HomeMy WebLinkAboutHatheway & Patterson - 3/6/1989FROM
HATH15WAY & PATTERSON CO., INC.
15 County Street • P. O. Box 177
Mansfield, MA 02046
(617)339-8934
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FORM 11353 RAFIBFORMS, INC., BELLMAWR, N J. 0801
ODOR LOG
MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH DIVISION OF TUBERCULOSIS CONTROL
INTERAGENCY REFERRAL FROM Mass. Respiratory Hospital CLINIC Braintree 02184
Patient: Bennett orie SS # 010 77 7388
Date: 11 / 16 / 19 88
(Last Ni,ame) (Fist)
(Middle)
Hospital #
Address: 10 Erick Rd
Phone #
A, B_C_D_E_ Visit
City/Town: Mansfield
Zip:
Physician:
Birth Date: ll/ 14119 29
Birth Place: Sex: M_ F X
Name: MancfiplA ROB
How long in U.S.A.
Alien Status: Class A_ B_ P.O.E.:
Address: 111 North Main Sf .
occupation: Retired
Employer: Phone #
City MAncf jell Zip -_
Referral Source:
Phone #
Phone #
HISTORY: Referred for:
Symptoms: PAST MEDICAL HISTORY:
Routine Screening.
_ Liver Disease
_
Job Clearance.
Here for certification. _ Diabetes
_
Immigration.
_ Gastrectomy
_
Recent Converter.
_ Immunosupression
_
Other:
Close Contact To:
Address:
_
Relationship:
Exposure Date:
PHYSICAL EXAMINATION: Weight: , Temp: , Pulse: , Resp. Rate: , BP: / _
TUBERCULIN TESTS:
BACTERIOLOGY: Source of specimen: _Sputum, _Urine, _Other:
PPD result /_/19_
Smear Results: Culture Results: _M.Tb. _ Other:
_mm
Past PPD _mm _/ /19_
Past multiple puncture tests:
B.C.G. vaccination history:
Date last positive /_/_ Date last positive
Date last negative _/_/_ Date last negative
No bacteriology: _ Diagnosis on clinical basis, _ Pathology only.
Details:
X66230
CHEST X-RAY: Date _/
_/19_. X-ray PTM . Previous X-rays:
Results: PA and Lateral reveals that there is apical pleural thickening on both sides.
Costophrenic angles are
clear. Diaphragms are smooth in contour. Heart is within
nNormal limits in size
and shape. IMPRESSION: Bilateral apica�l4ppleural thickening.
T�x-ry evide�cle q# actived �uiY ar disea e, g Pp g f"/�sd
T ere s a sma fibrotic e si se n in tie ri ht upper lung ie at the level of
lst rib, anteriorly.
IMPRESSION: There is no x-ray evidence of active pulmonary
CLASSIFICATION:
CHEMOTHERAPY STATUS: —mos. completed, mos. remain,
0 No Tb exposure, not infected.
DRUG DOSAGE FREQUENCY DATE START DATE STOP
_
1 Tb exposure, not infected.
INH
_
X 2 Tb infection, no disease.
EMO
RIF
3 Tb disease, current
_
pulmonary
STREP
other
PZA
_ 4 Tb disease, not current.
OTHER
5 Tb suspect, pending:
_
RECOMMENDATIONS: Sputum, _Liver function, _CBC, _U/A.
Other: Certified
_ Discharged.
_l M.D.
_ Continue same medication, next visit in _ weeks: _/ _/19_
Mohh nha Amstar. M_
- MRd-
ROUTING: White Copy-Physi 'an; Yellow Copy -Board of Health; Blue Copy -Clinic; Green Copy-TSA Nurse MDPH; Orange Copy--MDPH
PHT-47 B-16 M-9-87-800531