10/24/2024 Continuity of Care Document

NIELSON, SARAH ELOIZA Admin Sex: Female DOB: 12/6/1998

Continuity of Care Document

Summarization of Episode Note | -- to 10/24/2024
Source: --
Created: 10/24/2024

Demographics

Contact Information:
APT 14 1960 NORTH CANYON ROAD PROVO, UT 846041666, USA
APT 14 1960 NORTH CANYON ROAD PROVO, UT 846041666, USA
Tel: (385)384-6375
Tel: (385)306-8725
Tel: (385)306-8725
Mail: [email protected]
Mail: [email protected]
Mail: [email protected]
Marital Status: Single
Religion: Church of Jesus Christ/Latter-Day Saints
Race: White
Previous Name(s):
NIELSON, SARAH ELOIZA
NIELSON, BABY MONICA
NIELSON, GIRL MONICA
NIELSON, SARAH EJOIZA
NIELSON, SARAH E
NIELSON, SARAH
NIELSON, SARAH
Ethnic Group: Not Hispanic or Latino
Language: English
SSN: ###-##-1449
ID: URN:CERNER:IDENTITY-FEDERATION:REALM:A455F55A-F11C-4091-B40C-17E4525661F7:PRINCIPAL:SARAHNIELSONN6, 543227130, URN:CERNER:IDENTITY-
FEDERATION:REALM:7393B7A3-D517-49E2-81C4-A7D94E4632DB:PRINCIPAL:40B476ED-7500-4CA9-AD9C-363F0E18F276

Care Team

Type Name Represented Organization Address Phone

primary care physician HEALEY, MICHAEL AUSTIN -- Work:395 COUGAR BLVD STE Work Tel: (801)357-0560
603PROVO, UT 84604- , USA

Relationships
No Data to Display

Document Details

Source Contact Info

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Author Contact Info
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Recipient Contact Info
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Healthcare Professionals
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IDs & Code Type Data

Document Type ID: 2.16.840.1.113883.1.3 : POCD_HD000040
Document Template ID: 2.16.840.1.113883.10.20.22.1.1 : --, 2.16.840.1.113883.10.20.22.1.1 : 2015-08-01, 2.16.840.1.113883.10.20.22.1.2 : 2015-08-01
Document ID: 4E4240CE-16E6-407B-8783-8ED239CA3EAD : --
Document Type Code: 2.16.840.1.113883.6.1, 34133-9
Document Language Code: en-US
Document Set ID: --
Document Version Number: --

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Encounter(s)

FIN 1272860802 Date(s): 11/18/24

Utah Valley Neurological 395 W Cougar Blvd Ste 801 Provo, UT 84604-3311 US (801) 357-7420
Attending Physician: ERICKSON, MD, PRESTON W.
FIN 1272833190 Date(s): 10/28/24
House Calls-South 852 N 500 W Provo, UT 84604-3322 US (801)357-8690
Attending Physician: ATWOOD, RN, BRENDA M
FIN 1273167259 Date(s): 10/22/24 - 10/22/24
House Calls-South 852 N 500 W Provo, UT 84604-3322 US (801)357-8690
Discharge Disposition: Home or Self Care
Attending Physician: BUSDICKER, NP, ASHLEY D
FIN 1272861687 Date(s): 10/16/24 - 10/16/24
Utah Valley Family Medicine 395 W Cougar Blvd Ste B Provo, UT 84604-4331 US (801)555-1212
Encounter Diagnosis
Class 1 obesity (Discharge Diagnosis) - 10/16/24
Dependent personality disorder (Discharge Diagnosis) - 10/16/24
Depression, major, recurrent, mild (Discharge Diagnosis) - 10/16/24
Bicornate uterus (Discharge Diagnosis) - 10/16/24
Discharge Disposition: Home or Self Care
Attending Physician: HEALEY, DO, MICHAEL AUSTIN
FIN 1272861230 Date(s): 10/11/24 - 10/11/24
Summit Womens Center-Obstetrics and Gynecology 395 W Cougar Blvd Ste 203 Provo, UT 84604-3328 US (801)357-7009
Encounter Diagnosis
Endometriosis (Discharge Diagnosis) - 10/11/24
Bicornate uterus (Discharge Diagnosis) - 10/11/24
Discharge Disposition: Home or Self Care
Attending Physician: GROVER, MD, STEVEN M.

Allergies, Adverse Reactions, Alerts

No Known Medication Allergies

Substance Criticality Severity Reaction Reaction Severity Status

Lactose High criticality Moderate milk bothers my gut Active

GI Reaction

Assessment and Plan

Extracted from:

Title: bmi Author: HEALEY, DO, MICHAEL AUSTIN Date: 10/16/24

ASSESSMENT AND PLAN

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1. Obesity.
She has lost over 10 pounds since the last visit two months ago. She was previously on Ozempic but has switched to Mounjaro for better efficacy and cost-
effectiveness. The prescription for Mounjaro will be provided, and she will start it next week. She has been cleared to resume exercising post-surgery, which
should aid in further weight loss.
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2. Anemia.
Her anemia is not due to any issues with red blood cell production. The hematologist recommended a neurology evaluation per hematology, although the rationale
for this is unclear. Her iron levels were low as of 09/30/2024, but not to the extent that would inhibit red blood cell production. A repeat CBC is recommended in 4
weeks.
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3. Endometriosis.
She underwent surgery a couple of weeks ago and has recovered well. Two medications to prevent the recurrence of endometriosis were recommended but have
not been started due to insurance issues. Prior authorization is being sought, and she hopes to start the medications this week.
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4. Bicornuate Uterus.
Confirmed during her recent surgery. No immediate treatment changes are indicated.
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5. Concussion.
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She reports a concussion a month or two ago but is unsure of any specific incidents of head trauma that could explain previous brain damage noted on MRI.
Awaiting further evaluation by neurology.
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6. Dependent Personality Disorder.
Confirmed diagnosis. No new treatment changes discussed.
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7. Depression.
Confirmed diagnosis. No new treatment changes discussed.
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Follow-up
Patient is scheduled for a follow-up visit on November 25, 2024.
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HISTORY OF PRESENT ILLNESS
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The patient is a 25-year-old female who presents for follow-up on morbid obesity and anemia.
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She reports no new health concerns. She was referred to a dietitian who switched her medication from Ozempic to Mounjaro and increased the dosage. She took
her last dose of Ozempic this week and will start Mounjaro next week. She has gained 2 pounds in the last 6 months but believes Ozempic has helped with weight
loss. She feels that she quickly builds tolerance to medications and constantly needs to increase the doses. She has been cleared to resume exercise following
her recent surgery.
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She underwent surgery for endometriosis a few weeks ago, which revealed a bicornuate uterus. She was advised to start two medications to prevent the
recurrence of endometriosis but has not yet started due to insurance issues.
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Her white blood cell count has returned to normal and she is no longer anemic.
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She experienced a concussion one to two months ago.
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She is currently under some stress due to a conflict with her roommate. She has been diagnosed with depression and dependent personality disorder.
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RESULTS
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Laboratory Studies
White blood cells have gone back down. Iron levels are low but not so low that it can't make red blood cells to the proper range.
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Imaging
MRI results show a perfectly normal looking brain.

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1. Class 1 obesity
2. Depression, major, recurrent, mild
3. Dependent personality disorder
4. Bicornate uterus
Orders:
Mounjaro 2.5 mg/0.5 mL subcutaneous solution, 2.5 mg, SubCutaneous, every week, # 1 EA, 2 Refill(s), Signed: 10/16/24 10:17:00 MDT, Maintenance, Pharmacy:
Walmart Neighborhood Market 4100, 2.5 mg SubCutaneous every week, 162, cm, 10/16/24 9:58:00 MDT, Height/Length Measured, 85.5, kg, 10/16/24 10...

Extracted from:

Title: GYN Office Visit Note Author: GROVER, MD, STEVEN M. Date: 10/11/24

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1. Endometriosis
Ordered:
Orilissa 150 mg oral tablet, 150 mg, Oral, Daily, # 90 tabs, 1 Refill(s), Signed: 10/11/24 13:21:00 MDT, Maintenance, Pharmacy: Walmart Neighborhood Market
4100, Pharmacy OP Main, 150 mg Oral Daily, 162, cm, 10/11/24 13:04:00 MDT, Height/Length Measured, 84.5, kg, 10/07/24 14:37:...
Aygestin 5 mg oral tablet, 1 tabs, Oral, Daily, # 90 tabs, 3 Refill(s), Signed: 10/11/24 13:21:00 MDT, Maintenance, Pharmacy: Walmart Neighborhood Market 4100,
1 tabs Oral Daily, 162, cm, 10/11/24 13:04:00 MDT, Height/Length Measured, 84.5, kg, 10/07/24 14:37:00 MDT, Weight Dos... Â
2. Bicornate uterus
Ordered:
Orilissa 150 mg oral tablet, 150 mg, Oral, Daily, # 90 tabs, 1 Refill(s), Signed: 10/11/24 13:21:00 MDT, Maintenance, Pharmacy: Walmart Neighborhood Market
4100, Pharmacy OP Main, 150 mg Oral Daily, 162, cm, 10/11/24 13:04:00 MDT, Height/Length Measured, 84.5, kg, 10/07/24 14:37:...
Aygestin 5 mg oral tablet, 1 tabs, Oral, Daily, # 90 tabs, 3 Refill(s), Signed: 10/11/24 13:21:00 MDT, Maintenance, Pharmacy: Walmart Neighborhood Market 4100,
1 tabs Oral Daily, 162, cm, 10/11/24 13:04:00 MDT, Height/Length Measured, 84.5, kg, 10/07/24 14:37:00 MDT, Weight Dos... Â
Recommended the patient start Orilissa and some form of birth control while on this medication. Caution with pregnancy and alert your OB physician about
bicornate uterus.
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SUBJECTIVE: This patient underwent a laparoscopy 2 weeks ago. The patient is doing well after surgery. There is no drainage from the incisions and no vaginal
bleeding. There is no pain.
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OBJECTIVE: The patient appears well. The abdominal incisions are healing nicely.
endometriosis was seen on laparoscopy and she had cauterization of endometriosis.
ASSESSMENT: Stable status post laparoscopy with cauterization of endometriosis
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PLAN: No restrictions.
I recommend that she undergo a course of Orilissa. I discussed the benefits and risks and side effects. She agrees to this plan and we are going to go ahead and
get insurance approval.
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We did also discussed the need for contraception and discussed Nexplanon and IUD.
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Extracted from:

Title: ED Note Author: BRINGHURST, MD, CORY L. Date: 9/30/24

Utah Valley Hospital Emergency Department

ED NOTE:
CHIEF COMPLAINT/REASON FOR VISIT:
Vision changes
Nursing Chief Complaint:
pt states weakness and blurred vision, seen yesterday
HISTORY OF PRESENT ILLNESS:
This patient is a 25-year-old female who for approximately the past week has been evaluated for abdominal pain associated with vomiting. No significant
problems were seen on the workup it has been done so far and those symptoms are actually improving, but over the past day she has developed some blurry
vision and also she reports that there was some swelling around the left eye last night but that has improved. Those are the only new changes she is
experiencing at this time. She states she feels generally weak. She denies any other specific symptoms or problems at this time.
ROS:
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All other systems reviewed and are negative.
PROBLEM LIST/PAST MEDICAL HISTORY:
Ongoing
Anemia
Anorexia nervosa, restricting type, in partial remission, moderate
Anorexia nervosa, restricting type, moderate
Attention deficit disorder (ADD) in adult
Bicornate uterus
Bicuspid aortic valve
BMI 33.0-33.9,adult
BMI 35.0-35.9,adult
Borderline personality disorder
Class 1 obesity
Class 2 obesity
Dependent personality disorder
Depression, major, recurrent, mild
Endometriosis
Fatigue
Female pelvic pain
GAD (generalized anxiety disorder)
Menorrhagia
PTSD (post-traumatic stress disorder)
S/P repair of coarctation of aorta
Sleep disturbance
Syncope
PROCEDURE/SURGICAL HISTORY:
Laparoscopic Diagnostic (No Laterality) (09/18/2024), Esophagogastroduodenoscopy (03/02/2022), Transcatheter intracardiac shunt (TIS) creation by stent
placement for congenital cardiac anomalies to establish effective intracardiac flow, including all imaging guidance by the proceduralist, when performed, left and
right heart diagnostic cardiac cath.
HOME MEDICATIONS:
Auvelity 45 mg-105 mg oral tablet, extended release, 1 tabs, Oral, every morning
promethazine 25 mg oral tablet, 25 mg= 1 tabs, Oral, every 6 hr, PRN
Sprintec, 1 tabs, Oral, Daily
traZODone 50 mg oral tablet, 50 mg= 1 tabs, Oral, Daily at bedtime
Vyvanse 70 mg oral capsule, 70 mg= 1 cap, Oral, every morning
Zofran ODT 4 mg oral tablet, disintegrating, 4 mg, Oral, every 6 hr, PRN
Zofran ODT 8 mg oral tablet, disintegrating, 8 mg= 1 tabs, Oral, every 8 hr, PRN, 2 refills
IMMUNIZATIONS:
No qualifying data available.
ALLERGIES:
Lactose (milk bothers my gut, GI Reaction)
No Known Medication Allergies
FAMILY HISTORY:
Anxiety: Grandmother (M) and Sibling.
Arrhythmia (cardiac) NOS: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
CHD - Congenital heart disease: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Cancer: Father, Grandfather (P) and Grandmother (P).
Cancer: Father.
Depression: Grandmother (M), Sibling and Sibling.
Drug addiction: Sibling and Sibling.
Emotional problems: Sibling.
Heart attack: Grandmother (M).Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Hyperlipidemia: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Substance Use: Sibling and Sibling.
Sudden cardiac death: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Suicidal behavior: Sibling and Sibling.
SOCIAL HISTORY:
Alcohol - 09/25/2024
Use: Never used.
Use: Never used. Household alcohol concerns: No.
Use: Never used.

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Use: Never used.
Employment/School - 09/25/2024
Status: Employed. Place of occupation/business: Pet grooming. Highest education level: High school.
Employed
Home/Environment - 09/25/2024
Lives with: Friend and her family.
Substance Use - 09/25/2024
Use, other than prescribed: Never used.
Use, other than prescribed: Never used. Concerns about substance abuse in household: No.
Use, other than prescribed: Never used. Date last used: CBD once.
Tobacco - 09/25/2024
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker.
Use: Never smoker.
Use: Never smoker.
ED Travel Outside US last 30 days: No (09/30/24)
PHYSICAL EXAM:
Triage Vitals
T:Â 36.7 degCÂ (Tympanic) HR:Â 140Â (Peripheral) RR:Â 20 BP:Â 139/101 SpO2:Â 100%
HT: 160 cm WT: 84.7 kg BMI: 33.09Â
Eye, Bilateral Visual Acuity: 20/70
Eye, Right Visual Acuity: 20/100
Eye, Left Visual Acuity: 20/100
SKIN: warm, dry, no rashes.
EYES: pupils are equally round, clear conjunctiva, non-icteric sclera. There is some slight swelling of the lid around the left eye. Extraocular movements are
intact. No evidence of foreign bodies.
HENT: normocephalic, atraumatic, moist mucus membranes, oropharynx clear without exudates.
NECK: Nontender and supple with no nuchal rigidity, full range of motion.
PULMONARY: clear to auscultation without wheezes, rhonchi, or rales, normal excursion, no accessory muscle use and no stridor.
CARDIOVASCULAR: regular rate, rhythm, normal S1 and S2. Â No appreciated murmurs. Â .
GASTROINTESTINAL: Â soft, non-tender, non-distended, no palpable masses, no rebound or guarding.
GENITOURINARY: No costovertebral angle tenderness to palpation.
LYMPHATICS: no edema in lower extremities, no cervical lymphadenopathy.
MUSCULOSKELETAL: Extremities are nontender to palpation and have no gross deformity, no edema, redness, or swelling.
PSYCHIATRIC: normal mood and affect, thought process is clear and linear.
REEXAMINATION/REEVALUATION:
Current Vitals
T: 36.6 °C (Tympanic) TMIN: 36.6 °C (Tympanic) TMAX: 36.7 °C (Tympanic) HR: 126(Peripheral) RR: 18 BP: 159/118 SpO2: 95%Â
WT: 84.70 kg WT: 84.7 kg BMI: 33.09Â
Ideal Body Weight Calculated: 52.382 kg
DIAGNOSIS:
1. Vision changes
MEDICAL DECISION MAKING/ED COURSE:
CT scan of the brain is obtained which shows no evidence of intracranial hemorrhage or any other acute abnormalities. CBC is unremarkable. She has a
slightly low sodium and potassium and the anion gap was slightly elevated at 17.  She does have some LFT abnormalities, and there have been some LFT
abnormalities on recent tests, but have nevertheless encouraged her to follow-up with her primary care physician for ongoing monitoring of those test
results. At this point I do not see evidence of an emergent cause of the patient's symptoms. I have referred her to follow-up with ophthalmology as well within
the next few days for recheck. I have also strongly encouraged her to follow-up with her primary care physician for ongoing management of the many
symptoms that she has been seen recently for here in the emergency department. Of course if she is worsening, return to the emergency department
immediately for recheck.

PHYSICIAN/APP INDEPENDENT INTERPRETATION:

RADIOLOGY:
CT scan of the brain shows no obvious large intracranial hemorrhage
DISPOSITION DECISION (ADMISSION VS DISCHARGE):
I considered this patient for admission but they are now improved and should do well as an outpatient.
ADMINISTERED MEDICATIONS:
ondansetron: 4 mg (09/30/24 13:06:00)
ORDERS:
ED Peripheral IV Insert

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LAB RESULTS:
This is an incomplete list of lab results from this encounter. Refer to Results Review for all results. Heme
WBC: 10.6 K/mcL
RBC: 4.87 x10^6/mcL
Hemoglobin: 12 g/dL
Hematocrit: 38.5 %
MCV:Â 79.1 fLÂ Low
MCH: 24.6 pg Low
MCHC:Â 31.2 g/dLÂ Low
RDW SD:Â 55.2 fLÂ High
RDW:Â 19.9 %Â High
Platelets: 366 K/mcL
MPV: 8.7 fL
Nucleated RBC Auto: 0 /100(WBCs)
Differential Type: Auto
Immature Granulocytes: 0.3 %
Neutrophil % Auto: 77.9 %
Lymphocyte % Auto: 14.5 %
Monocyte % Auto: 6.1 %
Eosinophil % Auto: 0.6 %
Basophil % Auto: 0.6 %
Immature Granulocyte, Abs: 0.03 K/mcL
Neutrophil, Abs:Â 8.3 K/mcLÂ High
Lymphocyte, Abs: 1.5 K/mcL
Monocyte, Abs: 0.7 K/mcL
Eosinophil, Abs: 0.1 K/mcL
Basophil, Abs: 0.1 K/mcL
Chemistries
Sodium Level:Â 136 mmol/LÂ Low
Potassium Level:Â 3.3 mmol/LÂ Low
Chloride Level:Â 99 mmol/LÂ Low
CO2: 20 mmol/L
Anion Gap (Na Cl CO2):Â 17 mmol/LÂ High
Glucose Level: 83 mg/dL
BUN:Â 6 mg/dLÂ Low
Creatinine Level: 0.91 mg/dL
est CrCl (Ideal BW for dosing): 78.15 mL/min
est CrCl (Actual BW for dosing): 126.36 mL/min
Creatinine GFR: 90 mL/min/1.73 m2
Cmt: GFR: See Comments
Calcium Level: 9.6 mg/dL
Protein Total: 7.8 g/dL
Albumin Level: 4.4 g/dL
Bilirubin Total: 0.4 mg/dL
Alk Phos: 57 unit/L
AST:Â 80 unit/LÂ High
ALT:Â 88 unit/LÂ High

IMAGING RESULTS:
Date/time is when order was placed.
CT Brain/Head w/o Contrast
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09/30/24 12:44:00
IMPRESSION:
No CT evidence of acute intracranial abnormality.
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 This report was electronically signed by
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Signed By: TRIMBLE, MD, CHRISTOPHER R.

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RISK STRATIFICATION TOOLS USED:
No qualifying data available.
Disposition:
Discharge Patient - OrderedÂ
 -- 09/30/24 14:10:00 MDT, 09/30/24 14:10:00 MDT
With When Contact Information Follow up with primary care provider Within 2 to 4 days
Additional Instructions:

LLOYD, MD, MICHAEL J., Ophthalmology. Within 1 week

1055 N 300 W STE 204
PROVO, UT 84604-
(801)357-7373
Additional Instructions:

Upcoming Appointments
Wednesday
Oct. 2, 2024
3:40 PM MDT
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With: GROVER, MD, STEVEN M.
Where: Summit Womens Center-Obstetrics and Gynecology
Status: Confirmed
Appointment Type GYN POV Post Operative Visit
Monday
Oct. 7, 2024
9:00 AM MDT
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With: VILLALOBOS HUITRON, RD, BRENDA
Where: UV_ST_Dietitian
Status: Confirmed
Appointment Type Nutrition Counseling - MNT Initial
Monday
Nov. 25, 2024
9:30 AM MST
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With: BUSDICKER, NP, ASHLEY D
Where:
House Calls-South|852 N 500 W
Provo, UT 84604-3322
(801)357-8690
Status: Confirmed
Appointment Type HC ROV Routine Office Visit
PRESCRIBED MEDICATIONS THIS VISIT:
No prescriptions given

Extracted from:

Title: Office Visit Freetext Author: ERICKSON, MD, PRESTON W. Date: 8/29/24

History of Present Illness: Â

NIELSON, SARAH ELOIZA is a   25 Years old Female who presents with syncopal episodes.
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She states that she hasissues with passing out.
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She states that she did a tilt table to evaluate for POTS. She was told that she did not meet criteria for POTS. She states that her symptoms were much worse in
May and June, returning again in July. She states that she went to the ER in August. She states that she can feel it most of the time before she passes out. She
states that she will break out into sweat and will feel nauseated, dizziness, and tunnel vision. She feels so sick she will have to sit down and then it gets dark. She
states that soon she will feel the symptoms again and she can have multiple episodes. She states that when she passes out she does lose consciousness, this is
only for a couple of seconds. When she wakes up she is not always confused, but sometimes she can be confused. She states that her anxiety and stress are
triggers for these episodes. If she does not get enough sleep this can trigger it as well. She also was diagnosed in 2022 with pseudoseizures which have since
resolved.
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Neurological Exam:
Mental Status: Attentive and responsive. Oriented to time, place, person. Recent and remote memory intact.
Speech is fluent and comprehension is appropriate
Cranial Nerves:
CN II: visual fields full to confrontation
CN III,IV,VI: PERRL; extra-ocular movements intact in all directions; no nystagmus noted.
CN V: facial sensation intact to light touch bilaterally
CN VII: symmetrical facial activation
CN VIII: hearing intact to voice
CN IX & X: soft palate elevates symmetrically in the midline
CN XI: shoulder shrug of normal strength bilaterally
CN XII: tongue is midline  Â
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Motor: Normal tone. Normal bulk. Strength 5/5 in all 4 extremities
Reflexes: 2+ throughout, toes downgoing, no clonus
Sensory: Intact to light touch in all 4 extremities
Coordination: Normal Gait: Normal stride length, arm swing, and base width.
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Results: Independently reviewed.
TTE 5/15/24:
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Impression:
 1. Left ventricular systolic function is normal. The left ventricular ejection fraction is 79 %(+- 3%).
 2. There are no segmental wall motion abnormalities.
 3. Normal diastolic pattern with normal left atrial pressure.
 4. Normal right ventricular size and systolic function.
 5. No evidence of aortic valve stenosis. Aortic valve morphology is bicuspid. No evidence of aortic regurgitation.
 6. Tricuspid regurgitation jet was not adequate to estimate the right ventricular or pulmonary artery systolic pressure.
 7. History of aorta coarctation repair, peak velocity of 2.7m/s.
 8. Compared to a prior transthoracic study from 5/2/2014, no significant changes are seen.
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Impression and Recommendations: Â
NIELSON, SARAH ELOIZA is a   25 Years old Female who presents with syncopal episodes. The etiology of her episodes are unclear.  She has had a
cardiac workup without any abnormalities on her echocardiogram to suggest a cardiogenic cause. With her statement of stress and anxiety being triggers for
this it is likely this is functional neurological disease. We discussed doing an MRI of the brain to rule out any other neurological causes that could be present. I
directed her to website for more information regarding FND. Â She does not tolerate contrast well and requested to have the MRI without contrast. Â Will follow up

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based upon results of MRI Brain.
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I spent 45 minutes in evaluation and management services, on the date of the encounter.  Excluding procedure time. I am responsible for giving ongoing care
for the patient’s condition identified in my plan of care.
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This note was written using medical terminology and is intended only to be used for communication with other health care professionals.Â
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1. Syncope

Extracted from:

Title: Retained Tampon Author: HAWKS, NP, AMY R Date: 8/13/24

Subjective: Â
Pt reports a retained tampon since yesterday after the string broke during attempted removal. Denies fever, chills, abnormal vaginal discharge, or abdominal
pain. No issues with urinary or bowel movements.
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Objective: Â
Gen: Well-appearing, no acute distress
Pelvic: No vulvar or vaginal lesions. No signs of trauma. Tampon visualized in the vaginal canal. No abnormal discharge or odor noted. Tampon removed easily
with ring forceps. No retained fragments.
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Assessment: Â
Retained tampon, uncomplicated
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Plan: Â
Tampon removed without difficulty. Pt advised to monitor for any symptoms such as fever, abnormal discharge, or odor. Educated on precautions to avoid
recurrence. RN served as chaperone during the procedure. Follow up as needed.
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1. Retained tampon

Extracted from:

Title: House Calls Self Care Plan Author: ATWOOD, RN, BRENDA M Date: 8/5/24

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Role/RelationshipÂ
ContactÂ
PhoneÂ
Primary Care PhysicianÂ
HEALEY, DO, M. AUSTINÂ
(801)357-0560Â
Nurse Practitioner LifetimeÂ
ROGERSON, NP, ANNÂ
(801)357-4600Â
Care ManagerÂ
ATWOOD, BRENDA MÂ
+1 8014922550Â

Extracted from:

Title: Housecalls APP visit Author: BUSDICKER, NP, ASHLEY D Date: 7/29/24

1. Dermatitis of eyelid of left eye

– Advised patient to discontinue use of lotion due to alcohol content and begin use of emollients (Vaseline, Aquaphor, etc.) or creams CeraVe, Eucerin,
etc.) instead. Recommended frequent application during the day as tolerated and application at bedtime to alleviate itchiness and flaking of the skin.

Extracted from:

Title: Cardiology Office Visit Note Author: FEENEY, MD, JAMES M. Date: 6/14/24

1. Syncope
- Tilt table test negative for POTS, although her blood pressure dropped and she experienced presycnope. Syncope likely a vasovagal response.
- Recommend she be careful with postural changes. Encouraged to stay well hydrated.
- Heart monitor negative for arrhythmia. Recommend she use her apple watch to monitor for abnormally high or low heart rates.
Â
Â
Â
2. Bicuspid aortic valve
Echo revealed no evidence of stenosis or regurgitation.  LV systolic and diastolic function normal. Recommend yearly follow-up with cardiology for symptom
assessment and echocardiography.
Â
 Follow up: with PCP
Â
I, Monet Seegmiller, entered information forÂ
 FEENEY, MD, JAMES M. exactly as directly spoken to me by them or for services performed as observed. Results or interpretations were transcribed as directed
by them. No pharmacy, laboratory, imaging, or consult orders were created by me. Medical history, family history, social history, review of systems and vital sign
components, if applicable to this patient visit were documented independently if provided to me by the patient. No interpretations, assumptions, or impressions
were entered by me based on my observations or patient comments. This documentation has been signed and dated by me in presence of and in behalf
of FEENEY, MD, JAMES M.. Â

Extracted from:

Title: Hospitalist Discharge Summary Author: HOLLADAY, DO, NADIA Date: 5/16/24

Recurrent syncopeÂ

S/P repair of coarctation of aortaÂ

Bicuspid aortic valve

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10/24/2024 Continuity of Care Document
Acute, present on admission. Patient presents with at least 2 confirmed syncopal events and multiple near syncopal symptoms over the last 6 days of unknown
etiology. Patient has a known cardiac history although she has not had consistent follow-up beyond childhood. Patient's syncope is often accompanied by a feeling
of weakness, diaphoresis, lightheadedness, palpitations. Denies any chest pain, shortness of breath, leg swelling, or pain. EKG in the ED was unrevealing apart
from tachycardia. However, given her history would like to conduct further cardiology workup. Upon admission, case was discussed with on-call cardiologist, Dr.
Wilkinson who agreed to consult on patient. Initial PE does not show volume depletion. Seizure also seems less likely as patient has not had any prolonged
postictal state, urinary incontinence, or tongue biting. Patient BNP is normal.Â

Telemetry reviewed this morning and patient continues to have irregular beats and was tachycardic in 140s earlier. Telemetry showed intermittent tachycardia.
Normal HR on discharge day in the morning. Normal echocardiogram. Cardiology consulted and patient cleared to be discharged home with a monitor and follow-
up outpatient.

– Cardiology consulted, recs appreciated.

– Dr. Sunkara reviewed Echo: No significant aortic stenosis identified at this bicuspid valve. Normal left ventricular systolic function. Mildly dilated right
ventricle.

– Given PVC burden and dilated right ventricle, Dr. Sunkara says to consider cardiac MRI.

– Echocardiogram 05/15/2024: LV systolic function is normal. EF 79%. No segmental wall motion abnormalities. Normal diastolic pattern. No evidence of aortic
valve stenosis. Bicuspid aortic valve with no regurgitation. No significant change from prior study of 05/02/2014.

– BNP is normal <6

– Continuous cardiac telemetry showed intermittent tachycardia, PVCs and intermittent irregular sinus rhythm

– Tylenol as needed for pain

SIRS without infection or organ dysfunction

Leukocytosis

Metabolic acidosis

Hypokalemia

Acute, microcytic, present admission. Patient meeting SIRS criteria with elevated white count, tachycardia, tachypnea. No obvious source of infection however
patient endorsed many symptoms on the ROS including hematuria, abdominal pain, nausea, vomiting, diarrhea, and constipation. Physical exam with some left
lower quadrant tenderness and tachycardia but otherwise unremarkable. Beta hydroxybutyrate is elevated but glucose only 123 on admission. Labs and PE are
reassuring against infection. Negative blood cultures to date.Â

– Lactic acid normal 1.2, UA unremarkable.

– Urine culture pending

– Blood cultures: NGTD

– MIVF with LR at 125 mL/h

– Tylenol as needed for pain, fever

Anemia

Chronic, present on admission. Patient has history of menorrhagia (see below). Given Sprintec to reduce menstrual cycles.Â

Hgb 9.4 this morning in the setting of IV fluids.

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10/24/2024 Continuity of Care Document

– Iron 22, TIBC 503, Iron saturation 4, Ferritin 7 - Iron deficiency anemia

– Venofer 300mg IV Infusion today. F/u in the infusion clinic outpatient.Â

– Monitored daily

Anorexia nervosa, restricting type, in partial remission, moderate

Historic diagnosis. Per most recent family medicine note does not appear to be undergoing treatment or dealing with any acute symptoms of this.

Borderline personality disorder

Depression, major, recurrent, moderate

PTSD (post-traumatic stress disorder)

Attention deficit disorder (ADD) in adult

Chronic, present on admission. Patient follows with psychiatric specialist in Salt Lake City. Symptoms of these disorders are currently stable. Takes hydroxyzine
50mg, Vyvanse 70mg, and trazodone 50mg.

– Continued home medications

Menorrhagia

Chronic, present on admission. Prescribed Sprintec in November 2023 by OB/GYN to decrease menstrual bleeding with hopes of improving anemia.Â

Addendum by
DALY, DO,
SARAH W on I have seen and examined this patient, and I reviewed the above note and agree with the Resident's findings, assessment, and plan.
May 17, 2024
08:59:18 MDT Â
Sarah Daly, DO, FAAFP

Extracted from:

Title: BEH Crisis Evaluation Note Author: WILCOX, CSW, JANELLE MARIE Date: 8/5/23

Crisis Evaluation -Â Reason for Treatment:

_ Patient is a 24 yo female presenting to UV ED via POV with passive SI. ED MD reports patient is medically cleared. Crisis worker met with patient to
complete crisis evaluation. Patient presents as calm, cooperative, alert and oriented X 4. Patient reports feeling more anxious lately. Patient reports finding
out her mother is in town visiting her sister. Patient reports she has not seen her mother but just the thought of her being in town has triggered anxiety,
panic attacks and nightmares. Patient reports having passive SI on and off for the last few days. Patient reports no plans or intent.  Patient reports
having a panic attack earlier today and her roommates encouraged her to come to ED for evaluation.Â

Patient has history of childhood abuse and trauma. Patient reports history of suicide attempts and hospitalizations. Patient has been coming to ED on and off
for crisis evaluations and is well known to crisis. Patient reports she is able to commit to safety. Patient reports having plenty of support during the week as
she is involved in an intensive outpatient program at Salt Lake Behavioral Hospital. Patient reports going to IOP every Monday, Wednesday and Thursday.Â
Patient reports she continues to see outpatient therapist Charity Hotton every Tuesday. Patient reports she is on a waiting list to get into residential
treatment at Phoenix Recovery Center. Patient reports she has been meeting with a prescriber at IOP and is taking medications as prescribed. Patient

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10/24/2024 Continuity of Care Document
reports she is able to utilize coping skills, she has a deck of "Stop" flashcards that lead her through coping skills when needed, also coloring and swimming or
tanning. Patient reports having supportive friends and roommates. Â

Patient reports having passive SI, no HI, no AH/VH, no self harm. Patient reports she is able to commit to safety. Patient roommate/friend Shilane Mansell 801-
891-2983 reports being willing to take patient home on safety plan. Patient reports no access to firearms, can remove access to sharp objects, and roommates
can lock up medications if needed. Patient completed safety plan. Patient reports she will follow up with therapist on Tuesday and Salt Lake Behavioral IOP
on Monday, Wednesday, Thursday. Patient reports she can utilize Wasatch Receiving Center if needed. Crisis provided resources for coping skills and crisis
lines. ED MD reports being in agreement with this plan.

Medical History

_Patient reports having been diagnosed with MDD, GAD, PTSD, ADD, BPD and history of anorexia nervosa restricting type. Patient reports participating in an
intensive outpatient program at Salt Lake Behavioral Hospital every Monday, Wednesday and Thursday. Patient reports she has been going to SLB IOP for the
last month.  Patient reports seeing a prescriber at SLB IOP who prescribes Lamotrigine, Prazosin, Trazodone, Vraylar, Buspirone, Adderall and Sprintec. Patient
reports she has been taking medications as prescribed and has no concerns. Patient reports participating in individual and group therapy at SLB IOP. Patient
reports seeing her therapist Charity Hotton every Tuesday. Patient reports history of SI, attempts and hospitalizations.Â

Mental Status:

_ General Appearance:Â Appropriate dress and grooming

Orientation:Â Alert and oriented x3

Recent and Remote Memory:Â Adequate

Behavior:Â Cooperative, appropriate psychomotor activation

Mood/Affect: ""worried""; Blunted, Congruent

Speech:Â Normal volume, prosody, latency

Thought Process:Â Logical and goal directed

Associations:Â Intact

Thought Content:Â Endorses passive SI

Attention/Concentration:Â Fair/fair

Insight/Judgement:Â Fair/fair

Language:Â Within normal limits

Fund of Knowledge:Â Awareness of current events

Â
Substance Use History

_ patient reports history of alcohol use, nothing recent and no other substance use

Current Providers

PCP: _Â HAFEN, NP-P, BRET D.LATER, MD, RICHARD W.

Therapist: _ Charity Hotton every Tuesday, SLB IOP Mon, Wed, Thurs

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10/24/2024 Continuity of Care Document

Psychiatrist: _ SLB IOP provider

Suicide Risk Assessment

Static: Patient's C-SSRS Results Lifetime Wish to be Dead: Lifetime, yes (08/05/23)

Lifetime Suicidal Thoughts: Lifetime, yes (08/05/23)

Lifetime Suicidal Behavior: Lifetime, yes (08/05/23)

Lifetime Ideation with Method No Intent: Lifetime, yes (08/05/23)

Lifetime Ideation with Intent No Plan: Lifetime, yes (08/05/23)

Lifetime Ideation with Intent and Plan: Lifetime, yes (08/05/23)

Wish to be Dead Comment: Pt currently has SI with no plan. Pt has a hx of past attempts but nothing recently. (07/09/23)

Suicidal Thought Comment: Patient reports that she has begun thinking about wanting to kill herself as her anxiety and panic attacks have increased. Denies
current intent and plan. (01/27/23)

Suicide Ideation w-Intent & Plan Comment: Pt has had multiple attempts in the past, but she said it has been a long time (a couple years according to her patient
history) since her last attempt. (04/20/23)

Past Month Columbia Suicide Severity Rating

Past Month Wish to be Dead: Past month, yes (08/05/23)

Past Month Suicidal Thoughts: Past month, yes (08/05/23)

Past Month Ideation w-Method No Intent: Past month, no (08/05/23)

Past Month Ideation with Intent No Plan: Past month, no (08/05/23)

Past Month Ideation with Intent and Plan: Past month, no (08/05/23)

Columbia Screen Suicide Behavior: No (08/05/23)

CSSRS Screen Suicide Behavior Timeline: Longer than 3 months (08/05/23)

CSSRS Suicidal Risk Level: Low (08/05/23)

Suicide Prevention Assessed Risk: Low (08/05/23)Â _Â

Critical Considerations

_Patient reports living in Provo with roommates

Â
Disposition/Plan

_Patient reports having passive SI. Patient reports she is able to commit to safety. Patient roommate/friend Shilane Mansell 801-891-2983 reports being willing
to take patient home on safety plan. Patient reports no access to firearms, can remove access to sharp objects, and roommates can lock up medications if
needed. Patient completed safety plan. Patient reports she will follow up with therapist on Tuesday and Salt Lake Behavioral IOP on Monday, Wednesday,
Thursday. Patient reports she can utilize Wasatch Receiving Center if needed. Crisis provided resources for coping skills and crisis lines. ED MD reports
being in agreement with this plan.

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10/24/2024 Continuity of Care Document

Extracted from:

Title: Office Visit Freetext Author: HAMMOND, MD, MARGARET I. Date: 3/8/23

Follow up: Follow up Acne (Isotretinoin)

Last seen: ~1 month ago
Pt states acne is (worse, better, unchanged, much improved): 100% improved
iPledge #:Â
Â
  8512352665
ÂÂÂ
HPI: Pt here for f/u evaluation and treatment of acne and currently on Isotretinoin. During the history, I reviewed side effects of Isotretinoin not limited to: severe
birth defects and need to avoid pregnancy while taking this medication, dry skin, dry lips, bloody nose, diarrhea, blood in stool, joint aches, muscle aches,
headaches, depression, photosensitivity, delayed wound healing, excessive scarring, thoughts of suicide, premature closure of growth plates, etc. Patient has now
completed her isotretinoin course.
ÂÂÂ
Â
Contraception:
Primary form:

Abstinence     Â
Secondary Form:
None    Â
Pregnancy test today:
Pending, see results review  Â
Â
Patient has completed 9 months of therapy
Total dose thus far is 19,800 mg
Goal dose over treatment course is 11,550 to 16,940 mg (150-220 mg/kg)
Goal dose of 19,800 has been met.
ÂÂÂ
Â
Â
Â
Â
Â
Pt complains of the following side effects:
[x] Patient is experiencing persistent dry skin, dry lips that are bothersome and worsened by isotretinoin. Â
[_] Patient is experiencing persistent cracked lips at the commissures that is bothersome and worsened by isotretinoin.Â
[_] Patient is experiencing persistent dry itchy red skin (dermatitis) that is and bothersome and worsened by isotretinoin. Â
[_] Patient is experiencing intermittent bloody noses (epistaxis) that are bothersome and worsened by isotretinoin. Â
[_] Patient is experiencing mil dry eyes, that is mildly bothersome and possibly worsened by Isotretinoin. Denies changes in vision.Â
[_] Patient is experiencing intermittent mild muscle aches and joint aches that are only mildly bothersome and slightly worsened by isotretinoin, but currently
controlled and not progressing.
[_] Patient complains of sunburn that they feel was exacerbated by isotretinoin.Â
[_] Patient is experiencing excessive hair shedding that is bothersome and may be related to isotretinoin.
[_] Patient has had hypertriglyceridemiaÂ
Â
Review of systems: Pertinent negatives include no recent wt loss, fever, chills, bloody stool, depression/mood changes, thoughts of suicide, facial/neck swelling, or
adenopathy.
ÂÂÂ

Changes in pts past medical history since previous exam:Â No

ÂÂÂ
PE: Patient is pleasant, alert and oriented, and in no acute distress today.a
Â
[x] Examination of the face, neck, upper chest, upper back, bilateral dorsal hands &Â forearms
Â
1. Skin is clear today.

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-----------------------------------------------------------------------------------------------------
Â
A/P: Acne vulgaris, on Isotretinoin (L70.0)(Z51.81) and Therapeutic drug monitoring
- Pt previously failed oral and topical medications, therefore Isotretinoin was started and she has now completed the appropriate course with a goal dose over
treatment course of at least 120-150mg/kg.
- Discussed avoidance of pregnancy, avoidance of sharing medications and avoidance of donating blood or plasma during treatment and for at least 1 month
following completion of treatment.

- Encouraged diet, exercise, and healthy lifestyle going forward and follow up for acne recurrence.
- Discussed avoidance of cosmetic acne treatments (ie laser), or repeat courses for at least 6 months after completing Isotretinoin.
- Follow up as needed for recurrence of with any concerns regarding her prior treatment course of isotretinoin.
Â
------------------------------------------------------------------------------------------------
Â
Â
Â
Â
Â
Â
Â
Â
Â
Â
Â
Â
Â
Â
Â
Â
Â
Â
Â
Â
Â
Â
 Â
1. Acne vulgaris
2. High risk medication use
3. Dry lips
O: Fissuring and erythema at angular commissures
Â
- Angular cheilitis secondary to isotretinoin
- Discussed causes of angular cheilitis including isotretinoin, saliva leading to irritant dermatitis, deep furrows, proliferation of bacteria, yeast, or virus
- Predisposing factors include thrush, infancy, old age, diabetes, corticosteroid/antibiotic use, dentures, poor nutrition, illnesses, atopics,
retinoids, lip licking
- Disease is usually 2/2 to candida, but can also be related to staph or HSV
- Discussed treatment options including ketoconazole cream, oral fluconazole, clindamycin lotion, keflex, etc
- Discussed potential side effects to topical and oral medications not limited to local irritation, hypersens, liver abnl, kidney abnl, rash, etc
Â
After thorough discussion, pt elected for treatment with:Â
Â
Â
Â
Â
Â
 copious amounts of Vaseline, Aquaphor, or CeraVe healing ointment to lips Â
------------------------------------------------------------------------------------------------ Â

Future Appointments
Appointment Date: 10/28/2024 10:00:00 AM
Scheduled Provider: ATWOOD, RN, BRENDA M
Location: HCSO_CM
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10/24/2024 Continuity of Care Document
Appointment Type: CM ROV Care Mgr Routine Office Visit
Appointment Date: 11/11/2024 01:30:00 PM
Scheduled Provider: VILLALOBOS HUITRON, RD, BRENDA
Location: UV_ST_Diet
Appointment Type: Nutrition Counseling - MNT FU-60
Appointment Date: 11/18/2024 01:00:00 PM
Scheduled Provider: ERICKSON, MD, PRESTON W.
Location: UVNE_Neurology
Appointment Type: NEU ROV Routine Office Visit
Appointment Date: 11/25/2024 09:30:00 AM
Scheduled Provider: BUSDICKER, NP, ASHLEY D
Location: HCSO_IM
Appointment Type: HC ROV Routine Office Visit

Functional Status

9/18/24

ADLs Independent

Immunizations

Given and Recorded

Vaccine Date Status Refusal Reason

SARS-CoV-2 mRNA (tozin-tris-sucrose) vac 1, 2 4/6/22 Given

SARS-CoV-2 mRNA (tozin-tris-sucrose) vac 3, 4 3/16/22 Given

varicella virus vaccine 5, 6 3/9/22 Given

influenza virus vaccine, inactivated 7, 8 3/9/22 Given

influenza virus vaccine, inactivated 11/3/20 Given

influenza virus vaccine, inactivated 9, 10 8/17/18 Given

influenza virus vaccine, inactivated 11, 12 11/15/17 Given

influenza virus vaccine, inactivated 13, 14 12/20/16 Given

influenza virus vaccine, inactivated 15, 16 1/2/15 Given

tetanus/diphth/pertuss (Tdap) adult/adol 17, 18 11/15/17 Given

tetanus/diphth/pertuss (Tdap) adult/adol 19 8/12/11 Given

meningococcal conjugate vaccine 20, 21 12/20/16 Given

meningococcal conjugate vaccine 22 8/12/11 Given

human papillomavirus vaccine 23, 24 9/22/14 Given

human papillomavirus vaccine 25, 26 8/2/13 Given

human papillomavirus vaccine 27 8/12/11 Given

Novel Influenza-H1N1-09, nasal28, 29 12/3/09 Given

influenza virus vaccine, split virus 30 10/19/07 Given

influenza virus vaccine, split virus 31 11/10/06 Given

influenza virus vaccine, split virus 32 12/16/05 Given

influenza virus vaccine, split virus 33 10/22/04 Given

hepatitis A pediatric vaccine 34 10/22/04 Given

hepatitis A pediatric vaccine 35 4/19/04 Given

measles/mumps/rubella virus vaccine 36 4/19/04 Given

measles/mumps/rubella virus vaccine 37 1/10/00 Given

poliovirus vaccine, inactivated 38 4/19/04 Given

poliovirus vaccine, inactivated 39 9/8/99 Given

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10/24/2024 Continuity of Care Document
Vaccine Date Status Refusal Reason

poliovirus vaccine, inactivated 40 7/12/99 Given

poliovirus vaccine, inactivated 41 4/20/99 Given

diphtheria/pertussis, acel/tetanus ped 42 4/19/04 Given

diphtheria/pertussis, acel/tetanus ped 43 3/14/00 Given

diphtheria/pertussis, acel/tetanus ped 44 9/8/99 Given

diphtheria/pertussis, acel/tetanus ped 45 7/12/99 Given

diphtheria/pertussis, acel/tetanus ped 46 4/20/99 Given

haemophilus b conjugate (PRP-T) vaccine 47 3/14/00 Given

haemophilus b conjugate (PRP-T) vaccine 48 9/8/99 Given

haemophilus b conjugate (PRP-T) vaccine 49 7/12/99 Given

haemophilus b conjugate (PRP-T) vaccine 50 4/20/99 Given

hepatitis B pediatric vaccine 51 9/8/99 Given

hepatitis B pediatric vaccine 52 7/12/99 Given

hepatitis B pediatric vaccine 53 4/20/99 Given

hepatitis B pediatric vaccine 54 12/6/98 Given

Rotavirus monovalent (RV1) 55 7/12/99 Given

Rotavirus monovalent (RV1) 56 4/20/99 Given

1 Location History: 1962 W 1800 N

2 Result Comment: New immunization record
3 Location History: 1962 W 1800 N
4 Result Comment: New immunization record
5 Location History: 22 S STATE ST
6 Result Comment: New immunization record
7 Location History: 22 S STATE ST
8 Result Comment: New immunization record
9 Location History: 151 S UNIVERSITY AVE STE 1900
10 Result Comment: New immunization record
11 Location History: 747 E 440 N STE A
12 Result Comment: New immunization record
13 Location History: 747 E 440 N STE A
14 Result Comment: New immunization record
15 Location History: 151 S UNIVERSITY AVE STE 1900
16 Result Comment: New immunization record
17 Location History: 747 E 440 N STE A
18 Result Comment: New immunization record
19 Result Comment: Historical information - source unspecified
20 Location History: 747 E 440 N STE A
21 Result Comment: New immunization record
22 Result Comment: Historical information - source unspecified
23 Location History: 747 E 440 N STE A
24 Result Comment: New immunization record
25 Location History: 747 E 440 N STE A
26 Result Comment: New immunization record
27 Result Comment: Historical information - source unspecified
28 Location History: 151 S UNIVERSITY AVE STE 1900
29 Result Comment: New immunization record
30 Result Comment: Historical information - source unspecified
31 Result Comment: Historical information - source unspecified
32 Result Comment: Historical information - source unspecified

