CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 18 0000. ref SDS 17 0000.
040502 -
040503 -
040504 -
040963 -
040965 - ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Slept well last night with right leg elevated, per Jan yesterday on
041302 - 091103 0347. ref SDS 18 G46G
041304 - ..
041305 - Examination shows the right leg incision now looks much less angry.
041306 - Got up to go hiking, and again no pain in the right leg incision on
041307 - initial weight transfer, nor while walking the halls, similar to
041308 - improvement yesterday after implementing Jan's advise. ref SDS 18 G73I
041310 - ..
041311 - Went for a hike; only did a few laps, because still a little tired,
041312 - and want to get entered in the record on Millie's case...
041313 -
041314 - Brigid's Rule: stable is good.
041315 -
041317 - ..
0414 -
0415 -
0416 - 0729
0417 -
041701 - After hiking a few laps, technician, Edwin, arrives to draw blood and
041702 - evaluate WBC, INR, Pre-albumin and albumin for rate of nourishment.
041703 - He has done blood draws several times the past few days, reported on,
041704 - ref SDS 18 4Z7C
041705 -
041706 - [On 091214 1100 Edwin did blood draw again for pre-op on Heller
041707 - Myotomy surgery to correct achalasia. ref SDS 23 5R5H
041708 -
041709 -
041711 - ..
0418 -
0419 -
0420 - 0754
0421 -
042101 - Paula arrives for visit.
042102 -
042103 - Paula examined the left leg incision. She agrees it looks much better
042104 - today than yesterday, reported on 091103 0347. ref SDS 18 HA49
042106 - ..
042107 - Commented that expect WBC to drop significantly, as a result of
042108 - implementing Jan's suggestion to elevate the right leg.
042110 - ..
042111 - Paula asked when the next blood draw will occur to check WBC.
042113 - ..
042114 - Advised the blood draw was done earlier this morning, per above.
042115 - ref SDS 0 LH8J
042117 - ..
042118 - Mentioned there are some suture strings still in the stomach.
042120 - ..
042121 - Paula will remove them later today.
042122 -
042123 -
042125 - ..
0422 -
0423 -
0424 - 1008
0425 -
042501 - Asked Angelica for results of blood draw this morning.
042502 -
042503 -
042505 - ..
0426 -
0427 -
0428 - 1039
0429 -
042901 - Angelica advises that report for the lab this morning shows WBC 12.
042902 -
042903 - This is a huge drop from WBC 19 yesterday, expected from examination
042904 - this morning, per above, ref SDS 0 I15I, and so is the ticket home,
042905 - resulting from following Jan's advice to elevate the right led so the
042906 - infection will subside, reported on 091103 0347. ref SDS 18 G46G
042908 - ..
042909 - Additionally, Albumin has increased slightly to 3.6 from 3.4 the day
042910 - before.
042911 -
042912 -
042914 - ..
0430 -
0431 -
0432 - 1102
0433 -
043301 - Doctor Tseng and the CT team visit, Joe, Paula, and Erick.
043302 -
043303 - The doctor has ordered discharge based on lab this morning showing
043304 - drop in WBC from 19 to the normal range of 12; and, Albumin remaining
043305 - in the target range for good nutrution, per above. ref SDS 0 PRPV
043307 - ..
043308 - Thanked the team for excellent work, Looking forward to seeing Neal
043309 - in a few weeks.
043311 - ..
043312 - Commended VA's commitment to "team care," illustrated by Jan, NP, in
043313 - TCU, whose theraputic suggestion yesterday on 091103 0347. ref SDS 18
043314 - G46G, may have helped reduce infection in lower right leg, leading to
043315 - drop in WBC, per above. ref SDS 0 I15I
043317 - ..
043318 - Very glad that Doctor Tseng took time to visit, so I could say what I
043319 - have been practicing this morning...
043320 -
043321 - Thanks to the VA, Doctor Tseng, and her team I am not
043322 - leaving my heart in San Francisco.
043324 - ..
043325 - Great seeing the doctor smile at the play on words from Tony Bennet's
043326 - renouned signature song....
043327 -
043328 - I left my heart in San Francisco
043329 -
043330 - [...below on 091104 0718 at 1234 Neal visits with Joe and Erik;
043331 - thanked the team again for outstanding work. ref SDS 0 G267
043333 - ..
043334 - [On 091119 1000 visited with Doctor Ratcliffe, and Neil to
043335 - credit the VA Medical Center for excellent medical services.
043336 - ref SDS 21 N14N
043338 - ..
043339 - [On 091219 0600 at 1104 visited with Doctor Ratcliffe and
043340 - commended Doctor Brezinski for excellent work planning
043341 - anesthesia for heart surgery based on reviewing patient history
043342 - on achalasia.
043344 - ..
043345 - [On 100928 0706 received CD with VA's medical chart for
043346 - angiogram test, heart surgery, and Heller Myotomy surgery, all
043347 - demonstrating exceptional care by the VA. ref SDS 27 J655
043348 -
043349 -
043350 -
043351 -
043352 -
043354 - ..
0434 -
0435 -
0436 - 1120
0437 -
043701 - Ramone visits.
043702 -
043703 - Ramone verifies schedule of follow up with primary care in Martinez,
043704 - and with Neal here on 091119.
043706 - ..
043707 - Ramone will further verify the date for doing the achalasia surgery.
043708 -
043710 - ..
