Wiliam Sepulvado - Trivent Legal



Proton Pump Inhibitor (PPI) Case Review

|Parameter |Findings |Bates Ref |PDF Ref |

|First name |XXXX |XXXXXX Kidney & other |1 |

| | |providers_000001 | |

|Initial |C | | |

|Last name |XXXX | | |

|DOB |11/05/YYYY | | |

|Gender |M | | |

|Proton Pump Inhibitor (PPI) Use |Reason for prescription: Gastro esophageal reflux disease |Ostroms drug list - 6 |295, 296, 297, |

|Details | |pages_000001 |271-275, |

| |Start Date: Not known |Ostroms drug list - 6 |266-270, |

| |*Reviewer's comment: As per the first available record dated |pages_000001, 000002, |259-265, |

| |02/10/YYYY, current medication list include Nexium, hence we do not |000003, Lakeshore Clinic |248-253, 20-22,|

| |know the exact start date of proton pump inhibitor medication |records 2.12.10 to |18-19, 15-17, |

| | |7.06.12_000025-000029, |48-50, 52-53, |

| |Duration: |000020-000024, |54-62, 40-41, |

| |Per Pharmacy Records: 02/10/YYYY-12/20/YYYY |000013-000019, |64 |

| |Per Medical Records: 02/10/YYYY, 02/17/YYYY, 04/10/YYYY, 07/06/YYYY, |000002-000007, XXXXXX | |

| |06/09/YYYY, 09/29/YYYY4, 10/29/YYYY, 12/04/YYYY, 12/05/YYYY, |Kidney & other | |

| |12/16/YYYY, 12/23/YYYY, 10/28/XXXXXX, 06/16/YYYY |providers_000020-000022, | |

| | |000018-000019, | |

| |Stop Date: Not known (Per last available record dated 06/16/YYYY, |000015-000017, | |

| |patient was on Prevacid 15 mg) |000040-000041, Everett | |

| | |Clinic Records 12.04.14 to | |

| |Dosage: |5.09.16 _000002-000004, | |

| |Nexium: 40 mg (As on 02/10/YYYY) /20 mg (As on 02/17/YYYY) |000006-000007, | |

| |Prevacid: 30 mg (As on 02/10/YYYY) / 15 mg (As on 06/09/YYYY) |000008-000016, 000018 | |

| |Omeprazole 20 mg (As on 04/10/YYYY) | | |

|Did the patient have any |Nil | | |

|pre-existing conditions, | | | |

|allergies or contraindications | | | |

|for Proton Pump Inhibitor (PPI)? | | | |

|(Kidney disease or | | | |

|failure/dementia)? | | | |

|Weight, Height, BMI Details of |Height: 5’ 8” |Lakeshore Clinic records |273 |

|the patient (At the time of | |2.12.10 to 7.06.12_000027 | |

|Proton Pump Inhibitor (PPI) use) |Weight: 210 lbs | | |

| | | | |

| |Body Mass Index (BMI): 30.46 kg/m2 | | |

|What was the injury due to Proton|Date of Diagnosis: 04/10/YYYY |Lakeshore Clinic records |254-258, |

|Pump Inhibitor (PPI) (Kidney | |2.12.10 to |248-253, 20-22,|

|disease or failure/dementia)? |Hospitalization for the adverse event: Yes |7.06.12_000008-000012, |23, 18-19, |

| | |000002-000007, XXXXXX |15-17, 48-50, |

| |Length of Hospital Stay: |Kidney & other |52-53, 54-62, |

| | |providers_000020-000022, |72-73, 38-39, |

| |Lab values: As on 12/05/YYYY (Original lab report not available) |000023, 000018-000019, |82-83, 93-94, |

| | |000015-000017, |104-105, |

| |Test Name |000038-000039, |115-116, 40-41,|

| |Result |000040-000041, 000046, |46, 44, 237-246|

| |Reference range/Units |000044, Everett Clinic | |

| | |Records 12.04.14 to 5.09.16| |

| |Sodium |_000002-000004, | |

| |135 |000006-000007, | |

| |135-145 mmol/L |000008-000016, | |

| | |000026-000027, | |

| |Co2 |000036-000037, | |

| |17 |000047-000048, | |

| |21-32 |000058-000059, | |

| | |000069-000070, | |

| |Potassium |000191-000200 | |

| |4.6 | | |

| |3.5-6.3 mmol/L | | |

| | | | |

| |Hemoglobin | | |

| |8.7 | | |

| |13.7-16.7 g/dl | | |

| | | | |

| |Chloride | | |

| |3.5 | | |

| |98-109 mmol/L | | |

| | | | |

| | | | |

| |Treatment/management. Any complications? Yes | | |

| | | | |

| |05/07/YYYY: Renal insufficiency: Patient has long history of renal | | |

| |insufficiency (Prior two years’ records from YYYY-YYYY are not | | |

| |available for review), frequent urinary tract infection related to | | |

| |prior bladder cancer, surgical changes. | | |

| |07/06/YYYY: Edema, discontinuation of diuretic back in YYYY by either | | |

| |his Nephrologist or Urologist. Hydrochlorothiazide 12.5 mg. Followup | | |

| |with his Nephrologist. He has close followup with his Nephrologist. | | |

| |06/09/YYYY: Other fluid overload, chronic kidney disease stage 4, | | |

| |severe, benign essential hypertension | | |

| |06/10/YYYY-05/16/YYYY: Assessed with end stage renal disease, disorders| | |

| |of phosphorus metabolism, urinary tract infection, pyelonephritis, | | |

| |acidosis, graft infiltration and anemia. He is on hemodialysis and | | |

| |taking Prevacid 15 mg | | |

|Other side effects of PPI |Disorders of phosphorus metabolism, Acidosis, Anemia (As on 09/29/YYYY)|XXXXXX Kidney & other |18-19 |

| | |providers_000018-000019 | |

|(Low Magnesium level, | | | |

|Osteoporosis, Hematologic | | | |

|laboratory abnormalities, Birth | | | |

|Defects, Cardiac effects, Birth | | | |

|Defects, etc) | | | |

|Other Medication Induced Kidney |Nil | | |

|disease or failure/dementia | | | |

|Any other medical conditions |He has end stage renal disease due to diabetes mellitus and obstructive|Everett Clinic Records |237-246 |

|leading to Kidney disease or |uropathy in the setting of prior bladder cancer |12.04.14 to 5.09.16 | |

|failure/dementia | |_000191-000200 | |

|Prior Medical History |Past medical history: Bladder cancer, gastroesophageal reflux disorder,|Lakeshore Clinic records |272, 267 |

| |acute onset diabetes mellitus, hypertension, coronary artery disease, |2.12.10 to 7.06.12_000026, | |

| |fatty liver disease, melanoma |000021 | |

| | | | |

| |Past surgical history: Urinary revision with bladder removal, urostomy | | |

| | | | |

| |Social history: Quit smoking in 1990, one pack per daily, alcohol use | | |

| |less than one (liquor) | | |

| | | | |

| |Family history: Family history of diabetes and hypertension. Mother had| | |

| |diabetes mellitus. | | |

| | | | |

| |Allergies: No known drug allergies | | |

|Smoker |Has he/she ever been a tobacco user? Yes |Lakeshore Clinic records |272, 20 |

| | |2.12.10 to 7.06.12_000026, | |

| | |XXXXXX Kidney & other | |

| | |providers_000020 | |

| |Period of time smoking: 20 years | | |

| |Heaviness of smoking: One pack per daily | | |

| |Brand of cigarettes smoked: Not known | | |

| |Has he/she quit smoking? Yes | | |

| |When did he/she quit: 1990 | | |

|Current Condition of the patient |As per available record dated 05/16/YYYY, End stage renal disease from |Everett Clinic Records |237-246 |

