041748 - ..
041749 - Doctor Simpson diagnosed dehydration of feet is caused by hiking 11
041750 - miles per day. During the meeting, he did research on the computer in
041751 - the office and could not find side effects of Atorvastatin causing
041752 - dehydration due to frequent urination. He requested source listing
041753 - Atorvastatin side effects including frequent urination, dehydration,
041754 - dry mouth.
041756 - ..
041757 - During a meeting in the Cardiology Department on 130603, at the VA
041758 - Clinic in Martinez, Doctor Egan submitted a source listing frequent
041759 - urination causing dehydration and dry mouth. ref SDS 16 BV4I This
041760 - source can be accessed directly on the Internet at...
041761 -
041762 - http://www.emedicinehealth.com/drug-atorvastatin/article_em.htm
041764 - ..
041765 - Patient history of increased urination frequency causing dry mouth and
041766 - feet injuries occurred taking Atorvastatin, and subsided on pausing
041767 - this medication, and then resumed again, when medication was resumed
041768 - further suggests causal link, per above. ref SDS 0 9G44 Evidence also
041769 - indicates that Omeprazole 80 mg may be a larger factor causing
041770 - frequent urination, reported in case study on 140101 for medication,
041771 - diet, exercise, and vitals - see the date on 150819. ref SDS 19
041772 - X07H
041774 - ..
041775 - Doctor Simpson related personal experience suffering feet injuries
041776 - resulting from hiking, per above. ref SDS 0 9G44 The doctor has had
041777 - favorable response to treatment with...
041778 -
041779 - Burt's Bees Foot Cream
041781 - ..
041782 - This is available from Amazon...
041783 -
041784 - http://www.amazon.com/Burts-Bees-Natural-Beeswax-Count/dp/B0054LHI5A/ref=sr_1_1/181-4399811-5233527?ie=UTF8&qid=1445648229&sr=8-1&keywords=burts+bees+amazon
041786 - ..
041787 - CCTA is additionally needed to evaluate side effects taking Omeprazole
041788 - (PPI) to prevent ulceration of LESV, and in lieu of Doctor Stewart
041789 - performing repair of Dor Fundoplication, as set out in a letter to
041790 - Doctor Stewart on 150730 0952. ref SDS 37 UR58 Omeprazole was
041791 - prescribed on 100305 1000. ref SDS 9 HC7K Started taking Omeprazole
041792 - on 100317. ref SDS 10 PU3W Case study on patient history dated
041793 - 140101, shows that since then, patient has taken 70780 mg of
041794 - Omeprazole (PPI). ref SDS 19 AU5L On 150611, report that Omeprazole
041795 - damages endothelium lining of blood vessels, and correlates with 16% -
041796 - 21% increase risk of myocardial infarction. ref SDS 33 5N3O This
041797 - record suggests CCTA can help assess patient tolerance for continuing
041798 - Omeprazole to treat acid reflux, or whether Dor fundoplication needs
041799 - to be repaired in order to control reflux without destructive effects
041800 - of PPI.
041802 - ..
041803 - Doctor Simpson asked about work plan in the event CCTA test finds
041804 - atherosclerosis plaques in the active circulatory system?
041806 - ..
041807 - This result would indicate increased treatment hiking to raise HDL
041808 - that clears atherosclerosis, and raises EPCs that repair endothelial
041809 - lining of blood vessels, and further increase statin medications for
041810 - lowering LDL-C on advice of the medical team. For example a few weeks
041811 - ago on 151005, Doctor Wisneski posited scenario of CCTA finding a
041812 - single 10% lesion. She indicated would be a high risk for the patient
041813 - requiring continuing high dose of statin medications. ref SDS 44 RF7L
041815 - ..
041816 - Doctor Simpson proposed ordering CCTA with calcium score, and resuming
041817 - treatment with Atorvastatin and Ezetimibe. He smiled and commented
041818 - that ordering CCTA will be an experiment for cardiology.
041820 - ..
