HomeMy WebLinkAboutMINUTES - 09162008 - C.23 (12) CLAIM
BOAAb OF SUPERVISORS OF CONTRA COSTA COUNTY
BOA.RD ACTION: SEPTEMBER 16, 2008
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
on your claim.by the Board of
�amvvSupervisors. (Paragraph IV below),
p
v given Pursuant to Government Code
AMOUNT: $25,000.00 . AUG 15 2008 Section 913 and 915.4. Please note all
COUNTY OOUNSEL "Warnings".
CLAIMANT: JIMMY TUCKER MARTINEZ CALIF.
ATTORNEY: RICHARD G. BATES, JR. DATE RECEIVED: AUGUST 15, 2008
LAW OFFICES OF RICHARD G. BATES, .JR. AUGUST 15, 2008
ADDRESS: 1465 ENEA CIRCLE, STE. 1040BY DELIVERY TO CLERK ON:
CONCORD, CA 94520
BY MAIL POSTMARKED: HAND DELIVERED
FROM: Clerk of the Board of Supervisors T0: County Counsel
Attached isa copy of the above-noted claim.
AUGUST 15, 2008 JOHN CULLEN, _ er
Dated: By: Deputy
II, FROM.: County Counsel TO: Clerk of the Board of S ervisors
(,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).
O 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).
O Other:
Dated: —0 By: Deputy County Counsel
ill. FROM: Clerk of the Board TO: County Counsel.(I) County Administrator(2)
( ) Claim was returned as untimely with notice to claimant (Section 911.3).
IV. OARD 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.
DAVID TWA
Date 4 _ CLERK, By Deputy Clerk
WARNNG (Gov. code section 913).
Subject to certain exceptions,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 Governinent Code Section 945.6.You may
seek the advice of an attorney of your choice in connection with this matter. [f you want to consult an
attorney,you should do so immediately. *For Additional Warning See Reverse Side of Diis Notice,
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, California, postage fully prepaid a certified copy of.this
Board Order and Notice to Claimant, addressed to the claimant as shown above.
Date��DAVID TWA CLERK By eputy Clerk
This warning�d- e.snot flpply to claims which
are not subject Ahe California Tort Claims
Act such as actions in,,averse condemnation,
actions for specifipreliet;such as mandamus or
injunction, or Federal Civil Rights.elaims. The
abovelistis not exha;us,tivehand;,lega.l
consultation is essential to understand all the
separate limitations- r`,io 'sthiQJha 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 tinder 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
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 Cleric of the Board of Supervisors at its office in Room 106,
County Administration Building, 651 Pinc 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 See. 72 at the end of this form.'
•a. .•••r••••.••••••.*sees•••9o• •••Dose••••e••o.•••s•s••••sells Segall�i••••.•...•
RE: Claim By: Reserved for Clerk's filing stamp
RECEIVE®
Against the County of Contra Costa or )
AUG 1 5 2008
f ) CLERK BOARD OF SUPERVISORS
C ►_yl �'� �t. C DISLriCt) CONTRA COSTA CO.
(Fill in the name) I Z
The undersigned claimagt hereby makes claim against the County of Contra Costa or the above-named
district in the sum of$ S,' c" and in support of this claim represents as follows:
1. When did the damage or injury occur? (Give exact date and hour)
2. Where did the damage or injury occur? (Include city and county) ]
CL_ ,>-, . .4- ► J COwV-*-4�. V ' Cored+-.. ces-"-
3• How did the damage or injury occur? (Give full details; u extra paperifrequired)
�'•..-ti
4. What particular act or omission on the part of county or district officers, servants• OT employees
caused the injury or damage?
L 4 r
S What are the names of county or district officers, servants; or employees causing the
damage or injury?
3
RECEI'V'ED - - FROM_
ED Oa 11 '0� 11:06 FPOl9 - ,
9_5 �1� 1913 TO Lr,i� OFFICES B: E;TES P02/03,
6. What damage or injuries do your claim resulted? (Give full extent of injuries or damages
claimed. Attach two estimates for auto damage.)
7. How was the amount claimed above computed? (Include the estimated amount of any
prospective injury or damage.)
S. Names and addresses of witnesses, doctors, and hospitals: a
9. List the expenditures you made on account of this accident or injury:
DATE TIME AMOUNT
6 0 e 2 9 e 2 1 2 9 6 9 4 6 9 e 6 6 8 9 0•11 4 1 9 0 6 8 1 4 2 1 6.0 0 1 9 6.1 1 6 1 4 6 2 6 4 1 6 6 1 1 0 4 4 0 6 9 1 4 4 1 1 e 0 6 1 1 0 9 4 0 e 11 1 4 0 2 9 1 1
Gov. Code See. 910.2 provides "The claim shall be
signed by the claimant or by some person on his
behalf."
SEND NOTICES TO: (Attorney) 1
Name and address of Attorney
(Claimant's Signature)
L—tx W f71=s : c t S O
mer, ei.�.
(Address)
Telephone No, P'o fs—TTelephone No.
$4ee8log"916486098 a 6480060606206040066020088616911011119228110@$/199098099 / o661018999961
PUBLIC RECORDS NOTICE:
Please be advised that this claim form, or any claim filed with the County under die Tort Claims Act, is subject to
public disclosure under the California Public Records Act. (Gov. Code, 55 6500 et seq.) Furthermore, any
attachments, addendums, or supplements attached to the claim form, including medical records, are also subject to
public disclosure.
46691998004969466868011o08oe08666989490,.1112000100069logo soto80os.eeseat 00of64199e1all
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 (51,000.00), 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.
r",ECEIVED 08-11- GE 11: 06 FFOM- 925 313 2913 TO- LAW OFFICES E. E TES P03/03
THE LAW OFFICES OF
RICHARD G. BATES, JR.
1465 ENEA CIRCLE,STE.1040
CONCORD,CA 94520
(925)798-8055
FAX:(925)798-8009
Attachment to Government Claim
3. Claimant boarded the County Connection Bus at Arnold Industrial Way, claimant Tucker is
wheel chair bound and an amputee. The Driver attendant did not strap Claimant Tucker in with
the straps that were provided. While operating the bus on the way to the county health facility,
the bus stopped abruptly and Claimants wheel chair tipped over and claimant Tucker was
dropped and thrown to the floor of the bus.
4. Failure to properly strap a wheel chair bound ticked passenger properly, and failure to act as a
reasonable bus operator would have under the same or similar circumstances. Failure as a
common carrier to deliver and transport the claimant passenger safely to his destination.
5. Unknown at this time
6. Injuries to his neck and back (see medicals)
7. See medicals
BACK TO HEALTH MEDICAL CENTER
Patient Account Ledger
As of 8/1/2008
Entry Date POS Description Procedure Document Provider Amount
TUCJI000 Jimmy Tucker (925)646-5094
Last Payment: 0.00
8,671 2/25/2008 11 99202 0802250000 1 129.00
8,672 2/25/2008 11 98941 0802250000 1 90.00
8,673 2/25/2008 11 97014 0802250000 1 30.00
8,708 2/29/2008 11 99204 0802290000 2 239.00
8,927 2/29/2008 11 98941 0803050000 1 90.00
8,928 2/29/2008 11 97014 0803050000 1 30.00
8,929 3/3/2008 11 98941 0803050000 1 90.00
8,930 3/3/2008 11 97014 0803050000 1 30.00
8,931 3/5/2008 11 98941 0803050000 1 90.00
8,932 3/5/2008 11 97014 0803050000 1 30.00
9,051 3/7/2008 11 98941 0803100000 1 90.00
9,052 3/7/2008 11 97014 0803100000 1 30.00
9,297 3/10/2008 11 98941 0803140000 1 90.00
9,298 3/10/2008 11 97014 0803140000 1 30.00
9,299 3/10/2008 11 97010 0803140000 1 25.00
9,300 3/12/2008 11 98941 0803140000 1 90.00
9,301 3/12/2008 11 97014 0803140000 1 30.00
9,346 3/14/2008 11 98941 0803170000 1 90.00
9,347 3/17/2008 11 98941 0803170000 1 90.00
9,348 3/17/2008 11 97014 0803170000 1 30.00
9,533 3/19/2008 11 98941 0803210000 1 90.00
9,534 3/19/2008 11 97014 0803210000 1 30.00
9,601 3/21/2008 11 98941 0803240000 1 90.00
9,602 3/21/2008 11 97014 0803240000 1 30.00
9,603 3/21/2008 11 97010 0803240000 1 25.00
9,628 3/24/2008 11 98941 0803240000 1 90.00
9,629 3/24/2008 11 97014 0803240000 1 30.00
9,747 3/28/2008 11 99214 0803280000 2 147.00
9,806 3/26/2008 11 98941 0803280000 1 90.00
9,807 3/26/2008 11 97014 0803280000 1 30.00
9,891 3/31/2008 11 98941 0803310000 1 90.00
9,892 3/31/2008 11 97014 0803310000 1 30.00
10,004 4/4/2008 11 98941 0804070000 1 90.00
10,005 4/4/2008 11 97014 0804070000 1 30.00
10,162 4/7/2008 11 98941 0804110000 1 90.00
10,207 4/7/2008 11 97014 0804110000 1 30.00
10,208 4/11/2008 11 99214 0804110000 2 147.00
10,352 4/14/2008 11 98941 0804160000 1 90.00
t
10,353 4/14/2008 11 97014 0804160000 1 30.00
10,538 4/21/2008 11 98941 0804230000 1 90.00
10,539 4/21/2008 11 97014 0804230000 1 30.00
10,592 4/25/2008 11 99215 0804250000 2 236.00
10,703 5/2/2008 11 99214 0805020000 2 147.00
10,855 5/5/2008 11 98940 0805050000 1 70.00
10,856 5/5/2008 11 97014 0805050000 1 30.00
Printed on:8/1/2008 1:58:34PM This program is registered to Page: 1
BACK TO HEALTH MEDICAL CENTER
i
BACK TO HEALTH MEDICAL CENTER
Patient Account Ledger
As of 8/1/2008
Entry Date POS Description Procedure Document Provider Amount
11,202 5/16/2008 11 99214 0805160000 2 147.00
11,319 5/16/2008 11 98940 0805210000 1 70.00
12,485 6/25/2008 11 98940 0806290000 1 70.00
13,283 7/18/2008 11 98940 0807210000 1 70.00
Patient Totals 3,682.00
Ledger Totals 3,682.00
3
1
Printed on:8/1/2008 1:58:34PM This program is registered to Page:2
BACK TO HEALTH MEDICAL CENTER
New Patient Established Pt.
• PLEASE EN ER THE NAM0-CrOR-SEQNG YOU TOIJAY
PATIENT • - •
PATENT NAME(LAST) �-- (FIR
1 Lie t fr c'
HOME PHONE SEX DATE OF BIRTH AGE MARiTA STATUS OSMGLE ❑MARRIED RACE ®CP.UCA$IAN OAFRICAN.AMERICAN
C c 99
SJ DiVDFICFD OWDOWED OSEPARATED ❑HISPANIC []ASIAN OJ
THEA
APT-/SPACE/UNIT Y
i�
CITY ..'. STATE� cC � 21P�
PATIENTS EMPLOYER(GuardMw 4 patient is a minor w unemployed OGGUPA T ION
EMPLOYER'S ADDRESS - (WORK PHONE
l
CITY STATE ZIP
GUARANTOR • •
GUARANTOR NAME (LAST) (FIRST) (M.I.) SSN HOME PHONE
GUARANTOR ADDRESS CIT STATE ZIP
GUARANTOR EMPLOYER OCCUPATION WORKPHONE
1
GUARANTOR EMPLOYER ADDRESS - CRY STATE ZIP
HOW DID YOU
• OUR OFFICE? (3 AD OFRIEND ❑YOURDOCTOR C3 YELLOW PAGES ❑INSURANCE COMPANY ❑OTHERL-'t Tr0y OU-
REASON FOR VISIT (REFERRING PHYSICIAN
WI40 TO NOTIFY IN CASE OF AN EMERGENCY (PHONE l RELATIONSHIP
ADDRESS CITY STATE DP
• ' •
PRIMARY INSURANCE Co. (PHONE
\ � v
ApORES$ CITY STATE ZIP
POLICY HOLDER NAME DATE OF BIRTH SSN
REiAT IONSHIPTO PATIENT POLICY HOLDERS EMPLOYER
POLICY k GROUP x .
EFFECTIVE PATE
SECONDARY INSURANCE CO.
PHONE
ADDRESS
Lln STATE IDP
POLICY HOLDER NAME i DATE OF BIRTH SSN
RELATIONSHIP TO PATIENT POLICY HOLDERS EMPLOYER
POLICY r I GROUP x -rFF T-VE DATE
The above information is complete and correct.I authorize treatment of the above named patient.I hereby authorize release of information necessary to file
a claim with my insurance company and I assignbene5ts otherwise payable to me to the doctor or group indicated or.the claim. All professional services
Tendered are charged to the patient. The patient is resopnsible for all fees regar Iess of insU'ance coverage In the event of coiiection proceedings due
io iack of payment on my part,i agree to pay any and all collection fees that may be added to my account in order to recover monies due the doctor.
?'A copy of the signature is as valid as the original.
Pf.TI.NT SIGNATURE DATE GUARANTOR SIGNATURE
i3
t ,
�yr✓�y�.v7 gyp✓✓
Back to Health Medical Center
1100 A Pleasant Valley Drive
Pleasant Hill, CA 94523-4334
Phone(925)287-8550 Fax(925)287-8224
NOTICE OF DOCTOR'S LIEN
Patient: J �hnw�1 1 � c."ca;.- Date of Accident:
I do hereby authorize �� Id s uI C A to furnish you, my attorney, with a full
report of his examination, diagnosis, treatment, prognosis, etc., of myself in regard to the accident in which i
was recently involved.
I hereby authorize and direct you, my attorney, to pay directly to said doctor such sums as may be due and
owing him for the medical service rendered me both by reason of this accident and by reason of any other
bills that are due his office and to.withhold such sums from any settlement,judgment or verdict as may be
necessary to adequately protect and fully compensate said doctor. And I hereby further give a Lien on my
case to said doctor against any and all proceeds of my settlement,judgment, or verdict which may be paid to
you, my attorney, or myself, as the result of the injuries for which I have been treated or injuries in connection
therewith.
I fully understand that I am directly and fully responsible to said doctor for all medical bills submitted by him
for service rendered me and that this agreement is made solely for said doctor's additional protection and in
consideration of his awaiting payment. And I further understand that such payment is not contingent on any
settlement,judgment or verdict by which I may eventually recover said fee.
I agree to promptly notify said doctor of any change or addition of attorney(s)used by me in connection with
this accident, and I instruct my attorney to do the same and to promptly deliver a copy of the lien to any such
substituted attorney(s).
Please acknowledge this letter by signing below and returning to the doctor's office. I have been advised that
if my attorney does not wish to cooperate in protecting the doctor's interest,the doctor will not await payment
and may declare the entire balance due and payable.
3 � ILl- S11
DATED ATIE 'S SIGNATURE
The undersigned being attorney of record for the above patient does hereby agree to observe all the terms of
the above and agrees to withhold such sums from any settlement,judgment, or verdict, as may be necessary to
adequately protect and fully compensate said doctor above-named. Attorney further agrees that in the event
this lien is litigated, that the prevailing party will be awarded attorney fees and costs.
DATED ATTORNEY SIGNATURE
.RON J.CLEVELAND,M.D.
fc y
T \ } 01
actor: _
Name: �� �L s��/ .;� Age:�' 1 Date:
History:
Physical Exam: W H T P + l R �L- BP_ _ LMP
Y -
WNL SIGNIFICANT FINDINGS LAB RESULTS
GEN
HEENT
HEART
LUNGS
BREASTS
ABD
EXT - - -- {
MUSC-SK -
SKIN
NEURO
PELVIC - `-
OTHER
LABS' CBC CP CHEM 6 PSA HgA1C UA&C+S TSH&FT4 EKG C-XRAY MAM ECHO PFT
ASSESSMENT: PLAN:
2.
3.
4,
5.
6.
PATIENT EDUCATION:
Ref. Doctors signature/initials: F/U _
c BACK TO HEALTH MEDICAL CENTER
1100 A/B Pleasant Valley Drive
Pleasant Hill, CA 94523
Aaron Cleveland, M.D.
FOLLOW-UP PROGRESS REPORT
PATIENT: TUCKER, Jimmy
DATE OF SERVICE: 02/29/08
HISTORY OF PRESENT ILLNESS:
This is a 51-year-old patient who basically has had a run of bad luck. The patient lost his leg
about 10 months ago secondary to diabetic complications. He was also in a bus that was in an
accident two weeks ago and suffered an injury to his right lower extremity. The patient states that
he is a diabetic and he has hypertension. He might have some peripheral vascular disease and
he has been on some antidepressants. He is not sure exactly why he is on them. He states that
he was given the antidepressant while he was in the hospital but he says it does not really work
that well and he is still depressed. He says he has doctors who are trying to take care of him. He
currently is under a lean and his attorney is Richard Bates. The patient is seeing Dr. Hamilton for
a general chiropractic care: The patient also notes a history of cellulitis and diabetic neuropathy.
