568
JUN 0 8 2007 r:-;::::;-:-;::;:~:-;::-;;:;-r:;-:::-;-;::;:;:;;:::-:~::---. - . Patient Care A.c.u~itiYiiRlI!elIclo~r.d l:O:j:J

DATE SlARTED
~SSM
NrAllll
C:Aftf~
000569
24 HOUR MEDICAL/SURGICAl. PATIENT CARE RECORD

DPt,',IOOO 071 1412(06) PAGE 4 Of 6

KEY: ,., WNL's or
ta~k
JUN 032007
compl&ted
~
Follows Mmm,nM
*'" Saa addiUol1i'll comments

V
Irm m~ ~ III IE III III IE mJD~~ m Ell

V
Use
bolooo key leiter It indic<Jtcd
KE
Jlmltta~_am
I
ILOe
'Q~
""
CUnfust:ll. Le\l1arg!c.
In.
~
~
A
Speech (AI) lasi~. Delayed, llIrl'lld)

. Moves
Motor rBsplllse (AbnormHllieKion. ExtensIOn. Flacr:id, LOi~diiles, None.
, with equal strength
"
'V
- .'-
SPastic, Strong. Weak,
WDWilhdnws.l
Tnlfflors
" l R ... ~fG L HAND R /

GRIPS L
R ARM i .
i~
,:"
/
..
.'
.v
/
//
s-
....'
,/
.'
/
/
.
I
D-
i/
1;/
/
,/
Co
WN
1~111
,. " ~.
i"
:'
1/
/
/
if
./
(
"
".
./' //
,,1:<
i/,
.;~
/
.
./
.. '
.:'
./
;'
('
./
I vim
tian
L
......
I:
"
/ i/
/
PUPIL SeAI.E
BflliS\(
8--S~liguish hnm ~mm ~"tmm 4mm
.
&mm 7mm
'.fmd
O-SwuMnl
Closed
NllmhnR~~
.lmm
ee
~Il'llw~
Sizp.
IH
l
'"
.,/
./
/.//
'1/ ~/
... /
./ I
../
./
./
..../
l
l/
..."/
....
.//
. ...../ .//
Reactic'n
I~i L
.'
. / .....
..... /
.-
.. '
./
...
// l/
I
.Sa
Pa
Dvspnagla rPresent, AtJseoi) Tingling
IE
Fadal drool R f L
~,crlUl'
Clear
TI'tJ
~m
\
Almorma! bteatll sounds Specify HhnOlmal breath sounds Of] diagrilm
1f(f) tJ
2
~ IIIIII 1m
(Ahs6flt, Dmmed, CRaGkles,

Rhom:hi, WheeZES, COarse)
~~~V~'l
l
11l"~~~
V""--"" \
~'
""',
n
3
I
i
TE
Em
TIME
..
~
2
Il aD as
_-
POSTERiOR
~{?, ;= ~:
j
POStERIOR
R
I
= =
am ~
l1\UI] Gil'" i UlllWVl cu
li
i
V
!
I
."
... "
At
At
B( B(
Abnormal p:splratofY effort Dyspnea (01 ExerVQn, ~t Rest)

Cough (Prc ductivo.
HOrtprO~~{tive)
..
Cough dnG jeep breath
\.X
incentive ~r lromekr ImL I '# mps

Sputum (demioe amount, color,
Suction ("'1531, Oral. Trach)
.--
1-"Ir'
"
.. " .... -"
I
~/
,,'
.' .."
I
. - r--
,. "t
.. p'
~"'
-,,"
,-~
lrach
CHr~
o Trach type _ _ _ SlZ9 o CPAP [J a/PAP Setlings

I Ventilator
NO
liemnos; 0 CMV 0 S!MV m'l""IVI """"\1 (verif~d D",ord&r)
Tl
o
S'
Comments
f---
S
N
CHEST TUBES
L.ocatlon
Walet S$al
I Time
8\1ct!on
Crejil1us
DraInage
I
PATlf.Nf L48fL
o
o
... /
..../
//
SSM OEPAUL HEALTH CENTER 24 HOUR MEOICAWSURGICAL PATIENT CARE RECORD
DPM-l000011 (41200S) PAGE S OF 8
_..-
10/02/1976 30Y RNiMAN I Al'lt>lER Z
lIflARCH, PH!LLIP 0715100177 MED 0546-01

M
'1111111111111'111
rip
06/01/07 000748298
Df
000570
DATE
STARTEJUN 0 3 2001
24 H
KEY: I W
~ -~
~-Absent
~~
WWeak $-Slrong
D-Ooppler
Color temp sensauon
1V1t'. - 1ll1! ~~ pm!.:
rriisle3,;th~3 SOCt
Urine claa
Ili paln!e!l
c<~
Urine colo
'1&;
Fwl-sme
I VokIlW.:
llin W~f/l1 ""~ f!lll f~ 11~.
tiooto(ijl!lin~efi1Jl
3otn:<rmalmoclftS
SuPiaput
Aonormal,
Fr'tqu~nc:
II T
= tiona
= TracR
=
1+
..
IIfJlO Eondt
GSI (aBS(
I------,-
IS~~~
I Dramage 1
80n$ory
Cumpletel
VOIY Ilmit! SI~hUv lir Nnimpalr
Skinwam
Jaum!it'
Diap~o~
Mucous n
SIdn IniaC
Heel proc
Woond'ia
If skin wi

OPM-1f)(
000571

KEY: ./ \\fNL's or la(.\( romplolM
DATE STARTEOJUN
*" Sec adtJlllonal commonts
0 3 zanz
241
usc oolClocj key tonor If ll1C!tcalocl
Awm
ane
SJI
Resiql'
TIme
Oa3? V
TVil51in
Com,
call
2 CIl.lf\ 3 Er,,1*'(
'1 ktaM ~ Mel1'!
'I
= f'ros5ure ulCel
A
I
L R
G DlVffJ
BL
~s!
ff pressure uaf.
IV.
5liIQB I. II. Ill.
UH.i.gcabl~
- Vascular ule.:r (venou; slasi~. am,!'i,i

in:;ulfiutil!l;),j
o
Ii
BR
7 PJ1Iet 6 Al>d t
T8 ..
EX
H
lilA
= Wall ~ppr,)>dm~tsrt
Oln~r
T3~B
[rum
Olnel
flWlno
_ _ _ __ Orainge Amount:
SO - Scam
8 .. SOIal!
Ile,,'opalhic l~e( (diabetIC)

G
Dr&s$ing: S$ ~ Slen l1riP5

D = flwTIdonnrt
Sla~IIS
~
WOlll1d Bad Kay: ~ CrenoIH!ion
S
OTA
1I1lw tu
.:!lI
e - (,ch r o = Ol.lrc r
a = ;::;Jflll9t
Surrounding Skin Kay: Drainage lypa: I ~ intact G - Greeo E = h\<1he.m,; " ; Seroo\
R DI M
= Re19lU!&l W11/I~ = Dry "rid .<1,,;1 - Mont90ffiffY ~lrap5
o =
M - 1;~er31!(1l C = GY<ll1tliJl;!i)u.k
$$ PU
SerosaoO\JinWJs M = PUiu!clli L
=Lllrl!';
,Moderate
Ollml
II
'" 8111lllfy
= -'Iellow
'" COIllW!
(ltllcr
~ ~
C{U!tj
Other _ _ _ __
~SSM
N i
It l T H . C A It E'

DPM 1000-071 (412006) PAGe 7 or B
MARCH,PHILLIP
071.51.00177
Imllllllllllllilifl
MEl,} 0546-0l. 10/02/1976 30Y M 06/01/07

RAHJ-mN , AN.... ER Z
lip
0007482~t!
000572
AlMrfttl!m W I 10 Ayold I\W,.w

1 Ct)rnp,m.ilJfl$hp':~p;:ri(\silJfI
MEJ!!CAL NUri hi! 1Ul'lltillnl

1 Pmt,,:;! an MN,c.a1 MI'W3jand!()( O-~YQ"" utl.'e,y (e.Q._ III tlt.11H\'1It'l fNtdfJJra:""'el1r,lf.ru~ lIIDtis)
eutraln! E4uuliM
r~{::tlmllnl
fif));1' ;lJvl IalfMf (I Ii
p.
TfiSI Rilmt Kay

1
\h~hla
2 Cillf"lt '" Pdllnairocoo$U"" It, l",.v."_",,,1 I" IV IF ",,1 J fINfOOmNil-J! m;mf\1ill;!liI;11S 1'' 1' ' '~U'>l' sl;IIO"_ f'fll'I-;(ji
c*liql1t I'lC_I ~ R:e:ailW GriwUlkm 5 Mellie","," tnrua',,,,"
-& Qh,"t'Jbiml.M'fivily (lPttHlIrS, vilfFJ]:I;.. wi6~.. ina~~ir., Mr, )
pMMt..
~lii..l5C. f.!{l;,)
tu ('illl1l,V.J hlf Mftlt

int~_ fit,
1,,1Il?r>k- e.mfll ctoodion (B.y _.<>It wu;,e O\rurtOOIlll,

rncdk-uHun ijtkmriQr;!w~1 fif lrjdf.ttf#\)
:1 !i'!~ly
"' .\DIU, t'l'!!f,.l~s MMm menUtl tn 1h! lr~a1mM! ~Itm
('/l an eOl!ca-tloli txlY M,cCate:s fo-~lYh'iflQ

Ril''S Wv,ussoQ ..to Iwoe" 1 RMWn 101 r'>l'l<l1!
2 CQrl- to pil.I allubes.

4
~~~
3 Adivuy ,r",,..<5Ir.llfl,; "" of mJf\'

In I!"';''t Grt!~"'I1. WM<j, tR
i PJmwt"f<ll1'H, vtJtI''':.;,II~lH
v
oIIBt.,nl, wOO dr' <lGlp3CiUU~ /rom iIillrt Of IUi9i1:a! "",wi"", win, WD,,~j "Jr" (",Ih;" 'illry j tlJi;y r.l'" "XC""';,,, maVenWtll !!eWe tt is meQicalv S{lC(illl!i3tt (c.Q . cJirmr,iy
o\!.;;..$!~~MI\FJ11
hJM k10le-g
ffC"QUl.:ri(Y
lri:J.1
re-Ra:~.~
5-
C~Ni-(;l;m. . .f, ~ntf (Eo...~1~1tWlllM~d
4 ll<ha>iqrrtGUirN /0( ~"Will
Ii OIllafm
f
t~
sell
Qf 0'J1~' (S&~
ntu'/tO(1\I
R~sll.inl')
Ahdbllll~:'Sh!l ~kp.,.:(~Sit#It&.a:!iU~
t>att
fluMes Of ~asru", ,"r<)elie')
U BEHAViORAL ftf8TflAINTS;
Ofna. (I<1!Wf.S ~'T3INe
OOcu"~ntatbnl
9 Oil...
Alltrgy baM
!soorn~,preGmOOnSWM=========J~~~~~~~~~~~~====~==========~~~~~~~~~~~~===-------~====j =
II B~ll BSC = Bmlside CommGOi!
R = RighI
~
A = Ambldal6
posmO~INO
g: 6~:e
E-
KEY
B $ p
Left Back Sell
~ I'!~n~
DEf'NJL HEALTH CENTER
~SSM
If: f i l l t tf '
t " "
24 HOUR MEDlCAl!SURGICAL PATIENT CARE RECORD

DPM1000)71 [412006) PAGE 8 OF I:!
T<it\.RCH ,PHILLIP 1 071510047<1 NED OS46-0 14 06/01/07 lo/o?/~976 30\' 000748298
1IIIIlIUtllDIl11RB
riP
RAHMAN, MlvlER Z
000573
24 H
'TYPE
OlSCOM
I>AIN RATING
SCALES
{(;'-1<,.1f!tyr#
IJI
!~~fl.l\-'M
b~!>ll
iI'h~i-~~(!
TIME
~p
P
-
:~:::~, :=-.---"
HS NACK
ORA./TUIJEffEDllfGS ORAL IF FLUSH Amount IIlHUUllt AmQunt \ 11!1~INE r_==DTtlER:..:...,-_---.-----::-:-:--i BM Amount Amount Amount AIfIUFI~\l.
\l U'fU
Am(j{lnl
fl111iluot
~n!
0800
(}900 t---I---+....C,-",/\+----t--~./.,'_f'~f::T-ILL~,I+_--.1 11100 .LJ f ....
1100
i!!"""'
J
.-
12tHl
1300
1400
1500
1600
12t.rTui<iJS,(_ _ Sub 12 hr lot" Parents'al
lAD
I '~~
-1JJs
c;u
___ .
_ _----,,,,.-_ _ _ _ _ _ _ _ _ _
To Co~nt
1900
M:') LA}
12 hr 1o1al OI.L'fuM / 'sht 1make 1('\
_____-
I)
- -
ElEAAII:'
AfhAni r _ Emol
I. Int:ffc
0: Dmtt
12 or Shltt Olltfll.1 . . . , - - - - - - - - - - - j
20llD
2200
INTERV
i ?,
Ri)Oo/
~~211=rOO~ _ _+---+--_+--_f~U.r_--+_--;_--,r--~--_+--_+1'4~O
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Rmiirl
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ti
7.
CfK'Q\
~~Dll00~~_~~~--~--~i~rJ
020g
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nlX"J.
.90
.,---+----+/~[J....{'"""--+--__i,---t__- ..l
e41111
0500
0600
'''''''1"'''''' 1111"' ...".,

flUID EOUIVALI,NTS: 10l ...... :IOiliL 4 CIZ (1/2 cup) . 120rnL 6 Ul (3/4 cup) ... 1 BOmL
'W~"'Y'UU'
flUU,
'u,.,
80, (1 cup) . . . . . . 240mL 12 oz (soda i can) . 360rnL
PATIENT LABH
~SSM
tt E. ALI I{
(;", R
c'"

01' 8
DEPAUL nPlAl,TH CENTER
"'ARCH, p'UL1'.IE ~
1"
11I1111111!'IlIlll.
x/p
OJ
H E
If.
24 HOUR MEDICAL.,i$URGICAL PATIENT CARE RECORD

OPM1QOO-071 (412006) PA.GE 1
M"D 05~6-Ql 0 7 151004'/7 '" M 06/01/0 7 10/02/ 1976 30Y 00074 8 )98
R]\HlJlI\N, ANI-TEl{ Z
DPM1D1
000574
24 HOUR_M_E_D_I_C_A_L_/S_U_R_G_'_C_A_L_P_A_T_IE_N_T_C_A_R_E_R_E_C_O_R_D ___ D_A1E STARTED

./ = Task oerformcdllmcrvcntion
TYPE Of
DtSCOMfC'RT
* = Significant findinQ documented in Nurses Notes. Use hDldect key letter if imjir.a!fld.
_&_l~tr::::::=:::=::::;
24
L~tW 'Pl W V....>Jll7f'i-ltt ,,,~.~ !-='''''::;'''c::.'7~:...",:;;.fE:...J...;I_",..,......,...._ _ _ _ _ _ p,_",_ _ _ _ _ _ """,_:.h.iH ~~l!
~~ \~ll ;J~-v;:\W
..
Aching. ACute. Surning. CHronic, COnsl,,,,!, CRnrtlpihg. CS . GrushinO. Dull. HeallY, Inletmittent, NY Nausaa!Vomiling, Pressure, Ra(!iath1g, Sharp, 5Tilbbirrg, T-,,".'.'n':'.'tJc~r:...T~H~rot~Jb~I.'.'ng,,!:.:..:O::::t~h:::'-'r~==r===============T:::--_~:--_ _ _ _ _ _ _ _ __
,,![~oo'r'~ '+---." I
4 5
. SHe
10
$C(pn..;J
t:...1'l'rn
'J:r!JT'J.Gtv Mu-;"'~lrJ _"_';_""_'''_''''''''' __ ' _w_'_'''''_om_'<_,"'_ _ _ _ _ _ _ _-i
Site
Site
#0
INTERVENflONS:
I =
",,,,,.oon
= Sleep
I _ 1\1<>"
r
R
COMMENT:,:
BEHAVIOR f PSYCHOLOGICAL
BEHAVIOFIJRESPONSES:
AN - A(>..Y.mu~ E " CmoW"", \1 OiSlfUS t = In~fftelw.l CopInq
M ~ MuIIJIA~ R"'l,,""i
[) De",ehp n.ntallmpN'm(!'" INTERVENTIONS:

\
n~~ss.ur.ante ~
L : lelh",9'c
A
1'0
1:t.
~ 3.
a =GII~V"'!l
C .. ContHlilQ'"u5 Crymg DE l)"prosSlOl>
VnH3SPQl)sh!I' CO = (;Qm~I<'$~
=-
CD
Conlu~e<lJUi500enle<l Dolibe(~~ly
DS - Dl""pt~
H - I!aI~JCinalion>l D~"sions
WWilhh(>ll,'I1ng In!o A " Attention SMkirq DP DiSlupWe PaJi;>nt 1M
C;ig'llf",...11 Olher
T -= Threslenin.q Ptrysir.al
Hwmi('.oml:ttlfi'lf":
~ !mpl1t!~~ ...n
CI -::-
~ni1lve lmpaifm~nl
~----.-----------r'alleftt ,? Siqniflf.Rl1! OUlt;:'f
o ~ O""'.tin-....I..ledlO""'MCUV.
n
ottw !m1fu!~Ht bJ~f \.J-uutd\.l
R - ResUess
5 = Sleepmg O.CalmIO"iel COP GoopNnJNf1 LA !!! tm.~. An,'.l:v.ru~.

OH!w
1~
H.~
AOOfe<:h<n
3. (':Jli(i.lJr~:'<I':
4, GHP!!!~itfj! fHytl'H1IfmUl!! fiY!J!ml;t
PH,J<'ltlt.-: V'lkmnatKlI1 to jf;(;-r.ea&e !~y&l Qt i.iflOV:f61ijl001rl9 Encoora:g~ lam;ty hi Qrlrfg Vl famillbr ObjitCl$.
r,I~"'f~ \...-1th
16-,
17
He-o,ien\ I Aemotlv.a-te J OhierSHi-naJ ac-tivihes f'foa~11ve meh9.0I'eg.

nea~s.eS!i I
Re'lti\\lI\9
fa';t~
,1. fr0.'!?'
Dar\:~tl
musK:. imaQery. deep b{.eath~l prayl'r\ me'lJicaHon
"6.
5. E~.tabtsh rnai("~lah~ twnafmms'G kif" Gafe ~Ws. tncO'iH~& Ii' wfbahJ:ation I. Encouta~ e patient Yoith dt-cJsion malUng tor ~~le Meds
Ef1Coura99 !lQrmal $fll"fP ~:(C!.v- by osir\g iradlr~tf flghHr~
ani'! dro'k
is.
1!=t
Ar:que'itlOn I Seek C\.'lnf<C-lltoo
:i=,]1i1hit.;h h::)Hooadr:!:
(CUlM lllmflltl-lJ toUth i QuietslflO 1[1 rlr-..rrn:lw. rmtkml'H f(~~$K1H:';'~ {J) S(JflW!a.!V..ul
?ruvitfu !f~e'l!:>l\,r! sth.utity and safety maaeUfeS to min:tmlz-e OOhiJVlQfal p{Qbfllm~
~SSM
w r
A L. T I C A. R
f".
DePaul Health Cente1"
IJlIIIBIUTH CENTER r'lARCH PHTLLlflflllflH 071

I
DEPAUL HE:
5100477

DPMl000'171 (412005) f'AGE ? OF 8
10/02/1976 30Y RAHMAN, ANl'lER Z
X/P NED 05 46-01 M 06/01/07

000746298
o
H
DP~
000575
24
ACl
Poin
26-3 38-5
56-7
95-1
7H!
Site #2
84-
121 + RE(
NOTE
Site #3
Ii of attemnts for IV ffistart
1fT
r-
()
/
I'
--...,
\
\ I I.
.~ .=
$im;Jv/HWt)1i
/'t ( L !j J
i
/
I" \ 1\ \
f ) \
"
OL - Owv/e -,,,,,,,," 1/ C e T11m,
""'' :II
~~
ll0ic31e IIJrztlOO Di
IV on Me p!tJ"&.t;:d
z
Dre~~ing
Insertion O~Te _____ Lerl(J!/\ _ _ em

Arm circumlerence
r.rtange datf. _ _ __
11NJ
l,\}~
----------.--------~-
P4T1'NT i "RLL
DEPAUL I!EALTH CENTER
~SSM
N[lLTH
C"R~
MARCH,P.H:U~LIP 071~l00477 MED
!IIYBmlmGIIIII~1II10frn
O~46-01
rip
o
"
(

DPMl000C71 (412tlUfj) PAGE' ;1 OF A
10/02/1976 JOY M 06/01/07 RAJ-IlvlAN I A}JTtlER Z O O 0 '74 B 2 9 8
OPN
000576
,.~
;
\

Patient Care
ACUITY LEVEL ACUITY TOTALS A P
DATE STARTED
Record
Points
26-37 3855 56-70 7183 84-95
Level Subtotal SGCtiOll A" 1 Subtotal Section "sn - - - --_._-, 2

3
4
!l?\
.. .Qo
iF'
Subtotal Section "e"
r\
TOTAL POINTS ACUITY LEVEL
iZ4 lm
~,
'
1-PI VJ
96-120
121+
6
7
Sitter 0
----
~SSM
lif"\.T~ CAI\[~
000577
24 "lOUR MEDICAUSURGICAL PATIENT CARE RECORD

DPM-l00o-011 (412006) PAGE 4 OF 8

KEY: ./ WNL's or Wlll\ oompieled
DATE STAflTEO
_~ { '11'1_
~~ .. "imli;~IIiIIllIIlIIIIIiIJl.'iUIl~~EII _ _ tlllIlI
,
* .. SOiIe additional comments

/
Use boldeo key lattAr if indicated
LOC
, Speech C!ttllr
Confus6<1. Lethargic,
I'
/
SpeaGh (Apllasic. DBlayllll, 5lUlrel1)

Moves ...... equal &trenglti
/'
Motor fE spans!!
(Aboorrlal fl9xion, Ii\d:ension,
Flaccid, Localizes, NOllt!,

SPasti(;. Strong, Weak,
WD-WlIhdraws)
i
Tremor;
PUPlll;CAlE
B-6ri!;k
$-Sluggl ih
Tmm
FFi.M
.
cmrrl ,:Jmm 4mm
(lmm
CSwol~rV
C!osali
,-mrn
I Dyspn~lia
(present, Absent)
1~,"nI"" , I Tingling
-
Imm
Size
,
,
//l/
1//
,/
Reaction
~,
L
/,/
//
/'
POSTERIOR
Abnorrr.al respiratory &ffort Dyspnea (on ExrtlOn. at Res!)
I
~
ICough
productive,
ICough ,100 deep breath

."
""
:
'/>
."
>.,
i
..
..
ISuction (Nasal, Oral, Trach)

Trach care
..
i I o TraC1 tyPB _ _ _ Size __ o CPA) 0 BIPAP Settings -====-l--!--t---+-+-+---l-+--+-+-+-t---+-+-+---l-+-+-+-+-}-+-+-!

I
I
V"fllllal01 SeMlnqs: 0 CMV 0 SIMV __-4__

. Ve.nl\lalor seiling (verified per orller)
L-~-L~~~~~-L~_L-~-L~~
I __~~-L~_ _L-~~-l~__1
Commnot-ll
CHSTTUBES
11nw
LOGation
I Waur Seal
Sucllon
,//
I cr~Pit_u
--~
__ S -+'_Il_flI_i"_a!l_ti-j
I-lARCH, PHILLIP
\ ---+:----1
RAfrMA."I,A.NWE~Oi
15100477 MED lip 10/02/1976 . 0546-01 !'of 06/01/07 0()0748298
/11111111111 CENTER "II 07
DEPAUL HEALTH

DPM-1000-071 (4/20!J6) PAGE 5 OF B
000578

KEY: ,/ WNL'" or lasK completed
DATE STAR.TEO
C {y
241
Timl
~ See additional comments
Use bolded key letter if indicGlt!;u
A-Absent W-Weak
a-Strong DDopple!
ColOllemp ~ens3!ion WL = fl.~ 1",,1 fri '( Cilp
rehnsiffA ~ s >t~Qs. s)in )"l,:llm wHh f~l ~"r;J
lirine C iSpllinl
LhillC C
tit",
F<lul'SI
Iron 1D tnocn. ~><;u 'bll()lmaJ 10 fKlles
, Voidinl , 8!Jllf31
II = None T ~ TJal:B
1
I Fr~Qu6 I CSI (Of,

IIlMf.n( 15lIpra I
IOraina{
/Ahnnrn
= 1+
I Compll I Very ur
i Sli~tl~
Sklnl'l
E
Javndi Diaphi MUCClI Sklnlo
H~el pi ~'Io\Jf\d
INu im>
If skir
DEPAUl, HEALTH CENTgR
~SSM
Ht'A\.lH'if.AIi:E
f1ARCH,PHILLIP
1IIJIllIlj'IDIIfIIIIRUfI
lip
00074829fl
DPM-
0715100477 NED U546-01 10/02/1976 30Y M 06/01/07

RAHI'-11'IN',ANwE!{ Z
24 HOUR MEDICAWSURGICAL PATIENT CAREt RECORD

DPMl000-07! (4120013) PAGE 6 OF 8
000579
RGfCAL PATIENT CARE RECORD

Use bolded ky letter If indicated
DAlE; SlARTED _"-<"'--_--'--,_ __
lu
24 ..
Hskin with aile!! lions: indicalB sites wah numoers on fi(Jure3
ALTERED SKINJ\l/OUND KEY: PU = Pressure ulcer , If rr~ssll'e \flce, IiS1 Stage I, It, III, tV. VNstaQeable V ~ Vasclilar ulcer (vooous S1,1SI" artcnai
N
~
:::
Ah-fa~1Dn
Bt.. - O~ster BR = ilrui>t
R
TB
= Inci.~ion - Lacer31ion '" Rosh
iIlsufficiency) Ncu,ovaUlic ulc~r
(UiHIi~tic)
o - Denuded E '" tlyUluma EX = FXt;omtio!l H = Hematoma
WA
= Ta~~ hum = W~~ ~pprOxiillalW '" Other _ _ _ __

lie ;
Drusing,
as - Stell ~tr~
D = Ol''''dIrJ",j -Stilp~ S OTA; Open to .~ R ;o;!{iI!I!flMflf{llWM DI = OIy a~d intilC1 M - Mnniryflmmy !\llar.s
Q $ ~ Ii " 0=
Wound Bed KtY: Orarruillion Slov9!1

[SCMf
Surroundmo Skin Key; Dlainage Tr,e: I "lntitCI G = G'een E " Eryt/lemB S - Strous
M
~
Mlir.aratl{fi1
Cy~n01iC!DJrl;
QUlt'r
o -
Drllinege A!nQUIIl: 8c;ml $ - Small 88 ; &BfOsallGll1I!\,"'", M = MI!<h;.uP: PU - PurUlent L = urga
OIl.,;
B - BiOOOy
V
=
c.Jjiwus
YaUnw
11.0,8.(/1
~ Qtt'~I
_ _ __
C Q
~ r:;,u~1Y
Gali !lOh)
~ !!\h~r
OveroeO,
tin
C1I!n~B
Site tb. StlirWoaoo Driuing

i'Slaq., '
A<1"eG
Wound SUIfOllnding Otalnage Bed Skin Type
YIN
Odor
Traatmanl
" 1r.ic.le!
fleas$ceismenl
TIme !Bd Inlllals
BWlu(;h\
Tmlelmg
; Side rails
III burW
NlerQyb
DNA cod
I'l(MUOIl
~SSM
H E A \. T H
(A R f ....
OEPAUL HEALTH CENTER
MARCH,PHILLIP
24 HOUR MEOICA1.fSURGICAL PATIENT CARE RECORD
DPMl000-Q71 (412006) PAGE 7 OF 8
IfIlIlllIlllIlIIlI1
r/p
DPM-l0
0715100477 MED 0:;46-0J, 10/02/1976 30Y M 06/01/0', RAHf1AN I ANv-JER Z 0007482~8
000580
~HOUR MEDICAl/SURGICAL PATIENT CARE RECORD

I
MEDICAL Rmon jQr Riilrllll1
Rnt/alDl EdmIlllD
[),.'Il1en( \in1~ ;wj ~arne< (I~" PI. p-lront Spc;tl5&. ak;.)
(.") iii Jju~,lI}4J,j
DID! Ralene Kg!

1 iJf\ab{e In WrTtra,1 k'f
lll!h;~t'!.o;
"''''1' em.
Ql
tJi'~n!,
CnmpllfdvI'i'3trly.'SuoeMS%fl
n>l~ bOOleI~'QflW
II> !ree-(t.
"tro for IV; Tc ,'!'; }
\ PiOK:~1
,fH
,l-f\iJkwl.alI'l"\liY fI.J!{Vl}' UI.Y 1ll..'{l ~R~""\!I'f k.ll, ~}
mI'01/ff. ~Mw~,h.eW",'n..l ~~)
l El1VlcOOlerlat !11illlipiJlalii'ffi ([liar nufse~ stEIIOO 'il\t1i!l

fie"
M""PIlI illy",;i,-, b>~, III \!II), U~-'!!l$A 10 tiw i'u;,lnun' ullllU p,~en(S' wrolll C<)Jl(fticn (F,q, '01< ,IltlIN 01 "ullil",n,
1M'
fol\.HI',f.:jV
sa1.sty 2 COl'\! tn (XlI !l W~~>. MtS, <K
Aeatti ol1;>lllai()n
M~alic<>wiua1ioo
Oi'vfioiooa! ar i\>ity (_00'.
'00<0\,
Viall",
fll!lS!C,
ru;)
Paamt!1'1!II1i!y routalioo ? A1.1i,J birtt~,!l;~ 11 skt:'lw/Sl)Jn.'Ic'J.'5'iuU tN~

R ffirl.Jll
m!dicaMil ~(t11in.!l!aMn ()( ttrrjr~Wn) Salety 01 p.llrnls wim ,Ie in<<l)}.ct1.trd (rum an mit;ry 01 ""'Q~al pr(.e.aure wThO wClJiasufftr tur1J1tt iniln it m.y have frJ:tSliYl rrmemtlll baiOft .1 IS mtlltollir apvroproo 1M" ec.trtmily
lJ ilr).Ut"e::.-;
nt vM..t::atJl f'\~)f..Jiff;)
Rems dkeus-wd w.1lJ ti"J./rll,""t" 1 ReWlfi le< f<llrainl
ArJi'dr ~H1f~hilb:.s !id or (fit!~t)l)'

(:{)(!f~~ratia !11!l l'fl:.""r!lil1 !l1flH'tHd
i A!emi*"9 til femo'l<! arml"91. lIJ1u!\'t, <I<

5
2
.1
Asse~sma1l11rM
(j~,fJuirt';d
fume';
fur rrrr-.6V-111
loAf fi!l?aS:J! t(~lliHIC.)'
4 &L>h.'i}Vu.u
" Of nlrm to s!lf N nlners (st! [J,/la\1or.IJ
I!<-;l (,)
Pro!I'! lOa
~r;M tr~"rj'
palitn1 tt(>(lllonher in/li)'
I"'~"
eVA willi
BEHAVIORAL RESTMlNTS;
Ot~f1
(reqwftS ro''''Wl OOCUfflWl>lion)
jYAa~i~ Of
i1-aad lraun-u v.'ttll Mldmooal tili'tl'ia~)
ACTIVITY
KEY
POSITIONING
R L
KEY
~ Hight = left EI - Back iii = Sell
P - Prone
ri'};PAUL HEAL1'H CENTRR
~SSM
tI~AI.ThCA"C

OPMl000,Q71 (4/2006) PAGE 8 OF 8
MARCH, PHILLIp rip 0715100477 MED 0546-01 10/02/1976 JOY M 06/01/07 RAliMAN.ANWRR Z 000748298
1IIIIIDlltllfillfmfUl ~
000581
,----------------
----
-,
24 H
KEY: .!
"
RATING
SCALE~
i!:'-~~'~rYi.~
tJ<I &.';-..bJUWl.
O-a'~1Qn
1l#~;)-.)To(nO
INTERV
t
~,
2 ::;:
''/,Iakan
v
Tf I'LUSJi
I
(
\lOJ;')
v'V
TYPf
To COtlt1l
0700
"Dlr//.)/)
, _______ --j----::-::-:-:----r ORAI./T----::UBE:c:-: fE_EDrING-----:-S:-::--lf-;--fr-'-'"'-t-IIl\--.-INE_--+-___,___ T _ _ _ _~OT---=:.I!ER___,__----_,_-___l
ORAL
8M
_, ___ +__-+-.._-+-,-,AIT.l=OUnl-t--'-A.:.::=moun'-t-I=AmOun~t-=-lun=i.mt-1-....=milvnt~=IunOVn:.:...,t+-=-Am=Q~nt-1-A=l1lQ\!nl~Amo=un~tA=mt.!fr~eQ"
I ".,...
/4..(1 ( )
rt>(1.. )
,""1; U
- ---I-------+-It-~[...i;---+---+'II:-~:-=t"<---+---+---+---+---f-----i
L X'r D
l"'i )\. .J
1800
~::;~:::,/!!;9-~~---dlML :>~V~
10 Count
1? hr Sh~llnt~'~
1
r-.U
"
lX>O -------------12 nr Shift Output
BEHAV
"\
_,.-...
I
V"
AN An; E=Emo
,- ineffe
1900
i)
t> -
O~'It
2000
Z10\J
H:;I
INTal\
1, Reas 2. ) Guld'
Q
)
210D
\.L
\.
V '
n"",
4 '40.
~
F"ltnt
i--~,Q.:+-.u;,I~,;;/~..,C) ........ lLJ..-+---+----II----+--+-'--'- -
10
6. EncUl 7. t;flCCl
------
040
0500 0600
1v'\..J
lyV
--~.5
{1
/00
1 . - ,
________ ------1----+----1--+------1
/l ...
1~O\a1$ J;~ 0 0 r ~\J

12 hr Tnlal Pl!Ien! lral _ _
12 hr Total ~ -__
InMke
4<6tJ
tJfF___ _________ _
I
I ~ 3V
12 hr 3M! Output
IrP'J~';/E;:;] ...... ~L~--.-/-::-l
A..,/l p?
TWfnty'/OIJf lIeullotal
i...fC15t /
TW811IylOur b~ur hltal ,- ' /~

PATIEriT LABEL
<--:I'
FWIO EQUIVtlWHS: , O~ ,., , , .. ;IOmL
401 (\/2 GUp) _ 120mL
6 0, (314 cup) .. 180mL
8 Ol (1 cup) _ _. _240mL 12 OZ (soda-1 cao) ,. 360mL
~SSM
lt~ALT~'(A~f'~
'~
H F
1+

OPM-l000-071 (4/2G{)6j PAGE 1 OF 8
Ill-'M-l(l(
000582
DATE STARTED
Aching. ACute. Burning. CHronic. COnstant CRamplng, CS ' Crushing, Dull, Ht'ovy, Intermittent. NV NaU9saNomiting. Pressull1, RadietiJl9. Shu1p. STubDmg. Tender. THroO\m'9. Olh",
I I
10(~
o
2
4
"
7
"
J
a
,,
10
'Slt-w>l'~{
Q.l)jl'h~~~:;'
C.w.n
wI WtiNblm\l~~
fi,!Qo\:njfl"ol ffll!!'UVVl't1iml
F\etl.\.w~~
r-
S;Sk"'1l 1 ;AIe,1 2 = Occasronatly UtCf1'l8Y

~aij'
~
~
to
OV~e
I,
[.
BEHAVIOR/RESPONSES: AN " Ar.. Ow, - CmC{ on,1 0,.11'...
C =r.nnhnlJf1WI C'Y~l:!J
DE :;.OufMfJ-tif.illti G =G.Ji&'I1{ltI l.: letnflf9l{:
M ~ M"lIipl., fl,e<jll6sl
u ; ; . Unre.~p{m~lve
CO = f:mnnkl!Jn CI ;;: Cuymi!Ylt Itfl!J<WIll1:ff"
CD _ Conh,,,,,di{li3(lflenled H = H"I.""""lilllt!li nd,,";on~ w =DI~;I"mJlllly Will1vilit"9 1"ln

A = Atit!!!/J(jfj S~~k~tV 01' Ul.rupINS f'a(,,,,"
oS = [ljsllIplive Sinnifir,-iU,f Ofnr.r

T - Thff!iflnninlJ PhYfii:.a1
H<ifHv'Ccmu.;lli"""
o = C'-almt/)uiol
COP
S _ Sleeping
Cflufli~mHvH
I~
rn.eff~-Lt;i' C~n-9
;;0
Deve-Icpme,nftli inll=lS~ment
o =Ovan;Urnutat-sof(J\'6Hi.aCWIlJ
R" Restless
LA ;;;
OU~I:H
LH~'S
An<J;iuw.
1M
IrnptJ:SJ.."t:i
INTERVENTIONS:
nf~-S'IJ(B~~ . ra12~n'
RQ.1jl'~ ct~fi
/ '1:y\lhcanl Othet
lO
RI~.lrHf:
Ot1e, frt:qu.en! b-rtf:-f con~ Provide mft)lm~tion tD lncr1.il&sa lw-el 01 undefstafk..img

11.
!I~t:'dS
:.J Guidnx"!
4
fi
COf\."ti~;t('"nt
FnV-.l.ftlflffif:m;,
i="f'.(.'(tHrnqt' '~"}mity m Ollf1l111'l JamiH<'l1 ~('r.1S FfOvi.rSr~ Idw~<JUn.j1 with n.u,';ic_ lHtifQf.:f)" rtar.p hmathing f11nyl~c mf'rlf.r.iltlDfl
d'dd~.
E.st&:bt hh fuarnl::,wl:HJ
1!1l~h.m1e$
tor t..dle
6. !:.r,o.;ura.QEt WrOilHzatvo I. E.ncourage patte-m .,.,Nth de-G151O-t1 rnaj.:t'1g to: ,are need-s
12 E('iC(!Urd9~ nomlal s.iee-p (~}'C!B by IJ'3tfl{J mdw~d t'vltb!1tl drl~f 13. Van.'1 fWfl1l LnnfhnQ 10V~ ! ouwt ~gn (0 de-crease patient's respons-e to stiO'lvlatior;
14 n~Ofie-nl1 f1f:mo1ivet~ I n"5IaUn~ fact.s 15_ Oiv&fslo,'al aC1Mll.e-a 03 PfofH."1ive flle8S:O'.e~ f 7 Rn.'1.!'!>p-;;~ I Rflf1J ~f'~,;h!"11 I Sr.r:x rimilir-lltinn 1.8 Esl,~tl..rn~;h tx.mflfbrm. -;-; 19, Jo'rovh16 ln1tflSlVlt s6C.lJnly arvj Bclttt~1 mit:.tSUrtlS 1O minimize bcl1aytOi" a! pfobl'em.",
PAIIENT LABEL
~SSM r::"
W 1=' .A \ I W
R ~...

.
(
I
:~4
HQUR MED1CAL/SURGICAL PATIENT CARE RECORD
DPMl0(JQ,071 (412C.oo) PAGE 2 OF 8
000583
24
AC
Pol
26-
385671
Site #2
i
8496-
Sl\e #3
# 01 attllmpts IOf IV restar t
L+ RE NOT
112'
FRONT
Lf
BACK RT
flACK
r~
LT
51
! Ii (
/ (
II
L
(){ TIl:
= .'V",#- Im1l>!11 ~ lumen ~----t~=======i::""====I:;::::::::::::=I::"::===I::"::===l = UIpIa,\m>e!l
hiilitHf1.! fH1Arl~tU 1;1

,''t' {m fXH! protide(},
J / J
x _ __
Dressiog change dille _________ _
insertion Date _ _ _ _ Length ___ em

Ann cHcumfelence em
14#J
w Z
:c
c:; >-,
PATIENT LABEL
DEPAUL HEAT/PH CENTER
<fA;SSM DePaul Health Center

K E" 1\ l
rife
It. !t E-
MARCH/PHTLLIP r/p 071510U477 MED 05q6 01

10/02/1976 30Y IWU4AN I t>.NWER b
!vi
IIDIIIllIIIIIIIIIUUH
o
H
24 HOUR MED1CAUSURGICAL PATIENT CARE RECORD

D!'~\-1!XlO"071 (412G06) PAGE 3 OF 8
06101/07 0007182SS
DF
000584

----------~----------------------~--~~
l)ArE STARTED
t;.-P!7
i
Cryifl(l ---------------+""""'-;....-;-::--1
~SSM
IoIA ... l n
~~"i!~
24 HOUR MEDICAL/SURGICAL PATieNT CARE RECORD

DPM- 000-071 (4/2006j PAGE 4 OF 8
000585

KEY:.t WNL's or task Gomplet!l<J
DATE S1ARTED
_u=..:..:~~/'-----L-l_
KE
~ S~e additional comments
Use bokled key letter if indk..atAd
Ap
Ab Pe
AW
$.
Cc
W'
GRIPS
Size
s.
Pi
TI
TI
s
s
TIME
Specify abnormal i.J!cath soumlS on dia\lram (AhsenL Iloecreased. CRach1es, Ah:mcni, Wheez~s, Coarse)
POSTER!on
Abnormal i ~SJ)jrat()(y eftort Dyspnea (UO l5.~eftion, at Rest)
~~Ul
III I
Tr~f,h
carll
.J BIPAP
o Trach \!'Pe ~_ _ Size _ _
o CPAP
PATIENT LABEL

!>lARCH I PHILLIP
1.111111181111111D
MED 054.6-01
I/P
0715100477
lo/o~/1976
SSM DEPAUL
D?Ml00l-Q71 (4/2008) PAGE 5 OF B
H~L.TH
JOY
Z
M 06/01/07
0007Q8298
CfNTER
~~MAN,ANWER
24 HOUR MEOICAUSURGICAL PATIENT CARE RECORO
000586
24 HOUR MEDICAL/SURGfCAL PATIENT CARE RECORD

KEY: I Wi'll's Of task completed
DATE STARTED __
* : : See addlhonal commont"
fR/7
24
KEY:
Usc boldod key leUer II indicaled
Ti
W-WOSk
S-Slwog
D-DofJlllF.1
Urim
IS
Color temp ';ensation '11m ~ 1M ffi ~ e;\~

reM$ las!. troar~ :~ Sili {p\Q:i sYiv.ll wurr with uN 3.enSii-'
\fillli! !,)!i{,;h
pa
Urim Foul
ni wh~
voir
Sn~
$~m~i1'r:QlI1
Aboi
GSI,
IJ -- No,"
Freq
r - lra;~
lIeo I Supr
Orair
ISell:
TEDS
v;;
011
C;; removed
SCDs
.,: L Bilateral
---------------r-~~_+~--r_+_~_+~--r_+_~_r_+~--r_+_4_~_+~--~~
~
. SlIIn
Jaw
Dlaf
Mut SNn
Heel
Wou
R
(
~.
A}
~SSM "'ALl" CA."""
111111111111111111111 DePaul Health Center r'4ARCH, PHIr,LIP

07l510047'7 fl.1ED 0546-01
IT'>
,.
24 HOUR MEDICAL/SURGICAL PATIENT CARE FlECORD
10/02/19'/6 30Y
RAHMAN, l'LmlER Z
IIf
06/01/07
0007rl 82 9B
DPN
000587

Uw bvlded key leUer if indicated
DATE STARTED
-f':"-fJ(;;!:.L.+--7~-
24 H
Urine colo!!clarrty: Bloody C/ol S.dIIllRn!

Foul 5f1lal111g
~udy
OtllC'l
VoIdlno. Folay. : 81ralilhl cam, AlUIIW.
$uplapubic C ~th' Ilwtondul!

AblilJrfllal urinary IOldinq pattern: tn~ontinent R~l~ntion, Urn,lnCy, P'lsur'J
11 eOo:l~fl',l<""i
l CirinO!' 11
,,,,(hSU,
J tn;ilOflf
It ~n wIth ancr<l1 OilS,
ilil/i~al~ ~i!ij:;
wiih numbers un figures
ALTERED SKINIWOUND KEY: PU = PleS'!vIC ult:1lI It praS!;lIrR IIlr.(1r. &st SUM I. II, III, IV, UH!;t~geable V = Va:;cular ulw (veoou:; 51asi~, ailerlal
H
= AbJaslon BL - Blister BR .. Brul>e D = nPJ111rt~<1 E ;; Eryit.ema

EX .. hWffil(!D/l
,
L
R WA
0
= lacllfaoon = nash
Well approdmalr.d = OUlsr
Dralnalle AmOilnl:
SO S
L
= Incision
'1 Hll-Jilll'c, !,J M!dfC31n 6 o,'V",siiy 7 ~at!fTVt;
S Alld bm4
$ CMw'
TB .. Tape t.u,n
f\e(mo Qefl)(
insufflci~I\CY) N~UlWil\tliC ulWI (w~L'i!jjc)
H
I
~
Ilemaroma
K~y:
DIUSN1l1 55 - SrM S!(ipt
Wound Sen Key:

tI GrJnU~l!I,)n
Sorroumlinij Skin
Int,lel
M~r.:c{ltij)1I
Dralnaoe Type:
G
$
tI = Umn.ltlumj 5 = Slw9h Ii : fi,t.hJf S - Staples o ~ Other OTA ~ OV'''' to lir JI = ll~t~nMn ,'>I,tira',
~ [J~ma
= Grecll - Seroos
= S~an!
~
- Om.ln
-
M ;;
55 - Serosan!fJl'1wlJS M
PU B Y C
C - CyanO!ICiDMk e 0111",
= P,"IIlfnl
01
M
- Dry aM !nia-;1
I}
"\l'.Im _ _ __
Dlllinage Y l N
= MClfltl]WTlUY "ittJfJS
= Bloody = Y?i""v = (rusty

"lnn~
MOO?lale LalYc
CDptoU~
,-
_____
Indi~ates I
!lo, Siln
T:.,~~~r~OJ:e=ss:ln=nT~w~D~u;'nddlS;;;;;;;;n;;;riD),r;al~n~a9j;tJ,\Am~()U~;nrtl~Ofij(O~d~or;r-------:'Tr::8alm6nl
Bed Type
Reuseumont
No Ghanqa Time and Inilials
ACT
~SSM
".ALlH ("","","

e
MARCH, PHILLIP
1111111111110110
II n
~
2
DPM-l00
It E A L T
24 HOUR MEDlCAL!$VRGICAL PATIENT CARE 'RECORD

DPM-' 000-071 :4l2006) PAGE 7 OF
0715100477 MED 0546-01 10/02/1976 30Y M 06/01/0'1 RAHMAN,~ER Z 000748298
000588
24 HOUR MEDICAL(SURGICAL PATIENT CARE RECORD
I Reoponse 10 T"'''_ r":.<;,,,.
~
I
It
G
________________________~M~E=O~IC~A~L~/~S~U~R~GICAL.~R=E=ST~R=A~I~N~T~K=E~Y______________________________
~ 1 FNte.ct;\O a(tJf~ial 9:!'l't?I-y VJ1diot ~Y9;f! ol4Nf!Y (e.g, bj
AIlI.tMlim U$.lfl~~
I 1 CGmp.li'iOI1~Ii}itUOW-tl~jQn
i 3 rfl"fI)n'WAlffi' m~uii",,> (,";" coilligll1. lit,) 4 fItllllJy OC!e.1ta JOO ~atlon wUu.OOn
Clwtg: N~lm""'l>'_t R, (f\w.Ji, ","', In! ~l Tf, ,y;.)

I.",ff;
"tliTt2tn mdol.atfl!et'll.ltfl!til\iWll
"lak , sPI',,,1
2 _ ' " masr.'C W, (I: !vbls f,mo!hl 10 he
P,lloil!s GUlfMHOrnRl1jj\ ie,ij.l(>Ie SJ)Il'CI OI<l\.~.ltlon,
~ea{q""rl uilim
IIWllllntlw.;altim Docurr.ent time tiM ~3fner, (i.e ot p>rwl. spouse. (ljq

! fll,'><ifdo"esll.irlt
~~<l"<::::~ ~::, ~:,~~,~'loJ\Ow~
Tljaf BII.... hy I lo'rla.btf. to conlrar,t for Sd'cl.y 1 r:nn! to pHi ,11"0." ;nf$. <1(,
4 Al!","~lnrli'W'''&tW''9!,S>A''''~'' ~C. J CfrOPtfl!N~ Wl'J ,,,t!lim ,""'.(Ncd 6 ()j h.M' 10 ,.all .. ~ (... b'thaMIlI
J ActNil;' dem<lnSl"'o" ,isk.f rciiuf
I)ft'efSlona! at i\>it;> ~tJ.W.;:b"th.i, "-Hlntl!i w;tl,,;.:, Oilif.JC, sf<:-
nrrof"llillll dUmilllStr<l"'fl Of hy(!f,r.'O<1} ;; SafEty 01 paliWl1~ wllQ a" intapv.itl!<d fwm ar, i0iu'r (if 1UfQ'-nl
jlmr..8t111jEi
, PaliH~'1-anW/ ',;WJa;dl~H A.M bltxk:l;~~ n !hR't'ffi>.-'3fMHlw.JnJ w~
mowmt.1l! hchYlJ it i~* WK~i:;rl~1 fractures 0.1 Y~Ctltar 5Uqcrk<i)
wt-.o- ',lr!Jjf liuff.tJ:i furmer )f'I,fJilli Jtwy have ~X("~ssi'r'-e :iNH\1f}f!J!J1 t~.. G. e.ltfmi)
, As ....IT..,I\ tirn. (,arlll~ If'll IIDMS6 k<4ue,;;y &h;Jflllf '''ijuilffl'j fil1' IPJTI',,-$
ResrJCmts}
on""
BEHI\YIOMl R~STAAlIfTS,
~ ~
ACTtVIlY KI;Y
BSC ., 8ad&J1R CommQdp.

D ~
Bed
= ilmblihte
Dall9ie
posmONIfiO
KEY
C - Chatc
R = Rk.'ll\ L = L~rl B .. Baci< S= Self P = Prons
~SSM
H'1A.lTttC~a[~
24 HOIJR MEDlCAI../SURGICAl PATIENT CARE RECORD

DPM1000J71 l4i200t\\ PA.GE 8 OF 8
000589
~&bn,\-b 0.~ BIde e.g ~
Abnormal Assessment Findings:
1lL..~:L.tl.lf--1---L.:~~~~..L.JL.l..::..~~e-WLL_ _ _ _ _ _
Pneumonia ---I BloM Cultuf9s dona

Antibiotic @
Site: 1 Site: 2
Site: 3
Description:
List r"''Y'Inl,Qto.i?
Receiving RNJLPN:
DNo

n
.(
fatient Report Form 72006
JI~~l~!!"111
0715100477 ERS -
ERQ
10/02/1976 30Y M 05/31/07 EMERGENCY,PHYSICIA000746298
000590
24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD OAltSTARTED PREVIOUS 24 110 IntJ:lke Output ISOLATION: 0 Special Contact 0 Contact 0 Neutropenic 0 Alrbome 0 010plet 0 ~_ _ __ SCALE KEY U lied 0 StandiJlg 0 IN/Chair 0 Slin9 OTHER PR~.CAUTIONS: 0 Safety-Fall 0 Bleeding 0 AS[llrnUon 0 SHilllre 0 _ _ _ _ _ _ __ Ye11erlliln WI. ____ KG T!J!Jay'~ 'Nt, K(S (please reconcile weight difference if Breater Ihan 2.5 kV.'
lPIJlD1
24 H
KEY: ,/
'fi9
"0
TYPE
OISCOM
PAIN RATING
SCAL!!S
fC<tt4 t'"p.t
vf~"i'<.~
t~,>j\"
- - - -'-- - - - - - - ---1,--- - - - - - - - - - - - - - - - ---I
BEHAV
MI"Aru
1- Int'ffe
E =EmoD - Dey'.
INTERIJ 1. fleas!
2. AWHI
~
CUk;1
4
F
~9Mj
F~IUth EH\iU~
7.
tnCCl
_ _1-"""-..1...4_ - - - - - - - - - - - - - - -
fLUID EUUIVAI.I;/lTS: 1 oz . ,Oml
4 Ol (112 cup) . , . 120mL 6 (n (314 cup! ,1 SOmL
80z
(1 CUP!. .. 240ml 12 01 (sooa1 Gan) .. 360mL
DEPAUL HEAJ"TH CENTER

~-1AllCH,PHIT,LIP
~SSM
iotl"'tfHCA.RE~
IOllOllllflllJJlllmBll1II

,
rip
24 HO'JR MEDICAL/SURGICAL PATIENT CARE RECORD

DPM-IOOQ-071 (4f2001 PAGE 1 OF B
071!:.'100177 r'IED 0516 - 01 10/02/1976 30Y 1'1 06/01/07 JW-lMAN, JUWER Z 000'/48298
DPMjly'
000591
OATf STARTHl
G) \[0 ')
24
TYPE OF
Achirlfl. ACute. Burnin9. CHronic. CQm;1anl, CRamplflg, C8 - Crushing. Pull. Hoavy. Inloundtent, NV - NmJ9calVollliliny. Pru,;""ufll. Rudia1in9. 8hmp.
OISCOMFOliT STabbing. Tende!. THrobbing. Other: _ _ PAIN Vilma!

