CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up
040502 -
040503 -
040504 -
040505 -
040507 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Making a joke to start the meeting, asked Alex, if there is any way to
040902 - get a "Handicap Parking" permit out of all this?
040904 - ..
040905 - Doctor Yoo initially proposed ordering another Zio XT heart monitoring
040906 - test for another 2 weeks. He seemed say this was required for a
040907 - specific protocol, which has not previously been presented in the
040908 - record.
040910 - ..
040911 - Asked why more Zio XT heart monitoring is needed now 4 weeks past
040912 - suffering stroke-like symptoms on 160617, and which resolved 2 days
040913 - later?
040914 -
040915 - [...below on 160715 1630 Progress Notes say "...evidence
040916 - suggests at least 30 days of Zio XT monitoring is needed
040917 - looking for afib to support Neurology theory that stroke
040918 - occurred independently of EGD dilation on 160617, prior to
040919 - stroke symptoms becoming evident. ref SDS 0 TV5P
040921 - ..
040922 - [On 160727 0004 letter notifies Neurology that patient
040923 - agrees to undergo another 2 weeks of Zio XT testing for
040924 - afib. ref SDS 24 S162
040926 - ..
040927 - [On 160801 0923 notify Doctor Yoo in Neurology that Zio XT
040928 - device will be installed on 160805 OA 1000. ref SDS 26 WF5I
040930 - ..
040931 - Doctor Yoo advised that the medical team has found no evidence in CT
040932 - and MRI testing of atherosclerosis in the brain, nor any other form of
040933 - innate neurological reason for the patient to have suffered stroke
040934 - symptoms after the EGD dilation procedure on 160617, ref SDS 6 5F6F,
040935 - and so cling to the theory presented on 160623, ref SDS 12 P78F, that
040936 - symptoms could have resulted from cardioemblematic issue of afib that
040937 - momentarily slowed blood flow causing a clot to form in the heart.
040938 - This hypothetical blood clot could have flowed upward to the brain and
040939 - could have created a blood flow obstruction on encountering
040940 - atheroscloerotic plaque or stenosous, which then caused the "likely
040941 - SCA infarct" (stroke) at the location identified in the MRA study on
040942 - 160618. ref SDS 8 IY8H Part of this 1st blood clot could then broke
040943 - off and could have then created another obstruction further up, at a
040944 - location that could have caused patient stroke symptoms that occurred
040945 - after the EGD dilation procedure on 160617.
040946 -
040947 - [...below on 160715 1630 Doctor Yoo Neurology Progress
040948 - Notes say in part "given absence of vertebrobasilar
040949 - disease..." which is another way of saying there is no
040950 - evidence of atherosclerosis in the brain. ref SDS 0 TV4F
040952 - ..
040953 - [On 160717 2227 letter to medical team confirms Neurology
040954 - determination that CT and MRI testing on 160618, found no
040955 - evidence of atherosclerosis nor obstruction of any kind
040956 - that could have caused stroke symptoms. ref SDS 18 GW93
040958 - ..
040959 - The Neurology team feels that another Zio XT test for another 2 weeks
040960 - might yield an instance of afib, which the first Zio XT test did not.
040961 - Even though this is over a month past EGD Dilation on 160617, after
040962 - which symptoms occurred, and even though no symptoms occurred
040963 - previously, nor since, then the team could still take comfort
040964 - believing afib event could have caused stroke symptoms on 160617.
040966 - ..
040967 - Doctor Yoo further said Neurology wants additional tests on a
040968 - non-urgent basis: cerebral angiography, and then a final MRI test.
040969 - No date was given for these tests.
040970 -
040971 - [On 160717 2227 letter to Doctor Yoo at VAMCSF confirms
040972 - scope of additional testing. ref SDS 16 GW40
040974 - ..
040975 - Asked about doing another MRI study immediately, to see if adverse
040976 - findings from the test on 160618, have resolved in line with
040977 - resolution of stroke symptoms, as requested originally on 160620 0707,
040978 - ref SDS 10 IU9K, and in the letter the next day on 160621 1024.
040979 - ref SDS 11 D460
040980 -
040981 - [...below on 160715 1630 Doctor Yoo Neurology Progress
040982 - Notes show work plan to perform conventional cerebral
040983 - angiogram, and then if results are normal will order an
040984 - MRI. ref SDS 0 TW4N
040986 - ..
040987 - [On 160717 2227 letter to Doctor Yoo requests MRA be
040988 - performed immediately to see if brain anomolies have
040989 - resolved based on clinical symptoms having resolved.
040990 - ref SDS 17 GW50
040992 - ..
040993 - [On 160802 1300 Doctor Vora during meeting for 2nd opinion
040994 - from Stanford Neuroscience recommends immediate MRI to
040995 - compare with 1st MRI to see if white dots shown in 1st MRI
040996 - on 160618, have resolved, in line with resolution of stroke
040997 - symptoms 2 days after onset of symptoms on 160617, or are
040998 - still stable, or increased, toward diagnosing cause of
040999 - patient stroke symptoms, and risks for increased symptoms
041000 - in relation to repeating EGD with conscious sedation
041001 - procedures. ref SDS 27 Y64O
041003 - ..
