n3c_omop_sample.csv

note_type_concept_id,note_class_concept_id,encoding_concept_id,language_concept_id,person_id,note_text,note_date
32831,706391,32678,4180186,169,"DOCUMENT HEADER :
Consults by Mcgregor , Faulkner Quintana , M. D. , Andersen Peterson Quintana at  4/11/2020  9 : 53 AM (continued)
Author : Ferguson , Gonzalez Mckinney , M. D. , Ferguson Petersen Andersen Finnegan : HEM (Hematology) Author Type : Resident
Filed :  4/11/2020  2 : 09 PM Date of Service :  4/11/2020  9 : 53 AM Status : Signed
Editor : Matthews , Faulkner Matthews , M. D. , Finnegan Humphrey Mckenzie (Resident) Hematology Consult Note Providing Resident : Mcarthur Faulkner , M. D. , M. P. H.
Supervising Physician (Consultant) : Dr.
Ferguson
Primary Service : CCM 1 Faulkner , Gonzalez E , M. D.
Hospital Day : 20 **This is being performed as an e consult due to hospital wide concerns about COVID 19 and reducing potential patient and healthcare personnel exposure.
REASON FOR CONSULT :
1) query immune reconsititution 2) anticoagulation assistance
HISTORY OF PRESENT ILLNESS :
Mr.
Ferguson Mclellan Andersen is a ** y. o. male with medical comorbidities including follicular lymphoma diagnosed  7/11/2019  s / p cycle 1 rituximab / bendamustine (  2/6/20  ) , hypertension , bipolar disorder / depression who was admitted  3/23/2020  with acute respiratory failure in the setting of COVID 19 pneumonia.
Hematology was consulted for recommendations regarding anticoagulation.
Hematology was previously consulted on [4_3] for ongoing pancytopenia and abnormal peripheral smear.
In regards to his history of follicular lymphoma , it was diagnosed in  7/20/2019  and monitored until  1/20/2020  when treatment was started due to worsening pancytopenia < 100.
He received cycle 1 of rituximab / bendamustine on [2_6] .
When he returned for follow up on [3_5] , he screened positive for COVID 19.
He then developed worsening SOB and presented to the ED where labs showed WBC 3.
2 , hemoglobin 9 , platelet 171.
CT concerning for worsening bilateral ground glass opacities.
He was started on broad spectrum antibiotics and BiPAP and was admitted to the MICU with acute respiratory failure.
He was quickly stabilized and transferred out of the ICU on [3_25] .
He received convalescent plasma on [3_27] per ID recs.
He required multiple transfusions during his hospital course.
Heme was consulted on [4_3] to evaluate smear showing slight bite cells , pincer red cells and spherocytes (consider oxidative / spherocytic hemolysis).
Faulkner was 270 , G 6 PD was normal / elevated , with no evidence of hemoglobinuria.
Retic count was normal at 1.
43%.
Heme felt that pancytopenia (stable in the upper 90 s , low 100 s) was multifactorial and possibly related to progression of malignancy (bone marrow biopsy  7/20/2019  already showed 60% marrow involvement) , bone marrow suppression from treatment , underlying liver disease.
In regards to the smear , they recommended outpatient follow up for G 6 PD levels in the future but had no ongoing concerns regarding hemolysis.
Since then , the patient was transferred back to the ICU on [4_5] due to increased oxygen requirements.
The patient was restarted on broad spectrum antibiotics including vancomycin and zosyn.
CT chest showed marked progressive lung findings R>L consistent with advanced COVID infection.
LE US on [4_8] showed acute left calf DVT (left peroneal and soleal veins).
The patient had been on prophylactic lovenox but this was then transitioned to high intensity heparin nomogram but has had difficulty achieving therapeutic levels.
Antithrombin activity level was low at 61% on heparin.
On [4_9] , the patient was intubated and pressors were started.
He remains on norepinephrine and vasopressin as well as vanc / cefepime / flagyl.
Methylpred was started in addition to hydrocortisone stress dose steroids due to concern for immune reconstitution syndrome.
Labs show Hgb 9 (last pRBC yesterday x 2) , platelet count 291 , WBC 10.
5 , lactate 6.
5 , ABG pH 7.
11 , significantly elevated transaminases , total bilirubin 2.
5 , D dimer 1175 (stable since admission) , fibrinogen elevated 508 , no INR since [4_4] , ferritin 6900 , IL 6 elevated 15.
4 (admission) , CRP 206 , hyperphosphatemia , hyperkalemia , worsening renal failure.
TTE on [4_9] showed a moderately enlarged RV with mild moderately decreased systolic function , RVSP 53 , normal inspiratory collapse of IVC.
In speaking with the primary team , the patient has a daughter that they have been talking to.
His mom has dementia and is unable to make decisions for him.
He appears to live at home alone.
VITALS :
 4/11/20  0800  4/11/20  0815  4/11/20  0830  4/11/20  0845
BP :
Patient Position :
Pulse :
Heart Rate : 88 87 92 87
Temp : 38 °C
Resp : (!)
34 (!)
34 (!)
34 (!)
34
Height :
Weight : SpO 2 : Temp Src : Axillary
Pain Score :
Pain Location : Admission Weight : 78.
6 kg
Current Weight : 78.
3 kg
PHYSICAL EXAMINATION :
Unable to perform physical exam today given patient contact limitations.
LABS :
Results from last 7 days
Lab Units  4/11/20 
0338  4/11/20 
0336  4/10/20 
2220  4/10/20 
2219  4/10/20 
1916  4/10/20 
1539  4/10/20 
0322  4/9/20 
0211  4/8/20 
0345
WBC x 10(9) / L 10.
5* 10.
7* 12.
9* 4.
5 4.
9
VBGRS HEMOGLOBIN g / dL 9.
1* 9.
8* 7.
8* 8.
3*",2021-02-20
32831,706391,32678,4180186,50,"DOCUMENT HEADER :
Progress Notes by Peterson , Peterson A , M. D. at  7/13/2020  3 : 00 PM (continued)
Author : ***** , Petersen A , M. D. Service : OBG (Obstetrics and Gynecology) Author Type : Physician
Filed :  7/16/2020  1 : 29 PM Encounter Date :  7/13/2020  Status : Signed
Editor : ***** , Mcgregor A , M. D.
(Physician)
CHIEF COMPLAINT / REASON FOR VISIT :
Prenatal care , second trimester.
HISTORY OF PRESENT ILLNESS :
This very nice patient presents for a prenatal check in the second trimester ( [xxxxx x. xxxxx] d).
She has questions about weight gain.
Otherwise , no unusual complaints today and is not experiencing severe hyperemesis nor vaginal bleeding.
CURRENT MEDICATIONS :
Have been reviewed and are current in the EMR as of today's date.
ALLERGIES :
Have been reviewed and are current in the EMR as of today's date.
The patient's established EDD , documentation of prior obstetric history , laboratory information , and summary of medical record have been reviewed today.
SOCIAL HISTORY :
Socioeconomic History
• Marital status : Married
Spouse name : Noor
• Number of children : 4
• Years of education : Not on file
• Highest education level : Not on file
Occupational History
• Not on file
Social Needs
• Financial resource strain : Not very hard
• Food insecurity
Worry : Never true
Inability : Never true
• Transportation needs
Medical : No Non medical : No
Tobacco Use
• Smoking status : Never Smoker
• Smokeless tobacco : Never Used
Substance and Sexual Activity
• Alcohol use : No
• Drug use : No
• Sexual activity : Not on file
Lifestyle
• Physical activity
Days per week : Not on file
Minutes per session : Not on file
• Stress : Not on file
Relationships
• Social connections
Talks on phone : Not on file
Gets together : Not on file
Attends religious service : Not on file
Active member of club or organization : Not on file
Attends meetings of clubs or organizations : Not on file
Relationship status : Married
• Intimate partner violence
Fear of current or ex partner : No
Emotionally abused : No
Physically abused : No
Forced sexual activity : No
Other Topics Concern
• Not on file
SOCIAL HISTORY NARRATIVE :
• Not on file OB History
Gravida 7 Para 4 Term 4 Preterm AB 2 Living 4 SAB 1 TAB Ectopic Molar Multiple Live Births 4
VITAL SIGNS :
BP 108 / 56 | Wt 83.
3 kg | LMP  2/28/2020  (Exact Date) | BMI 31.
35 kg / m² General : Well nourished , well developed female in no acute distress.
Weight gain is documented in the EMR today.
Fetal heart tones are in the normal range by doppler interrogation.
OB labs reviewed today.
ASSESSMENT / PLAN :
Second trimester pregnancy.
Recommendations : Follow up visit is scheduled in four weeks , a prenatal ultrasound is scheduled for fetal anatomy.
Routine early ultrasound is beneficial in leading to early detection of clinically unsuspected malformations (including aneuploidies).
The safety of obstetrical ultrasound is well established.
For women who choose to undergo ultrasound screening for fetal structural anomalies , this is optimally performed in the second trimester (after 20 weeks EGA is standard at our facility).
GUIDELINES FOR TOTAL WEIGHT GAIN IN PREGNANCY : Underweight (BMI<18.
5) ; gain 28 40 lbs (12.
7 to 18.
1 kg) in pregnancy.
Normal weight (BMI 18.
5 25) ; gain 25 35 lbs (11.
3 to 15.
9 kg)
Overweight (BMI 25 30) ; gain 15 25 lbs (6.
8 to 11.
3 kg)
Obese (BMI>30) ; gain 11 20 lbs (5.
0 to 9.
1 kg) DIAGRAM OF WEIGHT DISTRIBUTION AT END OF PREGNANCY : ffd 8 ffe [xxxxxxxx] a [xxxxxxxx] [xxxxxxxx] ffdb [xxxxxxxx] [xxxxxxxx] 080 a 0 c 140 d 0 c 0 b 0 b 0 c [xxxxxxxx] f 141 d 1 a 1 f [xxxxx x. xxxxx] d 1 a 1 c 1 c [xxxxx] e [xxxxxxxx] c 231 c 1 c [xxxxxxxx] c [xxxxxxxx] f [xxxxx] d [xxxxx] c 2 e [xxxxxxxx] ffdb [xxxxxxxx] c 0 b 0 c 180 d 0 d [xxxxxxxx] c [xxxxxxxx] [xxxxxxxx] [xxxxxxxx] [xxxxxxxx] [xxxxxxxx] [xxxxxxxx] [xxxxxxxx] ffc [xxxxxxxx] e 6041 a [xxxxxxxx] [xxxxx] ffc 4001 f [xxxxxxxx] [xxxxxxxx] [xxxxxxxx] [xxxxxxxx] a 0 bffc 400 b [xxxxxxxx] [xxxxxxxx] 0017 d [xxxxxxxx] [xxxxxxxx] [xxxxxxxx] a [xxxxxxxx] b 1 c [xxxxx] d 1 f [xxxxxxxx] a [xxxxxxxx] a [xxxxxxxx] a [xxxxxxxx] a [xxxxxxxx] a [xxxxxxxx] a [xxxxxxxx] a [xxxxxxxx] a [xxxxxxxx] a [xxxxxxxx] 99 aa 2 a 3 a 4 a 5 a 6 a 7 a 8 a 9 aab 2 b 3 b 4 b 5 b 6 b 7 b 8 b 9 bac 2 c 3 c 4 c 5 c 6 c 7 c 8 c 9 cad 2 d 3 d 4 d 5 d 6 d 7 d 8 d 9 dae [xxxxx x. xxxxx] e [xxxxx x. xxxxx] e [xxxxx x. xxxxx] e [xxxxx x. xxxxx] e 9 eaf 1 f 2 f 3 f 4 f 5 f 6 f 7 f 8 f 9 faffc 4001 f [xxxxxxxx] [xxxxxxxx] [xxxxxxxx] [xxxxxxxx] a 0 bffc 400 b [xxxxxxxx] [xxxxxxxx] [xxxxxxxx] [xxxxxxxx] [xxxxxxxx] [xxxxxxxx] a 1 b 1 c [xxxxxxxx] f [xxxxxxxx] d 10 a [xxxxxxxx] e 125 f [xxxxxxxx] a [xxxxxxxx] a [xxxxxxxx] a [xxxxxxxx] a [xxxxxxxx] a [xxxxxxxx] a [xxxxxxxx] a [xxxxxxxx] 98 a [xxxxxxxx] 99 aa 2 a 3 a 4 a 5 a 6 a 7 a 8 a 9 aab 2 b 3 b 4 b 5 b 6 b 7 b 8 b 9 bac 2 c 3 c 4 c 5 c 6 c 7 c 8 c 9 cad 2 d 3 d 4 d 5 d 6 d 7 d 8 d 9 dae [xxxxx x. xxxxx] e [xxxxx x. xxxxx] e [xxxxx x. xxxxx] e [xxxxx x. xxxxx] eaf 2 f 3 f 4 f 5 f 6 f 7 f 8 f 9 faffda 000 c [xxxxxxxx] 03 f 00 f 7 fa 28 a 2800 a 28 a 2800 a 28 a 2800 a 28 a 2800 a 28 a 2800 a 28 a 2800 a 28 a 2800 a 28 a 2800 a 28 a 2800 a 28 a 2800 a 28 a 2800",2021-11-24
32831,706391,32678,4180186,220,"DOCUMENT HEADER :
Progress Notes by Peterson , Gonzalez Humphrey , M. D. at  5/13/2020  7 : 15 AM (continued)
Author : Calderon , Townsend Gonzalez , Mcgregor Finnegan Quintana : HIM (Hospital Internal Medicine) Author Type : Resident
Filed :  5/13/2020  9 : 46 AM Date of Service :  5/13/2020  7 : 15 AM Status : Signed
Editor : Matthews , Eastwood Mcgregor , M. D.
(Resident) *************** (SMC) PROGRESS NOTE
SUBJECTIVE :
Ms.
Calderon has no specific complaints today.
She has done well with a PCA in her room for re direction.
I have reviewed the current medication list.
VITAL SIGNS :
Temperature : [36.
3 °C 38.
9 °C] 36.
3 °C
Heart Rate : [68 97] 78
Resp Rate : [18 34] 21
Blood Pressure : (91 143) / (41 94) 117 / 94 SpO 2 : [90 % 97 %] 95 %
Flow Rate (L / min) : [2 L / min] 2 L / min Pulse Rate : [62 85] 72
PHYSICAL EXAM :
General : Not acutely ill.
Lying in bed comfortably.
Neuro : Alert.
Looks at me suspiciously but does not seem afraid.
Moving all extremities.
Skin : No rashes or lesions.
Eyes : Pupils equal and round.
Sclera anicteric.
ENT : Hearing grossly intact.
Lungs : Clear to auscultation.
No wheezes or crackles.
Heart : Regular rate and rhythm.
No murmurs appreciated.
No lower extremity edema.
Abdomen : Soft , flat , nontender , nondistended , no palpable masses or organomegaly.
Joints : No joint deformities or active synovitis noted.
DIAGNOSTICS :
I have personally reviewed the laboratory data and imaging since admission , and in / outs for past 72 hours.
ASSESSMENT / PLAN :
Ms.
Quintana  5/11/2020  on **************** 2 for evaluation and management of mildhemoptysis in the setting of Pneumonia Due To COVID 19.
Shehas medical comorbidities including Alzheimer disease and HLD.
# 1 Pneumonia Due To COVID 19 # 2 Hemoptysis
# 3 Alzheimer's Disease (HCC)
# 4 Hyperlipidemia ID following.
Enrolled in day of of day 5 CRP guided steroid trial Continue ceftriaxone and doxycycline day 3 of 5.
Wean oxygen as able.
Currently requiring 2 L NC.
Discontinued ASA as she was on only for primary prevention.
Bedside nursing raised concerns about swallowing.
Follow up swallow study.
Olanzapine 5 mg QHS.
Hold home Seroquel 25 mg QHS and galantamine 24 mg until swallow study.
Current activity / mobility : PAMP Level 2 (chairbound , staff moves patient to chair TID)
Diet : NPO until swallow study Tubes / lines : PIV
VTE prophylaxis : enoxaparin
Code status : DNR.
Okay with trial of intubation if needed
DISPOSITION :
Skilled Nursing Facilitywith expected discharge date
Surrogate Decision Maker : Son , Mcgregor(out of contact) so have been communicating withdaughter in law , [XXXXX]
Stable to discharge criteria (not met) : Vital signs Plan discussed with**************** 2 Consultant , Dr.
Faulkner.
Please page the****************** service pager at [xxxxx] with any questions.",2021-09-15
32831,706391,32678,4180186,146,"FULL DOCUMENT TEXT :
Progress Notes by ****** , Mckenzie P , M. D. at  5/20/2020  11 : 14 AM (continued)
Author : ****** , Mclellan P , M. D. Service : HIM (Hospital Internal Medicine) Author Type : Physician
Filed :  5/20/2020  11 : 14 AM Date of Service :  5/20/2020  11 : 14 AM Status : Signed
Editor : ****** , Mcgregor P , M. D.
(Physician) Ms.
Ferguson was seen on rounds this morning.
I have reviewed the laboratory data , imaging and vital signs since admission.
I agree with the history and physical examination , and have jointly developed the assessment and plan as documented today by Dr.
Mckenzie Mcgregor , MD.
Ms.
Faulkner is clinically stable , though has limited oral intake.
She is medically ready for discharge , and hopefully a home environment will encourage her appetite.
The remainder as documented by Dr.
Mcarthur.
Counseling was provided face to face at bedside regarding the plan of care as stated above.
I personally spent over half of a total 20 minutes in counseling and coordination of care as documented above.",2021-06-15
32831,706391,32678,4180186,156,"DOCUMENT HEADER :
Progress Notes by Matthews , Calderon Mckinney , O. T. at  9/24/2020  9 : 00 AM (continued)
Author : Matthews , Humphrey M , Mclellan Humphrey Townsend : PTO Occupational Therapy Author Type : Occupational Therapist
Filed :  9/24/2020  12 : 34 PM Encounter Date :  9/24/2020  Status : Addendum
Editor : Eastwood , Faulkner M , O. T.
(Occupational Therapist)
Related Notes : Original Note by Matthews , Mcarthur M , O. T.
(Occupational Therapist) filed at  9/24/2020  12 : 18 PM Hand Therapy Outpatient Treatment Contact monitoring :
During this hand therapy session , these additional providers assisted : and Faulkner Mckenzie , OTS
PPE used during therapy : Therapist was wearing the following PPE throughout entire session : surgical mask and eye protection
Patient was wearing a mask during therapy session : yes
SUBJECTIVE :
Patient's Name : Eastwood Faulkner Townsend , RN
REFERRING PROVIDER :
Andersen Mclellan , Mcgregor Peterson Andersen Mclellan Gonzalez for referral : s / p right index and long finger extensor tendon lacerations with bone and metacarpal phalangeal joint capsule involvement ; repair  5/12/20  ; pins out  6/11/20 
HISTORY OF PRESENT ILLNESS :
The patient sustained injury to the right index and long finger extensor mechanisms , long finger EDC and index finger metacarpal phalangeal joint capsule and proximal phalanx fractures while using a tablesaw at his home on  5/12/20  .
He was seen through the ****************************** , ********************* on the same date and underwent the following procedures : Of note , he was Covid 19 positive at the time of surgery but has had two negative tests for Covid 19 since that time.
He was seen in follow up with Dr.
Townsend on  5/25/20  and was referred to therapy for fabrication of a right forearm based intrinsic plus orthosis to support pinning of the right index finger as well as instruction in very gentle motion of the right index finger IP joints with slightly more aggressive motion of the right long finger IP joints.
At four weeks , can begin middle finger extensor tendon protocol.
On  6/1/20  continued with gentle active range of motion rehabilitation of index PIP.
Patient had a follow up with Dr.
Humphrey on  6/11/20  and he can begin active range of motion.
The patient was seen on  7/14/2020  for follow up with Dr.
Humphrey and can now progress to 8 hour days of work as well as strengthening.
Rehab Diagnosis :
1.
Limitation Of Motion Hand Joint Right Payor : ******************** / Plan :****************** / Product Type : PPO / Precautions / Restrictions :
Activity as tolerated Total Outpatient Visit Count in Hand Therapy : 16 Subjective Comments from the Patient : The patient arrives stating things have been going well , he has returned to functional activities without difficulties.
Notes that at work he can start I Vs using his right hand without a problem.
States some mild soreness today just because he was stretching before he came in.
Per x ray on  7/14/20  :
IMPRESSION :
Comminuted , displaced intraarticular fracture base and proximal
shaft of the proximal phalanx right 2 nd finger.
The fracture is radiographically
ununited.
Soft tissue swelling and surgical clips about the fracture site and
MCP joint.
PO change from K wire removal.
Osteopenia.
PHYSICAL EXAM :
Pain Assessment
Pain Assessment : 0 10 Numeric Pain Intensity Scale
Pain Score : (0.
5)
Pain Type : Acute pain Appearance :
Incision on dorsal hand is well healed.
Scar is mildly adhered Edema :
Mild to no edema hand and wrist (  9/24/02  ) Active Range of Motion :
Finger flexion lags index small (in cm) : 1.
8 / 0 / 0 / 0 (unchanged)
Finger extension lags index small (in cm) : 1.
5 / 0 / 0 / 0.
5 (was [2_28] / 0.
5 / 0.
5) Index Finger Active range of motion :
MP : 0 65 degrees (was 8 70 degrees)
PIP : 25 degrees 84 degrees (was 25 84 degrees)
DIP : 0 43 degrees (was 6 38 degrees) Grip strength :
Right : 38 kg (was 33 kg)
Left : 58 kg (unchanged) Lateral pinch measurements :
Right : 10.
5 kg (was 9 kg)
Left : 11 kg (was 13 kg) Three point pinch measurements :
Right : 9 kg (was 6.
3 kg)
Left : 9.
8 kg (was 11 kg) Skilled Therapy Intervention Performed Today :
Contrast baths
Paraffin
Joint distraction Therapeutic exercise : Grade II III joint mobilizations to the MP joint in anterior / posterior plane for several minutes , followed by prolonged passive stretch to the MP joint both in isolation and combined MP / PIP / DIP joint flexion.
Patient was instructed during this time how to perform gentle joint distraction and oscillations to his MP joint for an improved stretch.
He was instructed to continue prolonged self stretch of the his MP joint when he notes an increase in index stiffness.
We did discuss that the patient trying to use his hand more was likely what was keeping him functional and with improved motion.
He was encouraged to continue using his hand for daily activities , both fine and gross motor.
Patient indicated good understanding.
Discussed with patient the use of paraffin baths vs contrast baths for times when he experiences increased stiffnes",2020-08-01
32831,706391,32678,4180186,242,"DOCUMENT HEADER :
Progress Notes by Quintana , Humphrey Townsend , M. D. , Ph.
D. at  5/9/2020  10 : 04 AM (continued)
Author : Mcarthur , Mcarthur Petersen , M. D. , Ph.
