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Home My WebLink AboutMINUTES - 09182007 - C.16 CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY • BOARD ACTION: SEPTEMBER 18, 2007 Claim Against the County,or District Governed by ) the Board of Supervisors,Routing Endoi:scments, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. you is your notice of the action taken ( M1 •' on your claim by the Board of (`' _• N Supervisors.(Paragraph IV below), O.N given Pursuant to Government Code U� 0.2 AMOUNT: UNKNOWNSection 913 and 915.4.Please note all �1CD z2 "Warnings". . �p 4 ¢_ �LAIMANT: PETRA LUPE- BINAVIDEZ ATTORNEY: UNKNOWN DATE RECEIVED: AUGUST 13, 2007 ADDRESS: 16870 BARNELL AVENUE, APT. AY DELIVERY TO CLERK ON: AUGUST 13, 2007 MORGAN HILL, CA 95037 RECEIVED FROM RISK BY MAIL POSTMARKED: MANAGEMENT FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN,C 'k Dated: AUGUST 13, 2007 By: Deputy if. FROM.: County Counsel TO: Clerk of the Board of Supervisors ( his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant.The Board cannot act for 15 days(Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send waiving of claimant's right to apply for leave to present a late claim(Section 911.3). O Other: Dated: '37 0-7 By: ry-)CG�GDeputy County Counsel ili. FROM: Clerk of the Board TO: County Counsel(1) County Administrator(2) O Claim was returned as untimely with notice to claimant(Section 911.3). IV/BOARD ORDER: By unanimous vote of the Supervisors present: (v) This Claint is rejected in full. O Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Date • . /8' OHN CULLEN,CLERK, By Deputy Clerk WAiNi.. G(Gov.code section 913) Subject to certain exceptions,you have only six(6)months fium the date this notice was personally served or deposited in the mail to file a court actio[on this claim.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. II'you want to consult an attorney,you should do so immediately. *For Additional Wanting See Reverse Side of Dins Notice. AFFIDAVIT OF MALLING I declare under penalty of perjury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimant,addressed to the claimant as shown above. DatJOHN CULLEN,CLERK By Deputy Clerk • This warming does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be tiled may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your_particular claim. The County of Contra Costa does not waive any of its rights under California Tort Claims Act nor.d" es it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act I BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIlYLANT A claim relating to a cause of action for death or for injury to person or to personal property or groping crops shall be presented not later than six months after the accrual of the cause of action- A claim relating to any otherca- use cse of action shall be.presented not later than one year . after the accrual of the cause of action. (Gov. Code § 911.2.) Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building,651 Pine Street,Martinez,CA 945 53. If claim is against a district governed by the Board of Supervisors, rather than the County, the :name of the District should be filled in.. If the claim is against more than one public entity, separate claims must be filed against each. public entity. Fraud. See penalty for fraudulent claims,Penal Code Sec.72 at the end of this form. ■s A a 01 5 t ERRINEIR IS a f a MR In RK1 t[1 i MR on C 1 t E[[!![v e t z f C C e e e e e e e t t e t n o R o e a i e a i a n t c K c E: Claim By: Reserved for Clerk's filing stamp F"..'CEIVED Penny Bailey against the County of Contra Costa or ) AUG 1 3 2007 AUG C v '�pp ) 2007 I i District) CLERIC BOE,Tr,OF SUPERVISORS Fill in the name) ) CON i Fla COSTA CO. the undersigned claimant hereby makes claim against the Cmenty of Contra Costa or the above-named -i,ctri ct in the sum of$ and in support of this claim represents as follows: 1. When did the dale or injury occur? ((3ive exact date and hour) 2. %ere did the damage or injury occur? chide city and county) Ulm 3. How did the ae or injury occur? (Give full details;use extra paper if required) T v Da!� 11'1 i/� u:yYob .T�s��, ��d� SfP-.� f- S yUl�2a, YA kk � Anel, P I 4. What particular act kn oi�ssi on` a part o_ unty or et officers, servants, or employees -719 caused the injury or damage? wce1�C 5 What are the names of county or district officers,servants, or employees causing the damage or injury? What damage- or injuries do your claim resulted? (Give full extent of injuries or damages claimed:-Attach-two estimates for auto damage.) How was the amount claimed above computed? (Include the estimated amount of any prospective injury or dain.age.) Names.and addresses of witnesses,doctors, and hospitals: �. List the expenditures you made on account of this accident or injury: DATE TIME AMOUNT laa aaaafaalafaa as anaERN aa a afaa a a aafa[a/a[a[as aaaafa latafa Ism aa aafaaafa■9 aRIC■■alae[gal ) .Gov. Code Sec. 910.2 provides"The claim shall be )signed by the claimant or by some person on his behalf" SEND NOTICES TO: (Attorney) 1 I,Tame and address of Attorney (Claimant's Signature) (Address) Telephone No. )Telephone No. aereaafetraaaateeera[aaaaaaaaaaaaa[eaaaa■aca[MEEK aaa[aaaaaantanRaaaaaaIra a5aaEggs caNZI PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act, (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■a age a f a an a a a an RE an man a.a Is r ana[[t a a a a 111■a a lint a a a a a s a a a a a[a a a t a a a t a RON a a an an Ra RE a a RE NOTICE: Section 72 of the Penal Code provides: Every person Mho, Rrith intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account-'►oucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fot of not exceeding one thousand dollars ($I,ODD.DD), or by both such imprisonment and f ne, or by imprisonment in the state prison; by a fine of not excaeding t.n thousand dollars ($10,DOD),or by both such imprisonment and fine. .�.t e r-- i �k fr I .�w •tip ,x s,.. wc:• '�u, �'- .r �. ifs! �,.r F ��Zu".. Glass Pro 16170 Jacqueline Ct. Morgan Hill,CA 95037 Phone: 408-782-0700 Fax:408-778-7 124 Federal Tar ID:20-0825204 E-Mail: teamaab@aol.com Date: 8/7/2007 Quote 3153 Bill To: Customer: Quote Date: 8/6/2007 Benavidez, Petra CSR: Installer: Location: 1n-Shop Phone: Home: Fax: Work: Fax: Mobile: Insurance Information: Loss Information: Policy#: Date: 8/6/2007 Deductible: $0.00 Claim#: Type: Contact: Agent: Region/Dist: Vehicle: 2006 CHEV COLORADO 4DCRCB VIN: Odometer: 0 License Number: # Qty Part/Service Description ListPrice % NetPrice Labor Total 1 1.0 DWO1533GTYN Green Tint 225.35 -23.99 171.28 117.80 289.08 2 1.0 HAH000004 2.0 Adhesive 56.00 -60.71 22.00 0.00 22.00 (Urethane,Dam,Primer) Total Material: $193.28 Total Labor: $117.80 Subtotal: $311.08 Sales Tax @ 8.250%: $15.95 Total: $327.03 Deductihle Due: $0.00 Balance Due: $327.03 1 authorize Glass Pro to provide the above referenced services. 1 authorize Glass Pro to install glass and related aftermaket parts, which will be purchased from the supplier of their choice. I assign to Glass Pro any claim that I have under my insurance policy to recover and authorize the insurance company to pay Glass Pro the balance due. I agree to pay any balance not covered by my insurance company if applicable. I authorize Glass Pro to operate this vehicle for purposes of inspection and delivery if applicable. I have read the warranty and intructions on the reverse side. Customer Signature: date: CUSTOMER AKNOWLEDGEMENT: I have inspected the glass installed and the work performed by Glass Pro and agree that the job has been completed to my satisfaction. Customer Signature: Date: Copyright 1997-2006,National Auto Glass Specification. All Rights Reserved Page I of 1 Ic 1/a CC • Jv NII tt 33. �ry1 hJ v r Q oma � d -r US ,F 1'CL ASS IORI.VER .••. n sri .�• —jk lk. Av Ua '- o � —v O Zr h�1 d Q - i ti Ic N TA COUNTY i l R! CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY • BOARD ACTION: SEPTEMBER 18, 2007 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. �} � ��)? F you is your notice of the action taken on your claim.by the Board of AUG l 141,2007 Supervisors. (Paragraph IV below), given Pursuant to Government Code COUNTY C Section 913 and 915.4..Please note all AMOUNT: $5,549.50 MARTINEZ CALIF.CAIF. "Warnings". ALL STATE INSURANCE COMPANY CLAIMANT: FOR: CATHY A. FELTER BY: MICHELLE JOHNSON ATTORNEY: UNKNOWN DATE RECEIVED: AUGUST 14, 2007 3121 WEST MARCH LANE, SUITE 200 AUGUST 14 2007 ADDRESS: STOCKTON, CA 95219 BY DELIVERY TO CLERK ON: RECEIVED FROM BY MAIL POSTMARKED: RISK MANAGEMENT FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, Clei Dated: AUGUST 14, 2007 BY—Deputy iI. FROM.: County Counsel TO: Clerk of the Board of S Pervisors (ti)Ii'liis claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not tirnely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911-3). O Other: Dated: q' U r By: Deputy County Counsel ili.. FROM.: Clerk of the Board TO: County Counsel (1) County Adrninistrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: ( This Claim is rejected in full. O Other: I certify that this is.a true and correct copy of the Board's Order entered in its minutes for this date. Dated, D JOHN CULLEN, CLERK, By eputy Clerk WA NI.TTG– (Gov. code section 913) Ir Subject to certain exceptions,you have only six(6) nionths from the date this notice was personally served or deposited in the mall to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of art attorney of your choice in corrrrection with this matter. If you want to consult an attontey,you should do so immediately. *For Addidwal Wariiing See Reverse Side of This Notice. AFFIDAVIT OF MAILING [ declare under penalty of perjury that i. am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in RIartinez, Califol-nia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: 9 �� JOHN CULLEN, CLERK By eputy Clerk I 11.JJIt:i N J 0 r i.i I i This warning does not apply to claims which are not subject to.the California Tort Claims Act such as actions.in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the -separate limitations periods that may apply. The limitations period within which suit must be tiled may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa does not waive any of its rights under California Tort Claims Act 'nor.;d.oes it waive rights under the statutes of limitations applicable"to actions not subject to the California Tort Claims Act CAA95219 SUITE 200 WAustate.STOCKTO.TStockton You're in good hands. r RECEIVED AUG i 4 2007 Penny Bailey RISK MANAGEMENT AUG 1•® 2007 CONTRA COSTA COUNTY CLERK BOARD OF SUPERVISORS 2530 ARNOLD DR STE 140CONTRA COSTA CO. MARTINEZ CA 94553-4359 August 03,2007 INSURED: CATHY A FELTER PHONE NUMBER: 800-240-3762 DATE OF LOSS: May 28,2007 FAX NUMBER: 209-956-5305 CLAIM NUMBER: 3955025443 KMJ OFFICE HOURS: Mon-Fri 8:00am-5:30pm To Whom It May Concern, Allstate Insurance Company is presenting a claim on behalf of our insured's,Cathy and Bruce Felter in relation to the above mentioned loss. It is our stance that the lack of maintenance of the shrubbery contributed to this loss and the Felter's believe that this shrubbery is supposed to be maintained by the County. Allstate is hereby making a claim against the County of Contra Costa in the sum of$5549.50 which is 50%of the total payout on this claim. 1) The loss occurred on May 28, 2007 at 3:00pm 2) The loss occurred at the driveway of 1085 Bear Creek Rd,Martinez,Contra Costa County 3) The insured party, Cathy Felter,was attempting to turn left from her driveway and was struck by another vehicle driven by Reagan Ondler. 4) The insured's feel that the County is responsible for the maintenance of the shrubbery, bushes, and/or trees that border the roadway and failed to maintain them in order for divers to have a clear view and this failure to do so contributed to this accident. 5) It is unknown at this time who is the responsible county employee that is designated to maintain the shrubbery,bushes,and/or trees in this area. 6) Property Damage only: Felter's Horse Trailer(deemed total loss) $5000.00 Reagan Ondler's vehicle(deemed total loss) $6099.00 7) The value of the horse trailer was obtained from the selling dealership. The value of Mr Ondler's vehicle was determined by his insurance company, CSAA. 8) N/A 9) N/A Enclosures: a) Police Report b) Pictures of the scene with no vehicles C) Repair estimate and pictures of Ondler's vehicle d) Repair quote and pictures of Felter's Horse Trailer Thank you for your time in reviewing this matter. Please contact me at 209-475-5206. 3955025443 KMJ Sincerely, WKicheae johluon Michelle Johnson 209-475-5206 Allstate Insurance Company GEN1001 3955025443 KMJ "-A IE OF CALIFORNIA / V TRAFFIC COLLISION REPORT CHP 555 Paye t(Rev.1-03) OPI 061 �f :l 7 11411 Poy. or +'PECNI CORW ri I"• vxwro r.laW CtTYV .-^-'___—.__.__...___._ .._. AA7iAL D1570..GT LACAL REPORT NUNDEA v,Li,.✓G. ,3,Q Y L.Aw,r.lm un<.w cOv+YY aEPDRTnraaia:ci DEAL :,MSL I O �v��..4 GoSrrg Z3 *5;0 c0114'Kx1 OCL1sL7ED CN LAO. 047 YEAR TIME R<TN NG:,. OMCCR COL 4":9 ��d 7 Z; 0 /.ra J F3�7 I /yS// KI.EPOSTWORWDONQDAY OF NEfX TOW-WAY PtJTCCRAPMODY. Fitt NOP, U _PeernYLEa c. _�_ S QW T F S �_;YES NO J \ UPARTY IAT IN+04:4c-ICN VATH SIATE NWY REL_ riR 2�' et9-M /`-' OF pJ ^p LYES NC t:RiVETCSCKI:J+SE nULRFR �SYATE CLt3s AMOAU :SAFEre EOU:P, VE' evR INAxcvo0eLCOLOP UCEN:E NN.1.a!" ISrArc ] I;:uv�i+KARL �+�F�to �/ / �•' C��I.. .._ U/.?G T D/��Ct _._. Ow.EAs rua.E (YI SAME A:DRIVER PL'Jii „TRFF.I At#tRf3.. �y SME AS DRIVER - V.'.MR'S ATXW�SS PAR<LVCATV.CUATC YoL �o�� pylar a:T• - I . Drs•oOW TnOVENcLFaro-nnTAsor:... OFFICER DR=IV— R ❑OTIER DRTIMATIA /D ,A_rjAJR 1EKT Cusr I _....r_... —_.�..._. ...- n M ��j�•V ��L .,fir /�� Z Si' C�9 C.� P3�OR teEOcwC:Al DecFe7s tX1.Y APPAREM 'T'I REFER TDrNfiRATIVF, Oi110 PMC'E OUiINIIIS PNO`E VEIQLIl dMtf+GTK7N rtW�OUI L J �� // ✓ `�� .. VEMCLE 1YPE:UUNK ISO Vf11;C:E OAMCt SKADG IN DAW.CED AREA SWUNCP.C/MEA POLKY NIaVER 1 (NONE C]MWOA CA. `7G � , OD 0MAW OR❑ROLL-OVER (••• UIit OF tMvEI ON STPl E*O(+1aGravAT SPtLV LuIT ` / +%E• ��G'_'f� f'•CJ�TN � .,T --'-- teaPac------• "•utuc ,..�.._�.r I PARTY 01tr&R_LI:ENLC AVMSER 7TAlE t3A20 NR OAC 'SAPS TY COIN. `074MFJ4ODELC IICFJ<SE r+UM9ER 'eA 2 DPh'En NAuetFmsr,<rpp,E,LwsO ��/LlAJL3f !:R_t!Lr� err � 6 �}' L'Hf f_(r74,J Se=r3 "�qZT Z'A ' OWNERSCULIF SAVE AS ORNER PLOCY• �1REET AOORE.53 0VO4EA8A00Ru' � SANE AS CRNtJi PAACEO CMMTATMP vFM.'flT /",?�.L1f Z eA �Yr�.� --- .-- a Otcvo`mwOPv[Miclea+utofavo►. U OF DRIVER OTHER UICY• sr% IWR JEYeS J.HEIGHt 2 VIVGKT DIRTTOATI. fLKC /��( '/✓�/ y QIlT �� W. OTT Yer _— f'-t Al 7N J /O Z3 S � PRroPuee+u.+nu.oerecra. - rypNfApPMENT REIERTONARAAIM14 piRFR PnOrNE ^J'l / Ru -'P1QNE VDaCLP DENRF)CATICC!(UMBER: L ] �liJ 3 0^1�3� � ��r"^' VeNCIe TYPe DESCmne vEri+QLINWAG4 �jHD6 iT1 uw/.Oco ARU _ L �._ / Ali�L' V/ iVSN+ANCECARR1eR ?va.iC NLM(iEa 0� 1 ? 3� IDUNK ❑AOt?E c)mKOR VER % �--- L6- o yiv i�_» l —V C1 [-1 — >7 DtR OF TRAVEL ON.1TREET CR IDOIANAY --- - SPGED uIUT . S Gl�z-� Qv� 3c7 � Calif TCPNSC.--__M.JYR PARTY DRNCR3 uCE4sE NCAMEP TATE ClAss AI+eAC ;Wr'eTYE VENYE&R WI IlW0EUCOWR IICEJGGNUMOER :TATE tvMVPA M"O TFois T,AaaaE NS7 wa.Y! (] W..E AS DRIVER PCi1F,4' Sii4'Et AOUAEtls �' t TP•_AN _ �. CJPd7FJt'9 ADUtESS �_�•— •• SAME+L:pIiIVEN � vARi:u Ct1Y/STATf1:IP vo!+aL _ __ _ _ __ (� .. •;�'� p»POyrttOh OF YEL�C1E CEN dtOLMs d+: ---- FILF RIVER OTHER Iy-1 aF ' .Y• 5FX —ok P.jis '7I!EK,M IDMT D.RTN�ATE RACE / I LtSf WF__— QEFECtG NONE AWARENI RF.Fe'A TO NAHRAINi ormmm NOu.PMONE 0;J9M[Ss P1CRE VLKCLe DEMo-ICATiOJiRUY9ER:/ ..� { .I .l vE RtCLE•TYPE rESCRtBF L'£�IiQ.E OAU AOC sNADE IY UA+AACCO ARP.I +15twcE CMPE!R PD(ICY MJM.BLR f JUNSt. aNONF MINOR (]MoD. MAJOR ROLL •—�� ll5��..ggqqqqr�.. .. ..-___._._.... .._._ —_ .. _ __ f Vt OP 1RAY�ON 7TgCE'OP HiGNYAY _ fi`kkUi.IAN --- � '.`_— .-.----_• ly'�C _ .F.'AL•T ��TCPr►SC —yCJrJ7(—,—...�..- P.REPME�7•'swl'E OISPATGIWTU:ED REV NA.V .Dl.T REV:wEO fTh:i/i:rf. �1`/�'7/J YES n NO NIA 0 I STATE OF"ALOOHNIA TRAFFIC COLLISION CODINGr CHP 555 Paoe 2(Ray. 7-03) OPI OGf Page-?, S UAT[Ci:GOLIIGICN L!JiD. OAV ryYtl� TtMr Rim; O'MJEfre Y»wE Owr+EKaACrd NON[:p PROPERTY YCS El NO DAMAGE oEacRvnokoFrAUACE. SEATING POSITION SAFETY EQUIPMENT INATTENTION CODES OCCVPANT� L-AIH BAG UEPLOYEO MIC BI;YCLE-HELMET A-CELLPHONE HANDHELO /^ A.NONE.IN VEHICLE' M.AIR BAG NOT DEPLOYED DRIVER PASSENGER 0-CELLPhOTJC HAl:OSFRF•1: B•UN-OTHER VIVO X•NO C-ELECTRONIC FOUIPMEKT '.Ap.Av BELT USCI' P-NOT RLf1UIRFD LV•YES Y•YES IT•RADIO/CO 7.LAP BELT HOT USED E•SMOKING t•DRIVER F-5'LOULDER IIARNV!(S USCI) F-EATING TUG•PA5SENGEHS f •a iOULDCR HIRNESS NOT USED GIfILUf1uTIJA4T FJFCTFOFROMVFHICLE G.C111LUHUN 5 5 + 7.SI'A TION WAGON REAR G-LAr1SI IOULUER HARNESS USED O IM VEHICLE USED O.NOT EJECTEU If-ANWALS D•HE:AH 0(,(:.TRK OR'/AN YI-LAP)SHOULOER HARNESS NOf USCU R IN VEHICLE NO,USL'O T-FULLY EJC•CTEO 1.PERSONAL HYGIEHE 9-POSITION LNJKNOVRJ J•PASSWC RESTkAINT USED S-IN VL•I IICLL L+SE UNKNOWN 2-PARTIALLY LJCC'I ED J•RF.ADJNO T 4'OTHER IK.PASSNE RCSTRAW f NOT USED T-IN VEHICLE PAPROPr--R USI: 3-UNKNOWTI K.OT HER U-NONC IN VCHICLE IT 11S MARKED 8FLOW FOLLOWED BY AN AS'fL:HISK(')SHOULD BE EXPLAINED IN THE NARRATIVE. twMART COLLISION FACTOR 1RAFFIC CONTROL DEVICES •( 2 13 SPLCIALtNFORMAP.O"J 1 2 3 j MOVEMENT PRECEDING LIST HUMBER OF PARTY AT FAULT I COLLISION '- -! +.:ac+.+^�++.•:•� _ A COKIRULS FUNChUN1/JG A•IfAIJ+RDOUS AIA7 ER Jit `_ A rOPPEO �{ J y .. FI_�J (/�LIIG B CON T(IOLS NOT FUNCTIONIN(T• - _ H CELL PH OHNE HANOHELD IN IJSE _/_"_ _ EI PROCE-L.-C STRAK;HT _— OTHER IWTZOPERDRIVRJG•. _C CONTROLS OBSCURED IC CELL PllOHFHAhD9FRLEDIUSE I C RAN OFF ROAD 1 _ D NO CONINOS PRESENT 7 FAC TOR' Y LK PHONE NOT N USE _ D MAKING RIdiT TUHN LMERTHAN UILNkH' TYPE OF GC.LLISlGNCOL BUS REIATf.OE MAKING LEFT TURN D utlK!+ot+N A L_L[nD•GN ! tMOTORTRUCKCONDO f MnKwGUTUReJ. 8 SIDE SWIPE. T7RAfLER COn1B0 G MCXUJOC REAR ENDH SLOVANGISTOPPNJGFATNER MARA i70lITE+US D_ __ __ _ I PASSING OI HER VEHICLE A CLEAR E HITUUJECT -_ — ._- IfJ CHAJJGINC LAHFSF OVERTURNED r— I I K PARKING MANEUVER •__ C VFMCLF/PEDESTRIAN L -- _ — H11 L ENTERING TRAFFIC D sN01 AH:G __ H OTHER*: M _ Y)OTHER UNSAFE TURNWO E rOnIVISMILITY N ^-- N%INC I.YTO OPPOSING.UTNE � F otHEn': _ UOTOR VEHICLE INVOLVED WITH _ —0 _ _ O PARKED �.••G WIND A NON-COtLIS1ON Y_ _ _PMF.RGN:G LIGHTING 8 PEOESTRIAN �. - I Q TRAVELING WRONG WAY A DAYLIGHT_ ., C UT}ICR MOTOR VEHICLE 1 2 3 OTHER ASSOCIATED FAC TORTS) ' R OTHER': Ei DUSK•DAWN _ D MOTOR VEHICLE ON OTHER ROAVAAY (MARK I TO2ITEMT COA_RK•STREETLIGHTS E PARKED MOTOR VEHICLE ��A )r.APX•NO STREET LIGHTS __ F TRAIN E DARK,5TRFETLNJHTSNOT G BICYCLE 6 FUNCTIONW rEs ANAM: Po H .cuu+on Ycurm nun SOIIHICTY•DRUG 1 PHYSICAL ROADWAY SURFACE ^,C rce 2 3 (MARK 1 TOITEMS) A CRY .,_ ( FIXEDODJECT: A HAD NOT BEEN ORINXJHG _C SNOLW-ICY _ _ OTHER OBJECT: _ _ _E V!SI(N7 ODSCUREAtE.YT'^ EE�� 8 HDD-UNDER INFLUENCE ST IPPf.RY IMUDDY.OILY.ErC ^, F INATTENTION': C HDD-NOT UNDER INFLUENCE- ROADWAY CONDITION(S) _ •G .STROPS GO TRAFFIC _( D HBO•IMPAIRMENT UNKNOWN•_ fh RK 110217ELfSi PEDESTRIAN'S ACTIONS _ H ENTERING/LEAVING RAMP _E UNDER DRUG INFLUENCE' _ A HOLES.D EP RUT' A NO PEOESTRIANS INVOLVED _ _ 4� I PREVIOUS COLLISION _ F WPAIRMENT•PHYSICAL`_ H L00t;C OAATERUI ON ROAITWAY• BCRUSSINOIN CROSSWALK- _ J U:JFAMRUVTta%HUM _ GNAPA'AMEJJT NOT i?4AVN j_jC OBSTRUCTION ON ROAOV _ _ �Al INIERSEC71QIJ _ K,DEFEC7IVL!VEH EQUIP,: CITED I H NOT APPLICABLE D CONSTRUCTION.REPAIR ZONE C CROSSING IN CROSSWALK-N07 YES T-1 I SLEEPY I FAIIG ED' E REDUCED ROAD\YAY WIDTH AT INfEHSECTIOV _� NO F iL000ED' D CHOSSN+G•NOT IN CROSSWALK L UNINVOLVED VEHICLE G 07HER'. .. ......................_.___.E IN ROAD-IINCLUUCS SHOULDER ... .—Al OTHER•_..__— ......_ _ H NO UNUSUAL CONDITIONS ____ F NUT IN ROAD__.. 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''4'<' :'.!�'"� F. N+r:-� :%�° 9�� :�"'a •-.5. :*.,:.f:.�'(":a�� {';.'„+.�:`::$Tj., ::::�."'r,�.y. :•::us�.6f.�:" :n.;�.��^b'x. '�:1, •F?tr•1 ';'x`x; hk:;'•Y'! !• pt:S.'.�;`, �.��: r •1' .,k-:•I.Sk,� t?�.• ..a?iF'af:;,. "t.t' •..y...:,�l.i.�'.`�"" .J. .µ r;;+� i. 'r J' �.•. ..C`7 ..4iZ � .t. � � g „sa..,•:.�>•i:. �-�•�• 't"y Y �y XµbN is•�:a•,� `:x^?4.. s sill w hri• �> '9C'. ..L w3'. - A g � aria.. -.."'.as........ -�.......,.._... ,...........,...� ._ ..:................ _ l California State .4utonrobile Association Inter-Insurance Bureau P.O.Bos 920 Suisun Citi, CA 94585-0920 June 26. 2007 Allstate Insurance 3121 West March Lane Suite 200 Stockton, CA 95219 I RE:' . Your Insured: Kathy Felter r . Your Claim No:: . 3955025443 Our Insured: Reagan/Sally Ondler Ondler Our Claim No.: 06-E410724 Date of Loss: 05/28/2007 Dear Allstate Insurance: This will confirm our subrogation interest arising from this loss. We have settled the claim with our insured and based on the following facts, request payment directly to California State Automobile Association Inter-Insurance Bureau (CSAA-IIB): In order to assist with.and expedite the evaluation.and processing of this subrogation demand,we enclose the relevant documentation in support of our claim. This information may contain personal or privileged information abo,it,our ins '-ed,and is being provided to you pursuant to California Insurance Code Section 791.13 and may not be,,ired'for any ung &j-,i.:ed purpose. Bast.6 upon this it,fgnnation,we ask that you issue payment of$6099.99 Repair Bill $6,099.99 Deductible $0.00. Loss of Use $0.00 Tow/Storage $0.00 Miscellaneous $0.00 -------------------------- TOTAL $6.099.99 Please be advised that any payment in an amount less than that set forth in this letter that is forwarded to CSAA without its prior authorization as described below will not constitute a full and final settlement and will be accepted as partial payment only. Since payments received in the mail are processed by clerical staff and deposited as a matter of course without examination,unauthorized payments for less than the full amount demanded may be processed inadvertently. Although such payments may be demarked as"payment in full"or have other words of similar meaning written on them; their processing will not constitute an accord and satisfaction,as CSAA has not agreed to acceptance of such payments. Only an authorized Subrogation Specialist may communicate,orally or in writing,CSAA's specific agreement to accept an amount less than that demanded in this letter. If you have any questions,please feel free to contact the CSAA Subrogation Department. Sincerely, Subrogation Recovery Team B 888 900-6520 extension 6297 Fax 707-863-9052 F268K(Apr 2002) un 21 2007 16: 35 C S H A 7132665138 06121/2007 15:52 510759OS29 SAVON PINOI_E PAGE 01 c.ed`�' V1 fjf j)/ // �jfl C" Job Piumber; Ct6i;'.1IZOG7 += 1 'l:d'1 AM N 3358,1 o ;�NbY Is 11QZC► DWI Q Licenso #;AUP6430 Federal TD #;6H0:'42:63 135 24th St. U - R.1.;hmond, CA 94844 m 115101232-5745 Fax: (5I0l232-6Ii;t Q PR,F.L1txLt+M? ESTrMTE w w Written. By: Rick Crenshaw U w Adjuster: In-usedt: Eieg�.1). Ondler claia 1F vmea : .J;tc 3C is tJ*cdl er Policy .:.ess: X00 neduetit+le Add : �L (�/1 c,I res � CnDttCe of Loss: vexing: 'r IC 1750-1107 �ySGy'rype of Loss: paint of sarpa►r 711pact AN1Yf'S .-;.L-rD RCDY susineas; 335 2?th St. -ticras��adr CA 94804 =:�ssW asaae toaagiatty: Drys to Repair lga:t JrUt~ =t` cY.2 SWMTVIXE, 6-5.9L-TD 2D P/U Int: vL't: '_B'it4l,3fi?;14SJG '096 LiC: Prod Da": 2an� d' rlrr s: Dual Mirrors Ota 1t 113 int Pc'rrr:Y S'he*aliA{. Power Brakes At4 i:..id:ic� ., f'43 uarlio Stereo C�verdrive1. ' DESCRIPTION CITY .EXT. _Y-1C. L:.,Jt i'hIN'l` u..... ._.---------w-w--------------------------------- - FRONT BLWJ .ER Z.* 1iwpI A/P3 Sumpr_r.w/gve.rds chrome 1 2+54.0, X7. 9 3 J,.ep": LT Guard 1 120.01%11 0.2 4 Glk LLE S Rept Grille surround chrome 1 2'+9.0o Incl. t* Rept A/24 Lowe;, panel Adci for Clear. Coat 8 FRONT LAMPS 9 ATpi LT Sealed beam I:a3logen I 1.6.:35 Incl. Ci Aim "headlamps 0.5 =1 • Kt-p1. A/M L? Park laiftr. 0.3 22 COOLING t a 0 Rc:c:I Radiator support. W/intercooler 1 56".00" aJ.5 14 Evacuate 6 recharge m. 1.4 1J Bepfrigerant recovery m 0.4 :.6 Ad.d for trann cooler 0.2 a"► FEEL 2F Hr,t.) LIP Vender 1 3'>t).t.r{i 2.4 14 overlap Minor panel 1 [u un[ Val RS18?SZOLS Rpog 09rEi SRFuO g4ee:l t GO California State Automobile Association Inter-Insurance Bureau P.O.Box 910 Suisun City, CA 94585-0920 June 26, 2007 Allstate Insurance 3121 West March Lane Suite 200 Stockton, CA 95219 RE: Your Insured: Kathy Felter Your Claim No.: 3955025443 Our Insured: Realan/Sally Ondler Ondler Our Claim No.: 06-641072-4 Date of Loss: 05/28/2007 Dear Allstate Insurance: This will confirm our subrogation interest arising from this loss. We have settled the claim with our insured and based on the following facts,request payment directly to California State Automobile Association Inter-Insurance Bureau (CSAA-IIB): In order to assist with and expedite the evaluation and processing of this subrogation demand,we enclose the relevant documentation in support of our claim. This information may contain personal or privileged information ataoltt our ins-i_ed, and is being provided to you pursuant to California Insurance Code Section 7.91.13 and may not 6e!geed for any uniuthj:i,-:ed purpose. Based upon this ii,forination,we ask that you issue payment of$6099.99 Repair Bill $6,099.99 Deductible $0.00 ; Loss of Use $0.00 Tow/Storage $0.00 Miscellaneous $0.00 -------------------------- TOTAL $6,099.99 Please be advised that any payment in an amount less than that set forth in this letter that is forwarded to CSAA without its prior authorization as described below will not constitute a full and final settlement-and will be accepted as partial payment only. Since payments received in the mail are processed by clerical staff and deposited as a matter of course without examination, unauthorized payments for less than the full amount demanded may be processed inadvertently. Although such payments may be demarked as"payment in full"or have other words of similar meaning written on them, their processing will not constitute an accord and satisfaction, as CSAA has`not agreed to acceptance of such payments. Only an authorized Subrogation Specialist may communicate,orally or in writing,CSAA's specific agreement to accept an amount less than that demanded in this letter. If you have any questions,please feel free to contact the CSAA Subrogation Department. Sincerely, Subrogation Recovery Team B 888 900-6520 extension 6297 Fax 707-863-9052 1 Jun 21 2007 16: 35 CSRR 7192665138 P. 1 06/21/?007 15:52 5107588629 SAVOR PINCLE PAGE 01 - y/07VV C 0 N U6/:'1120G7 ,fit 1 'I:9'1 AM Jos Number. N 335K1 co o U !-QMY F S AUTO BODY Q Li.crnsn: #:4L1f6430 rederal III #:680::42263 v� 135 24th St. Rlf;hmondr CA 99804 >- '5101232-5745 Fax: (510)232-3190 W PRET bLT.NPX? 99TIMTE U Written, Ey: Rick Crenshaw W Adjuster: Iess�ueti: El?g A. Ondler Claim o►n►et: ;;t2JOT) OndlQr Policy iF ".14- Deduc tibl t':: omt& Of Loss: gvcx�ing: (51.C)75n-1107 �►�SGyram of loss: Pont o£ rapaa' Point : I spec`- !kN1)-i'S ,';.Ul'O RCDY Business: (51.0)232-5149 Richanond, CA 94804 x:�snranee . c:ornyaay: Day-L .to Repair 19 a':. JDDC, �Y.2 SWE--'TLZME 6-5.9L-TI) 23 P/B Int: VLN: Lie-: Prod Oat*: Odcnoeter: %n,;"ed Class . I Dual Mirrors :,J.es:: Cn.At Faint Pc:wr r SY�aerin''- Power Brakes AN :'i:,din , F•M Ridlo Stereo t.nti-Lock 9i•aka> (?; - 4 Ov^rdrive DESCRIPTION QTY ZXT. _RICL -1 JEe5l FA.iN1' FRONT 9UW.EcZ . o laFpi. A/M etunper wlgu2.rds- Chrome1 264.0', %), 9 3 hep'-1 LT Guard 1 1?.0.1?i) 0.,2 1 . GR 7 LLE . ' Repl Grille surround. chrome 1 2'19.DO Incl. t*� ta.ep1 A/24 Lower panel I IS S0 0.7 Add for Clear. Coat X7.2 5 FROPT LAMPS 9 Real LT Sealed beam halogen I 7.6.:15 Incl. Ar, Aim headlamps U.5 Fttp1. A/M Li Fork Lamp 1 -..8.:6 0.3 12 COOLING t; c) .Ric,1-1 Radiator support. w/intercooler 1 511`2,00 4.5 .14 Evacuate 6 recharge m 1.4 15 refrigerant recovery m 0.4 IE Add for trans ccoler 0.2 a7 FENCER LT mender 1 1 >0.00 2.4 2 . ±9 Overlap minor Fanel 1 'd O�T9?EZOI$ spoil OZr'q SFRuy aLS=TT 60 la linr Jun 21 2007 16: 35 CSRR 7192GG5138 p. 2 06/21/2007 15.52 5197588629 SAVON PINOLE PAGE 92 0 E/23/2007 ;.z '.3 :4 1 AY, ..job ;,;umber;: • J3581 P'lI L MILV)&Y ESTIMME ;.991 7JDG 1)350. 02 SWEPTLIN2: 6-5.91-TD 'il ='/q Ir. 1`O O.r'- DESCRIPTION QTY EXT. P1-:10E LABOR PAINT 20 Adc? for Clear Coat .1.0- :'. i Add for Edcing p,g J1. Add for Cl_Par Coat 21 Deauet for Ov-:�z3-Mp -0. 5 24 Rein.) LT Splmsh shield 1 1-011.00 0. 6. ,0,° Z5 Ow!rlap [Minor Panel -0.2 24 Real LT Front moldj.ng 1 66.3"1 0.1 27 Dr.111 Time 0.2 2F? I3O0i 4"* RepI AIM. hood 1 29 4-00 1 .1 3.7 30 Overlap Major Ad: . el -0- q 3:!. Acid :for Clear Coat C,�6 Add for Underside(Complete I 1 . 5 3; Add for Clear Coat U,.3 34 fit:p1 'Lace . 1 e;i,7r, 0.3 :3 H. P.epl Pop-ep spring 1 3.60 :iblR B.r�P i g shmi Ld 1 89.95 DO0rc 3p Rept, A/M-LT Outer panel 1 9`1 ,2; 4,5 39 C) erlep Major Ad-i- Panel .Add for Clear Coat 9i Add for Edging J,5 Add for Clear Coat 1&4d for Inside 41 Add fC'r Clear Cort 45. FItAN1$ T6 :. Ipt Prams assy diesel 5 4. 47o , €e is Up 1 ? 5; F 4.?fr Pull t:o Square ------------------------ ------------------------------ ,------ subtotals ==> 2303.00 ?.8;. 2 15- ° 0 --------- ---- -- - -------------------------------- ---- Note3. ------This is a Closed hid agreement.I understand that the Insurance wil., nct acL-ro;= any -;upp).entrnt.s or add.i t:ional cost for this vehicle Any additional cost. vil. vp at tf:E e�pelase of Regan Ond.ler as per agreed with Rick Cr-en�,ha-w anci t:he incurance Parts 23C;1.11;, Body Labor 2e. 7 hes r $ 70.00;lht• 2.E,0.1)0 l Paint Labor 15.9 :",.rs @ a 10.00/hr ].10(.,.00 Frame Labor 1. 5 brs @ ; 70.00/hr Ori.00 . Paint supplies 15.8 'hrs @ S 30.00/hr 4-11.00 S7jo to SUBTOTAL Sales Tax S 2777,00 Ca 9. 1540rr�2�9p�p. GS o. -d OELBZE20IS RP 8 O Ozn sA u d P d eGE=I.