County General Hospital 120 NE Valley View Drive Worcester, MA 01608 | (508) 929-1300 Fax:
508-665-1011
Chart Document
04/01/2010 - Lab Report Provider: Harry S. Winston MD Location of Care: Southside Clinic
Patient: Bessie Crandell Note: Prelim.
Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
Home: 508-644-9139
Tests: (1) Urine Culture (ML-06MICRO) URINE CULTUR 20-50,000 CFU/ml <10*2
(1) Order result status: Prelim Collection or observation date-time:
03/31/2010 18:00:00 Requested date-time: 03/31/2010 18:00:00 Receipt
date-time: Reported date-time: 03/31/2010 18:00:00 Ordering Physician:
(smitchell) Specimen Source: Producer ID: (LabQuest) Filler Order
Number: Lab site:
Note: An exclamation mark (!) indicates a result that was not dispersed into
the flowsheet. GNR noted Document Creation Date: 04/01/2010 10:24 AM
Signed by Vladimir Nocturnisto MD on 04/01/2010 at 11:11 PM
________________________________________________________________________
County General Hospital 120 NE Valley View Drive Worcester, MA 01608 | (508) 929-1300 Fax:
508-665-1011
Chart Document
Home: 508-644-9139
04/01/2010 - Hospital Discharge Summary: R Hip Fracture Provider: Harry S. Winston MD Location
of Care: Southside Clinic
HOSPITAL DISCHARGE SUMMARY
Date of Admission: 03/27/2010
Date of Discharge 04/01/2010
Admitting Physician: Dr. Robin Janoff
Admission Diagnosis: Total Hip Replacement Right
Discharge Diagnosis: 1) Total Hip Replacement Right 2) Deep Venous Thrombosis
Procedures: Total Hip Replacement Right
Procedures: R THR with special steel alloy prosthesis.
Hospital Course: The patient was admitted to the surgical ward after a fall with a right hip fracture. For
details of medical history, please refer to the attached office notes which Dr. Winston faxed. The patient
was placed in Bucks traction and treated with morphine. In the morning she was taken to OR6 where
THR right was performed without difficulty or complications. Post-operatively day 2 the patient is found to
have tenderness in the right calf, and on doppler was found to have a significant DVT running up to the
right common iliac. The patient was heparinized and Coumadin begun to achieve anticoagulation. The
patient was not hemodynamically compromised. The patient complained of dysuria. A catheter was
placed for this and some redness to the perineal area. Culture is no growth so far.
Discharge Medications: URISPAS TAB 100MG (FLAVOXATE HCL) 1 po tid COUMADIN 2.5 MG TABS
(WARFARIN SODIUM) as directed LASIX TAB 20MG (FUROSEMIDE) 1 po bid MICRO-K 10 MEQ CRCAPS (POTASSIUM CHLORIDE) PERCOCET 2.5-325 MG TABS (OXYCODONE-ACETAMINOPHEN)
as directed
Disposition: To Peaceful Gardens Nursing And Rehab Center.
Signed by John J. Doconcall MD on 04/01/2011 at 7:07 PM
________________________________________________________________________
Bessie A. Crandell Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
Eastside Internal Medicine 130 NE Valley View Drive Worcester, MA 01608
Page 3 508-665-1010 Fax: 508-665-1011
Chart Document
Bessie A. Crandell Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
04/01/2007 - Office Visit Provider: Harry S. Winston MD Location of Care: Southside Clinic
HPI: no complaints no edema no sob no new pain
Height(in) Weight(lbs) BMI Arm Circ FAST PPS INR HCT WBC PLTS ALB PreAlbumin BUN CR
CrClearance Sodium Potassium pCO2 pO2 Oxygen Flow 60 70 70 70 2.9 30 2.3 04/01/2007 04/01/2007
04/01/2007 04/01/2007
Impression & Plan Summary: HIP PAIN LEFT - Improved.
PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN - Improved.
FISTULA FEMALE GENITAL TRACT.
INCONTINENCE URINE - Unchanged.