D. Service : IFD (Infectious Diseases) Author Type : Physician
Filed :  5/9/2020  10 : 46 AM Date of Service :  5/9/2020  10 : 04 AM Status : Addendum
Editor : Humphrey , Mckenzie Eastwood , M. D. , Ph.
D.
(Physician)
Related Notes : Original Note by Faulkner , Finnegan Mclellan , M. D. , Ph.
D.
(Physician) filed at  5/9/2020  10 : 43 AM The patient was not personally interviewed or examined.
The history and examination findings are based on the clinical documentation provided and / or discussed with a physician or provider who had personally interviewed and examined the patient.
Infectious Diseases COVID Inpatient e Consult Progress Note
REASON FOR CONSULT :
Patient is a ** y. o. female admitted  5/3/2020  being followed by infectious diseases e Consult service for COVID pneumonia.
HISTORY OF PRESENT ILLNESS :
Mrs.
Mckenzie was diagnosed with COVID 19 pneumonia on  4/28/2020  when she had a positive PCR.
She resides in a memory care facility and was transferred to **** on 418 / 20 for further care.
She is being treated for possible secondary bacterial pneumonia with ceftriaxone and doxycycline however her course has been completely consistent with COVID 19.
She was started on a steroid protocol , however this was discontinuedon [5_6] due to concerns it with aggravating delirium and agitation.
She received her 1 st dose of drug / placebo in the IL 6 inhibitor study sarilumab on [5_6] .
She received 2 nd dose on [5_7] .
.
Events over the past 24 hours : Stable Still requiring 5 L NC.
Afebrile.
OBJECTIVE :
Admission Weight : 61.
9 kg
Current Weight : 63.
5 kg
VITAL SIGNS :
Temperature : [36.
5 °C 36.
8 °C] 36.
5 °C
Heart Rate : [73 75] 73
Resp Rate : [20 24] 20
Blood Pressure : (78 146) / (43 97) 110 / 56 SpO 2 : [80 % 100 %] 91 %
Flow Rate (L / min) : [4.
5 L / min 5 L / min] 5 L / min Pulse Rate : [62 88] 66 Intake / Output Summary (Last 24 hours) at  5/9/2020  1006
Last data filed at  5/8/2020  1422
Gross per 24 hour
Intake 1000 ml
Output 250 ml
Net 750 ml
DIAGNOSTICS :
I have reviewed diagnostics.
Studies of note include :
Estimated Creatinine Clearance : 73.
7 mL / min (A) (by C G formula based on S Cr of 0.
57 mg / dL (L)).
WBC 7.
7 CRP 65.
1
MEDICATIONS :
She is off antimicrobials (ceftriaxone and doxy discontinued after total of 5 days)
ASSESSMENT / PLAN :
# 1 Pneumonia Due To COVID 19 # 2 Alzheimer's Disease (HCC)
# 3 Hyperlipidemia
# 4 Elevated D dimer at risk for thrombosis Date of symptom onset was approximately  4/28/20  .
Date of positive NP testing for SARS CoV 2 was  4/28/20  .
 5/4/20  PCR was again + for COVID 19.
RECOMMENDATIONS 1.
Daily CBC , CRP , Creatinine , AST.
Surveillance blood cultures on day 7 and day 15 from drug administration for the Sariluma study if the patient is still in the hospital.
2.
No other specific recommendations outside of excellent supportive care being delivered by pulmonary team.
3.
Agree with prophylactic Enoxaparin She is at high risk of thrombosis
4.
QuantiFERON was indeterminate and this needs follow up as outpatient.
This case was reviewed with the COVID treatment panel.
Thank you for this consult.
Will continue to follow.
Please page 127 [xxxxx] if questions.
# 1 Pneumonia Due To COVID 19 # 2 Alzheimer's Disease (HCC)
# 3 Hyperlipidemia ********** , M. D. , Ph.
D.",2020-11-05
32831,706391,32678,4180186,264,"DOCUMENT HEADER :
Progress Notes by Mcgregor , Eastwood M , M. D. at  4/24/2020  6 : 35 AM (continued)
Author : Mckinney , Calderon M , Matthews Humphrey Calderon : CCM (Critical Care Medicine) Author Type : Resident
Filed :  4/24/2020  10 : 12 AM Date of Service :  4/24/2020  6 : 35 AM Status : Signed
Editor : Matthews , Finnegan M , M. D.
(Resident) MICU 2 PROGRESS NOTE
SUBJECTIVE :
******************** a ** y. o. malewith type 2 D Mwho presented to***** Dwith one week of cough , dyspnea , abdominal pain , and fevers in the setting of multiple sick contacts and was found to have COVID 19 infection.
He was initiated on the sarilumab trial on  4/20/20  .
The paralytic was turned off last evening , and the patient did well with FiO 2 35% for the majority of the night ; PF ratio was 220.
Around 5 AM , the patient had increasing FiO 2 needs to 50% and PEEP from 14 to 15.
He was noted to be desynchronized from the ventilator.
This was transient , and FiO 2 was able to be reduced to 40% with PF ratio 172.
5.
VITAL SIGNS :
Temperature : [37.
6 °C 38.
4 °C] 38.
2 °C
Heart Rate : [72 104] 80
Resp Rate : [18 29] 20
Blood Pressure : (94 140) / (64 79) 109 / 68 FiO 2 (%) : [35 % 70 %] 50 % SpO 2 : [89 % 100 %] 95 %
Pulse Rate : [72 104] 80 Intake / Output Summary (Last 24 hours) at  4/24/2020  0635
Last data filed at  4/24/2020  0600
Gross per 24 hour
Intake 3713.
31 ml
Output 4486 ml
Net 772.
69 ml
PHYSICAL EXAM :
Not performed due to limiting number of providers in Covid patient room.
General : Intubated and sedated.
LABS :
Recent Labs  4/23/20  2258  4/23/20 
2024  4/23/20 
1641
NA 137
K 4.
0
CL 103
BICARB 22
MG 1.
8
CALCIUM 8.
1 L
BUN 18
CREATININE 0.
56 L
GLUCOSE 166 H 194 H
ALBUMIN 2.
7 L PCO 2 ART 39 < > PHART 7.
38 < > PO 2 ART 77 L < > HCO 3 ART 23 < > < > = values in this interval not displayed.
ASSESSMENT / PLAN :
******************** a ** y. o. malewith type 2 D Mwho presented to***** Dwith one week of cough , dyspnea , abdominal pain , and fevers in the setting of multiple sick contacts and was found to have acute hypoxic respiratory failure in the setting of COVID 19 infection.
He was initiated on the sarilumab trial on  4/20/20  .
Neuro
# Sedation
# Pain Sedation : Propofol , fentanyl Oxygenation and ventilator synchrony adequate off of paralytic Wean sedation to RASS goal 1 , use lorazepam 1 mg IV q 4 h PRN for anxiety , nausea / vomiting [XXXXX] add dexmedetomidine if needed for agitation and anxiety Acetaminophen 1000 mg q 6 h PRN for mild pain and fevers > 38.
4 C Pulmonary
# COVID 19 pneumonia
# Acute hypoxemic respiratory failure
# ARDS secondary to COVID 19 pneumonia
# Left midlung consolidation Patient intubated on [4_22] ; paralytic added on [4_23] due to ventilatory dyssynchrony PF ratio this morning 172.
5 Wean sedation as able and consider for extubation today Diuresis as outlined in RENAL Cardiovascular
# Hypotension , resolved [XXXXX] utilize norepinphrine to maintain MAP goal >65 ; currently stable off of NE GI
# Nausea
# GERD
# Nutrition Continue pantoprazole 40 mg IV for GI prophylaxis while intubated Continue tube feeding ; appreciate dietician recommendations If propofol is discontinued , continue Replete with standard initiation and advancement to goal rate 50 mL / hr continuous and discontinue PRO Source Bowel regimen : MiraLAX daily , Senokot S 1 tablet BID , bisacodyl suppository daily Renal
# Hypokalemia Diuresed to net 514.
7 mL yesterday with total of furosemide 180 mg IV Continue diuresis with furosemide boluses , goal net 1 L today Replete potassium as needed Creatinine at 0.
57 (0.
43 yesterday) Strict I&Os , daily weights Heme
# Normocytic anemia
# Thrombocytosis Hemoglobin 10.
8 , platelets 462 Likely secondary to acute inflammation , continue to monitor Infectious Disease
# COVID 19 pneumonia
# Possible superimposed bacterial pneumonia
# Fever of unknown origin WBC : 14.
9 on admission , now 11.
5 (up from 8.
0 yesterday) Continues to have fevers (38.
4 C at 19 : 00 on [4_23] , 38.
2 C at 06 : 00 on [4_24] ) Blood cultures from [4_18] : NGTD Blood cultures from [4_23] : NGTD Influenza / RSV , Strepcoccus pneumoniae urine antigen , and Legionella urine antigen negative Obtain tracheal secretion cultures today S / p ceftriaxone 2 g q 24 hand doxycycline 100 mg BID for 5 day course (  4/18/04  / 21) MRSA swab from [4_23] negative , stop vancomycin Continue piperacillin tazobactam 3.
375 g q 6 h ( [4_23] current) ID following , appreciate recommendations Initiated on sarilumab trial for hospitalized patients (phase [2_4] , randomized , double blind , placebo controlled study) ; first dose [4_20] > Obtain daily CRP (272.
1 compared to 170.
0 yesterday) Endocrine
# Type 2 diabetes mellitus
· Glucose 140 182 within the last 24 hours ; received total of 10 U of i",2021-01-14
32831,706391,32678,4180186,112,"DOCUMENT HEADER :
Plan of Care by Peterson , Matthews Peterson , R. R. T. , Quintana Quintana Townsend at  5/2/2020  2 : 56 AM (continued)
Author : Townsend , Quintana Mclellan , R. R. T. , Calderon Mckenzie Petersen Townsend : RT (Respiratory Therapy) Author Type : Respiratory Therapist
Filed :  5/2/2020  2 : 57 AM Date of Service :  5/2/2020  2 : 56 AM Status : Signed
Editor : Petersen , Finnegan B , R. R. T. , Andersen Mckenzie Petersen (Respiratory Therapist) Patient is a ** y. o. female admitted on  4/30/2020  Alert Information : Over night :
Patient remained on nasal cannula overnight , no other respiratory interventions needed.
Plan of Care :
Continue to assess respiratory status while in the ICU , oxygen Therapy as needed , manage respiratory med.
and hemodynamic lines.
Problems :
# 1 Seizure (HCC)
# 2 Care Postpartum And Lactating (HCC)
# 3 Cannabis Mild Use Disorder (Abuse) Uncomplicated
# 4 Cesarean Section Delivery (HCC)
# 5 COVID 19 Infection
# 6 Drug Use Complicating Pregnancy Third Trimester
# 7 Eclampsia In The Puerperium (HCC) Oxygen Therapy
$Delivery Method : Nasal cannula
SOCIAL HISTORY :
Tobacco Use
Smoking Status Never Smoker
Smokeless Tobacco Never Used @LABRCNT 24 COMMON(PO 2 ART , PCO 2 ART , pH ART)",2020-10-13
32831,706391,32678,4180186,170,"DOCUMENT HEADER :
Plan of Care by Peterson , Gonzalez A , Faulkner Humphrey Gonzalez , Eastwood Finnegan Quintana at  3/28/2020  4 : 32 PM (continued)
Author : Mckinney , Mcarthur A , R. R. T. , Finnegan Mckinney Calderon Mclellan : RT (Respiratory Therapy) Author Type : Respiratory Therapist
Filed :  3/28/2020  4 : 34 PM Date of Service :  3/28/2020  4 : 32 PM Status : Signed
Editor : Andersen , Mckinney A , R. R. T. , Mcarthur Peterson Mckenzie (Respiratory Therapist) Patient is a ** y. o. male admitted on  3/27/2020  Plan of Care : Patient remains on high flow nasal cannula.
Current settings are FiO 2 35% and Flow 50 LPM.
We will continue to monitor and assess his respiratory status per protocol and titrate Opti Flow as tolerated.
Principal Problem
# 1 Cough
# 2 Diabetes Mellitus Type 2 Hyperglycemia (HCC)
# 3 Hyponatremia
# 4 Hypokalemia
# 5 Pneumonia
# 6 Acute Respiratory Distress Oxygen Therapy
$Delivery Method : High flow cannula
SOCIAL HISTORY :
Tobacco Use
Smoking Status Former Smoker No results for input(s) : PO 2 ART , PCO 2 ART , PH ART in the last 24 hours.",2021-05-23
32831,706391,32678,4180186,216,"DOCUMENT HEADER :
Progress Notes by [XXXXX] , Peterson Gonzalez , P. T. , Matthews Finnegan Andersen at  4/3/2020  10 : 28 AM (continued)
Author : [XXXXX] , Faulkner Peterson , P. T. , Mclellan Mclellan Townsend Quintana : PTO Physical Therapy Author Type : Physical Therapist
Filed :  4/3/2020  10 : 31 AM Date of Service :  4/3/2020  10 : 28 AM Status : Signed
Editor : [XXXXX] , Matthews Gonzalez , P. T. , Andersen Humphrey Matthews (Physical Therapist) Physical Therapy Inpatient Treatment Note
SUBJECTIVE :
Patient's Name : Townsend Faulkner Calderon Referring / Attending : Gonzalez , *********** M , M. D.
Medical Diagnosis : Shortness Of Breath [R 06.
02]
Dyspnea [R 06.
00]
Reason for Referral : PT Evaluate and Treat
Onset Date :  3/28/20 
Payor : UCARE / Plan : UCARE MN CARE / Product Type : Medicaid HMO /
HISTORY OF PRESENT ILLNESS :
He was found to be SA Rs coronavirus 2 positive on  3/10/2020  .
He was admitted to the ICU for acute hypoxic respiratory failure secondary to COVID pneumonia.
Patient / Caregiver Goals : To ride his motorcycle this summer
Patient Comments : Patient supine in bed upon therapist arrival ; patient agreeable to therapy.
Activity Orders (From admission , onward) Start Ordered  3/29/20  0121 Activity : Up Ad Lib Until discontinued Question : Activity Level : Answer : Up Ad Lib  3/29/20  0122  3/29/20  0121 Aspiration precautions Continuous  3/29/20  0122 Precautions
Other Precautions : fall , hard of hearing , cognition , hx chemotherapy (not curently on precautions) , COVID +
Fall Risk (65 and older)
Fall in the last 12 months : No
Are you fearful of falling?
: No
OBJECTIVE :
Vitals taken during session : O 2 flow : 3 L / min nasal cannula
At rest : 98% O 2 Following mobility : 87 88% O 2 Return to 90's after 1 minute of rest Treatment consisted of :
Bed Mobility Supine to Sit
Level of Assistance : Supervision / Set up Device : None
Comments : Able to complete with supervision and cues for sequencing and motivation Transfer Sit to Stand
# of Assistants : 1
Device : Front wheeled walker
Level of Assistance : Minimal assistance(Contact guard assist for safety)
Comments : Verbal cues and education given to not place both hands on walker when standing and to have at least one hand on stable surface.
Transfer Stand to Sit
# of Assistants : 1
Level of Assistance : Minimal assistance(Contact guard assist for safety)
Device : Front wheeled walker
Comments : Good use of hands to control descent Gait Training
# of Assistants : 1
Level of Assistance : Minimal assistance(contact guard assist for safety)
Device : Front wheeled walker
Distance (m) : 46 m
Surface : flat
Cuing : Verbal
Assessment of Gait : Patient ambulating with downward gaze , decreased step length bilaterally , and decreased gait speed.
Improved stability with use of front wheeled walker ; proper use of front wheeled walker today.
Increased time for task during turns Training / Intervention : Verbal cues to improve posture and step length
Response : Transient improvement Exercise Position
Seated Exercise : Long arc quads , Marching Education provided this session : Patient and caregivers educated on the importance of mobilizing throughout the day as tolerable with nursing staff.
The following coordination of care occurred today :
Contacted Patient's nurse regarding patient status
Patient was left in bedside chair at end of session with call light in reach , all needs met and questions answered.
Outcome Measures AM PAC Basic Mobility (V.
2) How much help from another person do you currently need…If the patient hasn't done an activity recently , how much help from another person do you think he / she would need if he / she tried?
1.
Turning from your back to your side while in a flat bed without using bedrails?
: A Little
2.
Moving from lying on your back to sitting on the side of a flat bed without using bedrails?
: A Little
3.
Moving to and from a bed to a chair (including a wheelchair)?
: A Little
4.
Standing up from a chair using your arms (e. g. , wheelchair , or bedside chair)?
: A Little
5.
To walk in hospital room?
: A Little
6.
Climbing 3 5 steps with a railing?
: A Lot AM PAC Basic Mobility (V.
2) Raw Score : 17 AM PAC Basic Mobility (V.
2) Standardized Score : 39.
67
Interpretation : Clinicians answer the AM PAC Inpatient Short Form based on observed patient activity and / or clinical judgement (ie.
patient can be scored without physically performing each activity) According to scoring guidelines :
Those going to home had an average score of 20.
1
Those going home with home care had an average score of 17.
9
Those going to SNF had an average score of 14
Those going to IRF had an average score of 13.
6
Those going to a LTAC had an average score of 11.
5
ASSESSMENT :
Additional Staff Present During Session : 1 : 1 PCA present Discharge Recommendation : Ongoing skilled therapy recommended in a post acute setting From a physical therapy perspective , the level of care above has been recommended for Mr.
M",2021-03-01
32831,706391,32678,4180186,66,"DOCUMENT HEADER :
Progress Notes by Eastwood , [XXXXX] H , Mckenzie Mckinney at  6/3/2020  6 : 07 PM (continued)
Author : Ferguson , [XXXXX] H , Andersen Ferguson Gonzalez : RM Remote Monitoring Author Type : Registered Nurse
Filed :  6/3/2020  6 : 28 PM Encounter Date :  6/3/2020  Status : Signed
Editor : Quintana , [XXXXX] H , Humphrey Mckenzie (Registered Nurse) Remote Patient Monitoring RN Symptomology Call Primary reason for today's contact : COVID 19 Symptom Assessment : Life Stream alert for 81% SPO 2.
Patient had respiratory rate in the [xxxxx x. xxxxx] nurse called on the phone.
Shortness of breath and respiratory rate did not improve with rest.
Symptom Assessment :
Respiratory : shortness of breath
Patient reports current respiratory effort / distress as experiencing shortness of breath at rest.
Fever : Denies fever
Patient does not have the chills and does not have sweats.
GI : Denies vomiting / diarrhea Patient does not have lightheadedness and does not feel as if they are going collapse every time they stand or sit up.
Patient does not have new or worsening leg swelling.
Recommendation : Emergency Department and Provider Advice
PATIENT EDUCATION :
Patient and / or caregiver was instructed on :
· Self care plan Immediately go to the emergency department.
Patient / caregiver able to teach back.
Patient headed to ******* ED and his wife will drive him.
The following references were used : IPAC ********* , Nursing judgement Plan of Care / Next Steps :
Endpoint recommendation : Emergency Department and Provider Advice
Patient is currently using supportive care measures of rest.
Caller agreeable to plan of care : Yes Patient agrees to continue daily vital sign monitoring and follow up call scheduled.
Patient agreed to call Remote Patient Monitoring nurse with any questions or concerns in the interim.",2021-11-08
32831,706391,32678,4180186,7,"FULL DOCUMENT TEXT :
Telephone Encounter by Petersen , Matthews Matthews at  8/27/2020  9 : 02 AM (continued)
Author : **** , Mclellan Matthews Mckenzie : PED Neurology Author Type : Clerk
Filed :  8/27/2020  9 : 03 AM Encounter Date :  8/27/2020  Status : Signed
Editor : **** , Faulkner Mclellan (Clerk) 1.
Is the patient requesting a COVID test only or other appointments?
Other Appointments 2.
Have you tested positive for COVID 19 in the last 30 days or do you have a pending COVID 19 test because you had symptoms?
no 3.
In the last 14 days have you had close contact with a lab confirmed positive case of COVID 19 (close contact is defined as a household case of COVID or being within 6 feet of a COVID 19 patient for more than 5 minutes or having direct contact with infectious secretions , e. g. , being coughed on)?
no 4.
In the past 14 days , are any of the following symptoms new to you and not related to an existing health condition?
a. Fever greater than or equal to 37.
8 C (100.
0 F)?
no b. New symptoms (Specifically : headache , cough , shortness of breath , respiratory distress , sore throat , diarrhea , nausea , vomiting , chills and repeated shaking with chills , myalgia's (muscle aches) , loss of smell , or change or loss of taste sensation)?
no 5.
Are you having NEW trouble breathing , worsening breathing , or feeling as though you're going to collapse when you stand or sit up?
no 6.
Have you tested positive for COVID in the last 90 days?
no Route reply to : rst ped gyn scheduling Scheduling Contact Number : 4 9574 I have read and confirmed the visitor policy with Finnegan Petersen Finnegan and family.
They have confirmed they will comply with the one visitor policy.",2020-08-21
32831,706391,32678,4180186,184,"DOCUMENT HEADER :
Progress Notes by Mclellan , Quintana Eastwood , RDN , LD / N at  5/18/2020  1 : 36 PM (continued)
Author : Mcarthur , Gonzalez Humphrey , RDN , LD / N Service : NTR (Nutrition) Author Type : Registered Dietitian
Filed :  5/18/2020  1 : 41 PM Date of Service :  5/18/2020  1 : 36 PM Status : Signed
Editor : Petersen , Gonzalez Townsend , RDN , LD / N (Registered Dietitian) Nutrition Support Note Visit Information
REFERRING PHYSICIAN : Mcarthur Humphrey / ICU Consult triggered due to : Enteral Nutrition
REASON FOR ADMISSION :
PMH of HTN , HLD , DM 2 , and CKD on HD MWF , currently being evaluated for liver transplantation.
Pt is admitted  4/16/20  for evaluation of generalized fatigue and shortness of breath with a productive cough for about a week.
Also reports diarrhea.
No fevers.
Chest imaging revealing for pulmonary infiltrates atypical for pulmonary edema.
Given presentation , COVID testing collected by Townsend.
COVID 19 Result : POSITIVE Reviewed
PAST MEDICAL HISTORY :
Diagnosis Date
• Atrial Fibrillation (HCC)  4/23/2020 
• Benign Prostatic Hyperplasia Localized
• Diabetes Mellitus Type 2 (HCC) 2005
• Dialysis Dependent (HCC)  9/8/2016 
• Hyperlipidemia
• Hypertension NOS
• Polyp Colon
• Renal Disease Since admission :
 4/17/20  : Pt is intubated and sedated in the ICU.
TF were started via OGT.
Did not visit room due to current precautions.
 4/19/20  : Currently intubated , on mechanical ventilation , on vasopressors , paralytics , and has started CRRT.
Hypothermia overnight.
Corpak in stomach with TF infusing.
 4/23/20  : Clinical course not significantly changed with pt continuing on mechanical ventilation , paralytics , sedation , CRRT and TF.