041004 - Doctor Yoo said the "no urgency" schedule represents neurology feeling
041005 - there is no urgency for final tests, as they do not influence the work
041006 - up.
041008 - ..
041009 - The doctor confirmed again that the cerebral MRI angiography study
041010 - (also "MRA") performed on 160618, the day after the EGD dilation
041011 - procedure, found no evidence of blood clots nor atherosclerosis in the
041012 - patient's brain.
041014 - ..
041015 - Doctor Yoo seemed to indicate the medical team supports the
041016 - atherosclerosis theory of the case, despite there being no evidence of
041017 - atherosclerosis, based on patient history of not taking asperin, and
041018 - taking low dose of statin drugs in order to avoid adverse side effects
041019 - of both.
041021 - ..
041022 - Doctor Yoo asked why the patient takes a low dose of statin drugs?
041024 - ..
041025 - Reviewed the record showing low dose reduces side effects of
041026 - dehydration. This enables hiking 300 miles per month, which elevates
041027 - EPCs and raises HDL 30 at time of CABG on 091022, to HDL 73 on 160202.
041028 - Elevated HDL and EPCs regresses atherosclorosis to protect against
041029 - strokes, heart attack, pullmonary embolism, etc, as shown in CCTA on
041030 - 151019, ref SDS 4 SU62, and the recent MRA on 160718. ref SDS 8 VN4G
041031 - Taking a higher dose would prevent hiking shown by the record in this
041032 - case. Doctor Abrams, Chief of Neurology, prescribed hiking as the
041033 - only treatment to recover from stroke symptoms that occurred following
041034 - EGD dilation on 160617, reported during the meeting 2 days later with
041035 - Doctor Yoo in the TCU hospital room on 160619. ref SDS 9 J66L
041036 - Following this advice to reduce the risk of heart attack and another
041037 - stroke, requires lowering the dose of statins.
041039 - ..
041040 - Doctor Yoo asked why the patient does not take aspirin?
041042 - ..
041043 - Reviewed the record of difficult digestion issues, which can be
041044 - compounded with aspirin side effects. Aspirin lowers risk of adverse
041045 - events for patients with atherosclerosis. CCTA on 151018, showed
041046 - there is no athersclerosis to treat. This is confirmed by Doctor
041047 - Yoo's report today, that the MRA on 160618, found no evidence of
041048 - atherosclerosis. Since there is nothing to treat, and since aspirin
041049 - risks increased digestion problems, avoiding aspirin lowers the risk
041050 - of over medication.
041051 -
041052 - [On 160722 1304 Doctor Massa asked how swallowing is going
041053 - - explained LESV seems to be shutting down sooner this
041054 - cycle; could effects of adding aspirin last month to list
041055 - of prescribed medications. ref SDS 20 LI4G
041057 - ..
041058 - The doctor advised that planning to perform a sonogram of carotid
041059 - arteries have been abandoned, since the liklihood is 0 of
041060 - atherosclerosis in the carotid arteries that lie between the coronary
041061 - area and the cerebral area where testing has shown no evidence of
041062 - atherosclerosis.
041064 - ..
041065 - Doctor Yoo advised the Neurology Department continues to plan for the
041066 - patient to undergo a conventional angiogram of brain. He explained
041067 - this will be scheduled as "not urgent," because Neurology believes it
041068 - will not reveal more than MRA radiology study performed on 160618.
041070 - ..
041071 - After the conventional angiogram is performed in 2 - 4 months,
041072 - Neurology will schedule another MRA examination to see if signs of
041073 - stroke have resolved, or have progressed. Similarly, Neurology wants
041074 - to know if inflammation area above the brain has also resolved.
041076 - ..
041077 - Doctor Yoo said the stroke that he thinks may have occurred in this
041078 - case, could not have caused stroke symptoms diagnosed on 160617
041079 - following EGD Dilation, and the next day.
041081 - ..
041082 - He seemed to say results of lumbar puncture procedures on 160618 and
041083 - on 160620, show that initial "suspicions" of leptomeningeal
041084 - enhancement is not supported by the lab evidence for diagnosing the
041085 - large area of inflammation above the brain found in the MRI
041086 - angiogrpahy test performed on 160618. As a result, at this time VA
041087 - Neurology has no diagnosis of the large inflammation area on top of
041088 - patient's brain.
041089 -
041090 - [On 160717 2227 letter to Doctor Yoo confirms understanding
041091 - that Neurology found the 2 lumbar puncture tests performed
041092 - by Doctor Yoo show no evidence of leptomeningeal
041093 - enhancement. ref SDS 15 GW90
041095 - ..
041096 - Either it or something else caused stroke symptoms on 160617 following
041097 - EGD dilation, but at this time both requiry further inquiry.
041099 - ..
041100 - Doctor Yoo said something can cause strokes besides atherosclerotic
041101 - plaques. Requested this be explained in Progress Notes for review by
041102 - the independent team ordered Doctor Lee ordered yesterday.
041104 - ..
