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Drexyl NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Mrnneso�n State Stak�te 46�.05 stcttes tltnt °...every person...tivho claims dmm�ges from any municipcilitv...slrall cause Io be prese�ttecl to dre governing bocly of the municipnlity within 180�fays after t)te alle�;ed loss or injury is�/iscoverecl a notice sfaliiig the[ime,pince,nnrl circumstances thereof,nnd the amount of compei�sntion or odler relief demm�cled." Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is needed,attach additional sheets. Please note that you will not be contacted Uy telephone to clarify answers,so provide as much information as necessary to explain your claim,and the amount of compensation being requested. You will receive a written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the nature of your claim. This form must be signed,and both pages completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL SAINT PAUL, MN 55102 First Name CV� �1�1 Middle Initial�Last Name � 1r'� � Company or Business Name IVED Are You an Insurance Company? Yes/� If Yes,Claim Number? 4 2��4 Street Address ��,�o . �,�n �y--;�,� Sfi CITY CLERK City `�� - � ' State Zip Code�� Daytime Phone (�)�-g��Cell Phone ( ) - Ev ning Telephone(�)�-�7 Date of Accidend Injury or Date Discovered�' ��— ��j Time �a��0 am/� Please state, in detail, what occurred(happened),and why you are submitting a claim.Please indicate why or how you feel the City of Sai t Paul o�r,�' �employees are invol ed d/or esponsiblqfor your damag (..l,�h 1� 1'1�' ,J�Ir C'� � � � v ' �n Please check the box(es)that most closely represent the reason for completing this form: ❑ My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ❑ My vehicle was damaged by a pothole or condition of the street ❑ My vehicle was damaged by a plow � My vehicle was wrongfully towed and/or ticketed ,�I w1s injured on City property ❑ Other type of property damage–please specify ❑ Other type of injury–please specify In order to process your claim you need to include copies of all applicable documents For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a co�y for yourself before submitting your claim form. v� O Property damage claims to a vehicle: two estimates for the repairs to your vehicle if the damage exceeds \.�$500.00; or the actual bills and/or receipts far the repairs ��,�e Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt ��O Other property damage claims: two repair estimates if the damage exceeds$500.00;or the actual bills and/or receipts for the repairs;detailed list of damaged items • Injury claims: medical bills,receipts � Photographs are always welcome to document and support your daim but will not be returned. Page 1 of 2–Please complete and return both pages of Claim Form Failure to complete and return both pages will resutt in delay in the handling of your claim. All Claims—please complete this section Were there wimesses to the incident? Yes No c o � (circle) Provide their names,addresses and telephone numbers: Were the police or law enforcement called? es No ` �� ;�e) If yes, what department or agency?_ ��Y15 �` �-��n '1,�� ,l,V1C�� r r � ��I Y'�2`� J Where did the accident or injury take place? Provide street address,cross street, intersection, name of park or facility, closest landmark,etc. Please be as detailed a possible. If necessary, attach a diagram. Cla ✓� �. ' �,n . � � , � Please indicate the amo t yo are see ing in com ensation or what �ou�wo,u d like t e Ci S `p SiSR.� y ��K�1(l�"P �� K-�1'l�" � t�o to resolve this claim to our satisfaction. Vehicle Claims—nlease comalete this section �I check box if this section does not apqlv Your Vehicle. Year Make Model License Plate Number State Colar Registered Owner Driver of Vehicle Area Damaged City Vehicle: Year Make Model License Plate Number State Color Driver of Vehicle(City Employee's Name) Area Damaged In'ur Claims— lease com lete this section ❑ check box if this section does not a 1 How were ou i 'ured? S ► °,► -(', � � . What part(s)of your body ere injured? Have you sought medical treatme ? Yes No��do� Planning to Seek Treat nt c�r le) When did you receive treatment? l� �l VZ� � � �� (provide date(s)) Name of Medical Provider(s): Vl i _ . Address Telephone Did you miss work as a result of your injury? Yes No When did you miss work? (provide date(s)) Name of your Employer: Address Telephone ❑ Check here if you are attaching more pages to this claim form. Number of additional pages By signing this form,you are stating that all informatio�t yoic have provi�led is true and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed �� Print the Name of the Person who Completed this Form: �1�1�j� ��,�'�� Signature of Person Making the Claim��-- ' �.J Revised February 2011 ' � a + -�- _..� � � -- � _�. � -•- � - � , ;±� � • � '�iir`� • • � :�'�� -,-=r-��^'-'"-++�.-'�, _: ',' . -_ , = . — •_s.... ; ,_ _ �,-►___ �__ .... _ � -� � �•``•v ` '� r " • _ _ . ,;;.'� . ., ' � ttw ... _� ---, ��•'f - A •. . . I�~� ��r � - ^ . ' . • � �. . � • ^ � . • T . ^_41�' __" . ��i � �. � , ' • _ � I"•�� _�� _ • .�• \��.i -...�, ,,' ' _ �+`��i ��+'�^' � ♦` •� .�� V•` �� `_^f �� .� r �� . �. _-`��_1��1 ,�� ~ .e w�;.. _'� �� . r - �. . '[. .-.«-. '� i• " .«. w� � - �.r�- a �� . •r � ► w �� _,._.-__ , - - - . - - -- , :. ,�, :�._3 .f_1::�;:._.. : - - - - .;, : , ., .. . :: ... :; . . .�. . .. .. . .. . :::-.rt , , . . �:;::.::, ...,: , �� r � �� ' t F�►'` � ,.. � , � �. ; . 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'. _ ,� ' � . ��L ' ` ' i . � '•'J � �• ..#�' , � : � � �: , �.� , �� - , �� , � 1 � ^ �V' .r j �" ��• • 1 .r • . �. `' r._ r. ,, �• - . ��,� .� �:LT ' - ' ' . �► �� '�f, T . �'i t ' _` , � ' � �,;;r � �, .� Y , �� • � ��- ' � t, � .. �, « �'. , •�, . ; R. 7 ► � +' Y'\ ! � . . :�� f � �� .. ,�;. . r �• „�� i �'+�4 �- , *�� ',�. 5j;�1 ,_ , _ _ :,, � �f. ...:. _..:: ��.. E� � _:;' -, • Drexl,Bevr-•'y J MRN: 100494"'90 n�ge 1 of 6 � ,._ .... _ �..._ ,.. Drexl, Beverl J MRN Sex DOB Age y 1004949190 Female 07/09/1936 77 M Sharma, Himanshu S, Physician Addendum H&P 12/28/2013 1651 MD __ __......... __ __.. __..__.. . _ ___ __..__ .. . _._ _ ___ .. _ __. .. ....._.... ...__. ........ ._._....... ATTENDING NOTE I saw and examined Beverly J Drexl. Seen in presence of her daughter. I reviewed the resident Dr. Giffin's note and agree with the documented findings and plan of care. Primarily managed by neurointensivist, 1. SAH, old deafness and old anisocoria, 3 mm incidental anneurysm-with likely new bleed- mild, icu monitoring, neuro checks, mgt per nuurointensivist. 2. Hyponatremia- serum osmols pending, euvolemic- likely siadh, mgt per neurointensivist, likely not water deficit but relative water excess, 3. Hypothyroidism- had nl tsh few days ago 4. Increased gl- on ss with aq check monitoring 5. Full code. 6. htn- close monitoring, keep spb<140 systolic, Primary mgt per neurointensivist. Himanshu S Sharma, MD Revision History... Date/Time User Action 12/28/2013 1710 Sharma, Himanshu S, MD Addend 12/28/2013 1710 Sharma,Himanshu S,MD Sign View Details Report Routing History... Date/Time From To Method 12/28/2013 1710 Sharma, Himanshu S,MD Rumsey,Timothy J,MD In Basket __ __.._.,_ Giffin,Joel S,DO Physician Signed H&P 12/28/2013 1439 _ ____.... _... __._ __ ___ _.__ _. __ __._ _......_ __ _. .... __._ _..... _.. .._ __. UFM RESIDENT ADMISSION HISTORY AND PHYSICAL Admission Date/Time: 12/28/2013 10:34 AM Primary Care Provider: TIMOTHY J RUMSEY, MD Hospital Attending Physician: Himanshu Sharma MD Informant: Electronic Health Record, ED Provider, patient, daughter and brother CHIEF COMPLAINT: Garbled speech HPI: Beverly J Drexl is a 77 y.o. female who presents to United's ED via private car for evaluation of the above complaint. Patient was just discharged from this hospital 4 days ago (Dec 24) after 6 day stay after traumatic subarachnoid hemorrhage. She had a waxing/waning hospital course with some delirium and agitation, but overall improved and returned to home. She had 24 hour care from her son (who lives upstairs) and her daughter. She was hyponatremic in the hospital and did require sodium tablets and a few hours of 3% hypertonic saline. 12/30/2013 �Drexl,BevP��y J MRN: 100494�"90 page 2 of 6 V , � � � Yesterday the patient became quite nauseated and was vomiting any food up. She got some Compazine from her primary care physician but fhat provided minimal relief. She vomited many times, no diarrhea. She was mentating fairly well, had no fever, didn't complain of any pain. This morning the patient was very lethargic and confused, when she would talk it was gibberish. Her son decided to bring her in to the hospital, and the patient actually walked to the car without her walker. In the ED she has had a waxing/waning course with some intelligible answers and some non-sense. She had a Heat CT and MRI. Her Sodium was found to be 115. Concern for seizure so was given a dose of Keppra. REVIEW OF SYSTEMS: Limited due to patient somnolence p Abnormals as above PAST MEDICAL HISTORY: Past Medical History Diagnosis Date • HTN • Hyperlipidemia • Bronchitis • Disc � HAD SURGERY FOR A DISC THAT WAS PINCHING A NERVE • Deafness,R,congenital 3/29/2010 • Anisocoria R>L 3/29/2010 • Varicose Veins,L leg 3/29/2010 • HTN (hypertension) 3/29/2010 • Chronic LBP 3/29/2010 • Hypothyroid 3/29/2010 • Sinusitis, chronic 3/29/2010 • Hyperglycemia,A1 c 6.6 2009 3/29/2010 PAST SURGICAL HISTORY: M Past Surgical History Procedure Laterality Date • Hx back surgery 1986 L5-S1 laminectomy • Hx tah and bso 1985 abnl pap MEDICATIONS: Prescriptians priar to admission Medication Sig • acetaminophen (TYLENOL) 500 Take 1 capsule by mouth every 6 hours if needed. mg capsule Max acetaminophen dose: 4000mg in 24 hrs. • atenolol (TENORMIN) 25 mg Take 1 tablet by mouth once daily. tablet • citalopram (CELEXA) 10 mg Take 2 tablets by mouth once daily. tablet • DOCOSAHEXANOIC ACID/EPA Take by m�uth once daily if needed. (FISH OIL ORAL) • hydrochlorothiazide (HCTZ) 25 Take 1 tablet by mouth once daily. mg tablet • levothyroxine (SYNTHROID) 25 Take 1 tablet by mouth before breakfast. mcg tablet • lisinopril (PRINIVIL; ZESTRIL) 10 Take 1 tablet by mouth once daily. 12/30/2013 Drexl,Bev�rly J MRN: 100494�'90 nage 3 of 6 ..,.. .� , -- �.. mg tablet • loratadine (CLARITIN) 10 mg Take 1 tablet by mouth once daily. tablet • MULTIVITAMINS WITH Take by mouth once daily. FLUORIDE (MULTI-VITAMIN ORAL) • nystatin powder (NYSTOP) Apply topically to affected area(s) 4 times daily if powder needed for Other (Specify). • prochlorperazine (COMPAZINE) Take 1-2 tablets by mouth every 6 hours if needed 5 mg tablet for Nausea/Vomiting. • simvastatin (ZOCOR) 20 mg Take 2 tablets by mouth once daily with evening tablet meal. • traMADoI (ULTRAM) 50 mg Take 1 tablet by mouth 2 times daily if needed for tablet Pain (for headache). • traZODone (DESYREL) 50 mg Take 0.5 tablets by mouth at bedtime. tablet ALLERGIES/SENSITIVITIES: No Known Allergies M SOCIAL HISTORY History Social History • Marital Status: Divorced Spouse Name: N/A Number of Children: N/A • Years of Education: N/A Social History Main Topics I • Smoking status: Never Smoker • Smokeless tobacco: Never Used • Alcohol Use: No • Drug Use: No • Sexually Active: Not on file Other Topics Concem • Not on file Social History Narrative Dec 2013: Prior to hospital stays--lives alone, independent, drives. Son and his family lives upstairs and help with cooking and cleaning. 2 kids, several grandkids. FAMILY HISTORY Family History Problem Relation Age of Onset • Diabetes Mother • Heart Disease Mother • Other Father copd • Cancer Brother lung • Cancer-breast No Family History PHYSICAL EXAM: 12/3 0/2013 1', ,,,,, �,,,� s� �„� , . � Drexl,Bevr-•'y J MRN: 100494'"90 n3ge 4 of 6 � ._ ,.._ �-- �..- VITAL SIGNS: BP 149/63 � Pulse 57 � Temp(Src) 99 °F (37.2 °C) � Resp 20 � Wt 83.915 kg (185 Ib) � BMI 28.14 kg/m2 � Sp02 93% on RA GENERAL: adult female, appears approximately stated age, pleasant, confused, lethargic SKIN: No rashes, ecchymoses, lesions, orjaundice. Normal skin turgor. LYMPH: No palpable cervical, supraclavicular nodes. HEENT: Atraumatic, cranium &temples non-tender to palpation. Pupils 4mm, equal and reactive. Visual fields not able to be assessed due to patient cooperation. NECK: Supple, LUNGS / CHEST: Normal rate and effort, lungs clear to auscultation bilaterally. No wheezes, crackles, or rhonchi. CV: Regular rate and rhythm. Normal S1 & S2. No S3 or S4. No murmurs, rubs, or gallops. No peripheral edema. Peripheral pulses 2+ in the u�per and lower extremities. No JVD noted. ABDOMEN: obese, hypoactive bowel sounds, soft, nontender, nondistended, no hepatomegaly or splenomegaly appreciated. No CVA tenderness. GU / RECTAL: Foley in place NEURO: Can identify her daughter and brother by name, other answers to where, who, when are garbled and incomprehensible. Strong bilateral hand grasp and toe wiggle. Down going toes. Opens eyes and mouth to command. Laboratory: � Recent Labs 12/28/13 12/23/13 1045 0800 WBC 16.4 H 11.0 RBC 4.03 3.73 L HGB 11.7 L 10.7 L HCT 32.0 L 31.6 L MCV 79 � 85 MCH 29.0 28.7 MCHC 36.6 H 33.9 PLT 318 253 MPV 9.5 9.9 Recent Labs 12/28/13 12/24/13 1045 0636 SODIUM 115 LL 130 L POTASSIUM 3.2 L 3�9 CHL4RIDE 75 L 98 CO2TOTAL 28 26 BUN 11 13 CREATININE 0.77 0.66 GLUCOSE 172 H 128 H CALCIUM 9.9 8.3 L Recent Labs 12l28/13 1045 ALKPH�SPH 85 PROTEIN 7�0 BILITUTAL ��$ AST 24 ALT 2� Recent Labs 12/2�/13 1141 COLOR Yellow 12/30/2013 /'\ ^ r� '"t r� , . ,Drexl,BevP�1y J MRN: 100494��9p Dage 5 of 6 _ ,- _ �-- �.- CLARITY Clear SPECGRAV 1.0'10 PHURINE 7.0 UROBILIN�GEN Normai PROTEINUA Trace A GLUCOSEUA Negative KETONESUA Negative BLOODUA Nec�ative NITRITE Negative LEUK�CYTE Negative WBGUA 0-2 RBCUA 0-2 BACTERIAUA Nor.e Seen EPITHE�IALUA Few Imaging: CT Head Brain Without 12/28/2013 1. No definite CT evidence of acute ischemic injury. No evidence for intracranial mass. 2. Small amount of hyperdense blood products over the right parietal region. These appear slightly diminished compared to the 12/19/2013 comparison study. However, given that the hyperdense blood products associated with the bifrontal contusion injuries have largely resolved, this could represent a small amount of new, interval bleeding. Consider followup. 3. The hyperdense blood products associated with the bifrontal contusions has largely resolved. The areas of hypoattenuation associated with this injury are better defined on today's study consistent with evolving injury. 4. Sagittal frontoparietal fracture. 5. Presumed changes of chronic small vessel ischemic injury within the supratentorial white matter. X-ray Chest 1 View Portable 12/28/2013 Lungs are clear. There is mild basilar atelectasis No pleural effusion or pneumothorax. The heart size is normal. MRI brain 12/28/2013 1. Scattered areas of subacute subdural hematoma in the bifrontal and temporal regions and over the right parietal convexity where it measures approximately 5 mm in thickness. 2. Signal abnormality consistent with traumatic injury involving the right gyrus rectus and bilateral superior frontal gyri. 3. No evidence for recent infarct, mass or hydrocephalus. 4. Background of presumed chronic small vessel ischemic injury within the supratentorial white matter. MRA head 12/28/2013 � 1. 3 mm aneurysm arising from the undersurface of the right supraclinoid internal carotid artery. 2. No proximal vessel occlusion, high-grade intracranial stenosis or high flow vascular lesion. 3. Persistent left trigeminal artery. Assessment/Plan: 77 y.o. female with a history of recent traumatic subarachnoid hemorrhage admitted with acute worsening of inental status and speech. Found to be hyponatremic to 115. Etiology could be new ischemic or hemorraghic stroke (no changes on CT or MRI), secondary to hyponatremia (nausea/vomiting, history of hypon�tremia), seizure (secondary to low Sodium). HOSPITAL PROBLEM LIST: Altered mental status 12/30/2013 � ,,..,� �,,,� �"t �,,,t , Drexl,BevF°�y J MRN: 100494�'90 D�ge 6 of 6 � -- _ -- � Subarachnoid hemorrhage Metabolic vs vascular vs seizure vs other. Will slowly correct Sodium with NS (per NeurolCU staffl, follow closely. Will need EEG and Keppra to evaluate for ongoing seizure activity. Imaging reassuring thus far. --admit to NeurolCU, discussed with intensivist --Sodium correction with NS, frequent rechecks --BP control due to history of bleed --NPO and swallow evaluation --DVT and GI prophylaxis --EEG, Keppra for now, no MN Epilepsy consult at this time --sociat work consult, OT/PT consults Delirium/agitation Has been agitated in past. Responded fairly we!! to 1:1 sitter, low dose Seroquel and Haldol. --have both medications and sitters available, try to get out of ICU as soon as safe Anisocoria R>L; Deafness, R, congenital -- be aware of for Neurological checks Prophylaxis: Stress ulcer: H2 blocker IV, DVT: SCDs due to history bleed Code Status: full, was discussed at admission with kids, patient does have a living will at home kids will try to find it, no long term ventilator support but short term intervention is desired FEN: NPO for now, blood pressure medications okay with sips Dispo: pending next 12-24 hours, may need TCU Patient and plan discussed with staff Dr. Himanshu Sharma. Joel S Giffin, DO .................... 2:39 PM 12/28/2013 United Family Medicine Resident PGY3 Pager 612-654-8131 Routing History... Date/Time From To Method 12/28/2013 1501 Gi�n,Joel S, DO Rumsey,Timothy J, MD In Basket 12/30/2013 rr �.•� �1 �'`� i"'� ; . ` " �rexl,BevP��y J MRN: 100494��90 nage 1 of 2 ..,r �... �..., �...• L... Drexl, Beverl J MRN Sex DOB Age y 1004949190 Female 07/09/1936 77 NURS- Nordell,Jeffrey N,RN Registered Signed Procedures 12/28/2013 2039 Nurse _.............._............................._.........................._.........._....................._..........._......._............._...................................._.........._......................................................_._........_..................................._. PICC Line Insertion Note 12/28/2013 8:39 PM Procedure education reviewed: Placement procedure, Benefits, Risks, Complications and Questions answered, discussed with: Family via the telephcme. Family via the telephone confirms understanding of procedure. Verbal consent was obtained: Family Reason for insertion: Blood Draws, IV access, IV medications and MD order Medical/Surgical/Allergies History reviewed: Yes. Preprocedure Verification: Yes 1) Patient identity verified; 2) side/site/procedure confirmed; 3) relevant information/documentation available, reviewed and properly matched to the patient; 4) consent accurate and complete; 5) equipment and supplies available Site Marking: Not Applicable Site marked if not in continuous attendance with the patient Time Out: Yes Time out was conducted just prior to starting procedure to verify the four required elements: 1) patient name and date of birth 2) confirmation that the correct side/site are marked if applicable, including visualization of the site mark 3) name of procedure including laterality if applicable, and 4) essential imaging and results are properly labeled and appropriately displayed, if applicable. Site assessment pre-insertion: Intact. Local anesthetic used at site: Yes, 1% Lidocaine. PICC line was placed using the following Central Line Insertion Checklist: Hand Hygiene: Yes Maximal Barrier Precautions including St�rile Gown, Hat and Mask: Yes Full Body Drape: Yes Site cleansed with: Chlorhexidine gluconate prep. PICC LINE 2 LUMEN Purple Right;Basilic PICC/SVC (Active} 12/28/13 2030 Right;Basilic (IA) Lumen One Designation: (IA) Lumen Two Designation: Lumen One Designation: Red Lumen Two Designation: Purple Visible Catheter Length (cm): 0 cm Placed/Present Prior to Encounter: Removed/Resolved Prior to Encounter: (IA) Placed Prior to Admission?: Type: Valved Catheter Size: 5 French about:blank 12/30/2013 ' Drexl,Bev�-�y J MRN: 100494�"90 nage 2 of 2 �..