l (b)(6); (b)(7)(C) From: Sent : To : . 27 Jul 2018 14:14:27 +0000 l(b)(6); (b)(7)(C) l Subject: FW: ALMAZAN Attachments : ALMAZAN DDR Medical Narrative - Glades County Detention Center .docx, ALMAZAN DDR Medical Narrative - Krome North Service Processing Center.docx, ALMAZAN DDR Medical Narrat ive Polk County Adult Detention Center.docx FYI Subject : ALMAZAN (b)(6); / h \/ 7 \ff -..\ i~\i~\rr., dn't do timelines but instead, did three separate narrat ives. Here they are. Please give me a call when you have a chance. (b)(6); (b)(7)(C) 2020-ICLl-00006 2514 Detainee Death Review: ALMAZAN-Ruiz, Felipe A028866428 Medical Compliance Analysis Glades County Detention Center Moore Haven, Florida Medical Staffing Armor Correctional Health Services (ACHS), with headquarters in Miami , Florida has provided 24-hour medical care since the facility's activation in June 2007. GCDC earned their most recent accreditation through the National Commission on Correc tional Healthcare (NCCHC) in May 2017, and at the current time, eight medical employees have earned status as Certified Correctional Health Professionals (CCHP) 1• Full time position s include the Director of N urses (DON), a licensed clinical social worker, the Administrative Assistant , and the Health Services Administrator (HSA), the latter of whom is not a clinician but has a health services administration background. Three part time registered nurses (RN) provide a total of 56 hours per week, and 13 part time licensed practical nurses (LPN) provide 460 hours per week. Other part time positions include a mental health physician assistant, two licensed mental health professionals , a dentist , and a dental assistant. The Clinical Director , a CCHP is licensed in Puerto Rico and Florida , with certification to work in critical need areas. He is available on site for clinical services four days per week. Staffing numbers were found to be sufficient for the provision of detainee healthcare, in accordance with the NDS, and all professional licenses were present, current and primary source verified. Summary of Events On Saturday, August 12, 2017, at 3: 15 a.m.j; (b)(?)(C) tated low platelets wou ld not affect clearance for air travel, and even with a low hemoglobin leve l of 10.5, " I would still clear someone at tho se leve ls 5); (b)( to fly." In discussion of the transfer summary , which omitted serious diagnosesJ C 5 >; (b)(?)(C) Ir fillin My EYES DRY. PLEASE I need My GLASES Please When I go To Court They Give to mi but I canT SEE NO THING My EYES I filling Burning and MY HEAD I HA VE PAIN So I need My GLASES Pleas (b)(6); (b)(?)(C) The sick call response was left blank, ~ request was signed as receive ... _ ,_ eon ugust 21, 2017 . During interview LPN ~eviewed the medical record and verified a sick call encoun ter was not present , stating that he was not seen in nursing sick call because he had a pending appointment with the provider for this eva luation. I Advanced Registered Nurse Practitioner (ARNP) conducted a provider assessme nt on August 22, 2017, at 3:17 p.m. to address ALMAZAN ' s complaint s of, "I am having a lot of pain in my joints. I cannot see, either. I had glasses at Krome but they say they are not in my ICb)(B); (b)(?)(C) DETAINEEDEATHREVIEW: Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 2568 property here. My vision is very bad. The medication is helping some, but I still can only sleep two to three hour s." There is no documentation of barriers to communication, languag e preference , or use of interpretat ion assistance. l(b)(5); (b)(?)(C) ~ocumented his extens ive history of alcohol dependence , and noted he was currently taking Zoloft and trazodone with some benefit. He was described as cooperative with a congr uent affect78, logical thought process , anxious mood, and a restless and fidgety manner. There is no object ive assessment, includin g vital signs. The treatme nt plan was to continue Zoloft 100 mg daily and increase trazodone to 75 mg nightly to impro ve his insomnia. A Specific Authorization for Psychotropic Medications form was signed by ALMAZAN, but the specific medication was not indicated with a check mark. The treatment plan did not address the · t of vision difficulty. He was electronically sched uled for follow-up in 60 days. As NP o longer works for GCDC, an interview could not be conducted to clarify if the encounter was intended to serve only as a mental health follow-up , as opposed to a sick call assessment. Kb)(6) ; (b)(7)(C) The initial health assessment was conducted by L RN on August 24, 2017 , at 2:33 p.m., with review and approved electronic signatu re oj(b)(6); Ion September 5, 2017. A review of the training and credentials file showed RN Bonner was trained for conducting initial medical and dental assessments on Janua1y 12, 2016 and on August 22, 2017. Detainee ALMAZAN identified current complaints as right knee pain and vision difficulty. He denied blood in his sputum, blood in his stools, or black tarry stools 79• His vita l signs and physical assessment were all within normal limits, including the abdomen , which was described as having normal bowel sounds and no masses or tenderness. Tremor s were not observed, and his gait and coordination were normal. Examination of his skin showed no rashes, lesions 80 or infestations 8 1. ALMAZAN's visua l acuity using the Snellen Eye Chart measured 20/200 in the right eye, 20/200 in the left eye, and 20/200 in both eyes, without correction , for which he was refened to the doctor for visual disturbance. The dental screening found no missing teeth and "four upper implant s per patient." )~i)~i,c:, I A third sick call request was subm itted on August 27, 2017, in which ALMAZAN wrote, "I NEED SEE THE DOCTOR BECAUSE I have To Much Pain in My Bond's I Want Somthin XXXike Bengay is Hard THE PA A and I want A see The doctor THE LAST Went I see HE PuT in THE Sistem For Examen in My Eyes I Need glases PLE! I can'T Read NoThing I need Realy The Glases". The Triage Decision By Nursing Staff noted referral to nurse sick call and was signed two days later on August 29, 2017 , at 9:00 p.m. by l(b)(5); (b)(?)(C) ILPN 78 Congruent affect means a person's emotions are appropriate for the situation. 79 Black tarry stools can indicate bleeding in the upper portion of the digestive tract . 80 Lesions are regions of an organ or tissue which have suffered damage through injury or disease, such as a wound, ulcer or tumor. 81 Infestations refer to a state of being invaded or overrun with pests or parasites. DETAINEEDEATHREVIEW:Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii 111et i 1111 :s 2020-ICLl-00006 2569 I l(b)(5); (b)(?) (C) LPN, CCHP conducted a sick call assessment on August 30, 2017 , at 2:24 p.m. to address ALMAZAN's complaint of pa in in both shoulders and both knees . The pa in was described as moderate, co nstant and worsening. A pain scale was not used to determine pa in level. Vital signs were all recorded within normal limits. The genera l exam ination noted an uncomfortable appeara nce with tenderness on palpation. There was no swelling or gait abno rmality. The nursing assessmen t was Alterat ion in Comfort in joints. The plan was to prov ide ibupro fen 400 mg twice daily for fiv.,.__..........,c...u.,,needed in accordance with the Nurs ing Protocol on Muscular Skeletal problems. LPN ~) \~t -, noted, "NO history of bleeding ulcers." He was provided patient education and instructed to return to sick call if symptoms worsen or persist more than seve n days. Documentation fails to show ALMAZAN's comp laint of vision difficulty was addressed. During interv iew, LPN ~)\~t,--, who triaged this sick call req uest, offered that nurses allow only one complaint per sick call request and that the detainees are expected to submit an individual requ est for each c · they have, with the sick call nurse prioriti zing the issues. HSA l(bl(6); (b)(7)(C) and V )~( )~\ic): oth agreed }J--W"""""" ......."'l'. erview that the two issues absol utely should have been addressed in a single visit. o..:..:..:,..:....::.:.."--..... electronically approved the sick call assessment on August 31, 2017. I On September 1, 2017, ALMAZAN comple ted a fourth sick call request, stating , "I Need See The Docto r The Name of1(b)(6); (b)(7)(C) II wan 'T To Se becase I ned Glases THE Nurse OnL Y No GIME Apoimen For Opticol I have Pain in Myy Head and My EYES in My EYES I fell likefire and The Peop le I see Strange Aron' T Read No thing Please I need See THE DOCTOR For My Apo inmenT an Medicinefo EYES LiKe Vicine SO...._ on-site medical services one six-hour day per week. For medica l reaso (b)(5 ); (b)(l )(C) DETAINEEDEATHREVIEW: Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti11 11:s 2020-ICLl-00006 2575 MD was not available during the three days detainee ALMAZAN was at the facility, and therefore he was unfamiliar with the case. He was not interviewed during this review . A part time ce1tified physician ass istant is on site from 6:00 p.m. to 7:00 p.m. on Mondays, Tuesdays, and Thursdays. On call coverage is shared between the two providers. A licensed professional counse lor provides full time services, and an MTC psychiatrist is available via telemedicine four to six hours a week. Nw-sing staff includes a full time director of nw-ses (DON), three fulltime RNs and six licensed vocational nurses (LVN), all assigned twelve-hour shifts from six to six. Two medical assistants and one pharmacy techn ician provide clinical and administrative suppo rt. There were no vacancies at the time of the review. ODO finds staffing adequate to provide basic medical services for all detainees . A credent ial review found all profess ional licenses current and primary source verified. CHI St. Luk es in Livingston , approx imately six minute s from PCADC and Conroe Hospital, appro xima tely 50 miles are used for emergency and specialty care beyond the scope of services The PCADC medica l department consists of two examina tion rooms , a medical records room, xray room , med icatio n room with a pi ll pass window, and a health services admini strator (HSA) office . There are four medical observation cells, one suicide watch cell, and an infectio n control room with negative airflow. The detent ion officer 's desk is loca ted in the hallway , afford ing correctional supervision in the clinic. The clinic was found to be clean and adequately sized and equipped. PCADC uses hard copy medical records, with the except ion of chronic care appointm ent scheduling and electronic medication adm inistration reco rds. Detainees access sick call by filling out paper reques ts and depositing them into a locked box. Sick call request forms and deposit boxes were inconveniently located outside the locked cells in C Unit, where detainee ALMAZAN was housed. Acco rding to detain ees who were res iding in the same cell with detainee ALMAZAN, they request sick call forms from an officer and when completed put it up to the window so the officer who is making rounds can retrieve the requests. This practice does not ensure the confidentiality of detainees who request appointme nts for sensitive medica l problems. According to the detainee handbook , "Detainees desiring routine medical care will fill out a sick call request which will be picked up daily by the nursing staff." Officer rounds are conducte d through window observation only; however, intercoms are avai lable in those units for contacting officers on duty. Detention Summary Detainee ALMAZAN arrived at IAH/PCADC on Friday , September 8, 2017 . An I-203 Order to Detain form was presen t in the detention file but incorrectly liste d the detainee's name as "Alaman" and his date of birth as June 6, 1966, rather than th e correct date of June 26, 1966. Intake Officer l(b)(5); (b)(?)(C) b ted on interview that his main concern is ensuring the A numbers match and in this case-.......,The IAH/PCADC records document the detainee arrived at 4:00 (b)(6); p.m. However , Office tated the document would have indicated the time the information was ente red into the system, rathe r than the actual time of arrival. He was on duty the night the detainee arrived and recalled the bus arr ived later in th e eveni ng. Video surveillance footage from / h \/ 7 \/r-, DETAINEEDEATHREVIEW: Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii 111et i 1111 :s 2020-ICLl-00006 2576 the vehicle sallyport shows the first of four buses arrived at 10: 19 p.m. Detainees and their property were removed from the buses between the hours of 10: 19 p.m. and 11: 10 p.m. The intake processing area contains a long bench with a curtain that can be drawn across the middle of the room. On the opposite side of the curtain are two folding tables and chairs. Acoustic boards for sound baffling have been added to the ceiling. Video survei llance footage from the intake area was reviewed. At 1:04 a.m. detainee ALMAZAN can be seen seated on the bench partially obscured by a curtain. At 1 :21 a.m. a nurse arrives , sits next to him and appears to take his blood pressure. At 1:23 a.m. a blood pressure machine is wheeled to the detainee and his blood pressure is again taken. At 1:25 a.m. the detainee leaves the intake area. The detention file contained intake screening forms for suicide and medical or mental impairments as well as screening for risk of victimization and ab (b;(6 l Detainee ALMAZAN's classification review was comp leted on this date by 1,ir., It was documented that the detainee's primary language was Spanish. Officer \~) \~t ,, acknow ledged he does not speak Spanish and he recalled that a fellow intake officer who does sat with him and went over the intake process in Spanish with detainee ALMAZAN. The officer appropriately rated detainee ALMAZAN high custody based on the severity of his charge, his serious offense histo · · nvictions. This rating was approved by Reception and Discharge Superviso the same day. !~l l~lc ci ~~~~ On September 8, 2017, the clothing the detainee was wear ing was inventoried. He had one pair of shoes, socks, underwear, sweatpants and one sweatsh irt. Detainee ALMAZAN was issued facility clothing, linens and hygiene supplies. Neither the incoming pr b)(6); inventory form nor the facility property issued form were signed by the detainee. Officer b)(?)(Cl stated that because there was such a large influx of detainees on this date, medical staff took half of the group and the officers took the other half. When the property was inventoried , the detainee was with the medical staff and was not available to sign the forms. Detainee ALMAZAN did sign a form acknowledging he received a copy of the facility handbook and PREA information form and that he viewed the ICE orientation video . Documentation confirm s he was also fingerprinted. The detainee financial h·ansaction history report shows he had no funds on an-ival. It is unknown what happened to the $4.00 check sent with the detainee from GCDC. (b)(6); Office (b)(?)(C) stated that addit iona l property arrived in red mesh bags clearly marked with each detainee's name and A#. However, no property invento1y had been completed by the send ing facility. Per (bl(5 ); (b)(?)(Cl ERO instructed staff not to inventory and distribute propi=-u.l£....LLLJ.IJJ....U.J.C....., ·1· . . d at IAH/PCADC . (b)(5 ); (b)(?)(C) mes h b ags unh·1th e C:1ac1 1ty kn ew 1'f th e d etamees wou ld b e retame stated that 28 detainees stayed at IAH/PCADC and their mesh bags were inventoried a~n~a~ o_w_a~ e~ property distributed to those detainees. All other mesh bags were stored and then transferred with the detainees when they left IAH/PCADC after their temporary stay. DETAINEEDEATHREVIEW:Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11r ii111eti 1111 :s 2020-ICLl-00006 2577 Detainee ALMAZAN was assigned to Donn C, Bed 20-04. The log maintained by the officers assigned to this unit docume nted the detainee's placement in ce ll C-20 at 2:40 a.m . on September 9, 2017. Cell C-20 is a four person handicap access ible unit. The unit is accessed through a sallyport with two steel doors. The doors are opened remotely from central control when an intercom is pressed and staff are identified. Inside the unit, four single metal bunks are welded to the floor with one on the left wall, two on the back wall and one on the right wall. In the middle of the unit is a picnic style metal table with a bench on each side. A TV is mounted on the wall on the left side. Detainee ALMAZAN's bunk was directly under the TV on the left wall. Two phones are on the wall by the entry door as is a camera which is mounted near the ceiling. A single handicap shower is located behind a cmta in and a stainless steel toilet and sink with grab bars are located behind a partial partitio n on the right hand wall which blocks the camera view of the bathroom facilities. An intercom on the inside of the unit by the door alerts in central control. A large w indow in the hallway provides a direct view into the unit. IAH/PCADC utilizes indirect supervision with an officer assigned to the hallway outside the dorm. Dorm officer post orders require that a security round be conducted twice per hour at irregular intervals with no more than 40 minutes elapsing between rounds. The officers are not required to enter each dorm during these rounds. Officers do enter the dorms during the seven officia l counts conducted daily and to distribute and retrieve trays for all meals. Indoor recreation is offered in an area directly across from the dorm. There is also a large recreation field outside. Detainees are pennitted one hour of recrea tion daily. Video surve illance footage from inside Dorm C for detainee ALMAZAN's detention period was viewed. At 2 :44 a.m. on September 9, 2017, deta inee ALMAZAN entered the dorm carrying a bag of property. Detainee ALMAZAN took a seat at the table and spoke to another detainee. At 2:50 a.m . an office r entered the unit and handed detainee ALMAZAN a mattress and pillow. Detainee ALMAZAN, with the assistance of the detainee he was speaking with, made up his bed. Detainee ALMAZAN then placed his property in his assigned property storage box and laid down at 2:57 a.m. Between 3:00 a.m. and 6:30 a.m. detainee ALMAZAN went to the bathroom four times. Other than that, he laid on his bunk. At 6:36 a.m. he showered. At 6:43 a.m . breakfast h·ays were delivered by an officer. Detainee ALMAZAN did not eat but rather gave his tray to the other detainees. Throughout the morning, detainee ALMAZAN slept, only rising to use the bathroom or watch TV for a few minutes. When the lunch tray was delivered at 11:45 a.m., detainee ALMAZAN sat on his bunk eating a port ion of the meal and then handed his tray to the other three deta inees for them to share the remaining food. Detainee ALMAZAN slept, laid on his bunk and went to the bathroom throughout the afternoon. At 6:07 p.m. he walked to the unit door. As the door is obscu red by a wall, it is not known if the detainee left the unit but it is surmised he did, perhaps for pill call. At 6: 17 p.m. an officer delivered meal trays to the unit. Detainee ALMAZAN returned to his bunk at 6:27 p.m., appeared to take an item off of his food tray and then handed the tray with the remaining food items on it to the DETAINEE DEATHREVIEW:Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 2578 other detainees who were seated at the table eating. Those detainees took and shared the food from the tray. Throughout the evening, the other detainees played checkers, watched TV and read. Detainee ALMAZAN did not participate in any of these activities and simply laid on his bunk or went to the bathroom. On Septem ber 10, 2017, detainee ALMAZAN went to the unit door at 5:53 a.m. and returned to his bunk at 6:03 a.m. Again, he ate some food from his meal tray while seated on his bunk but brought the tray to the other detainee s to share the remaining food . Again, he slept and went to the bathroom numerous times . At 10: 13 a.m. he sat up on his bunk and ate what appeared to be a piece of fruit. At 11:34 a.m. the lunch trays were delivered and he ate some food while sitting on his bunk and then placed some items from the tray into a brown paper sack which he retained by his bunk . He then took the tray to the other detainees who shared the remaining items. Between 8:00 a.m. and 4:30 p.m . he went to the bathroom area nine times. Dinner trays were delivered at 6:40 p.m. and again, detainee ALMAZAN ate some items from the h·ay at his bunk and gave the remaining items away to the other detainee s. At 8:01 p.m. he went to the door of the unit and returned to his bunk at 8: 16 p.m. Throughout the evening, he slept or went to the bathroom. On September 11, 2017, at 5 :31 a.m. detainee ALMAZAN went to the unit door. He returned to his bunk at 5:42 a.m. carrying his breakfast tray . Again, he sat on his bunk eating and then brought the tray to the three detainees seated at the table eating. They could be seen taking food items off the tray. Between 5:00 a.m. and 11:00 a.m., he went to the bathroom four times. At 11:54 a.m. lunch trays were delivered and the detainee ate on his bunk. He placed some items from his h·ay in a separate container and then offered the remaining food items to the other detainee s. At 12: 12 p.m. another detainee walked to detainee ALMAZAN's bunk and appeared to offer him some food. Detainee ALMAZAN did not take the food item and the other detainee walked away. At 1:43 p.m. detainee ALMAZAN went to the unit door and returned to the unit at 1:48 p.m. He stood up speaking with another detainee until he returned to his bunk at 2:05 p.m. For the next several hours he sat or laid on his bunk, went through his property bin or went to the bathroom. At 6: 11 p.m . he went to the unit door and returned to his bunk at 6:36 p.m. carrying some paperwork which he placed under his mattres s. At 7:04 p.m. the dinner trays arrived and another detainee offered detainee ALMAZAN a tray but 5); (b)(?)(C) he did not take it. At 7:28 p.m . Officd (b)( lntered the unit and a detainee spoke with the officer. The officer and the detainee then went to detainee ALMAZAN' s bunk and appeared to speak with him while he remained laying down. Detainee ALMAZAN handed the officer his identification card and the officer walked away. A minute later, the officer returned to the DETAINEEDEATHREVIEW: Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 2579 detainee's bunk and spoke with him again. The officer then walked toward the unit door while speaki ng on his hand held radio . (b)(6); (b)(?)(C) At 7:32 ~()~(ir., returned to the unit with O~;;;;---;~"""':----------....--____J (b)(6); (b)(?)(C) A t 7 :33 p.m. LYN' -.__ (b)(__________ 6); (b)(?)(C) . dm . _,.rnve the unit pushing a wheelchair . The six staff surrounded detainee ALMAZAN's bunk so the view of the detainee from the camera was blocked. At 7:34 p.m. it appeared the detainee was helped into a sitting position on his bunk and at 7:35 p.m. he was assisted into the wheelchair. At 7:35 p.m . the detainee was wheeled off the unit by the nurses. The video surveillance footage from other cameras throughout th e facility showed the detainee was wheeled into the medical unit at 7:38 p.m. and was taken to the vehicle sallyport at 8:38 p.m . for tran sport to the hospital. Two of the three detainees who were housed with detaine e ALMAZAN during his detention at IAH/PCADC were still housed at the facility during this review and were interviewed . Detainee l(b)(5); (b)(?)(C) recalled detainee ALMAZAN and stated he was a "little sick" when he arrived. He stated detaine e ALMAZAN did not eat or drink ~~ slept most of the time and that he declined soup or other foods when offered. Detainee tated detainee ALMAZAN didn't want to do anything and he thought he was sad or depresse . etainee ecalled that on September 11, 2017, detainee ALMAZAN vomited thre e or four times. en e observed drops of blood on the floor and some dried blood around the mouth of detainee ALMAZAN he stated he alerted the dorm officer. I a ............ ~ii~\cc) i~li~lrcl I l Detaine e ~--------------~ recalled detainee ALMAZAN was always sleeping and that he would only eat a few bites of his meal tray. He and the other detainees in the dorm would try to get detainee ALMAZAN to attend recreation or to play cards or chess in the dorm but he refu sed. Detainee )~()~(1r., oted that if another detainee is not open to minglin g with other detainees , they cannot force it. While he did not observe detainee ALMAZAN vomit up blood on September 11, 2017 , he did observe dried blood around the detainee' s mouth. ~~~W~) Both detainees noted that once the officer arrived and assessed the situation , he called an emergency on his radio. They est imated that security and medical staff arrived within two or three minutes and detainee ALMAZAN was removed from the dorm in a wheelchair. Kb )(6); (b)(?)(C) I Officer .... L____ ____, was assi ned to Dorm C hallway for the 2:00 p.m . to 10:00 p.m . shift on September 11, 2017. Officer \~/\~\ ,, ecalled that he had pulled detainee ALMAZAN from the dorm to the medication pill window at 5: 15 p.m. and the detainee was walking slow and appeared dizzy. He ask,......... ......... .......,.,tain ee ifhe was okay and detain ee ALMAZAN responded that his stomach hurt. Officer )~()~i(r., served dinne r trays at 6:00 p.m . When he later picked up the dinner trays he was told by th e other detainees in Dorm C that detainee ALMAZAN had been vomiting up blood. Officd (b)(6); I who speaks Spanish, noted that detainee ALMAZAN did not speak Eng lish. He wen t to detainee ALMAZAN ' s bunk and asked him ifhe had been vomiting up blood. The detainee responded that he did not know becau se he just flushed the toilet after he vomited DETAINEEDEATHREVIEW: Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 2580 b)(6); withou t lookin g. Office b)(?)(C) emergency on his radio . observed blood on the detainee's lip and called a med ical The C Dorm logbook documents that the detainee was pull ed for pill call at 6: 14 p.m. At 7 :00 p.m. dinner trays were served and at 7:30 p.m. one detainee wa s sent to medical. The C Dorm logbook had no entries related to · rgency, including the response of medical and security personnel. When asked, Officer \~l \~l;r, acknowledged his error in not documenting the medical emergency. He stated that since this event he has been recording any unusual incidents in the logbook. As for an incident report , Officeitb)(6); _ !stated he was told by an unknown supervisor that medi ca l would document the incident and he did not need to do so. (b)(6); b)(6) Upon hearing the emergency call, Sergean (b)(?)(C) responded first along with Lieutenan b)(7)(C) followed by the two nurses with a wheelchair and emergency medical bag. Sergean (b)(6); state that no staff observed the detainee vom iting blood so he was sent to medical to be evaluated. I (b)(6); (b)(?)(C) (b)(6); (b)(?)(C) ~--------~ responded to the emergency medical call to Dorm C.~---~ stated on interview that she ob ·ed blood on the detainee's lips. She recalled the detainee stated his chest hurt . Office translated for the me . . nd they had him ask detainee ALMAZAN how long he had been vom iting blood. (bl(5l, (b)(?)(C) reca lled the detainee responded that it had been five days. The detainee was then assisted into the wheelchair and wheeled to medical. fb)(6); (b)(?)(C) I Physician's Assistant ~I____ ~ was on duty and both b)(6); ' stated they wheeled detainee AZAN right in to the provider for examination. PA b)(?)(C) rdered a blood draw. L VN stated the detainee was able to transfer himself from the wheelc hair to the chair for the blood draw . She took his blood pressure and recalled it was elevated but was lower the second time she took it. PA \~1\ ~/;r then found out detainee ALMAZAN had cirrho sis so b)(6) lied the blood draw and said the detainee needed to go to the emergen\-,>1-,.,u...ii..l.L!,,L.,.,,.,...,:;,n.. b)(?)(C)determined an 6); (b)(?)(C) ' d h ld b C ·1· (b)( . am bu lance wasn t necessary an e cou go y 1ac11ty van~---~ reca 11 ed th e detamee was able to transfer himself from the chair back to the wheelchair for transpo1t to the facility vehicle. l [~\mrci i~;i~\r ~\i~\< Cl recalled on interview that the detainee was reluctant to tell him anything. (b)(5); (b)(?)(C) surmise t e detainee didn ' t o know he was sick and believed if he went tot e osp1ta 6 he wouldn't get to go home. ~\)1\ic: , stated he observed blood aro und the detainee's mouth and the detainee reported he had been vomiting blood for five days. (b)(6); (b)(?)(C) tated it was " obvio us" to him that the detainee had varicies. (b)(5___ ); (b)(?)(C) . o f th"1s review . an d was there1ore c .__ _. was no longer emp Ioye d at IAH/PCADC at t he time 5 not ava ilable to be interv iewed . According to the critical incident report comp leted b~(b)( ); (b)(?)(C) the medical emergency was called at 7:52 p.m. and the Ward en was notified at 7:53 p.m. Lt. \~1! ~/;r, documented that upon arrival at C-20 , detainee ALMAZAN was "lying in bed moaning " . DETAINEEDEATHREVIEW: Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11r ii111eti 1111 :s 2020-ICLl-00006 2581 I (b)(6); After he was brought to medical and examined by Docto (b)(?)(C) the doctor determined the detainee needed to be transported to CHI St. Luke's Health Memoria l Hospita l. The Stationa Guard Roster re ort documented that on September 11, 2017, at 8:45 p.m. Officers (b)(6); (b)(?)(C) transported detainee ALMAZAN to CHI St. Luke's Health Memorial Hospital in Livingston, TX, a distance of 7 mi les . They arrived at 9 :00 p.m . On interview, Officer )~!)~!;,,, stated that she assisted detainee ALMAZAN into the van because he was wearing leg irons, handcuffs and a waist belt. As with all detainees who are transported in restraints, she stated a crate was used for the detainee to step up on to safely enter the van. She recalled the detainee was quiet and cooperative during the transport . Officer l\~/\~L , lcarried the wea on and drove the van . Upon arrival at the hospital, she dropped the detainee and Officer \?!\~\-. a~ the door where they were met by h (b)(~); taff with a wheelchair. The detainee was wheeled mto the ER for treatment and Officer .(b)(7)(C) arked the van. Officer l\?!\~!;J recalled the hosp ita l staff had trouble getting an IV into detainee ALMAZAN's arm . The Hospital Act ivity Log the officers completed noted permission was received from the shift supervisor to remove one handcuff and the belly chain and to restrain the detainee with one cuff attached to the bed. These officers were relieved at 11 :00 p.m. and returned to the facility at 11: 15 p.m. kb)(6); (b)(?)(C) I Officed ,._ ___________ __,assumed vigi l duty at 11 :00 p.m . and documented that the detainee received an IV and the doctor informed them at 1:10 a.m. that the detainee needed to be transferred to another hospital. These officers sta ed with the detainee until 6: 15 a.m. on September 12, 2017. At 6:00 a.m. Officer b)(5); (b)(?)(C) reported for vigil duty and relieved Officeq (b}(6); (b)(7)(C) I A Texan EMS LLC report documents a paramedic and EMT responded to CHI St. Luke's Health Memorial Hospital at 6:45 a.m. to transport detainee ALMAZAN to Conroe Regional Medical Center (CRMC) in Conroe , TX for treatment of "upper GI bleed noticed when pt began vomit ing blood @ 12 hours ago " . The report noted detainee ALMAZAN was ambulatory and was able to walk to the stretcher. He was assessed and no abnormalities were found. It was documented he was being transported by ambulance due to the need to administer IV medications and oxygen en route. Upon anival at CRMC at 8: 13 a.m., EMS staff documented the detainee was able to ambulate to a chair and his care was turned over to staff at CRMC. (b)(6); According to Sergea (b)(?)(C) e is weapons certified so he followed the ambulance in the facility van wh ile Offi (b)(6); (b)(?)(C) rode in the ambulance . Sergeant!~\ )~\1.., ated the trip usually takes an hour but it took 90 minutes due to heavy traffic. They logg ·val time of 8: 13 a.m. at CRMC and noted the detainee was admitted to the ICU. Sergea called that the detainee was alert when not sleeping, ate his meals and was able to sit up o unnate. The office rs logged that they were relieved at 4 :40 p .m . !~\m (c) Office ~l \~t.., as since been promoted to sergeant at PCADC. She will be referred to as officer throughout this report. 89 DETAINEEDEATHREVIEW:Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii 111et i 1111 :s 2020-ICLl-00006 2582 I . . ~b)(6); (b)(7)(C) l(b)(6); (b)(7)(C) Rehevmg Sergeant .... l _________ ~_ were Officer~..... -----------~ who arr ived at 4:32 p.m . They documented in the Hospital Activity Log that technicians were in the room performing an EKG and an X-Ray at 5:10 p.m. As medical staff were having trouble with the IV in the detainee's neck , the officers requested and received permission from the facility to remove the handc uffs from the detainee so an IV cou ld be placed in his aim. I were OfficJ:b)(5); (b)(?)(C) ~ 10:30 relieved tj(b)(6); (b)(?)(C) p.m. They documented that during their shift nursing staff checked the detainee ' s IV , changed his beddi ng, drew blood and assisted him to the restroom throughout the night. l{b )(6); (b)(7)(C) I On September 13, 2017 Officers.,.._________ ~r eported for vigil duty at 6:26 a.m. Throughout their shift, they logged the detainee went for a procedure at 7:37 a.m. and returned to his room at 7:43 a.m. Staff logged that nursing staff cha n ed his line ns bro u ht him food and delivered pain medicaJ;iao throughout the shift Officer (b)(5); (b)(?)(C) ere relieved at 5 8: 14 p.m. by Officers ); (b)(?)(C) ~oughout their shift , they logged that nursing staff gave the detainee medication , walked him to the restroom , and checked his v ital signs. e)( An emai l from Commander )~()~(;r, sent th is date to ERO offic ials inquired as to the plan for detainee ALMAZAN upon discharge from the hospital. She not ed, "Hi s condition is chronic and will only get worse with time. GI bleeds can happen suddenly and can vary in severity depending on where the blee d occ urs" . (b)(6); (b)(7)(C) .~~~~11S...Jlilli&1:~~ll2er~~.!..l..L.Jlll.O.....S:!J..llllw.lll&JtQ..l:il.l.J.lJl...._ __ ,__ __ J and documented a ~--------------------------~ visit they made to the CRMC on September 13, 20 17. They documented that upon their arrival, deta inee ALMAZAN was asleep but he woke up w hile they were talking with MTC vigil officer s. The deportation officers spoke with detain ee ALMAZAN about the status of his imm igration case and the detain ee informed them he intended to appeal his case and had a petition pending . They then discussed with him whet her he had family in the U nited State s and he stated he had fami ly in Florida and po ssibly New York. They then concluded their interview of detainee ALMAZA N . The deportation officers' statements do not document the time of their visit. The MTC hospital log does not document any visit to detaine e ALMAZAN by ERO offic ers. (b)(6); (b)(7)(C) I . . On September 14, 2017 at 6 :20 a.m. Officers.,..__________ reported for v1g1l duty. They logged that nursing staff checked the detainee ' s vital sign s and at 8: 10 a.m. Doctor ](b/\~/;,J infom1ed the nurse the detainee should be moved from the ICU to a "regular room " . At 1: 15 p.m. office rs logged the detainee was "co mp lain ing of chest pain " . At 2:20 p.m . the deta inee stated he "had gas". At 2 :40 p .m. the detainee was move d from the ICU to room 141. At 3:15 p.m . the detainee reported he had ain. He was iven M lanta and other unknown medic ations per the log . At 6:56 p.m. Officer (b)(6); (b)(7)(C) reported for vigil duty. They logged nursing staff checked vitals, gave pain medication and took a blood sample durin g their shift. Also on l DETAINEE DEATHREVIEW: Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii 111et i 1111 :s 2020-ICLl-00006 2583 (b)(6); (b)(6); (b)(7)(C) this date , AFOD (b)(?)(C) oted in an email to Commande .______ __,h at the detainee , when discharged, would be moved to HCDF until he could be moved back to Florida. (b)(6); (b)(7)(C) I . . On September 15, 2017 at 6:20 a.m. Officers ,_________ __,lt" eported for vigil duty. Throughout their shift they logged that nursing staff checked the detainee's blood pressure and gave him medication. They also noted the detainee took a shower at 2:00 p.m . These officers were relieved at 6:37 p.m. by Officfb l(5); (b)(?)(C) b)(6); b)(?_)(C)_. man . . ls prov1'de d a me d"1cal up date on C omman der.__ ema1·1th'1s d ate to van.¥J,l,oi,.,..i..J~ offi1cia l I /~\i~\rci detainee ALMAZAN . In the emai l, Commande oted that a cardiac stress test was being sched uled and it was possible the detainee would be discharged in time to make a flight back to KNSPC schedule4:,,Ll *-""'"=~mber 17, 2017. If the detainee was not released in time for the Sunday flight , Command ecommended that he be moved , when discharged , to "Houston CDF due to his combined chronic medical issues". ~li~l(c) kb)(6); (b)(7)(C) I Officer~~--------~who had assumed vigil duty logged that nursing staff met with the detainee at 7:04 p.m. to review paperwork with the detainee authori zing a stress test scheduled for the following day. At 5:38 a.m. on September 16, 2017 the detainee signed the paperwork . At 6:40 a.m. Officer~b )(6); (b)(?)(C) arrived for vigil duty. At 9: 18 a.m. they logged that the detainee went for his heart stress test and returned at 10:49 a.m. I I Officerl(b)(5); (b)(?)(C) reported for vigil duty at 6: 10 p.m . They logged that three nur ses and a doctor entered the room at 00:34 a.m . on September 17, 2017. At 00:55 officers contacted the warden to receive permission to remove handcuffs for "blood gas testing" and noted it was an "emergency". At 1:04 a.m. the detainee was moved to the ICU and a chest X-Ray and blood samples were taken. At 2:01 a.m . office rs called the facility to report the deta inee was on life support. At 2: 11 a.m . chest X-rays were again taken. At 2:31 a.m. the cuffs and belly cha in were noted as removed after permission was received by a shift sergeant. At 3:23 a.mJ(b)(5); (b)(?)(C) l'-!,al.l--,>~~...., $2.10 in coins. Multip le hygiene items and multiple medications were also marked. b)(5); (b)(?)(C) noted on interview that the shirt with elep hants on it whic h the detainee was wear ing upon adm ission to Krome and for his intake photo as well as b)(6); (b)(?)(~) rts had small spots on them with a "moldy, reddish tint" that may have been blood. tated the ro er!)' was turned over to Supervisory Detention and Deportation Officer (SDDO) (b)(5); (b)(?)(C) (b)(6); Per SDD (b)(7)(C) pon receipt of the property, it was taped shut in a cardboard box and secured in his office with the inventory sheet taped on top. The box was opened by the SDDO for the reviewers on October 18, 2017 and the contents were inspected. The various clothing items were reviewed and the elephant shirt and one pair of shorts did appear to have small spots of blood on them. The clot hes he had worn on the trip from Folkston to IAH/PCADC were inspected and no blood was observed on the orange pants or cream colored t-shirt he wore during that trip. 6 Ass istant Field Office DirectoJ< ·d 1 · (bl< c> D · Offi1cer w h o was wor ki ng mt · he d etamee · 's prov1 e anguage ass1stance . .t--r-....... '"T"l~-r--' etentJon unit , also stated detainee AL spo e no English and that because he himself was fluent in Spanish , he provided interpretation assistance. Throughout interviews , other custody staff having had direct contact with detainee ALMAZAN also described his minimal ability to speak and understand English . At five feet , one inch tall, detainee ALMAZAN weighed 170 pounds. A pain level of four on a scale of zero to ten was reported at the time of arrival , as he complained of general joint pain and discomfort in the upper right quadrant of his abdomen . The reviewer notes that pain in this location is common in liver cirrhosis. Vital signs were recorded within normal limits with the exception of a significantly elevated blood pressure of 180/ 109 (See Appendi x I). Rechecks at unrecorded times noted a decrease in blood pres sure to 164/100 and finally to 152/86, levels that remained abnormally high (See Appendix /l). l l nurse responded to the unit when the call came through. This nurse was identified as LVN. Wh n uestioned during interview as to why she did not document a note, she explained that (b)(5); (b)(?)(C) as taking charge of the situation . She did report assisting with the detainee' s trans er om t e ed to the wheelchair , however. According to the "Provider Progre ss Notes/Or " (b)(6 ); (b)(?)(C) compl eted his evaluation of detainee ALMAZA N at 9:57 p.m. Durin g . . (b)(5 ); (b)(?)(C) . ly recor de d the m1·1· . . d"mg to have s1.gne d mterv1e ~---~ epo1ted h e incorrect 1tary time, mten off at 7:57 p.m. According to the note, he was brought to medical with complaints of vomiting blood, similar to an incident he reported having occurred seven years ago. He wa~~ -~~,....._ --. . h os1s . wit. h van.ces, m1ormat10n . I". • (b)(7)(C) have c1rr th at was extracte d from th e ch art, as~(b)(6); ___ __. determined, " · t] poo r historian" . When questioned as to how he arrived at this descript ion, (b)(5); (b)(?)(C) stated that detainee ALMAZAN offered no medical history, as if he did not want medical to know -~~~e was. When directly questioned about his cirrhosis, howeve · edit. )~\)~\1c:, voiced his opinion that the detainee did not speak English and tha b) Med ica l Assistant, prov i ·...~.,,r.,.,• ~'"ion. He was described as alert and oriented and appeared to be in no acute distres (b)(5); (b)(?)(C) tated there were no symptoms or patient behaviors at the time of assessment to suggest t 1s was an emergency situation. Bright red blood was observed on both the inside and outside his mouth, but there was no blood on his shirt or pants. He was diagnosed with gastrointest inal bleed of five days duration and was sent to the emergency room for evaluation on a stat basis, but not via 911. .-,..= ............. ~lm(C) 0 A "Timelin e/Checklist - Depart from the Facility" form w,a.,,...Ju...u..LJ.U.J=d by an unidentified medical . h' d b)(5 ); (b)(?)(C) staff mem ber at 8 :42 p.m. A ccord mg tot 1s ocument, ._ __ _, was noh'fi e d o f th e nee d to ti·ansport detainee ALMAZAM to CHI St. Luke 's via van with security escort. Hospita l updates were recorded daily, as follows: Reporting Nu rse, Date, - ;me Report Summary b)(6); (b)(7)(C) I September 12, 2017 Kb)(6); (b)(7)(C) ~VN September 13, 2017 5:35 p.m. LVNPena Stable at this time. Most recent vitals: Blood pressure 99/58, pulse 7 5, and respirations 17. Pulse oxygen 97. Temperature rema ins nonn al. Two units of platelets given due to critical platelet level of 27. Post tran sfusion level is up to 55. All other labs remain within normal limits. Scheduled to have EGD 98 in the morning. Prev ious ly receiving cardene drip 99 via external jugu lar line. Has been stopped and is now receiving oral lisinopril JOO_ Alert and oriented. Blood pressure 117/58, pulse 88, R 19, Temperat ure 98.3, pulse oxyge n 100. Received two units of platelets . Hemoglobin is 11.2, and platelets are 27. Alert and oriented. Blood pressure 101/51 , pulse 69, respirations 14, 98 An EGO,short for esophagogastroduodenoscopy is a scope used to examine the lining of the esophagus, stomach , and duodenum (upp er part of th e small intestin e) 99 A cardene drip is an intravenous therapy infused with medication to treat high blood pressure. 100 Lisinopril is a medication to tr eat hypertensio n. DETAINEE DEATHREVIEW: Filipe ALMAZAN-Ruiz Medical an d Security Compliance Review December 4-5, 2017 l_C •r e:ali1t ,e i::11rii111eti11 11:s 2020-ICLl-00006 2590 September 14, 2017 6:41 a.m. (b)(6); (b)(7)(C) ~N September 14, 2017 6:31 p.m. temperature 98.3, pulse oxygen 99. Continues lisinopri l orally. Denied pain thro ughout the night. Alert and or iented. Blood pressure 125/73 , pulse 79, respirat ions 18, temperature 98.7, and pulse oxygen 99. Continues oral lisinopril. Pain is eight of ten, repmting severe GERD. Moved to medicalsurgical unit. Rema ins stable. Removed from ICU room 18 to medical surgical floor, room 141. Blood pressure 93/54, temperature 98. 1, pulse 72, respirations 18, pulse oxygen 97. Rema ins stable. Blood press ure 1006/65, temperature 98.2, pulse 72, respirat ions 16, pulse oxygen 98. Had a normal cardiac stress test earlier in the day. Medications remain Zoloft, folic acid, metoprolol 10 1 Protonix 102 , lactulose, and aldactone. Possible discharge Sunday after seen by doctor. At about 1:00 a.m. pat ient coded and is now critical and has been moved to ICU, room 36. He is on life support and is intubated with agonal 103 breathing. When able to get a blood pressure , it is in the 50s by palpation 1°4 . Hemoglobin is 5. Blood being given. Warden Stacks has notified ICE personne ll!~li~l cc) I I September 15, 2017 b)(6); (b)(7)(C) ,, Lt{) " (b)(6); (b)(7)(C) IRN September 16, 2017 7:24 p.m. (b)(6); (b)(7)(C) I September 17, 2017 2:32 a.m. On September 20, 2017 the State of Texas issued a Ce1tificate of Death which listed the cause of death as "pending" . APPENDIX I Vital Signs DATE TEMPERATURE PULSE RESPIRATIONS BLOODPRESSURE Oxygen September 8, 2017 97.0 98 14 September 11, 2017 97.5 106 18 180/109 164/100 152/86 151/95 APPENDIX II 101 Metoprolol is a beta-blocker to treat high blood pressure. 102 Protonix is a treatment for GERO. 103 Agonal breathing is abnormal respirations characterized by gasping, and labored breath ing. 104 Palpation is a method of examining the body using the hands. DETAINEE DEATH REVIEW: Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 2591 98 100 American Heart Association Blood Pressure Parameter Blood Pressure Category Systolic (Upper number) Diastolic (Lower number) Prehypertension 120-139 or StaaaOna IA04S!I ar 80-89 CONCLUSIONS Medical Compliance Findings Medical Care, Section (IIl)(D) , which states, "Non-English speaking detainees and detainees who are deaf or hard of hearing will be provided interpretation or translation services or other assistance as needed for medical care activities. Language assistance may be provided by another staff member competent in the language or by a profess ional service, such as a telephone translation service." • During the intake screening fbl(5 l; (bl(7 l(Cl p oted ALMAZAN spoke En lish and therefore did not require language assistance. During interview, however, (bl(5 l; (bl(7 l(C) tated he "spoke very little English" but that an unidentifie · ..,.,,r,.,,.....,. provided interpretation. 