Universidad de Puerto Rico Mail - (No Subject)

Universidad de Puerto Rico Mail - (no subject)
1/3/16, 11:01 AM
Raymond E Rivera Vergara <raymond.rivera3@upr.edu>
(no subject)
1 message
Rivera-Vergara, Raymond <Raymond.Rivera-Vergara@va.gov>
To: raymond.rivera3@upr.edu
Sun, Jan 3, 2016 at 10:49 AM
LOCAL TITLE: H&P-MEDICAL SERVICE

STANDARD TITLE: INTERNAL MEDICINE H & P NOTE
DATE OF NOTE: DEC 30, 2015@20:55
ENTRY DATE: DEC 30, 2015@20:55:22
AUTHOR: MROUEH,GABRIELA
EXP COSIGNER: URBINA-REYES,BRENDA Y
URGENCY:
STATUS: COMPLETED
Internal Medicine Services History and Physical Examination

===========================================================
********** *** ***

********** **** ****
****
*********
****
*** ***
*** ***
*** *******
*** ***
*** *** ****
*********
*********
***
***
*** ****
*******
********** *** ***
***
** ***
***
********** *** ***
***
** ***
***
CHIEF COMPLAINT:
===============
"Me transfirieron pero ya me siento mucho mejor"
HISTORY OF PRESENT ILLNESS:

https://mail.google.com/mail/u/1/?ui=2&ik=91c01141a5&view=pt&search=inbox&th=15207f75b068f681&siml=15207f75b068f681
Page 1 of 77
1/3/16, 11:01 AM
==========================
Mr. DIAZ-MENDEZ, ULISES is a 85 year old MALE patient with the below mentioned
medical history who was in his usual state of health consisting of free
ambulation, self care, and total independence on activities of daily living
until approximately 1 week ago when patient began with nausea, ~4 episodes of
gastric content vomiting, watery diarrhea, dry cough, fever and general malaise.
He denied abdominal pain. Patient refers that he had been feeling well for a
while, but last Thursday patient felt worse than ever and his grandson decided
to call the ambulance to take patient to hospital. He also refered that his eyes
had become more yellow. He did not come to VAER because ambulance was not
allowed to come to VAER so he was taken to Hospital Buen Samaritano. There he
was hospitalized with the diagnosis of obstructive jaundice, suspected
cholangitis, pancreatitis and bronchial pneumonia. Studies available in chart
show that patient had abd/pelvic CT and abdominal sonogram done. CT abd/pelvic
remarkable for "cystic duct stone, biliary tract and common bile duct multiple
stones resulting in obstructive jaundice with intrahepatic biliary ductal
dilatation". Abdominal sonogram remarkable for "findings compatible with
intrahepatic and extrahepatic biliary ductal dilatation likely from biliary
tract obstruction secondary to choledocholitiasis...The common bile duct
measures 13mm in diameter...The pancreas demonstrates slight ill defined
echotexture that may represent early pancreatitis." Patient now refers feeling
marked improvement. Patient there was treated with Zosyn and Levaquin. He refers
not being evaluated by GI service. Patient transfered to our insitution for
further care and for evaluation by GI service for possible MRCP or ERCP.
COMORBIDITIES:
==============
- Diabetes Mellitus Type II
- Chronic Pancreatitis
Page 2 of 77
1/3/16, 11:01 AM
>s/p pancreatic pseudocyst and exploratory laparotomy

- Depression
- Duodenal Ulcers
- Hypercholesterolemia
- Low back pain
- Diabetic Neuropathy
- Macular Degeneration
- Lumbar Radiculopathy
MEDICATIONS:
============
Admission Medication Reconciliation
Outpatient includes Prescriptions and Non-VA meds
Inpatient includes Unit Dose and IV
Medications Ordered for Both Outpatient and Inpatient
---------------------------------------------------------------...None
Outpt Meds with No Corresponding Inpt Meds
-------------------------------------------------------------Acetaminophen 325mg tab 650mg 2 tablets po q6h prn
Alcohol prep pad 1 pad misc qid
Atorvastatin calcium 80mg tab 40mg 0.5 tablet po at bedtime
Buspirone hcl 5mg tab 1 tablet po am-pm
Cholecalciferol (vit d3) 1,000unit tab 2000units po daily
Clotrimazole 1% top soln a small amount top bid
Freestyle lite (glucose) test strip 1 strip misc tid
Gabapentin 400mg cap 1 capsule po bid and at-bedtime
Insulin glargine,human 100 unt/ml inj 20 units sc at bedtime
Insulin syringe 1ml 30g 0.5in 1 syringe misc daily
Lancet,freestyle 1 lancet misc tid
Page 3 of 77
1/3/16, 11:01 AM
Latanoprost 0.005% oph soln 1 drop ou at bedtime

Multivit/ophth areds2/lute/zeax cap/tab 1 capsule po bid
Omeprazole 20mg ec cap 1 capsule po daily
Pneumococcal 13-valent conjugate vaccine 0.5 milliliter im once
Trazodone hcl 50mg tab 1 tablet po at bedtime
Zolpidem tartrate 5mg tab 1 tablet po at bedtime
Inpt Meds Only (that are not on Outpt)
---------------------------------------------------------------...None
CODE STATUS:
FULL
============
PAST HISTORY:
============
Adult Illnesses:
See COMORBIDITIES above.
----------------
DRUG SENSITIVITIES AND ALLERGIC REACTIONS:

-----------------------------------------Penicillin, Aspirin
IMMUNIZATIONS:
-------------Immunization
FLU
C
C
Series Date
Facility
Reaction
10/14/2009 SAN JUAN V* NONE

Page 4 of 77
FLU WHOLE
1/3/16, 11:01 AM
11/19/2003 SAN JUAN V*

10/23/2002 SAN JUAN V*
INFLUENZA
11/18/2010 SAN JUAN V*

10/14/2009 SAN JUAN V*
10/14/2009 Va SAN JUA*
Comments: ADMINISTERED BY
MS:NIEVES,MARIA-LPN.LEFT DELTOID
AREA-LOT-98446P1-EXP-JUN/2010--DATA ENTRY
ONLY
10/14/2009 Va SAN JUA*
10/01/2008 In HOSPITA*
10/01/2008 In HOSPITA*
10/15/2007 SAN JUAN V*
12/01/2006 SAN JUAN V*
11/03/2005 SAN JUAN V*
10/13/2004 SAN JUAN V*
B
PNEU PCV13
PNEUMOVAX
TD-ADULT
C
C
09/10/2015 SAN JUAN V*

08/19/2003 SAN JUAN V*
SURGERIES:
---------MAR 14, 2016 Proc: PHACOEMULSIFICATION AND INTRAOCULAR LENS RIGHT EYE
SEP 11, 2015 Proc: AVASTIN INTRAVITREAL INJECTION LEFT EYE
JUL 16, 2015 Proc: INTRAVITREAL INJECTION OF AVASTIN LEFT EYE
MAY 19, 2015 Proc: LEFT EYE AVASTIN INTRAVITREAL INJECTION 1/3
FAMILY HISTORY:
Page 5 of 77
1/3/16, 11:01 AM
===============
FATHER: DM
MOTHER: DM
SOCIAL HISTORY:
===============
HABITS:
------ALCOHOL: Drank for many years, quit 22 years ago
TOBACCO: smoked 1ppd for 30 years, quit 18 years ago
DRUGS:
REVIEW OF SYSTEMS:
=================
GENERAL
(+) Fever
BREASTS
(-) Lumps
(-) Night sweats
(-) Pain/tendernes
(-) Excessive thirst
(-) Nipple discharge
(-) Easy bruising
(-) Gynecomastia
(-) Falls
(-) Itching
(-) Weakness
(-) Rash
ENT
(-) Visual changes
GASTROINTESTINAL
(-) Melena
Page 6 of 77
(-) Double vision

(-) Eye pain
(-) Hearing loss
(-) Vertigo
(-) Ear infection
(-) Nose bleed
1/3/16, 11:01 AM
(-) Abdominal pain

(-) Rectal pain
(-) Bowel incontinence
(+) Jaundice
(-) Changes in bowel habits
(-) Constipation
(-) Nasal obstruction
(-) Rectal bleeding
(-) Frequent sneezing
(-) Hematemesis
(-) Nose running

(-) Nocturia
(-) Tooth ache
(-) Bleeding gums
(+) Nausea
(-) Heartburn
(-) Dysphagia
(+) Vomiting
(-) Loose teeth
RESPI/CARDIO
GENITOURINARY
(-) Cough-productive
(-) Polyuria
(+) Cough non-productive

(-) Hemoptysis
(-) Shortness of breath
(-) PND
(-) Orthopnea
(-) Hematuria
(-) Urinary infection
(-) Stones
(-) Venereal disease
(-) Frequency or urgency
(-) Palpitations
(-) Incontinence
(-) Murmur
(-) Dysuria
(-) Edema
(-) Hesitancy
(-) Claudication
(-) Dribbling
(-) Thrombophlebitis
(-) Orthopnea
(-) Wheezing
(-) Chest pain
NEUROLOGICAL
MUSCULOSKELETAL
Page 7 of 77
(-) Seizures
1/3/16, 11:01 AM
(-) Joint pain
(-) Weakness
(-) Stiffness
(-) Pain
(-) Joint swelling
(-) Difficulty speaking

(-) Tremor
(-) Backache
(-) Painful feet
(-) Gait problems

(-) Headaches
(-) Syncope
(-) Head trauma
(-) Hallucinations
(-) Delusions
(-) Loss of Consciousness
PHYSICAL EXAMINATION:
====================
VITAL SIGNS:
-----------VITAL SIGNS:
DATE/TIME
TEMP
12/30/15 @ 2021
98.2
PULSE
69
18
RESP
BP
124/70
PAIN
6
1. GENERAL APPEARANCE: Active, alert, oriented to time, place, and person.

