THE SECOND COMING AND ROCK AND ROLL – Page Fifty-Five

image of Coronavirus Disease 2019 (COVID-19)

Coronavirus image created by Alissa Eckert and Dan Higgins

of the Centers for Disease Control and Prevention

CORONAVIRUS - COVID-19

How It Began

March 20, 2020

The Coronavirus originated in Wuhan, China in December 2019. On December 31, 2019, China notified the World Health Organization (WHO) that there were several cases of unusual pneumonia in Wuhan, a port city in the central Huebi province of China and home to 11 million people. Many of those infected with the unknown virus worked at the city's Huanan Seafood Wholesale Market. The market was shutdown January 1, 2020.

Before the virus was identified and given a name, over forty people had been infected with pneumonia. At first, officials had thought that this virus was a recurrance of SARS, a virus that originated in China in 2002 and killed 770 people across the globe. But this was a new virus that was identified as belonging to the coronavirus family that included SARS. The officials named this new virus 2019-nCoV, and we know it as the coronavirus or COVID-19.

On January 9, 2020 the virus claimed its first victim in China. He was a 61 year-old man who had purchased a few goods from the Huanan Seafood Wholesale Market. He had been receiving treatment outside the hospital but when he was not getting better he was hospitalized and later died of heart failure.

On January 13, 2020 a case was reported in Thailand and on January 16, 2020 another case was reported in Japan. Both carriers of the virus had recently visited Wuhan, China. On January 17, 2020, a second person from Wuhan, China died from the virus. After this second death in Wuhan, health officials from The United States began to screen passengers at three airports who were arriving from Wuhan.

Over the next few days reports were coming in from Nepal, France, Australia, Malaysia, Singapore, South Korea, Vietnam, Taiwan and the United States, with confirmed cases of the virus. The first confirmed case of the virus in the United States came from a person who had contracted the disease in Wuhan, China and flew to the state of Washington on January 15, 2020 for treatment. Since then the outbreak became rampant in the United States and has affected every state in America.

On January 20, 2020, China reported its third death and over 200 infected with the virus. This virus has spread and by today, March 20, 2020, coronavirus-related deaths surged past 10,000 globally. The number of cases in Germany rose by 2,958 overnight to 13,957. Spain, meanwhile, said the death toll due to COVID-19 had risen to 1,002. In China, however, no new domestic cases were reported for a second consecutive day even as concerns remained about infected people flying into the country and importing a second wave of the disease.

How The Disease Has Spread

Coronaviruses are common and spread through being in proximity to an infected person and inhaling droplets generated when they cough or sneeze, or touching a surface where these droplets land and then touching one's face or nose.

My Thoughts

On April 26, 2019, I stated that I expected something of significance to happen within a year of Fr. Geidman's death. Why did I say within a year? Because that has been the pattern; that if something happened after any of my contacts with Fr. Geidman, it always happened within a year of my last contact with him. I only expected something personal to happen to me within a year of his death. I did not expect anything out of the ordinary. I did not expect anything worldwide. I did not expect any catastrophes outside of my personal life. I certainly did not expect the coronavirus. I only expected something personal. And sure enough something personal did happen within a year of his death, and so did something worldwide; the coronavirus.

Today, March 20, 2020 around 12:45 AM, I was watching a Christian News Program where the guests were talking about the coronavirus. They prayed and then they engaged in communion with each other. I was in bed watching the program and I began to doze off. Now I have fallen asleep many times with the TV on. When this happens, I no longer hear the TV because I have fallen asleep. So, I must have been asleep when I was awoken by the sound of an audible ferocious roar like that of a lion. It was a deep roar, and it was loud and it was vicious. It fully woke me up and brought me to my senses. I sat up in bed and looked around the room but I saw nothing.

The Christian program was still playing and they were still participating in communion. So I was not out very long at all. Then, I began to doze off again. Again, I must have fallen asleep. This time I was awoken by an audible voice that called out my name, followed by an audible three rings of what sounded like a small hand bell. I again became fully awake and the Christian program was still being broadcast. I did not recognize the audible voice. It was not a voice that I could put a name to. I do not know whose voice it was, but it was a male human voice.

I rarely have heard anything audible over the past 49 years. Usually, if I hear strange things or voices, it is silent, but I hear it. Voices are usually silent, not audible. The last time I heard an audible voice was in 1993, twenty-seven years ago. The audible voice was Jesus's voice and He said, "He is God the Father", referring to Father Geidman. In fact, I have only heard two audible voices over the course of 49 years. The rest have been silent voices. So the audible roar, the audible voice and the audible bell ringing three times, are very significant.

The sound of a bell is an indication that angels, guides or loved ones are present. They are simply making their presence known. It is a sign of comfort, but it is not necessarily a sign of a specific message. Spirits are communicating with you when you hear the sound of bells. Bells symbolize something of sacred origin. A bell rung three times has a quality of calming the atmosphere, attracting the attention of the worshippers, welcoming in the spirits, and setting the scene for a ritual. The sound of a bell is universally accepted as a herald for the arrival of a supernatural, holy power.

The roar of a Lion signals that the great deception is being brought down. When the Lion of Judah roared from heaven 500 years ago, it came at a time of great disillusionment and was used to bring forth great hope and new life. The Lion of Judah is also mentioned in the Book of Revelation, as a term representing Jesus, according to Christian theology.

The roar of a lion that I heard could have represented the Lion of Judah. It could also have represented Satan, who prowls around like a roaring lion looking for someone to devour. (1 Peter 5:8). I heard the roar of a lion to the right of me and I heard my name being called out followed by the three rings of a bell to the left of me, if that means anything.

Here are a few scripture verses about the roar of a lion. Amos 3:8 “Surely the Sovereign Lord does nothing without revealing his plan to his servants the prophets. The lion has roared—who will not fear? The Sovereign Lord has spoken—who can but prophesy?”

