CONTACTS
SUBJECTS
VA Doctor Patient Partnership Collaboration Effective Communication
3303 -
3303 - ..
3304 - Summary/Objective
3305 -
330501 - Follow up ref SDS 60 0000. ref SDS 47 0000.
330502 -
330503 -
330504 -
330505 -
330507 - ..
3306 -
3307 -
3308 - Background
3309 -
3310 -
331001 - Lab on 131015, showing LDL-C cholesterol remained high, 131015 0724,
331002 - ref SDS 35 BE6O, conflict with increased exercise and weight loss,
331003 - discussed in the letter to the medical team yesterday on 131016 1632.
331004 - ref SDS 36 IW57
331006 - ..
331007 - On 131017 1000 VA medical chart Progress Notes assessment report
331008 - patient status CAD stable, asymptomatic. hyperlipidemia not
331009 - controlled. ref SDS 37 T24N
331011 - ..
331012 - On 131017 1000 Doctor Egan proposed referring patient for clinical
331013 - trial to reduce cholesterol with new "targeted" drugs. ref SDS 37 179N
331015 - ..
331016 - On 131017 1000 VA medical chart Progress Notes assessment report
331017 - patient status hyperlipidemia not controlled, ref SDS 37 PSXT; Doctor
331018 - Egan makes referral to SF VA Medical Center for consult on
331019 - participation clinical trials, ref SDS 37 EU9F, with experimental
331020 - agents such as AMG 145 and REGN 727 to resolve multiple statin
331021 - intolerances. ref SDS 37 CN4H
331023 - ..
331024 - On 131103 received letter from VA SF Medical Center scheduling meeting
331025 - on 131121 1000, to consider clinical trial for lowering cholesteral.
331026 - ref SDS 38 YT4N
331028 - ..
331029 - On 131112 New York Times published several articles reporting that the
331030 - day before on 131113, American Heart Association published new
331031 - guidelines for treating CAD patients that expand use of statin
331032 - medication regardless of cholesterol levels, ref SDS 39 0001, and
331033 - further raise the LDL 70 to LDL 190, as a target for cardiovascular
331034 - risk. ref SDS 39 CW6H
331036 - ..
331037 - On 131114 New York Times published several articles reporting that the
331038 - day before on 131113, American Heart Association published new
331039 - guidelines for treating CAD patients. ref SDS 40 SH6G
331041 - ..
331042 - On 131121 0930 meeting with Doctor Alba at San Francisco Medical
331043 - Center - prescribed Atorvastatin 20 mg 4-week trial and evaluate
331044 - adding Zetia 10 mg, schedule follow up on 131219 0930. ref SDS 41 6H6K
331046 - ..
331047 - On 131121 1604 in another record later in the day, VA prescription RX
331048 - # 5674471 for Atorvastatin 20 mg was ordered. ref SDS 42 GH5M
331050 - ..
331051 - On 131125 0005 letter from Karen reports VA work plan to take statin
331052 - drug low dose Atvorstatin 10 mg for 4 weeks, then add ezetimibe
331053 - (Zetia) 10 mg in clinical trial for lowering cholesterol. ref SDS 43
331054 - V154
331056 - ..
331057 - On 131125 0005 research seems to indicate this clincial trial of low
331058 - dose Atorvasatatin 10 mg with Zeitia 10 mg has lowered cholesterol LDL
331059 - < 70, ref SDS 43 CO45; aligns with VA work plan, shown in VA Progress
331060 - Notes on 131121 0930. ref SDS 41 S26O
331062 - ..
331063 - On 131205 1448 received new prescription for Atvorstatin 20 mg,
331064 - ordered by Doctor Alba today for 4-week trial to assess side effects
331065 - for adding 2nd drug, Zetia 10 mg to lower LDL 249. ref SDS 44 GH5M
331067 - ..
331068 - On 131216 0028 letter to Doctor Alba submit agenda for meeting at VA
331069 - SFMC on 131219. ref SDS 46 HY6O
331071 - ..
331072 - On 131219 0930 meeting Doctor Alba at San Francisco VA Medical Center
331073 - ordered Ezetimibe 10 mg prescription for adding to Atorvastatin, and
331074 - ordered blood test to evaluate changes in lipid profile. 131219 0930,
331075 - ref SDS 47 NJ6G
331077 - ..
331078 - On 131230 1450, received Ezetimibe in US mail, ref SDS 48 5N3O,
331079 - ordered by Doctor Alba on 131219, 131219 0930, ref SDS 47 6H6K; begin
331080 - trial to manage cholesterol with Atorvastatin 10 mg and Ezetimibe 10
331081 - mg, planned during meeting at VA on 131121 0930. ref SDS 41 6H6K
331083 - ..
331084 - On 140114 0845 letter to Diana request Progress Notes meeting 131219,
331085 - ref SDS 50 HY6O, and ask about expanding scope pending lab to include
331086 - LDL-P. ref SDS 50 2140
331088 - ..
331089 - On 140115 1842 letter Diana will look for Progress Notes meeting
331090 - 131219, ref SDS 51 HY6O; investigating prospects for ordering lab test
331091 - LDL-P, ref SDS 51 CE80; VA claims patient cholesterol and LDL are above
331092 - target. ref SDS 51 CE91 VA further claims testing LDL-P not effective
331093 - in this case because LDL-C is not optimal. ref SDS 51 FF4H
331095 - ..
331096 - On 140116 0814 letter thanks Doctor Alba for investigting to find
331097 - Progress Notes for meeting at VA on 131219. ref SDS 52 HY6O Cite
331098 - research indicating patient with discordant LDL-C high and LDL-P low,
331099 - shown in patient lab on 131015, constitutes least risk for
331100 - arterialsclorosis disorder, CVD, mycardial infarction. ref SDS 52 735Y
331102 - ..
