Wiliam Sepulvado€¦ · Web viewExtensive confluent hypodensity is seen within the corona radiata and centrum semiovale consistent with microvascular ischemic changes with focal

Bennie XXXXX DOB: 02/23/YYYY DOD: 02/25/YYYY

MEDICAL CHRONOLOGY - INSTRUCTIONS TO FOLLOW

General Instructions:

Brief Summary/Flow of Events: In the beginning of the chronology, a Brief Summary/Flow of Events outlining the significant medical events is provided which will give a general picture of the focus points in the case

Patient History: Details related to the patient’s past history (medical, surgical, social and family history) present in the medical records

Detailed Medical Chronology: Information captured “as it is” in the medical records without alteration of the meaning. Type of information capture (all details/zoom-out model and relevant details/zoom-in model) is as per the demands of the case which will be elaborated under the ‘Specific Instructions’

Reviewer’s Comments:Comments on contradicting information and misinterpretations in the medical records, illegible handwritten notes, missing records, clarifications needed etc. are given in italics and red font color and will appear as * Reviewer’s Comment

Illegible Dates: Illegible and missing dates are presented as “00/00/0000”(mm/dd/yyyy format)

Illegible Notes: Illegible handwritten notes are left as a blank space “_____” with a note as “Illegible Notes” in the heading of the particular consultation/report.

Specific Instructions: This chronology focuses on the admission for hip surgery status post fall on 03/25/YYYY, CT

cervical spine findings, functional status, rehab stay (04/08/YYYY-05/14/YYYY), assessment of strength and weakness of the extremities, patient’s complaints of pain and suffering, hospitalization for generalized weakness and bilateral paresthesia (11/04/YYYY to 11/09/YYYY)till diagnosis of cord compression at ABCD Health Inc during the 11/12/YYYY to 11/18/YYYY hospitalization

From 03/25/YYYY-11/18/YYYY, routine nurse notes and flow sheets have not been included. Only significant nurse notes pertaining to case focus have been included. Repetitive details are not included

From minimum data sets, only the functional status and continence have been included Only significant diagnostic studies have been included in detail. Other diagnostic studies that are

not pertaining to case focus are not included Only general, neurological and musculoskeletal examinations have been included from the office

visits From damage period hospitalization (12/03/YYYY-12/09/YYYY), only admission and discharge

summary have been included As there are many neurological assessments from 11/12/YYYY-11/18/YYYY hospitalization, these

assessments have been included separately in excel sheet aXXXX with the time for ease of reference

Visits for other medical conditions have been included in brief with reason for visit, assessment and plan for reference

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Facility name is included in the beginning and not repeated in the provider column Snapshot of the provider signature is included if provider name is not available Snapshot of the CT images has been included for reference

Missing Medical Records:

What Records/Bills are Needed

Hospital/Medical Provider

Date/Time Period

Why we need the records/bills?

Is Record Missing Confirmatory or Probable?

Hint/Clue that records are missing

Office visits and hospitalization for pain and other related complications

ABCD County Hospital

05/25/YYYY-03/15/YYYY

We need to know whether the patient had any complications during this time period.

Confirmatory There is an admission record on 08/03/YYYY, in which the previous admit date is given as 06/16/YYYY(Ref: ABC 00229)

Office visits and hospitalization for pain and other related complications prior to death

03/17/YYYY- till patient’s death on 02/25/YYYY

Will be easy to establish causation between the quadriplegia - inability to take food - chances of aspiration - lung infection - pneumonia – death

Death certificate

Brief Summary/Flow of Events

XYZ Regional Medical Center03/25/YYYY to 04/08/YYYY: Admitted to hospital for hip fracture status post fall - CT cervical spine taken on 03/25/YYYY showed severe bony canal stenosis at C3 level and neural foraminal stenosis/prominent bony canal stenosis seen at C5-6 and C6-7 - –underwent right hip repair – transferred to nursing home for inpatient rehab

XXYY – Low Country 04/08/YYYY to 05/14/YYYY: Nursing home rehab stay – incontinent of bowel and bladder –

ADL support provided - PT/OT/ST services provided

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ABCDE Medical Center05/13/YYYY-10/27/YYYY: Office visits for elevated BP, constipation, blood in stool, increased pain in neck – pain medications prescribed

XYZ Regional Medical Center11/04/YYYY to 11/09/YYYY: Hospitalization for generalized weakness and bilateral paresthesia

– suspected CVA or due to dementia - discharged with home health PT and assistance

ABCD County Hospital11/12/YYYY: Presented for generalized weakness and neck pain – transferred to ABCD/Neurology

Medical College of SDFG (ABCD Health Inc)11/12/YYYY to 11/18/YYYY: Admitted for weakness in arms and legs – Neurosurgery consulted – diagnosed with quadriplegia due to cord compression - family declined spinal cord surgery as the risk of surgical intervention overweighed potential benefits of surgical intervention - opted for pain control - discharged with home health services

ABCDE Medical Center11/24/YYYY: Office visit for constipation and paralysis

ABCD County Hospital 12/03/YYYY to 12/09/YYYY: Hospitalization for increased pain and constipation – pain

controlled with medications – discharged with Home Health PT

ABCDE Medical Center 03/31/YYYY to 05/24/YYYY: Visits for burning and itching at cath site, increased pain, lab

works, venous Doppler study

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Patient History

Past Medical History: Hypertension, status post CVA, un-described heart disease

Surgical History: Not available

Family History: Non contributory

Social History: No tobacco/alcohol use. Lived with her daughter

Allergy: No known allergies

Detailed Chronology

DATE PROVIDER OCCURRENCE/TREATMENT BATES REF

ABCDE Medical Center06/25/YYYY

Thomas XXXX, M.D.

Visit for Monilia infection: She has had CVA with right-sided weakness and walks with a walker. She says she is continent.

Treatment; We will treat her with Mycolog cream and continue her other regular medication.

Xxxx & XXXX records 003-004

03/25/YYYY

Provider signature not available

Office visit: (Illegible Notes)Temp: 97.1, BP: 150/80, P 76.No BP medications today – to get lab work. Call her ___ report

Xxxx & XXXX records 005

XYZ Regional Medical Center (03/25/YYYY-04/08/YYYY)*Reviewer's comments: During this hospitalization for hip surgery, daily progress notes and nurse notes are not available. Other available records

such as admission and discharge summary, consultation report, CT scan of cervical spine have been summarized in detail.

03/25/YYYY

XXXXX, M.D., FACP

History and Physical:History of present illness: Patient with right sided hemiparesis, who fell at home yesterday and sustained a subtrochanteric fracture of the right hip. Patient will be admitted to the hospital for hip repair.

Physical examination:General exam: Patient is awake, alert, and oriented; not in acute distress. There is mild right facial droop.Vital Signs: Blood pressure is 161/95, respirations 20, temperature 98.7, pulse 65, respirations 18.HEENT: Mucosa moist.Lungs: Clear to auscultation.Heart: Regular in rhythm and rate, S1 and S2.Abdomen: Benign.Extremities: Lower extremities have no cyanosis and no edema. There is significant tenderness of the right hip with some valgus deformity.

XYZ Regional 005-006

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Admission laboratory data: White count 9.3, hemoglobin 12.3, hematocrit 36.3, platelet count 170. LFT’s are within normal range. Sodium is 143, potassium 3.2, chloride 105, CO2 32, BUN 10, creatinine 0.8. Coagulation - PT 18.1, INR 1.3, PTT 29.

Assessment: 1. Status Post Fall2. Right Hip Subtrochanteric Fracture3. History of Hypertension4. Status Post CVA

Plan: Patient is to be admitted to the hospital for immobilization,

followed by open reduction and internal fixation by Dr. XXXXX. At this point, patient will be given a couple of doses of DVT prophylaxis, low molecular weight Heparin. She will be prepared to undergo surgery, March 27, YYYY. A _________ (Missing word in record itself) traction will be placed.

Hypertension - Will continue Vasotec. She will be started on Atenolol to decrease preop mortality, 25 mg a day and will hold off on the HCTZ (Hydrochlorothiazide).

GI prophylaxis and DVT prophylaxis.03/25/YYYY

ABCD

XXXX, M.D.

Preliminary radiology report of CT cervical spine: Clinical history: Fall. Complains of fracture of cervical spineTechnique: Axial and coronal and sagittal reformatted images were submitted.

Axial images: The exam is limited due to positioning, and technique/field of view. There is marked diffuse osteopenia.

There is no evidence of fracture. The vertebral bodies and posterior elements are intact. Punctate calcifications are noted in the dorsal spinal canal at the C4-5 level aXXXX the lamina bilaterally.There is a 1.2 x 0.6 cm hyperdensity in the left dorsal spinal canal at the C3-4 level with severe canal stenosis. There is calcified disc osteophyte complex bulge, probable left lateral herniation and uncovertebral hypertrophy and severe bilateral foraminal narrowing. There is severe disc space narrowing and uncovertebral hypertrophy at the C5-6 and C6-7 level with severe bilateral foraminal narrowing and severe C6-7 canal stenosis. There is evidence of chronic right sphenoid sinusitis.

Coronal and sagittal images: The patient is rotated. There is reversal of the normal lordosis, due to positioning, pain or spasm. Alignment is anatomic. The interspaces are intact. There is no evidence of fracture.

Impression:No evidence of fracture. 1.2 x 0.6 cm hyperdensity in the left dorsal spinal canal al the C3-4 level, likely residual contrast. Probable left lateral

9103-A-001-002

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herniation. Severe bilateral foraminal narrowing and severe canal stenosis. C5-6 and C6-7 severe bilateral foraminal narrowing and severe C6-7 canal stenosis. Chronic right sphenoid sinusitis. Remainder of findings as described aboveComparison with a prior exam is recommended.

