CONTACTS
SUBJECTS
Stroke Symptoms After EGD Dilation Pocedure VAMC Sacramento Left Si
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 32 0000. ref SDS 30 0000.
040502 -
040503 - Received today an excellent initial report from Doctor Vora and Doctor
040504 - Kim reporting preliminary impressions from meeting on 160802.
040505 - ref SDS 0 R66J Stanford Neuroscience seems to report finding no
040506 - evidence of atherosclerosis nor other condition that could have
040507 - innately caused stroke symptoms, absent an external event. ref SDS 0
040508 - V46K Questions and possible action items to complete work on
040509 - determining what likely caused stroke symptoms following EGD on
040510 - 160617, including consideration of issues to assess prior to next EGD,
040511 - presented in Doctor Massa's Progress Notes on telecon with Doctor Lee
040512 - on 160811. ref SDS 0 3G5M
040513 -
040515 - ..
040516 - [On 160822 1321 Doctor Kim called OA 1320; was in a
040517 - meeting, he will call back in 2 hours to discuss Stanford
040518 - Neuroscience letter dated 160802. ref SDS 34 R66J
040520 - ..
040521 - [On 160822 1321 at 1545 letter to Doctor Massa notified
040522 - medical team at VAMCSF that Doctor Kim called to discuss
040523 - 2nd opinion on what caused stroke symptoms following EGD on
040524 - 160617, ref SDS 34 VA58; proposed conference call to
040525 - collaborate on resolving difficult assessment. ref SDS 34
040526 - VA80
040528 - ..
040529 - [On 160822 1321 at 1642 Doctor Kim called and seemed to
040530 - advised that Stanford Neuroscience has not reviewed
040531 - additional assessment Doctor Massa reported on 160811, for
040532 - 2n opinion determination of what caused stroke symptoms
040533 - after EGD procedure on 160617. ref SDS 34 VK4J
040535 - ..
040536 - [On 160822 1321 at 1642 Doctor Kim called again - he has
040537 - not seen letter notifying of action items on Stanford
040538 - Neuroscience letter issued on 160802, and received on
040539 - 160820, because it was sent to Doctor Vora, because she is
040540 - only adressee available to the patient listed in Stanford's
040541 - electronic communication system, and there was no evident
040542 - procedure for sending a separate copy to Doctor Kim. He
040543 - will ask Doctor Vora in next 10 minutes for a copy, so he
040544 - can access the record reviewing his letter on 160802,
040545 - received on 160820, and call back to discuss pending action
040546 - items for determining what caused stroke symptoms on
040547 - 160617, to complete 2nd opinion work in this case.
040548 - ref SDS 34 U65K
040549 -
040550 -
040551 -
040552 -
040553 -
040555 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Received in the mailbox a printed letter dated 8/2/2016 (160802), from
040902 - Doctor Kim, countersigned by Doctor Vora, representing Stanford
040903 - Neuroscience. Postmark is difficult to read, could say August 2, 3 or
040904 - 8. Unclear why document issued August 2, would not be received until
040905 - today, August 20.
040906 -
040907 - 1. Stanford Health Care
040908 - Neuroscience
040909 - 213 Quarry Road
040910 - Palo alto, CA 94304
040911 - USA
040912 - 650 725 5792 Ext 1
040914 - ..
040915 - 2. August 2, 2016 05 00003 60 16080201
040917 - ..
040918 - 3. Mr Stephen M Massa, MD PhD
040919 - Attending Physician
040920 - Stephen.Massa@ucsf.edu
040921 - Neurology Department
040922 - VA Medical Center
040923 - San Francisco, CA
040924 - CC: Dr Randall Lee
040926 - ..
040927 - Copy to "Dr Randall Lee" references Doctor Lee's referral for 2nd
040928 - Opinion work by Stanford Neuroscience shown in a document listing
040929 - Doctor "Randall M Lee" making referral from the VA in this case,
040930 - presented by Doctor Sun Kim during the meeting at Stanford
040931 - Neuroscience on 160802 1300. ref SDS 19 NM4L
040933 - ..