The bus accident occurred+in February of 2008. He states that he was not strapped in.
PHYSICAL EXAMINATION:
I
VITAL SIGNS: Pulse 94, respirations 15, and blood pressure 145/89.
HEENT: Nose and throat are clear.
CARDIOVASCULAR SYSTEM: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
EXTREMITIES: The patient has sort of a dusky rubor left lower extremity and some
hyperpigmentation. Right leg shows right below the knee amputation. The stump is clean, dry,
and intact though there is some mild swelling at the superior aspect of the stump. No discharge.
No major discomfort.
ASSESSMENT AND PLAN:
1. Diabetes, on insulin. The patient is on Lantus at 40 units p.m. and metformin 500 mg two in
the morning and one in the afternoon. The patient was unaware of his hemoglobin Al c. The
goal of this patient at this particular time is to get his hemoglobin A1c down less than 6.5.
Given the fact that .he has had diabetic complications, his diabetic neuropathy and
amputation, I suspect,in part some of it is probably noncompliance and some of it is just
difficult to control diabetes and perhaps financial constraints. The patient was told to bring in
his previous lab work to try to look at his hemoglobin A1c and to take his sugars in the
morning. From those two points of data, I can determine how we want to proceed in regards
to adjusting his Lantus and also his metformin. We also could add additional medications
such as glipizide XL to the patient. The patient does not have a history of alcoholism which
would conflict with metformin. The patient is on an aspirin and an ACE. The patient most
likely will need a baseline EKG as well. He is certainly at risk for coronary artery disease. He
has a history of smoking as well.
(1
BACK TO HEALTH MEDICAL CENTER MEMO
Back to Health Medical Center.
1100 A Pleasant Valley Dr
Pleasant Hill, Ca 94523
Date: 3-14-08
To: Staff
Re: Concord Homeless Shelter
This letter is to inform Concord Homeless Shelter that there has been a change in the following
prescriptions:
1. Lantus: Increased from 40U to 44U PM
2. Metformin: Increase from 1,500 a day to 2,000 total a day.
3. Cymbalta started at 20mg a day for 1 week and then 20mg twice a day after the first
week.
Thank You,
Aaron Cleveland, MD
AON J.CLEVELAND,M.D.
Name: �'r\� 1 L.{GU �-- Age: -?./f Date: 3)� �-1 _D9ctor
---
History:
Physical Exam: W H T P iiL DEA#BC7100023 NPI#1497829147
BACK TO HEALTH MEDICAL CENTER Uc#A73159
Aaron Cleveland,M.D.
1100 AVB Pleasant Valley Cr.
WNL SIGNIFICANT FINDINGS s. Pleasant Hill,CA 94523
GEN Tel:(925)287-8550 Fax:(925)287-8241
e �
HEENT Name.......... ........... A ..............
HEARTAddress...............................................................................................
LUNGS P SECURITY FEATURES ON BACK Date....,:.'...................................
BREASTS — R ❑1.24 U 75-100
j� l �,r� __.,4, _ U25-49 (9.101-150
zzt, 1 j;_; A' t- t:;� U 50-74 U over 151
ABD - vc a DONOt Substitute
EXT - u„ Refill NR 1 2,3,_4 5
:.o VSs"'
MUSC-SK units
t..,
SKIN f ❑1.24 ❑75-100
RA 2 7iY-.Y ✓ L, „�- -UU 255-49 U 101-150
0-74 O over 151
NEURO
❑ Do Not Substitute
PELVIC Refill
OTHER
nR 01-24 LJ 75-100
is 1x 3 O 25-49 U 101-150 m
�. O 50-74 O over 151 •.
LABS: CBC CP CHEM 6 PSA HgA1C UA&C+S T4 Opo Not SubsMue
- F Rerdt NR 1 2 3 4 5
i' Units
A SESSMENT:
1. Drugs Prescribed c„ Jk4^t1��zCiT�S�Ef�. E
1 ature
PRESCRIPTION IS VOID IF THE NUMBER r IfJ��\
2 OF DRUGS PRESCRIBED IS NOT NOTED ]
3.
4.
5.
47
6.
PATIENT EDUCATION: _ �7 d—zw—>
Ref. Doctors signature/initials: _ F/U _ _ _
{ ^ .RON J.CLEVELAND,M.D.
Jame: �l rn(�1��w��P,-- �Age: Date: 31� �-/ �' Doctor: -
iistory:
'hysical Exam: W H T; P l i! i R�_---`- BP _ LMP
WNL SIGNIFICANT FINDINGS LAB RESULTS
3EN
iEENT _
iEART _
.UNGS
BREASTS
kBD
:XT
AUSC-SK
'KIN
4EURO
'ELVIC
)THER
LABS: CBC CP CHEM 6 PSA HgA1C UA&C+S TSH&FT4 EKG C-XRAY MAM ECHO PFT
k5SESSMENT: PLAN:
4-414 U
14TIENT EDUCATION: �7 �-�,,� _7>
tef. Doctors signature/initials: FIU
BACK TO HEALTH MEDICAL CENTER
1100 AIS Pleasant Valley Drive
Pleasant Hill,CA 94523
Aaron Cleveland, M.D.
FOLLOW-UP PROGRESS REPORT
PATIENT: TUCKER, Jimmy
DATE OF SERVICE: 03/13/08
HISTORY OF PRESENT ILLNESS:
This is a 51-year-old patient who was last seen on February 29, 2008. The patient has several
issues. The patient is a diabetic. He has a questionable history of peripheral vascular disease,
hypertension, depression`right stump discomfort, previous trauma, and diabetic neuropathy. The
patient was seen back on•February 29, 2008. At that time, a full review of his history was made-
He was originally sent here to see Dr. Hamilton for a general chiropractic care. He currently has
a lean. He has a recent history of cellulitis, diabetic neuropathy, and amputation. He also had an
accident back in February of 2008. The patient states that he is not aware that he has had any
lower extremity workup. He thinks he had maybe an ultrasound but he is not sure exactly what it
was for. He has been on 1500 mg of metformin. He does not look like he has been on more. He
has uncontrolled diabetes taccording to the patient. I do not have any lab work in front of me
unfortunately to confirm that although he has a missing limb which infers I think that he obviously
has some uncontrolled disease most likely diabetes. The patient is not complaining of any major
issues. The stump seems to be fairly without incident or complaint today but he is here to review
some of his other comorbidities, which I think are important. He is still complaining of numbing,
tingling, and pain in his limb and his left foot.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 107;;respirations 14, and blood pressure 128/81.
HEENT: Nose and throat are clear. _
CARDIOVASCULAR SYSTEM: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
EXTREMITIES: Show somewhat dusky rubor in the left lower extremity and some
hyperpigmentation. Right shows below-the-knee amputation. The stump is clean, dry, and intact.
No sloughing, swelling, or.discharge.
LABORATORY DATA:
No lab work or investigations are available unfortunately at this particular time.
ASSESSMENT AND PLAN:
1. Diabetes. The patient states that his sugar levels are generally about 200 in the morning.
The patient's Lantus will be increased from 40 to 44 units. His metformin will be maximized
to 2000 mg. The patient will follow up in two weeks. I suspect the patient most likely will
have a glipizide XL added to his regimen in'order to get his fasting blood sugars consistently
below 120. 1 do not know what his hemoglobin A1c is. We will try to obtain a recent lab work
so as to not to occur any more financial stress on this patient. We will see what we can find
out before we start ordering a bunch of the tests.
y
Page 2 of 2
RE: Tucker, Jimmy
03-13-08
2. Questionable historyof peripheral vascular disease. I suspect this patient has peripheral
vascular disease and probably some elements of coronary artery disease. I did call NorCal.
It does not look like they do any lower extremity arterial investigations. I will have to find out
who does. We have.to send him back over to Contra Costa but this may have already been
done. We will need to look at the old labs and charts to see if any of this has been done.
The patient is already on aspirin. The patient will benefit from Pletal as well, difficult to say at
this time. The patient may also benefit from vascular consultation which I suspect he has
already had since he has had an amputation although I cannot be for certain.
3. Hypertension. The patients systolic seems to be consistently below 130s, on lisinopril mg
and fortunately this ismot a major issue.
4. Depression. The patient is currently on Wellbutrin. The patient will have Cymbalta added to
his regimen at 20 mg a day and then b.i.d. after the first week.
5. Diabetic neuropathy. ,,Once again, Cymbalta will be added to his regimen 20 mg a day and
then 20 mg twice a day after the first week. We will continue his Wellbutrin.
6. Right stump. The patient probably should via consultation be referred for a limb and also
have a chair. The patient was told to ask his other primary if this is something that they can
handle or it is something that I would need to also try to take care of. He keeps saying that
his insurance is adult limited and I guess it does not allow him to have any further care which
I find sort of ridiculous as the patient has a missing limb and his insurance will not cover any
prosthetic limb, rehab;; or anything so I am going to have to try to look into that as best I
possibly can.
a
7. In the meantime, his #1 complaint is diabetic neuropathy and his depression which I have
treated with Cymbalta, and we are also going to tighten up his sugars and then we will
continue forth and look at what we can find in regards to his records and labs and try to plug
the holes and get this patient much better.
Aaron Cleveland, M.D.
Family Practice-Board Certified
AC: sb/ap/0313DW 80738/not edited --- -
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1100 AIB Pleasant Valley Cc
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BACK TO HEALTH MEDICAL CENTER
1100 A/B Pleasant Valley Drive
s` Pleasant Hill,CA 94523
Aaron Cleveland, M.D.
FOLLOW-UP PROGRESS REPORT
PATIENT: TUCKER, Jimmy
DATE OF SERVICE: ; 04/11/08
HISTORY OF PRESENT ILLNESS:
This is a 51-year-old patient who was last seen on March 13, 2008. The patient has multiple
medical problems including but not limited to questionable peripheral vascular disease,
hypertension, depression, right stump discomfort from previous trauma, diabetic neuropathy, and
nocturnal enuresis. If r..
1. Diabetes and diabetic heuropathy. The patient is here to follow up for his diabetic screening.
He says that he has more energy. He feels better. He is in a better mood. Since he has
been taking the Cymbalta his depression is better and also his lower extremity neuropathy
has improved about 60% to 70%. The patient is still taking Lantus at approximately 46 units
as well as 2000 mg of.metformin. His sugar levels overall is 130.
2. Hypertension. The patient is currently on lisinopril at 20 mg a day.
3. Depression. The patient states he feels less depressed. He is on Wellbutrin and is currently
also on Cymbalta.
4. Hypertension. The patient is currently on hypertensive medications. The patient is not
complaining of any major issues at this particular time with the exception of some continued
numbing, tingling, and burning sensation in his foot and in his right stump area which has
improved 60% to 70%,and having to get up and go to the bathroom two to three times at
night.
REVIEW OF SYSTEMS:
Rest of review of systems is negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 101, blood pressure 118/76, and respirations 18.
HEENT: Nose and throat'are clear.
CARDIOVASCULAR SYSTEM: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
EXTREMITIES: The right'stump is clean, dry, and intact, very little mild redness but no swelling.
No tenderness. Some mild pedal edema in the extremities, questionable clubbing, grade 1.
LABORATORY DATA:
Overall lab work, chem-w8 .is unremarkable. GFR is greater than 60. His cholesterol is 238,
triglycerides 186, LDL 159, cholesterol HDL ratio, microalbumin 2.9, and hemoglobin A1c is 8.2
Page 2 of 2
RE: Tucker, Jimmy
04-11-08
ASSESSMENT AND PLAN:
1. Diabetes and diabetid'neuropathy, rule out diabetic nephropathy. The patient does not have
diabetic nephropathy:• His diabetic neuropathy is approximately 60% to 70% better and his
diabetes overall is better controlled. His sugar level average is approximately 130. Our goal
is an average of about 110. The patient will most likely need to get a baseline EKG which he
says he can get through his primary care. The patient will continue on 46 units of Lantus and
metformin at 2000 mg a day. We will consider going up on the Lantus to about 50 units on
our next visit. Also adding glipizide XL to his regimen could be useful although since his
hemoglobin A1c is 8:2. Usually hemoglobin A1cs around 7 and 8 give more predominant
postprandial sugars contributing to overall hemoglobin A1c and Lantus can take of
postprandial sugars land glipizide and metformin do not. Other medications like DD4-P
Byetta can help but'they usually bring lots of side effects and expense. At this particular
time, we will discontinue him on the metformin and the Lantus and consider going up on the
Lantus on our next visit. The patient is currently on aspirin. The patient will be put on a statin
as well. The patient will most likely also need to get a cardiac workup beyond an EKG,
perhaps a Cardiolite adenosine stress test. Obviously the patient is not going to be able to
be on a treadmill.
2. Questionable peripheral vascular disease, seemingly or maybe perhaps less likely given his
overall cholesterol but I just do not know. I do not have enough charts here to tell me
whether or not he has ever been worked up. I certainly think he needs a lower extremity
arterial Doppler with ABI. The patient does have decent pulses but still at the same time I
think it is worthwhile to:get. The patient is currently on aspirin.
3. Hypertension, well controlled. Our goal is to keep his systolic less than 130. The patient is
on lisinopril at 20mg.
4. Depression, better controlled, currently on Wellbutrin and Cymbalta at 60 mg.
5. Smoking. The patient;states he is smoking about half. Currently he is on Wellbutrin. He
feels like he can stop entirely. We will readdress the issue in two weeks. We may consider
perhaps trying to put the patient on some Chantix if he can afford it or if he can get it with
prior authorization coverage.
6. Mixed dyslipidemia. The patient has been on lovastatin at 40 mg one pill p.o. q.d. Our goal
is to get his LDL less than 100. The patient will follow up in two weeks.
The patient was told to talk to his physician about getting a baseline EKG to consider a possibility
of getting a lower extremity arterial duplex with ABI of the lower extremity and also to send him to
a rehab specialist so he can be fitted for a prosthetic leg. The patient does have below the knee
amputation and I think just sitting around in a chair all day is not going to do him any good. The
patient needs to be active.and he needs his prosthetic leg. He said he will talk to his physician
about that as well.
Aaron Cleveland, M.D.
Family Practice-Board Certified
AC: sb/ap/0411 DW_B0767/not edited
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BACK TO HEALTH MEDICAL CENTER
1100 A/B Pleasant Valley Drive
Pleasant Hill, CA 94523
Aaron Cleveland, M.D.
FOLLOW-UP PROGRESS REPORT
PATIENT: TUCKER, Jimmy
DATE OF SERVICE: 04/25/08
HISTORY OF PRESENTILLNESS:
This is a 51-year-old patient who comes in for multiple medical problems and followup.
1. Diabetic neuropathy:- The patient states that since being on Cymbalta, his numbing, tingling,
and pain in his lower-extremities have improved.
2. Nocturia. The patient states he has had multiple episodes of getting up going to the
bathroom. He said he recently put on trazodone by his primarily care. He says it did not
matter because he still has to get up in the middle of the night one to two times. He says his
insomnia is more predominantly related to the fact that he has to get up every couple of hours
to go to the bathroom. He says he can get a deep sleep but unfortunately at this time it
seems to be more related to his inability to stay asleep as a result of having to get up and go
to the bathroom.
3. Hypertension. The patient is on hypertensive medications. He has not suffered any ill
effects, dizziness, shortness of breath, chest discomfort, and currently on his lisinopril.
4. Diabetes. The patient's blood sugars are roughly around 130 average which is best than
they have ever been-:They used to be over 200. He is taking Lantus and maximized doses
of metformin with no side effects.
5. High cholesterol. The patient states that he is currently still taking his statin and not having
any ill effects.
6. Depression. The patient says that first time in his life, he feels like he is not as depressed as
he used to be. He is,finally taking care of things.
7. Insomnia. The patient states that he recently was put on trazodone by his primary care.
8. Neck discomfort. The patient has suffered accident back on February 18, 2008 when he was
in a bus without a seatbelt. His right stump did his wheelchair but he did not hit his head and
did not lose consciousness. He says with chiropractic adjustment, he is doing well. He still
has some residual right neck discomfort but no migraines.
9. Right stump. The, patient has above the knee amputation secondary to widespread
osteomyelitis. The patient is currently being fitted for a shrinking sock in order to help him for
his prosthetic leg.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 95, blood pressure 117/78, and respirations 14.
HEENT: Nose and throat are clear.
CARDIOVASCULAR SYSTEM: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
EXTREMITIES: Right stump shows a very mild redness and swelling but does not appear to be
infected. It is nontender. No discharge. The patient is afebrile and very small amount of redness
and swelling.
LABORATORY DATA:
Lab work was already reviewed. EKG is not in the chart. The patient does not have an EKG
baseline.
