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My Medical Records with Dr. James Kim, Benjamin Nguyen and Dr. Stanley H. Appel



DATE OF PROCEDURE:       10/15/03
PHYSICIAN:                            JAMES J. KIM, M.D.
TECHNICAL SUMMARY:    Somatosensory evoked response obtained for left median nerve stimulation.  Frequency filter setting was 5.64 Hz.  Stimulation frequency filter setting was 10-3000 Hz.  Derivations recorded are EP-EPC, C5-EPC, CPI-EPC, CPC-CPI.
Latency results in milliseconds:  EP latency was 8.83 ms, N13 latency was 11.95 ms, N20 latency was 17.58 ms.  Interpeak latency of EP-N13 was 3.12 ms, N13-N21  5.63 ms.
IMPRESSION:  This is a normal median SSEP

PHYS:     KIMJ944                                   ____________________________

DIST DATE:  10/21/03                                Kim, James J. , M.D.

TRANS DATE:    10/22/03
Job #11501-2
Willis Knighton PCI  **LIVE**  (PCI: OE Database WIK)
Run:  01/07/04-08:23 by BARNES, MARY


WILLIAMS, PEGGY GRAY                       REG CLI
DATE OF PROCEDURE:                    10/15/03
PROCEDURE:                                      VISUAL EVOKED POTENTIAL REPORT
REFERRING PHYSICIAN:                  James J. Kim, M.D.
TECHNICAL SUMMARY:    Patient was seated at eye level and 75 cm distance.  Stimulation rate was 2.1 Hz.  Stimulation was a full field and checkerboard size was 32x32.  Frequency filter setting was 1.21 Hz.
From the right eye stimulation P100 latency was 101 ms with N75-P100 amplitude of 9.65 mV.
From the left eye stimulation the P100 latency was 99.61 ms with N75-P100 amplitude of 5.8 mV.
IMPRESSION:   This is a normal pattern reversal visually evoked potential.
Job #11501 -----------------------------------------------------------------------------------------------
DATE OF PROCEDURE:             October 15, 2003 PHYSICIAN:                                   JAMES J. KIM, M.D. PROCEDURE:                    TIBIAL NERVE SOMATOSENSORY EVOKED POTENTIAL
TECHNICAL SUMMARY:  Tibial nerve somatosensory evoked responses were obtained from left tibial nerve stimulation.  Stimulation rate was 5.64 Hz.  Frequency filter setting was 30-3000 Hz.  The derivations recorded are popliteal fossa, L3-IC, FPZ-C5, CZ prime-FPZ.
Latency results in milliseconds:  Lumbar potential latency was 18.75 ms and P37 was 36.09 ms.  LP-cortical interpeak latency was 17.34 ms.
IMPRESSION:  This is normal tibial nerve SSEP.
Job #11501-3
Unit No:                         SS#:
Admitting Diagnosis:  MULTIPLE SCLEROSIS
EXAM#                          TYPE/EXAM                    RESULT

02: N
LUMBAR PUNCTURE INCLUDING FLUORO:  The patient's informed consent was obtained prior to the procedure.  The lower back was prepped and draped in a sterile fashion and 1% Xylocaine was used to anesthetize the soft tissues.  Under fluoroscopic guidance, a lumbar puncture was performed at L3-4 level and thee fluid was initially bloody.  Fluid then cleared and fluid was collected and sent for the requested studies.  The patient tolerated the procedure well.
IMPRESSION:  Fluoroscopically guided lumbar puncture as described.
           Reported By:  J.P. PRICE, M.D. (ELECT. SIGN) WKP

Name:  Williams, Peggy Gray
Phys:  KIM, JAMES J., M.D.
Dob:  03/14/1945 Age 58
Exam Date:  11/17/2003  Status:  REG CLI

Louisiana Neurologic Specialties

2015 Fairfield Avenue, Suite 2 C           Benjamin B. Nguyen, M.D.              8001 Youree Drive, Suite 500    Shreveport, LA 71104                Diplomate, American Board of Neurology       Shreveport, LA 71115             (318) 424-3268, Fax (318)424-3280       Fellow, EMG/NCV/EEG,Botox            (318) 212-9111

January 8, 2004



RE: Peggy Keyes Williams, 1204 Dot Avenue, Bossier City, LA 71111

CHIEF COMPLAINT: Leg weakness and pain.

HISTORY OF PRESENT ILLNESS: Patient is a 58 year old female who complains of having 6 months history of gait difficulty.

