142215 -
142216 -
142217 -
142219 - ..
1423 -
1424 -
1425 - 1530
1426 -
142601 - Meeting Primary Care VA Examin Injury Hematoma Lower Left Leg
142602 -
142603 - Doctor Rao had not had time to review the letter submitted earlier
142604 - today, presenting rising symptoms, per above, ref SDS 0 JN3J, and with
142605 - the agenda for the meeting today, per above. ref SDS 0 XR82
142607 - ..
142608 - Handed the doctor a printed copy of the letter to read in order to
142609 - prepare for a productive meeting.
142611 - ..
142612 - Doctor Rao read the letter.
142614 - ..
142615 - She examined the wound on the lower left leg. The doctor checked
142616 - blood vessels on inside of both ankles. She expects severe pain in
142617 - the left leg hematoma is not due to blockage in blood flow, based on
142618 - feeling the rate of flow seems the same in both legs, and is normal.
142620 - ..
142621 - Doctor Rao proposed calling General Surgery Department to request
142622 - immediate examination this afternoon to evaluate need for surgical
142623 - intervention treating rising symptoms, shown in the letter today, per
142624 - above. ref SDS 0 XR60
142626 - ..
142627 - The doctor was unable to reach anyone by telephone.
142628 -
142630 - ..
1427 -
1428 -
1429 - 1552
1430 -
143001 - Doctor Rao left the office to go consult with someone in General
143002 - Surgery Department.
143003 -
143004 -
143006 - ..
1431 -
1432 -
1433 - 1628
1434 -
143401 - Doctor Rao returned. She reported a surgen will come to Doctor Rao's
143402 - office in Medical Practice to examine the patient, and that staff in
143403 - General Surgery know the patient. Turned out later that she had
143404 - talked to Isagani.
143406 - ..
143407 - Doctor Rao said she has to leave early today. She explained Medical
143408 - Practice Department closes at 1700, but the patient waiting area
143409 - remains open for another hour or so while nursing and other staff
143410 - complete daily administration.
143412 - ..
143413 - The doctor suggested waiting for the representative of General Surgery
143414 - to arrive in the Patient Waiting area to make an initial examination
143415 - of the wound, and decide on line of care, if any, for the Surgery
143416 - Department. She will notify the Medical Practice staff that the
143417 - patient is authorized to wait in the Waiting area after hours until
143418 - the examination by Surgery.
143420 - ..
143421 - Thanked Doctor Rao for taking immediate action on the agenda this
143422 - afternoon, per above, ref SDS 0 XR82, following up on her request for
143423 - the patient to come into the hospital for examination, set out in the
143424 - doctor's letter on 150921 1247. ref SDS 9 JN3J
143426 - ..
143427 - Doctor Rao said it helps to have a written agenda to maintain focus on
143428 - steps to consider for advancing recovery.
143429 -
143430 -
1435 -
143501 -
1436 -
SUBJECTS
VA Meeting Flue Immunization Injection Meeting VA Medical Practice P
1803 -
1804 - 1633
180501 - ..
180502 - Flu Immunization Annual Injection
180503 -
180504 - Follow up ref SDS 3 HY6O.
180505 -
180506 - After meeting with Doctor Rao, returned to patient waiting area for
180507 - Medical Practice.
180509 - ..
180510 - The nurse Judie Mabutas offered to perform flu immunization injection.
180512 - ..
180513 - So, we did this in the upper right arm. Follows up flu injection last
180514 - year on 141024 0900. ref SDS 3 HY6O
180515 -
180516 -
180517 -
1806 -
SUBJECTS
VA Notify Injury Hematoma Left Leg Symptoms Worsening Pain Need Crut
2903 -
2904 - 1648
290501 - ..
290502 - Waiting in Medical Practice.
290504 - ..
290505 - Spoke briefly with Lisa, and thanked her for scheduling the meeting
290506 - today, needed to relieve considerable pain reported to Doctor Rao on
290507 - Sunday, 150920 1917, ref SDS 8 MS82, and after Doctor Rao notified to
290508 - come to the hospital in her letter the next day on 150921 1247.
290509 - ref SDS 9 JN3J At that time on 150921, on arrival at the hospital as
290510 - instructed by the doctor to relieve rising symptoms pain level "12,"
290511 - Lisa notified the patient to return two (2) days later, reported on
290512 - 150921 1247 at 1437, ref SDS 9 7L6M
290514 - ..
290515 - Walked around the empty waiting room for Medical Practice, waiting for
290516 - someone from General Surgery, and in order to avoid pain from standing
290517 - up after sitting for awhile, explained in the letter to the doctor
290518 - earlier today, per above. ref SDS 0 XR60
290519 -
290520 -
290522 - ..
2906 -
2907 -
2908 - 1735
2909 -
290901 - Walked to the ground floor and across to the canteen in building 203,
290902 - and bought a soft drink and fritos.
290904 - ..
290905 - On returning, Lisa said a doctor finally showed up from Surgery. Said
290906 - he will return in 15 minutes.
290907 -
290908 -
2910 -
SUBJECTS
VA Progress Notes ER General Surgery Debridement Infected Wound Hema
3603 -
360401 - ..
360402 - Progress Notes Meeting Medical Practice Examination Injury Hematoma Lower Left Leg
360403 -
360404 -
360405 - F:\05\00003\SM\CC\AGMJ\20150923-223900\mhv_WELCH_20150923_223900.txt
360406 -
360407 -
360408 - Date/Time: 23 Sep 2015 @ 1552
360409 - Note Title: MP F/U NOTE (MED/NURSING/CLINIC)
360410 - Location: SAN FRANCISCO VAMC
360411 - Signed By: RAO,MADHU
360412 - Co-signed By: RAO,MADHU
360413 - Date/Time Signed: 23 Sep 2015 @ 1646
360415 - ..
360416 - LOCAL TITLE: MP F/U NOTE (MED/NURSING/CLINIC)
360417 - STANDARD TITLE: PRIMARY CARE OUTPATIENT NOTE
360418 - DATE OF NOTE: SEP 23, 2015@15:52 ENTRY DATE: SEP 23, 2015@15:52:25
360419 - AUTHOR: RAO,MADHU EXP COSIGNER:
360420 - URGENCY: STATUS: COMPLETED
360422 - ..