| |diabetes mellitus and obstruction. Doing well with dialysis but with |12.04.14 to 5.09.16 | |

| |catheter now after old fistula failed. Current new fistula. Advancing |_000191-000200 | |

| |gradually | | |

| | | | |

| |*Reviewer’s Comments: No further medical records are available after | | |

| |05/16/YYYY to know the health status of the patient. | | |

|MD Comments |Upon reviewing the records, we find that the patient had significant | | |

| |past history including diabetes, hypertension, and fatty liver. These | | |

| |pre-existing factors also should be considered for the development of | | |

| |CKD. We do not have the relevant past medical records to verify if the| | |

| |patient was already having microalbuminuria and declining GFR in the | | |

| |past. Hence we suggest you to retrieve the missing medical records | | |

| |without which it would not be possible to ascertain liability. | | |

|Past Medical History & Risk |Cardiac problems (coronary artery disease, hypertension, cardiac stent |Lakeshore Clinic records |272 |

|Factors |placement, CABG): Coronary artery disease |2.12.10 to 7.06.12_000026 | |

| |Stroke: Not available | | |

| |Hyperlipidemia: Not available | | |

| |Others: Not available | | |

Proton Pump Inhibitor (PPI) Medication Chart

|Date |Drug Name |Dosage |Prescriber’s name |Dispensing Pharmacy |Link to Records |

|03/15/YYYY |Lansoprazole |30 mg |XXXXXX, M.D |XXXXXX |Ostroms drug list - 6 |

| | | | | |pages_000001 |

|06/24/YYYY |Lansoprazole |30 mg |XXXXXX, M.D |XXXXXX |Ostroms drug list - 6 |

| | | | | |pages_000002 |

|10/06/YYYY |Lansoprazole |30 mg |XXXXXX, M.D |XXXXXX |Ostroms drug list - 6 |

| | | | | |pages_000003 |

|12/19/YYYY |Lansoprazole |30 mg |XXXXXX, M.D |XXXXXX |Ostroms drug list - 6 |

| | | | | |pages_000003 |

|12/20/YYYY |Lansoprazole |30 mg |XXXXXX, M.D |XXXXXX |Ostroms drug list - 6 |

| | | | | |pages_000003 |

Missing Medical Record:

|What Records are |Hospital/ |Date/Time Period |Why we need the |Is Record |

|Needed |Medical Provider | |records? |Missing |

| | | | |Confirmatory or|

| | | | |Probable? |

|02/10/YYYY |XXXXXX |Office Visit For Sinusitis: |Lakeshore Clinic |271-275 |

| | | |records 2.12.10 to | |

| |XXXXXX, DO |Patient complained of Gastroesophageal reflux disorder (GERD) symptoms continue to come |7.06.12_000025-0000| |

| | |and go. He is asking about follow up on use of medications today. Nexium had been |29 | |

| | |previously partially effective, but he continues to have troubles and would like to look | | |

| | |to other alternatives. He complained of sinus pressure, ears being blocked, nasal | | |

| | |congestion, and frontal headache. | | |

| | | | | |

| | |Current medication: Nexium 40 mg | | |

| | | | | |

| | |Vitals: Height: 5’ 8”, Weight: 210 lbs, BMI: 30.46 kg/m2 | | |

| | | | | |

| | |Assessment: | | |

| | |GERD, prescribed Prevacid 30 mg | | |

| | | | | |

| | |*Reviewer's comment: Above it is mentioned that patient used Nexium, hence we do not know | | |

| | |the exact start date of proton pump inhibitor medication | | |

| | |*Reviewer’s Comments: Interim medical records from 02/10/YYYY-02/17/YYYY are not available| | |

| | |to know the status of the patient. | | |

|02/17/YYYY |XXXXXX |Office Visit For Sinusitis: |Lakeshore Clinic |266-270 |

| | | |records 2.12.10 to | |

| |XXXXXX, DO |Patient has ongoing issues with chronic GERD symptoms. Difficulties with insurance |7.06.12_000020-0000| |

| | |coverage. Had been on Nexium in the past, but her insurance coverage issues had changed to|24 | |

| | |prescription Omeprazole which was only partially helpful. Over the counter Prilosec has | | |

| | |not been very helpful at all. | | |

| | | | | |

| | |Current medications: Prevacid 30 mg | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |Patient had chronic GERD. Relates that his insurance is no longer covering previously | | |

| | |effective Prevacid. Omeprazole/Prilosec was of only minimal benefit for him. He recalls | | |

| | |distant use of Nexium in the past. | | |

| | |Prescribed Nexium 20 mg | | |

|04/10/YYYY |XXXXXX |Office Visit For Sinusitis: |Lakeshore Clinic |259-265 |

| | | |records 2.12.10 to | |

| |XXXXXX, DO |GERD follow up problems and concerns. Insurance will not cover prescription and he has |7.06.12_000013-0000| |

| | |tried all the over the counter medications with no relief. Nexium cost $700, insurance |19 | |

| | |will not cover it. He also complained of headache symptoms related to chronic sinusitis. | | |

| | |He complained of musculoskeletal symptoms. He notes no problems with any antihypertensive | | |

| | |medication side effects. | | |

| | | | | |

| | |Current medications: Prevacid 30 mg, Nexium 20 mg | | |

| | | | | |

| | |Positive history for target organ damage include ASHD (either angina, prior myocardial | | |

| | |infarction, prior CABG) and renal insufficiency | | |

| | | | | |

| | |Physical exam: Head: Some minor discomfort with palpation over the maxillary sinuses. | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |GERD, patient seems fairly confused about his medication history. Describe utilizing a | | |

| | |questionable over the counter product that was partially helpful. He describes fairly good| | |

| | |control on Nexium in the past. Apparently his insurance does not cover any PPI | | |

| | |medications. He relates that Prevacid was not very effective at all. Omeprazole was | | |

| | |partially effective for him. | | |

| | |Combination of daily Omeprazole and Carafate will give him some better control. If | | |

| | |symptoms persist, despite continuous PPI and mucosal barrier medication, would consider | | |

| | |referral back for gastroenterology follow up and recheck. | | |

| | |Prescribed Omeprazole 20 mg. | | |

|05/07/YYYY |XXXXXX |Office Visit For Ringing In Ears: |Lakeshore Clinic |254-258 |

| | | |records 2.12.10 to | |

| |XXXXXX, DO |Patient had GERD, cost concerns. Labs requested from his Nephrologist, Dr. XXXXXX. He |7.06.12_000008-0000| |

| | |would like to have those done at this office, but has questions about process, |12 | |

| | |phlebotomist. | | |

| | | | | |

| | |Physical exam: Head: Some minor discomfort with palpation over the maxillary sinuses | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |Renal insufficiency: Patient has long history of renal insufficiency, frequent urinary | | |

| | |tract infection related to prior bladder cancer, surgical changes. | | |

| | |GERD, difficulties with medication coverage for GERD problems. Protonix has been helpful, | | |

| | |but no coverage under his present formulary plan. Discussed insurance coverage issues and | | |

| | |ongoing proper medical care. | | |

|07/06/YYYY |XXXXXX |Office Visit For Dizziness: |Lakeshore Clinic |248-253 |

| | | |records 2.12.10 to | |

| |XXXXXX, DO |Patient complained of dizziness for 4-5 days. Sudden balance problems. He states yesterday|7.06.12_000002-0000| |

