CONTACTS
SUBJECTS
VA Prescribe Atorvastin 10 MG Trial 4 Weeks Evaluate Side Effects In
4903 -
4903 - ..
4904 - Summary/Objective
4905 -
490501 - Follow up ref SDS 44 0000. ref SDS 41 0000.
490502 -
490503 - Meeting to review clinical trials for lowering cholesterol.
490504 -
490505 -
490506 -
490507 -
490509 - ..
4906 -
4907 -
4908 - Background
4909 -
4910 -
491001 - Lab on 131015, showing cholesterol remained high, 131015 0724,
491002 - ref SDS 37 BE6O, conflict with increased exercise and weight loss,
491003 - discussed in the letter to the medical team yesterday on 131016 1632.
491004 - ref SDS 38 IW57
491006 - ..
491007 - On 131017 1000 VA medical chart Progress Notes assessment report
491008 - patient status CAD stable, asymptomatic. hyperlipidemia not
491009 - controlled. ref SDS 39 T24N
491011 - ..
491012 - On 131017 1000 Doctor Egan proposed referring patient for clinical
491013 - trial to reduce cholesterol with new "targeted" drugs. ref SDS 39 179N
491015 - ..
491016 - On 131017 1000 VA medical chart Progress Notes assessment report
491017 - patient status hyperlipidemia not controlled, ref SDS 39 PSXT; Doctor
491018 - Egan makes referral to SF VA Medical Center for consult on
491019 - participation clinical trials, ref SDS 39 EU9F, with experimental
491020 - agents such as AMG 145 and REGN 727 to resolve multiple statin
491021 - intolerances. ref SDS 39 CN4H
491023 - ..
491024 - On 131103 received letter from VA SF Medical Center scheduling meeting
491025 - on 131121 1000, to consider clinical trial for lowering cholesteral.
491026 - ref SDS 41 YT4N
491028 - ..
491029 - On 131112 New York Times published several articles reporting that the
491030 - day before on 131113, American Heart Association published new
491031 - guidelines for treating CAD patients that expand use of statin
491032 - medication regardless of cholesterol levels, ref SDS 42 0001, and
491033 - further raise the LDL 70 to LDL 190, as a target for cardiovascular
491034 - risk. ref SDS 42 CW6H
491036 - ..
491037 - On 131114 New York Times published several articles reporting that the
491038 - day before on 131113, American Heart Association published new
491039 - guidelines for treating CAD patients. ref SDS 43 SH6G
491041 - ..
491042 - On 131121 1604 meeting with Doctor Alba at San Francisco Medical
491043 - Center - prescribed Atorvastatin 20 mg 4-week trial and evaluate
491044 - adding Zetia 10 mg, schedule follow up on 131219 0930. ref SDS 44 6H6K
491046 - ..
491047 - On 131121 1604 in another record later today, VA prescription RX #
491048 - 5674471 for Atorvastatin 20 mg has been ordered. ref SDS 45 GH5M
491050 - ..
491051 - On 131125 0005 letter from Karen reports VA work plan to take statin
491052 - drug low dose Atvorstatin 10 mg for 4 weeks, then add Zetia 10 mg in
491053 - clinical trial for lowering cholesterol. ref SDS 47 V154
491055 - ..
491056 - On 131125 0005 research seems to indicate this clincial trial of low
491057 - dose Atorvasatatin 10 mg with Zeitia 10 mg has lowered cholesterol LDL
491058 - 70.
491060 - ..
491061 - On 131205 1448 received new prescription for Atvorstatin 20 mg,
491062 - ordered by Doctor Alba today for 4-week trial to assess side effects
491063 - for adding 2nd drug, Zetia 10 mg to lower LDL 249. ref SDS 48 GH5M
491064 -
491065 -
491066 -
491067 -
491068 -
491070 - ..
4911 -
4912 -
4913 - Progress
4914 -
491401 - Hyperlipidemia Not Controlled Cholesterol Elevated Despite Exercise
491402 - Cholesterol Elevated Despite Exercise Discuss Clinical Trial
491403 - Clinical Trial Considered Lower Cholesterol Without Statin Drugs
491404 -
491405 - Follow up ref SDS 44 HY6O, ref SDS 41 VY6H.
491406 -
491407 - Visited with Karen in Cardiology Department.