0438 -
0439 -
0440 - 1126
0441 -
044101 - Ramone advises there is a schedule with General Surgery on 091219. He
044102 - does not say if this is for surgery for only consult.
044104 - ..
044105 - Ramone agrees to work by email, and the communication contact with
044106 - the team.
044108 - ..
044109 - Wheels are starting to turn again for the "train to leave the station"
044110 - going home.
044111 -
044112 -
044114 - ..
0442 -
0443 -
0444 - 1222
0445 -
044501 - Paula visits.
044502 -
044503 - Removes stitches left over from the operation on 091022, and which
044504 - were protruding from the small horizontal incision above the stomach.
044506 - ..
044507 - Paula explains that Pharmacy is making up medications for taking home,
044508 - including 6-week treatment of Coumadin.
044510 - ..
044511 - Paula advised that arrangements will be made for follow up with
044512 - Coagulation Control Department at the VA in Martinez; this will
044513 - require follow up blood draws to maintain INR between 2.0 - 3.0.
044515 - ..
044516 - Current INR was 2.5, exactly at the target level; this may require
044517 - dropping the dose of Coumadin, since maintenance with Coumadin is
044518 - less than starting out with Levonox and Coumadin.
044520 - ..
044521 - Did not discuss scheduling follow up CT to evaluate recovery from
044522 - blood clot identified on 091030 0810, ref SDS 14 KF5W
044523 -
044524 - [On 091208 1300 follow up sonogram finds no evidence of DVT
044525 - nor blood clotting of any kind in location discovered
044526 - today; Doctor Stewart orders treatments with Coumadin to
044527 - end, which is needed for surgery on 091216, but with
044528 - findings today, Coumadin need not be resumed after surgery.
044529 - ref SDS 22 D24G
044531 - ..
044532 - Paula will check with Pat and verify that travel arrangements have
044533 - been made for today.
044535 - ..
044536 - Need supply of Ensure to maintain nutrition.
044538 - ..
044539 - Paula said she will be back for discharge.
044540 -
044541 -
044543 - ..
0446 -
0447 -
0448 - 1231
0449 -
044901 - Neal, Joe, and Erick stop by to say good-by.
044902 -
044903 - Discussed slight drop in pre-albumin 17 to below the target 18, on
044904 - the lab this morning.
044906 - ..
044907 - Neal feels this reflects the day or so of NPO (no eating), when
044908 - everyone was worried about aspiration pneumonia, reported on 091102
044909 - 0642. ref SDS 17 PB6Y
044911 - ..
044912 - Good news that albumin actually increased slightly.
044914 - ..
044915 - Neal said that everybody on the team now feels comfortable sending the
044916 - patient home with achalasia to manage eating in a way that will
044917 - maintain nutrition and enable medications to be digested.
044919 - ..
044920 - As said to Doctor Tseng and Paula this morning, per above, ref SDS 0
044921 - DX5L, thanked the team for outstanding surgery on 091022, ref SDS 13
044922 - PQWU, and continuing care through recovery the past 2 weeks. VA
044923 - quality of work in this case from doctors, nurses, technicians,
044924 - administrators, management, down to custodian staff all brings credit
044925 - to the VA, particularly at this time with the nation at war.
044926 -
044927 -
044928 -
044930 - ..
0450 -
0451 -
0452 - 1245
0453 -
045301 - Astrid with the Nutrition Department visits.
045302 -
045303 - Just tell her about discharge, so will no longer need special diet
045304 - arrangements for lunch or dinner today.
045305 -
045306 -
045308 - ..
0454 -
0455 -
0456 - 1304
0457 -
045701 - Angelica visits.
045702 -
045703 - Says the "wheels of discharge" are turning again. She saw Paula who
045704 - said the patient will be discharged. Waiting for order signed by the
045705 - doctor.
045706 -
045708 - ..
0458 -
0459 -
0460 - 1522
0461 -
046101 - Beth and Ilene visit from the Pharmacy.
046102 -
046103 - Medicine taking home...
046105 - ..
046106 - 1. Amiodorane
046107 - 2. Aspirin
046108 - 3. Semistatin
046109 - 4. Coumadin
046111 - ..
046112 - Ilene used notes and documents to explain various medications. Beth
046113 - filled in the gaps to assist Ilene, sort of a training exercise.
046114 -
046115 - [...below Angelica submits medications and presents another
046116 - explanation on each protocol. ref SDS 0 G361
046117 -
046118 - [...below at discharge received printed instructions for
046119 - medications in the Medical Record. ref SDS 0 4193
046120 -
046121 -
046122 -
046123 -
046125 - ..
0462 -
0463 -
0464 - 1613
0465 -
046501 - Sachin Garg and another doctor visited with the patient next door.
046502 -
046503 - After their meeting asked to speak with Sachin, following up the
046504 - meeting last Friday on 091030 0810 at 1348. ref SDS 14 0345
046506 - ..
046507 - Sachin was aware that the General Surgery Department will perform
046508 - Heller Myotomy surgery to fix the achalasia problem, rather than use
046509 - pneumatic dilation.
046511 - ..
046512 - Sachin indicated that the GI Department supports this decision.
046514 - ..
046515 - We reviewed representations in the paper Sachin submitted on 091031
046516 - that pills or botox injections could both provide a short-term
046517 - solution, ref SDS 14 495I, of at least a few weeks until surgery can
046518 - be performed by Doctor Stewart on 091219, and as discussed with Doctor
046519 - Ratcliffe and the CT team also on 091030 0810. ref SDS 14 T87O
046521 - ..
