CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 28 0000. ref SDS 26 0000.
040502 -
040503 -
040504 -
040505 -
040507 - ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 090908 meeting with Doctor Lee at VA Clinic Martinez reported chest
040902 - pains hiking up first hill at Lafayette Reservoir, and which persisted
040903 - for entire lap. ref SDS 2 MY4N Previously, pain only occurred for
040904 - short distance after 1st hill, then subsided for rest of lap, and any
040905 - additional laps. Chest pain recurred 3 days in a row. Requested
040906 - Doctor Lee order EGD dilation procedure to resolve achalasia
040907 - swallowing problem, expecting this to end chest pain caused by
040908 - esophagus pressing on lungs. ref SDS 2 BU63 Doctor Lee also ordered
040909 - EKG and stress tests to assess possible coronary artery disease (CAD).
040910 - ref SDS 2 BU6W
040912 - ..
040913 - On 091002 0900 Doctor Egan, Oncology Department reports stress test
040914 - shows failure on 10 of 11 probes tested, ref SDS 3 1W5I; diagnosis
040915 - triple vessel disease - orders angiogram test to evaluate heart
040916 - problems. ref SDS 3 V86G
040918 - ..
040919 - On 091021 0716 angiogram test (cardiac catheterization) discovers
040920 - blockages in multiple cornorary arteries, ref SDS 4 7L43, schedule
040921 - heart bypass surgery on 091222. ref SDS 4 WB3K
040923 - ..
040924 - On 091021 0716 at 1429 case study VA 10+ doctors ask for patient
040925 - history achalasai and discovery of cornorary artery disease (CAD),
040926 - beginning with chest pains reported today. ref SDS 4 LJ7L
040928 - ..
040929 - On 091022 0600 CABG Progress Notes report INDICATIONS FOR SURGERY:
040930 - Patient 64-year-old man recent onset of angina. Cardiac
040931 - catheterization found extremely tight LAD lesion with TIMI II flow.
040932 - He also had multiple other lesions and severe three-vessel disease.
040933 - Referred for urgent coronary artery bypass grafting. He has normal
040934 - ventricular function. ref SDS 11 C59K Locations of 4 byass grafts was
040935 - reported. ref SDS 11 HT9G
040937 - ..
040938 - On 091022 0600 CABG Progress Notes report finding "good quality" veins
040939 - that are "good targets" for heart bypass grafts - gives confidence
040940 - there is not general widespread circulatory disease, and that
040941 - replacement grafts can hold up for a long time with good post-op diet
040942 - and exercise. ref SDS 11 YI7K
040944 - ..
040945 - On 091029 0700 patient hiking 10 laps around Telemetry ward, 3 - 6
040946 - times per day, and at all hours, e.g., 2300, 0200, 0500, 1100, 1500,
040947 - and fitted between meals, meetings, calls, tests, and rest throughout
040948 - the day. Generally averaging 3 - 4 miles per day, ref SDS 6 01F9,
040949 - Hiking is prescribed therapy to strengthen the heart and circulatory
040950 - system to recover from cardiothoracic surgery on 091022. It helps
040951 - dissipate pain and illness feeling from surgery that occur throughout
040952 - the day, reducing reliance on medications. ref SDS 6 PS7H
040954 - ..
040955 - On 091030 1742 Ultrasound results reviewed show evidence of thrombus
040956 - of right IJ vein. ref SDS 11 JL73
040958 - ..
040959 - On 091104 0718 discharged from VA recovering from quadruple heart
040960 - bypass surgery, ref SDS 7 PR4V, performed on 091022 0700. ref SDS 5
040961 - PQWU; received medical record with list of medications, also on 091104
040962 - 0718, ref SDS 7 1Q6P, and follow up meetings. ref SDS 7 9T6O
040964 - ..
040965 - On 100104 0930 meeting Primary Care VA Martinez Clinic Doctor Sandhu
040966 - indicated patient demonstrates good recovery from heart surgery on
040967 - 091022, and Heller Myotomy surgery to recover from achalasia,
040968 - performed at VA in San Francisco on 091216. ref SDS 9 PP8W
040970 - ..
040971 - On 100104 0930 medications - continue Simvastatin 20 mg 1 pill per
040972 - day, post CABG prescription ordered by Doctor Sandhu, primary care
040973 - physician. ref SDS 9 3X4L
040975 - ..