Page 2 of 2
RE: Tucker, Jimmy
04-25-08
ASSESSMENT AND PLAN:
1. Diabetic neuropathy, The patient is currently on Cymbalta 60 mg one pill p.o. q.d. The
patient is currently being able to take care of his diabetic neuropathy with Cymbalta alone
and we will not at this time need to add any Neurontin. He says that apparently he does not
have any numbing, tingling, or pain.
2. Nocturia. I suspect this is probably obstructive uropathy secondary to an enlarged prostate.
We will do rectal exam on next visit. The patient will get a PSA. I do not like the rectal exam
and then get PSAs.•' Occasionally, they could falsely elevate the PSA, although that is
debatable. Nonetheless, he is going to get a rectal exam next week. The patient was put on
Flomax 0.4 mg 30 minutes after dinner. We will follow up in one week after PSA will be
obtained. The patient'will get a urinalysis.
3. Hypertension. The patient is currently on ACE inhibitor. The patient's systolic is less than
130 which is our goal.;,The patient is on lisinopril at 20 mg one pill p.o. q.d.
4. Diabetes. Current!y,,sugars are well controlled. We will go up to Lantus 1 unit from 46 to 47
and continue metformin at 2000 mg. Currently, the patient is doing very well with his
diabetes and I look forward to retesting his hemoglobin C in a couple of months. The patient
will get a baseline EKG.
5. High cholesterol. Ourigoal is to get his LDL less than 100. His last cholesterol check, his
LDL was 159, triglycerides 186, and total cholesterol 238. With a patient with as bad as
diabetes as this patient, it is definitely LDL goal less than 100 and actually preferably less
than 70. So far, he seems to be doing well and seems to be tolerating his lovastatin at 40 mg
a day and I look forward to retesting his cholesterol in the months to come.
6. Right stump. The patient is currently being fitted for shrinking sock in order to fit him for
prosthetic leg. He needs to do the shrinking socks because if we put the prosthetic leg on,
his stump will shrink, and then he will have to have to be refitted and Medi-Cal will not pay for
it.
7. Depression, stable. The patient feels less depressed on Cymbalta and Wellbutrin currently
and doing better.
8. Insomnia. The patient says he liked the trazodone but he still has to get up during the night
multiple times as a result of having to urinate.
9. Cervicalgia, very mild probably related to semispinalis and splenius muscles of the right neck.
The patient at this point does not need any other further medications. I told him to try to get
some massage one or two times a week. I think that will help and continue his chiropractic
care which seems to be doing very, very well for this patient. The patient will follow up in one
week. Risks, benefits,`and side effects of this medication were explained to the patient.
Aaron Cleveland, M.D.
Family Practice-Board Certified
AC: sb/ap10425DW_B07911not edited
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.ROH J.CLEVELAND.M.Q.
Name: /v'yt1 {
Age: ' .. Date: S`_ t ? Doctor:—
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BACK TO HEALTH MEDICAL CENTER
1100 A/B Pleasant Valley Drive
Pleasant Hill,CA 94523
Aaron Cleveland, M.D.
FOLLOW-UP PROGRESS REPORT
PATIENT: TUCKER, Jimmy
DATE OF SERVICE: 05/02/08
HISTORY OF PRESENT ILLNESS:
1. This is a 52-year-old- patient who comes in for followup for his hypertension, cholesterol,
diabetes, right stump,?nocturnal enuresis, probable BPH. The patient states that he tried to
get an EKG with his?insurance, and the lab would not do it because either they do not know
what they are doing:or they do not take his insurance or they are too cheap to do it but
otherwise unfortunately he did not get it done due to his horrible insurance.
2. The patient unfortunately was unable to get the Flomax due to his horrible insurance did not
cover it.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 97, respirations 14, and blood pressure 114/71.
HEENT: Nose and throat are clear.
CARDIOVASCULAR SYSTEM. Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
RECTAL: Deferred until two weeks.
ASSESSMENT AND PLAN:
1. Hypertension, well controlled. The patient is on lisinopril 20 mg a day. This can afford also
some renal protection.,
2. Nocturnal enuresis, probable BPH. The patient is switched over to Cardura 10 mg one pill
p.o. q.h.s. This is supposed to be covered by his plan. The patient's PSA was obtained and
it is completely unremarkable along with his urine.
3. Diabetes. The patient is on 1000 mg in the morning and 1000 mg in the afternoon. The
patient is on Lantus.:.We will go up 1 unit to a total of 48 units. His blood sugars are roughly
around 130 to 140. 1 would like to get them to about 120. The patient is on ACE, statin, and
aspirin.
4. Diabetic neuropathy. The patient is currently on Cymbalta 60 mg one pill p.o. q.d. Labs are
stable, doing well.
5. Cholesterol. The patient is on lovastatin 40 mg a day. We will retest in two months. The
patient will follow up in approximately two weeks. At that time, we will probably get an EKG
and see how he is doing with the Cardura.
6. Right stump. The patient is still trying to get coverage for shrinking socks.
.9
Aaron Cleveland, M.D.
Family Practice-Board Certified
AC: sb/ap/0502DW_B0800/not edited
RON J.CLEVELAND,M.D.
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Name: � '
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5.
6.
PATIENT EDUCATION:
RQ{. Doctors signature/initials: cz —+ q4 FSU
BACK TO HEALTH MEDICAL CENTER
1100 AIB Pleasant Valley Drive
Pleasant Hill, CA 94523
Aaron Cleveland, M.D.
FOLLOW-UP PROGRESS REPORT
PATIENT: TUCKER, Jimmy
DATE OF SERVICE: 05/15/08
HISTORY OF PRESENT ILLNESS:
This is a 52-year-old patient who comes in with a long history of hypertension, nocturnal enuresis,
diabetes, diabetic neuropathy, cholesterol, right stump, depression, and insomnia. The patient
states that overall he is feeling much, much better than he has in a long time. He was recently
put on Cardura which was switched to Avodart due to insurance. The patient states that he went
from three times at night:to one to two times at night. He says he is not really,depressed
anymore. His blood pressure is good. His sugars are around 130. He does not have any
numbing, tingling, or pain in his lower extremities.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 102,and blood pressure 112/73.
HEENT: Nose and throat are clear. '
CARDIOVASCULAR SYSTEM: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
EXTREMITIES: The patient has a shrinker sock on the right stump.
ASSESSMENT AND PLAN:
1. Hypertension, well controlled. Lisinopril 20 mg one pill p.o. q.d.
2. Nocturnal enuresis, probably BPH. Avodart 0.5 mg one pill p.o. q.d. Improved.
3. Diabetes, improved. Hemoglobin A1c, UA and microalbumin in approximately two months.
The patient is on a total of 2000 mg of metformin and approximately 48 units of Lantus. The
patient's sugars are hovering around 130. The patient is already,on an ACE inhibitor, statin,
and aspirin. The patient will need a baseline EKG with his primary care.
4. Diabetic neuropathy, improved, and resolved. The patient is on Cymbalta at 60 mg a day.
5. Depression, improved. 'The patient is on Wellbutrin and Cymbalta.
6. Cholesterol, on lovastatin at 40 mg. LDL goal is less than 100. Last LDL was measured at
159. The patient will have another test of fasting lipid panel in approximately two months.
7. Right stump. The patient is waiting for Medi-Cal. The patient has been approved for a
proper shrinker sock, and at that point after he has the shrinker sock he should have a
prosthetic limb fitted.
Page 2 of 2
r'•
RE: Tucker, Jimmy
05-15-08
8. Social. The patient;overall is about to get some housing. He is getting approved for a
shrinker sock. Things are starting to look up and hopefully after he can get his prosthetic limb
the patient will be able to do some exercises, perhaps aquatic exercises to lose some weight,
and I think that will improve a lot of his other comorbidities. The patient will follow up in
approximately one month.
Aaron Cleveland, M.D.
Family Practice-Board Certified
AC: sb/ap/0515DW_B0809/not edited
i
vh I t ..t NCn,M.U.
WALNUT CREEK,CA 94598-3194 — LABORATORY DIRECTC
(925)947-4400
Patient Name: TUCKER, JIMMY E ' Requisition#: 08R0489692
Age/Sex/DOB: .51Y; M ;04130/1956Client: Collected: 04/041200817:27
Work Phone: BACK TO HEALTH MEDICAL CE Received:
Home Phone: 9256465082 1100A PLEASANT VALLEY RD Completed:
Unit M 5219473 • Page: 1 of 3
Account#: 0609552890 PLEASANT HILL,CA 94523 Req. Gond:
Report Status: Final
RESULT NAME OUTSIDE WITHIN REFERENCE RANGE/UNITS
I
CHEMISTRY _.
Autornated'Chemistry --
GlucoseCanceled.--
Urea Nitrogen ..Canceled-._.__
Greatlnlne:<: _ _Canceled.___
11
BUN/Cieat'Ra6o �
`Sodlum.':;.` den
Potassium` =i _Canceled
Chloride w Canceled
Gatban Diortde Canceled
Calcium ti t Canceled
Cholesterol` '> �anceled�
Triglyeendesance e(f
HDLG -Canceled-" `
.LDL . `3
aitietY
-Non HDLG -Cancetetf
CtoUHDI Ratio " -Ca
ncetert -- - -
Glucose' _ _ 4z 70-90 mg/dL
Urea Nitrogen �` _ 9 5-26 mg/dL
'Pat t'ant to F2eturn
.PATIENT TO RETURN AT A LATER DATE.
'Patient to Return .'_.-
PATIENT T.O:RETURN AT A LATER DATE.
Normal (Fasting)70-99 mg/dl
Prediabetes or impaired glucose metabolism(Fasting) 100-125 mg/df
Diabetes Mellitus(Fasting)>125 mg1d)on two occasions.
Diabetes.Mell tus(Non fasting)>200 mg/dl with appropriate symptoms
Itis recommended that high riskindividuals who do not meet"-
the above critena have a'-75:gram 2 hr.-Glucose tolerance'Te'st"to'"
diagnose Diabetes Mellitus:(American`Diabetes Association-2004}
nt ��
This documeht'cor)Wins confidential health information that is legally profec`tea. T information is intended only for the use of the
Individual it is'addressed�,i 'The authoiized recipient of this inficSmt tl'0n ts'ptoYlibited.from disclosing this information to any other
Party unless permitted to da so by contact with the health system;law,-o"egulation:-,If you fiave received this document in error,
please contactCiient Services at(800}677 4525 for instructionson-aetuming4t.'
BACK TO HEALTH.MEDICAL CENTER_.,_,__, t
jlMM
OPSUM.04!04!2008'2222, OUB 04/04/2008
R4418797 "y M-04/30/1956
a-—--- CLEVELAND,AARON J
Muirl-ab
The outreach laboratoryservice of John Muir,Heaith
1Y Li.l IR L AB
The Ou' treach Laboratory Service of John Muir Medicalq Center SC44L
,.�x.�„n•T,."'`ktf.a.dAa-l-i"Ytpp.'' wT :axa. mnt� -� v...,�+,,"k�<''`fF"e,w,-'3 '4.-'�+ ia.>d+7
??
'�
RPYe 2np
_, Sk 'r
i t i,rst• N,(,:A 94b98-3194 _
47-4400
Patient,Name: TUCKER,JIMMY,E Requisition#: 08R0489692
Age/SextDOB: 51Y; M 04/3011956:1 Client: Collected: 04/04/2008 17:27
Work Phone: BACK TO HEALTH MEDICAL CE Received:
Home Phone: . 92564650$2 1100A PLEASANT VALLEY RD Completed:
Unit#: 5219473 Page: 2 of 3
Account#: 0$09552$90 ; , PLEAASANT HILL,CA 94523 Req,Gond:
Report Status: Final
RESULT NAME OUTSIDE Uvi-now � REFERENCE RANGE 1 UNITS
Creatinine.." 0.66' 0:61-1.24 mg/dL
BUN/Creat:Raf,o, ___14_.__. _ , 7-25 Ratio
Sodium '. . 7 135-145 mmol/L
Po#asslum 3.5-51 mmoliL
,Chloride . X91 _..__., - 95-110 mmoiiL
Carbon 6ioxide — 26- - 22-32 mmol/1.
Calcium . ; ___._ g 4 _ 8.6>10.5 mg/dL
Cholesterol' , 238 a 140-199 mgldL
.Trigtycandes, : > 186 A _ _ 35-149 mg/dL
HDLG +: ---��
--42 _. 40-60 mg/dL
LDL 159 x
0-129 mg/dL
_ _ ___
Non=HDLC 296 " x 1-159 mg/dL
•Choi(HDL Ratia 5.7 x �� 0.0-4.9
s
GFR=NonAfrcan American >60 mUmin/1.73m2
CFR-Afncan"Amencan; >60'^ mUmin/1.73m2
3T his Creatinine methodiis calibrated to'be traceable _
to.
IDM
S.
4R-SLIGHT HEMOLYSIS , � k
Slightly Hemolyzed,result may be increased. K
'T'he recommended HDL reference interval per the National--.._
Cholesterol Education Program is>40 mg/dL.
6American Heart Association -- --,
Goal: <5.0 . '
Optimum: <3.5
'eGFR Reference Range:'>60 mUmin/1.73m2 ---
This'eGFR uses'the'IDMS-traceatils MDRE7 ---
Study equation;
This document contains confidenfia!health,information that is�liy protecfe3-This information is intended only for the use of the
Individual it is,addresse'd to: The authorized recipient of this ihformatiorris prohibited from disclosing this information to any other
Party untess,permitied to do so by.contaot with the health system taw;s-regaiation. if you have received this document in error,
please oontaot Client Services at'WO*77-4525 for instruct ons on returesing ii
BACK TO HEALTH MEDICAL CENTER,-_,___
OPSUM�44tQ412009 212:122'4 �` OUB 0410412008
844113797. M-04130/1956
r —— CLEVELAND,AARON J
'MuirLab
'The outreach laboratory seNice of John Muir Health
AMUIRLAB
)The Outreach Laboratory Service of John Muir Medical Center
+$'v ye2
'ia s�.,, f tY 5� A,
+4..nlYi SLYM 1wGnL .v. n
vu r 4HttK,GA 94598-3194 -
947-4400
Patient Name: TUCKER,JIMMY E Requisition#: 08R0489692
Age/Sex/DOB; 51Y;M,0413011956 Client: Collected: 041041200817:27
Work Phone: BACK TO HEALTH MEDICAL CE Received:
Home Phone: . 9256465082 11 ODA PLEASANT VALLEY RD Completed:
Unit#: 5219473 Page: 3 of 3
Account#: 0809552890 PLEASANT HILL,CA 94523 Req.Gond:
Report Status: Final
RESULT NAME OUTSIDE WITHIN REFERENCE RANGE f UNITS
"UR INE CHEMISTRY
Urine Chemistry.'
,
Abnormal Normal .
Microalbumin-Urine _ _2.9 mg/L
Microalbumin-UJ8. Canceled
$Patient to Return::'_
PATIENT 7O.RETURN.AT A LATER DATE.
SPECIAL CHEMISTRY
Misc.Special Chemistry
HemoglobinA1cg Canceled o
Hemoglobin Ales: 8.2 x 4.5-6.1 !o
_.
9Patierit to Return`'
PATIENT'TOR E FU,RN AT A LATER:DATE.