040934 - On 160816 0800 Doctor Lee with GI Clinic at VAMC Sacramento reported
040935 - that he did not authorize referral for 2nd opinion on stroke symptoms
040936 - after EGD on 160617, from Stanford Neuroscience and did not know there
040937 - was a consultation. ref SDS 29 7Z5N
040938 -
040939 - [On 160921 0917 letter to Jesse notifies Stanford
040940 - Neuroscience that Doctor Lee in GI Clinic at VAMC
040941 - Sacramento advised that he did not make referral and did
040942 - not know a referral was made, and so requests that Stanford
040943 - Neuroscience submit documentation showing Doctor Lee made
040944 - referral from the VA for Stanford Neuroscience to perform
040945 - 2nd opinion work on stroke case. ref SDS 35 386R
040946 -
040948 - ..
040949 - 4. Subject: Stroke Diagnosis 2nd Opinion
040951 - ..
040952 - Letter from Stanford Neuroscience on 160802 continues...
040953 -
040954 - 5. Dear Doctors,
040955 -
040956 - Thank you for requesting neurovascular consultation for Mr
040957 - Rodney Charles Welch at the Stanford Stroke Center. He is a 71
040958 - Year old right-handed male seen for transient neurological
040959 - episode. He alone provides history, further supplemented by
040960 - review of his medical records. ref DRT 1 0001
040962 - ..
040963 - This letter refers to the meeting at Stanford Neuroscience in Palo
040964 - Alto on 160802 1300. ref SDS 19 3P9N
040966 - ..
040967 - Reference to "Dear Doctors" plural, though single addressee, Doctor
040968 - Massa, is reconciled by cc sent to Doctor Randall Lee, shown in the
040969 - address block, per above. ref SDS 0 H044
040971 - ..
040972 - Patient submitted access to medical records on 160808 1000.
040973 - ref SDS 26 LU4J Maria with Stanford Neuroscience sent a letter
040974 - reporting access to patient medical records was accomplished, reported
040975 - on 160818 0800. ref SDS 33 AV9I
040977 - ..
040978 - The initial sentence thanking Doctor Massa for requesting
040979 - neurovascular consultation provides documentation that the VA
040980 - requested the work. ref SDS 0 JY5L
040981 -
040982 - [On 160822 1321 Doctor Kim called OA 1320; was in a
040983 - meeting, he will call back in 2 hours to discuss Stanford
040984 - Neuroscience letter dated 160802. ref SDS 34 R66J
040986 - ..
040987 - [On 160822 1321 at 1642 Doctor Kim called again - he has
040988 - not seen letter notifying of action items on Stanford
040989 - Neuroscience letter issued on 160802, and received on
040990 - 160820, because it was sent to Doctor Vora, because she is
040991 - only adressee available to the patient listed in Stanford's
040992 - electronic communication system, and there was no evident
040993 - procedure for sending a separate copy to Doctor Kim. He
040994 - will ask Doctor Vora in next 10 minutes for a copy, so he
040995 - can access the record reviewing his letter on 160802,
040996 - received on 160820, and call back to discuss pending action
040997 - items for determining what caused stroke symptoms on
040998 - 160617, to complete 2nd opinion work in this case.
040999 - ref SDS 34 U65K
041001 - ..
041002 - [On 160921 1130 Doctor Lee meeting in GI Clinic at VA
041003 - Medical Center in Sacramento, said he did not authorize
041004 - Stanford Neuroscience 2nd opinion; he found on VA computer
041005 - system another Doctor Randall Lee working at UCSF Parnasus
041006 - campus, who likely approved 2nd opinion work by Stanford
041007 - Neuroscience; after reading 2nd opinion dated 160802,
041008 - Doctor Lee said he would make sure VA pays patient for the
041009 - cost of 2nd opinion work by Stanford Neuroscience.
