ࡱ> 36012 pbjbj 8nccGhN     8U<MM(uuuPPP~$v PPPPP  uu///P u u~/P~//[X_upΝ&\(jϡ0] l  P__, b>PP/PPPPP'PPPPPPP PPPPPPPPP : Benicar Case Review XXXXX ParameterFindingsPDF RefFirst NameXXXXX16InitialL16Last NameXXXXX16DOB01/04/YYYY16Past Medical History (including history of past GI disorders)Gastroesophageal reflux disease, hypertension, rheumatoid arthritis, migraine, high cholesterol, heart murmur, joint pain16List of previously used anti hypertensive medicationsPropranolol 40 mg Triamterene/Hydrochlorothiazide 37.5-25 mg Benazep/Hydrochlorothiazide 20-25 mg Metoprolol ER 50 mg Inderal LA 60 mg 125, 123, 121, 101-103Prior use of other ARBs (Losartan, Telmisartan)Not availableConcomitant use of other anti-hypertensiveMetoprolol ER 25 mg, Hydrochlorothiazide 25 mg105-107, 109-111, 113-115, 120Concomitant use of other medicationsDepo-Medrol injection, Zithromax Z-pak 250 mg, Zyrtec, Naproxen 400 mg, Ibuprofen, Epipen, Dulera, Ventolin, Cyclobenzaprine 10 mg, Clonazepam 1mg, Flexeril 10 mg, Topiramate 25 mg, Cholestyramine 4 gm, Flagyl 500 mg, Levaquin 750 mg, Sumatriptan 100 mg, Vitamin D 50000 units, Omeprazole 20 mg, Gabapentin 300 mg, Align 4 mg, Advil 200 mg, Aleve 220 mg, CoQ-10 50 mg, Fish oil 1000 mg, Imitrex 100 mg, Neurontin 300 mg, Propo-N/APAP 100-650 tablet, Klonopin 1 mg, Megestrol AC 20 mg, Clindamycin 300 mg, Terbinafine 250 mg, Azithromycin 250 mg, Topiramate 250 mg14, 15, 16-18, 19-21, 22-24, 59-63, 25-26, 27, 63-69, 51-56, 74-78, 105-106, 109, 112, 114-115Benicar Start DateUnknown *Reviewers comment: Per pharmacy records, we note the first Benicar use on 04/13/YYYY; but prior records are not available to know the exact start date of Benicar104Dosage40-25 mg104-107Benicar Stop DateUnknown Per available medical records: 06/23/YYYY *Reviewers comment: Per visit dated 06/23/YYYY, we note patient had stopped Benicar for several weeks on hearing that it makes diverticulitis worse. Hence exact stop date of Benicar intake is unknown.120, 31-32Benicar Adverse Events (Whether diagnosed with enteropathy, diarrhea, dehydration, malnutrition, villous atrophy and villous blunting)Yes Diarrhea19-21Date of Diagnosis of Adverse Event08/19/YYYY: Colonoscopy Multiple medium diverticula in colon 08/14/YYYY-08/20/YYYY: Abdominal pain, diarrhea, diverticulosis 08/21/YYYY: Diarrhea, nausea, vomiting 08/23/YYYY-10/16/YYYY: Diverticulitis, fatigue 02/17/YYYY: Diverticulitis, diarrhea, vomiting and nausea, IBS 04/01/YYYY: Colonoscopy - Moderately severe diverticulosis in the sigmoid colon. 04/01/YYYY: CT abdomen Pandiverticulosis 04/21/YYYY: Diarrhea, diverticulitis of colon 06/26/YYYY-01/12/YYYY: Recurrent episodes of diverticulitis87-89, 19-21, 22-24, 59-63, 25-26, 27, 63-69, 84-85, 90-91, 51-56, 33-34, 94-98, 3-5Management of Adverse EventLevaquin 500/750 mg Flagyl 500/750 mg Restriction of food that increases bowel activity Ondansetron 8 mg Cholestyramine 4 gm Align 4 mg 04/01/YYYY: Colonoscopy and colon biopsy - Histologically unremarkable colonic mucosa Ciprofloxacin 500 mg Metronidazole 250 mg 02/10/YYYY: Underwent laparoscopy, left hemicolectomy with low pelvic anastomosis, open mobilization of splenic flexure, placement of bilateral on-q postoperative pain control pump and catheters, intra-operative colonoscopy, repair of colovesical fistula for chronic recurrent diverticulitis, impending colovesical fistula under general anesthesia19-21, 22-24, 59-63, 27, 63-69, 84-85, 86, 51-56, 74-78, 94-98, 6-8Other significant GI conditionsNot availableSmoking historyFormer smoker, smoked for 33 years, quit on 10/199716-18Condition of the Patient Per Last Available Record02/24/YYYY: Patient doing well. Eating without difficulty. Bowels moving satisfactorily. Incisions healing well. Good healing ridge. Satisfactory post operative course. Increase activity as tolerated. Return in 3 weeks. *Reviewers comment: Further medical records after 02/24/YYYY are not available to know the progress of the patient.2 Missing Medical Records: What Records/Medical Bills are NeededHospital/ Medical ProviderDate/Time PeriodWhy we need the Records/BillsIs Record Missing Confirmatory or Probable?Hint/Clue that records are missingMedical Records during YYYY-07/YYYYUnknown04/YYYY-07/YYYYTo note the Benicar use detailsConfirmatoryPharmacy records are available for Benicar during this time period Detailed Chronology DATEPROVIDEROCCURRENCE/TREATMENTPDF