9Patient to:Return; _.._._-
PATIENT,TO RETURN ATA LATER DATE,
Thrs document contains canfldential health information that is tegally'protectelis;information is intended only for the use of the
Individual it is addresseddo. The authorized recipient of this intofmation-is-prohibited from disclosing this information to any other
Party unless permitted to do so by contact with the health system„law,.or_regulation.'If you have received this document in error,
please cantact Client Services,at,($00}877-.4525 for instructions on returning}
BACK TO HEALTKMEDiCAL CENTER "' v
oPSUM 04/04/2008 22,22, _ _ OUB 0410412008
144418797 M-04/3011958
h; M_ CLEVELAND,AARON J
Mul -a
The i
outreach aboratory service ofJol Or Hea4th:
MUIRLAB
The Outreach Laboratory Service of john Muir Medical Center FA
. rte
.. _s
PIC
� a ��` .f� a ern all, �Y'3
- �tF,".. u��-"r'.�r ?�. %a �:v s�.":L
LABORATORY DIRECT
(925) 692-5600
Patient Name: TUCKER,'JIMMY E Requisition#: 08R06D6950
Age/Sex/DOB: 51Y; M ;04/30/1956- Client: Collected: 04/2812008 11:15
Work Phone: BACK TO HEALTH MEDICAL CE Received: 04/28/2008 15:57
Home Phone: 9256465082 1100A PLEASANT VALLEY RD Completed: 04/28/2008 17:15
Unit#: 5219473 Page: 1 of 3
Account#: 0811951553 PLEASANT HILL,CA 9452.3 Req. Cond: Not Given
Report Status: Final
RESULT NAME OUTSIDE WITHIN REFERENCE RANGE/UNITS
URINALYSIS/OCCULT.BLOODS/`MISC _ uw
Urinalysis
Urine-Random
Clarity-UA4 CLEAR
Color-UA YELLOW
Glucose-UA '300 _ _-� NEG nrl
Bilirubin-UA NEG NEG
Ketone-UA '—NEG " ' NEG mgfdL
Specific Gravity-UA "T:0T9 1.000-1.030
Blood-UA NEG
pH-UA 5.0-9.0 pH units
Protein-UA --"NEG --- NEG mg/dL
Urobilinogen-UA ~--Or2-9:0— 0.2-1.0 mg/dL
Nitrite-UA — NEC--- NEG
Leukocyte Esterase-UA ---NE-G•--•--•--- NEG
WBC's u_ c1_.____ _. 0-2 /HPF
RBC's 0-2 /HPF
Squamous Epithelial Cells 0-2,3-5 /HPF
Mucus 1itESENT ABSENT /LPF
Bacteria
._._...E�.�S.ENT - ' ABSENT /HPF
1Not Given
Xv
This document contains confidential health information that is legally-protected-This information is intended only for the use of the
Individual it is addressed to. The authorized recipient of this information-is-prohibited from disclosing this information to any other
Party unless permitted to do so by contact with the health system.law._Qr-regulation. If you have received this document in error,
please contact Client Services at(800)677-4525 for instructions on returning iL
BACK TO HEALTH.MEDICAL CENTER � M TUCKER,JIMMY E
OPSUM 04128/200822:26 OUB 0472812008
R4474506 -- -- M-04/30/1956
CLEVELAND,AARON J
MuirLab
The outreach laboratory service of John Muir Health
MUIRI.AB
The Outreach Laboratory Service of John Muir Medical Center 5044L(2/150)
121-
,.fi. ''^ � �' m°,ti;._.�_• '�..reM�''r'0 #�,.3�'s.�sxM.&.;�✓.�`.g,+iFA"'��L,e ,..�.�.�- �- X, .:r�`.0
LABORATORY DIRECT(
(925) 692-5600
Patient Name: TUCKER, JIMMY E Requisition#: 08RO606950
Age/SexID06: 51Y ; M ; 04/30/1956 Client: Collected: 04/28/2008 11:15
Work Phone: BACK TO HEALTH MEDICAL CE Received: 04/281200815:57
Home Phone: 9256465082 1100A PLEASANT VALLEY RD Completed: 04/28/2008 17:15
Unit#: 5219473 Page: 2 of 3
Account#: 0811951553 - PLEASANT HILL,CA 94523 Req. Cond: Not Given
Report Status: Final
RESULT NAME �UTSIDE WITHIN REFERENCE RANGE/UNITS
TUMOR MARKERS
Tumor Markers`
Note:As of 1/22/2007 the reference ranges on several tests in Tumor Markers.have changed. Please review results carefully.
Blood
Prostate Specific Antigen (PSA)? 0.07 0.00-4.00 ng/mL
PSA Free <0.1
ng/mL
_
% Free PSA 26.0°____.-.,_ %
% Free PSA lnterp gee No{eg
zNotGiven � _
3Performed by Beckman Coulter Immunoassay. ---- - --
Results from different methods are not.interchangeable. -----
4
PSA; FREE PERCENTAGE Interpretative Data: — - —
The Access Hybritech Free PSA method is used in
conjunction with the Access Hybritech PSA method to -- ------
determine the free PSA percentage.Values obtained -�-- -- - --with different assay methods should not be used inter-
changeably.The free PSA percentage is an aid in
distinguishing prostate cancer from benign prostate ` ____..____-.___ _
conditions in men age 50 and older witW6 total PSA
between 4 and 10 ng/mL and negative digital rectal
examination findings. Prostatic biopsy is`required for
the diagnosis of cancer.
NOTE:
Reference ranges may vary from laboratory to laboratory
even using.the same methodology,since each laboratory_____.
establishes its own reference ranges..
5 PROBABILITY OF PROSTATE.CANCER -
For Men with Non-Suspicious DRE Results
and a PSA Value Between 4 and'10 ng/mL . --
This document contains confidential healthinformation that is legatly-protectedThis information is intended only for the use of the
Individual it addressed to. The authorized recipient of this irnformation4spfohibited from disclosing this information to any other
Party unless permitted to do so by contact with the health system„law,,or--regulation. If you have received this document in error,
please contact Client Services at(800)677-4525 for instructions on returning it:_ ”
BACK TO HEALTH MEDICAL CENTER _ TUCKER,JIMMY E
OPSUM 0412812008 22:26 Y OUB 04/28/2008
R4474506 — M-04/30/1956
CLEVELAND,AARON J
The outreach laboratory service of John Muir Health
1 V 1lJ 1RLAB
The Outreach Laboratory Service of John Muir Medical Center 5044L(2/15/08)
d` ��Mil-.- l-t,^,,�i� '*ate, S^ ?f
r a s
S h.+aVa
Patient Name: TUCKER, JIMMY E Requisition#: 08R0606950
Age/Sex/DOB: 51Y ; M ; 04/30/1956 Client: Collected: 04/28/2008 11:15
Work Phone: BACK TO HEALTH MEDICAL CE Received: 04/28/200815:57
Home Phone: 9256465082 1100A PLEASANT VALLEY RD Completed: 04/28/2008 17:15
Unit#: 5219473 Page: 3 of 3
Account#: 0811951553 PLEASANT HILL,CA 94523 Req. Cond: Not Given
Report Status: Final
%FREE PSA 50-64 YRS 65-75 YRS _.._._...._..._......
0.0 to 10.0% 56% 55% _......_._._...
10.1 to 15.0% 24% 35%
15.1 to 20.0% 17% 23%
20.1 to 25.0% 10% 20%
>25.0% 5% 9%
NOTE: Percent free PSA values should not be interpreted"
as definitive evidence for the presence or absence of
prostate cancer.Prostatic biopsy is required for diagnosis
of cancer. _ ...__. .._._.,....
This document contains confidential health information that is legally-protected_This information is intended only for the use of the
Individual it is addressed to. The authorized recipient of this information is prohibited from disclosing this information to any other
Party unless permitted to do so by contact with the health system,.law,.or.regulation. If you have received this document in error,
please contact Client Services at(800)677-4525 for instructions on returning it._
BACK TO HEALTH MEDICAL CENTER TUCKER,JIMMY E
OPSUM 04/28/2008 22:26 OUB 04128/2008
R4474506 — '- -- M-04/30/1956
CLEVELAND,AARON J
The outreach laboratory service of John Muir Health
Mg
i'hc Outreach Laboratory Service of john.viuir Meciic l% e.r_e
., 1
CHRONIC PRESCRIPTION/
ONGOING MEDICATION DOCUMENTATION
ez"
T
Medication /"j V S A. U-, Condition/dx..being treated
71 Continued
elsewhere
Quant I Refills 0
Date I Initial ---X, LX\ L\Q
Medication Condition/dx being treated
'!ant/Refills Continued
elsewhere
CD
Date/Initial
Medication t k Condition/ft. being treated
Continued
elsewhere
Quant/Refills 0
Date/Initial
Medication A sA Condition/dx being treated
Continued
Quant/Refills elsewhere
O
Date/Initial
Medication �6 -1 •tr-L �- Condition/dx being treated.
C.,
Continuec
elsewhere
Quant/Refills
iDate/Initial
Medication n6-Ae-ri%-- Cond ition1dx being treated
Continue,
elsewhen
Quart/Refills
0
Date/Initial
Medication \j x 0 Ik Aj Condition/dx being treated�
Quant Relfills
I
Date[Initial
Continue
elsewhei
Quant Refills
Date Initial
AAtrtni
' U
L
z;
. . f
CHRONIC PRESCRIPTION/ i
ONGOING MEDICATION DOCUMENTATION
Medication V Q AC Condition/dx being treated
7Quant
Continued
fillselsewhere
al
Medication -qt fry A1"- Condition/dx being treated
i vv'}c<i
' Continued
Quant 1 Refills elsewhere
Date/Initial
Medication Condition/dx. being treated
��
Continued
Quant/Refills elsewhere
1 Date/Initial
Mediation ' Condition/dx being treated -
i �
- Continued
Quant/Refills elseere
Date/Initial
Medication Condition/dx being treated
•�
Continues
elsewhere
Quant/Refills
Date 1 initial
Medication Condition/dx being treated
Continue
elsewhen
Quant/Refills u
y Date/initial
Medication Condition/dx. being treated
i Continue
elsewhei
I.Quant/Refills O
Date/Initial
CL
Name: Jimmy TUCKER
FAX
CONTRA COSTA REGIONAL MEDICAL CENTER & MARTINEZ HEALTH CENTERS
MEDICAL RRCQRPO DEPARTMENT,RELEASE OF INFORMATION
ii '
2500 AL14AMBRA AVE.,MARTINEZ,CA 94553
Release of Informabo'In PHONE:9251370-5220 FAX:925/370-5275
To: Or Cleveland Date: March 18,2008
Facility: Back To Health Medical Center Number of Pages(including cover skeet): `l'Q
Phone# 925 / 2 6 7 - 8 5 5''0 From: Frank
Fax# 925/ 287 - 824-:l
Reason: Information Sent! Date(s):
❑ Payment or payment authonzaU on F] HIP
❑ Benefit determination(SDI.WC;,etc.) Op/procedure report 516/07-0,6/25/07-C)
❑ Grievance follow-up,sent to CCHP ❑ Pathology
❑ &nsenl form sent to authonize'dis&tutb 1,8j ER note-.5 52107-0,MWOB-D
❑ amol wulfal,immumimp;R am Sept n Clinic notes
❑ Other: ❑ Mental Health notes
Comments ❑ Lab
Patient has an appointment 3128/08 X-ray reports 613t07,2/19,'08
F-1 EKG,echo,stress,EEG
Per Patient's request faxing records relating to
May 07 amputation. F1 PT,OT,Speech
if additional records needed lot us knd I W. ❑ Prenatal records
❑ Problem List ❑ Medication Ust
❑ Other:
Notice:The document being faxed Is intended only for the use of the individual or entity to Which it is addressed,and
may contain information that is privileged,confidential,and redisclosure is prohibite& If the reader of this fax is not the
intended recipient,or is the employee or,agent responsible for delivering the fax to the intended recipient,you are
hereby notified that any dissemination,distribution,or copying of this communication is strictly prohibited.If you have
received this communication in error, please notify us immediately by telephone and return the original fax tc. us at the
address above via the United States Postal Service.
If you do not receive all of the pages,please contact the above sender as soon as possible.Thank you.
BERGUER,RAMON,MD a.
DICTATION: 05/06/07 175246 '
TRANSCRIPTION: 05/06/07 201413SPI
OP2RATIVS/PROC8DURB/D8LIV8RY
CONTRA COSTA HEALTH SERVICES-MR#: 6368559
CCRMC, Martinez Health Centers-NAME: Tucker,Jimmy E
2500, Alhambra Avenue, Martinez, CA 94553-DOB: 04/30/1956
OPERATIVE REPORT
DATE: 05/06/2007
SURGEON: Ramon Berguer, MD'.
ASSISTANTS:
1. Kimberley Haglund, ISD
2, Chantal Morrison, MD
m.±
PREOPERATIVE DIAGNOSIS: Extensive osteomyelitis and infection of the right fact.
POSTOPERATIVE DIAGNOSIS: Extensive osteomyelitis and infection of the right foot.
PROCEDURE DONE: Right below-knee amputation.
ANESTHESIA: Spinal.
COMPLICATIONS: None.
r ;
PROCEDURE: After placement of a central line, patient underwent spinal anesthcHia.
The right leg was prepped and draped sterilely. The leg was wrapped with Esmarch
bandage and the proximal thigh cuff placed at 300 mmHg and the point of transectir..za .,-,f
the bone was placed 8 cm below the tibial tuberosity. Posterior flaps were out:.l ned
in a fishmouth shape. Incisions were made with the cutting cautery down to the. t:ib•i.a;
which was exposed, cleared,approximately with a periosteal elevator divided 4rirl-. n.
Gigli saw. Lateral compartment was divided and vessels tied with Vicryl.. The
posterior compartment was exposed by dividing the fibula proximally with the Gi.gl:i Gaar
as well. The posterior compartment was exposed. The vessels clamped on mass and t.hfn
the gastrocnemius left on the muscle and the rest of the muscle was divided arid. th4o-
specimen delivered. The neurovascular bundle was then dissected clear and the oci.atic
nerve cut proximally. The'-vessels were multiply ligated with 0 Vicryl suture
ligatures. The cuff was led down. Bleeders were either tied or cauterized. P.1ter
appropriate hemostasis, the...posterior flap was sutured fascia-to-fascia Anterior!.;%
dividing it each half each;� ime with the 0 Vicryl sutures. Excellent oppositic:n 'wa-111
obtained. The Penrose drain was laid in the wound. The wound was thoroughly
irrigated. The skin closed*,with clips. A sugar-tong splint was placed with
appropriate padding and the procedure terminated. The patient tolerated the F�L,'�c .ci'ure
well.
COMPLICATIONS: None.
BLOOD LOSS: 400.
SPONGE COUNTS: Correct.
SPECIMEN: Right foot and lower leg.
Signed by Ramon Bergner, M..D. on 05/07/2007
Ramon Berguer, M.D.
Contra Costa Regional Medical Center (PCI: OE Database CCS)
Run: 03/18/08-09:37 by WALL ACE,FRANK Payne. l Cif ;:'.
BERGUER,RAMON,MD
DICTATION: 05/06/07 175246
TRANSCRIPTION: 05/06/07 201413SPI
OPERATIVE/PROCEDURE/DELIVERY
RS/mtG08 D: 05/06/2007 171:52:46 T: 05/06/2007 20:14:13 Job: 1718872 / 1672Fi9
a ;
a
BERGUER,RAMON,MD
DICTATION: 05/06/07 175246.''.
TRANSCRIPTION: 05/06/07 201413SPI
OPERATIVE/PROCEDURE/DELIVERY
Contra Costa Regional Medical Center (PCI: OE Database CCS)
Run: 03/18/08-09:37 by WALLACE,FRANK Palle 2 of 1
r4
l ;
s $
PATCOM # MR#: M006368559
NAME; TUCKER,JIMMY
SPECIALTY CLINIC NOTE DDB: 04/30/56 SEA-: M
PCp:
PCS:
CONTRA COSTA HEALTH SERVICES-MR#: 6368559
CCRMC, Martinez Health Centers-NAME: Tucker,Jimmy E
2500, Alhambra Avenue, Martinez, CA 94553-DOB: 04/30/1956
SPECIALTY NOTE
DATE: 05/17/2007
This patient is here, followup from right below-knee amputation. He .is complaa.ni:ng of.
significant back pain after the surgery which he did not have before, lie hav .hidi_.o
drive himself. He is doing his best to keep the leg clean.
EXAMINATION: The leg is significantly swollen. The staples are inr_act. The ?
lateral margins are open and granulating where the drain was. There is slight wo,:ru'
dehiscence in the middle which is probed only about 0. 5 cm deep. No drainage, no
cellulitis.
IMPRESSION: Patient doing reasonably well with swollen leg which will be somewhaz:
difficult to heal.
PLAN:
1. Local care to the leg. '
2. Percocet 60 tablets.
3. Lumbar spine x-rays and followup in 1 week. He has an appointment to see. li=.
Denise Tai next Monday.
Signed by Ramon Berguer, M.D. on 05/23/2007
Ramon Berguer, M.D.
RS/mtH37 D: 05/17/2007 17:12:29 T: 05/17/2007 23:23:36 Job: 1736477 / 1710153
BERGUER,RAMON,MD
DICTATION: 05/17/07 171229
TRANSCRIPTION: 05/17/07 232336SPI
SFZCIALTY CL C NOTE
Contra Costa Regional Medical Center (PCI: of Database CCS)
Run: 03/18/00-09:37 by WALLACE, FRANK Page t. c,� ].
PATCOM # MR#: M006366559
NAME: TUCRER,J.IWIY E
SPECIALTY CLINIC NOTE DOB: 04/30/56 C;f;*), NI,
PCP:
PCs:
CONTRA COSTA HEALTH SERVICES-MR#: 6368559
CCRMC, Martinez Health Centers-NAME: Tucker,Jimmy E
2500, Alhambra Avenue, Martinez, CA 94553-DoH: 04/30/1956
SPECIALTY NOTE
DATE: 05/24/2007
This patient is here, followup from amputation. He is essentially homeless, living
mostly in his car, using some friends' homes to take a shower.
EXAMINATION: The right leg is substantially more swollen than before with the stump
very edematous and the skin pulling apart in the middle. He has a 1 x 3-cm sligt,r:i.r
fibrinous open wound. It is probed with a slight lip above it but without an;• *aeep
penetration or pus draining.
IMPRESSION: Significant edema of the leg with severe social problems, lack.. of: income.
and disability.
PLAN:
1. Continue local wound care.
2. Lasix 10 mg daily for 3 days.
3. I have contacted social work today to assist with obtaining some; income or
disability status for this patient.
