Wiliam Sepulvado - Trivent Legal



Benicar Case Review – XXXXX

|Parameter |Findings |PDF Ref |

|First Name |XXXXX |16 |

|Initial |L |16 |

|Last Name |XXXXX |16 |

|DOB |01/04/YYYY |16 |

|Past Medical History (including|Gastroesophageal reflux disease, hypertension, rheumatoid arthritis, migraine, high cholesterol, |16 |

|history of past GI disorders) |heart murmur, joint pain | |

|List of previously used anti |Propranolol 40 mg |125, 123, 121, |

|hypertensive medications |Triamterene/Hydrochlorothiazide 37.5-25 mg |101-103 |

| |Benazep/Hydrochlorothiazide 20-25 mg | |

| |Metoprolol ER 50 mg | |

| |Inderal LA 60 mg | |

|Prior use of other ARBs |Not available | |

|(Losartan, Telmisartan) | | |

|Concomitant use of other |Metoprolol ER 25 mg, Hydrochlorothiazide 25 mg |105-107, 109-111, |

|anti-hypertensive | |113-115, 120 |

|Concomitant use of other |Depo-Medrol injection, Zithromax Z-pak 250 mg, Zyrtec, Naproxen 400 mg, Ibuprofen, Epipen, |14, 15, 16-18, |

|medications |Dulera, Ventolin, Cyclobenzaprine 10 mg, Clonazepam 1mg, Flexeril 10 mg, Topiramate 25 mg, |19-21, 22-24, |

| |Cholestyramine 4 gm, Flagyl 500 mg, Levaquin 750 mg, Sumatriptan 100 mg, Vitamin D 50000 units, |59-63, 25-26, 27, |

| |Omeprazole 20 mg, Gabapentin 300 mg, Align 4 mg, Advil 200 mg, Aleve 220 mg, CoQ-10 50 mg, Fish |63-69, 51-56, |

| |oil 1000 mg, Imitrex 100 mg, Neurontin 300 mg, Propo-N/APAP 100-650 tablet, Klonopin 1 mg, |74-78, 105-106, |

| |Megestrol AC 20 mg, Clindamycin 300 mg, Terbinafine 250 mg, Azithromycin 250 mg, Topiramate 250 |109, 112, 114-115 |

| |mg | |

|Benicar Start Date |Unknown |104 |

| | | |

| |*Reviewer’s comment: Per pharmacy records, we note the first Benicar use on 04/13/YYYY; but prior| |

| |records are not available to know the exact start date of Benicar | |

|Dosage |40-25 mg |104-107 |

|Benicar Stop Date |Unknown |120, 31-32 |

| | | |

| |Per available medical records: 06/23/YYYY | |

| | | |

| |*Reviewer’s comment: Per visit dated 06/23/YYYY, we note patient had stopped Benicar for several | |

| |weeks on hearing that it makes diverticulitis worse. Hence exact stop date of Benicar intake is | |

| |unknown. | |

|Benicar Adverse Events (Whether|Yes – Diarrhea |19-21 |

|diagnosed with enteropathy, | | |

|diarrhea, dehydration, | | |

|malnutrition, villous atrophy | | |

|and villous blunting) | | |

|Date of Diagnosis of Adverse |08/19/YYYY: Colonoscopy – Multiple medium diverticula in colon |87-89, 19-21, |

|Event |08/14/YYYY-08/20/YYYY: Abdominal pain, diarrhea, diverticulosis |22-24, 59-63, |

| |08/21/YYYY: Diarrhea, nausea, vomiting |25-26, 27, 63-69, |

| |08/23/YYYY-10/16/YYYY: Diverticulitis, fatigue |84-85, 90-91, |

| |02/17/YYYY: Diverticulitis, diarrhea, vomiting and nausea, IBS |51-56, 33-34, |

| |04/01/YYYY: Colonoscopy - Moderately severe diverticulosis in the sigmoid colon. |94-98, 3-5 |