*Reviewer's comments: Snapshots of the CT cervical spine are included for reference.

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*MD comments: Cervical stenosis noted.03/25/YYYY

Edward XXXX, III, M.D.

CT cervical spine reviewed by Edward XXXX, M.D.:Clinical indications: 81 year old patient who fell. Insufficient plain films for evaluation.

CT scan of the cervical spine is performed. Direct axial helical plus sagittal and coronal reconstructed images are reviewed. No fracture or dislocation seen. Diffuse osteopenia. Multilevel degenerative disc space narrowing seen specifically at C3-4 and C5 through C7 with posterior spur formation at each level. There is severe bony canal stenosis at the C3 level aXXXX with neural foramina stenosis. There is a 12 x 6 mm oval shaped hyperdensity seen in the left posterior aspect of the spinal canal at the C3-4 level likely representing prior contrast material. Prominent bony canal stenosis seen at C5-6 and C6-7 with bilateral foraminal narrowing as well.

Impression: No fracture. Chronic features as described.

XYZ Regional 0024

03/26/YYYY

Jeffrey XXXXX, M.D.

Orthopedic consultation report:Reason for consultation: Patient had fallen in her home after having lost her balance. She is noted to have a peritrochanteric/subtrochanteric fracture of the right hip and was admitted

Physical exam: Patient with external rotation deformity of the right lower extremity. She has no other complaints of pain elsewhere.

Recommendations: She is a candidate for intermedullary hip screw XXXX type rod with probable distal locking screw. Tentative arrangements will be made for the above later this afternoon. Risks, procedures and prognosis explained.


03/27/YYYY

Jeffrey XXXXX, M.D.

Procedure report:Preoperative and postoperative diagnosis: Subtrochanteric fracture, right hip

Procedure: Open reduction and internal fixation with intramedullary hip screw (Gamma-3 nail)


03/30/YYYY

Provider name and signature not available

Physical therapy evaluation: Prior level of functioning: Ambulated with walker in home

Current level of functioning: Maximum assistance

Physical therapy diagnosis: Difficulty walking

Subjective: Patient feels much better. Complains right hip pain which she is unable to quantify.

Mobility and transfers: Bed: Moderately mild 4.0Chair: Severe 1.0


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Locomotion: Walk, level: Severe 1.0

State of observation: Bed mobility with moderate assistance, bed to chair with maximum assistance standing pivot. No Weight Bearing (NWB) right. Did not attempt ambulation 2 to patient. Not following instructions with walker.

Strength/motor: Right Lower Extremity (UE) grossly 3-/5Range of Motion (ROM): Right lower extremity Within Functional Limits (WFL)

Treatment plan: Active ROM, therapeutic exercise, transfer and gait training.

Assistive devices: Walker

Short term treatment goals: Home exercise program. Stand by Assist (SBA) with bed mobility. Patient will ambulate 10 feet with Roller Walker (RW) NWB – Toe Touch Weight Bearing (TTWB) right with MOD

XXXX term treatment goals: Patient will continue inpatient rehab to facilitate return to home

04/08/YYYY

XXXXX, M.D., FACP

Discharge summary:Discharge diagnosis: 1. Status Post Pall2. Right Hip Peritrochanteric/Subtrochanteric Fracture3. Intestinal Ileus4. Left Sided Colitis5. Anemia6. Coagulopathy Secondary to Anticoagulation with Coumadin7. Hypertension8. Hypophosphatemia9. Heme Positive Stools10. Klebsiella Pneumoniae Urinary Tract Infection11. Status Post CVA with right sided hemiparesis

Procedures: Open reduction and internal fixation of right hip fracture CT scan of abdomen/CT urogram, transfusion of packed red blood cells

Physical examination:General exam: Patient is awake, alert, and oriented; not in acute distress. There is mild right facial droop.Vital Signs: Blood pressure is 161/95, respirations 20, temperature 98.7, pulse 65, respirations 18.HEENT: Mucosa moist.Lungs: Clear to auscultation.Heart: Regular in rhythm and rate, S1 and S2.Abdomen: Benign.Extremities: Lower extremities have no cyanosis and no edema. There is


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significant tenderness of the right hip with some valgus deformity.

Admission laboratory data: White count 9.3, hemoglobin 12.3, hematocrit 36.3, platelet count 170. LFT’s are within normal range. Sodium is 143, potassium 3.2, chloride 105, CO2 32, BUN 10, creatinine 0.8. Coagulation - PT 18.1, INR 1.3, PTT 29.

Current laboratory data: Hemoglobin is 9.1, white count 12.4, hematocrit 25.9, platelet count 217. Electrolytes - sodium 134, potassium 3.4, chloride 109, CO2 23, BUN 6, creatinine 0.5.

Hospital course: The patient was admitted to the hospital. She underwent right hip repair with open reduction and internal fixation. Patient tolerated the procedure. In the postop period the patient developed a GI bleed, associated with an increased INR secondary to Coumadin and Lovenox therapy. She was admitted to the intensive care unit and was transfused packed red blood cells. She developed an ileus where an NG tube was placed and she was connected to intermittent suction. Symptoms gradually improved. Patient was evaluated by Dr. XXXX who gradually increased her diet.

During the course of hospitalization, patient had no remarkable complaints other than difficulty holding food down. Eventually patient’s ileus resolved. Patient was found to have a Klebsiella urinary tract infection. She was started on peroral antibiotics. She was afebrile, tolerating diet, and having regular bowel movements. She was found to have questionable colitis in the left descending colon. Dr. XXXX advanced her diet and patient has been afebrile, pain free, and has been decided to be transferred to Heritage Nursing Home of the Low Country for inpatient rehab. She will be transferred today to the care of Dr. Michael XXXX.

Medications on discharge: Coumadin 2.5 mg peroral every night. (PT/INR have to be

monitored at least every other day.) Levaquin 250 mg for 5 more days Reglan 10 mg peroral every 8 hours prn Tylenol 650 mg peroral every 4 hours prn pain Enalapril 10 mg peroral everyday

XXYY – Low Country (04/08/YYYY-05/14/YYYY)04/08/YYYY

Nursing admission assessment: Diagnosis: CVA/status post fall

Neurosensory/cognitive: Person, place, time

Elimination: Continent of bowel and bladder.

Musculoskeletal: Movement of extremities: Voluntary. Unable to move right.

Heritage records 0093-0095

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Circulatory/respiratory: Normal, regular heart rate and respiratory rate, warm extremities

Pain: No complaints04/08/YYYY-05/14/YYYY

Nursing Notes/Records:During this rehab stay, patient was incontinent of bowel and bladder. OT/PT/ST services were provided for rehab /mobility. Feeds self with tray set up. Able to voice needs. Out of bed daily for PT/OT. Total care with ADL.

*Reviewer's comments: The daily nurse notes during this time period have been reviewed and presented briefly to know the routine nursing care provided. If needed can be elaborated.


04/15/YYYY

Minimum Data Set (MDS):Functional status: (Ref: Heritage records 0030)ADL self performance: ADL activity did not occur: Walk in room, walk in corridorExtensive assistance: Bed mobility, transfer, locomotion on unit and off unit, dressing, personal hygiene, Toilet useIndependent: EatingPhysical help in part of bathing activity: Bathing

Functional limitation in range of motion: Arm, hand, leg, foot: Limitation in one side

ADL support provided: ADL activity did not occur: Walk in room, walk in corridorOne person physical assist: Bed mobility, transfer, locomotion on unit and off unit, dressing, personal hygiene, toilet use, bathingSet up help only: Eating

Continence: Incontinent of bowel and bladder, multiple daily episodes


04/18/YYYY

Minimum Data Set (MDS):Functional status: (Ref: Heritage records 0019)ADL self performance: ADL activity did not occur: Walk in room, walk in corridorLimited assistance: Bed mobilityExtensive assistance: Transfer, locomotion on unit and off unit, dressing, personal hygiene, Toilet useIndependent: EatingPhysical help in part of bathing activity: Bathing


ADL support provided: ADL activity did not occur: Walk in room, walk in corridorOne person physical assist: Bed mobility, transfer, locomotion on unit and


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off unit, dressing, personal hygiene, toilet useSet up help only: Eating

Continence: Incontinent of bowel and bladder, multiple daily episodes05/13/YYYY

Thomas XXXX, M.D.

Follow-up visit: Patient comes back in today; she fell and broke her right hip. She had it pinned and has been in the nursing home and is getting ready to go home. She is still on Coumadin and her other medicine is on the chart. She is doing fairly well. She needs some equipment at home and I have written this. I have written her medication. She will check with her surgeon to see how XXXX he wants her on the Coumadin.

Impression: 1. Hypertension well controlled2. Hyperlipemia3. History of cardiovascular accident with right-side weakness.4. Gastroesophageal reflux disease5. Recovering from fracture of right hip6. Also has a small decubiti on the hip

Treatment: We will follow aXXXX with Home Health and help in any way that we can.


05/14/YYYY

Minimum Data Set (MDS):

Functional status: (Ref: Heritage records 009)ADL self performance: ADL activity did not occur: Walk in room, walk in corridorExtensive assistance: Bed mobility, transfer, locomotion on unit and off unit, dressing, personal hygieneTotal dependence: Toilet useIndependent: EatingPhysical help in part of bathing activity: Bathing


ADL support provided: ADL activity did not occur: Walk in room, walk in corridorOne person physical assist: Bed mobility, transfer, locomotion on unit and off unit, dressing, personal hygiene, toilet useSet up only: Eating

Continence: Incontinent of bowel and bladder, multiple daily episodes


05/14/YYYY

Discharge summary:Rehabilitation services provided: Status post therapy for dysphagia x weekly. PT for exercise, activity and gait training. OT for self care, then activity, then exercise.

