CONTACTS
SUBJECTS
VA Cardiology Examination Resovastatin 20 Mg LDL 110 Increase Contin
4703 -
4703 - ..
4704 - Summary/Objective
4705 -
470501 - Follow up ref SDS 6 0000.
470502 -
470503 -
470504 -
470505 -
470506 -
470507 -
470509 - ..
4706 -
4707 -
4708 - Progress
4709 -
470901 - Reviewed results lab on 120831...
470902 -
470903 - 1. WBC 10.9 4.8 - 10.8............. 120831 1400, ref SDS 8 RP4N
470904 -
470905 - a. Sore throat from Rosuvastatin dehydration causing dry
470906 - mouth and throat.
470908 - ..
470909 - b. Blisters under arms from hiking.
470911 - ..
470912 - c. Blisters on lower legs.
470914 - ..
470915 - 2. Lymph % 13.0 20 - 51
470916 -
470917 - Lymph 1.4 1.2 - 3.4
470918 -
470919 - Wikipedia
470920 -
470921 - http://en.wikipedia.org/wiki/Lymphocyte
470923 - ..
470924 - A lymphocyte is a type of white blood cell in the
470925 - vertebrate immune system.
470927 - ..
470928 - A low normal to low absolute lymphocyte concentration is
470929 - associated with increased rates of infection after surgery
470930 - or trauma.
470932 - ..
470933 - 3. Neuts 8.6 1.5 - 7.9
470935 - ..
470936 - 4. Neuts % 78.7 40 - 80
470938 - ..
470939 - 5. T Bilirubin 2.3 .3 - 1.2
470941 - ..
470942 - 6. LDL 110 <= 160
470944 - ..
470945 - However, CAD patient has risk factors goal is < 70
470947 - ..
470948 - LDL actually increased from 94 for prior lab on 120509 1108.
470949 - ref SDS 5 IM9N
470951 - ..
470952 - Elevated WBC may be due to sore throat from past month caused by
470953 - dehydration from Rosuvastatin 20 mg.
470955 - ..
470956 - Could also be caused by severe blisters under arms from hiking.
470958 - ..
470959 - WBC can be elevated by hiking exercise, explained by Doctor Johnson at
470960 - Kaiser on 030606 1630. ref SDS 1 JP7G May not have hiked enough this
470961 - period to increase WBC.
470963 - ..
470964 - Reviewed all side effects of Rosuvastatin and Omperazole...
470965 -
470966 - 1. WBC 10.9 H 4.8 - 10.8......... 120831 1400, ref SDS 8 RP4N
470967 -
470968 - 2. T Bilirubin 2.3 H .3 - 1.2.......... 120831 1400, ref SDS 8 KK9M
470970 - ..
470971 - 3. Dizziness
470973 - ..
470974 - Major new problem reported in patient history including research on
470975 - dizzness caused by CAD on 120815 0621. ref SDS 7 HU5K, and in case
470976 - study on 101010 0744. ref SDS 2 TW5J
470978 - ..
470979 - On 120815 0621 OA 0400 woke up and turned to sleep on the other side.
470980 - Noticed immediately an uneasy, dizzy feeling - lasted 4 - 6 hours.
470981 - ref SDS 7 HU5K
470983 - ..
470984 - Consultation today aligns with work plan on 120815 0621. ref SDS 7
470985 - LL8I
470986 -
470987 - [...below on 120906 1100, Doctor Egan progress notes
470988 - report, Transient lightheadedness possibly due to
470989 - hypotension. ref SDS 0 P252
470991 - ..
470992 - Seems to be improving.
470994 - ..
470995 - 4. Periperhal neuropathy reported on 120514 1300. ref SDS 6 6I70
470997 - ..
470998 - On 120625 another severe episode of peripheral neuropathy in right
470999 - foot that lasted entire hike at American River, shown in case study on
471000 - 101010. ref SDS 2 7G5M
471002 - ..
471003 - Since that date, patient history shows reduced frequency and severity
471004 - of peripheral neuropathy parathesia.
471005 -
471006 - [On 121206 0900 report to VA continued reduced frequency
471007 - and severity peripheral neuropathy parathesia after hiking
471008 - 700 miles over 3 months. ref SDS 10 PK5K
471010 - ..