� L- �... � � Tip Location: PICC/SVC PICC Mid-Arm Circumference (cm): 37 cm Total Length of Catheter (cm): 43 cm Insertion Attempts: 1 (IA) Insertion Attempts: Placement Verification: ECG Removed Catheter Length (cm): Visible Catheter Length (cm) 0 cm 12/28/2013 8:30 PM Status Lumen One Blood 12/28/2013 8:30 PM Return;Capped/Locked Status Lumen Two Blood 12/28/2013 8:30 PM Return;Capped/Locked Site Description Dry/Flat 12/28/2013 8:30 PM Site Intervention Site Care 12/28/2013 8:30 PM Dressing Assessment Intact 12/28/2013 8:30 PM Dressing Intenrention Antimicrobial Patch 12/28/2013 8:30 PM Applied;Catheter Securement Device Applied;Hospital Cressing Policy/Protocol Followed;Secured Line Manufacturer Name:Bard, Solo Power PICC (proximal valve) Lot Number: REXK0141 Access Assistance:Modified Seldinger Technique (Micro-Introducer) WITH Dermatotomy (skin nick), Ultrasound Guidance and Tip Locating System Post-insertion: Able to remove guidewire: Smoothly. Able to aspirate blood in each lumen: Yes Able to flush catheter without resistance in each lumen: Yes Each lumen flushed with: 10 ml(s) of 0.9% saline, and no Heparin.. Cap applied to each lumen: Yes Line secured with: Stat-Lock and Steri-Strips Site dressed with: Hospital dressing policy/ protocol followed , Transparent and Stat-Lock and Bio-Patch applied.. PICC Line standing orders implemented: Yes X- ray pending: No, explain: PICC tip location verified via ECG during insertion Intended tip location: PICC (Superior Vena Cava) Insertion complications: None Patient tolerated the procedure: Yes about:blank 12/30/2013 � - ' Drexl,Bev��y J MRN: 100494�"90 n�ge 1 of 6 �..f �..- ..� �• �.,,.. Drexl Beverl J � "'R" SeX o06 Age � y 1004949190 Female 07/09/1936 77 Shaik,Arif M,MD Physician Signed Consults 12l28/2013 1556 _.. .......... ._._.......__. ......_........ .........__..... _ ......_._................. _...._ ..........__. . _._........... ......._ ____............. .__......_.. ..._._...... . ......__..... ............ Orders: Insert and Maintain Peripheral IV(5082827581 ordered by Giffin,Joei S, DO at 12/28/2013 1424 Consult to Intensivist f5082827671.ordered bv Giffin,Joel S, DO at 12/28/2013 1424 NEURO ICU CONSULT NOTE I was asked by Dr. Giffin to evaluate this patient for mental status change HISTORY OF PRESENT ILLNESS: 77 y/o female pt who is known to our service from last admission, she was here for TBI, Bifrontal ICH from falling on ice. Her iCU stay was complicated with mild hyponatremia, delirium , required precedex drip. She went home 12/24. With anti htn meds and home anti depressants. With home care service. According to the daughter at bedside, she was fine until this am. Yesterday she had lot of nausae/vomiting, more trips to bathroom. Called pcp, ordered compazine. Which didn't help. Today am, very confused, sleepy, didn't recognize the daughter. Home care nurse identified she is not herself, sent to ER. Initial CT- old frontal contusions, sdh, nothing new. Sodium showed up to 115. keppra was given as there is suspicion for hyponatremia induced seizures. MRI was also done on route to ICU. No fever, no chest pains, no sob, no alcohol. No bowel or bladder incontinence. No new falls. PAST MEDICAL HISTORY: Past Medical History Diagnosis Date • HTN • Hyperlipidemia • Bronchitis • Disc HAD SURGERY FOR A DISC THAT WAS P/NCHING A NERVE • Deafness,R,congenital 3/29/2010 • Anisocoria R>L 3/29/2010 • Varicose Veins,L leg 3/29/2010 • HTN (hypertension) 3/29/2010 • Chronic LBP 3/29/2010 • Hypothyroid 3/29/2010 • Sinusitis, chronic 3/29/2010 • Hyperglycemia,A1 c 6.6 2009 3/29/2010 HOME MEDICATIONS: Prescriptions prior to admission Medication Sig Dispense Refill • acetaminophen (TYLENOL) Take 1 capsule by mouth 0 500 mg capsule every 6 hours if needed. Max acetaminophen dose: 4000mg in 24 hrs. about:blank 12/30/2013 • ' Drexl,BevPr�y J MRN: 100494�'90 page 2 of 6 �. �-- .... `�-- �..� • atenolol (TENORMIN) 25 mg Take 1 tablet by mouth once 90 tablet 2 tablet daily. • citalopram (CELEXA) 10 mg Take 2 tablets by mouth once 180 tablet 3 tablet daily. • DOCOSAHEXANOIC Take by mouth once daily if ACID/EPA (FISH OIL ORAL) needed. • hydrochlorothiazide (HCTZ) Take 1 tablet by mouth once 90 tablet 0 25 mg tablet daily. • levothyroxine (SYNTHROID) Take 1 tablet by mouth before 90 tablet 4 25 mcg tablet breakfast. • lisinopril (PRINIVIL; ZESTRIL) Take 1 tablet by mouth once 30 tablet 0 10 mg tablet daily. • loratadine (CLARITIN) 10 mg Take 1 tablet by mouth once 30 tablet prn tablet daily. • MULTIVITAMINS WITH Take by mouth once daily. FLUORIDE (MULTI-VITAMIN ORAL) • nystatin powder (NYSTOP) Apply topically to affected 1 Bottle 3 powder area(s) 4 times daily if needed for Other (Spe�ify). • prochlorperazine Take 1-2 tabl�ts by mouth 30 tablet 1 (COMPAZINE) 5 mg tablet every 6 hours if needed for Nausea/Vomiting. • simvastatin (ZOCOR) 20 mg Take 2 tablets by mouth once 180 tablet 4 tablet daily with evening meal. • traMADoI (ULTRAM) 50 mg Take 1 tablet by mouth 2 20 tablet 0 tablet times daily if needed for Pain (for headache). • traZODone (DESYREL) 50 Take 0.5 tablets by mouth at 15 tablet prn mg tablet bedtime. ESSENTIAL INPATIENT MEDICATIONS: No Known Allergies FAMILY HISTORY: Family History Problem Relation Age of Onset • Diabetes Mother • Heart Disease Mother • Other Father copd • Cancer Brother lung • Cancer-breast No Family History SOCIAL HISTORY: History Sacial History • Marital Status: Divorced Spouse Name: N/A Number of Children: N/A • Years of Education: N/A about:blank 12/30/2013 ' Drexl,BevP��y J MRN: 100494��90 nage 3 of 6 .... �. ..... �,..� �..-. Occupationai History • Not on file. Social History Main Topics • Smoking status: Never Smoker • Smokeless tobacco: Never Used • Alcohol Use: No • Drug Use: No • Sexually Active: Not on file Other Topics Concern • Not on file Social History Narrative Dec 2013: Prior to hospital stays--lives a/one, independent, drives. Son and his family lives upstairs and help with cooking and cleaning. 2 kids, severa/grandkids. ROS: ROS was unobtainable from the patient due to lethargy; no further information was contributory EXAM: BP 138/65 � Pulse 51 � Temp(Src) 99 °F (37.2 °C) � Resp 20 � Ht 1.651 m (5' 5") � Wt 85.4 kg (188 Ib 4.4 oz) � BMI 31.33 kg/m2 � Sp02 94% � Breastfeeding? No Temp (24hrs), Avg:98.6 °F (37 °C), Min:98.2 °F (36.8 °C), Max:99 °F (37.2 °C) Pt lethargic, not awake to my exam. Resist eye opening and jaw opening. Clinically Doesn't appear dehydrated. EYES: PERRL R> I pupil , old right pupil injury. HENT: Old staples exist occipital area. No new bruises noted. Deafness R - congenital. NECK: supple. RESP: CTA, CV: RRR, S1, S2 ABD: soft, nontender, nondistended GU: foley catheter in place. EXT: pulses present, no edema. SKIN: warm, dry. NEURO: lethargic, not following commands, spontaneously moves all, withdraws to pain all extremities. She received ativan for MRI. From ER note, she apparently was non focal. LAB DATA: No results found for this basename: PHARTERIAL, PCO2ARTERIAL, P02ARTERIAL, HCO3ARTERIAL, BASEEXCART, 02SATARTERIA, INSP02ART, in the last 720 hours Recent Labs 12/28/13 1045 GLUCOSE 172 H No results found for this basename: PHARTERIAL, PCO2ARTERIAL, P02ARTERIAL, HCO3ARTERIAL, in the last 720 hours No results found for this basename: BASEEXCART, 02SATARTERIA, INSP02ART, in the last 720 hou�s Recent �abs 12/28/13 12/23/13 1045 �$Q� �/�/gC 16.4 H 11.0 RBC 4.03 3.73 L about:blank 12/30/2013 � ' Drexl,BevF-�y J MRN: 100494�"90 n3ge 4 of 6 � � � � � HGB 11.7 L 10.7 L HCT 32.0 L 31.6 L MCV 79 L 85 MCH 29.0 28.7 MCHC 36.6 H 33.9 PLT 318 253 MPV 9.5 9.9 Recent Labs 12/28/13 12/24/13 1045 0636 SODIUM 115 LL 130 L POTASSIUM 3.2 L 3.9 CHLORIDE 75 L 98 CO2TOTAL 28 26 BUN 11 13 CREATININE 0.77 0.66 GLUCOSE 172 H 128 H CALCIUM 9.9 8.3 L Recent Labs 12/28/13 1045 A�KPHOSPH 85 PROTEIN 7.0 BILITOTAL 0.8 AST 24 ALT 29 Imaging: CT Head Brain Without 12/28/2013 1. No definite CT evidence of acute ischemic injury. No evidence for intracranial mass. 2. Small amount of hyperdense blood products over the right parietal region. These appear slightly diminished compared to the 12/19/2013 comparison study. However, given that the hyperdense blood products associated with the bifrontal contusion injuries have largely resolved, this could represent a small amount of new, interval bleeding. Consider followup. 3. The hyperdense blood products associated with the bifrontal contusions has largely resolved. The areas of hypoattenuation associated with this injury are better defined on today's study consistent with evolving injury. 4. Sagittal frontoparietal fracture. 5. Presumed changes of chronic small vessel ischemic injury within the supratentorial white matter. X-ray Chest 1 View Portable 12/28/2013 Lungs are clear. There is mild basilar atelectasis. No pleural effusion or pneumothorax. The heart size is normal. MRI brain 12/28/2013 1. Scattered areas of subacute subdural hematoina in the bifrontal and temporal regions and over the right parietal convexity where it measures approximately 5 mm in thickness. 2. Signal abnormality consistent with traumatic injury involving the right gyrus rectus and bilateral superior frontal gyri. 3. No evidence for recent infarct, mass or hydro�ephalus. 4. Background of presumed chronic small vessel ischemic injury within the supratentorial white matter. MRA head 12/28/2013 1. 3 mm aneurysm arising from the undersurface of the right supraclinoid internal carotid artery. about:blank 12/30/2013 • ' Drexl,Bev�--�y J MRN: 100494�'90 nage 5 of 6 a.. �.. �... `+- �..� 2. No proximal vessel occlusion, high-grade intracranial stenosis or high flow vascular lesion. 3. Persistent left trigeminal artery. ASSESSMENT AND PLAN: Active Hospital Problems *Altered mental status Brain contusion HTN (hypertension) Hyponatremia Hypokalemia Subarachnoid hemorrhage Bronchitis Depression with anxiety Anisocoria R>L Deafness,R,congenital Plan: 77 with recent ICH/SAH/TBI/CONCUSSION admitted with altered mental status with sodium of 115. Differential include seizures form sodium, low sodium induced confusion, UTI. CNS: Admit to NICU, neuro checks, Icu monitoring, W/u for hyponatremia sent ( urine sodium, urine osm, serum osm, uric acid, tsh) , possible she is SIADH from brian injury, clinically appears euvolemia, at the same time she had many nausea/vomiting and not eating last 24 hours. So could be combination of both dehydration and SIADH. Not sure of seizures. keppra given, cEEG. Will continue keppra. Free water defecit is approx 6 litres, Serial sodium checks. Goal sodium in 24 hours is 123-125. q2 checks, endocrine consult. If she does had seizures, may require 3% sodium. Incidental brain aneurysm 3 mm aneurysm arising from the undersurface of the right supraclinoid internal carotid artery -will ask neurosurgery/IR to follow with that on Monday. Cardiovascular: Continue beta blocker from home, Keep Sbp < 160 with nicardipine infusion prn with prn labetalol. Pulmonary: Monitor Airway, breathing closely. Nebs prn, Incentive spirometry. Prn Oxygen as required. GI: npo Renal: D/c Hctz , for hyponatremia, lisinopril ( cough), continue foley catheter,monitor UO, electrolyte replacement procotol ID: Send UC. Endocrine: Accucheck q6 with insulin sliding scale coverage. about:blank 12/30/2013 - ' ' ' Drexl,BevF-�y J MRN: 100494n'90 nage 6 of 6 � *-- �--- �-- `- MAINTENANCE THERAPIES � DVT prophylaxis: scd GI prophylaxis: pepcid Nutrition:NPO Sedation/analgesia:na Thank you for the consult. I will discuss the above with Dr Giffin. Critical care time: 45 mins D/w family at bedside,. Close follow the labs and formulate the plan. Arif M Shaik MD 12/28/2013 3:56 PM 612-510-4755 Routing History... Date/Time From To Method 12/28/2013 1624 Shaik,Arif M,MD Rumsey,Timothy J,MD In Basket about:blank 12/30/2013 � �Drexl,Bevc-�y J MRN: 10049a^'90 ^�ge 1 of 7 �.. �.. �.,. �.�. �.,. Drexl, Beverl J MRN seX oog Age y 1004949190 Female 07/09/1936 77 Atkinson,Paul B,MD Physician Signed Progress Notes 12/29/2013 1702 __........._....................._._......................................................._..........__.........._......._.........._......,......................................................................................._................................................._................................._. MEG Update: No seizures or epileptiform activity noted through the day. Discussed with Dr. Qureshi, and will discontinue video EEG. Called EEG techs, and they are aware. Paul B. Atkinson, MD Minnesota Epilepsy Group Qureshi,Mohammed Physician Signed Progress Notes 12/29/2013 1224 A,MD _ ......._ . .......__. .........._........ .............. _._............... ._.... .... ........ _.............. _...... ._..___..... ... _. ICU PROGRESS NOTE Patient Description: 77 y.o. year old female admitted with Altered mental status 77 y/o female h/o of TBI, Bifrontal ICH from falling on ice admitted due to Encephalopathy. Found to have Sodium of 115. keppra was given, continues EEG was placed EVENTS: Uneventful night. Current Facility-Administered Medications Medication Dose Route Frequency Provider Last Rate • acetaminophen 650 Per NG Tube q4h prn Giffin, Joel S, 650 mg tablet mg DO (TYLENOL) • acetaminophen 650 Rectal q4h prn Giffin, Joel S, suppository 650 mg DO mg (TYLENOL) • bisacodyl 10 mg 10 mg Rectal one time prn Giffin, Joel S, suppository DO (DULCOLAX) • DOPamine 400 1-10 Intravenous continuous Shaik, Arif M, mg in D5W 250 mcg/kg/ prn MD mL (INTROPIN) min (Dosing Weight) • famotidine 20 mg 20 mg Intravenous q12h Giffin, Joel S, injection DO (PEPCID) • hypoglycemia Protocol protocol Shaik, Arif M, protocol MD • insulin aspart 0-5 0-5 Subcutaneous q6h Shaik, Arif M, Units injection pen Units MD (NOVOLOG) • labetalol 20 mg 20 mg Intravenous q10min prn Giffin, Joel S, about:blank 12/30/2013 � 'Drexl,Bevr-�y J MRN: 100494^'90 n�ge 2 of 7 ..� �-- � � � injection DO (TRANDATE; NORMODYNE) • lactulose 20 g 20 g Oral/NG Tube tid prn Giffin, Joel S, liquid DO • IevETIRAcetam 500 Intravenous b12h Shaik, Arif M, 500 mg in D5W mg MD 100 mL (KEPPRA) • levothyroxine 25 25 mcg Oral before Giffin, Joel S, mcg tablet breakfast DO (SYNTHROID) • LORazepam 1 mg 1 mg Intravenous pre Hennessey, injection (ATIVAN) Thomas W, MD • magnesium citrate 120 Oral/NG Tube Each Time Giffin, Joel S, 120 mL solution mL PRN DO (CITRATE OF MAG) ' • magnesium IV Protocol protocol Giffin, Joel S, SUBARACHNOID DO HEMORRHAGE REPLACEMENT protocol • milk of magnesia 30 mL Oral/NG Tube bedtime Giffin, Joel S, 30 mL suspension DO (MOM) • milk of magnesia 30-60 Oral/NG Tube bedtime prn Giffin, Joel S, 30-60 mL mL DO suspension (MOM) • NaCI 0.9% 75 Intravenous continuous Katz, Harold H, 75 mL/hr MD mL/hr (12/29/1 3 1020) • NaCI 0.9% 3-9 Intravenous continuous Sharma, 3 mL/hr mL/hr Himanshu S, MD (12/28/1 3 2353) • nalOXone 0.08 0.08 Intravenous q3min prn Giffin, Joel S, mg injection mg DO (NARCAN) • niCARdipine 20 2.5-15 Intravenous continuous Shaik, Arif M, mg in NaCI 0.9% mg/hr MD 200 mL (CARDENE) • norepinephrine 5-20 Intravenous continuous Giffin, Joel S, 4,000 mcg in D5W mcg/min prn DO 250 mL (LEVOPHED) • ondansetron 4 mg 4 mg Intravenous q6h prn Giffin, Joel S, injection DO (ZOFRAN) • potassium Protocol protocol Giffin, Joel S, REPLACEMENT DO protocol I about:blank 12/30/2013 •Drexl,BevF-�y J MRN: 100494�'90 "3ge 3 of 7 �,,,F �... .,... •.,. �..f • sennosides- 1-4 Oral bid Giffin, Joel S, docusate (8.6-50 tablet DO mg) 1-4 tablet (SENOKOT S) • simvastatin 40 mg 40 mg Oral aily wm Giffin, Joel S, tablet (ZOCOR) �vening DO • sodium chloride 10 mL Intravenous Each Time Giffin, Joel S, 0.9% 10 mL pRN DO syringe (NORMAL I SALINE) • sodium chloride 10 mL Intravenous �12h Katz, Harold H, 0.9% 10 mL MD syringe (NORMAL SALINE) • sodium chloride 10 mL Intravenous Each Time Katz, Harold H, 0.9% 10 mL PRN MD syringe (NORMAL SALINE) • sodium chloride 20 mL Intravenous Each Time Katz, Harold H, 0.9% 20 mL PRN MD syringe (NORMAL SALINE) • sodium chloride 5 mL Intravenous q12h Giffin, Joel S, 0.9% 5 mL syringe DO (NORMAL SALINE) • sodium chloride 5 mL Intravenous Each Time Giffin, Joel S, 0.9% 5 mL syringe PRN DO (NORMAL SALINE) PHYSICAL EXAM BP 153/67 � Pulse 55 � Temp(Src) 98.6 °F (37 °C) � Resp 17 � Ht 1.651 m (5' 5") � Wt 85.4 kg (188 Ib 4.4 oz) � BMI 31.33 kg/m2 � Sp02 96% � Breastfeeding? No Temp (24hrs), Avg:98.7 °F (37.1 °C), Min:98.4 °F (36.9 °C), Max:99 °F (37.2 °C) Patient Vitals for the past 72 hrs: Weight 12/28/13 g5.4 kg (188 Ib 4.4 oz) 1548 12/28/13 g5.4 kg (188 Ib 4.4 oz) 1415 12/28/13 g3.915 kg (185 Ib) 1039 Intake/Output Summary (Last 24 hours) at 12/29/13 1224 Last data filed at 12/29/13 1100 Gross per 24 hour Intake 3153.33 ml Out ut 3275 ml Net -121.67 ml about:blank 12/30/2013 � 'Drexl,Bev�-�y J MRN: 100494�"90 nage 4 of 7 � � . � � � EYES: PERRL, EOM's intact. HENT: oropharynx clear. LYMPHATIC: no peripheral lymphadenopathy NECK: supple. � RESP: CTA, CV: RRR, S1, S2 ABD: soft, nontender, nondistended ' GU: foley catheter in place. , EXT: pulses present, no edema. ' SKIN: warm, dry. NEURO: CN's II -XII intact. No motor or sensory deficits. PSYCH: alert, oriented x 3. Mood, affect normal. Central line : The area looks clean, dry, no erythema. Foley Catheter: Placed. Need to be kept for monitoring Urine out put. Labs Personally reviewed: Recent Labs 12/2$/13 2351 PHARTERIAL 7.39 PCQ2ARTERIAL 42 P02ARTERIAL 116 H HCO3ARTERIAL 25 BASEEXCART 0.0 02SATARTERIA 98 Recent Labs 12/28/13 1045 GLUCC?SE 172 H Recent Labs 12/28/13 2351 PHARTERIAL 7.39 PCO2ARTERIAL 42 P02ARTERIAL 116 H HCO3ARTERIAL 25 Recent Labs 12/28/13 2351 BASEEXCART 0.0 025ATARTERIA g$ Recent Labs 12/28113 12/23/13 1045 0800 �/�/gC 16.4 H 11.0 RBC 4.03 3.73 L HGB 11.7 L 10.7 L HCT 32.0 L 31.6 L about:blank 12/30/2013 - 'Drexl,Bevn~�y J MRN: 100494�'90 "age 5 of 7 .f �-- �. � �..� MCV 79 L 85 MCH 29.0 28.7 MCHC 36.6 H 33.9 PLT 318 253 MPV 9.5 9.9 RecentLabs 12/29113 12/29I13 12/29/13 '12/29/13 �2/28/13 12i24113 1000 0815 0535 0134 1045 0636 SODIUM 129 L -- 126 L < > ! 136 < > 115 LL 130 L POTASS -- 4.5 -- -- � 3.4 L -- 3.2 L 3.9 IUM ' CHLORI -- -- -- -- � -- -- 75 L 98 DE CO2TOT -- -- -- -- 28 26 AL BU N -- -- -- -- -- -- 11 13 CREATI -- -- -- -- -- -- 0.77 0.66 NINE GLUCOS -- -- -- -- -- -- 172 H 128 H E CALCIU -- -- -- -- -- -- 9.9 8.3 L M < > = values in this interval not displayed. RecentLabs 12/28/13 1045 ALKPHOSPH 85 PROTEIN 7.� BILITOTAL �•8 AST 24 ALT 29 ASSESSMENT/PLAN 77 with recent ICH/SAH/TBI/CONCUSSION admitted with altered mental status with sodium of 115. Differential include seizures form sodium, low sodium induced confusion, UTI. CNS: Hyponatremia: Neuro checks, Icu monitoring, Slow Correction of Na Per Endocrinology. D/C HCTZ Encephalopathy: I mproving. Likely from Hyponatremia. Watch the mental status. Incidental brain aneurysm 3 mm aneurysm arising from the undersurface of the right supraclinoid internal carotid artery -will ask neurosurgery/IR to follow with that on Monday. Cardiovascular: Continue beta blocker from home, Keep Sbp < 160 with nicardipine infusion prn with prn labetalol. about:blank 12/30/2013 • ` ' 'Drexl,Bev��y J MRN: 100494�'90 � nage 6 of 7 � �.. �... `� �- GI: Diet as tolerated. Renal: D/c Hctz , for hyponatremia, lisinopril ( cough), continue foley catheter,monitor UO, electrolyte replacement procotol ID: Send UC. I Endocrine: Accucheck q6 with insulin sliding sc�le coverage. MAINTENANCE THERAPIES DVT prophylaxis: scd GI prophylaxis: pepcid Nutrition: Diet as tolerated. D/w family at bedside. Physical Therapy. Spent 45 minutes with the patient, more than half of which was spent face-to-face in counseling and coordination of care Mohammed A Qureshi, MD .................... 12/29/2013 12:24 PM Pager 612-510-1953 Atkinson,Paul B,MD Physician Signed Progress Notes 12/29/2013 0722 _. ...._...,. ._.. .. __..... ....... ...... _..........._ ... ._...... . ............ __ _..... .... ....._... . ........_. ... ._.... . .. .. ....... .. ...._.. ... .... ..._ .... _.... MEG Initial Video EEG Monitoring Report History: 77 year old woman with recent admission for subarachnoid hemorrhage. Was discharged, but brought back to the emergency room due to persistent nausea, vomiting, and confusion. She had a sodium of 115 in the ER, now at 126. Medications: Keppra Record: The record overall is diffusely slow. A 35 microvolt 5-6 Hz activity is seen with some intermixed further slowing. Slowing is a little more predominant on the right side. No epileptiform activity is seen. When awake, the patient does have marked motor artifact. Stages I, II, and slow wave sleep were seen. Heart rate is in the 50s-60s at rest. Impression: Abnormal EEG due to the presence of diffuse slowing, though the EEG is better organized today. No evidence of seizures at this time. Clinical correlation: This EEG demonstrates generalized abnormalities, which imply diffuse or bilateral cortical dysfunction. Generalized abnormalities may be related to toxic, metabolic, degenerative, structural, vascular, or other epileptogenic pathologies. No evidence of seizures at this time. Clinical correlation is advised. Paul B. Atkinson, MD Minnesota Epilepsy Group about:blank 12/30/2013 • ' ' 'Drexl,BevPr�y J MRN: 100494�'90 Dage 7 of 7 �...! �. �... `-�' \..f Atkinson,Paul B,MD Physician Signed Progress Notes 12/28/2013 1712 _....... . ......