331103 - On 140128 1327 letter asks again about Progress Notes meeting 131219,
331104 - ref SDS 53 HY6O; report hiking 11 miles per day continued, weight hit
331105 - 165, ref SDS 53 TZ8U; ask where to get lab at VA Martinez, in San
331106 - Francisco, or at UCSF. ref SDS 53 TZ96 No side effects from
331107 - Atorvastatin and Ezetimibe. ref SDS 53 TZ99
331109 - ..
331110 - On 140131 0815 have not received instructions from VA on getting lab
331111 - to test LDL-P, so ordered test. ref SDS 54 OO5G lab blood draw at
331112 - Labcorp in Walnut Creek on Ygnacio Valley Road. ref SDS 54 NT6T
331114 - ..
331115 - On 140201 1159 obtained blood draw for Lipid NMR test at Labcor on
331116 - Health Testing Centers order # 27716, ref SDS 55 KQ4L, showing
331117 - "concordance" LDL-P 861, LDL-C 81, HDL 61, TG 68, LDL (pattern A) size
331118 - = large bouyant protective. ref SDS 55 IM9N
331120 - ..
331121 - On 140203 1147 since have not received instructions from VA, obtained
331122 - blood draw at VA in Martinez to cross check Labcorp blood test. 140203
331123 - 1147, ref SDS 56 KK9M, showing LDL-C 93, HDL 58, TG 47, ref SDS 56
331124 - IM9N, indicating "concordance" LDL-P 626, LDL (pattern A) size = large
331125 - bouyant protective. ref SDS 56 QV5G
331127 - ..
331128 - On 140204 1236 letter from VA today, notifies that Progress Notes for
331129 - meeting on 131219, have been posted and are available for customer to
331130 - receive from ROI department. ref SDS 57 HY6O Cause for 6-weeks delay
331131 - issuing Progress Notes not clear in the record. ref SDS 57 V44F VA
331132 - Progress Notes for meeting on 131219, are comprehensive and helpful.
331133 - ref SDS 57 MR3G Progress Notes have many minor grammatical errors
331134 - likely due to limited time, ref SDS 57 MZ5H, VA does not support NMR
331135 - lipid tests to determine LDL-P and discordance with LDL-C; patient can
331136 - obtain test from another lab. ref SDS 57 CE80 VA letter today
331137 - maintains discordance with low LDL-P and high LDL-C is "unhealthy" -
331138 - submits no evidence from medical literature supporting this
331139 - proposition, nor to address literature submitted to the VA stating
331140 - discordance is the healthiest condition for CVD patients. ref SDS 57
331141 - 6U4L VA concurs that lowering weight toward BMI standards aids
331142 - resolving hyperlipidemia. ref SDS 57 8N9H VA maintains lifestyle
331143 - through exercise and diet to control weight and hyperlipidemia require
331144 - support taking statin medications, e.g., Atorvastatin and Ezetimibe.
331145 - ref SDS 57 GT5F VA letter today says patient mis-reads literature on
331146 - discordance between LDL-P and LDL-C, and proposes discussions to
331147 - clarify this matter during meeting scheduled on 140213. ref SDS 57 HU5M
331148 - VA prefers patient get labs drawn at San Francisco VA Medical Center.
331149 - ref SDS 57 PT3M
331151 - ..
331152 - On 140213 0830 meeting VA San Francisco, ref SDS 60 195I, report good
331153 - progress lowering risks of recurrant CVD based on concordant low LDL-P
331154 - 861 with low LDL-C 81. shown by lab NMR lipid panal. ref SDS 60 TB6J
331155 - Medical team excellent results collaborating doctor/patient
331156 - partnership. ref SDS 60 1L7M Atorvastatin 40 mg started 131121, and
331157 - then changed to Atorvastatin 10 mg with Ezetimibe 10 mg started
331158 - 131230. ref SDS 60 IE7F No side effects taking medication past 6
331159 - weeks. ref SDS 60 333L Objectives and ramifications of discordance
331160 - between LDL-P and LDL-C discussed. ref SDS 60 WM8J Regression of
331161 - atherosclerosis plaque can be assessed with CT and IVUS modalities to
331162 - evaluate recovery from prior acute condition that required surgery in
331163 - 2009. ref SDS 60 JZ4O Will continue medication, diet, exercise and
331164 - weight loss protocols, and test lipid panal again in 3 months on
331165 - 140519 0800. ref SDS 60 8X5O Did not discuss today elevated potasium
331166 - and bilirubin. ref SDS 60 GT7G
331168 - ..
331169 - On 140226 1243 letter to VA submits this record of meeting on 140213,
331170 - ref SDS 61 HY6O, and notifies cold/flu symptoms began a week ago,
331171 - similar to side effects for Atorvastatin and Ezebimibe. ref SDS 61
331172 - JR8H Request consideration order CT test evaluate regression of
331173 - athersclorosis plaque. ref SDS 61 JR99
331175 - ..
331176 - On 140303 1644 letter requests submission of Progress Notes for
331177 - meeting on 140213. ref SDS 63 E792
331179 - ..
331180 - On 140310 0939 received Progress Notes from VA for meeting on 140213.
331181 - ref SDS 67 VP9O
331183 - ..
