Medical Record Summary of Jeffery Van Sloten

As of 12-06-2023
Date of Loss: SSD: H 12/31/07 Y

Exhibit Facility Date of Service Page #’s Note

1F MRO 11/24/2008 3 Chest XR, no findings
1F MRO 09/13/2008 4-5 Right elbow XR, no findings
1F MRO 09/13/2008 6-7 Right humerus XR, no findings
Lumbar Spine MRI. There is a slight decrease in size of the left
paracentral disc protrusion, broad-based at L5-S1. It extends to
1F
the level of the S1 nerve root w/in the spinal canal. Pt experienced
MRO 08/15/2008 8 low back pain radiating to left leg.
Chest XR. Pt heart is not enlarged, and the pulmonary vasculature
1F is not engaged. The costophrenic angles are sharp and no
MRO 08/10/2008 11 infiltrates are seen.
Emergency CT Facial Bones. Pt had sinus disease of the maxillary
1F
MRO 08/10/2008 12 sinuses.
1F MRO 08/10/2008 14 Head CT
AP of sacroiliac joints which appear normally aligned and well
1F
MRO 08/04/2008 16 maintained.
1F MRO 08/04/2008 18 Lumbosacral spine XR.
1F MRO 07/15/2008 20 Chest XR
Lumbar Spine MRI. Pt had a very small left paracentral disc
1F protrusion at the L5-S1 level that minimally touching but not
MRO 12/29/2007 21 displacing the left S1 nerve root.
Pelvic ultrasound. There is an approximately 2 cm area of altered
echogenicity in the anterior aspect of the fundic portion of the
1F
uterus suggesting a small uterine fibroid. No dominant cysts or
MRO 11/07/2007 23 solid adnexal masses.
1F MRO 09/05/2007 25 Left hip AP and Lateral Left. Pt fall in tub three days ago.
1F MRO 06/06/2007 28 Moderate functional aerobic impairment
1F MRO 03/22/2007 29 CT brain without contrast. Negative unenhanced head CT.
 Pelvic ultrasound, 2x2 cm anterior fibroid, which appears to be
1F
MRO 02/01/2007 31 intramural.
Chest XR. Poor inspiration which increased markings in both the
1F
MRO 12/27/2006 33 lung bases, more prominent on the right.
Soft tissue biopsy right elbow mass. There is capillary
1F
MRO 10/10/2008 38 hemangioma.
Pt presented for a follow up about her right elbow biopsy. She
complained of minimal pain in the elbow. It was a bit stiff and her
1F
right shoulder was sore from not moving too much. No symptoms
MRO 10/15/2008 240 of infection.
Pt presented for the recheck of her diabetes as well as her chronic
low back pain, obesity, and hypothyroidism. She is going to be
seen at the University of Washington for her ongoing thyroid
1F
problems. She has had difficulty controlling her thyroid despite
large amounts of replacement after surgical resection. She has
MRO 10/09/2008 242 type 2 diabetes well controlled by recent Alc.
Pt presented for her pre-operation of her right elbow excisional
biopsy. Diagnosed with right olecranon bursal mass. Treatment
1F
plan is right elbow olecranon excisional biopsy to be done by Dr.
MRO 10/08/2008 245-247 Randy. Surgery is scheduled 10/10/2008.
Pt is a right-hand dominant patient who presented with right
elbow pain and tenderness over her olecranon. She is an
unemployed disabled due to chronic back pain following injury in
the hospital when she reports that she fell out of a bed. After
1F physical examination, she was diagnosed with symptomatic right
olecranon bursal mass. Treatment plan is to undergo attempted
needle aspirator, further imaging such as ultrasound or MRI as
well as surgical excision. Pt would like to proceed with the
MRO 10/01/2008 249-256 surgical excisional biopsy.
Pt presented for her yearly exam. She had irregular cycle wherein
she bleeds two to three weeks out of each month over the last six
1F months. It became painful and had a significant weight loss over
30 pounds in the last six months. She was recommended for a
MRO 09/16/2008 258-261 pelvic ultrasound.
1F MRO 09/13/2008 263 Pt presented with swollen and tender upper arm. She also
presented with pain involving her right elbow primarily the
 medial side, and the upper arm in the region of the biceps. This
has been ongoing for about a week and a half.
Pt presented with a low back pain and a follow up on her thyroid
cancer. She had difficulty replacing her thyroid. She is having
1F
increased left sciatic complaints of numbness, pain and some
MRO 08/08/2008 267 locking of her left leg at times.
Pt presented a worsening back pain. She has difficulty with back
pain for several years. She has apparently been seen for this in the
emergency department several times within the last week. They
