#1 ·
Hello there.
I’m struggling to make sense of my grandfather's medical records, so I figured I’d post them here—maybe someone can translate all this jargon into plain English for me.
So, here is what it says:
Patient was evaluated due to suspicion of an expansive process in the right lobe of the liver. He also complained of pain in his arm and right leg, along with polyarthralgia (I assume they missed a letter there).
His appetite has dropped, and he's lost weight, though I'm not sure how much. He experiences occasional incontinence regarding bowel and bladder movements. About 30 years ago, the patient had surgery for a meningioma in Chicago. He has a long history of arterial hypertension. He takes Valium 2.5 mg and Xanax 5 mg, along with Ranix and Ibuprofen. He was examined in the emergency department at the Neurology Department at Bjelovar Hospital.
Post-op status: meningioma of the right lateral parietal region. Tumor ablation/Simpson II/ bilateral parietal osteoplastic recraniotomy performed on 7/3/2012 by the Neurosurgery Department at Mayo Clinic.
Uncontrolled arterial hypertension.
History of large lipoma on the right shoulder and chronic syndrome involving a lesion of the right peroneal nerve.
The patient was seen in the emergency surgical clinic at Bjelovar Hospital due to abdominal colic.
For about ten days, the patient reported pain in the upper right quadrant of the abdomen.
An abdominal ultrasound was performed, showing a swollen, round, heterogeneous lesion measuring 79mm, which appears mostly hypoechoic.
Peripoortal and near the celiac trunk, enlarged lymph nodes are visible, the largest being 39mm near the aorta in the retroperitoneal area.
From the clinical status:
He is immobile and uses a wheelchair, wearing an orthopedic brace on his right leg for the peroneal lesion.
He appears pale but is breathing normally; tongue color is normal.
Cardiopulmonary assessment shows BP 140/90 and a pulse of 90.
Abdomen is soft, with tenderness felt upon palpation in the epigastrium and most severely under the right rib cage. The liver is enlarged by 2cm. Spleen is not palpable. No edema present.
Dr. Infiltration of the right hepatic lobe.
Due to his immobility, the patient has been scheduled for admission to the Internal Medicine Department at Bjelovar Hospital on 10/24/2012 at 8:00 AM, with a referral for inpatient treatment to conduct a clinical workup for suspected malignancy.
-I’ve transcribed everything exactly as it is, typos and all, but I suspect it makes a lot more sense to you than it does to me.
Thanks to anyone who takes a moment to read through this.
I’m struggling to make sense of my grandfather's medical records, so I figured I’d post them here—maybe someone can translate all this jargon into plain English for me.
So, here is what it says:
Patient was evaluated due to suspicion of an expansive process in the right lobe of the liver. He also complained of pain in his arm and right leg, along with polyarthralgia (I assume they missed a letter there).
His appetite has dropped, and he's lost weight, though I'm not sure how much. He experiences occasional incontinence regarding bowel and bladder movements. About 30 years ago, the patient had surgery for a meningioma in Chicago. He has a long history of arterial hypertension. He takes Valium 2.5 mg and Xanax 5 mg, along with Ranix and Ibuprofen. He was examined in the emergency department at the Neurology Department at Bjelovar Hospital.
Post-op status: meningioma of the right lateral parietal region. Tumor ablation/Simpson II/ bilateral parietal osteoplastic recraniotomy performed on 7/3/2012 by the Neurosurgery Department at Mayo Clinic.
Uncontrolled arterial hypertension.
History of large lipoma on the right shoulder and chronic syndrome involving a lesion of the right peroneal nerve.
The patient was seen in the emergency surgical clinic at Bjelovar Hospital due to abdominal colic.
For about ten days, the patient reported pain in the upper right quadrant of the abdomen.
An abdominal ultrasound was performed, showing a swollen, round, heterogeneous lesion measuring 79mm, which appears mostly hypoechoic.
Peripoortal and near the celiac trunk, enlarged lymph nodes are visible, the largest being 39mm near the aorta in the retroperitoneal area.
From the clinical status:
He is immobile and uses a wheelchair, wearing an orthopedic brace on his right leg for the peroneal lesion.
He appears pale but is breathing normally; tongue color is normal.
Cardiopulmonary assessment shows BP 140/90 and a pulse of 90.
Abdomen is soft, with tenderness felt upon palpation in the epigastrium and most severely under the right rib cage. The liver is enlarged by 2cm. Spleen is not palpable. No edema present.
Dr. Infiltration of the right hepatic lobe.
Due to his immobility, the patient has been scheduled for admission to the Internal Medicine Department at Bjelovar Hospital on 10/24/2012 at 8:00 AM, with a referral for inpatient treatment to conduct a clinical workup for suspected malignancy.
-I’ve transcribed everything exactly as it is, typos and all, but I suspect it makes a lot more sense to you than it does to me.
Thanks to anyone who takes a moment to read through this.