FILE NAME: Herschel Moore  DOB: 6/13/1972  DOI: 9/11/2008  Social HX: Smokes 1ppd. Lives with spouse in 1 story home 

FILE NAME: Herschel Moore DOB: 6/13/1972 DOI: 9/11/2008 Social HX: Smokes 1ppd. Lives with spouse in 1 story home Twisted ankle (2004); Stepped on rusty nail (2002) INJURIES SUSTAINED IN MVA: 1. Four pelvic factures ‐ bilateral superior/inferior pubic rami factures; facture/dislocation of symphysis pubis; facture/dislocation left sacroiliac join 2. Compound facture left tibia/fibula 3. Nondisplaced facture of right fibula 4. Urethral tear SUMMARY: Herschel Moore’s truck was struck by a front‐loader and was pinned in the cab of his truck. He was crushed and as a result, he suffered multiple injuries to his lower extremities and pelvis. RECORDS REVIEWED 1. PIH Air Medical Warsaw, KY 41095 2. University Hospital, Cincinnati, OH Emergency Department report: 9/11/2008 Inpatient records: 9/11/2008‐9/22/2008 Emergency Department report: 9/10/2010 3. University Orthopedics & Sports Medicine Drs. John Wyrick & Michael Archdeacon 222 Piedmont Avenue, Suite 2200 Cincinnati, OH 45219 Office records through 8/19/2010 4. Gateway Rehabilitation Hospital, 5940 Merchant Street, Florence, KY 41042 Inpatient records: 9/22/2008‐10/2/2008 Outpatient therapy: 12/11/2008‐2/9/2009; 10/22/2009‐8/11/2010 5. Three Rivers District Home Health Agency 510 South Main Street, Owenton, KY 40359 Home health services: 10/3/2008‐7/29/2009 27G
1
6. Tri‐State Gastroenterology Associated Kevin Moreman, MD 425 Centre View Boulevard Crestview Hills, KY 41017 Office visits: 1/20/2010; 3/10/2010 7. St. Elizabeth Physicians (Summit Medical Group) Joseph Hartig, MD 520 Violet Road Crittenden, KY 41039 Office records: 11/2008‐7/31/2012 8. Mayfield Clinic Donald Carruthers, MD Bradbury Skidmore, MD Steven Wunder, MD 506 Oak Street, Cincinnati, OH 45219 Office records: 2/3/2010; 3/3/2010; 6/23/2010 9. New Horizons Medical Center ProTime and INR reports 10. St. Luke Hospital West, Florence, KY ED report: 6/20/2009 11. St. Elizabeth Medical Center Edgewood, KY Labs/diagnostic testing Emergency Department visit: 12/15/2011 12. UC Physicians Krishnanath Gaitonde, MD ‐ Urology Office visits: 7/30/2010;8/27/2010; 9/17/2010; 10/15/2010; 1/14/2011; 7/7/2011; 1/5/2012; 2/23/2012; 3/5/2012; 13. UC Physicians Ayman Mahdy, MD ‐Urology Office visit: 1/12/2012; 2/23/2012; 3/23/20102; 7/26/2012 2
14. Robert Klickovich Neuroscience Associates of Northern Kentucky ‐ Pain Physician 2845 Chancellor Drive Crestview Hills, KY 41017 Office visits: 3/27/2012‐8/22/2012 15. Bradley Davis, MD UC Health‐Surgery, Colon, Rectal 2123 Auburn Avenue /Suite 524 Cincinnati, OH 45219 Office visit: 3/7/2011; 4/11/2011 16. Vlnod Krishnan, MD St. Elizabeth Neurology Office visit: 10/25/2012 17. Bradley Davis, M.D., UC Health‐Surgery, Colon, Rectal 12/5/2012‐3/7/2013 PROCEDURES  9/11/2008: Left tibia I&D; left tibia intramedullary nailing; anterior pelvic external fixation  9/11/2008: Insertion of suprapubic tube  9/13/2008: I&D open medial wound left medial calf; layered coverage of exposed saphenous vein on left medial calf  9/15/2008: Placement of vena caval filter d/t femoral clot  9/16/2008: Skeletal fixation of sacrum facture; skin graft to anterior tibial wound  1/15/2009: Dilation of meatal stenosis and suprapubic tract; suprapubic catheter change  2/11/2009: Balloon dilation of suprapubic tract; cystogram; cystolithalopaxy; suprapubic tube change  5/7/2009: Perineal urethroplasty; antegrade/retrograde cystoscopy; cystolithalopaxy; Foley catheter placement; suprapubic catheter change  7/2/2009: 1) retrograde urethrogram; 2) cystoscopy; 3) cystoscopic removal of bladder stone; 4) insertion of Foley catheter  4/2/2010: Repair of nonunion of anterior tibial facture with autogenous bone graft  6/23/2010: Fluoroscopically guided sacroiliac joint injection  9/7/2010: 1) retrograde urethrogram; 2) dilation of meatal stenosis; 3) cystoscopy; 4) filiform follower dilatation of urethral stricture; 5) cystogram; 6) complicated Foley catheter placement  2/9/2012: flexible cystourethroscopy; placement of suprapubic catheter  5/29/2012: transperineal urethroplasty; reposition suprapubic tube  11/2/2012: MRI Sacral Plexus (Pain): Instability of Left S1 joint, chronic finding.  3