have tried various palliative measures such as IM morphine and
1F Percocet. She was also taking Methacarbamol , MS Contin and
got an early refill of Vicodin via her PCP. She had her MRI of the
lumbar spine done in Dec 2007 which showed a small disc
protrusion at L5-S1. There is minimal touching of nerve root. She
MRO 08/04/2008 270-271 had significant palpation of the left sacral iliac joint.
Pt presented for follow-up on her thyroid. She is having a
1F normal thyroglobulin level and normal nuclear scan of the
MRO 05/19/2008 274 thyroid. She does have type 2 diabetes.
Pt presented for review of chronic pain as well as hypothyroidism
secondary to thyroidectomy for cancer. She had her Thyrogen
injection and will be getting a thyroid scan. She had difficulty
maintaining her thyroid replacement. She was also getting a
1F
thyroid ultrasound. She had assessment at the Vancouver Pain
Clinic here at the end of May. She had a significant lower back
pain and lower leg complaints. Low back is tender in the para
MRO 05/06/2008 277-278 lumbar spine bilaterally.
Pt presented for a follow-up on thyroid cancer, anxiety and
diabetes. She had a history of obesity and chronic back pain. She
1F
is now followed at Vancouver Clinic for the chronic pain. Recent
MRO 03/24/2008 280 thyroid tests were back in Jan showed good suppression of TSE.
1F MRO 03/13/2008 284 Pt complained to left buttock and left hip pain. She presented with
her daughter and reported that although the injection provided her
significant pain relief in her left hip and left buttock area was only
short-lived. After three days of good pain relief she was back to
where she was before and reported pain at 7-8/10 on MS Contin
30 mg twice daily as well as Vicodin 10-500 twice daily as
 needed w/o side effects.
Pt presented with pain in the left buttock as well as a cramping
sensation in both legs. The problem began in July 2006 and had
chronic problems when she developed thyroid cancer. She
1F
described an aching and throbbing pain in the left buttocks, and
she complains of weakness in her legs. She was unable to get up
MRO 02/21/2008 292 off the floor.
The patient returns with worsening low back pain, diabetes, and
hypertension. Recent emergency department visit led to a referral
to the Vancouver Pain Clinic. MRI shows increased pain.
Diabetes is well-controlled, but thyroid replacement therapy is
1F
poorly managed due to past papillary carcinoma thyroid. Pain
levels are 8-9 in the morning and evening, reduced to 6 with
morphine. Hydrocodone use is frequent, and the patient is running
MRO 01/14/2008 303 out of medication.
Pt returns for a follow-up on chronic low back pain and
hypothyroidism post-papillary carcinoma thyroid removal. TSH
control has been challenging, with a recent high of 56. Medication
1F
adherence has improved, but pain has worsened despite doubling
hydrocodone to 30 mg daily. A referral to the Vancouver Pain
MRO 12/20/2007 306 Clinic is pending, awaiting approval for an MRI.
1F MRO 11/26/2007 308 Pt visited provider due to irregular menses.
Follow-up from the ED for acute menorrhagia with persistent
bleeding. Regular cycles with increasing heaviness, culminating
in 3 days of heavy bleeding. Slight drop in hemoglobin noted
during the ED visit. Prescribed Provera, which has currently
1F stopped her period. Pelvic ultrasound revealed a 2 cm fibroid;
unclear if internal or external. Complaining of left foot pain for 2
weeks, especially across the metatarsal head when walking, with
no specific injury reported. Persistent low back pain and
MRO 11/12/2007 311 worsening headaches are also mentioned.
Pt presented with prolonged vaginal bleeding. Symptoms ongoing
for nearly a month. Experiencing low abdominal cramping. Tubal
1F ligation history. Workup in the ER advised ultrasound. Started on
Provera, and bleeding has started to diminish. Previously using 8-
MRO 11/07/2007 316 10 tampons a day.
 Pt complained of migraines and memory problems. She also
1F indicates that as a child and she had symptoms of myasthenia
MRO 10/30/2007 318 gravis. Pt is currently taking various medications for pain control.
Daycare worker ill for 2 weeks with increasing cough, chest
congestion, sore throat, nausea, and diarrhea. Diabetic on
glyburide, fasting sugar usually in the 140s. Takes Plaquenil for
1F
joint pain, nonsmoker. No wheezing or shortness of breath but