Heritage records 001

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Outstanding events: Resident had UTI, which antibiotic therapy was started prior to discharge. Resident also had periods of increased right hip pain. Resident was medication with relief.

Significant changes in condition: Resident had little progress with PT was able to stand but could not pivot right foot. No ambulation noted. Speech therapy: resident was able to tolerate diet without aspiration. Required moderate assist with scooting to edge of bed, little progress

Final diagnosis/condition upon discharge: Resident discharged with daughter back home. To continue with home health care and PT.


Thomas XXXX, M.D.

Visit for elevated BP: Patient comes in today; she has been a patient of ours for a number of years. She was in the nursing home and then they took her home. She had her hip pinned and she is having physical therapy at home. The therapist has noted that her blood pressure is elevated before he starts. The daughters say that she does not particularly like the therapy because it hurts. They doubled her Lisinopril 20/12.5 to 2 a day on Monday and she got where she could not sit up in the chair and was staring a lot. She comes back in today; they went back to the 1 Lisinopril a day.

Physical exam:Chest: Has equal expansionLungs: Fairly clear to palpation and auscultationHeart: Her blood pressure is 130/80 and her pulse is 79. Her heart is a sinus rhythm.Extremities: She has a right hemiplegia and is doing some exercise. Impression: 1. Hypertensive cardiovascular disease, fairly well controlled2. Possibly elevated diastolic pressure because of anxiety3. Hyperlipemia4. Right hemiplegia5. Gastroesophageal reflux disease6. Recovering from fracture of her right hip7. Believe she has a genitourinary tract infection; we could not get urine

Treatment: I put her on Cipro 500 mg twice daily for 6 days. We will recheck her urine later. I told the family to get a blood pressure cuff and check her pressure and we would see if it was related to anxiety or something else and they understand. Return as necessary.


09/10/YYYY

Visit for blood in stool, dysuria and vaginal bleeding:Complains of blood in stool x 1, yesterday also complains of dysuria and pain right finger also vaginal bleeding x 3 weeks

Assessment/plan: UTI - Septra DS twice daily


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Constipation - Onychomycoses – right fifth finger – Nystatin cream twice daily

10/27/YYYY

Visit for neck pain: Complains of pain in neck x 1 day – especially hurts when she moves back

Exam: Decreased ROM cervical spine secondary to pain

Assessment: Acute neck pain.

Plan: Toradol Solumedrol Nubain Medrol dose pak Lorcet 5/500 #40 every 4-6 hours Tramadol


XYZ Regional Medical Center (11/04/YYYY-11/09/YYYY)11/04/YYYY

Emergency nursing record:Arrival mode: EMSChief complaint: Complains of neck – muscle spasms, cannot feel extremities, elevated BP, headache, dizziness, weakness, neck discomfort.

Vitals – BP: 167/83, P: 75, RR: 20, Temp: 97%

Initial assessment: General appearance: No acute distress, alert, neat, cleanFunctional/nutritional assessment: AssistedRespiratory: No respiratory distressCVS: Regular rate, pulses strongNeuro: Oriented x 2, weakness both hands cannot grasp, feeling to both legs, wiggle toes right side not left, left pupil pin point and non reactive

@0005 hrs: Labs drawn

Notes: @2203 hrs: Came by EMS. Patient alert and oriented x 2 – both arm weal and unable to grasp – neuro checks completed – EKG and chest X-ray done

@0005 hrs: Left for CT in stable condition

@0015 hrs: Back from CT in stable condition

@0020 hrs: In and out cath and specimen sent to lab

@0145 hrs: Anxious – agitated

@0205 hrs: Left ER in stable condition

ABC 007-009

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11/04/YYYY

Emergency Department History and Physical: Time seen: 2320 hrsChief complaint: Complains of neck pain – 6 PM. Unable to move arm and legs.

History of present illness: @ 8 PM gave pain medications

Positive for blurred vision, no dysphagia, no fever/shills/night sweats, no pain/dizziness

Other problems: OA, Klebsiella UTI, hypertension

Nursing assessment reviewed.

Physical exam: Alert, no acute distressExtremities: Non-tender, no pedal edema. Gaze to left slow to follow commandsNeuro: Tongue deviat tions to left, left facial droop, left pupil pinpoint. Toes upgoing on the right side and no response on the left side. Wiggles toes on right and moves hand on right, Touch intact.

*Reviewer's comments: We note that the word paralysis is striked in this record and also some details are not visible. Medical decision making: X-ray, CT scan

Discussed with Dr. XXXXOld records reviewed

Clinical impression: Left sided weakness – rule out CVA, UTI, Hypokalemia, mildly increased ALT, immobility

ABC 008-009

11/04/YYYY

Edward XXXX, M.D.

CT head and cervical spine: Clinical indications: 81 year old patient unable to move left side.

Direct axial unenhanced CT scan of the head is performed from the foramen magnum to the vertex at contiguous levels without IV contrast. Advanced diffuse brain volume loss is seen with appropriate dilatation of the CSF containing spaces. Minor periventricular hypodensity is seen consistent with chronic ischemic change. There is advanced patchy periventricular hypoattenuation. No acute ischemia, mass or mass effect, or intracranial hemorrhage is evident. No unusual intracranial calcifications are seen. No vascular abnormality is seen on this unenhanced study. The calvarium and skull base are normally defined. The sinuses are clear.No acute arterial distribution infarction seen. I see no change from prior head CT exam 4/1/YYYY.


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Impression: Advanced diffuse atrophy with chronic ischemic changes. No acute abnormality identified.

Unenhanced CT scan of the neck is performed with direct axial helical plus sagittal and coronal reconstructed images. No fracture or dislocation. Degenerative disc changes at multiple levels. Spinal canal width at C3/4 measures no more than about 8 mm. Clinical assessment needed.

Impression: No fracture or dislocation. Spinal canal narrowing at C3-4 which may be responsible for cord compression at that level as described. Clinical assessment needed.

11/05/YYYY

Labs:Collected: 11/04/YYYYNormal: Serum creatinine (0.80), serum sodium (137)Low: Serum potassium (3.1)

XYZ Regional 0032

11/05/YYYY

Cindy XXXX, LPN

June XXXX, LPN

Nurse notes: @0200 hrs: Patient admitted to room from ER via stretcher to DR. XXXX with diagnosis of left sided weakness, rule out CVA and UTI in stable condition. Complains of neck pain but refuses pain medication.

@0400 hrs: Patient sleeping at this time. Moved right foot when touched but on previous check states could not move right foot. Grips remain weak. Has been medicated for complaints of pain and nausea.

ABC 00141-00142

11/05/YYYY

Edward XXXX, M.D.

Doppler carotid artery ultrasound:Clinical indication: CVA

Impression: We were never able to successfully visualize the distal portion of the right internal carotid artery which raises the possibility of possible occlusion. No other hemodynamically significant carotid artery abnormality identified. The significance of the presence of plaque formation should be correlated with current patient symptomatology.

XYZ Regional 0041-0042, ABC 0052

11/05/YYYY

ABCD

David XXXX, M.D.

CT head and cervical spine: History: Unable to move left side

Findings: No acute intracranial hemorrhage or mass. There is diffuse global atrophy. No abnormal extra-axial fluid collections are identified. No midline shift or herniation. There are advanced small vessel ischemic changes in the periventricular white matter. No evidence of an acute cortical infarct. No acute bony abnormality. There is no evidence of acute cervical fracture. There is no evidence of malalignment or dislocation. There are marked degenerative changes present.

Impression: No acute intracranial abnormality. Changes of an acute infarct may not be visible on CT for up to 24 to 48 hours. If this is of clinical concern, a follow up examination and/or MRI may be of benefit. No acute bony abnormality.

9103-A-003-004, 9103-A-011

11/05/YYYY

Physical therapy notes: Visit this morning – For physical therapy. PT compliant. But unable to

ABC 0030

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perform active movements – upper and lower extremities bilateral. Maximum assistance x 1 supine to sit posture. Status post “old” hip fracture.Treatment: Home health physical therapy, had been working with assistance. We will mobilize from bed following clarification of MRI result – to be done today.

11/05/YYYY

David XXXX, M.D.

MRI of brain and MRA of head:Clinical history: Altered mental status, weakness, question CVA.

Opinion: There is advanced cerebral atrophy predominantly affecting the temporal lobes. Mild ventriculomegaly is present somewhat disproportionate to the degree of atrophy present. There is moderately extensive diffuse white matter disease. There is no evidence of an acute ischemic event.

Intracranial angiogram:

Opinion: High-grade stenosis of the right posterior cerebral artery indicative of intracranial atherosclerotic disease. No other specific intracranial vascular abnormalities are evident.


11/05/YYYY

Edward XXXX, M.D.

History and physical:Chief complaint: Generalized weakness.

History of present illness: Patient presents to XYZ ER secondary to complaints of generalized weakness and what appears to be some bilateral paresthesia/paralysis. The patient’s family noticed that patient complained of some neck and muscle spasms the night of admission and the patient appeared to collapse on the bed. EMS was activated and patient was transported to XYZ Regional Medical Center. They denied any loss of consciousness but patient had complained of some headache and some dizziness and as stated did complain of profound weakness and neck discomfort. On examination patient was without any voluntary limb movement except for head and neck.

Medications on admission: Include the following: Plavix 75 mg daily, Lisinopril 20 mg daily, Tramadol 50 mg every 6 hours prn, Lortab 5 mg every 4-6 hours prn

Review of systems: Hard to obtain secondary to patient’s cooperation.

Physical examination:Vital signs: Blood pressure 167/83, pulse 75, respirations 20, temperature 97.3, saturation 97% on room air.General: Well nourished, slightly built female laying supine in bed but in no acute distress.HEENT: Head is normocephalic, atraumatic. Pupils are equally reactive to light and accommodation. Extraocular movements are intact. No scleral icterus or infection. Oral cavity is clear.Neck: Supple without JVD or adenopathy.