046522 - Sachin was not aware of any reason why experimenting with the pill to
046523 - provide a short term solution cannot be tried. It only takes 20
046524 - minutes.
046526 - ..
046527 - He will review with the Chief of the GI Department this issue, and
046528 - notify of any grounds for refusing to use the pill as a short-term
046529 - solution to eating for adequate nutrition, and to inject medications
046530 - required to advance recovery from heart surgery.
046532 - ..
046533 - Thanked Sachin for taking a few minutes for an unscheduled meeting,
046534 - that only occurred by accident.
046535 -
046536 -
046538 - ..
0466 -
0467 -
0468 - 1710
0469 -
046901 - Angelica came and said everything is now signed off for travel.
046902 -
046904 - ..
0470 -
0471 -
0472 - 1721
0473 -
047301 - Angelica arrives in the room with 2 cartons of Ensure for home
047302 - nutrition until surgery on 091217 to correct achalasia problem.
047304 - ..
047305 - Angelica also brought a sack full of medications. She reviewed
047306 - instructions for each one, duplicating work by the visit from the
047307 - pharmacy, earlier today, per above. ref SDS 0 G38J Some of these need
047308 - to be taken twice a day, which compounds the eating managment problem.
047309 - Angelica's explanation seems to align with printed instructions for
047310 - medications in the Medical Record, also received from her, and listed
047311 - below. ref SDS 0 4193
047313 - ..
047314 - Angelica removed the IV in right arm required for surgery patients,
047315 - until leaving the hospital.
047316 -
047317 -
047318 -
0474 -
SUBJECTS
Default Null Subject Account for Blank Record
0503 -
050401 - ..
050402 - Medical Record Discharge Instructions Medications Follow Up Meetings
050403 -
050404 - Angelica submitted the following document...
050405 -
050406 - Medical Record Progress Notes
050407 -
050408 - 1. Note dated: 091104 1555
050410 - ..
050411 - 2. Local title: Discharge Instructions Note
050413 - ..
050414 - 3. Standard Title: Physician Discharge Note
050416 - ..
050417 - 4. Admitted: 091021 0055 2(B)3S
050419 - ..
050420 - 5. Discharge Medications:
050421 -
050422 - Patient is being discharged to home.
050424 - ..
050425 - Patient: with these discharge instructions, you will receive
050426 - a printout of the medications from the San Francisco VA
050427 - Medical Center which you should take afer discharge.
050429 - ..
050430 - Ask your doctor, nurse, or pharmacist if you have any questions
050431 - about your medication.
050432 -
050433 - [On 091119 1000 Neil approved ending post-surgery
050434 - medications on 091122, 30 days after surgery on 091022.
050435 - ref SDS 21 LC5F
050437 - ..
050438 - You should do the following with medications that you already
050439 - have at home that are not on the list from San Francisco.
050441 - ..
050442 - [Printed list of medications...]
050444 - ..
050445 - Location: MTZ ANC Pharmacotherapy (new) 091117
050447 - ..
050448 - Printed 091116 2359
050450 - ..
050451 - Confidential medication reconciliation summary
050453 - ..
050456 - ..
050457 - MRP - Unified Activ Pharm
050459 - ..
050460 - Alphabetized list of outpatient Rx's, inpatient orders, remote
050461 - and non-VA meda
050463 - ..
050464 - Legend: OPT = VA issued outpatient prescription.
050465 - INP = VA issued inpatient order
050467 - ..
050468 - Non-VA Meda Last Documented On: ** data not found **
050469 -
050470 - 1. Amiodarone HCL (Pacerone)............... 200 MG
050471 -
050472 - Take one tablet every day
050473 -
050474 - Last filled: 091104 (active at San Francisco VAMC)
050476 - ..
050477 - Rx (prescription) expiration........ 091129
050478 - Days supply......................... 30
050479 - Refills............................. 0
050481 - ..
050482 - 2. Aspirin................................. 325 MG
050483 -
050484 - Take one tablet every day
050485 -
050486 - [On 100305 1000 active medication list received from VA
050487 - on 100312, and prepared on 100305, does not list
050488 - aspirin. ref SDS 25 3C5N
050490 - ..
050491 - Last filled: 091104 (active at San Francisco VAMC)
050493 - ..
050494 - Rx (prescription) expiration........ 101031
050495 - Days supply......................... 90
050496 - Refills............................. 3
050498 - ..
050499 - 3. Ciprofloxacin HCL....................... 500 MG
050500 -
050501 - Take one tablet every 12 hours for infection
050503 - ..
050504 - Last filled: 091104 (active at San Francisco VAMC)
050506 - ..
050507 - Rx (prescription) expiration........ 091204
050508 - Days supply......................... 10
050509 - Refills............................. 0
050511 - ..
050512 - Research seems to indicate Ciprofloxacin HCL is the antibiotic to
050513 - treat aspiration pneumonia, diagnosed on 091102, ref SDS 17 PB6Y, and
050514 - which turned out not to be an issue, reported on 091103. ref SDS 18
050515 - HA5L
050517 - ..
050518 - Yesterday on 091103 Doctor Tseng seemed to end treatment with
050519 - antibiotics because of corrected findings that withdrew initial
050520 - diagnosis of aspiration pneumonia. ref SDS 18 P26X
050522 - ..
050523 - Research on Ciprofloxacin HCL 500 MG
050524 -
050525 - Emedicine
050526 - Pneumonia, Aspiration: Treatment & Medication
050527 -
050528 - 090807 (updated)
050529 -
050530 - http://emedicine.medscape.com/article/296198-treatment
050532 - ..
