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x Emergency § Room Record : C Maternat Outpatient Observation Record
‘x Discharge Summary \ (NST}
C) History & Physical } © Vaccination Record
IK Consult Report | © Hearing Screen”
() Operative Report | C Newborn Records
(J Cath Lab Report \ BA Laboratory Results
01 Colonoscopy. Report | () Mammography Report
0 Delivery Note 10 Radiclogy Report:

0 ECHO Report . | . Syocte ify (ypur of Exurn (MAY, CY, Koray, eet}
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1) Stress Test Report G Radiclogy Report & CO:
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5700 East Highway 90
Sierra Vista, AZ 85635
CANYON VISTA orone 2026200
MEDICAL CENTER
Patient: Location: MedSurg
WIRN: Provider:
FIN: Admit: 12/29/2016
DOB/Age/Sex: 77 years Female Discharge: 01/02/2017

Routine Hematology
Collected Date 9 O1/01/2017 12/34/2016 12/81/2016 12/30/2016 = 12/29/2016
Collacted Time O150MST 12:338MST 02:25MST O3:20MST 11:35 MST
Procedure Units
WBC Count 3.4L 43.L 3414 48 x10(3)mebL
RBC Count 2.93 I. 3.22 417 L 449 x10(6)imel
HGB 8.0L 951 91 L M44 424 g/dL
HCcT 26.2 1 30.7 L 28.5 L 36.6 L 305 %
MCV 89 88 88 88 fl
MCH 27 28 27 28 g/dl
MCHC 30 L 32 3 31 g/dl.
ROW-CV 17.8 H 17.9 H 18.0 H 18.1 H %

PLT 130 L 149 L 164 171 x10(3)meL.
12/31/2016 12:36:10 MST HGB+HCT:
pt in bone scan, RN will call when pt is back in room 12/31/2016 12:04:42 MST marten
WBC Differential
Collected Date OUO1/2017 = 12/30/2016
Collected Time 01:50 MST 03:20 MST
Procedure Units Ref Range
Neutrophil # 2.26 2.22 x10(3)mcL =—([1.78-5.38]}
Immature Granulocytes # «0.03 <0.63 xt0(3)mci —-[0.00-0.02)
Lymphocyte # 0.65 L 0.73 L xX10(3)mcL — [1.18-3.74]
Monocyte # 0.39 H 0.38 H x10(3jmcL = f<=0.24]
Easinophil # 0.13 0.05 xt0(3)mcl —«[0.04--0.96]
Basophil # <0.03 <0.03 x10(3)met. —-[0.01-0.08]
Neutrophil % Auto 65.5 65.5 % [40.0-77.0]
immature Granulocyies % Auto 0.3 0.0 1 % (0.1-0.3]
Lymphocyte % Auto 13.8 215 % [15.0-50.0]
Monocyte % Auto 113 11.2 % [<=12.0]
Egsinophil % Auto 3.8 15 % [<=6.0]
Basophil % Auto 0.3 0.3 % [<=2.5]

Ref Range
[4.8-10.8]
[4.20-6,10]
[12.0-16.0]
(37.0-47.0]
[80-100]
[25-35]
[31-37]
[11.6-14.8}
[150-400]
LEGEND @=Corrected *=Abnormal C=Critical LeLow H=High f=Footnote #=Interpretive Data
Chart Request Id: : Page 1 of 25 Print Date/Time: 1/17/2017 16:27
R=Ref Lab
CANYON VISTA MEDICAL CENTER
§700 E Hwy 90, Sierra Vista, AZ 85635 Phone (520) 263-2000
MRN: Provider: Asawaeer, Majid
FIN:
DOB/Age/Sex: 77 years Female

Routine Coagulation
Collacted Date 12/3
Collacted Time 03:2
Procedure
Coumadin Therapy? No
Prothrombin Time 14.6
INR 14
Heparin Therapy? No
PIT
43H
0/2016
O MST
Units Ref Range
second(s) [12.0-15.4]
ratio [0.9-14 2]
second(s} [23-34]
Collected Date 12/29/2018
Collected Time 12:31 MST
UA Color Straw
UA Appearance Clear [Clear]
UA pH 5.0 unit(s) [5.0-8.0]
UA Specific Gravity 1.003 [1.003-1.035]
UA Glucose Negative [Negative]
UA Ketones Trace * [Negative]
UA Protein Negative [Negative]
UA Bilirubin Negative [Negative]
UA Urobilinagen Nagative mg/dL = [Negative]

UA Blood Negative [Negative]
UA Leukocyte Esterase Trace * [Negative]
UA Nitrite Negative [Negative]
UA WBC None Seen ‘hpt [None Seen]
UA RBC None Seen /npt {None Seen]
UA Squamous Epithelial Few fipf {None Seen]
UA Bacteria None Seen fhpf [None Seen]
UA Comment See Comment f
Urine Cultured? Yes
12/29/2016 12:31 MST UA Comment:
Specimen referred for Culture/Suscepiibility.
C=Critical L=Low H=High f=Footnate #=Interpretive Data R=Ref Lab
LEGEND @=Corrected *=Abnormai
Chart Request ID:
Page 2 of 25 Print Date/Time: 1/17/2047 16:27

NMIRN: Provider: Asawaeer, Majid
FIN:

Routine Chemistry
Collacted Date
Collected Time
Procedure
Sadium
Potassium
Chicride
coz
Anion Gap
Glucose
BUN
Creatinine
African-American GFR
Non-African-American GFR #
Calcium
Phosphorus.
Magnesium
01/01/2017
01:50 MST
136 Lb
44
103
31H
92
0.7
BIL
3.9
2.9
12/31/2016 12/31/2016 12/30/2016
1236 MST 02:25MST 03:20 MST

Units Ref Range
136 L 142 mmol [137-145]
4.2 3.6 3.8 mmol — [3.5-6.14]
99 408 H mmal/. [98-107]
31H 27 mmol [22-36]
5 7 mmol/L [8-11]
114 H 81 mg/dL = F70-106]
10 6L mg/dL [7-17]
0.8 0.6 mg/dL [0.5-1.0]
>60 mL/min
>60 mLimin
79L 8.6 L mg/dL [8.8-10.3]
44 4.6 H mg/dL [2.54.3]
1.8 1.6 1.9 mg/dl. [1.6-2.3]
12/29/2016 11:35:00 MST Non-African-American GFR:
GFR Reference Ranges: Chronic Kidney disease, < 60 mLimin/1.73m2; Kidney Failure, < 16
mL/min/1.73m2.
GFR estimate performed utilizing the Modification of Diat in Renal Disease Formula (MDRD). Values are
calculated
based on Serum Creatinine, Age, Race and Sex. Calculated values are provided for both Non-African
American and
African-American races. The interpreting physician should determine the appropriate value. Calculating
the GFR ts not
recommended for patients under the age of 18, over the age of 80, or for inpatients. Reference:
National Kidney
Foundation,
Sedium 144 mmol. = [137-145]
Potassium 46 mmol, — (3.5-5.1]
Chicride 102 mmolf, [98-407]
CO2 27 mmol. = [22-30]
Anion Gap 1 mmol [3-14]
Glucose 95 mg/dL [70-106]
BUN 9 mgidk [7-17]
Creatinine 0.7 mg/dL [0.5-1.0]

African-American GFR >60 mLimin
Non-African-American GFR# >60 mUmin
Calcium 8.2 mgd {8.8-10.8]
LEGEND @=Corrected *=Abnormai C=Critical L=Low H=High f=Footnate #=Interpretive Data R=Ref Lab
Chart Request ID: Page 3 of 26 Print Date/Time: 1/17/2017 16:27

FIN:
DOB/AgelSex: 77 years Female
I
Thyroid Testing
T4 (Thyroxine) Free # 13 ng/dl. [0.8-2.2]
TSH (Thyroid Stimulating Hormone)# 0.43 L melU/mL — [0.47-4.70]
12/30/2016 03:20:00 MST T4 (Thyroxine) Free:
Laboratory Alert: This assay was performed using the Ortho Diagnostics Vitros 5600 system. Since there
are
significant differences between commercially available immunoassays, values should not be compared
across
laboratories unless the same assay is employed.
12/30/2016 03:20:00 MST TSH (Thyroid Stimulating Hormone):
Laboratory Alert: This assay was performed using the Ortho Diagnostics Vitros 5600 system. Since there
are
significant differences between commercially available immunoassays, values should not be compared
across
laboratories unless the same assay is employed.
Coliected Date 12/30/2016
Pathology Specimen Sentto SVP f
12/30/2016 09:15 MST Pathology Specimen:
Verified by Discern Expert. Specimen referred to Sierra Vista Pathology. See separate paper report.
LEGEND @=Corrected *=Abnormai C=Gritical L=Low H=High f=Foofnote #=Interpretive Data R=Ref Lab

FIN:
logy
PROCEDURE: Wound Culture: Anaarobic, Aerobic Gram Stain
SOURCE: Excision Site COLLECTED: 12/30/2016 69:00 MST
BODY SITE: Right Lag
FREE THAT SOURCH: wound culture- right femur
ACCESSION: 216-365-0113
see STAINS / PREPARATIONS wt®
Gram Stain Report Varified:12/30/2016 12:52 mst
Rare White Blood Celis seen
deavy Red Blood Cells seen
No organisms seen
aes PINAL REPORT **+
Final Report Yerlfied:063/04/2617 67:01 met
No growth at 3 days
No anaerobic growth
PROCEDURE: Urine Culture
SOURCE: xSea ED chart COLLECTED: 12/29/2018 12:31 MST
BODY SITE:
FREE TEXT SOURCE: xSee ED chart
ACCESSION: 16-364-0227
kes FINAL REPORT *#4#%
Final Report Verified: 12/31/2016 07:41 Mer
No growth at 2 days
Collected Date MMidalyyyy —- 12/30/2016
Collected Time HHimm 08:00 MST
Procedure Ret Range
BBID# FC18158
LEGEND @=Corrected *=Abnormai C=Gritical L=Low H=High f=Foofnote #=Interpretive Bata R=Ref Lab
Chart Request ID: . Page 5 of 26 Print Date/Time: 1/17/2017 16:27

$700 E Hwy 90, Sierra Vista, AZ 85635 Phone (520) 263-2000
FIN:

Collected Date MMidd/yyyy —- 12/30/2016
Collected Time Heimm 68:00 MST
Procedure Ret Range
ABO/Rh 0 POS
Antibody Screen. Negative
aphy.
Accession Number Exam Exam Date/Time Ordering Physician
CT-16-014735 CT Abdomen and {2/29/2016 16:18:19 = Archer, Kerry
Pelvis w/ Contrast MST

Diffuse lower abdominal pain; h/o colostomy for diverticulitis surgery; Diffuse lower abdominal pain; hfo
colostamy for
diverticulitis surgery
Report
CT ABDOMEN AND PELVIS WITH CONTRAST
History: Diffuse lower abdominal pain; h/o colostomy for diverticulitis surgery
Comparison: 09/16/2016
Technique: CT examination of the abdomen and pelvis was performed using the standard post
intravenous
contrast protocol. Radiation dose reduction technique was utilized for this examination.
Findings:
Abdomen: There is a colostomy in the left lower quadrant without evidence of obstructions or
parastomal
hernias. There is a large amount of stool throughout the colon which may represent fecai stasis. The
small
bowel is unremarkable. The stomach is unremarkable.
The liver demonstrates no suspicious mass lesions or cirrhotic changes. The biliary tree is unremarkable,
The pancreas and pancreatic duct are normal in appearance.
The kidneys demonsirate nc masses, hycronephrosis, or inflammatory changes. There are no masses or
enlargement of the adrenal glands. The spleen is unremarkable. There is no abdominal
lymphadenopathy.
The abdominal aorta and iliac arteries are patent and normal in caliber. There are significant calcified
plaques of the aorta and major branch vessels including the origins of the renal arteries. The inferior
vena
cava and iliac veins are patent. The portal and splenic veins are patent.
Pelvis: No suspicious soft tissue masses of the pelvis are identified. The urinary bladder demonstrates no
significant wall thickening. There is no wall thickening or surrounding inflammatory changes of the
recturn.

NIRN: Provider: Asawaeer, Majid
FIN:

ography
AccessionNumber Exam Exam Date/Time Ordering Physician
CT-16-014735 CT Abdomen and 12/29/2016 16:18:19 Archer, Kerry
Pelvis w/ Contrast MST
There is no pelvic lymphadenopathy. There are no abnormal pelvic fluid collections.
Limited evaluation of the abdominal and pelvic osseous structures demonstrate no acute appearing
fractures or
grossly destructive lesions. Severe levoscoliosis of the lumbar spine is present centered at L3.
IMPRESSION:
1. Left lower quadrant colostomy without evidence of complications.
2, Large amount stool throughout the colon is suspicious for fecal stasis.
Aetesde de de Final Se
Kazerm, Imran
Signed (Electronic Signature): 12/29/2016 4:33 pm


FIN:

AccessionNumber Exam Exam Date/Time Ordering Physician
XR-16-029316 XR Chest 1 View 12/29/2016 19:36:40 Dainas, Brian K
MST
pre op clearance
Report
RADIOGRAPH OF THE CHEST FRONTAL VIEW
INDICATION: Preop
COMPARISON: 09/01/2016
FINDINGS:
The heart size is normal.
The pulmonary vascularity and hila appear unremarkable.
No abnormal pulmonary parenchymal opacity, consolidation or pleural effusion identified.