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Lungs: Clear to auscultation bilaterally.CV: Regular rate and rhythm. No murmurs, rubs or gallops.Abdomen: Soft, nontender, nondistended with normal abdominal bowel sounds present.GU/Rectal: Deferred.Extremities: Without clubbing, cyanosis or edema with +2 pulses bilaterally in both upper and lower extremities noted.Neuro: Patient is alert and oriented to person, somewhat to place as she knows that she is in a hospital. Cranial nerves II-XII are grossly intact. There is generalized flaccidity is movement in both upper and lower extremities bilaterally though I have noted spontaneous movements in patient’s hands and fingers and toes bilaterally. Noticed involuntary response to painful stimulus in distal portions of the upper and lower extremities. Patient has an equivocal Babinski on examination. No tongue deviation on head/neck exam. Normal movements of strap muscles. During swallowing evaluation there were no indications of any aspiration noted.

Assessment and plan:1. Questionable CVA: The clinical findings are not supported by labs

and radiological studies. There is no real evidence of any acute cerebral vascular event occurring here. In talking with the family, patient for a number of months has required the assistance of offspring to do daily ADL’s and in my opinion this kind of seems that this is a continued progression of a chronic problem. In looking at the MRI showing global atrophy of the cerebral cortex I am inclined to believe that patient is in the latter stages of clinical type senility. We will treat this as a possible event. Will get a PT evaluation. Although the patient’s family is kind of not inclined to commit the patient to a rehab facility for extensive rehabilitation. Other than this I really don’t have a whole lot more to offer.

2. Hypertension: Continue patient’s antihypertensive meds and monitor blood pressure.

We will get a PT evaluation in the morning and decide just how we will proceed from there.

11/05/YYYY

Physical therapy initial evaluation: Medical diagnosis/history: Left sided weakness

Prior level of functioning: Minimum assistance x 1, ambulate with Roller Walker 25-50’ at home

Current level of functioning: Maximum assistance x 1

Physical therapy diagnosis: Muscle paresis Bilateral Upper Extremities (BUE) and Bilateral Lower Extremities (BLEs)

Subjective: History of left sided weakness

Mobility and transfers:

ABC 0031-0032

17 of 40



Bed: Severe 1.0Wheel chair, chair, commode: Not tested

Statement of observation: Bedbound at time of evaluation. IV left arm. Considering indwelling catheter. Flaccid upper and lower extremities bilateral. Decreased trunk (abdominals) synergy.

Strength/motor: Unable to elicit/initiate movement; 2-/5 MMT gradeROM: Tongue thrust and lateral movement of mastication/hyoids are affected

Treatment plan: Bed mobility, passive ROM, active ROM, balance retraining, transfer training, therapeutic exercise

Weight bearing status: Full Weight Bearing (FWB) BLEs

Assistive devices: Wheel chairFrequency: Everyday Mon-Fri

Short term treatment goals: Enhance supine to sitting at EOB and bed mobility. Transfers bed to wheelchair with moderate to maximum assistance x 1

XXXX term treatment goals: Transfer o PAC facility for XXXX term rehab for all disciplines (PT, OT, ST)

11/05/YYYY

Cindy XXXX, LPN

Miriam XXXX, RN

June XXXX, LPN

Neurological assessment:

Extremities movements: Time Left Upper

ExtremityRight Upper Extremity

Left Lower Extremity

Right Lower Extremity

0200 Weak Weak Weak No voluntary movement

0400 Weak Weak Weak Weak0600 Weak Weak Weak Weak0800 No voluntary

movementNo voluntary movement

No voluntary movement


1400 No voluntary movement












Grasp:Time Left hand Right hand Hand grasp0200 Weak Weak Unequal0400 Weak Weak Unequal0600 Weak Weak Unequal

ABC 0087-0098

18 of 40



0800 Absent Absent Equal1400 Absent Absent Equal1800 Absent Absent Equal2200 Absent Absent Equal

Musculoskeletal assessment: Joint movement: Limited range of motionLocation: All extremities

11/05/YYYY

Labs:Collected: 11/05/YYYYNormal: Serum creatinine (0.70), serum sodium (135)Low: Serum potassium (3.4)

XYZ Regional 0031

11/06/YYYY

IM progress notes: Subjective: No distress this morning. Objective: No change from previous exam

Assessment/plan: CVA/Dementia – Patient to evaluate. Would possibly benefit from

short term rehab Hypertension – Continue BP medications

ABC 0030

11/06/YYYY

June XXXX, LPN

Allison XXXX, RN

Nurse notes: @0920 hrs: No voluntary movement in extremities at this time.

@1500 hrs: Patient picked both arms up and stretched them out at the same time. No complaints of pain voiced.

@2255 hrs: Complains of pain, given pain medication per medication order.

ABC 00143-00144

11/06/YYYY

Linda XXXX, CNA

Janice XXXX, RN

June XXXX, LPN

Allison XXXX, RN


















1400 Limited Limited No voluntary movement










Grasp:Time Left hand Right hand Hand grasp

ABC 0098-00107

19 of 40



0200 Absent Absent Equal0600 Absent Absent Equal0920 Absent Absent Equal1400 Absent Absent Equal1800 Absent Absent Equal2000 Absent Absent -

Musculoskeletal assessment: Joint movement: Limited range of motionLocation: All extremities

11/06/YYYY

Kristie XXXX, PTA

Physical therapy notes: Patient was seen for continued PT treatment at bedside secondary to weakness. Patient presented left side lying upon approach. Patient received PROM to all extremities, all joints and planes as tolerated by patient. Worked on bed mobility and trunk flexibility with total assistance needed. Patient transferred supine to sit with total assistance x 1. Patient sat at Edge of Bed (EOB) with maximum assistance x 1 for ~5 minutes. Patient is unable to correct or maintain her posture and balance without assistance. Assessment: Patient tolerated treatment fair. Patient is total assistance at this time. Appears that she will need extensive rehab services.Plan: Will continue with inpatient services as per POC.

ABC 00144

11/07/YYYY

IM progress notes: Subjective: No discomfort at present Objective: Neck-supple, extremities – no cyanosis/clubbing/edema

Assessment/plan: CVA/Dementia – PT in place. No impairment at present. Hypertension – BP reasonable UTI – Levaquin 500 mg every day. Blood tinged urine, may be

secondary to foley trauma Hypokalemia – replace potassium

ABC 0033

11/07/YYYY

Amber XXXX, RN

Nurse notes: @0750 hrs: Bilateral hand grips weak but equal.

@1300 hrs: Warm compress to patient neck per family’s request.

@1320 hrs: Complains of neck pain – medicated with Ultram 50 mg peroral.

ABC 00145

11/07/YYYY

Allison XXXX, RN

Amber XXXX, RN

Teresa XXXX, RN














ABC 00107-00117

20 of 40



1000 Weak Weak Weak Weak1400 Weak Weak Weak Weak1800 Weak Weak Weak Weak2200 No voluntary

movementNo voluntary movement



Grasp:Time Left hand Right hand Hand grasp0000 Absent Absent -0400 Absent Absent -1000 Weak Weak Equal1400 Weak Weak Equal1800 Weak Weak Equal2200 Absent Absent -

Musculoskeletal assessment: Joint movement: Limited range of motionLocation: Generalized weakness

11/08/YYYY

IM progress notes: Subjective: Resting comfortably at present Objective: No change from previous exam

Assessment/plan: CVA/Dementia – NO change at present Hypertension – Continue medications UTI – Continue IV antibiotics Hypo potassium - Normalized

ABC 0033

11/08/YYYY

Allison XXXX, RN

Nurse notes: @0538 hrs: Patient rested throughout the night. Complains of pain, gave pain medication per medication order.

ABC 00146

11/08/YYYY

Allison XXXX, RN

Abby XXXX, RN






























ABC 00117-00125

21 of 40



Grasp:Time Left hand Right hand Hand grasp0200 Absent Absent -0600 Absent Absent -0800 Absent Absent -1200 Absent Absent Equal1600 Absent Absent Equal2000 Absent Absent Equal


11/09/YYYY

Allison XXXX, RN

Nurse notes:Patient rested throughout the night. Family at bedside. No needs voiced.

ABC 00147

11/09/YYYY

Allison XXXX, RN

Amber XXXX, RN














Grasp:Time Left hand Right hand Hand grasp0000 Absent Absent -0400 Absent Absent Equal


ABC 00125-00131

11/09/YYYY

Labs:Collected: 11/09/YYYYNormal: Serum creatinine (0.60), serum potassium (4.0), serum sodium (138)

XYZ Regional 0030

11/09/YYYY

Edward XXXX, M.D.

Discharge summary:Provisional diagnosis:

1. Questionable CVA2. Hypertension

Discharge diagnosis: 1. Questionable CVA/progressing dementia2. Hypertension3. Urinary tract infection4. Hypokalemia

Physical examination: Patient was afebrile with stable vitals. Head was

ABC 0010-0012, 00149-00150

22 of 40



normocephalic atraumatic with equal pupils. Neck was supple without JVD. Lungs were clear to auscultation. Cardiovascular regular rate and rhythm. Abdomen was benign. Extremities without clubbing, cyanosis or edema with +2 pulses bilaterally. Neurological exam showed cranial nerves II-XI grossly intact with reduced movement in both upper and lower extremities bilaterally. On examination during course of hospitalization, I did notice that patient did spontaneously move 1 or 2 legs when examination was directed elsewhere. One of the nurses had noted that patient raised her arms to her a couple of days.