_......... ....... .. ......._. _..........._._... . ........_ .. ............. . ..._.._... .. .._......... .........__ ..... , ..... .. ..._......_ .. ............._ .. .. .. _......... ....... _. _... MEG Initial Video EEG Monitoring Report History: 77 year old woman with recent admissi for subarachnoid hemorrhage. Was discharged, but brought back to the emergency room due to ersistent nausea, vomiting, and confusion. She had a sodium of 115 in the ER. Keppra was given d to concern for hyponatremia inducing seizures. Medications: Keppra, 1 mg lorazepam at 1256 I Record: The record overall is diffusely slow and disorganized. A 45 microvolt 2-5 Hz activity is seen. Slowing is a little more predominant on the right side. No epileptiform activity is seen. No sleep yet recorded. Heart rate is in the 50s-60s at rest. Impression: Abnormal EEG due to the presence of diffuse slowing and disorganization. No evidence of seizures at this time. Clinical correlation: This EEG demonstrates generalized abnormalities, which imply diffuse or bilateral cortical dysfunction. Generalized abnormalities r�ay be related to toxic, metabolic, degenerative, structural, vascular, or other epileptogenic pathologies. No evidence of seizures at this time. Clinical correlation is advised. Paul B. Atkinson, MD Minnesota Epilepsy Group about:blank 12/30/2013 � � 'Drexl,Bev�- -'y J MRN: 100494"'90 �'�ge 1 of 6 �. � �.. �... �, Drexl, Beverl J MRN seX ooB Age y 1004949190 Female 07/09/1936 77 Olson,Christine C,PT PT-Physical Signed Progress Notes 12/30/2013 0958 Therapist _..............................._........._......._......................,..........__............................................................................................................._................._........_.._..................._............._........__....................._................ Problem: Functional Status Goal: PT MAINTAINS/IMPROVES FUNCTIONING WITH ADL AND ACTIVITY. Physical therapy care plan Outcome: Progressing per plan Courage Kenny Rehabilitation Institute United Hospital Physical Therapy Progress Note Date: 12/30/2013 Name: Beverly J Drexl Diagnosis: Treatment Diagnosis: difficulty walking Therapist Assessment: . Patient seen for continued Physical Therapy this date. She is progressing quite well with mobility and was able to ambulate 300' with rolling walker and Standby Assistance today. She was a bit steady at times with turns but was able to recover without assistance. Maintained BP within parameters. She will continue to benefit from ongoing Physical Therapy. . Narrative Summary (Based on level of impairment and/or activity limitation) Patient demonstrating mild/moderate impairments and/or activity limitations. Patient is not at baseline level of functional ability. Patient would benefit from ongoing acute therapy services to reduce deficits. Therapist Recommendation for PT/OT/SLP after discharge from acute care hospital (updated every visit): Likely will be able to return home with family support Activity Limitations: Difficulty with Ambulation, Difficulty with Stairs and Decreased Activity Tolerance Precautions: General Precautions: Fall Risk Hearing Loss HOB Invasive Line/Tube Monitor BP Telemetry SBP < 160 Subjective Pain Rating: 0 = no pain, comfortable Description: None Location: None Objective Current Status/Treatment: TRANSFERS: Sit to Stand: SBA to CGA about:blank 12/30/2013 � � �Drexl,BevPr�v J MRN: 100494�'90 n�ge 2 of 6 � ti.. �.. �.. ... Stand to Sit: SBA to Contact Guard Assistance Cues and assist for line management Patient requires totalA for pericares after having BM, able to complete toilet transfer with Standby Assistance and use of grab bars GAIT: Distance: 300' Device: Rolling Walker Assist: Supervision, Set-Up or Standby Prompting Did quite well overall. Had 3-4 instances of small losses of balance or running into objects on right side but was able to recover without physical assistance. Reports she feels that she is a lot better and closer to baseline BP 138/73 after walking. Patient reports no dizziness with mobility today. Interventions: THERAPEUTIC ACTIVITIES/FUNCTIONAL TRAINING IP: Transfer Training Gait Training Training in Use of Medical Equipment/Assistive & Supportive Devices Toileting task as above Patient Safety Awareness: Follows safety precautions Progress Toward Goals: Patient, Family and Caregiver response to intervention: Patient progressing as planned toward targeted outcomes; continue current plan of care. GOALS: Patient's Goal(s): To go home. PT GOALS: Patient will demonstrate bed mo�ility skills Modified Independence in Length of Stay (LOS). Not assessed today Patient will demonstrate Sit to Stand: Modified Independence Ongoing Stand to Sit: Modified Independence in Length of Stay (LOS). Ongoing Patient will ambulate 100 feet using Rolling Walker with Modified Independence in Length of Stay (LOS). Ongoing Patient will ascend / descend 5 Steps using 2 Hand Rails with Modified Independence in Length of Stay (LOS). Not assessed today Patient will perform exercise program with Complete Independence in Length of Stay (LOS). Not assessed today Plan Plan for Next Treatment: Continue toward current goals. Continue current plan with emphasis on strengthening, mobility, stairs. Christine C Olson, PT, DPT .................... 12/30/2013 9:51 AM Pager: 612.654.8737 Harris,Jeff,PT PT-Physical Addendum Initial Assessments 12/29/2013 1503 Therapist .............................................................................................................................................................................................................................................................................. Inpatient Initial Assessment Physical Therapy about:blank 12/30/2013 � 'Drexl,BevF-•'v J MRN: 100494`"90 n�ge 3 of 6 �.. �... � � � United Hospital Patient Name: Beverly J Drexl Treatment Diagnosis: difficulty walking Date of Evaluation: 12/29/2013 Referring MD/Provider: Dr. Giffin As essment Therapist Assessment: 77 year old female hospitalized with AMS and garbled speech. She had been an inpatient here last week, discharging home on 12/24 after suffering a traumatic SAH. She reportedly had been doing well at home and was independent with mobility using a RW. She had close supervision from her family, who lives in the unit upstairs from her (duplex). She is now limited by fatigue and lines/tubes, but is mobilizing up to a RW with stand by assist. She follows commands well and shows no signs of confusion during our session. She demonstrates good lower extremity strength and is steady on her feet for the little bit of activity that we did. She will benefit from further physical therapy assessment as we were limited by the many lines/monitors. I anticipate that she will progress quickly. . Narrative Summary (Based on level of impairment and/or activity limitation) Patient demonstrating mild/moderate impairments and/or activity limitations. Patient is not at baseline level of functional ability. Patient would benefit from ongoing acute therapy services to reduce deficits. Therapist Recommendation for PT/OTISLP after discharge from acute care hospital (updated every visit): Unknown at this time. Unable to complete the full assessment. Will update discharge recommendations as able. Activity Limitations: Difficulty with Ambulation, Difficulty with Stairs and Decreased Activity Tolerance Precautions: General Precautions: Fall Risk Hearing Loss HOB Invasive Line/Tube Monitor BP Telemetry SBP < 160 Subiective: Living Situation: Style of Home: Duplex Outside Steps: 5 Steps. Outside Stair Rails: 2 Inside Steps: None. Inside Stair Rails: 0 Available Equipment: Cane and Walker (Rolling) Living Situation: Alone, but daughter and son in law live upstairs. Preadmission Mobility Status: Independent with Assistive Device, Walkers, Type: Rolling about:blank 12/30/2013 • � �Drexl,BevP��v J MRN: 100494�'90 n�ge 4 of 6 �.,f �... `.. �,.. �...� Walker Caregiver(s) Available to Assist with Post D/C Care: Family Members is available Evenings, Can Provide Moderate Physical Assistance or Friend / Neighbor is available Days, and is able Not Assessed Transportation / Driving: Not Assessed Initial Pain Rating / Description: 0 = no pain, comfortable/ Not applicable Acceptable Level of Pain: 0 = no pain, comfortable Objective Additional Information: Social and Medical History Reviewed: Yes - see additional information section below for further details. Past Medical History Diagnosis Date • HTN • Hyperlipidemia • Bronchitis • Disc HAD SURGERY FOR A DISC THAT WAS PINCHING A NERVE • Deafness,R,congenital 3/29/2010 • Anisocoria R>L 3/29/2010 • Varicose Veins,L leg 3/29/2010 • HTN (hypertension) 3/29/2010 • Chronic LBP 3/29/2010 • Hypothyroid 3/29/2010 • Sinusitis, chronic 3/29/2010 • Hyperglycemia,A1 c 6.6 2009 3/29/2010 Past Surgical History Procedure Laterality Date • Hx back surgery 1986 L5-S1 laminectomy • Hx tah and bso 1985 abnl pap Were cultural /age or other special adaptations needed? Yes - HOH Patient is a vulnerable adult: Yes, due to patient hospitalization Patient is aware of diagnosis: Yes Risks and benefits explained: Yes Objec�ive Findinas BP = 153/75 in supine at rest, 145/66 in sitting, 145/60 in standing Mobility: Bed Mobility: Supine-Sit: SBA Sit to supine with min A for the LE's Transfers: Sit to Stand: SBA Stand to Sit: SBA *took several side steps to get up to the HOB with cueing, using a RW, stand by assist. about:blank 12/30/2013 ~ ' 'Drexl,BevF�-'v J MRN: 100494�'90 n�ge 5 of 6 � �.,i � �./ � Steady. Ambulation: On Level Surfaces: Distance - NA feet with Not Applicable Assist: Activity does not occur On Stairs: NA Balance: Sitting Balance: Good Standing Balance: Unable to formally Assess Balance Characteristics: Not Tested Fall Risk Screening: Screening required for fall risk when finro or more criteria present: History of a fall in the last six months Age of 65 or older and currently on medication identified as causing balance or gait disturbances: Any Anti-Epileptics: Any Anti-Epileptic, Any Benzodiazepines: No Benzodiazepines administered last 24 hrs per MAR Primary acute neurological diagnosis Screening required: TBA Endurance: Endurance: Fair Complicating Factors: Fatigue Sensation: Screened and Intact Range of Motion: Items not addressed indicate that the test was inappropriate or not meaningful at the time of evaluation and therefore not performed. Screened with-in functional limits Strength: Items not addressed indicate that the test was inappropriate or not meaningful at the time of evaluation and therefore not performed. Screened with-in functional limits Today's Intervention: Completed Evaluation Plan Due to impairments as listed above plan for therapy as below: Frequency: daily Duration of Treatment: Length of stay or until goals are met. Anticipate Core Outcome Goals to be achieved within 1 wk. Interventions: Completed Evaluation Patient's Goal(s): To go home. PT GOALS: Patient will demonstrate bed mobility skills Modified Independence in Length of Stay (LOS). Patient will demonstrate Sit to Stand: Modified Independence Stand to Sit: Modified Independence in Length of Stay (LOS). about:blank 12/30/2013 • ' -Drexl,BevP°'v J MRN: 100494�'90 n�ge 6 of 6 �,_., �..- �,.. �.. �,... Patient will ambulate 100 feet using Rolling Walker with Modified Independence in Length of Stay (LOS). Patient wiil ascend /descend 5 Steps using 2 Hand Raiis with Modified Independence in Length of Stay (LOS). Patient will perform exercise program with Complete Independence in Length of Stay (LOS). Patient participated in goal selection and understand(s) the plan of care: Yes Treatment Plan for Next Visit: Bed mobility tr�ining, Transfer training, Gait training, Stair training, Therapeutic exercises and Balance training. Student or PTA has been instructed in and dem�nstrates skills necessary to carry out above stated treatment plan as needed. Minutes/Units of Time for this Session are documented on the flowsheet. Revision History... Date/Time User Action 12/29/2013 1515 Harris,Jeff,PT Addend 12/29/2013 1512 Harris,Jeff, PT Sign View Details Report Routing History... Date/Time From To Method 12/29/2013 1515 Harris,Jeff,PT Rumsey,Timothy J,MD In Basket Harris,Jeff,PT PT-Physical Signed Progress Notes 12/29/2013 0831 Therapist _.__........ . .._......_ ..._.....__. __....... .. ....._..... . ._ ........... ... .. ._ .........._.... _. _._ __....... _. .....__... .__ ._ Physical therapy orders received. Patient is currently on bedrest. I will check back later today for updates on activity. Jeff Harris, PT .................... 12/29/2013 8:30 AM about:blank 12/30/2013 • 'Drexl,BevF-•'v J MRN: 100494�"90 "�ge 1 of 5 �,..� �..f �.,� � �.. Drexl, Beverl J MRN seX ooB Age y 1004949190 Female 07/09/1936 77 SLP-Speech ' Klukas,Caitlin A,SLP Language Signed Initial Assessments 12/29/2013 1513 Pathologist _,........__..................._........_..............................,.........,...................._........._......._.._......_.........................................................................,......................._...........................................__................................................ Initial Speech-Language Pathology Assessment United Hospital Patient Name: Beverly J Drexl Date of Evaluation (Start of Service): 12/29/2013 Referring MD/Provider: Giffin, Joel S, DO Date Order Received: 12/28/13 Time evaluation was completed: 1000 History of present illness: Beverly is a 77 year old female admitted for garbled speech. She was discharged from this hospital 4 days ago after a 6 day stay due to fall causing SAH. She lives at home and was receiving 24 hour care from her son who lives upstairs. She was brought back to the ED on 12/28 due to vomiting and increased confusion. Beverly was seen by speech service during her previous hospital stay. She was not on a modified diet and standardized testing (CLQT) revealed mild overall impairment in cognitive-linguistic functioning. Impression: Speech-Language Diagnosis: Cognitive/Linguistic Impairment Therapist Assessment: . Bev participated in a bedside swallow evaluation. No ssx aspiration across all consistencies. Bev followed directions well when they were spoken clearly and stated in simple terms. Recommend regular texture diet with thin liquids. . Bev participated in cognitive-linguistic screening which revealed impairments in memory and cognitive functioning. She had difficulty naming and describing family members in the room, but was oriented to person and place. Recommend repeat CLQT to compare to discharge results from recent hospital stay. Bev is appropriate for ongoing speech therapy due to cognitive- linguistic impairment. . Narrative Summary (Based on level of impairment and/or activity limitation) Patient demonstrating mild/moderate impairments and/or activity limitations. Patient is not at baseline level of functional ability. Patient would benefit from ongoing acute therapy services to reduce deficits. Swallowing: Mann Assessment of Swallowing Ability: 187 /200 indicating No Abnormality Detected risk for dysphagia and No Abnormality Detected risk for aspiration. Languaae: Western Aphasia Battery-bedside: Bedside Aphasia Score/ Quotient: not administered. No word finding difficulties. Though difficulty following complex directions during assessment. May have been due to poor hearing aid placement. Memory Screen: Short Blessed: Patient scored 22 indicating Memory impairment . Recommendations: about:blank 12/30/2013 'Drexl,BevP~'v J MRN: 100494�'90 n�ge 2 of 5 �... `. *,., �... �.. Diet: Regular with Thin Liquids Next diet upgrades: Solid/Liquids as Tolerated Swallowing Instructions/Precautions: Supervision: Distant supervision, check 2-3 times per meal Positioning: Seat fully upright and midline when eating Upright for 20 minutes after eating Plan for next session: no swallowing treatment n�cessary Therapist Recommendation for PT/OT/SLP af#er discharge from acute care hospital (updated every visit): Patient appropriate for ongoing therapy. Patient will tolerate a low intensity therapy schedule with improvement expected over an extended period of time Activity Limitations: Decreased Cognition Analysis of Performance 1. Altered mental status 2. Hyponatremia 3. Subdural hematoma 4. Intracerebral hematoma 5. Anisocoria 6. Delirium 7. Depression with anxiety 8. HTN (hypertension) 9. Hypothyroid 10 Subarachnoid hemorrhage 11 SIADH (syndrome of inappropriate ADH production) Precautions: None Past Medical History, including information regarding previous hospital stay if pertinent: Past Medical History Diagnosis Date • HTN • Hyperlipidemia • Bronchitis • Disc HAD SURGERY FOR A DISC THAT WAS P/NCHING A NERVE • Deafness,R,congenital 3/29/2010 • Anisocoria R>L 3/29/2010 • Varicose Veins,L leg 3/29/2010 • HTN (hypertension) 3/29/2010 • Chronic LBP 3/29/2010 • Hypothyroid 3/29/2010 • Sinusitis, chronic 3/29/2010 • Hyperglycemia,A1 c 6.6 2009 3/29/2010 Social and Medical History Reviewed: Yes Were cultural / age or other special adaptations needed? Yes: Increased Vocal Loudness, Repeated Information and Face-to-Face Communication about:blank 12/30/2013 • 'Drexl,BevF--'v J MRN: 100494�"90 n�ge 3 of 5 �., �... �... �.. �.... Patient is a vulnerable adult: Yes, due to patient hospitalization Patient is aware of diagnosis: Yes Risks and benefits explained: Yes Initial Pain Rating / Description: Patient unable to provide rating for pain. Location: low back Acceptable Level of Pain: 2 = Mild Pain, (Bothersome, Annoying, Irritating, Nagging) Learning Barriers: Hearing, None Patient's Readiness to Learn: Willing Family's Readiness to Learn: Willing Learning Needs were Addressed by Providing: Verbal Information and Cueing Primary Limiting Factors for Achieving Core Outcomes: Impairment(s): Executive Function Orientation Problem Solving Short Term Memory Functional Impairment(s): Receptive Language: Difficulty understanding conversation Cognition: Orientation: Unable to understand time of year, holidays or events Memory: Unable to remember information recently heard Problem Solving/Reasoning: Unable to use problem solving or reasoning to solve simple, everyday problems Suggestions for Facilitating Communication: use hearing aids and devices Prognosis for Achieving Desired Outcome: Excellent Current Status: Language(s) Spoken: English Hearing: Patient has Right Hearing Aid and Patient has Left Hearing Aid Handedness: right and left Visual Acuity: Glasses Worn Dentition: Full set of dentures that fit Evaluation Results Pertinent Information: Respiratory Status: Oxygen: Nasal Cannula Level of Consciousness: Alert Current Diet: Nothing by Mouth Patient Position: Upright in bed, 70degrees Tests Administered: Mann Assessment of Swallowing Ability (MASA), Western Aphasia Battery- Bedside (WAB-Bedside), Animal Naming, Short Orientation Memory Concentration Test (Sho�t Blessed) Swallowina: Swallowing: Within functional limits MASA: Total Score: 187 /200 Risk for Dysphagia: No Abnormality Detected Risk for Aspiration: No Abnormality Detected about:blank 12/30/2013 • `Drexl,BevP�'v J MRN: 100494�"90 n�ge 4 of 5 �,, `. �.,, �. �,,.