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Continued Exams- Please review for details

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lfredrick123

Question

Here is the most recent CT Exam 

GOOD SAMARITAN MEDICAL CENTER

 

 

 

 

Adm: 6/6/2017, D/C: 6/6/2017

CT Chest Abdomen And Pelvis Wo Contrast]

Resulted: 06/06/17 1617, Result status: Final

result

Ordering provider:

Resulted by: MD

Performed: 06/06/17 1522 - 06/06/17 1539 Resulting lab: SVB STRESS SERVICES

Narrative:

CT OF THE CHEST, ABDOMEN AND PELVIS WITHOUT INTRAVENOUS CONTRAST

EXAM DATE AND TIME: 6/6/2017 3:22 PM

INDICATION: Lung mass. Vascular disorder of the kidneys.

TECHNIQUE: Routine CT of the chest, abdomen and pelvis without IV

contrast. Dose reduction techniques were employed.

COMPARISON: None available.

FINDINGS:

CHEST:

Lungs: Evaluation lung bases is hindered by extensive respiratory

motion artifact. There is patchy left greater than right bilateral

lower lobe consolidations, consistent with pneumonia and/or

atelectasis. The upper lobes appear clear.

Mediastinum/Hila: There is mild cardiomegaly. Aortic valvular

calcifications are noted. Calcified plaque is seen in the aortic arch.

No mediastinal or hilar adenopathy. Tracheostomy tube appears in

satisfactory position.

Pleura: Tiny left pleural effusion.

Chest Wall: Right-sided VP shunt catheter is seen in the subcutaneous

right anterior chest wall, terminating in the right upper quadrant of

the abdomen.

ABDOMEN:

Liver: Normal size and homogeneous, without focal suspicious

parenchymal lesion.

Gallbladder/Bile Ducts: Few tiny calcified gallstones are seen

layering in the gallbladder, which otherwise appears unremarkable.

There is no biliary dilation.

Pancreas: The pancreas appears normal.

Spleen: The spleen appears normal.

Adrenals: The adrenal glands appear normal.

Kidneys: 3.3 cm simple left upper pole renal cyst. No hydronephrosis

or nephrolithiasis.

Bowel: Numerous colonic diverticuli are noted, without CT evidence of

acute diverticulitis.

Mesentery/Omentum/Peritoneum: The mesentery, omentum and peritoneum

appear normal.

Lymph Nodes: Lymph nodes appear normal. No adenopathy.

Vessels: Calcified plaque in the abdominal aorta, without evidence of

aneurysm.

Abdominal Wall: The abdominal wall appears normal.

PELVIS: Unremarkable urinary bladder. Unremarkable prostate gland. No

free air. No free fluid.

Printed on 6/8/2017 9:37 AM Page 1

GOOD SAMARITAN MEDICAL CENTER

200 Exempla Cir

Lafayette CO 80026

FREDRICK,GERALD W

MRN: S0406306

DOB: 2/28/1940, Sex: M

Adm: 6/6/2017, D/C: 6/6/2017

CT Chest Abdomen And Pelvis Wo Contrast [213904399]

(continued)

Resulted: 06/06/17 1617, Result status: Final

result

BONES: Multilevel degenerative changes in the lumbar spine are noted.

No destructive bony lytic or sclerotic osseous lesion.

IMPRESSION:

1. Patchy bilateral lower lobe left greater than right

consolidations, possibly representing atelectasis and/or pneumonia.

Evaluation of these regions are hindered by extensive respiratory

motion artifacts. Underlying mass, while considered less likely cannot

entirely be excluded. Follow-up chest CT suggested after resolution of

acute symptoms.

2. Right-sided VP shunt apparently in satisfactory position, tip

terminating right upper quadrant.

3. Cholelithiasis, without CT evidence of acute cholecystitis.

4. Diverticulosis, without CT evidence of acute diverticulitis.

THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED:

 MD

6/6/2017 4:17 PM

Contributed By:

Printed

What do you see in this report? 

as compared to the initial finding in February?

 

02/19/2017 6:16 PM

Ordered By:

, MD

Result Status:

Final result

 

CT ABDOMEN AND PELVIS WO CONTRAST - Details

 

About This Test

The My Chart portal may not provide a complete representation of the laboratory test results in your medical record. 
If you have questions, please contact your physician. If the report is not complete, you may contact Health Information Management for a complete report.