040976 - On 100721 0800 visit Doctor Sandhu Martinez VA; patient demonstrates
040977 - continuing recovery from heart surgery last October, ref SDS 10 PP8W;
040978 - patient paused Simvastatin after completing initial prescription on
040979 - 091220. ref SDS 10 3X4L Lab on 100610 shows cholesterol HDL 35, and
040980 - LDL 209 increased from 164. ref SDS 10 HY76 Doctor increased dose of
040981 - Simvestatin 40 mg. ref SDS 10 RP4F New lab ordered today shows
040982 - cholesterol reversed long-term decline and increased dramatically in
040983 - just 30 days, suggesting possibly error in lab testing process.
040984 - ref SDS 10 E19L
040986 - ..
040987 - On 101207 0906 lab shows cholesterol LDL 96 fell 40% from 209, and HDL
040988 - 47 increased 30% from 35, after Doctor Sandhu doubled Simvastatin 40
040989 - mg per day; resulting in reduced risk of coronary artery disease (CAD)
040990 - and heart attack. ref SDS 12 E19L
040992 - ..
040993 - On 110406 1230 follow up treadmill stress test performed; initial
040994 - indications are 100% performance, with one node showing possible
040995 - slight irregularity. ref SDS 13 OF8F
040997 - ..
040998 - On 110415 0900 patient reports to Doctor Egan in Cardiology VA Clinic
040999 - Martinez hiking increased, now includes doing 11 miles twice per week.
041000 - ref SDS 14 527F
041002 - ..
041003 - On 130603 0930 Doctor Egan in Cardiology at VA Clinic Martinez
041004 - presents research in Emedicine Health showing Atorvastatin side
041005 - effects include increased thirst, increased urination, hunger, dry
041006 - mouth, fruity breath odor, drowsiness, dry skin, blurred vision.
041007 - ref SDS 15 BV4I
041009 - ..
041010 - On 131125 0005 research indicates Atorvastatin 10 Ezetimibe 10
041011 - Increase HDL 5% TG 30% Lower LDL-C 50%. ref SDS 16 PU6I
041013 - ..
041014 - On 131125 0005 research in Drugs.Com indicates Ezetimibe less common
041015 - side effects include Dizziness, Dryness or soreness of throat,
041016 - Hoarseness, which have all occurred and may compound side effects of
041017 - Atorvastatin. ref SDS 16 JO6K
041019 - ..
041020 - On 131125 0005 research yielded public reporting Tim Russert, popular
041021 - television news commentator died from heart attack despite achieving
041022 - reduction of cholesterol LDL 68, below the "gold standard" for
041023 - coronary health; yet, his HDL 37 remained very low, and he continued
041024 - overweight (metabolic syndrome). ref SDS 16 RK6O
041026 - ..
041027 - On 131125 0005 research yielded public reporting coronary CT
041028 - angiography test measures calcium present in the arteries. Tim
041029 - Russert had the scan done in 1998 with a score of 210. It should be
041030 - 0. ref SDS 16 N73K Coronary computed tomography angiography (CTA)
041031 - allows coronary artery visualization and the detection of coronary
041032 - stenoses. In addition; it has been suggested as a novel, noninvasive
041033 - modality for coronary atherosclerotic plaque detection,
041034 - characterization, and quantification. ref SDS 16 VW3W
041036 - ..
041037 - On 131125 0005 research yielded public reporting HDL > 60 are
041038 - associated with a reduced risk of coronary artery disease (CAD). HDL
041039 - "scour" the walls of blood vessels cleaning out excess cholesterol
041040 - that otherwise might have been used to make the plaques that cause
041041 - CAD. ref SDS 16 4E6H
041043 - ..
041044 - On 131125 0005 research yielded public reporting clinical trials found
041045 - that increasing HDL with drugs does not yield benefits of regressing
041046 - atherosclerotic plaques. ref SDS 16 KG9F
041048 - ..
041049 - On 131125 0005 research yielded public reporting that aerobic exercise
041050 - (any exercise, such as walking, jogging or bike riding, that raises
041051 - your heart rate for 20 to 30 minutes at a time) may be the most
041052 - effective way to increase HDL levels in a way that does appear to
041053 - lower risk of heart disease. Evidence suggests the duration of
041054 - exercise, rather than the intensity, is the more important factor in
041055 - raising HDL choleserol. ref SDS 16 SH4J
041057 - ..
