121524 - ..
121525 - Patient history - case study - on difficulty setting IVs is shown in
121526 - the record on 110429 1230. ref SDS 22 UN6K
121528 - ..
121529 - About 20 minutes later, was led into the CT scanner room.
121531 - ..
121532 - Jean did most of the prep. She and her colleage, a male nurse, were
121533 - terrific assisting patient position on the moveable gurney, connecting
121534 - patient to monitoring devices, and explaining the CT scan process.
121536 - ..
121537 - We reviewed scope of work to perform Coronary CT angiography (CCTA)
121538 - scan with calcium score (CS) to evaluate regression of atherosclerosis
121539 - since CABG +4 heart surgery 6 years ago on 091022 0700. ref SDS 5 PQWU
121541 - ..
121542 - The male nurse advised that calcium score is not typically performed
121543 - for patients with prior CABG surgery. He said a doctor must approve
121544 - doing the test with calcium score for the test today. Advised that
121545 - Doctor Simpson in Cardiology ordered CCTA with calcium score on 151014
121546 - 0900. ref SDS 48 OG3N
121548 - ..
121549 - The nurse said he wants to verify including calcium score with a
121550 - doctor on staff with the Radiology Department. He left the room to
121551 - consult a doctor.
121553 - ..
121554 - About 10 minutes later, a doctor came into the CT scanner room. His
121555 - name is Colin.
121557 - ..
121558 - He explained that experienced physicians here in the Radiology
121559 - Department at the VA Medical Center in San Francisco, and who read
121560 - radiology scan files, have formulated a common opinion, i.e.,
121561 - department paradigm - thus policy, that calcium score is not useful
121562 - for patients with prior CABG (heart bypass) surgery, because bypassed
121563 - blood vessels contain calcium plaque that yields misleading results,
121564 - in that they do not actually impair health by threatening blockage of
121565 - blood flow in the active circulatory system. Colin indicated this
121566 - Radiology Department work practice should be applied for the test
121567 - today, i.e., omitting calcium score for the CT scan, because the
121568 - patient had CABG +4 surgery 6 years ago on 091022. 0700. ref SDS 5
121569 - PQWU
121571 - ..
121572 - Discussed meeting with Doctor Simpson in Cardiology on 151014.
121573 - ref SDS 48 NV5I He ordered the test today at patient request to
121574 - assess, in the form of an "experiement" or "trial," using CCTA with
121575 - calcium score to evaluate response to treatment for regressing
121576 - atherosclerosis in order to reduce debilitating side effects,
121577 - ref SDS 48 OG3N, in the same way CT scans evaluate response to
121578 - treatment for cancer in order to reduce debilitating side effects of
121579 - chemotherapy treatments. If CT scans show cancer has been regressed
121580 - in sufficient measure, then treatment is reduced or even paused so
121581 - patients can recover from side effects.
121583 - ..
121584 - Consideration today in the Radiology Department to change doctor's
121585 - order in cardiology for CCTA with calcium score, aligns with
121586 - experience at Kaiser, where Millie was treated for nearly 10 years
121587 - with stage 4 breast cancer. Written orders in Oncology were resisted
121588 - many times by other departments, and so required significant efforts
121589 - through doctor/patient partnership to provide prescribed care, shown
121590 - in case study on 061012 1451. ref SDS 1 A55J This prior experience at
121591 - Kaiser guided efforts today, offering rational grounds for Radiology
121592 - to carry out referral orders issued by Cardiology.
121594 - ..
121595 - Presented objective to evaluate regression of atherosclerotic plaques
121596 - in response to treatment hiking 10,000 miles since 2011, along with
121597 - taking statin drugs for the past 6 years after CABG +4 surgery on
121598 - 091022 0700. ref SDS 5 PQWU
121600 - ..
121601 - Doctor/patient partnership has carefully vetted over the past 2 years
121602 - CCTA scan with calcium score (see meeting with VA on 140519 0800,
121603 - ref SDS 29 OF7N, for providing quantifiable evidence that daily
121604 - treatment with statin drugs and extended endurance exercise hiking 11
121605 - miles per day (300 miles per month) has regressed atherosclerotic
121606 - plaques sufficiently to reduce requirements for treatment, which in
121607 - turn will reduce debilitating side effects, including feet injuries,
121608 - dizziness, and dehydration that compounds feet injuries, and so that
121609 - treatment with hiking can continue while treatment with drugs can be
121610 - reduced.
121612 - ..
121613 - Colin commented that orientation of analysts reading scans on
121614 - cardiology patients is looking for evidence of coronary artery disease
121615 - (CAD) that requires timely intervention with increased treatment.
