CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 13 0000. ref SDS 12 0000.
040502 -
040503 -
040504 -
040505 -
040507 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Doctor Yoo arrived for meeting scheduled yesterday, reported on 160619
040902 - 0800. ref SDS 13 5S4O
040904 - ..
040905 - He performed another lumbar puncture procedure with me sitting on the
040906 - bed and bending over to provide a curved arch for ease in penetrating
040907 - the spine at the lower back, and then sliding the thin-needle wire up
040908 - the vertibrae spinal column to the head, and drawing more fluid.
040910 - ..
040911 - This took about 20 minutes. Went much better than the 1st lumbar
040912 - puncture on 160618 0800. ref SDS 12 PQ5P There were 2 or 3 instances
040913 - of acute pain which lasted only a few seconds each. Most of the
040914 - procedure was painless.
040916 - ..
040917 - Thank Alex for doing a great job.
040918 -
040919 -
040921 - ..
0410 -
0411 -
0412 - 1010
0413 -
041301 - Doctor Yoo returned and introduced Doctor Massa, who will be
041302 - attending in this case, at least for awhile.
041304 - ..
041305 - Doctor Yoo advised that the medical team has made further review of
041306 - MRI study performed yesterday on 160619. There is now concensus that
041307 - radiology evidence shows a stroke occurred on 160617.
041309 - ..
041310 - Doctor Massa related that he and Doctor Yoo met with the attending
041311 - radiologist who read the MRI study. The three of them spent a great
041312 - deal of time to make a thorough and careful review of the MRI scans.
041313 - They eventually came to agreement there is evidence of a likely
041314 - stroke, possibly a blood clot in some part of the brain. They feel
041315 - this could reasonably have caused stroke-like symptoms reported on
041316 - 160617 1637. ref SDS 11 5F6F
041318 - ..
041319 - The need for "concensus" suggests the diagnosis of stroke is inclusive
041320 - in the MRI study, in that it can be read multiple ways.
041322 - ..
041323 - Doctor Massa repeated clinical tests, which...
041325 - ..
041326 - Doctor Yoo performed on 160603 1430. ref SDS 9 2Y49
041328 - ..
041329 - Doctor Smith performed on 160617 1637. ref SDS 11 8V5G
041331 - ..
041332 - Doctor Yoo again on 160618 0800. ref SDS 12 QR8F
041334 - ..
041335 - Arianna performed on 160618 0800. ref SDS 12 L25O
041337 - ..
041338 - Doctor Abrams performed on 160619 0800. ref SDS 13 UG71
041340 - ..
041341 - Doctor Massa performed today on 160620. ref SDS 0 1I4H
041342 -
041343 - [On 160705 1400 Doctor Collins performed another series
041344 - of neurology tests. ref SDS 19 NH6O
041346 - ..
041347 - It was important for Doctor Massa to repeat these tests in order to
041348 - directly observe and thereby appreciate results, and further to
041349 - demonstrate complete recovery from prior symptoms, with passage of
041350 - time.
041352 - ..
041353 - Doctor Massa commented that not seeing 2 numbers for the hour that
041354 - display to the left of 2 numbers for minutes on a cellpone suggests
041355 - possible right side stroke causing left side debilitations. This
041356 - indication is supported by the record of not seeing a number to left
041357 - of the string of numbers, which Megan presented on initial examination
041358 - in the ER on 160617 1637. ref SDS 11 N55I Difficulty connecting and
041359 - disconnecting the seatbelt which fastens on the left side, further
041360 - indicates left side weakness, sympomatic of right side stroke.
041362 - ..
041363 - After doing these clinical tests again, Doctor Yoo and Doctor Messa
041364 - seemed to agree the patient exhibits no symptoms of stroke nor
041365 - diminution of cognitive function of any kind at this time, 4 days
041366 - after presenting with significant stroke-like symptoms on 160617 1637.
041367 - ref SDS 11 5F6F
041369 - ..
041370 - Doctor Yoo advised that this record of evident recovery from symptoms
041371 - justifies discharge from the hospital today. The doctor cautioned
041372 - that any recurrence of symptoms could be very serious and should
041373 - result in immediate return for care in the VA Medical Center.
041374 -
041375 - [On 160621 1024 letter confirms work plan for returning to
041376 - the VA Medical Center for continuing care in the event
041377 - stroke symptoms recur. ref SDS 16 D463
041379 - ..
041380 - [On 160622 1506 received call from Jenna in Neurology
041381 - Department - she submitted a letter with attached medical
041382 - literature explaining common signs of stroke, with notice
041383 - that in the event of such events, patients should seek
041384 - immediate medical care at the VA Medical Center in San
041385 - Francisco. ref SDS 18 A95H
041387 - ..
041388 - Discussed causation for evident stroke symptoms in this case. Doctor
041389 - Massa noted this is an important consideration in order to verify
041390 - diagnosis, and to avoid factors that might further compound maladies.
041392 - ..
041393 - The doctor initially commented that age is typically not considered a
041394 - likely factor causing stroke-like symptoms in this case, as reported
041395 - on 160617 1637. ref SDS 11 5F6F He feels that nothing in the record
041396 - points to age at this time.