041010 - ref SDS 36 1C6F
041012 - ..
041013 - What review of patient "medical records" was made?
041015 - ..
041016 - Did Doctor Massa facilitate access to patient records at an earlier
041017 - date? When was patient notified?
041019 - ..
041020 - Letter from Stanford Neuroscience on 160802 continues...
041021 -
041022 - 6. On 6/17/16, he underwent an EGD procedure for achalasia. After
041023 - the procedure, he was picked up by his friend. He was unable
041024 - to buckle or unbuckle his seatbelt on the left side, feeling a
041025 - lack of necessary fine motor control and requiring assistance.
041027 - ..
041028 - He dropped his phone from his left hand. After being served a
041029 - soda in the restaurant, he felt unaware of his and the soda's
041030 - whereabouts.
041032 - ..
041033 - What is the source for representing the patient felt "unaware of
041034 - his... whereabouts"?
041036 - ..
041037 - The record on 160617, says in part, the patient could not see a glass
041038 - of Doctor Pepper (AKA soda), and was told it was on the table in front
041039 - of him. When someone pointed to the glass he then became aware.
041040 - 160617 1637, ref SDS 5 CP4M
041042 - ..
041043 - This may be minor quibbling over terminology, but it is helpful for a
041044 - medical report to state sources for verification of factual
041045 - understandings.
041047 - ..
041048 - Moreover, the sequence and timing seems at least interesting - seeing
041049 - the glass of Doctor Pepper well enough to add lemon juice, and then
041050 - minutes later being unable to see the same thing, would seem to
041051 - indicate progression of symptoms. The following day, patient could
041052 - not identify all of the elements in the neurology test picture on
041053 - 160618 0800, ref SDS 7 ZO9M, and on following day presented a full
041054 - account, indicating resolution of symptoms, reported on 160619 0800,
041055 - ref SDS 10 TO9K This aligns with evidence showing recovery from
041056 - elevated WBC after midnight on 160618, and then falling the next day
041057 - on 160619 - see comment on review of lab studies, below. ref SDS 0
041058 - J149
041060 - ..
041061 - Letter from Stanford Neuroscience on 160802 continues...
041062 -
041063 - At home, while attempting to use a remote control, he had
041064 - difficulty selecting the correct buttons. At the SF VA, he was
041065 - unable to recognize the letters on the left-side of an eye
041066 - chart. When asked to elaborate, he states he was able to see
041067 - the letters, but not able to "process" what he was seeing.
041069 - ..
041070 - Overall, symptoms progressed for several hours, lasted about 24
041071 - hours, and the[n] resolved gradually over the subsequent day.
041073 - ..
041074 - What can cause neurologic symptoms after EGD dilation procedures with
041075 - conscious sedeation, and then subside in 24 - 48 hours?
041077 - ..
041078 - It seems that something happened to the patient and then wore off.
041080 - ..
041081 - Research on 160621 reviews complications from upper GI endoscopy.
041082 - 160621 2024. ref SDS 11 IW5H This should be carefully addressed in
041083 - 2nd opinion.
041085 - ..
041086 - Letter from Stanford Neuroscience on 160802 continues...
041087 -
041088 - There have been no recurrent symptoms, and he remains
041089 - independent with ADLs at his baseline. There was no associated
041090 - headache, preceding personality changes, or systemic symptoms
041091 - (e.g. fever, cough, diarrhea, night sweats, unintentional
041092 - weight loss, neck stiffness or pain). He denies any prior CNS
041093 - infections (meningitis or encephalitis), head trauma, or prior
041094 - or family history of seizures.
041096 - ..
041097 - Regardless of what is remembered or denied, there is no evident record
041098 - that shows any such maladies.
041100 - ..
041101 - Letter from Stanford Neuroscience on 160802 continues...
