Policy Number:

DDPH68

Claim Number:
GQWDK7CA

Page 1/
Provider: Root Insurance Co.
Root Insurance Company
Claims Department (Bodily Injury)
80 E Rich Street, Suite 500
Columbus, OH 43215

Claimant: Aisha Nour

9555 Via Pereza
San Diego, CA 92129
Phone: (415) 214-3353
E-mail: aishanour821@gmail.com

Policy number: DDPH68

Claim number: GQWDK7CA
Date of Loss: April 29, 2021
 3/21/2023

To Whom It May Concern: (or Attn: Claims Department and/or

Andrew Sullivan-Cook; First Party Medical Adjuster I; (614) 412-7462;
andrew.sullivan.cook@joinroot.com
Blake Ross; Injury Adjuster; (614) 706-5612; blake.ross@joinroot.com
Tamara Goulden; Injury Adjuster II; (614) 699-6029; tamara.goulden@joinroot.com

I have received your letter letting me know of your assignment to my bodily injury claim:
GQWDK7CA.

I am writing to inform you that I have completed and gathered the medical treatments
resulting from the motor vehicle collision that took place on April 29, 2021. As of March
21st, 2023, all medical procedures have been concluded. I kindly request reimbursement
pertaining to the corresponding medical documents and bills incurred as a result of this
incident. I would appreciate it Root Insurance can make a decision on this matter within
seven (7) business days upon receipt of this demand. Thank you for your attention to this
matter.

Regards,
Aisha Nour

9555 Via Pereza

San Diego, CA 92129
Phone: (415) 214-3353
E-mail: aishanour821@gmail.com
 March 21, 2023

ACCIDENT DETAILS:

Named Insured: Mohamed Ainab, AISHA NOUR

Policy Number: DDPH68
Claim Number: GQWDK7CA
Date of Loss: April 29, 2021

On April 29, 2021, I was the driver of a 2018 GMC Acadia that was traveling in the leftmost
lane of a 4-lane street - 28TH STREET of Kentwood, MI. This was the lane dedicated to left
turns onto the 2-laned street- E PARIS AVE SE. When the light turned green, I attempted to
make the left turn- however, we were hit by a city bus being driven by MOORE LYNCH.
Driving past a red light from E PARIS AVE SE, he collided the front-driver side of his vehicle to
the middle-right passenger of ours. Diagram below:

Unit 1: Rapid
Transit City Bus

Unit 2: GMC Acadia

Following the collision, our airbags deployed and we travelled several feet along E PARIS AVE
SE. The car became unresponsive and was later deemed a “total loss” by Root Insurance
The following are preliminary responses to Root’s accident questionnaire initially submitted to
Adjuster- Andrew Sullivan on 11/4/2021.

Driver Aisha Nour's responses are notated with an “A” and passenger Mohamed Ainab’s notated
with an “M”

What happened in the accident?

-M/A: We were taking a left turn from a one-lane turn after signaling. The light turned green
and as we were entering the right lane a city bus hit us. The airbags deployed, the vehicle, with
us still in, travelled several feet. The car wouldn’t start afterwards and was deemed a total
loss.

Where was the impact on your vehicle?

-M/A: Seemed all around and all the bags deployed but the main side was the passenger right side.

Why were you on the road that day?

-M/A: Visiting family

Were you working for a business as the time?

-M/A: No. On vacation

Where were you sitting in the vehicle?

-M/A: We were together so both driver and passenger.

Were you wearing your seatbelt?

-A: Yes, but the impact was so severe against our vehicle that I hit my forehead.
-M: Yes

Did your body hit any part of the inside of the vehicle?
-A: My forehead hit the steering wheel, and the left side elbow sweater was burned due the
airbags deployed.
-M: My left hand/thumb hit inside the vehicle. Head/Neck whiplash.

Have you had any injuries before this accident?

-M/A: No.

Do you have any ongoing or chronic health conditions that would affect your recovery time?
-M/A: No.

What injuries did you suffer from the accident?

-A: Yes, a concussion. Whiplash. I was not quite sure at the moment but in fact after current
treatments I have come to realize that I suffered from a concussion and the state of the accident
has left me in a state far more traumatized than I had thought initially. I was driving safely and
in my lane. The bus driver who hit our vehicle, I believe to have been traveling at a fast
distance. I may have been in his blindspot and in essence, he t-boned our car, and I have had an
increase in anxiety since.
-M: Concussion. Left/Thumb injury. Neck. Head. Body aches.

Were you transported from the scene of the accident by emergency medical services?
-M/A: No

What treatment have you had so far for your injuries? (please be specific with dates you received
treatment and where you went)
-M/A: Hospital E.R. 5/11/2021; Physical Therapy – ongoing; Concussion center – ongoing

Have you had any scans completed to assess your injuries? (X-ray, MRI, CT scan)
Yes. ct scan -M/A: see attached.

What are your plans for treatment in the future? Family doctor F/U
-M/A: Continue treatment under Family doctor’s management.
-A: Ask about psychiatry – I get extremely scared and traumatized when it comes to traveling in
a vehicle even still.
If you have no future treatment plans, please confirm that you are no longer seeking additional
treatment.
Do you have any other health insurance that may apply to this accident?
-No.
 3/21/2023

INJURY DETAILS:

While traveling through a busy intersection, my attention was focus on the traffic ahead.
Despite having my window open, I did not hear any horns or screeching noises, leaving me
vulnerable and unable to brace or react before the collision occurred. Upon impact, my head was
jolted forward and backward, causing my neck to extend in both directions, leading to a
momentary loss of consciousness. When I regained consciousness, my vision was blurred, and I
experienced dizziness and nausea. The intense headache, abdominal and back pain persisted,
prompting me to visit to the nearest emergency department on May 1, 2021. I sustained injuries
that included a concussion, intracranial injury, nausea, emesis, multiple contusions, cervical
strain/sprain, thoracic and cardiac injury, whiplash injury, lumbar strain/sprain, lumbosacral
strain with radicular pain, and neurovascular injury. The emergency physician prescribed pain
medication, discussed the need for a further concussion management, and careful assessment and
monitoring of my symptoms.
Over the next few days my symptoms continued to worsen, with the pain in my back
progressively intensifying and radiating to my left leg. Additionally, I experienced abnormal
tightness in my chest and heart palpitations, leading me to return to the hospital on 5/6. I
was informed I had been experiencing bradycardia and may have suffered an L5-S1 disc
herniation and further neurovascular procedures and imaging with an MRI would be needed. I
was prescribed stronger pain medication and muscle relaxants. The pain in my back, hip, and
pelvis did not see much improvement of the next two weeks and I also experienced an abnormally
early and prolonged menstruation. During my follow up visit on 5/16, my primary care physician
ordered lab tests and referred me to a combination of physical therapy and chiropractic
manipulation. She also concluded the need for an MRI and pelvic ultrasound and referred me to
Imaging Healthcare Specialists. The imaging found progressed retrolisthesis at L5-S1, spinal
stenosis and bilateral foraminal narrowing at L4-5. The physical therapy and chiropractic care did
help with the soreness and mobility issues but I continued to feel numbness and tingling sensations
across my chest, back, and left leg. Sharp pains in my back and pelvis with abnormal menstruation
and swelling in my legs. During a physical therapy appointment on 6/25, I was instructed to return
to the emergency room for evaluation as the symptoms had become emergent. The findings
included bradycardia associated with the chest pains, irregular menstruation, and venous
insufficiency associated with the swelling. I was again referred to a combination of physical
therapy and chiropractic manipulations, a gynecologist, and cardiologist for further examination.
Their findings included another episode of bradycardia, continued irregular menstruation, venous
insufficiency, and eventually indications of mild congestive heart failure confirmed by several
cardiologists. Despite the medication and treatments since the motor vehicle accident, I
continued to experience severe pain in my back, anxiety, and serious cardiac implications that
are still persisting for well over a year since the accident.

SETTLEMENT and/or DEMAND:

My expenses for the hospital services were: $18,734.05. I have obtained recovery services
including physical therapy, chiropractic manipulations, and primary care follow-ups at $2,422.44.
The MRI and ultrasound examinations at Imaging Healthcare Specialists were $3,224.19. The
echocardiogram at Cardiovascular Institute of San Diego was $950. I have incurred $350 in
medication and supplies. The total is $25,677.49. As of 3/21/2023, Root Insurance Co. has paid a
total of $4,597.05 as a medical payment on 1/26/2022. Therefore, alongside the hard costs of my
current outstanding medical bills at: $21,080.44, without seeking additional
treatments/examinations, I am willing to settle my case with you, Root Insurance Co. as provider
of bodily injury protection and/or uninsured protection to motorists AISHA NOUR and Mohamed
Ainab, when you pay my medical remaining bills of $20,130.44, and an additional pain and
suffering, mental anguish/emotional distress, and lost opportunity/wages of $23,919.56. The total I
am willing to close my claim comes to $45,000.
Before this accident, I led a very healthy and active lifestyle. Despite this, I have been assured I
will never fully recover to 100% from this accident. This accident had a direct and negative
impact on many aspects of my life; I have been unable to complete many of my usual obligations
at home and had to miss a substantial amount of work. I cannot take part in the same recreational
or fitness activities I used to enjoy. I was completely blind-sided by this accident, and it has
taken a severe toll on the quality of my life and disrupted it immensely. The permanent nature of
some of these injuries has altered the way I walk, sleep, and conduct many other normal
activities. I still have pain, discomfort, and anxiety throughout many days and trouble sleeping at
night. I believe the $45,000 value is less than I deserve but given the coverage allotments on my
policy: DDPH68 of $50,000 under Bodily Injury coverage and uninsured motorist liability as
well. I am willing to settle for this amount. Furthermore, I believe the $45,000 value should be
easily recovered from the responsible party, The Rapid public transit.
I am well-aware of the risk I am taking in settling this claim, however as the deadline to file a
lawsuit in my preferred state is approaching, I am willing to settle this claim as-is; if it is done in
a timely fashion. After consulting with a personal injury attorney, I am adamant what I am
asking is very fair and given the circumstances, cost effective for Root Insurance Co. I demand
payment of $45,000 to completely settle this claim, I will not try to collect any other dues
including, but not limited to, any treatments and/or examinations. However, I reserve all
rights I am afforded before, during, and after this settlement procedure. As such, I will be
seeking the maximum fair compensation for this claim should I decide to file suit with the aid of
an attorney and all the supporting documentation, pictures, and witnesses I have thus far and
onwards.
Let us close this claim, although I feel it is less than I deserve, I am being extremely reasonable
as I want to settle this claim quickly so that I may move on with my life. I would appreciate a
prompt answer to my demand within seven (7) business days upon receive.

Sincerely,

Aisha Nour
9555 Via Pereza
San Diego, CA 92129
Phone: (415) 214-3353
E-mail: aishanour821@gmail.com
 SUMMARY OF CHARGES

1. Hospital Services: 18,734.05$

i) Grant Medical Center Hospital: 4,597.05$ - PAID
ii) Sharp Memorial Hospital: 14,137$

2. Recovery Services: Primary Care, Physical therapy/Chiropractic manipulations: 2,422.44$

i) Family Health Centers: 2,422.44$

3. Outpatient Services:
i) Imaging Health Services: MRI and Ultrasound 3,224.19$
ii) Cardiovascular Institute of San Diego: Echocardiogram: 950$

4. Medication and Supplies: 350$

5. Pain and suffering/Mental Anguish/Emotional Distress/Lost Opportunity: 23,919.56$

TOTAL: 45,000$
9/27/21, 1:46 PM MyChart - Visit Summary

Name: Aisha Nour | DOB: 7/16/1993 | MRN: 5005300503 | PCP: Physician No

ED Provider Notes
I Smith at 5/01/2021 4:00 PM
Emergency Department Encounter

Patient: Aisha Nour

MRN: 5005300503
DOB: 7/16/1993
ED Provider: Ian Louis Truitt Smith

Chief Complaint
Patient presents with
• Motor Vehicle Crash

Chief Complaint: Motor vehicle crash, neck pain, back pain

History Provider: Patient

Interpreter Used: No

HPI:
Aisha Nour is a very nice 27 y.o. female with notable PMH of breast disorder, mental
disorder, postpartum depression who presents to the emergency department with concern
for motor vehicle crash, neck pain and back pain. Aching pain, located to the upper back
and neck region without numbness, tingling or weakness. Was restrained driver with airbag
deployment after collision with bus traveling at moderate speed. Denies loss of
consciousness or use of blood thinning medication. Denies bleeding, laceration or abrasion.
Symptoms are constant and associated with occasional intermittent nausea and headaches.

History provider unsure of answers to other

"location/quality/alleviating/exacerbating/associated symptoms/setting/timing/severity"
questions aside from those above, and denies other concerns.

ROS (in addition to HPI):

Constitutional: denies fever.
Endocrine: denies weight loss.
Neurological: denies seizure.
Eyes: denies eye pain.
Cardiovascular: denies chest pain, syncope.
Respiratory: denies dyspnea.
Gastrointestinal: denies vomiting, change in bowel function.
Genitourinary: denies abdominal pain, change in bladder function.
Integumentary: denies rashes.
Psychiatric: denies suicidal ideation.

Past History:
Past Medical History:
Diagnosis Date
• Breast disorder
• Mental disorder
anxiety & depression- takes welbutrin
• Postpartum depression

History reviewed. No pertinent surgical history.

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9/27/21, 1:46 PM MyChart - Visit Summary
Social History

Socioeconomic History
• Marital status: Single
Spouse name: Not on file
• Number of children: Not on file
• Years of education: Not on file
• Highest education level: Not on file
Occupational History
• Not on file
Social Needs
• Financial resource strain: Not on file
• Food insecurity
Worry: Not on file
Inability: Not on file
• Transportation needs
Medical: Not on file
Non-medical: Not on file
Tobacco Use
• Smoking status: Never Smoker
• Smokeless tobacco: Never Used
Substance and Sexual Activity
• Alcohol use: Not Currently
• Drug use: Not Currently
Comment: has used marijuana in past
• Sexual activity: Yes
Partners: Male
Lifestyle
• Physical activity
Days per week: Not on file
Minutes per session: Not on file
• Stress: Not on file
Relationships
• Social connections
Talks on phone: Not on file
Gets together: Not on file
Attends religious Not on file
service:
Active member of club Not on file
or organization:
Attends meetings of Not on file
clubs or organizations:
Relationship status: Not on file
Other Topics Concern
• Not on file
Social History Narrative
• Not on file

Medications/Allergies:
No current facility-administered medications for this encounter.

Current Outpatient Medications:

• buPROPion (WELLBUTRIN) 100 MG tablet, Take 300 mg by mouth every morning ., Disp:
, Rfl:
• buPROPion (WELLBUTRIN) 100 MG tablet, Take 150 mg by mouth at bedtime ., Disp: ,
Rfl:
• ondansetron (ZOFRAN-ODT) 4 MG disintegrating tablet, Dissolve 1 (one) tablet (4 mg
total) on top of tongue every 8 (eight) hours as needed for nausea ., Disp: 3 tablet, Rfl: 0
No Known Allergies

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9/27/21, 1:46 PM MyChart - Visit Summary
Physical Exam:
BP (!) 115/95 (BP Location: Right arm, Patient Position: Sitting) | Pulse 90 | Temp 98.6 °F
(37 °C) (Oral) | Resp 16 | Ht 5' 2" | Wt 59 kg (130 lb) | SpO2 99% | BMI 23.78 kg/m²
VITALS: Reviewed, blood pressure 115/95.
GEN: Nontoxic, speaking full sentences.
HEENT: NC, MMM, no trismus. No evidence of CSF otorrhea, rhinorrhea, Battle sign,
raccoon eyes.
NECK: Supple, no JVD. Mild tenderness midline.
CARDIO: Normal S1/S2, no murmurs. Symmetric, 2+ radial and PT pulses.
RESP: Normal effort, CTAB with adequate airflow; no crepitus/wheezes/crackles/stridor.
ABDOMEN: Soft; warm; no tenderness/distension/guarding/rebound/rigidity/pain out of
proportion/crepitus; normoactive bowel sounds; no hepatosplenomegaly/palpable
masses/pulsatile masses/Murphy's sign/tenderness at McBurney's point.
BACK: Nontender midline, no stepoffs/CVA tenderness/tenderness elsewhere.
NEURO: GCS 15.
Mental status: Normal.
Cranial nerves: CN II-XII intact, no nystagmus or dysarthria.
Cerebellar function: Intact to finger-to-nose bilaterally, no dysdiadochokinesia or truncal
ataxia.
Motor: 5/5 strength to SAb/SAd/EF/EE/WF/WE/HI in BUE.
5/5 strength to HF/HE/KF/KE/DF/PF/EHL in BLE.
No clonus.
Reflexes: Negative Hoffman's in BUE. 2+ Achilles reflex in BLE.
Sensation: SILT/temperature x3 in BUE, SILT/temperature x5 in BLE.
Gait: Normal.
MSK: Extremities nontender, no edema. Compartments are soft/compressible.
SKIN: Normal color, no rash.
PSYCH: Normal affect, no suicidal ideation.

Diagnostics:
XR Thoracic Spine 3 Views (Standard)
Final Result

No acute abnormality of the thoracic spine

Workstation ID: RADX-GMC-05

CT Cervical Spine Without Contrast

Final Result

1. No acute intracranial abnormality.

2. No acute traumatic abnormality involving the
cervical spine.

Workstation ID: RADX-GMC-06

CT Head Or Brain Without Contrast

Final Result

1. No acute intracranial abnormality.

2. No acute traumatic abnormality involving the
cervical spine.

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9/27/21, 1:46 PM MyChart - Visit Summary

Workstation ID: RADX-GMC-06

ED Course and MDM:

In brief, Aisha Nour is a wonderfully pleasant 27 y.o. female with pertinent PMH of breast
disorder, mental disorder, postpartum depression who presented to the emergency
department with concern for injuries after motor vehicle crash. Head CT obtained given
concern for severe mechanism of injury motor vehicle collision. Well-appearing and
nontoxic, feels potential benefits of CT scan outweigh the potential risks after extensive
discussion, imaging negative, discharged with outpatient follow-up and brain rest.

Patient is nontoxic in appearance and will be discharged in stable condition with instructions
for follow up. All results of medical workup were discussed with the patient. Patient
verbalized comprehensive understanding of treatment plan. Instructed patient to avoid
driving until being cleared by primary physician and never while under the influence of any
prescribed medications from an emergency department (unless cleared to do so by primary
physician).

Further advised to avoid any physical exertion or potentially dangerous activities (including
but not limited to running, swimming, climbing; crossing the street alone) until being re-
evaluated by primary physician. Patient instructed about possible medication side effects.

Discharge information provided in writing with additional verbal instructions; advised to read
all of the discharge instructions prior to leaving the ED so any additional questions could be
answered; all of the patient's questions were answered in layman's terms and there were no
further questions at time of discharge. Advised to have blood pressure monitored and
checked by primary physician.