20 to 142
10/24/2024 Continuity of Care Document
33 Result Comment: Historical information - source unspecified
34 Result Comment: Historical information - source unspecified
35 Result Comment: Historical information - source unspecified
36 Result Comment: Historical information - source unspecified
37 Result Comment: Historical information - source unspecified
38 Result Comment: Historical information - source unspecified
39 Result Comment: Historical information - source unspecified
40 Result Comment: Historical information - source unspecified
41 Result Comment: Historical information - source unspecified
42 Result Comment: Historical information - source unspecified
43 Result Comment: Historical information - source unspecified
44 Result Comment: Historical information - source unspecified
45 Result Comment: Historical information - source unspecified
46 Result Comment: Historical information - source unspecified
47 Result Comment: Historical information - source unspecified
48 Result Comment: Historical information - source unspecified
49 Result Comment: Historical information - source unspecified
50 Result Comment: Historical information - source unspecified
51 Result Comment: Historical information - source unspecified
52 Result Comment: Historical information - source unspecified
53 Result Comment: Historical information - source unspecified
54 Result Comment: Historical information - source unspecified
55 Result Comment: Historical information - source unspecified
56 Result Comment: Historical information - source unspecified

Medications

amoxicillin 500 mg oral capsule

1 cap, Oral, every 12 hr, X 10 days, # 20 cap, 0 Refill(s), Signed: 11/25/22 6:34:00 PM MST, Acute, 12/5/22 6:34:00 PM MST, Pharmacy: Walmart Neighborhood
Market 4100, 1 cap Oral every 12 hr,x10 days, 163, cm, 11/25/22 18:19:00 MST, Height/Length Measured, 74.7, kg, 02/27/22 13:30:00 MST, Weight Dosing
Start Date: 11/25/22
Stop Date: 12/5/22
Status: Completed
busPIRone
Oral, BID, 0 Refill(s), Signed: 7/1/23 8:13:00 PM MDT, Maintenance
Start Date: 7/1/23
Stop Date: 5/14/24
Status: Completed
clindamycin 1% topical lotion
1 appl, Topical, Daily, # 120 mL, 3 Refill(s), Signed: 1/25/22 3:40:00 PM MST, Maintenance, Pharmacy: Walmart Pharmacy 5234, 1 appl Topical Daily, 163, cm,
01/19/21 15:34:00 MST, Height/Length Measured, 85.73, kg, 02/01/21 7:30:00 MST, Weight Dosing
Start Date: 1/25/22
Stop Date: 6/22/22
Status: Completed
clindamycin 1% topical lotion
1 appl, Topical, Daily, # 120 mL, 3 Refill(s), Signed: 1/25/22 9:34:00 AM MST, Hard Stop, Pharmacy: COSTCO PHARMACY # 484, 163, cm, 01/19/21 15:34:00 MST,
Height/Length Measured, 85.73, kg, 02/01/21 7:30:00 MST, Weight Dosing
Start Date: 1/25/22
Stop Date: 1/25/22
Status: Completed
cloNIDine
0 Refill(s), Signed: 6/1/23 2:27:00 PM MDT, Maintenance
Start Date: 6/1/23
Stop Date: 8/5/23
Status: Completed
Cymbalta 20 mg oral delayed release capsule
1 cap, Oral, Daily, # 30 cap, 0 Refill(s), Signed: 11/3/20 11:59:00 AM MST, Maintenance, Pharmacy: WALGREENS DRUG STORE #02519, 1 cap Oral Daily, 162.56,
cm, 10/31/20 14:09:00 MDT, Height/Length Measured, 83.2, kg, 10/30/20 20:56:00 MDT, Weight Dosing
21 to 142
10/24/2024 Continuity of Care Document
Start Date: 11/3/20
Stop Date: 1/18/21
Status: Completed
dexAMETHasone 0.5 mg/5 mL oral liquid
See Instructions, Rinse, gargle and spit with 5 mL of solution 3-4 times daily; hold medication in mouth for up to 5 minutes, # 100 mL, 0 Refill(s), Signed: 2/23/24
3:48:00 PM MST, Acute, Pharmacy: Walmart Neighborhood Market 4100, Rinse, gargle and spit with 5 mL of solution 3-4 times daily; hold medication in mouth for
up to 5 minutes, 160, cm, 02/08/24 14:31:00 MST, Height/Length Measured, 88.3, kg, 02/23/24 15:26:00 MST, Weight Dosing, Aphthous ulcer of mouth
Start Date: 2/23/24
Stop Date: 3/1/24
Status: Completed
doxepin 10 mg/mL oral concentrate
0.6-1 mL, Oral, Daily at bedtime, PRN sleep, # 225 mL, 0 Refill(s), Signed: 1/19/21 12:31:00 PM MST, Maintenance
Start Date: 1/19/21
Stop Date: 3/1/22
Status: Completed
doxycycline monohydrate 100 mg oral capsule
1 cap, Oral, BID, X 90 days, # 180 cap, 0 Refill(s), Signed: 1/25/22 3:40:00 PM MST, Hard Stop, 4/26/22 9:24:38 AM MDT, Pharmacy: Walmart Pharmacy 5234, 163,
cm, 01/19/21 15:34:00 MST, Height/Length Measured, 85.73, kg, 02/01/21 7:30:00 MST, Weight Dosing
Start Date: 1/25/22
Stop Date: 4/26/22
Status: Completed
doxycycline monohydrate 100 mg oral capsule
1 cap, Oral, Daily, X 30 days, # 30 cap, 0 Refill(s), Signed: 4/26/22 9:23:00 AM MDT, Hard Stop, 4/26/22 11:58:46 AM MDT, Pharmacy: Walmart Pharmacy 5234,
163, cm, 03/02/22 11:13:00 MST, Height/Length Measured, 74.7, kg, 02/27/22 13:30:00 MST, Weight Dosing
Start Date: 4/26/22
Stop Date: 4/26/22
Status: Completed
doxycycline monohydrate 100 mg oral capsule
1 cap, Oral, BID, X 90 days, # 180 cap, 0 Refill(s), Signed: 1/25/22 9:34:00 AM MST, Hard Stop, 1/25/22 3:41:07 PM MST, Pharmacy: COSTCO PHARMACY # 484,
163, cm, 01/19/21 15:34:00 MST, Height/Length Measured, 85.73, kg, 02/01/21 7:30:00 MST, Weight Dosing
Start Date: 1/25/22
Stop Date: 1/25/22
Status: Completed
doxycycline monohydrate 100 mg oral tablet
1 tabs, Oral, BID, X 7 days, # 14 tabs, 0 Refill(s), Signed: 5/29/23 9:26:00 PM MDT, Acute, 6/5/23 9:26:00 PM MDT, .er
Start Date: 5/29/23
Stop Date: 6/5/23
Status: Completed
hydrOXYzine hydrochloride 50 mg oral tablet
1 tabs, Oral, 0 Refill(s), Signed: 3/1/22 9:32:00 AM MST, Maintenance
Start Date: 3/1/22
Stop Date: 5/14/24
Status: Completed
ISOtretinoin 40 mg oral capsule
2 cap, Oral, Daily, Take 2 pills daily with food, # 60 cap, 0 Refill(s), Signed: 12/1/22 10:10:00 AM MST, Hard Stop, Pharmacy: Walmart Neighborhood Market 4100,
ipledge number: 8512352665, 163, cm, 11/25/22 18:19:00 MST, Height/Length Measured, 74.7, kg, 02/27/22 13:30:00 MST, Weight Dosing
Start Date: 12/1/22
Stop Date: 1/11/23
Status: Completed
ISOtretinoin 40 mg oral capsule
2 cap, Oral, Daily, # 60 cap, 0 Refill(s), Signed: 7/28/22 10:00:00 AM MDT, Hard Stop, Pharmacy: Walmart Pharmacy 5234, 163, cm, 03/02/22 11:13:00 MST,
Height/Length Measured, 74.7, kg, 02/27/22 13:30:00 MST, Weight Dosing
Start Date: 7/28/22
Stop Date: 9/30/22
Status: Completed
ISOtretinoin 40 mg oral capsule
2 cap, Oral, Daily, Take 2 pills daily with food, # 60 cap, 0 Refill(s), Signed: 9/30/22 4:25:00 PM MDT, Hard Stop, Pharmacy: Walmart Pharmacy 5234, 163, cm,
07/28/22 10:25:00 MDT, Height/Length Measured, 74.7, kg, 02/27/22 13:30:00 MST, Weight Dosing
Start Date: 9/30/22
Stop Date: 10/27/22
Status: Completed

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ISOtretinoin 40 mg oral capsule
2 cap, Oral, Daily, Take 2 pills daily with food, # 60 cap, 0 Refill(s), Signed: 10/27/22 9:58:00 AM MDT, Hard Stop, Pharmacy: Walmart Neighborhood Market 4100,
ipledge number: 8512352665, 163, cm, 07/28/22 10:25:00 MDT, Height/Length Measured, 74.7, kg, 02/27/22 13:30:00 MST, Weight Dosing
Start Date: 10/27/22
Stop Date: 12/1/22
Status: Completed
ISOtretinoin 40 mg oral capsule
1 cap, Oral, Daily, # 30 cap, 0 Refill(s), Signed: 5/27/22 1:22:00 PM MDT, Maintenance, Pharmacy: CVS/pharmacy #10230, 1 cap Oral Daily, ipledge #:
8512352665, 163, cm, 03/02/22 11:13:00 MST, Height/Length Measured, 74.7, kg, 02/27/22 13:30:00 MST, Weight Dosing
Start Date: 5/27/22
Stop Date: 6/22/22
Status: Completed
ISOtretinoin 40 mg oral capsule
2 cap, Oral, Daily, Take 2 pills daily with food, # 60 cap, 0 Refill(s), Signed: 1/11/23 2:13:00 PM MST, Hard Stop, Pharmacy: Walmart Neighborhood Market 4100,
ipledge number: 8512352665, 163, cm, 11/25/22 18:19:00 MST, Height/Length Measured, 74.7, kg, 02/27/22 13:30:00 MST, Weight Dosing
Start Date: 1/11/23
Stop Date: 2/9/23
Status: Completed
Minipress 1 mg oral capsule
1 cap, Oral, Daily at bedtime, # 30 cap, 0 Refill(s), Signed: 11/3/20 1:16:00 PM MST, Maintenance, Pharmacy: WALGREENS DRUG STORE #02519, 1 cap Oral Daily
at bedtime, 162.56, cm, 10/31/20 14:09:00 MDT, Height/Length Measured, 83.2, kg, 10/30/20 20:56:00 MDT, Weight Dosing
Start Date: 11/3/20
Stop Date: 1/18/21
Status: Completed
Mounjaro 2.5 mg/0.5 mL subcutaneous solution
2.5 mg, SubCutaneous, every week, # 1 EA, 2 Refill(s), Signed: 10/16/24 10:17:00 AM MDT, Maintenance, Pharmacy: Walmart Neighborhood Market 4100, 2.5 mg
SubCutaneous every week, 162, cm, 10/16/24 9:58:00 MDT, Height/Length Measured, 85.5, kg, 10/16/24 10:01:00 MDT, Weight Dosing
Start Date: 10/16/24
Status: Ordered
Norco 5 mg-325 mg oral tablet
1 tabs, Oral, every 4 hr, PRN as needed for pain, # 7 tabs, 0 Refill(s), Signed: 9/18/24 10:28:00 AM MDT, Acute, 9/22/24 12:00:00 AM MDT, Pharmacy: Walmart
Neighborhood Market 4100, 1 tabs Oral every 4 hr,PRN:as needed for pain, 163, cm, 09/18/24 7:25:00 MDT, Height/Length Measured, 88.6, kg, 09/18/24 7:57:00
MDT, Weight Dosing
Start Date: 9/18/24
Stop Date: 9/22/24
Status: Completed
omeprazole 20 mg oral delayed release capsule
20 mg, Oral, Daily, X 30 days, # 30 cap, 0 Refill(s), Signed: 2/27/22 4:47:00 PM MST, Acute, .er
Start Date: 2/27/22
Stop Date: 3/29/22
Status: Completed
pantoprazole 40 mg oral delayed release tablet
40 mg, Oral, Daily, X 30 days, # 30 tabs, 0 Refill(s), Signed: 9/22/23 2:51:00 PM MDT, Acute, .er
Start Date: 9/22/23
Stop Date: 10/22/23
Status: Completed
prazosin
Oral, TID, 0 Refill(s), Signed: 7/1/23 8:13:00 PM MDT, Maintenance
Start Date: 7/1/23
Stop Date: 5/14/24
Status: Completed
prazosin 1 mg oral capsule
1 cap, Oral, Daily at bedtime, # 30 cap, 0 Refill(s), Signed: 1/19/21 12:07:00 PM MST, Maintenance
Start Date: 1/19/21
Stop Date: 3/1/22
Status: Completed
promethazine 25 mg oral tablet
1 tabs, Oral, every 6 hr, PRN as needed for nausea/vomiting, X 4 days, # 12 tabs, 0 Refill(s), Signed: 9/28/24 9:05:00 PM MDT, Acute, 10/2/24 9:05:00 PM MDT,
Pharmacy: WALGREENS DRUG STORE #11734, 1 tabs Oral every 6 hr,x4 days,PRN:as needed for nausea/vomiting, .er Phenergan, 160, cm, 09/28/24 18:19:00
MDT, Height/Length Measured, 85.2, kg, 09/28/24 18:20:00 MDT, Weight Dosing
Start Date: 9/28/24

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10/24/2024 Continuity of Care Document
Stop Date: 10/2/24
Status: Completed
Promethazine DM 6.25 mg-15 mg/5 mL oral syrup
5 mL, Oral, every 6 hr, PRN as needed for cough, # 120 mL, 0 Refill(s), Signed: 3/30/24 4:25:00 PM MDT, Acute, Pharmacy: Walmart Neighborhood Market 4100, 5
mL Oral every 6 hr,PRN:as needed for cough, 160, cm, 03/30/24 15:42:00 MDT, Height/Length Measured, 88.3, kg, 02/23/24 15:26:00 MST, Weight Dosing, Cough
Start Date: 3/30/24
Stop Date: 4/6/24
Status: Completed
ramelteon 8 mg oral tablet
1 tabs, Oral, Daily at bedtime, # 30 tabs, 0 Refill(s), Signed: 1/19/21 12:31:00 PM MST, Maintenance
Start Date: 1/19/21
Stop Date: 6/22/22
Status: Completed
Semaglutide (Eqv-Wegovy) (1.7 mg dose) subcutaneous solution
1.7 mg, SubCutaneous, every week, # 2 mL, 1 Refill(s), Signed: 9/25/24 1:09:00 PM MDT, Acute, Pharmacy: Walmart Neighborhood Market 4100, 1.7 mg
SubCutaneous every week, 161, cm, 09/25/24 12:48:00 MDT, Height/Length Measured, 87.5, kg, 09/25/24 12:52:00 MDT, Weight Dosing
Start Date: 9/25/24
Stop Date: 9/26/24
Status: Completed
Slow Fe (as elemental iron) 45 mg oral tablet, extended release
1 tabs, Oral, Daily, # 30 tabs, 0 Refill(s), Signed: 3/1/22 9:33:00 AM MST, Maintenance
Start Date: 3/1/22
Stop Date: 6/22/22
Status: Completed
Sprintec
1 tabs, Oral, Daily, Signed: 5/14/24 6:36:00 PM MDT, Maintenance
Start Date: 5/14/24
Status: Ordered
Sprintec 0.25 mg-35 mcg oral tablet
112 EA, 0 Refill(s), TAKE 1 TABLET BY MOUTH ONCE DAILY, TAKING 21 DAYS OF ACTIVE TABLETS, THEN SKIP PLACEBOS AND START NEXT PACK, 0 Refill(s), Signed:
3/30/24 3:51:00 PM MDT, Soft Stop
Start Date: 3/30/24
Stop Date: 5/14/24
Status: Completed
Tessalon 200 mg oral capsule
1 cap, Oral, TID, PRN as needed for cough, # 30 cap, 0 Refill(s), Signed: 3/30/24 4:25:00 PM MDT, Acute, 4/6/24 12:00:00 AM MDT, Pharmacy: Walmart
Neighborhood Market 4100, 1 cap Oral TID,PRN:as needed for cough, 160, cm, 03/30/24 15:42:00 MDT, Height/Length Measured, 88.3, kg, 02/23/24 15:26:00 MST,
Weight Dosing, Cough
Start Date: 3/30/24
Stop Date: 4/6/24
Status: Completed
Topamax 25 mg oral tablet
1 tabs, Oral, Daily at bedtime, # 30 tabs, 0 Refill(s), Signed: 11/3/20 1:16:00 PM MST, Maintenance, Pharmacy: WALGREENS DRUG STORE #02519, 1 tabs Oral
Daily at bedtime, 162.56, cm, 10/31/20 14:09:00 MDT, Height/Length Measured, 83.2, kg, 10/30/20 20:56:00 MDT, Weight Dosing
Start Date: 11/3/20
Stop Date: 1/19/21
Status: Completed
topiramate 50 mg oral tablet
1 tabs, Oral, Daily at bedtime, 0 Refill(s), Signed: 1/19/21 12:31:00 PM MST, Maintenance
Start Date: 1/19/21
Stop Date: 3/1/22
Status: Completed
traZODone
150 mg, Oral, BID, 0 Refill(s), Signed: 3/1/22 9:29:00 AM MST, Maintenance
Start Date: 3/1/22
Stop Date: 6/22/22
Status: Completed
traZODone 50 mg oral tablet
1 tabs, Oral, Daily at bedtime, Signed: 5/14/24 6:36:00 PM MDT, Maintenance
Start Date: 5/14/24
Status: Ordered

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10/24/2024 Continuity of Care Document
tretinoin 0.025% topical cream
1 appl, Topical, Daily at bedtime, # 45 g, 11 Refill(s), Signed: 1/25/22 3:40:00 PM MST, Maintenance, Pharmacy: Walmart Pharmacy 5234, 1 appl Topical Daily at
bedtime, 163, cm, 01/19/21 15:34:00 MST, Height/Length Measured, 85.73, kg, 02/01/21 7:30:00 MST, Weight Dosing
Start Date: 1/25/22
Stop Date: 6/22/22
Status: Completed
tretinoin 0.025% topical cream
1 appl, Topical, Daily at bedtime, # 45 g, 11 Refill(s), Signed: 1/25/22 9:34:00 AM MST, Hard Stop, Pharmacy: COSTCO PHARMACY # 484, 163, cm, 01/19/21
15:34:00 MST, Height/Length Measured, 85.73, kg, 02/01/21 7:30:00 MST, Weight Dosing
Start Date: 1/25/22
Stop Date: 1/25/22
Status: Completed
Vraylar
0 Refill(s), Signed: 6/1/23 2:26:00 PM MDT, Maintenance, Pharmacy OP Main
Start Date: 6/1/23
Stop Date: 5/14/24
Status: Completed
Vyvanse
0 Refill(s), Signed: 6/1/23 2:27:00 PM MDT, Maintenance
Start Date: 6/1/23
Stop Date: 5/14/24
Status: Completed
Vyvanse 70 mg oral capsule
1 cap, Oral, every morning, 0 Refill(s), Signed: 5/14/24 6:36:00 PM MDT, Maintenance
Start Date: 5/14/24
Status: Ordered
Zofran ODT 4 mg oral tablet, disintegrating
4 mg, Oral, every 6 hr, PRN as needed for nausea/vomiting, X 3 days, # 10 tabs, 0 Refill(s), Signed: 9/28/24 9:05:00 PM MDT, Acute, 10/1/24 9:05:00 PM MDT,
Pharmacy: WALGREENS DRUG STORE #11734, 4 mg Oral every 6 hr,x3 days,PRN:as needed for nausea/vomiting, .er, 160, cm, 09/28/24 18:19:00 MDT,
Height/Length Measured, 85.2, kg, 09/28/24 18:20:00 MDT, Weight Dosing
Start Date: 9/28/24
Stop Date: 10/1/24
Status: Completed
Zofran ODT 4 mg oral tablet, disintegrating
1 tabs, Oral, TID, X 3 days, # 9 tabs, 0 Refill(s), Signed: 7/1/23 8:37:00 PM MDT, Acute, 7/4/23 8:37:00 PM MDT, Pharmacy: WALGREENS DRUG STORE #11734, 1
tabs Oral TID,x3 days, 161, cm, 07/01/23 20:10:00 MDT, Height/Length Measured, 87.3, kg, 07/01/23 20:12:00 MDT, Weight Dosing, Nauseous
Start Date: 7/1/23
Stop Date: 7/4/23
Status: Completed
Zofran ODT 4 mg oral tablet, disintegrating
1 tabs, Oral, every 8 hr, PRN as needed for nausea/vomiting, X 4 days, # 12 tabs, 0 Refill(s), Signed: 2/27/22 4:46:00 PM MST, Acute, 3/3/22 4:46:00 PM MST, .er
Start Date: 2/27/22
Stop Date: 3/3/22
Status: Completed
Zofran ODT 4 mg oral tablet, disintegrating
4 mg, Oral, every 6 hr, PRN as needed for nausea/vomiting, X 3 days, # 10 tabs, 0 Refill(s), Signed: 9/22/23 2:51:00 PM MDT, Acute, 9/25/23 2:51:00 PM MDT, .er
Start Date: 9/22/23
Stop Date: 9/25/23
Status: Completed
zolpidem 12.5 mg oral tablet, extended release
1 tabs, Oral, Daily at bedtime, # 30 tabs, 0 Refill(s), Signed: 11/3/20 1:17:00 PM MST, Maintenance
Start Date: 11/3/20
Stop Date: 1/18/21
Status: Completed

Mental Status

9/28/24

Orientation Assessment Oriented x 4

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Problem List

Condition Confirmation Course Effective Dates Status Health Status Informant

Attention deficit Confirmed Active

disorder (ADD) in adult

Anemia Confirmed Active

Anorexia nervosa, Confirmed Active

restricting type,
moderate

Anorexia nervosa, Confirmed Active

restricting type, in
partial remission,
moderate

Bicornate uterus Confirmed Active

Bicuspid aortic valve Confirmed Active

BMI 35.0-35.9,adult Confirmed Active

BMI 33.0-33.9,adult Confirmed Active

Borderline personality Confirmed Active

disorder

Dependent personality Confirmed Active

disorder

Sleep disturbance Confirmed Active

Endometriosis Confirmed Active

Fatigue Confirmed Active

GAD (generalized Confirmed Active

anxiety disorder)

S/P repair of coarctation Confirmed Active

of aorta

Menorrhagia Confirmed Active

Class 1 obesity Confirmed Active

Class 2 obesity Confirmed Active

Female pelvic pain Confirmed Active

PTSD (post-traumatic Confirmed Active

stress disorder)

Depression, major, Confirmed Active

recurrent, mild

Syncope Confirmed Active

Diagnosis Diagnosis Type Effective Dates Health Status Clinical Service Informant

Anorexia nervosa, restricting Discharge Diagnosis 12/12/22

type, moderate

Borderline personality Discharge Diagnosis 12/12/22

disorder

Nightmares Discharge Diagnosis 12/12/22

Depression, major, Discharge Diagnosis 12/12/22

recurrent, moderate

PTSD (post-traumatic stress Discharge Diagnosis 12/12/22

disorder)

Anemia Discharge Diagnosis 5/24/24

Borderline personality Discharge Diagnosis 5/24/24

disorder

Syncope Discharge Diagnosis 5/24/24

Recurrent major depression- Discharge Diagnosis 5/24/24

severe

Syncope and collapse Discharge Diagnosis 5/24/24 Non-Specified

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Diagnosis Diagnosis Type Effective Dates Health Status Clinical Service Informant

Nausea and vomiting Discharge Diagnosis 2/27/22

Hematemesis Discharge Diagnosis 2/27/22

Anemia Discharge Diagnosis 5/29/24

Syncope Discharge Diagnosis 5/29/24

Bicuspid aortic valve Discharge Diagnosis 5/29/24

S/P repair of coarctation of Discharge Diagnosis 5/29/24

aorta

GI bleed Discharge Diagnosis 9/22/23 Non-Specified

Gastritis Discharge Diagnosis 9/22/23

Anxiety and depression Discharge Diagnosis 9/23/23

Acute stress reaction Discharge Diagnosis 9/27/23

Acne vulgaris Discharge Diagnosis 1/5/23

High risk medication use Discharge Diagnosis 1/5/23

Syncope Discharge Diagnosis 6/7/24

Anxiety reaction Discharge Diagnosis 6/7/24

Chest pain Discharge Diagnosis 6/7/24

Anxiety reaction Discharge Diagnosis 6/8/24

Elevated blood pressure Discharge Diagnosis 6/8/24

reading

Chest pain Discharge Diagnosis 6/9/24

Tachycardia Discharge Diagnosis 6/8/24

High risk medication use Discharge Diagnosis 1/11/23

Acne vulgaris Discharge Diagnosis 1/11/23

Cheilitis Discharge Diagnosis 1/11/23

Recurrent major depression- Discharge Diagnosis 6/13/24

severe

Syncope Discharge Diagnosis 6/13/24

Anemia Discharge Diagnosis 6/13/24

Syncope Discharge Diagnosis 6/14/24

Bicuspid aortic valve Discharge Diagnosis 6/14/24

Recurrent major depression- Discharge Diagnosis 10/20/23

severe

PTSD (post-traumatic stress Discharge Diagnosis 10/20/23

disorder)

Anemia Discharge Diagnosis 10/20/23

Routine check-up Discharge Diagnosis 10/20/23

Attention deficit disorder Discharge Diagnosis 10/20/23

(ADD) in adult

Routine check-up Discharge Diagnosis 10/20/23 Non-Specified

Anemia Discharge Diagnosis 10/20/23 Non-Specified

Depression Discharge Diagnosis 1/27/23

Anxiety Discharge Diagnosis 1/27/23

Anxiety Discharge Diagnosis 2/3/23

Menorrhagia Discharge Diagnosis 11/1/23

Anorexia nervosa, restricting Discharge Diagnosis 11/1/23

type, in partial remission,
moderate

Anemia Discharge Diagnosis 11/1/23

Acne vulgaris Discharge Diagnosis 2/9/23

High risk medication use Discharge Diagnosis 2/9/23

Dry lips Discharge Diagnosis 2/9/23

High risk medication use Discharge Diagnosis 4/26/22 Non-Specified

Acne vulgaris Discharge Diagnosis 4/26/22 Non-Specified

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Diagnosis Diagnosis Type Effective Dates Health Status Clinical Service Informant

Bicornuate uterus Discharge Diagnosis 11/8/23

Heavy menses Discharge Diagnosis 11/8/23

Anemia Discharge Diagnosis 7/15/24

Recurrent major depression- Discharge Diagnosis 7/15/24

severe

Hypokalemia Discharge Diagnosis 7/16/24

Hypomagnesemia Discharge Diagnosis 7/16/24

Fatigue Discharge Diagnosis 7/17/24

Encounter for Papanicolaou Discharge Diagnosis 11/16/23

smear of cervix

Retained Tampon Discharge Diagnosis 11/30/17

Acne vulgaris Discharge Diagnosis 3/8/23

High risk medication use Discharge Diagnosis 3/8/23

Dry lips Discharge Diagnosis 3/8/23

Morbid obesity Discharge Diagnosis 7/31/24

Dermatitis Discharge Diagnosis 7/31/24

Anemia Discharge Diagnosis 7/31/24

Recurrent major depression- Discharge Diagnosis 7/31/24

severe

Hypomagnesemia Discharge Diagnosis 7/31/24 Non-Specified

Recurrent major depression- Discharge Diagnosis 7/31/24 Non-Specified

severe

Fatigue Discharge Diagnosis 7/31/24 Non-Specified

Hypokalemia Discharge Diagnosis 7/31/24 Non-Specified

Anemia Discharge Diagnosis 7/31/24 Non-Specified

Dermatitis of eyelid of left Discharge Diagnosis 7/31/24

eye

Acne vulgaris Discharge Diagnosis 5/27/22

High risk medication use Discharge Diagnosis 5/27/22

High risk medication use Discharge Diagnosis 3/15/23 Non-Specified

Acne vulgaris Discharge Diagnosis 3/15/23 Non-Specified

Recurrent major depression- Discharge Diagnosis 8/7/24

severe

Attention deficit disorder Discharge Diagnosis 8/7/24

(ADD) in adult

BMI 35.0-35.9,adult Discharge Diagnosis 8/7/24

Class 2 obesity Discharge Diagnosis 8/7/24

PTSD (post-traumatic stress Discharge Diagnosis 8/7/24

disorder)

Retained tampon Discharge Diagnosis 8/13/24

Syncope Discharge Diagnosis 8/17/24

Female pelvic pain Discharge Diagnosis 8/21/24

Bicornate uterus Discharge Diagnosis 8/21/24

Morbid obesity Discharge Diagnosis 8/22/24

Syncope Discharge Diagnosis 8/22/24

Anemia, iron deficiency Discharge Diagnosis 6/22/22 Non-Specified

S/P repair of coarctation of Discharge Diagnosis 2/6/18

aorta

Bicuspid aortic valve Discharge Diagnosis 2/6/18

Syncope Discharge Diagnosis 8/29/24

Headache Discharge Diagnosis 8/31/24

Closed head injury Discharge Diagnosis 8/31/24

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Diagnosis Diagnosis Type Effective Dates Health Status Clinical Service Informant

Traumatic hematoma of Discharge Diagnosis 8/31/24

head

Acne vulgaris Discharge Diagnosis 6/30/22

High risk medication use Discharge Diagnosis 6/30/22

Closed head injury Discharge Diagnosis 9/1/24

Migraine headache Discharge Diagnosis 9/1/24

Depressed mood Discharge Diagnosis 6/30/22

Cheilitis Discharge Diagnosis 6/30/22

Suicidal ideation Discharge Diagnosis 4/20/23

Borderline personality Discharge Diagnosis 4/20/23

disorder

Depression, major, Discharge Diagnosis 4/20/23

recurrent, moderate

Ingestion of bleach Discharge Diagnosis 4/20/23

Borderline personality Discharge Diagnosis 4/21/23

disorder

Depression, major, Discharge Diagnosis 4/21/23

recurrent, moderate

Female pelvic pain Discharge Diagnosis 9/18/24

Endometriosis Discharge Diagnosis 9/18/24

Acne vulgaris Discharge Diagnosis 7/28/22

High risk medication use Discharge Diagnosis 7/28/22

Xerosis of skin Discharge Diagnosis 7/28/22

Dry lips Discharge Diagnosis 7/28/22

Dry eyes Discharge Diagnosis 7/28/22

Class 1 obesity Discharge Diagnosis 9/25/24

BMI 33.0-33.9,adult Discharge Diagnosis 9/25/24

Endometriosis Discharge Diagnosis 9/25/24

Sleep disturbance Discharge Diagnosis 9/25/24

Recurrent major depression- Discharge Diagnosis 9/25/24

severe

GAD (generalized anxiety Discharge Diagnosis 9/25/24

disorder)

Depression, major, Discharge Diagnosis 9/25/24

recurrent, mild

Anorexia nervosa, restricting Discharge Diagnosis 9/25/24

type, in partial remission,
moderate

PTSD (post-traumatic stress Discharge Diagnosis 9/25/24

disorder)

Dependent personality Discharge Diagnosis 9/25/24

disorder

Attention deficit disorder Discharge Diagnosis 9/25/24

(ADD) in adult

Abdominal pain Discharge Diagnosis 9/28/24

Post-operative pain Discharge Diagnosis 9/28/24

Vomiting Discharge Diagnosis 9/28/24

Hypokalemia Discharge Diagnosis 9/28/24

Depression with suicidal Discharge Diagnosis 5/18/23

ideation

Vision changes Discharge Diagnosis 9/30/24

Viral URI Discharge Diagnosis 2/8/24

Hypothyroidism Discharge Diagnosis 10/7/24 Non-Specified

BMI 32.0-32.9,adult Discharge Diagnosis 10/7/24 Non-Specified

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Diagnosis Diagnosis Type Effective Dates Health Status Clinical Service Informant

Scalp contusion Discharge Diagnosis 5/29/23

Assault Discharge Diagnosis 5/29/23

Endometriosis Discharge Diagnosis 10/11/24

Bicornate uterus Discharge Diagnosis 10/11/24

Dependent personality Discharge Diagnosis 10/16/24

disorder

Depression, major, Discharge Diagnosis 10/16/24

recurrent, mild

Bicornate uterus Discharge Diagnosis 10/16/24

Class 1 obesity Discharge Diagnosis 10/16/24

Aphthous ulcer of mouth Discharge Diagnosis 2/23/24

Suicide attempt Discharge Diagnosis 10/30/20 Non-Specified

Borderline personality Discharge Diagnosis 6/11/23

disorder

Transient memory loss Discharge Diagnosis 6/11/23

Depression, major, Discharge Diagnosis 6/11/23

recurrent, moderate

Obesity (BMI 30-39.9) Discharge Diagnosis 10/31/20

PTSD (post-traumatic stress Discharge Diagnosis 10/31/20

disorder)

Nightmares Discharge Diagnosis 10/31/20

Alcohol use Discharge Diagnosis 10/31/20

Anorexia nervosa, restricting Discharge Diagnosis 10/31/20

type, moderate

S/P repair of coarctation of Discharge Diagnosis 10/31/20

aorta

Depression, major, Discharge Diagnosis 10/31/20

recurrent, moderate

GAD (generalized anxiety Discharge Diagnosis 10/31/20

disorder)

Borderline personality Discharge Diagnosis 10/31/20

disorder

Intentional drug overdose Discharge Diagnosis 10/31/20

Vaginal foreign body Discharge Diagnosis 6/3/16

Acute stress reaction Discharge Diagnosis 6/25/23

Nauseous Discharge Diagnosis 7/1/23

Viral pharyngitis Discharge Diagnosis 3/19/24

Tonsil stone Discharge Diagnosis 3/19/24

Acne vulgaris Discharge Diagnosis 9/30/22

High risk medication use Discharge Diagnosis 9/30/22

Xerosis of skin Discharge Diagnosis 9/30/22

Dry lips Discharge Diagnosis 9/30/22

Depression with suicidal Discharge Diagnosis 7/9/23

ideation

Cough Discharge Diagnosis 3/30/24

Acne vulgaris Discharge Diagnosis 10/27/22

High risk medication use Discharge Diagnosis 10/27/22

Dry lips Discharge Diagnosis 10/27/22

Xerosis of skin Discharge Diagnosis 10/27/22

Dry eyes Discharge Diagnosis 10/27/22

Confusion Discharge Diagnosis 1/18/21

Post traumatic stress Discharge Diagnosis 1/19/21 Non-Specified

disorder (PTSD)

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Diagnosis Diagnosis Type Effective Dates Health Status Clinical Service Informant

Head injury Discharge Diagnosis 1/18/21

Traumatic hematoma of Discharge Diagnosis 1/18/21

forehead

Confusion Discharge Diagnosis 1/19/21

Alcohol use Discharge Diagnosis 1/19/21

Depression, major, Discharge Diagnosis 1/19/21

recurrent, moderate

Post traumatic stress Discharge Diagnosis 1/19/21

disorder (PTSD)

Sexual assault of adult Discharge Diagnosis 1/19/21

Abrasion Discharge Diagnosis 1/19/21

Suicidal ideations Discharge Diagnosis 8/5/23

Acne vulgaris Discharge Diagnosis 1/25/22

Sore throat Discharge Diagnosis 11/25/22

Acne vulgaris Discharge Diagnosis 12/1/22

High risk medication use Discharge Diagnosis 12/1/22

Dry lips Discharge Diagnosis 12/1/22

Dry eyes Discharge Diagnosis 12/1/22

Recurrent syncope Discharge Diagnosis 5/14/24

PTSD (post-traumatic stress Discharge Diagnosis 5/14/24

disorder)

S/P repair of coarctation of Discharge Diagnosis 5/14/24

aorta

Metabolic acidosis Discharge Diagnosis 5/14/24

Anorexia nervosa, restricting Discharge Diagnosis 5/14/24

type, in partial remission,
moderate

Leukocytosis Discharge Diagnosis 5/14/24

Anemia Discharge Diagnosis 5/14/24

Borderline personality Discharge Diagnosis 5/14/24

disorder

Depression, major, Discharge Diagnosis 5/14/24

recurrent, moderate

Bicuspid aortic valve Discharge Diagnosis 5/14/24

Attention deficit disorder Discharge Diagnosis 5/14/24

(ADD) in adult

Menorrhagia Discharge Diagnosis 5/14/24

Hypokalemia Discharge Diagnosis 5/14/24

SIRS without infection or Discharge Diagnosis 5/14/24

organ dysfunction

Procedures

Procedure Date Related Diagnosis Body Site Status

Laparoscopic Diagnostic (No Laterality)1 9/18/24 Completed

Esophagogastroduodenoscopy 2 3/2/22 Completed

Transcatheter intracardiac shunt (TIS) creation by stent placement for Completed

congenital cardiac anomalies to establish effective intracardiac flow,
including all imaging guidance by the proceduralist, when performed,

left and right heart diagnostic cardiac cath 3

1 auto-populated from documented surgical case

2 auto-populated from documented surgical case
3 surgery as an infant/toddler

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Results

Laboratory List

Name Date

Thyroid Stimulating Hormone with reflex free T4 (TSH with reflex FT4) 10/7/24

CBC w/ Auto Diff 9/30/24

Comprehensive Metabolic Panel (CMP) 9/30/24

CBC w/ Auto Diff 9/28/24

Comprehensive Metabolic Panel (CMP) 9/28/24

Lipase Level 9/28/24

Comprehensive Metabolic Panel (COMPREHENSIVE METABOLIC PANEL) 9/28/24

HCG, Beta Quant, Serum (HCG, BETA QUANTITATIVE) 9/28/24

Urinalysis with Microscopic (UA with Microscopic and Reflex Criteria for Urine Culture) 9/28/24

Urine Culture Reflex Criteria 9/28/24

CBC w/ Auto Diff 9/28/24

Clinitek Status Point of Care Testing (CLINITEK STATUS POC TESTING) 9/18/24

HCG, Beta Qual, Serum 8/17/24

Thyroid Stimulating Hormone with reflex free T4 (TSH with reflex FT4) 8/17/24

Magnesium Level 7/31/24

Thyroid Stimulating Hormone (TSH) 7/31/24

Vitamin B12 Level 7/31/24

Vitamin D 25 Hydroxy Level 7/31/24

DDimer, Quantitative 6/8/24

HCG, Beta Qual, Serum 6/8/24

Magnesium Level 6/8/24

CBC w/ Auto Diff 6/7/24

HCG, Beta Qual, Serum 6/7/24

CBC w/ Auto Diff (CBC WITH AUTO DIFF) 5/29/24

Free T4 Level (Free T4) 5/29/24

Magnesium Level 5/29/24

Ferritin 5/15/24

Iron Level and TIBC 5/15/24

B-Type Natriuretic Peptide (BNP) 5/14/24

Lactic Acid, Plasma (Venous) 5/14/24

DDimer, Quantitative 5/14/24

Beta Hydroxybutyrate (BOH, B-OH) 5/14/24

Blood Gas Sample Collection 5/14/24

Venous Blood Gas with Co-ox (Respiratory) (VBG - Venous Blood Gas w/ Co-ox (Resp)) 5/14/24

CBC w/ Auto Diff 5/14/24

Phosphorus Level 5/14/24

Troponin (cardiac marker) 5/14/24

Urinalysis with Microscopic (UA with Microscopic and Reflex Criteria for Urine Culture) 5/14/24

Urine Culture Reflex Criteria 5/14/24

Manual Entry - Rapid Strep POC 2/8/24

Gonorrhea and Chlamydia (Adult/Cobas) by NAAT, Swab (GONORRHEA and CHLAMYDIA (GC/CT) by NAAT, SWAB) 11/17/23

Hemoglobin A1c (Glycosylated) 10/20/23

Lipid Panel (Chol, Trig, HDL, LDL, VLDL) 10/20/23

Lipase Level 9/22/23

HCG, Beta Quant, Serum 6/11/23

SARS-CoV-2, FLU and RSV by RT-PCR 6/11/23

Serum Drug Tox Screen 6/11/23

Drugs of Abuse Screen, Urine toxicology 6/1/23

HCG, Beta Quant, Serum 6/1/23

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Name Date

SARS-CoV-2, FLU and RSV by RT-PCR 6/1/23

Serum Drug Tox Screen 6/1/23

Drugs of Abuse Screen, Urine toxicology 4/20/23

Drug Confirmation/Quantitation by MS (DRUG CONFIRMATION/QUANTITATION BY MS) 4/20/23

HCG, Beta Qual, Serum 4/20/23

SARS-CoV-2, FLU and RSV by RT-PCR 4/20/23

Serum Drug Tox Screen 4/20/23

HCG Qualitative Urine 3/15/23

Manual Entry - Rapid Strep POC 11/25/22

SARS-CoV-2 by PCR (TF) 2/28/22

CBC w/ Auto Diff 2/27/22

Comprehensive Metabolic Panel (CMP) 2/27/22

Fecal Occult Blood (Guaiac), Random 2/27/22

HCG, Beta Quant, Serum 2/27/22

Lipase Level 2/27/22

Urinalysis with Microscopic (UA with Microscopic and Reflex Criteria for Urine Culture) 2/27/22

Urine Culture Reflex Criteria 2/27/22

Comprehensive Metabolic Panel (CMP) 1/18/21

Drugs of Abuse Screen, Urine toxicology 1/18/21

HCG, Beta Qual, Serum 1/18/21

Urinalysis with Microscopic (UA with Microscopic and Reflex Criteria for Urine Culture) 1/18/21

Basic Metabolic Panel (BMP) 11/1/20

Fasting Plasma Glucose 11/1/20

Lipid Panel (Chol, Trig, HDL, LDL, VLDL) (Fasting Lipid Profile) 11/1/20

Phosphorus Level 11/1/20

SARS-CoV-2 by PCR (Cepheid) 10/31/20

HCG, Beta Qual, Serum 10/30/20

Most recent to oldest

1 2 3
[Reference Range]:

D-dimer, quant. (ug/mL) [0.00- 0.35 mcg FEU/mL 1 0.49 mcg FEU/mL 2
0.50 mcg FEU/mL] (6/8/24 9:58 PM) (5/14/24 3:47 PM)

Blood Gas Draw Type Venous

(5/14/24 4:46 PM)

est CrCl (Ideal BW for dosing) 78.15 mL/min 3 75.65 mL/min 4 64.60 mL/min 5
(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 1:24 AM)

est CrCl (Actual BW for dosing) 126.36 mL/min 6 123.05 mL/min 7 102.79 mL/min 8
(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 1:24 AM)

Blood Gas Draw Time 2024/05/14 16:46:00

(5/14/24 4:46 PM)

Cmt: SARS-CoV-2 by PCR See Comments 9

(Cepheid) (10/30/20 11:59 PM)

SARS-CoV-2 by PCR (Cepheid) Not detected Not detected Not detected

[Not detected] (6/11/23 9:12 PM) (6/1/23 2:44 PM) (4/20/23 8:28 PM)

SARS-CoV-2 by PCR (TF) [Not Not detected

detected] (2/28/22 11:13 PM)

Cmt: SARS-CoV-2 by PCR (TF) See Comments 10

(2/28/22 11:13 PM)

Cmt2: SARS-CoV-2 by PCR See Comments 11

(2/28/22 11:13 PM)

Cmt5: SARS-CoV-2 by PCR See Comments 12 See Comments 13 See Comments 14

(6/11/23 9:12 PM) (6/1/23 2:44 PM) (4/20/23 8:28 PM)

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1 2 3
[Reference Range]:

Cmt: SARS-CoV-2, FLU and RSV See Comments 15 See Comments 16 See Comments 17
by RT PCR (6/11/23 9:12 PM) (6/1/23 2:44 PM) (4/20/23 8:28 PM)

Barometric Pressure 642 mmHg

(5/14/24 4:46 PM)

Temperature C 37.0
(5/14/24 4:46 PM)

Performed by hry08930
(5/14/24 4:46 PM)

pO2 Temp Corrected Ven 27

(5/14/24 4:46 PM)

Blood Gas Specimen Source Arterial

(5/14/24 4:46 PM)

Critical Value Type Printed Report given

(5/14/24 4:46 PM)

Crtiical Value Notification Date 05/14/2024

(5/14/24 4:46 PM)

Critical Value Notification Time 16:49

(5/14/24 4:46 PM)

Critical Value Notification to Jamie Matgzer RN

(5/14/24 4:46 PM)

pH Temp Corrected Ven 7.405

(5/14/24 4:46 PM)

pCO2 Temp Corrected Ven 32.80

(5/14/24 4:46 PM)

HCO3 [18.6-25.3 mmol/L] 20.1 mmol/L

(5/14/24 4:46 PM)

Fentanyl Screen, Ur [Negative] Negative 18 Negative 19

(6/1/23 2:44 PM) (4/20/23 9:37 PM)

WBC [3.6-10.6 K/mcL] 10.6 K/mcL 10.3 K/mcL 15.4 K/mcL

(9/30/24 12:53 PM) (9/28/24 7:17 PM) *HI*
(9/28/24 12:29 AM)

RBC [4.20-5.40 x10^6/mcL] 4.87 x10^6/mcL 4.59 x10^6/mcL 4.82 x10^6/mcL

(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

Neutrophil % Auto 77.9 % 78.9 % 80.6 %

(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

Lymphocyte % Auto 14.5 % 12.5 % 11.2 %

(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

Monocyte % Auto 6.1 % 7.5 % 7.3 %

(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

Eosinophil % Auto 0.6 % 0.2 % 0.1 %

(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

Basophil % Auto 0.6 % 0.6 % 0.5 %

(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

BUN [8-20 mg/dL] 6 mg/dL 7 mg/dL 12 mg/dL

*LOW* *LOW* (9/28/24 1:24 AM)
(9/30/24 12:53 PM) (9/28/24 7:17 PM)

Cholesterol Total [122-199 230 mg/dL 211 mg/dL

mg/dL] *HI* *HI*
(10/20/23 8:40 AM) (11/1/20 6:51 AM)

Amphetamine Screen Ur Negative Preliminary Report 20 Negative

[Negative] (6/1/23 2:44 PM) *ABN* (1/18/21 9:47 PM)

(4/20/23 9:37 PM)

WBC Urine [0-5 /HPF] 5 /HPF 0 /HPF 1 /HPF

(9/28/24 12:40 AM) (5/14/24 8:10 PM) (2/27/22 4:06 PM)

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[Reference Range]:

Rapid Strep POC Result Negative Positive

(2/8/24 2:45 PM) (11/25/22 6:24 PM)

LDL [<100 mg/dL] 136 mg/dL 123 mg/dL

*HI* *HI*
(10/20/23 8:40 AM) (11/1/20 6:51 AM)

Glucose Level [65-99 mg/dL] 83 mg/dL 96 mg/dL 96 mg/dL

(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 1:24 AM)

Potassium Level [3.5-5.0 3.3 mmol/L 3.2 mmol/L 3.3 mmol/L

mmol/L] *LOW* *LOW* *LOW*
(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 1:24 AM)

Benzodiazepines Ur [Negative] Negative Negative Negative

(6/1/23 2:44 PM) (4/20/23 9:37 PM) (1/18/21 9:47 PM)

MCV [80.0-100.0 fL] 79.1 fL 77.1 fL 79.5 fL

*LOW* *LOW* *LOW*
(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

RBC Morph [SRI] Slide review agrees with reported RBC Slide review agrees with reported RBC Slide review agrees with reported RBC
indices. indices. indices.
(6/7/24 4:25 PM) (5/29/24 9:52 PM) (5/14/24 3:47 PM)

HDL [40-83 mg/dL] 69 mg/dL 66 mg/dL

(10/20/23 8:40 AM) (11/1/20 6:51 AM)

Hyaline Cast [0-2 /LPF] 18 /LPF Negative /LPF 3 /LPF

*HI* (5/14/24 8:10 PM) *HI*
(9/28/24 12:40 AM) (2/27/22 4:06 PM)

T4 Free [0.93-1.70 ng/dL] 1.02 ng/dL

(5/29/24 9:35 PM)

UA Ketones [Negative mg/dL] 40(2+) mg/dL >=80(3+) mg/dL Negative mg/dL

*ABN* *ABN* (7/1/23 8:24 PM)
(9/28/24 12:40 AM) (5/14/24 8:10 PM)

AST [9-40 unit/L] 80 unit/L 47 unit/L 36 unit/L

*HI* *HI* (9/28/24 1:24 AM)
(9/30/24 12:53 PM) (9/28/24 7:17 PM)

ALT [0-40 unit/L] 88 unit/L 41 unit/L 34 unit/L

*HI* *HI* (9/28/24 1:24 AM)
(9/30/24 12:53 PM) (9/28/24 7:17 PM)

MCHC [32.0-36.0 g/dL] 31.2 g/dL 32.5 g/dL 30.5 g/dL

*LOW* (9/28/24 7:17 PM) *LOW*
(9/30/24 12:53 PM) (9/28/24 12:29 AM)

Ca Oxalate Crystal 1+
(2/27/22 4:06 PM)

Sodium Level [137-146 mmol/L] 136 mmol/L 136 mmol/L 138 mmol/L
*LOW* *LOW* (9/28/24 1:24 AM)
(9/30/24 12:53 PM) (9/28/24 7:17 PM)