121616 - There is no orientation looking for regression of plaque in response
121617 - to treatment, i.e., for the absence of CAD in order to reduce
121618 - treatments.
121620 - ..
121621 - On further discussion, Colin seemed to indicate the analyst who reads
121622 - the CT scan assigns a "score" to vessel areas that appear to have
121623 - calcium lesions, i.e., plaque (calcium) buildup. Evidently, analysts
121624 - vary in their work practices and preferences. Colin finally agreed to
121625 - collaborate with the analyst who reads the scan in this case to
121626 - separate calcium scores that appear associated with bypassed vessels
121627 - in order to assess regression of plaques in currently viable blood
121628 - vessels.
121630 - ..
121631 - As a result, Colin approved performing the test today with calcium
121632 - score.
121633 -
121634 - [On 151021 1208 Doctor Simpson called and advised that the
121635 - report on the CCTA test prepared by an analyst in the
121636 - Radiology Department failed to perform calcium score.
121637 - ref SDS 50 FR6F
121639 - ..
121640 - [...below on 151019 0930, Analyst's report says CCTA test
121641 - was performed in a manner that enables calcium scoring,
121642 - ref SDS 0 KS44; however, findings say calcium scoring was
121643 - not performed, ref SDS 0 8Q6I, because the patient had CABG
121644 - +4 on 091022. ref SDS 5 PQWU
121646 - ..
121647 - [On 151028 1000 failure to perform calcium score conflicts
121648 - with meeting Doctor Simpson in Cardiology advising that
121649 - atherosclerotic plaques can begin to recur within 2 years
121650 - after CABG heart bypass surgery. ref SDS 51 5L98
121652 - ..
121653 - [On 151029 2257 reported CCTA performed on 151019, to
121654 - Doctor Stewart. ref SDS 52 K176
121656 - ..
121657 - Thanked Colin for support.
121659 - ..
121660 - After Colin left, the male nurse explained the test process.
121661 -
121662 - 1. Patient receives nitrogliceryn beneath the tonge.
121663 -
121664 - 2. Electronic gurney moves patient beneath the circular CT
121665 - scanner.
121667 - ..
121668 - 3. Patient instructed to breath out, then breath in, then hold
121669 - breath for several seconds while scanning occurs. Patient
121670 - then instructed to breath normally.
121672 - ..
121673 - This step will be repeated several times.
121675 - ..
121676 - 4. Electronic gurney moves patient back from within circular
121677 - CT scanner.
121679 - ..
121680 - 5. Contrast medium injected through the catheter IV set
121681 - earlier, per above. ref SDS 0 J36M Patient will feel
121682 - warmth sensation, as contrast quickly circulates.
121684 - ..
121685 - 6. Steps 2 - 4 are repeated.
121687 - ..
121688 - 7. Patient returns to Preparation room for monitoring of
121689 - blood pressure to rise, since the medication lowers blood
121690 - pressure.
121692 - ..
121693 - The team waited a few minutes for heart rate to settle back below 60.
121694 - Jean said it jumped up into the 70s during discussion with the doctor
121695 - on changing the referral order for CCTA with calcium score, per above.
121696 - ref SDS 0 RF9U
121698 - ..
121699 - When it was varying between 54 - 56, the test process was started, per
121700 - above. ref SDS 0 ZL5G
121702 - ..
121703 - Might have taken 10 - 15 minutes with various pauses.
121705 - ..
121706 - After the test, Jean disconnected the monitoring equipment. She
121707 - suggested waiting for a minute to get up.
121709 - ..
121710 - On sitting up and standing, there was some initial dizziness.
121712 - ..
121713 - Jean suggested laying back down; but, dizziness passed in a few
121714 - seconds.
121715 -
121716 -
121718 - ..
1218 -
1219 -
1220 - 1113
1221 -
122101 - After CT test was completed, went back to the Radiology Preperation
122102 - room, and layed on a gurney for about 15 minutes. The nurses took
122103 - blood pressure at the end of this period in order to verify patient
122104 - has recovered from blood pressure lowered by combination of
122105 - nitrogliceryn and contrast medium.
122106 -
122107 - [On 170314 0817 Doctor Shunk proposed inquiry for including
122108 - the patient in coronary MRI study undersay at VMCSF; Karen
122109 - will follow up. ref SDS 71 A24I
122110 -
122111 -
122113 - ..
