Preview
FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015
NYSCEF DOC. NO. 137 RECEIVED NYSCEF: 09/25/2020
EXHIBIT S
FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015
--
Shellyann (MRN: DOB: Encounter
Hoffman,
NYSCEF DOC. NO. 137 71290660) RECEIVEDDate: 01/21/2016
NYSCEF: 09/25/2020
Provider: Adrien Nicole Phalen Bernstein, MD Patient: Shellyann HoNmen
Supervisor: Gilbert J Wise, MD MRN: 71290660
Dept: Weill Comell Urology DOB: (39 year old)
Address: 525 East 68th Street SEX: ema e
Encounter Summary New York, New York Date: Jan 21, 2016
10065-4870 Visit ( 9:30 AM)
Documentation Notes
Gilbert J. Wise, MD Attending Thu Jan 21, 2016 10:53 AM
Electronically Signed
The Shellyann Hoffman is a 39 year old female with:
CC: intraoperative ureteral injury
PMH: HTN (hypertêñsion) Asthma Pre-eclampsia Lupus Prior pregñañcy with fetal demise PID (acute
pelvic inflammatory disease) Depression Stroke 3/2015 Celiac disease
CAESAREAN SECTION 1993 keloid [Other] HYSTERECTOMY 9/2014 with findings of placenta accreta.
Subsequent ureteric injury. PERCUTANEOUS NEPHROSTOMY 2014 CYSTOSCOPY W/
URETEROSCOPY ureteral reimplantation with psoas hitch
Supervising Attending Note:
Patient seen and examined. Case reviewed and discussed with Dr. Berñsteiñ; I agree with her note.
Shellyann Hoffman has had right ureteral implant for ureteric obstruction November 2014. . Physical
examination today is remarkable for WD WN woman. No abdominal pain. Surgical scars noted.Nuclide
scan 01/08/16
Mildly asymetric renal size. Split renal function: left kiciney 59%,
right kidney 41%,
2. Left kidney: Normal flow and function. No evidence of obstruction.
3. B.ight kidney: Normal flow and function. No evidence of obstruction.
Urine study in August no evidêñce for infection. Impression is ureteric reimplant right; Left pelvic fluid
mass (? Lymphocele) and the plan is refer back to GYN for management of fluid mass. It will need
drainage by IR.
Attending: Gilbert J. Wise MD
Adrien Nicole Phalen Bernstein, Resident Thu Jan 21, 2016 10:53 AM
MD Electronically Signed
Referring Provider
Provider Name: Angela Dvorkina
Type: Attending
Address: 81 WILLOUGHBY STREET, BROOKLYN NY 11201
Phone: 718-522-3399
Fax: 718-522-1888
Effective Date: 10/22/2015
Provider name: ANGELA DVORKINA
Type: Attending
Address: 81 WILLOUGHBY STREET, BROOKLYN, NY 11201
Phone: 718-522-3399
Fax: 718-522-1888
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27
FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015
--
Shellyann (MRN: DOB: Encounter
Hoffman,
NYSCEF DOC. NO. 137 71290660) RECEIVEDDate: 01/21/2016
NYSCEF: 09/25/2020
Chief Complaint
1. intraoperative ureteral
injury
History of Present Illness
Initial Patient Visit 9/26/14
Shellyann Hoffman is a 37 year old woman recently admitted to NYPH to the OB/GYN service for
intrauterine fetal demise who subsequently underwent amniocentesis and hysterectomy with
placenta/fetus embicc resection on 9/9/14. Post-operatively her Cr was known to rise from baseline of 0.7
to 1.2. She underwent renal US which revealed mild bilateral hydro, but high index of suspicion for
ureteral injury led to CTU which revealed abrupt disruption of contrast opacification within the ureter
consistent with ureteral transection. She subsequently underwent cystoscopy and b/I retrograde
pyelogram on 9/19 which revealed prompt extravasation from the lower right ureter with RPG. A wire
could not be advanced into the proximal ureter across the disruption. The patient subsequently underwent
right PCN placement and was discharged home. She presents today for further follow-up.
Since discharge she has been feeling overall well, though her mood has been intermittently down.
Managing well with the PCN which has had occasional hematuria but currently clear yellow. Wound is
open and being packed by VNS. No fevers, chills, nauses, or emesis.