| |04/01/YYYY: CT abdomen – Pandiverticulosis | |

| |04/21/YYYY: Diarrhea, diverticulitis of colon | |

| |06/26/YYYY-01/12/YYYY: Recurrent episodes of diverticulitis | |

|Management of Adverse Event |Levaquin 500/750 mg |19-21, 22-24, |

| |Flagyl 500/750 mg |59-63, 27, 63-69, |

| |Restriction of food that increases bowel activity |84-85, 86, 51-56, |

| |Ondansetron 8 mg |74-78, 94-98, 6-8 |

| |Cholestyramine 4 gm | |

| |Align 4 mg | |

| |04/01/YYYY: Colonoscopy and colon biopsy - Histologically unremarkable colonic mucosa | |

| |Ciprofloxacin 500 mg | |

| |Metronidazole 250 mg | |

| |02/10/YYYY: Underwent laparoscopy, left hemicolectomy with low pelvic anastomosis, open | |

| |mobilization of splenic flexure, placement of bilateral on-q postoperative pain control pump and | |

| |catheters, intra-operative colonoscopy, repair of colovesical fistula for chronic recurrent | |

| |diverticulitis, impending colovesical fistula under general anesthesia | |

|Other significant GI conditions|Not available | |

|Smoking history |Former smoker, smoked for 33 years, quit on 10/1997 |16-18 |

|Condition of the Patient Per |02/24/YYYY: Patient doing well. Eating without difficulty. Bowels moving satisfactorily. |2 |

|Last Available Record |Incisions healing well. Good healing ridge. Satisfactory post operative course. Increase activity| |

| |as tolerated. Return in 3 weeks. | |

| | | |

| |*Reviewer’s comment: Further medical records after 02/24/YYYY are not available to know the | |

| |progress of the patient. | |

Missing Medical Records:

|What |Hospital/ |Date/Time Period |Why we need |

|Records/Medical |Medical Provider | |the |

|Bills are Needed | | |Records/Bills |

|08/19/YYYY |XXXXX Specialists |Colonoscopy report: |87-89 |

| | | | |

| |XXXXX, M.D. |Medical history: High blood pressure | |

| | | | |

| | |Reason for visit: Screening colonoscopy | |

| | | | |

| | |Anesthesia: Monitored anesthesia care | |

| | | | |

| | |Impression: | |

| | |The colonic mucosa appeared entirely normal. | |

| | |There were no masses or polyps found. | |

| | |Multiple medium scattered diverticula in the colon. | |

| | | | |

| | |Condition upon leaving procedure: Stable | |

| | |*Reviewer’s comment: Interim records from 08/19/YYYY to 01/29/YYYY are not available to know the health status of | |

| | |the patient. | |

|01/29/YYYY |XXXXX Family Medicine |Follow-up visit for headache and sinus pressure: (Illegible notes) |14 |

| | | | |

| | |Review of systems: | |

| | |Constitutional: Reports weight loss | |

| | | | |

| | |Social history: Former smoker. Quit 16 years back. | |

| | | | |

| | |Assessment: Sinusitis | |

| | | | |

| | |Plan: Dox/Depo intramuscular injection given. Z-pack, Zyrtec as prescribed. | |

| | | | |

| | |*Reviewer’s comment: Details related only to Benicar case review has been elaborated. | |

|02/20/YYYY |XXXXX Family Medicine |Follow-up visit for back pain: (Illegible notes) |15 |

| | | | |

| | |Review of systems: | |

| | |Constitutional: Reports weight loss | |

| | | | |

| | |Assessment: Arthritis, Vitamin D deficiency, multiple joint pain, fibromyalgia | |

| | | | |

| | |Plan: Increase Klonopin to 1 mg. Refill of EpiPen, Medrol dose pack given. | |

|05/22/YYYY |XXXXX, FNP |Follow-up visit for cough: |16-18 |

| | | | |

| | |Patient was taking Dulera and Ventolin. | |

| | | | |

| | |Current medications include Benicar Hct 40-25 mg (04/19/YYYY) once daily. | |

| | | | |

| | |Past medical history: Hypertension, gastroesophageal reflux disease, rheumatoid arthritis, migraines, high | |

| | |cholesterol, heart murmur, degenerative disc disease, fibromyalgia | |

| | | | |

| | |Weight: 189.6 lbs. | |

| | | | |

| | |*Reviewer’s comment: | |

| | |Details related only to Benicar case review have been elaborated. | |

| | |Per pharmacy records, we note the first Benicar use on 04/13/YYYY; but per available medical records we note Benicar| |