coughing up colored sputum. Appears tired, not dyspneic. Normal
MRO 10/24/2007 320 TMs, non-inflamed pharynx. Coarse rhonchi in both lungs.
Pt returns with ongoing pain; uncertain about Plaquenil efficacy.
Awaiting Pain Clinic visit, experiencing pain in lower back and
left hip, occasionally radiating down the leg. Describes aching
with occasional burning quality. Consulted Dr. Neville and
initiated nortriptyline; unable to increase due to dizziness,
1F
currently taking two. No respiratory symptoms, fever, chills, or
stool incontinence.
No rashes, alopecia, or joint swelling. Morning stiffness in the
back for one hour. Other peripheral joints negative. Overall, other
MRO 10/22/2007 324 review of systems is negative.
Pt reports ongoing memory difficulties, worsening over the last
three months. Examples include forgetting appointments,
1F destinations, medications, and occasionally missing work.
Husband now drives her due to erratic driving and forgetfulness
MRO 09/20/2007 329 about destinations.
Pt follow up on recurrent back problems, hypothyroid, and
1F
MRO 09/20/2007 338 ongoing memory and headaches.
1F MRO 09/05/2007 342 Pt presented with a chief complaint of hip pain.
Pt was referred for her muscle spasm. She stated that she has
1F increasing pain in her back, neck, hands, calves, thighs due to
MRO 08/20/2007 345 more cramping and muscle spasm.
Pt presented with a chief complaint of bilateral hand,
1F
MRO 08/15/2007 348 feet and leg cramps occurring intermittently for three days.
1F MRO 07/05/2007 351 Pt presented for a recheck of diabetes as well as for her
muscle aches and pains. She has Graves’ disease and mixed
connective tissue disease. She has seen Dr. Nakashima. She is
status post thyroidectomy. She is having significant difficulties
 with adjusting her thyroid.
Pt returned with continued pain in multiple regions. This appears
1F to be in the muscles and joints. Previously did have a
MRO 06/27/2007 357 cortisone injection, which did help.
1F MRO 06/18/2007 363 Pt presented for her DWAP exam.
Pt reported a primary complaint of weakness, pain and cramping
Rehab Plaza in her legs, back, arms, and shoulders. Tenderness to palpation of
1F
Physical the left first rib, left levator scapulae. The physical therapy plan is
Therapy 05/14/2007 368-371 to see this patient 2 times a week for 4-6 weeks.
Pt coming in with 2 1/2 days of bone pain, joint pain, muscle
1F cramps and intestinal cramps, diarrhea, vomiting, even with
MRO 05/07/2007 379 attempting to eat food.
Pt presented with shortness of breath and some chest pressure.
She was seen in the ER for this. Was fully evaluated. Was shown
to be mildly hypothyroid and having very minimal elevations of
1F
her troponin level. She had issues of anxiety disorders in the past.
Sometimes it wakes her up at nighttime with rapid thoughts,
MRO 05/03/2007 382 feeling of chest pressure.
Pt presented to fu on thyroid cancer. She had undergone repeat
nuclear scanning. She has a history of low back pain and obesity
1F as well as type 2 diabetes. She is married with children, works in a
daycare setting, which is difficult for her due to her lower back
MRO 04/17/2007 389 pain.
1F MRO 03/09/2007 396 Pt presented for Depo-Provera injection.
1F MRO 03/08/2007 402 Pt was evaluated due to headaches and generalized pain. Pt had
history of an elevated ANA (1:320 titer), hypothyroidism, due to
thyroid cancer, diabetes mellitus, reactive airway disease, and left
shoulder pain, as well as chronic low back pain, presents for the
evaluation of the above neurologic complaints. She states that she
has had headaches beginning approximately two months ago.
These occur approximately four times a week and last about three
hours. They can occur anytime in the morning, afternoon and
night. The pain is often throbbing. It is located in her neck, as well
as bitemporal region. It is accompanied by nausea, phono and
photosensitivity, as well as emesis sometimes. Approximately two
times a week her headaches are severe; the other two times they
 are more moderate. Her headaches are worsened by head
movement. She has found any foods or drinks, which exacerbate
her head pain.
Patient developed dysphagia, noted to have enlarged thyroid and
found to have a follicular carcinoma. She underwent
thyroidectomy. She continues to have significant symptoms.
