CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 12 0000.
040502 -
040503 -
040504 -
040505 -
040507 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Sent letter to Doctor and Neurology medical team saying...
040902 -
040903 - 1. Subject: Clarify Neurology Stroke Findings Following EGD Dilation Sep 17
040904 - Date: 2016-07-17 23:57
040909 - ..
040910 - 2. Dear Doctor Yoo,
040912 - ..
040913 - 3. Thanks for meeting on Friday afternoon, and reporting new and
040914 - favorable findings from your re-review of imaging on Jul 15th,
040915 - as further set out in your letter to Doctor Lee at the VA
040916 - Medical Center in Sacramento, shown below.
040918 - ..
040919 - 4. The MRA on June 18th the day after EGD Dilation in Sacramento
040920 - reported findings compatible with a likely subacute right SCA
040921 - territory infarct, meaning a stroke. Your letter to Doctor Lee
040922 - advises that none of patient stroke symptoms were referable to
040923 - this area.
040925 - ..
040926 - 5. During our meeting you clarified that the possible stroke, if
040927 - it did occur, caused none of my symptoms of left side weakness
040928 - and partial vision loss, nor any other stroke symptoms of any
040929 - kind, and thus is considered "asymptomatic."
040931 - ..
040932 - 6. MRA on June 18th, also made findings "suspicious for
040933 - leptomeningeal enhancement." At that time on June 18th, you
040934 - explained in the ER, this was a layer of inflammation over a
040935 - large portion on the top of the brain. This past Friday, on
040936 - July 15th, I was relieved and thankful to hear your update that
040937 - results from the 2 lumbar puncture procedures you performed,
040938 - the first on the June 18th, and then again on June 20th, have
040939 - confirmed that the inflammation layer over the brain is not
040940 - leptomeningeal enhancement, and moreover there is no evidence
040941 - of cancer. ref SDS 12 8Q88 Of course both a CT study on June
040942 - 18th and then the MRA done a few hours later both showed no
040943 - evidence of cancer.
040945 - ..
040946 - 7. I was further pleased to hear you confirm that CT and MRA
040947 - testing to date has found no evidence of cerebral
040948 - atherosclerosis, and consequently no evidence of blood clots
040949 - nor other obstruction that might have caused current symptoms,
040950 - nor could cause any future stroke symptoms. This finding
040951 - compliments prior findings of no coronary atherosclerosis in
040952 - CCTA on Oct 18, 2015, ordered by Doctor Simpson. For a patient
040953 - diagnosed with advanced CAD and treated with CABG x4 heart
040954 - surgery on October 22, 2009, to be found free of
040955 - atherosclerosis 7 years later, shows excellent care by the VA.
040956 - This record supports Doctor Abrams advice during the meeting in
040957 - TCU on June 20th, urging continuing the treatment plan for
040958 - extended endurance exercise that raises HDL, since elevated HDL
040959 - improves cognition, along with regressing atherosclerosis to
040960 - prevent heart attack and stroke. It is a very good feeling
040961 - that the most rigorous tests available show this works.
040963 - ..
040964 - 8. As you know, before our meeting at 0430pm I had 2 more tests,
040965 - EEG at 1200, and Echo at 0200pm. During the meeting you called
040966 - to get results, but by then everyone had gone home. Please let
040967 - me know if these additional tests change results from the MRA
040968 - on June 18th?
040970 - ..
040971 - 9. You also advised that the medical team wants 3 more tests...
040972 -
040973 - 1. Zio XT heart monitor for another 2 weeks.
040974 - 2. Conventional cerebral angiogram
040975 - 3. MRA to check if stroke and inflammation above the brain have resolved.
040977 - ..
040978 - 10. You explained the conventional angiogram is not expected to
040979 - find atherosclerosis nor cardioembolic based causation for
040980 - stroke-like symptoms that occurred in this case. That is why
040981 - the test is scheduled as "no rush," which will then occur in 3
040982 - - 4 months. This indicates nobody believes the patient is at
040983 - risk for another stroke.
040985 - ..
040986 - 11. Accordingly, during the meeting I asked, and here ask again to
040987 - have the MRA done immediately to see if the stroke and
040988 - inflammation have resolved, since all symptoms subsided on or
040989 - about the end of June 18th, and certainly on June 19th, when
040990 - Doctor Abrams made his examination.
040992 - ..
040993 - 12. Your letter to Doctor Lee speculates the "likely stroke" is
040994 - "cardioembolic", meaning a blood clot formed in the heart and
040995 - progressed to an atherosclerotic plaque obstruction, as you
040996 - presented previously on the pink 3x5 card in our meeting on
040997 - 160623.
040999 - ..
041000 - 13. Is the additional 2 weeks of Zio XT heart testing expected to
041001 - show afib or other events that support the cardioembolic
041002 - causation theory for the finding of "likely" stroke. You
041003 - seemed to cite some protocol. Hopefully, this is in the
041004 - Progress Notes.
041006 - ..
041007 - 14. During the meeting you used the computer in the Module 2
041008 - examination room to access Doctor Lee's Progress Notes stored
041009 - on the server for the VA Medical Center in Sacramento. Those
041010 - Progress Notes show Doctor Lee ordered peer review of the EGD
041011 - Dilation procedure that preceded stroke symptoms on June 17th.
041012 - This aligns with Doctor Lee's call the day saying he would
041013 - order an independent review to discover what might have
041014 - occurred during the EGD procedure that caused follow on stroke
041015 - symptoms.