� During MASA, PO trials of water, pudding, and cracker were presented to patient. Oral phase remarkable for mildly prolonged mastication, decreased sensation in lips? (pt did not open mouth wide enough without prompting), mild residue cleared with liquid wash. Pharyngeal phase remarkable for mildly reduced laryngeal elevation/excursion. Language: , Auditory Comprehension: Mild deficits Verbal Expression/Speech Production: Mild d�ficits Animal naming: 2 animals named in one minute task. This places patient in the < or equal to 25th percentile for age/education. Score above 25th percentile indicates no impairment. Score at or below 25th percentile indicates impairment. Cognition: Short Orientation Memory Concentration Test (Short Blessed) score:22 . This indicates Memory impairment . Attention/Concentration: mild impairment Orientation: Not oriented to time. Oriented to person and place. Memory: Moderate deficits Alternative/Augmentative Communication: NA Response to cues/compensatory strategies: V�/FL Plan Treatment Plan/Targeted Outcomes: Type of Session(s) Planned: Individual Frequency: 6-7 times per week Duration of Treatment: Length of stay or until goals met. Anticipate core outcome goals to be achieved within length of stay Interventions completed: Adult Eval Communication and Eval Oral/Phar Swallowing Diet modification and Swallowing precautions and techniques Interventions planned: Develop/Cognitive Skills and Cognitive compensatory techniques SLP Goals: Language: Patient will follow 2-4 step directions with 100% accuracy with minimal cues Cognition: Patient will achieve 100% accuracy on orientation tasks with no cues. Patient will achieve 75% accuracy on short-tE�rm memory tasks with minimal cues. Patient will participate in repeat CLQT assessmPnt. Swallowing: Pt will tolerate current diet (recular with thin) without ssx aspiration over 2-3 consecutive sessions. Patient and family will demonstrate use of safe swallow strategies (small bites, eat when alert and upright) independently. Patient and/or Family Goal(s): To order breakfast. Patient and/or Family were included in goal selection If you have any questions or concerns regarding these recommendations, please contact Speech- Language Pathology: 651-241-8290 about:blank 12/30/2013 � 'Drexl,BevF°'v J MRN: 100494�'90 "�ge 5 of 5 �,, ti.. L.. �... `.. Routing History... Date/Time From To Method 12/29/2013 1527 Klukas,Caitlin A,SLP • Rumsey,Timothy J,MD In Basket about:blank 12/30/2013 ' ' Drexl, Bev�°ly J (MR# 10049�'^�90) P�?e 1 of 11 � � � � � Results US TRANSCRANI/AL DOPPLER(Accession A8337110)(Order 508338854) Original Order Diagnosis Diagnosis SAH Result Information Exam Date and Time Status Reading Physician 12/29/2013 8:32 AM Final . CAROLAN, PAUL � ROBERT Reading Provider(s) Carolan, Paul Robert, MD PACS Images - Show imapes for US TRANSCRANIAL DOPPLER Study Result US TRANSCRANIAL DOPPLER 12/29/2013 8 : 32 AM INDICATION: Subarachnoid hemorrhage COMPARISON: None. FINDINGS : Transcranial Doppler ultrasound was attempted, but the sonographic window was inadequate for assessment for vasospasm. Hard Copy Result Report Open Hard Copy Result Report(Order#508338854 - US TRANSCRANIAL DOPPLER) US TRANSCRANIAL DOPPLER(Accession A8337110) (Order 508338854) Image Documentation: Technologist No findings _ Patient Release Status: This result is not viewable by the patient. Order US TRANSCRANIAL DOPPLER[93886.0] (Order 508287898) Orderinformation Date Ordering/Authorizing Department 12/28/2013 Shaik, Arif M, MD Utd Station 4400 Provider Information Ordering User Ordering Provider Authorizing Provider Shaik, Arif M, MD Shaik, Arif M, MD Shaik, Arif M, MD Attending Provider(s) Admitting Provider PCP Hennessey, Thomas W, MD; Shaik, Arif M, MD Rumsey, Timothy J, MD Sharma, Himanshu S, MD; Shaik, Arif M, MD Order US TRANSCRANIAL DOPPLER(93886.0] (Order 508338854) Order Information Date and Time Department 12/29/2013 7:26 AM Utd Station 4400 Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 1 of 11 ` ' Drexl, Bevr°�y J (MR# 10049�'"'90) P��*e 2 of 11 .. �-- �.. *-� `.. Frequency Elements and Transportation Info Frequency RAD TOMORROW AM Quantity Ordering Quantity 1 Order Information Order Date Service Start Date Start Time 12/29/13 Emergency 12/29/13 0600 Order Questions Question Answer Comment Reason for exam (free text) SAH Provider Information Ordering User Ordering Provider Authorizing Pravider Shaik, Arif M, MD Shaik, Arif M, MD Shaik, Arif M, MD Attending Provider(s) Admitting Provider PCP Bifling Provider Hennessey, Thomas W, Shaik, Arif M, MD Rumsey, Timothy J, MD Carolan, Paul Robert, MD MD; Sharma, Himanshu S, MD; Shaik, Arif M, MD Acknowledgement Info For At Acknowledged By Acknowledged On Placing Order 12/28/13 1526 Rainey, Jennifer M, RN 12/28/13 1536 Audit Trail Action User Date/Time Order Printed [4] KOEGEL, JODY D [A051797] Sun Dec 29, 2013 0726 CST Order Details Parent Order ID Child Order ID 508287898 508338854 Appointments for this Order 12/29/2013 0600 -45 min 6, Utd Mi Us Rm Utd Medical Imaging (Resource) EMAGEON Information Coliection Date Collection Time 12/29/2013 0846 Priority and Order Details Priority Class j Routine Normal Specimen Information Collection Date Collection Time � 12/29/2013 0846 i Lab IDs I Specimen# A8337110 Results MR Brain wo Contrast-TIA or Stroke(Accession A8336156)(Order 508276325) Comment Original Order Diagnosis *Refer to Results Diagnosis NEUROLOGIC PROBLEM Review for Normal Ranges and Result Status Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 2 of 11 ' � Drexl, Bev�-iy J (MR# 10049�'^i 90) P��e 3 of 11 ...F �.- �,... �.- �,.,. CREATININE 0.66 12/24/2013 CREATINISTAT 0.80 12/28/2013 GFRNOTAFRICA >60 12/24/2013 GFRAFRICAN >60 12/24/2013 GFRINOTAFRIC >60 12/28/2013 GFRIAFRICAN >60 12/28/2013 Result Information Exam Date and Time Status Reading Physician 12/28/2013 1349 Final GILLOON, BENJAMIN A Reading Provider(s) Gilloon, Benjamin A, MD PACS Images Show imaaes for MR Brain wo Contrast-TIA or Stroke Study Result UTD MEDICAL IMAGING HEAD MRI/MRA WITHOUT IV CONTRAST 12/28/2013 1 : 49 PM INDICATION: Garbled speech. Headache. Vomiting. Hospitalized last week with fall, skull fracture and intracranial hemorrhage. TECHNIQUE: Head MRI/MRA without intravenous contrast . COMPARISON: Head CT 12/28/2013 and 12/19/2013 FINDINGS : MRI brain: There is no restricted diffusion to indicate an area of recent ischemia. Sinuses, mastoid air cells and orbits are unremarkable . Ventricles are within normal limits for size for the patient ' s age . Major intracranial flow-voids appear intact . T1 hyperintense material below and within the posterior gyrus rectus on the right, over the right greater than left parasagittal frontal � convexities, within the right superior frontal gyrus, subdural in � location along the right frontal parietal and inferior bifrontal ' and temporal regions is most compatible with subacute blood products . The subdural blood measures approximately 5 mm in � thickness over the right parietal convexity, and thinner over the I frontal and temporal regions . FLAIR imaging demonstrates some � elevated T2 signal hyperintensity in the right gyrus rectus and bilateral superior frontal gyri reflecting evolving contusion/traumatic injury. Background of presumed chronic small vessel ischemic injury within the supratentorial white matter. MRA head: Intracranial circulat�on is patent without evidence for high-grade intracranial stenosis or proximal vessel occlusion. Persistent trigeminal artery is noted on the left . There is a 3 x 2 Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 3 of 11 ` Drexl, Bev�~�y J (MR# 10049a^'90) P�?e 4 of 11 �,,.� ...F �.. �-- �..,.. x 2 . 5 mm outpouching from the undersurface of the right supraclinoid internal carotid artery consistent with an aneurysm. No high flow vascular lesion. Conclusion: MRI brain: 1 . Scattered areas of subacute subdural hematoma in the bifrontal and temporal regions and over the right parietal convexity where it measures approximately 5 mm in thickness . 2 . Signal abnormality consistent with traumatic injury involving the right gyrus rectus and bila�.eral superior frontal gyri . 3 . No evidence for recent infarct, mass or hydrocephalus . 4 . Background of presumed chronic small vessel ischemic injury within the supratentorial white matter. MRA head: l . 3 mm aneurysm arising from the undersurface of the right supraclinoid internal carotid artery. 2 . No proximal vessel occlusion, high-grade intracranial stenosis or high flow vascular lesion. 3 . Persistent left trigeminal artery. Hard Copy Result Report Open Hard Copy Result Report(Order#508276325 - MR Brain wo Contrast-TIA or Stroke) MR HEAD BRAIN WO (Accession A8336156) (Order 508276325) Image Documentation: Technologist No findings Patient Release Status: This resuit is not viewable by the patient. Order MR Brain wo Contrast-TIA or Stroke [70551.0] (Order 508265839) Orderinformation Date Ordering/Authorizing Department 12/28/2013 Hennessey, Thomas W, MD Utd Station 4400 Provider Information Ordering User Ordering Provider Authorizing Provider Hennessey, Thomas W, MD Hennessey, Thomas W, MD Hennessey, Thomas W, MD Attending Provider(s) Admitting Provider PCP Hennessey, Thomas W, MD; Shaik, Arif M, MD Rumsey, Timothy J, MD Sharma, Himanshu S, MD; Shaik, Arif M, MD Order MR Brain wo Contrast-TIA or Stroke [70551.0] (Order 508276325) Order Information Date and Time Department 12/28/2013 1:07 PM Utd Station 4400 Frequency Elements and Transportation Info Frequency RAD ONE TIME Quantity Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 4 of 11 ' Drexl, Bev��ly J (MR# 10049�'^�90) P�?e 5 of 11 ..... �.. .,,, �.. �..� Ordering Quantity 1 Order Information Order Date Service Start Date Start Time 12/28/13 Emergency 12/28/13 1119 Order Questions Question Answer Comment Enter reason for exam NEUROLOGIC PRO�LEM Provider Information Ordering User Ordering Provider Authorizing Provider Hennessey, Thomas W, MD Hennessey, "�homas W, MD Hennessey, Thomas W, MD Attending Provider(s) Admitting Provider PCP Billing Provider Hennessey, Thomas W, Shaik, Arif M, MD Rumsey, Timothy J, MD Gilloon, Benjamin A, MD MD; Sharma, Himanshu S, MD; Shaik, Arif M, MD Acknowledgement Info For At Acknowledged By Acknowledged On Placing Order 12/28/13 1119 Starcher, Connie, RN 12/28/13 1131 Audit Trail Action User Date/Time Order Printed [4J MILLER, JILL MARIE [A050559] Sat Dec 28, 2013 1307 CST Order Details Parent Order ID Chiid Order ID 508265839 508276325 Comments *Refer to Results Review for Normal Ranges and Result Status CREATININE 0. 66 12/24/2013 CREATINISTAT 0. 80 12/28/2013 GFRNOTAFRICA >60 12/24/2013 GFRAFRICAN >60 12/24/2013 GFRINOTAFRIC >60 12/28/2013 GFRIAFRICAN >60 12/28/2013 Appointments for this Order 12/28/2013 1220 -30 min 1, Utd Mi Mr Rm Utd Medical Imaging (Resource) EMAGEON Information Coliection Date Collectian Time 12/28/2013 1408 ; Priority and Order Details j Priority Ciass � STAT Normal I Specimen Information , Coilection Date Collection Time 12/28/2013 1408 Lab IDs Specimen# A8336156 Results Angio Head for Aneurysm NO Contrast(Accession A8336157) (Order 508276380) Comment Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 5 of 11 ' Drexl, Bev�-�y J (MR# 10049�'^'90) P��e 6 of 11 ..� �-- �.. � .... Original Order Diagnosis `Refer to Results Diagnosis NEUROLOGIC PROBLEM Review for Normal Ranges and Result Status CREATININE 0.66 12/2412013 CREATINISTAT 0.80 12/28/2013 GFRNOTAFRICA >60 12/24/2013 GFRAFRICAN >60 12/24/2013 GFRINOTAFRIC >60 12/28/2013 GFRIAFRICAN >60 12/28/2013 Result Information Exam Date and Time Status Reading Physician 12/28/2013 1343 Final GILLOON, BENJAMIN A Reading Provider(s) Gilloon, Benjamin A, MD PACS Images Show imaqes for Anqio Head for Aneurvsm NO Contrast Study Result - UTD MEDICAL IMAGING HEAD MRI/MRA WITHOUT IV CONTRAST 12/28/2013 1 : 49 PM INDICATION: Garbled speech. Headache. Vomiting. Hospitalized last week with fall, skull fracture and intracranial hemorrhage. TECHNIQUE: Head MRI/MRA without intravenous contrast . COMPARISON: Head CT 12/28/2013 and 12/19/2013 FINDINGS : MRI brain: There is no restricted diffusion to indicate an area of recent ischemia. Sinuses, mastoid air cells and orbits are unremarkable. Ventricles are within normal limits for size for the patient ' s age. Major intracranial flow-voids appear intact . T1 hyperintense material below and within the posterior gyrus rectus on the right, over the right greater than left parasagittal frontal convexities, within the right superior frontal gyrus, subdural in location along the right frontal parietal and inferior bifrontal and temporal regions is most compatible with subacute blood products . The subdural blood measures approximately 5 mm in thickness over the right parietal convexity, and thinner over the frontal and temporal regions . FLAIR imaging demonstrates some elevated T2 signal hyperintensity in the right gyrus rectus and bilateral superior frontal gyri reflecting evolving contusion/traumatic injury. Background of presumed chronic small vessel ischemic injury within the supratentorial white matter. Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 6 of 11 ' � Drexl, Bev�°1y J (MR# 10049a^�90) P�?e 7 of 11 �. � � � � MRA head: Intracranial circulation is patent without evidence for high-grade intracranial stenosis or proximal vessel occlusion. Persistent trigeminal artery is noted on the left . There is a 3 x 2 x 2 . 5 mm outpouching from the undersurface of the right supraclinoid internal carotid artery consistent with an aneurysm. No high flow vascular lesion. Conclusion: MRI brain: 1 . Scattered areas of subacute subdural hematoma in the bifrontal and temporal regions and over the right parietal convexity where it measures approximately 5 mm in thickness . 2 . Signal abnormality consistent with traumatic injury involving the right gyrus rectus and bilai�eral superior frontal gyri. 3 . No evidence for recent infarct, mass or hydrocephalus . 4 . Background of presumed chronic small vessel ischemic injury within the supratentorial white matter. MRA head: 1 . 3 mm aneurysm arising from the undersurface of the right supraclinoid internal carotid artery. 2 . No proximal vessel occlusion, high-grade intracranial stenosis or high flow vascular lesion. 3 . Persistent left trigeminal artery. Hard Copy Result Report Open Hard Copy Resuit Report(Order#508276380 -Anqio Head for Aneurysm NO Contrast) MR ANGIO HEAD BRAIN WO (Accession A8336157) (Order 508276380) Image Documentation: Technologist No findings Patient Release Status: This result is not viewable by the patient. Order Angio Head for Aneurysm NO Contrast[70544.0] (Order 508265840) Orderinformation Date OrderinglAuthorizirc; Department 12/28/2013 Hennessey, Thomas W, MD Utd Station 4400 Provider Information Ordering User Ordering Provider Authorizing Provider Hennessey, Thomas W, MD Hennessey, Thomas W, MD Hennessey, Thomas W, MD Attending Provider(s) Admitting Pravider PCP Hennessey, Thomas W, MD; Shaik, Arif M, MD Rumsey, Timothy J, MD Sharma, Himanshu S, MD; Shaik, Arif M, MD Order Angio Head for Aneurysm NO Contrast[70544.0] (Order 508276380) Order Information Date and Time Department 12/28/2013 1:07 PM Utd Station 4400 Frequency Elements and Transportation Info Drexl, Beverly J (MR# 1004949190) Printed by i aylor, Robert B, HUC [A047102] at 12... Page 7 of 11 ` � Drexl, Bev�-�iy J (MR# 10049�'^'90) P�?e 8 of 11 ,.� �..E �... �..� �... Frequency RAD ONE TIME Quantity C?rdering Quantity 1 Order Information Order Date Service Start Date Start Time 12/28/13 Emergency 12/28/13 1119 Order Questions Question Answer Comment Enter reason for exam NEUROLOGIC PROBLEM Provider Information Ordering User Ordering Provider Authorizing Provider Hennessey, Thomas W, MD Hennessey, Thomas W, MD Hennessey, Thomas W, MD Attending Provider(s) Admitting Provider PCP Billing Provider Hennessey, Thomas W, Shaik, Arif M, MD Rumsey, Timothy J, MD Gilloon, Benjamin A, MD MD; Sharma, Himanshu S, MD; Shaik, Arif M, MD Acknowledgement Info For At Acknowledged By Acknowledged On Placing Order 12/28/13 1119 Starcher, Connie, RN 12/28/13 1131 Audit Trail Action User Date/Time Order Printed [4J MILLER, JILL MARIE [A050559] Sat Dec 28, 2013 1307 CST Order Details Parent Order ID Chiid Order ID 508265840 508276380 Comments *Refer to Results Review for Normal Ranges and Result Status CREATININE 0. 66 12/24/2013 CREATINISTAT 0.80 12/28/2013 GFRNOTAFRICA >60 12/24/2013 GFRAFRICAN >60 12/24/2013 GFRINOTAFRIC >60 12/28/2013 GFRIAFRICAN >60 12/28/2013 Appointments for this Order 12/28/2013 1250 -30 min 1, Utd Mi Mr Rm Utd Medical Imaging (Resource) EMAGEON Information Collection Date Collection Time 12/28/2013 1408 Priority and Order Details Priority Class STAT Normal Specimen Information Collection Date Coliection Time 12/28/2013 1408 Lab IDs Specimen# Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 8 of 11 ' � Drexl, Bev�-°�y J (MR# 10049a^'90) P��*e 9 of 11 ...... �.. `.. �.. �.,. A8336157 Results CT Head Brain wo(Accession A8335938) (Order 508262344) Comment Original Order Diagnosis `Refer to Results Diagnosis Eval and f/u cerebral vascular disease/ischemia Review for Normal Ranges and Result Status CREATININE 0.66 12/24/2013 GFRNOTAFRICA >60 12/24/2013 GFRAFRICAN >60 12/24/2013 Result Information Exam Date and Time Status Reading Physician 12/28/2013 1101 Final GILLOON, BENJAMIN A Reading Provider(s) Gilloon, Benjamin A, MD PACS Images Show images for CT Head Brain wo Study Result UTD MEDICAL IMAGING CT HEAD BRAIN WO 12/28/2013 11 : 01 AM INDICATION: Confusion and difficulty speaking. TECHNIQUE: CT scan of the head without contrast . CONTRAST: None. COMPARISON: Head CT 12/19/2013 . FINDINGS : Again seen is the sagittally oriented fracture in the midline frontal bone that extends over the vertex into the parietal region just to the left of midline . There is a small amount of hyperdense blood products over the parasagittal right parietal region. Evaluation of this area is limited by motion artifact . This appears slightly diminished com;�ared to the prior although again evaluation is limited. The hyperdense blood products associated with the right greater than left bifrontal contusion injuries has largely resolved. The hypoatten-uation within the brain parenchyma associated with these injuries ws better defined. No definite CT evidence of acute ischemia . No intracranial mass effect/midline shift . Small punctate calcification within the left pons is unchanged. Skin staples within the posterior midline scalp noted. Sinuses, middle ears and mastoids appear free from significant disease. Carotid siphon calcification noted. Patchy areas of hypoattenuation within the white matter presumably reflect sequela of chronic small vessel ischemic injury. CONCLUSION: Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 9 of 11 ' � Drexl, Bev�°ly J (MR# 10049�'^i 90) Pa�° 10 of 11 �.. �r � '�-- �..f 1 . No definite CT evidence of acute ischemic injury. No evidence for intracranial mass . 2 . Small amount of hyperdense b:Lood products over the right parietal region. These appear slightly diminished compared to the 12/19/2013 comparison study. However, given that the hyperdense blood products associated with �he bifrontal contusion injuries have largely resolved, this could represent a small amount of new, interval bleeding. Consider followup. 3 . The hyperdense blood products associated with the bifrontal contusions has largely resolved. The areas of hypoattenuation associated with this injury are better defined on today' s study consistent with evolving injury. 4 . Sagittal frontoparietal fracture . 5 . Presumed changes of chronic small vessel ischemic injury within the supratentorial white matter. Findings were discussed with Dr. Hennessey by Dr. Gilloon via telephone at 1108 hours on 12/28/2013 . Result History CT HEAD BRAIN WO (Order#508262344) on 12/28/13 -Order Result History Report. Hard Copy Result Report Open Hard Co�y Result Report(Order#508262344 -CT Head Brain wo) CT HEAD BRAIN WO (Accession A8335938) (Ordei�508262344) Image Documentation: Technologist No findings _ __ _ Patient Release Status: This result is not viewable by the patient. Order CT Head Brain wo [70450.0] (Order 508261792) Orderinformation Date Ordering/Authorizing Department 12/28/2013 Hennessey, Thomas W, MD Utd Station 4400 Provider information Ordering User Ordering Provider Authorizing Provider Hennessey, Thomas W, MD Hennessey, Thomas W, MD Hennessey, Thomas W, MD Attending Provider(s) Admitting Provider PCP Hennessey, Thomas W, MD; Shaik, Arif M, MD Rumsey, Timothy J, MD Sharma, Himanshu S, MD; Shaik, Arif M, MD Order CT Head Brain wo [70450.0] (Order 508262344) Order Information Date and Time Department 12/28/2013 10:55 AM Utd Station 4400 Frequency Elements and Transportation Info Frequency RAD ONE TIME Quantity Ordering Quantity 1 Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at ... Page 10 of 11 " ' Drexl, Bev�°�y J (MR# 100494^�90) P�� 11 of 11 �.,. �. e.., s,. �,.., Order Information Order Date Service Start Date Start Time 12/28/13 Emergency 12/28/13 1050 Order Questions Question Ansti�er Comment Enter reason for exam Eval and flu cerebral vascular disease/ischemia Provider Information Ordering User Ordering Provider Authorizing Provider Hennessey, Thomas W, MD Hennessey, Thomas W, MD Hennessey, Thomas W, MD Attending Provider(s) Admitting Provider PCP Billing Provider Hennessey, Thomas W, Shaik, Arif M, MD Rumsey, Timothy J, MD Giiloon, Benjamin A, MD MD; Sharma, Himanshu S, MD; Shaik, Arif M, MD Acknowledgement Info For At Acknowledged By Acknowledged On Piacing Order 12/28/13 1051 Starcher, Connie, RN 12/28/13 1056 Audit Trail Action User Date/Time Order Printed [4] BATAGLIA, JUDY A[A27741] Sat Dec 28, 2013 1055 CST Order Details Parent Order ID Child Order ID 508261792 508262344 Comments *Refer to Results Review for Normal Ranges and Result Status CREATININE 0. 