REF08/19/YYYYXXXXX Specialists XXXXX, M.D.Colonoscopy report: Medical history: High blood pressure Reason for visit: Screening colonoscopy Anesthesia: Monitored anesthesia care Impression: The colonic mucosa appeared entirely normal. There were no masses or polyps found. Multiple medium scattered diverticula in the colon. Condition upon leaving procedure: Stable87-89*Reviewers comment: Interim records from 08/19/YYYY to 01/29/YYYY are not available to know the health status of the patient.01/29/YYYYXXXXX Family Medicine Follow-up visit for headache and sinus pressure: (Illegible notes) Review of systems: Constitutional: Reports weight loss Social history: Former smoker. Quit 16 years back. Assessment: Sinusitis Plan: Dox/Depo intramuscular injection given. Z-pack, Zyrtec as prescribed. *Reviewers comment: Details related only to Benicar case review has been elaborated.1402/20/YYYYXXXXX Family Medicine Follow-up visit for back pain: (Illegible notes) Review of systems: Constitutional: Reports weight loss Assessment: Arthritis, Vitamin D deficiency, multiple joint pain, fibromyalgia Plan: Increase Klonopin to 1 mg. Refill of EpiPen, Medrol dose pack given.1505/22/YYYYXXXXX, FNPFollow-up visit for cough: Patient was taking Dulera and Ventolin. Current medications include Benicar Hct 40-25 mg (04/19/YYYY) once daily. Past medical history: Hypertension, gastroesophageal reflux disease, rheumatoid arthritis, migraines, high cholesterol, heart murmur, degenerative disc disease, fibromyalgia Weight: 189.6 lbs. *Reviewers comment: Details related only to Benicar case review have been elaborated. Per pharmacy records, we note the first Benicar use on 04/13/YYYY; but per available medical records we note Benicar usage only on 04/19/YYYY. Hence the exact start date is not unknown.16-1808/14/YYYYXXXXX XXXXX, M.D.Follow-up visit for evaluation of stomach bug: Patient presents for evaluation of stomach bug symptoms present for 2-3 days. She presents to the clinic with 72 hour history of diarrhea, vomiting at onset that has resolved. Diarrhea stool for 5 times today, watery brown. Has taken over the counter anti-diarrheal once. Has some left lower quadrant abdominal discomfort. Current medications include Benicar Hct 40-25 mg once daily. Review of systems: Genitourinary: Reports stomach virus Weight: 184.8 lbs. Physical examination: Abdomen: Abdominal tenderness present. Hyperactive bowel sounds all four quadrants. Tenderness to mild palpation with guarding in lower left quadrant. Diagnoses: Abdominal pain Diarrhea Diverticulosis Plan: Send patient for CT Abdomen, Complete blood Count (CBC), Comprehensive Metabolic Panel (CMP). Prescribed Levaquin 750 mg once daily for 10 days and Flagyl 500mg four times a day for 10 days.19-2108/20/YYYYXXXXX XXXXX, M.D.Follow-up visit for left lower quadrant pain: Patient presents with left lower quadrant abdominal pain, diverticulosis confirmed by CT (CT records not available). Patient reports pain has improved although she continues to have loose stools. Consistency has improved from watery diarrhea. Continues on Levaquin and Metronidazole. Current medications include Benicar Hct 40-25 mg once daily. Weight: 185 lbs Review of systems: Gastrointestinal: Admits to nausea, abdominal pain, diarrhea Physical examination: Abdomen: Tenderness lower left quadrant, tenderness has improved from last visit. Diagnosis: Diverticulitis of colon Plan: Labs today due to continued diarrhea. Continue medications as prescribed. Refer to GI, to see Dr. XXXXX tomorrow. Restrict foods that increase bowel activity and are low in fibers like refined bread, cereals, white rice, vegetable and fruit juice without pulp and dairy products.22-2408/21/YYYYXXXXX One Care XXXXX, M.D.Gastrointestinal consultation for abdominal pain, diarrhea: Patient was diagnosed with diverticulosis 2 years ago by Dr. XXXXX, diagnosed with diverticulitis last week at St. Francis, cannot eat anything she eats goes threw her, states she is having 20 Bowel Movements (BM) per day, loose stools, LLQ pain, nausea, dizziness. Colon screening Denies any problems. Patient here today with complaints of diverticulitis. Has been on Levaquin for 7 days with Flagyl. She states the pain is way better, still with complaints of frequent loose stools. She reports she is having 20 stools a day, has nausea, dizziness, has lost 5 pounds. She states her