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Bayfront ModicalCenter DATE OF ADMISSION: 12/09/2000 HISTORY OF PRESENT ILLNESS: This is a 50-year-old white male who presented to Bayfront Medical Center Emergency Room status post a moped accident. This was witnessed and he appeared not have been struck by a car. He did have a loss of consciousness. He is confused upon presentation to the hospital. PAST MEDICAL HISTORY: Negative. PAST SURGICAL HISTORY: Negative. ADMISSION MEDICATIONS: Negative. DRUG ALLERGIES: NEGATIVE. SOCIAL HISTORY: Unremarkable. PHYSICAL EXAMINATION: VITAL SIGNS: On physical examination, the patient is hemodynamically stable with a blood pressure of 154/95, heart rate 86, respiratory rate of 18. HEENT: Pupils are equal, round, and reactive to light. Extraocular muscles are intact. The patient has bilateral facial periorbital swelling with ecchymosis worse, on the left side. Aside from this ' he is normocephalic. NECK: Nontender posteriorly, but within cervical immobilization. LUNGS: Equal and clear breath sounds bilaterally. External chest exam shows some left anterior chest wall abrasion, but no subcutaneous air. ABDOMEN: Soft and nontender without peritoneal signs benign. There is left anterior abdominal abrasion. PELVIS: Stable and nontender. EXTREMITIES: Pulses equal, symmetric bilaterally in upper and lower extremities. There is no extremity injury or lesion noted with the exception of the left forearm, which is tender and swollen, and a midshaft to radial fracture is confirmed by an x-ray. NEUROLOGIC: The patient is awake, but confused. He moves all 4 extremities equally. CT scan demonstrates a number of findings including a subarachnoid hemorrhage with pneumocephalus and evidence of basilar skull fracture as well as multiple facial fractures, and a left renal laceration, which is contained. IMPRESSION: 1. Multiple fractures. 2. Closed head injury. 3. Renal laceration. PATIENT NAME: LYNHEART, JOHN PHYSICIAN NAA4E: FORREST C. ARTHUR, M.D. MR#: 350709 BILLING ROOM #: '21- HISTORY AND PHYSICAL ID Subject STAT Results for patient 00350709 BAYFRONT - ST.ANTHONY'S HEALTHCARE BAYFRONT MEDICAL CENTER 727-893-6108 PATIENT NAME: TRAUMA,YANKEE/755 XRAY#: 461044 DOB: 09-Dec-01 MR#: 00350709 AGE: 99 BUSINEGS#: 00674169 SEX: u ROOM NO: AA14,01 EXAM 223A-120900 PAT TYPE: EMERGENCY- DATE: 09-Dec-00 PHYSICIAN: FORREST C ARTHUR MD 666 6TH ST S 215 ST PETERSBURG FL 33701 REASON: TRUNK INJ. CT ABDOMEN PREVIOUS SIMILAR STUDIES AVAILABLE FOR COMPARISON: None from this institution. CLINICAL HISTORY SUPPLIED/REASON FOR EXAMINATION: Trunk injury and pain. TECHNICAL FACTORS: Thin axial imaging was performed through the abdomen before and after IV contrast and after oral contrast. FINDINGS: The liver and spleen are homogeneous in density. The pancreas, right kidney and gallbladder are normal. The left kidney demonstrates laceration and contusion and hematoma formation. IMPRESSION: 1. LEFT RENAL LACERATION AND CONTUSION. released by: STEVEN F. MERANDIA, M. D. SFM/ks cc: ROOM EMERGENCY, MD BAYFRONT - ST.ANTHONY'S HEALTHCARE