471011 - [On 121206 0900 Doctor Egan advised during meeting at VA
471012 - Cardiology Department that taking Rosuvastatin medication
471013 - may not be causing peripheral neuropathy parathesa, and
471014 - something internal may be the real cause, referral to
471015 - Neurology department may be needed. ref SDS 10 GS4H
471017 - ..
471018 - [On 130122 1330 peripheral neuropathy parathesia discussed
471019 - Doctor Stewart in General Surgery at VA Medical Center in
471020 - San Francisco, ref SDS 11 0S3K; preliminary diagnosis spinal
471021 - stenosis, referral made to Neurology Department.
471022 - ref SDS 11 OE6N
471024 - ..
471025 - 5. Sore throat due to dehydration
471027 - ..
471028 - Seems to be improving.
471030 - ..
471031 - Doctor Egan was pleased with evident improving side effects taking
471032 - Rosuvastatin 20 mg.
471033 -
471034 -
471036 - ..
471037 - LDL Lower Reduce Drugs 50% Increase Hiking Weight Loss Clinical Trial
471038 - Phase I Clinical Trial Lower LDL Hiking Weight Reduce Rosuvastatin 50%
471039 - Rosuvastatin Reduce 50% Test Exercise and Weight Loss Trial Reduce LDL
471040 - Clinical Trial Phase I Reduce Drugs 50% Lower LDL Exercise Weight Loss
471041 -
471042 - Want to continue Rosuvastatin medication toward reducing LDL below
471043 - 70.
471045 - ..
471046 - Discussed reducing dose Rosuvastatin 20 mg to 10 mg. This will test
471047 - whether increased exercise through hiking and weight loss can control
471048 - cholesterol, specifically LDL and HDL with less reliance on drugs.
471050 - ..
471051 - Reducing Rosuvastatin will hopefully reduce side effects of
471052 - peripheral neuropathy and dehydration.
471054 - ..
471055 - Doctor Egan prescribed dose reduction for Rosuvastatin 10 mg.
471056 -
471057 - [On 121130 0846 Total Bilirubin declined 30% to nearly
471058 - within range for first time, ref SDS 9 KK9M, since starting
471059 - Rosuvastatin on 110817 1030. ref SDS 3 JQ54 Side effects
471060 - dizziness and peripheral neuropathy improve significantly.
471061 - ref SDS 9 ER4K
471063 - ..
471064 - Doctor Egan did more research and found Omeprazole can cause side
471065 - effects of dizziness.
471067 - ..
471068 - He recommended reducing dose from 40 mg to 20 mg per day, i.e.,
471069 - taking only 1 pill per day.
471071 - ..
471072 - This was agreed.
471074 - ..
471075 - Customer will receive new prescription for Rosuvastatin 20 mg, which
471076 - are cut in half to take 10 mg per day.
471078 - ..
471079 - Until new prescription is received, customer will take Rosuvastatin
471080 - 20 mg once ever other day to average 10 mg per day.
471082 - ..
471083 - Doctor Egan ordered lab in 3 months to evaluate effects of dose
471084 - reduction, so if LDL rises significantly, can consider returning to
471085 - Rosuvastatin 20 mg, and or other measures.
471087 - ..
471088 - Next meeting scheduled on Thursday, 121206 0930. Will get another lab
471089 - on Monday, 121203.
471090 -
471091 - [On 121130 0846 Total Bilirubin declined 30% to nearly
471092 - within range for first time since being treated with
471093 - Rosuvastatin. ref SDS 9 ER4K
471094 -
471095 -
471096 -
471097 -
4711 -
SUBJECTS
Default Null Subject Account for Blank Record
4803 -
480401 - ..
480402 - Progress Notes Meeting VA Cardiology Department
480403 -
480404 - Follow up ref SDS 6 S16N, ref SDS 4 S16N.
480405 -
480406 - VA file from CD with Progress Notes for meeting on 120906 are stored
480407 - at...
480408 - ..
480409 - F:\05\00003\SM\CC\AGMJ\20120906-083220\welch_091812.pdf
480410 -
480411 - 1. LOCAL TITLE: Cardiology 10501
480412 - STANDARD TITLE: CARDIOLOGY NOTE
480413 - DATE OF NOTE: SEP 06, 2012@08:32 ENTRY DATE: SEP 06, 2012@08:32:20
480414 - AUTHOR: EGAN,JAMES EXP COSIGNER:
480415 - URGENCY: STATUS: COMPLETED
480420 - ..