PMH: depression, HTN, asthma, arthritis/LBP, headaches
PSH: hysterectomy as per HPI
SocHx: married, lives on Madison Ave and Jackson
FamHx: non-contributory
AII: NKDA
Interval History 11/26/14
Returns to clinic with her husband fo||owing open ureteral reimplant on 11/12/14. Post-op course was
uncomplicated and patient was discharged home 11/17 with right ureteral stent in place. She presented
to the ED on 11/22 with worsening abdominal pain and dysuria, CT revealed urothelial inflammation and
right stent in place. She was discharged home with PO Levaquin for ? UTI (Cx negative), as well as
Flomax/Pyridium.
Since discharge she has had bladder spasms and stent bother. Urgency and right flank pain with urination
but no fevers/chi||siñausea/emesis. She is still taking Percocet q4hrs, no constipation (taking Colace),
minimal relief from Pyridium/Flomax. Appetite is slowly improving. She has been quite active, walking
around, improvement in post-op right leg numbñêss, currently walking without issue.
We talked extensively about the post-operative course and timing of stent removal. She is apprehensive
about stent removal, will plan for cysto under MAC. We also discussed management of current
symptoms, will trial anti-cholinergic (warnings given re: retention, dry mouth).
Staples removed, steri-strips placed.
Interval History 4/16/15
Returns to clinic following stent removal in January. She had retinal detachment in March, had pr0cedure,
now with decreased vision in R eye. From GU standpoint, she continues to have occasicñal dysuria 1-2
times per week, particularly after having sexual intercourse. This is sometimes associated with right flank
pain. No fevers, chills, nausea, or emesis. No gross hematuria. She also has urinary urgency and
occasional UI.
PVR is O mL.
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FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015
--
Shellyann (MRN: DOB: Encounter
Hoffman,
NYSCEF DOC. NO. 137 71290660) RECEIVEDDate: 01/21/2016
NYSCEF: 09/25/2020
Interval history 8/19/15:
RTC for follow up. Recurrent bladder pain/dysuria. Helped with Pyridium, tramadol. Pain is worse at right
flank, the most ct demonstrates bowel thickening. No hydronephrosis. Felt much improved while on
antibiotics and that symptoms recurrent following, however all urine specimens recently have been
negative. Recently diagñcsed with celiac disease. Constipation since surgery (every four days) taking
colace and senna since surgery. Denies hematuria. Continues to have urge and urge incontinence. Slight
improvement with ditropan 5mg
Imaging:
CT ABDOMEN AND PELVIS W CONTRAST
Specimen Collected: 8/13/15
Last Resulted : 8/13/15
IMPRESSION:1. The duodenum and proximal jejunal loops are suboptimally distêñded.There is mild
fluid distêñticñ of the mid to distal jejunal and ilealbowel loops. No foci of small or large bowel wall
thickening are seen.No bowel obstruction.2. Mild to moderate abdominopelvic ascites.3. Chole|ithiasis.
Prepared By: Wladyka, Christopher MD
Interval history 11/25/15 :
RTC for follow up. Patient reports that she since stopping ditropan intc|êrable urinary frequency and
urgency, requesting to resume medication. Restarted with strict ED precautions however patient elected
not to re-initiate. Presents today with worsening UUI and pelvic discomfort and right flank pain and
difficulty urinating . PVR 594
Fevers: denies Dysuria: denies UTIs: denies Hematuria: dêñies Flank pain: right flank
pain Constipation: improving
Interval history 12/17/15:
RTC for follow up. CIC 4x/day. Without UUI continued urgency. Continued pain. Close review of
medications today. Patient reports that she is taking narotics/muscle relaxants for severe back pain.
Reports daily bowel movement with colace with senna. Denies fevers but endorcesOccasional hot
flashes. Right flank pain
Interval history 1/21/16:
RTC for follow up. CT demonstrates loculated fluid discussed with gyn. Continues with CIC 3x/day.
Continued abdominal pain. Constipation taking medication/high fiber diet. everyother day at this point.
1/8/2016 Lasix renoscan
Mildly asymmetric renal size. Split renal function: left kiciney 59%,
right kidney 41%,
2. Left kidney: Normal flow ancl function. No eviclence of obstruction.
3. Right kidney: Normal flow and function
Prior right ureteral reimplantation and psoas hitch, No hydronephrosis.
Mild interval increase size of slightly loculated fluid within the left
pelvis without evidence for contrast to suggest urinoma, like_Ly
loculated ascites.