| | |usage only on 04/19/YYYY. Hence the exact start date is not unknown. | |

|08/14/YYYY |XXXXX XXXXX, M.D. |Follow-up visit for evaluation of stomach bug: |19-21 |

| | | | |

| | |Patient presents for evaluation of “stomach bug” symptoms present for 2-3 days. She presents to the clinic with 72 | |

| | |hour history of diarrhea, vomiting at onset that has resolved. Diarrhea stool for 5 times today, watery brown. Has | |

| | |taken over the counter anti-diarrheal once. Has some left lower quadrant abdominal discomfort. | |

| | | | |

| | |Current medications include Benicar Hct 40-25 mg once daily. | |

| | | | |

| | |Review of systems: | |

| | |Genitourinary: Reports stomach virus | |

| | | | |

| | |Weight: 184.8 lbs. | |

| | | | |

| | |Physical examination: | |

| | |Abdomen: Abdominal tenderness present. Hyperactive bowel sounds all four quadrants. Tenderness to mild palpation | |

| | |with guarding in lower left quadrant. | |

| | | | |

| | |Diagnoses: | |

| | |Abdominal pain | |

| | |Diarrhea | |

| | |Diverticulosis | |

| | | | |

| | |Plan: Send patient for CT Abdomen, Complete blood Count (CBC), Comprehensive Metabolic Panel (CMP). Prescribed | |

| | |Levaquin 750 mg once daily for 10 days and Flagyl 500mg four times a day for 10 days. | |

|08/20/YYYY |XXXXX XXXXX, M.D. |Follow-up visit for left lower quadrant pain: |22-24 |

| | | | |

| | |Patient presents with left lower quadrant abdominal pain, diverticulosis confirmed by CT (CT records not available).| |

| | |Patient reports pain has improved although she continues to have loose stools. Consistency has improved from watery | |

| | |diarrhea. Continues on Levaquin and Metronidazole. | |

| | | | |

| | |Current medications include Benicar Hct 40-25 mg once daily. | |

| | | | |

| | |Weight: 185 lbs | |

| | | | |

| | |Review of systems: | |

| | |Gastrointestinal: Admits to nausea, abdominal pain, diarrhea | |

| | | | |

| | |Physical examination: | |

| | |Abdomen: Tenderness lower left quadrant, tenderness has improved from last visit. | |

| | | | |

| | |Diagnosis: Diverticulitis of colon | |

| | | | |

| | |Plan: Labs today due to continued diarrhea. Continue medications as prescribed. Refer to GI, to see Dr. XXXXX | |

| | |tomorrow. Restrict foods that increase bowel activity and are low in fibers like refined bread, cereals, white rice,| |

| | |vegetable and fruit juice without pulp and dairy products. | |

|08/21/YYYY |XXXXX One Care |Gastrointestinal consultation for abdominal pain, diarrhea: |59-63 |

| | | | |

| |XXXXX, M.D. |Patient was diagnosed with diverticulosis 2 years ago by Dr. XXXXX, diagnosed with diverticulitis last week at St. | |

| | |Francis, cannot eat anything she eats goes threw her, states she is having 20 Bowel Movements (BM) per day, loose | |

| | |stools, LLQ pain, nausea, dizziness. Colon screening – Denies any problems. | |

| | | | |

| | |Patient here today with complaints of diverticulitis. Has been on Levaquin for 7 days with Flagyl. She states the | |

| | |“pain is way better”, still with complaints of frequent loose stools. She reports she is having 20 stools a day, has| |

| | |nausea, dizziness, has lost 5 pounds. She states her oral intake is good. | |

| | | | |

| | |Current medications include Benicar Hct 40-25 mg once daily. | |

| | | | |

| | |Review of systems: | |

| | |Gastrointestinal: Decreased appetite. Nausea with vomiting, bloating and abdominal pain. Pain when defecating and | |

| | |bowel movement frequency has recently changed. Diarrhea. | |

| | |Genitourinary: Urinary loss of control. | |

| | | | |

| | |Assessment: | |

| | |Diarrhea | |

| | |Nausea with vomiting | |

| | | | |

| | |Plan: | |

| | |Vomiting/nausea - Ondansetron 8 mg every 6 hours for 30 days | |

| | |Diarrhea - Cholestyramine light 4 gm/dose powder, twice a day for 30 days, Align 4 mg 2 twice a day for 30 days | |

