DeclarationCal. Super. - 6th Dist.July 26, 2019\OOONQUI-PUJNt-t NNNNNNNNHt-tt-th-tt-tt-th-tt-tt-ti-t flONLll-PUJNt-‘OKOOONQU‘I#UJNHO 28 HINSHAW, MARSH, 12901 Saratoga Avenue Saratoga, CA 95070 1QCV352312 Santa Clara - Civil BARRY c. MARSH, ESQ. (SBN 99908) SCOTT R. KANTER, ESQ. (SBN 199696) HINSHAW, MARSH, STILL & HINSHAW, LLP 12901 SARATOGA AVENUE Electronically Filed by Superior Court of CA, County of Santa Clara, SARATOGA, CALIFORNIA 95070 0" 2/2/2021 12:56 PM Phone; (408) 861-6500 ReVIewed By: F. Mlller Fax: (408) 257-6645 Case #19cv352312 Email: bmarsh@hinshaw-law.com Envelope: 5761 176 Email: skanter@hinshaW-law.com Attorneys for Defendants NADINE GRAVEN, M.D. and VENTANA MEDICAL GROUP, dba A WOMEN’S CENTER SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA CLARA STEPHANIE ANNE JOHNSEN, N0.: 19CV3523 12 CHRISTOPHER JOHNSEN, Plaintiffs, DECLARATION OF SCOTT R. KANTER IN SUPPORT OF MOTION FOR SUMMARY JUDGMENT OR, IN THE ALTERNATIVE, SUMMARY V- ADJUDICATION BY DEFENDANTS NADINE GRAVEN, M.D. AND NADINE GRAVEN, M.D., VENTANA VENTANA MEDICAL GROUP, dba A CENTER and DOES 1 t0 10, inclusive, Date: Defendants. Time: 8.38 . . Dept: 2 Trial: Not Yet Set Complaint filed: July 26, 2019 I, SCOTT R. KANTER, declare: 1. I am an attorney at law duly licensed t0 practice before the courts of the State 0f California. I am an associate 0f the law offices 0f Hinshaw, Marsh, Still & Hinshaw LLP, attorneys for defendants NADINE GRAVEN, M.D. and VENTANA MEDICAL GROUP, dba A WOMEN’S CENTER herein. / / / 1 DECLARATION OF SCOTT R. KANTER IN SUPPORT OF MOTION FOR SUMMARY JUDGMENT OR, IN THE ALTERNATIVE, SUMMARY ADJUDICATION BY DEFENDANTS NADINE GRAVEN, M.D. AND VENTANA MEDICAL GROUP, dba A WOMEN’S CENTER N0. 19CV352312 LIN Offices 0| \DOONJQUILUJNH NNNNNNNNI-‘HHI-II-tI-It-aa-nu-‘H *«JQLh-P-UJNI-IOKOOOQONUI-bWND-‘O 28 HINSHRW. MARSH. STILLG HIN5HRW A Partnership 120m Samoan Avenue Santana. CA 95070 (405] 851-5500 2. Attached hereto as Exhibit “A” is a true and correct copy of the entire record from NADINE GRAVEN, MD. and the corresponding affidavit signed by the custodian of records that were reviewed by Timothy A. Leach, M.D. 3. Attached hereto as Exhibit “B” is a true and correct copy of the entire record from ANGELA POLLARD, MD. and the corresponding affidavit signed by the custodian of records that were reviewed by Timothy A. Leach, M.D. 4. Attached hereto as Exhibit “C” is a true and correct copy of the entire record from Good Samaritan Hospital Samaritan Endoscopy Center and the corresponding affidavit signed by the custodian of records that were reviewed by Timothy A. Leach, M.D. 5. Attached hereto as Exhibit “D” is a true and correct ccpy of the entire record from Valley Radiology Imaging and the corresponding affidavit signed by the custodian of records that were reviewed by Timothy A. Leach, MD. I declare under penalty of perjury under the laws of the State of California that all of the foregoing is true and correct, and as to those matters stated on my information and belief, I believe them to be true, and if called upon to testify to the matters herein, I can competently testify thereto. This declaration was executed on February 3' , 2021, at Saratoga, California. \Jscon R1 KANTER 2 DECLARATION OF SCOTT R. [CANTER IN SUPPORT 0F MOTION FOR SUMMARY JUDGMENT OR. IN THE ALTERNATIVE, SUMMARY ADJUDICATION BY DEFENDANTS NADINE GRAVEN. Ml). AND VENTANA MEDICAL GROUP. dba AWOMEN’S CENTER No. 19CV352312 #DJN OKDOOKJQUI 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 23 PROOF 0F SERVICE (C.C.P. §§ 1013a, 2015.5) I, the undersigned, say: I am now and at all times herein mentioned have been over the age of 18 years, a resident of the State of California and employed in Santa Clara County, California, and not a party to the within action 0r cause; my business address is 12901 Saratoga Avenue, Saratoga, California 95070. I am readily familiar with this firm's business practice for collection and processing of correSpondence for mailing with the U.S. Postal Service, mailing via Federal Express, hand delivery via messenger service, and transmission by facsimile machine. I served a copy 0f each of the documents listed below by placing said copies for processing as indicated herein. DECLARATION OF SCOTT R. KANTER IN SUPPORT 0F MOTION FOR SUMMARY JUDGMENT 0R, IN THE ALTERNATIVE, SUMMARY ADJUDICATION BY DEFENDANTS NADINE GRAVEN, M.D. AND VENTANA MEDICAL GROUP, dba A WOMEN’S CENTER XX ONLY BY ELECTRONIC SUBMISSION - Pursuant to California Rules 0f Court, Appendix 1, Emergency Rule 12, approved by the Judicial Council, I served a true copy of the aforementioned document(s) via electronic mail 0n the parties in said action by transmitting by e-mail to the e-mail addresses as set forth below on this date before 5:00 p.111. No electronic message 0r other indication that the transmission was unsuccessful was received within a reasonable time after submission. RECIPIENTS: Andrew M. Agtagma, Esq. LAW CENTER 951 Mariners Island Blvd, Suite 300 San Mateo, California 94404 Email: ama@lawcenter-esq.com I certify (or declare) under penalty of perjury under the laws 0f the State of California that the foregoing is true and correct and that this Declaration was executed on February i, 2021. Daglle Quebec Proof of Service Law Offices of OKOOOQQUI-PUJN NNNNNNNNHt-tt-th-tt-tt-th-tt-tt-ti-t \IONM-wat-Okoooflmm-bwwt-K 28 HINSHAw, MARSH, STILL & HINSHAW A Partnership 12901 Saratoga Avenue Saratoga, CA 95070 (403) 861-6500 EXHIBIT A 3 DECLARATION OF SCOTT R. KANTER IN SUPPORT OF MOTION FOR SUMMARY JUDGMENT OR, IN THE ALTERNATIVE, SUMMARY ADJUDICATION BY DEFENDANTS NADINE GRAVEN, M.D. AND VENTANA MEDICAL GROUP, dba A WOMEN’S CENTER N0. 19CV352312 DECLARATIDN 0FEUSTODIAN 0F RECflRDS Pafiem Harm: Elephanie 1011mm Eminess Facility: Nadine Graven, MD. CERTE'ICATIUN 0F RECORDS TD the best al'myknowledge, the copied dumrmms, records, and miner filings enclosed herewilh were and are prepared and nnirlained in the urdinary course ufhusiness by authorized persmn a: persunnel nflhis business ur faciliiy at ur near (he 111m nfthe acts, cunnilflum, nr mama described h}- smh remrdai The emluaed records ul' [he business or facility are a Lrue mp}- nflhz [olluwirg rewards described in the patiem aumufimdun. I, {he undersigned, amflm duly amImrLaed Cusuflian offlecurda uf the above muted business facility. Iamfamiliar with [he nude ul‘ preparariun DI; and Emu: me Emmy m aarlii'y, Ihe business 0r ficiliny mama's, Idaclare under penalty ofpcrjury umier the Iawa fifths Slate of Caflfiarnia [rm the [uregoing is 1m: and current. 71W 553MM\ > CladeanufRe-mrds ,_ 02/01/2021 Dated , 202] Appointments for Stephanie Johnsen O Appointmant Date Day ' 'V 03/09/2017 03:25 PM Thu 04/07/2017 07:00 AM Fri 04/1 7/2017 ,o4:35 PM Mon 08I24/2017 03:45 PM Thu Total appointments - 4 Missed: 0/0 Cancelled: OIO To Reschedule: 0/0 Scheduled: 4 Min. 30 90 15 20 Resource DR G DR G DR G DR G Status Billed Billed Billed-D Change Billed n 0 A Womens Center 476 East Campbell Avenue Campbell, CA 95008 (408) 378-1888 03/09/2017 Np Cons- NG Subjective: Chief Complaint~ohnson, Stephanie 31 Y.O. New pt here for consult BCM: mirena 2016 Last Pap: Pt wants to check the IUD placement. Pt had an ULSD and an MRI and no IUD was found Dr. Pollard ordered them and she wants a second opinion. Pt had some unusual bleeding 2 wks ago. Present Illness: IUD went in november. Sono a mo later showed poss no iud. MRI was done and iud not really seen. Here for second opinion. Objective: Vitals: BP: 103/72 Wt: 124.0lbs Ht: 64.5in BM!: 20.95 LMP mirena went over all the issues re iud displacement. Went over fact that Dr Pollard did the right tests. Discussed doing another sono today, Also went over how she has had no periods so iud must still be present. Sono shows what appears to be an iud in the c/s scar. String looks to be in the canal. Discussed hysteroscopy and poss I/s to look for it if it wasn't in the uterus or would not come out. Discussed salplngectomy as well as replacing the iud back in the fundus. Pt will talk to hubby about tubal. Wants to do hysteroscopy. All surgical risks discussed, including bowel or bladder damage, ureteral damage, risk of perforation, bleeding and infection. Discussed bladder perforation and possibility of catheter remaining in longer.All questions answered. Discussed salpingectomy and recent study that shows a 60% decrease in ovarian cancer. Assessment: Diagnosis: IUD Mechanical Complication T83.39XA Irregular Menstruation, Unspecified N92.6 Plan: Date Created: 03/09/2017 Date of Service: 03/09/2017 Patient Number: 12190 Chart ID: 8 Attending Staff : Attending Staff Name: Maria Marin Role: MA lJ Date of Service:03 /09/201 Page 1 of 1 A WnmPns C-Pnt?r Patient: Johnsen, Stephanie 07 /29/85 PMS ID: 23464-1 PreRared bv <;nri nnrh::a rt'=FMR A Womens Center 476 East Campbell Avenue Campbell, CA 95008 0 (408) 378-1888 Current Meds Patient Number: 12190 Chart ID: 7 (J (_) Patient: Johnsen, Stephanie 07 /29/85 PMS ID: 23464-1 PreQa red bv C:nrinnrh:i.r+c:FMR Page 1 of 1 A WnmPns <.Pntpr 0 A Womens Center 476 East Campbell Avenue Campbell, CA 95008 (408) 378-1888 03/14/2017 Surgery Scheduled to: maria from: maria date: 03/14/2017 time: 11:09 AM re: Johnsen, Stephanie 07/29/85 pt called returning your phone call from thursday in regards to scheduling her surgery she would like a call back #408-472-9996 03/14/17 JW 11:09 AM Pt was notified she is scheduled for 4/ 7 / 17 @Samaritan endoscopy mm Patient Number: 12190 Chart ID: 10 u Patient: Johnsen, Stephanie 07 /29/85 PMS ID: 23464-1 PreQared bv C:nri nnfh:::a r-t-c:FMQ Page 1 of 1 A Wnmpns 1PntPr O (“-1 \J’ I CHlegpoMPLAINT l l \ . NAME -“. y GS ’ ECLG BABG FOREST HIsToRY AND PHQJCAL EXAMIHAIION m I' . J/UD {stanq/ \LnMoUL'» ‘ mmmdm m": Em HALL - fipgwm 5T6 HO m-C mtshm "xmuAJxm .‘ CARDIORESPIRATORY ILLNESSES CID f” L OTHER ILLNESS r49" DIABETES W (' n PSYCHosocmL HISTORY CV ALLERGIESNWA FRIOR SURGERIES‘ C}:- xc 2L MEDICATIONS/ SUPPLEMENTSm . PHYSICAL 5P ”5 U’fl PULSE L1 WEIGHT m” HEENT Wk HEART $00k“ LUNGS Z. {W ABDOMEN W EXTREMITIES k... BREASTS WWW I PELVIC fi-U f {Ta O QMM; To bk r>_ ”J ¥- Canmi-q-MA JAM ”OE“ ”(WNW Nt‘W/LMMJBJW‘ LULH 3m Wt. sononMAGmG UN v MIC: P AN/PROC QURE'WA l' ' fii'r'.‘m: u hiring?IhflmjjmLHAJ-elugb. ‘11.“.“4 “AVJQII IHAVEGXPLAINED TH r BOVE PRO E' R SSOCIATED RISKS" IND COMPLICATIONS, BEN ITS AND ALTERNATIVES AND THE PATIENT UNDERSTANDSWISHESRW SURGEON SIGNATURE DATE PATIENT REASSESSED No NTERVAL CHANGE (a g Eonwr roaslifiliLDte :E A. Florence Lin, MD ' 2110 Forest Ave. 2nd Floor San Jose, CA fl To: samarilan Date: 41‘63'201? Kn“; Fax: 4083560978 Pages: 1 Subject: JOHNSEN. STEPHANIE Pt called Please start IV Please do UPT and 12 lead EKG ’ \ Thank you. Florence Lin. MD wawgw WWW Ed a IOXImIty Sent through Doximity. The Professional Network for Physicians. Claim your free fax nUmher at m.fioximflymmflraefax. This fax f5 intended sorely for :he use of the intended recipient and may contain information (ha! is privileged confldenfiai or pmpn'eraqz. Ir you are nor an intended recipient. prease norm: (he sender. and man p!eas:=: deiefe and destroy a!) capres. H.» ‘ f PRE-QP ORDERS , BMSICIAN'S ORDERS flease Date, Tim e, and sign all orders l. i NPO after lflpmthenightbeforc surgery - 2. Consantfor: 13‘?“ WUWSCQQA-fi thQUU-Q 0:8”?m0 - FciePbLn Y’MJQ‘SLQYN QDEsLu SwarmMEXum 3. D knee?! gm IV on~call to OR ' Q D SCD's lo be placed on patient if patient as a risk factor Score of'3 Dr yeater/f I I t- 1. 1 m m Uw-F"WNW Physic” Signamre' Avf''5 q 3 Date: xf 5 q Time: 7/ f P05120P NOTE 4H}? Gx 0M3 ( 1 R 3. OperatiVePruccdfire. LN m1, COP .c I , u - Jd l. Postggerative Diagnosis: T’T UTj (AV?W U . . \ I . 2. operative Findings: 30mMM LAM WW ODM4 \_ ‘u 1| zm dfi O 0M» ‘ m am a “a W lachdew mde Lce info 408-4 14-7421 ' A 4-1 U _n_ t "h A a Iictallou fl: Physician Signature: V )cdfi fl”. Date; 1 l _' Time: VVFVV 08120? ORDERS , 7 Y ‘ ' %-opemtive appointmentMuck U lndays Othenk J 3W3 patientsmy pre-printe’d instructions for home Patient may he disgharged to responsible adult when Anesthesia discharge criteria are met l . .ALAHT: .. \ g.gwmw §§- v 43‘.y. L . -pre!fve Guidefinar: §H6.52mm?) Na patient may be dischargedfi'om lire ASC Mules: thephysician who peo'hrmedrfre rurgéy ~a¢ en'm-e sign: a discharge order. TheASC1mm ensure Ihalphyflciamfiflaw uppfr‘mbie .S'mte Imps m- m-H a5 genera”): uck-epred {arch ofpmcrice and ASC‘ polka; when determining rim: apallem lms- recawred'uyficiemfivfmm surgery am!may be discharged rlze ASC'. aw. n: emph‘mbfe, Hm: Me patient 1mm be frangiwed (a dumber Jxeulthcarefacifig; rim! mm provide fire ongoing wen: (harm m' me patient requii-a: um!mat rise ASC‘ 2‘s «nab!!! (a provide. fl i: expacted ma: a patient xvi}! uanmafly Janna rite -w’flu'n {1-30 minute: qfrfie n'me when the pfwslciczn Jig": Hie :fischarge order (7.? FR 50478JLL ha..an n 1 n44} 'guan hns assessed the patient and cleared for dischafiKRN: Wwaagag ”U {fit / W Time].w“ Physician Signature: I ' Date: \k' F} ‘ v.7 Time: 10W5 HYSICIAN ORDERS 8c POST-0P_N0'r _) ‘ Patient Label thmsm WW bx > PATIENT SCHEDULING SHEET Fill out andfax to scheduler with any Physician's "Pre-Surglcat Orders" to: Scheduling Faxz4UB-356-0978 Aitemafiva Fax: Scheduling Phone 403-355-0933 Alternafive Phone: Mon Tues “Ed _ 00 - - t £9 Provfous Yes . General MAG Lml Block Choice Conscious Sedallon numhar YOU: 3y WE a masflag Emamenq Cgfflad: Home Horns; Ya: Nu Call: Yes Na le-OD I . A Procedutem ICPT Ca lea: P0661 e, aw. Sta “095C- . S arty Mama and pa . Child Spousc (ther rancac I i and Phone and Phone: fix J TBS” I & H a FBS ifdi c o P o E H&P ated: o Mo o Yes For Local or Conscious Sedation: o Start IV 0f Lactated Ringers o No IV ate; . Job #I Date: Time: Signature: n () u XUJIKE/fifilfllém JOHNSEN. STEPHANIE ID! Vlllt: 3905 I 1 Gender: F DOB: 7129/1985 Age: 31 Phys: Graven. Nadine DOS: 4!?!2017 l'fifi‘.‘ @191 ('1 () u Page 1 OPERATIVE REPORT Samaritan Endoscopy Surgery Center 15195 National Ave Suite 204 Los Gatos ,Ca 95032 Direct (408) 356-0988 Fax (408) 356-0978 SURGEON: NADINE GRAVEN, M.D. ANESTHESIA: General. ANESTHESIOLOGIST: Florence Lin, M.D. PREOPERATIVE DIAGNOSIS: Missing intrauterine device and desire for sterilization. POSTOPERATIVE DIAGNOSIS: 1. Missing intrauterine device and desire for sterilization. 2. Pelvic adhesions. 3. Left ovarian cyst. PROCEDURES: 1. Diagnostic hysteroscopy. 2. Diagnostic laparoscopy. 3. Lysis of adhesions. 4. Drainage of left ovarian cyst. 5. Exploration for IUD. 6. Bilateral salplngectomy. COMPLICATIONS: None. ESTIMATED BLOOD LOSS: 10 ml. INDICATIONS AND CONSENT: This is a lovely patient who came to see me for a second opinion approximately one month ago. She had an IUD placed in November after a C-section in August. She had some spotting and bleeding and some pain and went back in and the IUD string could not be seen. Imaging was done. She had an MRI of her pelvis and they did not see anything on MRI. On ultrasound, I felt that there was a thickening around where the bladder flap meets uterus, and I felt like I could possibly see it within the wall; however, it was not easy and the patient was very concerned. We discussed all the different options and she wished surgical exploration to make sure that the IUD does not stick somewhere. In PATIENT: JOHNSEN, STEPHANIE ID#:JOH-3906 DOB: 07/29/1985 PHYSICIAN: NADINE E. GRAVEN, M.D. DATE OF DICTATION: 04/07/2017 DATE OF PROCEDURE: 04/07/2017 TRANSCRIBER: pts_dg n C) u Page 2 addition, she wished to have her tubes removed If I had to go in Japaroscopically for fertility issues. She was counselled extensively regarding salpingectomy versus tubal and the decreased risk of ovarian cancer should her tubes be removed. She discussed it with her husband and did not want ii done if I did not have to do a laparoscopy, but if did it, a salpingectomy could be performed. She signed a consent. The patient had all her questions answered and all complication discussed, and she was consented to the following procedure. DESCRIPTION OF PROCEDURE: She was taken to the operating room where she was prepped and draped in dorsal lithotomy. Weighted speculum was inserted into the uterus and the cervix was grasped with a single-tooth tenaculum. A paracervical block was placed 5 ml on each side of her cervix. A small dilator was placed followed by a polyp forceps to see if there was any IUD string hanging in the cavity. The hysteroscope was placed gently and it looked like the dilator had gone into the wall at the top of the fund us, but did not appear to perforate. Otherwise, the endometrial cavity was completely normal and there was no IUD string seen. I carefully explored the entire cavity, especially on the anterior side, if she has a retrograded uterus and I did not see anything. I then called for a laparoscopy. So we changed gloves and moved up top after a Foley and then a HUMI manipulator was placed in the uterus. She was given 2 gm of Cefotan and then her umbilicus was injected with lidocaine and Marcaine. A small incision was made and a Veress needle was inserted and she was insufflated to 3 liters. An 8 mm port was placed into the C-section scar under direct visualization as this was a left 5 mm port. We injected with lidocaine and Marcaine. The abdomen was thoroughly explored looking up around the liver, around the abdomen, underneath the bowel and in both sides of the broad ligament. The bladder was definitely adhesed to the top of the uterus not felt typically adhesed to the uterus and I gently took that down with a combination of hydrodissection, blunt dissection and cautery with hook. I was able to free up the bladder from the uterus and look carefully underneath it and I did not see any IUD or any evidence that it had been there. I opened up the broad ligament on the right side to a slight amount and I dint not see anything in the broad ligament at all. There was a left ovarian cyst that was drained by puncturing it with the cautery hook. I took the Gyrus type cutting coagulating forceps and took each tube out, the left one first snugged under the tube coming down to the fimbria and detaching it. It removed through the 8 mm port, same exact thing was done on the right side. Both ovaries looked completely normal except for the cyst on the left side. There was no endometriosis. FloSeal was placed over the bladder flap as well as around where the tubes were removed and some lnterceed was placed over the bladder and uterus with the irrigator. Things were Irrigated sterilely to make sure things were clear and then the equipment was then removed after the gas was expelled. All incisions were closed with 3-0 Raplde absorbing Vicryl and then skin glue and then Steri-Strips. The patient was awakened and taken to PATIENT: JOHNSEN, STEPHANIE ID#: JOH-3906 DOB: 07/29/1985 PHYSICIAN: NADINE E. GRAVEN, M.D. DATE OF DICTATION: 04/07/2017 DATE OF PROCEDURE: 04/07/2017 TRANSCRIBER: pts_dg (\ \ _) u Page 3 Recovery in good condition and received Toradol intraop ively. NEG/PTS_DG DOT: 04/09/2017 PATIENT: JOHNSEN, STEPHANIE ID#: JOH-3906 DOB: 07/29/1985 PHYSICIAN: NADINE E. GRAVEN, M,D. DATE OF DICTATION: 04/07/2017 DATE OF PROCEDURE: 04/07/2017 TRANSCRIBER: pts_dg O Palo Surgical Pathology Report A It0 Kenneth Hanover, MD. - Director 2325 El Camino Real Palo Alto, California 94306 1-800-303~4PAPPatho Iogy Inc. PATIENT: STEPHANIE JOHNSEN DEPT #: 317-1712 DOB: Tf29f1985 [31)Years SEX: F SERVICE: 04(077201? PHYSICIAN: NADINE GRAVEN. MD. RECENED: o4x1oxzo17 LOCATION: 476 E. CAMPBELL AVENUE REPORTED: 04l1212017 Copies Sent to: SAMARITAN ENDOSCOPY CENTER SPECIMEN #1 1 RIGHT FALLOPIAN TUBE , SALPINGECTOMY SPECIMEN #: g LEFT FALLOPIAN TUBE , SALPINGECTOMY CLINICAL DATA: BLADDER ADHESIONS DRAINAGE OF LEFT OVARIAN CYST Gross Descrigtion: Received in formalin is a 6.0 cm. long fallopian tube with fimbriated end. The serosal surface is shiny and smooth with areas of hemorrhage. The diameter of the fallopian tube is up to 0.? cm. Sectioning reveals no gross abnormalities. Represented in a single cassette. [A, Right] Received in formalin is a 6.0 cm. long fallopian tube with a diameter of 0.4 to 0.5 cm. The serosal surface is shiny and smooth. A few fimbria is present at the fimbriated end. Gross abnormality is not noted. Represented in a single cassette. [B. Left] [AU] CommenflMicroscopic: Sections of both Specimens contain benign fallopian tube tissue. Cautery artifact distorts the architecture in left failopian tube. There are no atypicai features. DIAGNOSIS; 1~ RJGHT FALLOPIAN TUBE, SALPINGECTOMY;“-"- -- BENIGN FALLOPIAN TUBE 2 - LEFT FALLOPJAN TUBE, SALPINGECTOMY; -- BENIGN FALLOPIAN TUBE x" SAMARITAN ENDOSCOPY CENTER 15195 NATIONAL AVE. STE 204 LOS GATOS, CA 95032 Ayce' nal, MD. Page 1 of 1 COPY r 3 f“- .L/ ANESTHESIA EVALUATION (rev. 4.11 Preoperative Diagflosis: Procedure Proposed: jWWM wagwr d _ ‘38“ Pfl’wqégzyursing Preoperative Assessment Reviewed gical r0 c qnscuts for Surges) and Anesthesia signed and witnasse I [E'Surgical sitellncation verified and marked . [lRight DrLe a1 UNA Additional Histo JOHNSEN, STEPHANIE ID I Visit: 3905 l1 Gender: F DOB: 7f2911985 Age: 31 ¢é_ WW ,dwfififiw I Phys:Graven.Nadina A1165 csia almlé H story and Complications: DOS: 4!?!201? PhysicalstuntAirwayaWW Lungs:W Heart:Wm Ext: LABS: Hgbfi-Ic ‘ . n Electrolytes: EKG: I Other: ASA: 1’ 3 4 s E Anesthesia Plan: Mr. Jscussed risks. benefits and potential complications of anesthesia plan. [MH-questions answered % 5.3U PREOPERATIVE ANESTHESIA ORDERS I /(4/StartIV TRor (a) rnlfhx. [11000mL[JSOOmL @[JTKO[] _ PRN- 1% LidOcaine mixed 10: 1 with 4% Sodium Bicarbonate (2.4mquml) not to exceed 0 3 m1 as local prior to starting IV per sitem for males over 50 and females over 60 (H'Pregnancy test for women of childbearing age fl AddiltronTl orders: Battery). '7' 1'? Time [W Signamreng’flfik ‘ MD.IUUWHNZ" “HUI” P08'1‘ ANESTHESIA ORDERS $nygenpm}: or E JNC@ g _Lx [12 minutcs then PRN f9: o'xygcn saturation c: /o IV. LR or WW Discontinue IV before discharge. y? l IN: HoldIV narcottcsfar excessive samnalenceggfi <12. Notify auesthesiolagistfor RIF: 10. ‘QFentanngg; mag 1V every__5__minutes to mag PRN fur pain lave] [14-7m0 “ 5‘ ' Dilaudidggg‘ mg IV every“5“minutes to ' mg PRN fur pain level W [ ] 8-10 a; [3‘ May alternate thc above as needed f0: pain control if the same sequenced pain levels are checked [ ] IV every minutes to _ PRN for pain level [ 1 4-7 [ ] 8-10 g Ifme aria”! can tolerate BO. (oral) meds pteasefaflow the orders be ow: (NTE 3gm ofAPAPI24hrs) @Mfi' -v {325mg A tab every 4hours PEN for pain level- [J 1 -3 4- 7 [] B ~10: MAY Repeat X ldose ifno pain reliefiu 15 min. rcocct Sf325mg l tab every 4hours PRN for pain lewl {] I -W- 7 [J 8 - 10: MAY RepeatX Idose ifno relief 'm 15 min. [ J Tylenol with Codeine #3 l tab every 4hours PRN [] 1 -3 [] 4- '7 [] 8 -10: MAY Repeat X 1 dose ifno relief in 15 min. SHIVERING: o [ )Meperidine 12.5 mg IV every é minutes PRN shivering up tofig mg k ANXIETY: I[ ] Midazolam mg every minutes to mg in 1 hour. \ NA EA. (Follow the checked o1 dcls below us the sequence of administ: ation unless directed othe: wise) Zofian 4 mg IV PRN x __1 “OR" [ ]Anzemet I2.5 mg IVPRle , [] Phcnergan ______mg DVI PRN x 1 *prefermd route “OR" henargan E mg IV (dilute 10:1) PRN __ '5‘ [ ]W_ mg IV PENm m/Hr- a ADDITIONAL ORDERS: Call Physician forHR> 100 or < 60 bpm: SBP >140 or < 90; DBP >90 or < 50 1. 2. A Datcz44 [4‘ m_mf0 Signaer_/\;_fi; MD. DISCHARGE ORDERS ischarge: o e flOther: mments: . A ' . /, fl _.. Date:_’-H 2 | I l Timmg... Signature \J Q" MD. Eatisfactory: {jiflgs flNo. Complications: v m JOHNSEN. STEPHANIE Anesthesia Record Auesrnesmnscoan PamLL. Ibimsit: 390311 Gender: F WE mugnmr-Ew 'rne-mgmms ‘ Dos: mamas Age: 31mm dar year Annmmchlnal Ffifima n wbm Danna 4P w, ‘ I4 J16 afembcnun Daxilrarymn n elm...“ awn“ Phys: GraVeI'i. Nadine _ figs mbaardreslr. «darmalxckad a Miduum Danna DOS. 41?;2017 pads =|me amt n m: t n q__ 'DR fl lining fleasua p1: cm: a puma a amum n23; AS ' I [fl a “Enema uohmm Anfiblaliafl iiEX I&fimn - I ' ' Wrap“ npaus aohak-r_________ mun“ A LER 1 c: saline nengmus n sums: n Continuous m. mglampzndaummm Warmlng mnasutcs: amm nmuw D FIUId ,E‘Elanhals D \i x W‘ Munvnclivo Mud cum (g'r a (Ur Time Tlrne ___,__fi D Maths: Uclrtull t m fl Immldllldy Eeforn :lnducflan__ _ mawsLl-Igm MauarnpaflW a 4 a 02 nasal mask a ATnmr oral nasal n Maui: GAmm fl szhlu Blade Tutu 51 =Mgmpl: .x e Gram: I 2 3 i . | UNIIHI ‘ aired D mind n Flhempfic Dsulel ,Mmedflgk wrb-lO-fl ~~ I -Innucian R-Ruurut [1 (2mm u F a 6"“:0 (a) R side “p Equal numeral £32 ulmny a s {4} L n mmuu army sue REMARKS I I Luna INQUDTION . Prioryiennlmn " N Inducfinrl Raphl liq n Cflw'd fires! n lnhalhducl Tum: MESTECHMQUE D Regiond D mac ’fi GA r1 u Hmlmsfm u Fill: Avaldflncu a Snlnar u Manama uulnmcn Raglonal Block image GR Report MOT Retained 4a PW L u n mm:amLuflain m mas a N55 Tima1n______ mafm an I Temp f I f. Cua-rranumd m UM 9“” .Efis" Dom mm n En. nmcu:__ F sac: I ------° “mam RWm Almessmm I um3mm -‘. 97:4 W4 am Km cnRF. RA ouroa suns‘srop' ANESTHEsIoL elsr :2 menu cum ’0 WE 0%;m2; PRE-OPERATIVE' CALL _. -. _ __ PROCEDURE. .. ' 3 ' > ' " t .. -. .. 39.9.5. = POSSIBLE DIAGNOSTIC LAPAROSCOPY DIAGNOSTIW ._ ySWEROSCOPY. - 2. INSTRUCTIONS: 1. Bring.your insurance card a5 well 'as a check-0r credit card to cover an‘y connsurance or- deductibles? 2. No food or drink- after midnight or at least 8 hour's BEFORE Surgery. 3. If you are diabetic do NOT take your meds “ion the- day of surg'wery 4. Ifyou have high" blood pressure, DO TAKE yflourumfe‘ds as prescribed. . 5. 6 7 8 9. Patient agreesto and lndlcates a good understanding of all of these direcflon Called Big. \. 1 Patie‘n't Signature.- /-\ I _ {xx "ll I. - ‘l- r‘fJ/L- am’m QOww I . I SMOKER? HROVIDER: Graven, Nadine I _ . AN'ES':-'.G_EN .EToH pRINKE‘R? ' Dos; 42712017 7:00 AM 90 minutes RECReATIONAL DRUGS? PATIENT JOHNSEN, STEPHANIE- ' ' _ 1 ‘ COLD I SORE THROAT PAST 2 WEEKS? _ . HEIGHT gfy- WEIGHTm(/025- ALLERGIC To [.00INE? LMP 5:5”), I \ ALLERG‘CTO LATEX? . DATE LAST EKG .fi' . .. ' LABS; r69" l '- . ALLERGIC To ANYMEDICINES? - - . . ANY OTHER ALLERGIES? _ _ . . - . , _ - __ ._ MEDIC TIONS - ' ' I I I . ' . S'U [CAL- HEIISTO'RYII I I |Al3$UES~ ' NOTES SIGNIFICANT MEDIcAL'Hi's'TéRY ' _ _ . ;; - - - ' " ___ . ' x i ' -‘ None ‘2, fl W4 U Cancer" ' z .- 3 ID Heart Failure - ?E’ Igraln‘He'adache's B Water Retention Anemia / w 5" Chronic'Pain . - ' - ”U Hepatttlstaundlce {U Mi ta Valve Prolapse E Other... [:1 Aneurysm - D Diabetes - ‘ U Hlatal HemiafGE_RD D SeiZUres'tEpllepsy D Other... U Anxietnyepression D EmphysemaICOPD NU Hypertension D Sleep Apnea ,.- D Arthritis D Excessive Bleeding - D IrregularHeaI-tbeat III Steroid Medication Q > ' U AsthmalBronchitls D Heart Attack _ D Kidney'Disease U Stroke U Blood Clot E] Heartburn = i D Liver Disease D Thyroid Disease 1 Do you have transportation home@m0 (circle one] Name: C&(‘dadd‘w/ ' 50W! Phone:fl/dylé 5‘6”}“0 V} Who wilt be taking care" of patient a ome (name) Chic; {/Mgfiozafl __ '- DO'NOT shave or use a razor on or'near the site' Of- surgery. . . Wear comfonable. clothing: pull on pants and.