No pneumothorax detected.
The visualized osseous structures are intact.
IMPRESSION:
No acute cardiopulmonary process identified.
Sekine Final fie
XR-16-029345 XR Fluoroscopy Over = 12/30/2016 10:57:01 Daines, Brian K
1 Hour MST
ORIF FEMUR FX
Report
FLUOROSCOPY TIME UP TO 1 HR CPT 76000
INDICATION: ORIF
COMPARISON: Routine views of the femur from the 29th 2016.
FIN:

XR-16-029345 XR Fluoroscopy Over = 12/30/2016 10:57:01 Daines, Brian K
1 Hour MST
FLUOROSCOPY TIME: 3 minutes 19 seconds
NUMBER OF IMAGES: 6
FINDINGS:
Fluoroscopic images show intramedullary rod fixation of previously described distal femoral fracture.
Orthopedic sideplate and screws have been removed.
IMPRESSION: Please see above.
Selon arae Final ice
Wilson, George

XR-16-029356 XR Femur 2 Views 12/30/2016 12:34:56 Daines, Brian K
Min Right MST
post op
Report
RKGHT FEMUR, 2 VIEWS
HISTORY: Status post ORIF right fernur fractures.
COMPARISON: Previous femur x-rays 12/20/2016
FINDINGS: Since the prior examination, there is been interval removal of the stabilization plate and
screws
at the distal femoral fracture site. There is been interval insertion of a medullary rod and stabilization
anchors. Alignment at the femoral fracture site appears near anatomic.
Post surgical changes are noted within the soft tissues.
IMPRESSION: STATUS POST REVISION OF DISTAL FEMORAL FRACTURE FIXATION WITH A MEDULLARY
ROD.
ALIGNMENT APPEARS
NEAR ANATOMIC,
Dictated by: Timothy Olthoff, DO
LEGEND @=Corrected *=Abnormai C=Gritical L=Low H=High f=Foofnote #=Interpretive Data R=Ref Lab

FIN:

Accession Number Exam Exam Date/Time
XR-16-029356 XR Femur 2 Views 12/30/2016 12:34:56
Min Right MST
MRN: SV-178386
PT NAME:
PT DOB: 1/11/1940
tate Cinal tre
Olthoff, Timothy
Accession Number Exam Exam Date/Time
XR-16-029288 AR Femur 2 Views 12/29/2016 13:28:58
Min Right MST

trauma;trauma
Report
FEMUR 2 VIEWS CPT 73550
INDICATION: Posttraumatic pain
COMPARISONS: 2 views of the right fernur from to 09/20/2016.
TECHNIQUE: Frontal and lateral views of the right femur were obtained.
FINDINGS:
Ordering Physician
Daines, Brian K
Ordering Physician
Archer, Kerry
Since the previous examination there has been a fracture of the there is now angulation through the
fracture
site which is occurred since the previous ORIF.
The screws remain intact.

The femoral head remains in a normal position within the acetabulum.
IMPRESSION:
1. Fracture of the orthopaedic sideplate.
LEGEND @=Corrected *=Abnormai C=Critical L=Low H=High
Chart Request ID: - Page 10 of 25
f=Footnate #=Interpretive Bata R=Ref Lab
Print Date/Time: 1/17/2047 16:27

FIN:

XR-16-029288 XR Femur 2 Views 12/29/2016 13:28:58 Archer, Kerry
Min Right MST
2. Angulation at the fracture of the sideplate and angulation of the fracture through this portion of the
previous fracture in distal femoral diapnysis.
tee Ein gl ee
Wilson, George

NM-16-001375 NM Bone Imaging 12/31/2016 12:36:31 Asawaeer, Majid
Whole Body MST
non healing hip fracture mets and cancer
Report
BONE SCAN TOTAL BODY
History: Skin cancer
Comparison: Right femur radiographs 12/30/2016
Findings:
24.6 mCi Te 99m MDP.
There is multifocal abnormal uptake involving the proximal to distal right femur most pronounced
distally
associated with the presence of orthopedic hardware from recent surgery.
Uptake in the remainder of the skeleton is remarkable only for degenerative changes in the jumbar
spine,
bilateral wrists, right knee, right ankle and bilateral feat. There is tevoscoliosis of the lumbar spine.
Renal and urinary bladder uptake is present.

IMPRESSION:
LEGEND @=Corrected *=Abnormai C=Critical L=Low H=High f=Footnote #=Interpretive Data R=Ref Lab

FIN:

NM-16-001375 NM Bone Imaging 12/31/2016 12:36:31 Asawaeer, Majid
Whole Body MST
1. Abnormal uptake throughout the right femur is likely related to recent trauma and surgery.
2. No suspicious uptake in the remaining skeleton to suggest active metastatic disease...
feet Ein gl eee
Ruvo, Veronica

Decument Name: History and Physical
Document Status: Auth (Verified)
Performed By: Ballam, Corbin
Authenticated By: Asawaeer, Majid
History and Physical
DATE OF ADMISSION: 12/29/2016
ATTENDING PHYSICIAN: Majid Asawaeer, MD
PRIMARY CARE PHYSICIAN: Mark Carnett, MD
Orthopedic surgeon consulted on this case is Dr. Daines.
CODE STATUS: Full.
CHIEF COMPLAINT: Right leg pain since approximately 3:30 p.m. December 28, 2016.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old white female with a significant history of
right distal
femur fracture status post 10-hole 4.5 LCP condylar plate placement. Bowel perforation with colostomy
on September 17,
2016, hypertension, hypothyroidism, chronic back pain, gout, who presents with right fracture of the
distal femur on the
LCP condylar plate also broken.

The patient was recently seen just yesterday by Dr. Daines with no signs of problems, status post repair
of right cistal
fernoral fracture. The patient later that evening at about 3:30 p.m. noted that she twisted her leg,
probably to the left
LEGEND @e=Corrected *=Abnormai C=Critical L=Low H=High f=Footnate #=Interpretive Data R=Ref Lab

FIN:

Document Name: History and Physical
Document Status: Auth (Verified}
while trying to get into car with assaciated pain. The patient did not think it was possible that she could
have fractured her
leg and went home. The patient later saw that her leg had swollen up. While she was up and walking to
get ice for
swollen legs, she slid to the floor, denying any head injury, loss of consciousness or tripping. After she
was at the floor,
she could no longer get up, crawled to the phone, called her family and tried to get her to the bathroom
when she started
having numbness and tingling down the right leg and at that point called EMT to be taken to the
Emergency Department.
She has noticed that the leg pain is worse with pressure. It is improved when she is lying flat and still.
Her pain is
currently 7/10. This pain is diferent from the first fracture with it being more of an achy like description
than a sharp pain
as the first was.

REVIEW OF SYSTEMS: All 14 systems denied except depression, occasional shortness of breath with
exertion, chronic
constipation with last bowel movement yesterday and that mentioned in HPI.
PAST MEDICAL AND SURGICAL HISTORY:
1. Asthma.
. Hysterectomy total with bilateral oophorectomy.
. Hypertension.
. Lactose intolerance.
Hypothyroidism.
. Chronic back pain.
. Right distal femur fracture, status post 10-hole 4.5 LCP condylar plate done by Dr. Daines on
Saptember 2, 2016.
. Bowel perforation with subsequent colostomy and colostomy bag on September 17, 2016 by Dr. Butler.
. GERD.
10. Gout.
11. Left foot surgery.
12. Stress incontinence.
13. Cataract.
ONO oF > oo nN
MEDICATIONS:
. Albuterol sulfate inhalation up to 4 times a day as needed, usually takes it twice a day.
. Norvasc 2.5 mg po. daily.
. Escitalopram 10 mg p.o. daily.
. Allopurinol 100 mg p.o. q. 48 hours.
. Synthroid 26 mcg p.o. daily.
. Norco 3.25/5 mg 6.0. q. 6 hours as needed.
. Over-the-counter omeprazole.
. Vitamin D, vitamin 8, iron, probiotic and calcium supplementation.

eNO Of Go fh +
ALLERGIES:
1. SULFA WHICH CAUSES A RASH AND GI DISTRESS.
2. LATEX WHICH CAUSES RASH AND ITCHING.

FIN:

Parformed By: Ballam, Corbin
FAMILY HISTORY:
1. Intestinal cancer from her father. Mother died of a blood clot at approximately 50 years old.
2. Arthritis.
3. Multiple myeloma,
SOCIAL HISTORY: Never tobacco use. Daily alcohol use approximately 1 glass of wine daily, sometimes
hard liquor,
now currently at 1/2 glass of wine daily. No recreational drug use. No IV drug use. Before incident has
full ADL.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.5 degrees Fahrenheit, pulse 70, respiratory rate 18, blood pressure
163/72 with high of
185/79, axygen saturation 98% on 2 L nasal cannula.

GENERAL: Appears in moderate acute distress, moderate pain and responsive.
EYES: Nonicteric sclerae, moist conjunctivae. Pupils equal, round, reactive to light and accommodation.
HEENT: Atraumatic. Oropharynx is clear and moist with no lesions.
NECK: Trachea midline. Cervical spine preserved range of motion, nontender.
HEART: Regular rate and rhythm with Il/Vl murmur. No heaves noted. No additional pathological sounds
noted.
LUNGS: Clear to auscultation in all fields, no signs of respiratory distress, egophony shows no signs of
consolidation. No
additional pathological sounds noted.
KIDNEYS: Not painful upon palpation.
ABDOMEN: Observed to be grossly normal with definite surgical scars in the center and scarring
throughout colostomy
bag noted on the left lower quadrant. Bowe! sounds present. No pain on light palpation, mild pain on
epigasiric palpation
on deep palpation. No organomegaly noted.
SKIN: Warm to the touch, slightly diminished skin turgor.
EXTREMITIES: No peripheral edema. 2/4 peripheral pulses, 4/5 muscular strength in the major upper
and lower
extremities, limited evaluation due to pain of the right leg.

LYMPHATICS: No lymphadenopathy in the cervical, axillary or inguinal areas.
NEUROLOGIC: Cranial nerves ll-Xli checked and intact. Sensation checked and grossly preserved in all
regions.
PSYCHIATRIC: Appropriate mood and affect. Alert and oriented to person, place, time and situation.
OSTEOPATHIC: TART noted in the hip area.
SEROLOGY: White blood cell 4.8, hemoglobin 12.4, hematocrit 39.5, platelet 171. Sodium 141,
potassium 4.6, chloride
102, bicarbonate 27, BUN 9, creatinine 0.7, glucose 95, calcium 9.2.
IMAGING: CT of the abdomen and pelvis with contrast shows left lower quadrant colostomy, large stool
suspicious for
fecal stasis,
Chest x-ray of the right showed fracture through the orthopedic sideplate.
MICROBIOLOGY: Urine culture pending.
ASSESSMENT AND PLAN:
Chart Request ID: - Page 14 of 26 Print Date/Time: 1/17/2017 16:27

FIN:

Document Name: History anc Physical
1. Right distal femoral fracture through previously placed orthopedic plate.
~ N.p.o. after midnight. Holding anticoagulation.
-- Plan on surgical repair by Dr. Daines at 8 a.m. on December 30, 2016.
2. Hypertensive urgency.
-- Restart horne medication amlodipine 2.5 mg p.o. daily, monitoring with pain management.
-- Hydralazine 5 mg iV 9. 4 hours as needed for systolic blood prassure greater than 170,
3. Depression.
-- Escitalopram 10 mg p.o. daily.
4. Hypothyroidism.
— Synthroid 25 meg p.o. daily.
5. History of gout.
+ Allopurinol 100 mg p.o. 48 hours.
6. Constipation with suspicion of fecal stasis.
-- Bulcolax 10 mg p.o. once, we will monitor aggressively.
7, Gastroesophageal reflux disease.
~ Protonix 40 mg p.o. daily.
8. History of asthma.
- BuoNeb 3 mL nebulizer q. 6 hours as needed.
9. Supportive care.
~ Morphine 1 mg IV g. 2 hours if needed.
- Acetaminophen 660 mg p.o. q. 6 hours as needed.
- Zofran 4 mg IV q. 6 hours as needed.

10. Deep venous thrombosis prophylaxis.
~ Sequential compression device bilateral lower extremities while in bed.
CODE STATUS: Full.
ce: Majid Asawaeer, MD
Mark G. Garnett, BDO
Dictated By=Corbin Ballam, BO, OMGE-1 12/29/2016 18:21:50 Transcribed By=NTS 12/30/2016 00:24:36
Document ID=572179 Voice ID=464271
| have personally seen and evaluated ihe patient on the date of this original note date. | have discussed
the plan of care
LEGEND @=Corrected *=Abnormai C=Gritical L=low H=High f=Foofnote #=Interpretive Bata R=Ref Lab
Chart Request ID: . Page 15 of 25 Print Date/Time: 1/17/2017 16:27

NIRN: Provider: Asawaeer. Majid
FIN:
DOB/Age/Sex: ?¢7 years Female

Performed By: Ballarn, Corbin
with the resident and | agree with the assessment and plan with the exception=NONE.
Asawaeer, Majid MD
(Electronically Signed on 12/90/2016 09:49 AM)
Ballam, Corbin, BO
(Electronically Signed on 12/30/2016 04:49 PM)
Baliam, Corbin, DO

Asawaeer, Majid, MD, Intern
Document Status: Unauth
Authenticated By:
SHORT NOTE
CODE: Fuii
Consult: Dr. Daines, surgery tomorrow at 08:00
Main Diagnosis: Right fernoral fracture
Main Plan: Surgery tomorrow, control of constipation
(Electronically Signed on 12/29/2016 06:38 PM}
Baliam, Corbin, DO


FIN: .
uitati
Document Name: Consultation Note
Parformed By: Riesenberg-Karges, Margarat
Authenticated By: Riesenberg-Karges, Margaret
Consultation
DATE OF CONSULTATION: 12/29/2016
| was asked by Dr. Kerry Archer in the Emargency Department to see this patient regarding abdominal
pain in the setting
of a fernur fracture.
HISTORY OF PRESENT ILLNESS: This is a 76-year-old female wha | have known previously from a
complicated
hospital course. At that time | knew her because that she had fallen and broken her femur and about a
week or 2 weaks
later, she developed perforated diverticulitis, which required emergent surgery and a Hartmann
procedure. Since that
time, she has been doing quite well at home; however, she states that she was having a lot of leg pain
today, which she
believes was due to the use of a new walker yesterday. She was using some ice and went to Jean against
her countertop
in the kitchen when her feet slid out from underneath her anc she fell. She denied hitting her head or
any other
axtremities or body parts and complains only of leg pain. Unfortunately, at some point in time, there
maybe seams to
have been mentioned that she was having abdominal pain. Therefore, she did undergo a CT abdomen
and pelvis. She
has no complaints of nausea, vomiting, diarrhea or difficulty with ostomy output. She felt that she hac
been eating well at
home and really her only concern was that she had seen Dr. Butler, her surgeon, for discussion regarding
a ventral
incisional hernia.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypothyroidism.
3. Asthma.
4. Chronic low back pain.
PAST SURGICAL HISTORY: ORIF af the right femur in September 2016, a Hartmann procedure with end
cclostomy in
September 2016, history of total abdominal hysterectomy and bilateral salpingo-oophorectamy.
HOME MEDICATIONS:
1. Albuterol.
2. Allopurinol.
3. Synthroid.
4. Norvasc.
ALLERGIES: SULFA, LATEX AND INFLUENZA VIRUS VACCINE.
SOCIAL HISTORY: She does not smoke or use illicit drugs. She does drink occasionally.
FAMILY HISTORY: She has no relevant past family medical history.
REVIEW OF SYSTEMS: A 10-point review of systems was perfarmed and was negative with the exception
of above.

