certification of records patient name

Iii

I CERTIFICATION OF RECORDS

Patient Name:

Date of Birth:

Medical Record#:

Court Case #:

As a Release of Information Specialist employed by CIOX HEALTH, LLC, the health

information management service used by AdventHealth Central Florida Region , I do

hereby certify that the enclosed photographic copy of the medical record of the above

named patient covers the period from 1/21/2021 to 1/21/2021 , and has been

compared with the original medical record and, to the best of my knowledge, is a

complete, legible, and accurate duplicate of such record, except as outlined below:

__ No records for dates requested __ No patient found

Number of pages: _1_0 ____ _ Includes billing records: yes / no

6/9/2021

Elect onic Signature ofrepr sentative of CIOX Health Date

00001

AdventHealth Altamonte Springs Apopka c::etebration Chi1dren1s East ()rlando Kissimmee ()rlando \.Vinter G-arden \Vinter Park

Patient Name MRN Patient Rm erg ency Department DOB/AgeJSex: 29 years I Female Location: Adventl1ealth East Orlando

ED Pltysicia11 Slteet

Abdominal pain in early pregnancy

Patient MRN: FIN: Age: 29 years Sex: Female DOB: Associated Diagnoses: None Author: JONES MD, DREW NORMAN

Attestation

Provider Scribe Attestation

Provider: JONES MD, DREW NORMAN

Provider Scribe attestation: I, the provider working with the scribe personally pertormed the services described in the documentation, reviewed the documentation recorded by the scribe in my presence & it accurately & completely records my words & actions

Basic Information Time seen: Provider Contact Date and Time Provider 01/12120211406JONESMD, DREW NORMAN

, Room4_ History source: Patient Arrival mode: Private vehicle_ History limitation due to: None_ Additional information: Patient's physician(s): None, Pt's OB is Dr_ Alejandro Pena at the Women's Center of Orlando, Chief Complaint from Nursing Triage Note : Chief Complaint Detail

111212021 12:56 EST Chief Complaint Detail pregnant, right abd pain _ Gravida/Para: Gravida /Para ST Gravlda Para Information: Gravida: 0 Para Term: O Para Preterm: 0 Para Abortions: o

Para Living: 0,

History of Present Illness The patient presents with abdominal pain in pregnancy <14 weeks_ 29 y/o female G1 P0A0, LNMP

12/10/2020, with PMHx of PCOS_ Pt reports she and her partner have just started trying for a baby, and she recently took her first round of letrozole which was recommended by her OB after a hysteroscopy_ Pt explains that she has taken 5 positive at home pregnancy tests and has come to the ED today for RLQ abd pain onset

Patient Name Print Date/Time 61812021 0753 EDT

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El> Physicia11 Sheet

last night. She describes her pain as similar to menstrual cramps, with a dull constant pain and intermittent sharp stabbing pain radiating to the back, The pain began yesterday afternoon and was at its worst yesterday night. Pl notes that her menstrual is irregular due to PCOS, Her last menstrual period began on 1211012020 and lasted until 12/2012020, which she states is not unusual in length but she states the flow was heavier than normal. She denies vaginal bleeding, abnormal vaginal discharge, dysuria, hematuria, She denies fever/chills, CP, SOB, cough, or recent sick contact. The onset was Yesterday afternoon, The course/duration of symptoms is constant and fluctuating in intensity. Pregnancy Status Gravida: 1 Para: 0. Character of pain: sharp, stabbing, dull location: right and lower quadrant. Bleeding: none, Discharge: none. Associated symptoms: denies nausea and denies vomiting,

Review of Systems Constitutional symptoms: No fever, no chills, no sweats, no weakness, no fatigue, Skin symptoms: No rash, Eye symptoms: Vision unchanged. Respiratory symptoms: No shortness of breath, Cardiovascular symptoms: No chest pain, Gastrointestinal symptoms: Abdominal pain, right lower quadrant, no nausea, no vomiting, no

diarrhea, Genitourinary symptoms: No dysuria, no hematuria, no vaginal bleeding, no vaginal discharge, Neurologic symptoms: No headache, no weakness,

Additional review of systems information: All other systems reviewed and otherwise negative,

Health Status Allergies:

Allergic Reactions (All) Severity Not Documented

Iodine- Allergic rxn. Penicillins- Hives. Seafood- Allergic rxn ..