4. Follow up in 1 week.
Signed by Ramon Berguer, M.D. on 05/30/2007
Ramon Berguer, M.D.
RB/mt171 D: 05/24/2007 i8:34;22 T: 05/25/2007 01:58:32 Job: 1146796 / 1�3•t.>o
BERGUER,RAMON,MD
DICTATION: 05/24/07 183422 ,
TRANSCRIPTION: 05/25/07 Oi5832SPI
SPECIALTY CLINIC NOTE
Contra Costa Regional Medical Center (PCI: OE Database CCS)
Run: 03/18/08-09:37 by WALLACE,FRANA Page .J ., ..
PATCOM # MR#: M006368559
NAME: TUCKER,JIWA4Y E
EMERGENCY DEPARTMENT NOTE DOB: 04/30/56 SEX: M
PCP:
PCS:
CONTRA COSTA HEALTH SERVICES-MR#: 6368559
CCRMC, Martinez Health Centers-NAME: Tucker,Jimmy E
2500, Alhambra Avenue, Martinez, CA 94553-DOB: 04/30/1956
EMERGENCY DEPARTMENT REPORT
DATE: 06/02/2007
CHIEF COMPLAINT: "My wound is open. ,,
HISTORY OF PRESENT ILLNESS'r' The patient is a 51-year-old man who is status post right
BKA with extensive osteomyelitis on 05/06/2007, had been doing well, last seen by Dr .
Berger in the surgery clinic for followup 2 days ago who states he fell at parking lot:
today on to his right leg.'" States when he fell on it, his wound opened up last
evening. States that the bandage on it has been not really located today and C.,iie .lire
was draining and it was wide open. He denies any fevers.
PAST MEDICAL HISTORY:
1. Type 2 diabetes
2. Hypertension.
PHYSICAL EXAM:
VITAL SIGNS: Temperature 99.6, respirations 18, pulse 107, blood pressure 101/11,
pulse ox 96 percent on room air.
GENERAL: In general, this is a well-developed, well-nourished man, mild distress.
CHEST: Clear to auscultation.
HEART_ Regular rate and rhythm without murmur, gallop, or rub.
EXTREMITY: The right lower,:extremity, the BKA is completely dehisced, .Large
fish-mouthed wound. Good granulation tissue at the wound edges. The is some
serosanguineous fluid noted. No purulent fluid noted. No active bleeding. There is
no bone seen, but the muscle fascial layers are seen.
This case was discussed with Dr. Christiana Weng and the decision was3 made t.a admi= -c,
the hospital for dressing, :wound care, pain control.
ASSESSMENT: Wound dehiscence, right below-knee amputation,
DISPOSITION: Admit to surgery service.
Signed by Gerard Bland, M.D. on 07/10/2007
Gerard Bland, M.D.
GB/mtD23 D: 06/02/2007 16:"55:02 T: 06/02/2007 17:58:44 Job: 1759339 / 17fi1S7:
BLAND,GERARD,MD
DICTATION: 06/02/07 165502
TRANSCRIPTION: 06/02/07 17584SPI
EKERGENCY DEPT NOTE
Contra Costa Regional Medical Center (PCI: OE Database CCS)
Run: 03/lB/08-09:37 by WALLACE,FRANK Paye "` -
BERGUER,RAMON,MD
DICTATION: 06/25/07 144945
TRANSCRIPTION: 06/25/07 i83617SPI
OPERATIVE/PROCEDORB/DELIVERY
CONTRA COSTA HEALTH SERVICES-MR#: 6368559
CCRMC, Martinez Health Centers-NAME: Tucker,Jimmy E
2500, Alhambra Avenue, Martinez, CA 94553-DOB: 04/30/1956
OPERATIVE REPORT
DATE: 06/25/2007
SURGEON: Ramon Berguer, MD
ASSISTANTS: Dr. Raphael
PREOP DIAGNOSIS: Right beiow-knee amputation with open wound.
POSTOP DIAGNOSIS: Right below-knee amputation with open wound.
PROCEDURE: Revision by below-knee amputation.
ANESTHESIA: General.
COMPLICATIONS: None.
FINDINGS: Significant fibrous avascular tissue on the granulation.
PROCEDURE: After induction of general anesthesia, the right leg was prepped and
draped sterilely. Essentially all the granulation tissue and some underlying muscl!..
were removed with the small remnant skin in both half of the fish mouth.
was obtained and after irrigating the wound, the amputation was reclosed with
interrupted 0 Vicryl sutures around the edge and a 0.25-inch Penrose inside. Sterile
dressing was applied. The patients procedure terminated. Blood logs 20 mL.
counts correct.
SPECIMEN: Granulation fibrous tissue.
COMPLICATIONS: None.
Signed by Ramon Berguer, M.D. on 06/27/2007
Ramon Berguer, M.D.
RB/mtC29 D: 06/25/2007 14:49:45 T: 06/25/2007 18:36:17 Job: 1.792290 / 103350
BERGUER,RAMON,MD
DICTATION: 06/25/07 144945 ;
TRANSCRIPTION: 06/25/07 1836175PI
OPERATIVE/PROCEDURE/DELIVERY
Contra costa Regional Medical Center (PCI: OE Database CCS)
Run: 03/18/08-09:37 by WALLACE,FRANK F+ gee 1 ai:
PATCOM # MR#: M006368559
NAME: 'SUCKER,JIMMY F.
DISCHARGE/TRANSFER SUMMARY Don! 04/30/56 SEX: N;
PCP:
PCS:
CONTRA COSTA HEALTH SERVICES-MRU: 6368559
CCRMC, Martinez Health Centers-NAME: Tucker,Jimmy E
2500, Alhambra Avenue, Martinez, CA 94553-DOH: 04/30/1956
DISCHARGE SUMMARY
ADMITTED: 05/05/2007
DISCHARGED: 05/12/2007
ATTENDING STAFF: Ramon Berguer, MD
CHIEF COMPLAINT. Right foot pain.
PRINCIPAL DISCHARGE DIAGNOSIS: Right foot osteomyelitis/abscess.
OTHER DIAGNOSES:
1. Diabetes.
2. Hypertension.
3. Tobacco use.
4 . Depression,
PROCEDURES PERFORMED:
1. Right BKA.
2. Cheat x-ray.
3 . Right foot x-ray.
4. Right subclavian line.'.'
HOSPITAL COURSE: Briefly, ,this is a 51-year-old male with a history of.poorly
controlled hypertension and Alec with a history of hyperlipidemia,
obstructive sleep apnea, and a history of a right great toe: ray amputation in 08/141005
for gangrene and treated for diabetic foot ulcer, 06/2006, who presents on 05/05i.'L00?
complaining of worsening right foot redness and swelling. The patient was seen. :
weeks prior for a possible'.foot infection, was diagnosed with osteomyelitis by x-ray,
and although the emergency."room physician recommended admission, the patient refused
and was sent home with p.o: Cipro. He states his foot has been uninfected for "
years, " and it is unclear as to how long he has had fevers. He denies any orthopne ,
PND, or chest pain. He says his right lower extremity is chronically more swol.l[p::
than his left.
PHYSICAL EXAM:
VITAL SIGNS: On initial exam, the patient was noted to have a temperature of 101..8,
blood pressure 139/84, pulse of 113, respirations of 20, ratting 97 pE?rce:nt on rolm
air.
GENERAL: He was sleeping, mildly difficult to awaken. Questions had to be repe<ate:?
approximately 2 to 3 times. Although when awake, he was appropriately respon3ir,a.
HEENT: Revealed moist mucous membranes.
NECK: Showed no evidence of cervical lymphadenopathy. I was unable to assess J0
secondary to body habitus.
HEART: Regular rate and rhythm.
LUNGS Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, 'nondistended with good bowel sounds throughout.
EXTREMITIES Showed right lower extremity gFeater than 'left lower extremity edema,
right ankle erythema, shallow ulcer about;;8 x 3 .cm of the right great toe stump wir.:r:
foul-smelling exudate, wound was probed, no evidence of tracking, bilat-eral. .lowr,:
extremities with venous stasis changes, a brawny discoloration.
Contra Costa Regional Medical Center (PCI: of Database CCS)
Run: 03/18/08-09:37 by WALLACE,FRANK Page l c:F.
PATCOM # MRO.:? M006368559
NAM$: TUCKER,JIMNL'
DISCHARGE/TRANSFER SUMMARY,, DOB: 04/30/56 SE.K: M
PCP:
PCs:
LABORATORY EXAMINATION: The patient revealed an x-ray from 04/26 revealing
osteomyelitis of the 2nd and 3rd metatarsals as well as the 3rd toe. White blood ,�cjl
count of 12.3, hemoglobin 12.7, platelets of 528. Basic panel revealed sodium of 111.
potassium of 3. 9, chloride .of 92, bicarb of 30, BUN of 8, creatinine of, 0.6, gluccae:
422, CK of 61, CRP of 32, .1actate of 2.0.
Given the patient's right foot osteomyelitis,,.-he was admitted to the surgery eerv.r•e
and begun on vancomycin as''well as Fortaz with the plan for amputar.i.on the next day.
1. Right foot infection. ^ Given the patient's right foot osteomyelitis, the pla:r wa:)
to go to the operating room;. He subsequently received a right below-the-knee
amputation on 05/06/2007. Please see dictation done by Dr. Serguer for further
details of this procedure. ' The patient was Continued on Zosyn as well as vancomycin
and progressed well over his postop course. He was begun on physical therapy and wa.s
able to ambulate well with-a walker. On 05/12/2007, the patient expressed de:si.ce tc,
leave the hospital. He had remained afebrile. He was able to ambulate with his
walker and to do his ADLs. ' A long discussion with the patient was held to make sarc-
that he can understand that it was very important to watch the wound closely t:c
evaluate for any ongoing infection. Patient agreed to close followup and to return t0
the emergency room if there'were any further signs of worsening discharge, redness;,
pain, or swelling, or fever: The patient was then discharged home with oral
antibiotics for continued management of his infection. He was sent home with
Augmentin 500 mg p.o. 3 times a day x7 days.
2. Diabetes. The patient's diabetes is very poorly controlled. His last hemogl.ol..)i'rt
Alc from 05/08/2007 was 14':` 2 which is the highest that it has ever been. Hee staU-s
that he had run out of his ;diabetes medications for quite a while and does riot La.Ve
any medications at this time due to his lost insurance. He was begun on Lantus duriw•g
his hospital course and went up to approximately Lantus 70 units subcutaneous night.1v.
He was also begun on metformin 500 mg p.o. twice a day. His sugars went. from 30() to
approximately 100 to 150. on discharge, ,he will be sent home with Lantus 60 unit,
subcutaneous nightly as well as metformin lope mg p.o. q.a.m. and 500 mg p.o. q.p.m.
and will need close followup with his primary care provider for continuer) management
of this issue.
3. Cardiovascular. The patient has history of hypertension. He has not been o;.a
medications for•.a month, he,;states. However, his blood pressure has remained stable
during his hospital courser He was continued on his lisinopril 20 mg p.o. daily giv<-n
his history of diabetes and ,was sent home with lisinopril 20 mg p.o. daily.
4. Tobacco use. I encouraged the patient to stop smoking. The patient is an
agreement although is unsure as to whether or not he will stop smoking. He was be„um
on Wellbutrin for a dual purpose given that he is a smoker and in addition he, dog:-
exhibit signs of depression. He was begun on Wellbutrin SR 150 mg p.o. daily. a�
will continue to encourage smoking cessation, and he will likely need nicotine pa r.rti:ces
as well as nicotine cessation classes.
5. GU. The patient had a 'significant amount of a white creamy diecharge in the. 4roln
and penile area at this time. After swabbing the area, the culture came back poai.t;ive
for candidal infection. He was begun on miconazole cream to the peni,:; twice a day.
He will also be sent home with Diflucan 150 mg p.o. daily x7 days. He was instr,:cted
to keep the area very clean .and must shower daily. We will continue to monitoi 1:+
6. Depression. Patient has been significantly depressed during his hospital. cci:rse
Contra costa Regional Medical Center (PCI: OE Database CCS)
Run: 03/18/08-09:37 by WALLACE,FRANx Page of i
PATCOM # MR#: M006368559
NAME, TUCKER,JIMMY E
DISCHARGE/TRANSFER SUMMARY DOH: 04/30/56 Sf:i:: M
PCP:
PCS:
regarding his living situation and also health situation. I discussed the possibility
of antidepressants with the patient which he was agreeable to. )ie was begun an
Wellbutrin SR 150 mg p.o.. daily.
CONDITION ON DISCHARGE: :"Stable.
DISPOSITION: Home. '
ie
INSTRUCTIONS TO PATIENT: :.
1. He is to continue outpatient therapy_
2. He is to use an assistive device.
3. He is not to have any concentrated sweets. He is to continue a cardiac diec..
4. He is to keep hie wound clean and dry and to pack with gauze daily.
5. He is to wear splint,,and Ace wrap and return for any fever or. drainage or
worsening pain or redness in his wound.
6. He is to check his blood sugars 2 times a=day.
FOLLOWDP APPOINTMENTS:
1. Follow up with Dr. Tai in family practice clinic in Martinez in 1. to 2 wee.ku.
2. Follow up with Dr. Berguer in Martinez Surgery Clinic, Thursday, 05/17/2007 . Htc
is also to obtain a CBC the day of his appointment with Dr. Berguer.
DISCHARGE MEDICATIONS:
1. Lisinopril 20 mg p.o. daily.
2. Metformin 1000 mg p.o:; q.a.m. and 500 mg p.o. q.p.m.
3. Lantus insulin 60 units subcutaneous nightly.
4. Wellbutrin SR 150 mg p.o. daily.
5. Miconazole cream to his penis apply twice a day.
6. Diflucan 150 mg p.o. daily x7 days.
7. Augmentin 500 mg p.o. ;3 times a day x7 days.
8. Percocet 5/325 one to ,two tablets 4 times a day p.r.n. , number 60.
9. DSS 250 mg p.o. daily.
10. Multivitamins 1 tablet p.o. daily.
Signed by Denise Tai, M.D. on 06/29/2007
Denise Tai, M.D.
Signed by Ramon Berguer, M.D. on 07/11/200'7
Ramon Berguer, M.D.
DT/mt516 D: 06/27/2007'. 21:19t09 T: 06/28/2007 12:36:37 Jab: 1797006 1 ze-viee
BERGUER,RAMON,MD
DICTATION: 06/27/07 211909
TRANSCRIPTION: 06/28/07 12393SPI
DISCHARGE/TRANSFER SUMMARY
; i
Contra Costa Regional Medical Center (PCI: of Database CCs)
Run: 03/18/08-09:37 by WALLACE,MANX Page 3 of. 3
BERGUER,RAMON,MD
DICTATION: 06/21/07 205521
TRANSCRIPTION: 06/28/07 19252SPI
OFF SERVICE PROGREBB NOTE
CONTRA COSTA HEALTH SERVICES-MR#. 6368559
CCRMC, Martinez Health Centers-NAME: Tucker,Jimmy E
2500, Alhambra Avenue, Martinez, CA 94553-DOB: 04/30/1956
OFF SERVICE PROGRESS NOTE:',,
DATE: 06/27/2007
DATE OF ADMIT: 06/02/2007: :
ATTENDING PHYSICIAN: Ramon Berguer, MD
PMD: Denise Tai, MD
BRIEF HISTORY: This is a -51-year-old male with a history of diabetes mellitus type 2
which is poorly control led"status post a right BRA on 05/06/2007 by Lr. Berguer fc.:r
extensive osteomyelitis of the right foot and leg, who presented after falling and
causing dehiscence of his dight BKA stump when he was using his wa1)ter. Patient:
additionally has a history'''of significant methamphetamine and tobacco use as welt, a
depression. He was admitted for wound dehiscence with a question of superin.'.r:c:ti :.
He was admitted to surgical service for further evaluation.
HOSPITAL COURSE BY PROBLEM LIST:
1. Superinfection. The patient initially had a mild leukocytosi3 with low•gr,adr
fevers, and his would culture grew back pseudomonas and MRSA. Although initiall;r
started on Cipro with Ancef; he was switched to vancomycin and Ceptat for pseudamcnal
and MRSA coverage. These were continued for a total of 10 days and have since been
discontinued. The patient has remained afebrile with stable vital signs withoaC alk
significant leukocytosis throughout his hospital course.
2. Wound dehiscence: The;%sound was initially treated with wet-to-dry dressing
changes, was subsequently switched over to vacuum dressing changes. There was .s home
that the vacuum dressing would shrink the posterior flap which was quite boggy a. �j
would enable a secondary closure. Good granulation tissue was forming, but t1 .0 n,au
only increasing the size ofwthe flap. So, on 06/25, the patient was taken back t;_: the
operating room for revision of below-the-knee amputation by Dr. Berguer and
Dr. Raphael. The amputation was reclosed at this time with significant granulatic'n
fibrous tissue discovered. At this time, the patient's wound has been put back tt: i
vacuum dressing, although it is near totally closed in the hopes to sap some of t?.ie
significant serous discharge.