-loo's'e;.bUtton down or zippe'r’edtop. . Please remove A_LL jewelry. nail paiish. make-u'p; lipsticks, lotions and eye Contacts. . No chewing gum tobacco. or. smoking. Please allow AT LEAST a fuli day for recovery, and do not schedule any appointments on the day of your surgery "NowitélejiOnez _ J I Date”-‘//7//7 We’d; y'v :- . = v ...M. - .. a .... . "...... .p I .. ....... .. u ...-:umuwaw-m-u-mMn-un.......--~.m..»...;:.-. ..r «ma .:.....' u»- muflw-«ea Mm ¢ ....-. 4.,4....,-...,..... .-.....--...:. v ... .,.._.:.‘.~ www.ww,‘ .. .. .. O- Mallgnant Hyperthermia Review “Nate's: You or a Family Member at Risk for Ma'iiéna nt Hyperthermla YesK Unanticipated High .T'emperature after Ex'ercise orAnesthesia Yes N5" _ ComplicationsafterAnesthesia . Yes t No fl} Muscle or' Neuromuscula‘r‘DiSorder -.'(és /N_ 0’ - ) ; Dark or' Chocolate Urine Yés; (:N/’ 1 Advanced Dir‘ebt'we Pt. HAS an‘ Advanced Direc.tive[ple'ase bring cofixk'to facility] / Pt. DOES NOT have an Advanced Directive I Durable'Pawer of Attorney. _ = . - Pt. HAS a Durable Power 0f Attorney (please bring copy .to facility} - |//.Pt. DdES NDTihavea Duriable-{PoW'er ofAt'jt'omey. .. JOHNSEN STEPH N Inwisu- 3906M A IE i Gen :DOB' ?129i1985 Age:d39; F , F’:hys Graven Nadine IQ Dos 4173017 Pagéiiz ”.7? _ PREOPERATIVE NURSING ASSESSMENT Outcomestoals: Patient verbalizes understanding ofplanned procedure according to signed consent. Patient demonsmtes decreased anxiety. Patient is provided with a safe and comfortable environment. Date: 4,07 (H Timeln PSU: 002$ u Two p'altlent identifiers used {NamelDOB) Dlschar ePlannin :Relafionship: Hkgbwp Ride: Mimi- Waifing a Returning _ u Need to be caned; L403) £190 ' 904 '7 P .o V't m : - Trqeg-llRa fiw BIP W170 Saoz ED?OHt'54 . w: 11g; TwainLeveI Measures taken to relieve pain: (Nursing Interventions, Paln Mada) Allergies: D Yes KDA a Latex u Iodine Npo: Since HGJMU a No Voided Pre-og: n Yes Time: ‘a‘HoEHW 91w moWm“ Psychosocial: 41mm .bort' wm’: ”Mb" ,B’Calm uAnx‘mus uSpecialneeds “f” W'd' u Religiousfcultural beliefs a Interpreter, Language Preoperative Teaching: /t1’0 rientation - environment rientation to post-op care /ErPatienUfamily verbalizes understanding Advanced Directive;,a’flfA El Copy in chart ifapplicable /a1fiformation provided and policy reviewed, if requested Comfort Measures: osition for comfort ,B’Warm blankets/a'fiair Hugger m Other. Current Medlfica'rtlons - Herbals- OVer the Counter Meds: SEE “SUMMARY OF ADMISSIONSIMEDICATIONS LIST” Physical Assessment: Neurologicai ,a’Alert andforientated u Oth er Cardiovascular ,a’Reguiar 'n lnegular {a Other Pulmonary mngs cfear and equal a Other Skin condifion MNL u Other LMP m lb!!! WA Personal Items: Dentures: :1 Upper u Lower 1:: In :I Ouga‘None a Wipt u Wlfamlly Fanials: u Upper a Lower a In n Oula’fione u Wfpt. u Wffamfly Glasses: uOn c: Off u WIPt a Wifamilyfi’NTA Contacts: a 1n a Out n WfFarnllyrpr Jewélry: __cn Off n WKpL repiesantative a Taped KN!” n O_ane :1 Crutches n Waiker n Wheelchair u Prosthesis ab Parmmmf romivycrr in mmmx “1- Pre-on Procedures: Diagnostic Tests: u None [94G Time Test Normal values In parenthesis Hemoglobin Hgb (W 12-16; M 14-18) Glucose GIUcose (70-1 10) Urine pregnancy u MIA u Positive u Negative ”Abnormal Values MUST be reported to MD immediateiy“ MD notified DF- UM A Time DU RN Nurse Signature r w_ . Read back and verified by JMQ'J dIc'alions reviewed for ntraindicafions and impact on lab valueswa mo+ Médy “f9 lac; pramwf' par Dr. Gram . IV Started: u No [V Solution fi Size Ega Site WT flfj D u 1% Lidocaine w! 4.2% NaBicarb 10:1 -_l ml injected for IV Inserted by Fr UT N MD #A’ttempts _l__ Unsuccessful Attempts # Attempts _ By # Attempts By Time n 1 gm Ancef IV on-catl to OR fime I: “mg Vafiurn PO RN Nurse Signature cu Medications clarified with orders Pre-og Safety Check: M ,a'Pre-up orders complete I ose on’ u MIA fide rails up x2y6urney locked LVN Slgnature: . n ¢_ . RN Nurse Signature: 52E?g E" J To OR viwflarney nAmflje/dpnéariijd Interviewing OR RN: ' /n’FIandoff completed flutcomeslgoals met JOHNSEN. STEPHANIE ID {Visit 3906 H Gender: F DOB: 712911935 Age: 31 Phys: Graven. Nadine DOS: 4!?!201 ? (\, ' C) (j JOHNSEN. STEPHANIE ID I Vlsll: 3906 I 1 Gender: F DOB: 7/29“ 985 Age: 31 Phys: Graven. Nadine ‘ I DOS: 4/7/2017 m:1-7:4:-T=§'}E h l; I. O JOHNSEN. STEPHANiE ID I Visit: 3906! 1 Gender: F DOB: 'HZQMQBS Age: 31 Phys: Graven. Nadine DOS: 4!?!2017 W . HM” _..._‘ \ i - ' . ‘- PRL-UPLRAJLVJL AbblbbelLNfi _\DATE-fl02m TMmRM- D714 CISIQN =7 . - Patient Intemew/C ' Tmnsported via: ' Gilmcy ALLERGIES' NW Reviewby:-{‘,.WM IN“?(1W I:I AmbTflate .I: Camcd“ Patient I.D.a’fi1mba1‘1£ vaéibally I3 O_thm u Allergy Band I. Waund Clja'ssJ_fi’CIeaufi‘C’l DConscious Sedation mBier Block'- : _ ’ Time out eformed h‘y 2812193211 Techfififiugeon Masthesm \ - TimC' 07in Patient, p1cce 111:3,- site, allelgies, antibiotics,implants verified - can contammflted E1 Contaminated :1 Infected Anesthesia Typwfiéneral mRe'gio'na! nMac‘ aSpmal uLocal 0%,an TIME OUTRM fl?2 rm No N/A ”HART REVIEW _ .. ...C eiif Si ' nfirmgd (ed filesurgery Slte " _ PLB-op Diagnosis: See AnesthesiaRecmd SpecimenG): # 2... Cultures Procedme: Dh‘rG-NO(TIOHqumW DMQNM'HO WWW” DWNA'GQUPW 7?).WWW Mcfi'hflm'. " ’ pamology mamWWW T'meae 1991301 MN mas; 1 NURSINGDX .. MLEMENTATIQN LPT‘IOWCDIVIE' '._,afi1:txiety ' " ' Orient to .cfo‘pmg mechamsmssf-‘f' , Refiiain califi ' ' iktfPain.’ 131500me11 Roomteipaddmg. bd’dY Temp I V ‘ Pain connoll'dx ?MLy- ED _-pt 3c 3113;. safety shaprosmon dswces :j_.}N0 Ig]u1y ' :1 Late1a1 Le " - prPotential for Infection Asepsis, Sterile Field ' . - - ”No Cempmmnse El Othel . SIGN AS SSMIJNT: UIIfI‘lEN-T USED: 249940 POSITIONING AIDS 1* .- . Intact: es . D No - :I Arm BodefL -~ Alma Tuck: ' Desc'nbe: and Table: CIRJght mLefl -' _ _ . .. afetyStrg Th1%. i _. cmcULAToR ..,.SCRUB TECH-g-gg I g - _o mummy? - RELIEF W, I Timcm': -- ' ' . ‘ .Tnjgih. ' Timeout: u '. . -'T!n1's'n'ut: POST 0P ASSESSMENT} I 7 'i I : .. ECautery. Glound Site Clem/Intact NA D ‘ LOC -.|:|-Unconsclouslu-mesy/Reachngt1; . ‘j‘ EJOthe'r ' ' - . " I I J Tounfiquet Site- a ClearZInta'ctpiNA Report Given To: A HINT‘T- ; . R'.N." D Other ,By D- (GOO. I RN.‘ ylessure areas qhgclced- _ 'Q'Irm1doff completed...“ I_ , OPERATMGRQQMRECORD i mfigfmsrfirimm r ys; Grays”?N 008: 4M2 adme O U PROCEDUREW . .. j. q 2 h Ma I .: "W ' -. anz- ' gummy ' - mEmONAL CK Ms '._ ‘ .Pacu _ - - ' -. . .- z ' . ' - -‘ DRESSINGSFIE' ' V : " ' ' fiNIA 3 1" f}, >3 ' DRAINAEEON Dassnv N DSPUNT nSUNG n-HRAEE ExrommLLowlsn-s? Av .c'nLn THERAPY av NA DRAIN f(‘mN ADMHQ‘ED VIA GURNEV SIDE RAILS U 'er HOB nFLAT . gmwax. uNASAL DORAL nLMA DETF SYSI'OHCE DIASTDLIE“A ?{Eair HuggarfiWan‘n blanket Total DR IUfluids_ '. ' SLEEPING?- g ‘- PDST C?Emme- :D; RECOVERY SEDRE “A 30 ' '5. - 15 _ PMN- CONSEIOUSNESS - lawn 1=mmunsfnnowsv I; £90- VEN‘I‘IL'A Zena? EREATHE DR CDUEH mumwsi‘munw 55F -' -. ' Acnvm .- = mmsnunpugfim j= ~ ' anflwanvnfl; -m , nannvnwnrmnv COLOR - ,- . ' ~ . - . ‘. I I j 2=NoumL . - - _ I . . I I u I zérauynusm - " ' URCULATIGN- quznx nrm- . AN'EIHEIA' .-.1;ap'zn-sux nF PHE- manila . ' ' 'naap'éaxpfimr am. I nnwmzurau NU Tomw'tm ' TOTALURAL- 6". m’l EMesls: U235 N0 vomnn. DIES ml E450 ' DRESSING: u N ' " RN JOHNSEN. STEPHANIE rmwsn: 390611 Gender:F 005:7;29I1935 Age:31 ‘j_ Phys:Graven.Nadine Dos: 4:7!2017 - m v-u-wm Wham; m..u..~.._....._....~_---.«---.--- r031: AHESTHESIA CAMRECORD NARRATIVE NURSING NOTES DATE I TIME NARRATIVE NOTES: B/P, HR, RIB, and Pain Level. Ability to ambulate - RN INITIALS mowement of extyemities. Dressings, Ora! Fluids, Voided, Ok'd far discharge, Physicia _n’s name. M. PATIENT LABEL POSTANES'IHESIA CARE RECORD Palo . \ XTCRL Alto 4:42am m ".41!an M’E. 3 .‘E (3:04 m5. 6.1-1“ its. am Fitttriiszé PathO lOgy '"c- 1L uzmfi .'.3‘L;;zia~--(:aa;- :13 R 2-325 El Camino Real Palo Alto, CA 94306 fl 1-800~303-4PAP \____ ,2 Kenneth Hadler, M.D. Director nag. Requesting Physician NfimNE @QMFEN M9 Required Information FRESSHRMLY Name {Lash F151. MI} JOHNSEN. STEPHANIE . . [D i Visit: 3906 I '1 Gender' F s Is I a - £32m ?.B‘i'himben DOB: 7129“ 985 Age: 31 Phys: Graven. Nadine Specimen Scurcc DOS: 4!?!2017 Dale andTime Cullected 1/071’1 QIL’ D a 31$ P‘ Jumgsls (ThIanp vial) D Tissue Exam E3113 ESE EHPV PAP Smear (Sundard slides)- m - , , ’ fl Single SlideD 1n Prep c RLIILx HPV D Double Slide Molecular Tests minim} vial} L-l Gmhlamydm Other Cytology U cc: {Elwin m Chramydia é “m“ L R U Harper Simpiex D! 339"“ l and 2 [type spacificl .- “n“ . D cystic Fibrosis U Other - Specufy Molecular Tests C3 Group B Strep (Pap Group Ii Swab] CI Fetal Fibronecnn '{nullecliun kill -. ‘4; AFFIFEI‘I". {Sana . , G-aro’. , "r‘1’.c.-n.} z. [CDTWD'IagnDSIS [Ml Insurance} #Tg9 ' M.X. fl _ Ins. CD. {Please attach copy a! front & back ol card! Address ¢- z Z \Kfifii’ , Wm 5.5JI.D.: {1‘1 inMK xx Group 3 lnsurcd’s Name Billing Information Ulnforrnalian 0n File Birthdaln [ Sex Home Phone Address City Stale Zip OGY PAP Smear‘tihcck Source \' N J Inca loin insurnnoc ln'Ecrmatinn - ' will mull 1n pnflcnl being billed Dchange 0r Informalion cnmcuy. D Pal-iunl U Cash History Circle Yes - No Below a Cervical - Endocervical Date of Last Menstrual Period Y Nfita! Hysterectomy i] Cervical - Vagina! Y N IUD fl Vaginal Y N Birth Cnntml Pills I Vulvar Y N Hormone Thar. Type: Y N Gross Lesion Cl Regular Ci Irregufar D SpouLng Y N Previous Cancer - sue S Pregnanl ['J Post Partum Y N irradiation - Date -- U Past-Menopausal Y N Repeal oi Atypical Smear C) ' OGY ' Biopsy Shea x} RHH’H 'F‘A'UW Pl’h‘l THEE 6,; W History m-um-MAN T: ms: Clinical Diagnosis _ Far Cytology Dept. Only- . _ _ a Dx N A L H D Operative Procedu‘rem (DMQNUETIO MY» Wfl-MWW‘L s Comment www.warifiri bm'IEH/M» fajw: Nam? {¢th :1 gfif‘mm g ix :4 find. i; Comments Ufft'h' ?.l-mmfifl MMKX HHJJ. DQ-fu W185 s. MI u P: t: s: a < ’ so |-tnrm.Pm. c U 0+" (:41 whim 0M” a mm u a F T___,_ #8 Backgmund U M! Modl Mkl B #9 (:on _ :10 Path%__,________ Signature nf Requesting Physician a Type] U Type 2 D Types U TYPE” IT: Phone Consultation Requested _ ydditiunai Copies lo: Name Q’APMR’HM ’ENMIM‘CFOP" Address Dearmm CENTEF~ Advance Beneficiary Notace Your physlcinn Ins ordered Ihc abuvv: 1le because hmhe bellevm that the Ins: results are rulevhnl Ia evaluating and munlmdng [he stale ol ynur lwallh. Humour, unrlm Section 1302 tn] n) of Ihc Mcdlgan: Law.” paymum may Ix: denied by Medicare {ur lesls which. In their opinion. arc mmldcml 'scrccn‘mg lush“, suns which Ilavo. been performed-‘mo fruquénllr‘. 0r when rhn diagrams suhmItuzd dues no! [usury the lcsls wdm-d. Financial Rmpnnsihilily Actuawiedgmcnt: I have been notified bf my physicinnfprmlder that hmm believes Ihal. In my cam payment Ii ilke|y ta be denied for one nf :hu runsum nmnrl nbmn If pafmcnl Is :lcnicrl, I amen Io hr: llcrsunally and [ully mnsihlo far payment. and to make such paymnnl when billed. Yellow - Laboratory Copy 0 B1ue - Transcription Copy I- While - Physician‘s Com: .. “.1-.. mu- ._.......v i’micnl's Slgnatute um u-mm-u nan... u._,.._ ...._._......--.m..- .I w ......I-- ....._. ...._.......H “mana...- -_...‘... O Palo '7... Alto “ f; I-l‘ I- ‘-r.;'-.“' Patho |ogy Inc. ‘ 3.“..1'. i, .u .g. 2325 El Camino Real Falo Alto, CA 94306 1-8003 03~4PAP Kenneth Hadier, MD. Director LJ Tissue Exam PAP Smear (Slandatd slides) E “?sls {m‘ump vial] v n Prep Ll 111m Frep'é HPV ; LJ Singfe SlideD Thin Prep E Reflex Hm D Doulfle Slide Molecular Tests UhlnPrep vial] a GCIChlamydia om" cw°l°5Y mac U B L RC Chlamydia D 51:32:;E Herpes Simplex D Urine 1 and 2 (type specific} U Cysiic fibrosis D Other ' Spec"? Molecular Tests Requesting Physician NF)? t; i N {I $131!; iii?" rd ("Hi L] Group B Strep tPap Group I Swab) D Fetal Fibronectin _ (collcclion kll) .. Recfiiired Information: miss FIRMLY n “I . ‘ I W h “Cf! ‘ I Name(Lasl. Flrsl,Mll JOHNSFN' STEPHANIE _ , "{1? . ?qu s ls t g ID (Visa: 3906 I1 Gender; F Icoma‘Dragnosss mulnsumm-J v J " ' ocia ccuti y . , ll’111cm l.D. Number} DOB' 7’29“ 985 Age' 31 IflS- CO-fl _ ‘ Phys; Graven. Nadine Must: allaul: cup;- uI lmnl a back uf card: Specumen fiource Dos: 4ffl2017 Address ..--,a-l..r l : h” . ,. ,... I 1 x"- dk K -“ . u J 1 Wu I . m :. -. . r. I; .- '\ A- l’a- ‘ i Date and Time Collected " 1 i," f fl 7 Km" ‘ J 3" -/ 5.51m; L A” R ' ¥ vv' A m1 1 w Gruup .‘.‘ 1' Birlhdale Sex Home Phone ' Insured's Name Address Billing lnfarmation Dlnfotmalinn on File '"fnma'm" DChange of Information City Slate gip :Elelcrfisah Ln patiam biting lflllpd D Patient D Cash imp Smear‘IChcck Source h ' History CiIcIcch - Na Hclnw [ll Cervical - Endocewicnl Dale of Last Menstrual Period Y N Total Hystereclomy C Cervical - Vgginal Y N IUD U Vaginal n Y N Birlh Conlroi Fills 3 vulva]. Y N HormoneTher.Type: Y N Grass Lesion fl Regular U Irregular '_'_I Spelling Y N Previous Cancer - Site D Pregnant E Post Parlum Y N Irradiation - Date ' i“: Posl-Menopausul Y N Repeat of Atypical Smear SURGICAL ATHO OGY i f 1 ' '3; "' ,1 - ‘ I . 2;: f; ._-'_.a 1- ‘ a s-opsys.siget T M :41: 4 A f m MN 1W». 6 m- ! Him, ?nzhi W! M 11”.»? Clinical Diagnosis For Cytology Depl. Only a r I ,r r i i 3| OX N A L H D Operative Proqeduretsl E U1 1’ L' “i2 «IYW {{‘ii =’.3}? ; a comment .3} ', 1-, Hf. '~. I .l #55} ‘ ‘ -:-H ‘I'ikif €14??? 9" TIL“ :3 Class l J 4 5 wI; ' 1A!” ‘ (”fl ' 1‘; Li: i 1:; ”hp” :4 CellPattem S Ex A M Enr} H Comments - - h jfi- 'H.’ iulk. i=4”: ~ H“ f-‘Q HK-N1.--1‘~L;I€' #5 MI U P: l: 5= f} H,- / q , __, #6 Hetm. Pal. C U.a‘ 3F": “m ’11 LY r #7 Flora U B F T : Backgmunrl U M1 Mod! Mk! B #9 Cylo m... I _ _ _ #10 Path Signature of Requesting Physicmn U Type I U Twez D Twas D Tim“ D Phnnn (?nnsulmlinn Requested '~ ~ . -. - . ‘5: .h._ L-twt'q" LJAddilional Copies to: Name 4M IWH :l' I 1 9'” " 'H I Address ’.-' ”‘1".4: Demmm #j' v‘riff Advance Beneficiary Notice \‘nur physiclan has ordered Ihc above lcsl because heist“.- believes Ihat {kc lasl results me tdnvnnl lo evalualing and monlloring the mu.- olyour health. However. undchccllnn I862mm nfthe bluelign: Lam mrmum ma)- he denled hy Mcd'lcare for lcsls which.‘In Ihcir cpimuu, are cumidcxcd “screening lens", lam which hm: lv-on parlarmcd ”Ina [tequL-nlly'. or \vhcn the diagnosis svbmiucd docs mt imlfly llu: IC-yls unleml. Financial Huspnnsihllily Acknowledgement: l have Imcn natlfied by my physiciarvpmvidc: that hush;- hcllmrcs Ihal in my :osc. pwmcm ls llkcly tn lac denied [or one ol lhc- masons nmcd abuvv- II paifimnl iwhv' lame Io be personally and fully mpenslbm for Immunl and m make such payment when billed. Yellow- Laboratory Copy - Blue Transcripzinn Cnpy n While- PhysiciansCopy ._-. m--.“ ....._. _.__.. um... m..._. _.H --......- u-.. .- .....‘.,,...._ .m. _‘.... .. _... u-v-...!-...... . v. ... .-.._...‘ Patrcm's Signature aJ a' ..._ u..‘.--,_. .‘......_._,,.....u._‘; ACKNOWLEDGEIWEN'I‘ 01F RECEIPT 01F DISCHARGE INSTRUCTIONS RN ‘ RNPROCEDURE INSTRUCTIONS INITIALS moCEDURE INSTRUCTIONS INITIALS fl CENTER P031301: INSTRUCTIONS flux LAPAROSCOPY--GBNERALIGYNE M " BREAST BIOPSYPROCEDURES ARTHROSCOPY IQIBE ENTPROCEDURES ARTI-HIOSCOPY SHOULDER GENERAL SURGERY-OPBN CASES HANDHELBOW CASES FOOT/ANKLE CASES OTIER ORTHO CASES CRUTCHINSIRLICTIONS____-__'______ ___...._, ,... ,,. K F .93 :9. :5 a, § _ PAJN (INJECTION) MANAGEWNT . p, m}...7 g“ ix" .I x .cw- L:_ REGIONAL ANESTHESIA BLOCK. I. ' m ., ‘ E__ a a ~-~ Nt'msmMUST INITIAL ALL DISCHARGE Igi i ’ "6:1; m, .;' ‘"‘ r- a . :1 ,xzt': w .. wax '7 n f. m" c'f" n Qu 6' COMMENTS: Prescription o Pafient Documented Ki N ”g; ' '~ “fl r: g fig? E g i?! gm Patient at discharge. flYes [] N/A {IL E I \‘C/ ,z if ‘5'. g E): 2 g 3%,‘i x "m . -..,_ ‘ 1% a g ‘ a /,V] Written prescription given to patient ,K/of-eo .51~-' g ;;_-_ t, r é E $3 g g .5 I . ."~ i-----~ - Lpr: [ ] Prescription called Into pharmacy bv [ ] Surgery Ca; E. i \ :3, - L- E3 g g =2 g =2 :- Cg _ ‘.-- , ch fa "° > ' 1 Patlent received prescriptions prior to surger =5}; E? ’ 1-" .§ E E E § , v - Y g .-,. fl. ~34 ??w: flamkr [ ] MD wants OTC (overthe counter) pain relieVers only ’5 ' "f3 '33.. 3 g E g g $2 "‘z’ fiu ' “‘1‘“. ”:4 r- .” z; H W “ '. ' S“ 's-"J fig E aggfi w c; w‘ s: a: -': ' . .3 ‘ ‘ . i: [Pafientxnitials Reguired , a a 9 u a O a g g: gig 2 § E11"' The Surgew Center has permission to leave a disc} ,- g i‘g g E g g g g E é g E g é; La) K w 4 The Surgery Center has permission to leave a detg ' 52? z E, E z é, E a é g g r" FAMELY/PATIENT'S SIGNATURE BELc' gig g f? g ‘3}? w i ' 5 HAVE RECEIVED AND UNDERSTAND " 2 a ~33? Eff? 3 5; l 2 DISCHARGE INSTRUCTIONS. z z L g” z a i 1.; 0% ' ;. J. A E. ‘ ' I ‘ U‘ 2"; _,;_ a 5' fl’ é -f a m Signature ofPatient or Patiént Rgescnmfive Dgite u fl 4' f @4150?“K --¢E ~ ‘ Regf’stcred Nurse Signature Registered Nurse Initials After the form is completed, plays it in the patient‘s record. ‘ ' HANIE * JOHNSEN’ STEP der: F ID Man: 3906 H i3; 31 DOBz'HZQHQBS _ -_ Graven. Nadine -' EEK: anmnfi' M HOME POSTQPERMIVE uINS'ummows If you have received only LOCAL ANESTHESIA: ' You may eat and drink whatever you like as soon as yau get home. Be sure to drink plenty offluids. m If you have received GEN ERAL ANESTHESIA, momroam ANESTHESIA CARE, or SEDATIDN: . _ 1. Increase diet slowly, beginning with 'quuids, crackers, toast JeIl-o and soup. No fried orspicy foods for , the first 24 hours. Drink pienty of fluids , 2. Take only the medication(s) prescribed by your physician. You may resume your routine medicatioms} unless otherwise ordered by your physician. 3 It i5 recommended that you have a responsibie adult stay with you for the first 24 hours at home. 4. Take 3 «4 déep breaths every hour while awake. Continue this fur at least 3 days following surgery. 5. 'lf you are on blrth cor'ltrol and taking antibiotics, please consult your physician for a different means of contraceptive (bii-th control method) Antibiotics may disrupt your current form of birth control. 6. FOR TWENTY-FOUR {24) HOURSAFTER SURGERYAND WHILEON NARCOTICS PAIN MEDCIATION{S}: DO NOT DRIVE, OPERATIVE MACHINERYOR POWER TOOLS, DRWKALCOHOUC BEVERAGES, TRANSACTLEGAL BUSINESS, CARE FOR A DEPENDENT PERSON OR TAKE PUBLIC TRANSPORTATION ALONE. FOR CHILDREN: Do not Nd a bicycie, scooter, or skateboard. No strenuous outdoor activity. 1 Call Dr. £43,912: i ' 34m 5A73 lgJamediately if you have any unusual reactions such a5: a Fain not relieved by prescribed pain medication a e Chills and/or fever over 103. o Unexpected or excessive bleeding or swelling at Operative site a Extreme redness, blueness Dr swelling at operative site - 0 Persistent nausea or vomiting vhf a You are unable to urinate by the end of the day Seek emergency medical attention for any of, the following symptoms: o Rapid rise in bo’dv tem perature a Rigid or painful muscles, not associated with the surgery - o An abnormaliy rapid or irregular heartbeat ‘ a _ Brown or cala-colored urine o Very low blood pressure a Confusion - Muscle weakness or swelling, not associated with the surgery C) a Fiushed skin [Associated with any of the above) o Sweating [Associated with any of the above) Your doctor wants to see you in the offlceflon I MIL“ Ca|[§ngm.tomarmw-fananpgintment [II Afready has an appointment D N/A ’ {OJIOJJ instructionsfion__attanhed-siT€"EY flstrucfions on file D N/A (Take all medic'ationtslfliidlreflflgted i udmg-pam-medllafi ---m D N/A Médmons: D N/A E Prescription for pain/o her" medication attached Med(s).jfi rm 5: 337% Wrescriptmn for pain/other medlfigation attached '/M8d{5:: mrdrr‘“£60014 Additional Discharge Instructions: r V JOHNSEN. STEPHANIEHome with (si'gnatureM‘yfl/ 4. . ,D N‘s“: 3906 I 1 Gender F WitneSSLffifia .E DOB: 7129f1985 Age: 31 Phys: Graven, Nadine DOS: 4!?!201 7 O Samaritan Surgiéai fl-mup .. Minor GYN Post-On Instructions Nadine Graven MD, FACOG JOHNSEN. STEPHANIE [D I Visit: 3905f 1 Gender: F I Please take it easy around your home today. - DOB: ?I2QI1985 Age: 31 . N0 driving today Phys: Graven, Nadine Dos: 4;?!2017 If your IV site'15 sore you may put a warm compress 0n it. 0 Bath or showers are OK . o Please take your Motrin every 8 hrs as needed for pain or cramping. If you need the . stronger narcotic pifl, you may take it while you are also taking Motrin The two typos of ' pain pills do not have any intér'actmns. ' ’ c Pads or tampons are OK. . f C ‘ _ _ ‘ o No exercise restrictions“ . n0 ggY,Ev] wee [L o You may eat what you like. e Call (408) 378-1888 at any time day or night if you have severe pain, nausea, heavy bleeding or any other severe symptom that you are concerned about. We are happy to Speak with you. flr/e/mama¥an ”f Date ZI/M/L m; vaaiéfié, A No J/QO '“'" f“ I umew enemy?- ”Mau Mmm nof C) OLMW) shrew cad, i AU MJ LN/QQ J J I ~~ mo 8 • 9 n ( / ' () JOHNSEN, s,E?\-IANIE ID I Visit'. 3906 / 1 Gender: F ooe: 7/29/1985 Age: 31 Phys: Graven, Nadine oos: 4nJ2017 t m r l v n . u ._ . o ha u t 2 32 3 : 3 9 30 : n .u u a soc w gua fla . n// .m. m:. .v.u ._ . E E £ = Eo> 3 = 9X §Umu E r ; n: 5.. ] : va 3 7 5. 0 8 19 ; . .. K . S P. a fmu C v U- E re i gn . n . ~ ._ o Am L.. . z awwnw anum S E: 5Q ‘ M ? M _0 : . . S . m«“ fig .~ . n . 5 5 5 OM E . 0J5 \~ guy ga iLU/y‘ “N : w n . w p Eu : S a aued EcaO F 3. 5 IWw I C av.. . 5. E 9 9 mn C 2 3 3 5.: T .“ o» B L E . S n $ . fi .~ .. n fi § § =o OM. tn J va m 0U$O Z c . C E .X OW 1 . - I I - I . I 3. . . . A . I l . | . . A ! . i . . |. . . . c : . . u u : I l l . K a i l an I I A A I I mmwhub< 5 : . .. a d . - . i . . f i . - . - s l l - - 1 { $ 576 9 SUSM KW i g s ; 3 8 flu H g am 2 8 ‘ 3” 8 9. . 0 8 3 5 £ 3 9 50 . 4 5. 3 9 1 5 .w w : S 3 9» : 2mg 6 8. 3 .u. .. 4300.0 Girls (1-10 years) 6.0 - 27.0 Roche ECLIA methodology Estradiol Normals: Adult Female: Follicular phase 12.5 - 166.0 Ovulation phase 85.8 - 498.0 Luteal phase 43.8 - 211.0 Postmenopausal <6.0 - 54.7 Pregnancy 1st trimester 215.0 - >4300.0 Girls (1-10 years) 6.0 - 27.0 Roche ECLIA methodology reviewed and charted by MS 08/28/2017 10:01 AM Tech: mm ID#: lmportedLab Test Facility: LabCorp San Diego 13112 Evening Creek Dr So Ste 200 San Diego CA 92128410: Pt ID: 12190 Reported: Last Modified: 08/28/2017 Patient: Johnsen, Stephanie 07 /29/85 PMS ID: 23464-1 PreQa red by C::nr-innrh::1r+cR--'!~ Page 1 of 1 A WnmPn~ rPntpr n 0 u A Womens Center 476 East Campbell Avenue Campbell, CA 95008 (408) 378-1888 08/24/2017 FSH, Serum FSH 5.1 Note: FSH note: Adult Female: Follicular phase 3.5 - 12.S Ovulation phase 4.7 - 21.5 Luteal phase 1.7 - 7.7 Postmenopausal 25.8 - 134.8 FSH Normals: Adult Female: Follicular phase 3.5 - 12.S Ovulation phase 4.7 - 21.5 Lu teal phase 1.7 - 7 .7 Postmenopausal 25.8 - 134.8 reviewed and charted by MS 08/28/2017 10:01 AM Tech: mm ID#: Imported Lab Test Facility: LabCorp San Diego 13112 Evening Creek Dr So Ste 200 San Diego CA 921284101 Pt ID: 12190 Reported: Last Modified: 08/28/2017 Patient: Johnsen, Stephanie 07 /29/85 PMS ID: 23464-1 PreRared bv t;nr-i nnrh::i r+cJ:MR Page 1 of 1 A WomPn~ rPntpr 0 u A Womens Center 476 East Campbell Avenue Campbell, CA 95008 (408) 378-1888 08/24/2017 Progesterone Progesterone 0.2 Note: Progesterone note: Follicular phase 0.1 - 0.9 Luteal phase 1.8 - 23.9 Ovulation phase 0.1 - 12.0 Pregnant First trimester 11.0 - 44.3 Second trimester 25.4 - 83.3 Third trimester 58.7 - 214.0 Postmenopausal 0.0 - 0.1 Progesterone Normals: Follicular phase 0.1 - 0.9 Lutealphase 1.8- 23.9 Ovulation phase 0.1 - 12.0 Pregnant First trimester 11.0 - 44.3 Second trimester 25.4 - 83.3 Third trimester 58.7 - 214.0 Postmenopausal 0.0 - 0.1 reviewed and charted by MS 08/28/2017 10:01 AM Tech: mm ID#: Imported Lab Test Facility: LabCorp San Diego 13112 Evening Creek Dr So Ste 200 San Diego CA 92128410: Pt ID: 12190 Reported: Last Modified: 08/28/2017 Patient: Johnsen,Stephanie 07/29/85 PMS ID: 23464-1 PreRared bv <;,l"\rinnrh:::ar+c:FMR Page 1 of 1 A Wnmpn~ rPntPr (') 0 u A Womens Center 476 East Campbell Avenue Campbell, CA 95008 (408) 378-1888 08/24/2017 Prolactin Prolactin 8.9 4.8-23.3 Note: null reviewed and charted by MS 08/28/2017 10:01 AM Tech: mm ID#: lmportedlab Test Facility: LabCorp San Diego 13112 Evening Creek Dr So Ste 200 San Diego CA 921284101 PtlD:12190 Reported: Last Modified: 08/28/2017 Patient: Johnsen, Stephanie 07/29/85 PMS ID: 23464-1 PreP.a red bv C:nri nnrh~r+c:FMR Page 1 of 1 A WnmPn~ 1Pntpr n 0 u A Womens Center 476 East Campbell Avenue Campbell, CA 95008 (408) 378-1888 08/24/2017 Testosterone, Serum Testosterone, Serum <3 A Normal:8-48 Note: null reviewed and charted by MS 08/28/2017 10:01 AM Tech: mm ID#: lmportedLab Test Facility: LabCorp San Diego 13112 Evening Creek Dr So Ste 200 San Diego CA 921284101 Pt ID: 12190 Reported: Last Modified: 08/28/2017 Patient: Johnsen, Stephanie 07 /29/85 PMS ID: 23464-1 PreP.a red bv C:nrinnrh~r+c:FMR Page 1 of 1 A WnmPn, 1pntPr ('1 u u A Womens Center 476 East Campbell Avenue Campbell, CA 95008 (408) 378-1888 08/24/2017 Thyroxine (T4) Free, Direct, S T4,Free(Direct) 1.01 0.82-1.77 Note: null reviewed and charted by MS 08/28/2017 10:00 AM Tech: mm ID#: lmportedlab Test Facility: LabCorp San Diego 13112 Evening Creek Dr So Ste 200 San Diego CA 921284101 Pt ID: 12190 Reported: Last Modified: 08/28/2017 Patient: Johnsen, Stephanie 07 /29/85 PMS ID: 23464-1 PreRa red bv ~nr; nnrh~r+c-l=M~ Page 1 of 1 A WnmPn~ rPntpr A Womens Center 476 East Campbell Avenue Campbell. CA 95008 (i) (408)37aw1388 08/24/2017 Triiodothyronine (T3) Triiodothyronine (T3) 99.0 71-180 Note: null reviewed and charted by MS 08(28/2017 10:00 AM Tech: mm |D#: ImportedLab Test Facility: LabCorp San Diego 13112 Evening Creek Dr So Ste 200 San Diego CA 92128410: Pt ID: 12190 Reported: Last Modified: 08/28/2017 O Patient: Johnsen. Stephanie 07/29/85 PMS ID: 23464-1 page 1 of 1 anfiflafigigchln A Wnmen: (‘pnter ("I 0 u A Womens Center 476 East Campbell Avenue Campbell, CA 95008 (408) 378-1888 08/24/2017 TSH TSH 2.35 0.450-4.500 Note: null reviewed and charted by MS 08/28/2017 10:00 AM Tech: mm ID#: lmportedLab Test Facility; LabCorp San Diego 13112 Evening Creek Dr So Ste 200 San Diego CA 92128410: Pt ID: 12190 Reported: Last Modified: 08/28/2017 Patient: Johnsen, Stephanie 07 /29/85 PMS ID: 23464-1 Pr•P.• red bv C::nri nnrh::lrtc:FMA Page 1 of 1 A WnmPn~ rPntPr n 0 u A Womens Center 476 East Campbell Avenue Campbell, CA 95008 (408) 378-1888 08/24/2017 Vitamin B12 VitaminB12 525.0 211-946 Note: null reviewed and charted by MS 08/28/2017 10:00 AM Tech: mm ID#: lmportedlab Test Facility: LabCorp San Diego 13112 Evening Creek Dr So Ste 200 San Diego CA 92128410: Pt ID: 12190 Reported: Last Modified: 08/28/2017 Patient: Johnsen, Stephanie 07 /29/85 PMS ID: 23464-1 P reP-a red bv C::r\l'"i nnrh.::i r-+c:FMA Page 1 of 1 A WnmPns rPntPr n 0 u A Womens Center 476 East Campbell Avenue Campbell, CA 95008 (408) 378-1888 08/24/2017 Vitamin D, 25-Hydroxy Vitamin D, 25-Hydroxy 36.5 30.0-100.0 Note: Vitamin D, 25-Hydroxy note: Vitamin D deficiency has been defined by the Institute of Medicine and an Endocrine Society practice guideline as a level of serum 25-OH vitamin D less than 20 ng/mL (1,2). The Endocrine Society went on to further define vitamin D insufficiency as a level between 21 and 29 ng/mL (2). 