RATING SCALES
tCflUt/~ N)-uit\f.!.M
MYilM
o
!
t" WI'
10
-~~-----+-+-+-l
V..-;wj~H~1l'
W~I
---t -, _.- ._+

:-, ......pmy Calm
(,I\I\',IIl'"m{1
local
SHe
~
i).).EIi1TTlf<!!
,"'i\/fl
N-;\;~Yfi'iJ
"'~0";"."O
~ rTO{tw~r;t
,If!' ma"'"n:~m
INTERVENTIONS:
1 = HH.h3tlfn
;;~i>!J-M'l",g
!::.
*,T>i~lJf.f)'
11 =
U~!iv !>-~ath.l)'"i>J
mWlr.tna
t; r~JC1;
fi - Heal
to _ Ca-11
U :::
E ~ ~moflon[J1 nis-tr,ss I !!; lm~tfm~tlvn t~~~r'U o ';; D~'l-tllopJt":il~at lllljJ-dfrrntlnt
, Pn.:i:.HI !r.lnt' n
Rt!O;Il~L"i(}f1
Ufv.e~.p<;OS!\'~
co -:- L'omaiWB"
Cl ;:: Cc-gnlhve !mpa.Jfmenl
Hallu,;nahOf,r;/ O-eiUSlOf/$
COP
:f
W ::: Ufilbef.;Jt&ly YO/lth-hLl1dlng lfila
D,}C,J6'ff11!ve
o - OVe15tim1.llaled/OvereacHve
(11hN
R - Restle"
A - Attanl1Qn Se"In~ 01' - Dts,up1il''' Pa1lent

'4 t.1)
LoA
~ L~5t. ArlnOUb
OIOe<
Reorte-nl i ~mo1j'l.f\le t Restattnn tact'S
m\'m~>iomlJ af:tNllU}~;
Patiml f
S.~-umhcmTl
Off!'"f frr"lH~nt hn.;f r.l~nd PHNr.JH infumttltitnl ttl illt,1na~.t)
hlV1~
u! i.tl~Ir.~.r~j<ittt-tJ\U
Utidam:;B
GCflIJI~t~nt ~nvlf'onl1l6nt
~,
10
Em:.owage: l":iln!ly 10 btifllJ
~l lanlll!dl
obje-:.tb
\6
PH1'U.:lWU llit~ilSUfW)
( Moutl"l@
C.al~
E.stabt$-h matntaJ<\ed time1(ilrrt6"S for

E.rv~lI'dQ-a ,,~~~flOn
n&oo-s
11- f"rOY.iJ1< rtrlElJalOO \'nth mli~.
E.ne!fX!rRlJe Dat~fU 'NHh doosiOfl mtlkinq 101 .call? neoos
~llil\J@ry. a~>.JP IlftlilUllIl\j, (J1[W~f, mooJ0.1iO,) 12. Encourage noun.!! 'lSteep -cycle by U$tr'lg Uldfet.t i!9>'1ti"f<g <,UT cfarl<.. 10 Darken room I Um!ting lQ-vel< I Quietl 940 (C OOore8.'5B pWie-nl'a r(l.sp.onse to 9f1mu.lRt~
17,
lJ$
1~1.
R@il't~~ i RNJ~~!t0t11 ~k
t:~t~b-l~h bof,..'f;Q.jlfltt-~
U.nf'''llliUl
PtQ"fide Imen$fV~ securily and $flielY OleaS!"sCe3 to mlf'*mlz.e OMl!JvtDral P({lt<l.M'\!l
---.----- --1---+-+-----1- -----F-+

PatienVSigri ficant Other
IntervsntiOfi
Respons.
SPIRfrUltlm: Nil emf.!!!'$ BKplBSSM wt till, tl~
------. -------------'----'----'---"--'-->L.."-----'---'---r'----'--'---'----'----'--v---'---''---'----'----'---'-----'---'--'---'-----'
PATlFNT illRFI
~SSM
H Ii A I. r H
-.; A ft: E'"
~!~~~~!~JIlIiIII'B
0715100477 MED
DEPAUL HEALTII C'BNTER
24 J-OUR MEDICAL/SURGICAL PATIENT CARE RECORD

DPM1G1l0-0, \ (4/200fl) PAGE 2 OF i:I
10/02/1976 30Y RA.Hr-1.l>,N, M1VIEU Z
lip 054fl-01 f.f %/01/07
o ".
)
000748298
OPM-
000592
24
ACt
Poil 26-:
38-!
56'
71-1
Sits
in
B4-i
98-' 121
t RE
Site #3
# of al1emNs lor IV if-s1art
NOTE
FRONT
RT /iT RT
(~-
.-~\
{ ,J
\
;)
~
!
l
I,
\1
fA
& = S!{}q/' lume. UL - UOtiv~ Wr:YJ<J
nc;;;;
7nfli~ (U.'1fflJ
H\
I
,
H.
tJ
I J I /
F
/' (
KI\\\ 1\ \
E
1r!<fIC31t kJC3ln1flrJl tv {W hm,.,< f}1nviffl.'d
HI(;HI
r
l\}nglh _ _ cm
~)
Inserjlon - Date
is
::t:
w Z w
>-
r - - - - - + - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -.. - ... - -... - ... -
.. _.. _ - - - - - - - - - - - - - - - - - -
DEPl\UL HEALTH c.:l>NTER
~SSM
l1i"'LrH
I,;"RE~
MJ\lZCH, PHILLIP
IIIJIIIII~IIIIHUIIIBIIUI
I,' p
Z4 HOUR MEDICALISURGICAL PATIENT CARE RECORD

DPM-100U-071 (412006) PAGE:l OF 8
07151004 '1'1 HED OS46 -- 01 10/02/1976 30Y N ()6/01/0 7 RAHMAN, !UnmR Z 0007'! B29ll
DPM
000593

Patient Care
ACUITY LEVEL Points 26-37 ACUITY TOTALS
DATE STARTW
&;;
Record
Ir!tf't
Level
1
Subtotal Section "N

,
.. _"_._--
38-55 56-70
71-83
Subtotal Section "8" Subtotal Sectlon

TOTAL POIN1S
3
4
"e"
~1 ttr)
i~ ~~
It,
84-95
96-i~O
[q I~
I'"\'
121+
+
LEVEL S ACUITY 7 Sitter 0
REQUIRES FURTHER DOCUMENTATION NOTE; If mJre than one item on a line, eirels the serviCe indicated.
10
10
10
~SSM
KEAl,.!"
CA~E'"
DEPAUL HEALTH CENTER I!P 0715100'17 'l t>lED 0546-01 10/02/1976 30Y 1"1 06/01/0'/
000718298
,JPllllllifiDtillMl" ,,,",",CH, PIiILLn'

DPMll':)O{l71 (4/2CK1B) PAGE 4 Of 8
RAJmAN, MlWER Z
000594

KEY: 01' WNL's or t~ completed
DATE STARTED
* = Sea ;tddlrlonal comments
Use balded key leiter if Indicated
KI
AI
At
p,
A
lit
S
D
Cl
'111
,~,
,\
A
Specify .bnormal breath sounds on diagram.
(Absent, DeCfl)llSed, CRackles,

Rhonchi, t.Vheezes, Coa(se)
H
C
E
POSTERIOR R
POSTERIOR H
Abl1UTmal JeSplratufY etlan Dyspnea (on Exertion. al Rest)
I ! :I,
,B
re
r~
( <
nEP1\UL HEAlm'l CEN'1'EF.
IIIIIIIIIIIIID
lo/02/~976 30 RAHI.\AN I Affi'ffiR 7.
SSM DEPAVL HEALTH CENTER 24 HOUR MEDICAl/SURGICAL PATIENT CARE RECORD
DPMl00007' (4120W) PAGE 5
11 p
000748298
I'1ARCH, PHILLIl? 05.;6-01 07J 5100477 NED ttl o6/0~/07
~
o
or il
000595
DATE STARTED
~ kI
24 t
KEY: ,f\
...
TIme
A-Absen!
W-Weak S-S1rOng DDopplc!

Golortemp
Mil
~
Urtro eh
Sl!1SanOn
~".
i&pain!IJ
N<i11wd
CJp
!eIfJ Iel~ IhM , i
~COOQl;
UrIne cc f'Qu',sn
slin *;W11 "In
~iI Wlta
t11 10 tw> h
(I~w?
ibRr.lm;llinro)-~!i;
AM(}(ll'
~ ~ N()Ilt
FrequeJ
CAl (ct.1 lieu CQ1
Sllpr~
T 1
~ ll1Wf
~
UraJll3Y
Sklnwi
Jaumil
DiapM
M~eQ'lli
Sl<in int
Heel po
Wound
lts'km
a
\
!
~SSM
HE/..ltf.l,tlt ......

DPM-HXl{}-071 (412006) PAGE 60F 6
R~~AN,A1~ER Z
Ml\.RCH, PHIT~.LrP rip 07151D0477 MED 0546-01 10/02/19'/6 30V M 06/01/07
IJlDllllllflllllmlURII!
~
" F
000,48298
000596

KFr..,r WNL's
01 {ask mmple\ed
DATE STARTED
'"
= See addillOnal wmmenls
Use oolded key leiter ii indicated
_((i'-t}.1 . . t-[.... O)'-+--
241
WPE
rtJso I
Assess
Bno sal
A!IwItli:
1 r",('Jlt},1
;> CflJ'Q
3 iTMm
4 R""l~ h Modi,
If skin with aile 'alions' inditate sites with numbars on ligures
ALTERED SKmtWOOND KEV:

PU
V
N
= PI~SSU'C uk:Cf
iosul1iciency)
A - AllIasicn BL '" Bk;kr

8R
I
L R
incision
Tap~
ij Ui\lbi~
If pressure ulcer. li"t Stagll I, II. III
IV, UN,I~\le~l!l\: = V.w:lIl Idr.sr jveiHWS WIS/t, .rien~1
E
H
= NeurCjlailuc ulcer (dlabebct

Wound Bed KtV:
EX '- Excoriation
=Ery\hemJ
=fjrul," =Oenuded
~ L~Gtlfa!iul\
.,>1>,"
TB '"
WA
0
'" Rash
8 Ant b
=Weil JpproXI!rn!8l1
$
burn
~ 011\~" Retum~~
= HematolilO
Olht!r --".---.-._OlaiOl1fjs Amount
01.18Ing'
55 - elf(! strills
D - HetffiiibOild
SunOPm!ln~
Skin Key:
Otal~e
G -
Gr~nuls!ion
I - ialat!
E
on, = Open to ~iI R = R.8fMliOO !ufure:S

01 '" D,y ~"d intilct
Staples
& - SIoIJ/<h E EseRa!
= E.yltwllia
0= OU",>
o ; Cy.nvli!;!Oar' o = nthllI
M - Macelii',ion
S = lili 8
~
TVP8; - Green
S&UIIS
,Stant
~
5 " Slim!
5efosanglJineous M
RIC,iY.Iy
C
Moooafa
PU '" f>urulwl
y C
L " la.rqe
~
o " 0I1w1
liorrouniling Drainags,,,,,, __.,,.
Skin TY\le
= Mllg<lrn~ry Slta~!>
_'j
= 'klbw " r~",.'Y

-
Corn"'"
0
Y! n
O1Ilfr
Odor
Trealmelll
DNR
c(
1~(J!a!io
~"'~~M- DePaul Health Center

DPMl000071 (412006) PAGE 7 OF 6
Od
" E
OPM'
000597
MEDICAl
t Cwr~~.nit)rdiu~'GtJo.er'i:$~M
8m'"
MEDICAL f SURGICAL RESTRAINT KEY RflIlrainl EU'ti;aimn for f\utlaint

~l:I~iJHlI?;11
In.1 fltJmc ICY

fit
i
Pru!"iid ,),1 ;tlM~j;lf &~w~y atm:'\..>.f f)~ti1!r, dl!:hNY 1.f:,Q to
6ui!:
,HW P.:t1fl't'1. t:',~
"2 Ct@'l\!C Of ~~ mirm'f
~nN~Qln(' n.~ Jt~, fl6:~"d
to! f'l If. ~t. )
ma"r,-tair, 'C:Nk>-tJaf.-htl';{;\l~ffl.,El~i t\d\C~.. }

M~iJi1.1i1i lrlf:tf~wfi &ng~ m t..t~s p-~licrll>J> t:ijfH:lli C{f111Ail)ll (f.!)
m~~ijI!
J (rMfOM1eo 11 rtI<lIt(l<t&lOl'S pe3f ,,,1';1'5 }1"'un ,!ltoli CilI~.~t ..J

4 Re-illJY Cflff tabOO
~ tt~ditatiol\ ~<tml1\lll
KSinW1 to me
t!tltmer:~
Of
mt
~arwl iPO!]Se. e1E 1 V) VI OOlJCatlC4l bOx :ffl,tatt9 f(;%~l't-lTtQ
UnAAJ hi
(";!~Jj.J{:( !(r; f....ll~'Y
, Coot. U) Lttii 9'1 tlJD~S, ~n!~. ell;

1 AetJ"411y d(,H!(mdf~!\~ f~~~ I,H fijf~ljj}'
!'.nttl f:.m.il(.R <If m:hltif;[j,
%ms
Ot~r;.U& ~.al}
YlrJ.n ltM1\U
OOmlf":!stntI(Hl
)f
hydl<!1lO:l1\
Rf!:~$.i)(l
IOf
I~sllair~
r,
ONmioo~
K'1"'1t'{ IW,trW1. \'lOW"
w~.s,
m,,,,,,. ,'/( I
S~lh)\V iiI p;Aea!:, wIlD Jtf, Hif:.,\:jla:f..llalfl;j lmm an in~ or .;,~t>;;n
procedvte: Yr)'1Q 'h'lYJc sutkr fvrthox mfofY i! Ih::y h1wfJ I~l!.e:!r,.&<e

m~'t"",nt befOft
, is m~;]ft.l&t aPvroprl.atf (q., ..mv11!!'f

CVAwtn
Ikw h.}!illj!j Trial Rffla~ ff\liVen>;y ~ 6eNl?i'.t fe<l\Aff4 IQI '~IfW/3!
A';;:st~fllJ.'fli
., .1ltlrrOl!l1V IQ rf"""'~ QffiiW;S. sul!lf!l. elf Jj COij-~t'lu\r.;e .J;lV..l r~!sbtii!~ lel!t!wr:d

ti Of
n.,ffi It u1 Of WelS (M~
lre~u"".1
finV",M}
I 111M, (,equi." .,,_ (l(lcurr.el11l1iooj
11.d.,", or N IiM, WlOltttS)
8fHAVIDRM. HE81RII.1HTS;
ACTr/ITY
KEY
B ~ Belf 8$C = \>CdSloe CommDile A a Ambula1e
C Chai' I...-_ _ _ _....:...-_~~ ..-
U = Oa'9iQ
POSITIONING KEY
..-~.....~..- . - -
EI Bilek S - Sell p = i'1(l<1~
L = l8ft
Right
~SSM *" . ,
It I ~ L T
A t\ ["
24 HOUR MEDlCAUSURGlCAL PATIENT CARE RECORD

[)f'M-l000Q71 (4iZOO61 PAGE 8 OF B
0546-01 M 06/01/07
r/p
000748~~fJ
000598

Jun 08, 2007 06:10 am Post Discharge Work Report
F~i
1?at Name: lJnit #/Acct #; Dis Date phys-Service:

977280 975969
MARCH,PFfILLIP 00074829S/A0715100477 26;'06/07 SRlRAM,VISSA - MEDICAL

97~043
Page;
rIp
903572 917259 CULTURE BLOOD <c.
specimen: Blood {MI-arml Coll. Time: 06/01/07 0404 In at: 06/01/07 0456 ordering Phys: Sf-UTH, ROBERT B
Acct #: A0715l00477
Techs
V- ..JB Techs: TSfV1H
Out at: 06/07/07 0914
Final
[3666100]
**CULTURE * *
No Growth
Pel"formed by: SSM Health Care Lab - SMHC
:
CULTURE BLOOD
06/01/07 0456 Acct #: A0715100477 Techs V-JB
Soecimen: Blood (HI

C . Time:
ora~ring
06/01/07 0404 In at: Phys: SMITH,ROBERT B
out at: 06/07/07 0914
final
(3666101)
Techs: TSMH
. /' * CULTURE * *
No Growt h

End of Report - 06/08/07 06:10

*Post Discharge Work Report
MARCH/PHILLIP 00074829B/A0715100477 IIp 06/06/07 (M-10/02/76) Dr. SRlRAM,VrSSA
000599
LABOR.z"TORY
i'1ARCH, PHILLIP
TEMP
Room: 55- 05,16 - 01 Srvc: MEDTC~L ljP r - Phys: ZINSER, PHILLIP G .lIt name
CR~,Sensit1velmg/L)
Birth OatS: 10/02/76 Pat #: A0715100477 TLSCHVIC Collected: 06/02/U1 0520 V-hIT hccessionsd: 06/02/07 0553 [3668018] Completed: 06/02/07 1201 Spec. Type: Blood
Rcoult
0.953 H
Reference Range
0.000-0.500
Performed by; SSM Hct:llth Care Lab - SMHC

End of Report!
-"FINAL
C-REACTl.VE PROTEIN SENSITIVE 977?80 903:;-/2 975043 917259 He
06/02/07 1201
hoD
I>1ARCH I PHI LLI f'

l~oom:
58- 054 6 - 01
srvc; NEDICAL liP

~hys: ZINSER/PHILLiP G Jlt name
Birth Dale: 10/02/76 Pat #: A071S100417 TMVILLD Collected: 06/02/07 05;<0 v-va Accessioned: 06/02/01 0553 l36680181 Completed: 06/02/07 06101 Spec. 'l'ype: Blood Reference Range ResulL
0.2 3.52 L 9.6 1.. 29. S L
83.8
LABORATORY
TEMP
WBe (lOOO/mm3) : RBC{lOX6) :
4.5 11.0
-1.7-6.1
Hgb(gm/dl) :
Hct.(%):
13.0-18.0 39.0-54.0
MCV(fll : l'1CH (pg) ; MCHC(gm/dl) : RDW (%) :
80.0-99.0
27.3
32.5 14.4 270
25.0-31.0
32.0-36.0
11.5-1'1.5 130.0-400.0
Platelcts(lOOO/mm3) :
End of Report!
CBe WITH fY1A1"IUAL IHFF "'FINAL 977/.80 903572 975013 917259 HC
06/02/07 0614
000601
LABORi\TORY
TEMP
MARCH,PHILLIP
Room: 58-0546-01
Srvc: MDIC]l.L I/P Phys: ZINSER,PHILLIP G

.lit- l1<:lme
Sed Hate, v1estergren(nun/Hr:
Pat ff: A0115100477 Birth Date: 10/02/76 Tl'-WILLD collected: 06/02/07 0520 V-v1T Accessioned: 06/02/07 0553 [366BO~B) Completed: 06/02/07 06.n Spec. Type: B1 ood
Reoult
10
Repol.- t !
Reference Range
0-15
End of
*FIN.1\L
SEDHtlENTA"l'ION RATE,
WESTERGREN
06/02/07 0637
977280 903572 975043 917259 He
000602
LABOJ<A'l'ORY
t'lARCH, PHILLIP
Room~
Pat #: /0..0715100477
Birth Date:
TEMP 10/02/7G
55-0546-01
Srvc: r-1EDI C/o..L I/P Phys: ZINSER/PHILLIP G }, .11 t name

v/HC (IOoo/rom3) : RBC(IOX6);
nWILLD"" Collected: 06/02/07 0520 V-WT Accessioned: 06/02/07 0553 {366H01S] Completed: 06/02/07 0614 Spec. Type: Blood ResulL Reference Rdnge
6.2 3.52 L 9.6 L 29 ,5 L <1. 5-11. 0
Hgb(gm/dl):
He t (%) :
4.7-6.1 13.0-18.0
39.0-54.0
MCV (tl) ;
l>'JCH (pg) :
83 . 8
27.3
80,0'99.0 25.0"31.0
MCHC(gm/dj):
RDVI ('6) :
32.5
14.4
32.0-36.0
11,5-14.5 130.0-400.0
P 1 ate 1 e t 8 Segs (%) :
1 0 0 0 / mm3) :
270
Lymphs(%):
Monot) ( %) ; EosinGlt):
* ADDENDUM
tJ9 &, 34 & '1 . 3 &

CEe WITH r"ANUAL DIl'F
9172~9
40.e-iO.O
22.0-40,0 2.0-10.0 0.0-6.0
06/02/07 0651
977280 903572 975043

'H, PHILLIP
0:
5S-0~46-01
He
TE[VlP LABORATORY Birt.h Date: 10/02/76 Pal #: A07151004 7 TMVILLD* Collected: OG/ 2/07 O~20 V ~1T Accessioned: 06/ 2/07 0553 [3668018J Completed: 06/ 2/07 0614 Spec. Type: Blood Result Reference Range
Srvc: MEDICAL liP Ord Phys: ZINSER,PHILLIP G Result !lame

RBC f>iorph:
Normal *&:* End of RepoI'L 1
JENDlJl>1 9/7280 903572 975013
eBC i'HTH [1ANUAL DIFF

917~59
06/02/07 0651
He
000603

12303 DEPAUL DR. BRIDGETON, MO 63044 Thu Jun 07, 2007 06:11 am Discharge Cumulative Trend Report from Qu/Ol/07 0404 to 06/02/07 0520 Patient Name: MARCH,PHILLIP HEMATOLOGY-Page 1 Med Rec It: 000748298 Adm: 06/01/07 Dis Date 06/06/07 Phys-Service: SRlRAIv1, VISSA - f>1EDICAL I/P
977260 975043 903572 917259

Resul t:
Units;
LOlli Refer: High Ref:
'I
I
I I 6.1 I 99.0 ------- ---------------------"-.-----------------------------------------------1 06/02/07os2ol 270 I 9.6 LII 29,5 l41 3.52 LI 63,6 I I
I
341 11.9 L 35.8 L\ 4.37
I I
Platelet 10CO/mm3 130.0 400.0
Hgb
gm/dl
13.0 18.0
Hct
RBC
t.tlCV
% 39.0 54.0
lOX6 4.7
fl
80.0
I
I
06/01/070404\
LI
81.9
BLOOD CELL COUNT/DIFFERENTIAL,
Result;
Units: LOW Refer: High Ref:
MCH
MCHC
ROW
pg
06/02/07 05201 06/01/07 0404
--"----------------------------------------------------------------------------\
27.3
25.0 31.0
27,2
gm/dl 32.0 36.0

32.5
I
I
9,;
I
I I
WBC
Corr WBC
11.5 14.5
14.4
lOOO/mm3 4.5 11.0

6.2
IOaO/mm3
I I
I
I
33.2
14.1
7.2
BLOOD CELL COUNT/DIFFERENTIAL.,

Result:
Gran
%
Lymph
%
Mono
%
E08
Baso
%
0,0 3.0
Units:
Low Refer:
High Ref:
40.0 70.0
22.0 40.0
2.0
0.0
10.0
6.0
BLOOD CELL
l{esul t : Units:
High Ref;
I I ----- -------------------------------------------------------------------------1 06/02/07 05201 Normal &1 I I I I

Low Refer:
I I I I
RBC Morp
I
I I
com~T/DIFFERENTIAL
.....
WBC Morp
PI t Est
, I I
I
I
-~I
Alexander Babich, M,D. *w DO NOT DISCARD **

*Discha:rge Cumulative Trend Report
(1-1-10/02/76) Dr, SRIRAM,VISSA
000604
DePaul Health Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Thu Jun 07, 2007 06:11 am Discharge Cumulative Trend Report from 06/01/07 0404 to 06/02/07 0520 Patient Name: MARCH,PHILLIP HEMATOLOGY-Page 2 000748298 Adm: 06/01/01 Med Ree #: Die Date 06/06/07 SRlRAI'<1, VISSA - MEDICAL r/p Phys-Service:
9772BO 975043 903572 917259 In! 06/02/07 0553 ------------------------------~-Out! 06/02/07 0637
SEDIMENTATION RATE,
.'iESTERGREN
Spec: Blood Techs! V-WT TMVILLD
ColI Time: 06/02/07 0520---------------------------------Order Phys: ZINSER,PHILLIP G [A0715l00477j366801Sj

Result Name
Sed Rate, Westergren (mmjHr) :
Result
Reference Range
0-15
10
!>lARCH, PHILLIP
00074829B
**
DO NOT DISCARD **
(1)1-10/02/76)
Dr. SRlRAM,VISSA
000605
DePaul Health Center 12303 DEPAUL DR. BRIDGETON, MO 63044 Thu Jun 07, 2007 06:l1 am Dischal ge Cumulative Trend Report from 06/01/07 0404 to 06/02/07 0520 Patient Name: MARCH,PHILLIP CHEMISTRY-Page 3 Med Ree ~: 000748298 Adm: 06/01/07 Dis Date 06/06/07 Phys-Service: SRlRAM,VISSA - MEDICAL lIP
A
9772BO 903572 975043 917259 ROUTINE CHEMISTRY

Result:
Glucose
sodium
I'
mEq/L 137
Units: Low Refer:
High Ref:
mg/dl 75
110
I
\
Potassium mEq/L 3.6
i45
g.O
J!~
I
I
I I
chloride mEq/L
98.0
C02
107.0
100
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - . - - - - - - - - - ____________ w ___________
06/01/07 0404]
U~
I I
mEq/L 22.0
I
1
30.0 28
ROUTINE CHEMISTRY.
Rt
lot;
BUN
Creat
Dn.lcs: LO\~ Refer 1 High Ref:

06/01/07 0404\
mg/dl
9.0 20.0
mg/dl
0.8 1.5
Calcium mg/dl
8.4 10.2
PhoSphorus
mg/dl
2.5
4.5
I
I
i
fTlagnesium mg/dl
1.6
2,3
14
1.0
10.0
! ---I I
-------r
ROUTINE CHEM1STRY ..
Result : units: Low Refer: High Ref; 06/01/07 04041
Tot P.::-ot gm/dl

6,3
8,2
Albumin
gm/dl 3.5 5.0
I I I
A:LT/SGPT U/L
21. 0
AST/SGOT U/L
17.0 59,0 18
All<. Phos
UIL 38.0 126.0
84
.. ------------- -------.--------------------------------------------------_._---8,5
72.0
23
HI
4.B
ROUTINE CHEMISTRY,.,
Result:
Units! Low Re fer: High Ref:
Tot Bili mg/dl
____________
_____________________________
0 .2 1 .3
! I
!
Conjug Bil mg/dl

0.0 0.3
UnCQn Bili
mg/dl
0.0 1.1 ~
M __
Dir Bil i
mg/dl
0'0 0 .4
GOT U/L
8.0 7 B. 0
____
___________________________ A
06/01/07 04041
0.3
HARCrI,PHILLIP 000748298
** DO NOT DISCARD **
*DisC'harge cumulative T:r:'end Report
(M-IO/02/76) Dr. SRlRAM,VISSA
000606

12303 DEPAUL DR. BRIDGETON, MO 63044 Thu Jun 07, 2007 06:11 am DischalAge Cumulative Trend Report from 06/01/07 0404 to 06/02/07 0520 Patient Name: MARCH, PHILLIP CHEMISTRY-Page 4 000748298 Med Rec #: Adm: 06/01/07 Dis Date 06/015/07 SRIRru~,VISSA - MEDICAL I/P Phys-Se!'vice:
977280 903572 975043 917259 In: 06/02/07 0553 -------------------------------Out: 06/02/07 1201 I C-REACTIVE PROTEIN SENSITIVE I
Spec: Blood Techs: V-WT TLSCHWC [A0715100477/366801B]
ColI Time: 06/02/07

Result Name
CRP, sensitive (mg/L) :
0520---~-------~-----------------
Order Phys: ZINSER,PHILLIP G Result

0.953 H
S~ffiC
Reference Range
0.000-0.500
Performed by: SSM Health Care Lab -
!'-lARCH, PHILLIP 000748298
Alexander Babich. M.D.
"'''' DO NOT DISCARD ** "'Discharge Cumulative Trend Report
(M-10/ 02/76)
Dr.
SRI~VtJVISSA
000607
DePaul Health Center 12303 DEPAUL DR. B~!DGETON, MO 63044 Thu Jun 07, 2007 06;11 am Discharge Cumulative Trend Report from 06/01/07 0404 to 06/02/07 0520 Patient Name: MARCH,PHILLIP MICROBIOLOGY-Page 5 Med Rec #: 000748298 Adm: 06/Q1/07 Dis Date 06/06/07 Phys-Service: SRIRAM, VISBA - f>IEDICAL I/P 977280 903512 975043 917259
Order phys:
Out at:
CULTURE MRSA BATTERY Source: Nasal
Call. Time; 06/02/07 0050 In at: 06/02/07 0056 ZINSER,PHILLIP G

06/04/07 1016
Final [3667353]
Acct #: A0715100477 Techs VILL

Techs: TSMH'
VRE
Light grolHth ENTEROCOCCUS FAECIUM caxed ic

felicita-rbr~6/4/07-ps
Pertormed by: S51>1 Health Care Lab CULTURE BLOOD Source: Blood (M)-arml Tn at: 06/01/07 0456
S~fHC
coll. Time:
06/01/07 0404
Acct #: A0715100477
01'der Phys: SMITH, ROBERT B
Techs
V-JB
Techs: TSMH
Out at: 06/02/07 1154

* * CULTURE * *
No
G~owth
Performed by: SSM HealLh Care Lab - SMHC
CULTURE BLOOD Source: Blood (M) Aqqt #: A0715100477 Techs V-JB
ColI. Time: 06/01/07 0404

Ordel: Phys: SMITH, ROBERT B
Out at: 06/02/07 1154 "'*CULTURE*" No Growth
In at: Q6/01/07 Q456

Techs: TSMH
000608
DePaul Health center

12303 DEPAUL DR. BRIDGETON, MO 63044 Thu Jun 07, 2007 06:11 a.m Discharge Cumulative Trend Report from 06/01/07 0404 to 06/02/07 0520 Patient Name: ft1ARCH, PHILLIP BLOOD GAS ANALYS-Page 5 000748298 Med Rec U: Adm: 06/ 01/07 Dis Date 06/06/07
Phys-Service:
SRIRAM, VISSA - r'1EDICAL
r/p
977280 975969 975043 903572 917259
----------------------- ------06/02/07 0500 06/01/07 0404

06/01/07 0404
PENDING TEST
------------------------------Cancelled ORDERED IN ERROR Partial Partial
CBC W AUTO DI FF CULT1JRE BLOOD CULTURE BLOOD
End of Report
MARCH,PHILLIP
000'748298 Alexander Babich, M.D. ** DO NOT DISCARD ** *Discharge Cumulative Trend Report
(t>1-1 0/02/76) Dr. SRlHAl>'I,VISSA
000609
DePaul Health Center 12303 DEPAUL DR. BRIDGETON, HO 63044 Thu Jun 07, 2007 06:11 am Discharge Cum Incomplete toJork Listing from 06/01/07 0404 to 06/02/07 0520 Patient Name: MARCH, PHILLIP page 6 t4ed Ree #; OC0748298 Adm: 06/01/07 Dis Date 06/06/07 phys-Service; SRIRM<l, VISSA - MEDICAL lip
977280 975969 975043 903572 917259
Accession
Collect.ion Test Name

CULTURE BLOOD CULTURE BLOOD
Number
3666100 3666101
Spec Type
Blood (Ml
Date & Time

06/01/07 0404
Statu8
J?alt ial
Blood (M}
06/01/07 0404
Partial
End of. Repol't ** *******w*****, ******* *****************************************~**.***
tlLARCH, PHILLIP 000748298
Alexander Babich, M.D. *' DO NOT DISCARD **
(M-10/02/76)
Dr. SRlRAM,VISSA
000610
DePaul Health Center 12303 D8PAUL DR. BRIDGETON, MO 6)044 Thu Jun 07, 2007 06:11 am Discharge Cum Incomplete Work Listing from 06/03/07 0049 to 06/03/01 0636 Patient Name: t4ARCH, PHILLIP Page 15 Med Rec #; 000748298 Adm: 06/01/07 06/06/07 Dis Date Phys-Service: SRIRfu~,VISSA - MEDICAL r/p 977280 915395 975043 903572 917259
Accession Number
3666100 3666101
Collection
Test Name
CULTURE BLOOD CULTURE: BLOOD
Spec Type
Blood (M)
Date & Time

06/01/07 0404
Status
Partial Partial
Blood (M)
06/01/07 0404
End of Report
******~~***********~*.********~************.**
***********~***************.****
lVtARCH, PHILLIP
000748298
Alexander Babich, M.D. ** DO NOT DISCARD ** *Discharge Cum Incomplete Work Listing
(M-10/02/76) Dr. SRlRAM,VISSA
000611
1:'::;03
LleL'~u.l
DEPAUL HEALTH CENTER Drive Bridgeton, MO 630'11 DIAGnOSTIC IMAGING
Name:
MARCH,PHILLIP
Med Rec
30Y
n A000718298 ACCT: A071S100477
DaB:
10/02/76 Age:
Sex; N
Pt Location: 58-0546-01
Sl'-lITH, ROBERT B 1~303 DEPAUL DRIVE
EMERGt<;NCY m;l'T
Date; 06/01/07 0536
BRIDGETON
MO 63011
Ch@ckin-Exam Code Summary

971739-70487
Bone \.,.indows demonstrate mild mucosal thickeninq- of the et;hmoid ai~cells "lith a mucus ret.ention cyst arising from the ~'ight anterior sphenoid $~nUG. No additional faCial or orbital fractures are seen. zygomatic arches are symmet.rlcal.
Inci.dental note is made of very pruminent. OL- large ossified left and !' .Lght stylohyoid ligaments left greater than ri ght. There appears to be an unusual articulation within the pL'oximal left stylohyoid ligament noted on the coronal J:'econstructed images,
V-/ '
There "re omall lymph nodes within the left and right: anterior and posterior cervical chaln and up t.u 1 (.;(H lymph nodes within the bilateral submandibular regions. OPINION;
L@ft mandibular fracLure stabilized by metallic ocrew& and plate. There is soft tioDue Dwelling and thickening overlying and subadjacent to the left mandi.bular fracture which lllay be either secondary to t-ecent trauma
or r'ecent sUl-gical intervention. Soft tissue cellulitis and hematoma are considerations. This latter finding does n~l:Iull in some compression of the leEt lateral oropharynx ~nd hypophary~~.
Promlnent. oSRi tied bilateral stylohyoid ligaments left larger compared to I'ight as described above.
t,llld ethmoid and SPhenoid sinusitis. There .ue small ly'mph n>:;.des within the anterior and postel."tor cervical chaJ.D most, prominent Hithin the left and right submaw,libulat- J:-ogion. R@a.ding Radio1ogL'3t- HUT HUl\ SHU 11,D, Rddi.ologist - HUI HUA SHU :-1.D.
Reled8irI~
FINATJ DUPLICATE
Page
:2
000612
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC lMA.GlNG
Name: rvIARCH, PHILLIP DOB: 10/02/76 Age: Dale; 06/01/07 0536 30Y
Sex: 14
Med F.~c
It A00074B298
ACCT: A0715100477
SMITH,ROBERT B 12303 DEPAUL DRIVE EMERGENCY DEPT MO 63044 BRIDGETON
Checkin-Bxam Code Summary

971739-70487
Released Date Time- 06/02/07 0155
Tr.::lnscriptionist- MEO
ADt4: S'R I RAl>1 , VTSSA
REF:
PCP; PCP. NONE
ATT: SRIRAM,VISSA CON: DAVIS,SHELDON L

SCJ:';
FINAL DUPLICr\TE
Page
000613
DR PAUL HEALTH CENTER 12303 DepiJ,l"ll Vrive Bridgeton, MO 63044 DIAGNOSTlC Ir'IAGING
Name: MARCH, PHILLIP
DOD; 10/02/76 Age; 30Y Date: 06/01/07 OS36
Sex: M
Med Rec ~ A000748298 ACCT: A0715100477 Pt T.ocation: 5S-051J6 -01
SMITH,ROBERT B
12303 DEPAUL DRIVE
Et<1ERGENCY DEPT
BRIDGETON
J;l,?';~W\
MO 63044
Check-In #
971739
Order
Diayno~iB
CT t"N<ILLOFJ\CIl'-..L \'l/CONTRAST
Ord Diag: 526.9-JAW DISEASE NOS
CT
TvlAXILLOb'ACIAL WITHOUT CONTRAST
06/01/2007
INDICATION: The [.!tltient vIas stabbed In left jaw in April 2007 status post'. 1eft jaw repai1: in M.;ty 2007. The paCH;nt c:omplains of b1.n.-ning p.;l.in and lr;:ft-sided facial swelling. TECHNIQUE: Helical imageo of the facial bones were obtained with 2 mm sl ices. Sub::;;;quent retrospective lmages '"ere obtc,in.cd ill coronal plane.
COMPARISON:
None avai1able.
Vld!:!
FINDINGS: Initial int.erpretation of this study Radiologic Consult.ants.
performed by Virtual
The fracture of the left mandible stabilized by screwc and ha.rdware il::l identified, There 15 significant thickening or :;!welling of the soft tifJO\le overlying the le[t mtlndible with infi ltration of the overlying subcutaneOuR adjpose tiss\te, This process may be posttraumatic or may represent poasibl~ cellulitis.
Asymmet.ric soft tissue thickening or swelling .;l.$ well as ill-defined fat plane are also present;. subadjacent to the left mandibular fra<;'t1,.trfii "';hich may also be posttraumatic and correspond to possible posttraumatic or pootsurgict:ll ch",nge or' hematoma. This latter finding results in mild compression of the left lateral oropharYILx and hYE.?pharynx~ -----
Tnere lS a linear radlop~quO density projectlng medial to the left mandlble which may represent a emaIl displaced fracture fragment.
Soft: t i seue details are otherwiso l.imited wit.hout. benefi t
~nhi1m:;:GmeJlL
.-
------
of IV C'ont:rat:lt
F'rNAL DUPLICATE!
Page
000614
DEPAUL
12303 J)cPauI Urive
HE.~TH
CENTER
Bridgeton, NO 630H
DIAGNOSTIC IMAGING
Name: MARCH,PHILLIP DOB; 10/02/76 Age: 30Y

Sex: 1'1
Med Rec # A000748298 ACCT: A0715100477 Pt Location: 58-0546-01

SMITH,ROBERT B 12303 DEPAUL DRIVE
Dalc! 06/01/01
0~36
EMERGENCY DEPT MO 63044 BRIDGETON
Exam
CT NECK
CMckTn 11 ri (CONTRAST
!,npJ9
Ordr Diagnogj,s
Oxd Piag: 526,9JAW
O.j:SEA$1:';
NOS
CT NECK 'filTH CONTR.l\ST
06/01/2007
INDICATIONS: Sl.abbBO.l.Il jaw April 2007 W.l.l... h SLi;\l.uB posL Ie[l. Jaw rep"I.ir. l.n May, The patient complains .:If burning and pain in the left Ja'.... and lett. tacE.
TECHNIQUE: He I i ca 1 images ot the neck were ontCll ned vii th IV contrast.
100 cc Ornnipi;lquB 300 Wi;AB i;Admi.n.lsl.en~d.
COr.1PARISON:
None available,
FINDINGS; Initial interpretation of this study was performed by Virtual Radiologic Consult<:l.nts,
There is .. comminuted fra.cture of the left mandible which is Dtabilized by ~crew and long metallic plate. The visualized fractur@ fragments are ""cll opposed without definite he<lling.
BOrl~ YI~ndows
also
dcmon5trat~
some mucoS<ll thickening of the ethmoid ail'
cells and inferior maxillary sinuses without gross sinus opacification. There io aDymmetric thickening of the soft tissue overlying the left. mandible at the region of frOlcture and ~xt.erIla1 fixi;:\tion, Thi~ iIlvolvl;;!s pl:imarily the left masseter muscle with infiltration of the overlying subcut.aneous adipose tissue. There is a1so asymmetric soft tissue fullnr;;::I::l wiLl! adjacent.; ill-defined fat plane medial <lnd subCldjilcent to the left mandibular fracture \.;ith aome as'ymmetdc sof.t. ti ssue fu LlneRs or edema of the left parapharyngeal soft ti::J8ue which may x-esulL in mild compres~iQn of the left c'rophar)~x and hypopharynx, ThiD latter finding is nonspe~itlc and may represent sequela oE recent left mandibular
fracLure and subsoquent surgical intel-vention. Clinical followup and

follow1.1p im1'lging may be of value t.O assure resolution at UnB sott
FINAL DUPLTCA'r'R
Page
000615
12303 DePaul
DEPAUL HEALTH CENTER Drive Bridgeton, NO 630'14
DIAGNOSTIC
I~AGING
Name:
~ffiRCH,PHILLIP
Med
D08: 10/02/76
~ge:
30Y
Sex: M
H~c # AOU0748298 ACCT: A071S100Q77 Pi.. Locdtion: 55-0546-01
Date: 06/01/01 0536
SMITH,ROBERT B
12.'303 DEPI".UL DRIVE EMERGENCY DEPT
BRIDGETON
MO 6.3044
Gheckin-Ex:am Code Summary

971739-70491
tissue fullness or edema.tous changes within the left parapharyngeal region. This may be correlated clinically.
There are 8ma11 lymph nodes within the left and right anterior and posterior ee:r."vieal chain. slightly more prominent lymph nodes within bilateral submandibular regions are also present. There is a punctate radiopaque density within the anterior soft tissues 01- left ma::lseter muscle lateral to the left mandible on image 22 of uncertain significance_ This may repreoent ~ small foreign body or perhaps a very sma11 displaced fracture fragment, There is also
SQm~
v/
~.
inflltratiol1 of the subcutaneous adipose tissue and