041821 - Doctor Simpson has a strong record in medical research for
041822 - cardiology, shown at...
041823 -
041824 - Veteran's Health Research at NCIRE
041825 -
041826 - https://www.ncire.org/research/researchers_by_name/Paul-C-Simpson-MD/
041828 - ..
041829 - Staff Physician, Cardiology, SFVAMC
041830 - Professor of Medicine, UCSF
041831 - paul.simpson@ucsf.edu
041833 - ..
041834 - Agreed to resume working with Atorvastatin Ezetimibe drug combination
041835 - to try developing protocol that minimizes debilitating side effects,
041836 - as discussed with Doctor Wisneski on 151005 1102. ref SDS 44 GL7G
041837 - Favorable results of CCTA testing may support solving atherosclerosis,
041838 - the #1 cause of death for seniors.
041840 - ..
041841 - The challenge is to discover optimum extended endurance exercise that
041842 - also avoids side effects. Synergy between exercise and drugs can
041843 - extend quality of life that is worth living, as we did in Millie's
041844 - case at Kaiser and UCSF, enabling her to live with stage 4 cancer for
041845 - nearly 10 years.
041847 - ..
041848 - While we talked Doctor Simpson entered an order in the computer for
041849 - CCTA with calcium score.
041850 -
041851 - [On 151019 0930 CCTA with calcium score performed; meeting
041852 - with doctor in Radiology Department reviewed requirements
041853 - for calcium score to evaluate response to treatment
041854 - recovering from atherosclorosis. ref SDS 46 GR4K At the
041855 - end of the meeting, the doctor agreed to perform calcium
041856 - score for comprehensive CCTA test. ref SDS 46 LQ5F
041857 - However, analyst's report merely says "All the bypass
041858 - grafts are patent." ref SDS 46 JW8O
041860 - ..
041861 - [On 151019 0930 addendum received on 160113, and issued by
041862 - Doctor Priyanka Jha reports finding no evidence of
041863 - atherosclerosis plaque in active coronary circulatory
041864 - system. ref SDS 49 QW5F
041866 - ..
041867 - [On 151021 1208 Doctor Simpson called and advised that the
041868 - report on the CCTA test prepared by an analyst in the
041869 - Radiology Department failed to perform calcium score.
041870 - ref SDS 50 FR6F
041872 - ..
041873 - [On 151203 1014 meeting with Doctor Elicker in Radiology
041874 - Department seemed to clarify that he read the CCTA scan
041875 - file performed on 151019, and found no evidence of lesions
041876 - nor stenosis blockages of any amount anywhere in the active
041877 - circulatory system which was covered by the scan.
041878 - ref SDS 53 SZ5F
041880 - ..
041881 - [On 151217 2052 letter to Doctor Elicker requests
041882 - amend report on CCTA scan performed on 151019, to
041883 - say reading found no lesions nor blockages of any
041884 - amount anywhere within active circulatory system.
041885 - ref SDS 55 Y556
041887 - ..
041888 - Doctor Simpson advised that after CCTA test is performed, schedule
041889 - follow up meeting with him to review results and develop work plan
041890 - based on results of the test.
041892 - ..
041893 - Doctor Simpson advised that Doctor Mark Ratcliff continues to support
041894 - the Surgical Department at the VA Medical Center here in San
041895 - Francisco.
041896 -
041897 -
041898 -
041899 -
041901 - ..
0420 -
0421 -
0422 - 1014
0423 -
042301 - After meeting with Doctor Simpson in Module 2 on the Ground Floor,
042302 - went to the Radiology Department on the 2nd floor. Was directed to
042303 - go to the CT scan scheduling department around the corner.
042305 - ..
042306 - A clerk scheduled the CCTA test with calcium score for 151019 0930.
042307 -
042308 -
042309 -
0424 -
SUBJECTS
Default Null Subject Account for Blank Record
0503 -
050401 - ..
050402 - Medical Chart Progress Notes for Cardiology Meeting 151014
050403 - Progress Notes Cardiology Meeting 151014 Doctor Simpson
050404 - Doctor Simpson Progress Notes Cardiology Meeting 151014
050405 -
050406 - Follow up ref SDS 36 6Y7H.
050407 -
050425 - 1. Date/Time: 14 Oct 2015 @ 1145
050426 - Note Title: CARDIOLOGY CLINIC NEW (MED/CONSULT)
050427 - Location: San Francisco CA VAMC
050428 - Signed By: SIMPSON,PAUL C
050429 - Co-signed By: SIMPSON,PAUL C
050430 - Date/Time Signed: 14 Oct 2015 @ 1231
050432 - ..
050433 - 2. LOCAL TITLE: CARDIOLOGY CLINIC NEW (MED/CONSULT)
050434 - STANDARD TITLE: CARDIOLOGY OUTPATIENT CONSULT
050435 - DATE OF NOTE: OCT 14, 2015@11:45 ENTRY DATE: OCT 14, 2015@11:46:03
050436 - AUTHOR: SIMPSON,PAUL C EXP COSIGNER:
050437 - URGENCY: STATUS: COMPLETED
050438 -
050439 - *** CARDIOLOGY CLINIC NEW (MED/CONSULT) Has ADDENDA ***
050441 - ..
050442 - 3. Most Recent VITAL SIGNS:
050443 - Height: 64.5 in [163.8 cm] (09/23/2015 15:32)
050444 - Weight: 176.7 lb [80.3 kg] (10/14/2015 08:18)
050445 - BMI: 29.9 (Overweight)
050446 - Temp: 97.8 F [36.6 C] (10/05/2015 08:40)
050447 - Pulse: 77 (10/14/2015 08:18)
050448 - Comments:
050450 - ..
050451 - 4. Resp: 16 (10/05/2015 08:40)
050452 - BP: 134/84 (10/14/2015 08:18)
050453 - O2 Sat: 10/14/15 08:18:21 O97
050455 - ..
050456 - 5. 70 swm from Concord is referred to Cards for consideration of
050457 - coronary CTA, with a view toward stopping statin rx, which he
050458 - feels is causing dry feet via xs urination.
050460 - ..
050461 - 6. CARD PROBLEMS:
050462 -
050463 - 1) CAD sp CABG here 10-22-09 (LIMA, SVG diag, ramus, PDA)
050464 - last TTE here 10-26-09 wnl
050465 - last seen CT Surg 11-19-09, never cards
050466 -
050467 - 2) hyperlipidemia LDL 170 12-14-09; lately ok, see below
050468 -
050469 - 3) overwt/obesity (BMI ~30)
050471 - ..
050472 - 7. OTHER:
050473 -
050474 - 1) achalasia sp ops
050475 - 2) recent LLE hematoma w cellulitis sp fall (adm here 9-23 to 9-25-15)
050476 - 3) recent fx R radius (same fall)
050478 - ..
050479 - 8. ASSESS:
050480 -
050481 - He is doing extremely well w/o any CV sxs, esp no angina.
050482 - Lipid panel is very good, and HDL is high, which he attributes
050483 - to his vigorous exercise regimine. However, he feels that
050484 - statin rx is causing xs urination and dry/cracked feet, and he
050485 - would like to continue not taking it (he is not taking a statin
050486 - now). He feels that a good CTA will support that, whereas a
050487 - bad CTA would require further work.
050489 - ..
050490 - 9. PLAN:
050491 -
050492 - We had a very long discussion of the pros and cons. In my
050493 - opinion, a "good" CTA would not rule out unstable and/or
050494 - non-calcified plaque that might be prone to rupture and MI, and
050495 - might be stabilized by statin rx. On the other hand, a "bad"
050496 - CTA might present a quandry of what to do in a pt who is doing
050497 - so well clinically. I also said that I don't think CTA is
050498 - sufficiently sensitive to follow CAD, esp over short times, not
050499 - to mention the xs radiation exposure would make this not
050500 - indicated. Guidelines do not recommend this application.
050502 - ..
050503 - Nevertheless, he is very intent on getting this test, and I
050504 - have ordered it. We will reassess after. Obviously we can
050505 - adjust statin rx, although I doubt that statin is responsible
050506 - for urinary frequency and/or dry feet.
050508 - ..
050509 - I also suggested that he try Burt's Bees foot care for his feet
050510 - (Amazon).
050512 - ..
050513 - I will see again after the test.
050515 - ..
050516 - Need to review if/why no aspirin?
050518 - ..
050519 - Thanks for consult.
050521 - ..
050522 - 10. HPI:
050523 -
050524 - He had classic exertional angina and a very pos stress test in
050525 - 2009, with cath and subsequent CABG here. he has done very
050526 - well. He is very faithful w exercise, walking up to 11 miles
050527 - daily. He can walk up to lower yosemite valley
050528 -
050529 - w/o CV sxs. he does not smoke.
050531 - ..
050532 - he does have esophagela sxs and is concenred w PPI rx. he had
050533 - a fall in yosemite last month, w 2o LLE hematoma/cellulitis,
050534 - prompting adm, and a right wrist fx, doing ok now.
050535 -
050536 - 11. overall, he is doing very well.
050538 - ..
050539 - 12. Active Medications:
050540 -
050541 - not using 1) AMMONIUM LACTATE 12% LOTION APPLY LOTION TOPICALLY
050542 - EVERY DAY TO FEET AFTER BATHING
050543 - not taking 2) ATORVASTATIN CALCIUM 20MG TAB TAKE ONE-HALF TABLET
050544 - ORALLY AT BEDTIME FOR CHOLESTEROL
050545 - not taking 3) CLINDAMYCIN HCL 150MG CAP TAKE TWO CAPSULES ORALLY
050546 - EVERY 6 HOURS WITH FOOD TO TREAT INFECTION.
050547 - 4) CLOTRIMAZOLE 1% TOP CREAM APPLY CREAM TOPICALLY TWICE
050548 - A DAY UNDER AFFECTED TOE
050549 - not taking 5) DOCUSATE NA 250MG CAP TAKE ONE CAPSULE ORALLY TWICE A
050550 - DAY AS NEEDED TO SOFTEN STOOL
050551 - not taking 6) EZETIMIBE 10MG TAB TAKE ONE TABLET ORALLY EVERY DAY
050552 - not taking 7) FAMOTIDINE 20MG TAB TAKE ONE TABLET ORALLY AT BEDTIME
050553 - FOR STOMACH
050554 - 8) GAUZE PAD 4IN X 4IN 12-PLY STERILE USE GAUZE AS
050555 - DIRECTED TO COVER WOUND PACKING.
050556 - 9) HYDROCODONE 5MG/ACETAMINOPHEN 325MG TAB TAKE 1 TO 2
050557 - TABLETS ORALLY EVERY 6 HOURS AS NEEDED FOR PAIN
050558 - 10) KERLIX 4.5IN STERILE USE BANDAGE AS DIRECTED TO WRAP
050559 - LOOSELY AROUND WOUND.
050560 - 11) OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE ORALLY TWICE
050561 - A DAY
050562 - 12) TAPE,MICROPORE 2IN 3M #1530-2 USE TAPE AS DIRECTED
050563 - 13) UREA 20% CREAM APPLY CREAM TOPICALLY EVERY DAY TO DRY
050564 - CALLOUSED SKIN
050565 -
050567 - ..
050568 - 13. Computerized Problem List is the source for the following:
050569 -
050570 - 1. History of coronary artery bypass grafting, 10/14/2015
050571 - Onset 10/00/2009
050572 - SFVA LIMA, SVGs diag, ramus, PDA
050573 - 2. Hyperlipidemia 10/14/2015
050574 - 3. Body mass index 30+ - obesity 10/14/2015
050575 - 4. Esophageal Achalasia * (ICD-9-CM 530.0) 12/08/2009
050576 -
050578 - ..
050579 - 14. EXAM
050580 -
050581 - vs above
050582 - looks well
050583 - overwt (abd)
050584 - bandage LLE
050585 -
050587 - ..
050588 - 15. Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050589 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050591 - ..
050592 - Report Released Date/Time: Jul 28, 2015@13:09
050593 - Provider: RAO,MADHU
050594 - Specimen: PLASMA. CH 0728 819
050595 - Specimen Collection Date: Jul 28, 2015@11:54
050596 - Test name Result units Ref. range Site Code
050597 - CHOLESTEROL 153 mg/dl 100 - 240 [662]
050598 - TRIGLYCERIDE 54 mg/dl 10 - 190 [662]
050599 - HIGH DENSITY LIPOPROT (HDL) 65 mg/dl Ref: >=35 [662]
050600 - Eval: HDL <35 is associated with increased risk of CAD.
050601 - LDL CHOL(Calculated) 78 mg/dl Ref: <=131 [662]
050602 - Eval: Desired LDL: <130 mg/dL; evaluate in light of CHD risk factors.
050603 - ===============================================================================
050605 - ..
050606 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050607 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050609 - ..
050610 - Report Released Date/Time: Feb 09, 2015@11:59
050611 - Provider: RAO,MADHU
050612 - Specimen: PLASMA. CH 0209 735
050613 - Specimen Collection Date: Feb 09, 2015@11:21
050614 - Test name Result units Ref. range Site Code
050615 - CHOLESTEROL 161 mg/dl 100 - 240 [662]
050616 - TRIGLYCERIDE 50 mg/dl 10 - 190 [662]
050617 - HIGH DENSITY LIPOPROT (HDL) 70 mg/dl Ref: >=35 [662]
050618 - Eval: HDL <35 is associated with increased risk of CAD.
050619 - LDL CHOL(Calculated) 81 mg/dl Ref: <=131 [662]
050620 - Eval: Desired LDL: <130 mg/dL; evaluate in light of CHD risk factors.
050621 - Comment: NO VISIBLE HEMOLYSIS /HN
050622 - ===============================================================================
050624 - ..
050625 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050626 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050628 - ..
050629 - Report Released Date/Time: Oct 21, 2014@12:33
050630 - Provider: ALBA,DIANA
050631 - Specimen: PLASMA. CH 1021 413
050632 - Specimen Collection Date: Oct 21, 2014@11:48
050633 - Test name Result units Ref. range Site Code
050634 - CHOLESTEROL 159 mg/dl 100 - 240 [662]
050635 - TRIGLYCERIDE 65 mg/dl 10 - 190 [662]
050636 - HIGH DENSITY LIPOPROT (HDL) 57 mg/dl Ref: >=35 [662]
050637 - Eval: HDL <35 is associated with increased risk of CAD.
050638 - LDL CHOL(Calculated) 90 mg/dl Ref: <=131 [662]
050639 - Eval: Desired LDL: <130 mg/dL; evaluate in light of CHD risk factors.
050640 - ===============================================================================
050642 - ..
050643 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050644 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050646 - ..
050647 - Report Released Date/Time: May 14, 2014@11:30
050648 - Provider: ALBA,DIANA
050649 - Specimen: PLASMA. CH 0514 460
050650 - Specimen Collection Date: May 14, 2014@10:16
050651 - Test name Result units Ref. range Site
050652 - Code
050653 - CHOLESTEROL 164 mg/dl 100 - 240 [662]
050654 - TRIGLYCERIDE 58 mg/dl 10 - 190 [662]
050655 - HIGH DENSITY LIPOPROT (HDL) 66 mg/dl Ref: >=35 [662]
050656 - Eval: HDL <35 is associated with increased risk of CAD.
050657 - LDL CHOL(Calculated) 87 mg/dl Ref: <=131 [662]
050658 - Eval: Desired LDL: <130 mg/dL; evaluate in light of CHD risk factors.
050659 - Comment: SLIGHTLY Hemolyzed specimen /HN
050660 - ===============================================================================
050662 - ..
