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IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT
IN AND FOR ORANGE COUNTY, FLORIDA
MARCELO DIAZ, as Personal Representative CASE NO.: 2008-CA-11228-0
of the Estate of HERMINIA DIAZ,
Plaintiff,
HARINATH SHEELA, M.D., DIGESTIVE AND
LIVER CENTER OF FLORIDA, P.A.; ADVENTIST
2
0_ HEALTH SYSTEM/SUNBELT, INC. d/b/a FLORIDA
HOSPITAL ORLANDO and d/b/a FLORIDA
HOSPITAL APOPKA; JUNIAS DESAMOUR, M.D.;
u-)
MID-FLORIDA HOSPITAL SPECIALISTS, P.A.
a)
u_
0-) Defendants.
C
DEFENDANTS, HARINATH SHEELA, M.D. AND DIGESTIVE AND LIVER CENTER
OF FLORIDA, P.A.'S MOTION FOR SUMMARY JUDGMENT
Defendants, HARINATH SHEELA, M.D. ("Dr. Sheela") and DIGESTIVE AND LIVER
CENTER OF FLORIDA, P.A. ("DLC"), (collectively "Defendants"), through counsel and
of Civil Procedure 1.510(c), for summary judgment and state the
pursuant to Florida Rule move
following in support thereof:
I. INTRODUCTION AND STATEMENT OF MATERIAL FACTS
On January 2, 2007, Ms. Herminia Diaz ("Ms. Diaz") was referred to Digestive and Liver
Center of Florida, P.A. by her nephrologist, Dr. Howard Sackel, for evaluation of heme-positive
stools. See Exhibit 1. During the office visit of January 2, 2007, a colonoscopy, as well as an
esophagogastroduodenoscopy ("EGD"), were recommended to further evaluate the potential
causes of her heme-positive stools. Id. Those procedures were scheduled for January 4, 2007.
Defendant, Harinath Sheela, M.D., performed both the colonoscopy and EGD on January
4, 2007, at the Orlando campus of Florida Hospital. See Exhibit 2. Before performing the
procedure, the risks, benefits and alternatives were discussed with both Ms. Diaz and her
husband. Id Dr. Sheela discovered small hemorrhoids during the colonoscopy. Id. Ms. Diaz
was discharged the same day and discharge instructions were provided to her and her husband.
See cumulative Exhibit 3. There is no evidence contained within any of the medical records that
Ms. Diaz experienced or complained of any pain or discomfort after completion of the
procedures and until the time of her discharge. There is no evidence contained within the
medical records that Ms. Diaz experienced any bleeding or heme-positive stool after the
completion of the procedures and until the time of her discharge. Finally, there is no evidence in
the record that Mr. or Ms. Diaz expressed any concern regarding their understanding of the post-
procedure instructions provided by Dr. Sheela.
Three days later, on January 7, 2007, Ms. Diaz presented to the Florida Hospital
emergency room complaining of acute onset of abdominal pain and was admitted for further
evaluation. See Exhibit 4. An initial assessment was made by Dr. Junias Desamour, and a
consult was provided by Dr. Joseph Warren ("Dr. Warren"). See Exhibit 4; see also Exhibit 5.
Dr. Warren noted that Ms. Diaz's CAT scan indicated right pelvic fluid collection, a large
hepatic cyst, dilated intrahepatic bile ducts, and a right nephrectomy. See Exhibit 5. Dr. Warren
noted the need to rule out perforation due to the colonoscopy and EGD completed on January 4,
2007. Id.
On January 8, 2007, Ms. Diaz's condition began to deteriorate and she was brought to the
operating room for an exploratory laparotomy. See Exhibit 6. After initiation of the surgery, Dr.
Stephen Schreiber noted a perforation of the sigmoid colon and fecal contamination of the
peritoneal cavity. Id. Ms. Diaz was returned to the recovery room in stable, but extremely
critical condition. Id.
After the surgery, Ms. Diaz became ventilator-dependent. See Exhibit 7. Ms. Diaz's
family requested that any further aggressive treatments such as breathing assistance via the
ventilator be discontinued. Id. Ms. Diaz passed away on January 24, 2007. Id.
Ultimately, Plaintiff contends that Dr. Sheela failed to meet the applicable standard of
care owed to Ms. Diaz in the following ways: (1) by failing to recognize the potential for
perforated bowel during the colonoscopy procedure on January 4, 2007; (2) by failing to perform
an adequate colonoscopy procedure on January 4, 2007; and (3) by failing to provide proper
physician orders. See Plaintiff's Third Amended Complaint, at ¶ 52(a)-(c), attached as Exhibit 8.
Plaintiff contends that Ms. Diaz's death was a direct and proximate result of these alleged
failures. Id. at IF 53.
II. MEMORANDUM OF LAW
A. STANDARD OF REVIEW FOR SUMMARY JUDGMENT MOTIONS
A party moving for summary judgment must establish by the pleadings and evidence that
"there is no genuine issue as to any material fact and the moving party is entitled to judgment as a
matter of law." Rule 1.510, Florida Rules of Civil Procedure; see Volusia County v. Aberdeen at
Ormond Beach, L.P., 760 So.2d 126, 130 (Fla. 2000)(a material fact, for summary judgment
purposes, is a fact that is essential to the resolution of the legal questions raised in the case); see
also Continental Concrete, Inc. v. Lakes at La Paz III Ltd. P'ship, 758 So.2d 1214, 1217 (Fla.
2000). When the material facts are undisputed, they form a question of law which the trial court
is empowered to decide on a motion for summary judgment. See Johnson v. GulfLife Ins. Co.,
429 So.2d 744, 745-46 (Fla. 1983).
B. BURDEN OF PROOF: MEDICAL NEGLIGENCE
Under Florida law, for a plaintiff to prevail in a medical malpractice action, the plaintiff
must prove three essential elements. Gooding v. University Hospital Building, Inc., 445 So.2d
1015 (Fla. 1984). First, the plaintiff must demonstrate the applicable standard of care owed by a
physician. Id. Next, the plaintiff must demonstrate that the defendant physician breached that
standard of care. Id. Finally, Plaintiff must demonstrate that the physician's breach caused the
injuries of which plaintiff complains. Id.
In order for a plaintiff to prove that a defendant physician owed a certain standard of care
and breached said standard of care, the plaintiff must present a qualified expert witness to
support these contentions. See Torres v. Sullivan, 903 So.2d 1064 (Fla. 2d DCA 2005)( "The
standard of practice and treatment within a particular medical specialty when physicians in that
field are presented with a particular set of circumstances is 'a subject well beyond the jury's
expertise,' not a matter 'within the comprehension of laymen")(additional citations omitted).
Further, a plaintiff cannot meet his or her burden in proving medical negligence merely by
showing a breach of the standard of care in the medical community. The Plaintiff is compelled
to prove that defendant's action or inaction "more likely than not" caused the plaintiff s injuries.