Past Medical History
1. HTN (hypertension)
2. Asthma
3. Pre-eclampsia
4. Lupus
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29
FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015
--
Shellyann (MRN: DOB: Encounter
Hoffman,
NYSCEF DOC. NO. 137 71290660) RECEIVEDDate: 01/21/2016
NYSCEF: 09/25/2020
5. Prior pregnancy with fetal demise
6. PID (acute pelvic inflammatory disease)
7. Depression
8. Stroke 3/2015
left vision impairment
9. Celiac disease
Past Suraical History
1. Caesareañ Section Laterality: N/A 1993
pre-eclampsia
2. Keloid
left shoulder
3. Hysterectomy 9/2014
IUFD, placenta percreta
4. Percutaneous Nephrostomy Laterality: Right 2014
5. Cystoscopy W/ Ureteroscopy 9/18/2014
6. Hysterectomy
7. Supracervical Hysterectomy
8. Ureteral Reimplantation With Psoas Hitch Laterality: Right
Social History
Tobacco Use Never
Alcohol Use No
Drug Use No
Sexually Active Yes; Male partñêr(s); Birth Ctrl/Protection: Postmenopausal
Socioeconomic History
Occupation: homemaker -
Marital Status MARRIED
Number of Children: 3
ADL History,
ADL [No] Hobby Hazards, Exercise
Family History
Brother 1 Alive Allergies
Brother 2 Alive Asthma
Brother 3 Alive
Daughter 1 Alive
Father Alive No Sig. History
Mother Alive Allergies, No Sig. History (COPD)
Sister 1 Alive
Son 1 Alive
Son 2 Alive
Sexuality/Gender Identity
Topic Response Comments
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FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015
--
Shellyann (MRN: DOB Encounter
Hoffman,
NYSCEF DOC. NO. 137 71290660) RECEIVEDDate: 01/21/2016
NYSCEF: 09/25/2020
Sexual Orientation Straight/Heterosexual
Sex assigned at birth Female
Gender Identity Female
Medications (Reviewed in this Encounter by: Adrien Nicole Phalen Bernstein, MD)
Name Sig |Status
Inhale 2 Puffs every 6 hours
1. albuterol 108 (90 Base) Mcg/act Aero Soln as needed for wheezing or (Taking)
Shcitñêss of Breath.
Inh9a 3 ml eve ous as
. Albuterol Sulfate (2.5 Mg/3ml) 0.083% Nebu Soln (Taking)
e9
pray nasally 2 times
. Azelastine HcI 0.1 % Solution (Taking)
4. Bac!ofen 20 Mg Tab (Taking)
5. Bisaccdyi Ec 5 Mg Tab Ec (Taking)
6. Bupr0picñ XI 150 Mg Tab Sr 24hr (Taking)
7. Cho!ecalcifêrol (vitamin D3) 1000 Units Cap Take 1 Cap by mouth daily.
Apply 1 Drop to eye 4 times (Not
8. Cromolyn Sodium 4 % Solution
daily. Taking)
9. DOcqiace 100 Cap (Taking)
Mg
10. Dulera 100-5 Mcg/act Aerosol |(Taking)
a e 1 Tab W moum 2 hes
11. Enalapril Maleate 20 Mg Tab (Taking)
12. escitai0pram 20 Mg Tab Take 1 Tab by mouth daily. (Taking)
13. esomeprazole (nexium) 40 Mg Cap Dr h-ake 1 Cap by mouth daily. (Taking)
114. Fluticasone Propionate 50 Mcg/act Suspêñsicñ 2 Sprays daily. (Taking)
ñasally
15. Hydicchiarothiazide 25 Mg Tab Take by mouth. (Taking)
16. Hydroxychloroquine Sulfate (plaquenil) 200 Mg Tab Take 2 Tabs by mouth daily. |(Taking)
17. Mei0xicam 15 Mg Tab (Uñkñ0wn)
18. MetoDrolol Succiñate 50 Mq Tab Sr 24hr Take 1 Tab by mouth daily. (Taking)
19. Mometasone Furo-Formoterol Fum 200-5 Mcg/act
Inhale 2 Puffs 2 times daily. (Taking)
Aerosol
20. monte!ukest 10 Tab
ab W moum
Mg (Taking)
Iake 1 Tab by mouth 2 times
21. napr0xen 500 Mg Tab Ec (Taking)
daily as neeueu.