041102 -
041103 - 7. He was evaluated acutely at the SF VA. CT head did not reveal acute
041104 - intracranial findings. MRI brain initially reported as right cerebellar
041105 - stroke, scattered subcortical white matter changes, and leptomeningeal
041106 - enhancement.
041108 - ..
041109 - During the meeting on 160802, Doctor Kim was asked initially, to show
041110 - on the computer screen in the examination room, the location presented
041111 - by the VA Neuroradiology report as a stroke. Doctor Kim scrolled
041112 - through the MRI scan images, and stopped at a particular location,
041113 - saying this was the reference in the MRI report.
041115 - ..
041116 - Sun was asked to identify this particular scan image in the 2nd
041117 - opinion report. How does anyone find this particular image?
041119 - ..
041120 - He said he would do so, even though he went on to say, the image does
041121 - not actually support a finding of stroke.
041123 - ..
041124 - The term "white matter" is not evident in MRI report for the test on
041125 - 160618 1348, ref SDS 8 WK7K, though it seems to be pervasive based on
041126 - review by Doctor Kim during the meeting on 160802 1300. ref SDS 19
041127 - GZ5G
041129 - ..
041130 - This may simply be another way of representing MRI report finding...
041131 -
041132 - Diffuse right holohemispheric subarachnoid enhancement,
041133 - predominantly in the right frontal and right occipital
041134 - lobes. ref SDS 8 GM8M
041136 - ..
041137 - Letter from Stanford Neuroscience on 160802 continues...
041138 -
041139 - MRA head/neck did not show large vessel occlusion or vessel
041140 - irregularity.
041142 - ..
041143 - Is explanation that MRI did not find "large vessel occulusion or
041144 - vessel irregularity" another way of saying the MRI found no evidence
041145 - of plaque, stenosis, nor blockages of any kind commonly associated
041146 - with athersclerosis that causes strokes?
041148 - ..
041149 - This aligns with CCTA on 151019, finding no evidence of
041150 - atherosclerosis - see addendum. ref SDS 3 SU62
041151 -
041152 - [...below on 160820 0940 section on Diagnostic Data reports
041153 - MRI finding no evidence of atherosclerosis in the brain
041154 - area. ref SDS 0 PW4G
041156 - ..
041157 - Letter from Stanford Neuroscience on 160802 continues...
041158 -
041159 - CSF studies (performed after MRI) were negative. An extensive
041160 - infectious and autoimmune/inflammatory workup was negative
041161 - (summarized below). A Zio patch (6/16 - 6/27) did not reveal
041162 - any atrial fibrillation.
041164 - ..
041165 - 8. Past medical/surgical history: Achalasia s/p multiple
041166 - dilatation procedures, GERD, CAD s/p 4vCABG (2009), HLD, BPPV
041168 - ..
041169 - Should clarify "multiple dilation procedures" to say "17 prior
041170 - dilation procedures", see the record on 160315 0900, ref SDS 4 LD8O,
041171 - which conveys more significant record that nominally justifies
041172 - confidence in the procedures, instruments, drugs and practitioners,
041173 - than merely saying multiple, which could be as few as 2 or 3.
041175 - ..
041176 - Letter from Stanford Neuroscience on 160802 continues...
041177 -
041178 - 9. Current Outpatient Prescriptions:
041179 -
041180 - 1. atorvastatin (LiPITOR) 10 mg tablet, take 10 mg by mouth
041181 - Every 3 days, Disp: , Rfl:
041183 - ..
041184 - 2. CALCIUM CARB/MAGNESIUM HYDROX (MYLANTA PO), take 60 mL by
041185 - mouth every day, Disp: , Rfl:
041187 - ..
041188 - 3. C0Q10, LIPOSOMAL UBIOUINOL, PO, take 30 mL by mouth every
041189 - day, Disp: , Rfl:
041191 - ..