sk~u
thickening of the overly.i.nq left mOl."e compared tc, right" OPINION:
wLthin bilateral submandibular regions
<.:omrninut.cd f:ract .... le o[ left mandible ~ttitU!1 post external fixation. There is asymmetric thickening and prominence of the Goft tissue overlying the left mandibular fracture and infiltratjon of the overlying .'Jubcutaneol.tD adipose tisoue suggesting edema from recent trauma or surgery vs. component of cellulitis. Asymmetric soft tissue fullness medial and subadjacent to the left
mandib1.!lar fractul"e is also present extending to the left parapharyngeal region with some loss ot fat plane. This latter finding also suggests
possible edematol.lo Goft tiDGue which may be a seql.lela of l.'ecent left mandibul.ar fr.acture and surgical intervention, Followup to complete resolution is r~cummeIlded. Thia latter findin.g does result in mild
compression of the left oropharynx and
hypophal~.
Small lymph nodes within the left ilnd l"ight anterior and poster .Lor
FINAL DTJPLICF.TE
Page
:2
000616
DEPAUl, HEALTH CEInER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC I~mGING
Name: DOB:
Dat~:
~~~CHfPHILLIP
Med Rec # 7\000748298

ACCT; A071510Q4'/'I
lO/O~/7G
Age: JOY
Sex; M
06/01/07 0536
SMITH,ROBERT B
1230) DEPAUL DRIVE
EM~!{GI::NCY
BRIDGETON
Ch@cJcin~EXam
DEPT MO 63044
Code Summary
97173;J-'IQ491
cervical region.
Ch.'ill
n and slightly more prominent. wit.hin the submandibular
Please see above. Reading Radlologist- HUI HUA SHU M.D, Releacing Radiologist- HUT HUA SHU M.D. Released Date Time- 06/02/07 0145 Txanscriptionict- MBO
ADM: SRIRAM,VTSSA
REF: PCP:
ATT: SRrRru~.VISSA CON: DAVIS, SREI,DON L

Bep;
PCP,NONE
FINAL DUPLICA'l'l!:
Page
000617
07:00 07:10 07:20

01:30
~87.:...:..-.4.:.:0::.-----:'.::;O.=2~/_5=_4...:..{.:..._..::6~9~1~"':.:.:M.:.:.Hg~_ _=_H.::.R.::...=__=6..:..1___:..(":.:,.1::.;6::.:;P,..:l:....J 06/01

AtrIal Rail! 1
Rhythm
1011 1041 113/ 110/
56( 7&)
57( 70} """9 64{ 78) 59( 72) """9
"""9
"""9
UR= 65 ("IBP) HR= 72 ("IHP) HR= 63 (HIHP)
HR= 68 (HIUP)
LOST BP= 07:40

..
f
IHTERVAL[I] 10 .. in I
02
54
101 Inlervall
m ( 69) m H D 15
40
{Vent 11;1.101
PI<! InION!>ll
. Signaiure
QRS
1r;!I~I'Ial
In,)I'"
I
/1 flYIf!
06: 10
06:20
06:30 86:40 Ot>:fiO
111/ 6a{ 62) 1151 57' 781 " ..H9 1001 53' 71) ....Hg 1201 78( 861 """Hg 1101 62( 72)
I
IV~ntR~leJ
"""9
HR=
78 lHIBPJ
...."g
HR- 72 (HIBP) (HIBP) HR= 67 (HI8P)

HR"" 82
PI'! lnlorva!]
Oigoat\Jre
HR= 66
(HIBP)
IHTERVRLOO 10 Rin I LOST 8P= B 87: 40 p

q
06/01
1 02 54
I
1
m( 69)
m
9
H D 125
48
~ _
Alrlal Rate
Rhythm
I QRS Int6!'Val
I
10alB
JOT Interval!
111110
05: 30
O~:20
1151 71( 85) ftftHg HR= 74 (HIBP) 07:40 '-0:;:..;6::...::;...;:O;;.;;O:....---=-1..:..13.=.:/:.......:6:;.:6:..;:(:.......:.7...:9..:.)--=.::. .... ::.:H:..:.:9~_..!.:H::.:R~=_.!..;72~(~H~I~B!!P~):....J 86/01
05:50
., ,A.,.-t,;a ..-c-' R_;'lt_8_ 1___
" r-= ~ nhylhm
6~;41
HO RERD I HG
1411
90(101)
"""g
""H9
HR~ 79 (ECG)
14~1 9~(109J
HR= 6b (HIOP)
LR5T RP= B p
q 10 It i n
IHTERunL[I] I
102
69 )
D
54
)tf>.
125
40
--L_ _ _ _ _ _ _-+.:~=.-_ ~~ ~igna1Uri;j
}ve!lt AaleJ
rn fnt",rv;,!j
_ _ _...L.I Q_R_Sl_NOfV_O_II""""'_ _ _
Lln.T_l_r\lGTTv;-:::alf=--_~jl
IU t
! '''._'0~_----i
r
L-_ _ _ _ _ _ _ _ _ _ _ _ _~~_.l....__ _- , - - - _
P,1rtENT LA DeL
~SSM
H E A L T H . CAR

ERQ 0715100477 ERBl-0/02/1976 30Y M 05/31/07
E~
1 118
RHYTHM ANALYSIS SHEET
EMERGENCY,PHYSICIA000748298
000618
04;30 04:40 84:50

05:00
1491104( 118)
",,,Hg
1641110( 12IJ} .. ",H9
157/102(116) "MUg 147 J 104( 116) MMHg
HR= 71 (CG) HR- 13 (CG)

86 ([eG) UR= 91 ([eG)
"R~
HR=
q 110 .. in
0:):10
1501 g?(101)
Mit"!)
F=""
03:55 03:55 04:00 04: 10
04:?~
l'!!1f.@1
83 (EeGl
LAST BP~ 07:40
IHIEROOl[i] I
B
10
r: ...
I
lOT 1/lleNall
Tlm6
06101
Signature
r::lom,
q 10 ttin LRST BP= Of': 49
1551108(123J "'MHg
167/139 C153 } 167/1 16 ( 1 29) 1&3J112( 131) 166/10'7(124)
"MHg "'MUg MlMHg
It"Hg
HR= 76 (ECG) UR= 82 (ECG)

HR= 72 (CGl
IHTEROOl[i] I
p
HR= '11 ([CGl HR= 12 (ECG J
10 2
54
lOT totf!rvall !Time
m( m
9
69)
40
06/81
H D 125
r;~1
r~"fm~1
~I
roo:!!~
t5at6
AtffilfFfate I
Rhythm
LY\>nlfhilll1 I
[JiffJriliirVall
Signalun:.
lQfl$ Jriti#Vi!ll
lOT Intervai I
I
/Date
PATIENT LADEL
Titl1c
~SSM
SU.H ;JQ(HJ!J3
(9'200~)
H E A L T H . ( A R E-
JI!~M!!I~II
0715100477 ERS 10/02/1976 30Y M
ERQ
05/31/07
EMERGENCy,p~ISICrAOOO748298
" RACK
000619
CONSENT TO OPERATION OR OTHER MEDICAL PROCEDURES
Physician Procedure Declaration of Informed Consent Discussion

I have explained the nature, purpose, and necessity of the procedure; possible alternative methods of treatment, including non-treatment; the risks and benefits of treatment and non-treatment; the possibility of complications; the likelihood of achieving treatment goals; and what to expect during recuperation.
Check appropriate box:
o
~
I HAVE EXPLAINED THAT OTHER PRACTITIONERS MAY PERFORM SIGNIFICANT SURGICAL TASKS. OR NOT APPLICABLE
~-------------~----~-----------------,
For Procedures RequIring Sedation
---------------------~
I have explained the nature, purpose, and necessity of usfng sedation during the
procedlJre; possible alternative methods of sedation, including no sedation; the risks and benefits of sedation and of no sedation; the possiblUty 01 complications; and what
to expect during recuperation.
Physician Signature
ad
.~
Time
"AT/HIT LABEL
erl:;SSM
H E A L T H . CAR
SL.M-6611~'
E~
UEPJ\TJ1, lIEAI"TH CF.NTER

!6tro05l PAGE
j
NARCH, PHILLH' It P 0715100477 MED 0546-01 10/02/1976 30Y M 06/01/07
11tl1ll!IfIIIIIIIIUIIIIIIII
RAHMAN,ANWER Z
OF ,1
00074(!298
000620

_ _ _ _ _ _~~=====_ _ _ _ _ _ _ [Patient or Responsible Person (print name)) acting on behalf
of _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _~._ _ _ _ {Self or Patient Narne} hereby request and authorIze Dr. following procedure:
:rM . . 'fh~
and whoever he/she may designate ~jS his/her assistants. to perform the
,ct""'('yO..e&b-;J
U~
C .-:;:I::;i.;k ...
(Name of o~ration !proCOOUf&)
1. My physician has explained to me: the nature. purpose, and necessity of the procedure; possible alternative methods of treatment.
including non-treatment; the risks and benefits of treatment and non-treatment; the possibility of complications; the Ifkelihood of achieving treatment goals; and wha110 expect during recuperation. My phYSician has answered my questions to my satisfaction.
2. My physician has further explained to me tha1 during the course of the above procedura, unexpected conditions may be
discovered, which for my well being, may reqUire an extension 01 the original prooedure or the performance 01 a different procedure. I understand this explanation and authorize my physician, hisfher associates or assistants. 10 perform procedures as are necessary in their professional Judgment 3.
As part of my medical care. my physician may order the transfuSion of blood products. The risk.s which may occur with the administration of blood products includes transfusion reactions and contracting infectious diseases such as hepati1is and HtV. I have been made aware of the potential risks of not receiving blood products. I undorstand the associated riSKS and benefit::! and conMnt to the transfusion of blood products if ordered. Alternatives je 1ransfuslOn therapy (if appropriate) have been explained to me.
4. I consent to the performance of a biopsy of any tiSSUB as deemsd necessary by my physician. I also consent to the disposal of any tissue or body parts which may be removed.
5. I consent to the release o1lnlormation. including my social security number, to the appropriate medical device manu1acturers and the Food and Drug Administration as related to the implantation and(or expfan1ation of medical devices as required by the Federal Sale Medical Device Act of 1990.
6. I understand various medical professionals in training, including physicians in training, may provide assistance during the above operation/procedure. I also understand equipment manufacturers' rspresentativsf< or other obsslYefs may be present in the operating room. My physician has Identified any practltiongrs other then my physician who may perform sfg"ifieant surgical tasks,
7. I COrnlent to the photographing or videotaping of the operation/procedure 10 be performod, inclUding approprlate portions 01 my body, for Mure internal organizational purposes such as medical, scientific or educatiO!'\i31 purposes, provided my Identity is concealed as much as possible. 8. My physician has discussed with me that should a life-threatening situation arise during any operation(procedure, it is the poltey of this hospital to attempt resuscitation. Unless otherwise specified by my physician. this policy will rsmaln in effect during the post-operative time frame until deemed inappropriate by myself andior my physician,
9. I
understand that I may wi1hdraw my consent at any time.
THE TERM "RESPONSIBLE PERSON" MEANS THE PARENT. LEGAL GUARDIAN OR RESPONSIBLE ADULT IF THE PATIENT IS
A .. NOR OR ~1ACITATED PERSON
OR
Dale/Time
SignaturefRe/arionshlp
(Parent/Legal GU8,dJanlRmJponsibie Person)
Date/Time
IIwe have witnassed the patient's signature on this form by which the patient acknowledges that he/she has received adequate Information about the procedure or treatment from his/her physician.
Witness' Signature
)tJ
t 1'1167
Date/Time
/(h3
Second Witness' Signature
(If Oml/Telephone/Patient Mark)
Date/TimB
Complete gray shaded areas on page 3 for bedsIde procedures OR use entity specific procedure form.
pAliENt GlBEL
~SSM
H E A L T H CAR
Sl.M861l-QOl (61200&) PAGE 2 OF

NJ\RCH, PHILLiP
E~
111111111111/111111111111
lip
0715100477 t1ED 0545-01 lO/02/1976 30Y f'tI 06/01/07
RAHMAN,ANW.ER Z
000748298
000621
PATIENT PREPARATION C~ o Pre-op/Procedure Code StatllS_...;r _ _ _ _ _ __ o NPO s i n c e . . , Is patient 011 antlcoagulants ~V, SQ, PO)? 0 Yes erNo If yes, recent PT/PH results III chart? 0 Yes ~ Physician notified? 0 Yes 0 No o peA disconnectBd
TESTS ORDERED o Chemistry (BMP) o GBG/Hgo/Hc1 o Type & Screen Type & Cross Pregnancy Test
Re$ulls In Chart
o o
,CJ'"rpatient identifiers verified

'0 Isolation: Type. 0 Contact 0 Droplet 0 Airborne o Loose/Chipped teeth o Bladder amptied at ._ _
S".=.. _ _ _ _ _ _ __
y bracelet Bracelet
o EKG
o o o
TESTS ORDEREO R&slllts IA Cllarf OCXR o o Blood Glucose SiCKle Gelf DK+ Last mens~rual cycle Of applicable):
o o
PEDIATRIC PATIENTS (only):

YES
NO
0 0
Loose toeth
Sioo rails up/pare
0 0
ON CjIAflT
oj)Vsiclan Order for procedure migned Consent o.P!'eratiorv'Procedure 0 Anesthesia c;}I{& p o Listed allergies ~ o Old chart crffu~ci';r~d o Pre-Op/Procedure te8ching)1Dcumented o Pre-op scrub given 0 .NO!;Cered o Pre medication given O-'Not ordered Pre-op antibiotlc: 0 Giver) at _____- - o Sent to OR 0 Not ordered
Commenls/communic' nlpersonai belongings sent to {List ue!ollglllllS under commen

Did patienVfamily attend pre-ap
(l,R.
D
0
0
0 0 U
(I. R flavor of mask, etc.)
Parents With child immediately l}Tim to surger
Weight: _ _ _ kg, Height: _ __

Pre-Op/Procedure Vital Signs - Time: _ _ _ __ T _____ P R _ _ __
o PostOp Transfer Medication Orders from H60C In chart

Recent PrB-Op!prOClldure Wal Sinns:
10 surgery: o In bed with side ralls up.
Time. _ _ _ __
Time: _ _ _ __
Time
':1 u..;-
BP
VALUABLES:
tr,;'"rp <- 7 / YO 9 J
i
o In arms of;
'2<")
SITE VERIFICATION FOR
Sa02
NONE
Hearing Aide
Jewelry
Body Piercino Dentures Contacts Glasses Clothing Other
----
YES GIVEN TO: 0 0 0 0 0 0 0 0
OR AND BEDSIDE PROCEDURES
Patient indicates procedure is to 00 performed on
(>\c..'-.
o Site marKed
0 Entity specific form completed B"N;A
COMMENTS:
PRE-BEDSIDE P~EDURES CHECKUBT H&P on chart? es 0 No If no, why? ,/ Lab rasuns aVailable? dYes 0 No CJ N/A Radiology studies present? 0 Yes 0 No 9WA TI~ OUT PRE-PROCEDURE VERIfiCATION: Correct patlent patient identiflers verified morreet site ercorr~ procedure c;r(urrect position Correct QulpmentlsoppHes availahle
m rr
Family Wailing 0 Yes 0<0 Where _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Oal8
~SSM
SLM8611 IlO1 (ill2008) PAllE 3 OF
~
H E A L T H . CAR ~.
DEPAUL HBALTH CRNTER

f.{AHCH, PHILLIP
071~l00477
1IIIlllfilfIDltJUnUH
I/P
MED 0546.01 10(02/1976 30Y M 06/01/07 .f{AJ"l.l>1AN, ANWER 7, 0007<18298
000622
ASl!Jgn..,.titAAefttli I hat'(lDY autholize and assign payment to this facility of any type ot rttimburS6m~nt or Plt~nt .. from Medioare, Medicaid, or any other third partv payor. for any and an coat Incurred for my madical and related oare at this facility and/or by the indspenden1 contractors providing services at this facility.
of VerittmfllVJ &mpt; I ~(jrtlfy thitt I h~vfl rlllld (lfId UndfJr$lBnd tho pl'6c6ding ayrfJflfmmr. d lin..we/e., tfm8 1Ixp/#1Md f(; me and understllnd IU oontgan gnd accept It~ fflrm8, I undors.taoothst new I'I~COlJflt numbers mav be Issued for follow Uj) ";view fbllt6d to thl~ 6dmla.$.lonJ1reatment andu,at woUld not cnsnQ8 this ftileem6ftt Of be COn&idFad a dlsch&rge by Medloare, I unOsrnand I may withdraw my agreemont to tho preceding at any time by written notification to thfs facllfty.
Aclcno~
I hllvq
os: 31-07
Dat(J
OR
~otUf6lfW.kltjqrwAip
Date
(ParentfLeg& I GuardlanlResponsibht Person)
\)
Witness Slgrntture

bata
0715100477 ERS10/02/1976 30Y M 05/31/07 EMEROENCY,PHYSrCIA00074829B
YARCH, PHILLIP
/1111.111111
ERQ
Data
Sii,{-wtufa of Gv!lnmtOf /
PI,,/lS6 Print Name
1/
000623
COosont to AdmlS!!ioo; I requos( and consent to admission.
C9O$t)ot to Medical and Belated Health Cam: 1 request and consent to the medical care, cftagoostic and treatment procedures as determlnoo necessary by my physicianfs' or his/Mr assistants. I ACKnowledge the care I receive while in this tacftity Is. under the dlrection of my physician/a). This facility is not responsible for the a<:ts or omissions of my physicien(sl.
M&djcat end Alfiad Health Care Provldm.; I have beon informed and understand that the Physician(s, provldlno servloes to me in this facility, such ru; my personal Physiclan(s), Radiologists. Pathologists, Anootheslologist, ConsultJng Physicians, Surgeons and other Allied Hes/th Care P10vlders such as Dentists and P$yaholQ9l$ts ale Independant contractors and are not flmployees or agonts 01 this facility unless otherwise speclflcafly Identified.
TeachJrut PrCUlTflms: I understand thi~( facility may, from time to tim!), &nter Into agraaments with academic modioal. nu(sifl{l end alfi&d health programs. Bacau&e of th<lsa agreements, residents, interns, modical students, nursfng students and various allied heatth prot&ssIon students, may participate in my cara. 1 agrM to partIcipate in the$e pro!1fems, b!,Ji twv~ llw (lght to limit my p!!rtic!p!t11(ln at any time. ReI?!}$! of Information: I understand thIs facIlity will make avery effort to treat my mOOiosl information
8$
confidential; however, I realize infQrmatJQn must be shared with providers andlor Individuals involved in my Gare
01' in payment of my care. J unders:t8nd this will include information found If'! my medical record. I agree to the reloase 01 Information in my med/cal reooed, and to thD actual medIcal record docum~mt8, to the extoot necessary for the following purposes; a.) I have received the Notice of Privacy Practices on this visit/admission vr previous one. I understand I can request another copy at any time.
Ii
too
b.}
to any medical and/or health care providers responsible for my care while in this facility and if tr&nStarr&ci to another facility to( care, tq that faclfltv and it$ care providel'lI.
c.J
to those responsible fol' collecting and those responsibfe for tha payment of my carGo This may include a person, gcwemment agency, Insura/'le company, health plan or employer sponsored group plan. Tlus is for the purpose of verifying insur!lnc~ benefit$ for prec&rtification and extended stay review and/or the payment of the cost 01 my car~. to utilize for internal mtldical
C3re
d.) e.)
studlas and qoaltty impro'Alment activitlos.

~thar
to comply with the Fedefsl Sole Medical Device Act of 1990 aM

reporting.
required state and federal
Mef.ll<!rMChampys/Tricare Rights: If applicable, I acknowledge recl)lpt of the MedicilrMChampus!frlcare Latter explaining my rights as a patiollt of this tae/iity. I understand this Includes my right to request a rtwiew.
PAtltnt ftll$ta: I aGknowledgB

of this facUlty.
BCG65B
to tM Patlant Rights informatJoo ~jnill9 my rights aa .
1:1
pMlant
Personal Pnnmrty: I have be fin informed aoo understand this tacility will not be liable tor any 10M ot my personal property unless it is inventoried and placed in a s8curad area maIntained by thIs facilitY.
Peymwt Is! Phyai~i!:!l) Sltrvi~9B, Mtsii" 4md Rehtt!d Caf2: IlJnciar:;tand thal all physiciarl ~8IVic66 are bllled saparately from the facility chat~s. I agree to pay ttw charges inculrtKI for tile care I rece,lve as ordered by Q'ty phY~QJan'~} ilf thia facllky. I guarantee full payment of all charges un/$$S restricted by Medicare. Medicaid or contractual ar1angements
betw8~n my ir'I9Urance
company and this
t~itity.
~SSM
H E A l T H . CAR "
DEPAUL HEALTH CENTER 12303 DEPAUL DR . . 1lDGETON, MO 63044
000624
PATIENT BEWNGINGS INVENTORY

On transfer, Illlflslarring and receiving nurses inventory belongings and place initiBis on fines provt::dW:...__--!~~~=::.:4..::~:.j.....::~~.:::.::..=====-t_::::.:::...;:=====4!:::.::...;::::::;::::::;:::::::::::;~
Assislille Devices
Miscellaneous
P NONE 0 V'lith pationt 0 Pharmacy 0 Secutily 0 W,th
PLEASE REMEMBER TO CHECK PATIENT'S BELONGINGS PRIOR TQ DiSCHARGE

Date Staff Initials
~J!~'H~~~P}IIIII
IWl'LENT BELONGINGS INVENTORY
SLM1000.Q7a (1112005) FRONT PILOT

ERQ 0715100417 ERS
~
10/02/1976 30Y
M 05/31/07
EI"lERGENCY, PHYSIClAO00748298
000625
TRANSFER CHECKLIST
lNITIAL IN DATE COLUMN WHEN EACH ITEM COMPLETED If Item No1 Applicable, recQrd NI A In box.
DATE
DATE
DATE
From RoomfJ
Home medications
None '/iith pharmacy

With security
[]
(J
[] [J [J
0 0 0
0
With patient
i
If transferring from Telemetry Remove monitor
Sent with family
0 0 0 0 0
Enter transier inlo computer Make sure that labels are placed on all documents in tn& chart at tima of lmflSter Communicate daily and pending labs Medication Reconciliation completed Place MAR. Interdisciplinary Plan of Care/Care Pathway, & Educailon Record tn chart Place loday's 24hour record and all bedside flowsheets In chart Place Wound Tracking log in front of chart Complete Personai Belongings Inventory (on front) and place In "Admission" section of chart Take any old charts or thinned records with palienl to new room Place any Non-pyxis mads and IV mads in plastiC bag and clip to chart Notify Attending and ConSUlting Physicians of room change_
i
=+=
I
NOtify Family of new room number and print name 01 family member in date column
Transferring Nurse Transporter
RECEIV'NG DEPARTMENT
To Room It
Name of receiving Nurse Document date and time patienl arrived in new department Document patient status on arrivaf to unit Place New Room Number on chart
-.---
Print new labels and place in fronl of chan
!
I
I Ensure daily and pending labs are ordered

Label blank Physicians Orders & Progress Notes and place In proper sections of the chart
SfGNATUR INIT SIGNATURE INIT
SIGNATURE
[NIT
~SSM
PATIENT LABEL
HIOALTH-CARE"
PATIENT BELONGINGS [1I.'VENTORY

SlM1000{)73 (11/('005) BACK PILOT
000626
SSM DEPAUL EMERGENCY RECORD HPI BL~K (17:04 BCOP) CHIEF COMPLAINT: Pt. presents with c/o of left facial edema and pain that started several days ago. Pt. has hx. of penetrating stab wound to left face and neck with assoc. osteomyelitis of left mandible and ?maxilla. Pt. states he receives Merrem and Clindamycin via PICC line by home health services. Pt. had appt. with Dr. Zinser on Tuesday of last week, but missed the appt. HISTORIAN: History obtained from patient. TIME COURSE: Onset of symptoms reported as sudden, Onset was several days ago, Patient currently has symptoms, Complaint is constant. SEVERITY: Maximum severity is severe, Currently symptoms are severe.
lWN ALLERGIES
J
known drug allergies.
HISTORY MEDICAL HISTORY (16:26 MHOF): History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, . History of hypertension, jaw osteomyelitis. HAS PICC LINE FOR IV ANTIBIOTIC. History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, . History of hypertension, jaw osteomyelitis. HAS PICC LINE FOR IV ANTIBIOTIC. PSYCHIATRIC HISTORY (16:26 MHOF): No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. . No previous psychiatric history. SURGICAL HISTORY (16:26 MHOF); Jaw Repair, plate left jaw. facial repair Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. Jaw Repair, plate left jaw. facial repair . SOCIAL HISTORY (16:26 MHOF): Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. FAMILY HISTORY (16:26 MHOF): Fa~mily history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. NOTES (16:26 MHOF): Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Agree with nursing
000627
records. Nursing records reviewed. Nursing records reviewed. Nursing records reviewed, Agree with nursing records. (17:06 BCOP): Nursing records reviewed, PMHx: Left mandible osteomyelitis. MEDS: Merrem and Clindamycin IV. See nursing notes.
ROS (17:05 BCOP) CONSTITUTIONAL: No fever, No chills. EYES: No vision changes, No eye pain. ENT: No sore throat, No dysphagia, No dysphonia, No stridor, No drooling, No voice changes, No otalgia. CARDIOVASCULAR: No diaphoresis. ~ ~PIRATORY: No stridor, No SOB, No sputum . . No nausea, No vomiting, No appetite changes. MUSCULOSKELETAL: No neck pain, No injury. SKIN: Historian reports skin changes, No pigmentation changes, No rash, No induration, No skin lesions, No cellulitis. NEUROLOGIC: No headache, No speech changes. HEMO/LYMPHBTIC: No adenopathy, No swollen nodes. PSYCHIATRIC: No drug abuse, No alcohol abuse. ~TT" SYSTEMS NEGATIVE: All relevant systems reviewed and all negative except for the above. TRIAGE (Mon Jan 21 2008 16:10 HWE1) COMPLAINT (Mon Jan 21 2008 16:10 HWE1) COMPLAINT: Left Side Facial Swelling. PROVIDERS (Mon Jan 21 2008 16:10 HWE1) TRIAGE NURSE: Heather West, RN. ADMISSION (Mon Jan 21 2008 16:10 HWE1) : URGENCY: ESI-4, TRANSPORT: Ambulatory, BED: WAITING. P~TIENT (Mon Jan 21 2008 16:10 HWE1): NAME: Phillip H March, AGE: 31, GENDER: Male, DOB: Sat Oct 02 1976, RACE: Black, Code: NO, Trauma: *NO, Work Comp.: NO, Heat Related: NO, SSN: 493788699, ZIP CODE: 63121, KG WEIGHT: 88.5 (est.), HEIGHT: 175cffi, PHONE: 314387-8122, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0802100447, PRIMARY: Phillip G Zinser, ATTENDING: Emergency Physicians, IBEX NUMBER: 20080121161056ADT. PREVIOUS VISIT ALLERGIES (Mon Jan 21 2008 16:10 HWE1) : No known drug allergies. VITAL SIGNS (Mon Jan 21 2008 16:10 HWE1): BP 155/90, Pulse 75, Resp 18, Temp 98.3, Pain 8, 02 Sat 99, on ra, Time 1610. FALL RISK (16:26 MHOF): TIME: 1620, Gender (Male). ASSESSMENT: (16:26 MHOF): c/o swelling to left side face for last 2 days. TB Screening (16:26 MHOF): Denies TB screening. Educational/Cultural Barriers (16:26 MHOF): No educational/cultural barriers. TREATMENTS IN PROGRESS (16:26 MHOF): No treatment.
000628
SSM DEPAUL EMERGENCY RECORD PHYSICAL EXM~ (17:11 BCOP) CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3, Nontoxic AAM in NAD or appreciable discomfort at time of PEe HEAD: Atraumatic, Normocephalic, Minimal nonpitting edema of left cheeck and jaw without warmth, cellulitis, trauma, induration, or fluctuance. Left maxilla with scar c/w pt's PMHx. EYES: Pupils equal and reactive to light, Extraocular muscles intact, Sclera are normal, Left pupil: 2mm, Right pupil: 2mm, Left pupil is reactive, Right pupil is reactive. ENT: Ears normal to inspection, Nose examination normal, Oropharynx normal, Mouth normal to inspection, Poor dentition noted, Patient has dental caries, Lower right 1st molar (#30) with large carie at central and medial aspect of tooth. No d/c, bleeding or abscess. ~ilateral lower plate wisdom tooth impaction and diffuse gingivitis. No Stenson's duct d/c or masses. Wharton's duct negative. No intra-oral lesions, masses, or infection. NECK: Normal ROM, No meningeal signs, Cervical spine flOn-tender, Large irregular scar on left anterior aspect of neck at level of left mandibular angle; c/w pt's PM_Rx. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. _DIOVASCULAR: RRR, No murmurs, No rub, No gallop. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Normal range of motion. NEURO: GCS is IS, No focal motor deficits, No focal sensory deficits, No cerebellar deficits, Eye Opening: 4, Verbal Response: 5, Motor Response: 6, The GCS total is 15, eN v, VII, IX, and XII intact and appropriate. 2-point discrimination on left face is appropriate. N: Skin exam normal except as noted. LyMPHATIC: No adenopathy in neck. PSYCHIATRIC: Oriented X 3, Normal affect. ATTENDING (18:57 AMAJ) HISTORY: The documented history was done by the physician extender. PHYSICAL EX_~_M; The documented physical exam was done by the physician extender. DOCTOR NOTES (17:14 BCOP) Dr. Zinser contacted at 1652 and educated on pt's presentation, PE TEXT: findings, and current status. He states home health and BJC OMF clinic have stopped seeing/assisting pt. secondary to multiple missed appts. and non-compliance with medications. Dr. Zinser agrees with tx. plan and suggests pt. flu with OMF clinic at Barnes, as well as maintain compliance
000629
with home health/medication schedules. Pt. educated on impacted wisdom tooth r dental carie r gingivitis r osteomyelitis r and importance of flu with IDr home health r Barnes OMF clinic r and Dr. Zinser as scheduled. Pt. voices understanding and agrees to comply with tx. plan. Pt. in NAD or discomfort at time of d/c. D/W: Discussed this case with Dr. Zinser r Infectious disese. PATIENT PLAN: The patient will be discharged r The patient will follow up with primary care physician.
DIAGNOSIS
(17:16 BCOP) FINAL: PRIMARY: impacted wisdom tooth r ADDITIONAL: dental carie, gingivitis, left mandible osteomyelitis.
~POSITION
PATIENT (17:16 BCOP): X-RAY/CT Follow-up: NOr Critical Care: *None r Doctor Procedures: NOr Disposition: Homer Condition: Stable. (17:29 MHOF): Remove from ER. NOTES (17:16 BCOP): Patient discharged Patients primary physician was contacted before D/C Prescription given Verbal instructions given Written instructions given Follow-up with your doctor tomorrow. May return to work.
MEDICATION SERVICE (16:46 BCOP)
Vicodin: Order: Vicodin : 500mg-5mg xl By Mouth Ordered: Mon Jan 21 2008 16:46 Ordered by: Bryan Copas r PA-C Entered by: Bryan Copas r PA-C Mon Jan 21 2008 16:46 Acknowledged by: Matt Hoffman r RN Mon Jan 21 2008 17:13 Documented as given by: Matt Hoffman r RN Mon Jan 21 2008 17:17 MEDICATION r Time given: 1715 r Given in amount and via route as prescribed r Correct patient r timer router dose and medication confirmed prior to administration r Patient advised of actions and side-effects prior to administration r Allergies confirmed and medications reviewed prior to administration. INSTRUCTION (17:18 BCOP) DISCHARGE: TOOTHACHE r GINGIVITIS. FOLLOWUP: 2r PHILLIP G ZINSER MD 11125 DUNN ROAD SUITE 412 JENNINGS MO 63136 3143557997 r PAUL S MACE DDS 12255 DEPAUL DRIVE 875 BRIDGETON MO 63044 3142911242. SPECIAL: Follow up with Oromaxillofacial Surgeon or Clinic: BJC - 314-361-6006 SLU - 314-977-5110 St. John's - 314-251-6725
000630
SSM DEPAUL EMERGENCY RECORD Follow up with your physician within 3 days Return to ER immediately if signs and symptoms change Follow-up with your doctor Follow-up with Dental Clinic May return to work. Advance activity as tolerated Follow up with your private MD. Return to ED if worse. Return to the ER if worse Tylenol or Advil for Pain Encourage fluids Take medication as prescribed Follow up with referring physician.
~SCRIPTION (17:15 BCOP) Clindamycin Hydrochloride: Capsule: 300 mg : Oral=Quantity: ***1*** Unit: cap Route: Oral Schedule: QID Dispense: ***28***. Ultram: Tablet: 50 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: PRNQ6 Dispense: ***30***.
NURSING ASSESSMENT: FOCUSED (16:32 MHOF) pt states developed swelling to left side face 2 days ago, denies dental pain or sore throat, states had prior surgery this pasy year to same area after stabbed in face, states had plate inserted and then removed, obvious swelling noted to left side face, no redness noted, pt denies headache, fever or bodyaches, pt states has received treatment for infection to that site in past and even had picc line that he was receiving antibiotics through, states finished course of meds and removed picc line himself last wednesday, site with no redness, scab over area. TTME ASSESSED: Patient was assessed at 1625. 'S: Eyes are PERRL. ~~uRO: Orientation: Alert, Behavior: Cooperative, Coherent. GCS: GCS Eye Opening: Spontaneously (4), GCS Verbal Response: Oriented/conversive (5), GCS Motor Response: Obeys comands(6) , The GCS total is 15. MUSCULOSKELETAL: Good ROM. SKIN: Skin is warm.
P~~ES:
NURSING ASSESSMENT: NURSES NOTE (17:29 MHOF) TIME ASSESSED: Time: 1725, states pain improving, awaits dc. NURSING PROCEDURE: DISCHARGE NOTE (17:28 MHOF) TIME: Procedure was performed at 1725, Patient discharged to home, Patient ambulates without assistance, Transported via friend/family driving, Accompanied by friend, Patient instructed not to drive home,
000631
Simple/moderate discharge teaching performed, Prescription given and additional instructions on side effects of same given, Above Person(s) verbalized understanding of discharge instructions and follow-up care.
NURSING PROCEDURE: INTAKE AND OUTPUT (17:29 MHOF) TIME: Intake output performed, at 1725, PO Intake (ml) : 120, Urine Output (ml) : 0. IMAGING (17:35 MY) CONSENT TO TREAT:
Image captured from scanner.
ADMIN iITAL SIGNATURE (17:19 BCOP): Copas, PA-C, Bryan. \18:57 AMAJ): Majino, M.D., Angela. PATIENT DATA CHANGE (16:41 BCOP): Dr. Extender changed from (none) to Bryan Copas, PA-C. (16:41 BCOP): Attending: Angela Majino, M.D. (16:44): A08 71902889 by Interface, Payment: 90, Admitting Doctor: Zinser Phillip G, Attending Doctor: Physicians Emergency. (16:45):- A08 71902941 by Interface, Admitting Doctor: Zinser Phillip G, Attending Doctor: Physicians Emergency.
KEY: AMAJ=Majino, M.D., Angela BCOP=Copas, PA-C, Bryan MHOF=Hoffman, RN, Matt MY=Young, Matt
HWE1=West, RN, Heather
000632
SSM DEPAUL CLINICAL SUMMARY RECORD HPI BLANK CHIEF COMPLAINT: Pt. presents with c/o of left facial edema and pain that started several days ago. Pt. has hx. of penetrating stab wound to left face and neck with assoc. osteomyelitis of left mandible and ?maxilla. Pt. states he receives Merrem and Clindamycin via PICC line by home health services. Pt. had appt. with Dr. Zinser on Tuesday of last week, but missed the appt. HISTORIAN: History obtained from patient. TIME COURSE: Onset of symptoms reported as sudden, Onset was several days ago, Patient currently has symptoms, Complaint is constant. SEVERITY: Maximum severity is severe, Currently symptoms are severe. iTORY HISTORY: History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, . History of hypertension, jaw osteomyelitis. HAS PICC LINE FOR IV ANTIBIOTIC. History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, History of hypertension, jaw osteomyelitis. HAS PICC LINE FOR IV ANTIBIOTIC. :CHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. No previous psychiatric history . . No previous psychiatric history. SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. Jaw Repair, plate left jaw. facial repair . :IAL HISTORY: Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. FA_MILY HISTORY; Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. NOTES: Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. Nursing records reviewed. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, PMHx: Left mandible osteomyelitis.
~ICAL
000633
SSM DEPAUL CLINICAL SUMMARY RECORD MEDS: Merrem and Clindamycin IV. See nursing notes. ROS CONSTITUTIONAL: No fever, No chills. EYES: No vision changes, No eye pain. ENT: No sore throat, No dysphagia, No dysphonia, No stridor, No drooling, No voice changes, No otalgia. CARDIOVAS.CULAR: No diaphoresis. RESPIRATORY: No stridor, No SOB, No sputum. GI: No nausea, No vomiting, No appetite changes. MUSCULOSKELETAL: No neck pain, No injury. -N: Historian reports skin changes, No pigmentation changes, No rash, No induration, No skin lesions, No cellulitis. NEUROLOGIC: No headache, No speech changes. HEMO/LYMPHATIC: No adenopathy, No swollen nodes. PSYCHIATRIC: No drug abuse, No alcohol abuse. ALL SYSTEMS NEGATIVE: All relevant systems reviewed and all negative except for the above. r--,,(SICAL EXAM ,STITUTIONAL: Vi tal signs reviewed, Comfortable, Alert and oriented X 3, Nontoxic AAM in NAD or appreciable discomfort at time of PEe HEAD: Atraumatic, Normocephalic, Minimal nonpitting edema of left cheeck and jaw without warmth, cellulitis, trauma, induration, or fluctuance. Left maxilla with scar clw pt's PMHx. EYES: Pupils equal and reactive to light, Extraocular muscles intact, Sclera are normal, Left pupil: 2mm, Right pupil: 2mm, Left pupil is reactive, Right pupil is reactive. ': Ears normal to inspection, Nose examination normal, Oropharynx normal, Mouth normal to inspection, Poor dentition noted, Patient has dental caries, Lower right 1st molar (#30) with large carie at central and medial aspect of tooth. No dlc, bleeding or abscess. Bilateral lower plate wisdom tooth impaction and diffuse gingivitis. No Stenson's duct dlc or masses. Wharton's duct negative. No intra-oral lesions! masses, or infection. NECK: Normal ROM, No meningeal signs, Cervical spine non-tender, Large irregular scar on left anterior aspect of neck at level of left mandibular angle; clw pt1s PMHx. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion.
000634
SSM DEPAUL CLINICAL SUMMARY RECORD LOWER EXTREMITY: Normal range of motion. NEURO: GCS is 15, No focal motor deficits, No focal sensory deficits, No cerebellar deficits, Eye Opening: 4, Verbal Response: 5, Motor Response: 6, The GCS total is 15, CN V, VII, IX, and XII intact and appropriate. 2-point discrimination on left face is appropriate. SKIN: Skin exam normal except as noted. LYMPHATIC: No adenopathy in neck. PSYCHIATRIC: Oriented X 3, Normal affect. DOCTOR NOTES TEXT: Dr. Zinser contacted at 1652 and educated on pt's presentation, PE findings, and current status. He states home health and BJC OMF clinic have stopped seeing/assisting pt. secondary to multiple missed appts. and non-compliance with medications. Dr. Zinser agrees with tx. plan and suggests pt. flu with OMF clinic at Barnes, as well as maintain compliance with home health/medication schedules. Pt. educated on impacted wisdom tooth, dental carie, gingivitis, osteomyelitis, and importance of flu with ID, home health, Barnes OMF clinic, and Dr. Zinser as scheduled. Pt. voices understanding and agrees to comply with tx. plan. Pt. in NAD or discomfort at time of d/c. ~/,~: Discussed this case with Dr. Zinser, Infectious disese. lENT PLAN: The patient will be discharged, The patient will follow up with primary care physician. DIAGNOSIS FINAL: PRIMARY: impacted wisdom tooth, ADDITIONAL: dental carie, gingivitis, left mandible osteomyelitis. DTSPOSITION lENT: X-RAYiCT Follow-up: NO, Critical Care: *None, Doctor Procedures: NO, Disposition: Home, Condition: Stable. Remove from ER. NOTES: Patient discharged Patients primary physician was contacted before Dic Prescription given Verbal instructions given Written instructions given Follow-up with your doctor tomorrow. May return to work. MEDICATION SERVICE Vicodin: Order: Vicodin 500mg-5mg xl Ordered: Mon Jan 21 2008 16:46 Ordered by: Bryan Copas, PA-C Entered by: Bryan Copas, PA-C Mon Jan Acknowledged by: Matt Hoffman, RN Mon Documented as given by: Matt Hoffman, MEDICATION, Time given: 1715, Given By Mouth 21 2008 16:46 Jan 21 2008 17:13 RN Mon Jan 21 2008 17:17 in amount and via route as prescribed,
000635
Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration.
PRESCRIPTION Clindamycin Hydrochloride: Capsule: 300 mg : Oral=Quantity: ***1*** Unit: cap Route: Oral Schedule: QID Dispense: ***28***. Ultram: Tablet: 50 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: PRNQ6 Dispense: ***30***. INSTRUCTION "',CHARGE: TOOTHACHE, GINGIVITIS. ~LOWUP: 2, PHILLIP G ZINSER MD 11125 DUNN ROAD SUITE 412 JENNINGS MO 63136 3143557997, PAUL S MACE DDS 12255 DEPAUL DRIVE 875 BRIDGETON MO 63044 3142911242. SPECIAL: Follow up with Oromaxillofacial Surgeon or Clinic: BJC - 314-361-6006 SLU - 314-977-5110 St. John's - 314-251-6725 ~ollow up with your physician within 3 days _eturn to ER immediately if signs and symptoms change Follow-up with your doctor Follow-up with Dental Clinic May return to work. Advance activity as tolerated Follow up with your private MD. Return to ED if worse. Return to the ER if worse Tylenol or Advil for Pain :ncourage fluids Take medication as prescribed Follow up with referring physician.
000636
SSM DEPAUL RECORD
000637
I~
SSM DEPAUL EMERGENCY FLOW SHEET RECORD Name: March, Phillip VITAL SIGNS User Date/Time HWE1 01/21 16:10 Age: 31Y MR: 000748298 Acct: 0802100447
BP 155/90
PULSE
75
RESP 18
TEMP 98.3
PAIN
02 SAT
99 on ra
TIME 1610

Name: March, Phillip Age: 31Y MR: 000748298 Acct: 0802100-147 Prepared: Tue May 26 09:04:54 2009 by Stephanie Manetz Page: 1
000638
Picis Imaging
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000639
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING MARCH,PHILLIP H Sex: M Med Rec # A000748298 ACCT: A0902200197 Pt Location: *5S-0554-01 ZINSER,PHILLIP G 12774 BOENKER LANE BRIDGETON Exam MRI FACE MO 63044
~:
DOB: 10/02/76 Age: 32Y Date: 01/25/09 1107
Check-In # Order Diagnosis 1226957 Ord Diag: 682.9-CELLULITIS NOS
Examination: MRI face. Indication for examination: Left facial swelling and pain. Previous surgery. Noncontrast T1 and T2-weighted sagittal, axial and coronal images of the face are obtained. A skin marker was placed at the left side of the face at the area of clinical interest as designated by the patient. No cystic or solid soft tissue mass is identified. There is no significant superficial or deep soft tissue edema. There is normal bone marrow signal intensity without evidence of osteomyelitis or bone marrow replacement. There is a small cyst at the floor of the left maxillary sinus. There is no air-fluid level. Remaining visualized sinuses are well-aerated. There are no abnormally enlarged lymph nodes identified in the upper cervical region. Conclusion: Unremarkable MRI examination of the face as described in. detail above. No evidence of osteomyelitis or bone marrow edema. Read By- ROBERT J JR GRESICK M.D. Released By- ROBERT J JR GRESICK M.D. Released Date Time- 01/25/09 1139 Transcriptionist- RJG M.D.
ADM: SALEM,MOUNER FINAL DUPLICATE
ATT: SALEM,MOUNER Page 1
000640
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING Med Rec # A000748298 ACCT: A0904100209 Pt Location: *ER HODGES,HARLAN D 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044 Check-In # Order Diagnosis 1234411 Ord Diag: 723.1-CERVICALGIA
DOB: 10/02/76 Age: 32Y Date: 02/10/09 0756
Sex: M
Exam CT NECK W/CONTRAST
Indicaticn: History of stab wound and mUltiple fractures of chronic osteomyelitis of the jaw Technique: Thin section helical CT images of the neck were obtained following 60 mL of Omnipaque 350. Findings: Scans of the lung apices are unremarkable. Soft tissues of the nasopharynx, oropharynx and hypopharynx appear unremarkable. There are multiple lymph nodes present in all spaces of the neck. No definite bony destruction is identified. Some edema is noted just above the level of the hyoid best seen on series 2 images 91 through 94 however, no definite enhancing abscesses appreciated. The visualized mastoid air cells and paranasal sinuses appear clear. Clips are present adjacent to the left internal jugular vein. Impression: Mild edema is noted just above the level of the hyoid, otherwise unremarkable CT scan of the neck. Read By- MEGAN M GAU M.D. Released By- MEGAN M GAU M.D. Released Date Time- 02/10/09 0825 Transcriptionist- MMG M.D. ADM: EMERGENCY,PHYSICIANS REF: PCP: PCP,NONE ATT: EMERGENCY,PHYSICIANS CON: SCP:
FINAL DUPLICATE
Page
000641
SSM DEPAUL EMERGENCY RECORD HPI JAW PAIN (11:39 JEHR) CHIEF COMPLAINT: Patient presents for the evaluation of jaw pain, left. HISTORIAN: History obtained from patient. TIME COURSE: Onset of symptoms reported as gradual, Onset was 2-3 days ago, Patient currently has symptoms, Complaint is worse, Complaint is persistent. LOCATION: Pain most severe in left mandible, Radiation is to neck. QUALITY: Pain is sharp, stabbing, throbbing. ASSOCIATED WITH: HX OF OSTEOMYELITIS sip STAB WOUND TO JAW. SEVERITY: Maximum severity is moderate, Currently symptoms are moderate. EXACERBATED BY: Patient's condition exacerbated by chewing, PALPATION. RELIEVED BY: Patient's condition relieved by IBUPROFEN AND TYLENOL INEFFECTIVE. _ES: 32 YO MALE PW LEFT SIDED JAW PAIN X 2-3 DAYS. sip SURGICAL REPAIR REQUIRING PLATE AND SCREW PLACEMENT sip STAB INJURY 2007. DEVELOPED OSTEOMYELITIS 2/2008 REQUIRING PIC LINE FOR MERREM AND CLINDA. DENIES F/C/S, N/V/D, NEW TRAUMA, RASH, REDNESS. NOTABLE SWELLING ~~ PAIN OF LEFT MANDIBLE. KNOWN ALLERGIES ~~ known drug allergies. HISTORY MEDICAL HISTORY (Sat Oct 11 2008 11:07 CBLA): History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. jaw osteomyelitis . . see RN notes. PSYCHIATRIC HISTORY (Sat Oct 11 2008 11:07 CBLA): No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. GICAL HISTORY (Sat Oct 11 2008 11:07 CBLA): Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. Jaw Repair, plate left jaw. facial repair . . L jaw surgery, harware removal, chronic osteomyelitis. see RN notes. SOCIAL HISTORY (Sat Oct 11 2008 11:07 CBLA): Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Patient consumes alcohol socially, Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at horne with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies alcohol abuse, Denies tobacco ~uu~~, Denies drug abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse.
000642
FAMILY HISTORY (Sat Oct 11 2008 11:07 CBLA): Family history is not contributory to this case, Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. NOTES (Sat Oct 11 2008 11:07 CBLA): Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. Nursing records reviewed. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, PMHx: Left mandible osteomyelitis. AEDS: Merrem and Clindamycin IV. See nursing notes. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, Agree with nursing records. (11:40 JEHR): Nursing records reviewed, Agree with nursing records. (11:40 JEHR) CONSTITUTIONAL: Negative constitutional review of systems. I--~S: Negative eye review of systems . . : No rhinorrhea, No sore throat, No otalgia. CARDIOVASCULAR: Negative cardiovascular review of systems. RESPIRATORY: Negative respiratory review of systems. GI: Negative gastrointestinal review of systems. ALL SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above.
ROS (Sat Oct 11 2008 11:07 CBLA) :PLAINT: Facial Pain/Swelling. PKOVIDERS: TRIAGE NURSE: Cherie Blaesing, RN. ADMISSION: URGENCY: ESI-3, TRM~SPORT: Car, BED: WTG-RM. PATIENT: NAME: Phillip H March, AGE: 32, GENDER: Male, DOB: Sat Oct 02 1976, RACE: Black, Code: NO, Trauma: *NO, Work Comp.: NO, Heat Related: NO, SSN: 493788699, ZIP CODE: 63121, KG WEIGHT: 73.5, HEIGHT: 182cm, PHONE: 314393-1241, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0828500070, PRIMARY: Phillip G Zinser, ATTENDING: Emergency Physicians, IBEX NUMBER: 20081011110705ADT. PREVIOUS VISIT ALLERGIES: No known drug allergies. NOTES:Total score is: 0, Confusion (3), No Increased Risks patient. ASSESSMENT: 8, GCS Eye Opening: Spontaneously (4), GCS Verbal Response: Oriented/conversive (5), GCS Motor Response: Obeys comands(6), The GCS total is 15, co swelling and pain in It side of face stabbed last year states has had infections and problems since.
~ntAGE
000643
TB SCREENING: Denies TB screening. DOMESTIC VIOLENCE: The presence of domestic violence is unknown. EDUCATIONAL/CULTURAL BARRIERS: No educational/cultural barriers. TREATMENTS IN PROGRESS: No treatment. VITAL SIGNS: BP 148/90, Pulse 60, Resp 16, Temp 98, Pain 8, 02 Sat 99, on ra, Time 1103.
PHYSICAL EXAM (11:41 JEHR) CONSTITUTIONAL: Vital signs reviewed, Alert and oriented X 3, Patient appears uncomfortable. HEAD: Atraumatic, Normocephalic, SWELLING AND TTP OF LEFT MANDIBLE. NO ERYTHEMA, WARMTH TO TOUCH, RASH. NO DENTAL TTP OR GINGIVAL SWELLING. r~s: Pupils equal and reactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal, Conjunctiva are normal. ENT: Ears normal to inspection, External ear normal, TM's normal, no external auditory canal foreign body, no external auditory canal drainage, no external auditory canal bleeding, hearing normal, Nose examination normal, no nasal deformity, no active bleeding from nares, no active bleeding from hypopharynx, no foreign body visualized, no septal hematoma, no septal necrosis, Oropharynx normal, No stridor, No trismus, not injected, normal tonsils, no uvular edema, no uvular deviation, no exudates, no pharyngeal swelling, no pharyngeal asymmetry, Mouth normal to inspection, mucus membranes moist, no lesions, no lacerations, No drooling, Able to handle secretions, No tongue elevation, teeth normal, normal dentition, no abcess, no dental fractures, Sinuses exam normal, Sinuses non-tender, No erythema, No swelling. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. OMEN: Abdomen is non-tender, No masses, Bowel sounds normal, No distension, No peritoneal signs. BACK: There is no CVA Tenderness, There is no tenderness to palpation, Normal inspection. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, No calf tenderness, Normal range of motion. NEURO: GCS is 15, No focal motor deficits, No focal sensory deficits, No cerebellar deficits. SKIN: Skin is warm and dry, No rash or induration. LYMPHATIC: Cervical Nodes. PSYCHIATRIC: Oriented X 3, Normal affect. 02SAT INTERPRETATION (11:41 JEHR)
000644
02SAT:
02 saturation reading 99%, 02 AMT: R.A., 02 Sat normal, None needed.
RESULTS LAB (12:05 JEHR): CBC W AUTO DIFF Oct 11 2008 11:55, WBC 5.8 1000/mm3 Ref Range (4.5-11.0), RBC 5.00 10X6 Ref Range (4.7-6.1), Hgb 14.6 gm/dl Ref Range (13.0-18.0), Hct 43.1 % Ref Range (39.0-54.0), MCV 86.2 fl Ref Range (80.0-99.0), MCH 29.2 pg Ref Range (25.0-31.0), MCHC 33.9 gm/dl Ref Range (32.0-36.0), RDW 14.6 H % Ref Range (11.5-14.5), Platelets 227 1000/mm3 Ref Range (130.0-400.0), Gran 55.1 % Ref Range (40.0-70.0), Lymph 35.9 % Ref Range (22.0-40.0), Mono 7.8 % Ref Range (2.0-10.0), Eos 0.9 % Ref Range (0.0-6.0), Baso 0.3 % Ref Range (0.0-3.0), Manual Diff Not Indicated Absolute Neutrophil 3.17 1000/mm3 Ref Range (1.8-7.7). 112:36 LVIE): COMPREHENSIVE METABOLIC PANEL Oct 11 2008 12:28, BUN 15 mg/dl Ref Range (9.0-20.0), Sodium 139 mEq/L Ref Range (137-145), Potassium 4.4 mEq/L Ref Range (3.6-5.0), Chloride 102 mEq/L Ref Range (98.0-107.0), Glucose 86 mg/dl Ref Range (75-110), Creatinine 1.1 mg/dl Ref Range (0.8-1.5), AST/SGOT 28 U/L Ref Range (17.0-59.0), Alk Phos 63 U/L Ref Range (38.0-126.0), Calcium 9.3 mg/dl Ref Range (8.4-10.2), Bilirubin 0.6 mg/dl Ref Range (0.2-1.3), Albumin 4.4 gm/dl Ref Range (3.5-5.0), Prot Total 7.6 gm/dl Ref Range (6.3-8.2), C02 29 mEq/L Ref Range (22.0-30.0), ALT/SGPT 27 U/L Ref Range (21.0-72.0), GFR 99.8 ml/min/1.73m2. RADIOLOGY (14:16 JEHR): CT MAXILLOFACIAL W/O CONTRAST Oct 11 2008 14:10, Check-in number: 0001182696 Read By: 65017 CT maxillofacial bones without contrast with 3-D reconstructions. Indication- Left-sided facial swelling. Previous surgical repair of the left mandible. Previous CT 12/26/2007. Has visible swelling. A high-resolution axial scan is made through the facial bones. Both reformatted coronal, sagittal and 3-D images of the mandible were
f
000645