050533 - Medication List continues...
050534 -
050535 - 4. Ensure Plus Liquid Vanilla
050536 -
050537 - Drink one can 7 times per day for nutrition
050538 -
050539 - Last filled: 091105 (active at San Francisco VAMC)
050541 - ..
050542 - Rx (prescription) expiration........ 091205
050543 - Days supply......................... 27
050544 - Refills............................. 0
050546 - ..
050547 - Provides sufficient nutritient through liquid diet, and so avoids
050548 - eating solid food that gets stuck in the esophagus, and prevents
050549 - medications from being digested.
050551 - ..
050552 - Medication List continues...
050553 -
050554 - 5. Furosemide (Lasix)...................... 25 MG
050555 -
050556 - Take one tablet every day for 3 days
050558 - ..
050559 - Last filled: 091104 (active at San Francisco VAMC)
050561 - ..
050562 - Rx (prescription) expiration........ 091129
050563 - Days supply......................... 3
050564 - Refills............................. 0
050566 - ..
050567 - Removes fluid from the body that builds up from the operation on
050568 - 091022, and as reported in the record on 091102 0642. ref SDS 17 WB8Q
050569 -
050570 - [On 111121 1727 taking Rosuvastatin to reduce cholesterol
050571 - has side effect increase frequency urination, similar to
050572 - lasix. ref SDS 29 MX9G
050573 -
050575 - ..
050576 - Medication List continues...
050577 -
050578 - 6. Metoprolol Tartrate..................... 25 MG
050579 -
050580 - Take one half tablet twice per day.
050581 -
050582 - Last filled: 091104 (active at San Francisco VAMC)
050584 - ..
050585 - Rx (prescription) expiration........ 100128
050586 - Days supply......................... 90
050587 - Refills............................. 0
050589 - ..
050590 - Research indicates Metoprolol Tartrate is a "beta blocker" prescribed
050591 - to treat high blood pressure angina pectoris (chest pain, usually
050592 - caused by lack of oxygen to the heart due to clogged arteries), and
050593 - heart attack. Beta blockers decrease the force and rate of heart
050594 - contractions, thereby reducing the demand for oxygen and lowering
050595 - blood pressure.
050597 - ..
050598 - See article...
050599 -
050600 - Drugs.com
050601 - Metoprolol tartrate
050602 - Brand names: Toprol-XL, Lopressor
050603 -
050604 - http://www.drugs.com/pdr/metoprolol-tartrate.html
050606 - ..
050607 - Most important fact about Metoprolol tartrate
050609 - ..
050610 - If you have high blood pressure, you must take Lopressor
050611 - regularly for it to be effective. Since blood pressure
050612 - declines gradually, it may be several weeks before you get
050613 - the full benefit of Lopressor; and you must continue
050614 - taking it even if you are feeling well. Lopressor does not
050615 - cure high blood pressure; it merely keeps it under
050616 - control.
050618 - ..
050619 - Side effects may include:
050621 - ..
050622 - Depression, diarrhea, dizziness, itching, rash, shortness
050623 - of breath, slow heartbeat, tiredness
050625 - ..
050626 - Why should Metoprolol tartrate not be prescribed?
050628 - ..
050629 - If you have a slow heartbeat, certain heart irregularities,
050630 - heartbeat,low blood pressure, inadequate output from the
050631 - heart, or heart failure, you should not take Metoprolol
050632 - tartrate.
050634 - ..
050635 - Medical Chart medications continued...
050636 -
050637 - 7. Nitroglycerin (Nitrostat)............... 0.4 MG
050638 -
050639 - Disolve 1 tablet under the tongue as needed for chest
050640 - pain. If no relief in 5 minutes call 911 for Emergency
050641 - care. Take 1 tablet every 5 minutes (maximum of 3
050642 - tablets) if needed.
050644 - ..
050645 - Last released: 091002 (active at San Francisco VAMC)
050647 - ..
050648 - Days supply......................... 30
050650 - ..
050651 - This was actually received from the VA in Martinez, following
050652 - diagnosis of heart disease, and work plan to perform angiogram test in
050653 - San Francisco.
050655 - ..
050656 - Medication List continues...
050657 -
050658 - 8. Simvastatin............................. 20 MG
050659 -
050660 - Take one tablet every day for cholesterol.
050662 - ..
050663 - Last filled: 091104 (active at San Francisco VAMC)
050665 - ..
050666 - Rx (prescription) expiration........ 101031
050667 - Days supply......................... 90
050668 - Refills............................. 3
050669 -
050670 - [On 100420 0027 went to VA in Martinez and ordered
050671 - refill. ref SDS 26 5C7K
050673 - ..
050674 - 9. Simvastatin............................. 40 MG
050675 -
050676 - Take one-half tablet every day for cholesterol.
050678 - ..
050679 - Use pill cutter; do not take with grapefruit juice.
050681 - ..
050682 - Last released: 091005 (active at San Francisco VAMC)
050684 - ..
050685 - Rx 4734611 - expiration............. 100815
050686 - Days supply......................... 30
050687 - Refills............................. 5
050689 - ..
050690 - This duplicates treatment for cholosterol prescribed by Doctor Sandhu
050691 - during the meeting at the VA in Martinez, when bad cholesterol was too
050692 - high, and good cholesterol was too low, reported for the lab on 090813
050693 - 1500, ref SDS 5 4N5H, and ordered the day before on 090812 1030.