22. Nifedipiñe 60 Mg Tab Sr 24hr |(Taking)
k3. Nifedicine Cr Osmotic 60 Mg Tab Sr 24hr Iake 1 Tab mouth daily.
by
Iake 3 Tabs by mouth 3
24. Oxybutynin Chloride 5 Mg Tab limes daily. As ñêêdêd for (Taking)
bladder spasms
5. Phenazopyridine HcI 100 Mg Tab (Taking)
ee ed f a
26. Q-Pap Extra Strength 500 Mg Tab (Taking)
27. Ra Vitamin C 250 Mg Tab |(Taking)
28. Risperidone 0.5 Mg Tab
29. Seroquel Xr 150 Mg Tab Sr 24hr (Taking)
b0. Spacer/aero-Holding Chambers (optihaler) Misc No route applicable.
31. Tamsulosin HcI 0.4 Mg Cap Iake by mouth.
32. Tamsulosin HcI 0.4 Mg Cap
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FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015
--
Shellyann (MRN: DOB: Encounter
Hoffman,
NYSCEF DOC. NO. 137 71290660) RECEIVEDDate: 01/21/2016
NYSCEF: 09/25/2020
133. Tramadol-AcetaminoDhen 37.5-325 Mg Tab |(Taking)
Apply topically 2 times daily.
34. Triamciñcl0ñe Acetonide 0.1 % Cream Use to affected area twice a (Taking)
day. Avoid Groin
ake 1 Tab by mouth 2 times (Not
5. Trospium Ch|cride 20 Mg Tab
daily. Taking)
Allergies
1. Shellfish Itching
2. Shellfish-derived products
Review of Systems
Constitutional: As per hpi
Genitourinary: As per hpi
There were no vitals filed for this visit.
Physical Exam
Constitutional: NAD
Head: NCAT
ENMT: MMM
Resp: no work of breathing
Abd: soft nd nt no suprapubic tenderness
Back: min R CVAT
Neurologic: no gross motor defect
Psychiatric: appropriate affect
Assessment & Plan
38 year old woman with iatrogenic right ureteral transection during hysterectomy for intrauterine fetal
demise on 9/9/14 now s/p open right ureteral reimplant with psoas hitch on 11/12/14, subsequent removal
of ureteral stent 1/15. Now with urinary retention managed by CIC. Cont mild right flank pain and
worsêñing lowerback pain now with difficulty ambulating. Left sided fluid ccilêcticñ on MRI.
#s/p ureteral reimplant
-repeat UA/UCx today
-continue bowel regimen per PMD/GI
-Cr 9/2015 0.83
-Ct 813/2015 no hydronsphicsis
-ED warnings given for favers/chills, nauses/emesis
- lasix renolasix scan with good flow
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FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015
--
Shellyann (MRN: DOB: Encounter
Hoffman,
NYSCEF DOC. NO. 137 71290660) RECEIVEDDate: 01/21/2016
NYSCEF: 09/25/2020
- Large pelvic ccliêctioñ without evidêñce of urinoma, discussed fiñdiñgs with gyn. Patient will follow with
gyn for IR drainage
#urgency frequency/UI
- given UUI And retention discussed UDS risks benefits and patient would like to
wcisêñing urinary
picceed with UDS on 2/12. Ucx today for PAT
- continue CIC has supplies
- PVR 252
- AUR multifactorial 2/2 to pain muscle ?neurciOgic and left sided pelvic
medication, relaxant, component,
collection.