1222 -
1223 -
1224 - 1133
1225 -
122501 - On leaving Radiology Preperation Room, went to Radiology Check-in and
122502 - ordered CD with file of radiology CT scan, and analysts' narrative
122503 - report. Can pick it up on Friday, 151023, when at the VA for meeting
122504 - with Lana in Wound Care.
122505 -
122507 - ..
1226 -
1227 -
1228 - 1220
1229 -
122901 - While driving home on John F Kennedy Drive in Golden Gate Park,
122902 - remembered need for scheduling follow up meeting with Doctor Simpson
122903 - to review results of CT scan today, planned during initial meeting
122904 - with the doctor on 151014 0900. ref SDS 48 FB6L So, we turned around
122905 - and drove back to the VA.
122907 - ..
122908 - Scheduled meeting with Doctor Simpson next week on 151028 1000.
122909 -
122910 - [On 151021 1208 Doctor Simpson called and advised that the
122911 - report on the CCTA test prepared by an analyst in the
122912 - Radiology Department failed to perform calcium score.
122913 - ref SDS 50 FR6F
122915 - ..
122916 - [On 170314 0817 Doctor Shunk proposed inquiry for including
122917 - the patient in coronary MRI study undersay at VMCSF; Karen
122918 - will follow up. ref SDS 71 A24I
122919 -
122920 -
122921 -
122922 -
1230 -
SUBJECTS
Default Null Subject Account for Blank Record
1303 -
130401 - ..
130402 - Medical Chart Radiology Report Imaging Files CCTA Scan on 151019
130403 - CCTA Scan on 151019 Medical Chart Radiology Report Imaging Files
130404 -
130405 - VA Radiology reports assessible...
130406 -
130407 - https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome
130409 - ..
130410 - Customer....
130415 - ..
130416 - Stored Radiology Imaging Fiies...
130422 -
130423 - F:\05\00003\SM\CC\GMPF\GFJ\20151019-093000\GEARView.exe
130425 - ..
130426 - Radiology issued written report analysing findings and impressions
130427 - stored in...
130428 -
130429 - F:\05\00003\SM\CC\GMPF\GFJ\20151019-093000\20151019-102000.txt
130430 -
130431 - VAMC Department of Radiology
130432 - 4150 Clement Street San Francisco CA 94121
130433 - 415 750 2039
130434 - 415 221 4610 22640
130435 -
130436 - http://www.sanfrancisco.va.gov/services/radiology_contact.asp
130438 - ..
130439 - [...below on 151019 0930 an undated addendum was added to
130440 - this report that clarifies findings and impressions.
130441 - ref SDS 0 SU4L
130443 - ..
130444 - 1. Patient
130445 -
130451 - ..
130452 - 2. REQ PHY..................... Simpson, Paul C
130453 - REQ Area.................... Cardiology
130454 - Attending MD................ Unknown
130455 - Primary MD.................. Rao, Madhu
130457 - ..
130458 - 3. Read........................ Oct 21 2015
130459 - Typed....................... Oct 19 2015
130460 - Case No..................... 151+
130461 - Examination Date............ Oct 19 2015 1020
130462 -
130463 - 4. (Case 151 Complete)
130464 -
130465 - CTA Cardiac for structure/morphol (CT detailed) CPT: 75572
130467 - ..
130468 - Reason for study
130470 - ..
130471 - Patient s/p CABG wants to assess status re continuing statin
130472 -
130473 - 5. (Case 152 Complete)
130474 -
130475 - CT Cardiac without contrast for calci (CT detailed) CPT: 75571
130477 - ..
130478 - 6. Procedure................... CTA Cardiac for structure/MO+
130480 - ..
130481 - 7. Clinical History
130482 -
130483 - Report:
130485 - ..
130486 - Status verified
130488 - ..
130489 - Coronary CTA
130491 - ..
130492 - Technique:
130493 -
130494 - 1. Approximately 30 minutes prior to the examination, the patient
130495 - received 50 mg of oral Metroprolol.
130496 -
130497 - 2. Immediately prior to the scan, the patient received 0 doses of
130498 - 5 mg of IV Metroprolol for further heart rate control.
130500 - ..
130501 - 3. The patient also received 0.4 mg of SL nitroglyocerin.
130503 - ..
130504 - 4. The patient's heart rate was monitored and recorded to be in
130505 - the range of 58 beats per minute at the time of this study.
130507 - ..
130508 - 5. Prior to the administration of intravenous contrast, 2.5 mm
130509 - prospectively ECG (??) gated axial images were obtained
130510 - through the heart for coronary calcium scoring.
130512 - ..
130513 - 6. After the administration of intravenous Visipague followed by
130514 - a saline flush, 0.625 mm axial images were obtained through
130515 - the heart using prospective ECG (??) gating.