050694 - ref SDS 4 MA6I
050695 -
050696 - [On 100105 Doctor Sandhu ordered continued treatment
050697 - with simvastatin for blood test in July. ref SDS 24 WR7L
050699 - ..
050700 - Medication List continues...
050701 -
050702 - 10. Warfarin NA............................. 2 MG
050703 -
050704 - Take one tablet every day to thin the blood.
050706 - ..
050707 - Last filled: 091104 (active at San Francisco VAMC)
050709 - ..
050710 - Rx (prescription) expiration........ 091204
050711 - Days supply......................... 30
050712 - Refills............................. 0
050714 - ..
050715 - This is to treat DVT diagnosed on 091030. ref SDS 14 KF5W
050717 - ..
050718 - Medical Chart Discharge Instructions continued...
050719 -
050720 - 6. Inpatient attending: Doctor Tseng.
050721 -
050722 - 7. Discharge date/time
050723 -
050724 - Anticipated discharge date/time...
050725 -
050726 - 091104 1700
050728 - ..
050729 - Comments: [none]
050731 - ..
050732 - 8. Discharge diagnoses:
050733 -
050734 - Primary diagnosis............. post op CABG
050735 - Secondary Diagnosos........... achalasia
050737 - ..
050738 - 9. Discharge condition: good
050740 - ..
050741 - 10. Discharge disposition: home
050743 - ..
050744 - 11. Discharge activity: restrictions sternal precautions
050746 - ..
050747 - 12. Discharge transportation: VA transportation ordered
050749 - ..
050750 - 13. Discharge diet:
050751 -
050752 - Restrictions: liquid diet
050754 - ..
050755 - Your last calculated Body Mass Index (BMI) is 27.0
050756 - (Overweight). Patients with a BMI less than <18.5 should
050757 - contact our nutrition clinic at 415 221 4810 ext 2895 for
050758 - nutrition services. Patients with a BMI over 30 should speak
050759 - with their primary care provider about weight loss. Your last
050760 - serum albumin (blood test reflective of yor prtein stores)
050761 - is....
050762 -
050763 - 091104 Albumin 3.50 gm/dL 3.3 - 5.2 Plasma
050765 - ..
050766 - Patients with a serum albumin less than 2.8 gm/dL should
050767 - contact our nutrition clinic at 415 221 4810 ext 3354 for
050768 - nutrition services.
050770 - ..
050771 - 14. Discharge smoking instructions.
050772 -
050773 - Don't smoke. If you need help quitting smoking, talk to your
050774 - Primary Care Provider or call the Smoking Cessation Hotline at
050775 - 415 379 5566 or call Bloria Wilcher at the Smoking Cessatoin
050776 - Clinic 415 750 2050.
050778 - ..
050779 - 15. Discharge nursing instructions.
050780 -
050781 - Nursing instructions regarding patient teaching or other
050782 - specifics:
050784 - ..
050785 - Sternal precautions:
050786 -
050787 - a. No lifting > 10 pounds.
050788 - b. No raising arms overhead.
050789 - c. No pushing nor pulling with hands/arms.
050790 - d. No driving for 30 days.
050791 - e. No shoulder strap in the car.
050793 - ..
050794 - 16. Discharge wound instructions.
050795 -
050796 - Wound care as follows...
050797 -
050798 - a. Closely monitor incision at leg for redness, swelling discharge
050799 - or pain.
050801 - ..
050802 - b. Daily temperature: call if > 100.1
050804 - ..
050805 - c. Shower daily but do not scrub incision.
050807 - ..
050808 - 17. Special discharge instructions.
050809 -
050810 - a. Activity Congestive heart failure (CHF)
050811 -
050812 - Be as active as you can. Start slowly and increase your
050813 - activity little by little. Stop and rest whenever you
050814 - feel tired or get short of breath. Don't push yourself on
050815 - days when you don't feel well.
050817 - ..
050818 - b. Diet
050819 -
050820 - Do not add salt to foods. Avoid foods with hidden salt
050821 - such as soy suace, fast food, canned foods and soups, and
050822 - frozen prepared meals. Don't use salt substitutes that are
050823 - high in potassium. If yo need help planning your diet
050824 - contact the Nutrition Clinic at 415 221 4810 ext 2895.
050826 - ..
050827 - For 50 years, diet has included generous amounts of salt as an aide
050828 - for tasty meals.
050830 - ..
050831 - Last week, discussed salt issue with the doctor who assisted with the
050832 - angiogram test; and the doctor supported VA guidance on minimizing
050833 - adding salt to food, reported on 091021 0716. ref SDS 12 HA92
050834 -
050835 -
050836 -
0509 -
SUBJECTS
Salt Medical Necessity Avoid Overuse Reduce Heart Disease Hypertensi
1603 -
160401 - ..
160402 - Research salt issue finds...
160403 -
160404 - VA heart surgery discharge guidance to reduce salt, ref SDS 0 US7I,
160405 - research shows...
160406 -
160407 - About.com: Heart Disease
160408 - ..
160409 - Salt Wars - Is Salt Restriction Necessary?
160410 -
160411 - By Richard N. Fogoros, MD, About.com Guide
160412 -
160413 - Biography...
160414 -
160415 - http://heartdisease.about.com/bio/Richard-N-Fogoros-M-D-6616.htm
160417 - ..
160418 - Email: heartdisease.guide@about.com
160420 - ..