Cooperative. In no acute distress.
2. HEAD: Normocephalic, atraumatic.
3. NECK: No JVD at 45 degrees. No carotid bruits, masses, tracheal deviation.
Page 8 of 77
1/3/16, 11:01 AM
4. EYES: Pupils equally round and reactive to light and accomodation.

Extraocular movements intact. No corneal lesions. Non-icteric,
non-erythematous sclerae.
7. MOUTH: Moist oral mucosa. No erythema or lesions. No tongue deviation.
8. THROAT: No erythema, purulent secretions or exudates.
9. CHEST: No trauma. No use of accessory muscles during breathing.
11. LUNGS: Clear to auscultation bilaterally. No rhonchi, wheezes, crackles.
12. HEART: Regular rhythm. Audible S1/S2. No S3/S4. No murmurs, rubs, gallops.
13. ABDOMEN: Bowel sounds positive throughout all quadrants. Soft, depressible,
non-distended, non-tender to superficial and deep palpation.
No guarding or rebound tenderness.
15. BACK: No gross deformities, no pain during examination.
16. EXTREMITIES: No cyanosis or edema. +2 peripheral pulses.

Adequate range of motion.
17. SKIN: No erythema, petechia, bruises, or generalized rash.
21. NEUROLOGICAL: No focal neurological deficits.
LABS:
====
No labs available on admission. They have been ordered.
Page 9 of 77
1/3/16, 11:01 AM
IMAGING:
========
No imaging available on admission. Reports from CT and sonogram available in
physical chart in ward.
ECG:
====
- Normal Sinus Rhythm

- Vent Rate: 66bpm
- QTc: 423ms
INITIAL IMPRESSION:
==================
- Choledocholelitiasis
- s/p pancreatitis
ASSESSMENT & PLAN:

==================
Mr. DIAZ-MENDEZ, ULISES is a 85 year old MALE patient with the above mentioned
medical problems and comorbidities who was in his usual state of care until 1
week ago when he was hospitalized in Hospital Buen Samaritano for obstructive
jaundice, suspected cholangitis, pancreatitis and BKP. He was then transfered to
our institution for further care and for GI evaluation.
Patient was evaluated at bedside upon arrival at IM ward. He was alert, awake,
and oriented in all spheres. Currently patient afebrile, normotensive,
Page 10 of 77
1/3/16, 11:01 AM
hemodynamically stable, with adequate vital signs. Physical exam findings

remarkable for the above mentioned findings. Lungs esentially clear. Normal
heart sounds. Benign abdominal exam. No focal neurological deficits.
Labs are not available on admission. New labs are ordered.
In view of above mentioned history and physical exam findings, most likely
diagnosis is choledocholelithiasis and s/p pancreatitis.
Patient with CT from Buen Samaritano showing cystic duct stone, billiary and
common bile duct tone with intrahepatic ductal dilation. Patient has been
previously followed by GI service due to chronic pancreatitis with pancreatic
pseudocyst, dilated extrahepatic ducts and H.pylori causing ulcer. Patient had
MRCP done in 2005 which showed "Atrophy of the distal pancreatic body and tail
with pancreatic ductal dilatation, but without obvious pancreatic head and/or
neck masses noted. Cholelithiasis." Patient was discharged from their clinics in
2009 due to stabilization of patient's conditions. An abdominal sonogram has
been ordered. A GI consult will be placed to evaluate for possible MRCP or ERCP
if stones are still present.
Patient had CT finding suggestive of beginnings of pancreatitis. He did not have

abdominal pain but he did have nausea, vomiting and diarrhea. Labs are not
available to determine Ranson criteniia or BISAP score. Nevertheless, patient
has improved clinically and abdominal exam is completely benign. Will hydrate
patient with Ringer's lactate.
Additional medication for patient's comorbidities were reconciliated. He

will be followed by inpatient primary care team who will follow daily with
labs and monitoring of clinical improvement; changes in management will be
made accordingly. Patient was oriented regarding above recommendations and
verbalized understanding. Time was allowed for questions and doubts were
clarified to the best of my ability.
Page 11 of 77
1/3/16, 11:01 AM
DVT PROPHYLAXIS:
GI PROPHYLAXIS: Omeprazole
CODE STATUS: full code
PLAN:
=====
ADMIT TO: Medicine

DIAGNOSIS: As above
CONDITION: STABLE
PROGNOSIS: Guarded
VITALS: Q8h on chart
ACTIVITY: Bed rest
NURSING: Vitals as per protocol
DIET: See orders
IN/OUTS: Daily on chart
IV FLUIDS: See orders
LABS: See orders
IMAGINGS: See orders
CONSULTS: ID-done
/es/ GABRIELA MROUEH, MD

RESIDENT PHYSICIAN/MEDICAL SERV/INTERNAL MEDICINE
Signed: 12/31/2015 02:49
/es/ BRENDA Y URBINA-REYES, MD
Physician/Medical Service/Internal Medicine
Cosigned: 12/31/2015 07:23
LOCAL TITLE: INTERNAL MEDICINE OD NOTE

Page 12 of 77
1/3/16, 11:01 AM
STANDARD TITLE: INTERNAL MEDICINE NOTE

DATE OF NOTE: DEC 31, 2015@00:02
ENTRY DATE: DEC 31, 2015@00:02:45
AUTHOR: BAHAMONDE,EMMANUEL EXP COSIGNER:

URGENCY:
********* ***
STATUS: COMPLETED
***
********* **** ****

***
**********
***
***
***
*******
***
*** ***
*** ***
*****
**** ***
*** *** *** *** ***** ***

*** *** ********* *** *****
********* ***
***
*** *** ***
*** *** ****
********* ***
***
*** *****
****** ***
----------------- PGY-2 RESIDENT ADMISSION NOTE ------------------Last admission: DEC 30, 2015@20:13:26 DX: OBSTRUCTIVE JAUNDICE
Last discharge: JAN 28, 2009@16:58:35
*************************************************************************
Chief Complaint:
*************************************************************************
History of Present Illness:
*************************************************************************
Mr. DIAZ-MENDEZ,ULISES is a 85-year-old MAN with medical history
of DMII, chronic pancreatitis due to unknown etiology presenting with 5 days
hisotyr of nausea vomiting, diarrheas associated with fevers and dry cough.
Patient denied sick contacts nevertheless was found by nephew acutely ill reason
why an ambulance was called. Ambulance could not bring him so took him to
another hospital in the area. Patient was found with elevated liver enzymes and
jaundiced for which a CT and echogram were performed with findings suggestive of
acute pancreatitis and choledocholelithiasis. Patient was started on Zosyn and
Levaquin to cover pneumonic process and abdomen. Patient was trasnferred for GI
Page 13 of 77
1/3/16, 11:01 AM
evaluation for possible ERCP.
On evalaution patient was barely triaged in the ED. Medication reconciliation

was not done and labs not withdrawn. He was found in ed AAO x 3 in no acute
distress afebrile and hemodynamically stbale with Zosyn bag and IVF's. New labs
were requested andIVF's with RL were requested. Physical exam with benign
abdomen mildly hyperactive BS. Echogram noted on chart with evidence of
choledocholelithiasis. No jaundiced on physical exam noted yet liver enzymes
requested for evaluation as well as amylase and lipase. New echogram requested
to evaluated gallstone position. If choledochole found can consider MRCP.
patient without metal fragments for which checklist will be signed. GI consult
placed for recommendations. Diet has been tolerated in the meantime. No
antibiotics placed at the time. Primary team to rrevaluate need.
Patient was admitted to Internal Medicine Ward for further management.