Patient instructed to return to the ED immediately for any new, worsening, or otherwise
concerning symptoms, or if unable to be re-evaluated as indicated on the provided
discharge instructions.

The patient was evaluated during the global COVID-19 pandemic, and that diagnosis was
considered upon their initial presentation. Their evaluation, treatment, and testing was
consistent with current guidelines for patients who present with complaints or symptoms that
may be related or unrelated to COVID-19. Patient wore a surgical mask and this author wore
appropriate PPE during evaluation.

Decisions made amidst global COVID-19 pandemic. Author of this note does not currently
have symptoms of a viral process. In addition to the above, an extensive differential
diagnosis for the patient's symptoms was considered and emergent conditions that were
considered but felt to be sufficiently clinically unlikely were not further pursued. I advised the
patient to have PCP obtain records from today's visit as soon as possible to ensure potential
incidental findings are addressed and to further coordinate care once out of the hospital.
Nursing notes were reviewed.

Medications Ordered/Given During ED Visit:

Medications
acetaminophen (TYLENOL) tablet 975 mg (975 mg
Oral Given 5/01/21 1439)

Final Impression
1. Motor vehicle collision, initial encounter
2. Closed head injury, initial encounter

Ian Louis Truitt Smith, MD

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9/27/21, 1:46 PM MyChart - Visit Summary
05/01/21 1615

ED Triage Notes
Nurse Krista F at 5/01/2021 1:37 PM
Pt presents to NAED with c/o being involved in MVA on Thursday. Pt was a restrained driver
with airbag deployment who today is c/o neck pain and generalized body aches. Pt has not
taken anything for pain today. Pt with unlabored respirations. Pt with stable vitals. Pt
denies LOC. Pt states she is concerned for risk of concussion. Pt with steady gait into ED.

MyChart® licensed from Epic Systems Corporation © 1999 - 2021

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 Sharp Memorial Hospital
7901 Frost Street
San Diego, CA 92123-

Patient: NOUR, AISHA Location: Emergency Department

SHC#: 117-328-306 MRN# 01-38-12-07 Room: Admit: 05/06/2021
FIN: 44872061 Bed: Disch: 05/06/2021
DOB/Age/Sex: 07/16/1993 27 years Female Attending: Bowman MD,Ariel J

Emergency Documentation
Document Name: ED Note
Document Status: Auth (Verified)
Electronically Signed By: Lawrence MD,Cade T (05/06/2021 14:49 PST)
Authenticated By: Lawrence MD,Cade T (05/06/2021 14:49 PST)

Patient: NOUR, AISHA SHC: 117-328-306 MRN: 01-38-12-07 FIN: 44872061

Age: 27 Years Gender: Female DOB: 07/16/1993
Author: Lawrence MD, Cade T
Date/Time:
05/06/2021 03:47

Time of my initial contact with patient:

4 AM
Mode of Arrival:
POV/Walk-in
Triage Narrative:
pt presents to ED CC left lower back pain radiating down left leg increasing in severity over past 3-4 days s/p MVA on 4/29. pt CO HA
behind her eyes when she bends over. PERRLA. CP to palpation at site of seatbelt. pt restrained driver struck from side. Previously
seen at ED on 5/1 for MVA. Stable on RA NAD. AAOx4. ambulatory independently steady gait.
Entered by: Elliott , Angellee at 05/06/2021 03:40

Chief Complaint:
Back pain, MVA
History of Present Illness:
This is a 27-year-old female who reports no chronic medical issues who presents with a chief complaint of lower back pain which radiates
down the left leg, ongoing for the past few days. The patient states that her symptoms started after she was involved in a motor vehicle
accident. She was seen at an emergency department at the time and evaluated with CT scans of her head and cerfical spine, she was
then discharged following this workup. The patient states that the back pain has gotten more severe since then. On my physical exam the
patient has no evidence of acute neurologic compromise, no saddle anesthesia is noted. She states that the pain is a 7 out of 10. She also
reports persistent headache and a 5 out of 10.
Problem List & Past Medical/Surgical History:
None

Family History:
Noncontributory
Social History:
Denies alcohol or drug use
Allergies:
NKA

___________________________________________________________________________________________________
Request ID: 189074474 Page 1 of 9 12/20/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 05/06/2021
FIN: 44872061 Disch: 05/06/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Emergency Documentation

Medications:
Available Med List Reviewed
Review of Systems:
All other systems reviewed and are negative except per HPI
Physical Exam:
Vital Signs
BP: 132/82 mmHg Temp (Oral): 36.4 DegC ( 97.5 DegF) HR: 50 bpm Resp: 18 br/min SpO2: 100 %
Vitals reviewed and notable for stable vital signs
GENERAL: no apparent distress, able to communicate clearly
HEAD: normocephalic, atraumatic
EYES: PERRLA, EOMI
ENT: no pharyngeal erythema or exudate noted, membranes intact
CV: RRR, intact peripheral perfusion
RESP: CTAP, no wheezes noted, no respiratory distress
CHEST WALL: non-tender, no deformity
ABD: ND, NT
MSK: Intact ROM with no deformity appreciated
SKIN: no rash or lesion appreciated
PSYCH: Normal mood and affect
NEURO: No focal deficit appreciated, alert and oriented x 4

Test Results:
Labs Results
05/06/21 04:50

142 104 11
103
3.7 25 0.5

05/26/21 04:50

13.3
5.2 161
38.3

05/06/21 04:50

WBC 5.2
HGB 13.3
HCT 38.3
PLT 161
MCV 93
RBC 4.14
MCH 32
MCHC 34.6
RDW 14.0
MPV 9.5
Neutrophils 39 L
Lymphocytes 40

___________________________________________________________________________________________________
Request ID: 189074474 Page 2 of 9 12/10/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 05/06/2021
FIN: 44872061 Disch: 05/06/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Emergency Documentation
Monocytes 12
Eosinophils 7
Basophils 1
Neut Absolute 2.0
Lymph Absolute 2.1
Mono Absolute 0.6
Eos Absolute 0.4
Baso Absolute 0.0
CKMB 2.3
Troponin-T <0.03
Magnesium Lvl 1.9
eGFR Black >60
eGFR Non-Black >60
Anion Gap 13 H
Sodium Lvl 142
Potassium Lvl 3.7
Chloride 104
CO2 25
Glucose Lvl 103
BUN 11
Creatinine 0.5
Alk Phos 98
Calcium Lvl 8.8
ALT 17
AST 17
Bili Total 0.3
Total Protein 7.0
Albumin Lvl 3.9
PT 11.9
INR 1.1
hCG Quant <5

Diagnostic Results
Imaging Studies Reviewed
XR Spine Lumbar 2-3 Views
Performed By/Author: Kruk MD, Peter on 06 MAY 2021 08:20 PDT
IMPRESSION:
No acute abnormality.
XR Chest 1 View
Performed By/Author: Kruk MD, Peter on 06 MAY 2021 08:19 PDT
IMPRESSION:
1. No acute abnormality.
EKG Results
Bradycardia with a rate of 43 bpm. No ST elevations are noted. Slight first-degree block. Abnormal EKG

Emergency Department Course and Procedures:

Other Orders
Communication Order(Old Chart/Old ECG if available.)
Nursing to Initiate Saline lock Insertion Careset
Oximetry Assessment(On Room Air)

___________________________________________________________________________________________________
Request ID: 189074474 Page 3 of 9 12/10/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 05/06/2021
FIN: 44872061 Disch: 05/06/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Emergency Documentation
Oxygen Therapy

Medical Decision Making:

This is a 27-year-old female with no chronic medical issues presenting with a chief complaint of left lower back pain which radiates down the
left leg ongoing ever since a car accident 3 weeks ago. She also reports persistent headache, she has had CT scans of the head and
cervical spine completed on a prior visit that were negative. Workup was initiated this time with laboratory studies which were normal and a
chest x-ray and x-ray of the lumbar spine which revealed no acute disease. I believe the patient can safely be discharged home as she has
no neurologic compromise at this time. She is instructed to follow-up with her primary care provider and obtain an outpatient MRI should
her symptoms continue.

Of note, the patient was somewhat bradycardic during her time in the ER, an EKG was obtained which revealed no evidence of acute
disease. Blood pressure has remained normal.

The patient is discharged from the emergency department with instructions to contact their primary care provider to set up outpatient
follow-up as soon as possible. Strict return precautions, including any new or concerning symptoms, or worsening of current symptoms, are
provided. The patient understands this plan. Questions regarding prescription medications or nonprescription treatment have been
addressed.
Impression:
Lumbosacral strain with radicular pain
Plan:
Discharge
Follow Up
Please follow up with your primary care provider within the next couple of days for a repeat exam Within: 1-2 days
Please return to the emergency department if you develop any new or concerning symptoms following discharge Within: As needed
Patient Education
Radicular Pain
Lumbosacral Strain
Bradycardia
Discharge Meds
cyclobenzaprine 10 mg 1 tab, PO, TID, 15 tab
naproxen 500 mg 1 tab, PO, BID, 20 tab

Referral for suspected pre-hypertension or hypertension was given.

Please note: Unless specifically stated, all procedures mentioned, tests done and medications given were performed/interpreted by the
emergency physician, or were under the direct supervision of the emergency physician.
This ED Note was completed using voice-recognition transcription and may contain inadvertent errors.

___________________________________________________________________________________________________
Request ID: 189074474 Page 4 of 9 12/10/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 05/06/2021
FIN: 44872061 Disch: 05/06/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Hematology

Collected Date 05/06/2021

Collected Time 04:50 PDT
Procedure Reference Range Units
WBC 5.2 [4.5-11.0] K/mcL
HGB 13.3 [12.0-16.0] g/dL
HCT 38.3 [35.0-47.0] %
PLT 161 [140-400] K/mcL
MCV 93 [80-100] fL
RBC 4.14 [4.00-5.20] M/mcL
MCH 32 [26-34] pg
MCHC 34.6 [32.0-36.0] g/dL
RDW 14.0 [11.5-14.5] %
MPV 9.5 [7.5-11.2] fL
Neutrophils 39 L [44-77] %
Lymphocytes 40 [16-44] %
Monocytes 12 [5-13] %
Eosinophils 7 [0-8] %
Basophils 1 [0-3] %
Neut Absolute 2.0 [1.8-7.8] K/mcL
Lymph Absolute 2.1 [1.0-3.5] K/mcL
Mono Absolute 0.6 [0.3-1.0] K/mcL
Eos Absolute 0.4 [0.0-0.5] K/mcL
Baso Absolute 0.0 [0.0-0.1] K/mcL

Cardiac Studies

Collected Date 05/06/2021

Collected Time 04:50 PDT
Procedure Reference Range Units
Troponin-T <0.03 ^1 [<=0.02] ng/mL
CKMB 2.3 [0.9-2.9] ng/mL
Interpretive Data
^1: Troponin-T
0.03 – 0.10 Suggestive of myocardial necrosis
> 0.10 Indicative of myocardial necrosis

Chemistry

Collected Date 05/06/2021

Collected Time 04:50 PDT
Procedure Reference Range Units
Glucose Lvl 103 [70-109] mg/dL

___________________________________________________________________________________________________
Request ID: 189074474 Page 5 of 9 12/10/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 05/06/2021
FIN: 44872061 Disch: 05/06/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Chemistry

Collected Date 05/06/2021

Collected Time 04:50 PDT
Procedure Reference Range Units
Sodium Lvl 142 [136-145] mmol/L
Potassium Lvl 3.7 [3.4-5.0] mmol/L
Chloride 104 [98-108] mmol/L
CO2 25 [20-31] mmol/L
Anion Gap 13 H [3-11] mmol/L
BUN 11 [5-22] mg/dL
Creatinine 0.5 [0.5-1.3] mg/dL
eGFR Black >60 [>=60] mL/min
eGFR Non-Black >60 ^2 [>=60] mL/min
Calcium Lvl 8.8 [8.4-10.2] mg/dL
Alk Phos 98 [35-129] unit/L
ALT 17 [9-52] unit/L
AST 17 [0-34] unit/L
Bili Total 0.3 [0.0-1.2] mg/dL
Total Protein 7.0 [6.6-8.7] g/dL
Albumin Lvl 3.9 [3.5-5.0] g/dL
Magnesium Lvl 1.9 [1.4-2.3] mg/dL
Interpretive Data
^2: eGFR Non-Black
e GFR Reference Ranges

eGFR Values Description

(mL/min/1.73m2)
Above 60 Normal GFR
30-59 Mild to moderate Kidney damage
15-29 Severe kidney damage
Below 15 Kidney failure

eGFR Calculation and Classification Reference: Annals of Internal Medicine

145(4):247-54, 2006

Coagulation

Collected Date 05/06/2021

Collected Time 04:50 PDT
Procedure Reference Range Units
PT 11.9 [10.2-12.9] sec
INR 1.1 ^3 [0.8-1.2]
Interpretive Data
^3: INR
DIAGNOSIS TARGET INR RANGE

___________________________________________________________________________________________________
Request ID: 189074474 Page 6 of 9 12/10/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 05/06/2021
FIN: 44872061 Disch: 05/06/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Coagulation
Interpretive Data
^3: INR
Venous Thrombosis and/or Pulmonary Embolism 2.5 2.0-3.0
Prophylaxis with MI or Atrial Fibrillation
and most other indications
High risk patients with Mechanical Heart valves 3.0 2.5-3.5
or systemic Arterial Embolism

VALVE REPLACEMENT/MECHANICAL
Aortic: bileaflet in NSR with normal LA size 2.5 2.0-3.0
Medronic Hall tilting disk in NSR
with normal LA size 2.5 2.0-3.0
following prosthetic valve thrombosis 3.5 3.0-4.0
Mitral: bileaflet or tilting disk 3.0 2.5-3.5
following prosthetic valve thrombosis 4.0 3.5-4.5
Caged ball or caged disk (aortic or mitral) 3.0 2.5-3.5
With additional risk factors for thromboembolism 3.0 2.5-3.5
[AF, MI, LA enlargement, hypercoagulable condition, low EF]
With systemic embolism despite adequate anticoagulation-Increase INR goal

Reference: Chest 2012; 141 (2_supp).

Additional recommendations: “Antithrombotic and Thrombolytic Therapy: ACCP
Evidence based Clinical Practice Guidelines, 9th ed, 2012”
SHC Pharmacy website on optimal therapeutic ranges:
http://sharpnet.sharp.com/pharmacy/upload/102012-UW-Warfarn-INR- recs__rec_chronic_antithromb_tx.pdf

Pregnancy / Maternal / Fetal

Collected Date 05/06/2021 05/06/2021

Collected Time 05:31 PDT 04:50 PDT
Procedure Reference Range Units
hCG Quant - <5 ^4 [0-4] mIntl_unit/mL
U hCG Qual POC Negative -
Interpretive Data
^4: hCG Quant
Healthy non pregnant females: (less than) <5 mIU/mL.
Healthy peri or post menopausal females: (less than) <10 mIU/mL.
The expected hCG values at a corresponding gestational age are: (mIU/mL)

3 - 4 weeks 9 - 130
4 - 5 weeks 75 - 2,600
5 - 6 weeks 850 - 20,800
6 - 7 weeks 4,000 - 100,200
7 - 12 weeks 11,500 - 289,000
12 - 16 weeks 18,300 - 137,000
16 - 29 weeks 1,400 - 53,000 (2nd trim)
29 - 41 weeks 940 - 60,000 (3rd trim)

***This assay should not be used to diagnose any condition

unrelated to pregnancy. "Beta hCG TumorMarker" should
___________________________________________________________________________________________________
Request ID: 189074474 Page 7 of 9 12/10/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 05/06/2021
FIN: 44872061 Disch: 05/06/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Pregnancy / Maternal / Fetal

Interpretive Data
^4: hCG Quant
be used for other conditions.***

Diagnostic Radiology
ACCESSION PROCEDURE EXAM DATE/TIME ORDERING PROVIDER
02-17-306-000921 XR Spine Lumbar 2-3 Views 05/06/2021 06:26 PDT Lawrence MD,Cade T

Reason For Exam

(XR Spine Lumbar 2-3 Views) _Lower back injury, nonacute;_Lower back injury, nonacute

Interpretation
EXAMINATION: XR Spine Lumbar 2-3 Views

HISTORY: _Lower back injury, nonacute

COMPARISON:

FINDINGS:
There is no evidence for fracture or other acute osseous abnormality. Again noted is L5-S1 is of concern for possible
indication of disc herniation. Alignment is within normal limits.

IMPRESSION:
No acute abnormality.