TESTING:  9/11/2008: X‐ray pelvis=bladder is elevated from a hematoma; left obturator ring facture  9/11/2008: X‐ray pelvis=displaced factures of left inferior and superior pubic rami and anterior column left acetabulum facture; facture of left sacral wing extending to left SI joint  9/11/2008: X‐ray left tib/fib=displaced angulated factures of distal tib/fib with 90degrees external rotation of distal fragments; left tibia facture open through pretibial soft tissues; facture of the posterior malleolus of left tibia  9/11/2008: X‐ray left knee=no acute facture or dislocation  9/13/2008: X‐ray right tib/fib=nondisplaced transverse facture of proximal third of fibula  9/15/2008: Venous Doppler=acute non‐occluding DVT in mid LFV  9/16/2008: CT pelvis=s/p left sacroiliac joint fixation; no interval change in alignment of multiple bilateral pelvic factures  9/19/2008: X‐ray pelvis=s/p external fixator placement within right/left liliac wings; widening of right sacroiliac joint and diastases of pubic symphysis  9/19/2008: X‐ray right elbow/shoulder=no facture or dislocation  10/29/2008: X‐ray left tib/fib=factures of distal tib/fib with evidence of surgical intervention; medial malleolus facture extending to tibiotalar joint; suggestion of posterior distal tibial facture  10/29/2008: X‐ray pelvis=external fixator present; double vertical facture on left; anterior column facture on left; double vertical facture on right; facture of left sacral ala and diastasis of pubic symphysis  12/1/2008: X‐ray pelvis=facture of pelvic bones united; still marked deformity in superior left pubic ramus  12/1/2008: X‐ray left leg and ankle=fragments of tibia/fibula in good alignment and healing; no definite facture are visible in region of ankle  1/14/2009: X‐ray pelvis=delayed union of left double vertical facture; distortion of pelvic ring with medial rotation of left innominate bone and displacement of pubic symphysis to the left of midline  1/15/2009: Urethrogram/cystogram=segment of urethral narrowing within membranous structure  2/5/2009: CT abdomen=normal kidneys w/o evidence of hydronephrosis or hydroureter; extensive healing pelvic factures with result deformity and distortion of urinary bladder and rotation, elevation and left lateral deviation of prostate. Heterogenous calcification noted filling prostatic urethra  2/12/2009: X‐ray pelvis=unchanged from above  4/1/2009: X‐ray pelvis=possible union of inferior portion of facture, but non‐union of superior portion of ring  4/1/2009: X‐ray left tib/fib=tibia facture with intramedullary rod; comminuted facture of fibula; some demineralization of distal tib/fib  5/29/2009:Retrograde cystourethrogram=small leak at membranous urethra that tracks along proximal penile urethra  9/9/2009: Venous Doppler BLE= no evidence of venous obstruction  9/10/2009: X‐ray pelvis=left inferior pubic ramus facture appears united; left superior pubic ramus facture persists; post‐traumatic changes of left sacroiliac joint  9/11/2009: Venous Doppler BLE=no evidence of DVT  9/28/2009: X‐ray left tib/fib=s/p internal fixation of comminuted left tibia facture; comminuted and displaced left distal fibula facture; intra‐
articular nondisplaced medial malleolus facture; small bone fragment anterior to neck of talus  2/18/2010: X‐ray pelvis=left double vertical facture through obturator ring and sacroiliac ring with non‐united superior pubic ramus and sacroiliac joint stabilized by internal fixators  2/18/2009: X‐ray left tib/fib=incomplete union of tib/fib factures; posterior malleolus facture 4







1/18/2010: MRI lumbar spine=1) no evidence of compressive disc disease; 2) abnormal appearance of left sacroiliac joint; 3) no evidence of facture 1/28/2010: CT abdomen=1) IVC filter in situ; 2) non‐obstructed bowel gas pattern with large amount of stool throughout colon 2/7/2010: X‐ray abdomen=findings c/w functional constipation 5/27/2010: X‐ray left tib/fib=healed lower fibula facture; wedge resection of nonunion site in anterior tibial cortex with placement of bone graft 8/19/2010: X‐ray left tib/fib=mild interval healing of distal tibial shaft facture s/p ORIF 9/7/2010: Urethrogram=interval worsening of urethral stricture compared to 7/2/2009. 9/10/2010: X‐ray pelvis=1) left inferior pubic ramus facture appears united; 2) left superior pubic ramus facture line persists; 3) posttraumatic changes at left sacroiliac joint  9/10/2010: X‐ray left tib/fib=1) fibular facture line persists, with some interval healing; 2) tibial facture line unchanged>demineralization seen at distal tib/fib  4/1/2011: Anal manometry=testing essentially normal  3/20/2012:Angiogram of pelvis=chronic occlusion of anterior division of left internal iliac artery with reconstruction of distal segment of left internal pudendal artery via collaterals. Patent left internal pudendal artery with no disruption of dorsal penile artery. No angiographic evidence of atherosclerotic disease in the distal abdominal aorta and pelvic vessels  4/23/2012: Voiding cystourethrogram=urethral stricture disease  11/12/2012: MRI sacral pelvis=instability of left SI joint. CHRONOLOGY OF EVENTS/CONDITIONS/TREATMENTS DATE PROVIDER CONDITION/ASSESSMENT TREATMENT/TESTING Full spinal immobilization 9/11/2008 PIH Air Medical Restrained driver in head‐on collision. PIV x2 Required extrication from truck IV fluids Awake/alert Moves all extremities Splint LLE Initial BP>97/97 Oxygen BP upon arrival at UC>66/72 Fentanyl for pain IMPRESSION: Open tibia/fibula facture left leg Abrasions/contusions to lower mid chest, pelvic area and lower extremities Transported to UC Hospital 5