050663 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050664 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050666 - ..
050667 - Report Released Date/Time: May 14, 2014@11:29
050668 - Provider: ALBA,DIANA
050669 - Specimen: PLASMA. CH 0514 459
050670 - Specimen Collection Date: May 14, 2014@10:16
050671 - Test name Result units Ref. range Site Code
050672 - CHOLESTEROL 169 mg/dl 100 - 240 [662]
050673 - TRIGLYCERIDE 59 mg/dl 10 - 190 [662]
050674 - HIGH DENSITY LIPOPROT (HDL) 67 mg/dl Ref: >=35 [662]
050675 - Eval: HDL <35 is associated with increased risk of CAD.
050676 - LDL CHOL(Calculated) 90 mg/dl Ref: <=131 [662]
050677 - Eval: Desired LDL: <130 mg/dL; evaluate in light of CHD risk factors.
050678 - Comment: SLIGHTLY ICTERIC SPECIMEN /HN
050679 - ===============================================================================
050681 - ..
050682 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050683 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050685 - ..
050686 - Report Released Date/Time: May 14, 2014@11:39
050687 - Provider: ALBA,DIANA
050688 - Specimen: SERUM. CH 0514 458
050689 - Specimen Collection Date: May 14, 2014@10:16
050690 - Test name Result units Ref. range Site Code
050691 - HEMOGLOBIN A1C 5.4 % 4.0 - 6.0 [662]
050692 - ===============================================================================
050694 - ..
050695 - Performing Lab Sites
050696 - [662] SAN FRANCISCO VAMC [CLIA# 05D0988226]
050697 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050698 - ===============================================================================
050699 -
050701 - ..
050702 - 16. Clinical Reminder Activity
050703 - MED REC NON PRIMARY CARE:
050704 - Current medications reviewed with patient/caregiver and reconciliation
050705 - of medications related to today's visit completed, including non-VA
050706 - medications and discrepancies, if identified, were addressed.
050707 - Medication changes and the importance of medication management were
050708 - reviewed with the patient/caregiver today based on individual needs.
050709 - Patient/caregiver acknowledged understanding of instructions as
050710 - stated. An updated list of reconciled medications has been provided
050711 - to the patient/caregiver.
050712 -
050713 - 17. /es/ Paul C. Simpson MD
050714 - Attending MD Cardiology, NPI 1548374093
050715 - Signed: 10/14/2015 12:31
050717 - ..
050718 - 18. Receipt Acknowledged By:
050719 - 10/15/2015 17:06 /es/ MADHU RAO
050720 - Staff Physician
050721 - 10/14/2015 12:54 /es/ JUDITH A WISNESKI, MD
050722 - Medicie/Cardiology attending (VA2010)
050723 -
050724 - 19. 10/14/2015 ADDENDUM STATUS: COMPLETED
050725 - ECG today is sinus at rate 64 w minor RVCD
050726 -
050727 - /es/ Paul C. Simpson MD
050728 - Attending MD Cardiology, NPI 1548374093
050729 - Signed: 10/14/2015 12:33
050730 -
050731 - 10/14/2015 ADDENDUM STATUS: COMPLETED
050732 - I agree with above. CTA is not a sensitive test to follow
050733 - coronary lesions. Patient is doing very well but with his
050734 - prior hx--indication for statin therapy is strong--- need to
050735 - find a statin and dose of statin that he can tolerate. Patient
050736 - has stopped me in hallway and I had similar discussion with him
050737 - that CTA is not recommended for this purpose.
050738 -
050739 - /es/ JUDITH A WISNESKI, MD
050740 - Medicie/Cardiology attending (VA2010)
050741 - Signed: 10/14/2015 12:54
050743 - ..
050744 - Receipt Acknowledged By:
050745 - 10/14/2015 15:59
050746 - /es/ Paul C. Simpson MD
050747 - Attending MD Cardiology, NPI 1548374093
050748 -
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050751 -
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