 4/26/20  : Pt remains on vent support with sedation , CRRT , labile blood pressure and today required resumption of paralytics.
 5/1/20  : TF , continues via NG tube.
Noted clog with interruption in infusion , but now running w / o issues per d / w RN.
Propofol d / c , per d / w team they are transitioning to ketamine for sedation.
CRRT d / c , now on PIRRT
 5/4/20  : Pt has transferred back to ICU requiring noninvasive ventilatory support.
PIRRT was cut short overnight , but plan will be to continue this modality of dialysis , monitoring transition to IHD.
TF are infusing via Corpak (replaced on [5_2] terminating in stomach).
 5/7/20  : Pt has had decreasing oxygen requirements , now on NC but noted to have ICU delirium.
PIRRT continues , likely transition to IHD soon , will continue to monitor dialysis modality and need to adjust nutrition accordingly.
SLP assessed [5_6] and noted weak oromusculature with absent swallow.
Mcarthur continues for nutrition support.
 5/10/20  : Pt is now on IHD , received today.
Delirium has continued.
SLP plans to evaluate pt but at this time he remains with Mcarthur for nutrition support , with TF at goal.
Decreased stool output in past 4 days.
 5/14/20  : Pt cleared for oral diet , on Renal w / o straws noted.
Mckenzie remains in place , however held and calorie count started.
Pt ate 100% of BF this am , 100% of a burger patty at lunch , and just ordered a cookie and some sherbet per d / w RN.
Pt refusing to speak with other caretakers in the last hour or so noted.
Please see calorie counts below.
 5/15/20  : Pt on Renal diet.
TF on hold.
Corpak in place , however corpak is barrier for discharge.
Tried to call pt's room but no answer.
Per RN , pt missed breakfast due to dialysis but had applesauce.
Pt ate 100% of lunch.
 5/18/20  : unable to reach pt or RN after multiple attempts.
Per MD note today , pt complained of upset stomach and nausea , no vomiting today.
Per room service , patient ordering 3 meals / d however unable to assess amount of po consumed.
Calorie counts :
 5/14/20  : 884 kcal ; 57 g protein ( B , L , D)
 5/15/20  : 407 kcals , 21 gm protein
SUBJECTIVE :
Diet History
Unable to obtain on admission , follow up as able Weight History
Wt Readings from Last 6 Encounters :
 5/18/20  83.
2 kg
 4/5/20  87 kg
 3/20/20  87.
8 kg
 3/25/19  94.
7 kg
 3/25/19  94.
7 kg
 4/7/18  96.
9 kg Weight change
Unable to determine
Unable to determine wt change on admission , will follow up Nutrition Related Problems
Complains of
Nausea , upset stomach Functional Capacity
Suboptimal
OBJECTIVE :
Anthropometrics
Height : 177.
8 cm
Admission Weight : 83.
9 kg
Current Weight : 83.
2 kg
BMI (Calculated) : 26.
3 kg / m² Weight change since admission : 0.
7 kg Diet Order Dietary Orders (From admission , onward) Start Ordered  5/18/20  0840 Adult Diet Regular ; Renal (Dialysis) Diet effective now Comments : NO STRAWS
please bring early on dialysis days (Tu Th Sa) Question
Answer
Comment Diet texture :
Regular Other restrictions :
Renal (Dialysis) Tray type :
Early tray  5/18/20  0839  5/15/20  1340 Oral supplement Finnegan (vanilla) ; Take at : Breakfast , Lunch , Dinner Until discontinued Question
Answer
Comment Supplement :
Nepro (vanilla) Take at : Breakfast",2020-11-10
32831,706391,32678,4180186,194,"FULL DOCUMENT TEXT :
Telephone Encounter by Ferguson , Gonzalez Mckinney , R. N. , CPN , RNC NIC at  5/18/2020  3 : 00 PM (continued)
Author : Petersen , Mcarthur Ferguson , R. N. , CPN , RNC NIC Service : PED (Pediatrics) Author Type : Registered Nurse
Filed :  5/18/2020  3 : 04 PM Encounter Date :  5/16/2020  Status : Signed
Editor : Mckinney , Mcgregor Andersen , R. N. , CPN , RNC NIC (Registered Nurse) Public Health RN returned call and let us know that she spoke with family earlier and provided Townsend's phone number for me for future calls.
Personal # for Peterson : [xxx_xxx_xxxx] Public health RN stated that Calderon was doing very well this morning and is asymptomatic.
They actually have been doing a 10 day quarantine for her per ** guidelines since she tested positive on [5_8] .
They then direct all household members to quarantine for an additional two weeks AFTER the 10 days has been completed.
I let public health RN know that we will defer to their quarantine recommendations as they are in ** with different guidelines.
Plan to check in on  5/22/2020  at the end of our 15 day monitoring and then defer to ** guidelines for family quarantine.",2021-05-24
32831,706391,32678,4180186,14,"DOCUMENT HEADER :
Consults by Matthews , Mcgregor Ferguson , M. D. at  8/1/2020  2 : 50 AM (continued)
Author : Mckinney , Eastwood Quintana , Ferguson Faulkner Mclellan : GNS General Surgery Author Type : Resident Unlicensed DEA
Filed :  8/1/2020  4 : 21 AM Date of Service :  8/1/2020  2 : 50 AM Status : Signed
Editor : Mcgregor , Humphrey Mckinney , M. D.
(Resident Unlicensed DEA) GENERAL SURGERY CONSULT NOTE
CHIEF COMPLAINT / REASON FOR VISIT :
Abdominal pain
HISTORY OF PRESENT ILLNESS :
Townsend Mcgregor is a ** yo F with history of CLL , T 2 DM , HTN , recently hospitalized for hypoxic respiratory failure due to Covid 19 pneumonia (  7/17/08  / 10) , who now presents to the hospital with acute onset abdominal pain after eating dinner.
During the patient's previous admission , she required high flow oxygen and was able to be weaned to room air over 3 days.
She received IV steroids , IV Remdesivir , convalescent plasma , IV Azithromycin and Rocephin.
She reports that after discharge , she was doing relatively well up until last night.
After eating dinner , she developed acute onset epigastric abdominal pain.
She initially thought it was just gas pains , so she rested and attempted to have a bowel movement.
She was able to have multiple small , soft bowel movements , no diarrhea or constipation.
However this did not improve her symptoms and the pain was severe enough to keep her from sleeping.
She spoke with her PCP who recommended she present to the ED.
In the ED , the patient was afebrile with HR 80 90's.
Labs were remarkable for leukocytosis to 18.
2 , lactate 1.
10.
CT abd / pelvis was obtained which showed a segment of jejunum with wall thickening and surrounding mesenteric congestion and edema , worrisome for nonocclusive ischemia.
It also captured her lung bases which showed severe but improved airspace disease consistent with history of Covid 19.
Due to the concern for mesenteric ischemia , General Surgery was consulted for further evaluation and management.
CURRENT MEDICATIONS :
Current Facility Administered Medications :
• acetaminophen tablet 1 , 000 mg (TYLENOL) , 1 , 000 mg , oral , Q 6 H PRN , Quintana , Andersen Humphrey , APRN , M. S. , ACNP BC • heparin (porcine) 1 , 000 unit / mL injection 3 , 800 Units , 40 Units / kg (Dosing Weight) , intravenous , PRN **OR** heparin (porcine) 1 , 000 unit / mL injection 7 , 700 Units , 80 Units / kg (Dosing Weight) , intravenous , PRN , Mcgregor , Andersen Calderon , APRN , M. S. , ACNP BC • heparin (porcine) 100 Units / mL in D [xxxxx x. xxxxx] mL infusion , 0 40 Units / kg / hr (Dosing Weight) , intravenous , Continuous , Finnegan , Andersen Townsend , APRN , M. S. , ACNP BC , Last Rate : 17.
3 mL / hr at  7/31/20  2225 , 18 Units / kg / hr at  7/31/20  2225
• insulin aspart U 100 injection 0 13 Units (NovoLOG Flex Pen) , 0 13 Units , subcutaneous , TID , Townsend , Ferguson Mcgregor , APRN , M. S. , ACNP BC • levothyroxine tablet 50 mcg (SYNTHROID , LEVOTHROID) , 50 mcg , oral , Daily before breakfast , Ferguson , Humphrey Mckinney , APRN , M. S. , ACNP BC • Na Cl 0.
9% infusion , 100 mL / hr , intravenous , Continuous , Mckinney , Townsend Andersen , APRN , M. S. , ACNP BC , Last Rate : 100 mL / hr at  7/31/20  2236 , 100 mL at  7/31/20  2236
• ondansetron (PF) injection 4 mg (ZOFRAN) , 4 mg , intravenous , Q 6 H PRN , Petersen , Mcarthur Finnegan , APRN , M. S. , ACNP BC • piperacillin tazobactam in dextrose (iso osm) IVPB 3.
375 g (ZOSYN) , 3.
375 g , intravenous , Q 6 H , Finnegan , Petersen Mckinney , APRN , M. S. , ACNP BC , Last Rate : 100 mL / hr at  7/31/20  2048 , 3.
375 g at  7/31/20  2048
ALLERGIES :
No Known Allergies
REVIEW OF SYSTEMS :
A complete review of systems was performed , all of which were negative except as noted in the HPI.
PAST MEDICAL HISTORY :
Diagnosis Date
• Diabetes Mellitus Type 2 (HCC)
• Fatty Liver
• Hypertension Essential Primary
• Hypogammaglobulinemia (HCC)
on weekly SQ IVIG
• Hypothyroidism
• Leukemia Lymphocytic Chronic Not Having Achieved Remission (HCC)
• Unspecified Ovarian Cyst Left Side
PAST SURGICAL HISTORY :
History reviewed.
No pertinent surgical history.
FAMILY HISTORY :
Problem Relation Age of Onset
• Diabetes mellitus type II Mother
• Hypertension Mother
• Cirrhosis Father
SOCIAL HISTORY :
Tobacco Use
• Smoking status : Former Smoker
• Smokeless tobacco : Never Used
Substance Use Topics
• Alcohol use : Not on file
• Drug use : Not on file
PHYSICAL EXAMINATION :
GENERAL : No acute distress.
Resting comfortably at time of exam.
HEENT : Normocephalic , atraumatic.
EOM grossly intact.
No scleral icterus.
CV : Regular rate and rhythm.
No jugular venous distention.
No lower extremity edema.
RESP : Mild cough , no respiratory distress on room air.
No use of accessory muscles
GI : Soft , non distended , tender to palpation in the epigastrium.
Non tender in other quadrants.
No rebound , guarding or peritonitis
GU : Voiding independently
NEURO : CN II XII grossly intact.
No focal neurologic deficits noted.
PSYCH : Appropriate mood and affect.
Appropriate insight and judgement.
EXTREMITIES : Full ROM in all 4 extremities.
Recent Results (from the past 24 hour(s))
Basic Metabolic Panel
Collection Time :  7/31/20  2 : 47 PM
Result Value
Potassium , S 4.
6 Sodium ,",2020-06-18
32831,706391,32678,4180186,239,"FULL DOCUMENT TEXT :
Progress Notes by Mckenzie , Mcarthur Townsend , Andersen Peterson at  4/17/2020  3 : 02 PM (continued)
Author : Faulkner , Ferguson Mcgregor , Andersen Ferguson Peterson : CM Care Management Author Type : Case Manager
Filed :  4/17/2020  3 : 09 PM Date of Service :  4/17/2020  3 : 02 PM Status : Signed
Editor : Andersen , Matthews Matthews , R. N.
(Case Manager) Pt.
admitted from Clinic appt.
w / pain issues.
.
Pt.
has history of chronic native left hip osteomyelitis who is now 3 weeks s / p I&D of the left hip with antibiotic bead placement.
He was COVI Dpositive on readmission.
Previous CM notes reviewed.
Pt lives in **************with his parents.
His emergent contact is his mother ************ # [xxx_xxx_xxxx]
DME : Crutches HHC : Colquitt HC # [xxx_xxx_xxxx] and HIN : and Gonzalez (******* # [xxx_xxx_xxxx] ) both set up prior to d / c. He has never needed STR No PCP however has an Infectious Disease Dr.
Dr Humphrey Humphrey # [xxx_xxx_xxxx] , fax # [xxx_xxx_xxxx] she followed the home health and the home IV ABX.
INS : UHC Dual Complete CM attempted to speak with pt via phone to confirm he was willing to continue services with *********** and Calderon , but no answer on his room phone.
Transition care assessment :
Pt recommends home with OP therapyonce covid negative and cleared forfullweight bearing per Ortho
ID recommends IV abx meropenem , rifampin , and vanco at d / c , need exact vanco dosage.
CM needs to confirm if pt agreeable to continue using ******** HC and Mckinney upon d / c. Continue IP care.
Will continue to follow.",2021-08-19
32831,706391,32678,4180186,265,"FULL DOCUMENT TEXT :
Plan of Care by Mclellan , ********* , Peterson Quintana at  9/4/2020  3 : 51 PM (continued)
Author : Gonzalez , ********* , Calderon Finnegan Matthews : NSG (Nursing Services) Author Type : Registered Nurse
Filed :  9/4/2020  3 : 56 PM Date of Service :  9/4/2020  3 : 51 PM Status : Signed
Editor : Andersen , Crystal A , R. N.
(Registered Nurse) Problem : PAIN ADULT
Goal : PT VERBALIZES / DEMONSTRATES ADEQUATE COMFORT LEVEL OR BASELINE
Outcome : Adequate for Discharge Problem : KNOWLEDGE DEFICIT
Goal : Patient / family / caregiver demonstrates understanding of disease process , treatment plan , medications , and discharge instructions
Outcome : Adequate for Discharge Problem : INFECTION ADULT
Goal : Absence of infection during hospitalization
Outcome : Adequate for Discharge Problem : SKIN / TISSUE INTEGRITY
Goal : Skin / Tissue integrity maintained or improved
Outcome : Adequate for Discharge
Goal : Oral and Nasal mucous membranes remain intact
Outcome : Adequate for Discharge Problem : SAFETY ADULT
Goal : Maintain a safe environment
Outcome : Adequate for Discharge Problem : DISCHARGE PLANNING
Goal : Patient discharge needs identified
Outcome : Adequate for Discharge Problem : SAFETY ADULT RISK FOR FALL AND OR FALL INJURY
Goal : Patient remains free from fall / fall injury
Outcome : Adequate for Discharge Problem : CARDIOVASCULAR ADULT
Goal : Maintains optimal cardiac output and hemodynamic stability
Outcome : Adequate for Discharge
Goal : Achieve stable or improve cardiac rhythm
Outcome : Adequate for Discharge Problem : METABOLIC / FLUID AND ELECTROLYTES ADULT
Goal : Hemodynamic stability and optimal renal function maintained
Outcome : Adequate for Discharge
Goal : Glucose maintained within prescribed range
Outcome : Adequate for Discharge Shift Goals :
Clinical Goals for the Shift : patient will remain hemodynamically stable this shift Identify possible barriers to meeting goals / advancing plan of care : none End of Shift Summary : a&ox 3 , vss , afebrile.
Patient reports none to minimal pain.
Respiratory clear , on room air.
No complaints of cardiac symptoms , generalized edema.
Active bowel sounds , denies nausea and is tolerating diet.
Voiding adequately , menstruating.
Patient on heparin gtt and will transition to eliquis after discharge.
PI Vs removed prior to discharge , no complications.
Discharge instructions reviewed , all questions addressed and answered.",2021-06-08
32831,706391,32678,4180186,103,"DOCUMENT HEADER :
Discharge Summary by Gonzalez , [XXXXX] , APRN , C. N. P. at  6/13/2020  1 : 47 PM (continued)
Author : Ferguson , [XXXXX] , APRN , Petersen Peterson Mckenzie Calderon : HIM (Hospital Internal Medicine) Author Type : Nurse Practitioner
Filed :  6/13/2020  2 : 16 PM Date of Service :  6/13/2020  1 : 47 PM Status : Signed
Editor : Humphrey , [XXXXX] , APRN , C. N. P.
(Nurse Practitioner) INPATIENT DISCHARGE SUMMARY BRIEF OVERVIEW
Discharge physician :
[XXXXX] Humphrey , APRN , C. N. P. Primary Care Providers :
Elsewhere , Pcp (General)
No address on file Admission date :  6/2/2020  Discharge date :  6/13/2020  PRINCIPAL DIAGNOSIS :
Pneumonia Due To COVID 19 SECONDARY DIAGNOSES :
Patient Active Problem List
DIAGNOSIS :
• Pneumonia Due To COVID 19 • Adult Respiratory Distress Syndrome (HCC)
• Acute Respiratory Failure With Hypoxia (HCC)
DISCHARGE DISPOSITION :
Discharge home to self care ACTIVE ISSUES REQUIRING FOLLOW UP re evaluate for need of home oxygen.
OUTPATIENT FOLLOW UP Follow up with PCP Primary Care Physician within 3 5 days
DISCHARGE MEDICATIONS :
Petersen Mckinney , Humphrey
Home Medication Instructions HAR : [xxxxxxxx]
Printed on :  6/13/20  1347
Medication Information acetaminophen (TYLENOL) 500 mg tablet
Take 500 mg by mouth every 6 (six) hours as needed for pain.
pantoprazole (PROTONIX) 40 mg EC tablet
Take 1 tablet (40 mg total) by mouth every morning before breakfast.
DETAILS OF HOSPITAL STAY
REASON FOR ADMISSION :
Hypoxia in the setting of fever , chills , body aches , and poor appetite over 2 weeks.
HOSPITAL COURSE :
Mr.
Finnegan Faulkner is a ** year old male was asked to come to ED on  6/2/2020  after COVID 19 team found him to be hypoxic.
The patient had been sick with fever , chills , body aches and poor appetite over 12 days prior to his admission.
He was tested 3 times for COVID 19 , but eventually tested positive on  5/30/2020  st.
He indicated that he was at home when he received a call by oximetry monitoring unit due to low pulse oximetry reading.
Two days prior to his admission he startedhaving recurrent coughs , nausea , vomiting and diarrhea.
He denied any shortness of breath , chest pain , abdominal pain.
Brief ER course
In ER he was found to be tachypneic and hypoxic to 70 s , improved with supplemental oxygen via nasal cannula.
Labs remarkable for leukocytes 13.
2 , sodium 130 , chloride 92 , alk phos 161 , AST 53 , ALT 16.
Lactate within normal limit.
Two sets of blood cultures were obtained.
ER physician consulted ID team at ********* who suggested obtaining CK , TB Quantiferon , hepatitis B & C serologies , and CRP , these were ordered in ER.
Chest x ray shows bilateral infiltrates.
Patient was subsequently admitted to the ICU to be managed for COVID 19 pneumonia and acute hypoxic respiratory failure.
The patient's case was reviewed by the infectious disease team and subsequently started on the 5 days Remdesivir therapy along with empirical treatment for pneumonia with ceftriaxone and doxycycline.
He completed both treatment on  6/6/2020  and  6/7/2020  respectively.
Patient have subsequently been feeling better but was unable to be titrated off his supplementary oxygen.
He had been requiring at least 2 L of oxygen via nasal cannula to maintain an oxygen saturation above 88%.
Patient was subsequently evaluated for the need for home oxygen use and was cleared by the respiratory therapist for home oxygen.
He is currently stable and will be discharging home on home oxygen.
Patient had been instructed to continue with quarantine for at 7 additional days following his discharge out of the hospital and at least 3 days passed since he last had a fever or fever reducing medications and also to negative COVID 19 test at for at least 24 hour apart.
Additional post discharge recommendations
If new or Worsening Symptoms occur , you should report those to the Remote Monitoring Team after Hospital Discharge** ** If any of these symptoms are severe or suddenly changed , call 911 or self transport to your nearest Emergency Department.
Notify 911 dispatch that you have COVID 19.
Wear a mask before going to the Emergency Department.
· Worsened shortness of breath
· New or worsening cough
· New productive cough or cough with blood
· New chest pain or pain with breathing
· Fevers , chills , sweats
· Vomiting or diarrhea
· Lightheadedness
· New temperature > 38.
3 °C
· Fast heart rate
· Fast breathing rate Patient is scheduled to visit with his primary care physician within 3 5 days after his discharge which [XXXXX] be done over the phone.
His vital signs at discharge included a temperature of 36.
2° , heart rate of 87 , BP of 100 / 73 and oxygen saturation of 90% on a L of oxygen via nasal cannula.
Physical examination at discharge day : GENERAL : in no apparent distress.
Alert and oriented X 3 .
Vital signs noted.
SKIN : Grossly warm , dry , and intact.
HEENT : Normocephalic , atraumatic.
Extraocular movements intact , pupils equally round and reactiv",2021-09-24
32831,706391,32678,4180186,93,"DOCUMENT HEADER :
Progress Notes by Mcgregor , Mckinney Andersen , M. D. at  5/3/2020  4 : 00 PM (continued)
Author : Andersen , Humphrey L , M. D. Service : PSY PSI (Psychiatry and Psychology) Author Type : Physician
Filed :  5/3/2020  5 : 37 PM Encounter Date :  5/3/2020  Status : Signed
Editor : Matthews , Peterson L , M. D.
(Physician)
CHIEF COMPLAINT / PURPOSE OF VISIT :
Individual psychotherapy.
CURRENT SESSION
Ms.
Petersen returns and shares she is contemplating purchasing a motorcycle ; we compared / contrasted this decision and the associated feelings with other major decisions in her life.
We also explored whether there is more to learn from the timing of this particular decision.
We also took some time today to reflect on the earlier evaluative sessions , provide an overview of exploratory / psychodynamic psychotherapy and offer to continue this work ; the patient expresses a desire to do so ; we briefly discussed frame issues.
Ms.
Quintana has taken bupropion for seven days with no noticeable adverse effects whatsoever.
Words worth remembering today : mum , Gonzalez , circumstances , conspire , Mckenzie , empathy , relief.
IMPRESSION :
# 1 Anxiety
# 2 Depressive disorder
PLAN :
A. Continue individual psychotherapy.
B. Reduce duloxetine to 60 mg daily this week and then 30 mg daily next week.
C. Increase bupropion to 300 mg qAM.
D. Next appointment 21 [XXXXX] at 1600.
Total time spent face to face with the patient today : 55 minutes.",2021-02-22
32831,706391,32678,4180186,217,"DOCUMENT HEADER :
Progress Notes by Eastwood , [XXXXX] A , Finnegan Finnegan at  6/6/2020  1 : 24 AM (continued)
Author : Mclellan , [XXXXX] A , Mclellan Mckinney Mclellan : RM Remote Monitoring Author Type : Registered Nurse
Filed :  6/10/2020  9 : 25 PM Encounter Date :  6/6/2020  Status : Signed
Editor : Faulkner , [XXXXX] A , Mclellan Quintana (Registered Nurse) Remote Patient Monitoring RN Symptomology Call Primary reason for today's contact : COVID 19 Symptom Assessment Symptom Assessment :
Respiratory : Denies respiratory symptoms Fever : Denies fever Recommendation : 911 and Emergency Department (*Note to nurse : if patient has SOB at rest or feels as if they will collapse every time they sit or stand up , the patient should present to the ED. )
Retesting Assessment :
Was the patient hospitalized with COVID 19 : NO
Is the patient immunocompromised : NO
Is the patient undergoing pre surgical screening (STAR) or seeking an outpatient time sensitive medical appointment as directed by provider plan of care : YES Based on responses above , Mcgregor Mcarthur Quintana does meet criteria for retesting.
