10/20/21 Dr. Sabadia notices the acute sinus infection noted on the MRI, and suggests that my mom see a GP to get a prescriptions for anti-biotics, if needed. We take my mom to MedRite Urgent Care in Brooklyn to meet with a doctor, who prescribes Doxycycline for 7 days. My mom starts Doxy, which she says makes her nauseated (this is an expected side effect).
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10/19/21 Mom goes to JAG One Physical Therapy in Brooklyn, we visit with Dr. Mamie Shah. She begins vestibular therapy, which has an immediate positive effect on my mom’s ability to follow objects successfully with her eyes. As expected, the therapy causes residual dizziness and nausea, which is expected to last a day or two after each time. Mom reaches out to Dr. Sabadia to prescribe anti-nasuea and anti-dizziness medication, as suggested by Dr. Shah.
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10/14/21 Mom goes to JAG One Physical Therapy in Brooklyn, we visit with Dr. Shah. She establishes the vestibular issues my mom is having, and proposes follow up appointments to work on these. She describes that “crystals” are misaligned in my mom’s inner vestibular system. She believes she can work on this and have a positive effect quickly.
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10/18/21 MRI performed at NYU. Results here:
Study Result
Impression
IMPRESSION:
Moderate microvascular ischemic disease.
Concern for acute right maxillary sinus bacterial infection. Correlate clinically.
Narrative
CLINICAL INDICATION: Head injury November 2017 with loss of consciousness. Since then has had memory difficulties and daily headaches.
TECHNIQUE: Multi-planar multi-sequential MR imaging of the brain was performed without intravenous contrast.
COMPARISON: None available
FINDINGS:
No acute infarction, intracranial hemorrhage or mass. Moderately extensive patchy and confluent white matter disease 2/FLAIR hyperintensities are noted without mass effect. Additional signal abnormalities are noted in the pons. These findings are consistent with moderate microvascular ischemic disease.
There is mild to moderate cerebral volume loss.No extra-axial fluid collections. The skull base flow voids are present.
The right maxillary sinus is partially opacified by mucosal disease and central T2-hypointense foamy debris that appears to form a fluid level and which demonstrates restricted diffusion. These findings are concerning for acute bacterial sinusitis. Correlate clinically
The visualized intraorbital contents are normal. The mastoid air cells are clear. The visualized osseous structures, soft tissues and partially visualized parotid glands appear normal.
Electronic Signature: I personally reviewed the images and agree with this report. Final Report: Dictated by and Signed by Attending John Loh MD 10/19/2021 12:45 PM
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10/6/21 Dr. Sakinah B. Sabadia seen at NYU Langone Neurology. Dr. Sabadia was very patient and helpful, listened to my mom describe the issues she has been experiencing since the car accident in Nov 2017. She recommended blood work ( see summary above). She did many reflex and cognitive testes. Dr. Sabadia recommended physical therapy for the vestibular issues. She also recommended a Neuropsychological test through NYU. This test is a series of tests that last 3 days. It is very hard to schedule as there are very few doctors doing this test during covid.
Dr. Sabadia also scheduled an MRI on 10/18Blood work test were normal (see below). Summary of visit:
Sakinah B Sabadia, MD at 10/6/2021 4:00 PM
Sakinah Sabadia, MD
NYU Neurology Associates
222 East 41st Street, 9th Floor
New York, NY 10017
Phone: (212) 263-7744
Reason for Visit: concussion
HPI:
The patient is a 75 y.o. female who presents with persistent symptoms after a head injury
Details are as follows:
Date of injury: November 2017
Approximate time of injury: 6PM
History/mechanism of injury:
She is accompanied by her son Max.
She was in a motor vehicle accident (as a pedestrian) in November 2017 in Seattle. She was walking across the street at a traffic circle, and an SUV hit her and ran over her. She lost consciousness for a few minutes. This happened right in front of her tai chi class. The driver got out of his car and fled the scene. Her classmates came out and helped her crawl out from under the car. She laid down for about 20 minutes, and then they took her to the ED. She had some scans done over 2 hours. She had a terrible headache which they gave her medications for. She does not recall there being any abnormalities on her scans. She was told she had a concussion and then was sent home. She stayed in bed for about 3 weeks. She continued to have terrible headaches, light and sound sensitivity, neck pain, nausea and loss of appetite.
Since then, her memory has been significantly affected. She has difficulty carrying on a conversation. She used to work a full-time professor but retired prior to her injury. She has been very depressed since her injury. She has a lot of trouble with her balance, and needs to use a cane or hold on to the wall. She did physical/vestibular therapy in Seattle which she thinks helps. She has had constant tinnitus, usually a high pitched squealing sound, mainly in the right ear. She had some hearing aids for the tinnitus (not hearing loss) but didn't find them helpful. She often gets lightheaded when she sits up or stands up too quickly. She was started on buspirone, lyrica, celebrex and effexor by doctors in Seattle (psychiatrist and PCP at Kaiser). These medications have helped her with her depression, anxiety and generalized body aches.