Hospital course: 1. Questionable CVA/progressive dementia: Clinical findings

supported the radiological findings and we are of opinion that this is continuing dementia that was already in play. With spontaneous movements of patient’s legs and arms, we rather doubt that the patient experienced an actual CVA, but I think patient is experiencing a certain amount of wasting secondary to the dementia in which case I really believe that patient is kind of “giving up” since she was heard speaking to the ER about just wanting to die. Maybe a Long-term antidepressant might help patient in this particular situation. We will leave it up to Dr. XXXX, her outpatient doctor to consider this.

2. Hypertension: Patient’s blood pressure was maintained at a reasonable range during course of hospitalization

3. Hypokalemia: Patient was placed on potassium replacement and her potassium normalized. May need to continue this as an outpatient.

Disposition: Discussed with family and decided that patient will go home and will have home health PT and assistance. Will need to have a follow up with her primary care physician at first available time.

Discharge instructions: Follow-up appointment with: Dr. XXXX on 11/12/YYYY

ABCD County Hospital11/12/YYYY

Emergency Room record:Physician documentation: Arrival time: 1320 hrsVia EMSTriage/medical screening: Weakness since last Wednesday. Getting worse. Having difficulty eating. Poor intake since Monday.

Chief complaint: Diffuse weakness, right neck pain and decreased peroral intake. Duration: 1 week

History of present illness: Generalized weakness, right neck pain x 1 week

Review of systems: Severe neck pain, weakness in arms and legsAll systems reviewed and negative

ACH 003 -005

23 of 40



Physical examination: Head: Normal, atraumaticRespiratory: CTACardiovascular: Regular Rate RhythmExtremities: No clubbing/Cyanosis/EdemaNeurological: Decreased movement/weakness distal to neck

Given Dilaudid IV for right neck pain. Given Rocephin.

Dr. XXXX – 10/27/YYYY primary care MD – no history of __ symptoms.Discussed patient with another MD: Dr. XXXX @1400 – Possible progressive dementia (No significant lesion seen on scan)

Dr. ABCD/ortho/spine deferred to Neurology ABCD. DR. XXXX – Neurology accepted @ 1520 hrs for transfer

Diagnosis: Diffuse weakness x 1 week, bilateral upper extremity and lower

extremity C3/4 spinal canal stenosis UTI

Transfer to neurology/ABCD. Dr. XXXX

Disposition: StableMedical College if SDFG Hospitals (ABCD Health Inc)

11/12/YYYY

Saima XXXX, MBBS

Neurology TMS History and Physical: Chief complaint: Bilateral arm and leg paralysis

History of present illness: Patient direct admit from ABCD County Hospital complains of inability to move arms and legs since Wednesday (11/04/YYYY), according to patient’s daughter, patient was in normal health until 4/YYYY when she fell and fractured right hip, patient received surgery at XYZ hospital and since that she has developed frequent right neck pain/shoulder pain, patient was able to ambulate via walker and perform acts and daily living until Wednesday night (11/04/YYYY) when she developed bilateral arms and leg paralysis 15 min after an episode of severe neck pain, the neck pain occurred when the patient was using the commode, daughter reports patient was alert, oriented and coherently communicating during episode and did not fall, patient was admitted that night to XYZ Hospital, head CT and MRI reportedly showed no evidence of stroke, patient was discharged home on Monday, family reports that patent still was not able to move limbs and that by Tuesday she was unable to swallow food they were feeding her, family brought patient to ABCD County Hospital for re evaluation and patient was referred here.

Review of systems: Constipation, urinary retention

ABCD 0010-0011

24 of 40



Physical examination: General: Awake, alert and oriented x 3, NAD, head Normocephalic/AtraumaticChest: Vesicular breath sounds, shallow respirations, poor inspiration excursion. CVS: S1, S2, RRR (Regular Rate Rhythm), no murmurs, very loud intensityNeuro: Patient is awake and responds to commands, speech impaired very soft voice. Patient has difficulty swallowing.PERRLA: Patient poorly follows finger at eyes, EOEM intact, fundi not viewedFacial sensation intact to light touch, asymmetric face. Hearing appropriate. Symmetrical rise in palate, good head turn and cervical range of motion, poor shoulder shrug and weak tongue movement.Positive movement in toes bilaterally, otherwise no movement below neck. Sensation intact to parallel stimuli in UE (Upper Extremity)/LE. 4+ DTRs throughout, poor rectal tone. Bloody urine from foley likely secondary to complete bladder drainage.

Assessment/plan: Patient with quadriplegia, urinary retention and poor rectal tone likely secondary to cervical spinal cord compression or spinal cord infarct.MRI of brain and cervical spine

Apply Poor feeding due to dysphagia – soft mechanical diet Poor defecation – give enema Hemorrhagic cystitis – monitor DVT prophylaxis (Heparin, SCD’s) Right neck pain – Motrin 400 mg every 8 hours

11/12/YYYY

PGY-2 Neurology note: Chief complaint: Weakness in arms and legs

History of present illness: Patient is a direct admit request for weakness arms and legs. Patient has been transferred from ABCD County Hospital. Patient was admitted there for weakness and right neck pain x 1 week. Patient was not eating. Patient collapsed in her bed last week Wednesday. Complains of generalized weakness and weakness bilateral upper extremities. No Loss of Consciousness (LOC). No headache. No Nausea/Vomiting. Patient was admitted to XYZ Regional Medical Center on 11/04/YYYY then discharged on Monday admitted to ABCD today. Patient was transferred to ABCD today. Patient is having language problem since this Monday. No vision problems. No urine/bowel problems. Can control it. No fever, chest pain or Shortness of Breath (SOB).

Physical examination: Elderly female in NAD. Awake, alertCVS: S1, S2 no M/R/G (Murmurs/Rubs/Gallops).Resp: CTA bilaterallyAbdomen: Soft, non tender, non distended, bowel sounds positiveExtremities: No clubbing, cyanosis, edema

ABCD 008- 009

25 of 40



Neuro: Awake, alert and oriented x 4Facial symmetry. Tongue midline.Strength: UE 4/5 bilateral, LE 4/5 bilateral. Sensory: UE no withdrawal t painful stimuli, LE withdraws to painful stimuliPlantar toes upgoing on right side, downgoing on left side. Sensation intact on four UE/LE

ROS: Severe neck pain, weakness arms and legs, no cough, no wheezing, chest pain, SOB, diarrhea and vomiting

CT cervical spine: No fracture or dislocation. Spinal canal narrowing at C3-4. May be responsible for cord compression

Assessment/plan: Weakness bilateral UE/LE: Possible stroke – CT/MRI. We do not

have any CD from another hospital. Only got report. Stroke work up. CT/MRI with gad. PT/OT/speech

Neck pain – pain control. MRI of neck. Continue current medications

HTN – Continue lisinopril. Frequent vital checks every hour. Frequent neuro checks

Full code11/12/YYYY

Jessica XXXXr

Nurse notes: Patient not moving extremities.

ABCD 00286

11/12/YYYY

Nestor XXXX, M.D.

CT head:Patient history: Stroke work up

Findings: There are no prior studies available For comparison. The study is suboptimal due to patient motion, particularly to evaluate the posterior fossa in this patient. There is significant calcification involving the carotids bilaterally noted. In the supratentorial compartment, there is diffuse atrophy in keeping with patient’s age with prominent sylvian cisterns bilaterally, right side more prominent than the left side that may represent an old cortical infarct. Extensive confluent hypodensity is seen within the corona radiata and centrum semiovale consistent with microvascular ischemic changes with focal hypodensity within the area of the left thalamus extending to the left corona radiata/body of the caudate nucleus consistent with old infarct. Attention to the sulcation pattern at the high convexity, there is asymmetry with the left side poorly visualized sulci. This may be artifactual. However, the possibility of an acute infarct in the left frontal cannot he excluded. There is no evidence of acute bleed. There arc no abnormal extraaxial fluid collections. The visualized sinuses and mastoids are clear.

Impression: 1. Asymmetry in the sulcation pattern at the high convexity left

frontal lobe that may artifactual versus ischemic changes/infarct in evolution

ABCD 0038-0040

26 of 40



2. Advanced atherosclerotic vascular disease with the microvascular ischemic changes and old left thalamic/corona radiata infarct. If clinically indicated, a follow up CT in 24 hours would be helpful to evaluate for any acute infarct in evolution.

11/13/YYYY

Neurology PGY 4- History and physical: Patient seen with Dr. XXXX. Patient complains of acute weakness starting 8 days ago. She was sitting on the commode when she suddenly developed severe neck pain and within 10-15 minutes she had severe weakness of both arms and legs which had been constant since. She went to XYZ Hospital in SC where she stayed until 4 days ago and was discharged after CT spine and MRI Brain which showed cervical spine stenosis C3-4. Discharged 4 days ago and hasn’t been urinating in a diaper. Today, she became so weak that she has had difficulty talking and swallowing as well.

On exam, vitals P 89, RR 16, BP 132/46, O2 99%.General: Lying in bed, NAD. Neuro: Awake, alert, answers questions quietly but mostly appropriately though sometimes appears to have poor attention, speech soft and sparse. CN: PERRL, EOMI, unable to cooperate with visual field, positive blink to threat, face movements appear symmetric, tongue midline, palate elevated. Motor: 1/5 right distal UE, 0/5 left UE, 0/5 bilateral LE with triple flexion. Sensory: Grimaces to noxious stimuli bilateral. Reflexes: 3+ throughout with crossed adductors and clonus bilateral, bilateral plantar extensor.

Impression: Patient with quadriparesis likely secondary to acute cord lesion from 8 days ago. Concerning for cord compression Vs other cord lesions/infarct, mass . Given report of negative MRI brain, difficulty speaking likely due to dehydration, poor intake, UTI, etc and not acute brain or neuromuscular issue though respiratory can be involved in high cervical lesions.