9/11/2008 UC Hospital Emergency Department C/O pain in LLE/low back Able to move toes and has sensation Awake/alert Large abrasion over epigastrium Multiple abrasions to right buttocks and bilateral thighs Large deformity left tib‐fib>weak Doppler pulse Hypotensive>tachycardiac Hgb 14>9.5 Frank blood from Foley catheter IMPRESSION: 1. Left open tib‐fib facture 2. Left ramus factures 3. Possible bladder injury 4. Possible iliac vein injury Pelvis x‐ray>left superior and inferior ramus factures Fluid resuscitation Ortho consult>to OR Urology consult Left tibia I&D Left tibia intramedullary nailing Anterior pelvic external fixation Placement of wound Vac Placement of suprapubic catheter 9/11/2008 UC Hospital John Wyrick, MD James Donovan, MD Pre‐op dx: Left tibia grade II open facture Left medial malleolus facture Left sacral facture Anterior pelvic ring factures Found to have bladder rupture from urethra 9/13/2008 UC Hospital Joseph Hartig, MD (Primary Care) I&D open medial wound left calf Layered coverage of exposed saphenous vein on left medial calf 9/16/2008 UC Hospital Michael Archdeacon, MD (Orthopedics) Closed facture of sacrum Open wound anterior tibia 9/18/2008 UC Hospital To OR for skeletal fixation of sacrum facture. Staged split graft to anterior tibial wound. Removal of wound Vac 6
9/22/2008 UC Hospital Discharge Summary Discharge DX: 1. S/P MVA 2. Left open tib‐fib facture 3. Left acetabular facture 4. Multiple pelvic factures 5. Left L5 transverse process facture 6. Urethral rupture 7. Mesenteric hematoma 8. Right nondisplaced fibular facture 9. Left femoral DVT 10. Inferior vena cava filter Skin graft to calf>intact Hemodynamically stable Transferred to rehab for wound care/suprapubic catheter care Non‐weightbearing LLE; transfer only on RLE Discharge meds: 1. Ibuprofen 2. Coumadin 3. Oxycodone 4. Senna 9/22/2008 Gateway Rehabilitation Hospital C/O pain with movement Unable to roll or move around in bed Unable to care for catheter Numb over perineum with no apparent sensation in scrotum, penis or base of perineum Tenderness in low back Good BUE strength Skin graft/donor site>excellent External pelvic fixator in place Large hematoma at pelvis Suprapubic catheter in place 10/1/2008 John Wyrick, MD Skin graft to open tibia facture>taken nicely Still non‐weightbearing LLE 7
10/2/2008 Gateway Rehabilitation Hospital 10/9/2008 Joseph Hartig, MD Discharge summary DX: 1. Open left tib/fib facture s/p reduction and internal fixation with tibial nailing procedure 2. Right fibular facture 3. Multiple pelvic factures with external fixation 4. Left sacroiliac facture 5. Acetabular facture 6. Crush injury to left leg 7. Lumbar facture 8. Skin graft to left tibial area 9. Left medial malleolus facture 10. Mesenteric hematoma 11. Urethral tear s/p suprapubic catheterization 12. Acute blood loss anemia 13. Vit D deficiency PT: Non‐weightbearing LLE HFS RLE Progressed well at w/c level>supervision only Bed mobility/transfers>mod Independent OT: Eating>mod IND Grooming> mod IND Toileting‐toileting transfers>mod IND Bathing>min A Dressing UE>mod IND Dressing LE>SBA Discharged to home with home health and PT/OT through Three Rivers Multiple hip/leg factures>pain Wheelchair bound Urethral disruption DVT prophylaxis MEDS: Oxycontin Promethazine Neurontin Senna Vitamin D Coumadin Omeprazole Equipment: 3 in 1 commode Reacher Gait belt Small ramp into house Hospital bed Wheelchair 8
10/24/2008 Joseph Hartig, MD Multiple factures/contusions ROS:  Malaise  Insomnia  Anxiety  Weakness  Paresthesia  Joint pain  Muscle pain  Decreased ROM  Swelling  Myalgia  Stiffness  Cramping  Difficulty voiding  Incontinence  Constipation RX: OxyContin Oxycodone Senokot Previous visit 10/9/08 10/29/2008 John Wyrick, MD 11/14/2008 Three Rivers Home Health Transferring in wheelchair Transfer weight bearing ok’d Noted that Mr. Moore had oral surgery performed 4 days prior d/t abscess in right jaw>difficulty swallowing and breathing 3 teeth removed and inside of jaw excised X‐ray pelvis>good alignment X‐ray tib/fib>good alignment, not much healing RX antibiotic 11/17/2008 John Wyrick, MD Removal of external fixator for pelvis 11/24/2008 Joseph Hartig, MD RX: Oxycontin Walker 12/1/2008 John Wyrick, MD 12/11/2008 Gateway Rehab S/P MVA>multiple factures/contusions Iron deficiency anemia Evidence of some healing of left tibia/fib Start weight‐bearing Physical Therapy Assessment Pain 4/10>low back, left leg/hip, ankle Bladder spasms Noted to be in reclining w/c Start PT for ambulation and strengthening Recommend PT 2‐3X/week for 5‐6 months 9