1. IOM (Institute of Medicine). 2010. Dietary reference intakes for calcium and D. Washington DC: The National Academies Press. 2. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. JCEM. 2011 Jul; 96(7):1911-30. Vitamin D deficiency has been defined by the Institute of Medicine and an Endocrine Society practice guideline as a level of serum 25-OH vitamin D less than 20 ng/mL (1,2). The Endocrine Society went on to further define vitamin D insufficiency as a level between 21 and 29 ng/mL (2). 1. IOM (Institute of Medicine). 2010. Dietary reference intakes for calcium and D. Washington DC: The National Academies Press. 2. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D Patient: Johnsen, Stephanie 07 /29/85 PMS ID: 23464-1 PreRa red bv C:nrinnrh"'rtc:FMR Page 1 of2 A Wompn~ rPntPr n 0 u deficiency: an Endocrine Society clinical practice guideline.JCEM. 2011 Jul; 96(7):1911-30. reviewed and charted by MS 08/28/2017 10:00 AM Tech: mm ID#: lmportedlab Test Facility: LabCorp San Diego 13112 Evening Creek Dr So Ste 200 San Diego CA 921284101 PtlD:12190 Reported: Last Modified: 08/28/2017 Patient: Johnsen, Stephanie 07 /29/85 PMS ID: 23464-1 PreQa red bv C:nri nnrh;:ir+cFMR Page 2 of 2 A WnmPn~ rpntpr Study ID: 19984 Mary Kilkenny MD/ Nadine Glaven MD Name' JOHNSEN STEPHANIE ' _ u Study Date:OBI24I2017 o4:41 PM IMRN. 17-08-24-164159 Performed By: @003: Referring Physician: :Age: § Gender: Aw- ............... . ...................w 1....» u .. , _.. . ... ... . .. ......w...“ . .,....,,..,. _. m.‘ w. w. n.» .»-..wv-..-.n.- ......r....-.....,.,..._ ..- . . .. .... ......m......-... __._.. ....- ‘ H . LMP- Gravida: O }Expected Ovulation: Para: 0 5E2 Level: Aborta: 0 §HCG Given: _ v Ectopic: 0 2D/M.o gmeae fi,11_r.ewm§m§_&._cnaj§.u1§ti,oxi_s Used In Calc 1 2 3 4 5 UTL: 8.50 cm 6.50 Endometrium: 0.547 cm 0.547 ROL: 2.85 cm 2.85 LOL: 2.66 cm 2.66 \ {i?fi-égieg-rfmhthe report are not for diagnosss. - i muvxlx manlrxn ‘ I ’,- :uli PHIUDS I Hwn ulnurwl u ' I ‘m «pumps i ‘5 |( 5m Ht" ll' v '_l IIIL mu.- Hl) r. ville (imuu‘llr lrllf.‘ 14" lll I1! ll! II IIIyP'Uffimw “1| ‘3.)lm -i.l 'w- n‘m 1 IJ. III? I -Wnatrnal‘ ‘ '1'” I m- hm ' a1mm 17-08-244 641 5908/24/20 1 7 04:41 PM Page 1 of2 3 ' mwn'v.‘ annual: x; :1 2m) Dmups u uu '- l n. na- qaw t m .mnv W.) mum... thaw... "H. I Ium. I"! *-__ : u. .‘y . Interpretation Summary: This was essentially a normal study. O Reading Physician: 17-08-24-16435908/24/201 7 04:41 PM Page 2 om n 0 A Womens Center 476 East Campbell Avenue Campbell, CA 95008 (408) 378-1888 01/08/2018 Message to: claire from: claire date: 01/08/2018 time: 1:47 PM re: Johnsen, Stephanie 07/29/85 patient called and wanted to speak w/ someone about her account callback#408-4 72-9996 01/08/2018JW 1:48 PM Called patient back, she wanted to know if she had any balances on her account C.D. 01/15/18 12:54 PM Patient Number: 12190 Chart ID: 45 u Patient: Johnsen, Stephanie 07 /29/85 PMS ID: 23464-1 PreP.a red by C::nt"i nnrh~ r+-c::FMR Page 1 of 1 A WnmPns 1PntPr Law Offices of OKOOOQQUI-PUJN NNNNNNNNHt-tt-th-tt-tt-th-tt-tt-ti-t \IONM-wat-Okoooflmm-bwwt-K 28 HINSHAw, MARSH, STILL & HINSHAW A Partnership 12901 Saratoga Avenue Saratoga, CA 95070 (403) 861-6500 EXHIBIT B 4 DECLARATION OF SCOTT R. KANTER IN SUPPORT OF MOTION FOR SUMMARY JUDGMENT OR, IN THE ALTERNATIVE, SUMMARY ADJUDICATION BY DEFENDANTS NADINE GRAVEN, M.D. AND VENTANA MEDICAL GROUP, dba A WOMEN’S CENTER N0. 19CV352312 ACUI s Caption: Acuity Order Number: NorCal Case: NorCal Claim: Patient: Facility: E R V l Johnsen vs. Gravin, MD 162243 509626 CLA0511221 Johnsen, Stephanie C E s Angela Pollard, M.D. Womans Center Should you have any questions about this order your Case Manager, Zachary Marberg would be happy to assist you. They can be reached directly by phone at 720-941-9584 ext. 1014 or by email at zmarberg@acuityservices.com. 1764 Gilpin St Denver, CO 80218 Phone: 720-941-9584 Fax: 720-223-7279 www.acuityservices.com SUBP-D10 FOR COURT USE ONLYA'ITORNEY OR PARTY WITHOUT ATTORNEY (Name. Stare Bar number, and address): 99908 ~Hinshaw. Marsh, Still & Hinshaw LLP Barry Marsh, Esq. 12901 Saratoga Ave Saratoga. CA 95070 TELEPHONE No.1 (408) 861_6500 FAX No..‘ (403) 257-6645 E-MAIL ADDRESS: ATTORNEY FOR (Name): alozano@hinshaw-Iaw.com Gravin, Nadine MD. SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PLAINTIFFIPETITIONER: Stephanie Johnsen DEFENDANTIRESPONDENT:Grain. Nadine M_D_ CASE NUMBER: DEPOSITION SUBPOENA FOR PRODUCTION OF BUSINESS RECORDS 190V352312 THE PEOPLE OF THE STATE 0F CALIFORNIA. T0 (name, address, and telephone number of deponent, if known): ABOVE FARR WOMEN'S CENTER 700 West Parr Avenue, Suite I Los Gates, CA 95032 1. YOU ARE ORDERED TO PRODUCE THE BUSINESS RECORDS described in item 3, as follows: To (name of deposition officer): Acuity Services On (date) : 12M 3i2019 At (time): 10:00AM Location {addreSS)= 1764 Gilpin Street. Denver, co 8021s Do not release the requested records to the deposition officer prior to the date and time stated above. a. m by delivering a true. legible. and durable copy of the business records described in item 3. enclosed in a sealed inner wrapper with the title and number of the action, name of witness. and date of subpoena clearly written on it. The inner wrapper shall then be enclosed in an outer envelope or wrapper, sealed, and mailed to the deposition officer atthe address in item 1. b.E by delivering a true, legible, and durable copy of the business records described in item 3 to the deposition officer at the witness's address. on receipt of payment in cash or by check of the reasonable costs of preparing the copy, as determined under Evidence Code section 156303). c. E by making the original business records described in item 3 available for inspection at your business address by the attorney's representative and permitting copying atyour business address under reasonable conditions during normal business hours. 2. The records are to be produced by the date and time shown in item 1 (but not sooner than 2O days after the issuance of the deposition subpoena, or 15 days after service, whichever date 1's later). Reasonabie costs of Iocatfng records, making them available or copying them, and postage, if any, are recoverable as set forth in Evidence Code section 1563(b). The records shall be accompanied by an affidavit of the custodian or other qualified witness pursuant to Evidence Code section 1561. 3. The records to be produced are described as follows (if electronically stored information is demanded, the form or forms in which each type ofinformafion is to be produced may be specified): Any and all Medical and Billing Records, a5 well as Radiology Filmsllmages pertaining to Stephanie Johnsen (DOB: OTIZQM 985)m Continued on Attachment 3. 4. [F YOU HAVE BEEN SERVED WITH THIS SUBPOENA AS A CUSTODIAN OF CONSUMER OR EMPLOYEE RECORDS UNDER CODE 0F CIVIL PROCEDURE SECTION 1985.3 OR 1935.6 AND A MOTION TO QUASH 0R AN OBJECTION HAS BEEN SERVED ON YOU, A COURT ORDER 0R AGREEMENT OF THE PARTIES, WITNESSES, AND CONSUMER OR EMPLOYEE AFFECTED MUST BE OBTAINED BEFORE YOU ARE REQUIRED TO PRODUCE CONSUMER OR EMPLOYEE RECORDS. DISOBEDIENCE OF THIS SUBPOENA MAY BE PUNISHED AS CONTEMPT BY THIS COURT. YOU WILL ALSO BE LIABLE FOR THE SUM OF FIVE HUNDRED DOLLARS AND ALL DAMAGES RESULTING FROM YOUR FAILURE T0 OBEY. Date issued: ““31'2019 Barry Marsh. Esq. b 5 I . [TYPE 0R PRINT NAME) {SIGNAwRE 0F PERSON ISSUING SUWOENA} Attorney for Defendant Gravin. Nadine MD. (TITLE) (Proof of service on reverse) Page 1 ofz orm e for an D Us Den ivi race ure. . - . :F Adm M dam 9 DEPOSITION SUBPOENA FOR PRODUCTION Cd f0 'P gmggqggfgggglgc’ggngggJudicial Council of Califomia SUBP-O1D[Rev.January1.2012] OF BUSINESS RECORDS m.courls.ca.gov SUBP-025 ATTORN EY OR PARTY WITHOUT ATTDRN EY (Name‘ Stare Bar number, and address): 99908 FOR COURT USE ONLY -Hinshaw. Marsh. Still & Hinshaw LLP Barry Marsh. Esq. 12901 Saratoga Ave Saratoga. CA 95070 TELEPHONE No 818-844-0188 FAX Ho. ropfionau; (408) 257-6645 E'MA'L ADDRESS ”9'50””; alozano@hinshaw-Iaw.com ATTORNEY FOR (Name): Gravinl Nadine Mill SUPERIOR COURT OF CALIFORNIA. COUNTY OF STREET ADDRESS MAILING ADDRESS: CITY AN D ZIP CODE BRANCH NAME: PLAINTIFF! PETITIONER: Stephanie Johnsen CASE NUMBER: DEFENDANT! RESPONDENT Gravin. Nadine MD. 1 QCV35231 2 NOTICE To CONSUMER 0R EMPLOYEE AND OBJECTION (Code cw. Proc., §§ 1935.3,1935.6) NOTICE T0 CONSUMER 0R EMPLOYEE T0 {nam9): Stephanie Johnsen cfo Andrew Agtagma. Esq. 1. PLEASE TAKE NOTICE THAT REQUESTING PARTY (name): Defendant Nadine Gravin' MD. SEEKS YOUR RECORDS FOR EXAMINATION by the parties to this action on {specify date) 1211312019 The records are described in the subpoena directed to witness (specify name and address ofperson or entity from whom moords are sought): ABOVE FARR WOMEN'S CENTER 700 West Parr Avenue. Suite 1 Los Gates, CA 95032 A copy of the subpoena is attached. 2. IF YOU OBJECT to the production of these records, YOU MUST DO ONE OF THE FOLLOWING BEFORE THE DATE SPECIFIED. IN ITEM a. OR b. BELOW: a. lf you are a party to the above-entitled action. you must file a motion pursuant to Code of Civil Procedure section 1987.1 to quash or modify the subpoena and give notice of that motion to the witness and the deposition officer named in the subpoena at least five days before the date set for production of the records. b. If you are not a party to this action. you must serve on the requesting party and on the witness, before the date set for production of the records. a written objection that states the specific grounds on which production of such records should be prohibited. You may use the form below to object and state the grounds for your objection. You must complete the Proof of Service on the reverse side indicating whether you personally served or mailed the objection. The objection should not be filed with the court. WARNING: IF YOUR OBJECTION IS NOT RECEIVED BEFORE THE DATE SPECIFIED IN ITEM 1, YOUR RECORDS MAY BE PRODUCED AND MAY BE AVAILABLE TO ALL PARTIES. 3. YOU OR YOUR ATTORNEY MAY CONTACT THE UNDERSIGNED to determine whether an agreement can be reached in writing to cancel or limit the scope of the subpoena. If no such agreement is reached, and if you are not otherwise represented by an attorney in this action, YOU SHOULD CONSULT AN ATTORNEY TO ADVISE YOU OF YOUR RIGHTS OF PRIVACY. Date; 11r13r2019 Barry Marsh. Esq. ’ 5WW. 6% (TYPE OR PR'NT NAME} (SIGNATURE 0F d REQUESTING PARTY m ATTORNEY) OBJECTION BY NON-PARTY T0 PRODUCTION OF RECORDS 1.E | object to the production of all of my records specified in the subpoena. 2. m | object only to the production of the following specified records: 3. The specific grounds {or my objection are as follows: Date: (TYPEORPRINT NAME) {SIGNATURE} (Proof of service on reverse} F3991 of: o ‘ fl P . 5335'; fggfgififigfinfig ”“3 NOTICE To CONSUMER 0R EMPLOYEE AND OBJECTION “dagg‘fggs gagg‘gg. 5UBP-025 [Rev January1.2003] 2020 0104020510 MW: aourfinfo ca. gov SUBP-025 PLAINTIFFIPETITIONER: Stephanie Johnsen CASE NUMBER: 19CV352312 DEFENDANTIRESPONDENT: Gravin. Nadine M-D. PROOF 0F SERVICE OF NOTICE TO CONSUMER 0R EMPLOYEE AND OBJECTION (Code Civ. Prom. §§ 1985.3,1985.6)E Personal Service m Mail 1 . At the time of service | was at least 18 years of age and not a party to this legal action. 2. I sewed a copy of the Notice to Consumer or Employee and Objection as follows (check either a or b): a.E Personal service. | personally delivered the Notice to Consumer or Employee and Objection as follows: (1) Name of person sewed: (3) Date served: (2) Address where served: (4) Time served: b.m Mail. I deposited the Notice to Consumer or Employee and Objection in the United States rrail, in a sealed envelope with postage fully prepaid. The envelope was addressed as follows: (1) Name 0f person served: Andrew Agtagma, Esq- (3) Date of mailing : 1111312019 (2) Address: 951 Mariners Island Blvd. Ste 300 San Mateo, CA 94404 (4) Place of mailing (city and state): Denver, CO (5) l am a resident of or employed in the county where the Notice to Consumeror Employee and Objection was mailed. c. My residence or business address is (specffil): 1764 Gilpin Street. Denver, CO 80218 d. My phone number is (specify): (720) 941.9534 I declare under penalty of perjury under the laws of the State of Califomia that the foregoing is true and correct. Date: 1 1f13f2019 Zac Marberg ’ 240WW {TYPE OR PRINT NAME OF PERSON WHO SERVED] [SIGNATURE OF PERSON wHOSERVE D) PROOF 0F SERVICE 0F OBJECTION To PRODUCTION 0F RECORDS (Code cw. Proc., §§ 1935.3,19355)E Personal Service E Mail 1. At the time of service l was at least '18 years of age and not a party to this legal action. 2. | served a copy of the Objection to Production ofRecords as follows (complete eifhera orb): a. ON THE REQUESTING PARTY (1) E Personal service. l personally delivered the Objection to Production ofRecords as follows: (i) Name of person served: (iii) Date served; (ii) Address where served: (iv) Time served; (2) m Mail. | deposited the Objection to Production of Reconds in the United States mail. in a sealed envelope with postage iuily prepaid. The envelope was addressed as follows: (i) Name of person served: (iii) Date ofmamng: (ii) Address: (iv) Place of mailing (city and state): (v) | am a resident of or employed in the county where the Objection to Production of Records was mailed. b. ON THE WITNESS (’l) m Personal service. | personally delivered the Objection to Production of Records as follows: (i) Name of person sewed: (iii) Date served: (ii) Address where served: (iv) Time sewed: (2) E Mail. l deposited the Objection to Production ofRecords in the United States mail, in a sealed envelope with postage fully prepaid. The envelope was addressed as follows: (i) Name of person served: (iii) Date of mailing: (ii) Address; (iv) Place of mailing (city and state): (v) | am a resident of or employed in the county where the Objection to Production of Records was mailed. 3. My residence or business address is (specify): 4. My phone number is (specify): I declare under penalty of perjury under the laws of the State of Califomiathat the foregoing is true and correct. Date: D U'H": UH VHINI“AWN WHU thVtU] (SIGNATURE 0F PERSON WHO SERVED} 533' "Esme" jammy Hm] NOTICE TO CONSUMER 0R EMPLOYEE AND OBJ ECTION ' 3g; 25' 2 _ _ Deposition Suprcna for This Declarationmm be Production of Business Records signed and returned Whether- or " no! you have records. Regarding (name): Johnsen, Stcphnnic Facility: Above Parr Wumcn's Center Location (address). 700 Wesr Parr Avenue Los Gates CA 95032 l. 01c undersigned, being the duIy authorized Ousted an of Records and having authority to certify Lhc record declare UH: following (please check tppropriuc hosts): The records war: pr¢pmd by {he personnel of the business m lb: ordinary course ofbusincss at or near the lime ofthc act. condition, or event. The pholocopicd records submiucd hmwith m true copies of the wupkic (check all applicable): 'EMcdin Recorqs ERfliolom-imaps I Billing D Other: flufinnl Rgggrr.d ‘ E I um over the ngc of l8 years and not n puny Io this action. l am the dulj authorized cusmdinn ofrecords for the facility named on the dunes tccum.subpocna The copies accompanying this dcclaralion arc um: copies of ail mdrds described in the subpoena which are in my possession as Custodian of Records. Thu original records fi'orn which the accompanying copies were made were preparcd by' in the ordinary course of business at omen: the times of ihe acts. cunditibns. or events recorded therein. ' D McdicaIRccords D Radiologylmagcs gamma D 0am.- PLE-ASE SPECIFY REASON D RccordsfFilms are Lost D RecordsfFitms areDcs r0 m mm 0H? sH-o- NbrmMeAmm Bi Hing Lune 55b- Hqu A thorough scarchni‘our files, c'anicd out under my dircclion and control. rcvcach no documents, records. m- olher Items liSch'm U1: Subpoena prcsznlcdjn mc. II is understmd (hm such records may exist under another spelling, name, or clmiflmlion. but with the inron-nnzim' providw lo our nITroe and lo Lhé Ml ofmy knowledgt. no such records exist. ' I DECLARE UNDER '11:;errfl'Jfifi‘f AND UNDER THE LAWS Ol' THIS STATE'I'HJTTI‘IIE FOREWING IS TRUE AND CORRECT: Eucmcd on rm): ' .aucitylxm LmdamJ CA PrintNamc j’na Vfir0 Sigmwcz DO NOT WRITE BELOW THIS LINE. FOR USE BY COPY SERVICE ONLY I hm [he It'lumcy‘s.rcp'rmntuln Ind I 5m: mu: D fiudc True and Curran Cupiu a_l'ihe Retard: D Reednd Copic: onhc Ruorda D Rewind I Cmifiut: of No Rcrnrd: Fruvidcd la Inc by Ike custodial o! rech'rb of flu Ibo}: bull“. IDECLABE UNDER HNAIJY OFPEMUBV AND U808! TH! LAWS OP TIIESI'ATE OF Cs W'f'l'll'l ;DIEGDING IS TRUE AND CORRECT. D London did am pnpcrly compleu and!" nun Ila Declaration o! Records Custodian Nam: i Esmmd on {Rat} 1l_ ' _ . II (cm) By: Simian t_- uAME: LAST 'Sohnsfin 'O FIRST Sfiphc\n{e “GE GENETICS SCREENING INCUJDES PlTIEHT. BABY'S FATHER. OR MJYONE "I EITHER FamLY WITH! ?ES NO YES u. Paneurs nae a n: Yuan? W no. num‘mmoa mom» 2. Imam, anew. usmtannmam. on omeum. Bacxanouno tucv 4 Inn 3. NEUML run: uessn (uemnsomaccew. open spwe. on m:ncgmem Ii. MEN‘AI. EETAfiDhTDN? . IF YES. WAS PERSON TESTED FOE FWILE l? IR. 01m INHEHTEDSEW OHCNMWMm9?fl . 0mm SYNDROME {MONGOLISMH . Pimsm on aAaY‘s name: mm A cmm vnm BIRTH DEFEC‘I NOT LISTED ABOVE. a 3 Fins? TNMESTEfl SPom‘mEOus ABORTIONS. on n smum'm? I u, MEDICA‘IMS OR STREET ORUGS SINCE LAST MEMSTRUM. PERIOD? 5. JEWISH {TA‘I‘ SACH‘SF 6. MILE CELL DISEASE OH TENT? g\\ «a q . HEHOEHILIA? I. MOSCOW DYSTBDFHY? IF YES. NENWS} <5 _ fl (fl iu “WT 5 ‘ ‘1 (2/ 15/.5\\ ISé N“ 196 tSQ E cuuuunv: wens? mm a \ ?)v 15 _ ‘ 3..) S unauc: nweosuamunwflflfilts) wbfi/N § N/P] %~ /Q by?" i nu: «Wumusm I §$fll I 5:? ‘ toy. I mm mum“ I'NVo swam: H OLE fins rasr aaumuins ‘ cvsfi‘mmm case scmwnm res: em» . covv To Hosm'AL :m‘muv 0r I P0 2/65 r0} 3fl 0 ’0" S f (9 WW u- .---. _ ---_-- APMDWCOOO37 Fax Server 8(9/2018 8:29:48 AM PAGE 2i003 Fax Server Pauanlnfionnaflon PmmntName HAR MRN Sex DOB Johnsen. Stephanie Anne 3000020940 0001 1 46781 Female 7129;1985 Transcflpuon 1kpa ' ID AumOr Operative Nota- 1955646 Angeta Michelle Potlard. MD Signed by Angela Michelle Pollard, MD on OWUQMG at 0824 Document Text DATE OF SERVICE: 08108/2016 BREOPERATIVE DIAGNOSIS: Intrauterine pregnancy at 39 weeks with frank breech presentation. POSTOPERATIVE DIAGNOSIS: Intrauterine pregnancy ac 39 weeks with frank breech presentation. PROCEDURES PERFORMED: Primary low transverse cesarean section and local administracion.of anesthetic. SURGEON: AngELO Pollard, M.D. ASSISTANT: ANESTHESIOLOGIST: Brian Ash, M.D. ANESTHBSIA: Spinal. ESTIMATED BLOOD LOSS: 500 CC. INTRAVENOUS FLUIDS: 1500 cc of crystalloid. URINE OUTPUT: 200 cc of clear urine. FINDINGS: A viable female infant born at frank breech presentation. Apgars 9 at 1 minute, 9 ac 5 minutes. Birth weight 8 pounds 3 ounces, 19- 3f4 inches. No meconium. Normal uterus. ovaries, and tubes bilaterally. COMPLICATIONS: No complications. SPECIMENS: Cord blood. DISPOSITION: To PACU, awake in snable condition. COUNTS: Sponge, lap. inssrumenc. and needle counts correct x2 a: the end of case. fiBSCBIPTION 0F PROCEDURE: The patient is a delightful 31-year-old GZ P1 who had haen diagnosed with a frank breech pregentanion during the course i I --_._..-____._ ___.- APMDWCOOO3O Fax Server 8/9f2016 8:29:48 AM PAGE 3(003 Fax Server of her pregnancy. We did an-exnernal cephalic version, but the breech was wedged deep in the pelvis and with movement of the breech. we created discomfort fior the mother, and so the pnocedure Was abortéd. Decision was made to deliver by cesarean seccion. Informed consent was obtained and the patient was taken to the operating room and placed under spinal anesthetic. She-was placed in dorsal linho:omy position and prepped and draped in the usual Sterile manner. A Foley catheter was placed inside her bladder. Ancef was given prior to Star: of the case. A Pfafinenstiel skin incision was made with a knife and carried down to the fascia. The fascial incision was nicked in the midline and extended laterally using Mayo scissors. The rectus muscles were divided in the midline and the peritoneum was ennered into bluntly. The bladder blade was placed and bladder flap created using Metzenbaum scissors. 'The uterus was incised in low transverse manner with a scalpel. The uterine incision was extended using blunt traction. Clear amniotic fluid was encountered. The baby's breech was delivered and then the remainder of the baby was delivered. Nose and mouth were suctioned, cord was clamped and the infant was handed to awaiting pediatric team. Cord blood was obtained, and placenta was delivered. The ucerus was exteriorized and the inside of the uterus cleansed of all clot and debris. The uterus was closed in 2 layers with a running locking suture of 0 Monocryl. On'the left lower uterine segment. there was an extension noted and additiohal figure of eight sutures using 0 vicryl Were necessary for hembszasis. However. excellent hemostasis was achieved, and tfle uterus was placed back inside the abdomen. The bilateral gutters were cleansed of all Clo: and debris. The peritoneum was reapproximated with 3-0 Vicryl and the rectus muscles were réapproximated with 3-0 Vicryl. The fascia was closed from lateral asPect to midline with a running suture 0E 0 Vicryl. Irrigation was performed'of subcutaneous tissue. which was then reapproximaced with 3-0 Rapide. The skin was closed with buried subcuticular sucure of 4-0 Monocryl. Exparel _____ mg was injected into the subcutaneous tissue. A total of 40 cc was injecned as the 20 cc of Exparel was deliveyed with 20 cc of normal saline. .The skin was then closed with Dermabond and Steri-Strips and the patient was taken to the recovery room, awake in stable condition. There were no complications. Angela Pollard. M.D. CC: AP:AS Job Iv: 1956546 l 582351 D: 08/03/2015 08:59:53 'T: 08/0312016 10:03:49 I APMDWC00031 Fax Server BIBIZOLB 10:05:05 AH PAGE 2’003 Fax Server EL CAMINO HOSPITAL JOHNSEN, STEPHANIE , CALIFORNIA MRfi: 1146781 ANGELA POLLARD. MD. DOB: 07I29I1 986 . PROCEDURE REPORT DATE 0F SURGERY: i DATE OF SERVICE: 08/08/2016 I PREOPERATIVE DIAGNOSIS: Intrauterine pregnancy at 39 weeks wilh frank breech I presentation. POSTOPERATIVE DIAGNOSIS: Intrauterine pregnancy at 39 weeks with frank breech ' presentation. PROCEDURES PERFORMED: Primary low transverse cesarean section and local administration of anesthetic. 'SURGEON: Angela Pollard. MD. ASSISTANT: ______ ANESTHESIOLOGIST: Brian‘ Ash, M.D. .ANESTHESIA: Spinal. ESTIMATED BLOOD LOSS: 600 cc. INTRAVENOUS FLUIDS: 1500 cc of'crystalloid. URINE OUTPUT: 200 cé of clear urine. FINDINGS: A vi'able female infant 60m at frank breech presentation. Apga‘fs 9 al 1 minute, 9 at 5 minutes. Birth weight 8 p‘ounds 3 ounces, 19-3/4 inches. No meconium. Normal uterus. ovaries. and tubes bilaterally. COMPLICATIONS: No complications. SPECIMENS; Cord blood. DlSPOSITlON: To PACU, awake in siable condition. DESCRIPTmN OF- PROCEDURE: The paiient is a delightful 31-year-old G2 P1 who had been diagnosed with 'a frank breech presentation during the course of her pregnancy. We did an external cephaiic version, but the breech was wedged deep inihe pelvis and with movement of the breech, we created discomfort for the mother. and so the procedure was COUNTS: Sbbnge, lap, instrument. and needle counts correct x2 at the end of case. l I PRELIMINARY - UNEDITED --UNSIGNED :___-... . ......-V -muw APMDWCOOO32 Fax Server 8(8/2018 10:05:05 AH PAGE 3I003 Fax Server , EL GAMING HOSPITAL JOHNSEN, STEPHANIE , CA LIFORNIA 1146781 ANGELA POL-LARD, M.D. PROCEDURE REPORT Page 2 of2 aborted. Decision was made to deiiver by cesarean section. Informed consent was obtained and the patient was taken lo the operating room and placed under Spinal anesthetic. She was placed in dorsal iithotomy position and prepped and draped in the usual sterile manner. A Foley catheter was placed inside her bladder. Ancef was given prior to start of the case. A . Pfannensliei skin incision was made with a knife and carried down to the fascia. The fascia! incision was nicked in the midline and extend ed laterally using Mayo scissors. The rectus muscles were divided in the midline and the peritoneum was entered into blunily. The bladder blade was placed and bladder flap created using Metzenbaum scissors. The uterus was incised in low transverse manner with a scalpel. The uterine incision was extended using blunt traction. Clear amniotic fluid was encountered. The baby's breech was delivered and then the remainder of ihe baby was delivered. Nose and mouth were suctio'ned, cord was clamped arid the infant was handed to awaiting pediatric team. Cord blo‘od was obtained, and placenta was delivered. The uterus was exleriorized and the inside of the uterus cleansed of all clot and debfis. The uterus was closed in 2 layers with a running locking suture of O Monocryl. On the ten lower uterine segment, there was an extension noted and additional figure of eight sutures using O Vicryl were necessary for hemostasis. However, excellent hemostasis was achieved, and the uterus was placed back inside'the abdomen. The bilateral gutters were cleansed of all clot and debris. The peritoneum was reapproxlmated with 3-0 Vicry! and the. rectus musckes were reapproximated with 3-0 Vicryl. The fascia was closed from iateral aspect to midline with a running suture of'O'Vicryl. Irrigation was performed of subcutaneous tissue. which was then reapproxlmated wlth 3-0 Rapide. The skin was closed with buried subcuticular suture of 4-0 Monocryl. Exparel mg was injected into the subcutaneous tissue. A total of 4O cc was injected as the 20 cc of Exparel was delivered with 20 cc of norma! saline. The skin was then closed with Dermabond and Sleri-Strips and the patient‘was laken-to the recovery room. awake in stable condition. There were no complications. ; Angela Poilard. MD. APzas Job ID: 1956846! 582357 D: 080812016085953 T: 03089016100349 . PRELIMINARY - UNEDITED - UNSIGNED APMDWCDOO33 Page lSofIS Johnsen, Stephanie - 31 Y old Female, DOB: 07/29/1985 Account Numhc r: 1703.5 a 1480 DcTnlmn Dr- , Snn Jose, C:\w95120 Home: 408-472-9996 Guarantor: Johnsen, Stephanie Insurance: Z-SCCIPA I Anthem Blue Cross PnyerID: SCACO Appointment Facility: Angela Palln rd, Md). 08/22/2016 Progress Notes: Angela Pollard, M.D. I Current Medications Reason for Appointment I Taking 1. Incision check . ap postpartum . o ibuprofen g t CitmNatal Harmnny 27-1-260 MG Capsule History of present "mess Icapsulc Once a day Gm. I o Medication List reviewed and reconciled -' , . with the patient Last menstrual period: PP . I DATE 0F DELIVERY: I Past Medical History TYPE OF DELIVERY: ' No Medical History. BABY DATA: u POSTPARTUM COURSE TO DATE: I Surgical History BLEEDING: ' wisdom teeth extraction 11 yrs pAJN; ‘ cesarean section 8/2016 BREAST FEED] N62}: Family History MOOD‘ Father: alive 63 yrs, wcll-hcalthy . diagnoscd BLADDER AND BOWEL FUNCHON: with Hcallhyudult CONTRACEPTION PLANS: ' Mother: alive 59 yrs, chI-hcalahy , diagnosed LAST pAp: . - with Healthy adult i Paternal Grand Mother: deceased, breast Vital Signs cancer. diagnosed with Other malignant neoplasm of unspecified site 1 brothcr(s) . 