Signed by Harry S. Winston MD on 04/01/2007 at 6:27 PM
Eastside Internal Medicine 130 NE Valley View Drive Worcester, MA 01608
Page1 508-665-1010 Fax: 508-665-1011
Chart Document
11/10/2006 - Office Visit Provider: Harry S. Winston MD Location of Care: Southside Clinic
HPI: a fall with no injury is noted
Past Medical History: seee problem list Medications Prior to Visit: URISPAS TAB 100MG
(FLAVOXATE HCL) 1 po tid COUMADIN 2.5 MG TABS (WARFARIN SODIUM) as directed LASIX
TAB 20MG (FUROSEMIDE) 1 po bid MICRO-K 10 MEQ CR-CAPS (POTASSIUM CHLORIDE)
Advance Care Planning: Health care agent not currently available to discuss advance care
plan.
Respiratory Respiratory effort: no intercostal retractions or use of accessory muscles Percussion:
no dullness Palpation: normal fremitus Auscultation: no rales, rhonchi, or wheezes
Cardiovascular Palpation: no thrill or palpable murmurs, no displacement of PMI Auscultation:
S1S2, regular rate and rhythm, no murmur, rub, or gallop Carotid arteries: symmetric, no bruits
Abdominal aorta: no enlargement or bruits Femoral arteries: pulses 3+, symmetric, no bruits Left
Dorsalis Pedis: 2/4 Right Dorsalis Pedis: 2/4 Left Posterior Tibialis: 2/4 Peripheral circulation: no
cyanosis, edema, or varicosities
Gastrointestinal Abdomen: soft, non-tender, no masses, bowel sounds normal Liver and spleen:
no enlargement or nodularity Hernia: no hernias Rectal: Digital rectal exam reveals no mass, tenderness
or impaction Stool: guaiac negative
Genitourinary External genitalia: prolapse
Bessie A. Crandell Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
Home: 508-644-9139
Eastside Internal Medicine 130 NE Valley View Drive Worcester, MA 01608
Page1 508-665-1010 Fax: 508-665-1011
Chart Document
Lymphatic Neck: no cervical adenopathy Axillae: no axillary adenopathy Groin: no inguinal
adenopathy
Musculoskeletal Gait and Balance: Abnormal Get Up and Go Digits and nails: no clubbing,
cyanosis, petechiae, or nodes Head and neck: normal alignment and mobility Spine, ribs, pelvis:
kyphosis RUE: mild edema Ht: 60 in
Have you fallen since your last visit? Y
Influenza Consent Process: Denies history of severe allergic reactions to this vaccine Is not
moderately or severely ill Vaccine information given and explaines to the patient Consent and
authorization on file Vaccine information explained to the patient.
Lot #: AFLLA259AA Manufacturer: GlaxoSmithKline Dose: Influenza vaccine 0.5 ml Route
Intramuscular Injection Site: RT Deltoid
Influenza Consent Process: HIP PAIN, LEFT (ICD-719.45) LEG EDEMA (ICD-782.3) PHLEBITIS
AND THROMBOPHLEBITIS OF FEMORAL VEIN (ICD-451.11) BACT INF COND CLASS ELSW
BACTEROIDES FRAGILIS (ICD-041.82) FISTULA, FEMALE GENITAL TRACT (ICD-619.9) PROLAPSE,
VAGINAL WALL W/O UTERINE PROLAPSE (ICD-618.0) CYSTITIS (ICD-595.8) INCONTINENCE,
URINE (ICD-788.3)
Signed by Harry S. Winston MD on 11/10/2006 at 6:27 PM
Eastside Internal Medicine 130 NE Valley View Drive Worcester, MA 01608
Page1 508-665-1010 Fax: 508-665-1011
Chart Document
04/01/2006 - Office Visit Provider: Harry S. Winston MD Location of Care: Southside Clinic
Height(in) Weight(lbs) BMI Arm Circ FAST PPS INR HCT WBC PLTS ALB PreAlbumin BUN CR
CrClearance Sodium Potassium pCO2 pO2 Oxygen Flow 62 75 75 75 3.1 29 5 102 2.8 3.2 04/01/2006
04/01/2006 04/01/2006 04/01/2006 04/01/2006 04/01/2006 04/01/2006 04/01/2006 04/01/2006
Signed by Harry S. Winston MD on 04/02/2006 at 6:14 PM
________________________________________________________________________
11/12/2005 - Office Visit Provider: Harry S. Winston MD Location of Care: Southside Clinic
OFFICE VISIT
History of Present Illness Chief Complaint: follow up xray History of Present Illness: hoip pain
unchanged.. xray shows demineralization and osteoarthritis.