-RTC 1 month following CT to discuss püssib|ê IR drainage of ccliêcticn
Patient seen and discussed with attending Dr. Wise
RTC following UDS
Scan on: 01/22/2016 10:19 AM by Rechõña Sears [RES2031] Descripticñ: Lab Result Scan (Bladder Scan)
Scan on: 01/22/2016 10:14 AM by Reshona Sears [RES2031] Description: Diagñõsis sheet (Urology )
Diaanosis
1. Intraoperative Ureteral [N99.81 997.5 - Dx
Injury (ICD-10), (ICD-9)] Primary
Order Summary
Orders
1. Urine Culture [87086]
2. Urinalysis, Dipstick With Micresepic Exam [81001]
3. Sono Bladder Scan (Back Office) [51798]
Follow-up and Disposition
Level of Service LOS Modifiers
OFFICE/OUTPT VISIT,EST,LEVL Ill [99213] SERV PERF IN PART BY RES UNDER DIR OF A
TEACHING PHYSICIAN [GC]
SIGNIFICANT SPRTLY IDABLE EVAL & MGMT ON
SAME DAY BY SAME PROV [25]
LOS History Recorded
Results
URINE CULTURE
Preview
FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015 NYSCEF DOC. NO. 137 RECEIVED NYSCEF: 09/25/2020 EXHIBIT S FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015 -- Shellyann (MRN: DOB: Encounter Hoffman, NYSCEF DOC. NO. 137 71290660) RECEIVEDDate: 01/21/2016 NYSCEF: 09/25/2020 Provider: Adrien Nicole Phalen Bernstein, MD Patient: Shellyann HoNmen Supervisor: Gilbert J Wise, MD MRN: 71290660 Dept: Weill Comell Urology DOB: (39 year old) Address: 525 East 68th Street SEX: ema e Encounter Summary New York, New York Date: Jan 21, 2016 10065-4870 Visit ( 9:30 AM) Documentation Notes Gilbert J. Wise, MD Attending Thu Jan 21, 2016 10:53 AM Electronically Signed The Shellyann Hoffman is a 39 year old female with: CC: intraoperative ureteral injury PMH: HTN (hypertêñsion) Asthma Pre-eclampsia Lupus Prior pregñañcy with fetal demise PID (acute pelvic inflammatory disease) Depression Stroke 3/2015 Celiac disease CAESAREAN SECTION 1993 keloid [Other] HYSTERECTOMY 9/2014 with findings of placenta accreta. Subsequent ureteric injury. PERCUTANEOUS NEPHROSTOMY 2014 CYSTOSCOPY W/ URETEROSCOPY ureteral reimplantation with psoas hitch Supervising Attending Note: Patient seen and examined. Case reviewed and discussed with Dr. Berñsteiñ; I agree with her note. Shellyann Hoffman has had right ureteral implant for ureteric obstruction November 2014. . Physical examination today is remarkable for WD WN woman. No abdominal pain. Surgical scars noted.Nuclide scan 01/08/16 Mildly asymetric renal size. Split renal function: left kiciney 59%, right kidney 41%, 2. Left kidney: Normal flow and function. No evidence of obstruction. 3. B.ight kidney: Normal flow and function. No evidence of obstruction. Urine study in August no evidêñce for infection. Impression is ureteric reimplant right; Left pelvic fluid mass (? Lymphocele) and the plan is refer back to GYN for management of fluid mass. It will need drainage by IR. Attending: Gilbert J. Wise MD Adrien Nicole Phalen Bernstein, Resident Thu Jan 21, 2016 10:53 AM MD Electronically Signed Referring Provider Provider Name: Angela Dvorkina Type: Attending Address: 81 WILLOUGHBY STREET, BROOKLYN NY 11201 Phone: 718-522-3399 Fax: 718-522-1888 Effective Date: 10/22/2015 Provider name: ANGELA DVORKINA Type: Attending Address: 81 WILLOUGHBY STREET, BROOKLYN, NY 11201 Phone: 718-522-3399 Fax: 718-522-1888 Printed by [MGROCE] at 3/17/16 9:21 AM Page 1 of 8 27 FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015 -- Shellyann (MRN: DOB: Encounter Hoffman, NYSCEF DOC. NO. 137 71290660) RECEIVEDDate: 01/21/2016 NYSCEF: 09/25/2020 Chief Complaint 1. intraoperative ureteral injury History of Present Illness Initial Patient Visit 9/26/14 Shellyann Hoffman is a 37 year old woman recently admitted to NYPH to the OB/GYN service for intrauterine fetal demise who subsequently underwent amniocentesis and hysterectomy with placenta/fetus embicc resection on 9/9/14. Post-operatively her Cr was known to rise from baseline of 0.7 to 1.2. She underwent renal US which revealed mild bilateral hydro, but high index of suspicion for ureteral injury led to CTU which revealed abrupt