| | |he was vomiting due to the dizziness, yesterday was the worst day. He vomits multiple |07 | |

| | |times yesterday; he was unable to lay down at all. Every time he lay down he had trouble | | |

| | |sitting back up due to the dizziness. Sitting up is better, If he looks up he feels like | | |

| | |he might pass out, dizziness gets worse. Wife wonders if it is a pinched nerve, has had | | |

| | |similar symptoms in the past. | | |

| | | | | |

| | |He had previously been on diuretic for blood pressure, edema. Diuretic was discontinued by| | |

| | |his Nephrologist. They want to discuss cost issues regarding treatment for GERD. | | |

| | | | | |

| | |Physical exam: Extremities: 1+ edema of the bilateral ankles. Neurologic: Vertigo symptoms| | |

| | |are reproduced with sudden head movement, Hallpike maneuver. | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |Vertigo, most consistent with a viral labyrinthitis. As this time with nausea, he is | | |

| | |interested in pursuing symptomatic treatment. Prescribed Meclizine Hcl 25 mg | | |

| | |Edema, discontinuation of diuretic back in YYYY by either his Nephrologist or Urologist. | | |

| | |He relates that edema is uncomfortable and he is not willing to consider compression | | |

| | |stockings at this time. Posterior trial intermittent use of low-dose diuretic for | | |

| | |symptomatic control. Hydrochlorothiazide 12.5 mg. Followup with his Nephrologist. He has | | |

| | |close followup with his Nephrologist. | | |

| | |GERD, having no difficulties with present Prevacid medication. Discussed issues with | | |

| | |costs, formulary insurance coverage problems recently. Prescribed Prevacid 30 mg. | | |

| | |*Reviewer’s Comments: Interim medical records from 07/06/YYYY-05/07/YYYY are not available| | |

| | |to know the status of the patient. | | |

|05/07/YYYY |XXXXXX Kidney |Lab Report: |XXXXXX Kidney & |6-10 |

| |Specialists | |other | |

| | |GFR: 16 (Low), Sodium: 139, Potassium: 6.5, AGAP: 19 (High), BUN: 64 (High), Creatinine: |providers_000006-00| |

| | |3.9 (High), WBC: 11.5 (High), RBC: 3.56 (Low), Hemoglobin: 11.0 (Low), Hematocrit: 33.9 |0010 | |

| | |(Low), Glucose: 92, Calcium 9.1, Chloride 105 | | |

|06/09/YYYY |XXXXXX Kidney |Office Visit For Chronic Kidney Disease And Hypertension: |XXXXXX Kidney & |20-22 |

| |Specialists | |other | |

| | |Patient complained of chronic kidney disease stage 4, hypertension, recurrent urinary |providers_000020-00| |

| |XXXXXX XXXXXX, M.D |tract infection, obstructive uropathy. |0022 | |

| | | | | |

| | |He has been having issues with increased edema and shortness of breath since his last | | |

| | |hospitalization. I thought the edema may be due to his increase in Hydralazine so I had | | |

| | |asked him to decrease his dose from 75 mg to 50 mg (previous dose). I had asked him to | | |

| | |take 1 of the 50 mg tablets that I thought he had. The wife did not have the pills with | | |

| | |her and reduced his dose to 1 of the 25 mg tablets that he had. | | |

| | | | | |

| | |I have increased his oral Torsemide on 2 occasions, most recently to 60 mg on Friday for 4| | |

| | |days then down to 40 mg after that. He was seen earlier in the week by his PCP Dr. XXXXXX | | |

| | |and was felt to have fluid over load by exam and chest x-ray (Report not available). This | | |

| | |would be an increase from his prior dose of 20 mg. He was given a new prescription of | | |

| | |Lasix 20 mg. Have encouraging him to start dialysis but he has been resistant. | | |

| | | | | |

| | |Current medication: Prevacid 15 mg | | |

| | | | | |

| | |Physical exam: General: Mild respiratory distress. Extremities: 3+ edema | | |

| | | | | |

| | |Labs reviewed: | | |

| | |05/28/YYYY: Urine culture: Enterococcus. Sensitive to Cefazolin | | |

| | |05/23/YYYY: Sodium 133, Potassium: 4.2, Co2: 20, Chloride: 4.0, Hemoglobin: 9.0, Platelet:| | |

| | |101 | | |

| | |05/21/YYYY: Sodium 138, Potassium: 5.1, Co2: 20, Chloride: 4.4, Hemoglobin: 8.0, Platelet:| | |

| | |67 | | |

| | |05/20/YYYY: Sodium 136, Potassium: 6.7, Co2: 20, Chloride: 3.9, Hemoglobin: 9.8, Platelet:| | |

| | |97 | | |

| | |05/07/YYYY: Sodium 139, Potassium: 6.5, Co2: 19, Chloride: 3.9, Hemoglobin: 11.0 | | |

| | |04/23/YYYY: Cloudy Yellow, small blood, positive nitrite, leukocyte trace, loads of | | |

| | |bacteria, many WBC, few normal RBC. Urine culture: Multiple organisms. | | |

| | |04/16/YYYY: Sodium 138, Potassium: 5.0, Co2: 21, Chloride: 4.5 | | |

| | |02/26/YYYY: Sodium 137, Potassium: 4.8, Co2: 17, Chloride: 4.1 | | |

| | |01/16/YYYY: Sodium 140, Potassium: 4.7, Co2: 21, Chloride: 3.6 | | |

| | |01/13/YYYY: Sodium 138, Potassium: 7.2, Co2: 17, Chloride: 4.1, Hemoglobin: 11.3 | | |

| | |12/05/YYYY: Sodium 135, Potassium: 4.6, Co2: 20, Chloride: 3.5, Hemoglobin: 8.7 | | |

| | |10/14/YYYY: Urinary Protein to Creatinine Ratio (UPCR): 4.7 | | |

| | |*Reviewer’s Comments: Original lab reports are not available for review. | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |Other fluid overload, we do not have a pulse oximetry to check his oxygen saturation. | | |

| | |Admitted and started on dialysis | | |

| | |Chronic kidney disease stage 4, severe, he has a functioning left fore arm fistula. Dr. | | |

| | |XXXXXX had wanted to access his fistula prior to starting hemodialysis. | | |

| | |Benign essential hypertension, stable control though slightly suboptimal. He has not | | |

| | |tolerated increases in doses of his blood pressure medication. Start hemodialysis and | | |

| | |fluid removal. Emergency room called and informed. Will let Dr. XXXX know he is likely | | |

| | |being admitted and will start dialysis | | |

|06/10/YYYY |XXXXXX Vascular |Office Visit For Removal Of Hemodialysis Catheter: |XXXXXX Kidney & |23 |

| | | |other | |

| |XXXXXX, M.D |Patient here for removal of his tunneled hemodialysis catheter. He reports dialyzing via |providers_000023 | |

| | |the left wrist AVF without issue. | | |

| | | | | |

| | |Physical exam: Tunneled catheter in place right side | | |

| | | | | |

| | |Assessment/Plan: Successful removal of tunneled IJ hemodialysis catheter. Was given post | | |

| | |catheter removal instructions. | | |

|07/10/YYYY |Unknown Provider |Lab Report: |XXXXXX Kidney & |11-14 |

| | | |other | |

| | |Sodium: 140, Potassium: 4.3, Chloride: 101, CO2: 27, AGAP: 17 (High), Glucose: 107, BUN: |providers_000011-00| |

| | |37 (High), Creatinine: 5.5 (High), POC Hemoglobin: 10.2 (Low), POC Hematocrit: 30 (Low) |0014 | |