491409 - ..
491410 - Karen received the copy sent to her of the letter submitted on 131216
491411 - 0028. ref SDS 50 HY6O
491413 - ..
491414 - She seemed to indicate familiarity with using ratio of TG/HDL to
491415 - approximate LDL-P test results, presented para 3 and 4 in the letter
491416 - on 131216 0028. ref SDS 50 6T49 She feels the last lab showing 109/50
491417 - on 131015 0724, ref SDS 37 W25L, indicates LDL 249 is a positive test
491418 - report because the LDL particles are too big ("fluffy") to absorb into
491419 - artery wall tissue, rather than small and dense.
491421 - ..
491422 - Review agenda presented in letter to VA on 131216 0028. ref SDS 50
491423 - 8N53
491424 -
491425 - 1. VA follow patient history medications, diet, exercise,
491426 - vitals, proposed on 131216 0028. ref SDS 50 8N53
491428 - ..
491429 - 2. HDL/TG why hasn't this continued to track exercise, as in
491430 - prior years, presented in letter to VA on 131216 0028,
491431 - ref SDS 50 6T49, and citing lab study on 131015 0724.
491432 - ref SDS 37 W25L
491434 - ..
491435 - 3. Diet....
491436 -
491437 - 1. Chia seeds - seem to increase energy, shown by significant
491438 - increase ability to sustain faster times hiking 11 miles
491439 - per day from 5 to at least 8, shown in case study on 120101
491440 - 0900. ref SDS 11 TK6F
491442 - ..
491443 - 2. Orange juice, cranberry juice compared to lemon and
491444 - grape juice for increasing HDL, presented in letter to
491445 - VA on 131216 0028. ref SDS 50 8O3I
491447 - ..
491448 - Some authorities claim orange juice increases HDL 21%
491449 - ...[reported on 131125 0005. ref SDS 46 R48K...]
491451 - ..
491452 - 4. Clinical trials, non-statin lower cholesterol - research
491453 - status - who was contacted; what follow up is pending,
491454 - e.g., Doctor Bikle, other VA venues, implementing work plan
491455 - on 131121, presented in letter to VA on 131216 0028.
491456 - ref SDS 50 6T4I
491458 - ..
491459 - 5. Discordant LDL-C and LDL-P issue is complex. [...shown
491460 - in research on 131125 0005. ref SDS 47 PQ74...].
491461 - Authorities say measuring LDL-P is expensive, 131125
491462 - 0005, ref SDS 47 G45J...], but maintaining TG/HDL ratio
491463 - below 2 indicates low LDL-P (< 1000), that signals low
491464 - risk for CVD. [... shown on 131125 0005, ref SDS 47
491465 - EH9J, and, ref SDS 47 QS9F...]. VA guidance is
491466 - appreciated.
491467 -
491468 -
491469 -
491471 - ..
491472 - Atorvastatin 10 MG with Ezetimibe 10 MG Prescirbed to Manage Lipids
491473 -
491474 - Follow up ref SDS 44 6H6K.
491476 - ..
491477 - 6. Medications change - Atorvastatin 10 mg add Ezetimibe 10
491478 - mg, discussed in letter on 131216 0028, ref SDS 50 8N6L,
491479 - citing Progress Notes Plan on 131121 0930. ref SDS 44 S26O
491481 - ..
491482 - During the meeting today, Doctor Feingold and Doctor Alba confirmed VA
491483 - work plan for patient to begin new regimen taking Atorvastatin 10 mg
491484 - with Ezitimibe 10 mg. Doctor Alba ordered Atorvastatin and Ezetimibe
491485 - prescriptions at the VA pharmacy. Treatment will begin when the drugs
491486 - are received.
491487 -
491488 - [...below on 131219 0930 Doctor Alba's work plan in
491489 - Progress Notes is confusing, but is interpreted to align
491490 - with discussions during the meeting with Doctor Feingold
491491 - prescribing Atorvastatin 10 mg with Ezetimibe 10 mg.
491492 - ref SDS 0 E34O
491494 - ..
491495 - [On 120101 0900 case study reporting on 131230, received
491496 - prescription for Ezetimibe, so begin trial Atorvastatin
491497 - 10 mg and Ezetimite 10 mg to manage cholesterol.
491498 - ref SDS 12 6A6H
491500 - ..