RBC Urine [0-2 /HPF] 1 /HPF 1 /HPF 1 /HPF

(9/28/24 12:40 AM) (5/14/24 8:10 PM) (2/27/22 4:06 PM)

Leuk Esterase [Negative] Negative Negative Negative

(9/28/24 12:40 AM) (5/14/24 8:10 PM) (7/1/23 8:24 PM)

Chol/HDL [<4.5] 3.3 3.2

(10/20/23 8:40 AM) (11/1/20 6:51 AM)

Lymphocyte, Abs [1.2-3.4 1.5 K/mcL 1.3 K/mcL 1.7 K/mcL

K/mcL] (9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

Nitrite [Negative] Negative Negative Negative

(9/28/24 12:40 AM) (5/14/24 8:10 PM) (7/1/23 8:24 PM)

Glucose Urine [Negative mg/dL] 30 (TRACE) mg/dL Negative mg/dL Negative mg/dL
*ABN* (5/14/24 8:10 PM) (7/1/23 8:24 PM)
(9/28/24 12:40 AM)

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1 2 3
[Reference Range]:

Hematocrit [36.0-46.0 %] 38.5 % 35.4 % 38.3 %

(9/30/24 12:53 PM) *LOW* (9/28/24 12:29 AM)
(9/28/24 7:17 PM)

Bacteria Urine [Negative] Negative Negative Negative

(9/28/24 12:40 AM) (5/14/24 8:10 PM) (2/27/22 4:06 PM)

Lipase Level [10-70 unit/L] 45 unit/L 62 unit/L 39 unit/L

(9/28/24 7:17 PM) (9/22/23 1:46 PM) (2/27/22 1:52 PM)

Vitamin D 25 OH [30-80 ng/mL] 42 ng/mL

(7/31/24 12:15 PM)

Cocaine Screen Ur [Negative] Negative Negative Negative

(6/1/23 2:44 PM) (4/20/23 9:37 PM) (1/18/21 9:47 PM)

Triglycerides [36-131 mg/dL] 126 mg/dL 109 mg/dL

(10/20/23 8:40 AM) (11/1/20 6:51 AM)

Calcium Level [8.4-10.4 mg/dL] 9.6 mg/dL 9.3 mg/dL 9.3 mg/dL
(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 1:24 AM)

Phosphorus Level [2.3-4.7 2.8 mg/dL 4.3 mg/dL

mg/dL] (5/14/24 3:47 PM) (11/1/20 6:51 AM)

Albumin Level [3.5-5.2 g/dL] 4.4 g/dL 4.4 g/dL 4.3 g/dL
(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 1:24 AM)

Protein Total [6.0-8.4 g/dL] 7.8 g/dL 7.9 g/dL 7.7 g/dL
(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 1:24 AM)

Protein Urine [Negative mg/dL] 300 (3+) mg/dL Trace mg/dL Trace mg/dL
*ABN* *ABN* *ABN*
(9/28/24 12:40 AM) (5/14/24 8:10 PM) (7/1/23 8:24 PM)

Iron Sat [20-50 %] 4%

*LOW*
(5/15/24 1:10 PM)

MCH [26.0-34.0 pg] 24.6 pg 25.1 pg 24.3 pg

*LOW* *LOW* *LOW*
(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

Magnesium Level [1.9-2.8 2.1 mg/dL 1.8 mg/dL 2.0 mg/dL

mg/dL] (7/31/24 12:15 PM) *LOW* (5/29/24 9:35 PM)
(6/8/24 9:58 PM)

Neutrophil, Abs [1.8-6.8 K/mcL] 8.3 K/mcL 8.1 K/mcL 12.4 K/mcL
*HI* *HI* *HI*
(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

Cannabinoid Screen Ur Negative Negative Negative

[Negative] (6/1/23 2:44 PM) (4/20/23 9:37 PM) (1/18/21 9:47 PM)

Bilirubin Total [0.2-1.3 mg/dL] 0.4 mg/dL 0.3 mg/dL 0.3 mg/dL
(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 1:24 AM)

Hemoglobin [12.0-16.0 g/dL] 12.0 g/dL 11.5 g/dL 11.7 g/dL

(9/30/24 12:53 PM) *LOW* *LOW*
(9/28/24 7:17 PM) (9/28/24 12:29 AM)

Transferrin [190-362 mg/dL] 402 mg/dL

*HI*
(5/15/24 1:10 PM)

B12 Level [232-1245 pg/mL] 369 pg/mL

(7/31/24 12:15 PM)

Alk Phos [35-104 unit/L] 57 unit/L 53 unit/L 55 unit/L

(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 1:24 AM)

Hgb Urine [Negative] Trace Negative Negative

*ABN* (5/14/24 8:10 PM) (7/1/23 8:24 PM)
(9/28/24 12:40 AM)

MPV [8.6-12.4 fL] 8.7 fL 8.7 fL 9.3 fL

(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

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[Reference Range]:

pCO2 Ven [34-44 mmHg] 32.8 mmHg

*LOW*
(5/14/24 4:46 PM)

Salicylate Level [0.0-30.0 <5.0 mg/dL <5.0 mg/dL <5.0 mg/dL

mg/dL] (6/11/23 9:12 PM) (6/1/23 2:44 PM) (4/20/23 8:28 PM)

Ethanol Level [<13 mg/dL] <10 mg/dL 21 <10 mg/dL 22 <10 mg/dL 23
(6/11/23 9:12 PM) (6/1/23 2:44 PM) (4/20/23 8:28 PM)

Mucus Urine [Negative] 1+ 1+ 3+

*ABN* *ABN* *ABN*
(9/28/24 12:40 AM) (5/14/24 8:10 PM) (2/27/22 4:06 PM)

Specific Gravity, Urine [1.003- >1.030 <1.006 1.025

1.030] *HI* (5/14/24 8:10 PM) (7/1/23 8:24 PM)
(9/28/24 12:40 AM)

Ferritin Level [10-200 ng/mL] 7 ng/mL

*LOW*
(5/15/24 1:10 PM)

Platelets [150-400 K/mcL] 366 K/mcL 380 K/mcL 417 K/mcL

(9/30/24 12:53 PM) (9/28/24 7:17 PM) *HI*
(9/28/24 12:29 AM)

CO2 [19-30 mmol/L] 20 mmol/L 20 mmol/L 20 mmol/L

(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 1:24 AM)

TIBC [238-453 mcg/dL] 503 mcg/dL

*HI*
(5/15/24 1:10 PM)

Carboxyhemoglobin [0.0-2.5 %] 0.9 %

(5/14/24 4:46 PM)

Barbiturate Screen Ur Negative Negative Negative

[Negative] (6/1/23 2:44 PM) (4/20/23 9:37 PM) (1/18/21 9:47 PM)

Lactic Acid, Plasma (Venous) 1.2 mmol/L

[0.5-2.0 mmol/L] (5/14/24 7:05 PM)

FiO2 21.0
(5/14/24 4:46 PM)

Epithelial Cells [0-5 /HPF] 4 /HPF 5 /HPF 3 /HPF

(9/28/24 12:40 AM) (5/14/24 8:10 PM) (2/27/22 4:06 PM)

TSH [0.27-4.20 mcIU/mL] 1.81 mcIU/mL 24 3.61 mcIU/mL 25 5.35 mcIU/mL 26

(10/7/24 10:35 AM) (8/17/24 9:55 AM) *HI*
(7/31/24 12:15 PM)

Iron [37-170 mcg/dL] 22 mcg/dL

*LOW*
(5/15/24 1:10 PM)

RDW [11.3-15.6 %] 19.9 % 19.9 % 19.9 %

*HI* *HI* *HI*
(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

pO2 Ven [25-47 mmHg] 27.3 mmHg

(5/14/24 4:46 PM)

pH Urine [5.0-8.5] 6.0 5.5 5.5

(9/28/24 12:40 AM) (5/14/24 8:10 PM) (7/1/23 8:24 PM)

pH Ven [7.36-7.44] 7.405

(5/14/24 4:46 PM)

Opiate Screen Ur [Negative] Negative Negative Negative

(6/1/23 2:44 PM) (4/20/23 9:37 PM) (1/18/21 9:47 PM)

O2 Saturation Ven 39.0 %

(5/14/24 4:46 PM)

N. gonorrhoeae (DNA) by NAAT Not detected

[Not detected] (11/17/23 10:03 AM)

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[Reference Range]:

Cmt: Gonorrhea and/or See Comments 27

Chlamydia (DNA) by (11/17/23 10:03 AM)

C. trachomatis (DNA) by NAAT Not detected

[Not detected] (11/17/23 10:03 AM)

Appear [Normal] Slightly Cloudy Normal Normal

*ABN* (5/14/24 8:10 PM) (7/1/23 8:24 PM)
(9/28/24 12:40 AM)

Glucose Fasting [60-99 mg/dL] 87 mg/dL

(11/1/20 6:51 AM)

Hemoglobin A1c [<5.7 %] 5.1 %

(10/20/23 8:40 AM)

Acetaminophen Level [10-30 <3 mcg/mL <1 mcg/mL <3 mcg/mL

mcg/mL] *LOW* *LOW* *LOW*
(6/11/23 9:12 PM) (6/1/23 2:44 PM) (4/20/23 8:28 PM)

Chloride Level [102-111 99 mmol/L 101 mmol/L 104 mmol/L

mmol/L] *LOW* *LOW* (9/28/24 1:24 AM)
(9/30/24 12:53 PM) (9/28/24 7:17 PM)

Blood Gas Drawn By Drawn by RN/Lab/OR

(5/14/24 4:46 PM)

Creatinine Level [0.60-1.10 0.91 mg/dL 0.94 mg/dL 1.12 mg/dL

mg/dL] (9/30/24 12:53 PM) (9/28/24 7:17 PM) *HI*
(9/28/24 1:24 AM)

Fecal Occult Bld 1 Guaiac Negative

[Negative] (2/27/22 1:52 PM)

Troponin T Gen 5 [0.0-13.9 <6 ng/L

ng/L] (5/14/24 3:47 PM)

Troponin T Gen 5 Delta [<8 No calculation ng/L

ng/L] (5/14/24 3:47 PM)

N-Terminal proBNP [0-299 <36 pg/mL

pg/mL] (5/14/24 7:05 PM)

Cmt: Troponin T Gen 5 See Comments 28

(5/14/24 3:47 PM)

Cmt: N-Terminal proBNP See Comments 29

(5/14/24 7:05 PM)

Cmt2: HCG Quantitative See Comments 30

(9/28/24 1:24 AM)

Cmt2: HCG, Serum Qualitative See Comments 31 See Comments 32 See Comments 33
(8/17/24 9:55 AM) (6/8/24 9:58 PM) (6/7/24 4:25 PM)

Collect Method, Ur Urine Clean Catch Urine Clean Catch Urine Clean Catch
(9/28/24 12:40 AM) (5/14/24 8:10 PM) (2/27/22 4:06 PM)

Non HDL Cholesterol [<130 161 mg/dL 145 mg/dL

mg/dL] *HI* *HI*
(10/20/23 8:40 AM) (11/1/20 6:51 AM)

Synthetic Opioids [Negative] Negative Negative Negative

(6/1/23 2:44 PM) (4/20/23 9:37 PM) (1/18/21 9:47 PM)

Respiratory Syncytial Virus [Not Not detected Not detected Not detected
detected] (6/11/23 9:12 PM) (6/1/23 2:44 PM) (4/20/23 8:28 PM)

Monocyte, Abs [0.2-0.9 K/mcL] 0.7 K/mcL 0.8 K/mcL 1.1 K/mcL
(9/30/24 12:53 PM) (9/28/24 7:17 PM) *HI*
(9/28/24 12:29 AM)

Nucleated RBC Auto 0.0 /100(WBCs) 0.0 /100(WBCs) 0.0 /100(WBCs)

(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

Differential Type Auto Auto Auto

(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

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10/24/2024 Continuity of Care Document
Most recent to oldest
1 2 3
[Reference Range]:

Eosinophil, Abs [0.0-0.5 K/mcL] 0.1 K/mcL 0.0 K/mcL 0.0 K/mcL
(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

Average GFR for age 116 mL/min/1.73 m2 116 mL/min/1.73 m2 No calculation mL/min/1.73 m2 34
(2/27/22 1:52 PM) (1/18/21 9:47 PM) (11/1/20 6:51 AM)

Patient Fasting? Yes 35 Yes

(10/20/23 8:40 AM) (11/1/20 6:51 AM)

Anion Gap (Na Cl CO2) [3-16 17 mmol/L 16 mmol/L 14 mmol/L

mmol/L] *HI* (9/28/24 7:17 PM) (9/28/24 1:24 AM)
(9/30/24 12:53 PM)

Opiates by MS Negative
(4/20/23 9:37 PM)

Plt Est [PLTOK] Agrees with count Agrees with count Agrees with count
(6/7/24 4:25 PM) (5/29/24 9:52 PM) (5/14/24 3:47 PM)

Beta-Hydroxybutyrate [0.0-0.6 1.9 mmol/L 36

mmol/L] *HI*
(5/14/24 3:47 PM)

Plt Clumping [Negative] Observed

*ABN*
(6/7/24 4:25 PM)

Methemoglobin [0.3-1.5 %] 0.6 %

(5/14/24 4:46 PM)

VLDL [7-26 mg/dL] 25 mg/dL 22 mg/dL

(10/20/23 8:40 AM) (11/1/20 6:51 AM)

Bld Smear Scan Slide reviewed and is in agreement with Slide reviewed and is in agreement with Slide reviewed and is in agreement with
auto differential auto differential auto differential
(6/7/24 4:25 PM) (5/29/24 9:52 PM) (5/14/24 3:47 PM)

Basophil, Abs [0.0-0.1 K/mcL] 0.1 K/mcL 0.1 K/mcL 0.1 K/mcL
(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

Creatinine GFR [>60 90 mL/min/1.73 m2 86 mL/min/1.73 m2 70 mL/min/1.73 m2

mL/min/1.73 m2] (9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 1:24 AM)

Plts, Large [Negative] Observed

*ABN*
(5/14/24 3:47 PM)

RDW SD [36.7-47.2 fL] 55.2 fL 54.4 fL 55.3 fL

*HI* *HI* *HI*
(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

hCG Ur [Negative] Negative Negative Negative 37

(9/18/24 7:18 AM) (7/1/23 8:23 PM) (3/15/23 2:25 PM)

Base Excess Whole Blood [- 4.2- -3.5 mmol/L

0.9 mmol/L] (5/14/24 4:46 PM)

Estimated Average Glucose 100 mg/dL

(10/20/23 8:40 AM)

Immature Granulocytes [0.0-0.5 0.3 % 0.3 % 0.3 %

%] (9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

Immature Granulocyte, Abs 0.03 K/mcL 0.03 K/mcL 0.04 K/mcL

[0.00-0.04 K/mcL] (9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 12:29 AM)

Ovalocytes [Negative] 1+
*ABN*
(2/27/22 1:52 PM)

HCG, Beta Quantitative <1 mIU/mL <2 mIU/mL <2 mIU/mL

(9/28/24 1:24 AM) (6/11/23 9:12 PM) (6/1/23 2:44 PM)

O2 Hgb Ven 38.4 %

(5/14/24 4:46 PM)

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Most recent to oldest
1 2 3
[Reference Range]:

Methadone Screen Ur Negative Negative Negative

[Negative] (6/1/23 2:44 PM) (4/20/23 9:37 PM) (1/18/21 9:47 PM)

Buprenorphine Level [Negative] Negative Negative Negative

(6/1/23 2:44 PM) (4/20/23 9:37 PM) (1/18/21 9:47 PM)

Drugs by MS: General See Comments 38

Comments (4/20/23 9:37 PM)

Barbiturates by MS Negative
(4/20/23 9:37 PM)

Benzodiazepines by MS Negative
(4/20/23 9:37 PM)

Urine Culture Ordered? No No No

(9/28/24 12:40 AM) (5/14/24 8:10 PM) (2/27/22 4:06 PM)

Cmt4: Drug Screen Urine See Comments 39 See Comments 40 See Comments 41
(6/1/23 2:44 PM) (4/20/23 9:37 PM) (1/18/21 9:47 PM)

Cmt: HCG Beta Quantitative See Comments 42 See Comments 43 See Comments 44
(6/11/23 9:12 PM) (6/1/23 2:44 PM) (2/27/22 1:52 PM)

Cmt: GFR See Comments 45 See Comments 46 See Comments 47

(9/30/24 12:53 PM) (9/28/24 7:17 PM) (9/28/24 1:24 AM)

Cmt: Hemoglobin A1C See Comments 48

(10/20/23 8:40 AM)

Cmt: Vitamin D 25-Hydroxy See Comments 49

(7/31/24 12:15 PM)

Cmt: HCG Serum Qualitative See Comments 50 See Comments 51 See Comments 52
(4/20/23 8:28 PM) (1/18/21 9:47 PM) (10/30/20 8:59 PM)

Cmt: Fasting Plasma Glucose See Comments 53

(11/1/20 6:51 AM)

Cmt: LDL See Comments 54 See Comments 55

(10/20/23 8:40 AM) (11/1/20 6:51 AM)

Cmt1: Serum Drug Screen See Comments 56 See Comments 57 See Comments 58
(6/11/23 9:12 PM) (6/1/23 2:44 PM) (4/20/23 8:28 PM)

Cmt2: Serum Drug Screen See Comments 59 See Comments 60 See Comments 61
(6/11/23 9:12 PM) (6/1/23 2:44 PM) (4/20/23 8:28 PM)

Amorphous Crystals 1+
(1/18/21 9:47 PM)

O2 Content Ven 5.3

(5/14/24 4:46 PM)

Influenza B [Not detected] Not detected Not detected Not detected

(6/11/23 9:12 PM) (6/1/23 2:44 PM) (4/20/23 8:28 PM)

HCG Serum Qualitative Negative Negative Negative

[Negative] (8/17/24 9:55 AM) (6/8/24 9:58 PM) (6/7/24 4:25 PM)

Color Urine [Normal] Normal Normal Normal

(9/28/24 12:40 AM) (5/14/24 8:10 PM) (7/1/23 8:24 PM)

Cocaine & Metabolite by MS Negative

(4/20/23 9:37 PM)

THC by MS Negative
(4/20/23 9:37 PM)

Methadone & Metabolite by MS Negative

(4/20/23 9:37 PM)

Buprenorphine & Naloxone by Negative

MS (4/20/23 9:37 PM)

Influenza A PCR [Not detected] Not detected Not detected Not detected
(6/11/23 9:12 PM) (6/1/23 2:44 PM) (4/20/23 8:28 PM)

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Most recent to oldest
1 2 3
[Reference Range]:

Amphetamines by MS Positive
(4/20/23 9:37 PM)

Amphetamine, Urine [<100 >1000 ng/mL 62

ng/mL] *HI*
(4/20/23 9:37 PM)

1 Result Comment: (NOTE)

D-dimer is intended for use as an aid in the diagnosis of DIC
and exclusion of DVT and PE. Clinical diagnosis should not be
based on the results of this test alone. Clinical signs and other
relevant test information should be included in the diagnostic
decision. With a threshold of 0.50 ug FEU/mL up to age 50 and an age
adjusted cutoff (age divided by 100) over age 50, low D-dimer results
have a very high negative predictive value for venous thromboembolism
when clinical risk is moderate or low.
2 Result Comment: (NOTE)
D-dimer is intended for use as an aid in the diagnosis of DIC
and exclusion of DVT and PE. Clinical diagnosis should not be
based on the results of this test alone. Clinical signs and other
relevant test information should be included in the diagnostic
decision. With a threshold of 0.50 ug FEU/mL up to age 50 and an age
adjusted cutoff (age divided by 100) over age 50, low D-dimer results
have a very high negative predictive value for venous thromboembolism
when clinical risk is moderate or low.
3 Result Comment: 0.85 * ((140 - 25 yrs) * 52.38 kg) / (72.0 * 0.91 mg/dL) = 78.15 mL/min

Renal Function Assessment Guidelines:

https://documents.intermountain.net/pharmserviceswebsite/Pharmacy%20Documents/Renal%20Function%20Assessment%20Guidelines.pdf
4 Result Comment: 0.85 * ((140 - 25 yrs) * 52.38 kg) / (72.0 * 0.94 mg/dL) = 75.65 mL/min

Renal Function Assessment Guidelines:

https://documents.intermountain.net/pharmserviceswebsite/Pharmacy%20Documents/Renal%20Function%20Assessment%20Guidelines.pdf
5 Result Comment: 0.85 * ((140 - 25 yrs) * 53.29 kg) / (72.0 * 1.12 mg/dL) = 64.60 mL/min

Renal Function Assessment Guidelines:

https://documents.intermountain.net/pharmserviceswebsite/Pharmacy%20Documents/Renal%20Function%20Assessment%20Guidelines.pdf
6 Result Comment: 0.85 * ((140 - 25 yrs) * 84.70 kg) / (72.0 * 0.91 mg/dL) = 126.36 mL/min

Renal Function Assessment Guidelines:

https://documents.intermountain.net/pharmserviceswebsite/Pharmacy%20Documents/Renal%20Function%20Assessment%20Guidelines.pdf
7 Result Comment: 0.85 * ((140 - 25 yrs) * 85.20 kg) / (72.0 * 0.94 mg/dL) = 123.05 mL/min

Renal Function Assessment Guidelines:

https://documents.intermountain.net/pharmserviceswebsite/Pharmacy%20Documents/Renal%20Function%20Assessment%20Guidelines.pdf
8 Result Comment: 0.85 * ((140 - 25 yrs) * 84.80 kg) / (72.0 * 1.12 mg/dL) = 102.79 mL/min

Renal Function Assessment Guidelines:

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https://documents.intermountain.net/pharmserviceswebsite/Pharmacy%20Documents/Renal%20Function%20Assessment%20Guidelines.pdf
9 Result Comment: (NOTE)
GENERAL DISCLAIMER:
A test result should not be used as the sole basis for treatment
or other clinical decisions. Test results are best interpreted in
the context of patient history and physical examination.

The SARS-CoV-2 Real-time RT-PCR Assay is an in vitro diagnostic

test developed and optimized according to the FDA Emergency Use
Authorization process and adapted for use by the Intermountain
Central Laboratory (ICL).

ICL is authorized under the Clinical Laboratory Improvement

Amendments to perform high-complexity testing. Testing with the
SARS-CoV-2 Assay should not be performed unless the patient meets
clinical and/or epidemiologic criteria for testing.
10 Result Comment: (NOTE)
GENERAL DISCLAIMER:
A test result should not be used as the sole basis for treatment
or other clinical decisions. Test results are best interpreted in
the context of patient history and physical examination.

The SARS-CoV-2 Real-time RT-PCR Assay is an in vitro diagnostic

test developed and optimized according to the FDA Emergency Use
Authorization process and adapted for use by the Intermountain
Central Laboratory (ICL).

ICL is authorized under the Clinical Laboratory Improvement

Amendments to perform high-complexity testing. Testing with the
SARS-CoV-2 Assay should not be performed unless the patient meets
clinical and/or epidemiologic criteria for testing.
11 Result Comment: (NOTE)
"Not Detected" = NEGATIVE
This means that the Coronavirus (called SARS-CoV-2 or COVID-19)
was not found.

This result usually means you don't have COVID-19 (if you
are tested 7 or more days after coming in contact with someone
who had it).

Rarely, it could mean you were one of those who tested "false
negative". For the safety of yourself and others, if you have
symptoms, even if you tested negative, please consider yourself
as positive and isolate yourself until 10 days after the
symptoms started AND 24 hours fever-free without the use of
medications.

If your test is a true negative, it is still possible for you

to become infected in the future. For the health and safety of
you and your loved ones, please take precautions to reduce the
risk of contracting or spreading the virus.
12 Result Comment: (NOTE)
"Not Detected" = NEGATIVE
This means that the Coronavirus (called SARS-CoV-2 or COVID-19)
was not found.

This result usually means you don't have COVID-19 (if you
are tested 7 or more days after coming in contact with someone
who had it).

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10/24/2024 Continuity of Care Document

Rarely, it could mean you were one of those who tested "false
negative". For the safety of yourself and others, if you have
symptoms, even if you tested negative, please consider yourself
as positive and isolate yourself until 10 days after the
symptoms started AND 24 hours fever-free without the use of
medications.

If your test is a true negative, it is still possible for you

to become infected in the future. For the health and safety of
you and your loved ones, please take precautions to reduce the
risk of contracting or spreading the virus
13 Result Comment: (NOTE)
"Not Detected" = NEGATIVE
This means that the Coronavirus (called SARS-CoV-2 or COVID-19)
was not found.

This result usually means you don't have COVID-19 (if you
are tested 7 or more days after coming in contact with someone
who had it).

Rarely, it could mean you were one of those who tested "false
negative". For the safety of yourself and others, if you have
symptoms, even if you tested negative, please consider yourself
as positive and isolate yourself until 10 days after the
symptoms started AND 24 hours fever-free without the use of
medications.

If your test is a true negative, it is still possible for you

to become infected in the future. For the health and safety of
you and your loved ones, please take precautions to reduce the
risk of contracting or spreading the virus
14 Result Comment: (NOTE)
"Not Detected" = NEGATIVE
This means that the Coronavirus (called SARS-CoV-2 or COVID-19)
was not found.

This result usually means you don't have COVID-19 (if you
are tested 7 or more days after coming in contact with someone
who had it).

Rarely, it could mean you were one of those who tested "false
negative". For the safety of yourself and others, if you have
symptoms, even if you tested negative, please consider yourself
as positive and isolate yourself until 10 days after the
symptoms started AND 24 hours fever-free without the use of
medications.

If your test is a true negative, it is still possible for you

to become infected in the future. For the health and safety of
you and your loved ones, please take precautions to reduce the
risk of contracting or spreading the virus
15 Result Comment: (NOTE)
The SARS-CoV-2, FLU, RSV assay is a rapid, multiplexed real-time
RT-PCR test intended for the simultaneous qualitative detection
and differentiation of SARS-CoV-2, influenza A, influenza B and
respiratory syncytial virus (RSV) from respiratory specimens
collected from individuals suspected of respiratory viral
infection consistent with COVID-19, influenza and RSV. This
assay detects RNA target sequences in the genes that encode
proteins found in influenza A, influenza B, RSV A, RSV B and
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10/24/2024 Continuity of Care Document
SARS-CoV-2 E and N2.

This assay is an in vitro diagnostic test developed and optimized

according to the FDA Emergency Use Authorization process and
adapted for use by Intermountain Laboratory Services.
Intermountain Laboratory Services is authorized under the
Clinical Laboratory Improvement Amendments to perform high-complexity
testing. The SARS-CoV-2, Flu, RSV Assay should not be performed
unless the patient meets clinical and/or epidemiologic criteria
for testing. A test result should not be used as the sole basis for
treatment or other clinical decisions. Test results are best
interpreted in the context of patient history and physical examination.
16 Result Comment: (NOTE)
The SARS-CoV-2, FLU, RSV assay is a rapid, multiplexed real-time
RT-PCR test intended for the simultaneous qualitative detection
and differentiation of SARS-CoV-2, influenza A, influenza B and
respiratory syncytial virus (RSV) from respiratory specimens
collected from individuals suspected of respiratory viral
infection consistent with COVID-19, influenza and RSV. This
assay detects RNA target sequences in the genes that encode
proteins found in influenza A, influenza B, RSV A, RSV B and
SARS-CoV-2 E and N2.

This assay is an in vitro diagnostic test developed and optimized

according to the FDA Emergency Use Authorization process and
adapted for use by Intermountain Laboratory Services.
Intermountain Laboratory Services is authorized under the
Clinical Laboratory Improvement Amendments to perform high-complexity
testing. The SARS-CoV-2, Flu, RSV Assay should not be performed
unless the patient meets clinical and/or epidemiologic criteria
for testing. A test result should not be used as the sole basis for
treatment or other clinical decisions. Test results are best
interpreted in the context of patient history and physical examination.
17 Result Comment: (NOTE)
The SARS-CoV-2, FLU, RSV assay is a rapid, multiplexed real-time
RT-PCR test intended for the simultaneous qualitative detection
and differentiation of SARS-CoV-2, influenza A, influenza B and
respiratory syncytial virus (RSV) from respiratory specimens
collected from individuals suspected of respiratory viral
infection consistent with COVID-19, influenza and RSV. This
assay detects RNA target sequences in the genes that encode
proteins found in influenza A, influenza B, RSV A, RSV B and
SARS-CoV-2 E and N2.

This assay is an in vitro diagnostic test developed and optimized

according to the FDA Emergency Use Authorization process and
adapted for use by Intermountain Laboratory Services.
Intermountain Laboratory Services is authorized under the
Clinical Laboratory Improvement Amendments to perform high-complexity
testing. The SARS-CoV-2, Flu, RSV Assay should not be performed
unless the patient meets clinical and/or epidemiologic criteria
for testing. A test result should not be used as the sole basis for
treatment or other clinical decisions. Test results are best
interpreted in the context of patient history and physical examination.
18 Result Comment: (NOTE)
Test developed and characteristics determined by Intermountain Central
Lab. For medical purposes only. Not for legal use.
19 Result Comment: (NOTE)
Test developed and characteristics determined by Intermountain Central
Lab. For medical purposes only. Not for legal use.

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20 Result Comment: Screening test positive. Confirmation testing to follow.
21 Result Comment: For medical purposes only. Not for legal use.
22 Result Comment: For medical purposes only. Not for legal use.
23 Result Comment: For medical purposes only. Not for legal use.
24 Result Comment: Please note new reference range
This is a 3rd generation TSH assay.
25 Result Comment: Please note new reference range
This is a 3rd generation TSH assay.
26 Result Comment: Please note new reference range
This is a 3rd generation TSH assay.
27 Result Comment: (NOTE)
INTERPRETATION FOR CT/NG:
This assay is an FDA-approved, qualitative in vitro nucleic acid
test for the direct detection of Chlamydia trachomatis (CT)
and/or Neisseria gonorrhoeae (NG). It is intended as an aid in
the diagnosis of chlamydial and gonococcal disease in both
symptomatic and asymptomatic individuals. This test detects but
does not discriminate between the CT cyptic plasmid and the CT
ompA gene or between two conserved sequences in the NG DR-9
region.
--
FDA-approved specimens include male and female urine,
clinician-instructed self-collected vaginal swabs,
clinician-collected vaginal swabs, endocervical swabs,
oropharyngeal swabs, and anorectal swabs all collected in cobas
PCR Media. Cervical specimens collected in PreservCyt Solution
are also FDA-approved.
--
A PCR result of not detected does not exclude the presence of
inhibiting substances or target nucleic acid at levels below the
sensitivity of the assay.
28 Result Comment: (NOTE)
Elevated troponin of any etiology is associated with an increased
mortality risk and must be interpreted in the clinical context.
An elevated troponin value above the 99th percentile is defined
as myocardial injury. The injury is considered acute if there is
a rise and/or fall of troponin values. (Fourth Universal
Definition of Myocardial Infarction - Circulation 2018;
138:e6180e651)

Note: Elevation of troponin could emanate from skeletal muscle.

29 Result Comment: (NOTE)
NT-proBNP values should be assessed in conjunction with other
cardiovascular risk factors and clinical findings.

AGE NT-proBNP INTERPRETATION

<50 years 300-450 Indeterminate
<50 years >450 High; Indicates ADHF likely

50 to 75 years 300-900 Indeterminate

50 to 75 years >900 High; Indicates ADHF likely

>75 years 300-1800 Indeterminate

>75 years >1800 High; Indicates ADHF likely

Indeterminate results require further clinical information to

determine if ADHF is present.
30 Result Comment: (NOTE)
INTERPRETATION OF QUANTITATIVE hCG:

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10/24/2024 Continuity of Care Document
Non-Pregnant Female: <5 mIU/mL
Approximate Weeks Gestation Concentration (mIU/mL)
3 Weeks 5-70
4 Weeks 10-700
5 Weeks 220-8,200
6 Weeks 150-32,000
7 Weeks 4,000-154,000
8 Weeks 31,000-149,000
9 Weeks 59,000-136,000
10 Weeks 44,000-170,000
12 Weeks 27,000-202,000
--
NOTES:
1. This test is NOT to be used as a tumor marker. Order
separate hCG Tumor Marker Assay for this function.
2. The normal ranges serve as guidelines only.
3. Rare false positives have been reported
(LANCET 2000:355:712-5). Positive results should be
confirmed with a urine specimen prior to aggressive
therapy.
4. Testing performed using Roche Cobas Methodology.
31 Result Comment: Testing performed using Beckman Coulter ICON-25 Methodology
(NOTE)
INTERPRETATION OF QUALITATIVE hCG:
This test is NOT to be used as a tumor marker. Order separate hCG
tumor marker assay.
--
Rare false positives have been reported (LANCET 2000:355:712-5).
Positive results should be confirmed with a urine specimen prior
to aggressive therapy.
32 Result Comment: Testing performed using Beckman Coulter ICON-25 Methodology
(NOTE)
INTERPRETATION OF QUALITATIVE hCG:
This test is NOT to be used as a tumor marker. Order separate hCG
tumor marker assay.
--
Rare false positives have been reported (LANCET 2000:355:712-5).
Positive results should be confirmed with a urine specimen prior
to aggressive therapy.
33 Result Comment: Testing performed using Beckman Coulter ICON-25 Methodology
(NOTE)
INTERPRETATION OF QUALITATIVE hCG:
This test is NOT to be used as a tumor marker. Order separate hCG
tumor marker assay.
--
Rare false positives have been reported (LANCET 2000:355:712-5).
Positive results should be confirmed with a urine specimen prior
to aggressive therapy.
34 Result Comment: Not calculated for inpatients.
35 Result Comment: 16 h
36 Result Comment: This assay is approved for an hematocrit range of 30% to 60%
37 Result Comment: First morning urine recommended to avoid false negatives.
38 Result Comment: (NOTE)
The absence of expected drug(s) and/or drug metabolite(s) may
indicate non-compliance, inappropriate timing of specimen
collection relative to drug administration, poor drug absorption,
diluted/adulterated urine, or limitations of testing. The
concentration value must be greater than or equal to the cutoff
to be reported as positive. Interpretive questions should be
directed to the laboratory.

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10/24/2024 Continuity of Care Document

Methodology: Quantitative Liquid Chromatography-Tandem Mass

Spectrometry

Test developed and characteristics determined by Intermountain

Central Laboratory.

The Quantitative Liquid Chromatography-Tandem Mass Spectrometry

is a targeted testing that can detect only specific ananlytes as
listed in this report; therefore other drug analogs may not be
detected.

Drugs tested and cutoff concentrations (ng/mL):

AMPHETAMINES: Amphetamine (100), Methamphetamine (100),

MDA (100), MDMA (50), MDEA (100)

BARBITURATES: Amobarbital/Pentobarbital (100), Butabarbital (100),

Butalbital (100), Phenobarbital (100), Secobarbital (100)

BENZODIAZEPINES: Alprazolam (20), Aminoclonazepam (100),

Aminoflunitrazepam (25), Chlordiazepoxide (20), Clonazepam (20),
Diazepam (20), Flunitrazepam (50), Flurazepam (50),
Hydroxyalprazolam (40), Hydroxyethylflurazepam (20),
Hydroxymidazolam (20), Hydroxytriazolam (20), Lorazepam (50),
Midazolam (20), Nordiazepam (40), Oxazepam (50), Temazepam (50),
Triazolam (20)

COCAINE: Cocaine (50),Benzoylecgonine (50)

CANNABINOIDS: THC-COOH (15)

METHADONE: Methadone (100), EDDP (100)

OPIATES: 6-acetylmorphine (10), Codeine (50), Morphine (50),

Hydrocodone (50), Hydromorphone (50), Norhydrocodone (50),
Noroxycodone (50), Oxycodone (50), Oxymorphone (50), Fentanyl
(1.0), Norfentanyl (8), Dihydrocodeine (50)

BUPRENORPHINE: Buprenorphine (20), Norbuprenorphine (40),

Naloxone (10)
39 Result Comment: (NOTE)
INTERPRETATION OF DRUG SCREENS:
This is an unconfirmed screening test and should be used for
MEDICAL purposes only. False positive and false negative results
can occur with any screening test. Positive screening tests will
be referred out for confirmatory testing.
Synthetic Opioids include Oxycodone and Oxymorphone.

CUTOFF CONCENTRATION:
Amphetamines 1000 ng/mL
Barbiturates 200 ng/mL
Benzodiazepines 200 ng/mL
Cocaine (as Metabolite) 300 ng/mL

Cannabinoids 50 ng/mL
Methadone 300 ng/mL
Opiates 300 ng/mL
Synthetic Opioids 100 ng/mL
Buprenorphine 10 ng/mL
Fentanyl 1 ng/ml

47 to 142
10/24/2024 Continuity of Care Document
40 Result Comment: (NOTE)
INTERPRETATION OF DRUG SCREENS:
This is an unconfirmed screening test and should be used for
MEDICAL purposes only. False positive and false negative results
can occur with any screening test. Positive screening tests will
be referred out for confirmatory testing.
Synthetic Opioids include Oxycodone and Oxymorphone.

CUTOFF CONCENTRATION:
Amphetamines 1000 ng/mL
Barbiturates 200 ng/mL
Benzodiazepines 200 ng/mL
Cocaine (as Metabolite) 300 ng/mL

Cannabinoids 50 ng/mL
Methadone 300 ng/mL
Opiates 300 ng/mL
Synthetic Opioids 100 ng/mL
Buprenorphine 10 ng/mL
Fentanyl 1 ng/ml
41 Result Comment: (NOTE)
INTERPRETATION OF DRUG SCREENS:
This is an unconfirmed screening test and should be used for
MEDICAL purposes only. False positive and false negative results
can occur with any screening test. Positive screening tests will
be referred out for confirmatory testing.
Synthetic Opioids include Oxycodone and Oxymorphone.

CUTOFF CONCENTRATION:
Amphetamines 1000 ng/mL
Barbiturates 200 ng/mL
Benzodiazepines 200 ng/mL
Cocaine (as Metabolite) 300 ng/mL

Cannabinoids 50 ng/mL
Methadone 300 ng/mL
Opiates 300 ng/mL
Synthetic Opioids 100 ng/mL
Buprenorphine 10 ng/mL

Buprenorphine testing not available at all sites.

Check individual analyte results.
42 Result Comment: (NOTE)
INTERPRETATION OF QUANTITATIVE hCG:
Non-Pregnant Female: <5 mIU/mL
Approximate Weeks Gestation Concentration (mIU/mL)
0-1 Week 5-50
1-2 Weeks 50-500
2-3 Weeks 100-10,000
3-4 Weeks 1000-30,000
4-5 Weeks 3,500-115,000
6-8 Weeks 12,000-270,000
12 Weeks 15,000-220,000
--
NOTES:
1. This test is NOT to be used as a tumor marker. Order
separate hCG Tumor Marker Assay for this function.
2. The normal ranges serve as guidelines only.
3. Rare false positives have been reported
(LANCET 2000:355:712-5). Positive results should be

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confirmed with a urine specimen prior to aggressive
therapy.
4. Testing performed using Abbott Methodology
43 Result Comment: (NOTE)
INTERPRETATION OF QUANTITATIVE hCG:
Non-Pregnant Female: <5 mIU/mL
Approximate Weeks Gestation Concentration (mIU/mL)
0-1 Week 5-50
1-2 Weeks 50-500
2-3 Weeks 100-10,000
3-4 Weeks 1000-30,000
4-5 Weeks 3,500-115,000
6-8 Weeks 12,000-270,000
12 Weeks 15,000-220,000
--
NOTES:
1. This test is NOT to be used as a tumor marker. Order
separate hCG Tumor Marker Assay for this function.
2. The normal ranges serve as guidelines only.
3. Rare false positives have been reported
(LANCET 2000:355:712-5). Positive results should be
confirmed with a urine specimen prior to aggressive
therapy.
4. Testing performed using Abbott Methodology
44 Result Comment: (NOTE)
INTERPRETATION OF QUANTITATIVE hCG:
Non-Pregnant Female: <5 mIU/mL
Approximate Weeks Gestation Concentration (mIU/mL)
0-1 Week 5-50
1-2 Weeks 50-500
2-3 Weeks 100-10,000
3-4 Weeks 1000-30,000
4-5 Weeks 3,500-115,000
6-8 Weeks 12,000-270,000
12 Weeks 15,000-220,000
--
NOTES:
1. This test is NOT to be used as a tumor marker. Order
separate hCG Tumor Marker Assay for this function.
2. The normal ranges serve as guidelines only.
3. Rare false positives have been reported
(LANCET 2000:355:712-5). Positive results should be
confirmed with a urine specimen prior to aggressive
therapy.
4. Testing performed using Abbott Architect Methodology
45 Result Comment: (NOTE)
INTERPRETATION OF ESTIMATED GFR:
Estimated using CKD-EPI 2021 equation
(https://www.kidney.org/professionals/kdoqi/gfr_calculator)
Chronic Kidney Disease less than 60 mL/min/1.73 sq m
Kidney failure less than 15 mL/min/1.73 sq m
46 Result Comment: (NOTE)
INTERPRETATION OF ESTIMATED GFR:
Estimated using CKD-EPI 2021 equation
(https://www.kidney.org/professionals/kdoqi/gfr_calculator)
Chronic Kidney Disease less than 60 mL/min/1.73 sq m
Kidney failure less than 15 mL/min/1.73 sq m
47 Result Comment: (NOTE)
INTERPRETATION OF ESTIMATED GFR:
Estimated using CKD-EPI 2021 equation

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(https://www.kidney.org/professionals/kdoqi/gfr_calculator)
Chronic Kidney Disease less than 60 mL/min/1.73 sq m
Kidney failure less than 15 mL/min/1.73 sq m
48 Result Comment: (NOTE)
The American Diabetes Association considers an A1c of 6.5% or
greater to be diagnostic of diabetes when confirmed by repeat
testing on a different day.

An A1c of 5.7 to 6.4% indicates an increased risk of developing

diabetes. These guidelines do not apply to pregnant women or
children. Ref: Diabetes Care 2010;33:S62-9.

If A1c and estimated average glucose do not match clinical

picture, consider altered RBC turnover and/or variant hemoglobin.
49 Result Comment: (NOTE)
INTERPRETATION OF 25-HYDROXY VITAMIN D
Reference Intervals:
Deficiency : <=20 ng/mL
Insufficiency : 21-29 ng/mL
Optimum Level : 30-80 ng/mL
Possible Toxicity : >80 ng/mL
--
This assay accurately quantifies the sum of vitamin D3,
25-Hydroxy and vitamin D2, 25-Hydroxy.
50 Result Comment: Testing performed using Beckman Coulter ICON-25 Methodology
(NOTE)
INTERPRETATION OF QUALITATIVE hCG:
This test is NOT to be used as a tumor marker. Order separate hCG
tumor marker assay.
--
If hCG results are BORDERLINE, please repeat testing in 48 hours.
--
Rare false positives have been reported (LANCET 2000:355:712-5).
Positive results should be confirmed with a urine specimen prior
to aggressive therapy.
51 Result Comment: Testing performed using Abbott Architect Methodology
(NOTE)
INTERPRETATION OF QUALITATIVE hCG:
This test is NOT to be used as a tumor marker. Order separate hCG
tumor marker assay.
--
If hCG results are BORDERLINE, please repeat testing in 48 hours.
--
Rare false positives have been reported (LANCET 2000:355:712-5).
Positive results should be confirmed with a urine specimen prior
to aggressive therapy.
52 Result Comment: Testing performed using Beckman Coulter ICON-25 Methodology
(NOTE)
INTERPRETATION OF QUALITATIVE hCG:
This test is NOT to be used as a tumor marker. Order separate hCG
tumor marker assay.
--
If hCG results are BORDERLINE, please repeat testing in 48 hours.
--
Rare false positives have been reported (LANCET 2000:355:712-5).
Positive results should be confirmed with a urine specimen prior
to aggressive therapy.
53 Result Comment: (NOTE)
INTERPRETATION OF FASTING PLASMA GLUCOSE:
<100: Normal fasting glucose

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100-125: Impaired fasting glucose
>=126: Provisional diagnosis of diabetes
54 Result Comment: (NOTE)
INTERPRETIVE INFORMATION: LDL Cholesterol
The Intermountain Primary Care Clinical Program recommends that
for most patients without known atherosclerosis or
risk-equivalents, use "Pooled Cohort Equation" recommendations:
http://tools.acc.org/ASCVD-Risk-Estimator/
For most patients with known coronary artery disease,
atherosclerosis, diabetes mellitus, or LDL >190, target LDL <70.
(See "Intermountain Cardiovascular Risk and Cholesterol
Guideline.")
55 Result Comment: (NOTE)
INTERPRETIVE INFORMATION: LDL Cholesterol
The Intermountain Primary Care Clinical Program recommends that
for most patients without known atherosclerosis or
risk-equivalents, use "Pooled Cohort Equation" recommendations:
http://tools.acc.org/ASCVD-Risk-Estimator/
For most patients with known coronary artery disease,
atherosclerosis, diabetes mellitus, or LDL >190, target LDL <70.
(See "Intermountain Cardiovascular Risk and Cholesterol
Guideline.")
56 Result Comment: (NOTE)
INTERPRETATION OF ACETAMINOPHEN:
Toxic level: >=140 ug/mL 4 hours after ingestion or >50 ug/mL 12
hours after ingestion.
Acetaminophen may be falsely lowered in a specimen collected
during or shortly after a loading dose of N-acetylcysteine. NAC
interference is minimal in a specimen collected near the end of
the infusion, such as when AST and ALT are checked.
57 Result Comment: (NOTE)
INTERPRETATION OF ACETAMINOPHEN:
Toxic level: >=140 ug/mL 4 hours after ingestion or >50 ug/mL 12
hours after ingestion.
Acetaminophen may be falsely lowered in a specimen collected
during or shortly after a loading dose of N-acetylcysteine. NAC
interference is minimal in a specimen collected near the end of
the infusion, such as when AST and ALT are checked.
58 Result Comment: (NOTE)
INTERPRETATION OF ACETAMINOPHEN:
Toxic level: >=140 ug/mL 4 hours after ingestion or >50 ug/mL 12
hours after ingestion.
Acetaminophen may be falsely lowered in a specimen collected
during or shortly after a loading dose of N-acetylcysteine. NAC
interference is minimal in a specimen collected near the end of
the infusion, such as when AST and ALT are checked.
59 Result Comment: (NOTE)
INTERPRETATION OF SALICYLATES:
Analgesia and Antipyresis: 2-10 mg/dL
Anti-inflammatory: 15-30 mg/dL
60 Result Comment: (NOTE)
INTERPRETATION OF SALICYLATES:
Analgesia and Antipyresis: 2-10 mg/dL
Anti-inflammatory: 15-30 mg/dL
61 Result Comment: (NOTE)
INTERPRETATION OF SALICYLATES:
Analgesia and Antipyresis: 2-10 mg/dL
Anti-inflammatory: 15-30 mg/dL
62 Result Comment: (NOTE)
Interpretive text for Amphetamine
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Consistent with use of a drug containing amphetamine. May also
reflect metabolism of methamphetamine, when methamphetamine is
present. Amphetamine and methamphetamine exist in d- and l-
isomeric forms. These forms are not distinguished by this test.
Orders for Microbiology Reports

Name Date

Culture (CX),Blood 5/16/24

Culture (CX),Blood 5/16/24

Microbiology Reports

TEST: Blood Culture 1

STATUS: Auth (Verified)
BODY SITE: Peripheral
SOURCE: Whole Blood
COLLECTED DATE/TIME: 5/14/24 9:53 PM
***Blood Culture***
No growth 5 days

ORGANISM:No Growth 5 Days

Susceptibilty: No Growth 5 Days

Tested Drug

TEST: Blood Culture 2

STATUS: Auth (Verified)
BODY SITE: Peripheral
SOURCE: Whole Blood
COLLECTED DATE/TIME: 5/14/24 7:05 PM
***Setup Time***
202405142335

ORGANISM:No Growth 5 Days

Susceptibilty: No Growth 5 Days

Tested Drug

TEST: Urine Culture

STATUS: Auth (Verified)
BODY SITE:
SOURCE: Urine
COLLECTED DATE/TIME: 3/17/15 5:24 PM
***Urine Culture***
No Growth 2 Days

ORGANISM:No Growth 2 Days

Susceptibilty: No Growth 2 Days

Tested Drug

***INTERPRETIVE DATA***
1 Whole Blood Peripheral Left
Performed at Utah Valley Hospital, Provo, Utah

Nurse Collect Arm

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2 Whole Blood Peripheral Antecubital
Performed at Utah Valley Hospital, Provo, Utah

Nurse Collect Left

Radiology Reports (Most Recent Ten)

Exam Date Time Procedure Performing Provider Status

9/30/24 1:22 PM CT Brain/Head w/o Contrast IRVINE, SUZ M; Auth (Verified)

Notes:
(CT Brain/Head w/o Contrast) Reason For Exam: Visual changes
Report
EXAMINATION: CT Brain/Head w/o Contrast

COMPARISON: MRI Brain w/ + w/o Contrast 2024-Sep-16; CT

Brain/Head Trauma 2024-Sep-01

HISTORY: Blurry vision, worse in the left than the right.

