QUINONES, MARK Admin Sex: Male DOB: **/*/****

Continuity of Care Document

Summarization of Episode Note 01/11/2023 to 01/11/2023 Source: BMG NEU MLK

Created: 01/18/2023

Demographics

Contact Information:

16101 WASHBURN PL, TAMPA, FL 336471136, USA

16101 WASHBURN PL, TAMPA, FL 336471136, USA

Tel: advty1@r.postjobfree.com (Work)

Tel: 813-***-**** (Primary Home)

Tel: 813-***-**** (Mobile)

Email: advty1@r.postjobfree.com

Previous Address(es):

--

Marital Status: Legally Married

Religion: Christian

Race: White

Previous Name(s): --

Ethnic Group: Hispanic or Latino

Language: English

SSN: 5559

ID: URN:CERNER:IDENTITY-FEDERATION:REALM:A01CC5E9-1755-468C-B41C-495A18DEC39F- CH:PRINCIPAL:843NT4WW5HT4HB7G, 100126635, 209989, 1776648, 210-***-**** Care Team

Type Name

Represented

Organization

Address Phone

primary care

physician

Jain,

Sanjay K

-- (Work): 17512 Dona Michelle DrSte 5, Tampa, FL

33647-3265, USA

Tel: (813)586-

7600 (Work)

Relationships

No Data to Display

Document Details

Source Contact Info

2727 W DR MLK JR Blvd, Suite 700, Tampa, FL 33607-, USA Tel: 813-***-****

Author Contact Info

01/18/2023 4:31 PM

BMG NEU MLK

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: 2.16.840.1.113883.3.1106.5000.136.999362 : 90007061 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: 01/11/2023

Discharge Date: 01/11/2023

Visit ID: --

Location Information

BMG NEU MLK

(Work): 2727 W DR MLK JR Blvd, Suite 700, Tampa, FL 33607-, USA Providers

Type Name Address Phone

Admitting Eliazer,

Raj M

(Work): 2727 W Dr Martin Luther King Jr BlvdSte 700, Tampa, FL 33607-6383, USA

Tel: (813)321-

1429 (Work)

Attending Eliazer,

Raj M

(Work): 2727 W Dr Martin Luther King Jr BlvdSte 700, Tampa, FL 33607-6383, USA

Tel: (813)321-

1429 (Work)

Referring Jain,

Sanjay K

(Work): 17512 Dona Michelle DrSte 5, Tampa, FL 33647-3265, USA Tel: (813)586- 7600 (Work)

Encounter

BayCare FIN 106********* Date(s): 1/11/23 - 1/11/23 BMG NEU MLK 2727 W DR MLK JR Blvd, Suite 700 Tampa, FL 33607- US 813-***-**** Encounter Diagnosis

Complex partial seizures evolving to generalized tonic-clonic seizures (Discharge Diagnosis) - 1/11/23 Attending Physician: Eliazer, Raj M MD

Admitting Physician: Eliazer, Raj M MD

Referring Physician: Jain, Sanjay K MD

Author: BMG NEU MLK

Last Modified: 01/12/2023 6:12 AM

Reason for Visit

NP EVAL FOR SLURRED SPEECH AND TRIMMERS OK PER DR.ELIAZER Allergies, Adverse Reactions, Alerts

No Known Allergies

Author: Denmark, Tasheria K, BMG FAM New TPA

Last Modified: 07/16/2021 6:05 PM

Assessment and Plan

Extracted from:

Title: EEG report Author: Eliazer, Raj M MD Date: 1/12/23 EEG report date of service 1/11/2022 at the office Patient name-Quinones, Mark

History-Patient is a 62-year-old male with an episode of speech arrest as well as right arm sensory symptoms and what seems to be clonic activity.

