Wiliam Sepulvado · Web viewBowel prep and preoperative antibiotics and Heparin prophylaxis tonight and she will present to the Operating Room in the morning for unilateral salpingo

Patient Name DOB: 09/17/YYYY

Talcum Case Review

Case Report

Parameter Findings PDF Ref

First name XXXX 13

Initial R

Last name XXXX

DOB 09/17/YYYY

Gender Female

Documentation of Talc

Usage in medical records

(Yes/No)

No

Brand of talcum powder

used

Not available

Diagnosed with Ovarian

Cancer?

Yes –Right ovary dysgerminoma 17,16,15

Date of Diagnosis 02/18/YYYY (Per available medical records)

*Reviewer’s comment: Upon review of available records, we note

patient was admitted on 02/18/YYYY for the surgical treatment of

ovary dysgerminoma. Prior medical records are not available to

know the exact date of diagnosis

8-9

Stage of Cancer Not known

Metastases (If any) As per the pathology report (Dated 02/19/YYYY), no evidence of

metastasis

15

Other risk factors for

ovarian cancer (hormonal

therapy, obesity, fertility

medications)

Not available

Treatment for Ovarian 02/19/YYYY: Exploratory laparotomy, right oophorectomy, 10-11

1 of 16


Parameter Findings PDF Ref

cancer appendectomy, pelvic aortic node sampling and partial

omentectomy

Physical side effects of

cancer treatment

None

Other Complications

(Talcosis/Respiratory

problems)

None

Death from Ovarian

cancer?

No

Smoking history Has she ever been a tobacco user? Yes 8

Period of time smoking: Not available

Heaviness of smoking: One or two in a month

Brand of cigarettes smoked: Not available

Has she quit smoking? Not available

When did she quit? Not available

Condition of the patient

per last available record

As on 02/27/YYYY, patient was discharged to home without any

complaints following hospitalization for the surgical treatment of

ovary dysgerminoma. Prescriptions given for Darvocet, Ferrous

Gluconate and Colace with instruction to follow up with Dr.

XXXXXX, M.D. after one month

Reviewer’s comment: Medical records after 02/27/YYYY are not

available to know the condition of the patient post surgical

management of ovarian cancer.

7, 3

Patient History (As on

02/18/YYYY)

Past Medical History: No significant illnesses.

Prior Surgeries: Non-contributory.

Family history: Not available

Allergies: No known drug allergies.

8

2 of 16


Missing Medical Record:

What Records

are Needed

Hospital/

Medical Provider

Date/Time

Period

Why we need the

records?

Is Record

Missing

Confirmatory or

Probable?

Hint/Clue that records are

missing

Office visits and

diagnostic studies

for abdominal

complaints

Unknown

Prior to

02/18/YYY

Y

To know the exact

date of diagnosis

and also

treatments

underwent for

abdominal

complaints

Confirmatory

Per operative report dated on

02/19/YYYY, We have noted

that patient went to Gynecologist

for her complaints and had

diagnostic studies for the same

Medical records Unknown

After

02/27/YYY

Y

To know the post

operative

condition of the

patient

Confirmatory

Discharged on 02/27/YYYY

with instruction to follow up

with Dr. XXXXXX, M.D. after

one month

3 of 16


Detailed Chronology

DATE PROVIDER OCCURRENCE/TREATMENT PDF REF*Reviewer’s Comments:

As per available medical records, we do not have any evidence to suggest that patient used talcum powder.

Medical records prior to 02/18/YYYY are not available to know the abdominal complaints of the patient and its corresponding office visits.

02/18/YYYY

XXXXXX Health

XXXXXX, M.D.

Admission for surgical treatment of a probable dysgerminoma:

Chief complaint: Patient presents for surgical treatment of a probable dysgerminoma.

History of presenting illness: She initially presented to a chiropractor for chronic back pain approximately two months ago and after several weeks of treatment she noted increased abdominal girth and one particular area which was firm and slightly tender in her lower abdomen. Over the last month this mass has become much larger extending to the umbilicus. It is sometimes tender to palpation and does cause her some abdominal pains related to activity and she has noted increased bladder pressure with urgency over the last week or so.