States that she has increasing pain in her arms, legs, mostly in her
muscles,
deep ache, bone pain. Patient did have swelling and infection in
1F
the right parotid, tried antibiotics, but has residual pain, has
significant pain in her neck, lower back. Back pain radiates down
the posterior aspect of her left leg to her calf. Pain is worse with
cold exposure and at night. Does have throbbing, aching pain at
night. Difficulty with sleeping, does have episodes where she
MRO 02/27/2007 412 become lightheaded, nausea, especially after standing.
Pt presents with continued discomfort on the right side of her,
1F
MRO 02/23/2007 422 face, near the TMJ and the right parotid gland.
Pt presented for follow-up on dysfunctional uterine bleeding.
Pelvic ultrasound has demonstrated a uterine fibroid anteriorly. It
1F
appears to be intramural. It is unclear whether it is involved in her
MRO 02/13/2007 427 menorrhagia, but certainly can contribute to dysmenorrhea.
Pt complained of menstrual cramping and spotting which has been
ongoing for about three weeks. She has not had a true period since
1F last month. Her cycles have been fairly heavy and
general, lasting about a week and she has had no problems to this
MRO 01/29/2007 434 point about her cycles in the recent past.
Pt presented presents for discussion of her weight, as well as
chronic joint pain. Patient has also had some sores in her mouth
1F
which have been bothering her at times. She has poor dentition
MRO 01/22/2007 442 and is complaining of generalized fatigue and weakness.
Pt presents with a chief complaint of upper respiratory symptoms
for 1 week, a cough productive of green mucus, and a fever of
1F approximately 101 degrees that is relieved by Tylenol, night
sweats
and chills. Pt states that her cough is worse in the morning.
MRO 12/03/2006 449 Patient states that the cough and congestion have been associated
 with the migraine headaches, photophobia, as well as a runny
nose. She has a history of asthma, but has not been using her
inhaler.
St John Pt presented to triage w/ c/o generalized abdominal pain x 1.5
Medical weeks w/ nausea. She stated she took her pregnancy test recently
2F Center 08/29/2018 5 that was negative.
PMG Endocrine return visit. Pt was assessed w/ Type 1 diabetes
Endocrinology mellitus w/ long term current use of insulin. Chronic problem w/
3F West 12/20/2021 14 hyperglecemia.
OSS
Providence Pt visited Radiology and Family medicine and diagnosed with
Seaside numbness and tingling in left arm. Acute pain of left shoulder.
3F Hospital 12/06/2021 19 Neck pain. Stress incontinence of urine.
PHQ-2 Depression screening. Pt complained of left arm injury
due to car accident Sep 2021 where shoulder hurts and hand goes
numb. It is her right arm aches that has a shooting pain that goes
into her neck and states that her hand falls asleep in the morning
when she wakes up she notices it she also notices when she is
sitting and watching TV. She has started physical therapy but has
only been once as she got sick and has not yet rescheduled
appointments. She stated that it goes into her neck and causes
OSS Seaside fingers to be numb and when she turns her neck it seems to cause
3F RHC 12/06/2021 20 it to be more numb.
OSS
Providence PTSD, Type 1 diabetes mellitus with long-term current use of
Seaside insulin (HCC), Leukocytosis, unspecified, Anxiety, primary
3F Hospital 11/23/2021 26 insomnia
Pt complained of left-sided upper extremity and neck pain due to
OSS a recent motor vehicle accident. She missed her sessions due to
Providence illness, and desires to return but complained of weakness and leg
Seaside pain. Had blurred vision and an abnormal sleeping schedule. She
3F Hospital 11/22/2021 28 reported ongoing epigastric pain.
3F OSV 11/12/2021 34 Anesthesia Preprocedure Evaluation
Providence
Saint Vincent
Medical
 Center
OSV
Providence
Saint Vincent
Medical
3F Center 11/12/2021 38 D-C Instructions Provation
Pt presented with chronic left-sided abdominal pain over the past
year. Constant dull left upper quadrant pain.
Worsened with bowel movements.
Radiates into the left pelvic region.
OSV Not associated with oral intake.
Providence Associated with bloating and mild nausea.
Saint Vincent Present throughout the day but not nocturnally.
Medical Occasional bulging on the left side of the abdomen, tight and
3F Center 11/12/2021 39 distended during peak pain.