| | |Diverticulitis - Pain improved. Patient slowly improving will treat symptoms until they resolve. | |

|08/23/YYYY |XXXXX XXXXX, M.D. |Follow-up visit for diverticulitis: |25-26 |

| | | | |

| | |Patient presents for follow-up on her diverticulitis and continued fatigue. | |

| | | | |

| | |Patient recently saw GI, has finished antibiotic for diverticulitis, diarrhea is resolving states she had so many | |

| | |health problems she thinks she is going to have to stop working and go on disability. Patient states diverticulitis | |

| | |pain has almost resolved. Diarrhea has improved. She is being treated by GI. | |

| | | | |

| | |Current medications include Benicar Hct 40-25 mg once daily. | |

| | | | |

| | |Physical examination: | |

| | |Abdomen: Has mild tenderness lower left quadrant but no guarding, much improvement in symptoms. | |

| | | | |

| | |Diagnosis: Diverticulitis of colon, resolving. | |

| | | | |

| | |*Reviewer’s comment: Details related only to Benicar case review has been elaborated. | |

|10/16/YYYY |XXXXX Family Medicine |Follow-up visit for diverticulitis: (Illegible notes) |27 |

| | | | |

| |XXXXX XXXXX, M.D. |Patient presented to discuss about diverticulitis and her overall health. | |

| | | | |

| | |Keeps flaring with diverticulitis - ______ abdomen with Dr. XXXXX – Uses Cholestyramine. | |

| | | | |

| | |Assessment: | |

| | |Diverticulitis | |

| | |Fibromyalgia | |

| | |Paresthesia | |

| | | | |

| | |Plan: Z-pack, saline prescribed. | |

| | | | |

| | |*Reviewer’s comment: Details related only to Benicar case review has been elaborated. | |

|02/17/YYYY |XXXXX One Care |Follow-up visit for diverticulitis: |63-69 |

| | | | |

| |XXXXX, M.D. |Patient to talk with Dr. XXXXX to discuss dietary habits that goes with diverticulosis. Patient states she had | |

| | |several flares and has been treated for them but would like to know more about what causes them. She wants colon | |

| | |screening. | |

| | | | |

| | |Patient with bouts of abdominal pain sine last February. Patient reports CT last August that showed diverticulitis | |

| | |(CT report not available). Patient treated in August for diverticular disease. Patient reports still having multiple| |

| | |episodes of left lower quadrant pain. Patient reports having problem sitting. Patient recently treated with | |

| | |Ciprofloxacin and Flagyl for last 10 days. Patient reports now feeling OK still feeling tender. Patient reports | |

| | |hysterectomy 2 years ago. | |

| | | | |

| | |Weight: 186 lbs | |

| | | | |

| | |Current medications include Benicar Hct 40-25 mg. | |

| | | | |

| | |Review of systems: | |

| | |Gastrointestinal: Nausea with vomiting, bloating and abdominal pain. Pain when defecating and bowel movement | |

| | |frequency has recently changed. Diarrhea. | |

| | | | |

| | |Physical examination: | |

| | |Abdomen: Abdominal tenderness mild. Direct tenderness in the abdomen. | |

| | | | |

| | |Assessment: | |

| | |Diverticulitis of colon | |

| | |Diarrhea | |

| | |Nausea with vomiting | |

| | |No diverticulitis with abscess | |

| | | | |

| | |Patient appears stable but appears to have recurrent diverticulitis. Although would not be surprised if patient has | |

| | |an element of IBS. Patient taking Questran with help of diarrhea. Patient reports continued left lower quadrant | |

| | |pain. Would get CT of abdomen and pelvis. Discussed possible colon resection down the road. | |

|04/13/YYYY-03/24/Y|XXXXX pharmacy |Pharmacy dispensing record: |104-107, |

|YYY | | |109-111, 115, |

| | |Medication refilled: Benicar Hct 40-25 mg. |120 |

|04/01/YYYY |XXXXX Specialists |Colonoscopy report: |84-85 |

| | | | |

| |XXXXX, M.D. |Pre operative diagnosis: Diarrhea | |

| | | | |

| | |Anesthesia: Monitored anesthesia care | |

| | | | |

| | |Findings: The colon appeared to be normal. A biopsy was taken from the ascending colon and descending colon to | |