Gooding, 445 So.2d at 1018 (test for causation in medical malpractice actions requires plaintiffs
to prove by a preponderance of the evidence that the alleged negligence of the defendant
probably caused the injury at issue). The Gooding Court emphasized that the causation standard
should not be relaxed:
Relaxing the causation requirement might correct a perceived
unfairness to some plaintiffs who could prove the possibility that
the medical malpractice caused an injury, but at the same time
could create an injustice. Health care providers could find
themselves defending causes simply because a patient fails to
improve or where serious disease processes are not arrested
because another course of action could possibly bring a better
result. No other professional malpractice defendant carries this
burden of liability without the requirement that plaintiffs prove the
alleged negligence probably rather than possibly caused the injury.
Id. at 1019-1020 (emphasis supplied).
In the current case, Plaintiff has failed to demonstrate that Dr. Sheela's actions or
omissions constituted a breach of the applicable standard of care and/or were the proximate cause
of Ms. Diaz's death.
C. ARGUMENT
1. Plaintiff's allegation that Dr. Sheela breached the standard of care by
performing an inadequate colonoscopy procedure on January 4, 2007, should
fail.
Plaintiff's expert witness, Dr. David A. Morowitz ("Dr. Morowitz"), a specialist in
internal medicine with a subspecialty in gastroenterology, testified to various concerns regarding
the treatment Ms. Diaz received in January 2007. See Dr. Morowitz's deposition, at p. 5, lines
17-21 (Dr. Morowitz deposition excerpts attached as cumulative Exhibit 9). While Dr. Morowitz
believes that Ms. Diaz's colon was injured during the colonoscopy performed by Dr. Sheela on
January 4, 2007, he does not believe that injury during a colonoscopy indicates that a physician
failed to meet the applicable standard of care. Id. at p. 34, lines 10-13 and p. 77, lines 5-16 ("a
perforation does not mean malpractice").
Actually, Dr. Morowitz testified that he could not say that Dr. Sheela negligently
performed the colonoscopy. Id. at p. 128, lines 4-15; p. 129, lines 1-11. Therefore, Dr. Morowitz
provides no expert testimony which would support Plaintiff's position that the colonoscopy
5
performed on January 4, 2007, by Dr. Sheela fell below the standard of care.
Plaintiff has also retained two other medical experts: Joan Spitrey ("Ms. Spitrey"), a
registered nurse and Emilio Lobato, M.D., ("Dr. Lobato"), a board certified anesthesiologist.
First, neither of these experts are qualified to provide standard of care opinions regarding the
completion of a colonoscopy. Second, neither of these experts provided such opinions during
their deposition.
Ms. Spitrey has been a registered nurse for approximately 14 years. See Ms. Spitrey's
deposition, at p. 5, lines 24-25, p. 6, lines 1-3, (Spitrey deposition excerpts attached as
cumulative Exhibit 10.) While Ms. Spitrey did at one time help patients recover after
colonoscopies, she admits that she is not qualified to render standard of care opinions regarding
Dr. Sheela's alleged actions or omissions in the case. Id. p. 18, lines 12-24; p. 54, lines 16-25.
Accordingly, Ms. Spitrey provides no criticisms of Dr. Sheela or his staff. Id. p. 215, lines 6-18.
Dr. Lobato is a board certified anesthesiologist. See Dr. Lobato's deposition, at p. 4, lines
9-13 (Lobato deposition excerpts attached as cumulative Exhibit 11). Dr. Lobato is not a
gastroenterologist, and does not perform colonoscopies. Id. at p.24, lines 6-9; see also p. 156,
lines 16-23; p. 157, lines 1-6. Therefore, Dr. Lobato is not qualified to render opinions regarding
the technical completion of the colonoscopy, and/or whether said colonoscopy was inadequate.
See § 766.102(5)(a), Florida Statutes.' While Dr. Lobato did express criticisms during his
deposition of the amount of anesthesia used by Dr. Sheela during the procedure, he admitted that
he could not say that any alleged injury which occurred during the January 4, 2007 colonoscopy
qualified to render such opinions, he admits that perforations can and do
'
Even if Dr. Lobato was
occur during colonoscopies even when appropriate care is provided. See Exhibit 11, p. 40, lines
10-12.
was more likely than not caused by the amount of sedation given to Ms. Diaz. See Exhibit 11 at
p. 166, lines 1-25; p. 167, lines 1-9.
Consequently, Plaintiff has failed to provide any medical expert testimony establishing
that Dr. Sheela performed an "inadequate" colonoscopy on January 4, 2007. As stated above, Dr.
Morowitz, the gastroenterologist retained by the Plaintiff, expressly stated that he did not have an
opinion regarding the standard of care provided during this procedure. See Exhibit 9 at p. 128,
lines 4-15; p. 129, lines 1-11. Ms. Spitrey, a registered nurse, admitted that she was not qualified
to render a standard of care opinion regarding the performance of the colonoscopy. See Exhibit
10 at p. 54, lines 16-25. Finally, Dr. Lobato, an anesthesiologist, is not qualified to render a
standard of care opinion regarding the technical completion of the colonoscopy, and further
testified that he could not state that any alleged "under sedation" and "restlessness" caused any
injury to Ms. Diaz. See § 766.102(5)(a), Florida Statutes; see also Exhibit 11 at p. 166, lines 1-
25; p. 167, lines 1-9. Because Plaintiff has failed to provide any medical expert testimony which
would indicate that Dr. Sheela breached the applicable standard of care in performing the
colonoscopy or that any alleged breach related to that procedure more likely than not caused
injury to Ms. Diaz, any claim by Plaintiff that the colonoscopy performed on January 4, 2007 was
"inadequate" should fail.
2. Plaintiff's allegation that Dr. Sheela breached the standard of care by failing
to recognize the potential for perforated bowel during the colonoscopy
procedure on January 4, 2007, should fail.
First, as stated above, there is a complete lack of medical expert testimony to indicate that
Dr. Sheela breached the appropriate standard of care during his performance of the colonoscopy.
Second, any allegation that Dr. Sheela failed to meet the applicable standard of care after thc
colonoscopy should also fail for the reasons set forth below.
Dr. Morowitz contends Dr. Sheela failed to meet the applicable standard of care by not
keeping Ms. Diaz for observation for an extended period of time following her colonoscopy.2
See Exhibit 9, p. 145, lines 7-21. Specifically, Dr. Morowitz contends Dr. Sheela had an
obligation to "keep [Ms. Diaz] in-house for observation for a couple of hours." Id. at p. 130,
lines 22-25; p. 131, lines 1-8. Dr. Morowitz testified that if this extended observation had
occurred, Dr. Sheela "might have found... an injured sigmoid colon..." Id. (emphasis added).
Even if we assume for the sake of argument only that the timing of Dr. Sheela's discharge
decision breached the applicable standard of care, Plaintiff has failed to establish as required by
Gooding that that decision "more likely than not" caused Ms. Diaz's death. Instead, Plaintiff has
presented the above speculative testimony of Dr. Morowitz that a couple of hours of additional
observation after the colonoscopy might have resulted in diagnosis of an injured colon. Dr.
