medical summary-patient chronological medical...

1

MEDICAL SUMMARY-PATIENT

CHRONOLOGICAL MEDICAL SUMMARY

Ms. PATIENT

DOB: ……………

DOI: _________

SSN: …………………

SYNOPSIS:

On September 13, 2005, Patient presented to LC, M.D. for an evaluation and complained

of urinary leakage with coughing and sneezing. Impression revealed evidence of stress

incontinence which was visible by physical examination with a positive Marshall test. Surgical

therapy such as pubovaginal sling correction was deferred given her young age.

On February 12, 2008, Patient presented to LC, M.D. for an evaluation and complained

of urinary leakage. She had leakage with coughing, straining, sneezing and exertional activity.

Impression revealed mixed probably mostly stress urinary incontinence. She was advised to

undergo formal CMG and cystoscopy studies before considering surgical intervention such as

transobturator tape sling.

On March 20, 2008, Patient presented to LC, M.D. for an evaluation. She continued to

have urinary leakage. Impression revealed mixed, mostly stress, urinary incontinence. Patient

was scheduled to undergo transobturator tape urethrovaginal sling placement.

On December 19, 2008, Patient presented to LC, M.D. at AV Hospital for a surgical

procedure. Preoperative and postoperative diagnosis included mixed urinary incontinence.

Patient had mixed urinary incontinence and some hypermobility of the urethra was noted at

cystoscopy and physical examination. She underwent transobturator tape Obtrynx

urethrovaginal sling placement with cystoscopy on that day under general anesthesia.

On January 12, 2009, Patient presented to LC, M.D. for a postoperative evaluation after

vaginal sling placement for mixed urinary incontinence. She was doing very well, however

noticed that it took a little bit longer for her to empty her bladder and her stream was a little bit

slower. Patient was advised to hydrate well, limit activity and intercourse until 4 weeks post op

and to follow up in three months with a bladder scan.

On August 11, 2010, Patient presented to SA, M.D. at WG and O Clinic, Inc. for an

evaluation and complained of pelvic pain which was sharp in nature and present in the ovarian

area. She also complained of dyspareunia. Patient was assessed with pelvic pain/ uterine pain.

Possibility of a hysterectomy was discussed.

On November 15, 2010, Patient presented to SA, M.D. at AV Hospital for a surgical

procedure. Preoperative and postoperative diagnosis included chronic pelvic pain and

dyspareunia. She underwent total vaginal hysterectomy under general endotracheal anesthesia.

2

On January 10, 2011, Patient presented to SA, M.D. at WG and O Clinic, Inc. for an

evaluation and complained of pain with urination. She had a sling done and there might have

been a suture from the sling that was in the bladder causing her trouble. Patient was advised

to undergo a scope to see what was going on inside her bladder.

On January 18, 2011, Patient presented to LC, M.D. for a flexible cystoscopy which

showed small erosion and visible exposed sling material mid urethra. She complained of pain or

burning with urination. Patient was 25 months out from a mid-urethral sling placement. Patient

was assessed with dysuria. She was noted to have erosion of sling which is a known but

uncommon complication of slings from mesh. Patient was advised to undergo urethrolysis and

removal of sling.

On January 21, 2011, Patient presented to LC, M.D. at AV Hospital for a surgical

procedure. Preoperative and postoperative diagnosis included urethral sling erosion. Patient was

treated for mixed and mostly stress urinary incontinence with a midurethral transobturator

Obtryx sling in December 2008. She had done extremely well until approximately 2-3 months

ago when she developed dysuria and vaginal pain. Patient also had a urethral discomfort. She

was treated with hysterectomy without improvement by her gynecologist. Patient was also

worked up with cystoscopy and a small erosion into the ventral aspect of the urethra from her

sling was confirmed. Hence, excision of the sling was advised. Patient underwent mid urethral

sling excision with urethrolysis and repair under general anesthesia on that day.

On March 17, 2011, Patient presented to LC, M.D. for a postoperative evaluation. Her

leakage was worse since removal of her eroded sling 2 months ago. Patient had problems getting

to the bathroom in time after she had the urge to urinate. She also had problems with nighttime

incontinence. Patient also leaked urine when she coughed, laughed or sneezed. She was

assessed with mixed incontinence. Patient had post sling erosion and worsening incontinence.

She would require an autologous fascial sling to try and correct this.

On July 13, 2011, Patient presented to LC, M.D. for an evaluation of mixed incontinence.

She had severe leakage and needed repair with autologous fascial sling. Patient was advised to

undergo repair of synthetic mesh because of the risk of erosion. She was scheduled to undergo

autologous fascial sling with overnight stay.

On September 16, 2011, Patient presented to LR. C, M.D. at AV Hospital for a surgical

procedure. Preoperative and postoperative diagnosis included abdominal laxity. She underwent

abdominoplasty and tolerated the procedure well.

On September 16, 2011, Patient presented to LC, M.D. at AV Hospital for a surgical

procedure. Preoperative and postoperative diagnosis included mixed urinary incontinence

following urethral mesh sling erosion plus urethral vaginal fistula plus abdominal laxity being

treated by Dr. LC of Plastic Surgery. Patient underwent autologous fascial sling with repair of

urethrovaginal fistula under general endotracheal anesthesia.

3

On September 22, 2011, Patient presented to LC, M.D. at WU Clinic for a postoperative

evaluation. She complained of urinary retention and trouble urinating after fascial sling

placement six days ago. Patient was advised that it would loosen up over time and be fine. She

was also taught self-catheterization in the meantime.

On January 31, 2012, Patient presented to LC, M.D. at WU Clinic for an evaluation of

mixed and stress incontinence status post sling placement. She remained well and was totally

back to normal since autologous fascial sling surgery for prior mesh sling erosion. Patient had

a normal sensation when needing to urinate and felt that she was emptying her bladder well.

Document

(page no.)

Date of

Service

Provider Particulars Comments

Dr. SA –

0022

(22/42)

04/12/2004 WG and O

Clinic, Inc.

SA, M.D.

Progress Note

Subjective:

• 32 YOF who presented

for an annual GYN

exam.

• Patient wanted to talk

about getting her tubes

tied.

• Patient also felt a very

small breast lump of the

left breast and felt that

lump with breast-feeding.

• Breast ultrasound was

negative.

• Also complained of back

ache.

Physical Examination:

• A small, almost pinpoint

mass about five o’ clock

of the left breast was felt.

• Uterus was about 18-

weeks size enlarged.

Assessment/ Plan:

• Annual GYN exam was

done.

• Small breast mass was

found. Advised to

undergo a breast

ultrasound of the left

breast.

Annual GYN

exam

4

• Patient had an enlarged

uterus. Pregnancy test

was positive, probably

about 18 weeks.

• Patient was started on

prenatal vitamins.

• Scheduled for an initial

OB appointment.

• Advised to undergo

ultrasound of the fetus to

check for dates.

• Pap smear was also done.

Dr. SA –

0018

(18/42)

05/31/2005 WG and O

Clinic, Inc.

SA, M.D.

Progress Note

Subjective:

• Patient presented for an

annual GYN exam.

• Patient had a rash on the

right wrist that had not

gone away.

• Going to get primary care

doctor to see both her

wrist and get tested for

diabetes.


• Vagina: There was a

frothy, yellowish

discharge.

Assessment/ Plan:

• Annual GYN exam was

done.

• Patient had some frothy,

yellowish discharge from

the vagina with a fishy

odor.

• Bacterial vaginosis was

suspected.

• Prescribed with Flagyl.

• Also underwent a Pap

Smear.

• Appointment would be

made with primary care

Annual GYN

exam

5

doctor for her rash and

her family history of

diabetes.

• Return in one year or as

needed.

Dr. LC -

0055

(55/60)

09/13/2005 LC, M.D. Progress Note

Chief Complaint:

• Urinary leakage.

History of Present Illness:

• 33 YOF leaked when she

coughed and sneezed.

She was very physically

active.

• Patient was tried

empirically on some

Ditropan without

improvement.

• Patient was not interested

in a hysterectomy.

Impression:

• Evidence of stress

incontinence which was

visible by physical

examination with a

positive Marshall test.

• Surgical therapy such as

pubovaginal sling

correction was deferred

given her young age.

Plan:

• Salt Lake Research evaluation for evaluation

of stress urinary

incontinence medication.

Complained of

urinary leakage

with coughing

and sneezing.

Impression

revealed stress

incontinence.

Dr. LC-

0055

(55/60)


• Patient has both urge and

stress incontinence upon

further evaluation with a

seven-day diary review.