*************************************************************************
Past medical history:
********************
Computerized Problem List is the source for the following:
- Diabetes Mellitus Type II or unspecified

- CONSTIPATION, unspecified
- Tobacco Use Disorder QUITED SMOKING FEB 14 2008
- Pancreatitis HX. OF RECURRENT
- Depression
- Duodenal Ulcers
- Drusen (Degenerative)
Page 14 of 77
1/3/16, 11:01 AM
- Vertigo
- Hypercholesterolemia
- Intermittent Claudication
- Chronic Pancreatitis
- Unspecified gastritis and gastroduodenitis, without mention of hemorrhage
- Colonoscopy ARTERIOVENOUS MALFORMATION FOUND (AVM)
- Low Back Pain
- Polyneuropathy in diabetes
- Screening/Diab Retinopathy
- Lumbar Radiculopathy
- Neck Pain
HABITS:
=======
Denied
*********************************************************************
Outpatient medications:
*********************************************************************
Admission Medication Reconciliation
Outpatient includes Prescriptions and Non-VA meds
Inpatient includes Unit Dose and IV
Medications Ordered for Both Outpatient and Inpatient
---------------------------------------------------------------OP: Atorvastatin calcium 80mg tab 40mg 0.5 tablet po at bedtime
IP: Atorvastatin calcium 40mg tab po at bedtime
OP: Buspirone hcl 5mg tab 1 tablet po am-pm
IP: Buspirone hcl 5mg tab po am-pm
OP: Gabapentin 400mg cap 1 capsule po bid and at-bedtime
IP: Gabapentin 400mg cap po bid and at-bedtime
Page 15 of 77
1/3/16, 11:01 AM
OP: Insulin glargine,human 100 unt/ml inj 20 units sc at bedtime

IP: Insulin glargine,human 100 unt/ml inj 20 units sc at bedtime
OP: Multivit/ophth areds2/lute/zeax cap/tab 1 capsule po bid
IP: Multivit/ophth areds2/lute/zeax cap/tab 1 capsule po bid
OP: Omeprazole 20mg ec cap 1 capsule po daily
IP: Omeprazole 20mg ec cap po daily
OP: Trazodone hcl 50mg tab 1 tablet po at bedtime
IP: Trazodone hcl 50mg tab po at bedtime
OP: Zolpidem tartrate 5mg tab 1 tablet po at bedtime
IP: Zolpidem tartrate 5mg tab po at bedtime
Outpt Meds with No Corresponding Inpt Meds

-------------------------------------------------------------Acetaminophen 325mg tab 650mg 2 tablets po q6h prn
Alcohol prep pad 1 pad misc qid
Cholecalciferol (vit d3) 1,000unit tab 2000units po daily
Clotrimazole 1% top soln a small amount top bid
Freestyle lite (glucose) test strip 1 strip misc tid
Insulin syringe 1ml 30g 0.5in 1 syringe misc daily
Lancet,freestyle 1 lancet misc tid
Latanoprost 0.005% oph soln 1 drop ou at bedtime
Pneumococcal 13-valent conjugate vaccine 0.5 milliliter im once
Inpt Meds Only (that are not on Outpt)
---------------------------------------------------------------...None
*********************************************************************
Objective:
**********
Height: 66 in [167.6 cm] (09/11/2015 10:43)
Weight: 135.2 lb [61.5 kg] (12/30/2015 21:00)
Page 16 of 77
1/3/16, 11:01 AM
Vital signs:
************
Blood pressure
Heart rate
: 157/76 (12/30/2015 21:00)

: 74 (12/30/2015 21:00)
Respiratory rate
: 19 (12/30/2015 21:00)
Temperature
: 98 F [36.7 C] (12/30/2015 21:00)
Pain
: 0 (12/30/2015 21:00)
*********************************************************************
Physical exam:
*********************************************************************
General: Active, alert, oriented x 3. No acute distress

HEENT: PERRL, extra-ocular movements intact, moist oral mucosa, no JVD at 45
degrees.
Heart: Regular rate and rhythm, no murmurs, no gallops
Lungs: Clear to ausculation bilaterally
Abdomen: Bowel sounds positive, hyperactive, soft and non-tender, no guarding or
rebound
tenderness
Extremities: No cyanosis or edema, distal pulses present bilaterally +2.
Neurologic: No gross focal neurological deficits.
*********************************************************************
Laboratories:
*********************************************************************
---- CBC PROFILE ---BLOOD
Dec 30
Reference
2015
22:20
Units
Ranges
------------------------------------------------------------------------------WBC
12.6 H X10-3/ul 4.3 - 9.3
Page 17 of 77
1/3/16, 11:01 AM
RBC
4.5 L X10-6/ul 4.7 - 6.1
HGB
12.9
HCT
39.3
MCV
86.8
fL 81 - 102
MCH
28.5
pg 26 - 34
MCHC
RDW
PLT
g/dL 12.6 - 17.8
32.8
g/dl 31 - 36.5
13.6
256.0
MPV
9.9
SEGS
65.2
37.9 - 54.5
11 - 15
X10-3 155 - 371

fL 9 - 12.9
%
34 - 74
LYMPHS
22.1
17 - 48
MONOS
8.3
2 - 12
EOSINO
4.0
0-7
BASO
0.4
0 - 1.4
---- COAG PROFILE ---PLASMA
Dec 30
Reference
2015
22:20
Units
Ranges
------------------------------------------------------------------------------PT OLD1
Secs
INR
1.12
PT
13.8
PTT
31.3
10.6 - 12.6
Secs. 11.8 - 15
Secs. 22.4 - 38.3
---- CHEM PROFILE ---SERUM
Dec 30
Reference
2015
22:20
Units
Ranges
------------------------------------------------------------------------------https://mail.google.com/mail/u/1/?ui=2&ik=91c01141a5&view=pt&search=inbox&th=15207f75b068f681&siml=15207f75b068f681
Page 18 of 77
GLUCOSE
202 H mg/dL 70 - 99
BUN
14.9
CREA
mg/dL 10 - 26
0.9
NA+
K+
1/3/16, 11:01 AM
MG/DL .7 - 1.5
139
4.6
CL-
mEq/L 135 - 145

mEq/L 3.5 - 5
99 L mEq/l 100 - 110
CO2
27
mEq/l 24 - 32
SGPT
38
U/L
0 - 45
SGOT
24
U/L
0 - 40
EGFR
82
ALK PHO
mL/min Ref: >=60
323 H
U/L 30 - 115
T BILI
1.4 H MG/DL .2 - 1.3
D BILI
0.8 H MG/DL
IBILI
.62
CA++
TP
MG/DL 0 - 1.3
9.2
ALB
MG/DL 8.5 - 10.5
3.9
G/DL 2.6 - 5.2
6.8
CHOL EZ
HDL
G/DL 6 - 8.5
174
49.5
MG/DL 140 - 200

MG/DL 39 - 60
NON HDL
124.1
CHOL/HD
3.5
LDL CHO
100.0
VLDL
TRIGLYC
0 - .2
24.0
mg/dL Ref: <=130

mg/dL Ref: <=5
mg/dL Ref: <=100
mg/dL Ref: <=30
119
MG/DL 25 - 150
---- MISC. CHEMISTRIES ---SERUM
ACID PH
ACP
Ref range low
.02
Ref range high
.8
1.26
U/L
U/L
PSA
0
ng/mL
0
4
ng/mL
PSA
AMYLASE
25
115
U/L
------------------------------------------------------------------------------https://mail.google.com/mail/u/1/?ui=2&ik=91c01141a5&view=pt&search=inbox&th=15207f75b068f681&siml=15207f75b068f681
Page 19 of 77
1/3/16, 11:01 AM
[b] Dec 30, 2015 22:20
69
===============================================================================
SERUM
LIPASE FERRIT
FOL
V B12 2 HR PP AFP
CEA
Ref range low
Ref range high
60
30
4.2
400
19.9
243
894
72
140
U/L. ng/mL. ng/mL. pg/mL. mg/dL
0
8.6
ng/mL ng/mL.
------------------------------------------------------------------------------[b] Dec 30, 2015 22:20 33
*********************************************************************
Radiology:
*********************************************************************
On chart
*********************************************************************
ECG:
On chart
*********************************************************************
Consults:
PENDING CONSULTS - NONE FOUND
*********************************************************************
Diagnostic impression:
*********************************************************************
1. Suspected choledocholelithiasis
- s/p acute pancreatitis
2.
3.
*********************************************************************
Page 20 of 77
1/3/16, 11:01 AM
Assessment and Plan:

*********************************************************************
Mr. DIAZ-MENDEZ is a 85-year-old MAN with medical
problems and physical findings mentioned above who was admitted to internal
medicine ward due to Suspected choledocholelithiasis
On evalaution patient was barely triaged in the ED. Medication reconciliation

was not done and labs not withdrawn. He was found in ed AAO x 3 in no acute
distress afebrile and hemodynamically stbale with Zosyn bag and IVF's. New labs
were requested andIVF's with RL were requested. Physical exam with benign
abdomen mildly hyperactive BS. Echogram noted on chart with evidence of
choledocholelithiasis. No jaundiced on physical exam noted yet liver enzymes
requested for evaluation as well as amylase and lipase. New echogram requested
to evaluated gallstone position. If choledochole found can consider MRCP.
patient without metal fragments for which checklist will be signed. GI consult
placed for recommendations. Diet has been tolerated in the meantime. No
antibiotics placed at the time. Primary team to rrevaluate need.
DVT PROPHYLAXIS:heparin
GI PROPHYLAXIS:omeprazole
CODE STATUS: full
*********************************************************************
Plan:
*********************************************************************
ADMIT TO: Medicine
DIAGNOSIS: As above
CONDITION: STABLE
Page 21 of 77
1/3/16, 11:01 AM
PROGNOSIS: Guarded
VITALS: Q8h on chart
ACTIVITY: Bed rest
NURSING: Vitals as per protocol
DIET: See orders
IN/OUTS: Daily on chart
IV FLUIDS: See orders
LABS: See orders
IMAGINGS: See orders
CONSULTS: None
/es/ EMMANUEL I BAHAMONDE, MD
Resident Physician/Medical Serv/Internal Medicine
Signed: 12/31/2015 01:02
---- CBC PROFILE ----
BLOOD
Jan 02
Dec 30
2016
2015
08:24
22:20
Reference
Units
Ranges
------------------------------------------------------------------------------WBC
10.1 H
RBC
4.5 L
4.5 L X10-6/ul 4.7 - 6.1
HGB
12.7
12.9
HCT
38.6
39.3
MCV
86.7
86.8
fL 81 - 102
MCH
28.5
28.5
pg 26 - 34
MCHC
RDW
32.9
13.7
12.6 H X10-3/ul 4.3 - 9.3
32.8
37.9 - 54.5
g/dl 31 - 36.5
13.6
HDW
PLT
g/dL 12.6 - 17.8
11 - 15
g/dL
254.0
256.0
X10-3 155 - 371
Page 22 of 77
MPV
9.7
9.9
1/3/16, 11:01 AM
fL 9 - 12.9
PLT CRT
BLASTS
PROS
MYELO
0-0
META
0-0
BANDS
SEGS
Ref: 0
0-0
%
62.1
65.2
0-9
%
34 - 74
LYMPHS
21.4
22.1
MONOS
9.9
8.3
2 - 12
EOSINO
6.1
4.0
0-7
BASO
0.5
SEGS#
6.28
LYMPHS#
EOS#
BASO#
0.4
2.17
17 - 48
0 - 1.4
8.2 H X10-3/ul 1.64 - 6.96