SSM DEPAUL EMERGENCY RECORD obtained. There is slight deformity and some residual lucent lines involving the ramus of the mandible on the left compatible with previous trauma and/or surgery. There is no evidence of an acute fracture or bone destruction. The left mandibular condyle is in normal position within the condylar fossa. This appearance is unchanged from the ~revious study. The right mandibular condyle appears to be subluxed anteriorly on the sagittal reformatted images. There is extensive calcification of the stylohyoid ligaments bilaterally. There is a transverse lucency through the upper stylohyoid ligament on the left possible represent a pseudofracture. This was also present previously and is unchanged. The CT scan the facial bones is therwise unremarkable. ,ummary- Stable deformity of the ramus of the mandible on the left. Mild anterior subluxation the right mandibular condyle. Extensive stylohyoid ligament calcification with possible pseudofracture on the left. Read By- EDWIN C ERNST M.D. Released By- EDWIN C ERNST M.D. Released Date Time- 10/11/08 1411 Transcriptionist- ECE M.D. ADM- EMERGENCY,PHYSICIANS ATT- VIERODOTHAGE,LAURA M REF- CONPCP- ZINSER,PHILLIP G SCP- EHRET,JENNIFER J Released By: ERNST,EDWIN,C
A~~ENDING
(15:22 LVIE) TORY: The documented history was done by the physician extender. PhYSICAL EXAM: The documented physical exam was done by the physician extender.
DOCTOR NOTES ADMITTED TO PHIL ZINSER AT DEPAUL IN PAST FOR TEXT (11:48 JEHR) OSTEOMYELITIS. T I ME (11: 4 8 JEHR): Time: 11: 48 . DISCUSSED CASE WITH DR. VIERO. SEARCH OF PREVIOUS TEXT (12:20 JEHR): ADMISSIONS REVEALED PREVIOUS PIC LINE GREW OUT POSITIVE CULTURES WHICH PROMPTED CLINDA AND MERREM. PT DOES HAVE CHRONIC OSTEOMYELITIS BUT THE CHART STATED HE HAS BEEN TO MULTIPLE ERS FOR SAME ALWAYS W/O FEVER OR ELEVATED WBC AND HAS BEEN DEEMED WORRISOME FOR NARCOTIC SEEKING BEHAVIOR. PT STATES HE IS TO SEE A PAIN MGMT SPECIALIST FOR FIRST TIME NEXT MONTH. POST D/W VIERO- WILL ORDER CT TO BETTER R/O POSSIBILITY OF ACUTE
000646
INFECTION. TIME (12:20 JEHR): Time: 12:20. TEXT (12:48 JEHR): PER WALGREENS PT GIVEN SCRIPTS FOR NARCOTICS 9/10, 8/31, 7/30 (30 - 40 TABS EACH VISIT). ALL WRITTEN BY DIFFERENT PROVIDERS FROM BJC ER. TIME (12:48 JEHR): Time: 12:48.
DIAGNOSIS
(14:17 JEHR) FINAL: PRIMARY: left mandibular pain, ADDITIONAL:
DISPOSITION
PATIENT (14:17 JEHR): Disposition: Home, Condition: Stable. 115:21 MELD): X-RAY/CT Follow-up: NO, Critical Care: *None, Doctor Procedures: YES, Remove from ER.
MEDICATION SERVICE (11:42 JEHR)
1 tablet By Mouth Percocet 5/325: Order: Percocet 5/325 Ordered: Sat Oct 11 2008 11:42 Ordered by: Jennifer Ehret Pa-C Entered by: Jennifer Ehret Pa-C Sat Oct 11 2008 11:42 ~cknowledged by: James Caldwell, EMT-P Sat Oct 11 2008 11:46 ocumented as given by: James Caldwell, EMT-P Sat Oct 11 2008 11:52 MEDICATION, Time given: 1152, Given in amount and via route as prescribed, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient in position of comfort, Side rails up, Cart in lowest position, Family at bedside.
TRUCTION (13:08 JEHR) 2, PHILLIP G ZINSER MD 11125 DUNN ROAD SUITE 412 JENNINGS MO 63136 }vLLOWUP: 3143557997, YOUR PHYSICIAN. SPECIAL: PLEASE REST. ICE PACKS WRAPPED IN TOWELS X 20 MINUTES TO AFFECTED AREA OR HEAT THERAPY WHICHEVER IS MORE BENEFICIAL. PLEASE FOLLOW-UP WITH YOUR DOCTOR AND KEEP YOUR APPOINTMENT WITH PAIN MANAGEMENT APPOINTMENT AS SCHEDULED. RETURN TO ER IF INCREASED PAIN, FEVER, VOMITING AND ARE UNABLE TO KEEP ANYTHING DOWN, OR IF YOU FEEL WORSE IN GENERAL. PRESCRIPTION (13:49 JEHR)
Ibuprofen: Tablet: 600 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: As needed every 8 hours Dispense: ***30***. NOTES: Take with food as needed for pain, swelling, inflammation. Ultram: Tablet: 50 mg : Oral=Quantity: ***1-2*** Unit: tab Route: Oral Schedule: As needed every six hours Dispense: ***15***.
000647
NOTES:
Take as needed for pains.
NURSING ASSESSMENT: FOCUSED (11:33 MTAR) NOTES: pt amb to room 34 with c/o left jaw pain and swelling x 2-3 days, throat/gland on same side with slight swelling and tenderness. pt states he has hx of osteomylitis in jaw after being stabbed with a screwdriver and shattering jaw.
TIME ASSESSED: Patient was assessed at 1130. PAIN SCALE: left jaw, On a scale 0-10 patient rates pain as 8, Quality of pain is aching. EYES: Eyes are PERRL. NEURO: Orientation: Alert, Behavior: Cooperative, No weakness present, No numbness present. L .J: GCS Eye Opening: Spontaneously (4), GCS Verbal Response: Oriented/conversive (5), GCS Motor Response: Obeys comands(6) , The GCS total is 15. RESPIRATORY: Breath sounds:, Breath sounds are clear, bilaterally. ABDOMEN: Abdomen is non-tender. SKIN: Skin is warm, Skin is dry, Skin color is normal .
. l'--'?SING PROCEDURE: NURSE NOTES (11: 33 MTAR) ,E: Time: 1130, jennifer pa-c into see pt.
NURSING PROCEDURE: IV (11:47 JEC)
TIME: Procedure was performed at 1141, 18 gauge catheter inserted, into right Forearm, with 1 attempt, Saline lock established, Labs drawn at time of placement, After placement no swelling noted at site, no drainage noted at site .
LAB DRAW ( 11 : 47 JEC) Procedure was performed at 1141, Venipuncture performed/labs sent, Blood obtained from right forearm and labs sent, with 1 attempt. SAFETY: Side rails up, Cart in lowest position, Family at bedside.
.S ING PROCEDURE:
T~ME:
NURSING PROCEDURE: BLANK CHART (12:57 MPA)
TIME: Procedure was performed at 1305, CT Faical w/o completed by CB/TE.

IMAGING
ED PROTOCOL (16:07 MELD): Image captured from scanner. CONSENT TO TREAT (16:08 MELD): Image captured from scanner.
ADMIN
DIGITAL SIGNATURE (11:33 MTAR): Tarro, RN, Maureen. (11:41 JEHR): Ehret Pa-C, Jennifer.
000648
(14:17 JEHR): Ehret Pa-C, Jennifer. (15:22 LVIE): Viero-Dothage, MD, Laura. (Thu Dec 18 2008 11:08 JEC): Caldwell, EMT-P, James. PATIENT DATA CHANGE (11:27 JEHR): Dr. Extender changed from (none) to Jennifer Ehret Pa-C. (11:31): A08 82003268 by Interface, Payment: 90, Admitting Doctor: Zinser Phillip G, Attending Doctor: Laura M Vierodothage. (11:43): A08 82003571 by Interface, Admitting Doctor: Zinser Phillip G, Attending Doctor: Laura M Vierodothage. (11:44): A08 82003597 by Interface, Admitting Doctor: Zinser Phillip G, Attending Doctor: Laura M Vierodothage. (11:47 JEHR): Attending: Laura Viero-Dothage, MD, Payment: (none). r12:10 JEC): Extender changed from (none) to James Caldwell r EMT-P. KEY: CBLA=Blaesing r RN r Cherie JEC=Caldwell r EMT-P r James JEHR=Ehret Pa-C r Jennif LVIE=Viero-Dothage, MD, Laura MELD=Elder r Mathew MPA=Arthur, Michael MTAR=Tarro r RN r Maureen
000649
SSM DEPAUL CLINICAL SUMMARY RECORD HPI JAW PAIN CHIEF COMPLAINT: Patient presents for the evaluation of jaw pain, left. HISTORIAN: History obtained from patient. TIME COURSE: Onset of symptoms reported as gradual, Onset was 2-3 days ago, Patient currently has symptoms, Complaint is worse, Complaint is persistent. LOCATION: Pain most severe in left mandible, Radiation is to neck. QUALITY: Pain is sharp, stabbing, throbbing. ASSOCIATED WITH: HX OF OSTEOMYELITIS S/P STAB WOUND TO JAW. SEVERITY: Maximum severity is moderate, Currently symptoms are moderate. EXACERBATED BY: Patient's condition exacerbated by chewing, PALPATION. RELIEVED BY: Patient's condition relieved by IBUPROFEN AND TYLENOL INEFFECTIVE. l, ~ES: 32 YO MALE PW LEFT SIDED JAW PAIN X 2-3 DAYS. S/P SURGICAL REPAIR REQUIRING PLATE AND SCREW PLACEMENT S/P STAB INJURY 2007. DEVELOPED OSTEOMYELITIS 2/2008 REQUIRING PIC LINE FOR MERREM AND CLINDA. DENIES F/e/S N/V/D, NEW TRAUMA, RASH, REDNESS. NOTABLE SWELLING AND PAIN OF LEFT MANDIBLE.
f
HISTORY r'--'ICAL HISTORY: History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. jaw osteomyelitis . . see RN notes. PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. Jaw Repair, plate left jaw. facial repair . . L jaw surgery, harware removal, chronic osteomyelitis. see RN notes. SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Patient consumes alcohol socially, Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies smoking, Patient consumes alcohol socially! Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco Denies alcohol abuse, Denies tobacco abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. FAMILY HISTORY: Family history is not contributory to this case, Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is
000650
not contributory to this case. Family history is not contributory to this case. NOTES: Nursing records reviewed r Agree with nursing records r Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. Nursing records reviewed. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, PMHx: Left mandible osteomyelitis. MEDS: Merrem and Clindamycin IV. See nursing notes. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, Agree with nursing records. : Nursing records reviewed r Agree with nursing records.
J., ..J
CONSTITUTIONAL: Negative constitutional review of systems. EYES: Negative eye review of systems. ENT: No rhinorrhea r No sore throat r No otalgia. CARDIOVASCULAR: Negative cardiovascular review of systems. RESPI~~TORY: Negative respiratory review of systems. GI: Negative gastrointestinal review of systems. p~T, SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above.
PHYSICAL EXAM CONSTITUTIONAL: Vital signs reviewed r Alert and oriented X 3 r Patient appears uncomfortable. HEAD: Atraumatic r Normocephalic r SWELLING AND TTP OF LEFT MANDIBLE. NO ERYTHEY~, WARMTH TO TOUCH, RASH. NO DENTAL TTP OR GINGIVAL SWELLING. FVES: Pupils equal and reactive to lightr No discharge from eyes r Extraocular muscles intact r Sclera are normal r Conjunctiva are normal. BN~: Ears normal to inspection r External ear normal r TM's normal r no external auditory canal foreign bodYr no external auditory canal drainage r no external auditory canal bleeding r hearing normal r Nose examination normal r no nasal deformitYr no active bleeding from nares r no active bleeding from hypopharynx r no foreign body visualized r no septal hematoma r no septal necrosis; Oropharynx normal r No stridor r No trismus r not injected r normal tonsils r no uvular edema r no uvular deviation r no exudates r no pharyngeal swelling r no pharyngeal asymmetrYr Mouth normal to inspection r mucus membranes moist r no lesions r no lacerations r No drooling r Able to handle secretions r No tongue elevation r teeth normal r normal dentition r no abcess r no dental fractures r Sinuses exam normal r Sinuses non-tender r No erythemar No swelling. RESPIRATORY/CHEST: Chest is non-tender r Breath sounds normal r No respiratory distress.
000651
SSM DEPAUL CLINICAL SUMMARY RECORD CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. ABDOMEN: Abdomen is non-tender, No masses, Bowel sounds normal, No distension, No peritoneal signs. BACK: There is no CVA Tenderness, There is no tenderness to palpation, Normal inspection. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, No calf tenderness, Normal range of motion. NEURO: GCS is 15, No focal motor deficits, No focal sensory deficits, No cerebellar deficits. SKIN: Skin is warm and dry, No rash or induration. T --'1PHATIC: Cervical Nodes . . CHIATRIC: Oriented X 3, Normal affect. DOCTOR NOTES TEXT: ADMITTED TO PHIL ZINSER AT DEPAUL IN PAST FOR OSTEOMYELITIS. TIME: Time: 11:48. TEXT: DISCUSSED CASE WITH DR. VIERO. SEARCH OF PREVIOUS ADMISSIONS REVEALED PREVIOUS PIC LINE GREW OUT POSITIVE CULTURES WHICH PROMPTED CLINDA AND MERREM. PT DOES HAVE CHRONIC OSTEOMYELITIS BUT THE CHART STATED HE HAS BEEN TO MULTIPLE ERS FOR SAME ALWAYS W/O FEVER OR ELEVATED WBC AND HAS BEEN DEEMED WORRISOME FOR NARCOTIC SEEKING BEHAVIOR. PT STATES HE IS TO SEE A PAIN MGMT SPECIALIST FOR FIRST TIME NEXT MONTH. POST D/W VIERO- WILL ORDER CT TO BETTER R/O POSSIBILITY OF ACUTE INFECTION. TIME: Time: 12:20. TEXT: PER WALGREENS PT GIVEN SCRIPTS FOR NARCOTICS 9/10, 8/31, 7/30 (30 - 40 TABS EACH VISIT). ALL WRITTEN BY DIFFERENT PROVIDERS FROM BJC ER. TTME: Time: 12:48. L ... AGNOSIS FINAL: PRIMARY: left mandibular pain, ADDITIONAL: .
DISPOSITION PATIENT: Disposition: Home, Condition: Stable. X-RAY/CT Follow-up: NO, Critical Care: *None, Doctor Procedures: YES, Remove from ER. MEDICATION SERVICE Percocet 5/325: Order: Percocet 5/325 1 tablet By Mouth Ordered: Sat Oct 11 2008 11:42 Ordered by: Jennifer Ehret Pa-C Entered by: Jennifer Ehret Pa-C Sat Oct 11 2008 11:42 Acknowledged by: James Caldwell, EMT-P Sat Oct 11 2008 11:46
000652
Documented as given by: James Caldwell, EMT-P Sat Oct 11 2008 11:52 MEDICATION, Time given: 1152, Given in amount and via route as prescribed, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient in position of comfort, Side rails up, Cart in lowest position, Family at bedside.
PRESCRIPTION Ibuprofen: Tablet: 600 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: As needed every 8 hours Dispense: ***30***. NOTES: Take with food as needed for pain, swelling, inflammation. ram: Tablet: 50 mg : Oral=Quantity: ***1-2*** Unit: tab Route: Oral Schedule: As needed every six hours Dispense: ***15***. NOTES: Take as needed for pains. INSTRUCTION FOLLOWUP: 2, PHILLIP G ZINSER MD 11125 DUNN ROAD SUITE 412 JENNINGS MO 63136 3143557997, YOUR PHYSICI~~. SPECIAL: PLEASE REST. ICE PACKS WRAPPED IN TOWELS X 20 MINUTES TO AFFECTED AREA OR HEAT THERAPY WHICHEVER IS MORE BENEFICIAL. PLEASE FOLLOW-UP WITH YOUR DOCTOR AND KEEP YOUR APPOINTMENT WITH PAIN MANAGEMENT APPOINTMENT AS SCHEDULED. RETURN TO ER IF INCREASED PAIN, FEVER, VOMITING AND ARE UNABLE TO KEEP ANYTHING DOWN, OR IF YOU FEEL WORSE IN GENERAL.
000653
SSM DEPAUL RECORD
000654
Ii
SSM DEPAUL EMERGENCY FLOW SHEET RECORD Name: March, Phillip VITAL SIGNS User Date/Time
CBLA 10/11 11:07
Age: 32Y
MR,
0007'~8298
Acct: 0828500070
BP
148/90
PULSE
60
RESP
16
TEMP
98
PAIN
8
02 SAT 99 on ra
TIME
1103

Name: March, Phillip Age: 32Y MR, 000748298 Acct: 0828500070 Prepared: Tue May 26 08:55:34 2009 by Stephanie Manetz Page: 1
000655
Picis Imaging
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000656
Picis Imaging
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000657
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING ,me: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 10/11/08 1259 Sex: M Med Rec # A000748298 ACCT: A0828500070 Pt Location: *XER EHRET,JENNIFER J 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044
Checkin-Exam Code Summary 1182696-70486
ADM: EMERGENCY,PHYSICIANS REF: PCP: ZINSER,PHILLIP G
ATT: VIERODOTHAGE,LAURA M CON: SCP: EHRET,JENNIFER J
FINAL DUPLICATE
Page
000658
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING me: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 10/11/08 1259 Sex: M Med Rec # A000748298 ACCT: A0828500070 Pt Location: *XER EHRET, JENNIFER J 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044 Check-In # Order Diagnosis 1182696 Ord Diag: 784.0-HEADACHE
Exam CT MAXILLOFACIAL W/O CONTRAST
CT maxillofacial bones without contrast with 3-D reconstructions. Indication: Left-sided facial swelling. Previous surgical repair of the left mandible. Previous CT 12/26/2007. Has visible swelling. A high-resolution axial scan is made through the facial bones. Both reformatted coronal, sagittal and 3-D images of the mandible were obtained. There is slight deformity and some residual lucent lines involving the ramus of the mandible on the left compatible with previous trauma and/or surgery. There is no evidence of an acute fracture or bone destruction. The left mandibular condyle is in normal position within the condylar fossa. This appearance is unchanged from the previous study. The right mandibular condyle appears to be subluxed anteriorly on the sagittal reformatted images. There is extensive calcification of the stylohyoid ligaments bilaterally. There is a transverse lucency through the upper stylohyoid ligament on the left possible represent a pseudofracture. This was also present previously and is unchanged. The CT scan the facial bones is otherwise unremarkable. Summary: Stable deformity of the ramus of the mandible on the left. Mild anterior subluxation the right mandibular condyle. Extensive stylohyoid ligament calcification with possible pseudofracture on the left. Read By- EDWIN C ERNST M.D. Released By- EDWIN C ERNST M.D. Released Date Time- 10/11/08 1411 Transcriptionist- ECE M.D. FINAL DUPLICATE
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000659
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING Med Rec # A000748298 ACCT: A0902200197 Pt Location: *ER MAJINO,ANGELA R 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044 Check-In # Order Diagnosis 1226218 Ord Diag: 526.9-JAW DISEASE NOS
.me: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 01/22/09 0521 Sex: M
Exam CT MAXILLOFACIAL W/CONTRAST
CT facial bones without contrast Indication: Facial pain, facial swelling. Comparison: 10/11/2008. Technique: Preliminary interpretation was provided by Virtual Radiologic Consultants. Axial CT images of the facial bones were obtained without contrast. Coronal multiplanar reformats were created on an independent workstation. Findings: There is stable remote posttraumatic versus postinfectious deformity to the left mandibular ramus. No definite acute mandibular fractures are seen. There are no periapical lucencies. There is no malalignment. There are no soft tissue fluid collections to suggest abscess. Surgical clips are noted in the left neck. A small mucous retention cyst is present within the left maxillary sinus. Again noted is ossification of the stylohyoid ligaments compatible with eagle syndrome. Impression: Stable remote posttraumatic versus postinfectious deformity to the left mandibular ramus. No acute findings. Stable appearance of eagle syndrome. FINAL DUPLICATE Page 1
000660
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING <me: MARCH,PHILLIP H DOB: 10/02/76 Age: 32Y Date: 01/22/09 0521 Sex: M Med Rec # A000748298 ACCT: A0902200197 Pt Location: *ER MAJINO,ANGELA R 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044
Checkin-Exam Code Summary 1226218-70487 Read By- NOAMAN W SIDDIQI M.D. Released By- NOAMAN W SIDDIQI M.D. Released Date Time- 01/22/09 0926 Transcriptionist- MEO ADM: SALEM,MOUNER REF: PCP: PCP,NONE ATT: SALEM,MOUNER CON: ZINSER,PHILLIP G SCP:
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000661
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING .ne: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 10/04/07 1601 Sex: M Med Rec # A000748298 ACCT: A0727400691 Pt Location: *5N-0524-01 MELKAVERI,SONIA N 1066 EXECUTIVE PARKWAY SUITE 105 CREVE COEUR MO 63141 Check-In # Order Diagnosis 1024609 Ord Diag: V67.59-FOLLOW-UP EXAM NEC
Exam XR CHEST ONE VIEW PORTABLE
CHEST SINGLE VIEW INDICATION: Osteomyelitis, PICC line placement. FINDINGS: A single view portable AP upright examination of the chest, 1608 hours, shows a PICC line has been placed via the right upper extremity. The distal end is directed into the anticipated location of the mid superior vena cava. No other changes are seen when compared to the prior chest radiograph of 10/1/2003. The lung fields are clear. The heart size is at the upper limits of normal. IMPRESSION Interval placement of a PICC line, the tip of which is directed into the anticipated location of the mid superior vena cava.
Read By- ANDRE S STRZEMBOSZ M.D. Released By- ANDRE S STRZEMBOSZ M.D. Released Date Time- 10/04/07 1811 Transcriptionist- BEM ADM: MELKAVERI,SONIA N REF: PCP: ZINSER,PHILLIP G ATT: MELKAVERI,SONIA N CON: ZINSER,PHILLIP G SCP:
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000662
SSM DEPAUL EMERGENCY RECORD HPI BLANK (10:14 AWAH) CHIEF COMPLAINT: cc: L jaw pain hpi: chronic L jaw pain sip stabbing 4/07, fracture repaired at Barnes, complicated by osteomyelitis. multiple visits for same complaint. poor compliancy regarding follow up. no fever, headache or dysphagia. no new trauma. HISTORIAN: History obtained from patient. TIME COURSE: Onset was as above, Patient currently has symptoms. SEVERITY: Currently symptoms are moderate. KNOWN ALLERGIES No known drug allergies. ,TORY MEDICAL HISTORY (Sat May 31 2008 08:07 HWE1): History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. jaw osteomyelitis. PSYCHIATRIC HISTORY (Sat May 31 2008 08:07 HWE1): No previous psychiatric history. No previous psychiatric history. No previous psychiatric history.
;:'TT-q.GICAL HISTORY (Sat May 31 2008 08: 07 HWE1): Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. Jaw Repair, plate left jaw. facial repair. L jaw surgery, harware removal, chronic osteomyelitis. SOCIAL HISTORY (Sat May 31 2008 08:07 HWE1): Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. FAMILY HISTORY (Sat May 31 2008 08:07 HWE1): Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. NOTES (Sat May 31 2008 08:07 HWE1): Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. Nursing records reviewed. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, PMHx: Left mandible osteomyelitis.
000663
MEDS: Merrem and Clindamycin IV. See nursing notes. Nursing records reviewed, Agree with nursing records. MEDICAL HISTORY (10:14 AWAH): see RN notes. SURGICAL HISTORY (10:14 AWAH): see RN notes. SOCIAL HISTORY (10:14 AWAH) Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. FAMILY HISTORY (10:14 AWAH) Family history is not contributory to this case. NOTES (10:14 AWAH): Nursing records reviewed, Agree with nursing records.
ROS (10: 14 AWAH) CONSTITUTIONAL: No fever, No chills. ENT: No sore throat, No dysphagia, No otalgia, L jaw pain. r -TROLOGIC: No headache. J SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above. TRIAGE (Sat May 31 2008 08:07 HWEl) COMPLAINT: Jaw Pain. PROVIDERS: TRIAGE NURSE: Heather West, RN. ADMISSION: URGENCY: ESI-4, TRANSPORT: Ambulatory, BED: WAITING. P~~IENT: NAME: Phillip H March, AGE: 31, GENDER: Male, DOB: Sat Oct 02 1976, RACE: Black, Code: NO, Trauma: *NO, Work Comp.: NO, Heat Related: NO, SSN: 493788699, ZIP CODE: 63121, KG WEIGHT: 70.3 (est.), HEIGHT: 167cm, PHONE: 314393-1241, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0815200054, PRIMARY: Phillip G Zinser, ATTENDING: Emergency Physicians, IBEX NUMBER: 20080531080726ADT. PREVIOUS VISIT ALLERGIES: No known drug allergies. FALL RISK: TIME: 0805, Gender (Male), Get up and go test: Able to rise in a single movement, Score: 1. ESSMENT: pt c/o swelling and pain to the left side of jaw.pt states swelling 2 days ago.pt denies fever. IMMUNIZATIONS: Immunizations up to date, Unknown when last tetanus shot recived. TB SCREENING: Denies TB screening. DOMESTIC VIOLENCE: No domestic violence. EDUCATIONAL/CULTURAL BARRIERS: No educational/cultural barriers. TREATMENTS IN PROGRESS: No treatment. VITAL SIGNS: BP 149/81, Pulse 66, Resp 18, Temp 98.3, Pain 5, 02 Sat 99, on ra, Time 0807. PHYSICAL EXAM (10:15 AWAH) CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3. HEAD: no facial swelling or erythema. tenderness over angle of madible. no crepitus or submandibular fullness. no trismus. no signs of intraoral
000664
infection. EYES: Pupils equal and reactive to light, Extraocular muscles intact. ENT: Ears normal to inspection, Nose examination normal, Oropharynx normal, Mouth normal to inspection. NECK: Normal ROM. RESPIRATORY/CHEST: Breath sounds normal. CARDIOVASCULAR: RRR. SKIN: Skin is warm and dry, No rash or induration. LYMPHATIC: No adenopathy in neck. PSYCHIATRIC: Oriented X 3, Normal affect.
02SAT INTERPRETATION (10:16 AWAH) 'AT: 02 saturation reading 99%, 02 AMT: R.A., 02 Sat normal. RESULTS (09:33 ACT) LAB: CBC W AUTO DIFF May 31 2008 08:35, WBC 6.0 1000/mm3 Ref Range (4.5-11.0), RBC 4.74 10X6 Ref Range (4.7-6.1), Hgb 13.5 gm/dl Ref Range (13.0-18.0), Hct 39.1 % Ref Range (39.0-54.0), MCV 82.5 fl Ref Range (80.0-99.0), MCH 28.5 pg Ref Range (25.0-31.0), MCHC 34.5 gm/dl Ref Range (32.0-36.0), RDW 14.5 % Ref Range (11.5-14.5), Platelets 199 1000/mm3 Ref Range (130.0-400.0), Gran 56.3 % Ref Range (40.0-70.0), Lymph 36.5 % Ref Range (22.0-40.0), Mono 6.0 % Ref Range (2.0-10.0), Eos 0.7 % Ref Range (0.0-6.0), Baso 0.5 % Ref Range (0.0-3.0), Manual Diff Not Indicated , Absolute Neutrophil 3.37 1000/mm3 Ref Range (1.8 7.7). COMPREHENSIVE METABOLIC PANEL May 31 2008 08:45, BUN 14 mg/dl Ref Range (9.0-20.0), Sodium 140 mEq/L Ref Range (137-145), Potassium 4.0 mEq/L Ref Ranqe (3.6-5.0), Chloride 105 mEqlL Ref Range (98.0-107.0), Glucose 94 mg/dl Ref Range (75-110), Creatinine 1.2 mg/dl Ref Range (0.8-1.5), AST/SGOT 31 U/L Ref Range (17.0-59.0), Alk phos 70 U/L Ref Range (38.0-126.0), Calcium 8.5 mg/dl Ref Range (8.4-10.2), Bilirubin 0.2 mg/dl Ref Range (0.2-1.3), Albumin 4.1 gm/dl Ref Range (3.5-5.0),
000665
Prot Total 6.0 L gm/dl Ref Range (6.3-8.2), C02 27 mEq/L Ref Range (22.0-30.0),
ALT/SGPT 18 L U/L Ref Range (21.0-72.0),
GFR 90.8 ml/min/l.73m2, ER WR L JAW PAIN. RADIOLOGY: XR MANDIBLE MIN 4 VIEWS May 31 2008 09:08, Check-in number: 0001125700 Read By: 979456 Indication- Left-sided pain since stabbing one year ago Exam- Mandible, 4 views Comparison- CT maxillofacial December 26, 2007 Findings- There are surgical clips in the left neck. 'To acute fractures or subluxations. As before, there is an old left Jubcondylar mandibular fracture which is presumed to be healed based on the prior CT. The visualized sinuses are clear. Impression- Old left mandibular fracture. Read By- DAWN M HASTREITER M.D. Released By- DAWN M HASTREITER M.D. Released Date Time- 05/31/08 0909 Transcriptionist- DMH M.D. ADM- EMERGENCY,PHYSICIANS ATT- EMERGENCY,PHYSICIANS REF- CONPCP- ZINSER,PHILLIP G SCPReleased By: HASTREITER,DAWN,M
'TOR NOTES
~~AT:
(10: 18 AWAH)
labs and xray ok. not concerning for osteomyelitis. encouraged pt to follow up with his previous doctors at Barnes and ID Dr Zinser. will supply IM on call and name of pain specialist.
PATIENT STATUS: Patient has stablized since admission. PATIENT PLAN: The patient will be discharged, The patient will follow up with primary care physician.
DIAGNOSIS
(10:19 AWAH) FINAL: PRIMARY: chronic L jaw pain, ADDITIONAL: PATIENT (10:19 AWAH): X-RAY/CT Follow-up: NO, Critical Care: *None, Doctor Procedures: NO, Disposition: Home, Condition: Stable. (10:38 CKl): Remove from ER.
DISPOSITION
000666
SSM DEPAUL EMERGENCY RECORD INSTRUCTION (10:21 AWAH) DISCHARGE: CHRONIC PAIN MANAGEMENT. FOLLOWUP: 3, PHILLIP G ZINSER MD 11125 DUNN ROAD SUITE 412 JENNINGS MO 63136 3143557997, HELAL EKRAMUDDIN MD 11125 DUNN ROAD SUITE 411 ST LOUIS MO 63136 3143552700, MAHENDRA P GUNAPOOTI MD 247 DUNN ROAD FLORISSANT MO 63031 3148302600. SPECIAL: vicodin may cause drowsiness, no driving or alcohol follow up with your surgeon at Barnes, your infectious disease doctor Dr Zinser internal medicine doctor on call and name of pain specialist also supplied for further management.
~SCRIPTION (10:19 AWAH) Vicodin: Tablet: 500 mg-5 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: As needed every four hours Dispense: ***15***.
NURSING ASSESSMENT: ENT (09:52 CK1) TIME ASSESSED: Patient was assessed at 0945. NOTES: PT PRESENTS C/O LEFT SIDED JAW PAIN; PT REPORTS BEING STABBED 1 YEAR AGO AND HAVING PLATES PLACED WHICH HAVE NOW BEEN REMOVED; PT STATES "PAIN HAS ALWAYS BEEN THERE, JUST GETTING WORSE"; PT DENIES N/V; PT STATES LOSS OF APPETITE DUE TO PAIN AND LOSS OF SENSATION IN LEFT JAW AREA; PT HAS HX OF HTN WHICH IS NOT TREATED. CONSTITUTIONAL: Patient arrives ambulatory with steady gait to treatment area, History obtained from patient, Patient appears comfortable, Patient is cooperative, Patient is alert and oriented x 3, Patient appears in no acute distress, Patient's skin is warm and dry, Patient's mucous membranes are moist and pink. : No obvious abnormality to the ears, No obvious abnormality to the nose, No obvious abnormality to the oropharynx, Mucous membranes are pink/moist, No obvious foreign bodies noted to ears, nose or throat, Patient able to handle oral secretions, No blood or fluid noted from ears, No nasal drainage or epistaxis noted, PAIN TO LEFT JAW/FACIAL AREA. SAFETY: Side rails up, Cart in lowest position, Call light within reach. NURSING PROCEDURE: LAB DRAW (08:21 LSTE) TIME: Venipuncture performed/labs sent, Blood obtained from left AC and labs sent, and labs sent from rt ac, with 2 attempts. NURSING PROCEDURE: INTAKE AND OUTPUT (10:36 CK1) TIME: Intake output performed, at 1035, PO Intake (ml) : 0, Total Intake: 0, Urine Output (ml) : 0, Total Output: 0, Intake is greater than output by 0, Output is greater than intake by o.
000667
SSM DEPAUL EMERGENCY RECORD NURSING PROCEDURE: DISCHARGE NOTE (10:37 CK1) TIME: Procedure was performed at 1036, Patient discharged to home, Patient ambulates without assistance, Transported via patient driving, Patient unaccompanied, Discharge instructions given to patient, Simple/moderate discharge teaching performed, Prescription given and additional instructions on side effects of same given. VITAL SIGNS: BP: 138, / 82, Pulse: 68, Resp: 18, Temp: 98.3, Pain: 5, 02 sat: 100, RA. IMAGING PROTOCOL (16:11 KWOE): Image captured from scanner. r 'SENT TO TREAT (16:12 KWOE): Image captured from scanner. ADMIN DIGITAL SIGNATURE (08:21 LSTE): Stehly, Laurie. (10:38 CK1): Keen, RN, Christie. (22:02 AWAH): Wahle, PA-C, Andrew. (Sat Jul 12 2008 22:02 RSCH): Schmidt, MD, Richard. PATIENT DATA CHANGE (09:36 CK1): Primary Nurse changed from (none) to Christie Keen, RN. 10:01): A08 77003833 by Interface, Payment: 90, Admitting Doctor: Zinser Phillip G, Attending Doctor: Physicians Emergency. (10:03 AWAH): Dr. Extender changed from (none) to Andrew Wahle, PA-C. (10:05): A08 77003907 by Interface, Admitting Doctor: Zinser Phillip G, Attending Doctor: Physicians Emergency. (10:10 RSCH): Attending changed from (none) to Richard Schmidt, MD.
yRy:
.CT=Tourville, Alexandra AWAH=Wahle, PA-C, Andrew CK1=Keen, RN, Christie BWE1=West, RN, Heather KWOE=Woehr, Katherine LSTE=Stehly, Laurie RSCH=Schmidt, MD, Richard
000668
SSM DEPAUL CLINICAL SUMMARY RECORD HPI BLANK CHIEF COMPLAINT: cc: L jaw pain hpi: chronic L jaw pain sip stabbing 4/07, fracture repaired at Barnes, complicated by osteomyelitis. multiple visits for same complaint. poor compliancy regarding follow up. no fever, headache or dysphagia. no new trauma. HISTORIAN: History obtained from patient. TIME COURSE: Onset was as above, Patient currently has symptoms. SEVERITY: Currently symptoms are moderate. HISTORY MEDICAL HISTORY: History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. jaw osteomyelitis . . CHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. Jaw Repair, plate left jaw. facial repair . . L jaw surgery, harware removal, chronic osteomyelitis. ~n~IAL HISTORY: Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. FAMILY HISTORY: Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. NOTES: Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. Nursing records reviewed. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, PMHx: Left mandible osteomyelitis. MEDS: Merrem and Clindamycin IV. See nursing notes. Nursing records reviewed, Agree with nursing records. MEDICAL HISTORY: see RN notes. SURGICAL HISTORY: see RN notes. SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. FAMILY HISTORY: Family history is not contributory to this case. NOTES: Nursing records reviewed, Agree with nursing records.
000669
SSM DEPAUL CLINICAL SUMMARY RECORD ROS CONSTITUTIONAL: No fever, No chills. ENT: No sore throat, No dysphagia, No otalgia, L jaw pain. NEUROLOGIC: No headache. ALL SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above. PHYSICAL EXAM CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3. HEAD: no facial swelling or erythema. tenderness over angle of madible. no crepitus or submandibular fullness. no trismus. no signs of intraoral infection. 'S: Pupils equal and reactive to light, Extraocular muscles intact. L ~': Ears normal to inspection, Nose examination normal, Oropharynx normal, Mouth normal to inspection. NECK: Normal ROM. RESPIRATORY/CHEST; Breath sounds normal. CARDIOVASCULAR: RRR. SKIN: Skin is warm and dry, No rash or induration. LYMPHATIC: No adenopathy in neck. rVCHIATRIC: Oriented X 3, Normal affect. DOCTOR NOTES TEXT: labs and xray ok. not concerning for osteomyelitis. encouraged pt to follow up with his previous doctors at Barnes and ID Dr Zinser. will supply 1M on call and name of pain specialist. PATIENT STATUS: Patient has stablized since admission. PATIENT PLAN: The patient will be discharged, The patient will follow up with primary care physician.
D~AGNOSIS
FINAL: PRIMARY: chronic L jaw pain, ADDITIONAL:

DISPOSITION PATIENT: X-RAY/CT Follow-up: NO, Critical Care: *None, Doctor Procedures: NO, Disposition: Home, Condition: Stable. Remove from ER. PRESCRIPTION Vicodin: Tablet: 500 mg-5 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: As needed every four hours Dispense: ***15***. INSTRUCTION DISCHARGE: CHRONIC PAIN MANAGEMENT.
000670
FOLLOWUP: 3, PHILLIP G ZINSER MD 11125 DUNN ROAD SUITE 412 JENNINGS MO 63136 3143557997, HELAL EKRAMUDDIN MD 11125 DUNN ROAD SUITE 411 ST LOUIS MO 63136 3143552700, MAHENDRA P GUNAPOOTI MD 247 DUNN ROAD FLORISSANT MO 63031 3148302600. SPECIAL: vicodin may cause drowsiness, no driving or alcohol follow up with your surgeon at Barnes, your infectious disease doctor Dr Zinser internal medicine doctor on call and name of pain specialist also supplied for further management.
000671
SSM DEPAUL RECORD
000672
II
SSM DEPAUL EMERGENCY FLOW Name: March, Phillip VITAL SIGNS Age:: 31Y MR: 000748298 Acct: 0815200054
SHEE~r
RECORD
User CK1 TRSC HWE1
Date/Time
05/31 10:37
05/31 10:18 05/31 08:07
BP 138/82 140/85 149/81
PULSE 68 58 66
RESP 18 18 18
TEMP 98.3 98.3
PAIN
5
5 5
02 SAT 100 on RA 100 on ra 99 on ra
TIME 1015 0807

Prepared: Tue May 26 08:58:12 2009 by Stephanie Manetz
Page: 1
000673
Picis Imaging
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000674
Picis Imaging
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000675
DePaul Health Center Tue May 26/ 2009 09:50 am Patient Detail Report Name: MARCH/PHILLIP H _ #/Acct #: 000748298/A0815200054 Loc: XER 05/31/08 Attending Dr-Svc: SCHMIDT/RICHARD U - EMERGENCY Admitting Dr: EMERGENCY/PHYSICIANS 997075 16102 978730 903572 In: 05/31/08 0825 ------------------Out: 05/31/08 0835 I CBC W AUTO DIFF I Coll Time: 05/31/08 0820 ------------------Order Phys: TENG/MARCUS S *STAT*STAT*STAT* Result Ref Range Result Name Result Name WBC(1000/mm: RBC (10X6) : Hgb(gm/dl) : Hct (%) : MCV (1) : MCH (pg) : jV'--'r: (gm/ dl) :
1
Page:
Spec: Blood Techs: V-LS TKSOLOM [A0815200054/4271050] Result Ref Range
\%) :
6.0 4.74 13.5 39.1 82.5 28.5 34.5 14.5
4.5-11.0 4.7-6.1 13.0-18.0 39.0-54.0 80.0-99.0 25.0-31.0 32.0-36.0 11.5-14.5
Platel(1000/mm: Gran(%) : Lymph(%) : Mono (%) : Eos (%) : Baso(%): Manual DiU: Absolu(1000/mm:
199 130.0-400.0 56.3 40.0-70.0 36.5 22.0-40.0 6.0 2.0-10.0 0.7 0.0-6.0 0.5 0.0-3.0 Not Indicated 3.37 1.8-7.7
End of Report - OS/26/09 09:50
Alexander Babich/ M.D.

~ent
Detail Report
MARCH/PHILLIP H 000748298/A0815200054 XER 05/31/08 (M-10/02/76) Dr. SCHMIDT/RICHARD U
000676
DePaul Health Center Tue May 26, 2009 09:50 am Patient Detail Report P Name: MARCH,PHILLIP H Page: 1 000748298/A0815200054 \ _ #/Acct #: Loc: XER 05/31/08 Attending Dr-Svc: SCHMIDT,RICHARD U - EMERGENCY Admitting Dr: EMERGENCY,PHYSICIANS 997075 16102 978730 903572 In: 05/31/08 0825 --------------------------------Spec: Blood Out: 05/31/08 0845 I COMPREHENSIVE METABOLIC PANEL I Techs: V-LS TDLOVEH ColI Time: 05/31/08 0820--------------------------------Order Phys: TENG,MARCUS S [A0815200054/4271050] *STAT*STAT*STAT* Result Reference Range Result Name BUN (mg/dl) : Sodium(mEq/L) : Potassium(mEq/L) : Chloride (mEq/L) : Glucose (mg/dl) : Creatinine (mg/dl) : P -"/SGOT (U/L) : Phos (D/L) : Calcium (mg/dl) : Bilirubin (mg/dl) : Albumin (gm/dl) : Prot Total (gm/dl) : C02 (mEq/L) : ALT/SGPT GFR(ml/min/1.73m2) : 14 140 4.0 105 94 1.2 31 70 8.5 0.2 4.1 6.0 L 27 18 L 90.8 9.0-20.0 137-145 3.6-5.0 98.0-107.0 75-110 0.8-1.5 17.0-59.0 38.0-126.0 8.4-10.2 0.2-1.3 3.5-5.0 6.3-8.2 22.0-30.0 21.0-72.0
(U/L) :

~ent
Detail Report
MARCH,PHILLIP H 000748298/A0815200054 XER 05/31/08 (M-10/02/76) Dr. SCHMIDT,RICHARD U
000677
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING Med Rec # A000748298 ACCT: A0815200054 Pt Location: *ERQ TENG,MARCUS S 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044 Check-In # Order Diagnosis 1125700 Ord Diag: 780.99-0THER GENERAL SYMPTOMS
DOB: 10/02/76 Age: 32Y Date: 05/31/08 0858
Sex: M
Exam XR MANDIBLE MIN 4 VIEWS
Indication: Left-sided pain since stabbing one year ago Exam: Mandible, 4 views Comparison: CT maxillofacial December 26, 2007 Findings: There are surgical clips in the left neck. No acute fractures or subluxations. As before, there is an old left subcondylar mandibular fracture which is presumed to be healed based on the prior CT. The visualized sinuses are clear. Impression: Old left mandibular fracture. Read By- DAWN M HASTREITER M.D. Released By- DAWN M HASTREITER M.D. Released Date Time- 05/31/08 0909 Transcriptionist- DMH M.D. ATT: EMERGENCY,PHYSICIANS CON: SCP:
ADM: EMERGENCY,PHYSICIANS REF: PCP: ZINSER,PHILLIP G
FINAL DUPLICATE
Page
000678
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING .ne: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 06/01/07 0536 Sex: M Med Rec # A000748298 ACCT: A0715100477 Pt Location: *ER SMITH, ROBERT B 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044 Check-In # Order Diagnosis Ord Diag: 526.9-JAW DISEASE NOS 971739
CT MAXILLOFACIAL WITHOUT CONTRAST
06/01/2007
INDICATION: The patient was stabbed in left jaw in April 2007 status post left jaw repair in May 2007. The patient complains of burning pain and left-sided facial swelling. TECHNIQUE: Helical images of the facial bones were obtained with 2 mm slices. Subsequent retrospective images were obtained in coronal plane. COMPARISON: None available.
FINDINGS: Initial interpretation of this study was performed by Virtual Radiologic Consultants. The fracture of the left mandible stabilized by screws and hardware is identified. There is significant thickening or swelling of the soft tissue overlying the left mandible with infiltration of the overlying subcutaneous adipose tissue. This process may be posttraumatic or may represent possible cellulitis. Asymmetric soft tissue thickening or swelling as well as ill-defined fat plane are also present subadjacent to the left mandibular fracture which may also be posttraumatic and correspond to possible posttraumatic or postsurgical change or hematoma. This latter finding results in mild compression of the left lateral oropharynx and hypopharynx. There is a linear radiopaque density projecting medial to the left mandible which may represent a small displaced fracture fragment. Soft tissue details are otherwise limited without benefit of IV contrast enhancement. FINAL DUPLICATE Page 1
000679
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING .ne: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 06/01/07 0536 Sex: M Med Rec # A000748298 ACCT: A0715100477 Pt Location: *ER SMITH, ROBERT B 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044
Checkin-Exam Code Summary 971739-70487 Bone windows demonstrate mild mucosal thickening of the ethmoid air cells with a mucus retention cyst arising from the right anterior sphenoid sinus. No additional facial or orbital fractures are seen. Zygomatic arches are symmetrical. Incidental note is made of very prominent or large ossified left and right stylohyoid ligaments left greater than right. There appears to be an unusual articulation within the proximal left stylohyoid ligament noted on the coronal reconstructed images. There are small lymph nodes within the left and right anterior and posterior cervical chain and up to 1 cm lymph nodes within the bilateral submandibular regions. OPINION: Left mandibular fracture stabilized by metallic screws and plate. There is soft tissue swelling and thickening overlying and subadjacent to the left mandibular fracture which may be either secondary to recent trauma or recent surgical intervention. Soft tissue cellulitis and hematoma are considerations. This latter finding does result in some compression of the left lateral oropharynx and hypopharynx. Prominent ossified bilateral stylohyoid ligaments left larger compared to right as described above. Mild ethmoid and sphenoid sinusitis. There are small lymph nodes within the anterior and posterior cervical chain most prominent within the left and right submandibular region. Reading Radiologist- HUI HUA SHU M.D. Releasing Radiologist- HUI HUA SHU M.D. FINAL DUPLICATE
Page
000680
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING me: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 06/01/07 0536 Sex: M Med Rec # A000748298 ACCT: A0715100477 Pt Location: *ER SMITH, ROBERT B 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044
Checkin-Exam Code Summary 971739-70487 Released Date Time- 06/02/07 0155 Transcriptionist- MEO ADM: SRIRAM,VISSA REF: PCP: PCP,NONE ATT: SRIRAM,VISSA CON: DAVIS, SHELDON L SCP:
FINAL DUPLICATE
Page
000681
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton/ MO 63044 DIAGNOSTIC IMAGING me: MARCH/PHILLIP H DOB: 10/02/76 Age: 32Y Date: 06/01/07 0536 Sex: M Med Rec # A000748298 ACCT: A0715100477 Pt Location: *ER SMITH/ROBERT B 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044 Check-In # Order Diagnosis 971 739 Ord Diag: 526.9-JAW DISEASE NOS
Exam CT NECK W/CONTRAST
CT NECK WITH CONTRAST
06/01/2007
INDICATIONS: Stabbed in jaw April 2007 with status post left jaw repair in May. The patient complains of burning and pain in the left jaw and left face. TECHNIQUE: Helical images of the neck were obtained with IV contrast. 100 cc Omnipaque 300 was administered. COMPARISON: None available.
FIl~INGS: Initial interpretation of this study was performed by Virtual Radiologic Consultants.
There is a comminuted fracture of the left mandible which is stabilized by screws and long metallic plate. The visualized fracture fragments are well opposed without definite healing. Bone windows also demonstrate some mucosal thickening of the ethmoid air cells and inferior maxillary sinuses without gross sinus opacification. There is asymmetric thickening of the soft tissue overlying the left mandible at the region of fracture and external fixation. This involves primarily the left masseter muscle with infiltration of the overlying subcutaneous adipose tissue. There is also asymmetric soft tissue fullness with adjacent ill-defined fat plane medial and subadjacent to the left mandibular fracture with some asymmetric soft tissue fullness or edema of the left parapharyngeal soft tissue which may result in mild compression of the left oropharynx and hypopharynx. This latter finding is nonspecific and may represent sequela of recent left mandibular fracture and subsequent surgical intervention. Clinical followup and followup imaging may be of value to assure resolution of this soft FINAL DUPLICATE Page 1
000682
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton/ MO 63044 DIAGNOSTIC IMAGING .me: MARCH/PHILLIP H DOB: 10/02/76 Age: 32Y Date: 06/01/07 0536 Sex: M Med Rec # A000748298 ACCT: A0715100477 Pt Location: *ER SMITH/ROBERT B 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044
Checkin-Exam Code Summary 971739-70491 tissue fullness or edematous changes within the left parapharyngeal region. This may be correlated clinically. There are small lymph nodes within the left and right anterior and posterior cervical chain. Slightly more prominent lymph nodes within bilateral submandibular regions are also present. There is a punctate radiopaque density within the anterior soft tissues or left masseter muscle lateral to the left mandible on image 22 of uncertain significance. This may represent a small foreign body or perhaps a very small displaced fracture fragment.
There is also some infiltration of the subcutaneous adipose tissue and thickening of the overlying skin within bilateral submandibular regions left more compared to right.
OPINION: Comminuted fracture of left mandible status post external fixation. There is asymmetric thickening and prominence of the soft tissue overlying the left mandibular fracture and infiltration of the overlying subcutaneous adipose tissue suggesting edema from recent trauma or surgery vs. component of cellulitis. Asymmetric soft tissue fullness medial and subadjacent to the left mandibular fracture is also present extending to the left parapharyngeal region with some loss of fat plane. This latter finding also suggests possible edematous soft tissue which may be a sequela of recent left mandibular fracture and surgical intervention. FoIlowup to complete resolution is recommended. This latter finding does result in mild compression of the left oropharynx and hypopharynx. Small lymph nodes within the left and right anterior and posterior FINAL DUPLICATE Page 2
000683
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING
~
.ne: J'vLARCH, PHILLIP H Sex: M
DOB: 10/02/76 Age: 32Y Date: 06/04/07 1527
Med Rec # A000748298 ACCT: A0715100477 Pt Location: *5S-0546-01 SRlRAM,VISSA 1066 EXECUTIVE PKWY SUITE 105 CREVE COEUR MO 63141 Check-In # Order Diagnosis Ord Diag: 682.9-CELLULITIS NOS 972959 Ord Diag: 682.9-CELLULITIS NOS 972959
Exam SP INSERT PICC PER WO SQ PT 5+YRS SP GUIDANCE W FL CVAD PL-REPL-REM
Examination: Left percutaneous PICC central venous catheter placement under fluoroscopic control. Indication for examination: Cellulitis, soft tissue infection, in need of long-term intravenous antibiotic therapy. This procedure was performed in the radiology department by Dr. Gresick. After explanation of the procedure to the patient and routine Betadine and lidocaine skin prep, the left basilic vein was punctured under fluoroscopic control. 10 cc of Omnipaque-300 contrast were injected into a vein on the left hand in order to opacify the basilic vein prior to needle placement. A small diameter angiographic guidewire was advanced through the needle into the superior vena cava under fluoroscopic control. The needle was removed. An angiographic sheath was advanced over the guidewire into the left basilic vein. Through this a 5 French single lumen PICC central venous catheter, trimmed to 45 cm, was advanced so that the tip of the catheter was near the junction of the superior vena cava and right atrium. The catheter was secured to the skin surface using a 2-0 Prolene suture. The patient tolerated the procedure well and there were no apparent immediate complications. Conclusion: Fluoroscopically guided placement left percutaneous PICC central venous catheter, performed in the radiology department by Dr. Gresick as described. Reading Radiologist- ROBERT J JR GRESICK M.D. Releasing Radiologist- ROBERT J JR GRESICK M.D. Released Date Time- 06/05/07 0907 Transcriptionist- RJG M.D. FINAL DUPLICATE Page 1
000684
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING me: r1ARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 06/04/07 1527 Sex: M Med Rec # A000748298 ACCT: A0715100477 Pt Location: *5S-0546-01 SRIRAM,VISSA 1066 EXECUTIVE PKWY SUITE 105 CREVE COEUR MO 63141
Checkin-Exam Code Summary 972959-58331,972959-58502
ADM: SRIRAM,VISSA REF: PCP: PCP,NONE
ATT: SRIRAM,VISSA CON: DAVIS,SHELDON L SCP:
FINAL DUPLICATE
Page
000685
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING .ne: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 06/01/07 0536 Sex: M Med Rec # A000748298 ACCT: A0715100477 Pt Location: *ER SMITH, ROBERT B 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044
Checkin-Exam Code Summary 971739-70491 cervical chain and slightly more prominent within the submandibular region. Please see above. Reading Radiologist- HUI HUA SHU M.D. Releasing Radiologist- HUI HUA SHU M.D. Released Date Time- 06/02/07 0145 Transcriptionist- MEO ADM: SRIRAM,VISSA REF: PCP: PCP, NONE ATT: SRIRAM,VISSA CON: DAVIS, SHELDON L SCP:
FINAL DUPLICATE
Page
000686
SSM DEPAUL EMERGENCY RECORD HPI BLANK (05:03 MST1) CHIEF COMPLAINT: DISCHARGED FROM HOSPITAL YESTERDAY AFTER IV ABX GIVEN ON PO ABX AND PAIN MEDS AND STATES STILL HAVING PAIN, FEVER AND CHILLS AT HOME, PATIENT APPEARS VERY COMFORTABLE HERE TALKING ON CELL PHONE, REVIEW OF OLD RECORDS REVEALK THAT PATIENT HAS HAD FREQUENT VISITS TO BARNES SINCE SURGERY.