Patient had both

urge and stress

incontinence on

evaluation.

6

• Patient will enroll with a

urge and stress

incontinence study.

Dr. SA –

0016

(16/42)

05/11/2006 WG and O

Clinic, Inc.

SA, M.D.

Progress Note

Subjective:

• Patient presented for an

annual GYN exam.

• Patient was doing well

and had no complaints.

• Last Pap smear from

June 06, 2005, was

normal.

Assessment/ Plan:

• Annual GYN exam.

• Advised to return in one

year or as needed.

Annual GYN

exam

Dr. SA –

0016

(16/42)

05/31/2006 WG and O

Clinic, Inc.

J Cluny,

FNP

Progress Note

• Patient complained of

itchiness, dryness and

discharge in the vagina.

Her urine showed 2+

leukocytes.

• Suspected to probably

have a bladder infection.

• Treated with Macrobid

for 7 days and MetroGel

for the vagina for

bacterial infection.

• Urine was sent for a

culture.

Complained of

itchiness,

dryness and

discharge in the

vagina.

Dr. SA –

0039

(39/42)

05/31/2006 Biolabs Laboratory Report

Urine Culture:

• >10,000 CFU/ mL mixed

contaminating flora, no

further workup.

• Repeat collection

following clean catch

protocol was advised.

Laboratory

Report

7

Dr. SA –

0014

(14/42)

11/13/2006 WG and O

Clinic, Inc.

J, FNP

Progress Note

Subjective:

• Patient presented with

complaints of urinary

tract infection and

possible vaginal

infection.

• Patient was having a hard

time distinguishing the

two different areas.

• Patient did have 2+

leukocytes in her urine.

Treated with Macrobid

for 7 days.

• Inspection of the vagina

was normal. Patient was

placed on Diflucan.

• Patient would be referred

to a urologist for

continued urinary tract

infections.

Presented with

complaints of

urinary tract

infection and

possible vaginal

infection.

Dr. SA –

0037

(37/42)


Urine Culture:

• 10,000 CFU/ mL mixed contaminating flora, no

further workup.

Laboratory

Report

Dr. LC-

0054

(54/60)


Chief Complaint:



• Patient wanted to deal

with her bladder. She

tolerated overactive

bladder medication study

poorly.

• Patient had leakage with

coughing, straining,

sneezing and exertional

activity.

Impression

revealed mixed

probably mostly

stress urinary

incontinence.

8

Impression:

• Mixed probably mostly

stress urinary

incontinence.

• Formal CMG and

cystoscopy studies

advised before

considering surgical

intervention such as

transobturator tape sling.

Plan:

• CMG uroflow, EMG,

leak point pressure

determination.

• Return with results for

cystoscopy evaluation

and possible surgical

scheduling.

Dr. LC-

0053

(53/60)

03/10/2008 LC, M.D. Urodynamic Clinical Report

Diagnosis:

• Mixed urinary

incontinence.

Urodynamic

Clinical Report

Dr. LC-

0047

(47/60)


Chief Complaint:


Procedure:

• Placed on supine

lithotomy.

• Perineum was checked.

• Grade I cystocele noted

with 30 degree urethral

hypermobility.

• Posterior vaginal wall

support was good.

Impression:

• Mixed, mostly stress,

urinary incontinence.

Plan:

Impression

revealed mixed,

mostly stress,

urinary

incontinence.

Scheduled to

undergo

transobturator

tape

urethrovaginal

sling placement.

9

• Transobturator tape

urethrovaginal sling

placement.

• Risks and benefits were

reviewed. Patient gave

consent.

AV

Hospital -

0040-041

(40-41/48)

12/19/2008 AV

Hospital

History & Physical Report

Admission Diagnosis:

• Mixed urinary

incontinence.


• 37 YOF has urinary

leakage with straining,

coughing and sneezing.

• Urethral hypermobility

noted at cystoscopy and

physical examination.

• Wears pads to control her

leakage.

• Presented for

transobturator tape


placement to give her

better bladder control.

Past Surgical History:

• No prior surgeries.

• Given birth to 3 children.


• Grade 1 cystocele.

• Normal uterus and

parous cervix.

Impression:

• Mixed, mostly stress

urinary incontinence.

Plan:

• Transobturator


placement.

Complained of

urinary leakage

with straining,

coughing and

sneezing.

Presented for

transobturator

tape

urethrovaginal

sling placement

to give her better

bladder control.

10

• Patient consented for

treatment.

AV

Hospital -

0004-005

(4-5/48)

12/19/2008 AV

Hospital

Operative Report

Preop/Postop Dx:

• Mixed urinary

incontinence.

Operation:

• Transobturator tape

Obtrynx urethrovaginal

sling placement with

cystoscopy.

Surgeon:

• LC, M.D.

Anesthesia:

• General with laryngeal

mask airway.

History:

• 37 YOF with mixed

urinary incontinence

including leakage or

straining, coughing,

sneezing and some

urgency.

• Has some hypermobility

of the urethra noted at

cystoscopy and physical

examination.

• Presented for

transobturator tape sling

placement.

Procedure:

• General anesthesia was

established.

• Placed in a supine dorsal

lithotomy position.

• Perineum was shaved,

prepped thoroughly with

Betadine solutions

including vaginal

Patient

underwent

transobturator

tape Obtrynx

urethrovaginal

sling placement

with cystoscopy

under general

anesthesia.

11

Betadine prep.

• Sterile cystoscopy drapes

were applied.

• A weighted vaginal

speculum was positioned

and the bladder was

drained with a small

catheter.

• The anterior urethral

mucosa was infiltrated

with 1% Xylocaine with

epinephrine.

• An incision was made

from back of the sternum

1.5 cm from the urethra/

meatus for a distance of 2

cm.

• The underlying vaginal

mucosa was sharply

dissected away from the

urethra dissecting out

towards the pubocervical

fascia on either side.

• The left side of the

vaginal mucosa had a

small bleeding site,

which was controlled

with a figure-of-eight 3-0

chronic suture ligature.

• Then able to palpate

through this incision up

towards the pubocervical

fascia towards the

obturator fossae.

• Small stab wounds were

made over the obturator

fossae at the level of the

clitoris towards the

insertion of the adductor

longue muscles which

was done bilaterally.

• A curved halo needle was

then passed through the

stab wound through the

obturator fossa and

staying below the bladder

12

and coming out through

the vaginal incision.

• The Obtryx tape was then

grasped which had been

soaked in antibiotic

solution and drawn back

out through the wound.

This was repeated

contralaterally and the

tape was then centered

and verified to be non-

twisted.

• A 22 French cystoscope

was passed with a 70

degree lens on into the

bladder at that point.

• The bladder and urethra

were both inspected and

no violation or injury of

these structures was

noted.

• There appeared to be

clear effluxing urine

from both ureteral

orifices.

• The bladder was drained

and the scope was

removed.

• A curved Heaney needle

driver was then placed

between the urethra and

the tape and the

cellophane sheathing was

then cut and removed

from the tape leaving the

tape position without any

significant tension. The

redundant ends of the

tape were then trimmed

at the stab wounds.

• Everything was

thoroughly irrigated with

saline solutions.

• The vaginal mucosa was

then closed with

interrupted 3-0 chromic

13

sutures in a mattress

fashion.

• The stab wounds were

then cleaned off, closed

with Mastisol and Steri-

Strips.

• A lap sponge was then

placed in the vagina for

gentle packing pressure

and the vaginal speculum

was removed.

• The vaginal sponge was

removed upon transfer to

PACU.

• Estimated blood loss was

200 mL.

• Sponge, needle, and

instrument counts were

correct.

• Patient remained

hemodynamically stable.

Discharge Medications:

• Levaquin.

Instructions:

• No intercourse for 3

weeks.

• No driving and no lifting

greater than 5 to 10

pounds for the next 2

weeks.

• Office follow-up as

scheduled.

Dr. LC-

0041, 045

(41, 45/60)


Chief Complaint:

• Post op vaginal sling for

mixed urinary

incontinence.

Subjective:

• Patient was doing very

well, however noticed

that it took a little bit

Presented for

postoperative

evaluation status

post Obtryx sling

placement for

mixed urinary

incontinence.

Patient noticed

that it took a

little bit longer

14

longer for her to empty

her bladder and her

stream was a little bit

slower.

• This was improving. She

was pleased overall.

Impression:

• Postop Obtryx sling for

mixed urinary

incontinence.

• Patient was doing well.

Plan:

• Hydrate well.

• Limit activity and intercourse until 4 weeks

post op.