disruption of contrast opacification within the ureter consistent with ureteral transection. She subsequently underwent cystoscopy and b/I retrograde pyelogram on 9/19 which revealed prompt extravasation from the lower right ureter with RPG. A wire could not be advanced into the proximal ureter across the disruption. The patient subsequently underwent right PCN placement and was discharged home. She presents today for further follow-up. Since discharge she has been feeling overall well, though her mood has been intermittently down. Managing well with the PCN which has had occasional hematuria but currently clear yellow. Wound is open and being packed by VNS. No fevers, chills, nauses, or emesis. PMH: depression, HTN, asthma, arthritis/LBP, headaches PSH: hysterectomy as per HPI SocHx: married, lives on Madison Ave and Jackson FamHx: non-contributory AII: NKDA Interval History 11/26/14 Returns to clinic with her husband fo||owing open ureteral reimplant on 11/12/14. Post-op course was uncomplicated and patient was discharged home 11/17 with right ureteral stent in place. She presented to the ED on 11/22 with worsening abdominal pain and dysuria, CT revealed urothelial inflammation and right stent in place. She was discharged home with PO Levaquin for ? UTI (Cx negative), as well as Flomax/Pyridium. Since discharge she has had bladder spasms and stent bother. Urgency and right flank pain with urination but no fevers/chi||siñausea/emesis. She is still taking Percocet q4hrs, no constipation (taking Colace), minimal relief from Pyridium/Flomax. Appetite is slowly improving. She has been quite active, walking around, improvement in post-op right leg numbñêss, currently walking without issue. We talked extensively about the post-operative course and timing of stent removal. She is apprehensive about stent removal, will plan for cysto under MAC. We also discussed management of current symptoms, will trial anti-cholinergic (warnings given re: retention, dry mouth). Staples removed, steri-strips placed. Interval History 4/16/15 Returns to clinic following stent removal in January. She had retinal detachment in March, had pr0cedure, now with decreased vision in R eye. From GU standpoint, she continues to have occasicñal dysuria 1-2 times per week, particularly after having sexual intercourse. This is sometimes associated with right flank pain. No fevers, chills, nausea, or emesis. No gross hematuria. She also has urinary urgency and occasional UI. PVR is O mL. Printed by [MGROCE] at 3/17/16 9:21 AM Page 2 of 8 28 FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015 -- Shellyann (MRN: DOB: Encounter Hoffman, NYSCEF DOC. NO. 137 71290660) RECEIVEDDate: 01/21/2016 NYSCEF: 09/25/2020 Interval history 8/19/15: RTC for follow up. Recurrent bladder pain/dysuria. Helped with Pyridium, tramadol. Pain is worse at right flank, the most ct demonstrates bowel thickening. No hydronephrosis. Felt much improved while on antibiotics and that symptoms recurrent following, however all urine specimens recently have been negative. Recently diagñcsed with celiac disease. Constipation since surgery (every four days) taking colace and senna since surgery. Denies hematuria. Continues to have urge and urge incontinence. Slight improvement with ditropan 5mg Imaging: CT ABDOMEN AND PELVIS W CONTRAST Specimen Collected: 8/13/15 Last Resulted : 8/13/15 IMPRESSION:1. The duodenum and proximal jejunal loops are suboptimally distêñded.There is mild fluid distêñticñ of the mid to distal jejunal and ilealbowel loops. No foci of small or large bowel wall thickening are seen.No bowel obstruction.2. Mild to moderate abdominopelvic ascites.3. Chole|ithiasis. Prepared By: Wladyka, Christopher MD Interval history 11/25/15 : RTC for follow up. Patient reports that she since stopping ditropan intc|êrable urinary frequency and urgency, requesting to resume medication. Restarted with strict ED precautions however patient elected not to re-initiate. Presents today with