|09/01/YYYY |XXXXXX Laboratories |Lab Report: |XXXXXX Kidney & |1-2 |

| | | |other | |

| | |Calcium Phosphate: 58 (High), Glucose: 163 (High), Urea: 67, Bun: 52 (High), Creatinine: |providers_000001-00| |

| | |7.1 (High), Phosphorus: 6.3 (High), Calcium phosphate: 57 (High), RBC: 2.62 (Low), |0002 | |

| | |Hemoglobin: 9.0 (Low), Hematocrit: 25.1 (Low), RDW: 16.4 (High) | | |

|09/15/YYYY |XXXXXX Laboratories |Lab Report: |XXXXXX Kidney & |3 |

| | | |other | |

| | |Hemoglobin: 9.4 (Low) |providers_000003 | |

|09/29/YYYY |XXXXXX Kidney |Follow Up Visit For End Stage Renal Disease: |XXXXXX Kidney & |18-19 |

| |Specialists | |other | |

| | |Patient continuous have some issues with access occasional infiltration. He is no longer |providers_000018-00| |

| |XXXXXX XXXXXX, M.D |has a catheter in. He is having some low blood pressure. He is getting O2 while on |0019 | |

| | |dialysis and this is helping some. He is getting around 3L US. He is taking TUMS. We | | |

| | |filled out the forms for Renvela, but neither of us has heard anything back. He is down to| | |

| | |25 mg of Atenolol on non hemodialysis days. | | |

| | | | | |

| | |Medication: Prevacid 15 mg | | |

| | | | | |

| | |Physical exam: General: Mild respiratory distress. Extremities: 3+ edema | | |

| | | | | |

| | |Lab Report: | | |

| | |08/04/YYYY: Sodium 139, Potassium: 4.0, Co2: 20, Chloride: 8.3, Calcium: 9.0, Phosphorus: | | |

| | |6.9, Calcium phosphate: 57, Hemoglobin: 9.6, Kt/V: 1.0 (Report not available) | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |Other fluid overload, improved. Low blood pressure now. Will stop Atenolol and see how his| | |

| | |blood pressure reacts. | | |

| | |Benign essential hypertension | | |

| | |End stage renal disease, adequacy is low. Will review order and consider increasing time | | |

| | |or larger dialyzer | | |

| | |Disorders of phosphorus metabolism, not taking Renvela. Will start phos-lo | | |

| | |Acidosis, mild, improved | | |

| | |Anemia in chronic kidney disease, below goal. ESA and iron per protocol. | | |

|10/08/YYYY |XXXXXX Diagnostics |Lab Report: |XXXXXX Kidney & |4-5 |

| | | |other | |

| | |Glucose: 209, Ferritin: 790, Hemoglobin: 9.8, Hematocrit: 27.9, RDW: 16.5, Platelet: 101, |providers_000004-00| |

| | |BUN: 53, Creatinine: 7.2, Sodium: 135, Bicarbonate: 21, Phosphorus: 5.7 |0005 | |

|10/29/YYYY |XXXXXX Kidney |Follow Up Visit For End Stage Renal Disease: |XXXXXX Kidney & |15-17 |

| |Specialists | |other | |

| | |Patient continuous have some issues with access occasional infiltration. He did have an |providers_000015-00| |

| |XXXXXX XXXXXX, M.D |angioplasty (Report not available) recently and his fistula is still problematic according|0017 | |

| | |to him. He does not know if he has a follow up with Dr. XXXXXX or not. His blood pressures| | |

| | |are much better off the Atenolol. He is taking TUMS. Started him on phos-Lo, but he has | | |

| | |having nausea, so he went back on the TUMS. He is being treated for another urinary tract | | |

| | |infection and Pneumonia (PNA). He is not bleeding much better, but some | | |

| | | | | |

| | |Medication: Prevacid 15 mg | | |

| | | | | |

| | |Physical exam: General: Mild respiratory distress. Lungs: Decreased breath sounds. | | |

| | |Extremities: 3+ edema | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |Other fluid overload, improved to euvolemic | | |

| | |Benign essential hypertension, at goal | | |

| | |End stage renal disease, adequacy was better and at goal last month, no available data for| | |

| | |October. November labs coming up. Will review order and consider increasing time or larger| | |

| | |dialyzer. Access issues, will have see Dr. XXXXXX soon | | |

| | |Disorders of phosphorus metabolism, improved taking TUMS as binders | | |

| | |Acidosis, mil, improved | | |

| | |Anemia in chronic kidney disease, below goal. ESA and iron per protocol. Levels improving | | |

| | |Continue to watch intake of high phosphorus foods | | |

| | |Follow up in two weeks | | |

|12/04/YYYY-12/05/Y|XXXXXX Clinic |Follow Up Visits For End Stage Renal Disease: |Everett Clinic |48-50 |

|YYY | | |Records 12.04.14 to| |

| |XXXXXX, ARNP |Patient transfer of care from Dr. XXXXXX. Currently receiving outpatient hemodialysis at |5.09.16 | |

| | |PSKC south. Left UE AVF, last fistulogram on 11/27/YYYY (Report not available). Currently |_000002-000004 | |

| | |feeling well. Reports tolerating hemodialysis well. Currently having issue with insurance | | |

| | |covering binders. | | |

| | | | | |

| | |Medication: Prevacid 15 mg | | |

| | | | | |

| | |Physical exam: Respiratory: Mild expiratory wheezing bilateral base. Extremities: | | |

| | |Ecchymosis left UE over AVF 2nd to fistulogram 11/27/YYYY. | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |End stage renal disease, transfer of care from Dr. XXXXXX. Will assume Nephrology care as | | |

| | |of now. Will follow up with him during dialysis rounding. | | |

| | |Mineral metabolism: Insurance not covering binders. He is also trying to get medication | | |

| | |covered through the VA. Will call if prescription needed. | | |

| | |Renal dialysis | | |

| | |Hypertension, stable | | |

|12/16/YYYY |XXXXXX Clinic |Office Visit For Hemodialyses: |Everett Clinic |52-53 |

| | | |Records 12.04.14 to| |

| |XXXXXX, ARNP |Patient reports having brief mild tremor to his right hand. History of having mild tremors|5.09.16 | |

| | |in past, better after taking oral magnesium supplementation. No tremor now. Overall |_000006-000007 | |

| | |feeling well. Reports his insurance will not cover binders, unable to afford out of pocket| | |

| | |expense at this time. Working on getting medication from the VA. MSW helping with assist | | |

| | |program which will start in January. For now patient is being provided with samples from | | |

| | |RD. Discussed avoiding high phosphorus foods. Currently on antibiotic for chronic | | |

| | |recurrent urinary tract infection | | |

| | | | | |

| | |Medications: Cipro 250 mg, TUMS 750 mg, Prevacid 15 mg | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |End stage renal disease, hemodialysis stable | | |

| | |Mineral metabolism, po4 elevated and improved from last month, discussed diet and binders,| | |

| | |see note above. Calcium elevated, hold TUMS for now, and repeat serum calcium next week. | | |

|12/23/YYYY |XXXXXX Clinic |Office Visit For Hemodialyses: |Everett Clinic |54-62 |

| | | |Records 12.04.14 to| |

| |XXXXXX, M.D |Patient has end stage renal disease transfer from Dr. XXXXXX due to diabetes mellitus and |5.09.16 | |

| | |obstructive uropathy in the setting of prior bladder cancer. He complained of cramping at |_000008-000016 | |

| | |the end of hemodialysis and night sweats on the evening of dialysis days. He does not take| | |