480421 - 67 year old MALE followed in Cardiology Clinic for problems
480422 - including
480423 -
480424 - 1. CAD
480425 -
480426 - a) Angina, class II- III 10/2/09
480428 - ..
480429 - b) Abnormal TMST, relatively low work load 9/16/09
480431 - ..
480432 - c) CABGx4v 10/22/09 SFVA (LIMA-->LAD, SVG-->diag,
480433 - SVG-->Ramus,SVG-->PDA).
480435 - ..
480436 - 2. Hyperlipidemia
480438 - ..
480439 - 3. Achalasia, S/P laparoscopic myotomy with fundoplication at
480440 - the San Francisco VA December 2009. Subsequently recurrent
480441 - stricture, most recent dilatation 3/22/12.
480443 - ..
480444 - 4. PACs with exercise on ETT 4/6/11
480446 - ..
480447 - 2. The patient was last seen in clinic on 5/14/12 , A&P as follow:
480449 - ..
480450 - This part of Progress Notes repeats from prior notes on 120514...
480451 -
480452 - 1. ASSESSMENT:
480453 -
480454 - 1. CAD, stable asymptomatic.
480455 -
480456 - 2. Hyperlipidemia, marked improvement on rosuvastatin 20 mg
480457 - daily.
480459 - ..
480460 - 3. PACs with exercise on ETT 4/6/11
480462 - ..
480463 - 4. Paresthesias, uncertain etiology. Possibly but low
480464 - likelihood realted to rosuvastatin.
480466 - ..
480467 - 5. Hyperbilirubinemia, possible relationship to rosuvastatin
480469 - ..
480470 - 2. PLAN:
480471 -
480472 - 1. Current medications reconciled, no changes made.
480473 -
480474 - 2. Will continue current dose of rosuvastatin but will
480475 - continue to monitor bilirubin.
480477 - ..
480478 - 3. Will discuss hyperbilirubinemia and paresthesias with
480479 - Dr Sandhu at his appointment today.
480481 - ..
480482 - 4. RTC 4 months with lipids, CMP just prior.
480484 - ..
480485 - 5. Encouraged to continue hiking and planned weight loss.
480486 -
480487 - 3. /es/ James Egan, MD
480488 - Staff Physician, Cardiology
480489 - Signed: 05/14/2012 13:38
480491 - ..
480492 - Remainder of Progress Notes pertain to meeting today on 120906...
480493 -
480494 - 3. Currently seems to be doing well generally. Still hiking long
480495 - distances without symptoms suggestive of angina and without
480496 - significant limitation by dyspnea.
480497 -
480498 - 1. Several non-cardiac complaints including
480499 -
480500 - 1. intermittent paresthesias of lower extremity,
480501 -
480502 - 2. transient non-vertiginous lightheadedness,
480504 - ..
480505 - 3. dry mouth,
480506 -
480507 - 3. elevated WBC.
480508 -
480509 - 4. Would like to try decreasing rosuvastatin to 10 mg
480510 - daily to see whether any of these or elevated bilirubin
480511 - improve.
480513 - ..
480514 - 2. No palpitations.
480516 - ..
480517 - 3. Denies PND, Orthopnea, Edema
480519 - ..
480520 - 4. PAST MEDICAL HISTORY:
480521 -
480522 - 1. Computerized Problem List is the source for the following:
480523 -
480524 - 1. Vitamin D Deficiency 08/03/11 Sandhu, Harkesh
480526 - ..
480527 - 2. Postsurgical Aortocoronary Bypass Status (ICD-9-CM
480528 - V45.81) 03/09/11 Egan, James
480530 - ..
480531 - 3. Esophageal Stricture 03/05/10 LEE,RANDALL E
480533 - ..
480534 - 4. Screening for Malignant Neoplasms of colon 11/15/11
480535 - LEE,RANDALL E (ICD-9-CM V76.51)
480536 -
480537 - 2010 colonoscopy: no polyp. Next screen 2020
480539 - ..
480540 - 5. Coronary Atherosclerosis (unspecified type 02/02/10
480541 - LEE,RANDALL E vessel, native or graft) (ICD-9-CM 41
480543 - ..
480544 - 6. Coronary Artery Bypass using Venous and 01/04/10
480545 - SANDHU,HARKESH Arterial Grafts (Single Vein Graft),
480546 - Onset 10/00/09 done at vasf
480548 - ..
480549 - CABG was performed at VA San Francisco Medical Center on 091022.