She was being taken care of by her partner for 3 years, then moved to NYC to spend time with her son and grandsons. She lives alone but a few blocks from her son. She often trips at home, and has fallen on the ground a few times. She doesn't always use her cane but feels she needs it.
Was there loss of consciousness? Yes, Over one minute
Was there amnesia for the event? yes
If yes, for how long? unclear
Current symptoms:
Headache: Yes, but improved, still occurring every day. Lasting about 1-2 hours. She takes Tylenol which helps.
Neck pain / MSK: yes
Vestibular / Autonomic: lightheaded with standing. tinnitus
Visual: light sensitivity
Sleep: sleeps often throughout the day
Cognitive (briefly): very slowed
Affective: depressed
Functional activity levels:
Work: retired
Physical activity: goes on walks, feels worse
Is there a history of prior concussion(s)? yes
How many previous concussions? 2
Is there a personal or family history of headaches? No
Is there a personal or family history of psychiatric problems or substance abuse? No
Concussion Symptom/Severity Evaluation:
Current symptoms are as follows (0-6 scale):
Headache: 5.
“Pressure in head:” 6.
Neck pain: 4.
Nausea or vomiting: 4.
Dizziness: 4.
Blurred vision: 0.
Balance problems: 5.
Sensitivity to light: 4.
Sensitivity to noise: 5.
Feeling slowed down: 6.
Feeling like “in a fog:” 6.
“Don’t feel right:” 6.
Difficulty concentrating: 6.
Difficulty remembering: 6.
Fatigue or low energy: 6.
Confusion: 5.
Drowsiness: 6.
More emotional: 4.
Irritability: 5.
Sadness: 6.
Nervous or anxious: 6.
Trouble falling asleep: 2.
Total number of symptoms: 21/22.
Symptom severity score: 107/132.
Do the symptoms get worse with physical activity? No.
Do the symptoms get worse with mental activity? No.
If 100% is totally normal what % of normal do you feel? 20%
Standardized Assessment of Concussion (SAC):
Orientation
What month is it? 1.
What is the date today? 1.
What is the day of the week? 1.
What year is it? 1.
What time is it right now (within one hour)? 1.
Orientation score: 5/5.
Immediate memory (5 Word List)
Baby monkey perfume sunset iron
First time: 5.
Second time: 5.
Third time: 5.
Immediate memory score: 15/15.
Concentration (reverse digit span)
4-1-5 Score: 1
4-9-6-8 Score: 1
6-1-8-4-3 Score: 1
7-2-4-8-5-6 Score: 0
Months in reverse order Score 1
(Dec-Nov-Oct-Sep-Aug-Jul-Jun-May-Apr-Mar-Feb-Jan)
Concentration score: 4/5.
Delayed recall score: 0/5.
SAC total score: 24/30.
Modified Balance Error Scoring System (MBESS):
Which leg is dominant? left
20 second double leg firm ground: 10
20 second single leg firm ground (non-dominant foot): 8 (falls over and takes seconds to reset)
20 second tandem firm ground (non-dominant foot at back): 10
MBESS Total Score: 28/30.
MULES: 128 seconds, 3 errors (calls fish a blue jay, camel/llama a giraffe and shark a fish)
Neurological Screen
Can the patient read aloud and follow instructions without difficulty? yes
Does the patient have a full range of pain free passive cervical spine movement? yes
Without moving their head or neck , can the patient look side-to-side and up-and-down without double vision?yes
Can the patient performed the finger nose finger test normally?yes
Can the patient perform tandem gait normally? no
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Past Medical History:
History reviewed. No pertinent past medical history.
Past Surgical History:
Past Surgical History:
Procedure
Laterality
Date
•CERVICAL DISCECTOMY
1998
after an MVA
Family History:
Family History
Problem
Relation
Age of Onset
•Frontotemporal Dementia
Father
Social History:
Social History
Tobacco Use
•Smoking status:
Never Smoker
•Smokeless tobacco:
Never Used
Substance Use Topics
•Alcohol use:
Not Currently
•Drug use:
Never
Allergies:
Allergies
Allergen
Reactions
•Penicillins
Other (See Comments)
Since child
Meds:
Current Outpatient Medications
Medication Sig
•busPIRone (BUSPAR) 15 mg tablet
Take 15 mg by mouth 3 (three) times daily.
•celecoxib (CELEBREX) 100 mg capsule
Take 100 mg by mouth 2 (two) times a day.