360423 - ID: 70 yo male who is well known to me, here for worsening
360424 - pain of the left LE.
360426 - ..
360427 - See ED note from 9/18 for details...
360429 - ..
360430 - This seems to refer to ER note for meeting on 150917 1028. ref SDS 7
360431 - 4N3L, and that the note was prepared and/or entered in the VA record
360432 - the next day on 150918.
360434 - ..
360435 - Progress Notes Medical Practice on 150923 continues...
360436 -
360437 - pt fell while hiking Yosemite 1 week ago and hit left leg,
360438 - hands (no loc, no trauma to head). He continued to hike
360439 - subsequently, but then stopped when pain worsened. Seen in ER
360440 - 2 days later-- vasculature intact, recommended non-wt bearing,
360441 - activity OK. Pt continued to walk (and in fact, has been
360442 - walking for miles daily...up to 10 miles on 1 day). On monday,
360443 - pt started to have increased pain after the walking, and made
360444 - appt to see me today.
360446 - ..
360447 - His pain is most severe when he changes positions...improved
360448 - with walking or with lying down. No cold feet, numbness,
360449 - tingling. Pt has been taking ibuprofen prn, with some mild
360450 - relief of pain.
360452 - ..
360453 - This generally aligns with the report pain level 12 requires using
360454 - crutches, shown on 150922 0502. ref SDS 10 XQ60 Letter today reports
360455 - pain increased significantly, causing falls, per above. ref SDS 0 XR60
360457 - ..
360458 - PMH/PSH:
360459 -
360460 - 1. Esophageal Achalasia - s/p lap heller myotomy and fundoplication 12/2009
360461 - - s/p EGD with dilations
360462 - 2. CAD s/p CABG x4 in 2009
360463 - 3. GERD
360464 - 4. Hyperlipidemia
360465 - 5. left knee repair
360467 - ..
360468 - MEDICATIONS:
360469 - Omeprazole 40 mg BID
360470 - Atorvastatin 10 mg po daily
360471 - Zetia 10 mg po daily
360472 - ibuprofen prn as per above
360474 - ..
360475 - PEX:
360476 - Height: 64.5 in [163.8 cm] (09/23/2015 15:32)
360477 - Weight: 178.4 lb [81.1 kg] (09/23/2015 15:32)
360478 - Pulse: 93 (09/23/2015 15:32)
360479 - Resp: 16 (09/23/2015 15:32)
360480 - Temp: 98 F [36.7 C] (09/23/2015 15:32)
360481 - B/P: 136/78 (09/23/2015 15:32)
360482 - O2 Sat: 9/23/15 15:32:42 O295
360483 - BMI: 30.2 (Obesity Level I)
360484 - WAIST CIRCUMFERENCE: 38 (09/23/2015 15:32)
360485 - comf male, nad
360486 - heent=ncat, op clear, anicteric
360488 - ..
360489 - ext= left LE with large, 5x4 inch hematoma on lateral anterior lower leg,
360490 - protruding about 1 inch above skin surface. Well healing scab on surface.
360491 - Slightly soft hematoma surface.
360492 - Left foot warm, with dp and pt pulses 2+ (and symmetrical with rt LE).
360493 -
360494 - a/p: 70 yo male with CAD, here for worsening pain of left LE
360495 - hematoma that
360496 - occurred 2/2 fall while hiking. Pt strongly desires aspiration
360497 - of the hematoma
360498 - (as was mentioned by ER physician) for improvement of sx's. I
360499 - did inform him
360500 - that, since the blood is clotted, it is unlikely that
360501 - aspiration will yield
360502 - anything. And, given that exam of the vasculature is WNL,
360503 - there is no indication to do do an I&D of the hematoma.
360504 -
360505 - --Based on pt's strong desire, will obtain gen surgery consult
360506 - regarding possible aspiratio nor I&D to improve pain.
360507 - --Will also obtain xray of tib/fib to r/o fracture (I don't
360508 - see that an xray was done in ER)
360509 -
360510 - ==============================================
360511 - Clinical Reminder Activity included in Progress Notes omitted
360512 - from this entry in SDS record.
360513 - ==============================================
360514 -
360515 - ==============================================
360516 - Active Outpatient Medications included in Progress Notes omitted
360517 - from this entry in SDS record.
360518 - ==============================================
360519 -
360520 - /es/ MADHU RAO
360521 - Staff Physician
360522 - Signed: 09/23/2015 16:46
360523 -
360524 -
360525 -
360526 -
360527 -
360528 -
3606 -
SUBJECTS
VA General Surgery Examination Lab Elevated WBC 13.6 above Range 4.8
4903 -
4904 - 1810
490501 - ..
490502 - ER Examination Elevated WBC 13.6 Hematoma Wound Lower Left Leg Injury
490503 - Leg Injury ER Examination Elevated WBC 13.6 Hematoma Wound Lower Left
490504 - Elevated WBC 13.6 Infection Leg Injury ER Examination Hematoma Wound Lower Left
490505 - Wound Leg Infection Elevated WBC 13.6 Injury ER Examination Hematoma
490506 -
490507 - Doctor Yoo arrives in Medical Practice waiting room.
490508 -
490509 - Makes initial examination. Report fall injuring lower left leg, as
490510 - set out in the record on 150916 0535. ref SDS 6 O87H
490512 - ..
490513 - Doctor Yoo asked if the patient has received any medical care?
490515 - ..
490516 - Reported visit to ER VA MCSF and examination by Doctor Turner on
490517 - 150917 1028 at 2256. ref SDS 7 PSRR
490519 - ..
490520 - The doctor asked about line of care prescribed?
490522 - ..
490523 - Explained Doctor Turner prescribed hiking, based on personal
490524 - experience with similar injury some years ago, reported on 150917
490525 - 1028. ref SDS 7 4N6Q
490527 - ..
490528 - The doctor asked for current symptoms?
490530 - ..