130517 - ..
130518 - 7. Post processing included multiple reconstructions throughout
130519 - the cardian cycle and 3d reformats.
130520 -
130521 - [On 151119 2141 CCTA ACCURACY study with Quantitative
130522 - Coronary Analysis (QCA) 3D image analysis workstation
130523 - (GE Advantage Workstation 4.3,GE Healthcare,
130524 - Milwaukee, WI). CCTA readers were permitted to
130525 - utilize any or all available post-processing image
130526 - reconstruction algorithms, including two-dimensional
130527 - (2D) axial,or three-dimensional (3D) maximal
130528 - intensity projection (MIP), multiplanar reformat
130529 - (MPR), cross-sectional analysis, or volume rendered
130530 - technique (VRT). ref SDS 53 R24J
130531 -
130533 - ..
130534 - Radiation Dose:
130535 -
130536 - 1. The volume CT Dose index (CTDI vol, measured in mGy) and
130537 - Dose Length Product (DLP, measured in mGy-cm) for each
130538 - individual CT scan pass were:
130539 -
130540 - 9.3
130541 - 21
130542 - 10.9
130544 - ..
130545 - Total...... 407 mGy-cm
130547 - ..
130548 - 2. These indicators are not patient dose, but values
130549 - generated from the CT scanner acquisition factors and may
130550 - substantially underestimate or overestimate the absorbed
130551 - dose based on patient size and other factors. A medical
130552 - physicist or other qualified health professional should be
130553 - consulted for specific questions regarding the radiation
130554 - dose for this exam. For additional information on
130555 - radiation dose, safety and protection please refer to...
130556 -
130557 - http://www.radiology.ucsf.edu/patients/radiation
130558 -
130560 - ..
130561 - 8. Comparison................... none
130562 -
130564 - ..
130565 - 9. Findings
130566 -
130567 - A contrast-enhanced CT angiogram was obtained after a
130568 - noncontrast study.
130569 -
130570 - 1. Cardiac:
130571 -
130572 - 1. Severe native coronary vessel calcification as expected
130573 - in a post CABG patient. Numerical calcium score was
130574 - not calculated in this post-bypass patient.
130576 - ..
130577 - Will calcification continue to expand in bypassed arteries, despite
130578 - elevated HDL? Seems conflicting with research showing atherosclerosis
130579 - plaques regress rapidly with elevated HDL, reviewed on 131125 0005.
130580 - ref SDS 24 RA7K
130581 -
130582 - [...below on 151019 0930 addendum filed on 160113 states
130583 - "Coronary calcium score is calculated to be 1360."
130584 - ref SDS 0 SU5O
130586 - ..
130587 - [On 151028 1000 failure to perform calcium score conflicts
130588 - with meeting Doctor Simpson in Cardiology advising that
130589 - atherosclerotic plaques can begin to recur within 2 years
130590 - after CABG heart bypass surgery. ref SDS 51 5L98
130592 - ..
130593 - [On 151203 1014 meeting with Doctor Elicker in Radiology
130594 - Department yielded calcium score of about 1200, but this
130595 - presents no health risk, because all plaque lesions are
130596 - located in bypassed native blood vessels that are not part
130597 - of active circulatory system. ref SDS 58 GP6M
130599 - ..
130600 - [On 160104 0855 meeting with Doctor Jha, attending
130601 - radiology physician for CCTA on 151019, advised that
130602 - Radiology says calcium was not calculated, even though it
130603 - actually was calculated above 1200 in bypassed grafts,
130604 - because calcium in bypassed grafts pose no health risk to
130605 - the patient, and no calcium was found in active blood
130606 - vessels. ref SDS 62 FF5K
130608 - ..
130609 - How much has calcification increased, and will this cause bypassed
130610 - arteries to eventually burst, causing internal bleeding that requires
130611 - repair?
130613 - ..
130614 - Reseach indicates CABG patients require repair surgery within 5 - 10
130615 - years. Do findings of "increased calcification of native coronary
130616 - arteries" provide basis to estimate rate of failure in this case that
130617 - will require repair in another year, 2 years, 5 years, 10 years?
130619 - ..
130620 - Radiology Report on CCTA 151019, continues...
130621 -
130622 - 2. The left internal mammary artery is anastomosed to the
130623 - distal LAD.
130625 - ..
130626 - 3. There are 2 bypass grafts arising from the anterior aorta,
130627 - traveling antterior in the pericardial space and are
130628 - anastomosed to the left circumflex branches.
130630 - ..