This exam was performed at: Sharp Memorial Hospital

*****Final*****

Dictated by: Kruk MD, Peter

Signed (Electronic Signature): 05/06/2021 8:20 am

Signed by: Kruk MD, Peter

-----------------------------------------------------

ACCESSION PROCEDURE EXAM DATE/TIME ORDERING PROVIDER

02-17-306-000947 XR Chest 1 View 05/06/2021 06:25 PDT Lawrence MD,Cade T

Reason For Exam

(XR Chest 1 View) Chest pain;Chest pain

Interpretation
EXAMINATION: XR Chest 1 View

HISTORY: Chest pain

___________________________________________________________________________________________________
Request ID: 189074474 Page 8 of 9 12/10/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
NOUR,AI SHA SHARPMEMORI ALHOSPI
TAL
Jul16,1993 XRSpineLumbar2-3Views
ID:104053156 StudyI
D:0217306000921
Female Ac.Nb:0217306000921
27Years Acq.
:May6,2021
Acq.:6:
26:
10AM

Frame:[4]2/2
Zoom:44%
Window/Level:2,
087/5,345 SeriesNb:6938
Pi
xel:Novalue-Out si
dei mage Lat
erali
ty:U
DX( 1063x2000) Lumbar -spi
ne

NOUR,AI SHA SHARPMEMORI ALHOSPI

TAL
Jul16,1993 XRSpineLumbar2-3Views
ID:104053156 StudyI
D:0217306000921
Female Ac.Nb:0217306000921
27Years Acq.
:May6,2021
Acq.
:6:26:
42AM

Frame:[1]1/2
Zoom:45. 15%
Window/Level:1,
914/5,583 SeriesNb:6938
Pi
xel:Noval ue-Outsi
dei mage Lat
erali
ty:U
DX( 1176x1932) Lumbar -spi
ne
 HILLCREST FHC

4094 4th Ave AISHA NOUR

San Diego CA 92103 9555 VIA PEREZA
SAN DIEGO, CA 92129

Tax Id : 95-2833205
MR#: 1021322 NAME: NOUR, AISHA DOB: 07/16/1993
Date Description Unit Charges
05/16/2021 99201 OFFICE/FOCUSED, NEW 1 $100.00
05/16/2021 87591 N GONORRHOEAE, DNA, AMP PROB 1 $50.00
05/16/2021 87491 CHYLMD TRACH, DNA, AMP PROBE 1 $50.00
05/16/2021 87389 HIV 1/0/2 AG/AB PANEL 1 $42.94
05/16/2021 86592 BLOOD SEROLOGY, QUALITATIVE 1 $8.73
05/16/2021 81025 URINE PREGNANCY TEST 1 $11.28
05/16/2021 80061 LIPID PANEL 1 $27.41
05/16/2021 80050 GENERAL HEALTH PANEL 1 $25.00
05/16/2021 36415 ROUTINE VENIPUNCTURE 1 $15.00
06/01/2021 99395 PREV VISIT. EST, AGE 18-39 1 $150.00
06/01/2021 99000 SPECIMEN HANDLING 1 $15.00
06/07/2021 99201 OFFICE/FOCUSED, NEW 1 $100.00
06/07/2021 97161 PHYS THERAPY EVAL, LOW COMPLEXITY 1 $85.00
06/08/2021 97110 THERAPEUTIC EXERCISES-INT 15 MI 1 $70.00
06/08/2021 97140 PHY THER MANUAL ONE AREA-INT 15 MI 1 $60.00
06/15/2021 97110 THERAPEUTIC EXERCISES-INT 15 MI 1 $70.00
06/15/2021 97140 PHY THER MANUAL ONE AREA-INT 15 MI 1 $60.00
06/16/2021 97110 THERAPEUTIC EXERCISES-INT 15 MI 1 $70.00
06/16/2021 97140 PHY THER MANUAL ONE AREA-INT 15 MI 1 $60.00
06/21/2021 97110 THERAPEUTIC EXERCISES-INT 15 MI 1 $70.00
06/21/2021 97140 PHY THER MANUAL ONE AREA-INT 15 MI 1 $60.00
06/24/2021 97110 THERAPEUTIC EXERCISES-INT 15 MI 1 $70.00
06/24/2021 97140 PHY THER MANUAL ONE AREA-INT 15 MI 1 $60.00
06/25/2021 97110 THERAPEUTIC EXERCISES-INT 15 MI 1 $70.00
06/25/2021 97140 PHY THER MANUAL ONE AREA-INT 15 MI 1 $60.00
07/01/2021 99213 OFFICE EXPANDED, EST 1 $150.00
07/19/2021 99395 PREV VISIT, EST, AGE 18-39 1 $155.00
07/19/2021 83036 GLYCOSYLATED HEMOGLOBIN TEST 1 $19.86
07/19/2021 36415 ROUTINE VENIPUNCTURE 1 $15.00
07/23/2021 99213 OFFICE EXPANDED. EST 1 $155.00
07/23/2021 98941 CHIRO MANIPULATIVE TREAT (CMT); 3-4 1 $60.00
07/26/2021 99214 OFFICE DETAILED, EST 1 $170.00
07/26/2021 93000 ELECTROCARDIOGRAM, COMPLETE 1 $65.00
08/16/2021 98941 CHIRO MANIPULATIVE TREAT (CMT); 3-4 1 $60.00
08/27/2021 98941 CHIRO MANIPULATIVE TREAT (CMT);, 3-4 1 $60.00
01/03/2023 CLINICAL CHARGE TOTAL $2,370.22

1021322 < Account #

Balance Due > $2,370.22

Total Late Charges : $0.00

Payer Payments : $0.00
Total Charges : $2,370.22
Total Received : $0.00
Total Adjustment : $0.00
Balance Due: $2,370.22
 MasterId: 102678144
7444431-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 27YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
HFHC/ADULTS PSR: EVANISEF
Payer: SELF ENC: 7444431
Prov: MOLNAR, ESTHER M PGM:
Printed: 01/03/2023 10:08 AM DOS: 05/16/2021

Chief Complaint:
Follow-up: ER follow-up

Vital Signs:
BP T P R WT HT BMI BW HC

125lbs 0oz 0.00

128 79 98.4 72 16 65.00" 23.3
56.7 Kgs
Other Data/Comments:

Subjective:
27 yo lady from presents for back pain, menstrual irregularities, ER follow up and to establish care.
0
Reports she was recently involved in a motor vehicle accident on 04/29/21

was hit by bus

Reports she has intense low back pain, LOC, did not hit head. After MV A had vomiting and headache,
neckpain and back pain, torso pain. Next day after MVA woke up with headache, she couldn't sleep. Went to
ER. ER did CT head- was told it was negative and was discharged home.

Went to ER second time with chest, abdomen, and back pain. Underwent more imaging, with no acute findings.
Also reported abnormal vaginal spotting and bleeding lasting 10+ days

Patient reports low back pain 7/10. More pain in left side and left leg. Pain and numbness go down left leg-
especially when sitting in car. Shooting "like electricity" going down left leg. no similar symptoms in right leg.
Feels back pain is most worrisome. Neck is getting better now. HA resolving. No emesis this week. Trouble
sleeping.

Also reports abdomen pain. Period not regular. Menses care more sporadic, periods short, sometimes 3 months
go by between periods. Reports pain in lower abdomen. Occasional vaginal discharge. no sexual intercourse x
ROS: no diarrhea, no constipation, no dysuria. +GERD history, no burning pain now. no fevers, no weight loss +
weight gain.

Family History:unsure of medical history no FH diabetes

OB/Gyn History:none
Social History:tobacco: never ETOH: never drugs: never
Surgical History:none

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 5

Objective:
Temp 98.4; BP 128/79; HR 72; RR 16; BMI 23.28

Gen: NAD, awake, alert

HEENT: MMM, no scleral icterus, EOMI, PERRL
LYMPH: no cervical or supraclavicular lymphadenopathy
Chest: CTAB, no tachypnea
CV: RRR no murmurs nl S1S2
Ab: +BS soft ND slightly tender in RLQ and epigastric area with no rebound/guarding
Ext: neck ROM intact. + tenderness to palpation of low back, paraspinal area of left back. + straight leg test on
left . + slightly tender left hip to palpation.
Skin: no rashes on exposed skin. no jaundice.
Neuro: CN 2-12 grossly intact

Psych: normal affect

Assessment/Plan:

• Hospital Follow-up - V679[I10: Z09] . Reviewed records from Sharp. lumbar xray with DJD of L5 and S1 with no acute
abnormality. Borderline Broncho vascular marking on CXR, CT scan head and neck on written note from ER on 5/6 states negative
studies.

• Neck pain (finding) - 7231[I10: M54.2] . Resolving. CT of neck in ER negative for acute problem. Continue to monitor
resolution of pain.
• Sciatica (disorder) - 7243[I10: M54.30] . Reviewed lumbar xray from ER. Recommend naproxen BID. Recommend PT,
chiropractor.
• Patient Education : Back Pain PT - Eng

• Patient Education : Basic Core Program for Lower Back Pain PT - Eng

• Patient Education : Back Pain - English

• Concussion with no loss of consciousness (disorder) - 8500[I10: S06.0X0A] . Improving headaches. No more emesis.
Concussion precautions given to patient.
• Abnormal menstrual cycle (finding) - 6269[I10: N92.6] . Recommend WWE. Will order TSH, urine HCG, urine GC/CT.
• Abdominal pain (finding) - 78900[I10: R10.9] . Will assess with CMP, CBC, urine GC/CT. . WWE next week.
• Hip pain (finding) - 71945[I10: M25.559] . Eval for OA with hip xray.
• Imaging : X-Ray-73510 : HIP UNILATERAL COMPLETE ]Left}
(VERIFY AUTH REQUIREMENT ) Consult,

Coding Addendum :

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 5

 · Diagnosis Coded for this visit
o M542 - Cervicalgia
o M5432 - Sciatica, Left Side
o Z113 - Encounter For Screening For Infections With A Predominantly Sexual Mode Of
Transmission
o Z114 - Encounter For Screening For Human Immunodeficiency Virus [Hiv]
o Z13220 - Encounter For Screening For Lipoid Disorders
o N926 - Irregular Menstruation, Unspecified
o R109 - Unspecified Abdominal Pain
o S060X0D - Concussion Without Loss Of Consciousness, Subsequent Encounter
o M25552 - Pain In Left Hip
o Z3202 - Encounter For Pregnancy Test, Result Negative
· Procedures Coded for this visit
o 81025 - urine pregnancy test
o 87389 - hiv 1/o/2 ag/ab panel
o 86592 - blood serology, qualitative
o 80061 - lipid panel
o 87591 - n.gonorrhoeae, dna, amp prob
o 87491 - chylmd trach, dna, amp probe
o 99201 - office/focused, new
o 80050 - general health panel
o 36415 - routine venipuncture

Acive Problem List (Diagnosis)

Problem List

Abdominal pain (finding)

Abnormal menstrual cycle (finding)
Hip pain (finding)
On examination - general observation (finding)
Sciatica (disorder)
Screening of lipid level (finding)
Viral Screening

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 3 of 5

Acute Diagnoses
78900 Abdominal pain (finding)
Labs COMP. METABOLIC PANEL (17) w/ GFR (Architect) - Fasting: No, Scheduled
Draw Date: 05/16/2021
Labs CBC w/ AutoDiff (Sysmex) - Fasting: No, Scheduled Draw Date: 05/16/2021
6269 Abnormal menstrual cycle (finding)
Labs GONORRHEA/CHLAMYDIA AMPLIFIED DNA, URINE - Fasting: No, Scheduled
Draw Date: 05/16/2021, Draw Location: HILLCREST FHC
Labs GONORRHEA/CHLAMYDIA AMPLIFIED DNA, URINE - Fasting: No, Scheduled
Draw Date: 05/16/2021, Draw Location: HILLCREST FHC-ANNEX
Labs Pregnancy Test - Urine (Waived) - Fasting: No, Scheduled Draw Date: 05/16/2021,
STAT
Labs THYROID-STIMULATING HORMONE (Architect) - Fasting: No, Scheduled Draw
Date: 05/16/2021
71945 Hip pain (finding)
Imaging [IHS RADIOLOGY MEDICAL GROUP INC. WASHINGTON ST.], Services
Ordered: X-Ray, Other Service(s): 73510 Reason:DX; Hip pain; imaging to include
weight bearing AP, X-Ray - 73510 : HIP UNILATERAL COMPLETE [Left]
7243 Sciatica (disorder)
Consult Chiropractic , Services Ordered: Consult,EVALUATION,TREATMENT[FHCSD
CHIROPRACTIC ] Reason:Referral for Chiropractic exam and manipulation for this
patient with back pain, recommend 2 visits per month for 3 months
Consult Physical Therapy , Services Ordered: Consult,EVALUATION,TREATMENT[FHCSD
PHYSICAL THERAPY ] Reason:Referred for evaluation and treatment for this
patient with acute low back pain; 2-3 x/week for 6-8 weeks
Medication Naproxen - 500 mg oral (Allow Substitution) MaxDailyDose: 2 tabs Instruction:for
pain. Avoid long term use
SIG:Take orally 1 every 12 hours
(As Needed) for pain. Avoid long term use Not to exceed 2 tabs daily
V7791 Screening of lipid level (finding)
Labs LIPID PANEL w/ DIRECT LDL (Architect) - Fasting: No, Scheduled Draw Date:
05/16/2021
V7389 Viral Screening
Labs HIV 1/2 AG/AB COMBO (GW-AR), RFX CONF (Q); RPR (GW), RFX TPA -
Fasting: No, Scheduled Draw Date: 05/16/2021
Other Orders
No Diagnosis
Nursing
Code
Nursing Chief Complaint [Completed]
Nursing Allergy [Completed]
Nursing Vitals [Completed]
Nursing Patient Additional Info [Completed]

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 4 of 5

 Nursing Immunization Review [Completed]
Patient Back Pain PT - Eng
Education
Patient Basic Core Program for Lower Back Pain PT - Eng
Education
Patient Back Pain - English
Education
Follow Up Follow up in next available Week[s] for Well woman exam (WWE) Instruction. It is
important for you to have a regular well woman exam as part of your preventative
care. You are overdue. Es muy importante tener una examen de mujeres
regularmente, y es su tiempo tener una.
Template Consent And Authorization Form - Eng
Template Core Screening
Template Well Woman
Template Sexual Orientation Screening
Template Housing Screening
Template Healthy Literacy
Template Adult Imms

Electronically signed by: Date: 05/16/2021

( ESTHER MOLNAR MD )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 5 of 5

 MasterId: 102678144
7479656-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 27YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
HFHC/ADULTS PSR: EVANISEF
Payer: SELF ENC:
Prov: MOLNAR, ESTHER M PGM:
Printed: 01/03/2023 10:08 AM DOS: 06/01/2021

Chief Complaint:
Follow-up, Lab results review, Well Woman Exam,

Vital Signs:
BP T P R WT HT BMI BW HC

126lbs 0oz 0.00

108 65 98.0 57 16 65.00" 33.5
57.15 Kgs
Other Data/Comments:

Subjective:
27 yo presents for WWE. And follow-up review of lab results from previous visit.

Reports period
usually every 30 days and normal, but latest one has been irregular pt believes this is related to a recent MVC.

LMP 4/20 x5 days, with spotting/bleeding again on 5/4.

ROS: continues to have low back pain. no neck pain.

Family History: unsure of medical history no FH diabetes

OB/Gyn History: none
Social History: tobacco: never ETOH: never drugs: never
Surgical History: none

Objective:
see template

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 3

Assessment/Plan:

Problems addressed this Visit :

• Well Woman Exam - V7231[I10: Z01.419] . Reviewed labs with patient from last visit. Ordered Pap smear and
mammogram.

• Irregular periods (finding) - 6264[I10: N92.6] . Will refer to GYN for evaluation of periods. Has irregular menstrual bleeding,
with bleeding in between periods

Follow up in 12 months re: wwe.

Coding Addendum :

· Diagnosis Coded for this visit

o Z01419 - Encounter For Gynecological Examination (General) (Routine) Without
Abnormal Findings
o Z1239 - Encounter For Other Screening For Malignant Neoplasm Of Breast
o N926 - Irregular Menstruation, Unspecified

· Procedures Coded for this visit

o 99395 - prev visit, est, age 18-39
o 99000 - specimen handling

Acive Problem List (Diagnosis)

Problem List

Irregular menses (finding)

Well Woman Exam

Acute Diagnoses
6264 Irregular periods (finding)
Consult Gynecology , Services Ordered: Consult,HEALTH EDUCATION,WEIGHT
MANAGEMENT[North Park FHC Women's Clinic] Reason:Referral of this female
patient w/ abnormal/irregular menses for further evaluation
V7231 Well Woman Exam

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 3

Other Orders
No Diagnosis
Nursing
Code
Nursing Chief Complaint [Completed]
Nursing Allergy [Completed]
Nursing Patient Additional Info [Completed]
Nursing Immunization Review [Completed]
Nursing Vitals [Completed]
Follow Up Follow up in 12 Month[s] for Recheck
Template Core Screening
Template Well Woman
Template Smoking History
Template Female Medical Exam

Electronically signed by: Date: 06/01/2021

( ESTHER MOLNAR MD )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 3 of 3

 MasterId: 102678144
7492451-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 27YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
HFHC/ADULTS PSR: EVANISEF
Payer: SELF ENC:
Prov: MOLNAR, ESTHER M PGM:
Printed: 01/03/2023 10:08 AM DOS: 06/07/2021

Chief Complaint:

Comments: Eval LBP

Vital Signs:
BP T P R WT HT BMI BW HC

Other Data/Comments:

Subjective:
Please see physical therapy evaluation template for detailed notes pertaining to this encounter.

Family History: unsure of medical history no FH diabetes

OB/Gyn History: none
Social History: tobacco: never ETOH: never drugs: never
Surgical History: none

Objective:
Physical Therapy Evaluation: 97161

Assessment/Plan:

Problems addressed this Visit :

• Back pain (disorder) - 7245[I10: M54.9] .

Coding Addendum :

· Diagnosis Coded for this visit

o M545 - Low Back Pain
· Procedures Coded for this visit
o 97161 - phys therapy eval, low complex

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 2

Addendum By: ELENA HAPKE( Jun 7 2021 2:06PM) FinalizedBy: ESTHER MOLNAR( Jun 8 2021
8:33AM)
Please sign if you concur for certification of plan of care.

Acive Problem List (Diagnosis)

Problem List

Back pain (disorder)

Acute Diagnoses
7245 Nursing
Nursing Chief Complaint [Completed]
Other Orders
No Diagnosis
Template
Code
Template Pt - Spinal

Electronically signed by: Date: 06/07/2021

( ELENA HAPKE PT )

Co Signature: Date: 06/08/2021

( ESTHER MOLNAR MD )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 2

 FAMILY HEALTH CENTERS OF SAN DIEGO
ADULT REHABILITATION SERVICES
Adult Specialty Clinic

Name: Patient ID: DOB: Age:

Aisha Nour 1021322 07/16/1993 27 Yrs

Diagnosis: ICD‐10:
Back pain M54.9
Funding Source:
Referral Source: Internal SELF

Primary Physician: Referring Physician:

There is no Provider/PCP at this moment. To be defined. Molnar, E
Reason for Referral:
LBP
Physical Therapist:
Elena Hapke

Background Information
Patient:
back pain, spinal, lumbar

Surgical:

History of Current Complaint:

Pt is a 27 yo female c/o back pain following MVA about a month ago.
Currently c/o LBP radiating down LLE mostly ant and lat hip, as well as anterior thigh pain.
Numbness/tingling down LLE to toes. Denies recent dizziness, nausea, vomiting. Had dizziness and HAs, as well as nausea following MVA but currently
denies symptoms.