( LO ung 7192665138 P• 3 Jun 21 2007 16: 35 CSAR • PAGE 01 SAVON PINDLE 06/20%2807 09:32 51875(38629 Jtin 20 2007 8: 15 CSRri 7192%65139 p-2 IMPQR"FANT NOTICE-READ BEFOIREE Sj rm hn al¢ninp the IbllDrrk+tt Idolise or Al[Prooe't' Dan+aBs C140M Y13110 are gMmO Wes YVur rlshts end otelm frar prope•Zy daMape rebuking from Zhu slccldert:, castugy ar avant We ad 114 In the 115110414*. MhICb Yfw may not oven kpow or buepW to "fsL which .1 hnOw n N You would hew rrateda�r st#.cwdkrvreett11ement. . 1 ruttnOnMaAse tllal l 14w*read and undonlood fie above Nodes. 4wsC t1F3M7URa- . PM01'of,Loss Receipt an Release . s-Eaio"j2-4 x 01 COI. rory. r» aeeyErpl�w 410724 Accerding to the!arms and rondltlolls of the Policy of 1ltoursnea Identified above, the California r5wt6 Arrtomobllr A3eo0Aton Igl*r•1:,nrnr+ce t3uroe+i(EurAeL)lfrsureC R NSall�r errtkrOndbr speio5t!rAa 101he nutomor+rla . .fnncilbsd In said ftllCy or,follVwrs: ..:inin ar DoCr10 1991 Truck 1�?ME36C7MS3ti30�iG A loan osua*d by 96114lon ocow lrad on the 231h day of Miry13 2011; abr.vt the her 3--W pm the p♦f1�41arsi 411 whp:+the se FDIC" --�—r.�-^----�Wit-- - - - ---- — -- A,dkevee vehlclt pu1W in f:enl of#=fed vehicle Causlnp a oottom Tle vehlde Trill 44 retel:lpd by: q Puts" ® Irdtuve 'k foes d"Clo ed curs not ralmed fronfic rimer or others, by to dwV%proasto nerd or 4+iod of the fnsufOd not by any ogerit or nrry nfTer pares n epinp r:r tx on t»naN,a the kleu►sd, ' Ther-4 ms ather hnura Hoe In fame tavertng thfs Wer, ?fie,a 1s i i..n,contalotial Bak ca*w.oatmeal tens*,of clhas Irltenest(n the cheat ataoraeblln et<oept: i�+w.W-sT• baa+,ww rr.soisro . ` rtfBDM�J+e n+lr5d $Q.UC2.D9 $0.09 jt10 �6 Dug ipl _� to Dcstrider[l[nl a(IAs?symoM a: Slx Th^xyy.d tfin5ty k'rwyolmrs991100 the Irt_;W1 X Hereby asaiprw Iran-fere+fad-- to over to the Bureau any and al cl41bns or causes of aclion for pto; f%i dorir:gavrl"the 14%uma nrw has,or May hereafter Move,apsinst any pemon or persons its the ranult Of:hr occurrc nce. RrW Iota as descrlbs.7 if4ovs,to the extent of the pAytnek ebwo theft the tnsuted sprees that the aureas Inrry 4nlorce the rams M such marvel 21'aholl be neoesawy a appropllso for the use and benoM of the Bureau,sillier I"!% ewn!an" or M 11e nc--4 of the Insur-)d;that the Insured w11N iura{sh such popers,Iamrww"On'of*valence sus DIr4;1 be wHlwn th! ; Irwtrred•s,psrHsasia0 or contrDl far!lie Purpose of eaforfing such claim,demand,or cause of action; and the Insumd endr-startds..sne igloos shat itis Nrnlahlng of IMP ronin at the pWarelion thereof by arty adjustar or agent of the ftrerw Is lir t 7 w"f.7f qw rights of l3uir"il. The Insufedodboowlelillpes mcalpt d the ours at Six Tho+sad Ntmety Nkre Co3ars 99900 and nersby relapses rad dicflhereen th.! Duress,pont any end all 11ebllily whalsoover .ror sny claim r+nde.Policy No. E410}14 Ilpr the properly dartleye dsacrllbW above end ILrther ecknowtedges r*calpt'of sold amount in full cattsfaotlos for all*ath Naime cr Qernends. 1 Pr�On ta.ot) XPORTAW-READ BCITN PAGES BEFORE SIGNING suw r et Jun 21 2007 16: 36 CSAR 7192665138 p. 4 06/2012007 09:32 5107598629 SAWN PINDLE PAGE 02 Jun 20 2007 9: 15 CSAR 7192665x38 p-3 1'1111h tiped 10 ttre IMuraa'e ptooarlr 9otrU�oa dsim,firs tatderelpnad haroby BRalensly vtsNes the Drovl.ion9 dl,`'•HCtfOri 15.;•1 . of the ChrE Code o`the state of Caftml% wAteh roa4e as k"&Aa: 'A gffwml re10299 float not oxf"to etafms which tho creditor do"not knew or ewoect to 4ufet In hIF faeoq nt the time of x*cuting"ratesae whlch F trnowa by Itlrn rnwt he"malerteMy xf4ecled hip so tlemal with the doDlor.- The tnoared ACMO�dodpea roedpt of 111e auri� Qx Thaunand wwr!►mmll I:'oRors 9"00 ( S fi.099.t19 ) Ppktrmderhit dhpctbnm.reae . 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R•• •>1•"�- .. ?S'mr .k`r��.e;i.�4•`.r;?'w • r`w•'� z' i ��: ��:e,` �� _ mad 3• y,�a f c •� QI.(:C i' c Gt�:G f b , l • t i t Claim:3955025443B02 Autosource Valuation 1991 Dodge Ram 350/3500 STD Diesel Turbo 2VVD Long Bed AS Request:20254922 Standard Cab rAudarex Autosource Valuation Dave Scholz Claimant Allstate Insurance Company Insured Felter Capitol Auto MCO Branch Claim 39550254431302 1025 Creekside Ridge Dr#203 Loss Date 05/25/2007 Roseville CA 95678 Loss Type Liability Policy Other • t.( . 1 1 1 : ( • 1 B7ME36C7MS363086 Decodes as 1991 Dodge Ram 350/3500 STD Diesel Turbo 2WD Long Bed Standard Cab Accuracy Decodes Correctly History Activity was reported o Autosource activity:(NONE). U Autotrak activity:(NONE). o Audatex/Estimating activity: Reported by ALLSTATE -SACRAMENTO on July 16, 2007. Call them regarding Claim: 3955025443602.DOL:05/25/2007 with a primary impact point of Front Center. o Sales history activity:(NONE) No NICB/ISO Activity C E C C C( f o' • Quote 1. Quote 2 Averag,4� Price $5,530 $4,600 $5,065 Engine 6 Cylinder Diesel Turbo 5.9 Engine 6 Cylinder Diesel Turbo 5.9(Engine Transmission 4 Speed Manual 4 Speed Manual ( Odometer 165,568 Mi 165,568 Mi Actual Cash Value $5,065 General Sales Tax 1 Title/Transfer Fee — • The market value displayed may not Subtotal reflect the activity detected by VINSOURCE and/or NICB research. Deductible Net Adjusted Value 22 L7 Salvage/Other t, `The market area identified has multiple tax jurisdictions. Please see valuation notes for explanation. Ll �5•SL Version:1 Page:1 07/20/07 14:07 Claim:39550254431302 Autosource Valuation 1991 Dodge Ram 350/3500 STD Diesel Turbo 2WD Long Bed AS Request:20254922 Standard Cab Average,Quote 1 Quote 2 Actual Cash Value' $5,065 o Adjustments of Special Note ° The requested Exception valuation has been processed using Two Dealer Quotes in order to meet state regulatory. requirements" ° No special adjustments were made for this vehicle. o Information provided by Allstate Insurance Company ° Loss vehicle description was provided by Allstate Insurance Company ° All values are in U.S. dollars. o Autosource Valuation Process ° Over 2,400,000 vehicles are entered weekly into the database used for researching this value. This database includes dealer inspected,dealer inventory,dealer advertised, phone verified and advertised private party vehicles. o The originating search area for this valuation was Pinole, California. ° The market area expansion was authorized by Autosource Guidelines. ° Dealer Quotes have been used as the basis for this valuation. Autosource utilizes Dealer Quotes in situations where there is limited market data due to the relatively uncommon nature of the loss vehicle. Each Dealer Quote reflects the dealer's professional opinion and represents the expected retail price for the loss vehicle as described on this valuation. ` ° Dealer Quote 1 is from Autometric Used Cars ° Dealer Quote 2 is from California Auto Sales ° The market area identified has multiple tax jurisdictions.Autosource was unable to identify which county or city was applicable to the total loss vehicle. Upon verification of the correct amount, you will need to select the tax from the possibilities shown below. County City State Tax Contra Costa Pinole CA $443.19. Contra Costa Tara Hills CA .$417.86 o Other Adjustments or Comments ° It was necessary to use typical mileage in order to obtain dealer quotes,as no mileage was p:ovided. 1111 10 1, IMPOSE IMF 1151pas e• I •1 1 D e o •• r •, No salvage title history found for this VIN. Processed on 07/16/07 2:35 PM. Title History is powered by Experian AutoCheck. The Experian data,contained:•r•, this report involves the conveyance of information provided to Experian by other sources. Accordingly, neither Experian nor'A-Ap..t1x can, or will, be an insurer or guarantor of the accuracy or reliability of the Experian data. e. I 11 e e e Nat'l. Highway Traffic Safety Admin(US)has issued a total of 2 recall bulletins that may apply to this vehicle. NHTSA ID Number 93E034001 Date Issued 12/07/93 Quantity Affected 35,000 Manufacturing Dates February 1991 -June 1992 System Fuel:fuel pump. Equipment Description Cummins intercooled turbo-diesel engine using Bosch fuel pumps. Description Of Defect Bosch distributor-type fuel pumps have a manufacturing defect that can cause the ball pin,which is part of the pump's control lever assembly, to break causing the link between the control sleeve and the control lever to become inoperative. Version: 1 Page:3 07/20/07 14:07 Claim:39550254431302 Autosource Valuation 1991 Dodge Ram 350/3500 STD Diesel Turbo 2WD Long Bed AS Request:20254922 Standard Cab Consequence Of Defect When the link between the control lever and the control sleeve breaks, the speed control no longer responds to movement of the accelerator pedal, resulting in loss of speed control and a possible accident. Corrective Action The fuel pumps will be inspected, and if necessary, repaired and replaced. 95V089000 Date Issued 05/03/95 Quantity Affected 78,000 Manufacturing Dates Jul 1990-Apr 1991 System Steering,wheel and column Vehicle Description Light duty trucks,vans and wagons equipped with"Premium"steering wheels Description Of Defect The steering wheel armature stamping can crack due to fatigue and separate from the center hub attachment to the steering column. Consequence Of Defect This condition can cause separation of the center hub attachment to the steering column resulting in a loss of control and an accident.. Corrective Action Dealers will inspect the steering wheel for armature cracks and replace and wheels exhibiting cracks. All other vehicles will have a reinforcement plate installed to prevent steering wheel separation if cracking occurs. Engine Options Transmission Options * 6 Cylinder Diesel Turbo 5.9 Engine STD 4 Speed Manual STD 5 Speed Manual $0 3 Speed Automatic $648 4 Speed Automatic $887 Other Optional Equipment Power Accessories * Anti-Lock Rear Brakes STD Power Brakes STD Camper Mirrors $102 Power Door Locks $182 Dual Rear Wheels $1,059 Power Mirrors $138 Limited Slp Differential $257 Power Steering STD Rear Step Bumper $234 Power Windows $182 Sliding Rear Window $115 Convenience O.ptons Tutone Paint $255 Air Conditioning $797 .. . * Tinted Glass STD Cruise Control $23� Camper/Towing Package $318 Tilt Steering Wheel $230 Radio/Phone/Alarm Options Seat Options AM/FM Stereo Tape $205 Velour/Cloth Seats $72 " AM/FM Stereo STD Base retail price $18,330 • $18,330 Editions available for the same body style(in order of original cost, increasing): *STD, SE, LE * Indicates loss vehicle equipment. OWS.. - .-i . . . . . After your claim is settled,Autosource provides free assistance in locating your next vehicle.Your request can be submitted online 24hrs. per day at www.support.audatex.us/Autosource. Please click the Online Submission link and then click the Vehicle Locator Service Form link to complete the VLS form. Or you can call us Monday through Friday, between 8:00 AM and 5:00 PM, Pacific time at(800)351-3133,ext 7428.Our specialists will work with you to find a new or.used vehicle in your area. Version: 1 Page:4 07/20/07 14:07 CIa1m:3955025443B02 Autosource Valuation 1991 Dodge Ram 350/3500 STD Diesel Turbo 2WD Long Bed AS Request:20254922 Standard Cab MIM This report contains proprietary information of Audatex and shall not be disclosed to any third party (other than the insured or claimant)without Audatex's prior written consent. If you are the insured or claimant and have questions regarding the description of your vehicle, please contact the insurance company that is handling your claim. Information within VINsource/NICB is provided solely to identify potential duplicative claims activity. User agrees to use such information solely for lawful purposes. Tax rates contained herein are based on general sales tax data provided by Vertex Inc. Excise, use, registration, licensing and other taxes and fees that may be applicable are not included. Audatex makes no representations or warranties concerning.the applicability or accuracy of such tax data. Report Generated by Audatex,a Soiera Company ©2007 Audatex North America, Inc.All Rights Reserved. Version: 1 Page:5 07/20/07 14:07 1207 10:26a Bruce Felter 925 228 8117 p.1 PAIR ORDER blo Marine & Trailer R/O # : 2217 1 0 A. Nardi Ln Name : Felter Martinez, CA 94553 - Date 06/04/2007 X25-372-0855 ID # : FELTERC Make :TRAIL WEST Model : CLASIC 2 Year: 2003 Cathy Felter Hours In: Save Parts :NO 1085 Bear Creek Road Briones, CA 94553 )25-8724025 1M I C k-N LLG C3ci '5 ,s 0 2 5 443 .ustomer Complaint/Service to Perform Visual Frame and damage check out and advise. Trailer hit by truck ,ABOR HRS AMOUNT Checked out damage to trailer. Inner wall and left front corner of trailer are heavily damaged from 1.00 103.00 impact.Measured out trailer frame and found that it is 9116"out of square. The trailer needs extensive repairs of which is beond our capacity.Recommend having the trailer sent back to the manufacturer for these repairs. Highly suspect that repair costs will outweight the cost of a new trailer. Job Sub-Total 103.00 LABOR 103.00 PARTS .00 SUBLETS .00 EPA#CAL 000273703 .00 FREIGHT .00 SUB TOTAL 103.00 TAX .00 Amount Received:1100 Balance : 103.00. TOTAL 103.00 stimates given good for 30 days of above date. hereby authorim the above named business to perform the repair work listed above along with necessary materials.You and your employees may operate the above vehicle .or purposes of testing,inspection,or delivery at my risk.An express mechanics lien is acknowledged on above vehicle to secure the amount of repair.Thereto it is inderstood that this company assumes no responsibility for loss or damage by theft or fire to vehicles placed with them for storage,sale,repair,or while road testing. 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QI � - +�• •.t,. a 7 r ins. b; r. ,t,ir i n rr}�'t '"'.`a v S' t t i t ♦ ;1 + Sa«tl 1 ra,: � �6� s� A ��a �1�t r:, •��as'�,, t�r 1 ; t` a •la�'7 � j,.� } �,�+, 5r ,� ,fit= �`� r .. y �s,.d�, .�-�r �K :•-'1 +r«r•�S .G�t;�- -^' <=a r,. :.r „ .,;, ,�e iIi r 1 ` w r. j tt;,c, s'fiY.'sy�GtC ,s-"w X39 ep��y L.5+3t`<- a'1' � ��a A ,�x•+ ..x .<�.. 1J, � _ � . �".aa el t ME 4} t �e sk t r o ca w 0(-) vco �. CC ze cn o C . U 'w ' CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY BOARD ACTION: SEPTEMBER 18, 2007 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Eadoi)semefnts;-, . 72 NOTICE TO CLAIMANT 111d1 . �� r ' . and Board Action. All Section i-eferencess,ar�tol;��3 .'\),� � The copy of this document mailed to California Government Codes. AUG 14 app you is your notice of the action taken 7 on your claim by the Board of COUNTY COUNSEL Supervisors. (Paragraph IV below), MARTINEZ CALIF. given Pursuant to Government Code AMOUNT: $2, million — for Kristin McGuire Section 913 and 915.4. Please note all $500,000. — for Frank McGuire "warnings". CLAIMANT: KRISTIN MARIE McGUIRE and FRANK McGUIRE ATTORNEY: MICHAEL PETER SEMANSKY DATE RECEIVED: AUGUST 14, 2007 SEMANSKY LAW FIRM ADDRESS: 535 MAIN STREET, THIRD FLOOHY DELIVERY TO CLERK ON: AUGUST 14, 2007, MARTINEZ, CA 94553 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. AUGUST 14 2007 JOHN CULLEN, Cl 'k , Dated: By: Deputy I.I. FROM: County Counsel TO: Clerk of the Board of Supervisors ( his claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( ) Other: Dated: By: Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator (2) O Claim was returned as untimely with notice to claimant (Section 911 .3). IV BOARD ORDER: By unanimous vote of the Supervisors present: (6This Claim is rejected in full. O Other: I certify that this is a true and con-ect copy of the Board's Order entered in its minutes fol- this date. Dated: s JOHN CULLEN, CLERK, B Deputy Clerk WA IN (Gov. fode section 913) Subject to certain exceptions,you have only six(6) months finm the date this notice was personalty served or deposited in the mail to file a couwt action on this claim.See Goveninient Code Section 945.6. You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Wareing See Reverse Site ofThis Notice. AFFIDAVIT OF MAILING I. declare under penalty of perjury that I am now, and at all tinies herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Ntartinez, California, postage fully prepaid a certified copy of' this Board Order and Notice to Claimant, adch•essed to the claimant as shown above. Dated �Q d JOHN CULLEN, CLERK By Deputy Clerk i J � i This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The abovelist is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be tiled may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa does not waive any of its.rights under California Tort Claims Act ,nor.., does it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act i i I 4 BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in... . D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. ■■Mrrrrrrrrrr ■■ ■rrrnrrrrrrro . RE: Claim By: Reserved for Clerk's filing stamp KRISTIN MARIE McGUIRE AND FRANK McGUIRE ) AP Against the County of Contra Costa or ) AL/0 1 District) C4FRKeOq 4 loo,, (Fill in the name) ) �ONTA°°Fs�P COSTq FR��SO ) CO RS The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$2 million for and in support of this claim represents as follows: Kristin McGuire an $500,000 for Frank McGuire 1. When did the damage or injury occur? (Give exact date and hour) March 14, 2007, 9:15 a.m. 2. Wher48 id the damage or injury occur? (Include city and county) Pacheco Boulevard, Martinez, Contra Costa 3. _ How did the damage or injury occur? (Give full details; use extra paper if required) Claimant was struck by a motorist due to the dangerous and defective condition of the roadway.in question. 4. What particular act or omission on the part of county or district officers, servants, or employees caused the injury or damage? The County did fail to place warnin signs, traffic signs adjacent to said area of accident and being aware of passing pedestrians did not place any signs for pe.destrian crosswalks or cross traffic, thereby causing a dangerous and defective 5 What are the names of county or district officers, servants, or employees causing the condition. damage or injury? Unknown at this time. 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) Claimant KRISTIN. McGUIRE sustained leg and knee, head injury, condussion, neck and shoulder injuries. Claimant FRANK McGUIRE is KRISTIN.McGUIRE's father- who witnessed the accident and suffered damages. 7. How was the amount claimed above computed? (Include.the estimated amount of any prospective injury or damage.) Medical bills totaling over $600,000. and continuing; as well as wage loss specials. 8. Names and addresses of witnesses, doctors, and hospitals: Robert Stewart, 261 Safari Way, Pacheco, California; John Muir Medical Center, 1601 Ygnacio Valley Road, Walnut Creek, California. 9. List the expenditures you made on account of this accident or injury:. DATE TIME AMOUNT 3/14/07 9:15 a.m. $1,283.98 AMR 3/14/07-4/13/07 $611,715.72 John Muir Medical Center Continiiing. ■■r■■r■■r■■rrr■■r■ .■■■rrrrr■■rrrrr■■r■■■■errrrrrrrr■rrr■■rrrrrrrrrrrrrrNames . ago wool Gov. Code Sec. 910.2 provides"The claim shall be signed by the claimant or by some.person on his . behalf., SEND NOTICES TO: (Attorney) ) Name and address of Attorney ) ) MICHAEL PETER SEMANSKY, ESQ. ) (CIaimant's ignature) SEMANSKY LAW FIRM ) MICHAEL PETER SEMANSKY, for Claimants KRISTIN McGUIRE and 535 MAIN STREET, THIRD FLOOR ) .10 CROLONA HEIGHTS, CROCKETT, CA 94525-1102 FRANK McGUIRE MARTINEZ, CA 94553 ) (Address) ) ) Telephone No. (925) 372-8766 )Telephone No.4975)2298-9400 .......rrr.rrrrrrrrrrrrrrrrrrrrrrrrrrrrrr■rar...rWoman■rrrrrrrrrrrrrwage.rir..rrrrrr# PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments, addendums,or supplements attached to the claim form, including medical records, are also subject to public disclosure. r.■r■r■■rrr■r■■■■■■rr■rrr.■■■rrrrr■r■■r■rrrr■■rrr■rr■■■rrrrrrrrrrrrrrrrrname rrrrrrrrl NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. l CLAIM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY • BOARD ACTION: SEPTEMBER 18, 2007 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Sec .i r�-r ea'ences-ar:e,to ) The copy of this document mailed to California Government Cd�sl � 1 � ) you is your notice of the action taken " AUG 1 6 2007 on your claim by the Board of Supervisors. (Paragraph IV below), COUNTY COUNSEL given Pursuant to Government Code AMOUNT: $522.88 WRTINEZ CALIF. Section 913 and 915.4. Please note all "Warnings". PLACER COUNTY SHERIFF CLAIMANT: BY: EDWARD N. BONNER ATTORNEY: UNKNOWN DATE RECEIVED: AUGUST 16, 2007 ADDRESS: P.O. BOX 6990 BY DELIVERY TO CLERK ON: AUGUST 16, 2007 11500 "A" AVENUE AUBURN, CA 95604 BY MAIL POSTMARKED: AUGUST 15, 2007 FROM: Clerk of tine Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, Clerk Dated: AUGUST 16, 2007 By: Deputy i lI. FROM: County Counsel TO: Clerk of the Boan-d of Supervisors �— (< ,`Fhis claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should retum claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911.3). ( } Other: Dated: — By: �Y� a� Deputy County Counsel III. FROM: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). IV. BOARD ORDER: By unanimous vote of the Supervisors present: (� This Claim is rejected in full. ( ) Other. I certify that this is.a true and correct copy of the Board's Order entered in its minutes for this date. Dated: _ A N CULLEN, CLERK, By Deputy Clerk. WA 1. G (Gov. code section 913) Subject to certain exceptions,you have only six(6) months finrn the date this notice was personally served or deposited in the snail to file a court action on this clainn.See Government Code Section 945.6.You may seek the advice of an attorney of your choice in connection with this matter. If you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side of This Notioe. AFFIDAVIT OF MAILING I declare under penalty of perjury that i. am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in Martinez, Callf'ol•nia, postage fully prepaid a certified copy of this Board Order and Notice to Claimant, addressed to the claimant as shown above. Dated: '� 4AOHN CULLEN, CLERK By eputy Clerk iJ tli� r;l This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as. mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa does not waive ally of its rights under California Tort Claims Act nor does it waive rights under the statutes of limitations applicable to actions not subject to the California Tort Claims Act r • �vl �gERIFF PLACER COUNTY SHERIFF CORONER-MARSHAL _. ` FA,yR� ��.�L MAIN OFFICE TAHOE SUBSTATION ^�� fill p�CER COL'S � � P.O.BOX 6990 DRAWER 1710 r'�l�rll�f d"'\ AUBURN,CA 95604 TAHOE CIN,CA 96145 EST. 1851 S �� PH:(530)889-7800 FAX:(530)889.7899 PH:(530)581.6300 FAX:(530)581-6377 EDWARD N.BONNER STEPHEN L.D'ARCY SHERIFF-CORONER-MARSHAL UNDERSHERIFF CLAIM AGAINST THE COUNTY OF CONTRA COSTA RECEIVED Board of Supervisors County of Contra Costa AUG 1 6 2001 651 Pine St. Martinez,CA 94553 CLERK BOARD Of SUPERVISORS CONTRA COSI-A CO. Re: Case Number SO-07-5591 The Placer County Sheriffs Department files this claim of$522.88 for reimbursement under Government Code 26614.5 for Search and Rescue expenses. Victims: Fickel,Lauren Wilkinson,Glen 408 Monti Cir. 4081 Clayton Rd#125 Pleasant Hill,CA Concord,CA How search occurred:Became stranded.in snow while camping Expenses: $622.88 100.00 Deduction pursuant to G.C.26614.5 $522.88 Report and expense sheets are attached. Please make the check payable to County of Placer County Sheriffs Department, Attn: Accounting Department,P.O.Box 6990,Auburn,CA 95604. Sincerely, Edward N. Bonner Sheriff—Coroner-Marshal I , Placer County Sheriffs Search & Rescue Expense Summary Fickel, Lauren — Contra Costa County Wilkinson, Glen — Contra Costa County S007-5591 4/22/07 Talbot Campground/French Meadows Federal band Fuel: Brian Hadley 70 miles @ 48.5 cents $ 33.95 Officer Wages: Dep. Bob Bumpus 9 hrs @ $62.85 $565.65 Officer Mileage: Dep. Bob Bumpus 48 miles @ 49.5 cents $ 23.28 Overall Total $622.88 1 PLACER COUNTY SHERIFF/CORONER'S DEPARTMENT 'AL(J E LOSS 31 00 REPORT0. RER GEO. CODE CRIMEANCIDENT REPORT year month day events SECTION F M I CRIME TITLE OADDITIONAL CRIMES (SEE ADDITIONAL CRIME VICTIM REPORT ATTACHED) A teeB '-i E O E LOC,GTICN OF OCCURRENCE MO DAY YEAR TIME MO DAY YEAR TIME REPORTED a, f!/ �J�7 a l �- CONNECTED REPORTS TT OCCURRED NAME LAST, FIRST,MIDDLE) - FIRM NAME IF BUSINESS Race Sit I Age HI. WI. Hair Birthdate A B C D I VI ^iGKcL c [. �L ic=LLc JAJ -r ZO �5/ / RES4 ADDRESS CITY RES. PHONE V BUS. PHONE o �, Z. c S — j OCCUPATION VICTIM'S VEHICLE IYEAR.MANUF.,MODEL,LIC.NO. BVS.' I NA-.AE It.AST, FIRST. MIDC.LEI Race I Set I Age H1. Wt. Hair Birthdate A B I C r4 . ADDR[SS _ CITY �- RESPHOOHNE r BU-5- PHONE R ES .I OCCUPATION VICTIM'S VEHICLE (YEAR.MANUF.,MODEL,LIC.NO BVS. U ADDITIONAL VICTIMS REPORTING PERSON (SEE ADDITIONAL CRIME VICTIM REPORT ATTACHED) -7 n ADL T. NAME (LAST, FIRST. MIDDLE) ARRESTED MIRANDA WARNING YES A 0 C D t S FL— C I`1 JUV. OYES ON BNO. U S ADD R E S 5 CITY PHONES (DAY NUMBER = X IN BLOCK) P _ C EJ (NAME OF SCHOOL IF JUVENILE) C kADOITIONAL SEX AGE BIRTHDATE HEIGHT I WEIGHT HAIR EYES CLOTHING DESCRIPTIONS (1) TATTOO (2) MARKS SCARS (3) HAIR TYPE (A) FACIAL HAIR (5) TEETH (6) SPEECH (7) COMPLEXION ADDITIONAL SUSPECTS (SEE ADDITIONAL SUSPECT VEHICLE REPORT ATTACHED) V LICENSE NUMEER STATEANUFACTURE MAKE MODEL YEAR TOP - COLORS - BOTTOM E pI (1) DAMAGE (BODY.WINDOWS,INTERIOR, REPAIRS), !21 WHEELS (MAG.CHROME.OVERSIZE). (3) INTERIOR DESCRIPTION E C C L ADDITIONAL VEHICLE (SEE ADO;TIONAL SUSPECT VEHICLE REPORT ATTACHED) T E tESCP.IBE CHARACTERISTICS OF PREMISES AND AREA WHERE OFFENSE OCCURRED rESCRIBE WEAPON. INSTRUMENT. rOUIPMENT. TRICK. DEVICE OR FORCE USED. POTIVE - TYPE OF PROPERTY TAKEN OR OTHER REASON FOR OFFENSE - Y [: IHAT DID SUSPECT%S SAY - NOTE PECULIARITIES ) ,I%E BRIEF SYNOPSIS ON ALL FELONIES AND SEX CRIMES ON MISDEMEANOR CRIMES, EITHER. COMPLETE REPORT IN THIS SPACE, OR GIVI IRIEF SYNOPSIS STATEMENT AND BEGIN IN VESTIGATI ON O'N//CONTINUATION REPORT. n iE) 1 N V PA T-Rp` 0 P R o B . .,c�1/ It(�IAJ SO -J (�N ` Others v &S U i5 'I -52� —/✓ �J e /— �!!�- l�gc• i�li OcC i [tee S...I C -r-,09.Z /2e�;'n,-J 4 c Other j A hI 4W`Q J Further ACtlon (� YES r O Compute i C YES ONO I ' PO DING OFFIC ER(SI 20 TING OFFICER APP NG OFFICER - TITLE s �� AC3DI T ION--- l,.L GNDE-I MG PLACER COUNTY SHERIFF/CORONER/MARSHAL DEPARTMENT VICTIM(LIST FIRST VICTIM ONLY IF MICRE THAN ONE) REPORT NU BER S.O. YEAR MONTH DAY -EVE NT a SECTION F M CRIME TITLE ADDITIONAL VICTIMS/REPORTING PERSON/SUSPECTS CONNECTED REPORTS NAME(LAST,FIRST,MIDDLE) RACE SEX AGE BIRTHDATE HEIG T WEIGHT HAIR EYES KA Q ADD ESS RES.PHONE VEH.LIC.NO. RES. 6,3 � C BUS.PHONE MANUF.MODEL BUS NAME(LAST,FIRST,MIDDLE) RACE SEX I AGE/ BIRTHDATE HEIGF'T I WEIGHT HAIR EYES ADDRESS RES.PHONE / VEH.LIC.NO. RES. BUS. BUS.PHONE MANUF.MODEL NAME(LAST,FIRST,MIDDLE) RACE SEX AGE/ BIRTHDATE HEIGFJT WEIGHT HAIR EYES ADDRESS RES.PHONE / VEH.LIC.NO. RES. BUS.PHONE MANUF.MODEL BUS. NAME(LAST,FIRST,MIDDLE) RACE SEX AGE/ BIRTHDATE HEIGryT WEI GH T HAIR EYES ADDRESS RES.PHONE / VEH.LIC.NO. RES BUS.PHONE MANUF.MODEL BUS. 7NAME(LAST,FIRST,MIDDLE) RACE SEX AGE/ BIRTHDATE HEIGHT WEIGHT HAIR EYES ADDRESS RES.PHONE / VEH.LIC.NO. RES. BUS.PHONE MANUF.MODEL BUS. NAME(LAST,FIRST,MIDDLE) RACE SEX I AGC/ BIRTHDATE HEIGyT WEIGHT HAIR EYES ADDRESS RES.PHONE / VEH.LIC.NO. RES. BUS.PHONE MANUF.MODEL BUS NAME(LAST,FIRST,MIDDLE) RACE SEX AGE/ I BIRTHDATE HEIGHT WEIGHT HAIR EYES HES. ADDRESS RES.PHONE VEH.LIC.NO. Pt BUS.PHONE MANUF.MODEL BUS. ° ij` t� {i ADDITIONAL VEHICLES LICENSE NUMBER-STATE MANUFACTURER MAKE MODEL YEAR TOP-COLORS-BOTTOM CHARACTERISTICS(1)DAMAGE(BODY.WINDOWS,INTERIOR,REPAIRS) (2)WHEELS(MAG.CHROME,OVERSIZE) (3)INTERIOR DESCRIPTION N0. LICENSE NUMBER-STATE MANUFACTURER MAKE MODEL YEAR ITOP-COLORS-BOTTOM CHARACTERISTICS(t)DAMAGE(BODY,WINDOWS,INTERIOR,REPAIRS) (2)WHEELS(MAG.CHROME.OVERSIZE) (3)INTERIOR DESCRIPTION 7h2-B REV.3/91 PLACER COUNTY SHERIFF'S DEPARTMENT NARRATIVE CRIME: SEARCH AND RESCUE REPORT#: S.O. 07-5591 GEO CODE: 299 VICTIM: FICKEL, LAUREN DANIELLE DEPUTY'S ACTIONS & OBSERVATIONS: 04-22-07 2241 Hrs: On this date and time dispatched advised me that r/p Cheryl Fickel reported her 20 y/o daughter Lauren was over due from at camping trip at the Talbot Campground in French Meadows. The r/p related to dispatch that as many as eight people may be in the group. They were reported to be in two Jeep four wheel drive vehicles. R/P Fickel is concerned due to the possibility of the group being stranded in snow. I drove Mosquito Ridge Road leading to French Meadows. By the time I reached Mile Marker 24 1 was unable to continue in my four wheel drive patrol unit due to deep snow. At that time I requested the Search and Rescue Snow Cat be dispatched to my location in order to resume the search. Search and Rescue Volunteer Brian Hadley responded to my location with the snow cat. We continued on Mosquito Ridge Rd. near Mile Marker 32 we located Fickel and Wilkinson in the Black Jeep Cherokee. The vehicle was buried in deep snow on the edge of a drop off. Wilkinson stated only he and Fickel had been camping, the other parties did not come camping. Both parties appeared to be in good health but very cold. They were transported by snow cat to my patrol unit and from there they were transported to Auburn, at the old Sheriff Office building where they waited for Mrs. Fickel to arrive. REPORTING DEPUTY: BUMPUS ID: 76 APPROVED PAGE 1 r_ } Placer County Sheri ffs Department SAR General Briefing incident Name: Date: �/ Z t Report Number: E/Missing Person / Operational Periods: $o- 3��2 � o7•SS 5� � Incident Summary: k/. / 7,-=/C-K 4a ✓ 2 /� cA ! ✓ n/Cr 6c�J2 G/¢!Y7/�i�G rTi a6� G/9�T�1+�7u�✓� C - 1744-)` bx�e�L �GcD 4?