The patient states that she always has some painful muscle spasm in her legs on and off for the past 5 years, but starting about 6 months ago she begin to have slow increased difficulty with walking and gradually getting worse and worse. Mow she cannot walk for prolonged period of time without falling down. She states that when she walks her legs become stiff and she cannot bend her knees or move her legs.

She also complains of having diffuse pain from the hip down to her foot when she walks. When she sits down she feels a little bit better.

She states that her leg problem is much worse in the right leg compared to the left.

She has intermittent low back pain and also neck pain, but not anything severe, at least now as severe as her leg pain.

She denies any numbness and paresthesias in her legs.

She has no motor dysfunction or motor deficit of her bilateral upper extremities.

She states that she can still use her hands very well. She has no trouble using them at all.

She has no bowel or bladder incontinence.

PAST MEDICAL HISTORY: She has a history of breast cancer in 1971 which apparently is in remission.

MEDICATIONS: She currently takes Vioxx and Quinine, both for pain and muscle spasms.




SOCIAL HISTORY: She smokes 1 1/2 packs a day, denies alcohol intake.

REVIEW OF SYSTEM: Noncontributory.

PHYSICAL HISTORY: Patient is a well developed, well nourished female who is awake, alert, in no acute distress.

Cognitive and memory functions are normal.

Speech is normal. Patient is able to follow commands well.

Funduscopic exam is normal.

NEUROLOGICAL EXAMINATION: Cranial nerve 2 through 12 are normal.

Visual fields are intact.

Sensory and motor exam in both upper extremities are normal.

Sensory in both lower extremities are normal to pin prick, light touch, vibratory and proprioception. She has no evidence of sensory level on her spine.

On motor exam she has diffuse weakness about 5-/5 in the left leg and 4/5 in the right leg. She has fairly severe spasticity in both legs, worse on the right compared to the left. When she walks she has spastic gait.

She has marked increased reflexes on the right knee and ankle and to a lesser extent on the left.

She has sustained clonus on the right.

Her toes are upgoing on the right and downgoing on the left.

Subsequently EMG/NV study in both lower extremities was found to be normal.

She had extensive work up recently by Dr. James Kim including normal MRI of brain performed 10/25/03 at W/K Pierremont. Also performed on 11/14/03 at W/K Pierremont was a normal MRI of thoracic spine along with MRI of the lumbosacral spine, which showed mild bulging disc. MRI of the cervical spine at C5-C6 cervical disc was associated with spinal cord compression, however this is described as being "mild cord compression.

IMPRESSION: Probable cervical myelopathy producing bilateral lower extremities paraplegia, worse on the right leg compared to the left.

At this time, I have told the patient that I will attempt to get the MRI films to be reviewed within the next few days. Will go ahead and refer the patient to Dr. D. Cavanaugh to be seen within the next week for evaluation of possible cervical decompression.



She also has had normal MRI of brain and normal spinal tap with no evidence of multiple sclerosis or increased myelin protein or oligioclonal bands.

She also has had complete evoked potential studies, which were found to be normal.

I appreciate this kind referral from Dr. Kim.

Benjamin Nguyen, M.D.

CC: Dr. David Cavanaugh
Dr. Wayne Barksdale



Dr. Benjamin Nguyen

Electrodiagnostic Medicine Consultation

Name: Williams, Peggy K. Social Security number: xxx-xx-xxxx
Hospital number: xxxxx Date of Birth: 03/14/1945
Age: 58
Sex: F
Address: 1204 Dot
Bossier City, LA 71111
Home Phone Number: (xxx) xxx-xxxx

Date of EMG: 01/08/2004

**** Referring Physician ****

Dr. James Kim


Nerve Identification         Amplitude           Latency          Cond Veloc         Dist

1 R Peroneal
       Proximal Stim               2.9 [> 2.2]             14.8              41.1 [.41.0]          37.0
       Distal Stim                   3.0 [> 2.2]               5.8 [<5.7]
2 R  Posterior tibial
        Proximal Stim              6.1 [> 2.8]             14.5             43.3 [.41.0]           42.0
        Distal Stim                  6.2 [> 2.8]               4.8 [<5.7]
3 R   Distal Sural                8.0 [> 5.0]               4.1 [<4.2]
4 R   Superficial peronea   6.0 [> 5.0]               3.3 [<3.4]
5 R   Medial Plantar            6.0                          4.2
6 R   Saphenous                 6.0                           3.9
7 L Peroneal
       Proximal Stim               2.4 [>2.2]               13.3                43.8  [>41.0]     42.0
       Distal Stim                   2.9 [>2.2]                 3.7 [<5.7]
8 L  Posterior tibial
        Proximal Stim              6.1 [>2.8]               12.8                43.6 [>41.0]      41.0
        Distal Stim                  6.5 [>2.8]                  3.4 [<5.7]
9 L   Distal Sural              10.0 [>5.0]                   4.0 [<4.2]
10 L  Superficial peroneal 10.0 [>5.0]                 3.2 [<3.4]
11 L  Medial Plantar             8.0                            4.1
12 L Saphenous                  11.0                            3.8