·        Details

Narrative

HISTORY:
76M. Diarrhea. Noncontrast CT abdomen and pelvis with coronal
and sagittal reformats.
FINDINGS:
Mild basilar atelectasis.
Mild cardiomegaly.
Right abdominal ventriculoperitoneal shunt partially seen
extending along the liver.
Dependent cholelithiasis without pericholecystic inflammation.
Unremarkable spleen, adrenals, pancreas.
Retroperitoneal lipomatosis with mildly atretic kidneys.
Left renal 3.3 cm hypodense lesion with indeterminate density.
Diffuse fluid-filled stomach, small bowel, and large bowel
without evidence of obstruction compatible with infectious
gastroenteritis/enterocolitis and diarrhea.
Normal appendix, axial image 64.
Distal colonic diverticulosis without diverticulitis.
Central mesenteric misty appearance with subcentimeter lymph
nodes.
Unremarkable bladder.
No free fluid or free air.
Small fat-containing inguinal hernia is without inflammation.
Bowel seen immediately deep to the umbilicus.
No acute osseous finding.
IMPRESSION:
1. Diffuse fluid-filled stomach and bowel compatible with
infectious gastroenteritis or enterocolitis.
2. Indeterminate left renal 3.3 cm lesion, most, a hyperdense
cyst. Recommend all sound further evaluate if not stable on
prior exams.
3. Cholelithiasis.
4. Central mesenteric misty appearance with subcentimeter lymph
nodes most commonly associated with mesenteric panniculitis or
sclerosing mesenteritis. Consider 6 month follow-up CT abdomen.

 

Component Results

There is no component information for this result.

General Information

Collected:

02/19/2017 7:02 PM

Resulted:

02/19/2017 7:02 PM

Ordered By:

 MD

Result Status:

Final result

Help Please!!!!

Blood Testing

KAPPA/LAMBDA LIGHT CHAINS FREE WITH RATIO, SERUM
KAPPA LIGHT CHAIN, FREE, SERUM Reference Range: 3.3-19.4 (mg/L)     Actual  41.3 H


LAMBDA LIGHT CHAIN, FREE, SERUM Reference Range: 5.7-26.3 (mg/L)  Actual   24.2
KAPPA/LAMBDA LIGHT CHAINS FREE WITH RATIO, SERUM Reference Range: 0.26-1.65  Actual   1.71 H

 

DOB: 02/28/1940
Sex: M
Phone: 
Patient ID: 
Age: 77
Fasting:
Specimen: KS400824A
Requisition: 7737005
Report Status: FINAL / SEE REPORT
Collected: 05/31/2017 17:19
Received: 06/02/2017 06:23
Reported: 06/09/2017 05:21
Client #: 70300946

Quest, Quest Diagnostics, the associated logo, Nichols Institute, Interactive Insights and all associated Quest Diagnostics marks are the registered trademarks of Quest Diagnostics. All third party marks - '®' and '™' - are the
property of their respective owners. Privacy policy can be found at: http://questdiagnostics.com/home/privacy-policy/online-privacy.html. © 2017 Quest Diagnostics Incorporated. All rights reserved.

These results have been sent to the person that ordered the tests. Your receipt of these results should not be viewed as medical advice and is not meant to
replace discussion with your doctor or other healthcare professional.
Performing Sites
AMD Quest Diagnostics/Nichols Chantilly-Chantilly VA, 14225 Newbrook Drive, Chantilly, VA 20151-2228 Laboratory Director: Patrick W Mason M.D.,PhD
EZ Quest Diagnostics/Nichols SJC-San Juan Capistrano,, 33608 Ortega Hwy, San Juan Capistrano, CA 92675-2042 Laboratory Director: Jon Nakamoto
MD,PhD
THYROGLOBULIN
THYROGLOBULIN Reference Range: <0.1 (ng/mL)
Reference range applies to differentiated thyroid
cancer patients following treatment. The presence of
measurable thyroglobulin indicates the presence of
thyroglobulin-producing thyroid tissue. Clinical
correlation is advised.
This test was performed using the Beckman Coulter
Chemiluminescent method. Values obtained from
different assay methods cannot be used interchangeably.
Thyroglobulin levels, regardless
of value, should not be interpreted as absolute
evidence of the presence or absence of disease.
THYROID CANCER (THYROGLOBULIN) MONITOR
THYROGLOBULIN ANTIBODY Reference Range: <=1 (IU/mL)
This Thyroglobulin antibody test was performed
using the Beckman Coulter Immunoenzymatic method.
Values obtained from different assay methods cannot be
used interchangeably. Thyroglobulin antibody levels,
regardless of value, should not be interpreted as
absolute evidence of the presence or absence of
disease.
If the sample contains anti-thyroglobulin antibodies
of greater than 1 IU/mL, the presence of these
autoantibodies may cause falsely low thyroglobulin
values.
SEROTONIN, SERUM
SEROTONIN, SERUM Reference Range: 56-244 (ng/mL)
This test was developed and its analytical performance
characteristics have been determined by Quest Diagnostics
Nichols Institute San Juan Capistrano. It has not been
cleared or approved by FDA. This assay has been validated
pursuant to the CLIA regulations and is used for clinical
purposes.
10.4 H


 


 

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Bronco vet I have the nexus too. Just cant get it to redact so cant post without the identifiable info on it. I  am sending this for hubby who can not speak and is wheelchair bound. All well documented. Also have tons of proof of conditions on base including the  Industrial Hygiene Surveys, the Colonels statement that they were using 2,4,5,T and the others, and affidavits showing that others also experienced them. I have the C file that they sent. and am waiting on the updated one. I also have a disk of all my VA med recs. And I found a form they had him sign at discharge stating he was aware he could file for compensation, but was declining to at that time (he just wanted out) and he could do so at a later date.  I think I have it loud and clear, and am just waiting now on the DRO Review Hearing.