491501 - Weight Lower 165
491502 -
491503 - 7. Doctor Alba reported the medical team concurs with goals to
491504 - lower triglycerides and increase HDL, supported by research
491505 - on 131125 0005, ref SDS 46 VR5N, toward reducing LDL
491506 - particle count and increasing particle size, so that
491507 - cholesterol-rich/triglyceride-depleted LDL particles that
491508 - are large and "fluffy" cannot penetrate endolthlial layer
491509 - lining the arteries, reducing CVD risk (arterialsclorosis,
491510 - mycardial infarction), indicated by research on 131125
491511 - 0005. ref SDS 46 N044 The team feels continued weight loss
491512 - to 165 or even 160 supports this objective, through
491513 - exercise and diet control, further cited in research on
491514 - 131125 0005. ref SDS 46 PD69
491515 -
491516 - [...below on 131219 0930 VA Progress Notes Physical Exam
491517 - show BMI 29.2 overweight, ref SDS 0 L74L; work plan to
491518 - continue diet control and exercise. ref SDS 0 F56N
491520 - ..
491521 - [On 120101 0900 finally hit 165 on scales; next
491522 - objective is to stabalize this weight, then work toward
491523 - 160, based on lab results. ref SDS 13 A39H
491525 - ..
491526 - [On 140204 1236 letter from VA notifying Progress Notes
491527 - for meeting today are available for patient use, cites
491528 - discussion on lowering weight to 165, that aligns with
491529 - BMI standards. ref SDS 58 8N9H
491531 - ..
491532 - Scheduled next meeting in 8 weeks on 140213 0830.
491533 -
491534 -
491535 -
491536 -
491537 -
4916 -
SUBJECTS
Default Null Subject Account for Blank Record
5003 -
500401 - ..
500402 - Medical Chart Progress Notes Meeting 131219 VA SF Medical Center
500403 -
500404 - Follow up ref SDS 44 NV6H, ref SDS 40 TF5O.
500417 -
500418 -
500419 - 1. LOCAL TITLE: ENDOCRINE-METABOLISM CLINIC (MED)
500420 - STANDARD TITLE: ENDOCRINOLOGY OUTPATITNE NOTE
500421 - DATE OF NOTE: DEC 19, 2013 @ 1525
500422 - ENTRY DATE: JAN 15, 2014 @152538
500435 - ..
500436 - CC: follow up for high cholesterol
500438 - ..
500439 - 2. HPI
500440 -
500441 - 1. 68 year old male with history of CAD, s/p CABG in 2009,
500442 - Hyperlipidemia, achalasia, s/p lap heller myotomy and
500443 - fundoplication in 2009, who was referred by his Cardiologist,
500444 - Doctor Egan for management of hyperlipidemia.
500446 - ..
500447 - 2. He was last seen in endocrine clinic November 2013. On our
500448 - last appointment patient was started on atorvastatin 10 mg
500449 - daily - however he reports taking Atorvastatin 40 mg po
500450 - daily - he had an old prescription at home - denies any
500451 - side effects at this point. He continues to hike multiple
500452 - days per week and continue to follow a low fat/low
500453 - cholesterol diet.
500455 - ..
500456 - VA's record here stating patient hikes "multiple days per week," may
500457 - not orient medical team on patient exercise lowering cardiovascular
500458 - risk by hiking 11 miles per day 7 days per week, beginning OA 130417,
500459 - shown in case study on 120101 0900, ref SDS 11 F35N, and cited in
500460 - letter to VA on 131125 0005, ref SDS 46 UK7K, and more recent letter
500461 - on 131216 0028. ref SDS 50 6T49 The letter on 131216, expressly
500462 - referenced case study that can be bookmarked for easy access to track
500463 - daily hiking, diet, and medications. ref SDS 50 8N53 Hiking twice or
500464 - 3 times per week for 1 - 3 miles, at most 9 miles a week, would not be
500465 - expected to yield benefits for cardiopulmonary health (e.g.,
500466 - cholesterol management, blood pressure and heart rate derived from
500467 - hiking 80 miles per week.
500469 - ..
500470 - VA Progress Notes meeting 131219 continues...