**** H - REFLEXES ****

                                                                LATENCY                  LIMITS           Axonal
Nerve Identity           Amplitude     Meas'd    Normal       Upper    Lower    Length
1  Right  tibial                                         31.6
2  Left    tibial                                          31.6


                                                          Insert.    Spont.      Activ.      Volunta. Motor
Muscle Identity                                 Activity     Fib.         Fasc.       Unit Potentials
1 R Tibial Anterior                             Normal        0               0                Normal
2 R Gastrocnemius                           Normal        0               0                Normal
3 R Quadratus Femoris                   Normal        0              0                Normal
4 R Semitendinosus                      Normal        0              0                Normal
5 R Extensor Digitorum Brevis         Normal         0             0                Normal
6 L Abductor Hallucis Brevis           Normal         0             0                Normal
7 L Tibial Anterior                         Normal          0            0                 Normal
8 L Gastrocemius                         Normal          0            0                Normal
9 L Quadratus Femoris                   Normal           0           0                Normal
10 L Semitendinosus                     Normal           0           0                Normal
11 L Extensor Digitorum                Normal           0           0                Normal
12 L Abductor Hallucis Brevis       Normal           0           0                Normal

**** Summary ****

Nerve conduction study in both lower extremities shows normal motor and sensory responses throughout including bilateral H - reflexes.

Needle exam was performed in both lower extremities and shows normal insertional activity with no evidence of fibrillation or fasciculation. Motor unit potential and recruitment patterns are normal throughout.

**** Interpretation ****


I appreciate this kind referral from Dr. Kim.


Benjamin Nguyen, M.D.
Electromyographer and Attending Physician


OUR # xxxxx

Ms. Williams returns today still complaining of severe spastic gait along with bilateral leg weakness. The patient has seen Dr. Cavanaugh who felt the patient does not have any significant cervical spine disease to need surgery. He He agrees that patient does appear to have upper motor neuron problem associated with clonus and weakness and spasticity.

Neurological exam is unchanged compared to before. She still has clonus in both legs at both ankles, hyperreflexia in both lower legs and spastic and weakness in both lower legs.

IMPRESSION: Spastic paraparesis, etiology unclear.

This may be of hereditary. However, would like to send patient to see Dr. Appel to rule out atypical upper motor neuron disease/ALS.

Review of her records shows that she has had extensive workup including MRI of the brain, MRI of the thoracic and lumbar along with spinal tap that was found to be unremarkable.

Will see patient 1 to 2 weeks after she sees Dr. Appel.



DISCHARGE SUMMARY                                  BAYLOR COLLEGE OF MEDICINE   
 Name:  Peggy K. Williams                                 One Baylor Plaza

 Hospital Number: xxxxxx                                 Houston, Texas  77030-3498       

 Date of  Admission: 03/08/2004                      Stanley H. Appel

Date of Discharge:  03/10/2004                        Professor and Chairman

Discharge Diagnosis:     ALS                             TEL:(713) 798-4073

                                                                                 FAX:(713) 798-3854

Procedures in Hospital


2. Bedside force vital capacity

3. Neuropsychological testing


Ms. Williams is a 58-year-old lady presenting with progressive spasticity and weakness in her legs as well as multiple falls. About six years ago she started having cramps in her feet and charley horses in her legs which have progressively worsened since then and now bothers her constantly even waking her from sleep. About eight months ago she was out in her yard and just fell for no reason. Since then, she has started falling more frequently, about two to three times per week. She has trouble walking and notes that her legs will either lock up or just crumble underneath her. After she falls, she is too weak to get up. She first noticed weakness in her right leg about five months ago. This has also gotten worse and now the left leg is also weak. About four months ago, Ms. Williams noticed that her right leg would start jerking when she was sitting down. This would only happen every now and then, but now both legs will jerk and it occurs every day. Over the past two to three months, she has just started to have urinary and fecal incontinence. The urinary incontinence is described as leaking not long after she has gone to the bathroom and feels like she had completely emptied her bladder. This occurs every day. Her fecal incontinence is described as a sudden urge to defecate and then not being able to hold it until she gets to the bathroom. This only happens about twice a month. Ms. Williams also reports having a bad headache each morning for the past few months. She notes her short-term memory is not as good as it was six months ago.