160421 - For over a century, doctors have recognized that there is
160422 - a relationship between dietary salt and blood pressure.
160423 - But despite 100 years of study, doctors can't seem to
160424 - agree on just how important it is to restrict dietary
160425 - salt. Does everybody need to restrict their salt intake?
160426 - Does anybody?
160428 - ..
160429 - [On 101207 0906 lab report on blood test shows salt (NA
160430 - 137) near danger level of being too low. ref SDS 28 GM65
160432 - ..
160433 - These questions are of pressing importance for more than
160434 - merely public health purposes. There are professional
160435 - reputations and big bucks involved here.
160437 - ..
160438 - On one side are the National Heart, Lung, and Blood
160439 - Institute, the National High Blood Pressure Education
160440 - Program, and academic experts on hypertension whose
160441 - careers have been based on funding from these
160442 - organizations. These parties have long held that it is
160443 - important to restrict dietary salt as a matter of public
160444 - policy, for the purpose of reducing the incidence of
160445 - hypertension in the United States. They cite scores of
160446 - scientific studies bolstering their argument that high
160447 - salt intake is responsible for a substantial amount of the
160448 - hypertension present in our population, and that salt
160449 - restriction is the best public policy.
160451 - ..
160452 - On the other side is the Salt Institute, the rich and
160453 - powerful manufacturers of processed foods (note: virtually
160454 - all processed foods contain huge amounts of salt), and the
160455 - academic experts on hypertension whose careers have been
160456 - based on funding from these sources. These parties site
160457 - scores of scientific studies bolstering their argument
160458 - that high salt intake has little to do with the
160459 - hypertension present in our population, and that salt
160460 - restriction is bad public policy and possibly dangerous.
160462 - ..
160463 - The bottom-line problem is that salt metabolism, and its
160464 - effects on hypertension, are extremely complex. And after
160465 - decades of research, over 20,000 scientific studies have
160466 - been published on the relationship between salt and
160467 - hypertension, with conflicting and contradictory results.
160468 - Since nobody can read all these articles, let alone digest
160469 - their meaning, hypertension experts are left to pick and
160470 - choose which articles they think are most important - and
160471 - invariably, it seems, they pick the articles that seem to
160472 - bolster their pre-conceived notions. Reading the medical
160473 - literature on salt has become uncomfortably like reading
160474 - the Bible: no matter what odd notion you care to espouse,
160475 - you'll be able to find something in there to support it.
160476 - There seems to be little hope that anything approaching an
160477 - objective resolution of the salt issue will ever be
160478 - reached - at least among hypertension experts.
160480 - ..
160481 - Now a new study, published in February 2001 in
160482 - Hypertension, puts a new spin on the salt controversy that
160483 - may open a path to "true enlightenment."
160485 - ..
160486 - This study, conducted at the Indiana University School of
160487 - Medicine, suggests that it is not the hypertension
160488 - produced by salt that is the most important cause of
160489 - health problems - instead, it's whether the individual is
160490 - "salt-sensitive." For people who are salt-sensitive, the
160491 - risk of dying from cardiovascular problems are increased
160492 - with high dietary salt, whether or not they are
160493 - hypertensive.
160495 - ..
160496 - People who are salt-sensitive experience an exaggerated
160497 - blood pressure elevation when they are given a salt load.
160498 - (There is no standard way to test for salt-sensitivity,
160499 - and such tests are currently done only in a research
160500 - setting.) While salt-sensitivity is felt to be a risk
160501 - factor for developing hypertension, many salt-sensitive
160502 - people are, in fact, not hypertensive at all. The Indiana
160503 - study suggests that, while hypertension is a major cause
160504 - of cardiovascular disease, it's not the hypertension that
160505 - causes early death in salt-sensitive people - it's the
160506 - salt-sensitivity itself. That is, in these individuals,
160507 - high dietary salt causes cardiovascular disease even if
160508 - their blood pressures remain normal.
160510 - ..
160511 - How does salt cause cardiovascular disease without
160512 - increasing the blood pressure? Dr. Aviv from the
160513 - University of Medicine and Dentistry of New Jersey thinks
160514 - he has the answer - salt increases the reactivity of
160515 - platelets, the tiny blood elements that help the blood to
160516 - clot. Thus, he says, high dietary sodium might lead to
160517 - cardiovascular events like stroke, heart attack, and
160518 - kidney disease directly, even in the absence of
160519 - hypertension.
160521 - ..
160522 - Why is this new information important to the Salt Wars?
160524 - ..
160525 - Until now, it has been assumed that any cardiovascular
160526 - problems related to high salt intake had to be mediated by
160527 - hypertension. That is, if salt didn't cause hypertension,
160528 - it wasn't a problem. So until now the battle has been
160529 - largely fought - on both sides - by the hypertension
160530 - experts.
160532 - ..
160533 - Now it appears that salt may cause cardiovascular disease
160534 - even in the absence of hypertension. This new data invites
160535 - neurologists and cardiologists - specialists whose
160536 - opinions haven't become hopelessly entrenched by 30 years
160537 - of warfare - to take a fresh look at the importance of
160538 - dietary salt. This new opportunity - a small beam of
160539 - sunlight breaking through a dense cover of clouds - is a
160540 - fragile thing. The moneybags at the NIH and the Salt
160541 - Institute stand ready to fund research within these new
160542 - specialties - research that will, they hope, prove their
160543 - respective and opposite points of view. One can only hope
160544 - that these fresh specialists, unencumbered by 30 years of
160545 - dense and conflicting research, will be able to remain
160546 - objective long enough to take advantage of this promising
160547 - new avenue of investigation.