041105 - Doctor Yoo said he has not read Doctor Lee's Progress Notes for the
041106 - EGD dilation procedure on 160617, for clues about what might have
041107 - caused stroke symptoms after the procedure.
041109 - ..
041110 - Discussed call from Doctor Lee yesterday, in which he reported the
041111 - Progress Notes for the EGD dilation on 160617, have not been signed,
041112 - confirmed in a letter to the medical team, including Doctor Lee and
041113 - Doctor Yoo.
041115 - ..
041116 - Doctor Yoo accessed VA Sacramento medical records on the computer in
041117 - the examination room; he navigated to Doctor Lee's Progress Notes for
041118 - the telephone call yesterday, following telecon between Doctor Lee and
041119 - the patient on 160714. We both observed on the computer screen, at
041120 - the top of the list in Doctor Lee's Progress Notes is an entry that he
041121 - ordered peer review of procedure on 160617, to identify possible
041122 - factors causing stroke symptoms that occurred after the procedure.
041124 - ..
041125 - After we read Doctor Lee's Progress Notes, Doctor Yoo then said that
041126 - after he read the letter yesterday reporting GI Department at VA
041127 - Medical Center in Sacramento is investigating correlations between EGD
041128 - Dilation with Conscious Sedation procedure on 160617, and follow on
041129 - stroke symptoms, he reviewed MRA again, and discovered the stroke
041130 - occurred a day to a week prior to 160617, and so he concludes there
041131 - could be no causative relationship with the EGD Dilation procedure.
041133 - ..
041134 - [...below on 160715 1630 at 1942 received copy of letter
041135 - from Doctor Yoo to Doctor Lee with GI Clinic at VA Medical
041136 - Center in Sacramento, and who performed the EGD dilation
041137 - procedure with conscious sedation on 160617, preceeding
041138 - stroke symptoms; and Doctor Yoo's letter saying "the
041139 - stroke" preceeded the procedure. ref SDS 0 MO5P
041141 - ..
041142 - Asked if this conclusion is shared with Doctor Massa, attending in
041143 - this case, and with Doctor Abrams, Chief of Neurology? Did Doctor Yoo
041144 - work with the neurointerventional radiologist team who consulted in
041145 - the case on 160622, cited in Doctor Yoo's letter on 160621?
041146 - ref SDS 11 2I79
041148 - ..
041149 - Doctor Yoo advised that he discussed his new interpretation of the
041150 - MRI findings with Doctor Massa, attending in this case.
041152 - ..
041153 - Asked Doctor Yoo to submit the new evidence he found that justifies a
041154 - conclusion that stroke, if any, did not occur when stroke symptoms
041155 - occurred on 160617, and explain why this was not discovered until 4
041156 - weeks after the MRA on 160618?
041158 - ..
041159 - The doctor said he will submit a letter responding to the copy he
041160 - received of the letter sent to Doctor Lee yesterday, saying that
041161 - Neurology will notify the GI Clinic at VA Medical Center in
041162 - Sacramento, when Neurology has cleared the patient for another EGD
041163 - Dilation procedure, shown in the record on 160714 0814. ref SDS 13
041164 - SH39
041166 - ..
041167 - [...below on 160715 1630 at 1942 Doctor Yoo wrote a letter
041168 - to Doctor Lee at VA Medical Center in Sacramento, saying
041169 - the patient is cleared by Neurology for repeat EGD
041170 - dilation procedure. ref SDS 0 MO6F
041172 - ..
041173 - [...below on 160715 1630 at VA Progress Notes confirm
041174 - patient cleared by Neurology for repeat EGD procedure.
041175 - ref SDS 0 K39G
041177 - ..
041178 - Doctor Yoo performed again the series of neurology tests originally
041179 - performed in the initial Neurology Clinic on 160603 1430. ref SDS 5
041180 - 2Y49 This extends the number of these standard neurological tests
041181 - given the patient in this case, listed on 160620 0707. ref SDS 10 1I4H
041183 - ..
041184 - He was pleased these tests were all performed satisfactorily today,
041185 - continuing to show the patient has no neurological deficits, and thus
041186 - continues full recovery from prior stroke symptoms evident following
041187 - EDG dilation on 160617, and which he diagnosed the next day on 160618
041188 - 0800. ref SDS 7 QR8F
041190 - ..
041191 - We discussed the biggest health problem in the case at the moment is
041192 - the injury to right knee while hiking this morning, reported in case
041193 - study on 140101 0600. ref SDS 2 UH9K It threatens ability to maintian
041194 - elevated HDL that prevents atherosclerosis from causing coronary and
041195 - cerebral events.
041197 - ..
041198 - The next priority is getting clearance to perform EGD dilation on
041199 - 160909, in order to continue recovery from achalasia by increasing
041200 - LESV from 15mm to 18mm in order to enable normal swallowing that
041201 - maintains nutrition.
041202 -
041203 - [...below on 160715 1630 at 1942 Doctor Yoo wrote a letter
041204 - to Doctor Lee at VA Medical Center in Sacramento, saying
041205 - the patient is cleared by Neurology for repeat EGD
041206 - dilation procedure. ref SDS 0 MO6F
041208 - ..