130631 - 4. Additional bypass graft is anastomosed to the right lateral
130632 - aortic wall and to the distal RCA.
130634 - ..
130635 - 5. All the bypass grafts are patent.
130637 - ..
130638 - Research indicates grafts are patent with 70% stenosis, and can fail
130639 - requiring replacement within 8-15 years, reported on 091022 0700.
130640 - ref SDS 5 F58J and ref SDS 5 RY6H
130642 - ..
130643 - Thus, finding bypass grafts are merely "patent" could represent 70%
130644 - stenosis. Purpose of this CCTA study is to determine if bypass grafts
130645 - have 0 plaque, 10%, 80%, whatever. What has occurred in the past 6
130646 - years to these bypass grafts? How much more work is required to
130647 - achieve regression, or can the patient reduce line of care from 15
130648 - miles per day down to say, 6 miles per day, saving time and side
130649 - effects (i.e., injuries)?
130650 -
130651 - [...below on 151019 0930 an undated addendum was added to
130652 - this report that clarifies findings and impressions.
130653 - ref SDS 0 SU4L
130655 - ..
130656 - [On 151203 1014 meeting with Doctor Elicker in Radiology
130657 - Department seemed to clarify that he read the CCTA scan
130658 - file performed on 151019, and found no evidence of
130659 - blockages of any amount anywhere in the active circulatory
130660 - system which was covered by the scan. ref SDS 58 SZ5F
130662 - ..
130663 - [On 160104 0855 Doctor Jha, attending physician for this
130664 - CCTA imaging study, advised that standard of practice for
130665 - radiology reporting is to present any and all blockages of
130666 - any kind observable in CCTA scan imaging; so, in this case,
130667 - since none are reported, the CCTA test on 151019,
130668 - ref SDS 0 JW8O, can correctely be interpretted to mean
130669 - there are no blockages, plaques, stenosis of any kind
130670 - evident from the scan file record. ref SDS 61 AA64
130672 - ..
130673 - [On 160107 2042 letter to Doctor Jha submits proposed
130674 - language for addendum to clarify findings on CCTA study,
130675 - ref SDS 63 8P70, originally performed on 151019.
130676 - ref SDS 49 JW8O
130678 - ..
130679 - [On 160108 2106 letter from Doctor Jha proposes omitting in
130680 - 1st para "...and present no risk to patient health," and in
130681 - 2nd para "...indicating substantial recovery..."
130682 - ref SDS 64 QQ6L
130684 - ..
130685 - [On 160108 2106 at 0820 letter to Doctor Jha approved
130686 - proposed omissions, ref SDS 64 TE4U, with explanation why
130687 - omitted language is helpful. ref SDS 64 TE51
130689 - ..
130690 - [On 160113 2234 received letter from Doctor Jha saying the
130691 - radiology faculty approved issuing an addendum. ref SDS 65
130692 - A85F
130694 - ..
130695 - What interpretation protocols were applied for this CCTA study that
130696 - indicate reliability?
130697 -
130698 - 1. How many readers - 1, 2, 3?
130699 -
130700 - 2. Were readers blinded to patient characteristics?
130702 - ..
130703 - 3. Were CCTA images evaluated on a 3D image analysis workstation
130704 - (GE Advantage Workstation 4.3,GE Healthcare, Milwaukee, WI, or
130705 - better)?
130707 - ..
130708 - 4. Were CCTA readers permitted to use post-processing image
130709 - reconstruction algorithms, including two-dimensional (2D)
130710 - axial,or three-dimensional (3D) maximal intensity projection
130711 - (MIP), multiplanar reformat (MPR), cross-sectional analysis, or
130712 - volume rendered technique (VRT)?
130714 - ..
130715 - [On 151119 2141 CCTA interpretation prtocols for
130716 - ACCRURCY study of CCTA with Quantitative Coronary
130717 - Analysis (QCA) used 3 readers working separately and
130718 - using 3D image analysis workstation (GE Advantage
130719 - Workstation 4.3,GE Healthcare, Milwaukee, WI). CCTA
130720 - readers were permitted to utilize any or all
130721 - available post-processing image reconstruction
130722 - algorithms, including two-dimensional (2D) axial,or
130723 - three-dimensional (3D) maximal intensity projection
130724 - (MIP), multiplanar reformat (MPR), cross-sectional
130725 - analysis, or volume rendered technique (VRT).
130726 - ref SDS 53 R24J
130728 - ..