160549 - ..
160551 - ..
160552 - dietary salt? Well, frankly, you can find research to
160553 - support just about any position you care to take. (Ain't
160554 - science wonderful?) But especially in view of this latest
160555 - information, it would seem prudent to reduce your salt
160556 - intake to a reasonable and practical degree - especially
160557 - if you have risk factors for heart disease or stroke.
160559 - ..
160560 - Another source claims...
160561 -
160562 - Salt Deficiency: The Cause Of Many Serious Diseases
160563 -
160564 - http://www.shirleys-wellness-cafe.com/salt.htm
160565 -
160566 - An eight-year study of a New York City hypertensive
160567 - population stratified for sodium intake levels found those
160568 - on low-salt diets had more than four times as many heart
160569 - attacks as those on normal-sodium diets - the exact
160570 - opposite of what the "salt hypothesis" would have
160571 - predicted. (1995).
160572 -
160573 - [On 101207 0906 lab report on blood test shows salt (NA
160574 - 137) near danger level of being too low. ref SDS 28 GM65
160576 - ..
160577 - Doctor Jeffrey R Cutler documented no health outcomes
160578 - benefits of lower-sodium diets.
160580 - ..
160581 - Both sea salt and rock salt were well known to the ancient
160582 - Greeks who noted that eating salty food affected basic body
160583 - functions such as digestion and excretion (urine and
160584 - stools). This led to salt being used medically. The
160585 - healing methods of Hippocrates (460 BC) especially made
160586 - frequent use of salt. Hippocrates mentions inhalation of
160587 - steam from salt-water. We know today that the
160588 - antiinflammatory effects of inhaled salt provide relief
160589 - from respiratory symptoms (c). Thus, 2000 years ago, Greek
160590 - medicine had already discovered topical use of salt for
160591 - skin lesions, drinking salty or mineralized waters for
160592 - digestive troubles and inhaling salt for respiratory
160593 - diseases!
160594 -
160596 - ..
160597 - Another source claims...
160598 -
160599 - Health Benefits of Salt
160600 -
160601 - http://www.himalayancrystalsalt.com/health-benefits.html
160602 -
160603 - Salt is not only critical to your life, but it is one of
160604 - the basic elements of which your body is made. Like true
160605 - lovers, the relationship between salt and your health is
160606 - so intricately involved as to make them impossible to be
160607 - disentangled or untied. Without salt, you could not exist
160608 - for a moment. At the fundamental level of the physical
160609 - body, you are a walking, breathing, salty ocean.
160610 -
160611 - [On 101207 0906 lab report on blood test shows salt (NA
160612 - 137) near danger level of being too low. ref SDS 28 GM65
160614 - ..
160615 - Another source claims...
160617 - ..
160618 - How Much Salt Daily Diet
160619 - Reduce Salt and Sodium in Your Diet
160620 -
160621 - http://www.nhlbi.nih.gov/hbp/prevent/sodium/sodium.htm
160622 -
160623 - A key to healthy eating is choosing foods lower in salt
160624 - and sodium. Most Americans consume more salt than they
160625 - need.
160627 - ..
160628 - The current recommendation is to consume less than 2.4
160629 - grams (2,400 milligrams[mg] ) of sodium a day. That equals
160630 - 6 grams (about 1 teaspoon) of table salt a day. The 6
160631 - grams include ALL salt and sodium consumed, including that
160632 - used in cooking and at the table.
160634 - ..
160635 - For someone with high blood pressure, the doctor may advise
160636 - eating less salt and sodium, as recent research has shown
160637 - that people consuming diets of 1,500 mg of sodium had even
160638 - better blood pressure lowering benefits. These
160639 - lower-sodium diets also can keep blood pressure from rising
160640 - and help blood pressure medicines work better.
160641 -
160642 - [On 101207 0906 lab report on blood test shows salt (NA
160643 - 137) near danger level of being too low. ref SDS 28 GM65
160644 -
160645 -
160646 -
160647 -
160648 -
1607 -
SUBJECTS
Default Null Subject Account for Blank Record
1703 -
170401 - ..
170402 - Medical Chart Special Discharge Instructions continued...
170403 -
170404 - c. Weight.
170405 -
170406 - Weigh yourself first thing each morning after you urinate.
170407 - Do not wear any cloths or wear the same clothes each day.
170408 - Record your weight. If you gain 2 pounds in one day or you
170409 - gain 3 - 5 pounds in one week contact your Primary Care
170410 - Provider.
170412 - ..
170413 - What to do if symptoms worsen...
170414 -
170415 - a. Weight gain or swollen feet and ankles may be a sign of
170416 - a flare up of your heart failure. Other signs may
170417 - be...
170418 -
170419 - b. Feeling more fatigued than usual.
170421 - ..
170422 - c. Shortness of breath during usual activities.
170424 - ..
170425 - d. Waking up at night feeling short of breath.
170427 - ..
170428 - e. Needing to sleep on more pillows than usual.
170430 - ..
170431 - f. Needing to sleep in a chair.
170433 - ..
170434 - If any of the above symptoms occur and are mild, you should
170435 - call your Primary Care Provider and not wait until your
170436 - next appointment. If your symptoms are severe, you should
170437 - go to an Emergency Room.
170439 - ..
170440 - 18. Discharge Follow-up.