| | |blood pressure at home. | | |

| | | | | |

| | |Dialysis: | | |

| | |Dialyzer | | |

| | |Frequency | | |

| | |Treatment Duration (Min.) | | |

| | | | | |

| | |Fresenius Optiflux 200A | | |

| | |135 | | |

| | |240 | | |

| | | | | |

| | |Dialysate flow rate | | |

| | |Dialysate | | |

| | |Bicarb and or Dialysate 2 | | |

| | | | | |

| | |800 | | |

| | |Citrasate 2k, 2.5 calcium | | |

| | |35 Bicarb | | |

| | | | | |

| | |Heparin Bolus | | |

| | |Heparin maintenance | | |

| | | | | |

| | | | | |

| | |2000 | | |

| | |1000 | | |

| | | | | |

| | | | | |

| | | | | |

| | |Medication: Prevacid 15 mg | | |

| | | | | |

| | |First dialysis date: 06/10/YYYY | | |

| | | | | |

| | |Recheck platelets. TUMS as needed does not like PhosLo. Repeat CBC. He is on no blood | | |

| | |pressure medications. Outside blood pressure 140/80 | | |

|01/09/XXXXXX |XXXXXX Clinic |Office Visit For Recurrent Urinary tract Infection: |Everett Clinic |72-73 |

| | | |Records 12.04.14 to| |

| |XXXXXX, ARNP |Patient complained of recurrent urinary tract infection, was seen by Dr. XXXXXX who |5.09.16 | |

| | |started him on Cipro and changed to Augmentin 500 mg with final culture result. Advised |_000026-000027 | |

| | |him to take renal dose of Augmentin 500 mg daily will contact his PCP with dose change. He| | |

| | |reports decreased cramping with recent increased EDW. | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |End stage renal disease, hemodialysis stable. Good phosphate and PTH control. Albumin at | | |

| | |goal. | | |

| | |Urinary tract infection, Augmentin 500 mg | | |

|02/02/XXXXXX |XXXXXX, M.D |Office Visit For Recurrent Urinary Tract Infection And Pyelonephritis: |XXXXXX Kidney & |38-39 |

| | | |other | |

| | |Patient with past medical history of chronic kidney disease, on hemodialysis as well as |providers_000038-00| |

| | |type 2 diabetes mellitus, bladder cancer, status post ileal conduit and a history of |0039 | |

| | |recurrent urinary tract infection. He is here for evaluation of his recurrent urinary | | |

| | |tract infection and pyelonephritis. | | |

| | | | | |

| | |In the past he has had recurrent urinary tract infection with multiple different | | |

| | |organisms. Many of there were Klebsiella species that had different sensitivity patterns | | |

| | |and it looks like they had intermittently been resistant to TMP sulfa, Ciprofloxacin. They| | |

| | |were also intermediate to Amoxicillin and Nitrofurantoin. | | |

| | | | | |

| | |He reports that he had done quite well, and for several years did not have any urinary | | |

| | |tract infection. However in recent report he has had changes in the color of his urine | | |

| | |with Malodor from his urine and associated right flank pain. He has undergone several | | |

| | |courses of antibiotics. He reports that he is usually given antibiotics for 10 to 14 days | | |

| | |with resolution of his right flank pain, but reports that about one week after he has | | |

| | |recurrence of discolored urine, malodorous urine and right flank pain. | | |

| | | | | |

| | |It appears that some time in his treatment course he had nephrostomy tubes that my partner| | |

| | |thought could have been the etiology of his recurrent urinary tract infection. These tubes| | |

| | |were removed at some point, but cannot tell exactly when this occurred. | | |

| | | | | |

| | |Most recently he has been on Amoxicillin 500/125 mg daily, after dialysis, which has been | | |

| | |going on since February 5th. He reports associated fatigue, lack of energy, and myalgias | | |

| | |for about the last month | | |

| | | | | |

| | |Review of systems: Some nausea and shortness of breath | | |

| | | | | |

| | |Physical exam: Skin: He has a left radial fistula present that has a good thrill | | |

| | | | | |

| | |On 02/04/XXXXXX, he has a urine culture that has greater than 100, 000 Klebsiella | | |

| | |pneumoniae. | | |

| | | | | |

| | |Assessment/Plan: He is having recurrent symptomatic urinary tract infection in the setting| | |

| | |of an ileal conduit. Talked to him extensively about the need to not take antibiotics if | | |

| | |he is asymptomatic, as he can frequently have colonization of his ileal conduit. However | | |

| | |he does seem to have had symptomatic urinary tract infection recently, and his having | | |

| | |these frequently enough that if there is some physiologic reason leading to inadequate | | |

| | |drainage and recurrent urinary tract infection. Advised for CT scan (Report not available)| | |

|02/05/XXXXXX |XXXXXX Clinic |Office Visit For Nausea And Cramping: |Everett Clinic |82-83 |

| | | |Records 12.04.14 to| |

| |XXXXXX, ARNP |Patient complained of increased nausea, better with Zofran and increased cramping. Reports|5.09.16 | |

| | |urinary tract infection from last month resolved. Current dialysis treatment stable and |_000036-000037 | |

| | |increased shortness of breath. | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |End stage renal disease, hemodialysis stable. | | |

| | |Access: Stable | | |

| | |Adequacy, Lower this month, however in range, will continue to monitor | | |

| | |Anemia, stable | | |

| | |Mineral metabolism, good phosphate control, Zemplar increased to 8 mcg. | | |

| | |Nutrition: Albumin at goal. | | |

| | |Blood pressure: Stable | | |

|04/24/XXXXXX |XXXXXX Clinic |Follow Up Visit For Nausea And Cramping: |Everett Clinic |93-94 |

| | | |Records 12.04.14 to| |

| |XXXXXX, ARNP |Patient was seen by his Urologist yesterday for possible recurrent kidney infection. |5.09.16 | |

| | |Awaiting urine culture results. Overall feeling well. No issue with current dialysis |_000047-000048 | |

| | |treatment. | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |End stage renal disease, hemodialysis stable. No change | | |

| | |Anemia, stable | | |

| | |Mineral metabolism, good phos control. Albumin at goal. Blood pressure stable | | |

|04/30/XXXXXX |XXXXXX Clinic |Follow Up Visit For Nausea And Cramping: |Everett Clinic |104-105 |

| | | |Records 12.04.14 to| |

| |XXXXXX, ARNP |No complaints at this time. Current dialysis treatment stable. Currently not taking |5.09.16 | |

| | |antibiotics for urinary tract infection. Feeling sad secondary to the passing of his |_000058-000059 | |

| | |mother last week. Went to Harborview Pulmonology on Monday for lung asbestos, was told his| | |

| | |lung capacity has gotten a little worse based on the pulmonary function test. | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |End stage renal disease, hemodialysis stable. No change | | |

| | |Anemia, stable. Epogen 5000 units | | |

| | |Mineral metabolism, good phosphate and PTH control. Albumin at goal. Blood pressure stable| | |

|05/15/XXXXXX |XXXXXX Clinic |Office Visit For Diarrhea: |Everett Clinic |115-116 |

| | | |Records 12.04.14 to| |

| |XXXXXX, ARNP |Patient seen at dialysis center. He reports onset of diarrhea this morning. He had nausea |5.09.16 | |

| | |and vomited once prior to arrival, better after taking antiemetics. Current treatment |_000069-000070 | |

| | |stable. Reports have an appointment with his PCP post dialysis today. | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |End stage renal disease, hemodialysis stable. No change | | |