Isaiah 31:4 “This is what the LORD says to me: “As a lion growls, a great lion over its prey— and though a whole band of shepherds is called together against it, it is not frightened by their shouts or disturbed by their clamor— so the LORD Almighty will come down to do battle on Mount Zion and on its heights.”

I don't know what this means, but the omens continue. This is the first thing of its kind that has happened to me since Fr. Geidman's death. And this happened on my 67th birthday, March 20, 2020. And this happened just one month before the first anniversary of Fr. Geidman's passing. Significant? Yes, I believe so. Father Geidman died on April 19, 2019. By the way, there is a movie called "Let The Lion Roar". The opening statements are as follows: "I heard the roar. It was the roar of the Lord. The Lord who is the Lion, the Lion of the Tribe of Judah. He is declaring His territory. He is calling His church to its end time purpose. He is looking to the final victory and the glory that will then follow."

Could it be that God has cancelled so much of our social gatherings because we have chosen to go to those social gatherings instead of attending Church? We have chosen to go shopping, instead of choosing to go to Church. We have chosen to go to the theatre, instead of going to church. We have chosen to go to sports events on Sundays, instead of going to church. We have chosen to go to restaurants and bars, instead of going to church. We have chosen to go to concerts, instead of going to church. We have chosen to travel, instead of going to church. We have chosen to go to parks, beaches, and parties, instead of going to church. Now we are confined to our homes and can't go to church because they too are now closed. God has closed our society. God has shut us down. Our idols have gone by the wayside. The things we have given our time to are closed down. We say we don't have time for church. Now, with time on our hands, we reach for that Bible and began reading it. We have time for God now. We can watch church anytime on TV.

July 13, 2020

I had two surgical procedures done today. First I had an endoscopy done, then I had a colonoscopy done. I was prepared for the procedures in a private room, then I was wheeled down to the surgical room where the procedures were performed. There was music playing in the surgical room where I was given the sedative, Propofol, a conscious sedation agent. I was put to sleep by the IV medication and saw nothing, heard nothing and felt nothing. After the procedures I was taken back to my private room where a nurse woke me up.

The endoscopy took five minutes. The colonoscopy took fifteen minutes. I was given the results with further results to come after pathology reports.

September 1, 2020

I had a Myocardial Imaging Perfusion (MPI) also called a Nuclear Stress Test, today, September 1, 2020. I have been having shortness of breath upon excursion and this test may show why. The test went flawlessly and I had no trouble with it at all. I drove myself home and went on with my daily usual activities. The results showed a normal heart with no previous heart attack. The only thing I have is a heart murmur.

September 17, 2020

I awoke around 7AM and sat up in bed. Immediately, everything began to spin and then I started to vomit. I am not sure what brought this on but it could have been from the injection of the Nuclear Stress Test I had just 16 days earlier. It could also have been an allergic reaction from something I ate. At any rate, the dizziness and vomiting continued off and on for the next 15 hours. I fell asleep during the episodes. Evertime I moved, I vomited. I just lay in bed trying to be as still as I could hoping the vomiting would subside. But evertime I moved, I vomited. About 9:30 that evening I decided I better get up regardless of my condition to clean things up. I made it to the bathroom where I became dizzy, and began to vomit again. I decided this was not going to stop and so I called 9-1-1. The squad came, started an IV in the ambulance, and transported me to the hospital. There I was given a series of tests, and IV solutions to control my vomiting. I was released around 3:00 AM. I called a cab to take me home since I did not want to bother any friends or family members at that time of the night to take me home.

A few days later I was out in my backyard and inspected something under my van. When I rose to my feet, everything began to spin and I fell against my fence. Good thing, it caught my fall. I had been taking Meclazine, 25mg after I was released from the hospital because of dizziness. But the medication was from a previous hospitalization many years ago, and was old. So I went to my primary care physician and got some fresh Meclazine. She wanted me to see a neurologist so on October 6, 2020 I went to see Dr. AAshra Gudlavalleti, a neurologist.

October 6, 2020 In Office Appointment with Dr. AAshra Gudlavalleti

Dr. AAshra Gudlavalleti did a series of tests on me including lying down on my back with my head hanging over the examining table. I became extremely dizzy as he turned my head from the right to the left. The left side was worse than the right side. He said it is possible I had ...... (a diagnosis I cannot remember) but wanted me to see Dr. Collazo, an ENT to verify the diagnosis. I cannot get in to see Dr. Collazo until January 20, 2021. Dr. Gudlavalleti gave me a prescription for Indomethacin, an anti inflammatory med for my headaches and eye pain, unrelated to my dizziness. If this medicine took my eye and head pain away on my left side he was certain I had hemicrania continua. I return November 6, 2020.

Progress Notes October 6, 2020 In Office Appointment / The Following are Dr. G's Progress Notes. This was my first visit in office.

Patient Instructions

A Gudlavalleti at 10/6/2020 8:52 AM - You were seen today for Meniere's flare up as well as possible headache syndrome known as hemicrania continua - Referral placed to ENT physician Dr. Collazo. If you do not hear from their office in a week, please give them a call. - Please start taking indomethacin for hemicrania continua as follows : Take 25 mg three times a day with meals x 10 days. Then take 50 mg three times a day with meals x 10 days. Then take 75 mg a day with meals for 10 days. If you find your headache gets better with 25 mg three times a day or 50 mg three times a day, stop at that dose and call me. Side effects of indomethacin were discussed. Please call with any new symptom as discussed or with questions. END of October 6, 2020 Progress Notes.