500471 -
500472 - 3. We explored his interests in participating in a clinical
500473 - trial - I discussed the issue with Doctor Feingold and was
500474 - directed to Doctor Bersot at SFGH. However at the point
500475 - the SF VA is not involved in any research. I found
500476 - information about SANOFI, one of the pharmaceutical
500477 - companies involved in the research for the Antibody to
500478 - PCSK9 for Hypercholesterolemia. I provided Mr Welch with
500479 - this information and other website about clinical trail in
500480 - the San Francisco area that he can explore.
500482 - ..
500483 - 4. Today, he denies CP, SOB, abdominal pain, muscl pain.
500484 -
500486 - ..
500487 - 3. Patient History
500488 -
500489 - 1. Patient was started on Simvastatin approximately 2-3 years
500490 - ago, LDL at that time was around 180's - reports this his
500491 - LDL dropped to 96 while on simvastatin, however he reports
500492 - he develop "left shoulder myopathy"- he described pain on
500493 - his left shoulder and inability to raise it above 90
500494 - degrees- No CPK on records.
500496 - ..
500497 - 2. He was then started on Rosuvastatin 10 mg po daily and
500498 - report that his LDL improved. Rosuvastatin was then
500499 - increased to 20 mg and he developed sexual dysfunction,
500500 - dizziness, dry mouth and right foot numbness. As per
500501 - cardiology notes in September 2012- rosuvastatin was
500502 - decreased to 10 mg po daily and dizziness improved, but he
500503 - continued to complain of right foot numbness. He now has
500504 - he has been off the rosuvastatin since 12/2012, and he
500505 - continues to complain of right foot nmbness, but he reports
500506 - less episodes of right sole numbness with decreased
500507 - intensity.
500509 - ..
500510 - See comment on Progress Notes for meeting on 131121, presenting record
500511 - on peripheral neuropathy, also called numbness. ref SDS 44 E34O
500513 - ..
500514 - VA Progress Notes meeting 131219 continues...
500515 -
500516 - 3. Of note, he was seen by neurology February 2013 for the
500517 - foot numbness, Vit B12 level was within normal range,
500518 - fasting glucose level ranges from 108 to 115 mg/dl, Hgalc
500519 - 5.5 October 2013, as per neurology notes no evidence of
500520 - radiculopathy or neuropathy.
500522 - ..
500523 - See comment on Progress Notes for meeting on 131121, presenting record
500524 - on HGA1c lab results. ref SDS 44 XQ7R
500526 - ..
500527 - VA Progress Notes meeting 131219 continues...
500528 -
500529 - 4. PMH:
500530 -
500531 - 1. Esophageal Achalasia
500532 - 2. CAD s/p CABG x4 in 2009
500533 - 3. GERD
500534 - 4. Hyperlipidemia
500536 - ..
500537 - 5. Surgical, social and family history reviewed an unchanged
500539 - ..
500540 - This notes reflects entry in Progress Notes para 4, PSH, for meeting
500541 - at VA on 131121 0930. ref SDS 44 669N
500543 - ..
500544 - Corrections to family history reported in VA Progress Notes on 131121
500545 - 0930, ref SDS 44 U45N, were submitted to the VA on 131216 0028.
500546 - ref SDS 50 8N61
500548 - ..
500549 - VA Progress Notes meeting 131219 continues...
500551 - ..
500552 - 6. MEDICATIONS
500553 -
500554 - 1. Omeprazole 20 mg BID
500555 - 2. Atorvastatin 40 mg po daily
500557 - ..
500558 - 7. PHYSICAL EXAM
500559 -
500560 - 1. Vital Signs:
500561 -
500562 - 1. HR: 64 (12/19/2013 0905)
500563 - 2. BP: 123/71 (12/19/2013 0906)
500564 - 3. WT: 180.5 lb [82.0 kg] (12/19/2013 0905)
500565 - 4. BMI: 29.2 (Overweight)
500567 - ..
500568 - 2. Gen : NAD, cooperative
500569 - deferred
500571 - ..
500572 - 8. LABS:
500573 -
500574 - 1. October 2013
500575 -
500576 - TC............. 321
500577 - LDL............ 249
500578 - HLD............ 50
500579 - TG............. 85
500580 - TBil........... 1.7
500581 - HGA1c.......... 5.5
500582 - CPK............ 110
500583 - TSH............ 2.6
500585 - ..