TECHNIQUE: Axial CT images were obtained through the brain

without contrast. Sagittal and coronal reformations were
created.

FINDINGS:

Diagnostic Quality: Adequate for interpretation and

recommendations.

Brain: Normal for age, without acute abnormality.

Ventricles/Basal Cisterns and Extra-Axial Spaces: Appropriate

size of ventricles for cortical volume. No abnormal extra-axial
collections and/or masses.

Vasculature: Normal for age.

Pituitary: Normal for age.

Soft Tissues: Normal.

Orbits: Normal.

Included Sinuses: Normal.

Mastoids: Normal.

Calvarium: No acute injury or aggressive bone lesion.

IMPRESSION:
No CT evidence of acute intracranial abnormality.

This report was electronically signed by Christopher R. Trimble,

MD on 9/30/2024 1:42 PM.
***** Final *****

Dictated by: TRIMBLE, MD, CHRISTOPHER R.

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Dictated DT/TM: 09/30/2024 1:42 pm
Signed by: TRIMBLE, MD, CHRISTOPHER R.
Signed (Electronic Signature): 09/30/2024 1:42 pm
Transcribed by: CRT

Exam Date Time Procedure Performing Provider Status

9/28/24 2:21 AM CT Abdomen and Pelvis w/ TRYCH, ALENA; Auth (Verified)
Contrast

Notes:
(CT Abdomen and Pelvis w/ Contrast) Reason For Exam: Abdominal pain
Report
EXAMINATION: CT Abdomen and Pelvis w/ Contrast

COMPARISON: None available.

HISTORY: Abdominal pain. The patient underwent surgery for

endometriosis last Wednesday.

TECHNIQUE: Axial CT images were obtained through the abdomen and

pelvis with the administration of intravenous contrast. Sagittal
and coronal reconstructions were created.

References: http://short/liverles

FINDINGS:

Diagnostic Quality: Adequate for interpretation and

recommendations.

Lower Thorax: Normal.

GE Junction and Stomach: Normal.

Liver: Normal.
Liver lesion(s) requiring follow-up: No.

Gallbladder: Normal.

Bile Ducts: Normal.

Pancreas: Normal.

Spleen: Normal.

Adrenals: Normal.

Kidneys: The left kidney appears normal. The right kidney is

somewhat low-lying and is not completely rotated with the pelvis
extending anteriorly. There are at least 2 right renal arteries.
No urinary calculus or urinary collecting system dilatation is
noted.

Vasculature: Otherwise normal.

Nodes/Retroperitoneum: Normal.

Bowel: There is a very short segment of intussusception

involving jejunum measuring about 2 cm maximally as seen on
coronal series 601 image 48 and axial series 2 image 87. The
small bowel otherwise appears normal. The colon is not

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well-distended and not optimally evaluated but otherwise appears
normal. Normal appearance of the appendix.

Mesentery/Peritoneum: No significant free fluid or free air.

There are mildly prominent lymph nodes in the right lower
quadrant portion of the mesentery that are nonspecific; in the
setting of fever consider mesenteric adenitis.

Pelvis: Bicornuate uterus. The adnexa appear normal. Normal

urinary bladder.

Abdominal Wall/Soft Tissues: Normal.

Bones: Normal for age.

IMPRESSION:
1. There is a short segment of intussusception involving
proximal jejunum measuring about 2 cm in length. Normally,
intussusception of less than 3 cm it is thought to be a possible
normal occurrence in the setting of peristalsis and this may be
transient. I do not see any evidence of obstruction or fat
stranding to indicate inflammation.
2. There are mildly prominent mesenteric lymph nodes in the
right lower quadrant portion of the mesentery that are
nonspecific; in the setting of fever consider mesenteric
adenitis. Given recent surgery, consider reactive lymph nodes.
3. Otherwise no acute abnormalities identified within the
abdomen or pelvis. No pneumoperitoneum or significant free fluid
is identified.
4. Bicornate uterus.

This report was electronically signed by Tyler L. Crawford, MD

on 9/28/2024 2:47 AM.
***** Final *****

Dictated by: CRAWFORD, MD, TYLER L

Dictated DT/TM: 09/28/2024 2:47 am
Signed by: CRAWFORD, MD, TYLER L
Signed (Electronic Signature): 09/28/2024 2:47 am
Transcribed by: TLC

Exam Date Time Procedure Performing Provider Status

9/16/24 3:22 PM MRI Brain w/ + w/o Contrast CERNER TEST, NON-PERSON Auth (Verified)
POSITION, RadNet: Radiology
Technologist;

Notes:
(MRI Brain w/ + w/o Contrast) Reason For Exam: Syncope
Report
EXAMINATION: MRI Brain w/ + w/o Contrast

COMPARISON: CT brain exams, most recent 9/1/2024. MRI brain

2/1/2021.

HISTORY: Syncope

TECHNIQUE: Multiplanar, multisequence MR images were obtained of

the head with and without intravenous contrast.

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FINDINGS:

Diagnostic Quality: Adequate for interpretation and

recommendations.

Brain: The cerebral parenchyma is normal in volume and

morphology. Unchanged small focus of white matter T2/FLAIR
hyperintense signal in the right anterior subinsular region
compatible with gliosis from remote insult. No intraparenchymal
hemorrhage. No abnormal foci of gradient susceptibility,
diffusion restriction, or enhancement. No mass effect or midline
shift.

Ventricles and Extra-Axial Spaces: The ventricles are normal in

size and configuration. No basal cistern effacement. No abnormal
extra-axial collections.

Vascular: Dedicated imaging not performed. No gross acute

abnormality.

Pituitary: Unremarkable appearance for age.

Soft Tissues: Unremarkable appearance.

Orbits: Unremarkable appearance.

Included Sinuses: Unremarkable appearance.

Mastoids: Unremarkable appearance.

Calvarium: Unremarkable appearance for age.

IMPRESSION:
1. No acute intracranial abnormality. No structural abnormality
to account for patient's clinical symptoms.

This report was electronically signed by Chad T. Christensen, DO

on 9/16/2024 3:19 PM.
***** Final *****

Dictated by: CHRISTENSEN, DO, CHAD T.

Dictated DT/TM: 09/16/2024 3:19 pm
Signed by: CHRISTENSEN, DO, CHAD T.
Signed (Electronic Signature): 09/16/2024 3:19 pm

Exam Date Time Procedure Performing Provider Status

9/1/24 5:09 AM CT Brain/Head Trauma TRYCH, ALENA; Auth (Verified)

Notes:
(CT Brain/Head Trauma) Reason For Exam: Trauma / Injury
Report
EXAMINATION: CT Brain/Head Trauma

COMPARISON: Head CT from June 11, 2023.

HISTORY: Trauma / Injury

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TECHNIQUE: Axial CT images were obtained through the brain
without contrast. Sagittal, coronal and 3-D reformations were
created.

FINDINGS:

Diagnostic Quality: Adequate for interpretation and

recommendations.

Brain: Normal for age, without acute abnormality.

Ventricles/Basal Cisterns and Extra-Axial Spaces: Appropriate

size of ventricles for cortical volume. No abnormal extra-axial
collections and/or masses.

Vasculature: Normal for age.

Pituitary: Normal for age.

Soft Tissues: Normal.

Orbits: Normal.

Included Sinuses: Normal.

Mastoids: Normal.

Calvarium: No acute injury or aggressive bone lesion.

Evidence of acute cranial trauma (excludes soft tissue injury):

No.

IMPRESSION:
1. No acute intracranial injury identified.

This report was electronically signed by Robert Snowden, MD on

9/1/2024 5:29 AM.
***** Final *****

Dictated by: SNOWDEN, MD, ROBERT R.

Dictated DT/TM: 09/01/2024 5:29 am
Signed by: SNOWDEN, MD, ROBERT R.
Signed (Electronic Signature): 09/01/2024 5:29 am
Transcribed by: RRS

Exam Date Time Procedure Performing Provider Status

6/7/24 4:23 PM XR Chest 1 View Portable MCMILLAN, DANIELLE JONES; Auth (Verified)

Notes:
(XR Chest 1 View Portable) Reason For Exam: Shortness of breath;Chest pain
Report
EXAMINATION: XR Chest 1 View Portable

COMPARISON: Chest radiograph 5/20/2024.

HISTORY: Chest pain and shortness of breath.

TECHNIQUE: Single frontal view of the chest.

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FINDINGS:
Medical devices: None.

Cardiomediastinal Silhouette: Normal heart size. Normal

mediastinum.

Lungs: No pulmonary edema, pneumonia, or pneumothorax.

Pleural space: Clear.

Bones: Unremarkable for age.

Additional Findings: None.

IMPRESSION:
1. No radiographic evidence of acute cardiopulmonary disease.

This report was electronically signed by Ryan B. Nielsen, MD on

6/7/2024 4:24 PM.
***** Final *****

Dictated by: NIELSEN, MD, RYAN B.

Dictated DT/TM: 06/07/2024 4:24 pm
Signed by: NIELSEN, MD, RYAN B.
Signed (Electronic Signature): 06/07/2024 4:24 pm
Transcribed by: RBN

Exam Date Time Procedure Performing Provider Status

5/29/24 9:47 PM XR Chest 1 View Portable HELMER, JORDON W; Auth (Verified)

Notes:
(XR Chest 1 View Portable) Reason For Exam: Shortness of breath;Chest pain
Report
EXAMINATION: XR Chest 1 View Portable

COMPARISON: None

HISTORY: Chest pain;Shortness of breath

TECHNIQUE: Single frontal view of the chest.

FINDINGS:
Medical devices: Electronic device centered over the mediastinum
.

Cardiomediastinal Silhouette: Unremarkable.

Lungs: Unremarkable.

Pleural space: Unremarkable.

Bones: Unremarkable for age.

Additional Findings: None.

IMPRESSION:
1. No radiographic evidence of acute cardiopulmonary disease.

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This report was electronically signed by Jonathan Harrison, MD

on 5/29/2024 9:48 PM.
***** Final *****

Dictated by: HARRISON, MD, JONATHAN H.

Dictated DT/TM: 05/29/2024 9:48 pm
Signed by: HARRISON, MD, JONATHAN H.
Signed (Electronic Signature): 05/29/2024 9:48 pm
Transcribed by: JHH

Exam Date Time Procedure Performing Provider Status

5/15/24 4:41 PM Echo TransTHORacic TTE GIBSON, KAELA MARIE; Auth (Verified)

Notes:
(Echo TransTHORacic TTE) Reason For Exam: Arrhythmia(s)
Report
Utah Valley Hospital
Echo Lab
1034 North 500 West
Provo, UT 84605
(801) 357-7272

Transthoracic Echocardiogram Report

Pt. Name: SARAH ELOIZA NIELSON Study Date: 5/15/2024

Birth Date: 12/6/1998 MRN: 543227130
Patient Age: 25 years Accession Number: 14400EC240044646
Pt. Gender: F FIN: 1268906033
Pt. Height: 63.0 in (160.0 cm) BSA: 1.9 m²
Pt. Weight: 189.6 lb (86.0 kg) Blood Pressure: 125/70 mmHg
Pt. Class: Inpatient Pt. Location: IP-933

Referring Physician: SARAH DALY

Ordering Physician: ETHAN HALL
Reading Physician: James Feeney
Sonographer: Kaela Gibson RVT

--------------------------------------------------------------------------------
Study Information: The following procedure(s) were performed: Complete echo, cardiac Doppler and color flow. Image
quality for this study is adequate. Imaging quality was affected by prominent lung artifact. The patient was awake.
Resting EKG showed normal sinus rhythm at a rate of 73 beats per minute. Definity perflutren lipid microsphere
suspension was given to enhance visualization of the left ventricle as indicated per protocol. The patient was verbally
consented. Definity perflutren lipid microsphere suspension was diluted 1.3 ml in 8.7 ml of normal saline. 3 ml of
Definity suspension was administered as an IV bolus.

Indication: Arrhythmia.

Past Medical History:

Syncope, history of aorta coarctation, bicuspid aortic valve, anemia.

--------------------------------------------------------------------------------
Impression:
1. Left ventricular systolic function is normal. The left ventricular ejection fraction is 79 %(+- 3%).
2. There are no segmental wall motion abnormalities.

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3. Normal diastolic pattern with normal left atrial pressure.
4. Normal right ventricular size and systolic function.
5. No evidence of aortic valve stenosis. Aortic valve morphology is bicuspid. No evidence of aortic regurgitation.
6. Tricuspid regurgitation jet was not adequate to estimate the right ventricular or pulmonary artery systolic pressure.
7. History of aorta coarctation repair, peak velocity of 2.7m/s.
8. Compared to a prior transthoracic study from 5/2/2014, no significant changes are seen.

Signed by: James Feeney

--------------------------------------------------------------------------------

M-Mode/2D Measurements and Calculations IVSd: 0.8 cm LVIDd: 3.8 cm Ao Sinus: 2.8 cm EF: 79 % +/-
3%
LVPWd: 0.9 cm LVIDs: 2.4 cm Ao 1.5 cm/m² FS: 37 %
Sinus/BSA:
RVd LAX: BP LV EDV: 93 ml Asc Ao: 2.5 cm IVC:
RVd Base: 2.70 BP LV EDV i: 49 ml/m² Asc 1.3 cm/m² RV area:
Ao/BSA:
BP LV ESV: 19 ml Asc Ao/Ht: 1.6 cm/m RWT: 0.47
BP LV ESV i: 10 ml/m² LAs: 3.1 cm
BP LV SV: 74 ml LV ESV: 19 ml
LVIDd Index 2.0 LV Mass i: 49 g/m²
cm/m²
LA Vol (MOD) index: 24 ml/m²
RA Vol (MOD) index: 26.1 ml/m²

Doppler Measurements
AV MV TV
LVOT: 1.80 cm E Vel: 1.16 TR Vel: 2.4
LVOT 1.4 m/s m/s m/s
Vel: A Vel: 1.09 TR Pk 22 PV
LVOT 28 cm m/s Grad: mmHg Pk 0.74
VTI E/A: 1.1 RA 3 mmHg Vel m/s
AoV 1.6 m/s PHT: 60 msec press: :
Vel: MVA: 3.7 cm² RVSP: 25 Pk 2
AoV VTI 33 cm MV MnG: 3 mmHg mmHg Gra mmHg
Mean 5 mmHg MV DT: 206 d:
Grad: msec RV
Pk 10 mmHg e' Medial: 12.70 s' 15.4
Grad: cm/s VMax: cm/s
DVI 0.84 e' 14.70 TAPSE: 2.1 cm
(VTI): Lateral: cm/s
AoV 2.1 cm² E/e' Med: 9
area: E/e' Lat: 8
LVOT 70 ml E/e' Avg: 9
SV:
LVOT 37
SVi ml/m²

--------------------------------------------------------------------------------

PHYSICIAN INTERPRETATION

Left Ventricle:
Left ventricular ejection fraction is estimated to be 79 %(+/_ 3%). Left ventricular systolic function is normal. The
ejection fraction was obtained by the biplane Simpson's method. There are no segmental wall motion abnormalities.
The left ventricle chamber size is normal. Normal left ventricular wall thickness. Left ventricular mass index is normal.
Left ventricular concentric remodeling is present. Normal diastolic pattern with normal left atrial pressure.

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Right Ventricle:
Normal right ventricular size and systolic function. The estimated right ventricular systolic pressure is 25 mmHg
assuming a right atrial pressure of 3 mmHg. Tricuspid regurgitation jet was not adequate to estimate the right
ventricular or pulmonary artery systolic pressure.

Left Atrium:
Left atrial volume index is 24 ml/m² which is normal.

Right Atrium:
The right atrial volume index is 26.1 ml/m² which is normal. The estimated right atrial pressure is 3 mmHg.

Interatrial Septum:
The interatrial septum was not well visualized.

Aortic Valve:
The aortic valve morphology is bicuspid. There is no evidence of aortic valve stenosis. There is no evidence of aortic
regurgitation. The peak transaortic velocity (Vmax) is 1.6 m/s. The peak aortic valve gradient is 10 mmHg. The mean
aortic valve gradient is 5 mmHg. The Doppler velocity index is calculated at 0.84. The left ventricular outflow tract
diameter is 1.80 cm. The calculated aortic valve area and area index by the continuity equation are 2.1 cm² and 1.1
cm²/m². The left ventricular stroke volume index is 37.2 ml/m².

Mitral Valve:
Normal mitral valve. There is no evidence of mitral valve stenosis. The mitral valve mean gradient is 3 mmHg at a
heart rate of 82 bpm. No evidence of mitral valve regurgitation.

Tricuspid Valve:
The tricuspid valve appears normal. Trace tricuspid valve regurgitation.

Pulmonary Valve:
The pulmonic valve was not well visualized, but grossly normal. There is no evidence of pulmonary valve stenosis.
Trace pulmonary valve regurgitation.

Pericardium:
No pericardial effusion is seen.

Aorta:
The ascending aorta is normal size measuring 2.5 cm (1.3 cm/m²). The aortic valve sinuses of Valsalva are normal
measuring 2.8 cm (1.5 cm/m²). The aortic arch measures 2.3 cm. The aortic arch is normal in diameter with no
evidence of dilatation. The visualized segments of the descending aorta appear normal, with no evidence of dilatation.
History of aorta coarctation repair, peak velocity of 2.7m/s.

Pulmonary Artery:
Normal estimated right ventricular systolic pressure.

Venous:
The IVC is normal size with respiratory size variation greater than 50%.

REST:
EKG Findings:
Resting EKG showed normal sinus rhythm at a rate of 73 beats per minute.

Diagnosing Physician: James Feeney.

Electronically signed by James Feeney on 5/16/2024 at 11:04:51 AM

cc report to: SARAH DALY

ETHAN HALL

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10/24/2024 Continuity of Care Document
*** Final ***
***** Final *****

Dictated by: FEENEY, MD, JAMES M.

Dictated DT/TM: 05/16/2024 11:04 am
Signed by: FEENEY, MD, JAMES M.
Signed (Electronic Signature): 05/16/2024 11:04 am
Transcribed by: JMF

Exam Date Time Procedure Performing Provider Status

5/14/24 5:30 PM CT Angio Pulmonary BAUER, SERE; Auth (Verified)

Notes:
(CT Angio Pulmonary) Reason For Exam: chest pain/shortness of breath;Other (must specify details)
Report
EXAMINATION: CT Angio Pulmonary

COMPARISON: CT Angio Chest 2018-Feb-09

HISTORY: Syncope every day for 6 days, lightheaded

TECHNIQUE: Axial CT images were obtained through the chest with

the administration of intravenous contrast, tailored to
evaluation of the pulmonary arteries. Multiplanar and maximum
intensity projection reconstructions were created.

FINDINGS:

Diagnostic Quality: Adequate for interpretation and

recommendations.

Lower Neck and Axillae: Normal.

Pulmonary arteries: No filling defects are identified. The main

pulmonary artery is normal in caliber. Pulmonary artery
branches are normal in course and caliber.

Classification: No evidence of pulmonary embolism.

RV to LV ratio: Not measured.

Heart: Normal.

Coronary Artery Calcification: None.

Aorta: No acute abnormality

Mediastinum: Normal.

Lungs and Airways: Normal.

Pleural Space: Normal.

Soft Tissues: Normal.

Bones: Normal for age.

Upper Abdomen: Patchy appearance of the liver. Liver is

incompletely imaged on this study. Possibly due to incomplete
fatty infiltration. Other etiologies possible. Please correlate.

Additional Findings: None.

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10/24/2024 Continuity of Care Document

IMPRESSION:
1. No evidence of acute or chronic pulmonary embolism
2. See above for other findings

This report was electronically signed by John S. Collins, MD on

5/14/2024 5:35 PM.
***** Final *****

Dictated by: COLLINS, MD, JOHN S.

Dictated DT/TM: 05/14/2024 5:35 pm
Signed by: COLLINS, MD, JOHN S.
Signed (Electronic Signature): 05/14/2024 5:35 pm
Transcribed by: JSC

Exam Date Time Procedure Performing Provider Status

3/30/24 4:09 PM XR Chest 2 Views BRINGHURST, CARRIE SUE; Auth (Verified)

Notes:
(XR Chest 2 Views) Reason For Exam: Cough
Report
EXAMINATION: XR Chest 2 Views

COMPARISON: Chest radiograph 2/27/2022

HISTORY: Cough

TECHNIQUE: Two views of the chest.

FINDINGS:
Medical devices: None.

Cardiomediastinal Silhouette: Unremarkable.

Lungs: Unremarkable.

Pleural space: Unremarkable.

Bones: Normal for age.

Additional findings: None.

IMPRESSION:
1. No radiographic evidence of acute cardiopulmonary disease.

This report was electronically signed by Jason W. Curtis, MD on

3/30/2024 4:13 PM.
***** Final *****

Dictated by: CURTIS, MD, JASON W.

Dictated DT/TM: 03/30/2024 4:13 pm
Signed by: CURTIS, MD, JASON W.
Signed (Electronic Signature): 03/30/2024 4:13 pm
Transcribed by: JWC

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10/24/2024 Continuity of Care Document

Exam Date Time Procedure Performing Provider Status

11/6/23 11:43 AM US Pelvis Comp w/Transvag if BLACK, OLIVIA; Auth (Verified)
indicated

Notes:
(US Pelvis Comp w/Transvag if indicated) Reason For Exam: manorrhagia;Menorrhagia
Report
EXAMINATION: US Pelvis Comp w/Transvag if indicated, 11/6/2023
11:43 AM

COMPARISON: None

HISTORY: Menorrhagia

TECHNIQUE: Transabdominal imaging of the pelvis was performed.

Subsequently, transvaginal imaging was also performed to improve
visualization of the pelvic organs given the clinical scenario.

FINDINGS:

Diagnostic Quality: Adequate for interpretation and

recommendations.

Uterus: Normal. Bicornuate anatomy.

Endometrium (mm): 5.9

Normal for patient age (assumes menopause at 50 years of age).

Right ovary: Normal. Normal blood flow documented.

Left ovary: Normal. Normal blood flow documented.

Adnexa: Low volume free fluid in cul-de-sac.

IMPRESSION:
1. Bicornuate uterine anatomy
2. Exam otherwise unremarkable.

This report was electronically signed by Carl M. Black, MD on

11/6/2023 11:58 AM.
***** Final *****

Dictated by: BLACK, MD, CARL M.

Dictated DT/TM: 11/06/2023 11:58 am
Signed by: BLACK, MD, CARL M.
Signed (Electronic Signature): 11/06/2023 11:58 am
Transcribed by: CMB

Vital Signs

Most recent to oldest

1 2 3
[Reference Range]:

Use of Ambulatory Aid Morse None, bedrest, wheelchair, nurse None, bedrest, wheelchair, nurse None, bedrest, wheelchair, nurse
(9/18/24 7:25 AM) (5/16/24 8:30 AM) (5/15/24 7:15 PM)

Blood Pressure Method Automatic Automatic Automatic

(5/16/24 10:00 AM) (5/16/24 6:04 AM) (5/16/24 2:30 AM)

Blood Pressure Location Left arm Right arm Right arm

(9/1/24 3:29 AM) (5/16/24 10:00 AM) (5/16/24 6:04 AM)

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10/24/2024 Continuity of Care Document
Most recent to oldest
1 2 3
[Reference Range]:

Heart Rate Monitored [50-100 107 bpm 1 109 bpm 2 110 bpm
bpm] *HI* *HI* *HI*

(9/28/24 4:14 AM) (9/28/24 4:00 AM) (9/28/24 3:40 AM)

Heart Rate Monitored, Median 114 bpm 113 bpm 118 bpm
[50-100 bpm] *HI* *HI* *HI*
(9/28/24 4:00 AM) (9/28/24 3:45 AM) (9/28/24 3:30 AM)

Mean Arterial Pressure, Cuff 101 mmHg 108 mmHg 132 mmHg
[65-140 mmHg] (10/16/24 9:58 AM) (10/11/24 1:04 PM) (9/30/24 1:22 PM)

Mean Arterial Pressure, Cuff, 121 mmHg 125 mmHg 116 mmHg
Device (9/28/24 4:14 AM) (9/28/24 4:00 AM) (9/28/24 3:40 AM)

Peripheral Pulse Rate [50-100 93 bpm 61 bpm 126 bpm

bpm] (10/16/24 9:58 AM) (10/11/24 1:04 PM) *>HHI*
(9/30/24 1:22 PM)

Respiratory Rate [12-20 br/min] 18 br/min 20 br/min 16 br/min

(9/30/24 1:22 PM) (9/30/24 11:53 AM) (9/28/24 7:14 PM)

Respiratory Rate, Median [12-20 18 br/min 17 br/min 18 br/min

br/min] (9/28/24 4:00 AM) (9/28/24 3:45 AM) (9/28/24 3:30 AM)

Blood Pressure [91-139/0-89 127/88 mmHg 138/93 mmHg 159/118 mmHg

mmHg] (10/16/24 9:58 AM) (10/11/24 1:04 PM) *HI*
(9/30/24 1:22 PM)

Temperature Temporal Artery 36.3 Deg C 36.1 Deg C 36.7 Deg C

[36.5-38 Deg C] *LOW* *LOW* (9/18/24 10:38 AM)
(9/27/24 11:53 PM) (9/18/24 11:48 AM)

Temperature Tympanic [36.1- 36.5 Deg C 36.6 Deg C 36.7 Deg C

38 Deg C] (10/16/24 9:58 AM) (9/30/24 1:22 PM) (9/30/24 11:53 AM)

Height/Length Measured 162 cm 162 cm 162 cm

(10/16/24 9:58 AM) (10/11/24 1:04 PM) (10/7/24 2:33 PM)

Weight Measured 85.5 kg 84.5 kg 84.7 kg

(10/16/24 9:58 AM) (10/7/24 2:33 PM) (9/30/24 11:53 AM)

BMI Percentile 88.01 87.96 84.71

(2/5/18 2:27 PM) (11/30/17 8:04 PM) (6/3/16 12:25 AM)

Body Mass Index Measured 32.58 kg/m2 32.2 kg/m2 33.09 kg/m2
(10/16/24 9:58 AM) (10/7/24 2:33 PM) (9/30/24 11:53 AM)

Oxygen Flow Rate 0 L/min 2 L/min 2 L/min

(9/28/24 6:19 PM) (9/18/24 11:48 AM) (9/18/24 11:38 AM)

SpO2 [90-100 %] 98 % 92 % 95 %
(10/16/24 9:58 AM) (10/11/24 1:04 PM) (9/30/24 1:22 PM)

1 Result Comment: Dr. Starnes aware

2 Result Comment: Dr. Starnes aware

Social History

Social History Type Response

Tobacco Use: Never smoker (less than 100 in lifetime).

Birth Sex

Sex Representation Female (finding)

Health Concerns

No data available for this section

Implantable Device List

No data available for this section

Hospital Discharge Instructions

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10/24/2024 Continuity of Care Document
Section Author: , ,
Follow Up Care
With: Follow up with primary care provider
Address:

When: 2 to 4 days
With: LLOYD, MD, MICHAEL J., Ophthalmology.
Address:
1055 N 300 W STE 204
PROVO, UT 84604-
(801)357-7373

When: 1 week
With: HEALEY, DO, MICHAEL AUSTIN, Family Medicine.
Address:
395 COUGAR BLVD STE 603
PROVO, UT 84604-
(801)357-0560

When: 2 to 4 days
Comments: Return to ED if symptoms worsen.
With: HEALEY, DO, MICHAEL AUSTIN, Family Medicine.
Address:
395 COUGAR BLVD STE 603
PROVO, UT 84604-
(801)357-0560

When:
Unknown
With: HEALEY, DO, M. AUSTIN, Family Medicine.
Address:
395 COUGAR BLVD STE 603
PROVO, UT 84604-
(801)357-0560

When:
Unknown
With: HEALEY, DO, M. AUSTIN, Family Medicine.
Address:
395 COUGAR BLVD STE 603
PROVO, UT 84604-
(801)357-0560

When:
Unknown
With: Follow-up in Emergency Department
Address:

When:
Unknown
Comments: Return to ED if symptoms worsen.
With: HEALEY, DO, M. AUSTIN, Family Medicine.
Address:
395 COUGAR BLVD STE 603
PROVO, UT 84604-
(801)357-0560

When:
Unknown
With: Wasatch Mental Health South Campus
Address:

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10/24/2024 Continuity of Care Document
580 E 600 S
Provo, UT 84606-
8013734760

When:
Unknown
Comments: Call for followup appointment.
With: Follow up with primary care provider
Address:

When: 5 to 7 days
Comments: Return to ED if symptoms worsen.
With: Follow up with primary care provider
Address:

When: 5 to 7 days
Comments: Return to ED if symptoms worsen.
With: HEALEY, DO, M. AUSTIN, Family Medicine.
Address:
395 COUGAR BLVD STE 603
PROVO, UT 84604-
(801)357-0560

When: 06/25/2024 10:00:00

Comments: Appointment Scheduled.
With: FEENEY, MD, JAMES M.
Address:
395 W COUGAR BLVD
PROVO, UT 84604-
(801)357-7081

When: 06/14/2024 08:00:00

Comments: Appointment Scheduled.
With: FEENEY, MD, JAMES M.
Address:
395 W COUGAR BLVD
PROVO, UT 84604-
(801)357-7081

When:
Unknown
With: HEALEY, DO, M. AUSTIN, Family Medicine.
Address:
395 COUGAR BLVD STE 603
PROVO, UT 84604-
(801)357-0560

When: 1 week
Comments: Call for followup appointment.
With: HAFEN, NP-P, BRET D.
Address:
934 S MAIN STREET
LAYTON, UT 84041-
(801)773-7060

When:
Unknown
With: Follow-up in Emergency Department
Address:

When:

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10/24/2024 Continuity of Care Document
only if needed
Comments: For worsening signs or symptoms.
With: Follow up with primary care provider
Address:

When: 5 to 7 days
With: HAFEN, NP-P, BRET D.
Address:
934 S MAIN STREET
LAYTON, UT 84041-
(801)773-7060

When:
Unknown
Comments: Call to arrange follow-up. Take an antacid as previously recommended. Take the prescribed nausea medication as directed. Return to ED with any
concerning symptoms.
With: Your Specialist(s)
Address:

When:
Unknown
Comments: Reach out to your therapist on Monday morning to arrange close outpatient follow-up for reassessment, further evaluation and management through
them.
With: Follow-up in Emergency Department
Address:

When:
only if needed
Comments: Return to our emergency department (or the nearest emergency department) immediately for reevaluation if your symptoms change or worsen.
With: Your Primary Care Provider
Address:

When: 2 to 4 days
Comments: Follow up with your primary care provider within the next few days for reevaluation unless your symptoms have markedly improved. Follow up with
your primary care provider for health maintenance and routine healthcare as well.
With: HAFEN, NP-P, BRET D.
Address:
934 S MAIN STREET
LAYTON, UT 84041-
(801)773-7060

When: 1 week
With: HAFEN, NP-P, BRET D.
Address:
934 S MAIN STREET
LAYTON, UT 84041-
(801)773-7060

When:
Unknown
With: HAFEN, NP-P, BRET D.
Address:
934 S MAIN STREET
LAYTON, UT 84041-
(801)773-7060

When: 3 to 5 days
Comments: Call for followup appointment.
With: HAFEN, NP-P, BRET D.
Address:
934 S MAIN STREET

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10/24/2024 Continuity of Care Document
LAYTON, UT 84041-
(801)773-7060

When:
Unknown
Comments: Take the prescribed medication as directed. Return to ED with any concerning symptoms.
With: Follow up with primary care provider
Address:

When: 2 to 4 days
With: Altium Health
Address:
7181 South Campus View Drive Suite A
West Jordan, Utah 84084-
385-832-8267

When: 05/03/2023 14:00:00

Comments: Appointment Scheduled for IOP intake via telehealth.
With: Keep Upcoming Appointment(s)
Address: Unknown
When:
Unknown
With: HAFEN, NP-P, BRET D.
Address:
934 S MAIN STREET
LAYTON, UT 84041-
(801)773-7060

When: 1 week
With: Follow-up in Emergency Department
Address:

When:
only if needed
Comments: Return to the emergency department or call 911Â immediately for any new or worsening symptoms.
With: HAFEN, NP-P, BRET D.
Address:
934 S MAIN STREET
LAYTON, UT 84041-
(801)773-7060

When: 1 week
With: Keep Upcoming Appointment(s)
Address: Unknown
When:
Unknown
With: Follow-up in Emergency Department
Address:

When:
only if needed
Comments: Return to the emergency department or call 911Â immediately for any new or worsening symptoms.
With: HAFEN, NP-P, BRET D.
Address:
934 S MAIN STREET
LAYTON, UT 84041-
(801)773-7060

When: 1 week
With: Follow up with primary care provider
Address:

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10/24/2024 Continuity of Care Document

When: 2 to 4 days
With: VANDERSTEEN, DO, JOSHUA G., Credentialed Provider, Gastroenterology, Internist, Internist., User Group - LH_Layton Hosp, User Group - MK_McKay-Dee
Hosp
Address:
4650 HARRISON BLVD
OGDEN, UT 84403-
(801)475-3011

When:
Unknown
Comments: Please call his office tomorrow afternoon if you have not heard from him for follow-up.
With: The Phoenix Recovery and Counseling Center
Address:
9980 South 300 West Ste: 105
Sandy UT, UT 84070-

When: 01/20/2021 10:00:00

Comments: Appointment Scheduled PHP day treatment program
With: RICHARD LATER
Address:
1055 N 300 W STE 311
PROVO, UT 84604-
(801)357-7883 Business (1)

When:
Unknown
With: Phoenix Recovery Center- Draper
Address:
11762 South State Street Ste 360
Draper, UT 84020-
P: (801) 571-6782 F: (801) 438-3184

When: 11/04/2020 13:00:00

Comments: In office appointment for a biopsychosocial assessment with a clinician on Wednesday, November 4 at 1:00 p.m. BH follow up, tobacco, and/or
addiction treatment referral.
With: Draper Integrated Counseling and Wellness
Address:
13552 South 110 West #204
Draper, UT 84020-
P: 801-432-0883 F: 801-335-6440

When: 11/10/2020 13:30:00

Comments: Appointment scheduled with Charity Hotton, AMFT on Tuesday, November 10 at 1:30 p.m. for therapy. BH follow up, tobacco, and/or addiction
treatment referral.
With: Draper Integrated Counseling and Wellness
Address:
13552 South 110 West #204
Draper, UT 84020-
P: 801-432-0883 F: 801-

When: 11/12/2020 16:30:00

Comments: Appointment scheduled with Charity Hotton, AMFT on Thursday, November 12 at 4:30 p.m. for therapy. BH follow up, tobacco, and/or addiction
treatment referral.
With: Patient Navigator- Utah County
Address:
801-357-3177

When:
only if needed
Comments: If you need further assistance with obtaining mental health resources for outpatient services, please call the number listed, and I'll be glad to assist

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10/24/2024 Continuity of Care Document
you.
With: Tobacco Quit Line
Address:

When:
only if needed
Comments: Please call 1-800-QUIT-NOW.BH follow up, tobacco, and/or addiction treatment referral
With: Follow up with primary care provider
Address: Unknown
When:
Unknown

Goals

I will have no unplanned ED visits/hospitalizations for the next 3 Start Date:8/5/24 End Date:11/5/24
months

Status:Met Progression:Not Met

I will have a signed copy of my Utah Advanced Healthcare Start Date:8/5/24 End Date:2/5/25
Directives in my medical record

Status:Met Progression:Not Met

I will have a job to provide income for living expenses Start Date:8/5/24 End Date:12/5/24

Status:Met Progression:Not Met

I will have the transportation I need to attend my medical Start Date:8/5/24 End Date:10/4/24
appointments

Status:Met Progression:Not Met

I will implement 2 strategies to manage symptoms of ADHD Start Date:8/5/24 End Date:11/5/24

Status:Met Progression:Not Met

Reason for Referral

No data available for this section

Hospital Course

No data available for this section

Procedure note

VANDERSTEEN, DO, JOSHUA G.: PERFORM, MODIFY

Event Display: Procedure Note
Authored Date: 20220302120348-0700

PROCEDURE:Â Upper endoscopy

 Date of Service:  03/02/2022

 Location:  Layton Hospital

PRIMARY CARE CLINICIAN:Â Â HAFEN, NP-P, BRET D.

INDICATION AND CLINICAL HISTORY:  23 year old female presents with nausea, vomiting and hematemesis. She is
here for an endoscopic evaluation for this.
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10/24/2024 Continuity of Care Document

PROCEDURE SEDATION:Â MAC Sedation

DESCRIPTION OF PROCEDURE:Â Procedure and sedation risks (including but not limited to bleeding, missed lesions,
perforation, pain, bradycardia, hypoxia and hypotension) and benefits were explained to the patient. Procedure consent
was obtained. A surgical time out was performed. The patient was placed in the left lateral decubitus position. The
Olympus endoscope was inserted through the mouth and advanced into the upper digestive tract. The scope was then
carefully withdrawn and the mucosa was carefully examined.

Â
 ASA category:  2

 Depth of insertion:  3rd portion of duodenum

FINDINGS:

Esophagus: Normal esophagus. The GE junction was identified at 37Â cm from the incisors. LA Class A
esophagitis. Biopsies of the mid esophagus were taken with cold forceps.

Stomach: Normal stomach. There were no visualized ulcers or erosions, masses or polyps. Retroflexion evaluation of
the proximal stomach was normal. The pylorus was patent. Biopsies of the antrum of the stomach were taken with cold
forceps.

Â
Duodenum: Normal duodenum. Biopsies of the duodenum were taken with cold forceps.

POST PROCEDURE:

Complications:Â The patient tolerated the procedure well. There were no immediate complications.

Estimated blood loss:Â Â None

Specimens:Â Â See above

IMPRESSION:

-23 year old female has undergone an EGD. Biopsies of the duodenum, stomach and esophagus were taken with cold
forceps. LA Class A esophagitis.

RECOMMENDATIONS:

-Await biopsy results.

-Continue Omeprazole.

-Follow up in clinic in 3-4 weeks.

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10/24/2024 Continuity of Care Document
Â

Medical scribe declaration:Â

I entered information for the licensed provider exactly as directly spoken to me by the provider or for services
performed as observed. Results or interpretations were transcribed as directed by the provider. No pharmacy,
laboratory, imaging, or consult orders were created by me. Medical history, family history, social history, review of
systems and vital sign components, if applicable to this patient visit were documented independently if provided to me
by the patient. No interpretations, assumptions, or impressions were entered by me based on my observations or
patient comments. This documentation has been signed and dated by me in presence of and in behalf of the provider.

Â
Physician attestation:

I was present for all parts of documentation completed by the scribe and attest that I have reviewed the content for
accuracy and completeness of the information as written by the scribe. Portions of this note may have been created
using voice recognition software and errors in sound-alike words may occur.

Electronically Signed on 03/02/22 12:03 PM

________________________________________________________
VANDERSTEEN, DO, JOSHUA G.

Electronically Signed on 03/02/22 12:03 PM

_________________________________________________
BENNETT, BROOKE

Radiology

VANDERSTEEN, DO, JOSHUA G.: PERFORM

Event Display: Clinician Performed Imaging in Endoscopy
Authored Date: 20220302113807-0700
Please click on link to see image.

Event Display: Clinician Performed Imaging in Endoscopy

Event Display: Clinician Performed Imaging in Endoscopy

Cardiology Consult note

BLANCHARD, NP, AUSTIN G: PERFORM

Event Display: Cardiology Consultation
Authored Date: 20240515180428-0600

Chief Complaint
Syncopal episode x6 days.
Reason for Consultation
Bicuspid Aortic Valve
History of Present Illness
Pt is a 25 Years Female with hx of bicuspid aortic valve, aortic coarctation, anorexia nervosa, borderline personality
disorder, depression, and ADHD who presents with a 6 days of daily syncope.
Â
Per the ED physician: Has had daily syncope for past 6 days. Is tachycardic here, improved with fluids. Ddimer. Has
not followed up regarding bicuspid aortic valve and aortic coarctation. Last syncopal episode today. Not endorsing any
other acute symptoms. Intermittent urinary urgency, no back pain, no spinal trauma or IVDU. DDminer, troponin, TSH
all WNL. b-hydroxybutyrate elevated. No concern for infection.
Â
Per the patient: Patients reports first episode of syncopal event was Thursday. Notes that she has had approximately 2
episodes since that time. Reports that one episode occurred on Saturday and occurred after multiple episodes of sitting
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10/24/2024 Continuity of Care Document
and standing. Was told by a bystander that she was passed out for only a couple seconds. Notes that she had some
confusion following the syncopal event which lasted for a few seconds. Notes that walking, even short distances, was
difficult and caused diaphoresis, SOB, and lightheadedness. She denies any head trauma during these episodes. Denies
any extremity or truncal injury from these falls. She denies witnessed seizure like activity, tongue biting, urinary
incontinence. She does admit to urinary frequency and urgency. She admits to palpitations. She describes these
palpitations as being intermittent but worsening for the past few weeks. Was sick in early April with viral symptoms.
States that she has lost weight but unclear how much. Admits to increased appetite but reports decreased thirst. Has
glasses but doesn't wear them, feels as though vision has gotten worse. Denies acute double vision or black spots in
vision. Denies overt chest pain or pressure. Admits to nausea, vomiting, diarrhea, and constipation stating that these
have been going for 2 years. Admits to red urine but denies dysuria. Admits to pins and needles sensation throughout
entire body. States that this sensation occurs unprovoked.
 In the ED: Hypertensive up to 160s over 110s, tachycardic to 131, briefly tachypneic to 23, saturating well on
RA.  Labs significant for WBC 13.1, hemoglobin 9.9, platelets 587, D-dimer WNL at 0.49, sodium 135, potassium
3.1, chloride 100, bicarb 18, anion gap 18, glucose 123, beta hydroxybutyrate 1.9, troponin negative, TSH
WNL.  CTAP with no acute abnormalities, no evidence of PE. EKG showing sinus rhythm with ventricular trigeminy.
 Today: Patient has not had echocardiogram in our system to understand anatomy, structure and function of her
heart. based on above history, it is pertinent to answer this question to assess for aortic stenosis versus other
cardiac etiologies which may explain her symptom pattern.
Review of Systems
10 systems were reviewed and are negative except as noted in the HPI
Physical Exam
Vitals & Measurements
T: 36.4 °C (Temporal Artery) TMIN: 35.7 °C (Temporal Artery) TMAX: 36.5 °C (Temporal Artery)Â
HR: 89(Monitored) RR: 16 BP: 124/83 BP: 147/121(Supine) SpO2: 97% WT: 86.5 kg BMI: 33.79Â
 General: Alert and oriented, no acute distress.
Neck: Trachea midline, supple, non-tender, no carotid bruits, no JVD .
Lungs: Clear to auscultation; normal respiratory effort with non-labored breathing; no rales, rhonchi, or
wheezing.
Heart: Regular rate and rhythm; No murmur present. No rubs, gallops or clicks; normal S1 and S2.
Extremities: No bilateral LE edema; warm
Neurologic: Awake, alert, and oriented X3. No lateralizing weakness.Â
Psychiatric: Cooperative; appropriate mood and affect.
Assessment/Plan

1. Recurrent syncope

Unknown etiology at this point. TTE pending interpretation to assess for aortic stenosis based on history of bicuspid
aortic valve. Continue to monitor with telemetry. Telemetry reveals nearly a 7% PVC burden, without malignant
arrhythmia identified.
2. S/P repair of coarctation of aorta
TTE pending
3. Bicuspid aortic valve
See #1
4. SIRS without infection or organ dysfunction
5. Leukocytosis
6. Metabolic acidosis
7. Hypokalemia
Replace per protocol
8. Anemia
Patient currently on birth control due to heavy menstruation.  She reports that she is unable to tolerate oral iron
supplementation. Recommend thoughtful approach to trying to correct underlying anemia.
9. Anorexia nervosa, restricting type, in partial remission, moderate
10. Borderline personality disorder
11. Depression, major, recurrent, moderate
12. PTSD (post-traumatic stress disorder)
13. Attention deficit disorder (ADD) in adult
14. Menorrhagia
Syncope/Near syncope
I, Austin Blanchard, spent 29 minutes in the interpretation of received data and interactive communication with the
patient discussing the aforementioned with the patient.
 Portions of this chart may have been created with Dragon voice recognition software. Occasional wrong-word or
`sound-alike´ substitutions may have occurred due to the inherent limitations of voice recognition software. Please
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10/24/2024 Continuity of Care Document
read the chart carefully and recognize, using context, where these substitutions have occurred.
Problem List/Past Medical History
Ongoing
Anemia
Anorexia nervosa, restricting type, in partial remission, moderate
Anorexia nervosa, restricting type, moderate
Attention deficit disorder (ADD) in adult
Bicuspid aortic valve
Borderline personality disorder
Depression, major, recurrent, moderate
Menorrhagia
PTSD (post-traumatic stress disorder)
Recurrent major depression-severe
S/P repair of coarctation of aorta
Procedure/Surgical History
Esophagogastroduodenoscopy (03/02/2022), Transcatheter intracardiac shunt (TIS) creation by stent placement for
congenital cardiac anomalies to establish effective intracardiac flow, including all imaging guidance by the
proceduralist, when performed, left and right heart diagnostic cardiac cath.
Medications
Inpatient
Artificial Tears preservative-free ophthalmic solution, 1 drops, Eye-Both, every 2 hr, PRN
hydrALAZINE, 10 mg= 0.5 mL, IV Push, every 4 hr, PRN
hydrOXYzine, 50 mg= 2 tabs, Oral, BID, PRN
ibuprofen, 600 mg= 1 tabs, Oral, every 6 hr, PRN
LR drip 1,000 mL, 1000 mL, IV Drip
melatonin, 3 mg= 1 tabs, Oral, Daily at bedtime, PRN
MiraLax, 17 g= 1 EA, Oral, BID, PRN
Senna S, 1 tabs, Oral, BID, PRN
traZODone, 50 mg= 1 tabs, Oral, Daily at bedtime
Tums 500 (calcium carbonate 500 mg (elemental Ca 200 mg)) oral tab, chewable, 1 tabs, Oral, every 6 hr, PRN
Tylenol, 500 mg= 1 tabs, Oral, every 4 hr, PRN
Zofran, 4 mg= 2 mL, IV Push, every 6 hr, PRN
Home
hydrOXYzine hydrochloride 50 mg oral tablet, 50 mg= 1 tabs, Oral, BID, PRN
Sprintec, 1 tabs, Oral, Daily
traZODone 50 mg oral tablet, 50 mg= 1 tabs, Oral, Daily at bedtime
Vyvanse 70 mg oral capsule, 70 mg= 1 cap, Oral, every morning
Allergies
No Known Medication Allergies
No Known Allergies
Social History
Alcohol - 02/08/2024
Use: Never used. Household alcohol concerns: No.
Use: Never used.
Use: Never used.
Employment/School - 02/08/2024
Status: Employed. Place of occupation/business: Pet grooming. Highest education level: High school.
Employed
Home/Environment - 02/08/2024
Lives with: Friend and her family.
Substance Use - 02/08/2024
Use, other than prescribed: Never used. Concerns about substance abuse in household: No.
Use, other than prescribed: Never used. Date last used: CBD once.
Tobacco - 02/08/2024
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker.
Use: Never smoker.
Use: Never smoker.
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10/24/2024 Continuity of Care Document
Family History
Anxiety: Grandmother (M) and Sibling.
Arrhythmia (cardiac) NOS: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
CHD - Congenital heart disease: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Cancer: Father.
Cancer: Father, Grandfather (P) and Grandmother (P).
Depression: Grandmother (M), Sibling and Sibling.
Drug addiction: Sibling and Sibling.
Emotional problems: Sibling.
Heart attack: Grandmother (M).Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Hyperlipidemia: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Substance Use: Sibling and Sibling.
Sudden cardiac death: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Suicidal behavior: Sibling and Sibling.
Lab Results
Labs (Last four charted values)
WBC Â Â Â Â Â 9.0Â Â Â (MAY 15)Â Â Â HÂ 13.1Â Â Â (MAY 14)
Hgb      L 9.4   (MAY 15)   L 9.9   (MAY 14)   L 11.4   (MAY 14)
Hct      L 32.3   (MAY 15)   37.0   (MAY 14)
Plt      H 411   (MAY 15)   H 587   (MAY 14)
Na      L 136   (MAY 15)   L 135   (MAY 14)
K Â Â Â Â Â 3.6Â Â Â (MAY 15)Â Â Â LÂ 3.1Â Â Â (MAY 14)
CO2 Â Â Â Â Â LÂ 17Â Â Â (MAY 15)Â Â Â LÂ 18Â Â Â (MAY 14)
Cl      106   (MAY 15)   L 100   (MAY 14)
Cr      0.80   (MAY 15)   0.95   (MAY 14)
BUN Â Â Â Â Â LÂ 7Â Â Â (MAY 15)Â Â Â 10Â Â Â (MAY 14)
Glucose Random        80   (MAY 15)   H 123  (MAY 14)
Mg      2.1   (MAY 14)
Phos      2.8   (MAY 14)
Imaging Results (Last 24 Hours)
CT Angio Pulmonary
Â
05/14/24 16:46:00
IMPRESSION:
1. No evidence of acute or chronic pulmonary embolism
2. See above for other findings
Â
Â
Â
 This report was electronically signed by John S. Collins, MD on
5/14/2024 5:35 PM.
Â
Signed By: COLLINS, MD, JOHN S.