Morowitz was unable to testify within medical probability that Dr. Sheela's decision to discharge
Ms. Diaz when he did resulted in delayed diagnosis of an injured colon.
Furthermore, Ms. Diaz's husband, Marcelo Diaz ("Mr. Diaz") testified that his wife was
not experiencing any issues of medical significance until the morning she was admitted to
Florida Hospital, January 7, 2007. Specifically, Mr. Diaz testified that Ms. Diaz did not
experience any significant pain at home on January 4, 2007 following her discharge. He also
testified that she did not complain of pain on January 5, 2007 or January 6, 2007. See Mr. Diaz's
deposition, at p. 67, lines 12-14; p. 71, lines 2-4; p. 72, lines 7-15; p. 73, lines 4-7. (Diaz
Morrowitz testified in deposition, that when only looking at the medical records, his
2
Dr.
position would be that Dr. Sheela discharged Ms. Diaz at the appropriate time. See Exhibit 9 at
p. 79, lines 23-25; p. 80, lines 1-4.
deposition excerpts attached as cumulative Exhibit 12.) In fact, he testified that her condition
improved during the time she was home so much so that she felt strong enough to prepare a
family dinner on the evening of January 6, 2007. Id., pp. 73-74. He further testified that it was
not until the early morning hours of January 7, 2007 that Ms. Diaz woke up complaining of
severe abdominal pain. Id., p. 78, lines 1-13; and p. 82, lines 2-22. Due to that severe pain, Mr.
Diaz took her to the emergency department at Florida Hospital Apopka on the morning of the 7th,
as she had not complained of even mild pain in the abdominal area prior to that time. Id.; see
also Exhibit 5 ("[Ms. Diaz] was stable until this morning when she developed severe abdominal
pain at which time she presented to the emergency department.")
Once Ms. Diaz arrived at the emergency department, she underwent a panel of tests
including CT scans of the abdomen and the pelvis. See Exhibit 4. She presented with a normal
temperature and a normal white blood count. See Exhibit 11 at p. 150, lines 16-22. The cause of
Ms. Diaz's complaints remained unclear until January 8, 2007. See Exhibit 13; see also Exhibit
6.
Accordingly, Ms. Diaz's uneventful clinical course during the three days she was home
following the colonoscopy is further evidence that observing her for a "couple of hours" more on
January 4th would not have yielded any additional clinical information to suggest an injury to the
sigmoid colon. Furthermore, even when she became symptomatic on the morning of January 7th
and underwent evaluation by multiple specialists, the cause of her complaints was not diagnosed
until the following day.
Because Plaintiff has failed to establish that the timing of Mrs. Diaz's discharge on
January 4, 2007 more likely than not caused any injury to her, any allegation that Dr. Sheela
breached the applicable standard of care in this marmer should fail.
3. Plaintiff's allegation that Dr. Sheela breached the standard of care by failing
to provide proper physician orders, should fail.
Plaintiff has failed to provide sufficient medical expert testimony to support his
contention that the physician orders given by Dr. Sheela breached the applicable standard of care.
First, in detailing his specific criticisms of Dr. Sheela, Dr. Morowitz stated that due to the
language barrier between Dr. Sheela and Ms. Diaz, he was concerned that Dr. Sheela did not
adequately convey the discharge instructions to Ms. Diaz or her husband. See Exhibit 9 at p.
131, lines 18-25; p. 132, lines 1-13. However, after asserting this position, Dr. Morowitz
testified that he did not know whether Dr. Sheela spoke with the Diaz's post colonoscopy, and
therefore, Dr. Morowitz could not know the sufficiency of any instructions given. Id. at p. 132,
lines 11-13. Further, it is documented in the nursing records that Mr. Diaz was informed of post
procedure care. Id. at p. 134, lines 10-13. A nurse, Ms. Olga Marquez, whose primary language
was Spanish, advised the Diaz's of post-procedure care. Id. at p. 134, lines 19-22, p. 135, lines
2-9. Ultimately, Dr. Morowitz could not dispute that Ms. Marquez gave these instructions;
instructions which Dr. Morowitz deemed were appropriate. Id. at p. 135, lines 23-25; and p. 135,
line 1.
Mr. Diaz admits that he signed the endoscopic outpatient discharge instructions, which
detail the post-procedure treatment necessary for Ms. Diaz. See Exhibit 12, p. 63, lines 17-25; p.
64, lines 1-6. Mr. Diaz read from these instructions during his deposition and states that he
understood the language in which the instructions were written (English). Id at p. 65, lines 17-
25; and p. 66, lines 1-21.
10
Second, while Dr. Lobato expressed concerns regarding the discharge instructions given
by the nurses at Florida Hospital and Dr. Sheela, he testified specifically that he had not and
would not take a position as to whether the Diaz's understood the discharge instructions. See
Exhibit 11 at p. 158, lines 9-20. Finally, as discussed earlier, Plaintiff's third expert, Ms. Spitrey,
expressly stated that she would not provide any criticisms of Dr. Sheela or his staff. See Exhibit
10 at p. 54, lines 16-25.
Because Plaintiff has failed to present sufficient medical expert testimony regarding the
alleged inadequate nature of the discharge instructions given by Dr. Sheela, Plaintiff's contention
of the same should fail.
WHEREFORE, Defendants' motion for summary judgment should be granted for all the
foregoing reasons.
DENNIS, JACKSON, MARTIN
& FONTELA, P.A.
By: 7go
ROGELIO J. FONTELA (FBN: 0956473)
W. BENNETT CARTER, JR. (FBN: 90952)
Dennis, Jackson, Martin & Fontela, P.A.
1591 Summit Lake Drive, Suite 200
Tallahassee, FL 32317
(850) 422-3345
(850) 422-1325 (Fax)
roger@djmf-law.com
ben@djmf-law.com
Attorneys for Defendants Harinath Sheela, M.D. and
Digestive and Liver Center of Florida, P.A.
CERTIFICATE OF SERVICE
I HEREBY CERTIFY that a true and correct copy of the foregoing was furnished by ECF
system this 5th day of February, 2013 to: Carlos R. Diez-ArgueHes, Esquire, Diez-Arguelles &
Treiedor, 505 North Mills Avenue, Orlando, Florida 32803; Patrick H. Telan, Esquire,
Grower, Ketcham, Rutherford, Bronson, Eide & Telan, P.A., 901 North Lake Destiny Road,
Suite 450, Maitland, Florida 32751; and Mary Jaye Hall, Esquire, McEwan, Martinez &
Dukes, P.A., P.O. Box 753, Orlando, Florida 32802-0753.
DENNIS, JACKSON, MARTIN
& FONTELA, P.A.