HISTORIAN: History obtained from patient. TIME COURSE: Onset of symptoms reported as sudden, Onset was TODAY, Patient
currently has symptoms, KNOWN ALLERGIES
~
Complaint is constant.
SEVERITY: Maximum severity is moderate, Currently symptoms are moderate. known drug allergies.
HISTORY
MEDICAL HISTORY (Fri Jun 08 2007 01:32 JWHI):
which is not being treated, Stabbed in left face April 24th, 2007. History of hypertension, Patient is noncompliant with treatment, stab wound 1 face 4\24\07. PSYCHIATRIC HISTORY (Fri Jun 08 2007 01:32 JWHI): No previous psychiatric history. No previous psychiatric history. P"~GICAL HISTORY (Fri Jun 08 2007 01:32 JWHI) Jaw Repair, plate left jaw. facial repair . SOCIAL HISTORY (Fri Jun 08 2007 01:32 JWHI): Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives alone, Denies smoking, Lives at home alone. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives alone. FAMILY HISTORY (Fri Jun 08 2007 01:32 JWHI): Family history is not contributory to this case. F~mily history is not contributory to this case. ES (Fri Jun 08 2007 01: 32 JvVHr): Stabbed in left face April 24th, 2007. Underwent surgery the week following.
(05: 03 MST1): Nursing records reviewed.

ROS (05:03 MST1) NOTES: SEE HPI. ALL SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above. TRIAGE (Fri Jun 08 2007 01:32 JWHI)
COMPLAINT: Burning Right Jaw. PROVIDERS: TRIAGE NURSE: Jeannette White, RN, CHARGE NURSE: Julie Sanchez, RN. ADMISSION: URGENCY: ESI-3, ADMISSION SOURCE: Home, TRANSPORT: Ambulatory, BED: WAITING. PATIENT: NAME: Phillip March, AGE: 30, GENDER: Male, DOB: Sat Oct 02 1976,
000687
RACE: Black, Code: NO, Trauma: *NO, Work Comp.: NO, Hypothermia: NO, SSN: 493788699, ZIP CODE: 63121, KG WEIGHT: 72.6 (est.), HEIGHT: 182cm, PHONE: 314521-0600, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0715900171, PRIMARY: None Pcp, ATTENDING: Emergency Physicians, IBEX NUMBER: 20070608013225ADT, NOTIFICATION: Attending physician or charge nurse notified. PRE-TRIAGE NOTES:Attending physician or charge nurse notified. PREVIOUS VISIT ALLERGIES: No known drug allergies. FALL RISK: TIME: 0129, Gender (Male), Get up and go test: Able to rise in a single movement, Score: 1. ASSESSMENT:The GCS total is 15, DISCHARGE YESTERDAY AT 1800 AND IV ANTIBIOTICS WAS DISCONTINUED. STATES SWELLING AND PAIN RETURNED TO LEFT JAW AFTER DISCONTINUATION OF IV ANTIBIOTICS. STATES HE ALSO DEVELOPED A FEVER. RATE PAIN 10/10 AND DECRIBES THE PAIN AS BURNING. Last tetanus shot received less than 5 years ago. IMMUNIZATIONS: TB SCREENING: Denies TB screening. DOMESTIC VIOLENCE: Not Applicable. EDUCATIONAL/CULTURAL BARRIERS: No educational/cultural barriers. TREATMENTS IN PROGRESS: No treatment, Protocols: General Chief Comolaint. VITAL SIGNS: BP 151/102, Pulse 78, R~SP 18, Temp 99.1, Pain 10/10,~02 Sat 99, on RA, Time 0128.
PHYSICAL EXAM (05:04 MST1) CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3. HEAD: Atraumatic, Normocephalic. EYES: Pupils equal and reactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal, Conjunctiva are normal. ENT: Ears normal to inspection, Nose examination normal, Oropharynx normal, Mouth normal to inspection, LEFT JAW APPEARS SWOLLEN COMPARED TO RIGHT, NO FLOCULENCE, NO ABSCESS APPRECIATED, AIRWAY PATENT. ~~CK: Normal ROM, No jugular venous distention, No meningeal signs, Cervical spine non-tender. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. NEURO: GCS is 15, No focal motor deficits, No focal sensory deficits, No cerebellar deficits. SKIN: Skin is warm and dry, No rash or induration. PSYCHIATRIC: Oriented X 3, Normal affect. 02SAT INTERPRETATION (05:04 MST1) 02SAT: 02 saturation reading 99%, 02 AMT: R.A., 02 Sat normal, None needed. RESULTS
(02:48 MST1)
000688

LAB: CBC W AUTO DIFF Jun 08 2007 02:31, WBC 6.7 1000/mm3 Ref Range (4.5-11.0), RBC 4.41 L 10X6 Ref Range (4.7-6.1), Hgb 11.9 L gm/dl Ref Range (13.0-18.0), Hct 35.9 L % Ref Range (39.0-54.0), MCV 81.4 fl Ref Range (80.0-99.0), MCH 27.0 pg Ref Range (25.0-31.0), MCHC 33.1 gm/dl Ref Range (32.0-36.0), RDW 14.3 % Ref Range (11.5-14.5), Platelets 311 1000/mm3 Ref Range (130.0-400.0), Gran 61.0 % Ref Range (40.0-70.0), Lymph 28.5 % Ref Range (22.0-40.0), Mono 9.2 % Ref Range (2.0-10.0), Eos 0.9 % Ref Range (0.0-6.0), Baso 0.4 % Ref Range (0.0-3.0), Manual Diff Not Indicated , Absolute Neutrophil 4.09 1000/mm3. COMPREHENSIVE METABOLIC PANEL Jun 08 2007 02:47, BUN 13 mg/dl Ref Range (9.0-20.0) Sodium 142 mEq/L Ref Range (137-145), Potassium 3.8 mEq/L Ref Range (3.6-5.0), Chloride 102 mEq/L Ref Range (98.0-107.0), Glucose 85 mg/dl Ref Range (75-110), Creatinine 1.2 mg/dl Ref Range (0.8-1.5), AST/SGOT 21 U/L Ref Range (17.0-59.0), Alk Phos 78 U/L Ref Range (38.0-126.0), Calcium 10.0 mg/dl Ref Range (8.4-10.2), Bilirubin 0.4 mg/dl Ref Range (0.2-1.3), Albumin 5.0 gm/dl Ref Range (3.5-5.0) I Prot Total 8.4 H gm/dl Ref Range (6.3-8.2), C02 26 mEq/L Ref Range (22.0-30.0), ALT/SGPT 22 U/L Ref Range (21.0-72.0), GFR 91.4 ml/min/1.73m2.
f
DIAGNOSIS (05:05 MST1) FINAL: PRIMARY: LEFT JAW PAIN, ADDITIONAL:
DISPOSITION PATIENT (05:05 MST1): X-RAY/CT Follow-up: YES, Critical Care: *None, Doctor Procedures: NO, Disposition: Home, Condition: Improved. (05:59 DWEL): Remove from ER. NOTES (05:05 MST1): Patient discharged. MEDICATION SERVICE
000689
Dilaudid (05:39 MST1): Order: Dilaudid : 1mg : IV Push Time: 0539 Notes: v.o. repeated back Ordered: Fri Jun 08 2007 05:39 Ordered by: Marcus Teng D.O. Entered by: Dale Wells, EMT-P Fri Jun 08 2007 05:39 Documented as given by: Dale Wells, EMT-P Fri Jun 08 2007 05:40 MEDICATION, Time given: 0540, Given in amount and via route as prescribed, Amount given: 1 mgt IV site 1, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient tolerated procedure well, Patient in position of comfort, Side rails up, Cart in lowest position. Dilaudid (02:01 MSAL): Order: Dilaudid : 1mg : IV Push POTENTIAL MODERATE INTERACTION Zyvox Notes: v.o. repeated back Irdered: Fri Jun 08 2007 02:01 )rdered by: Milton Sallis, MD Entered by: Jeffrey Borho, EMT-P Fri Jun 08 2007 02:01 Documented as given by: Dale Wells, EMT-P Fri Jun 08 2007 02:14 MEDICATION, Time given: 0200, Given in amount and via route as prescribed, Amount given: 1 mg, IV site 1, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient tolerated procedure well, Patient in position of comfort, Side rails up. Dilaudid (03:53 MST1): Order: Dilaudid : 1mg : IV Push Time: 0352 Notes: v.o. repeated back Ordered: Fri Jun 08 2007 03:53 Ordered by: Marcus Teng D.O. Entered by: Dale Wells, EMT-P Fri Jun 08 2007 03:53 Documented as given by: Dale Wells, EMT-P Fri Jun 08 2007 03:53 MEDICATION, Time given: 0352, Given in amount and via route as prescribed, Amount given: 1 mg, IV site 1, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of
000690
infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient tolerated procedure well, Patient in position of comfort, Side rails up, Cart in lowest position.
INSTRUCTION (05:17 MST1)
FOLLOWUP: 4, YOUR PHYSICIAN, SHELDON L DAVIS MD 253 DUNN RD FLORISSANT MO 63031 3149217770, MAHENDRA P GUNAPOOTI MD 2865 NETHERTON DRIVE ST. LOUIS MO 63136 3147417171, SSM REHAB MD 1 VILLAGE SQUARE DRIVE HAZELWOOD MO 63042 3147314555. ~ ~CIAL: CALL PERSONAL PHYSICIAN, DR. DAVIS, OR DR. GUNAPOOTI AND SSM REHAB TOMORROW FOR FOLLOW UP APPOINTMENT. OFF WORK TODAY AND TOMORROW.
PRESCRIPTION (05:04 MST1) Soma: Tablet: 350 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: As needed every six hours Dispense: ***12*** ~OTENTIAL MODERATE INTERACTION Dilaudid. NURSING ASSESSMENT: ENT (02:30 AMON)
TIME ASSESSED: Patient was assessed at 0230. NOTES: Pt complaint of pain and swelling to his left jaw. Pt states his jaw burns when he coughs. Pt was stabbed in the jaw in april. CONSTITUTIONAL: Complex assessment performed, Patient arrives ambulatory with steady gait to treatment area, History obtained from patient, Patient is cooperative, Patient is alert and oriented x 3, Patient appears in no acute distress, Patient's skin is warm and dry, Patient's mucous merr~ranes are moist and pink, Patient appears in pain distress. ENT: Patient denies pain to ears, nose, or throat, No obvious abnormality to the ears, No obvious abnormality to the nose, No obvious abnormality to the mouth, No obvious abnormality to the oropharynx, Mucous membranes are pink/moist, No obvious foreign bodies noted to ears, nose or throat, pt is coughing up thick secretions, RESPIRATORY/CHEST: No complaint of pain, Breath sounds clear bilaterally, No acute respiratory distress, No intercostal retractions, No supraclavicular retractions, Equal chest expansion, No nasal flaring, No cough. SAFETY: Side rails up, Cart in lowest position, Family at bedside.
NURSING ASSESSMENT: NURSES NOTE
(06:04 AMON) TIME ASSESSED: Time: 0605, Pts monitor was turned off and vital signs were lost.
000691
SSM DEPAUL EMERGENCY RECORD NURSING PROCEDURE: IV (02:23 DWEL) TIME: Procedure was performed at 0200, 20 gauge catheter inserted, into left AC, with 1 attempt, 0.9NS 1 Liter hung, at KVO, via primary tubing, Labs drawn at time of placement, After placement no swelling noted at site, no drainage noted at site, Sterile dressing applied, Patient tolerated procedure well. SAFETY: Side rails up, Cart in lowest position. NURSING PROCEDURE: LAB DRAW (02:24 DWEL) TIME: Procedure was performed at 0215, Venipuncture performed/labs sent. Patient < 3 years old, Blood obtained from left forearm and labs sent, with 1 attempt, Blood cultures sent, No swelling, Dressing applied, Patient tolerated procedure well. SAFETY: Side rails up, Cart in lowest position. NURSING PROCEDURE: TRANSPORT TO TESTS (04:14 AMON) TIME: Procedure was performed at 0345, Patient transported to CT scan. NURSING PROCEDURE: NURSE NOTES (04:18 DWEL) ~-~E: Time: 0415, pt returns from ct, resting comfortably. NURSING PROCEDURE: DISCHARGE NOTE (05:59 DWEL) TIME: Procedure was performed at 0545, Patient discharged to home, Patient ambulates without assistance, Accompanied by family member, Patient instructed not to drive home, IV discontinued with catheter intact. Dressing placed to IV site, Discharge instructions given to patient, Simple/moderate discharge teaching performed, Prescription given and additional instructions on side effects of same given, Above Person(s) verbalized understanding of discharge instructions and follow-up care, Patient treated and evaluated by physician. VITAL SIGNS: BP: 151, / 98, Pulse: 80, Resp: 18, Temp: 98, Pain: 0, 02 sat: 99, raJ Time: 0545. IMAGING CT REPORT (07:53 AS): Image captured from scanner. (07:53 AS): Image captured from scanner. PROTOCOL (07:53 AS): Image captured from scanner. CONSENT TO TREAT (07:54 AS): Image captured from scanner. (07:54 AS): Image captured from scanner. ADMIN DIGITAL SIGNATURE (04:18 DWEL): Wells, EMT-P, Dale. (05:59 DWEL): Wells, EMT-P, Dale.
000692
(Thu Jun 21 2007 19:09 MST1): Teng D.O., Marcus. (Thu Jan 15 2009 02:33 DWEL): Wells, EMT-P, Dale. PATIENT DATA CHANGE (01:56 MST1): Attending changed from (none) to Marcus Teng D.O. (02:20): A08 63396783 by Inte~face, Payment: 90, Admitting Doctor: Pcp None, Attending Doctor: Physicians Emergency. (02:25): A08 63396881 by Interface, Payment: 95, Admitting Doctor: Pcp None, Attending Doctor: Physicians Emergency. (03:18 JBOR): Extender changed from (none) to Jeffrey Borho, EMT-P. KEY: AMON=Montgomery, RN, Anita TBOR=Borho, EMT-P, Jeffrey lST1=Teng D.O., Marcus AS=Spilker, Andy DWEL=Wells, EMT-P, Dale JWHI=White, RN, Jeannette MSAL=Sallis, MD, Milton
000693
SSM DEPAUL CLINICAL SUMMARY RECORD HPI BLANK CHIEF COMPLAINT: DISCHARGED FROM HOSPITAL YESTERDAY AFTER IV ABX GIVEN ON PO ABX AND PAIN MEDS AND STATES STILL HAVING PAIN, FEVER AND CHILLS AT HOME, PATIENT APPEARS VERY COMFORTABLE HERE TALKING ON CELL PHONE, REVIEW OF OLD RECORDS REVEALK THAT PATIENT HAS HAD FREQUENT VISITS TO BARNES SINCE SURGERY. HISTORIAN: History obtained from patient. TIME COURSE: Onset of symptoms reported as sudden, Onset was TODAY, Patient currently has symptoms, Complaint is constant. SEVERITY: Maximum severity is moderate, Currently symptoms are moderate. HISTORY JICAL HISTORY: which is not being treated, Stabbed in left face April 24th, 2007. History of hypertension, Patient is noncompliant with treatment, stab wound 1 face 4\24\07. PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair SOCIAL HISTORY; Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives alone, Denies smoking, Lives at home alone. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives alone. lILY HISTORY: Family history is not contributory to this case. Family history is not contributory to this case. NOTES: Stabbed in left face April 24th, 2007. Underwent surgery the week following . . . : Nursing records reviewed. ROS
~nTES:
J
SEE HPI. SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above.
PHYSICAL EXAM CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3. HEAD: Atraumatic, Normocephalic. EYES; Pupils equal and reactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal, Conjunctiva are normal. ENT: Ears normal to inspection, Nose examination normal, Oropharynx normal, Mouth normal to inspection, LEFT JAW APPEARS SWOLLEN COMPARED TO RIGHT, NO FLOCULENCE, NO ABSCESS APPRECIATED, AIRWAY PATENT. NECK: Normal ROM, No jugular venous distention, No meningeal signs, Cervical spine non-tender. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress.
000694
CARDIOVASCULAR: RRR t No murmurs t No rub t No gallop. NEURO: GCS is 15 t No focal motor deficits t No focal sensory deficits t No cerebellar deficits. SKIN: Skin is warm and drYt No rash or induration. PSYCHIATRIC: Oriented X 3 t Normal affect.
DIAGNOSIS FINAL: PRIMARY: LEFT JAW PAINt ADDITIONAL: DISPOSITION PATIENT: X-RAY/CT Follow-up: YES t Critical Care: *None t Doctor Procedures: NOt Disposition: Home t Condition: Improved. Remove from ER. Patient discharged. _ES: MEDICATION SERVICE Dilaudid: Order: Dilaudid 1mg IV Push Time: 0539 Notes; v.o. repeated back Ordered: Fri Jun 08 2007 05:39 0rdered by: Marcus Teng D.O. ,ntered by: Dale Wells t EMT-P Fri Jun 08 2007 05:39 Documented as given by: Dale Wells t EMT-P Fri Jun 08 2007 05:40 MEDICATION t Time given: 0540 t Given in amount and via route as prescribed t Amount given: 1 mgt IV site 1t IVP t SlowlYt Catheter placement confirmed via flush prior to administration t IV site without signs or symptoms of infiltration during medication administration t No swelling during administration t No drainage during administration t IV flushed after administration t Correct patient t timet route t dose and medication confirmed prior to administration t Patient advised of actions and side-effects prior to administration t Allergies confirmed and medications reviewed prior to administration t Patient tolerated procedure wellt Patient in position of comfort t Side rails UPt Cart in lowest position. Dilaudid: Order: Dilaudid : 1mg : IV Push POTENTIAL MODERATE INTERACTION Zyvox Notes: v.o. repeated back Ordered: Fri Jun 08 2007 02:01 Ordered by: Milton Sallis t MD Entered by: Jeffrey Borho t EMT-P Fri Jun 08 2007 02:01 Documented as given by: Dale Wells t EMT-P Fri Jun 08 2007 02:14 MEDICATION t Time given: 0200 t Given in amount and via route as prescribed t Amount given: 1 mgt IV site 1t IVP, SlowlYt Catheter placement confirmed via flush prior to administration t IV site without signs or symptoms of infiltration during medication administration t No swelling during
000695
administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient tolerated procedure well, Patient in position of comfort, Side rails up. Dilaudid: Order: Dilaudid : Img : IV Push Time: 0352 Notes: v.o. repeated back Ordered: Fri Jun 08 2007 03:53 Ordered by: Marcus Teng D.O. Entered by: Dale Wells, EMT-P Fri Jun 08 2007 03:53 locumented as given by: Dale Wells, EMT-P Fri Jun 08 2007 03:53 MEDICATION, Time given: 0352, Given in amount and via route as prescribed, Amount given: 1 mg, IV site 1, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route; dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient tolerated procedure well, Patient in position of comfort, Side rails up, Cart in lowest position.
PRESCRIPTION Soma: Tablet: 350 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: As needed every six hours Dispense: ***12*** POTENTIAL MODERATE INTERACTION Dilaudid. TRUCTION rvLLOWUP: 4, YOUR PHYSICIAN, SHELDON L DAVIS MD 253 DUNN RD FLORISSANT MO 63031 3149217770, MAHENDRA P GUNAPOOTI MD 2865 NETHERTON DRIVE ST. LOUIS MO 63136 3147417171, SSM REHAB MD 1 VILLAGE SQUARE DRIVE HAZELWOOD MO 63042 3147314555. SPECIAL: CALL PERSONAL PHYSICIAN, DR. DAVIS, OR DR. GUNAPOOTI AND SSM REHAB TOMORROW FOR FOLLOW UP APPOINTMENT. OFF WORK TODAY AND TOMORROW.
000696
SSM DEPAUL RECORD
000697
II
SSM DEPAUL EMERGENCY FLOW SHEET RECORD Name: March, Phi.llip VITAL SIGNS Age, 30Y MR: 000748298 Acct: 0715900171
User DWEL JWHI
Date/Time
06/08 05:59 06/08 01:32
BP
151/98 151/102
PULSE
80 78
RESP
18 18
TEMP
98 99.1
PAIN
o
10/10
02 SAT 99 on ra 99 on RA
TIME
0545 0128

Name: March, Phillip Age: 30Y I'IR: 000748298 Acct: 0715900171
Page: 1
000698
Picis Imaging
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000699
Picis Imaging
Page 2 of3
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000700
Picis Imaging
Page 2 of3
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000701
Picis Imaging
Page 2 of3
PAGE
l/(J02
PreHminary Radiology Report

Name;
M.~'CH
PHILLIP'
Ago: ;;0 "'0
F'rocodUfO
AGGossiOIl
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000702
Page 2 of3 Picis Imaging

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000703
DePaul Health Center Tue May 26, 2009 09:54 am Patient Detail Report Name: MARCH,PHILLIP H _ #/Acct #: 000748298/A0715900171 Loc: ER 06/08/07 Attending Dr-Svc: TENG,MARCUS S - EMERGENCY Admitting Dr: EMERGENCY, PHYSICIANS 978730 16102 805137 917259 CULTURE BLOOD Specimen: Blood (M)-2 ColI. Time: 06/08/07 0215 In at: 06/08/07 0227 Ordering Phys: SALLIS,MILTON
P
Page:
Acct #: A0715900171 Techs V-DFW Techs: TSMH
Out at: 06/14/07 0636
Final
[3678336J
* * CULTURE * *
No Growth Performed by: SSM Health Care Lab - SMHC 6420 Clayton Road St Louis, Mo 63117 End of Report - OS/26/09 09:54

~.ent
Detail Report
MARCH,PHILLIP H 000748298/A0715900171 ER 06/08/07 (M-10/02/76) Dr. TENG,MARCUS S
000704
DePaul Health Center Tue May 26/ 2009 09:54 am Patient Detail Report Name: MARCH/PHILLIP H _ #/Acct #: 000748298/A0715900171 Loc: ER 06/08/07 Attending Dr-Svc: TENG/MARCUS S - EMERGENCY EMERGENCY/PHYSICIANS Admitting Dr: 978730 16102 805137 917259 CULTURE BLOOD Specimen: Blood (M) Coll. Time: 06/08/07 0200 In at: 06/08/07 0227 Ordering Phys: SALLIS/MILTON
F
Page:
Acct #: A0715900171 Techs V-DFW Techs: TSMH
Out at: 06/14/07 0636
Final
[3678334]
* * CULTURE * *
No Growth Performed by: SSM Health Care Lab - SMHC 6420 Clayton Road St Louis/ Mo 63117 End of Report - OS/26/09 09:54
Alexander Babich/ M.D. .. .ent Detail Report
MARCH/PHILLIP H 000748298/A0715900171 ER 06/08/07 (M-10j 02/76) Dr. TENG/MARCUS S
000705
DePaul Health Center Tue May 26, 2009 09:54 am Patient Detail Report Name: MARCH,PHILLIP H ; #/Acct #: 000748298/A0715900171 Loc: ER 06/08/07 Attending Dr-Svc: TENG,MARCUS S - EMERGENCY Admitting Dr: EMERGENCY,PHYSICIANS 978730 16102 805137 917259 In: 06/08/07 0225 ------------------Out: 06/08/07 0231 I CBC W AUTO DIFF I Coll Time: 06/08/07 0200 ------------------Order Phys: SALLIS,MILTON *STAT*STAT*STAT* Result Ref Range Result Name Result Name WBC(1000/mm: RBC(10X6) : Hgb(gm/dl) : Hct (%) : MCV (fl) : MCH (pg) : ]V'~.Tr::: (gm/ dl) :
~
p.
Page:
Spec: Blood Techs: V-DFW TESHOEM [A0715900171/3678335] Result Ref Range
%) :
6.7 4.41 L 11. 9 L 35.9 L 81. 4 27.0 33.1 14.3
4.5-11.0 4.7-6.1 13.0-18.0 39.0-54.0 80.0-99.0 25.0-31. 0 32.0-36.0 11.5-14.5
Platel(1000/mm: Gran (%) : Lymph (%) : Mono (%) : Eos (%) : Baso(%) : Manual Diff : Absolu(1000/mm:
311 130.0-400.0 61. 0 40.0-70.0 28.5 22.0-40.0 9.2 2.0-10.0 0.9 0.0-6.0 0.4 0.0-3.0 Not Indicated 4.09
Alexander Babich, M.D. .....__ ent Detail Report
MARCH, PHILLIP H 000748298/A0715900171 ER 06/08/07 (M-I0/ 02/76) Dr. TENG,MARCUS S
000706
DePaul Health Center Tue May 26, 2009 09:54 am Patient Detail Report MARCH,PHILLIP H Page: 1 000748298/A0715900171 Loc: ER 06/08/07 Attending Dr-Svc: TENG,MARCUS S - EMERGENCY Admitting Dr: EMERGENCY,PHYSICIANS 978730 16102 805137 917259 In: 06/08/07 0225 --------------------------------Spec: Blood Out: 06/08/07 0247 I COMPREHENSIVE METABOLIC PANEL I Techs: V-DFW TTWILMT Coll Time: 06/08/07 0200--------------------------------Order Phys: SALLIS,MILTON [A0715900171/3678335] *STAT*STAT*STAT* Result Reference Range Result Name
~
Name: #/Acct #:
BUN (mg/dl) : Sodium(mEq/L) : Potassium(mEq/L) : Chloride (mEq/L) : Glucose (mg/dl) : Creatinine (mg/dl) : ISGOT (U/L) : Phos (U/L) : Calcium (mg/dl) : Bilirubin (mg/dl) : Albumin (gm/ dl) : Prot Total (gm/dl) : C02 (mEq/L) : ALT/SGPT GFR(ml/min/1.73m2) :
(U/L) :
13 142 3.8 102 85 1.2 21 78 10.0 0.4 5.0 8.4 H 26 22 91. 4
9.0-20.0 137-145 3.6-5.0 98.0-107.0 75-110 0.8-1.5 17.0-59.0 38.0-126.0 8.4-10.2 0.2-1.3 3.5-5.0 6.3-8.2 22.0-30.0 21.0-72.0

~ent
Detail Report
MARCH,PHILLIP H 000748298/A0715900171 ER 06/08/07 (M-10/ 02/76) Dr. TENG,MARCUS S
000707
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING .ne: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 06/08/07 0413 Sex: M Med Rec # A000748298 ACCT: A0715900171 Pt Location: *ER TENG,MARCUS S 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044 Check-In # Order Diagnosis 974484 Ord Diag: 526.9-JAW DISEASE NOS
CT maxillofacial area with contrast: Clinical Indication: Stab wound to left side of neck and face with left-sided facial pain. Postoperative repair of mandible fracture. Technique: 3.2 mm axial images through the maxillofacial facial area with intravenous contrast. 100 cc of Omnipaque injected intravenously. Virtual Radiologic consultants interpreted the exam and sent a preliminary report. Comparison: CT of the neck from 6-01-7. Findings: There is redemonstration of a comminuted, left mandible fracture with postoperative fixation device. There are surgical clips overlying the musculature surrounding the mandible. These create metallic streak artifact limiting the exam somewhat. Since the prior exam, there has only been a slight decrease in the subcutaneous, mild stranding consistent with either cellulitis or scarring or postoperative changes. Soft tissue density and/or thickening surrounds the left distal common carotid artery. There is associated surgical clips adjacent to this region. In addition, there is mild increased soft tissue density overlying the region of the anterior margin of the sternocleidomastoid muscle to the angle of the mandible. This likely represents postoperative changes and possibly some scarring as well. There is no focal fluid collection to suggest an abscess. The visualized paranasal sinuses are well aerated. There does appear to be some callus formation involving the fracture lines of the left mandible consistent with healing. Impression: FINAL DUPLICATE
Page
000708
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING ,ne; MARCH, PHILLIP H DOB; 10/02/76 Age; 32Y Date; 06/08/07 0413 Sex; M Med Rec # A000748298 ACCT; A0715900171 Pt Location; *ER TENG,MARCUS S 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044
Checkin-Exam Code Summary 974484-70487 1. No evidence of a focal abscess. Soft tissue swelling and stranding in the subcutaneous tissue and fat suggest some component of inflammatory change, although postoperative changes may still look similar. See above. 2. Healing, comminuted, left mandible fracture with fixation.
Reading Radiologist- MATTHEW W STADNYK M.D. Releasing Radiologist- MATTHEW W STADNYK M.D. Released Date Time- 06/08/07 1418 Transcriptionist- SVM ADM; EMERGENCY, PHYSICIANS REF; PCP: PCP,NONE ATT; TENG,MARCUS S CON; SCP;
FINAL DUPLICATE
Page
000709
SSM DEPAUL EMERGENCY RECORD KNOWN ALLERGIES No known drug allergies. HISTORY (04:09 AHAR) MEDICAL HISTORY: History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, . History of hypertension, jaw osteomyelitis. PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. No previous psychiatric history.
SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. SOCIAL HISTORY: Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. FAMILY HISTORY: Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case . .'ES: Agree with nursing records. Nursing records reviewed.
TRIAGE (Sat Oct 13 2007 04:09 AHAR) COMPLAINT: pick Line Pulled Out/ Bite On Li. PROVIDERS: TRIAGE NURSE: Ameenah Williams, BSN. ADMISSION: URGENCY: ESI-3, TRANSPORT: Ambulatory, BED: WAITING. PATIENT: NAME: Phillip March, AGE: 31, GENDER: Male, DOB: Sat Oct 02 1976, RACE: Black, Code: NO, Trauma: *NO, Work Comp.: NO, Heat Related: NO, SSN: 493788699, ZIP CODE: 63121, KG WEIGHT: 72.6, HEIGHT: 180cffi, PHONE: 314522-8730, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0728600028, PRIMARY: Phillip G Zinser, ATTENDING: Emergency Physicians, IBEX NUMBER: 20071013040934ADT. PREVIOUS VISIT ALLERGIES: No known drug allergies. FALL RISK: TIME: 0405, Gender (Male), Get up and go test: Able to rise in a single movement, Score: 1. ASSESSMENT: PICC LINE PULLED OUT BY GIRLFRIEND DURING FIGHT. PT BIT ON LIP. IMMUNIZATIONS: Last tetanus shot received less than 5 years ago. TB SCREENING: Denies TB screening. DOMESTIC VIOLENCE: No domestic violence. EDUCATIONAL/CULTURAL BARRIERS: No educational/cultural barriers. TREATMENTS IN PROGRESS: No treatment. VITAL SIGNS: BP 163/99, Pulse 109, Resp 22, Temp 98.4, Pain 7, 02 Sat 100, on RA, Time 0407.
000710
SSM DEPAUL EMERGENCY RECORD RESULTS (09:44 MST1) RADIOLOGY: XR CHEST 2 VIEWS Oct 13 2007 09:25, Check-in number: 0001028032 Read By: 978614 TWO-VIEWS chest 10/13/2007 Indication- Osteomyelitis, history of cough, retraction of the PICC line Comparison- 10/4/2007 DescriptionThe right upper extremity PICC is again demonstrated with tip overlying the superior vena cava. There has been no significant change in the position of the PICC line. Lungs remain clear. Read By- NOAMAN W SIDDIQI M.D. Released By- NOAMAN W SIDDIQI M.D. Released Date Time- 10/13/07 0926 Transcriptionist- NWS M.D. ADM- EMERGENCY;PHYSICI&NS ATTREF- CONPCP- ZINSER,PHILLIP G SCP~eleased By: SIDDIQI,NOAMAN,W
EMERGENCY;PHYSICIA~S
DOCTOR NOTES (10:34 MST1) TEXT: PT LEFT AMA THERE WAS NO PATIENT CONTACT. DISPOSITION P~TIENT (10:12 JDIE): Disposition: Left Without Being Seen. :10:13 8ZIM): X-RAY/CT Follow-up: NO, Critical Care: *None, Doctor Procedures: NO, Condition: Unknown, Remove from ER. PRESCRIPTION: No Documented Prescriptions
NURSING ASSESSMENT: NURSES NOTE (10:03 SZIM) TIME ASSESSED: Time: 0945, SPOKE WITH DR TENGE RE PT X-RAY RESULTS. NOTIFIED DR OF PT INTENT TO LEAVE AMA DUE TO 5 HR 47 MIN WAIT. NURSING ASSESSMENT: EXTREMITY UPPER (10:06 SZIM) TIME ASSESSED: Patient was assessed at 0900. NOTES: PT PRESENTS WITH CONCERN THAT PIC LINE WZS DISPLACED AFTER FIGHT WITH GIRLFRIEND. PT STATES HE IS ABLE TO GET RETURN AND FLUSH W/O INCIDENT. PT HAS ABRASSION ON L WRIST AND L LIP PT DECLINES MED ATTNTION TO THESE AREAS.
000711
CONSTITUTIONAL: Complex assessment performed, Patient arrives ambulatory with steady gait to treatment area, History obtained from patient, Patient appears comfortable, Patient is. cooperative, Patient is alert and oriented x 3, Patient appears in no acute distress, Patient's skin is warm and dry, Patient's mucous membranes are moist and pink. LEFT UPPER EXTREMITY: No complaint of pain, Radial pulse present, Brachial pulse present, Brisk capillary refill, Sensation intact, No numbness/tingling, Full range of motion. RIGHT UPPER EXTREMITY: No complaint of pain, Radial pulse present, Brachial pulse present, Brisk capillary refill, Sensation intact, No numbness/tingling, Full range of motion. SAFETY: Side rails up, Cart in lowest position, Call light within reach .
.<.SING PROCEDURE: BLANK CHART (04: 23 DJB) cxr done SR/KA. TIME: NURSING PROCEDURE: DISCHARGE NOTE (10:08 SZIM) TIME: Procedure was performed at 1000, Patient left against medical advice, Above Person(s) verbalized understanding of discharge instructions and follow-up care . . GING PROTOCOL (13:15 VYOU): Image captured from scanner. CONSENT TO TREAT (13:15 VYOU): Image captured from scanner. REFUSAL OF TREATMENT (13:18 VYOU): Image captured from scanner. TRIAGE CARD (13:19 VYOU): Image captured from scanner. CONSENT TO TREAT (13:19 VYOU): Page 002 added Image captured from scanner. l>nl':-1:IN ITAL SIGNATURE (04:10 AHAR): Williams, BSN, Ameenah. (10:09 SZIM): Zimmerman, Shelley. (Wed Oct 24 2007 06:23 MST1): Teng D.O., Marcus. PATIENT DATA CHANGE (09:22 SZIM): Primary Nurse changed from (none) to Shelley Zimmerman. (09:38 MST1): Attending changed from (none) to Marcus Teng D.O. (10:10): A08 68171113 by Interface, Payment: 90, Admitting Doctor: Zinser Phillip G, Attending Doctor: Marcus S Teng. (10:12 JDIE): Payment: (none).
KEY: AHAR=Harrison, BSN, Ameenah DJB=Barton, Danielle JDIE=Nordike, RN, Jeana MST1=Teng D.O., Marcus SZIM=Zimmerman, RN, Shelley VYOU=Young, Victoria
000712
SSM DEPAUL CLINICAL SUMMARY RECORD HISTORY MEDICAL HISTORY: History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, . History of hypertension, jaw osteomyelitis. PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. ~IAL HISTORY: Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. FAMILY HISTORY: Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. NOTES: Agree with nursing records. Nursing records reviewed.
}-~TOR
.T:
NOTES PT LEFT AMA THERE WAS NO PATIENT CONTACT.
DISPOSITION PATIENT: Disposition: Left Without Being Seen. X-RAY/CT Follow-up: NO, Critical Care: *None, Doctor Procedures: NO, Condition: Unknown, Remove from ER.
PO~SCRIPTION:
No Documented Prescriptions
000713
SSM DEPAUL RECORD
000714
II
SSM DEPAUL EMERGENCY FLOW SHEET RECORD Name: March, Phillip VITAL SIGNS User Date/Time AHAR 10/13 04:09 Age: 31Y MR: 000748298 Acct: 0728600028
BP 163/99
PULSE 109
RESP 22
TEMP 98.4
PAIN
7
02 SAT 100 on RA
TIME 0407

Name: March, Phillip Age: 31Y MR: 000748298 Acct: 0728600028 Prepared: Tue May 26 09:10:10 2009 by Stephanie Manetz Page: 1
000715
Picis Imaging
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000716
Picis Imaging
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RELEASE OF RESPONSIBILITY
(R,E,FUSAL 01= SCRl:;fNING EXAM, REFUSAL 01= CARE; LEAVING AGAINST MEDiCAL ADVJCE)
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000717
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000719
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000720
DePaul Health Center Tue May 26, 2009 09:49 am Patient Detail Report MARCH,PHILLIP H Page: 000748298/A0828500070 Loc: XER 10/11/08 Attending Dr-Svc: VIERODOTHAGE,LAURA M - EMERGENCY Admitting Dr: EMERGENCY,PHYSICIANS 977173 16102 903572 CULTURE BLOOD Specimen: Blood (M) Coll. Time: 10/11/08 1141 In at: 10/11/08 1148 Acct #: A0828500070 Techs VNUR Ordering Phys: VIERODOTHAGE,LAURA M
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Name:
_ #/Acct
#:
Out at: 10/17/08 1230
Final
[4492145]
Techs: TSMH
* * CULTURE * *
No Growth Performed by: SSM Health Care Lab - SMHC 6420 Clayton Road St Louis, Mo 63117 End of Report - OS/26/09 09:49
Alexander Babich, M.D. :ent Detail Report
MARCH,PHILLIP H 000748298/A0828500070 XER 10/ 11 / 0 8 (M-10/02/76) Dr. VIERODOTHAGE,LAURA M
000721
DePaul Health Center Tue May 26, 2009 09:49 am Patient Detail Report Name: MARCH,PHILLIP H c #/Acct #: 000748298/A0828500070 Loc: XER 10/11/08 Attending Dr-Svc: VIERODOTHAGE,LAURA M - EMERGENCY Admitting Dr: EMERGENCY,PHYSICIANS 977173 16102 903572 In: 10/11/08 1148 ------------------Out: 10/11/08 1155 I CBC W AUTO DIFF I Coll Time: 10/11/08 1140 ------------------Order Phys: VIERODOTHAGE, LAURA M *STAT*STAT*STAT* Result Name Result Ref Range Result Name WBC(1000/mm: RBC (10X6) : Hgb (gm/ dl) : Hct (%) : MCV (1) : MCH (pg) : ':(gm/dl) :
(%) :
Page:
Spec: Blood Techs: VER TSDUBAL [A0828500070/4492147] Result Ref Range
5.8 5.00 14.6 43.1 86.2 29.2 33.9 14.6 H
4.5-11.0 4.7-6.1 13.0-18.0 39.0-54.0 80.0-99.0 25.0-31. 0 32.0-36.0 11.5-14.5
Platel(1000/mm: Gran (%) : Lymph (%) : Mono (%) : Eos (%) : Baso (%) : Manual Diff : Absolu(1000/mm:
227 130.0-400.0 55.1 40.0-70.0 22.0-40.0 35.9 7.8 2.0-10.0 0.9 0.0-6.0 0.3 0.0-3.0 Not Indicated 3.17 1.8-7.7

~ent
Detail Report
MARCH,PHILLIP H 000748298/A0828500070 XER 10/11/08 (M-10/02/76) Dr. VIERODOTHAGE,LAURA M
000722
DePaul Health Center Tue May 26, 2009 09:49 am Patient Detail Report MARCH,PHILLIP H Page: 1 000748298/A0828500070 Loc: XER 10/11/08 Attending Dr-Svc: VIERODOTHAGE,LAURA M - EMERGENCY Admitting Dr: EMERGENCY,PHYSICIANS 977173 16102 903572 In: 10/11/08 1148 --------------------------------Spec: Blood Out: 10/11/08 1228 I COMPREHENSIVE METABOLIC PANEL I Techs: VER TLSCHWC* Coll Time: 10/11/08 1140--------------------------------Order Phys: VIERODOTHAGE, LAURA M [A0828500070/4492147] *STAT*STAT*STAT* Result Result Name Reference Range
l ; #/Acct #:
Name:
BUN(mg/dl) : Sodium (mEq/L) : Potassium (mEq/L) : Chloride (mEq/L) : Glucose (mg/dl) : Creatinine (mg/dl) : .r~/SGOT(U/L) : Phos (U/L) : Calcium(mg/dl) : Bilirubin(mg/dl) : Albumin (gm/dl) : Prot Total (gm/dl) : C02 (mEq/L) : ALT/SGPT GFR(ml/min/1.73m2) :
(U/L) :
15 139 4.4 102 86 1.1 28 63 9.3 0.6 4.4 7.6 29 27 99.8
9.0-20.0 137-145 3.6-5.0 98.0-107.0 75-110 0.8-1.5 17.0-59.0 38.0-126.0 8.4-10.2 0.2-1.3 3.5-5.0 6.3-8.2 22.0-30.0 21.0-72.0
Alexander Babich, M.D. ----ent Detail Report
MARCH,PHILLIP H 000748298/A0828500070 XER 10/11/08 (M-10/ 02/76) Dr. VIERODOTHAGE,LAURA M
000723
DePaul Health Center Tue May 26, 2009 09:50 am Patient Detail Report Name: MARCH, PHILLIP H Page: 000748298/A0828500070 _ #/Acct #: Loc: XER 10/11/08 Attending Dr-Svc: VIERODOTHAGE,LAURA M - EMERGENCY Admitting Dr: EMERGENCY, PHYSICIANS 977173 16102 903572 CULTURE BLOOD Specimen: Blood (M)-2 ColI. Time: 10/11/08 1140 In at: 10/11/08 1148 Acct #: A0828500070 Ordering Phys: VIERODOTHAGE,LAURA M Techs VNUR Out at: 10/17/08 1230 **CULTURE** No Growth Performed by: SSM Health Care Lab - SMHC 6420 Clayton Road St Louis, Mo 63117 End of Report - OS/26/09 09:50 Final [4492146] Techs: TSMH P 1
Alexander Babich, M.D. . . ent Detail Report
MARCH, PHILLIP H 000748298/A0828500070 XER 10/11/08 (M-10/02/76) Dr. VIERODOTHAGE,LAURA M
000724
DePaul Health Center Tue May 26/ 2009 09:52 am Patient Detail Report MARCH/PHILLIP H 000748298/A0726000387 Loc: XER 09/17/07 Attending Dr-Svc: SALLIS,MILTON - EMERGENCY Admitting Dr: EMERGENCY,PHYSICIANS 805137 16102 978162 917259 In: 09/17/07 1730 ------------------Out: 09/17/07 1854 I CBC W AUTO DIFF I Coll Time: 09/17/07 1650 ------------------Order Phys: WENSLEY/ROSEMARY K *STAT*STAT*STAT* Result Ref Range Result Name Result Name
l _ #/Acct #:
Name:
Page:
Spec: Blood Techs: VILL TTTRIMC* [A0726000387/3839546] Result Ref Range
WBC(1000/mm: RBC(10X6) : Hgb (gm/dl) Hct (%) : MCV (fl) : MCH (pg) : ]V"'-; (gm/ dl) :
1
,%) :
Platel(1000/mm:
7.1 5. 08 13 . 3 40.1 78.9 L 26.2 33.2 16.2 H 240
4 . 5 -11 . 0 4.7 - 6.1 13 . 0 - 18 . 0 39.0 - 54 . 0 80.0-99.0 25.0-31.0 32.0-36.0 11.5-14.5 130.0-400.0
Gran ( %) : Lymph (%) : Mono ( %) : Eos (%) : Baso(%): Manual Diff: Plt Comment:
Absolu(1000/mm:
68.4 40.0-70.0 25.3 22.0-40.0 5.9 2.0-10.0 0.1 0.0-6.0 0.3 0.0-3.0 Not Indicated Automated platelet count inaccurate due to large platelets. Platelets appear adequate when reviewed on peripheral smear. 4.86

-:cc_
ent Detail Report
MARCH,PHILLIP H 000748298/A0726000387 XER 09/17/07 (M-10/02/76) Dr. SALLIS/MILTON
000725
DePaul Health Center Tue May 26/ 2009 09:53 am Patient Detail Report Name: MARCH/PHILLIP H Page: 1 _ #/Acct #: 000748298/A0726000387 Loc: XER 09/17/07 Attending Dr-Svc: SALLIS/MILTON - EMERGENCY Admitting Dr: EMERGENCY/PHYSICIANS 805137 16102 978162 917259 In: 09/17/07 1730 --------------------------------Spec: Blood Out: 09/17/07 1803 I COMPREHENSIVE METABOLIC PANEL I Techs: VILL TLLARDD Coll Time: 09/17/07 1650--------------------------------Order Phys: WENSLEY/ROSEMARY K [A0726000387/3839546] *STAT*STAT*STAT* Result Reference Range Result Name BUN (mg/dl) : Sodium(mEq/L) : Potassium(mEq/L) : Chloride (mEq/L) : Glucose (mg/dl) : Creatinine (mg/dl) : l'~/SGOT(U/L) : Phos (U/L) : Calcium (mg/dl) : Bilirubin(mg/dl) : Albumin (gm/ dl) : Prot Total (gm/dl) : C02 (mEq/L) : ALT/SGPT GFR(ml/min/1.73m2) :
9 137 3.8 101 86 1.2 17 76 9.9 0.9 4.7 7.6 28
(U/L) :
<3 L 91.4
9.0-20.0 137-145 3.6-5.0 98.0-107.0 75-110 0.8-1.5 17.0-59.0 38.0-126.0 8.4-10.2 0.2-1.3 3.5-5.0 6.3-8.2 22.0-30.0 21.0-72.0
\lexander Babich/ M.D.

~ent
Detail Report
MARCH/PHILLIP H 000748298/A0726000387 XER 09/17/07 (M-10/02/76) Dr. SALLIS/MILTON
000726
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING . ae: MARCH,PHILLIP H DOB: 10/02/76 Age: 32Y Date: 10/13/07 0426 Sex: M Med Rec # A000748298 ACCT: A0728600028 Pt Location: *ER HODGES,HARLAN D 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044 Check-In # Order Diagnosis 1028032 Ord Diag: 780.99-0THER GENERAL SYMPTOMS
Exam XR CHEST 2 VIEWS
TWO-VIEWS chest 10/13/2007 Indication: Osteomyelitis, history of cough, retraction of the PICC line Comparison: 10/4/2007 Description: The right upper extremity PICC is again demonstrated with tip overlying the superior vena cava. There has been no significant change in the position of the PICC line. Lungs remain clear. Read By- NOAMAN W SIDDIQI M.D. Released By- NOAMAN W SIDDIQI M.D. Released Date Time- 10/13/07 0926 Transcriptionist- NWS M.D. ADM: EMERGENCY,PHYSICIANS REF: PCP: ZINSER,PHILLIP G ATT: EMERGENCY,PHYSICIANS CON: SCP:
FINAL DUPLICATE
Page
000727
SSM DEPAUL EMERGENCY RECORD HPI BLANK (05:27 RSMI) CHIEF COMPLAINT: pt to ed with c\o sorew throat jaw pain second trip this week . HISTORIAN: History obtained from patient. TIME COURSE: Onset of symptoms reported as sudden, Onset was 1 weeks ago, Patient currently has symptoms, Complaint is constant. SEVERITY: Maximum severity is moderate, Currently symptoms are moderate. KNOWN ALLERGIES No known drug allergies. HISTORY 'ICAL HISTORY (04:25 LBUR): which is not being treated, Stabbed in left face April 24th, 2007. History of hypertension, Patient is noncompliant with treatment, stab wound 1 face 4\24\07. PSYCHIATRIC HISTORY (04:25 LBUR): No previous psychiatric history. No previous psychiatric history. SURGICAL HISTORY (04:25 LBUR): Jaw Repair, plate left jaw. facial repair. SOCIAL HISTORY (04:25 LBUR): Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives alone, Denies smoking, Lives at home alone. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives alone. FAMILY HISTORY (04:25 LBUR): Family history is not contributory to this case. Family history is not contributory to this case. NOTES (04:25 LBUR): Stabbed in left face April 24th, 2007. Underwent surgery the week following . . . Nursing records reviewed. MEDICAL HISTORY (05:28 RSMI): History of hypertension, which is being treated, stab wound 1 face. p0YCHIATRIC HISTORY (05:28 RSMI): No previous psychiatric history . .GICAL HISTORY (05:28 RSMI): Patient's previous surgical history is not relevant to the case. SOCIAL HISTORY (05:28 RSMI): Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives with others. FAMILY HISTORY (05:28 RSMI): Family history is not contributory to this case. NOTES (05:28 RSMI): Nursing records reviewed, Agree with nursing records. ROS (05:27 RSMI) CONSTITUTIONAL: Negative constitutional review of systems. EYES: Negative eye review of systems. ENT: Negative ENT review of systems. CARDIOVASCULAR: Negative cardiovascular review of systems. RESPIRATORY: Negative respiratory review of systems. GI: Negative gastrointestinal review of systems. GENITOURINARY MALE: Negative genitourinary review of systems.
000728
MUSCULOSKELETAL: Negative musculoskeletal review of systems. SKIN: Negative skin review of systems. NEUROLOGIC: Negative neurologic review of systems. ENDOCRINE: Negative endocrine review of systems. HEMO/LYMPHATIC: Negative hemo/lymphatic review of systems. ALLERGIC/IMMUNOLOGIC: Negative Allergic review of systems. PSYCHIATRIC: Negative psychiatric review of systems. ALL SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above.
TRIAGE (Wed Jun 13 2007 04:25 LBUR)
COMPLAINT: Burning Jaw,CanT Clear Throat. lVIDERS: TRIAGE NURSE: Linda Burkhart,RN. AISSION: URGENCY: ESI-5, TRANSPORT: Ambulatory, BED: WAITING. PATIENT: NAME: Phillip March, AGE: 30, GENDER: Male, DOB: Sat Oct 02 1976, RACE: Black, Code: NO, Trauma: *NO, Work Comp.: NO, Hypothermia: NO, SSN: 493788699, ZIP CODE: 63121, KG WEIGHT: 72.1, HEIGHT: 182cm, PHONE: 314522-8730, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0716400175, PRIMARY: None Pcp, ATTENDING: Emergency Physicians, IBEX NUMBER: 20070613042537ADT. ~~~VIOUS VISIT ALLERGIES: No known drug allergies. ~L RISK: TIME: 422, Gender (Male). ASSESSMENT: 10 throat pain states burning pain, pt states cannot clear throat. pain is burning can still swallow and has no difficulty speaking. IMMUNIZATIONS: Immunizations up to date, Last tetanus shot received less than 10 years ago. TB SCREENING: Denies TB screening. DOMESTIC VIOLENCE: Not Applicable. \TTTAL SIGNS: BP 153/103, Pulse 72, Resp 20, Temp 99, Pain 10, 02 Sat 100, on rat Time 425.
PHYSICAL EXAM (05:28 RSMI) CONSTITUTIONAL: Vit~l signs reviewed, Alert and oriented X 3, Patient appears uncomfortable, Patient appears to be in pain. HEAD: Atraumatic, Normocephalic. EYES: Pupils equal and reactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal, Conjunctiva are normal. ENT: Ears normal to inspection, Nose examination normal, Oropharynx normal, Mouth normal to inspection. NECK: Normal ROM, No jugular venous distention, No meningeal signs, Cervical spine non-tender. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop.
000729
ABDOMEN: Abdomen is non-tender, No masses, Bowel sounds normal, No distension, No peritoneal signs. BACK: There is no CVA Tenderness, There is no tenderness to palpation, Normal inspection. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, No calf tenderness, Normal range of motion. NEURO: GCS is 15, No focal motor deficits, No focal sensory deficits, No cerebellar deficits. SKIN: Skin is warm and dry, No rash or induration. LYMPHATIC: No adenopathy in neck, No adenopathy in axillae, No adenopathy in groin. ~ ~CHIATRIC: Oriented X 3, Normal affect.
EKG INTERPRETATION (05:29 RSMI) MONITOR STRIP: Interpreted by ED Physician, Cardiac Monitor Strip interpretation is Normal Sinus, Rate is normal. LAB INTERPRETATION (05:29 RSMI)
T'~~ERPRETATION:
I reviewed the lab results.
02SAT INTERPRETATION (05:29 RSMI) 02SAT: 02 saturation reading 100%, 02 AMT: R.A., 02 Sat normal, None needed, Continuous Pulse Ox. RESULTS (05:29 RSMI) LAB: CBC W AUTO DIFF Jun 13 2007 05:26, WBC 6.0 1000/mm3 Ref Range (4.5-11.0), RBC 4.35 L lOX6 Ref Range (4.7-6.1), Hgb 11.8 L gm/dl Ref Range (13.0-18.0), Het 35.4 L % Ref Range (39.0-54.0), MCV 81.4 fl Ref Range (80.0-99.0), MCH 27.1 pg Ref Range (25.0-31.0), MCHC 33.3 gm/dl Ref Range (32.0-36.0), RDW 14.5 % Ref Range (11.5-14.5), Platelets 265 1000/mm3 Ref Range (130.0-400.0), Gran 55.3 % Ref Range (40.0-70.0), Lymph 33.9 % Ref Range (22.0-40.0), Mono 9.8 % Ref Range (2.0-10.0), Eos 0.3 % Ref Range (0.0-6.0), Baso 0.7 % Ref Range (0.0-3.0), Manual Diff Not Indicated , Absolute Neutrophil 3.32 1000/mm3.
000730
SSM DEPAUL EMERGENCY RECORD DOCTOR NOTES (05:30 RSMI) TEXT: pt stable recent ct reviewed will dc home wwith meds has ent appt in place. PATIENT STATUS: Patient has improved since admission. PATIENT PLAN: The patient will be discharged. DIAGNOSIS (05:30 RSMI) FINAL: PRIMARY: facial pain, ADDITIONAL: sore throat. DISPOSITION PATIENT (05:30 RSMI): X-RAY/CT Follow-up: NO, Critical Care: *None, Doctor Procedures: NO, Disposition: Home, Condition: Improved, Complaint: Burning Jaw,CanT Clear Throat. (06:23 AKOF): Remove from ER. Patient discharged. NOTES (05:30 RSMI): MEDICATION SERVICE (05:31 RSMI) Dilaudid: Order: Dilaudid : Img : IV Push POTENTIAL MODERATE INTERACTION Soma DOTENTIAL MODERATE INTERACTION Zyvox rdered: Wed Jun 13 2007 05:31 Ordered by: Robert Smith, MD Entered by: Robert Smith, MD Wed Jun 13 2007 05:31 Acknowledged by: Chantal Brooks, RN Wed Jun 13 2007 05:35 Documented as given by: Andra Kofahl, EMT-P Wed Jun 13 2007 05:51 MEDICATION, Time given: 0550, Given in amount and via route as prescribed, Amount given: Img, IV site I, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration. Phenergan: Order: Phenergan : 12.5mg : IV Push POTENTIAL MODERATE INTERACTION Dilaudid POTENTIAL MODERATE INTERACTION Soma Ordered: Wed Jun 13 2007 05:31 Ordered by: Robert Smith, MD Entered by: Robert Smith, MD Wed Jun 13 2007 05:31 Acknowledged by Chantal Brooks, RN Wed Jun 13 2007 05:35 Documented as g ven by: Andra Kofahl, EMT-P Wed Jun 13 2007 05:51 MEDICATION, T me given: 0550, Given in amount and via route as prescribed,
000731
Amount given: 12.5mg, IV site 1, Concentration confirmed prior to administration, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration. Rocephin: Order: Rocephin : 1 gram: Intravascular Repeat: no Ordered: Wed Jun 13 2007 05:31 irdered by: Robert Smith, MD ~ntered by: Robert Smith, MD Wed Jun 13 2007 05:31 Acknowledged by: Chantal Brooks, RN Wed Jun 13 2007 05:35 Documented as given by: Andra Kofahl, EMT-P Wed Jun 13 2007 05:51 MEDICATION, Time given: 0550, Given in amount and via route as prescribed, Amount given: 1 gm, IV site 1, Concentration conf~rmed prior to administration, Slowly, Drip/IVPB, Premixed, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration.
INSTRUCTION (05:32 RSMI) SORE THROAT. DTSCHARGE: :LOWUP: 2, YOUR PHYSICIAN, MAHENDRA P GUNAPOOTI MD 2865 NETHERTON DRIVE ST. LOUIS MO 63136 3147417171. SPECIAL: Follow-up with your doctor. PRESCRIPTION (05:32 RSMI) Dilaudid: Tablet: 2 mg : Oral=Quantity: ***1*** Unit: pill Route: Oral Schedule: As needed every four hours Dispense: ***20*** POTENTIAL MODERATE INTERACTION Soma POTENTIAL MODERATE INTERACTION Phenergan POTENTIAL MODERATE INTERACTION Zyvox. NURSING ASSESSMENT: NECK (05:47 CBRO) TIME ASSESSED: Patient was assessed at 0435. NOTES: PT WAS STABBING VICTIM TO FACE AND NECK IN APRIL. L SIDE OF FACE ENLARGED. HEALED SCARS ON L JAW, CHEEK, EAR. STATES HE WAS IN LAST WK FOR
000732
SAME PN/BURNING IN JAW AND THROAT WHEN SWALLOWING. HAS APPT WITH PCP JUNE 25. CONSTITUTIONAL: Patient arrives ambulatory with steady gait to treatment area, History obtained from patient, Patient is cooperative, Patient is alert and oriented x 3, Patient's mucous membranes are moist and pink, Patient is well-groomed, Patient appears in pain distress, Skin temperature is warm, Skin moisture is moist. NECK: No jugular venous distention noted, Patient complains of pain to left neck, Pain is muscular in nature, Pain described as burning, Pain is continuous, On a scale 0-10 patient rates pain as 10, Duration of pain: ALL WK, Patient complains of neck pain on passive range of motion, Patient complains of lateral tenderness, Deformity, Edema, Swelling. :K: Patient denies back pain, Patient is able to ambulate normally, Patient denies parasthesias, Patient denies CVA tenderness, Patient denies extremity weakness, No obvious signs of trauma noted to back, Patient has strong pulses to upper and lower extremities bilaterally. RESPIRATORY/CHEST: No complaint of pain, Breath sounds clear bilaterally, No acute respiratory distress, No intercostal retractions, No supraclavicular retractions, Equal chest expansion, No nasal flaring, No cough, Able to speak in full sentences. r~~ETY: Side rails up, Cart in lowest position . .'AL SIGNS: BP: 153, / 97, Pulse: 69, Resp: 16, Pain: 10, 02 sat: 98, RA, Time: 0445.
NURSING PROCEDURE: IV (05:15 AKOF) TIME: Procedure was performed at 0510, 20 gauge catheter inserted, into right Forearm, with 1 attempt, Saline lock established, Blood cultures drawn at time of placement, After placement no swelling noted at site, no drainage noted at site, 2x3 ensure dressing applied.