1 sisteds) - healthy. aduughlcr Wt 137 lbs, Ht 5 ft 4 in, BP 120/60 mm Hg, BMI 23.51 Index. (s) . healthy; Examin ation I Pt denies any gi, gyn. and colon cancer in Gynecologica]: I fanub‘ GENERALAPPEARANCE normal, pleasant, in no acute distress. ' Social History D BREAST$z_normal appearance, nipples unremarkable, lactating, no Tobacco ”5e: Slgns of mastitis. . .D o . Tobacco Usc/Smoking ABDOMhN: no herma, no hernia, nondlstendcd, normoactwc {Wynn a "onsnwi'cr bowel sounds, soft, non-tender, nonodistendedlncision C/D/I. . EXTERNAL GENITALLA: introitus normal . Manta! status: married. URETHRAL M EATUS' lOccupation: works fullvtimc, Hyatt Corp. o . narma . . IVAGINA: atmphlc changes,, no lemons, wakened muscles. IOB History VAGINA VAULT: normal}. I Total Qrggnangics 3- CERVIX: external os normal, n0 bieeding, no cervical movement i lafiggflflggcfglf’c“ 2' tenderness, no lesions or discharge or bleeding. Pregnancy , I: n'orma. swmmousvagiml L_ITERUS: normal mobility, nontender, normal size. shape and I delivery (NSVDJ- ?014 female . C0 nSlStcncy. ' Pregnancy l‘ 31 "llsmmab'c- ADNEXA: no mass, nontender, ovaries normal size, nontendcr . Pregnancy AI 3 ‘anary ccsarcan- 8/8/16 bilam ml), Dr.Pollard Female ECLG ”Aubrcc Rosc" . ANUé/PERINEUM_ normqlo t v I Aller ies ' mm: Assessments ' Patient: Johnscn, Stcpl-ianie DOB: 07/29/1985 Progress Note: Angela Pollard, MJ). 08/22/2016 Note generated by eCIFnkaIWorks EMR/PM Saltware {mmme’nicaMrfiscom} httpszllcaapkdapp.eclinicalweb.comlmobiledoc/jSp/cataIoglxml/printMultipleChartOption... 11/26/2019 APMDWCDDOM HospitalizationIMajor Diagnostic Procedure Second dciivcry 812016 Page 160f18 1. Encounter for postpartum care of lactating mother - 239.1 (Primary) 2. Encounter for other general counseling or advice on contraceptiOn - 230.09 Normal postpartum course and exam. Lacation support. Treatment 1. Others - Continue CitraNatal Harmony Capsule, 27-1-260 MG, 1 capsule, Orally, Once a day Notes: postpartum weightless and fitness reviewed Continue prenatal vitamins Birth control and family planningfiirth control - slow release methods materia} was published to portal. Follow Up 2 Weeks M(QLQX Electronicnliy signed by Angela Pollard , MD on 08/28/2016 at 09:23 PM PDT Sign offstatus: Completed Angela Pollard, MJ). 700 “7 FARR AVE LOS GATOS, CA 95032-1416 Tel: 408-3?0-3630 Fax: 408-370-3790 Patient: Johuscn, Stephanie DOB: 07/29/1985 Progress Note: Angela Pollard, MD. 08/22/2016 Note generaied by eCfinicalWorks EMR/PM Softwam (m.eC!£nfcaMorks.com} httpszllcaapkdapp.eclinicalweb.com/mobiledocljsp/calalog/xml/printM ultipleChartOption... 1 1/26/20] 9 “- r o- t-Io-HIIIIO .m- APMDWCOOU‘I 5 Page 13 of18 Progress Notes 2:22:33; fl:§2;fl§g:§me provider: Christin'e Kune, Np DOB: 07/29/1985 Age: 31 Y Sex: Female Date: 10/24/2016 Phone: 408-472-9996 Address: 1480 De Talma Dr , San Jose, CA~95120 Subjective: Chief Complaints: 1. Swelling. HPI: 9m: Last menstrual period: no menses Breast feeding . c/o bilateral lower Ieg swelling at night since c/s on 8/8/16-has fluid retention only in the middle of the night, drinking a ton of water, salt intake-eats more salt than sugar. Eats lightly Salted cashews. Doesn't eat out much, but does put garlic salt on alot of food-on meat and vegetables at dinner and about 4x/week. No leg swelling during the day, going to Washington D.C. Has PCP. OB History: Total pregnancies 3. Total living children 2. Miscarriage(s) 1. - Pregnancy # 1: normal Spontaneous vaginal delivery (NSVD)- 2014 Female . Pregnancy # 2: miscarriage. Pregnancy # 3 Primary cesarean- 8/8/16 Dr.Pollard Female ECLG "Aubree Rose" . Surgical History: wisdom teeth extraction 11 yrs , cesarean section 8!2016. Hospitalization] Major Diagnostic Procedure: Second delivery 8/2016. . Family History: Father: alive 62 yrs, well-healthy , diagnosed with Healthy adultMother: alive 59 yrs, well- healthy , diagnosed with Healthy adultPaternal Grand Mother: deceased, breast cancer, diagnosed with Other malignant neOplasm of unspecified site1 brother(s) , 1 sister(s) - heaithy. 2daughter(s) - healthy. Pt denies any gi, gyn, and colon cancer in family. Social History: Tobacco gge: Tobacco Use/Smoking Are you a: nonsmoker . Miggellaneous: Marital status: married. Occupation: works fuII-time, Hyatt Corp . Medications: Discontinued ibuprofen , Discontinued CitraNatal Harmony 27-1-260 MG CapSuIe 1 capsule Orally Once a day, Medication List reviewed and reconciled with the patient Allergies: N.K.D.A. Objective: Vitais: Wt 126 lbs, Ht 5 ft 4 in, BP 112/74 mm Hg, BM! 21.63 Index. Examination: ngeral Examination: GENERAL APPEARANCE: in no acute distress, well developed, well nourished. THROAT: clear. NECK/THYROID: neck supple, full range of motion, no cervical lymphadenopathy. HEART: no murmurs, regular rate and rhythm, $1, 52 normal. LUNGS: clear to auscultation bilaterally. EXTREMITIES: no clubbing, cyanosis, or edema. NEUROLOGIC: bilateral leg reflexes 1+ . Assessment: https:licaapkdapp.eclinicalweb.com/mobiIedoc/jSpicalalog/xmlfprintMultipleChartOption... l 1/26/20 l 9 u-r I i APMDWCUUO'IB PageMc-FIS . Assessment: 1. Leg sweliing - M79.89 (Primary) ¢- -u-- nu--_. Plan: 1. Leg swelling Notes: No bilateral leg swelling noted In today's exam. Discussed elevating both legs on pillows at night, drinking 64-80 ounces of water per day, eliminating garlic salt from diet to see if the bilateral swelling at night resolves on its own, reviewed reading labels to make sure she is not getting increased amounts of sodiUm, discussed eating out, portion sizes, eating a natural whole foods diet, and hidden sodium in different foods. Discussed strategies to take during her long flight to Washington D.C. Pt to follow up with primary care MD if swelling continues with the above measures. Follow Up: schedule annual exam now Provider: Chrlstine Kulle, NP ' Patient: Johnsen, Stephanie DOB: 07/29/1985 Date: 10/24/2016 IE Electronically signed by Christine Kullc on 10/24/2016 at 02:29 PM PDT Sign off status: Completed httpszllcaa pkdapp.eclinicalweb.com/mobiledoc/jsp/catalog/xml/pri ntMuItipleChartOption... l 1/26/20 l 9 APMDWCODO’I? Page H OHS Iohnsen, Stephanie 31 Y old Female, DOB: 07/29/1985 Account Number: 170M; 1.480 Dc '. ‘aln'm Dr , Sam Jose, CA-gsuu Horne: 408-472-9996 Guarantor: Johnscn, Stephanie Insurance: ZrSCCIPA Anthem Blue Cross Payer El): SCACO Appointment Facility: Angela Pollard, Md). 11/01/2016 Current Medications None Past Medical History Breast Feeding: yes Surgical History wisdom teeth extraction 11 yrs cesarean section 8/2016 Family History Father: alive 62 yrs, well-hcalthy , diagnosed with Healthy adult Mother: alive 59 yrs, wcil-hcalthy , diagnosed with Healthy adult Paternal Grand Molhcr: deceased. breast cancer, diagnosed with Other malignant ncopiusm of unsmcificd site 1 bmlhcds) , I sislcrfs) - hcalthy. 2daughlcr (s) - healthy. Pt denies any gi. syn. and colon cancer in family. Social History Tohnggn um: Tobacco Use/Smoking Arc you a: nonsmokcr. Misgcllancous; Marital status: married. Occupation: works fulI-timc, Hyatt Corp . OB History Total pregnancies 3. Total living children 2. Miscarriagets) 1. Pregnancy i I: normal spontaneous vaginal delivery (NSVDJa 2o 14 Female . Pregnancy fl 2: miscarriage. Pregnancy u: 3 Primaryccsnrcan- 8/8/16 Dr.Pollard Female ECLG “Aubrcc Ruse" . Allergies N.I<.D.A. HospitalizationIMajor Diagnostic Proced ure Second delivery 8/2016 Progress Notes: Angela Pollard, MJD. Reason for Appointment 1. Mirena Iud Insert. Patient here for IUD insertion, no complaints History of Present Illness GYN History: Denies : History of pelvic inflammatory disease:. iHistory ofsexnally transmitted diseases (S'I‘Ds):. Abnormal vaginal bleeding: none. Breast complaints: none. Calcium intake: adequate. Contraception: none. History ofan abnormal PAP: none. History of gynecologic surgery: denies. Last menstrual period: Datez, . Menses: regular. Urinary problems: none. Vaginal discharge: none. Sexual partner: same. HCG urine negative. Vital Signs Wt 1271138, Ht 5 ft 4 in, BP 115/75 mm Hg, BM! 21.80 Index. Examination Gynecologicai: BREASTS: non-render, no masses appreciated, no axillary adenopathy. EXTERNAL GENITALIA: no erythema, no lesions. VAGINA: healthy pink mucosa without any lesions. CERVIX: downward, normal appearing, no cervical movement tenderness. UTERUS: normal size, shape and consistency. ADNEXA: no masses or tenderness bilaterally. Genera] Examination: ABDOMEN: soft, nontender, nondistended, bowel sounds present. Assessments 1. Encounter for IUD insertion - 230.430 (Primary) Treatment 1. Others Patient: Johnscu, Stephanie DOB: 07/29] 1985 Progress Note: Angela Pollard, Md). Nate generated by aCfinicaIWm-ks EMR'PM Sorlware (mm.eCIfnicaMbdrs.com) https://caapkdapp.eclinicalweb.com/mobiledocfjsp/calaiog/xml/printMullipleChartOption... l 1/2 6/20 l 9 11/01f2016 APMDWC0001 8 PageIZOfIS Start Mirena Intrauterine Device, 2o MCG/24HR, as directed, ' Intrauterine Notes: Uterus sou nd ed to 7.5 'cm, Mirena IUD placed without difficulty, strings cut to 2-3 cm length. Good hemostasis present. Ultrasound canfirmed position of IUD at the fundus. Patient counseled to notify provider with late period, abdominal pain, fever and chills, string missing, shorter/longer. Information on IUD given. Procedure Codes 76857 US EXAM, PELVIC, LIMITED 81025 URINE PREGNANCY TEST 58300 INSERT INTRAUTERINE DEVICE Follow Up 3 Months I 26219644 , ; Electronically signed by Angela Pollard ,MD on 11/01/2016 at 12:09 , PM PDT Sign off status: Completed Angela Pollard, MJ). 700W PARK AVE LOS GATOS, CA 95032- 1416 Tc]: 408-370-3630 Fax: 408-370-3790 Patient: Johnson, Stephanie DOB: 07/29/1935 l’i'ogrcss Note: Angela Pollard, MJ). ‘u/m/zmfi i Note generated by elenicaIWoms EMR/PM Software {numeCHnicaMorkacamJ https:l/caapkdapp.cclinica[web.com/mobiledoc/jSp/catalog/xml/primMullipleChartOption... 11/26/2019 APMDWCOOO19 . . g i a z t é , i h fi fi g fi i : me fi a t fim : 3 . 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E u k cmu c § § fi flmm g f a n fi fi fi a n . a lo} E. 5 3" krywn i i n. E S E : fi nfi s w Y 5. .. ! u ‘wmu fi fi fi 99‘ s « J 5 Ja y s 3 3m . m w : . fi me fl : . m ga g “ :W E . . i é iw : $ 3 ? ? ? m. fi amw fi ao s . , , , . . . . E mm am f r , g : E fi fl fi fi APMDWCOOOQS F 2 1 $ «é MM. afimuk Em : 5 4mm a 3 m annin g 2 : x i , . ‘. 3 E 5 }... x” ? z . £ 5 5 3 . .. ¥¢w2 3 4u 9 aw Cmd. r EQ hw APMDWCDODQ? Page 9 of 18 Progress Notes Patient: Johnsen, Stephanie Account Number: 17015 DOB: 07/29/1985 Age: 31 Y Sex: Female Date: 02/03/2017 Phone: 408-472-9996 Address: 1480 De TaIma Dr , San Jose, CA-95120 Provider: Linda Joshua, NP Subjective: Chief Complaints: 1. F/U Iud check. HPI: m: Last menstrual period: no mesnes IUD . Had a lot of pa the first month, now only few pinching sensations. No menses on Mirena. c/o headaches, fatigue. OB History: Total pregnancies 3. Total living children 2. Miscarriage(s) 1. Pregnancy # 1: normal Spontaneous vaginal delivery (NSVD)- 2014 Female . Pregnancy # 2: miscarriage. Pregnancy # 3 Primary cesarean- 8/8/16 Dr.Polla’rd Female ECLG "Aubree Rose" . Surgical History: wisdom teeth extraction 11 yrs , cesarean section 8/2016. Hospitalization/Major Diagnostic Procedure: Second delivery 8/2016. Family History: Father: alive 62 yrs, well-healthy , diagnosed with Healthy aduftMother: alive 59 yrs, well- healthy , diagnosed with Healthy adultPaternal Grand Mother: deceased, breast cancer, diagnosed with Other malignant neoplasm of unspecified sitel brother(s) , 1 sister(s) - healthy. 2daughter(s) - healthy. Pt denies any gi, gyn, and colon cancer in family. Social History: Tobacco Use: Tobacco Usemeoking Are you a: nonsmoker . Miscellaneous: Marital status: married. Occupation: works full~time, Hyatt Corp. Medications: Taking Mirena 20 MCG/24HR Intrauterine Device as directed Intrauterine , Medication List reviewed and reconciled with the patient Allergies: N.K.D.A. Objective: Vitals: Wt 124 lbs, Ht 5 ft 4 in. BP 120/80 mm Hg, BM! 21,28 Index. Examination: Gynecologigal: string not visualized. seen an U/S. Assessment: Assessment: 1. IUD check up - 230.431 (Primary) 2. Chronic fatigue - R5182 Plan: 1. IUD check up Notes: discussed the IUD in detail for the patient. Labs given. https:I/caapkdapp.eclinicalweb.com/mobiledoc/jsp/catalog/xmlfprintMultipieChartOplion... 11/26/2019 h-u APMDWCDUOZD Pag6100f18 Provider: Linda Joshua, NP Patient: Johnsen, Stephanie DOB: 0712991985 Date: OZIDBIZON [E Electronically signed by Linda Joshua on 02/03/2027 at 09:32 AM PST Sign off status: Completed u-n-n-m 4p m_- https://caapkdapp.eclinicalwcb.com/mobilcdoc/jSp/cata]og/xml/pri111MultipleChartOption... I 1/26/20l9 APMDWCDOOZ1 Page 7 of 18 Johnsen, Stephame 311:“ old Female, DOB: 07/29/1985 Account Number: 17015 1480 Dc '.‘laima Dz ,San Jose, CA-95120 Horne. 408-472-9996 Guarantor: Johnsen, Stephanie Insul uncc: Z-SCCIPA Anthem Jiluc Cross Payer 1]]: SCACO Appointment Facility: Angela Pollard, Md). 02/09/2017 Current Medications Taking o Mircna 20 MCGfaqHR Intrauterine Device as directed Intrauterine o Medication List reviewed and reconciled with lhc patient Past Medical History No Medical History. Surgical History wisdom tccth extraction 11 yrs cesarean section 8/2016 Family History Father: alive 6: yrsnchI-hcalthy , diagnosed mth Healthy adult M other: alive 59 yrs”.vcll-healthy. diagnosed vilh Healthy adult Paternal Grand Mather: deceased, brcasl cancer, diagnosed with Other malignant neoplasm of unspecified site 1 brothcr(s) Isistcrfs)- healthy. adaughtcr (s) - healthy. Pt denies any gi. gyn. and colon cancer in family. Social History Tuba Tobacco Usu/Smoking Arc you a: nonsmoker- Miscellunggug: Marital status: married. Occupation: works fulI-timc. Hyatt Corp. Gyn History Sexual Activity monogamous with husband. Birth control Mircna inlraulcrinc device. Abnormal pap smear denies. Sexually Transmitted Diseases [STDsJ none. OB History Total pregnancies 3. Total living children 2. Miscarriagcts) 1. Pregnancy all I: normal Spontaneous vaginal deiivcry (NSVD) 2014 Female. Pregnancy t 2: miscarriage. Progress Notes: Angela Pollard, M.D. Reason for Appointment 1. iud f/u / cant see strings . ap ROS History of Present Illness gm: Last menstrual period: No mensesMirena IUD . Stephanie was referred for Linda not able to see the IUD strings. Stephanie never felt the strings She notes that following the insertion of the IUD she had bad pain. The insertion was a bit uncomfortable but afterward she had increased pain and terrible cramps. She has had bleeding the entire time since the insertion. Vital Signs Wt 125 lbs, Ht 64 in, BP 120f80 mm Hg, BMI 21.45 Index. Examination Qvnecological: GENERAL APPEARANCE normal, pleasant, in no acute distress. ‘ ABDOM EN: normal, soft, non-tender, no mass. EXTERNAL GENITALIA: norm a1. URBTHRAL MEATUS: normai. VAGINA: normal, no lesions. CERVIX: downward, normal appea ring; no IUD string visibleCenrix probed-no IUD string present. UTERUS: normal mobility, nontender, normal size, shape and consistency. ADNEXA: normal. Physical Examination u/s: see report Eclwgenicity'm the lower uterine segment near c-section scar. Assessmen ts I. Pelvic pain; R102 (Primary) 2. Displacement of intrauterine contraceptive device, initial encounter - T83.32XA ?IUD in c-section scar. Treatment 1. Displacement of intrauterine contraceptive device, initial Patient:Jolmsclysmphauic 003:07/29/1985 Progx-css'Notcuh1gclal’ollard,M.D. "2/09/2017 Note generated by eCflnicleorks EMR/PM Software (mgminicammsmmj https:I/caapkdapp.eclinicalweb.com/mobiledoc/jsp/catalog/xmllprintMultipleChartOption... I 1/26/20] 9 n-n-I-n ----- -w n .- - -- APMDWCDOO22 Pregnancy a 3 Primaryccsarcan- 8/8/16 Dr.Pollnrd Female ECLG "Aubrce Rose" . Allergies N.K.D.A. HospitalizajionlMajor Diagnostic Procedure Second delivery 8/2016 Review of Systems women OnIv: Dcnics Breast lump. Denies Breast pain. Denies Discharge from the breast. Dc nics Heavy bleeding during menses. Denies Hot flashes. Admits Irregular mcnsms. Admits Missed periods. Denies Painful intercourse. Denies Painful menses. Denies Vaginal hiccding between periods. Denies Vaginal dischargcfilching. Brcgnsl: Denies Bloody nipple discharge. Denies Breast lump. Denies Breast pain. Dcnits Breast swelling. Denies Fever. Denies Gland swelling. Denies Nipple discharge. Denies Red skin. Denies. Weight loss. Genitourinnn': Admits Abdominal pnin/Sivelling, Since insertion Of IUD. Denies Blood in urine. Denies Difficulty urinating. Denies Frequent urination. Denim Pain in lower back. Denies Painful urination. GcgcrallConstilugional: Denies Change in appetite. Denies Chills. Dc nies Fatigue. Denies Fever. Denies Headache. Denies Lighthcadcdncm. Denies Sleep dislurhnncc. Denies Weight gain. Dcnics Weight loss. Psvgiatrig: Denies Anxiety. Denim Auditorylvisual hallucinations. Denies Delusions. Denies Depressed mood. Denies Difficulty sleeping. Denies Eating disorder. Denies loss of appetite. Denies Mcmal or Physical abuse. Denies Slressors. Denies Substance abuse. Denies Suicidal thoughts. _-._... ._-. Page 8 ot‘ 18 encounter Clinical Notes: MRI of pelvis to determine location of the IUD Hysteroscopy and laparoscopy for removal of IUD reviewed. Procedure Codes 76857 US EXAM, PELVIC, LIMITED Follow Up 2 Weeks #463444 Electronically signed by Angela Pollard , MD on 02/10/2017 at 10:05 AM PST Sign ofi‘stutus: Completed Angela Pollard, M.D. 700 “7 PARKAVE LOS GATOS, CA 95032- 1.1 16 'l‘cl: 408-370-3630 Fax: 408-370-3790 Patient: Julmsun, Stephanie DOB: 07/29/1985 Progress Note: Angela Pollard. MA). 02/09/2017 Nola generated by aCflnicatWorks EMR/PM Software {meCflnicaMomscom} https://caapkdapp.eclinicalweb.com/mobiledoc/jsp/calaIog/xml/prinlMultipleChartOption... 11/26/2019 APMDWCDUDZ3 pzmc uLTR‘Asouuo fl .fl. 63%AW Mama w tj-E L7ASQY) Age Weight 21/?fl? ‘ Physician Scan No.W NewWW RepeatGate Tape Na..m Frames - LMPW Cram WW... ?arity 1.8.3: Dating: Menstruat Agem week‘s. Fill Yes m No .._._ Stewed 113:3 Yes“... N9m Rammed Binding Temperature Pelvic Pain? Na W. Yes W. Where? VAGINAL m$CHARGE? Hismy ‘~* {a [/42375+ jg,- £3 075-303. 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APMDWCOM 02 ZIZ-HZUIT 10:57 Ni I'M: Fol! TD: *1 “OBI 370*3792 PAGE: 091 OF DD? r; ' . VRI Montpeligr ' @alley Radiology Imaging‘ éfisfisi'ft’éfi'éfl? 'HRudNet Imaging Centers §§§:”?éé§?§e%§%°° Ordered By JOHNSEN, STEPHANIE ANGELA POLLARD, MD MRN: 8514719 I ?00w FARR AVE. STE I DOB: 07-29-1965 Sex: F L05 GATOS CA. 95032 Prone:(408) 4?2-9996 FAX: (408} 379-3790 Dale at Sewice: 02-24-2017 |st.\'.-\M: Nun PEst wrmom‘ .a -\:D wrn-a cowrrmsr CLINICAL Imromcun'lom Lost ml). TlECI-INIQUE: MRI ofthc pelvis with anti without contrasL 1.5 'l‘ Magnu- multiplanar 'l'l and TZ-wciglncd imaging pcrfonncd. Crmlrasl: l0 cc IV Dolmzun COMPAR lSt)N: None availa'blc. FINDINGS: Uterus: Antarctica, 4.5 x 3.4 x 5.5 cm. UIa-us is within nurmnl limils. Na focal'fibroid is identified. Junctianal zone is within normal limits nl 8 mm. Along lhc anlcrinr lower merino segment, .at lhcjunciion ol' line cervix, there is low 1‘2 signal, with associated susceptibility artifact. consistml with 'a csarcan section scar. No IUD is idcnlifiod within lhc myomclrium. Along Lhc outfit cunlour ol’lllc ulcws, aimg [he anlu'ior wall. then: is within '1'2 hypoinlmsily, numpmific. Endometrium: Normal T2 hwu‘inlmsc; I mm. No abnormal mlumccmcnt. An IUD is no! idmtificd within the mtbmdrial cavity. Cervix: 2.4 cm in length. Normal zonal anatomy. Ovaries: Both ovariw arc within normal limits. 'l‘hc right ovary measures approximately 3.1 x 1.3 x 2.3 cm. The lcfl ovary mmsunw 3.6 x 2.3 x 2.0 cm. 'l'hu'c amnonual subcmtimclcr fofliclm in bolh ovaries. within normal lim‘ils. ' Pcr‘itoncumf ' ff: . P, . ”-1"! -. a:- . Nuasmlcs. E 4.5 1, , fifl‘a?’ e‘fiuffi; 2'! UrinaryBladdcr: “ imd- Unrcrmrkahlc Nudes: Confidential Patient: JQHNSEN, STEPHANIE DOB: 075294985 t Pagan ct 2 .-1 --_-_ -- ' : f APMDWCDOOGQ L 212-II-2017 10:51 Mi Fm: Fall TO: +1 HOBi 170-3790 ?AGB: 002 0F 002 VRI Montpelier 2385 Montpelier Drive I Galley Radiology Imaging San Josetmm Phone: (408) 964-1 000 RUdNBi Ilnflgillg [eMBl’S Fax: (403)964-1035 No l3mpluglmopalhy Bowel: Unrcnun'kablc IMPRESSION: IUD is not idmlified within Ihc uterus'or in Lhc cndomclrinl cavity. The utwus is within normal limits for sizev’and mmphnlngy. There is no widmcu fur Focal fibroid or atlenmnyosis. Al the juncli'on ci' lhc lower uterine scgnwpf {Ind ccrvix, along the anterior wall ofiul'crus, there is susccpiibility artifact and T2 hwohltcnsity, consistent w'ith postsnrgical changes, Iikcly from prior cesarean scctinn. No disc'rd'c IUD idmlifigd. For incalizalionpflhc IUD, radiography or CI-ngy b: beneficial. 3. No ascitcs. Ox'arics arc within normal limits. Em! ol' dlngnoslic n-purt I'or accession: 9369635 Dirlnlrd: 02-24-20]? l0:52:18.}\M Diclaicd By: Kung, So‘ph'm ThMD Sigurd By: Hung, Sophia 'r.MD 02.2mm? 10:52:! s AM Confidential Patient: JOHNSEN. STEPHANIE DOB: 07.294985 Panezdz n - --.. ..-_l n..." ”u...- APMDWCDDDYO Fax Server 7(2712018 1:14:58 PM PAGE 71'018 Fax Server vuuu-O i - Goon 3:1.me Inn HosPITAL (comm EMERGENCY paovzoap. REPORT REPORTfi : 0725- 653 q. REPORT STATUS: s i.gned DATE = 07/26/18 TIME: 1555 l PATIErnr-z JOHNSENJTEPHANIE ANNE UNIT 11.: rdoooaaum ' Accouma: Maoassazozso _ I aocm/azn: I ma.- o7/29/as AGE: 32 sax: F pap PHYS: Chauahuri,manti ! MD I SERVICE 0T: mmsna mmon: Watanagnaena s MD ‘ REP 31w 0T: 07x26na Rap srw Tm: 1555 ' v" ALL edits; or amendments must ba‘ made on the electronic/compucer document * I i H.E.I;C.enenal.ill.nfiss l Cenaral Initial Great DntclTime 02125118 153G u Presentation Chief Complaint Abdominal pain : Context E Additional Context ‘ 32-year-old remade with no gas: amdical history [mesents with lower ab‘dnminal pain. One . week ago patienl repous having lo'wer Grumpy aydnminal pain which fasted fer 2 hows am! - seif-resolved. Yesmrday natiem was kicked in the abdomen by her mung daughter accidentally,‘afte: which she had gradual Onsm of suprapubic abdominal pain which raalialad to h‘er right lomr Quadrant and- lower back, crampy, cnnsmnt. She had 2 episodes or von-Iiting nanbkmrly nonhilious vesrerday and has. been feeling nauseous today. No fevers. Wen! Io her PMD whn referred her to the emergency room for concern for appendicitis. Denies dysuria, urinary urgency, frequency, flank pain. Reports dyspareunia 2- days'ago but no new-vaginat discharge. Patient ‘is sexually active with her husband only. Of note, parinm reports her IUD is “iosr' in her abdomen; She had a Iaparoscopy in February of 201 ? .to try and remove the IUD bu! it was not found.RWiW Free Text ROS Notes Free Tex: ROS Notes Cnnsfitutinnal: Denies few}; or ”chills _ Eyes: rJanies vision changes Eera'r: Denies- sore throat CV: Denies chest pain'or palpitations Resp: Daniels SOB’ CI: vomifing, no diarrhea GU: Denies painfu'z urinalion MSK: Denies regent trauma Wage 1. o: 3.4} PatiencJO'I-INSEN. STEPHANIE MINE. MRMMOOUBMM 4- Encaunz‘erflaogfis’dzozsa Page 1 o! 1a ‘ APMDWCOOOOZ Fax Server 7/27/2018 1:14:58 PM PAGE 81018 Fax Server I patient: JQHNSEN,5TBP§ANIE ANNE Unit#:M000392414 Date: 07126118 Acctfizmoossaazozso Skin: Denies mew rashes Memo: Dlanier. new numbness m‘ tingling nr weakness Enticicrinez Denies- unexpectmi weight loss i-Ifims: Danie; bleeding rl'rsc.:rders Enfimzlmaml.inslpxygfiduli. Staied Compiainl ABDOh-HNN. PAIN Altergies ‘Cadetl Allergies: No Known Allergies {Oran 3!]4) Home Meclicatinns Active Scripts l-h’DROLtudmmemCETM-HNOPHEN (NORCOSIBZS MG} 1 TAB PO Q4H PRH PRN MILD ' PAIN (PAIN SCALE 1-3) #90 va: II-EJ’UIIM IBIJPROL‘JFEN (MOTRIN) 600 MC] PC: QQH PRN PRN CR.-\;\-‘$PS #9 Prov: Izmma-‘I Reported Mcdicalions PNWFE CARBONYLIFA [PRENATABS RX} “i TAB PO DAILY I Additional Medical History Migraine, occasiona: GQPOAB'I - Additional Surgical History - ' C-secfion, tubal ligation, breast augmentation. laparoscopy to :emove perforated IUD 201 7 which was unsuccessful Alcohol Use Alcohol use (Social; Drug Use Denies recreation! drugs. E none} smoking status for patienis '1 3 years old or older.- Never Smoker flbxaimLEmm Vital Signs Vital Signs First Dommentefl': u “a :7" 'o‘w'zm '33: .E€59!.a_. DmeTime ' LEPu‘is'é OK" Page 2 of 1".) PnlidritLJOHNSEN, STEPHANIE ANNE MRMMOOOBSZMS Encodnter:M00355420250 Page 2.0f 10 APMDWCOOODS Fax Server 7/27/2018 1:14:58 PH PAGE 9/018 Paflifillc: JOHNSEN,STEPHANIE ENNE unitfl':M000592-414 . -te: U73262'15 acctfifi'100355420250 0'7. 00m am ll l J Lastbtxumenfed: u __ u I _ t ' A ' FteE'iiTr“ Lhazeymo """ a {Pylwm .. ..... . ???‘aqm's 2mm": «ms ' rzw’afimryztfimm ' 'ka ?O‘i’ffi'fifi'fili'i a‘- I General: awake and alert, n0 acute distress Oxygen saturation: no hypoxia, oxygen sa1uralion within normal amount Head: normocephaiic and atraumatic I Eyes: PERM... extraocuiar mqvements inl'acl, no cuniuncliml pallor Fax Server Ear, nose, throat: atraumatic external nose and ears, clear oropharynx with no-exudates. Wain mirjlinv. Neck: trachea midline, neck Supple, no meningismus Regpiraiory: onlaborecl brealhing, iungs. CTAB Cmdiovnscular: nun rachycardic, RRR, nu murmurs, rubs, galtoizas. Cl: abdomen soft, mild tenderness to palpation suprapubic and right lower quadrant. no guarding m rebomcl Pelvic: Normal external genitalia. no CM’I‘ or adnexa! tendemess, normal white vaginal discharge Back: normal mSpecti'on of the back with 306d strength and range bf motion throughout. Nu chT. Extremiliesz pulses intact, 3009i capiliary mfiii. no edema, n9 tenderness. lo paipatian Neura: alert and oriented x3, no gross molar or sansury defects. Skin: Warm, dry, 'and intact. No rashes _ quiuw u!" Vital Signs Rexrlewed Free Text. PE Notes: Free Text PIE Notes General: awake and .aien. no a'cule distress Oxy en salm-arinn: no 11y dxia', oxygen saturation is within normal limits Mean : norn'lucepl'lalic amt atmumalic Rage. ?.- n‘f 1-"; PatientJOHNSEN.STEPHANIE ANNE MRMMOOUBSZMé' Encouniermflflfi355420250 Page 3 o! 10.- u-r- APMDWCDOOO4 Fax Server 7/27/2018 1:131:58 PM PAGE 10/018 Fax Server Patient: JOHNSEi-I, STEPHANIE ANNE Unit]! :51000892414 Date: 07226/18 Acccfi:mooassqzozso EYES: PEERL, extraocuim mama‘memls intact. no cnniunctival pallet Ear. nnse, throat: atraumarit: external nose and ears, clear oropharynx wilh no exutlates. uvuia midlinc Neck: {rache'a micfline, neck summer, nu meningismus Respiramry: uniabornd bremhing, lungs CTAB Cardiovascular: nor tachycardia, RRR, no murmurs, rubs, gaflom. Cl: abdomen soft, mild :enclerness to palpa'liOn right lower quadranl and Sunrapubic region,m guarding or rebmmd Pelvic: Normal external genitalia. no CMT or adnexal tenderness, os. visualized. nonfriahlc Eick; normal' inspection of ihe back with good'stmngsh zind,range of motion throughout. No 'A '. ' 'Extremities: pulsms intact, good capillary refill, 'nn edema, nomndemcss to pal'patinn Neura: stair: and oriented x3, no gross motor or semen: defeat; Skin: Warm, dry; and intaci. No ras mes m.tatpmhnignm&_magwfics Lab Results Interpretation Results Laboratory Tam 07a'26l'18 1606: 1 1-1.3 I mo - 1.05 7.3 223 Labora T i'lf'ium' W- .. m ubm . - Rage: r. n: La. Pati'oszOHNSEN. STEPHANIE ANNE MRN:M000892414 Encountermooasmzozso Page 4 ol’ 1o ® APMDWCOOOO5 Fax Server 7/27/2018 1:14:58 PM PAGE 11/018 Fax Server Patient: JOHNSEN.STEPHANIE nwus Unit#;M000892414 Daze: 0?i26f18 Rcct#:M00355420250 Ukafiflaf’rmei“ NE 15.0.:53".