500586 - HLD 50 should be HDL 50 - minor correction. Repeats error in notes
500587 - for prior meeting on 131121 0930. ref SDS 44 FJ6G
500589 - ..
500590 - Triglycerides (TG) reported 109 not 85, for lab on 131015 0724.
500591 - ref SDS 37 BE6O Repeats error in notes for prior meeting on 131121
500592 - 0930. ref SDS 44 FJ6G
500594 - ..
500595 - CPK and TSH shown in Progress Notes today, are not evident in VA on
500596 - 131015 0724. ref SDS 37 RP4N CPK and TSH are not shown in Progress
500597 - Notes for prior meeting on 131121 0930. ref SDS 44 FJ6G
500599 - ..
500600 - Progress Notes for meeting with Primary Care on 131209, also, show Tsh
500601 - 2.62 for lab on 131015. ref SDS 49 ZU59
500603 - ..
500604 - VA Progress Notes LABS meeting 131219 continues...
500605 -
500606 - 2. May 2013
500607 -
500608 - TC............. 307
500609 - LDL............ 240
500610 - HLD............ 54
500611 - TG............. 85
500612 - TBil........... 1.3
500614 - ..
500615 - 3. November 2012
500616 -
500617 - TC............. 173
500618 - LDL............ 105
500619 - HLD............ 57
500620 - TG............. 53
500621 - TBil........... 1.6
500622 -
500623 - 4. 14 December 2009
500624 -
500625 - TC............. 241 H 100 - 240 PLASMA
500626 - LDL (Calcultd). 170 H - 131 PLASMA
500627 - HLD............ 44 35 - PLASMA
500628 - TG............. 136 10 - 190 PLASMA
500630 - ..
500631 - 9. Assessment and Plan:
500632 -
500633 - 1. 68 year old male with history of CAD, s/p CABG in 2009,
500634 - Hyperlipidemia, referred by cardiology for management of
500635 - hyperlipidemia. Here today for follow up.
500636 -
500637 - Patient was started on low dose Atorvastatin in our last
500638 - visit [10 mg po daily] - however he started Atorvastatin 40
500639 - mg - despite my specific indication to start at low dose to
500640 - monitor side effects.
500642 - ..
500643 - Progress Notes today accurately report original work plan presented by
500644 - VA on 131121 0930, ref SDS 44 6H6K, and as shown in prior Progress
500645 - Notes. 131121 0930, ref SDS 44 S26O
500647 - ..
500648 - VA Progress Notes Assessment and Plan meeting 131219 continues...
500649 -
500650 - 2. Today he denies any muscle pain that might be related to
500651 - myopathy.
500653 - ..
500654 - Unclear how myopathy relates to side effects taking Atorvastatin that
500655 - primarily causes digestion problems.
500657 - ..
500658 - VA was notified in a letter that patient suffered minimal side effects
500659 - of any kind taking Atorvastatin 40 mg for about 4 weeks, shown in the
500660 - record on 131216 0028. ref SDS 50 8O4H
500662 - ..
500663 - VA Progress Notes Assessment and Plan meeting 131219 continues...
500664 -
500665 - 3. We discussed again that despite appropriate diet and
500666 - exercise, his LDL is still not at goal, and increasing
500667 - exercise activity is of little benefit at this point, since
500668 - elevated cholesterol in his case has a genetic component,
500669 - that needs to be treated with medication.
500671 - ..
500672 - Patient asked in a letter about testing cholesterol for discordance
500673 - goal with LDL-P < 1000 (low), and LDL-C elevated above conventional
500674 - practice goals - signaled when TG/HDL ratio < 2 - actually improves
500675 - cardiovascular health, reported on 131216 0028. ref SDS 50 6T60
500676 -
500677 - [On 140203 1147 obtained blood draw at VA in Martinez,
500678 - ref SDS 55 X45G, showing LDL-C 93, HDL 58, TG 47,
500679 - ref SDS 55 IM9N indicating "concordance" LDL-P 626, LDL
500680 - (pattern A) size = large bouyant protective. ref SDS 55
500681 - QV5G
500683 - ..
500684 - VA Progress Notes Assessment and Plan meeting 131219 continues...
500685 -
500686 - 4. Mr Welch is asking about direct measurement of LDL-P vs
500687 - LDL-P. however I don't think that direct measured of
500688 - LDL-C is of any value to his treatment.