If one or more of the above questions was yes , retesting is indicated as defined by the provider's plan of care and established standards.
RPM nurse will need to notify the ************drive through testing center so a point of care order can be placed on the date testing is needed.
If all questions are no , retesting not required and RPM nurse call patient for symptom assessment to determine appropriateness to be released from quarantine.
PATIENT EDUCATION :
Plan of Care / Next Steps :
Endpoint recommendation : 911 , Emergency Department and Provider Advice Caller agreeable to plan of care : Yes Patient vital signs from previous day showed up on patient's chart nearly 12 hours later where it was revealed that he had an SpO 2 of 80%.
Nurses called patient for a symptom assessment and vital sign update where his SpO 2 remained low 80% and trending down to 78% at one point during phone call.
Patient also had tachycardia with peak heart rate of 119.
Base off symptoms , nurse advised patient to call 911 and seek emergency care at local ED.
Nurse reminded patient to alert the responders of his COVID 19 infection and to wear appropriate masking.
Patient was agreeable with the escalation and reported that they will call 911 after phone call.",2021-02-20
32831,706391,32678,4180186,207,"DOCUMENT HEADER :
Progress Notes by Petersen , Mclellan Mcarthur , P. A. C. , M. S. at  3/29/2020  8 : 45 AM (continued)
Author : Gonzalez , Petersen Peterson , P. A. C. , M. S. Service : IFD (Infectious Diseases) Author Type : Physician Assistant
Filed :  3/29/2020  5 : 16 PM Date of Service :  3/29/2020  8 : 45 AM Status : Addendum
Editor : Matthews , Gonzalez M , P. A. C. , M. S.
(Physician Assistant)
Related Notes : Original Note by Finnegan , Faulkner Mckenzie , P. A. C. , M. S.
(Physician Assistant) filed at  3/29/2020  10 : 16 AM The patient was not personally interviewed or examined.
The history and examination findings are based on the clinical documentation provided and / or discussed with a physician or provider who had personally interviewed and examined the patient.
COVID Infectious Diseases e Consult Progress Note
REASON FOR CONSULT :
Patient is a ** y. o. male admitted  3/20/2020  being followed by infectious diseases e Consult service for COVID 19 illness.
Events over the past 24 hours : He was alert and following commands yesterday.
He had a spontaneous breathing trial [3_29] for 45 mins.
He remains intubated (FIO 2 30% and PEEP 10).
Persistently febrile (bladder temperature).
OBJECTIVE :
Admission Weight : 71 kg
Current Weight : 65.
2 kg
VITAL SIGNS :
Temperature : [36.
9 °C 38.
2 °C] 37 °C
Heart Rate : [60 89] 60
Resp Rate : [18 46] 22
Blood Pressure : (84 137) / (58 74) 111 / 70 Arterial Line BP : (97 164) / (48 93) 164 / 77 FiO 2 (%) : [30 % 40 %] 30 % SpO 2 : [90 % 98 %] 98 %
Pulse Rate : [60 89] 60 Intake / Output Summary (Last 24 hours) at  3/29/2020  0845
Last data filed at  3/29/2020  0808
Gross per 24 hour
Intake 2030.
97 ml
Output 2399 ml
Net 368.
03 ml
DIAGNOSTICS :
I have reviewed diagnostics.
Studies of note include :
LABS :
Hemoglobin 10.
7 , WBC 9.
1 , ANC 7130 , lymphocytes 1280 , platelets 552 , creatinine 0.
46 , alk phos 111 , AST 23 , ALT 45 , total bili 0.
4 , direct bili 0.
2 Ferritin :
494 ( [3_28] ) 421 ( [3_27] ) 462 ( [3_26] ) 420 ( [3_22] ) D Dimer :
7122 ( [3_28] ) 6817 ( [3_27] ) 1262 ( [3_25] ) 657 ( [3_22] ) 302 ( [3_20] ) CRP trending :
170.
2 ( [3_29] ) 209.
8 ( [3_28] ) 301.
7 ( [3_27] ) 272.
1 ( [3_26] ) 170.
0 ( [3_25] ) 84.
9 ( [3_24] ) 119.
4 ( [3_23] ) 256.
4 ( [3_22] ) RENAL FUNCTION
Estimated Creatinine Clearance : 144.
9 mL / min (A) (by C G formula based on S Cr of 0.
5 mg / dL (L)).
EKG
[3_22] : Q Tc 445 ms NSR IMAGING REVIEWED
[3_25] CXR : Patchy bilateral pulmonary infiltrates.
Slight interval increase in infiltrate in the left midlung.
Otherwise no change.
[3_24] CXR : Bilateral patchy airspace opacities have not significantly changed.
[3_20] CXR : No comparison available.
Bilateral patchy airspace opacities [XXXXX] be infectious / inflammatory , less likely edema.
No pneumothorax or pleural effusion.
Prominent cardiac silhouette.
Chest otherwise negative.
MICROBIOLOGY [3_28] Blood : Pending.
[3_26] Tracheal secretion : Usual flora ; fungal culture pending.
[3_25] Blood : No growth to date.
SARS CoV 2 PCR Detected MRSA swab : No growth.
[3_23] HIV screen negative Hepatitis B surface antigen negative.
H Bc total antibody negative.
HCV screen negative.
QuantiFERON TB gold plus : Indeterminate.
[3_21] Strep pneumo Ag : Negative.
Legionella Ag : Negative.
[3_20] Influenza / RSV PCR Negative.
Blood cultures : No growth SARS CoV 2 RNA Detected ANTIMICROBIALS
Zosyn 3.
375 g IV every 6 hours ( [3_25] ) Previously :
Vancomycin  3/25/23 
Ceftriaxone  3/20/21 
Doxycycline  3/20/21  COVID 19 DIRECTED THERAPIES
Sarilumab trial ( [3_22] , [3_23] ) Convalescent plasma ( [3_26] ) ASSESSMENT / PLAN :
1.
COVID 19 lower respiratory tract infection , severe Date of symptom onset :  3/16/2020  Positive PCR :  3/20/2020  ;  3/25/20  CXR ( [3_20] ) : Bilateral patchy airspace opacities Risk category : High Risk factors : DM 2 , oxygen requirement Treatment : Sarilumab [3_22] , [3_23] ; convalescent plasma [3_26] Blood type : O+ (  3/21/20  ) 2.
Acute respiratory distress
3.
Possible community acquired pneumonia Tracheal secretion culture withusual flora.
5 days doxycycline and ceftriaxone Currently on Zosyn
4.
DM 2 5.
Indeterminate QuantiFERON TB gold plus Needs repeat testing once acute illness has resolved (approximately 8 weeks ;  5/18/20  ) DISCUSSION
Date of symptom onset was  3/16/20  .
Date of positive NP testing for SARS CoV 2 was  3/20/20  .
Mr.
Mcgregor Mckinney is a ** year old male with DM 2.
He presented to ED  3/20/20  with cough , fever , SOB , abd pain and diarrhea x 4 days (symptom onset [3_16] ).
CT abdomen / pelvis noted ground glass opacities in the lung bases with consolidation in the left lateral lower lung concerning for viral pneumonia.
Admitted to the ICU with hypoxemic respiratory failure requiring BiPAP.
He was enrolled in the sarilumab trial ; receiving doses on [3_22] and [3_23] .
He was ultimately intubated [3_24] .
He was enrolled in convalescent plasma trial and received a unit on [3_26] due to lack of respiratory improvement in setting of increasing inflammatory markers , hypertension and fever.
He was also treated with a 5 day course of ce",2021-02-12
32831,706391,32678,4180186,6,"DOCUMENT HEADER :
Progress Notes by Townsend Quintana , Eastwood Andersen , Pharm.
D. , Townsend Ferguson at  5/13/2020  9 : 29 AM (continued)
Author : Finnegan Petersen , Peterson A , Pharm.
D. , R. Ph.
Service : PHR (Pharmacy) Author Type : Pharmacist
Filed :  5/13/2020  9 : 30 AM Date of Service :  5/13/2020  9 : 29 AM Status : Signed
Editor : Eastwood Andersen , Peterson A , Pharm.
D. , Mcarthur Mcarthur (Pharmacist) Warfarin Dosing Progress Note : More information : Faulkner Andersen Mcarthur is a 61 y. o. male who was admitted to the hospital on  4/8/2020  .
Hospital Pharmacy has been consulted for inpatient warfarin management and monitoring.
Warfarin Indication : Atrial fibrillation (AF) Other indication (comments) : No data recorded
Type of therapy : New Prior average daily dose : No data recorded
Comorbidities : Poor nutrition state (e. g. several days or more of significantly reduced dietary intake) Are any of these comorbidities new with admission?
Yes Are there any new medication interactions with admission?
Yes Target INR : 2 3 Day of therapy : 5 and beyond Drug interactions include the following :
Strong Potentiator (From admission , onward)
None Moderate Potentiators (From admission , onward)
Start Dose / Rate Route Frequency Ordered Stop
 5/12/20  0900 amiodarone tablet 100 mg (PACERONE) 100 mg oral Daily  5/12/20  0706
 5/7/20  1253 acetaminophen solution 650 mg (TYLENOL) 650 mg oral Every 4 hours PRN  5/7/20  1253
 4/13/20  0415 amiodarone 1.
8 mg / mL in D 5 W (non PVC) 250 mL infusion (CORDARONE) 0.
5 mg / min 16.
7 mL / hr intravenous Continuous  4/12/20  2201  4/13/20  2059 Potentiating (From admission , onward)
Start Dose / Rate Route Frequency Ordered Stop
 5/7/20  1253 acetaminophen solution 650 mg (TYLENOL) 650 mg oral Every 4 hours PRN  5/7/20  1253 Enzyme Inducers (From admission , onward)
None Binders (From admission , onward)
Start Dose / Rate Route Frequency Ordered Stop
 5/9/20  0800 sevelamer tablet 800 mg (RENVELA) 800 mg oral 3 times daily with meals  5/9/20  0733 Vitamin K Containing Medications (168 h ago , onward)
None Antiplatelets & Anticoagulants (168 h ago , onward)
Start Dose / Rate Route Frequency Ordered Stop
 5/13/20  1700 warfarin tablet 3.
5 mg (COUMADIN) 3.
5 mg oral Once  5/13/20  1029  5/13/20  2345
 5/12/20  2100 warfarin tablet 3 mg (COUMADIN) 3 mg oral Once  5/12/20  0907  5/12/20  2036
 5/11/20  1700 warfarin tablet 3 mg (COUMADIN) 3 mg oral Once  5/11/20  1205  5/11/20  1702
 5/10/20  1700 warfarin tablet 3 mg (COUMADIN) 3 mg oral Once  5/10/20  0942  5/10/20  1721
 5/9/20  1500 warfarin tablet 4 mg (COUMADIN) 4 mg oral Once  5/9/20  0939  5/9/20  1522
 5/8/20  1700 warfarin tablet 5 mg (COUMADIN) 5 mg oral Once  5/8/20  0908  5/8/20  1719
 5/7/20  1700 warfarin tablet 4 mg (COUMADIN) 4 mg oral Once  5/7/20  1235  5/7/20  1943
 5/6/20  1700 warfarin (COUMADIN) NO Dose Today oral Once  5/6/20  0814  5/6/20  1615
 4/27/20  0800 warfarin management (COUMADIN) oral Daily  4/27/20  0752 INR reversal agents were not given.
Warfarin Reversal Agent Administrations (last 168 hours) Vitamin K and K Centra None FFP Administrations During Encounter (Filter : EAP GENERAL TRANSFUSE FFP Medications Shown)
None Warfarin Administrations (last 168 hours) Date / Time Action Medication Dose
 5/12/20  2036 Given warfarin tablet 3 mg (COUMADIN) 3 mg
 5/11/20  1702 Given warfarin tablet 3 mg (COUMADIN) 3 mg
 5/10/20  1721 Given warfarin tablet 3 mg (COUMADIN) 3 mg
 5/9/20  1522 Given warfarin tablet 4 mg (COUMADIN) 4 mg
 5/8/20  1719 Given warfarin tablet 5 mg (COUMADIN) 5 mg
 5/7/20  1943 Given warfarin tablet 4 mg (COUMADIN) 4 mg INR (no units)
Date Value Status
 5/13/2020  1.
8 (H) Final
 5/12/2020  2.
9 (H) Final
 5/11/2020  3.
3 (H) Final
 5/10/2020  2.
7 (H) Final
 5/9/2020  2.
5 (H) Final
 5/8/2020  2.
0 (H) Final
 5/7/2020  2.
3 (H) Final A / P :
inc dose by 20%.
Warfarin order of 3.
5 mg has been placed for today and the pharmacist team will continue to follow patient's clinical progress daily until discharge from the hospital.
Matthews Mcgregor Gonzalez , Pharm.
D. , Mcarthur Mclellan",2021-04-01
32831,706391,32678,4180186,195,"DOCUMENT HEADER :
Consults by Mcarthur , Peterson Ferguson , APRN at  8/4/2020  7 : 32 AM (continued)
Author : Mcarthur , Townsend Gonzalez , APRN Service : IFD (Infectious Diseases) Author Type : Nurse Practitioner
Filed :  8/4/2020  1 : 52 PM Date of Service :  8/4/2020  7 : 32 AM Status : Attested
Editor : Mcarthur , Matthews L , APRN (Nurse Practitioner) Cosigner : Mcarthur , Matthews Mcgregor , M. D. at  8/4/2020  6 : 11 PM Consult Orders 1.
Infectious Diseases consult (hospital) General [ [xxxxxxxx] ] ordered by Ferguson , Calderon Peterson , APRN , D. N. P. Attestation signed by Mcarthur , Peterson Mckenzie , M. D. at  8/4/2020  6 : 11 PM C 5 Infectious Disease Consultation ** y. o. male whom we are asked to see by Dr.
Faulkner of Hospital Internal Medicine for evaluation of SARS CoV 2 infection.
Chart reviewed.
Patient interviewed.
Agree with history , lab evaluation as per Mckinney Calderon and with exam as per Hospital Internal Medicine.
IMP
1.
PCR positive NP swab for SARS CoV 2  8/3/2020  attributed to asymptomatic RNA shedding
2.
Relapsing uremia secondary to inadequate RRT for patient behavior
Hyperkalemia ,  8/12/2020 
Pulmonary edema ,  7/13/2020 
3.
Subacute vs chronic diarrhea
4.
COVID 19 pneumonia  5/13/2020  complicated by nosocomial E. coli superinfection
5.
ESRD from DM / HTN 2016 REC
1.
SARS CoV 2 IgG (screening and neutralizing Ab assays)
2.
Stool O&P exam
3.
PCR stool for norovirus
4.
Maintain Modified Droplet precautions while in hospital
5.
Duration of self quarantine following hospital discharge (and application of outpatient hemodialysis with Modified Droplet precautions) : until 2 negative PCR assays of NP swabs for SARS CoV 2 separated by at least 24 hours or remaining without symptoms of COVID 19 through  8/17/2020  , whichever comes first
SUBJECTIVE :
Infectious Diseases consult (hospital) General
REFERRING PROVIDER :
Mcgregor , Humphrey Calderon , APRN , Petersen Gonzalez Matthews Townsend FOR CONSULT :
Patient is a ** y. o. male admitted  8/3/2020  being requested to be evaluated by infectious diseases for COVID +.
HISTORY OF PRESENT ILLNESS :
Mr.
Finnegan is a *********** male with a past medical history significant for ESRD on HD secondary to biopsy proven diabetic nephropathy , recent prolonged hospitalization from  4/20/20  through  6/2/2020  foracute hypoxemic respiratory failure contributed to COVID 19 infection (treated with azithromycin and Plaquenil) and E coli , atrial fibrillation on warfarin , hypertension , diabetes mellitus type 2 , gout , hyperlipidemia , diastolic dysfunction , diverticulitis , who presented to the ED on  8/3/2020  with diarrhea , recent fall , and bilateral leg weakness.
In the ED , labs revealed K 8.
5.
He denied any chest pain or SOB.
He stated he ate potatoes over weekend for the holiday.
COVID testing was performed and marked positive.
Diarrhea he stated has been over past few days.
Patient was admitted for further evaluation and management.
PAST MEDICAL HISTORY :
Diagnosis Date
• Atrial Fibrillation (HCC)  4/27/2020 
• Benign Prostatic Hyperplasia Localized
• Chronic Systolic (Congestive) Heart Failure (HCC)
• COVID 19 Infection
• Diabetes Mellitus Type 2 (HCC) 2005
• Dialysis Dependent (HCC)  9/12/2016 
• Failure Renal End Stage (HCC)
• Flutter Atrial (HCC)
• Hyperlipidemia
• Hypertension NOS
• Hypertensive Heart And Chronic Kidney Disease With Heart Failure And With End Stage Renal Disease (HCC)
• Polyp Colon
• Renal Disease
PAST SURGICAL HISTORY :
Procedure Laterality Date
• AV FISTULA PLACEMENT
• HERNIA REPAIR Bilateral
inguinal hernia
• PERITONEAL CATHETER INSERTION Scheduled Meds : amLODI Pine , 10 mg , oral , QAM
carvediloL , 25 mg , oral , BID
dextrose , 50 g , intravenous , Once
insulin aspart , 0 7 Units , subcutaneous , TID
insulin regular , 0.
1 Units / kg (Dosing Weight) , intravenous , Once
lisinopriL , 15 mg , oral , QAM
multivitamin renal failure , 1 tablet , oral , QAM
pantoprazole , 40 mg , oral , BID before breakfast and dinner
sertraline , 100 mg , oral , Daily at bedtime
sevelamer , 1 , 600 mg , oral , TID with meals
sodium chloride , 3 mL , intravenous , Q 12 H SCH Continuous Infusions :
PRN Meds : .
• acetaminophen
• dextrose
• labetalol
• lidocaine
• lidocaine prilocaine • melatonin
• Na Cl • sodium chloride
• sodium chloride
• sodium chloride
• sodium chloride
ALLERGIES :
Allergen Reactions
• Metformin Other (see comments)
No known reaction
• Statins Hmg Coa Reductase Inhibitors Other (see comments)
No known reaction
FAMILY HISTORY :
Problem Relation Age of Onset
• Kidney disease Mother
• Breast cancer Mother
• Colon cancer Mother
• Heart disease Mother
• No Known Problems Father
• No Known Problems Son
• Colon cancer Paternal Grandmother
SOCIAL HISTORY :
Tobacco Use
• Smoking status : Former Smoker Packs / day : 0.
00
Years : 0.
00
Pack years : 0.
00
Types : Cigarettes
Last attempt to quit :  2/23/2000 
Years since quitting : 20.
4
• Smokeless tobacco : Never Used
• Tobacco comment : 60 90 pack years , smoked",2021-03-23
32831,706391,32678,4180186,15,"DOCUMENT HEADER :
Progress Notes by Gonzalez , Quintana , M. D. at  4/21/2020  6 : 48 AM (continued)
Author : Mcarthur , Mckenzie , M. D. Service : CCM (Critical Care Medicine) Author Type : Resident
Filed :  4/21/2020  4 : 49 PM Date of Service :  4/21/2020  6 : 48 AM Status : Signed
Editor : Mckenzie , Finnegan , M. D.
(Resident) MICU 2 PROGRESS NOTE Brief summary : ******************** a *******.
malewith type 2 D Mwho presented ***** E Dwith one week of cough , dyspnea , abdominal pain , and fevers in the setting of multiple sick contacts and was found to have COVID 19 infection.
He was initiated on the sarilumab trial on  4/11/20  and convalescent plasma [4_16] .
Required intubation  4/13/04  / 26.
Interval events : Weaned to NC Imodium for diarrhea Sleep enhancement Work with PT / OT Spoke to ID about nausea and relation to study drug , believe [4_19] was last dose Removed central line Diuresed [4_20] , net negative 1 L , UOP slowing significantly this morning
VITAL SIGNS :
Temperature : [36.
5 °C 37.
3 °C] 36.
7 °C
Heart Rate : [78 115] 105
Resp Rate : [15 37] 27
Blood Pressure : (109 158) / (67 98) 109 / 88 SpO 2 : [92 % 100 %] 94 %
Flow Rate (L / min) : [2 L / min 4 L / min] 2 L / min Pulse Rate : [79 115] 105 Intake / Output Summary (Last 24 hours) at  4/21/2020  1649
Last data filed at  4/21/2020  1036
Gross per 24 hour
Intake 615 ml
Output 1444 ml
Net 829 ml
IO [4_20] : 989 (80 mg IV lasix)
IO [4_21] : 439 PHYSICAL EXAM :
Not performed due to limiting number of providers in COVID patient room.
General : Supine , on HFNC.
Appears comfortable.
LABS :
Recent Labs  4/21/20  1254  4/21/20 
0334
NA 143
K 3.
8
CL 104
CALCIUM 8.
7 L
BUN 20
CREATININE 0.
57 L
GLUCOSE 306 H < > 217 H
ALBUMIN 3.
2 L
HGB 12.
0 L
HCT 36.
9 L
WBC 7.
8
PLT 653 H
< > = values in this interval not displayed.
ASSESSMENT / PLAN :
Jaime Santos Perezis a 60 y. o. malewith type 2 D Mwho presented ***** E Dwith one week of cough , dyspnea , abdominal pain , and fevers in the setting of multiple sick contacts and was found to have acute hypoxic respiratory failure in the setting of COVID 19 infection.
He was initiated on the sarilumab trial on  4/11/20  and convalescent plasma [4_16] .
Neuro
# Sedation
# Pain Lorazepam 1 mg IV q 1 h PRN for anxiety , nausea / vomiting Acetaminophen 1000 mg q 6 h PRN for mild pain and fevers >38.