331184 - On 140312 1720 submitted comments on Progress Notes, requesting
331185 - document identification, ref SDS 68 5N3O, notify of grammitical errors
331186 - in Progress Notes, ref SDS 68 IL83, advise Progress Notes mistake
331187 - citing LDL-P as focus of VA medical efforts, but likely intended to
331188 - present VA policy that advocates lowering LDL-C, ref SDS 68 IL87,
331189 - confirm VA notice that LDL-P has stronger association with CVD risk,
331190 - ref SDS 68 IL4R, request VA report HDL and TG improved in lab due to
331191 - customer intervention hiking, diet and weight loss, ref SDS 68 IL50,
331192 - which present opportunity for regression of atherosclerosis systemic
331193 - plaque, ref SDS 68 PSXX, clarify customer goals to assess medication
331194 - for maintaining lipid profile that reduces CVD risk, and consider
331195 - reducing reliance on medication in the future. ref SDS 68 IL61
331196 -
331197 -
331198 -
331200 - ..
3313 -
3314 -
3315 - Progress
3316 -
331601 - Hyperlipidemia Cholesterol Controlled Exercise Diet Medication
331602 - Cholesterol Managed Clinical Trial Exercise Diet Medication
331603 - VA Excellent Health Care Aligns Lipid Panel with Good Health Ranges
331604 -
331605 - Follow up ref SDS 60 HY6O, ref SDS 47 HY6O.
331606 -
331607 - This morning at 0412, submitted agenda to the doctor. During the
331608 - meeting at 0900, Doctor Egan said he had not yet received the letter.
331609 - Never-the-less we conducted the meeting based on the agenda, as
331610 - follows...
331611 -
331612 - 1. Subject: Agenda Meeting Cardiology 0900 Today
331613 - Date: 2014-04-30 04:12
331621 - ..
331622 - 2. Visiting this morning to follow up planning in the meeting with
331623 - you on 131017, 131017 1000, ref SDS 37 D95H, see also Progress
331624 - Notes. ref SDS 37 9P5K
331625 -
331626 - [...below on 140430 0900 at 1632 letter from Doctor Egan
331627 - reporting that he received this letter after the meeting
331628 - ended; and demonstrating improved communication and
331629 - collaboration for effective doctor/patient partnership.
331630 - ref SDS 0 WK8M
331631 -
331632 -
3317 -
SUBJECTS
Cholesterol Research Internet Low Carbohydrate Diet Lower Triglyceri
5803 -
580401 - ..
580402 - Hyperlipidemia Controlled LDL-P 861 HDL 61 TG 47 CVD Low Risk after CABG
580403 - Medication Minimum Atorvastatin 10 Ezetimibe 10 Excellent CV Health
580404 - Discordance Low Priority Primary Reliance LDL-C Manage CVD Risk
580405 - CABG +4 Hyperlipidemia Controlled LDL-P 861 HDL 61 TG 47 CVD Low Risk
580406 -
580407 -
580408 - 3. At that time, patient was active with strong vitals, but lipid
580409 - panel indicated possible discordance with LDL-C 249 "high," and
580410 - LDL-P likely low, based on TG 109/HDL 50 ratio below 2. [...
580411 - see lab on 131015 0724. ref SDS 35 BE6O...]. Referral to SF
580412 - Medical Center resulted in prescribing Atorvastatin 10mg and
580413 - Ezetimibe 10mg. [...reported during meeting on 131219 0930.
580414 - ref SDS 47 6H6K...]. This regimen began on 131230, shown in
580415 - case study of patient history on 120101. ref SDS 11 6A6H
580417 - ..
580418 - 4. VA lab on 140203 showed strong concordance with NMR lipid panel
580419 - on 140201, with LDL-P 861 (Labcorp), TG 47 VA and 68 Labcorp,
580420 - and HDL 58 VA and 61 Labcorp. ref SDS 56 U45J VA lab
580421 - calculates LDL-P 626 applying ratios in Labcorp study.
580422 - ref SDS 56 4Z66 Analysis of lab on 140203, indicates favorable
580423 - lipid control for lowering CVD risk. ref SDS 56 QV5G
580425 - ..
580426 - 5. Patient history further shows failure to maintain low LDL-C
580427 - after good results with statins, also, reported on 140203.
580428 - ref SDS 56 W25L
580430 - ..
580431 - 6. The same history, may suggest patient maintained low CVD risk
580432 - with HDL above 50 and TG below 100, indicating low LDL-P based
580433 - on TG/HDL ratio below 1, although LDL-P was not previously
580434 - measured directly.
580435 -
580437 - ..
580438 - VA Cardiologist Dubious Regression Atherosclerosis Coronary CTA
580439 - Coronary CTA Unnecessary Cardiologist VA Doubts Atherosclerosis Regression
580440 - CTA Coronary Test Regression Atherosclerosis Cardiologist VA Doubts
580441 - Regression Atherosclerosis VA Cardiologist Refuses CTA Coronary Test
580442 -
580443 -
580444 - 7. Labs scheduled in 2 weeks will show if this pattern can be
580445 - improved by holding LDL-P below 1000. If LDL-C is held below
580446 - 100, CVD risk due to concordance will be somewhat controlled.
580448 - ..
580449 - During the meeting today, the doctor cited VA primary reliance on
580450 - LDL-C for managing CVD risk, which aligns with research on 131125
580451 - 0005, ref SDS 43 FI3G, and further aligns with discussing
580452 - "discordance" during the meeting at the VA in San Francisco on 140213
580453 - 0830. ref SDS 59 WM8J
580454 -
580455 -
580456 -
5805 -
SUBJECTS
Default Null Subject Account for Blank Record
5903 -
590401 - ..
590402 - Half Dome Hike Scheduled September 17 Extended Stress Test
590403 - Extended Stress Test Half Dome Hike Scheduled September 17
590404 - Extended Exercise Hike 60 Miles Per Week Low Carb Diet Strong Vitals
590405 -
590406 - Doctor Egan asked today, about patient exercise?
590408 - ..
590409 - Presented explanation in the letter saying in part...