2.78
X 10-3 1 - 3.5
0.62 H
0.50 H X10-3/ul 0 - .4
0.05
0.05 X10-3/ul 0 - .1
MONOS#
NRBC
1.04 H X10-3/ul .2 - 1
/100WBC
PLT.E
0 - .2
Ref: Adq
TOXIC G
"+" Ref: ABSENT
ANISO
"+" Ref: <1+
MICROCY
"+" Ref: <1+
MACRO
"+" Ref: <1+
VAR
"+"
HYPO
"+" Ref: <1+
HYPER
"+"
LUC
HPX
LI
MPXI
Comments:
Page 23 of 77
1/3/16, 11:01 AM
g. Ordering Provider: Yashira E Veras-Vazquez MD

Report Released..: Jan 02, 2016@08:41
Reporting Lab....: SAN JUAN VA MEDICAL CENTER [CLIA# 40D0987710]
10 Casia St. One Veterans Plaza SAN JUAN, PR 00921-3200
Performing Lab...: SAN JUAN VA MEDICAL CENTER [CLIA# 40D0987710]
u. Ordering Provider: Gabriela Mroueh

Report Released..: Dec 31, 2015@00:40
---- COAG PROFILE ----
PLASMA
Dec 30
Reference
2015
22:20
Units
Ranges
------------------------------------------------------------------------------PT OLD1
INR
PTT#1
Secs
10.6 - 12.6
1.12
Secs
23.1 - 35.5
FIBRINO
mg/dL
155 - 351
THROMBI
Secs
5.9 - 10.7
PROTAMI
DIL.
FDP/fdp
PT OLD2
PTT#2
Ref: NEGATIVE
ug/ml Ref: < 5

Secs 9.8 - 13
Secs 26.5 - 39
Page 24 of 77
PT OLD3
Secs. 11.3 - 14.4
PT OLD4
Secs. 9.8 - 12.3
PTT#3
PT
PTT
1/3/16, 11:01 AM
Secs. 24.7 - 36.7

13.8
Secs. 11.8 - 15
31.3
Comments:
Secs. 22.4 - 38.3
w. Evaluation for INR:
RECOMMENDED THERAPEUTIC RANGES FOR ORAL ANTICOAGULATION THERAPY**
INR 1.5:
a. Patients treated with OAC requiring ambulatory surgery
INR 2.0-3.0:
a. Prophylaxix of venous thrombosis during high risk surgery
b. Treatment of venous thrombosis
c. Treatment of pulmonary embolism
d. Prevention of systemic embolism
(Tissue heart valves, AMI, Atrial fibrillation)
INR 2.5-3.5:
a. Mecahnical prosthetic valves
b. Prevention of recurrent myocardial infarction
REF:
Oral Anticoagulants: Mechanism of Action, Clinical Effectiveness,
and Optimal Therapeutic Range. Sixth ACCP Consensus Conference on
Antithrombotic Therapy. 2001
Ordering Provider: Gabriela Mroueh

Page 25 of 77
1/3/16, 11:01 AM

---- CHEM PROFILE ----
SERUM
Jan 02
2016
Dec 31
2015
08:24
Dec 30
Reference
2015
22:20
Units
Ranges
------------------------------------------------------------------------------GLUCOSE
BUN
CREA
NA+
272 H
7.6 L
14.9
mg/dL 10 - 26
0.8
0.9
MG/DL .7 - 1.5
139
139
mEq/L 135 - 145
K+
4.0
CL-
100
CO2
202 H mg/dL 70 - 99
4.6
mEq/L 3.5 - 5
99 L mEq/l 100 - 110
25
27
mEq/l 24 - 32
SGPT
28
38
U/L
0 - 45
SGOT
22
24
U/L
0 - 40
LDH
141
U/L 60 - 200
CPK
U/L 5 - 169
CK-MB-
ng/mL. 0 - 4.94
EGFR
ALK PHO
T BILI
D BILI
IBILI
96
82
266 H
1.3 H
mL/min Ref: >=60

323 H
U/L 30 - 115
1.4 H MG/DL .2 - 1.3

0.8 H MG/DL
.62
0 - .2
MG/DL 0 - 1.3
Page 26 of 77
1/3/16, 11:01 AM
G-GT
U/L
UA
mg/dL 2.7 - 9
ING PHO
CA++
2.2 L
mg/dL 2.5 - 4.5
8.9
MG
1.6 L
ALB
3.6
TP
0 - 60
9.2
MG/DL 8.5 - 10.5

mg/dL 1.8 - 2.4
3.9
6.3
G/DL 2.6 - 5.2
6.8
CHOL EZ
G/DL 6 - 8.5
174
HDL
49.5
MG/DL 140 - 200

MG/DL 39 - 60
NON HDL
124.1
CHOL/HD
3.5
LDL CHO
100.0
D-LDL
mg/dL Ref: <=130

mg/dL Ref: <=5
mg/dL Ref: <=100
mg/dL Ref: <=100
VLDL
24.0
TRIGLYC
mg/dL Ref: <=30
119
TIBC
MG/DL 25 - 150
ug/dL 260 - 400
GLOB
G/DL 1.5 - 3.5
FE
ug/dL 40 - 150
A/G
1.1 - 2.2
OSMOLAL
MOSM/L 275 - 295
ADJ CA
8.5 - 10.5
AN GAP
0 - 12
BUN/CRE
11 - 21
CA*IN P
22 - 47
ACETONE
Comments:
Ref: NEG
f
f. Ordering Provider: Yashira E Veras-Vazquez MD

Page 27 of 77
1/3/16, 11:01 AM
t. Ordering Provider: Gabriela Mroueh

v. Ordering Provider: Gabriela Mroueh

---- MISC. CHEMISTRIES ----
SERUM
ACID PH
ACP
Ref range low
.02
Ref range high
.8
1.26
U/L
U/L
PSA
0
ng/mL
PSA
AMYLASE
25
115
ng/mL
U/L
------------------------------------------------------------------------------[v] Dec 30, 2015 22:20
69
===============================================================================
SERUM
LIPASE FERRIT
FOL
V B12 2 HR PP AFP
CEA
Ref range low
30
4.2
243
72
Page 28 of 77
Ref range high
60
1/3/16, 11:01 AM
400
19.9
894
140
8.6
U/L. ng/mL. ng/mL. pg/mL. mg/dL
ng/mL ng/mL.
------------------------------------------------------------------------------[v] Dec 30, 2015 22:20 33

===============================================================================
SERUM
PROLAC B-12
Ref range low
1.98
200
Ref range high
19.86
978
ng/mL pg/mL
TESTOST
1.1
12
ng/mL
FOLIC
VIT-B12
197
12.6
ng/mL
871
pg/mL
------------------------------------------------------------------------------v. Ordering Provider: Gabriela Mroueh

---- POINT OF CARE GLUCOSE ----
BLOOD,CAPILLA
Jan 03
Jan 02
Jan 02
2016
2016
2016
2016
06:17
21:16
16:49
16:35
Jan 02
Units
Reference
Ranges
------------------------------------------------------------------------------POC-GLU
Comments:
286.0
a
277.0
b
384.0
c
366.0
mg/dl 70 - 99
a. For Glucose:Reg. Insulin Subcutaneous
Ordering Provider: Francisco De Jesus