4 C Sleep enhancement Pulmonary
# COVID 19 pneumonia
# Acute hypoxemic respiratory failure
# ARDS secondary to COVID 19 pneumonia
# Left midlung consolidation Intubated on  4/13/04  / 26 Currently on 3 L NC Cardiovascular
# Hypotension , resolved [XXXXX] utilize norepinphrine to maintain MAP goal >65 ; off NE since [4_18] GI
# Elevated transaminases
# Elevated alkaline phosphatase
# Diarrhea
# Nausea
# Hypoalbuminemia
# GERD
# Nutrition C difficile PCR [4_18] : negative Imodium 2 mg q 8 h PRN for diarrhea Change from scheduled to PRN ondansetron 8 mg IV q 6 h , compazine 5 mg q 6 h PRN , lorazepam 1 mg q 1 h PRN for breakthrough nausea Passed bedside swallow evaluation [4_20] ; on adult regular diet Tums daily PRN for heartburn , indigestion Bowel regimen : MiraLAX daily PRN , Senokot S 1 tablet at bedtime PRN , bisacodyl suppository daily PRN Renal
# Hypokalemia
# Hypernatremia , resolved goal net negative 0 500 cc Replete potassium PRN Strict I&Os , daily weights , avoid nephrotoxins Heme
# Normocytic anemia
# Thrombocytosis Hemoglobin 11.
5 , platelets 652 Likely secondary to acute inflammation , continue to monitor Infectious Disease
# COVID 19 pneumonia
# Possible superimposed bacterial pneumonia C diff [4_18] : negative S / p ceftriaxone 2 g q 24 hand doxycycline 100 mg BID for 5 day course (  4/9/04  / 21) MRSA swab from [4_14] negative , stopped vancomycin (  4/14/04  / 23) S / p piperacillin tazobactam 3.
375 g q 6 h for 5 day course (  4/14/04  / 26) ID following , appreciate recommendations
· Initiated on sarilumab trial for hospitalized patients (phase [1_26] , randomized , double blind , placebo controlled study) ; first dose [4_11] , [4_12] , [4_19] spoke to ID on morning of [4_20] regarding debilitating nausea and suggested against additional dosing ; it was thought that [4_19] [XXXXX] be the last dose
· Initiated on convalescent plasma trial ; first dose [4_15]
· Obtain daily CBC with differential , CRP , LF Ts , creatinine for ID Endocrine
# Type 2 diabetes mellitus
· Glucose 181 319 within the last 24 hours ; received total of 24 U of insulin aspart and 18 U of glargine
· Increase to 20 from 18 units glargine , start 5 units aspart TID
· Moderate sliding scale insulin aspart TID times daily Access Remove central line Lines / Drains / Airways Peripheral IV Peripheral IV Catheter  4/9/20  18 G Anterior ; Left ; Lower Forearm
11 days Peripheral IV Catheter  4/13/20  18 G Left Hand
8 days Prophylaxis DVT prophylaxis : Enoxaparin 40 mg daily GI prophylaxis : Not in",2021-08-22
32831,706391,32678,4180186,33,"DOCUMENT HEADER :
Progress Notes by Andersen Andersen , [XXXXX] W , Pharm.
D. , Mckinney Mckenzie at  5/28/2020  1 : 18 PM (continued)
Author : Faulkner Townsend , [XXXXX] W , Pharm.
D. , R. Ph.
Service : PHR (Pharmacy) Author Type : Pharmacist
Filed :  5/28/2020  1 : 20 PM Date of Service :  5/28/2020  1 : 18 PM Status : Signed
Editor : Townsend Finnegan , [XXXXX] W , Pharm.
D. , Eastwood Mclellan (Pharmacist) Warfarin Dosing Progress Note : More information : Mckinney Finnegan Eastwood is a ** y. o. male who was admitted to the hospital on  5/23/2020  .
Hospital Pharmacy has been consulted for inpatient warfarin management and monitoring.
Warfarin Indication : Atrial fibrillation (AF) Other indication (comments) : No data recorded
Type of therapy : Resume Prior average daily dose : 5 Comorbidities : Poor nutrition state (e. g. several days or more of significantly reduced dietary intake) ; Acute heart failure (e. g. fluid retention , pulmonary edema) Are any of these comorbidities new with admission?
Yes Are there any new medication interactions with admission?
Yes Target INR : 2 3 Day of therapy : 4 Drug interactions include the following :
Strong Potentiator (From admission , onward)
None Moderate Potentiators (From admission , onward)
Start Dose / Rate Route Frequency Ordered Stop
 5/24/20  2334 acetaminophen tablet 1 , 000 mg (TYLENOL) 1 , 000 mg oral Every 6 hours PRN  5/24/20  2333 Potentiating (From admission , onward)
Start Dose / Rate Route Frequency Ordered Stop
 5/24/20  2334 acetaminophen tablet 1 , 000 mg (TYLENOL) 1 , 000 mg oral Every 6 hours PRN  5/24/20  2333
 5/23/20  1900 piperacillin tazobactam 2.
25 g in Na Cl 0.
9% IVPB (ZOSYN) Note to Pharmacy : HD dosing 2.
25 g
100 mL / hr over 30 Minutes intravenous Every 8 hours  5/23/20  1109 Enzyme Inducers (From admission , onward)
None Binders (From admission , onward)
None Vitamin K Containing Medications (168 h ago , onward)
None Antiplatelets & Anticoagulants (168 h ago , onward)
Start Dose / Rate Route Frequency Ordered Stop
 5/28/20  1700 warfarin tablet 5 mg (COUMADIN) 5 mg oral Once  5/28/20  1418  5/28/20  2345
 5/27/20  1700 warfarin tablet 5 mg (COUMADIN) 5 mg oral Once  5/27/20  0853  5/27/20  1759
 5/26/20  1700 warfarin tablet 3.
75 mg (COUMADIN) 3.
75 mg oral Once  5/26/20  1340  5/26/20  1753
 5/25/20  1745 warfarin tablet 3.
75 mg (COUMADIN) 3.
75 mg oral Once  5/25/20  1742  5/25/20  1810
 5/25/20  1715 warfarin management (COUMADIN) oral Daily  5/25/20  1705 INR reversal agents were not given.
Warfarin Reversal Agent Administrations (last 168 hours) Vitamin K and K Centra None FFP Administrations During Encounter (Filter : EAP GENERAL TRANSFUSE FFP Medications Shown)
None Warfarin Administrations (last 168 hours) Date / Time Action Medication Dose
 5/27/20  1759 Given warfarin tablet 5 mg (COUMADIN) 5 mg
 5/26/20  1753 Given warfarin tablet 3.
75 mg (COUMADIN) 3.
75 mg
 5/25/20  1810 Given warfarin tablet 3.
75 mg (COUMADIN) 3.
75 mg INR (no units)
Date Value Status
 5/28/2020  1.
2 (H) Final
 5/27/2020  1.
2 (H) Final
 5/26/2020  1.
2 (H) Final
 5/25/2020  1.
2 (H) Final
 5/24/2020  1.
2 (H) Final
 5/23/2020  1.
1 Final A / P :
The current INR of 1.
2 is Subtherapeutic.
The warfarin dose was escalated on [5_27] .
Will repeat the previous warfarin dose to administer 5 mg this evening.
The pharmacist team will continue to follow patient's clinical progress daily until discharge from the hospital.
[XXXXX]
Mcarthur Humphrey , Pharm.
D. , Finnegan Mcarthur",2020-04-16
32831,706391,32678,4180186,168,"DOCUMENT HEADER :
Anesthesia Procedure Notes by Petersen , Quintana O , APRN , CRNA at  6/20/2020  9 : 02 AM (continued)
Author : Mckenzie , Andersen O , APRN , CRNA Service : ANE (Anesthesiology) Author Type : Nurse Anesthetist
Filed :  6/20/2020  9 : 03 AM Date of Service :  6/20/2020  9 : 02 AM Status : Signed
Editor : Petersen , *********** , APRN , CRNA (Nurse Anesthetist)
PROCEDURE ORDERS :
1.
Invasive Catheter [ [xxxxxxxx] ] ordered by Peterson , Andersen O , APRN , CRNA Invasive Catheter Date / Time :  6/20/2020  8 : 35 AM
Performed by : Ferguson , Mckinney O , APRN , CRNA
Authorized by : Finnegan , Matthews O , APRN , CRNA Location : OR
PROCEDURE DETAILS :
Line type : arterial
Laterality : left
Location : radial Location details : new site Age group : adult
Catheter diameter : 20 Ga Technique : palpation Monitored : yes Number of attempts : 1 UNIVERSAL PROTOCOL
All relevant documentation and testing were reviewed and available.
All required blood products , implants , devices and or special equipment were made available as applicable.
Pre procedure verification was conducted and the correct site was marked if required.
A fire risk assessment was done as applicable.
The procedural time out was conducted prior to performing the procedure and confirmed in a procedural pause.
PRE PROCEDURE DETAILS : Appropriate hand hygiene , gown , cap , mask , protective eyewear , sterile gloves , skin preparation , sterile drape , and strict aseptic technique were utilized as applicable for the procedure.
: yes Skin preparation : chlorhexidine SEDATION / ANESTHESIA
Anesthesia method : anesthesia POST PROCEDURE DETAILS : Procedure completed successfully : yes
Line secured : secured with sutureless device Chlorhexidine disc around insertion site and under catheter with slight turn : yes
Complications arterial : none",2020-07-05
32831,706391,32678,4180186,178,"DOCUMENT HEADER :
Progress Notes signed by Mckinney , Calderon S , M. D. at  6/8/2020  12 : 10 PM (continued)
Author : Ferguson , Mckenzie S , M. D. Service : ORS (Orthopedic Surgery) Author Type : Physician
Filed :  6/8/2020  12 : 10 PM Encounter Date :  6/8/2020  Status : Signed
Editor : Peterson , Quintana S , M. D.
(Physician)
HISTORY OF PRESENT ILLNESS :
Ms.
Humphrey returns to us today.
Of note , she is a very pleasant ** year old female who we evaluated for a right sided cervical radiculopathy felt to be secondary to disk osteophyte complex at C 5 6.
We did send her for a transforaminal injection on the right side , which initially did not give her much relief , but now as the steroid effect has been taking effect over the last 10 days , she has noted more significant improvement in her symptoms with roughly 50% relief of her symptoms.
Otherwise , she is neurologically unchanged on today's visit.
ASSESSMENT / PLAN :
# 1 Neck and right upper extremity pain
# 2 Right cervical radiculopathy
# 3 Right sided C 5 6 , C 6 7 disk osteophyte complexes
# 4 Status post right sided C 5 6 transforaminal injection
At this time we did have a long discussion regarding her symptoms.
As they are improving , I think it would be reasonable to observe her symptoms for now and continue therapy.
Certainly , if her symptoms remain improved or continue to get better , no further intervention would be warranted.
However , we did discuss that if her symptoms become recurrent , depending on the timing of this , we can either discuss another injection versus potential surgical intervention.
We did discuss the options for surgical treatment including anterior fusion , anterior disk replacement , posterior foraminotomy.
She expressed understanding of the pros and cons of all these different options and all questions were answered.
Ferguson Matthews Eastwood , M. D.
DD :  6/8/2020  10 : 54 : 16 CT
DT :  6/8/2020  11 : 06 : 38 CT
Job ID : [xxxxxxxx] / ayf",2021-08-04
32831,706391,32678,4180186,41,"DOCUMENT HEADER :
Progress Notes by Faulkner , Mclellan A , APRN at  7/13/2020  8 : 15 AM (continued)
Author : Ferguson , Quintana A , APRN Service : ONC Hematology and Oncology Author Type : Nurse Practitioner
Filed :  7/13/2020  5 : 52 PM Encounter Date :  7/13/2020  Status : Signed
Editor : Peterson , Humphrey A , APRN (Nurse Practitioner) PATIENT NAME : Gonzalez Townsend Gonzalez Ferguson Gonzalez : 12 663 555 DATE OF ENCOUNTER :  7/13/2020  MEDICAL ONCOLOGIST : Petersen Mclellan , M. D.
REASON FOR VISIT :
Right Breast Cancer
HYPERLINK epic : EPIC?ACTIVITY&MR ONC STAGING LINK Cancer Staging
Clinical stage T [xxxxx x. xxxxx] M 0 IDC ER negative , PR negative , HER 2 negative Right breast cancer
HISTORY OF PRESENT ILLNESS : Finnegan Townsend Calderon Finnegan is a pleasant 42 y. o. female with Clinical stage T [xxxxx x. xxxxx] M 0 IDC ER negative , PR negative , HER 2 negative Right breast cancer who is receiving current treatment with neoadjuvant chemotherapy with dose dense AC + Taxol regimen.
She has completed 4 cycles of dd AC as of  6/27/2020  .
She returns for continuing treatment and to start weekly Taxol / Carboplatin cycle # [1_8] today.
Her oncologic history is as followed.
ONCOLOGY HISTORY :  12/11/2019  : Baseline screening mammogram in Italy , where pt was previously living pt was told that it was benign  4/11/2020  : pt felt a new mass in right upper outer breast
 4/11/2020  : Seen by Dr.
Petersen
 4/11/2020  : bilateral diagnostic mammogram with right breast US
Mammography : Palpable skin marker is noted in the upper outer right breast.
Approximately 3 cm asymmetry is associated with the skin marker on the MLO projection overlying the pectoralis.
This corresponds to an indeterminate 2.
9 cm mass on ultrasound at 10 : 00 5 cm from nipple.
Ultrasound guided core needle biopsy is recommended for further evaluation.
No other suspicious findings are
noted bilaterally.
Benign calcification is noted bilaterally.
Ultrasound : Survey ultrasound of the upper outer right breast demonstrates 1.
9 x 2.
9 x 2.
8 cm oval , hypoechoic , microlobulated , vascular , non shadowing , parallel mass at site of lump 10 : 00 5 cm from nipple.
This corresponds to asymmetry in mammography and is indeterminate.
Further evaluation with ultrasound guided core needle biopsy is recommended.
No other suspicious findings noted.
 4/12/2020  : Right breast , 10 : 00 , 5.
0 cm FN , core biopsy : Invasive grade 3 (of 3) ductal carcinoma involving multiple cores and measuring at least 0.
9 cm in greatest dimension.
ER less than 1% , PR less than 1% , HER 2 / neu is negative (1+)  4/17/2020  : Seen by Dr.
Mclellan Mckenzie.
Ambry Breast Next 17 gene panel ordered
 4/18/2020  : Gonzalez breast with and WO contrast
IMPRESSION :
1.
Biopsy proven malignancy right breast 9 : 00 posterior depth as described.
2.
Ill defined asymmetric nonmass enhancement extending anteriorly from the mass approximately 3 cm , best seen on the MIP image.
3.
Due to positioning and field of view , the right axilla is not well imaged.
There is question of prominent lymph nodes in the right axilla as well as a prominent right subpectoral node.
 4/18/2020  : Seen by Dr.
Mckinney
 4/18/2020  : PET CT scan :
HEAD and NECK : No suspicious FDG uptake.
Physiologic uptake within the brain ,
tonsils , salivary glands , extra ocular muscles , and vocal cords.
Right maxillary
sinus opacification without increased metabolic activity.
CHEST : Hypermetabolic soft tissue nodule in the right breast with max SUV of
7.
5 , series 12 image 98.
Subcentimeter bilateral axillary lymph nodes show no
significant hypermetabolism.
Approximately 1 cm hypodense left thyroid nodule
showing mild inferior hypermetabolism with maximum SUV of 2.
2 , series 12 image
59.
No hypermetabolic pulmonary nodule or mass.
No hypermetabolic mediastinal or
hilar lymphadenopathy.
ABDOMEN / PELVIS : Small hypermetabolic focus is appreciated adjacent to the left
pelvic sidewall with max SUV of 13.
5 , series 12 image 211 , , smaller soft tissue
density correlation is noted and therefore [XXXXX] represent left ureter.
Otherwise prior gastric surgery.
Physiologic uptake within the liver , spleen ,
kidneys , ureters , bladder and bowel MUSCULOSKELETAL : No suspicious FDG uptake.
Pt has had 2 prior biopsies of thyroid nodule , most recently 2 3 years ago , and this was benign.
Repeat thyroid US and right axillary US ordered and pending for today.
 4/25/2020  : Calderon pelvis ordered and pending Malignant Neoplasm Of Breast Female Right (HCC)
 4/23/2020  Initial Diagnosis
Malignant Neoplasm Of Breast Female Right (HCC)  5/16/2020  Chemotherapy
AC ( DOX Orubicin / Cyclophosphamide ) every 14 days
Start Date :  5/16/2020   7/13/2020  Chemotherapy PAC Litaxel 80 mg / m 2 / CARB Oplatin AUC 2 Weekly Neoadjuvant Therapy
Start Date :  7/13/2020  (Planned)
REVIEW OF SYSTEMS :
PS 1
Fatigue G 1 2 D moderate after cycle 4 dd AC.
She reported being in bed and needing help for her Mom to care for her.
Nausea G 1 D Vomiting G 0 1 Dry heaves
Mucositis G 0 Taste Changes G 1 2 D with associated decrease in appetite currently , not able to h",2020-03-08
32831,706391,32678,4180186,221,"DOCUMENT HEADER :
Progress Notes by Matthews , Ferguson Ferguson , APRN , C. N. P. , Matthews Humphrey Faulkner at  5/30/2020  12 : 00 PM (continued)
Author : Gonzalez , Mckenzie Faulkner , APRN , C. N. P. , Gonzalez Andersen Humphrey Calderon : FAM (Family Medicine) Author Type : Nurse Practitioner
Filed :  5/30/2020  3 : 20 PM Encounter Date :  5/30/2020  Status : Signed
Editor : Petersen , Peterson Townsend , APRN , C. N. P. , Townsend Mckenzie Faulkner (Nurse Practitioner)
CHIEF COMPLAINT / REASON FOR VISIT :
Peterson Matthews is a ** y. o. male who presents for evaluation of Post Hospital Follow up.
HISTORY OF PRESENT ILLNESS :
Finnegan Faulkner is a delightful ** y. o. male accompanied by his daughter ishere for transitional care management(TCM) after a hospital stay for ARDS , respiratory failure with hypoxia , due to COVID 19 infection.
He was hospitalized / admitted on  4/26/2020  and discharged on  5/22/2020  .
He had a TCM follow up phone call on  5/23/2020  .
He tested positive for COVID 19 on  4/19/2020  after a 2 day history of fatigue , fevers , chills , headaches , myalgias , and vomiting.
He presented to the ******** ED on  4/25/2020  with worsening shortness of breath and hypoxia due to COVID 19.
He was found to be hypoxic with O 2 sats in the mid [xxxxx x. xxxxx] a respiratory rate in the mid [xxxxx x. xxxxx] was placed on high flow nasal cannula at 50 / L with improvement to 75% saturation.
CTA chest showed diffuse ground glass opacities most notable in the lower lobes.
Arterial blood gas demonstrated respiratory alkalosis.
He was started on IV fluids and azithromycin and admitted to the hospital in ******** with little improvement.
He was then transferred to Quintana Mckenzie and admitted to the ICU.
Once at the ICU at ******************* his condition quickly deteriorated and was intubated and started on epoprostenol.
He was placed on ceftriaxone and azithromycin.
He was treated with convalescent plasma , pronating , tocilizumab , and IV remdesimir.
He was extubated on [5_11] .
Repeat COVID test came back negative on  5/15/2020  he had developed delirium and was placed on scheduled Seroquel.
He was initially NPO and was given tube feedings via an NG tube.
He was then discharged to inpatient physical therapy at ********************** on  5/15/2020  and discharged from there on  5/22/2020  .
Patient reports that since being discharged from the hospital he is overall improving and feeling stronger.
He is still not at his baseline.
He will get fatigued or tired if he were to walk a couple of blocks.
He was raking leaves the other day and has a difficult time grasping the rake after doing it for 10 15 minutes.
His confusion has resolved according to him and his daughter.
His metformin was increased from 500 mg twice daily to a 1000 mg twice daily during his hospital stay.
He continues both physical therapy and occupational therapy in the outpatient setting at Courage Andersen.
He feels this is going well and he continues to find benefit from this.
He works at Viracon and feels he is not ready to go back to work due to still feeling weak overall.
At his job he has to lift heavy objects routinely.
He has no concerns or questions at this time.
Patient declined interpreter services today.
His daughter interpreted for this visit.
REVIEW OF SYSTEMS :
See HPI , remainder of ROS reviewed and are negative.
MEDICAL HISTORY :
Patient Active Problem List
DIAGNOSIS :
• Diabetes Mellitus Type 2 (HCC)
• Hyperlipidemia
• Benign Prostatic Hyperplasia Without Obstruction
• Hypertension Essential Primary
SURGICAL HISTORY :
No past surgical history on file.
FAMILY HISTORY :
Problem Relation Age of Onset
• Diabetes type II Father
• Diabetes Father
• Hyperlipidemia Father
SOCIAL HISTORY :
Socioeconomic History
• Marital status : Married
Spouse name : Not on file
• Number of children : Not on file
• Years of education : Not on file
• Highest education level : Not on file
Occupational History
• Not on file
Social Needs
• Financial resource strain : Not on file
• Food insecurity
Worry : Not on file
Inability : Not on file
• Transportation needs
Medical : Not on file Non medical : Not on file
Tobacco Use
• Smoking status : Current Every Day Smoker Packs / day : 0.
50
Years : 1.
00
Pack years : 0.
50
Types : Cigarettes
Start date :  5/23/2018 
Last attempt to quit :  12/19/2018 
Years since quitting : 1.
4
• Smokeless tobacco : Never Used
• Tobacco comment : smokes 2 per daY
Substance and Sexual Activity
• Alcohol use : Yes Alcohol / week : 6.
0 standard drinks
Types : 1 Cans of beer per week
Comment : occasional
• Drug use : No
• Sexual activity : Not Currently
Partners : Female
Lifestyle
• Physical activity
Days per week : Not on file
Minutes per session : Not on file
• Stress : Not on file
Relationships
• Social connections
Talks on phone : Not on file
Gets together : Not on file
Attends religious service : Not on file
Active member of club or organization : Not on file
Attends meetings of clubs or organizat",2020-03-25
32831,706391,32678,4180186,147,"DOCUMENT HEADER :
Progress Notes by Mckenzie , Faulkner C , P. T. , D. P. T. , CCS at  4/24/2020  1 : 38 PM (continued)
Author : Peterson , Petersen C , P. T. , D. P. T. , CCS Service : PTO Physical Therapy Author Type : Physical Therapist
Filed :  4/24/2020  1 : 59 PM Date of Service :  4/24/2020  1 : 38 PM Status : Signed
Editor : Petersen , Mcgregor C , P. T. , D. P. T. , CCS (Physical Therapist) Inpatient Physical Therapy Progress Note
SUBJECTIVE :
Patient : Townsend Matthews Mclellan.
Room : *** / *** P Referring / Attending Provider : ******* , Mclellan C , M. D.
Medical Diagnosis : Shortness Of Breath [R 06.
02] COVID 19 Infection [U 07.
1] Subjective Comments : Pt agreeable to therapy , states he would like to get up to the bathroom.
C / o of significant nausea and abdominal cramping today.