5 There was no documentation to substantiate this. (bl( l; (b)(? )(C) Intake Detention Officer recalled detainee ALMAZAN onl s oke Spanish, requiring another intake officer to provide language assistance. (bl(5 ); (b)(? )(C) , Detention Officer who was working in the detainee's unit, also stated etamee AZAN spoke no English and required interpretation assistance. There is no telephone access in the medical intake area. Medical Care, Section (Ill)(D), which states, "Medica l and mental health interviews and examinations shall be conducted in settings that respect detainees ' privacy." DETAINEEDEATHREVIEW:Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii 111et i 1111 :s 2020-ICLl-00006 2592 • Curtain dividers and ceiling-mounted acoustic boards do not fully protect a detainee's privacy to fully and comfortably discus s sensitive medical information. Medical Care, Section (III)(D), which states , "T he clinical medical authority shall be responsible for review of all health screening forms within 24 hours or next business day to assess the priority for treatment (for example Urgent, Today , or Routine). • The intake screen does not include a signature ofreview by the clinical medical authority. Of note , the evening detainee ALMAZAN was transferred to the hospital was the first business day for that review. Medical Care, Section (IIl)(B), which states, "Health care personne l perform duties for which they are credentialed by tra ining, licensure, certification, job descriptions, and/or written stand ing or direct orders by personnel authorized by law to give such orders." • A seriously elevated blood pressure of I 80/102 was not reported to a provider in accordance with MTC's Nursing Protocols. Additionally , regular blood pressure monitoring was not done during the three days detainee ALMAZAN was detained at PCADC. Areas of Concern • Sick call forms and deposit boxes are inconveniently placed in the hallway outside the locked unit. Detainees reported they access them when they go to recreat ion and after completion , hold them to the window when the officer passes by doing rounds. The officer then takes the request and deposits it in the locked box. This practice does not protect the privacy and confidentiality of the detainees. Detainee ALMAZAN did not request a sick call appointment during his detention. Safety and Security Compliance Findings Creative Corrections cites the following deficienc ies in releva nt compone nts of facility pol icies and post orders. Dorm Officer Post Orders , section III 8. Post Activity Log Entries requires unusual incidents to be recorded in the log. • The medical emergency called to the detainee's dorm and the response of both security and medical staff was not logged. DETAINEEDEATHREVIEW:Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 2593 Stationary Guard Medical Officer Post Orders, section II, 9.B requires the assigned officer to maintain a daily log of activities to include visits by physicians , nurses, room attendants, and any other relevant information. • Assigned vigil officers did not log the visit by two deportation officers to detainee ALMAZAN while he was hospitalized. DETAINEEDEATHREVIEW: Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti11 11:s 2020-ICLl-00006 2594 (b)(6); (b)(7)(C) From: Sent : 23 Ju 2018 17:33:53 +0000 I l(b)(6); (b)(7)(C) To: Subject: Attachments : FW: ALMAZAN ALMAZAN DOR Merged Report.docx l(b)(6); (b)(7)(C) Management & Program Analyst ICE/OPR/ERAU sw~~ /\~L, 950 L'Enfant Plaza Wash· 20536 (b)(6); 202- (b)(7)(C) 202-2~-~ esk) ell) !(b)(6); (b)(7)(C) From~ , Sent : Monday, February 05, 2018 11:06 AM To: 1gov> ~(b)(6) ; (b)(7)(C) Subject : FW: ALMAZAN From: (b)(6); (b)(7)(C) Sen,.,,.·.,+,,U~~=W>.L._, 02, 2018 3:50 PM To : (b) Sub~~:mvl7\ZITTr"___. 2020-ICLl-00006 2595 Detainee Death Review: ALMAZAN-Ruiz, Felipe A028866428 Healthcare and Security Compliance Analysis Krome North Service Processing Center, Miami, Florida Glades County Detention Center, Moore Haven, Florida Polk County Adult Detention Center, West Livingston, Texas As requested by the ICE Office of Professional Responsibility, Office of Detention Oversight (ODO), Creative Corrections participated in a review of the death of detainee Sergio Alonso LOPEZ who had been detained at the Krome Service Processing Center (KSPC) from July 12 to August 11, 2017 , Glades County Detention Center (GCDC) from August 11 to September 8, 2017, and Polk County Adu lt Detention Cente r (PCADC) from September 8 until his death on September 17, 2017. Site visits were conducted at each of these facilities by members of a review team comprised ofl (bl(6l; (bl(7J(C) !External Reviews and Analysis Unit, and Management and Program fbJ(6); (b)(7)(C) kccompanied by Creative Corrections contract personnel l(bl(6J; (bl(7J(C) I, Secur ity Subject J(bl(6J; (bl(7J(C) lealthcare Subject Matter Expert. Creative Corrections' participation was requested to detennine compl iance with the National Detention standards at GCDC and PCADC and the 2016-revised 2011 Performa nce Based National Detention Standards (PBNDS) at KNSPC. The reviews were conducted from October 17-19, 2017, at IAH/PCADC, from December 4-5, 2017, at Krome North Service Processing Center (KNSPC) and from December 6-7, 2017 , at Glades County Detention Center (GCDC). The information and findings herein are based on analysis of detainee LOPEZ ' medical record and detention file, tour of housing units and the medical area, interviews of staff, and review of facility policy , video survei llance footage , hospital records, and suppo1ting documentation. Synopsis Per the ERO Fonn 213, Felipe ALMAZAN entered the Uni ted States on or around May 4, 1985, at or near San Ysidro , CA, without having been admitted by an immigration officer. Once in the United States he acquired an extensive criminal history which included convictions for Larceny in August 1994, and July 1998, Indecent Exposure in July 1998, and Driving under the Influence of Liquor in May 2001. Per the Miami-Dade Police booking form , ALMAZAN was arrested at 10:20 p.m. on Apr il 14, 2017 , for alcoholic beverages /drinking in public and engaging in sexua l act with a familial child. On July 10, 2017 , he was convicted of two counts of Child Abuse/ Aggravated /Great Bodily Harm and Torture and sente nced to 15 years of probation. The Miami Dade Prob ation Office notified the Miami Fugitive Operations Team about his case on July 12, 2017, and he was taken into custody at the Miami Dade Probat ion Office in Miami , FL and transported to Krome Nort h Service Processing Center (KNSPC) for processing. DETAINEEDEATHREVIEW:Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11r ii111eti 1111 :s 2020-ICLl-00006 2596 Detainee ALMAZAN had an extensive criminal history and was placed on probation for a term of 15 years after being convicted of child abuse aggravated, causing great bodily harm and torture. ERO tran sported him from the Miami -Dade probatio n office to KNSPC on July 12, 2017 . He was detained at KNSPC for 30 days. During his stay there he made no phone calls, had no visits and had no disciplinary issues. He was next transferred to GCDC. While there, he completed three phone calls and worked for five days as a trustee in the food service area earning $1.00 per day. After 26 days at GCDC, he was transferred to the Folkston Processing Center in anticipation of the approaching Hurricane Irma. One day later he was transported to the PCADC when the projected pat h of Hurricane Irma changed. He was housed at IAH/PCADC from Septembe r 8 to September 11, 2017. During that time he filed no grievances, had no disciplinary violations and made no phone calls. A review of the video surveillance footage from inside his housing pod showed that he slept almost all of the time and ate very little from his food trays. On September 11, 2017, other detainees in his housing unit alerted the officer that detainee ALMAZAN was vomiting blood. Both security and medical staff responded and the provider ordered him to be sent to the hospital. He was transported to a local hospital and then transported a day later to a regional medical center for treatment of cirrhosis of the liver. On Septem ber 17, 2017 he coded and was transferred to the Intensive Care Unit where he was placed on life support. He was declared dead at 5: 15 a.m. on the same date. There were minor security defic iencies noted at two of the three facilities detainee ALMAZAN was housed at. None of these issues contributed to his death. Krome North Service Processing Center Facility Description KNSPC is owned by ICE and managed by ERO, Miami Field Office. The facility has a capacity of 581. While female detainee s are temporarily brought to KNSPC for court, only male detainees are detained overnight. On September 12, 2017, the population was 608. There are approx imately 90 ICE employees on staff at the facility. Contractors Akima Global Services (AGS), with regional headquarters in Herndon, Virginia, and AKAL Security, with corporate headquarte rs in Espanola, New Mexico , provide security and armed transportation services. AGS officers are not weapons certified and supervise detainees in areas such as housing units and the cafeteria inside the fac ility. AKAL officers are weapons certified and work the processing/intake area, transport detainees and provide vigils when detainees are at one of the three hospitals used by KNSPC. There are 177 AKAL contract security staff. A ll officers involved in this event were AKAL staff. Healthcare Services DETAINEE DEATHREVIEW: Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti11 11:s 2020-ICLl-00006 2597 KNSPC's primary health care prov ider is ICE Health Service Corps (IHSC), suppo1ted by contractor InGenesis Medical Staffing based in San Antonio, Texas. InGenesis Medical Staffing sub-contracts STG International , Incorporated. Medical services are provided 24 hours a day, seve n days a week. The staffing plan includes 21 comm issioned Pub lic Health Service officers, five GS emp loyees , and 31 contract emp loyees. Add itiona lly, there are four casua l nurse s. The commissioned officers include the Hea lth Services Administrator (HSA), assistant HSA , Clinical Director , three mental health professionals , dentist , pharmacist , three mid level providers , nurse manager, program manage r, and eight registered nurses (RN) . The GS emp loyees include three med ical records technicians, a denta l assistant, and a radio logy technician. l(b)(7)(E) I (b)(7)(E) !(b)(7)(E) ~ casual pool of three contract RNs and one contract LPN supp lement the staffing mode l. Accord ing to thd ._b_)(6_);_(b _)(_7_H_) C______ _. vacancies at the time of ALMAZAN's detention included five RNs and a radiology technician . Credential files were reviewed and found to be current and primary source verified. KNSPC achieved American Correct ional Assoc iation accreditation in August 2015, and National Commission on Correctiona l Health Care accred itat ion in Apr il 2015. IHSC's electronic medical record system, e-Clinica l Works (eCW), is used at KNSPC. It is noted that unless indicated, the times of medical encounters identified in this report are the times nurses and prov iders electron ically entered their notes, per system-produced timestamps. The times encounters were actually conducted are not avai lable unless documented in the notes. Detention Summary I b)(6); (b)(7)(C) Detent ion Office .______ ~ processed deta inee ALMAZAN into KNSPC, documenting that the detainee 's primary language was Spanish. Officd \~/\~k--, lknow ledged he does not speak Spanish and he stated that he typically obtains assistance fro ...,_.. ................... ..., u.al fellow officer when processing the deta inee into the facility. On interview, Office tated he had on ly slight recollectio n of this deta inee but wou ld have followed his usua l prac ice when process ing him. He initially pat searches each detainee when they arrive and he completed ~ of Search form confirming no contraband was found on detainee ALMAZAN. Office \~!\ ~l;r, stated he would next provide the deta inee the oppo1tunity to shower and then send the deta inee to be cla ssified. Deta inee ALMAZAN's classificat ion review was completed by other members of the process ing team and he was appropriate ly classified as medium high. The classification level was approved by a supervisor on the same date. b)(6); Once classified , deta inee ALMAZAN was sent back to Officer b)(?)(C) so the proper color uniforms could be issued as well as facility linens , hygiene supplies and other clothing. The detainee would have next been sent to property to have his persona l property inventoried and his funds placed into an accou nt. The deta inee's inventory form documents he arr ived with one f ~l[~lcc) J,L-'-' ......... DETAINEEDEATHREVIEW:Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii 111et i 1111 :s 2020-ICLl-00006 2598 billfold, one pair of jeans, two pairs of shorts , some personal papers , two pairs of shoes, one pair of sung lasses , two t-shirts and valuables that were not ident ified. These items were placed in property bin #3666037 . A receipt for the property was signed by the detainee . The detainee also arrived with a check for $9.00 and the funds were deposited into the kiosk system for his use at commissary. Detainee ALMAZAN was issued facility clothing , linens and hygiene supplies and he signed a receipt for these items. Detainee ALMAZAN did not prov ide the facility with a fo1ward ing address and signed a form documenting this. He also signed a form acknow ledg ing he receive d a copy of the local and national handbooks. Per Officer J(b)(6); Ithe detainee was then sent to medica l for intake screening. Officer (b)(6); reca lled that detainee ALMAZAN moved (h\ (7\ (r'.\ sow l l y. During his stay at KNSPC, detainee ALMAZAN was assigned to units four, five and six in building eight. Building eight houses high and medium high detainees and contains six units; units one through three on the lower leve l and units four through six on the upper level. On each floor there is a contro l pod in the center with an officer assigned at all times. Another officer is assigned to each pod for direct supervision of the detainees. On the upper level, pods four through six are located clockwise around the control center. Each pod is essentially identical with small variations in the unit set up. Pod four has a capacity for 60 detainees with 30 bunk beds in the center of the unit. Upon entry to the un it, the officer's station is located to the left and there are a bank of phones along the left wall. To the right of the entry way is a kiosk for orde ring commissary and sending requests or grievances . There are also numerous chairs for detainees to use while viewing the TV located on that wall. A second TV is mounted on the ceiling near the center of the unit. Along the right wall at the rear of the unit is a shower and toilet area separated from the open area by a half wall. There are long, narrow windows along the left and rear walls which allows natural light into the unit. There are four ceiling mounted cameras in the unit ; approp riately none with a view of the bathroom area. EARM documents that the detainee was originally on a manifest to transfer to Glades County Detention Center (GCDC) in Moo re Haven , FL on July 13, 2017 ; however, he was removed from that trip for unknown reasons. There is no record of any requests, visits, pone calls or unusual incidents involv ing detainee ALMAZAN during his stay at KNSPC. On August 11, 2017, deta inee ALMAZAN's personal property was again inventoried for transfer to GCDC. A receipt for $9.00 in funds was signed by the detainee and a heck was issued at 3:08 p.m. per the Resident Transaction Receipt. The check notes , "Re lease Glades". Detainee ALAZAN was provided with the address and phone number of GCDC a,nd he signed a form acknow ledg ing that he received the informatio n. Per EARM , he was transferred out ofKNSPC at 7:30 p.m. Summary of Events DETAINEE DEATHREVIEW:Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 2599 l(b)(6); (b)(7)(C) I , , , RN documented a pre-screen at 5:47 p.m . on July 12, 2017, notin g that detainee ALMARAZ arrived to the facility at 1500 hours, the latter time believed to be in error. Lieutenant (b)(5); (b)(?)(C) tated during interview he is alerted whenever detainees arrive. After verifying the etamee s name, nationality and date of birth on the Order to Detain or Release Alien 203 form, he stated it is his common pract ice to then ask the officer at the desk to tell him the time from the computer screen, and he notes the time on the form. In this case, the arrival time noted was 5:00 p.m. When asked if the time he documented could have been an error as medical had noted a medical screen ing was done at 3 :00 p.m. the Lieutenant replied that he did not think that was possible as the time of arrival is verified by the office r at the desk . In addition, the EARM records document the detainee arrived at 5:00 p.m. Interpretation assistance was not provided at the time of the pre-scree (b)(6) (b)(?)(C) speaks English fluently," and there were no barriers to com munication identified ' adv ised she does not speak Spanish but, "If I say do you have any medical questions an can see he is struggling with my questions , I can get an interpreter." It was noted ALMAZAN had not transferred from another faci lity. He was noted to have current , unspecified healt (b)(6) (b)(?)(C) was taking medicat ion. He was placed on a Priority 2 status, which acco rding to ~- ·---~ means a provider must eva luate the detainee within 24 hours because of a chronic condition or if he is taking medications. 5); (b)(?)(C) ~G enes1.s, con d ucted th e mta . ke screen , notmg . th at D etamee . At 9 ·.39p. Illl(b)( ..... ________ ___.~ ALMAZAN was S anish s,.,..........._.......,...........,_...__.."' ,ich interpretation assistance was provided. Inconsistent (b)(6); (b)(7)(C) +'. d f:rom anot her f:ac11ty, ·1· h avmg . wit. b)(6)·, (b)(7)(C) s note , ._ ____ _.state d h e h ad trans1erre arriving with a transfer summary. Attem pts to locate a transfer form, however , found no evidence of its existence. Detainee ALMAZ AN stated he was feeling fine and was not in pain . He offered his previous diagnosis of cirrhos is I and that he was on medication. The only medication listed, however , was sertraline (Zoloft) , a medication to treat depression. When asked if he was now or ever had been treated by a doctor for a medica l cond ition , he replied no. He denied symptom s of tuberculo sis infection , and his chest x-ray was negat ive. He den ied drug abuse but admitted to drinking 12 to 15 beers a day, having last used on April 1, 2017. He also admitte d to being a smoker, smoking two cigarettes per night. The examination , mental health screening, and vital signs were all within normal limits (See Appendix I for vitals). A Spanish version of the conse nt for medica l treatment was signed . He was noted to have an abno1mal intake screening and was referred to a medical provider. He was medically cleared for custody. LT l(b)(5); (b)(?)(C) kN documented a sick call visit on July 16, 2017, at 3 :34 p.m. to assess an unspecified skin irritation. An interpreter was not used, as, "Detainee speaks English fluently. " When questioned during interview as to how she determines when interpretation assistance is needed , she replied that she is able to understand the issue, sometimes using "sign 1 Cirrhosis is liver damage from a variety of causes, such as alcohol abuse, leadi ng to scarring and liver failure. DETAINEEDEATHREVIEW: Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 2600 language" and since this visit occurred on a Sunday, "We probably had a Spanish speaking person to translate, and I didn't document it." Vital signs were all within normal limits, and ALMAZAN's general appearance was described as well developed, well nourished, and in no acute distress. In spite of the complaint of skin irritation, the skin was documented only as normal , warm and dry. His heart was regular in rate and rhythm , and his lungs were normal. Treatment included Clotrimazole cream 2, with application to the affected area twice a day for seven days, as keep-onperson (KOP) medication and hydroco1tisone cream 3 with application to the affected area, externally, twice a day for seven days , also as a KOP medication. An English version of a KOP agreement was signed by ALMAZAN. Treatment notes refer only to "RN Guidelines for Foot Fungus" ' whi le a referencf b)(6); to a mm:ina auideliJ e authorizing use of hydrocortisone cream was not (b)(7)(C) filed . During interview, ._ ______ _. admitted her failure to document the complete physical assessment and was unable to recall why she ordered the hydrocortisone cream , stating, "If I treated him, there was a reason I treated him". jb )(6) ; (b)(7)(C) I Seven days following intake , on July 19, 2017, at 5:34 a.m ., LCDR 1-------,-----,-~ NP, conducted an initial physical examination, noting that the intake screen was reviewed. An interpretation service was used , with the Language Line identification number recorded. During interview ~tated, "Even if they say they speak a little bit of English, I use the service to make sure they understand ." Detainee ALMAZAN denied all medical and dental comp laints, with the exception of hepatitis and depression. He admitted to suicidal ideation one year ago but denied any attempts. NP l\~/\~L , barrative states detainee ALMAZAN was taking medication for cirrhosis whi le in Metrowest Detention Center (MDC) 4• He stated he felt fine, was eating and sleeping well, and had regular bowel movements. He denied homicidal or suicida l ideations or thoughts of potential for violence towards others. He denied chest pain, shortness of breath , nausea or vomiting, fever or chills , abdominal pain , diarrhea, constipation or any other complaints or concerns at that time. His vital signs were all within norma l limits. His eye test showed a visual impairment 5 of 20/200 in the left eye, 20/ 100 in the right eye, and 20/70 in both eyes, wit hout glasses. The general examination found him to be in no acute distress , well developed, well nourished, and calm and relaxed. He was noted to be asymptomatic 6 and clinically stable. The assessment diagnoses were alcoholic cin-hosis of liver without ascites 7 and visual disturbance . The h·eatment plan included renewal of sertraline , follow up with mental hea lth, comprehensive laboratory studies on July 28, 2017 , referral to ophthalmology 8, and referral to radiology for an ultrasound 9 of the liver. A medical consent was sent to MDC to obtain medical and medication 2 Clotrimazole cream is an antifungal medication, commonly used to treat athlete 's foot. 3 Hydrocortisone cream is a steroid used to treat skin conditions. 4 MDC is a Dade County prison in Doral, Florida 5 A visual impairment refers to loss of vision and decreased ability to see. Normal vision is 20/20, while 20/200 is a significant vision loss. 6 Asymptomatic means an absence of symptoms. 7 Ascites is an abnormal accumulation of fluid in the abdomina l cavity. 8 Ophthalmology refers to a specialty in eye disease. DETAINEEDEATHREVIEW:Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 2601 records. Detainee ALMAZAN informatio n. was provided pa tient instructio ns and preventive health (b)(6);(b)(7)(C) The initial men tal health screen was conducted on July 20, 2017 , at 2:18 p.m~------~ Psychologist, STG recalled conducting the enco unter in Spanish and was not aware of wha t ALMAZAN's leve l of Eng lish proficiency was . Durin g questioning ALM AZAN verbalized that the fat her of a 43 year-o ld woman he had been dating was angry that he was go ing out with his daughter and later accused him of sexual assault. His past psychiatric history include d hospitalization at Jackson Memorial Hospital (JMH) for alcoho l abuse four years ago, but was later refe rred to menta l health whi le at the hospital. He reported that he was drinking heavily due to depress ion and stress. He said he would experience sadness, crying spells, and had suicidal ideations. He said he felt this way because of no t having a wife or significa nt other , not having his parents, having a sibli ng pass away , and losing his job. He report ed that whi le at JMH he was seen by a psyc hiatrist who presc ribed medication , whic h helped him significantly, but he did not reca ll the nam e of it. As per medica l records, he was taking Zoloft (sertraline) 100 mg . He reported a history of suic idal ideations prior to his hospi talization, having had thoughts of ju mp ing off a building, but he did not follow throu gh as he began to think about his family, and he started to read the Bible. He also reporte d suicida l ideat ions three years ago with thoughts of cuttin g him self with a knife, but focusing on his faith, he did not follow throu gh. He denied cun-ent suicidal/homic idal ideation , intent or plans. He also denied a history of perceptua l disturbances or delusions. The substance abuse history noted detainee ALMAZAN had been convic ted for driving under the influence of alcohol and participated in in-patient alcohol treatment. The assessment findings were 1. Major depressive disorder 10, recurre nt, mild; and 2. Alco hol abuse, uncomplicated. Treatmen t included follow-up in two to three weeks and referral t~b)(5); (b)(?)(C) for me dicatio n management. (b)(6); (b)(7)(C) On July 24, 2017 , at 5:46 p.m ., LCDR~----~RN documented a progress note related to a sick call refusa l, stating, " Patient called for sick call on eveni ng shift but refus b)(6); iple calls were placed by PHS desk officer with no result. Will continue to monito r." b}(?)(C) xplained that detainees are typ ically seen in sick call between 8:00 a.m . to 3 :00 p.m. every day, but in the eve nt of a spill over, a list is made of those not seen, and the detainees who are return ed to the housing until after 3 :00 p .m. are called back on the evening shift of the same day. Prior to the sick call visit, nurses do not know the nature of the request. Thr ee days later on July 27, 2017 , at 12: 19 p.m., l(b)(6); (b)(?)(C) IRN documented a late entry for a sick call visit conducted on July 26, 2017 . An interpretation serv ice was not used as "Detainee speaks English fluently. " Detainee ALMAZAN stated he had been taking pill s for his liver but had not yet received them. " He denied pain , and his vital signs were all within normal limits. Th e nursing pl an was to send 'I-'"' ........ ~........., encounter to a medical provider. The follow ing day of July 28 , 2017 , at 12:00 p.m ., l I 9 An Ult rasound is a diagnostic too l using sound waves to produce images of inside the body. 10 Major depressive disorder is a mental health disorder characterized by persistently depressed mood or loss of interest in activi ties, causing a significant impairment in dai ly life. DETAINEEDEATHREVIEW: Filipe ALMAZAN-Rui z Medical an d Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii 111et i 1111 :s 2020-ICLl-00006 2602 documented another sick call visit for complaint of respiratory symptoms and sore throat. An interpreter wa s not used for his visit as, "Deta inee speaks Engl ish fluently ." Detainee ALMAZAN denied pain , and his vital signs were all within norma l limits. He stated his cold symptoms we re mild and had been present for a few days. His general appearance was described as pleasant, in no acute distress. His throat appeared norma l, and his respirations were even and unlabored. He was instructed to do salt water gargles three times daily for three days and was returned to the dorm. I (b)(6) ; (b)(7)(C) ....________ _. RN, InGenesis documented a sick call assessment for complaint of skin itching on August 2, 2017 at 1:39 p.m. An interprete r was not used, as, "Deta inee speaks English fluent ly." Deta inee ALMAZAN denied pain, and his vital signs were all within normal limits. He described moderate itchiness over his who le body , having started weeks ago. He was observed to be persistently scratching. His general examination found him to be alert , we ll hydrated , and in no acute distress . There were no suspicious lesions , and psyc holog ically he was alert, oriented, cooperative with the exam, and showed intact cogn itive 11 function ing. The nursing treatment plan included application of hydrocortisone cream to the affected areas twice daily, start polyvinyl alcohol ophthalmic solution 12 to the eyes four times daily , and patient instructions regarding bathing, avo idance of irritants, and increase of water intake . Following repeated requests for a RN Guide line address ing itching to ver ify the prescr ibed treatment of hydrocortiso ne cream, it was never produced. l fbl(5); (b)(?)(C) !docume nted a follow-up mental health assessment on Au ust 4 2017, at 12:29 p.m., not ing the conve rsatio n was in Span ish. Vita l signs conducted by b)(5); (b)(?)(C) were all within norma l limits, and detainee ALMAZAN denied pain. He expressed having symptoms of depressed mood , but they were decreased from those previously reported. He stated he was participating in recreational activ ities and soc ializing with his peers . He presented as psyc hiatrically stable and was able to remain housed in the general population . He reported he had been comp lying with his psychiatric medication, with improvement in his level of sadness, energy, and motivation. His mood and attitude seemed better , and he no longer felt tearful. He offered he had talked to his sister who told him she was in the process of legalizing her stay in the U.S. and therefore did not want contact with him . He also discussed having gone to court the previo us day, at which time the judge asked him if he found a lawyer with the list given to him. He said he informed the judge that no one returned his call. The judge asked him if he wanted to proceed with the case on his own which he replied yes to. An appointment was pending with U(b)(6); (b)(?)(C)!Psycho log ist on August 11, 201 7, and he was scheduled for follow -up with~b)(6) ; (b)(?)(C) in th ree to four weeks. I I At 2:32 p.m. the same day,fbl(6); (b)(?)(C) PA, STG documented a provider visit to review laboratory stud ies with deta inee ALMARAZ. According to the laborato ry reports, the blood samples were drawn and forwa rded to the laboratory on Jul y 28, 20 17, results were rece ived on 11 Cognitive refers to the process of knowing and perceiv ing. 12 Po lyvinyl alcohol ophthalmic so lution is also known as artificial tears , a treatment for dry eyes . DETAINEE DEATHREVIEW:Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii 111et i 1111 :s 2020-ICLl-00006 2603 kb)(6); (b)(7)(C) I July 31, 2017 , and l._ _____ .... h-iwiewed them on August 3, 2017 , noting , "M J...-IC.---""'-.LI.L........,..i.....i..,c.., "th · " I · · d c h. (b)(6); (b)(7)(C) w t patient tomorrow . nterpretat1on services we re not use 1or t 1s encounte r, a~----~ l<5>;(b)(?)(C) k10:30 p.m. T ey ocumen e a during their shift nursi ng staff checked the detainee ' s IV , changed his bedding, drew blood and assisted him to the restroom throu gho ut th e night. I .. (b)(6); (b)(?)(C) On Septemb er 13, 2017 Officers ~---------~ reported for vigil duty at 6:26 a.m. l Throughout their shift , they logged the det ainee went for a procedur e at 7:37 a.m . and returned to his room at 7 :43 a.m. Staff logged that nur sing staff c~anged bis linens brou]ht him food and delivered pain med icatio n throu hout the shift. Offi ce ~(b)(5); (b)(?)(C) _were relieved at 6 8: 14 p.m. by Office rs (b)( ); (b)(?)(C) Throu ghout their shift, they logged that nursing staff gave the detainee medication , walked him to the restroom, and checked his vi tal signs. An emai l from Commande l~\)~\rcl sent th is date to ERO officials inquir ed as to the plan for detainee ALMAZAN upon discharge from the hospit al. She noted , "His condi tion is chronic and will only get worse with time. GI bleeds can happen suddenly and can vary in severity depend ing on where the bleed occ urs" . (b)(6); (b)(7)(C) In written statements dated Se tember 25 2017 and subm itted to SDDO 1d AF OD (b)(5); (b)(?)(C) documented a visit they made to the CRMC on September 13, 20 17. They documented that upo n their arrival, detainee ALMAZAN was asleep but he woke up w hile they were talking with MTC vigil officers. The deportation officers spoke with detainee ALMAZAN about the status of h is immigration case and the detainee in forme d them he intended to appeal his case and had a petition pending. They then discussed with him whether he had fami ly in the U nited States and he stated he had fami ly in Florida and po ssibly New York. They then concluded th eir interview of detainee ALM AZAN. The deport ation officers' statemen ts do not document the time of their vis it. The MTC hospital log does not document any visit to detain ee ALMAZAN by ERO officers. l(b)(6); (b)(?)(C) I On September 14, 2017 at 6 :20 a.m..._ ____________ __,t eported for vigi l duty. They logged that nur sing staff checked the detainee ' s v ital signs and at 8: 10 a.m. Do cto~(b)(6);~infom1ed the nurse the detainee should be moved from the ICU to a "regu lar room " . A t 1: 15 p.m. officer s logged the detainee was "complaining of chest pain " . At 2:20 p.m . the detainee stated he "had gas". At 2 :40 p .m. the detainee was mo ved from th e ICU to room 141. At 3:15 p.m . the detainee reported he nain He was gjven Mv)antj and other unknown medications per the log. 5 At 6:56 p.m. Officer ?>< >;(b)(?)(C) _ repor ted for vig il duty. They logged nur sing staff checked vitals, gave pain medication and took a blood sampl e during their shift . Also on rd DETAINEEDEATHREVIEW: Filipe ALMAZAN-Rui z Medical an d Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 2632 I b kb)(6) (b)(7)(C) (b)(6); (b)(7)(C) this date , L ' oted in an email to Comm ander ._ ____ ....,that the detainee , when discharged, would be moved to HCDF until he could be moved back to Florida. 6 On September 15, 2017 at 6:20 a.m. Officer{b )( ); (b)(?)(C) reported for vigil du ty. Throu ghout their shift they logged that nurs ing stafl checked the detamee's blood pressure and gave him medication.. They also not:d the detainee took a shower at 2:00 p.m . These officers 5 were relieved at 6:37 p.m. by Officer{b lC l; (b)(?)(Cl I I ~i!~1r. i, Comman der in an email this date to vari (b)(6l O officials pro vided a medical update on detainee ALMAZ AN . In the email, Commande (b)(7)(C) noted that a cardiac stress test was being scheduled and it was po ssib le the detainee would be discharged in time to make a flight back to KNSPC scheduled b)(6l mber 17, 2017. If the deta inee was not release d in time for the Sunday flight , Commander b)(7)(C) commen ded that he be moved , when discharged , to "Houston CDF due to his combin ed chronic med ical issues". I (b)(6); (b)(7)(C) Officers .______ ___,, .....who had assumed vigil duty logged that nursing staff met with the detainee at 7:04 p.m. to review paperwork with the detain ee author izing a stress test sche duled for the following day. At 5·38 a ro oo Seotewr~r 16, 2017 the detainee signed the paperwork . At 5 6:40 a.m. Officers l(blC l;(b)(?)(Cl _ rrived for vigil duty . At 9: 18 a.m. they logged that the detainee went for his heart stress test and returned at 10:49 a.m. l(b)(6); (b)(7)(C) Officer~'----~---__,r eported for vigil duty at 6: 10 p.m . They logged that three nur ses and a doctor entered the room at 00:34 a.m . on September 17, 2017. At 00 :55 office rs contacted the war den to receive permission to remove handc uff s for "blood gas testing" and noted it was an "emergency". At 1:04 a.m. the detainee was move d to the ICU and a chest X-Ray and blood sampl es were taken. At 2:01 a.m. officers called the facility to report the detainee was on life support. At 2: 11 a.m . chest X-rays were again take n. At 2:31 a.m. the cuffs and belly cha in were noted as removed after permission was received by a shift sergeant. At 3:23 a.m. Doctor s )~()~(ir , and Slaugh ter entered to check on the detainee and searched for veins for IV picks. At 4:41 a.m. nur sing staff asked if th e facil ity could notify detainee ALMAZ AN ' s next of kin to "pr epare for the worst" . At 4:57 a.m. the detainee we nt into card iac arrest and nurses started CPR . At 5:15 a.m. the detainee was pronounc ed dead. At 5: 18 a.m. Warden David Stacks was notified by the vigil officers of the detainee's death. (b)(6); (b)(7)(C) Per an email from Ass istant Officer in Charg ~----~ at KNSPC, at 8:04 a.m . EST he notified the detainee's sisterl(bl(6l; (bl(7l(Cl ~at her brother had passed away. l I Vigil duties were performed as follows : Date September 12, 201 7 Officers (b)(6);(b)(7)(C) Arrival 4:32 p.m. 10:30 p.m. DETAINEEDEATHREVIEW: Filipe ALMAZAN-Ruiz Medical an d Security Compliance Review December 4-5, 2017 l_C •r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 2633 Deoartur e 10:47 p.m. 7:15 a.m. b)(6); (b)(7)(C) September 13, 201 7 6:26 a.m. 8:14 p.m. 6:20 a .m. 6:56 p.m. 6:20 a.m. 6:37 p.m. 6:40 a.m. 6:10 p.m. 6:01 a.m. September 14, 2017 September 15, 2017 September 16, 2017 September 17, 201 7 8:34 p.m. 6:35 a .m. 7:25 p.m. 6:28 a.m. 6:55 p.m. 7:23 a.m. 6:22 p.m. 7:20 a.m. 7:02 a.m. Warden Stacks completed a Critical Incident Report on September 17, 20 17. In the report he noted that detainee ALMAZAN had been transported to IAH/PCADC at approximately 11:00 p.m. on September 8, 2017 , "due to expected imminent damage and dangers from Hurri cane Irma to the state of Florida" . Warden Stack also documented that the detainee arrived at the facility , " with noticeable jaundice skin". Warden Stacks ' report lists the initial apparent cause of death as a heart attack. An autopsy was ordered by Precinct Judge Wayne Mack through Texas Range i~li~lcc) fb)(6); (b)(7)(C) jper the Warden ' s report. On September 18, 2017, Detainee ALMAZAN's personal property was inventoried and photographed by Officer J(b)(6); (b)(7)(C) I The property consisted of one pair of pants , four shirts, 11 pa irs of soc ks, one sweat pants, two t-shirts , eight pairs of underwear, three pairs of shoe s, one wash rag, one ID card, one wristband , books, legal paperwork, a Bible, a watch, necklace , wallet , sunglasses , a homemade ring, one,..><.1.>......_ ........,......,....._ ..... 2.10 in coins. Multip le hygiene items and multiple medications were also marked. (b)(5); (b)(?)(C) oted on interview that the shirt with elep hants on it whic h the detainee was wear ing upon adm ission to Krome and for his intake photo as well as a · · rts had small spots on them with a "moldy, reddish tint" that may have been blood. (b)(5): (b)(?)(C) tated the ro er was turned over to Supervisory Detention and Deportation Officer (SDD (b)(6): (b)(?)(C) (b)(6); Per SDD (b)(?)(C) upon receipt of the property, it was taped shut in a cardboard box and secured in his office with the inventory sheet taped on top. The box was opened by the SDDO for the reviewers on October 18, 2017 and the contents were inspected. The various clothing items were reviewed and the elephant shirt and one pair of shorts did appear to have small spots of blood on them. The clot hes he had worn on the trip from Folkston to IAH/PCADC were inspected and no blood was observed on the orange pants or cream colored t-shirt he wore during that trip. Ass istant Field Office Directol(b)(5l: (b)(?)(C) ~ documented in an ema il dated September 18, 201 7 that he was contacted that date by the brother of detainee ALMAZAN request ing that ERO assist with the payment to ship the body back to Florida. DETAINEEDEATHREVIEW: Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti11 11:s 2020-ICLl-00006 2634 On Sl,,LIJ .i::..u.=;.i., 18, 2017 , Texas Ran .._______ ___,from Livingston , TX sent an email to APO stating he had b b Montgomery County Justice of the Peace lIJ ~,.,..., . h . .h . . I". • h d fr h h b)(6); (b)(7)(C) have c1rr os1s wit vances , m1ormat10n t at was extracte om t e c art, as determined " · t] poor historian" . When questioned as to how he arri~ v-e ~a- t-t -1~ s 5l; (b)( · · (bl( ?)( C l d h d . ALMAZAN f'C'. d d. 1 h' 'f h d'd desc npt10n,,_____ ..,tate t at etamee o 1ere no me 1ca 1story , as 1 e 1 not want medical to know (b)(6l (b)i?)(C) was. When directly questioned about his cirrhosis, however , he then admitted it. ' oiced his opinion that the detainee did not speak English and thatl(b)(6); (b)(7)(C) IMedical Assistant, provided inter retation. He was de scribed as alert and oriented and appeared to be in no acute distress. (bl(5); (b)(?)(C) stated there were no sympto ms or patient behaviors at the time of assessment to suggest this was an emergency situation. Bright red blood was observed on both the inside and outside his mouth , but there was no blood on his shirt or pants. He was diagnosed with gastrointest inal bleed of five days duration and was sent to the emergency room for evaluation on a stat basis, but not via 911. )~ii~iic:, A "Time line/Checklist - Depart from the Facility " form """"""'-'--'.I.LI.L=u:;d by an unidentified medical . h' d (b)(6); (b)(7)(C) 'fi d f h d sta ff mem ber at 8 :42 p.m. A ccor d mg tot 1s ocumen.._____ __, wa s notI e o t e nee to ti·ansport detainee ALMAZAM to CHI St. Luke's via van with security escort. Hospital updates were recorded daily , as follows: ReportingNurse, Date, ReportSummary (b)(6); (b)(7)(C) 1-T _im _ e _____________________________ -----l Stable at this time. Most recent vitals: Blood pressure 99/58, pulse September 12, 2017 7 5, and respirations 17. Pulse oxygen 97. Temperature remains nonnal. Two units of platelets given due to critical platelet level of 27. Post transfusion level is up to 55. All other labs rema in within normal limit s. Scheduled to have EGD 98 in the morning. Previou sly receiving cardene drip 99 via external jugular line. Has been stopped and is now receivin oral lisino ril JOO_ (b)(6); (b)(7)(C) Alert and oriented. Blood pressure 117/58, pulse 88, R 19, Temperature 98.3, pulse oxyge n 100. Received two units of platelets . Hemo lob in is 11.2, and latelets are 27. Alert and orient ed. Blood ressure 101/51, ulse 69, res irations 14, 98 An EGO,short for esophagogastroduodenoscopy is a scope used to examine the lining of the esophagus, stomach, and duodenum (upper part of the small intest ine) 99 A cardene drip is an intravenous therapy infused with medication to treat high blood pressure. 100 Lisinopril is a medication to treat hypertension. DETAINEEDEATHREVIEW:Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 2639 September 14, 2017 6:41 a.m. l(b)(6); (b)(7)(C) IRN September 14, 2017 6:31 p.m. b)(6); (b)(7)(C) temperature 98.3, pulse oxygen 99. Continues lisinopri l orally. Denied pain thro ughout the night. Alert and or iented. Blood pressure 125/73 , pulse 79, respirat ions 18, temperature 98.7, and pulse oxygen 99. Continues oral lisinopril. Pain is eight of ten, repmting severe GERD. Moved to medicalsurgical unit. Rema ins stable. Removed from ICU room 18 to medical surgical floor, room 141. Blood pressure 93/54, temperature 98. 1, pulse 72, respirations 18, pulse oxygen 97. Rema ins stable. Blood press ure 1006/65, temperature 98.2, pulse 72, respirat ions 16, pulse oxygen 98. Had a normal cardiac stress test earlier in the day. Medications remain Zoloft, folic acid, metoprolol 10 1 Protonix 102 , lactulose, and aldactone. Possible discharge Sunday after seen by doctor. At about 1:00 a.m. pat ient coded and is now critical and has been moved to ICU, room 36. He is on life support and is intubated with agonal 103 breathing. When able to get a blood pressure , it is in the 50s by palpation 1°4 . Hemoglobin is 5. Blood being given. Warden Stacks has notified ICE personne l Simpson. I September 15, 2017 5:40 a.m. kbll6l (bl(Zl(Cl "' ,t, RN September 16, 2017 7:24 p.m. b)(6); (b)(7)(C) I September 17, 2017 2:32 a.m. On September 20, 2017 the State of Texas issued a Ce1tificate of Death which listed the cause of death as "pending" . APPENDIX I Vital Signs DATE TEMPERATURE PULSE RESPIRATIONS BLOODPRESSURE Oxygen September 8, 2017 97.0 98 14 September 11, 2017 97.5 106 18 180/109 164/100 152/86 151/95 APPENDIX II 101 Metoprolol is a beta-blocker to treat high blood pressure. 102 Protonix is a treatment for GERO. 103 Agonal breathing is abnormal respirations characterized by gasping, and labored breath ing. 104 Palpation is a method of examining the body using the hands. DETAINEE DEATH REVIEW: Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 2640 98 100 American Heart Association Blood Pressure Parameter Blood Pressure Category Systolic (Upper number) Diastolic (Lower number) Prehypertension 120-139 or StaaaOna IA04S!I ar 80-89 CONCLUSIONS Medical Compliance Findings Medical Care, Section (IIl)(D) , which states, "Non -English speaking detainees and detainees who are deaf or hard of hearing will be provided interpretation or translation services or other assistance as needed for medica l care act ivities . Language ass istance may be provided by another staff member compete nt in the language or by a profess ional service, such as a te lephone translation service." • During the intake screen itj(b)(B) ; (b)(?)(C) bted ALMAZ AN spoke · therefore did not requi re language ass istance. Durin g interview , however (b)(B); (b)(?)(C) stated he "spoke very little English" but that an unidentified medical person prov1 e m erpretation. There was no documentation to substant iate this. l(b)(B);(b)(?)(C) lntakeDetention Officer reca lled detainee ALMAZ A __ '-"=..._ ................., pan ish, requ iring anoth er intake officer to "d l . (b)(B) ; (b)(?)(C) D . Offi h ki . h prov1 e ang uage ass istance .