590411 - ..
590412 - Letter to VA continues...
590413 -
590414 - 8. Patient has maintained training protocol hiking 11 miles daily,
590415 - along with low-carb diet. Weight has reached 164, as shown in
590416 - patient history, but is most often about 170 after hiking.
590418 - ..
590419 - Reported during the meeting that increased training this year will
590420 - aid hiking Half Dome again, scheduled on 140917.
590422 - ..
590423 - Doctor Egan was pleased patient is scheduled to climb Half Dome again
590424 - this year in yosemite on 140917, following up same hike last year on
590425 - 130918 0620. ref SDS 34 0001
590426 -
590427 -
590428 -
5905 -
SUBJECTS
Default Null Subject Account for Blank Record
6003 -
600401 - ..
600402 - Discussed CTA imaging tests to assess regression of atherosclerosis
600403 - plaque that required CABG +4 on 091022 0700, ref SDS 3 PQWU, as
600404 - considered previously with the VA during the meeting in San Francisco
600405 - on 140213 0830, ref SDS 59 JZ4O, and cited in the letter on 140312
600406 - 1720. ref SDS 68 PSXX
600408 - ..
600409 - Doctor Egan seemed to indicate today, that because patient history of
600410 - CABG +4 surgery 5 years ago on 091022, evaluating regression of
600411 - atherosclerosis plaque is not necessary to consider adjusting
600412 - prescribed care of medication and extended exercise, for the purpose
600413 - of saving and money, and reducing painful side effects, e.g., feet.
600414 -
600415 - [...below on 140430 0900 reviewed further painful side
600416 - effects to feet from physical activity of endurance hiking,
600417 - which has yielded favorable labs. ref SDS 0 XQ4J
600419 - ..
600420 - The doctor recommended drinking water during 11 mile hikes to prevent
600421 - blood clots caused by dehydration, especially during hot weather of
600422 - summer in the next few months.
600424 - ..
600425 - Previously, there was discussion of taking aspirin to prevent blood
600426 - clots when plateletts are fall below mid-range, reported during
600427 - meeting on 120216 1000. ref SDS 14 IY5O
600429 - ..
600430 - There was no review in the meeting today of prior analysis in the
600431 - meeting on 110817. At that time, Doctor Egan explained platelets
600432 - elevated above mid-range recorded in this case during 2009-2010 can
600433 - cause blood clots that present severe health risks, especially for
600434 - patients with high blood pressure and heart rate and suffering CAD
600435 - following heart surgery (CABG - 4x), as occurred on 091022 0700.
600436 - ref SDS 3 PQWU At that time on 110817, the doctor further advised
600437 - that the VA prescribes aspirin for CAD patients to thin the blood that
600438 - helps prevent blood clots. ref SDS 10 IY5O
600440 - ..
600441 - Most recent lab on 140203 - VA did not order CBC to check platletts;
600442 - lab 2 days earlier on 140201 show plateletts 303 stable at mid-range.
600443 - ref SDS 56 YX8K
600445 - ..
600446 - Review of patient history shows blood pressure has been normal to
600447 - below normal along with heart rate typically between 45 - 60, reported
600448 - in the record on 120101 0900, see past 2 weeks beginning on 140415.
600449 - ref SDS 11 MQ5N
600450 -
600452 - ..
600453 - Hiking 300 Miles Per Month Reduce CVD Risk Causes Painful Side Effects
600454 - Side Effects Extended Endurance Exercise Hiking 300 Miles Per Month
600455 - Extended Endurance Exercise Hiking 300 Miles Per Month Causes Side Effects
600456 -
600457 - Letter to VA continues...
600458 -
600459 - 9. This level of effort stresses left knee injured in a fall of
600460 - 40' back in 1973, causing degenerative arthritis. In past
600461 - month or so, feet have begun to hurt, so it remains a challenge
600462 - to control CVD risk through exercise. Glucosamine Chondroitin
600463 - helps resolve some of this problem, with the result that hiking
600464 - this year is about 300 miles ahead of the record hiking through
600465 - the 1st 4 months of last year.
600467 - ..
600468 - During the meeting today, explained difficulties finding shoes to
600469 - replace those wearing out, and in order to prevent feet from hurting
600470 - at the end of hikes, see background on 140416 1002, ref SDS 69 0U6M,
600471 - citing the record of feet hurting on 140202, shown in case study on
600472 - 140101 0600, ref SDS 49 Z75O
600474 - ..
600475 - [On 140519 0800 Doctor Alba examined feet during the
600476 - meeting on 140519, at the VA Medical Center in San
600477 - Francisco, and on request for referral to Podiatry
600478 - resolving side effects of treatment to lower CVD risk by
600479 - hiking 300 miles per month, because this level of extended
600480 - endurance exercise yielded significantly improved lipids.
600481 - ref SDS 75 ZV5N
600483 - ..
600484 - [On 140520 0732 letter to VA Medical Center in San
600485 - Francisco cites discussion on sore feet side effects of
600486 - hiking to lower CVD risk. ref SDS 76 UT5M
600488 - ..
600489 - Noted above, the doctor is not enthusiastic about coronary CTA test
600490 - with calcium score to evaluate response to treatment with prospect
600491 - that favorable results could support reducing hiking 300+ miles per
600492 - month, 11 miles per day, which would reduce painful side effects on
600493 - feet. ref SDS 0 OK7L
600495 - ..
600496 - Doctor Egan encouraged continuing extended endurance hiking to
600497 - maintain benefits lowering LDL cholesterol and triglycerides and
600498 - raising HDL, creating a favorable lipid profile for lowering CVD risk,
600499 - reported on 140203 1147. ref SDS 56 W25L
600500 -
600502 - ..