Plan: Admit to Neuro – unable to seal for NIF or FVC Urgent MRI neck – check post void residual IV fluids

ABCD 0012

11/13/YYYY

Neil XXXX, M.D.

MRI of brain:Clinical indication: An 81-year-old female with acute quadriplegia with hyperreflexia, constipation, and urinary retention.

Impression:1. Question of underlying communicating hydrocephalus. Does the patient exhibit the clinical stigmata of NPH2. Findings compatible with chronic microvascular ischemic changes and old infarcts involving the left thalamus, adjacent posterior limb of the left internal capsule and posterior left lentiform nucleus in addition to the left periventricular region adjacent to the body of the left lateral ventricle3. Diffusion images demonstrate a possible small acute/recent infarct involving the left thalamus

ABCD 0040-0042

27 of 40



4. Study is limited due to excessive patient motion degrading image quality on multiple pulse sequences, particularly the postgadolinium images

Intracranial MRA:

Impression:1. Markedly limited examination due to excessive patient motion2. Patency of the vertebrobasilar system3. Patency of the intracranial internal carotid arteries extending to the proximal Al and Ml segments. Beyond the proximal Al and Ml segments, there is inadequate visualization of the intracranial vasculature

11/13/YYYY

Neil XXXX, M.D.

MRI cervical spine:Clinical indication: An 8 1-year-old with acute quadriplegia with severe neck pain, hyperreflexia, constipation, and urinary retention. Rule out acute cord compression.

Findings: Examination is limited due to excessive patient motion on multiple pulse sequences. Nonspecific straightening of the cervical curve is seen. There is near anatomic alignment. No acute compression fracture deformity is seen. There are multilevel degenerative changes with degenerative disk disease with disk space narrowing, loss of normal T2 signal, generalized disk bulging and disk protrusions/herniations. Vertebral endplate/uncovertebral spurring is seen. Cervical canal stenosis is seen and appears most severe at C3-4, where it appears to be moderately severe with evidence of cord compression. Suspect subtle increased T2 signal within the cord at this level, which could reflect contusion and/or myelomalacia. There may be minimal enhancement of the cord in this region.

Less severe cervical canal stenosis is present at C6-7, where it appears to be mild-to-moderate in degree with mild associated cord deformity/flattening.

Suspect mild cervical canal stenosis at C2-3, eccentric to the left. I also suspect mild cervical canal stenosis at C4-5 and C5-6. Multilevel neural foraminal stenosis is suspected but difficult to quantify due to the limited nature of this examination.

Impression:1. Limited examination due to excessive patient motion degrading image quality on multiple pulse sequences2. Multilevel degenerative changes with cervical canal stenosis.3. Canal stenosis is most severe at C3-4 where it appears to be moderately severe with associated cord compression and suspicion of increased intramedullary T2 signal and possibly minimal enhancement within the cord, which could reflect contusion and/or myelomalacia.Clinical correlation is needed.4. Mild-to-moderate cervical canal stenosis with mild cord deformity at C6-75. Findings were discussed with Dr. Aryal at approximately 12:35 p.m. on November 14, YYYY

ABCD 0043-0044

28 of 40



11/13/YYYY

Speech pathology note:Subjective: Patient seen at bedside with daughter present

Objective: Speech/language and clinical swallowing evaluation completed.

Assessment: Mild oropharyngeal dysphagia. Severe dysarthria mild – moderate receptive/expressive aphasiaRecommendations:

Mechanical soft diet – ground meats/nectar thick liquids Aspiration precaution Speech/language/swallowing treatment 2-3 x weeks to address

goals in POC

ABCD 0013

11/13/YYYY

Brian XXXX

Corey XXXX, RN

Nurse notes: Patient admitted from ED via stretcher. No independent movement noted in bilateral upper and lower extremities. Patient family states patient in pain when she moves her had back in forth. Family states patient has neck pain.

ABCD 00285

11/14/YYYY

Neurosurgery note: Briefly this is a patient who presented with history of weakness/quadriplegia for 10 days that acutely began she was taken to an OH where MRI brain and CT spine and discharged 5 days later, she had acute worsening while on the commode. Taken to OH then transfer to ABCD. MRI C spine shows severe cord compression secondary to anterior and posterior stenosis at C3/4 and C1/T1

On exam, patient is 1/5 RUE, 0/5 elsewhere, DTR 4+, increased Babinski bilateral positive Hoffmans bilateral

Patient has history of stroke ~15 years prior for which she was placed on anticoagulation with Plavix. Since then, she had been walking with a cane. In 3/09 patient fell and had hip surgery. Since injury she has been ambulating with walker and assistance until this episode. Previously she could meet basic ADL’s.

Case discussed with family including possible surgical intervention with C3/4 ACDF +/- laminectomy. Risks and benefits discussed including possible of no improvement/worsening post op given the time course. Possible of bleeding also discussed due to Plavix. Family will confer and discuss decision about surgical intervention in the morning.

ABCD 0015

11/14/YYYY

Saima XXXX, MBBS

Neurology TMS note: Subjective: No acute event overnight; still complains of right neck pain. Neurosurgery was consulted regarding MRI findings. NS spoke to patient and family early this morning, patient and family decide this morning whether to go through surgery or not; patient NPO since midnight

General: Awake, alert and oriented x 3, NADChest: Shallow non labored breathing, vesicular breath soundsCVS: Loud S1/S2 with no murmurs, RRRAbdomen: Absent bowel sounds, non distended, more clots in blood from

ABCD 0016

29 of 40



foleyNeuro: Patient follows commode, weak localization, poor swallowing, EOEM intact, follows finger pointing, otherwise Cranial Nerves intact.

strength in left arm, in toes bilaterally, 0/5 otherwise. Decreased reaction to light touch below knees and elbows bilaterally, reaction to deep pressure intact throughout in legs, decreased in arms below elbows. 4+ DTRs; gaot not observed.

Assessment/plan: Patient with quadriplegia likely secondary to cervical cord infarct or spinal stenosis.

1. Possible surgery – Type and cross2. UTI – resolving, Continue Levaquin3. Follow bladder hemorrhage4. Control BP – Continue Lisinopril5. DVT prophylaxis

11/14/YYYY

PGY-2 neuro note: Subjective: No acute events overnight. Patient complaining neck pain this morning

Objective: General: NADChest: Clear to Auscultation (CTA)CV: RRRNeuro: Alert, hypophonia, follows commands, PERRL, EOMI, face symmetric, tongue midline, 0/5 in all extremities

Assessment/plan: Patient with acute onset quadriplegia 10 days ago. Patient with cervical stenosis and possible infarction

Quadriplegia: MRI of C spine and T spine. Patient out of overdose for steroids. Have consulted neuro surgery. Have given 2 units pits as patient on Plavix previously. Family making decision about surgery.

HTN stable – continue regimen Hypernatremia: Will change IVF for ½ NS UTI – Urine culture pending. Continue regimen Hypokalemia – will replace peroral Prophylaxis – Heparin Full code Hypophosphatemia: Will replace peroral

ABCD 0017

11/14/YYYY

Neurosurgery notes: No events. Afebrile. Vital signs stable. Assessment/plan:

At this time family does not desire surgical intervention Call with questions and concerns

Per discussion with family, they have decided against surgical intervention at this time. They have decided the risk of surgical intervention overweighs the potential benefits of surgical intervention. Family has opted for pain

ABCD 0018-0019

30 of 40



control.11/14/YYYY

Neurosurgery attending note: I had discussed with family about options and have offered surgical decompression. I explained that without surgery she may get worse and even have respiratory compromise. Since she has been in this condition for over a week she may not improve but it could possibly prevent progression if there were no significant surgical complications. Multiple family members have decided with her against surgery

ABCD 0019

11/14/YYYY

Corey XXXX, RN

LaToya XXXX, RN

Nurse notes: @0357 hrs: No movement noted in all extremities.

@0603 hrs: Able to respond to commands appropriately. Moves left arm to commands. Some involuntary reflexes noted to left LE.

ABCD 00282-00283

11/15/YYYY

Saima XXXX, MBBS

Neuro TMS note: (Illegible notes)No acute events overnight, right shoulder pain, no other complaints, tolerated feeding well yesterdayGeneral: Awake, alert and oriented x 3, poor speech, C-collar removedChest: Vesicular breath sounds shallow inspiration capacityCVS: Loud S1/S2 no murmursAbdomen: Non tender, _____Neuro: Follows commands, move toes bilaterally, positive sensation to light touch from elbows down bilaterally and from right knee down and ___right leg, 4+ DTR

Assessment/plan: Patient with paraplegia secondary to spinal cord compression at C4-T1

Control neck and right shoulder pain Continue soft diet and fluids – family counselled on keeping patient

upright 30° to prevent aspiration DVT prophylaxis Control BP Train family in caring for patient tomorrow

ABCD 0020

11/15/YYYY

PGY-2 neuro note: (Illegible notes)Patient with 11 day history of acute onset neck pain and quadriplegia. Once patient arrived to ABCD found to have cord compression due to sever cervical stenosis C3-C4 due to herniated disk. Neuro surgery consulted but at this time family declines surgical intervention. On admission patient found to have post void residual of 1600 ml and patient then had resultant cystitis with hematuria due to removal of >1000 ml from bladder at on time. Patient also found to have UTI and treated with Levaquin. Urine culture pending. Patient evaluated by speech therapy and at this time. On mechanical diet with nectar thick liquids.

Subjective: No acute events. Patient complaining of right left shoulder pain.