I began taking the medicine as prescribed: One pill three times a day with meals for 10 days. Two pills three times a day with meals for 10 days. Then three pills three times a day with meals for 10 days. I was fine, with no problems, until the thirty-third day. Then I developed diarrhea. I kept taking the medication regardless until about the thirty-sixth day. Then I became very nauseated and thought I was going to vomit. I took one ondanestron 4mg tab (for nausea), followed by one meclizine 25mg. Then I took another ondanestron six hours later. I began to feel better and never developed vomiting. I decided to quit taking the indomethacin without calling Dr. G's office.

November 6, 2020 In Office Appointment

I returned to Dr. AAshra Gudlavalleti and he was a bit upset with me when I told him I could not finish the medication because it began to make me sick. So I quit taking it. He said that I should have finished the medication because if my pain went away after finishing the medication, it meant I had hemicrania continua, and that was the only way to verify the diagnosis. After the lecture he prescribed a new medication for me, gabapentin. I am to take one pill at night for five days. Then one pill in the morning and one pill at night. Then one pill three times a day. I return December 10th at 10 AM.

Progress Notes November 6, 2020 In Office Appointment / The Following are Dr. G's Progress Notes. This was my 2nd visit in office.

A Gudlavalleti at 11/6/2020 8:00 AM Neurology Outpatient Clinic Consult OhioHealth Physician Group 11/6/2020 Aashrai Gudlavalleti, MBBS, ABPN 990 S Prospect St Suite 2 Marion OH 43302-6283 740-383-7833 Patient Name: Benita M Cutarelli DOB: 3/20/1953 Primary care provider Qihui Joanna Liu, MD Referring physician No ref. provider found

Assessment and Plan

Subjective Benita M Cutarelli is a 67 y.o. right handed female who presents for a follow up visit for presumed hemicrania continua. ast medical history pertinent for Meniere's disease. She has unilateral headaches in the V1 distribution which is constant and associated with lacrimation and redness of the eye (trigeminal autonomic symptoms). She reports significnat improvement with NSAIDs such as naproxen. Hence, my suspicion for hemicrania continua is quite high. She was unable to tolerate the indomethacin and would like to avoid a repeat trial as of now. I explained that there are not any good alternatives with robust data. However, there are reports of trial of other medications such as gabapentin. She was agreeable to take the gabapentin. We discussed the risk of sedation, dizziness or worsening mood. She was asked to call if she experiences any new symptoms or the aforementioned side effects. She agreed to the same and elected to take the medication. Plan Take gabapentin 100 mg at night for 5 days then increase to 100 mg twice daily for 5 days, and if there are no side effects increase to 100 mg 3 times a day. She was asked to give me a call before she discontinued the medication. Patient offered telemedicine follow up visit: Yes Patient accepted telemedicine follow up: Possible if her bandwidth supports it. Follow up visit in 1 month or sooner if needed. She was asked to call for new or worsening symptoms. She was counseled about the assessment and plan and was given an opportunity to ask questions, which were subsequently addressed. She demonstrated understanding of the assessment and plan and agreed with the same. I spent a total of 30 minutes for the visit, greater than 50% of which was spent on counseling the patient regarding diagnosis and treatment plan, ordering meds/tests/procedures and coordination of care.

Chief Complaint/Reason for follow up

Hemicrania continua History of Present Illness: Subjective Benita M Cutarelli is a 67 y.o. right handed female who presents for a follow up visit for Hemicrania continua Interim History: 11/6/20: She tried indomethacin but was unable to tolerate the higher dose. Went up to 50 mg three times daily without problems but without an effect on the headache. Unable to tolerate 75 mg three times daily due to gastritis and diarrhea. Dizziness is stable. She has an ENT appointment on 1/20/21. Denies any new symptoms.

Prior Clinic Visits

10/6/20: As per my assessment and plan "Benita M Cutarelli is a 67 y.o. right handed female who presents to the clinic for a worsening of Meniere's disease symptoms. The vertigo, associated with left ear fullness and hearing loss suggests that this is worsening of Meniere's disease. It is conceivable that aggravation of Meniere's symptoms may produce vertigo during Dix Hallpike while the head position is being changed. Hence, the Dix Hallpike may be falsely positive. However, I would not rule out the possibility completely. In addition, the chronic left eye pain might be hemicrania continua as it has trigeminal autonomic symptoms associated with the same. The patient was referred to ENT for management of Meniere's disease. Vestibular therapy was deferred during the last visit. The patient was also started on an indomethacin trial for hemicrania continua. MRI was deferred pending response to the medication. "

Past Medical History

Anemia: Diagonised per Dr. Mitchell on 6-17-2013• Arthritis• Endoscopy and Colonoscopy done on 7-13-2020• Back pain/Sciatica• Blood in stool June 12-17 stopped then blood stopped• Depression• Dizziness 9-2013• Dyspnea• Eye pain Chronic; Left• GERD (gastroesophageal reflux disease)• Migraine headache• PONV (postoperative nausea and vomiting)• Syncope• Tinnitus, bilateral• Vertigo• Wears glasses

Past Surgical History

Procedure Laterality Date•CLSD RED JOINT DISLOCATION Left elbow• ENDOSCOPY and COLONOSCOPY N/A 7/13/2020• Procedure: COLONOSCOPY ANESTHESIA; Surgeon: Akeek Sanat Bhatt, MD; Location MMC Endo; Service: Gastroenterology•EGD N/A 7/13/2020• Procedure: ESOPHAGOGASTRODUODENOSCOPY ANESTHESIA; Surgeon: Akeek Sanat Bhatt, MD; Location: MMC Endo; Service: Gastroenterology• ENDOSCOPY SINUS,SEPTO-NASAL RECONSTRUCTION x5• ESOPHAGOGASTRODUODENOSCOPY•Pt reports years ago• WRIST SURGERY Left

Family History

Family History Problem Relation Age of Onset• Hypertension Mother• Atrial fibrillation Mother• Thyroid disease Mother• COPD Mother• Heart failure Father MI• Heart attack Father