*Reviewer’s comment: Corresponding chiropractic records are not available for review to know the diagnosis and treatment rendered for chronic back pain.

Preoperative workup showed an elevated Lactate Dehydrogenase (LDH) at 4574 with an Alpha-Fetoprotein (AFP) of less than 30 and a Human Chorionic Gonadotropin (HCG) of less than 10. Chest X-ray and CAT Scan results are not available.

*Reviewer’s comment: Corresponding labs reports of LDH, AFP and HCG are not available for review.

Physical examination:Abdomen: Soft and nontender except for a mass which extends from the symphysis to the umbilicus. It appears to be somewhat mobile and is mildly tender.Neurological: Cranial nerves II—XII are grossly intact. She is pleasant and cooperative although somewhat anxious about her hospitalization. Deep tendon reflexes and patellar reflexes 4+ with one beat of clonus

8-9, 25-26

4 of 16


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFappreciated.

Impression: Patient with probable dysgerminoma, here for surgical treatment.

Plan: Bowel prep and preoperative antibiotics and Heparin prophylaxis tonight and she will present to the Operating Room in the morning for unilateral salpingo oophorectomy and possible total abdominal hysterectomy and bilateral salpingo oophorectomy.

02/18/YYYY

XXXXXX Health

Labs:Urinalysis:

Parameter ResultsBlood 3+RBC 8-12

CBC:Test Result Reference RangeWBC 4.46 (Low) 4.5-13.5 x103

RBC 3.78 (Low) 4.2-5.4 x106

HGB 10.5(Low) 12.0-16.0 gm/dLHCT 33 (Low) 37-47%

Segmented neutrophil

63.7 (High) 30-60%

37, 35

02/19/YYYY

XXXXXX Health

XXXXXX, M.D.

Operative Report of laparotomy, right oophorectomy, appendectomy, pelvic aortic node sampling and partial omentectomy:

Pre and postoperative diagnosis: Germ cell tumor, Ovary

Anesthesia: General

Procedure performed: Exploratory laparotomy, right oophorectomy, appendectomy, pelvic aortic node sampling and partial omentectomy.

Preoperative Problems & Preparations: The patient is a 20-year-old female who gives a history of increased size of the lower abdomen over the past month or so. The patient obviously has a large pelvic tumor extending up to the umbilicus. Just for the record’s sake, the tumor has been virtually asymptomatic except increased size of the lower abdomen with clothes being tight.

The patient’s Gynecologist verified this clinically by examination, ultrasound and CT scan.

10-11

5 of 16


DATE PROVIDER OCCURRENCE/TREATMENT PDF REF

*Reviewer’s comment: The corresponding Gynecological visits and the Ultrasound and CT scan reports are not available to note the abdominal symptoms and its findings.

After examining the patient, I had a very lengthy discussion with the patient and her family indicating that this is in all probability a germ cell tumor of the ovary and this will be best treated by conservative surgery if at all possible. I explained to the patient that it might be necessary to do a Total Hysterectomy and Bilateral Salpingo-Oophorectomy (THBSO) if we got into bleeding problems and it was unavoidable or if this turned out to another tumor that required this form of therapy. However, in all probability, we would do conservative surgery removing one ovary, sampling lymph nodes and the patient my require chemotherapy. The risk factors concerning this problem have been discussed with the patient and the family and they fully understand them, especially injury to any of the surrounding structures intraoperatively. By that, I mean any structures that surround the uterus or are in close proximity to the uterus or the ovary. Postoperatively, the patient may have fatal embolism, postoperative infection, hemorrhage, bowel obstruction, etc. The patient fully understands this.

