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PDFDelgado_Record_FINAL_v3.pdfsynthetic01234567890,012345678900123456789001234567890of 1,412−100%+
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MAR-02-2024 14:22FROM: NORTHWIND GENERAL HIM 503-555-0142TO: 503-555-0199P.0001/1412
NORTHWIND GENERAL HOSPITAL
Health Information Management · 2200 NW Synthetic Ave · Portland, OR

CERTIFIED COPY OF MEDICAL RECORDS

PatientDELGADO, MARIADOB03/02/1985
MRN00-SYN-4471Pages1,412
Dates of service03/14/2023 – 01/19/2024
Requested byRecords request #R-20931 (synthetic)

I certify that the attached pages are true and complete copies of records kept in the regular course of business, made at or near the time of the events recorded by persons with knowledge of those events.

Contents: emergency department, radiology, operative and anesthesia records, inpatient nursing, physical therapy, laboratory, pharmacy, billing and correspondence.

L. WhitcombCustodian of Records · 03/02/2024
CONFIDENTIAL
DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
1
NORTHWIND GENERAL — CLINICAL LABORATORYAccession L23-051904

LABORATORY REPORT

Patient Delgado, MariaCollected 05/20/2023 05:40Ordering R. Okafor, MDStatus Final
TestResultFlagUnitsReference
WBC11.8HK/µL4.0–11.0
Hemoglobin12.9g/dL12.0–16.0
Hematocrit38.4%36–46
Platelets262K/µL150–400
Sodium139mmol/L135–145
Potassium3.4Lmmol/L3.5–5.1
Chloride103mmol/L98–107
CO₂24mmol/L22–29
BUN14mg/dL7–20
Creatinine0.78mg/dL0.57–1.00
Glucose131Hmg/dL70–99
CRP1.9Hmg/dL< 0.5

H = above reference range · L = below reference range. Verified by K. Osei, MLS(ASCP).

DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
2
HARBOR ORTHOPEDIC ASSOCIATES
1180 Harbor Blvd, Suite 300 · Portland, OR · 503-555-0160

June 14, 2023

A. Reyes, MD
Riverbend Family Medicine
Portland, OR

Re: Maria Delgado · DOB 03/02/1985

Dear Dr. Reyes,

Thank you for allowing me to participate in Ms. Delgado's care. I saw her today, four weeks after a left L4–L5 microdiscectomy performed on May 19. Her leg pain has largely resolved. She continues to report low back pain with prolonged sitting, which is expected at this stage.

Her incision is well healed. Strength is full and symmetric. I have recommended she continue formal physical therapy twice weekly for eight more weeks with a focus on core stabilization and sitting tolerance, and return to modified duty in two weeks.

I will see her again in six weeks. Please don't hesitate to call with any questions.

Sincerely,

Rob Okafor

R. Okafor, MD · Spine Surgery

cc: Riverbend Physical Therapy

DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
3
NORTHWIND GENERAL HOSPITAL — PATIENT FINANCIAL SERVICESAcct 7730-SYN-0412

ITEMIZED BILLING STATEMENT

Guarantor Delgado, MariaStatement date 06/30/2023Admit 05/19/2023Payer Synthetic Mutual Ins.
DateCodeDescriptionQtyCharge
05/19/2363030Laminotomy, lumbar, one interspace18,420.00
05/19/2300630Anesthesia, lumbar spine12,115.00
05/19/2372100X-ray lumbar spine, 2–3 views1312.00
05/19/230360Operating room services114,680.00
05/19/230710Recovery room11,904.00
05/19/230250Pharmacy141,062.40
05/19/230272Sterile supplies92,388.15
05/20/230120Room & board, semi-private13,250.00
05/20/2397161PT evaluation, low complexity1286.00
05/20/230300Laboratory3418.50
Total charges$34,836.05Payments / adjustments−$27,902.18Balance$6,933.87

Questions about this statement: 503-555-0177, Mon–Fri 8–5. This statement is synthetic.

DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
4
NORTHWIND GENERAL — 3 WEST SURGICAL05/19/2023 – 05/20/2023

MEDICATION ADMINISTRATION RECORD

Patient Delgado, MariaAllergies Penicillin (rash)
Medication / order000004000800120016002000
Oxycodone 5 mg PO q4h PRNJKLMRS
Acetaminophen 1,000 mg PO q8hJKDP
Cefazolin 2 g IV q8h ×2LMRS
Ondansetron 4 mg IV q6h PRNRS
Docusate 100 mg PO BIDJKJK
Enoxaparin 40 mg SC dailyRS

Pain reassessment

04107/10 → 4/10 at 0510 after oxycodone
08205/10 → 3/10 at 0915
16154/10, ambulating in hall with PT
DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
5
RIVERBEND FAMILY MEDICINEClinic note

PROGRESS NOTE

Patient Delgado, MariaDOS 04/18/2023Provider A. Reyes, MDVisit Follow-up, established

Chief complaint. Low back pain, worse with sitting.

HPI. 38-year-old female seen in follow-up after motor vehicle collision on 03/14/2023. Reports persistent low back pain, 6/10, radiating to the left buttock and posterior thigh. Tried NSAIDs and heat with partial relief. Sleep disrupted 3–4 nights per week. No bowel or bladder change.

BPHRTempSpO₂Wt
128/827698.4 °F99%146 lb

Exam. Paraspinal tenderness L4–S1, left greater than right. Straight-leg raise positive on the left at 45°. Strength 5/5 except EHL 4+/5 left. Reflexes symmetric.

Assessment / plan.

  1. Lumbar radiculopathy, left. Order MRI lumbar spine without contrast.
  2. Continue naproxen 500 mg BID with food. Start PT referral after imaging.
  3. Return in 3 weeks or sooner if symptoms progress.

Electronically signed by A. Reyes, MD · 04/18/2023 16:02

DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
6
THIS PAGE INTENTIONALLY LEFT BLANK
DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
7
MAR-02-2024 15:07NORTHWIND GEN HIMP.0428/1412
NURSING NOTES — 3 WEST
PT: DELGADO, MARIA MRN 00-SYN-4471 RM 312-B

05/19 2130ARRIVED FROM PACU. A&O X4. DRSG CDI. PAIN 6/10 LOW BACK, MEDICATED PER MAR. VOIDED X1.

05/20 0015 RESTING, RESP EVEN/UNLABORED. NEURO CHECKS WNL BLE. SCDS ON.

05/20 0410 C/O PAIN 7/10, INCISIONAL. PRN GIVEN. REPOSITIONED.

05/20 0820 UP TO CHAIR W/ ASSIST X1. TOLERATED WELL. DIET ADVANCED.

05/20 1330 PT EVAL DONE, AMBULATED 150 FT. MD ROUNDED. D/C PLANNING STARTED.

05/20 1615 PAIN 4/10. D/C TEACHING REVIEWED W/ PT + SPOUSE.

see d/c summ.
RECEIVED
MAR 04 2024
DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
8
HARBOR ORTHOPEDIC ASSOCIATESForm HOA-12 rev. 2021

NEW PATIENT INTAKE FORM

NameMaria DelgadoDate of birth3/2/85Referred byDr. ReyesToday's date4/27/23Reason for visitlow back pain since car accident, L leg

Medical history (check all that apply)

DiabetesHigh blood pressureAsthmaPrior back injuryPrior surgerySmokerDepression / anxietyHeart disease

Rate your pain today (0 = none, 10 = worst)

012345678910

Current medications

naproxen 500mg 2x/day, albuterol as needed

Allergies

penicillin (rash)
M DelgadoPatient signature · date
DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
9
RIVERBEND PHYSICAL THERAPYVisit 19 of 24

DAILY TREATMENT NOTE

Patient Delgado, MariaDOS 09/12/2023Therapist T. Marsh, PTDx M54.16 lumbar radiculopathy

S. Reports pain 4/10 today, 6/10 after sitting through a long meeting. Sleeping better.

ExerciseSets × repsLoadNotes
Pelvic tilts, supine2 × 15—cues for breathing
Bridges3 × 12—↑ hold 5 s
Bird dog2 × 10 ea—L side slower
Sciatic nerve glides2 × 10—mild pull L thigh
Recumbent bike10 minLvl 4warm-up
Cable row3 × 1015 lbneutral spine
Sit-to-stand, 18 in3 × 8—pain 5/10 on rise

O. Lumbar flexion 55°, extension 12°. SLR negative R, mildly positive L at 70°.

A. Tolerating progression. Sitting tolerance remains the limiting factor.

P. Continue plan of care 2×/wk. Add hip hinge drills next visit.

T. Marsh PT97110 ×3 · 97140 ×1 · 55 min
✓ HEP reviewed
DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
10
NORTHWIND GENERAL HOSPITAL — SURGICAL SERVICESOR 4

OPERATIVE REPORT

Patient Delgado, MariaDate 05/19/2023Surgeon R. Okafor, MDAnesthesia General endotracheal

Preoperative diagnosis. Left L4–L5 paracentral disc herniation with L5 radiculopathy.