Page 29 of 77
1/3/16, 11:01 AM

b. For Glucose:Reg. Insulin Subcutaneous

c. For Glucose:Reg. Insulin Subcutaneous

d. For Glucose:Reg. Insulin Subcutaneous

Page 30 of 77
1/3/16, 11:01 AM
BLOOD,CAPILLA
Jan 02
Jan 02
Jan 01
2016
2016
2016
2016
11:36
06:50
21:35
20:49
Jan 01
Units
Reference
Ranges
------------------------------------------------------------------------------POC-GLU
Comments:
216.0
e
310.0
h
109.0
i
70.0
mg/dl 70 - 99
e. For Glucose:Reg. Insulin Subcutaneous

h. For Glucose:Reg. Insulin Subcutaneous
Ordering Provider: Yashira E Veras-Vazquez MD

i. Ordering Provider: Yashira E Veras-Vazquez MD

Page 31 of 77
1/3/16, 11:01 AM

j. For Glucose:Juice given

BLOOD,CAPILLA
Jan 01
Jan 01
Jan 01
2016
2016
2016
2015
16:37
11:55
06:48
23:02
Dec 31
Units
Reference
Ranges
------------------------------------------------------------------------------POC-GLU
Comments:
363.0
k
157.0
l
213.0
281.0
mg/dl 70 - 99
k. For Glucose:Reg. Insulin Subcutaneous

l. For Glucose:Reg. Insulin Subcutaneous

Page 32 of 77
1/3/16, 11:01 AM

m. For Glucose:Reg. Insulin Subcutaneous

n. For Glucose:Patient Rn Notified

BLOOD,CAPILLA
Dec 31
Dec 31
Dec 31
2015
2015
2015
2015
20:46
20:23
15:51
12:11
Dec 31
Units
Reference
Ranges
------------------------------------------------------------------------------POC-GLU
Comments:
229.0
o
48.0 L* 259.0
p
182.0
mg/dl 70 - 99
Page 33 of 77
1/3/16, 11:01 AM
o. For Glucose:Patient Rn Notified

p. For Glucose:Patient Rn Notified

q. For Glucose:Reg. Insulin Subcutaneous

r. Ordering Provider: Yashira E Veras-Vazquez MD

Page 34 of 77
1/3/16, 11:01 AM

BLOOD,CAPILLA
Dec 31
Reference
2015
08:25
Units
Ranges
------------------------------------------------------------------------------POC-GLU
177.0
Comments:
mg/dl 70 - 99
s. For Glucose:Patient Rn Notified

---- MRSA Surveillance DNA ----
NARES
Ref range low
MrsaPCR
NEGATIVE
Ref range high
------------------------------------------------------------------------------[x] Dec 30, 2015 22:02
NEGATIVE
x. NEGATIVE: No MRSA detected, MRSA Nasal colonization unlikely.
Page 35 of 77
1/3/16, 11:01 AM
Ordering Provider: Brenda Y Urbina-Reyes MD

---- BLOOD BANK ----
*** [LEGACY VISTA BLOOD BANK REPORT] ***

The following historical information comes from the Legacy VISTA Blood Bank System
It represents data collected prior to the installation of VBECS. Some of the information
in this report may have been duplicated in the VBECS report above (if available).
---- CBC PROFILE ----
BLOOD
Jan 02
Dec 30
2016
2015
08:24
22:20
Reference
Units
Ranges
------------------------------------------------------------------------------WBC
10.1 H
12.6 H X10-3/ul
4.3 - 9.3
RBC
4.5 L
4.5 L X10-6/ul
4.7 - 6.1
HGB
12.7
12.9
HCT
38.6
39.3
g/dL
%
12.6 - 17.8
37.9 - 54.5
Page 36 of 77
1/3/16, 11:01 AM
MCV
86.7
86.8
fL
81 - 102
MCH
28.5
28.5
pg
26 - 34
MCHC
32.9
32.8
g/dl
RDW
13.7
13.6
HDW
31 - 36.5
11 - 15
g/dL
PLT
254.0
256.0
X10-3
MPV
9.7
9.9
fL
155 - 371
9 - 12.9
PLT CRT
BLASTS
Ref: 0
PROS
0 - 0
MYELO
0 - 0
META
0 - 0
BANDS
0 - 9
SEGS
62.1
65.2
34 - 74
LYMPHS
21.4
22.1
17 - 48
MONOS
9.9
8.3
2 - 12
EOSINO
6.1
4.0
0 - 7
BASO
0.5
0.4
0 - 1.4
SEGS#
6.28
LYMPHS#
2.17
2.78
EOS#
0.62 H
0.50 H X10-3/ul
0 - .4
BASO#
0.05
0.05
X10-3/ul
0 - .1
1.04 H X10-3/ul
.2 - 1
MONOS#
NRBC
8.2 H X10-3/ul
X 10-3
/100WBC
PLT.E
1.64 - 6.96
1 - 3.5
0 - .2
Ref: Adq
TOXIC G
"+"
Ref: ABSENT
ANISO
"+"
Ref: <1+
MICROCY
"+"
Ref: <1+
MACRO
"+"
Ref: <1+
VAR
"+"
Page 37 of 77
1/3/16, 11:01 AM
HYPO
"+"
HYPER
"+"
Ref: <1+
LUC
HPX
LI
MPXI
Comments:
g.

u.

---- COAG PROFILE ----
PLASMA
Dec 30
Reference
2015
22:20
Units
Ranges
-------------------------------------------------------------------------------
Page 38 of 77
PT OLD1
1/3/16, 11:01 AM
Secs
10.6 - 12.6
PTT#1
Secs
23.1 - 35.5
FIBRINO
mg/dL
155 - 351
THROMBI
Secs
5.9 - 10.7
INR
1.12
PROTAMI
DIL.
Ref: NEGATIVE
FDP/fdp
ug/ml
Ref: < 5
PT OLD2
Secs
9.8 - 13
PTT#2
Secs
26.5 - 39
PT OLD3
Secs.
11.3 - 14.4
PT OLD4
Secs.
9.8 - 12.3
PTT#3
Secs.
24.7 - 36.7
PT
13.8
Secs.
11.8 - 15
PTT
31.3
Secs.
22.4 - 38.3
Comments:
w.
Evaluation for INR:
RECOMMENDED THERAPEUTIC RANGES FOR ORAL ANTICOAGULATION THERAPY**
INR
1.5:
a. Patients treated with OAC requiring ambulatory surgery
INR
2.0-3.0:
a. Prophylaxix of venous thrombosis during high risk surgery

b. Treatment of venous thrombosis
c. Treatment of pulmonary embolism
d. Prevention of systemic embolism
(Tissue heart valves, AMI, Atrial fibrillation)
INR
2.5-3.5:
Page 39 of 77
1/3/16, 11:01 AM
a. Mecahnical prosthetic valves

b. Prevention of recurrent myocardial infarction
REF:
Oral Anticoagulants: Mechanism of Action, Clinical Effectiveness,
and Optimal Therapeutic Range. Sixth ACCP Consensus Conference on
Antithrombotic Therapy. 2001

---- CHEM PROFILE ----
SERUM
Jan 02
Dec 31
Dec 30
2016
2015
2015
08:24
22:20
Reference
Units
Ranges
------------------------------------------------------------------------------GLUCOSE
272 H
BUN
7.6 L
CREA
202 H
mg/dL
70 - 99
14.9
mg/dL
10 - 26
0.8
0.9
MG/DL
.7 - 1.5
NA+
139
139
mEq/L
135 - 145
K+
4.0
4.6
mEq/L
3.5 - 5
Page 40 of 77
CL-
100
CO2
1/3/16, 11:01 AM
99 L
mEq/l
100 - 110
25
27
mEq/l
24 - 32
SGPT
28
38
U/L
0 - 45
SGOT
22
24
U/L
0 - 40
U/L
60 - 200
U/L
5 - 169
LDH
141
CPK
CK-MBEGFR
96
82
ng/mL.
0 - 4.94
mL/min
Ref: >=60
ALK PHO
266 H
323 H
U/L
30 - 115
T BILI
1.3 H
1.4 H
MG/DL
.2 - 1.3
D BILI
0.8 H
MG/DL
0 - .2
IBILI
.62
MG/DL
0 - 1.3
U/L
0 - 60
mg/dL
2.7 - 9
mg/dL
2.5 - 4.5
MG/DL
8.5 - 10.5
mg/dL
1.8 - 2.4
G-GT
UA
ING PHO
2.2 L
CA++
8.9
MG
1.6 L
ALB
3.6
3.9
G/DL
2.6 - 5.2
TP
6.3
6.8
G/DL
6 - 8.5
174
MG/DL
140 - 200
49.5
MG/DL
39 - 60
NON HDL
124.1
mg/dL
Ref: <=130
CHOL/HD
3.5
mg/dL
Ref: <=5
LDL CHO
100.0
mg/dL
Ref: <=100
mg/dL
Ref: <=100
24.0
mg/dL
Ref: <=30
119
MG/DL
25 - 150
TIBC
ug/dL
260 - 400
GLOB
G/DL
1.5 - 3.5
CHOL EZ
HDL
9.2
D-LDL
VLDL
TRIGLYC
FE
ug/dL
40 - 150
Page 41 of 77
1/3/16, 11:01 AM
A/G
1.1 - 2.2
OSMOLAL
MOSM/L
ADJ CA
275 - 295
8.5 - 10.5
AN GAP
0 - 12
BUN/CRE
11 - 21
CA*IN P
22 - 47
ACETONE
Ref: NEG
Comments:
f.

t.

v.