Medications: Per nurse's notes, Keppra, Menstrual history: Last menstrual period: 1211012020-1212012020, irregular secondary to PCOS.

Past Medical/ Family/ Social History Medical history: Neurological: Seizure, PCOS, Surgical history:

Cerebral meningioma (290621015), Entire tonsils and adenoids (479092019) ..

Social history: Alcohol Details: Current, Beer, Wine, Uquor, Occasionally; Comment(sj: once or twice a month Tobacco Details: Never smoker, NIA , Drug use: Denies, Occupation: Employed (realtor).

Physical Examination

Vital Signs Time: 0111212021 14:10:00.

Patient Name' Printed On

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ED Physicia11 Sheet

Vital Signs 1112/202112:56 EST Temperature Temporal

Heart Rate Respiratory Rate Spontaneous 02 Saturation 02 Delivery Device

97 .4 DegF LOW 94 bpm Normal 18 brlmin Normal 98% Normal Room air

Systolic Blood Pressure NBP Diastolic Blood Pressure NBP

114 mmHg Normal 75 mmHg Normal

Interpretation of 02 Sat: No hypoxia. Measurements

111212021 12:56 EST Estimated Weight in lbs 172 Lb Estimated Weight in kg 78.017 kg Medication Dose Weight (Verify 78.017 kg UOM)

Height in cm 160.02 cm Height in inches 63 inch

General: Alert, no acute distress, Non-toxic appearing. Skin: Warm, intact, no rash. Head: Normocephalic. Neck: Supple. Eye: Pupils are equal, round and reactive to light, extraocular movements are intact. Ears, nose, mouth and throat: Tympanic membranes clear, oral mucosa moist, no pharyngeal

erythema or exudate. Cardiovascular: Regular rate and rhythm, Arterial pulses: Bilateral, radial, 2+, Arterial pulses:

Bilateral, dorsalis pedis, 2+, Capillary refill: < 2 seconds. Respiratory: Lungs are clear to auscultation, respirations are non-labored. Gastrointestinal: Soft, Tenderness: Right lower quadrant, Guarding: Negative, Rebound: Negative. Neurological: Alert and oriented to person, place, time, and situation. Psychiatric: Cooperative.

Medical Decision Making Documents reviewed: Emergency department nurses' notes, emergency department records, No

known metro Orlando Advent Health Emergency Department visits or admissions in the past 30 days.

Results review: Lab results : Lab View

Patitmt Name: Printed On

1112/2021 14:21 EST UA Color Ur Clarity UASpecGrav UApH UAAlbumin UAGlucose UA Ketones UABile UA Blood UA Nitrite UA Urobillnogen

61812021 07:53 EDT

Report Request ID/I:

YELLOW CLOUDY 1.024 5.0 NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE NORMAL

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ED Physicia11 Sheet

UA Leuk Est 3+ UA RBCs 4 /[H PF] UA WBCs 27 /[HPF] HI UA Bacteria 2+ /[HPF] UA Squamous Epithelials 16 /[HPF] HI UA Mucous OCCASIONAL /(HPFJ

1112/202113:18 EST WBC 8.02 10*3/uL RBC 4.44 10'6/ul Hgb 13.0 gldL Hct 39.2 % MCV 88.3fl MCH 29.3 pg MCHC 33.2 g/dL ROW 12.7% Platelet Count 24510*3/uL MPV 11.2fl Neutrophils 61.7 % Lymphocytes 33.4 % Monocytes 3.2 % Eosinophils 1.0 % Basophils 0.7 % Abs Neutrophil Cnt 4.92 10'3/uL Abs Lymphocyte Cnt 2.68 10*3/uL Abs Monocyte Cnt 0.26 10'3/uL Abs Eosinophil Cnt 0.08 10'3/uL Abs Basophil Cnt 0.06 10'3/uL Sodium Lvl 137 mmol/L Potassium Lv! 4.2 mmol/L Chloride Lvl 104 mmol/L CO2 Lvl 23 mmol/L LOW AGAP 10 mmol/L Glucose Lvl 123 mg/dL HI BUN Lv! 9 mg/dL Creatinine Lvl 0.72 mgldL GFR Non Afr Amer by CKD-EPI 113 ml!min/1.73_m2 Calcium Lvl 9.3 mgldL Total Protein Lvl 7.3 gldl Albumin Lvl 4.0 gldl Globulin Lvl 3.3 gldL NG Ralio 1.2 Bllirubin Total 0.3 mgldl A!k Phos 76 units/L ALT 28 units/L AST 26 units/L Beta hCG Quant 465 m[IU]/ml