• Follow up in 3 months

with a bladder scan.

for her to empty

her bladder and

her stream was a

little bit slower.

Dr. LC-

0040-041

(40-41/60)


Chief Complaint:

• Voiding follow-up.


• Patient was post Obtryx

sling placement

12/19/2008.

• No longer leaks with

coughing, straining or

physical activity.

• Complained of some

puffiness and swelling

around her menses.

• Gynecology follow-up

was advised.

Impression:

• Successful Obtryx


placement.

• Female hormone

changes, peripheral

edema, etc.

Patient

complained of

some puffiness

and swelling

around her

menses.

15

Plan:

• Follow up with Dr.

Chichester.

• Follow up as needed.

Dr. LC-

0039

(39/60)


• 37 YOF with the last

term pregnancy five

years ago.

• Patient has had an

increase in the past year

with premenstrual

bloating discomfort

which started at the time

of ovulation and ended

after her menses started.

• This stared to complicate

her life because she felt

very uncomfortable with

it.

• Going to try and block

ovulation as a first step

using a low dose oral

contraceptive.

• Patient had no plans to

have any more children,

and her husband has had

a vasectomy.

• Patient was given a

sample of Ortho-

TriCyclen Lo as well as a

prescription. She was

just finishing up her

menses and was advised

to start the oral

contraceptives that

weekend.

Progress Note

Dr. SA –

0012

(12/42)

04/08/2010 WG and O

Clinic, Inc.

SA, M.D.

Progress Note

Subjective:

• Patient presented for her

annual GYN exam.

• Patient was doing well.

Annual GYN

exam

16

• Patient has had a sling

done in 2009.

Assessment/ Plan:

• Pap smear was done and

going to get a baseline

mammogram.

• Health maintenance

issues were discussed.

• Advised to return as

needed or in one year’s

time.

Dr. SA –

0036

(36/42)

04/08/2010 PH &

SCHI

M SH, CT

Cytology Report

Cervical/ Endocervical – Sure

Path Pap Test:

Diagnosis:

• Negative for

intraepithelial lesion or

malignancy.

Cytology Report

Dr. SA –

0035

(35/42)


Urine Culture:

• Organism 1: Resembles

normal vaginal flora, no

further workup.

• Organism #1:

Streptococcus Viridans.

• Quantitation: >100,000

CFU/mL (N).

Laboratory

Report

Dr. SA –

0011

(11/42)

08/11/2010 WG and O

Clinic, Inc.

SA, M.D.

Progress Note

Subjective:

• Patient presented with

complaints of pelvis pain

which was sharp in

nature and present in the

ovarian area.

• Pain was intermittent for

the past three months and

seemed to be getting

worse.

Presented with

complaints of

pelvic/ uterine

pain.

Possibility of a

hysterectomy

was discussed.

17

• Urine dipstick was

slightly suspicious for a

UTI with 1+ leukocytes.

• Patient felt that the pain

was in her uterus and was

a sharp cramping pain.

• Patient had a retropubic

sling done in 2009 for

urinary stress

incontinence.

• Pelvic exam was done.

Uterus was pretty painful

on palpation.

• Patient also complained

of dyspareunia.

Assessment and Plan:

• Pelvic pain/ uterine pain.

• Treated with Macrobid

for 7 days for presumed

UTI.

• Possibility of a

hysterectomy was

discussed.

• Advised to return in two

to three weeks for

follow-up evaluation.

Dr. SA –

0034

(34/42)


Urine Culture:

• Organism #1: Strep

Agalactiae (Group B).

• Quantitation: 15,000

CFU/ mL.

• Organism #2:

Gardnerella Vaginalis.

• Quantitation: Greater

than 100,000 CFU/mL

Laboratory

Report

Dr. SA –

0010

(10/42)

08/24/2010 WG and O

Clinic, Inc.

SA, M.D.

Progress Note

Subjective:


with complaints of pelvic

Patient appeared

to still have a

urinary tract

infection.

Prescribed with

18

discomfort and uterine

discomfort.

• Urine culture dated

08/11/2010 grew out

streptococcus.

• Still had some uterine

pain.

• Urine dipstick still

showed 2+ leukocytes

and positive titrates,

hence it was still

suspicious for a UTI.

• Possible hysterectomy

was discussed.

• Pelvic exam was done.

Slight uterine tenderness

was noted.


• Patient appeared to still

have a urinary tract

infection.

• Prescribed with Levaquin

and Flexeril.

• Complained of back pain

that was work related.

• Advised to call in 7-10

days.

Levaquin and

Flexeril.

Dr. SA –

0009

(9/42)

09/03/2010 WG and O

Clinic, Inc.

T. G, FNP

Progress Note

Chief Complaint:

• Yeast infection.

Subjective:

• Patient had been on 3

rounds of antibiotics to

get over a UTI which

was now totally resolved

as noted on culture,

however she developed

signs and symptoms of

yeast.

Objective:

• Erythematous external

Complained of

yeast infection.

Assessed with

yeast

vulvovaginitis.

19

genitalia.

• Vagina was red, rugated

and there was thick

yeast-like discharge in

the vaginal vault.

Assessment:

• Yeast vulvovaginitis.

Plan:

• Given some Lotrisone

cream to apply externally

and Diflucan for yeast.

Dr. SA –

0032

(32/42)


Genital Culture:

Gram Strain:

• Many Gram Positive

Bacilli resembling

Lactobacilli.

• Moderate yeast.

• Moderate gram variable

bacilli

• Few gram positive cocci

Genital Culture:

• Organism 1: Probable

non-candida albicans

based upon colony.

• Morphology. No further

work-up.

• Moderate normal vaginal

flora.

• No group B Beta Strep

isolated.

• No Neisseria

Gonorrhoeae isolated.

Organism #1: Yeast:

• Quantitation: Moderate.

Laboratory

Report

Dr. SA –

0008

(8/42)

09/30/2010 WG and O

Clinic, Inc.

Progress Note

Subjective:

Assessed with

uterine pain and

dyspareunia.

20

SA, M.D. • 38 YOF with pelvic/

uterine pain.

• Patient has been treated

for a UTI previously.

• Advised to undergo urine

culture.

• Still had ongoing pelvic

pain, dysmenorrhea and

dyspareunia.

• Patient’s cramping and

the pelvic pain was right

in the location of the

uterus.

• Patient was ready for a

hysterectomy and her

options would be OCPs/

hormonal manipulation

which was declined.


• There was some cervical

motion tenderness.

• There was some descensus of the uterus

and it was tender to

touch.


• Uterine pain and

dyspareunia.

• Patient was desirous of a

hysterectomy which

would be scheduled. Her

ovaries would be

retained.

Patient was

desirous of a

hysterectomy

which would be

scheduled.

Dr. SA –

0008

(8/42)

11/13/2010 WG and O

Clinic, Inc.

SA, M.D.

Progress Note

• 39 YOF with pelvic pain,

dyspareunia.

• Underwent total vaginal

hysterectomy.

• Also had a 3 cm

pedunculated fibroid on

top of the uterus.

Progress Note

21

• No complications.

RH – 0026-

027

(26-27/154)

11/15/2010 RH

SPA, M.D.

History and Physical Report


• 38 YOF with a long

history of chronic pelvic

pain.

• Also complained of

dysmenorrhea and

dyspareunia. Her

cramping and the pelvic

pain was right in the

location of the uterus.

• Patient has had a history

of UTIs which has been

adequately treated.

• Patient was given options

of hormonal

manipulation or

laparoscopy to help to

manage her pelvic pain.

However she was

seeking definitive

therapy in the form of a

hysterectomy as she was

done with childbearing.

• Patient wished to retain

her ovaries.

• Patient has had a sling

done for urinary stress

incontinence in 2009.


• Retropubic sling.


• There was 1+ descensus.

• Uterus was tender to the

touch.


• Pelvic pain, dyspareunia,

and dysmenorrhea.

• Patient was desirous of a

hysterectomy.

Assessed with

pelvic pain,

dyspareunia, and

dysmenorrhea.

Patient was

desirous of a

hysterectomy.

22

• The procedure, potential

risks of the procedure

and postoperative course

was discussed with the

patient.

AV

Hospital -

0009-010

(9-10/48)

11/15/2010 AV

Hospital

Operative Report

Preop/Postop Dx:

• Chronic pelvic pain,

dyspareunia.

Operation:

• Total vaginal

hysterectomy.

Surgeon:

• SPA, M.D.

Anesthesia:

• General endotracheal.

Findings:

• Normal appearing uterus

with a 3 cm pedunculated

fibroid on the fundus of

the uterus.