480550 - ref SDS 3 PQWU
480552 - ..
480553 - Onset reported to VA on 090908 1130. ref SDS 2 MY4N
480555 - ..
480556 - VA Progress Notes Cardiology meeting 120514 continue...
480557 -
480558 - 7. Surgical Thoracoscopy with Esophagomyotomy 01/04/10
480559 - SANDHU,HARKESH (Heller Type), Onset 12/16/09 at vasf
480561 - ..
480562 - 8. Hyperlipidemia * (ICD-9-CM 272.4) 10/02/09 EGAN,JAMES
480564 - ..
480565 - 9. Inflamed Seborrheic Keratosis (ICD-9-CM 702.11)
480566 - 03/12/07 LIN,BERTHA
480568 - ..
480569 - 10. Rosacea * (ICD-9-CM 695.3) 03/12/07 LIN,BERTHA
480571 - ..
480572 - 11. Dermatitis * (ICD-9-CM 692.9) 03/12/07 LIN,BERTHA
480574 - ..
480575 - 12. Tinea Unguium * (ICD-9-CM 110.1) 03/12/07 LIN,BERTHA
480577 - ..
480578 - 13. Tinea * (ICD-9-CM 110.9) 03/12/07 LIN,BERTHA
480580 - ..
480581 - 14. Rosacea conjunctivitis (ICD-9-CM 372.31) 03/02/07
480582 - MARGULIES,LINDA
480584 - ..
480585 - 15. Rosacea * (ICD-9-CM 695.3) 03/02/07 MARGULIES,LINDA
480587 - ..
480588 - 16. Blepharitis NOS 02/21/07 MARGULIES,LINDA
480590 - ..
480591 - 17. Achalasia * (ICD-9-CM 530.0) 12/22/05 SANDHU,HARKESH
480593 - ..
480594 - 18. Abn. LFT's 08/16/05 SANDHU,HARKESH
480596 - ..
480597 - 19. Obesity 06/29/05 SANDHU,HARKESH
480599 - ..
480600 - 20. Rosacea 06/29/05 SANDHU,HARKESH
480602 - ..
480603 - 21. Tinea Unguium 06/29/05 SANDHU,HARKESH
480605 - ..
480606 - 2. Patient has answered NKA (no known allergies)
480608 - ..
480609 - 5. Active Outpatient Medications (including Supplies):
480610 -
480611 - 1. OMEPRAZOLE 20MG EC CAP TAKE TWO CAPSULES BY MOUTH TWICE A
480612 - ACTIVE DAY 15 MINUTES BEFORE A MEAL FOR SEVERE ACID REFLUX
480613 - AND ESOPHAGEAL NARROWING. **DOSE INCREASE**
480615 - ..
480616 - 2. ROSUVASTATIN CA 40MG TAB TAKE ONE-HALF TABLET BY MOUTH
480617 - ACTIVE ONCE DAILY - TO LOWER CHOLESTEROL. REPLACES
480618 - SIMVASTATIN *USE PILL CUTTER* (APPROVED)
480620 - ..
480621 - 6. PHYSICAL EXAM - Date: 120906 1103
480622 -
480623 - T....................... 98.6 F (37.0 C)
480624 - P....................... 69
480625 - R....................... 18
480626 - B/P..................... 119/70
480627 - Wt...................... 197.00 (89.55 KG) (ACTUAL STANDING WEIGHT)
480628 - Body Mass Index......... 32*
480629 - Pulse Oximetry.......... 99%
480630 - Pain.................... 0 - No pain
480632 - ..
480633 - 7. Head atraumatic, PERRL.
480634 - JVP wnl.
480635 - Cor:Regular, no ectopy. No sig mrg.
480636 - Lungs clear of rales, ronchi and wheezes.
480637 - Extremities without cyanosis, clubing or edema.
480639 - ..
480640 - 8. PLASMA 08/31 05/09 Reference
480641 - 2012 2012
480642 - 15:24 11:24 Units Ranges
480643 - -------------------------------------------------------------------------
480644 - CHOL 176 158 mg/dL Ref: <=200
480645 - TRIGLYC 94 76 mg/dL Ref: <=150
480646 - HDL 47 49 mg/dL Ref: >=40
480647 - LDL 110 94 mg/dL Ref: <=160
480649 - ..
480650 - These valuations align with VA lab on 120831 1400. ref SDS 8 KB5L
480652 - ..