FIN:

Parformed By: Riesenberg-Karges, Margaret
Authenticated By: Riesenberg-Karges, Margaret
VITAL SIGNS: Temperature 97.5, blood pressure 169/76, heart rate 76, saturating 99% on roorn air.
GENERAL: She is in no acute distress. She is alert and oriented x3,
HEENT: She is normocephalic and atraumatic. Her pupils are equal, round and reactive.
RESPIRATORY: She has unlabored breathing.
CARDIOVASCULAR: Regular rate and rhythm.
ABDOMEN: Soft, nontender. She does have an astomy in place, which is working well with stool in the
bag. She has a
very smail ventral incisional hernia at the middle aspect of her incision; however, this is nontender.
SKIN: Warm and dry.
EXTREMITIES: Moving all 4 with good range of motion with the exception of her right leg, whichis limited
due to pain.
NEUROLOGIC: Craniai nerves Il-Xll intact grossly.
PSYCHIATRIC: Appropriate mood and affect.
LABORATORY DATA: White blood cell count 4.8, hematocrit 39.5, platelets 171. UA is normal.
Chemistries are normal.
CT abdomen and pelvis with KV contrast on my review, there are essentially no abnormalities praesent
on the CT scan in
regards to bowel wall thickening, fluid collections, free air or any other source of concerns. She does
have her ostomy in
place anc as | mentioned before, a very small ventral incisional hernia at the middie aspect of her
incision, which contains
asmail amount of fat.
ASSESSMENT AND PLAN: This is a 76-year-old female who unfortunately has had a very difficult last
several months
after sustaining a right femur fracture and then shortly thereafter having exploratory laparotomy for
perforated diverticulitis.
She is now returning with the recurrent femur fracture and broken hardware. Unfortunately, | am not
really clear what the
cause for concern regarding abdominal pain was in this patient as she denies any such concerns. As
mentioned before,
she has a completely benign abdominal exam and her CT scan is essentially normal. At this time, | can
see no indication
for her to not proceed with her femur fracture repair or ary reason why she should not be admitted per
the Orthopedic
Surgery Services’ discretion. She should follow up with Dr. Butler as previously scheduled regarding her
ventral incisional
hernia and their possible plan for repair.
Dictated By=Margaret Riesenberg-Karges, MD 12/29/2016 18:08:04 Transcribed By=NTS 12/29/2016

23:25:57
Docurnent ID=572177 Voice ID=464269
(Electronically Signed on 01/08/2017 07:35 PM)
Riesenberg-Karges, Margaret, MD


FIN:
sonsuiltatl
Performed By: Daines, Brian K
Authenticated By: Daines, Brian K
Consultation
DATE OF CONSULTATION: 12/29/2016
The patient is a 76-year-old with a past medical history of asthma, hypertension, hypothyroidism,
chronic lower back pain
and gout. She had a right femur fracture that was treated with an open reduction and internal fixation
on Septamber 3,
2616. Following the surgery, she was treated with exploratory laparotomy and sigmoid colectomy with
colostomy for a
perforated sigmoid diverticulitis on September 17, 2016. Following the surgeries, she did well. She
mabilized. She was
able to return home. At 6 weeks after surgery, she was advanced to weightbearing as tolerated. She
continued to
improve for mobilization using a walker. She was seen on December 28, 2016. She was having absolutely
no pain in her
leg. She denied any fevers or chills and it was felt that she could continue weightbearing as tolerated. X-
rays at that time
were reviewed, which demonstrated the lateral plate demonstrated some callus formation. This was a
bridging construct.
Earlier this moming, she had a sliding fall to the ground. She had noticed prior to falling some swelling in
her leg. When
she was on the ground, she found herself unable to get up. She had immediate pain and deformity. She
was brought to
the Emergency Room. X-rays demonstrated a broken plate. She was admitted to the hespitalist service
for further
evaluation and management.
PAST MEDICAL HISTORY: Asthma, hypertension, hypothyroidism, chronic iower back pain and gout.
PAST SURGICAL HISTORY: Left foot surgery, hysterectomy, sigmoid colectorny with colostomy and open
reduction
internal fixation of the femur.
HOME MEDICATIONS: Reviewed and are part of the medical record.
ALLERGIES: SULFA AND LATEX.
SOCIAL HISTORY: She does not smoke. She drinks a glass of wine daily.
FAMILY HISTORY: Reviewed and is noncontributory.
REVIEW OF SYSTEMS: Comprehensive review of systems was done, is jocated in chart, is negative for all
systems
reviewed other than the HPI.
VITAL SIGNS: Afebrile. Vital signs are stable.
HEENT: Normocephalic, atraumnatic.
HEART: Regular rate and rhythm.
LUNGS: No increased work of breathing.
EXTREMITIES: Bilateral upper extrernities, no tenderness to palpation shoulder, elbow, wrist and hand,
5/6 grip strength.
Sensation fs intact to light touch in tha madian, radial, uinar, and axillary distribution. Hand is warm and
well perfused.
Right lower extremity, she has a deformed right femur with swelling. She has no tenderness to palpation
around her

FIN:

knee. She has got 5/5 strength in ankie dorsiflexion, plantar flexion, extensor hallucis longus. Sensation
is intact to light
touch in the sural, saphenous, superficial peroneal and deep peroneal distributions. Left lower
extremity, no pain with
internal or extemal rotation of hip, no tenderness to palpation around knee or ankle, 5/5 strength in
ankle dorsiflexion,
plantar flexion, extensor hallucis longus, Sensation is intact to light touch in the sural, saphenous,
superficial peroneal
and deep peroneal distributions.
RADIOGRAPHS: AP and lateral of her right femur demonstrate the distal third femur fracture. There is a
iateral plate that
is fractured.
ASSESSMENT AND PLAN: This is a 76-year-old woman who had a nonunion of her right femur. She has
had failure of
the hardware. Risks and benefits of operative and nonoperative treatment were discussed. Risks include
and are not
limited to bleeding, infection, neurovascular damage and the need to do further procedures. Goal would
be to remove the
broken plate and screws and then do an operative fixation. Our plan would be to do a retrograde
intramedullary nail.
Risks include and are not limited to bleeding, infection, neurovascular damage, need to do further
procedures. There is
an increased risk of bleeding. She has recently had a colectorny. She will need to be seen by the general
surgeons
incurred for surgery prior to surgery.
Dictated By=Brian K. Daines, MD 12/29/2016 14:24:36 Transcribed By=NTS 12/29/2016 17:35:01
Daines, Brian K, M.D.


FIN:
Operative Rep
Document Name: Operative Report
Parformed By: Daines, Brian K
Operative Report
DATE OF SURGERY: 12/30/2016
PRIMARY SURGEON: Brian Daines, M.D.
ASSISTANTS: None.
PREOPERATIVE DIAGNOSIS: Right femur nonunion and failed hardware.
POSTOPERATIVE DIAGNOSIS; Right femur nonunion and failed hardware.
PROCEDURE: Removal of broken hardware, right femur and placement of an intramedullary rod
retrograde.
IMPLANTS: A 10mm titanium cannulated retrograde nail 360 mm, spiral blade 60 mm end cap and
locking screws.
COMPLICATIONS: Noné.
ESTIMATED BLOOD LOSS: 200 mL.
ANESTHETIC: General.
INDICATIONS: The patient is a 76-year-old waman who had a ground level fall in September 2016. She
was treated with
a lateral lacking plate. Follawing surgery, she did well. She was seen on December 29, 2016 and she was
noted to be
mobilizing well without any pain in her hip. On the 29th, she had a ground level fall. X-rays
cemonstrated a broken lateral
plate with angulation of her femur. Risks and benefits of operative and nonoperative treatment were
discussed. Risks
include and are not limited to bleeding, infection, neurovascular damage, the need to do further
procedures, and the risks
af malunion and nonunion. She understocd these risks and she wished to proceed forward.
PROCEDURE: The patient was met in the preoperative holding area where her right fernur was marked
as the operative
site. She was taken io the Operating Room where she submitted fo a general anesthetic. All bony
prominences were
well padded. She was placed supine on the operating table. She was prepped and draped in normal
sterile fashion. A
preoperative timeout was done in which antibiotics and the procedure were reviewed with the team.
Using her previous lateral incision, a lateral incision was made. The IT band was identified. it was split in
line with the
incision and the broken plate was identified and the distal plate was removed, Cultures were then sent
as weil as soft
tissue around the femur. The edge of the femur was debrided of fibrous tissue.

FIN:

Operative
Document Name: Operative Report
The proximal screws were then ramoved. One of these screws head sheared off. A burr was used fo
create a space
around the screw and the broken screw removal set was used to remove the broken screw.
The wound was thorcughly irrigated. The reduction of the fracture with accomplished with inline
traction. AP and lateral
imaging demonstrated complete removal of the blade and the screws.
A midline incision was made. The patellar tendon was then identified. it was split in the middie. A
guidepin was used to
make a starting point in the center of the femur and abave blumestads line on the lateral imaging. The
guidepin was
advanced to the center of the femur, proximal reamer was used, a large guidepin was then advanced
proximal to the
lesser trochanter on AP and lateral imaging. Reaming was started at 7 mm and carried up to 11.4 mm.
There was good
chatter heard. The 360 mm, 10 mm titanium cannulated retrograde nail was then advanced. She was
noted to have
excellent reduction of the fracture and restoration of the femoral length and angulation of the fracture.
A locking screw
was then placed distally as well as a spiral blade using the guide. An end cap was then placed and 2
proximal screws
were placed using the perfect circle technique. AP and lateral imaging demonstrated excellant position
of the
intramedullary nail, the blade, and the screws. There were no prominent screws. The wounds were
thoroughly irrigated.
The deep tissue was closed with #1 Vieryl. The IT band was closed with #1 Vicryl. The subcutaneous
tissue was closed
with 2-0 Monocryl and the skin was reapproximated with staples. The patella tendon was closed with #1
Vieryl. The
subcutaneous tissue was closed with 2-0 Monocryl and the skin was reapproximated with staples.
Aquacel dressings
were placed and she was taken to the postop recovery area in stable condition.
POSTOPERATIVE PLAN: She is to be toe touch weightbearing on her right lower extremity. She will
mobilize with the
physical therapy. She will be on Lovenox for DVT prophylaxis. She will foliow up in my clinic in 2 weeks
for a wound
check. We will continue to investigate her nonunion. | would like to fellow up on her cultures taken
during the case as
well as the pathology. | will talk with the medicine doctors and we will consider getting a bone scan.
Dictated By=Brian K. Daines, MD 12/30/2016 12:00:45 Transcribed By=NTS 12/30/2016 16:16:53
Document ID=572726 Voice [ID=464795
Daines, Brian K, M.D.


FIN:

Document Name: Discharge Summary
Discharge Summary
DATE OF ADMISSION: 12/29/2016
DATE OF DISCHARGE: 01/02/2017
ATTENDING PHYSICIAN: Majid Asawaeer, M.D.
PRIMARY CARE PROVIDER: Dr. Camett.
DISCHARGE DIAGNOSES:
1. Right distal femoral fracture through the previously placed orthopedic plate.
2. Hypertensive urgency.
3. Anemia of blood loss.
4, Hypokalemia.
5. Depression.
6. Hypothyroidism.
7. History of gout.
8. Canstipation.
9. Gastroesophageal reflux disease.
10. History of asthma.
HOSPITAL COURSE: The patient is a 76-year-old white female with a significant history of right distal
femur fracture
status post 10-hole 4.5 LCP condylar plate placement, bowel perforation and colostomy on September
17, 2016,
hypertension, hypothyroidism and chronic back pain who presented with right fracture of the distal
fernoral including the
LCP condytar plate on December 29, 2016. The patient was seen by Dr. Daines who performed
successful orthopedic
surgery on December 30, 2016. The patient has done well post-surgery. Given iron for anemia of blood
loss and
potassium for hypokalemia, found to be stable for discharge to Skilled Nursing Facility on January 1,
2017.
CONSULTATIONS: Dr. Daines, Orthopedic Surgery.

PROCEDURES:
1. Removal of broken hardware, right femur and placement of an intramedullary rod, 10 mm titanium
cannulated
retrograde nail, 360 mm spiral blade, 60 mm and locking screw.
TRANSFUSIONS: None.
GENERAL: Appears in mild acute distress, mild pain and responsive.

