BORUNDA, MARIA ALLISON Admin Sex: Female DOB: **/*5/1962

Continuity of Care Document

Summarization of Episode Note 02/27/2024 to 02/27/2024 Source: VHM- Valley Hospital Medical Center

Created: 04/14/2024

Demographics

Contact Information:

140 E ROME BLVD UNIT 3020, N LAS VEGAS, NV 890841427, US Tel: 909-***-**** (Primary Home)

Email: ad499v@r.postjobfree.com

Previous Address(es):

--

Marital Status: Divorced

Religion: None

Race: Black or African American

Previous Name(s):

BORUNDA, MARIA

Ethnic Group: Hispanic or Latino

Language: English

ID: 63800130

Care Team

Type Name

Represented

Organization

Address Phone

primary care

physician

Lorenzana,

Gerardo G

-- (Work): 2825 SIENA HEIGHTS DR, HENDERSON,

NV 89052-0000, US

Tel: (702)617-

1227 (Work)

Relationships

No Data to Display

Document Details

Source Contact Info

620 Shadow Lane, Las Vegas, NV 89106-4194, US

Tel: 702-***-****

Author Contact Info

04/14/2024 10:42 AM

VHM- Valley Hospital Medical Center

Recipient Contact Info

--

Healthcare Professionals

No Data to Display

IDs & Code Type Data

Document Type ID: 2.16.840.1.113883.1.3 : POCD_HD000040 Document Template ID: 2.16.840.1.113883.10.20.22.1.1 : --, 2.16.840.1.113883.10.20.22.1.1 : 2015-08-01, 2.16.840.1.113883.10.20.22.1.2

: 2015-08-01

Document ID: 2.16.840.1.113883.3.2063.999362 : 78243109 Document Type Code: 2.16.840.1.113883.6.1, 34133-9 Document Language Code: en-US

Document Set ID: --

Document Version Number: --

Primary Encounter

Encounter Information

Registration Date: 02/27/2024

Discharge Date: 02/27/2024

Visit ID: --

Location Information

Valley ER at N. Las Vegas

(Work): 6625 N. 5th St, North Las Vegas 89084-

Providers

Type Name Address Phone

Admitting Davidson, Jeffrey A (Work): 500 N RAINBOW BLVDSUITE 203, LAS VEGAS, NV 89107- 0000, US

Tel: (702)259-

1228 (Work)

Attending Davidson, Jeffrey A (Work): 500 N RAINBOW BLVDSUITE 203, LAS VEGAS, NV 89107- 0000, US

Tel: (702)259-

1228 (Work)

Referring No DOCTOR,

Referring Doctor

(Work): 2075 E FLAMINGO RD, LAS VEGAS, NV, US --

Encounter

FIN-VHM 120195847 Date(s): 2/27/24 - 2/27/24

VHM- Valley Hospital Medical Center 6625 N. 5th St North Las Vegas, 89084- 702-***-**** Encounter Diagnosis

Sprain of other ligament of left ankle, initial encounter (Final) - 2/27/24 Fibromyalgia (Final) - 2/27/24

Other long term (current) drug therapy (Final) - 2/27/24 Acquired absence of both cervix and uterus (Final) - 2/27/24 Acquired absence of other specified parts of digestive tract (Final) - 2/27/24 Family history of ischemic heart disease and other diseases of the circulatory system (Final) - 2/27/24 Family history of diabetes mellitus (Final) - 2/27/24 Overexertion from prolonged static or awkward postures, initial encounter (Final) - 2/27/24 Sprain of other ligament of left ankle, initial encounter (Discharge Diagnosis) - 2/27/24 Discharge Disposition: AHR-ROUTINE DISCHARGE

Attending Physician: Davidson MD, Jeffrey A

Admitting Physician: Davidson MD, Jeffrey A

Referring Physician: No, Referring Doctor MD

Reason for Visit

L ANKLE INJURY

Allergies, Adverse Reactions, Alerts

No Known Medication Allergies

Assessment and Plan

Extracted from:

Title: Ankle pain-swelling Author: Davidson MD, Jeffrey A Date: 2/27/24 Impression and Plan

Sprain of other ligament of left ankle, initial encounter - ICD10-CM S93.492A, Plan

Condition: Stable.

Prescriptions: patient has naprosyn and pain medicine at home . Patient was given the following educational materials: ANKLE SPRAIN (Adult). Limitations: Activity as tolerated.

Follow up with: Referring No; C Milne, IMD Within 2-4 days 03-Return immediately if symptoms worsen; Follow-up with your primary care doctor within the next 3 days Within 1-2 days 03-Return immediately if symptoms worsen 05-Call to schedule next business day.

Counseled: Patient, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Regarding prescription, Patient indicated understanding of instructions.