• Normal appearing

ovaries and tubes.

Procedure:

• Patient was taken to the

OR where anesthesia was

given.

• Placed in dorsal

lithotomy position and

was prepped and draped

in usual sterile fashion.

• Weighted speculum was

placed in the vagina.

• Two Lahey clamps were

used to grasp the anterior

and posterior lip of the

cervix.

• The cervix was

circumferentially injected

Underwent total

vaginal

hysterectomy

under general

endotracheal

anesthesia.

23

with 10 mL lidocaine

with epinephrine.

• Scalpel was then used to

excise around the cervix

and the vaginal mucosa

was then excised off the

pubovesicocervical fascia

using Metzenbaum

scissors and blunt

dissection using a wet

sponge.

• Posterior cul-de-sac was

entered without any

difficulty using Mayo

scissors.

• A long neck weighted

speculum was placed at

that side.

• Uterosacral ligaments on both sides were then

clamped with Heaney

clamps, transected and

suture ligated with 0

Vicryl.

• The bladder was then

carefully dissected off

the cervix in lower

uterine segment with

sharp dissection using

Mayo scissors and then

pushed up using blunt

dissection with a wet

sponge.

• Cardinal ligament, both

sides were clamped with

Heaney clamps,

transected and suture

ligated with 0 Vicryl.

• Hemostasis was assured.

• Uterine arteries on both

sides were then clamped

with Heaney clamps,

transected and suture

ligated with 0 Vicryl.

• Hemostasis was assured.

• The anterior peritoneal

24

fold could be seen. The

anterior peritoneum was

then entered using

Metzenbaum scissors

which was done without

any difficulty and a

Deaver retractor was

placed at that side.

• The pedicles were

clamped with Heaney


suture ligated with 0

Vicryl next.

• Hemostasis was assured

again.

• The remaining tubal

round ovarian ligaments

on both sides were then

clamped with Heaney


uterus with the fibroid

was delivered.

• The 2 remaining tubal

round ovarian ligament

pedicles were then

doubly ligated with free

ties of 0 Vicryl followed

by stick ties of 0 Vicryl.

• The pedicles were then

checked for hemostasis

again.

• The tubal round ovarian

pedicle was oozing just a

little bit underneath it

which was made

hemostatic after

clamping with Heaney

clamps and then tying

down with 0 Vicryl.

• All the pedicles were

checked and found to be

completely hemostatic.

• Peritoneum was then

closed with 2-0 Vicryl in

a pursestring suture.

• The vaginal cuff angles

25

were closed with figure-

of-8 sutures of 0 Vicryl.

• The rest of the vaginal

cuff was closed with

figure-of-8 sutures of 0

Vicryl.

• Hemostasis was again

checked along the

vaginal cuff angles and

found to be hemostatic.

• The bladder was then

drained with a straight

steel catheter and clear

urine was noted.

• Patient tolerated the

procedure well.

• Sponge, lap and needle

counts were correct.

• Patient received Ancef

intraoperatively.

• Patient went to Recovery

in good condition.

Specimens:

• Uterus.

RH– 0021-

022

(21-22/154)

11/15/2010 IC

Laboratory

MW, M.D.

Surgical Pathology Report

Specimen Submitted:

• Uterus cervix.

Clinical History:

• Pelvic pain,

dysmenorrhea,

dyspareunia.

Final Diagnosis:

Uterus, hysterectomy:

• Three uterine

leiomyomas.

• Secretory endometrium.

• Unremarkable cervix and

serosa.

Surgical

Pathology

Report

RH– 0070

(70/154)

11/15/2010

through

RH Medications List

Medications List

26

11/17/2010 Medications:

• Saline.

• Influenza virus vaccine.

• Ondansetron.

• Hydrocodone.

• Ketorolac.

• Ibuprofen.

• Docusate Sodium.

RH– 0151-

154

(151-

154/154)

11/15/2010

11/16/2010

11/21/2010

11/24/2010

IH Laboratory Report

Urine Macro:

11/15/2010:

• Leuk Esterase was

moderate (Abnormal).

• Prot, Ur was abnormal at

30.

• Hgb, Ur was large

(Abnormal).

11/21/2010:

• Leuk Esterase was small

(Abnormal).

Urine Microscopics:

11/15/2010:

• WBC, Ur was high at 17.

• RBC, Ur was high at 23.

• Amorph Cryst was

abnormal at 3+.

11/24/2010:

• WBC, Ur was high at 8.

• Amorph Urate was 1+

(Abnormal).

CBC without Diff:

11/15/2010:

• MPV was high at 10.2.

11/16/2010:

• RBC was low at 3.50.

• HGB was low at 11.1.

• Hcl was low at 31.1.

• PLTS was low at 137.

Laboratory

Report

27

• MPV was high at 10.5.

11/21/2010:

• Glucose was high at 103.

11/24/2010:

• Neut, Auto was high at

67.9.

RH– 0069

(69/154)

11/16/2010 RH

CH, RN

Case Management Note

• Case management role

was introduced to patient.

• Continue to review

patient in daily care

coordination rounds, and

will follow upon request

from nursing or

physician.

• Will discuss with other

members of medical

team at daily care

coordination rounds.

Case

Management

Note

RH– 0002

(2/154)

11/17/2010 RH

SPA, M.D.

Discharge Summary Report

Hospital Course:

• Patient underwent a total

vaginal hysterectomy for

history of chronic pelvic

pain and dyspareunia on

November 15, 2010.


100 mL.

• Patient had a fibroid

uterus and normal

appearing ovaries. She

went to the floor for

recovery.

She had flatus and was

tolerating regular diet by

postop day 2.

• Patient was sent home

with a prescription of

Percocet.

Patient was

discharged after

having

undergone a

total vaginal

hysterectomy for

chronic pelvic

pain and

dyspareunia on

November 15,

2010.

28

Plan:

• Will follow up in 2

weeks in the office.

RH– 0107-

109

(107-

109/154)

11/24/2010 RH

DB. H,

M.D.

Emergency Department

Physician/ LIP Report

Chief Complaint:

• Left side pain.


• 39 YOF a week ago had

undergone a vaginal

hysterectomy by Dr. SA

and felt fine after that,

however two days ago

had slipped on the ice

and cut her right arm.

• Patient had twisted and

she complained of some

left pelvic and side pain

thereafter.

• Patient was directed to

present to the emergency

room by Dr. SA’s office.

Review of Systems:

• A bit of bony pain to the

back.


• A little bit of left pelvic

discomfort, which was

reproducible.


Course:

• Patient was triaged to

room 6.

• Differential included

possibility of

hysterectomy

complications, free fluid,

hemorrhage,

pyelonephritis,

diverticulitis, ovarian

Patient had

slipped on ice

and had cut her

right arm.

Complained of

some left pelvic

and side pain.

Discharged

home in stable

condition.

29

pathology, cyst,

abdominal trauma or

other complication.

Case Analysis:

• Complained of left pelvic

discomfort.

• Advised to take over-the

counter Ibuprofen at

home.

Clinical Impression:

• Pelvic pain, status post

hysterectomy.

• Possible urinary tract

infection versus

contamination.

Plan:

• Discharge home in stable

condition.

Dr. SA –

0007

(7/42)

11/24/2010 WG and O

Clinic, Inc.

SA, M.D.

Progress Note

• Patient had undergone

vaginal hysterectomy on

11/15/2010.

• Had fallen on ice two

days ago.

• Complained of

something popping on

left side of abdomen.

• Also had a burning

sensation.

• Advised to present to the

emergency room for

postoperative evaluation.

• Also advised to undergo

ultrasound.

Progress Note

RH– 0123

(123/154)

11/24/2010 RH

DP. H,

M.D.

Radiology Report

Examination:

• Transabdominal pelvic

ultrasound.

Underwent

transabdominal

pelvic

ultrasound.

30

History:

• Hysterectomy one week

ago.

• Left lower quadrant

pelvic pain.

Impression:

• No obvious free pelvic

fluid or hematoma.

• Left ovary obscured by

overlying bowel gas.

• Normal right ovary.

• Patient was status post

hysterectomy.

Dr. SA –

0007

(7/42)

12/01/2010 WG and O

Clinic, Inc.

SA, M.D.

Progress Note

Subjective:

• Patient was two weeks

out from a total vaginal

hysterectomy.

• Doing better.

• Patient just felt very tired

and had a lack of

appetite.

• Incision was well healed.


• Patient has done well

after her hysterectomy.

• Return in three weeks

before she went back to

work.

Patient was

doing better from

a total vaginal

hysterectomy.