| | |Anemia, stable, in range | | |

| | |Mineral metabolism, good phosphate and PTH control. Albumin at goal. Blood pressure stable| | |

|07/31/XXXXXX |XXXXXX Health Medical |Emergency Visit For Diplopia: |XXXXXX Kidney & |33-36 |

|@ 0012 hours |Center | |other | |

| | |Patient with history of dialysis dependent renal failure, dialyzed Monday, Wednesday, |providers_000033-00| |

| |XXXXXX, M.D |Friday, who underwent complete dialysis this morning, history of type II diabetes |0036 | |

| | |mellitus, asbestosis and bladder cancer, who presents to emergency department, sent in by | | |

| | |Dr. XXXXXX of ophthalmology to rule out a third nerve palsy. He has had diplopia since | | |

| | |yesterday morning when he woke up with pain in his right eye. He has history of detached | | |

| | |retina in his eye and went to the Ophthalmologist. I did discuss case with Dr. XXXXXX who | | |

| | |notes that that he is concerned about a possible cerebral aneurysm that he has an afferent| | |

| | |pupillary defect on the right and extraocular movement entrapment. No headache just | | |

| | |complained of some mild right eye pain. Per Dr. XXXX, there is no ophthalmological problem| | |

| | |on his evaluation in the office and feels that this is a central or peripheral nerve | | |

| | |process. | | |

| | | | | |

| | |Hospital Course: To rule out third nerve palsy as patient had an efferent pupillary defect| | |

| | |in his right eye and right eye extraocular movement restriction and there was concern by | | |

| | |ophthalmology for a third nerve aneurysm as patient had diplopia since yesterday morning. | | |

| | |On evaluation, patient appears to have a possible mild third nerve palsy with some mild | | |

| | |ptosis, but primarily a sixth nerve palsy as he is unable to abduct his eye as he can | | |

| | |adduct and inferior, superiorly move his eye. He does have some mild diplopia to monocular| | |

| | |vision only with the right eye as with his left eye; he has normal vision without | | |

| | |diplopia. With both eyes open he had, diplopia in the right visual field only. His pupil | | |

| | |is reactive at this time, although sluggish to light. Case was discussed with Dr. XXXXXX, | | |

| | |the on-call neurologist, who did evaluate the patient in the Emergency Department. Patient| | |

| | |is a dialysis patient, who had his full run of dialysis today. To rule out aneurysm, we | | |

| | |will need to obtain a CT angiogram as GAD is contraindicated in a patient with renal | | |

| | |failure. | | |

| | | | | |

| | |He was sent for an MRI without contrast which was negative for any signs of stroke or | | |

| | |findings of any sixth nerve infarct. I did contact Dr. XXXXXX, on-call for Dr. XXXXXX. his| | |

| | |nephrologist, for clearance to obtain a CT angiogram of head and neck given that we need | | |

| | |to rule out an aneurysm urgently and XXXXXX notes that he can get a contrast and does not | | |

| | |need any other significant followup except for dialysis on Monday as already scheduled. | | |

| | |Dr. XXXXXX feels the patient is stable to be discharged home at this time as this is | | |

| | |likely a diabetic neuropathy. He will be discharged home with instructions to follow up | | |

| | |with Dr. XXXXXX patient’s ophthalmologist next week as well as Neurological Associates for| | |

| | |outpatient neurological reevaluation for possible diabetic neuropathy. | | |

| | | | | |

| | |Diagnosis: | | |

| | |Diplopia | | |

| | |Sixth nerve palsy | | |

| | | | | |

| | |Plan: His condition is currently stable and improved. He discharged home with instructions| | |

| | |to follow up with Dr. XXXXXX his ophthalmologist on Monday for outpatient ophthalmological| | |

| | |reevaluation. He was given referral for Neurologic Associates followup on Monday for | | |

| | |outpatient neurological reevaluation (Report not available). | | |

|07/31/XXXXXX |XXXXXX Hospital Medical|EKG: |XXXXXX Kidney & |24 |

|@1644 hours |Center | |other | |

| | |Impression: Normal sinus rhythm. T wave abnormality, consider anterolateral ischemia. |providers_000024 | |

|07/31/XXXXXX |XXXXXX Health Medical |Lab Report: |XXXXXX Kidney & |30-32 |

|@ 1724 hours |Center | |other | |

| | |RBC: 3.28 (Low), Hemoglobin: 11.9 (Low), Hematocrit: 32.7 (Low), Platelet: 128 (Low), |providers_000030-00| |

| | |Chloride: 92 (Low), AGAP: 19 (High), Creatinine: 4.1(High) |0032 | |

|07/31/XXXXXX |XXXXXX Hospital Medical|MRI Brain: |XXXXXX Kidney & |28-29 |

|@ 1812 hours |Center | |other | |

| | |Indication: 6th nerve palsy |providers_000028-00| |

| |Daniel Susanto, M.D | |0029 | |

| | |Impression: Normal study | | |

|07/31/XXXXXX |XXXXXX Hospital Medical|CT Angiogram Head And Neck: |XXXXXX Kidney & |25-27 |

|@1908 hours |Center | |other | |

| | |Indication: 6th nerve palsy |providers_000025-00| |

| |Daniel Susanto, M.D | |0027 | |

| | |Impression: Mild diffuse cerebral volume loss. | | |

|10/20/XXXXXX |XXXXXX Vascular |Left Dialysis Duplex Scan For Evaluate Graft Patency: |XXXXXX Kidney & |42 |

| | | |other | |

| |XXXXXX, M.D |Patient history: Patient is status post left radio cephalic fistula creation on |providers_000042 | |

| | |02/07/YYYY, by Dr. XXXXXX, and reports of low kinetics following dialysis runs. He is | | |

| | |currently able to complete his dialysis runs (last complete run on 10/19/XXXXXX), and | | |

| | |presents of LWVL to evaluate for graft patency. | | |

| | | | | |

| | |Findings: | | |

| | |Evidence of DAF conduit splitting into small caliber two branches at low mid forearm, with| | |

| | |elevated velocities of 602/343 cm/sec and 591/357 cm/sec | | |

| | |Mild to moderate narrowing seen within the proximal anastomosis and low wrist | | |

| | |No evidence of significant arterial inflow or venous outflow obstruction. | | |

| | | | | |

| | |Interpretation: Stenosis in proximal AVF. Called patient and scheduled a clinic visit to | | |

| | |examine. | | |

|10/28/XXXXXX |XXXXXX Vascular |Office Visit For End Stage Renal Disease: |XXXXXX Kidney & |40-41 |

| | | |other | |

| |XXXXXX, M.D |Patient here to discuss issues with his current right Radio Cephalic Arteriovenous Fistula|providers_000040-00| |

| | |(RC AVF) access. He has had recent issues with poor Kt/v and needle access issues. Last I |0041 | |

| | |saw him was in November YYYY with a fistulogram for proximal stenoses. It appeared his AVF| | |

| | |was not going to last long but it has made it to a year. Ultrasound shows stenosis in the | | |

| | |proximal portion again | | |

| | | | | |

| | |Medication: Prevacid 15 mg | | |

| | | | | |

| | |Physical exam: Extremities: Left wrist AVF has poor thrill and edema at both access sites.| | |

| | |Prior ultrasound showed good basilic and cephalic vein in upper arm for VF creation, less | | |

| | |than 4 mm. | | |

| | | | | |

| | |Assessment/Plan: We can salvage this access any further. Referred him to have a tunneled | | |

| | |line placed and will then do an elective creation of a left BC or brachiobasilic AVF at | | |