§32’E.:. Urine G EGA'TIVIE, ., .Q"E'i.37r]il?l..... . N cmwg 'MUDERKTEW‘ Microbiology: PatientJOHNSEN. STEPHANIE ANNE MRN:M000392414 Elmountertf‘t100355420250 P890 5 of 10 APMDWCODUDB Fax Serv'er 7l27/2018 l:14:53. PM PAGE 12/018 Fax Server Patient: JOHNSE;N,STERHANIB 3mm Unit]! : b1000892'414 Date: 0?.)‘26/18 Ac0ti€=fi100355¢|20250 Datefiirnu Procedure: - Status z fifastm... .. .. C‘rmvlh . . amt; 165$ Neisser‘ua 5mma-rhminE'DN'K"(TKKFi'TTfi'i-TW" ' Emrzsocx- . nms 1 655 chlamydia nachomaris DNA {mm - REED I *NDOW ' ' ems 1605 Urine Cultur‘e-RECD‘“ """""'" " “ ‘ umNs Recent Imnrcsfiions: ULTRASOUNDS - US APPENDIX 07.126 1745fl" Report Impression - Smtus: SIGNED Entmed: 07f2fil2018 1849 IMPRESSION: {uppendix is n01 vismlized. Hmwzver, there is no fluid collecfion within the. righr lower quadrant. gémll's were transmitted to the emergency room a! men's at 18-16 ours. Impression By: PRTRAMAT ”Matthew Tran, MD. ULTRASOUNDS - US PELVIS NON OB 07126 1759 ""'" Report Impression - Stami: SIGNED Entéred: 071’26f2018 18:17 IMPRESSION: 1. 1.2 cm linear echogenic struclure in the zesirm of the cervix, likely relawd to a dislod ed 'mtraulerirm- device. Calcification is aiso a consideration, If: inicaliy indicated. additional evaluation with peivic radiograph may he considered. 2. Trace: amoum of free fluid wilhln lhe endometrial cavity, nonspecific. 3. Trace amount of {rec fluid in lhc‘cque-sac. nonspecific.- Resulls were transmitted In the emetgen'cy romn an 7/2Eaf18 at l-Bzm houfi. Impression By: PR1WWW? - :‘x-‘iaflhew Tran. MD. ULTRASOUNDS - US ENDOVAGINAL SCAN 07.326 1808M" Report Impression - Swtus: SIGNED Entered: 0?!26/2018 184.7 iMPRESSION: 1. 1.2 cm linear etzhugenir. Structure in film reginnpf- the Cervix, likely related lo a. disiod ed intrauterine device. (.‘alcitficntion is , also a consideration. l-Ic inimily inciicaled, additional evaiualjon Peg?! 6' 05 3-3 PhlianltJOHNSEN. STEPHANIE ANNE MRNH’JOOUESZM 4 Enc0unier:M0035$420250 Page 5 0f 10 APMDWCDDDD? Fax server 7/27/2018 1:14:58 PM PAGE 13/018 Fax Server Patient: JOHNSEN,STEPHANIE ANNE Unit#:M000392414 Date: ovfneilfi Accufi:H00355d20250 wiih pelvic radiograph may be considered. 2. Trace mnount rat free fluid within the enclometrial cavity, -nonspeci{ic. 3. Trace amount af free fluid in the culade-sac, nnnspecific. {iesulis were transmitted to the emergency room on '7/26f18 ai 1'344 -1nur5. Impressiczn' By: F’RTkAs'x-M‘i' - :‘viatlhew Tran, MD. COMPUTERIZED TOMOGMPH? - CT ABD AND PEI. W CONT 07126 2027 "m“ Report Impression - Status: SIGNED Entered: (J7I2f5f2018 2217 1MPRIESSION: iUi‘J is aeen outside ofrha u'terus,~and lies inferior r‘o the reams; uhdominis muscle 0n the. right. Findings are conce‘rning for perforated IUD. No free'fluid. Impression By: PRFRERY - Ryan Anthony Frederiksen, MD. u-Iu-m. .n-n u-r-u-n .EmEmeilon..&M.DM Free Text MDM Notes Free Text MDM Notes’ A 32-year-old female C3323? {1 miscarriage) with history of perforated IUD status post ; laparoscomr which did no; find lUDpresents with 'I _'day of right iower quadrant pain. On exam patient i5 afebrile with stablewtal signs and nuld right lower quadrant and suprapubic I tenderness to palgarjquil'h no guatding or rebound, pelvic exam with nu CMT, udnexa'r tenderness or vaginal d:scharge. Labs no Ieukocytusis, um‘emmkable chemistry, urine with “3-10 while blood cells and few E bacteria with moderate bison}. cervicai GC Chlamydia sent and pending. Pelvic ultrasaund with no ovarian cysts 0r evidence of torsion. bur 1.2 centimeter linear structure clase- tn cervix which may be. consismm with IUD. CT abdomen and petm obtained with no swidance uf appendicitis bul IUD viaualized outside or Ihe mews, inferior Lo the» :ectus , abdominal muscle rm the righl dosed area patient‘s pain. I The patient given Diinudid frmowed by n'wrphipe. 0n repeat abdominal exam patient much more comfortable with mild tenderness in {he ugh! iower quaclranl hut no guardmg or rcbpund. Page “I a: 1.9 PatielztzJOHNSEN. STEPHANIE ANNE MRN:M0008924'14 Encoumal'2M00355420250 Page T of 10 l APMDWCOOUDS Fax Server 7/27/2018 1:14:58 PM PAGE 14/018 Fax Server patient: JOHNSEN.STEPHANIE ANNE Uni:#:M000892414 Date: 07/25218 Acctfizmoosssazozso Pain must likely clue to perforated IUD which patient has Iikely had for some time, recenl onset uf pain perhaps due to daughter kicking patient in her righl lower quadrant area. Patient hm: no urina symploms so doubi UTI or pyeloneplwilis. Diriy UA likely cluc'lo aqrn-u'mmal'ir. tmcmrluria. Daub! PID givéL-n m1 v3“ inai rflscharge, GMT or adnexal tenderness. £301an gall bladder pmhrsmgy zcholalit 1iasi~;, choletyslitis, choian itis, choledoclmlit‘niasis), mncreatifis, AAA. mesenteric isclwmia, 560, bowml peer oration, sigmoid volwhm, diverl'icuiilis, appendicitis, perforated PUD, significant GI mead, hepalic abScess, splenic infarct, nephrolil‘hiasis, pyeloheph'ritis, slrangulated hernia. She has no evidence of sepsis or perilonitis. I s ke with Dr. Poilaré oiOB Gym who advised patient callihg‘ her in the morning for . fa Iow-up this week given that the IUD has been perldratecl f0: same time. I l have reviewed the pal'ient'5 vital signs, nursing notes. and other relevant lestsfinforn‘lafion. | Based on the workup, 1 ‘rJo nor believe this patient has an emergent: r medical condition requiring hospitalization or further IEfJ management and is 5a fr;- for ischarge home. with outpatient follow up. I had a detailed discussion with the patiem regardin the workup performed in the ED, results supporting 1hr: discharge. diagnogis and the: fo tow up plan. I £650 discussed {he need lo return lo lhc ED if symptoms worsen or if there are any questions or concerns lhat arise a1? home. Al! questions were answered. The patient and famiiy confirmed understanding of djscharge plan andmetum precautions. In ED Course . Medicatimfls) Ordered I :\-Ietlication(s] Ordered: Central Nervous System Agents g Sichh Start Iime L33! EMedication Dose Route Stop Time Status Admin morphine Sulfate iii MG Xlt'O STA 07526 1939 DC 07126 Iv , 0:725 194.0 . 195_b__ ' i-'lydron10rp|1|?ne MCI 0.5 MG 55(1EDS1A 0.7126 15-10 DC. D7325 .W 032’26 1 S41 1702 Diagnostic Agents _ k, g SigISch Stan lime gust . éMediwfion E2959 Rouxfl. <10 J..T.itt.3.e.._... .Slaw.5..é.fieir.nvtt.. gloparfi'idol 3‘0 ML .S'IIKMED ONE (17m; 2055 0C 07/26 H: ; IV 07:”26 205? 2056 I ?age a o! 1.3:: PatientiJOHNSEN. STEPHFINIE ANNE MRNEMOOOBSZMIS Elicounler2M00355420250 Pa go 8 o‘l 10 APMDWCODOOQ ....-.___._- . _. Fax Server Uni:#:M600392414 .nate: o7izaxls Accc#:M00355420250 Gastrointestinal Drugs 7r27x2018 L:14:58 pm pAGE 15¢018 Fax Server Patient: JOHWSENLSTEPHMIE Aims Electrolytic, Caloric, And Wat ' SigSch 'Siarl time £351 Nledicafinn Dose Route , Stop Time Status Admip" Sodium Chloride 1.000 ML X'IED STA U7i26 19-10 DC _ 0747156 .. .. .. .8E".1-.c‘e<-3E... P?QG. 3. 915?. 1... .. 1' 95.5. Sodium Chloride 1.000 ML XIED STA. Q7126 1540 DC 07/26N 07/26 1:341 Um I SigISch Start lime Last Medication Dose Ramp. Step Time Sratus Admin Ondansmrun HCI '4 MG X'IED STA 07/26 1540 DC. . D7126: , Iv 07/26 154: i 1702': EalianifliachmgaéLDmdmLte Vital Signs/COndition Vital Signs First Docmucnted: Last Documented: .. 1.2.7.. 1. n1 H' .-... l d?/2_ra" ’4 AI! Vila! signs available .al the iima of {his entry have been reviewed. 4 PmienlzJOHNSEN. 8TE?HANIE ANNE MRN:M000892414 En:Ounicr:M00356420250 ?agl 9 of .10 Page 9 of10 APMDWCODM 0 Fax Server ?{27/2018 1:14:58 PM PAGE 16(018 Patient: JOHNSEN,5TEPHANIE ANNE unit#:M000332414 Date: oviaails Acctfi:M00355420250 Cnmliliou Slalfl'lfl Clinical Impression Ci'mical Impression Primary impression: llJl') migration Secondary hnpressiuns: Abdominal pain Disposition Decision [)ischarfl'c Jt Disc11zirg‘ed to Hume Yes 1t Iime 231 6 l K Date 0?;{26a'1 8 Electronically Signed by Watcha,Daena S MD on 07I26n B at 2-349 RPT fl: 0'326-0534. *‘iBI-E'D OF REPORT“’* Page 16 sf. 1.9 PatientJOI-INSEN.STEPHANIEANNE MRN:M000892414 EI‘ICOUHRflMOOWSfiZpZEO Fax Server Page 10 o} 10 “‘4.- n ”W- APMDWCOOO1 1 Page 3 OHS Iohnsen, Stephanle 32 Y old Fenmle, DOB: 07].?9/1985 Account Number: 17015 1480 Dc Tnlmn DI“ , San JOSE, CA~95120 Home: 408-472-9996 Guarantor: Johnson, Stephanie Insurance: Z-SCCIPA An them Blue Cross Payer H): SCACO Appointment Facility: Angela Pollard, NJ). 07/27J2018 Progress Notes: Angela Pollard, M.D. Reason for Appointment 1. Eclg opp lapx ' Assessments 1. Right sided abdominal pain - R109 (Primary) 2. Displacement of intrauterine contraceptive device, initial encoun ter - T83.32XA 3. Pelvic pain - R102 Procedure Codes 49320 DIAG LAPARO SEPARATE PROC Follow Up 2 Weeks Mpgééax Electronically signed by Angela Pollard , MD on 07/30/2018 at 09:46 AM PDT Sign off status: Completed Angela Pollard, MD. 700 W PARKAVE LOS GATOS, CA 95032-14 16 Tel: 408-370-3630 Fax: 408-370-3790 Patient:Johnson,Stcphanic 1303:07/29/1985 Progress Nuthngcla Pollard,M.D. 07/27/2018 Nara generated by eCfinicaMorks EMR/PM Software(meClinIcaMorks.aom) https://caapkdapp.cclinicalweb.com/mobiledoc/jsp/catalog/xml/printMultiplcChartOption... l i/26/2019 a u- unann- -‘.~--- n APMDWCOOUZ4 Page 4 of‘18 ___l . Iohnsen, Stephanle 3:2 1’ old Female, DOB: 07/29/1985 Accounl‘Numbcr: 17015 1480 Dc Talmu Dr , San Jose, CA-gsuzo Home: 408-472-9996 Guarantor: Johnscn, Stephanie Insurance: Z-SCCIPA Anthem Blue Crass Payer ID: SCACO Appointment Facility: Angela Pollard, MD. 07f27/2o18 Progress Notes: Angela Pollard, M..D. Current Medications Taking o Mircna 20 MCG/quiR Intrauterine Device as directed Intrauterine Past Medical History Medical History Vcrificd.. Surgical History wisdom teeth extraction u yrs cmarcan section 8/2016 diagnostic laparoscopy and bilateral salpingectomics 2/2017 Family History Father: alive 62 yrs, wcll-hcalthy, diagnosed with Healthy adult Mother: alive 59 yrs, wclI-hcallhy, diagnosed with Healthy adult Paternal Grand Mot her: deceased. breast cancer, diagnosed with Other malignant neoplasm of unspecified site 1 bmlhcr{s) , 1 sistcds) - healthy. adaughtcr (s) - healthy. Pt denies any gi. gyn, and colon cancer in family. Social History Tohncgg gag: Tobacco Usc/Smoking Arc you :1 nonsmokar Gyn H istory Sexual Activity managamous with husband. Birth control Mircna intrauterine device. Ahnormal pap smear dc nies. Sexually Transmitted Diseases (S1135) none. OB History Total pregnancies 3. Total living children 2. Miscarriagds) 1. Pregnancy! 1: nonnalspoutancous vaginal delivery (NSVD) 2014 Female . Pregnancy ; 2: miscarriage. Pregnancy r 3 Priman- ccsnrcan- 8/8/16 Dr.PoiIa rd Female ECLG “Aubrcc Rose“ . Reason for Appointment 1. F/U ER Ind 2. Preop-general 3. ap ROS History of Present Illness g: Stephanie pesents for evaluation of severe right mid abdominal pain. 2 weeks ago she had R. mid quad pain for the irst time. She thought she had an appendicitis and thought about going to the ER the pain was so severe. However, the pain resolved after several hours. Weds night she had again R mid quad pain. ?ever to 99.6 fdf Doctor Shadri’s office thought she had appendicitis. She scheduled . her for an ultrasound. However while wailing for the ultrasound the pai n became intolerable and she went to ER Thursday afternoon. ultrasound of the abdomen was done-tech thonght she saw the IUD C'l‘sczm was performed and the IUD was seen "in thc abdominal wan." Stephanie had previously evaluation done for the displaced IUD. 3 months after insertion, an abdominal xray failed to see the IUD. She had had pain and bleeding prior to that event, so it was thought that the IUD had been expelled. Stephanie wanted to be sure so she obtained the opinion of Dr. Graven who thought she saw the IUD in the uterus and scheduled a hysterosocpy/laparoscopy. Dr. Graven did the hysteroscopyflaparoscopy and did not find the IUD (2/2017). She started OCPs which regulated the period. Vital Signs Wt 1251bs, Ht 64 in, BP 118/70 mm Hg, BM! 21.45 Index. Examination General Examination: GENERAL APPEARANCE: normal, alert, well hyd rated, in no distress , in no acute distress. THROAT: clear, no erythemn, no exudate, pharynx narmal, uvula midline. NECK/THYROID: carotid pulse normal, neck Supple, no thyromegaly, thyroid nontender, trachea midline. LYMPH NODES: no axillary, supraclavicular or inguinal Patient: Johnson, Stephanie DOB: 07/29/1985 Progress Note: Angela Pollard, M.D. 07/27/2018 Nate generated by oClinicarWorks EMRIPM Software fm.aCfinicaM/’oflrs.com} httpszlicaapkdapp.cclinicalwcb.con1/mobiledoc/jsp/calalog/xmlfprinlMultipleChartOplion... l 1/26/20 I 9 APMDWCODOZS Allergies N.K.D.A. HospitalizationlMajor Diagnostic Procedure Second delivery 8/2016 Review of Systems Womgn Only: Denies Breast lump. Denies Breast pain. Denies Diachnrgc from the breast. Denies Heavy bleeding during menses. Denies Hot flashes. Admits Irregular menses. Denies Missed periods. Denies Painful intercourse. Denies Painful menses. Denies Vaginal bleeding between periods. Denies Vaginal dischargc/itching. Brgnst: Denies Bloody nipple discharge. Denies Breast lump. Dania Breast pain. Denies Breast swelling. Denies Fever. Denies Gland swelling. Denies Nipple discharge. Denies Red skin. Denies Weight 10$. figniggyrinmy: Admits Abdominal pain/swclling. right mid quad. Denies Blood in urine. Denies Difficully urinating. Denies Frequent urination. Denies Pain in lower back. Denies Painful urination. nggmMConslilutionnl: Denies Change in appetite. Donia Chills. Denies Fatigue. Dcnics Fever. Denies Headache. Denies Lighthcadedncss. Denies Sleep disturbance. Denies Weight gain. Denies Weight 105$. Psmhiatric: Denies Anxiety. DcnimAuditary/visunl hallucinations. Denies Delusions. Denies Dcpmscd mood. Denim Difficulty sleeping. Denies Eating disorder. Denies Lass of appetite. Denies Mental or Physical abuse. Denies Stressors. Denies Substance abuse. Denies Suicidal thoughts. Page 5 0T I8 adenopathy, no lymphadenopathy. SKIN: good turgo r, no rashes, no suspicious lesions, normal hair distribution. HEART: regular rate and rhythm, , no murmurs, rubs, gallops. LUNGS: dear to auscultation bilateraliy, good air movement, no wheezes, rales, rhonchi. ABDOMEN: normal, bowel sounds present, liver edge one finger breadth below costal margin, no hepatosplenomegaly, no masses palpable, no hernias present, no rebound tenderness, tender to palpation in the right middle quadrants, . RECFAL: normal tone. Genitourinam - Female: EXTERNAL GENITALS: normal, no lesio ns. URETHRAL MEATUS: normal. URE’I‘HRA: normal. VAGINA: normal. I ADNEXA: no masses palpated, ovaries normal size, non-tender. ANUS/PERINEUM: normal, normal tone. CERVIX: no cervical movement tenderness, normal. UTERUS: normal size, mobile, OVARJES: no masses felt in adnexa, norma} size, nontcnder. Assessments 1. Right sided abdominal pain - R109 (Primary) 2. DiSpIaccment of intrauterine contraceptive device, initial encounter - T83.32XA ' Treatment 1. Others Clinical Notes: PLANNED PROCEDURE: My impression is that the patient has severe right sided abdominal pain due to a diSplaced IUD. I am ey concened as to the actual position of the IUD as Stephaine has had multiple fadiographic scan as well as a diagnostic laparoscopy which have all failed to locate the IUD. She is continuing to have severe abdominal and requires immediate surgery to remove the IUD I had a long detailed discussion with her raga rding options available for therapy, including medical and surgical modalities. If she were to go the surgical route, she would be an excellent candidate for operative laparoscopy, possible hysteroscopy, with removal of the IUD We did discuss all risks, complications, and alternatives to surgery, including, but not limited to bleeding, trasfusions, infection, damage t0 any internal organ, death, stroke, heart attack. Stephanie is going home to think things over and decide what she would like to do. If she chooses surgery, we will set her up for the above mentioned surgery at a mutually convient time. We are conta cting the hospital andinsurance as to availabilities for today. Follow Up 2 Weeks Patient: Johnson, Stephanie DOB: 07/29/1985 Progress Note: Angela Pollard, M.D. 07/27/2018 Nata generated by eClinIcaIWoms EMR’PM Software (maCfim‘caMmem) https://caapkdapp.ecli nicalweb.com/mobiledocIjsp/catalog/xml/printMuhipleChartOption-. .. 1 1/26/20 1 9 ____._________ ___| u dnnl .- APMDWCOODZB Page 6‘of 18 M3444 I i 03:02 PM PDT Electronically signed by Angela Pollard , MI) on 07/27/20 18 nt I Sign off status: Completed g Angela Polls rd, MJ). 700W PARKAVE LOS GATOS, CA 95032-14 L6 Tel: 408-370-3630 Fax: 408-370-379o Patient: Jnhnscn, Stephanie l)OB: 07/29/1985 Progress Note: ‘Angcla Pollard, Md). 07/27/2018 Note generated by oClinicaIWams EMRIPM Schwara {mm.eClinicaMorks.oam) I ..- u--- htlps://caapkdapp.eclinicalweb.com/mobi|edoc/j5p/catalog/xmllprintMuitipleChartOption... 1 1/26/20 l 9 APMDWCOODZ? Fax Server ?l27/2018 6:09:52 PM PAGE 2/002 Fax Server ___..i Patient Informallon .Paliefit Name HAH MRN Sex DOB Johnsen. Stephanie Anne 3000085450 0001 'l 467B! Female 72911985 Procedures by Anqela Michelle Pouard. M0 a: mmma 6:07 PM E Author: Angeta Michelle Pollard. MD Service: ADT - Obstetrics Author Type: Physician Filed: 7!??(2013 6:09 PM Craalion 'fima: 7!27!2018 6:07 PM Slams: Signed Editor: Angela Michelle Pollard. MD (Physician) INPATIENT . GYM aRIEF OPERATNE NOTE DATE. 0F OPERATmN: mmma PHE-OP DIAGNOSIS: 1. fight abdominal pain; dispkmed iUD POST-OP DIAGNOSIS: I I 1. Same OPERATION: Diagnostic Iaparoscopy Removal oi displaced IUD SURGEON: Angela Panam. MD ASSISTANT: Adroum MD ANESTHESIOLOGIST: Sara Cristy Herman, :IEJ ANESTHESIA: Genetal FINDENGS: Paii-eni' had normal appearing upper abdomen. normal gallbiau'der, liver edge. and appendix: The uterus and o'varies war? surgically removed. IUD in omenlum at zhe right abdomen . EBL: OmL mL FLURDS: 1000 mL, URiNE OUTPUT: 5:) ml. SPECIMENS; none i0 paihology COMPUCATSONS: None BRAINS: Foley caiheter Angela Pollard..MD 712712018 6:07 PM I APMDWCODDSB Fax Server 8/2/2018 7:41:38 AM PAGE 2!003 Fax Server -- ._.___J Patient lnformallon Patient Name HAR MRN Sax DOB Johnsen, Stephanie Anna 3000085450 0001 1467'81 Female ?12911 985 Tmnsctlplion Type . ID Dictaling Provider Fuil Oparatwa Report 31 29902 Angela Michelle Pollard, MD Signed by Angela Michelle Pollard. MD on O&‘OZIIB at 07'35 DATE-OF SERVICE: 07/27/2018. PHEOPERATIVE DIAGNOSES: Right mid-quadrani abdominal pain. displaced intrauterine device. POSTOPERATIVE DIAGNOSES: Right midquadrant abdominal pain. displaced intrauterine device. - -- ----_-_-- P'HOCEEUHES PERFORMED: Operalive Iaparoscopy with removal displaced IUD and local administration o anest etic. . SURGEON: Angela Pollard. MD. ASSISTANT: Melissa Adrouny. M.D. ANESTHESIOLOGIST: Sara Herman. MD. ANESTHESIA: General endotracheai. ESTIMATED BLOOD LOSS: Minimai. ' INTRAVENOUS FLUIDS: 1 titer. URINE OUTPUT: 50 cc of clear urine. FINDINGS: The patient had normal appearing upper abdomen. normal gaflbtadder. fiver edge. and appendix. The intestines were a bit dilated with stool to the appendix edge. The uterus and ovaries were normal. except [or a very vascular aSpect on the right uterine fundus. Fattopian tubes were surgically removed. The IUD was embedded in the omemum and the right side of 'the abdomen. COMPLICATIONS: No complications. SPECIMENS: None. DISPOSITION: To PACU. awake. in stable conditign. DESCRIPTION OF PROCEDURE: The patient is a“ delightiul (52 P2..who had a several day history of right mid-quadrant pain. In the pasL we had concerns about displacement oi IUD, but a prior laparoscopy failed to show the IUD and x-ray showed that the lUD was not in the abdomen. However, the day prior to. ' presentation, a CT scan done (or severe abdominal pain showed an IUD in the right abdomen. Decision was made lo proceed to the OR to remove this iUD as the pain was severe. lnlormed consent was obtained. She was taken to the Operating room and placed in dorsa! lithotomy position. She was placed . under general endotracheal anesthesia and prepped and draped in the usual sterile manner. A weighted speculum was placed inside the vagina and the anterior lip o! the cervix grasped with single tooth tenaculum. A paracervical block with 0.25% Marcaine and epi was gefiormed. ApproximaIeSy 26 cc were injected. A HUMI catheter was placed in the cervix and used for manipulation of the uterus. Tenaculum was removed. Attention was directed'io the abdomen where loca! anesthetic was injected in the umbilicus in the bilateral lower quadrants. Through the umbilicus. a Veress needle was placed and its intraabdominal position confirmed with gas. The Veress needie was removed after a pressures! 15 was obtained. Through the inclsiOn, a5 mm disposable trocar was placed under direct visualization of the laparoscope. 1 APMDW000034 Fax Server 8(2I2018 7:41:33 AM PAGE 3/003 Fax Server Two addition a! 5-mm trocars were placed in the bilateral lower quadrants under direcx visualization with laparoscopa. The pelvis and abdomen were then explored with the findings slated above. The IUD, which wasjn the omentum‘ was grasped and using graspers. the IUD was dissected out of the omentum. The IUD was then grasped by its stn‘ng and removed through the 5 mm pan. lrrigaiion ol the area showed good hemostasis present. The pelvis Was inSpected and in particular the area of the appendix was run. The appendix appeared normal, but the bowel was siightly dilated. The appendix was deep insidejhe fight sidewall wilh the ileum dilated superioriy. The pelvis was irrigated and aiso oi note that the pelvis had very increased vascularity. In the posterior cuI-de-sac. there was extremely dilated vascularity along the uterosacrai ligaments and the broad ligaments bilaterally. No other source oi abdominal pain was found and so gas was allowed to exit from the abdomen. The instrumean were removed. and the Irocars removed from the abdomen. The incisions were closed with a bun‘ed subcuticular suture of 4-0 Monocryl and. Dermabond. Additiona! local aneslhetic was iniected. Incision was washed and dressed. The patient was taken to the recovery room awake and in stable condition. There were no complications. Angela Pollard. MD. CC: APLS Job ID: 3129902 I 021058 D: 07-1277201 8 18:1 5:20 T: 0712712018 23:23:09 I APMDWCOUOSS SOLOOOMGWdV Surggm: Pmmmp Pageant it}: 3601iii?“ Pusan} Name: JafiMSEHQSTEmu; -. .,.mn_,_.,_.. . .;: - . dl- .. Page: 3 #0 LOOOMGWdV surgeon: mum!) Patiarxt H3: m11&6?! 2 Félicnt Name; JGHNSENSTEPHMEIE Page: 1 Page l of18 § Johnsen, Stephame 33 Y nld Female, DOB: 07/29/1985 Account Number: 17015 1480 Dc Tallinn Dr , San Jose, CA-gsmo Home: 4084729996 Guarantor: Johnson, Stephanie Insurance: Z-SCCIPA Anthem Blue. Crass Payer 1]): SCACD Appnin tmunt Facility: Angela Pollard, M3). 08/10/2018 Current Medications Discontinued o Mircna 20 MCG/24HR Intrauterine Device as directed Intrauterine ,stnp date 07/27/2013 o Medication List reviewed and reconciled m'th the patient Past Medical History Medical History Vcrifind.. Surgical History wisdom teeth extraction ”yrs cesarean section 8/2016 diagnostic lnpnroscopy and bilateral salpingcclomics 2/2017 Mircna iUD Removal 2018 Family H istory Father: alive 62 yrs, wclI-hcallhy, diagnosed wiLh Healthy adult Mather: alive 59 yrs, wcll-hcalthy, Healthy adult Paternal Grand Mother: deceased, breast cancer, Other malignant neoplasm of unspecified silc 1 brothclfs) , 1 sistcds} - healthy. adaughtcr (s) - healthy. Pt denies any 3i. syn. and colon cancer in family. Social History Tohngcg use: Tobacco Usc/Smoking Arc you a: nonsmokcr . Gyn History Sexual Activity monogamous with husband. Birth control Mircnn intrauterine device- >pcrforalion bilatcrpl snlpingcctomima. Abnormal pap smear denies. Sexually Transmitted Diseases (STDs) none. Progress Notes: Angela Pollard, M.D. Reason for Appointment‘ 1. Post 0p History of Present Illness Stephanie is doing very well. She has not had again thc RLQ since the procedure. She had bleeding soon after the precedurc but none since. She had previously been spotting continuously. Currently she has no pain. Normal bowel and bladder function. Vital Signs Wt 124 lbs, Ht 64 in, BP 120/80 mm Hg, BMI 21.28 Index. Examination Gynecglogical: GENERAL APPEARANCE normal, pleasant, in no acute distress. ABDOMEN: normal, soft, non-tender, no mass; incision c/d/i. Assessments 1. Right sided abdominal pain - R109 (Primary) 2. Displacement of intrauterine contraceptive device, sequela - T83.32XS Treatment 1. Right sided abdominal pain Clinical Notes: Resolved after removal of IUD Findings of procedure reviewed Return to usual activities precautions given. 2. Displacement of intrauterine contraceptive device, scqu cln Clinical Notes: Findings reviewed of procedure IUD removed successfully Resuje usual activities. 03 History Follow Up Tolnl pregnancies 3. pm Total living children 2. Miscarriagc(s) x. ngnancy II I: normal spontaneous vaginal Patient: Johnsen, Stephanie DOB: 07/29/l985 Progress Note: Angela Pollard, MJ). 08/10/2018 Nola generated by eCfinr'caMorks EMR/PM Software (tmneCfinicaMorksgom) https://caapkdapp.eclinicalwebso m/mobiledoc/j3p/catalog/xml/printMultiplcChartOption... I 1/26/2019 ua-n-a-- -- l.- _ _- u APMDWCODOZB .1 Page 2 of 18 delivery (NSVD)- 2014 Female . Pregnancy l 2: miscarriage. Pregnancy t 3 Primary ccsarcan- 8/8/16 | Dr.Pollard Female ECLG "Aubrcc Rose" . A l a ’ e 6'2 X Sign offstntus: Completed Allergies N.K.D.A. . HospitalizatinnlMaior Diagnostic Procedure Second delivery 8/2016 Electronically signed by Angela Pollard , MD on 08/10/2018 nt 11:13 AM PDT | E I ! Angela Pollard, MAID. 700W FARR AVE ' ' STE l LOS GATOS, CA 9503244115 Tel: 403-370-3630 Fax: 408-370-3790 Patient: Jolmscn, Stephanie DOB: 07/29,! 1985 Progress Note: Angela Pollard, MJ). 08(10/2018 Note generated by eCfinicaMorks EMR/PM Software (tmv.aCHnicaMorks.cam} httpchaapkdapp.eclinicalweb.comlmobiledoc/jsp/catalog/xmllprintMultipIeChartOption... 1 112 6/20 l 9 APMDWCOOUZQ Fax Server 712712018 1:19:58 PH‘ PAGE 3/018 Fax Server coon SAHARIIAH HOSPITAL . Name: JonnsEn,sannAan Anna 2G25 Samaritan Drive Phys: Watcha,Dacna S MD San Jose, CA 95124 Don; D?x29f1935 : 32 Sex: P Acct: M00355420250 Lac: M.EO PHONE fl: (405)559-2141 Exam Date: 07/26/2018 Status: R36 ER FAX fl: (403)559-2679 Rndiolngy Unit No: M000392414 EXAMS: CPT: 002394710 US PELVIS NON OB 76856 092394736 U3 ENDOVABIHAL SCAN 76830 ULTRASOUND OF THE PEfiVIS, 7/26/16 COMEARISON: None. HISTORY: 32-year-old female with pelvic pain. ?JHDIHGS: chl-tima ultrasound imaging of tho pelvis was performed 1n longitudinal and czansuersc projectiona via cransabdominal and transvaginal approaches. Uterus is normal size, contour and cchouexcura. It mcaaures 7.9 x 3.7 x 0.7 cm. No discrete mans is identified. Endometrial stripe maaauzas up to 5 mm. There is trace annunt of free fluid within the endometrial cavity. Thorn 15 a linear echogenic structure 1n tho cervical region, measuring approximately 1.2 cm in length. No linear cchoqenic struccuxc 13 identitiad within she cndnmetrial cavity. Right ovary is identified and measuring 2.0 x 1,6 x 1.6 cm. There is nu adnexal maaa. ' flLeft avary 1: identified and mcaauring 2.5 x 1.3 x 2.4 cm. Tharo i: no adncxal mass. Narmnl arterial and venous flow is documented in each ovary. There is trace nmcunt 0E free fluid 1n the cul-de-sac. IMPRESSION: 1. 