Social History

Tobacco Use Smoking Status Never Smoker Smokeless Tobacco Never Used• Substance and Sexual Activity/Alcohol Use No• Alcohol/week:0.0 standard drinks• Substance and Sexual Activity Drug Use No

Allergy Information

I have reviewed the patient's allergies. Cefprozil, Erythromycin base, and Penicillin

Home Medications

Current Outpatient Medications on File Prior to Visit. Medication Sig Dispense Refill• Aspirin 81 MG EC tablet Take 81 mg by mouth daily• Vitamin D3 (Cholecalciferol), 5,000 unit Tab tablet Take 1 (one) tablet (5,000 Units total) by mouth daily. Pt currently taking 2000 units daily. 90 tablet 3 Refills• Ferrous sulfate 325 (65 FE) MG tablet. Take 325 mg by mouth 2 (two) times a day• FLAXSEED OIL ORAL Take 1,200 mg by mouth daily• Garlic 1,000 mg cap Take 1 capsule by mouth daily• Indomethacin (INDOCIN) 25 MG capsule Take 1 (one) capsule (25 mg total) by mouth 3 (three) times a day with meals for 10 days, THEN 2 (two) capsules (50 mg total) 3 (three) times a day with meals for 10 days, THEN 3 (three) capsules (75 mg total) 3 (three) times a day with meals for 10 days. 180 capsule 0 Refill• Meclizine (ANTIVERT) 25 mg tablet Take 1 (one) tablet (25 mg total) by mouth 3 (three) times a day as needed for dizziness or nausea. 30 tablet 2 Refills• NAPROXEN SODIUM (ALEVE ORAL) Take 1 tablet by mouth 2 (two) times a day as needed• Omega-3 fatty acids/fish oil (fish oil-omega-3 fatty acids) 300-1,000 mg capsule Take 2 g by mouth daily• Omeprazole (PRILOSEC) 20 MG capsule Take 20 mg by mouth daily• Ondansetron (Zofran ODT) 4 MG disintegrating tablet Dissolve 1 (one) tablet (4 mg total) on top of tongue every 6 (six) hours as needed for nausea 20 tablet 0 Refills• Potassium 99 mg Tab Take 1 tablet by mouth daily• Triamcinolone (KENALOG) 0.1 % cream Apply topically 2 (two) times a day as needed 45 g 0 Refills• Triamterene-hydrochlorothiazide (Dyazide) 37.5-25 mg per capsule Take 1 (one) capsule by mouth daily 90 capsule 1 Refill• VITAMIN E, DL,TOCOPHERYL ACET, (VITAMIN E, DL, ACETATE, ORAL) Take 1 tablet by mouth daily• No current facility-administered medications on file prior to visit.

ROS (Review of Systems)

All systems reviewed and negative except as mentioned in the HPI

Physical Examination

Vital signs BP 127/73 (BP Location: Right arm, Patient Position: Sitting, BP Cuff Size: X-large Adult) | Pulse (!) 53 | Wt 88.5 kg (195 lb) | SpO2 94% | BMI 33.47 kg/m² Constitutional: Well developed and well nourished. In no acute distress. Cardiovascular: Normal rate. No pedal edema noted. Respiratory: Normal respiratory rate. No accessory muscle use noted. Musculoskeletal : No joint swelling noted Skin: No rash or bruise noted on visible skin. Psych : Normal mood. Neurological Examination Neurologic Exam Mental Status Oriented to person, place, and time. Attention: normal. Speech: speech is normal Level of consciousness: alert Cranial Nerves CN II Visual acuity: normal CN III, IV, VI Pupils are equal, round, and reactive to light. Extraocular motions are normal. Nystagmus type: horizontal and vertical CN VII Facial expression full, symmetric. No scalp or cervical paraspinal tenderness on palpation. Motor Exam Strength Strength 5/5 throughout. Gait, Coordination, and Reflexes Coordination Positive Romberg's test: mild swaying. Tandem walking coordination: abnormal (unable to perform) Aashrai Gudlavalleti MBBS, ABPN General Neurology, Clinical Neurophysiology. Patient Instructions A Gudlavalleti at 11/6/2020 8:25 AM For the headaches, take Gabapentin as follows 100 mg a night for 5 days, then 100 mg in morning and 100 mg at night for 5 days then, if you do not have side effects, increase to 100 mg three times daily. Call before stopping the medication. END of November 6, 2020 Progress Notes.

December 10, 2020 Virtual Visit via Computer Telehealth Appointment 10:AM with Dr. G. This was my first Telehealthe Visit via computer. The following are Dr. G's Progress Notes.

Progress Notes A Gudlavalleti at 12/10/2020 10:00 AM Neurology Outpatient Clinic Consult OhioHealth Physician Group 12/10/2020 Aashrai Gudlavalleti, MBBS, ABPN 990 S Prospect St Suite 2 Marion OH 43302-6283 740-383-7833 Patient Name: Benita M Cutarelli DOB: 3/20/1953 Primary care provider Qihui Joanna Liu, MD Referring physician No ref. provider found ===================================================================

Virtual Visit Consent Statement:

I discussed risks, benefits and alternatives of telemedicine consultation with the patient including the risks that the patient's personal health details and medical records will be discussed over interactive video/audio/telecommunication technology, and that there are inherent diagnostic limitations compared to face-to-face evaluations. The patient elected to proceed with the telemedicine consultation.