041209 - [...below on 160715 1630 at VA Progress Notes confirm
041210 - patient cleared by Neurology for repeat EGD procedure.
041211 - ref SDS 0 K39G
041213 - ..
041214 - Additionally, need medication solution to resolve rising ulceration
041215 - of LESV found in EGD dilation on 160617.
041217 - ..
041218 - Solving achalasia requires completing neurology study to discover the
041219 - cause of stroke symptoms following EGD dilation on 160617, so that
041220 - everyone feels confident the next one on 160909, will not cause stroke
041221 - symptoms to recur.
041222 -
041223 - [...below on 160715 1630 at 1942 Doctor Yoo wrote a letter
041224 - to Doctor Lee at VA Medical Center in Sacramento, saying
041225 - the patient is cleared by Neurology for repeat EGD dilation
041226 - procedure, and indicates no progress on determining what
041227 - caused stroke symptoms. ref SDS 0 MO6F
041229 - ..
041230 - Asked Doctor Yoo to write a letter to Doctor Lee confirming that
041231 - Neurology is working on this objective.
041232 -
041233 -
041235 - ..
0413 -
0414 -
0415 - 1942
0416 -
041601 - After arriving home, received copy of letter from Doctor Yoo to Doctor
041602 - Lee, as requested during the meeting with Alex, earlier today, per
041603 - above. ref SDS 0 5Z5G
041605 - ..
041606 - Letter from Doctor Yoo at VA Medical Center in San Francisco, says...
041607 -
041608 - 1. Subject: Updates from Neurology
041609 - Date: 2016-07-15 18:21
041614 - ..
041615 - 2. Dear Dr. Lee,
041617 - ..
041618 - 3. I wanted to touch base regarding Mr Welch, a patient I've had
041619 - the pleasure of seeing recently both on the inpatient service
041620 - and in clinic. He asked me to communicate with you regarding
041621 - the issue of his recent procedure resulting in his stroke and
041622 - cleared me to e-mail you. He is CC'd on this letter. When the
041623 - patient presented on the 17th of June, he had symptoms and
041624 - signs on his exam that warranted neuroimaging; we found a right
041625 - superior cerebellar artery territory infarct that was actually
041626 - incidental given that none of his symptoms were referable to
041627 - this area.
041629 - ..
041630 - I suspect that the etiology is cardioembolic since he does not
041631 - have any vertebrobasilar disease.
041633 - ..
041634 - This confirms understanding that MRI on 160618, showed no evidence of
041635 - atherosclerotic plaque in blood vessels of the brain.
041637 - ..
041638 - Doctor Yoo's letter continues...
041639 -
041640 - Of note, I re-reviewed the imaging to try to precisely date the
041641 - stroke since there was some concern that his EGD and stroke
041642 - might be causally related. Based on the imaging
041643 - characteristics, my impression is that the stroke is actually
041644 - several days or perhaps even greater than a week old, which
041645 - predates the event to the procedure.
041647 - ..
041648 - This aligns with discussion during the meeting earlier today, per
041649 - above. ref SDS 0 VM9N
041651 - ..
041652 - Doctor Yoo's letter continues...
041653 -
041654 - I think mechanistically, even if the timing of the stroke lined
041655 - up with the procedure, it is difficult to connect the two
041656 - causally unless one invokes that a transient arrhythmia
041657 - occurred during the procedure and resulted in an embolic event.
041659 - ..
041660 - Identifying a specific scenario for EGD dilation and conscious
041661 - sedation to have caused stroke symptoms is helpful.
041662 -
041663 - [On 160811 1546 Doctor Massa, attending physician in the
041664 - case, letter lists potential ways EGD could have caused
041665 - stroke symptoms, and concludes noting "significant
041666 - possibility" of causal relationship remains to be
041667 - identified. ref SDS 28 HR5J
041669 - ..
041670 - Doctor Yoo's letter continues...
041671 -
041672 - In any case, he is neurologically cleared for a repeat
041673 - procedure.
041675 - ..
041676 - This clearance relates to discussions during the meeting, earlier
041677 - today with Doctor Yoo, per above. ref SDS 0 KO5O
041678 -
041679 - [...below on 160715 1630 at VA Progress Notes confirm
041680 - patient cleared by Neurology for repeat EGD procedure.
041681 - ref SDS 0 O466
041683 - ..
041684 - [On 160726 1117 public reporting by CNBC that Olympic
041685 - gastrointestinal scopes have caused illness and deaths due
041686 - to design flaw that spreads infection, should be considered
041687 - for cause of infection in this case resulting in large area
041688 - of inflammation above the brain, possibly caused by VA
041689 - using Olympic gastrointestinal scopes. ref SDS 23 FH6N
041691 - ..
041692 - [On 160729 0119 letter to Doctor Stewart notifies Neurology
041693 - has cleared patient for repeat sedation procedures, so
041694 - request schedule meeting to consider surgical solution to
041695 - achalasia. ref SDS 25 DZ3T
041697 - ..
041698 - 4. Please let me know if you have any questions.
041700 - ..