Description of Procedure: Under general anesthesia, the patient is prepped and draped in the usual sterile manner. Through a low midline incision, the peritoneal cavity was entered. There was only about 10-15 cc of acitic (Must be ascitic) fluid present, but it was aspirated for cytologic purposes. The pathology encountered was a large tumor filling the pelvis and upper and lower abdomen. It extended from the right to the left side. The tumor did originate from the right ovary. There was no recognizable ovarian tissue left. The tumor was approximately 20 cm in greatest diameter. The right tube was normal. There were no adhesions. The tumor had a smooth lobulated surface, dull gray and dull pink in color. The opposite tube and ovary were normal. The uterus was normal in size. Pelvic abdominal exploration was essentially negative, especially the pelvic and aortic node bearing areas. On the right side, the infundibulopelvic ligament was clamped, cut and the pedicle ligated with Chromic 1 catgut and relegated. The remaining connections with the uterus were very easily removed by clamping with a Heaney clamp and excising the tumor. The tumor was sent down to pathology and the path report came back dysgerminoma. With this present, the retroperitoneal space was opened on both sides and pelvic node sampling was carried out involving the iliac vessels, obturator fossa. Small, medium and large hemoclips were used for lymphatic and hemostasis. At the completion of

6 of 16


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFthe procedure, the retroperitoneal space was irrigated. The anatomy was found to be intact including the genitofemoral nerve, obturator nerve, large iliac vessels, the ureter. The retroperitoneal space was rinsed and on the right side was drained with a large Hemovac suction and brought out through the right lower quadrant of the abdomen. On the left side, it was extremely dry and it was closed with two or three interrupted Chromic catgut sutures leaving the spaces open so that any drainage could drain into the main peritoneal cavity. This was followed by-an incidental appendectomy. The bowel was packed out of the way and the peritoneum was opened over the bifurcation of the aorta up to the retroperitoneal duodenum. Lymph node sampling was carried out in the aortocaval area removing the fat pad 4x6 cm from the bifurcation to the retroperitoneal duodenum. Small and medium hemoclips were used for lymphatic and hemostasis. The retroperitoneal space was closed over Surgicel using Chromic 00 catgut.

As I said before, an incidental appendectomy had been carried out. This was followed by a partial omentectomy on a routine basis. Once again, the entire peritoneal cavity was examined and found to be intact. There were no enlarged nodes that could be palpated anywhere in the pelvis or in the aortic area.

With hemostasis secured and sponge count reported correct, the peritoneal cavity was rinsed and then closed using Chromic 0 to the peritoneum, Vicryl 1 in the anterior rectus sheath, metal clips in the skin. Postoperative condition is good. Blood loss negligible. The patient goes to the Recovery Room in stable condition.

02/19/YYYY

XXXXXX Health

Labs – CBC:Test Result Reference RangeRBC 3.32(Low) 4.2-5.4 x106

HGB 9.6 (Low) 12.0-16.0 gm/dLHCT 29.0 (Low) 37-47%

35

02/20/YYYY

XXXXXX Health

Progress note POD#1: (Illegible)

Vital signs stable. Temperature 100.6 last evening, now 100.Poor _______effortComplains of itching, does not want Patient Controlled Analgesics (PCA) discontinued

Examination: Lungs: Diffused rhonchiAbdomen: Soft, diffuse tenderness and negative bowel soundsIncision clean and dryExtremities: No tenderness

27

7 of 16



Labs: WBC: 8.45, hemoglobin/ hematocrit 9.6/29.0Pathology pending

Assessment/plan: Stable POD#1 Complains of itching with PCA – Benadryl Increased respiratory effort Increased activity

02/20/YYYY

XXXXXX Health

Labs – CBC:

Test Result Reference RangeRBC 3.16 (Low) 4.2-5.4 x106



63.7 (High) 30-60%

Lymphocyte 21.7 (Low) 25-50%

35

02/20/YYYY

XXXXXX Health

Post operative progress notes: (Illegible)@2045 hrs

Regarding: Temperature 101. 4 °F

Patient has been febrile all day. As per above poor ___ effort. Patient still on PCA and seems drowsy. May not be breathing deeply secondary to sedation. Has been up in chair thrice today. Not doing well with respirer.