This is EEG is recorded utilizing 10–20 international Electrode placement with 18 channels. Report-

This is an awake, drowsy EEG. The waking background was composed of a sustained 9-9.5 Hz posterior dominant waveforms of moderate amplitude which attenuates symmetrically with eye opening. During drowsiness the waking activity becomes intermittent and is attenuated. Stage I sleep and deeper intensity nor stage II sleep is seen. There is rare to occasional polymorphic delta slowing over the left central parietal region with spike and slow-wave discharges. Activation procedures with photic stimulation did not produce additional abnormalities. Hyperventilation produced mild generalized slowing as a normal response. Impression-

This is an abnormal awake and drowsy EEG due to the presence of polymorphic slowing as well as spike and slow wave discharges over the left central parietal region phase reversing over C3 and P3 electrodes. This is potentially epileptogenic in nature. We are requesting a prolonged 72 hour ambulatory EEG to characterize these findings in a more thoroughly

Eliazer,

Raj M

BMG

NEU

MLK

01/12/2023 3:31 PM

Extracted from:

Title: Tremor * Author: Eliazer, Raj M MD Date: 1/11/23 Impression and Plan

Diagnosis

Complex partial seizures evolving to generalized tonic-clonic seizures (ICD10-CM G40.209, Discharge, Medical).

Plan: Request MRI the brain with and without contrast, EEG. Ativan when necessary. If EEG is negative we will proceed with a 72 hr ambulatory EEG. We will see the patient back in 2 months for follow-up, sooner if needed.

Orders

PowerOrders

Ambulatory E&M:

Office Consult, 99244 (Order): 01/11/2023 12:34 EST, Complex partial seizures evolving to generalized tonic-clonic seizures.

Eliazer,

Raj M

BMG

NEU

MLK

01/11/2023 5:34 PM

Future Appointments

Appointment Date: 01/27/2023 08:20:00 AM

Scheduled Provider: Jain, Sanjay K MD

Location: BMG FAM New TPA

Appointment Type: ESTABLISHED PATIENT ERS

Appointment Date: 03/27/2023 10:40:00 AM

Scheduled Provider: Eliazer, Raj M MD

Location: BMG NEU MLK

Appointment Type: ESTABLISHED PATIENT ERS

Immunizations

No data available for this section

Medications

levETIRAcetam (Keppra 1000 mg oral tablet)

Status: Ordered

Start Date: 1/12/23

1 tablet(s) By Mouth Twice a day. Refills: 1.

Ordering provider: Eliazer, Raj M MD

CVS/pharmacy #6007

6206 Commerce Palms Dr

Tampa, FL 336471506

Eliazer,

Raj M

BMG NEU

MLK

01/12/2023 3:22 PM

lisinopril (lisinopril 10 mg oral tablet)

Status: Ordered

Start Date: 12/3/20

TAKE ONE TABLET BY MOUTH ONE TIME DAILY.

Santos,

Jeanette

BUC NEW

TAMPA

12/3/2020 11:43 PM

cyclobenzaprine (cyclobenzaprine 10 mg oral tablet) Status: Completed

Start Date: 7/16/21

Stop Date: 8/18/21

1 tablet(s) By Mouth Twice a day as needed for pain/spasm. Refills: 0.

Ordering provider: Jain, Sanjay K MD

CVS/pharmacy #6007

6206 Commerce Palms Dr

Tampa, FL 336471506

Jain,

Sanjay K

BMG FAM

New TPA

08/18/2021 2:24 PM

cyclobenzaprine (Flexeril 10 mg oral tablet)

Status: Completed

Start Date: 8/18/21

Stop Date: 10/1/21

1 tablet(s) By Mouth Twice a day as needed. PAIN/SPASM.. Refills: 0.

Ordering provider: Jain, Sanjay K MD

CVS/pharmacy #6007

6206 Commerce Palms Dr

Tampa, FL 336471506

Jain,

Sanjay K

BMG FAM

New TPA

10/1/2021 2:03 PM

LORazepam (Ativan 2 mg oral tablet)

Status: Completed

Start Date: 1/11/23

Stop Date: 1/12/23

1 tablet(s) By Mouth every 4 hours as needed Seizure activity. Refills: 0.

Ordering provider: Eliazer, Raj M MD

CVS/pharmacy #6007

6206 Commerce Palms Dr

Tampa, FL 336471506

BMG NEU

MLK

01/12/2023 5:41 PM

methylPREDNISolone (MethylPREDNISolone Dose Pack 4 mg oral tablet)

Status: Completed

Start Date: 7/16/21

Stop Date: 7/22/21

1 packet(s) By Mouth as directed for 6 Day(s). as directed on package labeling. Refills: 0.