Radiology results: Completed Radiology imaging Impressions:


61812021 07:53 EDT MRN FIN#

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El> Physicia11 Sheet

us Pregnancy <14 WeeksfIV (01/12 1424): pregnancy of unknown location. no intrauterine gestational sac visualized. in the setting of a positive pregnancy test,

considerations include early intrauterine pregnancy, early ectopic pregnancy, and spontaneous abortion_ correlate wtth quantitative beta-hcg and follow-up ultrasound.

, reviewed radiologist's report.

Reexamination/ Reevaluation Time: 01112/202114:15:00. Interventions: Order Profile (Selected)

Inpatient Orders Ordered

Tylenol: 1 gm, Tab, PO, Once, Routine, 0111212115:00:00 EST, Stop date 0111212115:00:00 EST, Dispense Loe: PYX EOED6AF:

Notes: Discussed with pt current plan of care, pt verbalizes understanding and agreement with plan. Time: 01112/2021 15:45:00. Notes: Pt is resting comfortably in bed and currently rates her pain as 3110. US did not confirm ectopic or

uterine pregnancy. Call out to Dr. pena placed. Anticipating discharge home wtth close follow-up. Time: 01112I202116:35:00. Notes: Discussed results, treatment plan, and prescriptions with pt and instructed 48 ED return for hcg recheck

and OB follow-up. Discussed ED return precautions for return to the ED immediately if any new or worsening symptoms develop. Pt understands and agrees with discharge plan.

Vital signs results included from flowsheet : Vital Signs

111212021 16:43 EST Temperature Oral Heart Rate

Procedure Ultrasound

Time: 011121202114:17:00.

Respiratory Rate Spontaneous 02 Saturation Systolic Blood Pressure N BP Diastolic Blood Pressure NBP

Confirmed: Patient, procedure, and site correct. Consent: Patient. Indication: Abdominal pain, Rule out ectopic pregnancy, Pregnancy. Exam type: Transabdominal.

98.3 DegF Normal 76 bpm Normal 16 br/min Normal 99% Normal 131 mmHg Normal 69 mmHg Normal

Pelvic findings: fluid: positive no intrauterine pregnancy, no ectopic pregnancy, right Performed by: Self. Total time: 10 minutes. Notes: images saved to qpath.

Impression and Plan Diagnosis

Right lower quadrant abdominal pain Positive pregnancy test

Calls.Consults

Patient Name' Printed On

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ED Physicia11 Sheet

• 01/12/2021 15:30:00 , PENA MD, ALEJANDRO JAVIER, OB, consult. Plan

Condition: Improved. Disposition: Discharged: Time 01/12/2021 16:35:00, to home. Prescriptions: Launch Mads List (Selected)

Prescriptions Prescribed

Tylenol 500 mg oral tablet: 2 tab, PO, q6hr, PRN breakthrough pain,# 24 tab, 0 Refill(s). Patient was given the following educational materials: Abdominal Pain, Early Pregnancy. Follow up with: ALEJANDRO PENA, OBSTET GYNECOL, Obstret Gynecol Within 3-5 days; Return to

Emergency Department Within 48 hours Please return to the ED in 2 days for hcg recheck. Return to the ED immediatley for any new or worsening symptoms ..

Counseled: Patient, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Regarding prescription, Patient indicated understanding of instructions.

Scribe Signature By signing my name below, I, Anna Capuno , attest that this documentation has been prepared under the

direction and in the presence of: JONES MD, DREW NORMAN , Electronically Signed: Anna Capuno, 01/12I202114:14:00.