041701 - 5. Best,
041702 - Alexander Yoo
041703 -
041704 -
041705 -
041706 -
041707 -
041708 -
0418 -
SUBJECTS
Default Null Subject Account for Blank Record
0503 -
050401 - ..
050402 - Progress Notes Meeting Doctor Yoo Neurology 160715 1630
050403 -
050404 - File is stored at...
050405 -
050406 - F:\05\00003\SM\CC\AGMJ\20160715-163000\welch.pdf
050407 -
050408 - 1. LOCAL TITLE: NEUROLOGY RESIDENT CLINIC F/U NOTE
050409 - STANDARD TITLE: NEUROLOGY RESIDENT NOTE
050410 - DATE OF NOTE: JUL 15, 2016@15:57 ENTRY DATE: JUL 15, 2016@15:57:41
050411 - AUTHOR: YOO,ALEXANDER EXP COSIGNER: YENARI,MIDORI A
050412 - URGENCY: STATUS: COMPLETED
050413 -
050414 - *** NEUROLOGY RESIDENT CLINIC F/U NOTE Has ADDENDA ***
050416 - ..
050417 - 2. INTERIM HISTORY
050418 -
050419 - 1. Since Mr Welch's last visit, he has been seen by audiology
050420 - who diagnosed him with L BPPV which resolved with epley.
050422 - ..
050423 - 2. He additionally completed his two weeks of cardiac
050424 - monitoring and was found to not have any evidence of any
050425 - arrhythmia.
050427 - ..
050428 - 3. He had his EEG and TTE today, results are pending.
050430 - ..
050431 - 4. He continues to report absence of any neurologic symptoms
050432 - including the ones he experienced when he presented on
050433 - 6/17. Specifically, he notes no new weakness, numbness,
050434 - visual changes, double vision, vertigo, facial weakness.
050436 - ..
050437 - 5. The patient continues to wonder if his EGD procedure was
050438 - linked to his presentation and offers that his GI physician
050439 - in Sacramento has started to investigate the matter.
050441 - ..
050442 - 6. Otherwise, Mr Welch states that he has been well with the
050443 - exception of a repeat injury to his right knee which
050444 - occurred while he was hurrying across a crosswalk to make
050445 - the light
050447 - ..
050448 - During the meeting with Doctor Lee today at 1630, reported the injury
050449 - occurred while hiking this morning, per above. ref SDS 0 KP3F
050451 - ..
050452 - Progress Notes for meeting on 160715 continue...
050453 -
050454 - 3. Active Outpatient Medications (including Supplies):
050455 -
050456 - 1. AMMONIUM LACTATE 12% LOTION APPLY LOTION TOPICALLY ACTIVE
050457 - EVERY DAY TO DRY SKIN
050459 - ..
050460 - 2. ASPIRIN 81MG CHEW TAB CHEW ONE TABLET ORALLY ACTIVE
050461 - EVERY DAY TO THIN BLOOD
050463 - ..
050464 - 3. EZETIMIBE 10MG TAB TAKE ONE TABLET ORALLY ACTIVE
050465 - EVERY DAY
050467 - ..
050468 - 4. GAUZE PAD 4IN X 4IN 12-PLY STERILE USE GAUZE AS ACTIVE
050469 - DIRECTED TO COVER WOUND PACKING.
050471 - ..
050472 - 5. KERLIX 4.5IN STERILE USE BANDAGE AS DIRECTED TO ACTIVE
050473 - WRAP LOOSELY AROUND WOUND.
050475 - ..
050476 - 6. OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE ORALLY HOLD
050477 - EVERY OTHER DAY
050479 - ..
050480 - 7. TAPE,MICROPORE 2IN 3M #1530-2 USE TAPE AS DIRECTED ACTIVE
050481 -
050483 - ..
050484 - Examination
050485 -
050486 - 1. BP: 142/78 (07/05/2016 13:38)
050487 - Pulse: 97 (07/05/2016 13:38)
050488 - Temp: 97.5 F [36.4 C] (06/20/2016 07:44)
050489 - Resp: 20 (06/20/2016 07:44)
050490 - 02 Sat: 7/5/16 13:38:15 O2:98
050492 - ..
050493 - Why are these numbers taken from 160705, when vitals taken today for
050494 - EEG test reported BP 111 58, 160715 1400? ref SDS 14 IJ47
050496 - ..
050497 - Normally, it might not matter; however, at this time blood pressure is
050498 - a factor considering heart condition in relation to stroke stymptoms.
050500 - ..
050501 - Progress Notes for meeting on 160715 continue...
050502 -
050503 - 2. General - well appearing man in no distress. Pleasant.
050504 -
050505 - 3. Neurologic examination:
050506 -
050507 - 1. Mental status: Alert and oriented x4, eloquent. No visual
050508 - or tactile neglect. No apraxia present
050510 - ..
050511 - 2. CN: PERRL, EOMI without nystagmus, VFFTC. Face symmetric at
050512 - rest and with activation, normal sensation. Tongue/palate
050513 - midline, shrug symmetric.
050515 - ..