66 12/24/2013 GFRNOTAFRICA >60 12/24/2013 GFRAFRICAN >60 12/24/2013 Appointments for this Order 12/28/2013 1100 -30 min 1, Utd Mi Ct Ed Utd Medical Imaging (Resource) EMAGEON Information Collection Date Collection Time 12/28/2013 1111 Priority and Order Details Priority Class STAT Normal Specimen Information Collection Date Collection Time 12/28/2013 1111 Lab IDs Specimen# A8335938 Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at ... Page 11 of 11 � � � �� L� , � Prehospital Care Report Summary � ; ' ; , St Paul Fire Department Date:i?J18/20 3 Call#:37208 Booklet:78705525 Incident#:37208 Matching#:287 Time Zone: merica/Chicago � Call Ip rmation: #Patlents�1 : Call Origin:9 1 Run Type: Emergency(Immediate) Disposition: Treated/Transported #Pati nts at Scene:' ; Un(t#: ' i0-Medic 10 Lights/Siren: To Scene all Received I , Incident Loc: NEIDA STBST CLAIR AV Saint Paul,MN 55102 Dlspatched:1 30:20 i Location Type: reet/Hwy En Route:1 31:29 j Receiving Facility: nited Hospital On Scene: 1 33:31 i Dest.Reason: tient/Famfly Choice P ient Contact:1 34:05� Loaded Mileage:21 Left Scene:;1 44:41; Crew Members: 'KEEFE,MICHAEL(DOC)(EMT Paramedic);TSCHIDA,MICHAEL(DS)(DH)(EMT t Destinationi 1 46:00 ramedic);DALY,FRANK(EMT Basic);NELSON,TIMOTHY(EMT Baslc) In Servicei Moved to Amb By: retcher Ti ne On Scene:1� Min i Transport Posltion: pine 7ime t Destinatlon:1 Min , Tota Tlme of Runc � n Inf rma io : Ins.Type: � Name:BEVERLY REXL DOB:07/09/1936 Ins.Name/Payer: � Address:�s SUPeRI R Gender: Female Policy Neme: Saint Paul, N 55102 Age:77 Yeers Address: Medicare: Phone: We19ht� Medtcaid: SSN: Policy: PMH: Group: Comment: Auth Stgnature:No ; Privacy Sig:No Unable to Slgn:Yes � Retused to Sign:No � Guarantor ' Name: � � Onset Time: ; ' Env Allergies: Med Aflergies:UNKNOWN Current Meds: NKNOWN ' i Medical Need IiC nical; Dispatch Reason(E D): 17D03-FALUNOT ALER7 Provider Impre on:7rauma Injury Mechanism of In� ry:Fall ' Chief Compl int:Fal1 Proto o11:Other Protocol2: Ini Airway: Patent Breathing- Rate:N rmal Quaiity: Unlabored Lung Sounds: Left:Clear Right:Clear Sldn- Color:Normal Temp: Nort'nal Condition:Normal Cap Refill: Edema: Pupils- Left: Rea Right:Reacts � Glasgow Coma Scor -1: E(4)+V(4)+M(6)=14 2: AVPU:Alert � Trauma Score:N/A APt3ARScore: l-mfn: 5-min: 10-min: � ; Rhythm 1: Rhythm 2: : � V s. � '� ; I� BP P�� S O � B•Sugar ��111 I��2 I � 1�14�2 �O'KEEFE 165/100 62 95 � � MICHAE j ' � 3 en ' .Treatment Level Medication ��.$� �AII H93�g AI[ Noable Time PIA O'K�ID E�EF� ALS Assessment N/A M ICHAEL ��q No DALY,FR NK C-Collar,Backboard,Spine 12/1 8/2013 1 1:59 Confidentlal PHI�A 2000-2013 Sans7o•HealthEMS� 12/1 A2013 Ca11M 372A91NetchB 287 of 3 i �... �.. �..- `►/ \„f' Immobilization rr iv Hi `••••'•""SUMMARY" '•'**" 77 YEARS OLD FEM LE CHIEF COMPLAINT: ALL VITALS: � 11:42:29 B/P:165/10 HR:62 RR: SATS:95 B/S: TEMP: TREATMENTS: ALS ASSESSMENT GCOLLAR,BACKBO RD,SPINE IMMOBILIZATION ' � PAST MED HX:[NOT NTERED] ALLERGIES:UNKNO N ' MEDICA710NS:UNK OWN j ' , � ; .....,,«..NARRATIVE. »..,..,, I i : , SAINT PAUL FIRE M DIC 10 ARfiIVED AT THE PATIENT'S SIDE AT 11:34:05 ON DEC 18 2013. ' 1 UPON ARRIVAL PATI NT WAS FOUND TO BE A 77 YEARS OLD FEMALE WITH A CHIEF COMPLAINT OF F lL. � ; � INIT{AL ASSESSME : AIRWAY IS PATENT. REATHING IS NORMAL.BREATHING IS UNLABORED.LUNG SOUNDS CLEAR ON L .LUNG SOU DS + CLEAR ON RIGHT.S IN COLOR IS NORMAL.SKIN TEMP IS NORMAL.SKIN CONDI710N IS NORMAI, PUPI REACTS ON'L FT. ' PUPIL REACTS ON R GHT.MENTAL STATUS(AVPU)IS ALERT.INITIAL GLASGOW COMA SCALE IS 14. i � � PT SLiPPED ON ICE ND HIT HER HEAD.SOME LOC.HAS LAC ON BACK OF HEAD,WAS NOT ABLE TO S E HOW BIG BU ;, APPEARS TO HAVE TOPPED BLEEDING.SLIGHT CONFUSION.FULL GSPINE IN P[.ACE BUT PT WAS M VlNG ALL � � EXTREMITIES. ' � PROVIDER IMPRESS ON OF THE PRESEIVTING PROBLEM IS TRAUMA INJURY. � , MECHANISM OF INJ RY:FALL � THE FOLLOWING INJ RIES ARE NOTED UPON EXAM: INJURY ' THE PATIENT WAS T EATED UNDER THE OTHER PROTOCOL. ! ' THE FOLLOWING TR ATMENTS AND MEDICATIOMS WERE ADMINISTERED: � ALS ASSESSMENT C-COLLAR,BACKBO RD,SPINE IMMOBILfZATION THE PATIEPlT WAS OVED TO THE AMBULANCE BY STRETCHER AND TRANSPORTED IN THE SUPINE P SITION. MRCG CONTACTED ENRO E. � i U�,able to Sian: Unable to Sign Reas n:Injury/Condltion restrlcts abiliry Authorized Represe tive:No Authorized Representative is available Authorized Represe tive Signature: No Secondary Documen ation: linable to obtain secondary documentation ; ' Secondary Documen ation Signature: No Comment: �, � � ' i n i a Privac Notice Si nature �, �� Authorization Sig ature Y g � i t � Receiving RN/ D Signature Technician Signature �� O� � �� 12/18/201311:59 Confidenfial PHI�2000-2013 Sanslo•HeallhEMS� 12/iN2073 Ca!!F 37208 Matcl+Y 287 � 2 ot 3 �,,. *... �,,,, �,.. `, I � i JOAN 1?11&201311:68 OKEEFE 1?!18/201317: Recommended Servi Level: / Dispatch Service Level:WA Agency Definable FI d 1: Agency Definable Field 2: i � i i ; i I . i i � i I � ; , � i � � 1 : I I � I I . ; � k i I ( � i � �, I � � � �. i ! ; � � i i i � 12J18/201311:59 ConHdentlal PHI-0 2000-2013 Sartsb•HealfhEMS� 12/1B/2013 Cell�M 37208 Matchp 287 Of 3 � D�ge 1 of 7 ..� �. �.., �,.� �.. Patient Information Patient Name MRN Sex DOB Drexl, Beverly J 1004949190 Female 7/9/1936 Discharge Summaries signed by Betcher, Leah A, MD at 12124/13 1541 Author: Betcher, Leah A, MD Service: (none) Author Physician Type: Filed: 12/24/131541 Note 12/24/131055 Time: DISCHARGE SUMMARY Patient Name: Beverly J Drexl DOB: 7/9/1936 MRN: 1004949190 Primary MD: TIMOTHY J RUMSEY, MD ADMIT DATE: 12/18/2013 DISCHARGE DATE: 12/24/2013 REASON FOR ADMISSION: traumatic subarachnoid hemorrhage Beverly J Drexl is a 77 y.o. female with a relevant past medical history of HTN, deafness, anxiety, depression, back surgery (1986) who present� to the Emergency Department for evaluation following a fall. PTA, the patient was walking across the street when she slipped on some ice falling backwards. She did hit her head and sustained a laceration. It is unsure as to whether she lost consciousness or not. When EMS arrived, the patient was complaining of neck pain and back pain. She currently denies any nausea, abdominal pain or any other concerns at this time. Patient takes aspirin. She does not take coumadin. See also Admission H&P dated 12/18/2013. BRIEF HOSPITAL COURSE: Patient was admitted to NeurolCU on 12/18/13 after sustaining traumatic fall with head injury, found to have subarachnoid hemorrhage and parenchymal hematoma in front lobe. In the emergency department, patient did have small laceration of posterior head that was closed with staples. Overnight patient required nicardipine drip to keep systolic blood pressure < 140. On day 2 of hospitalization patient had a repeat CT scan which showed hematoma and subarachnoid hemorrhage were stable in size and appearance. She was changed to home blood pressure medications and allowed to eat. Later on 12/19/13 patient became quite combative and delirious. Another CT head was completed which again did not show any changes. She required precedex until midnight of 12/19/13. Delirium was thought likely related to intracranial bleed. Electrolytes remained stable and there was no evidence of infection. Slowly over 12/20 - 12/22 patient's delirium cleared. By 12/23 she was back to baseline per family. On 12/22/13 patient was noted to be hyponatramic likely 2/2 SIADH from subarachnoid hemorrhage. Patient was started on sodium chloride tabs of 3 grams twice daily. Overnight on 12/22/13 she was started on hypertonic saline when sodium decreased from 128 to 126. On morning of 12/23 patienYs sodium was 129. Hypertonic saline was stopped and patient was restarted on sodium tablets. Patient's sodium was stable at 130 on day of discharge and she was discharge to continue salt tablets until reevaluated in clinic. Neurology was consulted during hospitalization on 12/20 for further recommendations regarding head trauma. They followed patient throughout course of hospitalization and did not see need for any further intervention. Patient worked with physical therapy and occupational therapy and with help of PM&R it was determined that patient would require ongoing therapies. Per family request, she was discharged home with home cares to continue ongoing therapies. On day of discharge patient's blood pressure continued to be elevated > 160s. She was started on lisinopril 10 mg for better blood pressure control and will need follow up Electrolytes and creatinine in clinic. DISCHARGE DIAGNOSES: , Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:11:49 AM D�ge 2 of 7 �,, `. . � ... 4. Principal Problem: Subarachnoid hemorrhage Active Problems: Hyperlipidemia HTN (hypertension) Hypothyroid Hyperglycemia, A1 c 6.4 on 7/10/13 Depression with anxiety Bronchitis Delirium Hyponatremia CONDITION ON DISCHARGE: Gen: Relaxed, in NAD. Lungs: Clear bilaterally. Full excursion. Heart: Regular in rate and rhythm. No murmurs. Abdomen: Soft, non-tender. Normoactive bowel sounds. Extremities: No peripheral edema. Sensation intact. Skin: Free of rash, bruising, ulcerations. Neuro: Alert and oriented x 3. Cranial nerves II-XII intact, moving all 4 extremities, equal sensation CONSULTS: -- Neurology -- Neurointensivist -- PM&R PROCEDURES: -- None PERTINENT LABS AND IMAGING: Labs: Recent Labs 12/23/13 12/22/13 0800 0644 �/�/gC 11.0 13.9 H RBC 3.73 L 3.96 L HGB 10.7 L 11.4 L HCT 31.6 L 33.7 MCV 85 85 MCH 28.7 28.8 MCHC 33.9 33.8 PLT 253 258 MPV 9.9 10.4 Recent Labs 12/24/13 12/23/13 12/23/13 0636 1805 0800 SODIUM 130 L 129 L 129 L POTASSIUM 3.9 4.� 3.$ CHLORIDE 98 9$ g9 CO2TOTAL 26 25 24 BUN 13 15 14 CREATININE 0.66 0.71 0.67 Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:11:49 AM ' n�ge 3 of 7 �.,,. �,.� �.., � �.. CALCIUM 8.3 L 8.3 L 8.4 L GLUCOSE 128 H 159 H 139 H HEMOGLOBIN A1C MONITORING (POCT) (% Total Hgb) Date Value 12/19/2013 6.7* 7/10/2013 6.4 2/16/2011 6.2 HEMOGLOBIN A1C SCREENING (% Total Hgb) Date Value 4/10/2013 6.4" TSH (ulU/mL) Date Value 12/19/2013 3.19 Recent Labs 12/23/1 12/23/ 12l23/ 12/22/ 12/22/ 12/22/ 12/22/ 12i21/ 12/21/ 12/21/ 3 13 13 13 13 13 13 13 13 13 2148 1114 0733 2133 1637 1147 0734 2110 1711 1227 GLUC 161 H 139 H 139 H 156 H 143 f-� 151 H 139 H 161 H 190 H 188 H OSEM ETER Ima in : CT cervical spine 12/18/13: CONCLUSION: 1. No acute findings to the cervical spine CT thoracic spine 12/18/13: FINDINGS: Mild degenerative change throughout the thoracic spine. Thoracic spine otherwise negative. No fractures or subluxations. 12/18113 CT head: CONCLUSION: 1. 1.0 cm parenchymal hematoma right fronta! lobe anteriorly and 0.9 cm hematoma right frontal lobe inferiorly. No mass effect. 2. Surrounding mild subarachnoid hemorrhage over the frontal lobes bilaterally. 3. Frontal bone fracture that is nondisplaced. 4. Findings called to Kevin Guenard in the ER 12/19/13 CT head: CONCLUSION: 1. Slight increased prominence of the bifrontal parenchymal contusions, more prominent on the right, with a small amount of associated subarachnoid hemorrhage. 2. Slight increased prominence of the parenchymal contusion in the right planum sphenoidale/right cribriform plate. 3. Stable 4 mm extra-axial hematoma overlying the high right frontoparietal junction. Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:11:49 AM ' "�ge 4 of 7 �... \.. �..� � �.. 4. Stable nondisplaced fracture through the frantal bone, which extends to the sagittal suture. 12/19/13 CT head: CONCLUSION: 1. No change in the bifrontal intraparenchymal hematomas or the small extra-axial hemorrhage over the right frontoparietal convexity comparFd to the head CT earlier 12/19/2013. 2. Again demonstrated is the nondisplaced acute fracture through the midline frontal bone extending to the sagittal suture. This immediately overlies the sagittal sinus. DISCHARGE MEDICATIONS: Current Discharge Medication List STOP taking these medications ASPIRIN 81 MG TAB Comments: Reason for Stopping: ibuprofen (ADVIL; MOTRIN) Comments: 800 mg tablet Reason for Stopping: START taking these medications " Details docusate (COLACE) 100 Take 1 capsule by mouth 2 times daily if needed for mg capsule Constipation. lisinopril (PRINIVIL; Take 1 tablet by mouth once daily. ZESTRIL) 10 mg tablet ondansetron (ZOFRAN) 4 Take 1 tablet by mouth every 6 hours if needed for mg tablet Nausea/Vomiting. traMADoI (ULTRAM) 50 Take 1 tablet by mouth 2 times daily if needed for Pain mg tablet (for headache). CONTINUE these medications which have NOT CHANGED Details acetaminophen Take 1 capsule by mouth every 6 hours if needed. Max (TYLENOL) 500 mg acetaminophen dose: 4000mg in 24 hrs. capsule atenolol (TENORMIN) 25 Take 1 tablet k�y mouth once daily. mg tablet Associated Diagnoses: HTN (hypertension) citalopram (CELEXA) 10 Take 2 tablets by mouth once daily. mg tablet Associated Diagnoses: Depression with anxiety DOCOSAHEXANOIC Take by mouth once daily if needed. ACID/EPA (FISH OIL ORAL) Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:11:49 AM ' n�ge 5 of 7 � � � � � hydrochlorothiazide Take 1 tablet by mouth once daily. (HCTZ) 25 mg tablet Associated Diagnoses: HTN (hypertension) levothyroxine Take 1 tablet by mouth before breakfast. (SYNTHROID) 25 mcg tablet Associated Diagnoses: Hypothyroid loratadine (CLARITIN) 10 Take 1 tablet by mouth once daily. mg tablet Associated Diagnoses: Sinusitis, chronic MULTIVITAMINS WITH Take by mouth once daily. FLUORIDE (MULTI- VITAMIN ORAL) nystatin powder Apply topically to affected area(s) 4 times daily if (NYSTOP) powder needed for Other(Specify). simvastatin (ZOCOR) 20 Take 2 tablets by mouth once daily with evening meal. mg tablet traZODone (DESYREL) 50 Take 0.5 tablets by mouth at bedtime. mg tablet Associated Diagnoses: Depression with anxiety DISCHARGE ORDERS: After Discharge Orders and Instructions Activity per rehab recommendations. Consult to Allina Home Health My clinical findings of balance/coordination deficit, loss of function due to extremity weakness and use of supportive device support that the patient is homebound and in need of the requested services. Services needed are: Physical Therapy. I certify that the patient is homebound because taxing effort to leave home. Diabetic diet: Your body struggles to change carbohydrates into energy. Carbohydrates are milks, fruits, starches (such as bread, cereal, potatoes and pasta); peas and corn; and sweets and desserts. Eat these foods in moderation. Tips for health: - eat balanced meals with fruits, vegetablES, starches, meats and milk products - limit foods high in calories like cake, candy, cookies, pie and regular soda - choose sugar-free beverages - build a plate that is one-half vegetables, one-quarter starch, and one-quarter meat or other protein source - consider fruit for dessert - choose foods that have fiber, such as whole grains - eat healthful fats such as olive oil or canola oil Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:11:49 AM ' � � p�ge6of7 �,,. ��.. �,,, �.. L,.. Follow up appointment(s) Please follow up with UFM early next week by calling 651-241-1000. For your safety: If prescribed, use your cane, walker, or crut�hes as directed. Carry a phone (cordless or cellular) with you at all times in case of an emergency Reduce your chance of falling in your horr�e by: - removing throw rugs - using a night light - clearing the path from your bed to the bathroom. Other activities: Contact the following if you are in need of additional help after you leave the hospital: Allina Care Navigation #612-262-2200 United Way First Call For Help #2-1-1 Senior Linkage Line #1-800-333-2433 Disability Linkage Line #1-866-333-2466 Recommendations for outpatient provider Specific recommendations to be addressed at the follow up visit - 1. Follow up blood pressure (started on lisinopril) 2. Needs staples removed 3. Follow up progress with working with physical therapy and occupational therapy at home 4. Follow up sodium (was started on salt tabs for SIADH), hopefully should be able to d/c soon 5. Follow up creatinine and potassium since starting lisinopril 6. Follow up for any signs of confusion, headache, nausea Reason(s) medications were stopped or changed - NSAIDs and ASA held given recent bleed. Lisinopril 10 mg started for continued elevated blood pressures Sodium tabs twice daily added because of SIADH Anticoagulation/Oxygen Recommendations - None Tests and Studies needed - Phosphorous BMP to check sodium, potassium ,creatinine Patient Weight in the past 120 hrs: 12/24/13 0400, Weight:86.909 kg (191 Ib 9.6 oz) 12/23/13 0300, Weight:85.367 kg (188 Ib 3.2 oz) 12/22/13 0510, Weight:85.775 kg (189 Ib 1.6 oz) 12/21/13 0639, Weight:85.775 kg (189 Ib 1.6 oz) 12/20/13 0500, Weight:82.5 kg (181 Ib 14.1 oz) LEAH A BETCHER, MD When should you be concerned? Your health care provider is: TIMOTHY J RUMSEY, MD Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:11:49 AM � . . n�ge 7 of 7 �.,, �.. �,,.� �... �.. Please call your health care provider if: - if you start to feel very sleepy, worsening headache - if you start to feel confused - you feel you are getting worse or having an increase in problems -fever greater than 101 degrees - increasing shortness of breath - any signs of infection (increasing redness, swelling, tenderness, warmth, change in appearance, or increased drainage) - blood in your urine or stool - coughing or vomiting blood - nausea (upset stomach) and vomiting and/or diarrhea that will not stop - severe pain that is not relieved by medicine, rest or ice Call 911 if you feel you are having a medical emergency. Why were you at the hospital? The reason you were in the hospital you had an intracranial bleed. DISPOSITION: Discharge to Home with Home Care. Time spent on discharge: 30 minutes. Patient seen and discussed with Dr. Balasubrahmanyan Leah Betcher, MD 3:22 PM 12/24/2013 United Family Medicine Resident- G2 Pager 612-510-8033 CC: TIMOTHY J RUMSEY, MD Electronically signed by Betcher, Leah A, MD at 12/24/13 1541 Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:11:49 AM � p�ge 1 of 6 � a.s �, �./ � Patient Information Patient Name MRN Sex DOB Drexl, Beverly J 1004949190 Female 7/9/1936 Discharge Summaries signed by Balasubrahmanyan, Ravi, MD at 12/24/13 1724 Author: Balasubrahmanyan, Service: (none) Author Physician Ravi, MD Type: �iled: 12/24/131724 Note 12/24/131721 Time: DISCHARGE SUMMARY Patient Name: Beverly J Drexl DOB: 7/9/1936 MRN: 1004949190 Primary MD: TIMOTHY J RUMSEY, MD ADMIT DATE: 12/18/2013 DISCHARGE DATE: 12/24/2013 REASON FOR ADMISSION: traumatic subarachnoid hemorrhage Beverly J Drexl is a 77 y.o. female with a relevant past medical history of HTN, deafness, anxiety, depression, back surgery (1986) who presents to the Emergency Department for evaluation following a fall. PTA, the patient was walking across the street when she slipped on some ice falling backwards. She did hit her head and sustained a laceration. It is unsure as to whether she lost consciousness or not. When EMS arrived, the patient was complaining of neck pain and back pain. She currently denies any nausea, abdominal pain or any other concerns at this time. Patient takes aspirin. She does not take coumadin. See also Admission H&P dated 12/18/2013. BRIEF HOSPITAL COURSE: Patient was admitted to NeurolCU on 12/18/13 after sustaining traumatic fall with head injury, found to have subarachnoid hemorrhage and parenchymal hematoma in front lobe. In the emergency department, patient did have small laceration of posterior head that was closed with staples. Overnight patient required nicardipine drip to keep systolic blood pressure < 140. On day 2 of hospitalization patient had a repeat CT scan which showed hematoma and subarachnoid hemorrhage were stable in size and appearance. She was changed to home blood pressure medications and allowed to eat. Later on 12/19/13 patient became quite combative and delirious. Another CT head was completed which again did not show any changes. She required precedex until midnight of 12/19/13. Delirium was thougYit likely related to intracranial bleed. Electrolytes remained stable and there was no evidence of infection. Slowly over 12/20 - 12/22 patient's delirium cleared. By 12/23 she was back to baseline per family. On 12/22/13 patient was noted to be hyponatremic likely 2/2 SIADH from subarachnoid hemorrhage. Patient was started on sodium chloride tabs of 3 grams twice daily. Overnight on 12/22/13 she was started on hypertonic saline when sodium decreased from 128 to 126. On morning of 12/23 patient's sodium was 129. Hypertonic saline was stopped and patient was restarted on sodium tablets. Patient's sodium was stable at 130 on day of discharge and she was discharge to continue salt tablets until reevaluated in clinic. Neurology was consulted during hospitalization on 12/20 for further recommendations regarding head trauma. They followed patient throughout course of hospitalization and did not see need for any further intervention. Patient worked with physical therapy and occupational therapy and with help of PM&R it was determined that patient would require ongoing therapies. Per family request, she was discharged home with home cares to continue ongoing therapies. On day of discharge patient's blood pressure continued to be elevated > 160's. She was started on lisinopril 10 mg for better blood pressure control and will need follow up Electrolytes and creatinine in clinic. DISCHARGE DIAGNOSES: Printed by TAYLG�, ROBERT B [A047102] at 12/30/2013 11:11:56 AM � � n�ge 2 of 6 � � � � � Principal Problem: Subarachnoid hemorrhage Active Problems: Hyperlipidemia HTN (hypertension) Hypothyroid Hyperglycemia, A1 c 6.4 on 7/10/13 Depression with anxiety Bronchitis Delirium Hyponatremia CONDITION ON DISCHARGE: Gen: Relaxed, in NAD. Lungs: Clear bilaterally. Full excursion. Heart: Regular in rate and rhythm. No murmurs. Abdomen: Soft, non-tender. Normoactive bowel sounds. Extremities: No peripheral edema. Sensatior intact. Skin: Free of rash, bruising, ulcerations. Neu�o: Alert and oriented x 3. Cranial nerves II-XII intact, moving all 4 extremities, equal sensation CONSULTS: -- Neurology -- Neurointensivist -- PM&R PROCEDURES: -- None PERTINENT LABS AND IMAGING: Labs: Recent Labs 12/23/13 12/22/13 0800 0644 �/gC 11.0 13.9 H RBC 3.73 L 3.96 L HGB 10.7 L 11.4 L HCT 31.6 L 33.7 MCV 85 �5 MCH 28.7 28.8 MCHC 33�9 3��$ PLT 253 258 MPV 9.9 10.4 Recent Labs 12/24/13 12/23/13 12/23/13 0636 1805 0800 SODIUM 130 L 129 L 129 L POTASSIUM 3.9 4.1 3.8 CHLORIDE 98 98 99 G02TOTAL 26 25 24 BUN 13 15 14 CREATININE 0.66 0.71 0.67 Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:11:56 AM � n�ge 3 of 6 �.. '�..