Medical: Breast Cancer in 1971; 3 spontaneous abortions and one stillbirth. Surgical:  Appendectomy; radical mastectomy in 1971; hystorectomy in 1986; partial left mastectomy and breast implants in 1976.   Allergies: Codeine causes a severe headache.   Medications: Vioxx 25 mg p.o.q.d.; Quinine 325 mg p.o.q.h.s.  Family History:  Mother is alive at 81 years old and has had multiple strokes and COPD.   Father died at age 73 of emphysema and myocardial infarction.   A sister has hypertension.   There is no neurological disease in the family.   Social History: She smokes 1 -pack/day for 29 years.   She seldom uses alcohol.   She denies recreational drug use.   She is married and has one child and two grandchildren. She works as a secretary.  Review of Systems:  Notable for headaches and incontinence as noted in HPI.   Negative for weight gain or loss, fatigue, fever, chills, sore throat, chest pain, palpitations, shortness of breath, cough, nausea, vomiting, diarrhea, dysuria, hematuria, heat or cold intolerance, excessive thirst, excessive bleeding or bruising. 


Physical ExaminationVital Signs: T = 97.3. P = 71. RR = 16. BP = 128/70.General Appearance:  The patient is sitting comfortably in the bed and is in no acute distress. 

HEENT: Normocephalic, atraumatic. Sclera anicteric. Oropharynx clear.   Neck: Supple.  No carotid bruits.   Chest/Lungs:  Clear to auscultation bilaterally.   Heart: Regular rate and rhythm without murmurs, rubs or gallops.  Abdomen:   Soft, nontender, and nondistended. Positive bowel sounds.  Extremities:   No clubbing, cyanosis or edema.  Skin:  No rashes or lesions. 

NeuroexaminationMental Status: She scored 30/30 on the Mini-Mental Status Examination.  Speech:  Fluent without repetition or comprehension errors.  Labial, lingual and guttural sounds are intact.

Cranial Nerves:

I. - Not tested.

II. - Pupils are equal, round and reactive to light and accomodation. Visual fields are full to confrontation bilaterally. Visual acuity is intact.

III., IV., VI. - There is a full range of motion of extraocular movements without nystagmus.

V. - Pinprick and light touch are intact in VI - V3 bilaterrally. Corneal reflex is present bilaterally. There is good bulk and strength of masseter, pterygoid and temporalis muscles bilaterally.

VII. - Orbicularis oris and orbicularis oculi strength 4/5 bilaterally.

VIII. - Hearing is intact bilaterally.

IX., X. - Symmetric elevation of the palate. Gag reflex is present and equal bilaterally.

XI. - Sternocleidomastoid strength 4+/5

Trapezius strength 5/5.

XII. - Midline tongue protrusion without atrophy or fibrillations.

Motor Examination:

Neck flexors                                                          3+/5

Extensors                                                               4/5

Deltoids                                                                  4-/5 bilaterally                                         

 Biceps                                                                    4+/5 bilaterally

Triceps                                                                    5-/5 right                4+/5 left

Wrist extensors                                                     4+/5 bilaterally

Wrist flexors                                                         4+/5 right                4/5 left

Finger extensors                                                  4+/5 right                4/5 left

Finger flexors                                                       5/5 bilaterally

Hip flexors                                                             4-/5 bilaterally

Knee extensors                                                      4-/5 right                4+/5 left

Knee flexors                                                           4/5 bilaterally

Ankle dorsiflexors                                                4/5 right                  4+/5 left

Plantar flexors                                                      4+/5 bilaterally

Toe extensors                                                         4/5 bilaterally

Toe flexors                                                              4/5 right                  4+/5 left

Muscle tone is normal in the upper extremities and increased in the lower extremities with clonus of right lower extremity.


Triceps                                                          3+ right 2+ left

Biceps                                                           3+ right 2+ left

Brachioradialis, patellar                         3 bilaterally

Ankle jerks                                                  4 right                               3 left

Crossed abductor responses are positive bilaterally. Plantar responses are downgoing. Hoffmann's, jaw jerk, and snout are positive. Glabellar and palmomental are negative.

Sensory Examination:  Pinprick is slightly decreased in the right leg below the shin down. Vibration is slightly increased in toes on the right. Temperature and propriception are normal. Romberg is negative.

