Free Redacted Document - District Court of Delaware - Delaware

Case 1:04-cv-01334-KAJ Document 23-3 Filed 10/26/2005 Page 1 012
BEEBE MEDICAL CENTER
424 Savannah Road
Lewes, Delaware 19958
(302} 645-3300
PREOPERATIVE HISTORY & PHYSICAL
PATIENT NAME: JORDAN, DONALD J ROOM:
pmxzm mean: ¤~·
DATE OF ADMISSION: 07/13/2005 DATE OF DISCHARGE:
HISTORY: This is an elective admission for this 40-year—old
gentleman from Sussex Correctional Institute, who is being
admitted to same day surgery for cystoscopy and litholapaxy,
that is destruction of stone. In this case, I am going to use
electrohydraulic energy. so this is going to be a cystoscopy
with EHL of the bladder calculus 8 mm, which was seen on the KUB
on April 21, 2005. This was also seen on the ultrasound
examination as well as on the KUB.
The patient also has a 5 mm renal calculus in the lower pole and
superior calyx. y
This stone needs to be treated by EHL, which I elect to use it.
This patient has multiple history of recurrent kidney stones,
and he had a cystoscopy: removal of gravel in November 2002 by
me and then again he had cystoscopy with laser lithotripsy and
stenting of the right side. ESWL of the left kidney stone in
November of 2003 and now he presents with a bladder calculus and
also a small calculus in the lower pole of the kidney. He had a
flank CT in November of 2004.
The patient has a history of gastroesophageal reflux disease,
hepatitis C.
ALLERGIES: HE HAS A HISTORY OF ALLERGIES TO TETRACYCLINE. I
SOCIAL HISTORY: He does not drink. He smokes about 10 to 15
cigars per day.
MEDICATIONS: The last time we saw him in the office he was on {
Zantac and Tylenol for pain.
x
No history of diabetes, hypertension, or heart attack. , Y駧{
PHYSICAL EXAMINATION: GENERAL/VITAL SIGNS: Revealed an alert v\
male, tall, 5 feet 8 inches, weighing 168 pounds, blood pressure
PREOPERATIVE HISTORY & PHYSICAL
Page 1 of 2

Case1:O4-cv-01334-KAJ Document 23-3 Fi|ed10/26/2005 Page20f2
PREOPERATIVE HISTORY & BEEBE MEDICAL CENTER
PHYSICAL
JORDAN, DONALD J 424 Savannah Road
go Lewes, Delaware 19958
(302) 645-3300
128/94. NECK: Supple. No thyromegaly. No supraclavicular
lymphadenopathy. LUNGS: Clear to auscultation and percussion.
HEART: Tones regular. Normal sinus rhythm. No murmurs. A
ABDOMEN: Soft. No abnormal masses. EXTERNAL GENITALIA:
Normal. No evidence of hydrocele or rectocele. No groin
hernia. RECTAL EXAMINATION: Prostate 25 grams, soft and
smooth, without any nodularity. EXTREMITIES: No edema, no
varicose veins. CNS: No gross generalized or focal
neurological deficit.
One time, he did have a large residual in the urine. He was
treated with Flomax of prostatism and the lower urinary tract
symptoms.
Once this session is over, would like to work him up from a
metabolic point of view to see whether we can put him on some
_ prophylactic medication.
ADMITTING DIAGNOSIS: Fairly large bladder and renal calculus.
The possibility of Foley catheter had been mentioned. We
discussed the risks and benefits of the procedure. The patient
is agreeable. Dr. is aware of this. Dr. is the .
physician in charge at SCI.
RAMACHANDRA HOSMANE, MD
TR: RH /JJ
DD: 07/l2/2005 20:25:00
DT: 07/12/2005 01:05:50
JOB: 4953110 /575404 ‘
CC: SAME DAX SURGERY
Dr. Burns; Sussex Correctional Institutute
UPDATE:
Signature Date
PREOPERATIVE HISTORY & PHYSICAL
Page 2 of 2