~----~ etentio n 1cer w o was wor ng m t e detainee's un it, also stated detainee ALMAZAN spoke no English and req uired interpre tation assistance. There is no telephone access in the medical intake area. Medical Care, Section (Ill)(D), which states, "Medica l and mental health interviews and examinations shall be conducted in sett ings that respect detain ees ' privacy." DETAINEEDEATHREVIEW:Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii 111et i 1111:s 2020-ICLl-00006 2641 • Curtain dividers and ceiling-mounted acoustic boards do not fully protect a detainee's privacy to fully and comfortably discus s sensitive medical information. Medical Care, Section (III)(D), which states , "T he clinical medical authority shall be responsible for review of all health screening forms within 24 hours or next business day to assess the priority for treatment (for example Urgent, Today , or Routine). • The intake screen does not include a signature ofreview by the clinical medical authority. Of note , the evening detainee ALMAZAN was transferred to the hospital was the first business day for that review. Medical Care, Section (IIl)(B), which states, "Health care personne l perform duties for which they are credentialed by tra ining, licensure, certification, job descriptions, and/or written stand ing or direct orders by personnel authorized by law to give such orders." • A seriously elevated blood pressure of I 80/102 was not reported to a provider in accordance with MTC's Nursing Protocols. Additionally , regular blood pressure monitoring was not done during the three days detainee ALMAZAN was detained at PCADC. Areas of Concern • Sick call forms and deposit boxes are inconveniently placed in the hallway outside the locked unit. Detainees reported they access them when they go to recreat ion and after completion , hold them to the window when the officer passes by doing rounds. The officer then takes the request and deposits it in the locked box. This practice does not protect the privacy and confidentiality of the detainees. Detainee ALMAZAN did not request a sick call appointment during his detention. Safety and Security Compliance Findings Creative Corrections cites the following deficienc ies in releva nt compone nts of facility pol icies and post orders. Dorm Officer Post Orders , section III 8. Post Activity Log Entries requires unusual incidents to be recorded in the log. • The medical emergency called to the detainee's dorm and the response of both security and medical staff was not logged. DETAINEEDEATHREVIEW:Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti 1111 :s 2020-ICLl-00006 2642 Stationary Guard Medical Officer Post Orders, section II, 9.B requires the assigned officer to maintain a daily log of activities to include visits by physicians , nurses, room attendants, and any other relevant information. • Assigned vigil officers did not log the visit by two deportation officers to detainee ALMAZAN while he was hospitalized. DETAINEEDEATHREVIEW: Filipe ALMAZAN-Ruiz Medical and Security Compliance Review December 4-5, 2017 l_C 'r e:ali1t ,e i::11rii111eti11 11:s 2020-ICLl-00006 2643 l(b)(6); (b)(7)(C) From: Sent : To : Subject: 27 Dec 2017 09:22:42 -0500 f b)(6); (b)(7)(C) I FW: Almazan - Prelim findings Fro ~ (b)(6); (b)(7)(C) I Sent: Friday, December 22, 2017 12:21 PM To: (b)(6); (b)(7)(C) SubJect: Amazan - Prelim findings • • • • Almazan's serious medical conditions were omitted from his transfer summary for his transfer from KNSPCto GCDC,and copies of his abnormal laboratory reports and chronic care clinics did not accompany the transfer summary. KNSPCdid not place a medical hold on Almazan pending his evaluation and treatment by a hematology specialist. KNSPCmedical staff conducted at least two sick call encounters in English without the use of an interprete r or interpretation line. KNSPCmedical staff did not completed a medical alert form for Almazan's diagnoses of two chronic diseases. 2020-ICLl-00006 2644 r b)(6); (b)(7)(C) From: Sent : To : 29 Aug 2018 11:47:29 +0000 r b)(6); (b)(7)(C) Cc: Subject: ALlvlAZAI\J 1 (b)(6); (b)(7)(C) I'm hoping we don't have too many more questions, but I have a few below: • • • Was it your understanding that &~~~~~ir, lgave him BP medication between the first and second check, or once before the second and once before the third? o And do we know for sure she gave him his missed dose of Spironolactone as the medication? I didn't see that anywhere, but I may have missed that . Did we get the nursing protoco l for BP for Polk, I don't have it in my docu ments? We wrote up, "Creative Corrections notes MTC nursing protocol requires provider contact after a blood pressure reading of 160 100 or hi her". Would you say this is correct? PA Young states that (b)( 5 ); (b)(?)(C) hould have contacted hi m about the high BP considering ALMAZAN had been diagnosed with cirrhosis and possible portal hypertension , but the transfer summary does not list portal hypertension at all. Should (b)(6); (b)(7)(C) ave known ther e was a likelihood of portal hypertension? This w ill help me rewor 1s. Thank you and I hope you are enjoying the California weather! 😊 l(b)(6); (b)(7)(C) Management & Program Analyst ICE/OPR/ERAU 950 L' Enfant Plaza SW Washington, DC 20536 202-732 b)(6); desk) 202 -253 b;(7)( cel l) ~li~ib 2020-ICLl-00006 2645 From: Sent : To : :37:55 +0000 (b)(6); (b)(7)(C) Cc: Subject: Passworl (b)(6); (b)(7)(C) l(b)(6); (b)(7)(C) Management I I & Program Analyst ICE/OPR/ERAU 950 L'Enfant Plaza S b)(6); (b)(7)(C) Washin ton, DC 205 202 -732 desk) 202 -253 cell) 2020-ICLl-00006 2646 l(b)(6); (b)(?)(C) From : Sent : To : Subject: 17 Oct 2017 15:54:06 +0000 l(b)(6); (b)(7)(C) I ALMAZAN Here are the A numbers for the cell mates (b)(6); (b)(?)(C) r )(6); (b)(?)(C) 1 Management & Program Analyst ICE/OPR/ERAU b)(6); 950 L'Enfant Plaza SW b)(?)(C) Washi C 20536 202-73 (desk) (cell) 202 -25 2020-ICLl-00006 2647 (war i Well cal/? i i (1,ng N53 WW6 il>l MM ,Blwm?H? 8mm WW1 Mun? - Mal ll ?ij bladwx W(%i 31% wok Ll Ml m: ?ll/(M mm Amw'm MWM +003 Loomwduwzi 120mm Ojlfl? MEN mm . L?l lull-(lull MW lama mm mm (Wham mall. Cm. Ema/lab. (Ml NW th}w A 1 h} 2/ Qegl; "1 ~lfT\.~r )(6);(b)(7)(C) lRN Leng+Y1 ·. 2-'{e0~ ( fevi1,tfY)) _ll+ll: 1Jn,'«U1t.f '. Atmor - Giv1.,, cwevi1c\,0f1D1 ~ 't1'-u tiWt,L ow - ~e,;~~ 1YW1\i04r/~t ~\;1ld"\t'0 - fl kn,~bCni~6( - si()J_ ccllrs pic{LU\u,pQ;W\~i cloo-e_\JlNVl N-1/=tJ~ I ·~ bClCA.. 7o Y)\U{;1 C£l1 ( S\CU... c4 l t 0 ltiLQ.,,i) , It e,,rr~,l'/f\,U,,\ ..tw,1 •lhA'Jmru..vJOJ rtfttY~ "-Paps~ on °'--~.st- viP(ht lU,JO--vJ ~ JW1R.N5) CiLCcu\ t,~-+- --'6"\2,,q me,t;itwJd) 8\ct Cit ll d(JY\Q_ 1?1 oo - ~c_ g\ctSs essi:~a.dcGressl0 7 n~ tu')+t1 Cl/2.. - i C..ovv,~cun ~ ()Ur Sk,t2caI\ - Ul(AL~ IV\ Q,{&,v) c\OV'm 2020-ICLl-00006 2649 (b)(6); (b)(7)(C) tJame 11-Ht:----.} f7"""1\ -< ""7T7'>,-r;;-;- ---....J Ltngth1\\leGtvs- ( ~ A Lt~ eW(j LGmpCU1y. funttov - CtHP 1=Lo ~ in-1 v~J-mus tlid.. \{ttl;t,~ (W-t-CCttP l lJPN {\1~'\+ •. .$"\"l it.+- - \/()f}A)v')C)-lJ- NW-vr ll CMt ltvwf ~1 Smf-fi11£} .L'.\ bu)\ -\- fctC:1\1~bnxet1 u.,p e1.,•~-ti'\i~ 9i 01\l)tcd sUYY1MCU1ts. - Fow~\ oUvr CAo~~ p~1or --th.tb ~ rw.clu{ -tn ~ o\.l;t_ ~ -~ 1 ~m Y--P('\.U't) ~-L (J-tt'lW (Y\.Wl,S iW_ loCfa.-l pKCLVy¾QCti. - 3X1[\~ c\D()Q-t, dOJ-VS+1 !SH~ pxk .S,CAL Cttl), (;lll ·1&~U£s CJl!A.kle.tWt\VffJeo{ Ctt 1 +1rY'e. - teuvJnin+~w o.i 1n,e,~~-ft-tll- ~01cie-trt,i,c-e..0cu-v'\L - ~~\&'h E, 0"611sh C0Y\~t1{ 1L01V1 - Whtn ,tr-tau scne..n 00(\(_ - Ct-Sw -\•1ei-tn l,,U\d.e.v,ttooeil 8v\~\16\ri - Lab pmctss\JlU \ l( L. lDaUJu ltil'¼ I iicetut£, lV1 e,oultr\ -fuu,y-p,uu vLfq 17) \(W-rltflfn1 rt.sulk) (A{1e,ll iiu Y\ cuwv00\ ~ \ctti~ C\ltav, ~ wVLU, lPJ~ LN-etY'L ~ ~w.d Ovv' - W~l ~ hw, ~ ·,+h.-t LJOJ mLA-1 1Y7vU~v1~ ~ iJoit- Jc~ Wl\t 1/Qmrfi) 4-t,nct~11 I~ y'\t)IY\ - H-oqx'z;{_L~ ;,r PoJm twp- - Not {)_~ ~ N0t ~ tlUil ~-R-v,. \4 tlAl prnla\uv1 lwA-~ h-ow~¼{}, PlJt·1t ~hoLl(d V\01,LL ~n on1°Ylu11Stv fv,tw\ - 1h'1nt. i,t WJ-~u.lcohol \{ULU(I ChlYn-~) noi\-le{)virus. - f\ffifY\O"ft~tlJ ~[ tfJJJ\ ~ (J,_ ~"J\;'t;l'J__ ill ~ - 1+w...JvlMt-lt,{l.t(J{( \)U,tt'N 3osSrppI ... 2020-ICLl-00006 2654 \ vJ~ tuu (b)(6); (b)(7)(C) NfMW_· '---,-,-r,-- -----.1 ]l1{e.t ~~ ~ ~htrY ~'i _- 20rJ ~ ~ ~I( ltg: ~1-tttU! · ~Wlvf ~ ~ V'~ •~ t-o ~ ~.QA,Lv{,u\ 1,t)/'th L!KhY-S if 'l~J U,Ll'\. ~ 2..%v:t - fwt1-0: ~ Ul}, '1 (u;o~\b\_t ~ ~ \tJV\-1) ~CA__ ~vt Y'~ ~ k WN ~OJI'-~ (b)(6); (b)(7)(C) --~cans\r\'im bwt ~+- ~- ~ Y\J\W{ ,$ - ~UL CALl °1/l - WOlili\ V\ll1-tw1W _- V\Q_~ ·eor~ ~ k. _ \t\M,i,_flA,u.At1VL~ WAW~-tAAA ~ ~ LvlM ~ ~ 7t) ~ w ttlo_,W 2020-ICLl-00006 2655 _ a 0/ ?RJLmun/bjc - WW a?wm VIM. AM we Wm Max/1U +0 pm?cmm, Merka 1w? Wam - (Mgme mg dob/max, ?x 04'? Maw W1 0ngst A: (1307(0) - NW1 . 'asi?c/Lcm 61/2,. :?fi?wgmm??m mfg/M ?6v op?vngv??- W??2020-lCLl-00006 2656 49mm WWO) 7? VP [Hurt a. gasses/(mam? Coma WW My mo (ma. Lao/Wmm?feu?m WWII, (WW MM ?Maw Wm ?32m} an Wm?v??mmk wasm bk) um Hr WM am 4601/) Mam, (98W $53me mm WW W8 WW mamas a4 WUU Mommies (ham Oath/mi Womoaho Wm WW mas :7:me WPWW m: mam ass, 2020-iCLl-00006 2657 Glu¼l) ~, 'i(jI Z.. cU/110\1 C,IOfYl Mll Z.OU- )(if [J.._ )(vi,,V"'I ~-rlA.[oK- Jul,c_ ~c { c\ l-Nd (()CIJn- ,suYl(_ x'iW--Ktvi 711fYlvt<(\ 0 1ON. 2020-ICLl-00006 2658 fwrivui@ foUL- oi/~l,, fwM fbt--UWN - Merl l11:tu~ {1(Vlme.cf..l(d.(__ hWm UW\Cl.rt..fo1;vln,V'fJ4>-,~Y', c.i}~t A6YlL- f.~f!lrtll\ ~ rw..A-PmM. d-OV V\I'- ~ruvtS~ 10 fv,f1W - N\'JoL~ (1 -w-vuY\M-r-h~\o\~. ~ lrtlVl - IfW ~. ~ '-IO'tL~ (_ nS"i 1'r) Ytr'-leAJ - ~ a.AM r ~ -hi /llfs-pt\rvl ~ t/Win.,-f¾vvt>t_ t{vsk ,2-cr/,2./ 11 - ,v\ov-~~ Cth.i,t. w us h Conn>L-~UV\Al fny tr~ vtL (),rn,~~ a v '.t.Js-;~ vri r.(_,ti' t,-Ov\ rn. 0 r,.,1> vu~Rl\.\ vtp~~ ~tt/116!1 A tf-~ (_ aJ -h~ - Mtm~~,'Nt~1 ~1 -~~ (rumIW-h r\\ut~. Pi(Hvll1 ---\WW AA~ 'al-tlPA , ft¼\\?~d;6WJf ~ a,,rfr, IO\Mli&' ~ - 1~00~MJ ·h~I WVJVIJi il IW. D~l1il 1 CNl ~-r--lvYtL o+~ G •.1< M1t\ 2020-ICU-00006 2659 ~P~- . //Ai /!Ju1 ~ ---------.... , ~k ~ (-VJ )-=1 ' ,"~ I t.LJ I 2020-ICLl-00006 2660 I ~c~ \f~ ~ K5): me 3449*" wmew) NHL 91m me wn?r hum N95 *Pa?jo SPIWU (DR/{Czar ?37 Wm WL 6016616 DY Sip wotM11601) ?ewmg2 34M at: W. *P?pra La/lqmq OWL, an an . Ma ywm, 1mm?l ms (M51) (Baspm-mb ?NU/fat- MAO-[tww??s M) 3% husp?? (WM ?Vin . 43%me WW UM s?gchm 1 ?10 @313 mm Smart/?wiwok an 0m; Mu) bu lam: Wmihw) lomd ?Bmmus 417 - 647w. mu b )(6); (b )(7)(C) ~n»,l i.___ __ __.J - RM~ obN...~l,\ ~~ ~ pro~ WW- ~ - t4_ ~ ~ - ~ ~~ ~fM~ tA.M--+i\~&\ ~ ~~ ~ 2-Y ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ - Did not &1~ fro~ t'~ LOY\h ~~ k?lt, k- ~!AA- -ro~~ I - rwt O+{ ~ I.A,\ I -tMu- ~ ( -f-bda,>,?tya__(f~ ~~ ~- - '3L4-U ~ ~ - C-20 ~ C--\ OMf.. --N D o~ COY\~ ~v-~o4 fuv Y\,\.Ul',CA w/ \ ~ ~ l,vV\ ,4_,t iK ~ 2020-ICLl-00006 2663 ~~ ~ (b)(6) ; (b)(l )(C) - ~ CU 6 +f-J'UV, - wo~ ~ TX ~ ¥ L.-l---5~tJI'. · cg-~Y3' I ~ /CvpJLLY'-~ ~VCTU bh-J - lt \.S ~~ - L-t li\)a,(~ ->;, qwT 2--!D -{\A,lWl MW - l,JO~~ ~ ~ vt~ - ND Utn?-6t-- ~ ~ ~~ - OWU-Y ~ tltJ ~ - &v cl ()IDo~ - Gb+ MVV\. -h M&p,~ - v) JA+ ~ ~ ~ -h ~-tvt5Yv\.,~ - \-\€._ &x)j \,- lj~\ k5t-ood\~ ~ ~ ~l - tu lt~ t&~-d ~ ~ ~\ tt JD ~5pl~ 1 VU> M»re, vi~1sa~ -u- VOVV-'i~ , ~ ~ ~ fa-<-. ~ ~ ~ M J p )~ t- tJ-J-f--tt_~ '7:>~ 00 ~~ ~ ~ Cvv"L W~ Wr-f-7~~ - LA)lr\_ + -k, ~\A~ --h~➔, ~ ~,~ V\/)VV'\ h Canro"-VJ~WV'-b~. b#)~ votf.;._u] , I\. ~~ , ~ ~ VM1· - D>O'lY\,Df~ ~ vv(.) 0 ++ ~ NV-H~ ~ V\A.llf ¾ ~ f"N.. Dttfv\rutnvl~ ~ h,V\/', - tW 1\\f ~ - V ~ UJ~ . - 5(.,U' p ~1-u1\ ~ d1'l.A - (::)?A µ~ o¼:,v-w1D 6 f-~ ~ 2020-ICU-00006 2664 ~~ ~ (DWEC) Nam;- WM lilW 3' bf [101% (HUNG) mem ow, Wis mm, 0mm {#th NW 1W1 +3 10th mum MawGBPW 2665 Nt1r ()'\I) -Trvjl~ tv ~~ tn,l,t }\L)tu Dc,N Nl4 v~es - \C,6 ~\ fop pr,ov1~ CM- VVLO~D:iE'~n.~ ~.LL~ lJ)/\. t- ~CttJ kold . ~~ - ~-\at\ \AL ~CJ 4eigt- - ~ ~! ~ WVU/}V\t ~ ~ ~ +v6~6"5 - Nu-'1ft>~~~ Or\~ ot-~ cl«-· - ~ 11'-Mo.. Ott,y Ccl ffi\ t:&~ ~ 1D1WLL ~ ~~ tD PBNOC> '201\ (po~)k,U-t) - Med-tci'YtL ~-r 'BP - ~"1'1V) ~ N\JS ...,f b~( ~6);-(b)(-7)(-C) --.- , ___ "' -\6m..---~ - IO ld ~ _JI15DO a._ 5 CZ-¥Y"'\ 1 r\D-r 0 ~ ~ ~ -n) ~ [A,A.;,h l ~ w~ ~ 2020-ICLl-00006 2666 ,I I I_ (b)(6); (b)(7)(C) fT ::t+=" • b)(6 ; (b)( )(C N - D<~~ ~l~ 4 - Nt»Vr - WM.~ W - ~ l~ ~ ~ \ ~wt fl) UA.~ ~ io u..:t- VU'v( 8\0~ - Wi~~ ~ ~ \o~ - ~ ~ UY\QY\ (MIY)\/~ l--J~--KA to cAiz_ , v~ ._s~ - 0)~ vUfloc« U-1~ lL wo._s~\ ~ _- ~ olVl~ L ~- k 1 ~ ttl\ ~ ~ - WM14J!--h p'll w~wl ~,~ ~ ~~ bl.d - Wov,te{M +-~ --tv V\,U.XU_ IA.-+p ~ l Ll, l"\000 - 3-4 'f.. o.c- vOM·, ~ , l~~ OVL ~ b~ -~ D\M+ ~.,-1) ~ - lLMWS ~ --furMS~ pu.,t OV\. w~w ~ s,C,L GA-ll - ~pOYU-t_ wM r~ty ~+- ~ ~¾ ~ muf1CAl r 2020-ICU-00006 2667 k~; (b)(6) ; (b)(7)(C) N~~ (b)(6); (b)(7)(C) '--- -u---------_J ~ ~ --rn'l.Ol -h ~-to •~ Tv'uf ~ ~ h, ~+ ~-+h W\tW'L - f ~ -h ~ VVA'v' Ovvt"-ti>'1~ \ol/l?t- \,()~(A_,~ . - ~6Btulv~;wod ( ~ ~ ~') - \}~ W ~. o.._~ 'o;-ie.~~ ~ - Wo~ ~ ~""-- -f'~ wr;..W' - --rvi-tol4v \,)~ • - ]/4._f\DOJ ~ fv -hcj \tvt'M ~ 4·l --rt)~ ~ ~ ox.:,\-" ~ <.j Q..M V1 I ~ l.,,(_A ~ A_ L~1+k.L ~~~Jt> ~ \ 'fM7' fV '"t'O~ 2020-ICLl-00006 2668 ~ ~L · ~ . We); (MUMC) ?No Wm -No Com grief?) Damn WHW rum h'rm mm mm - amwmbu 0m ?mlbm 41> WMMW wow can? ~1n 1w MW 730445 MW ?Dim 6804*pr {wt ream 2669 (b)(6); (b)(7)(C) r-St,,u..:. *lt·~ ~~ ~ ~ ~ \(ws +- w ~M'\1 '· vvvrc --No tiin~ b.l--hrt 'rv,~~ \ - 2 -IO ~ 'i H J ~ po~{& - {lt\~ ~+ -ro ~ hc:i~p,~( CV\. Ci/11.tJ 1 ~ vy-; ✓U( od- to: ,op'),'\ - ~w.w\ ?1~ Wu.11.e.1 Y.>tvrr1 ~ - rroweAlh.J. ~ - fJ\AA ·+ ~ wl ~·1M \olc. u ~r{-1- ~ s~~~ri - Wti+'lkdtAJa.fer N, ~ tu, q do ·1t ~ Y\,(M'U. ('.i'loft · I - t-k-o-\nA-ed,1-ell}"9, \Nd-Vt~ l,Wif\w\ 1 ~ ~ ~ ,+ -fb ktM - ~eeout-to~ ~ ~ b~-tl')ruom, ~ --to w-,1u...-of+~ e ~ ()+4.v,,v---~t ~~- ~ - 45 rY\. h""\ p oJ5.~ , M 'r~ \.je Il ~ ~ u w~ h.ur-f.,':, ~u f-t-~E:.~ , -~1'ht~~~~~-k~ ~t ~, -fN_ ~ - t~~d /\M ~ ,# u (\ C-Od.i (,blM( ~ - ~ ~ I"' rfO'fv\~l \irv1Y\ ~ i~ LAY\.U'\ w-tWl~ ~ - tlt~ {'f:J \~ ~ l)v vuf fl\bW._ _- IVlO~ +v CCtA,IL lot- o4 ~-1R4~~1\t\ ~ ~ ,- ~1~1 ~/ -w~11)~ \o\-1~ 1'Q ~~ ~ o{ ~n -tuld YUW-en-r i't1nlCMiillf 0./l'l~+ ~)' - \..W,r 1iftl- ~ WOvk:tJ GY1VUM ~{ ~ 'LOrntv\C,LJU'I - ~ ~~ d)«;( r}'t1~d wartuvto~U-J I dl\d 1b &tcJv'f - Ulu l,A/,i. +.1 VL ( $,~ 2020-ICLl-00006 2670 .kl\ ~~ss l'('l• (bX7)(C) • ...G~ I (Y'J.),. (61'\,~-t"VY wrv,JY Ovr~U"\PlMc,~\¼l),'{L, @;W !~ ~ct (1 \ \ ~ . :.>0\:ivv ,,t-S) 8-- /,1-,3 t)o+ivvV' Y>~(pwpptv ~aYJQut~ -2---~ ~ 10--l~ _-to ffl\C(~( ~ GJ)ru;t.jj~- w( vt.S ~-tm --hl ~~s 1\'° UNY V\A>O,\ w~ ti uttx.ol'.eJ ?) "1\J( Pod 4( roe~ 5 Pod Lt?, ~\MIJ ~ 3~ t 2020-ICLl-00006 2671 , - Ste)l,u~ ~ l~ 6 ·.-~\.\pm W'-n ~sw.e • - DvY\i-wcA -~ ()Yvv\S' let- l ~v,.,(V' o~ ~~~ - w~ ~ ~ ~V\ '1± - W\~~ r (ile.,vv-J,~.s) --\-v'~+ r b}(6), ~}(7XC) Nc,.r,u., : 11-rl.e.. : fl.N _.... ()O~......- Ull' 1 2.015 1 1o1S- PH~ ~~<. ~~) - - r~ ~ ~ -tt:> ~ -~£t,,(') ~ °1,~ ~ l.f-~ - ~ h)V\..,V" ~D~--Z.U ~ ~'LJ_ ~ ~\4- ~ - DY'\- - l~ - ~ V\.l)\M~ IV t,~t_LQ\ ~ ~ - ftS~ (i.... to+ u.f -tvv'-~ iv"~bfc-,r u.. ~\ ~ - 7 ~ ~ \.u ~ 1.u I ~ _- \t Y\.L ~ ~ ~ ~\ ~ ~ C. ~sv - Pn'--Mlb 2 ~s - 1\.-Lti ~ o.- rvu.A c:..M 1l-\: D~ ~~ { ~ -,f\.¥-,v CK'~ J_U.. ~~ ~~4ev- V\.O+- Vt,CA(.,()..L "'- ~CMd. v.f ~ ~. C h-M~-+ C)..MA(. WNV'-~'-< - lJtft'l'4 ~ ~ ~.f @_ - Qo(LJ Yi~ ~ 1.f- lL - ~ ml'-SW- ~ UJ..L ~ -~ - \,-\-W A,~"'t'r+ ~ ~~"' ,S..onic..e.,, ~ O...WOW"\ 4)fi ;(b)(7)(C) ~~ ' \-~ I',\_ ~~ ~ -o{ou ~lt p~~ tlt,~ - 8 /q - fo \l O¾.J ~ hv __a\o r\OY-~ - f\-~if\/J..,l .__ ______ ____J ~ -rWv\.£VV\'6€/ LJ.tAo~!1,,J. ..:~ av--~ ~ . vu,-\- ~ ~~ - Pti.. ~ - - vJ[~ ~ ~'('t 1. - tk vu.. tt'::.'t::.1,\..£.~ du,..e. ~ s ( - ~~ ~~ - teu'1 M-\ - ('{U.ol~l '-\1) -tu.. 0 CM.JJ.~ ~1't)VI~ ~ w~l o# C,,,tt(.,~~~ ~ 0-.9(\ IJ../ ~J - G~ r(O{ "- ht,,fv'w10Io~ CftA. fVv. --t - Pvd ~ 1_,,4{).'::. - T\o¾ pwt~ s~: G.. Q,ou_,p\LWt~lu:.) ~ '"f'\vJ.. ~ ~ ~~ ~~~-f- fv\.tM(A/\ #~ O"\. ~~ ~¾r [µyu_ bl{ R_~, - ~ ~ CUi\ dA~e..,-s ~ rivr-o'A- ~l ~Ctil\ 1~ A_ rv\\ ·~w~ 2020-ICLl-00006 2673 ftw ________ l (b)(6); (b)(7)(C) N~'- . TT L<-: ~~· ___. t\s t'1- CRI l · MOt ~: q)~ - b \[~ C1tS - ttol0'\ \) - ~ 0V\.,lA.ft'olo\,0r\ - ~·1+- ,.. bll--tolo~ ~ ~Is:. - ND+ ~ ~ -1\.,WUS ( ( JO ~ Q ~ ~ ~ (\0~ ~ to ~ LA{.S Wlk~ ~ -h> ~ WV\"'\ 80 OJW\f - IO~ - Oph~o - ~ QY\ WV\.,~ m~s~ ~ cfe> - pop~ wli--V\~ WO.V\~ It -- t.e.,vp°'-- t?;x~ I ·,v ~ S"~ -tb d..o ~ lMf o.... .fuilo~ ~ (\,0 + ~ c...f'- (i.., ~ cY\ - ~ P... /,o+ o -f i'!s ~--s t,..J I e 00 - f'l ~ ~~ lY\ '(~ '1'\'V_ 1 - biD 11) \.A.»'\~ ~l ClM()'()M\Lt_ b\'L "- + Lot Ca. v.u_. \q w\lA. -~\- rvo \\clv,-- N 1\\ -'-lt ~ 8~ l( -tliv'1,-.)\\.M COM. pl1ttR1,t- rJ,. ~OV\ ~ ~~~ s~~ (i:..~~ ~ -UC. (\w-~ ~v lvO~ M.U1\ CLA-l VU>\ J V\.Al+-~ WVV/) r- k" ~' - r\Vf:.-t ~l~ Cl M • \M'A,f?ltvU,-S. CrJN._ tn.. ~MU"" - -eC..L-J St~ ~ \& ~ ~ ~),..)~ ~~, ~ i~ Y\O; ~U~$ n7u'\~¼ Irv/~ 41t Stz<_,vq ~ - Do f\O ~ r?A.d lOL,cr1~ r ~+ -\o o~\ \ ~ VvJ~ ~ ~ ~CQ.S(tJ - fV\r~ ~ (}}-~~ p~W~ O'-l.- ~ (Jv\,U w t-..o ~ ~ ~ fTl~ J~ 2020-ICLl-00006 2674 r )(6); (b)(7)(C) Nciru: Q, 0 1'-rtt-: {J))r2~ ·. WID c~~: ~b~) -~ 2..'1 &.c;l7 -.S1CA... C,MI ~ ' ~ oit.,-u - S1CM...- ~ ~ C,.fu\\ ~&~ 3;9 6u. \ ~ _. Pcotl - 3 , '-\:- L, · Ou:rodL ~l~~ olOYu., ~ ~ Uhroo - ln o{J)V"'YV\,g. · CAM ~ " htl-1\1\~ \ ~ - ~ ~¼-f+- ~ ~~ N)-\,t_ 'M-- Ll4co~ ~ Wl\tA CAl l ou,t- ~'V\clu_a_l~ - ~r.. v¼CVI' N'\. t,/\JJPiei?J\ r111 o v-ur ·,~1'~ o~ r -\-o -s ~ ~\\ olL~lc:-A~ ~u.... ~ ~ do~ n'+ &~ ~ - CoV'vlp1C<.,Ut\ 1 \S Y\O-t - ~\ ~ - -,IUo ~"le,r ~ CL.! n.o~ CL. I( £,j ~ o -f - WilA ~~ ft' ~ O'f\ 4, \-4~ M ov1_·,-tor ~ 4v t~ ~ ~ ~ - 2020-ICLl-00006 2675 --b-L. ~~ "'::>1 C-«- CAJ l v',,\ CA..l ~ -to ck.e... b)(6); (b){7){C) Nc.N. : r_ . . ~ ~~ : ~'1'11\ ~:<{ 0¼ ~ ~MO GQ\'V'f>(µ\ 1t t.WLl - f\\l)YY\l\tU po$:\ pf'VCl~SlY'(J L'.\ - ~ o,o~ tu! 'w\..\e,r/1~ ~ f(\f¥\..>-.2/µ/\ - lMOVIM DY\.R..af a...t,~ - (j~ - \lt ~~ o~aw- ~ ~ ~~n to ~\M'\.r¥vM ~ crY\ CA_LA.ss1-8 Uvtto'I\ _ &~ C01~ ¥ -w LAM,\~ - rtll--W ~ ~VVVJ . ~~& W ~ pro~ r;._~-no~ Yc,)2AMd- tk- ~'z;l --UlfU-()Jr \700 ~ w J'\l)-t ~ ~ t) ou¾). _. ~ M-t- ~ ~ - Proa£~ ~ Pro~ -~ \ DY 2 \f\~ ~~ V\olL ~ . ~ R O\JJ . r;._ ~y- ~ ~ ~ 0.. ~ ~ M'N.. ~ u ()._ M O't -t,'NJL . ~-to ~ Ot+,~ - v~~s 1 CMh. ~ ~ - jV\Wl1\t\-tiLlu--~ ..-{huss·1•vr,8 txJ~ - ~\~ ~ 1V\ ~-k- ~ ~ 0~ ~ l y'\~ do- -J9Pr\" ~ ~ ~ pn,ttso-eq ~ ~ '), WJ~ 2020-ICLl-00006 2676 -ft,o. b)(6); (b)(7)(C) -- ~ wt Prus , ~+ ~ --to ~( - WDrL- 1lW\SpoA-ct,h'W\ - ~~-~\ ~ &~ ~ - Kt0.~~~ -w w * . OJ~ \'0-~liY\ ~~ - ~l ~~ LA(Y\.QN"\ '1" oo.twi ~ - No+ ~O-S&1~ ~ \\t w~~ s,~ ~ ~~s(.K~€1'\ ~-w - (h_s ~04 - ~~ ~ 2-..~~ ""\1"l)WS~~-' '(\l...U"\ ~ ~ ~l ~ '* µ.J 2020-ICLl-00006 2677 ~~ o_+f IN'- L+- (b)(6); (b)(7)(C) ~ "-------r-,---_J ---r-~-+(1/ ~ ~ ut.J.~7 - ~utu..A ~ ():}r ftD'ot0h01 -= fv\_(Jl}{_ cJ)(.::;t- ~ -tu ~ ~ ~ - 0~ r~ ~ -,~ ~ ~ cfs ~ r += r-.o+ ,~ 6.._ (5~ -ht-~·l?n.-\ fD b.L 11) ~- ....ft, ~--cy/'\ ~ _ ~ ..Jb~ol!i-- ~ ~ ~ \V'--ttiYVVvh~ .. - 2020-ICLl-00006 2678 (JY\ MIN ~ - ~ rur\- ~ ~ -- ~ - ~ 00 t}{)QQ.{AI~ - ~~ - Wo~ '\ fi\Q_~~ ~~ ~ eCl-J ~ ~c..k ~b~ ~ ~ ~ ~ ~ ~ CV\~~~ (J't-.eJ,/ Y-f! Q.rt-n (L ~ ~ -~ VV~ ~ ~ ~C-¥'\ou\ M ~ ~.e ~ d.vtl()- 2020-ICLl-00006 2679 t,.l(A__\ ~ ~o ·,~<' ~ \c)~ ~1 (b)(6); (b)(?)(C) - ~ &p~~Y\ -~ ( ~~ V\.,C=\- I+ ~-tL I\...L ~(.<._ s;..~•~ ......... ~~-ve C \, ( C- ~ - M ~ a)ovu..L 1/vV\,,(WYVltp\ ~ - --w-0 ~ ~ ~ oiMV\. ~ - ~a,w ~ fb-i'N>lvr ~ "k ~ 2 w~~~J, --111-p~cM ~ (ok_ k 1 lo..:) I d ~, M.~ ~l ~ ~ ~~Mk.- .- ~ ~~~, dAJ ~ ~~'~ ~~'£1)-\ - ~ if 2020-ICLl-00006 2680 o'T\_ +o ~ - Lab ' b(:) ~ ~ cy) I - PLRst..t,lvr · ~ 3-i , VV'V\ lnN , Vt~ IL V)~ ~.\-- p(~..ielt.,~ VUl5{_ l,)/vV'- ~ o+ wt'CtM..\'vol.~ ~Lu.J.s/ ~~ ~ \f ~~ ~1~ n--~ d)L ~ (\ - &rnpUw>-1A 64 -- I - ,+ ~ -\"Qu\L. ~---nu\~ ~ ~ y~~ wt\ ~ ~ t\r-.~~"JY\_ ~ ~ +-> ~ 0~ ~,t"M, ~\Ji. ~ ~ ~ ~ ~)-kY ~ -1'0-Mf~+rrm.wOJ ~ \}"1\-tti"'~ 'M.~ - ~~ S~ ~ ~ ~V<_. ~--t'k.a.k-S WW\ ~ oh~ ~ CvL ~4<-v~ - 0~ -=~~ - reLlb V\,(){~ ~ W{ ~~ ~f. ~ r~~- 2020-ICLl-00006 2681 b)(6); (b)(7)(C) - ~ lJJN l6c - D~ t.:r· ~1l- ~ ~u , ~ l ~n- - r(1)1o~ \o~ -W- ~ ~-\-vi. ~~~ ~~ ~'d ~ -:: wavJ). - -'~ . ~--s !)Ql 1\.,(-vU" I ~~ ?wt-~ (r~ci-rC'-f ~~ · - loo'ZoCoM/P~ CL- --lo ~ CUf\St,,u4--~ 01AM.,~ ~ ~\.-.Q. QV\,V1JY\11'l- tS,S~ ~ ~ ~ ~ +v~ - - G~ (,,.)}--y\~+ ~ ~ p~ . ~~ Vl.,l)\&. bivr C)ryV~~- 1f. ~ ~-\, cSf'J.. - -rw). ~ ..:. ~ ,~ l;\bT Owt---Y\/0+-~ ,Y\..~¼ - W,l-~ -- ~ .,.(.,...,__ --t, ~ ~ ~ ~~~~~~ - A1~rv~~ ~ ~ Y\.AflV'-{o ~ ~IA..~ 1 _- w~ ~- ~~ ~ ~ ~ ~ ~ ~ , - ~ --fu- Q.;tv. ~ /'v\_ L,~~ ~ cvvt. ~~., ~ INJ ~ (A1r-.t< s~ ~ ~ J.c. . -____:-lt'.!4f5¥effl< tV & Pt:!· dW * ~ ~~ ~s 6 {- ~~ 4tJ Ct, '{'v) cJ.l l-.J11 I 6 twN, ~~~J"('v ~t ~~w.~~~~ ~ , fv\jY ~:\N\YC ~ p..__gt~~ - N'(fN1~ ~ ~{J ~ tJ M. -h~ 6~. 2020-ICLl-00006 2682 (b)(6); (b)(7)(C) ~ WN./~ ~ -ll ; ~ I r• Co-rvvp~·. - l'2 YlM ~~t3 ~\-0-r ~ Cftr._~ - \f\~ - ½--\\.Q.__~ ~ 0-»\..0\'t\J..1 ~ \.~ ~o\A..A-A.~ ~ \v...._ ~~-~- - e Ct0 ~ ~ ~, ::_Uu.J '~'rrY1 - (<)o,a ~ - D,J f\n~ ....~~ ~ -~ -~ ~GU ~ ~~ l ~ ~m ~ ~ ~ ~ sc~f\.51J}... ~ ~~~ u. ~ 0(A~ (JY\ \.-., N'-' --h:>~<- tt(C/1'-b(tW(~( ~ W( ~is ~ M., wl 7.,vlo~ 2020-ICLl-00006 2683 . (b)(6); (b)(?)( C ) - 'rl~ -~ (b)(6); (b)(?)(C) SU-- ~~6h --"\M \u.. w i:...s - ~d. lJ_ uC-~ ~f "i-o ~ ~ ~"C.cf0:'{ ~ . 4-k. ~ ~~ ~ ~ 't-J--Ld-4c> l,rj'v\ -~ ~ ~ ~~ - ~ B - ~ ~ lrvt~~ - ~ (JJY\:lr\~ - HzJ---(\t ~~ \\ o.,~'K?- vu..~~ ~ ll -tw- \ . G-1 . "1e~ ~'=t-~~~ f\ b~ ~ .J\.tit ~ oY\.._ r-e,__,~rm_\.::') - [)\u\.,V\_~ ~ {c e, t w~ \ CN\·--n (.A. t - - ~b i\r\ o-f- q ~ O"\AA.Aw.. ~ -ro - PtaJrclut IN~ t;v\1''C""-l C~ ""--~,) - ff\lul ~ld S~ ~ ~ {)~ - u 2020-ICLl-00006 2684 Y\.}:l~-~ b)(6); (b)(?)(C) N{MY\.L ~ f>rli : ..,,._-.--------------1 tv.e:'{~✓ ~; U)W\f~ ~ ~ l \y\,·L - 7 /i.-,: LAA-L ~9 ii V\t) olO-M- ~~_/ ct Ltw.L-h, kP\ ~ 100~ ~ &.,u__ CAI\ ~ ~ \..-\ ~~ ~ ~ ~~ o.}6u.- ~ ~~ ~ ~ ~~- ~ ~ ~~Ok- ~ ~ ~ ~ f:C- t~- (l ~ ~ ~ ~ , - \Jw~~ ~~ ~ ~ ~ ~ - hJ~ t,W.J_.. . \+ ~ - - cWf) ~-o- - vl ~!::::::::,: _::: Da~· ~j~ ~~~ ~~ ~~7 ~~15 AM ~> b)(6); (b)(?)(C) 6 . d I have c han ed an d se t up, at OPR 's request, a new mterv1 . .ew time . c); Be advise and date 1 or O f·fiice (b)( lh\17\lf:\ (b)(6); (b)(7)(C) 2020-ICLl-00006 2690 (b)(6) ; The two officers will be at the fro"" (b..,.. )(,5..,)..... _......, bby conference room on the date of 10-18-17. Office interview at 3:00 p.m. and Office lh\17\tr.1 ill interview at 4:00 p.m. b)(6); b)(7)(C) Sent from my iPhone 2020-ICLl-00006 2691 ~i(7)( ill r )(6); (b)(7)(C) From: Sent : To : S Oct 2017 13·12·50 -0400 r b)(6); (b)(7)(C) Cc: RE:Polk County Jail Subject: Thank you for the update! Looks like we are rescheduling for the second week of November. R/ -=CDR,USPHS IHSC Investigations Unit Chief, RN DHS/ICE/ERO/IHSC 610 W. Ash St., Ste f.... b-)(6-l;-(b-)(7--l(-Cl_,I San Diego.~:>.....<..O--t01 (619) 338 ice (202) 321 '=---=-' (866) 833-7133 Fax (secure) !~lm cci Wa be exe OR OFFICIALUSE ONLY (U//FOUO). I . . nac~""'-.1:" · .1Jl~to7:J e TfTT ~~+ll.e incrttt~~~~EmS nei:~rnetwh ,on o 1sreport shoul handled is not t Fro~ b)(6); (b)(7)(C) VoTirtt-"-A.e.E~ . n that may lied, stored, O information and ithout prior e urn, I Sent: Thursday, October 05, 2017 8:00 AM I ~~~fb)(6); (b)(7)(C) SubJect: RE:Polk County Jail b)(6); (b)(7)(C) I confomed wi copied above), one of the ODO Section Chiefs, and yes their staff is conducti._n_ g_,.,..---,---.-..,.. etent ion standard s inspection the week of October 29, 2017. f b)(6); (b)(7)(C) ICE - 0 P_R..,____, 202-423l(b)(G); - sent with BB, so excuse typos From l(b)(6); (b)(7)(C) Date: Thursday, Oct 05, 20 17, I 0:33 AM To :f b)(6); (b)(7)(C) 2020-ICLl-00006 2692 l ~b)(6); (b)(7)(C) Cc: ~l_______________ Subject: RE: Polk County Jail __. > Ma'am, Do you know if there is annual inspection scheduled for the last week of October 31 thru November 2 nd ? We're trying to lessen the impact on the facility. R/ r b)(6); (b)(7)(C) j' ;%irl; 7l(Cl as been pu bl.1she d . Everyt h.mg e Ise 1.s st1·11pen d.mg. 0 nI b)( Sent with BlackBerry Work (www.blackberry.com) Fro~ (b)(6); (b)(7)(C) Date: Wednesday, Apr 11, 2018, 5:56 PM To:l rti b)(6) ; (b)(7)(C) o,lty: tJ If no, Why not? Phone Number: D te Signed : 863-946- (b)(B); (b)(7)(C) Original - Upon Transfer Form USM-553 (Est. 6/98) 2020-ICLl-00006 2721 II I. Master Problem List Medical Date of Occ,urrence D 5<~ ll1,,r 7017 ........ _ ct g '/fl q ~ / W.7 I Problem (Medical, Dental, Mental Health) (b)(6); (b)(7)(C) / /0~-~\Lo f ~ -i I ·1 • • f'\n, \'C______ _ No walking on wet or uneven surfaces :J No temperature extremes '.J No humidity extremes hrs D No walking> yds □ No exposure to environmental pollutants D No lifting > lbs □ No work with chemicals or irritants D No bending at the waist □ No work requiring safety boots D No squatting D No work around machines or moving parts D No climbing D No work exposure to loud noises D Limited sitting □ OR DISCIPLINARYPROCESS: n Consult repr No work requiring complex instructions entative of medical department before taking disciplinary action NEEDS: C On Dialysis C Adolescent in Adult facility , • Infected with serious communicable disease - Precautions required: _____________ _ :J Physically Disabled :J Frail or elderly ::::J Pregnant '.J Terminally ill □ Mentally ill or suicidal □ Developmentally disabled D Suspected victim of physical or sexual abuse ~-- b)(6); (b)(7)(C) d2J3o nme 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/26/66 2020-ICLl-00006 2723 Reviewed May 201 7 / rnb 1111 Medical INTAKE SCREEN Translator available □ Yes Date/Time of Arrival at the facility:_. In the last 21 days what countries Have you been in contact have ou isited outside of the U.S,? -"--~~'-"--'-✓- / with anyone who traveled from these countries in the last 21-days and who is sick? Yes__ In the last 21-days have you been in close contact with anyone who has been diagnosed with an ir.fectious disease? Ye>_ NZ NoZ If yes please e,rplain: Do yo ave any current medical, mental health or dental problems that need attention now? NONE __ YES- explain: include any special health or dietary needs: *** Note Detainee should be Instructed on sick call processfor any non-urgent healthcare eeds. Do you have a family history of any Medical conditions? Yes o 6 a 10 Location .--'\-6.JJ..!...-'i.~~~6..l..i..~~~"---..1---~ uration ___ Do you ave any physical injuries, open wounds, cuts bruises or signs of trauma/violence? NONE NOTED/DENIES -~ YES(de5cribe) ____________________ . Do you have a past history cf seriousinfectiousor communicable illness (to includeTB)? (include ar.ytreatment _ __ YES or previous symptoms) Do yo, h,ve •nv meat oomm,a;cable maess symptoms, k lfye;, iadicate, :1 Chronic Fatigue □ Weight Loss/ Loss of Appetite :::i Night Sweats □ Bloody Sputum - •"'*If yes, cont.ct tile medTcaI pro11iderto determine lf the plltient requiresP. □ Frequent Productive *** □ Fever r: Weakness eme.nt in Respiratory isolation (Neg;,tiveAir Flow Fioom) until testing is completed ,rnd the patient ls cleared to be pla :ed in t~e general Do you have any Chronic Diagnosis? __ If Diabetic - Blood Sugar____ (\ YES !1.:tfil.,Note Diagnosis below NO HTN Cough DM SZR RESP H fer to Chronic Clinic\..:_.).\,-~" e · MENTALHEALTHDX:~~'H-l'--l-.."'-"':_: __ GS = ... =.·=YES~----~-~A ... C>--.·_-""_ .. Do you have a history of PhysicalIllness,Surgeriesor Dental Problems? , ~--·---..-~"""'--'.1-tMr-- (include past hospitalizations, surgeries and treatments) · / Do you identify yourself as a Transgender?-~_Nno ____ .,.YES (lf so, document history of trans ition- elated care and notify security supervisor) Are you currently taking a and/or herbal? Yes medications, Induding over the counter No /fyey V_ __ Current Medication listed on transfer paperwork - See Orders Patient states he/she is on the current medicatio ns, however they (b)(6); (b)(?)(C) are no: received, I--------':--,-.--~--------------------' DON ~ Time 028 866 428 ALMAZAN~RUIZ,FELIPE ADM 09/08/17 DOB06/26/66 2020-ICLl-00006 2724 Revised May 20:7 / mb i . .INTAKE SCREEN- Mental Health {Page 2 of 3) .Do you have a current or past history of Mental Illness or disabilities? Treatment: INPT Diagnosi ~:::t::A~<\--1~~~~~~-~..---,-:J.l~~~!C!~..::___--\------- Do you have current, recent or past history of Physical, Emotio ff yes • Perpetrator When _______ Have you been sexually assaulted prior to arrival at this facility? ~NO ~----------------------1 __ ~.,.L__~ _____ notified lmmediately ______ uSeCl.lrity Supervisor Victim or YES tfyes: Name _________ Date/nme ~-~Y~-n~e:i:~1#rify~~,~~rii~~k'.~~6~:s·~:·?~-~i61~-n~~-i _-7 ·~b-· · -··_·'f~s--· - -··-··· . •. , . h1Jui{ot'~oner if ap~ropr1ate ~i_ii.n Do you use Tobacco? __ YES If yes: Cigarettes Type: \ . I -..P.~ Method: IV Smoke \\ How Often?_______ _ Ingest S11orting Other Lastdrug(s) used? When? (if a female patient reports curre:,t Opiate use, make sure she was offered the pregnancy test. If positive she must be referred to the provider to avoid opiate withdrawal risk to \\ '. '(~~~'l)J'-"cs~~ ~ '. :"\ Cocaine Meth Heroin Inhalants LSD Opiate Other ty\\)~ How Much? ~ \ 0~~ \.\, 1[,~ ...... ~ -~~(L;'( NO Ty~ijuana o5Z:Y \O....~~ Oral =::::::::: Haw Oft~e~? ....-----=..-------i ~ If yes: ~ llfeg ~ How Much? Do you have a history of Alcohol or Substance Abuse? Pipe the fetus) Current or past illnesses & health problems r/t substance abuse: □ 't"' □ Hepatitis Seizures 1:; Trauma □ Liver Disease Do you get sick wher> you qu'rt usirlgthose drugs? ____ NO __ □ Infections YES (Le.: convul~Tons) If yes, what happens? ______________________ Any history of substance abuse hospitalization ___ _ NO ___ YES If yes, when and for? _______________________ _ Any history of detoxification and outpatient treatment? __ NO __ YES If yes, when and for? _____________________ Do you have any withdrawal symptoms? __ NO ~s Symptoms:_'o~~~~~'~~~~.,,__ ·Have you ever thought about killing yourself? _ /_N NOO __ If yes, when and why? _____ iHave you ever tried to harm yourself? ~o Do you want to harm yourself now? Do you want to harm someone else? b)(6); (b)(7)(C) YES _________ _ --J --,,.~---------------------..~~~-------i ···- __YES If yes, when, how and why?--l'e..:Q.&J==•...,,\-=\l...,,,_""'-'~~----- 0o __ __/_ ~ NNIO __ YES If yes, do you have a plan? YES If yes to what degree - explain?______________ you /No __ _ YES (If yes, notify Security SupeNisory Immediately 1) Time 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/26/66 2020-ICLl-00006 2725 Rt!vised May2017/ mo ■ INTAKESCREEN Medical (Page 3 of 3) OBSERVATIONS Is this person unconscious, semiconscious, bleeding, mentally unstable, severely intoxicated, in alcohol or~ withdrawal or disoriented to person/place/time or otherwise urgently in need of medical attention? G-N6" u YES If yes, immediately refer to medical persormel for further evaluation & care. IS T~ATIENT DISPLAYING ANY SYMPTOMS or UNUSUAL BEHAVIOR? c YES ~ rt"¢pearance - appropriate o Weakness o Seeing visions 121""' ~ropriate behavior □ o tTN/4al ~lert gait responsive :.i Yellowing of skin or eyes/jaundice o Hyperventilation o Disheveled o Rashes o Infestations (lice/crabs) o Persistent cough o Hearing voices o Evidence of self mutilatio n o Body deformities o Bizarre/ insensible o Alcohol or drug withdrawal □ o Loud / obnoxious c, Communication difficulties Slurred Speech Abnormal gait Unusual su5pidou,ness u Disorderly u Other physical abnormalities n Sweating n Assaultive or violent behavior o other: __________________ _ o Tremors u Lethargy n NeedlF. Marks ls his~? o Crying/Tearful o Incoherent c.YWNL/ Cooperative □ □ o 1~ted Any body piercings _/__ ;; N~O--__ Recent Tattoo(s) o Embarrassed Confused □ Uncooperative o Passive o Scared Depressed o Anxious YES DISPOSITION Population with NO Immediate Health ServicesReferral r:::i ~ral ~;.n;;al Population with Immediate Health Servkes Referral to ¼).t::':\'°"'!1Lf=~zf~~~~~u~~~~~\-~:::'.:.l..L..:L!~~.2..Jh::, :J Transfer to Hospital for Emergency Treatment LJ Constant Suicide Watch - provider contacted for order □ D Single Cell Housing Medical Observation / Isolation If a female patient and pregnancy test is positive, refer to provider to avoid opiate withdrawal risks to fetus ,., ..- . · .. --··. -~- ··-· - .. -· .... -. :O .tf viol~nce, M~ta! Health referra!madewithin 72 hours: □ ars0°~r~~:y~tc1JJqrr1esti~al;l~_se or P/PA . □ macy / Order Meds Request Records/ Call MD D Dental Clinic 1~1~~~ 5~~aks; GR/-Spani~h:/~th_er:;=~(b)(6); (b)(?)(C) ==~_·=. -_-·~---~---··:_-_ .-_~:_:.,.._~c~~a;1~~-f$:p_~~k;i~spanish I other:_··-,-,-~------,-,.......,.·....,-,..,.·-_·,-_·--,---_·. ···- · ...... --·· tan_~~-~ ~e~_:_-· _____ .... ______ ........ ______;....:.....;. _ __;.;__;___ ~,~ i Date f-"~":'"JP...,.,. .,.,-,. Time -- 028 866428 I ~ I: ALMAZAN-RUIZ, FELIPE OB 06/26/66 ADM 09/08/l? D 2020 -ICLl -00006 2726 Revised M2y 2.01.7/ mb I Medical FORMA DE CONSENTIMIENTOMEDICO · PRO(iRAMADE CUI DADODE SALUD FORMADECDNSENTIMIENTO MEDICO El pro;i6sito de la clfnica es provcer a listed ,3tnecl6n me::!ica. Los inforrnes medicos que te obtengan seran niatenidos er. us expedientP. medico, confidem:ial. Se espen; usted que se someta a un examen medico para determinar su estado de salud al presente. Yo, par la presente c□nsient□ o aut□riio a una evaluaci6n o examen medico pa,a determinar mi estacio salud presente. ':"ambien corislento a cualquier otra evaluaci6n o procedimiento medico, cuidado rutiniariio, y tratamiento medico o dental o salud mental que el pl"rsonal medico de la clinica considere necesario, aconsejable o apropiacio. Yo .utorlz.o la divulgaci6n de mi historial medico a cualquier hospi~al er, case de que hospitalization sea necesari2 or recomendada. autoriza la divulgaci6n de mi informacl6n medica para el reporte a entidades federale~ y/o e5tales para la vigilancia y coritrol de enfermedades. Yo Esta forma se me has ex:i 1icado completa:nente y yo entiendo su contenido. Tambien entiendo que nose me han hecho garantia con respect□"' resuhado de tratamiemtos o examenes administrados en la clinica. He recibido instn,cciones sobre c6mo acceder a: • cuidado medico en esta unldad, dental y mental • el pmgrama de ,arifa-por-servicio :::i NA • el proceso de queja para las quejas relacionadas con la salud Pacientes se se.xofemenino: • Servicios di!' embarazo incluyendo pnuebas, nitina o atenci6n prenatal espedalizada, atencion en el posp,nto, Posparto seguimiento, servicios de l"ctancia y los servicio, de aborto como se indica • Asesor.miento y asii>tencia para las mujeres embarazadas de ac:uerdo con su expreso deseos en la planificacic\n de su embarazo, si desean aborto, servicios adoptivos o para mantener al nifio • Rutina, apropiados para la edad, ginecol6gica servicios de ateru.:i6n medica, incluyendo otretlendo cuidados preventives es;:ieclficos de las mujeres Solamente medicamentos basicos seran proveloos de a:::uerdo a los protocolos medicos. El Paciente podra obtener medi::amento y sern responsable para tomarse las pastllla.i cie acuerdc a las instrucciones para tomarse como en la vida libre. Este privileglo siars d.ido solamente a los Paciente que sean capaces y responsables. ElDetenido tiene q ue: 1. Tomar e, medlcamento como e~ sen,dado y no deben abandonar dosis ni tampocotomar dosis dob!es. 2. Cuidarel medicamento, nose d!"be vender, nose debe cambiar, no descuidar el rnedicamento para que sea extravlado o robado. 3. No acumular medicament□ en ei dormitorio. 4. Ser cumplido todo el tiempo. ·~a1 Date Time 1 ~lla-01 Time 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/26/66 Spanish Consen, Form July 2014 / mb 2020-ICLl-00006 2727 acidyour facility name t,,,n, Intake Screening and Testing Provid~rSpe~~~~/Spanisb/Other:._· !nterpre!er?, ~- Y N - ' - __.. :_~:;:_·__ - P~tientSpe~anish/Other._- ~a~e: □ TB - CLEAR D - - .-· · ------,----.------ ·_t?ngliage:_· ____________ __,_ __ AT PREVIOUSFACILITY- via (must have documentation of Negative PPD on file) Negative PPO- date completed ______ OR 0 TB - CLEARANCEREQUIREDAT THIS FACILITY D CXR required and scheduled (b)(6); (b)(7)(C) Time Expiration-Date of Vaccine-::·._· Administered by (signature) ________________________ Date PPD Read __________ _ mm lnduration Results.____ Results Read by (signature) _________________________ _ Female Patients: Have you recently been Pregnant ___ Yes __ NO ( if yes,when): _______ Is there a possibility that you are currently pregnant? ___ Yes --- _ No * If pregnant PPD planted and read* Urine Pregnancy Test ___ Date Negative ___ Positive _____ Time Medical Staff Signature r 1 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/26/66 Initials Date Allergies:~ Time '(.'{j~ 2020-ICLl-00006 2728 Rev1secMay2017/mb .• ·. . ; Facility: ALMAZAN -RUIZ,FELIPE ADM 09/08/17 DOB06/26/6G Patient Nar,.____ Time Da e Telephone Orders M e d ic al 028 866 428 _ _ __ __ Patient# _______ _ Signature Order: -- r-.11t-Of:011f di/ 111Pllirah~ns 1P\' o~ ()rt!.1d K~·ti - (CJ.M ~ '(J/f/1.pJ J,J~£lfh ht! /Jr(.::>c)K\.okJ Neck Throat [! f C'\\ CL:,;_V, ({_I)/h--.;, ., 7:)O ~ \3:: Cv, cJ I' Abdomen Additional Findings REVIEWOF CURRENTMEDICATIONS c ___ _ -=-------,~f--'--r-f-' VPc / ASSESSM ENT(DIAGNOSIS) :_----1r-t-L ~ (.f) -+-sf:i1-~t--?r~/Jfj---------,----------i=-:-_LL-+-· ~---..-.c---- tJJf'cx "o5r iX PLAN:. _________________________________________ FOLLOW-UP: D PRN r:i 30 day n 60 Oay~ Medication (s) Order : r::90 days _ □ Referral 5-e..-t"cl ~, □ £((_ Other -L~ _eVc~( SJ;~7 (- tvftr· 9t1~ ./ Lab/Radiology Order: Other orders: Time Frame for any requested consults u within 2 weeks o within 30 days EDUCATION: □ Diet □ Signs and S) □ Patient vert □ b)(6); (b)(7)(C) N Name: nefits, and alternatives and agrees to the plan ~ ~ Language: - Prov0id2e8r S8p6ea6ks4: ~_L__spanish ~ c7 ) ( J//1 I ~ / ·?.~ 2 ~~'°' I / Other·,=====""-·""- ..-;;a·~~-P-at_ie_n_t-!Sp'-e_a_ks_:_E_n!::.gl'-is~h..:../...:..S~,a;...:........::.~:.:...:.:============; Allergies: ALMAZAN-RUIZ, FELIPE r ADM 09/08/17 Risk Factors and Reducers Date/Time: Provider Signature/ Title: Interpreter?®/ :::i other: ~~',\-- DOB 06/26/66 RevisedJuly 2017 / mb II Emergency/ Injury Assessment Medical Date/Time injury: Date/Time reported: Subjective: n~ (State wh;it occurred, who/ what/ where/ how) ca½\d::ta::tM1 !<-c,io "~n~ 'doo&. Pain Scale: (0-10) __ Objective: Date '1l . tt\n be1A1JS0 o\tto1rLQ.t ~ r~~ Time l~D Temp Pulse Resp t,\15 toll w Sa02 BP BG q_,;;.... ___ _ Narrative fOO'f. \'\1~-V\0l HVt. ?'l-c1ti ,L\'MY) f-\-umtrr!holrt:_af¾- nvrlot1A:tt ~r~ q~r; nu---c~W 6k-' "'l-l- .r) Y\' ~( ,~ --,. V1.•'"!!!,,.117_.r n /\ . -. ,~ Assessment Decision:· . ~urther D No Further CJ re Needed D Care-RequirE!d Other _____________ _ Plan: u Cleared lo Return to Current Hci.;singin Facilityper Provider:__ ...--------- Date/Time_______ _ > 1111 Timeline / Checklist - Depart from the Facility Medicai Departing Facility Via: Transport via VAN: Date Time Initials q\\\\t1 ~~i (b )(6); (b)(7)(C) Comments (b)(6); (b)(7)(C) Security SLpervi• ~AR notified of need to transport via VAN to o Progress notes 9#atient f11-tL S\-,LU.~';) left via van with security escort Transport via EMS: Time Date Initials Comments 911 / EMSActivated Security Supervisor o MAR Returning to Facility: Vital Signs: Temp Pain Scale: (0-10) Date Time □ notif;ed of need to Progress notes Date/Time EMSarrived at facility c Returned frcm ER ____ Pulse ___ Initials Comments ~dm Resp --- tra11s~artv·,a~MS to B/P itted to Hospital and returned ______ Sa02 (roomair) ____ _ Patient returned to the facility Hospital Records and Orders Received forwarded to medical provider for review o Continue previous orders 0 New orders from provider noted □ New medication(s) entered into pharmacy system Assessment/ Notes: _____________________________________ _ Telephone Order: (b)(6); (b)(7)(C) Date/Time ne Order per Provider Medical Staff Signature Date/ Time 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/lG/GG Allergies: Y\V-,,OA- Medications: ~ VY\~ RevisedMay 201S / mb Emerge1cy Tlmeliie/Checkiist 2020-ICLl-00006 2733 1111 Emergency Treatment Order Medical Date Time ro,..~\-,-l-\\_:"\_--t-\~-61--+.;;, \r1,- Initials ~=;',' li ~;;;= l(= C)===-. ran sport Patient to _L ______ _ R for f rther eva[uatiqn and \rfatme11t(telat~d .___-\1()\'V\\ Per P.:~ei \?\bO(l C: tt )( t fJ.\-"{A ( ,T~cfer c Via EMS b)(6); (b)(?)(C) Date/Time p~~------t Receiving staff member - Si 1--- __ . C\ Date/Tlme __________ ........,._~-- (b)(6); (b)(?)(C) N.ime Print ~ l'\ I k'V Y\ 1-----Title: When the Patient is Released form the ER/Hospital, please do the following: /\DC F/\CII.ITY 5Pf'CIFIC INFO~MATION HcRr If you should have any questions regarding this Patient, please contact: HSA Name Phone# & Extension (b)(6); (b)(?)(C) 0fu .f\lJ,"1 028 866 428 ALMAZAN-RUIZ, FELIPE ADM 09/08/17 DOB 06/26/66 ~m ergency ·reatme ~t Order 2020-ICLl-00006 2734 \\ 1 ,zof 1111 M,2L1ical UM call prep Chronic Care: Yes/ No Last Visit ____ Riskfactors: \\•'\' Current Medications: Compliant: Yes/ No 'l',B ~' ~o..-~c.,..i;,,oe ~ ,,, CCDiagnosis (s)_______________ _ , ---------------------------------------- Tests prior to leaving (i.e. EKG- labs} Yes/ No If yes results ____________ _ Facility: Vitals ➔ Time-!, Temp Pulse Resp BP Sa02 Recent CC results - i.e. Ale - PT/INR I I I I Tests in the ERand results: ---------------------------------Medications received in the ER/Hosp.______________________________ Sa02 Return Vitals Temp Notes ?a _ Medication changes at Hosp: \ Pulse \\Sh,,c :be,,,e,>,~\:i~. Resp BP Sa02 -~ Seen upon return - Date Time By: ~I'.'\\\ c;\,\s ~~..Jc UM call May 201S / mb 2020-ICLl-00006 2735 Subject: HOSPITAL DAILY REPORT DETAINEENAME: XXXXXXXXXXXXXX ALIEN NUMBER: XXXXXXXXXXXXX DATE OF BIRTH: 06/26/1966 COUNTRYOF CITIZENSHIP:MEXICO DATE OF ARRIVAL:09/08/17 RELEVANTMEDICAL HISTORY:Detainee with history of heavy alcohol use, last drank 3 months ago. Presented to medical reporting he was vomiting blood xS days, assessed by RN who noted blood in mouth. Reports history of this happening 7 years ago as well. Has history of cirrhosis of the liver with varices. DATE OF ADMISSION: 9/11/17 CURRENTDIAGNOSIS:GI BLEED ATTENDINGPHYSICIAN:I""(b..,..., )(6 .,,..,. );....,, (b..,.. )(=7)..,.. (C,,.... ) ---, CURRENTSTATUS:PT STABLEAT THISTIME. MOST RECENTVITALS B/P-99/58, P-75, R-17, 02-97% REMAINS AFEBILE. 2UNITS OF PLATELETSGIVEN DUETO CRITICALPLATELETLEVELOF 27. POSTTRANSFUSIONLEVELIS 55. All OTHERLABSREMAIN WITHIN NORMAL LIMITS. DETAINEESCHEDULEDTO HAVE EGOIN THE MORNING. DETAINEEWAS PREVIOUSLYRECEIVINGCARDENEDRIPVIA EXTERNALJUGULARLINE, HAS BEENSTOPPEDNOW RECEIVINGLISINOPRIL PO. DISCHARGEPLAN: NONE AT THISTIME REPORTGIVEN BY f b)(6); (b)(7)(C) CONROEREGIONALHOSPITAL(936) S39-1 (b)(6); (b)(7)(C) I l(b)(6); (b)(7)(C) I ILVN AH-SADF-POLK _ivingston, Tx 77351 936-96 7-~(b)(6); (b)(7)(C) m 936-96 7-8846-Fax 11.1,c,c cal 3 2020-ICLl-00006 2736 r b)(6); (b)(7)(C) From: Sent: r b)(6); (b)(7)(C) Wednesday, September 13, 2017 5:35 PM To: Cc: Subject: RE:HOSPITALDAILY REPORT Hospital Daily Report Hospital day #J_ Detainee Name: Felipe Almazan Ruiz Alien#: A028866428 Date of Birth: 06-26-1966 Country of Citizenship: Mexico Date of Arrival: 09-08-2017 Relevant Medical History: Cirrhosis of the Liver Date of Admission: 09-12-2017 (correct date of admission) Current Diagnosis: U er GI Bleed Attending physician: b)(6); (b)(7)(C) Current Status; (NOTE: include Vitals, Meds, Labs, etc.) report received from Dee, RN at 1200 A+O x 4 BP 117/58, P88, R19, T98.3, 100% on RA Afebrile, received 2 units of platelets hemoglobin is 11.2, platelets 27'"L Discharge Plan: NO DISCHARGEPLAN AT THISTIME. PLEASECONTACTA-1EDICAL FORANY FURTHER INQUllllES. DWOODS-LVN Fro~ (b)(6);Jb)(7)(C) Sent: Wednesday, September 13, 2017 7:44 AM (b)(6); (b)(7)(C) Subject: RE: HOSPITALDAILYREPORT I should also mention that you do need to have the detainee full name and A#. I always have to remove it when I am communicating out of the ICE network (to your emails) or encrypt the emails to protect PII per policy. You all however when you send me this information are sending it to an ICE email (in network). Very Respectfully, l(b)(5); (b)(?)(C) ~N, BS:\r, CCNM Houston Field Medical Coordinator ICE Health Service Corrs / USPHS 16038 Vickery Dr, Suitel CL I 95-105 11HO 1/L ! 09)14/17-0541 I I :> :t CO2 ,l 'I :> AHIO 6AP 25 7,0 2020-ICLl-00006 2745 I 21-32 111101/L 09/14/17-0541 4.0-15,0 GRPcalc I 09/14/17-0541 ' ,. I.', I, ~: ::v· :n:, ·.1. 111-----+------------------------------""S:1 ::"' ConroeRegionalMedical center, Conroe TX Spe iNen Inquiry Report 11ed.oi rec to~..... (bl_(B_>: (_b>_(7l_(c_> ____ PATIEHT: RUIZ,FELIPE FD: OD:ABBAL __.I CAPIZ1190-01 ILac: s.Hrnu A[CH ~(b)(6); (b)(7)(C) AGE)S>{:51/N STATUS:ROMHt RESDR: (b)(6); (b)(7)(C) ':w,:' UI: BH00861890: •',i:· REG:09/12/17 DIS: ROOM: B. 141 BEO:U Id ffl f . ·)u. I-:-.-;• ;~: .·➔; Coll: : 0~14:CR: B0871R COMPJ Test 09/14/17-0◄50 flee~: 09/11/17-0503 CRff0767◄936) .Result Flag SHe Reference i-l_ !,J.. ·:.:.._,; Uerlfled 'I : ! l> i tee UBC J ,J,· I I ' !> ' L 4 . I - 12. I k/ 11t13 09/14/17-0542 L I 3.8-5.5 M/nnJ RBC I O'.:J/14/17-0542 i I !> I HGB L I 10.6-15.8 6/0L I : HCT 25.5 ) ttCU 93 .1 L I I. 36.0-47.4 "/. SIi. 1-101, I fl I 09/14/17-0542 I 09/ 14/17-0542 -··~···-·•-.......- 2020-ICLl-00006 2746 •: ' i :: '. '• ' ' 09/ 14/ 17-0542 i> :·;~:; ::;;: ! : 1,:;~ i ::·' : : j : ' ',·: ' . ' ConroeRe ional Mec:lical Center.. ConroeTX --1~--i;iJ,m::.,~R-1-1JUc.......4.2t..!:,__ ' !PATIENTRUIZ,FELIPE Med,Df rector: i RESll MD ACCTit: l(b)(6); (b)(7)(C) ' : FD: I (bl(5J; (bl(7J > PT PT ATJENT IttR :.'...... · i ~. I 1I .3 H I 9.4-12.5 SECONDS 09/14/17-0538 H I 0.85-1.11 INRUnit 09/14/17-0538 ----------------------------------------------------------Therapeutic range for IHRls dependent upon the situation. I 2.B-3.0 Proph~Iaxls/ venous throttbOeHbolisNJ TreatHent af OUT,Acute Myocardial infarction stroke preuention, SysteHic eMbolisNpreuentlon In fibrillation 3.0-4.5 AH[recurrence preventlon1 SysteNlc enbulisM 'I 2020-ICLl-00006 2747 q ( · )f t±r1 drH: dC t 1 ! ••... ·, I •• ,,, '. I 11 ' L' ' Patient Information Form I Phone: !{936~539-~ HosptlalName: Jconroe Regional Medical Center HospitalAddress:lso4MEDICAL CE::'.'ITERBL VD co:KROE, TX 77304 ~----------------~--------------------------------- PatientDemO{lraphlcs PatientName: RUIZ, FELIPE MedloalRae #::=ju;-2=92=4=53=1=6 ===;::::;]-;SSN;;;;;::i1ih' iffil'.'"ihm'iir'i ---,:::::~ Marttalstatus:!Single : Ga Dateof Birth:i,..:: I 06=_ 2== 6 _= 19 6 6 ==::;lAQe: 51 Religion·r-: J == ·=~:--io=~=E=============il Episode ID:[~H9023078383 ! ...,,Ad.,.,_m....,l"'"'t a=n....,d'--"Len=gt..,hc,...=,d_.S1ay=._,l"""nforma'-"'-'--:'~tl"';on;:.... ____ ____,: Unit: CR Admlt'fypa:!ELECTIVE Roorn=:-PB=_rc=u=4====4i Adml&Blon Date:[09-12-2C17 jBed:B.!ClJl 8 Eet.DlsohargeDate:!09-14-20111 ALC';.;;Oa.:::-:te.:-:.,: PL Functlonalstatus r,::--:-:Prt 1Bed0nly -·-1 ====:::::, I PhoneNumber:~.i.-----.......,-------ii Halght:j : weight:[ - (b)(6); (b)(7)(C) AttendingPhy&lolan (6); (bl(7l(Cl Dlag0911s lgfao!11Uon: Rugs:L..__:_:_,]Pr1mary:,..ju-P-PE-,R-G-,I-B_L_EE-,D------.! Secondary:....._ ___________ · ModectTransportatlon:..._I ____________ WIii 1908lveradiationor dlalyslaoff-site? 0YespatientNo .] O _ Peyer Sou roe:_ ""·--:----=======··=-=·--·Schedulerl TreatmBl'lta: ,,_,,________ -'! Emergency eom1,,ct: Llvi1gArrangement. ________ FirstNama/M;..:.:;.:Jl:fipw=F.Fi=:1=,1::•:P:;;:-:J:'i.=-=:===:::=: ~Jl1 First Nam&IM,----1:/:JJJ; L=====-"''"=:J~ -~ ...... se'"""-le ..... ct ...... O'"'""ne-.LastNameqRl:1Z LastName: FacllllyName: stNet: r_:-:-:---7 S1reet.----1 •l}LOCTh! 350 SOUTH I . ____i ~--========! City:LIVINGSTON City: Natt rl Kin Patla1tAddrass 1 Straat:3400 FM 350 SOUTII CIW:LIVINGSTON 35_1 i Stats/Zip:TX ?};-- statalZlp:TX 77 351 Homa Phone:9 3 6-96 - ======~ ~~~~~~;r Work.Phone: i~\i ~\cc -···-·-·Ralatk>n:01 HomePhone:r2.3..it9-~ WorkPhone:0.:...99...::.9-"_9-=99= \_ __.__--'I IncomeIf kncwm: ~--,;;;;=======~ D Emerg.Contact POA □SSA VA D PrtvateFunds Pension PatientMedicaidEllglble'1 0 Yes Siate/Zlp: Home Phon....._e-;::: Work Phone: Ralatlon:.--~=======ll □Em erg.Contact D No □ss1 Oother lf'Yes,submltted t7,-ourflnanclaloffice? Y• Phonei(936)53~ naviHealth Form 450 Rev 7/2012 2020-ICLl-00006 2748 No 1oate: 09-12-2017 □POA 9/:..2/.2C17 (I:;: :n PM CONF~r.