By:
ROGELIO J. FONTELA
41 22
(FBN: 0956473)
W. BENNETT CARTER, JR. (FBN: 90952)
Dennis, Jackson, Martin & Fontela, P.A.
1591 Summit Lake Drive, Suite 200
Tallahassee, FL 32317
(850) 422-3345
(850) 422-1325 (Fax)
roger@djmf-law.com
ben@djmf-law.com
Attorneys for Defendants Harinath Sheela, M.D. and
Digestive and Liver Center of Florida, P.A.
12
Exhibit 1
„.
.
Seela, M.D.
Srinivas Board of Gastroentefology
à t. Diptomate, Arnedcan
and Harinath Sheela,
Digestive
)M.D..
eff44.
r ltver Center of Florida PA
Boma of Gastroenterology
Dipio.n.,.. ArneOcon
INITIAL OFFICE CONSULTATION REPORT
Diaz, Herminia
PATIENT NAME: 04/25/1944
DATE OF BIRTH: 01/02/2007
DATE OF OFFICE VISIT:
Howard A Sackel, M.D.
REQUESTING PHYSICIAN: 2501 North Orange
Avenue
Suite 537N
Orlando, FL 32804
Ph#: (407) 894-4693
Fax#: (407) 895-1496
Heme-positive stools.
REASON FOR CONSULTATION:
Dear Dr. Sackel:
in my office today
for evaluation of heme-positive
Ms. Diaz summarize her
It was my pleasure seeing I would like to
well aware of her history, with history of
As very
years old female
stools. you are
she is 62
information for my medical
records. Briefly, 2 and also complicated
post transplant
x
on dialysis and
status
renal disease, The patient was recently
end-stage and has been on dialysis again. is
with abdominal hemorrhage, and is here for further consultation.
The patient
stools denied
noticed to have heme-positive with the help of our staff. The patient
and examined and was translated Denied any hematochezia.
seen
of breath, fever or chills.
chest pain, shortness The patient did have a
having any constitutional symptoms.
Denied any weight loss or any other than 10 years ago. The
EGD performed in 1990, which was more
colonoscopy as wellrecent
as
patient denied any change in her medications.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS:
1. Isosorbide 30 mg once daily.
2. Norvasc 10 mg once daily.
3. Lisinopril 40 mg once daily.
4. Catapres patch.
fin1298
407-384-7388.
7975 Lake Underhill Road,Suit 350, Orianda.Florida-32822
Fax: 470-384-7391wWw.DlgestiveandLiverCenterofFlorlda.org
RE: Diaz, Herminia
PAGE TWO
5. Folic acid 1 mg once daily.
6. Pravachol 40 mg at bedtime.
7. Singulair 10 mg daily.
8. Synthroid 25 mg daily.
9. Prevacid 30 mg daily.
10. Aspirin 81 mg daily.
11. Renagel 800 mg.
and Ambien p.r.n.
12. Combivent, Pulmicort,
PAST MEDICAL HISTORY:
1. Hypertension. status post kidney transplant
x 2.
2. End-stage renal disease,
Dialysis,
abuse.
SOCIAL HISTORY: Denied smoking, alcohol, or IV drug
in the family.
No history of malignancy
FAMILY MEDICAL HISTORY:
of present illness.
As mentioned in the history
REVIEW OF SYSTEMS:
PHYSICAL EXAMINATION: 160/86, pulse of 64, and weight of
97.2, blood pressure
VITAL SIGNS: Temperature
143 lbs. EOMs are
equal, round, and reactive tolight and accommodation.
HEENT: Pupils are
intact.
NECK: Supple. No JVD.
HEART: Regular rate and rhythm. No wheezing, rales, or rhonchi.
LUNGS: Clear to auscultation bilaterally.
bowel sounds.
ABDOMEN: Soft, non tender with positive
EXTREMITIES: No cyanosis, clubbing, or edema.
Not available. Occult stool positive x 3.
LABORATORY DATA:
female with above-mentioned
ASSESSMENT: The patient is 62 years old very pleasant Anemia
medical problems with heme-positive stools,
anemia, and for further evaluation. renal
secondary to chronic blood gas versus end-stage
is multifactorial most probably
disease.
it is lower GI causes,
stools: Majority of the cases greater than 85% a
Heme-positive versus polyps versus
AVMs versus ulcers and malignancy.
which include diverticulosis differential
to upper GI bleed for which the
Less than 15% of the causes, it can be related
versus esophagitis.
includes peptic ulcer disease versus gastritis
1 2 o
rt-kur, rucrx,..
PLAN:
CBC from your dialysis lab. above differential.
1. We will obtain the to further evaluate
as well as EGD
2. We will perform colonoscopy well
supplementation if needed.
as
3. Iron benefits, and alternatives as
the patient regarding the risks,
with
4. Discussed
of procedure and the patient
agreed for the procedures.
complications is performed.
5. Return to clinic after the procedure
of this patient.
Thank you Dr. Sackel for allowing
us to participate in the care
8'4
Srinivas Seela, M.D.
nnlln
Exhibit 2
FLORIDA HOSPITAL M197670H
FLORIDA HOSPITAL -
ORLANDO
DICTATING PHYSICIAN: Harinath Sheela, MD (5227)
NAME: HERMINIA DIAZ
ACCOUNT 4: MRI: 000883705
DATE: January 4, 2007
PROCEDURE PERFORMED:
1. Esophagogastroduodenoscopy plus biopsies.
2_
Colonoscopy. •
PHYSICIAN: Harinath Sheela, MD
INDICATIONS: The patient is a 62-year-old white female with hemodialysis
for chronic renal noted be anemic, iron-deficiency, and
insufficiency, to
rectal bleeding. The patient is an outpatient for
questionable melena,
colonoscopy and EGD.
•
After the risks, benefits, and alternatives of the procedures
explaining
including, but not limited to, infection, bleeding, perforation,
effects conscious sedation, informed consent was obtained
hemodynamic of
husband.
from the patient. We also discussed with the patient's
COLONOSCOPY: Versed 6 IV, fentanyl 75 mcg IV.
MEDICATIONS USED FOR THE mg
PROCEDURE COLONOSCOPY: After administrating the above medications in
#1
the patient in the left lateral decubitus
incremental.doses, placing
rectal examination, the Olympus video endoscope
position, and performing
PCP 160F was advanced to the cecum. After the patient experienced
to distention and passing flatus, and
significant difficulty secondary
of the patient's spasms have been
after administrating 0.5 glucagon,
decreased and could easily advance to the cecum without
endoscope
of the preparation was noted to be excellent.
difficulty. The quality
orifice identified. The
Ileocecal valve, cecal strap and appendiceal were
cecal descending, rectosigmoid mucosa.with
mucosa, ascending, transverse,
careful examination while withdrawing the scope on the circumferential
the multiple views has been normal.
views, and also advancing scope on
There diverticular disease, no mucosal abnormalities
were no polyps, no
PROCEDURE NOTE HARINATH SHEELA MD
JAL648
D: 01/04/07
T: 01/05/07 14:02 PAGE: 1
DIAZ, HERMINIA
MRI: 883705
P: 01/10/07 14:23
0/T/P:BYC8-KG49-HLCO FLORIDA HOSPITAL
JOB: 99 60363.