Electronically Signed on 05/15/24 06:04 PM

________________________________________________________
BLANCHARD, NP, AUSTIN G
SUNKARA, MD, NIRMAL T.: PERFORM
Event Display: Cardiology Consultation
Authored Date: 20240515235100-0600

Cardiology attending addendum:

Patient seen and examined.

Note above reviewed

Echocardiogram images reviewed.

No significant aortic stenosis identified at this bicuspid valve.

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10/24/2024 Continuity of Care Document

Normal left ventricular systolic function.

Mildly dilated right ventricle.

Given PVC burden, dilated right ventricle, consider cardiac MRI.

Continue telemetry monitoring.

Elevated blood pressures noted in the emergency room.

Not on any blood pressure medications at home.  Continue to monitor. If significantly elevated blood pressure, in
addition to initiation of medications, she will need evaluation for secondary causes of hypertension.

Â
Medications (12) Active

Scheduled: (1)

traZODone 50 mg tablet  50 mg 1 tabs, Oral, Daily at bedtime

Continuous: (1)

Lactated Ringers 1,000 mL Â 1,000 mL, IV Drip, 125 mL/hr

PRN: (10)

acetaminophen 500 mg tablet  500 mg 1 tabs, Oral, every 4 hr

calcium carbonate 500 mg (elemental Ca 200 mg) chewable tablet  1 tabs, Oral, every 6 hr

carboxymethylcellulose 0.5% (Refresh Plus) droperette  1 drops, Eye-Both, every 2 hr

hydrALAZINE 20 mg/mL 1 mL vial  10 mg 0.5 mL, IV Push, every 4 hr

hydrOXYzine 25 mg tablet  50 mg 2 tabs, Oral, BID

ibuprofen 600 mg tablet  600 mg 1 tabs, Oral, every 6 hr

melatonin 3 mg tablet  3 mg 1 tabs, Oral, Daily at bedtime

ondansetron PF 2 mg/mL 2 mL injection  4 mg 2 mL, IV Push, every 6 hr

polyethylene glycol 3350 powder 17 g packet  17 g 1 EA, Oral, BID

sennosides/docusate sodium 8.6 mg-50 mg tablet  1 tabs, Oral, BID

Total time spent evaluating the patient, reviewing records, care, documenting in the chart, 60 minutes

Electronically Signed on 05/15/24 11:51 PM

________________________________________________________
SUNKARA, MD, NIRMAL T.

Mental health Progress note

PITCHER, DO, MATTHEW D.: PERFORM

Event Display: Behavioral Health Progress Note
Authored Date: 20201102140232-0700

Chief Complaint
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10/24/2024 Continuity of Care Document
OD on 38 nyquil
Diagnosis/Treatment Plan
1. Depression, major, recurrent, moderate
2. Suicide attempt
3. Intentional drug overdose
4. Obesity (BMI 30-39.9)
5. GAD (generalized anxiety disorder)
6. PTSD (post-traumatic stress disorder)
7. Nightmares
8. Attention deficit disorder (ADD) in adult
9. Anorexia nervosa, restricting type, moderate
10. Alcohol use
11. Borderline personality disorder
12. S/P repair of coarctation of aorta
Subjective
I met with the patient in her room.  Patient reports that she is feeling better than she was before she was admitted.
 States that she is glad that her suicide attempt did not work at this point. States that she is thankful
for her friends who continue to be supportive. She reports that she slept well last night.  Expresses that she has
not had any nightmares for a couple of nights now. States that she is getting along well with other patients. Reports
that she is looking forward to getting back out of the hospital. Patient reports that her appetite has been normal and
that she is eating appropriately.
Â
We engaged in individual therapy for 16 minutes using supportive therapy discussing the patient's recent stressors, in
order to reduce the patient's risk of maladaptive coping mechanisms. We discussed the patient's reasons for hope. The
patient said they would continue working on developing positive coping skills. I suggested working on improving their
cognitive distortions. The patient agreed to work on focusing on goals and people that matter to them. Overall, the
patient engaged well in therapy and responded well.
Â
Review of Systems
Psychiatric: as per HPI
Â
Mental Status Exam
General Appearance: Casually dressed, moderately groomed
Behavior: [Cooperative]
Mood/Affect: "Okay"/congruent
Thought Process: [Logical and goal directed ]
Thought Content: Patient denies SI/HI. Â Nonpsychotic.
Insight/Judgement: Fair
Â
Risk Assessment: Moderate risk
Â
Assessment: Patient showing improvement.  Expressing future oriented thinking. Denying thoughts of suicide at
this time.  Patient expressing sedation that she still does have a lot of work to do to process trauma.Â
Expressing desire for intensive outpatient programming, states that she was supposed to start this this week at
Phoenix recovery. Patient tolerating medications well.  Still on low doses, but did not have a reason to increase at
this time.  Need to monitor carefully has this is patient's third hospitalization in the last couple of months.
Â
Estimated date of discharge: 11/3 or 4
Â
Goals to be Achieved Prior to Discharge: Continued stability. Â Continued decrease in suicidal ideation.
 Plan:
1. Â Will continue 15 minute checks.
2. Â Patient to engage in individual and group therapy.
3. Â Continue current medication regimen.
Objective
Vitals & Measurements
T: 36.6 °C (Temporal Artery) HR: 79(Peripheral) RR: 18 BP: 122/73 SpO2: 98%Â
HT: 162.56 cm WT: 80.7 kg BMI: 30.54Â
Total Unit Time/Complexity
$$ Psychotherapy, 30 minutes with Patient, Â with E/M Service 90833 - OrderedÂ
 -- 11/02/20 14:02:00 MST, PTSD (post-traumatic stress disorder) | Depression, major, recurrent, moderate | GAD
78 to 142
10/24/2024 Continuity of Care Document
(generalized anxiety disorder) | Anorexia nervosa, restricting type, moderate
$$ Subsq Inpatient Care/Day, Moderate Severity 99232 - OrderedÂ
 -- 11/02/20 14:02:00 MST, PTSD (post-traumatic stress disorder) | Depression, major, recurrent, moderate | GAD
(generalized anxiety disorder) | Anorexia nervosa, restricting type, moderate
Medications
Inpatient
Benadryl, 50 mg= 2 EA, Oral, every 6 hr, PRN
cloNIDine, 0.1 mg= 1 tabs, Oral, every 8 hr, PRN
Cymbalta, 20 mg= 1 cap, Oral, Daily
influenza virus vaccine, inactivated preservative-free quadrivalent intramuscular suspension, 0.5 mL, IntraMuscular,
Vaccine
loperamide, 4 mg= 2 cap, Oral, Once, PRN
loperamide, 2 mg= 1 cap, Oral, As Directed PRN, PRN
Milk of Magnesia 8% oral suspension, 30 mL, Oral, every 8 hr, PRN
Minipress, 1 mg= 1 cap, Oral, Daily at bedtime
Mylanta, 30 mL, Oral, QID, PRN
nicotine 2 mg oral transmucosal gum, 2 mg= 1 EA, Buccal, every 1 hr, PRN
Topamax, 25 mg= 1 tabs, Oral, Daily at bedtime
Tylenol, 650 mg= 2 tabs, Oral, every 6 hr, PRN
Vistaril, 50 mg= 1 cap, Oral, every 4 hr, PRN
Vistaril, 50 mg= 1 cap, Oral, Daily at bedtime, PRN
Zofran, 4 mg= 1 tabs, Oral, every 6 hr, PRN
zolpidem extended release, 12.5 mg= 1 tabs, Oral, Daily at bedtime, PRN
ZyPREXA, 10 mg= 1 vials, IntraMuscular, every 4 hr, PRN
ZyPREXA Zydis, 10 mg= 1 tabs, Oral, every 4 hr, PRN
Home
Misc Prescription, See Instructions,  Not taking
Allergies
No Known Medication Allergies
Lab Results
WBC: 9.1 K/mcL (10/30/20 20:59:00)
RBC: 4.55 x10^6/mcL (10/30/20 20:59:00)
Hemoglobin:Â 11.9 g/dLÂ Low (10/30/20 20:59:00)
Hematocrit: 38.1 % (10/30/20 20:59:00)
MCV: 83.7 fL (10/30/20 20:59:00)
MCH: 26.2 pg (10/30/20 20:59:00)
MCHC:Â 31.2 g/dLÂ Low (10/30/20 20:59:00)
RDW SD:Â 51.2 fLÂ High (10/30/20 20:59:00)
RDW:Â 16.9 %Â High (10/30/20 20:59:00)
Platelets: 379 K/mcL (10/30/20 20:59:00)
MPV: 9.2 fL (10/30/20 20:59:00)
Nucleated RBC Auto: 0 /100(WBCs) (10/30/20 20:59:00)
Immature Granulocytes: 0.2 % (10/30/20 20:59:00)
Differential Type: Auto (10/30/20 20:59:00)
Neutrophil % Auto:Â 74.9 %Â High (10/30/20 20:59:00)
Lymphocyte % Auto:Â 17.3 %Â Low (10/30/20 20:59:00)
Monocyte % Auto: 6.7 % (10/30/20 20:59:00)
Eosinophil % Auto: 0.3 % (10/30/20 20:59:00)
Basophil % Auto: 0.6 % (10/30/20 20:59:00)
Immature Granulocyte, Abs: 0.02 K/mcL (10/30/20 20:59:00)
Neutrophil, Abs: 6.8 K/mcL (10/30/20 20:59:00)
Lymphocyte, Abs: 1.6 K/mcL (10/30/20 20:59:00)
Monocyte, Abs: 0.6 K/mcL (10/30/20 20:59:00)
Eosinophil, Abs: 0 K/mcL (10/30/20 20:59:00)
Basophil, Abs: 0.1 K/mcL (10/30/20 20:59:00)
Sodium Level: 138 mmol/L (11/01/20 06:51:00)
Potassium Level: 4.4 mmol/L (11/01/20 06:51:00)
Chloride Level: 108 mmol/L (11/01/20 06:51:00)
CO2:Â 18 mmol/LÂ Low (11/01/20 06:51:00)
Anion Gap (Na Cl CO2): 12 mmol/L (11/01/20 06:51:00)
Glucose Level: 87 mg/dL (11/01/20 06:51:00)
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10/24/2024 Continuity of Care Document
Glucose Fasting: 87 mg/dL (11/01/20 06:51:00)
Cmt: Fasting Plasma Glucose: See Comments (11/01/20 06:51:00)
BUN: 15 mg/dL (11/01/20 06:51:00)
Creatinine Level: 0.93 mg/dL (11/01/20 06:51:00)
est CrCl (Ideal BW for dosing): 82.63 mL/min (11/01/20 08:14:01)
est CrCl (Actual BW for dosing): 125.68 mL/min (11/01/20 08:14:02)
Creatinine GFR: No calculation (11/01/20 06:51:00)
Average GFR for age: No calculation (11/01/20 06:51:00)
Cmt: GFR: See Comments (10/30/20 20:59:00)
Calcium Level: 9.2 mg/dL (11/01/20 06:51:00)
Protein Total: 7.8 g/dL (10/30/20 20:59:00)
Albumin Level: 4.5 g/dL (10/30/20 20:59:00)
Bilirubin Total:Â 0.1 mg/dLÂ Low (10/30/20 20:59:00)
Alk Phos: 71 unit/L (10/30/20 20:59:00)
AST: 24 unit/L (10/30/20 20:59:00)
ALT: 14 unit/L (10/30/20 20:59:00)
Magnesium Level: 1.9 mg/dL (11/01/20 06:51:00)
Phosphorus Level: 4.3 mg/dL (11/01/20 06:51:00)
Cholesterol Total:Â 211 mg/dLÂ High (11/01/20 06:51:00)
HDL: 66 mg/dL (11/01/20 06:51:00)
LDL:Â 123 mg/dLÂ High (11/01/20 06:51:00)
Cmt: LDL: See Comments (11/01/20 06:51:00)
Chol/HDL: 3.2 (11/01/20 06:51:00)
Triglycerides: 109 mg/dL (11/01/20 06:51:00)
Patient Fasting?: Yes (11/01/20 06:51:00)
Non HDL Cholesterol:Â 145 mg/dLÂ High (11/01/20 06:51:00)
VLDL: 22 mg/dL (11/01/20 06:51:00)
Cmt: HCG Serum Qualitative: See Comments (10/30/20 20:59:00)
HCG Serum Qualitative: Negative (10/30/20 20:59:00)
TSH: 2.17 mcIU/mL (10/30/20 20:59:00)
Acetaminophen Level:Â 8 mcg/mLÂ Low (10/30/20 20:59:00)
Cmt1: Serum Drug Screen: See Comments (10/30/20 20:59:00)
Salicylate Level: <5.0 (10/30/20 20:59:00)
Cmt2: Serum Drug Screen: See Comments (10/30/20 20:59:00)
Ethanol Level: <10 (10/30/20 20:59:00)
Methadone Screen Ur: Negative (10/30/20 21:39:00)
Amphetamine Screen Ur: Negative (10/30/20 21:39:00)
Barbituate Screen Ur: Negative (10/30/20 21:39:00)
Benzodiazepines Ur: Negative (10/30/20 21:39:00)
Cannabinoid Screen Ur: Negative (10/30/20 21:39:00)
Cocaine Screen Ur: Negative (10/30/20 21:39:00)
Opiate Screen Ur: Negative (10/30/20 21:39:00)
Synthetic Opioids: Negative (10/30/20 21:39:00)
Buprenorphine Level: Negative (10/30/20 21:39:00)
Cmt4: Drug Screen Urine: See Comments (10/30/20 21:39:00)
Collect Method, Ur: Clean Catch (10/30/20 21:39:00)
Color Urine: Normal (10/30/20 21:39:00)
Appear: Normal (10/30/20 21:39:00)
Specific Gravity, Urine: 1.025 (10/30/20 21:39:00)
pH Urine: 7 (10/30/20 21:39:00)
Glucose Urine: Negative (10/30/20 21:39:00)
UA Ketones: Negative (10/30/20 21:39:00)
Nitrite: Negative (10/30/20 21:39:00)
Hgb Urine: Negative (10/30/20 21:39:00)
Protein Urine: Negative (10/30/20 21:39:00)
Leuk Esterase: Negative (10/30/20 21:39:00)
WBC Urine: 1 /HPF (10/30/20 21:39:00)
RBC Urine: 1 /HPF (10/30/20 21:39:00)
Epithelial Cells:Â 11 /HPFÂ High (10/30/20 21:39:00)
Bacteria Urine: 1+ Abnormal (10/30/20 21:39:00)
Hyaline Cast: Negative (10/30/20 21:39:00)
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10/24/2024 Continuity of Care Document
Urine Culture Ordered?: No (10/30/20 21:39:00)
SARS-CoV-2 by PCR (Cepheid): Not detected (10/30/20 23:59:00)
Cmt5: SARS CoV 2 BY PCR: See Comments (10/30/20 23:59:00)
Cmt: SARS-CoV-2 by PCR (Cepheid): See Comments (10/30/20 23:59:00)
Other Information
Psychotherapy Summary:
Time Spent in Psychotherapy: 20 minutes
Topics Discussed During Visit: Managing anxiety, Managing depression, Managing mood, Family Conflict, Family issues,
Managing side effects, Relationship issues, Work stress, Traumatic experiences
Session Participants: Patient
Therapeutic Interventions: CBT, DBT, Supportive therapy
Progress Toward Treatment Plan/Goals: Improve overall functioning
Caregiver Participated and Benefited: Yes
BEH Recommended Level of Care: Outpatient Treatment
BEH Estimated Signed Time: 10:35
BEH Treatment Strategy: Spent 20 min processesing trauma of step fathers abuse and mother neglect, setting healthy
boundaries and how to work through guilt they project on her for not having contact with them. Discussed intimate
relationships and healthy boundaries and behavior

Electronically Signed on 11/02/20 02:02 PM

________________________________________________________
PITCHER, DO, MATTHEW D.
STAHELI, NP, KENDRA A.: PERFORM
Event Display: Behavioral Health Progress Note
Authored Date: 20201101210557-0700

Chief Complaint
OD on 38 nyquil
Assessment
Information gathered from patient, staff, and medical records. Patient has been interacting well, going to groups,
medication compliant, and pparticipating in unit milieu per staff. Â Patient appears to have bright affect, feeling better
from yesterday has overdosed medication has come out of her system more. Patient reports she still struggles last
night with sleep and woke up at 2 AM and could not go back to sleep.  Patient does reports she didn't have a
nightmare. Patient like to try Ambien as she took the on her mission and had success in sleeping. Starting
Cymbalta to target anxiety and panic as well as depression and sleep. Patient denies suicidal thoughts but lacks
confidence in ability to stay safe outside of the hospital as this is her third suicide attempt in 2 months.  Continue
hospitalization necessary for safety and stabilization.
Clinical Status: Major depressive episode, Agitation or severe anxiety
Ongoing Need for Services: Medication initiated or adjusted within the last 48 hours
Clinical Global Impression: Moderately Ill (4)
Prognosis: Maintain current baseline
Barriers to Discharge: Elevated suicide risk outside of hospital
Anticipated Discharge Date: 11/10/20
Reasons for Continued Stay: No SI in protective hospital setting by lacks confidence in ability to adhere to a safety plan
outside of such, Is felt to be currently unreliable
Benefits/Risks/Side Effects/Alternatives of Medications and Other Treatments were discussed and Informed Consent
given by Patient/Guardian
Informed Consent Discussed and Given: Yes
Diagnosis/Treatment Plan
1. Depression, major, recurrent, moderate
2. Suicide attempt
3. Intentional drug overdose
4. Obesity (BMI 30-39.9)
5. GAD (generalized anxiety disorder)
6. PTSD (post-traumatic stress disorder)
7. Nightmares
8. Attention deficit disorder (ADD) in adult
9. Anorexia nervosa, restricting type, moderate
10. Alcohol use
11. Borderline personality disorder
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10/24/2024 Continuity of Care Document
12. S/P repair of coarctation of aorta
Orders:
DULoxetine, 20 mg, Oral, Daily, Cap-DR, First Dose: 11/01/20 12:01:00 MST
zolpidem, 12.5 mg, Oral, Daily at bedtime, PRN sleep, Tab-ER, First Dose: 11/01/20 12:04:00 MST
Treatment Plan
Start cymbalta 20 mg daily.  Start Ambien controlled release 12.5 mg daily at bedtime. Continue other
medications as ordered. Continue titrating Topamax per schedule weekly. Spent 20 min processesing trauma of
step fathers abuse and mother neglect, setting healthy boundaries and how to work through guilt they project on her
for not having contact with them. Discussed intimate relationships and healthy boundaries and behavior
Estimated length of stay 5-6 days.
General Treatment Plan Inpatient: Adjust medications as per orders, Participate in group psychotherapy, Participate in
individual psychotherapy, Encourage balanced diet, Exercise as able
Subjective
Participating in Care: Yes
Side Effects: Headache
Anxiety and depression "better than yesterday, had a meltdown yesterday". Denies suicidal thoughts. "Nighttime is
really hard. Sleeping patient reports that night is worse.  Patient denied nightmares last night that she did wake up
at 2 or 3 AM and did not go back to sleep. Good appetite. Reports having a headache, possibly a side effect.
 Medications working well.  Patient would like to try Ambien as she did that in the past and help with her sleep.
Review of Systems
Review of Systems Documented: Ten point
HEENT: No complaints
Cardiovascular: No complaints
Respiratory: No complaints
Integumentary: No complaints
Genitourinary/Sexual: No complaints
Neurological: Forgetfulness, Headache
Hematologic/Lymphatic: No complaints
Reproductive: Not Sexually Active at this Time
Psychiatric: As per HPI, Anxiety, Trauma history
Constitutional: As per HPI, Fatigue
Musculoskeletal,: No complaints
Gastrointestinal: No complaints
Endocrine: No complaints
BEH ROS Sexual: No complaints
Psychiatric Review of Systems
Thought Content Comment: She has suicidal thoughts, anxiety and depression at nightwhen she is worried about
nightmares.
Objective
Vitals & Measurements
T: 36.7 °C (Temporal Artery) HR: 89(Peripheral) RR: 16 BP: 122/78 SpO2: 98%Â
HT: 162.56 cm WT: 80.7 kg BMI: 30.54Â
Mental Status Exam
General Appearance of Patient: Appropriately dressed and groomed
Orientation: Alert and oriented x4
Recent and Remote Memory: Recent & Remote memory appear to be intact
Musculoskeletal Strength/Tone: Observed muscle strength/tone within normal limits
Musculoskeletal Gait/Station: Within normal limits
Speech: Slowed
Mood/Affect: Depressed, Anxious, Full, Guarded
Thought Process: Concrete, Racing, Rumination
Associations: Circumstantial
Thought Content: Non-psychotic
Attention/Concentration: Grossly intact attention
Insight/Judgement: Impaired
Language: Within normal limits
Fund of Knowledge: Awareness of Current Events, Past History
Risk Assessment in Inpatient Setting
Risk for Suicide in this Setting: Low
Risk for Self-Harm or Self-Mutilation: Low
Risk for Harm to Others in this Setting: Low
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10/24/2024 Continuity of Care Document
Total Unit Time/Complexity
$$ Psychotherapy, 30 minutes with Patient, Â with E/M Service 90833 - OrderedÂ
 -- 11/01/20 20:49:00 MST, Depression, major, recurrent, moderate | Suicide attempt | Intentional drug overdose |
Obesity (BMI 30-39.9) | GAD (generalized anxiety disorder) | PTSD (post-traumatic stress disorder) | Nightmares |
Attention deficit disorder...
$$ Subsq Inpatient Care/Day, Moderate Severity 99232 - OrderedÂ
 -- 11/01/20 20:49:00 MST, Depression, major, recurrent, moderate | Suicide attempt | Intentional drug overdose |
Obesity (BMI 30-39.9) | GAD (generalized anxiety disorder) | PTSD (post-traumatic stress disorder) | Nightmares |
Attention deficit disorder...
Evaluation Type: By complexity
Detailed Description of Time Spent: Discussed with patient current situation and s/s, history, tx plan, triggers, goals
exercise, therapy. Benefits, risks, side effects, alt of meds, and other treatments discussed. Informed consent given by
patient/guardian.
Number of Diagnosis/Management Options: Moderate
Amount /Complexity of Data Reviewed: Moderate
Medications
Inpatient
Benadryl, 50 mg= 2 EA, Oral, every 6 hr, PRN
cloNIDine, 0.1 mg= 1 tabs, Oral, every 8 hr, PRN
Cymbalta, 20 mg= 1 cap, Oral, Daily
influenza virus vaccine, inactivated preservative-free quadrivalent intramuscular suspension, 0.5 mL, IntraMuscular,
Vaccine
loperamide, 4 mg= 2 cap, Oral, Once, PRN
loperamide, 2 mg= 1 cap, Oral, As Directed PRN, PRN
Milk of Magnesia 8% oral suspension, 30 mL, Oral, every 8 hr, PRN
Minipress, 1 mg= 1 cap, Oral, Daily at bedtime
Mylanta, 30 mL, Oral, QID, PRN
nicotine 2 mg oral transmucosal gum, 2 mg= 1 EA, Buccal, every 1 hr, PRN
Topamax, 25 mg= 1 tabs, Oral, Daily at bedtime
Tylenol, 650 mg= 2 tabs, Oral, every 6 hr, PRN
Vistaril, 50 mg= 1 cap, Oral, every 4 hr, PRN
Vistaril, 50 mg= 1 cap, Oral, Daily at bedtime, PRN
Zofran, 4 mg= 1 tabs, Oral, every 6 hr, PRN
zolpidem extended release, 12.5 mg= 1 tabs, Oral, Daily at bedtime, PRN
ZyPREXA, 10 mg= 1 vials, IntraMuscular, every 4 hr, PRN
ZyPREXA Zydis, 10 mg= 1 tabs, Oral, every 4 hr, PRN
Home
Misc Prescription, See Instructions,  Not taking
Allergies
No Known Medication Allergies
Lab Results
WBC: 9.1 K/mcL (10/30/20 20:59:00)
RBC: 4.55 x10^6/mcL (10/30/20 20:59:00)
Hemoglobin:Â 11.9 g/dLÂ Low (10/30/20 20:59:00)
Hematocrit: 38.1 % (10/30/20 20:59:00)
MCV: 83.7 fL (10/30/20 20:59:00)
MCH: 26.2 pg (10/30/20 20:59:00)
MCHC:Â 31.2 g/dLÂ Low (10/30/20 20:59:00)
RDW SD:Â 51.2 fLÂ High (10/30/20 20:59:00)
RDW:Â 16.9 %Â High (10/30/20 20:59:00)
Platelets: 379 K/mcL (10/30/20 20:59:00)
MPV: 9.2 fL (10/30/20 20:59:00)
Nucleated RBC Auto: 0 /100(WBCs) (10/30/20 20:59:00)
Immature Granulocytes: 0.2 % (10/30/20 20:59:00)
Differential Type: Auto (10/30/20 20:59:00)
Neutrophil % Auto:Â 74.9 %Â High (10/30/20 20:59:00)
Lymphocyte % Auto:Â 17.3 %Â Low (10/30/20 20:59:00)
Monocyte % Auto: 6.7 % (10/30/20 20:59:00)
Eosinophil % Auto: 0.3 % (10/30/20 20:59:00)
Basophil % Auto: 0.6 % (10/30/20 20:59:00)
Immature Granulocyte, Abs: 0.02 K/mcL (10/30/20 20:59:00)
83 to 142
10/24/2024 Continuity of Care Document
Neutrophil, Abs: 6.8 K/mcL (10/30/20 20:59:00)
Lymphocyte, Abs: 1.6 K/mcL (10/30/20 20:59:00)
Monocyte, Abs: 0.6 K/mcL (10/30/20 20:59:00)
Eosinophil, Abs: 0 K/mcL (10/30/20 20:59:00)
Basophil, Abs: 0.1 K/mcL (10/30/20 20:59:00)
Sodium Level: 138 mmol/L (11/01/20 06:51:00)
Potassium Level: 4.4 mmol/L (11/01/20 06:51:00)
Chloride Level: 108 mmol/L (11/01/20 06:51:00)
CO2:Â 18 mmol/LÂ Low (11/01/20 06:51:00)
Anion Gap (Na Cl CO2): 12 mmol/L (11/01/20 06:51:00)
Glucose Level: 87 mg/dL (11/01/20 06:51:00)
Glucose Fasting: 87 mg/dL (11/01/20 06:51:00)
Cmt: Fasting Plasma Glucose: See Comments (11/01/20 06:51:00)
BUN: 15 mg/dL (11/01/20 06:51:00)
Creatinine Level: 0.93 mg/dL (11/01/20 06:51:00)
est CrCl (Ideal BW for dosing): 82.63 mL/min (11/01/20 08:14:01)
est CrCl (Actual BW for dosing): 125.68 mL/min (11/01/20 08:14:02)
Creatinine GFR: No calculation (11/01/20 06:51:00)
Average GFR for age: No calculation (11/01/20 06:51:00)
Cmt: GFR: See Comments (10/30/20 20:59:00)
Calcium Level: 9.2 mg/dL (11/01/20 06:51:00)
Protein Total: 7.8 g/dL (10/30/20 20:59:00)
Albumin Level: 4.5 g/dL (10/30/20 20:59:00)
Bilirubin Total:Â 0.1 mg/dLÂ Low (10/30/20 20:59:00)
Alk Phos: 71 unit/L (10/30/20 20:59:00)
AST: 24 unit/L (10/30/20 20:59:00)
ALT: 14 unit/L (10/30/20 20:59:00)
Magnesium Level: 1.9 mg/dL (11/01/20 06:51:00)
Phosphorus Level: 4.3 mg/dL (11/01/20 06:51:00)
Cholesterol Total:Â 211 mg/dLÂ High (11/01/20 06:51:00)
HDL: 66 mg/dL (11/01/20 06:51:00)
LDL:Â 123 mg/dLÂ High (11/01/20 06:51:00)
Cmt: LDL: See Comments (11/01/20 06:51:00)
Chol/HDL: 3.2 (11/01/20 06:51:00)
Triglycerides: 109 mg/dL (11/01/20 06:51:00)
Patient Fasting?: Yes (11/01/20 06:51:00)
Non HDL Cholesterol:Â 145 mg/dLÂ High (11/01/20 06:51:00)
VLDL: 22 mg/dL (11/01/20 06:51:00)
Cmt: HCG Serum Qualitative: See Comments (10/30/20 20:59:00)
HCG Serum Qualitative: Negative (10/30/20 20:59:00)
TSH: 2.17 mcIU/mL (10/30/20 20:59:00)
Acetaminophen Level:Â 8 mcg/mLÂ Low (10/30/20 20:59:00)
Cmt1: Serum Drug Screen: See Comments (10/30/20 20:59:00)
Salicylate Level: <5.0 (10/30/20 20:59:00)
Cmt2: Serum Drug Screen: See Comments (10/30/20 20:59:00)
Ethanol Level: <10 (10/30/20 20:59:00)
Methadone Screen Ur: Negative (10/30/20 21:39:00)
Amphetamine Screen Ur: Negative (10/30/20 21:39:00)
Barbituate Screen Ur: Negative (10/30/20 21:39:00)
Benzodiazepines Ur: Negative (10/30/20 21:39:00)
Cannabinoid Screen Ur: Negative (10/30/20 21:39:00)
Cocaine Screen Ur: Negative (10/30/20 21:39:00)
Opiate Screen Ur: Negative (10/30/20 21:39:00)
Synthetic Opioids: Negative (10/30/20 21:39:00)
Buprenorphine Level: Negative (10/30/20 21:39:00)
Cmt4: Drug Screen Urine: See Comments (10/30/20 21:39:00)
Collect Method, Ur: Clean Catch (10/30/20 21:39:00)
Color Urine: Normal (10/30/20 21:39:00)
Appear: Normal (10/30/20 21:39:00)
Specific Gravity, Urine: 1.025 (10/30/20 21:39:00)
pH Urine: 7 (10/30/20 21:39:00)
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10/24/2024 Continuity of Care Document
Glucose Urine: Negative (10/30/20 21:39:00)
UA Ketones: Negative (10/30/20 21:39:00)
Nitrite: Negative (10/30/20 21:39:00)
Hgb Urine: Negative (10/30/20 21:39:00)
Protein Urine: Negative (10/30/20 21:39:00)
Leuk Esterase: Negative (10/30/20 21:39:00)
WBC Urine: 1 /HPF (10/30/20 21:39:00)
RBC Urine: 1 /HPF (10/30/20 21:39:00)
Epithelial Cells:Â 11 /HPFÂ High (10/30/20 21:39:00)
Bacteria Urine: 1+ Abnormal (10/30/20 21:39:00)
Hyaline Cast: Negative (10/30/20 21:39:00)
Urine Culture Ordered?: No (10/30/20 21:39:00)
SARS-CoV-2 by PCR (Cepheid): Not detected (10/30/20 23:59:00)
Cmt5: SARS CoV 2 BY PCR: See Comments (10/30/20 23:59:00)
Cmt: SARS-CoV-2 by PCR (Cepheid): See Comments (10/30/20 23:59:00)
Other Information
Psychotherapy Summary:
Time Spent in Psychotherapy: 20 minutes
Topics Discussed During Visit: Managing anxiety, Managing depression, Managing mood, Family Conflict, Family issues,
Managing side effects, Relationship issues, Work stress, Traumatic experiences
Session Participants: Patient
Therapeutic Interventions: CBT, DBT, Supportive therapy
Progress Toward Treatment Plan/Goals: Improve overall functioning
Caregiver Participated and Benefited: Yes
BEH Recommended Level of Care: Outpatient Treatment
BEH Estimated Signed Time: 14:39
BEH Treatment Strategy: Spent 20 min processesing trauma of step fathers abuse and mother neglect, setting healthy
boundaries and how to work through guilt they project on her for not having contact with them. Discussed intimate
relationships and healthy boundaries and behavior

Electronically Signed on 11/01/20 09:05 PM

________________________________________________________
STAHELI, NP, KENDRA A.

Cardiology Hospital Progress note

ROGERSON, NP, ANN: PERFORM

Event Display: Cardiology Hospital Progress Note
Authored Date: 20240516142842-0600

Subjective
Pt is a 25 Years Female with hx of bicuspid aortic valve, aortic coarctation, anorexia nervosa, borderline personality
disorder, depression, and ADHD who presents with a 6 days of daily syncope. ECHO showed EF 79%, no WMA, normal
RV size and function, BAV with no stenosis or regurg, hx of aorta coarctation repair with peak velocity 2.7m/s.
Occasional PVCs were noted on tele.
 Today: Doing well. No further syncope or lightheadedness since admit. Denies CP, SOB, palpitations or other cardiac
symptoms.
Â
Medications
Inpatient
Artificial Tears preservative-free ophthalmic solution, 1 drops, Eye-Both, every 2 hr, PRN
hydrALAZINE, 10 mg= 0.5 mL, IV Push, every 4 hr, PRN
hydrOXYzine, 50 mg= 2 tabs, Oral, BID, PRN
ibuprofen, 600 mg= 1 tabs, Oral, every 6 hr, PRN
LR drip 1,000 mL, 1000 mL, IV Drip
melatonin, 3 mg= 1 tabs, Oral, Daily at bedtime, PRN
MiraLax, 17 g= 1 EA, Oral, BID, PRN
Senna S, 1 tabs, Oral, BID, PRN
traZODone, 50 mg= 1 tabs, Oral, Daily at bedtime
Tums 500 (calcium carbonate 500 mg (elemental Ca 200 mg)) oral tab, chewable, 1 tabs, Oral, every 6 hr, PRN
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10/24/2024 Continuity of Care Document
Tylenol, 500 mg= 1 tabs, Oral, every 4 hr, PRN
Zofran, 4 mg= 2 mL, IV Push, every 6 hr, PRN
Home
hydrOXYzine hydrochloride 50 mg oral tablet, 50 mg= 1 tabs, Oral, BID, PRN
Sprintec, 1 tabs, Oral, Daily
traZODone 50 mg oral tablet, 50 mg= 1 tabs, Oral, Daily at bedtime
Vyvanse 70 mg oral capsule, 70 mg= 1 cap, Oral, every morning
Intake and Output
Â
This visit (24 hour periods starting at 06:00 MDT)Â

Â
05/16/24 *Â
05/15/24Â
05/14/24Â

Total SummaryÂ
Â

  Intake mLÂ
265Â
1,323.12Â
2,140Â

  Output mLÂ
--Â
--Â
--Â

  Fluid Balance Â
265Â
1,323.12Â
2,140Â

Intake (7)Â
Â

  Lactated Ringers Injection mLÂ

--Â
--Â
2,000Â

  Sodium Chloride 0.9% mLÂ

--Â
--Â
40Â

  Sodium Chloride 0.9%, iron sucrose mLÂ

265Â
--Â
--Â

  Sodium Chloride 0.9%, perflutren mLÂ

--Â
3Â
--Â

  iopamidol mLÂ
--Â
--Â
100Â
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10/24/2024 Continuity of Care Document

  lactated ringer's injection 1,000 mL mLÂ

--Â
1,318.12Â
--Â

  ondansetron mLÂ
--Â
2Â
--Â

  TotalÂ
265Â
1,323.12Â
2,140Â

Output (0)Â
Â

Counts (1)Â
Â

  Patient Voided, Unknown Amount - Count Â

--Â
--Â
1Â
 * This column has not completed the indicated time period.Â
Physical Exam
Vitals & Measurements
T: 36.5 °C (Temporal Artery) HR: 100(Monitored) RR: 16 BP: 120/73 BP: 116/83(Supine)Â
SpO2:Â 96%Â
HT: 160 cm WT: 86.5 kg BMI: 33.79Â
General: Alert and oriented, no acute distress.
Neck: Trachea midline, supple, non-tender, no carotid bruits, no JVD .
Lungs: Clear to auscultation; normal respiratory effort with non-labored breathing; no rales, rhonchi, or
wheezing.
Heart: Regular rate and rhythm; No murmur present. No rubs, gallops or clicks; normal S1 and S2.
Extremities: No bilateral LE edema; warm
Neurologic: Awake, alert, and oriented X3. No lateralizing weakness.Â
Psychiatric: Cooperative; appropriate mood and affect.
Lab Results
Labs (Last four charted values)
WBC Â Â Â Â Â 6.5Â Â Â (MAY 16)Â Â Â 9.0Â Â Â (MAY 15)Â Â Â HÂ 13.1Â Â Â (MAY 14)
Hgb      L 9.3   (MAY 16)   L 9.4   (MAY 15)   L 9.9   (MAY 14)   L 11.4   (MAY 14)
Hct      L 31.0   (MAY 16)   L 32.3   (MAY 15)   37.0    (MAY 14)
Plt      H 416   (MAY 16)   H 411   (MAY 15)   H 587   (MAY 14)
Na      139   (MAY 16)   L 136   (MAY 15)   L 135   (MAY 14)
K Â Â Â Â Â 3.9Â Â Â (MAY 16)Â Â Â 3.6Â Â Â (MAY 15)Â Â Â LÂ 3.1Â Â Â (MAY 14)
CO2 Â Â Â Â Â 20Â Â Â (MAY 16)Â Â Â LÂ 17Â Â Â (MAY 15)Â Â Â LÂ 18Â Â Â (MAY 14)
Cl      109   (MAY 16)   106   (MAY 15)   L 100   (MAY 14)
Cr      0.86   (MAY 16)   0.80   (MAY 15)   0.95    (MAY 14)
BUN Â Â Â Â Â 10Â Â Â (MAY 16)Â Â Â LÂ 7Â Â Â (MAY 15)Â Â Â 10Â Â Â Â (MAY 14)
Glucose Random        H 101   (MAY 16)   80   (MAY 15)    H 123   (MAY 14)
Mg      2.1   (MAY 14)
Phos      2.8   (MAY 14)
Assessment/Plan
1. Recurrent syncope
- Possibly vasovagal
- VSS since admit
- No significant arrhythmia on tele
- ECHO showed BAV
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10/24/2024 Continuity of Care Document
- Recommend 2 week monitor on discharge and follow up outpatient
2. S/P repair of coarctation of aorta
- Stable on ECHO
3. Bicuspid aortic valve
- No sig stenosis or regurg on ECHO
4. SIRS without infection or organ dysfunction
5. Leukocytosis
6. Metabolic acidosis
7. Hypokalemia
- Resolved
8. Anemia
9. Anorexia nervosa, restricting type, in partial remission, moderate
10. Borderline personality disorder
11. Depression, major, recurrent, moderate
12. PTSD (post-traumatic stress disorder)
13. Attention deficit disorder (ADD) in adult
14. Menorrhagia
Syncope/Near syncope

Problem List/Past Medical History

Ongoing
Anemia
Anorexia nervosa, restricting type, in partial remission, moderate
Anorexia nervosa, restricting type, moderate
Attention deficit disorder (ADD) in adult
Bicuspid aortic valve
Borderline personality disorder
Depression, major, recurrent, moderate
Menorrhagia
PTSD (post-traumatic stress disorder)
Recurrent major depression-severe
S/P repair of coarctation of aorta
Procedure/Surgical History
Esophagogastroduodenoscopy (03/02/2022), Transcatheter intracardiac shunt (TIS) creation by stent placement for
congenital cardiac anomalies to establish effective intracardiac flow, including all imaging guidance by the
proceduralist, when performed, left and right heart diagnostic cardiac cath.
Allergies
No Known Medication Allergies
No Known Allergies
Social History
Alcohol - 02/08/2024
Use: Never used. Household alcohol concerns: No.
Use: Never used.
Use: Never used.
Employment/School - 02/08/2024
Status: Employed. Place of occupation/business: Pet grooming. Highest education level: High school.
Employed
Home/Environment - 02/08/2024
Lives with: Friend and her family.
Substance Use - 02/08/2024
Use, other than prescribed: Never used. Concerns about substance abuse in household: No.
Use, other than prescribed: Never used. Date last used: CBD once.
Tobacco - 02/08/2024
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker.
Use: Never smoker.
Use: Never smoker.
Family History
88 to 142
10/24/2024 Continuity of Care Document
Anxiety: Grandmother (M) and Sibling.
Arrhythmia (cardiac) NOS: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
CHD - Congenital heart disease: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Cancer: Father, Grandfather (P) and Grandmother (P).
Cancer: Father.
Depression: Grandmother (M), Sibling and Sibling.
Drug addiction: Sibling and Sibling.
Emotional problems: Sibling.
Heart attack: Grandmother (M).Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Hyperlipidemia: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Substance Use: Sibling and Sibling.
Sudden cardiac death: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Suicidal behavior: Sibling and Sibling.

Electronically Signed on 05/16/24 02:28 PM

________________________________________________________
ROGERSON, NP, ANN
FEENEY, MD, JAMES M.: PERFORM
Event Display: Cardiology Hospital Progress Note
Authored Date: 20240516155200-0600

Patient seen and examined with Ann Rogerson, NP. Â Above note reviewed, agree with findings and
recommendations. Patient is stable for discharge to home today.

Electronically Signed on 05/16/24 03:52 PM

________________________________________________________
FEENEY, MD, JAMES M.

Nurse Progress note

THOMPSON, RN, SHERALYN: PERFORM

Event Display: Nursing Narrative Note
Authored Date: 20210119125713-0700
BEH Shift Summary  (DASHPEGS)

Mood/Affect:Â Â Congruent
Comment: _

Depression:Â Â 4
Comment: _

Anxiety:Â Â 6
Comment: _

SI:Â Â Yes
Comment: _Pt reports that her Suicidal Thoughts are "2"

HI:Â No
Comment: _

Hallucinations:Â Â _
Comment: Denies _

Pain:Â Â _Â 0
Comment: _

Appetite:Â Good
Comment _

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10/24/2024 Continuity of Care Document
Groups:Â Attending and participating
Comment: _

Sleep:Â _
Comment: _Pt commented "?"

Significant Behaviors:Â Â _
Comment: _

Coping Skills:Â Â Fair

Comment: Pt reports that she is stressed due to having a meeting w the lawyer because she is getting a "I am getting a
Restraining Order on my Mom because she is Crazy"

Medication Compliance:Â Good

Comment: _

Discharge Plan:Â Â _
Anticipated DC date _
Comment: _Pt will be getting discharged today, however, due to the issues that have come up after meeting w the
Therapist pt will not Discharged until later due to numerous people coming to meet w her for Follow Up.