050516 - 3. Motor: Normal bulk and tone, no PD, fast finger and foot
050517 - taps bilaterally. Full to confrontation proximally in
050518 - deltoids and distally in FE bilaterally. Full in
050519 - proximally in IPs and distally in TAs bilaterally.
050521 - ..
050522 - 4. Sensory: SILT in all 4 extermities
050524 - ..
050525 - 5. Coordination: Normal FTN, HKS bilaterally.
050527 - ..
050528 - 6. Gait: Normal narrow based gait, able to heel/toe and
050529 - tandem walk.
050530 -
050531 - 4. ---STROKE WORK-UP---
050532 -
050533 - 1. LABS:
050534 -
050535 - 1. Hba1c 5.5 (2015)
050536 - 2. LDL 153.4
050537 - 3. HDL 63.4
050539 - ..
050540 - 2. Echocardiogram: Pending
050542 - ..
050543 - 3. Ziopatch results:
050544 -
050545 - During the 14 d recording period, there was sinus
050546 - rhythm with 295 episodes of SVT, likely atrial
050547 - tachycardia with longest duration of 51.6 seconds.
050548 - There was 1 triggered event and 1 diary event which
050549 - were associated with PACs and sinus rhythm.
050550 -
050551 -
050552 - 5. ---LEPTOMENINGEAL WORK-UP---
050553 -
050554 - LP Results:
050555 - Labs & Microbiology:
050556 - Lumbar Puncture (6/18): 4 WBCs, 2 RBCs, 81 glucose, 71 protein (abnl)
050557 - - Gram stain: no organisms seen
050558 - - culture: No growth
050559 - - IgG index: 0.5
050560 - - OCB: 0
050561 - - VZV DNA, IgG/IgM: Negative
050562 - - HSV DNA PCR: Negative
050564 - ..
050565 - Lumbar Puncture (6/20):
050566 - - Cell differential: 7 WBCs, 1325 RBCs, 65 glucose, 47 protein
050567 - - Glucose: 65
050568 - - Protein: 47
050570 - ..
050571 - ESR: 7
050572 - CRP: 4.5
050573 - ANA: Negative
050574 - RF: Negative
050575 - SSA/SSB: Negative
050576 - ACE: 25
050578 - ..
050579 - Lyme: Negative
050580 - HIV: Negative
050581 - RPR: Negative
050582 -
050584 - ..
050585 - 6. MRI Brain 6/18/2016
050586 -
050587 - 1. Findings compatible with a likely subacute right SCA
050588 - territory infarct.
050589 -
050590 - 2. No hemodynamically significant stenosis.
050592 - ..
050593 - 3. Diffuse right holohemispheric subarachnoid enhancement
050594 - with several areas suspicious for leptomeningeal
050595 - enhancement. Correlate with lumbar puncture.
050596 - Alternative etiologies include a vascular shunting
050597 - lesion such as an occult dural fistula or arteriovenous
050598 - malformation. Correlate with conventional angiography
050599 - if clinically indicated.
050601 - ..
050602 - 7. AUDIOLOGY REFERRAL IMPRESSIONS
050603 -
050604 - Ocular motor tests were within normal limits suggesting
050605 - normal central vestibular function. Dix Hallpike testing
050606 - was positive for left sided BPPV. Sinusoidal harmonic
050607 - acceleration testing was abnormal indicating normal
050608 - peripheral function at higher frequencies.
050610 - ..
050611 - 8. ASSESSMENT & WORKING DIAGNOSES
050612 -
050613 - 71M with a history of CAD s/p CABG 2009 presenting for
050614 - follow-up for subacute R SCA territory infarct as well as
050615 - incidentally noted leptomeningeal enhancement on MRI no
050616 - 6/18/16.
050618 - ..
050619 - 1. Cerebellar Stroke: Cryptogenic etiology
050620 -
050621 - Regarding his cerebellar stroke, the patient's initial
050622 - presentation of visual disturbance and later on
050623 - examination, evidence of L sided neglect, are unrelated
050624 - to his R SCA territory infarct. There does not appear
050625 - to be any deficits secondary to this stroke, which was
050626 - found unexpectedly while evaluating him for his other
050627 - symptoms. Mr Welch today asks if his EGD procedure may
050628 - have provoked the event; however, upon re-review of the
050629 - MRI, the chronicity of the stroke seems best placed at
050630 - several days out (occuring prior to the procedure).
050632 - ..
050633 - Review of the imaging discloses DWI/FLAIR
050634 - hyperintensity, ADC isointensity, and T1 hypointensity.
050635 - The ADC isointensity in particular is suggestive that
050636 - the lesion was at least several days old from the time
050637 - of imaging (which was obtained approximately 24 hours
050638 - out from the patient's procedure). The etiology of the
050639 - patient's stroke remains unclear, but given the absence
050640 - of vertebrobasilar disease, is likely cardioembolic.
050642 - ..
050643 - At this time, there is no evidence of stroke.
050645 - ..
050646 - "...absence of vertebrobasilar disease" seems to be another way of
050647 - saying there is no evidence of atherosclerosis in the brain, which
050648 - confirms understandings from meeting with Doctor Yoo, per above.