BAYFRONT MEDICAL CENTER 727-893-6108 PATIENT NAME: LYNHEART,JOHN XRAY#: 461044 DOB: 09-Dec-01 MR#: 00350709 AGE: 99 BUSINESS#: 00674169 SEX: m ROOM NO: P210,02 EXAM 113A-121000 PAT TYPE: INPATIENT DATE: 10-Dec-00 PHYSICIAN: FORREST C ARTHUR MD 666 6TH ST S 215 ST PETERSBURG FL 33701 REASON: BASILAR SKULL FRACTURE PNEURMOCEPHALIX CT CONTRAST WITHOUT CONTRAST REASON: HEAD INJURY. SKULL FRACTURE. FOLLOW-UP PNEUMOCEPHALUS. Comparison CT brain 12/09/00. PROCEDURE: Computed tomography of the brain was performed using contiguous 5 mm transaxial images through the posterior fossa, followed by 10 mm transaxial images to the vertex without intravenous contrast. FINDINGS: There are multiple facial and skull fractures including the following: 1. Comminuted left zygomatic arch fractures without significant displacement. 2. Left maxillary sinus fracture at the posterior lateral wall. 3. Left lateral orbital wall fracture extending orbital roof. 4. Vertical fracture through squamosal portion of left temporal bone extending to anterior aspect of left mastoid air cells. 5.1 Tiny amount of pneumocephalus is noted in the left middle cranial fossa adjacent to the left temporal skull fracture. 6. The brain is normal in attenuation. No mass, hemorrhage, or (cont,d) Page 1 PHYSICIAN: FORREST C ARTHUR MD 666 6TH ST S 215 ST PETERSBURG FL 33701 REASON: BASILAR SKULL FRACTURE PNEURMOCEPHALIX extra-axial fluid collection is seen. The ventricles are normal in size. The third and fourth ventricles are midline. 7. The left sphenoid sinus shows near complete opacification consistent with blood. Air fluid level layers within the left maxillary sinus. There is partial opacification of the left mastoid air cells. IMPRESSION: 1. LEFT TEMPORAL SKULL FRACTURE EXTENDING TO ANTERIOR MASTOID. 2. MULTIPLE FACIAL FRACTURES INCLUDING LEFT ORBIT, LEFT ZYGOMATIC ARCH, AND LEFT MAXILLARY SINUS. 3. MINIMAL PNEUMOCEPHALUS. 4. OTHERWISE NEGATIVE UNENHANCED CT BRAIN. released by: GREGG A. BARAN, M.D. GAB/dh BAYFRONT - ST.ANTHONY'S HEALTHCARE BAYFRONT MEDICAL CENTER 727-893-6108
DATE: 09-Dec-00 PHYSICIAN: FORREST C ARTHUR MD 666 6TH ST S 215 ST PETERSBURG FL 33701 REASON: PAIN LEFT FOREARM REASON: TRAUMA AND PAIN No previous exam available for comparison. There is a fracture of the distal-thirds of the shaft of the radius with slight displacement. I do not see a fracture of the ulna. released by: JOHN J. O'BRIEN, JR., M.D. .JJO/ks cc: ROOM EMERGENCY, MD BAYFRONT - ST.ANTHONY'S HEALTHCARE BAYFRONT MEDICAL CENTER 727-893-6108 PATIENT NAME: LENHART,JOHN XRAY#: 461044 DOB: 09-Dec-01 MR#: 00350709 AGE: 99 BUSINESS#: 00674169 SEX: m ROOM NO: N578,01 EXAM 189A-121300 PAT TYPE: INPATIENT DATE: 13-Dec-00 PHYSICIAN: ROBERT HAMILTON MD 4600 4TH ST N ST PETERSBURG FL 33703 REASON: PLATING OF L FOREARM IN RR LEFT FOREARM, TWO VIEWS, 12/13/00 AT 1515 REASON: FRACTURE REDUCTION AND FIXATION. Comparison preop left forearm 12/09/00. AP and lateral views of the left forearm are submitted. Since the earlier radiographs, the comminuted fracture of the mid radius has been reduced and internally fixed