History Past Medical History:
Current Problems (prior to this update): HIP PAIN, LEFT (ICD-719.45) LEG EDEMA (ICD-782.3)
PHLEBITIS AND THROMBOPHLEBITIS OF FEMORAL VEIN (ICD-451.11) BACT INF COND CLASS
ELSW BACTEROIDES FRAGILIS (ICD-041.82) FISTULA, FEMALE GENITAL TRACT (ICD-619.9)
PROLAPSE, VAGINAL WALL W/O UTERINE PROLAPSE (ICD-618.0) CYSTITIS (ICD-595.8)
INCONTINENCE, URINE (ICD-788.3)
Current Medications (prior to this update): URISPAS TAB 100MG (FLAVOXATE HCL) 1 po tid
COUMADIN 2.5 MG TABS (WARFARIN SODIUM) as directed LASIX TAB 20MG (FUROSEMIDE) 1 po
bid MICRO-K 10 MEQ CR-CAPS (POTASSIUM CHLORIDE)
Vital Signs Ht: 62 in.
Physical Exam neg slr,
Impression possible arthritis of hip
Plan non pharmacologic managment uness worsens. Disposition:
Signed by Harry S. Winston MD on 11/12/2005 at 6:10 PM
________________________________________________________________________
Bessie A. Crandell Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
Home: 508-644-9139
Eastside Internal Medicine 130 NE Valley View Drive Worcester, MA 01608
Page1 508-665-1010 Fax: 508-665-1011
Chart Document
Home: 508-644-9139
Bessie A. Crandell Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
Eastside Internal Medicine 130 NE Valley View Drive Worcester, MA 01608
Page1 508-665-1010 Fax: 508-665-1011
Bessie A. Crandell Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
Home: 508-644-9139
11/10/2005 - Office Visit Provider: Harry S. Winston MD Location of Care: Southside Clinic
Visit Type: Established office visit
Chief Complaint: Resident is here for evaluation and management of multiple medical problems; See
HPI for details of problems HPI: Continues with mild leg edema
no sob
no chest pains
has now developed right hip pai with ambulation. exam benign. will xray
Signed by Harry S. Winston MD on 11/10/2005 at 6:08 PM
________________________________________________________________________
Eastside Internal Medicine 130 NE Valley View Drive Worcester, MA 01608
Page1 508-665-1010 Fax: 508-665-1011
Bessie A. Crandell Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
Home: 508-644-9139
04/01/2005 - Office Visit Provider: Harry S. Winston MD Location of Care: Southside Clinic
CC Leg edema
no sob
lungs clear
rx lasix
fu prn
Signed by Harry S. Winston MD on 04/01/20051 at 6:04 PM
________________________________________________________________________
11/10/2004 - Office Visit Provider: Harry S. Winston MD Location of Care: Southside Clinic
Signed by Harry S. Winston MD on 11/10/2004 at 5:54 PM
________________________________________________________________________
Eastside Internal Medicine 130 NE Valley View Drive Worcester, MA 01608
Page1 508-665-1010 Fax: 508-665-1011
Bessie A. Crandell Female DOB: 11/19/1915
81-TEST011
Ins: CHC (Gold Plan)
Grp: CHCS5355
Home: 508-644-9139
Date of cardiac study: 11/01/2003
BMI: 18.36
Smoking Status: Reformed Smoker
Pneumococcal vaccination status: Administered and Previously received
Do you have leakage of urine? Yes
Do you sometimes drink beer, wine or other alcoholic beverages? Yes
In the past year have you had one or more days where you drank more than 4 drinks in a day?
Yes In the past 12 months, the residents alcohol use has repeatedly caused: Risk of bodily harm such as
drinking and driving, swimming or operating machinery Relationship troubles with family or friends
Interference with home, work or other obligations Legal problems such as DUI. In the past 12 months, the
residents alcohol use has: been unable to stick to drinking limits. not been able to cut down or stop.
shown tolerance to alchohol. had signs of withdrawl. kept drinking despite problems. spends a lot of time
drinking. spent less time on other matters that should have been important or pleasurable.