CONFIDENTIAL AND PRIVILEGED INFORMATION FOR PROFESSIONAL
USE ONLY. ANY REDISCLOSURE IS FORBIDDEN BY STATE
-.. -.
-.. _.
..
STATUTE.,
---....1
Preview
IN THE CIRCUIT COURT OF THE NINTH JUDICIAL CIRCUIT IN AND FOR ORANGE COUNTY, FLORIDA MARCELO DIAZ, as Personal Representative CASE NO.: 2008-CA-11228-0 of the Estate of HERMINIA DIAZ, Plaintiff, HARINATH SHEELA, M.D., DIGESTIVE AND LIVER CENTER OF FLORIDA, P.A.; ADVENTIST 2 0_ HEALTH SYSTEM/SUNBELT, INC. d/b/a FLORIDA HOSPITAL ORLANDO and d/b/a FLORIDA HOSPITAL APOPKA; JUNIAS DESAMOUR, M.D.; u-) MID-FLORIDA HOSPITAL SPECIALISTS, P.A. a) u_ 0-) Defendants. C DEFENDANTS, HARINATH SHEELA, M.D. AND DIGESTIVE AND LIVER CENTER OF FLORIDA, P.A.'S MOTION FOR SUMMARY JUDGMENT Defendants, HARINATH SHEELA, M.D. ("Dr. Sheela") and DIGESTIVE AND LIVER CENTER OF FLORIDA, P.A. ("DLC"), (collectively "Defendants"), through counsel and of Civil Procedure 1.510(c), for summary judgment and state the pursuant to Florida Rule move following in support thereof: I. INTRODUCTION AND STATEMENT OF MATERIAL FACTS On January 2, 2007, Ms. Herminia Diaz ("Ms. Diaz") was referred to Digestive and Liver Center of Florida, P.A. by her nephrologist, Dr. Howard Sackel, for evaluation of heme-positive stools. See Exhibit 1. During the office visit of January 2, 2007, a colonoscopy, as well as an esophagogastroduodenoscopy ("EGD"), were recommended to further evaluate the potential causes of her heme-positive stools. Id. Those procedures were scheduled for January 4, 2007. Defendant, Harinath Sheela, M.D., performed both the colonoscopy and EGD on January 4, 2007, at the Orlando campus of Florida Hospital. See Exhibit 2. Before performing the procedure, the risks, benefits and alternatives were discussed with both Ms. Diaz and her husband. Id Dr. Sheela discovered small hemorrhoids during the colonoscopy. Id. Ms. Diaz was discharged the same day and discharge instructions were provided to her and her husband. See cumulative Exhibit 3. There is no evidence contained within any of the medical records that Ms. Diaz experienced or complained of any pain or discomfort after completion of the procedures and until the time of her discharge. There is no evidence contained within the medical records that Ms. Diaz experienced any bleeding or heme-positive stool after the completion of the procedures and until the time of her discharge. Finally, there is no evidence in the record that Mr. or Ms. Diaz expressed any concern regarding their understanding of the post- procedure instructions provided by Dr. Sheela. Three days later, on January 7, 2007, Ms. Diaz presented to the Florida Hospital emergency room complaining of acute onset of abdominal pain and was admitted for further evaluation. See Exhibit 4. An initial assessment was made by Dr. Junias Desamour, and a consult was provided by Dr. Joseph Warren ("Dr. Warren"). See Exhibit 4; see also Exhibit 5. Dr. Warren noted that Ms. Diaz's CAT scan indicated right pelvic fluid collection, a large hepatic cyst, dilated intrahepatic bile ducts, and a right nephrectomy. See Exhibit 5. Dr. Warren noted the need to rule out perforation due to the colonoscopy and EGD completed on January 4, 2007. Id. On January 8, 2007, Ms. Diaz's condition began to deteriorate and she was brought to the operating room for an exploratory laparotomy. See Exhibit 6. After initiation of the surgery, Dr. Stephen Schreiber noted a perforation of the sigmoid colon and fecal contamination of the peritoneal cavity. Id. Ms. Diaz was returned to the recovery room in stable, but extremely critical condition. Id. After the surgery, Ms. Diaz became ventilator-dependent. See Exhibit 7. Ms. Diaz's family requested that any further aggressive treatments such as breathing assistance via the ventilator be discontinued. Id. Ms. Diaz passed away on January 24, 2007. Id. Ultimately, Plaintiff contends that Dr. Sheela failed to meet the applicable standard of care owed to Ms. Diaz in the following ways: (1) by failing to recognize the potential for perforated bowel during the colonoscopy procedure on January 4, 2007; (2) by failing to perform an adequate colonoscopy procedure on January 4, 2007; and (3) by failing to provide proper physician orders. See Plaintiff's Third Amended Complaint, at ¶ 52(a)-(c), attached as Exhibit 8. Plaintiff contends that Ms. Diaz's death was a direct and proximate result of these alleged failures. Id. at IF 53. II. MEMORANDUM OF LAW A. STANDARD OF REVIEW FOR SUMMARY JUDGMENT MOTIONS A party moving for summary judgment must establish by the pleadings and evidence that "there is no genuine issue as to any material fact and the moving party is entitled to judgment as a matter of law." Rule 1.510, Florida Rules of Civil Procedure; see Volusia County v. Aberdeen at Ormond Beach, L.P., 760 So.2d 126, 130 (Fla. 2000)(a material fact, for summary judgment purposes, is a fact that is essential to the resolution of the legal questions raised in the case); see also Continental Concrete, Inc. v. Lakes at La Paz III Ltd. P'ship, 758 So.2d 1214, 1217 (Fla. 2000). When the material facts are undisputed, they form a question of law which the trial court is empowered to decide on a motion for summary judgment. See Johnson v. GulfLife Ins. Co., 429 So.2d 744, 745-46 (Fla. 1983). B. BURDEN OF PROOF: MEDICAL NEGLIGENCE Under Florida law, for a plaintiff to prevail in a medical malpractice action, the plaintiff must prove three essential elements. Gooding v. University Hospital Building, Inc., 445 So.2d 1015 (Fla. 1984). First, the plaintiff must demonstrate the applicable standard of care owed by a physician. Id. Next, the plaintiff must demonstrate that the defendant physician breached that standard of care. Id. Finally, Plaintiff must demonstrate that the physician's breach caused the injuries of which plaintiff complains. Id. In order for a plaintiff to prove that a defendant physician owed a certain standard of care and breached said standard of care, the plaintiff must present a qualified expert witness to support these contentions. See Torres v. Sullivan, 903 So.2d 1064 (Fla. 2d DCA 2005)( "The standard of practice and treatment within a particular medical specialty when physicians in that field are presented with a particular set of circumstances is 'a subject well beyond the jury's expertise,' not a matter 'within the comprehension of laymen")(additional citations omitted). Further, a plaintiff cannot meet his or her burden in proving medical negligence merely by showing a breach of the standard of care in the medical community. The Plaintiff is compelled to prove that defendant's action or inaction "more likely than not" caused the plaintiff s injuries. Gooding, 