| | |evaluate for microscopic colitis there was evidence of moderately severe diverticulosis in the sigmoid colon. | |

|04/01/YYYY |XXXXX and Therapeutics |CT of abdomen and pelvis: |90-91 |

| | | | |

| |XXXXX, M.D. |History: Abdomen pain, diarrhea, nausea, vomiting, remote cholecystectomy, hysterectomy and appendectomy | |

| | | | |

| | |Opinion: | |

| | |Previous cholecystectomy, appendectomy, and hysterectomy | |

| | |Pandiverticulosis | |

| | |No urinary tract calcification is seen on the right or left and there is no hydronephrosis. | |

| | |Otherwise negative CT scan of the abdomen and pelvis | |

|04/04/YYYY |XXX Specialists |Pathology report: |86 |

| | | | |

| |XXXXX, M.D. |Collected: 04/01/YYYY | |

| | | | |

| | |Final diagnosis: | |

| | |Ascending colon and descending colon - Histologically unremarkable colonic mucosa. Colitis not identified. | |

|04/21/YYYY |XXXXX One Care |Follow-up visit status post colonoscopy: |51-56 |

| | | | |

| |XXXXX, M.D. |Patient presented today for follow-up on her colonoscopy. She states she is working hard on her diet to help her | |

| | |diverticulosis. She does still have some diarrhea and is using the Cholestyramine for the diarrhea and she is | |

| | |satisfied with this. She states she cannot tolerate fiber because it causes a lot of bloating and gas pain. | |

| | | | |

| | |Review of systems: | |

| | |Abdomen: Same as on 08/21/YYYY | |

| | | | |

| | |Weight: 187 lbs | |

| | | | |

| | |Current medications include Benicar Hct 40-25 mg. | |

| | | | |

| | |Physical examination: | |

| | |Abdomen: Same as on 02/17/YYYY | |

| | | | |

| | |Assessment: | |

| | |Diverticulitis of colon | |

| | |Diarrhea | |

| | |Nausea with vomiting | |

| | |No diverticulitis with abscess | |

| | | | |

| | |Plan: | |

| | |Diverticulitis of colon - Ciprofloxacin 500 mg twice a day for 10 days, Metronidazole 250 mg three times a day for | |

| | |10 days. | |

| | |Diarrhea - Recommend using Cholestyramine daily | |

| | |Return in 3 weeks. If patient does not get relief with antibiotics would consider surgery evaluation. | |

|05/12/YYYY |XXXXX One Care |Follow-up visit for diarrhea: |74-78 |

| | | | |

| |XXXXX, M.D. |Patient reports that she has felt great reports taking Questran with control of diarrhea. Patient off NSAIDS. | |

| | |Patient takes APAP and Neurontin. Patient with few bouts of diverticulitis last year. We discussed possible surgery | |

| | |in future. Patient unable to eat vegetables secondary to pain. | |

| | | | |

| | |Current medications include Benicar Hct 40-25 mg. | |

| | | | |

| | |Review of systems: | |

| | |Abdomen: Same as on 08/21/YYYY | |

| | | | |

| | |Weight: 179 lbs | |

| | | | |

| | |Physical examination: | |

| | |Abdomen: Abdominal tenderness mild. Direct tenderness in the abdomen. | |

| | | | |

| | | | |

| | |Assessment: | |

| | |Diverticulitis of colon | |

| | |Diarrhea | |

| | |Nausea with vomiting | |

| | |No diverticulitis with abscess | |

| | | | |

| | |Plan: | |

| | |Diverticulitis - Appears stable has resolved | |

| | |IBS - Controlled on Questran | |

| | |Patient wants to hold on surgery continued to follow. | |

|06/23/YYYY |XXXXX, FNP |Follow-up visit for diverticulitis: (Incomplete record) |31-32 |

| | | | |

| | |Patient came in today to discuss medications. She has stopped Benicar for several weeks due to hearing on television| |

| | |that it might make her diverticulitis worse, she has stopped and feels much better in addition she did stop her | |