Signed by Harry S. Winston MD on 11/10/2004 at 5:54 PM
_________________________________________________________
Eastside Internal Medicine 130 NE Valley View Drive Worcester, MA 01608
Page1 508-665-1010 Fax: 508-665-1011
Home: 508-644-9139
Female DOB: 11/19/1915
81-TEST011 Ins: CHC (Gold Plan)
Grp: CHCS5355
04/01/2004 - Office Visit Provider: Harry S. Winston MD Location of Care: Southside Clinic
Signed by Harry S. Winston MD on 04/01/2004 at 5:57 PM
09/23/2003 - Lab Report: Lipids Provider: Sam A. Mitchell MD Location of Care: Millennium Health
System
Patient: Bessie Crandell
Note: All result statuses are Final unless otherwise noted.
Tests: (1) Lipids (ML-11LIPID)
CHOLESTEROL 136 mg/dl 130-200
HDL 70 mg/dl 30-75
LDL 64 mg/dl 0-129
TRIGLYCERIDE 175 mg/dL 30-250
(1) Order result status: Final Collection or observation date-time: 09/23/2003
18:00:00
Requested date-time: 09/23/2003 18:00:00
Receipt date-time: Reported date-time: 09/23/2003 18:00:00
Ordering Physician: (smitchell)
Specimen Source:
Producer ID: (LabQuest)
Filler Order Number: Lab site:
Signed by Harry S. Winston MD on 09/23/2003 at 9:06 AM
________________________________________________________________________
Bessie A. Crandell Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
Home: 508-644-9139
Note: An exclamation mark (!) indicates a result that was not dispersed into
the flowsheet. Document Creation Date: 09/23/2003 10:32 AM
_________________________________________________
09/22/2003 - Lab Report: Urine Culture Provider: Sam A. Mitchell MD Location of Care: Millennium
Health System
Patient: Bessie Crandell Note: All result statuses are Final unless otherwise
noted.
Tests: (1) Urine Culture (ML-06MICRO) URINE CULTUR 0 CFU/ml <10*2
Note: An exclamation mark (!) indicates a result that was not dispersed into
the flowsheet. Document Creation Date: 09/22/2003 10:24 AM
________________________________________________
(1) Order result status: Final Collection or observation date-time: 09/20/2003
18:00:00 Requested date-time: 09/20/2003 18:00:00 Receipt date-time: Reported
date-time: 09/21/2003 18:00:00 Ordering Physician: (smitchell) Specimen
Source: Producer ID: (LabQuest) Filler Order Number: Lab site:
Filed automatically (without signature) on 09/24/2003 at 10:28 AM
______________________________________________________________
Bessie A. Crandell Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
Home: 508-644-9139
09/21/2003 - Lab Report: Urinalysis Provider: Sam A. Mitchell MD Location of Care: Millennium
Health System
Patient: Bessie Crandell Note: All result statuses are Final unless otherwise
noted.
Tests: (1) Urinalysis (ML-09URIN) PROTEIN, URN Neg GLUCOSE, URN Neg BILIRUBIN
UR Neg KETONES URN Neg MG/DL NITRITE URN Neg PH URINE 6.44 4.5-7.8 SPEC GR
URIN 1.017 1.003-1.029 WBC DIPSTK U Neg APPEARANCE U clear UA COLOR yellow
Note: An exclamation mark (!) indicates a result that was not dispersed into
the flowsheet. Document Creation Date: 09/21/2003 10:24 AM
(1) Order result status: Final Collection or observation date-time: 09/19/2003
18:00:00 Requested date-time: 09/19/2003 18:00:00 Receipt date-time: Reported
date-time: 09/20/2003 18:00:00 Ordering Physician: (smitchell) Specimen
Source: Producer ID: (LabQuest) Filler Order Number: Lab site:
Filed automatically (without signature) on 09/24/2003 at 10:28 AM
________________________________________________________________________
Bessie A. Crandell Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
Home: 508-644-9139
09/21/2003 - Office Visit: Incontinence, Skin lesion Provider: Sam A. Mitchell MD Location of Care:
Eastside Internal Medicine This document contains image attachments Doc ID:
OFFICE VISIT
History of Present Illness Chief Complaint: Incontinence History of Present Illness: Pt.
presents with 5 year history of recurrent cystitis and urinary incontinence; worsening incontinence over
last 3 months. Pt had tolerated condition well until lately, now requests thorough evaluation due to
worsening sx.
She also points out a small raised lesion on the back of her left shoulder. She first noticed it about a
month ago, but denies that it has bothered her in any way. She has no history of skin problems, but does
relate a history of significant sun exposure as a child.
History Past Medical History: Previous records in paper chart.