Objective: General: NAD

31 of 40



Chest: CTA CV: RRRNeuro: Alert. Allows simple commands, face symmetric, PERRL, EOMI, 0/5 in extremities, hypertensive, decreased sensation in extremities

Assessment/plan: Patient with cord compression.Cord compression: Continue PT/OT/Speech till dischargeAspen Collar – continue pain managementHTN: Slightly elevated. Will add HCTZ. Continue Lisinopril. Prophylaxis: HeparinFull codeUTI: Afebrile – continue Levaquin, awaiting urine culture Hypokalemia will replace peroralHypophosphatemia: Will replace peroralHave instructed family not to __tilt for aspiration risk

11/15/YYYY

LaToya XXXX, RN

Clovalyn Jeffrey-XXXX, RN

Nurse notes: @0716 hrs: Patient complains of pain in her left arm and left shoulder.

@1507 hrs: Able to rotate and move bilateral UE to command. Complains of left shoulder pain.

ABCD 00280-00281

11/16/YYYY

PGY-2 neuro notes: Patient with 11 day history of acute onset of neck pain and quadriplegia. Subjective: No acute changes over the night. Patient still in the same condition.

Objective: Physical examination: Alert, awake. Follows simple commands. Face symmetric. Strength: tongue midline. PERRL, EOMI, 0/5 in bilateral. Sensory: LE withdraws to painful stimuli. UE’s no withdrawal to painful stimuli. Reflexes: hyperreflexia.Toes upgoing on right side and down going on left sideGait: Not able to asses as patient cannot walkToes: Right upgoing. Left downgoing

Assessment/plan: Cervical stenosis at C3-C4 level - MRI C3-C4 cervical spinal

stenosis. Neurosurgery has seen the patient and per these recommendations patient needs surgery but family have refused it.

PT/OT/Speech continues Home PT/OT/Speech – social worker working out with that UTI: Continue Levaquin HTN: Continue HCTZ and Lisinopril Electrolyte impairment – hypokalemia replace peroral K+.

Hypophosphatemia – replaced peroral phosphatase. SW – Working on arranging home PT

ABCD 0023-0024

11/16/YYYY

Saima XXXX, MBBS

Neurology TMS notes: (Illegible notes)Subjective: Patient complains of left arm/hand swelling and intermittent

ABCD 0025

32 of 40



left neck pain

Objective:General: NADChest: Normal, vesicular breath sounds, shallow breathingCVS: S1/S2, RRR, no murmursNeuro: Awake, alert and oriented x 3, dysarthria, slow soft speech, follows commands. strength in hand, left hand and right toes otherwise 0/5. Decreased sensations to light touch in arms and legs bilaterally. Ankle clonus not as marked.Extremities: Positive left hand swelling, negative redness, warmth ____

Assessment/plan: Patient with paraplegia, bowel and urinary incontinence secondary to C3/C4 disc compressionHTN – Increase Lisinopril to 30 mg Left shoulder pain – continue Lortab every 4 hoursWBC – follow, continue Levaquin, check urine, watch for pneumoniaeQuadriplegia: ____ came up with discharge plan for family and possible necessary training

11/16/YYYY

Clovalyn Jeffrey-XXXX, RN

Nurse notes: Slightly moving left arm to commands

ABCD 00279

11/17/YYYY

Neuro TMS notes: (Illegible notes)Complains of left shoulder pain as well as generalized body pain; also complaining of pain in neck in her face; no nausea/vomiting, dizziness, chest or abdominal pain, patient did not sleep well

General: NADChest: Non labored breathing, vesicular breath soundsCVS: S1/S2, RRR with 1/6 SEM at right upper sternal borderAbdomen: Non distended, positive bowel sounds, ____non tenderExtremities: Good radial pulses; left hand swelling, no redness or ____Neuro: AAA x 3, alert and appropriate speechSpeech much more audible when compared to yesterday___ - intactStrength, sensation and reflexes unchanged from yesterdayFoley – continuing hematuria

Assessment/plan: Patient with paraplegia, urinary retention, bowel incontinenceUTI/hematuria – consult urology for ____bladder hemorrhageParaplegia – set up appointment ___ tomorrow for PT to meet and train familyHTN – Continue current dose of Lisinopril and followContinue Levofloxacin and follow WBCPain – continue Lortab and give Amitriptyline 10 mg at night tonight __Continue DVT prophylaxis, ____ diet, stool softener/enemaDisposition: Discharge tomorrow home

ABCD 0027

33 of 40



11/17/YYYY

Neuro staff notes: (Illegible notes)Patient seen and examined with ____ I ___ and plan_____Hemorrhagic cystitis – Culture and sensitivityDischarge planning

0029

11/17/YYYY

Sonia XXXX, RN

Nurse notes:Complained of pain in right shoulder and neck

ABCD 00277

11/18/YYYY

Saima XXXX, M.D.

Neuro TMS note: (Illegible notes)Subjective: Slept well overnight, good appetite, pain controlled, more hematuria since Urology ____bladder yesterday evening. No new complaints.

Objective: General: AAA x 3, NADChest: Vesicular breath soundsCVS: S1/S2 with 1/6 SEM, RRRFoley: Urine is free of blood grosslyAbdomen: Non tender, positive bowel soundsNeuro: Physical examination: unchanged from yesterday

Assessment/plan: Patient with paraplegia, urinary retention and fecal incontinencePT to care and train family this morning

Disposition: Discharge today to home, follow-up with Urology in 1 month, follow-up with ABCD clinic at 02:30 pm 11/22/YYYY. Follow-up with ABCD Neurology

ABCD 0030

11/18/YYYY

Saima XXXX, M.D.

PGY-2 neurology progress notes: Subjective: No acute events overnight

Objective: HEENT: PERRLA, EOMIChest: CTA bilateralCVS: RRR, no M/R/GAbdomen: Non tender, non distended, bowel sound positive

Neuro exam: MS: Awake, alert, follows commands, AAO x 3. Dysarthria.CN: Visual fields intact. EOMI, no facial asymmetric, tongue midlineMotor: 0/5 bilateral UE and LESensory: Pain, touch intactReflexes: 2+ bilateralCoordination/gait: Not accessable.

Assessment/plan: C3-4 spinal stenosis: Acute quadriplegia. Neurosurgery

recommended surgery family has refused the surgery. Family has refused NG placement. Social worker working on making

ABCD 0032

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arrangements for home health, hospital bed, wheel chair, patient lift.

Will discharge home11/18/YYYY

Chanta XXXX, LPN

Nurse notes:Notes: Patient in stable condition.

00276

11/18/YYYY

Jeffrey XXXX, DO

Discharge summary:Reason for hospitalization: Patient was admitted for chief complaint of weakness in ann and legs.

History of present illness: Patient was a direct admit request for weakness in the arms and legs bilaterally. The patient has been transferred from ABCD County Hospital. The patient was admitted there for weakness and right- sided neck pain today and the patient was not eating. The patient collapsed in her bed last week on Wednesday with complaining of generalized weakness and numbness in bilateral upper extremities. No loss of consciousness, no headaches. No nausea or vomiting. The patient was admitted to XYZ Regional Medical Center on that day, on November 4, YYYY; then discharged home on Monday and readmitted in ABCD Hospital today. The patient is still complaining of neck pain this morning at 6 and became weak. No headaches. No nausea, vomiting. The patient was complaining of neck pain from last month, received pain medicines. The patient was transferred to ABCD Hospital. The patient was admitted over there and she was also having some language problem starting from this Monday. She was not able to eat because of having swallowing problem. No vision problem. She was not making much urine and also was having complaint about constipation. No fever, no chest pain, and no shortness of breath.

Review of Systems: Severe neck pain, weakness in arms id legs. No cough or wheezing. No chest pain or shortness of breath. No diarrhea, vomiting. No anxiety. Constipation positive.

Physical examination:General: Elderly female in no acute distress, awake, alert. CVS: Si and S2. No murmurs, rubs, or gallops.Respirations: CTA bilaterally. ABDOMEN: Soft, nontender, and nondistended. Bowel sounds positive.Extremities: No clubbing, cyanosis, or edema. Neurologic: AAO x 3. Face symmetric. Tongue midline. Strength in upper extremity 1/5 bilaterally, lower extremity 4/5 bilaterally. No rectal tone. Sensory: Upper extremities - no withdrawal to painful stimuli; lower extremity - withdraw to painful stimuli. Plantar toes upgoing on right side, downgoing on left side. Sensation intact on face, upper extremity, and lower extremity.

Imaging data: Spinal canal narrowing at C3. C4 level may be responsible for this cord compression.

Hospital course: The patient was admitted for weakness in bilateral upper

ABCD 003-006

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extremities and lower extremities. The patient also bad 1600 mL residual in her bladder. MR1 spine showed C3-C4 narrowing and cord compression. Neurosurgery was consulted. Per Neurosurgery recommendations, the patient needs spinal cord surgery, which family has declined. The patient was offered nursing home placement, but family wants to take the patient back home. Swallow study was done, which the patient passed. The patient was started on mechanical soft diet, so the patient was continued on physical therapy, occupational therapy, and speech therapy and she was improving and doing better. The patient had dark colored urine. Urology was consulted and they did irrigation of the bladder and it became clear. The patient was complaining that she was not able to sleep well at night. Amitriptyline 10 mg by mouth each bedtime was started, which helped the patient for her night sleep and the patient stated that she was able to sleep good at night. The patient’s family wants to take care of her and they wanted to take her home, social worker is making arrangement. The patient left. For mechanical goals we ordered specialized wheelchair and also arranged for home health who are going to take care of her and also hospital bed and low air pressure mattress. Home health is also going to come in to teach the daughter and the people who are going to take care of her, how to take care of the patient. The patient also got some training from the physical therapy to do some exercise and also got the catheter management. Transportation was arranged and the patient was discharged home.

Condition at discharge: Stable.