Date of injury/Onset of pain:

Pain Scale ﴾0 ‐ 10﴿: 7 at evaluation 4 best 9 worst

Location and Quality of Pain:
LBP into LLE: numbness/tingling, sharp with certain movements, achy

Difficulty: Sleeping Dressing Grooming Bathing Grocery shopping Reaching overhead

Getting in and out of chair/bed/car Balancing Bending Housework Yard work Going up/down stairs
Lifting/Carrying heavy objects Sitting > 1 hour Standing > 1 hour

Job related activities Walking Other:

Aggravating/Alleviating Factors:
Aggravating: lifting, standing, sleeping, sitting
Alleviating: walking
Have you had prior treatment for this injury/illness?
No Yes

Prior Level of Function ﴾PLOF﴿:

WNL

Diagnostic Testing: ‐‐Select‐‐

Results: Negative
Findings:

MR# : 1021322, Nour, Aisha [07/16/1993] Page 1 of 4

Falls in the past 12 months No

Observation/Inspection/Palpation: WNL
Edema: Tenderness to Palpation:
L/S paraspinals, L piriformis, L QL

Ecchymosis: Other:

Erythema:

Posture Assessment: WNL Sensory Exam: WNL

Sitting: Light Touch:
mod slumped posture

Standing: DTR:

Other:

Special Tests: Spinal All Special Tests Negative Specific Body Part: LUMBAR
Repetitive Movements Assessment: NT Neural Tension Testing: NT
+ unable to assess secondary to increased pain +
‐ ‐

Radicular Pain Pattern: NT Provocative SI Testing: NT

LBP radiating down LLE + ﴾‐﴿ ASIS comp, ﴾‐﴿ ASIS gap, ﴾‐﴿ sacral comp, ﴾‐﴿ post shear +
‐ ‐

Postural Deviation: NT Other:

mod slumped posture + ODI= 24%; ﴾+﴿ L/S distraction
‐

AROM

Motion ROM ﴾deg﴿ Strength ﴾/5﴿

Lumbar Flexion
50% lim

Lumbar Extension
25% lim

R L R/L Lumbar Sidebending 50% lim

MR# : 1021322, Nour, Aisha [07/16/1993] Page 2 of 4

 R L R/L Lumbar Rotation 25% lim

Other:
RLE grossly 4+/5, LLE grossly 4/5

Joint Play: Muscle Tone:

WNL WNL
Limitations Present: Abnormal Tone Present:
unable to assess secondary to increased pain

Balance: Muscle Flexibility:

WNL WNL
Limitations Present: Tightness/Limitations Present:
NT due to time constraint hamstrings, gastroc/soleus, piriformis, QL

Gait:
WNL

Assistive or Adaptive Device: ‐‐Select‐‐

Limitations Present:

Balance Assessment: WNL

Time Up & Go ﴾TUG﴿: 5 Time Sit to Stand Test:

Functional Reach Test: Other:

Summary of Findings
Patient presents to PT with LBP radiating down LLE into toes. Physical exam today is consistent with lumbar radiculopathy. Limited functional capacity
noted secondary to pain/tenderness, decreased back AROM, poor posture, decreased L>R LE strength, and tight mms. Will assess nerve tension as
pain reduces and pt able to get into testing position. Patient will benefit from physical therapy to decrease pain and to improve functional capacity in
an effort to maximize current level of function.

Functional Goals
1. Pt will be independent with HEP in 2 weeks.
2. Pt. will be able to perform daily activities with 3/10 or less back pain in 6 weeks.
3. Pt will be able to perform 20 sit to stand with no more than 3/10 pain in 6 weeks.
4. Pt. will be able to stand > 1 hour with 3/10 or less back pain in 6 weeks.
5. Pt will demonstrate 25% improvement in ODI in 5 weeks.

Treatment Plan Recommendations

Modalities Physical Therapy Treatment 2 x per week for 6 weeks.
Posture Education Physical Therapy Re‐evaluation ‐‐Select‐‐
Range of Motion Physical Therapy is not indicated at this time.
Strengthening Patient to schedule follow up with primary care physician.
Stretching Refer to
Gait Training
Balance Training
Sport‐specific Training
Patient provided with comprehensive home exercise program ﴾HEP﴿.
Home Exercise Program
Other: Patient educated on proper completion of HEP and reported
MR# : 1021322, Nour, Aisha [07/16/1993] Page 3 of 4
understanding. Handout provided with pictures and detailed instruction of
each exercise.

MR# : 1021322, Nour, Aisha [07/16/1993] Page 4 of 4

 MasterId: 102678144
7501623-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 27YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
CHFHC/PHYSICAL THERAPY PSR: CGARCIA
Payer: SELF ENC:
Prov: HAPKE, ELENA PGM:
Printed: 01/03/2023 10:08 AM DOS: 06/08/2021

Chief Complaint:

Comments: tx LBP
Vital Signs:
BP T P R WT HT BMI BW HC

Other Data/Comments:

Subjective:
Patient was seen for physical therapy treatment. Patient reported having pain following eval, but felt much
better yesterday and slept very well last night.

Location: LBP

Family History: unsure of medical history no FH diabetes

OB/Gyn History: none
Social History: tobacco: never ETOH: never drugs: never
Surgical History: none

Objective:
Intervention was provided in the following areas: __ See Exercise Log for details

x Therapeutic Exercises (97110)

__ Range of Motion: - __ PROM __ AAROM __ AROM
x Strengthening: abdominal bracing and supine marching with Stab Cuff, supineclams RTB, glute sets
__ Proprioception
__ Postural training/education
__ Lift training/education
__ Balance
__ Coordination

__ Therapeutic Activities(97530)

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 3

__ Walking
__ Pre-gait ther ex __ Gait Training
__ Running
__ Treadmill
__ Stairs
__ Education __ There ex

x Manual Therapy(97140)
x Joint mobilizations: L/S distraction in hooklying Gr III
__ PNF
__ Manual Stretching

__ Deep Tissue Mobilization/STM(97140)

Area: _______
Time: __ 8 min __ 12 min

__ Application of Heat/Ice(97010)

__ Electrical Stimulation(97014)

__ Ultrasound(97035)

__ Mechanical Traction (97012)

__ Home Program
__ Detailed instruction provided, HEP reviewed with return demonstration noted
__ Written/Electronic information provided for patient to review at home

Assessment/Plan:
Patient is demonstrating:
__ Continued steady progress
__ Minimal or Limited progress due to: _______

Min relief with L/S traction in hooklying. Patient responded very well to Stabilizer Cuff to maintain PPT during
supine marching. Able to progress NV. Difficulty maintaining hip positioning during sidelying clams and
demonstrated hip rolling back. Required frequent tactile cues to correct and to isolate hip abd mms. Increased
pain with LTR and when lying on L side for clams. Modified to supine clams. Will reassess NV.

Recommendations (mark all that apply):

x Continue physical therapy treatment. Frequency recommended on initial evaluation remains appropriate.
__ Current authorization has expired; reauthorization request submitted
__ Discharge from physical therapy due to: _______ .
__ Refer for the following: _____
__ Other: _______

Plan for next visit:

x Continue functional strength and conditioning program in an effort to meet stated goals and to maximize
functional capacity. Review and progress HEP. Progress core and hip strengthening, reassess response to L/S
distraction in hooklying
__ D/C to HEP and return to MD for follow-up care

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 3

Treatment time: 30 min

Problems addressed this Visit :

•Lumbar radiculopathy (disorder) - 7244[I10: M54.16].

Coding Addendum :

· Diagnosis Coded for this visit

o M545 - Low Back Pain
· Procedures Coded for this visit
o 97140 - phy ther manual one area-int 15 min
o 97110 - therapeutic exercises-int 15 min

Acive Problem List (Diagnosis)

Problem List

Lumbar radiculopathy (disorder)

Chronic Diagnoses
7244 Nursing
Nursing Chief Complaint [Completed]

Electronically signed by: Date: 06/08/2021

( ELENA HAPKE PT )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 3 of 3

 MasterId: 102678144
7501623-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 27YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
CHFHC/PHYSICAL THERAPY PSR: CGARCIA
Payer: SELF ENC:
Prov: HAPKE, ELENA PGM:
Printed: 01/03/2023 10:08 AM DOS: 06/15/2021

Chief Complaint:

Comments: tx LBP
Vital Signs:
BP T P R WT HT BMI BW HC

Other Data/Comments:

Subjective:
Patient was seen for physical therapy treatment. Patient reported back has not improved and has been doing HEP.

Location: LBP

Family History: unsure of medical history no FH diabetes

OB/Gyn History: none
Social History: tobacco: never ETOH: never drugs: never
Surgical History: none

Objective:
Intervention was provided in the following areas: __ See Exercise Log for details

x Therapeutic Exercises (97110)

__ Range of Motion: - __ PROM __ AAROM __ AROM
x Strengthening: abdominal bracing and supine marching with Stab Cuff, supineclams RTB, glute sets
__ Proprioception
__ Postural training/education
__ Lift training/education
__ Balance
__ Coordination

__ Therapeutic Activities(97530)

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 3

__ Walking
__ Pre-gait ther ex __ Gait Training
__ Running
__ Treadmill
__ Stairs
__ Education __ There ex

x Manual Therapy(97140)
x Joint mobilizations: L/S distraction in hooklying Gr III
__ PNF
__ Manual Stretching

__ Deep Tissue Mobilization/STM(97140)

Area: _______
Time: __ 8 min __ 12 min

__ Application of Heat/Ice(97010)

__ Electrical Stimulation(97014)

__ Ultrasound(97035)

__ Mechanical Traction (97012)

__ Home Program
__ Detailed instruction provided, HEP reviewed with return demonstration noted
__ Written/Electronic information provided for patient to review at home

Assessment/Plan:
Patient is demonstrating:
x Continued steady progress
__ Minimal or Limited progress due to: _______

Min relief with L/S traction in hooklying. Patient responded very well to Stabilizer Cuff to maintain PPT during
supine marching. Able to progress NV. Difficulty maintaining hip positioning during sidelying clams and
demonstrated hip rolling back. Required frequent tactile cues to correct and to isolate hip abd mms. Increased
pain with LTR and when lying on L side for clams. Modified to supine clams. Will reassess NV.

Recommendations (mark all that apply):

x Continue physical therapy treatment. Frequency recommended on initial evaluation remains appropriate.
__ Current authorization has expired; reauthorization request submitted
__ Discharge from physical therapy due to: _______ .
__ Refer for the following: _____
__ Other: _______

Plan for next visit:

x Continue functional strength and conditioning program in an effort to meet stated goals and to maximize
functional capacity. Review and progress HEP. Progress core and hip strengthening, reassess response to L/S
distraction in hooklying
__ D/C to HEP and return to MD for follow-up care

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 3

Treatment time: 30 min

Problems addressed this Visit :

•Lumbar radiculopathy (disorder) - 7244[I10: M54.16].

Coding Addendum :

· Diagnosis Coded for this visit

o M545 - Low Back Pain
· Procedures Coded for this visit
o 97140 - phy ther manual one area-int 15 min
o 97110 - therapeutic exercises-int 15 min

Acive Problem List (Diagnosis)

Problem List

Lumbar radiculopathy (disorder)

Chronic Diagnoses
7244 Nursing
Nursing Chief Complaint [Completed]

Electronically signed by: Date: 06/15/2021

( ELENA HAPKE PT )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 3 of 3

 MasterId: 102678144
7501623-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 27YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
CHFHC/PHYSICAL THERAPY PSR: CGARCIA
Payer: SELF ENC:
Prov: HAPKE, ELENA PGM:
Printed: 01/03/2023 10:08 AM DOS: 06/16/2021

Chief Complaint:

Comments: tx LBP
Vital Signs:
BP T P R WT HT BMI BW HC

Other Data/Comments:

Subjective:
Patient is feeling slightly better today. Here for PT.

Location: LBP

Family History: unsure of medical history no FH diabetes

OB/Gyn History: none
Social History: tobacco: never ETOH: never drugs: never
Surgical History: none

Objective:
Intervention was provided in the following areas: __ See Exercise Log for details

x Therapeutic Exercises (97110)

__ Range of Motion: - __ PROM __ AAROM __ AROM
x Strengthening: abdominal bracing and supine marching with Stab Cuff, supineclams RTB, glute sets
__ Proprioception
__ Postural training/education
__ Lift training/education
__ Balance
__ Coordination

__ Therapeutic Activities(97530)

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 3

__ Walking
__ Pre-gait ther ex __ Gait Training
__ Running
__ Treadmill
__ Stairs
__ Education __ There ex

x Manual Therapy(97140)
x Joint mobilizations: L/S distraction in hooklying Gr III
__ PNF
__ Manual Stretching

__ Deep Tissue Mobilization/STM(97140)

Area: _______
Time: __ 8 min __ 12 min

__ Application of Heat/Ice(97010)

__ Electrical Stimulation(97014)

__ Ultrasound(97035)

__ Mechanical Traction (97012)

__ Home Program
__ Detailed instruction provided, HEP reviewed with return demonstration noted
__ Written/Electronic information provided for patient to review at home

Assessment/Plan:
Patient is demonstrating:
x Continued steady progress
__ Minimal or Limited progress due to: _______

Min relief with L/S traction in hooklying. Patient responded very well to Stabilizer Cuff to maintain PPT during
supine marching. Able to progress NV. Difficulty maintaining hip positioning during sidelying clams and
demonstrated hip rolling back. Required frequent tactile cues to correct and to isolate hip abd mms. Increased
pain with LTR and when lying on L side for clams. Modified to supine clams. Will reassess NV.

Recommendations (mark all that apply):

x Continue physical therapy treatment. Frequency recommended on initial evaluation remains appropriate.
__ Current authorization has expired; reauthorization request submitted
__ Discharge from physical therapy due to: _______ .
__ Refer for the following: _____
__ Other: _______

Plan for next visit:

x Continue functional strength and conditioning program in an effort to meet stated goals and to maximize
functional capacity. Review and progress HEP. Progress core and hip strengthening, reassess response to L/S
distraction in hooklying
__ D/C to HEP and return to MD for follow-up care

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 3

Treatment time: 30 min

Problems addressed this Visit :

•Lumbar radiculopathy (disorder) - 7244[I10: M54.16].

Coding Addendum :

· Diagnosis Coded for this visit

o M545 - Low Back Pain
· Procedures Coded for this visit
o 97140 - phy ther manual one area-int 15 min
o 97110 - therapeutic exercises-int 15 min

Acive Problem List (Diagnosis)

Problem List

Lumbar radiculopathy (disorder)

Chronic Diagnoses
7244 Nursing
Nursing Chief Complaint [Completed]

Electronically signed by: Date: 06/16/2021

( ELENA HAPKE PT )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 3 of 3

 MasterId: 102678144
7501623-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 27YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
CHFHC/PHYSICAL THERAPY PSR: CGARCIA
Payer: SELF ENC:
Prov: HAPKE, ELENA PGM:
Printed: 01/03/2023 10:08 AM DOS: 06/21/2021

Chief Complaint:

Comments: tx LBP
Vital Signs:
BP T P R WT HT BMI BW HC

Other Data/Comments:

Subjective:
Pt reports slight improvement. Physical therapy

Location: LBP

Family History: unsure of medical history no FH diabetes

OB/Gyn History: none
Social History: tobacco: never ETOH: never drugs: never
Surgical History: none

Objective:
Intervention was provided in the following areas: __ See Exercise Log for details

x Therapeutic Exercises (97110)

__ Range of Motion: - __ PROM __ AAROM __ AROM
x Strengthening: abdominal bracing and supine marching with Stab Cuff, supineclams RTB, glute sets
__ Proprioception
__ Postural training/education
__ Lift training/education
__ Balance
__ Coordination

__ Therapeutic Activities(97530)

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 3

__ Walking
__ Pre-gait ther ex __ Gait Training
__ Running
__ Treadmill
__ Stairs
__ Education __ There ex

x Manual Therapy(97140)
x Joint mobilizations: L/S distraction in hooklying Gr III
__ PNF
__ Manual Stretching

__ Deep Tissue Mobilization/STM(97140)

Area: _______
Time: __ 8 min __ 12 min

__ Application of Heat/Ice(97010)

__ Electrical Stimulation(97014)

__ Ultrasound(97035)

__ Mechanical Traction (97012)

__ Home Program
__ Detailed instruction provided, HEP reviewed with return demonstration noted
__ Written/Electronic information provided for patient to review at home

Assessment/Plan:
Patient is demonstrating:
x Continued steady progress
__ Minimal or Limited progress due to: _______

Min relief with L/S traction in hooklying. Patient responded very well to Stabilizer Cuff to maintain PPT during
supine marching. Able to progress NV. Difficulty maintaining hip positioning during sidelying clams and
demonstrated hip rolling back. Required frequent tactile cues to correct and to isolate hip abd mms. Increased
pain with LTR and when lying on L side for clams. Modified to supine clams. Will reassess NV.

Recommendations (mark all that apply):

x Continue physical therapy treatment. Frequency recommended on initial evaluation remains appropriate.
__ Current authorization has expired; reauthorization request submitted
__ Discharge from physical therapy due to: _______ .
__ Refer for the following: _____
__ Other: _______

Plan for next visit:

x Continue functional strength and conditioning program in an effort to meet stated goals and to maximize
functional capacity. Review and progress HEP. Progress core and hip strengthening, reassess response to L/S
distraction in hooklying
__ D/C to HEP and return to MD for follow-up care

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 3

Treatment time: 30 min

Problems addressed this Visit :

•Lumbar radiculopathy (disorder) - 7244[I10: M54.16].

Coding Addendum :

· Diagnosis Coded for this visit

o M545 - Low Back Pain
· Procedures Coded for this visit
o 97140 - phy ther manual one area-int 15 min
o 97110 - therapeutic exercises-int 15 min

Acive Problem List (Diagnosis)

Problem List

Lumbar radiculopathy (disorder)

Chronic Diagnoses
7244 Nursing
Nursing Chief Complaint [Completed]

Electronically signed by: Date: 06/21/2021

( ELENA HAPKE PT )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 3 of 3

 MasterId: 102678144
7501623-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 27YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
CHFHC/PHYSICAL THERAPY PSR: CGARCIA
Payer: SELF ENC:
Prov: HAPKE, ELENA PGM:
Printed: 01/03/2023 10:08 AM DOS: 06/24/2021

Chief Complaint:

Comments: tx LBP
Vital Signs:
BP T P R WT HT BMI BW HC

Other Data/Comments:

Subjective:
Patient was seen for physical therapy treatment. Patient report numbness and tingling.

Location: LBP

Family History: unsure of medical history no FH diabetes

OB/Gyn History: none
Social History: tobacco: never ETOH: never drugs: never
Surgical History: none

Objective:
Intervention was provided in the following areas: __ See Exercise Log for details

x Therapeutic Exercises (97110)

__ Range of Motion: - __ PROM __ AAROM __ AROM
x Strengthening: abdominal bracing and supine marching with Stab Cuff, supineclams RTB, glute sets
__ Proprioception
__ Postural training/education
__ Lift training/education
__ Balance
__ Coordination

__ Therapeutic Activities(97530)

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 3

__ Walking
__ Pre-gait ther ex __ Gait Training
__ Running
__ Treadmill
__ Stairs
__ Education __ There ex

x Manual Therapy(97140)
x Joint mobilizations: L/S distraction in hooklying Gr III
__ PNF
__ Manual Stretching

__ Deep Tissue Mobilization/STM(97140)

Area: _______
Time: __ 8 min __ 12 min

__ Application of Heat/Ice(97010)

__ Electrical Stimulation(97014)

__ Ultrasound(97035)

__ Mechanical Traction (97012)

__ Home Program
__ Detailed instruction provided, HEP reviewed with return demonstration noted
__ Written/Electronic information provided for patient to review at home

Assessment/Plan:
Patient is demonstrating:
x Continued steady progress
__ Minimal or Limited progress due to: _______

Min relief with L/S traction in hooklying. Patient responded very well to Stabilizer Cuff to maintain PPT during
supine marching. Able to progress NV. Difficulty maintaining hip positioning during sidelying clams and
demonstrated hip rolling back. Required frequent tactile cues to correct and to isolate hip abd mms. Increased
pain with LTR and when lying on L side for clams. Modified to supine clams. Will reassess NV.