Dr. SA –

0006

(6/42)

12/21/2010 WG and O

Clinic, Inc.

SA, M.D.

Progress Note

• Patient was doing well

and was 6 weeks postop.

• Going back to work.

• Vaginal cuff was well

healed.

• Return to clinic as

needed or for annual

exam.

Progress Note

Dr. SA – 01/10/2011 WG and O Progress Note Complained of

31

0005-006

(5-6/42)

Clinic, Inc.

SA, M.D.


pain with urination.

• Patient indeed had 2+

leukocytes, positive

protein. She wondered

why she kept getting

infections.

• All of her infections have

not been true bladder

infections with gram

positive bacteria and it

has not been greater than

100,000 colonies.

• Going to treat her with

Amoxicillin, have her

increase her fluids quite a

bit and have a visit with a

urologist because there

was something else going

on with her bladder other

than a typical infection.

• Has had a sling done

and there might have

been a suture from the

sling that was in the

bladder causing her

trouble.

• Patient might need to

have a scope to see what

was going on inside her

bladder.

• Prescribed with Diflucan

and Ibuprofen.

pain with

urination.

Patient has had

a sling done and

there might have

been a suture

from the sling

that was in the

bladder causing

her trouble.

Dr. SA –

0029

(29/42)

01/10/2011 IC

Laboratory Laboratory Report

Urine Culture:

• 10000 CFU/mL Beta

hemolytic Streptococcus

species.

• Group B groups A, B, C,

F and G Beta

Streptococci are

uniformly sensitive to

Penicillin and

Laboratory

Report

32

Cephalosporin class

antibiotics.

Dr. LC-

0036-037

(36-37/60)

01/12/2011 LC, M.D. Office Visit Report

Chief Complaint:


pain or burning with

urination.


• Post TOT sling 12/08,

hysterectomy 11/10.

• Having more bladder

pains.

• Patient first noticed the

symptom 5 months ago.

• Usually got up at night to

urinate 2 times.

• Patient did dribble at the

end of urination.

• Patient did have a history

of frequent urinary tract

infections.

Review of Systems:

• Patient reported painful

urination, urinary

frequency and urinary

urgency.

Procedures:

• Bladder scan.

• Urinalysis.

Assessment:

• Dysuria.

• Urgency.

• Voiding symptoms.

• Patient remained

continent, free of leakage

with physical activity,

since TOT sling 2008.

Bladder symptoms were

Complained of

pain or burning

with urination.

Advised to return

for cystoscopy

and urinalysis.

33

recently worse.

Plan:

• Return for cystoscopy

and urinalysis.

Dr. LC-

0034-035

(34-35/60)


Chief Complaint:


pain or burning with

urination.


• Patient presented for

cystoscopy. Was having

pain; 25 months out from

mid-urethral sling

placement.

Office Procedures:

• Flexible cystoscopy.

Small erosion and visible

exposed sling material

mid urethra.

• Urinalysis.

Assessment:

• Dysuria.

• Complc Oth GU device.

• Erosion of sling, a

known but uncommon

complication of slings

from mesh. Removal

required.

Plan

• Urethrolysis.

• Removal of sling.

Assessed with

dysuria.

Plan was to

undergo

urethrolysis and

removal of sling.

Dr. LC-

0032-033

(32-33/60)

01/21/2011 AV

Hospital

LC, M.D.

Progress Note

Diagnosis:

• Urethral sling erosion.


Impression

revealed mid

urethral sling

erosion causing

voiding

symptoms.

34

• 39 YOF who had mixed

and mostly stress urinary

incontinence, treated

with mid urethral


placement in December

2008. Her urinary

control was significantly

improved.

• Patient was feeling well until the past 4-5 months

when she has had

increasing urinary

discomfort and pelvis

pain.

• Also had some bladder

spasms.

• Hysterectomy was

completed in November

2010, to try to improve

symptoms, however

nothing has gotten better

since surgery.

• Patient has healed well,

however because of the

persistent voiding

symptoms has returned

and cystoscopy

evaluation showed a

small erosion of the

urethral sling into the

ventral aspect of the

urethra.

• Sling excision was

required to relieve these

symptoms and promote

healing.

Past Medical History:

• Voiding difficulties and

incontinence, improved

with sling surgery.


• Transobturator mid

urethral sling December

Plan was to

undergo vaginal

exploration with

urethrolysis and

sling removal.

35

19, 2008, hysterectomy

November of 2010.


• Pelvic exam, mild

urethral tenderness.

• Vaginal vault was well

healed.

Impression:

• Mid urethral sling

erosion causing voiding

symptoms.

Plan:

• Vaginal exploration with

urethrolysis and sling

removal.

• Patient understood she

might have some urinary

incontinence

postoperatively which

would be dealt with once

she has healed.

• Patient consented for

treatment.

AV

Hospital -

0002-003

(2-3/48)

01/21/2011 AV

Hospital

Operative Report

Preop/Postop Dx:

• Urethral sling erosion.

Operation:

• Mid urethral sling

excision with urethrolysis

and repair.

Surgeon:

• LC, M.D.

Anesthesia:

• General with a laryngeal

mask airway.

History:

• 39 YOF who was treated

Underwent mid

urethral sling

excision with

urethrolysis and

repair.

36

for mixed and mostly

stress urinary

incontinence with a

midurethral

transobturator Obtryx

sling on December 2008.

• Did extremely well until

approximately 2-3

months ago when she

developed dysuria and

vaginal pain.

• Had a urethral

discomfort.

• Treated with

hysterectomy without

improvement by her

gynecologist.

• Patient was worked up

with cystoscopy and a

small erosion into the

ventral aspect of the

urethra from her sling

was confirmed.

• Excision of the sling was

advised.

Procedure:


established.

• Medicated with Ancef

and placed in a supine

dorsal lithotomy position.

• Perineum was thoroughly

prepped with Betadine

solutions including

vaginal prep, sterile

drapes were applied.

• A 22-French cystoscope

was passed into the

urinary bladder. The

bladder was

unremarkable.

• Urethral erosion was

noted and photographed

and the bladder was

drained.

37


speculum was positioned

and the anterior vaginal

wall was hydrodissected

with 8 mL of 1%

Xylocaine with

epinephrine.

• A midline suburethral

vaginal incision was

made and dissection

accomplished out lateral

to the urethral dissecting

the vaginal mucosa away

from the underside of the

urethra, however not

penetrating into the

pubocervical fascia.

• Dissected down onto the

urethral sling identifying

the structure.

• Started dissecting out

along the sling on either

direction and sharply

excised an approximately

2 cm segment of the

sling.

• Repeat urethroscopy

confirmed a small

urethrotomy.

• Catheter was passed

through the urethra and

over this catheter several

interrupted 4-0 Vicryl

sutures were placed to

reconstruct the urethra.

• A small flap of some of

the scar tracking back

towards the bladder was

able to be slung up over

this urethrotomy and

patched in a position

again with several


sutures.

• The repair appeared

watertight.

38

• A Lone Star retractor was

used to facilitate

exposure.

• The area was thoroughly

irrigated.

• The vaginal mucosa was

then reconstructed in 2

layers with running 3-0

Vicryl suture layer in the

submucosal deeper layer

and with several


sutures in an interrupted

fashion in the superficial

layer.

• The area was then

thoroughly irrigated once

again and a lap sponge

was placed in the vagina

for packing and pressure.

• Speculum was removed.

• A 16-French Foley

catheter was anchored

and left to drainage.

• Patient was then

transferred to Recovery

where the vaginal

packing was removed.


100 mL.

• Complications were

none. Sponge, needle

and instrument counts

correct.


• Lortab.

• Bactrim.

Follow-up:

• Office follow-up would be scheduled for catheter

removal.

AV

Hospital -

01/21/2011 AV

Hospital Surgical Pathology Report

Surgical

Pathology

39

0014-015

(14-15/48)

Chris

Campana,

M.D.

Specimen Submitted:

• Uterosling erosion.

Clinical History:

• String placed in

December of 2008, now

with erosion.

Final Diagnosis:

• Uterosling erosion:

Squamous mucosa and

submucosa with acute

and chronic

inflammation,

granulation tissue

response, and focal

foreign body giant cell

response to suture

material.

Report

Dr. LC-

0028-029

(28-29/60)

02/02/2011 LC, M.D. Office Visit Note

Chief Complaint:


postoperative visit.


• Patient felt better and her

pain was gone.


urethrolysis and sling

removal. Surgery was

done on 01/21/2011. She

has not had incisional

drainage and has not had

pain in her incision.