Coordination:  Finger-to-nose shows terminal oscillations. Heel-to-shin is slow. There is no truncal ataxia or titubation.Gait: Spastic but normal base. Unable to walk on heels or toes.

HOSPITAL COURSE: The patient was admitted to the Jones 9 Outpatient Unit for evaluation of her progressive spasticity and muscle weakness. On day one, she underwent bedside forced vital capacity and EMG. On day two, the patient underwent neuropsychological testing. During the hospital course, she developed no headache and remained basically unchanged.Laboratory Studies: Sodium 145, potassium 3.6, chloride 108, bicarbonate 27, BUN 12, creatinine 1.0, glucose 87, calcium 9.2, WBC 4.92, hemoglobin 13.8, hematocrit 42.0, platelet count 241,000, MCV 92.1, PT 13.1, PTT 28.7, INR 0.9, AST 19, ALT 9, alkaline phosphatase 104, protein 7.0, albumin 4.6, total bilirubin 0.3, direct bilirubin 0.1, CPK 93, ESR 16, RPR nonreactive, TSH 2.73, T3 RU 81, T4 7.5.

Pending studies: ANA, HTLV and rheumatoid factor.

Urinalysis - negative protein, glucose, nitrites; WBC 0, RBC 1; moderate bacteria.

Special Studies: Bedside Forced Vital Capacity: 3.36 liters (104% of predicted).EMG/NCV: Abnormal study. Motor latencies and velocities are normal, but sural sensory responses are absent suggesting sensory neuropathy. In addition, there is evidence of denervation in tongue, thoracic paraspinous, arm, and leg muscles. This study suggests widespread motor neuron disease and sensory neuropathy.

Neuropsychological Testing: Please see separate report.

Outside Studies: Brain MRI is unremarkable.MRI of Cervical Spine revealed mild disk bulge at C5-6 and circumferential bulge at C6-7, but no cord compression.MRI of Thoracic Spine is unremarkable.

Consultations: ALS Team: Occupational Therapy; Physical Therapy; Speech Therapy; Dietary; Social Services; Dr Cross, Pulmonary Medicine; Neuropsychology.

SUMMARY: Ms. Williams is admitted for evaluation of her progressive spasticity and weakness. Physical examination showed spasticity and increased reflexes. Also, there was weakness. EMG showed findings suggestive of motor neuron disease and sensory neuropathy. Although she has urinary and bowel incontinence, the perianal sensation is good. We believe that Ms. Williams has ALS.  She was seen by the ALS Team and all questions were answered to her satisfaction. She will be followed in the MDA/ALS Clinic on Friday in three to four months. During her hospital course, baclofen was started and she noted her spasticity had improved.


  1. Rilutek 50 mg p.o.q.12 hours.

  2. Baclofen 10 mg p.o.t.i.d.

  3. Vitamin C 1,000 mg p.o.t.i.d.

  4. Vitamin E 1,000 IU p.o.t.i.d.

  5. Beta Carotene 25,000 IU p.o.b.i.d.

  6. Melatonin 3 mg p.o. 20 minutes before bedtime

  7. Coenzyme Q-10 100 mg p..b.i.d.



             Stanley H, Appel, M.D./Kenkich Nozaki, M.D.

            Professor and Chairman


cc: Benjamin Nguyen, M.D.


Ms. Williams returns today for a follow-up after returning from Houston. She has a diagnosis of ALS.

Neurological exam is unchanged compared to before. She still has severe weakness and spasticity in both legs. She has to hold on to her husband when she walks.

IMPRESSION: Amyotrophic Lateral Sclerosis.

Continue with Baclofen 10 mg as needed for muscle spasticity along with Rilutek bid. I have recommended patient not return to work. I am doubtful that she can be trained for any type of new job. I strongly urge patient to apply for disability at this time.

Will see patient for follow-up in 2 to 3 months or sooner if needed.


8001 Youree Dr., Suite 500 Louisiana Neurologic Specialties 2015 Fairfield Ave., Suite 2-C
(318) 212-9111 Benjamin B. Nguyen, M.D. (318) 424-3268 Fax (318)424-3280


  These pictures were taken in Houston, Texas the day of my diagnosis. This is my husband, Curtis Bryan Williams, Me, my sister, Jeanette Boman and her husband, Bennie Boman.

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  My Nurses in Houston I don't remember their names, but they are real sweet ladies and they really treated me well.

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  My Physical Therapist in Houston Her name is Wendy. I don't remember her name, but Jeanette and Bennie said she looks like their daughter-in-law.

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