THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com
S U M M A R Y
DIARY: May 20, 2011 03:37 PM Friday;
Rod Welch
VA received CD with medical chart for EGD and dilation on Apr 29th.
1...Summary/Objective
2...EGD Dilation Evaluate Stricture Dilate Improve Swallowing Nutrition
3...Stress Test Post CABG Cardiology Meetings
4...Cardiology Meetings Stress Test Post CABG
....................Premature Atrial Contractions (PAC)
....................Heart Palpitations PAC Benign Arrhythmia
5...Holter Heart Rate Test Post CABG Cardiology Meetings
6...Cardiology Holter Heart Rate Test Post CABG Meetings
7...Coronary Heart Function Significantly Stronger Post CABG 4x
..............
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CONTACTS
SUBJECTS
VA Medical Records EGA Dilation 110218 Rceived CD Transmittal Medic
2203 -
2203 - ..
2204 - Summary/Objective
2205 -
220501 - Follow up ref SDS 78 0000. ref SDS 74 0000.
220502 -
220503 -
220504 -
220506 - ..
2206 -
2207 -
2208 - Progress
2209 -
220901 - Visited Wilma at ROI Department and received CD with her letter dated
220902 - today on 110520, ref DRT 1 0001, and transmitting VA medical chart
220903 - records for work performing EDG and dilation reported on 110429 1230.
220904 - ref SDS 83 0001
220906 - ..
220907 - CD received from the VA today adds to patient history...
220908 -
220909 - 1. Medical chart received on........... 110520 1537, ref SDS 0 IF7J
220910 - for VA procedure EGD Dilation....... 110429 1230, ref SDS 83 0001
220911 - for VA meeting Cardiology........... 110309 0900, ref SDS 79 OF8F
220912 - for VA Helter Cardiology test....... 110310 0930, ref SDS 80 OF8F
220913 - for VA stress test EKG.............. 110406 1230, ref SDS 81 OF8F
220915 - ..
220916 - 2. Medical chart received on........... 110304 1126, ref SDS 78 125O
220917 - for VA procedure EGD................ 110218 0730, ref SDS 74 SR8M
220919 - ..
220920 - 3. Medical chart received on........... 110114 1309, ref SDS 72 1Y9K
220921 - for VA procedure EGD................ 101210 0930, ref SDS 67 BE44
220922 - for VA meeting Primary Care......... 101223 1030, ref SDS 71 PP8W
220924 - ..
220925 - 4. Medical chart received on........... 101014 1145, ref SDS 52 U455
220926 - for VA procedure on................. 100827 0738, ref SDS 47 0001
220928 - ..
220929 - 5. Medical chart received on........... 100827 1316, ref SDS 48 Y87U
220930 - for VA meeting Primary Care......... 100721 0800, ref SDS 45 PP8W
220932 - ..
220933 - 6. Medical chart received on........... 100312 1119, ref SDS 40 MN4O
220934 - for VA procedure on................. 100305 1000, ref SDS 39 0001
220936 - ..
220937 - VA medical records listed below, ref SDS 0 NX5I, were received today
220938 - transmitted with Wilma's letter, ref DRT 1 0001, and containing VA
220939 - document file saved in patient records....
220940 -
220941 - F:\05\00003\CG\CG\11\05\2001.PDF
220942 -
220943 - ...and in VA records...
220944 -
220945 - F:\05\00441\CG\CG\11\05\2001.PDF
220947 - ..
220948 - Photographs were not received in a separate CD in word.doc files, as
220949 - was done for the procedure on 110218, and reported in the record on
220950 - 110304 1126. ref SDS 78 548L
220952 - ..
220953 - Where are photographs showing findings from EGD, which were presented
220954 - by Doctor Lee post-procedure in recovery, reported on 110429 1230?
220955 - ref SDS 83 MM43 The medical chart says photographs were taken.
220956 - ref DRT 1 0855
220958 - ..