Disposition: Launch Disposition Order

Admit/Transfer/Discharge:

Discharge Request (Order): 2/27/2024 16:53 PST, Home Routine

.

Immunizations

Given and Recorded

Vaccine Date Status Refusal Reason

SARS-CoV-2 (COVID-19 JANSSEN) Ad26 vacci

Last Modified: 08/10/2021 4:40 PM

4/29/21 Recorded

Medications

amitriptyline (amitriptyline 10 mg oral tablet)

Status: Ordered

Start Date: 8/10/21

2 Tabs By Mouth Daily.

Last Modified: 08/10/2021 4:52 PM

amLODIPine (amLODIPine 10 mg oral tablet)

Status: Ordered

Start Date: 12/21/20

1 Tabs By Mouth Daily.

Last Modified: 12/21/2020 8:35 PM

atorvastatin (atorvastatin 20 mg oral tablet)

Status: Ordered

Start Date: 12/21/20

1 Tabs By Mouth Daily.

Last Modified: 12/21/2020 8:35 PM

baclofen (baclofen 10 mg oral tablet)

Status: Ordered

Start Date: 8/14/21

Stop Date: 8/28/21

1 Tabs By Mouth 3 Times a Day as needed Spasm for 14 Days. Refills: 0. Ordering provider: Empey, Lonnie R DO

Last Modified: 08/14/2021 4:47 PM

WALGREENS DRUG STORE #10782

5610 Centennial Center Blvd Las Vegas, NV

891497104

buPROPion (Wellbutrin XL 150 mg/24 hours oral tablet, extended release) Status: Ordered

Start Date: 12/21/20

2 Tabs By Mouth Daily.

Last Modified: 08/10/2021 4:52 PM

DULoxetine (Cymbalta 60 mg oral delayed release capsule) Status: Ordered

Start Date: 12/21/20

1 Capsules By Mouth Daily.

Last Modified: 12/21/2020 8:35 PM

naproxen (naproxen 500 mg (as sodium) oral tablet, extended release) Status: Ordered

Start Date: 12/21/20

2 Tabs By Mouth Daily as needed for arthritis.

Last Modified: 08/10/2021 4:52 PM

omeprazole (omeprazole 40 mg oral delayed release capsule) Status: Ordered

Start Date: 8/10/21

1 Capsules By Mouth Daily.

Last Modified: 08/10/2021 4:52 PM

verapamil (verapamil 120 mg/24 hours oral capsule, extended release) Status: Ordered

Start Date: 12/21/20

2 Capsules By Mouth Daily.

Last Modified: 08/10/2021 4:52 PM

Problem List

Condition Confirmation Course Effective Dates Status Health Status Informant ESBL - Extended

spectrum beta-

lactamase-producing

bacteria 1, 2

Last Modified:

12/26/2020 3:32 AM

Confirmed 12/21/20 Active

Last Modified:

12/26/2020 3:32 AM

Fibromyalgia

Last Modified:

12/21/2020 4:08 PM

Confirmed Active

Last Modified:

12/21/2020 4:08 PM

1 ESBL E. coli urine 12/212/2020

2 Problem added by Discern Expert based on Positive ESBL result Procedures

Procedure Date Related Diagnosis Body Site Status

CARPAL TUNNEL

Last Modified: 08/10/2021 4:47 PM

2018 Completed

TOTAL HYSTERECTOMY

Last Modified: 08/10/2021 4:47 PM

2018 Completed

COLONOSCOPY

Last Modified: 08/10/2021 4:49 PM

2013 Completed

GALLBLADDER REMOVAL

Last Modified: 08/10/2021 4:49 PM

2012 Completed

C SECTION

Last Modified: 08/10/2021 4:48 PM

1988 Completed

Results

Radiology Reports

Exam Date Time Procedure Performing Provider Status 2/27/24 4:48 PM XR Foot Complete Left Mynatt RT(R)(CT), Brianna;

Auth (Verified)

Notes:

(XR Foot Complete Left) Reason For Exam: Pain - injury VHM RADIOLOGY

XR FOOT

HISTORY: Pain - injury

COMPARISON: None.

TECHNIQUE: Left foot, 3 views.

