County General Hospital
546 That Street
Some Town, YY 12345
111-222-9998
DISCHARGE SUMMARY
PATIENT: Michael F. Byrnes
ADMISSION DATE: June 5, 2006
DISCHARGE DATE: June 6, 2006
ATTENDING PHYSICIAN: Jackson, Samantha
UNIT#: 345678
ACCT#: 98734512
DOB: 05/19/78
ROOM/BED: F. 345-B
Issac Johnson, DSA dictating for Dr. Samantha Jackson
DISCHARGE DIAGNOSES:
1. Post-Traumatic Stress Disorder.
2. Gastrointestinal pain, resolved.
HISTORY OF PRESENT ILLNESS:
This is a 28-year-old African American male with a recent history of anxiety and
paranoia. He was recently discharged from the Army after two tours in Iraq. He is
currently homeless and was yelling at anyone who came near him in the park. When
approached by police he lashed out and they brought him to the hospital. He was hyper
vigilant about his surroundings and had an exaggerated startle response when anyone
entered his hospital room. He was very anxious about all of the monitors around him.
The patient also complained of intense abdominal pain, likely related to ingesting rotten
food. He was admitted for further evaluation and management.
ALLERGIES:
No known drug allergies.
HOSPITAL COURSE:
His blood work was within normal limits. Abdominal pain responded to antacids and
acetaminophen.
On the morning of June 6, the patient had calmed down in response to the paroxetine 20
mg administered the night before. He denied AH/VH. He denied any suicidal or
homicidal ideations. He was prescribed paroxetine 20 mg, once daily.
Dr. Jackson noted that he would need to follow up with social services and the Veterans
Affairs Medical Center for ongoing treatment.
CONDITION AT DISCHARGE:
The patient was wanting to be discharged. He was alert and oriented x3. Vital signs
were stable. His last recorded blood pressure was 107/61, heart rate 75. Lungs were
PT: Byrnes, Michael F.
UNIT: 345678
ACCT: 98734512
clear. Abdomen was soft, nontender, nondistended with positive bowel sounds. He was
discharged on June 6, 2006, with discharge instructions given and medications
reconciled.
LABORATORY DATA:
On June 5, sodium 143, potassium 3.8, chloride 109, co2 of 28, anion gap 6.0, glucose
122, BUN 17, creatinine 1.1, total protein 6.5, albumin 3.4, globulin 3.1, calcium 8.8,
phosphorus 3.7, total bilirubin 0.3, AST 14, ALT 15, alkaline phosphatase 88,
magnesium 2.2, triglycerides 50, cholesterol 150, HDL cholesterol 45, and LDL 120.
Hematology values on June 6, white blood count 11.6, hemoglobin and hematocrit 12.3
and 36.5 respectively, with platelet count of 282,000.
DISCHARGE MEDICATIONS:
1. Paroxetine 20mg, daily.
2. Calcium Carbonate, as needed.
DISCHARGE INSTRUCTIONS:
Follow up with Social Services as instructed r.e. housing. Follow-up with Veterans
Affairs Medical Center for ongoing treatment.
Dictated by Issac Johnson DSA
DD: 06/08/2006 12:25:34 DT: 06/08/2006 13:15:25 CGHANYHSC; Job#543321
Authenticated by Samantha Jackson MD on 06/12/2006 06:45:21 PM
PT: Byrnes, Michael F.
UNIT: 345678
ACCT: 98734512
County General Hospital
546 That Street
Some Town, YY 12345
111-222-9998
HISTORY AND PHYSICAL REPORT
PATIENT: Michael F. Byrnes
ADMISSION DATE: June 5, 2006
ADMITTING PHYSICIAN: Jackson, Samantha
ATTENDING PHYSICIAN: Jackson, Samantha
DICTATING PHYSICIAN: Jackson, Samantha
UNIT#: 345678
ACCT#: 98734512
DOB: 05/19/78
ROOM/BED: F. 345-B
CHIEF COMPLAINT:
The patient came in with extreme anxiety and agitation. The patient also complained of
intense abdominal pain.
HISTORY OF PRESENT ILLNESS:
This is a 28-year-old African American male with a recent history of anxiety and
paranoia. He was recently discharged from the Army after two tours in Iraq. He is
currently homeless and was yelling at anyone who came near him in the park. When
approached by police he lashed out and they brought him to the hospital. He was hyper
vigilant about his surroundings and had an exaggerated startle response when anyone
entered his hospital room. He was very anxious about all of the monitors around him.
The patient also complained of intense abdominal pain, likely related to ingesting rotten
food.
PAST MEDICAL HISTORY:
None known.
SOCIAL HISTORY:
He is single, does not have any children, is currently unemployed and homeless. Does
not smoke, denies drinking or using drugs but smelled of alcohol at admittance.
FAMILY HISTORY:
None.
MEDICATIONS:
None.
REVIEW OF SYSTEMS:
All other systems are reviewed, otherwise negative.
ALLERGIES:
None.
PT: Byrnes, Michael F.
UNIT: 345678
ACCT: 98734512
PHYSICAL EXAMINATION:
GENERAL: The patient is lying in the bed, fidgeting often. Occasionally grimaces and
holds his abdomen.
VITAL SIGNS: Significant for patient’s temperature of 99.2, pulse of 88, respiratory rate
of 18, blood pressure of 107/61, and pulse ox of 97%.
HEENT: Pupils equal, round, reactive to light and accommodation. Extraocular muscles
are intact. No icterus, no pallor noted.
NECK: Supple, no jugular venous distention, no thyromegaly.
CARDIOVASCULAR: Regular rate and rhythm, s!, s2 heard. No mumurs, gallops, or
rubs.
CHEST: Clear to auscultation.
Abdomen: Soft, tender to the touch, nondistended.
EXTREMETIES: No edema, No cyanosis.
NUEROLOGIC: Alert and oriented x3 and follows all commands.
LABORATORY DATA:
The patient’s CBC was within normal limits. The patient’s CMP was also within normal
limits.
ASSESSMENT AND PLAN:
Abdominal pain. The patient will be given calcium carbonate and acetaminophen.
Anxiety and agitation. The patient will be given paroxetine 20 mg to stabilize. The
patient will get social worker involved for further plan of care. We will start the patient
on antianxiety medications.
If this history and physical was performed prior to admission, but within the last 30 days,
indicate by initialing one of the following:
__I have reassessed the patient and notes that there are no significant changes to the
assessment.
__I have reassessed the patient and note the following significant changes occurred:
DD: 06/05/2006 01:25:30 DT: 06/05/2006 03:14:09 CGHANYHSC; Job#569821
Authenticated by Samantha Jackson MD on 06/07/2006 08:49:45 AM
Samantha Jackson
Report ID: 0998-0098
Electronically Signed by Samantha Jackson on 06/07/2006 at 0932
PT: Byrnes, Michael F.
UNIT: 345678
ACCT: 98734512