/y►7'�' t,/- Z uli-1,r v✓S o AS Z 2 t�2.r/i✓G �1 ��fk t c2� j cv t� /lI� '°-`'` o cu►-;'� S T -� %.J �e�� T b�-e� A,J-�- �!'l rGe /yJ�KreZ- �� o y 3� �2s • /�6�.. ��. '�. Communication Plan: Frequency Channel Description Channel Communication Team CLEMARS 1 Tactical Team Sub' Information: Name to Call: Expected Response: Subjects Plans: Ph 'cal Description: H ' ht Complexion: Wei ht Hair. Build: Eyes- Race: esRace: Clothing Description: Footwearrrrack Description: Size: Mental State: p Date&Time Prepared: �e�a Page 1 . r Placer County Sheriffs Department SAR Incident t;l;njcident Name: Operational Periods: Case Number. Briefing L3e1-, /t/ / `�� c-i,pp Peled fX / .t7C 76 Op Period 2 Op Period 3 Op Period 4 Page 2 Prepared By Placer County Sheriffs Rq artment SAR Incident Name: Op.Periods Case Number. Incident Objectives So- General Objectives for the incident for Op Period 1 2. 3. 4. General Objectives for the incident for Op Period 2 1. 2. 3. 4. General Objectives for the incident for Op Period 3 1. 2. 3. General Objectives for the incident for Op Period 4 1. 2. 3. 4. General Objectives for the incident for Op Period 5 1. 2. 3. Weather forecast for operational period: �/��?>Z j;z 7 e,;z- —�7 Page Prepared By: Placer County Sheriffs Department SAR Resource Summary Inside Nemec Op.Periods: Case Number / SO-8"2, Resources ordered Resource Identification ETA Time On Scene Location/Assignment Operational Period 1 C Operational Period 2 Operational Period 3 Operational Period 4 Page 4 Prepared by: k,.,..., .. T, ii v Fri I ream- G� PWS co alb . Medical Plan IlDrident Name: Op.Periods: Case Number. so- C9 17 On Scene Medical Indicate EMT or Paramedic Op Period 1 Name Team Assignment 1 Team: 2 Team: 3 Team: Op Period 2 1 Team: 2 Team: 3 Team: Nearby Fire, EMS, and Ambulance Service Name Address Phone Number 2 3 Aero medical Evacuation Name Location Radio Frequency CLEMARS 1 2 3 Designated LZ: /7/ 41� 1�-fJff 1.,j Hospitals Name Address Phone Travel Time Trauma Helipad 1 :;4, Gmd: Air. Y N Y N 2�% .� qj� ,•//I? Gmd: Air. Y N Y N 3 Gmd: Air. Y N Y N Medical Emergency Procedures Provide emergency first aid and stabilize victim/injured person. Transport victim to CP1LZ and airlift to XXXXX Hospital. Prepared By: ' Page 6 Gc', Lt S� i �_ r �;f� PERSONAL AUTOMOBILE SHERIFF'S SAR ;. G NAME :.,..ins ?f. t_r. ( ) 1 (PRINT) - MILEAGE STATEMENT VOLUNTEERS, PLEASE FILL OUT # 1 - 4 SIGN & DATE r rl L;v'• . (t) lel �3) --- (4) (5) (6) _ --� —- -- - - -- MILES --- - --MILEAGE--- DATE ORIGIN DESTINATION TRAVELED RATE REIMBURSED (Col. 4 x Col.S) TOTAL "I,the undersigned,state Thal the above claim and the items as therein set out are true and correct,that no part Ihereo(has been hereloforr_paid.and that the amount therein is justly due,and that the same is presented within 100 days after the last itemthereof has accrued" 'I declare under penalty of per n tho!the foregoing is true and correct. Exculad on _ _�71Date),at \;b— —_California �"'I Check here if you are NOT a County employee ,51GATURE OF DECLIIRAN7.' . APP OVING SIGNATURE DiSTmEmiON: WHITE-AUDITOR CANDEPT PINK EMPLOYEE 12:39 5308865391 FC50 911 CENTER #3ubb F.uui/uuz Detailed History for Police Call #P0704-04510 As of 4/24/2007 13:50:49 Priority:3 Type:SAR-SEARCH&RESCUE Location:TALBOT CAMPGROUND/FRENCH MEADOWS Created: 04/22/2007 2.2:41:.18 .PD02 S7.1300 Entered: 04/2.2/2007 22:50:20 PD02 S71300 Dia etch: 0482/2007 22:53:46 PD02 57.1300 Enroate: 04/22/2007 2153:48 PD02 S71300 Onsce.ne: /23/2007 05:31:56 PDOS S71300 Trans rt: 4/23/2007 05:31:581.PDOS S71300 Com Tete: 04838007 07:01:40 PD05 571300 Closed; 04123/2007 07:19.421M085 S72000 PrimeUnit:13H Dispo:RT Type;SAR-SEARCH& RESCUE Name:CHERYL FICKEL Phone:925-687-6875 Address:PLEASANT HILL CA Agency:SO Dnrcn:SA1(n/a)BcacRENRY(n/a)Block:299(n/a) Case 1+:SO070005591 1+.Detail 22:41:18 CREATE Location:TALBOT CAMPGROUND/FRENCH MEADOWS Type:WELFAR Name:CHERYL FICKEL Address:P.LEASANT HILL CA Phone:925-687-6875 Type.Desc:*,VELFARE CHECK Priority:3 Response.I PAT Agency;SO 22:50:20 ENTRY Dsrea:None—>SAI Area:None-->299 Comment:RP'S 20 YR OLD DAUGHTER(LAUREN FICKEL)WENT CAMPING WITH 8 FRIENDS AT TALBOT CAMPGROUND AT.FRENCH MEADOWS.THEY WERE SUPPOSED TO BE HOME THIS EVENING BEFORE DARK. THEY HAVE NOT ARRIVED AND HAVE NOT CALLED IN EITHER.THEY ARE DRIVING A BLK JEEP CHEROKEE AND A UNK COLOR JEEP.RP FEELS SOME OF THE GUYS IN THE GROUP ARE SEMI EXPERIENCED CAMPERS BUT WOULD NOT HAVE BEEN READY FOR A SNOW STORM.FEARS THEY MIGHT BE STUCK IN THE SNOW AT THE CAMP.IN THE GROUP IS LAUREN FICKEL,GLEN WILKERSON, TOM?,DEREK?,NICK?,MICHELLE?,JESS(FEMALE)?&LAUREN? 22:50:20-PRE.MIS Comment(none) 22:54:26 SELECT 22:50:32 VIEWED 22:50:54 NOMORE 22:53:46 DISP 131(Operstor:S72000 OperNa.mes:RUMPUS.ROBERT 22:53:46-PRIU M-1 22:53:48 ENRTE 13H 22:56:04 MISC Comment:LEFT A MESSAGE ON 13'S N.EXTEL LETTING HIM KIrOW WHAT 15 GOING ON 23:03:13 MISC Cumment:CALLED THE RP BACK TO LET THEM KNOW WHAT IS HAPPENING.THEY HAVE A CORRECTION ON THE VEHICLES.BOTH ARE 4 DOOR JEEP CHEROKEE TYPE VEHICLES.1 IS BLACK AND HAS BEEN LIFTED AND HAS OVER SIZED TIRES. NO DETAILS ON THE OTHER.JUST AN UNK COLOR 4 DOOR JEEP CHEROKEE 23:58:24 MISC 1..3-11 Com ment:CALL OUT SNOW CAP AT 5600 FT I AM NOT SURE 1 CAN GET OUT-24 MILES UP MOSQUITO RIDGE ROAD-CAN'T GO FURTHER 104/23/20071 00:00:22 MISC 13H Commen1:10-39 IIS 00:02:37 MISC Comment;LEFT A MESSAGE ON RICH SHACKEL'S NEXTEL AND HOME PHONE.HIS PAGER NUMBER IS OUT OF SERVICE.WILL TRY BRIAN HADLEY NEXT 00:04:07 MISC Comment:RP WOULD LIKE A 10-21 IF THE SUBJS ARE LOCATED AND IS AVAIL TO RESPOND TO PICK THEM UP IF NEEDED WHEN WE GET THEM OUT 00:04:21 MISC 1_a{Comment:MESSAGE LEFT ON LT TORNBERG'S HO.MIi AND CELL PHONES 00:06:04 MISC Comment.10-39 BRIAN HADLEY.HE WILL MAKE SOME PHONE CALLS THEN HEAD DOWN TO PICK UP THE SNO CAT AND START TOWARDS 13H'S LOCATION 00:08:40 MISC Ccmment:PER TORNBERG W8 NEED TO 10-21 SGT THOMA_C BECAUSE TORNBE.RG IS file://C:\Ha=erhead\Placcr\Live\Display3.D8020A401 C786W.dat 4/24/2007 12:40 5308865391 PC50911 CENTER ' #:iy65 P.UUL/UUC it #1'0704045 1 0 OUT OF TOWN.AFTER THOMAS HAS.BEEN NOTIFIED TORNBERG WOULD LIKE A MSG LEFT ON HIS NEXTEL THAT WE HAVE SEEN ABLE TO CONTACT THOMAS 00:09:26 CHANGE L3f_1 Type:WELFAR—>&AR.Reoponse:I PAT-Mone TypeDesc:WE.LFARE,CHECK-- >SEARCH&RESCUE 00:09:36 MISC 13!j Comment.C.HANGE TYPE TO A SAR 00:09:57 MISC 131HI Comment:ATTEMPTING TO GET TO BETTER PLACE ON THE.ROAD TO OFF LOAD THE SNOWCAT 00:10:41 MISC Coinment:l0-39 CGT THOMAS 00:23:45 MISC Comment:PER TORNBERG THEY ARE BRINGING OUT SNOW CAT AND IF THAT DO,ESNT GET TO THEM BY MORNING THEY WILL GET HELICOPTER ETC AND GET THEM OUT IN THE A.M. 00:51:12 MISC Comment:IF AVE.LOCATE THE SUBJS TONIGHT AND 1311 CONFIRMS THAT WE ARE WITH THEM VIA RADIO THEN EVEN BEFORE WE GET THEM OUT TORNBERG WOULD LIKE US TO CALL THE RP AND ADV THEM JUST THAT WE ARE WITH THEM. 01:42:08 MISC Comment:CAN START THE SNOWCAT W/O KEYS 01:43:05 CASE QH Caset/:SO070005591 01:53:48 MISC 11H Comment:SNOWCAP ER TO FN 01:54:26 BACKUP SNO(:AT Unit1D:13.H 01:54:31 ENRTE SCAT 02:06:08 MISC Comment:RP'S CELL PHONE NUMBER IS 925-768-3132.THEY WILL BE SNRT TO THE AREA IN A LITTLE.BIT. 03:38:45 MISC 13_N Comment:WE ARE HEADED IN WITH THE SNOCAT.IT WILL BE A LONG TRIP. NOT SURE HOW WELL THE RADIOS WILL WORK.OUR VEHICLES ARE PARKED ON MOSQUITO RIDGE RD NEAR MILE MARKER 24 04:37:32 MISC 13H Comment:WE FOUND THE BLK JEEP CHEROKEE WITH FICKLE AND 1 MALE. THE OTHERS NEVER MADE IT OUT TO THE CAMP.WE WILL BE CHECKING I OTHER AREA ON OUR WAY OUT.WE FOUND SOME TRACKS.UNK IF RELATED OR NOT 04:37:49 MISC Commen t:IIS COPIES T14.E TRAFFIC 05:14:35 MISC 13k.1 Comment:BACK AT THE VEHICLES.HAVE GLEN WILKENSEN sir LAUREN ACKEL.DEREK AND OTHERS NEVER MADE IT TO CAMP.THEY WERE DRIVING A 2 WD TRUCK 0:15.01 MISC 131i Comment:10-21925 7051661.ASK FOR DEREK JONES.SEE IF EVERYONE IS ACCOUNTED FOR 05:16:19 MISC Comment:NONE OF TAE OTHERS CAME UP 05:21:35 MISC Comment:10-39 MOTHER 05:31:56 ONSCN 13H 05:31:58 TRANSP QH Location-OLD PCSO Mileage:26 5 05:32:04 ONSCN SNOCAT.. 05:32:14 CEIGLOC SNOCA'.0 Location:10-19 AUBURN 05:32:28 MISC Commcnt:UPDATES GIVEN TO SGT THOMAS 07:0.1:40 CMPLT 13H Mileage:70.6 07:10:52 ONSCN SNS AT 07:10:54 PRMPT SNOCAT 07,19:42*CLEAR 13H Dispo:.RT Cnseq:SO070005591 07:19:42-CLEAR 07:19:42 "CLOSE file://C.\Rammerhead\Placer\Livc\Displav3DS020A401 C786B2.dat 4/24/2007 o. .. ;. ... 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C-D z LLJ 00 co -4rsl LLJ (J) 0 w w 0) > (3) Z 0x U oz 0 0 w o o r. i a C LA iM BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY • BOARD ACTION: SEPTEMBER 18, 2007 Claim Against the County, or District Governed by ) the Board of Supervisors, Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are.to ) The copy of this document mailed to California Government Codes. ) you is your notice of the action taken ony our claim.by the Board of Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: UNKNOWN AUG 1 7 2007 Section 913 and 915.4. Please note all "Warnings". COUNTY COUNSEL CLAIMANT: CLEO McCRODEN PAARTINIEZ CALIF ATTORNEY: UNKNOWN DATE RECEIVED: AUGUST 17, 2007 ADDRESS: #36 MOTT DRIVE BY DELIVERY TO CLERK ON: AUGUST 17, 2007 ALAMO, CA 94507 RECEIVED FROM BY MAIL POSTMARKED: RISK MANAGEMENT FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. AUGUST 172007 JOHN CULLEN le , Dated: By: Deputy I.I.. FROM.: County'Counsel TO: Clerk of the Board of Supervisors ( This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should retu7i claim on ground that it was filed late and send warning of claimant's right to apply for leave to present a late claim (Section 911-3). O Other: Dated: By: d C Deputy County Counsel ill. FROM.: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( ) Claim was returned as untimely with notice to claimant (Section 911.3). I.V. BOARD ORDER: By unanimous vote of the Supervisors present: (vThis Claim is rejected in full. ( ) Other: I certify that this is a true and correct copy of the Board's Order entered in its minutes for this date. Dated: q?"AnN CULLEN, CLERK, By eputy Clerk WA i. (Gov. code section 913) Subject to certain exceptiau,you have only six(6) months from the date this notice was personally served or deposited in the mail to file a court action on this claim.See Government Code Section 945.6.You may seek the advice of'an attorney of your choice in connection with this matter. Il'you want to consult an attorney,you should do so immediately. *For Additional Warning See Reverse Side ormis Notice. AFFIDAVIT OF MAILING I declare under penalty of perjury that I. am now, and at all times herein mentioned, hive been a citizen of the United States, over age 18; and that today I deposited in the United States Postal Service in N.Iartinez, California, postage fully prepaid a certified copy of this i3oard Order and Notice to Claimant, addressed to the claimant as shown above. Dated: • /0 OHN CULLEN, CLERK Byputy Clerk Z,y fir' ` •. This warning does not apply to claims which are not subject to the California Tort Claims Act such as actions in inverse condemnation, actions for specific relief such as mandamus or injunction, or Federal Civil Rights claims. The above list is not exhaustive and legal consultation is essential to understand all the separate limitations periods that may apply. The limitations period within which suit must be filed may be shorter or longer depending on the nature of the claim. Consult the specific statutes and cases applicable to your particular claim. The County of Contra Costa does not waive any of.its rights under California Tort Claims Act it waive rights under the statutes of "limitations applicable to actions not subject to the California Tort Claims Act I I I I I ;J j BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAMANT A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be.presented not later than one year . after the accrual of the cause of action. (Gov. Code § 911.2.) Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, 7>CountyAdmiuii&ation Building, 651 Pine Street,Ma_dnez, CA 94553. // If claim is against a district governed by the Board of Supervisors, rather than the County, the :name of the District should be filled in. If the claim is against amore than one public entity, separate claims n asst be filed against each. public entity. Fraud. See penalty for fraudulent claims,Penal Code Sec. 72 at the en.d of this form- am tssssss nasals sass KKK ■1simt[■Q Qs!■CllClLlSINNEXIN am CC.0 QQltt[[i;xs iltf L[laL it ll _ E: C1aim By: C e !��`U ""'� Reserved for Clerk's filing stamp RECEll D ) gainst the Cpunty of Contra Costa or ) AUGA1 7 cuui G'�,•..N -� ✓�-�,r�;i✓f S�/�� CLERK e i s S2(-fi �.✓� _ ) Oo ARD 0 sup R .1�7 In�y n s� ��i✓i J/del District) NIRA COSTA C�VISO�S Fill is the name) ) the undersigned claimant hereby -makes claim against the County of Contra Costa or the above-named district in the sum of and in support of this claim represents as follows: I. When did the damage o� ' jury occur? (Give exact date and hour) �2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give hill details;use extra paper if required) V f h�l l i2,, K 4. Whatparticular act or omission on the part of county or district officers, servants, or employees caused.the injury or damage? 5 What are the names of county or district officers,sen►ants, or employees causing the damage or injury? What damage- or injuries do your claim resulted? (Give full extent of injuries or damages - --claimed: .Attach-two estimates for auto damage.) How was the amount claimed above computed? (Include the estimated amount of any prospective injury or(iamage.) y,�� Names and addresses of witnesses,doctors, and hospitals: �. List the expenditures you made-on account of this accident or injury: DATE TIRE AMOUNT , rtasaaararaaaaaraaataarear■rataraartartaaaaaaaaanartaerrtaaeateetrttaaratetaattsare, ) .Gov. Code Sec. 910.2 provides"The claim shall be ) signed by the claimant or by some person on his behalf" SEND NOTICES TO: (Attbrnev) Name and address of Attorney ) (Claimant's Signature) f 3 Asn 7 (Address) �2 � �� 9�� Telephone No. )Telephone No. ■.tnttBEV Rags KKR tataa■rtaa. . totaaaastotttataaaaetttta■aaaaatatartttataateraatataa.IIII PUBLIC RECORDS NOTICE: Please be advised that this claim farm, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act (Gov. Code, s^§ 650D et seq.) Furthermore, any adtachments,addendums, or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■ aaaattttttrttaaatattaat■ ■ ■attataataaataaataaatraataaat■aaatateattttttttttetttteatttt NOTICE: Section 72 of the Penal Codep,rovides: Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same if genuine, any false or fmudulent claim, bill, account voucher, or writing is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,00D.00), or by both sucb imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000),or by both such imprisonment and fine. FOURTH--1L-Am EN DED CLAIM BOARD QF SUPERVISORS OF CONTRA COSTA-COUNTY • BOARD ACTION: SEPTEMBER 18, 2007 Claim Against the County, or District Governed by ) the .Board of Supervisors, .Routing Endorsements, ) NOTICE TO CLAIMANT and Board Action. All Section references are to ) The copy of this document mailed to California Government Codes. you is your notice of the action taken FulUG on your claimby the Board of 14 2007 Supervisors. (Paragraph IV below), given Pursuant to Government Code AMOUNT: $15 Million COUNTY COUNSEL Section 913 and 915.4. Please note all ' MARTINEZ CALIF. "Warnings.". CLAIMANT: DANIEL AMYTHIST ATTORNEY: UNKNOWN DATE RECEIVED: AUGUST 14, 2007 ADDRESS: 2405 SUNNY LANE #7 BY DELIVERY TO CLERK ON: AUGUST 14, 2007 ANTI.00H, CA. 94509 BY MAIL POSTMARKED: HAND DELIVERED FROM: Clerk of the Board of Supervisors TO: County Counsel Attached is a copy of the above-noted claim. JOHN CULLEN, C k Dated: AUGUST 14, 2007 By: Deputy 11. FROM: County Counsel TO: Clerk of the Board of Supervisors ( This claim complies substantially with Sections 910 and 910.2. ( ) This Claim FAILS to comply substantially with Sections 910 and 910.2, and we are .so notifying claimant. The Board cannot act for 15 days (Section 910.8). ( ) Claim is not timely filed. The Clerk should return claim on ground that it was filed late and send warning of claimants,right to apply for leave to present a late claim (Section 911.3). ( ) Other: .Dated: U '� L�� 02 By: /9") Deputy County Counsel 111. FROM.: Clerk of the Board TO: County Counsel (1) County Administrator(2) ( j Claim was returned as untimely with notice to.claimant (Section 911.3). IV /BOARD ORDER: By unanimous vote of the Supervisors present: '.phis Claim is rejected in full. Other: THIS . ITEM HAS BEEN REFERRED TO RISK MANAGEMENT I certify that this is a true.and correct copy of the Board's Order entered in its minutes for this date. Dated:' m .i�� ,/OHN CULLEN, CLERK, By . eputy Clerk WA. N1' G (Gov. cod ion 913) - Subject to certain exceptiorrs .0ir have only six(6)months from the date this notice was personally served or deposited in the mail to.file'a court action on this claim.See Goventment Code Section 948.6.You May seek the advice of an attoniey of your choice in connection with this matter. if you want to consult all attorney,you should do so iminediately. *For Additional Warning See Reverse Side of This Notice. AFFIDAV[T OF MAILING l declare under penalty of per jury that I am now, and at all times herein mentioned, have been a citizen of the United States, over age 18; and that toddy 1. deposited in the United States Postal Service ill Allartinez, California, postage fully prepaid a certified copy of this Board Order and Notice to Claimmit, addressed to the claimant as shown above. Dated ,/ sJOHA?CUI..LE,N, CL.EItK By� Deputy Clerk f �f This warning does nt�t al�i�ij� to claims wlliclt' are not subject to the California Tort:Ciaims ( Act such as.actions in inverse coodemnati�ii + actions for specific relief such as mandamus or injunction;.or Federal Civil Rights claims. The above list is not exhaustive and legal' . consultation is essential to understand allahe ".,separate : limitations periods that n?aYAPPIY� ' The limitations period within which suit must lie filed may be shorter or:longer depending ori:. the nature of the: claim. Constilt the s ecific I P statutes and cases applicable to your particular:` claim. T1ie County.of Contra Costa:does not waive;any ., •its is rights.under California Torf`Claims Act :por,does it waive rights under the statutes of. imitations applicable to actions not subject to the California Tort Claims Act BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY INSTRUCTIONS TO CLAIMANT A. A claim relating to a cause of action for death or for injury to person or to personal property or growing crops shall be presented not later than six months after the accrual of the cause of action. A claim relating to any other cause of action shall be presented not later than one year after the accrual of the cause of action. (Gov. Code § 911.2.) B. Claims must be filed with the Clerk of the Board of Supervisors at its office in Room 106, County Administration Building, 651 Pine Street, Martinez, CA 94553. C. If claim is against a district governed by the Board of Supervisors, rather than the County, the name of the District should be filled in. D. If the claim is against more than one public entity, separate claims must be filed against each public entity. E. Fraud. See penalty for fraudulent claims, Penal Code Sec. 72 at the end of this form. RE: Claim By: Reserve r Clerk's filing stamp �dy=�: ' - ) �� ASG 1 4 Against the County of Co a Costa or ) RKeo CCN Rq of SUpE C v District) COSTA CRS (Fill in the name) ) The undersigned claimant hereby makes claim against the County of Contra Costa or the above-named district in the sum of$ in support of this claim represents as follows: 1. When did the damage or injury occur? (Give exact date and hour) Okla �- //-3-- o 0 7 2. Where did the damage or injury occur? (Include city and county) 3. How did the damage or injury occur? (Give full details; use extra paper if required) .6 r-J, — - —4 4. What particular act or omission on the part of county or district officers servan s, or employees caused the injury or damage? ` 5 What are the names of county or district ofAcLs, servants, or e*loyees causing the damage or injury? 6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages claimed. Attach two estimates for auto damage.) `&Vn ory� y t'A p-s �_ e �' / ��- L, 1�v2,T- aoAz-&, Z�1�6 7. How was the. aifi6unt claimed above computed? (Include the estimated amolt o any prospective injury or damage.) /��J� - .Ir-- a-� // 6k-k 14-v- 8. _ Names and add sses of witnesses, doctors, and hospitals: 9. List th9 expenditures you made on account of this accident or injury: V P Y - DATE �--``L AMOUNT #V5 �-13 07 7 . 7 muumuu;ma Venomous 111111111511111 Gov. Code Sec. 910.2 provides"The claim sh be signed by the claimant or by some person on his behalf" SEND NOTICES TO: (Attorney) ) Name and address of Attorney ) ( a" ant's pature) (Addr ss Telephone No. )Telephone No. ■■r■r■■■■■r■■■■■r■■■rr■■rrr■■■or.■rrr■■r■■r■■.r.r.■�■.■rrrrrrrrrrrrrrrrr■rr■■■r■■■■■� PUBLIC RECORDS NOTICE: Please be advised that this claim form, or any claim filed with the County under the Tort Claims Act, is subject to public disclosure under the California Public Records Act. (Gov. Code, §§ 6500 et seq.) Furthermore, any attachments, addendums,or supplements attached to the claim form, including medical records, are also subject to public disclosure. ■■■■■■■r■■■■r■■■■■■■u■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■r■■■.rr■■■■i■■.■■■r■■■ur■■monument NOTICE: Section 72 of the Penal Code provides: Every person who, with intent to defraud, presents for allowance or for payment to any state board or officer, or to any county, city, or district board or officer, authorized to allow or pay the same. if genuine,. any false or fraudulent claim, bill, account voucher, or writing, is punishable either by imprisonment in the County jail for a period of not more than one year, by a fine of not exceeding one thousand dollars ($1,000.00), or by both such imprisonment and fine, or by imprisonment in the state prison, by a fine of not exceeding ten thousand dollars ($10,000), or by both such imprisonment and fine. Q. MR i III MYTilli � . gng sAq I i i J ` • � e O -nD ,me, win ham MT - =wry✓ —vle, seRrr,ecQJ(5 --jz- �. -&Ice 17 !fie_ Win_ E.��e��3�-K� -r _ _ `7Ylf[7-Z-1�i V 4:7- At ��j jjf,ol zdy/s after ceo2 67. T7 n9 LAE 1�✓_�iJ_e—'a'_ZQ.n r7 A . ��- L61�, q �,c qs CONTRA COSTA HEALTH SERVICES MR#: 00-06-13-97-6 CCRMC,Martinez Health Centers NAME: Amythist,Daniel J 2500, Alhambra Avenue, Martinez, CA 94553 DOB: 10/21/1958 EMERGENCY'DEPARTMENT REPORT DATE: 04/12/.2007 Patient is a 48-year-old who has a long known history of mental disorder and polysubstance abuse, history of 68 visits, apparently 2 mental health are recorded at a period of time. The patient states that he is feeling depressed. He was seen and evaluated at Mt. Diablo where he states that he was depressed over his drug use.. Currently using cocaine as well as huffingpaint and drinking alcohol. The patient denies any physical complaints at this point. Patient's workup done,her potassium of 2.6,otherwise unremarkable workup. The patient at this point denies chest pain, shortness of breath, abdominal pain, nausea, or vomiting. On review all other systems are negative, noncontributory, and nonpertinent. PAST MEDICAL HISTORY: As above. PHYSICAL E)i:AM: GENERAL: On physical exam, patient is awake and alert. Patient is obese, speaking full sentences, in no acute distress. VITAL SIGNS.: The patient has a blood pressure 153/81 with heart rate of 91,respiratory rate of 22, temperature 99.6, saturations of 97 percent. HEENT: Pupils are equal and reactive. Pharynx clear. LUNGS: Clear. CARDIAC EXAM: Regular rhythm. ABDOMEN: Soft. Globus nontender. EXTREMITIES: Upper and lower extremities, good range of motion, nontender. At this point Dr. Shapiro contacted the psychiatry crisis stabilization unit. Patient has been worked up at Mt. Diablo. At this point, patient has a repeat basic panel ordered here to assess his potassium repletion.. Patient will be medically cleared for psychiatric evaluation at this point. Signed by William J. Peterson,M.D. on 04/13/2007 William J. Peterson, M.D. WJP/mtE41 D: 04/12/2007 02:47:02 T: 04/12/2007 02:45:35 Job: 1683012/159278 EMERGENCY DEPARTMENT REPORT Page 1 of 1 i Revr eAv ' Gee `e'er 1 s i0, Gary o.Ine Jas 1 CONTRA COSTA HEALTH SERVICES MR#: 00-06-13-97-6 CCRMC, Martinez Health Centers. NAME: Amythist,Daniel J 2500, Alhambra Avenue,Martinez,CA 94553 DOB: 10/21/1958 EMERGENCY DEPARTMENT REPORT DATE: 04/12/2007 HISTORY OF EVENT: Patient is a 48-year-old who was transferred from John Muir to our facility earlier this evening for psychiatric services. He reportedly had been drinking excessive alcohol, doing cocaine, and huffing gasoline in the attempt to self-harm. His workup at John Muir detected a hypokalemia. .When he was transferred to the emergency department,his basic metabolic panel was repeated at that time and his potassium increased from 2.6 to 3.0 here. Patient was of normal mental status at that time and was transferred to the crisis stabilization unit. Patient had been undergoing a workup there and was walking about, had even showered, and had received Seroquel 300 mg for mood stabilization. Patient had an acute decompensation, where he looked gray all over, and looked as though he stopped breathing. He got extremely diaphoretic and was unresponsive. His 02 sats at that time were in the low 80s. Excessive sternal rub woke the patient up, but he immediately fell back asleep. At that time,they urgently transferred the patient to the emergency department. He was brought in a wheelchair with loud sonorous snoring and head slumped over. His color looked normal. He could be aroused to sternal rub, but would stay awake 5 to 6 seconds,then slump over and fall back asleep versus entering a comatose type respiratory depressed state. Patient could give no history as he was nonverbal at this time. SOCIAL HISTORY: Cocaine use, alcohol use,huffs gas. PHYSICAL EXAM: VITAL SIGNS: Blood pressure 85/60, heart rate 112, respirations 22, 02 sat in the 80s. HEENT: His pupils are equal, round, and reactive to light. His sclerae are erythematous bilaterally. There is no nystagmus. Oropharynx has moist mucous membranes. I am unable to visualize distal into his mouth due to excessive soft tissue. NECK: Supple with no cervical lymphadenopathy. LUNGS: Have very poor air entry bilaterally. There are irregular, deep, labored breaths, followed by periods of apnea. There is expiratory wheezing in all lung fields and very poor air entry. HEART: Tachycardic with normal S1, S2. ABDOMEN: Obese. It appears nontender and no obvious organomegaly. SKIN: Profusely diaphoretic, but without rash. NEUROLOGIC: Patient with 5 out of 5 upper and lower extremity strength bilaterally. Patient does not comply with fine neuro testing. There is no clonus. Babinski is absent. There is no facial asymmetry. EMERGENCY DEPARTMENT COURSE: Patient was immediately put on CPAP, which somewhat improved his ventilation, but not his mental status. He continued to be slumped over, could be aroused to sternal rub, but otherwise could not stay awake. The CPAP improved the sats into the high 90s. Due to his continued altered mental status and questionable airway protection, it was decided to intubate the patient. His blood pressure did drop to the 80 systolic prior to giving any medications. Second IV was placed and 2 liters of normal saline were infused bringing his systolic blood pressure into the 115 to 120. Due to the patient's excess girth and minimal neck, anesthesia was paged to be at the bedside to aid in the intubation. The patient was given 2 mg of Versed, followed by 10 mg of etomidate, and 100 mg of succinylcholine. The resident,Dr. McEntee, initially attempted visualization of the vocal cords and was unable. At this time,the anesthesiologist, Dr.Nielsen, was able to visualize the cords without difficulty. EMERGENCY DEPARTMENT REPORT Page 1 of 2 i I i MR#: 00-06-13-97-6 NAME: Amythist,Daniel J The laryngoscope was again given to the hands of Dr. McEntee who could not properly visualize the cords, so Dr. Nielsen stepped in second time. At this point,the patient's 02 sats were in the low 80s. He intubated the patient easily with an 8-0 endotracheal tube. The lowest 02 saturations were 77. After approximately 1 minute of bagging,the patient's 02 saturation was up to 100 percent. The endotracheal tube was confirmed by end-tidal CO2 calorimetry, bilateral breath sounds and chest.x-ray. Patient's blood pressure after the intubation was 227/109. This came down well with proper sedation of morphine and Versed. Patient's 02 sats remained in the high 90s to 100 percent. His chest x-ray was a poor AP film with small lung volumes,but did not show any obvious acute infiltrate. His EKG was a sinus tachycardia without ST or T wave changes. His repeat potassium was 3.5. Patient to be admitted to the ICU. He will undergo a head CT due to the acute altered mental status. Patient is currently with normal blood pressure and normal oxygenation.and no further medications aside from sedatives will be given at this time. ADMISSION DIAGNOSES: 1. Respiratory failure. 2. Cocaine and alcohol toxicity. CONDITION ON ADMISSION: Poor. Signed by Ann Cappellari, M.D. on 04/21/2007 Ann Cappellari, M.D. AC/mtB93 D: 04/12/2007 07:04:30 T: 04/12/2007 07:20:09 Job: 1683110/ 159288 EMERGENCY DEPARTMENT REPORT Page 2 of 2 RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 1 RUN TIME: 0826 EDM Patient Record RUN USER: MR.PARR ; .Patient..