No upper teeth Thin male>atrophy noted Functional mobility: Sit>stand‐mod IND Stand>sit‐mod IND Rolling‐mod IND Sit>supine‐mod IND Supine>sit‐mod IND Gait‐200’ with rolling walker and SBA Decreased balance, strength, endurance Increased reliance on assistive devices for ADLs OT discharge note: Able to stand for 5 min during 1 hand tasks Instructed in HEP Safely able to transfer to achieve ADLs Able to complete light/mod housekeeping chores from wheelchair Unable to tolerate light activity standing d/t pain Has 5/5 BUE Has met maximum rehab potential Back pain S/P facture spine (L4‐5) S/P facture left tib/fob S/P left pelvis 12/19/2008 Three Rivers Home Health Agency 12/23/2008 Joseph Hartig, MD 1/14/2009 John Wyrick, MD Using walker and crutches with some weightbearing on LLE Good ROM knee and hip Possible limb length discrepancy>probably from pelvis deformity Noted to have some healing in left tibia, but still has defect anteriorly and 2/6/2009medially at facture site 1/15/2009 University Hospital Krishnanath Gaitonde, MD (Urology) Bladder spasm Back pain Constipation To OR for antegrade/retrograde urethrogram with dilation of meatus RX: Oxycontin Oxycodone Warfarin Continue PT DX: Urethral disruption 10
1/23/2009 Joseph Hartig, MD S/P pelvic facture Dysuria Noted to be walking with cane RX: Pyridium Cipro Oxycontin 2/6/2009 Joseph Hartig, MD Dysuria Chronic pain RX: Bactrim 2/9/2009 Gateway Rehab Refer back to Dr. Wyrick 2/11/2009 UC Hospital Krishnanath Gaitionde, MD Increased pain in pelvis and sacrum and decreased mobility Unable to bear weight on LLE PT dc’d Noted to have extensive pelvic bony factures with transaction of bulbar membranous urethra>developed stricture of urethra Hx of chronic bladder stones Post‐op note: Will need urethroplasty in near future Bony prominence or fragment is impinging on left anterior bladder wall > will require add’l surgery 2/23/2009 Joseph Hartig, MD S/P pelvic facture>pelvic pain S/P bladder stones RX: Oxycontin Oxycodone 2/27/2009 Krishnanath Gaitionde, MD Able to walk with support Intermittent pain/discomfort C/O ED Decreased sensation in bowel>constipation ASSESSMENT: 1.Urethral disruption at level of membranous urethra with displacement of posterior urethra with distortion of bladder/posterior urethral anatomy towards left hemipelvis 2.Left hemipelvic boney fragment pressing against left bladder wall 3. Erectile dysfunction 4. External meatal stenosis Plan urethroplasty To OR for balloon dilation of suprapubic tract, cystogram and suprapubic tube change 11
4/1/2009 John Wyrick, MD Pain left posterior pelvis Good motion left knee and ankle Full weightbearing on LLE Seen by Dr. Hartig on this same date for pelvic pain and refill of pain meds 4/30/2009 Michael Archdeacon, MD Noted to have pelvic deformity>large portion of ramus is impinging on bladder Surgery planned to reanastomosis his urethra 5/1/2009 Joseph Hartig, MD S/P pelvic facture>pelvic pain 5/7/2009‐
5/10/2009 UC Hospital Krishnanath Gaitonde, MD 6/2/2009 Joseph Hartig, MD Chronic pain d/t pelvic facture Constipation Bladder spasms 6/18/2009 Krishnanath Gaitonde, MD Perineal urethroplasty on 5/7/09>Foley catheter removed on 6/12/09 Decreased stream with some straining Occasional weak erections 6/20/2009 St. Luke West Knot on left leg>no trauma/Injury HX of DVT>Greenfield Filter in place IMPRESSION: Hematoma left leg Normal D‐dimer 6/22/2009 Joseph Hartig, MD RX: Coumadin 6/30/2009 J. Hartig MD 7/2/2009 Krishnanath Gaitonde, MD C/O swelling in left leg>red/tender Hx of blood clots Letter that states that he needs a wheelchair. Bladder spasms>10 per day HX of bladders stones and urethral collapse RX: Oxycontin Oxycodone Extensive pelvic factures>distraction injury of urethra through the To OR for repair of urethra by perineal urethroplasty junction of the bulbar and membranous urethra Bony spur>external compression of left portion of bladder Post‐op>developed high fever and elevated WBC Discharged to home with Foley and suprapubic catheter in place ABX therapy Instructed to continue oral antibiotics RX: Oxycontin Oxycodone MiraLax Ditropan Flexible cystoscopy>tight narrowing at site of repair Urethral dilation Foley catheter inserted Cystoscopy in OR> area slightly narrowed 12