220959 - CD file received today from Wilma shows following....
220960 -
220961 - 1. Wilma's transmittal........................ 110520, ref DRT 1 0001
220963 - ..
220964 - EGD Dilation Evaluate Stricture Dilate Improve Swallowing Nutrition
220965 -
220966 -
220967 - 2. EGD Dilation Procedure..................... 110429, ref DRT 1 0146
220968 -
220969 - 1. Biopsy........Not reported............. 110429,
220971 - ..
220972 - 2. Nurse Pre-proc check list 60439........ 110429, ref DRT 1 PURU
220973 - 1. Vitals............................. 110429, ref DRT 1 PUSW
220974 - 2. NPO solid food 110428 1700......... 110429, ref DRT 1 FC9J
220975 - 3. IV 3 tries not reported............ 110429, ref DRT 1 PVSQ
220976 - 4. Sedation nurse monitor progress.... 110429, ref DRT 1 PVWX
220978 - ..
220979 - Difficulty setting IVs may be important as this problem worsens with
220980 - repeated procedures, based on case study reported, 110429 1230,
220981 - ref SDS 83 UN6K
220983 - ..
220984 - Medical Chart EDG Dilation on 110429 continues...
220985 -
220986 - 3. PACU Record Nursing Recovery....blank.. 110429, ref DRT 1 SE9G
220988 - ..
220989 - 4. Meeting Doctor Lee..................... 110429, ref DRT 1 0491
220990 -
220991 - 1. Consent signature.................. 110429, ref DRT 1 0491
220992 - Dilation proc explained............ 110429, ref DRT 1 PTPY
220994 - ..
220995 - 2. Pre-proc Exam Assmnt 60440......... 110429, ref DRT 1 0264
220996 - 1. Vitals......................... 110429, ref DRT 1 PRSY
220997 - 2. Medications active............. 110429, ref DRT 1 PRWQ
220998 - 3. Sedation plan.................. 110429, ref DRT 1 0457
220999 - 4. Dilation 16.5mm Addendum....... 110429, ref DRT 1 PSRX
221001 - ..
221002 - 3. Procedures......................... 110429, ref DRT 1 PWPS
221003 - 1. Pre-sedation evaluation........ 110429, ref DRT 1 PWPS
221004 - 2. Endoscope equip................ 110429, ref DRT 1 QXSV
221005 - 3. Time Start 1523 End 1546....... 110429, ref DRT 1 0843
221006 - 4. Findings....................... 110429, ref DRT 1 PWTW
221007 - 5. Pictures attached.............. 110429, ref DRT 1 0855
221008 - 6. Dilation 18 mm................. 110429, ref DRT 1 PWVW
221010 - ..
221011 - Addendum later says 16.5 mm............ ref SDS 0 LX5I
221013 - ..
221014 - 7. Injection stricture...3.5mL.... 110429, ref DRT 1 QXXR
221015 - 8. Sedation Med IV................ 110429, ref DRT 1 PWXP
221016 - 9. Kendall signature - no heading. 110429, ref DRT 1 US3I
221018 - ..
221019 - 5. Recovery post-proc nurse note 60251.... 110429, ref DRT 1 0146
221020 - 1. Discharge Instructions............. 110429, ref DRT 1 PPYU,
221021 - 2. Chewing instructions............... 110429, ref DRT 1 0256
221022 - 3. Appt Pendg 3 months dilation....... 110429, ref DRT 1 0256
221023 - 4. Aspirin 81 mg start anytime........ 110429, ref DRT 1 P644
221024 - 5. Omeprazole 40 mg daily............. 110429, ref DRT 1 P644
221026 - ..
221027 - Next meeting in 3 months aligns with planning during the meeting after
221028 - the procedure, reported on 110429 1230, ref SDS 83 LJ6J
221030 - ..
221031 - During the meeting today, asked Wilma about pathology reports on
221032 - biopsies taken during the procedure on 110429?