Support person contact comment: _

Other: _
Electronically Signed on 01/19/21 12:57 PM
________________________________________________________
THOMPSON, RN, SHERALYN
MOWER, RN, KATHERINE LYNN: PERFORM
Event Display: Nursing Narrative Note
Authored Date: 20201104052959-0700

BEH Shift Summary  (DASHPEGS)

Mood/Affect:  Congruent Â

Comment: _

ÂÂ

Depression:Â Â 6Â Â

Comment: _

Anxiety:Â Â 6Â Â

Comment: _Â

SI:Â Â NoÂ

Comment: _Â

HI:Â NoÂ
90 to 142
10/24/2024 Continuity of Care Document

Comment: _

Hallucinations:  AH no Â

Comment:Â Â _

Pain:Â Â _Â 0Â

Comment: _Â Â

Appetite:Â GoodÂ

Comment _

Groups:Â _Â

Comment: _

Sleep:Â GoodÂ

Comment: _

Significant Behaviors:Â Â _Â

Comment: _

Coping Skills:Â Â FairÂ

Comment: _

Medication Compliance:Â GoodÂ

Comment: _

Discharge Plan:Â Â _Â

Anticipated DC date _

Comment: _

ÂÂÂ

91 to 142
10/24/2024 Continuity of Care Document
Support person contact comment: _

Other: Pt planning on DC in the AM when her ride arrives_

Electronically Signed on 11/04/20 05:29 AM

________________________________________________________
MOWER, RN, KATHERINE LYNN
BODILY, RN, MARTHA M: PERFORM
Event Display: Nursing Narrative Note
Authored Date: 20201103173651-0700

BEH Shift Summary  (DASHPEGS)

Mood/Affect:  Euthymic Â

Comment: _

ÂÂ

Depression:Â Â 4Â Â

Comment: _

Anxiety:Â Â 4Â Â

Comment: _Â

SI:Â Â NoÂ

Comment: _Â

HI:Â NoÂ

Comment: _

Hallucinations:Â Â _Â Â

Comment:Â Â _

Pain:Â Â _Â 0Â

Comment: _Â Â

92 to 142
10/24/2024 Continuity of Care Document
Appetite:Â GoodÂ

Comment _

Groups:Â AttendingÂ

Comment: _

Sleep:Â GoodÂ

Comment: _

Significant Behaviors:Â Â NoÂ

Comment: _

Coping Skills:Â Â FairÂ

Comment: _

Medication Compliance:Â GoodÂ

Comment: _

Discharge Plan:Â Â _Â

Anticipated DC date _

Comment: _

ÂÂÂ

Support person contact comment: _

Other: _

Electronically Signed on 11/03/20 05:36 PM

________________________________________________________
BODILY, RN, MARTHA M

Nutrition and dietetics Note

VILLALOBOS HUITRON, RD, BRENDA: MODIFY, PERFORM

Event Display: Nutrition Note
Authored Date: 20241007145833-0600

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10/24/2024 Continuity of Care Document
Assessment and Monitoring
Pertinent History: Pt was referred for weight management. Pt was on ED on 9/30 due to blurry vision and weakness. ED
on 9/28 due to hypokalemia. Pt mentioned she is unsure why Anorexia Nervosa is on her EHR. Pt mentioned that during
middle school and high school she was on lisdexamfetamine (Vyvanse) which really suppressed her appetite, but she
was never diagnosed with an ED.
Â
Medications/supplements:
Pt is currently on Ozempic (since August), and mentioned she is soon switching to Mounjaro.   Â
    - lisdexamfetamine (Vyvanse)
    - dextromethorphan-bupropion (Auvelity)
    - trazodone
    - norgestimate-ethinyl estradiol (Sprintec)
    - Zofran
Â
Nutrition related labs:
9/30:
Hemoglobin and hematocrit WNL
Sodium: 136 mmol/L (L)
Potassium: 3.3 mmol/L (L)
Chloride: 99 mmol/L (L)
AST: 80 unit/L (H)
ALT: 88 unit/L (H)
Â
9/28:
Lipase: 45 unit/L (WNL)
Â
7/31:
Magnesium: 2.1 mg/dL (WNL)
B12: 369 pg/mL (WNL)
Vit D: 42 ng/mL(WNL)
Â
Weight History: Pt mentioned that she was around 210 lbs when started on Ozempic (August).
9/30: 84.7 kg (186.34 lbs)
10/7: 84.5 kg (185.9 lbs)
Â
Physical Activity: Pt mentioned she had endometriosis surgery recently, so has been unable to do much PA. She usually
likes running and playing sports a couple times per week.
 Diet Hx: Allergies: Pt allergic tomilk (per EHR and pt's statement), pt mentioned she gets uncomfortable
symptoms when drinking too much milk, which sounds more like an intolerance. Pt is fine with cheese and yogurt. Pt
is currently having 2-3 meals per day. Pt mentioned her medication suppressed appetite during middle school and high
school, so she would not eat much during the day and then she would be very hungry at night. Pt feels like she can feel
her hunger and fullness cues better since she has been on the medication for so long. Currently, pt skips breakfast
sometimes. Pt does not like cooking. Pt eats out around twice per week.
Â
Usual Intake:
-B: sometimes Special K with milk and banana slices.
-L: ham and cheese sandwich and some fruit
-S: sometimes granola bar or pretzels.
-D: sandwich or frozen meal or eating out.
-S: sometimes granola bar or fruit or veggie.
 Clinical Assessment: Pt is in preparation stage of change. We talked about creating sustainable and enjoyable
habits. We reviewed food groups and pt identified foods in each food group that she likes. We talked about MyPlate and
pt identified that she would benefit from adding more protein and complex carbs and that she does well with fruits and
vegetables. We brainstormed some ideas of quick meals she could have. Pt said she will look at the lists of foods and
create something she would like. Pt acknowledged understanding of concepts reviewed. Follow up scheduled
for 11/11. Pt would like to discuss portions (My Plate 1,400 kcal plan and visuals).
 Education materials provided:
- brainstormed quick meal ideas
- Meal Planning Fact Sheet for Patients and Families.
Nutrition Diagnosis
Problem #1 - Food & nutrition related knowledge deficit related to Other: uncertainty on how to apply nutrition
94 to 142
10/24/2024 Continuity of Care Document
information as evidenced by questions about weight management and healthy eating (10/07/2024 14:37)Â Â
ÂÂ
Nutrition Goals
- eating more balanced meals (including more protein and complex carbohydrates)
- writing down and choosing fast meal ideas
Nutrition Interventions/Education
Intervention - Nutrition Intervention: Motivational interviewing, Goal setting, Self-monitoring (10/07/24 14:33:00)
Intervention - Nutrition Intervention Status: Complete (10/07/24 14:33:00)
Accommodation Interventions: Pt./home caregiver denies need (09/25/24 08:46:00)
Accommodation Provided For: Other: none (09/25/24 12:48:00)
Barriers to Learning: None evident (09/28/24 21:38:00)
Caregiver's Preferred Language: English (09/25/24 18:13:00)
Home Caregiver Present for Session: Yes (09/01/24 05:55:00)
Patient Preferred Language: English (09/30/24 11:53:00)
Patient Sensory Compensatory Devices: Glasses (09/25/24 12:48:00)
Patient Sensory Deficits: None (09/28/24 19:22:00)
Responsible Learner Present for Session: Patient, Friend (09/18/24 12:08:00)
Time Spent Teaching: 60 minutes (10/07/24 14:33:00)
Ed-Diet/Nutrition: Verbalizes understanding (10/07/24 14:33:00)
Ed-Weight Reduction: Verbalizes understanding (10/07/24 14:33:00)
Estimated Needs
Estimated Energy Needs High kcal/day: 1543 kcal/day (10/07/24 14:33:00)
Estimated Energy Needs Low kcal/day: 1386 kcal/day (10/07/24 14:33:00)
Estimated Needs Rationale: Other: MSJ for 1 lb wt loss per week (10/07/24 14:33:00)
Anthropometrics
Body Mass Index Measured: 32.2 kg/m2 (10/07/24 14:33:00)
Weight Measured: 84.5 kg (10/07/24 14:33:00)
Height/Length Measured: 162 cm (10/07/24 14:33:00)
Â
Ideal Body Weight Calculated: 52.382 kg (09/30/24 11:53:00)
Â
Weight Method: Standing (10/07/24 14:33:00)
Â
Reason for Consult
Weight Management
Facility
UVH
Problem List/Past Medical History
Ongoing
Anemia
Anorexia nervosa, restricting type, in partial remission, moderate
Anorexia nervosa, restricting type, moderate
Attention deficit disorder (ADD) in adult
Bicornate uterus
Bicuspid aortic valve
BMI 33.0-33.9,adult
BMI 35.0-35.9,adult
Borderline personality disorder
Class 1 obesity
Class 2 obesity
Dependent personality disorder
Depression, major, recurrent, mild
Endometriosis
Fatigue
Female pelvic pain
GAD (generalized anxiety disorder)
Menorrhagia
PTSD (post-traumatic stress disorder)
S/P repair of coarctation of aorta
Sleep disturbance
Syncope
95 to 142
10/24/2024 Continuity of Care Document
Procedure/Surgical History
Laparoscopic Diagnostic (No Laterality) (09/18/2024), Esophagogastroduodenoscopy (03/02/2022), Transcatheter
intracardiac shunt (TIS) creation by stent placement for congenital cardiac anomalies to establish effective intracardiac
flow, including all imaging guidance by the proceduralist, when performed, left and right heart diagnostic cardiac cath.
Social History
Alcohol - 09/25/2024
Use: Never used.
Use: Never used. Household alcohol concerns: No.
Use: Never used.
Use: Never used.
Employment/School - 09/25/2024
Status: Employed. Place of occupation/business: Pet grooming. Highest education level: High school.
Employed
Home/Environment - 09/25/2024
Lives with: Friend and her family.
Substance Use - 09/25/2024
Use, other than prescribed: Never used.
Use, other than prescribed: Never used. Concerns about substance abuse in household: No.
Use, other than prescribed: Never used. Date last used: CBD once.
Tobacco - 09/25/2024
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker.
Use: Never smoker.
Use: Never smoker.
Family History
Anxiety: Grandmother (M) and Sibling.
Arrhythmia (cardiac) NOS: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
CHD - Congenital heart disease: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Cancer: Father, Grandfather (P) and Grandmother (P).
Cancer: Father.
Depression: Grandmother (M), Sibling and Sibling.
Drug addiction: Sibling and Sibling.
Emotional problems: Sibling.
Heart attack: Grandmother (M).Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Hyperlipidemia: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Substance Use: Sibling and Sibling.
Sudden cardiac death: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Suicidal behavior: Sibling and Sibling.
Allergies
Lactose (milk bothers my gut, GI Reaction)
No Known Medication Allergies
Lab Results
Sodium Level:Â 136 mmol/LÂ Low (09/30/24 12:53:00)
Potassium Level:Â 3.3 mmol/LÂ Low (09/30/24 12:53:00)
Chloride Level:Â 99 mmol/LÂ Low (09/30/24 12:53:00)
CO2: 20 mmol/L (09/30/24 12:53:00)
BUN:Â 6 mg/dLÂ Low (09/30/24 12:53:00)
Creatinine Level: 0.91 mg/dL (09/30/24 12:53:00)
Glucose Level: 83 mg/dL (09/30/24 12:53:00)
Albumin Level: 4.4 g/dL (09/30/24 12:53:00)
Alk Phos: 57 unit/L (09/30/24 12:53:00)
Bilirubin Total: 0.4 mg/dL (09/30/24 12:53:00)
Magnesium Level: 2.1 mg/dL (07/31/24 12:15:00)
WBC: 10.6 K/mcL (09/30/24 12:53:00)
MCV:Â 79.1 fLÂ Low (09/30/24 12:53:00)
ALT:Â 88 unit/LÂ High (09/30/24 12:53:00)
Hematocrit: 38.5 % (09/30/24 12:53:00)
Hemoglobin: 12 g/dL (09/30/24 12:53:00)
Platelets: 366 K/mcL (09/30/24 12:53:00)
Vitamin D 25 OH: 42 ng/mL (07/31/24 12:15:00)
96 to 142
10/24/2024 Continuity of Care Document
Medications
Inpatient
No active inpatient medications
Home
Auvelity 45 mg-105 mg oral tablet, extended release, 1 tabs, Oral, every morning
Sprintec, 1 tabs, Oral, Daily
traZODone 50 mg oral tablet, 50 mg= 1 tabs, Oral, Daily at bedtime
Vyvanse 70 mg oral capsule, 70 mg= 1 cap, Oral, every morning
Zofran ODT 8 mg oral tablet, disintegrating, 8 mg= 1 tabs, Oral, every 8 hr, PRN, 2 refills
Face to Face
Time Spent Teaching: 60 minutes (10/07/24 14:33:00)

Electronically Signed on 10/07/24 03:14 PM

________________________________________________________
VILLALOBOS HUITRON, RD, BRENDA

Letter

Event Display: AMB PT LETTER

Authored Date: 20230611220954-0600

Event Display: AMB PT LETTER

Authored Date: 20230601154909-0600

Event Display: AMB PT LETTER

Authored Date: 20230420213555-0600

Progress note

HOLLADAY, DO, NADIA: PERFORM, MODIFY, MODIFY, MODIFY

Event Display: Progress Note Generic
Authored Date: 20240516061248-0600

Subjective
Sarah is a 25-year-old female, with past medical history significant for bicuspid aortic valve, aortic
coarctation, anorexia nervosa, BPD, depression and ADHD who presented to the ED for 6-day
history of syncopal episodes, meeting SIRS criteria with no identified source, admitted for management of
symptoms and further workup.
 Patient reports:
Patient feels tire this morning. Denies HA, CP, palpitations. She continues to have irregular rhythm with PVCs but is
asymptomatic. Currently denies dizziness.
I explained to that her iron levels are low and we will do an infusion of iron. Patient agrees with that. She notes some
sore throat, she has had some tonsillar stone and tried to remove it manually and caused some scratch and pain. No
other acute complaints.
Â
Nursing report / 24h events:
– Complaints of pain in her throat
– NAEO
Review of Systems
A 10 point review of systems was conducted and negative unless stated above in the HPI.
Vital Signs
T 36.5 (36.0-36.6) HR 82 (65-94) BP 116/77 (100-143/52-96) RR 16 (16-16) O2sat 93 Â L Room air (93-97)
Physical Exam
Vital Signs (last 24 hrs)_____Â Â Â Â Â Â Â Â Â Â Last Charted___________
Heart Rate Peripheral                 93 bpm  (MAY 15 14:27)
Resp Rate                       16 br/min  (MAY 16 06:04)
SBP                      116 mmHg  (MAY 16 06:04)
DBP                      77 mmHg  (MAY 16 06:04)
SpO2Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â 93 % Â (MAY 16 06:04)
Â
97 to 142
10/24/2024 Continuity of Care Document
General: Alert and oriented, well nourished, no acute distress.
Eye: PERRL, EOMI, normal conjunctiva
HENT: Normocephalic, normal hearing, moist oral mucosa, no scleral icterus
Neck: Supple, non-tender, no JVD, no lymphadenopathy
Lungs: Clear to auscultation bilaterally, non-labored respiration
Heart: Normal rate, irregular rhythm, no murmur, gallop or edema
Abdomen: Soft, nontender, non-distended, normal bowel sounds, no masses
Musculoskeletal: Grossly normal range of motion and strength, no tenderness or swelling
Skin: Skin is warm, dry and pink, no rashes or lesions
Neurologic: Awake, alert, and oriented X3
Psychiatric: Cooperative, appropriate mood and affect
 Labs:
 WBC: 6.5 K/mcL (05/16/24 04:08:00)
RBC:Â 4.01 x10^6/mcLÂ Low (05/16/24 04:08:00)
Hemoglobin:Â 9.3 g/dLÂ Low (05/16/24 04:08:00)
Hematocrit:Â 31 %Â Low (05/16/24 04:08:00)
MCV:Â 77.3 fLÂ Low (05/16/24 04:08:00)
MCH: 23.2 pg Low (05/16/24 04:08:00)
MCHC:Â 30 g/dLÂ Low (05/16/24 04:08:00)
RDW SD:Â 59.3 fLÂ High (05/16/24 04:08:00)
RDW:Â 21.2 %Â High (05/16/24 04:08:00)
Platelets:Â 416 K/mcLÂ High (05/16/24 04:08:00)
MPV: 9.2 fL (05/16/24 04:08:00)
Nucleated RBC Auto: 0 /100(WBCs) (05/16/24 04:08:00)
Differential Type: Auto (05/16/24 04:08:00)
Immature Granulocytes: 0.2 % (05/16/24 04:08:00)
Neutrophil % Auto: 56.9 % (05/16/24 04:08:00)
Lymphocyte % Auto: 31.7 % (05/16/24 04:08:00)
Monocyte % Auto: 8 % (05/16/24 04:08:00)
Eosinophil % Auto: 2.3 % (05/16/24 04:08:00)
Basophil % Auto: 0.9 % (05/16/24 04:08:00)
Immature Granulocyte, Abs: 0.01 K/mcL (05/16/24 04:08:00)
Neutrophil, Abs: 3.7 K/mcL (05/16/24 04:08:00)
Lymphocyte, Abs: 2.1 K/mcL (05/16/24 04:08:00)
Monocyte, Abs: 0.5 K/mcL (05/16/24 04:08:00)
Eosinophil, Abs: 0.2 K/mcL (05/16/24 04:08:00)
Basophil, Abs: 0.1 K/mcL (05/16/24 04:08:00)
Sodium Level: 139 mmol/L (05/16/24 04:08:00)
Potassium Level: 3.9 mmol/L (05/16/24 04:08:00)
Chloride Level: 109 mmol/L (05/16/24 04:08:00)
CO2: 20 mmol/L (05/16/24 04:08:00)
Anion Gap (Na Cl CO2): 10 mmol/L (05/16/24 04:08:00)
Glucose Level:Â 101 mg/dLÂ High (05/16/24 04:08:00)
BUN: 10 mg/dL (05/16/24 04:08:00)
Creatinine Level: 0.86 mg/dL (05/16/24 04:08:00)
est CrCl (Ideal BW for dosing): 82.69 mL/min (05/16/24 04:08:00)
est CrCl (Actual BW for dosing): 136.55 mL/min (05/16/24 04:08:00)
Creatinine GFR: 96 mL/min/1.73 m2 (05/16/24 04:08:00)
Calcium Level: 8.8 mg/dL (05/16/24 04:08:00)
Protein Total: 6.1 g/dL (05/16/24 04:08:00)
Albumin Level:Â 3.3 g/dLÂ Low (05/16/24 04:08:00)
Bilirubin Total:Â <0.2Â Low (05/16/24 04:08:00)
Alk Phos: 42 unit/L (05/16/24 04:08:00)
AST: 20 unit/L (05/16/24 04:08:00)
ALT: 16 unit/L (05/16/24 04:08:00)
Iron:Â 22 mcg/dLÂ Low (05/15/24 13:10:00)
TIBC:Â 503 mcg/dLÂ High (05/15/24 13:10:00)
Iron Sat:Â 4 %Â Low (05/15/24 13:10:00)
Ferritin Level:Â 7 ng/mLÂ Low (05/15/24 13:10:00)
Transferrin:Â 402 mg/dLÂ High (05/15/24 13:10:00)
Intake and Output
98 to 142
10/24/2024 Continuity of Care Document
Â
This visit (24 hour periods starting at 06:00 MDT)Â

Â
05/16/24 *Â
05/15/24Â
05/14/24Â

Total SummaryÂ
Â

  Intake mLÂ
--Â
1,323.12Â
2,140Â

  Output mLÂ
--Â
--Â
--Â

  Fluid Balance Â
--Â
1,323.12Â
2,140Â

Intake (6)Â
Â

  Lactated Ringers Injection mLÂ

--Â
--Â
2,000Â

  Sodium Chloride 0.9% mLÂ

--Â
--Â
40Â

  Sodium Chloride 0.9%, perflutren mLÂ

--Â
3Â
--Â

  iopamidol mLÂ
--Â
--Â
100Â

  lactated ringer's injection 1,000 mL mLÂ

--Â
1,318.12Â
--Â

  ondansetron mLÂ
--Â
2Â
--Â

  TotalÂ
--Â
99 to 142
10/24/2024 Continuity of Care Document
1,323.12Â
2,140Â

Output (0)Â
Â

Counts (1)Â
Â

  Patient Voided, Unknown Amount - Count Â

--Â
--Â
1Â
 * This column has not completed the indicated time period.Â
_____
Assessment/Plan
Sarah is a 25 Years Female with hx of bicuspid aortic valve, aortic coarctation, anorexia nervosa, borderline personality
disorder, depression, and ADHD who presents with a 6 days of daily syncope. Found to be persistently tachycardic and
hypertensive with elevated white count, electrolyte abnormalities, increased anion gap, and elevated beta
hydroxybutyrate. Patient meeting SIRS criteria without obvious source of infection although multiple symptoms
suggestive of acute process. Given cardiac history and symptoms associated with syncope patient being admitted for
further monitoring and evaluation.
Â
Recurrent syncopeÂ
S/P repair of coarctation of aortaÂ
Bicuspid aortic valve
Acute, present on admission. Patient presents with at least 2 confirmed syncopal events and multiple near syncopal
symptoms over the last 6 days of unknown etiology. Patient has a known cardiac history although she has not had
consistent follow-up beyond childhood. Patient's syncope is often accompanied by a feeling of weakness, diaphoresis,
lightheadedness, palpitations. Denies any chest pain, shortness of breath, leg swelling, or pain. EKG in the ED was
unrevealing apart from tachycardia. However, given her history would like to conduct further cardiology workup. Upon
admission, case was discussed with on-call cardiologist, Dr. Wilkinson who agreed to consult on patient. Initial PE does
not show volume depletion. Seizure also seems less likely as patient has not had any prolonged postictal state, urinary
incontinence, or tongue biting. Patient BNP is normal.Â
Telemetry reviewed this morning and patient continues to have irregular beats and was tachycardic in 140s earlier.
Currently she has normal rate. Normal echocardiogram. Cardiology consulted and patient cleared to be discharged
home with a monitor and follow-up outpatient.
– Cardiology consulted, recs appreciated.
– Dr. Sunkara reviewed Echo: No significant aortic stenosis identified at this bicuspid valve. Normal left ventricular
systolic function. Mildly dilated right ventricle.
– Given PVC burden and dilated right ventricle, Dr. Sunkara says to consider cardiac MRI.
– Echocardiogram 05/15/2024: LV systolic function is normal. EF 9%. No segmental wall motion abnormalities.
Normal diastolic pattern. No evidence of aortic valve stenosis. Bicuspid aortic valve with no regurgitation. No significant
change from prior study of 05/02/2014.
– BNP is normal <6
– Continuous cardiac telemetry
– MIVF with LR at 125 mL/h
– Tylenol as needed for pain
Â
Â
SIRS without infection or organ dysfunction
Leukocytosis
Metabolic acidosis
Hypokalemia
Acute, microcytic, present admission. Patient meeting SIRS criteria with elevated white count, tachycardia, tachypnea.
No obvious source of infection however patient endorsed many symptoms on the ROS including hematuria, abdominal
pain, nausea, vomiting, diarrhea, and constipation. Physical exam with some left lower quadrant tenderness and
tachycardia but otherwise unremarkable. Beta hydroxybutyrate is elevated but glucose only 123 on admission. Labs
and PE are reassuring against infection. Negative blood cultures to date.Â
– Lactic acid normal 1.2, UA unremarkable.
– Urine culture pending
100 to 142
10/24/2024 Continuity of Care Document
– Blood cultures: NGTD
– MIVF with LR at 125 mL/h
– Tylenol as needed for pain, fever
Â
Anemia
Chronic, present on admission. Patient has history of menorrhagia (see below). Given Sprintec to reduce menstrual
cycles.Â
Hgb 9.4 this morning in the setting of IV fluids.
– Iron 22, TIBC 503, Iron saturation 4, Ferritin 7 - Iron deficiency anemia
– Venofer 300mg IV Infusion today. F/u in the infusion clinic outpatient.Â
– Monitor daily CBC
Â
Anorexia nervosa, restricting type, in partial remission, moderate
Historic diagnosis. Per most recent family medicine note does not appear to be undergoing treatment or dealing with
any acute symptoms of this.
Â
Borderline personality disorder
Depression, major, recurrent, moderate
PTSD (post-traumatic stress disorder)
Attention deficit disorder (ADD) in adult
Chronic, present on admission. Patient follows with psychiatric specialist in Salt Lake City. Symptoms of these disorders
are currently stable. Takes hydroxyzine 50mg, Vyvanse 70mg, and trazodone 50mg.
– Continue home medications
Â
Menorrhagia
Chronic, present on admission. Prescribed Sprintec in November 2023 by OB/GYN to decrease menstrual bleeding with
hopes of improving anemia.Â
– Continue home medication
Â
Â
MIVF:LR @ 125@mL/hr
Diet: Regular
O2: RA, baseline RA
Tubes/lines/drains: PIV
Abx: None
Pain: Tylenol
Prophylaxis: SCDs
Dispo: likely discharge home
Code Status: Full code
_____
Lab Results Hematology
WBC: 6.5 K/mcL (05/16/24 04:08:00)
RBC:Â 4.01 x10^6/mcLÂ Low (05/16/24 04:08:00)
Hemoglobin:Â 9.3 g/dLÂ Low (05/16/24 04:08:00)
Hematocrit:Â 31 %Â Low (05/16/24 04:08:00)
MCV:Â 77.3 fLÂ Low (05/16/24 04:08:00)
MCH: 23.2 pg Low (05/16/24 04:08:00)
MCHC:Â 30 g/dLÂ Low (05/16/24 04:08:00)
RDW SD:Â 59.3 fLÂ High (05/16/24 04:08:00)
RDW:Â 21.2 %Â High (05/16/24 04:08:00)
Platelets:Â 416 K/mcLÂ High (05/16/24 04:08:00)
MPV: 9.2 fL (05/16/24 04:08:00)
Nucleated RBC Auto: 0 /100(WBCs) (05/16/24 04:08:00)
Differential Type: Auto (05/16/24 04:08:00)
Immature Granulocytes: 0.2 % (05/16/24 04:08:00)
Neutrophil % Auto: 56.9 % (05/16/24 04:08:00)
Lymphocyte % Auto: 31.7 % (05/16/24 04:08:00)
Monocyte % Auto: 8 % (05/16/24 04:08:00)
Eosinophil % Auto: 2.3 % (05/16/24 04:08:00)
Basophil % Auto: 0.9 % (05/16/24 04:08:00)
Immature Granulocyte, Abs: 0.01 K/mcL (05/16/24 04:08:00)
101 to 142
10/24/2024 Continuity of Care Document
Neutrophil, Abs: 3.7 K/mcL (05/16/24 04:08:00)
Lymphocyte, Abs: 2.1 K/mcL (05/16/24 04:08:00)
Monocyte, Abs: 0.5 K/mcL (05/16/24 04:08:00)
Eosinophil, Abs: 0.2 K/mcL (05/16/24 04:08:00)
Basophil, Abs: 0.1 K/mcL (05/16/24 04:08:00)
Chemistry
Sodium Level: 139 mmol/L (05/16/24 04:08:00)
Potassium Level: 3.9 mmol/L (05/16/24 04:08:00)
Chloride Level: 109 mmol/L (05/16/24 04:08:00)
CO2: 20 mmol/L (05/16/24 04:08:00)
Anion Gap (Na Cl CO2): 10 mmol/L (05/16/24 04:08:00)
Glucose Level:Â 101 mg/dLÂ High (05/16/24 04:08:00)
BUN: 10 mg/dL (05/16/24 04:08:00)
Creatinine Level: 0.86 mg/dL (05/16/24 04:08:00)
est CrCl (Ideal BW for dosing): 82.69 mL/min (05/16/24 04:08:00)
est CrCl (Actual BW for dosing): 136.55 mL/min (05/16/24 04:08:00)
Creatinine GFR: 96 mL/min/1.73 m2 (05/16/24 04:08:00)
Calcium Level: 8.8 mg/dL (05/16/24 04:08:00)
Protein Total: 6.1 g/dL (05/16/24 04:08:00)
Albumin Level:Â 3.3 g/dLÂ Low (05/16/24 04:08:00)
Bilirubin Total:Â <0.2Â Low (05/16/24 04:08:00)
Alk Phos: 42 unit/L (05/16/24 04:08:00)
AST: 20 unit/L (05/16/24 04:08:00)
ALT: 16 unit/L (05/16/24 04:08:00)
Iron:Â 22 mcg/dLÂ Low (05/15/24 13:10:00)
TIBC:Â 503 mcg/dLÂ High (05/15/24 13:10:00)
Iron Sat:Â 4 %Â Low (05/15/24 13:10:00)
Ferritin Level:Â 7 ng/mLÂ Low (05/15/24 13:10:00)
Transferrin:Â 402 mg/dLÂ High (05/15/24 13:10:00)
Urinalysis
Collect Method, Ur: Urine Clean Catch (05/14/24 20:10:00)
Color Urine: Normal (05/14/24 20:10:00)
Appear: Normal (05/14/24 20:10:00)
Specific Gravity, Urine: <1.006 (05/14/24 20:10:00)
pH Urine: 5.5 (05/14/24 20:10:00)
Glucose Urine: Negative (05/14/24 20:10:00)
UA Ketones: >=80(3+) Abnormal (05/14/24 20:10:00)
Nitrite: Negative (05/14/24 20:10:00)
Hgb Urine: Negative (05/14/24 20:10:00)
Protein Urine: Trace Abnormal (05/14/24 20:10:00)
Leuk Esterase: Negative (05/14/24 20:10:00)
WBC Urine: 0 /HPF (05/14/24 20:10:00)
RBC Urine: 1 /HPF (05/14/24 20:10:00)
Epithelial Cells: 5 /HPF (05/14/24 20:10:00)
Bacteria Urine: Negative (05/14/24 20:10:00)
Mucus Urine: 1+ Abnormal (05/14/24 20:10:00)
Hyaline Cast: Negative (05/14/24 20:10:00)
Urine Culture Ordered?: No (05/14/24 20:10:00)

Medications
Inpatient
Artificial Tears preservative-free ophthalmic solution, 1 drops, Eye-Both, every 2 hr, PRN
hydrALAZINE, 10 mg= 0.5 mL, IV Push, every 4 hr, PRN
hydrOXYzine, 50 mg= 2 tabs, Oral, BID, PRN
ibuprofen, 600 mg= 1 tabs, Oral, every 6 hr, PRN
LR drip 1,000 mL, 1000 mL, IV Drip
melatonin, 3 mg= 1 tabs, Oral, Daily at bedtime, PRN
MiraLax, 17 g= 1 EA, Oral, BID, PRN
Senna S, 1 tabs, Oral, BID, PRN
102 to 142
10/24/2024 Continuity of Care Document
traZODone, 50 mg= 1 tabs, Oral, Daily at bedtime
Tums 500 (calcium carbonate 500 mg (elemental Ca 200 mg)) oral tab, chewable, 1 tabs, Oral, every 6 hr, PRN
Tylenol, 500 mg= 1 tabs, Oral, every 4 hr, PRN
Zofran, 4 mg= 2 mL, IV Push, every 6 hr, PRN
Home
hydrOXYzine hydrochloride 50 mg oral tablet, 50 mg= 1 tabs, Oral, BID, PRN
Sprintec, 1 tabs, Oral, Daily
traZODone 50 mg oral tablet, 50 mg= 1 tabs, Oral, Daily at bedtime
Vyvanse 70 mg oral capsule, 70 mg= 1 cap, Oral, every morning
Oxygen Settings
Oxygen Therapy: Room air (05/16/24 03:37:00)
Oxygen Therapy: Room air (05/16/24 02:30:00)
Oxygen Therapy: Room air (05/15/24 22:32:00)
Oxygen Therapy: Room air (05/15/24 18:46:00)
Oxygen Therapy: Nasal cannula (05/15/24 14:00:00)
Allergies
No Known Medication Allergies
No Known Allergies
Imaging Results (Last 24 Hours)
No qualifying data available.
Code Status
Resuscitation Status* - OrderedÂ
 -- 05/14/24 18:49:00 MDT, Full Code, 05/14/24 18:49:00 MDT

Electronically Signed on 05/16/24 12:55 PM

________________________________________________________
HOLLADAY, DO, NADIA
DALY, DO, SARAH W: PERFORM
Event Display: Progress Note Generic
Authored Date: 20240517085912-0600

I have seen and examined this patient, and I reviewed the above note and agree with the Resident's findings,
assessment, and plan.

Â
Sarah Daly, DO, FAAFP

Electronically Signed on 05/17/24 08:59 AM

________________________________________________________
DALY, DO, SARAH W
HOLLADAY, DO, NADIA: MODIFY, MODIFY, MODIFY, MODIFY, MODIFY, PERFORM, MODIFY
Event Display: Progress Note Generic
Authored Date: 20240515050250-0600

Subjective
Sarah is a 25-year-old female, with past medical history significant for bicuspid aortic valve, aortic
coarctation, anorexia nervosa, BPD, depression and ADHD who presented to the ED for 6-day
history of syncopal episodes, meeting SIRS criteria with no identified source, admitted for management of
symptoms and further workup.
Â
Patient reports:
Patient seen this morning during walking rounds. She notes that syncopal episodes are new. She does have hx of
menorrhagia for what she is taking Sprintec. Anemia have been associated with excessive bleeding. Tachycardia have
not been associated with hypotension, but patient feels dizzy upon getting up from seating position. She notes iron
infusions back in 2021 for chronic anemia.
Denies CP, SOB. Occasionally feels palpitations and dizziness. Denies dysuria, urinary frequency and hematuria. Denies
URI sxs.
 Nursing report / 24h events:

103 to 142
10/24/2024 Continuity of Care Document
– Complaints of pain in her throat
- NAEO
Review of Systems
A 10 point review of systems was conducted and negative unless stated above in the HPI.
Vital Signs
T 36.2 (35.7-37.0) HR 85 (85-132) BP 133/81 (133-165/81-121) RR 18 (13-23) O2sat 98 Â L Room air (98-100)
Physical Exam
Vital Signs (last 24 hrs)_____Â Â Â Â Â Â Â Â Â Â Last Charted___________
Heart Rate Peripheral                 H 116bpm  (MAY 14 18:33)
Resp Rate                       16 br/min  (MAY 15 06:34)
SBP                      125 mmHg  (MAY 15 06:34)
DBP                      70 mmHg  (MAY 15 06:34)
SpO2Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â 97 % Â (MAY 15 06:34)
Weight                      86.5 kg  (MAY 14 18:57)
Height                      160 cm  (MAY 14 18:57)
BMIÂ Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â 33.79 Â (MAY 14 18:57)
Â
General:Â Alert and oriented, well nourished, no acute distress.
Eye:Â PERRL, EOMI, normal conjunctiva
HENT:Â Normocephalic, normal hearing, moist oral mucosa, no scleral icterus
Neck:Â Supple, non-tender, no JVD, no lymphadenopathy
Lungs:Â Clear to auscultation bilaterally, non-labored respiration
Heart: Tachycardic, irregular rhythm, no murmur, gallop or edema
Abdomen: Soft, nontender, non-distended, normal bowel sounds, no masses
Musculoskeletal:Â Grossly normal range of motion and strength, no tenderness or swelling
Skin:Â Skin is warm, dry and pink, no rashes or lesions
Neurologic:Â Awake, alert, and oriented X3
Psychiatric:Â Cooperative, appropriate mood and affect
Â
Labs:
 Blood Gas Specimen Source: Arterial (05/14/24 16:46:00)
HCO3: 20.1 mmol/L (05/14/24 16:46:00)
pH Ven: 7.405 (05/14/24 16:46:00)
pCO2 Ven: 32.8 mmHg Low (05/14/24 16:46:00)
pO2 Ven: 27.3 mmHg (05/14/24 16:46:00)
pO2 Temp Corrected Ven: 27 (05/14/24 16:46:00)
O2 Saturation Ven: 39 % (05/14/24 16:46:00)
O2 Hgb Ven: 38.4 % (05/14/24 16:46:00)
O2 Content Ven: 5.3 (05/14/24 16:46:00)
FiO2: 21 (05/14/24 16:46:00)
Base Excess Whole Blood: -3.5 mmol/L (05/14/24 16:46:00)
Carboxyhemoglobin: 0.9 % (05/14/24 16:46:00)
Methemoglobin: 0.6 % (05/14/24 16:46:00)
Barometric Pressure: 642 mmHg (05/14/24 16:46:00)
Temperature C: 37 (05/14/24 16:46:00)
pH Temp Corrected Ven: 7.405 (05/14/24 16:46:00)
pCO2 Temp Corrected Ven: 32.8 (05/14/24 16:46:00)
Critical Value Type: Printed Report given (05/14/24 16:46:00)
Crtiical Value Notification Date: 05/14/2024 (05/14/24 16:46:00)
Critical Value Notification Time: 16:49 (05/14/24 16:46:00)
Critical Value Notification to: Jamie Matgzer RN (05/14/24 16:46:00)
Performed by: hry08930 (05/14/24 16:46:00)
Blood Gas Draw Type: Venous (05/14/24 16:46:00)
Blood Gas Draw Time: 05/14/24 16:46:00 (05/14/24 16:46:00)
Blood Gas Drawn By: Drawn by RN/Lab/OR (05/14/24 16:46:00)
WBC: 9 K/mcL (05/15/24 04:24:00)
WBC:Â 13.1 K/mcLÂ High (05/14/24 15:47:00)
RBC: 4.2 x10^6/mcL (05/15/24 04:24:00)
RBC: 4.99 x10^6/mcL (05/14/24 15:47:00)
Hemoglobin:Â 9.4 g/dLÂ Low (05/15/24 04:24:00)
Hemoglobin:Â 9.9 g/dLÂ Low (05/14/24 16:46:00)
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Hematocrit:Â 32.3 %Â Low (05/15/24 04:24:00)
Hematocrit: 37 % (05/14/24 15:47:00)
MCV:Â 76.9 fLÂ Low (05/15/24 04:24:00)
MCV:Â 74.1 fLÂ Low (05/14/24 15:47:00)
MCH: 22.4 pg Low (05/15/24 04:24:00)
MCH: 22.8 pg Low (05/14/24 15:47:00)
MCHC:Â 29.1 g/dLÂ Low (05/15/24 04:24:00)
MCHC:Â 30.8 g/dLÂ Low (05/14/24 15:47:00)
RDW SD:Â 58.5 fLÂ High (05/15/24 04:24:00)
RDW SD:Â 55.3 fLÂ High (05/14/24 15:47:00)
RDW:Â 21.2 %Â High (05/15/24 04:24:00)
RDW:Â 21.7 %Â High (05/14/24 15:47:00)
Platelets:Â 411 K/mcLÂ High (05/15/24 04:24:00)
Platelets:Â 587 K/mcLÂ High (05/14/24 15:47:00)
MPV: 9 fL (05/15/24 04:24:00)
MPV: 8.7 fL (05/14/24 15:47:00)
Nucleated RBC Auto: 0 /100(WBCs) (05/15/24 04:24:00)
Nucleated RBC Auto: 0 /100(WBCs) (05/14/24 15:47:00)
Differential Type: Auto (05/15/24 04:24:00)
Differential Type: Auto (05/14/24 15:47:00)
Immature Granulocytes: 0.2 % (05/15/24 04:24:00)
Immature Granulocytes: 0.2 % (05/14/24 15:47:00)
Neutrophil % Auto: 64.5 % (05/15/24 04:24:00)
Neutrophil % Auto: 78.2 % (05/14/24 15:47:00)
Lymphocyte % Auto: 24.8 % (05/15/24 04:24:00)
Lymphocyte % Auto: 13.8 % (05/14/24 15:47:00)
Monocyte % Auto: 8.4 % (05/15/24 04:24:00)
Monocyte % Auto: 6.9 % (05/14/24 15:47:00)
Eosinophil % Auto: 1.3 % (05/15/24 04:24:00)
Eosinophil % Auto: 0.3 % (05/14/24 15:47:00)
Basophil % Auto: 0.8 % (05/15/24 04:24:00)
Basophil % Auto: 0.6 % (05/14/24 15:47:00)
Immature Granulocyte, Abs: 0.02 K/mcL (05/15/24 04:24:00)
Immature Granulocyte, Abs: 0.03 K/mcL (05/14/24 15:47:00)
Neutrophil, Abs: 5.8 K/mcL (05/15/24 04:24:00)
Neutrophil, Abs:Â 10.3 K/mcLÂ High (05/14/24 15:47:00)
Lymphocyte, Abs: 2.2 K/mcL (05/15/24 04:24:00)
Lymphocyte, Abs: 1.8 K/mcL (05/14/24 15:47:00)
Monocyte, Abs: 0.8 K/mcL (05/15/24 04:24:00)
Monocyte, Abs: 0.9 K/mcL (05/14/24 15:47:00)
Eosinophil, Abs: 0.1 K/mcL (05/15/24 04:24:00)
Eosinophil, Abs: 0 K/mcL (05/14/24 15:47:00)
Basophil, Abs: 0.1 K/mcL (05/15/24 04:24:00)
Basophil, Abs: 0.1 K/mcL (05/14/24 15:47:00)
Plt Est: Agrees with count (05/14/24 15:47:00)
RBC Morph: Slide review agrees with reported RBC indices. (05/14/24 15:47:00)
Bld Smear Scan: Slide reviewed and is in agreement with auto differential (05/14/24 15:47:00)
Plts, Large: Observed Abnormal (05/14/24 15:47:00)
D-dimer, quant. (ug/mL): 0.49 mcg FEU/mL (05/14/24 15:47:00)
Sodium Level:Â 136 mmol/LÂ Low (05/15/24 04:24:00)
Sodium Level:Â 135 mmol/LÂ Low (05/14/24 15:47:00)
Potassium Level: 3.6 mmol/L (05/15/24 04:24:00)
Potassium Level:Â 3.1 mmol/LÂ Low (05/14/24 15:47:00)
Chloride Level: 106 mmol/L (05/15/24 04:24:00)
Chloride Level:Â 100 mmol/LÂ Low (05/14/24 15:47:00)
CO2:Â 17 mmol/LÂ Low (05/15/24 04:24:00)
CO2:Â 18 mmol/LÂ Low (05/14/24 15:47:00)
Anion Gap (Na Cl CO2): 12 mmol/L (05/15/24 04:24:00)
Anion Gap (Na Cl CO2):Â 18 mmol/LÂ High (05/14/24 15:47:00)
Glucose Level: 80 mg/dL (05/15/24 04:24:00)
Glucose Level:Â 123 mg/dLÂ High (05/14/24 15:47:00)
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BUN:Â 7 mg/dLÂ Low (05/15/24 04:24:00)
BUN: 10 mg/dL (05/14/24 15:47:00)
Creatinine Level: 0.8 mg/dL (05/15/24 04:24:00)
Creatinine Level: 0.95 mg/dL (05/14/24 15:47:00)
est CrCl (Ideal BW for dosing): 88.89 mL/min (05/15/24 04:24:00)
est CrCl (Ideal BW for dosing): 74.86 mL/min (05/14/24 15:47:00)
est CrCl (Actual BW for dosing): 146.79 mL/min (05/15/24 04:24:00)
est CrCl (Actual BW for dosing): 123.62 mL/min (05/14/24 15:47:00)
Creatinine GFR: 105 mL/min/1.73 m2 (05/15/24 04:24:00)
Creatinine GFR: 85 mL/min/1.73 m2 (05/14/24 15:47:00)
Cmt: GFR: See Comments (05/14/24 15:47:00)
Calcium Level: 8.9 mg/dL (05/15/24 04:24:00)
Calcium Level: 9.7 mg/dL (05/14/24 15:47:00)
Protein Total: 6.6 g/dL (05/15/24 04:24:00)
Protein Total:Â 8.6 g/dLÂ High (05/14/24 15:47:00)
Albumin Level: 3.6 g/dL (05/15/24 04:24:00)
Albumin Level: 4.7 g/dL (05/14/24 15:47:00)
Bilirubin Total: 0.3 mg/dL (05/15/24 04:24:00)
Bilirubin Total: 0.3 mg/dL (05/14/24 15:47:00)
Alk Phos: 47 unit/L (05/15/24 04:24:00)
Alk Phos: 59 unit/L (05/14/24 15:47:00)
AST: 32 unit/L (05/15/24 04:24:00)
AST: 33 unit/L (05/14/24 15:47:00)
ALT: 24 unit/L (05/15/24 04:24:00)
ALT: 24 unit/L (05/14/24 15:47:00)
Beta-Hydroxybutyrate:Â 1.9 mmol/LÂ High (05/14/24 15:47:00)
Lactic Acid, Plasma (Venous): 1.2 mmol/L (05/14/24 19:05:00)
Magnesium Level: 2.1 mg/dL (05/14/24 15:47:00)
Phosphorus Level: 2.8 mg/dL (05/14/24 15:47:00)
Troponin T Gen 5: <6 (05/14/24 15:47:00)
Troponin T Gen 5 Delta: No calculation (05/14/24 15:47:00)
Cmt: Troponin T Gen 5: See Comments (05/14/24 15:47:00)
N-Terminal proBNP: <36 (05/14/24 19:05:00)
Cmt: N-Terminal proBNP: See Comments (05/14/24 19:05:00)
TSH: 2.59 mcIU/mL (05/14/24 15:47:00)
Collect Method, Ur: Urine Clean Catch (05/14/24 20:10:00)
Color Urine: Normal (05/14/24 20:10:00)
Appear: Normal (05/14/24 20:10:00)
Specific Gravity, Urine: <1.006 (05/14/24 20:10:00)
pH Urine: 5.5 (05/14/24 20:10:00)
Glucose Urine: Negative (05/14/24 20:10:00)
UA Ketones: >=80(3+) Abnormal (05/14/24 20:10:00)
Nitrite: Negative (05/14/24 20:10:00)
Hgb Urine: Negative (05/14/24 20:10:00)
Protein Urine: Trace Abnormal (05/14/24 20:10:00)
Leuk Esterase: Negative (05/14/24 20:10:00)
WBC Urine: 0 /HPF (05/14/24 20:10:00)
RBC Urine: 1 /HPF (05/14/24 20:10:00)
Epithelial Cells: 5 /HPF (05/14/24 20:10:00)
Bacteria Urine: Negative (05/14/24 20:10:00)
Mucus Urine: 1+ Abnormal (05/14/24 20:10:00)
Hyaline Cast: Negative (05/14/24 20:10:00)
Urine Culture Ordered?: No (05/14/24 20:10:00)
Intake and Output
Â
This visit (24 hour periods starting at 06:00 MDT)Â

Â
05/14/24 *Â
05/13/24Â
05/12/24Â
106 to 142
10/24/2024 Continuity of Care Document

Total SummaryÂ
Â

  Intake mLÂ
2,140Â
--Â
--Â

  Output mLÂ
--Â
--Â
--Â

  Fluid Balance Â
2,140Â
--Â
--Â

Intake (3)Â
Â

  Lactated Ringers Injection mLÂ

2,000Â
--Â
--Â

  Sodium Chloride 0.9% mLÂ

40Â
--Â
--Â

  iopamidol mLÂ
100Â
--Â
--Â

  TotalÂ
2,140Â
--Â
--Â

Output (0)Â
Â

Counts (1)Â
Â

  Patient Voided, Unknown Amount - Count Â

1Â
--Â
--Â
 * This column has not completed the indicated time period.Â
_____
Assessment/Plan
Sarah is a 25 Years Female with hx of bicuspid aortic valve, aortic coarctation, anorexia nervosa, borderline
personality disorder, depression, and ADHD who presents with a 6 days of daily syncope. Found to
be persistently tachycardic and hypertensive with elevated white count, electrolyte abnormalities, increased
anion gap, and elevated beta hydroxybutyrate. Patient meeting SIRS criteria without obvious source of
infection although multiple symptoms suggestive of acute process. Given cardiac history and symptoms
associated with syncope patient being admitted for further monitoring and evaluation.
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 Recurrent syncopeÂ
S/P repair of coarctation of aortaÂ
Bicuspid aortic valve
Acute, present on admission.  Patient presents with at least 2 confirmed syncopal events and multiple near
syncopal symptoms over the last 6 days of unknown etiology. Patient has a known cardiac history although she
has not had consistent follow-up beyond childhood. Patient's syncope is often accompanied by a feeling of
weakness, diaphoresis, lightheadedness, palpitations.  Denies any chest pain, shortness of breath, leg swelling,
or pain. EKG in the ED was unrevealing apart from tachycardia.  However, given her history would like
to conduct further cardiology workup.   Upon admission, case was discussed with on-call cardiologist, Dr.
Wilkinson who agreed to consult on patient. Initial PE does not show volume depletion.  Seizure also seems less
likely as patient has not had any prolonged postictal state, urinary incontinence, or tongue biting. Patient BNP is
normal. Continues to be remains tachycardic despite fluids. Echocardiogram to be performed today.
– Cardiology consulted, recs appreciated.
– Echocardiogram today. F/u results
– BNP is normal <6
– Continuous cardiac telemetry shows nearly 7% PVCs burden with no malignant arrhythmias identified.
– MIVF with LR at 125 mL/h
– Tylenol as needed for pain
Â
SIRS without infection or organ dysfunction
Leukocytosis
Metabolic acidosis
Hypokalemia
Acute, present admission. Patient meeting SIRS criteria with elevated white count, tachycardia, tachypnea. No
obvious source of infection however patient endorsed many symptoms on the ROS including hematuria,
abdominal pain, nausea, vomiting, diarrhea, and constipation. Physical exam with some left lower quadrant
tenderness and tachycardia but otherwise unremarkable. Beta hydroxybutyrate is elevated but glucose only 123
on admission. This morning patient had complaints of sore throat, but morning labs are reassuring against infection.
Will continue to follow-up on Blood and urine cultures.
– Lactic acid normal 1.2, UA unremarkable.
– Urine culture pending
– Blood cultures pending
– MIVF with LR at 125 mL/h
– Tylenol as needed for pain, fever
 Anemia
Chronic, present on admission.  Patient has history of menorrhagia (see below). Given Sprintec to reduce menstrual
cycles.Â
Hgb 9.4 this morning in the setting of IV fluids.
– Iron studies ordered
– Monitor daily CBC
Â
Anorexia nervosa, restricting type, in partial remission, moderate
Historic diagnosis. Per most recent family medicine note does not appear to be undergoing treatment or dealing
with any acute symptoms of this.
Â
Borderline personality disorder
Depression, major, recurrent, moderate
PTSD (post-traumatic stress disorder)
Attention deficit disorder (ADD) in adult
Chronic, present on admission.  Patient follows with psychiatric specialist in Salt Lake City. Symptoms of these
disorders are currently stable. Takes hydroxyzine 50mg, Vyvanse 70mg, and trazodone 50mg.
– Continue home medications
Â
Menorrhagia
Chronic, present on admission. Prescribed Sprintec in November 2023 by OB/GYN to decrease menstrual
bleeding with hopes of improving anemia.Â
– Continue home medication
Â
Â
MIVF:LR @ 125@mL/hr
Diet: Regular
108 to 142
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O2: RA, baseline RA
Tubes/lines/drains: PIV
Abx: None
Pain: Tylenol
Prophylaxis: SCDs
Dispo: Admit to medicine
 Code Status: Full code
Â
 This encounter was supervised by Sarah Daly, DO, attending physician. Assessment and plan reviewed and agreed
upon by attending. Please see attestation and addendum for any further information or clarifications.
_____
Lab Results Hematology
WBC: 9 K/mcL (05/15/24 04:24:00)
WBC:Â 13.1 K/mcLÂ High (05/14/24 15:47:00)
RBC: 4.2 x10^6/mcL (05/15/24 04:24:00)
RBC: 4.99 x10^6/mcL (05/14/24 15:47:00)
Hemoglobin:Â 9.4 g/dLÂ Low (05/15/24 04:24:00)
Hemoglobin:Â 9.9 g/dLÂ Low (05/14/24 16:46:00)
Hemoglobin:Â 11.4 g/dLÂ Low (05/14/24 15:47:00)
Hematocrit:Â 32.3 %Â Low (05/15/24 04:24:00)
Hematocrit: 37 % (05/14/24 15:47:00)
MCV:Â 76.9 fLÂ Low (05/15/24 04:24:00)
MCV:Â 74.1 fLÂ Low (05/14/24 15:47:00)
MCH: 22.4 pg Low (05/15/24 04:24:00)
MCH: 22.8 pg Low (05/14/24 15:47:00)
MCHC:Â 29.1 g/dLÂ Low (05/15/24 04:24:00)
MCHC:Â 30.8 g/dLÂ Low (05/14/24 15:47:00)
RDW SD:Â 58.5 fLÂ High (05/15/24 04:24:00)
RDW SD:Â 55.3 fLÂ High (05/14/24 15:47:00)
RDW:Â 21.2 %Â High (05/15/24 04:24:00)
RDW:Â 21.7 %Â High (05/14/24 15:47:00)
Platelets:Â 411 K/mcLÂ High (05/15/24 04:24:00)
Platelets:Â 587 K/mcLÂ High (05/14/24 15:47:00)
MPV: 9 fL (05/15/24 04:24:00)
MPV: 8.7 fL (05/14/24 15:47:00)
Nucleated RBC Auto: 0 /100(WBCs) (05/15/24 04:24:00)
Nucleated RBC Auto: 0 /100(WBCs) (05/14/24 15:47:00)
Differential Type: Auto (05/15/24 04:24:00)
Differential Type: Auto (05/14/24 15:47:00)
Immature Granulocytes: 0.2 % (05/15/24 04:24:00)
Immature Granulocytes: 0.2 % (05/14/24 15:47:00)
Neutrophil % Auto: 64.5 % (05/15/24 04:24:00)
Neutrophil % Auto: 78.2 % (05/14/24 15:47:00)
Lymphocyte % Auto: 24.8 % (05/15/24 04:24:00)
Lymphocyte % Auto: 13.8 % (05/14/24 15:47:00)
Monocyte % Auto: 8.4 % (05/15/24 04:24:00)
Monocyte % Auto: 6.9 % (05/14/24 15:47:00)
Eosinophil % Auto: 1.3 % (05/15/24 04:24:00)
Eosinophil % Auto: 0.3 % (05/14/24 15:47:00)
Basophil % Auto: 0.8 % (05/15/24 04:24:00)
Basophil % Auto: 0.6 % (05/14/24 15:47:00)
Immature Granulocyte, Abs: 0.02 K/mcL (05/15/24 04:24:00)
Immature Granulocyte, Abs: 0.03 K/mcL (05/14/24 15:47:00)
Neutrophil, Abs: 5.8 K/mcL (05/15/24 04:24:00)
Neutrophil, Abs:Â 10.3 K/mcLÂ High (05/14/24 15:47:00)
Lymphocyte, Abs: 2.2 K/mcL (05/15/24 04:24:00)
Lymphocyte, Abs: 1.8 K/mcL (05/14/24 15:47:00)
Monocyte, Abs: 0.8 K/mcL (05/15/24 04:24:00)
Monocyte, Abs: 0.9 K/mcL (05/14/24 15:47:00)
Eosinophil, Abs: 0.1 K/mcL (05/15/24 04:24:00)
Eosinophil, Abs: 0 K/mcL (05/14/24 15:47:00)
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Basophil, Abs: 0.1 K/mcL (05/15/24 04:24:00)
Basophil, Abs: 0.1 K/mcL (05/14/24 15:47:00)
Plt Est: Agrees with count (05/14/24 15:47:00)
RBC Morph: Slide review agrees with reported RBC indices. (05/14/24 15:47:00)
Bld Smear Scan: Slide reviewed and is in agreement with auto differential (05/14/24 15:47:00)
Plts, Large: Observed Abnormal (05/14/24 15:47:00)
Chemistry
Sodium Level:Â 136 mmol/LÂ Low (05/15/24 04:24:00)
Sodium Level:Â 135 mmol/LÂ Low (05/14/24 15:47:00)
Potassium Level: 3.6 mmol/L (05/15/24 04:24:00)
Potassium Level:Â 3.1 mmol/LÂ Low (05/14/24 15:47:00)
Chloride Level: 106 mmol/L (05/15/24 04:24:00)
Chloride Level:Â 100 mmol/LÂ Low (05/14/24 15:47:00)
CO2:Â 17 mmol/LÂ Low (05/15/24 04:24:00)
CO2:Â 18 mmol/LÂ Low (05/14/24 15:47:00)
Anion Gap (Na Cl CO2): 12 mmol/L (05/15/24 04:24:00)
Anion Gap (Na Cl CO2):Â 18 mmol/LÂ High (05/14/24 15:47:00)
Glucose Level: 80 mg/dL (05/15/24 04:24:00)
Glucose Level:Â 123 mg/dLÂ High (05/14/24 15:47:00)
BUN:Â 7 mg/dLÂ Low (05/15/24 04:24:00)
BUN: 10 mg/dL (05/14/24 15:47:00)
Creatinine Level: 0.8 mg/dL (05/15/24 04:24:00)
Creatinine Level: 0.95 mg/dL (05/14/24 15:47:00)
est CrCl (Ideal BW for dosing): 88.89 mL/min (05/15/24 04:24:00)
est CrCl (Ideal BW for dosing): 74.86 mL/min (05/14/24 15:47:00)
est CrCl (Actual BW for dosing): 146.79 mL/min (05/15/24 04:24:00)
est CrCl (Actual BW for dosing): 123.62 mL/min (05/14/24 15:47:00)
Creatinine GFR: 105 mL/min/1.73 m2 (05/15/24 04:24:00)
Creatinine GFR: 85 mL/min/1.73 m2 (05/14/24 15:47:00)
Cmt: GFR: See Comments (05/14/24 15:47:00)
Calcium Level: 8.9 mg/dL (05/15/24 04:24:00)
Calcium Level: 9.7 mg/dL (05/14/24 15:47:00)
Protein Total: 6.6 g/dL (05/15/24 04:24:00)
Protein Total:Â 8.6 g/dLÂ High (05/14/24 15:47:00)
Albumin Level: 3.6 g/dL (05/15/24 04:24:00)
Albumin Level: 4.7 g/dL (05/14/24 15:47:00)
Bilirubin Total: 0.3 mg/dL (05/15/24 04:24:00)
Bilirubin Total: 0.3 mg/dL (05/14/24 15:47:00)
Alk Phos: 47 unit/L (05/15/24 04:24:00)
Alk Phos: 59 unit/L (05/14/24 15:47:00)
AST: 32 unit/L (05/15/24 04:24:00)
AST: 33 unit/L (05/14/24 15:47:00)
ALT: 24 unit/L (05/15/24 04:24:00)
ALT: 24 unit/L (05/14/24 15:47:00)
Beta-Hydroxybutyrate:Â 1.9 mmol/LÂ High (05/14/24 15:47:00)
Lactic Acid, Plasma (Venous): 1.2 mmol/L (05/14/24 19:05:00)
Magnesium Level: 2.1 mg/dL (05/14/24 15:47:00)
Phosphorus Level: 2.8 mg/dL (05/14/24 15:47:00)
Troponin T Gen 5: <6 (05/14/24 15:47:00)
Troponin T Gen 5 Delta: No calculation (05/14/24 15:47:00)
Cmt: Troponin T Gen 5: See Comments (05/14/24 15:47:00)
N-Terminal proBNP: <36 (05/14/24 19:05:00)
Cmt: N-Terminal proBNP: See Comments (05/14/24 19:05:00)
TSH: 2.59 mcIU/mL (05/14/24 15:47:00)
Urinalysis
Collect Method, Ur: Urine Clean Catch (05/14/24 20:10:00)
Color Urine: Normal (05/14/24 20:10:00)
Appear: Normal (05/14/24 20:10:00)
Specific Gravity, Urine: <1.006 (05/14/24 20:10:00)
pH Urine: 5.5 (05/14/24 20:10:00)
Glucose Urine: Negative (05/14/24 20:10:00)
110 to 142
10/24/2024 Continuity of Care Document
UA Ketones: >=80(3+) Abnormal (05/14/24 20:10:00)
Nitrite: Negative (05/14/24 20:10:00)
Hgb Urine: Negative (05/14/24 20:10:00)
Protein Urine: Trace Abnormal (05/14/24 20:10:00)
Leuk Esterase: Negative (05/14/24 20:10:00)
WBC Urine: 0 /HPF (05/14/24 20:10:00)
RBC Urine: 1 /HPF (05/14/24 20:10:00)
Epithelial Cells: 5 /HPF (05/14/24 20:10:00)
Bacteria Urine: Negative (05/14/24 20:10:00)
Mucus Urine: 1+ Abnormal (05/14/24 20:10:00)
Hyaline Cast: Negative (05/14/24 20:10:00)
Urine Culture Ordered?: No (05/14/24 20:10:00)
Coagulation/Thrombosis
D-dimer, quant. (ug/mL): 0.49 mcg FEU/mL (05/14/24 15:47:00)
Blood Gases
Blood Gas Specimen Source: Arterial (05/14/24 16:46:00)
HCO3: 20.1 mmol/L (05/14/24 16:46:00)
pH Ven: 7.405 (05/14/24 16:46:00)
pCO2 Ven: 32.8 mmHg Low (05/14/24 16:46:00)
pO2 Ven: 27.3 mmHg (05/14/24 16:46:00)
pO2 Temp Corrected Ven: 27 (05/14/24 16:46:00)
O2 Saturation Ven: 39 % (05/14/24 16:46:00)
O2 Hgb Ven: 38.4 % (05/14/24 16:46:00)
O2 Content Ven: 5.3 (05/14/24 16:46:00)
FiO2: 21 (05/14/24 16:46:00)
Base Excess Whole Blood: -3.5 mmol/L (05/14/24 16:46:00)
Carboxyhemoglobin: 0.9 % (05/14/24 16:46:00)
Methemoglobin: 0.6 % (05/14/24 16:46:00)
Barometric Pressure: 642 mmHg (05/14/24 16:46:00)
Temperature C: 37 (05/14/24 16:46:00)
pH Temp Corrected Ven: 7.405 (05/14/24 16:46:00)
pCO2 Temp Corrected Ven: 32.8 (05/14/24 16:46:00)
Critical Value Type: Printed Report given (05/14/24 16:46:00)
Crtiical Value Notification Date: 05/14/2024 (05/14/24 16:46:00)
Critical Value Notification Time: 16:49 (05/14/24 16:46:00)
Critical Value Notification to: Jamie Matgzer RN (05/14/24 16:46:00)
Performed by: hry08930 (05/14/24 16:46:00)
Blood Gas Draw Type: Venous (05/14/24 16:46:00)
Blood Gas Draw Time: 05/14/24 16:46:00 (05/14/24 16:46:00)
Blood Gas Drawn By: Drawn by RN/Lab/OR (05/14/24 16:46:00)