OSS Seaside Pt was asymptomatic for COVID19 pre-screening for surgical

3F RHC 11/09/2021 42 procedure.
Pt recently experienced a motor vehicle accident (MVA) while
using medical transportation. The management team assured close
PMG or Care follow-up with the patient to address medical needs and provide
3F Mgmt Service 10/21/2021 49 assistance in filing claims.
OSS
Providence
3F Rehab 10/20/2021 49 Physical Therapy Initial Assessment
OSS Pt presented to PT w c/o of L leg pain. Her L
Providence leg pain started from calf pain that travels up to anterior thigh and
3F Rehab 10/20/2021 59 occasionally has tremors in her whole body sporadically.
Pt presented w/ with pain at left upper back, left upper chest and
left shoulder after motor vehicle crash
OSS Seaside last week. Pt was assessed w/ MVA, trapezius muscle spasm,
3F RHC 10/20/2021 60 strain of left shoulder intl, contusion, chest wall left, init

OSS Seaside
3F RHC 10/19/2021 64 Pt presented w/ insomnia, anxiety, and PTSD.
 PMG
Endocrinology
3F West 10/15/2021 69 Telephone encounter re thyroid issue in right thyroid bed.
Pt was seen for Type 1 Diabetes and Postsurgical Hypothyroidism
PMG with hx of thyroid cancer. Chronic problem w/ hyperglycemia and
Endocrinology recent visualization of soft tissue in left thyroid surgical bed in
3F West 09/30/2021 71 US.
Pt reported that she is currently homeless and staying in an RV w/
his old man Pt has been in contact w/ the CCA but they are unable
to help w/ any assistance w/o some income for the household.
PMG or Care SSD has been terminated and did not complete the application for
3F Mgmt Service 09/17/2021 79 benefits when moving to OR.
Pt presented w/ hysterectomy, loss of bladder control. Pt had
chronic vulvitis and vaginitis and would like to pursue a
hysterectomy with BSO and still c/o current 8cm ovarian cystic
OSS Seaside pain. She also desires relief from her increasing USI and
3F RHC 09/16/2021 83 increasing urinary urge symptoms.
Pt presented for FU and she found out that her mom is in the
OSS Seaside hospital on the ventilator. She didn’t sleep well with Ambien and
3F RHC 09/07/2021 98 gets tired but wakes up midway through the night.
OSS
Providence Pt was diagnosed w/ bronchitis, SOB, cough, chest congestion,
Seaside fibromyalgia, mouth pain, vaginal symptom, urine abnormality ,
3F Hospital 08/23/2021 103 leukocytosis. Chest XR, negative
Pt reported chronic pain from her fibromyalgia condition, has
OSS Seaside flare of pain at left lower leg lateral aspect
3F RHC 08/03/2021 114 and at medial aspect of left knee region.

OSS Seaside
3F RHC 08/02/2021 118 Pt struggles w/ insomnia.

OSS Seaside
3F RHC 06/24/2021 126 PHQ-2 Depression screening positive
 OSS Seaside Pt in need of a new referral to CMH Urology and for an echo, also
3F RHC 06/23/2021 131 referral w/ the closest endocrinologist.
PMG
Administrativ
e Services and MSW received referral from MH NP Pt needs assistance w/
3F Departments 06/09/2021 133 transportation and other resources.
Medication management. Pt complained of PTSD and current
moderate episode of major depressive disorder, unspecified
OSS whether recurrent (HCC). She is forgetting things, and her
Providence memory is not very good. She had discomfort and at night she has
Seaside a restless leg syndrome where she continually thrashing and
3F Hospital 06/02/2021 134 kicking until she can finally fall asleep.
Pt presented for surgery due to 8cm right ovarian cyst
OSS Seaside adenomyosis w/ menorrhagia and pelvic pain, and urinary stress
3F RHC 04/02/2021 143 incontinence.