Postoperative diagnosis. Same.

Procedure. Left L4–L5 microdiscectomy with partial medial facetectomy (CPT 63030).

Findings. Large extruded fragment compressing the traversing left L5 nerve root. After removal the root was freely mobile.

Description. The patient was brought to the operating room and placed prone on a Wilson frame. Level was confirmed fluoroscopically. A 22 mm tubular retractor was docked on the left L4 lamina. Laminotomy and partial medial facetectomy were performed under the microscope. The ligamentum flavum was removed and the L5 root was gently retracted medially. The extruded fragment was removed along with loose disc material. The wound was irrigated and closed in layers.

EBL 25 mLComplications NoneSpecimens Disc fragment to pathologyDisposition PACU, stable

Dictated by R. Okafor, MD · transcribed 05/19/2023 18:40

DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
11
CASCADE IMAGING CENTERExam MR-23-04021

MRI LUMBAR SPINE WITHOUT CONTRAST

Patient Delgado, MariaExam date 04/02/2023Referring A. Reyes, MDReader S. Varga, MD

History. Low back pain with left leg radiation after MVC.

Technique. Sagittal T1, T2 and STIR; axial T2 from L1 to S1. Comparison. None.

Findings. Alignment is normal. Vertebral body heights are maintained. Conus ends at L1.

L1–L2 through L3–L4: No disc herniation or stenosis.

L4–L5: Left paracentral disc extrusion measuring 9 mm, contacting and posteriorly displacing the traversing left L5 nerve root. Mild left lateral recess narrowing.

L5–S1: Mild disc desiccation without herniation.

IMPRESSION

  1. Left paracentral L4–L5 disc extrusion contacting the traversing left L5 nerve root.
  2. No fracture or marrow edema.

Electronically signed · S. Varga, MD · 04/02/2023 11:17

DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
12
MAR-02-2024 14:22FROM: NORTHWIND GENERAL HIM 503-555-0142TO: 503-555-0199P.0001/1412
NORTHWIND GENERAL HOSPITAL
Health Information Management · 2200 NW Synthetic Ave · Portland, OR

CERTIFIED COPY OF MEDICAL RECORDS

PatientDELGADO, MARIADOB03/02/1985
MRN00-SYN-4471Pages1,412
Dates of service03/14/2023 – 01/19/2024
Requested byRecords request #R-20931 (synthetic)

I certify that the attached pages are true and complete copies of records kept in the regular course of business, made at or near the time of the events recorded by persons with knowledge of those events.

Contents: emergency department, radiology, operative and anesthesia records, inpatient nursing, physical therapy, laboratory, pharmacy, billing and correspondence.

L. WhitcombCustodian of Records · 03/02/2024
CONFIDENTIAL
DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
RIVERBEND FAMILY MEDICINEClinic note

PROGRESS NOTE

Patient Delgado, MariaDOS 04/18/2023Provider A. Reyes, MDVisit Follow-up, established

Chief complaint. Low back pain, worse with sitting.

HPI. 38-year-old female seen in follow-up after motor vehicle collision on 03/14/2023. Reports persistent low back pain, 6/10, radiating to the left buttock and posterior thigh. Tried NSAIDs and heat with partial relief. Sleep disrupted 3–4 nights per week. No bowel or bladder change.

BPHRTempSpO₂Wt
128/827698.4 °F99%146 lb

Exam. Paraspinal tenderness L4–S1, left greater than right. Straight-leg raise positive on the left at 45°. Strength 5/5 except EHL 4+/5 left. Reflexes symmetric.

Assessment / plan.

  1. Lumbar radiculopathy, left. Order MRI lumbar spine without contrast.
  2. Continue naproxen 500 mg BID with food. Start PT referral after imaging.
  3. Return in 3 weeks or sooner if symptoms progress.