Recommendations (mark all that apply):

x Continue physical therapy treatment. Frequency recommended on initial evaluation remains appropriate.
__ Current authorization has expired; reauthorization request submitted
__ Discharge from physical therapy due to: _______ .
__ Refer for the following: _____
__ Other: _______

Plan for next visit:

x Continue functional strength and conditioning program in an effort to meet stated goals and to maximize
functional capacity. Review and progress HEP. Progress core and hip strengthening, reassess response to L/S
distraction in hooklying
__ D/C to HEP and return to MD for follow-up care

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 3

Treatment time: 30 min

Problems addressed this Visit :

•Lumbar radiculopathy (disorder) - 7244[I10: M54.16].

Coding Addendum :

· Diagnosis Coded for this visit

o M545 - Low Back Pain
· Procedures Coded for this visit
o 97140 - phy ther manual one area-int 15 min
o 97110 - therapeutic exercises-int 15 min

Secondary diagnosis:
x Segmental and somatic dysfunction of Lumbar region M99.03

Addendum By: ELENA HAPKE( Jun 16 2021 9:57AM) FinalizedBy: ELENA HAPKE( Jun 16 2021
9:57AM)
Discussed with per pt that if she has saddle like paresthesias or increase leg discomfort of constant
numbness/foot drop, she should vist walk-in clinic.

Acive Problem List (Diagnosis)

Problem List

Lumbar radiculopathy (disorder)

Chronic Diagnoses
7244 Nursing
Nursing Chief Complaint [Completed]

Electronically signed by: Date: 06/24/2021

( ELENA HAPKE PT )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 3 of 3

 MasterId: 102678144
7501623-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 27YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
CHFHC/PHYSICAL THERAPY PSR: CGARCIA
Payer: SELF ENC:
Prov: HAPKE, ELENA PGM:
Printed: 01/03/2023 10:08 AM DOS: 06/25/2021

Chief Complaint:

Comments: tx LBP
Vital Signs:
BP T P R WT HT BMI BW HC

Other Data/Comments:

Subjective:
Patient reports symptoms did not improve from yesterday
She states that she feels that her back is "broken" right now and that she constantly feels pain.
Left;R leg pain.Patient reports an accident about 2 months ago and was hit by a bus.
During treatment patient reported 1-2 month of vaginal bleeding and b/l edema in both leg is visible.
Immediately referred to walk-in clinic or ER for further evaluation.

Location: LBP

Family History: unsure of medical history no FH diabetes

OB/Gyn History: none
Social History: tobacco: never ETOH: never drugs: never
Surgical History: none

Objective:
Intervention was provided in the following areas: __ See Exercise Log for details

x Therapeutic Exercises (97110)

__ Range of Motion: - __ PROM __ AAROM __ AROM
x Strengthening: abdominal bracing and supine marching with Stab Cuff, supineclams RTB, glute sets
__ Proprioception
__ Postural training/education
__ Lift training/education
__ Balance
__ Coordination

__ Therapeutic Activities(97530)

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 3

__ Walking
__ Pre-gait ther ex __ Gait Training
__ Running
__ Treadmill
__ Stairs
__ Education __ There ex

x Manual Therapy(97140)
x Joint mobilizations: L/S distraction in hooklying Gr III
__ PNF
__ Manual Stretching

__ Deep Tissue Mobilization/STM(97140)

Area: _______
Time: __ 8 min __ 12 min

__ Application of Heat/Ice(97010)

__ Electrical Stimulation(97014)

__ Ultrasound(97035)

__ Mechanical Traction (97012)

__ Home Program
__ Detailed instruction provided, HEP reviewed with return demonstration noted
__ Written/Electronic information provided for patient to review at home

Assessment/Plan:
Patient is demonstrating:
x Continued steady progress
__ Minimal or Limited progress due to: _______

Min relief with L/S traction in hooklying. Patient responded very well to Stabilizer Cuff to maintain PPT during
supine marching. Able to progress NV. Difficulty maintaining hip positioning during sidelying clams and
demonstrated hip rolling back. Required frequent tactile cues to correct and to isolate hip abd mms. Increased
pain with LTR and when lying on L side for clams. Modified to supine clams. Will reassess NV.

Recommendations (mark all that apply):

x Continue physical therapy treatment. Frequency recommended on initial evaluation remains appropriate.
__ Current authorization has expired; reauthorization request submitted
__ Discharge from physical therapy due to: _______ .
__ Refer for the following: _____
__ Other: _______

Plan for next visit:

x Continue functional strength and conditioning program in an effort to meet stated goals and to maximize
functional capacity. Review and progress HEP. Progress core and hip strengthening, reassess response to L/S
distraction in hooklying
__ D/C to HEP and return to MD for follow-up care

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 3

Treatment time: 30 min

Problems addressed this Visit :

•Lumbar radiculopathy (disorder) - 7244[I10: M54.16].

Coding Addendum :

· Diagnosis Coded for this visit

o M545 - Low Back Pain
· Procedures Coded for this visit
o 97140 - phy ther manual one area-int 15 min
o 97110 - therapeutic exercises-int 15 min

Secondary diagnosis:
x Segmental and somatic dysfunction of Lumbar region M99.03

Addendum By: PEGGY CHIN( Jun 1 2018 3:44PM) FinalizedBy: ESTHER MOLNAR( Jun 1 2018 4:03PM)
Dr. Cervantes. The patient continues to show little to no improvement with exacerbation of pain and
discomfortin her low back. I recommend a consultation to pain management for further evaluation.
If you concur, pleaseco-sign and finalize. Thank you.

Acive Problem List (Diagnosis)

Problem List

Lumbar radiculopathy (disorder)

Chronic Diagnoses
7244 Nursing
Nursing Chief Complaint [Completed]

Electronically signed by: Date: 06/25/2021

( ELENA HAPKE PT )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 3 of 3

 MasterId: 102678144
7976515-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 27YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
NPFHCII/GYNECOLOGY PSR: ANGELINAG
Payer: SELF ENC:
Prov: CERVANTES, SANDRA M PGM:
Printed: 01/03/2019 10:08 AM DOS: 07/01/2021

Chief Complaint:
Follow-up: ER follow-up
Comments: no travel
Vital Signs:
BP T P R WT HT BMI BW HC

125lbs 0oz 0.00

119 78 97.5 50 14 65.00" 23.3
56.7 Kgs
Other Data/Comments:

Subjective:
F/u ER visit for CP, LE edema, and menses x26d. Not taking any medications. Needs referral to cardiology and
GYN as recommended. Patient reports a miscarriage in 2013 but states menses has been normal for past 8 years.
Pt was involved in a motor vehicle collision about a 1.5 months ago and has noticed spotting and a heaver period
this monthhas hx acid reflux, not taking meds for it. Pt states she has had a spike in anxiety since then as well

pt d/c summary shows labs ok

CXR- enlarged cardiac silhouette w/out additional radiographic findings suggesting CHF
EKG- pending records
Pelvic U/S- thickened endometrial stripe

REVIEW OF SYSTEMS: CONSTITUTIONAL: No weight loss, fever, chills, weakness or fatigue. HEENT:
Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: No hearing loss,
sneezing, congestion, runny nose or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No
palpitations RESPIRATORY: No shortness of breath, cough or sputum. NEUROLOGICAL: No headache,
dizziness

Family History: unsure of medical history no FH diabetes

OB/Gyn History: none
Social History: tobacco: never ETOH: never drugs: never
Surgical History: none

Objective:
Vital Signs noted.

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 4

 Sharp Memorial Hospital
7901 Frost Street
San Diego, CA 92123-

Patient: NOUR, AISHA Location: Emergency Department

SHC#: 117-328-306 MRN# 01-38-12-07 Room: Admit: 06/26/2021
FIN: 45108862 Bed: Disch: 06/26/2021
DOB/Age/Sex: 07/16/1993 27 years Female Attending: Ho MD,Christopher B.

Emergency Documentation
Document Name: ED Note
Document Status: Auth (Verified)
Electronically Signed By: Smithson MD,James P (6/28/2021 08:46 PDT)
Authenticated By: Smithson MD,James P (6/28/2021 08:46 PDT); Smithson MD,
James P (6/28/2021 08:46 PDT); Smithson MD,James P
(6/28/2021 08:42 PDT); Smithson MD,James P (6/26/2021
19:47 PDT)

Patient: NOUR, AISHA SHC: 117-328-306 MRN: 01-38-12-07 FIN: 45108862

Age: 27 Years Gender: Female DOB: 07/16/1993
Author: Smithson MD, James P
Date/Time:
06/26/21 17:17

Time of my initial contact with patient:

1858 hours. Room 24.
Mode of Arrival:
POV/Walk-in
Triage Narrative:
pt presents from home with c/o vaginal bleeding x 25 days and leg swelling bilaterally x 2 weeks. Pt was seen by chiropractor yesterday and
sent here. pt has not seen OB/GYN. Multiple complaints of back and chest pain as well. Denies n/v/d/f. Denies any medical issues or
prescription meds
Entered by: Rabun RN, Jane at 06/26/2021 16:46

Chief Complaint:
Vaginal bleeding

History of Present Illness:

Has a few complaints. Her chief complaint is vaginal bleeding. She has been bleeding of and on since May 1. She was told it may be
due to transient increase in “stress” and should return to normal within 1-2 cycles. Secondary complaint is lower extremity edema. It
has been present for a few weeks. Gradual in onset. Was quite severe previously. Is gradually improving over the last several days.
Is presently moderate in severity. Patient also feels fatigued. She feels that her heart feels “tired”. She feels palpitations. No orthopnea.
No cough. No fevers. History of bradycardia.
No fevers.
ROS: Except as mentioned, no fevers/chills/diaphoresis/loss of appetite/nausea/vomiting/diarrhea/constipation/urinary symptoms/chest
pain/headache/neurologic symptoms

Problem List & Past Medical/Surgical History:

Musculoskeletal back pain

Social History:
Patient states no history of smoking

___________________________________________________________________________________________________
Request ID: 189074473 Page 1 of 13 12/20/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 06/26/2021
FIN: 45108862 Disch: 06/26/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Emergency Documentation
Patient denies history of treatment for substance dependence (alcohol, street drugs, and prescriptions).
Allergies:
NKA
Medications:
Available Med List Reviewed
Review of Systems:
All other systems reviewed and are negative except per HPI
LMP: JUN/14/2021
Physical Exam:
Vital Signs
BP: 131/83 mmHg Temp (Oral): 36.7 DegC ( 98.1 DegF) HR: 45 bpm SpO2: 98 %
VITAL SIGNS: Triage bradycardia noted.
GENERAL: The patient is comfortable and
well-appearing, alert and oriented and speaking complete sentences appropriately without dyspnea.
HEENT: Mucous membranes moist. No scleral icterus or
conjunctival injection.
CARDIOVASCULAR: bradycardic and regular
No murmurs, rubs, or gallops
Normal skin turgor and warmth. 2+ radial pulses bilaterally.
RESPIRATORY: Normal work of breathing. Lungs clear to auscultation bilaterally
GASTROINTESTINAL: Soft, non-tender abdomen
No percussion or rebound tenderness. Normal bowel sounds.
GENITOURINARY: No CVA tenderness.
MUSCULOSKELETAL: No joint swelling, tenderness or deformity.
SKIN: No diaphoresis or rash.
PSYCHIATRIC: Goal directed behavior.
NEUROLOGIC: Normal level of consciousness, normal speech and
gross motor function.
LYMPHATICS: 1+ bilateral peripheral edema pitting
No palpable cords or calf or thigh tenderness.
Test Results:
Labs Results
06/26/21 17:49

142 105 7
94
3.7 26 0.6

06/26/21 17:49

13.6
4.6 159
39.2

06/26/21 17:49
Hematology

WBC 4.6

___________________________________________________________________________________________________
Request ID: 189074473 Page 2 of 13 12/20/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 06/26/2021
FIN: 45108862 Disch: 06/26/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Emergency Documentation
HGB 13.6
HCT 39.2
PLT 159
MCV 92
RBC 4.25
MCH 32
MCHC 34.8
RDW 14.2
MPV 10.8
Neutrophils 46
Lymphocytes 38
Monocytes 13
Eosinophils 3
Basophils 1
Neut Absolute 2.1
Lymph Absolute 1.7
Mono Absolute 0.6
Eos Absolute 0.2
Baso Absolute 0.0

Cardiac Studies

ProBNP 26
Troponin-T <0.03

Chemistry

Anion Gap 11
Sodium Lvl 142
Potassium Lvl 3.7
Chloride 105
CO2 26
Glucose Lvl 94
BUN 7
Creatinine 0.6
Alk Phos 89
Calcium Lvl 8.6
ALT 14
AST 16
Bili Total 0.3
Total Protein 7.1
Albumin Lvl 3.8
eGFR Black >60
eGFR Non-Black >60

Coagulation

PTT 30
PT 12.5
INR 1.1

Pregnancy/Maternal/Fetal

___________________________________________________________________________________________________
Request ID: 189074473 Page 3 of 13 12/20/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 06/26/2021
FIN: 45108862 Disch: 06/26/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Emergency Documentation
hCG Quant <5

06/26/21 17:49
Microbiology

Urine Culture See

Results

Urine/Fecal Studies

Urine Culture? Ordered

UA Color Yellow
UA Clarity Hazy
UA Spec Grav 1.026
UA pH 5.0
UA Protein 1+
UA Glucose
Negative
UA Ketones
Negative
UA Bili
Negative
UA Urobilinogen < 1+
UA Blood 3+
UA Nitrite
Negative
UA Leuk Est 1+
UA WBC 5-10
UA RBC 10-20
UA Bacteria Few
UA Squam Epithelial Many
UA Mucous Present

Diagnostic Results
Imaging Studies Reviewed
US Pelvis w/ Transvaginal w/ D
Performed By/Author: Farah MD, Nazih N on 26 JUN 2021 18:31 PDT
IMPRESSION:
1. Thickened endometrial stripe. Please correlate with the LMP date. If the patient is pregnant, gynecological referral is suggested for
further management.
XR Chest 1 View
Performed By/Author: Farah MD, Nazih N on 26 JUN 2021 20:02 PDT
IMPRESSION:
Enlarged cardiac silhouette without additional radiographic findings to suggest congestive heart failure.
EKG Results
Obtained at 1941 hours. Interpreted by me. Sinus bradycardia. Rate 48. Normal axis. Normal intervals. No ST elevation or depression.
Borderline criteria for LVH

___________________________________________________________________________________________________
Request ID: 189074473 Page 4 of 13 12/20/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 06/26/2021
FIN: 45108862 Disch: 06/26/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Emergency Documentation

Emergency Department Course and Procedures:

Medications, IV's and Blood Products Ordered
Blood Bank Hold

Reexamination/Reevaluation:
1946 hours. Just reevaluated the patient. Discussed my plans to do a little bit more of an assessment given significant sinus bradycardia
and very modest symptoms suggestive of CHF. EKG obtained. Chart review performed. EKG shows sinus bradycardia with a rate of 48.
Nothing else really evident. Chart review notable for sinus bradycardia with heart rate of 50-52 on the last 2 visits.
Medical Decision Making:
27-year-old presents with acute menometrorrhagia. Suspect secondary to blunt abdominal trauma following a recent motor vehicle collision.
Has a known history of thickened endometrial lining. Noted again on ultrasound today. No other abnormal findings on ultrasound of the pelvis.
Also presents with acute lower extremity edema. No evidence of kidney dysfunction. There are some symptoms of mild CHF. No pulmonary
edema by exam or by x-ray. BNP not supportive of the diagnosis. Some evidence of cardiomegaly based on chest x-ray and EKG. Both of
these issues will need follow-up. Workup rules out significant acute life-threatening pathology. I personally discussed all findings impressions
and plans with the patient. The patient felt comfortable with outpatient management at the time of final reevaluation. I provided a copy of all
test results to facilitate with outpatient management and the patient agreed to return to the ED immediately if symptoms worsen.

Impression:
Acute/chronic menometrorrhagia with thickened endometrial lining requiring reevaluation by OB/GYN and possible endometrial biopsy
Lower extremity edema of unclear etiology requiring further evaluation in the outpatient setting
Possible LVH based on EKG and mild cardiomegaly on chest x-ray
Plan:
Discharge
Follow Up
Your Primary Doctor Within: 3-5 days
Comments: Discuss additional testing with your physician. Thickened endometrial need to be considered by her gynecologist. The
peripheral edema of unknown etiology, sinus bradycardia, evidence of left ventricular hypertrophy, need to be reconsidered by her primary
doctor. Outpatient echocardiogram is probably necessary.
Your Obstetrics and Gynecology Physician Within: 3-5 days
Patient Education
Peripheral Edema
Metrorrhagia
Referral for suspected pre-hypertension or hypertension was given.

Please note: Unless specifically stated, all procedures mentioned, tests done and medications given were performed/interpreted by the
emergency physician, or were under the direct supervision of the emergency physician.
This ED Note was completed using voice-recognition transcription and may contain inadvertent errors.