OSS Seaside
3F RHC 04/01/2021 151 Preop endometrial BX for TAH and RSO and TOT visit.
Pt reported ongoing significant anxiety and depression stemming
from past abusive trauma. She experiences auditory and visual
OSS Seaside hallucinations, answering nonexistent people, with a continuous
3F RHC 03/24/2021 161 humming in her ears resembling underwater sounds.

OSS Seaside
3F RHC 02/26/2021 167 Pt complained of significant urinary incontinence.

OSS Seaside Pt recently increased quetiapine by titration from 50 mg up to 200

3F RHC 02/25/2021 173 mg nightly for insomnia and anxiety.
Pt presented for FU and was having a lot of bone pain, myalgias
OSS Seaside and some night sweats. Been sick over the last 2 weeks. Arms and
3F RHC 02/23/2021 174 legs are tingly. Poor memory.
Pt was tearful during her Interview and expresses
OSS Seaside anxiety both verbally as well as observable in the form of rocking
3F RHC 02/11/2021 180 back and forth in her chair. Scheduled for PT.
 Pt presented w/ thyroid disorder and unsure if her total thyroid
OSS Seaside was removed. Pt had difficulty swallowing and she felt like she
3F RHC 12/28/2020 195 has a lump in her throat.
Pt has numbness in left pectoral and breast area. Certain
movements make it worse and stretching the arm forward is the
worst. The numbness and discomfort in her left breast area
appears to start at the midpoint of her scapula, on the medial edge,
left side, on her back. This area is tender to palpation. The
discomfort and numbness move forward and around her chest
OSS Seaside towards her breast from that
3F RHC 12/21/2020 201 point.
Pt visited orthopedics for evaluation of left shoulder pain left
posterior neck pain and numbness of the anterior and anterior
lateral chest wall just below the breast line level. Two-month
history of diffuse shoulder girdle pain, worse at night, leading to
OSS Seaside reduced left arm use. Despite pain, started moving arm through
3F RHC 12/20/2020 207 range of motion, followed by numbness in the chest wall.
Pt was seen for left arm numbness that started over her left breast
and in the back of her shoulder blade. She stated that her shoulder
was extremely painful. Pain was shooting down her arm and into
OSS Seaside her fingers. Ongoing for one month. She also complained of neck
3F RHC 12/18/2020 227 pain and headaches.

OSS Seaside Pt complained of arm pain, chest numbness, back pain and breast
3F RHC 12/18/2020 232 numbness.

OSS Seaside Pt visited for FU at OV, Diabetic eye exam and Diabetic foot
3F RHC 12/07/2020 233 exam.
Pt FU appointment who’s in distress due to high blood sugar
OSS Seaside running in the mid 300 range for at least a week. Been using
3F RHC 06/23/2020 236 insulin but has not seen any improvement.
Follow-up visit. Pt experienced increased in anxiety and agitation
over the last few weeks as her partner was in the hospital for a
OSS Seaside period. Not taking her medication because she misplaced the
3F RHC 05/12/2020 241 bottle.
 OSS Seaside Pt run out of amitriptyline and was having arrhythmias. Had
3F RHC 04/14/2020 246 insomnia and anxiety.

OSS Seaside
3F RHC 03/16/2020 250 Diagnosed w/ cyst of ovary, unspecified laterality
OSS
Providence
Seaside Diagnosed w/ urinary retention and menorrhagia w/ irregular
3F Hospital 03/12/2020 250 cycle, constipation, cubital tunnel syndrome on left.