• Urethral scarring was present.

• Healing well.

• Catheter was removed on

that day.

Assessment:

• Mixed incontinence.

Presented for

postoperative

visit.

40


• Patient was feeling better

after sling removal for

erosion.

Plan:

• Return in 2 months for

urinalysis.

• Cipro was given.

Dr. LC-

0026-027

(26-27/60)

03/17/2011 LC, M.D. Office Visit Note

Chief Complaint:


evaluation of mixed

incontinence.

• Leakage was worse since

removal of her eroded

sling 2 months ago.

Repair would be

required.

• Patient did have

problems getting to the

bathroom in time after

she has the urge to

urinate. She had an

accident when she

couldn't get there in time.

Her symptoms have

gotten worse over the last

year.

• Patient did wear

protective pads. She did

have problems with

nighttime incontinence.

• Patient did leak urine

when she coughed,

laughed, sneezed or bears

down.

Review of Systems:

• Reported urinary

frequency, urinary

leaking and urinary

urgency.

Patient presented

for evaluation of

mixed

incontinence.

Leakage was

worse since

removal of her

eroded sling 2

months ago.

Patient would

require an

autologous

fascial sling to

try and correct

this.

41

Assessment:



• Patient had post sling

erosion and worsening

incontinence.

• Patient would require an

autologous fascial sling

to try and correct this.

• Advised to wait for a few

more months, she was

healing well.

• Pain was resolved.

Plan:

• Return for urinalysis.

Dr. SA -

0003

(3/42)

04/19/2011 WG and O

Clinic, Inc.

SA, M.D.

Progress Note


• 39 YOF who was post

hysterectomy.

• Presented for annual

GYN examination.

• Getting a sling removal

done by Dr. Childs in

July.

• She had return of urinary

stress incontinence since

removal of _______?

sling.

• Doing well.

• Also complained of hot

flashes mainly at night,

vaginal dryness.

• Ordered a TSH, FSH and

estradiol.

Assessment/ Plan:

• Posthysterectomy female

with annual GYN exam

done.

• A Pap smear of the

vagina was done.

Annual GYN

exam

42

• Going to get a sling done

by Dr. Childs, Urologist

in July.

Dr. SA -

0002

(2/42)

07/07/2011 WG and O

Clinic, Inc.

SA, M.D.

Progress Note


• 39 YOF was

posthysterectomy.

• Presented with

complaints of

dyspareunia.

• Complained of cramping

and vaginal burning after

she had sex.

• Patient was seeing Dr.

Childs in about a week

who had removed her

spleen after a spleen

erosion.

• Also has urinary stress

incontinence again and

was always wet.

• Another sling might be done for her.

Examination:

• Pelvic exam revealed

tenderness at the vaginal

cuff.

Assessment:

• Complained of vaginal

tenderness and burning

after sex.

Plan:

• Offered the use of

estrogen Premarin cream

to help build up the

epithelium of the vagina

to make it less sensitive.

• Given a sample of

Premarin vaginal cream

to be used daily for about

three weeks and then

Presented with

complaints of

dyspareunia and

vaginal burning

and cramping.

43

once a week for

maintenance.

• Vaginal culture was also

done.

• Advised to return on as

needed basis or for her

annual exam.

Dr. SA –

0026

(26/42)

07/07/2011 IC

Laboratory Laboratory Report

Vaginal Culture:

• 3+ Beta hemolytic

Streptococcus species,

Group B groups A, B, C,

F and G Beta

Streptococci are

uniformly sensitive to

Penicillin and

Cephalosporin class

antibiotics.

• 3+ Vaginal flora.

• 2+ presumptive

Gardnerella vaginalis.

Urine Culture:

• 15000 CFU/mL Mixed

Gram Positive Organisms

two colony types.

• Questionable clinical

significance.

Laboratory

Report

Dr. SA –

0001

(1/42)

07/12/2011 IC

Laboratory Progress Note

• Patient underwent

vaginal culture which

was positive for

Gardnerella vaginalis.

• Advised to start Flagyl.

Progress Note

Dr. LC-

0023-025

(23-25/60)


Chief Complaint:

• Presented for evaluation

of mixed incontinence.


Presented for

evaluation of

mixed

incontinence.

Scheduled to

undergo

44


for evaluation of mixed

incontinence.

• Had a sling erosion; sling

removal 1/11. Now with

severe leakage – needs

repair with autologous

fascial sling.

• Patient did have

problems getting to the

bathroom in time after

she had the urge to

urinate. She had an

accident when she

couldn't get there in time.

Her symptoms had gotten

worse over the last year.

• Patient did wear

protective pads.

• Patient has not had a

urinary tract infection

recently.

• Patient did leak urine

when she walked.

GU Past Surgical History:

• Female sling – 2008.

• Cystoscopy –

01/18/2011.

• Revise/ remove sling

repair – 01/21/2011.

Non-GU Past Surgical History:

• Hysterectomy –

11/15/2010.

GU Past Medical History:

• Incont, Mixed -

3/17/2011, unspecified

date, 2/2/2011

• Dysuria - 1/18/2011, 1/12/2011

• Urgency - 1/12/2011

• Voiding Symptoms -


date.

autologous

fascial sling with

overnight stay.

45

Non-GU Past Medical History:

• Postsurgical States Ot -

2/2/2011

• Complc Oth GU Device -

1/18/2011, 2/2/2011,

3/17/2011

Assessment:



• Sling erosion now healed

since sling removal 1/11;

needs repair with

autologous fascia.

• Advised to repair this

synthetic mesh because

of the risk of erosion.

• Patient had considered

abdominoplasty, however

was leaning away from

this now.

Plan:

• Scheduled to undergo


with overnight stay.

AV

Hospital -

0021-022

(21-22/48)

09/15/2011 AV

Hospital

LC, M.D.

History and Physical Report

Diagnosis:

• Mixed urinary

incontinence.


• 39 YOF has urinary

leakage and had mixed

urinary incontinence,

which was treated

previously with an

Obtryx mesh, mid

urethral sling.

• Had some periurethral

and vaginal pain and was

found to have a urethral

Patient had

healed well

following repair

of urethral sling

erosion.

Incontinence

persisted.

Advised an

autologous

fascial sling for

repair rather

than

reintroduction of

artificial mesh

product.

46

erosion after a couple of

years.

• The sling was removed in

January 2011 and she has

been healing.

• Her bladder control has

worsened since sling

removal.

• Replacement of a sling

with her own autologous

tissue was advised at that

point.


• Urinary incontinence and

voiding symptoms.

• Generally in good health.

Medications:

• Ortho Tri-Cyclen, low

dose amoxicillin.


• Hysterectomy November

2010, transobturator sling

placement December 19,

2008, sling excision

January 21, 2011.

• Hysterectomy had been

completed when she was

having pelvic pain.

• Etiology of her pain

turned out to be from the

sling erosion.


• Vaginal vault well

healed.

• Some leakage noted with

Valsalva.

Impression:

• Healed well following

repair of urethral sling

erosion.

• Incontinence persisted.

47

• Advised an autologous

fascial sling for repair

rather than reintroduction

of artificial mesh

product.

Plan:

• Autologous vaginal sling

consent completed.

AV

Hospital –

0025-027

(25-27/48)

09/16/2011 AV

Hospital

Operative Report

Preop Dx:

• Mixed urinary

incontinence following

urethral mesh sling

erosion.

Postop Dx:

• Mixed urinary


urethral mesh sling

erosion plus urethral

vaginal fistula plus

abdominal laxity being

treated by Dr. Lee Chick

of plastic surgery.

Operation:

• Autologous fascial sling

with repair of

urethrovaginal fistula.

Surgeon:

• LC, M.D.

Anesthesia:

• General endotracheal.


• 39 YOF had mixed,

mostly stress, urinary

incontinence and was

treated with Obtryx

transobturator mesh sling

placement in December

Underwent

autologous

fascial sling with

repair of

urethrovaginal

fistula under

general

endotracheal

anesthesia.

48

2008.

• Did well until late in

2010 and later developed

vaginal pain and

discomfort and on exam

was found to have

developed a small sling

erosion with erythema

and tenderness.

• The sling was excised in January 2011, and she

has since been healing,

anticipating repair with

an autologous fascial

sling.

• Patient has had some

continued wetness and

worsening bladder

control and also

requested repair of

abdominal laxity by Dr.

Chick of plastic surgery.

Procedure:

• Patient was brought to

the operating room.


established, and she was

placed in lithotomy

position.

• The low abdomen and

genitalia and vagina were

thoroughly prepped with

Betadine solutions.