___________________________________________________________________________________________________
Request ID: 189074473 Page 5 of 13 12/20/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 06/26/2021
FIN: 45108862 Disch: 06/26/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Hematology

Collected Date 6/26/2021

Collected Time 17:49 PDT
Procedure Reference Range Units
WBC 4.6 [4.5-11.0] K/mcL
HGB 13.6 [12.0-16.0] g/dL
HCT 39.2 [35.0-47.0] %
PLT 159 [140-400] K/mcL
MCV 92 [80-100] fL
RBC 4.25 [4.00-5.20] M/mcL
MCH 32 [26-34] pg
MCHC 34.8 [32.0-36.0] g/dL
RDW 14.2 [11.5-14.5] %
MPV 10.8 [7.5-11.2] fL
Neutrophils 46 [44-77] %
Lymphocytes 38 [16-44] %
Monocytes 13 [5-13] %
Eosinophils 3 [0-8] %
Basophils 1 [0-3] %
Neut Absolute 2.1 [1.8-7.8] K/mcL
Lymph Absolute 1.7 [1.0-3.5] K/mcL
Mono Absolute 0.6 [0.3-1.0] K/mcL
Eos Absolute 0.2 [0.0-0.5] K/mcL
Baso Absolute 0.0 [0.0-0.1] K/mcL

Cardiac Studies

Collected Date 6/26/2021

Collected Time 17:49 PDT
Procedure Reference Range Units
Troponin-T <0.03 ^1 [<=0.02] ng/mL
ProBNP 26 [<=299] pg/mL
Interpretive Data
^1: Troponin-T
0.03 – 0.10 Suggestive of myocardial necrosis
> 0.10 Indicative of myocardial necrosis

Chemistry

Collected Date 6/26/2021

Collected Time 17:49 PDT
Procedure Reference Range Units
Glucose Lvl 94 [70-109] mg/dL

___________________________________________________________________________________________________
Request ID: 189074473 Page 6 of 13 12/20/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 06/26/2021
FIN: 45108862 Disch: 06/26/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Chemistry

Collected Date 6/26/2021

Collected Time 17:49 PDT
Procedure Reference Range Units
Sodium Lvl 142 [136-145] mmol/L
Potassium Lvl 3.7 [3.4-5.0] mmol/L
Chloride 105 [98-108] mmol/L
CO2 26 [20-31] mmol/L
Anion Gap 11 [3-11] mmol/L
BUN 7 [5-22] mg/dL
Creatinine 0.6 [0.5-1.3] mg/dL
eGFR Black >60 [>=60] mL/min
eGFR Non-Black >60 ^2 [>=60] mL/min
Calcium Lvl 8.6 [8.4-10.2] mg/dL
Alk Phos 89 [35-129] unit/L
ALT 14 [9-52] unit/L
AST 16 [0-34] unit/L
Bili Total 0.3 [0.0-1.2] mg/dL
Total Protein 7.1 [6.6-8.7] g/dL
Albumin Lvl 3.8 [3.5-5.0] g/dL
Interpretive Data
^2: eGFR Non-Black
e GFR Reference Ranges

eGFR Values Description

(mL/min/1.73m2)
Above 60 Normal GFR
30-59 Mild to moderate Kidney damage
15-29 Severe kidney damage
Below 15 Kidney failure

eGFR Calculation and Classification Reference: Annals of Internal Medicine

145(4):247-54, 2006

Coagulation

Collected Date 6/26/2021

Collected Time 17:49 PDT
Procedure Reference Range Units
PT 12.5 [9.4-12.5] sec
INR 1.1 ^3 [0.8-1.2]
PTT 30 [25-37] sec
Interpretive Data
^3: INR
DIAGNOSIS TARGET INR RANGE

___________________________________________________________________________________________________
Request ID: 189074473 Page 7 of 13 12/20/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 06/26/2021
FIN: 45108862 Disch: 06/26/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Coagulation
Interpretive Data
^3: INR
Venous Thrombosis and/or Pulmonary Embolism 2.5 2.0-3.0
Prophylaxis with MI or Atrial Fibrillation
and most other indications
High risk patients with Mechanical Heart valves 3.0 2.5-3.5
or systemic Arterial Embolism

VALVE REPLACEMENT/MECHANICAL
Aortic: bileaflet in NSR with normal LA size 2.5 2.0-3.0
Medronic Hall tilting disk in NSR
with normal LA size 2.5 2.0-3.0
following prosthetic valve thrombosis 3.5 3.0-4.0
Mitral: bileaflet or tilting disk 3.0 2.5-3.5
following prosthetic valve thrombosis 4.0 3.5-4.5
Caged ball or caged disk (aortic or mitral) 3.0 2.5-3.5
With additional risk factors for thromboembolism 3.0 2.5-3.5
[AF, MI, LA enlargement, hypercoagulable condition, low EF]
With systemic embolism despite adequate anticoagulation-Increase INR goal

Reference: Chest 2012; 141 (2_supp).

Additional recommendations: “Antithrombotic and Thrombolytic Therapy: ACCP
Evidence based Clinical Practice Guidelines, 9th ed, 2012”
SHC Pharmacy website on optimal therapeutic ranges:
http://sharpnet.sharp.com/pharmacy/upload/102012-UW-Warfarn-INR- recs__rec_chronic_antithromb_tx.pdf

Urine / Fecal Studies

Collected Date 6/26/2021

Collected Time 16:42 PDT
Procedure Reference Range Units
UA Color Yellow [Yellow]
UA Clarity Hazy [Clear]
UA Spec Grav 1.026 [1.005-1.030]
UA pH 5.0 [5.0-9.0]
UA Glucose Negative [Negative]
UA Ketones Negative [Negative]
UA Protein 1+ * [Negative]
UA Bili Negative [Negative]
UA Urobilinogen < 1+ [< 1+]
UA Blood 3+ * [Negative]
UA Nitrite Negative [Negative]
UA Leuk Est 1+ * [Negative]
UA WBC 5-10 * [0-5] /HPF
UA RBC 10-20 * [0-3] /HPF
UA Bacteria Few [None] /HPF
UA Squam Epithelial Many [None] /LPF
Urine Culture? Ordered
UA Mucous Present

___________________________________________________________________________________________________
Request ID: 189074473 Page 8 of 13 12/20/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 06/26/2021
FIN: 45108862 Disch: 06/26/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Pregnancy / Maternal / Fetal

Collected Date 6/26/2021

Collected Time 17:49 PDT
Procedure Reference Range Units
hCG Quant <5 ^4 [0-4] mIntl_unit/mL
Interpretive Data
^4: hCG Quant
Healthy non pregnant females: (less than) <5 mIU/mL.
Healthy peri or post menopausal females: (less than) <10 mIU/mL.
The expected hCG values at a corresponding gestational age are: (mIU/mL)

3 - 4 weeks 9 - 130
4 - 5 weeks 75 - 2,600
5 - 6 weeks 850 - 20,800
6 - 7 weeks 4,000 - 100,200
7 - 12 weeks 11,500 - 289,000
12 - 16 weeks 18,300 - 137,000
16 - 29 weeks 1,400 - 53,000 (2nd trim)
29 - 41 weeks 940 - 60,000 (3rd trim)

***This assay should not be used to diagnose any condition

unrelated to pregnancy. "Beta hCG TumorMarker" should
be used for other conditions.***

Blood Bank

Blood Bank Band ID

Collected Date 6/26/2021

Collected Time 17:49 PDT
Procedure Reference Range Units
Blood Bank ID R 77594

___________________________________________________________________________________________________
Request ID: 189074473 Page 9 of 13 12/20/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 06/26/2021
FIN: 45108862 Disch: 06/26/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Microbiology
Procedure: Urine Culture O1
Source: U CleanCatch
Body Site:
Free text:
Collected Date/Time: 06/26/2021 16:42 PDT
Start Date/Time: 06/26/202119:35 PDT
Accession: 02-18-146-002286

***FINAL REPORTS***
Final Report Verified Date/Time: 06/26/2021 11:58 PDT
>100,000 cfu/mL Streptococcus agalactiae (Group B)
Bacteriuria without symptoms usually does not require treatment except in patients who are pregnant,
neutropenic, have had a kidney transplant, or require GU instrumentation.
Order Comments
O1: Urine Culture
Order added by Discern Expert (GL_UA_CULTURE_RFX_MB_NIT_AV).

Diagnostic Radiology
ACCESSION PROCEDURE EXAM DATE/TIME ORDERING PROVIDER
02-18-146-002478 XR Chest 1 View 06/26/2021 20:02 PDT Smithson MD,James P

Reason For Exam

(XR Chest 1 View) Other (See Special Instructions);Other (See Special Instructions)

___________________________________________________________________________________________________
Request ID: 189074473 Page 10 of 13 12/20/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 06/26/2021
FIN: 45108862 Disch: 06/26/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Diagnostic Radiology
Interpretation
EXAMINATION: XR Chest 1 View

HISTORY: Other (See Special Instructions). Bradycardia, peripheral edema, fatigue

COMPARISON: 05/06/2021.

Findings:

The lungs are clear.

There is no pleural effusion or pneumothorax.
The cardiomediastinal silhouette is notable for mildly enlarged cardiac silhouette which could be related to the portable
technique or true cardiomegaly given the provided history.
No obvious acute osseous abnormality.

Impression:

Enlarged cardiac silhouette without additional radiographic findings to suggest congestive heart failure.

This exam was performed at: Sharp Memorial Hospital

***** Final *****

Dictated by: Farah MD, Nazih N

Signed (Electronic Signature): 06/26/2021 8:05 pm

Signed by: Farah MD, Nazih N

-----------------------------------------------------

Ultrasound
ACCESSION PROCEDURE EXAM DATE/TIME ORDERING PROVIDER
02-18-146-002050 US Pelvis w/ Transvaginal w/ 06/26/2021 18:28 PDT Smithson MD,James P
Doppler

Reason For Exam

(US Pelvis w/ Transvaginal w/ Doppler) Other (See Special Instructions);heavy bleeding

Interpretation
EXAMINATION: US Pelvis w/ Transvaginal w/ Doppler

HISTORY: Other (See Special Instructions)

COMPARISON: None

TECHNIQUE: Transabdominal and transvaginal sonographic imaging of the pelvis were performed.

___________________________________________________________________________________________________
Request ID: 189074473 Page 11 of 13 12/20/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 06/26/2021
FIN: 45108862 Disch: 06/26/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Ultrasound
Interpretation

FINDINGS:

The uterus is normal in size and echotexture and measures 8.6 x 6.8 x 4.6 cm. No focal uterine lesion is identified. The
central endometrial echo complex measures 15 mm.

The right ovary measures 2 x 1.5 x 1.9 cm, without grayscale sonographic abnormality.

The left ovary is not visualized.

No solid pelvic mass is identified.

No pelvic free fluid is identified.

Duplex Doppler evaluation of the right ovary was performed, demonstrating normal arterial and venous flow.

IMPRESSION:

1. Thickened endometrial stripe. Please correlate with the LMP date. If the patient is pregnant, gynecologica referral
is suggested for further management.

This exam was performed at: Sharp Memorial Hospital

***** Final *****

Dictated by: Farah MD, Nazih N

Signed (Electronic Signature): 06/26/2021 6:34 pm

Signed by: Farah MD, Nazih N

-----------------------------------------------------

Cardiac Rhythm Analysis

Document Name: ECG- 12 Lead
Document Status: Auth (Verified)
Electronically Signed By:
Authenticated By: Narula MD,Arvin (06/26/2021 19:41 PDT)

ECG Measurement and Diagnosis

Test Reason : Other (See Special Instructions).Blood Pressure : ***/*** mmHG.Vent. Rate :
048 BPM Atrial Rate : 048 BPM. P-R Int : 200 ms QRS Dur : 086 ms. QT Int :

___________________________________________________________________________________________________
Request ID: 189074473 Page 12 of 13 12/20/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
Facility: Sharp Memorial Hospital NOUR, AISHA
SHC#: 117-328-306 Admit: 06/26/2021
FIN: 45108862 Disch: 06/26/2021 DOB/Age/Sex: 07/16/1993 27 years Female

Cardiac Rhythm Analysis

430 ms P-R-T Axes : 034 -01 010 degrees. QTc Int : 384 ms..Sinus
bradycardia.Minimal voltage criteria for LVH, may be normal variant.Borderline
ECG...Referred By: Confirmed By:ARVIN NARULA, MD

___________________________________________________________________________________________________
Request ID: 189074473 Page 13 of 13 12/20/2021 09:07 PDT
*=Abnormal | C=Critical | #=Corrected Result | R=Result Comment | O=Order Comment | ^=Interpretive Data | @=Performing Lab | W=Witness
Unless otherwise noted, all lab testing is performed at Memorial Hospital, 7901 Frost Street, San Diego, CA 92123
General: WNWD, NAD, A&O x 3.
HEENT: PERRLA, EOMI, sclera white, conjunctiva pink; OP clear, neck supple, no LAD.
Lungs: CTA bilaterally. No wheezes/rhonchi/crackles/retractions.
Heart: Regular S1S2. No murmurs/rubs/gallops. Pulses and cap refill wnl
Abdomen: Soft, non-tender, bowel sounds present. No tenderness to deep
palpation/organomegaly/rebound/guarding.
Lower extremities: No edema.
Neuro: Grossly intact. no focal deficits
MSK: MAE, ambulates w/o difficulty.
SKIN: Pink, warm, dry; no rashes

• 05/16/2021 10:47:48 AM - Cholesterol (GW-AR) : 211 - H [100-199 mg/dL]

• 05/16/2021 10:47:48 AM - Triglycerides (TG) (GW-AR) : 105 - [0-149 mg/dL]
• 05/16/2021 10:47:48 AM - HDL Cholesterol, Direct (GW-AR) : 47.00 - [40.00-59.00 mg/dL]
• 05/16/2021 10:47:48 AM - LDL Cholesterol, Direct (GW-AR) : 143.00 - H [0.00-99.00 mg/dL]
• 05/16/2021 10:47:48 AM - VLDL CHOLEST (GW-AR) : 21 - [0-30 mg/dL]

Assessment/Plan:

Problems addressed this Visit :

• Menorrhagia (finding) - 6262[I10: N92.0] . refer to GYN
• Chest pain/discomfort; unknown etiology - 78650[I10: R07.89] . refer to cardiology
• Gastroesophageal reflux disease (disorder) - 53081[I10: K21.9] . rx pepcid

- request ER records

• Medication : Pepcid ] famotidine 20 mg oral tablet } Qty : 60 R : 3

Take orally 1 twice daily
CVS/pharmacy 3332 Sandrock San Diego, CA 92123

• Follow Up : 2 Week(s) w/Molnar

Coding Addendum :

· Diagnosis Coded for this visit

o N920 - Excessive And Frequent Menstruation With Regular Cycle
o K219 - Gastro-Esophageal Reflux Disease Without Esophagitis
o R0789 - Other Chest Pain
· Procedures Coded for this visit
o 99213 - office expanded, est

Addendum By: MICHELLE CUEVAS( Jul 02 2021 1:26PM) FinalizedBy: MICHELLE CUEVAS( Jul 02
2021 1:26PM)
ER 6/26/21 summary:

CC: vag blding.

Diagnostics: Pelvis US- thickened endometrial stripe; CXR-enlarged cardiac silhouette w/out additional
radiographic findings suggesting CHF; EKG- SB 48 w/minimal voltage criteria for LVH. Labs ok w/ H/H
Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 4
13.6/39.2

Dx: acute/chronic menometrorrhagia, LE edema of unknown etiology (see summary)

Acive Problem List (Diagnosis)

Problem List

Chest pain/discomfort; unknown etiology

Degeneration of lumbar intervertebral disc (disorder)
Gastroesophageal reflux disease (disorder)
Menorrhagia (finding)
Acute Diagnoses
78650 Chest pain/discomfort; unknown etiology
Consult Cardiology , Services Ordered: Consult,Consult, Other Service(s): Set 07-25-2021 @
10:10a[CARDIOLOGY FHCSD] Reason:Patient referred for chest pain - full work-
up including stress test desired
Chronic Diagnoses
53081 Gastroesophageal reflux disease (disorder)
Medication Pepcid - 20 mg oral (Allow Substitution)
SIG:Take orally 1 twice daily
6262 Menorrhagia (finding)
Consult Gynecology , Services Ordered: Consult,Consult, Other Service(s): Set 07-26-2021 @
10:10a[North Park FHC Women's Clinic] Reason:Referred for menorrhagia
w/abnormal pelvic u/s indicating thickened endometrial stripe for eval and tx
72252 Nursing
Nursing Request Record [Ordered] Instruction:Request records (ER, discharge summary,
other clinic). Location: ER records from recent visit
Other Orders
No Diagnosis
Nursing
Code
Nursing Chief Complaint [Completed]
Nursing Allergy [Completed]
Nursing Patient Additional Info [Completed]
Nursing Immunization Review [Completed]
Nursing Vitals [Completed]
Patient Heartburn - English
Education
Follow Up Follow up in 2 Week[s] for

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 3 of 4

 Reminder Head of bed elevation, which can be achieved either by putting 6- to 8-inch blocks
under the legs at the head of the bed or a Styrofoam wedge under the mattress. Head
of bed elevation is important for individuals with nighttime or back of throat
symptoms.

Template Core Screening

Electronically signed by: Date: 07/01/2021

( MICHELLE CUEVAS FNP )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 4 of 4

Provider of Services: Location of Services:
IHS RADIOLOGY MEDICAL GROUP GOLDEN TRIANGLE IMAGING CENTER GL
150 W WASHINGTON ST 4150 REGENT PARK ROW 195
SAN DIEGO, CA 921032005 LA JOLLA, CA 920379139

NPI: 1497148456 Tax ID: 473394746 NPI: 1497148456

Patient: Visit Info:

NOUR, AISHA Visit #: 44158246 Balance: $3,224.19
9555 VIA PEREZA Doctor: GLENN TSUKADA
SAN DIEGO, CA 92129 NPI: 1710938394
Referring: ESTHER MOLNAR
4152143353 07/16/1993 NPI: 1831456896

Primary Ins. Secondary Ins. Tertiary Ins.

Insurance
Insured SELF
Policy #
Group ID

Charges:
DOS CPT Mod Diag 1 Diag 2 Diag 3 Diag 4 Amt Pmt Adj Bal
07/14/2021 72148 M47. M43.17 $2,382.00 $2,382.00
817
MRI SPINAL CANAL LUMBAR W/O CONTRAST MATERIAL
07/14/2021 76856 N92.6 N92.0 $842.19 $842.19
US PELVIC NONOBSTETRIC REAL-TIME IMAGE COMPLETE

Claims:
Date Receiver Insurance
07/15/2021 BILLED BY PREVIOUS SELF
BILLING CO
 IHS RADIOLOGY MEDICAL GROUP
INC.
333 H ST
STE 1095
CHULA VISTA, CA-91910
8665584320 (phone)
Online results, images and scheduling available
Your Partner in Health - For Every Imaging Need 8665584329 (fax)
at: imaginghealthcare.com/results

Patient Name: NOUR, AISHA DOB: 07/16/1993 Age:

Exam Date: 07/14/2021 I.D #: 4612583 Sex: F
Accession #: 410694
At the SANDRA CERVANTES, MD
Request of: 823 GATEWAY CENTER WAY
SAN DIEGO CA 92102

PROCEDURE:
US PELVIC COMPLETE W/ EV

COMPARISON:
None.

INDICATIONS:
Irregular menstruation and menorrhagia.

TECHNIQUE:
Pelvic ultrasound was preformed utilizing both transabdominal and transvaginal scanning.
Transvaginal examination was performed for better assessment of the endometrium and adnexa.

FINDINGS:
UTERUS: Uterine dimensions are 4.6 x 7.2 x 9.3 cm. Myometrial echogenicity is normal. No
visible mass.
ENDOMETRIUM: Endometrial thickness is 15.7 mm. Echogenicity is normal. No visible
mass.
RIGHT ADNEXA: Right ovary is not visualized and may be obscured by bowel gas
LEFT ADNEXA: Left ovary is not visualized and may be obscured by bowel gas
CUL-DE-SAC: No significant free fluid.
OTHER: Negative

CONCLUSION:
1. Prominent endometrium at 15.7 mm. Clinical correlation advised and consider follow-up
study in 6-12 weeks.
2. This report was faxed at the report approval time and our office called to confirm receipt.

Dictated and Electronically Authenticated by: GLENN TSUKADA M.D. on

<<Approval_Date_Time1>>

4612583 NOUR, AISHA 07/16/1993

 IHS RADIOLOGY MEDICAL GROUP
INC.
333 H ST
STE 1095
CHULA VISTA, CA-91910
8665584320 (phone)
Online results, images and scheduling available
Your Partner in Health - For Every Imaging Need 8665584329 (fax)
at: imaginghealthcare.com/results

Patient Name: NOUR, AISHA DOB: 07/16/1993 Age:

Exam Date: 07/14/2021 I.D #: 4612583 Sex: F
Accession #: 410694
At the ESTHER MOLNAR
Request of:

PROCEDURE:
MR LUMBAR SPINE W/O CONTRAST

COMPARISON:
None.