~uRSING
PROCEDURE: LAB DRAW (05:16 AKOF) TIME: Procedure was performed at 0510, Venipuncture performed/labs sent, Blood obtained from left AC and labs sent, No swelling, Dressing applied.
llURSING PROCEDURE: NURSE NOTES (05:47 CBRO) TIME: Time: 0450, DR SMITH AT BEDSIDE. NURSING PROCEDURE: DISCHARGE NOTE (06:10 AKOF) TIME: Procedure was performed at 0610, Patient discharged to home, Patient ambulates without assistance, Transported via friend/family driving, Accompanied by parent, Patient instructed not to drive home, IV discontinued with catheter intact. Dressing placed to IV site, Discharge instructions given to patient, Prescription given and additional instructions on side effects of same given, Above Person(s) verbalized
000733
understanding of discharge instructions and follow-up care, Patient treated and evaluated by physician, script for dilaudid provided to pt. VITAL SIGNS: BP: 146, / 96, Pulse: 68, Resp: 18, Pain: 2, 02 sat: 98, ra, Time: 0600.
IMAGING TREND SHEET (06:32 VMAY): Image captured from scanner. PROTOCOL (06:33 VMAY): Image captured from scanner. CT REPORT (06:34 VMAY): Image captured from scanner. (06:34 VMAY): Page 002 addedImage captured from scanner. CONSENT TO TREAT (06:35 VMAY): Image captured from scanner.
'UN
JITAL SIGNATURE (05:16 AKOF): Kofahl, EMT-P, Andra. (05:32 RSMI): Smith, MD, Robert. (05:52 AKOF): Kofahl, EMT-P, Andra. (06:11 AKOF): Kofahl, EMT-P, Andra. PATIENT DATA CHANGE (04:54): A08 63583044 by Interface, Payment: 90, Admitting Doctor: Pcp None, Attending Doctor: Robert B Smith. (04:56 RSMI): Attending changed from (none) to Robert Smith, MD. (04:57 CBRO): Primary Nurse changed from (none) to Chantal Brooks, RN. ,05:06): A08 63583176 by Interface, Admitting Doctor: Pcp None, Attending Doctor: Robert B Smith. (05:17): A08 63583297 by Interface, Payment: 95, Admitting Doctor: Pcp None, Attending Doctor: Robert B Smith. KEY: AKOF=Kofahl, EMT-P, Andra CBRO=Brooks, RN, Chantal RSMI=Smith, MD, Robert VMAY=Mayes; Vickie LBUR=Burkhart,RN, Linda
000734
SSM DEPAUL CLINICAL SUMMARY RECORD HPI BLANK pt to ed with c\o sorew throat jaw pain second trip this CHIEF COMPLAINT: week . HISTORIAN: History obtained from patient. TIME COURSE: Onset of symptoms reported as sudden, Onset was 1 weeks ago, Patient currently has symptoms, Complaint is constant. SEVERITY: Maximum severity is moderate, Currently symptoms are moderate. HISTORY MEDICAL HISTORY: which is not being treated, Stabbed in left face April 24th, 2007. History of hypertension, Patient is noncompliant with treatment, stab wound 1 face 4\24\07. r -rCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair. SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives alone, Denies smoking, Lives at home alone. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives alone. FAMILY HISTORY: Family history is not contributory to this case. Family history is not contributory to this case. ~~~ES: Stabbed in left face April 24th, 2007. Underwent surgery the week following . . . Nursing records reviewed. MEDICAL HISTORY: History of hypertension, which is being treated, stab wound 1 face. PSYCHIATRIC HISTORY: No previous psychiatric history. SURGICAL HISTORY: Patient's previous surgical history is not relevant to the case. SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives with others. ILY HISTORY: Family history is not contributory to this case. ~u~ES: Nursing records reviewed, Agree with nursing records. ROS CONSTITUTIONAL: Negative constitutional review of systems. EYES: Negative eye review of systems. ENT: Negative ENT review of systems. CARDIOVASCULAR: Negative cardiovascular review of systems. RESPIRATORY: Negative respiratory review of systems. GI: Negative gastrointestinal review of systems. GENITOURINARY MALE: Negative genitourinary review of systems. MUSCULOSKELETAL: Negative musculoskeletal review of systems. SKIN: Negative skin review of systems. NEUROLOGIC: Negative neurologic review of systems. ENDOCRINE: Negative endocrine review of systems.
000735
SSM DEPAUL CLINICAL SUMMARY RECORD HEMO/LYMPHATIC: Negative hemo/lymphatic review of systems. ALLERGIC/IMMUNOLOGIC: Negative Allergic review of systems. PSYCHIATRIC: Negative psychiatric review of systems. ALL SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above. PHYSICAL EXAM CONSTITUTIONAL: Vital signs reviewed, Alert and oriented X 3, Patient appears uncomfortable, Patient appears to be in pain. HEAD: Atraumatic, Normocephalic. EYES: Pupils equal and reactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal, Conjunctiva are normal. r ~: Ears normal to inspection, Nose examination normal, Oropharynx normal, Mouth normal to inspection. NECK: Normal ROM, No jugular venous distention, No meningeal signs, Cervical spine non-tender. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. ABDOMEN: Abdomen is non-tender, No masses, Bowel sounds normal, No distension, No peritoneal signs. K: There is no CVA Tenderness, There is no tenderness to palpation, Normal inspection. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, No calf tenderness, Normal range of motion. NEURO: GCS is 15, No focal motor deficits, No focal sensory deficits, No cerebellar deficits. N: Skin is warm and dry, No rash or induration. LxMPHATIC: No adenopathy in neck, No adenopathy in axillae, No adenopathy in groin. PSYCHIATRIC: Oriented X 3, Normal affect. DOCTOR NOTES TEXT: pt stable recent ct reviewed will dc home wwith meds has ent appt in place. PATIENT STATUS: Patient has improved since admission. PATIENT PLAN: The patient will be discharged. DIAGNOSIS FINAL: PRI~ARY: facial pain, ADDITIONAL: sore throat. DISPOSITION
000736
PATIENT: X-RAY/CT Follow-up: NO, Critical Care: *None, Doctor Procedures: NO, Disposition: Home, Condition: Improved, Complaint: Burning Jaw,CanT Clear Throat. Remove from ER. Patient discharged. NOTES:
MEDICATION SERVICE Dilaudid: Order: Dilaudid : Img : IV Push POTENTIAL MODERATE INTERACTION Soma POTENTIAL MODERATE INTERACTION Zyvox Ordered: Wed Jun 13 2007 05:31 Ordered by: Robert Smith, MD 'ntered by: Robert Smith, MD Wed Jun 13 2007 05:31 ,cknowledged by: Chantal Brooks, RN Wed Jun 13 2007 05:35 Documented as given by: Andra Kofahl, EMT-P Wed Jun 13 2007 05:51 MEDICATION, Time given: 0550, Given in amount and via route as prescribed, Amount given: Img, IV site I, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration; No swelling during administration; No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration. Phenergan: Order: Phenergan : 12.5mg : IV Push POTENTIAL MODERATE INTERACTION Dilaudid POTENTIAL MODERATE INTERACTION Soma Ordered: Wed Jun 13 2007 05:31 Ordered by: Robert Smith, MD ntered by: Robert Smith, MD Wed Jun 13 2007 05:31 Acknowledged by: Chantal Brooks, RN Wed Jun 13 2007 05:35 Documented as given by: Andra Kofahl, EMT-P Wed Jun 13 2007 05:51 MEDICATION, Time given: 0550, Given in amount and via route as prescribed, Amount given: 12.5mg, IV site I, Concentration confirmed prior to administration, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration. Rocephin: Order: Rocephin : 1 gram: Intravascular Repeat: no
000737
Ordered: wed Jun 13 2007 05:31 Ordered by: Robert Smith r MD Entered by: Robert Smith r MD Wed Jun 13 2007 05:31 Acknowledged by: Chantal Brooks r RN wed Jun 13 2007 05:35 Documented as given by: Andra Kofahl r EMT-P Wed Jun 13 2007 05:51 MEDICATION r Time given: 0550 r Given in amount and via route as prescribed r Amount given: 1 gmr IV site lr Concentration confirmed prior to administration r SlowlYr Drip/IVPB r Premixed r Catheter placement confirmed via flush prior to administration r IV site without signs or symptoms of infiltration during medication administration r No swelling during administration r No drainage during administration r IV flushed after administration r Correct patient r timer router dose and medication confirmed prior to administration r Patient advised of actions and side-effects prior to administration r Allergies confirmed and medications reviewed prior to administration.
PRESCRIPTION Dilaudid: Tablet: 2 mg : Oral=Quantity: ***1*** Unit: pill Route: Oral Schedule: As needed every four hours Dispense: ***20*** POTENTIAL MODERATE INTERACTION Soma ~OTENTIAL MODERATE INTERACTION Phenergan .'OTENTIAL MODERATE INTERACTION Zyvox. INSTRUCTION DISCHARGE: SORE THROAT. FOLLOWUP: 2r YOUR PHYSICIAN r MAHENDRA P GUNAPOOTI MD 2865 NETHERTON DRIVE ST. LOUIS MO 63136 3147417171. SPECIAL: Follow-up with your doctor.
000738
SSM DEPAUL RECORD
000739
II
SSM DEPAUL
EMERGENCY FLOW SHEET RECORD

Name: March, Phillip Age: 30Y
]ffi:
000748298
Acct: 0716400175
VITAL User AKOF CBRO LBUR
SIGNS Date/Time 06/13 06: 10 06/13 05 :47 06/13 04: 25
BP
146/96 153/97 153/103
PULSE 68
69 72
RESP 18 16 20
TEMP
PAIN 2 10
10
99
02 SAT 98 on ra 98 on RA 100 on ra
TIME 0600 0445 425

Name: March, Ph:L11ip Age: 30Y NR: 000748298 Acct: 0716400175
Page: 1
000740
Picis Imaging
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000742
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000745
DePaul Health Center Tue May 26, 2009 09:53 am Patient Detail Report Name: MARCH, PHILLIP H l ~ #/Acct #: 000748298/A0716400175 Loc: ER 06/13/07 Attending Dr-Svc: SMITH, ROBERT B - EMERGENCY Admitting Dr: EMERGENCY, PHYSICIANS 975969 16102 917259 In: 06/13/07 0518 ------------------Out: 06/13/07 0526 I CBC W AUTO DIFF I Coll Time: 06/13/07 0510 ------------------Order Phys: SMITH,ROBERT B *STAT*STAT*STAT* Result Name Result Ref Range Result Name WBC(1000/mm: RBC (10X6) : Hgb (gm/ dl) : Hct (%) : MCV (fl) : MCH (pg) : '-:(gm/dl) : (%) : 6.0 4.35 L 11.8 L 35.4 L 81. 4 27.1 33.3 14.5 4.5-11.0 4.7-6.1 l3.0-18.0 39.0-54.0 80.0-99.0 25.0-31.0 32.0-36.0 11.5-14.5 Platel(1000/mm: Gran(%) : Lymph (%) : Mono (%) : Eos (%) : Baso (%) : Manual Diff: Absolu(1000/mm: Page: 1
Spec: Blood Techs: V-AK TLMOZEE [A0716400175/3686223] Result Ref Range
265 l30.0-400.0 55.3 40.0-70.0 33.9 22.0-40.0 9.8 2.0-10.0 0.3 0.0-6.0 0.7 0.0-3.0 Not Indicated 3.32
Alexander Babich, M.D. .. ent Detail Report
MARCH, PHILLIP H 000748298/A0716400175 ER 06/13/07 (M-10/02/76) Dr. SMITH, ROBERT B
000746
DePaul Health Center Tue May 26, 2009 09:53 am Patient Detail Report MARCH, PHILLIP H Page: 1 000748298/ A07164 00175 Loc: ER 06/13/07 Attending Dr-Svc: SMITH,ROBERT B - EMERGENCY Admitting Dr: EMERGENCY, PHYSICIANS 975969 16102 917259 In: 06/13/07 0518 --------------------------------Spec: Blood Out: 06/13/07 0535 I COMPREHENSIVE METABOLIC PANEL I Techs: V-AK TTWILMT ColI Time: 06/13/07 0510--------------------------------Order Phys: SMITH,ROBERT B [A0716400175/3686223] *STAT*STAT*STAT* Result Name Result Reference Range
l _
Name: #/ Acct #:
BUN(mg/dl) : Sodium (mEq/L) : Potassium (mEq/L) : Chloride (mEq/L) : Glucose (mg/dl) : Creatinine (mg/dl) : l ISGOT (U/L) : Phos (U/L) : Calcium(mg/dl) : Bilirubin(mg/dl) : Albumin (gm/ dl) : Prot Total (gm/dl) : C02 (mEq/L) : ALT/SGPT GFR (ml/min/ 1. 73m2) :
14
138
(U/L) :
4.0 102 86 1.2 17 73 9.6 0.3 4.9 8.2 25 20 L 91.4
9.0-20.0 137-145 3.6-5.0 98.0-107.0 75-110 0.8-1.5 17.0-59.0 38.0-126.0 8.4-10.2 0.2-1.3 3.5-5.0 6.3-8.2 22.0-30.0 21.0-72.0
\lexander Babich, M.D.

~
ent Detail Report
MARCH, PHILLIP H 000748298/A0716400175 ER 06/13/07 (M-10/02/76) Dr. SMITH, ROBERT B
000747
SSM DEPAUL EMERGENCY RECORD HPI BLANK (16:53 MSAL) CHIEF COMPLAINT: Pain left side of the face. Originally stabbed in the face on April 24. Surgery for a fractured jaw. Receiving iv antibiotics via a PICC line. Increased pain over the past 2 days. The patient points to the r~us of the mandible and describes an area over the zygoma that sweats. HISTORIAN: History obtained from patient. TIME COURSE: Onset was 2 days ago, Patient currently has symptoms. SEVERITY: Maximum severity is moderate, Currently symptoms are moderate. KNOWN ALLERGIES No known drug allergies. JTORY PSYCHIATRIC HISTORY (14:37 CBLA): No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. SURGICAL HISTORY (14:37 CBLA): Jaw Repair, plate left jaw. facial repair Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. ~IAL HISTORY (14:37 CBLA): Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with f~i1y, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. FAMILY HISTORY (14:37 CBLA): F~i1y history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. F~i1y history is not contributory to this case. ~nTES (14:37 CBLA): Nursing records reviewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. ~lnDICAL HISTORY (14:39 CBLA): History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, . History of hypertension, jaw osteomyelitis. HAS PICC LINE FOR IV ANTIBIOTIC. (16:53 MSAL): History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, . History of hypertension, jaw osteomyelitis. HAS PICC LINE FOR IV ANTIBIOTIC. PSYCHIATRIC HISTORY (16:53 MSAL): No previous psychiatric history. SURGICAL HISTORY (16:54 MSAL): Jaw Repair, plate left jaw. facial repair. SOCIAL HISTORY (16:54 MSAL): Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with f~i1y, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. NOTES (16:54 MSAL): Nursing records reviewed.
000748
(16:53 MSAL) CONSTITUTIONAL: No fever, No chills. ENT: No sore throat. CARDIOVASCULAR: No chest pain. RESPIRATORY: No Cough, No SOB. GI: No abdominal pain. GENITOURINARY MALE: No dysuria. MUSCULOSKELETAL: No myalgias, No arthralgias. SKIN: No skin lesions. NEUROLOGIC: No headache. ALL SYSTEMS NEGATIVE: All relevant systems reviewed and all negative except for the above.
ROS TRIAGE (Mon Dec 10 2007 14:06 CJS)
COMPLAINT (Mon Dec 10 2007 14:06 CJS): COMPLAINT: Chest Tightness/Tooth Pn. PROVIDERS (Mon Dec 10 2007 14:06 CJS): TRIAGE NURSE: Crystal Sinovich, RN, CHARGE NURSE: Rebecca Phillips, RN. ADMISSION (Mon Dec 10 2007 14:06 CJS): URGENCY: ESI-4! TRANSPORT: Car! BED: WAITING. ~-~IENT (Mon Dec 10 2007 14:06 CJS): NAME: Phillip H March, AGE: 31, GENDER: Male, DOB: Sat Oct 02 1976, RACE: Black, Code: NO, Trauma: *NO, Work Comp.: NO, Heat Related: NO, SSN: 493788699, ZIP CODE: 63121, KG WEIGHT: 73.9 (est.), HEIGHT: 182cm, PHONE: 314387-8122, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0734400380, PRIMARY: Phillip G Zinser, ATTENDING: Emergency Physicians, IBEX NUMBER: 20071210140602ADT. PREVIOUS VISIT ALLERGIES (Mon Dec 10 2007 14:06 CJS): No known drug allergies. VITAL SIGNS (Mon Dec 10 2007 14:06 CJS): BP 150/89, Pulse 76, Resp 20, Temp 98.4, Pain 10/10, 02 Sat 100, on RA, Time 1405 . .L RISK (14:37 CBLA): TIME: 1436, Gender (Male), Get up and go test: Able to rise in a single movement, Score: 1. ASSESSMENT: (14:37 CBLA): 10, GCS Eye Opening: Spontaneously (4), GCS Verbal Response: Oriented/conversive (5), GCS Motor Response: Obeys comands(6), The GCS total is 15, STATES L SID E FACE AND JAW HURTING LAST 2 DAYS, WORSE THIS AM. IMMUNIZATIONS (14:37 CBLA): Last tetanus shot received less than 5 years ago. TB Screening (14:37 CBLA): Denies TB screening. Domestic Violence (14:37 CBLA): The presence of domestic violence is unknown. Educational/Cultural Barriers (14:37 CBLA): No educational/cultural barriers. TREATMENTS IN PROGRESS (14:37 CBLA): No treatment.
PHYSICAL EXAM (16:57 MSAL) CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3. HEAD: Atraumatic, Normocephalic.
000749
EYES: Pupils equal and reactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal, Conjunctiva are normal. ENT: Oropharynx normal, the patient is able to open his mouth 3 fingers. He states that this is not worse than usual. There is mild swelling over the left zygoma. No fluctuance. NECK: Normal ROM, No jugular venous distention, No meningeal signs, Cervical spine non-tender. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. ABDOMEN: Abdomen is non-tender, No masses, Bowel sounds normal, No distension, No peritoneal signs. , ~K: There is no CVA Tenderness, There is no tenderness to palpation, Normal inspection. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, No calf tenderness, Normal range of motion. NEDRO: GCS is 15, No focal motor deficits; No focal sensory deficits, No cerebellar deficits. PTrTN: Skin is warm and dry, No rash or induration . .PHATIC: No adenopathy in neck. PSYCHIATRIC: Oriented X 3, Normal affect.
02SAT INTERPRETATION (16:57 MSAL) 02SAT: 02 saturation reading 100%, 02 AMT: R.A., 02 Sat normal.
P1B:
RESULTS (17:59 MSAL) CBC W AUTO DIFF Dec 10 2007 17:41, WBC 5.4 1000/mm3 Ref Range (4.5-11.0), RBC 4.94 10X6 Ref Range (4.7-6.1), Hgb 13.6 gm/dl Ref Range (13.0-18.0), Hct 38.9 L % Ref Range (39.0-54.0), MCV 78.7 L fl Ref Range (80.0-99.0), MCH 27.5 pg Ref Range (25.0-31.0), MCHC 35.0 gm/dl Ref Range (32.0-36.0) I RDW 14.7 H % Ref Range (11.5-14.5), Platelets 225 1000/mm3 Ref Range (130.0-400.0), Gran 52.5 % Ref Range (40.0-70.0), Lymph 38.2 % Ref Range (22.0-40.0), Mono 8.1 % Ref Range (2.0-10.0), Eos 0.6 % Ref Range (0.0-6.0); Baso 0.6 % Ref Range (0.0-3.0), Manual Diff Not Indicated ,
000750
Absolute Neutrophil 2.85 1000/mm3.

DOCTOR NOTES (18:28 MSAL) TEXT: Nor.rnal WBC. The patient will be discharged to have a CT as an outpatient and to follow up with Dr Zinser. D/W: Discussed this case with Dr. Zinser, Infectious disese. DIAGNOSIS (18:32 MSAL) FINAL: PRIMARY: Dental pain, ADDITIONAL: DISPOSITION PATIENT (18:32 MSAL): X-RAY/CT Follow-up: NO, Critical Care: *None, Doctor Procedures: NO, Disposition: Home, Condition: Stable. ,19:20 DC1): Remove from ER. MEDICATION SERVICE Dilaudid (18:50 MSAL) Order: Dilaudid : 1 mg : IV Push Time: 1845 Notes: VO; given then discharge; verified; Phyl Becker RN Ordered: Mon Dec 10 2007 18:50 ~rdered by: Milton Sallis, MD ,ntered by: Phyl Becker, RN Mon Dec 10 2007 18:50 Documented as given by: Phyl Becker, RN Mon Dec 10 2007 18:52 MEDICATION, Time given: 1845, Given in amount and via route as prescribed, given through PICC; flushed w/ 10 ml NS after administration. Toradol (17:20 MSAL): Order: Toradol : 30 mg : Intravascular Time: 1700 Notes: per vo read back 0rdered: Mon Dec 10 2007 17:20 rdered by: Milton Sallis, MD Entered by: Leslie Robledo, EMT-P Mon Dec 10 2007 17:20 Documented as given by: Leslie Robledo, EMT-P Mon Dec 10 2007 17:21 MEDICATION, Time given: 1700, Given in amount and via route as prescribed, Amount given: 30mg, Medication administered via PICC, Site: right upper arm, IVP, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Administered by phyl becker, Patient in position of comfort, Side rails up, Cart in lowest position, Family at bedside.
000751
SSM DEPAUL EMERGENCY RECORD INSTRUCTION (19:08 MSAL)
FOLLOWUP: 1, PHILLIP G ZINSER MD 11125 DUNN ROAD SUITE 412 JENNINGS MO 63136 3143557997. SPECIAL: Facial pain. Please follow up with Dr Zinser and have a CT as ordered.
PRESCRIPTION Motrin (18:30 MSAL): Tablet: 800 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: Every 6-8 hours Dispense: ***30*** POTENTIAL SEVERE INTERACTION Toradol. Percocet 5/325 (18:30 MSAL): Tablet: 325 mg-5 mg : Oral=Quantity: ***1-2*** Unit: TAB Route: Oral Schedule: Every 4-6 hours Dispense: ***20***. 'rin (19:08 MSAL): Tablet: 800 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: Every 6-8 hours Dispense: ***30*** POTENTIAL SEVERE INTERACTION Toradol. Percocet 5/325 (19:08 MSAL): Tablet: 325 mg-5 mg : Oral=Quantity: ***1-2*** Unit: TAB Route: Oral Schedule: Every 4-6 hours Dispense: ***20***. NTJRSING ASSESSMENT: ENT (15:50 PBl)
TIME ASSESSED: Patient was assessed at 1545. DIAGNOSIS: facial swelling. :ES: Pt. had surgery on face at Barnes Hosp.; pain, swelling infection since; hered today for pain; +1 swelling to L side of face; speech clear; no choking or drooling. CONSTITUTIONAL: Patient arrives to treatment area ambulatory, Patient with steady gait, Patient appears comfortable, Patient is cooperative, Patient is alert and oriented x 3, Patient appears in no acute distress, Patient's skin is warm and dry, Patient's mucous membranes are moist and pink. pHT: No obvious abnormality to the ears, No obvious abnormality to the nose, No obvious abnormality to the mouth, No obvious abnormality to the oropharynx, Mucous membranes are pink/moist, No obvious foreign bodies noted to ears, nose or throat, Pain is continuous, On a scale 0-10 patient rates pain as 10. RESPIRATORY/CHEST: No complaint of pain, Breath sounds clear bilaterally, No acute respiratory distress, No intercostal retractions, No supraclavicular retractions, Equal chest expansion, No nasal flaring, No cough.
v-~SING
NURSING PROCEDURE: IV (18:15 PB1)
TIME: Procedure was performed at 1800, into from PICC; wasted 10ml; flushed with 10ms NS when done, After placement no swelling noted at site, no drainage noted at site, redraw of CMP.
NURSING PROCEDURE: NURSE NOTES (18:16 PB1) VITAL SIGNS: BP: 158, / 94, Pulse: 70, Resp: 16, Pain: 6.5.
000752
SSM DEPAUL EMERGENCY RECORD NURSING PROCEDURE: NURSE NOTES (19:07 PB1) TIME: Time: 1900, Report to Beth. NURSING PROCEDURE: DISCHARGE NOTE (19:19 DC1) TIME: Procedure was performed at 1917, Patient discharged to home, Patient ambulates without assistance, Transported via patient driving, Patient unaccompanied, Patient instructed not to drive home, Discharge instructions given to patient, Simple/moderate discharge teaching performed, Prescription given and additional instructions on side effects of same given, Above Person(s) verbalized understanding of discharge instructions and follow-up care. ~AL SIGNS: BP: 156, / 99, Pulse: 58, Resp: 18, Temp: 97.6, Pain: 4, 02 sat: 100%, ra, Time: 1919. NURSING PROCEDURE: INTAKE AND OUTPUT (19:20 DC1) TIME: Intake output performed, at 1919, Urine Output (ml) : void 2. SAFETY: Side rails up, Cart in lowest position, Call light within reach. IMAGING
(19:36 LDA): Image captured from scanner. [SENT TO TREAT (19:37 LDA): Image captured from scanner. LAB WORK (Wed Dec 19 2007 10:11 TLEI): Image captured from scanner.
r~0TOCOL
ADMIN DIGITAL SIGNATURE (15:51 PB1): Becker, RN, Phyl. (18:16 PB1): Becker, RN, Phyl. (18:32 MSAL): Sallis, MD, Milton. (18:52 PB1): Becker, RN, Phyl. :19:07 PB1): Becker, RN, Phyl. (19:20 DC1): Cox, RN, Delores. (Mon Dec 17 2007 22:03 MSAL): Sallis, MD, Milton. PATIENT DATA CHANGE (14:06): A08 70346720 by Interface, Payment: 90, Admitting Doctor: Zinser Phillip G, Attending Doctor: Physicians Emergency. (15:47 PB1): Primary Nurse changed from (none) to Phyl Becker, RN. (15:51): A08 70351396 by Interface, Admitting Doctor: Zinser Phillip G, Attending Doctor: Physicians Emergency. (15:52): A08 70351440 by Interface, Admitting Doctor: Zinser Phillip G, Attending Doctor: Physicians Emergency. (16:37 MSAL): Attending changed from (none) to Milton Sallis, MD.
KEY: CBLA=Blaesing, RN, Cherie
CJS=Sinovich, RN, Crystal
DC1=Cox, RN, Delores
000753
LDA=Arnold t Lisa MSAL=Sallis t MDt Milton TLEI=Naughton t Tracey
PB1=Becker t RN t Phyl
000754
SSM DEPAUL CLINICAL SUMMARY RECORD HPI BLANK CHIEF COMPLAINT: Pain left side of the face. Originally stabbed in the face on April 24. Surgery for a fractured jaw. Receiving iv antibiotics via a PICC line. Increased pain over the past 2 days. The patient points to the ramus of the mandible and describes an area over the zygoma that sweats. HISTORIAN: History obtained from patient. TIME COURSE: Onset was 2 days ago, Patient currently has symptoms. SEVERITY: Maximum severity is moderate, Currently symptoms are moderate. HISTORY PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. SOCIAL HISTORY: Denies smoking; Patient consumes alcohol socially; Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco. Denies alcohol abuse, Denies tobacco abuse . Family history is not contributory to this case. Family . ILY HISTORY: history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. NOTES: Nursing records reviewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. MEDICAL HISTORY: History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, . H~story of hypertension, jaw osteomyelitis. HAS PICC LINE FOR IV ANTIBIOTIC. History of hypertension, Patient is noncompliant with treatment! Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, . History of hypertension, jaw osteomyelitis. HAS PICC LINE FOR IV ANTIBIOTIC. PSYCHIATRIC HISTORY: No previous psychiatric history. SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair SOCIAL HISTORY: Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at horne with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. NOTES: Nursing records reviewed. ROS CONSTITUTIONAL: No fever, No chills.
000755
ENT: No sore throat. CARDIOVASCULAR: No chest pain. RESPIRATORY: No Cough, No SOB. GI: No abdominal pain. GENITOURINARY MALE: No dysuria. MUSCULOSKELETAL: No myalgias, No arthralgias. SKIN: No skin lesions. NEUROLOGIC: No headache. ALL SYSTEMS NEGATIVE: All relevant systems reviewed and all negative except for the above.
PHYSICAL EXAM lSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3 . . ill: Atraumatic, Normocephalic. EYES: Pupils equal and reactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal, Conjunctiva are normal. ENT: Oropharynx normal, the patient is able to open his mouth 3 fingers. He states that this is not worse than usual. There is mild swelling over the left zygoma. No fluctuance . . NECK: Normal ROM, No jugular venous distention, No meningeal signs, Cervical spine non-tender. ,PIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. ABDOMEN: Abdomen is non-tender, No masses, Bowel sounds normal, No distension, No peritoneal signs. BACK: There is no CVA Tenderness, There is no tenderness to palpation, Normal inspection. lTDPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LvWER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, No calf tenderness, Normal range of motion. NEURO: GCS is 15, No focal motor deficits, No focal sensory deficits, No cerebellar deficits. SKIN: Skin is warm and dry, No rash or induration. LYMPHATIC: No adenopathy in neck. PSYCHIATRIC: Oriented X 3, Normal affect. DOCTOR NOTES TEXT: Normal WBC. The patient will be discharged to have a CT as an outpatient and to follow up with Dr Zinser. D/W: Discussed this case with Dr. Zinser, Infectious disese. DIAGNOSIS
000756
FINAL: PRIMARY: Dental pain, ADDITIONAL:

DISPOSITION PATIENT: X-RAY/CT Follow-up: NO, Critical Care: *None, Doctor Procedures: NO, Disposition: Home, Condition: Stable. Remove from ER. MEDICATION SERVICE Dilaudid: Order: Dilaudid : 1 mg : IV Push Time: 1845 Notes: VOi given then dischargei verifiedi Phyl Becker RN Ordered: Mon Dec 10 2007 18:50 Irdered by: Milton Sallis, MD ~ntered by: Phyl Becker, RN Mon Dec 10 2007 18:50 Documented as given by: Phyl Becker, RN Mon Dec 10 2007 18:52 MEDICATION, Time given: 1845, Given in amount and via route as prescribed, given through PICCi flushed w/ 10 ml NS after administration. Toradol: Order: Toradol : 30 mg : Intravascular Time: 1700 Notes: per vo read back ~rdered: Mon Dec 10 2007 17:20 ;rdered by: Milton Sallis, MD Entered by: Leslie Robledo, EMT-P Mon Dec 10 2007 17:20 Documented as given by: Leslie Robledo, EMT-P Mon Dec 10 2007 17:21 MEDICATION, Time given: 1700, Given in amount and via route as prescribed, Amount given: 30mg, Medication administered via PICC, Site: right upper arm, IVP, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration; Allergies confirmed and medications reviewed prior to administration, Administered by phyl becker, Patient in position of comfort, Side rails up, Cart in lowest position, Family at bedside. PRESCRIPTION Motrin: Tablet: 800 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: Every 6-8 hours Dispense: ***30*** POTENTIAL SEVERE INTERACTION Toradol. Percocet 5/325: Tablet: 325 mg-5 mg : Oral=Quantity: ***1-2*** Unit: TAB Route: Oral Schedule: Every 4-6 hours Dispense: ***20***. Motrin: Tablet: 800 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: Every 6-8 hours Dispense: ***30***
000757
POTENTIAL SEVERE INTERACTION Toradol. Percocet 5/325: Tablet: 325 mg-5 mg : Oral=Quantity: ***1-2*** Unit: TAB Route: Oral Schedule: Every 4-6 hours Dispense: ***20***.
INSTRUCTION FOLLOWUP: 1, PHILLIP G ZINSER MD 11125 DUNN ROAD SUITE 412 JENNINGS MO 63136 3143557997. SPECIAL: Facial pain. Please follow up with Dr Zinser and have a CT as ordered.
000758
SSM DEPAUL RECORD
000759
II
Name: March, Phillip VITAL User DCl PBl CJS SIGNS Date/Time 12/10 19:19 12/10 18:16 12/10 14:: 06 Age: 31Y MR:
0007~~8298
SSM DEPAUL EMERGENCY FLOW SHEET RECORD Acct: 0734400380
BP 156/99 158/94 150/89
PULSE 58 70 76
RESP 18 16 20
TEMP 97.6 98.4
PAIN 4 6.5 10/10
02 SAT 100% on ra 100 on RA
TIME 1919 1405

Name: March, Phillip Age: 31Y MR.: 0007~8298 Acct: 0734400380 Prepared: Tue May 26 09:07:31 2009 by Stephanie Manetz Page: 1
000760
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000762
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000763
DePaul Health Center Tue May 26/ 2009 09:51 am Patient Detail Report MARCH/PHILLIP H Page: 1 000748298/A0734400380 Lac: ER 12/10/07 Attending Dr-Svc: SALLIS/MILTON - EMERGENCY Admitting Dr: EMERGENCY/PHYSICIANS 805137 16102 977240 903572 In: 12/10/07 1812 --------------------------------Spec: Blood Out: 12/10/07 1857 I COMPREHENSIVE METABOLIC PANEL I Techs: VNON TDARTHV Call Time: 12/10/07 1811--------------------------------Order Phys: MARTIN/ALAN J [A0734400380/3974782) *STAT*STAT*STAT* Result Reference Range Result Name
r
Name: #/Acct #:
BUN (mg/dl) : Sodium(mEq/L) Potassium(mEq/L) : Chloride (mEq/L) : Glucose (mg/dl) : Creatinine (mg/dl) : T -/SGOT(U/L): Phos(U/L) : Calcium(mg/dl) : Bilirubin(mg/dl) : Albumin (gm/dl) : Prot Total (gm/dl) : C02 (mEq/L) : ALT/SGPT GFR(ml/min/1.73m2) :
13
138 4.7 101 78 0.8 27 74 9.0 0.6 4.8 7.4 30 (U/L) :

9 L
9.0-20.0 137-145 3.6-5.0 98.0-107.0 75-110 0.8-1.5 17.0-59.0 38.0-126.0 8.4-10.2 0.2-1.3 3.5-5.0 6.3-8.2 22.0-30.0 21.0-72.0
145.0
Alexander Babich/ M.D.

~ent
Detail Report
MARCH/PHILLIP H 000748298/A0734400380 ER 12/10/07 (M-10/02/76) Dr. SALLIS/MILTON
000764
DePaul Health Center Tue May 26/ 2009 09:52 am Patient Detail Report MARCH/PHILLIP H Name: ; #/Acct #: 000748298/A0734400380 Loc: ER 12/10/07 Attending Dr-Svc: SALLIS/MILTON - EMERGENCY EMERGENCY/PHYSICIANS Admitting Dr: 805137 16102 977240 903572 CULTURE BLOOD Specimen: Blood (M)-2 ColI. Time: 12/10/07 1700 In at: 12/10/07 1713 Ordering Phys: MARTIN/ALAN J
F
Page:
Acct #: A0734400380 Techs VILL Techs: TSMH
Out at: 12/19/07 0748
Final
[3974543]
************CULTURE************ **PANIC REPORT** called to/time DPH/ER-chrg.Julie/RBR@1950(fks) and faxed to DPH/ER@344-6697 aerobic bottle time to detection @20.8 hours
~LLUS
SPECIES not antracis ONLY 1 set drawn Growth from 1 of 2 bottles id confirmed by State lab Performed by: SSM Health Care Lab - SMHC 6420 Clayton Road St Louis/ Mo 63117 End of Report - OS/26/09 09:52
Alexander Babich/ M.D. ___ ent Detail Report
000765
DePaul Health Center Tue May 26/ 2009 09:52 am Patient Detail Report MARCH/PHILLIP H 000748298/A0734400380 Loc: ER 12/10/07 Attending Dr-Svc: SALLIS/MILTON - EMERGENCY Admitting Dr: EMERGENCY/PHYSICIANS 805137 16102 977240 903572 In: 12/10/07 1713 ------------------Out: 12/10/07 1741 I CBC W AUTO DIFF I Coll Time: 12/10/07 1700 ------------------Order Phys: MARTIN/ALAN J *STAT*STAT*STAT* Result Ref Range Result Name Result Name
l _ #/Acct #:
Name:
Page:
Spec: Blood Techs: V-PB TTTRIMC [A0734400380/3974544] Result Ref Range
WBC(1000/mm: RBC (10X6) : Hgb (gm/dl) Hct (%) : MCV (fl) : MCH (pg) : f'I'--r; (gm/ dl) :
1
\%) :
5.4 4.94 13.6 38.9 L 78.7 L 27.5 35.0 14.7 H
4.5-11.0 4.7-6.1 13.0-18.0 39.0-54.0 80.0-99.0 25.0-31.0 32.0-36.0 11.5-14.5
Platel(1000/mm: Gran (%) : Lymph(%) : Mono (%) : Eos (%) : Baso(%): Manual Diff : Absolu(1000/mm:
225 130.0-400.0 52.5 40.0-70.0 38.2 22.0-40.0 8.1 2.0-10.0 0.6 0.0-6.0 0.6 0.0-3.0 Not Indicated 2.85
Alexander Babich/ M.D. . ent Detail Report
000766
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING MARCH,PHILLIP H Sex: M Med Rec # A000748298 ACCT: A0736000302 Pt Location: *ER MARTIN,ALAN J 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044 Check-In # Order Diagnosis 1058370 Ord Diag: 526.9-JAW DISEASE NOS
~e:
DOB: 10/02/76 Age: 32Y Date: 12/26/07 2035
CT FACIAL BONES WITHOUT CONTRAST from 12/26/2007 INDICATION: Left facial swelling.
COMPARISON: 9/17/2007 CT examination of the facial bones was performed using axial imaging. Coronal reconstructions were obtained. Examination redemonstrates a healed fracture of the left submandibular ramus. It appears that there was previously hardware within the left mandible which has been removed. There is extensive calcification of the stylohyoid ligaments bilaterally. On the left side, there is an articulation at the junction of the ligament and the styloid process. There is minimal mucosal thickening in the floor of the left maxillary antrum. There is a 7 mm polyp in the anterior sphenoid sinus. The paranasal sinuses are otherwise clear. IMPRESSION: 1. No evidence of acute injury. 2. CT of the facial bones is unchanged from the previous study. Read By- JAMES G STEWART M.D. Released By- JAMES G STEWART M.D. Released Date Time- 12/26/07 2126 Transcriptionist- JGS M.D.
ADM: EMERGENCY,PHYSICIANS REF: PCP: ZINSER, PHILLIP G
ATT: EMERGENCY,PHYSICIANS CON: SCP:
FINAL DUPLICATE
Page
000767
SSM DEPAUL EMERGENCY RECORD HPI HAND (Wed Oct 29 2008 01:06 JEHR) CHIEF COMPLAINT: Patient presents for the evaluation of right, hand injury, hand pain. HISTORIAN: History obtained from patient. MECHANISM: Complaint occurred by punched someone 10/10/08- diagnosed with boxer's fracture- seen at ortho clinic yesterday. states he was not given a prescription for analgesics because the orthopedist left the office before he could make request. OCCURRED: Onset was 10/10/08, Patient currently has symptoms. LOCATION: Right, 5th digit, metacarpal phalengeal joint, Dominant Hand: Right. QUALITY: Patient describes pain as sharp, Patient describes pain as stabbing. ; TERITY: Maximum severity is moderate, Currently symptoms are moderate. ~IEVED BY: Patient's condition relieved by percocet and ibuprofen effective in past. EXACERBATED BY: Patient's condition exacerbated by nothing. ASSOCIATED WITH: Patient denies clavicle pain, Patient denies shoulder pain, Patient denies elbow pain, Patient denies wrist pain, Patient states hand pain is present, to right, Patient denies finger pain, Patient denies distal neuro c/o, Patient denies proximal injury, Patient denies distal injury. ES: pt is concerned that his cast does not appropriately immobilize fracture site. splint extends past 5th MCP. KNOWN ALLERGIES No known drug allergies. HISTORY MRDICAL HISTORY (Tue Oct 28 2008 22:40 KGAN): Stabbed in left face April 28th, 2007. jaw osteomyelitis. see RN notes. ~wfCHIATRIC HISTORY (Tue Oct 28 2008 22:40 KGAN); No previous psychiatric history. No previous psychiatric history. No previous psychiatric history.
SURGICAL HISTORY (Tue Oct 28 2008 22:40 KGAN): Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. Jaw Repair, plate left jaw. facial repair . . L jaw surgery, harware removal, chronic osteomyelitis. see RN notes. SOCIAL HISTORY (Tue Oct 28 2008 22:40 KGAN): Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Patient consumes alcohol socially, Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies smoking, Patient consumes
000768
SSM DEPAUL EMERGENCY RECORD alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. FAMILY HISTORY (Tue Oct 28 2008 22:40 KGAN): Family history is not contributory to this case, Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. NOTES (Tue Oct 28 2008 22:40 KGAN): Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. Nursing records reviewed. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, PMHx: Left mandible osteomyelitis. MEDS: Merrem and Clindamycin IV. See nursing notes. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, Agree with nursing records. Wed Oct 29 2008 01:06 JEHR): Nursing records reviewed, Agree with nursing records. ROS (Wed Oct 29 2008 01:06 JEHR) CONSTITUTIONAL: Negative constitutional review of systems. EYES: Negative eye review of systems. ENT: Negative ENT review of systems. CARDIOVASCULAR: Negative cardiovascular review of systems. PIRATORY: Negative respiratory review of systems. ADL SYSTEMS NEGATIVE: All relevant systems reviewed and all negative except for the above. TRIAGE (Tue Oct 28 2008 22:40 KGAN) COMPLAINT: Right Arm Pain. PROVIDERS: TRIAGE NURSE; Kimberly Gan, BSN, CHARGE NURSE: Julie Sanchez, RN. ADMISSION: URGENCY: ESI-4, TRANSPORT: Car, BED: WTG-RM. PATIENT: NAME: Phillip H March, AGE: 32, GENDER: Male, DOB: Sat Oct 02 1976, RACE: Black, Code: NO, Trauma: *NO, Work Comp.: NO, Heat Related: NO, SSN: 493788699, ZIP CODE: 63121, KG WEIGHT: 74.8, HEIGHT: 182cm, PHONE: 314393-1241, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0830200521, PRIMARY: None Pcp, ATTENDING: Emergency Physicians, IBEX NUMBER: 20081028224052ADT. PREVIOUS VISIT ALLERGIES: No known drug allergies.
000769
NOTES:Total score is: 0, Confusion (3), No Increased Risks patient, kjg. ASSESSMENT: Pain level 7, using numeric pain scoring., GCS Eye Opening: Spontaneously (4), GCS Verbal Response: Oriented/conversive (5), GCS Motor Response: Obeys comands(6) , The GCS total is 15, pt presents to ED for c/o R arm/hand pain. pt states he injured hand approx 2 wks ago, dx w/ fx. hard cast placed at Barnes on 10/27/2008. pt c/o incresing pain, pt not given Rx for pain meds. IMMUNIZATIONS: Immunizations up to date, Unknown when last tetanus shot recived. TB SCREENING: Denies TB screening. DOMESTIC VIOLENCE: No domestic violence. EDUCATIONAL/CULTURAL BARRIERS: No educational/cultural barriers. 'AL SIGNS: BP 149/96, Pulse 65, Resp 18, Temp 98.4, Pain 7, 02 Sat 98, on ra, Time 2240.
PHYSICAL EXAM (Wed Oct 29 2008 01:08 JEHR) CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3. NECK: Normal ROM, No jugular venous distention, No meningeal signs, Cervical spine non-tender.
RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. ,DIOVASCULAR: RRR, No murmurs, No rub, No gallop. BACK: There is no CVA Tenderness, There is no tenderness to palpation, Normal inspection. UPPER EXTREMITY: cast appropriately placed. sensations intact thru-out. 5/5 ms strengths thru-out, Hand evaluation shows, RIGHT to have, no ecchymosis, no swelling, no tenderness to palpation, full range of motion, capillary refill less than 2 seconds, distal motor intact, distal senory intact, rue cast in place, Left hand unaffected. ER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, No calf tenderness, Normal range of motion. SKIN: Skin is warm and dry, No rash or induration. PSYCHIATRIC: Oriented X 3, Normal affect.
02SAT INTERPRETATION (Wed Oct 29 2008 01:08 JEHR)
02SAT:
02 saturation reading 98%; 02 AMT: R.A., 02 Sat normal, None needed.
DIAGNOSIS
(Wed Oct 29 2008 01:12 JEHR) FINAL: PRIMARY: right boxers fracture, ADDITIONAL: PATIENT (Wed Oct 29 2008 01:12 JEHR); X-RAY/CT Follow-up: YES, Critical Care: *None, Doctor Procedures: NO, Disposition: Home, Condition: Stable. (Wed Oct 29 2008 02:26 JWHI): Remove from ER.
DISPOSITION
000770
SSM DEPAUL EMERGENCY RECORD MEDICATION SERVICE
(Wed Oct 29 2008 01:15 JEHR) Ultram: Order: Ultram : 1tablet : By Mouth Ordered: Wed Oct 29 2008 01:15 Ordered by: Jennifer Ehret Pa-C Entered by: Jennifer Ehret Pa-C Wed Oct 29 2008 01:15 Documented as given by: Jeannette White, RN Wed Oct 29 2008 01:24 MEDICATION, Time given: 0123, Given in amount and via route as prescribed.
INSTRUCTION (Wed Oct 29 2008 01:14 JEHR) BOXERS FRACTURE. DISCHARGE: FOLLOWUP: 5, WILLIAM C SCHROER MD 12266 DEPAUL DRIVE SUITE 220 BRIDGETON MO 63044 3142913399, JOHN C MURPHY HLTH CLINIC MD 6065 HELEN AVE BERKELEY MO 63134 3145226410, NORTH CENTRAL COMM CLINIC MD 4000 JENNINGS STATION RD NORMANDY MO 63121 3146797800, PEOPLES HEALTH CNT CLINIC MD 5701 DELMAR ST LOUIS MO 63112 3143677848, PINE LAWN HLTH CLINIC MD 6150 NATURAL BRIDGE ST LOUIS MO 63120 3143894700. SPECIAL: ELEVATE HAND. KEEP CAST IN PLACE. RETURN TO ER IF CAST BECOMES COMPROMISED; LOSS OF SENSATION OR MOTOR FlCTION OR IF YOU FEEL WORSE IN GENERAL. PLEASE FOLLOW-UP WITH OUR ORTHO GROUP IF YOU WANT A SECOND OPINION OR SEE YOUR ORTHOPEDIST TO FURTHER DISCUSS YOUR CARE lease see special instructions Follow-up with your doctor. PRESCRIPTION (Wed Oct 29 2008 01:11 JEHR) Ultram: Tablet: 50 mg : Oral=Quantity: ***1-2*** Unit: tab Route: Oral Schedule: As needed every six hours Dispense: ***15***. NOTES: Take as needed for pains . .BING ASSESSMENT: EXTREMITY UPPER (Wed Oct 29 2008 01:48 JWHI)
ASSESSED: Patient was assessed at 0100. NOTES: HAS RIGHT SHORT ARM CAST AND IS REQUESTING THAT IT BE REMOVED. STATES
CAST WAS APPLIED YESTERDAY BUT HE DOES NOT LIKE THE WAY IT FEELS. CIRCULATION INTACT. NO NUMBNESS OR TINGLING.
l~ME
CONSTITUTIONAL: Patient arrives ambulatory with steady gait to treatment area, History obtained from patient, Patient appears comfortable, Patient is cooperative, Patient is alert and oriented x 3, Patient appears in no acute distress, Patient's skin is warm and dry, Patient's mucous membranes are moist and pink. LEFT UPPER EXTREMITY: No complaint of pain. RIGHT UPPER EXTREMITY: Brisk capillary refill, Sensation intact, No numbness/tingling; Area of assessment is 5th metacarpal, Pain described as
aching, On a scale 0-10 patient rates pain as 5.
000771
SSM DEPAUL EMERGENCY RECORD NURSING PROCEDURE: BLANK CHART (Wed Oct 29 2008 01:20 NLON) TIME: Procedure was performed at 0100, rt hand xray. NURSING PROCEDURE: DISCHARGE NOTE (Wed Oct 29 2008 01:49 JWHI) TIME: Procedure was performed at 0145, Patient discharged to home, Patient ambulates without assistance, Transported via patient driving, Patient unaccompanied, Discharge instructions given to patient, Simple/moderate discharge teaching performed, Above Person(s) verbalized understanding of discharge instructions and follow-up care. VITAL SIGNS: BP: 149, / 97, Pulse: 58, Resp: 18, 02 sat: 100, RA, Time: 0144. IMAGING (Wed Oct 29 2008 03:43 CLG) ~ PROTOCOL: Image captured from scanner. L ,SENT TO TREAT: Image captured from scanner. ADMIN DIGITAL SIGNATURE (22:42 KGAN): Gan, BSN, Kimberly. (Wed Oct 29 2008 01:08 JEHR): Ehret Pa-C, Jennifer. (Wed Oct 29 2008 01:12 JEHR); Ehret Pa-C; Jennifer. (Sun Nov 09 2008 21:28 MSAL): Sallis, MD, Milton. P~~IENT DATA CHANGE (Wed Oct 29 2008 00:35 JEHR): Dr. Extender changed from (none) to Jennifer Ehret Pa-C. (Wed Oct 29 2008 00:35 JEHR): Attending: Milton Sallis, MD. (Wed Oct 29 2008 00:49): A08 82631072 by Interface, Payment: 90, Admitting Doctor: Pcp None, Attending Doctor: Milton Sallis. (Wed Oct 29 2008 01:25): A08 82631586 by Interface, Admitting Doctor: Pcp None, Attending Doctor: Milton Sallis.
KRY: LG=Graves, Cynthia JEHR=Ehret Pa-C, Jennifer JWHI=White, RN, Jeannette KGAN=Gan, BSN, Kimberly MSAL=Sallis, MD, Milton NLON=Long, RT, Nina
000772
SSM DEPAUL CLINICAL SUMMARY RECORD HPI HAND CHIEF COMPLAINT: Patient presents for the evaluation of right, hand injury, hand pain. HISTORIAN: History obtained from patient. MECHANISM: Complaint occurred by punched someone 10/10/08- diagnosed with boxer's fracture- seen at ortho clinic yesterday. states he was not given a prescription for analgesics because the orthopedist left the office before he could make request. OCCURRED: Onset was 10/10/08, Patient currently has symptoms. LOCATION: Right, 5th digit, metacarpal phalengeal joint, Dominant Hand: Right. QUALITY: Patient describes pain as sharp, Patient describes pain as stabbing. ? 'ERITY: Maximum severity is moderate, Currently symptoms are moderate. h ~IEVED BY: Patient's condition relieved by percocet and ibuprofen effective in past. EXACERBATED BY: Patient's condition exacerbated by nothing. ASSOCIATED WITH: Patient denies. clavicle pain, Patient denies shoulder pain, Patient denies elbow pain, Patient denies wrist pain, Patient states hand pain is present, to right, Patient denies finger pain, Patient denies distal neuro c/o, Patient denies proximal injury, Patient denies distal injury. ES: pt is concerned that his cast does not appropriately immobilize fracture site. splint extends past 5th MCP. HISTORY Stabbed in left face April 28th, 2007. jaw osteomyelitis. MEDICAL HISTORY: see RN notes. PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. ~ICAL HISTORY: Jaw Repair, plate left jaw. facial repair. Patientis previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. Jaw Repair, plate left jaw. facial repair . . L jaw surgery, harware removal, chronic osteomyelitis. see RN notes. SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Patient consumes alcohol socially, Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse.
000773
FAMILY HISTORY: Family history is not contributory to this case, Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. NOTES: Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. Nursing records reviewed. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, PMHx: Left mandible osteomyelitis. ":EDS: Merrem and Clindamycin IV. See nursing notes. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, Agree with nursing records.
ROS
Negative constitutional review of systems . .S: Negative eye review of systems. ENT: Negative ENT review of systems. CARDIOVASCULAR: Negative cardiovascular review of systems. RESPIRATORY: Negative respiratory review of systems. ALL SYSTEMS NEGATIVE: All relevant systems reviewed and all negative except for the above.
~~~STITUTIONAL:
PHYSICAL EY...AM 'STITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3. ~bCK: Normal ROM, No jugular venous distention, No meningeal signs, Cervical spine non-tender. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. BACK: There is no CVA Tenderness, There is no tenderness to palpation, Normal inspection. UPPER EXTREMITY: cast appropriately placed. sensations intact thru-out. 5/5 ms strengths thru-out, Hand evaluation shows, RIGHT to have, no ecchymosis, no swelling, no tenderness to palpation, full range of motion, capillary refill less than 2 seconds, distal motor intact, distal senory intact, rue cast in place, Left hand unaffected. LOWER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, No calf tenderness, Normal range of motion.
000774
SKIN: Skin is warm and dry, No rash or induration. PSYCHIATRIC: Oriented X 3, Normal affect.
DIAGNOSIS FINAL: PRIMARY: right boxers fracture, ADDITIONAL:
DISPOSITION PATIENT: X-RAY/CT Follow-up: YES, Critical Care: *None, Doctor Procedures: NO, Disposition: Home, Condition: Stable. Remove from ER. MEDICATION SERVICE ram: Order: Ultram : 1tablet : By Mouth Jrdered: Wed Oct 29 2008 01:15 Ordered by: Jennifer Ehret Pa-C Entered by: Jennifer Ehret Pa-C Wed Oct 29 2008 01:15 Documented as given by: Jeannette White, RN Wed Oct 29 2008 01:24 MEDICATION, Time given: 0123, Given in amount and via route as prescribed. PRESCRIPTION r--Lram: Tablet: 50 mg : Oral=Quantity: ***1-2*** Unit: tab Route: Oral Schedule: As needed every six hours Dispense: ***15***. NOTES: Take as needed for pains. INSTRUCTION DISCHARGE: BOXERS FRACTURE. FOLLOWUP: 5, WILLIAM C SCHROER MD 12266 DEPAUL DRIVE SUITE 220 BRIDGETON MO 63044 3142913399, JOHN C MURPHY HLTH CLINIC MD 6065 HELEN AVE BERKELEY MO 63134 3145226410, NORTH CENTRAL COMM CLINIC MD 4000 JENNINGS STATION RD NORMANDY MO 63121 3146797800, PEOPLES HEALTH CNT CLINIC MD 5701 DELMAR ST LOUIS MO 63112 3143677848, PINE LAWN HLTH CLINIC MD 6150 NATURAL BRIDGE ST LOUIS MO 63120 3143894700. SPECIAL: ELEVATE HAND. KEEP CAST IN PLACE. RETURN TO ER IF CAST BECOMES COMPROMISED, LOSS OF SENSATION OR MOTOR FUNCTION OR IF YOU FEEL WORSE IN GENERAL. PLEASE FOLLOW-UP WITH OUR ORTHO GROUP IF YOU WANT A SECOND OPINION OR SEE YOUR ORTHOPEDIST TO FURTHER DISCUSS YOUR CARE Please see special instructions Follow-up with your doctor.
000775
SSM DEPAUL RECORD
000776
II
SSM DEPAUL EMERGENCY FLOW SHEET RECORD Name: March, Phillip VITAL SIGNS Age: 32Y MR: 000748298 Acct: 0830200521
User JWHI
KGAN
Date/Time 10/29 01:49 10/28 22:40
BP 149/97 149/96
PULSE 58 65
RESP 18 18
TEMP
98.4
PAIN
7
02 SAT 100 on RA 98 on ra
TIME 0144 2240