041192 - 4. ezetimibe (ZETIA) 10 mg tablet, take 10 mg by mouth Every 3
041193 - days, Disp: , Rfl:
041195 - ..
041196 - 5. famotidine (PEPCID) 40 mg tablet, take 40 mg by mouth 2
041197 - times a day, Disp: , Rfl:
041199 - ..
041200 - 6. NAPROXEN PO, take 400 mg by mouth every day, Disp: , Rfl:
041202 - ..
041203 - 7. omeprazole (PRILOSEC) 20 mg delayed release capsule, take
041204 - 20 mg by mouth Every 2 days, Disp: , Rfl:
041206 - ..
041207 - Daily medications should be revised to show...
041208 -
041209 - 8. Glucosamine Chondroitin 60 ml daily when hiking
041210 - (essentially every day).
041212 - ..
041213 - On 160816, Doctor Lee ended treatment with Omeprazole and Famotidine,
041214 - and replaced these with Panotrazole 40 mg twice per day.
041216 - ..
041217 - Letter from Stanford Neuroscience on 160802 continues...
041218 -
041219 - 10. Family history: Reviewed. Father: stroke, alcoholic, tobacco
041220 - user/smoker
041222 - ..
041223 - 11. Social history: By trade, he is a general contractor. Has
041224 - worked on development of a software program. He has never
041225 - smoked tobacco. He drinks on occasion. He denies use of
041226 - illicit substances. He is a veteran.
041228 - ..
041229 - Software program is Schedule Diary System, implementing POIMS
041230 - technology with a work practice of Communication Metrics, explained
041231 - at...
041232 -
041233 - http://www.welchco.com/
041235 - ..
041236 - Letter from Stanford Neuroscience on 160802 continues...
041237 -
041238 - 12. Review of symptoms: Comprehensive ROS completed and is negative except as
041239 - mentioned above.
041241 - ..
041242 - 13. Physical examination: BP 157/86 LUE sitting, HR 68, T 36.7C, wt
041243 - 83 kg, Ht 1.676 m
041244 -
041246 - ..
041247 - 14. Page 2
041249 - ..
041250 - 15. General: No apparent distress. Pulses regular, rate, and
041251 - rhythm. No gross skin lesions.
041253 - ..
041254 - 16. Neurological examination:
041255 -
041256 - 1. MS: Alert, oriented to self, place, and date. Speech is
041257 - clear/fluent. He paces back/forth as he relates certain
041258 - points of the HPI. MOCA score 27/30 (missed: 1 point on
041259 - abstraction, 2 points on delayed recall).
041261 - ..
041262 - SN should submit the question on abstraction that was missed.
041264 - ..
041265 - SDS was created to aid timely, accurate recall, see the record on
041266 - 890523 0650. ref SDS 1 P13O See explanation of "Hansel and Gretle" on
041267 - benefits of creating trails of associations. ref SDS 1 P13O
041269 - ..
041270 - Letter from Stanford Neuroscience on 160802 continues...
041271 -
041272 - 2. CN II-XII unremarkable: PERRL, VFs full in all quadrants,
041273 - EOMI, normal sensation, face symmetric, hearing intact to
041274 - finger rub, uvula/tongue midline, shoulder shrug symmetric, SCM
041275 - strength normal. Motor: Normal bulk and tone throughout.
041276 - Strength is 5/5 in all extremities throughout. No pronator
041277 - drift. Finger taps equal/symmetric.
041279 - ..
041280 - 3. Reflexes: BUE: 1+ throughout. BLE: patellae 2+, ankles 2+,
041281 - toes are mute. Sensation: Intact to light touch and
041282 - temperature throughout.
041284 - ..
041285 - 4. Coordination: Intact FNF and HKS - no dysmetria.
041287 - ..
041288 - 5. Gait: Normal station and gait. Able to take a few steps
041289 - with feet in tandem.
041290 -
041292 - ..