• Sterile drapes were

applied.


speculum was positioned.

The bladder was drained

with a 16-French

catheter.

• An anterior wall midline

vaginal incision was

made and carried down

to the bladder, and

dissection of the vaginal

49

mucosa off the underside

of the bladder and around

the bladder neck was

begun.

• A dissection plane was

created on the patient’s

right side which allowed

to push the bladder

upward and into the

pubocervical fascia and

reach back into the

retroperitoneal space

underneath the superior

pubic arch.

• Clear urine was seen

leaking through a fistula

tract on the patient's left

side. It was dissected

around this and again a

similar space was

developed pushing the

bladder upward.

• A couple of small holes

were seen entering

towards the bladder neck

and the urethra, which

were leakage sites.

• These edges were all

trimmed up and cleaned

of surrounding scar

tissue.

• A self retaining Lone

Star retractor was utilized

to facilitate exposure.

• These fistulous tracts

were then closed with


sutures at several points

with a couple of extra

layers being placed to

cover up and reinforce

these closures.

• The vaginal incision was

then packed with a

sponge.

• Attention was then

50

directed to the low

abdomen where anterior

abdominal fascia was

harvested.

• A transverse Pfannenstiel

type incision was made,

carried down through the

fatty layers.

• Bleeding sites were

controlled with

electrocautery.

• Exposure was achieved

at the anterior abdominal

wall fascia with Goulet

retractors.

• A transverse strip was

marked out, which

measured 2 cm wide and

12 cm long.

• This tissue was then

carefully excised with

electrocautery and sharp

dissection technique.

• This long rectangular

piece of tissue was then

placed on the back table

in moist gauze.

• Attention was then

directed to achieve

hemostasis.

• A couple of bleeders

running which included

epigastric perforators and

the rectus muscles were

controlled with 3-0

Vicryl ties.

• The remaining abdominal

wall fascial edges were

then carefully

undermined to facilitate

wound closure.

• On the back table, the

fascia was prepared by

suturing 2 long strands of

#1 PDS suture in a

whipstitch fashion on the

51

long ends of the fascia.

• Sling material was then

brought to the field.

• Using a double-armed

RAZ suture carrier, the

needles were passed

through the lower aspect

of the abdominal wall

fascia behind the pubic

bone and down through

the pubocervical fascia

alongside the lateral edge

of the bladder through

the previously dissected

space of vagina.

• The arms of the needle

were then visible out the

vaginal incision, being

careful to avoid the

bladder.

• The 2 suture strands were

passed through the suture

carrier and drawn back

up to the suprapubic

position and tagged with

a hemostat. This was

repeated on the opposite

side.

• Suture strands were

carefully drawn upward,

the sling material was

centered at the bladder

neck, and carefully

tacked into position with

several interrupted 4-0

Vicryl sutures to prevent

the material from folding

over on itself.

• The sling material was

then carefully covered up

the previous fistulous

tracts for reinforcement.

• The strands were then

gently elevated and were

tied and secured in a

snug up above, but not

52

too tight, fashion to cause

occlusion of the urethra.

• This was done on either

side and the tips of the

needle holder were able

to be passed between the

sling material and the

urethra. The 2 strands

were then crossed over

the midline and tied to

the opposite strands

forming a bridge.

• The vaginal wounds were

then thoroughly irrigated

and the vaginal mucosa

was closed in 2 layers

deeply with running 2-0

Vicryl suture, then in

another running layer on

the mucosal external

surface with 2-0 Vicryl

suture.

• A new 16-French Foley

catheter was anchored.

Clear urine was drained.

• A 22 French cystoscope

was passed prior to

catheter placement and

inspected within the

bladder, verifying no

evidence of injury to the

bladder, urethra, or

bladder neck.

• Clear effluxing urine was

seen from both ureteral

orifices.

• The Pfannenstiel rectus

fascial incision was then

closed with running #1

Vicryl suture from either

end by tying in the

midline.

• The area was thoroughly

irrigated.

• A couple of loose staples

were placed in the skin

53

for re-approximation

following which the

patient was then

positioned supine, taken

out of lithotomy, and the

abdomen was re-prepped

for the plastic surgical

procedure by Dr. Lee

Chick.

• Patient was then

observed in the hospital

for pain management

overnight.

AV

Hospital -

0023

(23/48)

09/16/2011 AV

Hospital

LR. C,

M.D.

Operative Report

Preop/Postop Dx:

• Abdominal laxity.

Operation:

• Abdominoplasty

Procedure:

• Patient had just

undergone a urological

procedure by Dr. Childs.

• Patient was re-prepped

and draped and new

instrumentation was

utilized at the completion

of the procedure.

• The previous excision

was extended laterally to

the mid axillary line and

then an incision was

carried out around tie

umbilicus.

• Dissection was carried

along the umbilical stalk

separating it from the

surrounding tissues.

• The skin flap was

elevated from inferior to

superior along the mid

axillary line to the costal

margins bilaterally just

Underwent

abdominoplasty.

54

above the anterior rectus

fascia.

• Patient had a rectus

diastasis of

approximately 3 cm

which was closed with

interrupted 2-0 Ethibond

sutures.

• Two Blake drains were

then placed over the

abdominal wall. She was

placed in approximately

60 degrees of flexion.

• The skin flap was then

retracted inferiorly and

excess skin and fat was

excised. This included

tissues from her pubic

hairline above the

umbilicus.

• The tissue weighed

approximately 1.2 kg.

Hemostasis being

assured, the wound was

then closed in layers of

2-0 Vicryl in scarpus

fascia and 3-0 Vicryl.

• The excision of skin was

made over the umbilicus

which was exteriorized

and sutured with 4-0

Vicryl and 4-0 nylon.

• Dressing and abdominal

binder were applied and

patient went to the

recovery room in good

condition.

• Sponge and needle count

was correct.

• Blood loss was minimal.

AV

Hospital –

0035

(35/48)

09/16/2011 AV

Hospital

SB. H,

LCSW

Social Work Note

• Patient will continue to

be reviewed in daily care

coordination rounds.

Social Work

Note

55

• Follow patient again

upon request from

nursing or physician.

AVHospital

– 0047-048

(47-48/48)

09/16/2011 IH Laboratory Report

CBC without diff:

• HCT was low at 35.7.

• MPV was high at 10.5

Laboratory

Report

AV

Hospital –

0036-037

(36-37/48)

09/17/2011 AV

Hospital

LC, M.D.

Discharge Summary Report

Date of Admission: September

16, 2011

Diagnosis:

• Mixed urinary


urethral mesh sling

erosion.

• Abdominal laxity.

• Diastasis rectus.

Procedures Performed:

• Autologous rectus fascial

pubovaginal sling on

September 16, 2011, with

repair of urethrovaginal

fistula, by Dr. Lane

Childs.

• Anterior abdominoplasty

with repair of diastasis

rectus by Dr. Leland

Chick.


• 39 YOF was treated for

mixed, mostly stress

urinary incontinence with

Obtryx mesh urethral

sling placement

December 2008.

• Bladder control was

significantly improved.

• Patient developed late in

2010 and was discovered

Patient had

undergone

autologous

rectus fascial

pubovaginal

sling with repair

of

urethrovaginal

fistula on

September 16,

2011.

Patient was

discharged in

stable condition.

56

to have urethrovaginal

mesh erosion.

• Mesh was excised in a

surgical procedure in

January 2011.

• Patient has been healing

these tissues anticipating

repair with autologous

fascia. She now

presented for this

surgical procedure.

• Patient also requested

abdominoplasty under

the same anesthetic

which was coordinated

through Dr. Leland Chick

of plastic surgery.

Hospital Course:

• Patient underwent

vaginal repair with an


on September 16, 2011.

• Small urethrovaginal

fistulae were identified in

that dissection, which

were repaired at the time

of the sling placement.

• Patient’s abdominal wall

relaxation was repaired

by Dr. Leland Chick.

She was noted to have

Jackson Pratt drains in

place, which had drained

small amounts of serous

fluid overnight.

• Pain control was

satisfactory. She was

ambulatory and tolerating

a regular diet on

postoperative day 1.

• Patient was in stable

condition for discharge.

• Foley catheter and

vaginal packing were

removed on the

57

postoperative morning.

She had voided small

amounts of urine couple

of times and was stable

to go home.

• Patient was instructed in

self-catheterization to be

done in an emergency at

home if unable to urinate.

• Office follow-up would be scheduled.

• Patient had arrangements

for Jackson Pratt drain

removal by Dr. Chick in

approximately 10 days.