FIN:

Parformed By: Ballam, Corbin
EYES: Nonicteric sclerae, moist conjunctivae. Pupils equal, round, reactive to light and accommodation.
HEENT: Atraumatic. Oropharynx is clear and moist with no lesions.
NECK: Trachea midline. Cervical spine preserved range of motion.
HEART: Regular rate and rhythm with a |VVI murmur, No heaves noted. No additional patholagical
sounds noted,
LUNGS: Clear te auscultation in all fields with diminished sounds on the left lower lobe compared to the
rest. Egophony
shows no signs of consolidation. No additional pathological sounds noted.
KIDNEYS: Not painful upon palpation.
ABDOMEN: Observed to be grossly normal. Bowel sounds present. No pain on fight or deep palpation.
No
organomegaly noted.
SKIN: Warm to touch. Normal skin turgor and capillary refill less than 2 seconds.
EXTREMITIES: Right lower extremity dressing clean and intact, 5/5 muscular strength in dorsiflexion and
plantar flexion
bilaterally. A 2/4 peripheral pulses bilaterally.
LYMPHATICS: No lymphadenopathy in cervical, axillary or inguinal areas.
NEUROLOGIC: Cranial nerves lIl-Xli checked and intact. Sensation checked and grossly preserved in all
regions.
PSYCHIATRIC: Appropriate mood and affect. Alert and oriented to person, place, time and situation.
OSTEOPATHIC: TART noted on hip area.
DISCHARGE SEROLOGY SUMMARY: Hemoglobin 8, hematecrit 26.2, white blood cells 3.4, platelets 130.
Sodium 136,
potassium 4.4, chloride 103, bicarbonate 31, glucose 92, BUN 8, creatinine 0.7.
IMAGING SUMMARY. Nuclear bone scan shows abnormal uptake throughout the right femur likely due
to the recent
trauma and surgery. No other suspicious uptake.
DISCHARGE ORDERS:
DISPOSITION: Life Care.

DIET: Cardiac.
ACTIVITY: Ad lib.
MEDICATIONS:
1. Acetaminophen 650 rng every 6 hours as needed.
2. BuoNeb 3 mL nebulizer 9.6 hours as needed for shortness of breath.
3. Allopurinol 100 mg p.o. every other day.
4. Amlodipine 2.5 mg p.o. daily.
5. Calcium carbonate 1000 mg p.o. daily.
6. Vitamin D3 2000 mg p.o. daily.
*. Escitalopram 10 mg p.o. daily.
8. Levothyroxine 25 mag p.o. daily.
9. Oxycodone 5 mg p.0. g. 4 hours as needed for pain.
10. Pantoprazole 40 mg p.o. daily.
FIN:
DOB/iAge/Sex: 7 years Female

11. Lovenox 30 mg subcutaneous daily for 4 weeks.
12. Gepacal q. 3 hours as needed.
13. lron sulfate 325 mg p.c. bid.
FOLLOWUP: With Dr. Mark Carnatt in 2 weeks.
if symptoms/conditions worsen before followup, please raturn to Emergency Department at CVMC.
Time on this discharge including coordination of care axceeded 30 minutes.
cc: Mark C. Carnett, DO
Dictated By=Corbin Balam, DO, OMGE-1 04/01/2017 11:23:58 Transcribed By=NTS 01/01/2017 12:48:11

All patient questions were answered by myself (Dr. Asawaeer) before the patient left hospital.
The total time spent providing the discharge services was 35 mins.
| have personally seen and evaluated the patient on the date of this original note date. | have discussed
the plan of care
with the resident and | agree with the assessment and plan with the exception=NONE.
Asawaeer, Majid MD
(Elactronically Signed on 01/03/2017 11:39 AM)
Ballam, Corbin, DO
Asawaeéer, Majid, MD, Intern
LEGEND @=Corrected *=Abnormai C=Gritical L=low H=High = f=Foofnote #=Interpretive Bata R=Ref Lab
CANYON VISTA MEDICAL CENTER 5700 East Highway 93, Sierra Vista, AZ, 85635 Printed = 01/07/2017
07:55
(520) 263-2000 Admitting Admitting
Patient Name Age DOB Gender Race Weight Height MedicatRecord © Account
76 yts Female ¢ 53.98kq 154.94cm

Insurance MCARE MEDICARE Reg. Bate 12/29/2016 11:04 Adm. Date 12/25/2016 17:08 Room £ED:CO9-
ER
Allergies Sulfa (Sulfonamide Antibiotics), Latex
Patient Demographics
Admission Data
Account Number MedicaiRecord Admit Date Admit'Time EMR MD Primary Care MD Admit Cierk
e 42/29/2016 |/ 17:08 ASAWAEER, Co _ few
MAHO i
Reason For Visit (HIP FRACTURE (RIGHT) MN Visit Dx | |
Other Doctors ws
Comments
Patient Data
Patient Name Date OF Birth Social Security Race Sex Religion Marital Maiden Name Patient Email
cF
Address 1
Address 2
City
Empioyer
Address 1
Address 2
City
Insurance Data
insurance Name Subscriber Subscriber Relationship Policy Number GroupNumber FinCiass Auth Number
IMCARE MEDICARE i [is ih I ‘J[z00 || |
Address 1
Address 2 |!
city | _ | State [ND | Zip | [Phone | |
insurance Name Subseriber Subscriber Relationship Policy Nurnber GroupNumber Fin Class Auth
Number
IBLUE CROSS 030 i 4o7 i il ||200 NONE
NEEDED
State [AZ Phone
Occupation
Phone
Address 4
Address 2
City [PHOENIX | State [AZ - | Zip Phone | |
insurance Name Subserber Subscriber Relationship Policy Number Group Number Fin Class Auth
Number
iSELF PAY AFTER MEDICARE i [a3 iL i ~ |200 “Ih
Address 1 | |
Address 2 | |
aiationship Policy Number Group Number FinCiass Auth Number
ISELF PAY AFTER INSURANCE i i I |i200 i |
Address 1 | |
Address 2 I |
City i | State | | Zip i | Phone | \
Person To Notify Data
Names Relationship
[I|
Address 1 |
Address 2
City | state [AZ | Zip

| Phone | ™ [Business Phone
CANYON VISTA MEDICAL CENTER 5700 East Highway 98, Slerra Vista, AZ, 85535 Printed 01/07/2017
07:55
Patient Name Age 6OB Gender Race Weight Height MedicalRecord Account
76 yrs Female ¢ 53.98kq 154.94cm
Insurance © MCARE MEDICARE Reg. Date 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Room
ED:CO9-ER
Guarantor Data
Narn Reiationship Social Security Employer Occupation
. [PATIENT I RETIRED | ;
Address 7 ,
Address 2 |
cy istate [AZ ap | | Phone | .
Name Relationship Social Security Employer Occupation
|[HUSBAND [| [RETIRED i
Address j
Address 2 |
City [SIERRA VISTA | State [AZ Zip | oT phone fSS™S™S™S™~™~™SC«i@Bu sins Phone |
Next Of Kin Data
Name Relationship
| _ |[HUSBAND |
Address 1
Address 2
City [SIERRA VISTA | State [AZ \Zip [Phone |Business Phone { :

CANYON VISTA MEDIC AL CENTER 5700 East Highway 93, Slerra Vista, AZ, 85535 Printed 01/07/2017
07:55
Patient Name Age bO8 Gender Race Weight Height wedicalRecord Account
76 yis Female = € 53.98kq 184,94cin
Insurance MCARE MEDICARE Reg. Date 12/29/2016 11:04 Adm. Date 12/29/2016 17:68 Room £D:CO9-
ER
Allergies Sulfa (Suifonamide Antibiotics), Latex
Admission Assessment Weight 53.98kg Height 154.94cm BME 22.5
Past Medical History Social History
Asthma 09/01/2016 19:63 = Smoker Never 09/16/2016 19:39
Hypertension 0101/2016 19:03 Alcohal use ~ Daily 12/29/2016 11:28
i 09/01/2016 16:03 .
rypotnyroe ‘ 09/01/2016 19:63 Allergies
Chronic Back Pain Sulfa (Sulfonamide Antibiotics) 03/01/2016 19:08
right femur fx 09/16/2016 19:39
Family History Latex 09/08/2046 19:04
No significant FMHx 8/6/2016 19:39
Home Medications - Admission
Albuterol Sulfate, 1 tablet(2 MG), 4 times per day, oral, take 1 tablet(? MG) by oral route 4 12/28/2016
11:29
times per day
Norvasc Oral, 2.5 MG, daily, Oral, take 2.5 MG by Oral route daily 42/29/2016 11:36
Escitalopram 10 mg Tab, 1 tablet(10 MG), daily, oral, take 1 tablet(10 MG) by oral route daily
12/29/2016 11:29
Allopurinol 100 mg Tab, 1 tablet{100 MG}, every 48 hours, oral, take 1 tablet(100 MG) by oral
12/29/2016 11:29
route every 48 hours
Synthroid 25 meg Tab, 1 tablet(25 MCG), daily, oral, take 1 tablet(25 MCG) by oral route daily
12/29/2016 11:30
Norco 525 mg-5 mg Tab, 1 tablet, every 6 hours, oral, take 1 tablet by oral route every 6 hours
12/29/2016 11:29
Advanced Directives Fall Risk
Ripley, Amy 12/29/2916 11:28 Age: 70-79 Q points) 42/29/2646 11:28
Nutrition Fall History: One fall in last 6 12/28/2016 11:28
months (5 points)
Good ; Ripley, Amy 12/29/2016 11:28
Appetite Elimination: Continent of bowel 12/29/2016 11:28
Suicide Self Harm Risk and bladder (0 points)
No Harm to self or others Ripley, Anly vse 1:78 «© Medications: On 2 or more Le/asfa0te 11:28
identified high risk fall drugs (5 points)
Patient Care Equiptment: one | 12/29/2016 11:28
present {1 point)
Mobility: Unsteady gait (2 12/29/2046 11:28
points)
Cognition: Alert and Oriented | 12/29/2016 11:28
(0 points)
Scoring: High Fall Risk score of ! 12/28/2046 11:28
14 or more points
Skin Integrity
Denies per patient 1 12/28/2016 11:28
VIF/DVT
Deferred for further evaluation | 12/20/2086 11:28
upon admission
CANYON VISTA MEDICAL CENTER 5700 East Highway 93, Slerra Vista, AZ, BS635 Printed 01/07/2017
07:55
Patient Name Age 608 Gender Race Weight Height MedicalRecord Account
76 yis Female ¢ 53.98kq 154.94cm
Insurance MCARE MEDICARE Reg. Bate 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Room £D:CO9-
ER
MD Notes
MD Name Archer, HD, Kerry Date Of Note 12/24/2016 12:14 Note Type EMERGENCY
History / Subjective
HPI Paragraph: Patient with Fall for several hours . The Onset is Sudden. The symptoms are Mederate,
Additional Symptoms or Pertinent History alse involve
PMH, SH, FH, Allergies, and Home medications as recorded by nursing staff were reviewed and affirmed
oy me..
Other Notes:
Review of Systems NOT Covered iy HPI:

ENT: NegHeart: Neg,Resp: Neg,GI: Neg,GU: Neg,Skin: Neg,Neure: Neg,Psych: Neg, Musculoskeletal:
Pos,Endocrine: Neg, Hematologic/Lymphatic:
Neg, Allergic/Immunoiogic: Neg, Constitutional Sxs: Neg,Eyes: Neg,
Exam / Objective
Date/fime of Exam: Dec 29 2016 12:14PM MD Name: Archer, MD, Kerry
GA? Awake A&OX3
Skin: No pailor/ rashes warrn & moist
HEENT: PERRL COMI Moist Mucous Membranes No Icterus
Neck: NT Full ROM Ne JVB
Lung/Chest Wall: Lungs-Lungs CTA No Ret/Chest Wall-Chast Wall NT
Cardio Vascular: RRR No M
Abdornen: Palpation-mild diffuse iower abdominal tenderness on palpation. No noted guarding, rigidity
or rebound. +Ostomy LLO/BS-present
Neuro: Motor-Major Muscle Groups 5/5/Sensory-Gross Sensory Intact/Coordination-

Back: NT no CVAT
GU: Normal
Extremity: Location-right dista! thigh/Pain-tendar and swollen/ROMdecreasad due to pain/Pulses-intact
REPEAT/ADDITIONAL EXAMS:
Dec 29 2016 12:14PM Archer, MD, Kerry - Reviewed pertinent diagnostic tests, vital signs, and clinical
notes
Dec 29 2016 1:46PM Archer, MD, Kerry « Patient's x-rays reveal apparent acute fracture through the
hardware w/ some anguiation of the distal femorat
diaphysis. The orthopedist attended her in the Department and requested she be admitted to the
hospitalist service. Surgical
Dec 29 2016 1:54PM Archer, MD, Kerry - Abd CT requested by the surgical consultant, who will see
patient after the results are available,
MD Procedures: Critical Care Time less than 31 minutes, Comments: , MD Name:Archer, MD, Kerry
Date/time: Dec 29 2036 5:54PM, CPT Cade: 99285
Assessment / Plan (Problem List)