041398 - ..
041399 - We reviewed issues that came up yesterday, meeting with Doctor Abrams
041400 - and Doctor Yoo...
041401 -
041402 - 1. EGD Dilation procedure the morning before symptoms started.
041403 -
041404 - Lack of symptoms prior to this procedure, proximity in time
041405 - of symptoms starting after the procedure, and evident
041406 - complete ending of symptoms with progression of time since
041407 - the procedure on 160617 at 0800, strongly suggests
041408 - something occurred during this event that caused
041409 - stroke-like symptoms later, and as more time passed simply
041410 - wore off, and so symptoms abated.
041412 - ..
041413 - 2. Fall hitting head on concrete floor, entering VA building 203,
041414 - reported on 160519 0527. ref SDS 7 MS5J
041416 - ..
041417 - 3. Fall attempting to step across shallow creek in Crystal
041418 - Rock Creek on 160501, reported in case study on 140101
041419 - 0600. ref SDS 3 YS8N
041421 - ..
041422 - 4. Fall hiking Half Dome on 150916 0535. ref SDS 4 O87H
041424 - ..
041425 - Doctor Massa and Doctor Yoo seemed to indicate that none of these
041426 - events seem likely to have caused stroke-like symptoms beginning on
041427 - 160617, and ending the next day OA 160618.
041429 - ..
041430 - We reviewed understandings meeting with Doctor Abrams yesterday,
041431 - seeming to say that verifying nothing was done or not done during the
041432 - EGD Dilation that caused stroke symptoms that occurred after the
041433 - procedure on Friday, is important for doing the next EGD Dilation in
041434 - September. Doctor Massa concurred, but noted he cannot think of
041435 - anything at the moment that is typically done in EGD dilations that
041436 - seems likely to have caused stroke symptoms in this case. He said
041437 - not to worry though because the VA will ensure the next procedure is
041438 - safe.
041440 - ..
041441 - Discussed potential for drug side effects and particularly when taken
041442 - for long periods and in many combinations to elevate risks of stroke.
041443 - Doctor Massa cited numerous articles published the past few years
041444 - reporting PPIs in some cases have adverse affects on circulatory
041445 - system. The doctor seemed say that doctors who prescribe daily
041446 - medications should verify the combined effects are well controlled.
041447 -
041448 - [On 160621 1024 letter to Doctor Yoo and medical team cites
041449 - consideration for reviewing drug combinations to reduce
041450 - risk of adverse effects. ref SDS 15 D439
041452 - ..
041453 - They want to do further tests likely on Wednesday...
041454 -
041455 - 1. Sonogram
041456 - 2. Angiogram of brain
041458 - ..
041459 - Possibly, there is only 1 test - sonogram angiogram - not sure.
041461 - ..
041462 - Doctor Yoo will submit a letter scheduling a sonogram and/or angiogram
041463 - test of the brain, possibly on Wednesday, 160622.
041464 -
041465 - [On 160621 1024 received letter from Alex reporting
041466 - neuroradiology team will meet Wednesday to review imaging
041467 - in this case for further consideration of diagnosis and
041468 - course of care, i.e., further testing, treatment,
041469 - hospitalization. He does not expect patient to be called
041470 - into the hopsital the rest of this week. ref SDS 14 5F6F
041472 - ..
041473 - Doctor Yoo encouraged adding aspirin to the current list of
041474 - medications. He advised that aspirin has been shown to be effective
041475 - for thinning blood that reduces risks of strokes commonly caused by
041476 - blood clots.
041478 - ..
041479 - There was not enough time during the meeting today, to evaluate the
041480 - effect of adding aspirin to the current list of medications, nor how
041481 - aspirin in this case might increase already difficult digestion
041482 - problems.
041484 - ..
041485 - What are INR goals?
041487 - ..
041488 - What are relative benefits of taking warfarin to maintain INR goals
041489 - rather than aspirin?
041491 - ..
041492 - We briefly, reviewed the record taking warfarin for several months
041493 - after CABG on 091022, because post procedure radiology CT test to
041494 - evaluate achalasia and fluid on the lungs indicated possible DVT at
041495 - the location where the Cordis catheter was placed; sonogram test
041496 - confirmed DVT, reported on 091030 0810. ref SDS 1 1N6L
041498 - ..
041499 - Further discussed hiking.
041501 - ..
041502 - Doctor Yoo proposed delaying more hiking until after tests planned on
041503 - Wednesday.
041505 - ..
041506 - Doctor Massa concurred that the patient should be aware there is a
041507 - slight risk of further stroke symptoms from hiking under the current
041508 - state of the record.
041509 -
041510 - [On 160622 1428 notified Doctor Yoo and Doctor Simpson that
041511 - hiking to support line of care for stroke-like symptoms
041512 - went well; reported minor neurapathy in left fingers of
041513 - left hand occurred and subsided for short periods
041514 - throughout the hike.; also reported new MCL injury right
041515 - knee will prevent hiking for 10 days or more. ref SDS 17
041516 - 5F6F
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041518 -
041519 -
041520 -
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041529 -