~N'':'TAT. For Facility: ----------------------------------Acct N'o.: Start -- Patier,t 9/12/2017 8:20AM CR-3 IN':'E.NSIVE C Date.: B. :cu1e-;;, 1 Room: Re.port PATTENT Ccnroe. - IQ :NFORMATION Regional Medical Center ENC~~TNTER/ IICM DATA---------------------------===-=--=•••• ?..H9023073363 Location: PAGE l HCA CoYporate Ce.rtific&tion Insurance A::.:com.'l'toda ti on : Home J\.dci.r: 340G F~ 3!:>0 SCUTH RUIZ,FELIPE Name: Age: - '>lY (b)(6); (b)(?)(C) Adm P'.1.ys: MD _.MD Att l?:-.Lys:.__ ____ D2.te: Ci.sch Enc Type: IN?A': IEN':' {Inpa ti.en t) Cou::1ty: Country: Zip Cocie: United 6/26/1%6 - MR'li: BH0086H9C F~c: Conroe Rcqio Sex: M'a.clo1l LIVINGS':'ON DOS: s;~ot: ?1 S:.ngle TX I Sta:es of Arr.e 77351 (b)(6); Home l?hor.e : 93 E, 9 E,"/ /h\/ 7 \lr.\ Work Phor,e: 999· 999-9999 Emer SSK: Cor,~aL:t.s: Work Tel: Mame: RUIZ,FELI?E Rela~~on~hip: Self current HCM DRG: Admit ::oJr.plaint: HCM Di;..gnosis: S':ay: 1 GLOS: l.LOS: outlier: UPFER Gl BL£.ED HCM Procedure: Dx ca::eqc ry: P.eview: Adrni t ,.,'·',_."'""'"'==================== 'PAYF,R ( S) ================== =========================== State;:,;: OVF.R?.Ir>E WITH PAYOR NA'MF. Auth No: NR/: OVERi<.IDE WITH PAYOR NAME Aut:h No: NP./-:- Statt:.s: P Cert? Insur s Ce.rt? I!lsur ~o: 028866428 No: 028866428 ====== LJ:\.ST COMPLrTED REVIEW Q}J::,y ~eview S/12/2017 Date Review Care Date 9/12/2Cl 7 Severity Reviewer Ca::egcry Fe1~:iewer ID l(b)(6); (b)(?)(C) I::ttensity Ccrn.~e!lts: ---9/::..2/2017 1531 :0A b)(5); (b)(?)(C) Point cf Entry: per cpoe ddm.:. L :::.:1pl paye"'-· over1·ide -:;~anster trom L.::.vingsto~ P~ese~ting symplcms: Gi bleed, Failec OP treatment: Vita.:. signs: p 93, Medications/route: ~abs/Cul::ures: h/h p94, 77, bp 181/1C7, 184/95 1 1,,i th payror 203/95, ::.2/30.1 Irnag.::.ng: :Jiel/Acliv.::.ty: ox~rgen: ?'l/C':'/ST: 2020-ICLl-00006 2749 211/1J4 N;,.mc Referral From: Conroe Regional Medical Center (b)(6); (b)(?)(C) From: Phone: (9 36) 539 IAH Immigration To: (b)(6); /h\1 (b)(6); (b)(?)(C) Attention: 7 \tr\ (936) 788-8076 Fax: Comment: 028866428 ins# our fax 936 788 8076 tax id 621 801 361 npi 196?455816 The following documents are included in this fax: Name Pages Patient Information Form (rev.7/2012) 09-12-17 03:37 pm 1 Insurance Certification Report - IQ 2 Patient Health Information Legal Disclosure: This facsimile transmission contains coniidential information, some or al: of which may be protected health information as defined by HIPAA (the federal Health Insurance Portability & Accountability ACT) or persona: information protected by state data privacy or security laws. This transmission Is intended for the exclusive use of the individual or entity to wncm It is addressed and may contain information that is proprietary, priviieged, contidentiai and/or exempt !rom disclosure under applicable law. If you are not the imended recipient (or an employee or agent responsible lor delivering this facsimile transmission to the intended recipien1), you are hereby notified that any disciosure, dissemination, distribution or copying of this information is strictl ronibited and ma be subject lo le al restriction or sanction, If ou received this in error, please notif (bl(6l : (bl(?l(Cl re-mail a b)(6) ; (b)(?)(C) to arrange the return or destruction of the information and all copies __. . · n. ~\ (bX6); (b)(?XC) \~(\,, d-\71CT \a--\o->- (oi- ,• \ q(o1 &fo ~s- \(i(c IS1o \)\~ 2020-ICLl -00006 9/12/2017 03:33 PM CCNF!DEN"::'IAL Fc,r Acct :Vo.: Facil:..Ly: BH9C23078383 Conroe Regional Facility: Medic~] ?AGE HCA corporate C.ti('nt ~.,n~P.r =======-==="-===============LAST COMPL~TED F.EV~EW ONLY (conti!lt.:.ed) T::-ciltmcnts: :evel of care cvzJ/TP~P.rri'l1~: 9/12 to ICU dx G: bleed, rr.l hr, bp 2lfl/ cc1rdene gt:t, , :dh stabli; i:;latellets er to~t<.Jrrow, bp cont:.~nl 1 F-rl , C":?.. rdene g-:.t tur:neci. of.t 1300 ..--Yili Treatmen~ Plan.~: Commer.t s/Othec 51Y DOB: 6/26/1966 ===='~--=-==================="'= lef~ 27, plar: lisir..cpril with ns al .i.:J f,E· EGD po staled ·..--··-· -----==========LAST : NT EP.QUAL RE VIEW ONLY =="' "'-"'"' "'===========•••=~•Review S/12/2017 1~0 tociay at •· •· • DateRevie.WP.T JD !(b)(6); (b)(7)(C) InterQu~l R~vie.w ~evie~ Vers 1 on: Interc;-ua.H:: date: 09-12 2011 Status: In Primary Product: crj~er:.a Cri~er:.a LOC:Acute Adult subset: Ger.eral status: Critical or ::i:i.ding within 2 Cl"/. 1 MeQical M~t (Syrr.ptorr. 24h) (ixcludes PC ~edications unle5s noted) Select Day, 0,-.e: Epi$ode Jay~, One: CRITICAL, >= 8ne: General, >= One: IV medicat.io:i administration, Medica~ion, >= One: Antihypcrtcn::,ive Both: Admi:-.istration, > Or.e: Titr~1tion q1-2h a:--.ci:m,.,:,:i::odng Int.erO.ual(t Corporation CPT only;;;: C01\21Lf:fl __ ;...:.t ccntain.s CareEnhance•.ct• Review M,mager and/or one o::. it ..5 ~t:bs-.d~a.riec1. and 2016 Americar. YlHiical ;c:, 20] 7 McKes.~on All Rights Reserved. A.~sociat:.cn. AL_ Rights Rese:::ved. pr opri e tar 9 i.1fcxmz l"ion. Hoe 2 JQ i.11tenelc el f:o_ ewee fftL'tl distrieu:i 2020-ICLl-00006 2751 on. ::: ::; Referral From: Conroe Regional Medical Center b)(6); (b)(7)(C) From: )~() ~(;r Phone: (936) 53 Fax: (936} 788-8076 Comment: To: Attention: IAH 0ENTENTION _jt b_l(-6)_; (-b-)(7-l(_c _i ______ CENTER _, NOTES AS REQUESTFD The following documents are included in this fax: Pages Name Insurance Certification Report - IQ 4 0913_ 12:23:13 1 0913_ 12:23:04 4 Patient Health Information Legal Disclosure: This facsimile transmission contains confidential informatio n , some or al: of which May be protected health information as defined by HIPAA (the federal Health Insurance Poriability & Accountablllty ACT) or personal intorrnation protected by state data privacy or security laws This transmission is intended for the exclusive use of the individua. or entity to whom it is addressed and may conta in information that is proprietary, privileged, conlidenfal and/or exempt from disclosure under applicable law, If you are not the intended rec pient (or an employee or agent responsible for delivering this facsimile transmission to the intended recipient), you are hereby notified hat any disclosure, dissemination, distribution or copying of this information is strictly prohibited and may be subject to legal restriction or sanction. If ou received this in error, please notily! /bl/ 6): (bl/7)/Cl pr e-mail b)(6); (b)(7)(C) arrange the return or destruction of the inlormation and all copies 2020-ICLl -00006 2752 9/13/2017 11:4l AM COKFIDENT:J\T, For Acct No.: ~acili~y: Patien~ BH9023078383 PAGE 1 HCA ::nrp,.,rate nn Report - Selectec. ::c.rtif:.~:c,::·. In.suranc:?.X: M S7:at:: Single TX ccunty: Countrjr: Un1.t.,od '."tates o: An·.e :S:.p Cod<".'. 7735·1 (b)(6); Eo~c ~hone: Work ?hone: ~!Iler 936-S67 ~v~~ 999-999-9999 SSN: Cont;,cts: Name: RTTJi,~~tT?E Relatio~5hip: HCM DRG: Home Te~: 936-967-8000 Work ':'el: 3.8 o·-1.tlier: Sel: Ver: 872 Co~plaint: Admit HCM D:..agnosi Curren-:: Stay: 34 1 ALOS; 4.5 GLOS: UPPER G- BLEEJ s: HCM Prccedi..;re: clx Category: Adrr.i t Review: ===:===-- ==== ===:· ; ===:= ====-=========::: OVERRI!:JEw:TH PAYm NAME .D,..uth No: Statu."l: NP./ I #Days Type 'Ihru From P Cert? :nsur No: 028866428 s~atus Auth No Cert - P Compa:-iy: SubmiL by: Jate: Submit Phone: Fax: ~ Statt.:.s: Date 2 017 Care Di'lte 9/~3/?017 Review Cert? CURRSNT No: 02EBE6428 REVIE' (b)(6); (b)(7)(C) Ca-::egory Int ens:::.ty Sever.:.ty Reviewer 'lime: l~3ur ======================"'-:.===========•"' Review Ref No to: OVERRIDE "\IHTH PAYCR NJ\ME Auth No: :-.R/ I S/13/ Cnr:llT.ents: ---9/13/2011 Vital s~qns: 36.E, 57, 1133 kb)(6 ); (b)(?)(C) ~ ~---------~ 109/66 TC 89/S,, 94 % 2020-ICLl-00006 2753 S~rvice 890 Regio 11:41 ?AGE 2 HCA Corpo:::ate 9/l3/2'Jl"/ Cc>r-::i ficatior. I,1tiur<1ncr-- AM Report - Selected Review PA~IENT INFORYIATION CCNF:DENT:AL Fnr Accl Nu_: Facility: BH9C2107RlR1 con.roe REgi one.l Facility: Co~roe Regional NaJr.e: Pat.:..ent ~edical - JQ ~An~~r Age: '.l.UIZ,FELlPE SlY D03: 6/26/ : 966 Ce::i.ler Meciical .. ····-·--------=~=----~-~---------~--- ...---·------====:===ac=-- CURREN'lREV l f;'tl Mf'rlicdtions/Route: PO MF.:JS, PROTON:::X IV, 1 V, :EVAl;UIN l V TRANOA'fF, PRN, IV ZOFRAN PRU, IV :10'.l.PHH'E PRN, -:.... J'' s ~ :::VY @ 75 :::v CA.-l.DEN~ CC/ER, Labs/c·.i.:. tu res: H1.H 8.4/23.e, PLT 35, I~aging/Other test~: C'l'T TITRJ\TFD P'f/ :NR 16.f'..;s_,:_r, RBC 2.60, Diet/A.c::tivit.y: CL DIET Oxygen: AS NEEDrD PT/OT/ST: Other treatment.,; 3LOOD PRODUCT Leve: cf CJI.Jrn:o, TR1'.NSFUSHJK"- PLATELE':'S care eval/referral$: GI, CRI~ CARE Barriers to :V PLJU :Jr.e: IV mcdic.ation adm.ini~trat:.on, 0 Medication, c~,lcium channe1 Amr.inis-:rat1 on , Titra-:io~ ql-2~ InterQual·~' ::orpc·raticn CPT only and careEnhance0 and/or one cf ·_o: 2016 Bo-::>-i.: >= one: b1oc:,er >= one: a~d monito=ing Rev:.ew Manager its s·-lbsidiarie:s. ll.mer i c an Mec.ica.:. Association. :;, 2017 McKesso n All Rights Reserved. Al: Rights Rc~erv<"-< 1.02 133.0 24 4.2 Laboratorv Tests 09/" 21 1530 09/12 1530 097IT 1530 __ 90.011T Amm0nia (11.0 - 32.0 mcMlJL/L) ! k -, 4.9 H B (( K-21(1.0- 3.6 N' ·""' l 0.270 *H, Troponin I (0.000 - 0.045 NG/ML) 1226.59 11 ~B-Natriurctic Pcolide (0.00 -100.00 PGIMLI I ·hemi st.ry 09/12 1155 hem1stry 133.o I Sodium (133 - 144 mmol/L) Page 2 of 4 2020-ICLl-00006 2758 l@iD~ ~132H Patient: RUIZ,FELIPE Unit#:BH00861890 Date:09/12/17 BH90230./8383 4.2 102 24 7.0 67 H .. - . ...:.....:... 1.36 H Potassium (3.5 - 5.1-mmol/L) - CFiloriae (95 - 1OS mmol7L) rcarbon Dioxide 1)1 - 32 mmol/L) Anion< ,ap (4.0 ~-, 5,0 GAP calCJ '--·· BUN (7----18 MG,Dli . Creatininc (0.55 - 1.30 MG1DL; l domerular Filtr Rate (> 60--Cst( d-KJ 53 L 132 H ---- Glucose (70 -110 MG/DL) 7.8 L Calcium (8.5 - 10.1 MG/DL) 6.56 H Total Biliru6iii (0.00- 1.00 ,\/2G/DLI 3.35 H Oirecl Biliru6in (0.00 - 0.30MG/DL) 3.21 H lncfficct Bi1irub1n (0.2 - 1.3 .'v\(]DL) 81 H Asl (15-37 Uni!/U 49, ALT (12 - 78 Unii7L) 107 Total AIR Pliosnliatase (45 -117 Unii7L) 5.4 L r-Total Protein (6.4 - 8.2 (,/UL) 2.9 L An urnin (3.4 - 5.0 r ;TDL) 1.2 A 11 umin/Globulin Ratio (1.2 - 2.2 RATIO) 5-10M(, 3 ,MALL lndex1DL) necimen Anncarance (1 N ' 2 TRAC:E10-25 MG . ,~cimen Hemo'"sis (1 NOR/v\AL lndcx/DL) Laboratory TP.sts 09112 1200 Coa_gu1at1on PT (9.4 - 12.5 ,E< 1JNlJS) 17.3 H INR (0.85 - 1.11 INR Unit) 1.52 H 29.4 PTT (Daae) 124 - 37.7 SECU"DS) Laboratory Tests ----- 09/12 1200 Hematology - - - WBC (4.1 - . 12.1 k/mm3) f--------RBC \3.8 - 5.5 "'mm3) Hgb 110.6 - 15.8 G/DL) Hct (3°6.0- 47.4 %) MCV (80.1 -101.1 tL) M[H (25.3 - 35.3 lv\CHC (32.7-35.1 -/DLI RDW (12.2 - 16.4 %) Pit Count (155 -337 K/mm3) Mn (7.6 - 10.4 ILi ----- e~ ---- . Page 3 of 4 2020-ICLl-00006 2759 15.1 Fl 3.50 L · 11 .2 30.1 L 86.0 32.0 37.2 H 17.2 H 27 'l 1D.3 ?atient: RUIZ,FE~IFE Unit#:BH00861890 Date:09/12/17 BH9023078383 Acct#: 65.81 12.1 L 12.7 H 1.T ))iagnosis. Assessment & Plan Free Text A&P: GI Bleed: management per GI hypotcnsion : better. RPT #:0912-05"/5 ***END OF REPORT*** Page 4 of 4 2020-ICLl-00006 2760 Referral From: Conroe Regional Medical Center L ~--;:::::::::;:::::::::::;-' (936) 53~(b)(B); Phone: Fax: Comment: I kb)(6); (b)(?)(C) From: I To: !AH IMMIGRATION 1FTENTION fb )(6); (b)(?)(C) Attention: (936} 788-8076 TAX ID: ~x: 936-788-8□76 f b)(6); (b)(?)(C) The following documents are included in this fax: Name Pages Insurance Certification Report - IQ 4 0913_12:23:13 0913_ 12:23:04 1 4 RAD/XR CHEST 1 V 1 Specimen Inquiry US/US ABDOMEN LTD 2 HISTORY ANDPHYSICAL 0913_12:22:40 3 8 Specimen Inquiry 2 Specimen Inquiry 1 Specimen Inquiry 1 Specimen Inquiry 2 Specimen Inquiry Specimen Inquiry 2 1 ELECTROCARDIOGRAM 1 ENDOWORKS REPORT 2 HISTORY AND PHYSICAL 1 Specimen Inquiry 1 0913_12:21:25 1 HISTORY AND PHYSICAL_FAKAL_09122017 _B.HIM201709130071.rtf 1 Clinical Rounds Report_ 20170913.rtf 7 HISTORY AND PHYSICAL_FAKAL_09122017 __8.HIM201709120324.rtf 3 US ABDOMEN LTD_US_09122017 _020697791.rtf 1 XR CHEST 1 V_RAD 09122017 _020697794.rtf 1 1 2020-ICLl-00006 2761 Patient Health Information Legal Disclosure: This facsimile transmission contains confidential information, some or all of which may be pro'.ected health information as defined by H IPAA (the federal Health Insurance Portability & Accountability ACT) or personal information protected by state data privacy or security laws. Th is transmission is intended for the exclusive use of the individual or entity to whom it is addressed and may contain information that is proprietary, privileged, confidential and/or exempt from disclosure Londerapplicable law. 11you are not the inter-ded recipient (or an employee or agent responsible for delivering this facsimile transmission to the intended recipient), you a'e hereby notified that any disclosure, dissemination, distribution or copying al this information i · · · to e al restriction or sanction. If au received this in error, please notify (b)(5); (b)(?)(C) arrange the r'--e;::-tu-::r_n_o-::r-::d;-e-s;-tr-uc--.t::--i o-::n:--o-:--:f~l:;::h-e-.i-nf,-o-rm=-a7-'ti-o:-n-::a-::n-.d-a°"il,-c-o-::p..,.ie-s:------------------_J 2020-ICLl-00006 2762 ·11 :41 Cnrpcnate ttr:A S/.11/7017 2ertifir~~inn Insuraz~e AM Fc-r Acct f'dcility: PA1'BNT Review - IQ INFORMAT:oN Reqional Conroe Medicc.l Cent;;r Age: RUIZ,FELIPE ~~m~: No. : !(b}(6): (b)(?)(C) - Selected Reper~ COJ\"FIDENTI.l'.I. nm,: 51Y 6/ 2 C/1966 b)(6); (b)(?)(C) Start Date: 9/12/2Jl7 B:201\M Locat~on: CR-3 lN~ENSIVE C Roon:.: B.ICU16-w Adm Ph'I'~ MC MRI\': BHC-0361690 Phy~ MLl Fae: Conroe SP.x: M Att Disch :C:nc Type: .ll.ccornmoda '..~.on: Home .Adc.r : 3 4 JO ~'YI 3 5 0 SOll l'F :NP.Ar:Ftf':' (Iupaticnt! S::at; L~ VlNGSTON, Regio Da~e~=----------' Single '.T'X count.y: :::ountry: Zip Code,: Home Phone;: Work Phone: Emcr of .b&.e 936-967-A~•GO 999-999-9999 Cont.\cts: Name: SSN: Home ~el: RIHZ,~F,,TPF. 936-967-8000 s~J~ Relationship: Ver: f.CM DRG-: 872 Adrr,i. t sr.,nes united 7735·1 f:c,mp 1 aj nt: 34 Stay: CUrIC1".t 1 ALDS: No: 028566428 4.5 G:.os: 3.8 0'-ltlicr: UPPER GI BLEED HCM Dia 11:L Ins·;,rancc A..'111 Crrh fi cat: on COKFI!JENT:AL For Ac.:cl PJ\.GE 2 HCA. Corporate 9/13/2017 No.: Faci:ity: l(b)(6); (b)(7)(C) Conrn~ R~giona Fad .1i ty: F.eport - PATIENT ?at.:.ent Medical Ce~ter Kame: ··-·,...- ========='-== = CU RP.ENT - IQ INFORMATION Medicc1l Co:::11:ce ~egional I Revie;,; Selecteci C•mte:,_· Age: RUIZ, FELE'E REVIEW --- s·:y DOB: 6/26/1966 =======~ 0 --··, Merli cations/Route: PO MF.0S, rv, PROTON IX :.EVAQUIN IV, IV ':':,.AND.An: P':>.l\, TV ioFRAN PF.N 1 :v MORPHINE PRN, :v· .;;: :V? @ 75 :v C:C/ER, Labs/ C'.il ture CARDENE GTT Tl TRATED s: 1-J'&H8.4/23.8, ?:.T 35, Inaging/Other te~ts: REC 2.60, PT/ INR 16.6/~-~6 Diet/Activity: CL DIET Oxygen: AS NEED~D ?T/OT/ST: Other ~realmenl:;: 3LOOD PRO:HJCT TRANSFUSIONLevel of care cval/re~errals: CARD~O, ~l, CRIT C18.~ Barr~crs IV ME:JS, to PT,A'l'F,T,F.'JS Ciscr.arge: PLAN STRES.~ WHF,N'HGR 10 Corr.mer.ts /Ot'.'1er: --===========-----=============== IN':ERQUAL ~;~~~~O~; RS )M?M)f f%}ID Inte:Qual Review Review Product: CritEria Criteria REVIEW HlS'l'ORY ------------------------.., I I:,:~e::Qi.,;al·t 2017. 1 Ver!io~: ca-:.e: 09 13 2Jl7 Sta::us: I~ Pr~ma::y :.,oc:A.cu Le Adt;.l t sub.'3et: General Medic"'l status: Critical Me:: (Synp::om or ::i::-.ding within 24h) (Excludes ?O :uedication.':l lL'l.:..e.ss r.otec) Selec:: :iay, One: Episode Cdy :, One: CRIT:CA.I,, >= Or:e: Ge:-i.eral, >= One: :v medic.:i.ti c,n acin'J.ni s::raticn, Bot:-.: Medication, >,· One: ca: ci·.lll\ char.nel bl,-,c: kier Adrr.i,.istra-cior., >= Cne: Titrat~on ql-2h and moni t o r ing Inte.r;Qual 1~: ar.d Care&hanc.e0 Review Manager Corporation and/or or.e of i::s S\;.bsiciar.:.es. CP'I on:..y ;t,; 2016 Arr,e.!"i,,:.n Medi.sal Associ2..tion. :;, 201'/ McKesson All Rights Rcscrvec. Al l Right!l REsc.:-vcd. 2020-ICLl-00006 2764 =-------- ... 9/U/2017 11:C AM lns·,1r.,n~:"' Ce1:tificatior. 11::A Corporate Report - Pl\GE Selected Review - 3 IQ CDNFIDEKTIAL PA".'IENT INJORMATION For Acct No.: ~a~i'.ity: RH9023078383 ConroE Peq~ona: CONF'TD"NTTAL - Co::itains Facility: Medical Conroe Patien-: CenLer Regional Nair.e: Meciical Center Age: !l.UTZ, FE::_rp;,; :ONflD~NT:ALTTY STATRVENT ·ot int.,,nrl~d ~or 2020-ICLl-00006 2765 exte~::ial ~1Y DOB: 6/26/1956 distr~butio~. FAX: FAX: (b)(6); 9 3 6 - 5 8 5 - , (b)(7)(C) l(b)(6); (b)(7)(C) 936-585-, Patient Name: .._ _ Campus: St: ADM _. Onit RUIZ,FELIPE C No: BH00861890 EXAMS: 020697794 RAD/XR CHEST 1 V To be perfonned PORTABLE? Travel Mode: Isolation Reason Type: for Exam: le~cocytosis comments: *? Location: Chest x-ray T 18 exam, AP frontal projection, CLINICAL HISTORY: Leukocytosis, Comparison Elevation given lack exams: right of prior the changes mainly lines obscure ** of t~e ICU patient. chest bemidiaphragm difficult to assess in terms exams. Probable scarring veroua atelectatic at the detail. Electronically ** ~one 9/12/2017 base. of right. lung No findings 5 No active high concern of age CHF. Overlying for pneumonia 7 Signed by fb_ )(_),_(b~)(_ )_ (c~)--,-=---------____Ji* 7 on 09/12/2017 at 1726 6); (b)(7)(C) Reported and signed by j'b)( .__ _______________ ** _J r )(6); (b)(7)(C) CC: Dictated ~ate Time: 09 12 2017 (1726) Technologist : (b)(6); (b)(7)(C) '--~~---~--__J Transcribed Date Time: 09 12 2017 (1726) Orig Print D/T: S: 09/12/2017 (1729) Signed By: NAME: ~UIZ,FELIPE CONROE MED CTR IN/OBS MEDICAL IMAGING 504 MEDICAL CENTER BLVD CONROE, TEXAS 77304 PHONE#: 936-539-7026 FAX#: 936-539-7681 PAGE 1 (b)(6); (b)(7)(C) PHYS DOB : Report j : kb)(6); (b)(7)(C) 06/ 6 6 AGE: 51 SEX : M ACCT NO (b)(6); (b)(?)(C) OC: B. ICU18 W EXAM DATE: 09/12/2017 STATUS: ADM IN RAD N8: DC Dt: Printed From PCI 2020-ICLl-00006 2766 Patient Name: Unit ~UIZ,FELIPE BH00861890 No: EXAMS: 020697791 US/US ABDOMENLTD Travel Mode: Isolation Type: ~eason for Ex.am: RUQ ahd pain.H/0 comr:ients: non alcoholic liver cirrhosis *? site:Rl6 Limited History: liver Abdominal Ultrasound upper Right cirrhosis. quadrant No prier Comparison: Technique: similar studies and color Gray scale pain, abdominal history e.vailable are imaging Doppler of nonalcoholic for were comparison. utilized. Findir.gs: 'l'his examination The liver markedly is markedly is measures 15.2 cm in limited. The main portal The gallbladder negative. is not The common bile duct The right kidney thickness measuring The pancreas The visualized unremarkable. is due well-visualized. is measures not is on this x 5.8 x 4.2 1.9 not beam penetration. of the liver visualized. Sonographic identified 10.9 to poor length. Evaluation vein is not well cm. It demonstrates or cortical thinning. nephrolithiasis There limited Murphy sign is is exam~natio~. cm, with a cortical ~o hydronephrosis, visualized. o= the abdominal portions no evidence aorta and IVC are of ascites. :Zrnpreesio:o: 1. Markedly limited examination due to poor beam penetration. The liver, gallbladder, common bile duct and pancreas are inadequately visualized on this exa.mina.tion. 2. Unremarkable right kidney and visualized portions of the abdominal NAME: PHYS:~~M7ii'ri'"""-1-=-:=--=-=------=-==__,...,....J CONROEMED CTR IN/OBS MEDICAL IMAGING DOB: 504 MEDICAL CENTER BLVD CONROE, TEXAS 77304 PHONE#: FAX#: Page l GE: 51 SEX: M ACCT N'""'o=--: ..,.., (b ,.... )(.,.,. 6 )-; (,... b )-(7-)(C ..... )--~ LOC : B . I CU 1 B W 936-539-7026 EXAMDAT: STATUS: ADM IN 936-539-7681 RAD NO: Signed Report Printed From PCI 2020-ICLl-00006 2767 (CONTINUED} Patient Name: EXAMS: 020697791 Travel ~nic RUIZ,FE~IPE No: BHOO861890 US/US ABDOMEN LTD Mode: Isolation Reason Type: for Exam: RUQ abd pain.H/O non alcoholic liver cirrhosis Comments: *? -< 102 133.0 4.2 24 LaUoratury Te!.ls 09712 1530 09/12 1530 Chemistry 90.0 'H •- Ammonia-( 11.0 ll /L) 32.0 me CK-MB (CK-2)(1.0 - 3.6 N "ML) ' Troponin I (0.000 -0,045 Nr :JML) I B_:_~_alnuret1ct'ept1r:1e -100.00 09/1~ 1530 4.9 H 0.270 'H, I-'{ .//\AD 216.59 1-1 09/12 1155 ------hemistry 133.0 4.2 102 24 7.0 67H ~odium (133 -144mmol/L) 1-'otass1um(3.5 - 5.1 mmo111\ Cnroridc (95 - 105 mmol/L) '---carbon bi6-xirle(21 - 3 2 mmol/L) Anion l ,ap (4.0 - 15.0 BUN(J-l8MC,1DL) l ,AP c:aTiJ Page 4 of 8 2020-ICLl-00006 2775 ----~ ~' Patient: RUIZ,FELIPE Unit#:BH00861890 Date:09/12/17 BH9023078383 Acctt: 1.36 H 55 L cTeatinine (0.S.I - 1.30 Ml,iUL) Ulomerular Filtr Rate (51)0 estGFR) Glucose (70 ll0Mr:tDL) Calcium (B.5 - 10.1 /Yll,/IJL) Total Bilirubin (0,d0- 1.00 M' ·'DL) Direct ~ilirubin (0.00 - 0.30 MGTDL) -Tu-direct Bil1rub1n {0.L - 1.J ,vu ;1u1, AST (15 - 3 7 Unit/LJ A T (12 - 78 Unit/LI 132 11 7.TT 3.21 H 6.56 H 3.35 H- - 81 H /49 107 TotaTA1Kr_nosphaJase(45 -117Tfnit/L) 5.41 Total Protein (6.4 -8.2 r ;1DL) 2.9 L Amumin (3.4 - 5.0 G/DL) Al6umin/Glo5ulin Ratio 11.2 -2.2 RATIO) 1.2 Snedmen Aimearanrc (1 NORMAL lndex/DL), 3 SMALL -5-1O MG Specimen Hemoltsis (1 NORMAL-lndex/DL) 12TRACE 10-25 MG. Laboratory l ests i I 09712 I 1200 · Coagulation PT (9.4 -1'"2~.s~sE~c~c~1N=D~sJ~---1,1·.J·H~ ' INR(0.85 -1.11 INR Unit) rs2 H. 1 [ PTT (Dade) (24 - 37.7 SECONDS) 29.4 1 Laboratory T_e~s~ls~------------ 09.12 1 7 [)() l1ematology WBC(Cc4~.1~--1~2~.~1 k/m.m,,;cl~I ----------+--RBC i3 ,8 - s:s lv\lmm.1) Hg6 (10.6-15.8 G7DC: Hct (Jn.O - 47.4 ¾) MCV(80.1 - 10-C';"1 ~L~) -----------Ml.H (2o.3 - 35.3 p-gl ~LHL (12.7 - 35.1 C/DL) ~RDW (12.2 - 16.4 %) t-"1t t ount (155 - 337"' mm3) Mev (7.6 - 10.4 tl) 77ran ¾ (37:B - 82.6 ¾) 6 1 vrnJJri % (Auto, (14.1 "4.5.4 1~) Mono ¾ (Auto) (2.5 - 11.7 ¾) ... Eos ¾ (Auto) (0.0 - 6.2 ¾; l:'laso % (Auto) (0.0 - 2.6 n,-r;,j Page 1s:T 11 1,1() L ·- - ' ···- - 5 of 0.5 8 2020-ICLl-00006 2776 11.2 30.1 L 86,0 32.0-, 37.2 H 17.2 11 27 • I 10.3 fi.5.8 12.1 L 12.7 H 1.7 Patient: ROIZ,FELIPE Onit#:BH00861E90 Date:09/12/17 BH9023078383 Acct#: 9.95 M · c,ran # (2.0 - 13.7, mm31 1.82 ~Lymph #(Auto) (0.6 - 3.8 K/mm3) 1.9-, H Mono# (Auto) (0.11 : 0.59 K/mm3) Cl.25 tos # (Auto) 10.0 - 0.4 "rrim3) 0.08 Baso # (Auto) (0.0 - 0.1 K/mmJ) MAN DIFF INDk,ATED Arlrl Manual Diff (( RITERIA DlntSCN) I 100 I otal l ounted ( 100 7.2 H lmmature Gran% (0.0 - 2.0 %) 73 ---seg"-Neutro.Olills % (40 - 75 %) -12 L Lymphocvtes % (Manual) (12.6-, 4.1.5 %) 0 14 H Monocyt.es /o (~fanua[) (4.2 - 12.7 %") 1 Eosin·onhils % (Manuali (0.0 - 5.2 %) 0 1.7 n Nucleated RBL % 10.0 - 1.D /100\V!JL 10) 0.25 H Nucleatea RBC:s# (0.00- 0.05 K/mmJ) SUullT Toxic Granulation (NONE ON SCAN) MRK uICR I. Platelet Estimate (ADE1 11IA It <)N ,cAN) PltMor~hologt' omment(NURMAL PL15UN SLAN) IARCE RARE I Sllu HT Polvcliromasia (NONE ON SCAN) !'Liu HT Hypochromasia (r..ll NE r N sc.AN) ---• SLICHT Poikilocytosis (NONE ON SCAN) SLIClff Anisocv•osis (NONE ON SCAN) , valocVTes (l"ll •NE f lt'\-SCAN) 'RARE Acanlhoc'"es (Sour) (NONE ON SCAN) IRARE ,chistocvtes (NONE UN SCAN) J Laboratory Te.~s~ts _________ _ 09 12 1530 Sero o Hepatitis A lgM A (Norireactivr:-Non Reactive (Nonreactive N G-NONREA _ He B·core 1·MA (Nonrr:ad1ve SCREEN) NonReactiVe Hepatitis_( Anti o y (Nonreactive R l NR --nc BsAnt1gen Radiologydata: Recent Impressions: ULTRASOUND - US ABDOMEN LTD 09/12 1637 •" Report Impression - Status: SIGNED Enrered: 09/12/2017 1913 Impression: 1. Markedly limited examination due to poor beam penetration. The liver, gallbladder, common bile duct and pancreas arc inadequately ?age 6 of 8 2020-ICLl-00006 2777 Patient: RUIZ,FELIPE Unit#:8H00861890 Date:09/12/17 Acct~: BH9 0 2 3 O'/ 8 3 8 3 visualized on this examination. 2. Unremarkable right kidney and visualized portions of the abdominal aorta and IVC. b)(6); (b)(?)(C) D Impression By: t.SDR.RH 1 Diagnosis. Assessment & Plan Free Text A&P: Consult:Hematemesis HISTORY OF PRESENT ILLNESS:The patient is a 51-year-oldHispanic incarcerated male, who was taken lo Livingston Memorial Emergency Room with complaiots of abdominal pain, and bcmatcmcsis. He has a past medical history significant for nonalcoholic liver cinhosis, generalized anxiety disorder, and depression. He bas been diagnosedw1thcirrhosis7 years ago. He is currently in the Dcpamncnt of Concctions. PAST MEDICAL HISTORY: As mentioned above 1 which includes, l. Nonalcoholic liver cirrhosis. 2. Depression. 3. Generalized anxiety disorder. SURGICALHISTORY: None. ALLERGIES: NO KNOWK DRUG ALLERGIES. MEDICATIONSFROM JAIL: Reviewed. SOC:L'\.L HISTORY: The patient ii;;incarcerated. He is originally from Florida; however, because of the flooding , he was transferred to Texas Jail. F/\MILY HISTORY: The patient is unaware of any medical problems running in the family. REVIEW OF SYSTEMS: Otherwise negative. GASTROTh'TESTINAL: He present<;with right upper quadrant abdominal pain and Page 7 of B 2020-ICLl-00006 2778 Patie~t: RUIZ,FELI?E Unit#:BH00861890 Date:09/12/17 BH9023078383 Ac:::t#: hematemesis. PSYCH: depression. Vitals as above: General appearance: alert, awake, oriented Head/Eyes: atraumat-ic, E0lv1I, icteric ENT: moist mucosal membranes Cardiovascular:regular rate & rhythm, normal he.artsounds Respiratory: clear to auscultation, no distress, no tenderness, aerating well Abdomeo/Gl: active bowel sounds, soft, non tenderness Extremities: moves all, no edema-all extemities Musculoskeletal:full range of motion Neun/CNS: alert, orientedX 3 Psychiatry:·unableto evaluate LABORATORY AND DIAGNOSTIC DATA: Reviewed ASSESSMENTAND PL/\N: A 51-year-oldincarceratedHispanic male with history of nonalcoholicliver cirrhosis,now presentswith bematemcsis Possible varices though PLTs are low will transfuse then have EGD possihle banding Agree with octreotidie and PPI drip with abx EG D planned tomorrow for now Follow up CBC in the AM )IFQ ,-------~ l(b)(6); (b)(7)(C) I on 09/12/17 at 2054 Elect,onically Signed b~ RPT #:09j_2-0667 ***END OF REPORT*** Page 8 of B 2020-ICLl-00006 2779 :.s'~·c·•··l:···m·:·~n. i.n.::::.;... ... :,·:··.:··.:R.=•.'-··'!!···~ ... :o ..,.·.r.tL Co~6:i i~~i~ril1Y:~dtt;;1: ciJf:~::.,.dkr0e:=:~£:: +~eci.P,ir~ctfa#:< 'f?'· ¢A?#~1~9:g:~lli i·.·:i..' ........ ;.i'f~N)!'.l:il~tA:L{•*~·. ~b)(6);( b)(7)(C) ····· .· .:....:. . . · .· ••:~1i:ENT:: RESDR;'j (b)(6),(b)(7)(C) 0912: CR: HO 02 72R :~~~~:J '.:~6: ,(~t~~)::::::,:}: ::1:~%g~;¥~I£~1s····· :•v#..:::~•~·~~! ··. ..................... COMP, Coll, :• : fHl~].'J~ify~i· i@?fo #{\ :)~Eci(:\rv' / . Recd: 09/12/17-2020 09/12/17-2059 . {R~07673BB9) }0:9/1'.2().7/:2105\:· 2.'78 .:·.:-:....... . ::>.::::::::::::: :--::'1:---, .·,·.··· ::;:::::::::: .·. ............ ..·.·.· ..·.·.· f=rr:: so.1-101.1 tL>>:~~1_ :~/: 11 / 105 \< ... QSJ12./l7:f21Q:5 '.,, i :·.·: ..... pg 25.3-35_3 32.4 o,ff:i.:i/it-~to:s.: . ::••::::::::::,:::.::::.:::::=::::::: .. ·1·1' ·:·:·.:<<<•::: ..... 3.6 . 6 32 .7-35.1 '{{\ +•--··•:: ......... . I G/DL ::•::::•==••••••••o:;i•Jii/17:;;;;::iQ,i:;) .. 1. ·:·:·:·:••:•()~112/1?l~;J,;0:~•: ......... I'(}~.-~·····~~~~~~....;.;.;.;.;.;....;.,;. ..,,.1 =~~~~.,.,..;....::C...,..,..,..- %- =··=··=·=,·:·· ...-.,.·:.L...., :::-:-:••·••:• .Q.9-:f 12/1· 7 -;;J.1.0S·:•:•:•:•:-: .«::::r=·=· Ji-'-••~=~=~"'---'--~~"""-"-~CC;: J'--.. _ ____;;.._ _ .~:~:;1~·/i7 ljj_6l····· .·.·. ______, ...JI ·.,,.,:,,. •:•·•:: ••:L:••··•o•~:/?c2/ ;I7l;:J.:of ·..·..·. 69.9 ~F> :~·. .<<<•·•·•• . l •:• •···...... l[- ... ... i . . . . . . . -. :-~:7·=·:.~.~82.:'"~ \' .... MV:J~/:t7lJ\~s .. 0.0-2.0 t 1..... ······ -·----_-_./:\-:-:-:.:.:::.-::\:::: ...:: -·········· i:P:$.)ft~/J J::~iJJt-~)'.:'. ···· . . . . . . . <:=:::=: •::•:):-:~:os#f/17:l+):¢:s::.:: ·•/;t:io:9;;.;:;i.,_:J2;; ••·.·•· l/:::.:._:·.. ••:t:{a•9Jt.:i:iJtl2:1:6.s: ..... : :-::,:::..... %....••}()b ~ Utlf 71 :@qf 0.0-1.0 I /lOOWBCt :2.0-13.'7 ·· •tt:•··•·• •:::::::·••:tt o~Jijii&2::'liS: K/mm3 · ·············:: :nr<:/09.J1.:iiij>:f1.~s<·=-· 00-0. 0. 03 K/rr.m3 :::::::::::: :/{, .··?o~lfi/i:'7}2io)f · ...... t : ·Ft} qf'.11:::9'9f 12/J?/.21:G~\< • ,:::•:•:•:• :: ::::::::::::: 0 · H.i_ 0.~1-0.59 1 ....... _. i ··•=••:?•• ••••••••••A•~1 :2/t%~2:9~/:•••· .. K/mm3 1 2020-ICLl-00006 2780 .. -#EH'.9023b7SJ_s:i s·ite T.es_t ._=-v~riLreo · EOS ff --,._-: I I I BA~9: 'j NRBC~-::_ CC?n.tiiiUed) ··: . 11 ,, 09/12/17-2105 _o_,,oa-o._os ..K)mm3 ·· ··:::::ti-:• 09/J.2/17-2105 I 2020-ICLl-00006 2781 l '7: CR: BC00114.19S Source: > RES, Coll: 09/12/1 BLOOD IBLOOD CU--~TURE '7~1530 Recd: Deoc: 09/12/17-1619 (RJi0'?6'73570 (b)(B); (b)(?)(C) PERIPHERA:., I Pf$~##r1~fy: o9 In/: NO GROWTH AFTER 12 HOURS 2020-ICLl-00006 2782 7 - 04 19 -:-·........... :.:-:-:-:-:-.:. 17:CR:BCDD1142DS Source: RES, Coll: D9/12/17-1530 BLOOD Recd: Desc: 09/12/1'7-1619 ..... -:·.·.·-:· :·.·.·.·.· 5 l(b)( ); (b)(?) (C) PERIPHERAL o9 I 13 / 1 7 - 0419 CUL T!JRE-j 1':it~].:;i:ihi~~cy. NO GROWTH AFTER 12 HOURS : .. ·.. (Rj;Q'l673570) .. ·.. . ..~#t!: llcm:z•; Fl!;t;t_p~•••WP•• -------;..;+~~--'-'-'',--'~ =I • 2020-ICLl-00006 2783 . ·. ..... ·.·.•.•,•.•.• . . . :<:':':' ... .·:·,· . ·, ........ . ......... ,•,•.•.·,·. ..................... ,,,,., . $~;¥##~: :1~4¥)iy J•i¢{t ....·.··.·. :¢o~ikfi~!'.it~;~i )j~td:fdE!;t:;;, •:cJhr:b l tt ..... ........ . ><.: :.~fT#(b)(6); (b)(7)(C) :::~~~J)t)cif\ :)\ ft: Elf0(}861:a9(i': ···.•.1 ,»>: )~J):i,)Ji)/o6°4f <<· · ..!-~-...,.,.,.,__..~,....c.,..,,-'--"-~~ ;u\....... I ON 09/13/17 l:fJjibh 'it::;:: .... :: ..:1.•• =:=:=:=:=:=. ... AT 0647 1 ······•••··•• : . \ .::~~:::;\::: / B.LAB.BRD CALLED TO ELAINA. HULL. The :;;,:~i~di'nt:i'fuiiid':6.Y reia 1.i~c:k: 1-1f;;,t}~~i~)f#V < :.iJ..·9·..•~<:.. . .• : 67.6 :=: •=:::: ·.. •==•·=·:> : 1 / ••>>>o~/))Yi1,@,~:i ·:.·.··:.•,•.········ ·.-:::::;;:::::::::::::::::::· .·..·.·.·-•.·.·· 91.5 j ~liib.i- :cfi(fi'( ·1 H I 7.6-10.4 »,>>> ·....·..·. T 3 1. a - s2 . 6 4 H 13 L · •:::• fL :-:-: 't : : }/:;:t;is;fii=tL::i::; oe;,if> : ::: . :1 : .. ,::o:9/13/:t7::.:064:$ •,•,.••: I ... ::::::~::1:: < :1::: . I ! /100WBC% ··············:o:f/i,s!:tt~oi4~ 3 ::::_)l~)):!}1'7:~0l.549:::•:•·•· m3 •:=9f/i3./i1.~:ci:~4-t::••· I 9:Ji~/1-7•~ q$J$•·••·:··•·•··: •··•··:••: Q 2020-ICLl-00006 2784 ··::-. s-.t:~ ', \/~uii~Cl·-- II ": .=:=. EOlf)! :--- H lflf: -.0.1.~:;:p,s():/ffiiri.3 ,,.,. }f·o ,... , =---:-. K/iyim3 09/13/17-0649 ?_-··. -: BA:SO:=·l! . . :-: -:O·,_,()l .· ::=. ;_ ·· 09)13/17-0649 I . 09/13/17-0649 jf__:l'.)0--!f/~·s ·>!J:/mni.3=-=-=-=:-.i•:-:-:- ·[ ,.,.0.02._.•:-· 09/13/17-0649 2020-ICLl-00006 2785 -: ·= · 0913: COMP, Coll: CR: COOll 7R 09/13/17-0420 )?<< 1· .. .. ::::::: 1· ......... GLU ,. BUN 0:9/;i.:1/i? - ()6 5j cai:C:::: I :: . . a.o °L__G0'_... .:-osfo/11:i:o~s:i:::::::: .• • .... j .... .. . 57 <1 .... :1· .......... I 1 09/J:3)1·?,(}155:3 GFR >:::::i:;:<· I The I ): {R#07673571) 23 : ::::( > 09/13/17-0614 Recd: 100 glome:nilar estimated ::=os/J)jj_"jl~f($~/ >60 estGFR filtration :rate ccmputed is using :;:::;:~:~Ji¥.ti!;;:::#.~-1~:;:;;~~~9~)::t~:ijjfiii;:i~~:,~r~:~-~##.::~:9-.#:~ ·.·.•--.·. needed data elements are missing the can not Laboratory :4i:>¥.iiu:fec•••~n::•.:.fb'.¼~:f:i'.9.ii\~t:•cii,,~f::1~~~:hi1.:i:f::tfl.tiit:icb The GFR value units= ml/min/1,73 meter squar~d. Estimated •&iii:=•:•;;,~iiiJJ• ..:C.JJ~}efo•==•1w:~.1a••:fa~:•••t,l,6~.7:piet:~c:i .:~s•••;=s=o, ••:n6ti ...... n exact number . .•.:} " ~' l)R_ri:G: :PMAii.(}@E:kf )/:;;2 : ) / Drug dosage adju~tments utiliz~ •p~f$] e=tfrs.\: ::<:t?/ ·· ::::::::: ············ j ••: I• I 0.81 <<::::::,i ==< ,: ··· ::-:::::::: Results n,ay be depressed : ············ '='·.•.•.•.•::: .·.==: : =.·.·= ,...: if is patient ta.king , ::::+ ••fe~/icil!:itfJ:~#i+~tn:i!f::Jiilili:cr 'a~4 Het:@iii61~.:..•.••.·•.:l•.s=-: ..... ···.·..· · 2. 4 LL ...·>:If<·········· ··•·:: ·;:?t:===:•:=-::·===· J .L ·.· ..·:-::t:..:.::,.:<;:;:::;:;:· 1 BILT BILD > BI:..I \:::::::· }t=::;::·:·····:'./. f 3. 4-5. 0 G/DL 1.2-2.2 El.t{r1 .·.:.:.=.:.·.:.:.·· .·..·.· i ,: :: : .·.·.·.·.•.•:•:-:•:-:•::.:··:• : :::: :: ::=:~)1)::1;3)1t~os$:ci:?::::= : RATICJ :~==:-ir =:.:.:.:.11:.1 INDIRECT ······ ········· ·:':':':':'::·:,:>:] ......... «ci~/))jf'/)~t.s::f// ........... 1.. MG/Df' ~~~n1~~? ... 091 .......... :::::::: :o!l/:i;~:/:L}:'~:!;isf:: :])iIPMi;ih,i\~ =•·····••??\9~/:ij•t4t:;.•~~·$ MG/DL I ··••>? eii/13/tt c (i.~:$~•··:•· 2020-ICLl-00006 2786 sPEc >#! ' ·.·.·. '.-'.·'.·'.<•:-:- :tr::rtJ:t •:I/•X• ALKF••:toT@.):)::).:•:•: ···-········-· 09/13/1 :1:n+:ti3:j:<< I ........·r.1 / ..< . •troR~ .... . .. ..tndi;:,~)ti:i, . oi/13/l •.1.•··•··3·······1···=·•.1.•········· I ...,. ••t]$1il(6tE11¢t/ttts· >:·>1, :•• ::: ./1 «< :=>2'!'RP.CE •4?~-Mtf •,;•••):mii$():¢r~"iC:: ... ••:tJ~~@8?:~·o•7•aJ~:j:·•• :i¢ori.#.#~~c11/ ogffdi:co@~}1f :/~iii~~~···R9#\Fm4~~g • J ... liOR~lAL:.fiid¢i./:ri1••• ,.............. 09 ' = ::f l>TC,RM1l.L: :tnde!x/Di, 09 ...... ...... . ···-·: :N~eH:~_wz:iFE~If¥:--:-:; ... ·. ... ·.·-· ... ·..... ·.•,•.·.·.·.· .·•· ......... · ... · . ...•••>1'.-f:@~,~~f~3~J~3~M&#It#s#ilof.;ii:pl.~◊ ): . i--:-:/--:-::: :--:-::::-'---'--'----'--'--'--'.;..;--:-:.""'"'"~-'---'--'------'"'""• 2020-ICLl-00006 2787 •••••••sp~~i~n::1Jf4ut#:,J ... port:••••••·-•• bkn.io~•\i~~Hi=>i~it~,c:1i~h•• cehf~ii•• 8<,~r:64! ::fk• ·•·:•::i:::::::::i·· ...-.... ~•t.~••::~PNn'.;~IMI'I1'l'.i ~"~• r< ..•~t:cTN ?ii~;;~ i:<~;;1 irci··· i@i i\fco4 ». b~}\i@oa:Krn3 o. ••FI)•:> AASAL •• ... . . •:)({,¢E/~i(•51/:t-! •: . < ROOM::: B ,j;: 1..•• ····<"--'-='""~-;..;..;.;.a~. ~~~b1t/ (b)(6); (b)(7)(C) 0913:CR:CG00DlSR · -:- · · · ODi: />M~:<:/ COMP, Coll: · · · · · · · · · · · · · · · · · · · · · ·::.~sliiA · •6:.•1•. ·••1·•.:'-<.:•.• :_·, ..•,.·.'.•.·•.•:: .••.••·-· · .•··.·.R·.·.·.•. ·.s·.-.:· ....•. •.:·•.~.•. •. •.•.•.=.•.o·.·_.· : --'---'--'--""-=""'-"" <1.... 1 \~o: •tt:::<:•JtW}f/ nit I 4~/if/17>§ =~::..:;;.,.;.~~~..,.......,...,,...,.,---,-,-,-J · 11 . t .. .•>.~ eB.P.i~}i¢ •:~@?Cfl'e .ib':t INR.:i:{.dfpe.tid~r#/•~po~{\:1:ie()iitrti{ii)~ii\\: •·•· .·· 2. G-.3. rl Prophyl~xis / venous throm.boe~'llbo] isrr:, Treatment of ········••??)•·· ·••kvti )1eiiit;#:•lfo:f6¢~hl..i,;ii••••i1li .ifrs c:J§..i:i•· s\#f.4.%~:•pfei/e:Il t:i§n}•··.·•· I Syst~~ic embolism prevention in fibrillation ..··.•Jc::-3:u#t• i31fo6s61=g~6' . f sj12)}{/ ...:~dc:ii<{ f:iciJia :•:•: Bll:D:~:•:•:w:: 17:CR:BOOl..SBOSR So·..i.rce: RES, Coll: 09/12/17-1530 URINE Recd: 09/12/17-1619 Desc: CLEAN CATCH (Rij07673572) .............. ·····-· .. Fakl-.ri,Alifiya . >>:< fuR_rnE: CUL'T~gj i:fo~H~Jna:rf ROUTINE WORKUP 09/13/17-0910 ~10,000 CFO/ML GRAMPOSITIVE 2020-ICLl-00006 2791 FLORA CONROE MEDICAL CENTER (COCCR) Note REPORT~:0913-0215 REPORT STATUS: Draft DATE:09/13/17 TIME: 1024 Clinical PATIENT: RUIZ,FELIPE UNIT#: BHOO861890 ROOM/BEG: B.ICU18-W ACCOUNT# : ~b)(6); (b)(7)(C) DOB: 06/26/66 AGE: 51 ADM DT: 09/12/17 SEX: M ATTEND: MD * ALL edics or amendments must be made on the L----------~ electronic/~omputer document* ClinicalNote Note: Seen9/13 See consult Admitted with GI bleed hypotension DEnies chest pain Tror mildly elevated EKG normal No H/O CAD stress test when H b close to 10 RPT #:0913-:)215 ***EN~ OF R~PORT*** Page 1 of 1 2020-ICLl-00006 f b)(6); (b)(7)(C) AOTHOR: 2792 ~O\'ROE 0913-007:. YJ:rn:C.AL CEt:tl'ER Center B~v~. Tex~s 77304 REGIONAi., 504 Medical Conroe, ADMIT CATE: ROOM l\'C: AGE: PA'l'lE)J'l' NAMII: RlJJ?:, F'R~,TPR ACCOUNT NO: kb)/6): (b)/7)/C) MEDlC!\..:.., !foCORD NO: RH0086183 0 H.EPUR'.? TYH: ffi STORY AND :?IIYSICAL ! I\DMll'l'ING 1:i. IC:T1.8 5' M 5 ~H:ST CTAN ,,(b)( ); (b)(?)(C) AT~ENDlNG _H_$1CIAN: '--------------' ADDEKDUJv:: 'J'O 'f'HF: HISTORY Ccnfi::-:n;,_t.Jon i:'lease SEX: 09/12/17 AND PEYSICJ\.L REPORT: 1/:l.035335 ~n assessment a:-.d plan a±ter CV'I' prophylaxis. 5ep~:s_ The patient has s~gnitican~ leukocytosis with a WHC count of ,~.1, rcna: failure, 1~d thA pat'.ent was tachycardic ~~on ~r~lva~ with a hear~ ratR nf :08. We will in~~ia~e ant~tiotics. We will not give ~l~id liberally as the RNP :eve: was ~ore t~an 400C at the outside ER. We will obtain x-ray and l:iNP :evel Lo rcasse.ss the f1uid status. The ;,at:ent does havte sy:.n?lODS' of vcl·.:mF>. rwl',_rload It h;i.,i hf'.en a pleasure part:.cipating have any quest.:inn8, please c.o r.ot D: eta ten Ry: r b_)(_5)_; (_b_)(?_)(_C_) ____ .... W'l': HP: 8. HIM/PAKA.T,/NTS DD: 05/12/2C17 D'l': 0C./12/2C17 CoY-.ft: 201S,6J/DTD#: ln hesitate tLe medica: care o:::: ~he to call. _, 15:25:01 19:'..-1:35 3991~68 FJ>.Tl ENT }l/\M!,: RUI 2, FK, T P"R 2020-ICLl-00006 2793 pc1-:-.iAnt. :::f you :,l)lz;, ~•t:~'.:..,_1_p_::__.··----~ /\C:C'.T: !rbl/6) /bl/?l/Cl SEX: :vJ DOB: This report NU"'-S; D. :CU4 3ED: B.ICU18-i;; 06/26/56 AGE: is NU'l' pare o[ NOTE: Truncated 51 the pen:12ment A'J''-1 D'< , l(b)(6); (b)(7)(C) ADMIT: 09/12/17 rr.edical rec::,rd arP. p;e<"!A:1?..rt by ~9sults MR: llH808611:!30 t--> Plc,ase 1 process per Consult chart ~ompany for Poi,r:y. entire result. ,i\;_,LERGES Coded A1 · "'rqi.<"S Nr:, Known Rc,a.ct ~on 1111 e:-gies C:rRRRJ\7' M'P.D: C'A':'l ON S MED ------------···. C'ARDEKE-KACL 5·:J MG/250 C:-fRONu"LAC 20 GM/JC ML CHLORLJE 8-9% 20ML R,>.DTO:,OGY Phy,n Cl a~ ' START Y.L 10 /12 10/12 10/12 10/13 C9 /1?. r.9 /12 1 ~ /1 2 l·J/12 PO C9 /,?. 1 0 /l 2 IV TV C9/:2 '..0/1?. ~0/12 PO J9 /'. ?. '. 0 /17. PO PO IV ?R:11 -->Q4R DAILY FRCYI: 09 /12 /1 7 OPD,O.KENLTD REPO~ATU8: MD: 281-2H~ PRK TO: rv lV IV IV IV TV ~9/:.2 09 /1 ~ /1 7 Signe.d 1mpreesion: 1. Markadl y l i ni !_c,d cx.a:uina Li ,::,:c du., to poor bearr. penetra t io:-.. The 1 i ver, :;ral lb ladder, corr,mon b~ 1 P. dur.:-. ~nd pancrcaG are inu.dec.i:c..<1tely visualized on this exarr.ination. 2. Unre:rnark:<.1ble right kidney and visualized portion.Q4E PRK )11, 11".PHESS.:.GNS - T7L1'1:A~o¼gi(6) (b)(7)(Cr by -->Q4H lC ML 12. 5 KG 1~ MG 4 MG lJO MG ZOLOFT Dic;;ated O.24:-J 1COO ':'OP"-OL XT, 7Rfu"\'JDA':13: 7CPRAN 09 /1 ?./17 1.0D Y!L 4C MG w~ IV !J/1.lLY 1 MG 250 YIJ' 250 :J~: r:.~9% 10J0 SOD~UJ\1 I i\SDIR ;:llO BED':'IME 50 M(s 1 MG PR:..J'l'ONlX .DJ,( 7.5C M!i JO MT, RO:JTE ------ FOLV:TE LEVAQUI~ 5~0MG/108ML MORPHINE SLFATE NORi'l1AL .'JAL:i:KE 250 ML NORMAL ;;ALlNE 250 ML CHI SIG/SCH -----~--------~~-------- -------------~m, IV DESYREL SODTUM :*D = Dea::::ti va':ed IJ:JS!,; 8.9 H 1:i.1 REC L 2.79 L J.SO HGB L 9.D 11. 2 2020-ICLl-00006 2794 09/U lC/12 lC/12 09/13 1~/12 C 24. 6 S 8. E MCV MCH 32.4 RDW RJW-SD PLT " s 17 .2 lMM CRA:;J % H '. 9 LABORATORY INFOR.''lATION 09/12/17 20:20 *L 27 1 [i. J 6'.c . B L 11 -4 MONO% H 11.9 EOS !'; .8 DASO% 0. 1 )[REC% 0. 8 # GRAD :CMM GRAN 6.21 -ft LYMPH -ft 1".CNO # f BASO if. KRBC# JVJ.JI.NDIFF NEEDED TOTAL CELLS SEC H 7 2 ?RON:: 89/:'..2/'...7 1~:30 LYMPH % E O 4t, 09/12/17 0.01 :I O. 07 'l'O: 800C. 09/12/17 12: 0 8 ::.82 H . C • U. 2:0 J. 0 E H 0 2:i -->!½AN ClFE' 100 7J ~•YMPH L 1?. H 14 EO~ 1 H I HYfC SL.lC.E'l' SL.lCH'l' POlK ST,1Gcl'I' AN/SO SLIGc!T FEW OV/\LOCYTES SCHI STO TOXIC 8E.ANTTI,A.T A.CAN':'.'IIOCYTR$ PLT EST PT.'f MORPH '.'.'.OAC~'l,A7f0'J PT PAI l~N'l' H~R F'l'T CJ:lP.MTS':'RY 02J6 11:55 MO~TOCYTE NREC POLYCHROM 09/U/1'1 09/17./17 L 12 .1 H 12 .7 1. I 0 .5 H 1 ./ 11 9. g_:: 11 1.06 1-01 E 1 . 06 0. 1 6 1 E 49 55 H 11.::. 69 . 9 MCV ECS ]2 0 H .17 . ?. H 3 6. 6 11 17 .2 11 50.6 .MCHC 30 .1 S6 . 0 L RARO s::.,rGHT RARE L MRK DECR LARG!l RARE H 17. 3 1l 1 . 5 /. ;:9. 4 NA. 133 . 0 4. 2 :02 K CL CC?. '4 2020-ICLl-00006 2795 GAF k'./ION '. 0 GLU H BON " L 55 II 1. 3 6 L 5 .4 GFR CR.EAT T . .l'HOT L 2. 9 ALB A/G CA 132 H 1 .2 li..ll.'110 II 6 . 5 6 II 3 . 3:': H 3 .2:.. BILT BILC BlLl HJUiH.l::C'J' E AS'I' 10, '":'CTA~, .. E 9C-.O H 226 .Y:9 H 4. 9 'H 0. 2·10 A.>m RIIC CKMB 'TROPI -->2 -->., INVEX HEMOLYSIS INDEX IC':::'ERIC T.Lis repu.::-t ls NO'l'E: ·1rcmca•_cC. NO':' parl :::-c8ult.s or are lhc pcrrr.anent. prece.:l.e.d :.ABORATCR.Y I:-JF03.MA':'ION 09/12/17 2·J, 2 0 medi~al by'-->'. re.cord -process P:e.ase. Cons·_;lt FRCM: 09/12./17 O'J/l"J./'...'f 15:30 1 '.,: 00 tor chart TU: OOJO 09/12/:i 'l'H/\.CI:: SY.ALL 02.'lC NORM'.AL -->NonReacti >NEG NOt:RE -->K"onReacti lGM: NR .'iCVAl:l V' L,.·, Signs OS/13/17 02:00 F::l.OM: 09/12/17 OOCO TO, 09/13/17 0236 C9/13/17 09/13/17 D9 /12/1"1 C1: CO 0 C: OC 23 , 00 Temp F Temp C Pulse 59 64 Fesp 13 n B/P, S?02.!', 96/5 87 /SJ. '.14 09/'...2/'...7 22: '...O 75 38 99 /5 5 97 3 " 09/12/17 09 /12 /11 :C:2: OU 21: 4.5 O'.!/l"J./17 21,30 2020-ICLl-00006 Policy. enti;::e 09/13/17 09/12/17 11 : 55 -->1 Hl\VMJ\B HBSi\G 1 pe:::- Co:npany INDEX LIPEMIA EEROLOCY /-il:l CCKI:: 8C " i\.L'.L' ALKP e L 7. 2796 .::-esult. Te:tip 7emp F :::' Fulse Resp 1S B/r: 6S G4 16 1C :6 98 97 G [) /5:l sron 9S 97 09/12/17 21: 1':> 'Temp Temp 63 89/17./17 09/12/17 21: Cl 2::.: F C JO 77 29 9 2 /66 93 95 67 17 Pulse Resp E/P: 83 S.?02% 09/-:7./'.7 20 ;J 0 'l'emp F Te.u1p C E-''J.lsc Re.up 66 13 09/12/17 09/12/17 09/12/1"1 20:15 20:00 1':! ,45 68 68 15 Ge H 69 44 1C6/56 R/P: " 95 SPC?'a Vital FROK: 09/n/l"I 09/12/17 19:-, 0 Signs C9/12/l'f ::_9: 3 6 Temp 7 Ternp c Pulse Resp SP02% ~008 TU· 09/17./17 09/lJ/17 58 ,, 27 17 96 n 98 09/12/17 09/12/17 18, 4.'i 18: J 8 'l ernp I:" Tc'-1:,p C Pu.:.i?e GB Resi;: n 09/12/17 18:30 69 17 111/SS 98 C9/12/17 -~s:16 9 E. 6 9 8. 2 JC. 8 76 72 '/1,. 17 26 18 :01/Y;, ~ 1G1/55 B/.E: SI'02% 07.36 09/:2/:7 '..9: C0 19: 15 67 JO B/P: Terip OS/12/17 20:45 oc. 09/12/17 09/12/17 09/:2/::.·1 1 8: 15 18:00 17:35 . [} :oo 9' lC-0 "/ 09/12/17 l '/: U~ F 2020-ICLl-00006 2797 ~ '::'emp C Pulse Resp 20 2ir: 10 Temp Temp 09/'...2/'...7 15: 00 1:.1/:,':l 99 98 09/12i17 14: 47 09/12/17 14,30 SC 117/~9 97 SP02% 09/12/17 14: 1':J Tc,up F 'j'C,,np '.'. E5 ReEp B/P: SP02% , 8 C-9/12/17 :.::i: 4':J 88 19 117 /5 8 97 09/12/17 C9/12/17 '...2; 45 NO'l'J:;: is '1'rUJicalc,d NO'~' p"lrl rcsu~•.s o:: a::-c '1 er:ir: C . " 1S lC-0/SS 96 113/S7 96 Lhe peIT!la:-.enl. prc,ccdcd rnodical C9 /17./17 09/12/17 1 7.: 01 ---------- 96 OJOO ':'O: 'J9j'.c2/:7 per Corupany charl 09/13/~7 for 8 7.3 6 1' : ~ 8 ---------- le enlirc 09/12/17 ---------- 97 97 16 '.:.18/SS 96 11 :115 , '9 , n -proceos '1 G 8 1311/E:C "7.3/58 record lc''...cc.Tc c.'onc:ull by'-->'. FROM: 96 19 "'" Re Rf: 09/12/17 12: 3 G 16 ---------- 11e 15 i 1J /5 8 97 9, , 1 2 : 1 '.c a 87 14 82 Vl tal Siqns 09/12/17 'Tenp 84 9o 97 SP02% 1 J: J 0 ---------- 96 13, 00 108/57 09/12/17 114/55 13, 15 B/1': 96 ---------- 09/12/17 Temp F Temp C ?ul,;e ReGp repc,n. '.00 09/12/:.7 11.1/.59 96 'l'hic 118/55 14:00 ---------- .t'ulse " :a 1E 116/56 % 29 l:'/F: SP02% 21 '...11 /':J~ 9 8. 3 F C I"ulse ac"cp R/f-: 18 99 09/12/17 16:00 74 73 :../:i:, 98 SF02% G. 5 73 2S 76 114/5~ 99 2020,ICLl,00006 1 00 '1 , 7.?./C,e Te:up Te;;op J'J/:2/:·1 09/12/17 11, 00 FF.OM: 09/12/17 10 C 100 0000 TO: 09/13/17 0236 93 4E '...81/10·1 1 oc 2020-ICLl-00006 2799 =/0 INTAKE IV i/:1: lV);'.:ls IV #2: #3: ::3ld ?::-odu:: TOTAL oUTrUT 0700 ~-RCYI; - 1500 0?/12/17 1500 r.e. ·l'OTAL TO: 23 00 C:9/:3/:7 C-70C 0700 U700 - 1',00 1500 - 7.300 9 00 HS TOTAL 75 5?.0 23 00 - 0700 1565 24 llR TOTAL ,oo 900 9 00 ------ F::.,UID BAf.A'\JCE 24 825 lUU '5 100 '5 75 520 1565 :v J_rj 0700 2300 825 6" ----------~ 2020-ICLl-00006 2800 65 0912 0324 MEDICAL CENTER Center Elvd. ':'exa 1a1 '/"/3 0 4. C:ONRo:,: !i.l:JIONA:... ~n/4 Me~ica: Co:-.roc, PATIENT NAME: ACCOIB-n' NO: RUTZ, FFT HE l(.ED:CAL REPORT' TYPE: EISTORY ~9/~ 2/n ADMIT DATE: Vh l/ R\ · /h\ /7 \ff":\ l RECORD NO: RHCl~.ifi'...89C li.00)! A::ID PHYSICAL ~!O: AGE: D. ICUl 8 SEX: I( 51 (b)(6); (b)(7)(C) AI:Y.!ITT:~G ?IIYSICIAN ATTE~"'D:NG ?HYSIC::-Ali ADMHlSICN DA':'5: 09/12/20'..7 PR:MA.;i.Y CA.RE ?IIYSICIA'.'J: C.:HEF C::JM?LAINT: 'The palicnl NO"'.P.. is frc:r1 immigration jail cent-.f>r. :1e..-nati:m.es '- 8. H:~TORY O!' PRESEl.'IT ILLNRSS: Tte palicn::. ~s a; :.1-year-old l!isi;:a::ic Jncarr.P.n.ted :nale,. who was t.akan t-.<1 Liv~ngslon Memori.,_: Erae:c~ency Rocm with co:T1:::,l11ints of .;.bdomina.:. pain, :eight "lank pil.~n, _, and hern<1terr,esis. IIe .r.as a past. merHcal history sig~i::can'fnr no~alcoho:ic l~ver c::.r~hos~s, gene~aii£P-'USCUT.OSKBJ,ETAL: Speech appears to be c:ear. J.ARORATORY AKD :JIAGNOS':'IC !JATA: From =..ivingston ER, soc..iun 12·/, potcts~ium 4 .3, ,,ON 85, ;;nn c.,..ea>::in'ne 1.5. Albu:n'..n c.ecrea.sed :.o 3 .3. AS':: 1J2, AL':' 6e, A.LKP :23, and ~otal bilirub~n '...0.8. CPK e:evated at 322. L:pase mildly elevated at 367. BNP P.'.evated at 1B5~. PTT 2,.1. ':'i:opon'.n I 0.07E. WBC 14.28, :t-.emoglobi~ :2.s, hematocrit 33 .2, and. platelets decreased -:.o 18. ASSESSMR:-J'T' Al\,T- P~.AN: A 5'...-year cld i~.ca.rcerated Eis;;:,anic ;::iale iv~-:.h hls-:.ory of r.ona1coho1ic liver cirrhosis, now presents with: G~strojntestina: bleed.. Cifferentia.:. d.'..agncs.'..s could be variceal, eso~hageal, or gastric t:leed.'..ng versus pept~c ulcer dlseuse vers~s ~astritis. The p~~lent :1as been started on octreotite drip. ~e will also iLitinte IV PPI and monito" ~emoqlobin/hernatocr~:: levels, so :ar are stajle. GI con8ul~atio~ has heen req'.:Ast.ed for evalua-:.ion of possible EGD. , . R i qht uppe:c quadrant at:dorr.i:-.al pai::, We wi 11 check t,epat 1th i,;a:!e 1 anatier.-:. is on Cardene drip. Lhiinopril was init:.c1.t-en. ';le wi 11 t'.trate medications as needed. We wi:l discontinue 1 i si~.opri :1 in view cf :?:"ena: :::ailure and ir.it.iate be::.a. !::locker in Vi<='w <..0£histor·y of 1:.ver ~~rrr.osts. 'l . r:;T a ncl deep vein thrornbos is prcp'.::yl ax:. s to be achievec. wi tL Proto::ix/ SC:Js , Unab:e ~.r. r,i Vf'. any hl ocd ttinne:::-s due to active gas-c:::-ointest:.nal b:eea.. C.ase disc.nssF>:"l wit.'."-. t.·ne :iatient, the gua:?:"::.s, and ll hac1 bee:-i. a ,:--,1 ;,,a ~u,e part1 ci ;ia t'. ng in the :nedical have any q-_iest'.ons, please do ~ct hesitate ~o call. t:r,e RN i::-. deta:.1. ca.re of the Fe..tie:::.~. (b)(6); (b)(7)(C) IJicta-.:.eu WT: ~r,: By ?~:R.HTM/FAKAT /h'TS S9/12/20:7 15:22:'...2 ACCOUJ',,""I #: i/h)/n ) /h)/ 7)/C:) 2020-ICLl-00006 2802 If you rnnft/: ?.035335/:JJD#: PA'TTRJ\""1' NAKF:: RU:z, 399104[1 FELIPE ACCOU)IT /1: 3H5D2J0'/8383 2020-ICLl-00006 2803 ~alicnl llr.i t No: R~IZ,FELIPR ~ame: BHOJ8(189 J CPT CODE: ~XMtS: 020697791 7 57 05 US A3DCMEN ~,Tn si~e:R16 Li:ni ~ed Ab<'.ornin;; 1 lJJ :-.,a sow:a Hislory: Right l j vf.'r r.:\ rrr.osi C.o.npa.ric;Gn: upper s. quadrant. Nn p:ricr siT'."dlar ~'indings: ~his exa~iration ~hP. liver 1s markediy is measures 15.2 limite-e.:na..-J<-a h 1 e.. Jmpre.ss4 rm: 1. Marked:y limitefi e.x11m1nat.io:: tue. ~o poor bea:n pe::etraticn. 1 i ver, qa 1: h.1 adde,_, col'.lmor. bi le d"Gct and pancreas are inadequa vi~ual~zed en this exaninil~inn. 2. unrf'.rnarfrnr.le. ..-;qht. '.dc:ney 1o:-.d ·-risua~ized port:ons of the acrla and :vc. "* El er::~.ro:·•_j r..; 11 y Si qnea 6 hy r b)( ); (b)(?)(C) Reported and siqnec: Ion 89/12/2817 by l(b)(6); (b)(7)(C) at 1989 ~he te:.y abdorr.inal •* r b)(6); (b)(7)(C) Wl •~•cc'>-:nc,lcq~si. : (b)(6); (b)(7)(C) Aqenr.y ':'rnscrb~ ,,,,,,,::~l:t~::::;~i~t; -~ii·J!ii~t~ni;~itt~ ~ ?.~\t;f~}~/::tt:~{ii:~:W\.I!~ ~: r:·:1\:;::~-~l~~i11t~r:1~1:{1t:)~:::2i~::i~ti!Jt [hf:r±~j~-~jf !Z:[·~~!f; Qi~~:g[:i\{ f-~ 1 H~if ~j{;;:0:0. 11ti~iiil 11n iitti~HgJ]ItirntliiigJJli mm:mtJmMr:tl1ti:~;:\\Fttt:i1ttzrrrn }t~ll'itJ~1:fM!t:t•i:i'~:wl:q:; :*{~[~:i~},1J!1iim111:§:~;, \1IiHI 1 1 :,, MCIIC . . . 1 34 . 1 . 32 . 7 - 3 5 . l G /DL C~i~ic~J v~lues after the first occurrence are excluded from ·:fIT\~::£:~~ :~f/f:i~~~~~~-~~7I~~rf l~,1~ ~"itt}¼!: Jf~~:;~:~f~~~i?fi~ii@!:-iti!:i1fl,t-jg,I~~~~H.~ii[!it~J.Jtt ~i'.'A~#.~::tefl~~:~f~~t~il~~~:~ .. ~nmr: i!KHm~v!.rt;rn;htJ!@itittiHtllrnl1?0::'i.~~:~iR;if\;t;1r;;t;tti;'.:ji\~:~.,;:;;.~~fi,?t])fil£it I , , o.9/i4/1?-os42 I . 0,114/17-os,2 I . 09;1,111-os12 ::::::~::::::::::1::::::[;;:i :::~ii! 1 ! - . · ~:::::,:::~::::~;:;:::~:::~:: 09/l4/17-0542 t~J; rl\fi~~:#@fti\~::[ffI1rn ii:i~mtim::mt: J11f·: mn1;ii~;1n:01~;y;~irii?$_:a~1r12nn11tsm~m;(Ot/t~tt!}tlt~@f@f¥~ m%t!