oral intake is good. Current medications include Benicar Hct 40-25 mg once daily. Review of systems: Gastrointestinal: Decreased appetite. Nausea with vomiting, bloating and abdominal pain. Pain when defecating and bowel movement frequency has recently changed. Diarrhea. Genitourinary: Urinary loss of control. Assessment: Diarrhea Nausea with vomiting Plan: Vomiting/nausea - Ondansetron 8 mg every 6 hours for 30 days Diarrhea - Cholestyramine light 4 gm/dose powder, twice a day for 30 days, Align 4 mg 2 twice a day for 30 days Diverticulitis - Pain improved. Patient slowly improving will treat symptoms until they resolve.59-6308/23/YYYYXXXXX XXXXX, M.D.Follow-up visit for diverticulitis: Patient presents for follow-up on her diverticulitis and continued fatigue. Patient recently saw GI, has finished antibiotic for diverticulitis, diarrhea is resolving states she had so many health problems she thinks she is going to have to stop working and go on disability. Patient states diverticulitis pain has almost resolved. Diarrhea has improved. She is being treated by GI. Current medications include Benicar Hct 40-25 mg once daily. Physical examination: Abdomen: Has mild tenderness lower left quadrant but no guarding, much improvement in symptoms. Diagnosis: Diverticulitis of colon, resolving. *Reviewers comment: Details related only to Benicar case review has been elaborated.25-2610/16/YYYYXXXXX Family Medicine XXXXX XXXXX, M.D.Follow-up visit for diverticulitis: (Illegible notes) Patient presented to discuss about diverticulitis and her overall health. Keeps flaring with diverticulitis - ______ abdomen with Dr. XXXXX Uses Cholestyramine. Assessment: Diverticulitis Fibromyalgia Paresthesia Plan: Z-pack, saline prescribed. *Reviewers comment: Details related only to Benicar case review has been elaborated.2702/17/YYYYXXXXX One Care XXXXX, M.D.Follow-up visit for diverticulitis: Patient to talk with Dr. XXXXX to discuss dietary habits that goes with diverticulosis. Patient states she had several flares and has been treated for them but would like to know more about what causes them. She wants colon screening. Patient with bouts of abdominal pain sine last February. Patient reports CT last August that showed diverticulitis (CT report not available). Patient treated in August for diverticular disease. Patient reports still having multiple episodes of left lower quadrant pain. Patient reports having problem sitting. Patient recently treated with Ciprofloxacin and Flagyl for last 10 days. Patient reports now feeling OK still feeling tender. Patient reports hysterectomy 2 years ago. Weight: 186 lbs Current medications include Benicar Hct 40-25 mg. Review of systems: Gastrointestinal: Nausea with vomiting, bloating and abdominal pain. Pain when defecating and bowel movement frequency has recently changed. Diarrhea. Physical examination: Abdomen: Abdominal tenderness mild. Direct tenderness in the abdomen. Assessment: Diverticulitis of colon Diarrhea Nausea with vomiting No diverticulitis with abscess Patient appears stable but appears to have recurrent diverticulitis. Although would not be surprised if patient has an element of IBS. Patient taking Questran with help of diarrhea. Patient reports continued left lower quadrant pain. Would get CT of abdomen and pelvis. Discussed possible colon resection down the road.63-6904/13/YYYY-03/24/YYYYXXXXX pharmacyPharmacy dispensing record: Medication refilled: Benicar Hct 40-25 mg.104-107, 109-111, 115, 12004/01/YYYYXXXXX Specialists XXXXX, M.D.Colonoscopy report: Pre operative diagnosis: Diarrhea Anesthesia: Monitored anesthesia care Findings: The colon appeared to be normal. A biopsy was taken from the ascending colon and descending colon to evaluate for microscopic colitis there was evidence of moderately severe diverticulosis in the sigmoid colon.84-8504/01/YYYYXXXXX and Therapeutics XXXXX, M.D.CT of abdomen and pelvis: History: Abdomen pain, diarrhea, nausea, vomiting, remote cholecystectomy, hysterectomy and appendectomy Opinion: Previous cholecystectomy, appendectomy, and hysterectomy Pandiverticulosis No urinary tract calcification is seen on the right or left and there is no hydronephrosis. Otherwise negative CT scan of the abdomen and pelvis90-9104/04/YYYYXXX Specialists XXXXX, M.D.Pathology report: Collected: 04/01/YYYY Final diagnosis: Ascending colon and descending