600503 - Heart Rate Blood Pressure Improve Hiking 300 Miles Per Month
600504 -
600505 - Doctor Egan asked about patient daily heart rate after getting up in
600506 - the mornings?
600508 - ..
600509 - Presented explanation in the letter saying in part...
600511 - ..
600512 - Letter to VA continues...
600513 -
600514 - 10. As further shown in patient history, blood pressure and heart
600515 - rate have dropped. [...e.g., on 140422 in case study on 140101.
600516 - ref SDS 49 RQ6H...]
600517 -
600518 - Tuesday
600519 - 140422 0702.............................................
600520 - 0702... 00 52200 Omeprazole
600521 - 0735..Blood Pressure Heart Rate Left Right Diff.. 115 60 48 107 53 48 8 7 0
600522 - 0746............................................. 111 53 48 114 52 49 -3 1 -1
600523 - 0755............................................. 110 53 48 117 62 47 -7 -9 1
600524 - 0808............................................. 113 59 46 118 58 47 -5 1 -1
600525 - 1030..Miles..Minutes.. 11.00 22.00 173 352
600526 - 1355..Weight............... 165
600527 - 1400..Blood Pressure Heart Rate Left Right Diff.. 128 70 85 112 63 78 16 7 7
600528 - 1406............................................. 115 67 77 117 66 79 -2 1 -2
600529 - 1414............................................. 115 63 76 114 68 70 1 -5 -6
600530 - 1421............................................. 114 64 73 117 68 68 -3 -4 5
600531 - 1638... 20 52220 Omeprazole
600532 - 2026............ 10 1600 Atorvastatin
600533 - 2026............ 10 990 Ezetimibe
600534 -
600536 - ..
600537 - 11. Only downside is some slight and occasional dizziness when
600538 - laying down and turning my head. Could be related to low blood
600539 - pressure, or other causes. Recall last year Rosuvastatin
600540 - caused significant dizziness. Don't think Atorvastatin is
600541 - causing the problem this time, but it could be. [...dizziness
600542 - not listed side effect for Atorvastatin, reported on 130603
600543 - 0930. ref SDS 33 PC6O; dizziness is listed as "less common"
600544 - side effect of Ezetimibe, reported on 131125 0005. ref SDS 43
600545 - JO6K; patient history a few days ago on 140428, shows diastolic
600546 - dropped below 50, shown in case study on 120101 0900.
600547 - ref SDS 11 CB6N...].
600549 - ..
600550 - 12. Overall health is very good. Seeing Doctor Lee on 140509 for
600551 - EGD Dilation to resolve rising achalasia swallowing problem.
600552 - CT study on 130117 showed esophagus has finally returned to
600553 - normal, without the big bubble that was there for 5 years or
600554 - so. Accordingly, VA has provided outstanding health care.
600556 - ..
600557 - 13. See you soon - off to do 11 miles.
600558 -
600564 -
600565 -
600566 -
600567 -
600569 - ..
6006 -
6007 -
6008 - 1632
6009 -
600901 - Received letter from Doctor Egan saying...
600902 -
600903 - 1. Subject: RE: [EXTERNAL] Agenda Meeting Cardiology 0900 Today
600904 - Date: 2014-04-30 09:52
600911 - ..
600912 - 2. Thank you for your note, discovered shortly after your visit.
600913 - In the future you might want to send correspondence less close
600914 - to your appointment time to maximize the chance of it being
600915 - read before your visit.
600917 - ..
600918 - VA making timely electronic written communication demonstrates
600919 - effective collaboration through doctor/patient partnership, and
600920 - continuing improvement in evidence-based health care, following up
600921 - prior resistance on 120216 1000. ref SDS 14 3M4H
600923 - ..
600924 - VA delayed receipt today, of electronic correspondence noted by Doctor
600925 - Egan, aligns with prior notice of multi-step process for handling the
600926 - mail at the VA, reported on 130304 0930. ref SDS 30 TS7I
600928 - ..
600929 - Doctor Egan's letter references the letter this morning submitting an
600930 - agenda for the meeting, per above. ref SDS 0 HY6O
600931 -
600932 - [On 140505 0936 letter responds to Doctor Egan.
600933 - ref SDS 70 HY6O
600935 - ..
600936 - [On 140430 0900 Doctor Egan incorporated entire contents of
600937 - letter on 140505, into Progress Notes. ref SDS 0 Y87M
600939 - ..
600940 - VA letter from Doctor Egan continues...
600941 -
600942 - 3. I was reviewing your lab while writing your note and I see that
600943 - your potassium level was high on the lab the SFVA ordered on
600944 - you in February. It doesn't appear that this was addressed at
600945 - the time of your visit there.
600947 - ..
600948 - VA team in San Francisco was notified in a letter on 140211 0133,
600949 - ref SDS 58 TV5F, of Doctor Egan's concerns about elevated T Bilirubin
600950 - and Potassium, in Notes for lab on 140203 1147. ref SDS 56 G34G
600952 - ..
600953 - For some reason (probably limited time) the team did not address these
600954 - issues during the meeting at the VA on 140213 0830. ref SDS 59 GT7G
600955 -
600956 - [On 140505 0936 letter notifies Doctor Egan that concerns
600957 - about potassium and bilirubin were submitted to SF VAMC
600958 - team, and that follow up lab will review these issues again
600959 - in 2 weeks. ref SDS 70 YV41
600961 - ..
600962 - [On 140508 1133 follow up lab by Labcorp shows potassium
600963 - (K) 5.6 elevated above range. ref SDS 71 ZG5O
600965 - ..