7/7/2009 Joseph Hartig, MD Chronic pelvic pain RX: Oxycontin Oxycodone 7/15/2009 Krishnanath Gaitonde, MD FU cystoscopy 7/2/09 Foley in place>removed>voided well Self cath demonstrated>will perform daily 7/22/2009 Krishnanath Gaitonde, MD S/P urethral stricture repair>has 14 Fr. Foley>upsized to 16fr Frequent bladder spasms RX: Enablex 7/29/2009 Three Rivers Home Health Agency Skilled nursing services provided from 10/3/2008 r/t anticoagulant regiment and maintenance of indwelling catheter. Observed for s/s infection, bleeding. Discharged and returning to PCP for ongoing care and evaluation 8/13/2009 Joseph Hartig, MD Seen 8/4/2009 with pelvic pain>continue Oxycodone/Oxycontin regiment 9/8/2009 Joseph Hartig, MD 9/10/2009 Michael Archdeacon, MD Medical Source Statement of Ability to do Work Related Activities 1. Lifting/carrying restricted to less than 10 pounds 2. Standing/walking restricted to less than 2 hours 3. Sitting restricted to less than 6 hours in 8 hour work day 4. Pushing/pulling limited in lower extremities d/t pelvic facture, multiple surgeries, can ambulate with cane only 5. Climbing, balancing, kneeling, crouching, crawling & stooping limited d/t injuries 6. Reaching and gross manipulations limited 7. Fine manipulations and feeling unlimited 8. Visual/communication unlimited 9. Environmental limitations include temperature extremes, humidity, vibration, hazards Chronic pelvic pain Numbness in buttock and thigh on right side>possible neurogenic Full ROM BLE Stated that in his opinion, Mr. Moore would be best suited for job retraining for sedentary work. RX: Oxycontin Oxycodone X‐ray of left tibia>non union of anterior cortex 13
9/11/2009 Krishnanath Gaitonde, MD Has to strain occasionally to void>dysuria Self cath>2x daily ASSESSMENT S/p urethroplasty with possible post op narrowing of anatomic site Possible worsening stenosis Erectile dysfunction RX: Viagra 9/16/2009 Krishnanath Gaitonde, MD Joseph Hartig, MD Poor results with Viagra Prostin trial Chronic pelvic pain DVT Bladder irritability>self cath 2x/day RX: Oxycontin Oxycodone 10/9/2009 Krishnanath Gaitonde, MD Voiding with good stream Self cath>1‐2xdaily Mild urine leak after voiding Urgency>some leak Increased numbness over pelvic area, extending anteriorly ASSESSMENT Possible stress leak d/t sphincter weakness Possible bladder overactivity>neurogenic Takes Enablex Decrease self cath>1x daily Taught Kegel’s exercises 10/22/2009 Gateway Rehab PT assessment Uses cane for mobility Has returned to driving Pain in back, proximal and distal tibia Right gluteal atrophy Decreased girth LLE Antalgic gait Decreased heel strikes on left Asymmetric posture with pelvic obliquity Decreased ROM Bilateral hips Decreased strength Decreased balance Recommend aquatic + non‐aquatic PT 2‐3x/weekx8‐12 wks. 10/5/2009 14
11/19/2009 Joseph Hartig, MD Chronic pelvic pain with radiculopathy Leg length discrepancy Constipation RX: Oxycontin Oxycodone 12/15/2009 Joseph Hartig, MD Chronic hip/back pain RX: Oxycontin Oxycodone 12/30/2009 Joseph Hartig, MD St. Elizabeth Medical Center Joseph Hartig, MD States bowels have not moved in 3 weeks Very tired No appetite 1/20/2010 Kevin Moreman, MD Gastroenterology 1/22/2010 Krishnanath Gaitonde, MD 1/31/2010 Bradbury Skidmore, MD (Neurosurgeon) C/O significant constipation PE: Normal sphincter tone Slow clonic transit vs. colonic inertia>r/t pelvic injury vs. chronic pain medication Self‐cath 1X/week Reasonable good stream Does not feel full bladder sensation>timed voiding Some post void dribble>wears pad for protection ED>intrapenile injection/meds>did not work ASSESSMENT: S/P urethroplasty after urethral injury Urethral narrowing post repair>requires self cath Minimal incontinence Occasional dysuria Mild degenerative disc disease Prior sacral surgery No evidence of disc compression Refer to GI for colonoscopy Outpatient milk and molasses enema with minimal results RX: Oxycontin Oxycodone Refer to GI specialist MRI back RX: Amitiza MiraLax 1/4/2010 Chronic back pain No sensation to urinate Constipation> 1 small BM q3 wks. with enema Recommend PT 15
2/2/2010 Krishnanath Gaitonde, MD Erectile Dysfunction related to motor vehicle accident Augusta pump trial>90% erection Trial at home 2/18/2010 Michael Archdeacon, MD 2/19/2010 Joseph Hartig, MD C/O neurogenic pain Lists to right side Pain in left anterior shin >bothers him with every step and interferes with sleep Chronic hip/back pain 3/3/2010 Steven Wunder, MD Mayfield Clinic (Physical Medicine & Rehabilitation) 3/10/2010 Kevin Moreman, MD Tri‐state GI associates Seen for neurogenic bladder dysfunction and pain management Chronic pain since MVA Deformity of pelvis Sacroiliac joint pain with sacroiliac degenerative arthritis Bowel/bladder dysfunction Noted to wear a TENS unit Uses cane to ambulate Limited ROM lumbar Sensation decreased over sacrum>intact in legs Motor strength distally intact ASSESSMENT: 1. Major multiple trauma 2. Multiple factures 3. Sacroiliac joint degeneration Noted that 30‐50% chance that an injection might help pain Doubt repetitive PT will alter pain Noted to have had a CT and Sitz marker colonic transit study>c/w markedly delayed colon transit Bowels only move every 2‐3 weeks ASSESSMENT: Colonic inertia r/t pelvic injury with neurologic damage. Refractory constipation>likely d/t colonic inertia. RX: Oxycontin Oxycodone Recommend evaluation by surgery to consider partial colectomy or ileostomy 16