` AMY TH : DP:N E; >; ;: » ;>;;:;:::.:::,;:::;:' <: ' IST, . .. I L..J Account No. M07.63182.11 A e :Sex:::>::: 4'8: Mi :':::::::::;;:<:::< .....:... /. IIni t..No;c<z>:M O:O:O:fi13:9:T6:<:>::>:>:::>:::::>::>> g::..:::.... .:.:...: .. ::::.:::.:::.:......::::::.::::::.:....::::::.::..:::..:....:......: :.::::..:.:::. .:::................... .. ........... —ER Caregivers— Arrival Date Physician PETERSON,WILLIAM J. ,MD Time Practitioner Triage Date 04/12/07 Nurse ROHLAND,RICHARD,RN Time 00.10 PCP Stated Complaint Chief Complaint Behavioral Problem Priority 2P Severity 2 Departure Disposition TRANSFER TO PSYCH Departure Date 04/12/07 Departure Diagnosis psychiatric hold Time 0105 Departure Comment Departure Condition ..:.:..:.:;::. e ems............. .......................................................................................................................................::::: ............::::.::......:.;:<.;;;;;:.;:;;::::,.: :.::...:. ALLERGY/ADR TYPE REACTION SEV CATEGORY NKDA (NO KNOWN DRUG ALLERGY) Allergy Unk Ingredient DRUG ALLERGIES W/REACTIONS: NKDA FOOD/ENV. ALLERGIES W/REACTIONS: NKFA :. . A tive Prescri t� .. . .... ons.. rovider PETERSON,WILLIAM J. ,MD Medication Location Issued Potassium Chloride 3B EMERGENCY DEPT 02 01/14/07 Kcl Sustained Release 8 MEQ 5 Days PO BID REF 0 Provider PHELPS,BRIAN,MD Medication Location Issued Potassium Chloride 3B EMERGENCY DEPT 02 01/26/07 Kcl Sustained Release 8 MEQ, #14 SRCAP PO DAILY REF 0 Provider Stinson,Mark,MD RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 2 RUN TIME: 0826 EDM Patient Record RUN USER: MR.PARR ........... .... .......... ......................................... ............. . . ..................... .. .... ......... Patient:...:...AMYTHIST::D :: . ::: .... ....... x ... ................ ................................................Account�: qi-::i�:M076318 ....... ....... ...... ........ . ......... ..... ...... ... ................. . ..................................... .. .... .. . . ...... ........... ........ .............. ............. ... ............ ................................... ............. ............ ........... ........... ......... .......... . . ..... ......... ..................... ............ .. ......................... ....... �ii�imbvdtl 97 ............ ..............................::.:.: 3 6. ........... ... . ................ ....................................... . ............ ................ .............. ......... .. ..... ....... Medication Location Issued. Potassium Chloride 3B EMERGENCY DEPT 02 08/12/06 Kcl Sustained Release 16 MEQ, #10 SRCAP PO DAILY REF 0 HISTORICAL PRESCRIPTIONS Quetiapine Seroquel 200 MG PO TAB Venlafaxine,Xr Effexor Xr 150 MG PO BID CAP ............. ........ l ... . .. .......... .............. ...............jeks.gmenti: '. "'. ................. . ....................... xx ..................... .............. .................. ...... ...... .. . ......................... . . . .. .... ......... .. ....... ..... ..... ................ . ...... .......... .:: ::: ... ... .......... .... .............. . ........ ...... .............. ...................................................... ....... ... ............ ........... ............ ........ ............................................ ................. ....... ................... ..................................................... .............. ................... .......... ............... ........... ............. . : : . ...................... ..... . ...... ..... ...... ............. ...... ................... ............ .. ............. .............. . ..... ............................................... ........... . ........ ........ ...... ... ........ ............. .................... ............. . ......... . ........... ........ ... . .......... . . ....Tim...e...:.:.:....0....0...1.....:5........:..:.......:.......U.....s..6......r.....:.:.:.:. ...R...H.L.. ANDRICARDi.: ............. .. ... . .. . ....... ... ........ . .................. ..... ... ... . . .... ... .... ......... ...... MR# M000613976 ----TRIAGE ASSESSMENT (Document All Applicable Queries) ---- Amb Code 2 Y Amb Code 3 5150 Y PD Transfer? Y From:. JMMC Arrival Mode: Gurney Referral<L> Return Visit <72 hours? N Visit Type <L> HPI/Sx: MED CLEARANCE, 5150 TRANSFER, CLEARED @ J.M. 2ND ETOH/PAINT HUFFING/COCAINE BINGE X 3 DAYS, HEARING VOICES Onset 3 DAYS Pain 0-10 7 Location WHOLE BODY Barriers to Comm. <L> None inguage English Language line? Interpreter Vaccinations Current? Last Tetanus Triage Interventions: LMP Gravida Para EDC Domestic Violence? N Smoker Y MRSA N PMH: DEPRESSION ASA, Tylenol or Motrin Given? PSYCH CBG done? Glucose Result HX-POSITIVE TB TEST "YRS AGO" Standing: V/Sls: B/P HR RR Temp Source B/P HR WEIGHT KILOGRAMS: 153/81 91 22 99.6 0 <L> Dizzy? 02 Sat%/Source Chart? N 97 Room Air Triage Reviewed/Concurred By: RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 3 RUN TIME: 0826 EDM Patient Record RUN USER: MR.PARR . . AMY.. iIST,DAN L,J Account:.,:No.. M076318211 /... :.. :.:::.: :.:/....::.:. .:.::::.:..:.:::::. :.: ::::...........:... . ......... .::.:Una.t::.No:-:<..M00.0.6..1.3:9...76 .:::::::::..::::::::::::::::. .:::.::.::.::::.::::.:...........:.:::.......;:. .... .... P„ ::.. 5:.:;.::;;:.;;:.;:.........::..::.:::.:::..:..... <Dae020 . ;.. : .:` ln0Q32IIRICHAR D,;RN ;;; Ht :4/1 / 7 ; ; ; ---- PAIN ASSESSMENT ---- Pain Scale (0-10) : 7 Comments: ead,;2; Toe.Assessment... Date:;:::. 04 2 .0:7 >:..:ini >: ..... 1 T e :0:0> .. . .. .. / . .�. . ....... .:..::.... ..::...... ::U...... :;.;ROHLAND.,:RI;CHARD.,.;......::::;;:,:,;,: c:.;;.;::;:::......;::;.;.;:.:..::;.:::.: **********SECONDARY ASSESSMENT********** (Not Applicable if No Response Indicated) --------------------------------------NEUROLOGIC------------------------------------------- Neuro exam WNL's: Y PUPILS/REACTIVE ORIENTED TO: _LEVEL_OF_CONSCIOUSNESS_ SPEECH L: mm/Y N Person Awake Alert Clear Slurred R: mm/Y N Place Arousable to Verbal Incoherant Time Arousable to Stimuli Inappropriate Event No Response to Stimuli Age Appropriate Non-Verbal GLASGOW—COMA—SCALE Nystagmus? Best Eye Response (4) : Tremors? GRIPS: Equal Best Verbal Response (5) : Facial Droop? R>L Best Motor Response (6) : Seizure? L>R GCS Score: Neuro Note: ------------------------------------CARDIOVASCULAR------------------------------------------ CV exam WNL's: Y SKIN_SIGNS PULSES irm/Dry/Normal Pale Equal/Strong/Reg Cap Refill Y? Warm Flushed Equal Unequal <3 Sec? N? Hot Dry Jaundiced Regular Irregular Cool Clammy Mottled Strong Weak JVD Edema Cold Diaphoretic Cyanotic Cardiac Monitor Rhythm: CV Note: --------------------------------------RESPIRATORY------------------------------------------- Resp exam WNL's: Y LUNG—SOUNDS AIRWAY BREATHING_PATTERN_ RIGHT _LEFT Clear/Open Regular/Nonlabored Cough/Productive Clear Clear Stridor Labored/Mild-Mod Cough/Non-Productive Rales Rales Obstructed Labored/Mod-Sev Rhonchi Rhonchi Artificial Nasal Flaring Speaks full sentences Wheezes Wheezes Retracting Speaks short sentences Decreased Decreased Manually Assisted Absent Absent Cry: Strong Weak Resp Note: RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 4 RUN TIME: 0826 EDM Patient Record RUN USER: MR.PARR 1en:: :: ;>::. Pat t AMYTHI::T DANIEL: J:::: ::>::.::<:::::>:::i::::::> :>::':>::>: :>::><< ::::: :::'> S iEL a:::..:N:>:: :';..,... .7631:.. 2.1> » Account t o MO 8 1 ...:.. . ......::::.....:...::..:....... :.:::...:...:::::.:;:.::...::::::::.::::::.:::::.:::...:;::.:.:::..::.: ... A e ;Sex:::..>4:8:.M'.:>::: :::;:: '::::>:<:. ;..... ::::::::: : .... .......:.... /... ....:.;: ..::.:::.::.;.;:.::.;:::.. .:::: ........ .. .:.:..IInit No:: M00;0.6,1.3;9.7:6:;:.;:.;;;;:.;:.;:.;;:::<;.;;;;:.;;:<.;:<.::.;:.:<.,<.;::. ........ .......... --------------------------------------GI/GU/GYN ---------------------------------------------- GI/GU/GYN exam WNL's: Y ABDOMEN BOWEL SOUNDS GU/GYN Soft Non-tender Diarrhea Normal Dysuria GENITAL: D/C Flat Tender Distended Hypoactive Hematuria Swelling Firm Nausea Constipation Hyperactive Vag Bleed Erythema Obese Vomiting Rectal Bleed Absent Penile Bleed Rash Itching GI/GU Note: FHT's: -----------------------------------MUSCULOSKELETAL----------------------------------------- M/S exam WNL's: Y Ambulatory CMSTP NL Crepitus SKIN INTEGRITY Non-Amb CMSTP ABNL Deformity Intact Abrasion Laceration Gait NL Cast/Splint Discoloration Abscess Avulsion Open Fracture Gait ABNL C-Spine Prec Swelling Burn Bleeding Rash Wound M/S Note: ------------------------------------PSYCHOLOGICAL------------------------------------------ Psych exam WNL's: N Age Appropriate X Combative Hallucinating X Pressured Speech Agitated Cooperative Non-Verbal Restless Anxious Crying X Pacing Threatening Calm Delusional Paranoid Uncooperative Psych Note: TALKING TO SELF, HEARING VOICES, SEEING PEOPLE WHO ARE NOT THERE ------------------------------------EYE/EAR/NOSE/THROAT------------------------------------ EENT Exam WNL's: Y EYE EAR NOSE DENTAL/THROAT Drainage: R L Drainage: R L Drainage: R L Pain Exudate Pain: R. L Pain: R L Pain: R L Red Swelling F.B. : R L F.B. : R L F.B. : R L Drooling Red: R L Epistaxis: R L Diff Swallowing —Visual—Acuity VA Uncorrected: R L Corrective Devices Used: cL> Corrected: R L EENT Note: Pa� eiti Node `''; ;` ':> ii '> < ' i >>°`«> > > >` >> >> ': PT ROOMED, AWAITNG MED EXAM FOR CLEARANCE TO C.S. , VSS, NOTES WHOLE BODY PAIN 7/10, BUT UNSURE WHY, PT TALKING TO SELF AND CRYING STABLE PT, TRANSFER TO C.S. VIA AMBULATION RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 5 RUN TIME: 0826 EDM Patient Record RUN USER: MR.PARR $ ie AMyTHT: T: >DAN:; >< :: : : ><:»:> :....:.: oust o MO 6 8211 :::.:::.;:::......::. :: A...e :5ex:: .4: M'<:::::::z::::::: »:>::::>:<:::»:.: :::» :'::> :<:> :::::<:>:::::::>::::::: >: » »:: Noc:.::. 0:61 :::' ::.....:>::;>::: >:::<:>:<:>::.»«>::<: ,......5::./;:::.:.:::. ..::.:;8./:::. .::...:.: Unit::.::::.::;.:::M0:0:::::.::3.:9.7:6::::.,,.::::::: .::::::.:...:.:..:.:::.:::.::: >;..:.: ::•>::>:rr::::.: :::.::. ::...::.::::. :. .:..:.:...::.. .:.:.:.. caton::::: » «> ..... ":' ..,:..:.....::.: Home::::Med:s Vers f l ................ ........................................... .. : : ...: NI NOA:Dat 01UA . .:: R. / 7...;:.. . .. .. ,....H *****HOME MEDICATION LIST VERIFICATION***** Pt's meds routinely taken at home reviewed and verified by: ROHLAND,RICHARD,RN Home med list updated in Meditech by: ROHLAND,RICHARD,RN Comments: <>: rd ate Time Procedure Ordering Provider 04/12/07 0026 Basic Panel PETERSON,WILLIAM J. ,bM 04/12/07 0350 ANESTHESIA AIRWAY KIT (ANESTHESIA AIRWAY KIT** UNKNOWN Date Time Test Result Reference 04/12/07 0040 ANION GAP 7.0 0-12 MMOL/L 04/12/07 0040 BLOOD UREA NITROGEN 7 L 7.0-21.0 MG/DL 04/12/07 0040 CALCIUM 8.4 L 8.5-10.5 MG/DL 04/12/07 0040 CARBON DIOXIDE 30 22-30 MMOL/L 04/12/07 0040 CHLORIDE 104' 98-107 MMOL/L 04/12/07 0040 CREATININE,SERUM 1.0 0.6-1.2 MG/DL 04/12/07 0040 EST.GFR AFRICAN AMERICAN NUM > 60 >60 mL/min 04/12/07 0040 EST.GFR NON-AFRICAN AMER- NUM > 60 >60 mL/min 04/12/07 0040 GLUCOSE 116 H 70-108 MG/DL 4/12/07 0040 POTASSIUM 3 .0 L 3.6-5.1 MMOL/L 04/12/07 0040 SODIUM 141 135-143 MMOL/L X. Z enol..... . medically cleared for psychiatric evaluation X. .. ... ate. MD Follow-up/Appt Request Patient Follow-up Instructions Patient Signature Page Page 1 of 1 04/12/07 ^: M076318211 AMYTHIST,DANIEL J Contra Costa Regional Medical Center-Emergency Department 3 8 PETERSON,WILLIAM J.,MD 2500 Alhambra Average,Martinez,CA 94553 Patient.Signature Page MR# M000613976 Patient Name: AMYTHIST,DANIEL J I have received printed discharge instructions. I have read and reviewed all these instructions with my caregiver today and I understand them. 5t 5Z,) Patient Signature 04/12/07 Patient's Guardian Signature 04/12/07 Nurse Signature 04/12/07 0.039 .RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 1 RUN TIME: 0825 EDM Patient Record RUN USER: MR.PARR Fa...i. n't . .::.....T:,.. atle AMY HIS:... .D. i' >:>::>::::»::>:.>:`:::::<:> :': '; T, AN EL J Account No., X076319260 . g / / Unit No.. X00061397,6 —ER Caregivers— Arrival Date Physician CAPPELLARI,ANN,MD Time Practitioner Triage Date 04/12/07 Nurse WOCHER,CHRISTINA,RN Time 0350 PCP Stated Complaint Chief Complaint ALOC Priority 1 Severity 1 Departure Disposition DISCH TO CCRMC CCU Departure Date 04/12/07 Departure Diagnosis RESP DISTRESS Time 0537 Departure Comment Departure Condition Critical ALLERGY/ADR TYPE REACTION SEV CATEGORY NKDA (NO KNOWN DRUG ALLERGY) Allergy Unk Ingredient DRUG ALLERGIES W/REACTIONS: NKDA FOOD/ENV. ALLERGIES W/REACTIONS: NKFA ..............................::.. Atrre;Fr��...r.. .to .ias. .. .........:::..::::::::....:..::.:::::::.::::::.:::.......:....P.................::: .:::;:.:.:;:::;;:;.:;;<;;: ;;;;;:;;;:;;;: rovider PETERSON,WILLIAM J. ,MD Medication Location Issued Potassium Chloride 3B EMERGENCY DEPT 02 01/14/07 Kcl Sustained Release 8 MEQ 5 Days PO BID REF 0 Provider PHELPS,BRIAN,MD Medication Location Issued Potassium Chloride 3B EMERGENCY DEPT 02 01/26/07 Kcl Sustained Release 8 MEQ, #14 SRCAP PO DAILY REF 0 Provider Stinson,Mark,MD RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 2 RUN TIME: 0825 EDM Patient Record RUN USER: MR.PARR P <;: a a en ... I >T :: :>:>::: t .t ..AMYTH S DANIE:. «:><:>>i:: ' '' . ':: : ><><> A..::..:::. at". MO 71.8 i:<:''' L J ccou. No. „63 260 :. M...................... Uait::.No:::::::N10:00: 9.7:6':;::>::;:;.<>:>::::; Medication Location Issued Potassium Chloride 3B EMERGENCY DEPT 02 08/12/06 Kcl Sustained Release 16 MEQ, ##10 SRCAP PO DAILY REF 0 HISTORICAL PRESCRIPTIONS Quetiapine Seroquel 200 MG PO TAB Venlafaxine,Xr Effexor Xr 150 MG PO BID CAP :.:.......:....:. .....:.:..:..;. :....:...:...:........::.. . •.. ..,.. ita Sign ... ... ate 04%12 07 Time 0403 User .,,...�CHER;CHRISTINA.,. B/P HR RR Temp Source 02 Sat%/Source 85/60 112 22 <L> 99 C-Pap Pain 0-10 Cardiac Rhythm: Comments: .:.:...:::: :::............ ..:..::....... . :.:.:... . ate 04/12/07 Time 0408 Us_, r OCHER.,CHR.,S MR# M000613976 ----TRIAGE ASSESSMENT (Document All Applicable Queries) ---- Amb Code 2 Amb Code 3 5150 Y PD Transfer? N From: Arrival Mode: Wheelchair Referral<L> Return Visit <72 hours? N Visit Type <L> HPI/Sx: BROUGHT BACK FROM CSU WITH ALTERED LOC. PROFUSELY DIAPHORETIC. PT. HAVING APNEIC BREATHING AND SNORING RESPIRATIONS. NOT ALERT OR ORIENTED. Onset TONITE Pain 0-10 0 Location Barriers to Comm. <L> None Language English Language line? Interpreter Vaccinations Current? Last Tetanus Triage Interventions: LMP Gravida Para EDC Domestic Violence? N Smoker N MRSA N PMH: DEPRESSION ASA, Tylenol or Motrin Given? PSYCH CBG done? Glucose Result HX-POSITIVE TB TEST "YRS AGO" Standing: V/S's: B/P HR RR Temp Source B/P HR WEIGHT KILOGRAMS: 116/61 119 30 <L> Dizzy? 02 Sat%/Source Chart? RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 3 RUN TIME: 0825 EDM Patient Record RUN USER: MR.PARR P ent TI at AMY i T;:D1 N I > .. ..... :::::::;: ::> > «:: ::;< :s: :»:>:;": S IE J Account No.. M076318260 .A e::.Sex: 4':B:.M'::;:::>':::..;: ; ....... ........ Uh t:::NO:+:::MQ 0 0.613.9.7.6......:...;:....'.:..::..:: ... ...... . . .. .... .. .............................. ........... ...................... .. ....................... ::::. 88 Room Air Triage Reviewed/Concurred By: ain Scale Ra n ......:.::. .. D >:.:::>;::> ate ().4./1210;7 Time 0.41.0 ;:..IIser WOCHE.R,CHRISTINA.,RN ---- PAIN ASSESSMENT ---- Pain Scale (0-10) : 0 Comments: ......... ................... ...........:::.:.;:.:.;:.;:.:: .:.:::.::.;:..:..:....::::::::.::.:.:::... ................. ...3.....;::::::. ..:::::..::.;::::.: ::.;.:::.::.;;..:::.::.;:.:..:.:.:.::::::.: .... . .; ( : .. :. : » :: : >.... ;:,. <:: a WOCHERISTINA» NTime0421se ..:.:.. ...... .:. : /0: .::. .;.; . . .,:.:; ...r..: .:.. :.: B/P HR RR Temp Source 02 Sat%/Source 227/109 111 20 <L> 100 Ventilator Pain 0-10 Cardiac Rhythm: Comments: .:.:.....::.....::...........:........ ..:::...:..::::..:.::.::.::.. .:..... ..........................................:: .::::::.......... :.:...;:..:............;:::::::,..:.;:.;:.; .::.::.:; : .:.:.....:;...:......... ...::::: >:::::::::: ::;:::::.:..:;:>::::;:::>.:.. ead :2:<::Toe Assessment »`:;:: ;:::>::......:................:»><::<:::> D .::.:: at :.::4: j: ` ' U'' r: WO HER RIS.TINP:' RN ..... ......... :.::. :. .. .....e::.0 .:/.12 0.:::.::::Tie.::.0:42:6.:..:.....se.... :.:.:..:..:C............�.....................:.,...............................:....................... **********SECONDARY ASSESSMENT********** (Not Applicable if No Response Indicated) ---------------------------------------NEUROLOGIC------------------------------------------- Neuro exam WNL's: N PUPILS/REACTIVE ORIENTED TO: _LEVEL_OF_CONSCIOUSNESS_ SPEECH L: mm/Y N Person Awake Alert Clear Slurred X R: mm/Y N Place Arousable to Verbal Incoherant X Time . Arousable to Stimuli X . . Inappropriate X Event No Response to Stimuli Age Appropriate Non-Verbal GLASGOW—COMA—SCALE Nystagmus? Best Eye Response (4) : Tremors? GRIPS: Equal Best Verbal Response (5) : Facial Droop? R>L Best Motor Response (6) : Seizure? L>R GCS Score: Neuro Note: ----------------•---------------------CARDIOVASCULAR------------------------------------------ CV exam WNL's: N SKIN_SIGNS PULSES Warm/Dry/Normal Pale X Equal/Strong/Reg Cap Refill Y? Warm Flushed Equal Unequal <3 Sec? N? Hot Dry Jaundiced Regular Irregular Cool X Clammy Mottled Strong Weak JVD Edema Cold Diaphoretic X Cyanotic Cardiac Monitor Rhythm: CV Note: --------------------------------------RESPIRATORY------------------------------------------- Resp exam WNL's:. N RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 4 RUN TIME: 0825 EDM Patient Record RUN USER: MR.PARR 8tient AMYTHIS DAN ELJ Accouat No: M0763182 0 ... ........:.:.::.................... ., . :....:I.. :::.:;::::.:::::::.:. .:.:.;:.;:.:.::...:::::.::.::::.:..::....;::::::::..::.:::::.:.;:..::...::.....:b:.:;::::::........:. A e Sex::;: 4B. :M::::>::::::::.::::::::<:::>:::.:<: :......:::::::<:;:::>:>:»::::::>::::::>:::>.::: .....:::: :::;:::::<:>::>:::>;:::>:>:::::::::>:::::::::>::Uast:::No:s:>:'::M0::0:0:;613'9:76::>:.>:::>< ......: ::>::':::<::::< .>;:::<:: 5... /. ..:..::.:: / . ::..:...::::::::.::::.::..:.. :::::::::.:::.::::.:....::::::.:::::.:.:..::::::...:..:::::::..: :: :::::::.:.::.::...::.:.:. .......... LUNG—SOUNDS _AIRWAY BREATHING PATTERN _RIGHT_ _LEFT Clear/Open Regular/Nonlabored` Cough/Productive Clear Clear Stridor Labored/Mild-Mod Cough/Non-Productive Rales Rales Obstructed Labored/Mod-Sev X Rhonchi Rhonchi Artificial Nasal Flaring Speaks full sentences Wheezes Wheezes Retracting Speaks short sentences X Decreased Decreased Manually Assisted Absent X Absent X Cry:. Strong Weak Resp Note: ------------------------------------GI/GU/GYN ---------------------------------------------- GI/GU/GYN exam WNL's: Y ABDOMEN —BOWEL—SOUNDS— GU/GYN Soft Non-tender Diarrhea Normal Dysuria GENITAL: D/C Flat Tender Distended Hypoactive Hematuria Swelling Firm Nausea Constipation Hyperactive Vag Bleed Erythema Obese Vomiting Rectal Bleed Absent Penile Bleed Rash Itching GI/GU Note: FHT's: -----------------------------------MUSCULOSKELETAL----------------------------------------- M/S exam WNL's: Y Ambulatory CMSTP NL Crepitus SKIN INTEGRITY Non-Amb CMSTP ABNL Deformity Intact Abrasion Laceration Gait NL Cast/Splint Discoloration Abscess Avulsion Open Fracture Gait ABNL C-Spine Prec Swelling Burn Bleeding Rash Wound M/S Note: -------------------------------------PSYCHOLOGICAL------------------------------------------ Psych exam WNL's: Y Age Appropriate Combative Hallucinating Pressured Speech Agitated Cooperative Non-Verbal Restless Anxious Crying Pacing Threatening Calm Delusional Paranoid Uncooperative Psych Note: ------------------------------------EYE/EAR/NOSE/THROAT------------------------------------ EENT Exam WNL's: Y EYE EAR NOSE DENTAL/THROAT Drainage: R L Drainage: R L Drainage: R L Pain Exudate Pain: R L Pain: R L Pain: R L Red Swelling F.B. : R L F.B. : R L F.B. : R L Drooling Red: R L Epistaxis: R L Diff Swallowing Visual—Acuity VA Uncorrected: R L Corrective Devices Used: <L> Corrected: R L EENT Note: RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 5 RUN TIME: 0825 EDM Patient Record RUN USER: MR.PARR n.'.. .No <M07i6318260 ::<''::> '.<.:i: <; > G' ; nt' AMY'THTS.,..'.:. .:::::: A c u t Pane DANIEL. J:< >:.::::> :: c o M:::::: ::;<::: :::::::::::::::.:< :: ::::><:.:;::: :;<:::::::::::: :::::::.:.::' as t::No?:;:::.N100:.0:6139.7:6:;:;:::;::;;::;:;:>:>:>:::>;:;;<:::':;;::> : >....... . . ....:.:... ../.:.::... .. .:: .:.:.::.::::::.:..:::.:::::...:::..:.:.::::..::............................:::.:::::: .:::::::::.:.:::.::::....::::. ......:.:........................ ....:...........:..:........:::.:. .::.:::::.::.:::,.:::: <3 ..:: . .. ...:.:::::. .:..::.:::::.::..::::.::.::...::: Vital .5.. g s.;,. ....::: :.::><:::»:.... ::::::::;::;. ::D....: ,...:: .:1::. 7 ::::::. ::.. ::::: 42 9.::::;zUs:er: .....00HER :CHR S.T. A .:. .... .ate 0:4./. 2./:R .. .::.T... e........ ....... .:.:....... ......... . .:... .::.:.........:..:................,.......:::::.:::.;:.... :.::.::.::.::.::::.::.::.::.::..................... B/P. HR . RR Temp Source 02 Sat%/Source 148/86 105 20 <L> 98 Ventilator Pain 0-10 Cardiac Rhythm: ST Comments: 1;;>::: t . 9n .....:... :. D. .:.:e:.:.. . ....... : ::> . ... : ....:..:::.:...... .....:.. :.:. ... ... ........ >. >.::.:: :::: : ... .: .:: .. . . 4T:... :7 ::::Tim ::: 4:49 ...::::W.:::.:..I.iE..:R.. CHRISTINA.: B/P HR RR Temp Source 02 Sat%/Source 103/68 114 16 <L> 99 Ventilator Pain 0-10 Cardiac Rhythm: ST Comments: :::::;:;::.:::>:::;...::.:Patit.. t�.s. ......... ................................................................................................................................................................................................................................................................................................ • 04 • PT. PLACED ON 100% NON-REBREATHER AND THEN AFTERWARDS PLACED ON C-PAP. ALBUTEROL TREATMENT HOOKED INTO C-PAP MACHINE. PT. BARELY MOVING AIR INTO LUNGS. DIMINISHED BREATH SOUNDS IN ALL LOBES. DR. CAPILARI STANDING BY. PT. WHEELED OVER FROM CSU DIAPHORETIC AND ALOC. PT. UNABLE TO STAY AWAKE. MEDS GIVEN IN CSU, BUT HOURS BEFORE. HAVING PERIODS OF APNEA. PT. PREPARED FOR INTUBATION. DR. OF ANESTHESIA HER ETO PERFORM INTUBATION. DR. AT BEDSIDE PERFORMING INTUBATION. YAUNKER SUCTIO USED. 8. 0 INTUBATION TUBE AT 30 AT THE LIP. 02 SAT 98%. CAPNOGRAPHY USED AND POSITIVE FOR INTUBATION. BREATH SOUNDS HEARD IN BOTH FEILDS. CHEST X-RAY DONE FOR CONFIRMATION. ABG DRAWN PER RESPIRATORY THERAPIST. WOCHER,CHRISTINAJ,RN 0• 04 LAB DRAWING LABS. VENTILATOR SETTINGS SET TIDAL VOLUME-740 AC RATE 16 . RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 6 RUN TIME: 0825 EDM Patient Record RUN USER: MR.PARR a' .N 6 18 0 int: ANl1'IHI..T'' F E « :>::< Accou t o 6 ..... :.e .:.. ::. :..:.:.::....:..5...:,:D-........L:.J:::::..::.:::::.:::::::.::..:::.:::..:..::::. ::::.:.:.::::.::::::.............. .....:............:;::. . .::.::.;:::.:::::.;:..::.::::.::.:.:::::::.:::.; ::::: :::::: :.:::::::::::.: ::;::;::::;::.:: ....::;::::<.....:::: ni. :::No'::::.M0:0::0:6fi3'9:7:.6:::::< : :<:>:::<: A ex ::::48./.M.::...::.:..:.:::..:... :::::.::....::::.::::.::..:::::::;;:... : :: ::..:::: U.....t:::.....:.... J.................... .. .. .. PEEP 5 • • 04/12/07 044 NG TUBE PLACED TO LT NARE. NO FRANK BLEEDING NOTED. CONNECTED TO LWS. • 0• 00 REPORT CALLED TO JACKIE,RN IN ICU. PT. PLACED ON TRANSPORT MONITOR. o..i::::P:.il.! ��:.....:'.::i? i::i::;:y::i:::::::::::::i::i•::::i?:':J::::::i:;'::::::::;:j:.....::::':i::::i::i:.:.::.:i:.:: ''::::f:Y:iiii::i:};:::++}+: .i:.�:::i. ::::::i::......:.....:::..........:::.:. :.::::.:.:. ...........F. ............ ..... ... .... ......................................................................................... ::............................. :::>:::::::>::::::.::.�w.:::.:........................n............. '....:ion .::.::::::::..:....:::::::::::::':;........ :::i::::::::.':)::::::: Y:'1`: L`:::J'::::::: ::'.;;:+i.`;,:L%:r: ii ::>t6 k>:>::-:;::Insert on.. ..... .. .... Iv: Sala e.. c. .......... ................ .............................................. :............. .....................::.::.:.... .:::::.:.::::: ..........::.::.;..:.::.;:.;:.:.: »;::>::>::: >:::>: ::;: :>Da:t ::0 2:::: Tsm 00: <U.ser OCHE . CHR e :. .4::1...:::9.7:...:. ........e::::0:4......::..:.:...... Catheter Type <L> Peripheral Catheter Size <L> Insyte 18g 1.16in Insertion Site: LH IV Insertion Performed by: N.WOCC # of Unsuccessful IV Attempts: 0 Blood Drawn For Labs? N IV Ports Flushed W/Normal Saline? Y Paramedic Field Start? N Comments: Device Discontinued? <Y/N>: D/C Time: Initials EICG...0 ........::::::..::::: .. .... .:::: :.::::.::.;:.;.::....:.::........:....... .:.:...:.::: .. .............::.:P...::::::::::::.::::::. ...... `> X; :::;.: >::;>:;: W. .::. ISTINF''RN :::<: >:<:<: :... .:.;::.: ...:. :.;::::.:.:: :..:::.;:. Dat.e::q4:/1. /:Q 7::.::T.Mme..:.0..4.0:6 ..::Oyer.::. ....00HER,..CH32. ... . .. .. . ....... ...... ..... . .. .................... ................ ...:... ....... .....:... ....... .....................................:::,...:.:::..:..:::::.:................;......:::..:::::::.::, EKG Completed Y EKG reviewed by: CAPAN CAPPELLARI,ANN,MD C: t<ra:t ' :r :12e ord ED': Med.:Admin i.s...:.::.. . ...o...:. .. Date::::04'.:.12 ::.07.>:. T.iaie; 04:12::::.II.ser WO:CHER :'CHRISTI A. .... ......... . .................. .... ........... ......... ./......../.... ........... ................ ............. ... .. Medication/IV Fluid, Dose/Rate Route Site VERSED, 2MG IVP LH Comments: .... .......... »:: .... :............ :: :::::::::.:.:.:::::::::::::::::::,:.::::::::::::,.:::.::::.:::,:,:..: .:. ..... ...... co Admiis:t r:aton::Re cord <::::« Date 04%12/0 Time 04 2 IIs.er VOGEL::SONYA.: Medication/IV Fluid, Dose/Rate Route Site VERSED 3 MG IVP IVP Comments: RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 7 RUN TIME: 0825 EDM Patient Record RUN USER: MR.PARR M 0'7 6 18.2 50 ; Patien. ......AMXTHTST....DT�N�EL..: :.::.:::::.;:.;:.;'..::.;::.:..:.;:.::::.::.::;:.:::<.:::::..:.;::.:::...:.::..::....:.::: :..:.;:.:;Accauat.:.,No.;.:.;:.;:::::::.::.; 3:..:::::::;::>::;:.::;:.;:.::.;:. . .............. ..................... .............. A e :Se .:.:::::48: .M.:::.::::.:.:::::.;;:::::.:::::::::::::::..:::.;:::::::::.:::;:::;:.:.:::<:«::.::;:::.;;:>:;::::::; ....::::::::>.; ;:>:.::Uni:t:::::No:: ::::;M0:0:. '6>:...:9.7:..6:>;`:>:>::> <'>::;<...:::>:::;:::?:>::: ::::: /. x...:.: . .. /..:.::...::::.... ..... .:::::::...::::::.:..:::::::.:.:::::::.::::::::.::::.:....:..:..... g.:..::::::.::::.. .::.::::..::::::. ..::::.:.. .:::. .::::::. .::::..:. .:::::.:. ::: ... :::::.. .....::.::.:::::::::::.;Date.•0.4. 12 .0:7...:::.T a.::0:412. IIser...... OCHE CHR /. ./ .....::... m....... ... ...........:......:..........:.::....:::.,........... ................... Catheter Type <L> Peripheral Catheter Size <L> Insyte 18g 1.16in . Insertion Site: RFA IV Insertion Performed by: N.REEM # of Unsuccessful IV Attempts: 0 Blood Drawn For Labs? N IV Ports Flushed W/Normal Saline? Y Paramedic Field Start? N Comments: Device Discontinued? <Y/N>: D/C Time: initials .....: Fteco d ... .:................:::..:::::..:::.::::E Me mi 1: r:ataon. »:::::::>::>::;::::: ..>::: D. d..Ad n st TNA'RN Date...:0.4;/12./,D. ...::Time::.04.15 ...Us:e.r.::: WOCHER..0HRIST..........,:......::..:.::.:.:::::::..:::.::.:::::::.:::.:;:.::.::::::::::. Medication/IV Fluid, Dose/Rate Route Site ETOMIDATE, 10MG IVP LH SUCCYCHOLINE, 100MG Comments: Irita: e..and..Out e ..:..:::.:...::::.:.:..:. Date 04: 12.: 07:.;:...:;T�me..0.416......... s:er::%:::<:WOCHER: CHR S.TIN. . ...: ......:..,:.:.....:::::..... .:.;::.: —INTAKE IN ML _OUTPUT_IN_ML_ Blood Product Blood Enteral Body Fluid Source: IV 2000 Emesis/NGT PO Stool Other Urine Other >n-measureable Intake: rTon-measureable Output: Comments: .I';:..:.::::...:::;::;t; O ';.; `' < :> ; X. <<' ::' :: <' � ntuba. ........ Date 04/12/07 Time 041.:8 Us. r WOCH.,R,CH,.,..8 I ...................::. .;...... .... .: .... .::................:: .:..:::::...::::. ....::...:.:::..:..:.::...R.:::. :::..d.. .:::::.:. «.: :::ED'::M d: cimin': ray on' ecor :::;::>::;::>: ............:. .::.::::::::::.::::.:.:::::::.,,::..:::::::: e A est »:»>::»>::>::>:::»>::;;,<:::;::>. e W E..... RIS I A .... . .... ........... . .... D ': e` s r OCH R :CH a t......0.4...12....0..7... Time:;:©:4:21;:.>:.:U..::...:.:::..:..:........... ,............................,..:....:.. Medication/IV Fluid, Dose/Rate Route Site VERSED, 5MG IVP LH Comments: RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 8 RUN TIME: 0825 EDM Patient Record RUN USER: MR.PARR s: ;:»:: Pat eat YT IST D I AM H AN EL::: c' unt>:No' M.:7<633:82:b0 :::::::::::::::?:::::>::::>::>::;:'> . ......... :.::;..... J.;:.;::::<:::.;::: :.::.::::::.::.:::..:::.::::.::.:::::::.::.:.;:.;; A...ca:.:...::..::.;...::..:.:.;:.;:::.:...:........:..... :.. ...................... :.:.::.. ..:::. .::.:::::...::::::::.:::.....::......:::....:::::.:..:.:....;:.;:::.::::.:::.:.;:..............::.:.:.::.::....:..:::::::::.:::::..... A e ex :4:8 .:M:::> >::: .... :: :»>.<::>:::: IInst:::::No M0:0'0:6139:7:. ::»::::> :::»>>>; ::::::::;<:;:::>': 4..:./ ::.. .:::::....::::.�:..:..:...:....:.... .:................:.:....... .....:..........: :::::..:. .: : : :.. .::. ...:.::.......:.:.... :.......:.: :::::::::.::.::::::.::.::::::.::.:::::.,:: N Da:.a ::: e:.: ER CHFZISTI A .RN t 0.4 12..07::: :Time::::0:42:3:> :::IIs r..:::::WO.CH .::::...:.::.::..::.::::..;:...;:.;:.: . .:. ....::::...::::::. .:::/. ............. ................. ---NG Tube Insertion--- Insert Time: Tube Size: 18 Volume Returned 100 ml Description of Output: Guiac Status <L> NG Tube Discontinued?: N Placed to Low Wall Suction?: Y Comments: PLACED PER SONIA,RN Device Discontinued? <Y/N>: D/C Time: Initials ..:::.::::::::. <::::::: ... .. ........ .:::.::.......:: .:.::....::: ::.::::....:.::.::::...:::;::..:.::;::ED::Me ::Admifti Y:at]Oii:`RCC�r ':>: >::>' :>: ::::.::>':::>:'::: :: ;:»;:><:;<::: ><:::;::::::>> ;;:: ...::.:...: . :.:::::.. ::...:.:::::.. . :.::.:. ::.::. . st. ..:............ D 4 WO:::::E "CHR .TSN =:RN:' Mate::.,0..../12/07 Time 042.5 IIser CA.R, . ,....5 A.., Medication/IV Fluid, Dose/Rate Route Site MORPHINE, 4MG IVP LH Comments: H: ::.: ;. :;:.ffe sne >::> . aZd..Ca . ...... ...... .... ..... ..... ...... ............ .. . ........ ........ .:.... :.....:.: .................... .............. ............. E:;:: . RI .T:INARN ...:.... . .::..:... Date ::: 4 .::12' 7::> Time:::: :42"6:':::;User':'>WOCH R CH S 0..../. ... ..0.:.::.: ..:.......:.:Q:..:.::..::::..-............::...: ....... .... ...........,. .. Home. Meds:::.,,e.r.,f .. at. o... ': :W:: E:::::.CHRIS TINA: RN: :. . : »; .:;> .::.:................ ::.::..:.:........................... :...:.. .......::::......... .::...... »Date'04: 12 0.7:::::::Tiuie::: 4'2`6:::::::::user... OCH R . *****HOME MEDICATION LIST VERIFICATION***** Pt's meds routinely taken at home reviewed and verified by: WOCHER,CHRISTINA,RN Dme med list updated in Meditech by: WOCHER,CHRISTINA,RN Comments: .......... ....... ;: »::::.::.>::::>::::.::ED::Med' Adi601 stra:.-t'n. Reco:::.d:: : :> .. D 1 s r:>: >:W "HER::::CHRISTI N RN'`: >:' >><': ate 12 0 T e 042 II e 0 R 0:4 ...... :: ............lm.............:8.....:::..........:::.::..................,.............. Medication/IV Fluid, Dose/Rate Route Site ROCURONIUM, 60MG IVP LH Comments: RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 9 RUN TIME: 0825 EDM Patient Record RUN USER: MR.PARR P . <::: a ... ::<::.< <::.:< ;:AccountNo.: M0:Z6at nt AMYTHISIRANIEL J ::::::: .......: ...........:::....:::: : : : : :: . : ..:::.::..:::.......::..:::::..:.::..:... ...::::.::.:.........:::.::...:.:::.:.. :.:::.::::::::...:::: .:...::::::::::::::..:::::::Unt.:.No:�.::.MD;0.;0,613;9;7.6 ::.;:.;:..:.::.;::.;::......:....:::.:.:. nsert .F.o.le ....Cath.....Ind lli Y.::..:...:..:.::..::.::.: :::. ate<. :. 7 `: II :W::::>:.H 12 GI ::>:IS:TINF D 0.4 12.. .0....... Tame...0443... . s.e O.0 E R . ...: .:::.......... .................:..:.::.::.. Insertion Time Urine Color DARK YELLOW Catheter Size 18 FR Urine Clarity CLEAR Catheter Type FOLEY INDWELLING Volume Returned 200 ML Urine bag to gravity? Y Comments: Urine Catheter Irrigated? N Specimen Sent to Lab? Y Device Discontinued? D/C by: D/C Time: :r:`: o ..::::::...:.:::.. ...::::..:;:.::.:;:.::.::. I s. ..:..:::.. ...:. .::.::::::.:.:::::::..:.;..; .:.::.;:.;:.::.::.:: :::.:.. .::.::...: .:...: ....::...:.::......;.. .:.::.;:.;.: .;:::.:. >.;.::.:. .:::... .... .. . ... .:.:.:.::::..Date:::N:::12':`0:.7::::>:Time''04:44.... ser.....VOGEI; SONY .......:: ..::::. ........ .::... .:::.:...:. :::::::.:.. ::.:.:.:..: ......:. ....:::...:::::::..::::.......... ......:........... ... .:.:.:.::....................:.....:.::::.:...:.:::.::......:.::............... ---NG Tube Insertion--- Insert Time: 0430 Tube Size: 16 Volume Returned 0 ml Description of Output: Guiac Status <L> NG Tube Discontinued?: N Placed to Low Wall Suction?: Y Comments: WITH NG TUBE TO ICU. . .PAENT AND ON LWS. S. VOGEL RN Device Discontinued? <Y/N>: D/C Time: Initials ... ...... ... ... .. ............ .. . .. . .. :::: .... ........ :.. . . . ..:... . . . .. : . .. . .:.,.... . ........... : ««. . EKGComPlet . . . :. . : . .:: ... .......; .... ....:....... e . : . .....:.::............ .........:..................:: . : . : :: z <>' ;;::: ».: 7<::.:T' 4 T :<:.User;::::::WOCHER: .CHR I Date. 0$/12./xVie, Q:.:S ;:.::....:....:..::.: ......................::.: .: :.::...::::.::.::::::::::::.::.:::::::. ::.::::::;: EKG Completed Y EKG reviewed by: CAPAN CAPPELLARI,ANN,MD .::......::........... l FR;:::.;::. =a <::<::ED:::Med:<Adms:nss:tra on.. eco D / ER,..CHRIS...IN...,..... ::::::::...::. ate::..04:;.12/.0:7;.;;T me::.050:2::.. ...ser.....,.00H... Medication/IV Fluid, Dose/Rate Route Site VERSED, 2MG IVP LH Comments: .::... ................... ...........: :: ::::::.:::,:.,.:::.....: M A nis.tra.tron :Recort3: ::::<:'<::<:>:::;: <:::...%. ED ed dmi .. .:.::.:;:.;:.;::..... Dat:..:::: 4:: 12: <0:7::< ime:>:0:5.:02::>:>:.Us er ...VOGEL ............... ............... ....... ... ........ ....... fl......... .. .. ...........::. ....:.....:...:............,:...:....... Medication/IV Fluid, Dose/Rate Route Site VERSED 3 MG SLOW IVP IVP Comments: RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 10 RUN TIME: 0825 EDM Patient Record RUN USER: MR.PARR _ .....:::>;::>:>:>::>::< :...:: Accouut:<::No: :<:::MO 6318 b0 P,at ent:.::;..Ai�lYTHI,ST, .ANIEL:.J .....;::......:: .:.............................::::.:::::::..........:.....:.:.::. .:..;.;::.;.:::..>...:.:::..:::2.;.:.:::.:.: ;.:;::.: ,;:.:: .:: ..::...:: ... . ::>::;:::::::>::;>:::>::::.::.::::::;;»<:::::;:::.::.::>::>::>::::«:::>: »::;:. No:::;:MOi0.06139:76: ...... .... >::::<:»»..... M....::.::.;:.;:..::.::.;:.;;:. :.;:..;.:.;:.:.::.....:....:.:. . ....................... ............ ... .:..:.:.:::::::::::.::.: :.::::::: Unit:.:...:.....:.............:.. . :..:.........:..:...:::...,.:..:.:.::.,:: g.:../.........:::: ::::..::.:::::::.:::::::.:. .:::::::::::::...:::::. .... .::::::. ecord:;:> >< »» ' . `<:': :> ED Med::::Admin3.s:tr:at on:::A..... .. ....... . ................................................. .................................. VOGET '.SO Date:::>:.0Q.1'2 0.7: Time' 0.527 :: User ... ,..... . .. ..,.... .....::.... ......... ............... :....................... .......::::�::... / Medication/IV Fluid, Dose/Rate Route Site MORPHINE SULFATE 6 MG IVP SLOW IVP Comments: ED:::>Med:::A minstra ion<::Re co ...................: .::::::::::.:.::::::.:::.:.:,:.:::::..,.::.:: :..:::.:..::, Da ..:1.2 ..0.7.......T�me.; »:VOC Eli 5ONYA,.......:::::..:..:.:::::::::::::::::.:.:::.:::.:,.::::::......:::::...... .......... :...........:.................:.::.. ..::.:.:::::.......... ....................... ... ..................................... ................................................................................................................................. Medication/IV Fluid, Dose/Rate Route Site ROCURONIUM 30 MG SLOW IV PUSH IVP '.omments: . .:...... .. ..... ,,:. c. a: .. . .............. ... ......................................... ffi ...::.:.:: ED.:Med:.,A .....ra . .......::...... ..................:::::::::::...:::.::.:::.:::.:..::..:::::.:..:::.:::::::.:::::::.:::::::.............. .:... ...:...:. .. .:....::::...:.. . RD ::: Date;;:.0.4:.:.12:.07 .:.T.�me.;:0:53:0.:::.:User:....:AOI3LAND:,:....... ::: ..:.... ..:::..::::..::::::::..::. :::: ................ .... :........... ............RIC ........... .. . ..........................:........................ Medication/IV Fluid, Dose/Rate Route Site VERSED 2MG IVPS IVPS Comments: Date Time Procedure Ordering Provider 04/12/07 0354 Arterial Blood Gas CAPPELLARI,ANN,MD 4/12/07 0354 Chest X-Ray AP View (Portable) CAPPELLARI,ANN,MD U4/12/07 0354 EKG Request* CAPPELLARI,ANN,MD 04/12/07 0357 SUCCINYLCHOLINE (SUCCINYLCHOLINE 20MG/ML MDV** UNKNOWN 04/12/07 0400 ANESTHESIA AIRWAY KIT (ANESTHESIA AIRWAY KIT** UNKNOWN 04/12/07 0416 Cardiac Test Series Panel CAPPELLARI,ANN,MD 04/12/07 0416 Comp. Metabolic Panel CAPPELLARI,ANN,MD 04/12/07 0416 No Caffeine CAPPELLARI,ANN,MD 04/12/07 0416 Urine Tox Adult CAPPELLARI,ANN,MD 04/12/07 0420 MIDAZOLAM, INJ (VERSED CONCENTRATED INJ 5 MG/1 UNKNOWN 04/12/07 0424 MORPHINE SULFATE, INJ (MORPHINE 10 MG/1 ML TUBE UNKNOWN 04/12/07 0521 MIDAZOLAM,INJ (VERSED(genr) 2MG/2ML SDV) UNKNOWN 04/12/07 2212 Electrocardiogram UNKNOWN 04/12/07 2212 Electrocardiogram UNKNOWN RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 11 RUN TIME: 0825 EDM Patient Record RUN USER: MR.PARR Pat en.t:::::::::AMYTHI ..T':: ..:EL::::: Account::iNo..:::N10 6318 60 .. ............. :..... .5...:.,..: NI...:::::J:.:. .. :.:::::.::::...::::.:::::::..::::..:...::::::::::.::::.::::.:.::::::::. :::..:.....:...:.........:....::..::.;:::::: ..::::..:::.;:.:::: e S. x.::.. .. »::.::»::: :>:;:::>::>::>::>:.. AJ: ./. e...::.;:.;::4 8/....:. : .. :. Date Time Test Result Reference 04/12/07 0354 BASE EXCESS -1.4 2.0-2.0 mEq/L 04/12/07 0354 BLOOD GAS HEMOGLOBIN 13 .7 L 14.0-18.0 G/DL 04/12/07 0354 HCO3 25 22-30 mEq/L 04/12/07 0354 02 SATURATION 97 94-100 % 04/12/07 0354 PATIENT TEMP 36.1 L 37.0-37.0 C 04/12/07 0354 pCO2 47 H 35-45 ��,rHg ****************CRITICAL VALUE REPORTING******************* CRITICAL VALUE CONFIRMED AT: REPORTED AT: TO: BY:RT.MCGO READBACK OF RESULTS DONE (YIN) : '14/12/07 0354 pH 7.34 L 7.35-7.45 ****************CRITICAL VALUE REPORTING******************* CRITICAL VALUE CONFIRMED AT: 0510 REPORTED AT:0510 TO:MCEA BY:RT.MCGO READBACK OF RESULTS DONE (YIN) : Y 04/12/07 0354 p02• 84 80-100 mmHg 04/12/07 0416 AMPHETAMINE NEGATIVE NEG <1000 NG/ML 04/12/07 0416 BENZODIAZEPINE POSITIVE H NEG <200 NG/ML 04/12/07 0416 COCAINE POSITIVE H NEG <300 NG/ML 04/12/07 0416 OPIATES NEGATIVE NEG <300 NG./ML 04/12/07 0420 ALANINE AMINOTRANSFERASE 18 0-36 U/L 04/12/07 0420 ALBUMIN 3 .2 L 3 .5-4 .8 G/DL 04/12/07 0420 ALKALINE PHOSPHATASE 81 38-126 U/L 04/12/07 0420 ANION GAP 8.0 0-12 MMOL/L 04/12/07 0420 ASPARTATE AMINO TRANSFERASE 28 10-38 U/L 04/12/07 0420 BILIRUBIN,TOTAL 0.7 0.2-1.2 MG/DL 04/12/07 0420 BLOOD UREA NITROGEN 10 7.0-21.0 MG/DL 04/12/07 0420 CALCIUM 8.1 L B.5-10.5 MG/DL 4/12/07 0420 CARBON DIOXIDE 26 22-30 MMOL/L u4/12/07 0420 CARDIAC TEST SERIES PANEL U/L 04/12/07 0420 CHLORIDE 106 98-107 MMOL/L 04/12/07 0420 CREATINE KINASE: 0 HRS 286 H 61-224 U/L 04/12/07 0420 CREATININE,SERUM 1.0 0.6-1.2 MG/DL 04/12/07 0420 EST.GFR AFRICAN AMERICAN NUM > 60 >60 mL/min 04/12/07 0420 EST.GFR NON-AFRICAN AMER- NUM > 60 >60 mL/min 04/12/07 0420 GLUCOSE 160 H 70-108 MG/DL 04/12/07 0420 POTASSIUM 3 .5 L 3 .6-5.1 MMOL/L 04/12/07 0420 SODIUM 140 135-143 MMOL/L 04/12/07 0420 TOTAL PROTEIN 6.4 6.1-7 .9 G/DL 04/12/07 0420 TROPONIN I: 0 HOUR OR RANDOM 0.01 0-0.049 NG/ML 04/12/07 1150 CREATINE KINASE: 6 HR 230 H 61-224 U/L 04/12/07 1150 TROPONIN I: 6 HRS 0.05 H 0-0.049 NG/ML 04/12/07 1640 CREATINE KINASE: 12 HR 230 H 61-224 U/L 04/12/07 1640 TROPONIN I: 12 HRS 0.01 0-0.049 NG/ML 04/13/07 0416 CREATINE KINASE: 24 HR 235 H 61-224 U/L 04/13/07 0516 TROPONIN I: 24 HRS 0.05 H 0-0..049 NG/ML RUN DATE: 05/15/07 Contra Costa EDM **LIVE** PAGE 12 RUN TIME: 0625 EDM Patient Record RUN USER: MR.PARR i T T Acc uat No: .MO 6318260 .. X..:HIS...,DP..NIEI;.:,J.. :.:.:... .:: ::::::.. ::.:::.:::::::::.:::...:,:::.:::..::..:.:::..;:::.:.:...::..........o...... ex: 4 8 M:: ::< »: :::. :>::::>:.::>:.: IIni:b<No:::::>:M00:0611976 .......:.............. . ..:.........../..:..........::.::...:.::::.. .. ... .. ....:.. .:: .. :::.::::. .:.....:.:::..:... .::..:. :: :....:. .. :.:.::::.......:::::..::.:.... ::::.:::.::::.:.:: :::::.:.:..:..::::::::.,.::.::.::...:::::.::<;.::::::: MD Follow-up/Appt Request Patient Follow-up Instructions Patient Signature Page II�IIIIIIIIIIIIIIIIIIIIIIIIIIIIIII V� 3 '� 3TRNS PATIENTC.,ONDITION-Including"rule out"and open differential diagnosis. A. 2-the patient has no reasonable risk of deterioration in condition from or during transfer... B. ❑ Patient might beat risk for deterioration from or during transfer-Complete RiskBenefit statement RISKS OF TRANSFER BENEFITS OF TRANSFER • Increased discomfort during transit ❑ Specialized equipment not available at this hospital • Accidents or delays during transit (List equipment: ) . • Possible worsening of condition in transit E- Medical services not.,available.at this hospital El Other (List services: ) ❑ Patient request (see attached) ❑ Other SENDING HOSPITAL: — Z ED ❑ Floor ❑ Other DESTINATION HOSPITAL: ACCEPTED: A (TIME) BY: (Name of Accepting Hospital Employee)Hospital has available space and qualified personnel for treatment of patient.,: ACCEPTING PHYSICIAN: /-t �" Name TIME: Vitals on arrival:Date: / f I C% Time: ! a.mlp m� Tom!�.' P %i 7 R � BPI � ��lasgow r ❑ Aldrete Vitals at destination:Date: /f' / Time^' " Y a:mJp.m . T')? P �- Rh' BP �� `1 ❑"Glasgow N running? ZNone .. Needle.type: I Gauge: Solution: IV Meds: / ❑ Aldrete ANSPORT VEHICLE LEVEL OF CARE Ambulance Unit#^_ El Helicopter ❑ ALS 11 RN ❑ RT Fixed Wing Aircraft ❑ Other _p�LS El CCT-RN ElCCT-Paramedic El Sent Not Done Sent Not Done 3tL3abwork: ❑" ❑ EKG: Q ❑ Chart: 0 ❑ Transferform: P-I ❑ Nurses notes: ❑ ❑ Other(specify): ❑ ❑ X-rays: ❑ ❑ Special equipment needs: Medical Orders during transit: PHYSICIAN CERTIFICATE: Based upori the information available to me at the time of transfer, I certify that(1)the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the risk of transfer to the patient or unborn child/ } children, (2)for nonmedical transfers,that,within reasonable medical probability,the transfer creates no medical hazard to the patient. PHYSICIAN SIGNATURE DATE TIME CONSENT OF TRANSFER: I acknowledge that my(patient's)medical condition has been explained to me,I understand that it is recommended that I(patient)be transferred to the above facility.The benefits of transfer,risks of transfer,and risks of not transferring and reason for transfer have been explained to me and I fully understand them.I understand that I have a right to receive medical screening,examination and evaluation by a physician without regard to my ability to pay prior to any transfer from this hospital.In the event that you have a concern regarding the hospital's conduct,the person to contact is: Nursing Supervisor(Dial T")or California Department of Health Services,850 Marina Bay Parkway Building P,Richmond CA94804,Phone !,510-620-5800. I hereby CONSENT TO TRANSFER and authorize the hospital to provide ❑ I hereby REFUSE TRANSFER to the named hospital. ��copies of my(patient's)medical records and to exchange medical information necessary for medical care and to comply with any law orsegulation.r h k�l, }--.-e'' ;- � ;� ,,; ; �� _ !�•_.,:�,.. .:' Ger-%'i SIGNATURE OF PATIENT/PAR EN.T `' DATE TIME WITNESS _ .CHART-10 (12/15/05) I IIIIIII IIII VIII ILII VIII VIII VIII VIII 11111111111111 IIII ®JOHN .MUIR H430467 DOB: 10/21/58 48/M H E A L T H AMYTHIST,DANIEL PATIENT 1rRANSFER FORM H020906814 04/11/07 17:41 HNE1233184378 DISTRIBUTION:WHITE-CHART YELLOW- REC'ING FACILITY PINK - PATIENT V&TT 6183 77,r: CONTRA 'OSTA HEALTH SERVICES 1 CONTRA COSTA REGIONAL MEDICAL CENTER INCOMING TRANSFER/CONSULTATION A N Y T €S T E A•. i Tit L r _ a RTMEN EMERGENCw :Xr "t I XT 4 Y GO lob 1 -4 1;1-D E TIME STAFFAKIN INFO :12/0 E,A . P .IE T AME SEX D q CITY OF RESIDENCE •MR NO. ❑CCRMC ❑Kaiser PATIENT FROM ❑ ED ❑ Inpatient ❑ Home ❑Jail ❑Juv Hall ❑ MD Office ❑SNF ❑Clinic: ❑Other: ov T" REF RRI A LITY RETURN PHONE NO. REFERRING D/FN OT R T" TATIVE D GN REFERRAL REASON ❑Admission =S 5150 ❑ ED Evaluation ❑ Follow-up Appt ❑Other: HISTORY VITAL SIGNS Time: Temp J1••r � vl S Resp L BP Pulse SPO2 s Plan of Care: ❑ Refused/Reason:_ ❑ No staffed beds TRANSFER MODE ❑Ambulance ❑ Private Auto ❑Taxi ❑ Police ❑Other: PATIENT DISPOSITION/PLAN OF CARE ,NrED Evaluation ❑ Direct to PES ❑Direct Admit: Bed ❑ Follow-up Appt: REFERRED TO CONSULTANT ON CALL FOR ❑ Medicine ❑Surgery ❑ Peds E)G N ❑Other: ED Physician Signature: POST ARRIVAL INFORMATION Time of Arrival: Transfer Review: ❑Yes ❑ N�oj Financial Code: Additional Comments: MR 144-6(3/02) INCOMING TRANSFER/CONSULTATION Dcu'-)�-cL PREHOSPITAL CARE REPORT CA - Contra Costa Case#: 7095429 Pt#: 1 of 1 UrAt ED: 6183 Date: 4/11/2007 Time of Call: 16:53:1 Incident Location: Home/Residence Time Dispatched: 16:56:4 Time To Hosp: 17:15:49 2405 SUNNY LN,ANTIOCH,CA 94509 Time Enroute: 16:57:1 Time At Hosp: 17:35:37 Response Code: 3 Time On Scene: 17:06:1 i Time Available: 17:55:00 Change in Code: Time at Pt Side: 17:07:0 Time Cancelled: ALS Assessment: Responding With: LOCAL POLICE, FIRE ALS ENGINE Nature of Call: ALS-UNKNOWN MEDICAL ASSISTANCE Age Estimated Name: AMYTHIST, DANIEL D.O.B.: 10/21/1958 Age: 48 years Months: Days: ?address: 2405 SUNNY LN,7 Sex: Male Weight: 170 KG City,State,Zip: ANTIOCH,CA 94509 Name: DR.ISLAND Triage Tag: Phone: (925)755-0915 Employer: - SSN: 559-11.70'i0 Responsible Party: AMYTHIST,DANIEL Phone: (925)755-0915 Chief Complaint: DRUG ABUSE/HEARING VOICES ARRIVED ON SCENE TO FIND THE PT SITTING ON THE STAIRS WITH THE FIRE MEDIC FROM ENGINE 83 BY HIS SIDE. PER THE PT AND THE FIRE MEDIC THE PT HAS BEEN ON A BENDER OF CRACK,ALCOHOL AND HUFFING PAINT FOR THE LAST COUPLE OF DAYS. TODAY THE PT FEELS HE IS LOSING HIS GRIP ON LIFE AND IS HEARING VOICES. THE PT REQUESTED TO BE TRANSPORTED TO MDMC. THE PT WAS ASSISTED TO THE GURNEY AND TRANSPORTED TO MDMC. THERE WAS NO CHANGE IN THE PT'S CONDITION WHILE ENROUTE. ALL PT CARE WAS TRANSFERRED TO A RN WITHOUT INCIDENT. ALL TIMES AND EVENTS ARE APPROXIMATE. PE::3TINENT POSITIVE:DIAPHORESIS,DRUG ABUSE,ETOH. Patient denies the following:ABDOMINAL PAIN, CHEST PAIN,DIARRHEA, DIZZINESS,GENERAL WEAKNESS, HEADACHE,NAUSEA, SOB,VOMITING. Mechanism of Injury: Safety Equipment: None. Contributing Factors: Environmental Factors: Factors Affecting Delivery Of Care: Ristory: DRUG ABUSE„ DIABETES, SLEEP APNEA. Allergies: ALLERGIC TO SOME MEDS BUT DOES NOT KNOW WHAT.. Medications: Primary Assessment: Street Drugs stimulant Secondary Assessment Pagel of 4 4/11/2007 6:06:50 PM 4:7095429 Unit LD'.fila, M904-4541-LA Pt p: I of 1 Date: 4/11(2007 Pt: AMYTHIST,DANIEL V2.0.71- ZZGEG6086ZZ6742 ... .i .. ... ..., ♦.. .. ... _.... 1.......J'r ,.?':;"` '�.`.w �.. :..-.�, C.,. '-�•. ...-..r`.. �... iW- .._.,.r'.h .: 1..,:.p. ..�r-. k. .�,:.X':�:!c,�- _ ��:.-•- �, s.- 4f?G: :t�v�'L•n 3s"� -a;.,-....r_ "v • s. .��>J• _ #� '€��, ,� >�{ - - _ .,a�tF�:��.,'' ;,may..',,, _a+vs�'s""��:. +�;� `.�`a'�• :� �1. c Si'r%.�� .•, '„? a$.w1E,..'+•x..43 r rc"'�,•.�, e,Y:.'� �. '. c•.-. ",_�j�a��' bay-iS• .fit•'..�". ?`�,c,� �:,. +if i st Qajri �r_L 48 year old 170 KG Male / /' CC DRUG ABUSE/HEARING VOICES lr 1 (� PERTINENT POSITIVE: DIAPHORESIS, DRUG ABUSE, ETOH. PERTINENT NEGATIVE:ABDOMINAL PAIN, CHEST PAIN, DIARRHEA, DIZZINESS, GENERAL WEAKNESS, HEADACHE, NAUSEA, SOB, VOMITING. PMH: DIABETES, SLEEP APNEA. DRUG ABUSE,. ALLERGIES: ALLERGIC TO SOME MEDS BUT DOES NOT KNOW WHAT.. PRIMARY ASSESSMENT: Street Drugs-stimulant. M • Zm PTA Time Medic Procedure Ll 1713 Martinezmoles, Pedro,A Blood Glucose- 176 mg/dL. ❑ 1714 Martinezmoles, Pedro,A Vital Sign/ECG-Patient Semi-Fowlers. BP: 146 /84, Pulse at Radial 110 Regular Normal. Respirations: 18 Non-labored Normal. Pulse Oximetry:98 %on 02:02 UMin:2.Cardiac Rhythm: Sinus Tachycardia at 110. Ectopy:None. ❑ 1725 Martinezmoles,Pedro,A Vital Sign/ECG-Patient Semi-Fowlers.BP: 164 /84, Pulse at Radial 104 Regular Normal. Respirations: 18 Non-labored Normal.Pulse Oximetry:97 %on 02.02 UMin:2.Cardiac Rhythm: Sinus Tachycardia at 104. Ectopy:None. 0000 FIRE,ALS,E:MS Oxygen-CANNULA at 2 Ipm. Indication:DRUG ABUSE. Result:NO CHANGE: CRAMS Score 'rysiological Criteria: .natolnic Criteria: Mechanism: Trauma Disposition: Paramedic Judgment: Dispostion: TRANSPORT TO ED Receiving Hospital: MT.DIABLO MEDICAL MD Consult: ❑ CENTER Est Time Death: 0 Other Hospital: Base Physcian: Mode of Transport: Ground by ALS Rendezvous Point: Transport Priority: 2 Air Request By: First Respond Assist: ❑ Change In Priority: Reason For Air: Base Hospital: MileageScene: 0 Destination Decis: PT/FAMILY Base Hosp Contact: ❑ Mileage Hospital: 14.2 REQUEST Hosp Divert From: Base Contact Time: Total Mileage: 14.20 Physician Order: 4• Mx Primary Insurance: Medi-Cal Secondary Insurance: Medicare Policy#:559117010A 1 st Attendant: Martinezmoles.Ped 2nd Attendant: Schollar,Tony,AMR 3rd Attendant: Hospital Signature: Page 3 of 4 4/11/2007 6:06:51 PM 7095429 Unit ID:6133 M904-4541 -LA +.... I oI I Date: 4/11/2007 Pt: AMYniISr,DANIEL V2.0.7L ZZGEG6096ZZ6742 YT� 1ci�, J PTA Time: By: FIRE,ALS EMS Cardiac Rhythm Pt.Position: Sitting Pulse Sldn Rate: 116 Blood Pressure: 210/ 116 Rate: 116 Color: Flushed ECG: Sinus Tachycardia Regularity: Regular Temp: Warm Ectopy: None Strength: Normal Moisture: Moist Location: Radial Cap Refill: Normal 12Lead Interpretation: N/A GCS Level of Consciousness Respiratory ETCO2 Eyes: 4 Conscious Rate: 20 � CO2 Value: N/A Verbal: 5 RespondTo: Alert Oriented to Time Effort: Non-labored CO2 Color: N/A Motor: 6 Oriented to Person Oriented to Event Depth: Normal Total: 15 Oriented to Place o Lung Sounds SA02: 100 /0 02 Right: Clear Pupils: Equal-Sluggish CSM Intact 02 L/Min 4 Left: Clear Acuity: Stable Comments: ry . AIRWAY PATENT BREATHING NORMAL CIRCULATION RADIAL STRONG LOC A&OX4 LVL OF DISTRESS NON APPARENT HEAD NORMAL CEPHALIC FACE NO ABNORMALITY NECK NO ABNORMALITY/NO JVD CHEST NON TENDER=EXPANSION LUNG SOUNDS CLEAR BILATERAL BACK. NO ABNORMALITY/NON TENDER ABDOMEN NO ABNORMALITY/NON TENDER PELVIS NO ABNORMALITY/NON TENDER UPPER EXTREMITY INTACT-CMSTP LOWER EXTREMITY INTACT-CMSTP BLOOD LOSS NONE NOTED DRUGS/ETOII EtOH ADMITTED BY PT.UNKNOWN AMOUNT OF WINE ABOUT AN HOUR AGO DRUGS/ETOH DRUGS ADMITTED BY PT.CRACK ROCK ABOUT ONE HOUR AGO DRUGS/ETOII DRUGS ADMITTED BY PT.HUFFING PAINT HALF HOUR AGO �. ❑ Special Study ARRIVED ON SCENE TO FIND THE PT SITTING ON THE STAIRS WITH THE FIRE MEDIC FROM ENGINE 83 BY HIS SIDE. PER THE PT AND THE FIRE MEDIC THE PT HAS BEEN ON A BENDER OF CRACK, ALCOHOL AND HUFFING PAINT FOR THE LAST.COUPLE OF DAYS. TODAY THE PT FEELS HE IS LOSING HIS GRIP ON LIFE AND IS HEARING VOICES. THE PT REQUESTED TO BE TRANSPORTED TO MDMC. THE PT WAS ASSISTED TO THE GURNEY AND TRANSPORTED TO MDMC. THERE WAS NO CHANGE IN THE PT'S CONDITION WHILE ENROUTE. ALL PT CARE WAS TRANSFERRED TO A RN WITHOUT INCIDENT. ALL TIMES AND EVENTS ARE APPROXIMATE. Page 2 of 4 411112007 6:06:50 PM M: 7095429 Unit ID:615: M904-4541 -LA ..d: 1 oI I Mte: 4111/2007 Pt: AMYfHIST,DANIEL V1.0.7L ZZGEG6086ZZ6742 Illnllllllllllllll llll Illlllll page Of� 1 PTIN �ergies/Reaction: u.14 ❑No Meds Info r c i frog ' ❑ Allergy Band ❑Latex Allergy Applied Unable to obtain Flu vaccine this Flu vaccine date Prior Pneumovax Pneumovax date Reason: flu season? ❑Y ❑N received? ❑Y ❑N Drug Dose Last Taken Discharge Instructions (Include herbal supplements and OTC medications) Route: out Shot ED Other: El Discontinue, do not take at home Fre CJ 1Jday ❑2/day ❑ 3/day ❑4/day ❑ Other: rZ> ❑See new prescription Route: Mouth ❑ Shot El Other: L, El Discontinue, do not take at home Fre 1/da ❑ 2/day ❑ 3/day ❑4/day El Other: El See new prescription ----------------------- ,oute:❑Mouth ❑ Shot ❑Other: ❑Discontinue, do not take at home Freq: ❑ 1/day ❑2/day ❑ 3/da ❑4/day ❑ Other: ❑See new prescription ----------------------- Route: ❑Mouth El Shot ❑Other: ❑Discontinue, do not take at home Fre : 0-1/da ❑2/day ❑ 3/day ❑4/day❑ Other: ❑See new prescription ----- ------------------ ite:❑Mouth ❑ Shot ❑Other: ❑Discontinue, do not take at home Freq: ❑ 1/day ❑2/day ❑ 3/day ❑ 4/day ❑ Other: ❑See new prescription --------------------- --- Route:❑Mouth ❑ Shot —0--he—r: E-1 Discontinue, do not take at home Freq: ❑ 1/day ❑2/day ❑ 3/day ❑4/day❑ Other: ❑See new prescription Route:❑Mo.uth ❑ Shot ❑ Ot—he r: ❑Discontinue, do not take at home req: ❑ 1/day ❑2/day ❑ 3/day ❑4/day ❑Other: ❑See new prescription ------------------------ Route:❑Mouth ❑ Shot ❑Other: El Discontinue, do not take at home Freq: ❑ I/day ❑2/day ❑ 3/day ❑4/day ❑ Other: ❑See new prescription — Route:❑Mouth [IShot ❑ Other: ❑Discontinue, do not take at home Freq: ❑ 1/day ❑ 2/day ❑ 3/day ❑ 4/day ❑ Other: ❑See new prescription Emergency RN/LVN Si nature #a , Other Date Although the Emergency Department and physicians have reviewed your medication list, except for the specific medication changes recommended by the emergency physicians,we cannot comment or adjust medications prescribed by your primary care physician or other specialist physician(s). Please follow up with your primary care or specialist physician(s), who is responsible for your general care and all other medical conditions, as well as for any continuing or long-term care. BRING THIS FORM TO THE NEXT PROVIDER OF CARE I PRESENTE ESTE FORMULARIO AL OTRO PROVEEDOR DE 7/--5 (2/16/07) ATENCION MEDIC" ... . -- ®JOHN H R 11111111111111111111111111111111111111111111111111111111 John Muir Medical Center H430467 DOB: 10/21/58 48/M ConcordCus EPMERGENCY DEPARTMENT AMYTHIST,DANIEL 1/07 MEDICATION RECONCILIATION H020906814HNE1123318437841 CHART COPY tom/ NungeC� EMT �e�ificat�o�: Nu�beC: 2'�p5 pacame�\` Ceti{i�atiOn. 41111200 6:06�5��P pt.. Page 2 of 2 S. _'for no&normal CIRCLE for yes HISTORY OBTAINED FROM: ❑Patient ❑Family ❑Paramedic/EMT ❑Police ❑Friend ❑PCP ❑Other ❑ Unobtainable due to patient's condition CC/HPI: (Level 1.3: 1-3 elements, Level 4-5.4 or more elements) ( �,( ! CC: p �, ( /c.+ vSL �% F `' fi uL 1\J 'I Lt Location/Radlat on: Severity: Quality:..._._.............._..._._........_....... Context: Duration: -...._..-- --............. . Modifying Factors: ......... — Associated Signs & Symptoms: - .. .....__. ... __.._._.._... ._...... _......__.._._....._.... ........ Timing: ----------- (Level -------(Level 1-3:None Level 41 area Level 5:2-3 areas) A eewit�RNnot ❑ Unobtainable due to clinical condition. LMP_ Last tetanus tax No serious illness Asthma COPD CHF HTN CAD Angina PTCA x Stent x CABG x PACER AICD AVR MVR T1A CVA High chol AFib PSVT IDDM AODM Hypothyroid GERD PUD UGI Bleed LGl Bleed Hiatal hernia Diverticular dz Appy Chole BPH TURP Vag hys TAH BSO Tubal lig C-section x Hepatitis B C Migraine Dialysis Glaucoma Lumbar surgery G _P Ab PVD Neuropathy Depression Bipolar Schiz Anxiety Seizure Dementia T&A Anemia AI r ORGIES/IN CES: NKDA ASke with RN Unobt PCN Erythro Sulfa ASA Cod Iodine Morphine k See concilliati orm SOCIAL HX Unobtainable Cigarettes: Y N Quit Alcohol: Y N Abuse Quit Drugs: Y N Marital Status: S M DIDOW/ER cupation: FAMILY.HX:'. DM HTN CA CAD N TORY-Unobt Unknown REVIEW.OF SYSTEMS: Level 1-3:1 system Level 4:2-9 systems Level 5:10+systems ❑ Unobtainable due to clinical condition CONST, All neg except Weak Lethargic Fever Chills Sweats Fussy Irritable NEURO: All neg except Headache Paresthesias Difficulty concentrating Focal weakness Change in function Seizure Syncope Dizziness f YF'- All neg except Visual loss Epiphora Pain Erythema Lid/lash crusting Diplopia Photosensitivity Discharge Glasses 111 neg except Otalgia Otorrhea Tinnitus Hearing loss Dysphagia Odynophagia Odontalgia Epistaxis Nasal congestion Sneezing Sore throat Dentures REQ. . All neg except Cough Sputum Hemoptysis SOB DOE Wheeze Pleuritic CP CARDIAC: All neg except Rest pain Exertional Pain Palpitations PND Orthopnea LE swelling Irreg rate GI. All neg except Nausea Vomiting Diarrhea Melena Hematochezia Constipation Tenesmus Abd Pain Hematemesis GU: All neg except Dysuria Hemaiuria Urgency Frequency Nocturia Vag bleed Discharge Anuria Oliguria ENDO: All neg except Polydipsia Polyuria Polyphagia Head/Cold Intolerance Hair loss Voice change MUSC: All neg except Arthralgia Myalgia Warmth Erythema Swelling Locking/Clicking Pain: Neck Back Ext HEME/LYMPH: All neg except Bruising Bleeding Lymphadenopathy Petechiae Lymphangitis ALLERGY/IMMUNO: All neg except Hay fever Pruritis Hives Itching Watery Eyes Rhinorrhea Asthma PSYCH: All neg except Depression Anxiety Hallucinations Sadness Suicidal thought Suicidal plan Anhedonia INTEG: All n xcept Rash Lesion Dry Skin Scaling Fissuring Abrasion Laceration I other systems are reviewed and are negative �.- SICAL EXAMINATION: I Lerte dy area/organ system Level 2-3: Lev 5-7 prvel 5: = 8+ VITAL SIGNS: All neg except A Per RN Notes P P_T_RR_Pulse oxT e o� rj�1..ABN Wt(kg) VA: R L B CONST: All neg except Well dove e I nourished Well Hydrated Obese Alert Appropriate Acute Distress Cyanotic Mottled Toxic HEAD: All neg except Normocephalic Atraumatic Fontanelle Bulging Fontanelle Soft EYES: All neg except PERRLA EOMI Fundi Benign Visual Field Cut Lids/Lashes WNL Nystagmus APD Conj Erythema EARS: All neg except TM Erythematous/Bulging TM's clear Ext and canal clear NOSE: All neg except Nares patent Septal hematoma Epistaxis Deformity Rhinorrhea THROAT/MOUTH: All neg except Mucus Memb pinkimoist Dentition Vesicles Lesion Abscess Exudate NECK: II n g xcept upple Adenopathy Meningeal Signs Thyromegaly Mass JVD Bruits Stiff Painful RESP: I ex _Clear Wheeze Stridor Rales Rhonchi Grunting Nasal Flaring Accessory Muscles Tachypnea Bradypnea Apnea CARDIAC n exc t S1S2 WNL Rub Murmur S3 S4 Irreg rate/rhythm Pulses: Car Rad Fern Pop DP PT Pulseless GI: All n except oft Mass Bruit Tender Hernia Bowel Sounds Guarding Rebound CVAT Prostate ool Heme pos.stool Heme neg.stool Internal Control OK GENITAL:. All neg except Unremarkable Discharge Lesion Adnexa CMT Penis Scrotum Epididymis Testicle NEURO: All neg except CN II-XII Motor Sensory Ataxia Romberg DTR's GCS_ Babinski Suck Grasp Engages Gait Oriented x_ Finger to Nose Heel to Shin PSYCH: All neg except Suicidal Depressed Anxious Paranoid Speech Pressured Hallucinating Mood. Affect Oriented Memory Judgement INTEG: All neg except Macule Papule Plaque Scaling Fissuring Vesicle Ulcer Abrasion Erythema Nodule Laceration cm MUSC/SKEL: All neg except Crepitus Deformity Swelling Warmth Instability Painful ROM Bruising Tenderness _SLR LYMPHADENOPATHY: All neg except Submental Ant. Cervical Post. Cervical Occipital Axillary Inguinal 74. 