600966 - [On 140515 2043 letter notifies VA Medical Center in San
600967 - Francisco that glucose, sodium and potassium are elevated
600968 - above expected levels in Labcorp Lab on 140508, and reminds
600969 - that Doctor Egan issued request for re-lab because elevated
600970 - potassium presents electrical problems for the heart, which
600971 - is at risk in this case based on CABG +4 on 091022.
600972 - ref SDS 73 YM75
600974 - ..
600975 - [On 140518 0920 at 2242 Doctor Alba notifies customer to
600976 - defer follow up chem profile (electrolyte) labs to verify
600977 - glucose, sodium and potassium elevated in Labcorp Lab on
600978 - 140508, responding to Doctor Egan's request based on
600979 - potential for potassium to cause heart problems.
600980 - ref SDS 74 NY4F
600982 - ..
600983 - VA letter from Doctor Egan continues...
600984 -
600985 - 4. May just represent a lab processing error but I think that we
600986 - should repeat it to make sure, as high or low potassium levels
600987 - may increase the risk of electrical problems with the heart. I
600988 - will order a repeat, perhaps you can swing by sometime in the
600989 - next week.
600990 -
600991 - [On 141028 1318 letter to VA notifies Doctor Egan that
600992 - Posassium 4.4 has declined within prescribed range.
600993 - ref SDS 77 XL6N
600995 - ..
600996 - 5. Doesn't have to be fasting, probably best not to do it
600997 - following a hike.
600998 -
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SUBJECTS
VA Cardiology Medical Chart Progress Notes Examination Investigate C
9303 -
930401 - ..
930402 - Medical Chart Progress Notes Meeting 130304
930403 -
930404 - Follow up ref SDS 37 TF5O, ref SDS 33 TF5O.
930405 -
930406 - 1. LOCAL TITLE: Cardiology 10501
930407 - STANDARD TITLE: CARDIOLOGY NOTE
930408 - DATE OF NOTE: APR 30, 2014@08:50 ENTRY DATE: APR 30, 2014@08:51:12
930409 - AUTHOR: EGAN,JAMES EXP COSIGNER:
930410 - URGENCY:
930411 - STATUS: COMPLETED
930412 -
930413 - *** Cardiology 10501 Has Addenda ***
930415 - ..
930416 - This record was received in the US mail on printed paper, so there is
930417 - no CD file to check against accuracy in the record.
930418 -
930422 -
930423 - 2. ...69 year old MALE followed in Cardiology Clinic for problems
930424 - including
930425 -
930426 - 1. CAD
930428 - ..
930429 - a) Angina, class II- III 10/2/09
930431 - ..
930432 - b) Abnormal TMST, relatively low work load 9/16/09
930434 - ..
930435 - c) CABGx4v 10/22/09 SFVA (LIMA-->LAD, SVG-->diag,
930436 - SVG-->Ramus,SVG-->PDA).
930438 - ..
930439 - 2. Hyperlipidemia intolerant simvastatin, atorvastatin,
930440 - rosuvastatin.
930442 - ..
930443 - 3. Achalasia, S/P laparoscopic myotomy with fundoplication at
930444 - the San Francisco VA December 2009. Subsequently recurrent
930445 - stricture.
930447 - ..
930448 - 4. PACs with exercise on ETT 4/6/11
930450 - ..
930451 - 3. Background
930452 -
930453 - ...[Doctor Egan enters in Progress Notes for the meeting today,
930454 - assessment and work plan from Progress Notes for prior meeting
930455 - on 131017, shown in the record for, 131017 1000, ref SDS 37
930456 - 4N6M...]
930458 - ..
930459 - The patient was last seen in clinic on 10/17/13 , A&P as
930460 - follow:
930462 - ..
930463 - 1. ASSESSMENT
930464 -
930465 - 1. CAD. Stable, asymptomatic. No diagnostic testing
930466 - currently indicated.
930468 - ..
930469 - 2. Hyperlipidemia. uncontrolled. Multiple statin
930470 - intolerances. Discussed potential use of colestipol but
930471 - there is little chance that this agent would allow us to
930472 - achieve LDL goal of < 100 mg/dl and I am concerned with his
930473 - chronic hyperbilirubinemia. Ezetemibe might be of some
930474 - value but would not achieve goal and may or may not prevent
930475 - atherogenesis.
930477 - ..
930478 - 2. PLAN:
930479 -
930480 - 1. Current medications reconciled, no changes made.
930482 - ..
930483 - 2. After thorough discussion we have elected to ask the help
930484 - of Endocrine at SFVA in managing his hyperlipidemia,
930485 - consult submitted.
930487 - ..
930488 - 3. RTC 6 months, will f/u Dr Sandhu next month.
930489 -
930490 - 3. /es/ James Egan, MD
930491 - Staff Physician, Cardiology
930492 - Signed: 2013 10 17 1040 PDT
930494 - ..
930495 - Doctor Egan enters in Progress Notes for today, activity that
930496 - occurred in the meeting today, as follows...
930498 - ..
930499 - VA Progress Notes continue...
930500 -
930501 - 4. Current Patient Status on 140430 0830 PDT
930502 -
930503 - Seen today with Kathy, seems to be doing very well. Still
930504 - exercising regularly, plans to attempt Half Dome again in
930505 - September. Is on atorv 10 + ezetimibe 10 from Endocrine
930506 - Department at the SFVA and tolerating that without side
930507 - effects. Remarkable 63% reduction in LDL-C with HDL increased
930508 - to 58 mg/dL (see below). ref SDS 0 JI7L No symptoms suggestive
930509 - of angina with effort. Does not carry water on his hikes,
930510 - notes sometimes that DBP may dip below 50 mm, occassional mild
930511 - lightheadedness but no syncope.
930513 - ..