130729 - [On 151203 1014 meeting with Doctor Elicker in
130730 - Radiology Department seemed to clarify that he read
130731 - the CCTA scan file performed on 151019, and found no
130732 - evidence of blockages of any amount anywhere in the
130733 - active circulatory system which was covered by the
130734 - scan. ref SDS 58 SZ5F
130736 - ..
130737 - [On 151217 2052 letter to Doctor Elicker requests
130738 - amend report on CCTA scan performed on 151019, to
130739 - say reading found no lesions nor blockages of any
130740 - amount anywhere within active circulatory system.
130741 - ref SDS 60 Y556
130743 - ..
130744 - [On 151215 1330 Doctor Stewart recommending notifying
130745 - Doctor Simpson of rising side effects; he may be able
130746 - to prescribe statin with less severe side effects.
130747 - ref SDS 59 IG6H
130748 -
130749 -
130790 - ..
130791 - Radiology Report on CCTA 151019, continues...
130792 -
130793 - 6. Mild right ventricular enlargement.
130794 -
130796 - ..
130797 - 2. Lungs:
130798 -
130799 - The study is not timed for PE but no large central PE is noted.
130800 - No focal consolidation, pleural effusion or pneumothorax in the
130801 - visiualized lung fields.
130803 - ..
130804 - 3. Mediastinum:
130805 -
130806 - Again seen in the distended esophagus with an air-fluid level
130807 - in keeping with patient's known history of achalasia.
130808 - Scattered subcentimeter mediastinal lymph notes.
130810 - ..
130811 - CCTA findings of "distended esophagus" in October, 6 months after
130812 - prior EGD dilation on 150421, aligns with patient history requiring 6
130813 - month intervals, compared with findings of CT barrium swallow test on
130814 - 150527, reporting improvement of esophagus. 150527 0930, ref SDS 38
130815 - TV5O
130816 -
130817 - [On 151201 2111 letter submits agenda to Doctor Lee for
130818 - meeting on 151204 to perform next EGD dilation, and
130819 - reports recent CCTA with partial/incidental findings that
130820 - esophagus has returned to distorted condition, aligns
130821 - with severe swallowing difficulties shown by severe
130822 - vomitting 8 months after prior EGD dilation and
130823 - recommending work plan to maintain 6 month intervals for
130824 - future procedures. ref SDS 55 QG81
130826 - ..
130827 - Radiology Report on CCTA 151019, continues...
130828 -
130829 - 5. Impression:
130830 -
130831 - 1. Postsurgical changes of multivessel CABG with patent
130832 - bypass grafts.
130834 - ..
130835 - Research indicates grafts are patent with 70% stenosis, and can fail,
130836 - requiring replacement within 8-15 years, reported on 091022 0700.
130837 - ref SDS 5 F58J and ref SDS 5 RY6H
130839 - ..
130840 - Radiology Report on CCTA 151019, continues...
130841 -
130842 - 2. Increased calcification of the native coronary arteries
130843 - when compared to prior CT dated 11/2/2009 as expected in a
130844 - post bypass patient.
130846 - ..
130847 - "Native coronary artiers" refers to bypassed arteries that have no
130848 - impact on patient health.
130850 - ..
130851 - Will calcification continue to expand in bypassed arteries, despite
130852 - elevated HDL? Seems conflicting with research showing atherosclerosis
130853 - plaques regress rapidly with elevated HDL, reviewed on 131125 0005.
130854 - ref SDS 24 RA7K
130855 -
130856 - [...below on 151019 0930 an undated addendum was added to
130857 - this report that clarifies findings and impressions.
130858 - ref SDS 0 SU4L
130860 - ..
130861 - [On 160107 2042 letter to Doctor Jha submits proposed
130862 - language for addendum to clarify findings on CCTA study,
130863 - ref SDS 63 8P70, originally performed on 151019.
130864 - ref SDS 49 JW8O
130866 - ..
130867 - [On 160113 2234 received letter from Doctor Jha saying the
130868 - radiology faculty approved issuing an addendum. ref SDS 65
130869 - A85F
130871 - ..
130872 - How much has calcification increased, and will this cause bypassed
130873 - arteries to eventually burst, causing internal bleeding that requires
130874 - repair?
130876 - ..
130877 - How was comparison performed between CT on 091102, and on 151019?
130878 - There is no mention of artery calcification findings on native
130879 - coronary arteries in the report for the CT test on 091102 0642,
130880 - ref SDS 8 FR6G
130882 - ..
130883 - Reseach indicates CABG patients require repair surgery within 5 - 10
130884 - years. Do findings of "increased calcification of native coronary
130885 - arteries" provide basis to estimate rate of failure in this case that
130886 - will require repair in another year, 2 years, 5 years, 10 years?