500690 - ..
500691 - Progress Notes likely intend to say "...measurement of LDL-P vs LDL-C.
500692 -
500693 - [On 140213 0830 Progress Notes repeat inadvertant error
500694 - substituting LDL-C, when LDL-P is intended. ref SDS 59
500695 - E66J
500697 - ..
500698 - VA Progress Notes Assessment and Plan meeting 131219 continues...
500699 -
500700 - 5. The accuracy of the calculated LDL-C, declines once
500701 - triglycerides exceed 250 mg/dL (which is NOT the case for
500702 - Mr Welch] and LDL-C cannot be calculated when the
500703 - triglycerides exceed 400 mg/dL. Recent data shows that The
500704 - Friedwald equation used to calculate LDl tends to
500705 - UNDERESTIMATE LDL-C levels in the setting of high
500706 - triglyceride levels, especially at low LDL-C levels, which
500707 - could result in undertreatment of high-risk patients. In
500708 - mr Welch's case, we already know you is a high risk patient
500709 - - known hx of CAD and both total cholesterol and calculated
500710 - LDl are both well above target.
500712 - ..
500713 - There is no record LDL-P is "well above target," shown by patient
500714 - history of lipid panel on 131015 0724. ref SDS 37 W25L VA Progress
500715 - Notes today state LDL-P has stronger association than LDL-C, with CVD
500716 - risk, ref SDS 0 GO35; and, research indicates discordance with LDL-P
500717 - low ( < 1000 ) and LDL-C high yields the best lipid profile for
500718 - reducing cardiovascular risk, reported on 131125 0005. ref SDS 46 FI3G
500719 - Since LDL-C is high, then if LDL-P is low, the patient is within the
500720 - target for optimal outcome.
500722 - ..
500723 - [On 140203 1147 obtained blood draw at VA in Martinez,
500724 - ref SDS 55 X45G, showing LDL-C 93, HDL 58, TG 47,
500725 - ref SDS 55 IM9N indicating "concordance" LDL-P 626, LDL
500726 - (pattern A) size = large bouyant protective. ref SDS 55
500727 - QV5G
500729 - ..
500730 - VA Progress Notes Assessment and Plan meeting 131219 continues...
500731 -
500732 - 6. Regarding LDL-P, after discussing the case with Doctor
500733 - Feingold - LDL-P is usually measured to assess risk for
500734 - cardiovascular disease, in patients with OPTIMAL levels of
500735 - LDL. For these patients, measuring and lowering LDL-P is
500736 - considered a primary goal of therapy due to its stronger
500737 - association with cardiovascular risk. In Mr Welch's case,
500738 - his LDL-C is not at optimal levels, so again measuring of
500739 - LDL-P will add no benefit to treatment management.
500741 - ..
500742 - Progress Notes reporting LDL-P has "stronger association with
500743 - cardiovascular risk" compared with LDL-C, aligns with research on
500744 - discordance, reported on 131125 0005, ref SDS 46 FI3G, and was
500745 - referenced in a letter submitted to the VA on 131216 0028. ref SDS 50
500746 - 6T60
500747 -
500748 - [On 140114 0845 letter to VA asks about ordering lab for
500749 - LDL-P to test for favorable discordance. ref SDS 52 2140
500751 - ..
500752 - [On 140116 0814 Doctor Attia's research and analysis
500753 - cited in letter to VA asking about testing lab for
500754 - discordance low LDL-P and high LDL-C showing patient
500755 - with lowest risk arterialsclorosis mycardial infarction
500756 - (heart attack). ref SDS 53 739K
500758 - ..
500759 - [On 140116 0814 letter to medical team cites research
500760 - that seems to indicate labs can be ordered to test
500761 - patients for discordance between high LDL-C and low
500762 - LDL-P that presents lowest risk for arterialsclorosis,
500763 - CVD, mycardial infarction. ref SDS 53 H29T
500765 - ..
500766 - [On 140201 1159 obtained blood draw for Lipid NMR test
500767 - at Labcor on Health Testing Centers order # 27716,
500768 - ref SDS 54 KQ4L, showing "concordance" LDL-P 861, LDL-C
500769 - 81, HDL 61, TG 68, LDL (pattern A) size = large bouyant
500770 - protective. ref SDS 54 IM9N
500772 - ..