On the day of this dictation, the wound was visualized to have some amount of puru.lerr.
drainage which, on Gram stain, is growing out gram-positive cocci. we will be
restarting the patient on vancomycin and ceftazidime with the hopes of stopping
is most likely a recurrenceof MRSA and/or,pseudomonal infection, considerations
stop these in the near future pending wound culture, identification and specif.ici,ti .
3. Diabetes mellitus type•2: The patient initially had a fairly prior control of his
diabetes with a hemoglobin Alc of 14.2 on 05/08/2007. He had been an Lantus ::0 :ic:it.e
subcutaneously q.a.m. He was subsequently started on glyburide 10 twice a dray a �n-1;
as metformin 500 twice a day, and we were able to titrate down his Lantus to 40 ur.ii:s
daily. He has had blood sugars which have been ranging actually low in the t;L`,:, r_c
loos, and thus we have at this time discontinued his glyburide. Conziderat:ion L.c
decrease his Lantus and increase his glyburide should be considered.
DISPOSITION: The patient is currently stable bpt is currently utilizing wound vacuum.
It is our hope that should the wound appear...to be well healing, wound. vacuum 1',ar. he
discontinued and the patient should be able to be discharged home. At this time, he
Contra Costa Regional Medical Center (PCI: of Database CCS)
Run: 03/18/08-09:37 by wALLACE,FRANK Pages i of 2
BERGUER,RAMON,MD
DICTATION: 06/27/07 205521' "
TRANSCRIPTION: 06/28/07 19252SPI
OYF SERVICE PROGRESS NOTE
is homeless and will require some aid from a social worker in term: of finding him an
adequate living situation- '
MEDS ON DAY OF TRANSFER: Heparin 5000 units subcutaneously twice a day; Lantus
40 units subcutaneously daily; lisinopril 20 mg daily; metformin 500 mg p.c. q.a.n -
500 q.p.m. ; iron 325 mg daily, sliding scale insulin; multivitamin and zinc.
Signed by Justin Chatten-Brown, M.D. on 07/09/2007
Justin Chatten-Brown, M.D.
Signed by Ramon Berguer, M.D. on 07/11/2007
Ramon Serguer, M.D.
JC/mt826 D: 06/27/2007 20:55:21 T: 06/28/2007 19:25:27 Job: 1796993 / 18438.1
BERGUER,RAMON,MD
DICTATION: 06/27/07 205521
TRANSCRIPTION: 06/28/07 19252SPI
OFP SERVICS PROGRESS NOTE
Contra Costa Regional Medical Center (PCI: O£ Database CCS)
Run: 03/18/08-09:37 by WALLACE,FRANK Page c:;Y :'
PATCOM # mR#: M006368559
NAMF: TUCKER,JIMMY E:
DISCHARGE/TRANSFER SUMMARY DOB: 04/30/56 SkA- ^,
PCP:
PCS:
CONTRA COSTA HEALTH SERVICES-MR#; 6368559
CCRMC, Martinez Health Centers-NAME: Tucker,Jimmy E
2500, Alhambra Avenue, Martinez, CA 94553-DOB: 04/30/1956
DISCHARGE SUMMARY F;
ADMITTED: 06/02/2007
DISCHARGED: 07/04/2007
ATTENDING MD: Ramon Berguer, MD
DISCHARGE DIAGNOSIS: Right below-knee amputation wound dehiscence.
OTHER DIAGNOSES:
1. Superficial surgical'site infection.
2. Type 2 diabetes.
3 . History of hypertension.
4 . Current smoker.
5. Depression,
6, Remote history of methamphetamine abuse.
PROCEDURES PERFORMED: IV` antibiotics, labs, revision of right below-knee amputation,
wound vacuum dressings, wound cultures.
HOSPITAL COURSE AND TREATMENT: This is a 51-year-old man who underwent. a right r-FA i.ri
early May of this year. He was sent home postoperatively and doing fairly well when
he fell and had the woun& reopen. He presented to the emergency room with z widely
open right BKA wound with healthy pink granulation tissue draining serosangu:lncou;a
fluid, no purulence, but with an elevated white count. The wound culture ther, gvew
out pseudomonas and MRSA, ..and he was put on vancomycin, Ancef and Cipro. The w*und
was dressed with Silvadene initially and subsequently it was treated with a wounc :ac.
When the wound was granulating well., he was taken back to the operating orl 6c;/2" for
revision of the wound and secondary closure. On postoperative day 2, purulent.
drainage began from the wound. The wound was recultured, and the wound was
subsequently opened up and, found to have 2 pockets of pus. An area about 6-cm i ).:g
on the lateral end of the wound and about a 3-cm area on the medial corner of the
wound were opened and drained. He was started on ceftaz and vanco, and suhsequenL
cultures came back positive for MRSA and pseudomonas. The pseudomonas was sensitive
to cipro and to gentamicin', and so the ceftaz was changed to cipro and gent . Ke was
continued on vancomycin. The open areas of the wound were packed with damp y-xuii., and
the erythema and edema and tenderness of the stump rapidly improved, By day of
discharge, his white count had normalized. He was afebrile. He was able t.o dci
dressing changes himself, and the bases of the 2 open areas showed beefy red
granulation tissue with no purulent drainage and no odor and with soft skin margin .
In other problems, his diabetes was well controlled by the time of discharge- on a see; e
of Lantus SO units subcutaneous nightly. He had previously been on 40 units a'.He was was also on metformin 1000 mg p.o. twice a day and his sugars were in the 76 tc 1.10
range on the day prior to discharge,
other problems: Cardiovascular. Patient has a history of hypertension bu% ,nnz:
currently on any medicines and despite that, his blood pressures were in the low
normal range. He is asymptomatic and had no episodes of chest pain this admii>tl .ors,
and he is on an aspirin for prophylaxis. An EKG done 2 days prior to disch.a.r?je snrl;+ea:
no change versus the previous EKG done in May. He is a current smoker and was
counseled to quit smoking but he is not currently interested in nicotine patr.:a
Contra Costa Regional Medical Center (PCI: OE Database CCS)
Run: 03/18/08-09138 by WALLACE,PPANK Pagtt. 1 of 2
PATCOM # MR#: M006368559
NAME: TUCKER,JIMMT E.
DISCHARGE/TRANSFER SUMMARY DOB: 04%30/56 SL''X: M
PCF',
PCB:
Depression: Patient was evaluated by the psychiatrist Dr, Echols, and he was started
on Wellbutrin SR 150 mg p.o. twice a day and with this, he seems to be doing sotm_�what
better. He is more optimistic about the possibility of getting medical coverage eccid
disability, and he is looking forward to going home.
.11
DISCHARGE MEDICATIONS: The patient is to resume his home medication of metfo rm:i;l. qe
was previously on 3.000 mg'in the morning and 500 in the evening, but we: have inr„„i eased
the dose to 1000 twice a`day. He is also to resume his Lantus insulin. Previ.ou:: dose
at home appears to be 40 but we have increased it to 50 units daily. He is also to
resume his iron sulfate 325 mg p.o. daily and DSS 250 mg 1 p.o. twice a day whit= on
narcotic pain medicines. - .
He is to stop his previous home medicines of lisinopril and Norco, and new medrear.lone
we will be adding are EC aspirin 81 mg p.o, daily, Wellbutrin SR 150 mg p.o. !:.wic:e a
day, ciprofloxacin 500 mg p.o. twice a day for the next 5 days, Septra Double St:-ength
1 P.o. twice a day for the next 5 days, Vicodin 1 p.o. q.6 h. p.r.n. break t.hroLla”'
pain, and morphine sustained release 30 mg p.o. every 8:00 a.m. and 11:00 p.m.
CONDITION ON DISCHARGE: Improved.
DISPOSITION: To home.
He is to follow a diabetic 2400-calorie diet and to pack his wounds twice a day with
damp gauze and return to the emergency room for fever, pus draining from the wotu d:s,
changes in his skin or out-of-control blood sugars.
FOLLOWUP: Will be in surgery clinic with Dr. Berguer in Martinez in 1 week and In
family practice clinic with Dr. Tai in 1 week.
Signed by Kimberley Haglund, M.D. on 07/06/2007
Kimberley Haglund, M.D. !�
KH/mtF68 D: 07/04/2007 12:54:37 T: 07/04/2007 13:41:24 Job: 1805480 / 18538:'
HAGLUND,KIMBERLEY,MD
DICTATION: 07/04/07 125437:
TRANSCRIPTION: 07/04/07 13412SPI
DISCHARGE/TRANSFER SUMMARY
Contra Costa Regional Medical Center (PCI: OE Database CCS)
Run: 03/1B/08-09:38 by WALLACE,FRANK
PATCOM # MR#: M006368559
NAME: TUCKER,J;C'MMY E .
SPECIALTY CLINIC NOTE DOB: 04/30/56 SE'S::
PCP:
PCS:
CONTRA COSTA HEALTH SERVICES-MR#: 6368559
CCRMC, Martinez Health Center-NAME: Tucker,Jimmy E
2500, Alhambra Avenue, Martinez, CA 94553-DOB: 04/30/1956
SPECIALTY NOTE
DATE: 08/09/2007
This patient is here, followup from right below-knee amputation. Patient is li:vitlu 6a
a friend's garage with limited access to bathrooms and, as he states, no disabi.li::y
income. He does continue '.to smoke, although he has cut back.
EXAMINATION: The right stump is healed in the lateralmost portions, has about. 2 x 6
CM open, granulating and partially fibrinous wound in the center. The posterior EJAT,
has some venous engorgement but is intact and in place.
IMPRESSION: This patient, is struggling financially and socially. I placed a Call. t!.
Juan Sosa at (650) 378-78bl to try to assist this patient with his disabilit
should be complete.
PLAN:
1. Continue local care. "
2. We supplied him, given him some more Norco.
3 . Follow him after 4 weeks.
Signed by Ramon Berguer, ,M.D. on 08/15/2007
Ramon Berguer, M.D.
RB/mt008 D: 08/09/2007 "18:13:11 T: 08/09/2007 22:42:10 Job: 1858380 / 1.989`. 7
BERGUER,RAMON,MD
DICTATION: 08/09/07 181311
TRANSCRIPTION: 08/09/07 224210SPI
SPECIALTY CLINIC NOTE
Contra Costa Regional MEdical Center (PCI: OE Database CCS)
Run: 03/18/08-09:38 by WALLACE,FRANK FaCii a t '!
PATCOM # MR#: M006368559
NAME: TUCKER,JIMM'tc
EMERGENCY DEPARTMENT NOTE :, DOS: 04/30/56 SY:C: Ff
PCP:
PCS:
CONTRA COSTA HEALTH SERVICES-MR#: 6368559
CCRMC, Martinez Health Center-NAME: Tucker,Jimmy E
2500, Alhambra Avenue, Martinez, CA 94553-DOB: 04/30/1956
EMERGENCY DEPARTMENT REPORT
DATE: 02/19/2008
Patient is a 51-year-old who presents to the emergency department with complain- C._'.
motor vehicle accident. Apparently, he was in a bus. Patient is stratus post
amputation of the right lower leg. He states he was in his wheelchair, the bus
stopped suddenly, he was jogged forward, he struck his stump. He complains of ,:mc.
right lateral neck pain. ;He complains of some pain to the stump. He had no wou,:,ii
dehiscence. Patient has a, history of previous complicated healing to the stump sta.t.t,s
post amputation. The patient denies any chest pain or shortness of breath. l-'at.i-nt
initially complained of some abdominal pain, but denies this. Denies any hem&tur;.a.
Denies any shortness of breath.
On review, all other systems are negative, noncontributory, nonpe.rtinent.
PAST MEDICAL HISTORY: As above, status post below-Che-knee amputation in the
SOCIAL HISTORY: Unremarkable.
PHYSICAL EXAM:
VITAL SIGNS: Blood pressure 146/98 with a heart rate of 92, respiratory rare at la,
temperature 98.3, saturation of 99 percent.
HEENT: Patient is normocephalic without sign of cranial trauma.
BACK: Patient has right lateral paraspinal muscle tenderness. No midline ce vi.c:a.l
spine tenderness. Patient's thoracic and lumbar spine nontender.
CHEST: Equal breath sounds bilaterally. Right lateral cheat no+,gender. Left
chest nontender.
ABDOMEN: Soft with no guarding, rebound, or rigidity.
EXTREMITIES: The patient is status post amputation of the right lower leg, is
no evidence of wound dehiTscence. There is no evidence of ecchymosis and/or bleedinc+.
There is no evidence of any foreign body.
At this point, patient has an x-ray of the knee, which reveals no sign of siani.f:c«nt
fracture. The patient has cervical spine, which reveals DJD
IMPRESSION AT THIS POINT: Motor vehicle accident, cervical strain, and stump
contusion_
PLAN:
1. Vicodin p.r.n. pain.
2. To fallow up with family physician.
3. To return if worse at, anytime for any problems.
Signed by William J. Peterson, M.D. on o2/29/2008
William J. Peterson, M.D. ,
Contra Costa Regional Medical Center (PCI: OE Database CCS)
Run: 03/18/08-09:38 by WALLACE,FRANK 1--age .L ^: 2
PATCOM # MR#: M00G368555-
NAME: TUCKER,JIMMY r
EMERGENCY DEPARTMENT NOTE DOH: 04/30/56 SEX': H
PCP:
PCS:
WJP/MtH72 D: 02/19/2008 ,22:19:38 T: 02/19/2008 22:36:44 ,lob: 2145038 / 2r610;
3
r
PETERSON,WILLIAM J. ,MD
DICTATION: 02/19/08 221938
TRANSCRIPTION: 02/19/08 21364SPI
MWGWCY DEPT ROTE
.a
Contra Costa Regional Medical Center (PCI: OE Database CCS)
Run: 03/18/08-09:38 by WALLACE,FRANK c;'-' 2
...... -- -..., r.to
CONTRA COSTA HEALTH SERVISCES MR#: M006368559
CONTRA COSTA REGIONAL MEDICAL CENTER Name: TUCKER,JIMMY E
CONTRA COSTA HEALTH CENTERS Ph #: (510)245-2722
DOH: 04/30/56 Sea: Pi
DIAGNOSTIC IMAGING DEPARTMENT Lac: 4-A
Acct# M011412210
RADIOLOGY REPORT PCP:
PCS: MART
Ordering MD: CHATTEN-BROWN,JUSTIN,MD
Order Date: 06/03/07
Order Time: OB00
SERVICE DATE- 6/03/07
SERVICE TIME: 0800
RIGHT STTWa
HISTORY: Evaluate for osteomyelitis.
FINDINGS:
A radiograph of the right,stump is performed. The surgical margins are intact. COrti.zal
bone is intact. No osteomyelitis is seen.
CONCLUSION: No osteomyelitis involves the stump.
PETER W. .WON, M.D.
WONP CAN
Dictated : 06/03/07
Transcribed : 06/05/07 0903 RADIOLOGY
«signature oa Pile»
Contra Costa Regional Medical Center (PCI: OE Database CCS)
Run: 03/18/08-09:39 by WALLACE,FRANK nue i of 7.
1 1J
CONTRA COSTA HEALTH SERVICES MR#: M006368559
CONTRA COSTA REGIONAL MEDICAL CENTER Name: TUCKER,JIMMY E
CONTRA COSTA HEALTH CENTERS Ph #: (530)245-•2722
DOB: 04/30/56 Se>: 11
DIAGNOSTIC IXRGING DBPARTMBNT Loc: 3-B
Acct# M076746411
RADIOLOGY REPORT PCP: TAIJ)ENICE K,MD
PCS: MART
Ordering MD: PETERSON,WILLIAM J. ,MD
Order Date: 02/19/08
Order Time:
SERVICE DATE- 2/19/02
SERVICE TIME: 1740
RIGHT RNER. Two VI$WS-
HISTORY: MVA.
FINDINGS:
A healed below knee amputation is seen without evidence of acute process. Minor patchy
deossification is present as expected. Small healed bone fragments are seen in the :oft
tissue stump. No fracture or dislocation is present.
IMPRESSION: 'Right below knee amputation, otherwise negative study.
ERIC 7'SAO, M.D.