worsening UUI and pelvic discomfort and right flank pain and difficulty urinating . PVR 594 Fevers: denies Dysuria: denies UTIs: denies Hematuria: dêñies Flank pain: right flank pain Constipation: improving Interval history 12/17/15: RTC for follow up. CIC 4x/day. Without UUI continued urgency. Continued pain. Close review of medications today. Patient reports that she is taking narotics/muscle relaxants for severe back pain. Reports daily bowel movement with colace with senna. Denies fevers but endorcesOccasional hot flashes. Right flank pain Interval history 1/21/16: RTC for follow up. CT demonstrates loculated fluid discussed with gyn. Continues with CIC 3x/day. Continued abdominal pain. Constipation taking medication/high fiber diet. everyother day at this point. 1/8/2016 Lasix renoscan Mildly asymmetric renal size. Split renal function: left kiciney 59%, right kidney 41%, 2. Left kidney: Normal flow ancl function. No eviclence of obstruction. 3. Right kidney: Normal flow and function Prior right ureteral reimplantation and psoas hitch, No hydronephrosis. Mild interval increase size of slightly loculated fluid within the left pelvis without evidence for contrast to suggest urinoma, like_Ly loculated ascites. Past Medical History 1. HTN (hypertension) 2. Asthma 3. Pre-eclampsia 4. Lupus Printed by [MGROCE] at 3/17/16 9:21 AM Page 3 of 8 29 FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015 -- Shellyann (MRN: DOB: Encounter Hoffman, NYSCEF DOC. NO. 137 71290660) RECEIVEDDate: 01/21/2016 NYSCEF: 09/25/2020 5. Prior pregnancy with fetal demise 6. PID (acute pelvic inflammatory disease) 7. Depression 8. Stroke 3/2015 left vision impairment 9. Celiac disease Past Suraical History 1. Caesareañ Section Laterality: N/A 1993 pre-eclampsia 2. Keloid left shoulder 3. Hysterectomy 9/2014 IUFD, placenta percreta 4. Percutaneous Nephrostomy Laterality: Right 2014 5. Cystoscopy W/ Ureteroscopy 9/18/2014 6. Hysterectomy 7. Supracervical Hysterectomy 8. Ureteral Reimplantation With Psoas Hitch Laterality: Right Social History Tobacco Use Never Alcohol Use No Drug Use No Sexually Active Yes; Male partñêr(s); Birth Ctrl/Protection: Postmenopausal Socioeconomic History Occupation: homemaker - Marital Status MARRIED Number of Children: 3 ADL History, ADL [No] Hobby Hazards, Exercise Family History Brother 1 Alive Allergies Brother 2 Alive Asthma Brother 3 Alive Daughter 1 Alive Father Alive No Sig. History Mother Alive Allergies, No Sig. History (COPD) Sister 1 Alive Son 1 Alive Son 2 Alive Sexuality/Gender Identity Topic Response Comments Printed by [MGROCE] at 3/17/16 9:21 AM Page 4 of 8 30 FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015 -- Shellyann (MRN: DOB Encounter Hoffman, NYSCEF DOC. NO. 137 71290660) RECEIVEDDate: 01/21/2016 NYSCEF: 09/25/2020 Sexual Orientation Straight/Heterosexual Sex assigned at birth Female Gender Identity Female Medications (Reviewed in this Encounter by: Adrien Nicole Phalen Bernstein, MD) Name Sig |Status Inhale 2 Puffs every 6 hours 1. albuterol 108 (90 Base) Mcg/act Aero Soln as needed for wheezing or (Taking) Shcitñêss of Breath. Inh9a 3 ml eve ous as . Albuterol Sulfate (2.5 Mg/3ml) 0.083% Nebu Soln (Taking) e9 pray nasally 2 times . Azelastine HcI 0.1 % Solution (Taking) 4. Bac!ofen 20 Mg Tab (Taking) 5. Bisaccdyi Ec 5 Mg Tab Ec (Taking) 6. Bupr0picñ XI 150 Mg Tab Sr 24hr (Taking) 7. Cho!ecalcifêrol (vitamin D3) 1000 Units Cap Take 1 Cap by mouth daily. Apply 1 Drop to eye 4 times (Not 8. Cromolyn Sodium 4 % Solution daily. Taking) 9. DOcqiace 100 Cap (Taking) Mg 10. Dulera 100-5 Mcg/act Aerosol |(Taking) a e 1 Tab W moum 2 hes 11. Enalapril Maleate 20 Mg Tab (Taking) 12. escitai0pram 20 Mg Tab Take 1 Tab by mouth daily. (Taking) 13. esomeprazole (nexium) 40 Mg Cap Dr h-ake 1 Cap by mouth daily. (Taking) 114. Fluticasone Propionate 50 Mcg/act Suspêñsicñ 2 Sprays daily. (Taking) ñasally 15. Hydicchiarothiazide 25 Mg Tab Take by mouth. (Taking) 16. Hydroxychloroquine Sulfate (plaquenil) 200 Mg Tab Take 2 Tabs by mouth daily. |(Taking) 17. Mei0xicam 15 Mg Tab (Uñkñ0wn) 18. MetoDrolol Succiñate 50 Mq Tab Sr 24hr Take 1 Tab by mouth daily. (Taking) 19. Mometasone Furo-Formoterol Fum 200-5 Mcg/act Inhale 2 Puffs 2 times daily. (Taking) Aerosol 20. monte!ukest 10 Tab ab W moum Mg (Taking) Iake 1 Tab by mouth 2 times 21. napr0xen 500 Mg Tab Ec (Taking) daily as neeueu. 