500773 - [On 140203 1147 obtained blood draw at VA in Martinez,
500774 - ref SDS 55 X45G, showing LDL-C 93, HDL 58, TG 47,
500775 - ref SDS 55 IM9N indicating "concordance" LDL-P 626, LDL
500776 - (pattern A) size = large bouyant protective. ref SDS 55
500777 - QV5G
500779 - ..
500780 - [On 140204 1236 VA letter maintains measuring LDL-C and
500781 - non-HDL provides adequate assessment for cardiovascular
500782 - risk without measuring LDL-P. ref SDS 57 Y67J
500784 - ..
500785 - [On 140213 0830 VA Progress Notes relate same
500786 - understanding in Progress Notes today on 141219, per
500787 - above, ref SDS 0 GO35, that LDL-P has stronger
500788 - association with CVD risk than LDL-C. ref SDS 60 S35H
500790 - ..
500791 - [On 140213 0830 VA Progress Notes cite and incorporate
500792 - this part of Progress Notes on 1301219 setting out that
500793 - LDL-P has stronger association with CVD risk than LDL-C.
500794 - ref SDS 60 K49F
500796 - ..
500797 - VA Progress Notes Assessment and Plan meeting 131219 continues...
500798 -
500799 - 7. Plan
500800 -
500801 - 1. Start Zetia [Ezetimibe] 10 mg po daily - NF request
500802 - was placed.
500804 - ..
500805 - 2. Continue Atorvastin - pt would like to decrease to 20
500806 - mg po daily - which agree with.
500808 - ..
500809 - This entry in the Progress Notes is mixed up. There was no discussion
500810 - of Atorvastatin 20 mg. The original prescription was for Atorvastatin
500811 - 10 mg, noted above (see Assessment and Plan). ref SDS 0 ON9M
500813 - ..
500814 - The "Plan" today is to continue the original Plan taking Atorvastatin
500815 - 10 mg and add Ezetimibe 10 mg, reported in the doctor's Progress Notes
500816 - for the meeting on 131121 0930, ref SDS 44 S26O, as discussed during
500817 - the meeting today, per above. ref SDS 0 6H6K
500819 - ..
500820 - VA Progress Notes Assessment and Plan meeting 131219 continues...
500821 -
500822 - 3. Regarding medical trials for PCSK9 ab - pt was provide
500823 - with the following information:
500824 -
500825 - http://www.centerwatch.com/clinical-trials/listings/studydetails.aspx?StudyID=189694
500826 -
500827 - http://en.sanofi.com/Images/31342_20121105_ODYSSEY_en.pdf
500828 -
500829 - http://www.pmri.org/research.html#articles
500831 - ..
500832 - 4. Continue physical activity and low fat/low cholesterol
500833 - diet.
500835 - ..
500836 - This generally aligns with discussion on lowering weight to 165,
500837 - toward BMI standards for cardiovascular health, shown above.
500838 - ref SDS 0 A56N
500840 - ..
500841 - Recommendation for "low cholesterol" diet conflicts with research
500842 - indicating eating cholesterol does not affect CVD risk due to elevated
500843 - lipids, reported on 131125 0005. ref SDS 46 PQ81
500845 - ..
500846 - Patient diet does not feature high cholesterol, but does strive to
500847 - limit carbohydrates (i.e., low-carb) to aid the goal of lowering
500848 - triglycerides below 100, indicated by research on 131125 0005.
500849 - ref SDS 46 QP9F
500850 -
500851 - [On 140204 1236 letter from VA notifying Progress Notes for
500852 - meeting today are available for patient use, cites
500853 - discussion on lowering weight to 165, that aligns with BMI
500854 - standards. ref SDS 58 8N9H
500856 - ..
500857 - VA Progress Notes Assessment and Plan meeting 131219 continues...
500858 -
500859 - 5. RTC in 8 weeks. Plan to repeat lipid panel before
500860 - next appointment.
500862 - ..
500863 - 8. Patient was discussed with Doctor Bikle.
500865 - ..
500866 - 10. /es/ DIANA ALBA, MD
500867 - Endocrinology Fellow
500868 - Signed: 01/21/2014 0900
500869 -
500870 -
500871 -
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500873 -
500874 -
500875 -
500876 -
500877 -
500878 -
5009 -