041293 - 17. Diagnostic data:
041294 -
041295 - MRI brain/MRA head+neck (6/18/16): Images personally reviewed
041296 - with Dr Nirali Vora (attending). There is no true restricted
041297 - diffusion, although there is T2/FLAIR shine through noted in
041298 - the R cerebellum and multiple subcortical white matter.
041300 - ..
041301 - "Shine through" aligns with Doctor Massa's letter revising the
041302 - original diagnosis of stroke from the MRI study on 160617, reported in
041303 - the record on 160802 1404. ref SDS 20 5K34 Doctor Massa's letter is
041304 - actually reported separately in another record the same day on 160802
041305 - 1404. ref SDS 20 5K34
041307 - ..
041308 - This indicates that the Stanford team called and notified Doctor Massa
041309 - of their findings, which then enabled Doctor Massa to call the patient
041310 - during the meeting with the Stanford team, reported on 160802 1300.
041311 - ref SDS 19 S36F
041313 - ..
041314 - Letter from Stanford Neuroscience on 160802 continues...
041315 -
041316 - Interestingly, there are minimal periventircular changes.
041318 - ..
041319 - Meaning of "periventricular" changes seems related to "white matter"
041320 - which is pervasive in the report, and so must be something different,
041321 - since this part of the report says there are "minimal" periventrcular
041322 - changes.
041324 - ..
041325 - See research on...
041326 -
041327 - MedFriendly
041328 -
041329 - http://www.medfriendly.com/periventricular-white-matter.html
041330 -
041331 - Periventricular white matter changes means that there has been
041332 - some change in the structure of the white matter near the
041333 - ventricles of the brain. This finding does not necessarily
041334 - mean that something serious, like a disease, has caused it. In
041335 - fact, the most common cause of periventricular white matter
041336 - changes is normal aging that is not associated with a disease
041337 - process.
041339 - ..
041340 - In people over age 65, research has shown that periventricular
041341 - white matter changes are found between 30% and 80% of the time
041342 - when an MRI scan of the brain is performed.
041344 - ..
041345 - Possible causes of periventricular white matter changes include
041346 - Binswanger's disease [...type of dementia...], stroke, migraine
041347 - headaches, multiple sclerosis, and CADASIL (Cerebral Autosomal
041348 - Dominant Arteriopathy with Subcortical Infarcts and
041349 - Leukoencephalopathy).
041351 - ..
041352 - Thus, Stanford Neuroscience report finding "minimal periventircular
041353 - changes" represents favorable health condition.
041355 - ..
041356 - So, what is difference between finding "multiple subcortical white
041357 - matter," and also finding "minimal "periventricular" changes?"
041358 -
041360 - ..
041361 - Letter from Stanford Neuroscience on 160802 continues...
041362 -
041363 - There is smooth leptomeningeal enhancement overlying the
041364 - bilateral hemispheres, R frontal >> L, and query if involvement
041365 - of the right cerebellar folia. SWI reveals no evidence of
041366 - cerebral microbleeds or prior hemorrhage. MRA head and neck
041367 - does not show any large vessel occlusions, aneurysm, or
041368 - significant vessel irregularity.
041370 - ..
041371 - Stanford Neuroscience (SN) cites MRI interpretation to support
041372 - representation above that there is no evidence of atherosclerosis in
041373 - patient brain area. ref SDS 0 V46K
041375 - ..
041376 - 18. Images taken from MRI study on 160618
041378 - ..
041379 - There is a red arrow superimposed on an image. This should be
041380 - explained in the narrative.
041382 - ..
041383 - 19. Page 3
041384 -
041386 - ..
041387 - Letter from Stanford Neuroscience on 160802 continues...