by a ventral metallic plate attached to multiple screws. The fracture appears anatomically aligned. No other fracture or dislocation is seen. IMPRESSION: REDUCED RADIUS FRACTURE WITH INTERNAL FIXATION. released by: GREGG A. BARAN, M.D. GAB/ac FINAL Laboratory RESULT INQUIRY @atient: LENHART,JOHN 00350709 Age/Sex: 99Y M Loc: N5 (N57801 Phys: ARTHUR, FORREST H25233 COLL: 12/14/00 LTNKNOWNREC: 12/14/00 09:15 PHYS:NOT LISTED HEPATIC FUNCTION PANEL BLOOD ALBUMIN 2.4 4.4-5.0 GM/DL TOTAL BILIRUBIN 1.0 0.2-1.0 MG/DL BILIRUBIN, DIRECT 0.3 0.0-0.2 MG/DL ALKALINE PHOSPHATASE 187 42-121 U/L SGOT (AST) 168 10-42 U/L SGPT (ALT) 179 10-40 U/L PROTEIN, TOTAL 5.5 6.4-8.3 G/DL H25228 COLL: 12/14/00 09:10 REC: 12/14/00 09:11 PHYS:ARTHUR, FORREST HEMOGLOBIN A2, QUANT. BLOOD HEMOGLOBIN A2, QUANT REQUEST CREDITED CANCELLED BY NURSING/M.D. H25227 COLL: 12/14/00 09:05 REC: 12/14/00 10:01 PHYS:ARTHUR, FORREST URINE MACROSCOPIC --Pend URIN Laboratory RESULT INQUIRY Patient: LENHART,JOHN 00350709 Age/Sex: 99Y M Loc: N5 (N57801 Phys: ARTHUR, FORREST H25227 COLL: 12/14/00 09:05 REC: PHYS: URINE MICROSCOPIC ---Pend URIN H24835 COLL: 12/14/00 05:08 REC: 12/14/00 05:55 PHYS:NOT LISTED METABOLIC PANEL, COMPR BLOOD SODIUM L 135 136-145 MMOL/L POTASSIUM 4.1 3.5-5.1 MMOL/L CHLORIDE 102 98-107 MMOL/L C02 (CARBON DIOXIDE) 25.5 23-31 MMOL/L GLUCOSE H 83-110 MG/DL BUN 5 7-18 MG/DL CREATININE 0.6-1.3 MG/DL 1-1 CALCIUM L 8.8-10.0 MG/DL BILIRUBIN, TOTAL H 1.3 0.2-1.0 MG/DL PROTEIN, TOTAL L 5.7 6.4-8.3 G/DL ALBUMIN L 2.5 3.0-4.6 G/DL AST (SGOT) H 165 10-42 U/L ALKALINE PHOSPHATASE H 199 42-121 U/L ALT (SGPT) H 183 10-40 U/L Laboratory RESULT INQUIRY Patient: LENHART,JOHN 00350709 Age/Sex: 99Y M Loc: N5 (N57801 Phys: ARTHUR,, FORREST H24835 COLL: 12/14/00 05:08 REC: PHYS: HEMOGRAM BLOOD WBC COUNT 9.51 4.8-10.8 K/UL RBC COUNT L 3.08 4.7-6.2 M/UL HEMOGLOBIN L 9.3 14.0-18.0 GM/DL Subject IAB 00350709 LENHART,JOHN LOC: N57801 (N5) H24835 COLL: 12/14/00 05:08 REC: 12/14/00 05:55 PHYS:NOT LISTED CBC AND DIFFERENTIAL HEMOGRAM WBC COUNT 9.51 4.8-10.8 K/UL RBC COUNT *L 3.08 4.7-6.2 M/UL HEMOGLOBIN *L 9.3 14.0-18.0 GM/DL HEMATOCRIT *L 26.0 42.0-52.0 mcv 84.4 80-94 FL MCH 30.2 27-31 pg MCHC 35.8 31-37 G/DL RDW 11.6 11.5-14.5 % PLATELET COUNT 178 130-400 K/UL MPV 9.1 7.4-10.4 FL DIFFERENTIAL NEUTROPHILS 69.8 45-75 LYMPHOCYTE *L 14.8 24-44 MONOCYTE *H 14.2 1-9 EOSINOPHIL 1.1 0-6 BASOPHIL 0.1 0-3 RBC MORPHOLOGY Normal FINAL LENHART, JOHN LENHART, JOHN 5763 38TH AVENUE N 50 72190533 ST PETE FL 33703 12/19/00 10:00 7275260600 12/19/00 12:44 RECI.BY: LENHART, JOHN 12/20/2000 08:10 ORO. COMM: FX 799-8024 FASTING 12/19/2000, 16:12,FAXED PARTIAL TO 7998024. SLC c o n t i n u e d GENERAL CHEMISTRY ROUTINE URINALYSIS COLOR yellow APPEARANCE hazy CLEAR SPECIFIC GRAVITY 1.020 1.005-1.035 PH 5.0 5.0-8.5 GLUCOSE NEG NEGATIVE KETONES NEG NEGATIVE BILIRUBIN NEG NEGATIVE PROTEIN AB 2+ NEGATIVE BLOOD AB 4+ NEGATIVE UROBILINOGEN NORM NORMAL LEUKOCYTES NEG NEGATIVE NITRITE NEG NEGATIVE MICROSCOPIC WBC AB 5-10 0-5/HPF /hpf RBC AB TNTC 0-4/HPF /hpf BACTERIA AB 1+ NEGATIVE EPITHELIAL CELLS 0-1 /lpf mucus 3+ |