Electronically signed by A. Reyes, MD · 04/18/2023 16:02

DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
NORTHWIND GENERAL HOSPITAL — SURGICAL SERVICESOR 4

OPERATIVE REPORT

Patient Delgado, MariaDate 05/19/2023Surgeon R. Okafor, MDAnesthesia General endotracheal

Preoperative diagnosis. Left L4–L5 paracentral disc herniation with L5 radiculopathy.

Postoperative diagnosis. Same.

Procedure. Left L4–L5 microdiscectomy with partial medial facetectomy (CPT 63030).

Findings. Large extruded fragment compressing the traversing left L5 nerve root. After removal the root was freely mobile.

Description. The patient was brought to the operating room and placed prone on a Wilson frame. Level was confirmed fluoroscopically. A 22 mm tubular retractor was docked on the left L4 lamina. Laminotomy and partial medial facetectomy were performed under the microscope. The ligamentum flavum was removed and the L5 root was gently retracted medially. The extruded fragment was removed along with loose disc material. The wound was irrigated and closed in layers.

EBL 25 mLComplications NoneSpecimens Disc fragment to pathologyDisposition PACU, stable

Dictated by R. Okafor, MD · transcribed 05/19/2023 18:40

DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
NORTHWIND GENERAL HOSPITAL — PATIENT FINANCIAL SERVICESAcct 7730-SYN-0412

ITEMIZED BILLING STATEMENT

Guarantor Delgado, MariaStatement date 06/30/2023Admit 05/19/2023Payer Synthetic Mutual Ins.
DateCodeDescriptionQtyCharge
05/19/2363030Laminotomy, lumbar, one interspace18,420.00
05/19/2300630Anesthesia, lumbar spine12,115.00
05/19/2372100X-ray lumbar spine, 2–3 views1312.00
05/19/230360Operating room services114,680.00
05/19/230710Recovery room11,904.00
05/19/230250Pharmacy141,062.40
05/19/230272Sterile supplies92,388.15
05/20/230120Room & board, semi-private13,250.00
05/20/2397161PT evaluation, low complexity1286.00
05/20/230300Laboratory3418.50
Total charges$34,836.05Payments / adjustments−$27,902.18Balance$6,933.87

Questions about this statement: 503-555-0177, Mon–Fri 8–5. This statement is synthetic.

DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
HARBOR ORTHOPEDIC ASSOCIATESForm HOA-12 rev. 2021

NEW PATIENT INTAKE FORM

NameMaria DelgadoDate of birth3/2/85Referred byDr. ReyesToday's date4/27/23Reason for visitlow back pain since car accident, L leg

Medical history (check all that apply)

DiabetesHigh blood pressureAsthmaPrior back injuryPrior surgerySmokerDepression / anxietyHeart disease

Rate your pain today (0 = none, 10 = worst)

012345678910

Current medications

naproxen 500mg 2x/day, albuterol as needed

Allergies

penicillin (rash)
M DelgadoPatient signature · date
DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
NORTHWIND GENERAL — CLINICAL LABORATORYAccession L23-051904

LABORATORY REPORT

Patient Delgado, MariaCollected 05/20/2023 05:40Ordering R. Okafor, MDStatus Final
TestResultFlagUnitsReference
WBC11.8HK/µL4.0–11.0
Hemoglobin12.9g/dL12.0–16.0
Hematocrit38.4%36–46
Platelets262K/µL150–400
Sodium139mmol/L135–145
Potassium3.4Lmmol/L3.5–5.1
Chloride103mmol/L98–107
CO₂24mmol/L22–29
BUN14mg/dL7–20
Creatinine0.78mg/dL0.57–1.00
Glucose131Hmg/dL70–99
CRP1.9Hmg/dL< 0.5

H = above reference range · L = below reference range. Verified by K. Osei, MLS(ASCP).

DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
THIS PAGE INTENTIONALLY LEFT BLANK
DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
CASCADE IMAGING CENTERExam MR-23-04021

MRI LUMBAR SPINE WITHOUT CONTRAST

Patient Delgado, MariaExam date 04/02/2023Referring A. Reyes, MDReader S. Varga, MD

History. Low back pain with left leg radiation after MVC.

Technique. Sagittal T1, T2 and STIR; axial T2 from L1 to S1. Comparison. None.

Findings. Alignment is normal. Vertebral body heights are maintained. Conus ends at L1.

L1–L2 through L3–L4: No disc herniation or stenosis.

L4–L5: Left paracentral disc extrusion measuring 9 mm, contacting and posteriorly displacing the traversing left L5 nerve root. Mild left lateral recess narrowing.