Medications
Inpatient
Artificial Tears preservative-free ophthalmic solution, 1 drops, Eye-Both, every 2 hr, PRN
hydrALAZINE, 10 mg= 0.5 mL, IV Push, every 4 hr, PRN
hydrOXYzine, 50 mg= 2 tabs, Oral, BID, PRN
LR drip 1,000 mL, 1000 mL, IV Drip
melatonin, 3 mg= 1 tabs, Oral, Daily at bedtime, PRN
MiraLax, 17 g= 1 EA, Oral, BID, PRN
Senna S, 1 tabs, Oral, BID, PRN
traZODone, 50 mg= 1 tabs, Oral, Daily at bedtime
Tums 500 (calcium carbonate 500 mg (elemental Ca 200 mg)) oral tab, chewable, 1 tabs, Oral, every 6 hr, PRN
Tylenol, 500 mg= 1 tabs, Oral, every 4 hr, PRN
Zofran, 4 mg= 2 mL, IV Push, every 6 hr, PRN
Home
hydrOXYzine hydrochloride 50 mg oral tablet, 50 mg= 1 tabs, Oral, BID, PRN
Sprintec, 1 tabs, Oral, Daily
traZODone 50 mg oral tablet, 50 mg= 1 tabs, Oral, Daily at bedtime
Vyvanse 70 mg oral capsule, 70 mg= 1 cap, Oral, every morning
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10/24/2024 Continuity of Care Document
Oxygen Settings
Oxygen Therapy: Room air (05/15/24 02:32:00)
Oxygen Therapy: Room air (05/14/24 23:43:00)
Oxygen Therapy: Room air (05/14/24 22:50:00)
Oxygen Therapy: Room air (05/14/24 18:53:00)
Oxygen Therapy: Room air (05/14/24 18:33:00)
Allergies
No Known Medication Allergies
No Known Allergies
Imaging Results (Last 24 Hours)
CT Angio Pulmonary
Â
05/14/24 16:46:00
IMPRESSION:
1. No evidence of acute or chronic pulmonary embolism
2. See above for other findings
Â
Â
Â
 This report was electronically signed by John S. Collins, MD on
5/14/2024 5:35 PM.
Â
Signed By: COLLINS, MD, JOHN S.
Code Status
Resuscitation Status* - OrderedÂ
 -- 05/14/24 18:49:00 MDT, Full Code, 05/14/24 18:49:00 MDT

Electronically Signed on 05/15/24 08:12 PM

________________________________________________________
HOLLADAY, DO, NADIA
DALY, DO, SARAH W: PERFORM
Event Display: Progress Note Generic
Authored Date: 20240515201935-0600

I have seen and examined this patient, and I reviewed the above note and agree with the Resident's findings,
assessment, and plan.

echo pending

Sarah Daly, DO, FAAFP

Electronically Signed on 05/15/24 08:19 PM

________________________________________________________
DALY, DO, SARAH W

Note

PITCHER, DO, MATTHEW: PERFORM, MODIFY

PAYNE, MD, DANIEL M.: MODIFY
Event Display: Psychiatric Assessment Note
Authored Date: 20210119130653-0700

Chief Complaint
Taken to ED by EMS, found in a parking lot. Unable to contract for safety.
Assessment
Sarah Nielson is a 22-year-old female with a past medical history of PTSD who presented to the ED via
EMS yesterday after being found confused and somewhat nonverbal in a parking lot after unintentional sedation
and presumed a victim of sexual assault. Patient has had more stability as of late than she had been experiencing
when she was last here November 2020. She is not expressing any thoughts of suicide at this point, mental status
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10/24/2024 Continuity of Care Document
has improved significantly. Â Patient is requesting discharge, stating that she wants to continue through with plans
to have a court hearing that is scheduled to consider restraining order against her mother. She states that she
feels like she is doing okay considering what she is gone through. Patient also requesting a rape examination and
this will be performed prior to discharge.
Psychosocial Strengths: Attending Treatment
Psychosocial Disabilities: None
Clinical Global Impression: Moderately Ill (4)
Anticipated Discharge Date: 01/29/21
Diagnosis/Treatment Plan
1. Confusion
 Patient was found reportedly confused and nonverbal. Etiology may be secondary unintentional sedative
ingestion from assaulting person. Alcohol intoxication less likely based on BAC. Psychosis/catatonia unlikely in
setting of patient having normal mental status exam this morning. Patient also did state that she was
intentionally not communicating with providers in the emergency room due to not wanting to discuss alleged
assault.
- Resolved. No concern for psychosis
Â
2. Sexual assault of adult
 - Pt will have rape exam performed today
- SW working with patient to provide appropriate legal option education
- Medical management as above
Â
3. Alcohol use
 Patient has a history of alcohol use however claims that she has not had a drink prior to last night in
approximately 3 months.
-Patient should continue to meet with therapist regularly and attend outpatient therapy at Phoenix recovery center
Â
4. Depression, major, recurrent, moderate
 Chronic. Per patient report today, does not appear that there is an acute exacerbation or signs of depressive
episode. No SI Patient has home medication of Escitalopram 15 mg daily and is reportedly stable.
-Continue home medication regimen.
Â
5. Bicuspid aortic valve
 Chronic.  Stable.  No changes or management at this time
Â
6. Post traumatic stress disorder (PTSD)
 Patient has history of PTSD with multiple traumatic life events and inciting factors.
-Management as above
 7. Will follow-up with outpatient behavioral health treatment team. Discussed with the patient the importance of
following up within 7 days after discharge and patient expressed understanding of this and agreed to follow-up within
that time.
 8. Crisis plan reviewed: If in distress or symptoms worsen, patient will utilize available coping skills, talk to family
or friends, contact outpatient providers, or in the event of emergencies or suicidal ideations with intent or plan, patient
will contact 911 or present to the nearest ER.
 Follow Up Appointments
Will be scheduled prior to discharge.  Patient attending PHP at Phoenix recovery center on a weekday basis.
Subjective
History of Present Illness
Sarah Nielson is a 22-year-old female with a past medical history of PTSD who presented to the ED via
EMS yesterday after being found confused and somewhat nonverbal in a parking lot. Per patient report, she is
currently living in Clinton Utah and drives down to Phoenix recovery center in Provo every single day to receive
therapy. She notes that after she was discharged from inpatient psychiatric service in November, she lived in
the Phoenix recovery rental house unit on January 4, she was transitioned to the outpatient program and now
lives with her friend.  She goes to therapy every day for approximately 5 hours and endorses good attendance.Â
Per the patient report, yesterday morning, she went to therapy, finished around 2 PM, and then met up with a male
who she met online. She notes that she got his car and together they began drinking. She endorses drinking 2
" Beer bottle size" beverages.  She is on sure what type of beverage it was. She notes that she open the first
bottle herself but did not open the second one herself. She reports that she remembers drinking these beverages
and does not remember much after that until she woke up with a bump on her forehead in a parking lot. She
reports being very confused and scared and texted her outpatient therapist who told her to call 911. She does not
remember much about when please came except that there were "a lot of feet".  Patient states that she also did
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10/24/2024 Continuity of Care Document
not want to discuss possibility of sexual assault with staff in the emergency room, but now requesting rape exam.
 Currently, she denies any suicidal ideation or depression. She denies any confusion at this time.  She notes
that she is very stressed out and noted that she was also stressed out yesterday. When asked why she is
stressed, after a long contemplation period, she expresses that it is primarily oriented around that she is supposed
to meet with her lawyer today and be in court tomorrow for issues regarding a restraining order against her
mother.
Â
Of note, the patient endorses minimal drinking at baseline and says this is the first time she has drank since she was
discharged in November. She says she only has drank a couple times in the last 4 years. She denies any
current recreational drug use including marijuana, or cocaine.  She denies any tobacco use.  Patient reports in
the past she has tried medications such as Zoloft, Lexapro, Seroquel, trazodone, Ambien, Vistaril, Intuniv, Vyvanse,
Zyprexa, Adderall, Ritalin, Concerta.  Does have a history of stimulant abuse to avoid sleep and has also abused
stimulants to lose weight. Patient reports highest level of education is high school. Patient has a history of
PTSD and reports reports physical abuse from her stepdad age 15-17 years old as well sexual abuse from a
cousin in Brazil lasting 6 months to year.  Currently, she denies symptoms of psychosis, or mania.Â
Â
We engaged in individual therapy for 16 minutes using supportive and motivational therapies discussing the patient's
safety plan, in order to reduce the patient's risk being unable to maintain the stability they have gained while in the
hospital. We discussed the patient's reasons for compliance with their medication regimen. The patient said they
would continue working on utilizing outpatient supports. I suggested working on improving working with outpatient
providers. The patient agreed to work on maintaining a safe environment. Overall, the patient engaged well in
therapy and responded well with improved hope and future oriented thinking.
 PMH:
Coarctation of aorta status post repair.
Â
PSH:
Anorexia nervosa, ADD, borderline personality disorder, MDD, GAD, PTSD, history of suicide attempts.
 Allergies:
No known drug allergies
Â
Family history:
Noncontributory
 Social history:
Lives with friend in Clinton Utah
Denies alcohol, tobacco, recreational drug use
Currently unemployed and looking for a job
Past Psychiatric History
Treatment #1 Diagnosis and Treatment: 3 hospitalizations due to 3 OD's in suicide attempt/interrupted.
Treatment #1 Illness Date: september-october 2020
Treatment #2 Diagnosis and Treatment: Devin, PA med management
Treatment #2 Illness Date: 2020
Treatment #3 Diagnosis and Treatment: Charity holton at integrated counseling and wealth in draper utah.
Treatment #3 Illness Date: 2020
Objective
Vitals & Measurements
T: 36.4 °C (Temporal Artery) HR: 80(Peripheral) RR: 16 BP: 115/80 SpO2: 99%Â
HT: 163 cm WT: 83.8 kg BMI: 31.54Â
Physical Exam
GENERAL: alert and oriented, no distress.
HEENT: no LAD, neck supple
LUNGS:Â non-labored breathing,
SKIN: Well perfused, no rashes, lesions.
NEURO: No focal deficit
Mental Status Exam
Mental Status Exam
General Appearance:Â Appropriately dressed and groomed
Behavior:Â Agitated
Orientation:Â Alert and oriented x4
Recent and Remote Memory: Intact
Gait/Station: Within normal limits
Musculoskelatal Strength/Tone:Â Observed muscle strength/tone within normal limits
114 to 142
10/24/2024 Continuity of Care Document
Mood/Affect: "Good" /Â Mildly constricted
Speech:Â Normal
Thought Process:Â Logical and goal directed
Associations:Â Intact
Thought Content:Â Non-psychotic
Attention/Concentration:Â Grossly intact attention
Insight/Judgement:Â Good
Language: Within normal limits
Fund of Knowledge: Awareness of Current Events
Risk Assessment
Activating Events (recent): Current or pending isolation or feeling alone
Treatment History: Previous psychiatric diagnoses and treatments
Protective Factors: Identifies reason for living
Non Modifiable Risk Factors: Adverse childhood experiences
Action Plan: Continue inpatient hospitalization
Risk for Harm to Others: Not currently
Homicide Ideation: None
Assault Ideation: None
Lifetime Wish to be Dead: Lifetime, yes (01/19/21)
Lifetime Suicidal Thoughts: Lifetime, yes (01/19/21)
Lifetime Suicidal Behavior: Lifetime, yes (01/19/21)
Lifetime Ideation with Method No Intent: Lifetime, yes (01/19/21)
Lifetime Ideation with Intent No Plan: Lifetime, yes (01/19/21)
Lifetime Ideation with Intent and Plan: Lifetime, yes (01/19/21)
Past Month Columbia Suicide Severity Rating
Past Month Wish to be Dead: Past month, yes (01/19/21)
Past Month Suicidal Thoughts: Past month, no (01/19/21)
Past Month Ideation w-Method No Intent: Past month, no (01/19/21)
Past Month Ideation with Intent No Plan: Past month, no (01/19/21)
Past Month Ideation with Intent and Plan: Past month, no (01/19/21)
Columbia Screen Suicide Behavior: No (01/19/21)
CSSRS Screen Suicide Behavior Timeline: Within last 3 months (01/19/21)
CSSRS Suicidal Risk Level: Low (01/19/21)
Suicide Prevention Assessed Risk: High (01/19/21)
Total Unit Time/Complexity
$$ Psychotherapy, 30 minutes with Patient, Â with E/M Service 90833 - OrderedÂ
 -- 01/19/21 13:03:00 MST, Post traumatic stress disorder (PTSD) | Sexual assault of adult | Confusion
$$ Same Day Admit/Discharge, Moderate Severity 99235 - OrderedÂ
 -- 01/19/21 13:03:00 MST, Post traumatic stress disorder (PTSD) | Sexual assault of adult | Confusion
Problem List/Past Medical History
Ongoing
Alcohol use
Anorexia nervosa, restricting type, moderate
Attention deficit disorder (ADD) in adult
Bicuspid aortic valve
Borderline personality disorder
Depression, major, recurrent, moderate
GAD (generalized anxiety disorder)
Nightmares
Post traumatic stress disorder (PTSD)
PTSD (post-traumatic stress disorder)
S/P repair of coarctation of aorta
Suicide attempt
Medications
Inpatient
Benadryl, 50 mg= 2 EA, Oral, every 6 hr, PRN
cloNIDine, 0.2 mg= 1 tabs, Oral, Daily at bedtime
cloNIDine, 0.1 mg= 1 tabs, Oral, every 8 hr, PRN
escitalopram, 15 mg= 1.5 tabs, Oral, Daily
gabapentin, 300 mg= 1 cap, Oral, TID
loperamide, 4 mg= 2 cap, Oral, Once, PRN
115 to 142
10/24/2024 Continuity of Care Document
loperamide, 2 mg= 1 cap, Oral, As Directed PRN, PRN
Milk of Magnesia 8% oral suspension, 30 mL, Oral, every 8 hr, PRN
Mylanta, 30 mL, Oral, QID, PRN
nicotine 2 mg oral transmucosal gum, 2 mg= 1 EA, Buccal, every 1 hr, PRN
Topamax, 25 mg= 1 tabs, Oral, Daily at bedtime
Tylenol, 650 mg= 2 tabs, Oral, every 6 hr, PRN
Vistaril, 50 mg= 1 cap, Oral, every 4 hr, PRN
Vistaril, 50 mg= 1 cap, Oral, Daily at bedtime, PRN
Zofran, 4 mg= 1 tabs, Oral, every 6 hr, PRN
ZyPREXA, 10 mg= 1 vials, IntraMuscular, every 4 hr, PRN
ZyPREXA Zydis, 10 mg= 1 tabs, Oral, every 4 hr, PRN
Home
atomoxetine 40 mg oral capsule, 40 mg= 1 cap, Oral, BID
cloNIDine 0.2 mg (200 mcg) oral tablet, 0.2 mg= 1 tabs, Oral, Daily at bedtime, PRN
doxepin 10 mg/mL oral concentrate, 0.6-1 mL, Oral, Daily at bedtime, PRN
escitalopram 10 mg oral tablet, 15 mg= 1.5 tabs, Oral, Daily
gabapentin 300 mg oral capsule, 300 mg= 1 cap, Oral, TID
prazosin 1 mg oral capsule, 1 mg= 1 cap, Oral, Daily at bedtime
ramelteon 8 mg oral tablet, 8 mg= 1 tabs, Oral, Daily at bedtime
topiramate 50 mg oral tablet, 50 mg= 1 tabs, Oral, Daily at bedtime
Allergies
No Known Medication Allergies
Social History
Alcohol - 10/31/2020
Use: Never used.
Employment/School - 10/31/2020
Status: Employed. Place of occupation/business: Pet grooming. Highest education level: High school.
Employed
Home/Environment - 10/31/2020
Lives with: Friend and her family.
Substance Use - 10/31/2020
Use, other than prescribed: Never used. Date last used: CBD once.
Tobacco - 10/31/2020
Use: Never smoker.
Use: Never smoker.
Family History
Anxiety: Grandmother (M) and Sibling.
Arrhythmia (cardiac) NOS: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
CHD - Congenital heart disease: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Cancer: Father, Grandfather (P) and Grandmother (P).
Cancer: Father.
Depression: Grandmother (M), Sibling and Sibling.
Drug addiction: Sibling and Sibling.
Emotional problems: Sibling.
Heart attack: Grandmother (M).Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Hyperlipidemia: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Substance Use: Sibling and Sibling.
Sudden cardiac death: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Suicidal behavior: Sibling and Sibling.
Other Information
NIDA:
NIDA Screening Objective: Patient accepts, document NIDA
MHI Adult alcohol use yes no: No
MHI adult rx non med yes no: No
MHI adult rx drug yes no: No
MHI adult street drugs yes no: Yes
Psychotherapy Summary:
BEH Recommended Level of Care: Residential treatment

Electronically Signed on 01/19/21 01:06 PM

________________________________________________________
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10/24/2024 Continuity of Care Document
PITCHER, DO, MATTHEW

History and physical note

GROVER, MD, STEVEN M.: PERFORM

Event Display: History and Physical
Authored Date: 20240918074452-0600

Vitals and Measurements

HT: 160 cm BMI: 25Â

PHQ2 Little Interest/Pleasure in Doing: More than half the days (09/05/24)
PHQ2 Feeling Down, Depressed or Hopeless: More than half the days (09/05/24)
PHQ-2 Score: 2 (08/22/24)
PHQ9 Score
PHQ-9 Total Severity Score: 4 (08/22/24)
EPDSÂ
No qualifying data available.
Note
Chief Complaint
lower abdominal pain
Assessment/Plan
1. Female pelvic pain
2. Bicornate uterus
Presenting Problem: constant pelvic pain.
Â
DD:
Â
1. Endometriosis.
Â
Problem list: OCP has not been helping with treating the pelvic pain. Bicornate uterus.
Â
Testing:
Â
1. laparoscopy.
Â
Patient education: educated patient on why they likely have endometriosis and how performing surgery may improve
her symptoms.
Â
Follow up: patient to schedule surgery. Will think about it.
Â
It would also be reasonable to consider doing a colonoscopy to make sure that there is not a gastrointestinal cause for
her lower abdominal pain.
History of Present Illness
Pain is pretty much every day. Scale of 1-10, she describes it as a 7 or 8. Ibuprofen doesn't really help. Heating pad
helps a little, but not much. Using back to back OCP. November to now: OCP hasn't really made a difference in
improving pain. Pain is localized to umbilicus down to the vagina. No consistent GI symptoms. No rectal bleeding
Physical Exam
   Vitals & Measurements
  HR: 96(Peripheral) BP: 126/96 SpO2: 98%Â
  HT: 162 cm WT: 90.5 kg BMI: 34.48Â
Ultrasound report: bicornate uterus.
Â
Pelvic exam: normal. Slight tenderness to palpation. No adnexal masses
Â
Â
I reviewed her ultrasound from November 6, 2023 showing bicornuate uterus but otherwise negative
PHQ2 Little Interest/Pleasure in Doing: Nearly every day (08/07/24)
PHQ2 Feeling Down, Depressed or Hopeless: Several days (08/07/24)
PHQ-2 Score: 4 (08/07/24)
PHQ9 Score
117 to 142
10/24/2024 Continuity of Care Document
PHQ-9 Total Severity Score: 11 (08/07/24)
 _____
Patient's Age
DOB: 12/06/1998AGE: 25 Years
Medications
    hydrOXYzine hydrochloride 50 mg oral tablet, 50 mg= 1 tabs, Oral, TID, PRN
  levothyroxine 100 mcg (0.1 mg) oral capsule, 100 mcg= 1 cap, Oral, Daily, 2 refills
  Semaglutide (Eqv-Ozempic 2 mg/3 mL) (0.25 mg or 0.5 mg dose) subcutaneous solution, 0.5 mg, SubCutaneous,
every week, 1 refills
  Sprintec, 1 tabs, Oral, Daily
  traZODone 50 mg oral tablet, 50 mg= 1 tabs, Oral, Daily at bedtime
  Vyvanse 70 mg oral capsule, 70 mg= 1 cap, Oral, every morning
Â
Â
Allergies
No Known Medication Allergies
No Known Allergies
Problem List/Past Medical History
 Ongoing
  Anemia
  Anorexia nervosa, restricting type, in partial remission, moderate
  Anorexia nervosa, restricting type, moderate
  Attention deficit disorder (ADD) in adult
  Bicornate uterus
  Bicuspid aortic valve
  BMI 35.0-35.9,adult
  Borderline personality disorder
  Class 2 obesity
  Fatigue
  Female pelvic pain
  Menorrhagia
  Morbid obesity
  PTSD (post-traumatic stress disorder)
  Recurrent major depression-severe
  S/P repair of coarctation of aorta
  Syncope
Procedure/Surgical History
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE
Esophagogastroduodenoscopy (auto-populated from documented surgical case)
Transcatheter intracardiac shunt (TIS) creation by stent placement for congenital cardiac anomalies
Gynecological History
Last Menstrual Period: 06/03/16
Â
No qualifying data available.
No qualifying data available.
Â
Â
Â
 Obstetric History
Pregnancy History   G0 P0(0,0,0,0)   Â
Â
  No previous pregnancies history have been recorded
Family History
  Anxiety: Grandmother (M) and Sibling.
  Arrhythmia (cardiac) NOS: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
  CHD - Congenital heart disease: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
  Cancer: Father.
  Cancer: Father, Grandfather (P) and Grandmother (P).
  Depression: Grandmother (M), Sibling and Sibling.
  Drug addiction: Sibling and Sibling.
  Emotional problems: Sibling.
118 to 142
10/24/2024 Continuity of Care Document
  Heart attack: Grandmother (M).Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
  Hyperlipidemia: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
  Substance Use: Sibling and Sibling.
  Sudden cardiac death: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
  Suicidal behavior: Sibling and Sibling.
Social History
  Alcohol - 06/19/2024
   Use: Never used.
  Use: Never used. Household alcohol concerns: No.
  Use: Never used.
  Use: Never used.
  Employment/School - 06/19/2024
   Status: Employed. Place of occupation/business: Pet grooming. Highest education level: High school.
  Employed
  Home/Environment - 06/19/2024
   Lives with: Friend and her family.
  Substance Use - 06/19/2024
   Use, other than prescribed: Never used.
  Use, other than prescribed: Never used. Concerns about substance abuse in household: No.
  Use, other than prescribed: Never used. Date last used: CBD once.
  Tobacco - 06/19/2024
   Use: Never smoker (less than 100 in lifetime).
  Use: Never smoker (less than 100 in lifetime).
  Use: Never smoker (less than 100 in lifetime).
  Use: Never smoker (less than 100 in lifetime).
  Use: Never smoker (less than 100 in lifetime).
  Use: Never smoker (less than 100 in lifetime).
  Use: Never smoker.
  Use: Never smoker.
  Use: Never smoker.
Ordered:
acetaminophen, 1,000 mg, Oral, PREOP, Tab, First Dose: 09/18/24 7:34:00 MDT
CeleBREX, 200 mg, Oral, PREOP, Cap, First Dose: 09/18/24 7:34:00 MDT
lactated ringer's drip 1,000 mL, IV Drip, Order Rate: 30 mL/hr, Order Weight: 88.1 kg, Start Date: 09/18/24 7:04:00 MDT
scopolamine 1 mg/72 hr transdermal film, extended release, 1 patches, Topical, PREOP, Patch, First Dose: 09/18/24
7:34:00 MDT
Clinitek Status Point of Care Testing
Confirm Beta Blocker Status
Criteria-Based EKG Preoperative
Criteria-Based Labs Day of Surgery
Forced Air Blanket*
HCG, Urine (POCT)
NPO (Perioperative/Ambulatory - Does NOT go to Nutrition Services)
OSA Screening Tool
Peripheral IV Insert/Maintain*
Preoperative Surgical Prep Instruction
Pulse Oximetry - Spot Check*
Resuscitation Status*
Vital Signs
Weight*

Problem List/Past Medical History

Ongoing
Anemia
Anorexia nervosa, restricting type, in partial remission, moderate
Anorexia nervosa, restricting type, moderate
Attention deficit disorder (ADD) in adult
Bicornate uterus
Bicuspid aortic valve
BMI 35.0-35.9,adult
Borderline personality disorder
119 to 142
10/24/2024 Continuity of Care Document
Class 2 obesity
Fatigue
Female pelvic pain
Menorrhagia
Morbid obesity
PTSD (post-traumatic stress disorder)
Recurrent major depression-severe
S/P repair of coarctation of aorta
Syncope
Procedure/Surgical History
EGD TRANSORAL BIOPSY SINGLE/MULTIPLE
Esophagogastroduodenoscopy (auto-populated from documented surgical case)
Transcatheter intracardiac shunt (TIS) creation by stent placement for congenital cardiac anomalies (surgery as an
infant/toddler)
Medications
acetaminophen, 1000 mg= 2 tabs, Oral, PREOP
CeleBREX, 200 mg= 1 cap, Oral, PREOP
hydrOXYzine hydrochloride 50 mg oral tablet, 50 mg= 1 tabs, Oral, TID, PRN
lactated ringer's drip 1,000 mL, 1000 mL, IV Drip
levothyroxine 100 mcg (0.1 mg) oral capsule, 100 mcg= 1 cap, Oral, Daily, 2 refills,  Not taking: not planning on
taking
scopolamine 1 mg/72 hr transdermal film, extended release, 1 patches, Topical, PREOP
Semaglutide (Eqv-Ozempic 4 mg/3 mL) (1 mg dose) subcutaneous solution, 1 mg, SubCutaneous, every week, 3 refills
Sprintec, 1 tabs, Oral, Daily
traZODone 50 mg oral tablet, 50 mg= 1 tabs, Oral, Daily at bedtime
Vyvanse 70 mg oral capsule, 70 mg= 1 cap, Oral, every morning
Allergies
Lactose (milk bothers my gut, GI Reaction)
No Known Medication Allergies
Social History
Alcohol - 09/13/2024
Use: Never used.
Use: Never used. Household alcohol concerns: No.
Use: Never used.
Use: Never used.
Employment/School - 09/13/2024
Status: Employed. Place of occupation/business: Pet grooming. Highest education level: High school.
Employed
Home/Environment - 09/13/2024
Lives with: Friend and her family.
Substance Use - 09/13/2024
Use, other than prescribed: Never used.
Use, other than prescribed: Never used. Concerns about substance abuse in household: No.
Use, other than prescribed: Never used. Date last used: CBD once.
Tobacco - 09/13/2024
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker.
Use: Never smoker.
Use: Never smoker.
Family History
Anxiety: Grandmother (M) and Sibling.
Arrhythmia (cardiac) NOS: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
CHD - Congenital heart disease: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Cancer: Father.
Cancer: Father, Grandfather (P) and Grandmother (P).
Depression: Grandmother (M), Sibling and Sibling.
Drug addiction: Sibling and Sibling.
Emotional problems: Sibling.
Heart attack: Grandmother (M).Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Hyperlipidemia: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Substance Use: Sibling and Sibling.
120 to 142
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Sudden cardiac death: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Suicidal behavior: Sibling and Sibling.
Lab Results
hCG Ur: Negative
Imaging Results (Last 24 Hours)
No qualifying data available.
ECG (Last 12 Hours)
No qualifying data available.

Electronically Signed on 09/18/24 07:44 AM

________________________________________________________
GROVER, MD, STEVEN M.
NELSON, MD, JORDAN ANDREW: PERFORM
Event Display: History and Physical
Authored Date: 20240514190930-0600

PCP
Primary Care Physician -
HEALEY, DO, M. AUSTIN
Chief Complaint
Syncopal episode x6 days.
History of Present Illness
Chief Complaint: Syncopal episode everyday x6 days. Denies hitting head. Pt reports she sits down when she feels
lightheaded. (05/14/24 15:33:00)
Â
HPI:
Pt is a 25 Years Female with hx of bicuspid aortic valve, aortic coarctation, anorexia nervosa, borderline personality
disorder, depression, and ADHD who presents with a 6 days of daily syncope.
Â
Per the ED physician: Has had daily syncope for past 6 days. Is tachycardic here, improved with fluids. Ddimer. Has
not followed up regarding bicuspid aortic valve and aortic coarctation. Last syncopal episode today. Not endorsing any
other acute symptoms. Intermittent urinary urgency, no back pain, no spinal trauma or IVDU. DDminer, troponin, TSH
all WNL. b-hydroxybutyrate elevated. No concern for infection.
Â
Per the patient: Patients reports first episode of syncopal event was Thursday. Notes that she has had approximately 2
episodes since that time. Reports that one episode occurred on Saturday and occurred after multiple episodes of sitting
and standing. Was told by a bystander that she was passed out for only a couple seconds. Notes that she had some
confusion following the syncopal event which lasted for a few seconds. Notes that walking, even short distances, was
difficult and caused diaphoresis, SOB, and lightheadedness. She denies any head trauma during these episodes. Denies
any extremity or truncal injury from these falls. She denies witnessed seizure like activity, tongue biting, urinary
incontinence. She does admit to urinary frequency and urgency. She admits to palpitations. She describes these
palpitations as being intermittent but worsening for the past few weeks. Was sick in early April with viral symptoms.
States that she has lost weight but unclear how much. Admits to increased appetite but reports decreased thirst. Has
glasses but doesn't wear them, feels as though vision has gotten worse. Denies acute double vision or black spots in
vision. Denies overt chest pain or pressure. Admits to nausea, vomiting, diarrhea, and constipation stating that these
have been going for 2 years. Admits to red urine but denies dysuria. Admits to pins and needles sensation throughout
entire body. States that this sensation occurs unprovoked.
Â
In the ED: Hypertensive up to 160s over 110s, tachycardic to 131, briefly tachypneic to 23, saturating well on
RA.  Labs significant for WBC 13.1, hemoglobin 9.9, platelets 587, D-dimer WNL at 0.49, sodium 135, potassium
3.1, chloride 100, bicarb 18, anion gap 18, glucose 123, beta hydroxybutyrate 1.9, troponin negative, TSH
WNL.  CTAP with no acute abnormalities, no evidence of PE. EKG showing sinus rhythm with ventricular trigeminy.
 ROS:
Constitutional: No fevers, chills, sweats
Eye: No acute visual changes
ENMT: No ear pain, nasal congestion. + sore throat over the past few weeks, reports tonsil stones
Respiratory: No shortness of breath, cough
Cardiovascular: No Chest pain, + palpitations, + syncope, + diaphoresis
Gastrointestinal: + chronic nausea, vomiting, diarrhea, constipation
Genitourinary: + hematuria
Endocrine: Negative for excessive thirst, + increased hunger
121 to 142
10/24/2024 Continuity of Care Document
Musculoskeletal: No back pain, neck pain, joint pain, muscle pain, decreased range of motion
Integumentary: No rash, pruritus, abrasions
Neurologic: Alert & oriented X 4
Psychiatric: + stable anxiety and depression
 PMH:
Anemia: (Medical)
Anorexia nervosa, restricting type, in partial remission, moderate: (Medical)
Anorexia nervosa, restricting type, moderate: (Medical)
Attention deficit disorder (ADD) in adult: (Medical)
Bicuspid aortic valve: (Medical)
Borderline personality disorder: (Medical)
Depression, major, recurrent, moderate: (Medical)
Menorrhagia: (Medical)
PTSD (post-traumatic stress disorder): (Medical)
Recurrent major depression-severe: (Medical)
S/P repair of coarctation of aorta: (Medical)
Throat pain: (Patient Stated)
Â
PSH:Â
Transcatheter intracardiac shunt (TIS) creation by stent placement for congenital cardiac anomalies to establish
effective intracardiac flow, including all imaging guidance by the proceduralist, when performed, left and right heart
diagnostic cardiac cath
Â
Allergies:
No Known Medication Allergies; No Known Allergies
Â
Medications:
Home Medications (6) Active
busPIRone , Oral, BID (NT)
hydrOXYzine hydrochloride 50 mg oral tablet 50 mg = 1 tabs, Oral
prazosin , Oral, TID (NT)
Sprintec 0.25 mg-35 mcg oral tabletÂ
Vraylar (NT)
VyvanseÂ
trazadone
Â
Social & Psychosocial Habits
Â
Alcohol
10/20/2023 Â Use:Â Never used
  Concerns about alcohol use in household: No
Â
Employment/School
02/05/2018 Â Status:Â Employed
Â
10/31/2020 Â Status:Â Employed
  Place of occupation/business: Pet grooming
  Highest education: High school
Â
Home/Environment
10/31/2020 Â Lives with:Â Friend and her family
Â
Substance Use
10/20/2023 Â Use, other than prescribed:Â Never used
  Concerns about substance abuse in household: No
Â
Tobacco
02/08/2024 Â *Smoking Tobacco Use:Â Never smoker (less than 1
Â
Occupation: Unemployed
Alcohol: Denies use
122 to 142
10/24/2024 Continuity of Care Document
Tobacco: Denies use
Drugs: Denies use
Â
Lives with roommates in apartment
 FH:
Â
Father (Deceased): Cancer; Cancer
Grandmother (M): Anxiety; Depression; Heart attack
Sibling: Anxiety; Depression; Drug addiction; Emotional problems; Substance Use; Suicidal behavior
Sibling: Depression; Drug addiction; Substance Use; Suicidal behavior
Grandmother (P) (Deceased): Cancer
Grandfather (P): Cancer
Â
Current Vitals
T:Â 35.7 degCÂ (Temporal) HR:Â 118Â (Peripheral) RR:Â 14 BP:Â 155/106 SpO2:Â 100%
HT: 160 cm WT: 86.5 kg BMI: 33.79Â
Ideal Body Weight Calculated: 52.382 kg
Â
Physical Exam:
General:Â Alert and oriented, well nourished, no acute distress.
Eye:Â PERRL, EOMI, normal conjunctiva
HENT:Â Normocephalic, normal hearing, moist oral mucosa, no scleral icterus
Neck:Â Supple, non-tender, no JVD, no lymphadenopathy
Lungs:Â Clear to auscultation bilaterally, non-labored respiration
Heart: Tachycardic, regular rhythm, no murmur, gallop or edema
Abdomen: Soft, tenderness in LLQ, non-distended, normal bowel sounds, no masses
Musculoskeletal:Â Grossly normal range of motion and strength, no tenderness or swelling
Skin:Â Skin is warm, dry and pink, no rashes or lesions
Neurologic:Â Awake, alert, and oriented X3, CN II-XII intact
Psychiatric:Â Cooperative, appropriate mood and affect
 Labs:Â
CBCÂ
ChemistryÂ
Albumin Level: 4.7 g/dL Albumin Level: 4.7 g/dL
Alk Phos: 59 unit/L Alk Phos: 59 unit/L
ALT: 24 unit/L ALT: 24 unit/L
Anion Gap (Na Cl CO2):Â 18 mmol/LÂ High
Anion Gap (Na Cl CO2):Â 18 mmol/LÂ High
AST: 33 unit/L AST: 33 unit/L
Barometric Pressure: 642 mmHg
Beta-Hydroxybutyrate:Â 1.9 mmol/LÂ High
Base Excess Whole Blood: -3.5 mmol/L Bilirubin Total: 0.3 mg/dL
Basophil % Auto: 0.6 % BUN: 10 mg/dL
Basophil, Abs: 0.1 K/mcL Calcium Level: 9.7 mg/dL
Beta-Hydroxybutyrate:Â 1.9 mmol/LÂ High
Chloride Level:Â 100 mmol/LÂ Low
Bilirubin Total: 0.3 mg/dL Cmt: GFR: See Comments
Bld Smear Scan: Slide reviewed and is in agreement with auto differential Cmt: Troponin T Gen 5: See Comments
Blood Gas Draw Time: 05/14/24 16:46:00
CO2:Â 18 mmol/LÂ Low
Blood Gas Draw Type: Venous Creatinine GFR: 85 mL/min/1.73 m2
Blood Gas Drawn By: Drawn by RN/Lab/OR Creatinine Level: 0.95 mg/dL
Blood Gas Specimen Source: Arterial est CrCl (Actual BW for dosing): 123.62 mL/min
BUN: 10 mg/dL est CrCl (Ideal BW for dosing): 74.86 mL/min
Calcium Level: 9.7 mg/dL
Glucose Level:Â 123 mg/dLÂ High
Carboxyhemoglobin: 0.9 % Magnesium Level: 2.1 mg/dL
Chloride Level:Â 100 mmol/LÂ Low Phosphorus Level: 2.8 mg/dL
Cmt: GFR: See Comments
Potassium Level:Â 3.1 mmol/LÂ Low
Cmt: Troponin T Gen 5: See Comments
123 to 142
10/24/2024 Continuity of Care Document
Protein Total:Â 8.6 g/dLÂ High
CO2:Â 18 mmol/LÂ Low
Sodium Level:Â 135 mmol/LÂ Low
Creatinine GFR: 85 mL/min/1.73 m2 Troponin T Gen 5: <6
Creatinine Level: 0.95 mg/dL Troponin T Gen 5 Delta: No calculation
Critical Value Notification Time: 16:49 TSH: 2.59 mcIU/mL
Critical Value Notification to: Jamie Matgzer RN
Critical Value Type: Printed Report given
Crtiical Value Notification Date: 05/14/2024
D-dimer, quant. (ug/mL): 0.49 mcg FEU/mL
Differential Type: Auto
Eosinophil % Auto: 0.3 %
Eosinophil, Abs: 0 K/mcL
est CrCl (Actual BW for dosing): 123.62 mL/min
est CrCl (Ideal BW for dosing): 74.86 mL/min
FiO2: 21
Glucose Level:Â 123 mg/dLÂ High
HCO3: 20.1 mmol/L
Hematocrit: 37 %
Hemoglobin:Â 9.9 g/dLÂ Low
Immature Granulocyte, Abs: 0.03 K/mcL
Immature Granulocytes: 0.2 %
Lymphocyte % Auto: 13.8 %
Lymphocyte, Abs: 1.8 K/mcL
Magnesium Level: 2.1 mg/dL
MCH: 22.8 pg Low
MCHC:Â 30.8 g/dLÂ Low
MCV:Â 74.1 fLÂ Low
Methemoglobin: 0.6 %
Monocyte % Auto: 6.9 %
Monocyte, Abs: 0.9 K/mcL
MPV: 8.7 fL
Neutrophil % Auto: 78.2 %
Neutrophil, Abs:Â 10.3 K/mcLÂ High
Nucleated RBC Auto: 0 /100(WBCs)
O2 Content Ven: 5.3
O2 Hgb Ven: 38.4 %
O2 Saturation Ven: 39 %
pCO2 Temp Corrected Ven: 32.8
pCO2 Ven: 32.8 mmHg Low
Performed by: hry08930
pH Temp Corrected Ven: 7.405
pH Ven: 7.405
Phosphorus Level: 2.8 mg/dL
Platelets:Â 587 K/mcLÂ High
Plt Est: Agrees with count
Plts, Large: Observed Abnormal
pO2 Temp Corrected Ven: 27
pO2 Ven: 27.3 mmHg
Potassium Level:Â 3.1 mmol/LÂ Low
Protein Total:Â 8.6 g/dLÂ High
RBC: 4.99 x10^6/mcL
RBC Morph: Slide review agrees with reported RBC indices.
RDW:Â 21.7 %Â High
RDW SD:Â 55.3 fLÂ High
Sodium Level:Â 135 mmol/LÂ Low
Temperature C: 37
Troponin T Gen 5: <6
Troponin T Gen 5 Delta: No calculation
TSH: 2.59 mcIU/mL
WBC:Â 13.1 K/mcLÂ High
124 to 142
10/24/2024 Continuity of Care Document
Â
EKG:Â Sinus rhythm, ventricular trigeminy
 Imaging:
CT Angio Pulmonary
Â
05/14/24 16:46:00
IMPRESSION:
1. No evidence of acute or chronic pulmonary embolism
2. See above for other findings
 This report was electronically signed by John S. Collins, MD on
5/14/2024 5:35 PM.
Â
Signed By: COLLINS, MD, JOHN S.Â
 Code Status: Full code
 Assessment/Plan:
Pt is a 25 Years Female with hx of bicuspid aortic valve, aortic coarctation, anorexia nervosa, borderline personality
disorder, depression, and ADHD who presents with a 6 days of daily syncope. Found to
be persistently tachycardic and hypertensive with elevated white count, electrolyte abnormalities, increased
anion gap, and elevated beta hydroxybutyrate. Patient meeting SIRS criteria without obvious source of
infection although multiple symptoms suggestive of acute process. Given cardiac history and symptoms
associated with syncope patient being admitted for further monitoring and evaluation.
 1 Recurrent syncopeÂ
2 S/P repair of coarctation of aortaÂ
3 Bicuspid aortic valve
Acute, present on admission.  Patient presents with at least 2 confirmed syncopal events and multiple near
syncopal symptoms over the last 6 days of unknown etiology. Patient has a known cardiac history although she
has not had consistent follow-up beyond childhood. Patient's syncope is often accompanied by a feeling of
weakness, diaphoresis, lightheadedness, palpitations.  Denies any chest pain, shortness of breath, leg swelling,
or pain. EKG in the ED was unrevealing apart from tachycardia.  However, given her history would like
to conduct further cardiology workup.  Patient's tachycardia was slightly fluid responsive however she remained
tachycardic despite bolus.  Discussed case with on-call cardiologist, Dr. Wilkinson, who agreed to consult on
patient. Does not appear volume depleted on physical exam.  Seizure also seems less likely as patient has not had
any prolonged postictal state, urinary incontinence, or tongue biting.
– Cardiology consulted, appreciate recs
– Echocardiogram ordered
– BNP
– Continuous cardiac telemetry
– MIVF with LR at 125 mL/h
– Tylenol as needed for pain
Â
4 SIRS without infection or organ dysfunction
5 Leukocytosis
6 Metabolic acidosis
7 Hypokalemia
Acute, present admission. Patient meeting SIRS criteria with elevated white count, tachycardia, tachypnea. No
obvious source of infection however patient endorsed many symptoms on the ROS including hematuria,
abdominal pain, nausea, vomiting, diarrhea, and constipation. Physical exam with some left lower quadrant
tenderness and tachycardia but otherwise unremarkable. Beta hydroxybutyrate is elevated but glucose only 123.
– Lactic acid, UA, urine culture, and blood cultures ordered
– MIVF with LR at 125 mL/h
– Tylenol as needed for pain, fever
 8 Anemia
Chronic, present on admission.  Patient has history of menorrhagia (see below). Given Sprintec to reduce menstrual
cycles. Initial hemoglobin today of 11.4, decreased to 9.9 following fluid bolus. Given that we will be continuing to
give fluids, will need monitoring.
– Monitor daily CBC
Â
9 Anorexia nervosa, restricting type, in partial remission, moderate
Historic diagnosis. Per most recent family medicine note does not appear to be undergoing treatment or dealing
with any acute symptoms of this.
Â
125 to 142
10/24/2024 Continuity of Care Document
10 Borderline personality disorder
11 Depression, major, recurrent, moderate
12 PTSD (post-traumatic stress disorder)
13 Attention deficit disorder (ADD) in adult
Chronic, present on admission.  Patient follows with psychiatric specialist in Salt Lake City. Symptoms of these
disorders are currently stable. Takes hydroxyzine, Vyvanse, and trazodone.
– Continue home medications
 14 Menorrhagia
Chronic, present on admission. Prescribed Sprintec in November 2023 by OB/GYN to decrease menstrual
bleeding with hopes of improving anemia.Â
– Continue home medication
Â
Â
MIVF:LR @ 125@mL/hr
Diet: Regular
O2: RA, baseline RA
Tubes/lines/drains: PIV
Abx: None
Pain: Tylenol
Prophylaxis: SCDs
Dispo: Admit to medicine
 Code Status: Full code
Lab Results Hematology
WBC:Â 13.1 K/mcLÂ High (05/14/24 15:47:00)
RBC: 4.99 x10^6/mcL (05/14/24 15:47:00)
Hemoglobin:Â 9.9 g/dLÂ Low (05/14/24 16:46:00)
Hemoglobin:Â 11.4 g/dLÂ Low (05/14/24 15:47:00)
Hematocrit: 37 % (05/14/24 15:47:00)
MCV:Â 74.1 fLÂ Low (05/14/24 15:47:00)
MCH: 22.8 pg Low (05/14/24 15:47:00)
MCHC:Â 30.8 g/dLÂ Low (05/14/24 15:47:00)
RDW SD:Â 55.3 fLÂ High (05/14/24 15:47:00)
RDW:Â 21.7 %Â High (05/14/24 15:47:00)
Platelets:Â 587 K/mcLÂ High (05/14/24 15:47:00)
MPV: 8.7 fL (05/14/24 15:47:00)
Nucleated RBC Auto: 0 /100(WBCs) (05/14/24 15:47:00)
Differential Type: Auto (05/14/24 15:47:00)
Immature Granulocytes: 0.2 % (05/14/24 15:47:00)
Neutrophil % Auto: 78.2 % (05/14/24 15:47:00)
Lymphocyte % Auto: 13.8 % (05/14/24 15:47:00)
Monocyte % Auto: 6.9 % (05/14/24 15:47:00)
Eosinophil % Auto: 0.3 % (05/14/24 15:47:00)
Basophil % Auto: 0.6 % (05/14/24 15:47:00)
Immature Granulocyte, Abs: 0.03 K/mcL (05/14/24 15:47:00)
Neutrophil, Abs:Â 10.3 K/mcLÂ High (05/14/24 15:47:00)
Lymphocyte, Abs: 1.8 K/mcL (05/14/24 15:47:00)
Monocyte, Abs: 0.9 K/mcL (05/14/24 15:47:00)
Eosinophil, Abs: 0 K/mcL (05/14/24 15:47:00)
Basophil, Abs: 0.1 K/mcL (05/14/24 15:47:00)
Plt Est: Agrees with count (05/14/24 15:47:00)
RBC Morph: Slide review agrees with reported RBC indices. (05/14/24 15:47:00)
Bld Smear Scan: Slide reviewed and is in agreement with auto differential (05/14/24 15:47:00)
Plts, Large: Observed Abnormal (05/14/24 15:47:00)
Chemistry
Sodium Level:Â 135 mmol/LÂ Low (05/14/24 15:47:00)
Potassium Level:Â 3.1 mmol/LÂ Low (05/14/24 15:47:00)
Chloride Level:Â 100 mmol/LÂ Low (05/14/24 15:47:00)
CO2:Â 18 mmol/LÂ Low (05/14/24 15:47:00)
Anion Gap (Na Cl CO2):Â 18 mmol/LÂ High (05/14/24 15:47:00)
Glucose Level:Â 123 mg/dLÂ High (05/14/24 15:47:00)
BUN: 10 mg/dL (05/14/24 15:47:00)
126 to 142
10/24/2024 Continuity of Care Document
Creatinine Level: 0.95 mg/dL (05/14/24 15:47:00)
est CrCl (Ideal BW for dosing): 74.86 mL/min (05/14/24 15:47:00)
est CrCl (Actual BW for dosing): 123.62 mL/min (05/14/24 15:47:00)
Creatinine GFR: 85 mL/min/1.73 m2 (05/14/24 15:47:00)
Cmt: GFR: See Comments (05/14/24 15:47:00)
Calcium Level: 9.7 mg/dL (05/14/24 15:47:00)
Protein Total:Â 8.6 g/dLÂ High (05/14/24 15:47:00)
Albumin Level: 4.7 g/dL (05/14/24 15:47:00)
Bilirubin Total: 0.3 mg/dL (05/14/24 15:47:00)
Alk Phos: 59 unit/L (05/14/24 15:47:00)
AST: 33 unit/L (05/14/24 15:47:00)
ALT: 24 unit/L (05/14/24 15:47:00)
Beta-Hydroxybutyrate:Â 1.9 mmol/LÂ High (05/14/24 15:47:00)
Magnesium Level: 2.1 mg/dL (05/14/24 15:47:00)
Phosphorus Level: 2.8 mg/dL (05/14/24 15:47:00)
Troponin T Gen 5: <6 (05/14/24 15:47:00)
Troponin T Gen 5 Delta: No calculation (05/14/24 15:47:00)
Cmt: Troponin T Gen 5: See Comments (05/14/24 15:47:00)
TSH: 2.59 mcIU/mL (05/14/24 15:47:00)