3/19/2010 Joseph Hartig, MD Chronic hip/ back pain TENS unit RX: OxyContin Oxycodone 4/2/2010 UC Hospital Michael Archdeacon, MD Michael Archdeacon, MD Nonunion of facture of left anterior To OR for repair of nonunion with autogenous bone graft S/P proximal tibia bone graft to left anterior tibial nonunion Wounds healed No instability Full weight bearing 4/15/2010 4/21/2010 Joseph Hartig, MD Chronic back pain Decreased effectiveness of pain meds RX: MS Contin 5/25/2010 Joseph Hartig, MD Incontinence Constipation Decreased ROM Lumbar spine>chronic pain RX: MS Contin Naprosyn 5/27/2010 Michael Archdeacon, MD Pain improving in LLE Good ROM Minimally tender over nonunion site 6/23/2010 Donald Carruthers, MD, Mayfield Clinic PMR Fluoroscopically guided sacroiliac injection 6/28/2010 Joseph Hartig, MD Chronic back/pelvis pain Walks with cane RX: Oxycodone. F/U on 8/2/2010 with same complaint and RX 7/30/2010 Krishnanath Gaitonde, MD Intermittent cath every 2 weeks Flow>good to weak Bladder sensation>decreased>performing timed voids ED>tried oral meds, injections>did not work Significant constipation>? Neurogenic bowel ASSESSMENT 1. Bladder outlet obstruction vs. neurogenic bladder 2. Normal perianal sensation and sphincter tone 17
8/2/2010 Joseph Hartig, MD Chronic back and pelvis pain Bladder injury>self cath Walks with cane RX: Oxycodone Oxycontin 8/11/2010 Gateway Rehab PT discharge assessment: Hip ROM limited and fixed Strength in bilateral hips>limited d/t severe and chronic pain Able to gain some pain relief from TENS unit + medication Pelvic pain>severe and unrelenting Able to perform reciprocal stair climbing with BUE support/weightbearing Requires cane for ambulation d/t left knee frequently buckling Strength and active ROM left knee>improved Able to use shower and commode with assistance Noted that bathroom was renovated to accommodate wheelchair 8/19/2010 Michael Archdeacon, MD Intermittent pain left lower extremity Uses cane Some pelvic pain Antalgic gait ASSESSMENT: Has reached maximal medical improvement He is candidate for vocational rehab. X‐ray tibia>nonunion site further consolidated, but not fully healed. Noted that facture site might not fully consolidate d/t smoking and cortical defect 8/27/2010 Krishnanath Gaitonde, MD Variable stream, slow to moderate Hx of decreased bladder sensation Attempt to insert UDM catheter>unsuccessful Cystoscopy>tight stricture in proximal bulbar area Will schedule Cysto under anesthesia and dilation of stricture (done 9/7/2010) 9/2/2010 Joseph Hartig, MD States urinary urgency C/O back pain ROS>no abnormalities identified Scheduled for urethral dilation 9/10/2010 University Hospital ED Hx of urethral stricture>s/p retrograde urethrogram and dilation of meatal stenosis with indwelling catheter (9/7/10) C/O bladder spasms>difficulty passing urine through Foley C/O suprapubic pain>7/10 Current meds: Meloxicam Lubiprostone Oxycodone Current meds: Oxycontin Omeprazole Coumadin 18
Urology consult>Foley flushing well No s/s infection or significant urinary retention Discharged to home Oxybutynin Cipro F/U ED visit Catheter removed>voiding with good stream Voiding well with no post void residual Change 16fr catheter to 18fr catheter for dilation daily x 2 wks. Continue intermittent self cath once daily RX: MUSE for Erectile dysfunction 9/17/2010 Krishnanath Gaitonde, MD 9/21/2010 Krishnanath Gaitonde, MD 10/1/2010 Joseph Hartig, MD C/O pain low back>chronic since 2008 MVA Appears to be in mild to moderate pain>antalgic gait Decreased ROM lumbar Straight leg raise>+ Motor strength/sensation>intact ASSESSMENT: Lumbar strain Degenerative disc disease w/o herniated disc Osteoarthritis of lumbo‐sacral spine 11/3/2010 Joseph Hartig, MD C/O pain in pelvis, stiffness in pelvis and weakness in back Exacerbating factors>bending in any direction, recumbency Lumbar>decreased ROM, tenderness, pain, spasm Normal strength/sensation; Deep Tendon Reflexes 2+ all Gateway Rehab Hospital Letter to Dr. Hartig Seen for 55 sessions from 10/22/09‐8/11/2010 for chronic pelvic pain Goals:  Increase active ROM bilateral hips>partially met, but hip ROM very limited and fixed  Increase strength of hip>partially met, but limited by severe and chronic pain  Decrease in pain>not met. Noted to have fallen on 8/10/10 d/t knee buckling and low back pain>exacerbated pain  Perform reciprocal stair climbing independently>partially met>able to do with UE weightbearing  Ambulate w/o assistive device>inconsistently met>required use of cane majority of time  Increase active ROM left knee for stair climbing>goal met  Increase strength of left knee>goal met 11/29/2010 19