170441 -
170442 - Follow up is important after discharge. Refer to the attached
170443 - list for future meetings with the medical team. ref SDS 0 9T6O
170445 - ..
170446 - 19. Discharge call information.
170447 -
170448 - For more information or if your symptoms worsen call Telephone
170449 - Care...
170450 -
170451 - 800 733 0502
170453 - ..
170454 - Other numbers...
170455 -
170456 - a. Ramon Datar CT administrator.... 415 421 4810 ext 3707
170457 -
170458 - b. Prescription Refills............ 415 750 2233 or
170459 - 800 847 3202
170461 - ..
170462 - Prescription number and number of refills are listed on
170463 - the prescription lable.
170465 - ..
170466 - c. Link to your health care by signing up for Myhealthevet at
170467 -
170468 - http://www.myhealth.va.gov
170469 -
170470 - ...to manage your VA prescription refills, personal health
170471 - journals and more. Contact the Myhealthevet POC at...
170472 -
170473 - 415 221 4810 ext 3834
170475 - ..
170476 - d. If there are no refills for the medication: please contact
170477 - your provider if you need new prescriptions.
170479 - ..
170480 - e. If you wish to have a copy of your discharge summary sent
170481 - to a provider not at the San Francisco VA Medical Center,
170482 - please contact Release of information at 415 750 6607 or
170483 - stop by room 176 in building 2 of the Medical Center.
170485 - ..
170486 - 20. A copy of these instructions was given to the patient at
170487 - discharge.
170489 - ..
170490 - 21. Signed by:
170491 -
170492 - Paula Price, PA-C MPH
170493 - Physician Assistant Cardio Thoracic Surgery
170494 - 091104 1604
170496 - ..
170497 - 22. Future Clinic Meetings
170498 -
170499 - 091117 1340 Surgery General New Doctor Lygia Stewart 415 750 6922 Building 200 Ground Floor Module 2
170501 - ..
170502 - This meeting has no support in the record. Paula advised that 2
170503 - meetings are scheduled with Doctor Stewart, initially on 091208, and
170504 - then surgery to correct achalasia problem on 091217, reported on
170505 - 091103 0347. ref SDS 18 PS60
170506 -
170507 - [On 091119 1000 Erick confirmed visit with Doctor Stewart
170508 - on 091208, and is reviewing date of surgery scheduled for
170509 - 091217. ref SDS 21 935H
170511 - ..
170512 - Medical chart continues...
170513 -
170514 - 091119 1000 Cardiothoracic Doctor Neil Cambronero 415 750 6922 Building 200 Ground Floor Module 1
170515 -
170516 - [On 091117 1317 Ramon called - requested that Ramon call
170517 - the VA in Martinez to coordinate labs and tests performed
170518 - at VA in Martinez needed for meeting with Neil in San
170519 - Francisco to review progress recovering from heart surgery.
170520 - ref SDS 19 QF7O
170522 - ..
170523 - [On 091117 1500 meeting at VA in Martinez; Ramon called and
170524 - coordinated getting tests for meeting with Neil on 091119
170525 - in San Francisco to review progress recovering from heart
170526 - surgery. ref SDS 20 TC4I
170527 -
170528 -
170529 -
170531 - ..
1706 -
1707 -
1708 - 1734
1709 -
170901 - Evon arrives to make arrangements for the ride home.
170902 -
170903 - She has 2 other customers who are currently getting treatment.
170905 - ..
170906 - Evon estimates time of departure will be 1900.
170908 - ..
170909 - She will bring a wheel chair to carry the 2 cartons of Ensure, the
170910 - computer and keyboard.
170912 - ..
170913 - Patient can use the walker to carry anything else.
170915 - ..
170916 - Two patients live in the City; we will take the Bay Bridge which
170917 - reopened, and travel through the Caldecott Tunnel to get to Concord.
170918 -
170919 -
170921 - ..
1710 -
1711 -
1712 - 1743
1713 -
171301 - Called Millie and advised should be home by 2100.
171302 -
171304 - ..
1714 -
1715 -
1716 - 1815
1717 -
171701 - Evon arrives 45 minutes early for the ride home.
171702 -
171703 - Dressed into civilian cloths. Angelica helped breakdown the computer
171704 - and put in the case.
171706 - ..
171707 - Evon brought a wheelchair. She put 4 cartons of Ensure in the
171708 - wheelchair. The computer was put on top. The keybpard was stored on
171709 - a tray below the seat of the wheelchair. Medicines were stored in
171710 - the walker.
171712 - ..
171713 - Pushed the walker out, and Ebon pushed the wheelchair.
171715 - ..
171716 - In front of the building, Evon loaded everything onto the mini-bus;
171717 - which took about 15 minutes, and then we left.
171719 - ..
171720 - She dropped two patients off downtown in the City. They were both
171721 - treated for kidney dialysis. Evon explained they come for treatment 3
171722 - times a week, and both required electornic scooters to get around.
171724 - ..
171725 - On the road to Concord, had nice discussion with Evon. She had a
171726 - prior assignment as a caregiver for a patient at UCSF, and for about 8
171727 - months, until her own mother became ill, and needed Evon's assistance.
171728 -
171729 -
171730 -
171732 - ..
1718 -
1719 -
1720 - 2054
1721 -
172101 - Arrived home.
172102 -
172103 - Evon did all the unloading, including bringing the 4 cartons of
172104 - Ensure.
172105 -
172106 -
172107 -
172108 -
172109 -
1722 -