Assessment and Plan:

Subjective

Benita M Cutarelli is a 67 y.o. right handed female who presents for a follow up visit for presumed hemicrania continua, past medical history pertinent for Meniere's disease. She has unilateral headaches in the V1 distribution which is constant and associated with lacrimation (eye tearing up) and redness of the eye (trigeminal autonomic symptoms). She reports significnat improvement with NSAIDs such as naproxen. Hence, my suspicion for hemicrania continua is quite high. We tried gabapentin after the last visit which does not seem to help. She is amenable to trying indomethacin again. If indomethacin trial does not work or if she is unable to tolerate the same, will consider a trial of triptans. She requested deferral of further imaging. She will try to get the MRI report from Riverside, and based on that we will discuss further need for imaging-would also consider noninvasive angiogram of the head and neck to evaluate for vascular causes for the headache(given that the headache is stable for several years this may be less likely). Her dizziness had improved and the improvement was also noted on exam.

Plan

Start taking indomethacin 50 mg(2 pills) 3 times a day for 1 week. Then slowly increase to 3 pills in the morning, 2 pills in the afternoon and 2 pills in the evening for a week, then take 3 pills in the morning, 3 pills in the afternoon and 2 pills in the evening for a week, and then take 3 pills 3 times a day. Side effects including gastritis, internal bleeding were discussed but the benefits were thought to outweigh the risk. She agreed to the same. A trial of total 6 weeks was planned. She was encouraged to take omeprazole every day while taking the indomethacin and was also asked to take over-the-counter antacids if needed. She was asked to keep her appointment with ENT to develop strategies to deal with recurrence of Ménière's. Patient offered telemedicine follow up visit: Yes Patient accepted telemedicine follow up: Yes Follow up visit in 6 month or sooner if needed. She was asked to call for new or worsening symptoms. She was counseled about the assessment and plan and was given an opportunity to ask questions, which were subsequently addressed. She demonstrated understanding of the assessment and plan and agreed with the same. I spent a total of 30 minutes face to face with the patient, greater than 50% of which was spent on counseling the patient regarding diagnosis and treatment plan, ordering meds/tests/procedures and coordination of care.

Chief Complaint/Reason for follow up: Hemicrania Continua
History of Present Illness:

Subjective

Benita M Cutarelli is a 67 y.o. right handed female who presents for a follow up visit for Hemicrania Continua.

Interim History

She states that the dizziness and vertigo have resolved. She wonders if she needs to keep her ENT appointment. Regarding gabapentin, she states that it only made her feel drowsy and did not help with the headache. Additionally, the effects lasted only for 3 hours after the dose. States that she continues to have left eye pain which has been stable over several years. She states she had an MRI of the brain about 10 years ago at Riverside which found some lesion in the left eye. She denies any new complaints today.

Prior clinic visits

11/6/20: She was unable to tolerate the indomethacin and would like to avoid a repeat trial as of now. I explained that there are not any good alternatives with robust data. However, there are reports of trial of other medications such as gabapentin. She was agreeable to take the gabapentin. Plan Take gabapentin 100 mg at night for 5 days then increase to 100 mg twice daily for 5 days, and if there are no side effects increase to 100 mg 3 times a day. She was asked to give me a call before she discontinued the medication.

Past Medical History: Diagnosis and Date

• Anemia sched for egd and c-scope 7-13-2020 • Arthritis • Back pain • Blood in stool-June 12-17 stopped then blood stopped • Depression • Dizziness 9-2013 • Dyspnea • Eye pain Chronic; Left • GERD (gastroesophageal reflux disease) • Migraine headache • Migraine headache • PONV (postoperative nausea and vomiting) • Syncope • Tinnitus, bilateral • Vertigo • Wears glasses

Past Surgical History

Procedure Laterality Date• CLSD RED JOINT DISLOCATION Left elbow• COLONOSCOPY N/A 7/13/2020• Procedure: COLONOSCOPY ANESTHESIA; Surgeon: Akeek Sanat Bhatt, MD; Location MMC Endo; Service: Gastroenterology• ENDOSCOPY N/A 7/13/2020 Procedure: ESOPHAGOGASTRODUODENOSCOPY ANESTHESIA; Surgeon: Akeek Sanat Bhatt, MD; Location: MMC Endo; Service: Gastroenterology• ENDOSCOPY SINUS,SEPTO-NASAL RECONSTRUCTION x5• ESOPHAGOGASTRODUODENOSCOPY Pt reports years ago • WRIST SURGERY LEFT

Family History

Problem Relation Age of Onset • Hypertension Mother • Atrial fibrillation Mother • Thyroid disease Mother • COPD Mother • Heart failure Father MI • Heart attack Father Social History: Social History Tobacco Use Smoking Status Never Smoker Smokeless Tobacco Never Used Social History Substance and Sexual Activity Alcohol Use No • Alcohol/week: 0.0 standard drinks Social History Substance and Sexual Activity Drug Use No

Allergy Information

I have reviewed the patient's allergies. Cefprozil, Erythromycin base, and Penicillin

Home Medications

Current Outpatient Medications on File Prior to Visit Medication Sig Dispense Refill • Aspirin 81 MG EC tablet Take 81 mg by mouth daily . • Cholecalciferol, vitamin D3, 5,000 unit Tab tablet Take 1 (one) tablet (5,000 Units total) by mouth daily Pt currently taking 2000 units daily . 90 tablet 3 • Ferrous Sulfate 325 (65 FE) MG tablet Take 325 mg by mouth 2 (two) times a day . • FLAXSEED OIL ORAL Take 1,200 mg by mouth daily. • gabapentin (NEURONTIN) 100 MG capsule 1 pill at night x 5 days, then 1 pill AM 1 pill PM x 5 days, then 1 pil three times daily with meals. . 90 capsule 1 • Garlic 1,000 mg cap Take 1 capsule by mouth daily. • Meclizine (ANTIVERT) 25 mg tablet Take 1 (one) tablet (25 mg total) by mouth 3 (three) times a day as needed for dizziness or nausea . 30 tablet 2 • Omega-3 fatty acids/fish oil (fish oil-omega-3 fatty acids) 300-1,000 mg capsule Take 2 g by mouth daily . • Omeprazole (PRILOSEC) 20 MG capsule Take 20 mg by mouth daily . • Ondansetron (Zofran ODT) 4 MG disintegrating tablet Dissolve 1 (one) tablet (4 mg total) on top of tongue every 6 (six) hours as needed for nausea . 20 tablet 0 • Potassium 99 mg Tab Take 1 tablet by mouth daily . • Triamcinolone (KENALOG) 0.1 % cream Apply topically 2 (two) times a day as needed . 45 g 0 • Triamterene-hydrochlorothiazide (Dyazide) 37.5-25 mg per capsule Take 1 (one) capsule by mouth daily . 90 capsule 1 • VITAMIN E, DL,TOCOPHERYL ACET, (VITAMIN E, DL, ACETATE, ORAL) Take 1 tablet by mouth daily. No current facility-administered medications on file prior to visit.

