MyConsult Online Medical Second Opinion

Following a thorough review of your medical records and diagnostic tests, our physician specialists render a second opinion that can be shared with your doctor.

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There are seven steps in the process of requesting a second opinion. We anticipate the steps will take you about 30-45 minutes to complete. A helpful hint that we recommend:

  • Have your medical records or those of your loved one on hand as you fill out the medical history questionnaire portion of the online process.
  • The medical history questionnaire is detailed so having medical records to quickly reference will help make the process more efficient.

Below is a brief description of the information being requested in each step of the online process:

»1. Requestor Information

This initial step only applies if the individual requesting the online second opinion is someone other than the patient that needs the second opinion. We ask the requestor basic information such as name, address, date of birth etc. If you are the actual patient requesting the second opinion, you can skip to step 2.

»2. Patient Information

In this step, we ask for information about the patient, including name, address and date of birth.

»3. Diagnosis or Problem

In this step, we will need to know the diagnosis the patient was given for his or her first opinion. If you aren't sure, type in a general term and then choose from the list given. We will then let you know if we have a physician specialist available who can render an opinion for your specific condition.

»4. Payment Process

In this step, your credit card information will be required to process your request for a second opinion. We will not charge your credit card until your second opinion is completed and ready for your review. If you are receiving this service as a benefit from your employer, you will not be required to enter your credit card information.

»5. Medical History

In this step, we ask for detailed information about the diagnosis from the first opinion and medical history information, which includes history of symptoms, any treatment received to date, medications and prior illnesses. Since this step is very specific, we recommend that the medical records for the patient needing/requesting a second opinion are available for easy reference.

»6. Requested Materials

In this section, we provide lists and forms for you to print out to assist in completing your second opinion request. We ask for actual films or studies that are necessary for our physicians to perform a thorough second opinion. For your convenience, you may print this checklist and take it to the doctor or hospital where the patient's tests were performed. Your checklist will also include mailing instructions for all of the necessary items to be mailed to us.

»7. Review and Final Approval

This section allows you to review and change any of the information you have provided. If you are charging the service to your credit card, this step also authorizes us to charge your card. The charge will be posted on your credit card when your second opinion is complete. Once you have submitted your opinion request, you may check on the status of your opinion by logging on to our website and logging on to your secure account that you created during the registration process. The opinion status will be displayed on the home page.

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The cost to receive an online medical second opinion is $565.00. If a pathology review (reading) is required to complete your online medical second opinion (as is the case with most cancer-related diagnoses), there will be an additional charge of $180.00 for that review for a total cost of $745.00 for the second opinion and the reading.

Cleveland Clinic MyConsult Online Medical Second Opinion service is not covered by Medicare and we are unable to accept insurance payments or Workman’s Compensation cases.

During the process, you will be asked to enter the diagnosis provided for your first opinion. Below is a list of diagnoses categories that will help you in choosing your appropriate diagnosis:

  • Brain Tumors and Neurological Diseases
  • Digestive Diseases and Cancers
  • Eye Diseases
  • Geriatric Conditions
  • Head and Neck Diseases and Cancers
  • Heart and Valve Diseases
  • Hematologic Blood Disorders
  • Kidney and Urological Diseases and Cancers
  • Lung Diseases and Cancers
  • Obstetrics & Gynecological Disorders and Cancers
  • Orthopaedic Injuries and Diseases
  • Pediatric Cancers and Diseases
  • Rheumatologic Disorders
  • Skin Disorders
  • Spine Disorders
  • Thyroid and Metabolism Diseases and Cancers

If you are unsure, you can search for your condition by entering a general term and then selecting the best condition. This is a significant step in your pursuit of an online medical second opinion from Cleveland Clinic. Subsequent steps depend upon this information to complete your opinion request, thus once a condition has been selected you may not change it.

If you have any questions about your diagnoses, you may contact us at 216.444.3223 or 800.223.2273 ext 43223.

Dear Mr. Doe,
Thank you for your recent request for a second opinion consultation from Cleveland Clinic. Please find below the second opinion consultation written by Dr. Joe Cardiology, Department of Cardiovascular Medicine. You will be contacted by a MyConsult nurse via email within the next 2-3 days to ensure that you have received your second opinion report and determine if you have any questions.

Feel free to contact a Cleveland Clinic MyConsult nurse at 216.444.3223 or 800.223.2273 ext 43223, 8 a.m. - 5 p.m., EST, Monday through Friday, should you have additional questions or concerns.