1.2 cm linear echogenic structdra in the region o: the cervix, likely related to a dislofignd intrautcxina device. Calcification i: also a consideration. If clinically indicated, additional evaluation with pelvic radiogrnph may be considered. ’ 2. Trace amount of free fluid within the endomdtrial cavity, nonspecific. . 3. Trace amount o£.£rcc fluid in tho cul-da-sac. nonspecific. Results Hera transmitted to the emergency room on 7/26/13 at 1344 hours. . PAGE 1 signmd Report (CONTINUED) Patient:JOHNSEN. STEPHANIE ANNE MRN:M006892414 Encountar:M00355420250 Page‘l 01'2 APMDWCDOOY1 Fax Server 7/27/2018 Goon SAMARxTAN HosperL 2425 Samaritan Drive San Shae, CA 95124 PHONE #z (403)559u21a1 Fax #: (a03)559-2679 Exams: 002394710 US PELVIS NON OB 002394736 US ENDOVASINAL SCAN (Continued) ** Electronically Signad by H.D. CC: Dacha S Waucha MD Dictabad Datc/Tima: 07/26/2018 Tachnologist: Dang,c1ndy N.: 1:19:53 PM PAGE 4/018 Name: JOHNSEN,STEPHAHIE ANNE Phys: Waucha,naena s MD DOB: 07/29/1985 Age: 32 Acct: u0035542925o Exam Data: 07/26/2018 Stabuh: Radiology No: Unit No: MOOOBSEdld CPT: 76056 76830 Fax Server Sax: LOG: B.ED REG ER Hatthcw Tran an 07/26/2018 ac 1044 ** Reported and signed by: Matthew Tran, flan. (1839) 5N” 4702 Transcribad Dano/Timn: 07/26/2013 (L639) Transcripbianist: PRTRAMNI 0:19 Print Dir: s: D?/26/2018 (1347) FAGE 2 PationtrJOHNSEN. STEPHANIE ANNE MRN‘. BATCH NO: N/A Signed Report M00089241 4 EncounterMDOSSSdzozso Page 2 of 2 E APMDWCDOOYE Fax Server 7/27I2018 1:14:58 PM PAGE 2/018 Fax Server GOOD ahnARITAN HOSPITAL Name: JOEHSEH,BTEPHAHiE AHHB 2&25 Samaritan Drivp Phys: Watcha,Dacna S MD San Jase, CA 95124 DOB: 07/29/1985 Agc: 32 sax: F Acct: u00355420250 Lac: H.BD PHONE fl: (408)559-2141 Exam Dace: 07126/2013 Status: REG En FAN fl: (403)559-2679 Rndiolagy No: Unit No: H000892414 BEAMS: CPT: 002394713 US APPENDIX 76705 ULTRASOUND OF THE RIGHT LOWER QUADRhNT, ?I26f18 COMPIRISON: Hfinu. - HISTORY: 32-yeax-old Eamalu with pelvic pain. r": ND IIIGS: Real-timz ultrasound imaging or the right Iowa: quadrant waa perccrmca 1n langitudinal and transvarsu projections with graded uompreaaion. Appendix is not visualized. Thezn is no Eluid collaction within tho right lawen quadrant. There-aré no abnormally anlaxgad manennaric lymph nodes. Compressible bowel sagmenth are idontified. Visualézcd portions oi right kidney and galrb;addnr are within normal limits. IHPRESSION: Appendix 13 non visualized. However, there 15 no £1u1d :cllcccion within tha right lower qpadxanc. Results ware transmitted go the emcrqgncy robm nu 7/36/18 ah 1946 hours. **.Elcctronica11y signed by M.D. Matthew Tran on o7/26I2018 a: 1346 ** quorned and signed by: natthcw Tran, M.D. cc: nnmna s Watcha MD Dictaccd Daucnime: 07/25/2018 c1845) Tachnologiau: fiang,6¢ndy u. Transcribed Date/Timc: 07/26/2018 (1845) Tsanncriptianint: DRTRLMAT Orig print n/T: s: 07/26/2013 (1849) BATCH no: Iain PAGE 1 Signud Report Pationt:JOHN$EN,STEP'HANIE ANNE MRN:M000892414 Ehcountor:M00355420250 ' Pugo 1 of1 APMDWCOOO73 Fax Server GOOD SAHARITAN HOSPITAL 2025 Samaritan Drive San Jose, CA 95124 PHONE fl: (403)559-2141 FAX #z (408)559-2679 EXAMS: 002394710 U5 PELVIS HON OB 002394736 US ENDOVABIHAL SCAN ULTRASOUND OF THE PELVIS, COMPARISON: Nona. 7/27/2018 1:14:58 PM PAGE ‘5/018 Fax Server Hume: JOHHSER,5TEPHANIE AHNB Phys: Watcha,0acna S MD D03: 07/25/1955 Aga: 32 Sex: p Acct: M00355420250 Lac: M.ED Exam Dace: 07/26!2018 Status: REG ER Radiology No: Unit No: MOOOBSZHIQ OPT: 76955 76030 7/26/18 HISTORY: 32-year-old £cma1e with pelvic pain. FINDINGS: Real-timu ultrasound imaging of the pelvis was performed in longitudinal and transverse pxojections via transabdcminnl and transvaginal appraachos. Uterus is natmal size, contour and ochotexture. It measures 7.0 x 3-7 x 4.7 cm. No discrete mass 15 identified. Endometrial stripe measures up to 5 mm. Thorn 1; trace annunt o£ free fluid within the endometrial cavity. There 13 a linear achoqenic structure 1n tha carvicnl region, mcaauring approximately 1.2 cm 1n length. No linear cchogenic structure 15 1d¢nt1E1ed within tho cndonctrial cavity. Right ovary i3 identified and measuring 2.0 x 1.6 x 1.6 cm. There i: no adnexal mass. Lctt ovary i: iduntifiicd and mcaauzing 2.5 x 1.3 x 2.2 cm. Thcrc 1: no adnaxal mass. Normal axtcrinl and venous flaw is documented in each ovary. There in trace amount of Exec fluid 1n tho cul-de-aac. IMPRESSION: 1. 1.2 cm linear echogenic structure in tha region of the cervix. likaly related to a dislodged intrauterine device. Calcification 15 also a consideration. If clinically indicated, additional evaluation with pelvic radiograph may be conaidcrcd. 2. Trace amount oi free {luid within the endometrial caviny‘ fionapacific. 3. Trace amount oi frec‘fluid 1n tfic cul-dc-sac, nonspecific» Results were transmitted to the emergency room on 7/26/18 at 1844 hours. PAGE ,1 Signed Report (CONTIN OED) Patinnt:JOHNSEN. STEPHhNIE ANNE MRN1M000892414 EncouMar:M00355d20250 Page 1 of? APMDWCODOY4 Fax server GOOD SAMARITAN HOSPITAL 242: Samaritan Drzvc San Jase, Ch 95124 (408)559-2141 (405)559-2679 PHONE: #2 FAX fl: EXAMS: 002394710 US PELVIS NON OB 002394736 US ENDOVAGIHAL SCAN (Continued) ** Electranically Signed by CC: Danna S Wnccha MD Technologist: Dang,c1ndy N. _T=:naar1bud Dacclwimn: Tznnscriptioniat: PRTRAMAT PAGE 2 PatientzJOl-INSENL STEPHANIE ANN 7/27f2018 1:14:53 PH PAGE 0:19 Print Df'r: 5-: 07/26/2019 (1847) 6/013 Name: JOHNSEN,STEPHA£IE ANHB Phys: Watcha,nncna 5 MD DOB: O7!29l1985 Age: 32 acct: M00355420250 Exam Data: 07/2612018 Status Radiology No: Unit Ho: M000092414 CPT: 76856 76830 Fax Server $632 LOG: £4.39 3 REG ER H.D. Matthew Tran an 07/26/2019 ac 1344 *- chcztcd and signed by: Hatthew Tran, M.D. niuuauud natc/Timc: 07/26/2015 (1333) : snfl 4702 07/25/2919 (1339) BATCH NO: RIB Signed Report \ E MRN:M00089241 d Encountormoo355420250 Page 2 of2 F -. m... _--_ _-‘r In..- ‘- APMDWCOOWS W Fax Server 7/27/20L8 1:14:58 PM PAGE 17/018 Fax Server i coop BAMARIIAH nospITAL Name:'Joanszu,5TuPHAn12 Anna 2&25 samaritan Drive Phys: Hatcha,Dacna s MD San Jose. CA 95124 DOB: OTIZS/ISBS Age: 32 3cm: P l Acct: H00355420250 Lac: M.ED I PHONE #1 (408)559-2141 Exam Data: 07/25/2018 Status: axe ER FAX #: (408)559-2679 Radiology no: Unit NO: MODOBSZdlfl EXAMS: CPT: 002394750 CT ABD AND PEL W CONT 74177 Patient: JOHHSEH. STEPHANIE Time Out: 22:14 anm{3): CT ABDOMEH + PBLVIS with Contrast zxAM: . CT Abdomen and Pelvis with Intravenous Contraat CLINICAL HISTORY: Right lower qpadranc pain TECHNIQUE: Axial camputod tomography images of :hc abdomen and pelvis I 1 1 1 with intravenous contrast. CTDI 15 8.13'mey and EL? La 370.76 mGy-cm. this CT exam was performed according to the principle cf ALHRA (A5 Low A: Reasonably Achiavable) by using onn o: mbra oi the tallowing doaa-ccduction techniques: automated exposure control, adjustment of the mA and/ur kv according co patient size. and/or use of iterative reconntxuction technique. CouvhRESON: Mo relevant prion studies available. FINDINGS: Lung busca: Unzcmarkable. no mass. no consolidation. ABDOMBH: Liver: Unremarxablc. Galrbzaéder and bile duets: unremarkable. Pancreas: Unnemarkablc. splaunt unremarkable. Adrenals: Unremarkable. Kidneys and uretera: Unramnrkablc. Stomach and bowel: unremarkable. PELVIS: Appcndix: No find¢nq5 co aqucst acute appcndicznxs. Bladder: Unuamarkablc. Repzaduccivu: IUD 15 seen outside oi the uterus. and lies inferioc to the racuus abdominis muscl: on she night. ABDOMER and PBLVIS: Intraparitcncnl space: Unzcmankablo. Bancsfjoints: No acute fracture. Ho dislocation. Soft tidsuao: unremarkable. Vasculaturo: Unxemnrxablo. Ho abdominal aortic aneurysm. Lymph nodes: unremarkable. PAGE 1 Signed Rmpart (CONTINUED) E ANNE MRMMOOOBQZM‘A Encquntar:M00355420250 Page 1 of 2PatientJOHNSEN. STEPHANI APMDW000076 Fax Server 71'27/2018 1:14:58 PM PAGE 18!018 Fax Server I l l GOOD SAMARITAN HOSPITAL Name: JOHHSEN,ST2PHANIE ANNE 2425 Samaritan Drive Ph‘irs: Hatchn,nacna. s Mn San Jose, CA 95124 DOB: 07/29/1585 Age: 32 Sax: P 3 Acct: ”00355420250 Lac: M-ED ' PHONE. fl: (408)559-2141 Exam Date: 07/26/2018 status: REG ER FAX fl: (408)559-2679 Radiology'No: Unit No: H000092414 ln-dI-u-u-I- EXAMS: CPT: 002394750 CT ABD AND PEL W CONT 74177 flConni nuod> IMPRESSION: IUD i: sect: outaidc 0E 1:11: uterus, and 11c: inferior to the rectum andominia muscle on the right. Finding: arc concerning 'Eo: pcxforatad IUD. 210 fxcc fluid. H Electronically Signed. by M.D. Ryan Anthony frederixsen '1' h' an 03/2612018 at 2214 'H ‘ Repcrtmd and aiqned by: Ryan Anthony r:eda.r:.1.knen, H.D. CC: manta. Crmudhum. HD: Dacha. s Watcha b-D Dictnbed Dauc/‘Eimc: 07/26/2016 (2214) Technologist: HOLIHAJIITCHELL Trannaribad Dacc/Titm: 07/26f2013 (2214) Transcriptianisu: PRPRBR! Orig Print Dir: s: 07/26/2018 (3211') BATCH t-Io: H/A FAG; 2 Signed Report Patient:JOHNSEN, STEPHAN‘E ANNE MRNzM000892414 Encounter:MOO355420250 Page 2 Of 2 APMDWCOOD77 Law Offices of OKOOOQQUI-PUJN NNNNNNNNHt-tt-th-tt-tt-th-tt-tt-ti-t \IONM-wat-Okoooflmm-bwwt-K 28 HINSHAw, MARSH, STILL & HINSHAW A Partnership 12901 Saratoga Avenue Saratoga, CA 95070 (403) 861-6500 EXHIBIT C 5 DECLARATION OF SCOTT R. KANTER IN SUPPORT OF MOTION FOR SUMMARY JUDGMENT OR, IN THE ALTERNATIVE, SUMMARY ADJUDICATION BY DEFENDANTS NADINE GRAVEN, M.D. AND VENTANA MEDICAL GROUP, dba A WOMEN’S CENTER N0. 19CV352312 C . Caption: Acuity Order Number: NorCal Case: NorCal Claim: Patient : Facility: ACU'IY Stephanie Ann Johnsen, et al. v. Graven, M.D., 8t OI. FILE # l‘ L/ 00 P 163231 REC'D___ i O FAx___ I I “' 509626 FORWARD m “" 0N CAL "m" CLA0511221 DIARIED “‘"‘“‘ T : C y/ Stephanie Johnsen 0 “Em M 00M" Samaritan Endoscopy'ikg M- Should you have any questions about this order your Case Manager, Zachary Marberg would be happy to assist you. They can be reached directly by phone at 720-941-9584 ext. 1014 or by email at zmarberg@acuityservices.com. 1764 Giipin St Denver, CO 80218 www.acuityservices.com Phone: 720841-9584 Fax: 720~223~7279 F1 (”5“ Deposition Subpoena for This Declaration MLLSI be Production of Busincss Records signed and returned whether or not you have records. W Regarding (name): Stephanie Johnscn Facility: Samaritan Endoscopy Center Location (address): 15 l 95 National Ave fl 204 Los Gums, CA 95032 l, the undcrsigned, being the duly authorized Custodian of Retard: and having authority to certify Ihc record declare the following (please check appropriate beam): - Th: records wcrc prcparcd by the personncl of the business in lhc ordinary cunts: 0f business at or near 1h: time ofthc ncl, condition, or event. Th: photocopied re Q submitted thCWEIh arc true copius aflhc complete (check all npph'c-ablc): Mediumecom Dkwiology image: D aims; D omen Ori inn R brds: l um aver the age of 18 years and no! a party lo this action. l am the dul)‘ aulhon'zcd custodian ofrccords for the facih'ty nnmcd on Ihc duccs :ccurp subpoena. The copies accompanying this dcclmtion arc m1: copies oral! records described in rhc subpoena which arc in my possession as Custodian ochcords. The original records fiom which the accompanying copics Were mad: were prcpnrcd by in the ordinary coursc uf‘ business at or near the timcs of lh: acts, conditions. or events recorded therein. y c. D Medical Records D Radiology Images D Billing D Other. PLEASE SPECIFY REASON D RccordsfFilrus an; Lost D RecordsfFilms arc Dcstnoycd D Other: A thorough search of our files, curried out under my direction and control. rcvcalcd no docummls. records. or othnr items listed in the Subpoena prescnwd Io mt. I: is undcmtood {hat such records may exist under another spelling, namc, or dmifiulion, bu: wilh the information pmVidcd to our office and m lhc best nfmy knowledge, no such records txist. l DECLARE UNDER PENALYOF PERJURY AND UNDER THE LAWS 0F THIS STATE THATTHE FOREGOING IS TRUE AND CORRECT: Emma a. (am : 0/ °w ' 2020 . a: (cigars: . Gnu. z CA Prim Nam: fl’3” k 55mmV ' v I V \ DO NOT WRITE BELOWTHIS LINE. FDR USE BY COPY SERVICEpNLY lam chit; Illwney‘s nprunufivle Ind I 3m: 1h: l: U Made Truc and Carnal Copies emu neemh . D Received Coplu ar ch: Retard: D Recefvcd a Certificate or No Record; Pruvifled tn me by Ihc cauldltn 01' "cords of the above hull“. I OECMRS UNDER ?ENALTV 0F VENUE? AND UNDER THE LAWS Of THE STATS OF CA THAT THE FOREGOING ISTRUE AND CORRECT. D Lenfioa did no: properly cnmplclc :udfur sign III: Detlarulon of Records Custodian Nam: Ermted an (due) . It fa’ly) By: Sigmm (\ \ ' H&P u OrsTEM ’- O 4u-uppApr 06 2017 03:30AM WENT HEALTH. ' . ’ _ NA E ' Le/ _ Gs - ECLG BAse FOREST ' Emgo (V... \{D HISLORY Arm PHYSICAL sxiMmAUON CHIEEOMPMINTJLD“ AAA) .m.ssln:/ umto . «@yaflls'xan/AJAR 00 56w» NRCL ' 4(0 CESUJEW HAMMWM" CARDIORESPIRATORYILLNESSES CD /‘A OTHER ILLNESS C .. DIABETES k? 1' n PSYCHosocmL HISTORY U? ALLERGIESNWA PRIOR SURGERJES CE; 1C 39w MEDICKTIONSI SUPPLEMENTS NDYJQ, . ' PHYSICAL BP “51961 PULSE V WEIGHT“mt? HEENT WV“ fimn HEART \XUOLR LUNGS L_JY’f ABDOMEN W Ex-rnemmes Wk. BREASTS WWW _ . PELVIC *W I L TR) O 01mm 1‘2) bk waxgdl b? _r>. JTLI- Cami”;- fearmuumm lnxaxkewwm' mu +0 m; L_jc sowoleAGmG "“ {rpm zg/MK p ANIpRoc QURE'VOBS'lbib, i'mms‘lrjapm L, . E. I * Lb“?LAMA“ wj' ‘1' J .Vll 4 “A‘JFJJ . b 1 SSOCIATED RISKS NDIHAVEEXPLAINED TH ¢ save PR0 5- R :Ts AND ALTERNATPVES AND THE PATIENTCOMPLICATIONS BEN UNDERSTANDS msnes 7 PR EED SURGEON SIGNATURE DATE n PATIENT REASSESSED N0 INTERVAL CHANGE _ OKAY FOR SUE F ate SECOOD‘i flflfl m_w- (\3 Apr 05 2017 08:29AM WT 1-1951.le '...._;-TEM p _PHYSICLAN'S ORDERS ‘ " Please Date, Time, and sign an orders 13': K ‘RE-OP ORDERS “ - .4 NPO nflcr [0pm the night beforc snrgery - .2. Consentfor: lj‘fw hWSCOQl {QmQUU-Q a_k LUD- - chpthu I’Mfio‘3LQIZL4 [JOQSIQLE- EUBflSMKXIKC, 3. D Arlee?! gm IV on-call to OR 4. D SCD‘s lo be_placcd on patient ifpaticn! as a risk factor Score of3 or greater ‘4: ' DA - //H t I r L . .c) n[flNWMW Physician Signaturc'fi( KT); Date; ‘1 b 1 I imc; ?I 7 Posr-OPNOTE 4HI7 G/ 0023 \ ’. l. Post-opcrativ: Diagnosis: 1U D VRJY(W U 2. Operative Findings: pm)MM MW: W 0L“)m 1 3. Operative Procedure- b:lmsc cox Dag \qn rm u s cd 0kmON zmama(”\OLEW fit)‘cL/UI’K bflrmail J fligmegcWEEW WE @691 buiN/M (ha _L Kim 403-414-7121 ./'\ A fl ‘ I J q Ah Egalfou fl: PhYSiCi-m 319mm”: VM f...»- Datc: VT V I j Time:'w /o$T-0P ORDERS l { Y ‘ ‘ iggerative appointment mack U lOdays Orhcr:\ J “viva patientsmy pre-pringginstructions for home # mien: may be discharged to responsible adult when An: sthcsia discharge criteria arc met r _. 4&5}:EM ".Jfl” A44; fi‘“ ‘1 l- a“? V :preu‘ve Guidelines: 5-! f6. 52f L1H?) No patient may be discfiangedfiOm the ASC 02:12.32; mepluufcinn why performedthe wrgézy racedme signs a discharge order. Tin: ASC'mm! ensure a‘mtphysiciamjblfaw uppir'caé (a Stare Jaws m- ire}! as gerramfljv uc'keprad u’ardr ofprac'u'ce andASCpom? when determining that apariem 1m: recoveredsuficientazfl-om .rE-Euy cma'may be Jiscbargsd theam. n: apph'mbfe, Hm! the patient mus! be frany'égrzcl ta another Jrecrlrhmre/acih'ty mart can provide h’re ongoing Mam {Ilaf'flmt me patient requir‘e: cma' Jim! rite ASC' is unabl'e (a provide. fr r1: expected (ha! dpalm! m?! mucufbv (emu: {he within LS-30 minute: offlm time when (he plysicr'rm sign: the diu/mrge order (7.? FR 50473) {fl I 1 m u) .mrL - geon has assessed lhe patientind cleared fordischafrgiRN‘. mwnate: ””1- ll/ Timefww Physician Signature: ' Bat?“ (W V7 Time; i0 4 a HYSICIAN ORDERS & POST-OP_NOT , Patient Label Q] 50%ng WW.r---.\ SECOOOZ ON. {r- SAMARI IAN ENDOSCOPY CENT ma ) PRE-OPERATIVE CALL m /-~\pR00EDURE: 3906 IPOSSIBLE DIAGNOSTIC LAPAROSCOPY . DIAGNOSTI ySTEROSCOPY. ‘1‘ HNA amm eDamx DWI .SMOKER? @l vesaay‘ PROVIDER: Graven. Nadme ANES; GEN grou- DRINKER? . No /@ Dos: 4m2017 7:00 AM 90 minutes RECREATIONAL DRUGS? PATIENT: JOHNSEN, STEPHANIE DENTURES? DOB: ?129/1985 AGE: 31 sex: F COLD ISORE THROAT PAST 2 WEEKS? HOME PHONE: 403 472 9996 CELL‘ HEIGHT 5W WEIGHT ALLERGIC To 100mm LMP rmap ALLERGIC TO LATEX? DATE LAST; EKG ”a _ LABS .flw ALLERGIC TO ANY MEDICINES? ANY OTHER ALLERGIES? MEDICATIDNS SURGICAL HISTORY I ANESTH IA ISSUES NOTES Q . SIGNIFICANT MEDICAL HISTORY None .j.‘ g D Cancer Anemia f U“ U Chronic Pain U Aneurysm D Diabetes D Anxietleepression D EmphysemalCOPD D Arthritis U Excessive Bleeding D AsthmalBronchitis D Heart Attack U Blood Clot E] Heartburn U Heart Failure El -,Headaches D Water Retention D HepatitisIJaundice flD Mi a Valve Prolapse D Other... D Hiatal HemialGERD D SeizuresIEpilepsy E] Other... D Hypertension D Sleep Apnea U Irregular Heartbeat D Steroid Medication D Kidney Disease D Stroke D Liver Disease U Thyroid Disease 1. Do you have tranSportation home@mo (circle one) Name: Cé‘fifldiw/ jam! Phone(Va/é 5‘6:ng (fr? 2. Who will be taking care of patient a ome (name):. am; [/Wgflgch INSTRUCTIONS: 1 . Bring your insurance card as well as a check or credit card to cover any coinsurance or deductibles. . No chewing gum. tobacco, or smoking. . Patient agrees to and indicates a good understanding of all of these direction UlledByMaé-fWPatient Signature Date _DateM- Time 95593M . No food or drink after midnight or at least 8 hours BEFORE surgery. . If you are diabetic. do NOT take your meds on the day of surgery. . If you have high biood pressure. DO TAKE your meds as prescribed. Do NOT shave or use a razor on or near the site of surgery. . Wear comfortable clothing: pull on pants and loose. button down or zippered top. . Please remove ALL jewelry. nail polish. make~up, tipsticks, lotions and eye contacts. . Please allow AT LEAST a full day for recovery. and do not schedule any appointments 0n the day of your surgery. NO (circie one)f u -M Lefi Message___________rx?- SECOOO3 O F") Maljgnant Hyperthermia B'eview Notes: You or a Family Member at Risk for Malignant Hyperthermia Yes’x No Unanticipated High Temperature after Exercise or Anesthesia Yes N3 Complications after Anestfiesia Yes Lio/ fl Muscle‘or Neuromuscular Disorder Yes'M ) (\zcxx Dark or Chocolate Urine Yes a:l‘Jo/’ Advénced Directive Pt. HAS an AdVanced Dire‘ctivefplease bring copy tO'facility) Pt. DQES NOT have an Advanced Directive ‘/ Durable Power of Attorney Pt. HAS a Durabie Power of Attorney (please'bring copy to facility) l/’Pt. DOES NOT have a Durable Power of Attorney JOHNSEN, STEPHANIE ID l Visit: 3906 l 1 Gende FDOB: 7(291’1 985 Age' 31R Phys: Graven, Nadine I DOS: 4/7l201 7 Page 2 _ I SECDOO4 J fl IIr‘ ' PM&PERATIVE NURSING ASSESSmeT OutcomeslGoals: Patient vcrbaflzcs understanding of planned procedure according to signed consent. Patient demonstrates decreased anxiety. Patient is provided with a safe and comfortable environment DatejLO'ZlH Timein Psu: 09% n Two patient identifiers used (Name/DOB) Dischar e Plannin :Relationship: MamD Ride: aiting a Returning a Needto be mned: i403) {990 ’ 504 7 Pre-o Vitalsi n5: T334 RLPTO B/P ”W70 Saoz Ht 8'4 Wt I 9.9 Pain Level 0 Measures taken to relieve pain: O (Numing Intewenflons, Pain Meds) Allergies: a Ye KDA u Latex a Iodine N_i_=___o: Since 12E} (183m n No Voided Pre-og: u Yes Time: offlfiugfflwMPH” Psychosocial: Wifilgw’ war WWW" ,a'Calm oAnxious c3 Specialneeds u Religiouslcullural beliefs a Interpreter. Language Preogerative Teaching: fientation - environment rientafion to post-op care /a’Patientlfamily verbalizes understanding Advanced Directive;,d‘fiiA c: Copy in chart if applicable \fi’lfifonnation provided and policy reviewed, if requested Comfort Measures: osifion for comfort warm blankets/a‘fiair Hugger a Other: Current Medicajgms - Herbals- Over the Counter Meds: SEE 'SUMMARY OF ADMISSiONSIMEDICATIONS LIST' Physical Assessment: Neumlogicax mien ancf-orientated a Other Cardiovascular Megular b lnegular n Other Pulmonary ,nvtfings clear and equal a Other Skin condition ,VWNL u Other LMP m’ lug pm Personal Items: Dentures: a Upper o Lower c1 In a Oupmwne n WIpL u Wlfamily Partials. D Upper u Lower c1 In u Ouidfione o Wlpl. u Wlfamiiy Glasses: uOn u Ofl’ a W/Pt n WlfamilygflfA Contacts: n In a Out a WFamileIA Jewejjry:“a or: u wIpL redesentafive a Taped KNIA a Cane n Crutches u Walker a Wheelchair n Prosthesis BE Pormavm1° Wl'W in MW“ ”631» Pre-og Procedures: Diagnostic Tests: a None KG Time Test Normal values in parenthesis Hemoglobin Hgb (W 12-1 6; M 14-18) Glucose Glucose (70-1 10) ______Urine pregnancy c: NIA D Positive n Negafive “Abnormal values MUST be reported to MD immediately" MD notified DY [/1 n Tme 00 RN Nume Signature Read back and verified by M ed‘mtions reviewedrfor combob'aindications and impact on lab vafuescm" ”01‘ baprgm par Dr. Gram N Started: uNolVr SolutionWl£ Si2e_ga Site WTW0 c: 1% Lidocaine w! 4.2% NaBicarb 10. 1 0- I ml injected forlv Inserted by F M N MD #AttemptsL Unsuccessml Attempts # Attempts By # Attempts By a 1 gm Ancef IV on-call to 0RTime Time ca “mg Valium P0 RN Nurse Signature n Medications clan‘fied with orders Pre-og Safeg Check: W ,a'vPre-op orders complete I ose on_ c3 MIA loaSide rails Up QPEumey locked LVN Signature: g kn fl . RN Nurse Signathre: MQZ" a To ORvaeyDMW Cam Interviewing OR RN. QT! Manda]? completed /a’0utcomeslgoals met JOHNSEN. STEPHANIE ID I Visit: 3906 I 1 Gender: F DOB: 7129/1985 Age: 31 Phys: Graven. Nadine DOS: 4/71201 7 SECODOS KW FN I C7 PRE-OPEIETIVEASSESCSMEN i DConscious Sedation DBier Block DATE.flflflfljmm 1N 11MBD7 fl gNCISIQN: D.SE-_3__TIME OUT RM 0702 (NTafienththgxwmwReview by ._{‘,-WM [D «IOU n JI‘mnSportcd ma u Ambulatc 1:1 Camcd F Yes No N/A CHART REVIEW Patient I D.?Knnban Mcrbally o Other c1 Allergy Band u Consent Signed ALLERGIES: N /a’ U Confirmed Surgery Site Time out rcfonned ngcal TecE/flS'ur eonMesthesia Site Marked Time: Patient, prose ure, site allexgies, anti iotics implants venfied D D ,G/Dentures Removed Wound Class ,BrCIe lean Contaminated D Contamnated D Infected OWL Anesthesia Typyneéneral uRegional nMac DSpinal DLocal IRmplaéltsyB’N’A 0333 1133131811“ I ecor 1 Pre--op Diagnosis: Sec Anesthesia Record Procedure DmeumloHNWMW DIXGNMTIC/ Wmmw Dmmee j 1W §pecimen(s): # 2- Cultures: WWW Md}3mm LCM! #55070 .. I‘d... . Pathology:(DEGWT WPM’N Tuba (2:)WTWWW THEE ”:3" W NURSING DX IMI’LEMENTATION PT OUTCOME PATIENT POSITION; ,aflnxiety Orient to coking mechanisms Remain calm D Supine D Prénc ' _ ,A’Pain I Discomfort Room temp, padding, body temp Pain controlled ,D’Eithotomy USitting f (ginjuxy ' ID E8: site, safety strap, position devices No Injury E1 Lateral LT RT 1 otcntial for Infection As sis, Stexile Field ' No Compromise i U Other , - A s T. W1) mm PosnerG AIDS.Intact: es n No ,aE cc c Sur nitfilm D Arm Board R/L firms Tucke@@ Descnbe: 1 Coag ipoIar and Table: D Right 1:1 Lefi I . 631cm mtactu re- @ pound s1te Kgafcty Stra w’Bod D Thi%hs ' SHAVE b : N l'I- ,B'Location Qjfifl] [ii%%%- El Pillow. D bd. a C est U (nees/Feet : a SKIN p P- b [who Laser f Type ,a’Heach-est: U Donut CI Pio n Eye Headresm D Betadinc Paint 3 D MCIOSGOPG rflmrups: D Candy Cane $11811 I D Betadine Soap D Power Equipment Beach Chair CI Tape a Bean Bag D Foot Board ' J_g-Hibjclcns, Nam I3 C-Arm D Lateral Positions: U C-Clamp a Lat Shoulde1 :3 Phisohex D Berkl/ggucnon Other C:J Vag Prep 9911110 idCO TOW&I# 4m;x0 Alcohol y’aqqqmmc SN-g fig Counts 1 Counts 2 Counts 3 : g Duraprep U Liposuction Sponge a NAg’Cm-rect DNA .a’tonect a NWm-rect t g Chlorhcxidine D Tourniquet U chbfil/Bias padded Sharps D NWox-rect o NA .dfiorrcct n NA fi’Corrcct Mmol-oprepr Pressure set Inst. ,ZNA Co chLa’NA U Ca act z’fiA D Correct ' ’ a Other: filed bY- Ex Initials RN: w ST:M \(D Correct ' Drains: , 3115;?“ iWowcr Surgeon Notified 0f Count: es a No “a’Nonc a Secured x“: Osthen w I Document Incorrect Count Type:_ _ “’4' : Locatlon: . . incldngfionc Medications l IrrigationyEI/Vcrified w! tech prior to receiving YPB’LOCfifiOD ac1 um]: s a GI 1 5V a Bss ' ._ _‘U__1_______'mag: Catheter: a None/G’Eserted 1n OR fimcr gar ycme o ' -.r__.__. SECOOOS r"1 0 Consult u onsult mI -fln - 06 2017 03:29AM WENT HEAL. __..ovsrm ;ge 1 a Patient Name. gkflmvue JO'MSHI (w Consent to Surgical andlor 8m Date ,1 )m , gg Medical Procedures Pmmm Q} Olfauen Physician or Licensed Independent Practitioner- Declaration: l have-explained the aperafionlprocedureitreahnent noted below. including [he risks. anticipated benefits and aftematives pertinent to this operaflonfprocaduraltreaUnanL I have answered ail questions. and to the best of my knowledge l believe the patient has been adequately[nsent Signature: Date/Time: bf {s l k 7 Physician or 'cense Independent Practitioner (LIP) who exp)ained the Operadan/Pmc reatment to the patient or the pafien t’s regal representative. Pr0cedure Nam e: (Physician (a compiata or enter order farnaming to cample(a fur exact procedure) llwe give permission to: EV G( item . associates, assistants andlorasslgned hospital staff. to perform the procedura(s): (9v: Enws-sfiwscoOKL vemwd 057 ”DUO . bombu \oxflmas‘togc} .D‘Q'éelw éofamycjwnk“ 7* Procedure to be perfumed upon S k 014an Aquun on \JL‘L ‘ ‘7 I (jWVW fafémzmm Parienrs.Name m gooé gem oats C)at El Carnino Hospital D Mountain View U Los Gates D Dialysis Site: ‘Qfldo Basic Risks Explained to Patient or Legal Representatlve: I 1 . The type and extent of the procedure to be done and the tisks involved, Including those which, even though unlikely lo occur. Involve serious complications. 2. Other risks. such as the risk of lnfectfon or other sen'ous complications that may occur before. during. or after the procedure and which may result In serious complications. such as loss of use of parts of my body or loss of life. Good results are expected. there is no guarantee as to the outcome (result) of the procedure. 4. Alternative (other) procedures and treatments including no treatment and the risks and outcomes 01‘ those alternatives. have been axpiained to me. . 5. The expected length of lime“In the hospital and the estimated length of lime for recovery. The 'esfimated time for recovery does not include added time if campiications occur. 6. It may be necessaty to go beyond the procedure discussed if unknown conditions are found at the lime of the procedure. lfwe give consent that the persons described above may make daclsians about any added pracedUres they believe are necessary to improve my outcome. 5'" (Continued) mfillfllllffllfi! v FM" 5032‘“ Re“ 5“” mine - PATIENTS CHART CANARY manem 5023A/‘,. *- SECOODT Apr O6 2017 0329le WT HEAU'HVJSTB'I.--- n- .n;o..-. fl L .