490531 - Explained symptoms presented in the letter to Doctor Rao, earlier
490532 - today, per above, ref SDS 0 XR60, which led Doctor Rao to request
490533 - referral examination by Surgery per above. ref SDS 0 4956
490535 - ..
490536 - Doctor Yoo took several photographs of the hematoma on lower left leg.
490538 - ..
490539 - He left to consult with other doctors in General Surgery.
490540 -
490541 -
490542 -
490544 - ..
4906 -
4907 -
4908 - 1833
4909 -
490901 - Doctor Rao and left message on home phone asking if doctor from
490902 - vascular surgery arrived for meeting in MP waiting room.
490903 -
490904 -
490906 - ..
4910 -
4911 -
4912 - 1848
4913 -
491301 - Doctor Lucy Kornblith and another doctor came to the Medical Practice
491302 - Waiting area.
491304 - ..
491305 - The doctor examined the wound, complimenting prior examination by
491306 - Doctor Yoo, per above. ref SDS 0 ET4T
491308 - ..
491309 - She asked about symptoms?
491311 - ..
491312 - Explained symptoms presented in the letter to Doctor Rao, earlier
491313 - today, per above. ref SDS 0 XR60
491315 - ..
491316 - Doctor Kornblith diagnosis infection of wound is causing severe pain
491317 - in this case.
491319 - ..
491320 - She said to return to ER on the Ground Floor. ER will order a lab to
491321 - check for elevated WBC, and in that case, the Surgery Department will
491322 - perform minor surgery to debride the wound. If this occurs, it will
491323 - require the patient to spend the night in the hospital in order for
491324 - the medical team to examin recovery and release the patient to go
491325 - home.
491327 - ..
491328 - Thanked Doctor Kornblith for timely action.
491329 -
491330 -
491332 - ..
4914 -
4915 -
4916 - 1913
4917 -
491701 - Went to the ER and checked in.
491702 -
491703 - The nurse said there is still no documentation on the procedure to
491704 - follow. She said Doctor Turner is on staff this evening, and so will
491705 - coordinate the work in the ER, following up prior work on this case on
491706 - 150917 1028. ref SDS 7 PSRR
491707 -
491709 - ..
4918 -
4919 -
4920 - 1918
4921 -
492101 - Triage with Nurse Roger Malonso initial case review.
492102 -
492103 - Roger asked about symptoms and pain level?
492105 - ..
492106 - Explained symptoms and pain level presented in the letter to Doctor
492107 - Rao, earlier today, per above. ref SDS 0 XR60
492109 - ..
492110 - Roger said to go to the 2nd floor for a blood draw, planned by Doctor
492111 - Kornblith earlier today to test of infection shown by elevated WBC,
492112 - per above. ref SDS 0 QM6H
492113 -
492114 -
492116 - ..
4922 -
4923 -
4924 - 1912
4925 -
492501 - Arrived at Lab on 2nd floor. The lab is closed, but there is a note
492502 - on the door saying to go down the all for after hours blood draws.
492504 - ..
492505 - Walked down the hall and knocked on the door.
492507 - ..
492508 - Someone answered, and said to go to the next door down the hall and
492509 - someone will do the blood draw.
492510 -
492512 - ..
4926 -
4927 -
4928 - 1916
4929 -
492901 - Blood draw at the lab.
492902 -
492904 - ..
4930 -
4931 -
4932 - 1927
4933 -
493301 - Returned to ER.
493302 -
493304 - ..
4934 -
4935 -
4936 - 1931
4937 -
493701 - Meeting Doctor Jessie Turner.
493702 -
493703 - [...below on 150923 1530 Doctor Turner's Progress Notes for
493704 - this patient encounter. ref SDS 0 HE4N
493706 - ..
493707 - The doctor reported lab today, shows elevated WBC (also called
493708 - "Leukocytes") 13.6 on range 4.8 - 10.8 indicates hematoma lower left
493709 - leg likely infected. He was disappointed that patient returned after
493710 - origional treatment in the ER on 150917 1028 at 2256. ref SDS 7 PSRR
493712 - ..
493713 - Jessie also mentioned possible cellulitis on leg surrounding the
493714 - wound.
493715 -
493716 - [...below on 150923 1530 at 2136 Doctor Dalle Vella also
493717 - diagnosed cellulitis. ref SDS 0 P45I
493718 -
493719 - [...below on 150923 1530 Doctor Turner's Progress Notes for
493720 - this patient encounter. ref SDS 0 4P6M
493722 - ..
493723 - He recommends surgical debridement to evacuate hematoma, and explained
493724 - that normally this minor surgical procedure is performed with
493725 - conscious sedation to avoid pain. Treating with conscious sedation
493726 - requires can only be performed in the ICU or the OR, where there is
493727 - equipment to monitor the patient while sedated. This evening, both
493728 - the OR and ICU are backed up, so the procedure will be performed in
493729 - the ER with local anesthetic and an IV of some sort. He said the
493730 - doctor can apply local injections of anesthetic around the perimeter
493731 - of the wound to minimzie expression of pain.
493732 -
493733 -
493734 -
493735 -
4938 -
SUBJECTS
VA ER General Surgery Debridement Infected Wound Hematoma Lower Left
6603 -
6604 - 2027
660501 - ..
660502 - Surgery Lower Left Leg Debridement Infected Wound Hematoma
660503 - Debridement Surgery Treat Infected Wound Hematoma Lower Left Leg
660504 -
660505 - Dressed for procedure, and layed on a gurney.
660507 - ..
660508 - Waiting for procedure to commence.
660509 -
660511 - ..
6606 -
6607 -
6608 - 2136
6609 -
660901 - Meet Doctor Jessica Della Valle. The doctor explained that she is a
660902 - resident on rotation at the VA and assigned from Stanford Medical
660903 - Center in Palo Alto.
660904 -
660905 - [...below on 150923 1530 Progress Notes for this encouter
660906 - are shown below. ref SDS 0 MV4F
660908 - ..
660909 - Jessica is listed on UCSF Profiles at...
660910 -
660911 - http://profiles.ucsf.edu/jessica.dellavalle
660912 -
660914 - ..