041017 - ..
041018 - 15. The protocol for independent review should be entered in the
041019 - record showing the lineaments of actual review meet accepted
041020 - standards for reliance on results.
041022 - ..
041023 - 16. You then disclosed that you made another review of the MRI on
041024 - June 18th, and discovered the stroke occurred before the EGD
041025 - Dilation, and thus there is no need for further review in
041026 - Sacramento, and further that the Neurology Department feels the
041027 - next EGD Dilation procedure can proceed as scheduled on Sep
041028 - 9th.
041030 - ..
041031 - 17. Your letter to Doctor Lee confirms this saying in part...
041032 -
041033 - "I re-reviewed the imaging to try to precisely date the stroke
041034 - since there was some concern that his EGD and stroke might be
041035 - causally related. Based on the imaging characteristics, my
041036 - impression is that the stroke is actually several days or
041037 - perhaps even greater than a week old, which predates the event
041038 - to the procedure. I think mechanistically, even if the timing
041039 - of the stroke lined up with the procedure, it is difficult to
041040 - connect the two causally unless one invokes that a transient
041041 - arrhythmia occurred during the procedure and resulted in an
041042 - embolic event. In any case, he is neurologically cleared for a
041043 - repeat procedure."
041045 - ..
041046 - 18. This is good news. I asked if you have checked the record of
041047 - the EGD dilation and conscious sedation on June 17th, and
041048 - spoken with Doctor Lee or anyone on his team about what was
041049 - done that might produce stroke symptoms? We then recalled that
041050 - Doctor Lee reported the day before on July 14th, that he has
041051 - not yet signed Progress Notes for the procedure on June 17th
041052 - ...[shown on 160714 0814, ref SDS 10 ZC7G...], so nobody can
041053 - read them.
041055 - ..
041056 - 19. During the meeting you explained a calculation of some kind
041057 - that enabled you to precisely determine the stroke did not
041058 - occur the day symptoms occurred. [...reported in Progress Notes
041059 - following the meeting on 160715 1630. ref SDS 12 TV4F...].
041060 - Please advise the date of your Progress Note showing MRI images
041061 - you examined, the figures and calculations, and other work
041062 - product which supports your impression that the stroke did not
041063 - occur on the date of stroke symptoms.
041065 - ..
041066 - 20. Was your impression that the stroke predated stroke symptoms
041067 - discussed with the attending physician, Doctor Massa. Did
041068 - Doctor Massa co-sign the Progress Note on this matter. Did
041069 - Doctor Abrams concur that VAMCSF Neurology has cleared the
041070 - patient for repeat procedure in advance of completing testing,
041071 - and the independent review ordered by Doctor Lee, of the record
041072 - performing the EGD dilation procedure on June 17th?
041074 - ..
041075 - 21. Since Neurology has determined that the "likely" stroke did not
041076 - cause stroke symptoms in this case, then even if likely stroke
041077 - pre-dated stroke symptoms, as you have evidently calculated,
041078 - ref SDS 0 GX32, I would ask the Neurology team to expedite
041079 - continuing review to determine what could have caused clinical
041080 - stroke symptoms, including the layer of inflammation that
041081 - covers a large area of the brain, as a condition to clear the
041082 - patient for repeat procedure. Since it wasn't the stroke, if
041083 - one occurred, what was it? What could have occurred during the
041084 - EGD dilation that can cause stroke-like symptoms? Was it an
041085 - overdose of a medication, under dose, no dose? Did somebody
041086 - step on a line, hook a line to the wrong thing? Did the
041087 - computer go down, the lights go off? Was something
041088 - inadvertently punctured internally, and not noticed? Were air
041089 - bubbles introduced; if so was this missed? Is there something
041090 - in the patients diet and/or combined with long list of
041091 - medications that might have weakened the patient for this
041092 - particular procedure, which did not exist previously?
041094 - ..
041095 - 22. Your letter to Doctor Lee helpfully points the Sacramento
041096 - review team to the possibility that "transient arrhythmia
041097 - occurred during the procedure and resulted in an embolic
041098 - event." What could have caused it.
041100 - ..
041101 - 23. Since strokes occur from time to time following EGD Dilation
041102 - with conscious sedation, has the team checked the record for
041103 - prior similar cases, and made a list of anything else that
041104 - might assist independent review Doctor Lee has ordered, so
041105 - there is confidence that repeating the procedure will not cause
041106 - a repeat of adverse symptoms.
041108 - ..
041109 - 24. If the conditions of this have not previously occurred at the
041110 - VA Medical Center in San Francisco, have outside experts been
041111 - contacted to consult on this matter?
041113 - ..
041114 - 25. I remain grateful for the high quality of care provided by the
041115 - VA in San Francisco and in Sacramento. It was greatly
041116 - reassuring to meet Chief of Neurology, Doctor Abrams, on June
041117 - 19th, and then Doctor Massa, attending, the next day on June
041118 - 20th, as they explained professional, thorough review is
041119 - essential to find out what happened on June 17th when stroke
041120 - symptoms occurred after a medical procedure, since recurrence
041121 - of stroke often causes death. Can we therefore meet again to
041122 - review the work plan for clearing the patient in time for the
041123 - next EGD Dilation scheduled on Sep 9th?
041124 -
041132 -
041133 -
041134 -
041135 -
041136 -
041137 -
041138 -
041139 -
041140 -
041141 -
041142 -
041143 -
041144 -