Physical examination: Lungs clear to auscultation bilaterally with minimal bibasilar crackles. Cardiovascular regular rhythm with tachycardia. IV sites without erythema.

Impression/Plan: POD#0 fever Probable source is respiratory overmedication Will reduce PCA rate to 0.2 every 15 minutes Will increase Albuterol to every 4 hours around the clock Will obtain urinalysis and culture and sensitivity to rule out

Urinary Tract Infection (UTI). Discussed with Urogyn doctor

28

02/21/YYYY

XXXXXX Health

Labs – CBC:


HGB 9.4 (Low) 12.0-16.0 gm/dL

35

8 of 16


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFHCT 28.4 (Low) 37-47%


83.6 (High) 30.60%

Lymphocyte 10.4 (Low) 25-50%02/21/YYYY

XXXXXX Health

XXXXXX, M.D.

POD#2 Progress note: (Illegible)

Patient complains of post operative pain and hot. (Ambient temperature in room probably >75°F)

Physical examination:Tmax 102.3 Overnight treated with aerosols. Morning labs pending.Temperature now 100.3°F BP 110/54Input 4200 output 2700 (JVAC 120 cc)Lungs: Few rales in __ no wheezesHeart: Regular Rate and Rhythm (RRR) without murmurAbdomen: Soft, ___ tender, negative bowel soundsSkin: Dry and intact without erythema. Drain site Okay

Assessment/plan: Post operative fever- if continues today would consider addition of antibiotics for broader spectrum

28

02/22/YYYY

XXXXXX Health

Labs –CBC:




83.3 (High) 30.60%


35

02/22/YYYY

XXXXXX Health

XXXXXX, M.D.


Patient complains of nausea, emesis x2 yesterday. Positive bowel movements with diet cola.Afebrile. Vital signs stableAbdomen soft and few bowel soundsJVAC patent, 65 cc out in 24 hours

Labs: RBC 8.5, Hb 10.0 HCT 30.2 platelets 261

Assessment/plan:Nausea may secondary to DemerolWill prescribe per oral analgesia with Phenergan as needed

29

9 of 16


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFWill give Dulcolax again todayDoubt ileusEncourage ambulation

02/23/YYYY

XXXXXX Health

Labs:CBC:


HGB 8.6(Low) 12.0-16.0 gm/dLHCT 26.3 (Low) 37-47%


75.7 (High) 30.60%


Chemistry: Test Result Reference Range

Potassium 3.1 (Low) 3.5-5.5 Meq/LBUN 3 (Low) 9-18 mg/dL

@0835 hrs BUN/Creatinine ratio

5 7-25

@2120 hrs BUN/Creatinine ratio

4 7-25

35, 36

02/23/YYYY

XXXXXX Health

XXXXXX, M.D.

Progress notes POD#4: (Illegible)

No complaints except labial edemaNausea resolved, Positive flatusAfebrile , vital signs stableUrine culture negative , CBC pendingAbdomen soft non tender and normal bowel soundsSkin dry and intactLeft labial edema markedNo erythema, lesions and drainageMinimally tenderJVAC approximately 100 cc over 24 hours

Assessment/plan:Doing wellLabial edema treated with sitz bath, ice and ambulationNo signs and symptoms of hematoma or infectionDiscontinued IV, Changed to Per oral Keflex with JVAC in bowel

___Advance diet

30

02/23/ XXXXXX X-Ray report of abdomen and PA chest: 40

10 of 16


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFYYYY Health

XXXXXX, M.D.

Impression: There is gaseous distention of the small bowel out of proportion to the large bowel and therefore suggestive of a small bowel obstruction.

02/23/YYYY

XXXXXX Health

Progress note:@1840 hrsAcute Abdominal Series (AAS) – Suspecting Small Bowel Obstruction (SBO), Marked air fluid levels of small bowel. No air in colonPatient reports nausea with bilious vomiting, Bowel movements X1 today. Small amount of flatus.Abdomen: Not tender non distended minimal (Hypoactive) Bowel sounds

Assessment/plan:SBO versus adynamic ileus – No reason for mechanical obstruction. Most likely with operative ileus. Will place Nasogastric. Keep NPO except ice chips. Repeat potassium tonight. Ask surgical Resident to review pulmonary.