660915 - The doctor asked about the wound on lower left leg?
660917 - ..
660918 - Presented report of injury hiking Half Dome in Yosemite on 150916
660919 - 0535. ref SDS 6 O87H
660921 - ..
660922 - Explained examination by Doctor Turner the next day on 150917 1028.
660923 - ref SDS 7 PSRR Line of care presented by Doctor Turner to hike in
660924 - order to prevent and disolve blood clots in lieu of draining the
660925 - wound. ref SDS 7 4N6Q This was implemented over the next several
660926 - days. When hiking there is no pain, but when getting up from a
660927 - vertical position on bed or sitting with leg elevated, e.g., working
660928 - in a chair with leg rest, there is very severe pain. At first this
660929 - lasted only a few seconds. But a day later it took several minutes,
660930 - and now it takes up to 5 minutes for pain to subside enough to put
660931 - weight on the leg, and then to walk, as set out in the letter
660932 - submitted to Doctor Rao in VA Medical Practice, earlier today, per
660933 - above. ref SDS 0 XR60
660935 - ..
660936 - Debra the nurse set an IV in the right arm.
660938 - ..
660939 - The doctor said the patient will receive Dilaudid (hydromorphone)
660940 - through the IV to ease pain, but this will not induce sedation that
660941 - prevents pain entirely.
660943 - ..
660944 - Made a joke for Debra to err on the high side because I was absent the
660945 - day tricks to tolerate pain were taught in spy training class.
660947 - ..
660948 - Jessica appoligized that the OR and ICU are busy this evening, so
660949 - debridement surgery must be done in the ER without sedation, because
660950 - the ER does not have monitoring equipment required for conscious
660951 - sedation. She gave an alert this procedure may be painful, hopefully
660952 - eased by hydromorphone.
660954 - ..
660955 - Jessica said she will try to minimize pain by making multiple
660956 - injections around the perimeter of the wound. Each injection will
660957 - hopefully numb the area sufficiently to reduce pain from the next
660958 - injection.
660960 - ..
660961 - The doctor then tied her hair on top of her head, and placed a mask
660962 - over her face.
660964 - ..
660965 - The nurse, Debra was kind enough to place her hand on my shoulder.
660967 - ..
660968 - Jessica was very considerate giving a verbal warning to grasp the
660969 - sides of the gurney for a brace to accept the first injection of local
660970 - anesthetic.
660972 - ..
660973 - The point of penetration seemed like pain level "20". Was difficult
660974 - to avoid responding to this pain.
660976 - ..
660977 - Told Jessica pain level 20 is a new experience having to hold the body
660978 - still under seemingly tortuous cutting on the leg. Appoligized for
660979 - not entirely succeeding.
660980 -
660981 - [...below on 150923 1530 Progress Notes correctly report
660982 - patient experienced "significant pain", and this may have
660983 - limited debridement. ref SDS 0 UM31
660985 - ..
660986 - [On 151001 1200 further debridement required and performed
660987 - in Surgery Wound Care Clinic using scaple again, and with
660988 - pain level "20" again. ref SDS 15 WW4I
660990 - ..
660991 - [On 151006 1315 Clara in Surgery Clinic performed
660992 - debridement using tweezers to remove infected tissue and
660993 - with pain level 0. ref SDS 16 PU9Q
660995 - ..
660996 - She said that's okay, and that she would pause for the patient to
660997 - recover. Seemed like she did several injections in this manner
660998 - pausing between each. Fortunately, pain quickly subsided from 20 to
660999 - 0 between pauses.
661001 - ..
661002 - Jessica explained she was removing infected tissue from the wound,
661003 - and asked if there was any feeling. At first said no, but then pain
661004 - increased dramatically. At that point, Jessica said she would do
661005 - another injection of local anesthetic.
661007 - ..
661008 - While Jessica worked, Jessie or someone spoke to her several different
661009 - times through curtain closing the cubical, and asked if Jessica could
661010 - take a moment to examine other evidently critical patients. She may
661011 - have left once or twice, then returned to continue in this case.
661013 - ..
661014 - Debra explained that the ER can be very hectic sometimes.
661015 -
661017 - ..
661018 - Debridement Infection Hematoma Lower Left Leg Recover Cellulitis
661019 - Cellulitis Lower Left Leg Recover Debridement Infection Hematoma
661020 - Hematoma Cellulitis Lower Left Leg Recover Debridement Infection
661021 - Infection Hematoma Cellulitis Lower Left Leg Recover Debridement
661022 -
661023 - Don't know how long this debridement procedure went on. Debra was
661024 - terrific quietly saying the removal of infected tissue was going well.
661025 - Jessica remarked how important it is to clear this severe hematoma
661026 - wound of infection; she also mentioned resolving cellulitis, which
661027 - aligned with Doctor Turner's analysis, per above. ref SDS 0 WN5K
661028 - Jessica was reassuring saying the patient was doing well under the
661029 - circumstances.
661031 - ..
661032 - Cellulitis can be difficult to differentiate from other maladies,
661033 - e.g., cancer, reported in Millie's case on 030109 1600. ref SDS 1 0T6N
661034 - Research on cellulitis is also reported on 030109. ref SDS 1 TE4P
661035 -
661036 - [...below on 150923 1530 Progress Notes report conditions
661037 - consistent with cellulitis diagnosis. ref SDS 0 MW8G
661039 - ..
661040 - Cellulitis can be difficult to differentiate from other maladies,
661041 - e.g., cancer, reported in Millie's case on 030109 1600. ref SDS 1 0T6N
661042 - Research on cellulitis is also reported on 030109. ref SDS 1 TE4P
661044 - ..
661045 - Appoligized numerous times for not being the ideal debridement
661046 - patient, and very grateful for Jessica's professional, thorough
661047 - surgical care. The hardest part of the exercise was to hold the body
661048 - still rather than react to pain. The right leg actually jumped
661049 - several times despite gripping the sides of the gurney with both
661050 - hands.
661052 - ..