FINDINGS:

The alignment of the foot is anatomic. No fractures are appreciated. Small plantar calcaneal spur is noted. The joint spaces are relatively maintained. The soft tissues are unremarkable. No other significant findings are seen. IMPRESSION:

1. No radiographic evidence of acute traumatic injury. 2. Small plantar calcaneal spur.

Electronically signed by: Maureen McCormack MD 02/27/2024 05:13 PM PST Workstation: DRHMERS31584

Final

Dictated by: Mccormack, Maureen MD Dictated DT/TM: 02/27/2024 5:15 pm Transcribed By: MMTranscribed by: MM Transcribed DT/TM: 02/27/24 17:13:44 Electronically Signed by: Mccormack, Maureen MD Signed DT/TM: 02/27/2024 5:13 pm Last Modified: 02/27/2024 4:17 PM

Exam Date Time Procedure Performing Provider Status 2/27/24 4:48 PM XR Ankle Complete Left Mynatt RT(R)(CT), Brianna;

Auth (Verified)

Notes:

(XR Ankle Complete Left) Reason For Exam: Pain - injury VHM RADIOLOGY

XR UNILATERAL ANKLE

HISTORY: Pain - injury

COMPARISON: None.

TECHNIQUE: Left ankle, 3 views.

FINDINGS:

There is no evidence of fracture. There is no evidence of dislocation or subluxation. The ankle mortise is maintained. Bone mineralization is normal. Mild degenerative changes. Plantar calcaneal enthesophyte. There are no osseous lesions. There are no soft tissue abnormalities.

IMPRESSION:

Negative acute osseous abnormality. If there is persistent pain after 7-10 days consider follow-up radiographs to rule out occult fracture. Electronically signed by: Marko Marbella MD 02/27/2024 05:17 PM PST Workstation: DRHMERS31601

Final

Dictated by: Marbella, Marko E MD Dictated DT/TM: 02/27/2024 5:19 pm Transcribed By: MEMTranscribed by: MEM Transcribed DT/TM: 02/27/24 17:17:44 Electronically Signed by: Marbella, Marko E MD Signed DT/TM: 02/27/2024 5:17 pm Last Modified: 02/27/2024 4:17 PM

Vital Signs

2/27/24

Temperature (Route Not

Specified)

Last Modified:

02/27/2024 4:13 PM

37.1 DegC (Normal is 36.5-37.3 DegC)

Peripheral Pulse Rate

Last Modified:

02/27/2024 5:16 PM

80 bpm (Normal is 60-100 bpm)

Respiratory Rate

Last Modified:

02/27/2024 5:16 PM

18 br/min (Normal is 12-20 br/min)

Blood Pressure 129/78 mmHg

Last Modified:

02/27/2024 5:16 PM

Last Modified:

02/27/2024 5:16 PM

(Normal is 90-135/60-80 mmHg)

Height

Last Modified:

02/27/2024 4:11 PM

160.02 cm

Weight

Last Modified:

02/27/2024 4:11 PM

72.57 kg

Social History

Social History Type Response

Tobacco Denies

Author: Lubrin, Bridget

Last Modified: 12/21/2020 4:09 PM

Smoking Status Never smoker

Birth Sex Female

Goals

No data available for this section

Hospital Discharge Instructions

Section Author:

Patient Education

02/27/2024 17:18:20

ANKLE SPRAIN (Adult)

Ankle Sprain (Adult)

An ankle sprain is a stretching or tearing of the ligaments that hold the ankle joint together. There are no broken bones. An ankle sprain is a common injury for both children and adults. It happens when the ankle turns, twists, or rolls in an awkward way. This can be caused by a sports injury. Or it can happen from doing something as simple as stepping on an uneven surface. Ligaments are made of tough connective tissue. Normally, ligaments stretch a certain amount and then go back to their normal place. A sprain happens when a ligament is forced to stretch more than the normal amount. A severe sprain can actually tear the ligaments. If you have a severe sprain, you may have felt or heard something like a pop when you were injured. Ankle sprains are given a grade depending on whether they are mild, moderate, or severe:

•Grade 1 sprain. A mild sprain with minor stretching and damage to the ligament.

•Grade 2 sprain. A moderate sprain where the ligament is partly torn.

•Grade 3 sprain. The most severe kind of sprain. The ligament is completely torn. Most sprains take about 4 to 6 weeks to heal. A severe sprain can take several months to recover. Your healthcare provider may order X-rays to be sure you don’t have a fracture, or broken bone. The injured area will feel sore. Swelling and pain may make it hard to walk. You may need crutches if walking is painful. Or your provider may have you use a cast boot or air splint. This will depend on the grade of ankle sprain that you have. Home care

•For a Grade 1 sprain, use RICE (rest, ice, compression, and elevation):

•Rest your ankle. Don’t walk on it.

•Ice should be used right away to help control swelling. Place an ice pack over the injured area for 20 minutes. Do this every 3 to 6 hours for the first 24 to 48 hours. Keep using ice packs to ease pain and swelling as needed. To make an ice pack, put ice cubes in a plastic bag that seals at the top. Wrap the bag in a clean, thin towel or cloth. Never put ice or an ice pack directly on the skin. The ice pack can be put right on the cast, bandage, or splint. As the ice melts, be careful that the cast, bandage, or splint doesn’t get wet. If you have a boot, open it to apply an ice pack, unless told otherwise by your provider.