Page 42 of 77
1/3/16, 11:01 AM
---- MISC. CHEMISTRIES ----
SERUM
ACID PH
ACP
PSA
PSA
Ref range low
.02
25
Ref range high
.8
1.26
115
ng/mL
ng/mL
U/L
U/L
U/L
AMYLASE
------------------------------------------------------------------------------[v]
Dec 30, 2015 22:20
69
===============================================================================
SERUM
LIPASE FERRIT
FOL
V B12
2 HR PP
30
4.2
243
72
400
19.9
894
140
AFP
CEA
8.6
Ref range low

Ref range high
1
60
U/L.
ng/mL.
ng/mL.
pg/mL.
mg/dL
ng/mL ng/mL.
------------------------------------------------------------------------------[v]
Dec 30, 2015 22:20
33
===============================================================================
SERUM
PROLAC
B-12
TESTOST
FOLIC
VIT-B12
Ref range low
1.98
200
1.1
197
Ref range high
19.86
978
12
12.6
871
ng/mL
pg/mL
ng/mL
ng/mL
pg/mL
------------------------------------------------------------------------------v. Ordering Provider: Gabriela Mroueh

Page 43 of 77
1/3/16, 11:01 AM

---- POINT OF CARE GLUCOSE ----
BLOOD,CAPILLA
Jan 03
Jan 02
Jan 02
Jan 02
2016
2016
2016
2016
06:17
21:16
16:49
16:35
Reference
Units
Ranges
------------------------------------------------------------------------------POC-GLU
Comments:
a.
286.0
277.0
384.0
366.0
mg/dl
70 - 99
For Glucose:Reg. Insulin Subcutaneous

b.

Page 44 of 77
1/3/16, 11:01 AM
c.

d.

BLOOD,CAPILLA
Jan 02
Jan 02
Jan 01
Jan 01
2016
2016
2016
2016
11:36
06:50
21:35
20:49
Reference
Units
Ranges
------------------------------------------------------------------------------POC-GLU
Comments:
e.
216.0
310.0
109.0
70.0
mg/dl
70 - 99

Page 45 of 77
1/3/16, 11:01 AM

h.

i.

j.
For Glucose:Juice given

Page 46 of 77
1/3/16, 11:01 AM
BLOOD,CAPILLA
Jan 01
Jan 01
Jan 01
Dec 31
2016
2016
2016
2015
16:37
11:55
06:48
23:02
Reference
Units
Ranges
------------------------------------------------------------------------------POC-GLU
Comments:
k.
363.0
157.0
213.0
281.0
mg/dl
70 - 99

l.

m.

Page 47 of 77
1/3/16, 11:01 AM

n.
For Glucose:Patient Rn Notified

BLOOD,CAPILLA
Dec 31
Dec 31
Dec 31
Dec 31
2015
2015
2015
2015
20:46
20:23
15:51
12:11
Reference
Units
Ranges
------------------------------------------------------------------------------POC-GLU
Comments:
o.
229.0
o
48.0 L*
259.0
182.0
mg/dl
70 - 99

Page 48 of 77
1/3/16, 11:01 AM
p.

q.

r.

BLOOD,CAPILLA
Dec 31
Reference
2015
Page 49 of 77
08:25
1/3/16, 11:01 AM
Units
Ranges
------------------------------------------------------------------------------POC-GLU
Comments:
s.
177.0
mg/dl
70 - 99

---- MRSA Surveillance DNA ----
NARES
MrsaPCR
Ref range low
NEGATIVE
Ref range high
------------------------------------------------------------------------------[x]
Dec 30, 2015 22:02
NEGATIVE
x. NEGATIVE: No MRSA detected, MRSA Nasal colonization unlikely.
Ordering Provider: Brenda Y Urbina-Reyes MD

Page 50 of 77
1/3/16, 11:01 AM

---- BLOOD BANK ----
*** [LEGACY VISTA BLOOD BANK REPORT] ***

The following historical information comes from the Legacy VISTA Blood Bank System
It represents data collected prior to the installation of VBECS. Some of the information
in this report may have been duplicated in the VBECS report above (if available).
MRI ABDOMEN WITH AND W/OUT CONT
Proc Ord: MRCP

Exm Date: DEC 31, 2015@10:24
Req Phys: VERAS-VAZQUEZ,YASHIRA E
Pat Loc: 6J MED/01-03-2016@10:38

Img Loc: MAGNETIC RESONANCE IMAGING
Service: MEDICAL
*** THIS IS AN AMENDED REPORT ***
(Case 18154 COMPLETE)MRI ABDOMEN WITH AND W/OUT CONT
(MRI
Detailed) CPT:74183
Contrast Media : Gadolinium
Page 51 of 77
1/3/16, 11:01 AM
Reason for Study: Evaluation of choledocolithiasis/cholangitis
(Case 18155 COMPLETE)MRI 3D RENDERING W/POSTPROCESS
(MRI
Detailed) CPT:76377
Clinical History:
Report Status: Verified
Date Reported: DEC 31, 2015

Date Verified: DEC 31, 2015
Verifier E-Sig:/ES/CARLA M BLANCO-URRUTIA
Report:
MRI of the abdomen and MRCP December 31, 2015:
Multi planar T2-weighted images were acquired throughout the

upper abdomen and reviewed at the workstation. Oblique, thick
slab cholangiographic images performed. Study done using a 1.5
Tesla magnet. 6 cc of gadavist administered IV. No comparison is
available.
The exam is remarkable for severe intra-and extrahepatic biliary

dilatation with common bile duct full of filling defects felt to
represent calculi. These are noted from the proximal common bile
duct to the distal intrapancreatic common bile duct level. The
proximal common bile duct measures roughly 2 cm in diameter.
There seems to be narrowing of the distal common bile duct, which
is difficult to evaluate given some motion blurring and presence
of endoluminal calculi/filling defects. The ampullary region and
the duodenum are suboptimally evaluated in this exam.
Postcontrast images show enhancement of the common bile duct and
cystic duct which is most conspicuous at the distal common bile
duct and may represent cholangitis.
Page 52 of 77
1/3/16, 11:01 AM
Currently, the gallbladder is free of calculi. No pericholecystic

fluid collections.
The largest choledochal calculus which is the most proximal one

measures 1.8 cm craniocaudal x 1.5 cm AP x 2 cm transverse.
There is no discrete mass lesion in the liver or spleen. Adrenal

glands are grossly within normal limits. Small renal cystic
lesions present. No hydronephroses. No free fluid or fluid
collections. No abnormal lymphadenopathy by size. The portal vein
is patent.
There is a cluster of T2 hyperintense/cystic structures at the

level of the pancreatic body likely representing incidental
intrapancreatic mucin producing tumor. Possible involvement of
the main pancreatic duct. Lesion at the level of the pancreatic
body measures approximately 2.2 cm craniocaudal x 3.3 cm
transverse x 1.9 cm AP at its widest.
Impression:
Extensive choledocholithiasis accounting for biliary obstruction.

Enhancement of the common bile duct walls may represent
cholangitis in the proper clinical scenario.
Incidental intrapancreatic mucin
producing tumor/cluster of
cystic structures (pancreatic body) with possible involvement of

Page 53 of 77
1/3/16, 11:01 AM
the main duct.
Addendum: Addendum:
Multi planar T1 and T2-weighted images were acquired. Axial

T1-weighted fat-saturated gradient echo, dynamic images acquired
for the contrast-enhanced portion of the exam.
Impression:
See addendum.
Primary Diagnostic Code: SIGNIFICANT ABNORMALITY, ATTN NEEDED
Primary Interpreting Staff:

CARLA M BLANCO-URRUTIA, Radiologist, Radiology Service (Verifier)
/CBU
Select an imaging exam...
Note: Listing displays limited data, view details for more information.
Date Range: All Results

Selected Items from 04/14/02 to 01/03/16
Lab Tests
Alkaline Phosphatase (serum) 95
U/L
30 - 115
04/15/02 07:49
U/L
30 - 115
11/22/04 09:00
U/L
30 - 115
04/14/05 10:07
Page 54 of 77
1/3/16, 11:01 AM
U/L
30 - 115
07/01/05 09:54
U/L
30 - 115
06/15/07 08:01
U/L
30 - 115
01/09/08 08:17
U/L
30 - 115
04/24/08 09:10
U/L
30 - 115
05/14/08 19:24
U/L
30 - 115
10/07/08 07:25
U/L
30 - 115
01/12/09 08:16
U/L
30 - 115
01/25/09 09:42
U/L
30 - 115
03/07/09 15:00
U/L
30 - 115
03/09/09 08:52
U/L
30 - 115
04/24/09 08:45
U/L
30 - 115
05/26/09 10:42
U/L
30 - 115
08/06/09 07:59
U/L
30 - 115
11/04/09 09:09
U/L
30 - 115
11/16/09 10:46
U/L
30 - 115
03/15/10 10:15
U/L
30 - 115
08/13/10 09:55
U/L
30 - 115
11/12/10 08:58
U/L
30 - 115
03/10/11 09:59
U/L
30 - 115
07/01/11 07:16
U/L
30 - 115
11/04/11 07:57
U/L
30 - 115
03/06/12 08:18
U/L
30 - 115
04/17/12 07:46
U/L
30 - 115
07/11/12 08:11
U/L
30 - 115
11/09/12 07:52
U/L
30 - 115
03/11/13 08:15
U/L
30 - 115
07/16/13 08:41
U/L
30 - 115
11/19/13 08:47
U/L
30 - 115
03/27/14 08:00
U/L
30 - 115
11/25/14 09:37
U/L
30 - 115
04/20/15 08:11
Page 55 of 77
1/3/16, 11:01 AM
Alkaline Phosphatase (serum) 323 H U/L
30 - 115
12/30/15 22:20
Alkaline Phosphatase (serum) 266 H U/L
30 - 115
01/02/16 08:24