| | |EVG in the next few weeks (Report not available). Will also ligate the wrist AVF. Asked | | |

| | |him to get the tunneled line placed as soon as possible as think the AVF will fail soon. | | |

|01/28/XXXXXX- |Multiple Providers |Monthly Comprehensive Notes: |Everett Clinic |64-71, 74-81, |

|12/19/XXXXXX | | |Records 12.04.14 to|84-92, 95-103, |

| | |Date |5.09.16 |106-114, |

| | |Changes |_000018-000025, |117-125, |

| | |Comments |000028-000035, |126-134, |

| | | |000038-000046, |136-144, |

| | |01/28/XXXXXX |000049-000057, |145-154, |

| | |Recheck platelets. Zemplar, Co2/K bath, EDW |000060-000068, |155-164, |

| | |- |000071-000079, |165-174, |

| | | |000080-000088, |175-184, |

| | |03/08/XXXXXX |000090-000098, |185-194 |

| | |Increase EDW to 106 kg. IV Zofran 4 mg. Obtain outside records. |000099-000108, | |

| | |Nausea is likely multifactorial, reviewed GERD, constipation and medication SE |000109-000118, | |

| | | |000119-000128, | |

| | |04/07/XXXXXX |000129-000138, | |

| | |Obtain outside records and XXXXXX access information. Call Dr. XXXXXX regarding infection |000139-000148 | |

| | |workup | | |

| | |Continue with current treatment. Advised him that we can give antibiotics if needed at | | |

| | |dialysis. | | |

| | | | | |

| | |04/18/XXXXXX | | |

| | |Add Lasix 80 mg | | |

| | |Overall stable, not proceeding with a nephrectomy at this time. Need to monitor closely | | |

| | |for recurrent stenosis | | |

| | | | | |

| | |05/26/XXXXXX | | |

| | |- | | |

| | |Offered stool testing but it is easier for him to get to his PCP’s office. Given supplies | | |

| | |and written instructions that he needs a clostridium difficile test completed | | |

| | | | | |

| | |06/30/XXXXXX | | |

| | |Repeat Kt/v and if it remains low then consider fistulogram | | |

| | |- | | |

| | | | | |

| | |07/01/XXXXXX | | |

| | |Check magnesium level and HgbA1C, cut Glipizide if low. Watch access closely | | |

| | |Clostridium difficile negative, consider possible diagnosis of radiation proctitis or | | |

| | |other bowel injury that might be causing the diarrhea. Consider that the Morphine and | | |

| | |Oxycontin might be the cause of the nausea and whether he can change to Dilaudid / | | |

| | |Fentanyl patch. He was referred to his pain provider and his urologist regarding radiation| | |

| | |proctitis work up | | |

| | | | | |

| | |09/04/XXXXXX | | |

| | |Replete magnesium, increase potassium diet. Try UF profile. Check HgbA1C, cut Glipizide if| | |

| | |low. Watch access closely. Discussed increasing fruits and vegetables and magnesium | | |

| | |supplement to decrease cramping. Low sodium diet. Will add Furosemide 80 mg daily | | |

| | |End stage renal disease from diabetes mellitus and obstruction. Doing well with dialysis | | |

| | | | | |

| | |09/05/XXXXXX | | |

| | |Watch access closely. Discussed increasing fruits and vegetables and magnesium supplement | | |

| | |to decrease cramping. Low sodium diet. Improved cramping with this and UF profile 2. Not | | |

| | |taking Furosemide. Cut Zemplar to 4 mcg. Stopped Zemplar 6 mcg, IV push, every scheduled | | |

| | |dialysis treatment on 09/04/XXXXXX because adjust. Prescribed Zemplar 4 mcg | | |

| | |End stage renal disease from diabetes mellitus and obstruction. Doing well with dialysis | | |

| | | | | |

| | |11/02/XXXXXX | | |

| | |Discussed increasing fruits and vegetables and magnesium supplement to decrease cramping. | | |

| | |Low sodium diet. Improved cramping with this and UF profile 2. Try Torsemide instead of | | |

| | |Furosemide to increase urine output. Continue Zemplar to 4 mcg. Will check recirculation | | |

| | |and kt/v and may need fistulogram. He declined and has advised him to see his vascular | | |

| | |surgeon Dr. XXXXXX again at XXXXXX. | | |

| | |End stage renal disease from diabetes mellitus and obstruction. Doing well with dialysis | | |

| | |but having low adequacy | | |

| | | | | |

| | |11/04/XXXXXX | | |

| | |Continue Zemplar to 4 mcg. Continue Torsemide. Has seen vascular surgeon Dr. XXXXXX again | | |

| | |at XXXXXX and now has catheter placed and has new fistula placed | | |

| | |End stage renal disease from diabetes mellitus and obstruction. Doing well with dialysis | | |

| | |but having low adequacy and now with catheter and will need new fistula | | |

| | | | | |

| | |12/19/XXXXXX | | |

| | |Continue Zemplar to 4 mcg. Continue Torsemide. Retry fistula in January | | |

| | |End stage renal disease from diabetes mellitus and obstruction. Doing well with dialysis | | |

| | |but with catheter now after old fistula failed. Current new fistula with infiltration | | |

| | | | | |

| | | | | |

| | |*Reviewer’s comments: Multiple monthly comprehensive rounding notes have been combined | | |

| | |with significant details elaborated. | | |

|01/06/YYYY |XXXXXX Vascular |Office Visit For Evaluate Fistula Patency: |XXXXXX Kidney & |46 |

| | | |other | |

| |XXXXXX, M.D |Patient here for follow up of his left BC AVF. It was created on 11/12/XXXXXX. The |providers_000046 | |

| | |dialysis center tried to use it twice and both times it failed. I am unsure who gave | | |

| | |clearance to use it since it was not matured yet. Both times he had bleeding | | |

| | | | | |

| | |Physical exam: Feeling poorly but looks fine. Left BC AVF has a good thrill and is large | | |

| | |caliber and easily identified by palpation and visually. Mild pulsatility to the AVF. Some| | |

| | |senile purpura around the biceps from hematoma | | |

| | | | | |

| | |Today’s ultrasound showed 7-9 mm AVF that is less than 5 mm deep. There is diffuse | | |

| | |turbulent flow with multiple side branches which may indicate a proximal obstruction. | | |

| | | | | |

| | |Assessment/Plan: | | |

| | |Good maturation of the left arm AVF with some concern for outflow obstruction. This may | | |

| | |not be an issue however. Will send a note to the kidney center to start using it in 2 | | |

| | |weeks with small needles. | | |

|01/06/YYYY |XXXXXX Vascular |Duplex Scan For Evaluate Fistula Patency: |XXXXXX Kidney & |45 |

| | | |other | |

| |XXXXXX, M.D |Findings: |providers_000045 | |

| | |Patent left brachiocephalic fistula with mild velocity increases in the proximal | | |

| | |anastomosis and confluence without significant diameter reduction | | |

| | |Significant turbulence noted throughout the outflow conduit, likely associated with | | |

| | |arteriovenous connection | | |

| | |Focal velocity increase in the distal upper arm brachial artery and cephalic vein at the | | |

| | |level of the chest. | | |

| | | | | |

| | |Interpretation: Widely patent left BC AVF. Appears near ready for access. | | |

|03/24/YYYY |XXXXXX Vascular |Duplex Scan For Evaluate Fistula Patency: |XXXXXX Kidney & |43 |

| | | |other | |

| |XXXXXX, M.D |Patient history: Patient is status post left brachiocephalic fistula creation on |providers_000043 | |