041388 -
041389 - 20. Other relevant labs/studies (6/2016):
041390 -
041391 - CSF: WBC 7, RBC 1325, protein 47, glucose 65
041392 - CSF: WBC 4, RBC 2, protein 71, glucose 81
041393 - OCB: neg, IgG index: 0.5 (wnl)
041394 - CSF cytology: neg for malignancy
041395 - ESR: wnl; CRP: wnl; SSA/SSB: neg; ANA: neg; RF: neg;
041396 - DS DNA: pending; C3/C4: pending
041397 - HIV screen: neg; Lyme screen: neg; RPR: non-reactive; Blood cultures: neg
041398 - TTE: normal systolic function, no significant valvular abnormalities, LA mildly
041399 - dilated, concentric remodeling of LV.
041401 - ..
041402 - Stanford Neuroscience should comment on labs showing WBC 15.2 elevated
041403 - 50% on 160618 0050, ref SDS 6 FK6I, and down to WBC 13.0 on 160619.
041404 - ref SDS 9 FK6I
041406 - ..
041407 - This seems like evidence the body was fighting against something, and
041408 - was beginning to win the fight the next day, i.e., effects of whatever
041409 - happened on 160617, were beginning to wear off.
041411 - ..
041412 - SN should request results of labs on 160620, to verify WBC returned to
041413 - normal.
041415 - ..
041416 - Letter from Stanford Neuroscience on 160802 continues...
041417 -
041418 - 21. Assessment:71 Year old gentleman with hours of transient
041419 - altered awareness, distal left hand fine motor incoordination,
041420 - and left visual neglect vs field cut in the context of
041421 - preceding EGD procedure.
041423 - ..
041424 - This aligns with Doctor Massa's letter on
041426 - ..
041427 - Letter from Stanford Neuroscience on 160802 continues...
041428 -
041429 - MRI does not show any acute stroke, but does have subcortical
041430 - and right cerebellar white matter changes of uncertain age.
041432 - ..
041433 - This references finding of pervasive white matter, per above.
041434 - ref SDS 0 JZ66
041436 - ..
041437 - How to evaluate age issue?
041439 - ..
041440 - Could the patient have contracted an affliction prior to EGD on
041441 - 160617, causing elevated WBC?
041443 - ..
041444 - Patient had no evident symptoms prior to EGD, after undergoing review
041445 - of vitals and then pre-proc examination by Doctor Lee. There was no
041446 - temperature nor other signals.
041448 - ..
041449 - Letter from Stanford Neuroscience on 160802 continues...
041450 -
041451 - The diffuse leptomeningeal enhancement! increased vascularity
041452 - most prominent in a culprit right frontal region raises
041453 - question of anesthetic-related changes +/- seizure, PRES, and
041454 - less likely malignancy, autoimmune/vasculitis, or infectious
041455 - changes given bland LP, patent's stability, and lack of
041456 - headache.
041458 - ..
041459 - What review of anesthetic-related changes has been made?
041460 -
041461 - [On 160921 1130 meeting with Doctor Lee in GI Clinic at VA
041462 - Medical Center in San Francisco, the doctor advised
041463 - Stanford's 2nd opinion is helpful for establishing no
041464 - stroke actually occurred, and that stroke symptoms of
041465 - pervasive leptomeningeal enhancement likely resulted from
041466 - anesthesia-related changes. ref SDS 37 G89I
041468 - ..
041469 - This report that stroke symptoms resulted from anesthetic-related
041470 - changes aligns with discussions during meeting at Stanford
041471 - Neuroscience on 160802 1300. ref SDS 19 ES30
041473 - ..
041474 - What are examples of anesthetic-related issues might cause symptoms
041475 - in this case?
041477 - ..
041478 - Could there have simply been an error performing conscous sedation of
041479 - some kind, which was not evident, and so it was entered in the record
041480 - correctly, but did not actually occur?
041482 - ..
041483 - Letter from Stanford Neuroscience on 160802 continues...