221034 - ..
221035 - Wilma said there is no record in the medical chart on this case for
221036 - biopsies on 110429.
221038 - ..
221039 - Why no biopsies to assess requirement to continue Omeprazole, and at
221040 - elevated dose, reported in Discharge document for work on 110429 1230.
221041 - ref SDS 83 MM43
221042 -
221044 - ..
221045 - Stress Test Post CABG Cardiology Meetings
221046 - Cardiology Meetings Stress Test Post CABG
221047 -
221048 -
221049 - 3. Cardiology 10501........................... 110415, ref DRT 1 PWYX
221050 -
221051 - 1. Patient profile......................... 110415, ref DRT 1 PXRQ
221052 -
221053 - For some reason this is listed again see below #5.
221054 - ref SDS 0 4P6G
221056 - ..
221057 - 2. Review prior visit 110309............... 110415, ref DRT 1 XH6J
221058 - Cholesterol LDL goal < 70............... 110415, ref DRT 1 XH6J
221060 - ..
221061 - 3. Work Plan............................... 110415, ref DRT 1 4D7H
221062 -
221063 - 1. Aspirin permenantly................. 110415, ref DRT 1 4D7H
221064 - 2. Simvastitan increase 80 mg.......... 110415, ref DRT 1 4D7H
221065 - 3. LDL weight reduce exercise diet..... 110415, ref DRT 1 4D7H
221066 - 4. Holter no evidence afib............. 110415, ref DRT 1 4D7H
221067 - 5. Stress test sets new baseline....... 110415, ref DRT 1 4D7H
221068 - 6. Cardiology follow up after lab July. 110415, ref DRT 1 4D7H
221070 - ..
221071 - 4. Findings/Discussion..................... 110415, ref DRT 1 IJ8O
221072 -
221073 - 1. Doing well post-CABG 4x............. 110415, ref DRT 1 IJ8O
221074 - 2. Aspirin discuss with Doctor Lee..... 110415, ref DRT 1 IJ8O
221075 - 3. Cholesterol LIPID lab in June....... 110415, ref DRT 1 IJ8O
221077 - ..
221078 - 5. Patient profile listed again............ 110415, ref DRT 1 DV9O
221079 -
221080 - Seems to repeat above list. ref SDS 0 C39F
221082 - ..
221083 - 6. Medications active...................... 110415, ref DRT 1 NY3H
221085 - ..
221086 - 7. Examination............................. 110415, ref DRT 1 Z44I
221088 - ..
221089 - 8. Labs listed for......................... 110415, ref DRT 1 X55L
221090 -
221091 - Date Spec Chol Trglyc HDL LDL-CHO
221092 - 1. 101207 0917 PLASM 151 41 47 96
221093 - 100721 0854 PLASM 261 87 35 209
221095 - ..
221096 - Date Spec Glucose BUN CREAT NA K CL
221097 - 2. 101207 0917 PLASM 102 8 0.85 137 3.8 104
221098 - 100721 0854 PLASM 117 12 0.89 139 3.9 106
221100 - ..
221101 - Date Spec WBC HGB HTC MCV MCHC PLT
221102 - 3. 101207 0917 Blood 6.7 14.4 43.3 90.7 33.1 310
221103 - 100721 0854 Blood 7.3 14.9 44.0 91.2 33.8 344
221104 -
221106 - ..
221107 - 9. EKG date 091117 1558.................... 110415, ref DRT 1 H96N
221108 -
221109 -
221111 - ..
221112 - 4. Treadmill Stress Test ECG/EKG............... 110406, ref DRT 1 QH7G
221114 - ..
221115 - This part of the record is unclear, doesn't say treadmill stress test;
221116 - content seems to relate details of EKG and diagnostics recorded during
221117 - treadmill stress test on 110406 1230. ref SDS 81 OF8F
221119 - ..
221120 - Medical Chart Stress Test 110406 continues...