MyConsult Office H2-260
Cleveland Clinic
9500 Euclid Avenue
Cleveland, OH. 44195
U.S.A.
Tel: 216.444.3223 or 800.223.2273 ext 43223
Fax: 216.445.6911
E-mail:eClevelandClinic@ccf.org

Date: August 26, 2009
Patient Name: Mr. John Doe
Physician's name: Joe Cardiologist, M.D.
Department: Cardiovascular Medicine
CCF#: (MRN) 1-234-567-8
Date of Birth: 2/19/1943
Patient Address:
555 Main Street
Anywhere, AK 12345

A MyConsult Online Medical Second Opinion also includes:

»Diagnosis / Reason for Consultation

In your preliminary materials provided, you asked three specific questions. These include:

  1. What treatment options can Cleveland Clinic offer us given that our current cardiologist has advised us that he considers the Ramus to be too small for angioplasty/stenting at our current medical facility (CABG was also ruled out as an option leaving only medical treatment)?
  2. What is the long-term prognosis if we continue on the current treatment plan versus what might be available at a more advanced level of care facility?
  3. Given that the patient has suffered 3 or 4 "coronary events" without any demonstrable damage to his cardiac muscle tissue, what kind of limitations or decrease in his quality of life might we anticipate in the future?
»Diagnostic Summary / Treatment Summary

Upon review of your records, you are a 59-year-old gentleman and with the exception of your coronary artery obstructive disease, remain quite healthy. Your cardiac history dates back to 2001 at which time you demonstrated multiple episodes of severe chest pain. This culminated in a three-vessel coronary artery bypass grafting procedure performed at Providence Alaska Medical Center in September 2001. This involved a left internal mammary artery bypass graft to the first diagonal branch of your left anterior descending coronary artery and a free right radial artery graft sequentially grafted to the right ventricular marginal branch and distal right coronary artery. In the year 2002, your severe chest pain recurred and in March you underwent a balloon angioplasty to the left internal mammary artery graft. Unfortunately, your severe chest pain recurred in April 2002 and an intracoronary stent was placed to the insertion site of the left internal mammary artery graft into the first diagonal branch. You presented once again in August 2002 with recurrent severe chest pain post angioplasty and stent placement. At the time of this catheterization, similar to prior catheterizations, your heart function remained normal without evidence of prior heart damage or myocardial infarction. Your native coronary circulation again remained relatively unchanged, fortunately only demonstrating mild obstruction in your left anterior descending coronary artery. The circumflex coronary also, had at most, mild to moderate obstruction but nothing flow limiting. The right coronary artery had severe native disease but continued to be served well by a patent right radial artery graft sequentially placed. The left internal mammary artery graft was also widely patent and demonstrated prompt flow to the diagonal branch. There was at most modest in stent re-stenosis. The native diagonal branch, which was located close to the distal or terminal aspect of the left main coronary artery demonstrated a subtotal blockage near 100% with very slow antegrade or forward filling of this vessel. In addition, no retrograde flow from the left internal mammary artery graft was seen into this vessel. Therefore, while the predominant portion of the first diagonal branching system was adequately perfused and subserved by the patent left internal mammary artery graft, a portion of the native vessel remained compromised at the time of the August 14, 2002 catheterization due to the antegrade stenosis and lack of retrograde filling via the left internal mammary artery graft.

It should be mentioned that serial nuclear perfusion tests have demonstrated an excellent workload without evidence of inducible myocardial ischemia. Additionally, lipid values have remained satisfactory with the most recent total cholesterol being 158.

Your current medications include Diltiazem in an extended release form at 120mg daily, Protonix 40mg twice daily, Imdur 60mg daily, Folic Acid 800mcg daily, Ecotrin 325mg daily, Atenolol 25mg daily, Plavix 75mg and Lipitor 20mg daily.

»Second Opinion Recommendations

Mr. Doe, it is apparent to me that you have received both excellent and thoughtful care locally. Cardiac catheterizations and percutaneous interventions in the form of angioplasty and subsequently an intracoronary stent have been appropriately applied in your situation. The chest discomfort that you continue to experience on an intermittent basis is most likely secondary to the high branching first diagonal coronary artery, which is in close proximity to the left main coronary artery. This is an extremely small vessel but can provide symptoms of myocardial ischemia in circumstances where oxygen supply does not meet oxygen demand.

At the present juncture, I see the risk to benefit ratio favoring medical therapy. Angioplasty and stenting of this native high branching diagonal coronary artery I believe, would be rather high risk as it is a small vessel and also, it's proximity to the left main coronary artery is of significant concern. A retrograde complication into the left main coronary artery could be very serious and life threatening. I should also add and emphasize that this diagonal branch subserves a small proportion of your heart muscle or myocardium. While responsible for intermittent symptoms of angina pectoris (cardiac chest discomfort), I do not believe that this small artery is prognostically significant and will not adversely affect your future health. I agree with your local physicians that bypass surgery would not be worth the risk and also, the likelihood of maintaining a patent graft to such a small native coronary artery branch, would be on the lower side. Thus, continued medical treatment seems best.