TSAE t CAN -
Dictated : 02/20/08
Transcribed : 02/20/08 1333 RADIOLOGY
4<9ignature on P13e�}
Contra Costa Regional Medical Center (PCI: OE Database CCS)
Run: 03/16/08-09t40 by WALLACE,FRANK
TOTAL P.19
SOAP Note Back To Health Medical Center I Llstinlis X-ray Results
7 C-Spine DJD
Patient Name: A e/� ;1 i,,. • L Telephone N °' GY L' �''� �' T-spine DJD
Age:, Sex: ate of Birth L-Spine DJD
Additional Notes
Chief Complaint e' Primary: Secondary:
Cause: DOI
Treating Doctor:
I Findings: _ - r Plan: Progress Affected b : Treated Region/Subjective Complaints:
Date: 'k Phys-Exercise Work TMJ/ Elbow:R/L Wrist R/L
enderness %'---- t(/��J. Neuro,Re-ED Complicating Illness OCC/ Knee:R/L Ankle:R/L
ammation Myofascial Release Daily Activity C 1 2 3 4 6
J j'j�t r � rt xr� tri.-' Cold laser treatment No Change T� 8 9 10 1112
✓'" g t. Ultrasound:C/T/L Some Improvement Lam' S Rib:Ant/Post
El
N Aomng 1 ilk j `4,y ect Stint 45PF/L Exacerbated S/L R/L Hip:R/L Shoulder:R/L
Visit: IROM(C/f/L) , (; / ', = Manual/Mech TXN Regressed Pain Scale:
n MM-weakness , .l?. 1-�' a Therapeutic Exercise Stabilizing Normal 0 1 2 3 4 5 6 7 8 9 10 Severe
.l I;_, /, �, ) / Therapeutic Activity A vated Freq:Occas=25%,Intermittent=50%
Ina n Seg Mot - t Hot Pack/Ice Pack ew Injury Frequently=75%,Constant=100%
;t w`X`,'
Edema (; Intersegmental TXN Guarded Additional Comments:
OM Seg F'."t Back yersified/Drop Pasture
Antal is Extremi ADJ Flare
2 Obective: r Plan: Prooress Affected b : Treated Region/Subjective Com laints:
Date: 'n i I T Phys-Exercise Work TMJ/ E1bow:R/L Wrist:R/L
enderness Neuro,Re-ED Complicating Illness OCC/ Knee:'$/L Ankle:R/L
/))) Inflammation t { _', r i, Myofascial Release Daily Activity C 1 2 3 5 6 7'
.m %-' -`i .�°; t Cold laser treatment No Change T 22.3 A/- 9 10 11 12
Tingling /; 1� f/ I t and:C/T/L Some Improvement L 723"445 Rib:Antl Post
x[ Achingq�Et _ i 'umµ �"t,� 9 t , Elect Stint :C/T/L Exacerbated SR:R2 Hip:R/L Shoulder:R/L
Visit: IROM(C/T/L) i i? / Manual/Mech TXN Regressed Pain Scale:
-weakness ,,g„ ,(i•- ',�„ j--j -{ a Therapeutic Exercise Stabilizing Normal 12 3 4 5 6 7 8 9 10 Severe
levell. ( 1 Therapeutic Activity Aggravated Freq:Occas=25%,Intermittent=50%
Initial Abn Seg Mot Hot Pack/ice Pack New In' Frequently=75% Constant=100%
1. -�! Jury 9 Y= a
ema a lr" lYfl,� gmental TXN Guarded
�,.� .? Additional Comments:
HEM/HOM Seg 'opt . arc; Diversified/Drop Posture
Antal cZG4-- Extremity ADJ Flare up
3 Objective: Plan: Progress Affected by: Treated Region/Subiective Com laints:
Date: "Rem } s r ( Phys-Exercise Work TMJ/ Elbow:R/L Wrist:R/L
Tenderness , Neuro,Re-ED Complicating Illness OCC/ Koe ' Ankle:R/L
Inflammation ! 1 t ` 'vc of Myofascial Release ally Activity CW3S
m ,1-r ,/ ` „tj r 1 i, u.✓ Cold laser treatment No Change T 10 11 12
Tingling t 'r �+ 1 ,t Ultrasound:C/T/L Some improvement L Rib:And Post
Next Aching t�,!
4 -.-++ i �, lett Stint :C/T/L Exacerbated S/L R/L Hip:R/L Shoulder:R/L
f
Visit: JROM(C/T/L) t 3 t `'1 !i 1' `"e• Manual/Mech TXN Regressed Pain Scale:
-weakness i i ;on r-s't- Therapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
,'S'ub level `{ ' t( ' Therapeutic Activity Aggravated Freq:Occas=25%,Intermittent=50%
Initial n Seg Mot } \i•('/ Hot Pack/Ice Pack New In' Frequently=75%,Constant=100%
t)ti\ ifK':I Jury
Edema +,/,.V., ( .�(.} gmental TXN Guarded Additional Comments:
'HEM/HOM Seg r,a-" +.• aao:. Diversified/Drop Posture
Antal c Extreon ADJ Flare u
4 Objective: .--� r...1 Plan: Progress Affected by: Treated Region/Subjective Complaints:
Date: Pain Z �'-�'d , • Phys-Exercise Work TMJ/ Elbow:R/L Wrist:R/L
Tenderness Neuro,Re-ED Complicating Illness OCC/-.Knee: Ankle:R/L
r
Inflammation / Gk Myofascial Release Daily Activity C 4
`�• Spasm s� y,✓ rt Cold laser treatment No Change T� 89 101112
Tingling ! r _r',L t;� I ' 1 trasound:C/T/L ome Improvement L 4 S Rib:Am/Post
Next Aching -�. Elect Stim :C/T/L Exacerbated S/I:R/L Hi R/L Shoulder:R/L
Visit: IROM(C/I'/L) ' i P•✓ ;' Manual/Mech TXN Regressed Pain Scale:
-weakness i �..,?'-I Therapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
level j Therapeutic Activity Aggravated Freq:Occas=25%,Intermittent=50%
Initial Abn Seg Mot 'l:�l:. Hot Pack/Ice Pack New Injury Frequently=75%,Constant=100%
demiLiaersegmental TXN Guarded Additional Comments:
-IVEMMOM Seg r:/on: Diversified/Drop Posture
Antalgic I Extremity ADJ Flare up
5 Objective: Plan: Progress Affected by: Treated Region/Subjective Complaints:
Daze: m -, ! Phys-Exercise Work TMJ/ Elbow:R/L Wrist:R/L
_ 'Tenderness Neuro,Re-ED q2triplicating Illness OCC/ :R/L Ankle:R/L
nflammation r ? Myofascial Release Daily Activity C 2' 4 6
�✓ prim } :�tj Cold laser treatment No Change T 89101112
Tingling jz. �1. Ultrasound:C/T/L Some Improvement L 3 S Rib:And Post
Nerzt Aching '� ' i j! ` a ' `;, Elect Stam :C/T/L Exacerbated SA:R/L Hip:R/L Shoulder:R/L
Visit: JROM(C/l/L) h�i ,f� Manual/MechTXN Regressed Pain Scale:
-weakness _s.. �: ;�iu Therapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
level 1 Therapeutic Activity Aggravated Freq:Occas=25%q Intermittent=50%
Initial Abn Seg Mot ♦`) �, • Hot Pack/Ice Pack New Injury Frequently=75%,Constant=100%
Nextma gmental TXN Guarded Additional Comments:
—19 MlHOM Seg Pro�r. a,ok ,y Diversified/Drop Posture
Antalgic Al. Extremity ADJ Flare up
Patient Name:
6 Objective: - Plan: Pro .._„Affected Treated Region/Subjective Complaints:
Date: 'n '; Phys-Exercise Work TMJ/Elbow:R/L Wrist:R/L
-Tsudemess Neuro,Re-ED Com I cating Illness OCC/ Rn Ankle:FA
Inflammation ,; Myofascial Release wily-Activity Cb 2
Spasm r ! , , Cold laser treatment No Change T 3 5 6111101111
Tingling and:C/T!L Sortie Improvement L 12 3 4 5 S Rib:An
Next Aching �' ' -is "> Elect Stint :C/T/L Exacerbated SR:R2 Hip:R/L Shoulder:R2
Visit: IROM(GT)L) ' " i Til r, Manual/Mach TXN Regressed Pain Scale:
-weakness �,i ,1 v. Therapeutic Exercise Stabilizing Normal 0 1 2 3 4 567 8 9 10 Severe
Sub level Therapeutic Activity Aggravated Freq:Occas=25%,Intermittent=50%
Initial Abn Seg Mot Hot Pack/Ice Pack New Injury Frequently=75%,Constant=100%
ma C.,fIn ental TXN Guarded Additional Comments:
HF.M/HOM Seg L l .,.:,.+ BO, versified/Drop Posture
Antal 'c I-Y"L'� "� Extremity ADJ Flare up
7 Objective: -_ _ Plan: Progress Affected by: Treated Region/Subjective Complaints:
Date: in Phys-Exercise Work TMJ/ Elbow:R/L Wrist:R/L
Tenderness , Neuro,Re-ED `plicating Illness OCC/ Knee-
_{{L Ankle:R/L
nflammation , Myofascial Release Daily Activity C 12 4 5
pasta `. �` % 1 r/, Cold laser treatment No Change 4 5 6 7 8 9 10 11 12
Tingling ;,` s, i. J/ - }1� ' Ultrasound:C/T/L Some Improvement L 2 33 4 5 S Rib:Ant/Post
Next Aching , �.r_ y < <._,t.� - ` ed Stint :C/T/L Exacerbated SR:R/L Hip:R/L Shoulder:R/L
Visit: IROM(C/f/L) l� + '' �i , Manual/Mech TXN Regressed Pain Seale:
-weakness I . -.? ,.,, },1� ,; Therapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
level Therapeutic ActivityAggravated Freq:Occas=25%,Intermittent=50%
Initial n Seg Mot },i.`� Hot Pack�ack New Injury Frequently=75%,Constant=100%
,Edema r;_i�,: !,It Imerseg@ental TXN Guarded Additional Comments:
HEM/HOM Seg F, sack Diversified/Drop Posture
Antalgic �''aS--7 %✓LLrc.- Extremi ADJ Flare u
8 Objective: Plan: ProjutessAffected by: Treated Region/Subjective Complaints:
Date: Pain `1 " Phys-Exercise Work TMJ/ Elbow:R/L Wrist:R/L
- Tenderness =� f Nemo,Re-ED Complicating Illness OCC/ Knee:R/L Ankle:R/L
Inflammation `'; Myofascial Release ail;Activity C 1254
Spasm ,t j i ,�„; Cold laser treatment No Change T6 8 9 10 11 12
Tingling t' - ` i ,t Ultrasound:C/T/L Some Improvement L5 Rib:Ant/Post
Next Aching j `r tri k .,.' Elect Stint :C!T/L Exacerbated SR:R/L Alp;R/L Shoulder:R/L
Visit: IROM(C/f/L) C Ij Manual/Mach TXN Regressed Pain Scale:
-weakness t r „ ;-!', } Therapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
_ b level ?, i l '- Thera utic Activi Aggravated F Occas=25%,Intermittent=50%
i i, ,. Pe tY ggm req:
Initial o Seg Mot 1 { ' 'r)i., Hot Pack/Ice Pack New Injury Frequently=75%,Constant=100%
a ( ;-s rsegmental TXN Guarded Additional Comments:
CIO HEMlHOM Seg =cn: Back Diversified/Drop Posture
Antal 'c Extremi ADJ Flaie'r
, i
9 Objective: - Plan: Progress Affected by! Treated Region/Subjective Complaints:
Date: m'" tom..„3 Phys-Exercise Work:, TMJ/Elbow:R/L Wrist:R/L
Tenderness --- Neuro,Re-ED Co I eating Illness Oe34)p
L Ankle:R/L
animation ( } `f v � Myofascial Release Y;Activity C,
palm 1�.,
Cold laser hwturertt No Cham T 910]1 I2
Tingling -j i r , ; / ' - 1^.l tiUltrascuad:C/T/L Some.Improvement L Rib:Ant/Post
N2 Aching; Elect Stim :C/T/L Exacerbated S/I:R/L Hip:R/L Shouldm:R/L
Visit: IROM(C!f/L) s\ ! r v Mantral/Mech TXN Regressed Pain Scale:
MM-weakness ,! r-i?y-f. Therapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
b level - ! Therapeutic Activity Agiravated Freq:Occas=25%,Intermittent=50%
Initial n Seg Mot ,)�r' Pack/Ice Pack New Injury Frequently=75%,Constant=100•
erne '.;k -gmental TXN Guarded Additional Comments:
HEMIHOM Seg r sate` J,,Hot
rsifiedlDrop Poshue
Antal 'c vo .,,/� re•; .L-vOOLe emi ADJ Flare up F
10 Ob"ective: Plan:
Affected Treated Region/Subjective Complaints:
-Pam Date:
Work. TMJ/Elbow:R/L Wrist:R/L
21 --Tenderness - Neuro,Re•ED Complicating Illness ON Ankle:R/L
2. Inflammation is�} Myofascial Release Dm1yActiviry C 7
Spasm f`i r s.) t t I, Cold laser treatment No Change T 7 8 9 101112
Tingling t 4 ,( - - t\ Ultrasound:C!T/L Some Improvement L} 3 S Rib:Ant/Post
Visit: Aching F ;'' :w �7 MA.._.{ j Elect Stint T/L Exacerbated SA:RIL Hip:R/L Shoulder:R/L
Re IROM(C/1'/L) Manual/N-Bch TXN Regeswil Pain Scale:
Exam weakness ,n f-?'+-; •,°„, Therapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
level ` Therapeutic Activity Aggravated Freq:Occas=259'0,Intermittent=50%
Initial Seg Mot i r' ' ;I+ Hot Pack!Ice Pack New Injury Frequently=?59'q Constant=100%
t',fi
a I gmemal TXN Guarded Additional Comments:
FiEM/1IOM Seg •.-��� e:,�k Diversified/Drc p Positve
Antalgic �o ---T 4-r'?,- AA--C- Extremi ADJ Flare:Mg
.`
Comments: '
1 1 6
2 7
3 8
4 9
5 10
1.
SOAP Note Back To Health Medical Center Listings X-ray Results
/� C-Spine DJD
Patient Name: Tele hone No��z�).ti / .�G7[L T-Spine DTD
J Ager Sex: D to of Birth �" � L-Spine DJD
n _ Additional Notes
r Chief Complaint: Primary: Secondary:
Cause: DOI
Treating Doctor:
1 Findin � an:r^ PlProAffected Treated Region/Subjective Complaints:
Date: Phys-Exercise Work TMJ/ Elbow:R/L Wrist:R/L
J-_
eademess ,= ti Neuro,Re-ED Cquq*cating Illness OCC/ ee: Ankle:R/L
Iftfla"InIabon J, - 7 Myofascial Release Daily Activity C tW39
Spasm 'i ;1�•� J It ��,� Cold laser treatment No Change T L101112
Tingling f h` /1%! ' • u nd:C/T/L Some Improvement L 1 Rib:Ant/Post
N xt Aching yam! ; y r t—1-1 u a Elect Stun :C/T/L Exacerbated S/1:R/L Hip:R/L Shoulder:R/L
Visit: jRDM(Gill L) 1_ k ) dU! 1 / ' Manual/Mech TXN Regressed Pain Scale:
ass „an, C 5. i Therapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
ell vel 1 ?i - - �tt Jv Therapeutic Activity Aggravated Freq:Occas=25%,Intermittent=50%
Initial Seg Mot }x� ! �;t I Hol Pack/Ice Pack New Injury Frequently=75%,Constant=100%
gmentat TXN Guarded Additional Comments:
HEM/FIOM Sag F.on' rack Diversified/Drop Posture
Antal 'c Extremi ADJ Flare
2 Ob "K: _-� Plan: Prowess Affected : Treated Re " d Subjective Complaints:
Date: Pain t `` Phys-Exercise Work TMJ/ Elbow:R/L Wrist:R/L
Tenderness `. Neuro,Ro-EDOuph
ing Illness OCC 4 Cnee:R/L Ankle:R/L
Inflammation Myofascial Release Daily Activity
Spasm t\ ��s� �� (tet(, Cold laser treatment G'hange T 89101112
Tingling f J h `�` 7 J J - 4' u UI :C/T/L Some Improvement L 3 4 5 5 Rib:Ant/Post
Next Aching liar/ u yj i I- ��+�.-{, ect Stim :C/T/L Exacerbated S/I:R/L Hip:R/L Shoulder:R/L
Visit: IROM(Cif/L) ,� �tLY I{ 1t �`I' Manual/Mech TXN Regressed Pain Scale:
Therapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
Therapeutic ActivityAggravated Freq:Occas=25%,Intermittent=50%
initial Hot Pack!Ice Pack New Injury Frequently=75%,Constant=100%
ma Cl-t j i J gmental TXN Guarded Additional Comments:
IOM Seg Ft oo q Diversi£ed/Drep Posture
Antal 'c w/ UJ Extremit ADJ Flare 22
3 Objective: „. Plan: Progress Affected Treated Region/Subjective Complaints:
Date: Pain ;1 ��"y� Phys-Exercise Work TMJ/ Elbow:R/L Wrist:R/L
Tenderness `\ ,-�ti Neuro,ReED -gomplicating Ift OCC/ Kn Ankle:R/L
Inflammation , r i Myofascial Release Daily Activity C 1 3
Spasm .., "�. 1 zit („ Cold laser treatment No Change T 7 8 9101112
Tingling /` , _ `; �,I 1 ` and:C/T/L Some Improvement L 4 5 S Rib:Ant/Post
Next Aching i : / t �.i { -. ., \;,,•v_, Elect Stim :C/T/L Exacerbated S/I:R/L Hip:R/L Shoulder:R/L
Visit: IROM(C/r/L) 1 !� i /? Manual/Meeh TXN Regressed Pain Scale:
1 - Therapeutic Exercise Stabilizing Normal 0 1 2 3 4 5 6 7 8 9 10 Severe
-weakness ,1.,1 I_�� •� ..ao' g o 0
eve! ;{ { Therapeutic Activity Aggravated Freq:Occas=25%,Intermittent=50
` t� ' ri !