221121 -
221122 - 1. Auto Instrument Diagnosis............... 110406, ref DRT 1 ZB7N
221123 -
221124 - Normal sinus rhythm
221125 - Nonspecific T wave abnormality
221126 - Abnormal ECG
221127 - When compared with ECG of 02-NOV-2009 07:43,
221128 - Nonspecific T wave abnormality no longer evident in Inferior leads
221129 - T wave inversion no longer evident in Anterior leads
221130 - Confirmed by URSELL MD, SHANTHA (703) on 11/18/2009 11:51:16 AM
221132 - ..
221133 - This part of the record is unclear; seems to relate historical data,
221134 - but comparison with work on 091102, and 091118, with ECG results on
221135 - 110406 is unclear. There was an EKG test to evaluate for discharge at
221136 - VA Med Center in San Francisco on 091102 0642. ref SDS 18 4Q3H There
221137 - is no actual comparison in this record, and the data for the test on
221138 - 091102, is not evident in the record nor the VA medical chart.
221140 - ..
221141 - There was an EKG at VA Clinic in Martinez on 091117, to prepare for
221142 - meeting with CT team at VA Med Center in San Francisco, and to
221143 - evaluate post-CABG recovery 2 weeks after discharge. ref SDS 21 UH7O
221145 - ..
221146 - Treadmill stress test on 110406, was ordered by Doctor Egan to compare
221147 - with the same test on 090916, cited in the record meeting with the
221148 - doctor on 091002 0900, ref SDS 10 7S8M, and as reported on 110309
221149 - 0900. ref SDS 79 OF8F
221151 - ..
221152 - Recent Treadmill stress test on 110406 shows significant improvement
221153 - compared with the same test on 090916, and reported by Doctor Egan in
221154 - in the meeting on 091002, as showing 11 nodes failed, ref SDS 10 1W5I,
221155 - and confirmed in the medical chart, ref SDS 10 7S8M, assessment
221156 - finding triple vessel disease (TVD), for meeting at the VA on 091002,
221157 - ref SDS 10 8X3G, that led to CABG surgery on 091022.
221159 - ..
221160 - Medical Chart Stress Test 110406 continues...
221161 -
221162 - 2. Auto Instrument Data?................... 110406, ref DRT 1 EO8N
221163 -
221164 - 3. ETT Comments............................ 110406, ref DRT 1 5P4I
221165 - BRUCE protocol 10 min
221166 - Work level Max.METS: 11.70.............. 110406, ref DRT 1 5P4I
221167 - Heart rate 71 to 160 bpm................ 110406, ref DRT 1 NX9N
221168 - 103% max age-predicted heart rate....... 110406, ref DRT 1 PYWQ
221169 - BP 120/86 to 160/82 mmHg................ 110406, ref DRT 1 PYWT
221170 - Completed 10 min Bruce Protocol......... 110406, ref DRT 1 NX4Y
221171 - PAC frequent peak exercise.............. 110406, ref DRT 1 I75J
221173 - ..
221174 - Research seems to indicate PAC relatively benign condition does not
221175 - require care...
221176 -
221177 - Wikipedia
221179 - ..
221180 - Premature Atrial Contractions (PAC)
221181 - Heart Palpitations PAC Benign Arrhythmia
221182 -
221183 -
221184 - http://en.wikipedia.org/wiki/Premature_atrial_contraction
221186 - ..
221187 - Premature atrial contractions (PACs) are one type
221188 - of premature heartbeat, irregular heart beat, or
221189 - benign arrhythmia. These ectopic beats occur in
221190 - the upper two chambers of the heart, called the
221191 - atria. These beats are not as serious as premature
221192 - ventricular contractions (PVCs) and usually require
221193 - no medical care. Individuals with this condition
221194 - usually report feeling that their heart "stops" or
221195 - misses a beat. Like PVCs, PACs are called heart
221196 - palpitations.
221198 - ..