Fall(E888.9) Status: Active
femur fracture Status: Active
Other Medical Orders/Additional Comments
Femur 2 Views Minimurn Right
** Orcler Cancelled ‘Holden ,RN, Jil Dawn’ 12/29/2016 3:47:55 PM ** UA wfireflex Cx -Cath
cBc
BMP/Chem-8
Fentany! 100 meg NV (Slow), , one time, Intravenous, , stat
Zofran 4mig IVP, , one time, Intravenous, , stat
CT Abd and Pelvis w/ Contrast (BUN Creat needed)
Fentany! 100 meg iV (Siow), , one time, Intravenous, , stat
Disposition - Admit
Disposition MD-Archer, MD, Kerry Dec 25 2016 5:53PM
Disposition RN:Ripley, Amy Dec 29 2016 6:15PM
Condition - Stable
Admit Ta - Asawaeer, Majid MD
Recommended MD Level Of Service - 4; Evatuation and Management Code - 99284
Recommended Facility/RN Level Of Service - 5: Evaiuation and Management Code - 612
Electronically signed and authenticated by the Following Physicians Archer, MD, Kerry Specialty
Emergency Medicine
CANYON VISTA MEDICAL CENTER 5700 East Highway $3, Slerra Vista, AZ, 85635 Printed 01/07/2017
07:55
Patient Name Age DOB Gender Race Weight Height MedicalRecord © Account
76 yis Female C 53.98kg 184.94cr
Insurance MCARE MEDICARE Reg. Date 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Room ED:CO9-
ER
Diagnostic Results
Ordering = bate/Time Diagnostic —sResult Interpretation Reviewed By Date/Time
Staff Entered Name Reviewed
Archer, Kerry 12/29/2016 CBC Description: WBC Count Archer, MB, Kerry 04/07/2017
1240 Result: 4.8 x10(3)mcL, Abnormal Flag: NORMAL, Normal Range: 4.6-10.3 07:54
AB FLAG: NORMAL UOM: x10(3) mel.
Description: RBC Count
Result: 4.49 x10(6}/mcl, Abnormal Flag: NORMAL, Normal Range: 4.20-6.10
AB FLAG: NORMAL UOM: x10(6)/met
Description: HGB
Result; 12.4 2Z, Abnormal Flag: NORMAL, Normal Range: £2.0-16.0
AS FLAG: NORMAL UOM: 22
Description: HCT
Result: 39.5 %, Abnormal Flag: NORMAL, Normal Range: 37.6-47.0
AB FLAG: NORMAL UOM: %
Description: MCV
Resuit: 88 fl, Abnormal Flag: NORMAL, Normai Range: 80-100
AB FLAG: NORMAL = UOM: fl
Description: MCH
Result: 28 22, Abnormal Flag: NORMAL, Normal Range: 25-36
AB FLAG: NORMAL UOM: 72
Description: MCHC
Resuit: 31 ZZ, Abnormal Flag: NORMAL, Normal Range: 31-37
AB FLAG: NORMAL UOM: 2Z
Description: PLT
Result: 171 x10(3)mcL, Abnormal Flag: NORMAL, Normal Range: 150-400
AB FLAG: NORMAL —UOM: xt0(3}mcL
Archer, Xerry 12/29/2016 UA rfGult Description: UA Color Archer, MD, Kerry 01/07/2017
12:42 Result: Straw, Abnormal Hag: NORMAL 07:54
AB FLAG: NORMAL = UOM:
Description: UA Appearance
Result: Clear, Abnormal Flag: NORMAL, Normal Range: Clear
AB FLAG: NORMAL UOM:
Description: UA pH
Result: 5.0 unit(s), Abnormal Flag: NORMAL, Normal Range: 5.0-3.9
AB FLAG: NORMAL -UIOM: unit(s)

Description: UA Specific Gravity
Result; 1.003, Abnormal Flag: NORMAL, Normal Range: 1.003-1.035
AB FLAG: NORMAL UGM:
Description: UA Glucose
Result: NEG, Abnormal Flag: NORMAL, Normal Range: Negative
~~
CANYON VISTA MEDIC ‘AL CENTER 5700 East Highway 93, Sletra Vista, AZ. 85635 Printed 01/07/2017
07:55
Patient Name Age DOB Gender Race Weight Height MedicalRecord Account
76 yis | Female C 53.98kq 154.94cm
Insurance MCARE MEDICARE Reg. Bate 12/29/2016 11:04 Adm. Date 12/29/2016 17:68 Room £D:CO9-
ER
Description: *UA Ketones
Result: ***Trace***, Abnormal Flag: ABNORMAL, Normal Range: Negative
AB FLAG: ABNORMAL UOM:
Description: UA Protein
Description: UA Bilirubin
Description: UA Urobilinogen
Resuit: NEG mg/dL, Abnormai Flag: NORMAL, Normal Range: Negative
AB FLAG: NORMAL UOM: mg/dL
Description: UA Blood
Result: NEG, Aonormal Flag: NORMAL, Normal Range: Negative
Description: *UA Leukocyte Esterase
Result: ***Trace**®, Abnormal Flag: ABNORMAL, Normal Range: Negative
AB FLAG: ABNORMAL = UOM:
Description: UA Nitrite
Result; NEG, Asnormal Flag: NORMAL, Normal Range: Negative
AB FLAG: NORMAL = UOM:
Description: UA WBC
Result: None Seen /hpf, Abnormal Flag: NORMAL, Normal Range: None Seen
AB FLAG: NORMAL UCM: /hpf
Description: UA RBC
Result. None Seen /hpf, Abnormal Flag: NORMAL, Normal Range: None Seen
AB FLAG: NORMAL UOM: /hpf
Description: UA Squamous Epithelial
Result: Few /ipf, Abnormal Flag: NORMAL, Normal Range: None Seen
AB FLAG: NORMAL —UOM: /ipf
Description: UA Bacteria
Result: None Seen /npf, Abnormal Flag: NORMAL, Normal Range: None Seen
AB FLAG: NORMAL UCM: /hpf
Description: UA Comment
Result: See Comment, Abnormal Flaq: NA
AB FLAG: NA -UOM:
Specimen referred for Culture/Susceptibility,
Description: Urine Cultured?
Resuit: Yes, Abnormal Flag: NA
AS FLAG: NA YOM:
-6-
Patient Name
Insurance MCARE MEDICARE
Ase 608 Gender Race Weight Height Medical Record
Female © 53.98kq 184.94cm
5700 East Highway 98, Sletra Vista, AZ, B5535 Printed 01/07/2017 07:55
Account
Reg. Bate 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Room ED:CD9-ER
Archer, Kerry
Archer, Kerry
12/
te:
12/
29/2016
46
29/2016
12:46
BMP
GFR
Description: Sediura Archer, MD, Kerry
Result: 141 mmol/L, Abnormal Flag: NORMAL, Normal Range: 137-145
AB FLAG: NORMAL UOM: mmol/L
Description: Potassiurs
Resuit, 4.6 mmol/L, Abnormal Flag: NORMAL, Norral Range: 3,5-5.%
AB FLAG: NORMAL = UOM: mmal/L
Bescription:
AB FLAG: NORMAL = UOM: mmol/L

Description: CO2
Result: 27 mmol/L, Abnormal Flags NORMAL, Normal Range: 22-30
AB FLAG: NORMAL = =UOM: mmol/L
Description: BUN
Result: 9 mg/d, Abnorrnal Flag: NORMAL, Normal Range: 7-17
AB FLAG: NORMAL UOM: mig/di
Description: Creatinine
Result: 0.7 mglel, Abnormal Flag: NORMAL, Normal Range: 0.5-1.0
AB FLAG: NORMAL UOM: mg/dL
Description: Glucose
Resuit: 95 mg/dL, Abnormal Flag: NORMAL, Normal Range: 70-106
AB FLAG; NORMAL UOM: mg/dl.
Description: Calcium
Result; 9.2 mgfdi, Abnormal Flag: NORMAL, Normal Range: $.8-10.8
AB FLAG: NORMAL =. UOM: mg/db

Description: Anion Gap
Result: 11 mmol/L, Abnormal Flag: NORMAL, Norraal Range: 3-11
AB FLAG: NORMAL =. UOM: mmol/L
Description: African-American GFR Archer, MD, Kerry
Result: >60 mL/min, Abnormal Flag: NA
AB FLAG: NA UOM: mt/min
Description: Non-Aftican-American GFR
Result: >60 mL/min, Abnormal Flag: NA
AB FLAG. NA UOM: mL/min
GFR Reference Ranges: Chronic Kidney disease, < 60 mL/min/1.73m2;
Kidney Failure, < 25 ml/min/1.73m2, GFR estimate performed utilizing the
Modification of Diet in Renal Disease Formida (MDRD). Values are calculated
based on Serum Creatinine, Age, Race and Sex. Calculated values are provided
for both Non-African American and African-American races. The interpreting
physician shoud determine the appropriate value. Calculating the GFR is not
recommended for patients under the age of 18, over the age of 80, or for
inpatients, Reference: Nationa! Kidney Foundation.
01/07/2017
07:54
01/07/2017
87:54
CANYON VISTA MEDIC AL CENTER 5700 East Highway 98, Slerra Vista, AZ, 85535 Printed 01/07/2017
07:55
Patient Name Age bOB Gender Race Weight Height MedicalRecord Account
76 yis Female 53.98kq 154,94cm
Insurance MCARE MEDICARE Reg. Bate 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Room ED:C59-
ER
ARCHER, 12/29/2016 Femur 2 Views Description: XR Femur 2 Views Min Right Archer, MD, Kerry
01/07/2017
KERRY 13:44 itinimum Richt — Result: IMPRESSION: 1. Fracture of the orthopedic sideplate.2.
Angulation at O7:54
the fracture of the sideplate and angulation of the fracture through this portion
of theprevious fracture in distal fernoral diaphysis.
FEMUR 2 VIEWS CPT 73550
INDICATION: Posttraumatic pain
COMPARISONS: 2 views of the right femur frorn to 09/20/2016.
FECHNIQUE: Frontal and jateral views of the right femur were obtained.
FINDINGS:
Since the previous examination there has beer a fracture of the there is now
angulation through the fracture

site which is occurred since the previous ORIF.
‘The screws remain intact.
The femoral head remains in a normal pesition within the acetabulum.
IMPRESSION:
1, Fracture of the arthopedic sideplate.
2, Angulation at the fracture of the sideplate and angulation of the fracture
through this portion of the
previous fracture in distal fermorel diaphysis.

CANYON VISTA MEDICAL CENTER 5700 East Highway 9, Slerra Vista, AZ, 85635 Printed = 01/07/2017
07:55
76 yrs Female € 53..98kq 154,54cm
Insurance MCARE MEDICARE Reg. Date 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Ream £D:CO9-
ER
Aliergies Sulfa (Sulfonamide Antibiotics), Latex
ARCHER, 12/20/2016 CT Abd and Palvis Description: CT Abdomen and Peivis w/ Contrast Archer, MO,
Kerry 01/07/2017
KERRY 16:36 tw/ Contrast (BUN Result: IMPRESSION: 1. Left lower quadrant colostomy without evidence
of O7:54
Crest needed) ——_compfications.2. Large amount stoal throughout the colon is suspicious for fecal
stasis.
CT ABDOMEN AND PELVIS WITH CONTRAST
History: Diffuse lower abdominal pain; h/o colastomy for diverticulitis surgery
Cormparison: 09/16/2016
Technique: CT examination of the abdornen and pelvis was perforned using
the standard post intravenous

contrast protocol. Radiation dose reductien technique was utilized for this
examination.
Findings:
Abdomen: There is a colostomy in the left lower quadrant without evidence of
obstructions or parastomal
hernias. There is a jarge amount of stool throughout the colon which may
represent faecal stasis. The salt
bowel is unremarkable. The stomach is unremarkable.
The liver demonstrates no suspicious mass lesions or cirrhotic changes, The
biliary tree is unremarkable.
The pancreas and pancreatic duct are normal in appearance.
The kidneys demonstrate no masses, hydronephrosis, or inflammatory changes.
There are no masses or
enlargement of the adrenal glands. The spleen is unremarkable. There is no
abdominal lwnphadenopathy.
The abdominal aerta and jlac arteries are patent and normal in caliber. There
are significant calcified
plaques of the aorta and major branch vessels including the origins of the renal
arteries. The inferior vena
cava and iliac veins are patent. The portal and splenic veins are patent.
Pelvis: No suspicious soft tissue masses of the pelvis are identified. The urinary
bladder demonstrates no
significant wall thickening. There is no wail thickening or surrounding
inflammatory changes of the rectum.
There is no pelvic lymphadenopathy. There are no abnormal pelvic fluid
collections,
Lirsited evaluation of the abdominal and pelvic osseous structures demonstrate
no acute appearing fractures or
grossly destructive lesions. Severe levescoliosis of the lumbar spine is present
centered at L3.
IMPRESSION:
1. Left lower quadrant colostomy without evidence of complications.
2. Large amount stool throughout the colon is suspicious for fecal stasis.
CANYON VISTA MEDICAL CENTER 5700 East Highway 93, Slerra Vista, AZ. 85635 Printed 01/07/2017
07:55
76 yis Female ¢ 53,98kq 154,94cm
Insurance MCARE MEDICARE Reg. Bate 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Reom £ED:C09-
ER
Allergies Sul'a (Suifonamide Antibiotics), Latex
BAINES, BRIAN 12/29/2016 XR Chest £ View Description: XR Chast 1 view Archer, MD, Kerry o1for/20.7
Result: IMPRESSION: No acute cardiopulmonary process identified.
RADIOGRAPH OF THE CHEST FRONTAL VIEW
INDICATION: Preop
COMPARISON: 09/01/2016
FINDINGS:
The heart size is normal.
The pulmonary vascularity and hila appear unrersarkabie.
No abnormal pulmonary parenchymal opacity, consolidation or pleural effusion
identified,
No pneumothorax detected.
The visualized osseous structures are intact.
IMPRESSION:
No acute cardiopulmonary process identified.
Ballam, Corsin 12/30/2086 © CRC/D¢f Description: “WBC Count Archer, MD, Kerry 01/07/2017
04.22 Result: *3.4 x10(3)meL***, Abnormal Flag: LOW, Normal Range: 4.6-10.6 07:54
AB FLAG: LOW UOM: x10(3)meb
Description; *RBC Count
Result: ***4.17 xidfeymcL***, Abnormal Flag: LOW, Normal Range: 4.20-
6.10
AB FLAG: LOW UOM: x10{6}imel.
Description: *HGB
Result: * 11.4 Z2***, Abnormal Flag: LOW, Nermal Range: 12.0-16.6
AB FLAG: LOW UOM: ZZ
Description: *HCT
Result: ***36.6 %***, Abnormal Flag: LOW, Normal Range: 37.0-47.0
AB FLAG: LOW UOM: %
Description: MCV
Result: 88 fl, Abnormal Flag: NORMAL, Norma! Range: 80-100
AB FLAG: NORMAL = UOM: ff
Description: MCH
Result: 2? 22, Abnormal Flag: NORMAL, Normal Range: 25-35
AB FLAG: NORMAL = UOM: ZZ
Description: MCHC
Result: 31 22, Abnormal Flag: NORMAL, Normal Range: 31-37
AB FLAG: NORMAL UOM: ZZ
Description: PLT
Result: 161 xi0(3)mcL, Abnormal Flag: NORMAL, Norma! Range: 150-400
AB FLAG: NORMAL JOM: xd0(3)mch
~10-
CANYON VISTA MEDICAL CENTER 5700 East Highway 93, Sierra Vista, AZ, 85635 Printed 01/07/2017
07:55
Patient Name Age
76 yis
poe Gender Race Weight Height MedicalRecord Account
Female € 53.98kg 154,94cm
Reg. Date 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Room ED:CO9-ER
Balam, Corbin = 12/30/2016 Auto Diff
Description: Neutrophil 9% Auto Archer, MD, Kerry 04/07/2017
Result: 65.5 96, Abnormal Flag: NORMAL, Normal Range: 40.0-77.0 Ons4
AS FLAG: NORMAL = UOM: %
Description: *Immature Granulocytes % Auto
Result: ***0_6 %***, Abnormal Flag: LOW, Normal Range: 0.1-0.3
AB FLAG: LOW = -UOM: %
Description: Lymphocyte % Auto