-...n|umm| ul hay": uni" ' I $OMINT FORM lNON-FEDEHALL? FUNDED] monca; voun nacmon Ar MY TIME nor r0 ae sremugao mu. NOT nssuu‘ m Tue m-monAwM 03 \ 1( consent r0 aramuurlou [hm ahd Io: Ind rccfivtd inhuman nboui3W wanna: av 51mm :htd for tho lnlcrmulm. I mu mid mu: tho docision m Lu mrinnd i: cam. ’Illlr UP la MI. l Ina told Ihu I could dadd- nan Io bntumud. ll’ I daddy DI (fl b0 Iwahld. "TY dlclllofl M” nut slhct my tEfl‘ll 1n funn- m. w utmml. l undamaud Ihu l con chino. my mind at am IImI. ' I UNDERSTAND THAT THE STERILIZATION MUST HE CONSIDERED EHMANENT ANU NOT REVERSIBLE. l HAVE OECID£U THATI DO NOT 'ANT To BECOME PREGNANT. BEAR CHILDH EN OR FATHER CHIL- BEN. I w. laid about men Imam” mama}: ol lint! comm! um ma awww- Id GM b! DIWdId {o mlhhfl will alley mi Io Inu- ur lather a child on {In mm. I Mu nice": um- dumulm and chum {a la smilkad. undmund that I VIII Marco us mullan known u I STER'L'ZAT'0N , Tim Maniac", kl. Ind btn-flu much” with |h- umrulon ht" bun upland Io nu.m mumhm bun annual! Io my salhlacuon.Maud Ihat [ha mullet! um not ho dun: mill It lull Jada” slur I u uh" farm uncut In mid“: lnumm mu hm bun lufly upturn“ Io mu. lwlfl I0 Inf“ 1h- JO-du unlual mlod m uni. [Nutlm man 7: hour” lama: 1m: IB rune! nw U J um and" 1's MiaD I hm Inlnnd Into t mid muflm. orD I am an nun wan! n-llh Ihl U3. armed linden. orD l hm ":er a dodunlou or mmdpulan purmnnl In Section 64 u um cm: Coda. o: o . (1‘1 l m cu: la gun aid, flu um: hum m9 noun" a uumlim and \J mmpmym naught main. 02 7 /aroa)fi 2 rumba! on 07 V.u 1 P LZP/Ldpz' till“ flaifi'gxmduuw consulw fun will m unduw 09:: on lnlmdld Io :mmu mu lo Dom um fl __ nnhudumd SALP'NC‘IECTDMYA ' . u ndl h lobar Ind It h: bout “Inn 24 hum. slnc- l w” ulnh u: bod n l'an. l urn not unhlnl Io ablaln or oblumnl an moon u mu Um a rm: undur mu lnflum ol dcohau or cum substances um nflm my t tmum“. dunlmd :hnl l may haw I wlmua or my choic. mum: during [ha um- fillnl lo obiflout :munt unlan IIJO din! h ICE! D N dun a! my luqnlmn lu-luw. . /9Am/7 Dal. Slfilulw Mann: 0w Yul: INTE ETER'! STATEMENT Inllmnm la provldud tn anlu tho Individual Io b: smnmt II trmuum mg In rgmulun :ndmm prnmufl onllv lo 0w Individual tufllud b! Ihc perm: obtaining thin consent. l hm mo wad hlmflm Hull lam Ii! l and uplalncd Iu comma Ia hlmlhor. To lhc hm of mv lmnv-‘Otlm ‘1. ho!!!” undullocd Ihll uplinlllon. Jninnruu 0°" /' '\ Q11"! l! ‘55" 47 E. CAMPBELL AVE. CAMPBELL. CA 95008 WITHHOLomo 0F AMY usnenrsmomma a‘r Pnocnnms on mosecrs necewma FeumAL Flmos s'rATEMENr or PERSON OBTAINING causal" ovume J chwseA i luau“ ol Inmtm; comm! tum. l unkind In hlmflur tho Mum o! tho Imillnllon apuulnn .SAmeapmw ; 4.. m. .. g It la Immdn! Ia b1 a "nu m4 Inmmhilmm! and lho damning, rln. and hmulm modulud nm- ll. Jcmmmm Ihnlmflvlm Io b- uufllnd Um mumfln mnmm u: bum cannot m cumu- whlchm runway. I upland ma; stumuuon h dml en!hem It 3! pummt. l inlmned lh- Indvlwd Io bl :udlhad mat Mimi: consume“ be MI dawn a any Um. and Ilia! Nit!!! will nut Ian my hudch "Mg" u: I- blnuflll. wuddod by chnl Fm Tu um lam o: amt humanly. and mini. Ila lnthhlnl Ia ho ultmud Ir luau IS hm aid. m- unu- Ihom op ImIr-nnu um vanilla! rcmlatlmm and mm Imldly compact". H013" Immuv and volt laxity requoum to b. ludllud Ind wean to mdmund 1h- mum Icmmmu ct 1h: procaine. I curl"? um I annular” orally Io sh.mm Io ha unudmnd mo "nu! menu (a 1a! c u III on LN: farm addln Icahn fit lulmg "‘K 3/61 2m ”L {Iyulu w- l --?fll ..._-_._A CENTER FOR WOMEN 0"“. ‘lw.d 1W“! PHVHCM1 STATlflm Shortly beta" Incrtomnd a llnlllnllon optimal 99M EPWLML 40 \MA‘a-E wmm ac samhu-I sHWT-ifl 07k c??cufifnflin Oflaflm Mum." flu nlmn ut 1hr utcrfllullm upgrade“ - .fi "fiduci- STERILIZATION O spud” um cl mulch lac: than I: I: humid lo b0 a final and lrmunlbl. pruningw Illa din. loch. mks. and hmullu madnrd "MI It. I cannula] ma Inward Io b. Imuud um alumna” named: cl b comm; an wilds" Mid:m lama". I upwind mu llulnuIJoo u d" 0M menu." lam I Inton-nu tho hdddmi ta ho uutlmd Um Mother comm! cm b. v. dra- um amending: Midt- wm notion ”Minnie” ubun' modded by F&ri Inna. I To lb! but d my Maddy. Ind halter. Ibo lndvldud Io bu murmua I luau In ynu ow. or mum 1h. mum In- rl'qukmnu now wm- uwhmm. sad appear! mummy emtnt. Helm Mofindv and yo wily remand m t- ncdflnd andW to undcmnd aha mumcmsmm o! mamum .llnnruetlcm tar mt at murmur. Hm! puwnahn Uu tho Hm pang baton «um In (fi- mo Er annular. Emmy. ormm nbdurn ummv. m- onk“: unbu- err 1h. lurilllulu ll mr'unmd lu- mar dun am: um dam cl m. luaMdu-n ulrmuu an uh: cum! foam. la u crud. th- Imnd 9::wa howl! mull b0 and Cebu oul 1h: afltwm w I! uni unfi’ 'mm nut JG dam mm pumabum th- dm of 1M fndM-l'! flun- on 1M: count" lorm and tho dam 1M llorflluuu m- pufm-nm l2]! cm"? mu mi: "munuon m- pulonmd um um: Jo div. but n than n hum anu- Iho dun o! mu fndvldud't :imalmi an um mam” I bonus: n! mt fallow!“ dtcumcmn lentil while“? 5°! ind '1" 3n h nmlon rmouldl: a. U ancmn Ihlittry U lndhlduul‘l llpnnd data o! dummy: b. a Entryway ahdanlnfl unruly: lducrlbc elrmrmnh D Gut individual Inlmdnd to b. nnmnd: c3. ul'lnl mind Ihl JO-dav waiting pitted Io {NM Int Ihsn 72 hnunJ Il"n- g ' A IRLGRAVELN i - “1-K W” W 1T 7Dale \J T SECOOOB r" .t.- Samaritan Endoscopy Center 15195 NATIONAL AVENUE. SUH'E 204 LOS GATOS. CA 95032 408-356-0938 ,fixl PATIENT NAME: ACCOUNT NUMBER: DATE: JOHNSEN. STEPHANIE 3906 403201 7 PROPOSED PROCEDURE: DIAGNOSTIC HYSTEROSCOPY REMOVAL OF INTRA ~ UTERINE DEVICEPOSSIBLE DIAGNOSTIC LAPAROSCOPYPOSSIBLE SALF’INGECTOMY. é‘u REFERRmG MD. DATE 0F BIRTH AGE GENDER ' Graven, Nadine 7f2911 985 31 F CONSENT TO OPERATION AND 0THER MEDICAL SERVICES 1. The facility maintains personnel and fa cilities lo assist physicians and surgeons as they perform various surgical operations and other diagnostic or therapeutic procedures. Generally. such physidans. surgeons and practitioners are not agents, servants or employees of the facility, but Independent contractors and, therefore. are the paflenl's agents or servants. The facility provides nursing and suppon services and facifilies: the facility does not provide medical physician care. 2. The procedure(s) listed to be performed and the advantages and disadvantages, risks and possible compiications as well as the alternatives have been explained lo me by my physician. The doctor has satisfactorily answered my questions. 3. My consent is given with the understanding that any Operation or procedure Involves fisks and hazards. The more common risks indude: infection, breeding wilh the need for blood transfusion. nerve injury. blood dots, hearl attack. stroke. allergic reaction. damage lo teeth or bfidgework, and pneumonia. These risks can be serious and possibly fatal. 4. I authorize and direct the above named surgeon to arrange for such additional services for me as he or she may deem necessary or advisable. including bul not limited to the administration and maintenance of anesthesia. and the performanca oi pathology and radioiogy services, to which! hereby consent. 5. I authorize the pathologist or physician to use his or her discretion in disposing of any member. organ, implant. prosthetic. or other tissue removed from my person during the operallon(s) or procedurem. 6. The facility may participate in residency and other training pmgrams for physicians. altied health profeSSionaIs and other providers of services. Al! care rendered by individuals in training will be supervised and reviewed. as appropriate. by appropriate personnel. I hereby consent to care and treatment from individuals In lrainlng and to lhe review of my patient record by same. 7. In the event of an accidental exposure of my blood or bodily fluids to a physician, contractor or employee o! the facility, l consent lo testing for HIV and H epatilis. 8. I understand that it is my responsibility and I have arranged for a responsible adull to drive me home and remain with me foHowing my surgery. I ‘- acknowiedga that l have been advised by facilfly personnel no! Io drive until the effects of any medications have worn off. I undersland this 10 mean thatQ I sh0uId not drive until the day after my surgery or procedure or as directed by my physician.9 I hereby consent to Ihe presence of other pemon(s] foraha sole purposa of observation andlor education] understand that lhis individual will not participate in the actual procedure. 10. I consent lo the use of videotaping or photography lha! may be used for scientific or teaching purposes. and lo the review of my medical record for bona fide medical healthcare research providing my name or identity is not revealed. 11. I release the I‘acillty trom any responsibility for loss andior damage to money. jewelry. or other valuabies that I brought lo the Iaciiily. 12. I understand that if I am pregnant or if there ls any possibillly that I may be pregnant. I mus! inform the facility immediately since the scheduled pmcedure could cause harm to my child or lo myself. 13. I am aware lhal my physician may have an ownershipinterest in the facmty. and I acknowledge tha! i have the right lo have the procedure performed elsewhere. 14. I understand that in the rare event that hospitalization is required dudn or immedialeiy after surgery. my physician will arrange for my lransier Io a Inca! hospital. 15. I have not eaten or taken fluids. not even water. since DATE 7 7’01 7 TIME l 0 o'w Am@ept tor a sip or water taken with medication as instructed by my physician. 16. My signature bekm constitutes my acknoMedgement that (1) l have read or have had read to me the foregoing. and I agree to It: (2) the procedure(s} has been adequately explained by my physician: (3) l authoriza and consent lo the performance of Ihe procedure(s) and any additional procedura(s) deemed advisable by my physician in his or her pmfessicmal judgment: {4} l authorize and consent to the administration of anesihesia for the said pmcedure(s). 17. If I am not the patient. I represent that I have lhe authority of the patient who, because oi age or other legal disability. Is unable £0 consent to the matters above. l have full n'ghl Io consent to the matters above, and Iconsent to the same: (b) I hereby indemnify and hold harmless the facility. Its employees. agents. medical stafi. panners and affiliates from any cost or liability arising out ol my lack oi adequate authority Io give consent. DATE 4/07“? TIME 9149 PATIENT SIGNATURE DATE A107”? TIME (94$ wlmess SIGNATURE 7mg”! If patient is a minor or unable to sign, complete the following: D Patient is a minor D Patient is unable to sign because DATE SIGNATURE U RELATIONSHIPDATE TIME WITNESS TO SIGNATURE _-I SECDOZS --~---- ------- A fl m, DA’TE 2/7/92'0/ 7 TIME ‘5‘5c/i‘fimm‘nem’s SIGNATURE §AMARITAN ENDOSCOPY éENTER 151 95 National Avenue, Suite'204 Los Gates. CA 95032 PATIENT CONSENT FOR ANESTHESIAIMODERATE SEDATION READ CAREFULLY BEFORE SIGNING I authorize and directm6, IQ] Vll t] 0511 MCC urgeon (Circle one) andlor his or her associates to administer 0r supervise the administration of anesthesia to me. Anesthesia or sedation invoives the use of drug and procedures. Not only do different individuals react differently to the same medications. but also the state of their physical health influences the action of medications. While all reasonable precautions wilt be taken, unforeseen reactions or complications may occur. I understand 'and accept the fact that certain hazards and risk are inherent 'In any anesthetic procedure. These risks include, but are not limited to. post anesthetic nausea and vomiting, headache, infection, sore throat. and backache. Even though steps are taken to protect bridgework, capped, or unsound teeth, there is no guarantee against damage. even to normal teeth. More serious heart and lung abnormalities or nerve andlor muscle disorders may occur. Although rare, there is always a remote risk of death. paralysis. or brain damage associated With the administration of anesthesia. The nature of the anesthetic procedure has been explained to me and no warranty or guarantee has been made as tb the outcome. I understand the risks, benefits, and alternatives of anesthesia that have been explained to me. . U DATE LU? [943:7 TIME E ?j' S.gm WITNESS To SIGNATURE[WU-Q If patient is a minor or unabie to sign, complete the following: Patient is a minor Patient is unable to sign because: DATE ' TIME PATIENT'S SIGNATURE RELATIONSHIP DATE ' TIME WITNESS To SIGNATURE ' JOHNSEN. STEPHANIE ID I Visit: 3906/ 1 Gender: F DOB: 772911 985 Age: 31 Phys: Graven. Nadine DOS: 4/7/2017 SECOOZQ OP Report o 4/7/2017 / . . ' u eport 2 O Page 1 OPERATIVE REPORT Samaritan Endoscopy Surgery Center 151 95 Nationai Ave Suite 204 Los Gatos ,Ca 95032 Direct (403) 356-0988 Fax (408) 356-0978 SURGEON: NADINE GRAVEN, MD. ANESTHESIA: General. ANESTHESIOLOGIST: Florence Lin. MD. PREOPERATIVE DIAGNOSIS: Missing intrauterine device and deéire for sterilization. POSTOPERATIVE DIAGNOSIS: 1. Missing intrauterine device and desire for sterilization. 2. Pelvic adhesions. 3. Left ovarian cyst. PROCEDURES: Diagnostic hysterosc0py. Diagnostic laparoscopy. Lysis of adhesions. Drainage of left ovarian cyst. Exploration for IUD. 6. Bilateral salpingectomy. @PPNT‘ COMPLICATIONS: None. ESTIMATED BLOOD LOSS: 10 mL. INDICATIONS AND CONSENT: This is a lovely patient who came to see me for a second Opinion approximately one month ago. She had an IUD placed in November after a C-section in August. She had some spotting and bleeding and some pain and went back in and the IUD string could not be seen. Imaging was done. She had an MRI of her pelvis and they did not see anything on MRI. On ultrasound. I felt that there was a thickening around where the bladder flap meets uterus. and I felt like I I could possibly see it within the wall; however, it was not easy and the patient i was very concerned. We discussed all the different Options and she wished surgical exploration to make sure that the IUD does not stick somewhere. In PATIENT: JOHNSEN, STEPHANIE DATE 0F DICTATION: 04/07/2017 mu: 1011-3906 Doe: 07/2911935 DATE 0F PROCEDURE: oaxomol? PHYSICIAN: NADINE E. GRAVEN, MD. TRANSCRIBER: pts_dg SECOO‘I 0 Page 2 addition. she wished to have her tubes removed if I had to go in Iaparoscopically for fertility issues. She was counselled extensively regarding salpingectomy versus tubal and the decreased risk of ovarian cancer should her tubes be removed. She discussed it with her husband and did not want it done if | did not have to do a laparoscopy, but if did it, a saipingectomy could be performed. She signed a consent. The patient had all her questions answered and ail complication discussed, and she was consented t0 the following procedure. DESCRIPTION 0F PROCEDURE: ~ She was taken to the Operating room where she was prepped and draped in dorsal lithotomy. Weighted speculum was inserted into the uterus and the cervix was grasped with a single-tooth tenaculum. A paracervical block was placed 5 mL on each side of her cervix. A small dilator was piaced followed by a polyp forceps to see if there was any IUD string hanging in the cavity. The hysteroscope was pieced gently and it looked like the ditator had gone into the wall at the top of the fundus. but did not appear to perforate. Otherwise, the endometrial cavity was completely normal and there was no IUD string seen. I carefully explored the entire‘cavity, especiaily on the anterior side, if she has a retrograded uterus and I did not see anything. l then called for a laparoscopy. So we changed gloves and moved up tap after a Foley and then a HUMI manipulator was placed in the uterus. She was given 2 gm of Cefotan and then her umbilicus was injected with lidocaine and Marcaine. A small incision was made and a Veress needle was inserted and she was insufflated to 3 liters. An 8 mm port was placed into the C-section scar under direct visualization as this was a Iefl 5 mm port. We injected with lidocaine and Marcaine. The abdomen was thoroughly eXplored iooking up around the liver, around the abdomen, underneath the bowel and in both sides of the broad ligament. The bladder was definitely adhesed to the top of the uterus not felt typically adhesed to the uterus and I gently took that down with a combination of hydrodissection, blunt dissection and cautery with hook. | was able to free up the bladder from the uterus and look carefully underneath it and l did n01 see any IUD or any evidence that it had been there. I opened up the broad ligament on the right side to a slight amount and l dint not see anything in the broad ligament at all. There was a left ovarian cyst that was drained by puncturing it with the cautery hook. I took the Gyms type cutting coagulating forceps and took each tube out. the left one first snugged under the tube coming down to the fimbria and detaching it. It removed through the 8 mm port. same exact thing was done on the right side. Both ovaries looked completely normal except for the cyst on the left side. There was no endometriosis. FloSeal was piaced over the bladder flap as we” as around where the tubes were removed and some Interceed was piaced over the bladder and uterus with the irrigator. Things were irrigated sterilely to make sure things were clear and then the equipment was then removed after the gas was expelled. All incisions were closed with 3-0 Rapide absorbing Vicry! and then skin glue and then Steri-Slrips. The patient was awakened and taken to PATIENT: JOHNSEN, STEPHANIE DATE OF DICTATION: 04/07/2017 E l Ins: JOH-aaos 003: 07/29/1985 DATE 0F PROCEDURE: 04/07/2017 PHYSICIAN: NADINE E. GRAVEN, MD. TRANSCRIBER: pts_dg SECOD’I 1' fl ' fl Page 3 Recovery in good condition and received Toradol intraOp ively. NEG!PTS_DG DOT: 04/09/201 7 PATIENT: JOHNSEN, STEPHANIE ' DATE OF DICTATION: 04/07/2017 IDfi: JOH-3906 DOB: 07/29/1985 DATE OF PROCEDURE: 04/07/2017 PHYSICIAN: NADINE E. GRAVEN, MD. TRANSCRIBER: pts_dg ADINE E. RAVEN, MD. Digat- , but not edited s SECOO‘I 2 0 Anesthesia u nest esi O ' a -' I LNESTIIESIA EVALUATION (rcv. 4/1 / Preoperative Diagnosis: Rroccdm'e Proposed: F. _ I flpm (0E flb pgagmcursing Preoperative Assessment Reviewed gical r0 ed r onscnts for Surgery and Anesthesia signed and wimesse I’ 5b urgical sitc/location verified and marked . flRight flLc ‘ JOHNSEN. STEPHANIE a1 UNA IDNisitzsaosn Gender:F Additional Histo Dos: 7.2911935 Age: 31 !L-xig:gen_ WWW;flwfiv’ Phys: Graven, Nadlne Iesia’Lamll tory and Camplications: Dos; 4nyzo1 7 Physical 95mm . AirwayW Lungs:W Heart:WM Ext: LABS: Hgb/Hc '. ' r Electrolytcs: EKG: Other: 3? ASA. 19 3 4 5 B Anesthesia Plan: g4... zscusscd risks. benefits and potential complications ofancsthesia plan. [J.AJJ-qucslions answered _ PREOPERATIVE ANESTHESIA ORDERS I StartIV LRor @ mllhr. []1000mL[]SODmL @[1TKO [1 PRN 1% Lidocainc mixed 10: 1 with 4% Sodium Bicarbonate (2.4mEq/ml) not to exceed 0-3 ml as local prior to starting IV per site JQIBK/for males over 50 and females ova:- 60 {Q'Pregnancy test for women of childbearing age jg - NMMS’N 407% [J Addilfo orders: [fl Datc'f/ ‘7 r? Time 07W Signature(JAM MD, L .. POST ANESTEESIA ORDERS . .H’OxygcnpMor [ ]NC@ g Lx m minutes, then PRN {qr o'iygcn saturation < A IV: LR or Wm. Discontinue IV before discharge. : HoldWunrcoticsfor ucessivesamnotencew <12. Notify aneflhesiologistfor RR< 10. Fentanylgfi. meg 1v every”5__minutes to meg PRN for pm}: level [ J 4-7 -10 . Dilaudid O: g mg 1V evcry__5_minutes to 23' mg PEN for pain level I] 8-10"\ May alternate the above as needed-for pain control if the same sequenced pain lcvels are checked [ ] IV every”minutes to PRN for pain level []4-7 [] 3-10 Ifihe atient can tolerate P. 0. (oral) medspleasefoflow the orders be w: (NTE 3gm of APAP/24hrs) 95mg 1 tab every 4hours PRN for pain lcvel- [j l ~3 -7 [] 8- 10: MAY Repeat X ldosc ifno pain reliefin 15 min. ercoccl 5/325mg l tab every4houm PRN for pain level [ ] l -W--7 [j 8 - 10: MAY Repeat X ldosc ifno reliefm 15 min. [ ] Tylenol with Codeine #3 l tab every 4hours PRN [1 l -3 I ] 4- 7 [J 8 -IO: MAY Repeat X l dose ifno rclicfin 15 min. SHIVERJDNG: rho [ ]Mapcridinc 12.5 mg IV every__5 minutes PRN shivering up to _S_0 mg \\mm [] Midazolam mg cvery_____minutes to mg in 1 hour. \ NA EA: (Follow the. checked orders below as the sequence of administrations,unless directed otherwise) I 0‘ Zofi'an 4 mg IV PRN x __l "OR" [ ]Anzemct 12.5 mg IV P '- \, [ 1 Phenergan____mg 1M PRN x 1 *preferred route "0R" henergan ________mg rv (dilute 10: 1) PEN _ - k [ ] ‘- mg Iv PRN______ l ADDITIONAL ORDERS: Call Physician for HR > 100 or '< 60 bpm: SBP >140 or < 90; DB? >90 or < 50 l. 2. A I Datc:44 (4 Time gig! g Signaturw A” ‘ MD. u I i IWV 1" MV DISCHARGE ORDERS afisfactory: fies [3No. Complications: E J ischargc: flame UOIher: F’ mmcnts: /] -. HI/fli/I -. rfla‘fll .. . ?LL'fl .mF I SECOO1 3 1.. JOHNSEN. STEPHANIE Anesthesia Record marmammom mem_L Imwsn: 3906 r1 Gender: F (\1 WE mem ‘ ' DOB: menses Age: 31 - gm 6" m ”Mm”. FE I a m" m '“' Phys: Graven, Nadine‘wd Summon a ml D GWI MMf . Almanac» um,4}?! HI p um Mr.“ ’IDF Dom . :wfisg- MW ”m i DOS: 4171201 7 Mud chmRm Palm ad 3mWM '1 ImmodluliyBw- mawmuqu'rWW 3 4 DOZnudm-uk hn- Domllrmy ueREl-KRKS__.__.._._._._._ \ woucmn C I .WmnE'Mm’ Mm D Mm U mm 11111.: MESI'ECHHlDUE n Rnghnll D MM: ’I‘J GA REGDNAL ARES? anluuiaiuck‘r ’\ ”CU L ‘ J TRANSFER 0F cm:’1" ' o . - Carermwu:029 b um- mnmnm 1mm _BP_LZEEURR €22 Tm QEIEF 2 -_-arn mp fin: g ' um DLIMDEn' “”0““ Pm Sac __ mes srmF'l'b , - sunssum mm” 1: mm» mm,“ i $711+ “Fm e , a ouro‘R " 'suaa 5709 mesmesowcrsrn mum cum (~ x} k0 fi {00615222 035’ -- SECOO'I 4 x '4- Mi: 5:13 '- my- 1‘51 ra} ‘PO‘Iig- ,_-. ,.- :51. i i; nLS __ . . "';,,. 31:; *{iip dowlqfil‘us m1”); am £9: 22w .1 'wrr Ln? ._;__._. {Pf _ mja1é1‘_hL} Lado-"lp‘fi ' mm am guit‘w a]; I ' 31;; ...‘vi‘lg' {Ll- mi. ifi'ifl‘b‘ ff? min r.- 1‘3551'3).."'..lJ-!H.L.'$J.r. REE? “fir '5;F" "KJL L'f ' {Wrzeefi-¢_"§}i_x_ . , r 'r {L‘IT‘E’S -{71f.;z‘7_ _ ME: rowfmrwqjflun Pup] fl?*2- molt}, Hui“ Lgkjj Wm:nrll1;_.L;IYH‘u‘fi-jnfigfiiu Adm 6L Rfigqu n“: ”Ll ': ‘i ‘mu’miu MTML Eran mm mam - luarsim “akin, olive «w; ‘ ’ -;_;.wz! ‘ na'”? b r‘hfl'lwtrujfl‘mqo)“ . §§L-igs 'Trisl'et. ‘d-MJ‘ 12 flgfill?‘ lfii‘fir‘ffiia? b?mmfimgjfir ‘I f « ' Emil réahflfi ”Ly;“1.1%: 5-. E [‘_‘ [1L4 éwrfif fine; ‘iggifyh'ré: Iii? V29. 13f»); 1939-2” ifihu Jig va‘gikrafi Eflwcmn Bl ;_ . ‘nlr 3-111"LE'T Fflflilgavgfik m‘Kigfiflt}? I sfifitej {£533};fi.‘ _' .-:'-.«.- .. ' ! i. «'c‘} 1:3“ vinlax-U \rc_ l. (Mr Eifsilfig) Ifflxlxlfih, 1L a; wrywa j; Wm; _._ am} {:1qu _-:: guanin- . w. _ . v’. .r‘t. A *- xi * w‘r‘xéfiiim . . . I _ ,m‘uhhcmu ”1L; nthw 'btoiwlofij'ymhqu :Prl'l‘klg}vfix. 11““ I‘JO‘ U'Umh ‘hj 1k} a ‘ «w ~ J -‘: :- g P? ?.?xu‘t‘iffifléfiif 1’5. Fi". 1331K! \fil’lj}? '53-, .EWItE‘y’fiT's'fli'E} "_ {Harold ’56:]Lug; "wmrlhmygw, ”Mm 33 k A . . .I ' \J fififia - i: :.. . -:: “fl ’I‘luaKJJl ‘9 l Lpr \ngaaiojmmu c r v.- ‘M 43mm I‘WWAJJ‘” Em511%» ,. “fifi WUMEMQU’EEEMEW {EVA k :‘A 3‘ "O 3; 3%?! 93L; ‘ r I .. .7 'I i' r. A ‘x - .4: - 1 ., _ f g ,_ i ..2’? z ' '- ' .4 :-. 7’ .o' g?! :41. ~r-.=-_r r fl Ir‘ 1’ J A} Y$j3* 1a“; ‘92}3/#5 JOHNSEN. STEPHANEE ID (Visit: 3906 I 1 DOB: 7129!1985 Gender:F Age: 31 Phys: Graven. Nadine hfifir- A flion-H' __-.. . fl PROCEDURE: , f . A .. 40¢ - 3 'DX Qa/d’mWM 00%;ma {9011}? A msrdmeonanrmo‘h): ’ mans: I mmmF /pmnlm. c REGIONAL mm swan Ms WU ( N mcuAnmssmrbficx. mxmzm am mm J Emma xx Ans: DRESNGSUE . -‘ ADM VIAGURNEY nN/A s .r; -.\ n 3 ‘ . ‘4‘; 1V “fig 3/!10 smemmsupxz o DRAINAGE on oaseuv KN _b;-{Ma;:s n, g “A "m/ “3;, Q] {m Hon m7 ’10 aspum nsuus :1ng ‘ " ' ' r" '-’ AIRWAV, BiTON P-ILLDW(S) uY A P ‘ aNASAL normm Ben“ A com THERAPY av NA " / REMOVED @ DRAIN: v a N mnuous u c i: )1 F/ f0, Removed N50 @ mIII-IR / d NAWAKE s ATED 5 / ‘ AIO/e Swel @IV u‘f /§___l(lN.a v pBfiY DMOISI' jgfi‘ ammatlonEN nYfie f _1_'£____MP: a SHWERING - ‘ f'flalr finggerflWan'n blankets Total OR WfluldsMm! “STOUC'JV putseaa mm”Dmutfin mag ' PMOPEMTNE A 5. 15 39 Dc L Pm” n u In u n u a n a an T n F Remvamrs‘mns ‘ S C 0f .S' 5' ,r J 1 2+ 2-. ; nME 9' W W .. conscmusnss- m é?) L ?f/ jg g " fiwfygzawm I 02. w lb 3 1!)" IA ' ' - awwwmwsv I ‘ r g 15° I ' ’mmmm "F'e 180 VENHLAHON PMPVS mmmanmmun IM ?.0W5" I; I l LL- 1W:3an 31 Q- ' ?0 150 ° mwmm PULSE 14aAW Posr-opvs BB ‘ ‘ a mauG/punmmn. fdfi' , I ' g j 1mmwamonz l. I / 2 iM 120 Vi, L [?Tp’ .’iguavowu‘rm t f ”a V v V V’x/ / /MWENT M 1W .3 I _' ' I /‘ I \ COLOR . ' 90 w 2=NOIIMAL ammunc Am 7o _ 1QRCmA-nou PREOPP A 3 ,_ Mrmosraa- ' i Ea. A /\ / ‘A 4.. A "“94- 2 . ANETHESLA a Q l ‘LL 50 - /\ k HPMSDXDFPHE- . Amman Q‘ * ‘0'mflfis '05“ wMM loo loom r‘i 9c NORMALscnnezm ? mp2 m5 REP IQ L9 b: m [6 L £67 jg jm , . ‘ . . , smug: _f_ Em 904 %%%% wQJ__ , , ,. J I Ivniscunfinnew- [zip . Catheter tip Intact paawnavanmmmmsmssmsmumoufi ms D No TOTALNINTAKE: 15ml ml TOTALDRALINTAKE 6’ ml 2m on Dc: I10 RN 0N nc. c1 mss’w/No mam: Elms I no vernal):Elms ml B’fio 015m: To 333201: ADULWfi D Ho D ssms: Y me - RAINAGE El N/A mm“? m“RE -. ??‘L-wq‘ m: wcmnMB I’o:nrovy’fio‘:______ " ESIGNATURE: -. HmNmAL- 3-0-- UP CON ' AW m_‘ m“ ' DISCHARGE TIME: m $45 U POSTANESTHESIA CARERECORD JOHNSEN. STEPHANIE ID! Visit: 3906 I 1 Gender: F DOB: 7i29i1985 Age: 31 Phys: Graven. Nadine SECUD16 (1 \ / DC o Instructions o _ .. . fl " bx I NARRATIVE NURSING NOTES DATE I 11ME NARRATIVE NOTES: B/P, HR, HJR, and Pain Level. Ability to ambulate - RN INITIALS -. mowement of extyemifies. Dressings, Oral Fluids, Voided, Ok’d for discharge, Physicia _n’5 name. O ta... PATIENT LABEL /' ' \- POST ANESTHESIA CARE RECORD k) SECUD‘I 7 (W O m m AT HOME POSTOPERATWE [INS] H&JCTHONS 1f you have received oniy LOCAL ANESTHESIA: You may eat and drink whatever you like as soon as you get home. Be sure to drink plenty offluids. lfyou have received GENERAL ANESTHESIA, MONITORED A'NESTHESlA CARE, or SEDATION: .- 1. lncrgase diet slowly, beginning with 'quuicis, crackers, toast, jell-o and soup. No fried or spicy foods for _ the first 24 hours. Drink plenty of fluids. A 2. Take only the medication(s) prescribed by your physician You m_ay resume your routine medication(s) unless otherwise ordered by your physician. 3. It Is recommended that you ha've a responsible adult stay with you for the first 24 hours at home. ' 4. Take 3 - 4 de'ep brea‘ths every hour while awake. Continue this for at least 3 days following surgery. 5. _If you are on birth cohtrol and taking antibiotics, please consult your physician for a different means of ‘ 'contraceptive (birth control method). Antibiotics may disrupt your current form of birth control. 