| | |11/12/XXXXXX (Report not available), with multiple revisions, and a failed left radio | | |

| | |cephalic DAF, all by Dr. XXXXXX. He is currently using his fistula, with some prolonged | | |

| | |bleeding after needle withdrawal. He presents to LKWV today to evaluate for fistula | | |

| | |patency. | | |

| | | | | |

| | |Interpretation: Widely patent left AVF by US. There may be a central stenosis not well | | |

| | |seen with US. He has an appointment to discuss. | | |

| | | | | |

| | |Findings: | | |

| | |Patent left brachiocephalic fistula DAF, with a mild narrowing at the proximal | | |

| | |anastomosis. | | |

| | |No evidence of significant arterial inflow or venous outflow obstruction. Turbulence seen | | |

| | |in outflow veins | | |

|04/21/YYYY |XXXXXX Vascular |Office Visit For Graft Infiltration: |XXXXXX Kidney & |44 |

| | | |other | |

| |XXXXXX, M.D |Patient here with a right sore arm after a large infiltration about a month ago. It still |providers_000044 | |

| | |hurts. He had pain after the needles were put in and a large bruise hematoma. It is | | |

| | |resolving and improved but there is still some pain. His had feels fine. Had needles | | |

| | |placed once that were very painful once they were in. Using Lidocaine cream helps with the| | |

| | |punctures. He is very apprehensive using the AVF. He is dialyzing via a right tunneled | | |

| | |catheter | | |

| | | | | |

| | |Physical exam: Left arm has a port at the shoulder. No collateral veins seen but the AVF | | |

| | |is large even at the shoulder. The AVF in the upper arm is large easily palpable and with | | |

| | |a pulsatile thrill. The biceps area has large brown discoloration and old bruising. Some | | |

| | |tenderness along biceps. | | |

| | | | | |

| | |Assessment/Plan: The AVF should be attempted to be accessed again with a single needle and| | |

| | |another port in his tunneled line for the next three sessions. Will proceed slowly. | | |

| | |Discussed this with them and also with his kidney center. If he is not able to be | | |

| | |cannulated then we can try another fistulogram to see if there is an outflow stenosis we | | |

| | |are not seeing on ultrasound that could be corrected to help with the access. | | |

|02/05/YYYY- |Multiple Providers |Monthly Comprehensive Rounding Notes: |Everett Clinic |196-205, |

|05/11/YYYY | | |Records 12.04.14 to|206-215, |

| | |Date |5.09.16 |217-226, |

| | |Changes |_000150-000159, |228-236 |

| | |Comments |000160-000169, | |

| | | |000171-000180, | |

| | |2/05/YYYY |000182-000190 | |

| | |Continue Zemplar to 4 mcg. Continue Torsemide. Retry fistula with one needle and advance | | |

| | |and remove catheter in a few weeks. TUMS with meals | | |

| | |End stage renal disease from diabetes mellitus and obstruction. Doing well with dialysis | | |

| | |but with catheter now after old fistula failed. Current new fistula with infiltration. | | |

| | |Advance gradually | | |

| | | | | |

| | |02/18/YYYY | | |

| | |Increase Zemplar to 5 mcg. Continue Torsemide. Advancing fistula. Can probably remove the | | |

| | |catheter soon. Discussed eating slightly more Potassium for cramping. TUMS with meals | | |

| | |End stage renal disease from diabetes mellitus and obstruction. Doing well with dialysis | | |

| | |but with catheter now after old fistula failed. Current new fistula. Advance gradually | | |

| | | | | |

| | |03/21/YYYY | | |

| | |Raised EDW to 107 kg. Continue Torsemide. Advancing fistula. Can probably remove the | | |

| | |catheter soon. Discussed eating slightly more potassium for cramping. TUMS with meals | | |

| | |End stage renal disease from diabetes mellitus and obstruction. Doing well with dialysis | | |

| | |but with catheter now after old fistula failed. Current new fistula. Advancing gradually | | |

| | | | | |

| | |05/11/YYYY | | |

| | |Raised EDW to 107 kg in 3/16. Continue Torsemide. Fistula infiltrated and is on catheter | | |

| | |with fistula rest. Discussed eating slightly more potassium for cramping and improved. | | |

| | |TUMS with meals. Phosphorus is better | | |

| | |End stage renal disease from diabetes mellitus and obstruction. Doing well with dialysis | | |

| | |but with catheter now after old fistula failed. Current new fistula. Advancing gradually | | |

| | |but had another infiltration | | |

| | | | | |

| | | | | |

| | |*Reviewer’s comments: Multiple monthly comprehensive rounding notes have been combined | | |

| | |with significant details elaborated. | | |

|05/09/YYYY |XXXXXX Clinic |Monthly Comprehensive Note: |Everett Clinic |237-246 |

| | | |Records 12.04.14 to| |

| |XXXXXX, M.D |Patient is an ESRD transfer from Dr. XXXXXX. He has ESRD due to diabetes mellitus and |5.09.16 | |

| | |obstructive uropathy in the setting of prior bladder CA. He has an ostomy and still has |_000191-000200 | |

| | |residual kidney function. He has radiation proctitis or other complications from his | | |

| | |cancer treatment (XRT was prior to cystectomy YYYYquetsionable). The last fistulogram was | | |

| | |in November or December YYYY at XXXXXX Hospital. Has issues with recurrent urinary tract | | |

| | |infections/infections and his main limitation is shortness of breath related to pulmonary | | |

| | |asbestosis. Sees physicians at XXXXXX and has seen UW pulmonary. He has dyspnea on | | |

| | |exertion for which he takes Morphine and Oxycontin. He has chronic diarrhea related to | | |

| | |radiation proctitis. | | |

| | | | | |

| | |Prior AV fistula failed in 11/15 and had catheter placed and new AV fistula placed by Dr. | | |

| | |XXXXXX in 11/15. He had infiltration of new BC fistula placed in 11/12/XXXXXX. The | | |

| | |dialysis center had received an order from vascular surgery to use the fistula. Has been | | |

| | |rested and with dialysis catheter since that time. Restarted usage attempts in mid-1/16. | | |

| | |He is on torsemide instead of furosemide and does not notice much more urine. | | |

| | | | | |

| | |Has had fistula used successfully on and off the last couple of weeks; had fistulogram on | | |

| | |05/02/YYYY. Breathing remains not great. Hard to tell if worse. Stable. Winded after | | |

| | |walking 100 feet. Cramping better after raising EDW to 107kg. He is eating more fruits and| | |

| | |vegetables. Diarrhea and urination stable. Settled asbestosis case and will be getting | | |

| | |settlement checks every 2 weeks. Reports breathing are not as good right now. Reports | | |

| | |having some bleeding issues at end of dialysis; no problems getting needles in and no | | |

| | |infiltrations for a couple of weeks. | | |

| | | | | |

| | |Raised EDW to 107 kg in 3/16 but now with edema but resistant to lowering although has | | |

| | |been reaching 106 kg. Is getting more dyspneic at more than 108 kg. Does not want DW | | |

| | |lowered back down. Advised considering checking in with his pulmonologist if not | | |

| | |improving. Continue Torsemide. Discussed eating slightly more potassium for cramping. This| | |

| | |is improved. TUMS with meals. Phosphorus is better. | | |

| | | | | |

| | |End stage renal disease from diabetes mellitus and obstruction. Doing well with dialysis | | |

| | |but with catheter now after old fistula failed. Current new fistula. Advancing gradually | | |

| | | | | |

| | |*Reviewer’s Comments: No further medical records are available after 05/09/YYYY to know | | |

| | |the health status of the patient. | | |

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