221199 - Prognosis
221201 - ..
221202 - In rare cases, a PAC, like a PVC, can trigger a
221203 - more serious arrhythmia such as an atrial flutter
221204 - or atrial fibrillation. This is seldom seen in a
221205 - healthy heart but if it does happen medical
221206 - attention should be sought to see what caused the
221207 - problem and what steps can be taken to fix it.
221208 - Unlike PVCs, PACs generally do not compromise the
221209 - hemodynamic system because the conduction
221210 - throughout is via the AV node and the ventricles
221211 - of the heart are activated in a normal sequence.
221213 - ..
221214 - Medical Chart Stress Test 110406 continues...
221215 -
221216 - 4. No ST-T changes with exercise....... 110406, ref DRT 1 FU5M
221217 -
221218 - 5. Myoview study pending............... 110406, ref DRT 1 PYYP
221220 - ..
221221 - Status of pending Myoview study from stress test on 110406?
221223 - ..
221224 - 6. Abnormal atrial arrhythmia exercise. 110406, ref DRT 1 PYYS
221226 - ..
221227 - Doctor Egan cited "abnormal" test findings, in the meeting on 110406,
221228 - and seemed to indicate this is not medically siginficant. 110415 0900,
221229 - ref SDS 82 LY3H
221230 -
221231 - [On 110817 1030 no "Myview" study was performed, so
221232 - no report is pending. ref SDS 84 PM6N
221233 -
221234 -
221236 - ..
221237 - Holter Heart Rate Test Post CABG Cardiology Meetings
221238 - Cardiology Holter Heart Rate Test Post CABG Meetings
221239 - Coronary Heart Function Significantly Stronger Post CABG 4x
221240 -
221241 -
221242 - 5. Holter cardiology test...................... 110310, ref DRT 1 356O
221243 - 1. Raeason for study: PALPITATIONS......... 110310, ref DRT 1 FX4F
221244 - 2. Tape quality good....................... 110310, ref DRT 1 NZ4L
221245 - 3. Heart rate - average 69................. 110310, ref DRT 1 MI5L
221246 - 4. Heart rate - max 152 1123............... 110310, ref DRT 1 MI5L
221247 - 5. Heart rate - min 42 0520............... 110310, ref DRT 1 MI5L
221249 - ..
221250 - On 110310 hiked 2 laps, about 5.5 miles moderate time, reported in
221251 - case study on 101010 0744. ref SDS 50 BT4L "Max heart" rate 152 is
221252 - significantly better than pre-CABG. During years before surgery on
221253 - 091022, heart rate always exceeded 200 hiking hills at Lafayette
221254 - Reservoir. Getting to only max 152 may indicate stronger coronary
221255 - function acheived with CABG 4x, performed on 091022 0700. ref SDS 12
221256 - PQWU
221258 - ..
221259 - Minimum rate 42 at time 0520, further indicates strong heart function
221260 - and aligns with patient history in case study on 101010 0744.
221261 - ref SDS 50 3H6J
221263 - ..
221264 - Medical Chart Cardiology Meeting 110415 continues...
221265 -
221266 - 4. INTERPRETATION:
221267 -
221268 - 1. Predominant rhythm sinus............ 110415, ref DRT 1 206W
221269 - Range 42-152, average 69............ 110415, ref DRT 1 206W,
221270 - Maximum R-R=1.84 seconds............ 110415, ref DRT 1 206W,
221272 - ..
221273 - 2. Beats tachycardia 10%,
221274 - bradycardia 30%..................... 110415, ref DRT 1 206W,
221276 - ..
221277 - 3. Isolated PVC's, no couplets or runs. 110415, ref DRT 1 206W,
221278 - 4. PAC's with couplets, no runs........ 110415, ref DRT 1 206W,
221280 - ..