Family History: 2 Children, both vaginal delivery. 1 Brother, lives out of state
Current Problems (prior to this update): recurrent cystitis and urinary incontinence
Current Medications (prior to this update): Antibiotic
Risk Factors Smoking (packs/day): 0 Alcohol use (drinks/day): <1 Drug use: none Caffeine
(drinks/day): 1 Exercise (times/week): 3 Passive Smoke Exposure: no HIV Risk Factors: no Sun
Exposure: rarely
Vital Signs Ht: 62 in. Wt: 125 lbs. T: 98.0 deg F. T site: oral P: 76 Rhythm: regular R: 18 BP: 140/ 86
Skin: Over her left scapula is a 7x7mm reddish raised lesion with smooth, pearly margins. It is well
demarcated and non-tender.
SKNBCC
Assessment
Bessie A. Crandell Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
Home: 508-644-9139
History of Present Illness Chief Complaint: Incontinence History of Present Illness: Pt.
presents with 5 year history of recurrent cystitis and urinary incontinence; worsening incontinence over
last 3 months. Pt had tolerated condition well until lately, now requests thorough evaluation due to
worsening sx.
She also points out a small raised lesion on the back of her left shoulder. She first noticed it about a
month ago, but denies that it has bothered her in any way. She has no history of skin problems, but does
relate a history of significant sun exposure as a child.
Social History: Widow for 5 years, lives alone, with weekly visits from both son and daughter (brought to
clinic by daughter)
Current Problems (prior to this update): recurrent cystitis and urinary incontinence
Current Medications (prior to this update): Antibiotic
Risk Factors Smoking (packs/day): 0 Alcohol use (drinks/day): <1 Drug use: none Caffeine
(drinks/day): 1 Exercise (times/week): 3 Passive Smoke Exposure: no HIV Risk Factors: no Sun
Exposure: rarely
Vital Signs Ht: 62 in. Wt: 125 lbs. T: 98.0 deg F. T site: oral P: 76 Rhythm: regular R: 18 BP: 140/ 86
Skin: Over her left scapula is a 7x7mm reddish raised lesion with smooth, pearly margins. It is well
demarcated and non-tender.
SKNBCC
Assessment
Bessie A. Crandell Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
Eastside Internal Medicine 130 NE Valley View Drive Worcester, MA 01608
Page1 508-665-1010 Fax: 508-665-1011
Page 2 508-665-1010 Fax: 508-665-1011Chart Document
Bessie A. Crandell Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
Home: 508-644-9139
Problems (including changes): Female Incontinence Length of Incontinence: 5 years Episodes: 4-5 in
24 hrs Quality of Voiding Nocturia Volume (oz.): 10 Number per night: 3 Stream weak hesitancy: (sec)
Urge Pads: yes Pads per 24 hrs: 5 maxi Lose urine on way to bathroom? half-time Do you feel empty
after incontinence? no
Stress Loss of urine with such stress laughing coughing sneezing lifting active exercise (walking) Pads:
yes Pads per 24 hrs: 5 Which type of incontinence would you fix if you could only fix one? Stress Which
occurs most often? Stress Which gets you wettest? Stress
Impression: Urinary incontinence, r/o pelvic relaxation, obstructive uropathy. Probable basal cell
carcinoma of the left posterior shoulder.
Plan Medications (including changes): URISPAS TAB 100MG Macrodantin Cap 50 mg
Patient/Family Instructions: The following HealthLogic handouts were given: Urethritis UTI, Endoscopy-Bladder cystoscopy
Treatment: Plan urodynamic studies. Will start on antibiotic and Urispas and schedule cystoscopy.
Orders: Bladder Cystoscopy, UA, Urine Culture, Lipid Panel, Pneumovax, Flu Vax, TD Booster,
Hemoccult, Follow-up next week for excisional biopsy of skin lesion.
Education/Counseling (time): 10 minutes
Coordination of Care (time): 5 minutes
Bessie A. Crandell Female DOB: 11/19/191581-TEST011Ins: CHC (Gold Plan) Grp: CHCS5355
Eastside Internal Medicine 130 NE Valley View Drive Worcester, MA 01608
Page1 508-665-1010 Fax: 508-665-1011
Chart Document
Bessie A. Crandell
Female DOB: 11/19/1915
81-TEST011
Ins: CHC (Gold Plan)
Grp: CHCS5355
Home: 508-644-9139
Follow-up/Return Visit: 2 weeks
Disposition: return to clinic