Discharge instructions:1. Diet - low salt.2. Physical activity as tolerated

Follow-up care:1. ABCD Clinic, Dr. XXXX, followup appointment on November 24, YYYY, at 2:30 pm2. ABCD Neurology with Dr. XXXX in two to free months

Discharge diagnoses:1. Cervical spinal stenosis at C3-4 disk2. Hypertension3. Quadriplegia4. Urine retention5. Fecal incontinence


Thomas XXXX, M.D.

Visit for pain: She comes in by transport. Patient has had a collapse, probably from a cervical disk that had pressed on her spinal column, and she is almost completely paralyzed. She can squeeze a little bit in her right hand but not her left hand. She is in pain. The family is trying to take care of her. She cannot have a bowel movement. I checked her and she is impacted. We will send her by the emergency room and give her an enema to see if we can clean her out. She has a Foley catheter in and has Home Health coming.


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She has had CVA before and has hypertensive cardiovascular disease.

Physical exam:Heart: Her blood pressure is 116/68. Pulse is 96.Rectal: She has a massive amount of feces in her rectum.

Impression:1. Fecal impaction.2. Hypertensive cardiovascular disease, controlled.3. History of cardiovascular accident.4. History of cervical disk disease with impingement on the canal and spinal chord with some paralysis.5. Slight movement of her right hand.treatment: Will continue her hydrocodone p.r.n. for pain.

ABCD County Hospital12/03/YYYY

Sushma XXXX, M.D.

History and Physical:Admitting diagnosis:1. Urinary tract infection.2. Hematuria.3. Quadriplegia / cervical cord compression.4. Hypertension.5. Constipation.6. Chronic pain.

Patient with history of quadriplegia secondary to spinal cord compression at the neck, whereby, she was admitted to ABCD. She had been discharged home with a foley catheter. She came into the Emergency Room with increasing pain and constipation and, also, bright red blood in the foley. According to the daughter, the foley had been changed on Monday. It took a XXXX time for them to be able to install the foley and the bleeding had started since then. Today, the patient feels slightly better in terms of her pain. She did have to take an enema to get a bowel movement. She has been eating fairly well with no episodes of any nausea or vomiting.

Physical exam: Patient is alert and oriented. Not in any acute distress. She is afebrile.She is speaking in full sentences. P-74; R-20; BP-170/84; O2 sat-97% on room air.Neck: is supple.Chest: Bilaterally air entry present.Cardiovascular: S1/S2 normal.Abdomen: Soft. Non-tender. Non-distended.Extremities: Tone present in all four limbs. The power is about 2 by 5 in the upper extremities and 1 by 5 in the lower extremities. Patient is able to move her upper extremities.

Assessment and plan:1. Urinary tract infection with indwelling foley-We will start patient on

ACH 0047-0048

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Rocephin2. Hematuria-Most likely traumatic. If bleeding persists, we will do an ultrasound of the bladder3. Anemia-Probably secondary to the hematuria as well as delusional. We will continue to monitor the H&H. If hemoglobin drops below 8, we will consider blood transfusion4. Quadriplegia secondary to cervical cord compression5. Constipation6. Hypertension-Continue with patient’s prior medications7. Chronic pain-Patient is on Lortab every 4 hours as needed. Will take Motrin in between

12/07/YYYY-12/09/YYYY

XXXX, patient service coordinator

Social service discharge note: PSC received Home Health consult order, per Dr. Sushma XXXX. Patient is being discharged home today. Patient’s family requested that the referral be sent to XYZ Co. Abcd. PSC phoned Abcd and faxed referral information. PSC later spoke with DHEC nurse, Judy, in regards to this referral. PSC also gave a courtesy call to Care One/Amedisys, who previously provided home health services for this patient, prior to this admission. Care One/Amedisys was advised that this family has chosen another agency for home health services. PSC spoke with Beverly at Care One/Amedisys.

ACH 0054

XYZ Regional Medical Center02/22/YYYY-03/25/YYYY

Visits for lab works: Urine analysis was performed on 02/22/YYYY, urine culture and sensitivity was preformed on and 03/25/YYYY

ABC 00201-00202-208


Follow-up visit: (Illegible notes)Check up and follow-up – also complaining of burning and itching at cath site.

Assessment: UTI, ____, indwelling catheter

Plan: ____, Diflucan, ____culture and sensitivity


04/09/YYYY

Follow-up visit:Complaints of pain in sides. Was taking SMZ/TMP but stop giving to her had difficulty

Assessment/plan: Hypertension - monitor history of CVA - stable cervical disk disease -stable Decubitus ulcer – 6 weeks Diflucan, Zantac, collagen Hydrogel


05/24/YYYY

Follow-up after hospitalization: Complains of increased pain.

*Reviewer's comments: There is no assessment and plan for this visit.


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Visit for lab works:

Labs performed: Urine analysis, culture and sensitivity

ABC 00209-00225

08/06/YYYY

Edward XXXX, M.D.

Venous doppler study: Clinical indications: Bilateral lower extremity swelling and elevated D-dimer levels

Impression: Acute deep vein thrombosis in the right and left lower extremities as described.

ABC 00226-00230


Visit at home: (Illegible notes)Patient was seen at home. She is cared by her daughter. She is getting 35 cc/hr of boost. ____

Assessment: Quadriparesis, large stage 3, decubitus ulcer of buttocks. _________Dressing 3 x days. Increase feeding rate to 40 cc/hr


Low Country Family Services. Inc03/16/YYYY

Notes: (Illegible notes)@1415 hrs: Client lying supine in hospital bed with tube feeding at 42 ml/hr with Jevity 1.5 cal formula. Tube in place right over belly button. Has central line in right side of chest. Has a Morphine pump __ at 10 mg/ml at 3 mg/hr. Maximum dose in 1 hour is 3 PCA has 13.7 ml ____. Pump is set to lack out 9.20 min. She demand dose 0.50 mg. Client also has a foley catheter with straw colored urine. Home health nurse comes 1 time a week to device central line. Client does speak but only short words.

@1430 hrs: Client has nothing by mouth. Medications are given though G tube.

Low Country Family Service records 003


Outpatient visits for lab works: *Reviewer's comments: During this period, the patient had visits for urinalysis labs. There are no records available for hospitalization prior to death of the patient on 02/25/YYYY (Mentioned in death certificate)

ABC 00231-00245, 00247-00251

02/25/YYYY

Certificate of death:Death occurred in a hospital: InpatientFacility name: ABCD County Hospital

Actual or presumed time of death: 0925

Manner of death: Natural

Cause of death: Part I: Immediate cause of death: PneumoniaApproximate interval: Onset to death: 2 daysPart II: Significant conditions contributing to death but not resulting in the underlying cause given in part I: Hypertension

ABCD Radio 007 (Poor scan quality)

Death Certificate

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Autopsy performed: No03/25/YYYY-10/15/2014

Other records:Patient education (Heritage records 0079, ABCD 00331-00340), insurance details (ABC 00156-00157), affidavit (ABCD Radio 002), correspondence (ABCD Radio 003-004, 008, Xxxx & XXXX records 001), authorization (ABCD Radio 005-006, Xxxx & XXXX records 002, ABC 00154-00155), fax sheets (ABC 00238, 00246, Low Country Family Service records 001), admission record (XYZ Regional 001, ACH 0044, ABCD 002, ACH 001, Heritage records 0066-0067, ABC 001), KUB (ACH 0073, ABC 003), nursing notes/records (ACH 0087, ACH 00117, ACH 00103-00110, ABC 00132-00133, 00148, ABCD 00142-00160, 00284, 00138-00141-), plan of care (ACH 0088-00101, ABCD 0014), assessment (ACH 00102, ABC 00134-00140, ABCD 0033), Intake/output (ACH 0086), labs (ACH 009-0011, 0062-0071, ABCD 0034-0037, 0055, XYZ Regional 0033-0036, ABC 0034-0048, XYZ Regional 0013-0017), orders (ACH 002, 0055-0061, ABCD 007, 0079, 0081-00121, 9103-A-005-010, ABC 0024-0029, Heritage records 0068-0078), vital signs (ACH 0084-0085, ABCD 00287-00323, ABC 0049, Heritage records 0096), progress notes (ACH 0049-0053, Heritage records 0097-0098), assessments (Heritage records 0013-0015, 0023-0026, 0044-0047, 0088-0090), CT brain (ACH 0074-0075), CT abdomen (ACH 0078-0081), EKG (ACH 0072, ABC 0055), renal ultrasound (ACH 0082-0083), medication sheets (ACH 0045-0046, 00111-00116, ABCD 0080, 00122-00137, ABC 0023, 00151, 00159-00200), evaluation (Low Country Family Service records 002), physical therapy records (ABCD 0056-0058, 0063-0070), speech therapy records (ABCD 0071-0078), occupational therapy records (ABCD 0059-0062), patient screening (ABCD 00341-00342, ABC 0053-0054), consent (ABCD 00328-00330, ACH 0012-0014, ABC 0050-0051, 00152), intake/output (ABCD 00324-00327), rhythm strips (ABCD 0045-0054, ACH 006, ABC 0058-0081), medical record certification (ABC 00153), attestation statement (ABC 002, XYZ Regional 0025), inventory (ABC 00158), echocardiogram (ABC 0056-0057, XYZ Regional 0037-0038), face sheet (Heritage records 003), immunization record (Heritage records 0065), checklist (Heritage records 004), X-ray abdomen (XYZ Regional 0020-0023), CT urinary tract (XYZ Regional 0018-0019), X-ray chest (XYZ Regional 0045, ABC 0018), nursing rounds (ABC 0082-0086), transfer request (ACH 007-008), protocol summary (Heritage records 0036-0043), plan of care (Heritage records 002, 0048-0064), occurrence reduction program (Heritage records 0091-0092), social worker note (ABCD 0026, 0031)

*Reviewer's comments: All the significant case related details have been included in the chronology.

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