445 So.2d at 1018 (test for causation in medical malpractice actions requires plaintiffs to prove by a preponderance of the evidence that the alleged negligence of the defendant probably caused the injury at issue). The Gooding Court emphasized that the causation standard should not be relaxed: Relaxing the causation requirement might correct a perceived unfairness to some plaintiffs who could prove the possibility that the medical malpractice caused an injury, but at the same time could create an injustice. Health care providers could find themselves defending causes simply because a patient fails to improve or where serious disease processes are not arrested because another course of action could possibly bring a better result. No other professional malpractice defendant carries this burden of liability without the requirement that plaintiffs prove the alleged negligence probably rather than possibly caused the injury. Id. at 1019-1020 (emphasis supplied). In the current case, Plaintiff has failed to demonstrate that Dr. Sheela's actions or omissions constituted a breach of the applicable standard of care and/or were the proximate cause of Ms. Diaz's death. C. ARGUMENT 1. Plaintiff's allegation that Dr. Sheela breached the standard of care by performing an inadequate colonoscopy procedure on January 4, 2007, should fail. Plaintiff's expert witness, Dr. David A. Morowitz ("Dr. Morowitz"), a specialist in internal medicine with a subspecialty in gastroenterology, testified to various concerns regarding the treatment Ms. Diaz received in January 2007. See Dr. Morowitz's deposition, at p. 5, lines 17-21 (Dr. Morowitz deposition excerpts attached as cumulative Exhibit 9). While Dr. Morowitz believes that Ms. Diaz's colon was injured during the colonoscopy performed by Dr. Sheela on January 4, 2007, he does not believe that injury during a colonoscopy indicates that a physician failed to meet the applicable standard of care. Id. at p. 34, lines 10-13 and p. 77, lines 5-16 ("a perforation does not mean malpractice"). Actually, Dr. Morowitz testified that he could not say that Dr. Sheela negligently performed the colonoscopy. Id. at p. 128, lines 4-15; p. 129, lines 1-11. Therefore, Dr. Morowitz provides no expert testimony which would support Plaintiff's position that the colonoscopy 5 performed on January 4, 2007, by Dr. Sheela fell below the standard of care. Plaintiff has also retained two other medical experts: Joan Spitrey ("Ms. Spitrey"), a registered nurse and Emilio Lobato, M.D., ("Dr. Lobato"), a board certified anesthesiologist. First, neither of these experts are qualified to provide standard of care opinions regarding the completion of a colonoscopy. Second, neither of these experts provided such opinions during their deposition. Ms. Spitrey has been a registered nurse for approximately 14 years. See Ms. Spitrey's deposition, at p. 5, lines 24-25, p. 6, lines 1-3, (Spitrey deposition excerpts attached as cumulative Exhibit 10.) While Ms. Spitrey did at one time help patients recover after colonoscopies, she admits that she is not qualified to render standard of care opinions regarding Dr. Sheela's alleged actions or omissions in the case. Id. p. 18, lines 12-24; p. 54, lines 16-25. Accordingly, Ms. Spitrey provides no criticisms of Dr. Sheela or his staff. Id. p. 215, lines 6-18. Dr. Lobato is a board certified anesthesiologist. See Dr. Lobato's deposition, at p. 4, lines 9-13 (Lobato deposition excerpts attached as cumulative Exhibit 11). Dr. Lobato is not a gastroenterologist, and does not perform colonoscopies. Id. at p.24, lines 6-9; see also p. 156, lines 16-23; p. 157, lines 1-6. Therefore, Dr. Lobato is not qualified to render opinions regarding the technical completion of the colonoscopy, and/or whether said colonoscopy was inadequate. See § 766.102(5)(a), Florida Statutes.' While Dr. Lobato did express criticisms during his deposition of the amount of anesthesia used by Dr. Sheela during the procedure, he admitted that he could not say that any alleged injury which occurred during the January 4, 2007 colonoscopy qualified to render such opinions, he admits that perforations can and do ' Even if Dr. Lobato was occur during colonoscopies even when appropriate care is provided. See Exhibit 11, p. 40, lines 10-12. was more likely than not caused by the amount of sedation given to Ms. Diaz. See Exhibit 11 at p. 166, lines 1-25; p. 167, lines 1-9. Consequently, Plaintiff has failed to provide any medical expert testimony establishing that Dr. Sheela performed an "inadequate" colonoscopy on January 4, 2007. As stated above, Dr. Morowitz, the gastroenterologist retained by the Plaintiff, expressly stated that he did not have an opinion regarding the standard of care provided during this procedure. See Exhibit 9 at p. 128, lines 4-15; p. 129, lines 1-11. Ms. Spitrey, a registered nurse, admitted that she was not qualified to render a standard of care opinion regarding the performance of the colonoscopy. See Exhibit 10 at p. 54, lines 16-25. Finally, Dr. Lobato, an anesthesiologist, is not qualified to render a standard of care opinion regarding the technical completion of the colonoscopy, and further testified that he could not state that any alleged "under sedation" and "restlessness" caused any injury to Ms. Diaz. See § 766.102(5)(a), Florida Statutes; see also Exhibit 11 at p. 166, lines 1- 25; p. 167, lines 1-9. Because Plaintiff has failed to provide any medical expert testimony which would indicate that Dr. Sheela breached the applicable standard of care in performing the colonoscopy or that any alleged breach related to that procedure more likely than not caused injury to Ms. Diaz, any claim by Plaintiff that the colonoscopy performed on January 4, 2007 was "inadequate" should fail. 2. Plaintiff's allegation that Dr. Sheela breached the standard of care by failing to recognize the potential for perforated bowel during the colonoscopy procedure on January 4, 2007, should fail. First, as stated above, there is a complete lack of medical expert testimony to indicate that Dr. Sheela breached the appropriate standard of care during his performance of the colonoscopy. Second, any allegation that Dr. Sheela failed to meet the applicable standard of care after thc colonoscopy should also fail for the reasons set forth below. Dr. Morowitz contends Dr. Sheela failed to meet the applicable standard of care by not keeping Ms. Diaz for observation for an extended period of time following her colonoscopy.2 See Exhibit 9, p. 145, lines 7-21. Specifically, Dr. Morowitz contends Dr. Sheela had an obligation to "keep [Ms. Diaz] in-house for observation for a couple of hours." Id. at p. 