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000777
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000778
Picis Imaging
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000779
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton/ MO 63044 DIAGNOSTIC IMAGING .me: MARCH/ PHILLIP H DOB: 10/02/76 Age: 32Y Date: 10/29/08 0119 Sex: M Med Rec # A000748298 ACCT: A0830200521 Pt Location: *ERQ SALLIS/MILTON 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044 Check-In # Order Diagnosis 1189973 Ord Diag: 959.4-HAND INJURY NOS
Exam XR HAND MIN 3 VIEWS*R
RIGHT HAND THREE VIEWS INDICATION: Right hand pain/ fifth metacarpal fracture 2 weeks ago which was casted at Barnes Hospital. FINDINGS: Three views of the right hand show fracture involving the distal fifth metacarpal with volar displacement as well as some comminution. The fiberglass cast superimposes the hand. The remainder of the bony structures are unremarkable. IMPRESSION CASTED DISTAL FIFTH METACARPAL FRACTURE Read By- MATTHEW W STADNYK M.D. Released By- MATTHEW W STADNYK M.D. Released Date Time- 10/29/08 1007 Transcriptionist- PMN ADM: EMERGENCY/PHYSICIANS REF: PCP: PCP/NONE ATT: SALLIS/MILTON CON: SCP:
FINAL DUPLICATE
Page
000780
SSM DEPAUL EMERGENCY RECORD HPI BLANK (12:01 AWAH) CHIEF COMPLAINT: cc: L jaw pain hpi: sip L jaw stabbing early last year, tx'ed by Barnes OMF, has had chronic pain since as well as osteomyelitis, last admit at Depaul 12/07 for IV abx. pt states was seen at Barnes approx 1 month ago and SLU approx 1 week ago (had CT with contrast showing "chronic osteomyelitis", finished zithromax, however states did not get pain meds. pt states he pulled out his own PICC line approx 1 month ago. states he is an investigator and has to leave town alot, has misses flu appt's with Barnes OMF as well as ID Dr Zinser. pt claims to have an appt with an internal medicine doctor next month, however cannot supply name. pt c/o L jaw pain. no fever, chills, sore throat, dysphagia or SOB. no DM. T 'TORIAN: History obtained from patient. ,E COURSE: Onset was as above. SEVERITY: Currently symptoms are moderate. KNOWN ALLERGIES No known drug allergies. HISTORY HISTORY (Thu Feb 21 2008 10:57 CBLA): History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, History of hypertension, jaw osteomyelitis. HAS PICC LINE FOR IV ANTIBIOTIC. History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, . History of hypertension, jaw osteomyelitis. HAS PICC LINE FOR IV ANTIBIOTIC. P~YCHIATRIC HISTORY (Thu Feb 21 2008 10:57 CBLA): No p~evious psychiatric history. No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. . No previous psychiatric history. SURGICAL HISTORY (Thu Feb 21 2008 10:57 CBLA): Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. Jaw Repair, plate left jaw. facial repair . SOCIAL HISTORY (Thu Feb 21 2008 10:57 CBLA): Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco Denies alcohol abuse, Denies tobacco abuse. FAMILY HISTORY (Thu Feb 21 2008 10:57 CBLA): Family history is not contributory to this case. Family history is not contributory to this
~~~ICAL
000781
case. Family history is not contributory to this case. Family history is not contributory to this case. NOTES (Thu Feb 21 2008 10:57 CBLA): Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. Nursing records reviewed. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, PMHx: Left mandible osteomyelitis. MEDS: Merrem and Clindamycin IV. See nursing notes. MEDICAL HISTORY (12:02 AWAH): History of hypertension, see RN notes self removed PICC line. r -..-,.GICAL HISTORY (12: 02 AWAH): L jaw surgery, harware removal, chronic osteomyelitis. SOCIAL HISTORY (12:02 AWAH) Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. FAMILY HISTORY (12:02 AWAH) Family history is not contributory to this case. NOTES (12:02 AWAH): Nursing records reviewed, Agree with nursing records.
ROS
F>.TT:
(12:01 AWAH) L jaw pain. SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above.
TRIAGE (Thu Feb 21 2008 10:57 CBLA) COMPLAINT: HIGH RISK COMPLAINT: Headache, COMPLAINT: Left Side Face Pn/Ha. PROVIDERS: TRIAGE NURSE: Cherie Blaesing, RN. ADMISSION: URGENCY: ESI-3, TRANSPORT: Car, BED: WAITING. PATIENT: NAME: Phillip H March, AGE: 31, GENDER: Male, DOB: Sat Oct 02 1976, RACE: Black, Code: NO, Trauma: *NO, Work Comp.: NO, Heat Related: NO, SSN: 493788699, ZIP CODE: 63121, KG WEIGHT: 73.5, HEIGHT: 182cm, PHONE: 314387-8122, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0805200249, PRIMARY: Phillip G Zinser, ATTENDING: Emergency Physicians, IBEX NUMBER: 20080221105720ADT, NOTIFICATION: Attending physician or charge nurse notified. PRE-TRIAGE NOTES;Attending physician or charge nurse notified. PREVIOUS VISIT ALLERGIES: No known drug allergies. FALL RISK: TIME: 1054, Gender (Male), Score: 1. ASSESSMENT: 10, GCS Eye Opening: Spontaneously (4), GCS Verbal Response: Oriented/conversive (5), GCS Motor Response: Obeys comands(6) , The GCS total is IS, co face pain and headpain for a while states has chronic infection in bone in face. TB SCREENING: Denies TB screening. DOMESTIC VIOLENCE: The presence of domestic violence is unknown.
000782
SSM DEPAUL EMERGENCY RECORD EDUCATIONAL/CULTURAL BARRIERS: No educational/cultural barriers. TREATMENTS IN PROGRESS: No treatment. VITAL SIGNS: BP 145/92, Pulse 72, Resp 16, Temp 97.7, Pain 10, 02 Sat 100, on ra, Time 1054. PHYSICAL EXAM (12:04 AWAH) CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3, nontoxic. HEAD: Atraumatic, Normocephalic, old scar inferior to L angle of mandible with local tenderness. no swelling, erythema or crepitance. EYES: Pupils equal and reactive to light, Extraocular muscles intact. ENT: Ears normal to inspection, Nose examination normal, Oropharynx normal, Mouth normal to inspection, no trismus or sings of intraoral infection. :K: Normal ROM, No meningeal signs, Cervical spine non-tender. RESPIRATORY/CHEST: Breath sounds normal. CARDIOVASCULAR: RRR. ABDOMEN: Abdomen is non-tender, No distension, No peritoneal signs. BACK: There is no CVA Tenderness. UPPER EXTREMITY; No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Normal range of motion. V~TJRO: GCS is 15, No focal motor deficits, No focal sensory deficits. _N: Skin is warm and dry, No rash or induration. LYMPHATIC: No adenopathy in neck. PSYCHIATRIC: Oriented X 3, Normal affect. 02SAT INTERPRETATION (12:04 AWAH) 02SAT: 02 saturation reading 100%, 02 AMT: R.A., 02 Sat normal.
P~CTOR
NOTES (12:07 AWAH) :T: pt with more of a chronic condition, no fever, nontoxic, has been to several ER's recently, CT passed week showed "chronic osteomyelitis". will supply rx vicodin. encouraged pt to flu at Barnes OMF and ID Dr Zinser. also supplying name of pain specialist. supposedly has an appt with an internal medicine doctor 3/08. PATIENT STATUS: Patient has stablized since admission. PATIENT PLAN: The patient will be discharged, The patient will follow up with primary care physician.
DIAGNOSIS (11:30 AWAH) FINAL: PRIMARY: chronic L jaw pain, hx osteomyelitis, sip stabbing, ADDITIONAL: DISPOSITION PATIENT (11:30 AWAH) X-RAY/CT Follow-up: NO, Critical Care: *None, Doctor
000783
Procedures: NO, Disposition: Home, Condition: Stable. (11:55 AHAA): Remove from ER. NOTES (11:55 AHAA): Verbal instructions given Written instructions given Prescription given.
INSTRUCTION (11:33 AWAH) DISCHARGE: CHRONIC PAIN MANAGEMENT. FOLLOWUP: 2, PHILLIP G ZINSER MD 11125 DUNN ROAD SUITE 412 JENNINGS MO 63136 3143557997, MAHENDRA P GUNAPOOTI MD 247 DUNN ROAD FLORISSANT MO 63031 3148302600. SPECIAL: vicodin may cause drowsiness, no driving or alcohol ibuprofen 600mg every 8 hours ,arne of pain specialist supplied for follow up /ou should follow up with the doctor at Barnes OMF clinic who did your surgery for further evaluation call Dr Zinser too to see if he will follow up with you keep appointment with internal medicine doctor as scheduled in March. PRESCRIPTION (11;31 AWAH) Vicodin: Tablet: 500 mg-5 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: As needed every four hours Dispense: ***20***. NURSING ASSESSMENT: FOCUSED (11:09 AMC) NOTES: PT AMBULATORY TO ER # 31 WITH C/O LEFT SIDED JAW PAIN. REPORTS WAS STABBED IN JAW APRIL 07, HAS CHRONIC PAIN TO JAW. HX OF PICC LINE FOR ABX. STATES PICC LINE NO LONGER IN PLACE AND NOT ON ANY ABX. PT REPORTS PAIN INCREASING OVER LAST 2 DAYS AND RADIATING TO HEAD. TIME ASSESSED: Patient was assessed at 1100. BVES: Eyes are PERRL. -RO: Orientation: Alert, Oriented, Behavior: Cooperative, Coherent. GLS: The GCS total is 15. MUSCULOSKELETAL: Good ROM, Normal pulses. SKIN: Skin is warm, Skin is dry, Skin color is normal. NURSING PROCEDURE: DISCHARGE NOTE (11:55 AHAA) TIME: Procedure was performed at 1155, Patient discharged to home, Patient ambulates without assistance, Transported via patient driving, Patient unaccompanied, Discharge instructions given to patient, Above Person(s) verbalized understanding of discharge instructions and follow-up care. IMAGING (12:11 MY) CONSENT TO TREAT: ADMIN
Image captured from scanner.
000784
DIGITAL SIGNATURE (11:55 AHAA): Hasenstab, Amber. (Tue Feb 26 2008 12:36 AWAH): Wahle, PA-C, Andrew. (Wed Mar 05 2008 10:38 MSTl): Teng D.O., Marcus. PATIENT DATA CHANGE (10:57 CBLA) Urgency: ESI-4. (11:10): A08 73138516 by Interface, Payment: 90, Admitting Doctor: Zinser Phillip G, Attending Doctor: Physicians Emergency. (11:12): A08 73138617 by Interface, Admitting Doctor: Zinser Phillip G, Attending Doctor: Physicians Emergency. (11:13 AWAH): Dr. Extender changed from (none) to Andrew Wahle, PA-C. (11:37 AWAH): Attending: Marcus Teng D.O., Payment: (none). (11:49 AMC): Primary Nurse changed from (none) to Amanda McLain, RN. iHAA=Davidson, Amber AMC=McLain, RN, Amanda AWAH=Wahle, PA-C, Andrew CBLA=Blaesing, RN, Cherie MSTl=Teng D.O., Marcus MY=Young, Matt
000785
SSM DEPAUL CLINICAL SUMMARY RECORD HPI BLANK CHIEF COMPLAINT: cc: L jaw pain hpi: sip L jaw stabbing early last year, tx'ed by Barnes OMF, has had chronic pain since as well as osteomyelitis, last admit at Depaul 12/07 for IV abx. pt states was seen at Barnes approx 1 month ago and SLU approx 1 week ago (had CT with contrast showing "chronic osteomyelitis", finished zithromax, however states did not get pain meds. pt states he pulled out his own PICC line approx 1 month ago. states he is an investigator and has to leave town alot, has misses flu appt's with Barnes OMF as well as ID Dr Zinser. pt claims to have an appt with an internal medicine doctor next month, however cannot supply name. pt c/o L jaw pain. no fever, chills, sore throat, dysphagia or SOB. no DM. T ~TORIAN: History obtained from patient. IE COURSE: Onset was as above. SEVERITY: Currently symptoms are moderate. HISTORY History of hypertension, Patient is noncompliant with MEDICAL HISTORY: treatment: Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, . History of hypertension, jaw osteomyelitis. HAS PICC LINE FOR IV ANTIBIOTIC. History of hypertension, Patient is noncompliant with treatment, Stabbed in left face April 28th, 2007. History of hypertension, Patient is noncompliant with treatment, History of hypertension, jaw osteomyelitis. HAS PICC LINE FOR IV ANTIBIOTIC. PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. No previous psychiatric history . . No previous psychiatric history. STTRGICAL HISTORY: Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. jaw fracture repairs. Jaw Repair, plate left jaw. facial repair . Denies smoking, Patient consumes alcohol socially, Denies SOCIAL HISTORY: drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. Denies smoking, Patient consumes alcohol socially, Denies drug abuse, Lives at home with family, Denies alcohol abuse, Denies tobacco . Denies alcohol abuse, Denies tobacco abuse. FAMILY HISTORY: Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. NOTES: Nursing records reviewed, Agree with nursing records, Nursing records
000786
reviewed, Agree with nursing records, Nursing records reviewed, Agree with nursing records, Agree with nursing records. Nursing records reviewed. Nursing records reviewed. Nursing records reviewed, Agree with nursing records. Nursing records reviewed, PMHx: Left mandible osteomyelitis. MEDS: Merrem and Clindamycin IV. See nursing notes. MEDICAL HISTORY: History of hypertension, see RN notes self removed PICC line. SURGICAL HISTORY: L jaw surgery, harware removal, chronic osteomyelitis. SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. FAMILY HISTORY: Family history is not contributory to this case. NOTES: Nursing records reviewed, Agree with nursing records.
j
ENT: L jaw pain. ALL SYSTEMS NEGATIVE: All systems were reviewed and are negative except as described above.
PHYSICAL EX_AM CONSTITUTIONAL: Vital signs reviewed, Comfortable, Alert and oriented X 3, nontoxic. ,D: Atraumatic, Normocephalic, old scar inferior to L angle of mandible with local tenderness. no swelling, erythema or crepitance. EYES: Pupils equal and reactive to light, Extraocular muscles intact. ENT: Ears normal to inspection, Nose examination normal, Oropharynx normal, Mouth normal to inspection, no trismus or sings of intraoral infection. NECK: Normal ROM, No meningeal signs, Cervical spine non-tender. RESPIRATORY/CHEST: Breath sounds normal. r~RDIOVASCULAR: RRR. )OMEN: Abdomen is non-tender, No distension, No peritoneal signs. bACK: There is no CVA Tenderness. UPPER EXTREMITY: No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Normal range of motion. NEURO: GCS is 15, No focal motor deficits, No focal sensory deficits. SKIN: Skin is warm and dry, No rash or induration. LYMPHATIC: No adenopathy in neck. PSYCHIATRIC: Oriented X 3, Normal affect. DOCTOR NOTES TEXT: pt with more of a chronic condition, no fever, nontoxic, has been to several ERls recently, CT passed week showed "chronic osteomyelitis". will supply rx vicodin. encouraged pt to flu at Barnes OMF and ID Dr Zinser. also supplying name of pain specialist. supposedly has an appt with an internal medicine doctor 3/08.
000787
PATIENT STATUS: Patient has stablized since admission. PATIENT PLAN: The patient will be discharged, The patient will follow up with primary care physician.
DIAGNOSIS
FINAL: PRIMARY: chronic L jaw pain, hx osteomyelitis, sip stabbing, ADDITIONAL:

DISPOSITION
PATIENT: X-RAY/CT Follow-up: NO, Critical Care: *None, Doctor Procedures: NO, Disposition: Home, Condition: Stable. Remove from ER. ~ES: Verbal instructions given Written instructions given Prescription given.
PRESCRIPTION
Vicodin: Tablet: 500 mg-5 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: As ne~ded every four hours Dispense: ***20***.
INSTRUCTION
P'SCHARGE: CHRONIC PAIN MANAGEMENT. jLOWUP: 2, PHILLIP G ZINSER MD 11125 DUNN ROAD SUITE 412 JENNINGS MO 63136 3143557997, MAHENDRA P GUNAPOOTI MD 247 DUNN ROAD FLORISSANT MO 63031 3148302600. SPECIAL: vicodin may cause drowsiness, no driving or alcohol ibuprofen 600mg every 8 hours name of pain specialist supplied for follow up you should follow up with the doctor at Barnes OMF clinic who did your surgery for further evaluation ~all Dr Zinser too to see if he will follow up with you keep appointment with internal medicine doctor as scheduled in March.
000788
SSM DEPAUL RECORD
000789
II
Name: March, Phillip Age:. 31Y MR: 000748298
SSM DEPAUL EMERGENCY FLOW SHE1~T RECORD Acct: 0805200249
VITAL SIGNS User Date/Time CBLA 02/21 1C:57
BP
145/92
PULSE
72
RESP
16
TEMP
97.7
PAIN
10
02 SAT
100 on ra
TIME
1054

Page: J.
000790
Picis Imaging
Page 2 of3
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000791
SSM DEPAUL EMERGENCY RECORD HPI BLANK (20:49 MSAL) CHIEF COMPLAINT: Pain left side of the face. The patient was stabbed in the face on April 28. On May 8 a plate was placed in his face. An artery was repaired. He developed a cellulitis with possible hardware infection and was treated with antibiotics. HISTORIAN: History obtained from patient. TIME COURSE: Onset was yesterday. SEVERITY: Maximum severity is moderate, Currently symptoms are moderate. KNOWN ALLERGIES No known drug allergies. JTORY MEDICAL HISTORY (Man Sep 17 2007 15:24 KCOR): which is not being treated, Stabbed in left face April 24th, 2007. History of hypertension, Patient is noncompliant with treatment, stab wound 1 face 4\24\07. History of hypertension, which is being treated, stab wound 1 face. PSYCHIATRIC HISTORY (Man Sep 17 2007 15:24 KCOR): No previous psychiatric history. No previous psychiatric history. No previous psychiatric history . Jaw Repair, plate left jaw. .GICAL HISTORY (Man Sep 17 2007 15:24 KCOR): facial repair. Patient's previous surgical history is not relevant to the case. SOCIAL HISTORY (Man Sep 17 2007 15:24 KCOR): Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives alone, Denies smoking, Lives at home alone. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives alone. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives with others. lILY HISTORY (Man Sep 17 2007 15:24 KCOR): F~~ily history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. NOTES (Man Sep 17 2007 15:24 KCOR): Nursing records reviewed, Stabbed in left face April 24th, 2007. Underwent surgery the week following . . . Nursing records reviewed. Nursing records reviewed, Agree with nursing records. MEDICAL HISTORY (20:50 MSAL): Stabbed in left face April 24th, 2007. History of hypertension, Patient is noncompliant with treatment, stab wound 1 face 4\24\07. History of hypertension, which is being treated, stab wound 1 face. PSYCHIATRIC HISTORY (20:50 MSAL): No previous psychiatric history. SURGICAL HISTORY (20:51 MSAL): Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not rele~ant to the case. SOCIAL HISTORY (20:51 MSAL) Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse.
000792
NOTES
(20:51 MSAL): Nursing records reviewed.
ROS (20:50 MSAL) CONSTITUTIONAL: No fever, No chills. ENT: No sore throat. CARDIOVASCULAR: No chest pain. RESPIRATORY: No Cough. GI: No abdominal pain. GENITOURINARY MALE: No dysuria. MUSCULOSKELETAL: No myalgias, No arthralgias. SKIN: No rash. ALL SYSTEMS NEGATIVE: All relevant systems reviewed and all negative except for the above. TRIAGE (Mon Sep 17 2007 15:24 KCOR) COMPLAINT: Pain On Lt Side Of Pain. PROVIDERS: TRIAGE NURSE: Keith Cornell, RN, CHARGE NURSE: Beth Hyman, RN. ADMISSION: URGENCY: ESI-3, ADMISSION SOURCE: Home, TRANSPORT: Car, BED: WAITING. PATIENT: NAME: Phillip March, AGE: 30, GENDER: Male, DOB: Sat Oct 02 1976, RACE: Black, Code: NO, Trauma: *NO, Work Comp.: NO, Heat Related: NO, SSN: 493788699, ZIP CODE: 63121, KG WEIGHT: 73.5, HEIGHT: 180cm, PHONE: 314522-8730, MEDICAL RECORD NUMBER: 000748298, ACCOUNT NUMBER: 0726000387, PRIMARY; None Pcp, ATTENDING: Emergency Physicians, IBEX NUMBER: 20070917152429ADT, NOTIFICATION: Attending physician or charge nurse notified. PRE-TRIAGE NOTES:Attending physician or charge nurse notified. PREVIOUS VISIT ALLERGIES: No known drug allergies. F~LL RISK: TIME: 1520, Gender (Male), Get up and go test: Able to rise in a single movement. AoSESSMENT: c/o left side face swelling sip plate taken out , hx stab in the face.04/2007. IMMUNIZATIONS: Last tetanus shot received less than 5 years ago. VITAL SIGNS: BP 144/100, Pulse 72, Resp 18, Temp 99, Pain 5, 02 Sat 99, on rat Time 1522. PHYSICAL EXAM (20:51 MSAL) CONSTITUTIONAL: Vital signs reviewed, Alert and oriented X 3, Patient appears uncomfortable. HEAD: Atraumatic, Normocephalic. EYES: Pupils equal and reactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal, Conjunctiva are normal. ENT: Oropharynx normal, Mouth normal to inspection. NECK: Normal ROM, No jugular venous distention, No meningeal signs, Cervical
000793
spine non-tender. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. CARDIOVASCULAR: RRR, No murmurs, No rub, No gallop. ABDOMEN: Abdomen is non-tender, No masses, Bowel sounds normal, No distension, No peritoneal signs. BACK: There is no CVA Tenderness, There is no tenderness to palpation, Normal inspection. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, No calf tenderness, Normal range of motion. TRO: GCS is 15, No focal motor deficits, No focal sensory deficits, No cerebellar deficits. SKIN: Skin is warm and dry, No rash or induration. LYMPHATIC: No adenopathy in neck. PSYCHIATRIC: Oriented X 3, Normal affect.
02SAT INTERPRETATION (20:52 MSAL) 02SAT: 02 saturation reading 100%, 02 AMT: R.A., 02 Sat normal. ,ULTS (20:11 MSAL) LAB: COMPREHENSIVE METABOLIC PANEL Sep 17 2007 18:03, BUN 9 mg/dl Ref Range (9.0-20.0), Sodium 137 mEq/L Ref Range (137-145), Potassium 3.8 mEq/L Ref Range (3.6-5.0), Chloride 101 mEq/L Ref Range (98.0-107.0), Glucose 86 mg/dl Ref Range (75-110), Creatinine 1.2 mg/dl Ref Range (0.8-1.5), AST/SGOT 17 U/L Ref Range (17.0-59.0), Alk Phos 76 U/L Ref Range (38.0-126.0), Calcium 9.9 mg/dl Ref Range (8.4-10.2), Bilirubin 0.9 mg/dl Ref Range (0.2-1.3), Albumin 4.7 gm/dl Ref Range (3.5-5.0), Prot Total 7.6 gm/dl Ref Range (6.3-8.2), C02 28 mEq/L Ref Range (22.0-30.0), ALT/SGPT <3 L U/L Ref Range (21.0-72.0), GFR 91.4 ml/min/1.73m2. CBC W AUTO DIFF Sep 17 2007 18:54, WBC 7.1 1000/mm3 Ref Range (4.5-11.0), RBC 5.08 10X6 Ref Range (4.7-6.1), Hgb 13.3 gm/dl Ref Range (13.0-18.0), Hct 40.1 % Ref Range (39.0-54.0), MCV 78.9 L f1 Ref Range (80.0-99.0),
000794

MCH 26.2 pg Ref Range (25.0-31.0), MCHC 33.2 gm/dl Ref Range (32.0-36.0), RDW 16.2 H % Ref Range (11.5-14.5), Platelets 240 1000/mm3 Ref Range (130.0-400.0), Gran 68.4 % Ref Range (40.0-70.0), Lymph 25.3 % Ref Range (22.0-40.0), Mono 5.9 % Ref Range (2.0-10.0), Eos 0.1 % Ref Range (0.0-6.0), Baso 0.3 % Ref Range (0.0-3.0), Manual Diff Not Indicated , PIt Comment Automated platelet count inaccurate due to large platelets. Platelets appear adequate when reviewed on peripheral smear. Absolute Neutrophil 4.86 1000/mm3.
DOCTOR NOTES TEXT (21:39 SYK) Verbal report received from Dr. Sallis. Pt waiting for CT scan result. (22:58 SYK): Informed patient CT scan was unremarkable and he must follow up with Dr. Zinser on this coming Wednesday. pt voiced understanding.
r~~POSITION
(23:04 RAP) lENT: X-RAY/CT Follow-up: NO, Critical Care: *None, Doctor Procedures: NO, Disposition: Home, Condition: Improved, Remove from ER.
MEDICATION SERVICE March, Phillip (20:29 MSAL): Free Text order: March, Phillip: 2028: Verbal order from Dr Sallis for 1 mg Dilaudid IVP now for pain. Verbal order readback for 1 mg Dilaudid IVP now for pain. : IV Push Ordered: Mon Sep 17 2007 20:29 rdered by: Milton Sallis, MD Entered by: Robin Peas, EMT-P Mon Sep 17 2007 20:29 Acknowledged by: Robin Peas, EMT-P Mon Sep 17 2007 20:29 Documented as given by: Robin Peas, EMT-P Mon Sep 17 2007 20:34 MEDICATION, Time given: 2034, Amount given: 1 mgt IV site I, Medication administered into left AC, IVP, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient tolerated procedure well, Patient in position of comfort, Side rails up, Cart in lowest position, Call light in reach. Follow Up (22:09 DCOO): Time: 2115, Decreased pain, On a scale 0-10
000795
patient rates pain as 6, Advised not to ambulate without assistance, Patient in position of comfort, Side rails up, Cart in lowest position, Call light in reach. March, Phillip (20:35 MSAL): Free Text order: March, Phillip: 2034: Verbal order from Dr Sallis for 25 mg Benadryl IVP for itching from the Dilaudid. Verbal order readback for 25 mg Benadryl IVP for the itching from the Dilaudid. : IV Push Ordered: Mon Sep 17 2007 20:35 Ordered by: Milton Sallis, MD Entered by: Robin Peas, EMT-P Mon Sep 17 2007 20:35 Acknowledged by: Robin Peas, EMT-P Mon Sep 17 2007 20:35 Documented as given by: Robin Peas, EMT-P Mon Sep 17 2007 20:41 MEDICATION, Time given: 2035, Amount given: 25 mg, IV site I, Medication administered into left AC, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient tolerated procedure well, Patient in position of comfort, Side rails up, Cart in lowest position, Call light in reach. March, Phillip (22:17 RWEN): Free Text order: March, Phillip: 2216: Verbal order from Dr Wensley for 1 mg Dilaudid IVP now for pain. Verbal order readback for 1 mg Dilaudid IVP now for pain. : IV Push Ordered: Mon Sep 17 2007 22:17 Ordered by: Rosemary Wensley, M.D. Entered by: Robin Peas, EMT-P Mon Sep 17 2007 22:17 ocumented as given by: Robin Peas, EMT-P Mon Sep 17 2007 22:17 MEDICATION, Time given: 2217, Amount given: 1 mg, IV site I, Medication administered into left AC, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient tolerated procedure well, Patient in position of comfort, Side rails up, Cart in lowest position, Call light in reach. Phillip March (20:22 MSAL): Free Text order: Phillip March: Toredol 30 mg IVP now, v.o. read back, Dr. Sallis. : IV Push Ordered: Mon Sep 17 2007 20:22
000796
Ordered by: Milton Sallis, MD Entered by: Dana Bryant, RN Mon Sep 17 2007 20:22 Documented as given by: Dana Bryant, RN Mon Sep 17 2007 20:23 MEDICATION, Time given: 2015, Given in amount and via route as prescribed, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Emotional support needed and given, Patient tolerated procedure well, Patient in position of comfort, Side rails up, Cart in lowest position, Call light in reach.
INSTRUCTION (20:52 MSAL) FOLLOWUP: 1, PHILLIP G ZINSER MD 11125 DUNN ROAD SUITE 412 JENNINGS MO 63136 3143557997. SPECIAL: Facial pain with possible soft tissue infection.
(20:53 MSAL) )mentin: Tablet: 875 mg-125 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: BID Dispense: ***10***. Percocet 5/325: Tablet: 325 mg-5 mg : Oral=Quantity: ***1-2*** Unit: TAB Route: Oral Schedule: Every 4-6 hours Dispense: ***20***.
r~~SCRIPTION
NURSING ASSESSMENT: FOCUSED (19:00 DAL) TIME ASSESSED: Patient was assessed at 1830. pnIN SCALE: clo OF PAIN TO LT SIDE OF FACE, STATES HAD A STAB WOUND TO FACE IN PAST, STATES PT IS NO CMPLAINT WITH PAIN, On a scale 0-10 patient rates pain as 4. EYES: Eyes are PERRL. NEURO: Orientation: Alert, Oriented, Disoriented, Lethargic, Comatose. MUSCULOSKELETAL: Good ROM. SKIN: Skin is warm, Skin is dry. NURSING ASSESSMENT: NURSES NOTE (20:22 DCOO) TIME ASSESSED: Time: 1940, Pt. reports left side of face is in pain. Dr. Sallis informed of that and pt's elevated BP. Orders receieved., LOC: Alert, Respirations: Normal, Skin: Warm, Skin Color: Normal. VITAL SIGNS: BP: 163, / 111, Pulse: 62, Resp: 18, Pain: 10, 02 sat: 100, RA. NURSING ASSESSMENT: NuRSES NOTE (22:10 DeOO) TIME ASSESSED: Time: 2200, Pt. resting quietly, reports pain decreased but
000797
feels as if it is coming back. , LOC: Alert, Respirations: Normal, Skin: Dry, Skin Color: Normal. VITAL SIGNS: BP: 153, / 105, Pulse: 64, Resp: 18, Pain: 6, 02 sat: 100, RA.
NURSING PROCEDURE: LAB DRAW (17:36 HWE1) TIME: Procedure was performed at 1700, Venipuncture performed/labs sent, Blood obtained from left AC and labs sent, No swelling. SAFETY: Side rails up, Cart in lowest position. NURSING PROCEDURE: BLANK CHART (17:49 DBEL) TIME: Procedure was performed at 17:50, facial bones xray by donna. 1SING PROCEDURE: IV (20:23 DCOO) AE: Procedure was performed at 2010, 20 gauge catheter inserted, into left AC, with 2 attempts, Saline lock established, After placement no swelling noted at site, no drainage noted at site, Sterile dressing applied, Patient tolerated procedure well. SAFETY: Side rails up, Cart in lowest position, Call light within reach. NURSING PROCEDURE: NURSE NOTES (20:24 DCOO) ~-~E: -Time: 2024, Dr. Sallis at bedside. NURSING PROCEDURE: DISCHARGE NOTE (23:03 RAP) TIME: Procedure was performed at 2300, Patient discharged to home, Patient ambulates without assistance, Transported via friend/family driving, Patient unaccompanied, IV discontinued with catheter intact. Dressing placed to IV site, Discharge instructions given to patient, Simple/moderate discharge teaching performed, Prescription given and additional instructions on side effects of same given, Above Person(s) verbalized understanding of discharge instructions and follow-up care, Patient treated and evaluated by physician, Patient discharged by physician. IMAGING PROTOCOL (Tue Sep 18 2007 00:05 SWLL): Image captured from scanner. EMS TRIP SHEET (Tue Sep 18 2007 02:50 AS): Image captured from scanner. (Tue Sep 18 2007 02:51 AS): Page 002 addedImage captured from scanner. CONSENT TO TREAT (Tue Sep 18 2007 02:52 AS): Image captured from scanner. EMS TRIP SHEET (Tue Sep 18 2007 02:52 AS): Image captured from scanner. (Tue Sep 18 2007 02:52 AS): Image captured from scanner. TIME CARD (Tue Sep 18 2007 02:52 AS): Image captured from scanner. ADMIN DIGITAL SIGNATURE (20:24 DCOO)
Bryant, RN, Dana.
000798
(22:10 DCOO): Bryant, RN, Dana. (22:58 SYK): Kim-Shepherd, Sony. (23:03 RAP): Peas, EMT-P, Robin. (Mon Oct 01 2007 21:06 MSAL): Sallis, MD, Milton. (Tue Mar 31 2009 23:03 RAP): Peas, EMT-P, Robin. PATIENT DATA CHANGE (17:48): A08 67188609 by Interface, Payment: 90, Admitting Doctor: Pcp None, Attending Doctor: Physicians Emergency. (18:46 MSAL): Attending changed from (none) to Milton Sallis, MD. (19:14): A08 67190926 by Interface, Admitting Doctor: Pcp None, Attending Doctor: Physicians Emergency. (19:25): A08 67191083 by Interface, Admitting Doctor: Pcp None, Attending Doctor: Physicians Emergency. '21:38 SYK): Dr. Extender changed from (none) to Sony Kim-Shepherd. KEY: AS=Spilker, Andy DAL=Lusain, RN, Debra DBEL=Belden, Donna DCOO=Bryant, RN, Dana HWE1=West, RN, Heather KCOR=Cornell, RN, Keith MSAL=Sallis, MD, Milton RAP=Peas, EMT-P, Robin RWEN=Wensley, M.D., Rosemary SWLL=Wollen, Stephanie SYK=Kim-Shepherd, Sony
000799
SSM DEPAUL CLINICAL SUMMARY RECORD HPI BLANK CHIEF COMPLAINT: Pain left side of the face. The patient was stabbed in the face on April 28. On May 8 a plate was placed in his face. An artery was repaired. He developed a cellulitis with possible hardware infection and was treated with antibiotics. HISTORIAN: History obtained from patient. TIME COURSE: Onset was yesterday. SEVERITY: Maximum severity is moderate, Currently symptoms are moderate. HISTORY MEDICAL HISTORY: which is not being treated, Stabbed in left face April 24th, 2007. History of hypertension, Patient is noncompliant with treatment, stab wound 1 face 4\24\07. History of hypertension, which is being treated, stab wound 1 face. PSYCHIATRIC HISTORY: No previous psychiatric history. No previous psychiatric history. No previous psychiatric history. SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives alone, Denies smoking, Lives at home alone. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives alone. Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse, Lives with others. FAMILY HISTORY: Family history is not contributory to this case. Family history is not contributory to this case. Family history is not contributory to this case. NOTES: Nursing records reviewed, Stabbed in left face April 24th, 2007. Underwent surgery the week following. . Nursing records reviewed. Nursing records reviewed, Agree with nursing records. MnDICAL HISTORY: Stabbed in left face April 24th, 2007. History of hypertension, Patient is noncompliant with treatment, stab wound 1 face 4\24\07. History of hypertension, which is being treated, stab wound 1 face. PSYCHIATRIC HISTORY: No previous psychiatric history. SURGICAL HISTORY: Jaw Repair, plate left jaw. facial repair. Patient's previous surgical history is not relevant to the case. SOCIAL HISTORY: Denies alcohol abuse, Denies tobacco abuse, Denies drug abuse. NOTES: Nursing records reviewed. ROS CONSTITUTIONAL: No fever, No chills. ENT: No sore throat.
000800
CARDIOVASCULAR: No chest pain. RESPIRATORY: No Cough. GI: No abdominal pain. GENITOURINARY MALE: No dysuria. MUSCULOSKELETAL: No myalgias, No arthralgias. SKIN: No rash. ALL SYSTEMS NEGATIVE: All relevant systems reviewed and all negative except for the above.
PHYSICAL EXAM CONSTITUTIONAL: Vital signs reviewed, Alert and oriented X 3, Patient appears uncomfortable. 'D: Atraumatic, Normocephalic. ~S: Pupils equal and reactive to light, No discharge from eyes, Extraocular muscles intact, Sclera are normal, Conjunctiva are normal. ENT: Oropharynx normal, Mouth normal to inspection. NECK: Normal ROM, No jugular venous distention, No meningeal signs, Cervical spine non-tender. RESPIRATORY/CHEST: Chest is non-tender, Breath sounds normal, No respiratory distress. r~~DIOVASCULAR: RRR, No murmurs, No rub, No gallop. )OMEN: Abdomen is non-tender, No masses, Bowel sounds normal, No distension, No peritoneal signs. BACK: There is no CVA Tenderness, There is no tenderness to palpation, Normal inspection. UPPER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, Normal range of motion. LOWER EXTREMITY: Inspection normal, No cyanosis/clubbing/edema, No calf tenderness, Normal range of motion. -RO: GCS is 15, No focal motor deficits, No focal sensory deficits, No cerebellar deficits. SKIN: Skin is warm and dry, No rash or induration. LYMPHATIC: No adenopathy in neck. PSYCHIATRIC: Oriented X 3, Normal affect. DOCTOR NOTES TEXT: Verbal report received from Dr. Sallis. Pt waiting for CT scan result. Informed patient CT scan was unremarkable and he must follow up with Dr. Zinser on this coming Wednesday. pt voiced understanding. DISPOSITION PATIENT: X-RAY/CT Follow-up: NO, Critical Care: *None, Doctor Procedures: NO, Disposition: Home, Condition: Improved, Remove from ER.
000801
SSM DEPAUL CLINICAL SUMMARY RECORD MEDICATION SERVICE March, Phillip: Free Text order: March, Phillip: 2028: Verbal order from Dr Sallis for 1 mg Dilaudid IVP now for pain. Verbal order readback for 1 mg Dilaudid IVP now for pain. IV Push Ordered: Mon Sep 17 2007 20:29 Ordered by: Milton Sallis, MD Entered by: Robin Peas, EMT-P Mon Sep 17 2007 20:29 Acknowledged by: Robin Peas, EMT-P Mon Sep 17 2007 20:29 Documented as given by: Robin Peas, EMT-P Mon Sep 17 2007 20:34 MEDICATION, Time given: 2034, Amount given: 1 mg, IV site 1, Medication administered into left AC, IVP, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient tolerated procedure well, Patient in position of comfort, Side rails up, Cart in lowest position, Call light in reach. Follow Up : Time: 2115, Decreased pain, On a scale 0-10 patient rates pain as 6, Advised not to ambulate without assistance, Patient in position of comfort, Side rails up, Cart in lowest position, Call light in reach. March, Phillip: Free Text order: March, Phillip: 2034: Verbal order from Dr Sallis for 25 mg Benadryl IVP for itching from the Dilaudid. Verbal order readback for 25 mg Benadryl IVP for the itching from the Dilaudid. : IV Push Ordered: Mon Sep 17 2007 20:35 Ordered by: Milton Sallis, MD ;ntered by: Robin Peas, EMT-P Mon Sep 17 2007 20:35 Acknowledged by: Robin Peas, EMT-P Mon Sep 17 2007 20:35 Documented as given by: Robin Peas, EMT-P Mon Sep 17 2007 20:41 MEDICATION, Time given: 2035, Amount given: 25 mg, IV site 1, Medication administered into left AC, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient tolerated procedure well, Patient in position of comfort, Side rails up, Cart in lowest position, Call light in reach. March, Phillip: Free Text order: March, Phillip: 2216: Verbal order from Dr
000802
, SSM DEPAUL CLINICAL SUMMARY RECORD
Wensley for 1 mg Dilaudid IVP now for pain. Verbal order readback for 1 mg Dilaudid IVP now for pain. : IV Push Ordered: Mon Sep 17 2007 22:17 Ordered by: Rosemary Wensley, M.D. Entered by: Robin Peas, EMT-P Mon Sep 17 2007 22:17 Documented as given by: Robin Peas, EMT-P Mon Sep 17 2007 22:17 MEDICATION, Time given: 2217, Amount given: 1 mg, IV site 1, Medication administered into left AC, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Patient tolerated procedure well, Patient in position of comfort, Side rails up, Cart in lowest position, Call light in reach. Phillip March: Free Text order: Phillip March : Toredol 30 mg IVP now, V.O. read back, Dr. Sallis. : IV Push Ordered: Mon Sep 17 2007 20:22 ~rdered by: Milton Sallis, MD ~ntered by: Dana Bryant, RN Mon Sep 17 2007 20:22 Documented as given by: Dana Bryant, RN Mon Sep 17 2007 20:23 MEDICATION, Time given: 2015, Given in amount and via route as prescribed, IVP, Slowly, Catheter placement confirmed via flush prior to administration, IV site without signs or symptoms of infiltration during medication administration, No swelling during administration, No drainage during administration, IV flushed after administration, Correct patient, time, route, dose and medication confirmed prior to administration, Patient advised of actions and side-effects prior to administration, Allergies confirmed and medications reviewed prior to administration, Emotional support needed and given, Patient tolerated procedure well, Patient in position of comfort, Side rails up, Cart in lowest position, Call light in reach.
PRESCRIPTION Augmentin: Tablet: 875 mg-125 mg : Oral=Quantity: ***1*** Unit: tab Route: Oral Schedule: BID Dispense: ***10***. Percocet 5/325: Tablet: 325 mg-5 mg : Oral=Quantity: ***1-2*** Unit: TAB Route: Oral Schedule: Every 4-6 hours Dispense: ***20***. INSTRUCTION FOLLOWUP: 1, PHILLIP G ZINSER MD 11125 DUNN ROAD SUITE 412 JENNINGS MO 63136 3143557997.
000803
SPECIAL:
Facial pain with possible soft tissue infection.
000804
SSM DEPAUL RECORD
000805
I~
SSM DEPAUL
EMERGENCY FLOW SHEE1' RECORD

Name: March, Phillip VITAL SIGNS User Date/Time DCOO 09/17 22:10 DCOO 09/17 20:22 KCOR 09/17 15:24 Age: 30Y MR: 000748298 Acct: 0726000387
BP 153/105 163/111 144/100
PULSE 64 62 72
RESP 18 18 18
TEMP
PAIN 6 10
02 SAT 100 on RA 100 on RA 99 on ra
TIME
99
1522

Name: March, Phillip Age: 30Y MR: 000748298 Acc1:: 0726000387 Prepared: Tue May 26 09:18:05 2009 by Stephanie Manetz Page: 1
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Picis Imaging
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000812
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING Med Rec # A000748298 ACCT: A0726000387 Pt Location: *XER SALLIS, MILTON 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044 Check-In # Order Diagnosis 1017129 Ord Diag: 784.0-HEADACHE
.ne: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 09/17/07 2137 Sex: M
CT scan of the facial bones without intravenous contrast . Clinical indication prior trauma to the left mandible with left neck surgery, continued left neck pain. Description routine CT scanning was performed of the facial bones without intravenous contrast and 9/17/2007. The thin section axial images were reconstructed into coronal images and on a independent workstation. The prior studies are not available at this time for comparison. Findings there is healing bony callus seen along the left mandibular ramus fracture. Surgical clips are seen in that the left neck soft tissues anterior to the carotid and jugular region. There is some soft tissue thickening in this region which was described in previous written reports most recent examination from 6/8/2007 although these studies are not available for direct comparison. If clinically indicated correlation with the IV contrast administered study may be helpful to ensure that there is no vascular abnormality. No definite large fluid collection or subcutaneous fat stranding in this seen. There are a few bilateral submandibular lymph nodes which are not overall pathologically enlarged. No definite acute fracture is seen. There is mild mucosal thickening seen in the left maxillary sinus and sphenoid sinus. The coronal reconstructions show the bony callus along the left mandibular ramus with overall good alignment. Impression: healing fracture of the left mandibular ramus with mild mucosal thickening in the left maxillary sinus. Please see above comments. This examination was transcribed using a computerized voice recognition FINAL DUPLICATE Page 1
000813
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING .me: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 09/17/07 2137 Sex: M Med Rec # A000748298 ACCT: A0726000387 Pt Location: *XER SALLIS, MILTON 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044
Checkin-Exam Code Summary 1017129-70486 system without human transcriptionist. In an effort to expedite patient care, this report has not been adjusted for typographical, grammatical, and syntax errors by a trained medical transcriptionist. I have reviewed the report for content on a urgent basis. I would be happy to review the films with you. Read By- THOMAS P BOCCHINI M.D. Released By- THOMAS P BOCCHINI M.D. Released Date Time- 09/17/07 2235 Transcriptionist- TPB M.D. ADM: EMERGENCY,PHYSICIru~S REF: PCP: PCP,NONE ATT: EiviERGENCY, PHYSICIANB CON: SCP:
FINAL DUPLICATE
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000814
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING .ne: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 09/17/07 1749 Sex: M Med Rec # A000748298 ACCT: A0726000387 Pt Location: *ERQ WENSLEY,ROSEMARY K 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044 Check-In # Order Diagnosis 1017051 Ord Diag: 784.0-HEADACHE
Exam XR FACIAL BONES MIN 3 VIEWS
Facial bone series Clinical Indication: Facial trauma and pain, left-sided jaw pain. A four-view examination of the facial bones shows no definite acute fracture or paranasal sinus opacification. Surgical clips are projected over the left upper neck. The study does not well profile the mandible, and if there is further concern regarding the mandible, a specific mandible series may provide additional information. If there is further clinical concern regarding occult facial bone fracture, correlation with CT scanning may provide additional information. Impression: Negative facial bone series for definite acute process. Read By- THOMAS P BOCCHINI M.D. Released By- THOMAS P BOCCHINI M.D. Released Date Time- 09/18/07 1149 Transcriptionist- MEO ADM: EMERGENCY,PHYSICIANS REF: PCP: PCP,NONE ATT: EMERGENCY,PHYSICIANS CON: SCP:
FINAL DUPLICATE
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000815
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING ,ne: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 09/24/07 0953 Sex: M Med Rec # A000748298 ACCT: A0726200199 Pt Location: *5S-0537-01 MELKAVERI,SONIA N 1066 EXECUTIVE PARKWAY SUITE 105 CREVE COEUR MO 63141 Check-In # Order Diagnosis 1019671 Ord Diag: V67.59-FOLLOW-UP EXAM NEC
Indication: PICC line placement A single portable view the chest shows lungs are clear. Mediastinal contour and heart size are within normal limits. Pulmonary vascularity is unremarkable. A PICC line is in place with its tip in the superior vena cava. Impression: No acute disease. Read By- MEGAN M GAU M.D. Released By- MEGA..N M GAU M.D. Released Date Time- 09/24/07 1015 Transcriptionist- MMG M.D. ADM: RAHMAN,ANWER Z REF: PCP: PCP,NONE ATT: RAHMAN,ANWER Z CON: ZINSER,PHILLIP G SCP:
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000816
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING ,ne: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 09/23/07 2011 Sex: M Med Rec # A000748298 ACCT: A0726200199 Pt Location: *5S-0537-01 MELKAVERI,SONIA N 1066 EXECUTIVE PARKWAY SUITE 105 CREVE COEUR MO 63141 Check-In # Order Diagnosis 1019464 Ord Diag: 719.41-JOINT PAIN-SHLDER
Exam XR SHOULDER MIN 2 VIEWS*L
Indication: Left shoulder pain Two views left shoulder provided. There is no fracture or dislocation. There is no destructive lesion. Impression: No fracture. Read By- MEGAN M GAU M.D. Released By- MEGAN M GAU M.D. Released Date Time- 09/24/07 1013 Transcriptionist- MMG M.D. ADM: RAHMAN, ANWER Z REF: PCP: PCP,NONE ATT: RAHMAN,ANWER Z CON: ZINSER,PHILLIP G SCP:
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000817
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING .he: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 09/19/07 2221 Sex: M Med Rec # A000748298 ACCT: AO~26200199 Pt Location: *5S-0537-01 ZINSER,PHILLIP G 12774 BOENKER LANE BRIDGETON Exam MRI FACE MO 63044
Check-In # Order Diagnosis 1017990 Ord Diag: 730.20-0STEOMYELITIS NOS-UNSPE
INDICATION: Swelling left face in region of mandible. Patient had plate removed from left jaw. TECHNIQUE: The following sequences were obtained: Coronal, sagittal and axial T1 pre- and postgadolinium and STIR images were obtained through the face. 16 cc Omniscan was administered for this examination. FINDINGS: Unenhanced T1-weighted sequences best demonstrate abnormal marrow signal involving the left ramus of the mandible. The cortical margin is lost at its posterior and medial aspect. The lateral cortical surface of the mandibular ramus appears disrupted in a small focal area, however there is some persistent metallic artifact in this location, indicating this is the site of a cancellous fixation screw which has since been removed. A very small volume of fluid is seen immediately adjacent to the medial body of the left mandibular ramus. Edema is seen in the adjacent masseter muscle and in the lateral pterygoid muscle. After administration of gadolinium, these muscles enhance slightly. This is consistent with myositis. Diffuse edematous changes are seen in the subcutaneous fat overlying the left lower face and jaw, consistent with a cellulitis. No mature abscess is seen at this time. Inflammatory changes extend into the fat of the deep face. The superficial temporal artery and transverse facial artery pass through this inflammatory change as they course posterior to the mandible. The inferior alveolar artery also passes through an area of inflammation. Mastoid air cells and middle ear cavities appear free of fluid. Impression: Marrow edema involving the left mandibular ramus is consistent with osteomyelitis, particularly in conjunction with loss of bony cortex at the medial border of the mandibular ramus. This is associated with FINAL DUPLICATE Page 1
000818