OSS Seaside LUQ ultrasound, pt has mild hepatomegaly. Ultrasound shows

3F RHC 03/11/2020 250-251 simple renal right cyst.
Pt seeks care with a history of prolonged physical abuse and
domestic violence. Married at 16, her first husband was abusive,
leading to a series of abusive relationships. She later married
again, facing abuse and drug use in the second marriage,
culminating in her husband and adoptive daughter leaving.
Anxious today as her ex-husband, recently released from prison,
prompts constant fear for her safety. Hope experienced severe
beatings, mentioning a cracked skull, leading to headaches and
OSS Seaside seizures. Despite a history of depression and anxiety treatment,
3F RHC 03/10/2020 257-258 she found no benefit from antidepressant medications.

OSS Seaside
3F RHC 02/17/2020 265-266 Pt has a long history of Type 2 DM.
OSS Cannon
Beach Fam Pt wants to discuss stomach issues – pain mostly in left side –
Medicine almost under ribs, unable to eat much, but always hungry, BM
3F RHC 02/12/2020 272 every few days. Has anxiety and insomnia.

OSS Seaside
3F RHC 01/21/2020 273 Knee XR due to acute left knee pain, unremarkable
 OSS Seaside Pt presented w/ list of chronic complaints w/ history of thyroid
3F RHC 05/10//2018 275 cancer w/ resultant hypothyroidism.
Providence
Oregon Cervical Spine XR, low-grade degenerative endplate spurring
Regional from C4 through C6. Bones are intact without fracture or focal
3F Laboratory 12/08/2021 364 destruction.
Left Shoulder XR, there is amorphous mineralization projecting
over the proximal left greater tuberosity measuring 9 mm and can
3F PHS Imaging 12/06/2021 365 be seen with calcific tendinopathy.
Providence Pt undergone surgical pathology such as duodenum biopsy and
Oregon gastric antrum and body due to left upper quadrant pain,
Regional hemorrhage of anus and rectum, and chronic idiopathic
3F Laboratory 11/16/2021 369 constipation. No findings.

Pt undergone upper GI endoscopy due to abdominal pain in the

3F OR Muse 11/12/2021 373 left upper quadrant. No findings.
Colonoscopy, three sessile polyps were found in the sigmoid
colon in 3 to 4 mm in size. Removed with a cold biopsy forceps.
OR Muse Resection and retrieval were complete. Medium sized internal
3F 11/12 11/12/2021 375 hemorrhoids were found.
CT Abdomen Pelvis w/ Contrast, large cystic lesion in the right
lower pelvis ovarian in origin. Mild fatty infiltration throughout
3F PHS Imaging 09/09/2021 380 the liver.

3F PHS Imaging 08/23/2021 387 Chest XR, no findings.

US Thyroid, Status post thyroidectomy. Possible small amount of
soft tissue in the left thyroid surgical bed. Consider nuclear
medicine thyroid scintigraphy to evaluate
3F PHS Imaging 05/27/2021 395 for functional thyroid tissue.
Providence
Oregon
Regional Endometrial Biopsy, negative for atypical proliferative lesions or
3F Laboratory 04/02/2021 398 malignancy
 US Pelvis w/ transvaginal due to left abdominal pelvic pain and
right ovarian cyst. Constellation of findings is suggestive of
adenomyosis. Increasing size of the complex cyst of the right
3F PHS Imaging 01/03/2021 403 ovary.

Thoracic Spine XR, no abnormalities and slight S-shaped

3F OR Muse 12/21/2020 409 scoliosis of the thoracolumbar spine.

3F PHS Imaging 12/21/2020 410 Chest XR, normal

Cervical Spine XR, mild degenerative changes and nonspecific

3F OR Cerner 11/18/2020 416 straightening, w/o an acute fracture.

3F PHS Imaging 11/19/2020 419 Left Shoulder XR, Calcific tendinitis.

US Pelvis w/ transvaginal, cystic structure of right ovary,
predominantly simple but with some small mural nodularity.
Slight interval growth compared with a report of prior ultrasound
from 4/11/2019. Gynecological management is recommended.
3F PHS Imaging 03/13/2020 421-424 Trace post void residual in urinary bladder.

US Abdomen, Mild hepatomegaly.

3F PHS Imaging 03/07/2020 424 Simple right renal cyst.