Result; 21.5 %, Abnormal Flag: NORMAL, Normal Range: 15.0-50.0
AB FLAG: NORMAL = UOM: %
Description: Monocyte % Auto
Result: 11.2 %, Abnormal Flag: NORMAL, Normal Range: <=12.0
Description: Eosinaphit % Auta
Description: Basophi % Auto
Result: 6.3 %, Abnormal Flag: NORMAL, Normal Range: <=2,5
AB FLAG: NORMAL UGM: %
Description: Neutrophil #
Result: 2.22 xl0(3)}ricL, Abnormal Flag: NORMAL, Normal Range: 1.78-5,38
AB FLAG: NORMAL UCM: x10(3)meL
Description: Intmature Granuiecytes #
Result: <9.03 x10(3)meL, Abnormal Flag: NORMAL, Normal! Range: 0.00-0.02
AB FLAG: NORMAL = UOM: x10(3)mcL.

iption:
Resuit: ***0.73 x10G)mcL***, Abnormal Flag: LOW, Normal Range: 1.18-3.74
AB FLAG: LOW = -UOM: x10f3)meL
Result, ***0,38 xLO3}ncl***, Abnormal Flag: HIGH, Normal Range: <=0,24
AB FLAG: HIGH = UOM: x10(3)mich
Description: Eosinophil #
Resuit: 6.05 xt0(3)mcl, Abnormal Flag: NORMAL, Normal Range: 6.04-0,36
AB FLAG; NORMAL = UOM: x10(3)met.
Description: Basophil #
Result, <0.03 x10(3)mcl, Abnormal Flag: NORMAL, Normal Range: 0,01-0.08
AB FLAG: NORMAL UOM: x10(3)met
“11 -
Patient Name
BOB Gender Race Weight Height Medical Record
Female € 53.98kq 154.94cm
5700 East Highway 93, Slerra Vista, AZ, 85535 Printed 01/07/2017 07:53
Account
Reg. Bate 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Room ED:COS-ER
Allergies Sul'a (Sulfonamide Antibiotics), Latex
Balam, Corbin 12/30/2016
121
Ballam, Corbin 12/30/2016
04:24
Ballam, Corvin = 12/30/2016

04:22
Ballam, Corsin 12/30/2086
04:22
PTAINR
PTAINR
PT
PIT
Description: Prothrombin Time Archer, MD, Kerry
Resuit: 14.0 second(s), Abnormal Flag: NORMAL, Normal Range: 12.0-15.4
AB FLAG: NORMAL UGM: secondis}
Description: INR
Result: 1.1 ratio, Abnormal Flag: NORMAL, Normal Range: 0.9-1.2
AB FLAG: NORMAL = UOM: ratio

Bescription: Coumadin Therapy? Archer, MO, Kerry
Result: No, Abnormal Flag: NA
AB FLAG: NA UOM:
Description: “PTT Archer, MD, Kerry
Result, ***43 second(sy**, Abnormal Flag: HIGH, Normal Range: 23-34
AB FLAG: HIGH UOM: second(s)
Description: Heparin Therapy? Archer, MD, Kerry
Result: No, Abnormal Flag: NA
ABFLAG: NA UOM:
~“42-
01/07/2017
a7s4
OL/O7 7201?
OF 734
1/07/2017?
07:54
01/07/2017
07:54
Patient Name
Age
76 yis
Ballam, Corbin
Ballam, Corin
Balam, Cordin
Balam, Corsin
12/30/2016
12/30/2016
04:32
12/30/2016
04:32
12/30/2016
06:58
BMP
Magnesium
Phosphorus
TSH b/FT4
bos Gender Race Weight Height Medical Record
Female ¢ 53,.98kq 154.94cm
Account
Reg. Date 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Reom ED:CO9-ER
Description: Sodium Archer, MD, Kerry
Resuit: 142 mmol/L, Abnormal Flag: NORMAL, Normal! Range: 137-145

Description: Potassium
Result: 3.8 mmol/L, Abnormal Flag: NORMAL, Normat Range: 3.5-5.1
Description: *Chioride
Resuit: *** 108 mmoi/L***, Abnormal Flag: HIGH, Normal Range: 98-107
AB FLAG: HIGH UOM: mmol/L
Description: CO2
Result; 27 mmol/L, Abnormal Flag: NORMAL, Normal Range: 22-30
AB FLAG: NORMAL = .UOQM: mmol/L
Beseriptlon: *BUN
Result: ***5 mg/di***, Abnormal Flag: LOW, Normal Range: 7-17
AB FLAG: LOW = UOM: ma/di.
Result. 0.6 mg/dL, Abnormal Flag: NORMAL, Normal Range: 05-10
AB FLAG: NORMAL = UOM: mg/éL
Result: BL mafal, Abnormal Flag: NORMAL, Normal Range: 70-106
AB FLAG: NORMAL —-UOM: mg/dL

Description: *Calcium
Result: ***8_6 mg/di***, Abnormal Flag: LOW, Normal Range: 8.8-10.8
AB FLAG: LOW UOM: ma/dL
Resuit: 7 mmol/L, Abnormal Flag: NORMAL, Normal Range: 3-11
AB FLAG: NORMAL UCM: mmol/L
Description: Magnesium Archer, MB, Kerry
Result: 1.9 mgfdb, Abnormal Flag: NORMAL, Normal Range: 1.6-2.3
AB FLAG: NORMAL YOM: ma/dl.
Description: *Phosphorus Archer, MD, Kerry
Result: ***4.6 mg/el™, Abnormaé Flag: HIGH, Normal Range: 2.5-4.5
AB FLAG: HIGH UOM: mg/dL
Description: *TSH (Thyroid Stimulating Hormene) Archer, MB, Kerry
Result: ***0.43 mel/mL***, Abnormal Flag: LOW, Normal Range: 0.47-4.70
AB FLAG: LOW UOM: melU/mL
Laboratory Alert: This assay was performed using the Ortho Diagnostics Vitros
S600 systam. Since there are significant differences between commercially

available immunoassays, values should not be compared across laboratories
unless the sae assay is employed.
~13-
01/07/2017
7:54
01/07/2017
07:54
OLO7 {2017
07354
01/07/2017
07:54
07:55
Patient Name Ase
76 yrs
bos Gender Race Weight Height MedicalRecord Account
1 Female 53. 98kq 154,54cm
Reg. Bate 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Room £ED:COOER
Baines, Brian K 12/30/2016 EKG
Baines, Brian 12/30/2016 ABO/RH
09:12
Daines, Brian & 12/30/2016 ABSC Gel
09:42
Baines, Brien K 12/30/2016 UPL Sper
9:15
BAINES, BRIAN 12/30/2016 XR Fernur 2 Views
13:47 fain Right
Daseription: EKG Archer, MD, Kerry 01/07/2017
Resuit: See Result Comments 07:54
Fest Reason ; HIP FRACTURE (RIGHT)\.br\Blaod Prassure °°" mmHG\.br
\Vent. Rate 071 BPM = Atrial Rate : O71 BPM\.br\ PR Int : 134 ms
QRS Bur: O98 ms\.br\ QT Int : 406 ms PRT Axes : 081 041 020
degrees\.br\ QTc Int : 441 ts\.bri\.briNoarmal sinus rnythen\br\Normal ECG
\.briWhen compared with ECG of 16-SEP-2016 19:50, \.br\Nonspecific T wave
abnormalty no longer evident in Lateral leads\.br\Confirmed by ELLIOT DO,
WILLIAM (3390) on 12/30/2016 8:28:09 AM\.br\\.briReferred By: DAINES
Confirmed By: WILLIAM ELLIOT DO
Description: ABO/RK Archer, MD, Kerry 01/07/2017
Result: O POS, Abnormal Flag: UNKNOWN 87:54
Description; BB ID # Archer, MD, Kerry 01/07/2617
Result: PCi8158, Abnormal Flag: UNKNOWN O7354
Description: Antibody Screen,
Resuit: NEG, Abnormal Flag: NORMAL
Description: Pathology Specimen Archer, MD, Kerry 01/07/2017
Result: Sent to SVP, Abnormal Flag: NA 07:54

AB FLAG: NA = UOM:
Verified by Discern Expert, Specimen referred to Sierra Vista Pathology, See
separate paper report.
Description: XR Femur 2 Views Mir: Right Archer, MD, Kerry 04/07/2017
Result: IMPRESSION: STATUS POST REVISION OF DISTAL FEMORAL 07:54
FRACTURE FIXATION WITH A MEDULLARY ROD. ALIGNMENT APPEARSNEAR
ANATOMIC. Dictated by: Timothy Olthoff, DO MRN: SV-178386 PT
NAME: VERA LHYLSKY PF DOS; = 1/11/1940
RIGHT FEMUR, 2 VIEWS
HISTORY: Starus post ORIF right femur fractures.
COMPARISON: Previous famur x-rays 12/29/2016
FINDINGS: Since the prior examination, there is been interval removal of the
stabilization plate and screws
at the distai femoral fracture site. There is been interval insertion of a
medullary rod and stabilization

anchors, Alignment at the femoral fracture site appears near anatomic,
Post surgical changes are neted within the soft tissues.
IMPRESSION: STATUS POST REVISION OF DISTAL FEMORAL FRACTURE
FIXATION WITH A MEDULLARY ROD. ALIGNMENT APPEARS
NEAR ANATOMIC.
Dictated by: Timothy Olthoff, bO
~14-
CANYON VISTA MEDICAL CENTER 5700 East Highway 93, Sierra Vista, AZ, 85635 Printed 01/07/2017
07:55
Patient Name Age bOB Gender Race Weight Height medicalRecord Account
76 yis 1 Female € 53.98kq 154,94cm
Insurance MCARE MEDICARE Reg. Bate 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Room £ED:C09-
ER
BAINES, SRIAN 12/30/2016 XR Fluoroscopy Description: XR Fluoroscopy Over 1 Hour Archer, MD, Kerry
01/07/2017
15:21 ‘Over | Hour Result: IMPRESSION: Please see above. O7S4
FLUOROSCOPY TIME UP TO 1 HR CPT 76900
INDICATION: GRIF
COMPARISON: Routine views of the feraur from the 29th 2016.
FLUOROSCOPY TIME: 3 minutes 19 seconds
NUMBER OF IMAGES: 6
FINDINGS;
Fluoroscopic images show intramedullary rod fixation of previously described

distal fernoral fracture.
Orthopedic sidepiate and screws have been removed.
IMPRESSION: Plaase see above.
Daines, Brien K 12/34/2016 eae Description: * WBC Count Archer, MO, Kerry 01/07/2017
02:48 Result: ***4,3 x10(3)meL***, Abnormal Flag: LOW, Normal Range: 4.8-10.8 07:54
AS FLAG: LOW -UOM: x10f3)mel.
Description: #RBC Count
Result: ***3,22 x10/6)/meL***, Abnormal Flag: LOW, Normal Range: 4.20~-
6.10
AB FLAG: LOW UOM: x10(6)/meL
Description; *HGB
Result: *°*9,.4 ZZ***, Abnormal Flag: LOW, Normal Range: 12.0-16.0
Description: *HCT
Resuit: ***28,5 %***, Abnormal Flag: LOW, Normal Range: 37.0-47.0
AB FLAG: LOW UOM: %

Description: MCV
Result; 88 ff, Abnormal Flag: NORMAL, Norma! Range: 86-100
AB FLAG: NORMAL UOM: fl
Description: MCH
Result: 28 ZZ, Abnormal Flag: NORMAL, Normal Range: 25-35
AB FLAG: NORMAL = UOM: 27
Description; MCHC
Result: 32 2Z, Abnormal Flag: NORMAL, Normal Range: 31-37
AB FLAG: NORMAL UGM: 2Z
Description: *PLT
Result: ***149 x10(3)mcL***, Abnormal Flag: LOW, Normal Range: 150-400
AB FLAG: LOW —-UOM: xi0(3)meL
~15-
Patient Name
Baines, Brian K
Baines, Brian K
12/31/2016
12/31/2016
03:02
BMP
GFR
Female C 53.98kq 154.94cem

Reg. Bate 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Room ED:CO9-ER
Description: *Sodium Archer, MD, Kerry 01/07/2017
Result: *** 136 mmol/L***, Abnormat Flag: LOW, Normal Range: 137-145 O7:S4
AB FLAG: LOW = UOM: mmol/L.
Result: 3.6 mmol/L, Abnormal Flag: NORMAL, Normal Range: 3.5-5.4
AB FLAG: NORMAL = UOM: mmol/L.
Description: Chloride
AB FLAG: NORMAL UGM: mmol/L
Description: *CO2
Resuit; ***31 mmol/L***, Abnormal Flag: HIGH, Normal Range: 22-30
AB FLAG: HIGH =. UOM: mmoi/L
Description: BUN
Result: 10 mg/dl, Abnormal Flag: NORMAL, Normal Range: 7-17
AB FLAG: NORMAL UOM: mg/dl.