041484 -
041485 - A repeat MRI with resolution would support a theory
041486 - of a monophasic event. Persistent enhancement or progression
041487 - of the white matter changes would suggest possible vasculitis
041488 - warranting more aggressive workup.
041490 - ..
041491 - Follow up MRI on 160805, reported anomolies in prior MRI on 160618,
041492 - were resolved, ref SDS 24 WQ54.
041494 - ..
041495 - Letter from Stanford Neuroscience on 160802 continues...
041496 -
041497 - 22. Recommendations:
041498 -
041499 - 1. Determine anesthetics/meds given during EGD, and if any
041500 - differences compared to prior procedures.
041502 - ..
041503 - 2. Repeat MRI brain with and without contrast. Vessel wall
041504 - imaging will be helpful, and available at Stanford.
041505 - Discussed with Dr Massa who will see if it is available at
041506 - SF VA, though preliminarily MRI is scheduled this Friday. .
041508 - ..
041509 - 3. Patient to alert us after MRI completed to coordinate
041510 - imaging review and further recs
041512 - ..
041513 - 4. If persistent leptomeningeal enhancement, we would
041514 - recommend a pursuing a repeat large volume LP for
041515 - cytology/flow cytometry, cerebral angiogram, and additional
041516 - studies as follows: ANCA, anti phospholipid antibodies
041517 - (cardiolipin, beta-2 glycoprotein, phosphatidylserine, and
041518 - lupus anticoagulant), LDH, haptoglobin, ACE, SPEP,
041519 - cryoglobulins, ant- TG/TPO, paraneoplastic antibodies, TSH
041521 - ..
041522 - 5. OK to hold on repeat Ziopatch / cardiac monitoring given
041523 - ischemia unlikely
041525 - ..
041526 - 6. At this time, no contraindication to EGD though review of
041527 - anesthetic history may guide future sedation choice or
041528 - monitoring post-procedure.
041530 - ..
041531 - What evidence supports withholding contraindication to EGD, without
041532 - explanation of what caused prior stroke symptoms?
041534 - ..
041535 - In the meeting on 160619, 2 days after EGD on 160617, Doctor Abrams,
041536 - Chief of Neurology at VAMCSF, said it is critical to determine what
041537 - happened during EGD in order to avoid future events, that could be
041538 - much more serious. ref SDS 10 SV4K
041540 - ..
041541 - Was Doctor Lee interviewed, as Doctor Massa did on 160811 1546.
041542 - ref SDS 27 OT3H
041544 - ..
041545 - Has Stanford Neuroscience reviewed additional considerations Doctor
041546 - Massa presented in his letter on 160811 1546. ref SDS 27 KQ4J
041547 -
041548 - [On 160822 1321 at 1642 Doctor Kim called and seemed to
041549 - advised that Stanford Neuroscience has not reviewed
041550 - additional assessment Doctor Massa reported on 160811, for
041551 - 2n opinion determination of what caused stroke symptoms
041552 - after EGD procedure on 160617. ref SDS 34 VK4J
041554 - ..
041555 - Have Progress Notes been reviewed from prior procedures?
041557 - ..
041558 - Letter from Stanford Neuroscience on 160802 continues...
041559 -
041560 - 23. Patient was seen and plan discussed with Dr Nirali Vora (stroke
041561 - neurology attending). Thank you for allowing us to participate
041562 - in the care of your patient. Recommendations given to Dr Massa
041563 - over the phone. He may return on an as needed basis.
041564 -
041566 - ..
041567 - 24. Sun Kim, MD
041568 - Stroke Fellow
041570 - ..
041571 - 25. Teaching Physician Attestation
041573 - ..
041574 - 26. I saw and examined the patient and discussed management with
041575 - the fellow Dr Kim. I reviewed/edited the fellow's note and
041576 - agree with the documented findings and plan of care.
041578 - ..
041579 - 27. Nirali Vora, MD
041580 - Clinical Assistant Professor, Neurology
041581 - Stanford Stroke Center '
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