•Compression devices help to control swelling. They also keep the ankle from moving and support your injured ankle. These devices include dressings, elastic bandages, and wraps.

•Elevate or raise your ankle above the level of your heart when sitting or lying down. This is very important for the first 48 hours.

•Follow the RICE guidelines for a Grade 2 sprain. This type of sprain will take longer to heal. Your provider may have you wear a splint, cast, or brace to keep your ankle from moving.

• If you have a Grade 3 sprain, you are at risk for long-term ankle instability. In rare cases, surgery may be needed. Your provider may have you wear a short leg cast or a walking boot for 2 to 3 weeks.

•After 48 hours, it may be helpful to apply heat for 20 minutes several times a day. You can do this with a heating pad or warm compress. Or you may want to go back and forth between using ice and heat. Never apply heat directly to the skin. Always wrap the heating pad or warm compress in a clean, thin towel or cloth.

•You may use over-the-counter pain medicine (NSAIDS or nonsteroidal anti-inflammatory drugs) to control pain, unless another pain medicine was prescribed. Talk with your provider before using these medicines if you have chronic liver or kidney disease, stomach ulcer or gastrointestinal bleeding, or if you take a blood thinner.

•Follow any rehabilitation exercises your provider gives you. These can help you be more flexible and improve your balance and coordination. This is helpful in preventing long-term ankle problems. Prevention

To help prevent ankle sprains, it’s important to have good strength, balance, and flexibility. Be sure to:

•Always warm up before you exercise or do something very active

•Be careful when walking or running on uneven or cracked surfaces

•Wear shoes that are in good condition and fit well

•Listen to your body’s signals to slow down when you are in pain or tired Follow-up care

Any X-rays you had today don’t show any broken bones, breaks, or fractures. Sometimes fractures don’t show up on the first X-ray. Bruises and sprains can sometimes hurt as much as a fracture. These injuries can take time to heal completely. If your symptoms don’t get better or they get worse, talk with your healthcare provider. You may need a repeat X-ray. Follow up with your healthcare provider, or as advised. Check for any warning signs listed below. When to get medical advice

Call your healthcare provider right away if any of these occur:

•Fever of 100.4 F (38 C) or higher, or as directed by your provider

•Chills

•The injury doesn’t seem to be healing

•The swelling comes back

•The cast or splint has a bad smell

•The plaster cast or splint gets wet or soft

•The fiberglass cast or splint gets wet and doesn't dry for 24 hours

•Pain or swelling gets worse, or redness appears

•Your toes become cold, blue, numb, or tingly

•The skin is discolored (looks blue, purple, or gray), has blisters, or is irritated

•You re-injure your ankle

© 2000-2023 The StayWell Company, LLC. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions. Reason for Referral

No data available for this section

Health Concerns

No data available for this section

Implantable Device List

Procedure Provider

Procedure

Date

Device Type Site

Fusion Spine Cervical Anterior

& Discect

Unknown 8/13/21 Unknown Neck

Device Identifier

Serial

Number

Lot or Batch

Number

Manufacturing

Date

Expiration

Date

Distinct

Identification

Code

MRI Safety

Implantable

Status

Assigning

Authority

Unknown NA 4805-3 Unknown 6/28/31 Unknown Unknown Active Unknown Unknown NA NA Unknown Unknown Unknown Unknown Active Unknown Unknown NA NA Unknown Unknown Unknown Unknown Active Unknown Unknown NA NA Unknown Unknown Unknown Unknown Active Unknown Procedure Provider

Procedure

Date

Device Type Site

Unknown Unknown 8/13/21 Unknown Neck

Device Identifier

Serial

Number

Lot or Batch

Number

Manufacturing

Date

Expiration

Date

Distinct

Identification

Code

MRI Safety

Implantable

Status

Assigning

Authority

Unknown NA B180602-713 Unknown 2/4/24 NA Unknown Active Unknown Clinical Note

No data available for this section

Patient Care team information

Care Team Personnel

Name: Lorenzana, Gerardo G MD

Member Role: Primary Care Physician

Address:

Address: 2825 SIENA HEIGHTS DR

HENDERSON, NV 89052-0000 US

Care Team Related Persons

Name: BORUNDA, CHRIS

Address: Home

UNKNOWN

LAS VEGAS, NV 89149 US

Name: OLIVO, PERCILLA

Address: Home

UNKNOWN

LAS VEGAS, NV 89084 US

Name: ROJAS, JESSIE

Address: Home

UNKNOWN

LAS VEGAS, NV 89149 US

Contact this candidate