480653 - VA Progress Notes Cardiology meeting 120514 continue...
480654 -
480655 - 9. ---- CHEM PROFILE ----
480656 - PLASMA 08/31 05/09 Reference
480657 - 2012 2012
480658 - 15:24 11:24 Units Ranges
480659 - -------------------------------------------------------------------------
480660 - GLUCOSE 113 108 mg/dL 74 - 118
480661 - GLUfast mg/dL Ref: <=99
480662 - NA 141 138 mmol/L 136 - 144
480663 - K 3.8 4.2 mmol/L 3.4 - 4.8
480664 - CL H 109 105 mmol/L 98 - 106
480665 - CO2 24 27 mmol/L 23 - 33
480666 - BUN 16 17 mg/dL 8 - 26
480667 - CREAT 1.02 0.94 mg/dL .5 - 1.1
480668 - eGFR >60 >60 mL/min Ref: >=60
480669 - CALCIUM 9.1 8.7 mg/dL 8.7 - 10.2
480670 - CA CORR mg/dL 8.7 - 10.2
480671 - PO4 mg/dL 2.4 - 4.5
480672 - MG mg/dL 1.8 - 2.5
480673 - ALK PHO 93 86 IntUnits/L 37 - 107
480674 - T. BIL H 2.3 H 2.5 mg/dL .3 - 1.2
480675 - D. BILI 0.3 0.3 mg/dL .1 - .4
480676 - AST 33 25 IntUnits/L 8 - 42
480677 - ALT 35 21 IntUnits/L 5 - 55
480678 - ALBUMIN 4.3 4.1 g/dL 3.3 - 4.8
480679 - PROTEIN 7.5 7.1 g/dL 6.5 - 8.1
480680 -
480682 - ..
480683 - 10. BLOOD 08/31 05/09 Reference
480684 - 2012 2012
480685 - 15:24 11:24 Units Ranges
480686 - -------------------------------------------------------------
480687 - WBC H 10.9 6.8 K/cmm 4.8 - 10.8
480688 - RBC 5.37 5.06 M/cmm 4.7 - 6.1
480689 - HGB 16.3 15.0 g/dL 14 - 18
480690 - HCT 48.8 45.8 % 42 - 52
480691 - MCV 90.3 90.7 fL 80 - 99
480692 - MCH 30.3 29.7 uug 27 - 34
480693 - MCHC 33.3 32.8 gm/dL 32 - 35.2
480694 - RDW 13.0 13.6 % 11.5 - 14.5
480695 - PLT 291 288 K/cmm 130 - 400
480696 - MPV 8.4 8.7 fL 7 - 10.4
480698 - ..
480699 - 11. EKG - NONE FOUND
480701 - ..
480702 - 12. ASSESSMENT:
480703 -
480704 - 1. CAD, stable asymptomatic.
480705 -
480706 - 2. Hyperlipidemia, Some concern with reducing rosuva as LDL is
480707 - already above goal but I am willing to attempt this for a
480708 - short period to assess for improvement in any of the above
480709 - noted symptoms.
480711 - ..
480712 - 3. Achalasia. Note that omeprazole may cause both dizziness
480713 - and paresthesias. I would favor a trial of a lower dosage.
480715 - ..
480716 - 4. Transient lightheadedness possibly due to hypotension.
480717 - Advised to caryy water on hikes and hydrate continuously
480718 - (Doesn't carry now).
480720 - ..
480721 - May relate to dizziness report during the meeting this morning, per
480722 - above. ref SDS 0 5L6H Carrying water on hikes may not correlate to
480723 - dizziness waking up at 0400 in morning with severe dizziness, reported
480724 - on 120815 0621. ref SDS 7 HU5K
480725 -
480727 - ..
480728 - 13. PLAN:
480729 -
480730 - 1. Current medications reconciled, no changes made.
480731 -
480732 - 2. Decrease omeprazole to 20 mg daily for now, will discuss
480733 - with Dr Lee 9/25/12.
480735 - ..
480736 - 3. Decrease rosuvastatin to 10 mg daily with fasting lipids
480737 - and CMP 3 months.
480739 - ..
480740 - 4. RTC 4 months with lipids, CMP just prior.
480741 -
480742 -
480743 - 14. /es/ James Egan, MD
480744 - Staff Physician, Cardiology
480745 - Signed: 05/14/2012 13:38
480746 -
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4808 -