Addendum

Teaching-Supervisory Addendum-Brief I participated in the following activities of this patients care: the medical history, the physical exam, medical decision making, the procedure, I personally performed: supervision of the patient's care, the medical history, the physical exam, the medical decision making. Evaluation and management service: I agree with the evaluation and management decisions made in this patient's care. Results interpretation: I agree with the study interpretation in this patient's care.

E/eclronica/ly Signed By, JONES MO DREW NORMAN


61812021 07:53 EDT


On: 01114/20211215

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ACCESSION

US-21-0006771

Reason For Exam

Radiology

EXAM DATEff!ME PROCEDURE

1/12/202115:13 EST US Pregnancy <14 WeeksffV

(US Pregnancy < 14 WeeksffV) Pain

Report EXAM US 08 FIRST TRIMESTER

INDICATION Pain

COMPARISON None

ORDERING PROVIDER JONES MD.DREW NORMAN

TECHNIQUE: Multiplanar gray-scale imaging of the was nerformed using transabdominal and for better assessment of the endometrium and/or adnexa, transvaginal technique.

FINDINGS

INTRAUTERINE GESTATION: No intrauterine gestation visualized

EDD LMP 9116121.

UTERUS: Measures 8.8 x 4.9 x 3.9 cm. No mass. No subchorionic hematoma is noted.

RIGHT OVARY: Measures 4.8 x 4.5 x 4.3 cm Probable corpus lu!eum visualized. An additional hypoechoic may represent a small hemorrhagic follicle/cyst and measures cm Several small follicles visualized.

LEFT OVARY Measures 3.2 x 2.0 x 2.2 cm. Several small follicles visualized.

CUL DE SAC FLUID: Small to moderate volume

IMPRESSION Pregnancy of unknown location. No intrauterine gestational sac visualized. In the setting of a positive pregnancy test, considerations include intrauterine pregnancy, early ectopic pregnancy, and spontaneous abortion. Correlate with quantitative beta-hCG and follow-up ultrasound.

Dictating Physician Aaron Lindsay, MD Dictated on 111212021 314 PM Signed by: Aaron Lindsay, MD Location OSRR52

WSNOSRR52


61812021 07:53 EDT


MRN

STATUS

Modified

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Radiology

Report *"'*Final Report**"

Transcribed By: AJL 01/12121 3:14 Signed end Verified By: LINDSAY MD, AARON JOSEPH 01112121 3:21

Procedure

WBC RBC Hgb Hct MCV ,MCH MCHC ROW Platelet Count MPV Neufroph1ls Lymphocytes Monocytes Eosinophils Basophils Abs Neutrophil Cnl Abs Lymphocyte Cnt Abs Monocyte Cnt Abs Eos1noph1I Cnt Abs Basophil Cnt

Procedure

Sodium Lvl R:>ta&&iurn Lvl Chloride Lvl C02Lvl AGAP Glucose Lvl WNLvl Creat,nine Lvl

Units .10•3/ul 10•6/ul gdL % j[ pg g/dl '% ·10•3tul

fl .% . :% % % .% ·10•3/ul

10•31,iL 10•3/uL 10•3/uL 10*3/uL

GFR Non Afr Amer by CKD-EPI Calcium Lvl

.

Collected Date Collected Time

Reference Range [440:10 50]

[3.75-500] [114-14 7] [34 3.45 5]

1so 5.99 ej [26.8-33.0] [31 0-35 4]

[11 [139-361] [9 7-12 5] (50.0:10.01 [20 5-45 O] {1-15] [0-5] [0-2] [1 50-7 50] [100-480] [O 00-0 80] [0.00-0 50] [0.00-0.20]

Units rnmol/L mmol/L rnmol/L rnmol/L rnmolll rngldl mg/dL mg/dl mUmin/{1.73_m2} mg/dl

Herm.1.tolo~1

1/1212021 1318 EST

802.

4.44 1:i O .