Result: 0.8 ma/dL, Abnormal Flag: NORMAL, Normal Range: 05-1.
AB FLAG: NORMAL = UOM: mg/dL
Description: *Glucase
Result: ***114 mo/dL***, Abnormal Flag: HIGH, Normal Range: 70-106
AB FLAG: HIGH = LIOM: mg/dl.
Description: *Caicium
Resuit: ***7,9 mg/ci***, Abnormal Flag: LOW, Normal Range: 8.8-10.8
AG FLAG: LOW = UOM: ma/dL
Result: 5 mmol/L, Abnorraal Flag: NORMAL, Normal Range: 3-11
Oascription: African-American GFR Archer, MD, Kerry 01/07/2047
Result: >60 mL/min, Abnormal Flag: NA 07:54
AB FLAG: NA VOM: mi/rin
Deseription: Nor-African-American GFR

Resuit: >50 mL/min, Abnormal Flag: NA
AB FLAG: NA UOM: mL/min
GFR Reference Ranges: Chronic Kidney disease, < 60 mL/min/1.73m2;
Kidney Failure, < 15 mL/min/i.73m2. GFR estimate performed utilizing the
Modification of Diet in Renal Disease Formula (MDRD). Values are calculated
based on Serum Creatinine, Age, Race and Sex. Calculated values are provided
for bath Non-African American and African-American races. The interpreting
physician should determine the appropriate value. Calculating the GFR is not
recommended for patients under the age of 18, over the age of 80, or for
inpatients. Reference: National Kidney Foundation.
-16-
Patient Name
Age
76 yis
Ballam, Corbin
Ballam, Corgin
Ballam, Corbin
Ballam, Corbin
Balam, Corsin
ASAWAEER,
MAJID
12/31/2016
03:08
12/31/2016
O08
12/34/2016
12:41
12/31/2016
13:04
12/31/2016
13:42
12/31/2016
16:20
Magnesiurt
Phosphorus
HGB+HCT
Polassum
Magnesiun
4M Bone Imaging
Whale Bory
Dos Gender Race Weight Height Medical Record
1 Female C 53.98kq 184.94em
5700 East Highway 90, Slerra Vista, AZ. 85635 Printed 01/07/2017 07:55
Account
Reg. Date 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Room ED:C89-ER
Description: Magnesium Archer, MD, Kerry
Result: 1.6 mg/dL, Abnormal Flag: NORMAL, Normal Range: 1.6-2.3
AB FLAG: NORMAL = UOM: mg/dL.
Description: Phosphorus Archer, “4D, Kerry
Resvit: 4.4 mgfdL, Abnormal Flag: NORMAL, Normal Range: 25-45
AB FLAG, NORMAL = UYOM: nig/dl.
Description: *HGB Archer, MD, Kerry
Result: 9,5 22°", Abnorial Flag: LOW, Normal Range: 12.0-16.0

pt in bone scan, RN will call when pt is back in room 12/31/2016 12:04:42 MST
marten AB FLAG: LOW UOM: ZZ
Dascription: *HCT
Result: ***30.7 %***, Abnormal Flag: LOW, Normal Range: 37.0-47.0
pt in bone scan, RN will call when pt is back in room 12/31/2016 12:04:42 MSF
marten AB FLAG: LOW UOM: %
Description: Potassium Archer, MD, Kerry
Result: 4.2 mmol/L, Abnormal Flag: NORMAL, Normal Range: 3.5-5.1
AB FLAG; NORMAL = UOM: mmol/L
Description: Magnesium Archer, MD, Kerry
Resuit: 1.8 m@feL, Abnormal Flag: NORMAL, Norrnal Range: 1.6-2.3
AB FLAG: NORMAL WOM: mg/dL.
Description: NM Bone Irsaging Whole Body Archer, MD, Kerry
Result: IMPRESSION: 1. Abnormal uptake throughout the right femur is likely
related to recent trauma and surgery.2, No suspicious uptake in the remaining

skeleton to suggest active metastatic disease...
BONE SCAN TOTAL BODY
History: Skin cancer
Comparison: Right femur radiographs 12/30/2016
Findings:
24.6 mCi Te 99m MDP.
‘There is multifocal abnormal uptake iInvelving the proximal to distal rignt femur
most pronounced distally
associated with the presence of orthopedic hardware from recent surgery.
Uptake in the remainder of the skeleton is remarkable only for degenerative
changes in the lumbar spine,
bilatera! wrists, right knee, right ankle and bilateraj feet, There is levoscoliosis
of the lumbar spine.
Renal and urinary bladder uptake is present,
IMPRESSION:
1. Abnormal uptake throughout the right femur is likely related to recent
trauma and surgery.
2. No suspicious uptake in the remaining skeleton to suggest active metastatic
disease
~“V7-
01/07/2047
o7rs4
01/07/2017
O7:54
O1/07/2017
07:54
O1O7/2017
97:54
01/07/2017
07:54
01/07/2017
07:54
07:55
Patient Name Age
76 yis
Female ¢ 53.98kq 184,.94cm
Balam, Corbin. 01/02/2017 CBC/Diff
Description: * WBC Count Archer, MD, Kerry 01/07/2017
Result: ***3.4 x10(3)meL***, Abnormal Flag: LOW, Normal Range: 4.8-10.8 07:54
AB FLAG: LOW = UOM: x03) met
Description: *RBC Count
Result: ***2,.93 x10(6)/mcL***, Abnormal Flag: LOW, Nermal Range: 4.20-
6.10
AB FLAG: LOW -UOM: x10(6}/mel
Description: *HGB
Result: *°*8.0 227°, Abnormal Flag: LOW, Nerraal Range: 12.0-16.0
Description: *HCT
Resuit: ***26.2 %***, Abnormal Flag: LOW, Normal Range: 37.0-47.0
AB FLAG: LOW UOM: %
Description: MCV
Result: 89 fl, Abnormal Flag: NORMAL, Norma! Range: 80-100
AB FLAG; NORMAL = -UOM: fi
Dascriotion: MCH
Resuit: 27 ZZ, Abnormal Flag: NORMAL, Normal Range: 25-35
AB FLAG: NORMAL = -UOM: 27
Description: *MCHC
Resuit: ***30 727***, Abnormal Flag: LOW, Normal Range: 31-37
AB FLAG: LOW = -UOM: Zz

Description: *PLT
Result: *** 136 xi0@)mci***, Abnormal Flag: LOW, Normal Range: 150-400
AB FLAG: LOW UOM: x10(3) mek
~18-
CANYON VISTA MEDIC ‘AL CENTER 5700 East Highway 93, Slerra Vista, AZ, 85635 Printed 01/07/2017
07:55
Patient Name Age
76 yts
bos Gender Race Weight Height Medical Record Account
{ Female ¢ 53.98kq 154.94cm
Reg. Date 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Room §ED:CO9-ER
Allergies Sul'a (Sulfonamide Antibiotics), Latex
Balam, Corbin. 01/02/2017 Auto Diff
Description: Neutrophil % Auto Archer, MD, Kerry 0107/2017
Resuit: 65.5 %, Abnormal Flag: NORMAL, Normal Range: 40.0-77.0 07:54
Descripticn: Imrmature Granulacytes % Auto
Result: 0.3 %, Abnormal Flag: NORMAL, Normai Range: 0.1-0.3

Description: Lymphocyte % Auto
Result: 18.8 %, Abnormal Flag: NORMAL, Normal Range: 15.0-56.0
Description: Monocyte % Auto
Description: Eosinaphil % Auto
Description: Basophi % Auto
Result. 6.3 %, Abnormal Hag: NORMAL, Normal Range: <=2.5
AB FLAG: NORMAL UGM: %
Description: Neutrophil #
Result: 2.26 xl0(3}meL, Abnormal Flag: NORMAL, Normal Range: 1.78-5,38
AB FLAG: NORMAL UOM: x10(3)meL
Description: Intnature Granulocytes #

Result: <9.03 x10(3)meL, Abnormal Flag: NORMAL, Normal! Range: 0.00-0.02
AB FLAG: NORMAL = UOM: x10(3)met.
iption:
Resuit: ***0.65 x103)mecL***, Abnormal Flag: LOW, Normal Range: 1.18-3.74
AB FLAG: LOW = UDOM: x10f3)meL
Description: *Monocyte #
Result, ***0,39 xEO(3)mcl***, Abnormal Flag: HIGH, Normal Range: <=0,24
AB FLAG: HIGH = UOM: x10(3)mci
Description: Eosinophil #
Resuit: 6.13 xt0(3)mcl, Abnormal Flag: NORMAL, Normal Range: 6.04-0,36
AB FLAG; NORMAL = UOM: x10(3)met.
Description: Basophil #
Result, <0.03 x10(3)mcl., Abnormal Flag: NORMAL, Norma! Range: 0.01-0.08
AB FLAG: NORMAL UOM: x10(3)met
~419-
Patient Name
Age
76 yis
Insurance 9 MCARE MEDICARE
bos Gender Race Weight Height Medical Record
Female 53..98kq 184.94cm
5700 East Highway 93, Sierra Vista, AZ, 85635 Printed 01/07/2017 07:55
Account
Reg. Date 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Reom £D:C89-ER
Ballam, Corbin
Ballam, Corin
Balam, Corsin
01/01/2017
01/01/2017
02:44
On/O1/2017
02:44
BMP
Magnesium
Phosphorus
Description: *Sodium Archer, MD, Kerry
Resuit: ***436 mmol/L***, Abnorma! Flag: LOW, Normal Range: 137-145
AB FLAG: LOW = -UDM: ramol/L
Result: 4.4 mmol/L, Abnormal Fleg: NORMAL, Normal Range: 3.5-5.1

Description: Chioride
Resuit: 103 mmol/L, Abrermal Flag: NORMAL, Normal Range: 98-107
AB FLAG: NORMAL = UGM: mmol/L
Description: *CO2
Result; ***34 mmol/L***, Abnormal Flag: HIGH, Normal Range: 22-30
AB FLAG: HIGH = UOM: mmol/L
Bescription; BUN
Result: & mg/dl, Abnormal Flag: NORMAL, Normal Range: 7-17
AB FLAG: NORMAL = UOM: mg/dl.
Result: 0.7 mafdl, Abnormal Flag: NORMAL, Norinal Ratige: 0.5-2,0
AB FLAG: NORMAL UIOM: mg/dL
Result: 92 mo/dL, Asnormal Flag: NORMAL, Normal Range: 70-106
AB FLAG: NORMAL WOM: mg/dl.
Description: *Caicium
Result: ***8,1 mg/dl ***, Abnormai Flag: LOW, Normal Range: 8.8-10.8
AB FLAG: LOW UOM: mg/dL

Description: Magnesium Archer, MB, Kerry
Resuit: 2.0 mofdL, Abnormal Flag: NORMAL, Normal Range: 1.6-2.3
AB FLAG: NORMAL WOM: mg/dl,
Description: Phosphorus Archer, MD, Kerry
Result: 3.9 med, Abnormal flag: NORMAL, Normal Range: 2.5-4.5
AB FLAG: NORMAL UOQM: mg/dL.
~ 20 -
01/07/2017
O7:54
O1/07/2017
07:54
O1/o7/2017
87354
Patient Name
Age 5608
76 yis
Gender Race Weight Height MedicalRecord Account
Femaie C 53.98kq 154.94cm
Reg. Bate 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Room ED:CO?-ER
Medical Orders
MD Name MotTime Medical Grder Clinical Staff Clinical Order
Staff Time Status
Archer, MD, 12/29/2016 Femur 2 Views Minimum Right Ripley, Amy 42/23/2016 Rad Campleted
Kerry 12:25 13:15
Archer, MD, 12/29/2016 = ** Order Cancelled ‘Holden ,RN, Jill Dawn’ 12/29/2026 3:47:55 PM ** UA
Morbrock, Rachael 12/29/2016 Cancelled
Kerry 12:25 wireflex Cx -Cath tar29

Archer, MD, 12/29/2016 = CBC Morbrack, Rachael 12/29/2016 RN Completed
Kerry 12:25 12:29
Archer, M0, 12/20/2016 BMP/Chem-3 Morbrock, Rachael 12/29/2016 RN Completed
Kerry 12:25 12:29
Archer, MB, 12/29/2016 Fentanyl 166 meg IV (Slow), , one time, Intravenous, , stat Gracia, Selena
12/2972015 RN Completed
Kerry 12126 12742
Archer, MD, 12fa9f2016 Zofran 4mg IVP, , one tine, Intravenous, , stat Gracia, Selena 12/29/2016 Rit
Completed
Kerry 12:26 12:42
Archer, MD, 42/29/2016 UWA w/refiex Cx -Clean Catch Verbal Read Back per Archer, MD, Kerry MO
Morbrack, Rachael 12/29/2016 ED Tech Hi
Kerry 12:35 12:35 Cornpleted
Archer, MD, 12/29/2016 CT Abd and Pelvis w/ Contrast (BUN Creat needed) Ripley, Amy 12/23/2016
Rad Completed
Kerry 13.53 15:57
Archer, MD, 12/29/2016 Fentanyl 160 mcg TV (Siow}, , one time, Intravenous, , stat Ripley, Amy
12/29/2016 RA Completed
Kerry 27:05 17:24
Admit To Asawaeer, Majid MD
MD MD Time RN RN Time
Disposition Archer, MD, Kerry 12/29/2016 17:53 Admit Ripley, Amy £2/29/2016 18:15
ga
Condition acre, MOD, Kerry 12/29/2016 17:53 Stable Ripley, Amy 12/29/2016 18:45
Date/Time Patient Physically Left the Emergency Department
12/29/2016 18:16
Electronically signed and authenticated by the Following Physicians : Archer, MD, Kerry
-21-
Patient Name Age 608
76 yis
Notifications By MD
Time
MD Notified Notifie
Asawaeer, Majid MD Discussed 12/29/2016 17:53
Relevant Hx, Exam, Diagnostic
Evaluation & Disposition-Agrees
c Plan.
Gender Race Weight Height MedicafRecord Account
Female ¢ 53.98ka 184.94crm