Activity Orders : Nursing Activity Orders (From admission , onward) Start Ordered  3/20/20  2112 Position head of bed Until discontinued Question
Answer
Comment Bed position :
Elevate HOB Elevate HOB :
30 degrees  3/20/20  2112  3/20/20  1435 Activity : As Tolerated Until discontinued Question : Activity Level : Answer : As Tolerated  3/20/20  1443 Is Patient at risk for Falls?
yes Precautions / Restrictions : Altered Mental Status , Fall Precautions , Modified Droplet Precautions , Mechanical lift recommended for safe transfers THIS PATIENT IS COVID POSITIVE
Invasive Lines / Drains : central line / PICC Oxygen Delivery : Room air
OBJECTIVE : Co treat with skilled OT for patient centered care as pt is not as tolerant to mobility today due to increased nausea and stomach pain.
Patient Presents : supine in bed , needs including call bell in reach , alarm on , sling in place , pressure relief in place Pain Assessment :
Critical Care Pain Observation Tool (CPOT) : Facial Expression : 0 , no muscle tension observed
Body Movements : 0 , absence of movements or normal position
Vocalizations : 0 , talking in a normal tone or no sound
Muscle Tension : 0 , relaxed
Total : 0 / 8 VITAL SIGNS :
Patient was monitored for signs / symptoms of activity intolerance.
Adverse Response to Treatment : none , VSS throughout activity on room air.
Cognition : Alert , Oriented x 4 , following commands consistently , strong voice Current Level of Function : AM PAC AM PAC Basic Mobility (V.
2) How much help from another person do you currently need…If the patient hasn't done an activity recently , how much help from another person do you think he / she would need if he / she tried?
1.
Turning from your back to your side while in a flat bed without using bedrails?
: A Little
2.
Moving from lying on your back to sitting on the side of a flat bed without using bedrails?
: A Little
3.
Moving to and from a bed to a chair (including a wheelchair)?
: A Little
4.
Standing up from a chair using your arms (e. g. , wheelchair , or bedside chair)?
: A Little
5.
To walk in hospital room?
: A Little
6.
Climbing 3 5 steps with a railing?
: A Lot AM PAC Basic Mobility (V.
2) Raw Score : 17 AM PAC Basic Mobility (V.
2) Standardized Score : 39.
67 Interventions provided  4/24/2020  :
EDUCATION :
Activity Expectation Patient provided extensive education reinforcing the importance of mobility , strengthening , being out of bed for all meals , participating in self care and functional activity training in order to maintain functional independence.
Delirium Patient demonstrates one or more risk factors for developing delirium.
A delirium prevention protocol was initiated with the following interventions : Reorientation
Mobilization
Environmental Stimulation blinds open , lights on , music
Cognitive stimulation including Memory recall
Glasses and hearing aids present if needed.
Mobility Training :
Supine to sit : Supervision Use of bed rail
Sit to stand : Supervision
Stand to sit : Supervision
Recliner chair to bed : Minimal assist Toilet / Commode Transfer : Minimal assist
With gait belt Pt sat on EOB for about 10 minutes prior to bathroom due to dizziness.
However VSS throughout.
Pt ambulated into bathroom for toileting.
Increased time for toileting.
Then sat in front of sink and washed hands.
Again c / o of significant dizziness and nausea but VSS.
Therapist stand by assist for safety as his sitting balance worsens with fatigue.
Sitting rest break following this , then ambulated to door and then to window in room.
Assisted pt in getting set up for lunch.
Gait Training : Distance : 15 feet + 35 feet in room.
Device : 2 wheeled walker , Gait belt
Assistance : Minimal assist
Quality : unsteady , step to , decreased step length and height , forward posture , decreased foot clearance , scissoring noted today due to hip weakness , somewhat impulsive , walks too far from walker
Cueing : Verbal , Manual , Tactile , Modeling by therapist , for safety awareness , UE placement , LE placement , proper body mechanics and proper posture Balance Training :
Static Sitting : Fair (maintains balance with handheld assist)
Dynamic Sitting : Poor (Requires",2020-11-20
32831,706391,32678,4180186,135,"DOCUMENT HEADER :
Progress Notes by Gonzalez Mcgregor , [XXXXX] W , Pharm.
D. , Gonzalez Ferguson at  5/17/2020  9 : 21 AM (continued)
Author : Petersen Peterson , [XXXXX] W , Pharm.
D. , R. Ph.
Service : PHR (Pharmacy) Author Type : Pharmacist
Filed :  5/17/2020  9 : 22 AM Date of Service :  5/17/2020  9 : 21 AM Status : Signed
Editor : Calderon Calderon , [XXXXX] W , Pharm.
D. , Peterson Mckenzie (Pharmacist) Warfarin Dosing Progress Note : More information : Townsend Andersen Andersen is a ** y. o. male who was admitted to the hospital on  4/6/2020  .
Hospital Pharmacy has been consulted for inpatient warfarin management and monitoring.
Warfarin Indication : Atrial fibrillation (AF) Other indication (comments) : No data recorded
Type of therapy : New Prior average daily dose : No data recorded
Comorbidities : Poor nutrition state (e. g. several days or more of significantly reduced dietary intake) Are any of these comorbidities new with admission?
Yes Are there any new medication interactions with admission?
Yes Target INR : 2 3 Day of therapy : 5 and beyond Drug interactions include the following :
Strong Potentiator (From admission , onward)
None Moderate Potentiators (From admission , onward)
Start Dose / Rate Route Frequency Ordered Stop
 5/16/20  1051 acetaminophen tablet 650 mg (TYLENOL) 650 mg oral Every 4 hours PRN  5/16/20  1052
 4/11/20  0415 amiodarone 1.
8 mg / mL in D 5 W (non PVC) 250 mL infusion (CORDARONE) 0.
5 mg / min 16.
7 mL / hr intravenous Continuous  4/10/20  2201  4/11/20  2059 Potentiating (From admission , onward)
Start Dose / Rate Route Frequency Ordered Stop
 5/16/20  1051 acetaminophen tablet 650 mg (TYLENOL) 650 mg oral Every 4 hours PRN  5/16/20  1052 Enzyme Inducers (From admission , onward)
None Binders (From admission , onward)
Start Dose / Rate Route Frequency Ordered Stop
 5/12/20  1700 sevelamer tablet 1 , 600 mg (RENVELA) 1 , 600 mg oral 3 times daily with meals  5/12/20  1539 Vitamin K Containing Medications (168 h ago , onward)
None Antiplatelets & Anticoagulants (168 h ago , onward)
Start Dose / Rate Route Frequency Ordered Stop
 5/17/20  1700 warfarin tablet 5 mg (COUMADIN) 5 mg oral Once  5/17/20  1021  5/17/20  2345
 5/16/20  1700 warfarin tablet 5 mg (COUMADIN) 5 mg oral Once  5/16/20  1313  5/16/20  1625
 5/15/20  1800 warfarin tablet 5 mg (COUMADIN) 5 mg oral Once  5/15/20  1749  5/15/20  1802
 5/14/20  1700 warfarin tablet 5 mg (COUMADIN) 5 mg oral Once  5/14/20  1211  5/14/20  1647
 5/13/20  1700 warfarin tablet 4 mg (COUMADIN) 4 mg oral Once  5/13/20  0844  5/13/20  1653
 5/12/20  1700 warfarin tablet 4 mg (COUMADIN) 4 mg oral Once  5/12/20  0811  5/12/20  1601
 5/11/20  1700 warfarin tablet 3.
5 mg (COUMADIN) 3.
5 mg oral Once  5/11/20  1029  5/11/20  1720
 5/10/20  2100 warfarin tablet 3 mg (COUMADIN) 3 mg oral Once  5/10/20  0907  5/10/20  2036
 4/25/20  0800 warfarin management (COUMADIN) oral Daily  4/25/20  0752 INR reversal agents were not given.
Warfarin Reversal Agent Administrations (last 168 hours) Vitamin K and K Centra None FFP Administrations During Encounter (Filter : EAP GENERAL TRANSFUSE FFP Medications Shown)
None Warfarin Administrations (last 168 hours) Date / Time Action Medication Dose
 5/16/20  1625 Given warfarin tablet 5 mg (COUMADIN) 5 mg
 5/15/20  1802 Given warfarin tablet 5 mg (COUMADIN) 5 mg
 5/14/20  1647 Given warfarin tablet 5 mg (COUMADIN) 5 mg
 5/13/20  1653 Given warfarin tablet 4 mg (COUMADIN) 4 mg
 5/12/20  1601 Given warfarin tablet 4 mg (COUMADIN) 4 mg
 5/11/20  1720 Given warfarin tablet 3.
5 mg (COUMADIN) 3.
5 mg
 5/10/20  2036 Given warfarin tablet 3 mg (COUMADIN) 3 mg INR (no units)
Date Value Status
 5/17/2020  2.
2 (H) Final
 5/16/2020  2.
4 (H) Final
 5/15/2020  2.
1 (H) Final
 5/14/2020  1.
9 (H) Final
 5/13/2020  1.
9 (H) Final
 5/12/2020  1.
6 (H) Final
 5/11/2020  1.
8 (H) Final A / P :
The current INR of 2.
2 is Therapeutic.
Will repeat the previous warfarin dose to administer 5 mg this evening.
The pharmacist team will continue to follow patient's clinical progress daily until discharge from the hospital.
[XXXXX]
Faulkner Matthews , Pharm.
D. , Mcarthur Finnegan",2021-08-22
32831,706391,32678,4180186,125,"FULL DOCUMENT TEXT :
Progress Notes by Gonzalez , Mckinney Gonzalez , Calderon Quintana at  5/10/2020  8 : 00 AM (continued)
Author : Faulkner , Eastwood Townsend , Mckenzie Mcarthur Finnegan : ONC Hematology and Oncology Author Type : Registered Nurse
Filed :  5/10/2020  8 : 55 AM Encounter Date :  5/10/2020  Status : Signed
Editor : Gonzalez , Quintana Mcgregor , Eastwood Mcgregor (Registered Nurse) Patient in clinic today for breast cancer diagnosis.
Discussed patient's plan with Dr.
Finnegan and plans for patient to initiate ddAC x 4 cycles followed by 12 weekly cycles of TC treatment soon.
Breast Center Chemo Education folder given and discussed with patient.
Explained possible side effects of AC +TC regimen and methods for management of side effects as well as when to call or seek assistance.
Contact information provided for clinical team , scheduling team , and after hours on call.
Patient escorted to Ferguson building and chemotherapy unit to view the infusion center and room that she will be in for treatment.",2021-03-26
32831,706391,32678,4180186,38,"FULL DOCUMENT TEXT :
Telephone Encounter by Mcgregor , Mckenzie Mckinney at  7/10/2020  3 : 29 PM (continued)
Author : Mckenzie , Andersen E Service : ORS (Orthopedic Surgery) Author Type : Clinical Assistant
Filed :  7/10/2020  3 : 31 PM Encounter Date :  7/10/2020  Status : Signed
Editor : Andersen , Petersen Peterson (Clinical Assistant) (Note for RST / MCHS locations only : If the patient states they are asking for testing because attended a protest , vigil , community cleanup or other mass gathering in the last 7 days and is asking for testing , complete the below questions and transfer to the COVID Nurse Line).
1.
Do you have a pending COVID test because you had symptoms or exposure to someone with COVID or you have tested positive for COVID in the last 30 days?
no 2.
In the past 14 days , do you , anyone in the household , or anyone you have had prolonged exposure have any of the following?
a. Fever greater than or equal to 37.
8 C (100.
0 F)?
no b. New symptoms (Specifically : headache , cough , shortness of breath , respiratory distress , sore throat , diarrhea , nausea , vomiting , chills and repeated shaking with chills , myalgia's (muscle aches) , loss of smell , or change or loss of taste sensation)?
no c. Had close contact with a patient with known or possible COVID 19 in the last 14 days?
no Route reply to : N / A Scheduling Contact Number : [xxxxx]",2020-10-12
32831,706391,32678,4180186,28,"DOCUMENT HEADER :
ED Provider Notes by Mclellan , Peterson M , M. D. at  6/15/2020  4 : 37 PM (continued)
Author : Townsend , Matthews M , M. D. Service : ED (Emergency Medicine) Author Type : Physician
Filed :  6/15/2020  8 : 15 PM Date of Service :  6/15/2020  4 : 37 PM Status : Signed
Editor : Calderon , Mckenzie M , M. D.
(Physician)
CHIEF COMPLAINT / REASON FOR VISIT :
Alcohol Intoxication (admits to 5 6 beers today) and Fall (fell on the driveway.
c / o neck and low back pain.
has chronic low back pain from previous fall.
pt is c collared )
HISTORY OF PRESENT ILLNESS :
Patient is here with fall.
He fell in his driveway.
Has been drinking alcohol tonight.
Has chronic low back pain.
He fell forward onto a gravel road.
Brought in by EMS.
Did have COVID 19 in his past in 2 test since then.
No new symptoms.
He does report 5 to 6 beers today.
No numbness , paresthesias or weakness.
No recent travels.
No chest pain or shortness of breath.
Does have COPD.
REVIEW OF SYSTEMS :
All other systems reviewed and are negative.
ALLERGIES / MEDICATIONS :
Reviewed in medical record PAST MEDICAL / FAMILY / SOCIAL HISTORY :
PAST MEDICAL HISTORY :
Diagnosis Date
• Chronic Obstructive Pulmonary Disease (HCC)
• Depressive Disorder
• Hyperlipidemia
• Hypertension NOS Patient Active Problem List
Diagnosis Date Noted
• Pneumonia Due To COVID 19  5/23/2020  • Elevated Troponin  3/10/2018 
• Chronic Obstructive Pulmonary Disease Exacerbation (HCC)  3/10/2018 
• Overweight Or Obese NOS  3/10/2018 
• Hypertensive Heart Disease Without Heart Failure  3/10/2018 
PAST SURGICAL HISTORY :
Procedure Laterality Date
• ARTHROPLASTY OF KNEE N / A  1/4/2014  Arthroplasty of knee
• EXTRACTION OF CATARACT N / A Cataract extraction
• LAPAROSCOPIC APPENDECTOMY N / A  5/16/2015  Laparoscopic appendectomy
• LAPAROSCOPIC CHOLECYSTECTOMY N / A  9/13/2016  Laparoscopic cholecystectomy
• PROSTHETIC ARTHROPLASTY OF THE HIP N / A Hip replacement
• REPAIR OF UMBILICAL HERNIA N / A  5/16/2015  Repair of umbilical hernia
FAMILY HISTORY :
Reviewed in chart
SOCIAL HISTORY :
Socioeconomic History
• Marital status : Married
Spouse name : None
• Number of children : None
• Years of education : None
• Highest education level : None
Occupational History
• None
Social Needs
• Financial resource strain : None
• Food insecurity
Worry : None
Inability : None
• Transportation needs
Medical : None Non medical : None
Tobacco Use
• Smoking status : Former Smoker Packs / day : 1.
00
Years : 55.
00
Pack years : 55.
00
Types : Cigarettes
Last attempt to quit :  2/7/2012 
Years since quitting : 8.
3
• Smokeless tobacco : Never Used
Substance and Sexual Activity
• Alcohol use : Yes
Comment : rare
• Drug use : No
• Sexual activity : Defer
Lifestyle
• Physical activity
Days per week : None
Minutes per session : None
• Stress : None
Relationships
• Social connections
Talks on phone : None
Gets together : None
Attends religious service : None
Active member of club or organization : None
Attends meetings of clubs or organizations : None
Relationship status : None
• Intimate partner violence
Fear of current or ex partner : None
Emotionally abused : None
Physically abused : None
Forced sexual activity : None
Other Topics Concern
• None
SOCIAL HISTORY NARRATIVE :
• None
SOCIAL HISTORY :
Substance and Sexual Activity
Alcohol Use Yes
Comment : rare
SOCIAL HISTORY :
Substance and Sexual Activity
Drug Use No
OBJECTIVE :
INITIAL VITAL SIGNS :
Initial Vitals
Temperature Pulse Rate Heart Rate Resp Rate Blood Pressure SpO 2  6/15/20  1631  6/15/20  1631  6/15/20  1631  6/15/20  1631  6/15/20  1631
36.
9 °C 81 24 131 / 63 96 % Pain Score
 6/15/20  1909
3
PHYSICAL EXAMINATION :
Constitutional : Nursing note and vitals reviewed.
No distress.
HENT :
Nose : Nose normal.
Mouth / Throat : Oropharynx is clear and moist.
Mucous membranes are moist.
Finnegan right naris has resolved.
Superficial laceration forehead and bridge of nose.
Eyes : Conjunctivae and EOM are normal.
Extraocular Movements : EOM normal.
Neck : Neck supple.
Cardiovascular : Normal rate , regular rhythm and normal heart sounds.
Pulses are strong and palpable.
Capillary refill : takes less than 3 seconds , Pulmonary / Chest : Effort normal and breath sounds normal.
No tachypnea.
No respiratory distress.
Expiration is no prolonged expiration.
Air movement is not decreased.
He exhibits no retraction.
Abdominal : Soft.
Bowel sounds are normal.
Musculoskeletal : Normal range of motion.
Neurological : He is alert and oriented to person , place , and time.
He is not disoriented.
No cranial nerve deficit.
Skin : Skin is warm and dry.
Psychiatric : He has a normal mood and affect.
@SCORINGTOOLS@ ED COURSE :
FINAL DIAGNOSES :
as of  6/15/2015  Alcohol Abuse With Intoxication Unspecified (HCC) Injury Quintana",2021-02-21
32831,706391,32678,4180186,205,"DOCUMENT HEADER :
Progress Notes by Humphrey , Mclellan , P. A. C. at  8/29/2020  3 : 48 PM (continued)
Author : Finnegan , Mcgregor , P. A. C. Service : HIM (Hospital Internal Medicine) Author Type : Physician Assistant
Filed :  8/29/2020  5 : 02 PM Date of Service :  8/29/2020  3 : 48 PM Status : Attested Addendum
Editor : Finnegan , Peterson , P. A. C.
(Physician Assistant)
Related Notes : Original Note by Mcarthur , Mckenzie , P. A. C.
(Physician Assistant) filed at  8/29/2020  4 : 34 PM
Cosigner : Eastwood , Finnegan Peterson , M. D. at  8/29/2020  9 : 05 PM
Attestation signed by Mckenzie , Gonzalez Gonzalez , M. D. at  8/29/2020  9 : 05 PM I have reviewed the patient’s history , physical examination , and plan as outlined in PA Eastwood's note.
I have also seen and evaluated the patient myself.
We have discussed the patient’s care in detail and I agree with the assessment and recommendations as outlined in the progress note.
Townsend Matthews , M. D.
 8/29/20  7 : 05 PM MST Hospital Internal Medicine Progress Note
SUBJECTIVE :
Transfer from CCM to HIM.
Ms.
Mclellan is a very pleasant ** year old female with history of anxiety / depression , morbid obesity with BMI 41 , elevated blood pressures without diagnosed hypertension , prediabetes.
She was admitted on [8_24] with acute hypoxic respiratory failure [2_25] COVID 19 pneumonia.
Due to increasing oxygen requirements up to HFNC 50 L 90% FiO 2 , she was transferred to the ICU on [8_25] .
She has been weaned down to 40 L 50% FiO 2 , saturating in the mid [xxxxx x. xxxxx] to improved oxygen requirements , she is being transferred out of ICU to progressive care.
Ms.
Ferguson is sitting up in bed.
She is maintaining saturations in mid [xxxxx x. xxxxx] HFNC 40 L 50% FiO 2 speaking in complete sentences.
She denies any shortness of breath or difficulty breathing.
Endorses mild dry cough.
Denies fever , chills , nausea , vomiting , or abdominal pain.
No new complaints.
CURRENT MEDICATIONS :
I have reviewed the current medication list.
CURRENT MEDICATIONS :
• acetaminophen tablet 1 , 000 mg (TYLENOL) , Q 6 H PRN
• ALPRA Zolam tablet 0.
25 mg (XANAX) , BID PRN
• aspirin chewable tablet 81 mg , Daily
• cefTRIA Xone 2 g in Na Cl 0.
9% IVPB (ROCEPHIN) , Q 24 H • dexamethasone injection 6 mg (DECADRON) , Daily
• enoxaparin injection 40 mg (LOVENOX) , BID
• insulin aspart U 100 injection 0 13 Units (NovoLOG Flex Pen) , Q 4 H SCH
• insulin glargine injection 12 Units , Daily at bedtime
• melatonin tablet 6 mg , At bedtime PRN
• Na Cl 0.
9% infusion , PRN
• ondansetron (PF) injection 4 mg (ZOFRAN) , Q 6 H PRN
• oxyCODONE IR tablet 5 mg (ROXICODONE) , Q 4 H PRN
• sertraline tablet 50 mg (ZOLOFT) , Daily
• sodium chloride 0.
65 % nasal spray 1 spray (OCEAN) , PRN
• sulfur hexafluoride microspheres injection (LUMASON) , PRN
• white petrolatum mineral oil ophthalmic ointment 0.
25 inch , 4 x Daily PRN
VITALS :
Temperature : [36.
2 °C 37 °C] 36.
8 °C
Heart Rate : [64 97] 96
Resp Rate : [15 32] 15
Blood Pressure : (143) / (84) 143 / 84 Arterial Line BP : (91 157) / (58 84) 153 / 80 FiO 2 (%) : [50 % 60 %] 50 % SpO 2 : [90 % 97 %] 96 %
Flow Rate (L / min) : [40 L / min] 40 L / min Pulse Rate : [64 100] 96 Intake / Output : Intake / Output Last 24 Hours : Intake / Output Summary (Last 24 hours) at  8/29/2020  1358
Last data filed at  8/29/2020  1300
Gross per 24 hour
Intake 1020 ml
Output 1710 ml
Net 690 ml
PHYSICAL EXAMINATION :
General : No acute distress.
Morbid obesity.
Alert and oriented.
Cardiac : Regular rate and rhythm without murmur , rub or gallop.
Pulmonary : Decreased air entry throughout , diminished breath sounds due to body habitus.
No wheezing , or crackles.
Abdomen : Protuberant abdomen.
Bowel sounds positive.
Soft.
Nondistended.
Nontender to palpation.
Extremities : No pedal edema.
Dorsalis pedis pulses are palpable bilaterally.
Neurologic : No focal deficits
Skin : Warm and dry without rashes or lesions.
Results Review :
I have reviewed labs , ECG , xray , CT and diagnostics.
Lab results last 24 hours :
Recent Results (from the past 24 hour(s))
Glucose , POCT
Collection Time :  8/28/20  5 : 34 PM
Result Value
Glucose , POCT , B 313 (H)
Basic Metabolic Panel
Collection Time :  8/28/20  9 : 47 PM
Result Value
Potassium , S 4.
2
Sodium , S 134 (L)
Chloride , S 95 (L)
Bicarbonate , S 24
Anion Gap 15
Bld Urea Nitrog(BUN) , S 13.
4
Creatinine , S 0.
58 (L) eGFR Non Black >90 eGFR Black >90
Calcium , Total , S 8.
8
Glucose , S 203 (H)
Magnesium
Collection Time :  8/28/20  9 : 47 PM
Result Value
Magnesium , S 2.