Ordering provider: Jain, Sanjay K MD

CVS/pharmacy #6007

6206 Commerce Palms Dr

Tampa, FL 336471506

BMG FAM

New TPA

07/22/2021 7:11 PM

cyclobenzaprine (Flexeril 10 mg oral tablet)

Status: Discontinued

Start Date: 10/1/21

Stop Date: 1/11/23

1 tablet(s) By Mouth Twice a day as needed. PAIN/SPASM.. Refills: 0.

Ordering provider: Eliazer, Raj M MD

CVS/pharmacy #6007

6206 Commerce Palms Dr

Tampa, FL 336471506

Eliazer,

Raj M

BMG FAM

New TPA

01/11/2023 5:43 PM

LORazepam (lorazePAM 1 mg oral tablet)

Status: Discontinued

Start Date: 7/16/21

Stop Date: 1/11/23

1 tablet(s) By Mouth once a day as needed Anxiety. Use 1 hour before MRI. Refills: 0.

Ordering provider: Eliazer, Raj M MD

CVS/pharmacy #6007

6206 Commerce Palms Dr

Tampa, FL 336471506

Eliazer,

Raj M

BMG FAM

New TPA

01/11/2023 5:43 PM

Problem List

Condition Confirmation Course

Effective

Dates

Status

Health

Status

Informant Author Last Modified

Cholelithiasis Confirmed Active Jain,

Sanjay K

BAYCARE

HEALTH

SYSTEM

07/22/2021 1:20 PM

BMI 37.0-37.9, adult Confirmed Active Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

CKD (chronic kidney disease) stage 3,

GFR 30-59 ml/min

Confirmed Active Jain,

Sanjay K

BAYCARE

HEALTH

SYSTEM

07/30/2021 1:02 PM

Lumbar degenerative disc disease Confirmed Active Jain, Sanjay K

BAYCARE

HEALTH

SYSTEM

07/22/2021 1:20 PM

Diverticulosis Confirmed Active Jain,

Sanjay K

BAYCARE

HEALTH

SYSTEM

07/22/2021 1:20 PM

History of renal cell cancer Confirmed Active Jain, Sanjay K

BAYCARE

HEALTH

SYSTEM

07/30/2021 1:01 PM

Obese Confirmed Active BAYCARE

HEALTH

SYSTEM

07/16/2021 6:06 PM

Condition Confirmation Course

Effective

Dates

Status

Health

Status

Informant Author Last Modified

Procedures

No data available for this section

Results

No data available for this section

Vital Signs

1/11/23

Pulse Rate 71 bpm (Normal is 60-110 bpm) Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Mean Arterial

Pressure, Cuff

94 mmHg Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Blood Pressure 124/79 mmHg (Normal is 90-120/60-90 mmHg) Paredes Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Weight, Actual kg 129.274 kg Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Weight, Actual lbs 285 lb Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Weight, Pounds

with Ounces

285 lb Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Weight, Ounces

with Pounds

0 oz Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Measured Weight Yes Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Height cm 185.42 cm Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

EHUM

Responses

Feet/Inches Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Height Feet with

Inches

6 ft Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Height Inches

with Feet

1 inch(es) Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Height Inches 73 inch(es) Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Body Surface

Area

2.5804 Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Body Mass Index

(BMI)

37.6 kg/m2 Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Ideal Body

Weight

Calculated

79.9 kg Paredes

Contreras,

Yocasta

BMG NEU

MLK

01/11/2023 4:47 PM

Social History

Social History Type Response Author Last Modified

Smoking Status Never a smoker

Birth Sex Male BAYCARE

HEALTH

SYSTEM

01/16/2023 2:26 PM

Goals

No data available for this section

Hospital Discharge Instructions

No data available for this section

Reason for Referral

No data available for this section

Health Concerns

No data available for this section

Implantable Device List

No data available for this section

Clinical Note

No data available for this section

Patient Care team information

Care Team Personnel

Author: BAYCARE HEALTH SYSTEM

Last Modified: 07/30/2021 12:15 PM

Name: Jain, Sanjay K MD

Position: Physician - PCP

Member Role: PCP Lifetime

Address:

Address: 17512 Dona Michelle Dr

Ste 5

Tampa, FL 33647-3265 US

Author: BAYCARE HEALTH SYSTEM

Last Modified: 07/30/2021 12:15 PM

Contact this candidate