| | |Cymbalta (Exact stop date of Benicar is not available). Her pain is pretty much controlled and BP is great today. | |

| | |Previous labs with low vitamin D, elevated lipids. Needs repeat fasting labs and states will return next month. | |

| | | | |

| | |Plan: Patient decides to stop additional medications. Lab order to patient, will return in July for fasting labs and| |

| | |make first morning appointment. Geno swab today. | |

| | | | |

| | |*Reviewer’s comment: We note patient had stopped Benicar for several weeks on hearing that it makes diverticulitis | |

| | |worse. Hence exact stop date of Benicar intake is unknown. | |

|06/26/YYYY |XXXXX, FNP |Visit for bilateral lower extremities pitting edema: |33-34 |

| | | | |

| | |Patient complaints of bilateral lower extremities pitting edema since off the Benicar for 1 week. Patient reports BP| |

| | |at home has been 160/106 mm Hg. | |

| | | | |

| | |BP is normal today. She did reports some lower extremity edema, stopped Benicar HCTZ about 1 week prior, edema has | |

| | |resolved for the most part. | |

| | | | |

| | |Weight: 188 lbs | |

| | | | |

| | |Diagnosis: | |

| | |Acute sinusitis | |

| | |Edema | |

| | |Colonic diverticulosis | |

| | |Dyslipidemia | |

| | |Essential hypertension | |

| | | | |

| | |Plan: Will prescribe Z-pack as directed. Will prescribe HCTZ 12.5 mg, monitor BP. If increased edema, dyspnea, watch| |

| | |sodium intake, caffeine | |

|07/07/YYYY |XXXXX One Care |Follow-up visit for diverticulitis: |78-83 |

| | | | |

| |XXXXX, M.D. |Patient states she is feeling better since being off Benicar. Patient reports developing abdominal pain with | |

| | |Benicar. Patient reports she was taken off it felt better. Patient reports all side effects have improved. Patient | |

| | |with increased strength. | |

| | | | |

| | |Review of systems: | |

| | |Abdomen: Same as on 08/21/YYYY | |

| | | | |

| | |Weight: 180 lbs | |

| | | | |

| | |Physical examination: | |

| | |Abdomen: Same as on 02/17/YYYY | |

| | | | |

| | |Assessment: | |

| | |Diverticulitis of colon | |

| | |Diarrhea | |

| | |Nausea with vomiting | |

| | |No diverticulitis with abscess | |

| | | | |

| | |Patient reports abdominal pain has been second to Benicar now improved will follow. | |

|10/17/YYYY |XXXXX Hospital |ER visit for diverticulitis: |94-98 |

| | | | |

| | |Impression: Diverticulitis | |

| | | | |

| | |Treatment: Flagyl 750 mg thrice daily for 7 days. Levaquin 500 mg once daily for 7 days. | |

| | | | |

| | |Disposition: To home. Condition: Stable. | |

| | | | |

| | |*Reviewer’s comment: Complete ER record is not available | |

|01/12/YYYY |XXXXX, M.D. |GI consultation for recurrent diverticulitis: |3-5 |

| | | | |

| | |Reason for consultation: Recurrent episodes of diverticulitis. | |

| | | | |

| | |Patient had multiple attacks of sigmoid diverticulitis diagnosed by CT scanning. The first episode was in August of | |

| | |YYYY. She was hospitalized at St. Francis Hospital after being diagnosed by her Primary Care Doctor Dr. XXXXX XXXXX.| |

| | |Most recent flare-up was in December of last year (Reports are unavailable). She thought that she was able to | |

| | |control it for a period of time by modifying her diet and taking Cholestyramine, but lately the attacks have been | |

| | |becoming increasingly frequent despite her precautions. She had to be hospitalized twice and had multiple other | |

| | |milder episodes. She cannot identify any particular cause or inciting factor that brings on an attack so there is | |

| | |nothing she can do to avoid them. She generally has three or four small bowel movements per day. Recently, she had | |

| | |one bowel movement with some blood in it, but it was bright red blood and she felt that it was due to straining and | |

| | |hemorrhoids. Workup included a colonoscopy done by Dr. XXXXX in April YYYY, which showed pancolonic diverticulosis, | |

| | |especially severe in the sigmoid colon. CT scanning done at that time confirmed the diverticular disease. | |