� `- '*i' �..� CALCIUM 8.3 L 8.3 L 8.4 L GLUCOSE 128 H 159 H 139 H HEMOGLOBIN A1C MONlTORING (POCT) (% Total Hgb) Date Value 12/19/2013 6.7* 7/10/2013 6.4 2/16/2011 6.2 HEMOGLOBIN A1C SCREENING (% Total Hgb) Date Value 4/10/2013 6.4" TSH (ulU/mL) Date Value 12/19/2013 3.19 Recent Labs 12/2411 12/23/ 12/23l 12/23/ 12/22/ 12/22/ 12122/ 12/22/ 12/21/ 12/21/ 3 13 13 13 13 13 13 13 13 13 0755 2148 1114 0733 213� 1637 1147 0734 2110 1711 GLUC 148 H 161 H 139 H 139 H 156 H 143 H 151 H 139 H 161 H 190 H OSEM ETER Imagin4: CT cervical spine 12/18/13: CONCLUSION: 1. No acute findings to the cervical spine CT thoracic spine 12/18/13: FINDINGS: Mild degenerative change throughout the thoracic spine. Thoracic spine otherwise negative. No fractures or subluxations. 12/18/13 CT head: CONCLUSION: 1. 1.0 cm parenchymal hematoma right fronta" lobe anteriorly and 0.9 cm hematoma right frontal lobe inferiorly. No mass effect. 2. Surrounding mild subarachnoid hemorrhage over the frontal lobes bilaterally. 3. Frontal bone fracture that is nondisplaced. 4. Findings called to Kevin Guenard in the ER 12/19/13 CT head: CONCLUSION: 1. Slight increased prominence of the bifrontal parenchymal contusions, more prominent on the right, with a small amount of associated subarachnoid hemorrhage. 2. Slight increased prominence of the parenchymal contusion in the right planum sphenoidale/right cribriform plate. 3. Stable 4 mm extra-axial hematoma overlying the high right frontoparietal junction. Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:11:56 AM � "�ge 4 of 6 `,.. .,.. 1�. `�.�- \..r 4. Stable nondisplaced fracture through the fr�ntal bone, which extends to the sagittal suture. 12/19/13 CT head: CONCLUSION: 1. No change in the bifrontal intraparenchymal hematomas or the small extra-axial hemorrhage over the right frontoparietal convexity compared to the head CT earlier 12/19/2013. 2. Again demonstrated is the nondisplaced acute fracture through the midline frontal bone extending to the sagittal suture. This immediately overlies the sagittal sinus. DISCHARGE MEDICATIONS: Cannot display discharge medications since this patient is not currently admitted. DISCHARGE ORDERS: After Discharge Orders and Instructions Activity per rehab recommendations. Consult to Allina Home Health My clinical findings of balance/coordination deficit, loss of function due to extremity weakness and use of supportive device support that the patient is homebound and in need of the requested services. Services needed are: Physical Therapy. I certify that the patient is homebound because taxing effort to leave home. Diabetic diet: Your body struggles to change carbohydrates into energy. Carbohydrates are milks, fruits, starches (such as bread, cereal, potatoes and pasta); peas and corn; and sweets and desserts. Eat these foods in moderation. Tips for health: - eat balanced meals with fruits, vegetables, starches, meats and milk products - limit foods high in calories like cake, candy, cookies, pie and regular soda - choose sugar-free beverages - build a plate that is one-half vegetables, one-quarter starch, and one-quarter meat or other protein source - consider fruit for dessert - choose foods that have fiber, such as whole grains - eat healthful fats such as olive oil or canola oil Follow up appointment(s) Please follow up with UFM early next week by calling 651-241-1000. For your safety: If prescribed, use your cane, walker, or crutches as directed. Carry a phone (cordless or cellular) with yuu at all times in case of an emergency Reduce your chance of falling in your home by: - removing throw rugs - using a night light - clearing the path from your bed to the bathroom. Other activities: Contact the following if you are in need of additional help after you leave the hospital: Allina Care Navigation #612-262-2200 United Way First Call For Help #2-1-1 Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:11:56 AM n�ge 5 of 6 �,,,. �..� �.... �...- �... Senior Linkage Line #1-800-333-2433 Disability Linkage Line #1-566-333-2466 Recommendations for outpatient provider Specific recommendations to be addressed at the follow up visit - 1. Follow up blood pressure (started on lisinopril) 2. Needs staples removed � 3. Follow up progress with working with physical therapy and occupational therapy at home 4. Follow up sodium (was started on salt tabs for SIADH), hopefully should be able to d/c soon 5. Follow up creatinine and potassium since starting lisinopril 6. Follow up for any signs of confusion, headache, nausea Reason(s) medications were stopped or changed - NSAID's and ASA held given recent bleed. Lisinopril 10 mg started for continued elevated blood pressures Sodium tabs twice daily added because of SIADH Anticoagulation/Oxygen Recommendations - None Tests and Studies needed - Phosphorous BMP to check sodium, potassium ,creatinine Patient Weight in the past 120 hrs: 12/24/13 0400, Weight:86.909 kg (191 Ib �.6 oz) 12/23/13 0300, Weight:85.367 kg (188 Ib 3.2 oz) 12/22/13 0510, Weight:85.775 kg (189 Ib 1.6 oz) 12/21/13 0639, Weight:85.775 kg (189 Ib 1.6 oz) 12/20/13 0500, Weight:82.5 kg (181 Ib 14.1 oz) LEAH A BETCHER, MD When should you be concerned? Your health care provider is: TIMOTHY J RUMSEY, MD Please call your health care provider if: - if you start to feel very sleepy, worsening headache - if you start to feel confused - you feel you are getting worse or having an increase in problems -fever greater than 101 degrees - increasing shortness of breath - any signs of infection (increasing redness, swelling, tenderness, warmth, change in appearance, or increased drainage) - blood in your urine or stool - coughing or vomiting blood - nausea (upset stomach) and vomiting and/or diarrhea that will not stop - severe pain that is not relieved by medici�ne, rest or ice Call 911 if you feel you are having a medical emergency. Why were you at the hospital? Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:11:56 AM n�ge 6 of 6 �.,.� .... �.., �... �.-, The reason you were in the hospital you had an intracranial bleed. DISPOSITION: Discharge to Home with Home Care. Time spent on discharge: 30 minutes. Patient seen and discussed with Dr. Balasubrahmanyan Leah Betcher, MD 5:21 PM 12/24/2013 United Family Medicine Resident - G2 Pager 612-510-8033 CC: TIMOTHY J RUMSEY, MD ATTENDING PROGRESS NOTE: I have seen and examined Beverly J Drexl. I have reviewed resident Dr. Betcher's note dated 12/24/2013 and agree with the documented findings and plan of care. Additional comments: Patient feeling much better and neurologically stable. Will discharge today. See Dr.Betcher's discharge summary for details of hospital stay and day of discharge exam. . Ravi Balasubrahmanyan MD 12/24/2013, 5:21 PM 99238 Electronically signed by Balasubrahmanyan, Ravi, MD at 12/24/13 1724 Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:11:56 AM D�ge 1 of 1 �, ...r �,, �.. �. Patient Information Patient Name MRN Sex DOB Drexl, Beverly J 1004949190 Female 7/9/1936 ED Provider Note signed by Hennessey,Thomas Y�l, MD at 12/18/13 1545 Authar: Hennessey, Thomas Service: (none) Author Physician W, MD Type: Fited: 12/18/131545 Note 12/18/131345 Time: Emergencv Department Staff Phvsician Note I had a face to face encounter with this patient seen by the Advanced Practice Provider (APP). I have seen, examined, and discussed the patient with the APP and agree with their assessment and plan of management. Relevant HPI: Beverly J Drexl is a 77 y.o. female here for evaluation after she slipped on a patch of ice and fell to the ground, hitting head. She is unsure if she lost consciousness. This occurred just PTA. She is currently on coumadin. I, Thomas Hennessey, MD attest that Jason Wiederin was acting in a scribe capacity, has observed my performance of the services and has documented them in accordance with my direction. Focused Exam: BP 196/90 � Pulse 88 � Temp(Src) 97.2 °F (36.,2 °C) � Sp02 98% Lethargic but answers questions Perrla No Scalp laceration over occiput The patient was found to have an intra parenchymal/subarachnoid bleed secondary to fall with frontal bone fracture. The patient has a scalp laceration repaired with staples The patient will be admitted to neuro ICU The patient's blood pressure has been acceptable Normal coags Please see APP note for complete detail and admission planning Critical care time spent with the patient 40 minutes Impression / ED plan: Beverly J Drexl is a 77 y.o. female presents to the ED for evaluation after fall. Please refer to the Advanced Practice Providers note for further details and ED course. Agree with history, plan and disposition. Final Diagnostic Impression: ENCOUNTER DIAGNOSES 1. Fall (E888.9) Thomas Hennessey, MD Staff Physician 12/18/2013 UNITED EMERGENCY DEPARTMENT CC: TIMOTHY J RUMSEY, MD Electronically signed by Hennessey, Thamas W, MD at 12/18/13 1545 Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:12:09 AM � n�ge 1 of 6 �.... ..� � �.,, �,,, Patient Information Patient Name MRN Sex DOB Drexl, Beverly J 1004949190 Female 7/9/1936 ED Provider Note signed by Guenard, Kevin Phillip, NP at 12/18/13 1816 Author: Guenard, Kevin Service: (none) Author PHYS- Nurse Practitioner Phillip, NP Type: Filed: 12/18/13 1816 Note 12/18/13 1210 Cosigner: Hennessey, Thomas W, Time: MD at 12/28/13 1011 Chief Complaint: Fall and Back Pain History of Present Illness: HPI I, AuBri Weatherspoon, am serving as a scribe to document services personally perFormed by Kevin Guenard, CNP based on my observation and the provider's statements to me. Beverly J Drexl is a 77 y.o. female with a relevant past medical history of HTN, deafness, anxiety, depression, back surgery (1986)who presents to the Emergency Department for evaluation following a fall. PTA, the patient was walking across the street when she slipped on some ice falling backwards. She did hit her head and sustained a laceration. It is unsure as to whether she lost consciousness or not. When EMS arrived, the patient was complaining of neck pain and back pain. She currently denies any nausea, abdominal pain or any other concerns at this time. Of note, the patient takes aspirin. She does not take coumadin. Primary Care Provider: TIMOTHY J RUMSEY, MD Social History: Non smoker. Does not drink alcohol. Does not use illicit drugs. I, Kevin Guenard, CNP attest that AuBri Weatherspoon is acting in a scribe capacity, has observed my performance of the services and has documented them in accordance with my direction. Allergies: Review of patienYs allergies indicates no known allergies. Medications: The patienYs medications were reviewed at the time of this encounter, please see the EMR for a complete list. Problem List: Depression with anxiety Deafness,R,congenital Anisocoria R>L Hyperlipidemia Varicose Veins,L leg HTN (hypertension) Chronic LBP Hypothyroid Sinusitis, chronic Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:12:15 AM . D�ge 2 of 6 �-- �-- �... � �.. Hyperglycemia,A1c 6.4 on 7/10113 Past Medical History: HTN Hyperlipidemia Bronchitis Disc Deafness,R,congenital 3/29/2010 Anisocoria R>L 3/29/2010 Varicose Veins,L leg 3/29/2010 HTN (hypertension) 3/29/2010 Chronic LBP 3/29/2010 Hypothyroid 3/29/2010 Sinusitis, chronic 3/29/2010 Hyperglycemia,A1 c 6.6 2009 3/29/2010 Past Surgical History: HX BACK SURGERY 1986 HX TAH AND BSO 1985 Family/Social History: Family History Problem Relation Age of Onset • Diabetes Mother • Heart Disease Mother • Other Father copd • Cancer Brother lung • Cancer-breast No Family History Marital Status: Divorced [4] Employment: Retired [5] Occupation: Substance Use: Smoking Status: Never Smoker Smokeless Status: Never Used Alcohol Use: No Review of Systems: Review of Systems HENT: Positive for neck pain. Gastrointestinal: Negative for nausea and abdominal pain. Musculoskeletal: Positive for back pain and falls. All other systems reviewed and are negative. � Physical Exam: First Vitals: Temp: 97.2 °F (36.2 °C) BP: 147/66 mmHg Pulse: 61 Resp: 16 Sp02: 94 % Wt.: 85 kg (187 Ib 6.3 oz) Height: 162.6 cm (5'4") Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:12:15 AM , , T'age 3 of 6 ._.. �-- �- �• � Phvsical Exam Nursing note and vitals reviewed. Constitutional: She is oriented to person, place, and time and well-developed, well-nourished, and in no distress. HENT: Head: Head is without Battle's sign, without abrasion, without contusion, without right periorbital erythema and without left periorbital erythema. Right Ear: Tympanic membrane normal. No hemotympanum. Left Ear: Tympanic membrane normal. No hemotympanum. Mouth/Throat: Oropharynx is clear and moist. Matted blood to occiput. No depression appreciated. Laceration in a star shaped pattern with the longest point being about an inch on occipital head. Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus. Neck: Neck supple. No JVD present. No tracheal deviation present. No thyromegaly present. No c spine tenderness Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop and no friction rub. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes. She has no rales. She exhibits no tenderness. Good expansion of chest. No crepitus. Chest is free of ecchymosis. Abdominal: Soft. Bowel sounds are normal. She exhibits no distension and no mass. There is no tenderness. There is no rebound and no guarding. Abdomen is free of ecchymosis. Musculoskeletal: Normal range of motion. She exhibits no edema and no tenderness. Tenderness around T4-T7. No lumbar tenderness. No pain to coccyx. Moves joints equally. Pelvis is stable. No pain with compresison of femur, tibia, fibula, ankle or feet Neurological: She is alert and oriented to person, place, and time. No cranial nerve deficit. GCS score is 15. Skin: Skin is warm and dry. No rash noted. No erythema. Psychiatric: Affect normal. IMAGING RESULTS (Reviewed and Interpreted): XR Spine Thoracic: Final Result: Mild degenerative change throughout the thoracic spine.Thoracic spine otherwise negative. No fractures or subluxations. I have reviewed the dictated radiology findings. Please see radiology dictation for complete repo�t. CT Head Brain wo: Final Result: 1. 1.0 cm parenchymal hematoma right frontal lobe anteriorly and 0.9 cm hematoma right frontal lobe inferiorly. No mass effect. 2. Surrounding mild subarachnoid hemor�hage over the frontal lobes bilaterally. 3. Frontal bone fracture that is nondisplaced. I have reviewed the dictated radiology findings. Please see radiology dictation for complete report. CT Spine Cervical wo: Final Result: No acute findings to the cervical spine I have reviewed the dictated radiology findings. Please see radiology dictation for complete report. LAB RESULTS (Reviewed and Interpreted): CBC: Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:12:15 AM . . n�ge 4 of 6 �, ,..- �.. '�.. � Recent Labs 12I18/13 1233 BC 14.1 H HGB 12.6 HCT 37.6 MCV 86 MCH 29.0 MCHC 33.5 RDW 14.0 PLT 263 BASIC METABOLIC PANEL: Recent Labs 12/18/13 1233 SODIUM 140 POTASSIUM 3.6 CHLORIDE 100 CO2TOTAL 28 NIONGAP 12 BUiV 25 CREATININE 0.86 GLUCOSE 141 H ALCIUM 9.7 MAGNESIUM 1.8 FR: Recent Labs 12/18/13 1233 GFRAFRICAN >60 GFRNOTAFRICA >60 INR: Recent Labs 12118/13 1233 INR 1.0 PROCEDURES: PROCEDURE: Laceration Repair INDICATIONS: Laceration PROCEDURE Kevin Guenard, NP PROVIDER: SITE: Occipital head TYPE/SIZE: A simple clean 1 cm laceration. FUNCTIONAL Distally/surrounding area sensation and circulation are intact. ASSESSMENT: MEDICATION: Lidocaine 1%with epinephrine. Injecting 4 mis. PREPARATION: Scrubbing with Normal Saline DEBRIDEMENT: no debridement CLOSURE: Wound was closed in one layer. Skin closed with staples. Total number of sutures/st�ples placed: 4 Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:12:15 AM , , "�ge 5 of 6 ,f �.- �.. � �...� INTERVENTIONS: All Medication Administration through 12118/2013 1816 Date/Time Dos Rou Order e te Action 12/18/201 metoclopramide HCI 10 mg 10 Intr Given 3 1644 injection (REGLAN) mg ave nou s 12/18/201 morphine 2 mg injection 0 Intr Held 31230 mg ave nou s 12/18/201 morphine 2 mg injection �2 Intr Given 31346 mg ave nou s 12/18/201 NaCI 0.9%with potassium 50 Intr New Bag 3 1638 chloride 20 mEq infusion mL/ ave hr nou s 12/18/201 ondansetron 4 mg injection 4 Intr Given 31230 (ZOFRAN) mg ave nou s 12/18/201 ondansetron 4 mg injection 4 Intr Given 31346 (ZOFRAN) mg ave nou s 12/18/201 sodium chloride 0.9% 5 mL 5 Intr Given 3 1615 syringe(NORMAL SALINE) mL ave nou s 12/18/201 sodium chloride 0.9% 5 mL 5 Intr Given 3 1756 syringe (NORMAL SALINE) mL ave nou s ED COURSE: 12:10 PM I met with the patient to gather history and to perform my initial exam. We discussed plans for the ED stay including diagnostic tests and treatment. 12:19 PM A CT bed will be unavailable due to another trauma patient so there will be a wait. 12:36 PM I rechecked the patient. 1:25 PM Radiology called to report a bleed on head CT. 1:29 PM I staffed the patient with Dr. Hennessey who agrees with the plan for care. 1:35 PM I spoke to Dr. Rashi, neurointensivist, who will come to the ED to evaluate the patient. 1:49 PM The patient will be moved to a trauma room in the ED. She has been updated on this and the plan for admission. She is comfortable with this plan. 2:03 PM I rechecked the patient. 2:35 PM I rechecked the patient and performed a laceration repair before she is transported upstairs. IMPRESSION AND PLAN: 77-year-old female patient presents emergency department for evaluation after a slip and fall. History of present illness physical exam is most consistent with traumatic head bleed. Patient underwent a CT of her brain without contrast Shirley after arrival in emergency department. Imaging showed a 1.0 cm Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:12:15 AM , � , "age 6 of 6 �.