L5–S1: Mild disc desiccation without herniation.

IMPRESSION

  1. Left paracentral L4–L5 disc extrusion contacting the traversing left L5 nerve root.
  2. No fracture or marrow edema.

Electronically signed · S. Varga, MD · 04/02/2023 11:17

DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
NORTHWIND GENERAL — 3 WEST SURGICAL05/19/2023 – 05/20/2023

MEDICATION ADMINISTRATION RECORD

Patient Delgado, MariaAllergies Penicillin (rash)
Medication / order000004000800120016002000
Oxycodone 5 mg PO q4h PRNJKLMRS
Acetaminophen 1,000 mg PO q8hJKDP
Cefazolin 2 g IV q8h ×2LMRS
Ondansetron 4 mg IV q6h PRNRS
Docusate 100 mg PO BIDJKJK
Enoxaparin 40 mg SC dailyRS

Pain reassessment

04107/10 → 4/10 at 0510 after oxycodone
08205/10 → 3/10 at 0915
16154/10, ambulating in hall with PT
DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
RIVERBEND PHYSICAL THERAPYVisit 19 of 24

DAILY TREATMENT NOTE

Patient Delgado, MariaDOS 09/12/2023Therapist T. Marsh, PTDx M54.16 lumbar radiculopathy

S. Reports pain 4/10 today, 6/10 after sitting through a long meeting. Sleeping better.

ExerciseSets × repsLoadNotes
Pelvic tilts, supine2 × 15—cues for breathing
Bridges3 × 12—↑ hold 5 s
Bird dog2 × 10 ea—L side slower
Sciatic nerve glides2 × 10—mild pull L thigh
Recumbent bike10 minLvl 4warm-up
Cable row3 × 1015 lbneutral spine
Sit-to-stand, 18 in3 × 8—pain 5/10 on rise

O. Lumbar flexion 55°, extension 12°. SLR negative R, mildly positive L at 70°.

A. Tolerating progression. Sitting tolerance remains the limiting factor.

P. Continue plan of care 2×/wk. Add hip hinge drills next visit.

T. Marsh PT97110 ×3 · 97140 ×1 · 55 min
✓ HEP reviewed
DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
HARBOR ORTHOPEDIC ASSOCIATES
1180 Harbor Blvd, Suite 300 · Portland, OR · 503-555-0160

June 14, 2023

A. Reyes, MD
Riverbend Family Medicine
Portland, OR

Re: Maria Delgado · DOB 03/02/1985

Dear Dr. Reyes,

Thank you for allowing me to participate in Ms. Delgado's care. I saw her today, four weeks after a left L4–L5 microdiscectomy performed on May 19. Her leg pain has largely resolved. She continues to report low back pain with prolonged sitting, which is expected at this stage.

Her incision is well healed. Strength is full and symmetric. I have recommended she continue formal physical therapy twice weekly for eight more weeks with a focus on core stabilization and sitting tolerance, and return to modified duty in two weeks.

I will see her again in six weeks. Please don't hesitate to call with any questions.

Sincerely,

Rob Okafor

R. Okafor, MD · Spine Surgery

cc: Riverbend Physical Therapy

DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
MAR-02-2024 15:07NORTHWIND GEN HIMP.0428/1412
NURSING NOTES — 3 WEST
PT: DELGADO, MARIA MRN 00-SYN-4471 RM 312-B

05/19 2130ARRIVED FROM PACU. A&O X4. DRSG CDI. PAIN 6/10 LOW BACK, MEDICATED PER MAR. VOIDED X1.

05/20 0015 RESTING, RESP EVEN/UNLABORED. NEURO CHECKS WNL BLE. SCDS ON.

05/20 0410 C/O PAIN 7/10, INCISIONAL. PRN GIVEN. REPOSITIONED.

05/20 0820 UP TO CHAIR W/ ASSIST X1. TOLERATED WELL. DIET ADVANCED.

05/20 1330 PT EVAL DONE, AMBULATED 150 FT. MD ROUNDED. D/C PLANNING STARTED.

05/20 1615 PAIN 4/10. D/C TEACHING REVIEWED W/ PT + SPOUSE.

see d/c summ.
RECEIVED
MAR 04 2024
DELGADO_MR_000001SYNTHETIC RECORDPage 1 of 1,412
Page01234567890,012345678900123456789001234567890/ 1,412
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