Module 5
PATIENT Todd K Anderson DOB 03/05/1970 AGE 47 yrs SEX Male PRN JR572205
FACILITY Northstar Physicians Center T (999) 999-9999 1234 Sunshine Way 100 Minneapolis, MN 99999
Patient identifying details and demographics
FIRST NAME Todd MIDDLE NAME K LAST NAME Anderson SSN 123-12-2311
SEX Male DATE OF BIRTH 03/05/1970 DATE OF DEATH - PRN JR572205
ETHNICITY Hispanic or Latino
PREF. LANGUAGE
English
RACE White STATUS Active patient
CONTACT INFORMATION
ADDRESS LINE 1 45 Deer Run Road
ADDRESS LINE 2 - CITY Livingston STATE NJ ZIP CODE 07039
CONTACT BY Email EMAIL todda@testpatie
nt.com HOME PHONE (555) 555-5555 MOBILE PHONE (555) 555-5555 OFFICE PHONE - OFFICE EXTENSION
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FAMILY INFORMATION
NEXT OF KIN Jessie Anderson RELATION TO PATIENT Spouse PHONE 5555555555 ADDRESS 45 Deer Run Ln
Livingston, NJ 07039
PATIENT'S MOTHER'S MAIDEN NAME
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Free cloud based EHR
Patient chart - Patient: Todd K Anderson DOB: 03/05/1970 PRN... https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/...
1 of 1 4/7/17, 5:12 PM
Northstar Surgical Group
5678 Sunshine Way #500
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Todd K Anderson
DOB: 03/05/1970
Indications: Patient with large renal calculus.
Procedure: Percutaneous Nephrolithotomy
The patient was placed in the supine position, given general anesthesia, then prepped and draped in the usual standard sterile manner. A flexible cystoscope was then placed into the urethral meatus and the length of the urethra inspected. No lesions noted.
The bladder neck and trigone showed no abnormalities. The ureteral orifices were noted to be normal bilaterally. A routine inspection of the bladder was completed with no sign of obvious lesions. A cone tip catheter was placed into the ureteral orifice. Under fluoroscopic visualization, a retrograde ureteropyelogram with diluted contrast was performed. No obvious lesions were noted. A 0.3 guide wire was passed through the ureter and into the renal pelvis. An urteral occlusion balloon catheter was passed over the wire and the balloon was inflated with contrast. The bladder was drained, wires removed, scope removed under direct vision.
The patient was then repositioned in the prone position, prepped and draped again in the usual, sterile manner. A 0.04 guide wire was passed through the previously placed nephrostomy tube. The nephrostomy tube was then removed over the wire. The tract was dilated to accommodate an introducer sheath of 10 French size. A safety wire was passed into the renal pelvis and into the ureter past the ureteral occlusion balloon and secured for emergency use. Sequential dilation was performed to insert a fascial dilator balloon. This balloon was inflated with contrast to 20 atmospheres of pressure under fluoroscopy over a period of 5-10 minutes. Then, a 30 French sheath was passed over the balloon into the inter-renal calyx. The balloon was deflated and removed. The nephroscope was introduced. An inspection of the renal pelvis identified the stone. No lesions were identified. The stone was fragmented with an ultrasound lithotripter. Larger fragments of calculi were removed intact with forceps until the patient was free of all calculi. The renal collecting system was inspected with the nephroscope and flexible nephroscopy to verify no additional stone material remained. Fluoroscopy was used to verify the absence of stone material. The guide and safety wires were removed. The nephrostomy tube was secured to the skin with a nylon suture. The cook catheter was capped. The wound was cleaned and bandaged. Patient was then awakened from anesthesia without complications and transferred to recovery. The patient is in stable condition and without complications.
Physician’s Signature Selena Hensen, MD
Northstar Nutritional Services
4567 Sunshine Way #400
Minneapolis, MN 99999
Phone: (555) 555-5555
Patient: Todd K Anderson
DOB: 03/05/1970
Referring Physician: Nazir Asaad, MD
Medical Nutritional Care Plan Current Diagnoses: Nephrolithiasis
Relevant S&S: Colic, Oliguria, Pyuria, Dysuria, Lumbalgia Relevant Lab Findings: Hematuria, dark amber urine
Current BMI: 33.9 Estimated energy needs: 3283 calories per day Estimated protein needs: 56-72 grams per day Estimated carbohydrate needs: 179 grams per day Estimated fat needs: 40-45 grams per day Nutrition Prescription: Increase water consumption daily. Decrease sodium intake. (Patient provided with information on DASH diet.) Include more alkaline foods, such as root vegetables, leafy greens, garlic, lemon, and cayenne peppers. Switch to olive oil for cooking vegetables and lean meats. Calculation of therapeutic diet for certain disease states: Nephrolithiasis: Restrict high-oxalate foods; restrict animal protein Family hx of hypertension: Reduce sodium intake to below 1500 mg/day Family hx of gouty arthritis: Reduce meat and fish intake. Replace protein sources with dairy products and legumes. Nutrition-related medical condition goals: Intervention #1: Increase fluid intake Goal(s): High fluid intake will be this patient’s first priority intervention. Goal is to consume two liters of water daily. This fluid intake should be spread evenly throughout the day. Bladder should be emptied as needed. Voluntary urine retention is highly discouraged. Intervention #2: Alkalinize diet Goal(s): Due to family history of gouty arthritis (father and paternal GF), it is suggested that the patient alkalinize his diet to prevent uric acid lithogenesis. The measurable goal is to maintain a urine pH above 6.5 through hydration and potassium citrate solution (30 mEq/day). Counselor’s Signature Francie McClanahan, R.D.