39.2 ·se.3 29 3 33 2 12.7 245 11.2 61.7 33 4 3.2 1.0 07

·4.92 2.68 026 0.08 0.06

Chemistry

Collected Date 1/1212021 Collected Time 13:18 EST

Reference ·Range [135-145] [3 5-5 OJ [98-110] [24-32] [5-15] (70-100] [5-25] !0 60-1.20] [>60] !8 5-10.5]

137

23' 10111

123" 9

0.72 113 9.3

Patitmt Name' Printed On:

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Procedure Tot81 Protein Lvl Album1nlvl Globulin Lvl AfG Ratio BillrubIn Total Alk Phos ALT AST Bet8 hCG Qu8nt

Result Comments R1: AST, Potassium Lvl

!,"dl g/dl g/dl

Units

mgldl unrtsA.. unit•~ unitsll m[IU]lml

Laboratory

Chemislty

Collected Date 1112/2021 Collected Time 13.18 EST

Reference Range [6 5-8 OJ 7.3 [3 2-5.5] 4 0 [1.9-3 9] 3 3 [1.1-2.2] 1 2 [O 1-1.5] 0.3 {35-104] 76 [4-51] 28 !5-46] 26 p,

465"'

RESULT MAY BE QUESTIONABLE DUE TO SLIGHT HEMOLYSIS R2 AGAP

Hypoalbuminemia can cause the anion gap to be underestimated. Each g/dl that albumin is decreased causes the anion gap to be decreased by 2 5 mmol/L Anion gap corrected for hypoalbuminemia ~ Anion Gap+ 2.5(4-Albumin)

R3 Beta hCG Quant APPROXIMATE GESTATIONAL AGE BASED ON HCG RESULT WEEKS SINCE LMP APPROXIMATE

(last menstrual period) HCG RANGE (mlU/ml) HEALTHY NON-PREGNANT FEMALE <5 0.2-1 WEEKS 5-50 1-2WEEKS 50-500 2 • 3 WEEKS 100 • 5,000 3 · 4 WEEKS 500 -10,000 4 - 5 WEEKS 1,000 - 50,000 5- 6 WEEKS 10,000 -100,000 6-8 WEEKS 15,000- 200,000 8-12 WEEKS 10,000 -100,000

Urinal:f:':__is ________________ ~

Procedure UAColor Ur Clarity UASpacGras UApH UAAlbumm UAGlucose UA Ketones UABile UABlood

Collected Date Collected Ti me

Units Reference Range JYELLCIN] jCLEAR] {1 005-1 030] 15,0-8 5] [NEGATIVE-NEGATIVE] [NEGATIVE-NEGATIVE] [NEGATIVE-NEGATIVE] {NEGATIVE-NEGATIVE] [NEGATIVE-NEGATIVE]

Patient Name: Printed On:

61812021 0753 EDT

Report Request ID/I·

111212021 1421 EST

YELLOW CLOUDY,

1 024 50

NEGATIVE NEGATIVE NEGATIVE NEGATIVE NEGATIVE

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00010

Procedure UA Nitrite UA Urob1l1nogen UALeukEst UARBCa UAWBCa UABactena UA Squamous Epithelials UA Mucous

Laboratory

Urinalysis

Collected Date Collected Time

Units Reference RaJ\je [NEGATIVE-NEGATIVE] {NORMAL] {NEGATIVE-NEGATIVE]

l[HPF] {0-4] l[HPF] J0-4] l[HPF] [NEGATIVE-NEGATIVE] l[HPF] !0-4] /[HPF] {NONE SEEN]

111212021 14 21 EST

NEGATIVE NORMAL

3+A 4

27" 2+A 16"

OCCASIONAL A

Urine Cult Ordered t,; Lab SEE ACCESSION NUMBER P<

Result Comments R4: Urine Cult Ordered by Lab

SEE ACCESSION NUMBER L337286014

il1icrobiology Testing

Urine Culture Clean Catch Cl Catch Vrnd Ur CLEAN CATCH VOIDED URINE 1/12/20211421 EST

***INTERFACED REPORTS*** Specimen Description Verified Date/Time/Personnel: CLEAN CATCH VOIDED URINE COLLECTED DATE/TIME: 01112/2021 1421 SETUP DATE/TIME: 01/1312021 0849 Report Status Verified Date/Time/Personnel:

FINAL 01/1412021 Culture Results Verified Date/Time/Personnel: NO GROWTH AFTER 19 HOURS

PROCEDURE SOURCE FREE TEXT SOURCE COLLECTED

Performed at AdventHealth Lab* 601 E. Rollins St* Orlando * FL * 32803 * 8


61812021 07:53 EDT


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