11/30/2010 Joseph Hartig, MD C/O back and hip pain RX: Oxycodone Ibuprofen Meloxicam Lubiprostone (Amitiza) 12/10/2010 Joseph Hartig 1/14/2011 Krishnanath Gaitonde, MD 1/27/2011 Joseph Hartig, MD C/O back and hip pain FU urethral stricture Self catheterization 2x/week Decreased bladder sensation Erectile dysfunction>multiple meds with no response Significant issues with constipation C/O insomnia x 1 year C/O back pain, arthralgias, gait problem Decreased ROM and decreased strength >left hip Decreased ROM, tenderness, pain>lumbar Discussed risks/benefits of penile prosthesis RX: Oxycodone Eszopiclone for sleep UPDATED RECORDS RECEIVED BELOW 3/2/2011 Brad Quatkemeyer, MD 3/7/2011 Bradley Davis, MD 4/11/2011 Bradley Davis, MD C/O back pain & insomnia Normal strength Normal reflexes Normal gait MEDs: Oxycodone Diazepam Chronic constipation since accident No sensation of needing BM>bears down and pushes on abdomen to have BM ASSESSMENT: Chronic constipation since crush injury>laxatives ineffective Sitz test>colonic inertia Plan anal manometry F/u manometry Anal manometry>normal No evidence of outlet obstruction constipation ASSESSMENT: Since accident has gone 6 weeks w/o BM Sitz markers>positive Recommend total colectomy 20
RX: Cialis 11/25/2011 Krishnanath Gaitonde, MD Self cath once every 7 days Voids well with good stream Does timed voids d/t decreased bladder sensation No incontinence other than occasional post void dribble Partial erections/penile fullness>not enough for intercourse Joseph Hartig, MD Chronic pain Decreased ROM, decreased strength and tenderness>right hip Decreased ROM, tenderness>lumbar back Joseph Hartig, MD Chronic pain; 12/2/2011 Joseph Hartig, MD 12/15/2011 St. Elizabeth ED Chronic pain>mild relief from pain meds Positive for myalgias, pelvic pain Negative for back pain, arthralgias, gait problem C/O abdominal pain States chronic abdominal pain x3 years>worse today despite pain meds Noted to be cachectic (6’2”>160#) IMPRESSION: Chronic pain syndrome Relief from pain shot 1/2/2012 Joseph Hartig, MD C/O pelvic pain>chronic problem>occurs daily Aggravated by bending, twisting, walking C/o left ankle swelling Decreased ROM LS spine>pain/spasm Current meds: Valium Oxycontin Oxycodone Ibuprofen 1/4/2012 Krishnanath Gaitonde, MD Increasing difficulty with self caths>resistance and some urethral bleeding post cath Decreased bladder sensation ED>some response with Cialis ASSESSMENT: Urethral stricture s/p pelvic injury with neurogenic bowel/bladder Refer to Ayman Mahdy, MD 1/12/2012 Ayman Mahdy, MD Plan Cysto under anesthesia 7/7/2011 10/4/2011 Persistent ED despite medical treatment Decreased sensation in bowel with 3‐8 weeks of Continued on pain medications Referred to pain clinic Morphine Phenergan 21
constipation Caths once a week>bleeding with caths Impaired bladder sensation IMPRESSION: Recurrent USD after pelvic distraction injury; ED C/O leg pain>chronic problem Associated symptoms>joint locking, joint swelling, limited ROM 2/3/2012 Brad Quatkemeyer, 2/23/2012 Ayman Mahdy, MD Post‐op visit Doing well>has to push sometimes to get debris out Discussed need for penile Doppler 3/2/2012 Joseph Hartig, MD C/O pelvic/back pain>6/10 Throbbing pain>radiates into left leg>some relief with meds Exhibits decreased ROM lumbar spine Pain/spasm ASSESSMENT: Degenerative disc disease 3/27/2012 Robert Klickovich, MD Seen for evaluation and management of low back, left leg and abdominal pain Rates pain>7/10 at best to 10/10 at worst Exacerbating factors>bending, lifting, twisting, prolonged standing or sitting Muscle tone>normal Sensory>intact Antalgic gait Lumbar paraspinous tenderness SLR>negative ASSESSMENT: Pelvic crush injury Neuralgia Plan: Oxycontin 20 mg Q8h Oxycodone 5mg TID, prn Consider SCS Noted that he would soon undergo bowel surgery to remove large intestine and contact small intestine to rectum Follow up visits on 4/26/2012 & 5/24/2012>no change in complaints or plan of action 22