colon - Histologically unremarkable colonic mucosa. Colitis not identified.8604/21/YYYYXXXXX One Care XXXXX, M.D.Follow-up visit status post colonoscopy: Patient presented today for follow-up on her colonoscopy. She states she is working hard on her diet to help her diverticulosis. She does still have some diarrhea and is using the Cholestyramine for the diarrhea and she is satisfied with this. She states she cannot tolerate fiber because it causes a lot of bloating and gas pain. Review of systems: Abdomen: Same as on 08/21/YYYY Weight: 187 lbs Current medications include Benicar Hct 40-25 mg. Physical examination: Abdomen: Same as on 02/17/YYYY Assessment: Diverticulitis of colon Diarrhea Nausea with vomiting No diverticulitis with abscess Plan: Diverticulitis of colon - Ciprofloxacin 500 mg twice a day for 10 days, Metronidazole 250 mg three times a day for 10 days. Diarrhea - Recommend using Cholestyramine daily Return in 3 weeks. If patient does not get relief with antibiotics would consider surgery evaluation.51-5605/12/YYYYXXXXX One Care XXXXX, M.D.Follow-up visit for diarrhea: Patient reports that she has felt great reports taking Questran with control of diarrhea. Patient off NSAIDS. Patient takes APAP and Neurontin. Patient with few bouts of diverticulitis last year. We discussed possible surgery in future. Patient unable to eat vegetables secondary to pain. Current medications include Benicar Hct 40-25 mg. Review of systems: Abdomen: Same as on 08/21/YYYY Weight: 179 lbs Physical examination: Abdomen: Abdominal tenderness mild. Direct tenderness in the abdomen. Assessment: Diverticulitis of colon Diarrhea Nausea with vomiting No diverticulitis with abscess Plan: Diverticulitis - Appears stable has resolved IBS - Controlled on Questran Patient wants to hold on surgery continued to follow.74-7806/23/YYYYXXXXX, FNPFollow-up visit for diverticulitis: (Incomplete record) Patient came in today to discuss medications. She has stopped Benicar for several weeks due to hearing on television that it might make her diverticulitis worse, she has stopped and feels much better in addition she did stop her Cymbalta (Exact stop date of Benicar is not available). Her pain is pretty much controlled and BP is great today. Previous labs with low vitamin D, elevated lipids. Needs repeat fasting labs and states will return next month. Plan: Patient decides to stop additional medications. Lab order to patient, will return in July for fasting labs and make first morning appointment. Geno swab today. *Reviewers comment: We note patient had stopped Benicar for several weeks on hearing that it makes diverticulitis worse. Hence exact stop date of Benicar intake is unknown.31-3206/26/YYYYXXXXX, FNPVisit for bilateral lower extremities pitting edema: Patient complaints of bilateral lower extremities pitting edema since off the Benicar for 1 week. Patient reports BP at home has been 160/106 mm Hg. BP is normal today. She did reports some lower extremity edema, stopped Benicar HCTZ about 1 week prior, edema has resolved for the most part. Weight: 188 lbs Diagnosis: Acute sinusitis Edema Colonic diverticulosis Dyslipidemia Essential hypertension Plan: Will prescribe Z-pack as directed. Will prescribe HCTZ 12.5 mg, monitor BP. If increased edema, dyspnea, watch sodium intake, caffeine33-3407/07/YYYYXXXXX One Care XXXXX, M.D.Follow-up visit for diverticulitis: Patient states she is feeling better since being off Benicar. Patient reports developing abdominal pain with Benicar. Patient reports she was taken off it felt better. Patient reports all side effects have improved. Patient with increased strength. Review of systems: Abdomen: Same as on 08/21/YYYY Weight: 180 lbs Physical examination: Abdomen: Same as on 02/17/YYYY Assessment: Diverticulitis of colon Diarrhea Nausea with vomiting No diverticulitis with abscess Patient reports abdominal pain has been second to Benicar now improved will follow.78-8310/17/YYYYXXXXX Hospital ER visit for diverticulitis: Impression: Diverticulitis Treatment: Flagyl 750 mg thrice daily for 7 days. Levaquin 500 mg once daily for 7 days. Disposition: To home. Condition: Stable. *Reviewers comment: Complete ER record is not available 94-9801/12/YYYYXXXXX, M.D.GI consultation for recurrent diverticulitis: Reason for consultation: Recurrent episodes of diverticulitis. Patient had multiple attacks of sigmoid