050649 - ref SDS 0 NM6N
050650 -
050651 - [On 160820 0940 section on Diagnostic Data reports finding
050652 - MRI shows no evidence of atherosclerosis in the brain area.
050653 - ref SDS 29 PW4G
050655 - ..
050656 - Where is this DWI/FLAIR - what scan image?
050658 - ..
050659 - Who has examined this scan, and signed off concurring it represents
050660 - evidence of stroke.
050661 -
050662 - [On 160722 1710 Doctor Simpson left voice message on
050663 - telephone saying he examined MRi and found evidence
050664 - indicating stroke; and, that he ordered another 2-week Zio
050665 - XT heart monitor study to look for an afib event.
050666 - ref SDS 21 509K
050668 - ..
050669 - What ADC isointensity was measured with what equipment, and were is
050670 - the record of this measurement or analysis stored for review. Has ADC
050671 - isointensity changed since 160618, to compare rates of decay that
050672 - supports dating when the stroke occurred?
050674 - ..
050675 - Progress Notes for meeting on 160715 continue...
050676 -
050677 - Evidence suggests at least 30 days of monitoring to
050678 - capture suspected atrial fibrillation and thus
050679 - recommended to the patient that he have additional
050680 - monitoring with another ziopatch.
050682 - ..
050683 - What evidence suggests "at least 30 days of Zio XT monitoring is
050684 - needed to capture evidence of afib, as proposed by the doctor during
050685 - the meeting today, shown above? ref SDS 0 8Q6I
050687 - ..
050688 - [On 160720 1142 Doctor Simpson Neurology typically
050689 - requests additional heart monitoring when the monitor
050690 - already performed does not support their theory of
050691 - the case, and they don't have time to develop
050692 - alternate etiologies nor take time to look for other
050693 - evidence. ref SDS 19 QW7F
050695 - ..
050696 - [On 160727 0004 letter notifies Neurology that
050697 - patient agrees to undergo another 2 weeks of Zio XT
050698 - testing for afib. ref SDS 24 S162
050700 - ..
050701 - [On 160801 0923 notify Doctor Yoo in Neurology that
050702 - Zio XT device will be installed on 160805 OA 1000.
050703 - ref SDS 26 WF5I
050705 - ..
050706 - Progress Notes for meeting on 160715 continue...
050707 -
050708 - Regarding secondary prevention, I recommend continuing
050709 - aspirin 81mg daily and increasing his atorvastatin to
050710 - 80mg daily for a goal LDL <100 (most recent LDL 153)
050712 - ..
050713 - --Continue ASA 81mg; would recommend increasing
050714 - atorvastatin to 80mg and dosing daily for goal LDL <100
050716 - ..
050717 - What criteria supports "goal LDL < 100? The goal used to be < 70,
050718 - reported on 131121 0930. ref SDS 1 UW4O
050720 - ..
050721 - Background on shifting LDL goals is reported on 140213 0830.
050722 - ref SDS 3 D65J
050724 - ..
050725 - What is recommended for maintaining HDL 73, that obviates controlling
050726 - LDL by regressing atherosclerosis to 0, shown in CCTA (see addendum)
050727 - on 151019 0930, ref SDS 4 SU62, and more recently MRI on 160618 1348?
050728 - ref SDS 8 WK7K
050729 -
050730 - [On 160722 1710 Doctor Simpson voice mail notified he
050731 - ordered Atorvastatin 10 mg, after we discussed medical team
050732 - consideration to raise this to 80 mg per day. ref SDS 22
050733 - 914O
050735 - ..
050736 - Progress Notes for meeting on 160715 continue...
050737 -
050738 - --Would recommend an additional 2 weeks of ziopatch
050739 - monitoring to eval for atrial fibrillation (did NOT
050740 - order, patient wished to discuss with other providers
050741 - first)
050743 - ..
050744 - --Patient cleared from neurology perspective to have
050745 - repeat EGD procedure. Have vanishingly low suspicion
050746 - that his procedure is related to his stroke given that
050747 - the lesion likely occurred prior to the EGD based on
050748 - the imaging characteristics.
050750 - ..
050751 - While there is no support presented here for an assessment that an
050752 - actual infarct (stroke) occurred, per above, ref SDS 0 O48L, neither
050753 - is there any assessment of what caused stroke symptoms reported on
050754 - 160617 1637. ref SDS 6 5F6F
050755 -
050756 - [On 160722 1710 Doctor Simpson left voice message on
050757 - telephone saying he examined MRi and found evidence
050758 - indicating stroke; and, that he ordered another 2-week Zio
050759 - XT heart monitor study to look for an afib event.
050760 - ref SDS 21 509K
050762 - ..
050763 - Progress Notes here clearing patient for repeat EGD procedure, aligns
050764 - with the letter sent by Doctor Yoo to Doctor Lee in GI Clinic at VA
050765 - Medical Center in Sacramento, per above. ref SDS 0 MO6F
050766 -
050767 - [On 160811 1546 Doctor Massa, attending physician in the
050768 - case, letter lists potential ways EGD could have caused
050769 - stroke symptoms, and concludes noting "significant
050770 - possibility" of causal relationship remains to be
050771 - identified. ref SDS 28 HR5J
050773 - ..