To mitigate your symptoms, reducing oxygen demand in the setting of reduced oxygen supply is best. While the Diltiazem medicine was appropriately prescribed initially in the postoperative period to prevent spasm of your radial artery graft, I believe this is a medication that should be limited. Reduction of your Diltiazem dose and potentially discontinuing it will allow your local doctors to increase the beta-blocker dose in the form of Atenolol. Beta-blockers such as Atenolol have been proven to extend life and prevent re-infarction in patients with coronary artery disease. The same cannot be said for a calcium channel blocker such as Diltiazem. I would actually favor that your local doctors switch your Atenolol to a longer acting form of Metoprolol such as Toprol XL. The target dose would be at least 100mg daily. I believe this would be attainable in the setting of a reduced and possibly discontinuing Diltiazem.

In addition, a program of regular exercise and dietary discretion is highly recommended. I have noted your height and weight and I presume you are of appropriate weight. I suspect you could lose approximately 5-10 pounds through an even more active exercise program and a program of dietary discretion. However, based on the numbers, your weight seems quite appropriate.

Goal lipid values should include a total cholesterol of less than 150, an HDL cholesterol greater than 45, an LDL cholesterol less than 100 and a triglyceride value less than 150. If you are not at these goals, further dietary modification is in order. The Folic Acid and Imdur medications seem most appropriate. I also agree with the long term Plavix. I believe your aspirin could be reduced to 162mg maximally as the Plavix and higher dose aspirin are felt to expose you to a higher bleeding risk but without significant therapeutic gain from the higher dose aspirin.

Thus, in summary, I concur with your local physicians that medical therapy is best. I suggest you approach your local doctors about adjusting your medications as I have outlined. Achieving your cholesterol and triglyceride goals may involve further dietary discretion and increased exercise. I should also add that your local doctors should check a rather new blood test termed an ultrasensitive CRP. CRP stands for C-reactive protein. If this is elevated, increasing your Lipitor (Atorvastatin) dose is appropriate.

In addition, you are not on a medication of the ACE inhibitor class. In patients with coronary artery obstructive disease, this is felt to be a helpful medication to reduce the likelihood of repeat heart attacks and sudden death in patients with coronary disease. I would encourage you to do some research on the Internet if you are so inclined. This would involve searching the HOPE Study findings, which involved a medication called Altace, also known as Ramipril. Approaching your doctors about this type of medication is appropriate. If you take the above lifestyle modification measures and continue with your medications, I suspect your future prognosis is excellent. I also think your quality of life will be very acceptable and above average. Particularly, given the lack of heart muscle damage, your ability to exercise and remain active should remain optimal.

We appreciate the opportunity to provide you with a second opinion consultation through the Cleveland Clinic MyConsult program. We hope that you find it informative and helpful.

Sincerely yours,

Joe Cardiologist, M.D.

»Cleveland Clinic MyConsult Disclaimer

By using this MyConsult: Online Medical Second Opinion service, you agree to abide by the Terms and Conditions posted at our Second Opinion Web Site, including particularly the Terms and Conditions described below:

Diagnostic Service

The service provided through our Web site is different from the diagnostic services typically provided by a physician. The Cleveland Clinic Foundation (CCF) physicians providing this service will not have the benefit of information that would be obtained by examining you in person and observing your physical condition. Therefore, the physician may not be aware of facts or information that would affect his or her opinion of your diagnosis. TO REDUCE THE RISK TO YOU OF THIS LIMITATION, CCF STRONGLY ENCOURAGES YOU TO SHARE THE SECOND OPINION WITH YOUR PHYSICIAN. BY DECIDING TO ENGAGE THIS SERVICE, YOU ACKNOWLEDGE AND AGREE THAT YOU ARE AWARE OF THIS LIMITATION AND AGREE TO ASSUME THE RISK OF THIS LIMITATION.

BY REQUESTING A SECOND OPINION PURSUANT TO THIS WEB SITE, YOU ACKNOWLEDGE AND AGREE THAT:

  • THE DIAGNOSIS THAT YOU WILL RECEIVE IS LIMITED AND PROVISIONAL;
  • THE SECOND OPINION IS NOT INTENDED TO REPLACE A FULL MEDICAL EVALUATION OR A FACE-TO-FACE VISIT WITH A PHYSICIAN;
  • THE PHYSICIAN DOES NOT HAVE IMPORTANT INFORMATION THAT IS USUALLY OBTAINED THROUGH A PHYSICAL EXAMINATION;
  • THE ABSENCE OF A PHYSICAL EXAMINATION MAY AFFECT THE PHYSICIAN'S ABILITY TO DIAGNOSIS YOUR CONDITION, DISEASE OR INJURY;

BY ENGAGING OUR SERVICES, YOU ACKNOWLEDGE AND AGREE TO ASSUME THE RISK OF THESE LIMITATIONS. YOU FURTHER UNDERSTAND THAT NO WARRANTY OR GUARANTEE HAS BEEN MADE TO ME CONCERNING ANY PARTICULAR RESULT OR CURE OF MY CONDITION.

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