~{1{:;~1'1illi 0:trti~ {\g@ 1 . · - [ · 09/lt/17-0542 i~EitH~~~'{#)g{ffrntPm1tm}rn:)rn:J,:rstiEtUUM%MtE%J\);~j~;,jJfi~~Mt?itl:fm\t'i-Jil~Iit~ i1i1)!j@\\i{Z®;{_$.J;:;t~~~ 1 I 09/14/11-0542 202Q-ICLl-00006 2805 :;;:;,::;~;;~:;;;;J::~;;~;;~;;;;~:~ }if~ti~ti~~dij_@tl·!ff:LII@};¼Uiif0hi1t,~'.;f~f/1;@m;rn:;gJnil]/plt~:~\)i\:mt~i::;~:@?rng \H'. Hi)i,~:~:~:~\f~N';'.p¥lI~{Mfuiil~''J: 1 I · 1 09/14/11-os,2 ,r 2020-ICLl-00006 2806 CONROE REGIONAL MEDICAL CENTER 504 Medic~l Center Blvd. Conroe, Texas 77304 0913-0070 PATIENT NAME: RUIZ,FELIPB ADMIT DATli:: ROOM NO: ACCOUNT NO: f h \lR\ lh \17 \lf:\ 09/12/17 B. ICU18 MEDICAL RECORD NO: BH0086l890 AGE: 51 REPORT TYPE: ENDOWORKS R!PORT SEX: M ADMITTING PHYSICIAN ______ (b)(6); (b)(7)(C) ATTENDING PHYSICIAN ._ Indications: MD _. Her:iatemesis Consent, The benefits, and informed consent MO (578.0). risks, and was obtair.ed alternatives from the to patient. the procedure were discussed Pre-Sedation Assessment: Hand P completed, I have examined the patient on this date and have reviewed the medical history, drug his~or/, and previous aneslhe:;ia experience. Results of the re'.::evant diagnos-:.i'c studies have been reviewed_ Planned choice of anesthesia, risk, complica~ions, benefits and alternatives have been disci...:.ssed. Preparation: throughout EKG, pulse, procedure. pulse the and oximetry, Ar. intravenous line blood pressure was inserted. were monitored The pat~ent waG :{.ep-;. NPO. See anesthesia Medications: Procedure: The gastroscope visualization The scope good. and Hypertensive and antrum. was passed through was Sent, None, unJess Entimated Blood Loss, Insignificant. Jnplanned Events: There direct the duodenum. The views ~ere noted. othe:i:wise were Summary: Normal proximal a:1.d distal third of the the fundus, body ot the and 2nd portion. no unplanned event3. third of the esophagus, ~iddle third of the esophagu3 esophagus. Hypertenaive portal gantropathy was found stomach, and antrum (572.B). Patchy erythema in bulb ~ecommendations: Avoid all non-steroidal including but not limited to Aspirin, Return to floor. Resume low salt diet medications. PPI 20 mg daily. Care Inquiry (PCI: ACCOUNT OE Database l(b)(6); (b)(7)(C) 09/13/17-1::21 b~ .__ ____ 1 in anti-inflammatory drugs (NSAID's) Ibupr~~en Advil, Motrin 1 and Nuprin. 1 as tolerated. Continue cur r ent PATIENT NAME: RUIZ,FELIPE Run: portion of examined. Esophagus: The proximal third of the esophagu~, middle third of the and cijstal t-.h.ird of the esophagus appeared to be normal. Stomach: portal gastropathy was found in the fundus, body of the stomach, Duodenum: Patchy erythema in bulb and 2nd portion. Specime:is Patient the mo·.1th under advanced with ease to th~ 2:id withdrawn ~nd the mucoGa wan carefully was ~indings: esophagus, report. ~; ~b)(6); (b)(7)(C) COCCR) ~ . _.2~0O-ICLl-00006 2807 Page 1 of 2 By: The procedu1e As5isted Procedu;i:-e Codes: Version 1, 07:42 AM. [43235) ~as EGD electronically by N/A. assist~d by ::1igned I J b)(6); (b)(7)(C) ________ ,_ __,~.D. a.t on 09/13/2017 (b)(6); (b)(7)(C) Electronically Signed by on 09/13/17 ~--------' ACCO'IJN'T PATIENT NAME: RUIZ,FELIPE Patient Run: Care 09/13/17-11: I~quiry (PCI: OE Database 6 2 1 by,_l<_b)<_ l_; _ (b_)(? _)_(C_) __ · at 0742 If : !(b)(6); (b)(7)(C) COCCR) '4!'41 4h'I 2020 IGLl-00006 2808 Page 2 of 2 Patient: RUIZ,FELIPE Unit#:8H00861890 Date:09/12/17 Acct.#: BH902307B383 - eotassium (3.5 - 5.1 mmol/ll Chloride (95 -105 mmol/L) 4.2 102 24 7.0 67H 1.36 H Carbon Dioxide 1:21- :12 -i-nmol/L) Anion (iap (4.0 - 15,0 GAi-' ca1C) BUN (7 -18 Mu1Dli Creatinrne (0.5.5 -T.30 M(;/DL) c ,lomerular ~Iltr tc-ite 1> 60 est, , r-KT ---,,--r f--t:-~ucose(70 -110 MG DL) 132 H 7.8 L alcium (8 __ 5··:-10.1 M 11DL) Total B111ruoin(0.00-1.00MG/Dl) Direct Bil1rubin (0.00- 0.30 MG/DL) Inc ifP.ct Bilirubi"n (0._~- 1.3 MC.j/l)_L) A, (15 -37 Un,uL) AL (12 - 78 Un ii/LI Total AIR Phosphatase(45 - 117 Unit/Li Total Protein [6.4 - 8.2 G/D11 Albumin (3.4 - 5.0 G/DL) Albumin/Ldobulin Ratio (1.2 -2.2 RATIO) h, ...h H 3.35 H 3.21 H 81 H 49 -- 107 5.4T 2.9 L 1.2 Specimen A~~earance "'{1 NORlvlA~__!_ndeX/UL)__ } ~MATT ~-10 M(, S~ecimen Hemolysis (1 NOR/v\Al Index/DU Laboratory Tests -- 2 TRALE 10-25 MG 09/12 1200 oae:ulafi0n PT (9.4 -12.5 SECOND\) INR(0.85-1.11 INR Uni\) ~-PTT (Dade) (24 - 37.7" ~-- LAN) MRK DELR L Platelet Estimate (ADE<, OATE ON,CAN) nt rpholo_gV-< 102 133.0 4.2 Tests 24 -b-9/l'.2°--09/12 09 12 1530 15301 1530 Chemist Ammonia (11.0 - 32.0 m --LR= --=rra 90Jf*H -2 ( 1 .0 - 3 .6 4. 9 0.2 70 * H (o.ooo B- a riuretic Pepti ML) 226.59 H 09 12 11551 1em1slry :--SoaiumlT33- 144 133 .0 mmol/U Page 2 of 4 2020-ICLl-00006 2811 1@~~132H.,. ~ CONROE MEDICAL CENTER (COCCR) Pulmonology Progress Note REPORT#:0912-0575 REPORT STATUS: Draft DATE:09/12/17 TIME: l7l4 UNIT#: BH00861890 ROOM/BED: B.ICU18-W ATTEND f b)(B); (b)(?)(C) PATIENT: RUIZ,FE~IPE ACCOUNT# DOB: : !(b)(6); (b)(?)(C) AGE: 06/26/66 ADM DT: SEX: M 51 AOTHOR{ 09/12/17 * ALL edits document* or L-------------__J amendments must be made on the electronic/computer Subjective ChiefComplaint: RFC: GI blced/lCu management. Objeclive Physical Exam VS/1&0: Last Documented: Rr.sut: Date ow I me 09 12 1600 0912 1447 Tern 98.3 Pulse x 100 0 2 Fl R~a~te-+-- 2 ·s P 11 7 58 Pu se 88 . 09 /r 2 144 09 12 1400 09112 1400 ··19 09/72 1400 Resp Medications: Active Meds + DC'd Last 24 Hrs Folic Acid 1 MG DAILY PO Lar.tulose 30 ML BID PO (CKD) Pantoprazole 40 MG Q12HR IV TraLodone HCI 50 MG BEDTIME PO Metoprolol Succinate 12.5 MG DAILY PO SertralineHCI lOOMG DAILY PO Sodium Chloride 250 ML ASDIR IV Labctalol HCI 10 MG Q4H PRN PRN IV Levofloxacin 100 ML Q24H IV Morphine Sulfate 1 MG Q41 l PRN PRN lV Ondansetron HCI 4 MG Q4H PRN PRN IV Sodium Chloride 250 ML ASDIR PRN IV Sodium Chloride 1o ML ASDIR IV Sodium Chloride 1,000 ML .QHH20M \V Lisinopril 20MG DAILY PO (DC) Nicardipine/Sodium Chloride 250 ML ASDIR Page 1 of IV 4 2020-ICLl-00006 2812 1~;~! -:--:... •.·,•,········· :·:·:·> ::;::::::-..... ·,·,·. '.{:}\ Ifhtf.... FELIPE•>< > {fo{//}:?].tU} (:>::::<:'.: > <6t>; ::~sll.L• ) ::;Adm )t~~P~ lb)/6) /b)/7)/C) . . COMP, 0912:CR:S00025R 09/12/17-1530 :::::·:·:··· . .-·... :_:::::: ....... _·_: '.:i.~c:;.tr#:>:~ttobs~ieici•: hi/i:o~/.12411>/ x: s1, M .................. ••·llqoit ==13·.::i:ofaa.• •Aorit:: IN) j<: Coll: :.:-:-:-·-:-:-.-: :-:.: :-.<·-:-:-:.:-:-:-:-:-:-:-:-:-:-:-:-:-:-:..:. -:-::::::::.: ..;:;->.. Recd: 09/12./17-1619 (Rl!07673575) SCREEN I ·•••·••. :=i:i:::i/i2/:('i:~1'i!i:<:i:>> .•• •:~j:::112.J~;.;111 8 ·.·.·.·.·.···.·.. ·.··.·.·...•.•·•=:•••••• =•• .SCREEN •·•······ •·•·······••#W12 l;'l@)::•·· .. SCREEN #J::, •·=:•::%H;~:E_--'-'-'.~---a-'-'.~-....,..;_~~ 2020-ICLl-00006 2813 CONROE MEDICAL CENTER (COCCR) Clinical Note REPORT#:0912-0490 DATE:09/12/17 REPORT STATUS: Signed TIME: 1522 UNIT#: BH0C861890 ROOM/BED: B.ICO18-W PATIENT: RUIZ,FELIFE ACCOUNT# : OOB: kb)(6); (b)(7)(C) AGE: 06/26/66 51 SEX: M ATTEND * ALL edits or r amendments must be made on the electronic/computer document* **See Addendum** ClinicalNote Note: 2ms:-us b)(6); (b)(7)(C) n 09/12/17 at 1 522 Electronically Signed Addendum 1; 09/12/17 1524 by 6 (b)( ); (b)(Y)(C) '-----------' 203 5363 Electronically Signed RPT )(6); (b)(7)(C) AUTHOR: AD~ DT: 09/12/17 7 5 bi..... ___ _.~n09/12/17 at 1.17S #:0912-0490 ***EN~ OF REPORT*** Page 1 of 1 2020-ICLl-00006 2814 t FAX: o 3,0 -~ )(6); (b)(7)(C) ~ FAX: Nane: Pa-::.ient EXAMS: C2O69779~ ,cJc:.ad on: x-ray CLIN:CAL Corrpar1 -' (b)(6); (b)(7)(C) No: C oHC0861890 eE•"l' C.OlJ'::: 710:.0 1 V T 18 exarr., HISTORY: son :::arr.pus: U!:it RUT7,FRTTP8 XR (;HEST Chest c-r. ~0 9.,6-'iA exar:is: AP frontal pro-je:::t:io:., T.euimcytosi !l, tJone of the 9/J 2/2rl:7 TC.U piltiA:,t .. che!lt-. Eleva-::.10:1 t'.~.e riq".t r.P.m'.niaphra(Jlr, ii.ffic;,:lt. to assess in terms cf qive~ li'!r.k of prior ex~ns. Probable ccarring versus a-::.e:ectatic changes rr.ai~ly at: the r'qht J·.:nq hi'!!le. No i'lctive ~•:-rl-'. Overlying 1 i nP.;; nh;;c;11re tetail. Ne findingo c,[ high concern for p::eun-onia w• F.Jectr,:rically ~'.qnerl hy ~b)(6); (b)(7)(C) on 09 /12/_2_0_1_7_a_:.._1._7_2_6 _________ w* Re:iort.P.rl CC: anrl f"'.gned by: •-•-- _l (b_)_(6-);-(b_)_(7-)(_c_) ________ _ ~ (b)(6); (b)(?)(C) tic-::.ated 'Jechnol Da t e T'me: 09 1~ 2~17 :-ic,is (b)(6); (b)(7)(C) . l(b)(6); (b)(7)(C) by:. 7ranscri~ed~n-a-t-.P.-_-T=:-rr-,e.-,~~~~........._/ (1726) r. r;q Pri!:: D/1: S: 09/12/20 :. 7 :1729) -------- CO~OF. MED CTR I~/U3S Nl\ME: MED::.CAL D1/\GDJC -~ 0 I'., J'cKlI CJG '.~EN'l'ER 3::..VlJ PHYS d(b)(6); (b)(?)(C) COJ\ROF:, PH~NE #: F'AX #: PAG: agc 1 'fF.XAS ~GIZ.FELIPE DOB: 06/26/1966 AGE: 5:. AC<."~' NO: (b)(6); (b)(?)(C) EXA.'l DATE: 09 12 201'1 77."l 04 336-53S-7026 9'.lfi-5~S-76A1 RAD !\Cl: "igncd SEX: M LOC; 3. I ::Tl 8 W STATUS: ADM :N DC Dt: Repor-::. 2020-ICLl-00006 2815 Fax Server 9/18/2017 8:35:47 AM To: 1st F'ax: 9193696'18846 E'rom: CHKR PAGE A-nobody Phone Pages: IMNET/EPRS 45 (including fax banner) n=,quest. 2020-ICLl-00006 2816 1/045 Fax Server Fax Server 8/18/2017 8:35:47 AM PAGE . ,_ ··,~·. .·.--. 2/045 Fax Server ,-.....--:--1, , •.• ' .1-. 0 ""'fCHI St. Luke's Lufkin ,,J: Health. Livingston □ MEMORANDUM OF TRANSFER San Augustine SECTIONA (To Be Filled Out At Transferring Hospital) ----------'--------------------I. Nam(:of Hospital: ,---------'~-~-------------~ 8. I furtherhave determinedthal lhe patientwouldbenefitfrom transferto ~,ia- Address: anolh~lh '--· HI St.Lukc's~ealthMemoria)L\vingst Ph~ne Numuc,.. . 1717High.Qy59LOOpN Pat~cntInformauon(!f,kn~wp) , iv~:riosto Paucnl's Full ~ame: ~~-G'? ~~___:_2\] Address: ~~\Q(~ :E ~ ___ 2. Cw\.\¼!. rzber: (~ Of\ ,t Phone s~x: M . F Age: Na~o_nalorigin: /9]¥1!,'.'G Race: Rehg!on: 0 .. ''Pliysical HllJldicaps: - . 5/ , f\ ,spau , \( _;e, _____________ ' 3. . SpecialtyCare for patient'sconditionnot availableat lhis institution ____ Hospitalbed accommodations al lllisfacilitynot available k::::,, Patientand/or familyrequest __✓ __ Patientwouldbenefitfromhigherlevelof clinical cm 1 furthc:rhave dclcnninedthe risks and bcncfiliof Lransfcranchave explained these to the patic t. These~ as follows: Risks: 1'-A;. _ ·\/'--------------------Nclitof Kin infonna~ {if known) 9, Acee ting hosvltal~ured by transferringhos ' 9 t I 2:-J17 Date: Ne~WfKin:---;;;,JI--------------Address: ::-4! can: facility due lo the following reasoning: ____ Time: N (b)(6); (b)(7)(C) ¢ IO. b)(6); (b)(?)(C) 4. 5. 6. 12. N Address:-~~r-:-7#''=-i.-"-~~.,__=.a....,_.,,~~.,....;~=-_,_, 13. 7. Transfeningphysician's-s-:-ig-n.-,at11::--~-;:: b:::: )::; (6::: );::: (b:::: )(:7= :::: )(C ::::: )======:;-~d-;-er physician•,orders: · d Addrc..s:-------=====c:;:,:;::;":;;: r,gsto __ i:.;::::;:::, 4;:;,;;:; 0.=:,q;:;:;; 11;;:; 11;.:,==-- PhoneNumber:(__J _____________ 14. Attachments: X-Ray__ ~Y..,.,y.,....·=MDProgressNoles Nu~esPro~s Noles.__ Lab Reports--~~;t.H & P __ _ __ _ M&lica.tion Record Other. __________________ -~X~,,---'?,._,. __ --~y__ __ _ ·rBYsICIAN CERTIFICATJON:IBased upon the informationa~ailablcal the time of th, (b)(6); (b)(?)(C) aP.propriatemedical1reaunen1 at anothermedicalfllciliryoutweighthe inc:easedrisks of the , ,tbeene,-aminedand is detenninedto be: ,S1~ble.;.\ (J Unstable · PhysicianSignarure:_________ ...,..____________ nablc cxpecledfrom the provisionof of labor,the unbornchild. The patient _ J'ATIEij;r,CERTIFICATION: I1,the undmigned, hereinafterreferredto as the patient,ackno\Vledgethat the physiciannamedaboveh~ explainedto me rhe risksand bendit.sof-'atransferLOarmlhermedicalfacility.! furtheracknowledgethat I have an emergencymedicalconditionwhich naslhasnot b~ensiabilizc:dand that the medical benefitsof the transferoutwdgh the risks.I herewit . facility,and herebyconsentlo the releaseof all 11.ppropri~medical recordsav~lable a.1the timeof transfer,to the recei b)(6), (b)(?)(C) ~ ~ J Po1tienl o i--- __________ Dateflime ~~ Date/TIme ~-----------I. ·;_.jjJ[ · · . ,.. · P-........-Tl'lll!'"._.,.......,.,...-.r.,.....TTTJ0'7T'"l.,,,,r-n-r-.7..,,.ei ving Hospital) - ------------- Nameof Hospital:_______________ Address.:__________________ _ Pt.oneNumber;(_ __J ________ _ _____ 2. Da1eof Anival:_____ _ Time: _ __ ___ _ _ __ Receivingphysicianassumingpatientresponsibility: Date:----,--,---,---lime: _ _ _ ___ Receivingphysidan'5signature: _ _ ;\i\t\i~:s:umber: (_) •:.:_;t\\~'f.:response transfer 0 WHtr£ _ _ 10 -~-ue_s_t _w_as_de--,-la-yc:d_bc_y_on-,d,...thirt-:-:-, -y-,(""30::7)-m-:i-nu-11 · '· :·'•'·dac11rQCnt the reason(s}for the delay,includinganytime extensionsagreed •. •lo byJrailsferring_ho~piutl. U.sedditlona!sheets,if necessary. · To 11~~/wng Fad/ii)' Y£LJ.OW • r,,b, nUaUJ#dby,Tran.i/~rri•i forililji· · /09/()6/()6) Kwjk ',Qpy /',inr/,ig 2020 -ICLl -000.06 :· 23.f r 3. HospitalAdministrationsignature: Tille;___ _ : :_M :::" 'r. • _' • Fax Server 9/18/2017 8:35:47 AM PAGE Fax 3/045 Server FINAL (SIGNED) J~~ ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Note add on I Sex: Patient: ALMAZON RUIZ, FELIPE Age: Male 09/11/2017 23:20 Room: DOB: 06/26/1966 51Y Bed: RM4 Attendinn Phvsiclan· I MR#: DOS: Visit#: 0300267948 A Created By: r )(6); (b)(7)(C) Creation Date: b)(6); (b)(?)(C) I 1 Physician ~ 10:06 PM date / time:09/11I2017 Informant: s1301:1se Exam limited by: 0010282353 UReonseiousness 09/11/2017 23:20 FMS arrival para me dies- witness: ffiCAia!impairmeAt unoooperauveness meAtal impaiFmeAt unsooper=a~i¥eness - intoKieation eommttniea!ion barFicr History limited by: uneenseiousness-- iRlm1isation eoRciR'IUnisalisn barrier Transfer from: See transfer record Ci H Pl Complaint: Onset: 1 ~ obdomiRal paiA min ~ hrs gradual onset ~ 1le11'lk pain: ago Duration: waxing --Rmin + hrs ~ waning since: gone now better ~ intermittent episodes - -Ua11~I out gf country Context diarrhea sudden onset worse Timing: ~ rn Updated Reviewed lasting: bad foml reGent trauma Comments: 51 Year old male, with a PMHx of Hep C, presents to the ED with a complaint of vomiting blood. The patient reports that he has vomi~d blood about 3 limes_ He states that he has abdominal pain at a 7/10. The patient notes that he also has blood in his stool. The patient denies all other complaints. Severity: pain max: pain currently: 0 0 1 2 3 4 5 6 (J) 8 9 10 Scale: ~ Wong Baker© 2 3 4 5 6 (!) 8 9 10 Scale: ~ Wong Baker© Documentation Cont. Next Page Circle ~ strikethrough [ NAME: ALMAZON RUIZ, FELIPE - MRN: 00102821020.ff~,SQ Ae§ati.•es unmarked = not applicable QC,00d8t8~~tember 12, 2017 5:18:14 AM- Page 1/20) Fax Server 9/18/2017 8:35:47 AM PAGE 4/045 Fax Server FINAL (SIGNED) °"' J~ CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Note add on Patient: ALMAZON RUIZ, FELIPE Quality: DOS: I Se" Male ~ MR#: 09/11/2017 23:20 0010282353 ashing Location: burning cramping sbB9ing fullness ~ Associated Symptoms: shills nausea ~ X3 ~ B!omi streaks seffco grounds Migration (show migration: ---m~----, Siarrhea x ~ grossly 91oody l9ss ef appetite ~ s1:1pine mucous- ----GfieG!-.paifl- testicular pain uprigAt position R9Ck pain A'IO'o'CffiCAtS walking eough ----eeey-breaths ~ food uf}fight ~osition -sttptt'te"- antacids ~ --food- Siffiilar S:fA9pteA'lsprevio1:1sly: seen Recently: treated by Eloetor ~ Reviewed ROS CONST recent GI censtipation illness £1 Aospiklli:ceel Updated injUF) ~ blaek- stools: Comments:bloody stools per patient CVS pal19itations RESP shortness of bFCath GU urine: I MUSC bloody sough hurts to breathe ----eafk.- problCA'ISuriAaUA§ LMP date: pregnant post-menopausal joint pain SKIN LYMPH 5\>VOIICA gl □ Ads EYES problems ~¢Ith visio1, Circle UAhk S'#CJliAg -R- ~ strikethrough + AB!'JBB•,•es unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE- MRN: 00102823282()?iretqd()(J00(5daIDffi!lember 12, 2017 5:18:14 AM - Page 2/20] Fax Server 9/18/2017 8:35:47 AM PAGE 5/045 Fax Server ·~ FINAL (SIGNt:O) ~f CHI St. Luke's Health MMC LIVINGSTON Abdorrnm:I Pain Flank Pain lCD10, Transfer of Care Nole add on Patient: ALMAZON RUIZ, FELIPE ENT sore throat NEURO heaelt!iehe Male diuiness PSYCH I MR#: DOS: I Sex: 09/11/2017 23:20 0010282353 light I 1eadeel1 ,ess depfessien ~ except as marked positive, all systems above reviewed and found negative ~ HISTORY Reviewed ■ Updated No ohFenie diseases Cardiac disease: Diabetes: At1b Type 1 CAD Type2 CHF Ml diet oral insulin Hypertension Peptic ulcer Gall stones Kidney stones Rladder infection Kidney infection lschemic bowel risk factors: valvular disease elderly low BP recent Ml Pancreatltis GERO Diverticulitis Abdomlnal aneurysm CVA TIA: deficit: R L Ectopic pregnancy Fecal impaction ~c Hyperllpidemia Intestinal obstruction Circle~ strikethrough !'lOgaWos unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE- MRN: 00102823idzoE,rel~Q()(J~edalffi_'tPtember 12, 2017 5:18:14 AM- Page 3/20] Fax Server 0/18/2017 AM PAGE 8:35:47 Fax Server 6/045 FINAL (SIGNl::.D) 11,~ ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Note add on I Sex; Patient: ALMAZON RUIZ, FELIPE Ovarian: cyst(s) Male MR#: 09/11/2017 23:20 0010282353 fibroids STD Pelvic infection: x DOS: Old records reviewed I summary Surgeries / Procedures: hernia repair R cardiac bypass none appendectomy cholecysteclomy endoscopy upper lower L cardiac stent hysterectomy BTL C-section tonsillectomy ·················· ..··············-···-···············--··--······················--··· ···············---······-······················· ·····-···-·--·········· ........ __ ._··-·..·····-1 Full Problem List ~ Reviewed D Updated IUpper GI bleed (2017) I Allergies ~ Reviewed Q Updated :&l Reviewed 0 Updated ~_. I Re~~w_e_d __ □_... _. _u_pd_a_te_d ________ f3 ■ Updated No Known Allergies . Home Medications [ t~.~~nizatio_n_s _____ SOCIAL HISTORY Reviewed --·-···----------------, _ Tobacco Use Never smoker None Reported: TOBACCO HISTORY Last Documented 8 b)(6); (b)(7)(C) n 09/12/2017 01:58 [Aicohol Use I Recreational D~~g Use FAMJLY HISTORY gall stones ~ Reviewed ovarian cysts Circle~ CAD ■ Updated ulcer strikethrough [ NAME: ALMAZON RUIZ, FELIPE - MRN: 0010282~.fi'C!fl!f.SO kidney stones Regatf,•ee aortic aneurysm unmarked== not applicable QCJOO daza~ptember 12, 2017 5:18:14 AM-· Page 4/20 I Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 7/045 ·~ FINAL (SIGNED) ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Fiank Pain ICD10, Transfer of Care Note add on Patient: ALMAZON RUIZ, FELl?E 09/11/2017 23:20 Male VITAL SIGNS ~ Reviewed Last Set of Vitals: Interpretation: ! DOS: I Sex: MR#: 0010282353 ■ Updated nonnal hypoxic BP: 160/103 09/12/2017 02:31 Pulse: 94 09/12/2017 01:10 Temp:98.1 F 09t11/201721:36 Resp: 18 09/11/2017 21:36 02 Sat 99.0% 09/11/2017 21 :36 Additional Vitals: PHYSICAL EXAM ~ Nursing assessment revtewed CONST ~ distress: mild ~ anxious lethargic Comments: moderate severe Patient is alert and in no acute distress on exam. EYES ~nnorimiD scleral icterus EOM palsy pale conjunctivac R L anisocoria R L hearing deficit R Comments: Normal on exam. ENT ~ ~ pharyngeal erythema abnormal TM R L L Comments: Normal on exam. NECK ~ Comments: thyromegaly lymphadenopathy Norma1 on exam. RESP ~respiratory Circ!e I NAME: distre~ ~ ALMAZON RUIZ, FELIPE wheezes strikelhrough R L RB!ilatives rales R L rhonchi R L unmarked= not applicable MRN: 0010282~flc!n!t-'OOOffiJdaz812:~tember 12, 2017 5:18:14 AM~ Page 5/20] Fax Server 9/18/2017 f-lNAL (SiGNED} 8:35:47 AM PAGE Fax Server 8/045 "'~- ~r CHI St. Luke's Health MMC LIVINGSTON AbdominalPain Flank Pain ICD10,-rans fer of Care Note add on Patient: ALMAZON RUIZ, FELIPE I MR#; I Sex: DOS: Male 09/11/2017 23:20 0010282353 ~ Comments: Normal breath sounds on exam. CVS ~ ~ ~ irregularly irregular rhythm JVD present tachycardia gallop: murmur: grade S3 decreased pulse(s): 84 systolic /6 radial bradycardia R diastolic femoral L dorsalis pedis R R L L Comments: Normal heart sounds on exam. L!::GENO T G = Tenderness "'Guarding R m = Rebound =Mild l·. mod = Moderate sv : Severe • I ABO rigid distended tenderness guarding rebound ~ hepatomegaly ~ abnormal bowel sounds: ~ prominent aortic pulsation ~ McBumey's point tenderness generalized RUQ LUQ RLQ splenomegaly increased psoas decreased absent Rovsing's sign tyrnpanic obturator sign mass: Comments: No abdominaltendernesson exam. GU external inspection normal catheter present PELVIC EXAM normal external exam vaginal bleeding normal speculum exam cervical motion tenderness Circle ~ strikethrough RB!21ati¥es LLQ vaginal discharge unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE- MRN: 0010282~O.oot!Ml00@6d@8:ii!~ternber 12, 2017 5:18:14 AM- Page 6/20] Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 9/045 _._:., FINAL (SIGNl::.U) ~r CHI St. Luke's Health MMC UVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Note add on Patient: Male ALMAZON RUIZ. l=ELIPE normal bimanual exam I MR#: DOS: I Sex: 09/11/2017 23:20 0010282353 adnexal tenderness adnexal mass enlarged ute,us tender uterus L R MALE GENITAL normal inspection testicular tenderness R L testicular swelling R L inguinal tenderness R L inguinal swelling R L RECTAL non-tender tenderness heme negative stool stool: fecal impaction heme positive trace black bloody BACK ~ CVA tenderness R L Comments: Normal on exam_ SKIN ~ cyanosis diaphoresis <@ir~ skin rash zoster-like embolic lesions signs of IVDA (§_iiii) ® ~ pressure ulcer location: depth/ stage: 1 2 3 pallor 4 Comments: Normal or, exam. EXTREMITIES ~ ca!ftendemess R L ~ Haman's sign R L ~ pedal edema R L C'.,ommenls:Normal on exam. NEURO ~ ~~ormal .@:!.__21:> disoriented to: person place weakness R L facial droop R ~ speech abnormalities ~ sensory loss R time situation L cognition abnormalities L Comments: Patient is alert and orientedx 4 on exam. Circle ~ slrlkelhrougt, Aogati1•oc unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE - MRN: 0010282~20fi€!.E!~OO@§da2~lember 12, 2017 5:18:14 AM - Page 7120] Fax Server 9/18/2017 I-INAL (SIGNl:::D) 8:35:47 AM PAGE 10/045 Fax Server J -~ - ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Nole add on I Sex: Patient: ALMAZON RU(Z, FELIPE MR#: DOS: Male 09/11/2017 23:20 0010282353 PSYCH ~ depressed mood .•ee Status Collection Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result Final Result 09/11/2017 23:29:00 09/11//017 23:29:00 09/11/2017 23:29:00 ------09/11/2017 23:29:00 09/11/2017 23:29:00 09/11/2017 23:29:00 ------------09/11/2017 23:29:CO 09/11/2017 23:29:CO 09/11/2017 23:29:00 09/11/2017 23:29:00 09/11/2017 23:29:00 -□ 9/11/2017 23:29:00 09/11/2017 23:29:00 09/11/2017 23:29:00 ---- 09/11/2017 23:29:00 09/11/2017 23:29:00 09/11/2017 23:29:00 unmarked= not applicable MRN: 0010282M0.fffil1!M)~d@8~5ptember --- - 12, 2017 5:18:14 AM - Page 6/20] ' --- .. Fax Server 0/18/2017 8:35:47 AM PAGE 11/045 Fax Server FINAL (SIGNED) .J~Jl ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Note add on Patient: DOS: I Sex: ALMAZON RUIZ, FELIPE Male I MR#: 09/11/2017 23:20 CBC PLATELET AUTO DIFF ·CBC PLATELET AUTO DIFF Nucleated RBC 0 (0-2 /100WBC) Neutrophils 1O L (42-75) -CKIVIB CKMB 7.49 HH (0.00-2-36 ng/ml) 0010282353 Decreased platelets, NO Platelet dumping , few large platelets seen on peripheral blood smear. RESULT CALLED TO CHELSEA BULLORD RN (ER) AT 0003 THEN READ BACK //HH/ Final Result Final Result 09/11/2017 23·29·00 09/11/2017 23:29:00 Final Result 09/11/2017 23:29:00 :CMP COMPREHENSIVE ,METABOLIC PANEL .CMP COMPREHENSIVE METABOLIC PANEL ,CMP COMPREHENSIVE METABOLIC PANEL Glucose 127 H (75-110 mg/di) Final Result 09111/2017 23:29:00 BUN 85.0 H (6.0-17.0 mg/di) Final Result 09/11/2017 23:29:00 1.5 H (0.4-1.2 mg/di) Final Result 09111/2017 23:29:00 CMP Sodium 127 L (137-145 mmol/I) Final Result CMP Potassium 4.3 (3.5-5.0 mmol/I) COMPREHENSIVE METABOLJC PANEL ·CMP COMPREHENSIVE METABOLIC PANEL Final Result 09/11/2017 23:29:00 Chloride 95 L (98-107 mmol/1) Final Result 09/11/2017 23:29:00 Creatinine " :coMPREHENSIVE 'METABOLIC PANEL " CMP co, 22 (22-30 mmol/I) ,COMPREHENSIVE 'METABOLIC PANEL 'CMP COMPREHENSIVE METABOLIC PANEL Final Result 09/11/2017 23:29:00 Calcium 8.6 (8.4-10.2 mg/di) Final Result 09/11/2017 23:29:00 CMP T Protein 6.5 (5.1-8.7 gm/di) Final Result 09111/2017 23:29:00 3.3 L (3.5-4.6 gm/di) Final Result 09/11/2017 23:29:00 1_Q L (1.122) Final Result 09/11/2017 23:29:00 ,COMPREHENSIVE METABOLJC PANEL ;CMP :coMPREHENS!VE :METABOLIC PANEL CMP ·-Albumin NG Ratio .. .COMPREHENSIVE METABOLIC PANEL Circle ~ strikethrough --·" 09/11/2017 23:29:00 Rege~Pi•ee unmarked= not applicable [ NAME: AUv\AZON RUIZ, FELIPE- MRN: 0010282~O.ff'Ot!Ml0{)00d$~/aptember 12, 2017 5:18:14 AM- Page 9/20] - - - Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 12/045 ,_ FINAL (SIGNED) ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD~0 . ..,.ransferof Care Note add I Sex: Patient: ALMAZON RUIZ, FELIPE CMP - I MR#: DOS; Male CMP COMPREHENSIVE 'METABOLIC PANEL !CMP COMPREHENSIVE METABOLIC PANEL 011 09/11/2017 23:20 0C10282353 102 H (11-36 U/L) Fina( Result 09/11/2017 23:29:00 ALT (SGPT) 68 H (11-40 UIL) Final Result 09/11/2017 23:29:00 Alkaline Phos 123 It (47"114 U/L) ICOMPREHENSIVE METABOLIC PANEL -----.CMP ,COMPRFHFNSIVF: 'METABOLIC PANEL Tota] -EIIlirubin 10.8 H - - ' Result . 09/11/2017 23:29:00 (0.2-1.2 mg/di) Final Result 09/11/2017 23·.29:00 (2.3~'.fS gm/di) Final Result 09/11/2017 23:29:00 Final Result 09111/2017 23:29:00 Final Result 09/11/2017 23:29:00 Final Resull ... Result Final Result 09/11/2017 23:29:00 09/11/2017 23:29:00 09/11/2017 23:29:00 Final Resull 09/11/2017 23:29:00 CMP Globulin 3.2 'COMPREHENSIVE METABOLIC PANEL ·CMP ;COMPREHENSIVE METABOLIC PANEL Anion Gap 11 CMP Calcium, Corrected 92 (8.4-10.2 in!ildl) :cPK CPK 322 H (30-135 U/L) ·---LIPASE SERUM Lipase 367 H (8-223 U/l) PRO BNP 8 NATRIURETIC PEPTIDE Pro BNP(B-Pepticie) 4850 HH (0-125 pg/ml) .PROTIME PT INR Protime 15.1 H (9.0-11.8 sec~_r:i~sf_ COMPREHENSIVE , METABOLIC PANEL Circle~ strikethrough ---- Rega&,,es Various formulas exist for corrected serum calcium results, each yielding different values. This ; corrected result was based on the formula: Corrected Calcium= SerumCalcium +[0.8·(4SerumAlbumin)] '' Final Final RESULT CALLED TO CHELSEA BULLORD RN (ER) AT 0003 THEN READ BACK /IHH/ - - unmarked= not applicable [ NAME; ALMAZON RUIZ, FELIPE - MRN: 00102823~~2!J'-'lif:!1:~fl0{)@661aQ~Jtember 12, 2017 5:18:14 AM - Page 10/20] -~-, ···-- - Fax Server 9/18/2017 8:35:47 AM PAGE 13/045 Fax Server ,~!# ~J FINAL (SIGNED) CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Nole add on I Sex: Patient: ALMAZON RUIZ, FELIPE Male ;PROTIME PT INR INR PTTPARTIAL THRO_~.BOPLASTIN Th1 j aPTT I MR#: DOS; 09/11/2017 23:20 1.4 H 1221 L I 0010282353 INR results are Final intended ONLY Result to monitor Oral Anticoagulant therapy in slablized patients. The JNR Therapeutic . Range is 2.0 3.0 Patients with a mechanical heart, !he INR Range 1s 2}:i - 09/11/2017 23:29:00 3.5 (25.3-35.7 seconds) Final Result 09/11/2017 23:29:00 Documentation Cont. Next Page Circle~ slrikethrougl'i Aegaw.- .. .. STAT Once STAT PROTIME PT INR CBC PLATELET AUTO DIFF Circle~ [ NAME: ALMAZON RUIZ , FE LIPE - MRN: 001028232 ~ 2cf-rin~ Met Met Met Met Dates Met STAT STAT strikethrough -·· Dates Met····· ... TM 9/1112017 9/11/2017 --·" i Dates Met Dates Dates Dates Dates STAT STAT ·-····· Status Active Dates Met Dates Met RB§B~ivss unmarked"' O!J9@61a~ ~lember not applicable 12, 2017 5:18:14 AM - Page 15/20] ~---· Fax Server 9/18/2017 8:35:47 AM PAGE 18/045 Fax Server FINAL (SIGNE:-:IJ) _Jlb ~r CHI St. Luke's Health MMC LIVINGSTON Abdorrnnal Pain Flank Pain IC□ 10, Transfer of Care Note add on Patient: ODS: I Sex: ALMAZON RUIZ, FELIPE 9/1112017 '9/11/2017 '9/11/2017 !9/11/2017 9/1112017 ]1f1i2.017 19/1112017 '9/1112017 09/11/2017 23:20 Male PRO BNP 8 - NATRIURETIC PEPTIDE Insert Saline Lock ObtaTnConsent for-Procedure/ Place in Chart Transfusion Vital Signs per Protocol TYPE AND SCREEN ··-· CROSSMATCH X 2 Transfuse 2 unils PRBCs .... UA URINALYSIS WITH MICROSCOPY CLINICAL IMPRESSION I MR#: 0010282353 (b)(6); (b)(7)(C) Once Dates Met .. STAT STAT -- Dates Met Dates Met ---·-. STAT STAT -stAt STAT Once Dates Met Dates Met Dates Met ~ -□ales Met Dates Met Initial visit unless marked: CJsubsequent - f3 sequelae CV Acute Ml: STEMI NSTEMI Angina: stable unstable anterior Aorta dissection: abdomen thoracic Aortic aneurysm: abdomen thoracic inferior posterior lateral with rupture lschemic chest pain lschemic colitis Mesenteric isch.emia: acute chronic GI Appendicitis: acute chronic with peritonitis: general local Bowel obstruction Clostridium difficile enterocolitis Constipation Crotm's disease: small bowel large bowel with: abscess bleeding fistula Diverticulitis: small bowel large bowel with: abscess bleeding perforation obstruction Fecal impaction Gastritis: acute Gastroenteritis: GERO: chronic infectious alcoholic with bleeding viral with esophagitis Circle ~ strikethrough Rsgoti1,'B6 unmarked = not applicable { NAME: ALMAZON RUIZ, FE LIPE - MRN: 00102823.?!32cf-r©~OOOO&Jai~tember 12, 2017 5:18:14AM - Page 16/20] ···-···•--' - ------- - ~ Fax Server 8/18/2017 8:35:47 AM PAGE 19/045 Fax Server ,-~ ~r FINAL (SIGNED) CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Note add on I Sex: Patient: Male ALMAZON RUIZ. FELIPE Irritable bowel: MR#: DOS: 09/11/2017 23:20 0010282353 with diarrhea Peptic ulcer disease: acute chronic hemorrhage involving. ,ectum sigmoid colon with: abscess bleeding fistula perforation Pelforated intestine Ulcerative colitis: obstruction Vo!vulus GU Ovarian cyst PIO: follicular acute Pregnancy: simple chronic GC 2nd 3rd trimester preterm term 1st labor: Pyelonephritis: rors ion: acute L Ureterolithiasis: with gout UTI. acute cystitis: + pregnancy test ectoplc~tubal false > 37wk <37wk chronic R testicular chlamydia ovarian chronic R L with hematurla LIVER/ GB I PANCREAS Biliary colic: with gallstones Cholecystitis: acute chronic with: gallslones Hepatitis: acute chronic viral: A Pancreatitis: acute chronic alcoholic B biliary obstruction C alcoholic drug induced: idiopathic OTHER Dehydration Peritonitis, acute Pneumonia: aspiration viral: Sepsis, severe: atypical RSV bronchopneumonia influenza: A B interstitial lobar bacterial: with shock SIRS Circle ~ strikethrough Aogativos unmarked= not applicable [ NAME: ALMAZON RUIZ, FELIPE - MRN: 001'J28232€12cf-~'1:P-OCl8m:fla'Q~tember 12, 2017 5:18:14 AM - Page 17/20] Fax Server 9/18/2017 8:35:47 AM PAGE 20/045 Fax Server FINAL (SIGNED) ,J~ ~r CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Nole add on I Sex: Patient: ALMAZON RUIZ. FELIPE I MR#; DOS: 09/11/2017 23:20 Male 0010282353 SIGN / SYMPTOMS Abdominal pain: RUQ LUQ RLQ acute abdomen LLQ generalized with: rebound tenderness Fever Flank pain Nausea Vomiting Diarrhea Comments: [ Cu_r_rentProblems Upper GI bleed 18] Reviewed I&] Updated Upper GI bleed (2017) DISPOSITION Decision made at 02:35 AM To: Left department at ~ Horne Present on arrival: patient condition: Nursing Horne Police pressure ulcer UTI unchanged improved ambulatory active Admit Morgue Funeral Home Medical Examiner senous drinking fluid Care transferred to Dr Abas critical eating deceased pain controlled time: 05:15 AM Basis For Discharge Decision: patient exam: test results: stable improved unchanged tenderness migratory no rebound no abnormal no serious abnormal social support: adequate good follow up: available arranged Circle ~ no rigidity min abnormal mod abnormal excellent discussed with physician strikethrough Ao§ati,•96 unmarked= not applicable I NAME: ALMAZON RUIZ, FELIPE - MRN: 001028232()2CJlt®etl-O@Oel61a)l2Si/5tember 12, 2017 5:18:14 AM - Page 18/20 J Fax Server 9/18/2017 8:35:47 AM PAGE 21/045 Fax Server ,~ ~r FINAL (SIGNED) CHI St. Luke's Health MMC LIVINGSTON Abdominal Pain Flank Pain ICD10, Transfer of Care Nole add on I Sex; Patient: ALMAZON RUIZ, FELIPE Male I MR#: DOS: 09/11/2017 23:20 0010282353 Basis For Admit Decision: need for. further evaluation additional testing monitoring telemetry pain control IV hydration IV medication IV antibiotics culture results surgery I intensive care TRANSFER OF CARE Report given to Assuming Scribe:f bl(6); (b)(?)(C) Relinquishing Mid-Level: Report given to Assuming Mid-Level: Relinquishing Mid-Level: R~port riven to Assuming Physician: Relinquishing Physician: Report givento Assuming Physician: Cheyenne Cooke Relinquishing Scribe: Brief history: Items pending that need to be checked and documented: Labs: X-Ray results : Pain conlrnl: CT results: MRI results: US results: Procedure(s): other Physician I consult arrival: Tentative impression of patient admit discharge transfer Pending results: Circle ~ strikethrough AB!Jaw.e1.1mento1Uon h'l$ b••"- pr.pued llnd•r ttle directionll'ld i" tha pra5"'1CQ of • Electronicallysigne1._ (b-)(-6)_; (-b-)(7_)_(C_) _ 1-----D,\a __, ... 09/1212017 Time: 02:35 AM 09/12/2017 05:17 Date!Time Emergency Physician Attestation rx··. , This scribe's documentation has been prepared under my direction and personally reviewed by me in its entirety. I confirm that the note accurately reflects all wor-1<,treatment, procedures , and medical decision making performed by me. (b)(6); (b)(?)(C) es have been reviewed and completed 09/1212017 05: 18 Dalerrime Authorized Signature Circle ~ strikethrough Aogati>o•o,s unmarked:= not applicable [ NAME: ALMAZON RUIZ, FELIPE- MRN: 0010282~ijCitt!+(QCJOOOda2~tember 12 , 2017 5:18:14 AM - Page 20/20 J · -· Fax Server 9/18/2017 8:35:47 PAGE AM MMC LIVINGSTON LIV ED Triage R&port Printed: 09/1112017 21 :35: 16 Page 1 of 1 Fax Server 23/045 11111111111111111 11111 llllllllll1111111111111111111111 Visil ID: Patient ALMAZON RUIZ, FELIPE Age: 51Y Chief DOB:06/26I1968 Acuity; Sex: M Heai:1 Clrcum_: 1-iemoptys Is Co1np1alnt: T~eg• err 09/11/2017 21:25 lnfecllOl'I Control: EMS: Room/Bed: Radio Cell: EMS Llnlt Afrlva I □11: A!Tlwdfrom: 09/11/2017 21:02 Forensic Faclllly Mode of Amwt: Law Enforcement 0300267948 Med Rec: 0010282353 3 N Pre Hcspitl!IICa.re: Screening·.'OomealioVlolenc:e, 'TB, Out us Lllot {None entere~ 300ay• NC Accompanied by: Olher Suldde Risk: Self Informant: Consent loTrest?: Sc'l!en~d - No S!Jclde Risk LMP: Pmgnant?: Pe~ent Nurruflve: Stroke Asa11111ment lsat KnownWell: I\IPOslnoe: BP 149/97 mmHg Site: Ami,Upper LI Cheracier: DfT LlqLJ\d: acs Height 15 61 in Qly: M-6 V-5 Weight Type: E-4 77.13 kg 98.1 F Slle: Forehead I. Pulae Tampareture P°"'. Pain Assessment Seore:7/10 ""tlnt,iko D/T Lest Intake Solid: SIie: ,a Qlv: Scale: 7,'-umerlo S00le stabblrig $g0,, Ra5,plrations 99bpm 99%0Um 0,Del: FSBS atxl I'CP: NONI:,NONI: SignedBy: WRIGHT, BRENDA DI Signed:091111201721:36:10 Fax 9/18/2017 Server 8:35:47 AM PAGE 24/045 Fax Server CHI ST LUKE'S HEALTH - LIVINGSTON ABORATORY - CUA# 45D0697930 1717 HIGHWAY 59 BYPASS LIVINGSTON, TEXAS 77351 PH: (936) 329-8589 -------------------------PATIENT: ALMAZON RUIZ, FELIPE DOB: 06/26!1966 SEX: M LDC: ER LIVINGSTON ENCOUNTER#: V0"""30",';0~2~6:!-"!7~94-8,--------, 5 :;:ATTO.PHYSIC1AN:_j(b)( ); (b)(?)(C) MR#: V0010282353 L_:;:::::;:========~~;::~~;:;:~:~;~~~~~~~--===========-=== HEMATOLOGY Collected 09/11/2D17 23:29' Ord Physician ZAHEER, WBC RBC Hemoglobin Hematocrit MCV MCH MCHC ROW Platelet MPV R-afenmca SYED J, MD 14.28 H 3.94 12.5 33.2 L L L 84.3 31.7 H 37.7 H 16.0 H 18 LP No1 Measured 2 ,um ·10.so 10'-.1/ul -1.70-6.l0 ·IQh6t.lJ 1/4.0-18.0 gm/di 4?.0 fiO.O '% 00.0-94.0 27.0-3·).0 33.0-37.0 pg •;·1.5-M.5 % 10h3/ul f~ % % 4.J-14.0 % % 0.9 L BA% 0.6 L ,.J-3.D '..J-3.D IG% NRBC, Auto Nucleated RBC 6.4 H O.:l-0 (_6>_: <_b>_____ COAGULATION Units Test 09111/2D17 2.3:29 Protime 15.1 INR aPTT 1.4◄ H 22.1 L 4 'r,.,;Rr8Sults sr8 irlerid60 2 mUl'I"in/1. 73m'· 52" 2 CARDIAC SE.CTfON "Estimated Glomemlar Filtration Rate (eGFR) Rderence hi.tervals Decision Points for l 8 years and older and average body ma;,~: >= 60 30 - 59 < 30 Do~ not exclude kidney disease. Suggests model'ale chronic kidney disease and indicates the oe~d fur fiirther investigation including assessment ofproteiunria and cardiova5Cularfllctors. u~u11llyii.1dicates?. need for referral for assessment and manaiemenf o: chronic kidney faiJure. - - - ---- -=== ALMAZON RUIZ. FELIPE ER LIVINGSTO l(b)(6); (b)(?)(C) PRINTED: 09:12(2017 18:43 REPORT: Final Chart Livingston PAGE: 5 OF 8 2020-ICLl-00006 2843 Fax Server 9/18/2017 8:35:47 AM PAGE Fax Server 29/045 CHI ST. 1.IJKF'S HFAI.TH - LIVINGSTON ABORATORY • CUA# 45D0697930 1717 HIGHWAY 59 BYPASS LIVINGSTON, TEXAS 77351 PH: (936) 329·8589 ==============~-------------=== --------------------------------------------------------~------------------------------------------MR#: V00,0282353 FA.TIENT: ALMAZON RUIZ, FELIPE DOB: 06/26/1966 SEX:M ENCOUNTER#: ATTD.PHYSICIAN: ADMITTED:09111/2017 ZAHEER, SYED J, MD -------------------------------------------------------- ------------------------------Collected 09/11/2017 23:29 ZAHEER, Cte Rh Antioody Screen x 2 Cross match 0 ZAr'EER , SYED J, Positive Negative C::impleted: Compatible 7AhEER, SYEClJ, MD ALMAZON RUIZ, FELIPE ER UVINGSTO J(b)(6); (b)(7)(C) Ord l'l1ys1aan Result MU PRINTED: 09/12/2017 18:43 REPORT: Final Chart Livingston PAGE: 8 OF 8 2020-ICLl-00006 2846 Fax Server 9/18/20 17 8 : 35 :47 AM PAGE 32/045 Fax Serv er .J-. ~r CHI St. Luke's Health BLOOD BANK TRANSFUSION RECORD . Lufkin• Livingston• San Augustine Mem o rial Spe cial ty Blood Band#: • Product Donor Unit Antibody Screen:~ Segment # : Expiry Dat e: Unit # ; fr tJ- t,-,), l!EV. j011'lQl15) KWII< KO/>Y Plll NT ,. t 2020-ICLl-00006 2847 Fax Server 9 /1 8 /2 0 17 8:35:47 AM PAGE Fax Ser ver 33/045 ·~ ~r CHI St. Luke's Health BLOOD BANK TRANSFUSION RECORD I,.ufkin • Livingston • San Augustine Memorial Specialty Blood Band #: Antibo dy Screen: Segment#: Expiry Date: Unit#: Donor Unit /(WIK 1(0PY Pf!ll'to IJ.2.() Crossmatch Interpretation: °'J\\o\~ Segment#: EKpiryDate: Unit#: ~~ q{tff::r-0/~ b)(6); b)(7)(C) 1 '\'·: Datemme: 1 ~':f'~; ,-:.·~'~:~:?' ~•;,, -,~· ··.:~?(!fiiAif~u~J'iff!:fiYsJtftiiilf~:··,r/I r:.::'-'\?~JJ~?·,~T8???t~F !hatprior·ro 1:1C?f!rti/y L-------.,,l'lD Blood Band #: Antibody Screen: !{J... - /'~ Product: Tech ID: RELEASED h~VB che<;lctKJ~ch x.___________ x.____ transfusion we havt1verified the identity pfthis unit and its ·intsht;led recipient item in the piesen<;e_of the;s/;ipienf . . . _,,__ _______ 6ate.· _ ___ .· Time. __ _ --;..,..-........,_2 ..... 0,..,2....,0.....,-IC.....,[r'-rl .... --0 .... 0...,00 .... 6__,..2'"8.,.,49..---"""""""",---Date._·~--,----TimB. __ _ Fax Server 9/18/2017 8:35:47 AM PAGE 35/045 Fax Server MMC LIVINGSTON Ambulatory Asa11ument/Hlatory 09/11/:ZD17 21:02 Patient Name: ALMAZON RUIZ, FELIPE Visit ID: 0300.267948 Admitted: 09/11/2017 21:02 MR Number: Throogh Report 09/14/2017 04:01 00102B23531 (b)(6); (b)(?)(C) Attendmg: 1 06/:Z6/1966 DOB: I Assessment Date Vit.Js Entry Data Pl. Location: 09/11/2017 21 :36 I Entered By: l(b)(6); (b)(7)(C) UNKNOWN_LOCATION UNKNOWN_BED Temp Pulse Resp BP 02 % Ht Wt 98.1 F 99 18 149/97 99.0% 61.00 lr, 77.13 kgs Ht Wt .------------- I ~b)(6); (b)(7)(C) I By; Pl Local:lon. uv Ent.rad Temp CM-, Pulse I v ut:PARTMENT RM-04-A BF' Resp 02% 09/1212017 00:46 09/12/2017 00:50 Assessment Date Entry Date IV Medlcation111.,_ ________ Entan1d By: Pl. Location: 09/12/2017 00:49 _,, l(b)(6); (b)(7)(C) l LIV EMERGENCY DEPARIM~NTRM04-A Site: Jugular, Left Started by: ~l (b-)(-6)-; (-b)-(7-)(C _ )__ 09/1212017 03:04 09/11/2017 2 ';;36 Arm,Upper Lt Forehead Fluid: octreotide 25mcg 09/12/2017 00:49 _,, 120 25 09/12/2017 03:04 150 09112/2017 03:04 Started by: b)(6); (b)(?)(C) Fluid: NSS started by: l(b)(6); (b)(7)(C) 09/1412017 04:01 NOTE: All striileoutf. were executed by person making original entry. 2020-ICLl-00006 2850 Page 1 of 1 Fax Server 9/18/2017 8:35:47 AM PAGE 36/045 Fax Server MMC LIVINGSTON Dally Focus A&&esi;.ment Report 09/1112017 21:02 Patient Name: ALM.AZON RUlZ, FELIPE Visit ID: 03002679411 MR Number; Admitted: 09/11(2017 21 :02 Attending: Through 09/14/21117 04:01 0010282353 ,::-:-.,,,.,--,,-:--:=:-,-:"""""----, l(b)(5); (b)(?)(C) I DOB: Assessmmt Date Entry Dele Actions Ent&Nd By: Pl Location: 09/12/2017 00:47 08/26/1966 r b)(6); (b)(?)(C) 1 Liv rc.""'"'"'"'El'll,YDEr'ARTMENT RM-M·A Critical Value - Name: Plstlets Critical Value - Result 1 B000 09/1212017 00:47 09/1212017 00:-47 Critical Value - Date/Time Received: 09/12/2017 00:48 Critical Value - Name of MD Nolllled: Critical Value - Date/Time MD Notified: Critic.al Vall.It! - Commel"lts/Orders Received: Rounding Action Zeheer 09/12/2017 00:47 09/12/2017 00:47 O!l/12/2017 00:48 09/1212017 00:47 No new orders 09/12/2017 00:4 7 Pl Visually Checked 09/1212017 00147 No change from previous assessment by this clinician A&tiessmentDalo Entry Date ED Med Tlme(s,.)__________ 09/12/2017 02:15 ~ l!ntered 8y~ l(b)(6); (b)(?)(C) Pt. Location: '-L-IV_E_M_E __ R __ G ___ E_N_G_Y_D_E_P_'A....,R'"'T"""M""', E=-'NT RM-04-A Pain Location Pain As6&sGment abd 09/1212017 03:02 Pain Scale 09/12/2[)17 02:15 Pain Score 5/10 Pain Goal acceptable pain reduction Name Of IV Push Med Givan octreotide Dose 25mog Time IV Push Med Given 09/12/2017 02:15 Re9ponse NoADR Asseissml!flt Dale 09/12/2017 03:02 09/12/2017 03:02 Entry Date Rounding 09/12/2017 02:33 09/1212017 03:02 09/1212017 03:02 I EnteN!d By: l(b)(6); (b)(7)(C) Pt. uic.atlan: LIV ~MERG!cNCY Dl=.PARTMENT FI.M-04-A Rounding Action Will continue to monitor patient for 09/12120'7 02:33 complaints or changes In status. Personal needs met Other 09/14/2017 04:01 NOTE: All strikeouts wore executed by p11rsonmaking ortglnal eiitry. 2020-ICLl-00006 2851 Page 1 of 3 Fax Server 9/18/2017 8:35:47 AM PAGE 37/045 Fax Server MMC LIVINGSTO~ Dally Foc:u&Aasessm.nt 09/11/2017 21:02 Through Patient Name: ALMAZON RUIZ, FELIPE Visit ID: 0300267!148 MR Number: Admitted; 09/11/2017 21 :02 At1endin": kh)ffn · /h)/7)/C:) Report 09/14/2017 04:01 0010282353 DOB: A$$e:i;$me11I Osle Erttry Date Rounding E.ntaredBy: l (b)(6); (b)(7)(C) . Pt. Location: 09112/2017 02;33 06/26(1988 LIV EMERGENCY DEPARTMENT RM-04-A Group Note: As&i&ted to BR by guards with wheeh:hair. Dizzy 09/1212D17 02:35 when 11tanding. NSRon monitor Rounding Status No change from previous assassmentby this cWnician 09/12/20 17 02:33 ~t resting, no complaints voloed el this lime Pt. denies any complaints et lhrs time. Assesi;mant Date !:ntry Dal• Rounding Entered By: j(b)(6); (b)(7)(C) Pt. Location: 09/12/2017 02;35 LIV EMERGENCY DEPARTMENT RM-04·A Round:ng Action .,;O::,;l:;;h'"'e'-r ----, Group Note: IV attempted x3. EJ ~ \b)(~);__ _ Rouneling Slatus Pt resting, no complaints voic1:1dat ttiis time Pl. denies any com plaints 111this time. A911es11mentDate 09/12/2017 02:35 09/12/2017 02:36 0911212017 02:35 Entry Date Rounding l(b)(6); (b)(7)(C) Entered By: Pt. Location: 09/1212017 03;30 LIV EMERGENCY DEPARTMENT RM-04-A Rounding Action WIii continue to monitor patient for complaint& or changes in status. 09/12/2017 06:18 Rounding Status No change from previous assessment by this clinician 09/12/2017 06:18 Pl resting, no complaints voiced et this time Pl. danl&s any complaints at this 11rne. 09/14/2(117 04:01 NOTE: All &trllceouts were eKecut&d by person making orlglnal entry. 2020-ICLl-00006 2852 Paga 2 of3 Fax Server 9/18/2017 8:35:47 AM PAGE 38/045 Fax Server MMC LIVINGSTON Dally Focu& A&&assment Report 09/1112017 21:02 Patient Nama: Al.MAZON RUIZ, FELIPE Visil ID: 030D267948 MR Number: Admitte(j: 09/11/2017 21 :02 Attending: As$955m,nt Through 09/14/2017 04:01 DOB: D0102B2353 l(b)(6); (b)(7)(C) I Date Entry Date Rounding Entered Sy: Kb)(6); (b)(7)(C) l Pt. Location; 09/1212017 06:57 08126/1918 LIV EMERGENCY DEPARTMENT RM-04-A Rounding Action Will continue to monitor patientfor complaints orchenges In status. Parsonalneeds met 09112/201 7 05:5 7 Rounding Status No change from previousasse&smentbythh; cllnlc!an Pt resting, no complaints voiced et this lime 09/1212017 05:57 Pt. denies. any complaints at this time. 09/141201704:01 NOTE: All strikeout& were el(ecuted by person making orlglnal entry. 2020-ICLl-00006 2853 Paga! of 3 Fax Server 9/18/2017 8:35:47 AM PAGE 39/045 Fax Server MMC LIVINGSTON Discharge AsSMsmant/Summary Patient Name: 09/14/2017 04:01 through 09/11/2017 21 :02 Report Al.MAZON RUIZ, FELIPE 001028?f..l.i",;..._, ____ MR Number: Visit ID: 0300267948 Discharged: 09/12/2017 07:00 Attending: __,, r b)( 5 ); (b)(?)(C) I DOB: I Allergy llat11 Allergies I No Known Allargl.' b)(6); (b)(?)(C) Last Documenied bf,___------~ Vlr.ls 06/28/1966 09/11/2017 on 09/11/2017 21 :35 Entered By: !(b)(6); (b)(7)(C) Pt. Location: Temp 09111/2017 21 :36 98.1 F Forehead v;tafs Entered By: Pulse 09112/2017 00:49 Rup BP 18 f b)(6); (b)(7)(C) Pt. Location: Temp Entry D11le UNKNOWN_LOCATION UNKNOWN_BED 02% Ht Wt 99.0% 61.00 In 77.13 kgs I 09/11/2017 21:36 Entry Data LIV EMERGENCY DEPARTMENT RM-04-A Pulse Rasp BP 02% 0911212017 04: 1D Ht WI 09/12/2017 02'.37 91 142/109 09/1212□ 17 05;5B Ami,UpperU As11eaamentO.te Transfer EntentG Sy: Pt. Location: 09/1212017 06:45 EntryD111te lli) )(6jj;" );j5j (b)(i] (?)iie (C)) ------------- EfV6 2~20-ICLl-00006 2861 p2 -rexan EMS Sep1817,09:24a ARCePCR - Alrr-.a.zon Ruiz- 842335-\vebJ .ARconcepts.com https://tel253.qcr.com.'newbase/repons/legacyprintitypc/hoq,1tal/: Subje,:t: =Ms P3ttnt Core Report Fax/Pmt Date: 0~/16/2017 ra: conmc R.egtinal(Fa><,) From: TEXAN EMS -LC (Phone: o; Fa)( Conrldenti.ility Notice: The ,rr'ormati:Jn ::or.ter-,e-:l1nthis fa> from s~ne: 06;45:58 08:13:43 Return to service·, D5·,4S:~2 ArrNi'II at d.KDA Patient contact: Cltr- LM'JGSTDN 1-1-.,ight(ft): county: PCIL< Sl::;ate: TX Zip: /73Sl Phone.: 9369(,'/8000 Nnme:c nore Next of Kin Phone: Name: Origin Faciatv: C!i! St. Lukes o' Eas'. Tex a~ City: U\ll'IJ:.STON Z-ip, 77351 Street Add~: county Patient 1717 H111)' so:;By~~, 936•327-8500 Assessment Su!lLK Phone#; Normal Br-e,;,t:1,.,9,CIEarL-tR Site of Pain: EKG Revealed: Patient I,;:,; In Place: N octreomkle drp 2Smcg_,'hr,02 4lpm vi. NSR (07:04:55; Pain Salle1 NC, EKG Neurological LevdA--rOX f" Dealh certi~ca'.eto be oomplelec'l>y~ Attending p~.y~1clin Q JP released remains (Sendr•H ~p requesled autopsy physician O0ther. ___ OP; ____ -;--------,...__ ______ ONA rn c]lk iour,ed.:,,.-1-~:---,r---,--,---------Prellmlnary cause of death: ('.:, I R \ t"' t"" ri )A1tondlng _ lu n_ I :I RM with p,~enr I : ir,(urm~h·rm) "Mote: Consenl from nex/ o/ ki • j5 nor req11/red I/ ';!fl autopsy IS ~rr1~rert by a Jusr;ce or me Paace or ,¼:¥ca, Examiner"~ ofa death inques/. 4arl (b)(6); (b)(7)(C) DISPOSITION REQUESTS I ! Conroe Regional Med•ca!Genier. Its physicians. and revresentatlves are avthorized to do the following: 1 2. Q, No AUTOPSY ~ Ye~ If au!cp5)c "'7'1 1~) !\ s-i.:,/JI ' f~'JG(V). c.o~rtp[:' f"' 1 mo ,-i'T. C.. arnine, s,i p~tl ol a deat h inques t -· ,.,,_ {b)(6) ; (b)(7)(C) I "···---- - I9Tj: 11 l I 1 1T;E5 =? i DISPOS1T!ON REQUE STS Come>eR•gion.l M-i icaJ Centc,, its physicians. and ieorcs entatives are aultlortzed lo do 11' .e folfowi'lg: O AUTO PSY 1. 2. No ~ Yu · STILLBORN - - . ; vtc;,sy is 1-,q,,,ut,d t,y ne,rt of kiri or physi~fl. compel• /he Texas o,partm enr or State He,;/th .fWl. ",s-., 1J,, f'\)(. (l .Jl Addres s: CO;-l (tv,f !f) ,.i _ 9,.