130, lines 22-25; p. 131, lines 1-8. Dr. Morowitz testified that if this extended observation had occurred, Dr. Sheela "might have found... an injured sigmoid colon..." Id. (emphasis added). Even if we assume for the sake of argument only that the timing of Dr. Sheela's discharge decision breached the applicable standard of care, Plaintiff has failed to establish as required by Gooding that that decision "more likely than not" caused Ms. Diaz's death. Instead, Plaintiff has presented the above speculative testimony of Dr. Morowitz that a couple of hours of additional observation after the colonoscopy might have resulted in diagnosis of an injured colon. Dr. Morowitz was unable to testify within medical probability that Dr. Sheela's decision to discharge Ms. Diaz when he did resulted in delayed diagnosis of an injured colon. Furthermore, Ms. Diaz's husband, Marcelo Diaz ("Mr. Diaz") testified that his wife was not experiencing any issues of medical significance until the morning she was admitted to Florida Hospital, January 7, 2007. Specifically, Mr. Diaz testified that Ms. Diaz did not experience any significant pain at home on January 4, 2007 following her discharge. He also testified that she did not complain of pain on January 5, 2007 or January 6, 2007. See Mr. Diaz's deposition, at p. 67, lines 12-14; p. 71, lines 2-4; p. 72, lines 7-15; p. 73, lines 4-7. (Diaz Morrowitz testified in deposition, that when only looking at the medical records, his 2 Dr. position would be that Dr. Sheela discharged Ms. Diaz at the appropriate time. See Exhibit 9 at p. 79, lines 23-25; p. 80, lines 1-4. deposition excerpts attached as cumulative Exhibit 12.) In fact, he testified that her condition improved during the time she was home so much so that she felt strong enough to prepare a family dinner on the evening of January 6, 2007. Id., pp. 73-74. He further testified that it was not until the early morning hours of January 7, 2007 that Ms. Diaz woke up complaining of severe abdominal pain. Id., p. 78, lines 1-13; and p. 82, lines 2-22. Due to that severe pain, Mr. Diaz took her to the emergency department at Florida Hospital Apopka on the morning of the 7th, as she had not complained of even mild pain in the abdominal area prior to that time. Id.; see also Exhibit 5 ("[Ms. Diaz] was stable until this morning when she developed severe abdominal pain at which time she presented to the emergency department.") Once Ms. Diaz arrived at the emergency department, she underwent a panel of tests including CT scans of the abdomen and the pelvis. See Exhibit 4. She presented with a normal temperature and a normal white blood count. See Exhibit 11 at p. 150, lines 16-22. The cause of Ms. Diaz's complaints remained unclear until January 8, 2007. See Exhibit 13; see also Exhibit 6. Accordingly, Ms. Diaz's uneventful clinical course during the three days she was home following the colonoscopy is further evidence that observing her for a "couple of hours" more on January 4th would not have yielded any additional clinical information to suggest an injury to the sigmoid colon. Furthermore, even when she became symptomatic on the morning of January 7th and underwent evaluation by multiple specialists, the cause of her complaints was not diagnosed until the following day. Because Plaintiff has failed to establish that the timing of Mrs. Diaz's discharge on January 4, 2007 more likely than not caused any injury to her, any allegation that Dr. Sheela breached the applicable standard of care in this marmer should fail. 3. Plaintiff's allegation that Dr. Sheela breached the standard of care by failing to provide proper physician orders, should fail. Plaintiff has failed to provide sufficient medical expert testimony to support his contention that the physician orders given by Dr. Sheela breached the applicable standard of care. First, in detailing his specific criticisms of Dr. Sheela, Dr. Morowitz stated that due to the language barrier between Dr. Sheela and Ms. Diaz, he was concerned that Dr. Sheela did not adequately convey the discharge instructions to Ms. Diaz or her husband. See Exhibit 9 at p. 131, lines 18-25; p. 132, lines 1-13. However, after asserting this position, Dr. Morowitz testified that he did not know whether Dr. Sheela spoke with the Diaz's post colonoscopy, and therefore, Dr. Morowitz could not know the sufficiency of any instructions given. Id. at p. 132, lines 11-13. Further, it is documented in the nursing records that Mr. Diaz was informed of post procedure care. Id. at p. 134, lines 10-13. A nurse, Ms. Olga Marquez, whose primary language was Spanish, advised the Diaz's of post-procedure care. Id. at p. 134, lines 19-22, p. 135, lines 2-9. Ultimately, Dr. Morowitz could not dispute that Ms. Marquez gave these instructions; instructions which Dr. Morowitz deemed were appropriate. Id. at p. 135, lines 23-25; and p. 135, line 1. Mr. Diaz admits that he signed the endoscopic outpatient discharge instructions, which detail the post-procedure treatment necessary for Ms. Diaz. See Exhibit 12, p. 63, lines 17-25; p. 64, lines 1-6. Mr. Diaz read from these instructions during his deposition and states that he understood the language in which the instructions were written (English). Id at p. 65, lines 17- 25; and p. 66, lines 1-21. 10 Second, while Dr. Lobato expressed concerns regarding the discharge instructions given by the nurses at Florida Hospital and Dr. Sheela, he testified specifically that he had not and would not take a position as to whether the Diaz's understood the discharge instructions. See Exhibit 11 at p. 158, lines 9-20. Finally, as discussed earlier, Plaintiff's third expert, Ms. Spitrey, expressly stated that she would not provide any criticisms of Dr. Sheela or his staff. See Exhibit 10 at p. 54, lines 16-25. Because Plaintiff has failed to present sufficient medical expert testimony regarding the alleged inadequate nature of the discharge instructions given by Dr. Sheela, Plaintiff's contention of the same should fail. WHEREFORE, Defendants' motion for summary judgment should be granted for all the foregoing reasons. DENNIS, JACKSON, MARTIN & FONTELA, P.A. By: 7go ROGELIO J. FONTELA (FBN: 0956473) W. BENNETT CARTER, JR. (FBN: 90952) Dennis, Jackson, Martin & Fontela, P.A. 1591 Summit Lake Drive, Suite 200 Tallahassee, FL 32317 (850) 422-3345 (850) 422-1325 (Fax) roger@djmf-law.com ben@djmf-law.com Attorneys for Defendants Harinath Sheela, M.D. and Digestive and Liver Center of Florida, P.A. CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing was furnished by ECF system this 5th day of February, 2013 to: Carlos R. Diez-ArgueHes, Esquire, Diez-Arguelles & Treiedor, 505 North