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING .ne: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 09/19/07 2221 Sex: M Med Rec # A000748298 ACCT: A0726200199 Pt Location: *5S-0537-01 ZINSER,PHILLIP G 12774 BOENKER LANE BRIDGETON Checkin-Exam Code Summary 1017990-70537 myositis of the medial and lateral pterygoid muscles and inflammation throughout the masticator space, extending to the anterior aspect of the carotid space and the parapharyngeal space. No discrete abscess is seen at this time. Read By- KAREN J BARANSKI M.D. Released By- KAREN J BARANSKI M.D. Released Date Time- 09/20/07 1040 Transcriptionist- PMN ATT: RAHlvIAJ.\J, ANWER Z CON: ZINSER,PHILLIP G SCP: MO 63044
ADM:
RAHMAN, ANWER Z
REF: PCP: PCP,NONE
FINAL DUPLICATE
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000819
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING MARCH,PHILLIP H Sex: M Med Rec # A000748298 ACCT: A0731100362 Pt Location: *O/P ZINSER,PHILLIP G 12774 BOENKER LANE BRIDGETON Exam MRI ORBIT FACE & NECK W/WO CONT MO 63044
~me:
DOB: 10/02/76 Age: 32Y Date: 11/07/07 2119
Check-In # Order Diagnosis 1038878 Ord Diag: 730.20-0STEOMYELITIS NOS-UNSPE
Comparison study dated 9/19/2007 has been reviewed and compared to the exam of 11/7/2007. In comparison to the study of 9/19/2007 there is interval improvement in the bone marrow abnormality within the left mandible and the abnormal signal within the left masseter muscle on the study of 11/7/2007. However significant signal abnormality does persist within these structures on the study of 11/7/2007 which is an unusual finding given the long time course since therapy was initiated and remains worrisome for a persistent inflammatory process. Findings discussed with Dr. Zinser on 11/12/2007 at 10:50 a.m. Addendum Read By- NOAMAN W SIDDIQI M.D. Addendum Released By- NOAMAN W SIDDIQI M.D. Addendum Released Date Time- 11/12/07 1053 Addendum Transcriptionist- NWS M.D. NWS M.D.
MRI face with and without contrast
11/7/2007
Indication: Left mandibular pain. History of prior trauma in April 2007, with surgical repair in May 2007. Infection. Osteomyelitis. Technique: The field-of-view is optimized to evaluate the structures of the face and not the intracranial structures. Imaging in the sagittal, axial, and coronal plane was performed utilizing both T1 pre- and postcontrast and STIR imaging. The postcontrast T1's were fat-suppressed as were an axial and coronal T1 precontrast sequence. 16 cc of Omniscan gadolinium contrast was utilized for the postcontrast scan. Findings: REVISION - Addendum X 1 DUPLICATE Page 1
000820
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING .me: MARCH, PHILLIP H DOB: 10/02/76 Age: 32Y Date: 11/07/07 2119 Sex: M Med Rec # A000748298 ACCT: A0731100362 Pt Location: *O/P ZINSER, PHILLIP G 12774 BOENKER LANE BRIDGETON Checkin-Exam Code Summary 1038878-70263 There is marked edema and enhancement within the left masseter muscle adjacent to the left mandibular ramus. Additionally, there is subcutaneous soft tissue swelling and skin thickening of the left face in this region. Additionally, ill-defined inflammatory change is seen within the deep left face near the carotid sheath. The flow-voids of the jugular vein and carotid are maintained. There is bone marrow edema and enhancement within the left mandibular ramus and neck with areas of cortical indistinctness. The inflammatory findings are greater than expected given the remote nature of the trauma and surgery and is worrisome for mandibular osteomyelitis with associated left masseter myositis and regional cellulitis. There are no focal fluid collections to suggest abscess. Blooming artifact is seen in the region of the left mandibular condyle compatible with retained metallic fragment. No other foci of abnormal signal is seen within the face. There is no other sites of abnormal signal within the mandible. There is no abnormal signal within the maxilla. The parapharyngeal soft tissues are unremarkable. The tongue and peritonsillar regions are normal in signal and morphology. Impression: MR findings are worrisome for left mandibular osteomyelitis involving the ramus and neck with an associated left masseter myositis and regional cellulitis as detailed above. MO 63044
Read By- NOAMAN W SIDDIQI M.D. Released By- NOAMAN W SIDDIQI M.D. Released Date Time- 11/08/07 1202 Transcriptionist- SVM REVISION - Addendum X 1 DUPLICATE
Page
000821
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING me: MARCH,PHILLIP H DOB: 10/02/76 Age: 32Y Date: 11/07/07 2119 Sex: M Med Rec # A000748298 ACCT: A0731100362 Pt Location: *O/P ZINSER,PHILLIP G 12774 BOENKER LANE BRIDGETON Checkin-Exam Code Summary 1038878-70263 MO 63044
ADM: ZINSER,PHILLIP G REF: PCP: ZINSER,PHILLIP G
ATT: ZINSER,PHILLIP G CON: SCP:
REVISION - Addendum X 1 DUPLICATE
Page
000822
DEPAUL HEALTH CENTER 12303 DePaul Drive Bridgeton, MO 63044 DIAGNOSTIC IMAGING Med Rec # A000748298 ACCT: A0727400691 Pt Location: *ERQ SCHMIDT,RICHARD U 12303 DEPAUL DRIVE EMERGENCY DEPT BRIDGETON MO 63044 Check-In # Order Diagnosis 1023201 Ord Diag: 786.50-CHEST PAIN NOS
.me: MARCH,PHILLIP H DOB: 10/02/76 Age: 32Y Date: 10/01/07 2154 Sex: M
Chest one view portable. Indication: Fever and chills and jaw pain. Findings: A frontal view of the chest compared to prior of 9-24-07 shows the lungs to be well expanded and clear. The heart size is normal. No change has occurred. Impression: No acute infiltrate. Read By- M..ZI.TTHE\A) \A) ST.ZI.DNYK M. D. Released By- MATTHEW W STADNYK M.D. Released Date Time- 10/02/07 1008 Transcriptionist- SVM ADM: RAHMAN, ANWER Z REF: PCP: ZINSER,PHILLIP G ATT: RAHMAN,ANWER Z CON: ZINSER,PHILLIP G SCP:
FINAL DUPLICATE
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000823
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09/24/2007 13:07:4
000824
D1SCHARGE SUMMARY
PATIENT: MARCH. PHilLIP ADMIT DATE: 09/19/2007 DISCH DATE: 09/24/20Q7 ~!ry_SICIAN: SONIA N, MELKAVERI. M,D, MR#: 000748298 ACCT#: 0726200199 DOB: 10/0211976 ROOM;
PROCEDURES DONE DURING THE HOSPtTAL COURSE: MRI of the face/mandible. DISCHARGE DIAGNOSES: 1 Osteomyelitis of the left mandible. 2 Hypertension.
:3
Pain.
HOSPITAL COURSE: The patient is a 30-year-old African Amencan male with sLab injuries to the face and initial hflrdware placement which was then removed at Barnes In July. The patient returned back with facial swelling and cellulWs and also increasmg pain. Dr Zinser with infectious disease was consulted and an MRI ot his face was done. which showed osteomyelitis of thR left mandible. He was started on Unasyn and his Unasyn will be continued for six weeks. The patlcnt is unemployed and has no insurance so SSM Health Care has arranged for IV antibiotics at home. He Will follow up with Dr. Zinser in 4 weeks. Also his pam was not controlled so he was given a fentanyl patch and Dilaudid and he will be switched to fentanyl patell and Vicadin at the time of discharge. He will follow up later wfth Dr. Gunapooti or Witt! JoInt C Murphy Clinic for his pain management and also for monitoring of his blood preSSLfre DISCHARGE MEDICATIONS: Norvasc 5 mg p,o, daily. 1 Z Fentanyl patch 50 mcg transdermal q. 72 hours. 3 Pepcid 20 mg p.o. daily. 4 Neurontln 300 mg p.O. t.i.d. 5 Calace 100 mg p.o. daily. 6 Unasyn 2 grams IV q. 6h. as per Dr. Zinser's instructions, which have been wntten for home htlalth Cflre. 7 Vicodin 2 labs q. 4 hours p.r.n.
DISCHARGE DIET: Regular, DISCHARGE ACTIVITY; As tolerated.
FOLLOWUP; Dr, Zinser in 4 weeks. Dr. Gunapooh for pain as needed. Follow up with primary care physician or John C. Murphy Clinic.
SONIA N. MELKAVERI. MD.

SNM:327 - 2029345 D: 9124/200712:56 PM T: 9/28(20078:32 AM E: 09(28/2007 10:08 AM
cc:
ANWER Z. RAHMAN, MD.
MEDICAlfSURGICAL DISCHARGE SUMMARY-DP
- Page 1 of'l
000825
)
/
o sIgnature ne6ded see orders.
o H@aring Aid{s)
0 Asslstive device
harged to: Home Othef_ _ _ _ _ _~_r;____;__]

PhOne #
r~c
Ambulatory
.14 \
f .
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OPO HAReH,PHILLIP 0726200199 I>1DO 0537-01 COP) 10/02/1976 30Y 1>1 09/19/Q7 RAHNAN,ANWER Z 000748298
1IIIIIIIIIIIfIllUI
Make 2 copies ofthisform. Original/oml to charI.
000826
~v~
(IV
y
DePaul Health Center 12303 DePaul Drive Bridgeton,HO 63044 Patient Active Medication List (YES NO) PAGE NUMBER: 1 ESTIMATED DISCHARGE TIME: NORSE PHONE EXT:
iJ
l'
Please circle: Discharge Meds or post-op Meds
Account Number: 0726200199 patient Name: MARCH.PHILLTp Room Number: 0537-01 Date: 09/24/2007 Attending Physician: RAHMAN,ANWER Z Patient Allergies: No Known Drug A,llergies
Continue? Medication Generic Nwne [Bran.d Nall'le) with Directions
AM
Noon
PM
Bedtime
-~
**~.~
l:2-eNO
'0
1
l~NO
FENTANYL IDURAGESIC) TRANSD'ERMAL, {DORAGESI C) 50 MeG TRANSDBRMAL e ...ery 72 hours

FAMOTID:tNE{PEPCID} 20 MG BoY MOU'TH Daily ANLODIP:tNE {NORVASC) 5 MG BY MOUTH Daily <lIVEN AS: GIVEN AS:
(1)
*~
9:00 AM - Every 3rd
Da~
20 MG TABLET
5 MG TABLET
(1)
x x
x
GABAPENTIN{NEURONTINI300
~G
BY' MOUTH 3 Times a Day
GIVEN AS: GIVEN AS,
(1) 300 KG CAPSULE

(ll 100 MG CAPSULE LF
DOCUSATE SODIUM {COLACE) 100 MG BY MOUTH ONCE DAILY DO NOT CRUSH - TASTE
4~NO
AMPICILLIN!SUL(UNASYN) (ONABYN) 3 GM INTRAVENOUS EVERY 6 HOURS
... ,. EVERY 6 HOURS
>
PHYSICIAN SIGNATURE IS REQUIRED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST Medication Substituted per H05~ital Approved Formulary Substitution
Pilo~
Form 4/2005
H
PAGE tl'UMBER: 2 ESTlKATED D~SCRARGE TIME:

NURSE PHONE EXT,
Please circle: Discharge Mads o:t:" Pos1t-op Meds Bridgeton,MO 63044 Patient Active Medication List (YES NO) Account Number: Patient Name: Room Number: Date: Attending Physician: Patient Allergies: 0126200199 MARCH,PHILLIP 0531-01
09/24/~DO'
RAHMAN.ANWER Z
No Known Drug
Aller~ieB
Continue? Medication Generic Name(Brarud Name) with Directions
AM I Noon
PM
Bedtime
-----g--------------------------------------------------------------------------------------------------------------------------------a x . x I I x I
7 YES 10 YE 0 DOlCH CHLORIDE BACT 0.9% (BACTERIOSTATIC)3 ML INTRAVENOUS EVERY
lPHENBYD~INE(BENADRYL)25 MG
HOURS
NO
INTRAVENOUS EVERY 4 HOORS Needed Medications .......

::2 TAB BY MOOTH Every 4hrs prn
BeNe
6
..,... .., As
HYPROCODONB/Al'AP 5/500MC(VICiJD:IN 5/500MC) SEVERE PAIN
YES~m~ANSE7RON(ZOFRAN)(ZOFRAW)4
MG INTRAVENOUS EVERY 6 HOURS
AS NEEDED
22 YE:0wROMORPHONE HCL (DlLAUDI:O) 1 MrG INTRAVENOUS Every 8 Hours AS Needed ........ ,.. Held Scheduled Medications
......
Pilot Form 4/2D05
PHYSICIAN SIGNATURE IS REQQIRED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST
:>
= Medication Suhst.ituted per Hoslpital. Approved Formulary Substitution
H
DePaul Health C~nter 12303 DePaul Drive
PAGE lNUMBBR: 3
ESTIMATED DISCHARGE TIME:
Please circle: Discharge Meds or post-op Meds

Bridgeton,~o 63044 Patient Active Medication List (YES NO)
NURSE PHONE EXT:
Account Number: Patient Name: Room Number: Datel Attending Physician: Patient Allergies:
0726200199
MARCH.PHILLIP
0537-01 09/24/2007
RAHMAN.ANWER Z No Known Drug Allergies

AM
Continue? Medication Generic Name(Brand Name) with Directions
Noon
i 1
PM
II
Bedtime
-- - - - ~-- ------ --- ----- -- - -- ---- -. -----. ----------------------------- ----- - ------- ------- - -------------- ---------- ------------ -----------8 YES~OXICILLIN-CLAVUIJl.NATE(AurGMENTIN)675 MG BY' .MOUTH :2 "rimes a Day GIVEN AS: (1) 875 MG TABLET
II
Additional Orders
~.k 05- V\.ouVll----------_._--_.._-_._------
Ffu e
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Dr - Gu.~f<JDA~-----------------_._.._-_.._.. ........_-------------------------
Physician Signature: Nurse Signature:
~L
Da'./Ti~
Date/rime
o-=((:;;z !( (()1
Readhack Co:nfirmed [ J
PHYSICIAN SIGNATURE IS REQUI:RED ONLY ON THE LAST PAGE OF THIS MEDICATION LIST
pilot Form 4/2005
Medication Substituted per Hoarpital. Approved Formulary Substitution
PAGE:
12303 DePaul Drive Bridgeton. MO 63044 Patient's DisGharge Home Medication List Account Number: Patient Name: Room Number: Date: Attending Physician:
0726200199 MARCH,PHILLIP 0537-0l 09/24/2007 RAHMAN,ANWER Z
Patient Allergies: No Kn.o1I/n Drug AllerS'ies

Medication Generic Name(Brand Name} with Directions
I AM
Noon
PM
Bedtime
~*
* Scheduled Medications *
TAKE: (1) 50 MeG PATCH BIWEEKLY
FENTANYL (DORAGESIC) TRANSDERMAL (DURAGESICl 50 MeG TRANS DERMAL every 72 hours
**
FAMOTIDINE(PEPCIO) 20 :KG BY MOOTH Daily'
AMLODIPINE (NORVASC)
5 MG BY MOOTH Daily
9: 00 AM - Every 3rd Da,},
TAKE: TAKE:
(I} 20 MG TABLET
(1) 5 MG TABLET
x x
300 MG CAPSULE
GAEAPENTIN(NBURONTIN)
300 MG BY MOUTH 3 'rimes a Day

~OUTH:
TARE:
TAlI:E:
(1)
(1)
DOCUSATE SODIUM{COLACE) 100 MG BY DO NOT CRUSH - TASTE DO NOT CRUSH - TASTE
ONCE DAILY
J.OO KG CAPSOLE 1,F
AMPICILLIN/SOL {UNASYN) (UNASYN) 3 GiM IN'I"RAVENOUS EVERY 6 HOURS
T1L~:
(1) 3 GM INJECTION
INJECTIO~
**
EVERY 6 HOURS
KYDROMORPHONE HCL(DILAODID)
1 MG INTRAVENOOS ONE TIME
TAKE: (1) 1 MG
-~.~.
***** As Needed Medications
IF YOU HAVE ANY MEDICATIONS AT HOME WHICH DO NOT APPEAR ON THIS LIST,
FOR PATIEN'!" S USE ONLY; NOT PART 0 F THE PATIENT'S CHART
PLEASE CHECK WITH YOUR PRIMARY PHYSICIAN BE:FORE RESDMING THEM.
PAGE.
2:
DePaul Health Center 12303 Depaul Drive Bridgeton, MO 53044 Patient"s Discharge Home Medicat10n List Account Number: Patient Name: Room Number: Date: Attending Physician:
0726200~99
MARCH,PHILLIP 0537-01 09/24/2007 RAHMAN.AHNER Z
Patient Allergies: No Known Drug Allergies Medication Generic Name(8rand Name) with Directions
AM
Noon
PM
Bedtime
HYDROCODONEjAPAl? S/SaOMG{'IlJ:CODrN S.lSOOMQ) SEVERE PAIN
2 TAB BY MOUTH Every 4hrs prn
Additional Orders
-~".-------.-",,-------------------
IF YOU HAVE ANY MEDICATIONS AT HOME WHICH 00 NOT APPEAR ON THIS LIST, PLEASE CHECK WITH YOUR PRlMARY PHYSICIAN BEFORE RESUMING THEM.
FOR PATIENT'S USE ONLY; NOT PART OF THB PATIENT'S CHART
Physl<;ian Office PhcJne' Number _ _"'--_ _ _ _ _---:_ __

DPS-3901-GGG (1012001)
.~,
#!3';If#;@41'11i#li'~'.],'i'I.1U"d.i3!Q-I: iPt i+l1;Ji&
! l
OPS-a9Q1-999 (10/2001)
f ff3J;liQ#i@1,.li#.i;i.itJ,l.it.,f,,'Ill.tR;'t'-la;IIM#31li'1UZLZ.i
000832
DRVB MAY BE 1J1:;l'fN~flJ IN ACCt'HIJANC~ Willi THE. '""" HO~PlT . CHECKED HERE o-y
PHYSICIAN'S ORDERS
1 'Oaijv' inS1Nd of ~,r In~;~M Ql Y 3 No uallinlJ zeros (lmq not 1.0mg)
5. *McfPhine' in~3d of 'MS04"

~. *t~I~.gnw\lfl1 ~vlt~lf in~l~~d Ql
f. "Vnl1f
"Mg$Q4"
4. Always ur.a lI!~ding was

PATIENT HEIGHT <=:>
(Olmqnot.tmol
7. *Ev!ry ot/l8r (Ily' insmad 01 '00 D "MeG' instead 01 "!ill' 9. "InlgrnaiionaJ units' Instead of'lU'
e.
~SSM
H E A L T H . CAR
SlM 1DOO 065 14j?007j
LABEL
E~
DEPl\UL HIU.I4TH CENTER HARCI-i, PHIL1JTP 01'Q 0726?OOlSl9 MDO 053'/-01 lO!O~/]971) 30Y 1>109/"l9/(l7 RAflNJ\N. ANrlER Z 000'118:''38
IHllfIllllHlLlmlltll1
PHYSICIAN'S ORDERS
000833
IN ACCOAOAN,;e WITH T~nE ORUG MAY DC ,., ..,1 SPtN5CD SYSTEM
PHYSICIAN'S ORDERS
2' .lJn!t~. irmreid n1'u'
I 'Dally instead of "qd'
3~
No trailing mas (lmg nat LOmg)
4, Always use ~dlng mos (O,lrr.Q I1(It ,1mq)
'~$~M
H E A L T
PATIENT LABEL
DRI.'AUL HEAL1'U CENTER
f.L~C'H, PHILLlP
O?;?6200l99
1II111BII11ltBIIIIIIlI
MDO 0537-(ll
OPo
PHYSICIAN'S ORDERS
SlM,10(JO-065
(~12007)
10/02/1976 JOY
RM!<1AN, Ai'JlfgR Z
M 0'/19/0;
0007'182,91,;
000834
Frl Sep 21, 2007 03:27 pm
PREPS & Spr;CIAI. INSTRUCTIONS NOTICE
PAT.LNT
TEST
0537-01 MARCH,PHILLIP
Unit (MR)
ORDERING PHYSICIAN
0726200199
979457
MELKAVBRl,SONIA N
# UOOH8298
DOB: 10/02/76
SP INS):;R'!' PIce PER \'TO SQ PT S+YF.S
09/2<1 09:00
ROUTINE
Patient needs COnsent form.
patient may eat normally.
Check
if patient. is allergic to iodjne dye.
If you need .;<dditional information, go to the Intranet. DePaul Home page click on "Nursing" link on right side of page. Then click on "Radiology Test::> and Procedures" on left side of page and then choo:::e appropriate test
If creatinine 1.4 Dr less, or Creatinine Clearance ~.60ml/min. Omnipaque 300 IV, If Cre.:ltinine gr'e,;J.ter than 1.4 or Creatinine Clearance <:GOml/min. no contrast.
........... SCl\N
TO DPHC PHARtJlACY PRIOR TO TEST"**"'"
000835
!!DR~UU~M"'~Y~ll~U~'l'~'P~EN:yS_(~~O~IN~A~cc~o~n~OA~NC~E~W9:!1T:!H::..!TH:!E~---"s:.JJ~ _ _ _~!I,!I~~~AN'S rrSPITAL SYSTEM UNLESS ~
ORDERS
IMPORTANT
REM'
1. 'Oaily' instead of 'qd' :? "Units" instead of 'u'
3 No trailing was (1 mg nol j .Omg)

PATIENT HEIGHT
Q
4 Always us. leading mGS (O.lmg notlmOJ
'Mmplillle" Instead of MS04" 'Maqntsium suKale' instoad oj 'MgS04' 'Every ,,!!Jee day" instead of '0.0.0: 'MCG" mstead of 'fJlJ" 9. 'Irrt~mll1kJf1i!1 unil>" insteild Of "IU' 5. 6. 7. 8.
~SSM
H f A L T H . CAR
SLMl000065 (4/2007)
PATIENT LABEL
E~
DEPAUL HBJ\l;rtl CENTF.R

PHYSICIAN'S ORDERS
~'\l\RCH l PHlLI,IP OPO 0726200199 MOO OS:j'I-Ol 10/02/1976 30Y M 09/19/07 Rl\HMAN, AN'I>TRR Z OOC748;; 9fl
1IIIMIlIllmIlUDIII~
000836
PHYSICIAN'S ORDERS
1. "DailY' il1ste~ of 'qd'
~.
2, "Unils' imlm pf'lt'

3. No lrailingmros (1mg not 1.0mgJ
'Morphlnf"llIlread 01 'MS04' , 'M~no~um 3lIn~u' in~g of 'h19~g4"
7. 'EYefY oilier oay- Instead of '0.0.0.'
4. "fwaY5 use leading woo

fA lIENT HEIGHT 0::>
(O.lm(J rotlmgl
8. 'MCG' lnS\(lad of "/JO' 9. 'Intama1lonal urns' il151no ot 'IU'
~SSM
H E A L T H . CAR
S!Jv1 j 000-065 (4/2oo7l
PATIENT LABEL
E~
PHYSICIAN'S ORDERS
000837
OflUe. MAY Ill' OISPENSED IN ACCORUANC~ W!lH THE """'" FORMUl.AR,( SYSTEM UNLESS CHe:GKED HERE .."..
PHYSICIAN'S ORDERS
'- 'Daily" Instaad of 'qd'
2.
3.
4.
'Unnq'lIl~tg3(19f
N{)
trailing was (1rT!!J nOl LOmo)
Always U!~ leading terns

{Q.1mg
PATIENT HEIGHT q
no1 .1mlll
5. 6. 7. B. 9.
'Morphine" instead of 'MS04' 'Magnesium subl!" Instead 01 'MgS04' "Every ot~.ar day" instead 01 "0.0.0.' 'MCtl" inswad of 'pg' "lflWmati(mal onlts' instcatl 01 lty
PATIENT /ABEL
D~PAUL
H E A L T H . CAR
E~
HEl\l/T'H CENTER
!IIIIIIIIIIIIIII1I8U fYlARCH, PH1LLIP
PHYSICIAN'S ORDERS
SLM1000086 (4/2007)
01'0 0)2620019" r'IDO O~.3'I 01 10/02/19 7 6 30't M 09/19,07 RAJWJUi,i\NWRR Z 000H8298
000838
PERIPHERALLY INSERTED CENTRAL CATHETER ORDERS

Insert Pice line catheter by Vascular Access RN. Enter in HBOC under Department Consults.
Allergies;
1.
Assessment;
Obtain consent for Peripherally Inserted Central Catheter
If unable to place Pice line by Vascular Access Nurse. refer patient to Interventional Radiology.
II.
Diagnostics:
J?!..-/f
._?=>rl
.-.
//
Call Physician for INR 4.25 and I Of platelet count < 25,000, STAT one view portable chest x-ray post PICC insertion (tip verHlcation in vena cava)
Repeat STAT one view portable chest x-ray If PICC is repositioned Radiologist'Phys;cian to confirm PIce placement prior to use,
III.
Medications:
Use Lidocaine Hydrochloride 1 % inject intradermally to produce wheal to locally anesthetize site. Flush each lumen of Pice with 10 ml sterile NS IVP: before and after medication I solution administration before and after blood product administration every 8 hours (regardless of continuous IV InfusiOn) when obtaining blood sample, discard small red tube, then obtain sample. Upon completion, poise flush with 20 ml sterile NS IVP PRN to determine patency
IV. Treatment:
Place transparent legaderm dressing and biopatch at time or line insertion. Change dressing after every 7 days and PRN If the Integrity of the dressing is compromised. Document in progress notes and on ftowsheel
NO BP OR NEEDLE STICK IN PICC ARM

DO NOT USE ANY SYRINGE SMALLER THAN 10 ml WHEN lNJECTlNG IN Pice
abov~
I agree with the
orders with the eJ(ceptTon of those crossed throu9h.
Date: _ _ _ _ _ _ Time: _ _ _ __ Time

not~d _____
Physician._ _ _ _ _ _ _~_ __
Scanned: _ _ _ _~~ RN _ _ _ _ _~_ _ __
~SSM
.,." 11 f.l .
et
..
DePaul Health Genter

7L~BtRS ABOVE SCANk~_INTO
DATE:
PYXIS
1.JJI!~'Ir!~nlllllll
D.l::PAUL HEALTH CENTER
rip
Pice Ordets
q\rll,~Cr;~ '-l T!MEOlt J;>
0726200199 MED 0537-01 10/02/1976 30Y M 09/19/07 RAHMAN,AmqER Z 00074B298
000839
PHYSICIAN'S ORDERS
1. 2,
!)~ily Instead
of "qo'
lJn~ ifl~l~il!! Q! 'y'
3. No lTWHOlizeros (11l11l ne! LOmg)

PATIENT HEIGHT
0;'>
4. Always uw I~a(llno mas (O.lmg not.lmg)
5. 'Morphine' IIlSUad of 'MS04' It 'M!G"eSlum SulliW' Insleao 01 'WVS04' 1. "eveI}' oIlt8T diY' in$wad 01 -a.O D' B. 'MeG' Ins1eid ul 'j.lg' 9. '!rrtama1lonal units' lnsteaO of 'IU'
~SSM
SLMl000065 (4t2007)
PATIENT /.ABEL
DEPAIJL HEALTH CENTER

H1\RCH, PHILLJ P
H E A L T H CAR EN
IS18111111\1J1I1IMII
M
0726200199
MDO O~37-0-
\'
() PO
PHYSICIAN'S ORDERS
10/')2/1.9"1630Y RJ\H~uili 1 .r..NVIER Z
. ::!9!l9/07
()O Q 741;5 2:)8
000840
to latex? 0
risf<) 0 Yes .-..describe

sneezing, or Itching after: o OentaVlnternal exams a Contact with rubber gloves/product}; a blowing up balloons q Uso of condoms or diaphragm bal1l<1n<llS-, ~!Q~!QQl3!,"!ater c~'l1tnl!!~. kiwi
_~_ _
Answering yes to any of
Check the box below If yO\! havo ever experl~nced runny nose, toaring,
o Chart labeled
lhese requIre Initiation of Lalex Allergy Protocol
Cl Allergy armband
Include blood thinning over-toe-counter medicalion, htnbaf supplements (fist Home Health Services beIng used? Yes tJ NQ If yes, Name Sources of Informalion: OPatient 0 Medication Boltlf',s 0 Pat1ont's-F=-a-m-I::-lv--::Q~M':""e-d~L:-:is-tc-::.a Doctor's Office o Pharmacy Name ___ Pharmacy Number ______ d Old Chart 0 Other;
.:..:::r=:=;:~=
Comlntmls
These chocked orders will onfy bec:onl8 active when authorized by Phy' iciall.
Mt;!dlcillionslll
Home M"d list Recorded by' ;-.--,,p....-..;;_____ _
r1J;>/IfvmiIlS IVIII 00 dfsp(;,;!_8ti III ~,~y;v{(janc(j wI/II fhe hopI/uti rmv/iuy.

tlrfM </'VillTr!IIIS WlflU9 tlMrl tlulillg h<J~pdllf .s/J y Rll_' "
afi.L' -/sl;tlfJfge
Im:.< iJlrer-lelf by the physiohm
NQlI-[l)rmuiai'
Dale:
Doto:
1 knme:_ __
Tf,rlf.j. - - r - - - '
Phy&ician.
Nurse:
_
0 Rcadback confirmQd
----
Scanned 10 PhartNlcy Date:
~1jI1'lrme:: 0'71'1~__ 'Ilijiaf~~~_
000841
MOCOCCAL VACCINE NURSING ASSESSMENTI PROTOCOL
o~ot.~S f.\eo\J'C..
?'f;"\S
\)~\t.~
IJ Qualifies for influenza v8Cdne,Influenza vaooine 0.5 ml 1M will be admlnistEfl9d on day 3 in AM or at discharge (when discharged before day 3) per pmtOCOI ....~ cou...~ b~..o~r of tm, wtItI ~me~.
_.;Date;::;:;:.:_ _ _...:n.:.lln~e:I:IIIIIIII\'IIIII~I:IIIIII;;;As=sessment completed by:

OPO
~'Il'l."'-" ..
DePaulHealthCenter
I Initials: 072 6 2 0 0 1 9 9 fmo 0537 - 0 1 '- ____________ 10/02/1976 .30';( M 09/19/07
IS~-;'~-tf~;--- ~J~~~!~~~Anmflu
RAHMAN,ANWER Z
000748298
000842

SHORT STAY NOTE
PATIENT: MARCH, PHILLIP ADMIT DATE: 09/19/2007 DISCH DATE: PHYSICIAN; SONJA N. MELKAVERI, M.D.
MR#; 000748298
ACCT#: 0726200199 ROOM; 0537
CHIEF COMPLAINT; Swelling of the left side of the face. HISTORY OF PRESENT ILLNESS: The patient IS a 30-year-old African American male wIth a past medical history of hypertension, stab wound to the ieft jaw with fracture of the mandible, which was status post open reduction and internal flxalion at Barnes and apparently there WBS infection of the hardware and so it was removed in July 8t Barnes again. The patient WflS admitted to DePaul HospItal before he got the hardware removed in July at Barnes The patient has been doing well since then but for the past onfl Wflflk has stRrted to have again increasing swelling on the left side of the face. The sweHinu 18 assnciateo with pain. He denies any fevers or chills. He also denies any trouble sv./flllowing. Hp. W'ilS supposed to have an appointment with ENT but has not seen Ihem yet. Hfl has no other eOri'plaints of chest pain, shortness of breath. diarrhea, dysuria, or any other complnints. PAST MEDICAL HISTORY: 1 Hypertension. 2 Stab Injury to lhe jaw status posl open reduction and internal fixation. 3 Removal of hardware ALLERGIES: The patienl has no known drug Clllergies.
CURRENT MEDICATIONS:
1
Augmentin 875/125 mg 2 tablets p.o. dally. Percocet 1 tablet p.o. Q 4 hours p.r.n.
No IV drug abuse.
SOCIAL HISTORY: No history of smoking No alcohol

REVIEW OF SYSTEMS: In general. no faver<; or chill::; Respiratory - no cough or shortness ()f breath Cardiovascular no Ghftst rains flnrJ no palpitations. GI - no nausea and no vomiting. No diarrhea GU - no hematuria or no dysuri8. Renal no abnormalities. Neurological no history of CVA. The resl of the review of systems is negative. PHYSICAL EXAMINATION: VITAL SIGNS: On admission - Blood pressure '1671"1 '13, pulse rate 58, respiratory rate 16, temperature 97 5. and pulse oxygenation 99 Q/a on room alr. GENERAL APPEARANCE: The pHtient is well-developed FInd weil-nourished African American male III no acute dis1ress. CARDIOVASCULAR Sl and 52 normal. Regular rate and rhythm. ~t:S~II~A"jORY Lungs bilaterally dear to auscultation. No crackles. ABDOMEN: SoH. nontender, nondislended, with normal bowel sounds. EXTREMITIES: Lower extremities - no ped",1 edema. FACE: Minimal swelling of the left cheek. No fluctuation present. LABORATORY & DIAGNOSTIC DATA: On admisSion CMP showed a sodium of 140, potass:urn 3.7, chloride 103, bicarbonate 28. BUN 14, and creatinine 1 2 AlkRline phosphatas8 71, AL T 6, AST 16, and bilirubin 0.4. White blood cell eGunt 4.l. hemoglobin 122. hematocrit 37.2, and platelet count 206,000.
MaxlHofacial CT sc~m showed healing frm;!ure of Ihe left mandibl1lar ramus with mild mucosal thickening of the left maxillary sinus.
---_.._-,-------MEDICAL/SURGICAL SHORT STAY NOTEDP - Page 1 of 2
000843

MR#:
SHORT STAY NOTE
000748296
ASSESSMENT AND PLAN: 1 Left facial swelling. Rule out abscess. Possible cellulitIS. Check CT scan of the mandible. maxillofAcial CT scan. Continue Unasyn for now Consult Dr. Zinser and followup with ENT 2 Hypeliension. Monitor blood pressure and st8rt the pFltienl on antitlypertensjves. 3 Pain control, on Pereoeel p .r.n. 4 Prophylaxis - The patient is to ambulate four times a day and start on Pepcid.
SONIA N. MELKAVERI, M.D. SNM:388 - 2025345 0: 9119/20072:47 PM
T 9/20/200710:15 AM E OS/20/200? 12:04 PM

cc; ANWER Z RAHMAN, M.D.
MEDICALISURGICAL SHORT STAY NOTE.DP
- Page 2 of 2
000844
INTERDISCIPLINARY H'STORY AND PROGRESS NOTES

Date
lime
NOlES MUST BE S/GHFD
~
----~----~--------------------~-------------~~~T=,E~Nr~L~AB=a~------------
~SSM
H E A. l. T H CAR
SLM-1000003 (612003) 02
VC;PAOL HB]\LTH CRN'rItR l-mRCH, PHILLIP
~.
IIIHIIUIII~111D111111I11
M
OPO
09/19/07 000748290
0726200199
MDO 0537-01
lO/02/19'1b JO~ RAHMAN,1\NWER Z
FRONT
000845
MRI AIiJ 1\ttICJ-, ~- Ce. COMPLElff) ===J:L=tvt.=l=:o=~=--='=S=c=c='Of..="--""=======
~SSM
H E A L T H . CAR
INTERDISCIPLINARY
HISTORY & PAOGI'IESS NOTES
E~
SLM,1000-003 (61200:,) 02 BACK
000846
{.
)c
~SSM
SLM-1000-003 (f;!(2003) 02 FRONT
DEL>AU'"u HEA.LTl-l CRNTER
H E A L. T H e ARE"
l'<1.i>.lK'H, PHILL1P
0726~00199
liUSmlllllllRJllUilli
CPO
RAHM.l'N, AJH~ER Z
14DO o~:p - O"J , 10/02/1976 ,lOY M 09/19/07

000'J48:r98
000847
~SSM r
H gAL H . CAR
SLMl000-0D3 (fi!20{l3) 02 BACK
E~
INTERmSCIPLINARY HISTORY & PROGRESS NOTES
000848
~----~----~--------------------~------------~~~~-------------
e#X;SSM
H E A L T H . CAR
SLMl000003 (612003) 02 FRONT
DEPAUL HEJ\L1'l-I CENTER
E~
INTERDISCIPLINARY HISTORY & PROGflESS NOTES
I1l\RCH, PHULIP OPO 0726:,:00199 tflDO O~;'7 .. 01 1 () I 02/19") 6 .3 0 y !'It 0 ';J / 1 9 I 0 "/ RJ\HlVlAN . 1\.NI'IER Z O O C ?4 0 :, ~ 8
1IIIIIIlIIIIIIIIUIII
000849
fYl:;SSM
H E A L T H ' C Po. R
eO.
INTERDISCIPLINARY
HISTORY & PROGFlESS NOTES
SLl,l 1000-003 (6/2003) 02 BACK
000850
1':
~----~----~------------------------~----------~~~~~~-------------
~SSM
H E A L T H . CAR
DRPI\UL nEALTH cEN'I'ER
e~
INTERDISCIPLINARY
HfSrORY & PROGRESS NOTS
MARCH f PH Il,LJ:P HOO oS.n 01 0726200199 . 1'1 0'.1/19(0 7 10/02/1976 30Y 0007~D298 Rl'lm.ffiN , ANWEH Z
\iUUI'lllllll[~IIRI
OPO
SLM1oooooa (612003) 02 FRONT
000851
fYl:;SSM
H E A L T H ' CAR
SLMl000-003 (612003) 02 BACK
E~
DEPAUL Hl!:ALTH CEN'l'ER
INTERDISCIPLINARY HISTORY $. PROGRESS NOTES
MARCH PH1::..LIP t1DO OS'}"! 01 07 26?-0019 9 O'{ M 09/19;'07
111111111111111111111
OPO
10/02/19 7 6 3
RPHT>1AN I Affi'lER Z
00074929B .
000852
~.
I----~--~-----------+Hh~~~~~~--~==~~---------
PATIENT
~ss
DEP]\UL HEALTH CI'.;NTEF
H E A L T H . CAR E
I'<1ARCH, PHILLTP
INTERDISCIPLINARY HISTORY 8< PROGRESS NOTES
111111 I DIO!lmnM
NI)O
OP~
o 7 2 & 2 0 (1199
u~i J -,. Q 1
t<!
RAHM1V-I, AN\"iER ~
10/02/} 976 30Y
'J9/l9/07
000748;;: 98
SLM-l000-003 (1)12003) (/2 FRONT
000853
tYl:;SSM
INTERDISCIPLINARY
SLM-IOOO..Q03 (612003) 02 BACK
H E A L T H . CAR e-
000854
Date: Q0.-'lWZ .t/] Time: --U..l-~-- SSM DEPAUL PASTORAL CARE

SPIRITUAL ASSESSM~NT; Initial q FollQw-up_J~] Referral 0 Trauma 0 Code 0 Death 0 _~ - - - - - - STRESS: 0 An~b Fear q,AtiX\ous Jd{o9~ly 0 Guilty 0 Pain 0 gt:iBf 0 _ _ _ _ _ _ _ _ _ _ _ _ __ rlESOURCES: [j'Gratitude ra1~--cr'ffope--v Positive Image of God ZFamHyJFriends 0 Church 0 -~-----SERVICES: 0 Sacraments rrPray~~EJSupport 0 Literature 0 Support To Family 0 _ _ _ _ _ _ _ _ _ _ _ __ ADVANCE DIRECTIVES: 0 Yes d No 0 Unknown by Patient 0 lnappropriate 10 Ask 0
t7;(ftt1r;;f:1:Ed~tt; )Ji;'t.t.>: :?i~~I~ln g"~,

I
PATiENT LASH
~SSM
H E A L T H . CAR
SLM-1000003 (612003) 02 FRONT
E~
fl1~ P;;;/I
000855
tYl:;SSM
H E A L T H . CAR
INTERDISCIPLINARY
SLM-l000-003 (612003) 02 BACK
E~
HISTORY & PROGRI'!'SS NOTES
000856
1--~--~----------------~r---------Prn~WT---------~SSM
H E A L T H . CAR
DEPAUL HEkLTH C8NTER

HARCH, PHILLIP
E~
Imllllllllll.'III'11II
UFO
0726200199 ~IDO O~37'Ol 10/02/1976 30Y M 09/19/07

PJ\Hl'-tAN , At'lWRR Z O O 0 7,* 8 2 98
SLMloo0 003 (612(,'031 02 FRONT
000857
INTERDISCIPLINARY H.STORY AND PROGRESS NOTES

Datil
Time
I NOTFS MUST BE SIGNED
, i
.'
I
PATIENT LA8EL
~SSM
SLM10CO.003 (612003) 02 BACK
000858
PERIPHERALLY INSERTED CENTRAL CATHETER/MIDLINE CATttETER INSERTION PROCEDURE NQTE

-~--
-------
Insertion
The risks and benefits of the procedure were explained to patient. Consent was obtaIned. ~ /'\- 'I- <01.. '+2 Patient Identifiers and Time Out performed with : fSv ,.z,..., A-<-.,<".,}<.>f.\-
~iMidline Information 6r~nQ :a A-11-0 ~~

Gauge/French 4:F(~ Lumens ~~e lumen CJ Double lumen 0 Triple
III men
REF 317"1Q~
~
RCRF0222
Procedure:: The site was prepped and draped in a sterile fashion, Under sterile conditions per hospital polley, 0.. 1 ml 1% lidocaine was injected intradefmaUy to produce wheal. PIce placed using modified Seldinger
technique,
Site: 0 right
~) "ii~~ein
'f....
Cephalic vein
Brachial vein_ _ __
Catheter t(immecr-~) No Length

Arm Circumference R\
4-<5~>""Mark Internal length ~~""Mark External

A-" ,c-'<..--'" A--'3b-V E -:s I
-r--ii'
cf
Mark
~c.,-..
Number of attempts:
PIce Up verification by CXR and order for use needed prior to using PIce.
Patient tolerated procedure
p./f-vL
fuvp
Ron.vr,.
C1n"-IF'~f.4-8. <_L'(,
Flush Protocol Each lumen of th~1Mid1ine f1us~ with 10ml NS IYP Positive blood return in all lumens. ~~))(. No _ _ __
Patient Education: Patient received
Pice booklet and card. Pice sign placed at head of bed. Patient
anel staff educated on Pice care.
Date:
9/;;,-//07
Time:
Signature:
' (3- '/Q-__

---~
rt1/l-if/<!:
I-<-~~'-'-evz..,,~ _
~SSM
.. f
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...
DEI'AUL HEALTH CENTER

MARCH,PHILLIP lip 0726200199 MED 0537-01
lolo~/1976
1IIIIIIIIIIIfllllBIIII
::lOY
1'1
PIce Procedure Note 8/007
09/19/0 1
RAHMAN,ANNER Z
000748298
000859
Attach this CMheter Mail,tenant'. GUide to patient's chart.
:\
Bard Access Systems, Inc.
Polyurethane
Pice
Th,S \Jilll(lf"<! has

!l1HHled (HI.
Powerf'ICC Cathp,\sr
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01'
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L:rJd:!!.;=::
R'l-~ rL-.___
New Impor1an1 Information:
When cleaning the exit site:

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11\1 ;'t-,)l e;rX~' \111} 1,',.a;.:'fI)\irt'l t'MY{t 1.3\11 (,1 5 mLi;'w, W&ming: PeN",)' ~pc\n! lI)a.f;n~ PI'('!,J.J'17 1Iif.i'tlH{..J f\.,I1!.HB f'T\.1 ,'ltV, v~nt o.V,:'f P''-':i!.,!iIiz.a\i9n fl.1 "II w.;G~'Jdi!'Q Cil~hdi-;i, wilK';' IY':<'1~' (; ..nl~k~
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t.3~etr 1 ..~}iC.atK<it !tN r<l"M'f Irt~l"''')~'< ot f:!fHtf3':'~ wjplW!; Ole CilltH:hjI 6 QOf.lty t('t V.iUl~~.arr.J t,~ pr:'K t...o;.f' f-. but r;tm~~,
PaworPlCC
Cath&!er Maintenance
h-i:$n me' til~!H".IlC4' .'..:ith ~Hr~l1Hl!~1 .":;,ll</:'i" O},',flo,:,y "I? mhHb I./( Nt.e( ('(ll:h U~~
r~ tn~V ilP:X(7l,)rll3le-t-c':s'l {)( Ht9 prcc-,!(h;u- !<n d ~ianjCula:r tM!n:nt ,fJ, 1iJl(tlant-O (1!~I'.t~IH ',6 j'espotl~n~(! 10 fI'1Bluetl."'.a) H;:.;: ilO.:Vtn ":.~;tllj'. (/1 " patlJ;nr as it pt';,talflS tn ;~ iJ(r.\lef rje r.lif}'l j.s;lXUi).<, re
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'...'(;Qlt8Sl1't\~(lm
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rill;..bGTl 01
Warning: Use 01 ff.m~}i<S Jltt rna(l<~~ -POWB( Ini:ct;fhk~ ~! ~~ef ~ ~l~tlOr)

01 CQnlW';\' nte&~ !"'Tft}' :.<1IJ.';V JaAufE 01 thf' {:~jtf1'~.ef.
Power Int1l'clion Procedure:

1
3
HenwY"e ttl(: ill~v:bOfl!l'lecd,\(~~G. tap lU;'<ll UI~ PQwerPfCC carl-,:C'leT,
2' AII<1:t1"i 0 to rill (:It t.vJ9r S:yf'f'lV,' MI~~u >t.ti1h ~terik f~1"I'laJ salt'\{: A.$p.r';;Uf" In~ aCe-'~\e tHuvJ !\.~urn f1fld '" q,nO'u:,~y ftRI1 fht:t Cil\ll{;t'1 wilh lilt' lull It) tnl oi slew- l'O!'ftl,11 ';ijhn~ ~
Warning; railur~ to t'W\,.\lIn })ftl~m~ (lj ih~ tlQn' 'JtU(Hi":~', HI&Y ie:::r,iU In J.",(j~\l)f iMJj!8.
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071 !(lI1 Hov 1 .. D"l.?H
_IJOWMP/W.-
000860

CONSULTATION REPORT
PATlENT: MARCH. PHILLIP ADMIT DATE: 09/19/2007 CONSULT DATE: 09/20/2007 ATTENDING PHYS: ANWER Z, RAHMAN, M,D, CONSULTING PHYSICIAN: JOHN J. BONACORSI, M,D, MR#: 000748298 AceT#: 0726200199 DOB: 10/02/1976
ROOM: 06J7
HISTORY OF PRESENT ILLNESS: The patient is 8 30-year-old, African American male who was well until earlier in the year when he incurred a stab wound to the left neck and associated left mandible fractllre, He was cared for at Barnes where he apparently had arterial ligation in addition to open reduction and internal fixation of his mandible fracture. He subsequently developed infection which required removal of his hardware in early July. He reportedly received only brief antibiotic therapy after the same. He has subsequently had ongoing issues with paln and swelling. He eats relatively well when he is taking significant analgesics. Because of his recurrent pain and swelling and limitation of motion of his jaw, he is admitted at this time for management of possible osteomyelitis. The patient had recent CT scans, plain fUms, and MRI. While all this therapy has previously been primarily carried out at Barnes, he does not desire to return for further management. It Is noteworthy that he has not had any difficulty swallowing or any difficulty breathing. He has had evaluation here a1 DePaul including CT, plain mandible films, and MRlln the past few days. PAST HISTORY: As per attending physician,
ALLERGIES: None are known. PHYSICAL EXAMINATION: GENERAL: Reveals a generally healthy appearing, African American male in no distress at the current time, HEAD AND NECK: Revealed normal tympanic membranes. The nares are clear. He does have a deviated septum. Oral examination reveals that he is able to open his mouth at least 3cm. Otherwise intraoral examination is relatively benign, Cervical examination is remarkable primarily for induration and mild swelling of the left parotid region without marked inflammation or evidence for either phlegmon or absces5
formation.
IMAGING; Review of the films there is demonstrable left mandible fracture on the left side with evidence for previous platin9. OthelWlse. there is no 9ross eyidence for cervical abscess, I did not see any significant radiographic evidence for osteomyelitis. IMPRESSION; The patient has facial pa!n and swelling likely due to cellulitis if not possibly early osteomyelitis, The patlent does not need any sort of surgical intervention at this time. He needs appropriate antibiotic therapy until this process has completely resolved and that resolution has been documented for a significant period of time. Thereafter, determination should be made regarding residual issues relating to his mandible fractllre. I would like to inform you that I no longer carry out surgical treatment of facial fractures other than nasal bones, When this process has resolved, oral maxillofacial consultation or consultation with an otolaryngologist or plastic SlJrgeon who manages mandible fractures should be sought regarding possible future intervention.
MEDICAUSURGICAL CONSULTATION REPORT-DP
- Page 1 of 2
000861

PATIENT: MARCH. PHILLIP
CONSULTATION REPORT MR#: 000748298
JOHN J. BONACORSI, M.D. JJS:1682026092 0: 9/20/200710:15 AM T: 9/20/2007 10:56 AM E: 09/20/2007 11 :21 AM
cc: ANWER Z. RAHMAN. M.D.

JOHN J, BONACORSI. M.D.
PHILLIP G. ZINSER, M.D.
MEDICAUSURGICAL CONSULTATION REPORTOP
Page 2 of 2
000862

CONSULTATION REPORT PATIENT: MARCH, PHILLIP ADMIT DATE: 09119/2007 CONSUL T DATE: 09/20/2007 ATTENDING PHYS: ANWER Z. RAHMAN, M.D. CONSULTING PHYSICrAN: JOHN J. BONACORSI, M.D. MR#: 000748298 ACCT#: 0726200199 DOB: 10/02/1976 ROOM: 0537
HrSTORY OF PRESENT ILLNESS: The patient is a 30-year-old. African American male who was weH until earlier in the year when he incurred a slab wound to the left neck: and associa1ed left mandible fracture. He was cared for at Barnes where he apparently had arterialliga1ion In additlon to open reduction and intemal fixation of his mandible fracture. He subsequently developed infection which required removal of his hardware in Etal'ly July, He reportedly received only brief antibiotic therapy after the same, He has subsequently had ongoing issues with pain and swelling. He eats relatively well when he is taking l'3ignificant analgesics. Because of his recurrent pain and swelltng and limitation of motion of his jaw, he is admitted at this time for rnanagement of possible osteomyelitis. The patient had recent CT scans, plain films, and MRI. While all this therapy has previously been primarily carried out at Barnes, he does not desire to return for further management It is noteworthy that he has nol had any difficulty swallowing or any difflculty breathing. He has had evaluation here at DePaul including CT, plain mandible films, and MRI In the past few days. PAST HISTORY: As per attending physiCian. ALLERGIES; None are known. PHYSfCAl EXAMINATION: GENERAL: Reveals a generally healthy appearing, African American male in no distress at the current time, HEAD AND NECK: Revealed norma! tym panic membranes, The nares are clear, He does have a deviated septum, Oral examination reveals that he is able to open his mouth at least 3-cm, Otherwise intraoral examination is relatively benign, Cervical examination is remarkable primarily for induration and mild swelling of the left parotid region without marked inflammation or evidence for either phlegmon or abscess formation, IMAGING: Review of the films there is demonstrable left mandible fracture on the left side with evidence for previous plating. Otherwise. there is no gross evidence for cervical abscess. I did not see any significant radiographic evidence for osteomyelitis, IMPRESSION: The patient has facial pain and swelling likely due to cellulitis if not possibly early osteomyelitis, The patient does not need any sort of surgical intervention at this time. He needs appropriate antibiotiC therapy until this process has completely resolved and that resolution has been documented for a significant period of time, Thereafter, determination should be made regarding residual Issues relating to his mandible fracture. I would like to inform you that I no longer carry out surgical treatment of facial fractures other than nasal bones. When this process has resolved, oral maxillofacial consultation or eOflsultatien with an otolaryngologi8t or plagtic ~urgeon who manages mandible fractures should .be sought regarding possible future intervention.
This document has been reviewed and signed by JOHN BONACORSI Sign DatelTime: 12107/2007 5:02PM EST
MEDICAUSURGICAL CONSULTATION REPORT -DP
- Page 1 of 2
000863

PATIENT: MARCH, PHILLIP
CONSUL TATION REPORT

MR#: 000748298
JOHN J. BONACORSI, M.D.

JJB:168 - 2026092 D: 9/20/200710:15 AM T: 9/20/2007 10:56 AM E: 12/08/2007 09:01 AM
cc:
ANWER Z. RAHMAN, M.D. JOHN J. BONACORS1, M.D. PHilLIP G. ZINSER, M.D.
MEO'CAUSURGICAL CONSULTATION REPORTDP
- Page 2 of 2
000864

CONSULTATION REPORT
q(
'1- ~t.{ ~
PATIENT: MARCH. PHILLIP MR#~ 000748298 ADMIT DATE: 09/19/2007 ACCT#; 0725200199 CONSULT DATE: DOB; 10f02f1975 ATTENDING PHY$: ANWER Z RAHMAN. M.D. ROOM: 0537 CONSULTING PHYSICIAN: MAHENDRA P. GUNAPOOTI. MD.
CHIEF COMPLAINT: Left-sider! far:ial swelling 8nfJ pain, status post surgery to the mandibulm region secondary to facial injury WIHl a screwdriver during an assault. HISTORY OF PRESENT ILLNESS; The patient is a 30-year-old African Amenc~:ln male admitted to the hospital because of increasing pain. He was seen a1 Barnes Jewish Hospital for assault with a screwdriver and a punching to the lefl-sided mandible region, for which an open reduction and internal fixation was done. He reports he got the hardware removed in July. The patient is having excruciating pain fiS well as tingling and numbness over the facial region and the longue region. I was called 10 evaluate further. Apparently the patient is on IV Oilaudid 1 mg every 6 hours as needed, which is giving some pain relief. PAST MEDICAL HISTORY: Significant For hypertension, stab injury to the jaw, status post open reduction and internal fixation and hardwGre removal. ALLERGIES: No known drug allergies. MEDICATIONS: Augmentin and Percocet. SOCIAL HISTORY: Denies alcoholic beverages and recreational street drug abuse.
FAMIL Y HISTORY: Noncontributory.

REVIEW OF SYSTEMS: Significant for pain and Fever. All other systems were reviewed and are negative. PHYSICAL EXAMINATION; GENERAL: The patlen! is alert. awake, and oriented x3. sitting up in bed, appears in no acute distress. VITAL SIGNS: Stable. Pain scale 7-8i10. HEAD/NECK: Normocephaiic, atraumatic. Neck supple. Throat is clear. PERRLA. Extraocular muscles are intact. CHEST: Bilateral good air entry noted. FACE: There is a healed surgical scar and swelling noted over the left facial region. EXTREMITIES: No calf tenderness noted. MRA of the facial region noted to show osteomyelitis. IMPRESSION: Left mandibular osteomyelitis on bIOpsy, and cellulitis. PLAN: At this time it is reasonable lo start him on Duragesic patch 50 mcg per hour today, just for 24 nours. The IV DliaucHd can be switcned to q. 4 hours for OM dey then change it to q. 6 hours 9/22. Neurontin can be started at 300 mg p.o. f.i.d. Thank you for allowing me to participate in the care of your patient. Upon discharge, the patient will be seen by the primary care physician and follow up at Barnes Jewish Hospital and pain management
MEDICAL/SURGICAL CONSULTATION REPORT -op
- Page 1 of 2
000865

PATIENT; MARCH, PHILLIP
CONSULTATION REPORT
MRt1; oo0746Z96
This document has been reviewed and signed by MAHENDRA GUNAPOOT! Sign DatefTime: 09/30/2007 2:27PM EST MAHENDRA P. GUNAPOOTI. MD.
MPG:221 - 2027564 QA11 0 D: 9/21/20072:12 PM T: 9/21120073:24 PM E: 09130/2007 17:GO PM
cc:
ANWER Z. RAHMAN. M.D.
MEDICAL/SURGICAL CONSULTATION REPORT yOP
- Page 2 of 2
000866
000867
000868
000869
II
Compfalnt: Factal Pain
Triage nme: Wed Sep 192007 01 :16
Name: Maroh, Phillip Age: MSO Wt 73.5 Kg (est.)

~9dRec:
000748298
AcctNum: 0726200199
Urgency: ESI-3 Room:

\......... Vital Signa: (0111) ,SP:16l/99
'oure.: Home By: Ambulatory
None Pcp Emergency
Pnyttctana:
Kg Weight: 73.5 (est.)

PhysIC~S
, T:98.7
R:18
kNOWN ALLERGIES
No known dr:ug 8".rgl&s.
HISTORY (Wed Sep 19200101 ' ,:MEOICAI. HISTORY; HI~ry

, ; AprtJ 28th, 2001. Hl$ry Of '--,' IpSYCHIATRIC HISTOAY; No i payohJatrlo hla'ory. No pHYfOu. i$URGICAL HISTORY: ....w Repair, ~ not retevant to the caM. Jaw
k1id1!Jt,,,~merat, Stabbed In left face
~=~::ihl.tOry, No prevfou$
~,Dt'ntcoho'abuie"
- .....n ..v
,-,' ,
not rot.vant to the CAe.. 'SOCIAL HISTORY: Denies drug abu~; '..,wwr.'aL (FAMILY HISTORY: Famflyhtatory .. '" this CMe. Family hletory is notcOl1ttt~l~
I'ODmONAL TRIAGE (Wed Sep 19 .._,r,V.',
lCOMPLAINT
fPROVIOERS~
Denlee tobacco . b.latory la not contributory to
TRIAGE NURSE: Jean~:~e~N\\Vl@i

;,HE:te~lT!
,ADMI8SION :Pf\TIENT: NAME: Phillip Mar~h.

~
314522-S730,' MeOICAL Ae~~OAD1NI l NUMBER: 20070919011

PRE-TRIAGE ' ,
, C~mp.: NO, He'!!ltReJated: '-'!"'I,,:V""!1:l
1,aQCm. PHONE:
Trauma:*NO, Work
NU.it4SE,R: 0726200199, IBEX or Cnart19 nurse n01I1fed.
;FALL RISK: TIMS: 0112. r2A.. '.M... ,'l.'A",f.. IASSESSMENT:The GeS r OCCURReD 4128107 AND ! NOTED. DENIES FEVER'. ,IMMUNrZATIONS: Last tetanue shot TS SCREENING: Denies TB screening. ' '''-:DOMESTtC VIOLENCE: Not Applic~bl,; '.:iu,cst!()OaUW1tlJiiirbWrlefi. 'EDUCATIONAL/CULTURAL BARRIERS; No .;~
PREVIOUS VISIT AlLERGIES:
000870
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~SSM

DePaul Health Center

2006 Missouri ; Quality Award Recipient

f&M 1dl flwm,(Signed) J /

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

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24 HOUR MEDICAL/SURGICAl.. PATIENT CARE RECQRD

DePaul Medical Records/Phillip H. March

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

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DePaul Health Center

24 HOU~ MEDICAL/SURGICAL PATIENT CARE RECORD

DePaul Medical Records/Phillip H. March

24 HOUR MED'CAL/SURGICAL PATIENT CARE RECORD

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10/02/1976 31Y M 10/02(07 MELKAVE!U, SONIA N 0007H12;l6

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DePaul Medical Records/Phillip H. March

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

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24 HOUR MEOICAI./SURGICAL PATtENT CARE RECORD

DePaul Medical Records/Phillip H. March

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DePaul Medical Records/Phillip H. March

24 HOUR MEDICAL/SURGICAL PATIENT CARE RECORD

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