Lab Tests
Amylase (serum)
106
U/L
25 - 115
04/15/02 07:49
Amylase (serum)
77
U/L
25 - 115
04/14/05 10:07
Amylase (serum)
105
U/L
25 - 115
05/14/08 19:24
Amylase (serum)
108
U/L
25 - 115
10/07/08 07:25
Amylase (serum)
81
U/L
25 - 115
01/25/09 09:42
Amylase (serum)
103
U/L
25 - 115
03/07/09 15:00
Amylase (serum)
113
U/L
25 - 115
03/09/09 08:52
Amylase (serum)
102
U/L
25 - 115
05/26/09 10:42
Amylase (serum)
96
U/L
25 - 115
11/04/09 09:09
Amylase (serum)
69
U/L
25 - 115
12/30/15 22:20

Lab Tests
Bilirubin,Direct (serum)
Bilirubin,Direct (serum)
0.2
0.78 H
MG/DL
0 - 0.2
04/14/05 10:07
MG/DL
0 - 0.2
12/30/15 22:20
Page 56 of 77
1/3/16, 11:01 AM

Lab Tests
Bilirubin,Total (serum)
1.0
MG/DL
.2 - 1.3
11/22/04 09:00
0.8
MG/DL
.2 - 1.3
04/14/05 10:07
0.6
MG/DL
.2 - 1.3
07/01/05 09:54
0.70
MG/DL
.2 - 1.3
06/15/07 08:01
0.70
MG/DL
.2 - 1.3
01/09/08 08:17
0.70
MG/DL
.2 - 1.3
04/24/08 09:10
0.65
MG/DL
.2 - 1.3
05/14/08 19:24
0.70
MG/DL
.2 - 1.3
10/07/08 07:25
0.70
MG/DL
.2 - 1.3
01/12/09 08:16
1.22
MG/DL
.2 - 1.3
01/25/09 09:42
0.80
MG/DL
.2 - 1.3
03/07/09 15:00
0.60
MG/DL
.2 - 1.3
04/24/09 08:45
0.80
MG/DL
.2 - 1.3
05/26/09 10:42
0.70
MG/DL
.2 - 1.3
08/06/09 07:59
0.90
MG/DL
.2 - 1.3
11/04/09 09:09
0.90
MG/DL
.2 - 1.3
11/16/09 10:46
0.80
MG/DL
.2 - 1.3
03/15/10 10:15
1.00
MG/DL
.2 - 1.3
08/13/10 09:55
0.70
MG/DL
.2 - 1.3
11/12/10 08:58
0.89
MG/DL
.2 - 1.3
03/10/11 09:59
0.55
MG/DL
.2 - 1.3
07/01/11 07:16
0.93
MG/DL
.2 - 1.3
11/04/11 07:57
0.73
MG/DL
.2 - 1.3
03/06/12 08:18
Page 57 of 77
1/3/16, 11:01 AM
0.58
MG/DL
.2 - 1.3
04/17/12 07:46
0.65
MG/DL
.2 - 1.3
07/11/12 08:11
0.59
MG/DL
.2 - 1.3
11/09/12 07:52
0.50
MG/DL
.2 - 1.3
03/11/13 08:15
0.63
MG/DL
.2 - 1.3
07/16/13 08:41
1.01
MG/DL
.2 - 1.3
11/19/13 08:47
0.59
MG/DL
.2 - 1.3
03/27/14 08:00
0.68
MG/DL
.2 - 1.3
11/25/14 09:37
0.56
MG/DL
.2 - 1.3
04/20/15 08:11
1.40 H
MG/DL
.2 - 1.3
12/30/15 22:20
1.32 H
MG/DL
.2 - 1.3
01/02/16 08:24

Lab Tests
Calcium (serum)
10.2
MG/DL
8.5 - 10.5
04/15/02 07:49
Calcium (serum)
10.0
MG/DL
8.5 - 10.5
10/21/02 08:46
Calcium (serum)
9.5
MG/DL
8.5 - 10.5
05/02/03 08:35
Calcium (serum)
10.1
MG/DL
8.5 - 10.5
11/14/03 06:41
Calcium (serum)
9.6
MG/DL
8.5 - 10.5
11/22/04 09:00
Calcium (serum)
9.3
MG/DL
8.5 - 10.5
04/07/05 08:07
Calcium (serum)
10.2
MG/DL
8.5 - 10.5
04/14/05 10:07
Calcium (serum)
9.1
MG/DL
8.5 - 10.5
07/01/05 09:54
Calcium (serum)
10.0
MG/DL
8.5 - 10.5
11/03/05 08:24
Calcium (serum)
10.1
MG/DL
8.5 - 10.5
02/21/06 07:50
Calcium (serum)
9.8
MG/DL
8.5 - 10.5
07/05/06 08:31
Calcium (serum)
10.6 H
MG/DL
8.5 - 10.5
08/22/06 07:32
Calcium (serum)
10.2
MG/DL
8.5 - 10.5
09/21/06 06:57
Page 58 of 77
1/3/16, 11:01 AM
Calcium (serum)
10.0
MG/DL
8.5 - 10.5
12/27/06 09:01
Calcium (serum)
9.7
MG/DL
8.5 - 10.5
06/15/07 08:01
Calcium (serum)
9.9
MG/DL
8.5 - 10.5
09/21/07 08:04
Calcium (serum)
10.2
MG/DL
8.5 - 10.5
11/21/07 08:56
Calcium (serum)
9.9
MG/DL
8.5 - 10.5
01/09/08 08:17
Calcium (serum)
10.0
MG/DL
8.5 - 10.5
01/29/08 07:58
Calcium (serum)
9.7
MG/DL
8.5 - 10.5
04/24/08 09:10
Calcium (serum)
9.7
MG/DL
8.5 - 10.5
05/14/08 19:24
Calcium (serum)
9.7
MG/DL
8.5 - 10.5
05/16/08 04:15
Calcium (serum)
10.2
MG/DL
8.5 - 10.5
09/05/08 08:42
Calcium (serum)
9.9
MG/DL
8.5 - 10.5
10/07/08 07:25
Calcium (serum)
9.3
MG/DL
8.5 - 10.5
11/18/08 08:43
Calcium (serum)
9.4
MG/DL
8.5 - 10.5
01/12/09 08:16
Calcium (serum)
9.1
MG/DL
8.5 - 10.5
01/25/09 09:42
Calcium (serum)
8.6
MG/DL
8.5 - 10.5
01/26/09 04:15
Calcium (serum)
8.4 L
MG/DL
8.5 - 10.5
01/28/09 04:15
Calcium (serum)
9.3
MG/DL
8.5 - 10.5
03/07/09 15:00
Calcium (serum)
10.1
MG/DL
8.5 - 10.5
03/09/09 08:52
Calcium (serum)
9.0
MG/DL
8.5 - 10.5
03/19/09 13:44
Calcium (serum)
10.1
MG/DL
8.5 - 10.5
04/24/09 08:45
Calcium (serum)
9.9
MG/DL
8.5 - 10.5
05/26/09 10:42
Calcium (serum)
9.8
MG/DL
8.5 - 10.5
08/06/09 07:59
Calcium (serum)
9.7
MG/DL
8.5 - 10.5
11/04/09 09:09
Calcium (serum)
9.8
MG/DL
8.5 - 10.5
11/16/09 10:46
Calcium (serum)
9.6
MG/DL
8.5 - 10.5
03/15/10 10:15
Calcium (serum)
10.0
MG/DL
8.5 - 10.5
08/13/10 09:55
Calcium (serum)
9.7
MG/DL
8.5 - 10.5
11/12/10 08:58
Calcium (serum)
9.4
MG/DL
8.5 - 10.5
03/10/11 09:59
Calcium (serum)
9.3
MG/DL
8.5 - 10.5
07/01/11 07:16
Calcium (serum)
9.9
MG/DL
8.5 - 10.5
11/04/11 07:57
Calcium (serum)
9.5
MG/DL
8.5 - 10.5
03/06/12 08:18
Page 59 of 77
1/3/16, 11:01 AM
Calcium (serum)
9.0
MG/DL
8.5 - 10.5
04/17/12 07:46
Calcium (serum)
9.2
MG/DL
8.5 - 10.5
07/11/12 08:11
Calcium (serum)
9.2
MG/DL
8.5 - 10.5
11/09/12 07:52
Calcium (serum)
9.5
MG/DL
8.5 - 10.5
03/11/13 08:15
Calcium (serum)
9.0
MG/DL
8.5 - 10.5
07/16/13 08:41
Calcium (serum)
9.7
MG/DL
8.5 - 10.5
11/19/13 08:47
Calcium (serum)
9.4
MG/DL
8.5 - 10.5
03/27/14 08:00
Calcium (serum)
9.3
MG/DL
8.5 - 10.5
07/30/14 08:54
Calcium (serum)
9.6
MG/DL
8.5 - 10.5
11/25/14 09:37
Calcium (serum)
9.7
MG/DL
8.5 - 10.5
01/20/15 12:42
Calcium (serum)
9.5
MG/DL
8.5 - 10.5
01/22/15 08:17
Calcium (serum)
9.4
MG/DL
8.5 - 10.5
04/02/15 10:13
Calcium (serum)
9.5
MG/DL
8.5 - 10.5
04/20/15 08:11
Calcium (serum)
9.4
MG/DL
8.5 - 10.5
04/20/15 08:11
Calcium (serum)
9.0
MG/DL
8.5 - 10.5
09/01/15 08:00
Calcium (serum)
9.2
MG/DL
8.5 - 10.5
12/30/15 22:20
Calcium (serum)
8.9
MG/DL
8.5 - 10.5
01/02/16 08:24
Date Range: One Week