3F PHS Imaging 01/21/2020 436-437 Left Knee XR, no findings

Providence
Therapy Addressed the ff. issues, fibromyalgia, left leg pain, age-related
3F Gearhart 10/20/2021 527 physical debility, at risk for falling
Pt presented to PT w/ c/o of L leg pain started from the calf pain
that travels up to anterior thigh and occasionally has tremors in
Providence her whole body sporadically. Pt had sudden sharp twitch pain
Therapy during standing calf stretch and is sensitive to movement and
3F Gearhart 10//21/2021 534 mechanical pressure.
 Physical Therapy Initial Assessment. Pt had a previous MVA and
OSS had some on and off pain and stiffness to the left shoulder w/
Providence occasional pins and needles sensation. Had difficulty in lifting the
4F Rehab 01/25/2022 12 left shoulder.
Columbia
Memorial Associated Diagnoses: abdominal pain, body aches, dizziness,
5F Hospital 09/24/2019 13 encounter for medication refill, nausea
Pt complained of getting evicted and out of her meds for 2
months. Pt h/o IDDM2, thyroid cancer s/p thyroidectomy, asthma
who p/w nausea, dizziness, body aches, abdominal pain since
Columbia around 3 am this morning in the setting of "head congestion" x 3-
Memorial 4 days. She concerned about her blood sugar as she’s been out of
5F Hospital 09/24/2019 14 her insulin.
Pt presented for 6-week follow up. She feels as though her mood
is switching back and forth between extreme agitation and
extreme depression. Distraught due to her mother and brother's
terminal conditions. Cannot communicate with her blind and non-
OSS Seaside verbal mother. Brother in hospice with shin, easily confused,
7F RHC 06/07/2022 12 expressing fear of dying alone.
OSS
Providence Physical Therapy Progress Assessment w/ diagnosis of
7F Rehab 05/25/2022 16 impingement syndrome of the shoulder region.
OSS
Providence Physical Therapy – has shown improvement to her left shoulder
7F Rehab 05/25/2022 23 mobility and muscle power
PMG Postoperative hypothyroidism. Pt had follicular variant PTCA w/
Endocrinology left lobe tumor of 3.8 cm and R lobe microscopic tumor. Limited
7F West 05/04/2022 32-33 walking due to balance issue and joint pain.
Pt was grieving over his brother who’s in hospice anywhere from
2 days to 2 weeks to live. Her bestfriend died several days ago.
OSS Seaside Had insomnia, anxiety and involuntary movement in the form of
7F RHC 04/26/2022 37 rocking back and forth.
Orthopedic Surgery due to shoulder pain. Pt presented for
OSS Seaside evaluation of left shoulder pain. Diagnosed w/ calcific tendinitis
7F RHC 03/16/2022 48 of her left shoulder and recommended PT. Had gone 3 PT
 sessions and still having significant pain and difficulty.
Cervical Spine MRI w/o contrast. There is a low-grade
degenerative change at C2-C3 resulting in mild right-sided neural
OSS Seaside foraminal stenosis. Incidental fatty atrophy of the right parotid
7F RHC 01/20/2022 54 gland.
Shoulder left MRI w/contrast, calcific tendinitis of the
supraspinatus, mild rotator cuff tendinopathy of the infraspinatus
and supraspinatus, small subacromial/subdeltoid bursal collection,
consistent w/ an adjacent bursitis, and superior labral irregularity
OSS Seaside due to mild degeneration or minimal type I superior labral
7F RHC 02/17/2022 54 anterior-posterior tear

OSS Seaside
7F RHC 02/16/2022 54 FL Shoulder Injection Left for MRI

OSS Seaside
7F RHC 02/02/2022 55 Left Shoulder XR, calcific tendinitis
OSS Pt w/ hx od DM1 ambulates to ED w c/o low blood sugar and her
Providence friend reported that pt looked like she was having a seizure for
Seaside about 20 minutes. Pt reported she was feeling shaky, confused and
7F Hospital 03/14/2022 55 had a headache.
OSS
Providence
Seaside
7F Hospital 02/16/2022 61 Left Shoulder MRI Injection w/ Steroid Completed

OSS Seaside
7F RHC 02/02/2022 64 Pt presented w/ complained of left shoulder injury.

OSS Seaside
7F RHC 01/18/2022 70 US Thyroid, w/ minimal residual thyroid bed tissue.

7F