•pregabalin (LYRICA) 25 mg capsule
Take 25 mg by mouth 2 (two) times a day.
•UNKNOWN TO PATIENT
Seriphos
Prempo 0.625mg/2.5 mg tab
•venlafaxine (EFFEXOR XR) 75 mg ER tablet
Take 75 mg by mouth daily.
ROS:
As per HPI
Physical Exam:
Vitals:
Vitals:
10/06/21 1544
BP:134/91
Site:Left Arm
Position:Sitting
Pulse:92
SpO2:96%
Weight:72.4 kg (159 lb 9.8 oz)
Height:1.689 m (5' 6.5")
General: Well-appearing woman
Resp: Breathing comfortably on room air
CV: Warm, well-perfused. Peripheral pulses intact
MSK: no obvious deformities
Neurological Exam:
Mental Status: Awake, alert. Very bradyphrenic. Very slow to answer questions, sometimes needing repetition
Cranial Nerves:
II: PERRL. VF intact with finger counting.
III/IV/VI: EOMI without nystagmus
V: Facial sensation intact
VII: Facial musculature intact with forceful eyelid closure, symmetric smile
VIII: Hearing roughly intact bilaterally
IX/X: Palate and uvula midline
XI: Shoulder shrug intact
XII: Tongue midline
Motor:
Bulk: normal
Tone: normal
Voluntary movements: bradykinetic
Involuntary movements: no tremor
Strength: No pronator drift. Normal finger taps. 5/5 throughout the upper and lower extremities proximally and distally
Sensory:
Light touch: intact in the upper and lower extremities
Vibration: mildly reduced in the toes
Reflexes:
Right
Left
Biceps
2+
2+
Brachioradialis
3+
3+
Triceps
2+
2+
Patellar
2+
2+
Ankle Jerk
2+
2+
Hoffman's
present
present
Babinski
absent
absent
Coordination: No dysmetria with finger to nose bilaterally.
Gait: Normal stance and stride. Arm swing normal and symmetric. Normal toe, heel and tandem walk.
Assessment: This is a 75-year-old woman with no significant past medical history who presents with progressive cognitive decline, imbalance, and depression following a head injury with LOC. It is possible that this is due to post-concussion syndrome, however given her age and progressive decline, consider a primary neurodegenerative process. Secondary causes such as a subdural hematoma should also be evaluated with imaging. Her imbalance could also be due to neuropathy given mildly decreased vibratory sense in feet, though this is less likely given preserved ankle jerks.
Plan:
- Neuropathy and dementia lab screening
- MRI brain
- Referrals made to PT and neuropsych
- Return in about 3 months (around 1/6/2022).
Sakinah Sabadia, MD
Clinical Assistant Professor
Department of Neurology
Patient Instructions - Clinical Notes
Sakinah B Sabadia, MD at 10/6/2021 4:00 PM
- Schedule MRI of the brain
- Blood work today
- Referrals made for Neuropsychology and Physical Therapy
Blood work results:
PROTEIN, TOTAL
Your Value
7.2 g/dL
Standard Range
6.3 to 8.2 g/dL
6.3 - 8.2 g/dL
ALBUMIN PROTEIN ELECTROPHORESIS
Your Value
4.07 g/dL
Standard Range
3.75 to 5.01 g/dL
3.75 - 5.01 g/dL
ALPHA-1-GLOBULIN
Your Value
0.35 g/dL
Standard Range
0.19 to 0.46 g/dL
0.19 - 0.46 g/dL
ALPHA-2-GLOBULIN
Your Value
1.10 g/dL
Standard Range
0.48 to 1.05 g/dL
0.48 - 1.05 g/dL
BETA GLOBULIN
Your Value
0.94 g/dL
Standard Range
0.48 to 1.10 g/dL
0.48 - 1.10 g/dL
GAMMA GLOBULIN
Your Value
0.74 g/dL
Standard Range
0.62 to 1.51 g/dL
0.62 - 1.51 g/dL
SPE INTERPRETATION
Your Value
NO MONOCLONAL PROTEIN SPIKE DETECTED.
INCREASED ALPHA 2 GLOBULIN CONSISTENT WITH ACUTE INFLAMMATION.
Performed by NYU Langone Hospitals, Tisch Labs. 560 First Avenue, NY, NY,
10016. CLIA: 33D0653358, PFI: 5153 Director: Maria E. Aguero Rosenfeld MD.
General Information
Ordered by Sakinah B Sabadia, MD
Collected on 10/06/2021 5:52 PM from Peripheral (blood)
Resulted on 10/07/2021 3:06 PM
Result Status: Final result
This test result has been released by an automatic process.
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10/1/21 AARP Medicare plan Part F and RX is activated