ROS: Review of Symptoms

All systems reviewed and negative except as mentioned in the HPI

Physical Examination

Vital signs: Not performed as this was a telehealth visit. Constitutional: Well developed and well nourished. In no acute distress. Cardiovascular: Not performed as this was a telehealth visit. Respiratory: Normal respiratory rate. No accessory muscle use noted. Abdomen: Not performed as this was a telehealth visit. Musculoskeletal : Mild tenderness near the lateral aspect of the left eye. Skin: No rash or bruise noted on visible skin. Psych : Normal mood.

Neurological Examination

Mental Status Oriented to person, place, and time. Attention: normal. Speech: speech is normal Level of consciousness: alert Cranial Nerves CN II Visual acuity: normal CN III, IV, VI Extraocular motions are normal. Nystagmus: none Ophthalmoparesis: none CN VII Facial expression full, symmetric.

Motor Exam

Right arm pronator drift: absent; Left arm pronator drift: absent; Able to move all extremities with at least antigravity strength.

Sensory Exam

Light touch normal. Gait, Coordination, and Reflexes Gait Gait: normal Coordination Positive Romberg's test: mild swaying. Tandem walking coordination: normal Tremor Resting tremor: absent; Intention tremor: absent.
Aashrai Gudlavalleti MBBS, ABPN General Neurology, Clinical Neurophysiology.

Patient Instructions A Gudlavalleti at 12/10/2020 10:20 AM

January 26, 2021 Virtual Visit via Computer Telehealth Appointment 10:AM with Dr. G. This was my second Telehealthe Visit via computer. The following are Dr. G's Progress Notes.

Progress Notes

A Gudlavalleti at 1/26/2021 10:00 AM Neurology Outpatient Clinic Consult OhioHealth Physician Group 1/26/2021 Aashrai Gudlavalleti, MBBS, ABPN 990 S Prospect St Suite 2 Marion OH 43302-6283 740-383-7833 Patient Name: Benita M Cutarelli DOB: 3/20/1953 Primary care provider Qihui Joanna Liu, MD Referring physician No ref. provider found.

Virtual Visit Consent Statement January 26, 2021

Assessment and Plan

Subjective Benita M Cutarelli is a 67 y.o. right handed female who presents for a follow up visit for presumed hemicrania continua, past medical history pertinent for Meniere's disease. She has unilateral headaches in the V1 distribution which is constant and associated with lacrimation and redness of the eye (trigeminal autonomic symptoms). She reports significnat improvement with NSAIDs such as naproxen. Hence, my suspicion for hemicrania continua is quite high. However, she is also complaining of blurred vision in the left eye and thus primary ophthalmologic disorders should be ruled out. In addition, trigeminal autonomic cephalgias are associated with structural lesions and thus an MRA head and neck should be considered as well.

Plan

Referral placed for ophthalmology. Request consideration of Humphrey's visual field testing, intraocular pressure testing and fundus photography. We will get an MR angiogram head and neck to rule out secondary causes of headache. Indomethacin 25 mg is a low dose as compared to naproxen 375/750 mg–The patient was asked to continue with the same. The goal would be to be on the minimum possible dose. Follow up visit in 2 months in clinic or sooner if needed. She was asked to call for new or worsening symptoms. She was counseled about the assessment and plan and was given an opportunity to ask questions, which were subsequently addressed. She demonstrated understanding of the assessment and plan and agreed with the same. I spent a total of 40 minutes on this encounter (on the day of the encounter) including time spent on on counseling the patient regarding diagnosis and treatment plan, conducting a chart review, ordering meds/tests/procedures and coordination of care.

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Chief Complaint/Reason for follow up

Hemicrania continua

History of Present Illness

Subjective Benita M Cutarelli is a 67 y.o. right handed female who presents for a follow up visit for Hemicrania continua.

Interim History

She was unable to tolerate the higher dose of indomethacin and had to discontinue. She saw ENT on 1/20/21 to establish care for Meniere's disease. She also continues taking the Dyazide every day. Give ENT a call back in case the Meniere's symptoms recur. She thinks that indomethacin does decrease the pain. She is using indomethacin 25 mg about 6 times a week instead of using Aleve 375-750 mg with the same frequency. She denies any side effects. She also complains of increasing blurry vision in the left eye as compared to the right. The pain is present every day in the back of the left eye.

Prior clinic visits

12/10/20: She states that the dizziness and vertigo have resolved. She wonders if she needs to keep her ENT appointment. Regarding gabapentin, she states that it only made her feel drowsy and did not help with the headache. Additionally, the effects lasted only for 3 hours after the dose. States that she continues to have left eye pain which has been stable over several years. She states she had an MRI of the brain about 10 years ago at Riverside which found some lesion in the left eye. She denies any new complaints today. Exam showed improvement in dizziness. Plan - Retrial of indomethacin; deferral of MRI as the patient will send the results from the prior MRI.