130888 - ..
130889 - CT test on 091102, was ordered to evaluate WBC 16 going up to WBC 18,
130890 - rather than go down, required for discharge. 091102 0642, ref SDS 8
130891 - RD8G
130893 - ..
130894 - Had to drink water to prepare for CT test. ref SDS 8 4R5W
130896 - ..
130897 - CT test performed on 091102 0642 at 1113. ref SDS 8 4R8H
130899 - ..
130900 - Cardiothoracic (CT) team diagnosed Aspiration pneumonia diagnosed from
130901 - the CT test that found pleural effusion in the left lung. The team
130902 - initially reported a lump in lower lobe of left lung. ref SDS 8 PB6Y
130904 - ..
130905 - On 091103 0347 at 1538 Penn and his team from Infectious Disease
130906 - Department notifies review of CT test does not support diagnosis of
130907 - aspiration pneumonia, nor of any disease that requires treatment with
130908 - antiobotics. ref SDS 9 LE7J
130910 - ..
130911 - How was plaque burden determined from CT test on 091102, that was not
130912 - ordered for identifying plaque?
130914 - ..
130915 - Radiology Report on CCTA 151019, continues...
130916 -
130917 - The images were personally reviewed by Priyanka Jha who agrees
130918 - with the above interpretation.
130920 - ..
130921 - Primary Interpreting Staff:
130923 - ..
130924 - Priyanka Jha, MD, Fellow-Radiology (Verifier)
130925 - Colin T Burke, Resident Physician
130927 - ..
130928 - Addendum: Addendum to findings and impression: Addendum performed
130929 - upon patient's request.
130931 - ..
130932 - Addendum should be dated for context.
130933 -
130934 - [On 160113 2234 received letter from Priyanka saying she
130935 - filed addendum to report on CCTA test performed on 151019.
130936 - ref SDS 65 A85F
130938 - ..
130939 - Radiology Report on CCTA 151019, continues...
130940 -
130941 - Coronary calcium score is calculated to be 1360.
130943 - ..
130944 - The original report stated no calcium score was calculated, per above.
130945 - ref SDS 0 8Q6I
130947 - ..
130948 - Stating merely that coronary calcium score is calculated to be 1360,
130949 - seems conflicting with understandings during meeting Doctor Elicker
130950 - stating calcium score 1360 occurred only in bypassed arteries and
130951 - therefore presented no health risk to patient, reported on 151203
130952 - 1014. ref SDS 58 4S6M
130954 - ..
130955 - Understandings meeting with Doctor Elicker on 151203, seemed confirmed
130956 - a month later during meeting with Doctor Jha, indicating the scan
130957 - performed on 151019, found substantial plaque buildup only in the
130958 - bypassed blood vessels, and no plaque anywhere else in the patient's
130959 - system visible on the CCTA scan, and further yielding calcium score
130960 - 1200+, and she explained that this does not present a health risk to
130961 - the patient. ref SDS 61 FF5K
130963 - ..
130964 - Addendum failure to disclose calcium score 1360 pertains solely to
130965 - bypassed blood vessels, and so presents no health risk to the patient
130966 - both seem material facts.
130968 - ..
130969 - On the other hand, the next part of the addendum may in fact limit
130970 - calculated calcium score to bypassed blood vessels.
130972 - ..
130973 - Even though calcium score was not calculated in the CT test on
130974 - 091102, it must have been significant to require 4 bypass grafts. Is
130975 - there a rough estimate of the original calcium score on 091022, when
130976 - CABG x4 was performed, such that growth in calcium can be calculated?
130978 - ..
130979 - Rate of growth over past 6 years in calcium score from 091022, to
130980 - 151019, could indicate risk avoided by maintaining HDL > 60.
130982 - ..
130983 - Favorable representations by Doctor Elecker and Doctor Jha that
130984 - calcium score 1360 presents no health risk to patient because all of
130985 - the calcium occurs in bypassed blood vessels, per above, ref SDS 0
130986 - Q16M, is supported by the original report that numerical calcium score
130987 - was not calculated, per above, ref SDS 0 8Q6I, since if the calcium
130988 - score disclosed a health risk to the patient, doctors would have a
130989 - legal duty to disclose it.
130991 - ..
130992 - There remains an issue of calcium score 1360 continuing to increase
130993 - over the months and years ahead. Will this present a health risk of
130994 - CABG failure, based on research that failure occurs in 7 - 15 years,
130995 - reported on 091022 0700. ref SDS 5 156H This issues seems resolved
130996 - by the next finding in the addendum...
130998 - ..