| | | | |

| | |Review of systems: | |

| | |Constitutional: Positive for fatigue and tiredness. | |

| | |Musculoskeletal: Positive for joint pain and muscle weakness. | |

| | | | |

| | |Physical examination: | |

| | |Abdomen: Abdomen is protuberant, but not distended. She has some very mild tenderness to deep palpation in the left | |

| | |lower quadrant in the region of the sigmoid colon. | |

| | | | |

| | |Assessment: Recurrent episodes of diverticulitis | |

| | | | |

| | |Plan: I explained available surgical and nonsurgical treatment options. I have explained that surgical resection of | |

| | |the involved area may reduce her risk of recurrent disease, but that she has pancolonic diverticulosis and she will | |

| | |still have some diverticula even following successful surgery. I have explained the procedure of colon resection | |

| | |including laparoscopic assisted colon resection and the use of the implantable pain pump. I have explained the use | |

| | |of intraoperative ureteral catheters placed by urologist to minimize the risk of injury. | |

|02/10/YYYY |XXXXX Memorial Hospital |Operative report for ureteral stent placement: |9-10 |

| | | | |

| |XXXXX, III, M.D. |Pre/Post operative diagnoses: | |

| | |Recurrent diverticulitis | |

| | |Request for preoperative ureteral stent placement | |

| | | | |

| | |Name of procedure: | |

| | |Cystoscopy | |

| | |Bilateral ureteral stent placement | |

| | |Foley catheter insertion | |

| | | | |

| | |Anesthesia: General endotracheal. | |

|02/10/YYYY |XXXXX Memorial Hospital |Operative report for left hemicolectomy, open mobilization of splenic flexure: |6-8 |

| | | | |

| |XXXXX, M.D. |Preoperative diagnosis: Chronic recurrent diverticulitis | |

| | | | |

| | |Postoperative diagnosis: | |

| | |Chronic recurrent diverticulitis | |

| | |Impending colovesical fistula | |

| | | | |

| | |Operation performed: | |

| | |Laparoscopy | |

| | |Left hemicolectomy with low pelvic anastomosis | |

| | |Open mobilization of splenic flexure | |

| | |Placement of bilateral On-Q postoperative pain control pump and catheters | |

| | |Intra-operative colonoscopy | |

| | |Repair of colovesical fistula | |

| | | | |

| | |Anesthesia: General endotracheal | |

| | | | |

| | |Findings at surgery: A long stenotic area of the sigmoid colon which was very densely adherent to the pelvic side | |

| | |wall and to the bladder, such that it had almost created a colovesical fistula. The remaining portions of the colon | |

| | |and the small bowel were normal to inspection and palpation. Liver showed no focal abnormalities. Patient was status| |

| | |post previous open cholecystectomy and there were omental adhesions to the undersurface of the liver in the upper | |

| | |abdominal wall. The patient is also status post complete hysterectomy. Ureters were carefully identified and | |

| | |preserved throughout the procedure. | |

| | | | |

| | |Procedure: A 3 cm incision was made by the umbilicus and dissection carried down into the abdominal cavity under | |

| | |direct vision. Lap Disk was inserted and the abdominal cavity was insufflated under direct vision with a 5 mm 30 | |

| | |degree laparoscope. Operating trocars were placed in the left upper quadrant and left lower quadrant. The sigmoid | |

| | |colon was mobilized from its attachments to the left lateral side wall. It quickly became apparent that the colon | |

| | |was very intensely scarred against the pelvic side wall and the bladder. It could not safely be separated | |

| | |laparoscopically. In addition, the transverse colon was involved with extensive adhesions to the patient’s previous | |

| | |subcostal incision, which also could not be safely mobilized laparoscopically, therefore, the decision was made to | |

| | |proceed with open resection. | |

| | | | |

| | |The lap disk was removed and incision was extended. The Bookwalter retractor was placed and used as an aid in | |

| | |operative exposure throughout the case. The remainder of the sigmoid colon was mobilized. The area where there had | |

| | |been adherence to the bladder was repaired in two layers. The descending colon was mobilized by dividing its lateral| |

| | |attachments. The splenic flexure was mobilized by dividing the splenocolic, renocolic and gastrocolic ligaments. The| |