- �-- �.. � �.. parenchymal hematoma in the right frontal lobe anterioriy an appointment centimeter hematoma right frontal lobe inferiorly with no mass effect. There was some surrounding mild subarachnoid hemorrhage. I spoke with Dr. Hennessey and informed of this case. I also paged Dr. Rashi the neurointensive would try to see the patient emergency department. Patient did not have any neurologic abnormalities no focal deficits or other concerning findings. Patient dizziness and nausea was treated with Reglan and Zofran in the emergency department. She was also given morphine for pain. Her blood pressure remained around the target of 140 systolic. CT of the patient's cervical spine was negative for fracture dislocation or subluxation of vertebrae. Thoracic spine x-ray was also negative for fracture. PatienYs laboratory studies were grossly normal. She did have an elevated white count but this is most likely due to stress of trauma. I did repair the burst laceration of the patienYs posterior occiput with staples. Bleeding was controlled prior to her going to the floor. Her tetanus status was updated recently. Patient remained hemodynamically stable and had normal neuro exams during her stay in the emergency department. Patient was admitted to the neurointensive. In stable condition. DIAGNOSIS: 1. Intraparenchymal hematoma of brain due to trauma 2. Fall 3. Nausea 4. Subarachnoid hemorrhage 5. Fracture of frontal bone CC: TIMOTHY J RUMSEY, MD Kevin Guenard, NP 12/18/2013 UNITED EMERGENCY DEPARTMENT Electronically signed by Guenard, Kevin Phillip, NP at 12/18/13 1816 Electronically signed by Hennessey, Thomas W, MD at 12l28113 1011 Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:12:15 AM • • Dage 1 of 5 � � � � � Patient Information Patient Name MRN Sex DOB Drexl, Beverly J 1004949190 Female 7/9/1936 H8�P signed by Reshi, Rwoof A, MD at 12/18/13 2153 Author: Reshi, Rwoof A, MD Service: (none) Author Physician Type: Filed: 12/18/13 2153 Note 12/18/13 1553 Time: Neuro ICU Daily Progress Note Brief History: Beverly J Drexl is a 77 y.o. female with a relevant past medical history of HTN, deafness, anxiety, depression, back surgery (1986) who presents to the Emergency Department for evaluation following a fall. PTA, the patient was walking across the street when she slipped on some ice falling backwards. She did hit her head and sustained a laceration. It is unsure as to whether she lost consciousness or not. When EMS arrived, the patient was complaining of neck pain and back pain. She currently denies any nausea, abdominal pain or any other concerns at this time. Patient takes aspirin. She does not take coumadin. Allergies: Review of patient's allergies indicates no known allergies. Problem List: Depression with anxiety Deafness,R,congen ital Anisocoria R>L Hyperlipidemia Varicose Veins,L leg HTN (hypertension) Chronic LBP Hypothyroid Sinusitis, chronic Hyperglycemia, A1c 6.4 on 7/10/13 Past Surgical History: HX BACK SURGERY 1986 HX TAH AND BSO 1985 Overnight Events. Lines: Line Date Placed Date Removed Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:12:31 AM - • Dage 2 of 5 ..� *�-. �. �..� �.. VitalS: Filed Vitals: 12/18/13 1330 12/18/13 1345 12/18/13 1500 12/18/13 1535 BP: 168/68 158/68 Pulse: 59 57 Temp: 97.5 °F (36.4 °C) 97.6 °F (36.4 °C) Height: 1.626 m (5' 4") Weight: 85 kg (187 Ib 6.3 oz) Sp02: 97% 94% I/O No intake or output data in the 24 hours ending 12/18/13 1552 Meds Current Facility-Administered Medications Medication Dose Route Frequency Provider Last Rate • metoclopramide 10 mg Intravenous one time Guenard, Kevin HCI 10 mg Phillip, NP injection (REGLAN) • sodium chloride 10 mL Intravenous Each Time Guenard, Kevin 0.9% 10 mL PRN Phillip, NP syringe (NORMAL SALINE) • sodium chloride 5 mL Intravenous Each Time Guenard, Kevin 0.9% 5 mL syringe PRN Phillip, NP (NORMAL SALINE) Labs: Recent Labs 12/18/13 1233 WBC 14.1 H RBC 4.35 HGB 12.6 HCT 37.6 MCV 86 MCH 29.0 MCHC 33.5 PLT 263 MPV 10.7 No results found for this basename: PHARTERIAL, PCO2ARTERIAL, P02ARTERIAL, HCO3ARTERIAL, in the last 720 hours No results found for this basename: BASEEXCART, 02SATARTERIA, INSP02ART, in the last 720 hours Recent Labs Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:12:31 AM � • "�ge 3 of 5 � � •� � � 12/18/13 1233 SODIUM 140 POTASSIUM 3.6 CHLORIDE 100 CO2TOTAL 28 BUN 25 CREATININE 0.86 CALCIUM 9.7 GLUCOSE 141 H Recent L.abs 12/18/13 1233 SODIUM 140 P4TASSIUM 3.6 CHLORIDE 100 CO2TOTAL 28 BUN 25 CREATININE 0.86 GLUCOSE 141 H CALCIUM 9.7 No results found for this basename: ALKPHOSPH, PROTEIN, BILITOTAL, AST, ALT, in the last 720 hours Radiological Exam: XR Spine Thoracic: Final Result: Mild degenerative change throughout the thoracic spine. Thoracic spine otherwise negative. No fractures or subluxations. CT Head Brain wo: Final Result: 1. 1.0 cm parenchymal hematoma right frontal lobe anteriorly and 0.9 cm hematoma right frontal lobe inferiorly. No mass effect. 2. Surrounding mild subarachnoid hemorrhage over the frontal lobes bilaterally. 3. Frontal bone fracture that is nondisplaced. CT Spine Cervical wo: Final Result: No acute findings to the cervical spine Exam: Constitutional: She is oriented to person, place, and time and well-developed, well-nourished, and in no distress. HENT: Head: Head is without Battle's sign, without abrasion, without contusion, without right periorbital erythema and without left periorbita� erythema. Right Ear: Tympanic membrane normal. No hemotympanum. Left Ear: Tympanic membrane normal. No hemotympanum. Mouth/Throat: Oropharynx is clear and moist. Matted blood to occiput. No depression appreciated. Laceration in a star shaped pattern with the longest point being about an inch on occipital head. Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus. Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:12:31 AM � - Dage 4 of 5 � � � � � Neck: Neck supple. No JVD present. No tracheal deviation present. No thyromegaly present. No c spine tenderness Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop and no friction rub. No murmur heard. Pulmonary/Chest: Effort normal and breath so�nds normal. No respiratory distress. She has no wheezes. She has no rales. She exhibits no tenderness. Good expansion of chest. No crepitus. Chest is free of ecchymosis. Abdominal: Soft. Bowel sounds are normal. She exhibits no distension and no mass. There is no tenderness. There is no rebound and no guarding. Abdomen is free of ecchymosis. Musculoskeletal: Normal range of motion. She exhibits no edema and no tenderness. Tenderness around T4-T7. No lumbar tenderness. No pain to coccyx. Moves joints equally. Pelvis is stable. No pain with compresison of femur, tibia, fibula, ankle or feet Neurological: She is alert and oriented to person, place, and time. No cranial nerve deficit. GCS score is 15. Motor 5/5 in all extremities. Sensory intact. Skin: Skin is warm and dry. No rash noted. No erythema. Assessment: 77-year-old female patient presents emergency department for evaluation after a slip and fall. History of present illness physical exam is most consistent with traumatic head bleed. Patient underwent a CT of her brain without contrast Shirley after arrival in emergency department. Imaging showed a 1.0 cm parenchymal hematoma in the right frontal lobe anteriorly an appointment centimeter hematoma right frontal lobe inferiorly with no mass effect. There was some surrounding mild subarachnoid hemorrhage. I spoke with Dr. Hennessey and informed of this case. I also paged Dr. Rashi the neurointensive would try to see the patient emergency department. Patient did not have any neurologic abnormalities no focal deficits or other concerning findings. Patient dizziness and nausea was treated with Reglan and Zofran in the emergency department. She was also given morphine for pain. Her blood pressure remain�d around the target of 140 systolic. CT of the patient's cervical spine was negative for fracture dislocation or subluxation of vertebrae. Thoracic spine x-ray was also negative for fracture. Pati�nt's laboratory studies were grossly normal. She did have an elevated white count but this is most likely due to stress of trauma. I did repair the burst laceration of the patient's posterior occiput with staples. Bleeding was controlled prior to her going to the floor. Her tetanus status was updated recently. Patient remained hemodynamically stable and had normal neuro exams during her stay in the emergency department. Patient was admitted to the neurointensive. In stable condition. Plan: NEURO ICH Most likely traumatic. - BP < 140 - CT head at 10 PM. - Hold Aspirin for a week. - If stable by AM can transfer to floor in AM. CVS Hx HTN - Restart home meds. RESP Saturating well on RA GI Regular diet. RENAL Follow renal fn. Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:12:31 AM � - n�ge 5 of 5 �...- �.- ...., \... �..� Monitor lytes ENDO ccuchecks and ISS DERM PROPHY SCD's - DVT PPI's - PPI DISPO ONSULTS Feedin nal esia Sedation hromboembolic ro h laxis Ulcer stress ro h laxis Head of bed elevation GI cemic control Spontaneous breathing rial Bowel re imen Indwelling catheter removal De-escalation of ntibiotics Met with family and plan communicated to th�rri. Total Critical Care time spent: 60 min in Direct Patient Care. Ahmed Reshi, MD Neurocritical Care Cell: 651-338-8424 Page: 612-510-1904 Electronically signed by Reshi, Rwoof A, MD at 12/18/13 2153 Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:12:31 AM � "�ge 1 of 2 .r `--- �.. �-' � Patient Information Patient Name MRN Sex DOB Drexl, Beverly J 1004949190 Female 7/9/1936 Consults signed by Boardman, Peter J, MD at 12/20/13 1605 Author: Boardman, Peter J, Service: (none) Author Physician MD Type: Filed: 12/20/131605 Note 12/20/131539 Time: DATE OF SERVICE: 12/20/2013 Beverly Drexl is a 77-year-old woman seen in neurologic consultation at the request of the neurosurgery service regarding'head trauma. She was admitted to the hospital on December 18, 2013 after she slipped on the ice and hit the back of her head. CT scan showed some small intraparenchymal hemorrhages anteriorly (frontopolar and orbitofrontal) and a little bit of subarachnoid blood. Things have been stable clinically. Unfortunately, she was quite confused and a bit agitated last night. She required Precedex. She did get some benzodiazepines on several occasions yesterday, likely for agitation. She denies any headache now. She is a bit slFepy. She did get up to walk to the bathroom earlier today. PAST MEDICAL HISTORY Hypertension, hyperlipidemia, hearing loss on the right, anisocoria, hypothyroidism, anxiety. FAMILY HISTORY Mother had diabetes and hypertension. Father had COPD. SOCIAL HISTORY She was never a smoker and does not drink alcohol. She is divorced and lives independently. MEDICATION ALLERGIES NONE. REVIEW OF SYSTEMS Other than the above-mentioned symptoms, a complete systems review is negative. MEDICATIONS AT TIME OF ADMISSION 1. Daily aspirin. 2. Atenolol. 3. Citalopram. 4. Fish oil. 5. Hydrochlorothiazide. 6. Ibuprofen. 7. Levothyroxine. 8. Loratadine. 9. Multivitamin. 10. Simvastatin. 11. Trazodone 25 mg q.h.s. A family member is with us at the bedside and says that Beverly takes a Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:12:52 AM ~ n�ge 2 of 2 �..,.- �.. �,, �.�.' �...� sedative for anxiety every day. I do not see any sedating medications on the list, and I suspect she means citalopram. She also reported that Beverly takes something for sleep every night, indicating that she does have some difficulty getting to sleep. I suspect this is the trazodone prescription. PHYSICAL EXAMINATION Blood pressure is 133/62, heart rate 56, temperature 99, respiratory rate 24, oxygen saturation 92%. She is asleep when I come in, but does wake up to voice. She is oriented x3. She can name the president. She had difficulty calculating nickels in a dollar, but could do dimes in a dollar. Cranial nerves are fine. I do not see obvious anisocoria now. There is no carotid bruit. She does have some difficulty hearing. I did not find any focal or lateralized weakness in the extremities, though she gave poor effort initially on the left. Reflexes are normal and symmetric. Finger-nose-finger testing, fine finger movements and rapid alternating movements are okay on both sides. Tone and sensation are fine. Gait testing is deferred. She is not anosmic (reports peppermint smell correctly) ASSESSMENT Traumatic brain injury: She does have some contrecoup injuries on the CT scan. Regarding the confusion, I would avoid benzodiazepines if at all possible. Seroquel is more helpful and causes less confusion. We should continue the trazodone at night for sleep, and I will make sure we have extra doses available if needed. We should have the physical therapist and occupational therapist evaluate her to see how she is doing in terms of discharge destination. If she is not yet independent, she may benefit from a PM&R consult or potentially a transitional care stay. Thank you for letting us participate in her care, and I will follow her up tomorrow. PETER J. BOARDMAN, MD PJ B/ckw D: 12/20/2013 15:34:13 T: 12/20/2013 15:39:17 Voice Job ID: 17653289 Text Job ID: 4427124 cc: UNITED HOSPITAL Allina Health St. Paul, MinnesotaNAME: DREXL, BEVERLY J M R#: 10-04-94-91-90 LOCATION: UTD440 ROOM: 4428 DOB: 07/09/1936 TYPE: IP CONSULTANT: PETER J BOARDMANPage 2 of 2CONSULTATION Electronically signed by Boardman, Peter J, MD at 12/20(13 1605 Printed by TAYLOR, ROBERT B [A047102] at 12/30/2013 11:12:52 AM � �Drexl, Be��---1y J (MR# 10049�'^�90) "�ge 1 of 3 �.. � � � � Results CT HEAD BRAIN WO (Accession A8307446) (Order 506517087) � Comment Original Order Diagnosis *Refer to Results Diagnosis FALL, Review for Normal BACK PAIN Ranges and Result Status CREATININE 0.93 2/11/2013 GFRNOTAFRICA 59 2J11/2013 GFRAFRICAN >60 2/11/2013 Result Information Exam Date and Time Status Reading Physician 12/18/2013 12:59 PM Final CASPERS, JOHN M Reading Provider(s) Caspers, John M, MD PACS Images Show imaqes for CT HEAD BRAIN WO Study Result UTD MEDICAL IMAGING CT HEAD BRAIN WO 12/18/2013 12 : 59 PM INDICATION: Headache after injury. TECHNIQUE: Routine CT head without IV contrast. Thin-section axial imaging with coronal and sagittal reconstruction. COMPARISON: None . FINDINGS: Small amount of intracranial hemorrhage both frontal lobes with a combination of a small parenchymal hematoma right frontal lobe measuring 1 . 0 x 1 . 0 x 1 . 0 cm with adjacent tiny amount of subarachnoid blood over both frontal lobes . Second area of parenchymal hemorrhage along the inferior aspect of the right frontal lobe measures 9 x 9 mm. No mass effect . No infarct . Vertical fracture through the frontal bone extends over the vertex into the suture and inferiorly down towards the sinuses but does not extend to the sinuses . Negative sinuses CONCLUSION: 1 . 1 . 0 cm parenchymal hematoma right frontal lobe anteriorly and 0 . 9 cm hematoma right frontal lobe inferiorly. No mass effect . Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 1 of 3 `Drexl, Be��ly J (MR# 10049�'^t 9p) D3ge 2 of 3 �,., �. �,.,. �.. �.,. 2 . Surrounding mild subarachnoid hemorrhage over the frontal lobes bilaterally. 3 . Frontal bone fracture that is nondisplaced. 4 . Findings called to Kevin Guenard in the ER Hard Copy Result Report Open Hard CopV Result Report(Order#506517087 -CT HEAD BRAIN WO) CT HEAD BRAIN WO (Accession A8307446) (Order 506517087) Image Documentation: Technologist No findings _ _ __ _ _ _ ___ __ Patient Release Status: This result is not viewable by the patient. Order CT HEAD BRAIN WO [70450.0] (Order 506516766) Orderinformation Qate Ordering Authorizing Department 12/18/2013 Graden, Karen J Guenard, Kevin Phillip, NP Utd Station 4920 Provider Information Ordering User Ordering Pro�✓ider Authorizing Provider Graden, Karen J Guenard, Kevin Phillip, NP Guenard, Kevin Phillip, NP Attending Provider(s} Admitting Provider PCP Guenard, Kevin Phillip, NP; Ctr, United Fam Pract Rumsey, Timothy J, MD Hennessey, Thomas W, MD; Ctr, United Fam Pract; Brian, Dana, MD Modify CT HEAD BRAIN WO [70450.0] (Order 506517087) Order Information Date and Time Department 12/18/2013 12:23 PM Utd Station 4920 Frequency Elements and Transpo�tation Info Frequency RAD ONE TIME Quantit Ordering Quantity 1 Order Information Order Date 5ervice Start Date Start Time 12/18/13 Emergency 12/18/13 1217 Order Questions Question Answer Comment Enter reason for exam FALL BACIK PAIN Provider Information Ordering User Ordering Provider Authorizing Provider Graden, Karen J Guenard, Kevin Phillip, NP Guenard, Kevin Phillip, NP Attending Provider(s) Admitting Provider PCP Billing Provider Guenard, Kevin Phillip, Ctr, United Fam Pract Rumsey, Timothy J, MD Caspers, John M, MD NP; Hennessey, Thomas W, MD; Ctr, United Fam Pract; Brian, Dana, MD Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 2 of 3 � 'Drexl, Be��ly J (MR# 10049�'^l 90) "�ge 3 of 3 �,,,, �..� .� �-- L.. Acknowledgement Info For At Acknowledged By Acknowledged On Placing Order 12/18/13 1219 Hanl�y, Joan, RN 12/18/13 1232 Audit Trail Action User Date/Time Order Printed [4] GRADEN, KAREN J [A096264] Wed Dec 18, 2013 1223 CST Order Details Parent Order ID Child Order ID 506516766 506517087 Reason far Exam NO INDICATION REQUIRED [9999] Comments *Refer to Results Review for Normal Ranges and Result Status CREATININE 0. 93 2/11/2013 GFRNOTAFRICA 59 2/11/2013 GFRAFRICAN >60 2/11/2013 Appointments for this Order 12/18/2013 1240 -30 min 1, Utd Mi Ct Ed Utd Medical Imaging (Resource) EMAGEON Information Collection Date CoNection Time 12/18/2013 1314 Priority and Order Detaits Priority Class STAT Normal Specimen Information Collection Date Collection Time 12/18/2013 1314 Lab IDs Specimen # A8307446 Order History Order Date/Time User Action Order ID 12/18/13 1219 Graden, Karen J Current Order 506516766 12/18/13 1219 Guenard, Kevin Phillip, NP Modified from 506515482 Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 3 of 3 ' 'Drexl, Be��ly J (MR# 10049�^l 90) n�ge 1 of 6 �.... � �.., �,.� �.. Results CT HEAD BRAIN WO (Accession A8313146) (Order 506860265) Comment Original Order Diagnosis *Refer to Results Diagnosis Other(neuro change-confusion) Review for Normal Ranges and Result Status CREATININE 0.89 12/1912013 GFRNOTAFRICA >60 12/19/2013 GFRAFRICAN >60 12/19/2013 Result Information Exam Date and Time Status Reading Physician 12/19/2013 4:49 PM Final PASSE, THEODORE J Reading Provider(s) Passe, Theodore J, MD PACS Images Show imaqes for CT HEAD BRAIN WO Study Result UTD MEDICAL IMAGING HEAD CT WITHOUT IV CONTRAST 12/19/2013 4 : 49 PM INDICATION: Traumatic injury. Followup intracranial hemorrhage. TECHNIQUE: Head CT without IV contrast . COMPARISON: 12/19/2013 head CT at 5 : 48 AM and 12/18/2013 head CT 1 : 02 PM. FINDINGS : Again demonstrated are bifrontal (right greater than left) hemorrhagic contusions in both frontal lobes superiorly as well as a hemorrhagic contusion in the inferomedial right frontal lobe along the planum sphenoidale/cribriform plate and also gyrus rectus regions . There is some associated edema with these areas of hemorrhage. Findings are similar to the head CT earlier today with no new hemorrhage identified. Thin acute extra-axial hematoma over the right frontoparietal convexity region measuring 4 mm in maximal thickness, unchanged. Mild generalized cerebral and cerebellar atrophy. Patchy low attenuation in the cerebral white matter most notable in the left parietal region. These findings are stable. Acute but nondisplaced midline fracture through the frontal bone extending superiorly into the sagittal suture, unchanged. Note that this directly overlies the superior sagittal sinus . CONCLUSION: 1 . No change in the bifrontal intraparenchymal hematomas or the small extra-axial hemorrhage over the right frontoparietal convexity compared to the head �T earlier 12/19/2013 . Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 1 of 6 ' 'Drexl, Be�•�-ly J (MR# 10049�^l9p) "age 2 of 6 �,. �,..� � �. �... 