Past Medical History

Diagnosis Date • Anemia Endoscopy and Colonoscopy done on 7-13-2020 • Arthritis • Back pain • Blood in stool June 12-17 stopped then blood stopped • Depression • Dizziness 9-2013 • Dyspnea • Eye pain Chronic; Left • GERD (gastroesophageal reflux disease) • Migraine headache • PONV (postoperative nausea and vomiting) • Syncope • Tinnitus, bilateral • Vertigo • Wears glasses

Past Surgical History

Procedure Laterality Date• CLSD RED JOINT DISLOCATION Left elbow• COLONOSCOPY N/A 7/13/2020 Procedure: COLONOSCOPY ANESTHESIA; Surgeon: Akeek Sanat Bhatt, MD; Location: MMC Endo; Service: Gastroenterology• ENDOSCOPY N/A 7/13/2020 Procedure: ESOPHAGOGASTRODUODENOSCOPY ANESTHESIA; Surgeon: Akeek Sanat Bhatt, MD; Location: MMC Endo; Service: Gastroenterology• ENDOSCOPY SINUS,SEPTO-NASAL RECONSTRUCTION x5• ESOPHAGOGASTRODUODENOSCOPY Pt reports years ago • WRIST SURGERY Left

Family History

Problem Relation Age of Onset• Hypertension Mother • Atrial fibrillation Mother • Thyroid disease Mother • COPD Mother • Heart failure Father MI • Heart attack Father

Social History

Tobacco Use Smoking Status Never Smoker• Smokeless Tobacco Never Used• Substance and Sexual Activity Alcohol Use No • Alcohol/week: 0.0 standard drinks• Substance and Sexual Activity Drug Use No•

Allergy Information

I have reviewed the patient's allergies. Cefprozil, Erythromycin base, and Penicillin

Home Medications

Current Outpatient Medications on File Prior to Visit Medication Sig Dispense Refill • Aspirin 81 MG EC tablet Take 81 mg by mouth daily • Vitamin D3 (Cholecalciferol), 5,000 unit Tab tablet Take 1 (one) tablet (5,000 Units total) by mouth daily. Pt currently taking 2000 units daily. 90 tablet 3 Refills • Ferrous sulfate 325 (65 FE) MG tablet Take 325 mg by mouth 2 (two) times a day • FLAXSEED OIL ORAL Take 1,200 mg by mouth daily • Gabapentin (NEURONTIN) 100 MG capsule 1 pill at night x 5 days, then 1 pill AM 1 pill PM x 5 days, then 1 pil three times daily with meals. . 90 capsule 1 Refill • Garlic 1,000 mg cap Take 1 capsule by mouth daily • Omega-3 fatty acids/fish oil (fish oil-omega-3 fatty acids) 300-1,000 mg capsule Take 2 g by mouth daily • Omeprazole (PRILOSEC) 20 MG capsule Take 20 mg by mouth daily • Ondansetron (Zofran ODT) 4 MG disintegrating tablet Dissolve 1 (one) tablet (4 mg total) on top of tongue every 6 (six) hours as needed for nausea . 20 tablet 0 • Potassium 99 mg Tab Take 1 tablet by mouth daily • Triamcinolone (KENALOG) 0.1 % cream Apply topically 2 (two) times a day as needed 45 g 0 Refills • Triamterene-hydrochlorothiazide (Dyazide) 37.5-25 mg per capsule Take 1 (one) capsule by mouth daily 90 capsule 1 Refill • VITAMIN E, DL,TOCOPHERYL ACET, (VITAMIN E, DL, ACETATE, ORAL) Take 1 tablet by mouth daily. No current facility-administered medications on file prior to visit.

ROS

All systems reviewed and negative except as mentioned in the HPI

Physical Examination

Vital signs: Not performed as this was a telehealth visit.

Constitutional

Well developed and well nourished. In no acute distress.

Cardiovascular

Not performed as this was a telehealth visit.

Respiratory

Normal respiratory rate. No accessory muscle use noted.

Abdomen

Not performed as this was a telehealth visit

Musculoskeletal

Not performed as this was a telehealth visit.

Skin

No rash or bruise noted on visible skin.

Psych

Normal mood.

Neurological Examination

Neurologic Exam Mental Status Oriented to person, place, and time.

Attention/Speech/Level of Consciousness

Attention: Normal. Speech: Speech is normal. Level of consciousness: Alert.

Cranial Nerves

Cranial Nerves CN II Visual acuity: (Left eye vision is blurred) CN III, IV, VI Extraocular motions are normal. Nystagmus: None Ophthalmoparesis: None CN VII Facial expression full, symmetric. Motor Exam Strength Strength 5/5 throughout. Gait, Coordination, and Reflexes Tremor Resting tremor: Absent

Aashrai Gudlavalleti MBBS, ABPN General Neurology, Clinical Neurophysiology.

January 20, 2021

Saw Dr. Collazo today. The following are his notes.

Benita M Cutarelli 3/20/1953 Female

Antonio E. Collazo, MD Qihui Joanna Liu, MD 5002462174

Chief Complaint: Patient presents with Meniere's disease.

HPI: 67-year-old female patient we have seen in the past because of Ménière's disease. She has been using Dyazide regularly every day and that seems to control her symptoms. Last year she had a bad episode of dizziness with nausea and vomiting that lasted several hours. She did not have any other episodes after that. She has not noticed any change in hearing. She has not noticed any ear pain or discomfort. She has complained in the past about pain in the retro-orbital area. She is seeing a neurologist for that.

ROS: Review of Systems Constitutional: Negative for fever. HENT: Positive for hearing loss and tinnitus. Negative for ear pain. Respiratory: Negative. Cardiovascular: Negative. Gastrointestinal: Negative. Musculoskeletal: Negative. Neurological: Negative for dizziness.