6. FOR TWENW-FOUR (24) HOURSAFTER SURGERYAND WHILE 01y NARCOTICS PAIN MEDCIATJONIS): ' DO NOT DRIVE, OPERATIVEMACHINERYOR POWER TOOLS, DRINKALCOHOUC BEVERAGES, TRANSACTLEGAL BUSINESS CAREFOR A DEPENDENTPERSON OR TAKE PUBLIC TRANSPORTATION ALONE. FOR CHILDREN: Do not rid a bicycle, scooter, or skateboard. No strenuous outdoor activity Call Dr ’ ‘ wéflwm$.78 lgJ&mediately if you have any unUSUal reactions such as: ‘ o Pain not relieved by prescribed pain medication .. o Chills and/onj fever over 101 ' o Unexpected or excessive bleeding or swelling at operative site o Extreme redness. blueness or sweliing at operative site - o Persistent nausea or vomiting - You are unabie to urinate by the end of the day Seek emergency medical attention for any of. the following symptoms} a Rapid rise in hotly temperature ' o Rigid or painful muscles, not associated with the surgery o An abnormafly rapid or irregular heartbeat t Brown or coIa-colored urine Very low blood pressure Confusion Muscle weakness or swelling, not associated with the surgery Flushed skin (Associated with any of the above) o Sweating (Associated with any of the above) O O 0 O Your doctor wants to see you in the officeflon I WK? /B/Cal| todgymiomer-row-fu-appointment Cl Already has an appointment D N/A {allow instructions_on attached-SW mistructions on file D N/A ke all medication{s) as dir__Fe___cted i ' ’ MnEa-ta'en-u-u D N/AMEfiWA Prescription for pain/o her medication attached Med(5): 1L6 rm? 5 33'5- W1. rescription for pain/(other medzcc’ation attachgd Meats):Mdn .A £60m Additional Discharge Instructions: E g’5’ 1’ , _. ‘ J0HNSEN.STEPHANIE Horne Wlth(SIgnatur§y0%#=¢-' . -I0Nisit:3soan Gem“ Witnes‘ijr , . ' DOB: 7129/1 985 r' ' ' “-"L_ _ Age: 31w . Phys: Graven. Nadine " ' DOS: 4/7/201 7 SECOO'I 8 t_- m Samaritan Surgical Group .. Miqor GYN Post-Op Instructions Nadine Gravefi BID, FACOG JOHNSEN. STEPHANIE ID I Visit: 3905! 1 Gender: F . Please take it easy around your home today. DOB: ?IZBH 985 Age: 31 . No dljvirig today. gray; 53:3?7Nadine ~ “ *0 Ifyour IV site is sore you may put a warm comprgss 0n it. o Bath or showers arc OK. a Please take your Motrin every 8 h'm as needed for pain or craznping. If you need thé stonger narcotic pill, you may take it while you ard'also taking Motrin. The two types of ' pain‘pflls_dp not have any intér‘agtldgns. ' I Pads or tampons are OK. .' I g/ l I ( o No exercise rcsnictions.. . n0 géy n wee L. o You may eat what you like. o Call (403) 378-1888 at any time day or night if you have severe pain, nausea, heavy bleeding or any other severe symptom that you are concerned about. We are happy to Speak with you. D I fl/ N/mccfl K' Date ql/ '?!///& fig 1300 W \QYPlomcL QUQMQ , JNW Ag mwQOf *“.;QD Owdwfl> ”1f w _ Qlimfalv €® SECOO1 9 POST-OP CALL ATTENIPTmmDATEacmm: an Lam“ ATTEwwz-DATBaa'm/LE: SPOKEwm-I 'TIENT spochwmiFMYNAME LEFT MESSAGE TORBTURN NAME CALL FOR QUESTIONS Aumpt 1 Attempt 2 Attempt 1 Attempt 2 Attempt 1 Attempt 2 WERAIURB: 6&119 - YES/FOLLOW UP TREATMENT . , I DREssmG/PROCEDURB srrE: DRY/INTACT DRAMAGE REDNEss REFERRAL T0 MD FOR POSSIBLE INFECTION CONTROL Ram: ® N0 LOCATION: 200 rafiflbflofs {‘9 65“?” PAIN MEDICATIQNS TAKEN: fl/WCO l x [bupmfim OTHER RELIEF WASURES: /U’ i FOLLOWUP WITH PHYSICIAN FOR PAIN RELIEF N/A ACTIVITY LEVEL: ANY PAIN OR SWELLING IN EXTERMII‘IESVKNO l] YES NL’ Ifycs have you notified surgeon YES D NOW If yes what were results: NAUSEA: ® YES WERE YOU SATISFIED WITH CARE?@ No ® to remm3w om COMMENTS. fiaMc/‘Dr fl/ZigA- Mm ’E'pffi‘ce {W394 '7FF m) fab" Ho HadWW/Wrmfix;7 FOLLOW UP APPOINTMEIh‘: CI-EDULED BY PATIENT INSTRUCTED I‘O CALL PHYSICIAN FEST ATTEMPT SECOND ATTEMPT SIGNATURE: '/’SIGNATURE: JOHNSEN. STEPHANIE 'n-n-p-n-w... 9 [DD I Visit: 3906 I 1 Gender: F 03: wzgnsas A :é1#(¢;:/V9:272 9? A Phys:Graven. Nadine Que DOS: 4/7/2017 L.- 4 secofifi’ ACKNOWLEDGEMENT 0F RECEIPT 0F DISCHARGE INSTRUCTIONS ( \I PROCEDURE msIRUCTIONs mfls PR0CEDURI'; INSTRUCTIONS MRHiLS CENTER P03120P INSTRUCTIONS mix LAPAROSCOPYHGENERAL/ GYNB 44,, BREAST BIOPSY PROCEDURES " ARTI-ROSCOPYKNEE - ENTPROCEDURBS ARIHROSCOPY SHOULDER GENERAL SURGERYLOPEN CASES HANb/ELBOW CASES FOOT/ANKLE CASES OTHER ORTHO CASES CRUTCH msmucnoivs ’ SLING MSTRUCTIONS mm (INJECTION) MANAGEWNT . REGIONAL ANESTHESIA BLoCK PT. SATISFACTION SURVEY 41 NTjRSE MUSTMAL ALL DISCHARGE INSTRUCTIONS PROVIDED TOPAW COMMENTS. Prescription o Patient Documented on Medication Sumnmry and Copy provided to Patient at discharge. ] Yes [] NIA . /KI Written prescription given to patient flora, .éyéazfgg [fifagfivH 69fl ”£4 O [ ] Prescription called inrto pharrfiacy by [ ] Surgery Center or [KT MD office ' [ ] Pétient received prescriptions prior to surgery [ ] MD wants OTC (over the counter) pain relievers oniy Patieht Initials Reguired I The Surgery Center has permission to leave a discreet message on answering machine. K n é The Surgery Center has pcrmissiofi to leave a detailed message on answering machine. FMYIPATIENT’S SIGNATURE BELOW INDICATES THAT THEY HAVE RECEIVED AND UNDERSTAND WRITTEN POST-OP ' DISCHARGE INSTRUCTIONS: . ' ' V/mzo/ 7 Signature ofPatient or Patient Répresentativc Da'tc f mfg“;k 4i“ I ¢ chétercd Nurse Signaturc Registered Nurse Inin‘als Afler the form is completed, place it in the patient's record. ‘1 - ~ § ' NIED JOHNSEN- STEPHA Gender: F lDIVisiL 3906! 1 DOB. 732911985 nmg: Graven Nadine Agtea‘i - | SECOO3D m-"' ---. vn-n-r-v M i ll r m" Q ‘ Cg: ACKNOWLEDGEMENT OF RECEIPT 0F DISCHARGE INSTRUCTIONS RNm . (:ROCEDURE INSTRUCTIONS MEALS PROCEDURE INSTRUCTIONS INITIALS :ENTER P0312013 INSTRUCTIONS flux LAPAROSCOPY-GBNERAL x GYNE A4, fl BREASEBIOPSY PROCEDURES mnmoscowms - ENTPROCEDUItEs mmoscow SHOULDER GENERAL SURGERYQPEN CASES mb/ELBQW CASES ?OOT/ANKLE CASES _ 3mm ORTHO CASES CRUTCH ' ' SLlNenJ ‘ ' ?Ang (INJEcnom MANAGEMENT . f 9;": ' KEGIONAL ANBSIHBSM BLOCK p'r. 3&1} f3“; 1.1: vNURSE MUST INITIAL ALL msCHARGE INSTRU - ‘ toms: Prescription o Patient Documented on Mtgf ‘atient at discharge. /I/]‘Yes [1 N/A Ia Written prescriptioig/iven to patient flare o 5/fl” g lfiagescription called irito pharrfiacy by [ J Surgery Centefii-a giant received prescriptions prior to surgery kt; "é; a fi g g 9 w t f; MD wants ,OTC {over the counter) pain relievers only 1'.- Ié; s? 3§§fl j4'1". ????gfiq‘” . $3 g E gag 1f . ienthitials Required , h g é?" gg v l! _____The Surgery Center has permission to leave a discr u s °' . fil" (Th6 Surgery Center has permissioli to leave a deta?:'f' J: fi ' g r- mY/PATIENT'S SIGNATURE BEL?- _:_-.;.* é VE RECEIVED AND UNDERSTAND/wg ' .' j -* - g CHARGE INSTRUCTIONS: ~41” ‘ _ . I E gW.“ . m Ire ofPaticnt or Patient R’spresentafivc Da'tc _ ' 4L“..-Ax .' ‘ Registered Nurse Initialsred Nurse Signahxre After the form is completed, place it in the patient‘s record. I A. m.gm mln- nJAJ-fin-fim":-‘;-m dfi‘aflm h I r: FLj ID Nisit: 3906 i 1 15:26; rmn- Tivnimnfi . SECooa1 n Pathology 0 l ,. Palo Surgical Pathology Report ( \ A It0 Kenneth Heaven MD. - Director 2325 El Camino Real Palo Alto, California 94306 1-800-303-4PAPPathology Inc. PATIENT: STEPHANIE JOHNSEN DEPT #1 317-1712 DOB: 7(29/1985 (31)Years SEX: F SERVICE: 043072017 PHYSICIAN: NADINE GRAVEN. MD. RECEIVED: 0411 0f2017 LOCATION: 476 E. CAMPBELL AVENUE REPORTED: 04/121201? Copies Sent to: SAMARITAN ENDOSCOPY CENTER SPECiMEN #: 1 RIGHT FALLOPIAN TUBE , SALPINGECTOMY SPECIMEN #z 2 LEFT FALLOPIAN TUBE , SALPINGECTOMY CLINICAL DATA: BLADDER ADHESIONS DRAINAGE OF LEFT OVARlAN CYST Gross Description: Received in formalin is a 6.0 cm. long fallopian tube with fimbriated end. The serosal surface is shiny and smooth with areas of hemorrhage. The diameter of the fallopian tube is up to 0.7 cm. Sectioning reveals no gross abnormalities. Represented in a single cassette. [A, Right] Received in formalin is a 8.0 cm. long fallopian tube with a diameter of 0.4 to 0.5 cm. The serosal surface is shiny and smooth. A few fimbria is present at the fimbriated end. Gross abnormality is not noted. O Represented in a single cassette. [B, Left] [AU] Commenthicroscopic: Sections of both specimens contain benign fallopian tube tissue. Cautery artifact distorts the architecture in left fallopian tube. There are no atypical features. DIAGNOSIS; 1 - RIGHT FALLOPIAN TUBE, SALPINGECTOMY:m -- BENIGN FALLOPIAN TUBE 2 - LEFT FALLOPMN TUBE. SALPINGECTOMY; -- BENIGN FALLOPIAN TUBE . r" SAMARITAN ENDOSCOPY CENTER 151 95 NATIONAL AVE. STE 204 LOS GATOS, CA 95032 Ayce nal. MD.U Page 1 of 1 COPY “I SECODZ1 _ ___'_.__ __.-fl__.. .__._.___ __._ __... "\.._.._ f A ---------../-Lg-----.-..--_._-_.__._~_l I II ' _ ""_"' Palo Alto Pathology Inc. I i325 El Camino Real ‘ 'rhlo Alto, CA 94305 1-800-303-4PAP Kenneth Hadler, MD. Director 13995- S C&N'ER. 1.5.195 \‘ATJflNAL AVE. 3"5 2Q“: L08 GATOS. CA 95632 ' 1w4®8a356-€|933 L. .u Prep D cocmamydia U CC U Chlamydia D Cystic Fibrosis Molecular Tests Requesting Physician NMI NE GlflA’I/EN MD U Group B Strep {collection km Required Information PRESS FIRMLY' Name (Last. First. MI) Social Security a (Paliem LD. Number} Specimen Source JOHNSEN. STEPHANIE ID i Visit: 3906! 1 Gender: F DOB: W29“ 935 Age: 31 Phys: Graven, Nadine DOS: 4171201 7 Date and Time Collected If" "Wits mainpmp vial} U Thin Prep E HPV U Thin Prep E Reflex HPV Molecular Tesls (ThinPrep vlan D Hespes Simplex 1 and 2 {type specific] (Pap amps Swab: U Fetal FibroneCIin U Tissue Exam PAP Smear (Sundard suds: U Single Slide U Double Slide Other Cytology 39m D areas: L R D Sputum U Urine D owe: - Specify :J ArF7Rm f. ICDIOIDEEEHOSI'S Ml! Immnccl jg a ‘ flXA Ins. CO. {Cand-. Gard., ‘*icn.) (Pleat: mach com of front a back cf cud} Address ’14 \Lfi 4fl7ji7 6/ 0M?) 5.5JLD.: 1K“ FW 1‘ 1'"U Group 3 [IQ r/ lnsured's Name Billing information "4“? Smear‘Check 50mm Binhdam Sex Home Phone Address Cil)! Slate Zip 00v. __ _' History Circle Yes - No Below D lncomplele immune information D will mull in pafienl being, billed directly. ' C] In{ormat‘mn on File Change of information Patient D Cash /Cervical - Endocervical Date of Last Menstrual Period Y N Tomi Hysterectom- D Cervical -Vagina| Y N IUD D Vaginal Y N Birth Contra! Pills [3 Vulvar Y N Hormone Then Type: Y N Gross Lesioa D Regular E] Irregular U Spottirg Y N Previous Cancar - Site D Pregnant D Post Panurn Y N Irradiation - Date D Post-Menopausal Repeat of Atypical Smear .._ § Biopsy Site w fl'l/mHA'rJ mg? Mam 13211;!»oner m SURGICAL ' é, JPN Clinical Diagnosis Operative Proceduqrds) r .- 0(7’ C“ H £7 3 LfifiA-Mflww, 61mm, gm?! mean nag, Comments .- .(\( ‘1 - A’QH D r 1M - 6 DE lfffi 0mm») 015T Signature of Requesfing Physician D Phone Consullaiion Requested yddilional Copies lo: Name Dear mien; \GMMMIAN ENDNCOW Address ATHOLOGY. ., __ -_ _ Hislory For Cytology Dept. Only 3‘1 OX ' N A L H D #2 Comment 13 Class I 2 J 4 5 14 Cell Pattern S E: M End‘ H IS Ml U P= I== S= 36 Harm. Pal. C U :7 Flora U B F T__,________ 18 Background U Ml Mod! Mk! B t9 Cyan :10 Path UType1 CTyp-ez UTypeS UType4 cENTW Advance Beneficiary Nolice EN". physician has mleu-d the above 1w because hash: belicvu Ihal the I5: result are tclmm Io evaluating and mlimhs Ihe state or rout health.Hm undchuctiun I862 mm oi the Meditate Law. paymenl ( '2 denied by Medicare far Em which. in Ihcir opinion. are considered ‘scrncning Icsu’. tans which hm been perform 'Ioo lrequenfly‘. m when the diagnosis submiucd does ml justify the lam nrdercd. Ikal Respomihifily Acknowledm: l have been notified by my pimic'ranfpmvida um hdshe bclim thai. in my Ease.WWI Ii ”WY ‘9 be denied fat me d :hcrum Med abov- If P-IY'W“ ‘5 “filed- \.-,...=e Io be pemlly and fully responsible forW and to make such pm: when billed. Yellmv - La boratory Copy - Blue - Transcription Copy ' While - Physicia n's Copy Phiieru's Signature Dale SECOO22 Law Offices of OKOOOQQUI-PUJN NNNNNNNNHt-tt-th-tt-tt-th-tt-tt-ti-t \IONM-wat-Okoooflmm-bwwt-K 28 HINSHAw, MARSH, STILL & HINSHAW A Partnership 12901 Saratoga Avenue Saratoga, CA 95070 (403) 861-6500 EXHIBIT D 6 DECLARATION OF SCOTT R. KANTER IN SUPPORT OF MOTION FOR SUMMARY JUDGMENT OR, IN THE ALTERNATIVE, SUMMARY ADJUDICATION BY DEFENDANTS NADINE GRAVEN, M.D. AND VENTANA MEDICAL GROUP, dba A WOMEN’S CENTER N0. 19CV352312 ACUI s Caption: Acuity Order Number: NorCal Case: NorCal Claim: Patient: Facility: E R V Johnsen vs. Gravin, MD 162244 509626 CLA0511221 Johnsen, Stephanie C E s Valley Radiology Imaging Montpelier Should you have any questions about this order your Case Manager, Zachary Marberg would be happy to assist you. They can be reached directly by phone at 720-941-9584 ext. 1014 or by email at zmarberg@acuityservices.com. 1764 Gilpin St Denver, CO 80218 Phone: 720 941-9534 Fax: 720-223-7279 www .acu ityservices.corn SUBP-O10 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number. and address): 99903 FOR COURT USE ONLY -Hinshaw, Marsh. Still & Hinshaw LLP Barry Marsh. Esq. 12901 Saratoga Ave Saratoga, CA 95070 TELEPHONE N05 (408) 861_6500 FAX N0; (408) 25?-6645 E-MAIL ADDRESS: ATTORNEY FOR (Name): alozan0@hin5haw'law.com Gravin, Nadine MD. SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PLAINTIFFIPETITIONER: Stephanie Johnsen DEFENDANTIRESPONDENT:Gravin, Nadine MD. CASE NUMBER: DEPOSITION SUBPOENA FOR PRODUCTION OF BUSINESS RECORDS 19CV352312 THE PEOPLE OF THE STATE 0F CALIFORNIA, T0 (name, address, and telephone number ofdeponent, ifknown): Valley Radiology Montpelier 2385 Montpelier Drive, San Jose. CA 951 16 1. YOU ARE ORDERED T0 PRODUCE THE BUSINESS RECORDS described in item 3, as follows: To (name of deposition officer): Acuity Services On (date) : 12(131'2019 Location {address}: 1764 Gilpin Street. Denver, co 3021s Do not release the requested records to the deposition officer prior to the date and time stated above. a.m by delivering a true. legible. and durable copy of the business records described in item 3, enclosed in a sealed inner wrapper with the title and number of the action, name of witness. and date of subpoena clearly written on it. The inner wrapper shall then be enclosed in an outer envelope or wrapper, sealed, and mailed to the deposition officer at the At (time): 10:00 AM. address in item ‘1. b.E by delivering a true. legible. and durable copy of the business records described in item 3 to the deposition officer at the witness's address, on receipt of payment in cash or by check of the reasonable costs of preparing the copy. as determined under Evidence Code section 1563(b). c. E by making the original business records described in item 3 available for inspection at your business address by the attorney‘s representative and permitting copying at your business address under reasonable conditions during normal business hours. . 2. The records are to be produced by the date and time shown in item 1 (bur not sooner than 20 days after the issuance of the deposition subpoena, or 15 days after service, whichever date is later). Reasonable costs of locating records, making them available or copying them, and postage, if any, are recoverable as set forth in Evidence Code section 1563(b). The records shall be accompanied by an affidavit of the custodian or other quafified witness pursuant to Evidence Code section 1561. 3. The records to be produced are described as follows (if erectronically stored information is demanded, the form or forms in which each type of information is to be produced may be specified): Any and all Medical and Billing Records. a5 well as Radiology Filmsilmages pertaining lo Stephanie Johnsen (DOB: 07f29l1 985)m Continued on Attachment 3. 4. IF YOU HAVE BEEN SERVED WITH THIS SUBPOENA AS A CUSTODIAN 0F CONSUMER 0R EMPLOYEE RECORDS UNDER CODE 0F CIVIL PROCEDURE SECTION 1985.3 0R 1935.6 AND A MOTION T0 QUASH OR AN OBJECTION HAS BEEN SERVED ON YOU, A COURT ORDER 0R AGREEMENT 0F THE PARTIES, WITNESSES, AND CONSUMER 0R EMPLOYEE AFFECTED MUST BE OBTAINED BEFORE YOU ARE REQUIRED T0 PRODUCE CONSUMER 0R EMPLOYEE RECORDS. DISOBEDIENCE OF THIS SUBPOENA MAY BE PUNISHED AS CONTEMPT BY THIS COURT. YOU WILL ALSO BE LIABLE FOR THE SUM OF FIVE HUNDRED DOLLARS AND ALL DAMAGES RESULTING FROM YOUR FAILURE T0 OBEY. Date issued: 11’13’2019 ’ 5WW, (Z?Barry Marsh, Esq. (TYPE 0R PRINT NAME) {SIGNAfiéRE 0F PERSON ISSUING SUEPbENA) Attorney for Defendant Gravin. Nadine MD. (Proof of service on reverse) (TITLE) Page 1 ofz FAdtdfMdtu " .-.;neposmonsusvoENAmRPRonucmN $44 SUBP-O‘IO [Rem January 1. 2012] OF BUSINESS RECORDS m_wuflscagav SUBP-025 ATTORN EY 0R PARTY WITHOUT ATTORNEY (Name. State 8a: number, and address): 99908 FOR COURT USE ONLY -Hinshaw. Marsh. Still & Hinshaw LLP Barry Marsh. Esq. 12901 Saratoga Ave Saratoga, CA 950m TELEPHONE No 818-844-01 88 FAX HQ {optima}.- (408) 257-6645 E‘MA'LADDRESS {09mg}: alozano@hinshaw-Iaw.com ATTORNEY FORM“); Gravin, Nadine MD. SUPERIOR COURT 0F CALIFORNIA, COUNTY 0F STREET ADDRESS MAILING ADDRESS: CITY AND ZIP CODE BRANCH NAME: PLAINTIFF! PETITIONER: Stephanie Johnsen CASE NUMBER? DEFENDANT! RESPONDENT Gravin. Nadine MD. 190135231 2 NOTICE T0 CONSUMER OR EMPLOYEE AND OBJECTION (Code Civ. Proc., §§ 1985.3.1985.6) NOTICE TO CONSUMER 0R EMPLOYEE T0 (name): Stephanie Johnsen cfo Andrew Agtagma. Esq. 1. ‘ PLEASE TAKE NOTICE THAT REQUESTING PARTY (name): Defendant Nadine Gravin' MD. SEEKS YOUR RECORDS FOR EXAMINATION by the parties to this action on (specify date) 12’1312019 The records are described in the subpoena directed to witness (specifi/ name and address ofperson or entity from whom records are sought): valley Radiology Montpelier 2385 Montpelier Drive, San Jose. CA 951 16 A copy of the subpoena is attached. 2. [F YOU OBJECT to the production of these records. YOU MUST DO ONE OF THE FOLLOWING BEFORE THE DATE SPECIFIED. IN ITEM a. OR b. BELOW: a. If you are a party to the above-entitled action. you must file a motion pursuant to Code of Civil Procedure section 1987.1 to quash or modify the subpoena and give notice of that motion to the witness and the deposition officer named in the subpoena at least five days before the date set for production of the records. b. If you are not a party to this action. you must serve on the requesting party and on the witness. before the date set for production of the records. a written objection that states the specific grounds on which production of such records should be prohibited. You may use the form belowto object and state the grounds for your objection. You must complete the Proof of Service on the reverse side indicating whether you personally served or mailed the objection. The objection should not be fiied with the court. WARNING: IF YOUR OBJECTION IS NOT RECEIVED BEFORE THE DATE SPECIFIED IN ITEM 1, YOUR RECORDS MAY BE PRODUCED AND MAY BE AVAILAB LE TO ALL PARTIES. 3. YOU OR YOUR ATTORNEY MAY CONTACT THE UNDERSIGNED to determine whether an agreement can be reached in writing to canoe! or limit the scape of the subpoena. If no such agreementis reached. and ifyou are not otherwise represented by an attorney in this actio n, YOU SHOULD CONSULT AN ATTORNEY TO ADVISE YOU OF YOUR RIGHTS OF PRIVACY. Barry Marsh. Esq. ’ 3WW, 5%. (TYPE 0R PR'NT NAME] {s:GNATURE 0F d REQUESTING PARTY m ATTORNEY: OBJECTION BY NON-PARTY TO PRODUCTION OF RECORDS ’l.E | object to the production of all of my records specified in the subpoena. 2. [j | object only to the production of the following specified records: 3. The specific grounds for my objection are as follows: Date: (TYPE ORPRINT NAME] (SlGNATUREI {Proof ol service an reverse) page 1 91:2 533?;gdggfgrgfigivgfig ”58 NOTICE To CONSUMER 0R EMPLOYEE AND OBJECTION °°d°ggfgggg°figgg‘; SUBP-OZS [Rev January1.2008] 2020 01:2;20510 , www.cou in cagov SUBP-025 PLAINTIFFIP ETITIONER: Stephanie Johnsen CASE NUMBER 19CV352312 DEFENDANT/RESPONDENT: GraVin. Nadine MD. PROOF 0F SERVICE 0F NOTICE T0 CONSUMER OR EMPLOYEE AND OBJECTION (Code Civ. Prom, §§ 1985.3,1985.6)E Personal Service m Mail 'I. At the time of service | was at least 18 years of age and not a party to this legal action. 2. | served a copy of the Notice to Consumer or Employee and Objection as follows (check either a or b): a.E Personal service. I pemonally delivered the Notice to Consumer or Employee and Objection as follows: (1) Name of person served: (3) Date served: (2) Address where served: (4) Time served: b.m Mail. I deposited the Notice to Consumer or Employee and Objection in the United States n‘ail, in a sealed enveiope with postage fuliy prepaid. The envelope was addressed as follows: (1) Name of person served: Andrew Agtagma. Esq. (3) Date of mailing: 11,!13/2019 (2) Address: 951 Mariners Island Blvd. Ste 300 San Mateo, CA 94404 (4) Place Of gailing £60m! and Steffi): enven (5) I am a resident of or employed in the county where the Notice to Consumeror Employee and Objection was mailed. c. My residence or business address is (specify): 1764 Gilpin Street. Denver, CO 80218 d. My phone number is (specify): (720) 941-9534 | declare under penalty of perjury underthe laws of the State of California that the foregoing is true and correct. Date: 1 1H 312019 Zac Marberg } 2wWW U (TYPE 0R PRINT NAME 0F PERSON WHO SERVED) V [SIGNATURE OF PERSON WHO SERVE D) PROOF OF SERVICE 0F OBJECTION TO PRODUCTION OF RECORDS (Code Civ. Proc., §§ 1985.3.1985.6)E Personal Service D Mail 1. At the time of service | was at least 18 years of age and not a party to this legal action. 2. I served a copy of the Objection fa Production ofRecords as follows (complete eithera orb): a. ON THE REQUESTING PARTY (1) E Personal service. I personally delivered the Objection to Production ofRecords as follows: (i) Name of person served: (iii) Date served; (ii) Address where servad: (iv) Time served: (2) E Maii. l deposited the Objection to Production of Records in the United States mail, in a sealed envelope with "postage iully prepaid. The envelope was addressed as follows: (i) Name 0f Person SBWBdI (iii) Date of mailing: (ii) AddF9553 (iv) Piace of mailing (city and state): (v) | am a resident of or employed in the county where the Objection to Production of Records was mailed. b. ON THE WITNESS (1) E Personal service. l personally delivered the Objection to Production of Records as follows: (i) Name of person served: (iii) Date served: (ii) Address where sewed: (iv) Time served: (2) E Mail. I deposited the Objection to Production of Records in the United States mail. in a sealed enveIope with postage iully prepaid. The envelope was addressed as foliows: (i) Name of person served: (iii) Date of mailing: (ii) Address: (iv) Place of maiiing (city and state): (v) l am a resident of or empioyed in the county where the Objection to Production of Records was mailed. 3. My residence or business address is (specify): 4. My phone number is (specify): | declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: ), [TYPE OR PRINT NAME 0F PERSON WHO SERVED) (SIGNATURE 0F pERSON WHO SERVED} SUBP"25ER9"“ January 1- 20°31 NOTICE T0 CONSUMER 0R EMPLOYEE AND OBJ ECTION ”9° 2°” Deposition Subpoena for This Declarationm b: Production cf Business Records signed and returned whether or not you have records. Regarding (name): Johnsen, Stephanie Facility: Valicy Rndioiog' lmag’ng Montpeiicr Location (address): 2385 Montpelier Drivc, San Jose, CA 951 i6 I, the undersignad, being flu: duiy authorized Custod§an ofkeoords and having authurity to ocrtify the record declare the foilowing {please check appmp‘riate bum): .' M 3' 4 '2 u. V :*' "I t 1;; 'ta. mu The records were mpamd by the personnel afthe hushm in the ordinary amuse ofbusincss at or near the time of {ha act, condition, er event. The photocopied records submitted herewith an: true wpies ofthe complete (check ali applicable}: mecdicaIRmmis _ERMioiogy Images D Bim‘ng D Other:W D I am ova: the age of 13 yam and no: a muty to this action. .i am the duiy authorized custodian ot'mcords for the facility namcé on the ducts lecum subpoena. '11:: copies accompanying this declaration an km: copies ofafl recornis described in the subpoena which are in my messiah as Custodian ofkwords. The original records fi‘m‘n which the accompanying copies wast made were prepared by'in the ordinary course of business a1 m- ncar the times affine acts, conditions. cr mzmts recorded therein. D Medical Recanis D Radiomgy images m Bitiing D 0mm ?LEASE SPECIFY REASON D Remdsfiilms are'Lost U Recordsa’Fiims arc Dcstzoyed gamer: fl \dhfig mama me.»W W A {homuyz search of‘our files, carried out under my direction and mntmhmveaied no documents, mmrds, or other items listed in the Subpoena presented Io me. Ii is understood that-sueh mrds "may exist under another spelling, name, or classification, but with the information wovided to our office and {a the best ofmy lmowiedge. no such records exist. I DECLfiRE UNDER PENALY 0FPWRYM3 UNDER THE LAWS 0F THIS-STATE THATTHE FOREGOING lsTRUEANDmmEm Emma unaware); {3E9 g} g 3mg km“ " t a1 (ciga’wu) San Josc, I ca. _ g I I . Inaammpimow THIS LINE. For: USE BY” coma smwcs ONLY l'a'm iii: attorney‘smasufinnl'ism: tin! I:- - - H I i D Mild: Tran ali'Comci Civic: crib: Ream D Ruched Capie: of sh: Raced: D Received I Ccnifimc am. Baud: ?ravidad to m; by the custom“ cf nkordl .n! the above locafiun‘ i backs“ {mammm?ar-sznvm135mm Ta: Law‘s6rm STAT: or CA11mm3romorm; Is nusANDconnw. D mm. am no:Way completeaw»agnm mamas; «Rama.swam Notes: Executed cu (due) . It ray} l3: W VRI MontpelierF . . (CVulley Radiology Imaging EETJ'S'EQEEi‘SEm’e - Phone: (403) 964-4000 RudNet Imaging Centers Fax; (408) 954-1035 Ordered By i JOHNSEN, STEPHANIE ANGELA POLLARD, MD MRN: 8514719 700 W PARR AVE! STE I DOB: 07-29-1985 Sex: F L08 GATOS CA, 95032 Phone:(403) 472-9996 Date of Service: 02-24-201 7 FAX: (408) 370'3790 EXAM: MRI PELVIS WITHOUT AND WITH CONTRAST CLINICAL INFORMATION: Lost IUD. TECHNIQUE: MRI of the pelvis with and without contrast. 1.5 T Magnet- muftiplanar T] and T2-weighted imaging performed. Contrast: 10 cc W Dotarcm COMPARISON: None availabie. FINDINGS: Uterus: Antevcrted, 4.5 x 3.4 x 5.5 cm. Uterus is within normal limits. No {deal fibroid is identified. Junctional zone is within normal limits at 8 mm. Along thc anteriOr lower uterine segment, at the junction of the cervix. there is low T2 signal. with associated susceptibility artifact, consistent with a cesarean section scar. N0 IUD is identified within the myometrium. Along the outer contour of the uterus, along the anterior wall, there is within 'I‘2 hypointensity, non5pecific. Endametrium: Normal T2 hyperintense, l mm. N0 abnormal enhancement. An IUD is not identified within the endometrial cavity. Cervix: 2.4 cm in length. Normal zonal anatomy. Ovaries: Both ovaries are within normal limits. The right ovary measures approximateiy 3.1 x 1.3 x 2.3 cm. The left ovary measures 3.6 x 2.3 x 2.0 cm. There are normal subcentimeter follicles in both ovaries. within normal limits. Peritoneum: No ascites. Urinary Bladder: Unremarkable Nodes: Confidential Patient: JOHNSEN. STEPHANIE DOB: 07-29-1985 P3991 072 F VRIMontpeIigr I (Valley Radiology Imaging iiingé’e'TtEi'Zgfiir'é’e RadNet Imaging Centers 523;“743’3‘i39’63?$5£°5°° No Iymphadcnopathy Bowel: Unremarkable IWRESSION: 1. IUD is not identified within the uterus or in the endometria! cavity. The uterus is within normal limits for size and morphology. There is no evidence for focaI fibroid or adenomyosis. E 2. At thejunction 0f the lower uterine segment and cervix, along the anterior wall of uterus. there is susceptibility artifact and T2 hypointensity, consistent with postsurgicai changes, likely from prior cesarean section. No discrete IUD identified. For localization ofthe IUD, radiography or CT may be beneficial. 3. No ascites. Ovaries are within normal limits. End of diagnostic report far accession: 9369635 Dictated: 02-24-2017 10:52:18 AM Electronically Signed By: Kung, Sophia T, MD 02-24-2017 10:52:18 AM Confidential Patient: JOHNSEN‘ STEPHANIE DOB: 07-29-1 985 Page 2 0f 2