~L S'\ L. \'7,·J Tela phcn " numb er: .. .. A uth111i zatio n fo1 Re leas e o ' Body L . M~c.k. ;Signatu;iJ _l.dq~ Nc1..11~, r ~ho11,h~J ? MoNt •C,n D>1le: q - f J-'2,()!7 nme:Ctf 30 Coot.ad Numbe1: Adcress Time: _ De te: Wl!neS$: _ --- RECEIPT OF REMA INS Indicate prese.nce ofk.nowr, or i:u!,peded e,mmun icable disease on tag per policy. Funera: /J'°~C/01 □ For trans porta tion ··- b ){6) ; {b)(7)(C) 9 -11,;;.0 n Time:q· : ) 0 (-\f' Time: Q/i 3 IJ Date: 2- l7- L7 Date: Slgn111ure Witnes s : - 1111 11 11 111111 l111 11111111 11 111 g~!i~ REPORT Pati ent: RUI Z, FEL IPE: serviceonly . Remai~sl o be lran sported to abo ve name d funera l horre . of2 EOEMF032 • ~ I!111~ Ul lllllllllllllllllllllllllll!IIIll C onroe Reg ional Med ic al Ce;n ter • [lat e ~/2012017 UIZ,FE LIPE • • eel II BH902307&38 oc: p,CCU35-0 OOB. Ansan,N am MO Pa ge 3 of 5 BH008511!90 166 51 M t'.1112J17 Fax Serv e r 9 /1 9 / 2 0 17 1 0 : 49:0 9 AM PAGE 5 / 0 49 Fax Serv e r LIFE GIFT DONATION REFERRAL ORGANDONATION REFERRAL FOR IMMINENT DEATH (Ventilator-depende1l patie nts only) Referral criter ia : 1) At fin;t ind ication that oie pal ient begins to lose nelJfo reflexe s; GCS of< 5 OR :>) Plan lo discuss withdrawal of life sustaining theraoies with the farn~y (this pati ent l'las the potential to tJuoat;; liv er and/ or kid ney:i immediately affe r c:ardjae death). 1. Contact l ifeGi ft Org b)(6); (b)(7)(C) 2. LUeGift Coordinato r: 3. LifeGift Respo n:ie : 656 2 lo de termine e~gibility for orga n a onation . - DCJ- iSO :2. 2-017 ~ The pat lent is NOT a candlc:late for urgan donation cue to: I O CO C C e: f' C'- b O 0 ::>onot approach the family. 0 The p atient is a cand idate fo r orga n donation . PrC11id e next of kin contact information lo LifeGift Coordinator . LlfeGift Co o'rdinator will contact next nf kin. r (6) ; (b)(7)(C) S\gr111ture: TISSUE DONATION REFERRAL FOLLOWING CARDIAC DEATH -- ------ Referral criteria : - --- - ---, Call li feGift with in one hour of cardiac asystole lo determ ine suitab ilrty 'or tissue donation . 1. Date of dea th: 9 j I 1 I \1 0 2. Cont3ci LifaG11tOrgan Donati~(b)(6), (b)(7)(C) • 3. "l ame of U(eGifl Coord inator.'--------= UfeGift Response: 4. D5 T ime of c eal h; 1 2 ' d" 2?2 S j s 1:11 or iPOOl SJ1 6562 ~o detem1ine eligibility for eye/tissue donation . =-= =:=: ::-- --::= _ _ -~ The pat ient :, NOT a c andidate for tissu e and eye d0n!!1iOn due to:_i..D ase : 2 __ DI J - 0 9 -\S O2 , <:0. ,..C c~r c-...·1 \ 0 ci Do Mt app roach the family . · :] The pati ent Is a candldale for donation of the following : __ __ .E ye n ssu e rro··; .J- -•wt~•., ,_ ---•--• (b)(6); (b)(7)(C) 1...,,......,.,tinnto Life Gift Coo' dinator . LifeGill Coordinator w·11conlact next of kin. ; e-3_L i J j} 1 Signature: Time : QS Y 3 OUTCOM E FOR POTENTIAL DONORS O O O Pat ient is a regi stered donor. Next of k.in consen ted to donation . Next of ~in does NOT con sent 10 donation Signature:_ _ _ _ _ _ _ _ _ ___ _ ___ _ _ _ _ Date :_ _ _ _ __ EDEMro322 REPOR T Patient:RUIZ, FELIPE • Date 312012 0 1I Tim e:_ _ __ _ _ flII~Illflllllllllmlllllllllllllllll!ll 11 1 Conroe Regional Medical Center 1111111111111111111111111111111 1 P..of2 g~~~ _ IZ,FELIPE • eel I BH902307838 - c: B.CCU36-D DOB: Aflsari,NilZlaMO Paga 4 of 5 BH00861890 ,66 b1 M ~112 117 9/19/2017 Fax Server 10:49:09 AM PAGE Fax 6/048 Server • • • LIFE GIFT DONATION REFERRAL ORGAN DONATION REFERRAL FOR IMMl~ENT DEATH (Ventilator-dependent patienls on y) Referral criteria: 1) Al firs( indication that the patient begins to lose neuro reHexes; GCS of"' 5 OR. 2) Pl,m to di$C\./Sswithdrawal of life sustaining ther.ipies with the iamily (this pc1lier,ihas tha potcnfo:::!!o don~!~ liver '!nd/ or kidneys immediately after cardiac dealh). 1. Contact LifeGift O) b)(t3); (b)(?)(C)- -~~ ~m bw -- ·---• •·-r5~ ;dt~"m~n~l~bi~ty;o~~n;,ialion. 2.. LileGift Coordinato 3. lileGift Response: ~ The patient is NOT a candidate for organ dona lion due to: \C ro ccrr ah on Do not approach the family. 0 The patient is a candidate for organ donation. Provide nel/1 of kin contar..t information to LifeGift Coordinator. LifeGi/t Coordinator will con1.ici next of kin. . r6 ); ~ )(7XC) L 0 ... S1gnat 'v ,;::i 9 I l 7 II1 D5Y 3 Time: TISSUE DONATION REFERRAL FOLLOWING CARDIAC DEATH Referral criteria; Call Li!eGilt within one hnur qt □f I cardiac a$ystole to determine sullabillty for th,sue donation. I J I IJ Time of death: De;~ 5 1. Dale. of c1eath: 2. Contact LifeGift Organ Donation Center et (713) 737-8111 or(800) 633-6562 to determine eligibility for eye/tissue donation. 3, Name of Life Gift Co:>rdiita r 4. LifeGift Response: rse:'2-.D \ J - (5); (b)(?)(C) . . }{ The patient is NOT a candic:'ate for I &s1.Je and eye d~~a;i~~ du~ lo:_i_Q Cl) w .,, O'.::) -1 SD 2 Cer 0.. _CQ,,_.r._ 1 IDn Do not approach the family. ~ 0 0 ,-.. The p.ilient is a candidate for donation of the following: __ Eye -- Tissue <::! :g .... r-0 Provide next of kin contact infcrmation to Life Gift Coordinator. LifeGifl Coordinator will contact next of kin. ~a; b)(6); (b)(7)(C) 0 N 0 B ::?: Bl.I "1 11J Signature ~ 0 Time: OSY ~ OUTCOME FOR POTENTIAL DONORS ir 0 N O Patient i~ a registered donor. u. O Next of kin consenled to donation. Cl O Nexl of kin does NOT consent to donatiori. N 8 s llJ I.LI Signature:_ IlllllllllllllllllllllllllllIllllll DEATH DEATH REPORT Patient: RUIZ, FELIPE ' Date: Co~roe Reclonal MedicalCenter Page 2 of2 EDEMF03~2/11ev. Dale 312012017 Time: ·- IIIrnIIIl IIIII111111111111111 HIIIII Ill1111 RUIZ,FELIPE Acct II BH90l3078383 MR# BH008618110 Loe: 1',CCU3&-:DDOB: 06/28/66 SI M 01112.'11 Ansari,Nazia MD Page 5 of 5 9/19/2017 Fax Server 10:49:09 AM PAGE MAI URN Nt-mber· BH54768:! Service/Localioo Lnit # Patient Fax 7/049 Server A0MISSIONfQRM Printed· □9117/17 21-40 Status F/C - Dale Account# Exp: f,n. C asi Mmis~ion Comment Adm Pr'oriiy 1 EL I AtteridinnPhvsidan: . l(b)(6): (b)(7)(C) I ""-~ SpecialPrgm, COMM -- __...:._ - - ..:::.. ·-___: Admittin,fP~v~c~·/TC-I 'A_Ns_ f b)(6); (b)(7)(C) FamilVPhysican: l Date: Time: - "''source: . - ---- 0911:1117 08:20 1 0 A · ~~~1~!. -bA~l~if E.GJ Tmi Froma Hospilal CCU3610 \ 1111111111111111111111 Illllll FACE , ,.,.~.., Phv!. r,1,.n· r b)(6); (b)(7)(C) I 1iii~g~lagnosls/Reas~ntorVisl(: . -- Adiilttedby: :r1!~:a·1~d1:ii-1 - UPPER GI BLEED .,FACILITY COPY:' -'-' _____ Conroe Region;i.lMedical Center Page 1 af 1 EADMFOOO',,' l',Qu. DalG FACESHEET PatiQnt:RUIZ, FELIPE - V l rb\/6\ /b\/ 7\/C\ 1 ·~-· P~rnoi~i;on· -·-. --~ -- - --Emergency'A?iorr·Ph}SIClan: ·--·-- -- A.BAD.SR1 ___;_ ___ .• __ _, IIIIIIIlllllllll llllllll IllIIllllllllill111111 c RUIZ,FELl?E Acct# Bt19023(l78383 MR# BHOOB61890 ooa, 06126/66 s1 v 09112117 Arisar~N~Zi8MD MRN: BH00861890 2~re~f.§tl'~~0~383 ..:.;~.;_· __ Page 1 of 1 Fax 9/19/2017 Server 10:49:09 AM PAGE Fax Server 8/040 CONROFREGIONALMEDICALCENTER 504 Medical center Blvd. Conroe, Texas 77304 0913-0071 ADMIT DATE: 09/12/17 ROOMNO: ~.141 AGE: 51 SEX: M PATIENT NAME: RUil,fELIPE ACCOUNTNO: BH9023078383 MEDICALRECORDNO: BH00861890 REPORTTYPE: HISTORY AND PHYSICAL (b)(6); (b)(?)(C) ADMITTING PHYSICIAN ATTENDINGPHYSICIAN ADMISSION DATE: 09/12/2017 ADDENDUM TO THE HISTORY AND PHYSICAL REPORT: #2035335 confirmation Please to assessment and plan after DVT prophylaxis. Sepsis. The patient has significant leukocytosis with a WBCcount of 15.1, renal failure, and the patient. was tachycardic upon arrival with a heart rate of 108. \oJewill initiate antibiotics. We will not ~ive fluid liberally as the BNP level was more than 4000 at the outside ER. We will obtain x-ray and BNP level to ~eassess the fluid status. The patient does have symptoms of volume overload at present. It has been a pleasure participating in the medical have any questions, please do not hesitate to call. • Bi~. ________ WT: HP: B.HIM/FAKAL/NTS DD: 09/12/2017 09/12/2017 DT: I l(b)(6); (b)(?)(C) Dictated __._ 15:25:01 19:14:36 confft·: ~03 5363/, (b)(~)' (b)(9 )(C )°r;o AUthenT1caTed b~'--- ' ____ Electronically I __,MD on 09/14/2017 (b)(6); (b)(?)(C) l signed by _ PATIENT NAME:RUIZ,~ELLPE Patient:RUIZ, FELIPE care of the patient. 09:05:15 MDon 09/14/17 PM at 2105 ACCOUNT#: BH90230783&3 Page 1 of 1 If you Fax Server 9/19/2017 10:49:09 AM Fax 9/049 PAGE Server CONROEREGIONALMEDICAL CENTER 0912-0324 504 Medical Center Blvd. Conroe, Texas 77304 PATIENT NAME: RUIZ,FELIPE ACCOUNTNO: BH9023078383 MEDICALRECORDNO: BH00861890 REPORTTYPE: HISTORY AND PHYST~AI ADMITTING PHYSI CIA (b)(5); (b)(?)(C) MD MD ATTENDING PHYSICIA 09/12/17 ROOMNO: B.141 AD:viIT DATE: AGE: SEX: Sl M '---------' ADMISSIONDATE: 09/12/2017 PRIMARYCARE PHYSICIAN: None. The patient 1s from immigration jai1 center. CHIEF COMPLAINT: Hemalemesi s. HISTORY OF PRESENT ILLNESS; The patient is a Sl-year old Hispanic incarcerated male, who was taken to Living~Lon Memorial Emergency Room with complaints of abdominal pain 1 right flank pain, __ , and hematemesis. He has a past medical history signiflcant for nonalcoholic liver cirrhosis, general·ized anxiety disorder, and depression. He was in his usual state of health until early morning, he complained of abdominal pain, right flank pa.in and started throwing up blood. His hemoglobin level at the Livingston ER was fairly stable at 12.S and hematocrit was 33.2. Ile was started on sandostatin drip and then transferred to Conroe Regional Medical Center ICU for further care. of note, his platelet level significantly decreased to 18,000. PAST MEDICALHISTORY: As mentioned 1. Nonalcoholic liver cirrhosis. 2. Depression. 3. Generalized anxiety disorder. PAST SURGICAL HISTORY: ALLERGIES: above, which includes, None. NO KNOWN DRUGALLERGIES. MEDICATIONSFROM JAIL: 100 mg daily, trazodone 40 mg daily. Reviewed. ·1he se include fo 1 i c acid 1 mg daily, Zo loft SO mg at bedtime, Aldactone 25 mg b.i.d., and omeprazole SOCIAL HISTORY: The patient is incarcerated. He is originally from Florida; however, because of the flooding, he was transferred to Texas Jail. FAMILY HISTORY: The patient is unaware of any medical problems running in the family. REVIEW OF SYSTEMS: GENERAL: Pos1t1ve for malaise. and fati~uP. HEENT: No headaches. CARDIOVASCULAR: No active chest pain. RESPIRATORY: No shortness of breath. GASTROINTESTINAL: He presents with right upper quadrant PATIENT NAME:RUIZ,FELIPE Patlent:RUIZ, FELIPE abdominal pain and ACCOUNT#: 8H9023078383 Page 1 of 3 9/19/2017 Fax Server 10:49:09 hematemesis. GENITOURINARY: Denies drsur~a.or AM PAGE he~aturia. nt pa 1 n. NEUROLOGICAL:He is moving all 4 extre~ities. PSYCHIATRIC: lie has history of depression. MUSCULOSl<.ELETAL: NO actl ve Fax Server 10/049 )01 Speech appears to be clear. LABORATORY AND DIAGNOSTIC DATA: From Livingston ER, sodium 127, potassium 4.3, BUN 85, and creatinine 1 .5. Albumin decreased to 3.3. AST 102, ALT 68, ALKP 123, and total bilirubin 10.8. CPK elevated at 322. Lipase mildly elevated at 367. BNP elevated at 4850. PTT 22.1. r~oponin I 0.076. WBC14.28, hemoglobin 12.5, hematocrit 33.2, and platelets decreased to 18. A 51-year-old incarcerated Hispanic male 1vith history of nonalcoholic liver cirrhosis, now presents with; 1. Gastrointestinal bleed. Differential diagnosis could be variceal, esophageal, or gast~ic bleeding versus peptic ulcer disease versus ~astritis. The patient has been started on oct.reoLide dr·ip. We will al~o initiate IV PPI and monitor hemoglobin/hematocrit levels, so far are stable. ~l consultation has been requested for evaluation of possible EGD. 2. Right upper quadrant abdominal pain. we will check hepatitis panel and right upper quadrant ultrasound. 3. Renal failure, unknown acute or chronic. We will hold Aldactone and other nephrotoxic medications. could be in the setting of gastrointestinal bleed. 4. Mild troponinemia at the Livingston ER with a troponin level of 0.076. could be in the setting of stress, gastrointestinal bleed. we will monitor troponin levels over here and also monitor EKG. Ille will hold antiplatelets secondary to active gastrointestinal bleed. S. Jaundice with elevated total bilirubin of 6.56 in the setting of liver cirrhosis. once again, check hepatitis panel. GI has been consulted. 6. severe thrombocytopenia secondary to liver cirrhosis. The parient will need platelet transfusion prior to EGO. 7. Depression. continue home regi~en of sertraline and trazodone. 8. Uncontrolled hype~tension. The patient is on cardene drip. Lisinopril was initiated. we will titrate medications as needed. we will discontinue lisinopril in view of renal failure and initiate beta blocker in view of history of liver cirrhosis. 9. GI and deep vein thrombosis prophylaxis to be achieved with Protonix/scDs. unable to give any blood thinners due to active gastrointestinal bleed. ASSESSMENT AND PLAN: case discussed with the patient, the guards, and the RN in detail. It has been a pleasure participating in the medical have any questions, please do not h@~itat~ to rall_ • Dictated WT: DD: OT: kb)(6); (b)(7)(C) By:~L ______ I ~_MD HP:B.HIM/FAKAL/NTS 09/12/2017 09/12/2017 15:22:12 19:48:10 ACCOUNTf: PATIENT NAME: RUlZ,~~LLP~ Patient:RUIZ, FELIPE care of the patient. MRN:BH008618SI0 2~t!~810~383 BH9023078383 Paga 2 of 3 If you 9/18/2017 Fax server confl: 2035335/ Authent:; cated El ectroni · 3991040 b .__b)(6); _____ (b)(7)(C) cal 1 y 10:49:09 si gncd ___J MD b~ (b)(6); (b)(7)(C) AM PAGE on 09/14/2017 I MD PATIE~T NAME: RUIZ,~ELIPE Patient:RUIZ, FELIPE MR.N:BH008618902~1'1t9~0i8948383 11/049 Fax Server O~:OS:15 PM on 09/14/17 at nos ACCOUNT~: BH9023078383 Page 3 of 3 Fax 9/19/2017 Server 10:49:08 AM PAGE Fax 12/049 Server CONROEREGIONALMEDICALCENTER 0917-0047 504 Medical center Blvd. Conroe, Texas 77304 ADMIT DATE: ROOMNO: AGE: PATIENT NAME: RUIZ,FELIPE ACCOUNT NO: BH9023078383 MED[CALRECORDNO: BH00861890 SEX: REPORT TYPE: DISCHARGESUMMARY 09/12/1-7 B.CCU36 Sl M (b)(6); (b)(?)(C) ADMITTING PHYSICIAN ATTENDINGPHYSICIAN MD MD ADMISSION DATE: 09/12/2017 DISCHARGEDATE.: 09/17/2017 PRIMARYCAREPHYSICIAN: Florida None. The patient is from immigration facility in jail. ADMITTING DIAGNOSIS: Hematemesis. HOSPITAL COURSE: The patient was a 51-year-old Hispanic inca~cerated male who was taken to I ivingston Memorial Emergency Room with c:ompla:ints of abdominal pain 1 right flank pain and hematemesis. He has a past medical history significant for nonalcoholic liver cirrhosis, generalized anxiety disorder and depression. Hemoglobin level at Livingston ~R was stable at 12.5 and hematocrit was stable at 33.3. He was transferred to Conroe ICU. In the hospital, he was started on octreotide drip and was followed by Dr. varia from GI and underwent EGD that was consistent with hypertensive portal gastropathy in the fundus, body of the stomach and antrum; pa.tc:hy erythema. in the bulb and second portion of the duodenum was seen. He was recommended to avoid any use of NSAIDs, recommended low-salt diet and continue medications, PPI 20 mg daily. He had mild trepone~a with a troponin level of 0.076 and 0.027. He was followed by Dr. Adnan Siddiqui. He underwent stress test on 09/16/2017 that was read as no~mal. No reversible ischemia was seen. He had normal left ventricular systolic function, calculated at 72% on stress imaging. He was fairly stable for discharge; however, a call was received early in the morning saying that the patient was hypotensive and code save had to be run. Stat labs revealed a drop of hemoglobin to 5.9 from 9.4 yesterday on 09/16/2017. The patient immediately went into respiratory failure. He was intubated. code blue was called and he was unable to be ~esuscitated, and then he was pronounced dead early in the morning. DIAGNOSESLEADING TO EXPIRATION OF THE PATIENT: 1. Possible gastroint_eslirial bleed with a massive drop in hemoglobin/hematocrit from 9.4/26.3 on 09/16/2017 to 5.9/18.4 on 09/17/2017 in setting of severe thrombocytopenia due to nonalcoholic liver cirrhosis. 2. Nonalcoholic live~ cirrhosis, status post esophagogastroduodenoscopy consistent with hypertensive portal gastropathy. 3. severe thrombocytopenia secondary to nonalcoholic liver cir~hosis. 4. Abnormal liver function tests seconda~y ro nonalcoholic liver cirrhosis. Of note 1 at the time of admission, his total bilirubin was elevated at 6.56, this morning it had normalized to 0.99. 5. sudden respiratory failure requiring ventilator support. 6. cardiac a~~est, the patient was then pronounced dead. PATIENT NAME: RUIZ,FELIPE Patient:RUIZ, FELIPE ACCOUNTf; BH9023078383 Page 1 of 2 9/19/2017 Fax Server (b)(6); (b)(7)(C) t.:. (b..:, )('::-'6 ),;a,: ("'"b )'"" (7,..:,)(:,,;C.,.,. l ,,.,.... ___ 3. (b)(6); (b)(7)(C) 10:49:08 5 7 careJ< bl( ); (b)( )(C) ___.__._,rom critical from ~---------' l,(b-)(-6)-; (-b)-(7-)(C _ )___ Dl ctated Bi.__ ,__ __ _________ lfrom Fax Server c,itical care. ~I test, intubation, and central line placement. ...J wr: DS:B.HIM/FAKAL/NTS DD: OT: Conf#: 10:40:26 2043774/DID#: 3999515 09/17/2017 09/17/2017 10:14:56 b)(6); (b)(7)(C) Authenticated 13/049 cardiology. PRINCIPAL PROCEDURES: EGD, stress • AM PAGE t by ~--------'~Don I 09/17/2017 01:04:50 PM b)(6); (b)(7)(C) Elect~onically signed by PATIENT NAME: RUIZ,FELIPE Pati,mt:RUIZ, FELIPE MRN:BH00861890 MD on 09/17 /17 at ACCOUNTf: 2~1:@tiit'OO~Om@383 1305 BH9023078383 Page 2 of 2 Fax 9/19/2017 Server 10:49:09 AM PAGE Fax Server 14/049 CONROE REGIONAL MEDICAL CENTER 09l6-0(l 100 H FiO2 (21 - 100 % 1:c'=a.,_lcc;):,_) ________ --+_-__-=~~500 oUO T1dal Volume (ML) 5 5 PEEP10.0 - 99.9 cm H20) 0.0 Pressure Support__(_0 cm H20) --------~-~~----~ I aboratory Te~s~ts~------------------ 09/17 0330 0911T 0200 Chemistry .. - S0 d' 1um 1'133 - 144 mmo Ill) Potassium (3.5 - 5.1 mmol/U Lrnoride (95 -105 mmol/L) Carbon Dioxide (21 - 32 mmol/L) Anion Gap \4.0 --15.0 GAi5-caic) "BUN (7 - ·1s 1\:1<,1Dll Crea tin, ne 10.3 5 - 1.3L /'v11 "DU .. G lomerular Filtr Rate\> 00 cstGFR) 148 0 H ' 5.4 H 105 25 18.0 H 1s· 1.49 H ' 50 I 87 Glucose (70 - 11 0 lv\C/DLJ cartic .~cid-lD.4 - L.U mmo11L; Calcium (8.5 - 10. 1 MG/DL) Total blllruLiin 10.00 -1.00 MGIDL) Direct 13il1rub1n(0.00 - 0.30 MG/DL) Indirect Bilirubin (0.2 - ·:3 l\:1G/DL) AST :15 - 37 Unit/LI Page Patient:RUIZ, FELIPE -- 12.B *H ----- 3 of 8.0 L 0.99 0.47 rl 0.:J2 114 H 9 MRN:BH00861890 2e26~~'1'l~ll!Jll%"2~8B~383 Page 3 of 9 8/18/2017 Fax Server 10:49:09 AM PAGE 19/049 Pa~~ent: RUIZ,FE~IPE Unit#:BHOOB61S90 Date:09/17/17 BH90230783B3 Fax Server AccL#: 54 - Al T (7 2 - 7B Unit/Li 104 TOtal All Phosohatase (45 117 uni 2.6 L TotaI Protein (6,4 - o.2 G1DLI 7.2 L AIcum1n (3.4-5.0 G,DU 0.9 L Albumin/Globulin Ratio (1.2 - 2.2 RATIO) 1 NORMAL <2 MG, Specimen ;l,..ppearance (1 NOR/\-\AL Index/DU ·specimen Hemo1ys1s (1 N 1Rf\.1AL1nr1e 1 1 L1 1 NOR,V1AL < 10 MG 1 09/7 7 09/17 0127 0027 l nem1~try Sodium (133 -144 mmo11_LJ Potassium (3.5 - 5.1 mmol/Ll Chloride (95 -105 mmol/L) Carbon Dioxide (21 - 32 mmol/1) Anion Cap (4.0- 15.0 GAP calc) BUN (7 -18 ,1G1DLI Creatinine (0.55 -1.30 MG/DL) Glucose (70 - 710 M DL) .iucose t7u- 1l~ Mi ,,DU I'<" 1 a1c1um (o,5 - l 0. l 1\-·\G/DL) Phosphorus (2.5 - 4.9 MG/DU Ma_gnesiurn (1-.6 - 2.6 tv\G/DL) ~pecirnen Appearance (1 NuK,v,AL lndex;DLJ Specimen Hemol 1 sis (1 NORMAi Index/DI) 143.0 3.4 L 114 H 13 "'L 76.0 H 7l LOI 9) ----1 10 6.1 "'L - 3.8: 2. 1 I NORMAL < 2 MG 1-----NORMAi_ --< 133. □ 102 4.2 24 Labora torv T ests ---- -- 09112 1510 .. 09112 1530 09/12 1530 C_ncmistr);' Ammonia (11.0 -J2.0 mcM 11IL) 90.0 *H ( K-MB" K-21(1.0 · 3.6 N ,,MU 4.9 H ---Trogonin I (0,000 -0.045 Nl,/1\-tl) 0.270 *H 226.59 11 -=Jl~Nat_riurPtic PP.rtide(0.00 - 100.Q_Q_ P(Jj~-1L) __ 09/12 1155 Chemistrv SouIum (133 -144 mmol/LJ Potassium (3.5 - 5.1 mmo!/L) Chloride 195 • 105 mmol/L) l. amon D1ox1ae (21 - 32 mmol/I) Anion Gap (4.0 - 15.0 (JAP calc) BUN (7 -18 MG/DL:, Fage Patient:RUIZ, FELIPE MRN:BH00861890 .:; of lJJ.0 4.2 102 ------- 24 7.0 67 H 8 ~~f-o/iWtl'2~%g!\383 Page 4 of 8 I®~ ~132H 9/19/2017 Fax Server 10:48:09 AM PAGE Fax Server 29/049 Pacicnt: RUIZ,FELIPE Unit#:BH0086~890 Date:09/12/17 BH9023078383 Acct#! - Creatinirii~ (0.53 - 1.30 MC7DIT .. . ,1omeru1ar Filtr Rate (>60 estGFR) Glucose (70-110 MG/DL) l .3(J H 55 L 132 H 7.8 L 6.56 H 3.35 H Calcium (8~5 - 10.1 tviG/[)L) Total Bilirubin (0.00 - 1 .00 .l\..'IG/nl) Direct Bilirubin (0.00 - 0.30 t\-iG/[)l) lnairect BI 1rurnn (0.2 - l .J tv1 -1 DU · AST (15 - 3 7 Linit/lJ-ALT(12-78 UnH/L) 3.21H Total Alk Phosphatase (45 - 117 Unit/I) I otal Protein (6.4 - 8.2 L/DLT A1uum1n _(3.4- 5.0G/DU --Albumin/Globulin Ralio (1.2 - 2.2 RATIO) Spe(.imen Appearance (1 NOR.lv1AL lndex/DL) SpecimE!_nHemolysis (1 -~_ORMAI. Index/DU 81 H 49 107 5.4 L 2;<, L 1.2 3 SMALL 5-10 MG 2 TRACF 10-25 MG Laboratory Tests 09/12 1200 Coagulation --PT (9.4 - 12.5 SECONDS) INR (0.85 - 1.11 INR Unit) 17.3 H 1.52 H PTT (Dade) (24 - 37.7 SECOND~S1~~2~9"-.4._ I ahoratory Tests --- 09/12 1200 Hematology WBC (4. 1 - 12.1 k/mm3) RBC i3.1l°- 5.5 M/mm3I 11gb tl 0.6 -15.8 G/DL) Hct (36.0 - 47.4 %) .~-1u, __ (_80.1 -101.1 t_l.J__ MCH [25.l - 35.J pg) MCHC i32:7 - 35. l G, DL) k 15. 1 H 3.50 I 1 1 .2 30.1 L - 8h.f' 37.0 .17.2 H 17.2 11 27 * L W 112.2 -16A %) P:t Count (155 - 337 _K/n7rr,3) 10.3 .MPV (7:6 - 10.4 fl) Gran% (37.8 - 82.6 %) LvmtJI1 % {AutoJ n 4.1 - 45.4 '%) f\-1ono ~10 (AutoJ \2,5 -11.7 °Jo) Eo~ '% (Auto) (0.0 - 6.2 %) Basa % (Auto) (0.0 - 2.6 °/ol ;:age Patient:RUIZ, FELIPE 65.8 1 l 12.7 H z;r 1.7 0.5 5 of 8 MRNcBH00861890 ;/iiW'll!n'~~2~~Y,,'83 Page 5 of 8 9/19/2017 Fax Server 10:49:09 AM PAGE Fax Server 30/048 Patient: RUIZ,FELIPE Unit#:BH00861890 Date:09/12/17 BH9023078383 Acct#: .. Gran# (2.0:. 13.7 K7nlm3) I vmnn #" (Auto) (0.6:. 3.8 K/rTim·~} IV1ono 1f"(Au10) \0.11 - 0.59 K/mm3/ (AUto) (0.0 - 0.4 K7mm3) Baso # (Auto) (0.0 - 0.1 k/mrr3) Add Manual [Jiff (CRITERIA DIFF/SCN) Total Counted (100 /fCELL') -TinmatUre Gran% (0.0 - 2.0 %) Seg Neutrophils % {40 - 7.'J %) Lvmnhocvtes % (.\·-\anua!) (7 2.6 ---43.5 <%) Monocytes % {MJ.nuall (4,2 ---12.7 %) tosinoPhils 0/o (.rv~anuali(O.O---5.2 %) Nucleated RBC % (0,0 - 1,0 /1 OOWBC%) Nucleated RBCs it (0.00 - 0.05 K/mm3) Toxic Granulation (NONE ON SCAN) 7'fatrlrt Fstimate (ADFQUATF ON SCANf Pit lv'lorphology Comment (NOR1\-1AL-PlTS ON Polychromasia (NONE ON SCA°') N sr AN) Hvpochromasia (NONE Poik1 OC);tosis (NONE ON SCAN) An1socvt0Sls (NON[ UN SCAN) varocytes (NONE ON SCAN! Acanthoq~cs \'.::lf2Ur) (NONE ON SCAN) Schistocytes (NONE ON SCAN) 9.95 H 1_RJ 1.91 H 0,25 0.08 MAN DIFF INDICATED 100 7.2 H ------cos·# 73 12 L 14 H 1' 1.7 H 0,25 11 :1 SLIGHT MRK I H---[R I AN) LARGE RARE SLIGHT SLIGHT Sllu!{I ...,Llr;HI FE\.V RAR, [RARE L1boratory Te"'''"-'-------- - 09/12 ·1 530 Sero lo e atitls A I 1V1A (NOnrcactTve Non Reactive _ i Hep Bs Antigen Nonreactive RE N) NEC-NONREAC Hep B Core lg/\·1Ab (Nonreactive SCREEN) Nor,Reactive --·Hepatitis C Anti God (Nonreactive S-=C"-R-=E-=E'-N"-)_.,· Ncc ...cR~---- Radiologydata: Recent Impressions: ULTRASOUND· US ABDOMEN LTD 09/12 7637 *** Report Impression ---Status: SIGNED Entered: 09/12/2017 1913 Impression: 1. /\.·\arkedly \imiteJ examination due to poor beam penetration. The liver, gallbladder, common bile duct and pancreas are inadequately Page Patient:RUIZ, FELIPE 6 cf 8 MRN:BH00861890 ~29~1!n.'l65%. Left ventricular systolic function is nor~al. The t~ans11itral spectral Doppler flow pattern ,s normal for age. The left ventricular wall motion is normal. Left Ventricle The left ventricle is normal in size. There is normal left ventricular wall thickness. Left ventricular systolic function is normal. Ejection rraction >65%. The t~ansmitral spectral Doppler flow pattern is normal tor age. The left ventricular wall motion is nor~al. Right Vent ri cl e The right ventricle Atria ·1he left atrium visualized. is normal in si2e and function. is mildly dilated. Right Mitral Valve The mitral valve is norMal in structure Tricuseid valve The tr1cuspid valve is normal in structure not suggest pulmonary hypertension. Aortic valve The aortic valve opens well. valve is not well visualized. Pulmonic valve The pulmonic valve regurgitation. The aort·ic is not well visuali2ed. atrial size is normal. IAS not well and function. and function. valve 1s mildly Doppler findings sclerotic. The aortic Trace pulmonic valvular Great Vessels The aortic root is normal size. Pericardium/Pleural There is no pericardial effusion. Fl P.,t roni call y signed b (b)(6); (b)(7)(C) ordering Physician: b)(6); (b)(7)(C) PATIENT NAME: RUIZ,FELIPE Patlent:RUIZ, FELIPE 09/17/2017 12:35 PM ACCOUNT i: BH9023078383 Page 2 of 3 do Fax Server Electronically 9/19/2017 signed ~-~-K_~_;(-bl_u_x_c i__ PATIENT NAME:RUIZ,FELIPE Patiant:RUIZ, FELIPE 10:49:09 MRN: BHO0861890 AM PAGE ~IMD on 09/17/17 38/049 at 1236 ACCOUNT#: 2~-~N!tf 6~~0~f383 Fax BH9023078383 Page 3 of 3 Server 9/19/2017 Fax Server Patient Name: 10:49:09 AM PAGE Unit RUIZ,FELIPE No: NM MYOCRD SPECT R/S Pharmacologic Protocol HULT Myocardial BH00861890 CPT CODE: 78452 EXAMS: 020699234 Fax Server 39/049 Perfusion Imaging Rest/Stress test; 1-day INDICATION: Diagnosis pain Clinical Patient chest of corondry arlery disease in patient with cardiac with atypical chest and atypical history: is pain a 51-year-old male risk factors PROCEDURE: Pharmacological stress testing was performed with Lexiscan 0.4 rng/5 mL from a prefilled syringe that was discarded after single use. The heart rate increased appropriately during Lexiscan infusion. Following Lexiscan injection and saline flush, the patient was injected with 32.0 mer of sestamibi and stress gated tomographic imaging was performed. Prior, resting imaging was also performed following the injection of 14.7 mCI of Sestamibi. FINDINGS: The EKG portion of the stress test shows no acute ST changes. overall quality of the study is fair. The left ventricle is normal in size. the raw images, there is no motion artifact. There is significant amount of gut uptake noted on both stress and rest images. On Stress: The stress SPECT images demonstrate hamogenous tracer distribution throughout the myocardium. The gated stress SPECT imaging reveals normal myocardial thickening and wall motion, The calculated left ventricle ejection fraction of 72%. Rest: The rest throughout SPECT images again the myocardium. demonstrate In comparing the stress and rest ischemia. There is no transient images, ischemic tracer homogenous there is dilatation, distribution no reversible calculated TID is 1.00. IMPRESSION: Normal myocardial perfusion 2. No reversible ischemia 1. 3. Normal left stress imaging ventricular inaging systolic l.TZ.Mli'.· Patient:RUIZ, FELIPE stress function, 'OTTT'7. test calculated li'i.".T.T'O~ Paga 1 of 2 EF 72% on Fax Server 9/19/2017 Patient Name: 10:49:09 AM PAGE RUIZ,FELIPB Unit No: BP.O0861890 CPT CODE: EX:AMS: 020699234 Fax Server 40/049 NM MYOCRD SPECT R/S MULT 78452 ** Electronically Signed Reported Nuclear ae CC: Patient:RUIZ, Medicine Cardiology riate software for ; )(7)(C) FELIPE kb)(6); (b)(7)(C) by~l _______ and signed exams rocessin i ~b on 09 16 2017 by; at 1253 ** b)(6); (b)(7)(C) performed on dual · head cameras MD Paga 2 of 2 with 9/19/2017 Fax Server 10:49:09 AM PAGE Fax Server 41/049 (b)(6); (b)(?)(C) FAX: FAX: FAX:._ ____________ _, 936-585 936-585 (b)(6); (b)(?)(C) M 936-756._ __ Ca.rnpus: St: C ADM _, --------------------------------------------------------------------~---------Unit No: BHC0861890 Patient Name: RUIZ,FELIPE EXAMS: 020699688 CPT CODE: 71010 XR CHEST 1 V AFTER HOURS SERVICE AP Portable ON: 9/17/2017 5:06 AM Chest Location Cade M12 HISTORY: POST LINE PLACEMENT FINDINGS: Inspiration is n.idway iliove the is shallow. NGT remains in the d.isLdl stomach. The ETT between the clavicles and the oa.rina, appi:oxirnately 3 cm carina. There are no infiltrates. There a.re no pleur~l effusions. The~e is no pneumcthorax. Cardiac silhouette and rnediastinum appear within normal limits. IMPRESSION: 1. No active intrathoracic ETT and NGT in place. 2. ** ** findings. Kb)(6); (b)(?)(C) Electronically Signed by~I---~---------' on 09/17/2017 at 05~0~7 _________ Reported d.lld signed by:~f b_)(-6)-; (-b)-(?_)(_cJ________ *~ •_~---~ cc: l(b)(6); (b)(?)(C) Dictated Date/Time: 09/17/2017 (0507) Technol.ogist: b)(6); Bickerstaff - Agency Transcribed Date Time: 09/17/2017 (0507) Orig Print D/T: S: 09/17/2017 (0510) l"'/"\M'Or,'ll' Patient:RUIZ, FELIPE 1,r.n1 r'T'P Tl-1/n'l:l.c:l MRN:BH00861890 lJ'hMt.'.· By ._(b)(6); (b)(?)(C) .1 'DTTT?. 2~~N~t f6~~0~Jl383 i;"'li'.T.TU'I.'! Page 1 of 1 __, Fax 8/19/2017 Server FAX: FAX: 10:48:08 r b)(6); (b)(7)(C) AM PAGE 43/049 (b)(6); (b)(7)(C) 936-585 Fax Server Campus: C St: ADM 936-585 Patien~ RUIZ,FELIPE Name; UniL ** EXAMS: 020699673 Report P.a3 Been No: BH00851890 Amended** CPT CODE: XR CHEST 1 V 71010 Addendum ADDENDUM: 020699673 - 09/17/2017 SIGNED 09/17/2017 RAD/CXRl Addendum: esu ts (b)(6); (b)(7)(C) were verbally (b)(6); (b)(7)(C) 1 : 53 ** ** Electronically AM communicated by WHRA by on- call. telephone to nurse I (b)(6); (b)(7)(C) l Signed by~ ___________ __.** on 09/17/2017 at 01 ** Reported and signed by: b)( 6 ); (b)(?)(C) Dictated Date/Time: 09/1---=7~2~0~1~7-(~0~1~5~4~)----~ Report AFTER HOURS SERVICE AP Portable ON: 9/17/2017 1:41 AM Chest Location Code M12 HISTORY: ETT PLACEMENT FINDINGS: Inspiration located in effusions. mediastinum is shallow. NG tube is noted in the stomach. The the right mainstem bronchus. There are no pleural There is no pneumothorax. Cardiac silhouette and appear ;.,ithin normal limits. ETT is IMPRESSION; ETT in the right ma.instem bronchus. It should be p·J.lled back 7 cm. *******************FOR INTERNAL CODING PURPOSES ONLY**************** RESULT CODE: CVR * * Electronically ** Signed by l(b)( 5); (b)(?)(C) on O9 /1 7 / 2 01.,.. 7=--a-t,--o-=--1=--4.,....3:=-------~. Reported and signed byl- (b_)(_6)_; (_b)_(7_)(_C _ ) --------~ l\TZ. Mk' • Patient:RUIZ, FELIPE 'CTTT 7 I** * ,..-., T. T 'Cli' Page 1 of 2 Fax Server FAX: 9/19/2017 10:49:09 AM PAGE r b)(6); (b)(?)(C) Fax Server 44/049 Campus: C St: FAX: Patient Name: RUIZ,FELIPE Unit ** EXAMS: 020699673 XR CHEST 1 V CC: !(b)(6); (b)(?)(C) Patient:RUIZ, FELIPE Report Has Been No: BH00861890 Amended** CPT CODE: 71010 ADM Fax Server FAX: 9/19/2017 10:49:09 b)(6); r b)(6); (b)(7)(C) 936-585 b)(7)(C) 936-585..._ __ _. FAX: Patient Name: AM PAGE Unit RUIZ,FELIPE Fax Server 45/049 Campus: No: St: C ADM BH00861890 CPT CODE: EXAMS: 020699673 71010 XR CHEST 1 V AFTER HOURS SERVICE AP PorLable Location ON: 9/17/2017 1:41 AH Chest Code M12 HISTORY: ETT PLACEMENT FINDINGS: Inspiration located in effusions. mediastinum is shallow. NG tube is noted in the stomach. The the ~ight m.ainstem bronchus. There are no pleural There is no pneum0thorax. Cardiac silhouette and appear within normal limits. ETT is IMPRESSION: E~T in the right mainstem bronchus. It should be pulled back 7 cm. *******************FOR INTERNALCODING PURPOSES ONLY**************** RESULT CODE: CVR ** ** cc: Electronically Dat~/Tiroe· st Tr;i.n.scribed Print FELIPE ng/11120 J bl( 5); (b)(?)(C) D;i.te/Time: D/T: l""f'I-..T0,....,1:1Ml:'li Patient:RUIZ, ** ....,I l(b)(6); (b)(7)(C) Dictated Technol.ogi Orig byf Signed ._b_lC_5)_;(_b)_C7_l(_C _) _______ on 09/17/2017 at 0143 Reported and signed by~k b-)(6 - )-; (-b)-(7-)(C _ )______ l"''T'D S: 09/17/2017 T't.T /t"\'Q~ 1 1 09/17/2011 (0143) (0143) (0147) ByJ NZ. Ml<.· 5 bl( ); (b)(?)(C) OTTT !7 'l.'RT. T 'D"I ---------~ l(b)(6); (b)(7)(C) Technologist:Transcril:,ed Orig Print !"'nNPf'lli! Patiant:RUIZ, 71010 . Dictated FELIPE AI:M T 18 x-ray CLINICAL ** St; CPT CODE: XR CHEST 1 V Location: Chest C BH00861890 EXAMS: 020697794 Fax Server 46/049 Date/Time: 09/12/2017 (1726) b_)(_6)_;(=b)~(7~)(_C_) __ ~~~ Date Time: 09 2 2017 (1726) D/T: S: 09/12/2017 (1729) Ml.'f"I l"''l'D Tl-1 //'1-.::t.C: MRN:BHO086189O (b)(6); (b)(7)(C) l ______ _, By: .__ I\T.Z.Mli'.• PT1T~- J.'Jll.'!"'Dli'. 2~-Y~rl~~~~0221ffi7~ps3 Paga 1 of 1 ** ** age Fax Server 9/19/2017 Patient Name: EXAMS: 020697791 AM PAGE 10:49:09 RUIZ,FELIPE Fax Server 47/049 Unit No: EH00861890 CPT CODE: US ABDOMEN LTD 76705 Site:R16 Limited Abdominal History: Right liver cirrho.s;is. Coll'\Parison: upper quadrant No prior Technique: Gray Findings: This examination The liver markedly Ultrasound similar scale and is markedly is measures limited. The The gallbladder negative. is The duct common bile abdominal 15.2 main not studies color pain, are cm in portal imaging due length. vein to is not is The visualized unremarka.ble. There is not poor on this identified nonalcoholic comparison. utilized. beam penetration. of the visualized. liver Murphy sign is is exa.rnination. cm, with a cortical no hydronephrosis, visu~lized. portions no evidence were Sonographic The right kidney measures 10.9 K 5.8 x 4.2 thickness measuring 1.9 cm. rt demonstrates nephrolithiasis or cortical thinning. The pancreas for Evaluation not well well-visualized. is of available Doppler limited history of the abdominal aorta and IVC arc 0£ ascites. I:mpressian: 1. Markedly limited examination due to poor beam penetration. The liver, gallbladder, common bile duct and pancreas are inadequately visualized on this examination. 2. Unremarkable right kidney and visualized portions of the abdominal aorta and rvc. * Electronically Signed '1t by l(b}(5); (b)(?)(C) Reported and signed Ion 09/12/2017 at 1909 by: .... r b-)(-6)_; (-b)-(7-)(C _ )______ (b)(6); (b)(7)(C) l cc:_ Technologist: l(b)(6); (b)(?)(C) ~ Agen,=c..... v~~~-----~ Trnscrbc. D/T: 09/12/2017 (1909) l(b}(6); (b)(7)(C) Orig Print D/T: S: 09/12/2017 (1913) P=obe: rr.~<"l'li' Patient:RUIZ, FELIPE 'l,fl,'.n r'T'P Tl,1/f"lP~ 'IJZ.Mt'.· I t:>fTT'7. 'i<'l<'T.T'O'li'. MRN:BH00861890 io~6~'ffl.f-b®6%02zgrn383 Page 1 of 1 ** ___. Fax Server 9/19/2017 0913-0070 10:49:09 AM PAGE Fax Server 48/049 CONROE REGIONAL MEDICAL CENTER Center Blvd. Texas 77304 504 Medical Conroe, PATIENT RUTZ ffl IPE NA.MF' ACCOUNT NO: kb)(6); (b)(7)(C) 09/12/17 ADMIT DATE: ROOM NO: I B.ICU18 MEDICALRECORDNO: BH00861890 AGE: 51 REPORT TYPE: SEX: E.NDO\IIORKS REPORT ADMITTING PHYSICIAN AllENDlNG PHYSICIAN.__ Indications: M (b)(B); (b)(?)(C) _______ Hematemesis __, (578.0). Consent: The benefits, risks, and alternatives to the procedure and informed consent was obtained from the patient. were discussed Pre-sedation Assessment: Hand P completed, I have examined the patient on this date and have reviewed the medical history, drug history, and previous anesthesia experience. Results of the relevant diagnostic studies have been reviewed. Planned choice of anesthesia, risk, complications, benefits and alternatives have been discussed. Preparation: EKG, pulse, pulse oximetry, throughout the procedure. An intravenous kept IIIPO. Medications: see anesthesia and blood pressure line was inserted. were monitored The patient was report. Procedure: The gastroscope was passed through the mouth under direct visualization and was advanced with ease to the 2nd portion of the duodenum. The scope was with drawn and the mucosa was carefully examined. The views were good. Findings: Esophagus: The proximal third of the esophagus, middle third of the esophagus, and distal third of the esophagus appeared to be normal. Stomach: Hypertensive portal gastropathy was found in the fundus, body of the stomach, and antrum. Duodenum: Patchy erythema in bulb and 2nd portion. Specimens Sent: None, unless Estimated Blood Loss: Insignificant. Unplarmed EvenLs: Ther·e othe~wise noted. wer·e no unplanned evenls. summary: No~mal proximal third ot the esophagus, middle third of the esophagus, and distal third of the esophagus. Hypertensive portal gastropathy was found in the fundus, ~ody of the stomach, and an~rum (S72.8). Patchy erythema in bulb and 2nd portion. Recommendations: Avoid all non-steroidal anti-inflammatory drugs (NSAID's) including but not limited to Aspi~in, Ibuprofen, Advil, Motrin, and Nuprin. Return to floor. Resume low salt diet as tolerated. Continue current medications. PPI 20 mg daily. PATIENT NAME: Patient:RUIZ, FELIPE RUIZ,FELIPE ACCOUNT #: ~b)(6); (b)(7)(C) Page 1 of 2 Fax Server Assisted 9/19/2017 By: The procedure 10:49:09 was assisted AM PAGE (b)(6); (b)(?)(C) signed l by ~.-------~on PATIENT NAME:RUIZ,FELIPE Patient:RUIZ, FELIPE Server by ~/A. I Procedure codes: [432 3 5] EGD by l(b)(6); (b)(?)(C) Version 1, electronically signed ~.--------~on 07:47 AM ~lectronically Fax 49/049 I 09/13/17 ACCOUNT 09/l~/2017 at 0742 it; l(b)(6); (b)(?)(C) Paga 2 of2 at b)(6); (b)(?)(C) _,h ~" 8/1812017 IALMAZAN RUIZ, FELIPE I A11enNumcer, A028866428 I GCSO17MNI005042 I 8/1812017 IFinal Treatment I I (b)(6); (b)(?)(C) I l(b)(6); ~- l(b)(6); ~- ~~)(6); b)(?)(C) I l)b)(6); I /h\/ 7\/C:\ w )(6); b)(?)(C) 2020-ICLl-00006 I 2913 I I I c/o of difficultv seeina I 8/22/2017 ALMAZAN RUIZ, FELIPE AlienNumber, A028866428 GCS017MNI005042 Manual (b)(6); (b)(?)(C) 2020-ICLl-00006 2914 (b)(6); (b)(?)(C) 8/23/2017 PT HAS ALREADY BEEN c/o eyes burning/vision difficulty request glasses/review REFERRED TO MO meds b)(6); (b)(7)(C) ~ /~ 8/30/2017 I ALMAZA N RUIZ, FELIPE I A lienNumber, A028866428 I GCS017MN I005042 I 8/30/2017 TFinal Tre atmeniT b)(6); (b)(7)(C) 2020-ICLl-00006 2915 T I I inmate cJo oainfu l ioints and reauests eve exam. b)(6); (b)(7)(C) r ~ 9/2/2017 -'---°' /I I ALMAZAN RUIZ , FELIPE I Alien Number, A028866428 I GCSO17MN I005042 I 91212017 I Final Treatment (b)(6); (b)(7)(C) 2020-ICLl-00006 2916 I I I I PATIENT C/O HEADACHE AND EYE PAIN, PATIENT REQUEST GLASSES TO SEE . l(b)(6); (b)(7)(C) From : 6 Dec 2017 16:33:03 +0000 Sent : To : !(b)/6): (b)(7)(C) Subject: Attachments : ! FW: Krome and Glades interview list - ADDING ON Almazan-Ruiz Sick Call Logs.pdf Can you print out one copy of this? Thank you! l(b)(6); (b)(7)(C) Management & Program Analyst ICE/OPR/ERAU 950 L'Enfant Plaza S Washin C 20536 202-73 (desk) (cell) 202 -25 (b)(5); (b)(?)(C) From~ (b)(6); (b)(7)(C) s~nt:Thursday.November30. 201zs:10 PM T (b)(6); (b)(7)(C) ________________________________ C ..,__ __, Subject: RE: Krome and Glades interview list - ADDING ON The following requested items are attached .. Glades Medical Staff Interview Schedule Almazan-Ruiz Sick Call activity log Glades Medical Staff Listing and Monthly Schedule From~ (b)(6); (b)(7)(C) Sent: Thursday, November 30, 2017 12:56 PM To:l (b)(6); (b)(7)(C) I Cc:I (b)(6); (b)(7)(C) Subject: RE: Krome and Glades interview list - ADDING ON . kb)(6); (b)(7)(C) Ma1or ~l--------~ Please see below regarding the death inquiry. Three more individuals for interview. Also, the staffing roster and plan, as well as the sick call logs, are requested. Thanks. Sent with BlackBerry Work (www.blackberry.com ) 2020-ICLl-00006 2917 From: r )(6); (b)(7)(C) Date: · 'hursday, Nov 30, 2017 , 12:42 PM To: 1b )(6); (b)(7)(C) Cc : Subj ect : RE: Krome and Glad es interview list - ADDING ON Good afternoon, I apologize to have to add more employees to the list, however we need to speak to 3 LPNs at Glades that triaged sick calls. Unfortunately, their signatures are hard to read and we have not yet received the staffing roster. What we could decipher was: (b)(6); (b)(7)(C) If possible, would we be able to get the medical staffing roster and staffing plan prior to arriving? Also, we are still missing the sick call log. Was there any luck getting that from the contractor . Thank you! r b)(6); (b)(7)(C) 1 Management & Program Analyst ICE/OPR/ERAU 950 L'Enfant Plaza SW Washin ton DC 2053 202 -732 (b)(5); desk) 202-253 i~\i~\icl ~JC7lCcell) Sen: er 30 2017 12:16 PM To (b)(6); (b)(7)(C) Cc S c-,-:::-=-:c:--r,,,...,..==::-==....,,..,, a = e=-= s'""1-=c nc-:: e:-:: rv""1-::: ew =-re-=t ,s Good afternoon, I wanted to check back on the interview schedule for Krome and Glades. Will it be possible to get it by tomorrow? Thank you and please let me know if there are any issues. l(b)(6); (b)(7)(C) Management & Program Analyst ICE/OPR/ERAU 950 L'Enfant Plaza swf?!\~/ :,~, Washin ton DC 20536 202 -732 (b)(5); desk) 202 -253 ~?<7lCcell) F . s -~----.--' T 2020-ICLl-00006 2918 I Cc:l (b)(6); (b)(7)(C) SutiJect: RE:Krome and Glades interview list Good morning, I have attached the interview schedule template we use. I'm also re-attaching the list of people we would like to interview. There is one additional name for Krome, highlighted. There is no change to the Glades list. Here is a list of documents we will need at Krome for review, if any are available now to be sent we would be glad to review them ahead of time: • • Original copy of the eCW available on site Credential files on site: ""'l (b"")(""' 5)-; <""' b)""' (?""' )(""' C,... ) -----------------------. the others were reviewed at the last DDR. • All scanned medical documents not previously filed in the record • • All complete telephone encounters Nursing Guidelines for sore throat, foot fungus, and general body itching (pruritus) • MARS for the month of August • Med PARSand schedule of outside appointments for hematology, ophthalmology, and radiology (ultrasound) • Non-formulary approval of the drug Rifaximin • Sick call logs for the period of July 11 to August 12, 2017 Here is a list of documents we will need at Glades for review, if any are available now to be sent we would be glad to review them ahead of time: • Original medical record on site • Credential files of all interviewees on site • Staff Roster • Staff Schedule • 2017 Staffing Guidelines • • Copies of psychiatry and optometry consultations if done Physical examination/dental training record for j~(b-)(6_ )_; (-b)-(7-)(C_ )___ • Nursing Protocols for muscular skeletal problems, general pain, and vision disturbance • Copy of problem list • Medication administration records for August and September 2017 I fb )(6); (b)(7)(C) Management & Program Analyst ICE/OPR/ERAU 950 L'EnfantPlaza SW; 1st Floor Washington, DC20536 202-~32!<_>_ ; (b _>_ <_ >c_> <___ _.ILVN - responded to the housing unit prior to ERtransport Please let me know if I should work with someone else on this. Also, will you be our contac t for onsite? If not, would you know who that would be we have need to request one item t o be physica lly present and also just talk about logi stics. Thank you! l Req Sto,t: 8/24/2017 Req End: 8/29120[7 Fully Admini~tercd: 8ti9tl0l7 1:======~:==::==::==::===s:c=a::==s~=~:==::--- r ~ -····- ....... .... ··-··· ---- -·-- ------ ·-··-· -·- ml}~~}~~; I yd (b)(~); _ j End: 9/IO/]0J"/ ! c Take l Liquid by mouth 2 tim cs per day about:blank not I YES availablc/Phann::1-r, b\/6\ nalilied vi.a.fax YES /bl/7\/C\ YPS I' i - 2 - 0900 Maalo, 30 or 5 days as m::edt:d RogSeart: 811212017 Roq End: 8116/2017 Fully Administ<:rcd: 11612017 NOJCb/\~/;,-, YES /hi/RI· ' Di:,;,:cnnlinucd: 9/61201"/ -- -------· ! ~~C~i~OSE\O GMIJH1LSOLN 10 SOJ,N by mouto 2 cimcsper day for 30 da)'s. a.~needed Rcq Start: 811Z/2017 Roq ·L- U[ (b)(6); YFS / h\ / 7 \/ LJ YE.J \~11 ~);,_,I (b )(6); .. ·----~=oe 2020-ICLl-00006 2930 mK b/\~L ! -· vco h i /R I· L 9/20/2017 MAR/TAR for: ALMAZAN RUIZ, FELIPE, #GCSOI 7MNI005042 @ REL EA SE ~I~ii:f ~~~\~;{ LJ······ LJ······ LJ ..... LJ ....LJ····· LJ···· LJ ...... LJ····· LJ ....LJ·LJ nsl ~J(6); (bJ D1s.contlnucd: )(C) I 91612017 Page 2 of9 1~ /6\r'-«!(b I (b)(6); (b)(7)(C) XB)j ~□[□==== ······· ······· 1 2 r;~~t-------,J;~. ;:;:a1~~~~ :::ili~S~•c:End - ······· ······· ······· 0···01 ·········· ·- ······ ······· ····· :i times per day ,;, far JO D1s.conbnued. 9/JflUU KOr4(b)(6);! .. = O'.!- 0900 SERTRAI.INF. HCL JOOMG TAB 100 Kb)(6); (b)(7)(C) I KOPq(b)(6); ! i=====1~====~~=~~--::-~-~------it--- Take I Table-----...----,..----- 21 MG TARI.FT 21 Taler:I T.abldby mouth 2 tim<:sper day YFS YESl (b)(6); (b)(7)(C) for JOday:;Rcq Start.: 8/12/2017 Req Fod· 9/10/2017 Disi;ontinucd: 91612017 ~!g;~~~~~~~~~~~□□□Kol(b)(6); 8/\412011 Rcq 10/1312017 End: I lvr.n (b)(6); Iv,-....., l/bl/6) /bl/7l/Cl I KO ta.-..\/ 7 \/ Dis:cont.inued: 91712017 02 -O?DO X!FAXAN SID MG TAIi iSO Take I T.at>l-e:l by mouth 2 times;per da}' for 30 day~ Req St.a.it; 8/1212017 Req 911012017 Eod: Di sc:oncinlied: 9/M20[7 0S-2100 IWWUilJLJW ! I I I II i 111111~ ~,::.:,=·::;:·::. Ct.OTRIMA1.01.F l % CR.Mby moueh2 !i mt=:\pee d.a.y for 7 day:\ Rt11 SI.art: 8/12/2017 Req End: 8118/20[7 fu[ly ',e~ ,~ ~~ '" ,w '"~ ,e, ~ l'ir'~ ..lb ~,_ )~(-6~):;-(~b~l.... (,.. 7.... )~(... C _-~ )-=--=--=--=--=--=-:":.~-=--=--=--=--:.:-:.-=.::-=.::":.~-=--=--=--= Administered: 8/18/2017 05 - 2[00 DOC!JSATE ;omuM IO0MG akc I Capsule hy 11nLJth 2 timc!I.per day or 30 days .as;needed ====a~=====:~---~:----~p--- b)(6); YES b)/7)/ b)(6); YFS h \/ 7 1/ Reg Start: 8/12/2017 Reg Fod: 9/10/2017 Di.scontinucd: 917/20\ 7 Kb)(6); KO~ h\171/rl about:blank 2020-ICLl-00006 2931 9/20/2017 I MAR/TARfor: ALMAZANRUIZ, FELIPE,#GCSO17MNI005042@RELEASE l°isconti nuod: 916120l7 0) - 2100 Maalox 30 J__ll __ILJLJLJLJLJLJLJLJLII II c.cTake 1 Liquidby mouth?.times per day for S ,,fay.sas c.ecded Rtq Start: &11112017 R«i End: R/l6/701"/ Fully Adminislc:::rcd: 8/16/2017 OS-2100 II [[[llijjj~ fROCTOSOL 2 S% 9/1J/ZOJ7 Dtscontmucd 9/7/2017 .. 05-2100 SERTRALINE HCL I00MGTAR IL II YESt ~/\~/;~I lfoj ~k~kJNO NO< NOl(b)(6); [[ IVFO /h \/R\ · mrrrmn nf1B NolEl> ApplyI Cream topic.al i'.ttm<:sper day for JCJ day" Rcq Searl S/1412017 Re~ l:nd Page 3 of9 KOi' .f,1,, 1(6)' . I 100 T;i.kc:1 Tablet by rnou(h I timc:p-erdily for 14 days Req Start: &/I 7.l?.017R,q End· S/25/2017 YES ,~ 1\~\,_ m! (bl(6l: I I b)/6 ) (b)(7ic) !(b)(6); YES YE~ ml\~/\~ /;,I I Discrmlinued: 8/2212017 --- - . 05-2100 .. -- --- .. Take I Tablet by rnoulh2 times per day for 30 days Rcq Stan: 8/121201"/ R,q End: ...... ---- ' SPIRONOLACTONE 1.5MGTAB LET21 I ... -· ...... ····- . - - YES \~1\~/;,_ -···· YESfbl(6): ! YES( ~ YF.S j(b)(6); 9/10/2017 Discontinued· 9/6/20] J '-"~:1.: ._,._,,:,, b)(6) : (b)(7)(Cl - D5 - 1.100 YES (b)(6 ); I YES b)(6); I -- -- LJLJ[IJ[ ~UJJ TRAZODONE SO MGT AHL£T50 I pa q 115 J th\1 7 \t r \ Rcq Slart: - 81220.017Req End: 10/2012017 Discoo1it11.1ed· ?/7/'2017 -. OS - 2100 ,o TRAZOl>ONE MGTA!lLET SO I T,kc I Tablet by mouth1 time perday for 14 days Rcq St~n: --· 81\2/iO 17 Rcq fod: {b )(6); YF /h \/ 7 \/(:\ YES (b)(6); /h\/ 7 \/ YJ.iS;~ YES J(b)(6); I ~(6 ); (b)(7)(2) 812512017 Dis~untinucd.' ~o5 -no" 8122/2017... --- TRAZODDNE HCL 50 MG l/2 tab PO at bedLi1nex 60 days Req start: &12mo l'I Reg J;nd: L0/20120IJ Diicontirtued: Yfl/ZUl'/ OS-2100 Tl!.A7.000NF. HCL 50 MG T~k-c I T81.Jlcc b)· nioudi I tin1e per d:a.yfor 10 day,; Rcq Slan:8/12/2017 Rcq F.nd: 9/10/2017 .. . Discontin11ed: 8/1212017 .. illflWDEJLn□[[ [_ illill~~ ···- . ... .....• TRIAMC:INOLONI! 0.1% Cl<.f'AM O. L CRM 2 time-5 pcr d.a.y for 60 days Req Start: 8/1412017 Req End: 10/11/2017 ---- -···- Di.~continue-.d: 9/712017 05-'.i100X1FAXAN 550 MG TAB550 T21kcI T.i!.bl-el by mouth2 times;per day for JOd.iys.Rcq Start: 8/1212017 R~o,-OOM" .. -- [si12120J"1 YES [811312011 . IILACTULOSE\0 GM/\5 ML SOI.N IQ ][XlfAXAN ,so MG TAIJ 5S0 ·· ··71R,a,on (b)(6); (b)(7)(C) I~ - o~lsrlRONOLAf:TONF. 25 MG TARJ.fiT?.i ___ Jo2 - 0900 lfcLoiRrMAzor:F. 1 % . --]102 -0900 l[HYDROCORTJSONEI% l•m.1:wnUNO [&112/2017 1u,cr I I _:___J I I I 9/20/2017 MARJTAR for: ALMAZAN RUIZ, FELIPE, 11-GCSO l 7MNI005042 @ RELEASE ls11s12011 l!No UM-0900 b)(6); l~AXAN;soMGTABsso lt[s~=.11';'5/'20:=:=1"', ~~[Y=.E""s====l1~10"'2 =_ 09~oo==H11iM~,=-=.1,=,,.