22. Nifedipiñe 60 Mg Tab Sr 24hr |(Taking) k3. Nifedicine Cr Osmotic 60 Mg Tab Sr 24hr Iake 1 Tab mouth daily. by Iake 3 Tabs by mouth 3 24. Oxybutynin Chloride 5 Mg Tab limes daily. As ñêêdêd for (Taking) bladder spasms 5. Phenazopyridine HcI 100 Mg Tab (Taking) ee ed f a 26. Q-Pap Extra Strength 500 Mg Tab (Taking) 27. Ra Vitamin C 250 Mg Tab |(Taking) 28. Risperidone 0.5 Mg Tab 29. Seroquel Xr 150 Mg Tab Sr 24hr (Taking) b0. Spacer/aero-Holding Chambers (optihaler) Misc No route applicable. 31. Tamsulosin HcI 0.4 Mg Cap Iake by mouth. 32. Tamsulosin HcI 0.4 Mg Cap Printed by [MGROCE] at 3/17/16 9:21 AM Page 5 of 8 31 FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015 -- Shellyann (MRN: DOB: Encounter Hoffman, NYSCEF DOC. NO. 137 71290660) RECEIVEDDate: 01/21/2016 NYSCEF: 09/25/2020 133. Tramadol-AcetaminoDhen 37.5-325 Mg Tab |(Taking) Apply topically 2 times daily. 34. Triamciñcl0ñe Acetonide 0.1 % Cream Use to affected area twice a (Taking) day. Avoid Groin ake 1 Tab by mouth 2 times (Not 5. Trospium Ch|cride 20 Mg Tab daily. Taking) Allergies 1. Shellfish Itching 2. Shellfish-derived products Review of Systems Constitutional: As per hpi Genitourinary: As per hpi There were no vitals filed for this visit. Physical Exam Constitutional: NAD Head: NCAT ENMT: MMM Resp: no work of breathing Abd: soft nd nt no suprapubic tenderness Back: min R CVAT Neurologic: no gross motor defect Psychiatric: appropriate affect Assessment & Plan 38 year old woman with iatrogenic right ureteral transection during hysterectomy for intrauterine fetal demise on 9/9/14 now s/p open right ureteral reimplant with psoas hitch on 11/12/14, subsequent removal of ureteral stent 1/15. Now with urinary retention managed by CIC. Cont mild right flank pain and worsêñing lowerback pain now with difficulty ambulating. Left sided fluid ccilêcticñ on MRI. #s/p ureteral reimplant -repeat UA/UCx today -continue bowel regimen per PMD/GI -Cr 9/2015 0.83 -Ct 813/2015 no hydronsphicsis -ED warnings given for favers/chills, nauses/emesis - lasix renolasix scan with good flow Printed by [MGROCE] at 3/17/16 9:21 AM Page 6 of 8 32 FILED: NEW YORK COUNTY CLERK 09/25/2020 01:28 PM INDEX NO. 805302/2015 -- Shellyann (MRN: DOB: Encounter Hoffman, NYSCEF DOC. NO. 137 71290660) RECEIVEDDate: 01/21/2016 NYSCEF: 09/25/2020 - Large pelvic ccliêctioñ without evidêñce of urinoma, discussed fiñdiñgs with gyn. Patient will follow with gyn for IR drainage #urgency frequency/UI - given UUI And retention discussed UDS risks benefits and patient would like to wcisêñing urinary picceed with UDS on 2/12. Ucx today for PAT - continue CIC has supplies - PVR 252 - AUR multifactorial 2/2 to pain muscle ?neurciOgic and left sided pelvic medication, relaxant, component, collection. -RTC 1 month following CT to discuss püssib|ê IR drainage of ccliêcticn Patient seen and discussed with attending Dr. Wise RTC following UDS Scan on: 01/22/2016 10:19 AM by Rechõña Sears [RES2031] Descripticñ: Lab Result Scan (Bladder Scan) Scan on: 01/22/2016 10:14 AM by Reshona Sears [RES2031] Description: Diagñõsis sheet (Urology ) Diaanosis 1. Intraoperative Ureteral [N99.81 997.5 - Dx Injury (ICD-10), (ICD-9)] Primary Order Summary Orders 1. Urine Culture [87086] 2. Urinalysis, Dipstick With Micresepic Exam [81001] 3. Sono Bladder Scan (Back Office) [51798] Follow-up and Disposition Level of Service LOS Modifiers OFFICE/OUTPT VISIT,EST,LEVL Ill [99213] SERV PERF IN PART BY RES UNDER DIR OF A TEACHING PHYSICIAN [GC] SIGNIFICANT SPRTLY IDABLE EVAL & MGMT ON SAME DAY BY SAME PROV [25] LOS History Recorded Results URINE CULTURE