Coagulation/Thrombosis
D-dimer, quant. (ug/mL): 0.49 mcg FEU/mL (05/14/24 15:47:00)
Blood Gases
Blood Gas Specimen Source: Arterial (05/14/24 16:46:00)
HCO3: 20.1 mmol/L (05/14/24 16:46:00)
pH Ven: 7.405 (05/14/24 16:46:00)
pCO2 Ven: 32.8 mmHg Low (05/14/24 16:46:00)
pO2 Ven: 27.3 mmHg (05/14/24 16:46:00)
pO2 Temp Corrected Ven: 27 (05/14/24 16:46:00)
O2 Saturation Ven: 39 % (05/14/24 16:46:00)
O2 Hgb Ven: 38.4 % (05/14/24 16:46:00)
O2 Content Ven: 5.3 (05/14/24 16:46:00)
FiO2: 21 (05/14/24 16:46:00)
Base Excess Whole Blood: -3.5 mmol/L (05/14/24 16:46:00)
Carboxyhemoglobin: 0.9 % (05/14/24 16:46:00)
Methemoglobin: 0.6 % (05/14/24 16:46:00)
Barometric Pressure: 642 mmHg (05/14/24 16:46:00)
Temperature C: 37 (05/14/24 16:46:00)
pH Temp Corrected Ven: 7.405 (05/14/24 16:46:00)
pCO2 Temp Corrected Ven: 32.8 (05/14/24 16:46:00)
Critical Value Type: Printed Report given (05/14/24 16:46:00)
Crtiical Value Notification Date: 05/14/2024 (05/14/24 16:46:00)
Critical Value Notification Time: 16:49 (05/14/24 16:46:00)
Critical Value Notification to: Jamie Matgzer RN (05/14/24 16:46:00)
Performed by: hry08930 (05/14/24 16:46:00)
Blood Gas Draw Type: Venous (05/14/24 16:46:00)
Blood Gas Draw Time: 05/14/24 16:46:00 (05/14/24 16:46:00)
Blood Gas Drawn By: Drawn by RN/Lab/OR (05/14/24 16:46:00)

_____
_____
Problem List/Past Medical History
Ongoing
Anemia
Anorexia nervosa, restricting type, in partial remission, moderate
Anorexia nervosa, restricting type, moderate
Attention deficit disorder (ADD) in adult
Bicuspid aortic valve
Borderline personality disorder
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Depression, major, recurrent, moderate
Menorrhagia
PTSD (post-traumatic stress disorder)
Recurrent major depression-severe
S/P repair of coarctation of aorta
Procedure/Surgical History
Esophagogastroduodenoscopy (03/02/2022), Transcatheter intracardiac shunt (TIS) creation by stent placement for
congenital cardiac anomalies to establish effective intracardiac flow, including all imaging guidance by the
proceduralist, when performed, left and right heart diagnostic cardiac cath.
Social History
Alcohol - 02/08/2024
Use: Never used. Household alcohol concerns: No.
Use: Never used.
Use: Never used.
Employment/School - 02/08/2024
Status: Employed. Place of occupation/business: Pet grooming. Highest education level: High school.
Employed
Home/Environment - 02/08/2024
Lives with: Friend and her family.
Substance Use - 02/08/2024
Use, other than prescribed: Never used. Concerns about substance abuse in household: No.
Use, other than prescribed: Never used. Date last used: CBD once.
Tobacco - 02/08/2024
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker (less than 100 in lifetime).
Use: Never smoker.
Use: Never smoker.
Use: Never smoker.
Family History
Anxiety: Grandmother (M) and Sibling.
Arrhythmia (cardiac) NOS: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
CHD - Congenital heart disease: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Cancer: Father, Grandfather (P) and Grandmother (P).
Cancer: Father.
Depression: Grandmother (M), Sibling and Sibling.
Drug addiction: Sibling and Sibling.
Emotional problems: Sibling.
Heart attack: Grandmother (M).Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Hyperlipidemia: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Substance Use: Sibling and Sibling.
Sudden cardiac death: Negative: Mother, Father, Sibling, Sibling, Sibling and Sibling.
Suicidal behavior: Sibling and Sibling.
Allergies
No Known Medication Allergies
No Known Allergies
Medications
Home
hydrOXYzine hydrochloride 50 mg oral tablet, 50 mg= 1 tabs, Oral, BID, PRN
Sprintec, 1 tabs, Oral, Daily
traZODone 50 mg oral tablet, 50 mg= 1 tabs, Oral, Daily at bedtime
Vyvanse 70 mg oral capsule, 70 mg= 1 cap, Oral, every morning
Code Status
Resuscitation Status* - OrderedÂ
 -- 05/14/24 18:49:00 MDT, Full Code, 05/14/24 18:49:00 MDT
Imaging Results (Last 24 Hours)
CT Angio Pulmonary
Â
05/14/24 16:46:00
IMPRESSION:
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1. No evidence of acute or chronic pulmonary embolism
2. See above for other findings
Â
Â
Â
 This report was electronically signed by John S. Collins, MD on
5/14/2024 5:35 PM.
Â
Signed By: COLLINS, MD, JOHN S.

Electronically Signed on 05/14/24 07:09 PM

________________________________________________________
NELSON, MD, JORDAN ANDREW
DALY, DO, SARAH W: PERFORM
Event Display: History and Physical
Authored Date: 20240515151148-0600

I have seen and examined this patient, and I reviewed the above note and agree with the Resident's findings,
assessment, and plan.

Cards consult, Echo to evaluate for valvular disorder. Initial EKG was ok. Continue on tele to evaluate for arrhythmia

Sarah Daly, DO, FAAFP

Electronically Signed on 05/15/24 03:11 PM

________________________________________________________
DALY, DO, SARAH W
MORILLO, EDEN: PERFORM
Event Display: History and Physical
Authored Date: 20231109105845-0700

Discharge summary

HOLLADAY, DO, NADIA: PERFORM, MODIFY, MODIFY

Event Display: Discharge Summary
Authored Date: 20240516133336-0600

Dates of Service

05/14/2024 - 05/16/2024

Discharge Diagnoses

Recurrent syncopeÂ

S/P repair of coarctation of aortaÂ

Bicuspid aortic valve

Acute, present on admission. Patient presents with at least 2 confirmed syncopal events and multiple near syncopal
symptoms over the last 6 days of unknown etiology. Patient has a known cardiac history although she has not had
consistent follow-up beyond childhood. Patient's syncope is often accompanied by a feeling of weakness, diaphoresis,
lightheadedness, palpitations. Denies any chest pain, shortness of breath, leg swelling, or pain. EKG in the ED was
unrevealing apart from tachycardia. However, given her history would like to conduct further cardiology workup. Upon

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admission, case was discussed with on-call cardiologist, Dr. Wilkinson who agreed to consult on patient. Initial PE does
not show volume depletion. Seizure also seems less likely as patient has not had any prolonged postictal state, urinary
incontinence, or tongue biting. Patient BNP is normal.Â

Telemetry reviewed this morning and patient continues to have irregular beats and was tachycardic in 140s earlier.
Telemetry showed intermittent tachycardia. Normal HR on discharge day in the morning. Normal echocardiogram.
Cardiology consulted and patient cleared to be discharged home with a monitor and follow-up outpatient.

– Cardiology consulted, recs appreciated.

– Dr. Sunkara reviewed Echo: No significant aortic stenosis identified at this bicuspid valve. Normal left ventricular
systolic function. Mildly dilated right ventricle.

– Given PVC burden and dilated right ventricle, Dr. Sunkara says to consider cardiac MRI.

– Echocardiogram 05/15/2024: LV systolic function is normal. EF 79%. No segmental wall motion abnormalities.
Normal diastolic pattern. No evidence of aortic valve stenosis. Bicuspid aortic valve with no regurgitation. No significant
change from prior study of 05/02/2014.

– BNP is normal <6

– Continuous cardiac telemetry showed intermittent tachycardia, PVCs and intermittent irregular sinus rhythm

– Tylenol as needed for pain

SIRS without infection or organ dysfunction

Leukocytosis

Metabolic acidosis

Hypokalemia

Acute, microcytic, present admission. Patient meeting SIRS criteria with elevated white count, tachycardia, tachypnea.
No obvious source of infection however patient endorsed many symptoms on the ROS including hematuria, abdominal
pain, nausea, vomiting, diarrhea, and constipation. Physical exam with some left lower quadrant tenderness and
tachycardia but otherwise unremarkable. Beta hydroxybutyrate is elevated but glucose only 123 on admission. Labs
and PE are reassuring against infection. Negative blood cultures to date.Â

– Lactic acid normal 1.2, UA unremarkable.

– Urine culture pending

– Blood cultures: NGTD

– MIVF with LR at 125 mL/h

– Tylenol as needed for pain, fever

Anemia

Chronic, present on admission. Patient has history of menorrhagia (see below). Given Sprintec to reduce menstrual
cycles.Â

Hgb 9.4 this morning in the setting of IV fluids.

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– Iron 22, TIBC 503, Iron saturation 4, Ferritin 7 - Iron deficiency anemia

– Venofer 300mg IV Infusion today. F/u in the infusion clinic outpatient.Â

– Monitored daily

Anorexia nervosa, restricting type, in partial remission, moderate

Historic diagnosis. Per most recent family medicine note does not appear to be undergoing treatment or dealing with
any acute symptoms of this.

Borderline personality disorder

Depression, major, recurrent, moderate

PTSD (post-traumatic stress disorder)

Attention deficit disorder (ADD) in adult

Chronic, present on admission. Patient follows with psychiatric specialist in Salt Lake City. Symptoms of these disorders
are currently stable. Takes hydroxyzine 50mg, Vyvanse 70mg, and trazodone 50mg.

– Continued home medications

Menorrhagia

Chronic, present on admission. Prescribed Sprintec in November 2023 by OB/GYN to decrease menstrual bleeding with
hopes of improving anemia.Â

Pertinent Information for PCP Follow Up

Patient was admitted on 05/15/20024 for syncopal episodes. Echocardiogram showed no significant aortic stenosis
identified at this bicuspid valve. Normal left ventricular systolic function w/ EF 79%. Patient had some tachycardia,
PVCs and sinus irregular rhythm. She is stable to be discharged home and follow-up outpatient. Cardio was consulted
and will have patient have a cardiac monitor for 2 weeks outpatient before follow-up.

Discharge Medications

What How Much When Instructions Next Dose Unchanged hydrOXYzine (hydrOXYzine hydrochloride 50 mg oral tablet)
1 tabs
Oral
2 times a day as needed for as needed

Unchanged lisdexamfetamine (Vyvanse 70 mg oral capsule)

1 Capsules
Oral
Every morning

Unchanged norgestimate-ethinyl estradiol (Sprintec)

1 tabs
Oral
Every day

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Unchanged traZODone (traZODone 50 mg oral tablet)

1 tabs
Oral
Daily at bedtime

Hospital Course
Patient is a 25-year-old female with history of aortic rotation status post repair, bicuspid aortic valve, BPD, anxiety,
depression, ADD, PTSD, chronic anemia, menorrhagia who presents with 6 days of recurrent syncopal events.Â
Endorsing palpitations, diaphoresis, and weakness with physical exertion and syncopal events. Found to be
persistently tachycardic despite fluid bolus with elevated white count, anion gap, electrolyte derangements, elevated
beta hydroxybutyrate. CTAP negative for PE, EKG only showing sinus rhythm with ventricular trigeminy. D-dimer,
troponin negative. Cardiology consulted, will see patient. Ordered echocardiogram, cardiac monitoring, BNP. Meeting
SIRS criteria, ordered UA, lactic acid, urine and blood cultures. Started on MIVF with LR at 125 mL/h.

5/15: Echo today. Follow-up Cardio recs. Tele shows some irregular rhythm with prolongation of PR interval, sinus,
intermittently tachycardic. Patient has chronic microcytic anemia, ordered iron studies.

05/16: Echo was normal. Per cardio, patient is stable to be discharged home with cardiac monitor for 2 weeks. Follow-
up outpatient w/ PCP. Ferritin 7. Patient received Venofer 300mg IV.

Consults
No qualifying data available.

Studies
CT Angio Pulmonary

05/14/24 16:46:00

IMPRESSION:

1. No evidence of acute or chronic pulmonary embolism

2. See above for other findings

This report was electronically signed by John S. Collins, MD on

5/14/2024 5:35 PM.

Signed By: COLLINS, MD, JOHN S.

**************************************************

Echo TransTHORacic TTE

05/15/24 15:33:08
132 to 142
10/24/2024 Continuity of Care Document

Impression:

1. Left ventricular systolic function is normal. The left ventricular ejection fraction is 79 %(+- 3%).

2. There are no segmental wall motion abnormalities.

3. Normal diastolic pattern with normal left atrial pressure.

4. Normal right ventricular size and systolic function.

5. No evidence of aortic valve stenosis. Aortic valve morphology is bicuspid. No evidence of aortic regurgitation.

6. Tricuspid regurgitation jet was not adequate to estimate the right ventricular or pulmonary artery systolic pressure.

7. History of aorta coarctation repair, peak velocity of 2.7m/s.

8. Compared to a prior transthoracic study from 5/2/2014, no significant changes are seen.

Â
Signed by:

Signed By: FEENEY, MD, JAMES M.

Post-Discharge Care
Follow Up Appointments

HEALEY, DO, M. AUSTIN, Family Medicine. within 1 week   Comment: Call for followup appointment.

Condition on Discharge

Stable

Discharge Disposition
Discharge Disposition - OrderedÂ

 -- 05/16/24 13:30:00 MDT, Home Independently, 05/16/24 13:30:00 MDT

Electronically Signed on 05/16/24 05:13 PM

________________________________________________________
HOLLADAY, DO, NADIA
DALY, DO, SARAH W: PERFORM
Event Display: Discharge Summary
Authored Date: 20240517085924-0600

I have seen and examined this patient, and I reviewed the above note and agree with the Resident's findings,
assessment, and plan.

Â
Sarah Daly, DO, FAAFP

Electronically Signed on 05/17/24 08:59 AM

________________________________________________________
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10/24/2024 Continuity of Care Document
DALY, DO, SARAH W
PITCHER, DO, MATTHEW: PERFORM
Event Display: Discharge Summary
Authored Date: 20210119130739-0700

Admission Information/HPI
Patient is a same-day admission/discharge. Â Please refer to admission note for details.
Hospital Course
Alcohol use
Bicuspid aortic valve
Confusion
Depression, major, recurrent, moderate
Post traumatic stress disorder (PTSD)
Sexual assault of adult

Review of Systems Psychiatric Review of Systems

Thought Content Comment: Pt did not have Nightmares last noct after having the Prazosin
Objective
Vitals & Measurements
T: 36.4 °C (Temporal Artery) HR: 80(Peripheral) RR: 16 BP: 115/80 SpO2: 99%Â
HT: 163 cm WT: 83.8 kg BMI: 31.54Â
Discharge Plan

1. Confusion
2. Sexual assault of adult
3. Alcohol use
4. Depression, major, recurrent, moderate
5. Bicuspid aortic valve
6. Post traumatic stress disorder (PTSD)
Orders:
acetaminophen, 650 mg, Oral, every 6 hr, PRN fever/mild pain (see comment), Priority Ranking: give 1st, Tab, First
Dose: 01/19/21 5:42:00 MST
Al hydroxide/Mg hydroxide/simethicone, 30 mL, Oral, QID, PRN dyspepsia, Susp-Oral, First Dose: 01/19/21 5:42:00 MST
cloNIDine, 0.2 mg, Oral, Daily at bedtime, Tab, First Dose: 01/19/21 21:00:00 MST
cloNIDine, 0.1 mg, Oral, every 8 hr, PRN hypertension (see comment), Tab, First Dose: 01/19/21 5:42:00 MST
diphenhydrAMINE, 50 mg, Oral, every 6 hr, PRN agitation, Priority Ranking: give 2nd, Cap, First Dose: 01/19/21 5:42:00
MST
escitalopram, 15 mg, Oral, Daily, Tab, First Dose: 01/19/21 11:20:00 MST
gabapentin, 300 mg, Oral, TID, Cap, First Dose: 01/19/21 11:30:00 MST
hydrOXYzine, 50 mg, Oral, Daily at bedtime, PRN sleep, Cap, First Dose: 01/19/21 5:42:00 MST
hydrOXYzine, 50 mg, Oral, every 4 hr, PRN anxiety, Cap, First Dose: 01/19/21 5:42:00 MST
loperamide, 2 mg, Oral, As Directed PRN, PRN diarrhea, Cap, First Dose: 01/19/21 5:42:00 MST
loperamide, 4 mg, Oral, Once, PRN diarrhea, Cap, First Dose: 01/19/21 5:42:00 MST
magnesium hydroxide, 30 mL, Oral, every 8 hr, PRN constipation, Susp-Oral, First Dose: 01/19/21 5:42:00 MST
nicotine, 2 mg, Buccal, every 1 hr, PRN nicotine withdrawal, Gum, First Dose: 01/19/21 5:42:00 MST
OLANZapine, 10 mg, IntraMuscular, every 4 hr, PRN agitation, severe, Injectable, First Dose: 01/19/21 5:42:00 MST
OLANZapine, 10 mg, Oral, every 4 hr, PRN agitation, Tab-Disintegrating, First Dose: 01/19/21 5:42:00 MST
ondansetron, 4 mg, Oral, every 6 hr, PRN nausea, Tab-Disintegrating, First Dose: 01/19/21 5:42:00 MST
topiramate, 25 mg, Oral, Daily at bedtime, Tab, First Dose: 01/19/21 21:00:00 MST
BEH Follow-up Care Exceptions
Discharge Activity Restrictions
Discharge Diet Instruction
Discharge Disposition
Discontinue Suicide Precautions
Escape Precautions
Fasting Plasma Glucose
Inpatient Psychiatric Certification
Legal Status
Level of Care Justification
Lipid Panel (Chol, Trig, HDL, LDL, VLDL)
Notify Treating Provider Vital Signs
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10/24/2024 Continuity of Care Document
Patient Safety Checks
Regular Diet
Resuscitation Status*
Suicide Precautions
Up ad Lib
Vital Signs
Weight*
Patient Discharge Condition
In my professional judgement, this patient was judged to be appropriate for discharge.
Discharge Disposition
Refer to post-discharge care follow-up on patient's clinical summary.
Total Unit Time/Complexity
$$ Psychotherapy, 30 minutes with Patient, Â with E/M Service 90833 - OrderedÂ
 -- 01/19/21 13:03:00 MST, Post traumatic stress disorder (PTSD) | Sexual assault of adult | Confusion
$$ Same Day Admit/Discharge, Moderate Severity 99235 - OrderedÂ
 -- 01/19/21 13:03:00 MST, Post traumatic stress disorder (PTSD) | Sexual assault of adult | Confusion
Medications
Inpatient
Benadryl, 50 mg= 2 EA, Oral, every 6 hr, PRN
cloNIDine, 0.2 mg= 1 tabs, Oral, Daily at bedtime
cloNIDine, 0.1 mg= 1 tabs, Oral, every 8 hr, PRN
escitalopram, 15 mg= 1.5 tabs, Oral, Daily
gabapentin, 300 mg= 1 cap, Oral, TID
loperamide, 4 mg= 2 cap, Oral, Once, PRN
loperamide, 2 mg= 1 cap, Oral, As Directed PRN, PRN
Milk of Magnesia 8% oral suspension, 30 mL, Oral, every 8 hr, PRN
Mylanta, 30 mL, Oral, QID, PRN
nicotine 2 mg oral transmucosal gum, 2 mg= 1 EA, Buccal, every 1 hr, PRN
Topamax, 25 mg= 1 tabs, Oral, Daily at bedtime
Tylenol, 650 mg= 2 tabs, Oral, every 6 hr, PRN
Vistaril, 50 mg= 1 cap, Oral, every 4 hr, PRN
Vistaril, 50 mg= 1 cap, Oral, Daily at bedtime, PRN
Zofran, 4 mg= 1 tabs, Oral, every 6 hr, PRN
ZyPREXA, 10 mg= 1 vials, IntraMuscular, every 4 hr, PRN
ZyPREXA Zydis, 10 mg= 1 tabs, Oral, every 4 hr, PRN
Home
atomoxetine 40 mg oral capsule, 40 mg= 1 cap, Oral, BID
cloNIDine 0.2 mg (200 mcg) oral tablet, 0.2 mg= 1 tabs, Oral, Daily at bedtime, PRN
doxepin 10 mg/mL oral concentrate, 0.6-1 mL, Oral, Daily at bedtime, PRN
escitalopram 10 mg oral tablet, 15 mg= 1.5 tabs, Oral, Daily
gabapentin 300 mg oral capsule, 300 mg= 1 cap, Oral, TID
prazosin 1 mg oral capsule, 1 mg= 1 cap, Oral, Daily at bedtime
ramelteon 8 mg oral tablet, 8 mg= 1 tabs, Oral, Daily at bedtime
topiramate 50 mg oral tablet, 50 mg= 1 tabs, Oral, Daily at bedtime
Allergies
No Known Medication Allergies
Other Information
NIDA:
NIDA Screening Objective: Patient accepts, document NIDA
MHI Adult alcohol use yes no: No
MHI adult rx non med yes no: No
MHI adult rx drug yes no: No
MHI adult street drugs yes no: Yes
Psychotherapy Summary:
BEH Recommended Level of Care: Residential treatment

Electronically Signed on 01/19/21 01:07 PM

________________________________________________________
PITCHER, DO, MATTHEW

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PITCHER, DO, MATTHEW D.: PERFORM
Event Display: Discharge Summary
Authored Date: 20201104074151-0700

Admission Information/HPI
History of Present Illness
Patient is a 21-year-old female, single no children. Patient is employed as a pet groomer. She enjoys his job.Â
Patient lives with her friend and their family. Patient reports this is her third admission in 6-8 weeks involving
suicide attempts.  Her friend Shilane 801-891-2983 is arranging outpatient care for patient for therapy.  Patient
reports in the past she has tried medications such as Zoloft, Lexapro, Seroquel, trazodone, Ambien, Vistaril, Intuniv,
Vyvanse, Zyprexa, Adderall, Ritalin, Concerta. Patient feels that the Ambien worked well inserted Vyvanse. Patient
denies medical illnesses.  Patient states she is seeing counselor, Charity, in Draper at integrated counseling and
well. Patient reports her main concern is that she is "tired, can't get brain to stop.  Constant anxiety". Patient feels
that nighttime is her worst due to PTSD and nightmares.  Patient states that she will abused stimulants to avoid
sleep and also abused stimulants to lose weight. Patient reports highest level of education is high school.  Denies
childhood problems, denies military history.  Patient reports legal problem she testified regarding the sexual
abuse from her stepdad and mother's neglect and he was sent to prison. Patient reports emotional abuse age
12 to current from her mother and stepfather. Patient reports physical abuse from her stepdad age 15-17 years old.
 Patient reports sexual abuse from her stepdad age 15-17, rape multiple times. Patient also reports sexual abuse
from a cousin in Brazil lasting 6 months to year. patient reports other​ problems with the with the court case,
her mother is looking at witness tampering charges because she tried to get the patient and her sisters to Brazil so
that they "could not testify against" mother and stepdad. Patient reports that was very difficult.  Patient
reports other traumatic experiences including the death of her father when she was age 14. Patient states all of
the sexual abuse and phsycial abuse began shortly after the patients father died which she "didn't understand".Â
Patient reports her mother saw what was happening and "did nothing to stop it". Patient reports she has had
flashbacks, severe nightmares each night, reexperiencing symptoms of hyperarousal symptoms. Patient denies
symptoms of OCD, psychosis, developmental disorder, mania. Patient reports depression 7 out of 10. Patient
reports symptoms of depression including poor interest in things, guilt and worthlessness, poor energy, poor on
centration. Â Patient states she now has over the future. Â Patient denies plan or access to lethal means. Â Patient
reports steady weight and appetite. Patient reports she has not slept for "2 days". Patient reports symptoms of
anxiety including excess worry, restlessness on edge, easily fatigued, muscle tension, decreased sleep, decreased
concentration. Patient reports she was diagnosed with ADHD in the sixth grade and includes difficulty concentrating,
distracted, and impulsive symptoms. Patient reports current eating disorder of restricting eating 1-2 times per
day 300-400 cal.  Patient reports her weight before the mission was 117 pounds and that is currently her goal
weight. She served an LDS mission September 2017 to April 2020.​ She took ambien during that time on mission
and "slept great". Patient and friend reports a weight gain of 80 pounds in the last 3-6 months   Patient reports
alcohol use in high school 1-3 drinks per sitting once per month.  Patient reports marijuana use once in high
school.  Patient denies other substance use.  Patient reports personality disorder including fear abandonment and
rejection, unstable relationship, chronic emptiness, decreased self-esteem, impulsivity.  Patient reports intense
anger and outbursts 2 times per month. [1]
Hospital Course
Alcohol use
Anorexia nervosa, restricting type, moderate
Attention deficit disorder (ADD) in adult (10/31/2020 23:46 MDT - STAHELI, NP, KENDRA A. Â
also uses stimulants for weight management and to avoid sleep due to nightmares)
Borderline personality disorder
Depression, major, recurrent, moderate
GAD (generalized anxiety disorder)
Intentional drug overdose
Nightmares
Obesity (BMI 30-39.9)
PTSD (post-traumatic stress disorder)
S/P repair of coarctation of aorta
Suicide attempt
On admission, the patient was started on Cymbalta 20 mg daily, prazosin 1 mg daily at bedtime, and Topamax 25
mg daily at bedtime.  Patient also given Ambien CR 12.5 mg daily at bedtime the patient tolerated this well
without notable side effects.  She reported that she was sleeping well for the first time in a long time.  Stated
that she still had anxiety, but felt more capable of dealing with the prospect of processing trauma that she
has been through.  Has been expressing for the last few days that she is not having any thoughts of suicide.  The
patient engaged in individual and group psychotherapy and patient reporting future oriented thinking.  Outpatient
social supports were reestablished and patient was in contact with friends and roommate. They continued to
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10/24/2024 Continuity of Care Document
expressed support.  Patient's social worker was in contact with the patient's roommate, held a family
session with the patient and her roommate and discussed safety plan. The patient participated fully in the treatment
and safety planning process. Â The patient did not have significant behavioral issues requiring interventions from
hospital staff or prn medications. Â At discharge, the patient denied suicidal ideation, was future focused and reported a
strong will to live. Â I believe that the patient had achieved maximal benefit from inpatient hospitalization and was
ready for transition to outpatient care.
Â
Mental Status Exam
General Appearance: [Appropriately dressed and groomed ]
Orientation: [Alert and oriented x4 ]
Recent and Remote Memory: [Intact ]
Behavior: [Cooperative]
Mood/Affect: "I am okay"/euthymic
Speech: [Normal ]
Thought Process: [Logical and goal directed ]
Associations: [Intact ]
Thought Content: Denies SI/HI. Â Nonpsychotic.
Attention/Concentration: [Grossly intact attention ]
Insight/Judgement: Fair
Language: [Within normal limits ]
Fund of Knowledge: [Awareness of Current Events ]
Â
Assessment (incl. Risk Assessment): Moderate risk. Patient with multiple suicide attempts in the last couple of
months.  Expressing that she feels more capable of processing trauma and working through emotions.  States that
she is sleeping well for the first time in a long time.  Patient reports that she does feel she has good support
from multiple individuals outside of the hospital, even if her family is not providing her great support. Patient
stating that she feels like her medications are beneficial for her. States that she is not having any thoughts of suicide
or harming anyone else at this time.  States that she will take medications as prescribed and follow-up as
scheduled. Patient reports she will follow-up in IOP, was supposed to start going to Phoenix recovery in Sandy
this week.
 Plan (incl. Safety Plan):
1. Continue medications as prescribed on discharge, see list below.
2. Will follow-up with outpatient behavioral health treatment team. Discussed with the patient the importance of
following up within 7 days after discharge and patient expressed understanding of this and agreed to follow-up within
that time.
3. Crisis plan reviewed: If in distress or symptoms worsen, patient will utilize available coping skills, talk to family or
friends, contact outpatient providers, or in the event of emergencies or suicidal ideations with intent or plan, patient will
contact 911 or present to the nearest ER.
 Follow Up Appointments
Tobacco Quit Line   Comment: Please call 1-800-QUIT-NOW.BH follow up, tobacco, and/or addiction treatment
referral
Draper Integrated Counseling and Wellness on 11/12/20 16:30Â Â Â Comment:Â Appointment scheduled with Charity
Hotton, AMFT on Thursday, November 12 at 4:30 p.m. for therapy. Â BH follow up, tobacco, and/or addiction treatment
referral.
Patient Navigator- Utah County   Comment: If you need further assistance with obtaining mental health
resources for outpatient services, please call the number listed, and I'll be glad to assist you.
Phoenix Recovery Center- Draper on 11/04/20 13:00Â Â Â Comment:Â In office appointment for a biopsychosocial
assessment with a clinician on Wednesday, November 4 at 1:00 p.m. BH follow up, tobacco, and/or addiction
treatment referral.
Draper Integrated Counseling and Wellness on 11/10/20 13:30Â Â Â Comment:Â Appointment scheduled with Charity
Hotton, AMFT on Tuesday, November 10 at 1:30 p.m. for therapy. Â BH follow up, tobacco, and/or addiction treatment
referral.
Â
Time Statement: More than 30 minutes were spent on the day of discharge in hospital stay discharge management.
Objective
Vitals & Measurements
T: 36.6 °C (Temporal Artery) HR: 81(Peripheral) RR: 16 BP: 124/78 SpO2: 99%Â
HT: 162.56 cm WT: 80.7 kg BMI: 30.54Â
Discharge Plan

1. Depression, major, recurrent, moderate

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2. Suicide attempt
3. Intentional drug overdose
4. Obesity (BMI 30-39.9)
5. GAD (generalized anxiety disorder)
6. PTSD (post-traumatic stress disorder)
7. Nightmares
8. Attention deficit disorder (ADD) in adult
9. Anorexia nervosa, restricting type, moderate
10. Alcohol use
11. Borderline personality disorder
12. S/P repair of coarctation of aorta
Orders:
DULoxetine, 1 cap, Oral, Daily, # 30 cap, 0 Refill(s), Signed: 11/03/20 11:59:00 MST, Maintenance, Pharmacy:
WALGREENS DRUG STORE #02519, 1 cap Oral Daily, 162.56, cm, 10/31/20 14:09:00 MDT, Height/Length Measured,
83.2, kg, 10/30/20 20:56:00 MDT, Weight Dosing
prazosin, 1 cap, Oral, Daily at bedtime, # 30 cap, 0 Refill(s), Signed: 11/03/20 13:16:00 MST, Maintenance, Pharmacy:
WALGREENS DRUG STORE #02519, 1 cap Oral Daily at bedtime, 162.56, cm, 10/31/20 14:09:00 MDT, Height/Length
Measured, 83.2, kg, 10/30/20 20:56:0...
topiramate, 1 tabs, Oral, Daily at bedtime, # 30 tabs, 0 Refill(s), Signed: 11/03/20 13:16:00 MST, Maintenance,
Pharmacy: WALGREENS DRUG STORE #02519, 1 tabs Oral Daily at bedtime, 162.56, cm, 10/31/20 14:09:00 MDT,
Height/Length Measured, 83.2, kg, 10/30/20 20:5...
zolpidem, 1 tabs, Oral, Daily at bedtime, # 30 tabs, 0 Refill(s), Signed: 11/03/20 13:17:00 MST, Maintenance
BEH Follow-up Care Exceptions
Communication Order
Discharge Activity Restrictions
Discharge Diet Instruction
Discharge Disposition
Discharge Patient
Discontinue Suicide Precautions
Patient Discharge Condition
In my professional judgement, this patient was judged to be appropriate for discharge.
Discharge Disposition
Refer to post-discharge care follow-up on patient's clinical summary.
Total Unit Time/Complexity
$$ Hospital Discharge Day Management > 30 Min 99239 - OrderedÂ
 -- 11/04/20 7:40:00 MST, PTSD (post-traumatic stress disorder) | GAD (generalized anxiety disorder) | Depression,
major, recurrent, moderate
Medications
Inpatient
Benadryl, 50 mg= 2 EA, Oral, every 6 hr, PRN
cloNIDine, 0.1 mg= 1 tabs, Oral, every 8 hr, PRN
Cymbalta, 20 mg= 1 cap, Oral, Daily
loperamide, 4 mg= 2 cap, Oral, Once, PRN
loperamide, 2 mg= 1 cap, Oral, As Directed PRN, PRN
Milk of Magnesia 8% oral suspension, 30 mL, Oral, every 8 hr, PRN
Minipress, 1 mg= 1 cap, Oral, Daily at bedtime
Mylanta, 30 mL, Oral, QID, PRN
nicotine 2 mg oral transmucosal gum, 2 mg= 1 EA, Buccal, every 1 hr, PRN
Topamax, 25 mg= 1 tabs, Oral, Daily at bedtime
Tylenol, 650 mg= 2 tabs, Oral, every 6 hr, PRN
Vistaril, 50 mg= 1 cap, Oral, every 4 hr, PRN
Vistaril, 50 mg= 1 cap, Oral, Daily at bedtime, PRN
Zofran, 4 mg= 1 tabs, Oral, every 6 hr, PRN
zolpidem extended release, 12.5 mg= 1 tabs, Oral, Daily at bedtime, PRN
ZyPREXA, 10 mg= 1 vials, IntraMuscular, every 4 hr, PRN
ZyPREXA Zydis, 10 mg= 1 tabs, Oral, every 4 hr, PRN
Home
Cymbalta 20 mg oral delayed release capsule, 20 mg= 1 cap, Oral, Daily
Minipress 1 mg oral capsule, 1 mg= 1 cap, Oral, Daily at bedtime
Topamax 25 mg oral tablet, 25 mg= 1 tabs, Oral, Daily at bedtime
zolpidem 12.5 mg oral tablet, extended release, 12.5 mg= 1 tabs, Oral, Daily at bedtime
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Allergies
No Known Medication Allergies
Lab Results
WBC: 9.1 K/mcL (10/30/20 20:59:00)
RBC: 4.55 x10^6/mcL (10/30/20 20:59:00)
Hemoglobin:Â 11.9 g/dLÂ Low (10/30/20 20:59:00)
Hematocrit: 38.1 % (10/30/20 20:59:00)
MCV: 83.7 fL (10/30/20 20:59:00)
MCH: 26.2 pg (10/30/20 20:59:00)
MCHC:Â 31.2 g/dLÂ Low (10/30/20 20:59:00)
RDW SD:Â 51.2 fLÂ High (10/30/20 20:59:00)
RDW:Â 16.9 %Â High (10/30/20 20:59:00)
Platelets: 379 K/mcL (10/30/20 20:59:00)
MPV: 9.2 fL (10/30/20 20:59:00)
Nucleated RBC Auto: 0 /100(WBCs) (10/30/20 20:59:00)
Immature Granulocytes: 0.2 % (10/30/20 20:59:00)
Differential Type: Auto (10/30/20 20:59:00)
Neutrophil % Auto:Â 74.9 %Â High (10/30/20 20:59:00)
Lymphocyte % Auto:Â 17.3 %Â Low (10/30/20 20:59:00)
Monocyte % Auto: 6.7 % (10/30/20 20:59:00)
Eosinophil % Auto: 0.3 % (10/30/20 20:59:00)
Basophil % Auto: 0.6 % (10/30/20 20:59:00)
Immature Granulocyte, Abs: 0.02 K/mcL (10/30/20 20:59:00)
Neutrophil, Abs: 6.8 K/mcL (10/30/20 20:59:00)
Lymphocyte, Abs: 1.6 K/mcL (10/30/20 20:59:00)
Monocyte, Abs: 0.6 K/mcL (10/30/20 20:59:00)
Eosinophil, Abs: 0 K/mcL (10/30/20 20:59:00)
Basophil, Abs: 0.1 K/mcL (10/30/20 20:59:00)
Sodium Level: 138 mmol/L (11/01/20 06:51:00)
Potassium Level: 4.4 mmol/L (11/01/20 06:51:00)
Chloride Level: 108 mmol/L (11/01/20 06:51:00)
CO2:Â 18 mmol/LÂ Low (11/01/20 06:51:00)
Anion Gap (Na Cl CO2): 12 mmol/L (11/01/20 06:51:00)
Glucose Level: 87 mg/dL (11/01/20 06:51:00)
Glucose Fasting: 87 mg/dL (11/01/20 06:51:00)
Cmt: Fasting Plasma Glucose: See Comments (11/01/20 06:51:00)
BUN: 15 mg/dL (11/01/20 06:51:00)
Creatinine Level: 0.93 mg/dL (11/01/20 06:51:00)
est CrCl (Ideal BW for dosing): 82.63 mL/min (11/01/20 08:14:01)
est CrCl (Actual BW for dosing): 125.68 mL/min (11/01/20 08:14:02)
Creatinine GFR: No calculation (11/01/20 06:51:00)
Average GFR for age: No calculation (11/01/20 06:51:00)
Cmt: GFR: See Comments (10/30/20 20:59:00)
Calcium Level: 9.2 mg/dL (11/01/20 06:51:00)
Protein Total: 7.8 g/dL (10/30/20 20:59:00)
Albumin Level: 4.5 g/dL (10/30/20 20:59:00)
Bilirubin Total:Â 0.1 mg/dLÂ Low (10/30/20 20:59:00)
Alk Phos: 71 unit/L (10/30/20 20:59:00)
AST: 24 unit/L (10/30/20 20:59:00)
ALT: 14 unit/L (10/30/20 20:59:00)
Magnesium Level: 1.9 mg/dL (11/01/20 06:51:00)
Phosphorus Level: 4.3 mg/dL (11/01/20 06:51:00)
Cholesterol Total:Â 211 mg/dLÂ High (11/01/20 06:51:00)
HDL: 66 mg/dL (11/01/20 06:51:00)
LDL:Â 123 mg/dLÂ High (11/01/20 06:51:00)
Cmt: LDL: See Comments (11/01/20 06:51:00)
Chol/HDL: 3.2 (11/01/20 06:51:00)
Triglycerides: 109 mg/dL (11/01/20 06:51:00)
Patient Fasting?: Yes (11/01/20 06:51:00)
Non HDL Cholesterol:Â 145 mg/dLÂ High (11/01/20 06:51:00)
VLDL: 22 mg/dL (11/01/20 06:51:00)
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Cmt: HCG Serum Qualitative: See Comments (10/30/20 20:59:00)
HCG Serum Qualitative: Negative (10/30/20 20:59:00)
TSH: 2.17 mcIU/mL (10/30/20 20:59:00)
Acetaminophen Level:Â 8 mcg/mLÂ Low (10/30/20 20:59:00)
Cmt1: Serum Drug Screen: See Comments (10/30/20 20:59:00)
Salicylate Level: <5.0 (10/30/20 20:59:00)
Cmt2: Serum Drug Screen: See Comments (10/30/20 20:59:00)
Ethanol Level: <10 (10/30/20 20:59:00)
Methadone Screen Ur: Negative (10/30/20 21:39:00)
Amphetamine Screen Ur: Negative (10/30/20 21:39:00)
Barbituate Screen Ur: Negative (10/30/20 21:39:00)
Benzodiazepines Ur: Negative (10/30/20 21:39:00)
Cannabinoid Screen Ur: Negative (10/30/20 21:39:00)
Cocaine Screen Ur: Negative (10/30/20 21:39:00)
Opiate Screen Ur: Negative (10/30/20 21:39:00)
Synthetic Opioids: Negative (10/30/20 21:39:00)
Buprenorphine Level: Negative (10/30/20 21:39:00)
Cmt4: Drug Screen Urine: See Comments (10/30/20 21:39:00)
Collect Method, Ur: Clean Catch (10/30/20 21:39:00)
Color Urine: Normal (10/30/20 21:39:00)
Appear: Normal (10/30/20 21:39:00)
Specific Gravity, Urine: 1.025 (10/30/20 21:39:00)
pH Urine: 7 (10/30/20 21:39:00)
Glucose Urine: Negative (10/30/20 21:39:00)
UA Ketones: Negative (10/30/20 21:39:00)
Nitrite: Negative (10/30/20 21:39:00)
Hgb Urine: Negative (10/30/20 21:39:00)
Protein Urine: Negative (10/30/20 21:39:00)
Leuk Esterase: Negative (10/30/20 21:39:00)
WBC Urine: 1 /HPF (10/30/20 21:39:00)
RBC Urine: 1 /HPF (10/30/20 21:39:00)
Epithelial Cells:Â 11 /HPFÂ High (10/30/20 21:39:00)
Bacteria Urine: 1+ Abnormal (10/30/20 21:39:00)
Hyaline Cast: Negative (10/30/20 21:39:00)
Urine Culture Ordered?: No (10/30/20 21:39:00)
SARS-CoV-2 by PCR (Cepheid): Not detected (10/30/20 23:59:00)
Cmt5: SARS CoV 2 BY PCR: See Comments (10/30/20 23:59:00)
Cmt: SARS-CoV-2 by PCR (Cepheid): See Comments (10/30/20 23:59:00)
Other Information
Psychotherapy Summary:
BEH Estimated Signed Time: 10:31

[1]Â BEH *Psychiatrist IP Admission Note; STAHELI, NP, KENDRA A. 10/31/2020 18:00 MDT

Electronically Signed on 11/04/20 07:41 AM

________________________________________________________
PITCHER, DO, MATTHEW D.

Patient Care team information

Care Team Personnel

Name: ATWOOD, RN, BRENDA M
Position: CPM House Calls CCM – Licensed
Member Role: Care Manager

Name: HEALEY, DO, MICHAEL AUSTIN

Position: Physician - Family Medicine
Member Role: Primary Care Physician
Address: 395 COUGAR BLVD STE 603

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10/24/2024 Continuity of Care Document
PROVO, UT 84604- US

Name: ROGERSON, NP, ANN

Position: Cardiology: LIP
Member Role: Nurse Practitioner Lifetime
Address: 395 W COUGAR BLVD STE 503
PROVO, UT 84604- US

Care Team Related Persons

Name: MANSELL, SHILANE

Name: MANSELL, SHILANE

Name: NIELSON, GARTH HUGH

Address: Home
2092 ALASKA AVE
PROVO, UT 846066712

Family History

No data available for this section

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