661053 - At one point, made a joke requesting a leather bite block, like you
661054 - see in the movies of surgery without sedation, for example during the
661055 - civil war. Debra was quick witted, saying they are short on bite
661056 - blocks, but there is plenty of whisky, if that will help??
661058 - ..
661059 - Finally, Jessica said "I think we've got it. There will be no more
661060 - pain." She indicated follow up by the surgery team tomorrow will
661061 - evaluate the wound to optimize recovery.
661062 -
661063 - [...below on 150923 1530 Progress Notes report patient
661064 - expression of pain may have prevented completing
661065 - debridement removal of infected tissue. ref SDS 0 UM31
661067 - ..
661068 - [On 151001 1200 Lana changed Hydrofera Blue Tunnel dressing
661069 - and the Enluxtra cover pad, ref SDS 14 LY79; she found
661070 - infected tissue along the edges of the wound, and so used a
661071 - surgeon's scaple to cut this tissue so that healing will
661072 - not be impeded; this caused considerable pain. ref SDS 14
661073 - NC9G
661075 - ..
661076 - Thanked Jessica profusely and asked about doing the next one with
661077 - sedation? What is her assessment of risk to the patient, if the work
661078 - had been done later after the OR or ICU could accomodate this
661079 - procedure?
661081 - ..
661082 - Jessica indicated she "just works here." She feels the important
661083 - thing now is to concentrate on good wound care for speedy recovery to
661084 - try Half Dome again next year. That was a nice thought.
661086 - ..
661087 - Did my best to assure that while this was a difficult experience for
661088 - everyone, very pleased and grateful the VA was represented by such
661089 - outstanding and caring talent that has finally got the leg injury from
661090 - a week ago on a path to recovery.
661092 - ..
661093 - By now it is after midnight.
661095 - ..
661096 - Slept some in the cubical where the procedure was performed. Sometime
661097 - later was wheeled down the hall to another room, to await transfer to
661098 - Med Surg for patient care and decision on release to go home later in
661099 - the day.
661101 - ..
661102 - The ER nurse took a picture showing the wound wrapped with gauze
661103 - dressing on the lower left leg...
661104 -
661105 - 
661106 -
661107 - [On 150925 0336 Christy Burns changed wound dressing
661108 - protocol to Hydrofera Blue Bacterostatic wound packing
661109 - protected with large foam bandage. ref SDS 12 LZ42
661111 - ..
661112 - [On 150928 0900 during treatment in Module 2 Surgery Wound
661113 - Care Clinic, Lana changed dressing scheme to cover
661114 - Hydrofera Blue Bacteriostatinc tunnel dressing with
661115 - Enluxtra medically treated 5" square foam pad and secured
661116 - this in place with 4" gauze roll wrapped fully around the
661117 - leg, and with another wrapping with 4" elastic-adhesive
661118 - Kobin tape, secured with 2" adhesive paper tape wrapped
661119 - around the leg, and then covered with stretch tube netting.
661120 - ref SDS 13 XI5O,
661121 -
661122 -
661123 -
661124 -
661126 - ..
6612 -
6613 -
6614 - 0324
6615 -
661501 - A nurse wheeled me through the ER for transfer to the hospital
661502 - Med-Surg patient rooms. On the way took a picture of Doctor Jesse
661503 - Turner on staff this evening, per above. ref SDS 0 ZF4J
661505 - ..
661506 - Thanked Jesse and the ER team for doing a good job...
661507 -
661508 -
661509 -
661510 -
661511 -
661512 -
661513 -
6616 -
SUBJECTS
VA Progress Notes ER General Surgery Debridement Infected Wound Hema
7603 -
760401 - ..
760402 - Progress Notes Medical Chart Debridement Surgery Lower Left Leg Hematoma
760403 -
760404 - Progress Notes for meeting to perform debridement, per above,
760405 - ref SDS 0 PUTY, which relates to examination by Doctor Turner in the
760406 - ER, also, above. ref SDS 0 ZF4J
760408 - ..
760409 - VA Medical Records website is at...
760410 -
760411 - https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome
760413 - ..
760414 - Customer....
760419 - ..
760420 - VA record Progress Notes for debridement surgery in ER OA 2230
760421 - performed by Jessica Della Valle, MD and assisted by Debra; record is
760422 - stored in ref OF 1 GV9L
760423 -
760424 - F:\05\00003\SM\CC\AGMJ\20150923-221500\MEDICAL_RECORDS_9-17-15_TO_9-28-15.pdf
760426 - ..
760427 - LOCAL TITLE: GENERAL SURGERY H&P NOTE (SURGERY)
760428 - STANDARD TITLE: SURGERY H & P NOTE
760429 - DATE OF NOTE: SEP 23, 2015@22:15 ENTRY DATE: SEP 24, 2015@10:07:01
760430 - AUTHOR: DELLA VALLE,JESSICA EXP COSIGNER:
760431 - URGENCY: STATUS: COMPLETED
760433 - ..
760434 - Jessica is listed on UCSF Profiles at...
760435 -
760436 - http://profiles.ucsf.edu/jessica.dellavalle
760438 - ..
760439 - The attending physician of record for this patient care
760440 - encounter
760441 - is Dr. Duh.
760443 - ..
760444 - CC: Left lower extremity hematoma
760446 - ..
760447 - REFERRING PROVIDER: Dr. Jesse Turner
760449 - ..
760450 - SOURCE: Patient and review of eletronic medical records.
760452 - ..
760453 - HPI (History Present Illness)
760454 -
760455 - 1. 70 y/o gentleman w/ PMH of GERD, achalasia (s/p
760456 - laparoscopic heller myotomy and fundoplication) and CAD
760457 - (s/p 4 vessel CABG) who was referred to ED from Medicine
760458 - clinic for evaluation of LLE hematoma.
760460 - ..
760461 - 2. Mr Welch was hiking in Yosemite 1 week ago on September
760462 - 16th when he slipped and fell onto a rocky trail. He
760463 - noticed the most severe areas of impact to be with his
760464 - bilateral wrists and left leg.
760466 - ..
760467 - 3. Patient was seen in the SF VA ED on September 18th for the
760468 - development of a LLE hematoma. Patient had minimal pain at
760469 - that time and was discharged with instructions of gentle
760470 - exercise and increase activity as tolerated.