050774 - Without an explanation for causation of stroke symptoms following EGD
050775 - dilation on 160617, VA Neurology clearance for a repeat procedure on
050776 - 160909, seems unsupported, and thus high risk for repeating stroke
050777 - symptoms and worse without a record of corrective action.
050779 - ..
050780 - This conflicts with Doctor Abram, Chief of Neurology at VAMCSF, saying
050781 - on 160619, that cause of symptoms must be determined to determine
050782 - safety of repeat EGD dilation. ref SDS 9 SV54
050784 - ..
050785 - Progress Notes for meeting on 160715 continue...
050786 -
050787 - 2. #Leptomeningeal enhancement:
050788 -
050789 - Regarding the patient's leptomeningeal enhancement,
050790 - etiology remains unclear. His studies have revealed no
050791 - evidence of even subtle inflammation in the CSF
050792 - (negative IgG index and OCB). His cytology has
050793 - returned as negative and there is no suggestion of an
050794 - underlying rheumatologic disorder. The remaining
050795 - possibility is a vascular shunting lesion, which is to
050796 - be investigated by conventional angiogram. Per
050797 - discussion with the neurointerventional radiologists,
050798 - suspicion is low. Should these results return normal,
050799 - I will elect to repeat imaging (Brain MRI w/ and w/o
050800 - contrast) to evaluate for any radiographic progression.
050802 - ..
050803 - Neurology work plan to perform conventional angiogram to check for
050804 - "low suspicion" of vascular problems, and then if normal will perform
050805 - another MRI, aligns with discussion during the meeting today, per
050806 - above. ref SDS 0 3L3H
050807 -
050808 - [On 160802 1300 Doctor Vora during meeting for 2nd opinion
050809 - from Stanford Neuroscience recommends immediate MRI to
050810 - compare with 1st MRI to see if white dots shown in 1st MRI
050811 - on 160618, have resolved, in line with resolution of stroke
050812 - symptoms 2 days after onset of symptoms on 160617, or are
050813 - still stable, or increased, toward diagnosing cause of
050814 - patient stroke symptoms, and risks for increased symptoms
050815 - in relation to repeating EGD with conscious sedation
050816 - procedures. ref SDS 27 Y64O
050817 -
050819 - ..
050820 - Progress Notes for meeting on 160715 continue...
050821 -
050822 - 3. Reassuringly, the patient remains clinically
050823 - asymptomatic with no recurrence of his visual
050824 - disturbance.
050826 - ..
050827 - During the meeting today, Doctor Yoo advised that 2 lumbar puncture
050828 - tests he performed showed evidence that inflammation area above the
050829 - brain is not leptomeningeal enhancement, per above. ref SDS 0 8Q88
050830 -
050831 - [On 160717 2227 letter to Doctor Yoo confirms understanding
050832 - that Neurology found the 2 lumbar puncture tests performed
050833 - by Doctor Yoo show no evidence of leptomeningeal
050834 - enhancement. ref SDS 15 GW90
050836 - ..
050837 - Since stroke symptoms completely abated with passage of several days
050838 - after EGD dilation on 160617, and have not recurred, this suggests
050839 - strongly that stroke symptoms were caused by somthing that occurred
050840 - during the procedure on 160617, there having been found no innate
050841 - neuroligical deficit in the patient.
050843 - ..
050844 - Progress Notes for meeting on 160715 continue...
050845 -
050846 - 9. Conventional Angiogram pending
050848 - ..
050849 - 10. Would repeat MRI Brain with and without contrast if
050850 - conventional angiogram negative
050852 - ..
050853 - 11. RTC in 4 months
050854 -
050855 - /es/ ALEXANDER YOO
050856 - Neurology Resident UC# 97147
050857 - Signed: 07/15/2016 18:09
050858 -
050859 - /es/ MIDORI A. YENARI
050860 - Staff physician
050861 - Cosigned: 07/19/2016 14:34
050862 -
050863 -
050864 - 12. 07/19/2016 ADDENDUM
050865 - STATUS: COMPLETED
050866 - Clinical Reminder Activity
050868 - ..
050869 - MED REC NON PRIMARY CARE:
050871 - ..
050872 - Current medications reviewed with patient/caregiver and
050873 - reconciliation of medications related to today's visit
050874 - completed, including non-VA medications and
050875 - discrepancies, if identified, were addressed. Medication
050876 - changes and the importance of medication management were
050877 - reviewed with the patient/caregiver today based on
050878 - individual needs.
050880 - ..
050881 - Patient/caregiver acknowledged understanding of
050882 - instructions as stated. An updated list of reconciled
050883 - medications has been provided to the patient/caregiver.
050884 -
050885 - /es/ MIDORI A. YENARI
050886 - Staff physician
050887 - Signed: 07/19/2016 14:35
050888 -
050889 -
050890 -
050891 -
050892 -
050893 -
050894 -
050895 -
050896 -
050897 -
050898 -
050899 -
050900 -
050901 -