930514 - Reference to Half Dome relates to report during prior meeeting on
930515 - 131017 1000, ref SDS 37 UU7J, which presented the record hiking Half
930516 - Dome on 130918 0620. ref SDS 34 0001
930518 - ..
930519 - Example of diastolic blood pressure below 50, occurred 2 days ago on
930520 - 140428, shown in case study on 120101 0900. ref SDS 11 CB6N
930521 -
930522 - [On 140509 0900 Doctor Lee asked about Half Dome hike
930523 - during meeting to perform EGD dilation treatment resolving
930524 - achalasia. ref SDS 72 ZZ6J
930526 - ..
930527 - [On 140523 DBP below 50 again, see case study on 120101
930528 - 0900. ref SDS 11 OS9N
930530 - ..
930531 - VA Progress Notes continue...
930532 -
930533 - Denies DOE.
930535 - ..
930536 - 5. PAST MEDICAL HISTORY:
930537 -
930538 - Computerized Problem List is the source for the following:
930539 -
930540 - 1. Dizziness * (ICD-9-CM 780.4) 09/06/12 Egan, James
930542 - ..
930543 - 2. Paresthesia * (ICD-9-CM 782.0) 09/06/12 Egan, James
930545 - ..
930546 - 3. Vitamin D Deficiency 08/03/11 Sandhu, Harkesh
930548 - ..
930549 - 4. Postsurgical Aortocoronary Bypass Status (ICD-9-CM
930550 - V45.81) 03/09/11 Egan, James
930552 - ..
930553 - 5. Esophageal Stricture 03/05/10 LEE,RANDALL E.......
930555 - ..
930556 - 6. Screening for Malignant Neoplasms of colon 02/02/10
930557 - LEE,RANDALL E (ICD-9-CM V76.51)
930559 - ..
930560 - 7. Coronary Atherosclerosis (unspecified type 02/02/10
930561 - LEE,RANDALL E vessel, native or graft) (ICD-9-CM 41
930563 - ..
930564 - 8. Coronary Artery Bypass using Venous and 01/04/10
930565 - SANDHU,HARKESH Arterial Grafts (Single Vein Graft),
930566 - Onset 10/00/09 done at vasf
930568 - ..
930569 - CABG was performed at VA San Francisco Medical Center on 091022.
930570 - ref SDS 3 PQWU
930572 - ..
930573 - Onset reported to VA on 090908 1130. ref SDS 2 MY4N
930575 - ..
930576 - Progress Notes continue...
930577 -
930578 - 9. Surgical Thoracoscopy with Esophagomyotomy 01/04/10
930579 - SANDHU,HARKESH (Heller Type), Onset 12/16/09 at vasf
930581 - ..
930582 - 10. Hyperlipidemia * (ICD-9-CM 272.4) 10/02/09 EGAN,JAMES
930584 - ..
930585 - 11. Inflamed Seborrheic Keratosis (ICD-9-CM 702.11)
930586 - 03/12/07 LIN,BERTHA
930588 - ..
930589 - 12. Rosacea * (ICD-9-CM 695.3) 03/12/07 LIN,BERTHA
930591 - ..
930592 - 13. Dermatitis * (ICD-9-CM 692.9) 03/12/07 LIN,BERTHA
930594 - ..
930595 - 14. Tinea Unguium * (ICD-9-CM 110.1) 03/12/07 LIN,BERTHA
930597 - ..
930598 - 15. Tinea * (ICD-9-CM 110.9) 03/12/07 LIN,BERTHA
930600 - ..
930601 - 16. Rosacea conjunctivitis (ICD-9-CM 372.31) 03/02/07
930602 - MARGULIES,LINDA
930604 - ..
930605 - 17. Rosacea * (ICD-9-CM 695.3) 03/02/07 MARGULIES,LINDA
930607 - ..
930608 - 18. Blepharitis NOS 02/21/07 MARGULIES,LINDA
930610 - ..
930611 - 19. Achalasia * (ICD-9-CM 530.0) 12/22/05 SANDHU,HARKESH
930613 - ..
930614 - 20. Abn. LFT's 08/16/05 SANDHU,HARKESH
930616 - ..
930617 - 21. Obesity 06/29/05 SANDHU,HARKESH
930619 - ..
930620 - 22. Rosacea 06/29/05 SANDHU,HARKESH
930622 - ..
930623 - 23. Tinea Unguium 06/29/05 SANDHU,HARKESH
930625 - ..
930626 - Patient has answered NKA (no known allergies)
930628 - ..
930629 - 6. Active Outpatient Medications (including Supplies):
930631 - ..
930632 - 1. OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE BY MOUTH TWICE A
930633 - HOLD DAY 15 MINUTES BEFORE A MEAL FOR SEVERE ACID REFLUX
930634 - AND ESOPHAGEAL NARROWING.
930636 - ..
930637 - 2. Ezetimibe 10 mg
930639 - ..
930640 - 3. ATORVASTATIN 10 mg
930642 - ..
930643 - 7. PHYSICAL EXAM - Date: 140430 0901
930644 -
930645 - T....................... 97.1 F (36.2 C)
930646 - P....................... 63
930647 - R....................... 16
930648 - B/P..................... 118/74
930649 - Wt...................... 177.5 (80.68 KG) (ACTUAL STANDING WEIGHT)
930650 - Body Mass Index......... 29*
930651 - Pulse Oximetry.......... 97%
930652 - Pain.................... 0 - No pain
930654 - ..
930655 - VITALS: 12/09/2013 07:58 BP:140/80 HR:68 Wt:182 lb [82.7 kg
930657 - ..
930658 - Head atraumatic, PERRL.
930659 - Carotid upstrokes normal, no bruits noted
930660 - Thyroid normal to palpation.