Physical Exam Constitutional: She appears well-developed and well-nourished. HENT: Head: Normocephalic and atraumatic. Right Ear: Tympanic membrane, external ear and ear canal normal. No drainage. Tympanic membrane is not perforated. No middle ear effusion. Decreased hearing is noted. Left Ear: Tympanic membrane, external ear and ear canal normal. No drainage. Tympanic membrane is not perforated. No middle ear effusion. Decreased hearing is noted. Nose: No mucosal edema, nasal deformity or septal deviation. Mouth/Throat: Uvula is midline, oropharynx is clear and moist and mucous membranes are normal. No oral lesions. No trismus in the jaw. Normal dentition. No posterior oropharyngeal erythema. Neck: Trachea normal, normal range of motion and phonation normal. Neck supple. Normal carotid pulses present. No tracheal tenderness and no muscular tenderness present. No thyroid mass present. No swelling of the salivary glands. Lymphadenopathy: She has no cervical adenopathy. Neurological: She is alert. No facial nerve deficit.

Impression/Plan: Problem List Items Addressed This Visit Nervous and Auditory Hearing loss, sensorineural, high frequency Meniere disease - Primary Other Tinnitus, subjective She seems to be doing very well. She had one episode last year which is not bad. She should continue with her Dyazide regularly. If she starts having more problems with dizziness regularly then we may have to consider some other options to treat her Ménière's. She has not had any change in hearing lately so there is no need to check her hearing today. We will see her back again as needed. Antonio E. Collazo, MD

February 8, 2021

Had an appointment with Dr. Wainwright, an opthamologist, today. The following are his notes.

1. Left Eye pain 2. Combined forms of age-related cataract, bilateral 3. Hemicrania continua 4. Meniere's disease of left ear.

1) She reports heavy feeling in Left Eye eye began 5/4/1971 and involved an acute viral illness with fever at the time. Frank pain in left eye either developed then or around age 20-24 years old following a sinus surgery, she is not sure (all history per pt report). Full eye examination today is normal. Normal ocular surface without any corneal disease. Dilated eye examination shows normal retina vessels. Normal appearing optic nerve head without swelling or pallor. She has a normal eye pressure. Gonioscopy does not show a narrow angle. Based on her experience during examination, left eye seems to be hypersensitive to touch. She reports her usual boring pain in in center of the eye (present for 40+ years with some fluctuations). Her priorly reported excruciating pain with caustic dilating drops in past did not occur when she received proparacaine to eye beforehand, but proparacaine did not relieve her boring chronic pain. This would be consistent with hypersensitivity to ocular surface stimuli but her chronic pain being neurologic/"down stream" from corneal nerves somewhere. She carries a diagnosis of Hemicrania continua from Dr. Gudlavalleti.

This diagnosis most fits the boring chronic character of her pain. However, onset after viral illness, may consider a V1 trigeminal neuralgia?, although her pain is fairly localized for this. She reports long history of many medications, interventions being tried, including injections in neck. Indomethacin seems to help some, and she actually recalls Valium helping some. Gabapentin made her too tired, it helped some as well. She does not recall trying Lyrica. Defer definitive dx and management to Dr. Gudlavaletti. No ocular cause or sequelae identified. Letter written. Automated visual field testing ordered and within normal limits in each eye.

2) Mild cataracts, minimal effect on vision, monitor.

3,4) Sees Neurology and ENT for these, included in this note for information Fu 1 year Additional MDM: Reviewed prior external note(s) from Dr. Gudlavalleti, Dr. Collazo

Chief Complaint/Reason for Visit: HPI Referral Dr. Gudlavelleti Neurogist - Ohio health Chief Complaint: Left eye pain x 40 years+, Saw Dr. Garvin for same problem and he saw nothing. Saw a neurologist Dr. Gudlavelleti (Ohiohealth) And he wanted her to be seen and have visual field, fundus photography and Ocular pressure. Patient has history of headaches, says not migraines that she knows of. Pt. States she screamed from pain last time she was dilated. Ocular Surgical Hx: NONE

Lab Results Component HGBA1C (Pre Diabetic) Value 5.9 (H) Date 06/08/2020 Last edited by William Bradley Wainright, MD on 2/8/2021 5:58 PM. (History) No outpatient medications have been marked as taking for the 2/8/21 encounter (Evaluation) with William Bradley Wainright, MD.

February 25, 2021

Had an Angiogram MRA of Brain without any contrast. Results showed no focal intracranial stenosis, large-vessel occlusion or aneurysm. Also had an Angiogram MRA of Neck without any contrast. Results showed the carotid bifurcations and cervical carotid arteries are normal in appearance. The left vertebral artery is dominant. In other words, nothing found from both tests that relates to my left head and eye pain.

March 19, 2021

Appointment with Dr. Aashrai Gudlavalleti scheduled for March 19, 2021 via Telehealth (computer). Date was originally scheduled for May 21, 2021. I made a plan with Jesus and told Him I needed my appointment to be before May 14, 2021. When Dr. Aashrai Gudlavalleti's office called to let me know the results of my MRI tests I asked them if I could reschedule my appointment sometime before May 14th. I was told there were no openings, that he was booked solid. I then asked her if she could call me if there was a cancellation before May 14th, and perhaps I could schedule myself at the cancellation date. She said okay. Many days passed and no phone call. I kept praying to Jesus that I really needed to have my appointment before May 14th. Many more days passed and no phone call. Then, finally the phone rang. It was Dr. Aashrai Gudlavalleti's office. The office girl said, "Dr. Gudlavalleti will be out of the office on May 21st, and we really need to get you in before then anyway." DUH! She rescheduled me for March 19, 2021. Thank You Jesus!

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CONTINUE