| | |omentum was elevated up off the transverse colon, which was dissected away from its adherence to the abdominal wall | |

| | |and the undersurface of the liver from the patient’s previous cholecystectorny when the entire colon had mobilized | |

| | |from the hepatic flexure to the rectum, dissection was carried down into the pelvis. Both ureters were carefully | |

| | |identified and preserved. The proximal rectum was cleared off circumferentially at approximately the level of the | |

| | |peritoneal reflection. Once it had been completely cleared off and it was divided by an application of the contour | |

| | |curved linear cutting stapler. | |

| | | | |

| | |The mesentery of the rectosigmoid was elevated off the presacral fascia back to the level of the inferior mesenteric| |

| | |artery. The descending sigmoid branch of the IMA was controlled, secured and divided. The more proximal branches | |

| | |were maintained. Now that the colon had been divided and the entire left colon was mobilized, point for division of | |

| | |the proximal colon was selected just proximal to the splenic flexure where the bowel was normal in size, shape and | |

| | |texture. The pursestring clamp was placed across the colon and the pursestring suture was placed. Kocher was placed | |

| | |on the specimen side and the bowel was divided. The remaining mesenteric attachments were controlled, secured and | |

| | |divided. | |

| | | | |

| | |Specimen was opened off the table by the pathologist who confirmed the adequacy of the resection. The proximal colon| |

| | |was sized and a 29 mm anvil was placed within it. The pursestring suture was tied. All the bowel ends were verified | |

| | |to be healthy and well vascularized. The rectum was dilated and the 29 mm stapler was introduced transanally to the | |

| | |apex of the rectal stump where it was opened, the anvil was attached. The proximal colon was carefully positioned | |

| | |without any angling, tension or twisting. Once the anvil was attached, the stapler was closed under direct vision | |

| | |and the stapler was then checked circumferentially. The stapler was fired. It was then opened and removed without | |

| | |difficulty and two complete tissue donuts were verified. Entire abdominal cavity was irrigated with warm saline | |

| | |solution and complete hemostasis was verified. | |

| | | | |

| | |On-Q tunnelers were placed on either side of the incision in the preperitoneal plane. Several sheets of Seprafilm | |

| | |were placed beneath the incision to minimize postoperative adhesions. Abdomen was closed with internal retention | |

| | |sutures in a doubled running fascial closure. Wound was irrigated with antibiotic solution and complete hemostasis | |

| | |was verified. All incisions were then closed in layers and dressed. On-Q catheters were placed through the peel-away| |

| | |sheath introducers and the introducers were removed. Catheters were secured, dressed and primed, and the On-Q pump | |

| | |was attached and activated. Patient was then awakened and transported to the post anesthesia care unit in good | |

| | |condition. Blood loss was less than 100 ml. There were no complications. No packs or drains were needed. Procedure | |

| | |was well tolerated throughout. | |

|02/16/YYYY |ABCD |Surgical pathology report of left colon: |11-12 |

| | | | |

| |XXXXX, M.D. |Collected: 02/10/YYYY | |

| | | | |

| | |Diagnosis: | |

| | |Diverticulosis of colon | |

| | |Diverticulitis of colon with abscess/phlegmon/giant cell reaction focally to chunky amorphous material. | |

| | |One reactive lymph node. | |

| | |Mild increase in subepithelial collagen band in the area of diverticular disease from Masson trichrome stain. | |

| | |This is a nonspecific finding that can be seen with diverticular disease. Sections away from the diverticuli do not | |

| | |demonstrate thickening of the subepithelial collagen band. Congo red stain is negative for amyloid. | |

|02/24/YYYY |XXXXX, M.D. |Follow-up visit status post left hemicolectomy: |2 |

| | | | |

| | |Patient doing well. Eating without difficulty. No problem voiding. Bowels moving satisfactorily. Activity level as | |

| | |expected. | |

| | | | |

| | |Physical examination: Incisions healing well. Good healing ridge. No weakness or defect. | |

| | | | |

| | |Assessment: Satisfactory post operative course. | |

| | | | |

| | |Plan: Increase activity as tolerated. Return in 3 weeks. | |

| | | | |

| | |*Reviewer’s comment: Further medical records after 02/24/YYYY are not available to know the progress of the patient.| |

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