Lab Tests
Chloride (serum)
Chloride (serum)
99 L
100
mEq/l
100 - 110
12/30/15 22:20
mEq/l
100 - 110
01/02/16 08:24

Page 60 of 77
1/3/16, 11:01 AM
Lab Tests
Chol/Hdl (serum)
3.5
mg/dL
- 5.0
12/30/15 22:20

Lab Tests
Cholesterol (serum)
174
MG/DL
140 - 200
12/30/15 22:20

Lab Tests
Co2 (serum)
27
mEq/l
24 - 32
12/30/15 22:20
Co2 (serum)
25
mEq/l
24 - 32
01/02/16 08:24

Lab Tests
Creatinine (serum)
0.88
MG/DL
.7 - 1.5
12/30/15 22:20
Creatinine (serum)
0.77
MG/DL
.7 - 1.5
01/02/16 08:24
Page 61 of 77
1/3/16, 11:01 AM

Lab Tests
Egfr (serum)
82
mL/min
60 -
12/30/15 22:20
Egfr (serum)
96
mL/min
60 -
01/02/16 08:24

Lab Tests
Eosino Absolute# [0.0-0.4] (blood) 0.5 H X10-3/ul 0.0 - 0.4 12/30/15 22:20
Eosino Absolute# [0.0-0.4] (blood) 0.62 H X10-3/ul 0.0 - 0.4 01/02/16 08:24

Lab Tests
Eosino% [0-7] (blood)
4.0
0 - 7
12/30/15 22:20
Eosino% [0-7] (blood)
6.1
0 - 7
01/02/16 08:24
CHEST PORTABLE (1 VIEW)
Exm Date: DEC 31, 2015@05:24

Req Phys: MROUEH,GABRIELA
Pat Loc: 6J MED/01-03-2016@10:45

Img Loc: GDR(GEN. DIAGNOSTIC RADIOLOGY)
Page 62 of 77
1/3/16, 11:01 AM
Service: MEDICAL
(Case 17652 COMPLETE)CHEST PORTABLE (1 VIEW)
(RAD
Detailed) CPT:71010
Reason for Study: HX OF BKP
Clinical History:
please evaluate for infectious process. thanks!

Verifier E-Sig:/ES/EDNA M RUIZ-QUIJANO
Report:
Chest AP portable view:
Lungs are mildly hyperexpanded. Ill-defined reticulonodular

pattern is noted. Linear opacities suggesting thickened
interlobular septa and interstitial changes are also noted. The
costophrenic angles are clear. No acute segmental opacities are
lobar consolidations are seen. The costophrenic angles appears
clear.
Small asthenic heart and tortuous aorta with mild atherosclerotic

changes is observed.
Impression:
Page 63 of 77
1/3/16, 11:01 AM
Mild hyperexpansion and increased pulmonary markings suggesting

obstructive and interstitial lung disease. Compare with prior, no
significant acute radiographic changes are noted.
Primary Diagnostic Code: NO ALERT REQUIRED

EDNA M RUIZ-QUIJANO, Radiologist, Radiology Service (Verifier)
/EMR
MRI 3D RENDERING W/POSTPROCESS
Proc Ord: MRCP

Exm Date: DEC 31, 2015@10:24
Pat Loc: 6J MED/01-03-2016@10:45

Service: MEDICAL
(MRI
Detailed) CPT:74183

(MRI
Detailed) CPT:76377
Clinical History:
Page 64 of 77
1/3/16, 11:01 AM

Report:

available.


fluid collections.

Page 65 of 77
1/3/16, 11:01 AM

is patent.

Impression:


the main duct.
Addendum: Addendum:

Page 66 of 77
1/3/16, 11:01 AM
Impression:
See addendum.

/CBU
Proc Ord: MRCP

Exm Date: DEC 31, 2015@10:24
Pat Loc: 6J MED/01-03-2016@10:45

Service: MEDICAL
(MRI
Detailed) CPT:74183

(MRI
Detailed) CPT:76377
Page 67 of 77
1/3/16, 11:01 AM
Clinical History:

Report:

available.


fluid collections.
Page 68 of 77
1/3/16, 11:01 AM


is patent.

Impression:


the main duct.
Addendum: Addendum:
Page 69 of 77
1/3/16, 11:01 AM

Impression:
See addendum.

/CBU
Proc Ord: MRCP

Exm Date: DEC 31, 2015@10:24
Pat Loc: 6J MED/01-03-2016@10:45

Service: MEDICAL
(MRI
Detailed) CPT:74183

Page 70 of 77
1/3/16, 11:01 AM
(MRI
Detailed) CPT:76377
Clinical History:

Report:

available.


Page 71 of 77
1/3/16, 11:01 AM
fluid collections.


is patent.

Impression:


the main duct.
Page 72 of 77
1/3/16, 11:01 AM
Addendum: Addendum:

Impression:
See addendum.

/CBU
JAN 03, 2016 (10:46)
Cumulative Vitals/Measurements Report
Page 1
-----------------------------------------------------------------------------01/03/16
08:57
T:
97.7 F (36.5 C)
P:
69
R:
18
B/P: 135/64
Pulse Oximetry: 97%
Page 73 of 77
1/3/16, 11:01 AM
Pain: 0 - No pain
00:53
T:
98.2 F (36.8 C)
P:
68
R:
19
B/P: 125/60*
Pulse Oximetry: 97%
Pain: 0 - No pain
01/02/16
16:40
T:
98.1 F (36.7 C)
P:
75
R:
17
B/P: 127/65
Pulse Oximetry: 97%
Pain: 0 - No pain
09:31
T:
97.7 F (36.5 C)
P:
75
R:
20
B/P: 148/68
Pain: 0 - No pain
01:23
T:
97.6 F (36.4 C)
P:
80
R:
19
B/P: 108/64
Pulse Oximetry: 95%
Pain: 0 - No pain
01/01/16
09:38
Page 74 of 77
T:
98.0 F (36.7 C)
P:
67
R:
18
1/3/16, 11:01 AM
B/P: 121/65
Pulse Oximetry: 94%
Pain: 0 - No pain
00:23
T:
97.8 F (36.6 C)
P:
75
R:
18
B/P: 145/71
Pulse Oximetry: 95%
Pain: 0 - No pain
12/31/15
15:49
*** (E) - Error entry
DIAZ-MENDEZ,ULI
1838
Unit: 6J MED
NOV 24,1930
85 YRS
MALE
VAF 10-7987j
Room: J6650-B-1
Division: SAN JUAN VA MEDICAL CENTER
JAN 03, 2016 (10:46)
Cumulative Vitals/Measurements Report
Page 2
-----------------------------------------------------------------------------12/31/15 (continued)
T:
98.1 F (36.7 C)
P:
55*
Page 75 of 77
R:
1/3/16, 11:01 AM
20
B/P: 133/64
Pulse Oximetry: 97%
Pain: 0 - No pain
15:00
P:
75
B/P: 121/64
08:50
T:
97.9 F (36.6 C)
P:
58*
R:
18
B/P: 135/67
Pain: 0 - No pain
00:40
T:
97.9 F (36.6 C)
P:
75
R:
16
B/P: 160/79
Pulse Oximetry: 98%
Pain: 0 - No pain
12/30/15
21:00
T:
98.0 F (36.7 C)
P:
74
R:
19
B/P: 157/76
Wt:
135.20 lb (61.45 kg)
Body Mass Index: 22

Pulse Oximetry: 98%
Pain: 0 - No pain
20:21
Page 76 of 77
1/3/16, 11:01 AM
T:
98.2 F (36.8 C) (ORAL)
P:
69
R:
18
B/P: 124/70
Pulse Oximetry: 95%
via ROOM AIR
Pain: 6
*** (E) - Error entry
DIAZ-MENDEZ,ULI
Unit: 6J MED
1838
NOV 24,1930
85 YRS
MALE
VAF 10-7987j
Room: J6650-B-1
Division: SAN JUAN VA MEDICAL CENTER
Page 77 of 77

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Raymond E Rivera Vergara <raymond.rivera3@upr.edu>

Sun, Jan 3, 2016 at 10:49 AM

LOCAL TITLE: H&P-MEDICAL SERVICE

ENTRY DATE: DEC 30, 2015@20:55:22

EXP COSIGNER: URBINA-REYES,BRENDA Y

Internal Medicine Services History and Physical Examination

********** *** ***

*** *** ****

********** *** ***

********** *** ***

HISTORY OF PRESENT ILLNESS: