CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 7 0000. ref SDS 6 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040508 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Meeting in Clinic Module 2...
040902 -
040903 - Svetlana Nakamura, RN, WCC, OMSN
040904 - United States Department Veteran's Affairs
040905 - Medical Center
040906 - Nursing Service
040907 - Building 200 Room GA-157
040908 - Clinic Module 2
040909 - 4150 Clement Street
040910 - San Francisco, CA 94121
040911 - 415 221 4810 ext 4772
040912 - Cell 415 260 3456
040913 - svetlana.nakamura@va.gov
040915 - ..
040916 - Lana removed the dressing she placed last Thursday on 151001 1200.
040917 - ref SDS 7 X67K
040919 - ..
040920 - Lana advised that the wound today is significantly improved from last
040921 - Thursday.
040923 - ..
040924 - Reported hiking 11 miles yesterday, which evidently increases
040925 - recovery, based on Lana's findings this morning.
040927 - ..
040928 - Lana seemed to indicate that "undermining" of the wound has improved
040929 - but remains major problem. She explained again today that further
040930 - debridement is needed for the wound to heal. She described this in
040931 - part as removing dead skin.
040933 - ..
040934 - Lana discussed doing this again today, using the scaple method which
040935 - she used last Thursday on 151001 1200. ref SDS 7 WW4I We discussed
040936 - using standard of care performing debridement with conscious sedation
040937 - that avoids excessive pain.
040939 - ..
040940 - Lana is meeting with Doctor Stewart tomorrow. She will recommend the
040941 - Surgery Department schedule a procedure to perform additional
040942 - debridement using conscious sedation, rather than perform this work
040943 - without sedation, and rather than attempt to use local anesthetic
040944 - applied with injections around the perimeter of the wound.
040946 - ..
040947 - Thanked Lana for working to have debridement performed with conscious
040948 - sedation.
040950 - ..
040951 - Scheduled next meeting on Thursday, 151008 1200.
040952 -
040953 -
040954 -
040956 - ..
0410 -
0411 -
0412 - 0842
0413 -
041301 - After meeting with Lana went to ER and reported problems with right
041302 - wrist. This began a long series of radiology imaging, and then
041303 - treatment with a form of removable cast, explained in another record.
041304 -
041306 - ..
0414 -
0415 -
0416 - 1028
0417 -
041701 - Received call on cell phone, while talking to the Radiology
041702 - Department on the 2nd floor of building 200.
041704 - ..
041705 - The caller was a assistant for Doctor Stewart, and advised a meeting
041706 - is scheduled tomorrow at 1315 with the doctor in Module 2 Clinic.
041708 - ..
041709 - Later, after returning to the ER on the ground floor, saw Lana walking
041710 - through the main VA Medical Center lobby. Asked if she was aware of
041711 - the meeting tomorrow with Doctor Stewart - is this the meeting which
041712 - Lana earlier this morning planned to schedule when she sees Doctor
041713 - Stewart tomorrow?
041715 - ..
041716 - Lana said it is. Instead of waiting until tomorrow to discuss the
041717 - matter with Doctor Stewart, she called Isagani and requested they
041718 - schedule the meeting with Doctor Stewart.
041719 -
041721 - ..
0418 -
0419 -
0420 - 1102
0421 -
042101 - Met by accident in the hallway, Doctor Judith Wisneski. Have seen her
042102 - over the past years talking with Doctor Stewart in the hallways, but
042103 - have never been introduced.
042105 - ..
042106 - None-the-less she knew my name. Doctor Wisneski advised that she
042107 - works in Cardiology and is aware of the meeting scheduled with Doctor
042108 - Simpson on 151014.
042110 - ..
042111 - This meeting today, took place in building 300 ground floor, near the
042112 - door to the stairs at the main elevators near the Clinic Modules. The
042113 - doctor had her back to the door, and while we talked somone opened the
042114 - door abruptly, striking her in the back, including her head. Of
042115 - course she was startled, and immediately said she must lay down to
042116 - recover from this blow. Doctor Wisneski went through door, and I
042117 - followed to render assistance. However, she leaned against the wall
042118 - of the stair well, and continued discussion.
042120 - ..
042121 - Later was told that Doctor Wisneski is Chief of Cardilogy at the VA.
042123 - ..
042124 - We had a long discussion in the stairwell, perhaps 30 minutes, about
042125 - performing coronary CT angiography (CCTA) with calcium score for the
042126 - purpose of...
042127 -
042128 - 1. Evaluate level of atherosclerotic plaques following CABG +4 on
042129 - 091022 0700. ref SDS 2 JF9K
042131 - ..
042132 - 2. Low levels of atherosclerotic plaques shown by CCTA with low
042133 - calcium score provides standard of care testing response to
042134 - treatment with extended endurance exercise through hiking 11
042135 - miles per day, 300 miles per month at the rate of 13 - 17
042136 - minutes per mile, and over the past 4 years which raised HDL
042137 - from 30 to 70, as shown in spreadsheet previously submitted to
042138 - Doctor Rao...
042139 -
042140 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
042142 - ..
042143 - General summary of hiking correlated with improved HDL and
042144 - Triglycerides is shown in case study of patient history on
042145 - 140101 0600. ref SDS 4 TTQS (see line 107069)
042147 - ..
042148 - 3. Low levels of atherosclerotic plaques shown by low calcium
042149 - score may occur from rapid regression and repair of lesions in
042150 - the endothelium lining of blood vessels with high levels of HDL
042151 - (> 60) cholesterol and EPCs, both produced with extended
042152 - endurance exercise through hiking 11 miles per day, 300 miles
042153 - per month.
042155 - ..
042156 - 4. Low levels of atherosclerotic plaques shown by low calcium
042157 - score supports reduced reliance on statin drug treatments,
042158 - since atherosclerotic plaques take years to regenerate.
042160 - ..
042161 - 5. Low levels of atherosclerotic plaques shown by low calcium
042162 - score that supports reduced reliance on statin drug treatments,
042163 - thereby reduces onerous side effects of statin drugs.
042165 - ..
042166 - Reduced dizziness increases effectiveness performing daily
042167 - work.
042169 - ..
042170 - Reduced urination reduces dehydration, which reduces feet
042171 - injuries of blistering, scaling, peeling, bleeding. Healthy
042172 - feet enables more hiking to increase HDL and EPCs maintaining
042173 - low levels of atherosclerotic plaques, lowering risks of
042174 - negative cardiovascular events, and thus extending chances of
042175 - longevity with a quality of life worth living.
042177 - ..
042178 - 6. Low levels of atherosclerotic plaques shown by low calcium
042179 - score supports reduced level of effort performing extended
042180 - endurance exercise through hiking, perhaps to 4 or 5 miles per
042181 - day, thus enabling investing 1 - 2 hours saved per day in
042182 - other necessities.
042184 - ..
042185 - The doctor was aware of pending meeting with Doctor Simpson scheduled
042186 - on 151014 0900. She noted the doctor feels this upcoming meeting is
042187 - unnecessary, and that nothing can be accomplished.
042189 - ..
042190 - Doctor Wisneski was sympathetic with objectives for reducing side
042191 - effects of statin medications, in this case mainly dizziness and
042192 - frequent urination, which in turn causes dehydration that injures the
042193 - feet, preventing hiking to raise HDL. She suggested continuing to
042194 - take statins but at reduced levels, e.g., here reducing Atorvastain 10
042195 - mg and Ezetimibe 10 mg to 5 mg.
042197 - ..
042198 - Doctor Wisneski further proposed changing use of statins from daily to
042199 - every other day, thus lowering the concentration in order to reduce
042200 - side effects. This would be trial and error finding levels of statins
042201 - that maintain favorable lipids with minimum side effects.
042203 - ..
042204 - The doctor asked about patient history taking statins?
042206 - ..