 

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  • Moderator

Also pay attention to the "Aid and Attendance" you may be eligible for.  There are different levels, mostly depending upon how skilled of care you need.  If you just need someone to help you get dressed, and daily activities, then that is likely the lower levels.  However, if you need around the clock nursing care to monitor vital organs and adminster IV meds, then that is likely the highest levels of Aid and Attendance, such as if you are avoiding the nursing home by getting care at home.  Remember, this care can be still compensated if provided by a relative.  

38 CFR 3.352 - Criteria for determining need for aid and attendance and “permanently bedridden.”

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§ 3.352 Criteria for determining need for aid and attendance and “permanently bedridden.”

(a)Basic criteria for regular aid and attendance and permanently bedridden. The following will be accorded consideration in determining the need for regular aid and attendance ( § 3.351(c)(3): inability of claimant to dress or undress himself (herself), or to keep himself (herself) ordinarily clean and presentable; frequent need of adjustment of any special prosthetic or orthopedic appliances which by reason of the particular disability cannot be done without aid (this will not include the adjustment of appliances which normal persons would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability of claimant to feed himself (herself) through loss of coordination of upper extremities or through extreme weakness; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect the claimant from hazards or dangers incident to his or her daily environment. “Bedridden” will be a proper basis for the determination. For the purpose of this paragraph “bedridden” will be that condition which, through its essential character, actually requires that the claimant remain in bed. The fact that claimant has voluntarily taken to bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice. It is not required that all of the disabling conditions enumerated in this paragraph be found to exist before a favorable rating may be made. The particular personal functions which the veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that the veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that the veteran is so helpless, as to be in need of regular aid and attendance will not be based solely upon an opinion that the claimant's condition is such as would require him or her to be in bed. They must be based on the actual requirement of personal assistance from others.

(b)Basic criteria for the higher level aid and attendance allowance.

(1) A veteran is entitled to the higher level aid and attendance allowance authorized by § 3.350(h) in lieu of the regular aid and attendance allowance when all of the following conditions are met:

(i) The veteran is entitled to the compensation authorized under 38 U.S.C. 1114(o), or the maximum rate of compensation authorized under 38 U.S.C. 1114(p).

(ii) The veteran meets the requirements for entitlement to the regular aid and attendance allowance in paragraph (a) of this section.

(iii) The veteran needs a “higher level of care” (as defined in paragraph (b)(2) of this section) than is required to establish entitlement to the regular aid and attendance allowance, and in the absence of the provision of such higher level of care the veteran would require hospitalization, nursing home care, or other residential institutional care.

(2) Need for a higher level of care shall be considered to be need for personal health-care services provided on a daily basis in the veteran's home by a person who is licensed to provide such services or who provides such services under the regular supervision of a licensed health-care professional. Personal health-care services include (but are not limited to) such services as physical therapy, administration of injections, placement of indwelling catheters, and the changing of sterile dressings, or like functions which require professional health-care training or the regular supervision of a trained health-care professional to perform. A licensed health-care professional includes (but is not limited to) a doctor of medicine or osteopathy, a registered nurse, a licensed practical nurse, or a physical therapist licensed to practice by a State or political subdivision thereof.

(3) The term “under the regular supervision of a licensed health-care professional”, as used in paragraph (b)(2) of this section, means that an unlicensed person performing personal health-care services is following a regimen of personal health-care services prescribed by a health-care professional, and that the health-care professional consults with the unlicensed person providing the health-care services at least once each month to monitor the prescribed regimen. The consultation need not be in person; a telephone call will suffice.

(4) A person performing personal health-care services who is a relative or other member of the veteran's household is not exempted from the requirement that he or she be a licensed health-care professional or be providing such care under the regular supervision of a licensed health-care professional.

(5) The provisions of paragraph (b) of this section are to be strictly construed. The higher level aid-and-attendance allowance is to be granted only when the veteran's need is clearly established and the amount of services required by the veteran on a daily basis is substantial.

(Authority: 38 U.S.C. 501, 1114(r)(2))

(c)Attendance by relative. The performance of the necessary aid and attendance service by a relative of the beneficiary or other member of his or her household will not prevent the granting of the additional allowance.

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Thank you kindly Broncovet. I would send you the info on the Nexus but dont want to overwhelm you with it all, and countles CT/MRI./ PFT's so on. I am 24/7 caregiver for him as he can not do any ADLs without help. We have been waiting now for years, Your help is so deeply appreciated.

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Bronco Vet - I finally did a redaction of the Nexsus here for you. Please let me know what you think. The CAD statement is not yet back.If you want to review it as I wanted the DBQ corrected first and the review done on all of the CT/MRI reports etc.

There are a number of other issues still awaiting that as well. I dont want to stall the DRO/Appeal filing a new claim. God knows this is taking long enough. I do have CAD already filed and several others including incontinence. kidney, etc.

 See what your thinking or if I need more here.

Gerald Fredrick- Dr Ellis Nexus.docx

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