3/30/2012 Joseph Hartig, MD C/O back pain and gait problem Normal ROM RX: Meloxicam 5/7/2012 Bradley Davis, MD Letter to Justin Lawrence: Mr. Moore seen 1 year prior for chronic constipation Sitz marker study>slow transit constipation>likely d/t chronic narcotic use Anal manometry>normal squeeze pressures, normal resting pressures, normal pudendal nerve latency C/O rectal distension and incontinence Recommend colostomy 6/29/2012 Robert Klickovich, MD Increased Oxycodone to 30 mg TID x 2 weeks 7/8/2012 Ayman Mahdy, MD Noted to have had bladder surgery one month prior C/O significant pain Noted to be 5 weeks s/p transperineal urethroplasty Pain and spasms from suprapubic catheter 7/17/2012 Robert Klickovich, MD Post‐op pain starting to ebb No change in assessment Decreased Oxycodone to 15 mg QID 7/27/2012 Robert Klickovich, MD Pain 6/10 C/o pain low back and LLE 7/31/2012 Joseph Hartig, MD C/O anxiety C/O pain in gluteal, lumbar spine and sacroiliac>radiates to left knee and right knee Current meds: n Amitiza Meloxicam Oxybutynin Oxycodone 5mg TID Oxycontin 20mg TID Valium 8/22/2012 Robert Klickovich, MD Pain 6/10 C/O pain low back and LLE Scheduled for bowel surgery>decreased meds so that post‐op med will be effective Meds: Oxycodone Oxycontin Amitiza Meloxicam Valium Ibuprofen Plan to address ED after USD stabilized Oxycodone 10mg q6h Oxycontin 20mg TID 23
Recommend PT for gait instability/falls Pain clinic for pain management MRI of pelvis 10/25/2012 Vlnod Krishnan, MD Peripheral neuropathy Chronic pain in BLE Numbness right low back/proximal thigh Numbness left ankle Significant difficulty with sensation to urinate or defecate Allodynia in scrotum and base of penis Instability Left knee>falls IMPRESSION: Likely number of focal mononeuopathies in BLE (left greater than right) Likely affected areas in sacral nerves/sacral plexus Possible compromised flow to arteries in perineum 12/3/2012 Dr. Bradley Davis visit F/U constipation ‐ Continues to have abdominal pain and significant delay in transit. Has BM every 2 weeks or longer. Laxatives and cathartics are of no benefit. Does not have sensation and only feels his BM when it is about to come out. Has had urethral stricture repaired. Would like to proceed with colectomy and ileostomy. Will leave rectum in for now as he is not committed to a lifetime stoma but realizes that w/o rectal sensation he will be incontinent which would be worse than his current problem. Plan: Laparoscopic total colectomy with end ileostomy; General anesthesia. 3 hours 1/17/2013 Dr. Bradley Davis Pre‐op exam past hx of GERD, Impotence, bladder spasms, arthritis, Tibia/Fibula fx, fx of pelvis, Hip fx, Ankle fx, vertebral fx, claudication, DVT, Neuropathy, bladder stones, bronchitis, complication of surgical procedures and constipation. Oxycodone (Roxicodone) 5mg every 4 hours as needed Amitiza 24mcg 2 x/day Meloxicam 15mg tab Oxycodone (OxyContin) 20mg 3 times/day 1/22/2013‐
1/25/2013 UC ‐ Bradley Davis MD Surgery on 1/22/2013: Laparoscopic total abdominal colectomy with ileorectal anastomosis; Cystoscopy for slow transit constipation and chronic narcotic use 2ndary to trauma in the past. Preop dx: Constipation 2/7/2013 UC‐Bradley Davis MD Postop visit: Lap colectomy and ileostomy 1/22/2013 Recovering well. Repouched with 14603 with paste. Given RX for supplies. F/U in 1 month. 3/4/2013 UC‐Bradley Davis MD Post op visit: No complaints. Doing well. No further abd. Pain. F/U in 4‐6 months. 24
Updated records received Jan. 2014 2/29/2012 Thomas Schussler MD, Gastro Referred by Dr. Hartig for GI complaints: Severe constipation. Has had only 2 BM since last visit. Goes 3‐4 weeks between BM. Enemas have not helped. Surgeon recommended a subtotal colectomy. 1/18/2013 Dr. Hartig F/U for re‐eval of chronic anxiety. It is uncontrolled with current treatments in place. He has inability to sleep. Presents with Anxiety/insomnia. 4/30/2013 St. Elizabeth Hospital Laboratory orders: T4, Free; TSH; Vit. B12 levels, CBC; CMP; Lipid panel; Folate level; Hepatic function panel; LDL Pain 6/10. C/o low back pain, left hip pain and LLE from knee to foot, R hip pain. Continued to have significant burning/lancinating/aching pain t/o left leg. Revisited possibility of SCS for the remaining neuralgia in lumbar spine and LLE and fee that this might be a viable option to lower his daily consumption of opioids. Started a Duragesic patch and reduced short acting meds by 50%. 9/5/13 Dr. Klickovich 9/25/2013 Dr. Klickovich CC: Low back pain; Left leg pain; Abdominal pain. Crushed from the waist down by a front loader when the brake on the machine failed. Current meds: Amitiza Meloxicam ‐ 1/day Oxybutynin Oxycodone 5mg every 4 hours; 5mg 3x/day OxyContin 20mg every 12 hours OxyContin 20mg, 3 times/day Valium 4/12/12 ‐ Urine drug screen consistent with prescribed TX plan 4/26/2012‐ reported he was going to have 2 abd. Surgeries. Referred to Dr. Burhman for psychological eval in the future for regarding living with chronic pain as a result of initial injury and multiple subsequent surgeries. 5/29/12‐ Plan for urological surgery, ureter shortened by 2 inches and reattached. 6/29/12: Pain 10/10 given recent gallbladder surgery. Increased visits to 2‐week intervals. 150mg OxyContin for next 2 weeks. 10/26/12 ‐ reported he was still waiting approval for abd. Surgery. Rated pain 7/10. Urine toxicology showed compliance. 25