12/28/06) JOHN MUIR IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII�IIIIIIIIIIIIIIII John Muir MEA L Center T 14 H430467 DOB: 10/21/58 48/M Concord Campus AMYTHIST,DANIEL EMERGENCY DEPARTMENT H020906814 04/11/07 17:41 PHYSICIAN RECORD HNE1233184378 2 RC P pelof2 TLj e of I.W Orders ED MD 11,117 TIME R00�1 LAB/DIAGNOSTIC;TESTS:`(Indicate Abnormal.lTreatments);: 1/ J ❑Prior Records—❑Reviewed ❑Unobtainable ❑NoneMEDICAL`::DECISION:MAKING' ;.. :' H&H BC ❑Blood Bank Hold ❑T&C_u PRBCs wnl abn Interpretation by ED MD ❑ECG ❑X-Ray(s) #Views ❑1-Stat ❑1-Stat Cret ❑Amyl ❑Lipase ❑NHa wnl abn ❑NSR w/normal axis&intervals.No sig.ST-T abn or BBB.No ischemic changes. MPS ❑CMPS Interpretation: ❑Gluc�se POC .❑Acetone wnl high low. p @PKSrop ❑D Dimer ❑BNP ❑PT [IAPTT ❑WESR writ abn ❑Preg ❑HCGB neg pos ❑Rh factor neg pos IV Infusion therapy hours ❑Dig Dila � f lyenol B'ArC rugs Indication: Response:. A cathold wnl abn ❑Urine preg.POC ❑Urine culture Pertinent/Pending Tests: ❑Culture of ❑Blood ❑Wound ❑Sputum ❑Stool ❑Chlamydia GC CG #1 wnl abn ❑ECG#2 writ abn ❑Serial EKG pm/chest pain i <, I i �•./ . `..� ' j[ice ❑Pulse Oximetry % on RA Ltrs Oz wnl abn �`�� ❑ABG on RA Itrs 0: ❑Chest x-ray ❑Portable Abdomen: ❑KUB ❑Flat&upright ❑C Spine: ❑3 View ❑ Cross Table ❑US Spine Ltd. Compl. %, Y 't•.'. i' J �. ❑CT Scan of ❑Head ❑Chest ❑Abd ❑Pelvis ❑Kid Stone t +lir 1 I '41C till) t I tt� ❑Contrast Y N ❑IV ❑Oral ❑Rectal ❑Pregnant Y N 9 ! ❑Ultrasound ❑Pelvic ❑OB ❑Abdomen ❑Appy ❑DVT ❑Carotid ry I ! ❑ 1 �.ti f tl 1 �,. 1'I; ",ason for Imaging study: RNILVN Time/ I d� Signature — ❑0 rgiac monitor ❑02 via—@ L per min Saline lock 98dbs-EMS or / Cmin �I IV infusion ® mL per hr 1; � ; .. ❑ Albuterol El2.5mg HHN ❑10mg per hr ❑15mg per hr ; ;r ( t� ..A ❑Atrovent 0.5mg HHN ❑Levalbuterol ❑0.63 mg nab ❑1.25 mg neb ❑5 mg neb per hr !, - 1 ❑DT 0.5 mL IM ❑Suture Removal ' = r, ❑Orthostatic VS ❑Ambulate Patient ❑Pelvic set-up ❑Hemocult/Gastrocult /. ,splint Applied \ l bC 1 l [3 Good position,Neuro Intact,Good CIPWMTI � IN CONSUL TION:.PCP- - CP b6nsultarit:kHaa Plari"NID Timm- lle�meofContacMiscussion,: ❑ LAt ❑Critical Care time(30.74 mi2kExcludes 6me spent for sepaty bills procedu/es j Diagnosis: J . 1 ❑ 4/LA (/i Z lV P DISPOSITION Physician Signature to dic anon q chart�—,�pl�tedCONDITION ON DC: ❑ Good ❑ Improved ❑ Poor 1G-fair p Expired when aled � � C � / ❑ Home ransfer Initials,circle one: D MB JG SG SBS JC JS JT BP TY JN DL HL "t) LF BF SS LM RR JY KJ BR TV JM JR KA CC AP LMF CD ❑ Admitted / Dr ❑ Other ❑ AMA 85 (12/28/06) &JOHN MU I R 11111 111111111 IN H430467 DOB: 10/21/58 48/M John Muir Mediae/Center Concord Campus AMYTHIST,DANIEL EMERGENCY DEPARTMENT H020906814 -04/11/07 17:41 PHYSICIAN RECORD HNE1233184378 IIIIIIIIIIII�IIIIIIIIII IIIIIIIIIII 2EDNN .PRIMARY :EVALUATION.::RN%LVN.1 ERT:.::::; Exam`Room: Lt MI Name st WA'4%V5 � �, . Date: V, Time: Age: DOB: v M / F PCP ❑ Family Present ❑Other Support Present ED T00: Permission to call for follow up if indicated ❑ No ❑Yes Phone: Arrival: ❑ Private Car Ambulance, rig # From: Home ❑ Other: Field Treatment: ❑C-Spine Prec. ❑IV solution: C 1@G:�� ❑02 Sat: ❑RA 002@ L per min ❑Meds: / ❑5150 placed prehospital ther: BP Lying: hal I Sittin Standing: Temp: R/T S,02 RA ❑02@ L/min❑NA P Lying: Sifting: Standing: Resp:, Last Tetanus z: ❑NA Visual Acuity: ❑ NA Right: Left: Bilateral: Corrected: ❑ Yes ❑ No Weight (req if <12 yrs): kg Speaks/Understands English ❑ Translator Present ❑ Translator Needed. Language spoken: CC: ❑ Pt. ❑ Family ❑Other: i>iF- at"l- -� Recent ED visit Data Collected by: . ......... .. ..: . ..:....TRIAGE VAL AT N K ? Alert&Oriented: ❑Yes ❑No Date&Time last ate: d NA Blood Glucose: ID: ❑NA P (provokes) P (provokes) _1 ❑Calm Glucose Reference Ran e Q (quality) 1,—) 0(associated op) � ❑ Playful 0 Day 30-65 Z R (radiation & Om S (sputum) , 0 earful 1 Mo. 40-100 location) N T (time or talking) U ❑Angry 6 Mo. . 60-100 n S (severity or intensity 0-j) E (exercise) a ❑ Anxious > 12 Yr. 50-130 T (time or duration) Goal pain < 3 or: _ What alleviates pain? iE. LTH: :.... :..:........:............. - - A !HISTORY.,RY....:.:.... ❑..N :Histor Available... . .....:......_. - - HS O o y - - - -- = - - - - - EENT: 9POGent Denies ❑ Cataracts ❑ Glaucoma ❑ Hearing Impaired Neuro: ❑ ient Denies ❑CVA ❑ Dementia ❑ Headache ❑ Seizure CV: atient Denies ❑Angina ❑ CHF ❑ CABG ❑ HTN ❑ MI ❑ Pacer ❑ AICD ❑ Stent Res atient Denies ❑ Asthma / COPD ❑Tuberculosis ❑ Smoke (Indicate packs per day): GI: ❑Patient Denies ❑GI teed ❑Hepatitis ❑ GERD ❑ Ulcer Endocrine: ❑Patient Denies 2157iabetes ❑Thyroid Problems Renal/GU: D-atief t Denies ❑ CRF: Last dialysis date: ❑ Kidney Stone ❑ Prostate ❑ LMP: Psych History: ❑Pati nt Denies ession ❑Apxrety Oipolar ❑ Schizophrenia uicidal ideation, security notified Surgeratient Denies Infectious ❑ ient Denies ❑ MRSA ❑ VRE ❑ C-DIFF Treatments/Interve at Triage: ❑ Ice ❑ Elevation ❑ Splint ❑ Dressing ❑ NPO Medications given at tria a (See Pg. 3) LVN Signature: RN Signature: TRIAGE LEVEL: 1 II III IV EXPE ..: ;.::,;::;:.,:: EDUCATION`:ASSESSMENT GE`{PL'AN;.". CTEi] OUTCOME.... .................. ❑Pain Achieves pain control of< 3 or acceptable leveleceptive to learning ❑Altered Body Temperature States methods for maintaining normal body temperature Factors affecting learnino ability:_ jbk)rte ❑Altered GI Function States methods to improve GI function ❑ n/verbal instructions adequate ❑Altered Respiratory Function Achieves improved respiratory function Alternate teaching method: ❑Impaired Mobility States methods to improve mobility I Cultural/religious practices lie ❑Impaired Tissue Integrity Identifies methods to promote wound healing a home available i nce at home available Q15neffective Coping States methods to improve coping ditional Comment: ❑ Other: RN Signature: Time: 1 am leaving the Emergency Dept, without being seen by a ph sician. ❑Not 4wering when called Date Time Patient Signature ❑Unable to obtain patient signature .124 (11/7/06) IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII ®JOHN MUIR ,IIIIIlIII! H430467 DOB: 10/21/58 48/M John Muir Medical Center Concord Campus AMYTHIST,DANIEL EMERGENCY DEPT. NURSING RECORD H020906814 04/11/07 17:41 PAGE 1 of 4 HNE1233184378 . �► it i s e SECONDARY EXAM 11JEUROLOGICAL RESPIRATORY CARDIOVASCULAR LOC: art& Oriented x 4 ❑Confused Respirations: . ❑ ored Apical Pulse: ❑ Regular ❑Dom' °riented ❑Lethargic ❑ Labored ❑ Irregular Speech: 8 Clear ❑Aphasic ❑ Ac ssory muscle use ❑ Murmur ❑ Repetitive ❑Slurred Lung Sounds: tear Cardiac Rhythm: Pupils: CLL ❑Unequal ❑ Crackles Capillary Refill: ❑ <3 seconds ❑>3 seconds L_ R_ ❑ Rhonchi Facial Droop: EILeft ❑Right ❑ Wheezes El JVD Present Tongue: ❑Midline 0 Left ❑ Right ❑Stridor ❑Pedal Edema Grips: ❑Equal ❑L>R ❑R>L Sputum: ❑Fistula Site: Weakness: ❑L sided ❑R sided ❑Bruit present ❑Thrill present Comment: Comment: Comment: GASTROINTESTINAL ❑ NA SKIN GENITOUR!NAP.Y/PELV{C ❑'NA Abdomen: ❑Soft ❑Firm Temp: ❑Warm ❑Hot ❑Cold ❑Bladder distension ❑Incontinent ❑ Non-tender ❑ Distended Moisture: ❑Dry ❑Moist ❑C/O burning ❑ C/O frequency ❑Tender ❑ Nausea Color: ❑Pink ❑Pale ❑ Foley ❑ C/O urgency ❑Vomiting #of emesis last 8 hr: _ ❑Jaundiced ❑ Flushed ❑Vaginal discharge ❑Vaginal bleeding ❑Diarrhea #of stools last 8 hr: _ ❑ Cyanotic ❑Penile discharge Bowel sounds: ❑ Present ❑Absent Integrity: ❑ Intact ❑ Decubitus OB/Gyn: ❑ Hypoactive ❑ Hyperactive ❑Burn ❑Abrasion Gravida: Para: AB: Last BM: ❑ Laceration ❑Rash ❑ Pregnant ❑ Prenatal care Location: ❑ Ecchymosis FHT: Prenatal Care Provider: Comment: Location/Comment: Comment: MUSCULOSKELETAL::.......:... .:....:..' ...:::: PSYCHSO I L -:, ; EENT;.,:.';❑ NA:. DelST intact ❑ Gait,steady ❑ Obesity Demeanor: ooperative nxious Comment: [I Deformity ses Palpable ❑Agitated ❑.Combative ❑Age appropriate ❑ Extremity Injury Substance Use: L�- TOHreet Drug ❑ROM Describe: ❑Eating Di r ❑Cane ❑Walker ❑ Crutches INFECTIOUS::.CONDITIONS..❑ PEDIATRICS METRA`: ❑Wheelchair. ❑Splint/Cast Recent Exposure:❑Chicken Pox ❑TB Immunizations Current:❑Yes❑No-describe: ❑Hepatitis ❑Meningitis ❑Isolation initiated Type: ❑Parent/Child interacting well Comment: Comment: Comment: ABUSE SCREENING :.;. .. :.. .. . :...... We are concerned about the safety of our patients, so we ask everyone about their safety.Do you feel safe in your living environment2.B�No If no, describe: ❑No visible signs of trauma or abuse Report to: ❑Police ❑CPS ❑Adult Protective Services ❑STAND Against Domestic Violence FUNCTIONAL and NUTRITION SCREENING Nutrition: .2o new problems identified ❑Unplanned weight loss> 10 lbs within 6 months, referred patient to PCP for follow up Functional Ability: neroble s identified ❑New mobility, speech or swallowing problems identified, referred patient to PCP for follow up LVN Signature: 77124 (11!7/06) &JOHN MUIR IIIIIIIIIIIII�III IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII John Muir Medical Center H430467 DOB: 10/21/58 48/1VI Concord Campus EL EMERGENCY DEPT. NURSING RECORD H02090 814 04/11/07 PAGE 2 of 4 HO2O9OGH14 HNE1123318437841 N CLINICAL PARAMETERS 0 co Time/Initials: b • a Safety Standard BP i •0+ Pulse _ s •RespIT °' D Temp `� • 0 (Enter liters per minute or RA) 1 A V S O • Cardiac Rhythm 00 Blood Glucose$ meter ID Neuro Check Std •ra Intake (indicate type) kx- Output (indicate type) Family at Bedside Y�t7 Fetal Heart Rate PAIN._ASSESSMENT/ NA EMENT.,.:_.:..._::�a.:::.:....._:,•_...,:...:. :;<::_y:a_r:,.> :. ..::>.;;:.:.. :.-...:..::: �._.,,•=PARENTERAI`;:7 NERAP.Yd ':.=. :-.:t ...,r .r:.:i.« N Time/Initials Time # So tion,Volumq,Rate Site/Init Pain Standard tf 1 fyEis /t�C�7n I v w Goal pain level 3 or: �) G Pain Intensity lohp 0-10 scale,A=Asleep,F/#=FLACC scale score,'=Other(see note) a Location R=Right,L=Left,A=Abdomen,B=Beck, -Chest,G=Generalized,H=Head,IS=lnjurysite,LE=Lowerextrem, UE=Upper extrem,*=Other(see note) )uality / L4 L s=Burning,S=Sharp/Stabbing,D= ull/Aching,P=Pressure/tightness,T=Throbbing,'=Other(see note) rn Intervention iivlo A=Alternative Therapy, C-Comlort measurs, M=Medicated. MD=MD notified, P=Palienl acceptable level. PM-Pre medicated. '-Other (see note) n Pain intensitit,post into i 0-10 scale A=Aslee ,F/# AC scale score,'=Other see note m Sedation level m 1=Awake,2=Sleepy/Drowsy,,- ous to erbalstimulus,4=Arouses to physical stimulus, m =So nniAnt/diffinilittoarousE Time to Room: ❑Cardiac Monitor A ❑02 Liters per minute via O NC ❑Mask NA KG ❑NA to ME.;. .MEDICATION/DOSEIROIITE '.:INTERENT10N5/RESPONSEti"' � • r' .:. .104 = INITi'k 7 3-04TAAl � -&ft�zt tbLA N i — La INIT.:v..::.._ .,.,SIGNATURE/iTTL .......,..:. : ........ ..:•.:�..:,:.. - <INR::;':- - - -- - - - .•.....:,,:;;:::..:,�..:':::.: ._,.l.r.:�;:- :::. .. ... •::r::n=:`x,` �^::ri °:i,`' �,'r�tr,T'br,.� xv,G,�F ym fn 77124 (11/7/06) ®)OAL MU IR IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII John Muir Medical Center Concord Campus H430467 DOB: 10/21/58 48/M EMERGENCY DEPT. NURSING RECORD AMYTHIST,DANIEL PAGE 3 of 4 H020906814 04/11/07 17:41 HNE1233184378 .. ...,'-... ,.......n..... .... .'-::- .. :�'."i":l i-�';:..Vii; •� ::��iY,Ly,A,::'y:•;.:..+� _�: IME:'�;:::+MEDICATION/DOSE/ROUTE..:,.. ERVENTIONS/RESPONSE/3..:�:: �,.e+:-_,...•�..,4i; a-•,: lh 1 7 ,.a •/vi ,w ZIA- ......•.s ......:_.-�....:. ................,-.,....,..,..:.. - - - J ATURE/TIl IT. . -_...S �SIGNi4TURE/TITLE..:.- 1 • .FAM LY..E •'�= - - ..:........ Topic(s): ❑ Medications ❑ Diet ❑ Activity ❑ Equipment ❑ Home Care ❑ Community Resources ❑Treatment technique ❑ Discharge Plan Describe Teaching Method(s): ❑ Written instructions ❑ Discussion ❑ Demonstration Taught to: ❑ Patient ❑ Family/SO Outcome/Response: ❑ Verbalizes Understanding ❑ Demonstrates Correctly ❑ Needs Reinforcement Time: Signature/Title: Topic(s): ❑ Medications ❑ Diet ❑ Activity ❑ Equipment ❑ Home Care ❑ Community Resources ❑Treatment technique ❑ Discharge Plan Describe Teaching Method(s): ❑ Written instructions ❑ Discussion ❑ Demonstration Taught to: ❑ Patient ❑ Family/SO Outcome/Response: ❑Verbalizes Understanding ❑ Demonstrates Correctly ❑ Needs Reinforcement Time: Signature/Title: S ....,-.. :. - .DISCHARGE..SUMMARY: ...... ... ..... . .. .... .. ...-.... ._ - '<;v:,:;��;:4:;:: IV: ❑ Discontinued, cath intact ❑ Patent at time of transfer Discharge Pain Intensity (0-10): Expected Outcome Met: ❑Yes ❑ No If no, plan for F/U: Discharge Disposition: ❑5150 ❑ SNF ❑ Board & Care: ❑Transfer: ❑ Home/accompanied by: ❑Admit to: Mode of Discharge: ❑ Ambulatory ❑ W/C ❑ Gurney Rx given to: ❑ Patient ❑ Other: Mode of Transport: ❑ Car ❑Taxi ❑Ambu-Cab ❑ Ambulance ❑ Coroner ❑ Police Discharged by: Date: Time: 77124 (11/7/06) ®JOHN MUIR IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII John Muir Medical canter H430467 DOB: 10/21/58 48/M Concord Campus A M YT H 1 ST,DA K I E L EMERGENCY DEPT. NURSING RECORD H020906814 04/11/07 17:41 PAGE 4 Of 4 HNE1233184378 O �� I I I CONTRA COSTA HEALTH SERVICES D A N 11_ 3. MENTAL HEALTH DIVISION K Y T H I S T g L s ()5 1 5 M L PSYCHIATRIC EMERGENCY SERVICE at41 I T55- Er jency AssessmentJ 4 b C q +� C h P; 2 Uv5I 1' / 21 / 1958 71 OPA j�u./ z"", =Cil L IL L Initial Diagnostic Impression Axis I: CD 0 2-g1.3 2-32, .11 Axis II: 1 Axis M-. -51,t44'' .c::AtCi, �r tcVki e0L. 1 Axis IV stressors: ii�C1'.�,(,t�.�`� - Axis V: Curr: ZO Highest Past 12 mos: Collateral Contacts: FINDINGS (incl, relevant labs,etc)&PLAN: I Signatare/License �, 1 f �i;2v s`3 TO Dates i Mme DISCHARGE PSYCHIATRIST NOTE: (include most relevant paE and,justification for dx and disposition) ❑ Pt. interviewed by this MD 1 'C—y---j —� F ^I r '-lt �� l I " ❑ 5150 Released by MID >'11- �L' i'��!"� ��_A'' ti r /•� (check box ONLY if a 5150 was released by MD) Physioian'Signaiure ID 9 ; Discharge Dx(IF CHANGED): Axis t: Axis II: GAF: Signature/License MANDATORY REPORTS: ❑ CPS ❑APS ❑TARASOFF by.SignaturelLicense FINAL DISPOSITION, D/' 'OUT: Legal StatusQ515o .❑VOL 115350(ICON) 115355(PERMC-W DE571NATION(hospital,grp home,residence,etc.) CONTACT STAFF[PHONE AT THAT FACILITY77 -. Clinician SignaturelLicense 1�...-y ;.a.; ;'.�;` "(,,- ,' ANTRA COSTA HEALTH.SERVICES. CONTRA OSWREGIONAL-MEDICAL CENTER PW,CHLAT RIC EMEItGENCY-SI-RVICES,-MARTINEZ A;H'Y.T:N:I S T. 0'A N.I11 1NnIAL NURSING ASSESSMENT M A'.N T I s.2.5 755-61515 H:L 'Date. /'Z''O 7 ~! Time _:.. Age; g Sex M D F. Race 1 1. 5, 1-0,�. S Legal latus: 150 0 Vol. Other, f 121-0�► _:.7:;:_: OR:A Arrived from. Acro Restraints onzrrival?,;B'No -0,Yes Describe mpanied.by Physical Description / . :.. CHIEFCOMPLAINT Cli ( nt s:own-words) 1.= :Medcalf cleared' whom �. _;... ltTA1.:SIGIILS- .;SP R _ T.- DD Time D19 O so .. .,MED- 'ICAL,/SURGICAL-li15TORY. . esectt and.Aast - _ - I] :Hea . (Check:-Pi d1 Nu!Y :.:; :.I].Hypertension U $owel.Problems`•.: :. fl He atitis ::_. .- �. Su p . D ,1Jrinary.,Problenis Diabetes...:.::.. 0 LOC M211re�Disorder, ,.�-byrold Probl D.:Asth . :,: :-.::. . . ., :. 1 Tardive Dyslanesia. D;ProSfhesisems DD ;D rdi c PromsQ... b1e -.:. . ma.;;:..;:. Other .. GSA-r►'-�-�, Pregnant= D Unknownse ya . _. ` es rPmance Ys Dbs� .:::- 4 ght`Chenge Aller fln. : Mantal`Heaith:.History Describe N1� 'i C yah C (�-,�i ��h�►� .. ::. ..... :'. ... . RRE�.'i':Tm`;��CITI©N '.(Rrescribed:and.overh :.. ...: y _. me.of.D. rug_ ...... - - D Osage •�� ': Last Fleese ��IiTy. P - : .......:. ,,�mpTantwith.regfineri : :.- `D =Unknown: D. Yes :: _ _ '.:.......:.... ,:.. ... . No:=�•�-: :.Source`Name �_ . :.. :'.. - . .. ... ... :... S1J3STANCEilSE ;(Present-within two weeks):: Rresent ; Past Present Yes :No . `Yes No . ;; :Pres es . 'No Yes IVO Tobacco D_. Amphetamines: :. D .: D Sedatives Past Caffeine D �[f D Manjuena 0 cods � .D yeso es o r7�Coho1 D .D P Hallucinb e s caino PCP .'. D D D D :`Describe:if yes' Breatholyzer Result Ti Result Time Nurse Signature tJiR500-0 .(12-9.7 Side 1 FSYCEIIA'L-IC EMERGENCY SEitVICES-INETIAL NU?SING ASSESSMEM atient Name .'. AMY T HIS.i D.ANJ,EL M AN; b 1 b U954.R:.8.�, VICIDE IDEATIONS/THOUGHTS 0 No ,.8yeyes 10;2 i •".1 5 5 c3 l n Main 0 ... ....tir ,,'. sA Attempts a No -Bees When potential for violence i, 'No 0 Yes Explain "`s -ast History of violence, 0-No 0 Yes D Unknown Explain:. ,WOLotential ,[3'fJo O Yes Explain P .. ;ontracts not to leave-8'NO_-_0 Yes. --•-•-•- ---- ---- --- ---— —--- -- -- -- - KmAL MENTAL HEALTH STATUS EVALUATION r r� ►ppearance 0 Clean 0 Neat D Disheveled Other lygiene 0 Good 0 Fair 0 Poor alodorous 0 Other =' Vchomotor a Calm a Lethargic ous D Agitated D Combative 0 Restless.� D Tremulous 0 Choreiform movements 0 Other 3ody Language 0 Relaxed *0 Closed 0 Tense IP Guarded 0 Hypervi9ifant 0. Rigid 0 Threatening 0 Slouched 0 Other e Contact D Good D 'Q .y Poor 0 Evasive 0 Eyes Closed a Glaring D Blank stare a Other '• - -~ ': =,�;:;�;;�:,;�;><�•��`'-:�,` ... iFJarrr►al a Soft Monotone 0 Slurred D Slow' peech 0 D Loud 0 Mo ton ,:� � • _ •'::,�y`�;- =i;;•.�� 0 Rapid D Pressured D Angry D Mute D Yelling :•': ' :•`:�tri;�-�::��.:a{ �: •:�� ::,>_. .. L �,�:,:�,..... Other nsciousness a1.lert a Hypervigilant D Pi eoccu ie r.T; _� �' ,o p d D Distracted D Confused 0 Disorganized . .. ''�==:+ . 0 Intoxicated 0 Other := I,ttitude 0-Tooperative 0 Uncooperative 0 Fearful a Suspicious 0. Testing limits. 0 Hostile• 0 Grandiose D Muni ulative D Sexually Inappropriate. D Daman ding. D Evasive&Va . _ - _ _-;N-:.L:•:rte: 0 Friendly 0 Ambivalent 0 Confident o Other - - - orientation PersonPlace Time Purpose/Situation ?-•` F�' -�r �It perception itory �1�isual 0 Tactile 0 Otfaatory. enation in erre on Hallucinations�Aud - - )ascrib. e ` � Vteration in thought process Delusions, a Pergecutory D Grandiose..0 Religious 0"Ideas of refereribe'' kffect 0 Appropriate 0 Bright 0 Euphoric O'bepressed 0 Angry:, , ... '0 Flatt :'' 0 Labile 0 Other ,rood D Appropriate 0 Euphoric 0 epressed 0 Angry A Amblvalent .0 Passive : D Hostile A D Labile 0 Other tIJ Signature - - =aYEE�6ETPJO EMERGENCY SERVICES-EF�€�!.[�ljt'SII��a 1sa..SSFdl1�`T ' - - r;�°-. CONTRA COSTA HEALTH SERVICES. Contra Costa Regional Medical Center. AMY ? Fi I $T DA'NIEl PSYCHIATRIC EMERGENCY SERVICES M ANT i 925 ?55=09 ]5 .M.L _ ... Nursing Record - VITAL SIGNS - PILOT ` n b ; _ b b10 5. g i C b 10/ 21 / : 958 +w , . Date BIP P R T OTHINR. 71. O P A Time INIT - Signature INIT Signature INIT Signature �/ r. AmyTHIST DAnIEL CONTRA COSTA HEALTH SERVICES _ N? I Contra Costa Regional Medical Center PSYCHIATRIC EMERGENCY SERVICES Nursing Record -MEDICATIONS -PILdf/ 2 1 -7 1 0 P A M 4 / 12 /07 Date I Medication Dose Rt Init Date/ Medication Dose Rt Init Time Time I I I I I INIT Signature 1141T Signature INIT Signature ' 'CONTP k COSTA HEALTH SERVICES CONTRA COSTA REGIONAL MEDICAL CENTEP. - - PSYCHIATRIC ELA RGENCY SERVICE' ' - • Ar;YTHIS.T � , •'DaN.IEt ' - . .• • .. pgp� p��+ tp�� ORDERS 111 ANTT S 92.5 755 -p915 ML :.: �A LA 1 -6 Date: .,2' 0� _ Tone: a" ' 10 , 2 1 / 1 956 71__OP'A Ci ief Comalairtlsl: ��vrn 1 - • w LZ.... �cd. c�ac-y- �I �-c.u�; E�vs e .�� Y '?DI � ('��... ":. . - Be.'�avioral Precaution Levels: Suicide �- Assault 1 Elopement I ` - /' Legal Status: 0 Voluntary .-0 5150 O T-Con ® P-Con 0 Jail Hold ®Other Diagnostics; ®UTDXA ®UPREG if female of childbearing age CBC, BASIC, LFP(Liver function profile), Cholesterol,Triglycerides - _Z� J1 (strongly consider if nonn-in computer in >6 months and taking antipsychotics) _ r /gin✓`. 8 Other LABS C "J S ✓l C O �/� ) 1 1 _ ❑ Other Tests: 612_ 4- S rtwals: 0 q shift 0 Other. ® Weight x1' ®Capillary Blood Glucose x1 (consider if inking antipsychotics and refuses lab draw) Allergws. Other Drdam t Z� M PLC)/-6 66-"-a- tlb� A Yy\' zFC 2Z5 rig c Aim b ® May use meds from own supply. Content vermed by MD. , Pr=-[iminaryD'aacxneses• r1� t/,, f2"r cf�-hcvl CU`'.�-e(.L�%. ( Ar/�S� C- t,t sti1�tcCLc,u Current GAFh / Initial T r eatment Plan: Encourage food/fluids,monitor for ADI-s,monitor vitals Assist patient to learn non violent, non-suicidal coping machanisms Psychosocial Assessment and Intervention by Therapist vft results reported to MD =: increased nursing supervision C31:1 ❑ lintiof-sight O Other Q Safety Precautions O falls CJ se'01res ®Other .•. �cohol Withdrawal Protocol (datarls on separate Withdrav►ral Protocols order page)' OTHER I'AD Signature: / ID i�-- - -•- ' �; � l/ ', 4,. Vii, .,r.- ;j, :�•:�� ;'"�.°�", .. . , :,• .. MD D�B�r G;,-D6-V.dm est printed o/�D�6 iC;G3 J4 �. _ _.♦ '•� _ - ,i r' lV �A�y �1 c CONTRA COSTA HEALTH SERVICES MR#: 00-06-13-97-6 CCRMC,Martinez Health Centers NAME: Amythist,Daniel J 2500, Alhambra Avenue, Martinez, CA 94553 DOB: 10/21/1958 CONSULT DATE: 04/1.2/2007 HISTORY OF PRESENT ILLNESS: A 48-year-old male with a history of depression and severe anger problems followed outpatient by Dr. Murry Eiland at Pittsburg Psychiatry,relapsed on alcohol and cocaine 5 days prior to admission. He said he had been sober for quite some time,but became bored so started drinking and then he quickly started smoking crack cocaine. He said.he binged on a crack cocaine for about 3 days in a row. After he crashed on crack,he became suicidal.and went to John Muir Hospital and was sent over to Psychiatry here on a 5150 as patient has said he was thinking about taking an overdose to kill himself. When he arrived here in the psych emergency service, he complained of hearing voices that were command and persecutory in nature. He felt like crying. He was very distractible, frustrated, angry. He said he had no money to take care of basic needs and just felt like hurting himself seeing no way to deal with his issues. The patient was given Seroquel, which he had normally taken as an outpatient 250 mg p.o. q.h. in the psych emergency and a couple of milligrams of Ativan and suddenly on 04/12/2007, he looks gray all over and looked at the.staff as though he had stopped breathing. He got extremely diaphoretic and was unresponsive and his 02 sats dropped to the low 80s and he was responsive only to excessive sternal rub. The patient was intubated and admitted to the ICU. He was intubated just for a very short time. On 04/12/2007, 1 saw the patient briefly and he was quite agitated and he was given Abilify 9.75 mg IM with-good effect and he was able to calm down and then I reevaluated the patient on 04/13/2007. The patient was feeling much better than he had the other day when he was acutely crashing after his heavy binge. He said mainly he needed help to get sober again. He said he does have a place to stay. Things had been going actually reasonably well in his life,he had just gotten a new boat,which he was working on and was trying to work on getting some old hobbies back, but then for reasons that he could not explain,just relapsed. He said he was no longer feeling like hurting himself and just wanted to get some help with substances. PAST MEDICAL HISTORY: Sleep apnea. PAST PSYCHIATRIC HISTORY: Patient is followed by Dr. Murry Eiland at Pittsburg Mental Health. He had missed his last 2 appointments,but said that he had been taking his medications Seroquel 250 mg at night and Effexor 300 mg per day until 3 days ago when he stopped during his crack and alcohol binge. He reports a substantial substance abuse history but actually had been doing well recently with sobriety and had been sober more often than not over the last couple of years. He has been to Herrick Rehab, 90 days program twice, and he has been in the center for behavioral medicine in Concord for 30 days, both of which he found quite helpful in regaining sobriety and requests help getting into alcohol treatment again. MENTAL STATUS EXAM: A 48-year-old very obese white male sitting up in the ICU bed who had logical goal-directed thought process and regular speech. He did not have any overt delusions. He was adamant that he was at no risk to self or others. He attributed prior statements to feeling very confused coming down from his substances. He said he had been sleeping fairly well at home until his recent binge. His appetite, he said is "too good." Energy is chronically low and some poor concentration. He ORIGINAL CONSULT Page 1 of 2 MR#: 00-06-13-97-6 NAME: Amythist,Daniel J did discuss chronic depression,but said he generally had been doing well. He has had auditory hallucinations in the past and did hear auditory hallucinations in the midst of his crack and alcohol binge, but he said that those have resolved today. He says he gets very paranoid and confused when he uses drugs, but still has had trouble staying sober because he said he does gets bored. IMPRESSION: A 48-year-old white male,with underlying history of depression and psychosis when using substances had presented acutely psychotic and depressed and suicidal after recent binge of alcohol and crack cocaine,but now sober with a couple of days of good treatment is no longer risk to self or others. His substance induce psychosis has resolved.. I believe the patient is correct in his assessment that what he needs most now is substance treatment. In that regard, Lana,the social worker worked with patient today for resources in the community to help regain sobriety. He says he most definitely will avail himself of them. If things do not go well or if he again feels unsafe,he feels quite comfortable calling again for help. His Seroquel 250 mg at night and Effexor will be maintained at his prior doses as he had no issues with those medications when he has maintained sobriety. We had a good conversation with him about the risks of substance abuse,not just in terms of his sleep apnea and getting another episode of depression after using and crashing,but really getting him to worry about cardiac and other risks that he is posing with the use of crack cocaine. He now gets it that substances are a bad combination with his morbid obesity placing him at very high risk of having a bad outcome if he used cocaine again. Signed by John Echols, M.D. on 05/15/2007 John Echols, M.D. JE/mt622 D: 04/13/2007 17:19:29 T: 04/13/2007 17:41:57 .lob: 1685771 / 159835 ORIGINAL CONSULT Page 2 of 2 me s r L O C ,rs. 5UA lv CONTRA COSTA HEALTH SERVICES o4 i no 1. 008-11 Cu CONTRA COSTA REGIONAL MEDICAL CENTER HISTORY&PHYSICAL . ; A`ArTH 5T DARILI :. M ANT 0 t;95 755-OSIS HT 00061 . ,..b C� 1 t DATE 10 x 2 1 !1S FA See Medication Reconciliation form for dr ,'s taken on admission. if / ile 14, fSe &"4"> Ht A014, `1cr 1 .. (.. /4 1,✓u f Ari .r/q • FS , I. 1'F5 ti. x 41 4 1v.9n T , > 12ov, cr ,�— r ---, /o - ., k,'i s!T a. 'C�� rA rarca' �� rvr,,^ /GGi E 17 ,ur �--- � _ fico lJly ! l f _ . �;v-•,N 1 �`'j X p.,f /C� c� 2 1U a9:1 f (OvV f rr'rr� G✓ l ,L",Z, MR4-5 C7-05) Side Com'; ! HISTORY& PHYSICAL CONTRA COS3k,.HEALTH SERVICES 1 , CONTRA COSTA REGIONAL MEDICAL CENTER HISTORY&PHYSICAL DATE ' 517 41 I 1 Gfr c" vg 2(L -lo�i�r r el-el a k 1 for v R° cnp: ,bj nom` r� A - U 111 ►r� {/,'l� — C/- /T �t — '- 3/ -2J / •—/r uIcvnoV Je. D41VC1(_41 MR4-5 (7-05) Side �� Sero�t� CONTRA COSTA HEALTH SERVICES CONTRA COSTA REGIONAL MEDICAL CENTER '1 6308- ICU HISTORY&PHYSICAL AMYTHIST DANIEL MArtTtO 925 755-0915 M T DATE D 15 fi See Medication Reconciliation form for drugs taken on admission. a / 1 /07 �. nou Prq�s.o Of—,(,,Z G' iS Glu r'c•:� ��, 'i :1 i f f ee � f . ;'�.r -�,r, i Ar' l�if. i�/ice �� •1 v-r� ✓ f /S/ f t of i -n z-. U1 ISG I��.;,, -- 1 �`! 5 C,r,P�'`' ��c�-r �c>v'1�S � -✓'' �- _ 1 MR4-5 (7-05) Side IHISTORY& PHYSICAL CONTRA C�STA HEALTH SERVICES- �? ! CONTRA COSTA`RkGIONAL' MEDI.CAL,-CENTER HISTORY&PHYSICAL DATE I c., n / C .-i f,y._. i /1717 rL,j S'/i 1I a 1r /lora/ 171 � G i i'2:� I L f i il r r HISTORY& PHYSICAL MR4-5 (7-05) Side, 2 CONTRA COSTA HEAL-9'sStg0ra CONTRA COSTA REGIONAL MEDICAL CENTER K Y ? Ff I 5 T INPATIENTD q K ANTI 0 `P dGRES$NQTF�SI 5'e T M A , — 00061 ( �, n �_ b _ 20/ 1 ~ �11 � E'h , [i ' ` DATEM M E t /07 A R O R E a 0 , / •:7,v rR j Ir 4�� r - r 8 L L Cl/F- 1,.P-7 ! C t � 1-2 Lf MR25-0 (5-01) Side 1 PROGRESS NOTES }p8-71 Cts Y rt�b� IGONTRA`COSTA f0 � j� CENTE#t A 'i '� CO T7 � �f_ _ - n AAlTO 2 . y,, 1 07 F Qom_ 0006 1 � '" PRE�S� OfiS C 2Glci /i n! 12 /Q? AROSE 01 F-, c-. I DATE ME AA --r • kill -- Www61 VAL-- rVG fit' I Gt/l #Z- I1v�- � ?�,�., i i I I MR25-0 (5-0{) Side 2 PROGRESS NOTES C U CONTRA COSTA HEALTH SERVICES + CONTRA COSTA REGIONAL MEDICAL CENTER ' AMYTMISTDANrEL INPATIENT M ANTI 0 $25 '755-0915 r T PROGRESSNOTES O O b 1 3- r- 1- 6 C- 1— Az O , 3 0/21 /19L5� DATE/TIME 10.30 rl.5 AAA � ��•- w=s ,�s.�,,."E .�..- �445 q� 4 L.V,f �,.� nL Watt X12 � L1c.4�`btti' `� �` �;�,�,�� : y'c• , '� f ma;( h1c,fl^✓z�2s w �'N (��,? . � !rte r�;ntic�1% MR25-0 (5-01) Side 1 PROGRESS NOTES i CONTRA COSTA HEALTH SERVICES CONTRA COSTA REGIONAL MEDICAL CENTER INPATIENT PROGRESS NOTES DATE/TI M E I I j I I I i PROGRESS NOTES MR25-0 (5-01) Side 2 no now. �, „r • CONTRA COSTA HEALTH SERVICES Q C' 0 � 0113�6 � i 0- CONTRA COSTA REGIONAL MEDICAL CENTER1 C /2 1 1 14 5 F _ 07 APOSER 01 INPATIENT PROGRESS NOTES DATE/TIME 100 o c-o i Oa f� 1--e. (2 l _ ^ a L 4- 05 kjiAnW(P n iInz 0. m/ ,t rF Cf(Ue a a t ize, 4 .4 V� J of t f n i n hU V SI ate. - U'`z 3 ,2 f 1 C- ^ �G� � •�� t' ,l7(1�07 t' GYM T'�a nC�Z �a1: C ' u :►"}" „% ' gvuv,�uAi f D IILa Al5 "fit10� (�: ✓.�`J. (/��✓'�n. �R A✓tom v4`/v PJ.IIA/Li - } (, lZ t PYt , MR25-0 (5-01) Side 1 PROGRESS NOTES I I CU CONTRA COSTA HEALTH SERVICES ._ CONTRA COSTA REGIONAL MEDICAL CENTER INPATIENT A.MY KIST D A N I Z L PROGRESS NOTES M a T I 0 5 2 5 ?5 5-G : 5 ►� T i 000 � 4 ,- b oil h : �- � r 4l1 � /0'7. ARCS r n J DATE/TIME I I 7O �,.� � - � Gam- !�iSL' � N�-�' �T: - ✓ In �J y la7 _ r — � ri . tood aaivere A144 S al U c 'd r 1 q- - a I'K C71412,1001,11 yea-Iye(SAIR44 Vtl 0644 a G� IA CAO jv Ll 7i u PRnGRESS NOTES MR25-0 (5-01) Side 2 tJ 1 Z. J CONTRA COSTA HEALTH SERVICES r CONTRA COSTA REGIONAL MEDICAL CENTER AmyTKIST oANiit INPATIENT M A>!TIO 525'_755-0915 KT . PROGRESS NOTES. 0113'%� 10— IG /21 / 1556 1 4 / 12 /07 AROBER 01 DATElfIME �rv� flniS� �QNIQ{ '4m Its 161 /cr OIL% K•, Nksa O S i 1-TI €. ;74 NZ. ars- Is2' µ �t a vS t3a- �y�/6o-tfo P It, 2.. 27,-2,1 1,928 10-yl aA c�o 34.4 f��' Gam, �' .sl �..F kh►� � I0.iD 281 Mg 1 \q p!.8 0Cc4D,cr- ,. ,4j Am /711.1 A F 13 416 "ka JpA .u.� S RL r7Jt� �SYr,�ly 7SN Z.Z. I FJj ;� 1 S".