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Actos Case Review – Martin Cly

Parameter / Findings / Page Ref
Our File No: / XXX / AT-001
First Name / Martin / AT-299
Initial / D / AT-299
Last Name / Cly / AT-299
DOB / 08/10/1942 / AT-001
Medication Taken / Actos / AT-106-110
Actos Start Date / 03/2000 / AT-108
Dosage / 30mg / AT-108
Still on Actos? / No
Last refill date: 08/08/2011
Diagnosed with bladder cancer? / Yes / AT-419
Date of Diagnosis / 06/04/2004 / AT-419
Stage of Cancer / Stage II as of 07/02/2004, low grade as of 07/30/2009 / AT-453-456, 48
Smoker / Yes, he is a former smoker / AT-764
Current Condition / Diabetes, atrial fibrillation, coronary artery disease, hypertension, cardiac stent placement, CABG / AT-618-623
Prior Medical History / Diabetes, coronary artery disease, GERD , Gout / AT-620
MD Findings

Pharmacy Log

Date / Drug / Rx. Doctor / NDC Code / Pharmacy / Dosage / Quantity / Manf. Name / Link to Records
01/26/2004 / Actos / Green / XXX / XXX / 30mg / 30
02/16/2004 / Actos / Green / XXX / XXX / 30mg / 90
05/05/2004 / Actos / Green / XXX / XXX / 30mg / 90
08/01/2004 / Actos / Green / XXX / XXX / 30mg / 90
10/24/2004 / Actos / Green / XXX / XXX / 30mg / 90
01/24/2005 / Actos / Green / XXX / XXX / 30mg / 90
04/01/2005 / Actos / Green / XXX / XXX / 30mg / 90
07/11/2005 / Actos / Green / XXX / XXX / 30mg / 90
09/20/2005 / Actos / Green / XXX / XXX / 30mg / 90
12/15/2005 / Actos / Green / XXX / XXX / 30mg / 90
02/26/2006 / Actos / Green / XXX / XXX / 30mg / 90
05/22/2006 / Actos / Green / XXX / XXX / 30mg / 90
08/09/2006 / Actos / Green / XXX / XXX / 30mg / 90
11/15/2006 / Actos / Green / XXX / XXX / 30mg / 90
02/08/2008 / Actos / XXX / XXX / 30mg / 90
04/18/2008 / Actos / XXX / XXX / 30mg / 90
08/19/2008 / Actos / XXX / XXX / 30mg / 90

Medical Chronology of Hospitalization Events

(including Operative Procedure, Reason for Surgery, Complications, Pathology, Findings)

DATE / PROVIDER / OCCURRENCE/TREATMENT / Bates
Ref /
06/04/2004 / Standard Hospitals / CT Urogram:
There is a 21-mm left posterior bladder mural nodule which is suspicious for neoplasm. / AT-419
06/08/2004 / Urology of Illinois
Chris A. Stanley, M.D. / Consultation for gross hematuria:
He has had two episodes of gross hematuria associate with some mild dysuria or a few clots associated with both of those episodes. Cystourethroscopy revealed normal urethra with no evidence of stricture disease. The prostatic fossa is about 3.5 cm in length with some trilobar hypertrophy. Inspection of the bladder reveals a 2 cm papillary appearing tumor consistent with transitional cell carcinoma on the left lateral wall.
He will be given prophylactic antibiotics for the next few days. I recommended proceeding with a cysto under anesthetic with Transurethral Resection for Bladder Tumor (TURBT). / AT-43-45
07/01/2004 / Standard Hospitals
Chris Stanley, M.D. / Operative notes:
Preoperative and postoperative diagnosis: Bladder tumor
Indications for procedure: The patient, former smoker, who presented to his primary care physician with pain with total gross hematuria. ACT scan was obtained which revealed normal upper tracts bilaterally, and a large filling defect within the bladder of approximately 2-cm in size. He was referred for urologic evaluation. Cystoscopy in the office confirmed the presence of about a 2cm left lateral wall bladder tumor. He presents now for resection of the bladder tumor.
Procedure: Cystourethroscopy with transurethral resection of bladder tumor, medium sized / AT-82-83
07/02/2004 / Standard Hospitals / Pathology report:
Bladder tumor, transurethral resection:
Transitional cell carcinoma, grade 2/3. No diagnostic invasion identified. No significant muscular tissue present
Microscopic examination of the bladder tumor demonstrates papillary transitional cell carcinoma. There is mild nuclear pleomorphism without significant mitotic activity identified / AT-453-456
11/11/2004 / Standard Hospital
Chris A. Stanley, M.D. / Operative notes:
Preoperative and postoperative diagnoses: Bladder lesion, history of bladder cancer
Indications for procedure: Prior history of bladder cancer, status post TURBT in July of 2004. Pathology revealed at that time a grade 2/3 transitional cell carcinoma of the bladder. The patient underwent recent surveillance cystourethroscopy, which revealed a small area of papillary growth and erythema right on the edge of a scar, worrisome for a local recurrence.
Procedure performed: Cystourethroscopy with bladder biopsy / AT-80-81
11/11/2004 / Standard Hospital / Pathology report:
Chronic cystitis with focal epithelial atypia. No definitive malignancy identified. Muscularis propria present / AT-68-69
01/14/2005 / Urology of Illinois / Pathology report-Prostate biopsy:
Benign prostatic tissues present / AT-65-66, 75
05/18/2007 / Standard Hospital
Chris A. Stanley, M.D. / Operative notes:
Preoperative and postoperative diagnosis: History of bladder cancer now with prostatic urethral lesion
Indications: Prior history of elevated PSA, with negative biopsies. He also has a history of superficial low-grade bladder cancer. On recent surveillance cysto, he was noted to have small papillary-appearing lesion anteriorly in the prostatic urethra. The remainder of the bladder was unremarkable. He has been having some mild dysuria over the last couple of months.
Procedure: Cystourethroscopy with prostatic urethral biopsy / AT-78-79
05/18/2007 / AnniPath / Pathology report:
The main differential is judged to be between reactive-hyperplastic changes of urothelium vs. papillary urothelial neoplasm of low malignant potential, non invasive, (grade I/III transitional cell carcinoma) / AT-201-202
06/18/2009 / Urology of Illinois
Chris A. Stanley, M.D. / Follow up visit:
History of recurrent superficial bladder cancer. Last tumor was in 2004. He has recently developed some intermittent painless hematuria. I proceeded with cystourethroscopy. He does have another papillary-appearing tumor in the prostatic urethra. Bladder itself appeared normal. Urinalysis just had a large amount of blood, no evidence of infection. I will set him up for a repeat TUR. Risks and benefits were explained. Patient wishes to proceed. / AT-13
07/30/2009 / Standard Hospital
Chris A. Stanley, M.D. / Operative notes:
Preoperative and postoperative diagnosis: Prostatic urethral tumors
Indication for procedure: Patient with recurrent superficial bladder cancer. He was recently found to have papillary tumors sitting within the prostatic urethra. He has been cleared from a cardiology standpoint. I have recommended anesthetic cysto with all indicated procedures. He is having intermittent hematuria.
Procedure: Cystourethroscopy with TUR of prostatic urethral tumors / AT-76-77
07/30/2009 / Illinois Surgery Center / Pathology report:
Prostatic urethra, tumor, transurethral resection:
Papillary urothelial carcinoma, low-grade. No evidence of invasion. / AT-48

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