760472 - ..
760473 - 4. Since them patient has been on multiple hikes up to 10
760474 - miles in distance. Two days ago, patient developed
760475 - worsening pain of LLE. Pain aggravated by standing for
760476 - prolonged periods of time and improves with
760477 - movement/walking. Yet the pain has progressively worsened
760478 - and is now impeding restful sleep and routine activity. Mr
760479 - Welch has taken ibuprofen PRN. He denies fevers or chills
760480 - but endorses feeling flushed in the ED.
760482 - ..
760483 - PMH (Patient Medical History)
760484 -
760485 - 1. Esophageal Achalasia
760486 - 2. CAD
760487 - 3. GERD
760488 - 4. Hyperlipidemia
760490 - ..
760491 - Why no report patient has resolved the more critical cholesterol
760492 - malady: Hypoalphalipoproteinemia (low HDL).
760494 - ..
760495 - Progress Notes Doctor Della Valle continue...
760496 -
760497 - PSH (Patient Surgical History)
760498 -
760499 - 1. s/p laparoscopic heller myotomy and fundoplication 12/2009
760500 - 2. s/p multiple EGDs with dilations
760501 - 3. s/p CABG x4 in 2009
760502 - 4. left knee repair
760504 - ..
760505 - ALLERGIES:
760506 -
760507 - 1. SIMVASTATIN
760508 - 2. ROSUVASTATIN
760510 - ..
760511 - OUTPATIENT MEDICATIONS:
760512 -
760513 - 1. Omeprazole 40 mg BID
760514 - 2. Atorvastatin 10 mg po daily
760515 - 3. Zetia 10 mg po daily
760516 - 4. ibuprofen prn as per above
760517 -
760519 - ..
760520 - HABITS: Enjoys Hiking
760522 - ..
760523 - FH (possibly Functional Hierarchy): non-contributory
760525 - ..
760526 - SOCIAL: Wife passed away from breast cancer. Profession-
760527 - General contractor
760529 - ..
760530 - ROS (Review of Systems): As per HPI, otherwise negative.
760532 - ..
760533 - PE (Physical Examination)
760534 -
760535 - 1. Vital Signs
760536 -
760537 - TEMP:97. F
760538 - PULSE:94
760539 - RESP:18
760540 - BLOOD PRESSURE:126/82
760541 - WT: 180.3 lb [82.0 kg] (09/24/2015 04:34)
760542 - HGT: 64.5 in [163.8 cm] (09/23/2015 15:32)
760544 - ..
760545 - 2. General: NAD,conversing appropriately
760546 - 3. HEENT: Flushed
760547 - 4. Chest/Lungs: Nonlabored breathing, normal heart rate
760549 - ..
760550 - 5. Extrems/Vascular:
760551 -
760552 - 1. Left LE with approximately 8-9 cm soft hematoma on
760553 - anterior-lateral lower leg over mid-shin. Area of Erythema
760554 - and severe TTP overlying Mid-Tibia-> no discrete fluctuance
760555 - palpated at this specific point of tenderness. Multiple
760556 - small punctate scaps over hematoma healed. Approximately 2
760557 - cm of dark skin with no sensation.
760559 - ..
760560 - 2. Left foot warm, dry with 2+ DP and PT pulses (symmetrical
760561 - with rt LE).
760563 - ..
760564 - 3. Left foot also with areas of eechymosis around ankle and
760565 - metatarsals.
760566 -
760568 - ..
760569 - Labs:
760570 -
760571 - 09/23/2015 WBC.................... 13.60 H
760572 - 09/23/2015 RBC.................... 4.73
760573 - 09/23/2015 HEMOGLOBIN............. 14.10
760574 - 09/23/2015 HEMATOCRIT............. 42.20
760575 - 09/23/2015 MCV.................... 89.40
760576 - 09/23/2015 MCH.................... 29.90
760577 - 09/23/2015 MCHC................... 33.40
760578 - 09/23/2015 PLATELET COUNT........ 388.00
760579 - 09/23/2015 NEUTS.................. 10.80 H
760580 - 09/23/2015 LYMPHS................. 1.50
760581 - 09/23/2015 MONOS.................. 1.10 H
760582 - 09/23/2015 EOSINO................. 0.10
760583 - 09/23/2015 BASO................... 0.10
760584 - 09/24/2015 EGFR................... 69.00
760585 - 09/24/2015 SODIUM................ 141.00
760586 - 09/24/2015 POTASSIUM.............. 3.90
760587 - 09/24/2015 CHLORIDE.............. 106.00
760588 - 09/24/2015 CARBON DIOXIDE......... 27.00
760589 - 09/24/2015 ANION GAP.............. 8.00
760590 - 09/24/2015 UREA NITROGEN.......... 27.00 H
760591 - 09/24/2015 CREATININE............. 1.06
760592 - 09/24/2015 GLUCOSE............... 123.00 H
760593 - 09/24/2015 CALCIUM................ 8.80
760594 - 09/24/2015 PHOSPHORUS............. 3.30
760595 - 09/24/2015 MAGNESIUM.............. 2.20
760596 - 09/24/2015 PROTHROMBIN TIME....... 15.00 H
760597 - 09/24/2015 INR.................... 1.10
760598 - 09/24/2015 PTT.................... 30.80
760600 - ..
760601 - LLE XRays: No acute bony injuries per my review.
760602 -
760603 -
760604 - ***** Interdisciplinary Care Plan Information *****
760606 - ..
760607 - A/P
760608 - 70 y/o gentleman w/ PMH of GERD, achalasia (s/p laparoscopic
760609 - heller myotomy and fundoplication) and CAD (s/p 4 vessel CABG)
760610 - who presents with 1 week history of LLE hematoma with worsening
760611 - pain over the pain the past 2 days. There is concern for
760612 - possible infection of hematoma and surrounding area. Patient
760613 - has erythema and severe tenderness overlying mid-shin along
760614 - tibia consistent with cellulitis. He has mild elevation in his
760615 - CBC 13.6, but with a 10.8 Neut shift. Plain films of LLE
760616 - obtained to rule out fracture in setting of traumatic fall and
760617 - bony TTP, although less likely etiology of pain.