�r` � � �V"t aP'G D*EtT1 Id�SD,K htv (a..•�`..� p z 'N P..S1 o� = ��,� �.� �. fir. E�l.,�s. M so. AG;�, N �u.— (ad JL ti j s lu.F vo --ti,U3LL jn,,Sjt JoLf I,- '{ mvl r,-" 7-4t:4--^A i-i 67,i,r fc' Jt,Asti c • Oh It S t C+ r a Ks HA w+ C�L,,j.A-� KL Z S1vj(Y.S 'AJ Ir -ve �S 0 7 MR25-0 (5-01) Side t PROGRESS NOTES I I •- CONTRA COSTA HEALTH SERVICES CONTRA COSTA REGIONAL MEDICAL CENTER INPATIENT - PRO•GRESS NOTES I DATE/TIME I I I I i r+'+r+nnr_o->anTtc MR25-0 (5-01) Side 2 CONTRA COSTA HEALTH SERVICES MR#: 00-06-13-97-6 CCRMC,Martinez Health Centers NAME: Amythist,Daniel J 2500, Alhambra Avenue,Martinez,CA 94553 DOB: 10/21/1958 DISCHARGE SUMMARY ADMITTED: 04/12/2007 DISCHARGED: 04/13/2007 ATTENDING PHYSICIAN: Sara Levin,MD CHIEF COMPLAINT: Respiratory distress. PRINCIPAL DISCHARGE DIAGNOSIS: Cocaine,benzodiazepine,and alcohol intoxication with resultant respiratory distress. OTHER DIAGNOSES: 1. Bipolar. 2. Obesity hypoventilation. 3. Morbid obesity. 4. Obstructive sleep apnea. 5. Hypertension. 6. Multisubstance.abuse including cocaine,benzodiazepine, alcohol, as well as paint sniffing. PROCEDURES PERFORMED: A chest CT was done to rule out pulmonary embolism and had a questionable perfusion defect noted in the right pulmonary artery. However,this could have been just an artifact, the radiologist recommended a VQ scan. VQ scan was done and was low probability. No evidence of PE. Head CT scan was done and was negative. EKG was essentially unremarkable. Patient received ventilator and ICU-level care as well as psychiatry consult which cleared the patient's 5150 and said it was okay to discharge patient. HOSPITAL COURSE: This is a 48-year-old male who has significant psychiatric history as well as polysubstance abuse,who recently presented to the John Muir Medical Center with suicidal ideation complaints and was also intoxicated on cocaine and alcohol. Patient was asking for help. He was medically cleared from their emergency room and was sent to our facility. He was medically cleared through our emergency room in Contra Costa Regional Medical Center. Patient was then transferred to psychiatric emergency services. During the course of his being transferred,patient was unable to sleep, was given his normal dose of Seroquel at which point, an hour later,patient was noted to be apneic and had a pulse ox of approximately 70 percent. Because of this,patient was brought over to the emergency room. Attempts at using BiPAP were unsuccessful, and patient was too altered and was fighting the machine. Because of this,patient was intubated. Patient then was kept overnight and was noted to have a significant A-a gradient. This prompted a workup for PE and other secondary causes of respiratory distress. Patient had a CT done to evaluate for pulmonary embolism. This essentially showed a potential artifact in the pulmonary artery versus PE. The radiologist recommended a VQ scan. This was done and was found to be low probability. During the course of waiting for the VQ scan,patient was kept on heparin. However, given the low clinical suspicion and the low probability VQ scan, we determined that he did not have a.PE and discontinued therapy. Patient was rapidly extubated shortly after admission and was doing well on room air. However,when patient was sleeping,the patient was noted to desat into the 80s quite frequently. Attempts at using BiPAP were unsuccessful because patient fought that, and patient ORIGINAL DISCHARGE SUMMARY Page I of 2 MR#: 00-06-13-97-6 NAME: Amythist,Daniel J has a known history of refusing BiPAP in the past. Patient gradually improved to his baseline mental status. Psychiatry was involved and interviewed the patient, and patient was no longer suicidal, and the 5150 was then lifted by psychiatric services. Social Services has been arranging outpatient rehab for the patient, and at time of discharge,patient is currently stable and is well at baseline. Other management during the course of the hospitalization: Patient,because of elevated blood pressures during the consultation,was also started on Toprol-XL 50 mg p.o. daily. Patient is to follow up with his PCP in 1 week in Antioch Health Center, and he is also being set up to have outpatient rehab in psychiatric services. This is being done through Psychiatry and through Social Services. Patient will be discharged on the following medications: He is to continue his Effexor and Seroquel at their previous doses. Patient is also to be sent home on folate 1 mg p.o. daily, thiamine 100 mg p.o. daily,Toprol-XL 50 mg p.o. daily, and multivitamins with minerals 1 p:o. daily. i Signed by Stephen Ruda, D.O. on 04/17/2007 Stephen Ruda, D.O. Signed by Sara Levin, M.D. on 04/25/2007 .F Sara Levin, M.D. SR/mt343 D: 04/13/2007 15:40:38 T: 04/14/2007 00:40:09 Job: 1685516 1159784 k r Y 4." � UG ' ! : INAL DISCHARGE SUMMARY j `page 4 012 . LU CONTRA COSTA HEALTH SERVICES CONTRA COSTA REGIONAL MEDICAL CENTER PUt 2500 ALHAMBRA AVENUE, MARTINEZ CA 94553 DISCHARGE SUMMARY AND ORDERS y. ADMIT ATE DIS'H RGE DATE ATTENDING STAFF y T I$T DANIEL ANT !0 25 755-0q15 OT Lc,) I rig COMPOAINI jj 0 01 16 16 3 1:'6` IL 0- PT: RGE DI+NOSIS(Cfiet reason for patient's admission.No abbreviations) /07 A P IDS f, 11 01 C ` t�,..�, `� C? rv> 1- 4,-,A Aat Z� print area must be readable on all.copies. OTHER DX (No abbrgiations.) DICTATED SUMMARY? ED No Yes q (D3 (3-101116*1111 iv-a- PROCEDURE:13 PERFOi VIED o- c Vej k�v T 171 - J'(Cry v4j HOSPITAL COURSE /TREATMENT"FINDINGS CONCLUSIONS R�ICO'MES IF�RE(Include studies pending at discharge.) P S_ cc L C C� Ate� A; CONDITION ON DISCHARGE DISPOaITION INSTRUCTIONS TO PATIENT(Include medications not being dispensed.) Activity: El No Restrictions(including driving,working,and bath/shower) [I Restrictions: Diet: El No Restrictions Dressing/Wound Care: Special Instructions: F-OLLOkNUPAPPOINTMENT(S) FOLLOW UP LABS: When? Clinic 0 MartinezP ED PHC RHC Clinic 0 Martinez El PHC ED RHC Dr. EE11 CHCA- AHC 0 NFICH Dr. Ac 0 CHC ED AHC El NRCH w� When CL, 0 BPFHC HC When ❑ BPFHC El BHC ———--——————————--- - ---———— ————————— DISCHARGE NIEDICATiON ORDER(DISPENSED) SPANISH SPEAKING a & § fl 7 ❑ t 'Q� IF r r n, Ilk N? a It RESUME PRE-ADMIT MEWAiONS: 3 to 7, STOP THE FOLLOWING MEDICATIONS: 77 Medi-Cal Patients: DEA# SIGNA 15 day supply only 1 0H 4P 7 F MR 141-:: ti 1/.qf)/nAl T%jLkr%U A C3^= nl IRAIAR A r%%f A k1M O CONTRA COSTA HEALTH SERVICES O STMP ALL RDER FGRURS CONTRA COSTA REGIONAL MEDICAL CENTER MEDICATION RECONCILIATION & ORDER FORM 171 L1 I CU LIST prescribed and OTC medications, herbal products, supplements and vitamins/minerals patient currently uses (prior to admission). D t,94 2'E TN, 0-% PATIENT USES 0 Check one or more. If checked, indicate drug on list 0 Prescribed medications ED OTC Cf 0 Herbal products ED Vitamins/minerals t T ❑ Supplements J1 IVIARKBOX SPECIFY MODIFICATIONS PREGNANT? ED Yes 0 No ED NA C Continue* Herbal products will not be DOSE DC Stop continued on admission. DRUG UNIT ROUTE 'FREQ M Modify a) J9 9 Dc R) CD 0 H) 09 10 0 EM) CO 091 CE 0 9 CTJ 0 E SIGN HERE CYr See other physician orders. -2 t/4,W 16 Provider Signature Date/Time MdF Transcribed by(clerk) Date/Time OF Noted by (RN) Date/Time Original: Physician Orders Yellow: H&P MR3191-0 Page 1 (10-06) Pink: Nursing ICU I IMCU ADMISSION ORDERS ' �0�T�� 0�T� ��L�� GE��U�� . xw S CONTRA COSTA REGIONAL MEDICAL CENTER INTERNAL MEDICINE GENERAL SURGERY 000� ADMISSION ORDERS ri Date Time E��Admit to inpatient Medicine 0 Admit to inpatient Surgery hv�A Attending: Resident: 0 Diagnosis: � Allergies- \I- Vital Signo: Condition: Diet: �� NPO �(_j Sips H2O with meds only 11 Dietitian referral LJ Other Activity: IV: rs Labu/Studiem: '/ Nursing: 1 ] i&O Foley to gravity drainage [] Call MD for Temp > 101.5"; BP systolic >180 or <90; Pulse >120 or < SU: RR )20 or <10. Dressing Change: DVT prophylaxis: Strongly consider for high risk medical pahonm with no contraindications — including pudon� v�dh myocardial in�mbon congestive hou� tai|un� cancer, _j H� m parin5OOOunituSCq l2hou — � mmko, prior DVT or critical illness. |fPatient bl.eoding. sequential pneumatic Ted hose SCD compression device isunalternative. Lovonox *omgSCq 24hrisan alternative. `— rtPatient Education (o.g, smoking, CAD, CHF, DM, asthma, ostomy, Wound care) |-� Drug and/or alcohol counseling Discharge planning issues: Homeless Lives alone SNF 1-1 Homo health PT/OT PT/0T referral: Frequency 'Duration ^/ Pain Management { j Tylenol 650 mg P0 every 6 hours or per rectum for NPO patients, prn fever, fair to mild pain Other: Medications: PRN Meds: ED Maalox Plus EX l (one)tablespoon PO every hours, pm heartburn DSS 250 mg PO B|D, for constipation, include for patients on nomndoo Phenergan 12.5 mg |M/PO//Vevery 4'S huura, prn nausea/vomiting ` MOM 30 mL PO every HS, prn constipation Both recommended in all patients over 55. plus -- all with chronic cardiopulmonary disemne Ll RemLoml5mgpO diub�ao. renal failure, cirrhosis. uubymno' abuse, Pneumovax 0.5 mL |M, at discharge, per protocol H\V, orother immune suppressing conditions. �� | Flu is Oomberthm February. Pneumovax �� F|uvaooineU.5mL |��.otdiunharg* (D«t-Fab]. P*rproton»|- with Noted by Date Time Physician Signature -----" Mnuun'o (3/20/06) paov 2 INTERNAL MEDICKNE / GENERAL SURGERY ADMISSION ORDERS �� AMYTHIST,DANIEL 'J CON."2A COSTA COUNTY HEALTH SERVICES M011396710 3-D 3D04 01 AMYTHIST,DANIEL J PAGE:1 CONTRA COSTA COUNTY MEDICAL RECORD #: M000613976 REGIONAL MEDICAL CENTER AGE: 48 SEX: M WT: 161.6kg ADMITTED: 04/12/07 PROVIDER: ADAMS.DAVID S,MD MEDICATION ADMINISTRATION RECORD RUN DATE/TIME: 04/13/07-0122 ALLERGIES: NKDA (NO KNOWN DRUG ALLERGY) NKDA FOR: 04/13/07 NKFA MEDICATIONS TO BE VERIFIED WITH THE KARDEX BEFORE ADMINISTERING RX# MEDICATION START/STOP 2300-0700 0700.1500 1500-2300 .. < > > > �;:> >>:: ;:::> .. .:.:::................................:...:: ::..:::::::::.::::::>.:..... ......:.:.>.::: ..:::::>::..::::>::<:>::::>::::;<:>::<.>:.;.;::.;::::.;:.: .::.;:.:..:..S:.:C.;H.>:E:.D:U::L :E:D;:::::::M.<E:'D .5;:.;::.::. ......::.::.::::::..: . ..... .. ...... ........ ................... ................... . ..... ................................... ............................................... .. IP01918363 VENLAFAXINE.XR 150 MG UDCAP (150 MG) 04/12/07 (EFFEXOR XR 150MG UD CAPS) 05/13/07 DOSE: 150 MG PO EVERY MORNING i.ABEL CMTS: 225MG = 150MG + 75MG :.VUHE / RX.VUHE STOP TIME: 05/13/07-0959 IP01918364 VENLAFAXINE.XR 75 MG UDCAP (75 MG) 04/12/07 (EFFEXOR XR 75MG UD CAPS) 05/13/07 DOSE: 75 MG PO EVERY MORNING ABEL CMTS: 225MG = 150MG + 75MG .,X.VUHE / RX.VUHE STOP TIME: 05/13/07-0959 IP01918366 ALBUTEROL 17 GM INHALER (None) 04/12/07 (VENTOLIN INHALER 200 METERED INH) 05/13/07 DOSE: 0 INH FOUR TIMES A DAY DOSE INSTP,: PER RT RX.VUHE / RX.VUHE STOP TIME: 05/13/07-1814 TP01918367 IPRATROPIUM BROMIDE (HFA)12.9 GM INHALER (None) 04/12/07 (ATROVENT HFA INHALER) 05/13/07 DOSE: 0 INH FOUR TIMES A DAY DOSE INSTR: PER RT RX.VUHE / RX.VUHE STOP TIME: 05/13/07-1814 .:: ... .....:.::.::.:::.;:.;::.;:.;:.;.::. P...R:N:::....M::E.:D::S.:::::.....:::::;.:.;;;::.;:.;:.;::;;:>::.::;:.::::::......:.... IP01917935 ACETAMINOPHEN 325 MG UDTAB (650 MG) 04/12/07 (TYLENOL 325MG UDTABS**) 05/13/07 DOSE: 650 MG PO EVERY 6 HRS AS NEEDED LABEL CMTS: PRN FEVER > 38 C or HEADACHE RXC.KWOE / RXC.KWOE STOP TIME: 05/13/07-0434 (1 Q, Vr e r3 PG{ n C, � r MEDICATION ADMINISTRATION RECORD 1 CONTRA COSTA COUNTY HEALTH SERVICES M011396710 3-D 3D04 01 AMYTHIST,DANIEL J PAGE:2 C O N T R A C 0 S T A C O U N T Y MEDICAL RECORD #: M000613976 REGIONAL MEDICAL CENTER AGE: 48 SEX: M WT: 161.6kg ADMITTED: 04/12/07 PROVIDER: ADAMS.DAVID S,MD MEDICATION ADMINISTRATION RECORD RUN DATE/TIME: 04/13/07-0123 ALLERGIES: NKDA (NO KNOWN DRUG ALLERGY) NKDA FOR: 04/13/07 NKFA MEDICATIONS TO BE VERIFIED WITH THE K A R D E X BEFORE ADMINISTERING RX# MEDICATION START/STOP 2300.0700 0700.1500 1500-2300 :.:::; ......... ........ P:.::R:.N .. :M.::E::>D. **..:.....::::........................ ........:::::::::::.:::.:.::.::.:::::::::..::.::::::. 5.;:::..>:.:::: ::>:.::::.;..::.; IP01917936 ACETAMINOPHEN 650 MG/SUPP (650 MG) 04/12/07 (TYLENOL 650MG SUPP (eq)**) 05/13/07 DOSE: 650 MG PR EVERY 6 HRS AS NEEDED LABEL CMTS: PRN FEVER > 38C or HEADACHE RXC.KWOE / RXC.KWOE STOP TIME: 05/13/07-0434 P01917959 BARIATRIC CRASH CART TRAY 1 EA EACH (1 EA) 04/12/07 (BARIATRIC SUPPLEMENTAL CRASH-CART TRAY) 05/13/07 DOSE: 1 EA IVP AS DIRECTED LABEL CMTS: Bariatric Supplemental Crash Cart Med Tray is. to be stored in med room throughout patient's stay & returned to Pharmacy on D/C. J.LEES / RX.LEES STOP TIME: 05/13/07-0759 IP01917937. DOCUSATE SODIUM 250 MG UDCAP (250 MG) 04/12/07 (DSS 250MG CAP) 05/13/07 DOSE: 250 MG . PO TWICE A DAY AS NEEDED LABEL CMTS: FOR CONSTIPATION DO NOT CRUSH!!! RXC.KWOE / RXC.KWOE STOP TIME: 05/13/07-0434 '.P01917940 FENTANYL.PCA 550 MCG/55 ML SYR (None) 04/12/07 (FENTANYL CITRATE 550 MCG/55ML PCA SYR) 04/15./07 DOSE: 0 IVP PATIENT CONTROLLED ANALGESIA DOSE INSTR: SEE PCA FLOWSHEET RXC.KWOE / RXC.KWOE STOP TIME: 04/15/07-0644 IP01917933 LORAZEPAM, INJ 2 MG/1 ML VL (None) 04/12/07 (ATIVAN,INJ(eq) 2MG/1ML VL**) 04/19/07 DOSE: 0 IVP AS DIRECTED LABEL CMTS: Q 10-20 MINUTS, UNTIL AT SDATION LEVEL GOAL, THEN Q 2-6 HR. SCHEDULED PLUS PRN WHEN USING IV MUST BE DILUTED WITH EQUAL AMOUNT OF NS OR STERILE WATER. DO NOT EXCEED IV PUSH RATE OF 2 MG/MIN. DOSE INSTR: 1-4 MG Z.KWOE / RXC.KWOE STOP TIME: 04/19/07-0644 MEDICATION ADMINISTRATION RECORD CONTRA COSTA COUNTY HEALTH SERVICES M011396710 3-D 3DO4 01 AMYTHIST,DANIEL J PAGE:3 C 0 N T R A C 0 S T A C 0 U N T Y MEDICAL RECORD #: M000613976 REGIONAL MED I CAL CENTER AGE: 48 SEX: M WT: 161.6kg ADMITTED: 04/12/07 PROVIDER: ADAMS,DAVID S.MD MEDICATION ADMINISTRATION RECORD RUN DATE/TIME: 04/13/07-0123 ALLERGIES: NKDA (NO KNOWN DRUG ALLERGY) NKDA FOR: 04/13/07 NKFA MEDICATIONS TO BE VERIFIED WITH THEK'ARDEX BEFORE ADMINISTERING RX# MEDICATION START/STOP 2300-0700 0700-1500 1500.2300 .::.::.::::.:.::.::.:..:::.::::.:..:::::.:::..::...::::.::::.:.::.::::..:,,. .:,.:..:::::::.::: IP01918121 MIDAZOLAM.INJ 2 MG/2 ML SDV (None) 04/12/07 (VERSED(genr) 2MG/2ML SOV) 04/15/07 r` .DOSE: 0 IVP AS NEEDED DOSE INSTR: 2-4 MG RX.PARR / RX.PARR STOP TIME: 04/15/07-0959 P01917939 FLU VACCINE.CHARGE 0.5ML/DOSE (1 DOSE) 04/12/07 (FLUZONE FLU VACCINE) 04/27/07 DOSE: 1 DOSE IM ONE TIME LABEL CMTS: (PER PROTOCOL 1X OCT-FEB EACH YEAR) RXC.KWOE/ RXC.KWOE STOP TIME: 04/27/07-0644 .P01917938 PNEUMOCOCCAL VAC.ADULT 2.5 ML/5 DOSE (0.5 ML) 04/12/07 (PNU-IMUNE 23 2.5ML MDV) 05/13/07 DOSE: 0.5 ML IM ONCE RXC.KWOE/ RXC.KWOE STOP TIME: 05/13/07-0644 .:.... .... ... .. :.:.:::.. .......... »: *t .:.:.....:......::.....:..:..:........... .......:..:..........:.::..:::;: N :f:.W.;:.;:.;;:M..:E.;D::.;I:..:C:..A.;:T.;.I:;O..N:::.;:.;::D..:.;R.D....;;.... :.;:: «.;..:.:..:::.::.: .. . . »::;:. .: :.:'':::':::..'::::.:. ': ::.:::::::::.;..:; ':.: P .:::::... . IN UDE.:M . i ca n:<::..Oo .....R u E i: ::;: 7i; . :l:e:>::>;.:.::<:::>; CL ........::. d.:. t..q.:..,:. ..5e:.:.4.:�e... :requency...:;:.;;(:Stop.:Date. aPP:.:.:cab..:..).::.:::::::::::::.::::.. MEDICATION ADMINISTRATION RECORD ff" CONTRA COSTA HEALTH SERVICES est +`� '�'�LOP ER �::�� fill 5 CONTRA COSTA REGIONAL MEDICAL CENTER MEDICATION RECONCILIATION & ORDER FORM .- LIST prescribed and OTC medications, herbal products, �r?¢„ supplements and vitamins/minerals patient currently uses ,•.;�,;. (prior to admission). y PATIENT !)SES 015 Check one or more. If checked, indicate drug on list. . _ Prescribed medications O OTC +.10 75 lJ Herbal products ❑ Vitamins/minerals Supplements bcve] K= `fNIARIS X `SPECIFY MODIFICATIONS ' PREGNANT? ❑ Yes ❑ No ❑ .NA `` C Continue" 'Herbal products will not be' DOSE DC Stop continued on admission. DRUG UNIT ROUTE FREQ M Modify 5: �1 © D M x,y Dc 0 �•: s © DC M❑ ,'` © DC M❑ �4:� F, y�. Cpp° ilyp © D © DC M ; u, �� 7 l C l DC 0 r;=: 0 DC M © DC C:MD Ev CCD DC M t �:s SIGN HERE C f See other physician orders. r2 /Time /y2' 7 cy! Provider Signature ,B ime/ / �l! iPAGE (Transcribed by(cl �fl to ime OF ✓ 7 AJ oNoted by (RN) ate/7ime ----- I Original: Physician Orders Yellow: H&P MR391-0 Page 1 (10-061 Pink: Nursing ICU % RMCU ADMESSIOKI ORDERS 1 ,;�.: >. 1 � _ - � � � _ ,' � . . i i 1 `� 1 11 1 � _ i �_ ��. i � k b . '1 1 �, t �' 1 CONTRA COSTA HEALTH SERVICES DANIEL CONTRA COSTA REGIONAL MEDICAL CENTER N 1 i 8 15 T z 5"': G g 15 ti T B At�TiQ SPECIAL PRECAUTION DOCUMENTATION -�— 13 G b, ''O—' FOR ALL PRECAUTION LEVELS Q , b 1 - REQUIRING 15 MINUTE CHECKS 1 2 1 /1 `'S P- APO B L P d1 i 4 � �2io� TYPE OF PRECAUTION AND PRECAUTION LEVEL Suicide ❑ Level 3 ❑ Assault ❑ Level 3 ❑ Elopement precautions ❑ Level 3 ❑ Vulnerable patient precautions OBSERVED PATIENT BEHAVIOR CODES 1 Crying 5 Responding to unseen stimuli 9 Eating/Drinking 2 Pacing 6 Threatening assault 10 Lying, sitting quietly 3 In Group 7 Demanding to leave 11 Talking of harming self 4 Talking with treatment team 8 Being intrusive with other patients 12 Sleeping 13 DATE TIME OBSERVED PATIENT STAFF INTERVENTIONS AND NOTES STAFF BEHAVIOR INITIALS 13 .7 V L14 0-1 LI 5 j X14 G� ov p r 1"P CU 0 1'.)((d Lc ► vi u rn S 1.5 WJ r90 (f �) � 2 1✓ IG3� / 0 d ear oi e i i iij2 f C,.yS P i STAFF NAME INITIALS STAFF NAME INITIALS MR165A-0 (4-98) Side 1 SPECIAL PRECAUTION DOCUMENTATION I CONTR6 'COSTA HEALTH SERVICES i CONTRA COSTA REGIONAL MEDICAL CENTER SPECIAL PRECAUTION DOCUMENTATION, CONTINUATION I DATE TIME OBSERVED PATIENT STAFF INTERVENTIONS AND.NOTES STAFF BEHAVIOR INITIALS i I I I I I i I I I I I i i i I I STAFF NAME INITIALS STAFF NAME I INITIALS �- .+.+.-..w■.ree.w. e.�+r+■■wwe-nerieTnwe MR1RSA-n r4-9Ri Sirie D� �� Ila 6:08- ICU A M-T T K I S T CONTRA COS13k4ffjIjjj SERVICES T4 ANT TC®NfRhtO2W%EGIVjI4LIhA401CAt'CENTER 000613q � Y - � 011�lP�.rFl�IT PROGRESS NOTES F {,�, p T y O t � I 4 / 11 /07 A p p 8 E p p11 -•—■.Y� �— 0 NUTRITIONAL ASSESSMENT S Present Appetite: Food Allergies/Intolerances: Diet Hx: Chewing /Swallowing problems: O No Yes Q Admitting Dx: -�'e 4i-cl Pertinent Medical History: - Diet Order: r,9 YZ— % PO Intake: /('ti Age: •j-) Height: —' Weight:#7j-7-,- LIBW: N,,4 IBW: 75—,J— %Weight change: Labs: I IqU Na Ci I "rtP BUN ///,,-� Albumin. Hgb/Hct: !�K+ CO2 Cr Glucose Prealbumin: Other: Present O Fever O Decubiti O Diarrhea O Constipation O Nausea O Vomiting O Edema/Ascites O Other: Pertinent Meds: �'.!f/7Z — l��CG - PIP-7 Vit/Min/Herbal Supplements: 3�e'z e, A Nutritional Risk: O Minimal: No significant problems noted at this time. Proceed to Plan. O Moderate XD High, due to: O Dx O Chewing/Swallowing problems,dysphagia .�' Inadequate PO intake O Abnormal lab values, nutritional indicators O History of significant weight loss O Poor skin integrity O Knowledge/Compliance deficit O Other: O Increased nutritional needs Estimated Needs:��% �= �'� Calories (.J�'z� F1 kg)� gm Protein 3/kg) ;7(�iOtdfluids NG/Dubhoff/PEG: i1 ( '70/trrovides:2,13?0 kcal Jas gm pro 3?-Q/irfree H2O TPN/PPN: provides: / total kcal ! NPC i' . gm pro GOALS O Maintain / improve intake to 0/6 of meals served O Maintain weight to within 10% of admit weight O Other: 7tir i�� lad', �' ,� . �:�� '� �- ;.e� ?� �✓i P O Continue current diet Rx Monitor NPO /CL status O Monitor intake, weight, labs O Begin kcal / protein count ' Monitor clinical investigations/findings CW Patient educationA . -I . v, O Monitor tolerance to enteral / parenteral support O Provide nutritional supplements Recommend nutritional intervention: i) Ni4 fir` - /1 '1,_9i �� 17�'%{� erv'1�'/ {r�� v► �a�� Date / C--- MR293 (4-03) Copynal RhDart NUTRITIONAL ASSESSMENT `e ,. 1� +I I S � I i 05/15/07 CONTRA COSTA HEALTH SERVICES Page 1 0834 CONTRA COSTA REGIONAL MEDICAL CENTER CONTRA COSTA HEALTH CENTERS 2500 Alhambra Ave. ,Martinez, 94553 Hye-Kyung Kim,M.D. , Dir. of Laboratory Services MARTINEZ FINAL - OUTPATIENT SUMMARY REPORT ..:. . . ..:. .........:........:...:::.:.:;. ::::.;.:: .:::.:::: :::.::;::::.::::.:::..,..:.::...::...:...:.::::.:.:::...:...::::.. .. .PATIENT-:>:' ` DANIEL 7:0 : ;LO .-C .>:::::<:< ::>:U ; ::>: 0 0.: :13:: :,; : :.:.;.::...::. ...;::, ACGT« ::>::M0;95'4:8.8.... .6..:::.....: . .C....... #..:,...:NI.:...D6 . .9.7.6.:: .::.:...: ............::.:.:..: ........ .. .. ..... ..>:.....::;;>:......;::>:«:: P25:::'7:5:.. -0 D •.;<: M:e:;>::::::::::>::::>:::::......::>::: ... 4:; 7:::<:... (9...:...... .... 9.15............. 08......10. 21 ..58..AGE:.:SX .:48. .:::...:.::::::.:::::..:,::::::.:.. ...G..:.::0 ./.l2/0. ......... ......:::::...: :......... :.::.::.:.:.: :.:.:::::.::/::...:./.:::::.:..:::.:... ::::.::.::::.:.:: ::::::::.::::..::.:::::::....::.:..;::::..::::....:::::..::::..:::::.:::::...:.:.::::::..:.:.:::::::.::. .:.: :..::.. : ..:..:..:::.: .:::.:::.:::.. .::.:::: .:::: >::::: :.::..:;:.;. ................... T :<:::<REG:::;:.Ci�I;:::>:.::>::>::>>:::::;::BED.:: z:>:>::> : < >is:"::::>:::::<::>::;::::: S ATIIS .::..:.....:.:::::..:......: .:.:... ..:. :... . :.::...: HEMATOLOGY....:::..:...::.::..::::::.:..::.............:.....:.:;:::.: ..:...:...:..:.. ... ..:........ :... OiM .LETEB D:... Day 1 Date APR 12 07 Time 0040 Reference Units ,.::A. .... :<: : ...::_ ::: 8 TH ;ul 31 9 :. .... ....H. (.:.. :B 10:.:. ) / RBC 4.90 (4.7-6.1) MIL/uL .... :.. ....:...:::::::.:::::..:..::::....:::::..::::.: HGB...... : 13:`?:;:;:>>:>:::>: :<:>:>:>:i: ::<::>::>:::<: <:::::< ;: :;:::> >:: .. .:' 0;'<;:: »:::';::G: :..... HCT Z':' 5€>€r`>€ ;;> < < »'.;' .... (42.0-54.0) % . :::. :::.:...::.:.:..:....;;. :...........:::8:4.:........... .:::.::.. ..:............9::.:...:.... .::.::.:.:.......:.........:.:: .......:.............::........... ........ MCH 28.0 (27-31) PG N! HC.:::.:: ::::>::::;::: ;:: ::>` s:. »:.:33::.':3:7:: ::::<` `:: <::> «:> C....... ...:::.::: :.:.:::.::..:............3:3:..............::.::::::. ..::::. .:. .:::..:.: .:::.:.. ::::.::.::.:................... :::.:........�.......::.....)... ::.::::.,.::::::::::.:::,.:::. .:........::::::.::......:::::.:::::.:........ RDW 14 .9 (11.5-14.5) ..:::..:.::::..:.::::.::::::::.::::::.:.::::::. .:::..:::.:::::::::.::.:::.: :.:PLT::: 3.73> ........ :::::: :>::: :::::: :::::::<:::> :::: »:::..13:0:=40.0 «<: < :: T uL .....:::.... ........ ....... ................. ............................ ..... .. .... ...... ...........:...:...:. :::::::.....::::.::(...............:..:.:)....::::.:..::...:::.:::..... .::.....::::::..:.::::.<:::::::..: MPV 9.3 (7.2-11.1) FL CHEMISTRY:::::.::.;:.::::.....::.. >: :R UT:INE S S :�> :: :CHEM: O Day 1 Date APR 12 07 Time 0040 Reference Units : . .T :: RTE N6.:::1-7< 9::;< >:<::::>:' :: '.<> G'.IjL: :> ::: »<:>;:>';<:> ELVER::.. .... ON::TESTS:.: . Day 1 Date APR 12 07 Time 0040 Reference Units .::...:::. ..................................................:. .:::.::: ............................................ .AL...............::.:::. ..::....:. ::.3:,,Z..:.::::::.:::::::...:::::::.::::::::::.#+.:::: :..::.:...:::::.:.:.:...:::.:.. ::::::.. ::.:...:::.:.(3:,.5...:4.. ::...).::::::.....:.:..:::::.:.::G... ................:::..;::.: ::.:::::::.;:.: ALK PHOS 87 (38-126) U/L ........................................................................... ... ....... .......... .... .... ..... ... .. ............................................................................ :::::::::;>:::::0.... ::;::: : 0=:: 2': :'::::>:::::::<::::::...........:. BILI,T 0.5 (0.2-1.2) MG/DL .. ...... AS 1 2:?.> ' ::... :...:.::.:: >::::::'>:::::::::'>;;:::::::::::,::';:::;':::::" : ::::::>:::. :: <::>::< 1:. :'-::38 ::>'<>: <:>:::«>::>:>::»: > . ALT 18 (0-36) U/L P:S erste: ..:::.: M:<.<:;`':4 6 >:>:><. :<;;# ::=>:i:: >;:75.' T:.:.IS..T..,:DANIEL:.... .. .::...:.::::::>:.:::: .:..::.;:.:::AgeLSex..::::4:8/M:.;;:.;:.;;.::::.;.:Acct#.:::;0:9..5::..:8::.;:. t#M:000.6139.<:;:.> 05/15/07 CONTRA COSTA HEALTH SERVICES Page 2 0834 CONTRA COSTA REGIONAL MEDICAL CENTER CONTRA COSTA HEALTH CENTERS 2500 Alhambra Ave. ,Martinez, 94553 Hye-Kyung Kim,M.D. , Dir. of Laboratory Services MARTINEZ FINAL - OUTPATIENT SUMMARY REPORT ....:.......::.::..::.:::.::::.::..::...::::::.:::::::::::..::::::::::::.:...::.::::::.:. P.atieat.:.;:;.AMYTHI.ST..:.D....A...N...I....E.....L.......;...:J..:...:.:.:... » .. .............. . .:.....:............,............,,.: . :::: .. M . : . ».>< . 76316 ;::;:.:s: ...........: ....... . ....... ................ ........ ..: :.. :: r�*: :*:*: : *: cont.:::.::.;::....:.;:.;:::;:.::*:.:::::..:.:::::.::::.::..::;;.:::::::::::.:.::. . .........:.: CHEI`jISTRY.::::.(................):....:...:...........:....:.::,..:.:..:.,::::::.:::..:::::::.::::::::.::..::::::................:..:.::.:::::. ::::...::..:.....:.....:.:: ...............:.........: „:..:.:. CARDIAC Day 1 Date APR 12 07 Time 0.420 Reference Units .................................... ............................................................................................................... I..:....::::.::::::. :............. .. CA1tD.IP C> PNS: > :; >: a<;:;: ::<:;;.::;:>::>«:::::>:<::'<:< <:.::<:::::::::::> >: ::::::::::::......>::::>::::>::>::>::: >'<:`::>::::<>:::><: :><:>::>':»::::>::«:' ......::<.>: > > ::.:::.......... ..... .::::.......:.....;::.:.:......: .........,.::.:......:.........:.....::............::........ .,.:..............:.:........ .70TES: (a) 0 HR CK 286 H Col: 04/12/07 0420 0 HR TROP 0.01 Col: 04/12/07 0420 6 HR CK 230 H" Col: 04/12/07 1150 6 HR TROP 0.05 H Col: 04/12/07 1150 12 HR CK 230 H Col: 04/12/07 1640 24 HR CK 235 H Col: 04/13/07 0416 See also (b) (b) CK NORMAL RANGE: MALE. . . . 61-224 U/L FEMALE. . 32-173 U/L TROPONIN INTERPRETATION: 0 - 0.04. . . . NEGATIVE FOR ACUTE M.I. 0.05 - 0.49. . . . INDETERMINATE FOR ACUTE M.I. >= 0.50. . . . POSITIVE FOR ACUTE M.I. cTnI >= 0.05 usually indicates myocardial injury either ischemic or nonischemic in origin. The level is proportional to the extent of injury. It also provides "risk stratification" information. False positive in vitro interferences include: heterophile antibodies, rhematoid factor and microfibrin clots. (The new accu-TnI significantly reduces these interferences.) Elevated cTnI has been reported in patients without overt clinical ischemic heart disease in the following conditions: cardiac trauma, CHF, severe hypertension, renal failure, myocarditis, sepsis, severe burns (TBSA >30%) , and severe hypothyroidism. Assay of serial samples as well as clinical information can be helpful in these situations. . ... .. . ........ >::<; G: :'; ::»::>:>:<::<:::>:<:::<:::: ex''6::::.4'8:':M.:;;:::< >:<;:>::Adc:t#M.O...6.3. 2. . ......... # . . 613.9.... ..: P:a.tient:s:<:: :MS'TH.I., T,DANIEL.::.J.::..:..:.::.:..:::::::.:. .::.:Age./$......:.::::....../..:.::.. .:::.::.:.:: :..:.::.:::.::::.:...:::::::.:::,:..::::::::::::::::::.::::::::.:::::::::: . be4n3 o �L`C 3 C.PC A fr 05/15/07 CONTRA COSTA HEALTH SERVICES Page 3 0834 CONTRA COSTA REGIONAL MEDICAL CENTER CONTRA COSTA HEALTH CENTERS 2500 Alhambra Ave..-,Martinez, 94553 Hye-Kyung Kim,M.D. , Dir. of Laboratory Services MARTINEZ FINAL - OUTPATIENT SUMMARY REPORT hued << >' '<> > <>> '' < > >i`< >:> ' Co nti ..........: :.::.... .... ..:...:. .. :.......::.::::..::.: .:::..:::.;:.::::.;:;::..:;: >::....:::......>: .:< : .:.::......;.. ><::>:: :::: :»: >: :::>:..::: : ::: 826©::;:;.;::.;:»:::>;»:> P.at.Yesit:•..:AMYT.H.i;ST ..DAME..L..:3:....::..:..:::.::.:::.:::::...:::.:..:..:.....#..... ..... :.::...: ..:::,::::::.:::::.: ...:.:....:....::....:.:.;:;.;:::..::.:;::.;:.::.;;;:.::.:::.::.::.:::......:::.:::.:::: . , *..*.*. . .#. ...:.:.::...::....: . ..:::..:...................... .. CHEMISTRY;: cont :.:.:::::-::::....::::::::.:.::.::::::::.:::::. .::::::: .:::.:: ::: ::::::::::.:::.:.::::::. .......................... :::::::::;.::::;:.;:.;;.::.::.:.....::::::::...........................::..(...............)................::-.::.::::: .::::::.:::...:...................................................................... ....... .................. ............. .: .......... ..:..:.... ,CIiEEM3STIZY >INDVI�U Day 1 Date APR 12 07 Time 0420 Reference Units .;:.::.::......::.::.::.:::..:.:::.::.::.:::... .::.::.::.::.......:.:::......::::.;. .... .. G. DL BILI.T:::..:...:....:...:: .:..::..:..::0:.:7:.:.::..:.::::....:::.:..:::..:..::::::::...:.:::::::: :::::::.:.:. ......::(:..:......:.:...:.:...;..:::..,......::................./.::..L.........:.:..........::............ �....:................... ....... ....................................................:................... .......... AST 28 (10-38) U/L ALT8 ::..::.:.:.:::...::..:::.::::.:::::....::::.::..:.::::.. ..:).::...:.:..::.....,.....:.:..:..........,:.::/:.,....:,.,...:..:...::,...............:::. jC .:...:.::::. . :.: ::::::::::...:.................................,.:.T...OXIOL..O..GY..::.:::::::::::..::...:.............:.::::::.:::::::::::::.:::.: ::. :.:::.::. ...............: .. — E _ r1 ............ ................ ............ Day 1 Date APR 12 07 Time 0416 Reference Units 0 0 G 0....:............:.:... AMP :: :..:.::::21EGATIVE:.::::::.:::::.::.: (.::...:....:.................)...........................:.......::::.::::.;::::,::::::::.::::.::::::::. :..................... BENZO ?{)S; Ii3 .> > > <:` >I3': (NEG <200) NG ML : : .:.....:........:......:.:.:: :...::::.::;:<.;:.::<.::::.: .;;.; : ;.::.::..................... ,.:::'<:'s'::;::: :::<:;;::;:;;<:..:,::.;::::.:;::.;:<;;.:::. .....:......::.:;...... ::::::.::::::::::.:. :..:......:::::.::::::..:::::..:.:::::::...:.::::::: ::.(NEG:..<3fl.�.3...,::::::::.:.::.:::....G/... .........................:::.......::.. PLU ..:..:.::.::.:..... i:...,.:::.:..:.........................::........::::.:..::...........::::::..:.:..:.. . OPIATES NEGATIVE (NEG <300) NG/ML .:..:...::.::.:..:.... . .. *:*.*:*:**.*.*.**:*.***.*: ,.:............ BLOOD.::GAS.::ANALYSIS.::...:.:............................................ Day 1 Date APR 12 07 Time 0354 Reference Units pCO2 - (35-45) mmHg NOTES: (c) ****************CRITICAL VALUE REPORTING******************* CRITICAL VALUE CONFIRMED AT: 0510 REPORTED AT:0510 TO:MCEA BY:RT.MCGO READBACK OF RESULTS DONE (Y/N) : Y See also (*d) (*d) TEST PERFORMED AT: CCRMC RT LAB, 2500 ALHAMBRA AVE. , MARTINEZ, CA 94553 DENIS MAHAR, M.D. , DIRECTOR (e) ****************CRITICAL VALUE REPORTING******************* CRITICAL VALUE CONFIRMED AT: REPORTED AT: TO: BY:RT.MCGO READBACK OF RESULTS DONE .(Y/N) : See also (*d) ` >:< 8:26 '< Un :t M0fl067.3574W ..::::::......:.: .:..:::..............::::::::.::.:::.::: ::.::::::: .:::::::.:::::.. :.: . .................. Aatsent..:.AMYTHI.ST..DIEL.::3...::. ... :.......:.....:....::::::::..:.A ef,Sex,..:..4..8/1'f::::::..::....::::... ..::::::::.:.:.::::.:::::::::::::..:..:.:.:.:.: .....:.:.:.: :..:.:::::.:....::.: ..:.:;; 05/15/07 CONTRA COSTA HEALTH SERVICES Page 4 0834 CONTRA COSTA REGIONAL MEDICAL CENTER CONTRA COSTA HEALTH CENTERS 2500 Alhambra Ave. ,Martinez, 94553 Hye-Kyung Kim,M.D. , Dir. of Laboratory Services MARTINEZ FINAL OUTPATIENT SUMMARY REPORT ........... . ...................... ..... ...... P ienAMYH1 7j:iDANIEL::.... .................. ...... . .. ......:::......... :T.... ... ............. #MD .................... ......... ........................ ....... ..................... q .. .... .................. ............... ............................. ............ ...... ....................... ..... ... ............. ....... ..... ........... ..................... . LOOD::::GAS: ..... ................ Day Date APR 12 07 Time 0354 Reference Units ........... ................. ....................... ............................... 2 ...... tMTE ... . ... . ........ ........... .... ............ HC 03 .. . .... ........................:..................2.. 5. (..*...f....)..................... ................................................. .. . .................... ..(22-30) mEq/L . .. ...................... ..................BASE::EXCESS........... ........................... .......... .......................... SO2 97 (*f) (94-100) X ... . .... .. ........... ...................... .... ..... . ......................... ..... [3:63.:.:..f. . . ......................... .... .......... . ........................... ........................... ..... ......... . ......................... ................ ... ...::::PATIENT: TEMk. . ......................... .. ..........:' ) 4. . 3.7 ........ .............::. ---------------------0 - - :::: ..... ..................................... ............... ................. ...... ................ .... ............... ....... ............................ ........... ... ...... ....... ............... ........................ ............ ........... ..... . .................. Test Day Date Time Result Reference Units ................... FR-�WON. AFR��.............. . .............. ............................................................................ ... ... ................................. ... ............................ ....... ........... GFR AFR 1 APR 12 07 0420 > 60 (>60) mL/min ............................ ...... . ............... ..... ...... ..... .. . . 0.. .. ........... ....... ...... R .::0 . . ....... .................... -49 .......... . .........TROP............................ ......................................................... ............................ TROP 1:24 2 APR 13 07 05115 ... ....... .... ............... .. ....... ....... D ..................... (0.-0.........0. .04 9) 0:. . NG/ML 1 /.......:::::::.::::::.:.:::..:::::::::::.:.:::..:::.:::L tHb ...... . . ..I. .... - 1 ....... NOTES: (*f) TEST PERFORMED AT: CCRMC RT LAB, 2500 .ALHAMBRA AVE. , MARTINEZ, CA 94553 DENIS MAHAR, M.D. , DIRECTOR (g) INTERPRETATION: 0 - 0.04 . . . . NEGATIVE FOR ACUTE M.I. 0.05 - 0.49 . . . . INDETERMINATE FOR ACUTE M.I. To be repeated on next sample regardless of CK value. >= 0.50, . . . . POSITIVE FOR ACUTE M.I. . .......... Pa: ....... ............. ........ .... ..................................... ............ ....................... ..............4.X. .............. ...................... OZ. 0.0.0;6:1.3;975:,. ti ........... ................. ................. ...mit#m............ ... . . ......... 5��,�,ry� C�t��r� 05/15/07 CONTRA COSTA HEALTH SERVICES Page 5 0835 CONTRA COSTA REGIONAL MEDICAL CENTER CONTRA COSTA HEALTH CENTERS 2500 Alhambra Ave. ,Martinez, 94553 Hye-Kyung Kim,M.D. , Dir. of Laboratory Services FINAL INPATIENT SUMMARY DISCHARGE REPORT .... ...... .. .......... ........... .... ...... 1ST:�DANIEL...: " " .:: ............ .. .............. Vail .. .. ..................... . . ......... ................. ................ . . ... .... ......... ...................... s Test Day. Date Time Result Reference Units 3 TdL :M Xmn R AFR APR: 1 ::0: F >GFR NON-AFR 1 APR 12 07 1640 > 60 (>60) mL/min 'MMI 0 > >GFR AFR 1 APR 12 07 1640 > 60 (>60) mL/min 0 0:7 0 9D 0 14:.�0 lb 77 E FE T 1 ZATORT CUL=mE Specimen: 07:B0009561R Collected: 04/12/07-0600 Status: COMP Reg#: 03096605 Received: 04/12/07-0726 Source: SPUTUM Sp Desc.: ASP Subm Dr: MCCAULEY,SHANE,MD Ordered: SPU GS/CULT Comments: COL BY (MNEMONIC) : N.PAUV Service to be performed at: MTMZ > M M M M M XX SPUTUM:GP-AM STAIN MANm m Ym Z' �p S SMS 16 S. G�RAMM 0 bPCd:f::: CELLULAR, Organism I HEADY x� BETA LACTAMASE POSITIVE HAEMOPHILUS INFLUENZAF— omsme Xx Z i!�pen 1 d d ng,: on tar e RX AB ROUTE DOSE COST IL L a AZITHROMYCIN �CES TRIAXOXE q a CEFUROXIME S S TRIMETH/SULFA NOTES: TEST PERFORMED AT: CCRMC RT LAB, 2500 ALHAMBRA AVE. , MARTINEZ, CA 94553 DENIS MAHAR, M.D. , DIRECTOR 1. . .0M AMY A sim NO 11 Pat z exit.:. TH rat�"t �'u 7m m m 7 05/15/07 CONTRA COSTA HEALTH SERVICES Page 1 0835 CONTRA COSTA REGIONAL MEDICAL CENTER CONTRA COSTA HEALTH CENTERS 2500 Alhambra Ave. ,Martinez, 94553 Hye-Kyung Kim,M.D. , Dir. of Laboratory Services FINAL - INPATIENT SUMMARY DISCHARGE REPORT PATIENT.:s:.:.: .........:.ACCT:a> .s:::::.:MO:Z7 3:9:.6..7:3 ....... ..... .... ............;:.;;:.::.::.: �9 5)755 0915 DOB. 10/21/58. AGE�SX. 48/M . ROOM,: 3Da4 : REG 04/12/ 7 DI.S: ::;:0 4::.1.3.:. :::.:::..:::::::....:......... .::.:..:::: *:*:* :st: :*:ir*kt,tr:vr.**:*:tr yr*. **:#�t �: :ror:w::ve:*:# HEMATOLOGY ................... . . ... ..................:.:::::::.::..::..: .........:........::..:.............;.:.... ........... .:... :.: (}MPI;ETE:';::::FOOD ;:Cp Day 2 1 Date APR 13 07 APR 12 07 Time 0416 1150 Reference Units .... 1...0..2 (4,6 10 :8) TH/.CMM . ... (40 - ...................:. ...:::. : .:.:, ... TH.8.. : .. .:0 : ;.; ...........: .uL .......: �:. ..:::. :::. ............ .... :........................... ....... - ->LYMPH ABS ............. - 1....5.:.: .:.::.:..::..:... ........::.:....:.......0..9.............:..:.:..:.::::.::::::....::.. .:.:::.:.::.:..:(0.;,9.;:.::4..:...D..):; .;::;;:.;::.;:.:::.;:::::TH/...nL:::::.. .... . ...... .............................................. ->MONO. $ 6.5 8.8 (3 .4-9.0) & .................:............................... ::>MONO ABS.':::> ;>'::::::::::::::::.. :> :.....; ::>:: » >:::> «: «<': ? : 7......... (0..16. 1,::Q) TH.uL 0..9 ->EOS % 1.6 0.4 (0.0-7.0) % .Efl ABS::::::::: «<: :: ->BASO $ 1.3 0.7 (0.0-1.5) ....ABS .::: D Z 0:..:1 (0..;:0 2) ::;: THEuI, ->RBC - :� �, �:.:a3L::.:. (4.7 6.1) MIL/uL ->HC T fi:........::.:.::::.:::::::::::::::::::::::::1+.::::.3.8.:,:��:::::::::::.::::.::::::::.:::::::.:Tr:::. (42.0 54.0) % -:> V 8...4.5::.... (8¢.; 94):::.. FL 8.x.,4 ->MCH 28.6 27.5 (27-31) PG CH 33 �.::.:. :.,.6.:..::.:.::. ::..: ... (33,37) ->RDW 14.6 15.1 (11.5-14.5) % 2.87 30.3:. ......:: . :.::::.:...:.::...:.:....::. ...::(13.0::..40:0) : : .: .::......TH:.ul�.:::::::::.:::::.::::::::.::::::::::::: .. ->MPV 9.2 18.7 (7.2-11.1) FL �c**;;r::�r:**<k:vr.:er;*:vr.,..*<..... .*......::*:it*;:t:,t+E:w:*#.;: *:i�:,t: *;.*.* .... : : :.::::.:.:..:::::...:.:.:::::::..::.:.::::..:.::::::..::::..:.::.:..:::.:.:.....CHEMISTRY::..:.:..:.. ..:::.. E MY T Day 2 Z Date APR 13 07 APR 12 07 Time 0416 1640 Reference Units ........................................... :.............:.... ......... .......................................... ...... ..... .::..... ..........:. 14 0.....::::............:..:..::....:::...........:....(.13 5:. 14 3:).....::::..::.:::.:..MMOL.L:.:::>:::::>::: >:::< ->POTASSIUM3 .6 .... .......................................... .............................. >CHLORIDE:` > <: : ; ::: . ::>:»>:;:>::>:>i:[>[::>::i:>::::>::< ::>'::::: ..... .:::...::::...: 5........:......:.:...... .................... .If.$........................................FI....... 9 8. .10 7. ....... ..:... :.....MM0. L:::>::::::>::::;>:>:::` ->CARBON DIOXIDE 28 126 (22-30) MMOL/L AG............................................7..0....:::..::.:. .....:::.....:::.:.......... .. :0.....::.... ...........::.....:::.::... .........0.: 12.... ...:. ...:: ::..MMOL ......................... .L at . . aT,DANiEL..7 AgefSex 48./M Acct#MO:I1396.7Z0 Dnit#M0:.0 3976;;. 05/15/07 CONTRA COSTA HEALTH SERVICES Page 2 0835 CONTRA COSTA REGIONAL MEDICAL CENTER CONTRA COSTA HEALTH CENTERS 2500 Alhambra Ave. ,Martinez, 94553 Hye-Kyung Kim,M.D. , Dir. of Laboratory Services FINAL INPATIENT SUMMARY DISCHARGE REPORT .. .......... Patient: AMYTHI.ST.:.:..DANIEL ContYn .......... ...... .......... ........... .... .. ... ........ .... .. . ........ ... .............. *:CHEMI ................. ............... .. ....... ..... ' : .. .... ..... ............. ................. ... ...... .............................. .......... M..'...TESTS::' ............ Day 2 1 Date APR 13 07 APR 12 07 Time 0416 1640 Reference Units ................ q................. ........... . ................ ...... ...... . .......... ......... ............ ->BUN (7.0 21.0) MG/DL ................................. ......... ............... .. . ...................... ............. ...... ............ ...... ... . ....... . . .......... .. ..... ...................... ... . -10.5) MG/DL (8.5 :�X:::NX X.: ..... ......CALCIUM. ......... .............................. ......... ................. ....... .................... .................. ........ ....... ................ -:�);PHOSPHOROUS..... . ................. ............... . ............;............... .. . ........... ..... ....... .... ....... ....... .......................... ......... ... w d::..CHEIaSTRY Day 2 Date APR 13 07 APR 12 07 Time 0416 1640 Reference Units ................................. . . . .... ....... . .............. ............. ............... - MG: DL::: ................ ............ ........ .................. ...... ....... ....... ............... ....... ....... ..... ............ ............... ............ ... . ..... IP Day 2 Date APR 13 07 Time 0416 Reference Units ... CHOLESTE ... 12:0;;:::213. .... ... . ........... ............. ........ . . ........... . ...................... ..:...NG... D....L...� .................... ... ............... >TRIGLYCERIDE 107 (35-160) MG/DL .......... ............ ... ............ .... ......... ... ............. ...................... .......... . ....... .... ... . ... ....... ........... . ...... . ... ............... ............I............................ ............... fID ..... .......... . ............................... .. .............................. ->LDL 17 1(a) (60-129) MG/DL NOTES: (a) CARDIAC RISK CLASSIFICATION DESIRABLE BORDERLINE HIGH RISK CHOLESTEROL 100-199 200-239 >240 HDL C. >45 36-45 <36 LDL C. 60-129 130-159 >159 LDL C. NOT VALID WHEN TRIGLYCERIDE IS >400. ........... ...... .......... ............................. . ......... ........... . . .... ... . THIST,M .... .... -.1 Vh moo 0: 1 3. 7 p I j��6.7 o.� it.4 .6. ..... ....... ....... ..... ................ ::: ..................... .............. ...... . ....... . ..... .... .. .... ..... .............. ............. 05/15/07 CONTRA COSTA HEALTH SERVICES Page 3 0835 CONTRA COSTA REGIONAL MEDICAL CENTER CONTRA COSTA HEALTH CENTERS 2500 Alhambra Ave. ,Martinez, 94553 Hye-Kyung Kim,M.D. , Dir. of Laboratory Services FINAL - INPATIENT SUMMARY DISCHARGE REPORT . .. ......................... ........... . ..... . ............ ... ................ ......................... .. ..................... .......... . ................... ... . .......... :Co tinuedj.::::::: :.::................ AMY THI:ST:.,�DANI.EL.:.::J ........... ... ...... . ...... .. ............ .......................... ...................... .. .................... .......... ................. ..... .... .... ................ ...... ... . ...... . .......... ......... .... .... . ....... ... . ........ ......... .................. *4****BLOOD.::BANK*.*. :*. ............................... .................. ................ . ............. .. .......... .......... ... ... ............. ........ ................... ........................... ............ ................... . .............. . .. ............. ............ ............. .. ............ ............ OP;GUAT3O ..... ...................................... .... ...... .... .. ............... . .. ............. ............. . . ..... Day 2 1 Date APR 13 07 APR 12 07 Time 0700 2230 Reference Units ... ............ ... ................... ------------------------ ................. ..................... .......... ... ...... . ....... ..... .. ....................... ....... ....... ..... ........: ............................................... ......... .... ........... . . ........ ... ... . .... ...... .............. ............ . ........................................................ ............ Day 1 Date --------------APR 12 07-------------- Time 1830 1640 Reference Units . ............. ....>::::<.::..... :: . . . ........................... . . ..:.SECONDS... .... .. . ...... . .. ............... ..... . ............ ........... ..... .. .... . .... ....................... ... ................................ .............. NOTES: (b) NEW HEPARIN THERAPEUTIC RANGE 10/06 PTT (seconds) <40 .2 (<1.2 x control) 40.2-50 .3 (1.2-1.5 x control) 50.3-77.1 (1.5-2.3 x control) 77.1-100.5 (2.3 to 3.0 x control) >100 .5 (>3.0 x control) (c) ****************CRITICAL VALUE REPORTING******************* CRITICAL VALUE CONFIRMED AT:2003 REPORTED AT:2005 TO:N.GORS FOR DR. ADAMS BY:LAB.THMA READBACK OF RESULTS DONE (YIN) : Y ***************CRITICAL VALUE REPORTING******************* CRITICAL VALUE CONFIRMED AT: 2003 REPORTED AT:2005 TO:N.GORS FOR DR. ADAMS BY:LAB.THMA READBACK OF RESULTS DONE (YIN) : Y See also (b) (d) ****************CRITICAL VALUE REPORTING******************* CRITICAL VALUE CONFIRMED AT:1743 REPORTED AT:1744 TO:N.CARBE BY:LA]3.IGAM READBACK OF RESULTS DONE (YIN) : Y See also (b) .... ................................................................ .. .... . .... ... .. ....................... .............................................................. ............................................................................................... .......... . ..........................�::................. ..... ........... :jp.a.tient':*:'..�AMYTHI�ST,D=IEL......J i # 0.006119.70' ..... ..... ....... .... ........... .................... .... . ......... ........ .... ............. ................................... ........... ..... ........... ............... .. .... ...... .. ......... ......... .. ...................................... .. 05/15/07 CONTRA COSTA HEALTH SERVICES Page 4 0835 CONTRA COSTA REGIONAL MEDICAL CENTER CONTRA COSTA HEALTH CENTERS 2500 Alhambra Ave. ,Martinez, 94553 Hye-Kyung Kim,M.D. , Dir. of Laboratory Services FINAL - INPATIENT SUMMARY DISCHARGE REPORT 1e:: >::: .P:at nt'i: AMYTHIS:s::: ;:>: T .DAN:..: #M0113:9:670: :>: >«: :>.. C tinu « :> ' > '< :>:°s:: .. .... c:.. . ...... .....:::......:.;::::::.::::::.:.::..::..:::::::....... :: :... .:::::::..:.:::..BLO.OD..BANK.: c..ont:..:::::: ::::::::...... :: ::.::::::.:....:.; C AG I N>::cont> 0 UI�P:T O Day 1 Date APR 12 07 Time 1150 Reference Units .......:.:::...::....:...... :.::::..::.:..: ::::::::..........::::..:.:.::::.:.::.:: 1.3..,.4.. ...:..:...........: ...... I............:.....:. ... ............:...............:..........7..12....5.. .................SECOND:>::>:<:::>:>:> ->INR >>.'>. <fI > (0 .99-1.14) ... . ..... ...::....::..:.::.:.:::: .:.:..: ..,..::::::::::..,...:::.:.:...::..:::::.:::::::....::::::: .::.:. :. .::::::..:. .: 1..(. ) . (27.0....4 0..0.)............SECONDS;: ......:: .:.:.....*.**:*,......**;,r k*: I; OD: AI;YS:. .S*:*:*....****. ***. **.... ,..*::*:k;*;,r:*:*:*:*::*::*;;r:.*: Day 1 Date APR 12 07 Time 0900 Reference Units H:.. .;.:..:.::. . . ::::.: ..:: ::. ....:..::..... .:::::.. .:. .;:.:..3 5:. 7..4 5::.; ... ->PCO2 44 (*h) (35-45) mmHg .. ......... .....:::.: ::..:.:..:..::.::.:..:.:.::.::::.:..::::::..............:.:::::::;::.:::.:::.:::::: .::::::::.:::::::::, P02:. :.:.. :...;.: IGO:: ...h :.:: ::::......:..::..::. .:..:.;;:.;..:....:...:;.::.;::.;.;;:...::: :;:.:::..:..:: 80::::10..0.. :.:.:::;:...:::::.:::..::.;.::::.mmH :;:.:::::.:...:::.;:.::.;;:::..::.::..::.;::.;:: ....:..:: ( ) .. .. ........... .....:::::..:.:.:..:. ...: ..::::::...:...::::.::... ........(.. ........... .......:...........::.: ..:..........:..:.g:.:.::...-:::::.::::::::............ ->HCO3 30 (*h) (22-30) mEq/L >BASE EXCESS.;;.::;: .: : :4;:c>8:::::.:,h:.:>:::<:»::»;:::::>:<<:a;:::;:;:><.::xT>:::«:::.. : :.: :..::: =:2.........2..... ::::.:......::::::.:....:mE L:::..:: :::...::.:::::::::::::.:. ->SO2 98 (*h) (94-100) % -> . . . :::. .. ..:: . .::.::PATENTTEM .::...: ....... ..... 3. 7:......0........3...7........0..) :.: :::;.:G:...:.:::::.. NOTES: (e) ***PLEASE NOTE ADJUSTED REFERENCE RANGE*** (f) CONDITION INR RANGE DEEP VEIN THROMBOSIS 2.0 - 3 .0 PULMONARY EMBOLISM 2.0 - 3 .0 INHIBITOR DEFICIENCIES 2.0 - 3 .0 ACUTE M.I./ATRIAL FIB. 2.0 - 3..0 MECHANICAL HEART VALVE 3.0 - 3 .5 (g) NEW HEPARIN THERAPEUTIC RANGE 10/06 PTT (seconds) <40.2 (<1.2 x control) 40.2-50 .3 (1.2-1.5 x control) 50.3-77.1 (1.5-2.3 x control) 77..1-100.5 (2.3 to 3.0 x control) >100 .5 (>3 .0 x control) (*h) TEST PERFORMED AT: CCRMC RT LAB, 2500 ALHAMBRA AVE. , MARTINEZ, CA 94553 DENIS MAHAR, M.D. , DIRECTOR P: :'.. ...:n T Hi >:.:,:D;:::::: C ><::>:;::; l3: 6 ::;1'0:; II ,: ;:> .. at..e t:.:..AMY.... ., ST.,.. .ANIEL J AgeJSex: 48/M Ac #.MO. .9..7 i;t# 000613976: CONTRA COSTA HEALTH SERVICES MR#: M000613976 CONTRA COSTA REGIONAL MEDICAL CENTER Name: AMYTHIST,DANIEL J CONTRA COSTA HEALTH CENTERS Ph #: (925) 755-0915 DOB: 10/21/58 Sex M DIAGNOSTIC IMAGING DEPARTMENT Loc: 3-B Acct# M076318260 RADIOLOGY REPORT PCP: PCS: ANTIO Ordering MD: CAPPELLARI,ANN,MD Order Date: 04/12/07 Order Time: 0354 SERVICE DATE: 4/12/07 SERVICE TIME: 0423 PORTABLE CHEST RADIOGRAPH: HISTORY: ET tube placement, shortness of breath. COMPARE: 1/14/07 FINDINGS: Cardiomegaly with cephalized pulmonary blood flow is noted. Motion artifact obscures the details. Patient is rotated. Endotracheal tube extends 3 cm above the carina. The trachea is deviated to the right, due to patient rotation. EKG monitoring devices overlie the chest. IMPRESSION: 1. Findings compatible with congestive heart failure on limited imaging. 2. Endotracheal tube in position. MICHELE SIBLEY, M.D. SIBM CAN Dictated 04/12/07 Transcribed 04/13/07 1322 RADIOLOGY <<Signature on File>> Contra Costa Regional Medical Center (PCI: OE Database CCS) Run: 05/15/07-08:20 by PARENTI,REGINA Page 1 of 1 CONTRA COSTA HEALTH SERVICES MR#: M000613976 CONTRA COSTA REGIONAL'MEDICAL CENTER Name: AMYTHIST,DANIEL J CONTRA COSTA HEALTH CENTERS Ph #: (925)755-0915 DOB: 10/21/58 Sex M DIAGNOSTIC IMAGING DEPARTMENT Loc: 3-D Acct# M011396710 RADIOLOGY REPORT PCP: PCS: ANTIO Ordering MD: MCCAULEY,SHANE,MD Order Date: 04/12/07 Order Time: 0700 SERVICE DATE: 4/12/07 SERVICE TIME: 0713 CHEST: AP Portable CLINICAL INFORMATION: Follow- intubation COMPARE: r4/11/071 703 FINDINGS: a Endotracheal tube is seen in satisfactory position unchanged since the prior study. Feeding tube is in place below the diaphragm likely within the stomach. Bilateral lung opacities are seen scattered throughout both lungs, especially in the lung bases. There has been no significant interval change when accounting for differences in technique and projection. IMPRESSION: No significant interval change in appearance of the chest compared with 4/11/07. There are persistent hazy opacities in both lungs. R. MASON COLEMAN, M.D. Gx� Y\43y ' 1 I I COLR SS Dictated 04/12/07 Transcribed 04/13/07 1318 RADIOLOGY <<Signature on File>> Contra Costa Regional Medical Center (PCI: OE Database CCS) Run: 05/15/07-08:20 by PARENTI,REGINA Page 1 of 1 rn�d�.. co�►sot��ro CONTRA COSTA HEALTH SERVICES MR#: M000613976 CONTRA COSTA REGIONAL MEDICAL CENTER Name: AMYTHIST,DANIEL J CONTRA COSTA HEALTH CENTERS Ph #: (925) 755-0915 DOB: 10/21/58 Sex M DIAGNOSTIC IMAGING DEPARTMENT Loc: 3-D Acct# M011396710 CT REPORT PCP: PCS: ANTIO Ordering MD: MCCAULEY,SHANE,MD Order Date: 04/12/07 Order Time: 0900 SERVICE DATE: 04/12/2007 SERVICE TIME: 0900 CT HEAD CLINICAL INFORMATION: Follow up loss of consciousness. COMPARISON: None. TECHNIQUE: A combination of 5- and 10-mm axial images were acquired from skull base to vertex without contrast. FINDINGS: The sulci and ventricles appear normal. No midline shift or mass effect is seen. No intracranial mass, hemorrhage, or extraaxial fluid collection identified. The brain parenchyma .demonstrates unremarkable attenuation. The visualized paranasal sinuses are notable for fluid levels in the maxillary sinuses and moderate mucosal thickening involving the ethmoid and sphenoid sinuses. The visualized portions of the globes and orbits and mastoid air cells appear unremarkable. The calvarium and scalp soft tissues appear preserved. IMPRESSION: 1. No evidence of acute intracranial pathology identified. 2. Acute and chronic-appearing maxillary, . ethmoid, and sphenoid sinusitis. AARON HAYASHI, M.D. HAYA ADA . Dictated 04/12/07 Transcribed 04/13/07 1417 COMP TOMOGRAPHY <<Signature on File>> Contra Costa Regional Medical Center (PCI: OE Database CCS) Run: 05/15/07-08:20 by PARENTI,REGINA Page 1 of 1 CONTRA COSTA HEALTH SERVICES MR#: M000613976 CONTRA COSTA REGIONAL MEDICAL CENTER Name: AMYTHIST,DANIEL J CONTRA COSTA HEALTH CENTERS Ph #: (925)755-0915 DOB: 10/21/58 Sex M DIAGNOSTIC IMAGING DEPARTMENT. Loc: 3-D Acct# M011396710 CT REPORT PCP: PCS: ANTIO Ordering MD: MCCAULEY,SHANE,MD Order Date: 04/12/07 Order Time: 0900 SERVICE DATE: 04/12/2007 SERVICE TIME: 0900 CT CHEST CLINICAL INFORMATION: Loss of consciousness. Evaluate for pulmonary embolism. COMPARISON: None. TECHNIQUE: Multiple 3-mm axial images were acquired from thoracic inlet through lung bases after administration of IV contrast. FINDINGS: The examination is technically limited due to large body habitus, motion, and contrast bolus timing. Mediastinum: A nasogastric tube is identified which extends to the lower thoracic esophagus and then doubles back to the midthoracic esophagus. The tip of the tube appears to be at the level of the inferior pulmonary veins. An endotracheal tube is also visualized with tip seen at a level 3 cm above the carina. The heart appears upper limits of normal in size. Great vessels demonstrate normal caliber. Evaluation for pulmonary embolism is quite limited due to the above-mentioned technical limitations of the examination. Cannot exclude thromboembolism involving the lower lobe branches of the left pulmonary artery. Lungs: Mild to moderate consolidation versus atelectasis involving the posterior lower lobes is noted bilaterally. No septal thickening is seen. Pleura: Tiny bilateral pleural effusions are noted. There is no evidence of pneumothorax. The osseous structures appear preserved without lytic or blastic lesions. There is no evidence of axillary adenopathy. Visualized portions of the upper abdomen appear unremarkable. The regional subcutaneous soft tissues appear normal. IMPRESSION: 1. Technically limited examination. Cannot exclude filling defect versus artifact within the lower lobe branches of the left pulmonary artery. Clinical correlation is recommended. If indicated, further evaluation with a VQ scan or follow-up CT pulmonary angiogram may be obtained. 2. Nasogastric tube is curled in the distal thoracic esophagus. Recommend repositioning and confirming placement of the tube. 3. Mild to moderate consolidation versus atelectasis of the posterior lower lobe. 4. Endotracheal tube. Preliminary results discussed with Dr. Ruda on 04-12-2007 at 1130. Contra Costa Regional Medical Center (PCI: OE Database CCS) Run: 05/15/07-08:20 by PARENTI,REGINA Page 1 of 2 CONTRA COSTA HEALTH SERVICES MR#: M000613976 CONTRA COSTA REGIONAL MEDICAL CENTER Name: AMYTHIST,DANIEL J CONTRA COSTA HEALTH CENTERS Ph #: (925)755-0915 DOB: 10/21/58 Sex M DIAGNOSTIC IMAGING DEPARTMENT Loc: 3-D Acct# M011396710 CT REPORT PCP: PCS: ANTIO Ordering MD: MCCAULEY,SHANE,MD Order Date: 04/12/07 Order Time: 0900 AARON HAYASHI, M.D. HAYA ADA Dictated 04/12/07 Transcribed 04/13/07 1421 COMP TOMOGRAPHY <<Signature on File>> Contra Costa Regional Medical Center (PCI: OE Database CCS) Run: 05/15/07-08:20 by PARENTI,REGINA Page 2 of 2 CONTRA COSTA HEALTH SERVICES MR#: 00-06-13-97-6 CCRMC,Martinez Health Centers NAME: Amythist,Daniel J 2500,Alhambra Avenue,Martinez,CA 94553 DOB: 10/21/1958 ECHOCARDIOGRAM DATE: 04/12/2007 Rhythm: Sinus. Tape Number: 07-54. Blood Pressure: 117/42. BSA: 3.2. FINDINGS: M MODE Rt. Ventricular Size(normal—mild RVE—moderate RVE—severe RVE): Normal. Lt.Ventricular.Septum Thickness (0.71-1.1 cm): 2.0. Lt.Ventricular Posterior Wall Thickness(0.71-1.1 cm): 2.0. Lt. Ventricular Diastolic Diameter(3.8-5.7 cm): 3.7. Lt.Ventricular Systolic Diameter(2.2-3.8 cm): 2.5. E Point Septal Separation(0-1.0 cm): 0.7. Aortic Root End Diastolic Diameter(2.0-3.9 cm): 3.4. Lt. Atrium Diameter(1.5-4.0 cm): 3.2. Aortic Valve Cusp Opening(1.5-2.6 cm): 1.9. Inferior Vena Cava Size(<2cm): 2.0; patient on ventilator. Ejection Fraction (>50%): 21): 77 percent. M-Mode: 60 percent. LV Mass Index(Age<60:<95 gm/m2,Age >60 =< 110 grn/mz): 75. FINDINGS: DOPPLER E Wave (meters/second): 0.7. A Wave(meters/second): 0.8. E/A: 0.8. Tissue Doppler: 8. ECHOCARDIOGRAM Page I of 2 MR#: 00-06-13-97-6 NAME: Amythist,Daniel J Deceleration Time (160-260 msec): 305. CONCLUSIONS: Limited study due to technical factors; 1. Marked concentric left ventricular hypertrophy with a hyperdynamic systolic ejection fraction, estimated at 75 percent to 80 percent. 2. Diastolic function is grossly normal for age. 3. No evidence of pulmonary hypertension. Signed by Denis J. Mahar,M.D. on 04/12/2007 Denis J. Mahar, M.D. DJM/mt824 D: 04/12/2007 11:16:54 T: 04/12/2007 11:25:40 Job: 1683383 / 159322 ECHOCARDIOGRAM Page 2 of 2 CONTRA COSTA HEALTH SERVICES MR#: M000613976 CONTRA COSTA REGIONAL MEDICAL CENTER Name: AMYTHIST,DANIEL J CONTRA COSTA HEALTH CENTERS Ph #: (925) 755-0915 DOB: 10/21/58 Sex M DIAGNOSTIC IMAGING DEPARTMENT Loc: 3-D Acct# M011396710 NUCLEAR MEDICINE REPORT PCP: PCS: ANTIO . Ordering MD: ADAMS,DAVID S,MD Order Date: 04/12/07 Order Time: 1400 SERVICE DATE: 04/16/2007 SERVICE TIME: 1020 VENTILATION AND PERFUSION LUNG SCAN Clinical History: PULMONARY EMBOLI Report: Status: VERIFIED Pulmonary ventilation and perfusion scan: Clinical History: 48-year-old male with equivocal findings for PE on CT. Please perform VQ scan to evaluate for acute pulmonary embolism. Comparison Study: No prior VQ scan for comparison. Radiopharmaceutical: 15.86 mCi Xe-133 gas inhalation, ventilation; 5.0 mCi Tc 99m labeled macroaggregated albumin IV, perfusion. Technique: Prior to performing the exam a review of the patient' s pertinent medications and contraindications was performed. Following the inhalation of Xe-133 gas, first breath views, equilibrium images, and pulmonary washout images were obtained in the anterior and posterior projections. Following the intravenous administration of technetium labeled MAA, perfusion images were obtained in the anterior, posterior, lateral and oblique views. Findings: Ventilation images demonstrate normal initial uptake of tracer on first breath images which subsequently fills in with a normal distribution on equilibrium images. Ventilation washout images demonstrate no retention abnormalities. Perfusion images demonstrate essentially homogeneous distribution of . tracer throughout the bilateral pulmonary fields without evidence of large, wedge shaped pleural based mismatched defects to suggest pulmonary embolism. Impression: 1. Low probability ventilation/perfusion pulmonary scan for acute pulmonary embolism. 2. Results with read back were discussed with Dr. Stephen Ruda at 1:10 p.m. on 4/13/2007. Primary Diagnostic Code: NORMAL Contra Costa. RegionaI Medical Center (PCI: OE Database CCS) Run: 05/15/07-08:20 by PARENTI,REGINA Page 1 of 2 CONTRA COSTA HEALTH SERVICES MR#: M000613976 CONTRA COSTA REGIONAL MEDICAL CENTER Name: AMYTHIST,DANIEL J CONTRA COSTA HEALTH CENTERS Ph #: (925)755-0915 DOB: 10/21/58 Sex M DIAGNOSTIC IMAGING DEPARTMENT Loc: 3-D Acct# M011396710 NUCLEAR MEDICINE REPORT PCP: PCS: ANTIO Ordering MD: ADAMS,DAVID S,MD Order Date: 04/12/07 Order Time: 1400 MATTHEW FALK, M.D. FALM IMA Dictated 04/13/07 Transcribed 04/13/07 1620 NUCLEAR MEDICINE <<Signature on File>> Contra Costa Regional Medical Center (PCI: OE Database CCS) Run: 05/15/07-08:20 by PARENTI,REGINA Page 2 of 2 II IIII II IIll II II II 0 5b2b9an33fda4117B7O2dild675od6lf ON t i= ........... .......... 0 '-s ........... -4� I 7r-i -T in ...........— T E C; ............................ 4-7.1 bi. L L) ::W: — N 4,7+ H x A r-I . . .... 4j w M 04 4 i ! 1.i�-.. rt 04 0 CD '1 4j > His r.:, .. 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