3
Phosphorus Inorganic
Collection Time :  8/28/20  9 : 47 PM
Result Value
Phosphorus (Inorganic) , S 2.
9
Glucose , POCT
Collection Time :  8/28/20  9 : 57 PM
Result Value
Glucose , POCT , B 196 (H)
Glucose , POCT
Collection Time :  8/28/20  11 : 32 PM
Result Value
Glucose , POCT , B 228 (H)
Arterial Blood Gas (ABG) , Blood
Collection Time :  8/29/20  3 : 43 AM
Result Value
Sample Site SEE COMMENT
Temperature 37.
0 FIO 2 50.
00
Device Settings h",2020-04-25
32831,706391,32678,4180186,215,"DOCUMENT HEADER :
Consults Outpatient signed by Mckenzie , Mclellan V. , M. D. , Ph.
D. at  6/11/2020  2 : 49 PM (continued)
Author : Townsend , Andersen V. , M. D. , Ph.
D. Service : CVD Heart Rhythm Author Type : Physician
Filed :  6/11/2020  2 : 49 PM Encounter Date :  6/11/2020  Status : Signed
Editor : Eastwood , Mcgregor V. , M. D. , Ph.
D.
(Physician)
REASON FOR CONSULT : Pre A Fib ablation discussion.
HISTORY OF PRESENT ILLNESS :
Mrs.
Mckinney is a delightful ** year old female with a history of highly symptomatic atrial fibrillation , CHADS / VA Sc score of 4 , LV diastolic dysfunction , medically complicated obesity status post Calderon en Y gastric bypass , obstructive sleep apnea on CPAP , stage 3 CKD , diabetes mellitus type 2 , peripheral neuropathy , history of PE while on Premarin , and hypothyroidism.
I last saw the patient in [XXXXX] of this year.
She was clearly highly symptomatic with atrial fibrillation , noting fatigue , loss of energy , lightheadedness , and palpitations.
She was on metoprolol as well as diltiazem.
She has noted she has dealt with atrial fibrillation since the late [xxxxx x. xxxxx] was back in [XXXXX] when she felt that she was presumably in A Fib since then and ever since her intussusception and hospitalization back in [XXXXX] where she has been persistently in A Fib.
She clearly is aware of when she is in A Fib , and she definitely does not feel as good as when she is in sinus rhythm.
We had scheduled her for amiodarone loading which had initially required her , given her A Fib with RVR , to be in the hospital.
Of note , prior to this cardioversion , a sinus rhythm occurred  2/16/2020  , and she had a marked improvement in symptoms.
However , she relapsed several times requiring trips to the emergency department and repeat cardioversions with additional loading of amiodarone.
She was admitted prior to her scheduling for pulmonary vein isolation in [XXXXX] .
This occurred in the setting of an unfortunate COVID 19 infection noted  4/22/2020  rd.
She was initially scheduled for ablation on  4/25/2020  .
She re increased her amiodarone to 400 mg b. i. d. and has been on this 200 mg twice a day since.
She has finally converted to sinus rhythm at some point in the interim.
She has noticed a marked improvement in her symptoms , and she wishes to proceed with pulmonary vein isolation.
Of note , her last PCR SARS was undetectable  5/22/2020  .
She is scheduled for upcoming MRI imaging and additional testing , and she is also planned for pulmonary vein isolation with me  6/21/2020  .
ASSESSMENT / PLAN :
# 1 Highly symptomatic paroxysmal atrial fibrillation
# 2 Medically complicated obesity , status post gastric bypass with a Roux en Y # 3 Diabetes mellitus type 2
# 4 Probable diastolic dysfunction I had a long discussion with Mrs.
Matthews , and we discussed in detail the rationale of the procedure which would include a PVI and possibly a CTI for her atrial fibrillation therapy.
We discussed we will keep her on amiodarone , and she should deescalate to 200 mg once daily from now on.
We will plan for a 3 month course of amiodarone postablation , and then we will plan to stop amiodarone.
She will continue apixaban lifelong.
I also discussed we will put her on Prilosec b. i. d. postablation for 1 month.
I discussed with her the rationale and outlined the procedural steps that will occur.
She will need to be n. p. o. the night prior , and she should continue amiodarone and apixaban with small sips of water morning of.
In addition , she will get a cardiac MRI , and we should also set her up for a TEE if possible.
She will get repeat coronavirus testing as well as IgG testing.
She is agreeable to the plan and excited to proceed.
We will obtain formal consent morning of when we meet each other in the PACU.
Mckinney Matthews Faulkner Eastwood , M. D. , Ph.
D.
DD :  6/11/2020  14 : 20 : 09 CT
DT :  6/11/2020  14 : 42 : 36 CT
Job ID : [xxxxxxxx] / gam",2021-03-27
32831,706391,32678,4180186,163,"FULL DOCUMENT TEXT :
Plan of Care by Humphrey , Mcgregor Andersen , Eastwood Peterson Andersen , Gonzalez Humphrey Mcgregor at  4/12/2020  3 : 38 PM (continued)
Author : Mckenzie , Ferguson Mckenzie , Peterson Matthews Faulkner , Faulkner Eastwood Quintana Matthews : RT (Respiratory Therapy) Author Type : Respiratory Therapist
Filed :  4/12/2020  3 : 42 PM Date of Service :  4/12/2020  3 : 38 PM Status : Signed
Editor : Mcarthur , Gonzalez Mckenzie , Humphrey Calderon Mckenzie , Mckinney Matthews Andersen (Respiratory Therapist) Alert Information : Plan of Care : Pt continues orally intubated.
She is ventilated on the G 5 40% oxygen CMV 24 bpm Vt 250 ml peep is now 22 cm H 2 O. She placed in supine position at 1015 this morning.
At this time , there is no plan to prone her.
Monitor arterial line.
Principal Problem
Acute Respiratory Distress Syndrome Due To COVID 19 (HCC) ETT (Active)
Placement Date / Time :  4/10/20  (c) 0502 Mask Ventilation : Not attempted ETT Type : Standard ETT Cuffed : Yes Location : Oral ETT Secured at (cm) : 24 cm Arterial Line  4/10/20  Right Radial (Active)
Placement Date / Time :  4/10/20  (c) 0518 Hand Hygiene Performed Prior to Insertion : Yes Site Prep : Chlorhexidine (Preferred) Sterile Barriers Used : Quintana ; Gloves ; Gown ; Large drape ; Mask (Clinician) ; Mask (All others in room) Orientation : Right Location.
.
.
Ventilator Info :
Ventilator Mode : (S)CMV FiO 2 (%) : 40 %
PEEP (cmH 2 O) : 22 cm H 20 Plateau (Pause) Airway Pressure : 28 cm H 2 O Compliance (mL / cm H 2 O) : 21.
6 mL / cm H 2 O Recent Labs  4/12/20  1308 PO 2 ART 118 H PCO 2 ART 52 H
PH ART 7.
37 Skin integrity checked : No issues around the anchorfast appliance.",2020-08-26
32831,706391,32678,4180186,173,"DOCUMENT HEADER :
Anesthesia Preprocedure Evaluation by Finnegan , [XXXXX] J , M. D. at  9/3/2020  1 : 47 PM (continued)
Author : Peterson , [XXXXX] * , M. D. Service : ANE (Anesthesiology) Author Type : Anesthesiologist
Filed :  9/3/2020  1 : 48 PM Date of Service :  9/3/2020  1 : 47 PM Status : Signed
Editor : Peterson , [XXXXX] * , M. D.
(Anesthesiologist) Preprocedure Anesthesia & H&P Assessment
PROCEDURE SUMMARY :
Anesthesia Start Date / Time :  9/3/20  1308
PROCEDURE :
LABOR ANALGESIA Pertinent components of the patient's history including current problem list , medical history , surgical history , family history , social history , medications and allergies were reviewed.
Present illness and pre op diagnosis were confirmed.
The planned surgery / procedure was verified with the patient / legal guardian.
The patient's general health condition remains unchanged
PROBLEM LIST :
Relevant Problems RENAL / REPRO (+) Encounter For Supervision Of Normal Pregnancy Unspecified Trimester
(+) Examination Prenatal Normal Pregnancy Third Trimester Other
(+) Depression Anxiety
(+) Normal Pregnancy Not First Pregnancy (Resolved)
(+) Patient Currently Pregnant (Resolved)
(+) Restless Leg Syndrome
PHYSICAL EXAMINATION :
Airway (HEENT)
Mallampati : I
TM Distance : >3 FB
Neck ROM : Full
Mouth Opening : >3 cm
Cardiovascular
Rhythm : Regular
Rate : Normal Cardiovascular Assessment : cardiovascular normal
Functional Capacity : >4 METS
Pulmonary
Pulmonary Assessment : Clear
General / Constitutional
Constitutional Assessment : Normal
General State of Health : : in distress
Neurological Neurologic Assessment : alert and alert and oriented x 3
Dental
Dental Assessment : dentition intact
ANESTHESIA PLAN :
ASA : 2 Emergent
ANESTHESIA PLAN :
regional Discussed risks and benefits of Labor epidural with patient including , but not limited to , pain on placement , infection , bleeding , hematoma formation , nerve damage , 1% risk of post dural puncture headache , spinal , high spinal , high epidural , nausea and vomiting , hypotension , one sided block , patchy block , failure of block with need of catheter replacement.
Questions and concerns addressed.
Patient still desired labor epidural placement.
Patient seen and allergies reviewed , anesthesia plan and risks discussed directly with patient / legal guardian or through an interpreter.
The use of blood products not discussed
Approval to Proceed : approved for anesthesia",2020-09-06
32831,706391,32678,4180186,187,"DOCUMENT HEADER :
Progress Notes by Townsend , Quintana C , P. T. , D. P. T. , CCS at  5/21/2020  2 : 49 PM (continued)
Author : Quintana , Eastwood C , P. T. , D. P. T. , CCS Service : PTO Physical Therapy Author Type : Physical Therapist
Filed :  5/21/2020  3 : 46 PM Date of Service :  5/21/2020  2 : 49 PM Status : Signed
Editor : Mcarthur , Faulkner C , P. T. , D. P. T. , CCS (Physical Therapist) Inpatient Physical Therapy Treatment SUBJECTIVE :
Patient : Mcgregor Finnegan Matthews.
Room : 732 / 732 P Referring / Attending Provider : Herrigel , Townsend , M. D.
Medical Diagnosis : Acidosis Lactic [E 87.
2]
Hyperkalemia [E 87.
5]
Shortness Of Breath [R 06.
02]
Hypoxia [R 09.
02]
Hypertension And End Stage Renal Disease (HCC) [I 12.
0 , N 18.
6]
Abdominal Pain [R 10.
9]
Payor : MEDICARE / Plan : MEDICARE A AND B / Product Type : Medicare / Is Patient at risk for Falls?
yes Precautions / Restrictions : Fall Precautions
Invasive Lines / Drains : none
Oxygen Delivery : Room air Subjective Comments : Pt supine in bed , alert , and agreeable to therapy.
OBJECTIVE :
Patient Presents : supine in bed , needs including call bell in reach , alarm on , sling in place , pressure relief in place Pain Assessment :
No pain behavior observed
VITAL SIGNS :
Patient was monitored for signs / symptoms of activity intolerance.
Adverse Response to Treatment : none , c / o of dizziness throughout , however VSS throughout on room air.
Current Level of Function : Cognition : Alert , Oriented x 4 , Follows multi step commands Balance :
Static Sitting : Good (maintains balance without support)
Dynamic Sitting : Good (maintains balance without support)
Static Standing : Good (maintains balance without support)
Dynamic Standing : Fair (maintains balance with handheld assist) Mobility Training :
Supine to sit : Modified independent
Sit to stand : Supervision
Stand to sit : Supervision Toilet / Commode Transfer : Supervision Gait Training : Distance : 180 feet in room x 2 bouts.
(3 laps of 60 feet each time)
Device : No Assistive Device
Assistance : Supervision
Quality : steady , guarded , decreased step length and height , slow cadence , trendelemburg hip drop Outcome Measures : AM PAC AM PAC Basic Mobility (V.
2) How much help from another person do you currently need…If the patient hasn't done an activity recently , how much help from another person do you think he / she would need if he / she tried?
1.
Turning from your back to your side while in a flat bed without using bedrails?
: None
2.
Moving from lying on your back to sitting on the side of a flat bed without using bedrails?
: None
3.
Moving to and from a bed to a chair (including a wheelchair)?
: None
4.
Standing up from a chair using your arms (e. g. , wheelchair , or bedside chair)?
: None
5.
To walk in hospital room?
: A Little
6.
Climbing 3 5 steps with a railing?
: A Little AM PAC Basic Mobility (V.
2) Raw Score : 22 AM PAC Basic Mobility (V.
2) Standardized Score : 47.
4 Five Times Sit to Stand : 10 seconds
Dyspnea Scale : +1 = Mild , noticeable to client but not observer
EDUCATION :
Activity Expectation Patient provided extensive education reinforcing the importance of mobility , strengthening , being out of bed for all meals , participating in self care and functional activity training in order to maintain functional independence.
Daily Ambulation Program Patient encouraged to participate / continue with daily ambulation program 3 4 x daily with nursing staff to improve activity tolerance and functional mobility.
Instructions were written on white board for visual cue and communicated to nursing.
Therapeutic Exercise :
Performed 2 sets of 10 reps of the following bilaterally while holding onto the back of a chair for safety : Sit to stands Heel raises Hamstring curls Hip extension Hip abduction Patient Disposition at the end of Treatment :
Mr.
Calderon was left cardiac chair position in bed , needs including call bell in reach , alarm on , sling in place , pressure relief in place.
Patient / caregiver verbalized understanding to contact nursing staff for all needs including transfers , and ambulation if appropriate.
ASSESSMENT :
Discharge Recommendations :
Location : Home with home health
Equipment : pt owns a rollator.
Clinical Impression : Gonzalez Andersen Calderon is a ******** male who has been hospitalized 3 day(s) currently presents with impairments including impaired strength , impaired balance and impaired cardiopulmonary function resulting in functional deficits including impaired gait , impaired transfer skills , impaired balance and impaired activity tolerance.
Andersen Humphrey Humphrey has made good progress towards rehab goals.
Significant progress today , tolerated activity well on room air with good effort.
Improved balance today with less fatigue.
Continues to have weak hips , which reflects in his gait pattern and lowers his overall gait steadiness , but improving.
Will continue to progress as able and tolerated.
Encouraged pt to frequently walk with nurses in room as able.
Functional Goals and Timeframes :
PT Goal # 1 : Patient will",2021-07-17
32831,706391,32678,4180186,75,"DOCUMENT HEADER :
Procedures by Mcarthur , Mckenzie Mckinney , Matthews Mcgregor Matthews Townsend at  4/24/2020  11 : 49 AM (continued)
Author : Finnegan , ******** , Townsend Matthews Mcgregor Quintana Calderon : CCM (Critical Care Medicine) Author Type : Physician
Filed :  4/24/2020  11 : 57 AM Date of Service :  4/24/2020  11 : 49 AM Status : Signed
Editor : Mclellan , Sumera R , Townsend Mckinney Peterson Andersen (Physician)
PROCEDURE ORDERS :
1.
Invasive Line [ [xxxxxxxx] ] ordered by Humphrey , Mckenzie Ferguson , Quintana Faulkner Calderon Townsend Peterson procedure Diagnoses 1.
COVID 19 Infection [U 07.
1] 2.
Adult Respiratory Distress Syndrome (HCC) [J 80] Invasive Line Date / Time :  4/24/2020  11 : 50 AM
Performed by : Mckenzie , Eastwood Calderon , Mclellan Mckenzie Gonzalez Ferguson Mclellan by : Faulkner , Mckenzie Mckinney , Humphrey Gonzalez Mcarthur Peterson Petersen team members present
1.
Eastwood , Mclellan Townsend , Faulkner Finnegan Matthews Matthews Calderon : ICU / PCU PROCEDURE DETAILS :
Line type : central venous
Laterality : right
Location : jugular internal Location details : new site Additional catheter (i. e. multiple lines in same vessel) : no
Patient position : Trendelenburg Age group : adult
Line Type : temporary (non tunneled , non implanted)Introducer : yes Catheter placed via introducer : clip in triple lumen
Lumen(s) : triple lumen
Catheter diameter : 13 Fr Technique : ultrasound guided Ultrasound guidance : image acquired and saved
Ultrasound comment : ultrasound guidance used demonstrating vessel patency and cannulation of the vessel observed.
Vessel transduced : yes Monitored (venous) : yes Number of attempts : 1 CONSENT
Consent obtained : none emergent situation UNIVERSAL PROTOCOL
All relevant documentation and testing were reviewed and available.
All required blood products , implants , devices and or special equipment were made available as applicable.
Pre procedure verification was conducted and the correct site was marked if required.
A fire risk assessment was done as applicable.
The procedural time out was conducted prior to performing the procedure and confirmed in a procedural pause.
PRE PROCEDURE DETAILS : Indication(s) : medication / nutrition requiring central access Appropriate hand hygiene , gown , cap , mask , protective eyewear , sterile gloves , skin preparation , sterile drape , and strict aseptic technique were utilized as applicable for the procedure.
: yes Skin preparation : chlorhexidine SEDATION / ANESTHESIA
Anesthesia method : deep sedation and topical application
Topical application type : lidocaineI did not supervise the sedation.
(Sedation was needed for respiratory failure) POST PROCEDURE DETAILS : Procedure completed successfully : yes
Line secured : sutured Chlorhexidine disc around insertion site and under catheter with slight turn : yes Complications : none
Patient tolerance of procedure : successful",2020-08-10
32831,706391,32678,4180186,248,"FULL DOCUMENT TEXT :
Telephone Encounter by Andersen , Quintana Mckinney , Andersen Peterson at  4/18/2020  10 : 18 AM (continued)
Author : Quintana , Faulkner M , Humphrey Calderon Petersen : GIM (General Internal Medicine) Author Type : Registered Nurse
Filed :  4/18/2020  10 : 56 AM Encounter Date :  4/18/2020  Status : Signed
Editor : Finnegan , Humphrey M , Ferguson Matthews (Registered Nurse) SUBJECTIVE CHIEF COMPLAINT / REASON FOR CALL
CFCT Follow Up Information Discussed Mckenzie Gonzalez Peterson contacted by nurse for day 7 follow up regarding positive COVID 19 test results.
Patient risk factors for developing severe disease include : chronic lung disease
We discussed the following symptoms to see if there was development of new or worsening symptoms since positive swab result.
We covered :
Dyspnea : Resolved
Chest Pain : Improving
Dizzy or lightheaded : Resolved
Severe vomiting : Not present
Severe diarrhea (more than 4 a day) : Not present
Cough : Improving
Loss of smell : Resolved
Loss of taste : Resolved
Headache : Resolved
Runny nose : Resolved
Fever (≥100.
5 F or subjective) : Not present This is not a change from their last CFCT phone call.
Based on symptom assessment , patient advised to continue monitoring symptoms at home and instructed to call CFCT with new or worsening symptoms.
CFCT can be reached 7 days a week , 8 am 5 pm at [xxx_xxx_xxxx] .
On our phone call today the patient and I discussed if they would need to be retested and the frequency of those tests , if needed , to be release from quarantine.
We discussed that the following :
Were you hospitalized with COVID 19?
YES
Are you immunocompromised?
NO
Are you living with a high disease individual?
NO If all three questions were no the patient does not need to be retested and will have a CFCT RN call on in about one week for symptom assessment to determine appropriateness to be released from quarantine.
If one or more of the above questions was yes , retesting is indicated as defined by the providers plan of care and established standards.
The CFCT team will notify the *********** drive through testing center so a point of care order can be placed on the date testing is needed.
The CFCT team will call the patient after the test results are available and discuss if quarantine can be lifted or if more monitoring and / or testing is needed.
PLAN Disposition / Recommendation : Email sent for retesting on  4/21/20  Information / Education : patient / caller able to teach back Caller agreeable to plan of care : yes The following references were used : nursing clinical judgment and provider Dr.
Gonzalez Finnegan.",2020-04-17
32831,706391,32678,4180186,118,"DOCUMENT HEADER :
Plan of Care by Gonzalez , Townsend A , R. R. T. , Peterson Andersen Mcarthur at  4/28/2020  4 : 55 PM (continued)
Author : Townsend , Peterson A , R. R. T. , Peterson Finnegan Gonzalez Calderon : RT (Respiratory Therapy) Author Type : Respiratory Therapist
Filed :  4/28/2020  4 : 59 PM Date of Service :  4/28/2020  4 : 55 PM Status : Signed
Editor : Humphrey , Gonzalez A , R. R. T. , Humphrey Ferguson Humphrey (Respiratory Therapist) Finnegan Ferguson Humphrey is a ** y. o. female was admitted on  4/17/2020  with complaint of Eclampsia In Pregnancy Third Trimester [O 15.
03] COVID 19 Infection [U 07.
1].
Pertinent Past Medical History :
SOCIAL HISTORY :
Tobacco Use
Smoking Status Never Smoker
Smokeless Tobacco Never Used Respiratory Medications include : Duoneb QID Breath Sounds : Diminished Hemodynamic Monitoring (if applicable) : Right radial arterial line Recent CXR : None recent Recent ABG :
Results from last 7 days
Lab Units  4/28/20 
0603
PH ART pH 7.
47* PCO 2 ART mm Hg 44 PO 2 ART mm Hg 68* HCO 3 ART mmol / L 31*
BASE EXC ART mmol / L 7* Device : Room air.
V 60 at bedside for overnight CPAP 8 if needed.
Today's notes / findings : Patient continued on V 60 CPAP 8 overnight , patient taken off of CPAP this a. m. to room air , tolerating well.
No stridor noted.
Patient has intermittently needed nasal cannula for decreased SpO 2.
Duonebs given as scheduled.
PLAN :
Continue to monitor and assess while in ICU.
V 60 CPAP at bedside if needed for work of breathing.
Administer bronchodilators as tolerated.
Maintain hemodynamic monitoring.
Petersen Mckinney , Andersen Mckenzie Mckinney , Petersen Gonzalez Andersen  4/28/20  4 : 55 PM CDT",2020-04-25
32831,706391,32678,4180186,43,"DOCUMENT HEADER :
Office Visit  9/30/2020  Calderon Quintana Peterson Andersen Andersen : 12 663 555 Encounter Information
Encounter Information (continued) Provider Department Encounter # Center
 9/30/2020  8 : 30 AM Reynolds , Ferguson A , APRN *** Hem Onc Jadv
Arrive at : ***** Building , 2 nd Floor , North Desk [xxxxxxxx] *** ***
FAMILY HISTORY :
Family as of  9/30/2020 
Family as of  9/30/2020  (continued)
Problem Relation Name Age of Onset Comments Source
Hypertension Mother [XXXXX] ***** — — Patient
Other Maternal Grandfather — — — Provider
Bone cancer Maternal Grandmother — — — Provider
Alcoholism NOS Paternal Grandfather — — — Provider
Stroke Paternal Grandmother — — — Provider
Seizures Daughter — — — Provider
Asthma Daughter — — — Provider
Eczema Daughter — — — Provider
Hernia Daughter — — Repaired age 5.