041058 - On 140213 0830 meeting at VA consider performing coronary CT
041059 - angiography (CCTA) test to evaluate regression of atherosclerosis
041060 - lesions based on labs showing elevated LDL-C, but also high HDL and
041061 - low triglycerides (TG), which could signal discordance, i.e., low
041062 - LDL-P, ref SDS 18 JZ4O, which is the healthiest condition for CVD
041063 - patients, shown by research on 131125 0005. ref SDS 16 FI3G
041064 -
041065 -
041066 -
041068 - ..
0411 -
0412 -
0413 - Progress
0414 -
041401 - Doctor Simpson called during hike this afternoon, reported in the
041402 - record on 140101 0600. ref SDS 17 KG5O Was on Clayton Road near
041403 - McDonald's, across from Food-4-less.
041405 - ..
041406 - The doctor has received the report on CCTA test on 151019 0930.
041407 - ref SDS 27 NV5I He advised that the report on the test prepared by an
041408 - analyst in the Radiology Department failed to perform calcium score,
041409 - which he ordered for CCTA on 151014 0900. ref SDS 26 OG3N
041411 - ..
041412 - Explained meeting with Colin, in which he ordered calcium score.
041413 - 151019 0930, ref SDS 27 RF9U
041415 - ..
041416 - Doctor Simpson seemed to say the radiologist findings for the CCTA
041417 - test on 151019, are vague, merely reporting bypass grafts are patent.
041418 - He feels this is not helpful without reporting what, if any, plaque
041419 - build up might have occurred in the active circulatory system around
041420 - the heart.
041422 - ..
041423 - Suggested that Doctor Simpson review the scan himself to prepare for
041424 - the meeting next Wednesday on 1000, so we can coorelate CCTA test
041425 - results for response to treatment attempting to regress
041426 - atherosclerosis.
041427 -
041428 -
041430 - ..
0415 -
0416 -
0417 - 1221
0418 -
041801 - After the call with Doctor Simpson, tried to call him back. This did
041802 - not work, because need extension, and it is not entered nor captured
041803 - by cell phone technology.
041805 - ..
041806 - Therefore, called and left message for Doctor Rao in Primary Care
041807 - requesting she call Doctor Simpson and convey request to order lab.
041808 -
041809 -
041810 -
041812 - ..
0419 -
0420 -
0421 - 1716
0422 -
042201 - On returning home from hike, there was message from Doctor Simpson,
042202 - saying he ordered a lab, as requested earlier today, per above.
042203 - ref SDS 0 RM8G
042204 -
042205 -
042207 - ..
0423 -
0424 -
0425 - 2302
0426 -
042601 - Sent letter to Doctor Simpson confirming undrestandings and
042602 - submitting agenda for meeting on 151028 1000, saying...
042603 -
042604 - 1. Subject: CCTA Calcium Score and Labs
042605 - Date: 2015-10-21 23:28
042612 - ..
042613 - 2. Thanks for calling today, notifying generally favorable results
042614 - of CCTA this past Monday. Calcium score issue was considered
042615 - at length meeting with a doctor prior to the test on 151019
042616 - (see line 041425. ref SDS 27 948H
042618 - ..
042619 - This letter follows up prior copy of letter to Doctor Rao, with copy
042620 - to Doctor Simpson on 150730 0952. ref SDS 19 PPVY
042622 - ..
042623 - Letter to Doctor Simpson continues...
042624 -
042625 - 3. When we meet next Wednesday on 151028 at 1000, there may be
042626 - better understanding if any plaques can be discerned from the
042627 - scan, other than in bypassed blood vessels, mentioned in your
042628 - call today. In that case, it would appear that all prior
042629 - plaques have regressed, yielding calcium score 0, as expected
042630 - with elevated HDL > 60 the past year from hiking 300 miles per
042631 - month.
042633 - ..
042634 - 4. Thanks for ordering a lab to correlate with the CT scan on
042635 - 151019. These criteria provide a baseline for treatment
042636 - protocols combining extended endurance exercise with drugs that
042637 - hopefully maintain favorable low CVD risk, shown by CCTA, and
042638 - with minimum side effects, as discussed with Doctor Wisneski on
042639 - 151005 (see line 041002. ref SDS 25 GL7G
042640 -
042641 - http://www.welchco.com/sd/08/00101/02/15/10/05/110244.HTM#GL7G
042643 - ..
042644 - 5. Will probably do blood draw OA 0800 on 151028, so results are
042645 - available when we meet at 1000. This provides a little more
042646 - time for HDL to rise with current hiking protocol at 15 miles
042647 - per day. Just curious what it takes to move the numbers.
042649 - ..