Initialn Seg Mot ;�:� 1` Hot Pack/Ice Pack New Injury Frequently=75%,Constant=100%
gmental TXN Guarded Additional Comments:
HEM(ROM Seg From Back V Diversified/Drop Posture
Antal "c ExtreMity ADJ Flare
4 Objective: .� Plan: Progress Affected b : Treated Region/Subjective Complaints:
Date: Paint r; Phys-Exercise Work TMJ/Elbow:R/L Wrist:R/L
Tendetuess Fes'--� .1 Nemo,Re-ED Complicating Illness OCC/ Kn L Ankle:R/L
Inflmnmation �� t Myofascial Release yActivity C 3 6 '
Spasm Cold laser treatment No Change 6 7 8 4 t0 t 1 12
Tingling ?! F. f - i\ ; and:C/T/L Some Improvement L 5s Rib:Ant/Post
Aching 41 ,y.7 a Elect Stim :C/T/L Exacerbated $/I:R/L Hip:R/L Shoulder:R/L
-aP .itr `� —) u
Visit: jROM(CI'/L) �` �i 1 {! Manual!Mech TXN Regressed Pain Scale:
Therapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
etel {� tx' �• e ` ' Therapeutic Activity Aggravated Freq:Occas=25%,Intermittent=50%
Initial Abn Seg Mm Hot Pack/Ice Pack New Injury Frequently=75%,Constant=100%
-fdemaInJprsegmcntalTXN Guarded Additional Comments:
'iffimIHOM Seg F.c,., Back versified/Drop Posture
` Antal "c Extremity ADJ Flare u
5 Objective: `-..., ,"._,} Plan: Progress Affected Treated Re 'on/Subjective Complaints:
Date: Pain .Phys-Exercise Work TMJ/ Elbow:R/L Wrist:R/L
Tenderness ,�'-_--�� --' .1 Neuro,Re-ED C -eating Illness OCC/ Ku Ankle:R/L
Inflammation ti i (:CCC..•//J t Myofascial Release ly Activity C 1 2 3 4 6
Cold laser treatment No Change T 7991011 12
S
Tingling %h \1t - ' Ultrasound:C/T/L Some Improvement L I Rib:Ant/Post
Next Achim : + `; `ate U:J i-- •act Stint :C/T/L Exacerbated S7: tip:R/L Shoulder:R/L
Visit: IROM(Cir/L) �, !i to I`y 1 t if
!Much TXN Rugrosacd Pain Soak:
MM- Therapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
nen< 'j' 1 ran ten x � :.an,
UD.Jcvel n / t, �! i Tkerapeutic Activity Aggravated Freq:Occas=25%,Intermittent=50%
If3
g Mot 1 y%% 3,.}t! Hot Pack/fee Pack New Injury Frequently=75%,Constant=100%
d a iJ?v; gmentalTXN Guarded Additional Comments:
MHOMSeg :"nr Back versified/Drop Posture
ntal is Extremity ADJ Flare up
SOAP Note Back To Health Medical Center Listines X-ray Results
j t f /' C-Spine DJD
Patient Name: a. Telephone No:/ &d W�G'�SG T-Spine DID
Age: Sex: Da of Birth S' — L-spine DJD
Chief Complaint: Primary: Secondary: Additional Notes
Cause: DOI
Treating Doctor
I Findings: - Plan: Progress Affected by: Treated Region/Subjective Complaints:
Date: ' t Pbys-Exercise Work TMJ/ Elbow:R/L Wrist:R/L
Tenderness -'�';., �• Neum,Re-ED Complicating Illness OCC/ Yepee:R/L Ankle:R/1,
nflammation i i Myofascial Release Daily Activity C 1 4
�+
Cold laser treatment No Change T 8 9 10 1112
Tingling UI ound:C/T/L Some Improvement L j 3 Rib:Ant/Post
1
ext Achivg - j = A t ' ,� j i 1,'�, lett Stim(�yJ�/L Exacerbated S/L R/L Hip:R/L Shoulder:R/L
Visit: $ROM(CR'/L) i! y Manual/hrecl'i'1"XN Regressed Pain Scale:
-weakness .i' „„ ,,,, +I.-�' Therapeutic Exercise Stabilizing Normal 0 1 2 3 4 5 6 7 8 9 10 Severe
level Therapeutic Activity Aggravated Freq:Occas=25%,Intermittent=50%
Initial ,dkbn Seg Mot '+If '� i,. H Pack/Ice Pack New Injury Frequently=75%,Constant=100%
ma '_ ?,� `;'! ' V5iersegrnenial TXN Guarded Additional Comments:
HEM/HOM Seg „+ e„mak 'versified/Drop Posture
Antalgic i✓ OG l.✓ -�a... r-ld Extremi ADJ Flare up
2 Objective: �- �., Plan: Progress Affected by: Treated Region/Subjective Complaints:
Date: Pain ` Phys-Exercise Work TMJ/ Elbow:R/L Wrist:R/L
✓ Tenderness -- J�,\ Neuro,Re-ED C plicating Illness OCC/ Kne 'R/L Ankle:R/L
Inflammation i Myofascial Release Daily Activity C 1 2 3 5
f Spasm i`;-i, '.',� !�' Cold laser treatment No Change T 7 89 10 1112
Tingling .%\ ', - t !, unit:C/T/L Some Improvement 1.12 Rb:Ant/Post
Next Aching K,,� +P ',i/` i °, Elect Stim :C/T/L Exacerbated S/1 'p:R/L Shoulder:R/L
Visit: jROM(C/f/L) i` 'o„� �” ,y!i_ `� Manual/Mech TXN Regressed Pa n Scale:
-weakness •�y.. , ; 1- s + Therapeutic Exercise Stabilizing Normat 0 12 3 4 5 6 7 8 9 10 Severe
level _ ii 'i i' % Therapeutic Activity Aggravated Freq:Occas-25%,Intermittent=50%
Initial Abn Seg Mot1 it I ` `' y Hot Pack/Ice Pack New Injury Frequently=75%,Constant=100%
malatersegmental TXN Guarded Additional Comments:
M/HOM Seg F,o„i _ Da=k Diversified/Drop Posture
Antal�c Extremitv ADJ Flare
3 Objective: r Plan: Progress Affected Treated Region/Subjective Complaints:
Date: Pain ".i ._r Phys-Exercise Work TMJ/ Elbow:R/L Wrist:R/L
Tenderness - .<;(���., Neuro,Re-EDComplicating Illness OCC 1 Knee:R/L Ankle:R/L
Inflammation i i C> : Myofascial Release y Activity C 1 2 3 4 5/fit
Spasm �- ' i ”. _ ,, 1 Cold laser treatment No Change T I�3 6 7 8 9 10 11 12
Tingling (P i unit:C/T/L Some Improvement L 12 3 4 5 S Rb:Ant/Post
eA Aching r,.,.: lea Stim :C/T/L Exacerbated S/I:R/L Hip:ILL Shoulder:R/L
Visit: $ROM(C/T/L) ,} r ;-_ ..-. y Manual/Mech TXN Regressed Pain Scale:
-weaknessTherapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
level Therapeutic Activity Aggravated Freq:Occas=25%,Intermittent=5001.
Initial n Seg Mot Hot Pack/Ice Pack New Injury Frequently=750/6nt,Consta =100%
ma ' •�' S1 Ierm
gmrntal TXN Guarded Additional Comments:
HEMMOM Seg t( rrom ` =a=� �versified/Drop Posture
Antalgic JiOla -/i Extremity ADJ Flare ti
4 Objective: - Plan: Progress Affected by: Treated Re 'on/Subjective Complaints:
Date: Pain ~r it s Phys-Exercise Work TMJ/ Elbow:R/L Wrist:R/L
* Tenderness Neuro,Re-ED Complicating Illness OCC/ Knec:RA, Ankle:R/L
n Inflammation + .`{� Myofascial Release at y Activity C 1 2 3 4 54ff:�
Spasm Cold laser treatment No Change 'I'I Y3 5 6 7 8 9 10 11 12
Tingling ,' r' ” '1 s �•' - 1 5 Ul and:C/T 11, Some Improvement L 1 2 3 4 5 S Rib:Ant/Post
Next Aching ' �2 :� ! ' lett Stint :C/T/L Exacerbated SA:R/L flip:R/L Shoulder:R/L
Visit: $ROM(C/T/L) .,- Manual/Mech TXN Regressed Pain Scale:
-weakness i .:t <„ y-( Therapeutic ExerciseStabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
level '! Therapeutic Activity Aggmvated Freq:Occas=25%,Intermittent=50%
Initial n Seg Mot i;-' Hot Pack/Ice Pack New Injury Frequently=75%,Constant=100%
Ed (i{`; In ginrntal TXN Guarded Additional Comments:
OM Seg 'rro,:� =.ck ! 'versified/Drop Posture
Antalgic Flare u
5 0 'ective: Plan: Progress Affected Treated Region/Subjective Complaints:
Date: Pain - ) ';� Phys-Exercise Work TMJ/ Elbow:R/L Wrist:R/I.
Tenderness - `-- ! Nemo,Re-ED C g Illness OCC/ Knee-11 Ankle:WL
Inflammation f �� Myofascial Release Daily Activity C II 4 5
/ Spasm i-,, ,^ .v}U !''r i', Cold laser treatment No Change 'CL2•g 4 5 6 7 8 9 10 11 12
/ Tingling 1 i rt�+ l and:C/T/L Some Improvement L 12 3 4 5 S Rib:Atilt Post
ext Aching r ! , t 1a `a.r (._ .. Elect Stim :C/T/L Exacerbated S/L R/L Hip:R/L Shoulder:R/L
Visit: $ROM(CITI L) '; ` tl / "' Manual/Mech TXN Regressed Pain Scale:
weakness t ��, f :"'S^ Therapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
le level :+ " Therapeutic Activity Aggravated Freq:Occas=25%,Intermittent=50%
Initial n Seg Mot Y t -{ Hot Pack/Ice Pack New Injury Frequently=75%,Constant=100%
Next Ed a I gmental TXN Guarded Additional Comments:
HOM Seg /����/ \�='�h Diversified/Drop Posture
Antal "c Extremity ADJ Flare u
Patient Name: 121
6 Objective: Plan: pro Affected by: Treated Region/Subjective Complaints:
Date: Pain Phys-Exercise Work TMJ/ Elbowilt,/L Wrist:RIL
Tenderness Nemo,Re-ED m beating Illness OCC I Knee:R/L Ankle:R/L
Tenderness
Myofascial Release Inflammation Activity C12306
Spasm,7 h 1 i cold law treatment No Change TY?3 789101112
Tingling Ultrasound:C/T/L Some Improvement 1, 4 5 S Rib:Ant/Post
Next Aching Elect Slim :CITIL Exacerbated Sfl:R/L Hip:R/L Shoulder:R/L
Visit: IROM(CIT/L)
Manuel/Mach TXN ReWessed Pain Scale:
-weaku
u level cSs nnn Therapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
tY Therapeutic Activity Aggravated Freq:Occas=25%,Intermittent=50%
Initial -,Abn Seg Mot , yJHot Pack/Ice Pack New Injury Frequently=75%,Constant=100%
W TXN Guarded 10 Comments:
Ili,'HEMMOM Seg Back -=7fie!mp Posturi:
AnWiLc I t::a� Exftm!y ADJ Flare M
7 Objective: Plan- Proaress Affectedbv: Treated Region/Subjective Complaints:
Date: Pain Phys-Exercise Work TMJ/Obow:R/L Wrist:R/L
Tenderness Nemo,Ri-ED Complicating Illness OCC/ Knee: l Ankle:R/L
Inflammation Myofascial Release Daily Activity C 12 3 4
-71 Spasm Cold laser treatment N ge T1(1271 12
Tingling Ultrasound:C/T/L Some Improvement LI 345S Rib:Ant/Post
Next Aching . i t Elect Stim -C/T/L Exacerbated S11:R/L Hip:R/L Shoulder:R/L
Za
Visit: IROM(CA'/L)
Manual/Mach TXN Regressed Pain Scale:
MM-weakness In tan
Thesupeutic Exermse Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
Ottnt
ub level Therapeutic Activity Aggravated Frog:Occas=25%,Intermittent=5019
Initial Abn Seg Mot Hot Pack/fee Pack New Injury Frequently=750/m,Constant=100%
-Edma
In ental TXN Guar&d Additional Comments:
-TW Seg 'versified/Drop post"
Antal 'cIle, Extren" ADJ FlaresE
I
8 Objective: Plan: Prooress Affected bv-. Treated Region/Subjective Complaints:
Date: Pain Phys-Exercise Work TMJ/ Elbow:RfL Wrist:R/L
Tenderness -'' ` / Neuro,Re-ED Com plicating Illness OCC I Knee:R/L Ankle:R/L
Inflammation . Myofascial Release Daily Activity C 1 2 3 4 5 6 7
Spasm
Cold law treatment No Change T 12 3 4 5 6 7 8 9 10 It 12
Tingling I Ultrasound C/T/L Some Improvement L 1 2 3 4 5 S Rib:Ant/Post
Next Achi.
g ._I Elect Stint C/T/L Exacerbated S/L R/L Hip:R/L Shoulder:R/L
Aching`
Visit: IROM(C/T/ k L) Manual It Mech TXN Regressed Pain Scale:
MM-weakness it Therapeutic Exercise Stabilizing Normal 0 12 3 4 5 6 7 8 9 10 Severe
Sub levelTherapeutic Activity Aggravated Freq:Occas=25%,Intermittent=500/6
Initial Abn Seg Mot
EdemaHot Pack/Ice Pack New Injury Frequently=7M Constant-100%
Intersegmental TXN Guarded Additional Comments:
HEM/HOM Seg Fror, rack Diversified/Drop posture
Antalgic Extremi ADJ
9 01 jective: Plan: Prooress Affected bv: Treated Region/Subjective Complaints:
Date: Pam
Phys-Exercise Work TMJ Elbow-R/L Wrist:R/L
Tenderness Neuro,Re-ED Complicating Illness OCC Knee:R/L Ankle:R/L
Inflammation Myofascial Release Daily Activity C 1 2 3 4 5 6 7
Spasm Cold laser treatment No Change T 12 3 4 5 6 7 8 9 1011 12
C/TIL Rib:Ant/Post
Tingling Ultrasound,C/T I L Some Improvement L12345S
Next AchingElect Stim C/T/L Eacerbaied SIL R/L Hip:R/L Shoulder:R/L
Visit: IROM(C/r/L) Manuel/Mecb TXN Revicsse(I
Pain Scale:
-weakness Tbempcutic Exercise izing Stabil NormialO 123456789 10 Severe
Sub level j
Therapeutic Activity Aggravated Freq:Occas;=250/a,Intermittent=50%
Initial Abn Set;Mot Hot Pack/Ice Pack New Injury Frequently=750/c,Constant=IGO%
Edema
Intersegmental TXN Guarded Additional Comments:
HEMIHOM Seg DiversiBed/Dinp Posture
Antalgic Extrem! AD] Flare!M
10 Objective: Plan: Progress Affected lyv: Treated Remn/Subjective Com taints:
Date., Pain Phys-Exercise Work TMJ Elbowlttfl, Wrist:R/L
Tenderness Neuro,Re-ED Complicating Illness OCC Knee:R/L Ankle:R/L
Inflammation
t Myof&qcml Release
Spasm Daily Activity C1234567
Next Ing Cold laser treatment No Change T 12 3 4 5 6 7 9 9 10 11 12
Ting]
Ultrasounuf:C/Til. some L 1 2 3 4 5 S Rib:Ant/Post
Elect Stir :C/T/L Exacerbated S11:R/L Hip:R/L Shoulder:R/L
Y
Visit: Aching 1�� i A ; — . Int
Re IROM(CIT/L) 1! Y, 1 A I Manual/Mech TXN Regressed Pain Scale:
Exam I 1� I � Ji — —
-weakness t
_�rt
T'herapeutic Exercise StatiflWialt Normal 0 12 3 4 5 6 7 8 9 10 Severe
Sub level Therapeutic Activity Aggravated Intermittent Freq:Occas=255*Intermittent=50%
Initial bo Seg Hot Pack/lee Pack New Injury Frequently=75°/a Constant 100%
Ifflersegmentid TXN
Seg
Mot Guaided Additional Comments:
HF.MlHOM
Sag
Flot-tt Back Diversified/Drop Posture
Antalc
h!nM!�r ADI Flarittup
Comments:
1 6-T
2 7 1
3 8
4 9
5
10