INDICATIONS:
Low back pain.

TECHNIQUE:
A variety of imaging planes and parameters were utilized for visualization of suspected pathology
without intravenous contrast.

FINDINGS:
PARASPINAL AREA: Normal with no visible mass.
BONES: Mild-to-moderate type 1 edematous or fibrovascular endplate changes at L5-S1 posteriorly
with retrolisthesis of L5 on S1 by 3 mm. No fracture.
CORD/CAUDA EQUINA: Normal caliber, contour, and signal intensity.
OTHER: None.

LUMBAR DISC LEVELS:

L1-L2: No significant disc/facet abnormality, spinal stenosis, or foraminal stenosis.
L2-L3: No significant disc/facet abnormality, spinal stenosis, or foraminal stenosis.
L3-L4: Unremarkable disc without bulge or herniation. No spinal stenosis or foraminal narrowing. Mild
posterior facet arthropathy is present.
L4-L5: Mild disc desiccation with trace bulging and moderate posterior facet arthropathy with
ligamentum flavum hypertrophy and mild spinal stenosis and bilateral foraminal narrowing
L5-S1: Grade 1 retrolisthesis and moderate disc desiccation with a 3 mm bulge and ridge of
osteophytes with moderate posterior facet arthropathy and subsequent moderate to severe bilateral
foraminal narrowing and L5 nerve root impingement. There is also moderate spinal stenosis and
narrowing of both lateral recesses.
OTHER: None.

4612583 NOUR, AISHA 07/16/1993

 IHS RADIOLOGY MEDICAL GROUP
INC.
333 H ST
STE 1095
CHULA VISTA, CA-91910
8665584320 (phone)
Online results, images and scheduling available
Your Partner in Health - For Every Imaging Need 8665584329 (fax)
at: imaginghealthcare.com/results

CONCLUSION:
1. Grade 1 retrolisthesis of L5 on S1 with posterior facet arthropathy and moderate to severe bilateral
foraminal narrowing and moderate central canal stenosis.
2. Mild spinal stenosis and bilateral foraminal narrowing at L4-5.

Dictated and Electronically Authenticated by: GLENN TSUKADA M.D. on

<<Approval_Date_Time1>>Proofread by: GLENN TSUKADA M.D. on 07/14/2021 09:50 AM

IMAGING HEALTHCARE SPECIALISTS

4150 REGENTS PARK ROW, SUITE 195
LA JOLLA CA 92037 858.622.6464

4612583 NOUR, AISHA 07/16/1993

 MasterId: 102678144
7610383-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 27YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
HFHC/ADULTS PSR: MATILDEM
Payer: SELF ENC:
Prov: MOLNAR, ESTHER M PGM:
Printed: 01/03/2023 10:08 AM DOS: 07/19/2021

Chief Complaint:
, Physical, for iha,

Vital Signs:
BP T P R WT HT BMI BW HC

126lbs 0oz 0.00

115 72 98.5 62 18 65.00" 23.5
57.15 Kgs
Other Data/Comments:

Subjective:
28 yo presents for physical to clear for PT.

Reports left leg a little numb at times. Denies frequency of urination, incontinence, trouble with bowels. Has
low back pain.

Otherwise, feels well today. Denies fevers, chills, sweats, rhinitis, sore throat, cough, chest pain, sob, abdominal
pain, n/v, diarrhea, dysuria, frequency, rash, joint pains. Remainder of ROS negative, except for HPI as above.

Family History: unsure of medical history no FH diabetes

OB/Gyn History: none
Social History: tobacco: never ETOH: never drugs: never
Surgical History: none

Objective:
see template

Assessment/Plan:

Problems addressed this Visit :

• Well Adult Exam - V700[I10: Z00.00] .
• Consult : DENTIST (DIRECT REFERRAL ) Consult, Dental Screening,
• Consult : OPTOMETRY (DIRECT REFERRAL ) Consult, Refer to one of the FHCSD Vision Care Clinics

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 2

Follow up scheduled

Coding Addendum :

· Diagnosis Coded for this visit

o Z0000 - Encounter For General Adult Medical Examination Without Abnormal
Findings
· Procedures Coded for this visit
o 83036 - glycosylated hemoglobin test
o 99395 - prev visit, est, age 40-64
o 36415 - routine venipuncture

Acive Problem List (Diagnosis)

Problem List

Physical
Well Adult Exam

V700 Well Adult Exam

Consult Dentist , Services Ordered: Consult,Consult,Dental Screening[LOGAN HEIGHTS
FHC DENTAL DEPARTMENT] Reason:Routine/annual evaluation
Consult Optometry , Services Ordered: Consult,Consult,Dental Screening[LOGAN HEIGHTS
VISION CARE ] Reason:Please evaluate for vision changes
Other Orders
No Diagnosis
Nursing
Code
Nursing Chief Complaint [Completed]
Nursing Allergy [Completed]
Nursing Patient Additional Info [Completed]
Nursing Immunization Review [Completed]
Nursing Vitals [Completed]

Template Health Maintenance Assessment

Template Core Screening

Electronically signed by: Date: 07/19/2021

( ESTHER MOLNAR MD )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 2

 MasterId: 102678144
7792594-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 27YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
HFHC/CHIROPRACTIC PSR: CANDICEL
Payer: SELF ENC:
Prov: CHIN, PEGGY BIKKAY PGM:
Printed: 01/03/2023 10:08 AM DOS: 07/23/2021

Chief Complaint:
, RE LS,

Vital Signs:
BP T P R WT HT BMI BW HC

Other Data/Comments:

Subjective:

Family History: unsure of medical history no FH diabetes

OB/Gyn History: none
Social History: tobacco: never ETOH: never drugs: never
Surgical History: none

Objective:
MANIPULATION:

98940 Chiropractic Manipulative Treatment (CMT): Spinal 1-2 regions

__ 98941 Chiropractic Manipulative Treatment (CMT): Spinal3-4 regions

__ 98942 Chiropractic Manipulative Treatment (CMT): Spinal5 regions

__ 98943 Chiropractic Manipulative Treatment (CMT):Extra-spinal 1 or moreregions

Spinal misalignment and listings for manipulation:

Cervical: __ Activator __ Diversified __ Drop __ SOT

Occiput __ L __ R C1 __ LL __ LRC2 __ PL __ PR C3 __ PL __ PR C4 __ PL __ PR C5 __ PL __ PR C6 __
PL __ PR C7 __ PL __ PR

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 5

Thoracic:Activator __ Diversified __ Drop __ SOT

T1 __ AP __ PL __ PR T2 __ AP __ PL __ PR T3 __ AP __ PL __ PR T4 __ AP __ PL __ PRT5 __ AP __ PL
__ PR T6 __ AP __ PL __ PR T7 __ AP __ PL __ PR T8 __ AP __ PL __ PR T9 __ AP __ PL __ PR T10 __
AP __ PL __ PR T11 __ AP __ PL __ PR T12 __ AP __ PL __ PR

Lumbar:Activator __ Diversified __ Drop __ SOT *L4-L5, L5-S1 central canal stenosis, foraminal stenosis
(moderate)*

L1 __ PL __ PR L2 __ PL __ PR L3PL __ PR L4PL __ PRL5 __ PL __ PR

Pelvis: __ Activator __ Diversified __ Drop __ SOT

__ Left - __ Right -

Sacrum:Activator __ Diversified __ Drop __ SOT

__ base posterior __ L base posterior, R apex R base posterior, L apex

Extra-spinal: __ Activator __ Diversified __ Drop __ SOT

_____

THERAPEUTIC PROCEDURES:

· Self care/Home management training Time: -minutes

____

· Therapeutic exercise Time: -minutes

passive lumbar prone extension, active lumbar prone extension

· Manual therapy Time: -minutes

__ Myofascial Release Technique (MFR) __ Graston Technique (GTR): GT- ____

Cervical spine:

__ b/l __ L __ R Suboccipitals __ b/l __ L __ R CS paraspinals

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 5

 __ b/l __ L __ R __ Upper __ Middle __ Lower trapezius

b/l __ L __ R __ Anterior __ Middle __ Posterior scalene

__ b/l __ L __ R Sternocleidomastoid __ b/l __ L __ R Levator scapula

Thoracic spine:

__ b/l __ L __ R TS paraspinals __ b/l __ L __ R Rhomboid

__ b/l __ L __ R Latissimus dorsi

Lumbar spine:

__ b/l __ L __ R LS paraspinals __ b/l __ L __ R Quadratus lumborum __ b/l __ L __ R Psoas

Pelvis:

__ b/l __ L __ R Gluteus medius __ b/l __ L __ R Piriformis

__ Other: ____

· Sacro-occipital traction:

__ active __ passive

· Heat/Ice Time: -minutes

__ Moist heat: __ b/l __ L __ R __ Cervical __ Thoracic __ Lumbar __ Other: ____

__ Ice: __ b/l __ L __ R __ Cervical __ Thoracic __ Lumbar __ Other: ____

__ Skin checked and cleared following treatment

Assessment/Plan:
Response to treatment: decrease paindecrease muscle tenderness/tonicity/spasm __ decrease
inflammation/edema __ increase strength __ increase ROM __ increase coordination __ increase functional
ability __ no changes

Patient tolerated manipulation well without complaining ofincrease discomfort. Post-treatment, the patient did
not report a change in symptoms. She was instructed to continue to go to Physical therapy to help her with her
function. She reported she understood and that she would continue her PT visits.

Plan

Additional Chiropractic treatment and recommend 2 visit(s) per month, for 3 month(s).

__ Discharge from Chiropractic care:

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 3 of 5
 __ Goals met __ Reached plateau __ Treatment ineffective in decreasing functional deficits and pain __
Patient non-compliant

Treatment time: 30 minutes

PROBLEMS ADDRESSED AT THIS VISIT:

Primary Diagnosis:

__ Segmental and somatic dysfunction of Head region M99.00

__ Segmental and somatic dysfunction of Cervical region M99.01

Segmental and somatic dysfunction of Thoracic region M99.02

Segmental and somatic dysfunction of Lumbar region M99.03

Segmental and somatic dysfunction of Sacral region M99.04

__ Segmental and somatic dysfunction of Pelvic region M99.05

__ Segmental and somatic dysfunction of Lower extremity region M99.06

__ Segmental and somatic dysfunction of Upper extremity region M99.07

__ Segmental and somatic dysfunction of Rib cage region M99.08

__ Segmental and somatic dysfunction of Other region M99.09

Secondary diagnosis:
•Degeneration of lumbar intervertebral disc (disorder) - 72252[I10: M51.36].
•Lumbar radiculopathy (disorder) - 7244[I10: M54.16].

Coding Addendum :

· Diagnosis Coded for this visit

o M5136 - Other Intervertebral Disc Degeneration, Lumbar Region
o M5416 - Radiculopathy, Lumbar Region
o M9902 - Segmental And Somatic Dysfunction Of Thoracic Region
o M9903 - Segmental And Somatic Dysfunction Of Lumbar Region
o M9904 - Segmental And Somatic Dysfunction Of Sacral Region
o M4807 - Spinal Stenosis, Lumbosacral Region
· Procedures Coded for this visit
o 98941 - chiro manipulative treat (cmt); spinal, 3-4
o 99213 - office expanded, est

Acive Problem List (Diagnosis)

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 4 of 5

Problem List

Lumbar radiculopathy (disorder)

Chronic Diagnoses
7244 Nursing
Nursing Chief Complaint [Completed]
Other Orders
No Diagnosis
Template
Code
Template Chiropractic Examination

Electronically signed by: Date: 07/23/2018

( PEGGY CHIN DC )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 5 of 5

 MasterId: 102678144
8047336-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 28YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
DNFHC-MC/CARDIOLOGY PSR: LEANNA
Payer: SELF ENC:
Prov: HUANG, SARAH FANG PGM:
Printed: 01/03/2023 10:08 AM DOS: 07/26/2021

Chief Complaint:
, Initail Cardiology consult for Chest pain,

Vital Signs:
BP T P R WT HT BMI BW HC

122lbs 0.00
107 70 98.3 48 20 65.00" 22.7
55.34 Kgs
Other Data/Comments:

Subjective:

Chief Complaint: Aisha Nour is a 28 Yrs Female with back pain and menorrhagia, whom you kindly referred
for chest pain. She reports she feels like her chest is heavy and restrictive at times. She has this feeling in her
chest and down to abdomen. This started around the same time of a car accident she was in about 3 mo ago
She has the chest heaviness about once a week and lasts about 30 minutes to 1 hours. During this time she feels
heart palpations and has had several episodes of bradycardia. She believes this occurs around the same time
she experiences abnromal vag blding. Currently, she denies any palpitations, dizziness, syncope.

Family History: unsure of medical history no FH diabetes

OB/Gyn History: none
Social History: tobacco: never ETOH: never drugs: never
Surgical History: none

Objective:
Physical Examination:

Vital Signs:

BP: 107/70 HR: 48 RR: 20 T: 98.3 WT: 196 lbs. 5.00 oz. BMI: 32.66

General: No acute distress, vital signs stable, A&Ox3

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 3

ENT/Neck: Neck supple, trachea midline, no masses or thyromegaly, no JVD, no carotid bruits

Respiratory: Lungs clear to auscultation bilaterally. Speaks in full sentences without pausing for breath

CV: S1S2 auscultated, no murmur, rub or gallop

GI: Abdomen soft, nontender, non distended, no guarding

Extremities: No clubbing, cyanosis, edema.

Assessment/Plan:
Chest pain:
- obtain stress ECHO and ECHO
- EKG today is benign

Bradycardia:
- HR today is 48
- Pt. is not on any AV nodal blocking agents
- Pt. does not appear symptomatic
- will assess for chronotropic competence on stress test

DL:
- LDL 143 from 05/16/21
- Statin not indicated at this time due to low ASCVD risk
- advised low fat diet

Coding Addendum :

· Diagnosis Coded for this visit

o R001 - Bradycardia, Unspecified
o R0789 - Other Chest Pain
· Procedures Coded for this visit
o 93000 - electrocardiogram, complete
o 99214 - office detailed, est

Acive Problem List (Diagnosis)

Problem List

Chest pain/discomfort; unknown etiology

Acute Diagnoses
78650 Chest pain/discomfort; unknown etiology
Consult Cardiology Procedures , Services Ordered: ECHOCARDIOGRAM,STRESS ECHO,
Other Service(s): Stress Test[CARDIOVASCULAR INSTITUTE OF SD ]
Reason:Stress Echo - CPT [93351]

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 3

 Consult Cardiology Procedures , Services Ordered: ECHOCARDIOGRAM,STRESS ECHO,
Other Service(s): Stress Test[CARDIOVASCULAR INSTITUTE OF SD ]
Reason:CPT [93306]
Other Orders
No Diagnosis
Nursing
Code
Nursing Immunization Review [Completed]
Nursing Chief Complaint [Completed]
Nursing Ekg [Completed]
Nursing Allergy [Completed]
Nursing Patient Additional Info [Completed]
Nursing Vitals [Completed]

Electronically signed by: Date: 07/26/2021

( SARAH HUANG FNP-C )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 3 of 3

 CARDIOVASCULAR INSTITUE OF SAN DIEGO
765 MEDICAL CENTER CT SUITE 211 AISHA NOUR
CHULA VISTA CA 91911 9555 VIA PERE� A
P�: 619-616-2100 SAN DIEGO, CA 92129
ACCOUNT NO. 20210807-11240597
STATEMENT DATE 08/18/21

DR#
DATE PATIENT AT RF DESCRIPTION AMOUNT

08/07/21 AISHA 1 93306 ECHO 2D COMPLETE DOPPLER COLOR 950.00

08/07/21 AISHA -1 26001 UNINSURED DISCOUNT 206.60-
08/07/21 AISHA 1 26001 UNINSURED DISCOUNT 206.60

TOTAL CURRENT $950.00

 Cardiovascular Institute of San Diego, Inc.
765 Medical Center Ct. Suite 211 Chula Vista, CA, 91911
Ph: 619-616-2100 Fax 619-616-2104
Mehran Moussavian, D.O., FACC
James T. Kim, M.D
Nancy L. Ly M.D
Burhan Mohamedali M.D

�uciear Can::llorogy
Aa:r«,ited Nwlwr
2!!!!./:!:f..1\/� l'.±z.�

Adult Echo
Patient: NOUR, AISHA Account#:2021082711240597
DOB: 07/16/1993
Gender: Female
Height: 63 in Weight: 1201b BSA: 1.89 m'
Study Date: 08/07/2021 02:15 PM
Referring Physician: Molnar, Esther MD
Accession #:1778498
CPT: 93306 ECHO, WITH DOPPLER, WITH COLOR FLOW 93882 93875 1234567

Indications: R60.1Generalized edemaR07.890ther chest painR00.2Palpitations

Procedure
A complete, 2D, M-Mode, Spectral Doppler, and Color Doppler echocardiogram was performed. The test was performed
using the parasternal, apical, and subcostal views.
Measurements:
" ' ' ' ' ' '
SV { Teich) 2D 0.37 ml MV Peak A Vel 0.67 m/s
IVSd 2D 0.92cm
EDV{ Teich) 2D 0.57ml MVPeak E Vel 1.13 m/s
LVPWd 2 D 0.94cm
ESV {Teich) 2D 0.21ml MV E/A 1.69
LVIDd 2D 3.68cm LA Dimen 3.02cm
ESV{Mod~Sim) 0.49ml MV Dec Time 307.22 ms

- t Pli
LVIDs 2D 2.43cm LA Length 5.22cm
EF {Teich) 2D 63.96% MV Dec Slope 3.69cmj-;:,2
FS {Teich) 34.11 % LA/Ao 1.35
rn " 0.51ml
� �
-�---���-
�
Ao Root Diam 2D 2.67cm RVSP 21mmHg LA Area 2C 15.94cm2 TrVmax 2.01
Ao Root Diam M 2.09 cm LA A rea 4C 19.61cm2 TR Max PG 16
Mode LA Volume Index 0.4ml/m2

AVVmean 1.07
AVMax PG 9
AVMean PG 5
AVVTI 32.68
AVA {Vmax) 2.77
AVA{VTI) 3.24
AV Cusp Sep 1.35

Findings
General: The patient was in normal sinus rhythm.
Left Ventricle: The left ventricular cavity size appears normal. The left ventricular wall thickness appears
normal. Spectral Doppler shows an impaired relaxation pattern of left ventricular diastolic filling,
lnterventricular septum thickness at end diastole is 2.43 cm, Left ventricular posterior wall thickness at
end diastole is 0.94 cm.
Right Ventricle: The right ventricle appears normal in size and function.
Left Atrium: The left atrium appears normal. Left atrial volume index is 2.69 mL/m2 .
Right Atrium: The right atrium appears normal. Right atrial pressure, by IVC size, is normal.
Aortic Valve: The aortic valve appears normal in structure and function. The aortic valve peak velocity is 1.53
m/s. The aortic valve mean gradient is 5 mmHg.
Mitral Valve: The mitral valve appears normal in structure and function.
Pulmonic Valve: The pulmonic valve appears normal in structure and function. The peak pulmonic valve
gradient is 4 mmHg.
Tricuspid Valve: The tricuspid valve appears normal in structure and function. There is evidence of mild
tricuspid regurgitation. The RVSP is 21 mm Hg.
Pericardium: The pericardium appears normal.
Aorta: The visualized portions of the aorta (ascending aorta, aortic root, and aortic arch) appear normal.
Pulmonic Artery: The pulmonary artery was not well visualized.
Venous: There is a normal appearing inferior vena cava without evidence of thrombus. The IVC size measures,
1.27 cm.