30

02/24/YYYY

XXXXXX Health

Labs – Chemistry:

Test Result Reference RangePotassium 3.3 (Low) 3.5-5.5 Meq/L

36

02/24/YYYY(Signed date)

XXXXXX Health

XXXXXX, M.D.

Pathology Report:

Collected date: 02/19/YYYY

Tissue submitted: Pelvic and aortic node sampling, omental biopsy

Frozen section diagnosis: Germ cell tumor, consistent with a dysgerminoma.Gross:The specimens are submitted in nine containers.Container A: This specimen is an ovary, which has been completely replaced by a 17 x 8.5 x 11 cm tumor mass. The capsule of the ovary which is smooth, glistening, grayish white is intact and free of adhesions. Sectioned surfaces of the tumor mass are smooth, soft, and tan pink, with focal areas of hemorrhage and cystic degeneration, but no gross massive necrosis. A fallopian tube is not identified on the external aspect of the ovary. (Multiple sections including sections from the cystic and hemorrhagic areas.)Container B: Right obturator lymph nodes. Four lymph nodesContainer C: Right common iliac lymph node. Two lymph nodes.Container D: The specimen is a 7 cm. vermiform appendix, which is

17,16,15

11 of 16


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFgrossly unremarkable on sectioning. (One section).Container E: Omentum biopsy. The specimen consists of an 8.5 x 4 x 2.5 cm. piece of omentum, the sectioned surfaces of which do not show any significant gross lesions. (Random sections).Container F: Right external iliac lymph node. One lymph node.Container G: Left obturator lymph nodes. Three lymph nodes.Container H: Left external iliac lymph nodes. Three lymph nodes.Container I: Aortic lymph nodes.Diagnosis:

Specimen A, right ovary, dysgerminoma (pure). Specimens B, C, F, G, H, I, lymph node groups, total of 16 lymph

nodes, no evidence of metastatic tumor Specimen D, vermiform appendix, a few peritoneal inclusion

cysts, serosal surface of the appendix. Specimen E, omentum, chronic inflammation and mesothelial

cell proliferations (no evidence of metastatic tumor) 02/24/YYYY

XXXXXX Health

Progress notes POD#5: (Illegible)

Patient with discomfort secondary to N6; labial edema improved but still with discomfort

Physical examination:Tmax 100°F Pulse 100’s otherwise stable vital signsAbdomen: Soft non tender, hyperactive bowel soundsIncision clean and dry intact without erythema. Labial edema decreased

Labs reviewedAssessment/plan:

POD#5, Patient still with decreased bowel sounds. Plan to continue N6___

Patient appears to be otherwise stableTachycardia to secondary to decreased Hb. Will follow. May need

transfusion if symptomatic

31

02/25/YYYY

XXXXXX Health

Labs:CBC:




78.6 (High) 30.60%


35, 36

12 of 16


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFChemistry:

Test Result Reference RangePotassium 3.1 (Low) 3.5-5.5 Meq/L

BUN 3 (Low) 9-18 mg/dLBUN/Creatinine ratio 5 (Low) 7-25

02/25/YYYY

XXXXXX Health

POD#6 Progress note: (Illegible)@0835 hours

Patient with discomfort from N6, Otherwise no complaints.

Physical examination: Tmax 100.7°F, tachycardia, vital signs otherwise stable. 3900/3730 over 24 hours. N6 ____ guaiac negativeAbdomen: Soft, non tender and no bowel sounds noted. No erythema around incision. Incision clean, dry and intact achieved with staples. Labial edema resolved

Assessment/plan: Patient remains without bowel sounds – Plan to repeat AAS

possibly consult surgery if unchanged from 02/23 Continue N6 suction, patient unchanged from yesterday. JVAC drain discontinued per Dr. XXXX Pathology indicated dysgerminoma without no nodal

involvement.

32

02/25/YYYY

XXXXXX Health

XXXXX, M.D.