-=-1,:=:o...;~~~ ..;.;;;.;;....:;-=.::_:_:~- ~-==== §"s:12onI~_ OP 1102 - 0900 llrRJAMCINOLONE0.1% 1102-MOO )[rROCTOSOL25¾ ll□s - [s11s12on lf~s_ 1[0_1 - 2100 1HYDROcoRrrsoNr: ~- l[TRAZODONE 1% SO MG TABLET 10 . ....;;;..:.;; INA I NA INA I NA [NA NA NA NA 1102 - 0900 1"2Qili_"cTE SODIUM 100 MG NA NA [8116/2017 l[YES J102-0900 UMULTIVITAMIN NA .. lol-0900 - - jOMEPRAZOLEDR20MGCAPSUL_E_·2_0~~-,-j I [02-0900 LACTULOSE 10GW15 ML.SO·[:;;;lO ~ln/2017 JIYES -- - ___ 1[02-0900 [SI'!RONOLACTONE25MGTAJILET2S §mo-17 .. -l[Kor . ]102 - o.9§ ____ ___]1c1.01RIMAZOLE 1¾ 18116/2017 JIYES &11612011 lfYF.S 8/16/2017 IIYES Js1161:®iJ(KoP jo2-0900 1% [[&i:AXAN550MGTAB5'.>0 1!02-0900 [IMoalodOec Ho2 - 0900 ITRIAMCINOLONEu. 1% CREAM lfop [3116/2017 HYES Hos-2100 IS116/2011 11'1'.E~ &/161?.017 IIYFS l(os - 21oo 05 - 2100 3116/2017 [os_-2!~=-.Jc1.oTR1MAZoi.E 1lo20900 l[YES !11116/201·1 HNil --~ 0.1 NA- .. I NA I ---.--1 jNA ·=---~-~~~---- --· .....- j[NA I _l[NA I !NA NA NA NA NA NA NA NA NA -- J I.ACTUJ,OSH 10 GM'J s ML SOLN 10 [SPIRONOLACTONH25 MG TAIJLET 25 - -- ]HYDROCORTiSONE I% -- · 11TRAZODONE50MGTADLET50 ) XJFAXAN sso MNE o 1•i:c:REAMo 1 l[os -210_0=i __J ]IN_A_ NA NA---·--·--. NA NA · J~a,lo.-30 c, [os - 2100 . Med nocavail.a.ble/Pham:1acy notifiedvia fa:i,;: NA XIFAXAN 550 MG TAil s:io ..=~~-ir:[o-=-s~-2cc1':".oo ...... 0 CREAM oi lsERTRALINEHCL 100 ~ciTAB 100 2100 [os :.2~ o ==f,; b)(7)(C) Page 5 of9 NA NA NA INA I INA I NA INA NA INA NA INA Met.Inot .i\V.aihblc/'Will [(:-fax or-dcr- NA INA INA NA INA I I NA NA NA NA NA 1~[8=/1=7=/2=01=7=:l:=Y=E=S===~:=0=2=-0=90=0==~:=[D=O=C=lJ=SA=rn=·=~s=o=p_-n_JM_I_OO_M_G.::__,_~~-=~~1$/171?.017 !YES 02-0900 ilMULTlVITAM lN [811712017 IYl'S j[vris __ 02-0900 ][□2--·0900 [81171Wl7 HYES 1[02• 0900 fii1'1;.2e1i7 - - 7 [s11mo11 IINO 11□2-0900 [811712017 ]lifo 8/17/2017 i:KOP 1[02_:~900_ 02 - 0900 KOP IYES /sm12011 Uns ls11mo17 HYES JS/17/2017 [!Kor NA 10 GM/I 5 ML SOLN 10 NA l-ACTUJ.OSE ISPIRONOLACTONE25 MG TAllLET2'.> lmnROCORTISONJ:1 % jXIFAXAN550MGTAB;;o TRIAMCINOLONE O.l % CREAM 0.1 02 - 0900 [8117/20177YES ls1n12011 IIOMEP)I.AZOl.F.PR20MGCAPSUJ.E10 05-2100 os- 2100 •w~ -- •~ j~ "" lloocusATh o, - 2100 LACnJLusE -- n '"" 100 MG soomM 10 <;w1s· ~1L soiN INA NA [NA ~cd nut availabh:Iwill n:-fax order INA \.'lednet availaDle/will re-fax order INA NA jNA :-IA :,!_A- !NA ia · ✓~- -:,/A 110s - 2100 11012100 [CLOTRlMAZOLr: 1 % 'IA !siimoyi::::::HYFs IIHYDROCORTiSONI' I~ 'IA_ js/17/7.on jRmt.m11 l(os - 2100 01 - i100 !!No 1sm12on[!KoP I 7ios -J.too l[o,.2100 . ·-· !TRAZODONtl:>oMG TABLEna a TAB ,,o IITRIAMCINOLONE0.1% CREAM0.1 fROCTOSOL D% I LACT_IJLOSE_IO (;M,'\~ML 0 or [81181:!017 j[l=v=•i=l•=bl=e/l'=h=•=""=•=cy=n=•=ti=fl•=d=v=i•=f•='===---:[NA-·-J :,/A l= ~A ============ ,-,---7INA INA 1=4= ,ed=n=o=I '="='i=l•=bl=c/P=h='=""=•=ov= •=•=li=fic=d=v=ia=f•~•~---=~~- J[TRJAMCINOLONE O.l % CREAM 0.1 ]IPROCTOSoi. is.;.·-_,_,~---__ , -ISERTI\AJ.lNEHCL lOOMGTAfl 100 DUCUSAlE SODIUM ioo MG [lo:i'i 100- --. I .. . r'IA===========-=·====l='/A======~-~----~-__,INA u 1--~A-~~========= 2020-ICLl-00006 2934 ___ _] =s[NA 1 _=---i I ™ - ___ =~[NA"""--- 9/20/2017 MAR/TAR for: ALMAZAN RUIZ, FELIPE, #GCSO l 7MNI005042 @ RELEASE [!118/'lOii_J YES [81180017- l[YES,, .=:J 11118/'lOJl l~or CLOTRIMAZQLE l % _ 1ra1- 2100 lilli/2017 IIKoP ~~rDROCORTlSONI! l% [il181'l01l IYES ITRAzonoNJ; sci MG TABLET 10 [811812017 IINO XIFAXAN 550MG TAR .1.10 [81\8/2017 ][iM 1[02- 0900 I INA JISER!RAf-INEHCL 100 MGTA!l 100 OCUSATE SODIUM 100 MG ·1,M 1(02- 0900_ :~ 1(02- 0900 lfm="o900 · ][NA NA NA 1102- 0900 IIYEs INA [NA NEO.\%CREAMO.I IIPROCTOSQL2.1% l~fKOr YES js12012011 jYES js12012011 Js12012011_-_]fr_Fs I R 20 MG CAPSlJI.E 20 ---GWI S ML SOJ.N 10 --- INA IINA .... [NA',, [NA GTAB lSO I~ [NA [Med~~t available/Pharmacy _n~fic_dvia _f~x .J ~~- [i,i91zor1 ]ll'!Q_ 1811912017 l[isoP b)(6); b)(?)(C) ILACTUJ,OSJ".10 GM/15 MLSOLN 10 SPJRONOLACTONE25 MG TABLET 2.1 1101-2100 Page 6 of9 - -· -- -·· _jjNA -7 I JNA I NA ·- I I JNA l[NA NA NA NA 9/20/ 2017 MAR/TAR for: ALMAZAN RUIZ, FELIPE, #GCSO17MNI005042@RELEASE b)(6); b)(7)(C) [i(l:21201"/ [[Kor . l[oi -_2..@£_____]TRJAMClNOLONE O.l % CREAM O,I i;-18~/2-'l/2_0_\_7--;l;fi@-o_P ___ --....a..;1;[05 -?.100 _· __] PROCTOSOL 2·sii. Page 7 of9 NA NA IINA I UYES l[oi 2100 l[TRAZOD_oi:niio MG TABLETl0 NA NA "VT'S II0l -1100 IITRAZODONE HCL 50 MG NA IIYES 1102- 0900 IIFOLICACID I MG NA INA I [8/2312017 J[YES II0Z-0900 NA INA I NA INA I NA NA INA I INA I INA I INA I [NA -··1 lsm/2017 i/231201l . _IIDOCUSATESOD!UM IO0MG la[1=12=J12=0=1=i]=:~[v=E=s===~--~l:,:[o:..:.2 _-0:..:.90:..:.0:..__· __j-lr Jv11JLnv1r AMlN 8/23/2011 [YES [I02 - 0900 Ii()MEPRAZOLE DR~oMGCAPSULE 20 [YES 1102-0900 [=[~:~ I LACTUL()SE 10 GM/I 5 Ml. SOLN 10 ~Tll NA l~l=Ko=P==== ==:;,;.1:::::::: NA NA lsmnon l8123/20l7 IKOP UYES [81231201 j l[YES li/2J/20l7 l[vEs ][os~~_!Ii_____] DOCUSATE SODIUM 100 MG [[oI]Too ]J.ACTUJ.OSE 10 c;M/isMi. soiN li!2312on l[YES [loi - 2100 t102· 0900 I SERTRALINE HC:L 100 MGTA.B \00 NA NA IQ. I srrRONOLACr◊NE2l MG TAIJLET 25 ·--· NA NA ·-- - . . - INA I [NA I l!JZJ/2017 UKOP I~--_ ][TRJAMC!NOLONE 0. l % C-!1£AM0.1 NA 1812,/2017 l[KOP [las - 2ioo I PROCTOSOL 2.5% NA INA I YES II0l - 2100 NA INA I NA NA NA , ___ TRAZODONE 50 MG TABLET l0 YES YES I.abs-Send Out II01-04JORS [[02 - 0900. .. ·- lc;NccA===============ir.;"N TRAZODONE HCL 10 MG [81241201"/ j[YES -- INA I ] FOLIC ACID I MG NA O_~?__jDOCUSA TE SODIUM I 00 MG NA ·-· NA NA [NA OMi;rRAZOLEDR 20 MG CAPSULE20 NA INA NA NA [NA I [NA I INA. I [NA I ,.... [812_· 4_n_:01_?-_-·,1,_[YE_•s_· ____ [,[02-. [st.!4/2011 UYEs I~--·· [s124/2on )[YES l[oi ~ 0900 8/24/2017 IIYES 7 IMULTIVITAMIN 1102- 09110 T.ACTULOSE IS/24/2017 IIYES [8124/2017 UYES II0.! - 0900 1@2 ..0900 SPJRONOLACl·ONE2S MG TABLET 25 10 GM/15 ML SOLN 10 B12412017 IKOP [102- 0900 m40.011 fi~A_(_N>~ssOl7 l[Yf's [s129non l[YF.S I I jNA NA NA A A . Jlrnuc ACID I MG I DOClJSATE SODJllM IODMG [02 - 0900 --7I A I IBUPROFEN200 MG . MlJLTIYITAM!!'. I OMEPRAZOLEIJR 20 MG CAPSULE 20 LACTIJLOSE 10 GM/Is ML SOLN 10 j SPIRONOLACTONE25 MG TABLET25 j XIFAXAN 550 MG TAB ·s-10 -· ... . ___] lo5 - 2100 [02 - 0900 102- 0900 1102- 0900 1[02-0900 [02 -0900 [YES INA 10, - 2100 102- 090D I~_~:::: 1~······ ·-. NA NA I JRUPROFEN200 MG I oocusATE soo111M . __@_- 09_00 !812812017 l[KOP lms12017 __Jfr.~. ls12s12017 lins jS/2812017 jjYES - -·· A A A ..~---=-=--=---=-----------INA-· A . --~===========,~1N=A====!1I A I los - 2100 18128/2017 l[YES 8/7.8il.Ot7 IIYES IINA 1[02- 0900 [05 . 2100 lo5 - 2100 [os- 2100 [oS-2[00 8/2011 ES ...... IS/78/2017 IIYbS 1812812017 l[vEs IINA A A A A A . =-_]@_ - o9i_R_ONOLACTONE 21 MG TABi.Er2s-XJFAXAN550MGTAil550 1[02-090(. 02- 0900 [02-0900 ;::::::::~~2:- l~=~~f=~==~@i.:ii_o_o. [8/30/2017 J[iis ___ -- . - s/1012017 IIY<'S IINA 0~90~o[_:.:. -=~)l;s~E~R!T~~~~I:N!'~-~ti.cr::L~-]1.o_:o:M~cj}T;AB~:100~=:==~==~ INA )[DOCUSAT::Ecc..$.=OD'-'!C::U:ccM'-'~0_0'-'M=G=======" 11alN=A========== -~l[os-2100 )ILACTULOSE10 GM/15ML SOLN 10 101 - 2100 SPlRONOLACTONE 25 MG TABLET 25 [NA 101. 2100 l[XJFAXANssoMGTAfl sio -···· · ... ][TRIAMCINOLONEo 1%CREAM 0.1 I~~ @I012oi1l[Kor l-s,-10-,2-0-,1,.__,l;...IYF----, ---~[~ iO05-2100 @ii_f!-0_17 l{YF.S 7~ 8/Jl/2017 l[ns IIYl'.S ··-)FOUCACID!M(i l102 - 0900 JIITS. )[~2_-0900 .. ·-. 18/11/2017 j[;,;H 1[02-0000 jk11111017 lli':':5 1[02-0900_ @"1126l~Jly£S 1102-0900 fu2~11 JIYES_ . ____ 7102-09<10 118/J 112~j[KOP !POCUSATF.SOr>TUM100 MG ]MULTIVITAMIN u~·-·· [81J112017 [slll/201771YES NA INA 1 - - N -~INA I I INA I INA I NA [NA I ~- [NA ___I IOMEPRAZ0LcDR20 MGCAPSULE20 ]~_.ACTIJLOSE 10 c;w1s ML soui 10 UsrIRONOLACTONE21 MG TABLET 25 jxrFAXAN 550MGTAii i·so· · ·- )[02 - ITRIAMCINOLONE0.1¾ CREAMo. t 99Q£_:=)PROCTOSOL2.5% SERTRALINEHCL lOOMGTAB 100 INA SODIUM 100 MG 1105- 2100. . . _ j 1.ACTUJ.OSE10 GM/I 5 Ml. SOLN 10 [sil 112011 Hv_.;s-· --~il['o:..:._s __.:...z :..:.too.:....c...~-blct by mooth I cim,cper day for 90 day, Rcq Statt: ?n/20 17 Rcq End: I 2/S/2017 Discontinued: 9/7/2()17 02 -0900 OMEPRAZOLE ◄O MG CPDR 40 Take l Capsule by mouth I time per day for 90 days Req Stan.: about:blank IC ---- (b)(6); (b)(?)(C) SOLN by mouth 2 times per day for 30 days.3 s nccdod Rcq Sea~: 811212017Roq End: 9/10/2017 Discontinued: II .Ir-=- DJLJDLIJITJ□□CI 02 - 0900 LACTUJ .OS E IO GM/15 ML SOLN 10 40m! 'Po daily x 90 day, Rcq Scatt: 917120l 7 Rcq End: I 0/712017 .11.... IE .... (b)(?)(C) 02 - 0900 FOLIC ACID I MG Take I T.abli=thy mooth I t..iniepeMG TABLtT 2j Take l Toblct by molJth?.tirncs per day fo1 90 da.ys Req Start: ?/tl/20 I "/ Req fi.:nd: 1211/2017 Disr;;ontinucd: 9nl2017 Ol-0900 TRJAMCINOLONE O.l¾CREAMO.I CRM2timcspcrd,y foc6od,ysR,qStan: 8/14/2017ReqEnd: ,~b)(6) ; KOP th " 7 " ~ Or K )~b )(6) KO . _b)(~);__ 1,111-K_O~r __ _.._K_<~lP __ KOP __.._ ___ KOP .._ __ b)(6); (b)(7)(C) ~ REVOKH) REVOKE□ (_AUTO __LABS) (_AUTO_LABS) R.elcosed Relca,cd REVOKl'D REVOKED ,__AUTO_LABS) LAUTO_LABSJ Released Rclcmd REV• (_Al. Rclc, l 0/1 l/2017 Discontinucd: 917/2017 on□□ SO MG TAIi.iSO oz°-0900Xll'AXAN ;,k,c I T.abl.c[tiy nauth 2 time:Sipe, Ul'i. - j(vES [911120\7 Future Oose/T~,limcnt tn he adm!nt'.1.1(:rcd IEl j(Yes-No-KOP___ __j[sh;ft Fl W:ls NOT 11.,d IIDos.e.o~·reatment Do~e/Tr~tm.enl is NOT t.otie th;, time ---- ~gcnd - -· l~••c -·-· /h\ /R \· 9161'-017 Rcq l,nd: 10/6/2017 ONCE [ REVOKED REVOKED ll£V0.Kfil> REVOKED RliV• ( AUTO LABS) ( AUTO J,AJlS) (.AU TO. LARS) _ AUTO_l.ABS) LAl Rclt!a:r.cd Rele.ued Released Reloasod Rele~ 550 MG TAB \50 Take I Tahl-e:1 bv Pe( ···- ....... □ o\ -7100 XIFAXAN moutl12 times day YF< for ;o d,y, Roq Start: l!:/1212017Rcq End: Kb)(6); ·-- llx£FAXAN 550 MGTAn 550 = IINA ~INA >--- ~ jNA -·O.1 2020-ICLl -00006 . 2942 - ..J{NA II .. H~"c_••b I 11~·]NA j[NA - - -----"] JINA ·-:=:J ~INA IINA liNA IINA Ir I I I 9/20 /2017 Page 5 of6 MAR/TAR for: ALMAZAN RUIZ, FELIPE, #GCSOl 7MNI005042 @RELEASE 1911/2017 1911/20\"/ !IKOP YfS 19/J/2011 l[ns llo2 -0900 llo2- 0900 I -- =7~s-2100 IIPROCTOSOL2.5% IISERTRALINEHCL100 MG TAil 100 IITFAIHE KHUGHES I ltNA IINA lloocusATESOPIUMlOOMG llr.MONTOYA I~-- 1~19'.:_11:..:h:..:o:..._1_"1~_ -==_]=!a~~o:..._-----~l(b:..:s_-.:_2:..:10.:_o __ -_-~11,:IL:;.A:..:C.:_l:l:..:iL:..:O:.;.,~;;;;E=lO=G=,M=l=ll=M;;;;;;;.L :..._so:..:-~;;:_N.,.: __1;._;.o ________ 191112011 [!YES l~s-2100 llmRoNoJ.ACTONE2lMGTAflJ.l'_T25 191112011 HYies l~s:2100 · ]lxJFAXAN.isoMGTAB-550 · 191112011 191112017 l911/J017 I KOP ···-7rrn 19/J/2011 [911012017 l[YES ![REVOKED I FSAPP liPROCTOSOL2.5% ]trRAZODONE-SOMGT_ABLET50 l&s-2100 ]~2-0900 llrRAZODONEHCL50MG ]ITR!AMCINOI.Ql(EO_l¾CREAM0.1 -- - ~ ] ~A ITFAHIE '"" - 2100 [bs-?.100 NA ____ l1~IL:..:M:..:O:..:N":..:r.:_o.:_y A:..::._ __ --!l,-fN'-"O-"'T=N=E.E=D=E=D--= ~------ii lrMONTOYA NA NA ]IMoN'riivil--NA NA ITRJAMCINOLONE0.1% CREAMo I 1m - noo IKOP NA .. l[L!-40NTOYA ---!LMONTOYA JI AUTO LAIIS __ _ ~A NA NA !jRelea,ed NA NA [NA ~[9=/l=0/=20=i1=C7-=l~~:ei=v==iiK=E=.D===·=· =··=l7~~-=2-=09=00==--=l]IEIP=RO=C=TO=c=S=01=.=e2.=5%~-=e=c=-----~~-~~eil~l-':-Al:'::JT~O::-:"LAil':':'-S:--_----:l~_le=as=ed~---~~--;J~N-A ____ 1 9/10/iOI"/ REVOKED .. ll0~-2100 _ lrRl_~ICJNOLONEO.l¾CRF.AMO.I AUTO 1.AllS ]IRclcmd HNA !911012017 19111/2017 1911112011 l91i112011 ~~ -[itE.vo.KEo J REVOKED IREVOKED I A~UTOJ.ARS~ lrROCTOSOL2.>% ITRJAMCINOLONE0.1% CREAMO~- AUTO ====~ll~IPR=0;;(;,;:1,;·o=so;;,1=. ;:,2.s;,;'Y<=• ============~:=-A,:; II0>-2100 lrR1AMCINOLONHo.1¾CREAM01 liu,:vOKED _ IINA ____:_ J[NA IA JjriuAMCINOJ.ONE0.1_%_(:_~~-AM_0.1 --- - ··)lrRDCTOSOL2.5% ·------ II AUTO LABS IJReleased IIR=:S=-=21=0=0 ====]aa[1.=A=C1=u=L=o=sE=·=1o=G=w===1s=M=L=s=o=L=N=1=0==~---_ 191212011 UYES . 2100 ]~LACTONE 25 MG TA.llT.F.T ,.; [91W0'7____ ][viis" --- --~~5-2100 lxlfAXANlSOMGTAilSSO !NA INA I§ ][NA ----------:JI--IN_A___ [9!_2_:2_0_1;;---JIKoP HTRIAMCINOLONEO1% CREAMo 1 ~A__ __ =1[NA I PROCTOSOL 2.l¾ [i,!A .J~s- __==_J@s [91212ci1C]IK0P 1~1-2100 191212011 UYES [91212011 _ ]IYEs [913l20jC 19/1/2017 !los_:__~100 ____ _]@-~ - 2100 91J12011 9/312017 9/3/2017 jw112011 b2 -0900 Jof:::owo ·==7~2-owo 50 ~- . )~2 .0900 IIYES b2 - O'lilO j@AXAN l50 MG T~ _150 fo2 0900 ==1[TRIAMClNOJ.QNF.0.1%CREAM0.1 1(02-0900 __J rROCTosou s¾ ump UKoP .=ifilf: -- J~ ]jsPm.oNoLAcToNE ]b2- 0900" -==7 los-2ioo __ 2s MG TABLET 2s -- · \91312on=t[KoP l[os - 21oo -- ~- 191112011 ~(~~~.7 [914/2017 l[YEs _JIYFS IIYES ____J1os-2100 IITRAZODONEHCL50MG IIFOLICACJD I MG _ [02-0900 [91•12017 l[YEs 9/4/201~-==l~ ~[02 - 0900 - - [02 - 0900 ,:;:~~:~ 15'Es----- ··-=ii:_-~:~J~ 1~14/20-i'i__jbri_ 9/4,.v - ~!YES 19/4/2017 [914 ,~9_14_1i_o1_1__ l§iP___ ,~YE _ ,_s ____ about:blank lloocusATE SODIUM 100MG l[MULTIVlTAM!N _ ----3 l~ ][02,~9_00 [02 - 0900 __1[02- 0900 §__ -~ [NA_ ... It!-!~. -_ ~ . ~--[NA I I I I I~ l[NA --______7 __I I l!NA ]NA ·· I I _=11NA _ ![NA ·-=i1NA --~ !NA - I I§ = =~-. .. =--=i l[NA ·=iJNA [w\"" - _ .. ... =~ ___ ___ I I ___ :JINA ~ __ IITRAZODONElOMGTAR!HSO 105-2100 INA ·:1 I I ![NA _ [NA -- .::_ ![X11'AXAN550!,,iGTABl50 ___ __ UnuAMCJNOLONE0.1%CRJi~!'{o.i·-· · -- ][PR□crosor. 2.w, HNA rw;::·· 25 l[o;-2100 Uos-2100 [NA li{A = !NA Sl'RTRAL!NF.l!CL 100 MG TAB 100 lloocusATESODIUM_iooMG !NA ][ii_ A_ JINA UNA fNA __ I l[NA I~. [NA__""- l~~['.'.::ljiYFs~YF~s'.::: __ :__ :'.::J~\0~1:-!21~0~0 :'.:::J1[11.~A~CT~l~JL~o~siE~1 o~G~-w~1sQM~1.[s~·oEL]N~1io:::::=:='.: [9mml-,. ]IYrs··. Hos- 2100 UsPJRONOLACTONE2S_ MG T_ABLH j913/20l7 _ UYES 19/J/2017 ··-!IKoP - ~ ___ _]ILAc:rnwse: 1oc;M11s MLSOLN 10 JlvE_s -- ==7~2-0900 "Ht..,,A====:I ][NA INA ][oocusATf sooiiJr-.! 100MG - --- - J[MUJ,nvr-rAMlN !IOMEPRAZOLEDR20MGCAl'smoo -;[ I~ ~- ~ !NA ]IYEs [91312011 1913/2011 HLabs- Send Out l[muc"AC!DIMG b2-0900 -=__ -- l[rwoooNE_loMGTABLET llfaAzonoNE 11c1: so MG !~1 -0430 BS [IYES IIYES 191112011 IIYEs 19n12011 ]IYEs [90:20_17 ·· JlvE~_ hii.mo1-, - 2100 f!'0_ 71 ___ J --------·7 l[R-EVOKF~ps-iinn l(iu,:voK.Eo Jfos-2100 !&2-0900 [ AUTO LAJIS I Rclmcd -- · JINA lcascd;===='llllt-;Nc;'A ___ [911211.0li J911212011 li!>J'vor~l,Jll,E, Daylight Time) • .... V"--_. .. .._..,._ S.W.12'IH ST. MIAMI, FL 331.94 Tel: 305-207-2170 Fax: 18201 Patient; ALMAZAN RUIZ, FELIPE DIONISIO DOB:· 06/26/1966 RN 08/11/2017 Progress Not (b)(5 ); (b)(?)(C) Note generated by eC!inica/Works EMRJPM Software (www.eClinicalWorks.com) 8/l 1/2017 2020-ICLl-00006 2948 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCS017MNI005042 09-06-2017 Encounter as of 09-20-2017 Wed 05:06.16 PM Patient c/o visual disturbance OS 201200 OD 201200 30 DAY CLINIC CIRRHOIS knee pain and joint pain CHRONIC CARE CLINIC: Dale/Time· 09-06-2017 Wed/ 09:48 Patient Name: FELIPE ALMAZAN RUIZ GCS017MNI005042 No: 06-26-1966 DOB: Male Sex. 1'DORM 1*0*048 1'DORM 1'D'048 Location: Clinic Membership: 571.5 CIRRHOSIS OF LIVER WITHOUT ALCOHOL 311 DEPRESSION 300.02 GENERALIZED ANXIETY DISORDER PAST MEDICAL HISTORY: 51 years old male with history of liver clrhosis, Gerd, possible portal hypertension, constipation here today for 30 days clinical evaluation, the patient disgnose 7 years ago and he's been on treatment since then Duration of condition(s). 5-10 years Prior hospitalization(s): No change since last visit Complications: none CURRENT MEDICATIONS: DOCUSATE SODIUM 100 MG FOLIC ACID 1 MG LACTULOSE 10 GM/15 ML SOLN 10 MULTIVITAMIN OMEPRAZOLE DR 20 MG CAPSULE 20 PROCTOSOL 2.5% SERTRALINE HCL 100 MG TAB 100 SPIRONOLACTONE 25 MG TABLET 25 TRAZODONE 50 MG TABLET 50 TRIAMCINOLONE O 1% CREAM 0.1 XIFAXAN 550 MG TAB 550 DATA REVIEW: CMP Sodium 141 Normal mmol/L 135-145 Final CL Potassium. 4.3 Normal mmol/L 3.5-5.5 Final CL Chloride 104 Normal mmol/L 95-110 Final CL Carbon Dioxide 26 Normal mmol/L 19-34 Final CL Anion Gap 15.3 Normal mmol/L 10-20 Final CL Glucose 86 Normal mgldL 70-110 Final CL Calcium 8.8 Normal mgldL 8.4-10.2 Final CL Protein, Total 6.9 Normal g/dL 5.5-8.7 Final CL Albumin 3.6 Normal g/dL 3 2-5.0 Final CL BilirubIn Total 1.7 Above Normal mgldL 0.1-1.2 Final CL Alkaline Phos 162Above Normal U/L 20-130 Final CL AST {SGOT) 35 Normal U/L 10-40 Final CL ALT {SGPT) 25 Normal U/L 10-60 Final CL Urea Nitrogen 17 Normal mg/di 6-22 Final CL Creatinine .. 0.70 Normal mg/dL 0.43-1.13 Final CL eGFR NonAfrican Am > 60 Final CL eGFR African Amer> 60 Final CL eGFR less than 60 (mllmin/1 73) square meters Lipids Profile Triglycerides 45 Normal mgldL 0-150 Final CL Cholesterol 92 Normal mgldL 0-200 Final CL HDL 54 Normal mgldL 0-60 Final CL NON-HDL 38 mg/di Final CL Goals for Patients with CHO or CHO risk equivalents: LDL: < 70 mg/di NON-HDL: <100 mg/di Goals for Patients with 2+ risk factors: LDL: <130 mg/di NON-HDL: <160 mg/di Goals for Patients with 0-1 risk 2020-ICLl-00006 2949 Page 2 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCS017MNI005042 09-06-2017 Encounter as of 09-20-2017 Wed 05:06:16 PM factors: LDL: <160 mg/di NON-HDL: <190 mg/di LDL Cholesterol 29 Normal mgldl 0-130 Final Cl Chol/HDL Ratio 1.7 Normal 1.5-5.6 Final Cl H Pylori Ab lgG H Pylori Ab lgG or= 1.10 (THIS IS THE ONE DR. NOEL ORDERS) 0.70 Normal Ulml 0.00-0.90 Final Cl Negative Equivocal Positive PSA Diagnostic PSA Diagnostic 0.1 Normal nglml 0-4 0 Final Cl Prothromin Time PT Seconds 9.4-12.5 In lab Cl Pro Time INR In lab CL Status Observation Date Performing Lab Performing MD PTT Activated PTT 41.6Above Normal Seconds 25.1-36.5 Final CL Therapeutic PTT range of 50-89 seconds CBC WBC 3 0 Below Normal 10 3/ul 3.6-11.0 Final Cl RBC 3.65 Below Normal 10 6/ul 4.50-5.90 Final CL Hemoglobin 11.3 Below Normal g/dl 13.0-18.0 Final Cl Hematocrit 34.8 Below Normal % 40 0-52.0 Final Cl MCV 95.6 Normal fl 81.0-97 0 Final Cl MCH 31.0 Normal pg 26.0-34.0 Final CL MCHC 32.4 Normal g/dl 31.0 - 37.0 Final Cl ROW 17.4Above Normal% 11 5-15.0 Final Cl Platelet Count 41 Below Normal 10 3/ul 150-400 Final Cl Mean Platelet Vol 9.6 Normal fl 7.4-10.4 Final Cl Neutrophil % 65.7 Normal% 36.0-66.0 Final Cl Lymphocyte% 25.2 Normal% 23.0-43.0 Final Cl Monocyte % 4.8 Normal% 0.0-10.0 Final Cl Eosinophil % 3.9 Normal% 0.0-5.0 Final Cl Basophil % 0.4 Normal% 0.0-1.0 Final Cl Neutrophil Abs# 2.0 Normal 10 3/ul 1.6-8.2 Final CL Lymphocyte Abs# 0.7 Below Normal 10 3/ul 1 1-4.7 Final Cl MonocyteAbs#0.1 Normal 103/ul0.0-1.1 Final CL Eosinophil Abs# 0.1 Normal 10 3/ul 0.0-0.5 Final Cl Basophil Abs# 0.0 Normal 10 3/ul 0.0-0.4 Final Cl Ammonia Ammonia 108Above Normal umolll 11-35 Final Cl Test Performed by: IRL- Florida 5361 NW 33 Avenue Adherence Ft Lauderdale, Fl 33309 SUBJECTIVE: the patient is complaining of abdominal pain radiating to the chest otherwise he's denies all others symptoms Stability of condition{s): Stable Issues with medication(s): None. Other: none OBJECTIVE: T: 97.6 P: 80 R: 18 BP: 122176 Weight· 170Ibs GENERAL APPEARANCE: Well-developed, well-nourished 51 year old w male in no acute distress. HEAD: Normocephalic. Atraumatic. EYES: PERRLA. EOMI Sciera non-icteric. ENT: EAC's clear. TM's white and shiny. Nares patent. Oral mucosa pink and moist. Oropharynx clear. NECK: Supple with full range of motion. No tenderness or lymphadenopathy. No JVD or carotid bruits. LUNGS: Clear to ausculation. Respiratory effort 2020-ICLl-00006 2950 Page 3 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCSO17MNI005042 09-06-2017 Encounter as of 09-20-2017 Wed 05:06:16 PM non-labored. HEART: RRR. S1 S2 WNL.. No murmurs or rubs. EXTREMITIES: Pedal pulses are palpable and equal. No extremity edema. ABDOMEN: Positive bowel sounds. Non-tender. No hepatosplenomegaly. No masses. pain mid epigastric radiating to the chest GU: Deferred. RECTAL: Deferred. MUSCULOSKELETAL: Moves all extremities well. No deformities, cyanosis or clubbing. Gait steady, SKIN: Warm, dry, normal color. Turgor elastic. NEUROLOGICAL: No sensory or motor deficits Deep tendon reflexes 2+ bilaterally. PSYCHIATIRC: Awake and alert. No depression, agitation or anxiety noted. ASSESSMENT: 1===THROMBOCYTOPENIA 2===571.5 CIRRHOSIS OF LIVER WITHOUT ALCOHOL 3===311 DEPRESSION 4===300.02 GENERALIZED ANXIETY DISORDER 5===mild increase total bil1and alkp 6===Normochromic anemia 7===Degree of Control - poor Status - Improved 8===Patient's adherence to treatment plan: poor 9===Patienl's understanding of condition: GOOD PLAN:' 1ca==Iwill increase lactulose doses and will continue wi1h the current meds cbc weekly the follow-up ,++ see below predn isone 100 mg x3 days then 80 mg x 3 days then 60 mg po x 3 days then 50 mg x 3 days ' the 40 mg x 3 days then 30 mg x 3 days then 20 mg x 3 days the 10 mg x 2 days then 5 mg x 2 days the 2.5 mg x 2 days then d/c FERROUS SULFATE, 325MG #90, Sig: 1 time per day for 90 days 2==a:+++++cbc weekly x 4 weeks+++++ 3===d/c dulcolax 4========1actulose 40 ml po daily x 90 days S===FOLIC ACID, 1 MG #90, Sig: Take 1 Tablet by mouth 1 lime per day for 90 days 6==aaMLJLTIVITAMIN, #90, Sig: Take 1 Tablet by mouth 1 time per day for 90 days 7===SPIRONOLACTONE, 25 MG #180, Sig: Take 1 Tablet by mouth 2 times per day for 90 days 8===xifaxan 550 mg po bid x 90 days 9===Patient c/o visual disturbance 10===OS 20/200 OD 201200 11====ammonia level 02 WEEK X 8 WEEKS 12===Renal diet x 180 days 13===cbc cmp lipid panel in 82 days 14===follow=up in 90 days 15===0MEPRAZOLE, 40 MG #90, Sig: Take 1 Capsule by mouth 1 time per day for 90 days ====== EDUCATION Adherence Weight Loss Medications Disease Process Smoking Cessation Transmission prevention Exercise daily Care after release Diet renal diet Lab Results explained Adjustment to Incarceration Other Med compliances (b)(6); (b)(?)(C) Electronically Approved by Don 09-06-2017 10:23:31 AM. 2020-ICLl-00006 2951 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCSO17MNI005042 08-14-2017 Encounter as of 09-20-2017 Wed 05.07:24 PM CIRRHOSIS CHRONIC CARE CLINIC - INITIAL: Name: FELIPE ALMAZAN RUIZ DOB: 06-26-1966 ID: Location: 1·DORM 1•c•o13 1*DORM 1•c·o13 Race: W Sex: Male Date: 08-14-2017 Mon ALLERGIES: NKDA CLINICS 51 years old male with history of liver cirhosis, Gerd, possible portal hypertension, constipation here today for initial clinical evaluation , the patient disgnose 7 years ago and he's been on treatment since then PERSONAL RISK FACTORS· Smoking: High Blood Pressure: High Cholesterol: Obesity: Diabetes: Alcohol: Substance Abuse: Injection Drug Use: Sedentary Lifestyle: Multiple Sexual Partners: Tattooing/Body Piercing: FAMILY HISTORY: Anemia: Asthma: Cancer: Diabetes: Heart Disease: High Blood Pressure: Mental Illness: Tuberculosis: Kidney Disease: yes 2 per day NO NO NO NO yes a lot NO NO NO NO NO NO NO mother neck cancer NO NO NO NO NO father die SURGERIES/HOSPITALIZATIONS: Inmate denies surgeries and/or hospitalizations. GENERAL DESCRIPTION/CHIEF COMPLAINT: FELIPE ALMAZAN RUIZ is a appears well, in no acute distress, obese, well-developed, well-groomed, and well-nourished 51 year old male presenting for initial chronic disease clinic visit. current comp-lains external hemorrhoid, dry itchy skin dry eyes itching, headaches ,otherwise the patient denies chest pain headaches abd pain nause no vomiting REVIEW OF SYSTEM EYES =normal: no papilledema or stye EARS: no tinnitus, vertigo or hearing loss Mouth/throat no throat pain, gum diseases or hoarseness RESP no shortness of breath or cough CARDIO: no chest pain, dyspnea, claudication or edema GASTRO: no dyspepsia nausea, vomiting, diarrhea or constipation GENITOURINARY: deferred RECTUM: deferred MUCULOSCKELETAL: no joint pain or arthritis NEUROPSYCHIATRY: no weakness, seizure, memory changes, or depression REVIEW OF SYSTEMS SKIN: no discoloration, dry scaly rashes HEAD: no head ache masses or dizziness EYES: Sciera non-icleric. Conjunctivae and lids are clear bilaterally. No redness. No hyphema. PERRLA No photophobia. FundoscopIc exam is grossly Current Medications: CLOTRIMAZOLE 1 % DOCUSATE SODIUM 100 MG FOLICACID 1 MG HYDROCORTISONE 1 % LACTULOSE 10 GM/15 ML SOLN 10 Maalox 30 cc MULTIVITAMIN OMEPRAZOLE DR 20 MG CAPSULE 20 SERTRALINE HCL 100 MG TAB 2020-ICLl-00006 2952 Full EOMs intact. No nystagmus. Page 2 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCSO17MNI005042 08-14-2017 Encounter as of 09-20-2017 Wed 05:07:24 PM 100 SPIRONOlACTONE 25 MG TABLET 25 TRAZODONE 50 MG TABLET 50 XIFAXAN 550 MG TAB 550 PHYSICAL EXAM: Vital Signs: Temp: 98.3 Blood Pressure: 101 I 66 Pulse: 62 Resp: 18 Height. 5 ft 3 in Weight: 165 lbs Peak Flow: % Pain Scale: Functional Assessment: GENERAL APPEARANCE. Well-developed, well-nourished male in no acute distress. HEAD. Normocephalic. Atraumatic. EYES: Sciera non-icteric. Conjunctivae and lids are clear bilaterally. No redness. No hyphema. PERRlA. Full EOMs intact. No nystagmus. No pholophobia. Fundoscopic exam is grossly normal: no papilledema or stye ENT: EAC's clear. TM's white and shiny. Nares patent. Oral mucosa pink and moist. Oropharynx clear. NECK: Supple with full range of motion. No tenderness or lymphadenopathy. No JV □ or carotid bruits. LUNGS: Clear to ausculation. Respiratory effort non-labored. HEART: RRR. S1 S2 WNL.. No murmurs or rubs_ EXTREMITIES: Pedal pulses are palpable and equal. No extremity edema. Color and temperature are uniform. Skin is warm and dry. Sensation and circulation are fully intact distally. Full ROM. Non-tender to palpation. dry scaly skin rashes ABDOMEN: Positive bowel sounds. Non-tender. No hepatosplenomegaly. No masses. GU: Deferred. RECTAL: external hemorrhoid No sensory or motor deficits. Deep tendon reflexes 2+ bilaterally. PSYCHIATIRC Awake and alert. No depression, noted. agitation or anxiety MUSCULOSKELETAL: Moves all extremities well No deformities, cyanosis or clubbing. Gait steady, SKIN: Warm, dry, normal color. Turgor elastic. NEUROLOGICAL: no weakness, seizure, memory changes, or.depression ASSESSMENT: 1===Iiver cirrhosis/ fatty liver 2===Gerd 3===possible protal hypertension 4===IBS 5===eczema PLAN: 1===TRIAMCJNOLONE ACETONIDE, 0.1 % #120, Sig: CRM 2 times per day for 60 days 2cc==PTPTT INR ,psa, cmp cbc lipid panel, h pylori test ammonia level tomorrow 3===follow=up thursday with labs results 4===increase fluid intake 5===continue with all others meds for 30 days 6===please renew when there are finishing ?===follow=up in 90 days 8===PROCTOSOL 2.5%, #60, Sig: Apply 1 Cream topical 2 times per day for 30 days EDUCATION PROVIDED: Disease Process/Treatment: Abnormal Labs: Medication Management (purposes, side effects): Lifestyle Changes: Nutrition: renal diet Smoking/Tobacco 2020-ICLl-00006 2953 Page 3 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCSO17MN!005042 08-14-2017 Encounter as of 09-20-2017 Wed 05:07:24 PM Use: Exercise: daily Alcohol/Substance Abuse: Other: meds compliances (b)(6); (b)(7)(C) Electronically Approved by.__ ____ ___,Don 08-14-2017 10:27:32 AM. 2020-ICLl-00006 2954 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCS017MNI005042 08-14-2017 Encounter as of 09-20-2017 Wed 04:43:42 PM INITIAL MENTAL HEALTH EVALUATION: Patient Name: FELIPE ALMAZAN RUIZ No: GCS017MNI005042 DOB: 06-26-1966 Sex: Male 1*DORM 1·c·o13 1"DORM 1·c·o13 Location: Date I Time: 08-14-2017 Mon / 10:26 Reason for Referral: Intake Screening Charges: CHIEF COMPLAINT: ASSESSMENT OF THE PRESENT ILLNESS: Pt reports he has a history of cirrohsis, depression, and anxiety. Pt reports a hx of alcohol dependence and reports he has not had a drink in 3 months Pt reports he has been prescribed trazadone for the past 3 months when he was incarcerated in metro west in dade county. Pt has current immigration hold. Pt presents with calm demeanor and is cooperative. Pts mood is sad with mild symptoms of anxiety. Pt denies SI/HI. Pt denies hx of AV hallucinations. Pt attributes his feelings of sadness and anxiety to stress of his current situation. Pt reports bouts of depression and crying for the past 3 months. Pt reports he lost his marriage 5 years ago due to his alcohol problem and reports he has continued to worsen with regards to alcohol use until he was incarcerated. Pt reports he feels guilt, sadness, and loss now. pt reports he uses prayer and his faith lo manage his feelings. Pre-Incarceration Medications: has liver cirrohsis Past Psychotropics: Desyrel / trazodone Alcohol: YES Amount: As much as I could get Last Drink: Day of arrest Hx of □T's: YES Drugs: No Past Psychotropics: Current Psychotropics: Current Psychotropics: Desyrel / trazodone PAST MEDICAL HX: Illnesses: cirrohsis Hospitalization: related lo liver cirrohsis Surgeries: none Head Injuries: Hit in head in a fight years ago. Allergies NKDA Current Non-Psychotropic Medications: CLOTRIMAZOLE 1 % DOCUSATE SODIUM 100 MG FOLIC ACID 1 MG HYOROCORTISONE 1 % LACTULOSE 10 GM/15 ML SOLN 10 Maalox 30 cc MULTIVITAMIN OMEPRAZOLE DR 20 MG CAPSULE 20 PROCTOSOL 2.5% SERTRALINE HCL 100 MG TAB 100 SPIRONOLACTONE 25 MG TABLET 25 TRAZODONE 50 MG TABLET 50 TRIAMCINOLONEACETONIDE 0.1 % XIFAXAN 550 MG TAB 550 PAST PSYCHIATRIC HX: Hospitalizations: No Outpatient Treatment: No Suicide Attempts: reports he has tried to commit suicide many times by drinking excessively. Hx of Arrests - Juvenile/Adult: YES - alcohol related , lewdness for urinating in public Hx of Sexual Abuse: No Hx of Predatory Behavior: No Hx of Physical Abuse: No Hx of Violent Behavior No SOCIAL HISTORY: Education: 10th grade Hx of Developmental/Education Disabilities: No Marital Status: Divorced Armed Forces: 2020-ICLl-00006 2955 Page 2 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCS017MNI005042 08-14-2017 Encounter as of 09-20-2017 Wed 04:43:42 PM No Occupation: plumbing FAMILY HISTORY: Family Psych Hx: denies Family Hx of Suicide: No Family Alcohol/Drug Abuse: No MENTAL STATUS EXAMINATION: General: Alert Behavior: Appropriate Cooperative Attitude: Orientation: Person, Place, Time, and Situation Eye Contact: Fair Appearance: Neal, Well-Groomed, and Appears older than age Psychomotor Activity: Normal Memory Immediate: Fair Recent: Fair Remote: Fair Concentration: Good Ability to Think Abstractly: With similarities and differences Good - With proverbs Good Hallucinations: Denies Delusions: Absent Speech Coherent Mood: Depressed, and Anxious Affect: Appropriate WNL Sleep: WNL Appetite: Hopelessness: No Intention - No Plan - No Ideation - No, reports past ideation and overdrinkIng in attempts to dre Suicide: Ideation - No Intention - No Plan - No Homicide: Insight: Fair Judgment: Fair DIAGNOSIS: Axis I 311 DEPRESSION 300.02 GENERALIZED ANXIETY DISORDER 303 90ALCOHOL DEPENDENCE, in remission PLAN: APPT: DISPOSITION: Housing: Appointment electronically created for patient to see psychiatrist as soon as possible. General Population Segregated: No Eligibility: Program Participation, Job Placement, and Job Placement Electronic Signature: Electronically Approved by MARCI VANDHUYNSLAGER, LMHC on 08-14-2017 10:41:35AM. 2020-ICLl-00006 2956 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCS017MNI005042 08-14-2017 Encounter as of 09-20-2017 Wed 04:43:52 PM INITIAL MENTAL HEALTH EVALUATION: Patient Name: FELIPE ALMAZAN RUIZ No GCS017MNI005042 00B. 06-26-1966 Sex: Male 1'DORM 1·c·on 1* □0RM 1Tuo13 Location: Date/ Time: 08-14-2017 Mon/ 10:26 Reason for Referral: Intake Screening Charges: CHIEF COMPLAINT: ASSESSMENT OF THE PRESENT ILLNESS: Pt reports he has a history of cirrohsis, depression, and anxiety. Pl reports a hx of alcohol dependence and reports he has not had a drink in 3 months. Pl reports he has been prescribed trazadone for the past 3 months when he was incarcerated in metro west in dade county. Pt has current immigration hold. Pt presents with calm demeanor and is cooperalIve. Pts mood is sad with mild symptoms of anxiety. Pt denies SI/HI. Pt denies hx of AV hallucinations. Pt attributes his feelings of sadness and anxiety to stress of his current situation. Pl reports bouts of depression and crying for the past 3 months. Pt reports he lost his mamage 5 years ago due to his alcohol problem and reports he has continued to worsen with regards to alcohol use until he was incarcerated. Pl reports he feels guilt, sadness, and loss now. Pl reports he uses prayer and his faith to manage his feelings. Pre-Incarceration Medications: has liver cirrohsis Past Psychotropics: Desyrel / lrazodone Alcohol: YES Amount: As much as I could get Last Drink· Day of arrest Hx of □T's: YES Drugs: No Past Psychotropics: Current Psychotropics: Current Psychotropics· Desyrel / trazodone PAST MEDICAL HX: Illnesses· cirrohsis Hospitalization: related to liver cirrohsis Surgeries: none Head Injuries: Hit in head i n a fight years ago. Allergies NKDA Current Non-Psychotropic Medications: CLOTRIMAZOLE 1 % DOCUSATE SODIUM 100 MG FOLIC ACID 1 MG HYDROCORTISONE 1 % LACTULOSE 10 GM/15 ML SOLN 10 Maalox 30 cc MULTIVITAMIN OMEPRAZOLE DR 20 MG CAPSULE 20 PROCTOSOL 2.5% SERTRALINE HCL 100 MG TAB 100 SPIRONOLACTONE 25 MG TABLET 25 TRAZODONE 50 MG TABLET 50 TRIAMCINOLONEACETONIDE 0.1 % XIFAXAN 550 MG TAB 550 PAST PSYCHIATRIC HX: Hospitalizations: No Outpatient Treatment: No Suicide Attempts: reports he has tried to commit suicide many times by drinking excessively. Hx of Arrests - Juvenile/Adult: YES - alcohol related, lewdness for urinating in public Hx of Sexual Abuse: No Hx of Predatory Behavior: No Hx of Physical Abuse: No Hx of Violent Behavior: No SOCIAL HISTORY: Education: 1oth grade Hx of Developmental/Education Disabilities: No Marital Status: Divorced Armed Forces: 2020-ICLl-00006 2957 Page 2 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCSO17MNI005042 08-14-2017 Encounter as of 09-20-2017 Wed 04:43:52 PM No Occupation: plumbing FAMILY HISTORY: Family Psych Hx: denies Family Hx of Suicide: No Family Alcohol/Drug Abuse No MENTAL STATUS EXAMINATION: General: Alert. Behavior: Appropriate Attitude: Cooperative Orientation: Person, Place, Time, and Situation Eye Contact: Fair Appearance: Neat, Well-Groomed, and Appears older than age Psychomotor Activity: Normal Memory Immediate: Fair Recent: Fair Remote: Fair Concentration: Good Ability to Think Abstractly: With similarities and differences Good - With proverbs Good Hallucinations: Denies Delusions: Absent Speech: Coherent Mood: Depressed, and Anxious Affect: Appropriate Sleep: WNL Appetite: WNL Hopelessness: No Suicide: Intention - No Plan - No Ideation - No, reports past ideation and overdrinking in attempts ta die Homicide: Ideation - No Intention - No Plan - No lnsight: Fair Judgment: Fair DIAGNOSIS: Axis I 311 DEPRESSION 300.02 GENERALIZED ANXIETY DISORDER 303.90 ALCOHOL DEPENDENCE, in remission PlAN: APPT: DISPOSITION: Housing: Appointment electronically created for patient to see psychiatrist as soon as possible. General Population Segregated: No Eligibility: Program Participation, Job Placement. and Job Placement Electronic Signature: 7 Electronically Approved i~(b_)< _6_>;_(b_)(_ _>< _ c _) -----~f MHC on 08-14-2017 10:41 :35 AM. 2020-ICLl-00006 2958 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCS017MNI005042 08-22-2017 Encounter as of 09-20-2017 Wed 04.44:18 PM "I am having a lot of pain in my Joints.I cannot see either I had glasses at Krome but they say they are not in my property here. My vision is very bad. The medication is hel[ping some but I still can only sleep 2-3 hours." 51 yo. male with extensive history of alcohol dependence. He is currently taking Zoloft and Trazodone with some benefit. He reports difficulty sleeping and has other medical complaints. Discussed increasing Trazodone to 75 mg nightly to improve insomnia. PROGRESS NOTE OUTPATIENT MENTAL HEALTH Date / Time: 08-22-2017 Tue I 15:17 S: Reason for Encounter/Patient Statement: Suggested by lCSW Appearance: Groomed. Red-Eyed Orientation: Person. Place Situation. Eye Contact: Appropriate Behavior: Restless. Fidgety .. Attitude: Cooperative Mood: Anxious .. Affect: Congruent. Speech: Goal-Directed. Coherent. Thought Content: Unremarkable. Suicidal: NO thoughts, intent or plan. Homicidal: NO Perceptions: No distortions. Thought Processes: Recent Memory: Remote Memory: homicidal thoughts, intent or plan. Logical. Intact Intact Vegetative Functions Sleep. Decreased Appetite: Good LAB RESULTS/ORDERS:n/a RESPONSE TO TREATMENT: Fair SIDE EFFECTS: None noticed/reported, LastA.I.M.S. evaluation /a, A: DIAGNOSTIC IMPRESSION: 311 DEPRESSION 300.02 GENERALIZED ANXIETY DISORDER TARGET SYMPTOMS: Anxiety, Anxiety, Depression, !nsomnia, Medical issues., PLAN: RX: Continue Zoloft 100mg daily and increase Trazodone 75 mg nightly Next appointment: Electronically placed for Follow-up in 60 days. E: PATIENT EDUCATION: Treatment Plan Alternatives Risks/Benefits Therapeutic/Side Effects Understood 2020-ICLl-00006 2959 Page 2 ALMAZAN RUIZ. FELIPE. 06-26-1966, #GCSO17MNI005042 08-22-2017 Encounter as of 09-20-2017 Wed 04:44:18 PM Agreed 5 Electronically Approved b (b)( ); (b)(?)(C) RNP on 08-22-2017 03:19:09 PM. 2020-ICLl-00006 2960 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCSO17MNI005042 08-24-2017 Encounter as of 09-20-2017 Wed 04:44:44 PM INITIAL HEALTH ASSESSMENT: Patient Name: FELIPE ALMAZAN RUIZ MNI #: GCSO17MNI005042 DOB: 06-26-1966 Sex: Male Location: 1*DORM 1'C*013 1*DORM 1*C*013 Intake Date: 08/11/2017 Date I Time: 08-24-2017 Thu 110:06 SIGNIFICANT PAST MEDICAL HISTORY: YES - Hx of Cirrhosis of Liver effective 2009 as per patient. Hospitalizations/ Surgery. Denies ALLERGIES. NKDA No Mother: Father. Brother: Throat cancer {Expired) KF (Expired) Cirrohosis (Expired) HABITS/BEHAVIORS: Alcohol Use: No Tobacco Use: No Drug Use: No Have you ever injected drugs? No Fever, blood in sputum, prolonged cough or night sweats? No Blood in stools or black/ tarry stools? No Skin lesions, "spider bites". or infections? Na No Unintentional weight loss more than 10%? No Experiencing penile discharge, burning or lesions? Lumps or lesions on testicles? No Any current complaints: YES - "Right knee pain and I can't see." Any current injuries? No PHYSICAL EXAMINATION T: 98.4 P: 65 R: 16 BP: 112/78 Ht: 5fl3in Wt: 163lbs Visual Acuity: OD 20/200 OU 20/200 DS 20/200 Without Correction Patient c/a visual disturbance and is unable to purchase glasses from commisary or have family member send glasses in. Based on the results of patient snellen acquIty Nurse will refer to patine! to MD for visual disturbance. General Condition: 51 year old w male free-moving, good hygiene, well developed. Mental Status: Alert and oriented x 3. Cooperative. Motor: Normal gait and coordInatIon. No tremors noted. Head/Neck Atraumatic. Na lesions or infestations. Neck supple. Thyroid not enlarged. Eyes, Ears, Nose: PERRL. Sciera white. EACs pink and patent. TM's intact and clear. No septal deviation. Oral: Mucosa is pink and moist Pharynx without lesions or exudate. Dental: See Dental Screening Lymph Nodes: No tenderness or enlargement at cervical or axillary nodes. Breasts: No lesions or masses. Skin: Pink, warm and dry. Good turgor. No rashes. lesions or infestations. Heart: RRR without adventitious sounds. Lungs: 2020-ICLl-00006 2961 Page 2 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCS017MNI005042 08-24-2017 Encounter as of 09-20-2017 Wed 04:44:44 PM CTA. Abdomen: Normal bowel sounds. No masses or tenderness noted. Genitals: Deferred. Back: Full ROM. No scoliosis. Extremities: Pedal pulses present and equal bilaterally. No edema or cyanosIs noted. CURRENT MEDICATIONS: DOCUSATE SOD!UM 100 MG FOLIC ACID 1 MG LACTULOSE 10 GM/15 ML SOLN 10 MULTIVITAMIN OMEPRAZOLE DR 20 MG CAPSULE 20 PROCTOSOL 2.5% SERTRALINE HCL 100 MG TAB 100 SPIRONOLACTONE 25 MG TABLET 25 TRAZODONE 50 MG TABLET 50 TRIAMCINOLONE 0.1% CREAM 0.1 XIFAXAN 550 MG TAB 550 DENTAL ASSESSMENT: Describe any significant dental problems or history: MENTAL HEALTH ASSESSMENT: Have you been hospitalized in a psychiatric unit? No Have you received outpatient counseling/treatment for emotional/nervous problems? No Past Psychiatric Medications? No Do you have current emotional problems? YES - Depression, "but I have already seen MH and have started medication." Patient will follow up with MH as needed. Have you ever attempted suicide? No Are you thinking about suicide now? No Do you ever think of hurting yourself or others? No Have you ever been a victim of sexual assault or physical abuse? No Have you ever perpetrated sexual assault or physical abuse? No PREVENT!VE HEALTH AND EDUCATION: Immunizations: Received routine childhood vaccinations? No Communicable Disease Screening (PT-022) Completed? Yes Tuberculosis Screening (PT-024) Completed? Yes Health education and prevention provided? YES Nurse educated patient on how to access healthcare services such as sick call, dental and MH if needed at a later time. Patient verbalized education. ANNUNAL HEALTH MAINTENANCE: Date of Incarceration: ALMAZAN RUIZ, FELIPE 08-12-2017 Sat 03· 1S·OOAM Intake Understand English?: Y Date of Incarceration: 08/11/2017 Intake Weight: 168.8 lbs Current Weight: 163 lbs Occult blood cards given times three with instructions on stool collection. Patient verbalized understanding. ASSESSMENT: No significant health conditions indentified at present. TREATMENT/PLAN: Reviewed Mental Health Intake (MH-014) Reviewed Intake Screening Provided instructions on accessing health care in the institution. Instructed in oral hygiene and provided preventive oral education. Follow-up in Sick Call as needed; Routine Health Maintenance REFERRAL: Routine referral lo Provider Sick Call electronically created. Armor PT-028 (Revised May 2017) Automated 2020-ICLl-00006 2962 Page 3 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCSO17MNI005042 08-24-2017 Encounter as of 09-20-2017 Wed 04:44:44 PM Entries: . . (b)(6); (b)(7)(C) The following items were created b RN on 08-24-2017 02:30:04 PM: ORDER: Provider - R01~J.l□IJJINN,Ef_...::===:-----' Electronically Approved ~ b)(6); (b)(7)(C) on 08-24-2017 02:29:24 PM. NURSING PROTOCOL - MUSCULAR SKELETAL: fN Patient Name: NO: DOB: Sex: Date: Time: Location: FELIPE ALMAZAN RUIZ GCSO 17MNI005042 06-26-1966 Male 08-24-2017 Thu 14:30 1'DORM 1·c·o13 1·□ORM 1·c·o13 SUBJECTIVE: "I have right knee pain." Complaint: 2 day(s) ago Acute problem, began: 1 week(s) Chronic problem, duration: How condition began: Unknown Pain: Mild Up and Down. Pattem of Pain: Level of activity related to pain: Able to function okay Remains at affected area Radiation of pain: Dull Other characteristics of pain: Advil/Ibuprofen, Rest, Elevation of affected area, Condition made better by: Stooping/Bending, standing long periods of time Condition made worse by: Associated Symptoms No Fever? No Nausea/vomiting? other Symptoms: Allergies: NKDA Hx of Bleeding Ulcer of complications of pain medication? No CURRENT MEDICAL PROBLEMS: 300.02, GENERALIZED ANXIETY DISORDER 311. DEPRESSION 571.5, CIRRHOSIS OF LIVER WITHOUT ALCOHOL OBJECTIVE: Vital Signs: VITAL SIGNS: (6) Weight: 163 lbs, Height: 5 ft 3 in, BMI: 28 9, BSA (Mosteller): 1.81, BSA (DuBois): 1.77, Blood Pressure: 112 / 78, Temperature: 98.4 "F, Pulse: 65, Respiration: 16 General Appearance: No acute distress, Describe are of concern: Describe gait and mobility: Freely moves about Describe range of motion of area concerned Swelling: No Tenderness: No Pupils: Equal and reactive, Neck: Supple, ASSESSMENT: Alteration in Comfort locastion - Righi knee Related to Occassional pain. PLAN/EDUCAT!ON:Nurse educated patient lo provide periods of rest when ever right knee pain is aggrevated , excercise as tolerated lo strengthen muscles, increase fluids and avoid straineous activities. Nurse instructed patient on treatment plan for today. Patient verbalized all understanding. For Chronic Pain related to back problems or joint problems Tx given: Ibuprofen 200 mg; two (2) labs BID x 5 days PRN (NO history of bleeding ulcers) Instructions given: Warm pads and head can provide relief Education given: Exercises as tolerated to improve muscle tone and strength. Return to sick call if symptoms worsent or persist more than 7 days. DENTAL SCREENING: Inmate/Detainee Name: FELIPE ALMAZAN RUIZ MNI#: GCSO17MNI005042 Dale of Birth: Missing Teeth: Fillings: 0 2020-ICLl-00006 2963 Page4 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCSO17MNI005042 08-24-2017 Encounter as of 09-20-2017 Wed 04:44:44 PM 0 Suspected: Dentures: Partials: other: _ 0 N/A NIA 4 upper implants as per patient Rb)(6); (b)(7)(C) I Electrorncally Approved bYl'i========;:=-=:RN tb )(6); (b)(7)(C) Electronically Approved byf on 08-24-2017 02:33:41 PM. lIIJID _ on 09~05-2017 04:02:46 PM. 2020-ICLl-00006 2964 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCSO17MNI005042 08-30-2017 Encounter as of 09-20-2017 Wed 04:44:58 PM NURSING PROTOCOL - MUSCULAR SKELETAL: Patient Name: NO: DOB: Sex: Date: Time: Location: FELIPE ALMAZAN RUIZ GCSO17MNI005042 06-26-1966 Male 08-30-2017 Wed 14:20 1'DORM 1·c·o13 1·DORM 1·c·o13 SUBJECTIVE: Complaint: Joint Pain - Bilateral Shoulder Bilateral Knee Bilateral Elbow Acute problem, began: NIA Chronic problem, duration: 6 monlh{s) How condition began: Unknown Pain: Moderate Pattern of Pain: Constant. Worsening. Level of activity related to pain: Able to function okay Radiation of pain: Remains at affected area Other characteristics of pain: None Condition made better by: Advil/Ibuprofen, Condition made worse by: Any movement Associated Symptoms Fever? No Nausea/vomiting? No Other Symptoms: Allergies: NKDA Hx of Bleeding Ulcer of complications of pain medication? No CURRENT MEDICAL PROBLEMS: 300.02, GENERALIZED ANXIETY DISORDER 311, DEPRESSION 571.5, CIRRHOSIS OF LIVER WITHOUT ALCOHOL OBJECTIVE: Vital Signs: VITAL SIGNS: (6) Weight 165.2 lbs, Height: 5 ft 3 in, BMI: 29.3, BSA {Mosteller): 1.83, BSA (DuBois): 1 78, Blood Pressure: 106 / 68, Temperature: 98.6 "F. Pulse: 74. Respiration: 18 General Appearance: Uncomfortable, Describe are of concern: Describe gait and mobility: Freely moves about Describe range of motion of area concerned Swelling: No Tenderness: YES ASSESSMENT: Alteration in Comfort Locastion - IN JOINTS AREA Related to UNKNOWN. Pl.AN/EDUCATION: For Chronic Pain related to back problems or joint problems Tx given: Ibuprofen 200 mg; two (2) tabs BID x 5 days PRN (NO history of bleeding ulcers) Instructions given: Warm pads and head can provide relief Education given: Exercises as tolerated to improve muscle tone and strength. Return to sick call if symptoms worsen! or persist more than 7 days. . b)(6); (b)(7)(C) Electronically Approved b,..______ Electronically Approved (b)(5); (b)(7)(C) ,....LPN,CCHP on 08-30-2017 02:24:30 PM. Non 08-31-2017 01:27:37 PM. 2020-ICLl-00006 2965 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCSO17MNI005042 09-02-2017 Encounter as of 09-20-2017 Wed 04:45:11 PM NURSING PROTOCOL - EYES, EARS, NOSE, TEETH ANO THROAT: Patient Name: NO: DOB: Sex: Date: Time: Location: FELIPE ALMAZAN RUIZ GCSO17MNI0OS042 06-26-1966 Male 09-02-2017 Sat 16:50 1*DORM 1 *D'048 1•DORM 1•0•048 SUBJECTIVE: Complaint: Vision problem/ eye glasses- patient states he's having difficulty seeing, things look blurry. AcLJ!eproblem, began: A few week(s) ago Chronic problem, duration: NIA Pain: None Description of problem: Patient is having difficulty seeing. Condition made better by: Nothing is helping, patient had an appointment scheduled with an optometrist prior to entering the facility. , Condition made worse by: unsure Associated Symptoms Fever: No Drainage: No Cough: No Shortness of Breath: No Sneezing: No Other: none Allergies: Other Comments: NKDA None at this time. CURRENT MEDICAL PROBLEMS: 300.02, GENERALIZED ANXIETY DISORDER 311, DEPRESSION 571.5, CIRRHOSIS OF LIVER WITHOUT ALCOHOL OBJECTIVE: Vital Signs: VITAL SIGNS: (6) Weight: 166 lbs 4 oz, Height: 5 ft 3 in, BMI 29.4, BSA (Mosteller): 1.83, BSA (DuBois): 1.79. Blood PressLJre: 113/77, Temperature: 98.3 "F, Pulse: 83, Respiration: 18 General Appearance: No acute distress Describe area of concern LJnremarkable Eye: Vision R: 20/200 Vision L: 20/200 Signs of Infection: None Sciera: Clear, white. ASSESSMENT: Disturbed Sensory Perception: R/0 Visual disturbance. PLAN/EDUCATION: Routine referral to Dr. Noel within 5 days secondary to Patient having difficulty seeing, may need glasses. Made same complaint during Initial Health Assessment. 