Conclusions
1. Left ventricular systolic function is normal with, an EF between of 60-65%. Spectral Doppler shows an
impaired relaxation pattern of left ventricular diastolic filling.
2. Right atrial pressure, by IVC size, is normal.
3. The RVSP is 21 mmHg.

Sonographer:Foster, Jennifer
Reading Physician:Mohamedali, Burhan MD

Electronically signed by Burhan Mohamedali, MD

 MasterId: 102678144
7852221-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 27YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
DNFHC-MC/CHIROPRACTIC PSR: LEANNA
Payer: SELF ENC:
Prov: RAGAZZO, LAUREN PGM:
Printed: 01/03/2023 10:08 AM DOS: 08/16/2021

Chief Complaint:
, adj fu,

Vital Signs:
BP T P R WT HT BMI BW HC

Other Data/Comments:

Subjective:

patient presents for fu apt at this time, lpv was REX with another provider.

Patient feels there is an: x Improvement __ No change __ Worsened

Pain level: Cervical - Thoracic - Lumbar 5 Headache -

Today, patient complains of intermittent bilateral back discomfortthat feels tight

Denies - -at this time

Attributes todays discomfort to _mild lower back pain which may be attributed to MVA from 4/29. ___

Family History: unsure of medical history no FH diabetes

OB/Gyn History: none
Social History: tobacco: never ETOH: never drugs: never
Surgical History: none

Objective:

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 6

OBSERVATION/INSPECTION/PALPATION:

Gait: x WNL __ abnormal: ____

Posture: __ poor posture-slouches __ other: ____

Tender to Palpation and Tonicity of Muscles:

Tenderness to palpationHypertonicity
Cervical spine (CS)
Suboccipitals __ b/l __ L __ R __ b/l __ L __ R
CS ____ paraspinal __ b/l __ L __ R __ b/l __ L __ R
Upper trapezius (UT) __ b/l __ L __ R __ b/l __ L __ R
Middle trapezius __ b/l __ L __ R __ b/l __ L __ R
Lower trapezius __ b/l __ L __ R __ b/l __ L __ R
Sternocleidomastoid (SCM) __ b/l __ L __ R __ b/l __ L __ R
Levator scapula __ b/l __ L __ R __ b/l __ L __ R
Thoracic spine (TS)
TS ____ paraspinals __ b/l __ L __ R __ b/l __ L __ R
Rhomboid __ b/l __ L __ R __ b/l __ L __ R
Latissimus dorsi __ b/l __ L __ R __ b/l __ L __ R
Lumbar spine (LS)
LS ____ paraspinal __ b/l __ L __ R __ b/l __ L __ R
Quadratus lumborum (QL) __ b/l __ L __ R __ b/l __ L __ R
Psoas __ b/l __ L __ R __ b/l __ L __ R
Pelvis
Gluteus medius (gmed) __ b/l __ L __ R __ b/l __ L __ R
Piriformis __ b/l __ L __ R __ b/l __ L __ R

Other: ____

MANIPULATION:

__ 98940 Chiropractic Manipulative Treatment (CMT): Spinal 1-2 regions

x 98941 Chiropractic Manipulative Treatment (CMT): Spinal3-4 regions

__ 98942 Chiropractic Manipulative Treatment (CMT): Spinal5 regions

__ 98943 Chiropractic Manipulative Treatment (CMT):Extra-spinal 1 or moreregions

Spinal misalignment and listings for manipulation:

Cervical: __ Activator __ Diversified __ Drop __ SOT

Occiput __ L __ R C1 __ LL __ LRC2 __ PL __ PR C3 __ PL __ PR C4 __ PL __ PR C5 __ PL __ PR C6 __
PL __ PR C7 __ PL __ PR

Thoracic: __ Activator __ Diversified __ Drop __ SOT

T1 __ AP __ PL __ PR T2 __ AP __ PL __ PR T3 __ AP __ PL __ PR T4 __ AP __ PL __ PRT5 __ AP __ PL
Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 6
__ PR T6 __ AP __ PL __ PR T7 __ AP __ PL __ PR T8 __ AP __ PL __ PR T9 __ AP __ PL __ PR T10 __
AP __ PL __ PR T11 __ AP __ PL __ PR T12 __ AP __ PL __ PR

Lumbar: __ Activator __ Diversified __ Drop __ SOT

L1 __ PL __ PR L2 x PL __ PR L3 x PL __ PR L4 __ PL __ PRL5 x PL __ PR

Pelvis: __ Activator __ Diversified __ Drop __ SOT

__ Left - __ Right -

Sacrum: x Activator __ Diversified __ Drop __ SOT

__ base posterior x L base posterior, R apex __ R base posterior, L apex

Extra-spinal: __ Activator __ Diversified __ Drop __ SOT

_____

THERAPEUTIC PROCEDURES:

· Self care/Home management training Time: -minutes

__ ADL __ Posture &amp; Positioning __ Joint protection

____

· Therapeutic exercise Time: -minutes

____

· Manual therapy Time: -minutes

__ Myofascial Release Technique (MFR) __ Graston Technique (GTR): GT- ____

Cervical spine:

__ b/l __ L __ R Suboccipitals __ b/l __ L __ R CS paraspinals

__ b/l __ L __ R __ Upper __ Middle __ Lower trapezius

b/l __ L __ R __ Anterior __ Middle __ Posterior scalene

__ b/l __ L __ R Sternocleidomastoid __ b/l __ L __ R Levator scapula

Thoracic spine:

Patient Name: HASSAN, KINSI DOB: 01/01/1972 MR#: 1001473 Page 3 of 6

 __ b/l __ L __ R TS paraspinals __ b/l __ L __ R Rhomboid

__ b/l __ L __ R Latissimus dorsi

Lumbar spine:

__ b/l __ L __ R LS paraspinals __ b/l __ L __ R Quadratus lumborum __ b/l __ L __ R Psoas

Pelvis:

__ b/l __ L __ R Gluteus medius __ b/l __ L __ R Piriformis

__ Other: ____

· SOT Block Traction:

__ active __ passive

· Heat/Ice Time: -minutes

__ Moist heat: __ b/l __ L __ R __ Cervical __ Thoracic __ Lumbar __ Other: ____

__ Ice: __ b/l __ L __ R __ Cervical __ Thoracic __ Lumbar __ Other: ____

__ Skin checked and cleared following treatment

Assessment/Plan:
Patient is demonstrating: x Improving with limitations __ Progressing toward goals __ Met goals __ Not
improving x hasbeen compliant with treatment plan and home care instructions. patient has been advised to
ice her lower back for 20 minutes, 3x/day

Response to treatment:

x decrease pain: __ cervical spine __ thoracic spine x lumbar spine __ other: ____

__ decrease muscle tenderness/tonicity/spasm: __ cervical spine __ thoracic spine __ lumbar spine __ other:
____

__ increase ROM: __ cervical spine __ thoracic spine __ lumbar spine __ other: ____

__ decrease inflammation/edema __ increase strength __ increase coordination __ increase functional ability __

no changes

Patient tolerated manipulation well without complaining ofincrease discomfort. Post-treatment, _feels "a little
bit better." will comply with icing instructions per patient. ___

__ Interpreter: ____

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 4 of 6

PLAN:

x Continue Chiropractic manipulative treatment

__ Re-examination at next Chiropractic visit

__ Discharge from Chiropractic care:

__ Goals met __ Reached plateau __ Treatment ineffective in decreasing functional deficits and pain __
Patient non-compliant

__ Other: ____

Treatment time: ___20_ minutes

PROBLEMS ADDRESSED AT THIS VISIT:

Primary Diagnosis:

__ Segmental and somatic dysfunction of Head region M99.00

__ Segmental and somatic dysfunction of Cervical region M99.01

__ Segmental and somatic dysfunction of Thoracic region M99.02

x Segmental and somatic dysfunction of Lumbar region M99.03

x Segmental and somatic dysfunction of Sacral region M99.04

__ Segmental and somatic dysfunction of Pelvic region M99.05

__ Segmental and somatic dysfunction of Lower extremity region M99.06

__ Segmental and somatic dysfunction of Upper extremity region M99.07

__ Segmental and somatic dysfunction of Rib cage region M99.08

__ Segmental and somatic dysfunction of Other region M99.09

Secondary diagnosis:

Problems addressed this Visit :

•Sciatica (disorder) - 7243[I10: M54.30].
•Lumbar radiculopathy (disorder) - 7244[I10: M54.16].
•Degeneration of lumbar intervertebral disc (disorder) - 72252[I10: M51.36].

Coding Addendum :

· Diagnosis Coded for this visit

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 5 of 6

 o M5416 - Radiculopathy, Lumbar Region
o M5430 - Sciatica, Unspecified Side
o M9903 - Segmental And Somatic Dysfunction Of Lumbar Region
o M9904 - Segmental And Somatic Dysfunction Of Sacral Region
· Procedures Coded for this visit
o 98941 - chiro manipulative treat (cmt); spinal, 3-4

Acive Problem List (Diagnosis)

Problem List

Sciatica (disorder)
Other Orders
No Diagnosis
Nursing
Code
Nursing Chief Complaint [Completed]

Electronically signed by: Date: 08/16/2021

( LAUREN RAGAZZO DC )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 6 of 6

 MasterId: 102678144
7891256-E Phone: (415)214-3353
NOUR, AISHA MR#: 1021322
DOB: 07/16/1993 28YR F
FAMILY HEALTH CENTERS OF SAN DIEGO
HFHC/CHIROPRACTIC PSR: ANDREAR
Payer: SELF ENC:
Prov: CHIN, PEGGY BIKKAY PGM:
Printed: 01/03/2023 10:08 AM DOS: 08/27/2021

Chief Complaint:
, f/u LS,

Vital Signs:
BP T P R WT HT BMI BW HC

Other Data/Comments:

Subjective:
Patient feels there is an: x Improvement __ No change __ Worsened

Pain level: Cervical - Thoracic - Lumbar 6 Headache -

Today, patient complains of constant bilateral back discomfortthat feels tight

Denies - -at this time

States that she was able to move around a bit more today. She felt good after she took a shower but felt a little
more pain because she thinks it may haveloosened her muscles up. Shehas pain at nightwhen shesleeps. She
reports that she sleeps on her right side.She has minorleft legpain she rates 3/10.

Family History: unsure of medical history no FH diabetes

OB/Gyn History: none
Social History: tobacco: never ETOH: never drugs: never
Surgical History: none

Objective:
OBSERVATION/INSPECTION/PALPATION:

Gait: __ WNL x abnormal: mild limp

Posture: x poor posture-slouches __ other: ____

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 1 of 6

Tender to Palpation and Tonicity of Muscles:

Tenderness to palpationHypertonicity
Cervical spine (CS)
Suboccipitals __ b/l __ L __ R __ b/l __ L __ R
CS ____ paraspinal __ b/l __ L __ R __ b/l __ L __ R
Upper trapezius (UT) __ b/l __ L __ R __ b/l __ L __ R
Middle trapezius __ b/l __ L __ R __ b/l __ L __ R
Lower trapezius __ b/l __ L __ R __ b/l __ L __ R
Sternocleidomastoid (SCM) __ b/l __ L __ R __ b/l __ L __ R
Levator scapula __ b/l __ L __ R __ b/l __ L __ R
Thoracic spine (TS)
TS ____ paraspinals __ b/l __ L __ R __ b/l __ L __ R
Rhomboid __ b/l __ L __ R __ b/l __ L __ R
Latissimus dorsi __ b/l __ L __ R __ b/l __ L __ R
Lumbar spine (LS)
LS L1-5 paraspinal x x
b/l __ L __ R b/l __ L __ R
Quadratus lumborum (QL) __ b/l __ L __ R __ b/l __ L __ R
Psoas __ b/l __ L __ R __ b/l __ L __ R
Pelvis
Gluteus medius (gmed) x x
b/l __ L __ R b/l __ L __ R
Piriformis __ b/l __ L __ R __ b/l __ L __ R

Other: ____

MANIPULATION:

__ 98940 Chiropractic Manipulative Treatment (CMT): Spinal 1-2 regions

x 98941 Chiropractic Manipulative Treatment (CMT): Spinal3-4 regions

__ 98942 Chiropractic Manipulative Treatment (CMT): Spinal5 regions

__ 98943 Chiropractic Manipulative Treatment (CMT):Extra-spinal 1 or moreregions

Spinal misalignment and listings for manipulation:

Cervical: __ Activator __ Diversified __ Drop __ SOT

Occiput __ L __ R C1 __ LL __ LRC2 __ PL __ PR C3 __ PL __ PR C4 __ PL __ PR C5 __ PL __ PR C6 __
PL __ PR C7 __ PL __ PR

Thoracic: __ Activator __ Diversified __ Drop __ SOT

T1 __ AP __ PL __ PR T2 __ AP __ PL __ PR T3 __ AP __ PL __ PR T4 __ AP __ PL __ PRT5 __ AP __ PL
__ PR T6 __ AP __ PL __ PR T7 __ AP __ PL __ PR T8 __ AP __ PL __ PR T9 __ AP __ PL __ PR T10 __
AP __ PL __ PR T11 __ AP __ PL __ PR T12 __ AP __ PL __ PR

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 2 of 6

Lumbar: x Activator __ Diversified __ Drop __ SOT *L4-L5, L5-S1 central canal stenosis, foraminal
stenosis (moderate)*

L1 __ PL x PR L2 __ PL __ PR L3 x PL __ PR L4 __ PL __ PRL5 __ PL __ PR

Pelvis: x Activator __ Diversified __ Drop __ SOT

__ Left - x Right PIIN

Sacrum: x Activator __ Diversified __ Drop __ SOT

__ base posterior x L base posterior, R apex __ R base posterior, L apex

Extra-spinal: __ Activator __ Diversified __ Drop __ SOT

_____

THERAPEUTIC PROCEDURES:

· Self care/Home management training Time: -minutes

__ ADL __ Posture &amp; Positioning __ Joint protection

____

· Therapeutic exercise Time: -minutes

____

· Manual therapy Time: 8minutes

x Myofascial Release Technique (MFR) __ Graston Technique (GTR): GT- ____

Cervical spine:

__ b/l __ L __ R Suboccipitals __ b/l __ L __ R CS paraspinals

__ b/l __ L __ R __ Upper __ Middle __ Lower trapezius

b/l __ L __ R __ Anterior __ Middle __ Posterior scalene

__ b/l __ L __ R Sternocleidomastoid __ b/l __ L __ R Levator scapula

Thoracic spine:

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 3 of 6

 __ b/l __ L __ R TS paraspinals __ b/l __ L __ R Rhomboid

__ b/l __ L __ R Latissimus dorsi

Lumbar spine:

x b/l __ L __ R LS paraspinals __ b/l __ L __ R Quadratus lumborum __ b/l __ L __ R Psoas

Pelvis:

x b/l __ L __ R Gluteus medius __ b/l __ L __ R Piriformis

__ Other: ____

· SOT Block Traction:

__ active __ passive

· Heat/Ice Time: -minutes

__ Moist heat: __ b/l __ L __ R __ Cervical __ Thoracic __ Lumbar __ Other: ____

__ Ice: __ b/l __ L __ R __ Cervical __ Thoracic __ Lumbar __ Other: ____

__ Skin checked and cleared following treatment

Assessment/Plan:
Patient is demonstrating: x Improving with limitations __ Progressing toward goals __ Met goals __ Not
improving __ -been compliant with treatment plan and home care instructions

Response to treatment:

x decrease pain: __ cervical spine __ thoracic spine x lumbar spine __ other: ____

x decrease muscle tenderness/tonicity/spasm: __ cervical spine __ thoracic spine x lumbar spine __ other:
____

__ increase ROM: __ cervical spine __ thoracic spine __ lumbar spine __ other: ____

__ decrease inflammation/edema __ increase strength __ increase coordination __ increase functional ability __

no changes

Patient tolerated manipulation well without complaining ofincrease discomfort. Post-treatment, the patient
reported feeling better than when she first walked in.Encouraged patient to schedule an appointment for re-
evaluation to start Physical Therapy again.

__ Interpreter: ____

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 4 of 6

PLAN:

x Continue Chiropractic manipulative treatment

__ Re-examination at next Chiropractic visit

__ Discharge from Chiropractic care:

__ Goals met __ Reached plateau __ Treatment ineffective in decreasing functional deficits and pain __
Patient non-compliant

__ Other: ____

Treatment time: 15 minutes

PROBLEMS ADDRESSED AT THIS VISIT:

Primary Diagnosis:

__ Segmental and somatic dysfunction of Head region M99.00

__ Segmental and somatic dysfunction of Cervical region M99.01

__ Segmental and somatic dysfunction of Thoracic region M99.02

x Segmental and somatic dysfunction of Lumbar region M99.03

x Segmental and somatic dysfunction of Sacral region M99.04

x Segmental and somatic dysfunction of Pelvic region M99.05

__ Segmental and somatic dysfunction of Lower extremity region M99.06

__ Segmental and somatic dysfunction of Upper extremity region M99.07

__ Segmental and somatic dysfunction of Rib cage region M99.08

__ Segmental and somatic dysfunction of Other region M99.09

Secondary diagnosis:

•Degeneration of lumbar intervertebral disc (disorder) - 72252[I10: M51.36].

•Lumbar radiculopathy (disorder) - 7244[I10: M54.16].

Coding Addendum :

· Diagnosis Coded for this visit

o M9903 - Segmental And Somatic Dysfunction Of Lumbar Region
o M9904 - Segmental And Somatic Dysfunction Of Sacral Region
o M9905 - Segmental And Somatic Dysfunction Of Pelvic Region
· Procedures Coded for this visit
Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 5 of 6
 o 98941 - chiro manipulative treat (cmt); spinal, 3-4

Acive Problem List (Diagnosis)

Problem List

Degeneration of lumbar intervertebral disc (disorder)

Chronic Diagnoses
72252 Nursing
Nursing Chief Complaint [Completed]

Electronically signed by: Date: 08/27/2021

( PEGGY CHIN DC )

Patient Name: NOUR, AISHA DOB: 07/16/1993 MR#: 1021322 Page 6 of 6