Ultrasound of Kidney, Ureter and Bladder (KUB):

Impression: The evidence of small bowel obstruction is no longer seen.

41

02/26/YYYY

XXXXXX Health

Labs:Test Result Reference RangeRBC 3.00 (Low) 4.2-5.4 x106


MCHC 31.3 (Low) 32-36 g/dLSegmented neutrophil

74.0 (High) 30.60%


Chemistry:Test Result Reference Range

Potassium 3.6 3.5-5.5 Meq/LBUN 3 (Low) 9-18 mg/dL

BUN/Creatinine ratio 6 (Low) 7-25

35, 36

13 of 16



Cardiac enzymes:Test Result Reference RangeLDH 305 (High) 118-242 U/L

02/26/YYYY

(Result date taken)

XXXXXX Health

N.XXXXXX, M.D.

Urine Culture report:Collected date: 02/18/YYYY

Final: No growth

38

02/26/YYYY

(Result date taken)

XXXXXX Health

N.XXXXXX, M.D.

Extragenital cytology report:Collected date: 02/19/YYYY

Sample: Peritoneal wash

Final: No malignant cells seen, RBC seen.

38

02/26/YYYY

XXXXXX Health

POD #7 Progress notes: (Illegible)

Patient much improved. N6 discontinued without complaints, positive bowel movementsTmax 100.6°F. vital signs stable. Input/ Output 1800/2000Incision clean/dry/intact with staples

Assessment/plan: Patient stable repeat AAS showed resolution of small bowel

obstruction N6 tube discontinued. Diet advanced Remove staples today

32

02/26/YYYY

XXXXXX Health

Progress note: (Illegible)

Skin chips outEating well and had bowel movementsSoft and regular diet and have to be followed by Resident in clinicNote: Explained necessity of close follow-up ___ and no more than 85%

33

02/27/YYYY

XXXXXX Health

XXXXXX, M.D.


No complaints

Labs:LDH: 308-decreased from 4574 preop, Hgb 8.3

Assessment/plan:Home with Darvocet, Iron. Instructions given. Follow-up in 4 weeks

33

02/27/ XXXXXX Discharge Summary: 3

14 of 16


DATE PROVIDER OCCURRENCE/TREATMENT PDF REFYYYY Health

XXXXXX, M.D.

Admit date : 02/18/YYYY

Disposition: Home or self care

Final ICD9 diagnoses: Principle: 1830-Malignant neoplasm of ovary Final diagnosis: 2768-Hypopotassemia Final diagnosis: 9974-Gastrointestinal complication, not

elsewhere classified Final diagnosis: 5609-Small bowel obstruction

Procedure information: Unilateral Oophorectomy Excision or destruction of peritoneal tissue Biopsy of lymphatic structure Incidental appendectomy

Final diagnosis: Uterus and adnexa procedures for ovarian or adnexal malignancy.

02/27/YYYY

XXXXXX Health

Discharge Instructions:

Darvocet N-100 for every 4-6 hours as needed for pain Ferrous Gluconate 300 mg 3x day Colace 100 mg per oral daily No sex, no heavy lifting and shower

Follow up: In one month with XXXXXX, M.D.

Discharged condition: Discharged to home with family member via wheelchair.

*Reviewer’s comment: Medical records after 02/27/YYYY are not available to know the condition of the patient post surgical management of ovarian cancer.

7

02/18/YYYY-08/29/2016

XXXXXX Health

Hospitalization and other non-related records 59-61, 2, 48, 4, 5-6, 12-14, 19-24, 43-46, 47, 62-63, 64, 65, 66-68, 88-89, 90-91, 94-95, 97-98, 42, 1, 96, 69-87, 99-156,

15 of 16


DATE PROVIDER OCCURRENCE/TREATMENT PDF REF49-58, 92-93

16 of 16

Documents

Wiliam Sepulvado · Web viewBowel prep and preoperative antibiotics and Heparin prophylaxis tonight and she will present to the Operating Room in the morning for unilateral salpingo