5 Electronically Approved bJ (b)( ); (b)(?)(C) 5 Electronically Approved ~ b)( ); (b)(?)(C) bn 09-02-2017 04:56:23 PM. ~Don 09-05-2017 04:03: 19 PM. 2020-ICLl-00006 2966 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCS017MNI005042 09-06-2017 Encounter as of 09-20-2017 Wed 04:45:26 PM Patient c/o visual disturbance OS 20/200 OD 201200 30 DAY CLINIC CIRRHOIS knee pain and joint pain CHRONIC CARE CLINIC: DatefTlme: 09-06-2017 Wed/ 09:48 Patient Name: FELIPE ALMAZAN RUIZ No: GCS017MNI005042 06-26-1966 DOB: Sex: Male 1*DORM 1*0*048 1"DORM Location: 1•□•04s Clinic Membership: 571.5 CIRRHOSIS OF LIVER WITHOUT ALCOHOL 311 DEPRESSION 300.02 GENERALIZED ANXIETY DISORDER PAST MEDICAL HISTORY: 51 years old male with history of liver cirhosis, Gerd, possible portal hypertension, constipation here today for 30 days clinical evaluation, the patient disgnose 7 years ago and he's been on treatment since then Duration of condition(s): 5-10 years Prior hospitalization(s). No change since last visit Complications: none CURRENT MEDICATIONS. DOCUSATE SODIUM 100 MG FOLIC ACID 1 MG LACTULOSE 10 GM/15 ML SOLN 10 MULTIVITAMIN OMEPRAZOLE DR 20 MG CAPSULE 20 PROCTOSOL 2.5% SERTRALINE HCL 100 MG TAB 100 SPJRONOLACTONE 25 MG TABLET 25 TRAZODONE 50 MG TABLET 50 TRIAMCINOLONE 0.1 % CREAM 0.1 XIFAXAN 550 MG TAB 550 DATA REVIEW: CMP Sodium 141 Normal mmol/L 135-145 Final CL Potassium. 4.3 Normal mmol/L 3.5-5.5 Final CL Chloride 104 Normal mmolll 95-110 Final CL Carbon Dioxide 26 Normal mmol/L 19-34 Final CL Anion Gap 15.3 Normal mmol/L 10-20 Final CL Glucose 86 Normal mg/dL 70-110 Final CL Calcium 8.8 Normal mg/dL 8 4-10.2 Final CL Protein, Total 6.9 Normal g/dL 5.5-8.7 Final CL Albumin 3.6 Normal g/dL 3.2-5.0 Final CL Bilirubin Total 1.7 Above Normal mg/dL 0.1-1.2 Final CL Alkaline Phos 162 Above Normal U/L 20-130 Final CL AST (SGOT) 35 Normal U/L 10-40 Final CL ALT (SGPT) 25 Normal U/L 10-60 Final CL Urea Nitrogen 17 Normal mg/di 6-22 Final CL Creatinine .. 0.70 Normal mg/dL 0.43-1.13 Final CL eGFR NonAfrican Am> 60 Final CL eGFR African Amer> 60 Final CL eGFR less than 60 (mllmin/1.73) square meters Lipids Profile Triglycerides 45 Normal mg/dL 0-150 Final CL Cholesterol 92 Normal mg/dL 0-200 Final CL HDL 54 Normal mg/dL 0--60 Final CL NON-HDL 38 mg/di Final CL Goals for Patients with CHO or CHD risk equivalents: LDL: < 70 mg/di NON-HDL: <100 mg/di Goals for Patients with 2+ risk factors: LDL: <130 mg/di NON-HDL: <160 mg/di Goals for Patients with 0-1 risk 2020-ICLl-00006 2967 Page 2 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCSO17MNI005042 09-06-2017 Encounter as of 09-20-2017 Wed 04:45:26 PM factors: LDL: <160 mg/di NON-HOL: <190 mg/di LDL Cholesterol 29 Normal mg/dl 0-130 Final CL Chol/HDL Ratio 1.7 Normal 1.5-5.6 Final CL . H Pylon Ab lgG H Pylori Ab lgG or= 1.10 9 (b)(6); bROERS) (THIS IS THE ON .. . -- · ·- · 0. 70 Normal U/ml 0.00-0 90 Final CL Negative Equivocal Positive PSA Diagnostic PSA Diagnostic 0. 1 Normal ng/ml 0-4.0 Final CL Prothromin Time PT Seconds 9.4-12.5 In lab CL Pro Time INR In lab CL Status Observation Date Performing lab Performing MD PTT Activated PTT 41.6 Above Normal Seconds 25. 1-36. 5 Final Cl Therapeutic PTT range of 50-89 seconds CBC WBC 3.0 Below Normal 10 3/ul 3.6-11.0 Final Cl RBC 3.65 Below Normal 10 6/uL 4.50-5.90 Final CL Hemoglobin 11.3 Below Normal g/dl 13.0-18.0 Final Cl Hemalocril 34.8 Below Normal% 40.0-52.0 Final CL MCV 95.6 Normal fl 81.0-97.0 Final CL MCH 31.0 Normal pg 26.0-34.0 Final CL MCHC 32.4 Normal g/dL 31.0- 37.0 Final CL RDW 17.4Above Normal% 11.5-15.0 Final Cl Platelet Count 41 Below Normal 10 3/ul 150-400 Final Cl Mean Platelet Val 9.6 Normal fl 7.4-10.4 Final CL Neutrophil % 65.7 Normal% 36.0-66.0 Final Cl Lymphocyte% 25.2 Normal% 23.0-43.0 Final CL Monocyte % 4.8 Normal% 0.0-10.0 Final Cl Eosinophil % 3.9 Normal% 0.0-5.0 Final CL Basophil % 0.4 Normal% 0.0-1.0 Final Cl Neutrophil Abs# 2.0 Normal 10 3/uL 1.6-8.2 Final Cl Lymphocyte Abs# 0.7 Below Normal 10 3/uL 1.1-4.7 Final CL Monocyte Abs# 0.1 Normal 1O 3/uL 0.0-1.1 Final Cl Eosinophil Abs# 0.1 Normal 10 3/uL 0.0-0.5 Final CL Basaph ii Abs # 0.0 Normal 10 3/ul 0.0-0.4 Final CL Ammonia Ammonia 108 Above Normal umol/L 11-35 Final Test Performed by: IRL - Florida 5361 NW 33Avenue Adherence Ft Lauderdale, FL 33309 CL SUBJECTIVE: the patient is complaining of abdominal pain radiating to the chest otherwise he's denies all others symptoms Stability of condition(s): Stable Issues with medication(s): None. Other: none OBJECTIVE: T: 97.6 P: 80 R: 18 BP: 122176 Weight: 170 lbs GENERAL APPEARANCE: Well-developed, well-nourished 51 year old w male in no acute distress. HEAD: Normocephalic. Atraumatic. EYES: PERRLA. EOMI. Sciera non-icteric. ENT: EAC's clear. TM's white and shiny. Nares patent. Oral mucosa pink and moist. Oropharynx clear. NECK: Supple with full range of motion. No tenderness or lymphadenopathy. No JV□ or carotid bruits. LUNGS Clear to ausculation. Respiratory effort 2020-ICLl-00006 2968 Page 3 ALMAZAN RUIZ, FELIPE, 06-26-1966, #GCSO17MNI005042 09-06-2017 Encounter as of 09-20-2017 Wed 04:45:26 PM non-labored. HEART: RRR. S1 S2 WNL.. No murmurs or rubs. EXTREMITIES: Pedal pulses are palpable and equal. No extremity edema. ABDOMEN: Positive bowel sounds. Non-tender. No hepatosplenomegaly. No masses. pain mid epigastric radiating lo the chest GU: Deferred. RECTAL: Deferred. MUSCULOSKELETAL: Moves all extremities well. No deformities. cyanosis or clubbing. Gait steady, SKIN: Warm, dry, normal color. Turgor elastic. NEUROLOGICAL: No sensory or motor deficits. Deep tendon reflexes 2+ bilaterally. PSYCHIATIRC: Awake and alert. No depression, agitation or anxiety noted. ASSESSMENT: 1===THROMBOCYTOPEN IA 2===571.5 CIRRHOSIS OF LIVER WITHOUT ALCOHOL 3===311 DEPRESSION 4===300.02 GENERALIZED ANXIETY DISORDER S===mild increase total bili and alkp 6===Normochromic anemia ?===Degree of Control - poor Status - Improved 8==-=Patient's adherence lo treatment plan: poor 9===Patient's understanding of condition: GOOD PLAN:' 1 ===I will increase lactulose doses and will continue with the current meds cbc weekly the follow-up,++ see below prednisone 100 mg x3 days then 80 mg x 3 days then 60 mg pox 3 days then 50 mg x 3 days' the 40 mg x 3 days then 30 mg x 3 days then 20 mg x 3 days the 10 mg x 2 days then 5 mg x 2 days the 2.5 mg x 2 days then die FERROUS SULFATE, 325MG #90, Sig: 1 time per day for 90 days 2===+++++cbc weekly x 4 weeks+++++ 3===d/c dulcolax 4========1actulose 40 ml po daily x 90 days ====== 5===FOLIC ACID, 1 MG #90, Sig: Take 1 Tablet by mouth 1 time per day for 90 days 6===MULTIVITAMIN, #90, Sig: Take 1 Tablet by mouth 1 time per day for 90 days 7===-SPIRONO!.ACTONE, 25 MG #180, Sig: Take 1 Tablet by mouth 2 times per day for 90 days 8===xifaxan 550 mg po bid x 90 days 9===Palient c/o visual disturbance 10===OS 20/200 OD 201200 11====ammonia level 02 WEEK X 8 WEEKS 12=ca=Renal diet x 1BOdays 13===cbc cmp lipid panel in 82 days 14===follow=up in 90 days 15===-OMEPRAZOLE, 40 MG #90, Sig: Take 1 Capsule by mouth 1 lime per day for 90 days EDUCATION Adherence Weight Loss Medications Disease Process Smoking Cessation Transmission prevention Exercise daily Care after release Diet renal diet Lab Results explained Adjustment to Incarceration Other Med compliances (b)(6); (b)(7)(C) Electronically Approved by n 09-06-2017 10:23 31 AM. 2020-ICLl-00006 2969 Lab Result Pagel of3 Collection Date: 2017-08-\7 Thu IIPatient IIID IIBirth Date [ALMAZAN RUIZ, FELIPE IIGcs611MNioo5042 l[o6 26 1966 I II I - I ,,,,. ormal Abnorma R~•ults Results Test Name Abnormal Units '" l ' " IIChloridc Normal 6 Anion Gap Glucose Calc!um ' ' ~rotein, Total llrnrnom 11;;-..;; ~I ' ; ,, J;=•• ,, "ell, ·····111.1_ _n __l~.s_ _ Normal ALTrSGPT) _J i,,::::J Urea Nitrogen [,_,__J Normal pe;i:;mne 0.70 lcGFR NonAfrican Am w cw AST(SGOT) [cGFRAfrican Amer eGE'R less It ,, k_idney Ms "" chrcrn1c, clinical dLt. LOn : )4 d plans and is taku1g Triqlycc,idcs patient ,, taking Os falsely decreased. [ <'.dn 00 " rnay ~ 6-22 w •mal ''' dL 0 43-1.13 •mal 1[ ma! It mal l!E· ' I CJ 7[ [ I[ l [ I L_J _JD " Pat ic.nt -~ Wll h CHD oc '<100,c Patients mg/dl TrLglycendes aco ace 7[ [ Normal Abnormal Results Results ~lUnlts li'7r Normal ''" risk with NON-HOT,: <160 mg/dl ,, risk Patient..s with [ R~~talus•1~,hse~;tj~ Date _ - II ____ Ra mWdL 0-150 equivalents: fact.on,: 11=1L L_J CJ CJ -200 risk •"' " -_,_ CJ factors: ,7,----' 2020-ICLl-00006 2973 r inal CL CL 'inal c, inal -00 L c-, r= ,, "m""" "ormal CL inal m_ayj mg/dl mq/dl about:blank Normal 7 3 -8 3 - '' ' I 10-40 [uiI_----1 10-60 CJ CJ <130 "'' ,nal L:J Mr,lamizol<', LDL: Goals lutL-- Normal fou~ E:::J lic:J foe Normal ----- ' 20-130 CJ IINON-HDI. c=~~als " U/L Normal E 1 1 AMve Normal II ~ NON-HDL: /dL Above Normal kidney ~- L lmwdL l•«oc~~ /dL 5587 [ lcholes!crol LDL: Normal f ma! C"lorida decreased. foe Normal 33309 " H Goals Normal F anal ' we1ghl. ITr~g!yce~,d-;,, I ____[mg!dL [ 70-110 ''"~I ILie1ds Profile I I I t f on ion Test Name fdlS<'ly mal Avenue. Lauderdale, H patient Acetylcycteine, 19.34 F r.sdiocontrast. corrcctjon NJ-:,JM )006:354 and by: estimated a, 's R~nal adJustments eGF'R, dc.finiti<1~s, Pertormed 5361 n '" dosing oC www.kidncy.org Test Din patient-specific d1sc.asc. "/3) '!'his Me, -14.'5 ·mal 3 5-5 5 anal ' Carbon Dio~1dc t I Ohservation]t a us Date I Ran~e II II [CMP IReferrnc, AbnormalllUnits Fla~• CJ l11r CJ 9/20/2017 Page 2 of3 Lab Result 1..... LDL: <160 :ng/dl NON-HOL; <190 :ng/dl .DL Cholesterol [ch~I/HDL Ratio I Test L ___ ~36l __NW JJ [__ ,·t by: Avenue Tcst Name IRL - E"lori.da _I .. C FL 33309 Lauderdale, II I RD=Py=~=-~=it=/=Ig=G=(1=:=H~is=; I~~=· 1~r-·-··----1,-------~----~-''--~~=□1 IllNorm_al _JAbnormal Results Results 1 [~S~1~-H=b~O~:-l-b-. 0-R-.N_O_E_L __ _ rLoci~:sr ~ertormed by: IRL ]I - NW 33 Avenu_':'_ 5361 Abnormal C][Rercr.:,;-e~Flag., _____ t:::::][Ranee re=_ Ii 111 Pylori Ab!gG II l[ l[Lab Performing MJJ =- -!:-C.-"---.a==..=II [JL~===_=_ ==!1:1===_-~.- . f71 .. ·=·==-_]===I =~II .. JI ====:!!u===·-=7:!!::=====:!i 1ra;mal Abnormal Abnormal II/nits 11~~;:11s,atusllg::;mtionJ[t~ Fl.ae. Results Results 0 ITc•t Name - ... [P_SA Diagnostic [PSA_D!~nostic PSA is See the I guidelines I Test 5]61 prost.ate used as cancer. American Uroloqlcal inlendr:d -. management Ft l[Date II --· I I II [71 _ !~=='l'l=======~'li===~ CJ I-· ·-71 I 11" _][ __ ·····- i[sut..,1roi.ser\'ali~n llrerforming I!~' -~=Jcs~luimiJ=J/=m=sl.:=[oo=oo=-0=.9=·0=cal[,1=n~La~b~lfa======!ll __ -!e---~~1 l!:I===n=r.='"=j(=lc=rc=l,=11="=' =F'=l.=3=3=3=09===]~1-=-=·=·· =·=··:!!-11=· -===i==:!e=· =~ I ~ Final Performed of 2013 tor Performed -· t.o h~ lRL NW 33 Avenue Lauderdale, ·-·-- in the l\ssociat ioc1 det.ectio~~L- {AUAI interpretation. result by: an aid - J,locida .- .. - !"L 33309 ... I . l~t== ClC l[Nocmal ]InglmLI[0-4.0 ··101 IL II··==7c IIFinal u-··· uo:··· IOI ICJ[ __ IL --=--1:=-1r ICII ii- I[ .:::Ji ICJI ICII I! --=e1c=--·ILII Ii =J =-_JC71 IOI L 1r-~1 1c:=11 II IC.JI.. JI II 1L.=ic·····11 IL:..-71 u II .. · 11 11= 11= c-=:: C . II~ If II Order Statu<: P CMJ' ID# 0 IO !03 ORDER Scqucncclll Control Number: LB\ 74_ 0005626AA Colleclion Date: 08-17-'J.017 02:34 Receipt ~08_-_I c..8--"20c..lc.c7_l..;;3.;..;:0..cS _____ ~ Lab Filler Accession ID LB 174_ 000.5626AA Date: Ordering Providerj (b )/6) /b )/7 )/C) Observation Rpl Dale: 08-18-20 I I 13:58 Rcsul1s Starus: All Results Available, Order Complclo. Final Lipids Profile JOff 0 l 0009 ORnER Scquence#2 Control Number: LB! 74_000567.6AA Collection Date: 08-l7-2017 02 34 I.ah Receipt Dat~ Di I 'il 11\17 I l-OS Filler Accession ID LB 174 000567.6AA Ordering Providcl(b)( 6 ); (b)( 7 )(C) Observation Rpt Dale: 08-18-2017 13:58 Results Stalu<: All Final Results Available, Order Complete, H Pylori Ab IgG (Tl !IS IS THE ONE DR. NOEL ORDF.RS) IDff 06003 \ ORDER Scqucncc#3 Control Number; LB 174 0005626!\J\ Filler Accession ID; LB 174 0005626AA Collection Date: 08-17-2017 02:34 Lab Receipt Date: 0,;8,..,-"-!18.;;,• 2..,0.,.1 .... ?.,;l,-,.3_,,:o,,,s ______ _, Ordering Provider: ~lth....\=IR _.. \._ · '-' /h'--' \/'--' 7-"\/'"r:...' '--------' Observation Rpt Date: 08-\8-2017 13:58 Results Status: I PSA Diagnostic ID# 026003 ORDER ScqucnccH4 Control Number: LB! 74 0005626AA Date: 08-\7-2017 Lab Receipt Oatc: 08-18-2017 13:08 Collection 02:34 Filler Accession ID: LB 174 0005626AA Order ing Providcd (b)(6) ; (b)( 7 )(C) Observation Rpt Date: OS-18-101/ l.l:58 Results Status: All Final Results Available, Order Complete. about:blank 2020-ICLl-00006 2974 9/20/2017 Lab Result loateffime ll Page 3 of3 · 0os0-01s0-20o0_1_1 01 0, 0o02~~~~~~1i& about blank l~~din,:: Applicatioo/hcility ____[Receiving Application/J'acility 0NNB 0-0s,,01A 0RM"""cco,_~~~~~~~~~~~~-"lclc 0orr 0,ccfeKIARMCOGL_ 2020-ICLl-00006 2975 9/20/2017 Lab Result Page I of2 Collection Date: 2017-08-17 Thu ~m-e IINormal Abnormal Abnormal U . Reference S Observation mts Dgn.... talus Date l\["""'_"'~~~~~~~~~~~~~J11 ~"~--,~l<~•J!R~e~sults IJ<'lga~ lrnc ~ - 11·==7 [Message Type !Results - llcontrol Number -- lfiiner Accession _I_J? IILBI74 0005626AA Order Status: P CBC ID# 050004 ORDER Sequence#! Control Number: LBl74_0005626AA Collection Date: 08-17-2017 02:34 Lab Receipt Date: 08-18-2017 13:08 about:blank "erforming ab Performing MD JI Filler Accession ID: LA174 0005626AA 2020-ICLl-00006 2976 9/20/2017 Page 2 of2 Lab Result Ordering Provider: fb l(5 ); (b)(?)(C) Observation Rpt Da.,.,.te""': .,.0,,..8-.,.[ g,,.._..,z0,,..,1 .../..,.[..-3 :...,49..----Results Status: All Final Result, Available, Order Complete. IReccivin [ate/fime Hl=P=r=oc=c=ss=I=D ________ [P'='Pr<>duction about:blank A licatio11/Faci-li· ~ Corrcc'[cK/ARMCOGL. ---71&N8SP/ARMCO ~l~IV=e=rs=io=n==-----'-···~]~[A_~_-c_'.ep_t-_A_ck_._~ __ ~~~~l[~A_:_:pp:_I_. A~_ c_k_. ~-=· __ ]li.3 I 2020-ICLl-00006 2977 · ~ :::::J 9/20/2017 Lab Result Page I of2 Collection Date: 2017-08-17 Thu Patient [A"°i:MAZ_AN RUIZ,rn1,i1;E· llrn Birth Date IIGCSO I 7MNI005042 06-26-1966 [SN IIM L -- II Normal Abnormal Abnormal Observation Reference IStatus] Date [units] Ranl!e Results Results Flal!S Test Name -- D 'BC Performing Lab Below Normal RBC 13.65 Below Normal l!JuL 114.50-5.90 Final Jc, [1£cmogl~bi~- IL3 Below Nonna] lg/dL 113.0-18.0 I Final ]er Hematocrit 34.8 Below Normal I% Final CL ''""' " CL CL MCV MCHC l 40.0-52.0 di 31.0- 37.0 Final CL RDW 17.4 1% 111.5-15.0 I Final CL Platelet Count 141 Below Normal [~JuL 11150-4~~ IIFinal ][ ------~ -_ -~ - Above Nonna] 0 Lymphocyte% Monocytc % 1rit71 Eosinophil % [Hasophjl %" _Ncutrophil Abs# ~Bi°IO" ~I No No .0-5.0 .0-1.0 Normal 2.0 lo, ymphocyte Abs# Below Normal 10 1.6-!U 3/uL 1 l~JuLll ~ [Normal - ·1[~Ju1. Eosinophil Abs# 0.1 !Normal ll~JuL llo~§_n_al IINorma~ ]l~JuL ]jo.0-0.4 -- - by: Test Performed 5361 NW 33 Avenue IRL - Florida Lauderdale, jPerforming ID FL 33309 -- EJC IINamc II J JIAddrcss Final ~nl CL ][Final I __::] rm;,··][state II 11 II II II II ][County II ][Control_Number j[Group Number IILB174 0005626AA Order Status: P CBC ID# 050004 ORDbR Sequence#! Control Number: LB174 0005626AA Collection Date: 08- l 7-2017 02:34 Lab Receipt Date: 08-18-2017 13:08 about:blank I I I CL CL CL ]]er l ---__J]cr II [Cif'Corc Lab/VVV\ !Results II II CL CL Final gnng~lJI =:__ II I CL ][o.o-;_-~7 0.1 Rasophil Abs# Final II -- IMonocyte Abs# Ft CL CL 9.6 Neutrnphil % I I I J~, 1~1 1~~~~1 [Mean Platelet Vol I ]]cL 1 6. Nonna] 32.4 II 3 l~JuL 11~11Final 1.097.0 lE [,-t_ctt MD CJ 13.0 WRC Performing Filler Accession ID: LBl74_0005626AA 2020-ICLl-00006 2978 9/20/20_17 Page 2 of2 Lab Result Ordering Providcr~i b_)_(5_);_(b_)(_7_)(C _ )_______ _. Observation Rpt Date: 08-18-2017 13:49 Results Status: All Final Results Available, Order Complete. iDatcfl~ime UsendingApplication/Facility lo&-1&-2ot113:55 U&NRSP/ARMCO llv J II 1.r~occss_rn ersion Accept Ack. .. ---=i1Appl. Ack. _ .~IP_:l.:..:.'ro.:..:.d.:.c:u_c=ti=on=..,,--------~-=-=~]1[~2.~_3=~===~]!~~~~====--=!~=-"'-"..:c....::..::-=-=~=====_.JI 1 about:blank 2020-ICLl-00006 2979 9/20/2017 Lab Result Page I of2 Collcclion Date: 2017-08-17 Thu ---- -:-=-llrn Patient AI.MA7.AN RUIZ, FbLIPE . -· ..... l!GCS017MN!005047. -· - [ - Birth Date !Sex 06-26-1966 IM l!ssN _ I I I ---I c=Jc-· . Abnormal lunitsIReferen,i;::,11observatiool~ Ranl!.c Date IProthromin Time ! 11··=--1 ·- PT Ah<>ve Normal [Te,t Name .. . ·" ... rang<': PT reference I I -- Use INR tor [ g_4-1~-~ - --- clinical Ranqe: 'fhcrvpcutic -·· dec::i~ion - TNDTCATION .. - - --- ereventlon and tr€!dt.m~nt. At.rial tibrillat ion Acute myoca~dial inf~rcl of V'l'f: - 3 2 - 3 - 3 2 .. 2 ion 3 ··- 2.5 - 3.5 i. - 3.5 . ••r..o-admir1istratio~ combined effect t ~-·bOI i /Sm . -· . I[ 11-11 ... 11--:=11 I[ . ·1[ 1[_11 l~I I I IC71 TARGETED INR RANGE ··-·· Val1mlar Prosthetic Prosthetic Recurrent ]I . _II IL_J L_J fst 1106-26-1966 11~1 Ill_._~_ --· --· [Test~~~e- I __ _l~rn============~~IB=i=d=h=D=a=te======:11s;:::::]ssN FL 33309 II II~□□[] IC-]~11 IC] IOI II 11 I[ 11_::::::::::::11ICJc=~71 11Secondsl[94-12 S [1111 Labll l[!nLab[I II :::::::::::: 11 II II [C]I lc=JI ·11 .. l[CL IICL II -l 11 II II 11 11 I II II I ITeslName Tl Activated PTT O.J-0.7 units anti- Xa activity. Test Performed by: IRL Florida I 5361 NW 33 Avenue Fl Laudccdalc, !Performing ID I[ ~L 33309 -----·--·. 7!Name l[Adtlres~ Control Number .I ·r- II II II I II -~,-,.-,,---~==~============== ][City ]ls1a1e ·-][zip··· jJ<'illcrAccession ID l II ]country . II -~.--1 [[county l[Group N11mber J.Bl74 0005626AA Order Status: P Prothromin Time ID# 050012 ORDER Sequence#! Control Number: Lill 74_0005626AA filler Accession ID: LB174_0005626AA Collection Date: 08-l 7-2017 02:34 Lab Receipt Date: \l~8.o;,--~18""°-2'--!:0~J,.,7""'J3-=·""'a8------, Ordering Provider:l.(.,_ b_._ )(,6__..) ;.,_ (b_._ )(,_7_..,)( _C.,_ ) _____ Observation Rpt Date: 08-18-2017 13: 56 Resulls Status: I _. PTT ID# 050016 ORDER Sequence#2 Control Number: LB 174_0005626A A Collection Date: 08-17-2017 02:34 Lab Receipt Oat~· QS-18-2017 )3 ·Q8 Ordering Provid /b)/6): /b)/7)/C) Observatiun RptDatc: 08-18-2017 13:56 Results Statll5: All Final Results Available, Order Complete. ~~ss!D ll~oduction about:blank ..7[version 1123 Filler Acces,ion ID: LB 174 00056261\A _llAcceptAck. ~7 2020-ICLl-00006 2982 9/20/2017 Lab Result Pagel of I Collection Date: 2017-08-17 Thu [Palie~t_ ~AN RUIZ, FELIPE ~---------- l~.-~.J ITes __ -:_~ame IINormal Abnormal Abnormal ~] R~"r~rcnce Observation Pcrform-ingllPerforming IIResultsResults Flags ~ Range ~ Date Lab JIMD L i:=IPT=T"-------~-~==== __ =_=-~--_ ~l:=1 = I -------c .. I l~I IC71 ,~IA=c=ti~va~_tc~d_P_TT__,_==---~·====7===s□41.6 ~~~~:!__ RBFinal I[s~econdsTherapeutic PTT range of 50- 11n ____ [_Jr ~ corccsponds to 11 L___J lr=[xa a=ct~~!=-~~:7=uni=ts an~ti_: ~7□[77□ Test Performed by: TRI, 1 - - ~-I -___ II --=-----=i;~I -=~1 1 [ - I_ [ ---JcL I_ .. 11-===i--il.------------'-i.-il □Clnc· ~Fl=o=r=i:=;~6-l _N_vl_3---,3_~~'---_v-e=.n:u:e:::::::: I _Jf-l]II~-·:_· ____ _]_Ji·-····-1 .. I !•t Lander::dale, FJ, 33309 _ /Message Typ~ l[control Number IRc_sults _=11LBI 74 0005626AA ----~=='==================="=====~~------c-7"""--c~' 1 l[nncr_~_cccssion ID j Grou Number · Order Stat us : P Prothromin Time I[)# 050012 ORDER Sequence#! Control Number: LB\74 0005626AA Filler Accession Collection Date: 08-17-2017 02:34 Lab Receipt Date: P.8-18-2011 ]3·08 Ordering Provider: Kb)(6); (b)(7)(C) Observation Rpt Da~t-c:....,o""g....,_1-=-g_-=z-=-o-:-:17,...,J,..,,3,...,:5,...,6----~ Rcsults Status: 1 m: LR174_0005626AA PTT J[)# 050016 ORDER Sequencc#2 Control Number LBl74 0005626AA Filler Accession ID: Ll3174 0005 626AA Collection Date: 08-17-2017 02:34 Lab Receipt Date: 0,..8~--' 8~-2_0~1_7 ~13_:~08~-----~ Ordering Providcr:l (b)(6); (b)(7)(C) Observation Rpt Da"'t-'e:.:,,u,;.g_...;.[.,;.g_..,z,;,;0,...11;...1~3~: 5~6------' Rc.,ull, .Status: All Final Resull, Available, Order Compktc. jrrocess ID ][version l[Acccpt_Ack.____ _ ___l[Appl.Ack.___ _ ____ __ [ about:b!ank 2020-ICLl-00006 2983 9/20/ 2017 Lab Result Page I of3 Collection Date 2017-08-17Thu ss 69 u Alkalme Phos == ; LT SGPT rca Nitro~en [ 17 IE,"ca',',.",o'," __ ec~~~~~~~~~~~~~~~~~~~~~~~-----illo 70 I~ ~;,~:ri:•n~e~m -U -130 Final - -60 Final Normal mg/di c_c,c,~~11,cicoc,lcii~~~~jt «1----jflNco rm·-,c,-·---·l1i m 0°0!! &-_-- 00 0 0 icc,-,-_C,CJi]~3 §~~-][_- t=-----+---,--, -~ ~:--::-: : :~ 1pc----jf 11 1:---~',',','~0' 000•,•~',";';"~;';"~ ,m,,;; chrrrn,c kidney disease lf-~~cc-ccccccc-cccccc~~~~~~~-cc~~~~~~~==~:-ccc"~=~=~~,1--~l----if----"l---l:----JLJL__J:-----<, the Modification ot Diet Hl Reonl DL8Nl:l<' (MDRD) cqual1on c=i 1 {Ann folern 1;"';";", 1,';;'~', 1~";,;"';'";;'';-~m,,,',',';",·cm;;'ec"c';";";';';;;';';'"i:cc~~ic~~~~l----ie---~l----i i-------s, This is an estirnatea GH\ based on ~ Med 1999;130:461-70.), mdl<' 8hould results he u,;cd not for which __d_ep_enct] for renal--dos1ng II [_ 0 00 0 00c:'c'-''''c'c"c'cm,,, lf---~';'~m;';';;';';';';';';";"~;'c'cc:'c''c"c-c'c' ,'c"~';:;c'~', ; ;'c'c'cc;c'c's'c';'c'c'~ ~'s'_,l1:---if-----i1----if---"l----iLJ,- wLt.houl. pat i_,,_n_t --.spc,c1 fic I.imitations ot the eGfR, _________ d,scasc definitions, and correction guidelines for height on chronic clinical action plans can be ____ sc ]I__J------<>LJ!\-----CC and weight. kLdney lf------ 60 > ;o ~FR Noru\frican Am ,FR African Amer ! [Fm_al __l[ ][25_ Urea Nitrogen Obscnation Date Status IFrnal I 10-40 " " ~ IALT(SGPI)_ """"" [No;,;.,aJl mo' 0 1,. 09 Results Status: All Final Results Available, Order Complete. PSA Diagnostic ID# 026003 ORDER Scqucncc#4 Control Number: LBl74 _0005626AA Collection Date: 08-17-2017 02:34 Filler J\cccs,ion !I): LBl74_000.567.6AA Lab Roccipt Dat 1(b")(6·)~1 (b~)~(? )~( ~) ;_ C OrdcnnE Prov•d1 __ -~ ObservationRpt•o-.-re~: --•---~,-~,~9-:-09-----~ Rc«,lts St~tus: All Final Results Available, Order Complete. [Date/Time lliicccivin..:Arplication,'.Facilit llconccTcK/ARMCOG-L- ·-··· ]lsending Applic,otiou/Faeility lac1o=s-=1=8"=20=1=1=1=9:=11====-----;11&N_BSP/ARMCO . =======~-=-~~=============~---~ Appl. Ack. Accept Ack. about:blank 2020-ICLl-00006 2989 9/20 /20 17 Lab Result Page l of l Collection Date: 2017-08-24 Thu . Im !Patient IALMAZAN RUIZ,FELIPE -- I iCSOl7W-IT005042 · ll!_iirth Date ----~~ISSN IJ06-26-I 966 -- 7 r--u A~onia l-7Ll -- Per:to:r:rned by: Tc,sl lRL Florida 5361 -- ft NormalllAbnormal ~bnormal Results Results }_l_al!"S_ NW 33 Avenue Lauderdale,, FT, 33309 ~n -1,__ JI _JI 11 II JM~ssagcType __ nit~IRefe~ncej[ Stat~sllObs~~a~i~~1iPerfo~~ini=J1Performing Range Date Lab MD IC] ___ JL l~L--]cL □□LIi -11 ___ J[. CJI I -II I =11 . ] _] lu -JI II II Abovelumol/Lll 11-35 Normal . --··1c11 - 11 r-~est Na~e I IIM=71 . ---- 1[71 llcountry I ][_. _II 71 IL=_ II 11~1_ ll~-- ][____ _J .. _] Jlcounty JJGroupNumber · . __ l~Number [Results I---------- Order Status: F Ammonia ID# 020007 ORDER Sequence#! Control Number: LB 174_000570650 Collection Date: 08-24-2017 00: 16 Receipt Date:0 "'8'°"'--;;;25.,..-"'20""1'=7.,.;l.,;,l;-=:2~0 _____ _, Ordering Provided (b)(6); (b)(7)(C) Filler Accession ID: LB 17'1 000570650 Lab Observation Rpt o·""a1~e~: o"""g~_7."'"_5~_2""".o-17'--11-:-39----~ Results Status: All Final Results Available, Order Complete. Jnateffime JlsendingApplica_!i_on/Facility l!:Jo=&=-2=5-=Z=O=l 7=1=1=:4=1 ~-----,--,,_-~~SP/ARMCO_ JProccssID · ··7Jversion i:-IP_=_P_ro~d~u~=t1=·o=n========]l2.3 about:blank __ ___ IIReceivingApplication/Facility ....::__~~===~:========================~ !CorrecTeK/ A RMCOGI. J!,\ccept Ack. IIAppl. Ack. I I 2020-ICLl-00006 2990 9/20/2017 J,ab Result Page ! of2 Collection Date: 2017-09-0 I Fri Patient ID jAC"M/\ZAN RUIZ. FELIPE GCSO17MNI005042 irth Jlate ~ ·::-7 26-1966 IIS II -- 11 -- Normal Abnorma A Results Results _ Flags Test Nome c:::J 'MC odium ~ Normal [io47 [Nor_r@__J mmo ~ mmo ~ olassium hlonde -I ~ ~ nionqap lucose alc,um administration depressed results. falsely ,, tho du~ polcnl Bl !!11. 20-130 Final -- 'I ial I I I I I I I L I I I If I Squaro meters may indicate kidney d,sease. This b so estimated GfR based °" the Modification Diet Ronal 0i,sc,;lS<, (Mllflll) .-,quation (Ann Intern Med 1999; 130· 4 61 --"/Q_ I, results for which depeo "" °' co race. This estimate medications "' wlthool or d,sease "' eGrR, definitions, ., w~•w_kidney.orq Test Performed " I ~l[Normal 2-5 0 l[u11. un. Normal IF1nal I IF,nal J tii,a1 I ll ' 7[<' _J ll•s1,1 J6-22 · l[Normal !Normal ' I I ~- II I I0.43-l. l~ldL l t "11 ' ' [' [ [ auidelines 00 and clinical act.ion and NJ::JM 2006;354 by: IRL - fLoridn '" ilnd wcigh\ --_JL_J kidney ---- II oh taking Ti:iqlycerides " N- b H patient b oc falsely decreased. t.akiog Met.amizole, Triglyc:l'.'ridcs ""' [NoN-1m1-.--- Goals L0L; '"' ~aticnts wi.th ,c mg/dl '< 100 Patients <•· C \\..\t -r he. \)o'.~\\: f>t, 'l~ t)o, N\,s.~r··r •'?t ~-~o& ~:.'\ ~\~;;, I 14.....,..· 1 ~- \'" ._,_ •....s...~____::,;=-----=-'----'--'-----...l........1:.::..._~~=.c...-:.::....,.__----'-----'---""--------¾''-----',.----"----'-\ .o~.} ~-- • ' TRIAGE DECISION BY NURSING STAFF (Only checkONE box be,.__~----------D Urgent ________ _ D Refer to Behavioral Health:___ D Referral to HCP: Jr/ Refer to Nurse Sick Call ___ ------ _ _ D Refer to Dental: -----D Call Provider w/ Assessment: Temp ~- D Other Pulse__ Resp __ BP ___ Wt (b)(6); (b)(?)(C) . TR;AGEnATE/JIME= PT-005 .·:· ... . . Cr/t•lrt:-_ ,,a-e~a'Nl:lijSESlGNATORE:'" I· .I - -. ' · - . . . (White Copy- Inmate Medical File Yellow Copy- Inmate) 2020-ICLl-00006 2995 • ~(\. Revised 09/20/07 ,{l~ Armor Correctional Health, Inc SICK CALL REQUEST n R-:(~Q?..~n . l. FROM: }~LEASE PRINT) 1:'ettfe (Inmate Name (Nombre) (Non) t) ~ 6 -l(;)- (CfGG C-i (Date of Birth) (Fecha de Nacimiento) (Dat Nesans Prizonye a) Se~i3 - ( Localidad) (Lojman) (Housing Unit/Cell#) · ~f ~ (ID#) [?- , 1'-, (Fecha) (Dat) (Date/ TimP.) 13E.-c.f;--J $ e :C, f210f')~ \~ 'l · l ~r r-rf.{~ fro_V)c\ "I- Wal{)l ~~---See.~ e ~QC..,~( Wetrr1· ~ e_ e· \4-S 'PuT r f\ ~ e-'jto IN\. ·tef~ J: ~iWI -ea ~ • ·;-- ... :~·· l{. u is.'le,~ ,J ~.. , • •• .. -rl~(6, i-o+~JT"" :r·~H o~ ~\e . .·.v::;\'l;1, f\ c~ -~ 1 f fl r •e ed A J. t··-n e..~d t t-d--\\ _;. .f: D , , lrf' s e ~~1.f(~ ,_ G\~, (b)(6); (b)(?)(C) ,·"DA\ . . > . .EdEIV~ri-: d;~~-:~_,;:/,L~:,; :.:NURSE.Sl~NA\td: TRl ..a.GEDECISION BY NURSING STAFF (Only check ONE bo•---r-------- D Refer to Behavioral D Urgent:-----~-- Jf □ Referral to HCP: ----- Health:__ Refer to Nurse Sick Call: ___ _ _ D Refer to Dental: ----D -D Call Provider w/ Assessment: Temp __ Pulse__ Resp __ BP __ Wt Other PT-005 (White Copy- Inmate Medical File Yellow Copy- Inmate) 2020-ICLl-00006 2996 Revised 09/20/07 Armor Correctional Health \Services, Inc . ORDER SHEET! (Write orders top to bottom) ' Date Ti me '?'lvi~ f\ I \ fl 31rV2,,1 I /41- .A, d-~~ l/ - -·-C,. /;;;;-/~; \ ~ -A.: 0 /0/)--e..,, /70 * I J ~ ' -/;;L/_ /"2'(,,....,,.✓ - ) /);.1 II {_(b)(6); (b){7)(C) \ Orders Noted Date JI. T im<> / b )(6); (b )(7)(C) : I / ' I nhU/ \ \ . I ·•HCP Orders /i I/ '' I '- . i.------- I i/ '' I •I .• ! I 'I I ' . .. I ' I' • I . ' ' I. .•I .. I. I . I ALLERG IES: PATIENT NA ME: NO : - 0. 0 .B. SEX : LOCATIO N: 6/IJllll'IN;nl AlillOOl,ll'rtl!11SAHl11, Clr.iu,..,, <><>WIJOON Otllli Oll'PIWl'a, >lho,l·"'""•Id• ""••I• m•Vl1ml,1d11 drym,"1111. lromuru,llBllllijR,1101vuuunos11, ,,,,,.i.,tv, ,11,mn.. ,. r..,,.d,.chD.rnl ynumay•ll!'••l•l'"n"'" oonlll!puULIII, haurll111m, llll111od 1'1•~1, raeh,lMl\lonbonu•~,rlbi:zlhlL<. ..,.,.,an,u-,11',.,,, 1t i,..., bo~" JO,l.T)!\l'l,W,,,'llVt. ,.rr,,.,,,, <1<,10,mln•d,n! llll~ Um• U\11.l lhlu ""'"WJ(Y"lmnd\ool\onI, .n.!11," It>!IJOO.lmO(lt ol ,lop"•~•kln, Otllor tn,.,h,.,,i,tn IMIUd~ !Mlv lhan>.PYnl>\/\111· mudlllm1lhm [IIU~li!lllll . .,,...M-WXIIINIHl! Ui;~arn~ OI' QJ>.f\li:.11~• in•dlo1>.llon uoual.y Ol"111 lo nalwllhli\ 11~1~d,ri• b\!ln\!li~nw"' 10<1\l nn 1-l\wooiu f!JrO,~nl!mm\11!11!!1H•• l, lnuud lo an"'"· II h, lm lh"t ym1 lnl«>1hlo 1,1'"11o0U~t1 l'G\lUlar!v la ual Ill~nlllbono]ll11fi1\IJ 'IBnllws~. YlY your m<0d\cml\,mdt»aQU<> Imm limo lu 11111B IIQyOIJl'Cllll!ill!~1YfllllljJllo. 'f1101JOEI oll-iJMl~ln !o U'I!O\!Illllflllllli i!lMlldm, (l)e~yz..-1) LJCJU"IW"I cOllllHOI~ SLPlll 1awiro-rs1 You tnny fenulllvl\y11,m.inrn·uun le,mpum..y devalop, Uwraf,;,ro mu,,0111~• •K1Km®I m\lalbnevoldnd, 1..llSS ~.owtWlllWSIDI, S'H;t .. --n;: An unoommm1•I™'ll!foolwllll "lhn:uU!ll•• lo prtu111,m wltloh\l u •11,.,bmo•"• •ruullan1ot1ljrln11 ,n1.rllc!II.I h,h11v•nllon. l>J..Tljlj'UIIIITIVIE "11~1$.RP,Pla<'!l It hll~ b<>UI\!lbl811nln&~, al q,J"Umo,uu,, ~,1,""1•1"11)' (II "'""''"II"" ITT all~Lll1"• !tlr IL1101n,011l '>Il1<1i,,Molon. on,,,, 1ro,11m.,n~ .. Inuit d" .. otivllv lfmrupy ""d 1all1U1""'l>v suol1 ..., umm••lihf) or heruwlorrn<1dlllu~11,,n 110'Uljl'"""· ,-BN.,..11.\ QI' !Jlhtllll~ntl'in~Y~ ~t11>1R7'11tllftlmr..,lhn~,li,u • ,......_. .....,~n1-nn •,. •lrnl1my,..!lll!lll'I•• ~~ ftnn 111Mk1 _,,1111111 )'tl\Jtll00\mn11W111,Uild , llr~1PJNl'llllllll ~ 11Eltilu111<1 VtoIM'II~ RJl--.1 "'"'"' 1111 1,,111 ~. '""~"' ,. .... ni,111dro ll11\'t,U ~. 1111 1AnttdTll!ll"lnll,e~Jnkl l!l>i1 l'll\lt,/~lrT 8IJIonaOIi ~ !ladlift 1Mloflt1t. ' will'"""' ,... UTlllll'III! OIJlil - Ql.lliun(),1- r.oM IICONfalle: 13'FGCTII! P n MihlR old• nll"Qn lrtBf lt11J1w, lalllil!R,IVlUlldl~: ,~n<>rtf~r. ,",,.,.,. ~~mlrln~nf AtiZllm. · t;, 11P.. . .. vFTOJOOITY:"""· " .,_ In\00 llllllfl llll'i,., r,,~l'fUll a,~, 1181L, ~ -,..i .~ vnrnlllll\l, llll llacin 1"'11Uf v,• 1tllnHl1111 . h'°"~ NIKin, mnh/'1111111. ~,,,. 1n1V1tllh lruL U11"" ,l,I I 11111,ntnull!lw llr ..,,11111111 . ,..,..,,., n11 l11111. IIM'!W! l!f1l'o, •- """"'Uoln, -.11wlainllY 1!11{!IGIIficrll(Jy 111ri1•• n'11"111Rff n11nr br,l,evlr,r1ao~11'1 'll""llll. • '"'~l l\lwllflliv<> lmtl'b!l""II"h1d111 tr. :1dMlv l'/t~~~trtch• 1;1lh 1twlll1111thulfllfllllll•0nolUIIl.1~111-tnnn tmn 111!Ir!"111rnll1 c,1fh.,, .,,.,y h,, /\PPffOXJNATilLE?IGttlIll' t'.ARE: <.'lnnt,nJ!ly , llt1'11nm1ln,lJan 'Pill/nlall!u IUQ\ll!ml\tJ 111'111 M!lldtmn11hooolft. Mla ~II h!( '/1111 ltei U. ~ I n,gui,,,-1"""9 1uauo1ty,, n,... n nn1lhl 1nnylld]ltRI\'Dlll'ntlllUoolft,n drmauo n1"111111oal11m11181'.11your nr1111!1m111. .,,d _ Vlntlnlb1 hll!~ nl l llt>_,, • Y,!nrlnil1 •""" r,r,ril R«in;zl L___ ,.-----r-----rG:---7~¢ ?.:f_r _ il114'.2114Atu...7fe ~ ARMOR Mtl-nn IAevtsP.tJ n1t.rni11 ·-- --- · :;;""1/. .~ r,n,n >lill!I;;; n/J<1JIIC!lrllllllt _ nl~lh ll' O< - th,, pn11'1d1r""" 11....,,, 1111,~ J /111$ :r__ f d/ 'Ji}-;;c;;, _,, 0 ;,1ClJ l 2999 020 .,cu-oooiis />.I'"'"' Corroolimml HP.althB~rvlullll,Inc TVl>K'...lll J>.NTU"SVOl•!Ol'IC-IIIIIID\le [JTrl(~"'P"'WerJJ\.. 1"11nill (ltw>IO Uui•• COMIIIIDN. UlllE IIIFl'le!C'l'&You may[Bal dmw~yw1111n llr'11 b\!IJII\I 1!U!" i. l'<>,;ulrud wl""' oUlu\da•-"~t>®ll!o IW'lol~!pho\oa,nIBIIMiy\1/)IOII WtJim~~,u 1001Kahi\lll,a, (;horM!!rm lllduo~elkm, IIVfllilll)BllI'""'"""'""" ILI\RB,,o..., dnb>lrllln<>tl, ~· U~•11m<> U,ol,~. """'ll"'V olmam~ q,1kll"1r u,un n1har~Ul\!!-111,o ,,voU~u,OU1arlrll11llllll11\a MM~~oll'lll\tUUllWJ \l!ld1\111 Ihm~)l\lllllil' Wlll!lall\l Dtllllllll'llormodlilu!1Unn 1''"011'1 •• AlT~TIVET•••WON•ll'O', ""''RD.>u;ulll.TJiu;rr~G"l'J.I OI' o~ ·n11umnlll""U""w1u"-Y•lnrl•lo O-~m• lllln roUIJinrh..,lo (llV,u\\u l yu\,r m .. cfuo,llnra. <>lll8rnlrl~ello"I" }'tllln,Qyw<µmllll\Oo nrn1omOU{u!IOm, homlllum,l!U1!<1<1slotao, ,.,bh,lL'rnlnqffk••·Olhnr \m>1t1n<>1lln l"'1lnd.. "llvllv lharnpy ,md lQ\k l11m't!py~uoh "" oou11,m\\11u or ~ohQll[(,r nw11Ul•aatlon 11tu11ram-. ,..a11, ur.rwnu O'I' OAl~ 1lilll 111at110Dlk>t1 uouelly11ot1& lo (IO\,jjl\liln 11J.14 ruiy4hill m•l'I M1•~11IDIJt •• 1r,U;11 \I h~!I baun de!enTiln•ll, UIu,111 uni,, Ulo\11\\lmn,11")'ol m•rapyond tall\ lhOl\nt, OL•mlyol.,U,!(I HwllhluI< IIWl\.7nl lhBI you l.ilm llllfl medlaaUon l~fll~llriYlo gal lh~ !tillbeh~!l0[0119 lloJI" ,.,adlom\\on c1a60lJ'" lrom limo lZ:l(l\owla.,,1 01./2011.) l'rmrl' 2020-ICLl-00006 3000 I 1•-~ 11H11 -P11R1um;c1Nt11N: 0°'1!1f,l11Jrt □""'E"'' (llf,,,.1rry,1,,,n111~1 ooMMON mllF. r:J'l'faCT9: m,m -lelmw•too,lrld!llnlltnhfoi~ .mnua1,n1<1-. IWll""""1ttn,b h ~ii)urbl&I!~ ~tt ,,n. 11111fd or1111111rill!j] hn~tlh~•~ eyepd!~ AIIIIr ~ t\Ill.. petl md llne\laclma. . 1 Wfll\il !frll~ nl1tkft1~m,t V/\U'OR1CI\CtJ YOK!CITY: loo MwlflllRIL41l nl C!Jltrnulllln>Wlll 10!111, laUli!Kil i\rillll tlllf',M~ ~ll!ill1,1llll\lw1 nrI inlondlMM 111 1y,arr!"'II mtt1dmn t11011111 1Jnl11nn t~ uvlll1111Uan ml lnl(1fVlll~kilL wm AUEIINJ\TIIIETl,IF.JV\Plt!II111111<1 IM!!ndu'""'11l1"11.,.. n,1n lhnntt,nlnilso~!. 111ynl 11""1 !Mllo11 ~.ollln1U•a•l!'~ 1tll1I tdl11rudm111~111Th,v·. n (ml(, nURvlr11R u,,.. n)'lfl!Jkffl:tQ!jlr,kftr"l!!m,ml"1t'llelJl!n(lnlno~ Ol!s~ bducla "'11'1 lillnlt!'fiml hlill!ffltt11tnn1t1 Al1tn•IIOllll.i111·hrdwi,t,.~~• 111lun1111~)11111m. l'Wl\mt!M~l.ENlmloPCMl:1l l1htme,lkllllb,U!U'llf11111!1'1Ed tlllii,-11 lllt!tlnllWfi(nll<>11A'r11111m!11u111n1A!ll llhb1n11lnr,1 *'"1111!blb1 lt!lllMlliYlu !Jill lhekllhamllllfllllm IKdtin ll. Y · IIUC VIJIi llll'Jnnnlkwlrlo.1S!ftl rmniltm, lo 1lt111ldl>r . lffl[f k!Qffll8ffllrfnlilll imn,1· y1~r n11111n1111lrrt11nnln (Un1u11~ ,vM ,n".,.,. .,,, 111011!oollon ll'(~IIDIIY la!lfllfl1aIUDbonnl/lrll'fftln !nj 11cl n"Lvn11r1 ... lidlull1 ,_.,1.-n,e,lln,,l!on1lnMr,oftn1• ll!neIn ihe di! ylln••l11111'llll In11-11 ~t,1I,~111 -r"',n ""~ 111Hobn1t11lh :nll1111 """' hn ~ lo t111h11nelCl1nurn tu,11,,m. II I• hnll!1rlanln,a1 'fllUlllliAl'ola 1-'lmllm1 Inu,,I ftm!nllhm1hlilnl llrl• h1'111rr ,, . Y,,., ,..,.11,rnn "'11<1"11<•• ·• wilt rr11~1n, .. w,1, nu 11 cngul..-b.., {U011811r..~""""'~all!IMYAdiU•Iy0111 ·111ffl111l6llwttlo1 u100' ·, r1111n lo llmc,9111'11\ll"t , llll!h, 1nrll1'IIIIL 11,11 ~o..,J nl btu1b1w-1 ,1bth, '" '" u.. 11tlnlmtlcw, un ~ oJ m~rllnnll01 1• t111r,rlml In m!aw, y,•ir '"""'1fmi.. ·. ____ _____ ______·---...,, .. ······•··•- ··-·. - .. .... ..·----· . . RISl(S ANDllAZJlll0.7; IJcrrt11g,_!r:llu"'""" .,. ~ """""""'-ahnl ml ""'' t1•• Ill!• ''"'"'hi "' I 1mdo11<1Bml U..ulCQ/1 ffirr:l rll)I Blllll!)r I<,mr.elvn l,n o/1/1-11 M llr ,;ii ]/lilt rnm,t nm11T1m"111u In 11/IM(I/ J IIr:mln1li!AII llflA!t.""'" mn 1,nh O 1,.,1,,,,1,.,,,.1 (/tva. /lc~,..-#Ml1f a rdMl/II lw/ 11lq!/n!,1r1t l #r/,vh1aBM -,I UlldlttHllor4<1,( IW/llfib ~ m,, ,.. .. ,JM, ,Jri,• fflllv.lt 11,~11 m11rniq.,~rl a,me.ffl'!// f1l/rt6"11&1111r It b 0___ ~ ....,(£:J ::.. . _ (Date of Birth) (Fecha de Nacimiento) (Dat Nesans Prizonye a) . ( loca11dadf- )c____ __ _.J.__.JI (1-'echa) ( Lojman) (Oat) {Housing Unit/Cell#) (Date/ Time) PROBLEM: (BE SPECIFIC) PROB LEMA: I _P_w_o_s_L_E_'_M--..Ta,;,...._----1.,......;,;_....::a..,:_.=...:d=--.· --c~....,_e;::;_··_e_-r__,,\_·ii_;·:'j--"e==-•;_ ... ....::S"-)--',:""'.~·J..l;~---:1-'\:~~t)""" ..x.:...·"_b_. _e_,,._(_·.-_o_. ..;;,S_f'_ ..__ l_;(;:::.e_--_i;_; ._cJ---=·o=--rn \ V.;;;.,·· -...:,_ 1 . '. TRIAGE DECISION BY NURSING STAFF (Only check ONE box below) D Urgent D ________ Referral to HCP: _ --~ D Refer to Behavioral Health:___ [9"'Refer to Nurse Sick Call: ___ --- _ _ D Refer-to Dental: -----□ Call Provider w/ Assessment: Temp __ D Pulse__ Resp __ BP ___ Wt Other ••TRIAGE tlAIEffiME, PT-005 \n1 ()LJoc,.. 't 6 N0RSE SIGNA~EL (b-)( _);-(b-)(l-)(C _ )___ (While Copy- Inmate Medical File Yellow Copy- Inmate) 2020-ICLl-00006 3005 J--~~~--:::'- Revised 09/20/07 Armor Correctiona I Health Services, Inc. Informed Conserit To Mental Health Treatment the agree to participate in menta l health treatment I here~y authorize staff members assigned to the M ntallHealth (or d~s igna ted volunteers (b)(6); (b)(7)(C) r such treatment as agreed to nd to perform se rvices: .µ..f\-'~i"t5-~~~6.<'.l~L.:...==-'-' ~6>'--1...+--~ I -- · ___ _ _ _ _ . ONflDE rea!~ent taff members follow all ethi cal s~ndards prescribed by state and federa l law. equ1(ed by law to practice guid elines and st~ndards of care to keep records of the servic es~ reco ds are confide ntial with the exc epti ons noted below. Discussions between am rofer sion I and a client are confidential. Nd information will be relea sed without the client nse nt uni mandated by law. Poss ible exceptions to confidentiality Includ e but are no ollo~ing sl ations: chlld abuse; abuse of th~ elderly or disabled; abuse of patients in me cllit(es ; se ual exploitation; AIDS/HIV infection and possible transm issio n; criminal prose st~~y ca es; su its In wh ich the mental he*h of a party is in issue; situation s where the roviC,erha a duty to disclose, or where, in the treatm ent provider's judgment, it is neces isc19se: a eglig ence suit brought by the client again st the provider; or the filing of a com I censing or certifying board_ If yo u havo any~uestlons rogardlng confidentiality. you shoul e at en tio of your tre atme nt provider so th~t yo u and he/she can discuss this matter furt ONTENT O TREATMENT: rov!ders are you receive. ntal health s written limited to the tal Health ulions ; child eatment ary to warn or laint with the brihg them to er. ' ' 1 y s~· nln g his Cl!ent lnfonnati on and Cons~nt Form I acknow ledge that I have read, und rstahd, and gre to th term s and co ndition s containod in the Information and Client Con sent form . I avfl been iven app m t me I am nd I pnd er rival of o riat A op portunity to address anyi questions or request clarification for anything that is unclear aluntarily agreeing to receive m~ntal health assessment, treatment and serv· es ft.Jrmyself tand that I may stop such treatment or services at any time. I also agree to re pect the her cllents and any information t~ey may disclose in a group settin g. . _ I understan f thel propo tten9ing th ischarge fr that no warranty or promise ha~ been made to me regarding the participation in or outcome ed treatment. No J b)(6) (b)(?)(C)' ntation will be provided s a result of service(s) listed a ' ms of this agreement wi expire upon m this facillty : r upon my request. I L......--- •.------' OT'=\: If yo have a legal guardian mental h~alth services will not be provided without the igtiaturc of our court a pointed guardian. I under stand that it is my duty to inform treabn ent staff of m legal status s it rJ1ates a guardianship. ' I 1 \:: 1 (b)(6); (b)(7)(C) 11 Am or: H--011 2020°ICLl-00006 3006 . .... ..... --- KEEPON PERSON(KOP) CONTRACT If I meet the requirements for the "Keep on Person" medication program, and agree to the requirements below, I will be allowed to keep my medication in my possession: 1. I understand that only medications that are approved and ordered by the facility clinician will qualify for this program. 2. I understand that medication may be given to me in a special package that will contain no more than a (30) day supply of medication. The package will contain a label that includes my name, identification number, the medication name, and directions for its use. 3. I understand I must follow instructions on the medication label. Health care staff can check my medicine at any time to make sure I am taking it correctly. 4. I understand, if I believe I am having a problem with the medication, it is my responsibility to notify the nurse or doctor as soon as possible. 5. I AM RESPONSIBLE FORMY MEDICATION. If I tose, tamper with, share or trade the medication, I will be terminated from the program and may be subject to disciplinary action. 6. If I am transferred or released from this facility I may take the medication with me t o complete the prescription. I understand that the medication is not in a child proof container, and accept responsibility. 7. I have received a pre-printed information sheet on all my initial Keep on Person Medications. 8. Once released, I will need to follow up with my health care provider as needed. 9. My Keep on Person (KOP) Medication(s) is/are: clotrimaiole 1% ALLERGIES:NKDA I HAVE READTHE KEEPON PERSON(KOP} CONTRACT.I ACCEPTTHESETERMSAND ACCEPT RESPONSIBILITY FOR MY MEDICATION. I KNOW HOW TO TAKEMY MEDICATIONSPROPERLY.ALL OF MY QUESTIONSHAVE BEENANSWERED. j.prn rooolQn~~!~If.\![1hlllf11dil\}' 1Pl\IQ0111in<>II ~1111> oill,llhl ...M~••1,ln•••• uu,,ru,lo11, fnl1~ood,dl~""'~111lwlu11 dumidiU])!l(l(ih, limo"" yol.11' oondl1QnW~lllill~. lh• ~ulll~f!ll!Ellill'!I~ Iii[DIii~!1Umlii111111lhl,ll\lllll\ulm,dlollllonu noll®d hl ,.,111,1ro Y,,llruvn1plo•n11. CliJu,on A"I-YP-11:.//J..JU,ITll"SYCHO"RC 111!6IB: COWll'JIONSil.IE 1,11'F'EWTS, You may fll~I dl"tl'WIIY WhGnllrr,ll;i\\111\J U1nug m~~l<111\!(1rn;, (lut UlJ ,i\ui,jlY IIUJ!\~lllll\lar iylnlJ \)lln\1101111 nH1)18!1<1 nmdl""UollH"1"Y""""" low bl(tnt\ pre,aaure. 81\mt-1<>1m sl<\e .,m,01,a,n.,y lnol'-'d•ln~umn\a,wllluhluan,,R\Jllo\lon, 1woil"ol10,<1n'4rlly,rhmlll1,Jll\lll~•rilllilllY,U\nfi!8IIIKI IN'"" Im""'""" In bru.,sl l\u,,u,. nnd ml\l<1n.,duullon. s,,,wU\v\\Y~' "'"' ur ""'' bVll(tnm,wdsv,~,, lhe«t[<"" Ul(puou'" muolIm !!Vnl<1Gt1. "'"""Jl/1' usss CDllJI\IIION $LOU.~l'FEIC"lli-t uornnol<>IP~,u\\\lntMu,.i,..iuiu, dlcin~ ... llttl,.\lpnl~m. 'llll\llH,nn,.!~lO!oMad \1om1 Tblnin"llf B •low haarll>1>11I. Guotkm a,a11 llllt\t,u~ Qn[I~U.J\y [Dimt,ourtbnu\~ru\\lllOdllan. ruu11•r~lll honh""u1111,o~ l1111-\ijnt111110 nmv nlnu 110\a11l\>1IIV "'"-"'" "'' ""°"" \rn,~,,,..,n,1,. '"""""I,.,-"'""""''°''l dlQonl~ra;lirnll~TTl\vaUyi!IIU1~u\a, ACI ARNllll> 11-... !W(n!)lotHG qu\rl\\BrUmnOlilPl,:aJIIMl~Tll'.IJ$>11.il'Tl'I OP IJJ'l 1111 .. me!I\Ql\llun '"11'11>\!\y lo IJBI11,nMl ben•lltorn11"\1"81m!•ot. Y-li»o!\11·••Jo 1L lu \lm~ tlU yQUI" oora\lUonWlll!anli,111Y WJilo!V9rllrnontl,1£1Ullll Um11illi11111'l A'1Dlffll lJ'ie!l)l.. "1Zlrnl lllill!l>I» l'r\(~IL'.Jf)t1<..,"1nto (~lrnimll"') t~"'l<)o!\ttll~,. r<>4n Pru!ll1"''"· . ~ IU•l"ROXIJIJIAi'l'-1..GliG'!'H Ol' myu)IU!y\l> ~ 11\iu11\bl\lQ&UunufllMiy i onllftnnlHV u, .. 1you 1,;110U1lo1mtd\na\l11n \ lhu I\Jj b II\ o\lirllI 1tnl "'"dl"°tk,n !l=Qo v~roond~~~:~,t•::i"=~~:=:~ ~"'::~-=::ri:~~=~~J;~:;'ui";,:,~l~'!:"}:;'~~ :;;~tt(}ll\11) from Uroo1n llma WI 1 n,,,~ .... ,(r......iln•) 2020-ICLl-00006 301o ~nd ITil!Y m1lt1t your Cl 7.t>lol\ (s""· oui,.,J I Cleoa-n {llm,!m(jl,,nJ lfflH' l\lTIIINS!ll'IINI: t)I !llllltru~,y,1,,. .,dlmJ ~td l\1tnn<:(f H!""'Yf11,..tl,hfl !l!OOlil'l'F.Ufll ! ll ht11 l•l1 , Mn1(111rnrt1t ES: IIhl!II llmt11ll'lllllffl'j191I , al Uilnlllllffnll!l llllnmniiN!lll (![ tntJ1Unnlln11 In RRIRltlvn r,irlnudi t ,~ l~dnr ,ll!llm!Pr, IIwtnhAII•nll~l•lnl~ II'" " ''"' ,r.,..,, q\llls lhennlllll'~ f/o.,,i tl!,ra.U~lltllll!llll~ftil!I hlnl hn rnrial,,,,! ~• 11 ,.,..,,,, 1"""" '"""""·"'" laqiollonl Uinl ynulelte Mtlu IOe1l111fflf1' 10tillltntfw!ll llllltllll' Yl~f1111 RIRUU! lll' llrulln{Unilllllv nrwennnk..Chl l\l"l'ROllll'll l\lt: Lmm-(01' llft. Thn(lllllht1t1111! 11t1m llnlntlflRN"' 0111l11111re 11111 i )'llln-ltllld l"" lt"'' ''"""ll" r""'" 1tn111"'Ina Qll 'fll\Jt~ a~ YOll 'Iii!lll!8dllfflJdla 11,'tU I llllilAIIIR• k'lr1111/,,t-1lln -- '._ ~ "'11r"'11-11"''""'~fftll .. ,n~•mlln1't,y'"" WS.ururltlN: 0 ~ CtJWM!lNSIJE-UTn\Pn,,nll,! A•klff,11 ..,..ie.-. end llklra,lued tktly·e:\.l\1Wfl.<>l]lt1111on,, IUl(al.l .. ,, ~111111dl11PiUMl, tlllln!J\\y waMnu,and prdlll\C\' ffl"-Vd,i~ml°". ~ \,, lrla0\ Hllll you 1&!18 111\r. m...:tlm!Uon IIUpr~o~<'I>~~ lo ll"tlh~!'\lllborivlllo(Mo lmo\m,nl. '/1,zi,Ollllt, llll'1Il)llllo lino no yo,.rronmilllOII w,mon!!I. lh• wulOllfOO)lmml It.lauou111111driinn1!iiiooll1Llmmor umlwupomavdovolo~, 11,o,~!OIII """'""lllulfllpu'1Hl'I mllnlbu avnill~,1. f'"'li~~ U'cSS COllllbllOl\lGl"Pli.lc.\nua, &11m,,.•o, oha!«,u,dfal\\ooo.uorlllUl"'ll,n~ a11U011, and~,..,,u,ndh!f,,f\rale.h1nomR villl1 Marl problr,11mor II Plow 11 hmnlllmal, G'10llnn oan aQUsa 081lm111 11mlpo\l.lnUWly [nu.IhDLlrl\mul hro1111\!l~Uou. lll•uilflliLI ~•u bMn l!~'"dlo <1L!h~\o•. L!!!!U•lam, 1111<1 mm sin" 11ote1,\IR\IV "'""'" ,m \ITl>\!<0rs\t>l" lllWillUlar 1nm>o,m<>11\ d\11JlmW\ll,l, Ill~"" llm~lll wi~~1,.,..,Lh,.,wmplPfl)J; quloll>ROlUNl/~11< wa,...tm QI" .,~ 1111 .. 111edl!"'ilnr\ uwllhy rJl!!blbl ~ot\'JIU!lo a r...idll'J<• 1JJlijf\allU lilll!II~ to!Ullo1@dlui\lltmtll>IY ImnaqLJl!lld la 110011 maillm.umbll!l~lil ll !11lm~lltl Ill, L\u.tyou loll11all\\~ ltJIIb<>nslll~flhl~ u... 1moro. )''1url1"nllh"""",uolll\c1M1·._l! moollor)'I\\IOU aAUU\!rb>llt\o (tlll\lt1li'/ unm m"':11.,,.llondu~mgo \tom U11,otu limo no y!lllfoondlllon\'Jlllliffi\11. "\1\Uiiu,,[olvm,11110!1! ,.~, u.ell111nUl!l'l ,.11U!lnl or1nocl!o•~••ILI lu rollll"•vm,r,r/mplnm"-1WJCAL 11ot,fflr>9VOl-10TIC 111,r,11."M,, Q"ll\flP"'..,;ne f_JC'l~t1tfllu1tL\O"mLI tn\tlllOlli"lll O 1111<11""'<1"! ~1'1ll1rrI vt• l1i 1,cUulnRnu,•mfda1A,n;dnp1T1m1lru1. ,..,,rm ,lnll h. 1\1.TenNIITIVl:THSl~II : llllanbam,d,llerlrh,d. .alIMlb MW~ ➔,_-,1J(nodnnl!Mhl1!1~""11\o· tlh1'111 "ftkin n,'IB.'1!1 r'4 fl'tll..tsl'd11i:11,..Qrlflllmn (nlr,,r ~ •ldlldRt<,w,,rtlllurdlnr:on1ln1mt1011 or,1111-vn~1ol!n ,.... 11<,,.Jtut ., • I\PPR(lll!MAT E l,E:NGTIHJI'CME: lllffln1'lltoull!m111111 "11vnlRrl•1ft...~ ,~•111111 UIRW~Ollr,r. III• (/1111A"1llY . ... , kY nlfitan.JU111 ,. llnlR., ..._. , llll '"'""'~"ln1111 -lnrrll IIMl\1tthlfMlllml, YCM'hel\llh<:o111 ~ 1IG~ lrlllfflllllllltn'; IIISMl....,..11111 'jllllrl'/1fl1Jllij 11D . 1' V~Mlkrhlnod ~111lnl"' .. ~r:J<~mn . · V/\1.J>OltlC /\Gill ,uKtCITY : nm de~ID!AI nl m. lrol ru~ 1 .1111\111Al dln, 1111 ff!lnAcl1,lllijlllRI t~11nlllll11 rr1 -IR111 !\nlwlOii\Ol ~lt r.wrn1,11r<111 llt1mm""'" 111rnfli:nt ~!lld~tC111~ .,.ii".~"' N..TERNl\tlW nF.RIWl.'1111tl11111 IJ0011"" p!nn1aPnllllllWI\TlllENl1lll OFCMUt n.-1 11 ello1>11ffiJfl!iy m11!111brnll1Wffl1bt'R d&jll.I.Ul!/·IMlll!ill'lJII II/DNnlA!r,_•11n1Al'MO'IIJll(n1rl lro11rrln 11rn,dun1111 lm1mll( 11I,, hnu lnl~ In yuo1!511"Kl!lllblimltll~IIIJ\'tboib 1"11 booel1(ll'n~ t~ Yl"'1UI l"n ll Will ' """' f1N~.t l11 Otltfl ..., 1':0MIIII OII Q1JF. Ef'A:-v.fla: IIhao !t 11111 "11bllml t~ lllfQanr111!11•1k, ·. 11WIiih~l11rillr1~11 t., Um"'"'"*~'"' 1o<-,1tm1, _.tnedb_,,, r-"11""''" 1'mlll<>Sl!Wllltii ' /11"'1IO)('(Mlll1l U31Gni or-cAtta, Tl., ""'1Allall0rt0t::ldf IIMtll,p. h f111 1-1l~l111 11llilt thrl\' t,,,~ ~•1""'1•"""'""' " hPl1'1{11,II II! loi,J011m1 llllllY""'...... ... ,lfQ~I...,.'. _._ fff!llllUTIIIM: 0 w~, '""""'·In~·-~-"-- ' t:OlffllONSIIJEEFFC-m'NI.,,.,_., __ ,.,,,, llht llun. b1111n Hk dlimnlcr. 0nJ l"""""'1 •1okIll' IIUl"'1~.. "lT01Nl\11VE Tl-tl=RJ\Pl i..~, n 11 .... ,,.,,.,. italB!rrllnRd. llnnll'1<1 lnrfi1'1111 0f!ltl 1ltera?ftnJ ID!lt!her1117Y ,i11d111• nrnmnmlnnnr hrrhevJ,.-t"'1rlllloall oll 111,gn,,1111, APPROllrlollATE lEN O'l"l-1OP ('J\111;1~- ~ l!Jba111Hcll111fte11 11!~11 !n wrnt~ mq1llmll low,,lnfflltlllt nutnhotldll, h hr• rc,,"1elllhal -,oaw,,i 11111 IIRhb t rogut,,r benb 11 11 111olly anon" nl('rl~h(end lnny PIii/URi yaurnr