930661 - JVP wnl.
930662 - Cor: Regular, no ectopy, no sig mrg.
930663 - Lungs clear of rales, ronchi and wheezes.
930664 - Extremities without cyanosis, clubbing or edema.
930666 - ..
930667 - 8. LAB Review
930668 -
930669 - Collection DT CHOL TRIGL HDL LDL-C
930670 - 02/03/2014 12:28 160 47 58 93 .......... 140203 1147, ref SDS 56 5C7M
930671 - 10/15/2013 08:25 321 H 109 50 249 H ........ 131015 0724, ref SDS 35 BE6O
930673 - ..
930674 - Collection DT Glucose Bun Creat NA K CL CO2
930675 - 02/03/2014 12:28 103 17 0.82 140 5.4 H 103 30 ........ 140203 1147, ref SDS 56 WJ5H
930676 - 10/15/2013 08:25 108 24 0.83 139 4.3 H 105 27 ........ 131015 0724, ref SDS 35 WJ5H
930678 - ..
930679 - Collection DT WBC HGB HCT MCV MCHC PLT
930680 - 05/29/2013 08:18 7.4 15.0 46.2 90.7 32.5 279 ................. 130529 0818, ref SDS 32 RP4N
930681 - 11/30/2012 10:01 7.5 14.5 43.9 90.3 33.0 254 ................. 121130 0846, ref SDS 22 RP4N
930683 - ..
930684 - 9. ASSESSMENT
930685 -
930686 - 1. CAD. Stable, asymptomatic.
930688 - ..
930689 - 2. Hyperlipidemia. significant improvement in LDL-C and HDL
930690 - under the guidance of Endocrine. Will f/u there next
930691 - month.
930693 - ..
930694 - 3. Achalasia, will have repeat dilation by Dr Lee in May.
930696 - ..
930697 - 4. Hyperkalemia on most recent lab, no clear reason for same,
930698 - consider processing error.
930700 - ..
930701 - 10. PLAN:
930702 -
930703 - 1. Current medications reconciled, no changes made.
930705 - ..
930706 - 2. Have asked patient to repeat BMS sometime in the next
930707 - week, can be non-fasting.
930709 - ..
930710 - 3. Otherwise plan on RTC 6 months.
930711 -
930712 - 11. /es/ James Egan, MD
930713 - Staff Physician, Cardiology
930714 - Signed: 2013 10 17 1040 PDT
930716 - ..
930717 - 12. 05/05/2014 ADDENDUM STATUS: COMPLETED
930718 -
930719 - Patient advised of abnormal lab as above; e-mail response as
930720 - follows:
930722 - ..
930723 - Doctor Egan incorporates into addendum for Progress Notes the entire
930724 - letter to VA Cardiology on 140505 0936. ref SDS 70 HY6O
930725 -
930726 - 1. Subject: Meeting Apr 30, Elevated Potassium Bilirubin Prior Lab
930727 - Date: 2014-05-05 10:04
930735 - ..
930736 - 2. Thanks very much for your letter on 140430, shown below.
930737 - ref SDS 70 4U3H Glad you received the agenda for our meeting.
930738 - I sent it at 0400, so it would get to you in time to prepare
930739 - for meeting at 0900.
930741 - ..
930742 - 3. As you can see, the team in San Francisco was notified that
930743 - both potassium and bilirubin were elevated in the last lab on
930744 - 140203. ref SDS 56 G34G
930746 - ..
930747 - 4. Your concerns were submitted with links to relevant Progress
930748 - Notes. The agenda for meeting on 140213, expressly cites
930749 - elevated potassium and T Bili [...in the letter to VA on 140211
930750 - 0133. ref SDS 58 TV5F...] in VA lab on 140203, and further
930751 - notes they are stable in Labcorp lab 2 days earlier on 140201,
930752 - all as shown in the record. ref SDS 56 ZG5O
930754 - ..
930755 - 5. Note that I hiked 22 miles the day before the VA lab on 140203,
930756 - so this may have affected results. [...see case study on 120101
930757 - 0900. ref SDS 11 GH4M...].
930759 - ..
930760 - 6. Next Monday, on 140512, will do another Labcorp blood draw to
930761 - get NMR results for LDL-P, HDL, TG, along with electrolytes
930762 - (Chem profile). On Wednesday, 140514, will get a blood draw at
930763 - VA in San Francisco, as requested by Doctor Alba. This will
930764 - cross check lipids and electrolytes. If potassium and
930765 - bilirubin continue elevated, will again present this in the
930766 - agenda for meeting on 140519, and cite your letter on 140430,
930767 - shown below.
930769 - ..
930770 - [On 140515 2043 letter submits agenda for meeting on
930771 - 140519, and notifies VA Medical Center in San Francisco
930772 - that glucose, sodium and potassium are elevated above
930773 - expected levels in Labcorp Lab on 140508, and reminds that
930774 - Doctor Egan issued request for re-lab because elevated
930775 - potassium presents electrical problems for the heart, which
930776 - is at risk in this case based on CABG +4 on 091022.
930777 - ref SDS 73 YM7H
930779 - ..
930780 - 7. Have increased hiking - 93 miles 2 weeks ago, and 82 miles last
930781 - week. If this week goes well, should have weight back to 165
930782 - again, in time for favorable labs next week.
930784 - ..
930785 - 8. Thanks again for excellent care.
930786 -
930792 -
930793 - 11. /es/ James Egan, MD
930794 - Staff Physician, Cardiology
930795 - Signed: 2013 10 17 1040 PDT
930797 - ..
930798 - User Class: Allopathic and Osteopathic Physicians (03/26/2008
930799 - 00:00 to present)
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