Notifications By RN
MD No Notification Documentation
Notified
Archer, MD,
Kerry
~22-
Patient Name
Age
76 yrs
DOB
Vitais
‘Taken at
12/29/2016
11:30
12/29/2016
12:30
12/29/2016
13:00
12/29/2016
13:30
12/29/2016
14:00
12/25/2016
14:30
12/29/2016
15:06
12f/29/2016
15:30
12f2gf2016
18:00
Taken by
Ripley, Amy
Ripley, Amy
Ripley, Amy
Ripley, Amy
Ripley, Amy
Ripley, Amy
Ripley, Amy
Ripley, Amy
Ripley, Atay
Temp
Temp 97.5
Pulse Resp 6?
67
7E
76
83
45
$1
76
76
18
18
18
18
18
18
18
16
163/72
155/70
152/66
495/74
176/27
185/79
L78/74
169/76
166/72
Pulse Pain
Gender Race Weight Height = wedicalRecord Account
Female 53.98kq 154.94cm
Reg. Date 12/29/2016 11:04 Adm. Date 12/29/2016 17:08 Room §£D:C59-ER
Head
Cire. LMP
we WE OHE
Seale (kg) cha. fom) ae © cen usec imp SHES Comments
4%
100%
100%
94%
100%
100%
99%
100%
4/10
4/10
4/10
4/10
4/10
4/10
6/10
6/10
4/10
Menopause
CANYON VISTA MEDICAL CENTER 5700 East Highway 93, Sierra Vista, AZ. 85535 Printed 01/07/2017
07:55
Patient Name Age DOB Gender Race Weight Height MedicatRecord Account
76 yis Female = C 53.98kq 154,94cm
Insurance MCARE MEDICARE Reg. Date 12/29/2016 11:04 Adm. Date 12/29/2016 17:68 Room £ED:CO9-
ER
Clinical-InterDisciplinary Notes
Date/Time Note Type Clinical Staff
Note
12/25/2016 14:26 ED - TRIAGE Triage - Emergency Department: Ripley, Amy
Triage Date/Time-12/29/2016 11:26
Chief Compiaint-fall injury
Onset of symptoms (date)-12/29/2015
Onset of symptoms (Time)-0930
Summary of History of Present INiness/Focused Assessrnert-EMS states pt slid to ground approx
2 hours ago, pt states pain, swelling, and numbness to right leg.

Family Physician Name-Carnett Mark
Pre-Hospital EMS Medications/Fluids Amount (Piease List)-75meg fentanyl IV
Pregnancy (include G P A and EDC if anglicable)-Not Applicable
Within the past 21 days have you, or someone you've been in close contact with, travelled to
West Africa specifically Guinea and Sierra Leone?-No - Complete next question
Have you had any contact with someone who is known or suspected to have Ebola?-No ~
Continue standard triage questioning
Tetanus and/or Immunizations UTD (less than § years)?-Up to Date
TB Screesing: fever, night sweats, vloody sputum, unitentional weight loss, If 2 or more Sx and
not r/t complaint, notify MD and consicer isofation.-Patient denies fever, night sweats, bloody
sputum, unintentional weight joss
Sepsis Sereen: Does patient have altered mentation and/or has a HR above 90, Resp above 20,
Temp greater than LOLF or less than 97F or SBP less than 90?-No
Historian-Ambulance FD, self
Aculby-Category-3 ESI-3 (Urgent) 2 or more resources

Injury/ liness Location-Home/House/Apartment
Transported By-ALS, ambulance
Moce-Stratcher
GCS Best eye response-4-Spontaneous--open with blinking at baseline
GCS Best verbal response-5-Oriented
GCS Best motor response-6-Obeys commands for movement
GCS Tatal-15
Patient Name
Age BOB
76 yis
5700 East Highway 93, Sierra Vista, AZ, 85635
Weight Height
53.98kq 154.94cm
Gender Race
Female ¢
Medical Record
Printed 01/07/2017 07:53
Account
Reg. Date 12/29/2016 11:04 Adm. Date 12/25/2016 17:08 Roam £D:CO9-ER
12/29/2016 12:28
12/25/2016 11:44
12/29/2046 12:24
12/28/2616 13:08
12/29/2646 13:10
12/25/2016 13:13
12/28/2046 13:42
12/28/2016 13:45
12/28/2016 13:51
12/29/2016 14:56
12/29/2016 15:57
12/29/2016 16:57
12/25/2616 17:05
12/29/2016 17:16
ED - NURSING
NURSING
NURSING
NURSING
NURSING
NURSING
ADMISSION
NAVILIFE
NURSING
NURSING
NURSING
NURSING
NURSING
ADMISSION
NN Assessment:
Exam Room Date/time-12/29/2016 11:45
Room assigned in ED-C09

Primary Nurse-Ripley, Amy RN
Reason for Vis:t-ED reason for visit consistent with triage complaint and unchanged
General Appeerance- No Acute distress, calm, cooperative, and appropriate
Nevrological-Alert and Oriented x 3, PERRL, GCS 15 and speech clear
Respiratory- Spontaneous and easy respirations, Breath sounds CTA
Cardiovascular- SR per monitor w/ regular rate. Pulses strong, skin warm/pink/dry, cap refill
brisk
GI- Soft, bowel sounds present, colostomy left side of abdomen
GU (Consult “NN Urine Cath Assessrnent Tool for any foley need)- Denies complaints or
complications
Musculoskeletal-Pain to right lower extremity, 4 out of 10 pain after fentanyl administration.
Eyes- Comeas clear, PERRLA, EOM intact, no drainage
Nose/Throat/Mouth- Moist mucous membranes
Integumentary-slight edema to right lower extremity
Precautions-Standard precautions with bedrails up, call light within reach, head of bed elevated
Standard Safety- Bed/chair in iow position, cal device within reach, HOB elevated, adequate
lighting and pt ready for MD medical screening
Patiant/ Allergy/ Fall Band- Verified and applied
CAGE I - Bo you consume alcohol, use Hlegal substarices or use medications not prescribed to
you?-NO
CAGE IT - Have you felt guilty or, been criticized for or steadied your nerves/hangover with
drugsfatcohal?-NG
CAGE HI - Referral Information-No referral information needed
Readiness to learn: Motivation, Knowledge and Comprehension level-Medium
Educational Assessment-Mo communication barriers or disabilities
Are you being hurt by someone you live with or who takes care of you?-NC
Functional discharge planning - Daily living, Living conditions-Independent
Patient Belongings Inventory-Ail belongings remain with patient
20 Gauge Angio Forearm R w/o complications. Blood drawn and sent to lab, prehospital
initiated
Pt placed on bed pan with assistance from patient by rolling side to side. Pt reports she will use
call light to notify me when she ls finished. Will adjust pt's position in bed when she has
finished voiding.
called rad tech to see about geiting the immage results
Dr. Daines at bedside with pt
pt taken to radiology for xray
ADMISSION ORGERS RECEEVED:
---SEE SCANNED ORDERS FOR DATE AND TIME WRITTEN OR orders
EZADMIT:
Contacted for patient ADMIT or TRANSFER-Spoke with: Nicki
Dr.Karges and Dr. Aswaweer on phone with Dr Archer
called rad tech; they have order just have a couple pt in front then will come get pt.
pt taken to radiology
assisted patient onte and off from a bedpan. Cail fight is within reach. Needs met at this time
Patient is reporting increased pain at this time. Amy R made aware
ADMISSION ORDERS RECEIVED:
---SEE SCANNED ORDERS FOR DATE AND TIME WRITTEN
-25-
Ripley, Amy
Ripley, Amy
Dye, Dawn
Schiffner, Jeniffer
Ripley, Amy
Ripley, Amy
Schiffrer, Jeniffer
Schiffner, Jeniffer
Sehiffrer, Jeniffer
Schiffrer, Jeniffer
Ripley, Amy
Morbrock, Rachael
Morbrock, Rachael
Schiffner, Jeniffer
CANYON VISTA MEDIC AL CENTER $700 East Highway 92, Slerra Vista, AZ, B5535 Printed 01/07/2017
07:55
76 yrs Female € 53.98kq 154.94cm
Insurance MCARE MEDICARE Reg. Date 12/29/2016 11:04 Adm. Date 12/25/2016 17:08 Room £D:CO9-
ER
12f29/2016 17129 ED - Hand Off NN 6 Admit Documentation: Scniffner, Jeniffer
Adrait unt assignment-ACS
Admit room assignrment-2209
Assigned Nurse to receive patient-michael
Nurses Phone or extension-2748
Room ready for patient?-Yes
12/28/2016 18:06 NURSING Michael called, will be down shortly Holden ,RN, Jill
Dawh
12/29/2016 18:15 NURSING Report given in SBAR format to accepting floor nurse, Michaat Ripley, Amy
~ 26 -
Patient Name
Ase DOB
7éyrs
Intake
5700 East Highway 93, Slerra Vista, AZ, 85635 Printed = 01/07/2017 07:55
Gender Race Weight Height Medical Record = Account
Female C 53.98kq 154.94cm
Basage/ Route/
Start/Ead Staff Medicine/ Device Type Rate Sita Amt. Residual Comments
12/25/2016 — Gracta, Selena Zofran 4mg IVP, , one time, Intravenous, , stat L wrist 4.MG
12:42
12/29/2016 Gracia, Selena End Time Comments
12:42
12/29/2016 Gracia, Selena Fentanyl 100 meq Iv (Slow), , one time, Intravenous, & wrist 106 meg
12:42 , Stat
12/29/2016 Gracia, Selena End Time Comments
12:42
12/25/2018 Ripley, Army Fentanyl 100 meg IV {Slow}, , ene dime, Intravencus, Lwrst 100 meg
17:24 , shat
12/25/2016 — Ripley, Amy End Time Comments
17:26
Output
No Guitput Documentation
~27 -
Patient Name Age bOB
76 yis
Medication Reconciliation
5700 East Highway 93, Serra Vista, AZ, 85635 Printed 01/07/2017 07:55
Gender Race Weight Height MedicalRecord Account
Femaie 53.98kq 184.94cm
No Medication Reconciliation Documentation

RE
‘CANYON VISTA.
BaP ie a oF eT Ew
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__ PATIENT INFORMATION SHEET

__PATENT FORMATION
TREO eonmmnmpnesinn, A ER Semana

STAR, 3
EE ESS SL a IS Hy
PAY ROYALE,
Dei. 90.08 oe CO nee |
PACHA NRRL IRT RES
CRED PORDER ern rnr |

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moo01/o601

| Health Information Mbnegement Department

520-268-3360 Phona | © 520-263-3370 Fax

_ Medical Records Request

Physictans office! Requested by: R. mate

Cheniett CLINIC |meGan| Bren

Patient Name: . Date of Birth:| Date of Service:

_ Please check the type ofldocument(s) needed

x Emergency § Room Record : C Maternat Outpatient Observation Record

‘x Discharge Summary \ (NST}

C) History & Physical } © Vaccination Record

IK Consult Report | © Hearing Screen”

() Operative Report | C Newborn Records

(J Cath Lab Report \ BA Laboratory Results

01 Colonoscopy. Report | () Mammography Report

0 Delivery Note 10 Radiclogy Report:

1) Stress Test Report G Radiclogy Report & CO:

Note: : Spaclly typo of Exam TMM, CF, Ryvay, oct}

: type of docurnent you ara looking for,

Please fax request to 520-263-3370

Raquests are pronessed fn the order thal thay are recelved.

Sierra Vista, AZ 85635

CANYON VISTA orone 2026200

Patient: Location: MedSurg

FIN: Admit: 12/29/2016

DOB/Age/Sex: 77 years Female Discharge: 01/02/2017

Collected Date 9 O1/01/2017 12/34/2016 12/81/2016 12/30/2016 = 12/29/2016

Collacted Time O150MST 12:338MST 02:25MST O3:20MST 11:35 MST

WBC Count 3.4L 43.L 3414 48 x10(3)mebL

RBC Count 2.93 I. 3.22 417 L 449 x10(6)imel

HGB 8.0L 951 91 L M44 424 g/dL

HCcT 26.2 1 30.7 L 28.5 L 36.6 L 305 %

ROW-CV 17.8 H 17.9 H 18.0 H 18.1 H %

12/31/2016 12:36:10 MST HGB+HCT:

Collected Date OUO1/2017 = 12/30/2016

Collected Time 01:50 MST 03:20 MST

Procedure Units Ref Range

Neutrophil # 2.26 2.22 x10(3)mcL =—([1.78-5.38]}

Immature Granulocytes # «0.03 <0.63 xt0(3)mci —-[0.00-0.02)

Lymphocyte # 0.65 L 0.73 L xX10(3)mcL — [1.18-3.74]

Monocyte # 0.39 H 0.38 H x10(3jmcL = f<=0.24]

Easinophil # 0.13 0.05 xt0(3)mcl —«[0.04--0.96]

Basophil # <0.03 <0.03 x10(3)met. —-[0.01-0.08]

Neutrophil % Auto 65.5 65.5 % [40.0-77.0]

immature Granulocyies % Auto 0.3 0.0 1 % (0.1-0.3]

Lymphocyte % Auto 13.8 215 % [15.0-50.0]

Monocyte % Auto 113 11.2 % [<=12.0]

Egsinophil % Auto 3.8 15 % [<=6.0]

Basophil % Auto 0.3 0.3 % [<=2.5]

LEGEND @=Corrected *=Abnormal C=Critical LeLow H=High f=Footnote #=Interpretive Data

Chart Request Id: : Page 1 of 25 Print Date/Time: 1/17/2017 16:27

§700 E Hwy 90, Sierra Vista, AZ 85635 Phone (520) 263-2000

Patient: Location: MedSurg

MRN: Provider: Asawaeer, Majid

DOB/Age/Sex: 77 years Female

Collacted Date 12/3

Collacted Time 03:2

Prothrombin Time 14.6

Units Ref Range

Collected Time 12:31 MST

Procedure Units Ref Range

UA Appearance Clear [Clear]

UA pH 5.0 unit(s) [5.0-8.0]