Mills Avenue, Orlando, Florida 32803; Patrick H. Telan, Esquire, Grower, Ketcham, Rutherford, Bronson, Eide & Telan, P.A., 901 North Lake Destiny Road, Suite 450, Maitland, Florida 32751; and Mary Jaye Hall, Esquire, McEwan, Martinez & Dukes, P.A., P.O. Box 753, Orlando, Florida 32802-0753. DENNIS, JACKSON, MARTIN & FONTELA, P.A. By: ROGELIO J. FONTELA 41 22 (FBN: 0956473) W. BENNETT CARTER, JR. (FBN: 90952) Dennis, Jackson, Martin & Fontela, P.A. 1591 Summit Lake Drive, Suite 200 Tallahassee, FL 32317 (850) 422-3345 (850) 422-1325 (Fax) roger@djmf-law.com ben@djmf-law.com Attorneys for Defendants Harinath Sheela, M.D. and Digestive and Liver Center of Florida, P.A. 12 Exhibit 1 „. . Seela, M.D. Srinivas Board of Gastroentefology à t. Diptomate, Arnedcan and Harinath Sheela, Digestive )M.D.. eff44. r ltver Center of Florida PA Boma of Gastroenterology Dipio.n.,.. ArneOcon INITIAL OFFICE CONSULTATION REPORT Diaz, Herminia PATIENT NAME: 04/25/1944 DATE OF BIRTH: 01/02/2007 DATE OF OFFICE VISIT: Howard A Sackel, M.D. REQUESTING PHYSICIAN: 2501 North Orange Avenue Suite 537N Orlando, FL 32804 Ph#: (407) 894-4693 Fax#: (407) 895-1496 Heme-positive stools. REASON FOR CONSULTATION: Dear Dr. Sackel: in my office today for evaluation of heme-positive Ms. Diaz summarize her It was my pleasure seeing I would like to well aware of her history, with history of As very years old female stools. you are she is 62 information for my medical records. Briefly, 2 and also complicated post transplant x on dialysis and status renal disease, The patient was recently end-stage and has been on dialysis again. is with abdominal hemorrhage, and is here for further consultation. The patient stools denied noticed to have heme-positive with the help of our staff. The patient and examined and was translated Denied any hematochezia. seen of breath, fever or chills. chest pain, shortness The patient did have a having any constitutional symptoms. Denied any weight loss or any other than 10 years ago. The EGD performed in 1990, which was more colonoscopy as wellrecent as patient denied any change in her medications. ALLERGIES: No known drug allergies. CURRENT MEDICATIONS: 1. Isosorbide 30 mg once daily. 2. Norvasc 10 mg once daily. 3. Lisinopril 40 mg once daily. 4. Catapres patch. fin1298 407-384-7388. 7975 Lake Underhill Road,Suit 350, Orianda.Florida-32822 Fax: 470-384-7391wWw.DlgestiveandLiverCenterofFlorlda.org RE: Diaz, Herminia PAGE TWO 5. Folic acid 1 mg once daily. 6. Pravachol 40 mg at bedtime. 7. Singulair 10 mg daily. 8. Synthroid 25 mg daily. 9. Prevacid 30 mg daily. 10. Aspirin 81 mg daily. 11. Renagel 800 mg. and Ambien p.r.n. 12. Combivent, Pulmicort, PAST MEDICAL HISTORY: 1. Hypertension. status post kidney transplant x 2. 2. End-stage renal disease, Dialysis, abuse. SOCIAL HISTORY: Denied smoking, alcohol, or IV drug in the family. No history of malignancy FAMILY MEDICAL HISTORY: of present illness. As mentioned in the history REVIEW OF SYSTEMS: PHYSICAL EXAMINATION: 160/86, pulse of 64, and weight of 97.2, blood pressure VITAL SIGNS: Temperature 143 lbs. EOMs are equal, round, and reactive tolight and accommodation. HEENT: Pupils are intact. NECK: Supple. No JVD. HEART: Regular rate and rhythm. No wheezing, rales, or rhonchi. LUNGS: Clear to auscultation bilaterally. bowel sounds. ABDOMEN: Soft, non tender with positive EXTREMITIES: No cyanosis, clubbing, or edema. Not available. Occult stool positive x 3. LABORATORY DATA: female with above-mentioned ASSESSMENT: The patient is 62 years old very pleasant Anemia medical problems with heme-positive stools, anemia, and for further evaluation. renal secondary to chronic blood gas versus end-stage is multifactorial most probably disease. it is lower GI causes, stools: Majority of the cases greater than 85% a Heme-positive versus polyps versus AVMs versus ulcers and malignancy. which include diverticulosis differential to upper GI bleed for which the Less than 15% of the causes, it can be related versus esophagitis. includes peptic ulcer disease versus gastritis 1 2 o rt-kur, rucrx,.. PLAN: CBC from your dialysis lab. above differential. 1. We will obtain the to further evaluate as well as EGD 2. We will perform colonoscopy well supplementation if needed. as 3. Iron benefits, and alternatives as the patient regarding the risks, with 4. Discussed of procedure and the patient agreed for the procedures. complications is performed. 5. Return to clinic after the procedure of this patient. Thank you Dr. Sackel for allowing us to participate in the care 8'4 Srinivas Seela, M.D. nnlln Exhibit 2 FLORIDA HOSPITAL M197670H FLORIDA HOSPITAL - ORLANDO DICTATING PHYSICIAN: Harinath Sheela, MD (5227) NAME: HERMINIA DIAZ ACCOUNT 4: MRI: 000883705 DATE: January 4, 2007 PROCEDURE PERFORMED: 1. Esophagogastroduodenoscopy plus biopsies. 2_ Colonoscopy. • PHYSICIAN: Harinath Sheela, MD INDICATIONS: The patient is a 62-year-old white female with hemodialysis for chronic renal noted be anemic, iron-deficiency, and insufficiency, to rectal bleeding. The patient is an outpatient for questionable melena, colonoscopy and EGD. • After the risks, benefits, and alternatives of the procedures explaining including, but not limited to, infection, bleeding, perforation, effects conscious sedation, informed consent was obtained hemodynamic of husband. from the patient. We also discussed with the patient's COLONOSCOPY: Versed 6 IV, fentanyl 75 mcg IV. MEDICATIONS USED FOR THE mg PROCEDURE COLONOSCOPY: After administrating the above medications in #1 the patient in the left lateral decubitus incremental.doses, placing rectal examination, the Olympus video endoscope position, and performing PCP 160F was advanced to the cecum. After the patient experienced to distention and passing flatus, and significant difficulty secondary of the patient's spasms have been after administrating 0.5 glucagon, decreased and could easily advance to the cecum without endoscope of the preparation was noted to be excellent. difficulty. The quality orifice identified. The Ileocecal valve, cecal strap and appendiceal were cecal descending, rectosigmoid mucosa.with mucosa, ascending, transverse, careful examination while withdrawing the scope on the circumferential the multiple views has been normal. views, and also advancing scope on There diverticular disease, no mucosal abnormalities were no polyps, no PROCEDURE NOTE HARINATH SHEELA MD JAL648 D: 01/04/07 T: 01/05/07 14:02 PAGE: 1 DIAZ, HERMINIA MRI: 883705 P: 01/10/07 14:23 0/T/P:BYC8-KG49-HLCO FLORIDA HOSPITAL JOB: 99 60363. CONFIDENTIAL AND PRIVILEGED INFORMATION FOR PROFESSIONAL USE ONLY. ANY REDISCLOSURE IS FORBIDDEN BY STATE -.. -. -.. _. .. STATUTE., ---....1