diverticulitis diagnosed by CT scanning. The first episode was in August of YYYY. She was hospitalized at St. Francis Hospital after being diagnosed by her Primary Care Doctor Dr. XXXXX XXXXX. Most recent flare-up was in December of last year (Reports are unavailable). She thought that she was able to control it for a period of time by modifying her diet and taking Cholestyramine, but lately the attacks have been becoming increasingly frequent despite her precautions. She had to be hospitalized twice and had multiple other milder episodes. She cannot identify any particular cause or inciting factor that brings on an attack so there is nothing she can do to avoid them. She generally has three or four small bowel movements per day. Recently, she had one bowel movement with some blood in it, but it was bright red blood and she felt that it was due to straining and hemorrhoids. Workup included a colonoscopy done by Dr. XXXXX in April YYYY, which showed pancolonic diverticulosis, especially severe in the sigmoid colon. CT scanning done at that time confirmed the diverticular disease. Review of systems: Constitutional: Positive for fatigue and tiredness. Musculoskeletal: Positive for joint pain and muscle weakness. Physical examination: Abdomen: Abdomen is protuberant, but not distended. She has some very mild tenderness to deep palpation in the left lower quadrant in the region of the sigmoid colon. Assessment: Recurrent episodes of diverticulitis Plan: I explained available surgical and nonsurgical treatment options. I have explained that surgical resection of the involved area may reduce her risk of recurrent disease, but that she has pancolonic diverticulosis and she will still have some diverticula even following successful surgery. I have explained the procedure of colon resection including laparoscopic assisted colon resection and the use of the implantable pain pump. I have explained the use of intraoperative ureteral catheters placed by urologist to minimize the risk of injury.3-502/10/YYYYXXXXX Memorial Hospital XXXXX, III, M.D.Operative report for ureteral stent placement: Pre/Post operative diagnoses: Recurrent diverticulitis Request for preoperative ureteral stent placement Name of procedure: Cystoscopy Bilateral ureteral stent placement Foley catheter insertion Anesthesia: General endotracheal.9-1002/10/YYYYXXXXX Memorial Hospital XXXXX, M.D.Operative report for left hemicolectomy, open mobilization of splenic flexure: Preoperative diagnosis: Chronic recurrent diverticulitis Postoperative diagnosis: Chronic recurrent diverticulitis Impending colovesical fistula Operation performed: Laparoscopy Left hemicolectomy with low pelvic anastomosis Open mobilization of splenic flexure Placement of bilateral On-Q postoperative pain control pump and catheters Intra-operative colonoscopy Repair of colovesical fistula Anesthesia: General endotracheal Findings at surgery: A long stenotic area of the sigmoid colon which was very densely adherent to the pelvic side wall and to the bladder, such that it had almost created a colovesical fistula. The remaining portions of the colon and the small bowel were normal to inspection and palpation. Liver showed no focal abnormalities. Patient was status post previous open cholecystectomy and there were omental adhesions to the undersurface of the liver in the upper abdominal wall. The patient is also status post complete hysterectomy. Ureters were carefully identified and preserved throughout the procedure. Procedure: A 3 cm incision was made by the umbilicus and dissection carried down into the abdominal cavity under direct vision. Lap Disk was inserted and the abdominal cavity was insufflated under direct vision with a 5 mm 30 degree laparoscope. Operating trocars were placed in the left upper quadrant and left lower quadrant. The sigmoid colon was mobilized from its attachments to the left lateral side wall. It quickly became apparent that the colon was very intensely scarred against the pelvic side wall and the bladder. It could not safely be separated laparoscopically. In addition, the transverse colon was involved with extensive adhesions to the patients previous subcostal incision, which also could not be safely mobilized laparoscopically, therefore, the decision was made to proceed with open resection. The lap disk was removed and incision was extended. The Bookwalter