760619 - ..
760620 - Cellulitis was diagnosed initially by Doctor Turner, per above.
760621 - ref SDS 0 WN5K Jessica also mentioned finding evidence of cellulitis
760622 - during debridement procedure, above. ref SDS 0 P45I
760624 - ..
760625 - Cellulitis can be difficult to differentiate from other maladies,
760626 - e.g., cancer, reported in Millie's case on 030109 1600. ref SDS 1 0T6N
760627 - Research on cellulitis is also reported on 030109. ref SDS 1 TE4P
760629 - ..
760630 - Progress Notes Doctor Della Valle continue...
760631 -
760632 - Plan
760633 -
760634 - 1. Admit to general surgery
760635 - 2. Bedside I&D of hematoma in ED
760636 - 3. Wound cultures obtained
760637 - 4. IV vanc and zosyn started
760638 - 5. Restart home meds
760639 - 6. Reg diet
760640 - 7. PRN Percocet and dilaudid for BTP
760641 - 8. Full set of am labs
760642 - 9. F/U final reads of LLE plain films
760644 - ..
760645 - I&D
760646 -
760647 - 1. 10 Ml of 1% Xylocaine injected into subcutaneous tissue for
760648 - a local field block around the edges of the hematoma.
760649 -
760650 - 2. 2 cm elliptical incision over dusky, dark skin on lateral
760651 - part of hematoma, which had no sensation even prior to the
760652 - administration of local anesthesia-> findings concerning
760653 - for nonviable skin.
760655 - ..
760656 - 3. Copious amounts of clotted dark blood were expressed. No
760657 - obvious purulence observed. Wound culture obtained.
760659 - ..
760660 - 4. The wound bed was irrigated with 1L of NS and debrided.
760661 - Blunt debridement was primarily achieved with my finger.
760662 - Any locations encountered along the edges were dissected.
760664 - ..
760665 - 5. Patient expressed more significant pain on examination of
760666 - wound edges possibly limiting full debridement of these
760667 - areas.
760669 - ..
760670 - Reporting "significant pain" aligns with the record performing the
760671 - procedure both injecting local anesthetic and removing infected
760672 - tissue, per above. ref SDS 0 WQ6I
760673 -
760674 - [On 151001 1200 further debridement required and
760675 - performed in Surgery Wound Care Clinic using scaple
760676 - again, and with pain level "20" again. ref SDS 15 WW4I
760678 - ..
760679 - [On 151006 1315 Clara in Surgery Clinic performed
760680 - debridement using tweezers to remove infected tissue and
760681 - with pain level 0. ref SDS 16 PU9Q
760683 - ..
760684 - 6. Wound was then packed with 1 inch cotton strip. Xeroform
760685 - was then used to dress wound given epidermolysis of
760686 - surrounding dusky skin, followed by gauze and paper tape.
760687 -
760688 -
760689 - **** End of Interdisciplinary Care Plan Information ****
760690 - /es/ JESSICA M. DELLA VALLE
760691 - Signed: 09/24/2015 12:07
760693 - ..
760694 - Jessica is listed at...
760695 -
760696 - http://profiles.ucsf.edu/jessica.dellavalle
760697 -
760698 -
760699 -
760700 -
760701 -
760702 -
7608 -
SUBJECTS
VA Progress Notes ER General Surgery Debridement Infected Wound Hema
8303 -
830401 - ..
830402 - Progress Notes Medical Chart ER Evaluate Hematoma Lower Left Leg
830403 -
830404 - Follow up ref SDS 7 GU5G.
830405 -
830406 - VA record ER re-examination performed by Jesse Turner, MD Progress
830407 - Notes for meeting reported above. ref SDS 0 ZF4J
830408 -
830409 - F:\05\00003\SM\CC\AGMJ\20150923-223900\mhv_WELCH_20150923_223900.txt
830411 - ..
830412 - LOCAL TITLE: EMERGENCY DEPARTMENT CLINIC (MED)
830413 - STANDARD TITLE: EMERGENCY DEPT E & M NOTE
830414 - DATE OF NOTE: SEP 23, 2015@19:36 ENTRY DATE: SEP 23, 2015@19:36:10
830415 - AUTHOR: TURNER,JESSE H EXP COSIGNER:
830416 - URGENCY: STATUS: COMPLETED
830417 -
830418 - cc: increase pain in hematoma
830420 - ..
830421 - HPI:
830422 - 70M CAD (s/p CABG 2009), HLD and achalasia.
830423 - Seen by me on 9/18 for LLE hematoma. He was seen by PMD f/u
830424 - today. Has increased pain at hematoma site x1d. no f/c. no
830425 - ulceration. sensation & ROM remains intact. No pallor/cold
830426 - extremity.
830428 - ..
830429 - PMH/PSH:
830430 - 1. Esophageal Achalasia - s/p lap heller myotomy and
830431 - fundoplication 12/2009
830432 - - s/p EGD with dilations
830433 - 7. CAD s/p CABG x4 in 2009
830434 - 8. GERD
830435 - 9. Hyperlipidemia
830436 - 10. left knee repair
830438 - ..
830439 - ALLERGIES: SIMVASTATIN, ROSUVASTATIN
830441 - ..
830442 - Active Medications:
830443 -
830444 - 1. AMMONIUM LACTATE 12% LOTION APPLY LOTION TOPICALLY
830445 - EVERY DAY TO FEET AFTER BATHING
830446 - 2. ATORVASTATIN CALCIUM 20MG TAB TAKE ONE-HALF TABLET
830447 - ORALLY AT BEDTIME FOR CHOLESTEROL
830448 - 3. CLOTRIMAZOLE 1% TOP CREAM APPLY CREAM TOPICAL
830449 - A DAY UNDER AFFECTED TOE
830451 - ..