130999 - Radiology Addendum to Report on CCTA 151019, continues...
131000 -
131001 - No significant calcified plaque is seen in the bypass grafts. All
131002 - the bypass grafts are opacified with contrast without evidence
131003 - for filling defect or wall calcifications.
131005 - ..
131006 - The finding "...without evidence for filling defect or wall
131007 - calcifications" may be another way of saying the CCTA shows no
131008 - evidence of stenosis nor plaques of any kind or amount.
131010 - ..
131011 - Radiology Addendum to Report on CCTA 151019, continues...
131012 -
131013 - No calcification is seen in the aortic wall in the visualized
131014 - portions of the thoracic aorta. No ostial calcifications at the
131015 - origins of great vessels from the aortic arch.
131017 - ..
131018 - This may represent that no stenosis nor blockage of any kind or
131019 - amount was visualized in the active circulatory system observable in
131020 - the scan file.
131022 - ..
131023 - These findings in the addendum showing favorable response to treatment
131024 - hiking 12K miles the past 4 years, meet objectives ordering CCTA
131025 - ordered by Doctor Simpson in Cardiology on 151014 0900. ref SDS 48
131026 - TA4V
131028 - ..
131029 - [On 160405 1305 Evacetrapib raised HDL 130% failed
131030 - clinical trial Eli Lilly cholesterol drug CEPT inhibitor
131031 - did not reduce CV events; raised blood pressure
131032 - (hypertension), ref SDS 66 AF51 Doctors discouraged
131033 - Merck anacetrapib and Amgen TA-8995 which raise HDL
131034 - similarly, expect fail to improve clinical outcomes.
131035 - ref SDS 66 OH42
131037 - ..
131038 - [On 160618 cerebral MRI evaluating stroke symptoms reports
131039 - finding no evidence of atherosclerosis in the brain.
131040 - ref SDS 67 J738
131042 - ..
131043 - [On 160715 1630 Doctor Yoo Neurology Progress Notes say in
131044 - part "given absence of vertebrobasilar disease..." which is
131045 - another way of saying there is no evidence of plaque in
131046 - blood vessels of the brain. ref SDS 69 TV4F
131048 - ..
131049 - [On 160820 0940 section on Diagnostic Data reports finding
131050 - MRI shows no evidence of atherosclerosis in the brain area.
131051 - ref SDS 70 PW4G
131053 - ..
131054 - [On 170314 0817 Doctor Shunk proposed inquiry for including
131055 - the patient in coronary MRI study underway at VAMCSF; Karen
131056 - will follow up. ref SDS 71 A24I
131058 - ..
131059 - [On 170428 1205 notified Doctors Jha and Elicker that on
131060 - 170414, Doctor Simpson discussed CCTA performed on 151019,
131061 - with "Radiology" and wrote addendum to Progress Notes
131062 - saying unnamed people said "...the technique cannot rule
131063 - out atherosclerosis, but can detect significant stenoses of
131064 - = or > 50% vessel diameter". ref SDS 72 8H5G Research
131065 - found CT "technique" is limited, as noted in Doctor
131066 - Simpson's addendum, ref SDS 72 Z89 This has no evident
131067 - clinical relevance to Doctor Jha's addendum reporting CCTA
131068 - on 151019 found no significant plaque, since that finding
131069 - was not based on CCTA automatic calculating technique,
131070 - which is limited, but on direct examination of CT scans,
131071 - reported by Doctor Elicker on 151203 1014, ref SDS 58 SZ5F,
131072 - and by Doctor Jha on 160104 0855. ref SDS 62 SU3M
131074 - ..
131075 - [On 180927 1000 ultrasound stomach found blood vessels
131076 - patent. ref SDS 73 PI97
131078 - ..
131079 - [On 181108 0930 another CCTA, ref SDS 74 U66M, finding no
131080 - evidence increasing calcifications in active blood vessel
131081 - system. ref SDS 74 GH4U
131083 - ..
131084 - [On 200124 0705 cardiac catheterization IVUS angiogram
131085 - found no evidence blocked coronary artery bypass grafts;
131086 - found 1 branch vessel with 80-90% blockage having no
131087 - medical significance; doctor described best condition every
131088 - seen 10 years after CABG; told patient to keep doing
131089 - whatever he is doing. ref SDS 76 ME8G
131090 -
131092 - ..
131093 - Primary Diagnostic Code:
131094 -
131095 -
131096 -
131097 -
131098 -
131099 -
131100 -
131101 -
131102 -
131103 -
131104 -
131105 -
131106 -
131107 -
131108 -
131109 -
1312 -