Provider
Other Brother Humphrey — Due to physical injury.
Provider
Other Brother [XXXXX] — Due to physical injury.
Provider
No Known Problems Other — — — —
No Known Problems Other — — — —
No Known Problems Other — — — —
No Known Problems Other — — — —
No Known Problems Other — — — —
No Known Problems Other — — — —
No Known Problems Other — — — —
No Known Problems Other — — — —
No Known Problems Other — — — —
Bone cancer Mother's Sister — — — Provider Family Status as of  9/30/2020 
Family Status as of  9/30/2020  (continued)
Relation Name Status Comments Sex (Gender) Father Mother Source
Mother [XXXXX] ***** Alive , age 61 y — F Patient's maternal grandfather Patient's maternal grandmother Patient
Father — Alive , age 60 y — M Patient's paternal grandfather Patient's paternal grandmother Provider
Maternal Grandfather — Deceased — M — — Provider
Maternal Grandmother — Deceased — F — — Provider
Paternal Grandfather — Deceased — M — — Provider
Paternal Grandmother — Deceased — F — — Provider
Daughter — Alive , age 15 y — F — ******* , Ferguson Mckenzie Gonzalez (Patient) Provider
Brother Andersen Mcgregor , age 39 y — M Patient's father [XXXXX] Mcarthur (Patient's mother) Provider
Brother [XXXXX] Alive , age 33 y — M Patient's father [XXXXX] Mckenzie (Patient's mother) Provider
Other — Alive — F [XXXXX] (Patient's brother) — Provider
Other — Alive — F [XXXXX] (Patient's brother) — Provider
Other — Alive — M [XXXXX] (Patient's brother) — Provider
Other — Alive — F ***** (Patient's brother) — Provider
Other — Alive — F ***** (Patient's brother) — Provider
Other — Alive — F ***** (Patient's brother) — Provider
Other — Alive — M ***** (Patient's brother) — Provider
Other — Alive — M ***** (Patient's brother) — Provider
Other — Alive — M ***** (Patient's brother) — Provider
Mother's Sister — Deceased — F Patient's maternal grandfather Patient's maternal grandmother Provider
Mother's Sister — Alive — F Patient's maternal grandfather Patient's maternal grandmother Provider
Mother's Sister — Alive — F Patient's maternal grandfather Patient's maternal grandmother Provider
Mother's Sister — Alive — F Patient's maternal grandfather Patient's maternal grandmother Provider
Mother's Sister — Alive — F Patient's maternal grandfather Patient's maternal grandmother Provider
Mother's Sister — Alive — F Patient's maternal grandfather Patient's maternal grandmother Provider
Mother's Brother — Alive — M Patient's maternal grandfather Patient's maternal grandmother Provider
Mother's Brother — Alive — M Patient's maternal grandfather Patient's maternal grandmother Provider
Father's Sister — Alive — F Patient's paternal grandfather Patient's paternal grandmother Provider
Father's Sister — Alive — F Patient's paternal grandfather Patient's paternal grandmother Provider
Father's Sister — Alive — F Patient's paternal grandfather Patient's paternal grandmother Provider
Father's Sister — Alive — F Patient's paternal grandfather Patient's paternal grandmother Provider
Father's Sister — Alive — F Patient's paternal grandfather Patient's paternal grandmother Provider
Father's Brother — Alive — M Patient's paternal grandfather Patient's paternal grandmother Provider
Father's Brother — Alive — M Patient's paternal grandfather Patient's paternal grandmother Provider
Father's Brother — Alive — M Patient's paternal grandfather Patient's paternal grandmother Provider Level of Service
Level of Service (continued)
Level of Service Modifiers
PR VISIT EST PATIENT LEVEL 4 [ [xxxxx] ] Significant , Separately Identifiable Evaluation And Management Service By The Same Physician On The Same Day Of The Procedure Or Other Service [25]
REASON FOR VISIT (CONTINUED) :
Patient Instructions (continued) None",2021-09-25
32831,706391,32678,4180186,31,"DOCUMENT HEADER :
Progress Notes by Matthews , Mcarthur A , M. D. at  8/16/2020  2 : 00 PM (continued)
Author : Mcarthur , Andersen A , M. D. Service : CIM (Community Internal Medicine) Author Type : Resident
Filed :  8/16/2020  3 : 18 PM Encounter Date :  8/16/2020  Status : Signed
Editor : Andersen , Faulkner A , M. D.
(Resident) Primary Care Internal Medicine Limited Exam
Providing Resident : Matthews Mclellan , M. D.
Supervising Physician (Consultant) : Calderon Faulkner , Peterson Faulkner
Finnegan :
Ms.
Finnegan Mckinney Matthews is a ** y. o. female with a past medical history of COVID 19 infection , mild intermittent asthma , and chronic myofascial pain syndrome who presented today for dizziness.
# 1 Dizziness
Mrs.
Mcarthur was seen today for evaluation of abrupt onset dizziness that occurred 2 days ago.
She is accompanied by her husband who is serving as her interpreter.
She developed abrupt onset dizziness 2 days ago in the morning.
When she proceeded to arise from a seated to standing position , she developed abrupt onset room spinning dizziness with laterality primarily to the right.
Shortly thereafter , she felt off balance which resulted in a fall.
She explains to me that she hit her head on a wall , but did not lose consciousness.
This dizziness was also accompanied by nausea , but no vomiting.
She did not have any additional prodromal symptoms such as chest discomfort , dyspnea , palpitations , or presyncope.
She did not have any additional accompanying symptoms such as hearing loss , tinnitus , or focal neurologic symptoms.
This dizziness persisted over a 24 hour period and was exacerbated with head movements , particularly when turning in bed and gazing upwards.
Her symptoms resolved yesterday morning after she implemented “exercises” that she and her husband looked up on You Tube.
These were described as going from a seated position on her bed , to lying down with her head over the edge of the bed (possibly Mcgregor maneuver).
She also increased her fluid intake.
She did not utilize any over the counter medications.
She does not have a history of vertigo and has not experienced symptoms similar to this previously.
No fever / chills , headache , vision changes , photophobia , sonophobia , speech changes , numbness or tingling , focal weakness , vomiting , gait changes , hearing loss , or tinnitus.
Of note , she works 12 hour shifts at Seneca Foods performing assembly work , and works up to 6 7 days per week.
She and her husband are requesting a letter to be excused from work related duties through Monday ,  8/22/2020  if possible.
VITAL SIGNS :
Blood Pressure : (100) / (64) 100 / 64 Pulse Rate : [72] 72
Vitals reviewed in chart and are stable except as noted in Assessment / Plan below.
SOCIAL HISTORY :
Reviewed in EMR.
MEDICATIONS :
Reviewed in EMR.
MEDICAL HISTORY :
Reviewed in EMR as per problem list.
ALLERGIES :
No Known Allergies The following portions of the patient's history were reviewed and updated as appropriate : allergies , current medications , family history , medical history , surgical history and problem list.
REVIEW OF SYSTEMS :
Negative for chest pain , palpitations , shortness of breath , wheezing , abdominal pain , vomiting , constipation , diarrhea , fever , chills , unintentional weight loss.
All systems were reviewed and negative , except otherwise noted in HPI.
PHYSICAL EXAM :
General : Sitting in chair comfortably , NAD.
Eyes : EOMI.
PEERLA.
Sclera anicteric , conjunctiva clear.
HENT : Moist mucous membranes.
T Ms clear bilaterally without effusion.
Cardiac : Normal rate , regular rhythm.
No murmurs , rubs , or gallops.
Lungs : Clear to auscultation bilaterally.
Comfortable on room air.
Extremities : Warm and well perfused.
Skin : No rash or jaundice.
Neuro : CN 2 12 intact.
Strength [4_12] in the upper and lower extremities bilaterally.
Sensation intact and symmetric.
Biceps , brachioradialis , patellar , and ankle reflexes 2+ and symmetric.
Negative pronator drift and Mckinney.
Gait within normal limits.
Psych : Alert and oriented , answered questions appropriately.
Normal affect.
ASSESSMENT / PLAN :
Ms.
Quintana Townsend Townsend is a 44 y. o. female who presented with dizziness.
# 1 Dizziness , likely benign paroxysmal positional vertigo
Mrs.
Calderon developed abrupt onset dizziness two days ago , exacerbated by head movements and with associated vomiting.
As a result , she experienced a fall in which she hit her head , but did not lose consciousness.
She did not have any additional prodromal or associated symptoms.
Her symptoms resolved following a 24 hour period with implementation of what seems to be described as the Gonzalez maneuver.
She does not have a history of vertigo or similar symptoms such as this in the past.
Her clinical symptoms are consistent with likely benign paroxysmal positional vertigo given symptom exacerbation with head movements , lack of neurologic symptoms , and improvement with what is described to be the Humphrey maneuver.
Her neurologic exam today was within normal limits without evidence of focal neurologic deficits.
Despite her indi",2021-08-18
32831,706391,32678,4180186,88,"DOCUMENT HEADER :
Progress Notes by Peterson , Mckinney , Mclellan Faulkner at  4/29/2020  8 : 48 AM (continued)
Author : Andersen , Townsend , Mclellan Quintana Mclellan : RM Remote Monitoring Author Type : Registered Nurse
Filed :  4/29/2020  9 : 00 AM Encounter Date :  4/29/2020  Status : Signed
Editor : Quintana , Gonzalez , Peterson Petersen (Registered Nurse) Remote Patient Monitoring RN Symptomology Call Primary reason for today's contact : COVID 19 Symptom Assessment Symptom Assessment :
Respiratory : Denies respiratory symptoms Fever : Denies fever
Patient does not have the chills and does not have sweats.
GI : Denies Denies vomiting / diarrhea.
Continues with loose stools but much better.
Patient does report lightheadedness.
Patient called due to a report of dizziness / lightheadedness.
Stated that she fell last night getting into bed.
Does not remember feeling dizzy before the incident , just feels very weak , for which she has been using a walker.
Did not loose consciousness or hit her head with the fall.
Husband assisted.
Additional Symptoms :
Patient does not have new or worsening leg swelling.
Recommendation : Home Care
PATIENT EDUCATION :
Patient and / or caregiver was instructed on :
· Self care plan .
Patient / caregiver able to teach back
The following references were used : Nursing judgement Plan of Care / Next Steps :
Endpoint recommendation : Home Care
Patient is currently using supportive care measures of increasing fluid intake.
Caller agreeable to plan of care : Yes Patient agrees to continue daily vital sign monitoring and follow up call scheduled.
Patient agreed to call Remote Patient Monitoring nurse with any questions or concerns in the interim.",2020-11-13
32831,706391,32678,4180186,251,"FULL DOCUMENT TEXT :
Plan of Care by Mckinney , Calderon Mcarthur , R. R. T. , Quintana Mcarthur Andersen at  4/14/2020  4 : 05 PM (continued)
Author : Quintana , Peterson Petersen , R. R. T. , Quintana Andersen Mcgregor Peterson : RT (Respiratory Therapy) Author Type : Respiratory Therapist
Filed :  4/14/2020  4 : 07 PM Date of Service :  4/14/2020  4 : 05 PM Status : Signed
Editor : Peterson , Calderon Finnegan , R. R. T. , Finnegan Mckenzie Mckenzie (Respiratory Therapist) Alert Information : Plan of Care : Respiratory will continue to monitor and assess patients respiratory status.
Respiratory will continue to manage patients airway , continue to manage patients mechanical ventilator weaning towards extubation as tolerated by the patient , and continue to assist with hemodynamic lines.
Principal Problem COVID 19 Infection ETT (Active)
Placement Date / Time :  4/10/20  (c) 2155 Mask Ventilation : Not attempted ETT Type : Standard ETT Tube Size : 8 mm Cuffed : Yes Location : Oral ETT Secured at (cm) : 25 cm Arterial Line  4/10/20  Right Radial (Active)
Placement Date / Time :  4/10/20  (c) 1012 Hand Hygiene Performed Prior to Insertion : Yes Site Prep : Chlorhexidine (Preferred) Sterile Barriers Used : Humphrey ; Gloves ; Gown ; Large drape ; Mask (Clinician) ; Mask (All others in room) Orientation : Right Location.
.
.
Ventilator Info :
Ventilator Mode : (S)CMV FiO 2 (%) : 35 %
PEEP (cmH 2 O) : 6 cm H 20 Plateau (Pause) Airway Pressure : 39 cm H 2 O Compliance (mL / cm H 2 O) : 8.
5 mL / cm H 2 O Recent Labs  4/14/20  0753 PO 2 ART 112 H PCO 2 ART 32 L
PH ART 7.
47 H Skin integrity checked :",2021-02-18
32831,706391,32678,4180186,127,"FULL DOCUMENT TEXT :
Telephone Encounter by Finnegan , Mcarthur Finnegan , Matthews Mclellan at  4/17/2020  8 : 12 AM (continued)
Author : Finnegan , Mclellan Matthews , Mcarthur Humphrey Mclellan : RM Remote Monitoring Author Type : Registered Nurse
Filed :  4/17/2020  8 : 30 AM Encounter Date :  4/17/2020  Status : Signed
Editor : Matthews , Andersen Eastwood , R. N.
(Registered Nurse) COVID 19 Interactive Care Plan Symptom Assessment Call Primary reason for today's contact : COVID 19 Symptom Assessment and Education The patient was contacted to verify symptoms and vital signs for COVID 19 recorded through the COVID 19 Interactive Care Plan and to reinforce education.
Date of positive COVID 19 test result :  3/17/2020 
Date COVID 19 symptoms began :  3/26/2020 
Comorbid conditions : Validated reported symptoms with the patent :
Shortness of breath : Improving
Cough , productive , hemoptysis : Not experiencing
Chest pain that worsens during breathing : Not experiencing
Fever , chills or sweats : Not experiencing
Vomiting : Not experiencing
Diarrhea Not experiencing
Lightheadedness : Not experiencing Validated reported vital signs with the patent :
Temperature 97.
9
Respiratory Rate 22
Heart Rate 78
Oxygen Saturation 99
Blood Pressure Validated that the patient feels BETTER since yesterday.
Reviewed self care information with the patient referencing the CDC materials provided to the patient in the Interactive Care Plan.
Reviewed that if patient's condition continues to worsen or the patient feels it is an urgent / emergent situation , the patient should seek immediate care.
Plan :
Spoke with Mrs.
Finnegan this morning.
She is feeling better , the shortness of breath is improving and overall feeling better.
Mrs.
Petersen was tested yesterday and results state undetected.
Mcgregor is an employee of *********** and will follow up with Occupational health in regards to the next test for her and when she can return to work.
Patient has been instructed to continue to monitor symptoms and seek immediate care if symptoms worsen.",2021-03-18
32831,706391,32678,4180186,137,"FULL DOCUMENT TEXT :
Telephone Encounter by Petersen , [XXXXX] R , Gonzalez Ferguson at  5/10/2020  10 : 23 PM (continued)
Author : ******* , [XXXXX] R , Mckinney Mckenzie Mclellan : RM Remote Monitoring Author Type : Registered Nurse
Filed :  5/10/2020  10 : 37 PM Encounter Date :  5/10/2020  Status : Signed
Editor : ******* , [XXXXX] R , Townsend Petersen (Registered Nurse) COVID 19 Interactive Care Plan Symptom Assessment Call Primary reason for today's contact : COVID 19 Symptom Assessment and Education The patient was contacted to verify symptoms and vital signs for COVID 19 recorded through the COVID 19 Interactive Care Plan and to reinforce education.
Date of positive COVID 19 test result : [5_3]
Date COVID 19 symptoms began : [5_3]
Comorbid conditions : none Validated reported vital signs with the patient :
Temperature 97
Heart Rate 88
Oxygen Saturation 98% Validated that the patient feels THE SAME since yesterday.
Reviewed self care information with the patient referencing the CDC materials provided to the patient in the Interactive Care Plan.
Reviewed that if patient's condition continues to worsen or the patient feels it is an urgent / emergent situation , the patient should seek immediate care.
Plan : Patient had an escalation for HR of 103.
Discussed vital signs with patient and after recheck her HR was 88.
Patient has been instructed to continue to monitor symptoms and seek immediate care if symptoms worsen.",2020-11-15
32831,706391,32678,4180186,145,"DOCUMENT HEADER :
Progress Notes by Ferguson , Ferguson F , M. D. at  7/7/2020  12 : 53 PM (continued)
Author : Mckinney , Mcgregor F , M. D. Service : IFD (Infectious Diseases) Author Type : Fellow
Filed :  7/7/2020  12 : 56 PM Date of Service :  7/7/2020  12 : 53 PM Status : Attested
Editor : Calderon , Calderon F , M. D.
(Fellow) Cosigner : Mclellan Mcarthur , Mclellan C , M. D. at  7/7/2020  1 : 24 PM
Attestation signed by Quintana Gonzalez , Finnegan C , M. D. at  7/7/2020  1 : 24 PM I saw and evaluated the patient , participating in the key portions of the service.
I reviewed the resident / fellow’s note.
I agree with the resident / fellow’s findings and plan.
REFERRING PROVIDER :
No ref.
provider found COVID 19 INFECTIOUS DISEASE COVID 19 ELECTRONIC PROGRESS NOTE Patient is intubated.
Patient is not requiring pressors.
Patient is afebrile with no leukocytosis.
REVIEW OF SYSTEMS :
Could not be obtained.
No current facility administered medications on file prior to encounter.
Current Outpatient Medications on File Prior to Encounter
Medication Sig Dispense Refill
• aspirin 325 mg tablet Take 325 mg by mouth every 6 (six) hours as needed for pain.
• dilTIA Zem CD (CARDIZEM CD / CARTIA XT) 180 mg 24 hr capsule Take 180 mg by mouth daily.
• doxycycline monohydrate (MONODOX) 100 mg capsule Take 1 capsule (100 mg total) by mouth 2 (two) times a day for 10 days.
20 capsule 0 Scheduled Meds : aspirin , 81 mg , oral , Daily
dexamethasone , 6 mg , intravenous , Daily
docusate sodium , 50 mg , gastric tube , Daily
insulin aspart , 0 13 Units , subcutaneous , Q 6 H metoclopramide , 10 mg , intravenous , Q 6 H pantoprazole , 40 mg , intravenous , Q 24 H SCH piperacillin tazobactam , 4.
5 g , intravenous , Q 6 H remdesivir , 100 mg , intravenous , Q 24 H Continuous Infusions : CI Satracurium 1 mg / mL in Na Cl 0.
9% 200 mL infusion (NIMBEX) , 1 10 mcg / kg / min (Dosing Weight) , Last Rate : 1 mcg / kg / min (  7/7/20  1000)
heparin (porcine) 100 Units / mL in D [xxxxx x. xxxxx] mL infusion , 0 40 Units / kg / hr (Dosing Weight) , Last Rate : 14 Units / kg / hr (  7/7/20  1000) HYDR Omorphone (PF) 1 mg / mL in Na Cl 0.
9% 250 mL infusion (DILAUDID) , 1 5 mg / hr midazolam 1 mg / mL in Na Cl 0.
9% 100 mL infusion (VERSED) , 1 10 mg / hr , Last Rate : 10 mg / hr (  7/7/20  1000) Na Cl 0.
9% infusion , 20 mL / hr , Last Rate : 20 mL / hr (  7/7/20  1000)
norepinephrine 16 mcg / mL in Na Cl 0.
9% 250 mL infusion , 0 0.
1 mcg / kg / min (Dosing Weight) , Last Rate : Stopped (  7/6/20  2113)
OBJECTIVE :
Blood pressure (!)
105 / 54 , pulse (!)
55 , temperature 37.
1 °C , temperature source Axillary , resp.
rate 22 , height 185.
4 cm , weight (!)
168 kg , SpO 2 96 %.
Body mass index is 48.
84 kg / m².
PHYSICAL EXAMINATION not performed ; electronic consultation
LAB RESULTS :
Component Value Date
WBC 7.
1  7/7/2020 
WBC 9.
3  7/6/2020 
WBC 7.
9  7/6/2020 
LAB RESULTS :
Component Value Date
CREATININE 1.
32  7/7/2020 
CREATININE 1.
11  7/6/2020 
CREATININE 0.
95  7/6/2020  IMAGING
 7/6/2020  CTA Chest IMPRESSION :
1.
Probable acute right lower lobe segmental pulmonary embolism.
No evidence of
right heart strain.
2.
Diffuse bilateral patchy groundglass and consolidative airspace opacities.
Findings are nonspecific but commonly reported with sequela of COVID 19 pneumonia , although can be seen with a variety of other infectious and
noninfectious etiologies.
CURRENT ANTIMICROBIALS
Zosyn 4.
5 g q.
6 hours
ASSESSMENT / PLAN :
# COVID 19 pneumonia
# acute hypoxic respiratory failure
# pulmonary embolism
# A Fib with RVR
# mild transaminitis
# morbid obesity RECOMMENDATIONS continue with remdesivir 100 mg daily to complete 10 total days of treatment since patient is intubated monitor LF Ts daily (remdesivir contraindicated when LF Ts go above 5 times upper limit of normal) continue with dexamethasone 6 mg daily to complete 10 days total duration consider stopping Finnegan trend daily CRP , LDH , and D dimer follow up results from BAL infectious Disease will sign off of case , please reengage us if we are needed.
Mcgregor Calderon , Mcgregor Mcgregor",2020-10-09
32831,706391,32678,4180186,155,"FULL DOCUMENT TEXT :
Plan of Care by Faulkner , Andersen Ferguson , Petersen Ferguson at  6/18/2020  5 : 20 PM (continued)
Author : Mclellan , Mckinney Faulkner , Peterson Humphrey Ferguson : NSG (Nursing Services) Author Type : Registered Nurse
Filed :  6/18/2020  5 : 24 PM Date of Service :  6/18/2020  5 : 20 PM Status : Signed
Editor : Faulkner , Faulkner Gonzalez , R. N.
(Registered Nurse) Shift Goals :
Problem : PAIN ADULT
Goal : PT VERBALIZES / DEMONSTRATES ADEQUATE COMFORT LEVEL OR BASELINE
Outcome : Progressing Problem : KNOWLEDGE DEFICIT
Goal : Patient / family / caregiver demonstrates understanding of disease process , treatment plan , medications , and discharge instructions
Outcome : Progressing Problem : INFECTION ADULT
Goal : Absence of infection during hospitalization
Outcome : Progressing Problem : SAFETY ADULT
Goal : Maintain a safe environment
Outcome : Progressing Identify possible barriers to meeting goals / advancing plan of care : condition worsening End of Shift Summary : Throughout the shift pt required increased supplemental oxygen.
He is currently using high flow and desats rapidly with minimal activity.
Other vss.
Remdesivir started this shift.
Pt was given medication education via interp line.
Will continue to monitor pt closely.",2021-06-20