830452 - 4. EZETIMIBE 10MG TAB TAKE ONE TABLET ORALLY EVERY DAY
830453 - 5. FAMOTIDINE 20MG TAB TAKE ONE TABLET ORALLY AT BEDTIME
830454 - FOR STOMACH
830455 - 6. UREA 20% CREAM APPLY CREAM TOPICALLY EVERY DAY TO DRY
830456 - CALLOUSED SKIN
830458 - ..
830459 - Latest Vitals:
830460 - Height: 64.5 in [163.8 cm] (09/23/2015 15:32)
830461 - Weight: 178.4 lb [81.1 kg] (09/23/2015 15:32)
830462 - BMI: 30.2 (Obesity Level I)
830464 - ..
830465 - Within Last 6H:
830466 - Pulse: 09/23/2015@19:18 94
830467 - Resp: 09/23/2015@19:18 18
830468 - Temp: 09/23/2015@19:18 97.4
830469 - B/P: 09/23/2015@19:18 126/82
830470 - O2 Sat: 09/23/2015@19:18 95
830471 -
830472 -
830473 - a&o, nad
830474 - loquacious
830475 - rrr. no mrg.
830476 - ctab
830477 - LLE hematoma soft, but markedly increase TTP since seen several
830478 - days ago. neurovascularly intact distally mae. antalgic gait
830480 - ..
830481 - Labs:
830482 - wbc 13.6 (Range 4.8-10.8) High
830483 - Neuts 10 (Range 2.2-8.6) High
830485 - ..
830486 - MDM
830487 - 70M with hematoma, likely now infected. May also have
830488 - overlying cellulitis.
830489 - Appreciate Gen Surg bedside evacuation of hematoma & admit
830490 - 1mg of dilaudid IV given at beginning of bedside procedure.
830491 -
830492 - /es/ JESSE H TURNER
830493 - Medicstaff MD
830494 - Signed: 09/23/2015 22:17
830495 -
830496 -
830497 -
830498 -
8305 -
SUBJECTS
Default Null Subject Account for Blank Record
8403 -
840401 - ..
840402 - Nursing Notes Medical Chart ER Debridement Hematoma Lower Left Leg
840403 -
840404 -
840405 - 1. Date/Time: 23 Sep 2015 @ 2239
840406 - Note Title: EMERGENCY DEPARTMENT NURSING NOTE
840407 - Location: SAN FRANCISCO VAMC
840408 - Signed By: WAITE,DEBRA J
840409 - Co-signed By: WAITE,DEBRA J
840410 - Date/Time Signed: 23 Sep 2015 @ 2242
840412 - ..
840413 - 2. LOCAL TITLE: EMERGENCY DEPARTMENT NURSING NOTE
840414 - STANDARD TITLE: RN EMERGENCY DEPARTMENT E & M NOTE
840415 - DATE OF NOTE: SEP 23, 2015@22:39 ENTRY DATE: SEP 23, 2015@22:39:13
840416 - AUTHOR: WAITE,DEBRA J EXP COSIGNER:
840417 - URGENCY: STATUS: COMPLETED
840418 -
840419 - *** EMERGENCY DEPARTMENT NURSING NOTE Has ADDENDA ***
840421 - ..
840422 - 3. E&A NURSING ASSESSMENT
840424 - ..
840425 - 4. ID band applied; name/SS verified?Yes
840427 - ..
840428 - 5. Allergies: SIMVASTATIN, ROSUVASTATIN
840430 - ..
840431 - 6. Was Patient transferred in? NO
840432 - If yes, report obtained from:
840434 - ..
840435 - 7. SYSTEM ASSESSMENT
840436 - EVALUATION OF PAIN
840437 - Patient reports pain (>0 on pain scale)............... 5
840438 - Quality of Pain (check all that apply)................ dull
840439 - Does the pain affect any of the following?
840440 - Sleep: Yes
840441 - Appetite: No
840442 - Energy: Yes
840443 - Physical Activity: Yes
840444 - Mood: No
840445 - Emotions: No
840446 - Relationships: No
840447 - ADL's: Yes
840449 - ..
840450 - Location: left lower leg
840451 - Duration: 2 weeks
840453 - ..
840454 - 8. NEUROLOGICAL
840455 - Follows simple commands
840456 - Orientated to Person, Place, & Time
840457 - PERRL Yes
840458 - Facial symmetry Yes
840459 - Headache No
840460 - Dizzy No
840461 - Blurred vision No
840463 - ..
840464 - 9. MUSCULOSKELETAL
840465 - 10. MAE
840466 - 11. PULMONARY
840467 - 12. Lung Sounds
840469 - ..
840470 - Comment
840472 - ..
840473 - 13. INTEGUMENTARY
840474 - Color: Normal
840475 - Skin: warm
840477 - ..
840478 - Decubitus
840479 - Stage:
840480 - Location:
840481 - Size:cm 0
840482 - Other:
840484 - ..
840485 - 14. Treatment:
840486 -
840487 - large hematoma on left anterior calf, also has bruising noted
840488 - on left foot ankle and rest of left calf
840489 -
840490 - /es/ DEBRA J WAITE, RN
840491 - ER
840492 - Signed: 09/23/2015 22:42
840493 -
840494 - 15. 09/24/2015 ADDENDUM STATUS: COMPLETED
840495 - 0030 patient awake c/o pain alert and oriented, hydromorphone 1
840496 - mg administered/
840498 - ..
840499 - BCMA . lt lower leg dressing intact no sign of bleeding noted. pt felt much
840500 - better after pain med . vancomycin IV started .
840501 -
840502 - 16. 0100 patient sound asleep
840503 -
840504 - /es/ Josefina Tumanguil,RN
840505 - ER
840506 - Signed: 09/24/2015 01:45
840507 -
840508 - 17. 09/24/2015 ADDENDUM STATUS: COMPLETED
840509 - 0200 vancomycin IV all infused. no sign of allergic reaction given
840510 -
840511 - /es/ Josefina Tumanguil,RN
840512 - ER
840513 - Signed: 09/24/2015 02:08
840514 -
840515 -
840516 -
840517 -
840518 -
840519 -
840520 -
840521 -
840522 -
840523 -
840524 -
840525 -
840526 -
840527 -
8406 -