042207 - Reported bad side effects with Simvastatin beginning in 2010, and
042208 - later with Rosuvastatin beginning in 2012. Since 131015, have been
042209 - taking Atorvastatin and Ezetimibe.
042211 - ..
042212 - Doctor Wisneski seemed say the medical team cannot support standard of
042213 - care in this case because there is no protocol for using coronary CT
042214 - angiography tests with calcium score to test for response to treatment
042215 - with extended endurance training hiking 11 miles per day and 300 miles
042216 - per month.
042218 - ..
042219 - The doctor seemed to mention that some years ago UCSF had a protocol
042220 - for testing response to treatment with extended endurance exercise.
042221 - She further indicated that testing only 1 person would not justify
042222 - publishing results. She noted there would be difficulty attracting
042223 - people to participate in a trial of extended endurance exercise at
042224 - levels 7 - 8 miles per day and even 250 miles per month required to
042225 - raise HDL above 60, sufficient to regress atherosclerotic plaques.
042227 - ..
042228 - The implication seemed to be that if other patients choose not to
042229 - invest effort for regressing athersclerotic plaques to extend
042230 - longevity, this justifies not testing to see if benefits in this case,
042231 - as set out above, ref SDS 0 HE5Y, support reducing drug side effects
042232 - by reducing treatment with statin medications.
042234 - ..
042235 - Doctor Wineski at one point noted patients are free to stop taking
042236 - statin drugs to control atherosclerotic plaques at any time, so there
042237 - is no need to perform coronary CT angiography test to determine that
042238 - former high concentrations of atherosclerotic plaques have been fully
042239 - regressed, which justifies ending treatment with statin drugs, and
042240 - also reducing treatment time performing extended endurance exercise,
042241 - thus reducing wear and tear on the body, i.e., side effects of
042242 - endurance training. (see point 6, ref SDS 0 IL4I)
042244 - ..
042245 - In other words, deciding to pause treatment with statins seems similar
042246 - to pausing chemotherapy so cancer patients can avoid debilitating side
042247 - effects of treatment, when testing shows cancer has been regressed,
042248 - shown by Millie's case fighting stage 4 cancer for nearly 10 years.
042250 - ..
042251 - The doctor also explained that even if coronary CT angiography (CCTA)
042252 - testing found even a single 10% lesion, this would not justify
042253 - reducing statin drug treatment, because the next day after the test,
042254 - that single 10% lesion could become a 100% blockage.
042256 - ..
042257 - Advised this theory has not been encountered in cardiology and lipid
042258 - management literature, reviewed on 131125 0005. ref SDS 3 JV5O
042260 - ..
042261 - There was no discussion today of how taking statin treatments would
042262 - avoid a catostrphic event of a 10% lesion suddenly expanding into a
042263 - 100% blockage.
042265 - ..
042266 - Doctor Wineski seemed to say at one point that while coronary CTA is
042267 - not a reliable test for evaluating regression of atherosclerotic
042268 - plaques, this can be evaluated effectively with conventional and
042269 - invasive cardiac catheterization angiogram testing. This procedure
042270 - was performed by Doctor Shunk in this case on 091021 0716. ref SDS 1
042271 - 7L43
042273 - ..
042274 - Indicated objective to forego invasive procedures. There was not
042275 - time today for discussing why finding no atherosclerotic plaques with
042276 - invasive procedures is any more helpful than making the same finding
042277 - with radiology methods.
042279 - ..
042280 - Further suggested that the meeting with Doctor Simpson scheduled for
042281 - 151014, can be cancelled, based on extensive time Doctor Wineski has
042282 - generously granted today presenting the views of the Cardiology
042283 - Department.
042285 - ..
042286 - Doctor Wineski seemed to indicate the meeting should take place.
042288 - ..
042289 - We did not discuss periodic treatment "holidays," as occurs in
042290 - oncology practice treating cancer.
042292 - ..
042293 - Thanked Doctor Wisneski for sharing ideas on managing atheroslclorsis
042294 - risks.
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0424 -