221281 - This "interpretation" section and also assessment and plan, indicate
221282 - the medical chart received from VA has commingled events, and now
221283 - shifts back from the Helter heart rate test on 110310, to continue
221284 - Doctor Egan's Progress Notes for the meeting on 110415, per above.
221285 - ref SDS 0 C39F
221287 - ..
221288 - Medical Chart Cardiology Meeting 110415 continues...
221289 -
221290 - 5. ASSESSMENT:
221291 -
221292 - 1. CAD,S/P CABG, asymptomatic.
221293 - Significant improvement in TM
221294 - performance post- CABG.............. 110415, ref DRT 1 PY4K,
221296 - ..
221297 - Asymptomatic commonly describes having no symptoms in this case of
221298 - coronary artery disease (CAD), which aligns with express finding of
221299 - significant improvement in the treadmill stress test, ref SDS 0 PY4K,
221300 - reflects comparing with prior test on 091002, per above. ref SDS 0
221301 - WT8G
221303 - ..
221304 - 2. Hyperlipidemia, target LDL < 70..... 110415, ref DRT 1 PY4K,
221306 - ..
221307 - 3. PACs with exercise on ETT 4/6/11,
221308 - no treatment mandated............... 110415, ref DRT 1 PY4K,
221309 -
221311 - ..
221312 - 6. PLAN:
221313 -
221314 - 1. Current medications reconciled, no
221315 - changes made........................ 110415, ref DRT 1 F55H,
221317 - ..
221318 - 2. To discuss asa use with Dr. Lee..... 110415, ref DRT 1 F55H,
221320 - ..
221321 - 3. F/U Dr Sandhu lipids 1-2 months..... 110415, ref DRT 1 F55H,
221323 - ..
221324 - 4. RTC 4 months........................ 110415, ref DRT 1 F55H,
221326 - ..
221327 - 7. Clinical Reminders...................... 110415, ref DRT 1 G05O,
221328 - 1. Consider Aspirin for risk of MI:
221329 - 2. Aspirin not used or prescribed for this patient:
221330 - 3. Reason -Patient declines despite risk
221331 -
221337 -
221339 - ..
221340 - 6. 04/29/2011 ADDENDUM STATUS: COMPLETED............ ref DRT 1 OK3G
221341 - Discussed use of ASA with patient.
221343 - ..
221344 - I believe he was mistaking the reports of adverse interaction
221345 - between omeprazole and clopidogrel.
221347 - ..
221348 - Doctor Lee cites meeting with patient during EGD Dilation procedure on
221349 - 110429 1230. ref SDS 83 SS8I
221351 - ..
221352 - Doctor Sandhu cites risks of aspirin in the record on 101223 1030.
221353 - ref SDS 71 454F
221355 - ..
221356 - Medical Chart addendum for 110429 Doctor Lee continues...
221357 -
221358 - I have no objection to ASA use for cardioprotection in this
221359 - patient, and I suggested that he start 81mg/day.
221361 - ..
221362 - Doctor Lee addresses Cardiology work plan reported by Doctor Egan
221363 - during the meeting on 110415, as shown in medical chart received
221364 - today, listed above. ref SDS 0 R87H
221366 - ..
221367 - Not clear if Doctor Lee issues addendum to Doctor Egan's report on
221368 - 110415, or to his own report o 110429.
221369 -
221370 - /es/ RANDALL E LEE, MD...................... ref DRT 1 UL4H
221371 - STAFF PHYSICIAN, GASTROENTEROLOGY
221372 - Signed: 04/29/2011 17:09
221374 - ..
221375 - 7. Receipt Acknowledged By:.................... ref DRT 1 G14W
221376 - 05/02/2011 07:57 /es/ Gisela Brunskill, NP
221377 - Nurse Practitioner, Cardiology
221378 - for JAMES EGAN
221379 -
221380 -
221381 -
221382 -
221383 -
221384 -
221385 -
221386 -
221387 -
221388 -
221389 -
221390 -
221391 -
221392 -
221393 -
221394 -