2 . Again demonstrated is the nondisplaced acute fracture through the midline frontal bone extending to the sagittal suture. This immediately overlies the sagittal sinus . Hard Copy Result Report Open Hard Co�v Result Report (.Order#506860265 -CT HEAD BRAIN WO) CT HEAD BRAIN WO (Accession A8313146) (Order 506860265) Image Documentation: Technologist No findings _. Patient Release Status: This result is not viewable by the patient. Order CT HEAD BRAIN WO [70450.0] (Order 506858431) Orderinformation Date Ordering Authorizing Department 12/19/2013 Hammell, Amanda L, RN Reshi, Rwoof A, MD Utd Station 4920 Provider information Ordering User Ordering Provider Authorizing Provider Hammell, Amanda L, RN Reshi, Rwoof A, MD Reshi, Rwoof A, MD Attending Provider(s) Admitting Provider PCP Guenard, Kevin Philiip, NP; Ctr, United Fam Pract Rumsey, Timothy J, MD Hennessey, Thomas W, MD; Ctr, United Fam Pract; Brian, Dana, MD Order CT HEAD BRAIN WO [70450.0] (Order 506860265) Order Information Date and Time Department 12/19/2013 4:17 PM Utd Station 4920 Frequency Elements and Transportation Info Frequency RAD ONE TIME Quantity Ordering Quantity 1 Order information Order Date Service Start Date Start Time 12/19/13 Emergency 12/19/13 1609 Order Questions Question Answer Comment Enter reason for exam Other(enter in neuro change-confusion comment field) Provider Information Ordering User Ordering Provider Authorizing Provider Hammell, Amanda L, RN Reshi, Rwoof A, MD Reshi, Rwoof A, MD Attending Provider(s) Rdmitting Provider PCP Billing Provider Guenard, Kevin Phillip, Ctr, United Fam Pract Rumsey, Timothy J, MD Passe, Theodore J, MD NP; Hennessey, Thomas W, MD; Ctr, United Fam Pract; Brian, Dana, MD Verbal Order 8� CoSi n Info Responsible Action Order Mode Communicator Comment Provider Signed By Signed On Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 2 of 6 ' �Drexl, Be��°Yly J (MR# 10049�"190) "age 3 of 6 �..,, �... �„r., �+.i �„f Ordering VORB/ Hammell, Reshi, Rwoof TORB Amanda L, A, MD RN Acknowledgement Info For At Acknowledged By Acknowledged On Placing Order 12/19/13 1609 Hammell, Amanda L, RN 12/19/13 1609 Audit Trail Action User Date/Time Order Printed [4] GRADEN, KAREN J [A096264] Thu Dec 19, 2013 1617 CST Order Details Parent Order ID Child �rder ID 506858431 506860265 Comments *Refer to Results Review for Normal Ranges and Result Status CREATININE 0. 89 12/19/2013 GFRNOTAFRICA >60 12/19/2013 GFRAFRICAN >60 12/19/2013 Appointments for this Order 12/19/2013 1630 -30 min 2, Utd Mi Ct Rm Utd Medical Imaging (Resource) EMAGEON Information Collection Date Collection Time 12/19/2013 1651 Priority and Order Details Priority Class STAT Normai Specimen Information Collection Qate Collection Time 12/19/2013 1651 Lab IDs Specimen # A8313146 Results CT HEA9 BRAIN WO(Accession A8309598) (Order 506664821) Comment Original Order Diagnosis *Refer to Results Diagnosis Other Review for Normal Ranges and Result Status CREATININE 0.86 12/18/2013 GFRNOTAFRICA >60 12/18/2013 GFRAFRICAN >60 12/18/2013 Result Information Exam Date and Time Status Reading Physician 12/19/2013 0552 Final MAY, BENJAMIN J Reading Provider(s) May, Benjamin J, MD Drexl, Beverly J (MR# 1004949190) Printed by i aylor, Robert B, HUC [A047102] at 12... Page 3 of 6 ' `Drexl, Be��ly J (MR# 10049�'^l90) "age 4 of 6 `.. `*s � �-' � PACS Images Show images for CT HEAD BRAIN WO Study Result UNITED MEDICAL IMAGING CT HEAD BRAIN WO 12/19/2013 5 : 52 AM INDICATION: Head laceration. Head pain. Follow-up posttraumatic intracranial hemorrhage. TECHNIQUE: Routine CT head without IV contrast . Thin-section axial imaging with coronal and sagittal reconstruction. COMPARISON: 12/18/2013 . FINDINGS : Slightly increased prominence of the bifrontal parenchymal contusions, more prominent on the right . Associated low-density changes compatible with edema. Slight interval increase in size of the parenchymal contusion along the right planum sphenoidale/right cribriform plate with associated vasogenic edema. There is a thin 4 mm extra-axial hematoma overlying the right parasagittal frontoparietal junction. This appears similar allowing for differences in technique. Stable linear nondisplaced fracture through the midline frontal bone, which extends to the sagittal suture . CONCLUSION: 1 . Slight increased prominence of the bifrontal parenchymal contusions, more prominent on the right, with a small amount of associated subarachnoid hemorrhage. 2 . Slight increased prominence of the parenchymal contusion in the right planum sphenoidale/right cribriform plate . 3 . Stable 4 mm extra-axial hematoma overlying the high right frontoparietal junction. 4 . Stable nondisplaced fracture through the frontal bone, which extends to the sagittal suture. Result History CT HEAD BRAIN WO (Order#506664821) on 12/19/13 -Order Result History Report. Hard Copy Result Report Open Hard Co�y Result Report,�Order#506664821 -CT HEAD BRAIN WO) CT HEAD BRAIN WO (Accession A8309598) (Order 506664821) Image Documentation: Technologist No findings - Patient Release Status: This result is not viewable by the patient. Order CT HEAD BRAIN WO [70450.0] (Order 506586316) Orderinformation Date Ordering/Authorizing Department 12/18/2013 Reshi, Rwoof A, MD Utd Station 4920 Provider Information Drexl, Beverly J (MR# 1004949190) Printed by "1'aylor, Robert B, HUC [A047102] at 12... Page 4 of 6 � -Drexl, Be��rly J (MR# 10049�^l 90) "�ge 5 of 6 \.. `•-� .� �+-' \..f Ordering User Ordering Provider Authorizing Provider Reshi, Rwoof A, MD Reshi, Rwoof A, MD Reshi, Rwoof A, MD Attending Provider(s) Admitting Provider PCP Guenard, Kevin Phiilip, NP; Ctr, United Fam Pract Rumsey, Timothy J, MD Hennessey, Thomas W, MD; Ctr, United Fam Pract; Brian, Dana, MD Order CT HEAD BRAIN WO [70450.0] (Order 506664821) Order Information Date and Time Department 12/19/2013 4:49 AM Utd Station 4920 Frequency Elements and Transportation Info Frequency RAD TOMORROW AM Quantity Ordering Quantity 1 Order Information Order Date Service Start Date Start Time 12/19/13 Emergency 12/19/13 0600 Order Questions Question Answer Comment Enter reason for exam Other(enter in comment field) Provider Information Ordering User Ordering Provider Authorizing Provider Reshi, Rwoof A, MD Reshi, Rwoof A, MD Reshi, Rwoof A, MD Attendinq Provider(s) Admittinq Provider PCP Billing Provider Guenard, Kevin Phillip, Ctr, United Fam Pract Rumsey, Timothy J, MD May, Benjamin J, MD NP; Hennessey, Thomas W, MD; Ctr, United Fam Pract; Brian, Dana, MD Acknowledgement Info For At Acknowledged By Acknowledged On Piacing Order 12/18/13 1550 Kasperovich, Tatyana O, RN 12/18/13 1614 Audit Trail Action User Date/Time Order Printed [4] BACKER, JESSILYN R [A032490] Thu Dec 19, 2013 0449 CST Order Details _ Parent Order IQ Child �rder ID 506586316 506664821 Comments *Refer to Results Review for Normal Ranges and Result Status CREATININE 0.86 12/18/2013 GFRNOTAFRICA >60 12/18/2013 GFRAFRICAN >60 12/18/2013 Appointments for this Order 12/19/2013 0450 - 30 min 1, Utd Mi Ct Ed Utd Medical Imaging (Resource) EMAGEON Information Collection Date Collection Time Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 5 of 6 � � -Drexl, Be��°rly J (MR# 10049�"^190) page 6 of 6 �.,. �..r �,.. `+-� `,, 12/19/2013 0606 Priority and Order Details Priority Class Routine Normal Specimen Information Collection Date Collection Time 12/19/2013 0606 Lab IDs Specimen # A8309598 Drexl, Beverly J (MR# 1004949190) Printed by Taylor, Robert B, HUC [A047102] at 12... Page 6 of 6 FN►nww o�oor�ca�w w�oureaaw Emergency Care Consultants 8 Oak Park Drive �►� ❑��o� Doiecore�� o�,.�- Bedford,MA 01730 ADDRESS SERVICE REQUESTED ��'� STAT�MENT DATE PAY THIS AMOIIIVT' ACCt3UNT NO. For xll billing qaestions,caU• 866-951-6774 12I30/2013 $1151.00 281 2078040 OtY[ce Hoan:Monday-Thttt�sday 8am to 9pm PAYMENT DUE WITHtI�I 30 DAYS SHOW AMOUNT@ Friday 8am to 8pm PAID HERE `p Tu ID:41-17Z2554 Or vlsit onr web site xt w�n►.doctorpayment�.com �� MAKE CHECKS PAYABLE TO: � '��I��'��'�'1'�'�i��lll��l��'��I�I�I�1�'��I'��I�II'��I" �10 Ea�ergency Care Consultants � ..��,. BEVERLY J DREXL PO BOX 86 . 536 SUPERIOR ST APT 1 LOCK BOX 12-0910 SAINT PAUL MN 55102-2854 MINNEAPOLIS, MN 55486-0086 I�I.I��I�I��I��II��I��II��II��II��I��I��II��I�.I��II��I��II ❑ Please check box'rf tlie abave address is incorrect or your insurance , PLEASE DETACH AND RETURN TOP PORTION WITH ir�ormation has changed,and indicate change(sj on reverse side. YOUR PAYMENT IN ENCLOSED ENVELOPE -"""PATILIvT NAMG �"` -� - ��--- — PATI •L'titT NLJM�GCc YOtIR PRf1YiD�R Beverly J Drexl 2078040 *z default DATG GP7' DGSCRIPTION CHARGGS P^�� NGT DUC AD3tiST1�[EN7S Provider: GUENARD, KEVIN P Voucher: 5429370 Diagnosis: 800.20 12/18/2013 99291 CRITICRL CARE 1 HR 820.00 820.00 Provider: HENNESSEY, THOMAS W Voucher: 5429360 Diagnosis; 873.0 12/18/2013 12001 SIMPLE SUTURE 2.5CM SCA 331:00 331.00 Please v'isit W�VW.doctorpayments.COM for a more convenierrt and secure way to provide us with your Health Insurance Information, Motor Vehicle Accident i�fOmtetio►1,woMcers Compensation insurance infortnation and to pay by Cradit Card. Or see reverse side to compiete and mail in. www.doctorpayments.oom Total Amount Due � $ i151.00 THIS SEPARATE BILL IS FOR TF�II�IERGENCY PHYSIGIAN AT ABBOTT �ce Hours:Monday-Thutsday 8am to 9pm NW/[TNTTED HOSPTTAL Friday 8am to 8pm For sIl billing qnest3ons,call:866-951-6774 Tu ID:41-1?22554 STATEMENT �►ccountNamber.281-2o78oao I��„ SEE REVERSE SIDE FOR IMPORTANT BIL�ING tNFORMATiON ��o �� _ _ Allirra Health �ci,�o n� Save a Stamp! Pay your bill ontine. ��I�� Minneapolis,MN 55407-1321 ; Billing Questio�? Please call us at(612)262-9000 or(800)868-6077 Pay Your Bill Online: Monaay-Thursday sam to 4:3opm.Friday 9am-4:3opn ��.�:°'Just go to allinahealth.org/paYbill 1� ACCOUNT IVUMEER : DATE DS1E 3 PAY THIS AMOUNT � AMOUNT PAID Ple�se cfieck box if address belav is incorrect a if your € ❑��u��s)«,y��. 101135732 Upon Receipt � 539,114.44 �� ., r � � ! _ _ _ � mdlinnq�i...�u�...�y.yu��ii�i��..�..i.fy��i..�l�id�h �I.�....ql��.n..i��.�n....�i.lilluhhq••N�ullrlry•�,� g BEVERLY J DREXL ALUNA HEALTH o � 536 SUPERIOR ST APT 1 PO BOX 77003 � SAINT PAUL MN 55102-2854 MINNEAPOLIS, MN 55480 N . .. .. _ . .. .. .. . .. . ._ . . . . • . myEasyMatch Code:P-TMDSN-1236�WGRWC2D Thank ycu for chooaing Allfna HeaHh ��^OUIV"°NU�'��:� �:�P�}PlSIBLE PA��Y��,�7� S'�r°,�`��{.�F�°t1��'� �`��;�'�`4�W 3 �U114BER 101135732 BEVERLY J DREXL 12l31/13 43806139 PATIENT NAME ATTENDING PHYSICiAN LOC�►TION BEVERIY J DREXL UNiTED HOSPITAL ACCOUNT CLASS TOTAL CHARGES SERVICE DATE FROM SERVICE DATE TO INPATIENT 539,114.44 12R8/13 CHARGES ..� _ : <_ Datie Cost Ctr. Rev.Code Proc.Code Description �t�l Amount 12t28/2013 : U7330 0271 520054 HCHG SLING PR60 1 $221.00 12/282013 U7800 0250 700000 POTASSIUM CHLORIDE 106 M 5 $254•50 12/282013 U7330 0272 515330 HCHG TUBING PR1 1 $4.40 12/28/2013 U7660 0320 707400010 RAD XR ABDOMEN SINGLE AP ; ��.� 12/28/2013 U7330 0272 515330 HCHG TUBING PR1 12/28i2013 U7800 025� 700000 MAGNESIUM SULFATE 4 GRAM 8 �8•� 12R812013 U7800 0250 700000 POTASSIUM CHLORIDE 106 M 3 �•`�•� 1228/2013 U7800 0250 700001 FAMOTIDINE 20 MG/2 ML SO '1 $52•80 1?128/2013 U7800 0250 700000 POTASSIUM CHLORIDE 106 M 5 �`�•� 12/28/2013 U7800 0250 700008 INSULIN ASPART 100 UNIT/ 1 $59.20 12/28/�U13 117800 _ 0250 700000 POTA8SIUM CHLORIDE 106 M 5 ��•� 12/282013 U7800 _ _ 0258- - 700004- -- NACL 3°�6(l�l(PERTONIC)IV � _._ _ �_. ,__��,-- 12/28/2013 U7800 0250 70�000 POTASSIUM CHLORIDE 106 M 5 ��•� 12/28/2013 U7070 0761 111048 HCHG INSERT PICC WO SUBC 1 $3,288.20 12/28/2013 U7330 0272 515749 HCHG DRSG PR5 1 $25.20 12/282013 U7330 0271 513966 HCHG CNNCTR PR1 2 $4•2� 12/28/2013 U7330 0272 516033 HCHG CATH INFUSION PR210 1 $817.70 12/28fL013 U7800 0250 700000 POTASSIUM CHLORiDE 106 M 5 �`�•� 12282013 U7800 0250 700001 SODIUM CHLORIDE 0.9%0.9 1 �.� 12282013 U7720 0351 707045000 RAD CT HEAD BRAIN Wi0 1?J28/2013 U7770 0730 110760 HCHG EKG 12LEAD TRACING ; �� 12/282013 U7800 0250 700000 NACL 0.9°�6 0.9 961,000 M 1 �.� 1228R013 U7330 0272 515330 HCHG TUBING PR1 12282013 U7660 032(2 707101010 RAD XR CHEST FRONTAL 1 V 1 a386.10 . . � .!� _ .., , �'�� . , E, � ;39,114.44 stateme�Message. oornenienoe are __ __._. . For , Thank yau fur�ng Allina Headth your Y� able tio make paymerrts online or over the phone at no cost to Please go to allir�ahee�Ith.org/paYbill to pay online or oorrtact us a� number above to make a payment over tfie Phone. If you�e unable to pay your biil in full in one payment, please contact us at the number below tor additional paYmerrt options. • � Account Summary ai�a�ann !'V'�1 �G�a��1 1 MinS�,MN 55407-1321 Aa�unt Number Statement Number Patierrt Name _ . ,._.�.__��.__ _ , - �:�BEVERLY J� 101135732 43806139 DREXL s ' Billing Qusstio�? . Ptesse cail us at(612)Z62-9000 or(800)859-6077 Date Page Number Total Balance ��_• ' Monday Thursday 8am bo 4:30pm,Friday 9am-4:30pm _ ,___. _._. . __.. __ _.�._.__. __.___; 12/31/13 2 ; See First Page ` CHARGES : Dabe ' ,:. Cost Ctr. Rev.Code Proc.Code Description Qty : Amount 1228/2013 U7800 0250 700000 LEVETIRACETAM 500 MG/5 M 75 $96.20 12/28/2013 U7800 0258 700004 DSVV 100 ML BAG 1 $45.75 1228/2013 U7800 0250 700000 LORAZEPAM 2 MG/AAL 1 ML S 1 $130.10 12282013 U6122 0272 514286 PATCHES QUADTRODE E.C.B. 1 $23-94 1228l2013 U7730 0610 707054400 RAD MR ANGIO HEAD Wi0 1 $2,171:,40 12/282013 U7730 0611 707055150 RAD MR HEAD SRAIN WO 1 $1,633.90 1228/2013 U7330 0272 517252 HCHG INSTRUMENT DISP PR4 1 $1,530.20 12J28/2013 U7330 0272 511790 HCHG KIT PRESSURE MONITO 1 $49.10 1?129/2013 U7330 0272 519588 HCHG TUBE PR5 � �8•� 12R92013 U7330 0271 519231 HCHG KIT INFUSION PR5 1 $28.80 12R9/2013 U7330 0272 512336 HCHG KIT BLD GAS DRY HEP 1 $3.80 12/29/2013 U7330 0272 512336 HCHG KIT BLD GAS DRY HEP 1 $3.80 12128/2013 U7800 0250 700000 NACL 0.8°�500 ML FLEX CO 1 $43.70 12282013 U6640 0200 100029 HCHG INTENSIVE CARE � $�� 12J28/2013 U6301 0305 17006180 HCHG CBC VWDtFF 1 $136.40 12/282013 U6301 0305 17006600 HCHG PROTHOMBIN TIME � �9•� 12/28/2013 U6301 0305 1700f675 HCHG ACTIVATED PTT 1 $56.40 12J282013 U6301 0301 17003765 HCHG MAGNESIUM BLOOD � $19•`w 12/282013 U6301 0301 17003710 � HCHG LIPASE � �8•20 12/28i2013 U6301 0305 17020384 HCHG COLLAGEN/EPI 1 $244.80 12/2812013 U6301 0305 17020385 HCHG COLLAGEN/ADP 1 a244.80 12/282013 U6301 0301 17100064 HCHG TROPONIN I 1 $41.10 1228/2013 U6301 0307 17005760 HCHG URINALYSIS COMPLETE � �•� 12/282013 U6301 0301 17004460 HCHG SODIUM 1 $19.40 12I28/2013 U6301 0301 17004635 HCHG TSH � ��•� 12/28/2013 U6301 0301 17004460 HCHG SODIUM 1 $19.40 12/28/2013 U6301 0301 17003945 HCHG OSMOLALITY,URINE � �2•� 1228/2013 U6301 0301 17003940 HCHG OSMOLALITY,SERUM 1 $42.30 12/282013 U6301 0301 17004795 HCHG URIC ACID 1 $19.40 12282013 U6301 0301 17004460 HCHG SODIUM 1 $19.40 12/28I2D13 ll63(11 -_-_03�1-_ _ - _._�ZQL11365__=_._�iCHCz�QMPRENENSIVE:�AET�B --- - - 1-- -__.- __._$9-89,80 . 12R8/2013 U7770 0761 110827 HCHG ARTERIAL PUNCTURE 1 $��•'� 1?J292013 U7800 0250 700000 LEVET'IRACETAM 500 MG/5 M 50 $81.15 1229/2013 U7800 0258 700004 D5W 100 ML BAG 1 $45.75 12R9/2013 U7800 0250 700001 SODIUM CHLORIDE 0.996 0.9 1 329.30 12/292013 U7800 0250 700001 SODIUM CHLOR�DE 0.9%0.9 1 �8•� 12/29/2013 U7800 0258 700004 NACL 0.9%WITH POTASSIUM 1 $48.80 1229/2013 U7330 0271 512039 HCHG SLEEVE KNEE PR 10 1 $66.20 1229l2013 U7800 0250 700000 POTASSIUM CHLORIDE 20 ME �� 7•80 1?J29/2013 U7800 0250 700000 POTASSIUM CHLORIDE 20 ME 10 $97.80 1229I2013 U7800 0250 700001 FAMOTIDINE 20 MGR ML SO 1 $52.80 1229/2013 U7680 0921 709388600 RAD US TRANSCRAN(AL DOPP 1 3640.10 12/29/2013 U7800 025Q 700000 NACL 0.9% 0.9 961,000 M 1 $45.40 1229�2013 U7800 0250 700030 ACETAMINOPHEN 325 MG TAB 2 $26.10 1229/2013 U7800 0250 700030 SENNOSIDES-DOCUSATE(8.6 2 $26.45 12/29/2013 U7800 0250 700030 LEVOTHYROXINE 25 MCG TAB 1 ��•� 12l29/2013 U7800 0250 700000 LEVET�RACEfAM 500 MG/5 M 50 $81.15 1229/2013 U7800 0258 7000Q4 D5VN 100 ML BAG 1 $45.75 12292013 U7800 0250 700030 CITALOPRAM 20 MG TAB 1 $21.20 12l29/2013 U7422 0420 110240 HCHG PT EVALUATION INITI 1 $191.80 • � Account Summary arma r�a, �I��I�� M'�mn ahpobs,MN 55a07-1321 Accourrt Number Statement Number Patiertit Name __ _ _ _ . . ..,._ ..: __- __ 101135732 43806139 B�RLY J Billing Questions? ! DREXL , Please call us at(612)262-.9000 or(800)859�6077 Date Page Number Total Balance Monday-Thursday 8am tio 4:30pm�Friday 8am-4:30pm . _ � .,.._.__ __ . ._ . _ . 12/31/13 3 See First Page CHARGES . pate . �,< Cast Ctr. : Rev.Code Proc.Code Description Qty Amount 12/29/2013 U7424 0440 110342 HCHG SLP ADULT EVAL COMM 1 $340.00 12/29/2013 U7424 0440 110341 HCHG SLP EVAL ORAUPHAR 1 $340.00 12129/2013 U7800 0250 700001 SODIUM CHLORIDE 0.9%0.9 1 $28.65 12/29/2013 U7800 0250 700030 SIMVASTATIN 20 MG TAB 2 $21.65 12/29/2013 U7800 0250 700001 FAMOTIDfNE 20 MG2 ML SO - 1 - $52.80 12/28l2013 U6301 0301 17002580 HCHG ISTAT CREATININE 1 $73.60 12128/2013 U6301 0301 17002940 HCHG ISTAT 3/GASES 1 $40.OU 12/28J2013 U6301 0301 17004495 HCHG SODIUM,URINE 1 $21.70 12J29/2013 U7800 0250 700000 NACL 0.9% 0.9°�6 1,000 M 1 $45.40 1229/2013 U7800 0250 700030 SODIUM CHLORIDE 1 GRAM T 2 $26.45 1229/2013 U7800 0258 700004 NACL 3%(HYPERTONIC)IV � $45•40 1229R013 U6640 0200 100029 HCHG INTENSIVE CARE 1 $�,��-� 1229/2013 U6301 0301 17004185 HCHG POTASSIUM 1 $19.40 1?J292013 U6301 0301 17003765 HCHG MAGNESIUM BLOOD 1 $19.40 12/29/2013 U6301 0301 17004460 HCHG SODIUM 1 $19.40 12292013 U6301 0301 17004460 HCHG SODIUM 1 $19.40 12/29�2013 U6301 0301 17004460 HCHG SODIUM 1 $19.40 1?J29/2013 U6301 0301 17004185 HCHG POTASSIUM 1 $19.40 12/29/2013 U6301 0301 17004460 HCHG SODIUM 1 $19.40 12/292013 U6301 0301 17004460 HCHG SODIUM � $19•� 12/29R013 U6301 0301 17004460 HCHG SODIUM 1 $19.40 12/30/2013 U7800 0250 700000 LEVETIRACETAM 500 MG/5 M 50 $81.15 12/3012013 U7800 0258 700004 D5W 100 ML BAG 1 $45.75 12/30/2013 U7800 0250 700001 SODIUM CHLORIDE 0.9%0.9 1 $Z8•g5 12/30/2013 U7800 0250 700001 FAMOTIDINE 20 MG2 ML SO 1 $52.80 12/3012013 U7800 0250 700030 SENNOSIDES-DOCUSATE(8.6 2 $26.45 1?J30/2013 U7800 0250 700030 SODIUM CH�ORIDE 1 GRAM T 2 $26.45 12/30/2013 U7800 0250 700030 LEVOTHYROXINE 25 MCG TAB 1 $21•60 12/30i'2013 U7800 0250 700030 CtTALOPRAM 20 MG TAB 1 $21.20 12/30/2013 U7800 0250 700000 MAGNESIUM SULFATE 4 GRAM 8 $58•$5 12/30/2013 U7472 0420 110271 HCHG PT THERAPEUTIC ACTI 3 $305J0 12/30R013 U7800 0250 700000 LEVETIRACEfAM 500 MG/5 M 50 $81.15 12/302013 U7800 0258 700004 D5W 100 ML BAG � �t5•75 12/30l2013 U7800 0250 700001 SODIUM CHLORIDE 0.9%0.9 1 $28.65 1?J30/2013 U7800 0250 700001 SODIUM CHLORIDE 0.9%0.9 � �9-� 12/30R013 U7423 0430 110300 HCHG OT EVALUATION INITI 1 $186.20 12/302013 U7800 0250 700000 MAGNESIUM SULFATE 4 GRAM 8 �8•85 12/302013 U7800 0250 700030 SIMVASTATIN 20 MG TAB 2 $21.85 12/29/2013 U6301 0301 17004255 HCHG PROLACTIN 1 $31.70 12/30/2013 U7800 0250 700030 FAMOTIDINE 20 MG TAB 1 $26.15 12/302013 U7800 0250 700030 SODIUM CHLORIDE 1 GRAM T 2 $26•4� 12/30/2013 U7800 0250 700001 SODIUM CHLORIDE 0.9%0.9 1 $29.30 12/30/2013 U6250 0120 100024 HCHG MED/SURG/OB ROOM � ��•� 12/30/2013 U6250 0230 100037 HCHG TELEMETRY ANC LEV 3 1 $1,510.00 12l302013 U6301 0301 17003765 HCHG MAGNESIUM BLOOD 1 $19.40 12/30/2013 U6301 0305 17006180 HCHG CBC W/DIFF 1 $136.40 12/30/2013 U6301 0301 17004085 HCHG ALK PHOSPHATASE 1 $19.40 12/302013 U6301 0301 17004460 HCHG SODIUM 1 $19.40 12/30/2013 U6301 0301 17004460 HCHG SODIUM 1 $19.40 12/302013 U6301 0301 17003765 HCHG MAGNESIUM BLOOD 1 $19.40 • � - Account Summary �� /��' r1' (., 2925 Chicago Avenue 1111�1 1G�a'�� 1 Nunr�eapoiis,MN 55407-1321 Accourrt Number Statemerrt Number Patier�t Name r. ...�. .. _ ._ . _._ __ � � . BEVERLY J _ 101135732 43806139 DREXL Billing Questions? ---- - - - Please call us at(612)262-9000 a(800)859-6077 Date Page Number Total Balance ��• Monday-Thursday 8am tio 4:30pm,Friday 9arn-4:30pm ;:.. u. ;=: __ M..._.. __�_ _.__ - 12/31/13 4 See First Page CHARGES `Date. '.:. C�t Ctr. Rev.Code Proc.Code Description QEy Amourrt 12/30/2013 U630t 0301 17004855 HCHG BASIC METABOIIC PAN 1 $108.50 12/312013 U7800 0250 700000 LEVETIRACETAM 500 MG/5 M 50 $8�-15 12/31/2013 U7800 0258 700004 D5W 100 ML BAG 1 $45.75 12/31/2013 U7800 0250 700001 SODIUM CHLORIDE 0.9°r6 0.9 1 $29.30 _ 12l3Yi2013 U7$00 -0238 ; - 700001-- LABETALOL 20 MG/4 ML(5-- - 1 $60•75 12/31/2013 U7800 0250 700001 SODIUM CHLORIDE 0.9%0.9 2 $30.60 12/31/2013 U7330 0272 515330 HCHG TUBING PR1 1 �•'� 12/31/2013 U7800 0250 700001 SODIUM CHLORIDE 0.9°r6 0.9 1 $29.30 12/31/2013 U7800 0250 700001 SODIUM CHLORIDE 0.9%0.9 1 $28.65 TOTAL PROFESSIONAL CHARGES s38,114.44 PAYMENTS ;�;.,� . .,: Amount ,,::t�:-�, Description Professionai Paymerrts TOTAL PROFESSIONAL PAYMENTS ADJUSTMENTS p� . _ Description . Amount TOTAL PROFESSIONAL ADJUSTMENTS OTAL BALANCES 539,114.44