Patient Name DOB: 01/04/YYYY
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 history of past GI disorders) / Gastroesophageal reflux disease, hypertension, rheumatoid arthritis, migraine, high cholesterol, heart murmur, joint pain / 16
List of previously used anti hypertensive medications / Propranolol 40 mg
Triamterene/Hydrochlorothiazide 37.5-25 mg
Benazep/Hydrochlorothiazide 20-25 mg
Metoprolol ER 50 mg
Inderal LA 60 mg / 125, 123, 121, 101-103
Prior use of other ARBs (Losartan, Telmisartan) / Not available
Concomitant use of other anti-hypertensive / Metoprolol ER 25 mg, Hydrochlorothiazide 25 mg / 105-107, 109-111, 113-115, 120
Concomitant use of other medications / Depo-Medrol injection, Zithromax Z-pak 250 mg, Zyrtec, Naproxen 400 mg, Ibuprofen, Epipen, Dulera, Ventolin, Cyclobenzaprine 10 mg, Clonazepam 1mg, Flexeril 10 mg, Topiramate 25 mg, Cholestyramine 4 gm, Flagyl 500 mg, Levaquin 750 mg, Sumatriptan 100 mg, Vitamin D 50000 units, Omeprazole 20 mg, Gabapentin 300 mg, Align 4 mg, Advil 200 mg, Aleve 220 mg, CoQ-10 50 mg, Fish oil 1000 mg, Imitrex 100 mg, Neurontin 300 mg, Propo-N/APAP 100-650 tablet, Klonopin 1 mg, Megestrol AC 20 mg, Clindamycin 300 mg, Terbinafine 250 mg, Azithromycin 250 mg, Topiramate 250 mg / 14, 15, 16-18, 19-21, 22-24, 59-63, 25-26, 27, 63-69, 51-56, 74-78, 105-106, 109, 112, 114-115
Benicar Start Date / Unknown
*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 / 104
Dosage / 40-25 mg / 104-107
Benicar Stop Date / Unknown
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. / 120, 31-32
Benicar Adverse Events (Whether diagnosed with enteropathy, diarrhea, dehydration, malnutrition, villous atrophy and villous blunting) / Yes – Diarrhea / 19-21
Date of Diagnosis of Adverse Event / 08/19/YYYY: Colonoscopy – Multiple medium diverticula in colon
08/14/YYYY-08/20/YYYY: Abdominal pain, diarrhea, diverticulosis
08/21/YYYY: Diarrhea, nausea, vomiting
08/23/YYYY-10/16/YYYY: Diverticulitis, fatigue
02/17/YYYY: Diverticulitis, diarrhea, vomiting and nausea, IBS
04/01/YYYY: Colonoscopy - Moderately severe diverticulosis in the sigmoid colon.
04/01/YYYY: CT abdomen – Pandiverticulosis
04/21/YYYY: Diarrhea, diverticulitis of colon
06/26/YYYY-01/12/YYYY: Recurrent episodes of diverticulitis / 87-89, 19-21, 22-24, 59-63, 25-26, 27, 63-69, 84-85, 90-91, 51-56, 33-34, 94-98, 3-5
Management of Adverse Event / · Levaquin 500/750 mg
· Flagyl 500/750 mg
· Restriction of food that increases bowel activity
· Ondansetron 8 mg
· 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 / 19-21, 22-24, 59-63, 27, 63-69, 84-85, 86, 51-56, 74-78, 94-98, 6-8
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 Last Available Record / 02/24/YYYY: Patient doing well. Eating without difficulty. Bowels moving satisfactorily. 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. / 2
Missing Medical Records:
Medical Provider / Date/Time Period / Why we need the Records/Bills / Is Record Missing Confirmatory or Probable? / Hint/Clue that records are missing
Medical Records during YYYY-07/YYYY / Unknown / 04/YYYY-07/YYYY / To note the Benicar use details / Confirmatory / Pharmacy records are available for Benicar during this time period
Detailed Chronology
DATE / PROVIDER / OCCURRENCE/TREATMENT / PDF REF /08/19/YYYY / XXXXX Specialists
XXXXX, M.D. / Colonoscopy report:
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 / 87-89
*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)
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. / 14
02/20/YYYY / XXXXX Family Medicine / Follow-up visit for back pain: (Illegible notes)
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. / 15
05/22/YYYY / XXXXX, FNP / Follow-up visit for cough:
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. / 16-18
08/14/YYYY / XXXXX XXXXX, M.D. / Follow-up visit for evaluation of stomach bug:
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. / 19-21
08/20/YYYY / XXXXX XXXXX, M.D. / Follow-up visit for left lower quadrant pain:
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. / 22-24
08/21/YYYY / XXXXX One Care
XXXXX, M.D. / Gastrointestinal consultation for abdominal pain, diarrhea:
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. / 59-63
08/23/YYYY / XXXXX XXXXX, M.D. / Follow-up visit for diverticulitis:
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. / 25-26
10/16/YYYY / XXXXX Family Medicine
XXXXX XXXXX, M.D. / Follow-up visit for diverticulitis: (Illegible notes)
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. / 27
02/17/YYYY / XXXXX One Care
XXXXX, M.D. / Follow-up visit for diverticulitis:
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. / 63-69
04/13/YYYY-03/24/YYYY / XXXXX pharmacy / Pharmacy dispensing record:
Medication refilled: Benicar Hct 40-25 mg. / 104-107, 109-111, 115, 120
04/01/YYYY / XXXXX Specialists
XXXXX, M.D. / Colonoscopy report:
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. / 84-85
04/01/YYYY / XXXXX and Therapeutics
XXXXX, M.D. / CT of abdomen and pelvis:
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 / 90-91
04/04/YYYY / XXX Specialists
XXXXX, M.D. / Pathology report:
Collected: 04/01/YYYY
Final diagnosis:
Ascending colon and descending colon - Histologically unremarkable colonic mucosa. Colitis not identified. / 86
04/21/YYYY / XXXXX One Care
XXXXX, M.D. / Follow-up visit status post colonoscopy:
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. / 51-56
05/12/YYYY / XXXXX One Care
XXXXX, M.D. / Follow-up visit for diarrhea:
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. / 74-78