retractor was placed and used as an aid in operative exposure throughout the case. The remainder of the sigmoid colon was mobilized. The area where there had been adherence to the bladder was repaired in two layers. The descending colon was mobilized by dividing its lateral attachments. The splenic flexure was mobilized by dividing the splenocolic, renocolic and gastrocolic ligaments. The omentum was elevated up off the transverse colon, which was dissected away from its adherence to the abdominal wall and the undersurface of the liver from the patients previous cholecystectorny when the entire colon had mobilized from the hepatic flexure to the rectum, dissection was carried down into the pelvis. Both ureters were carefully identified and preserved. The proximal rectum was cleared off circumferentially at approximately the level of the peritoneal reflection. Once it had been completely cleared off and it was divided by an application of the contour curved linear cutting stapler. The mesentery of the rectosigmoid was elevated off the presacral fascia back to the level of the inferior mesenteric artery. The descending sigmoid branch of the IMA was controlled, secured and divided. The more proximal branches were maintained. Now that the colon had been divided and the entire left colon was mobilized, point for division of the proximal colon was selected just proximal to the splenic flexure where the bowel was normal in size, shape and texture. The pursestring clamp was placed across the colon and the pursestring suture was placed. Kocher was placed on the specimen side and the bowel was divided. The remaining mesenteric attachments were controlled, secured and divided. Specimen was opened off the table by the pathologist who confirmed the adequacy of the resection. The proximal colon was sized and a 29 mm anvil was placed within it. The pursestring suture was tied. All the bowel ends were verified to be healthy and well vascularized. The rectum was dilated and the 29 mm stapler was introduced transanally to the apex of the rectal stump where it was opened, the anvil was attached. The proximal colon was carefully positioned without any angling, tension or twisting. Once the anvil was attached, the stapler was closed under direct vision and the stapler was then checked circumferentially. The stapler was fired. It was then opened and removed without difficulty and two complete tissue donuts were verified. Entire abdominal cavity was irrigated with warm saline solution and complete hemostasis was verified. On-Q tunnelers were placed on either side of the incision in the preperitoneal plane. Several sheets of Seprafilm were placed beneath the incision to minimize postoperative adhesions. Abdomen was closed with internal retention sutures in a doubled running fascial closure. Wound was irrigated with antibiotic solution and complete hemostasis was verified. All incisions were then closed in layers and dressed. On-Q catheters were placed through the peel-away sheath introducers and the introducers were removed. Catheters were secured, dressed and primed, and the On-Q pump was attached and activated. Patient was then awakened and transported to the post anesthesia care unit in good condition. Blood loss was less than 100 ml. There were no complications. No packs or drains were needed. Procedure was well tolerated throughout.6-802/16/YYYYABCD XXXXX, M.D.Surgical pathology report of left colon: Collected: 02/10/YYYY Diagnosis: Diverticulosis of colon Diverticulitis of colon with abscess/phlegmon/giant cell reaction focally to chunky amorphous material. One reactive lymph node. Mild increase in subepithelial collagen band in the area of diverticular disease from Masson trichrome stain. This is a nonspecific finding that can be seen with diverticular disease. Sections away from the diverticuli do not demonstrate thickening of the subepithelial collagen band. Congo red stain is negative for amyloid.11-1202/24/YYYYXXXXX, M.D.Follow-up visit status post left hemicolectomy: Patient doing well. Eating without difficulty. No problem voiding. Bowels moving satisfactorily. Activity level as expected. Physical examination: Incisions healing well. Good healing ridge. No weakness or defect. Assessment: Satisfactory post operative course. Plan: Increase activity as tolerated. 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