DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Colovesicular fistula.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male referred by Dr. John Doe for evaluation. The patient has had diverticular disease for about four years, which actually turned out to be almost six years. The patient thought it was a hernia but then he started to have a fever. He went to the emergency room. He had a colonoscopy and was diagnosed with diverticular disease. He did well for a few years and then started to have burning with urination, fevers, hematuria, and pneumaturia. The patient has felt well for two weeks now. He has been on Augmentin and then started ciprofloxacin. He is now starting on Macrodantin. Bowel movements daily are normal without any blood. The patient does have cloudy urine.
PAST MEDICAL HISTORY: Diverticular disease.
PAST SURGICAL HISTORY: The patient has had recurrent cystic hygroma of the left neck area surgically excised.
ALLERGIES: NKDA.
FAMILY HISTORY: Mother with COPD and a heart valve replacement.
SOCIAL HISTORY: The patient drinks three to four alcoholic beverages per week. Denies illicit drug or tobacco use.
REVIEW OF SYSTEMS: Corrective lenses, blood in the urine, burning with urination, and abdominal pain. Otherwise, 14-point ROS is as per HPI.
PHYSICAL EXAMINATION: The patient’s height is 5 feet 10 inches and weight is 252 pounds. There is no scleral icterus. His lungs are CTABL. Heart has S1, S2. Abdomen is soft and tender in the suprapubic area. There is no rebound or guarding. No peritoneal signs. No incisional or congential hernias can be palpated. Extremities are without cyanosis or edema.
The patient’s CT scan of the pelvis showed findings consistent with a diverticulitis and fistula connection to the bladder.
Ultrasound of the abdomen showed probable fatty changes in the liver; however, echotexture heterogeneous micrometastases cannot be excluded. Urinary bladder is very poorly distended. No gallstones are seen.
IMPRESSION: This is a gentleman with a colovesicular fistula from diverticular disease most likely, although malignancy cannot be excluded.
PLAN: We explained to the patient that he needs a colonoscopy to look for any other pathology, as it has been five years since his last colonoscopy. We also feel that he would be a good candidate for a minimally invasive sigmoid colectomy, preferentially done with robotic assistance, and possible closure of the bladder if indicated, but Foley decompression of the bladder would certainly be indicated. Primary anastomosis would be advantageous with bowel preparation ahead of time. Once the colonoscopy is done, we will determine exactly the dates for surgery, and we look forward to taking care of him. Ureteral stents will be used in this case.