• Lortab.

• DOSS stool softener.

• Ceftin.

Discharge Instructions:

• No driving for 3-4 days,

no lifting greater than 5-

10 pounds for 10 days.

• Patient was instructed in

care of the Jackson Pratt

bulb.

• Also instructed on self-

catheterization.

Dr. LC-

0015-017

(15-17/60)

09/22/2011 WU Clinic

LC, M.D.

Office Visit Report

Chief Complaint:


of urinary retention.

• Presented for a



• Currently having trouble

urinating.

• Patient was in retention -

not emptying bladder.


Presented for

evaluation of

urinary

retention.

Currently having

trouble

urinating.

Advised to return

in 2 weeks for

urinalysis and

bladder scan.

58


and abdominoplasty.

Surgery was done 6 days

ago.


• Female sling –

09/16/2011, 2008,

unspecified date

• Cystoscopy – 09/16/2011, 01/18/2011.


repair – 01/21/2011.



11/15/2010.


• Incontinence, Mixed -


date, 2/2/2011, 3/17/2011

• Dysuria - 1/18/2011,

1/12/2011

• Urgency - 1/12/2011



date.



2/2/2011


7/13/2011, 1/18/2011,

2/2/2011, 3/17/2011

Multi-System Physical

Examination:

• Abdominal tenderness,

rigidity.

• Pfannenstiel scar.

Procedures:

• Bladder scan.

• Catheter/ SP tube: A 14

straight catheter was

59

inserted into the bladder

using sterile technique.

1000 cc of urine was

obtained.

Urinalysis Results:

• Blood: Large.

• pH: 5.5.

• RBC/ hpf: TNTC.

• Epithelial cells: Few.

• Leukocyte Esterase:

Trace.

• Specific Gravity: 1.020.

Assessment:

• Urine retention.

• Patient had postop

urinary retention after

fascial sling 6 days ago.

• Also had abdominoplasty

by Dr. Chick.

• Will loosen up over time

and be fine.

• Taught self-cath in the

meantime.

Plan:

• Return in 2 weeks for

urinalysis and bladder

scan.

RH– 0129-

130

(129-

130/154)

09/23/2011 RH

AK L,

M.D.


Physician/ LIP Report

Chief Complaint:

• Bladder pain.


• 39 YOF who had

undergone a bladder

surgery last week.

• Patient stated that since

the previous day she has

not been able to go to the

bathroom and had visited

Presented with

complaints of

bladder pain.

Diagnosed with

postoperative

urinary

retention.

60

her urologist, did a

catheterization.

• Patient stated that she

had tried and was not

able to catheterize

herself.

• Patient stated that she has

some constipation along

with the urinary

retention.


• Bladder surgery and

abdominoplasty.


• Abdomen: Patient had

some mild tenderness

and some fullness in the

suprapubic area and then

had an abdominal band

noted across the central

abdominal area with

some tenderness to

palpation in the area of

her abdominoplasty.

Labs and Studies:

• Urinalysis was

performed. which did

appear to be a

contaminated specimen,

however really no signs

of infection whatsoever.


Course:

• Recommended to place a

Foley catheter by Dr.

Childs, urologist.

• Self catheterization

techniques would be

reviewed once again.

Diagnosis:

• Postoperative urinary

61

retention.

• Foley catheter placement.

Disposition:

• Patient was discharged.

• Advised to follow up

with Dr. Childs’ office

on that day.

RH– 0151

(151/154)

09/23/2011 IH Laboratory Report

Urine Macro:

• Hgb, Ur was moderate

(Abnormal).

• Clean catch specimen

was slightly cloudy and

abnormal.

Urine Microscopics:

• RBC, Ur was high at 10.

• Epl, Ur was high at 15.

• Bacteria, Urine was 1+

(Abnormal).

• Mucus was abnormal at

1+.

Laboratory

Report

Dr. LC-

0012-014

(12-14/60)


LC, M.D.

Office Visit Report

Chief Complaint:


of urinary retention.

• Presented for a



• Patient had catheter

placed in emergency

room that morning.

• Patient tried to self

catheterize, however was

unable to. She liked to

leave indwelling catheter

in place.


urinating. Having

Presented for

evaluation of

urinary

retention.

Currently having

trouble

urinating.

62

problems getting her

urine stream started.

• Has undergone

abdominoplasty and


surgery on 09/16/2011.

GU Physical Examination:

• Foley catheter in place

attached to leg bag

draining clear yellow

urine.

Assessment:

• Urine retention.

Plan:

• Prescribed with Uribel.

• Return visit in 1 week –

bladder scan.

• Advised to leave Foley

catheter in place over the

weekend and taught how

to remove Foley catheter

for voiding trial the

following week.

Dr. LC-

0009-011

(9-11/60)


LC, M.D.

Office Visit Report

Chief Complaint:

• Presented for a post

operative visit.



abdominoplasty and



• Patient had urinary

retention. She removed

catheter on her own that

morning and was able to

urinate with fairly good

stream, improving with

each void.


Patient currently

had trouble

urinating.

Having problems

getting her urine

stream started.

63

urinating. She was

having problems getting

her urine stream started.

• Did not feel that she was

emptying her bladder

well.

Procedures:

• Bladder scan.

• Catheter/ SP tube. A 14

straight catheter was

inserted into the bladder

using sterile technique.

400 cc of urine was

obtained.

Urinalysis results:

• pH: 6.0.


• WBC/ hpf: 20-25.

• Bacteria: 1+.

Assessment:


• Urinary retention.

Plan:

• Return visit in one month

for bladder scan.

• Patient was taught how to

self catheterize in case

she was unable to void

on her own.

Dr. LC-

0005-007

(5-7/60)


LC, M.D.

Office Visit Report

Chief Complaint:

• Presented for a post

operative visit.



abdominoplasty and



Diagnosed with

stress

incontinence and

urine retention.

Her post sling

retention has

resolved.

64

• Patient had urinary

retention.

• Has done well since

catheter removal. She

felt she was emptying her

bladder well.

• Also had stress

incontinence (status post

sling).

• Currently not having

trouble urinating.

• Had previously had an

indwelling catheter in for

more than two weeks at a

time.

Urinalysis Results:

• pH: 6.0.


Assessment:

• Stress incontinence and

urine retention.

• Post sling retention has

resolved.

Plan:

• Return visit in three

months - bladder scan.

Dr. LC-

0002-004

(2-4/60)


LC, M.D.

Office Visit Report

Chief Complaint:

• Stress incontinence

(status post sling).


• Patient remained well

and was totally back to

normal since autologous

fascial sling surgery done

on 9/11 for prior mesh

sling erosion 1/11

(placement 12/08).

• Patient was not having

problems getting her

Complained of

stress

incontinence

status post sling.

Assessed with

mixed

incontinence and

stress

incontinence.

Patient remained

well and was

totally back to

normal since

autologous

65

urine stream started, and

she could get to the

bathroom in time when

she got the urge to

urinate.

• Patient did have a normal

sensation when needing

to urinate.

• Patient did feel that she

was emptying her

bladder well.

• Patient had previously

had an indwelling

catheter in for more than

two weeks at a time.

• Also had mixed

incontinence.

• Patient had a sling

erosion; sling removal

1/11 that has now healed

and felt great.

• Had a normal sensation

when needing to urinate.

Medications:

• Lortab.

• Amoxicillin.

• Fluconazole.

• Ortho Tri-Cyclen.

• Uribel.


• Female sling –

09/16/2011, 2008.

• Cystoscopy –

09/16/2011, 01/18/2011.


repair – 01/21/2011.



11/15/2010.


• Incont, Stress (fml) -

fascial sling

surgery.

66

10/31/2011

• Retention - 10/31/2011,

9/22/2011, 9/23/2011,

9/30/2011

• Incont, Mixed -


date, 2/2/2011, 3/17/2011

• Dysuria - 1/18/2011,

1/12/2011

• Urgency - 1/12/2011



date.



10/31/2011, 2/2/2011,

9/22/2011, 9/23/2011


7/13/2011, 1/18/2011,

2/2/2011, 3/17/2011

Urinalysis Results:

• WBC/ hpf: 0-2.

• Epithelial cells: Few.

• pH: 5.0.


Assessment:


• Stress incontinence.

• Patient remained well

and totally back to

normal since autologous

fascial sling surgery done

9/11 for prior mesh sling

erosion 1/11 (placement

12/08).

• Abdominoplasty was

done by Dr. Chick and

patient was very happy

with all results.

Plan:

67

• Return visit as needed.

medical summary-patient chronological medical...

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