042650 - 6. Below is the letter we discussed during the meeting in your
042651 - office on 151014. It cites spreadsheet correlating labs with
042652 - extended endurance exercise. The spreadsheet is again
042653 - attached, if you have time to take a look.
042655 - ..
042656 - 7. Thanks very much for excellent support.
042657 -
042666 -
042667 - 10. ***********************
042669 - ..
042670 - 11. Date: 2015-07-30 10:05
042671 - Subject: Meeting Today Cardiology Follow Up
042673 - ..
042674 - 12. Rod Welch wrote:
042675 -
042676 - Doctor Rao,
042678 - ..
042679 - Concur Cardiology should have a role in CCTA considerations.
042681 - ..
042682 - After meeting in Medical Practice this morning, stopped by
042683 - Cardiology on the 2nd floor across the street. Karen was out of
042684 - the office today. Her colleague clarified the name discussed a
042685 - few months ago...
042687 - ..
042688 - Paul Simpson, MD... paulsimpson@va.gov
042690 - ..
042691 - He might take an interest in research/study to manage CVD risk
042692 - through treatment with extended endurance exercise, measured with
042693 - labs and CCTA that assess response to treatment, based on the
042694 - spreadsheet submitted in the letter on 150728, and attached again
042695 - today.
042697 - ..
042698 - Raising HDL 130% while lowering TG and LDL-P may suggest
042699 - potential for care that extends quality of life for, not all, but
042700 - for many patients and with minimal cost. The VA has sponsored
042701 - prior research in this area, but not perhaps with
042702 - current results.
042704 - ..
042705 - I also visited with Graciela, Doctor Stewart's PA. She plans to
042706 - speak with Doctor Stewart again to clarify Progress Notes for the
042707 - meeting on 150623, which we reviewed during the meeting
042708 - yesterday. The letter on 150721, to Doctor Stewart through
042709 - Asagani, requested an addendum stating...
042710 -
042711 - "Coronary CTA will assess patient tolerance for continuing PPI
042712 - treatment to prevent acid washing back into the esophagus,
042713 - supplementing Dor fundoplication that avoids ulceration of
042714 - LESV, which began occurring in this case reported in Doctor
042715 - Lee's Progress Notes for EGD dilatations on 140509, again on
042716 - 141107, and most recently on 150421. CCTA to assess tolerance
042717 - for PPI is indicated by recent massive study published just 3
042718 - weeks ago on 150610, correlating PPI with increased risk of
042719 - myocardial infarction, and cites damage to endothelial lining
042720 - of blood vessels. If CCTA shows this patient is not at risk,
042721 - then PPI can continue to provide improved swallowing."
042723 - ..
042724 - Here is the report you requested published on 150610, correlating
042725 - PPI with 16% - 21% increase risk of myocardial infarction, as
042726 - shown in the record the next day on 150611...
042727 -
042728 - http://www.welchco.com/sd/08/00101/02/15/06/11/071336.HTM#ZB96
042730 - ..
042731 - Hopefully, CCTA will show elevated HDL and EPCs have resolved any
042732 - injuries from PPI to provide tolerance for increasing Omperazole
042733 - to prevent and resolve ulceration of LESV and hiatal hernia,
042734 - rather than resort to further surgical consideration, which
042735 - Doctor Stewart feels are not a good solution.
042737 - ..
042738 - Please let me know about ordering radiology study on my knees.
042739 - Generally, Glucosamine Chondroitin has enabled daily hiking and
042740 - running. Would be helpful to know if there is torn cartilage in
042741 - the right knee now, and whether the left knee has actually
042742 - improved with treatment.
042744 - ..
042745 - Not sure what to do about the blisters you examined yesterday.
042746 - Simply resting causes HDL to fall and LDL-P to rise, as shown in
042747 - the spreadsheet. Resting further lowers conditioning for Half
042748 - Dome. It's a dilemma - will follow up with Doctor Tang. This
042749 - morning received 6 new pair of Hoka Stinson Lite shoes. They are
042750 - oversized in length (went from 10 to 10.5) to get better width at
042751 - the toe line. Hopefully this relieves pressure and provides
042752 - better footing to prevent feet from sliding sideways, thus
042753 - preventing blisters. By copy notify Doctor Tang of this issue,
042754 - as he requested during lunch on 150728.
042756 - ..
042757 - Thanks for a great meeting. Very fortunate getting you for
042758 - primary care.
042759 -
042764 -
042766 - ..
042767 - 13. Attachments:
042768 - hiking_miles_3.xlsx 170 KB
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