CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 69 0000. ref SDS 54 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040507 -
040508 -
040509 -
040510 -
040512 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Meeting this morning with Doctor Simpson was scheduled by Anna on
040902 - 190529 1002. ref SDS 89 7H53 Implements the doctor's letter 2 days
040903 - earlier on 190527 0857. ref SDS 88 4G6K
040905 - ..
040906 - Before meeting with Doctor Simpson, the nurse gave a flue shot in the
040907 - upper right arm, reported in VA progress notes shown below.
040908 - ref SDS 0 B53F
040910 - ..
040911 - Vitals after hiking 12 miles through Golden Gate park this morning
040912 - beginning at 0345 this morning...
040913 -
040914 - BP............. 130 74
040915 - HR............. 86
040916 - Weight......... 183 dressed
040917 - O2............. 98
040918 - Pain level..... 0
040919 -
040921 - ..
040922 - Agenda...
040923 -
040924 - 1. Ezetimibe need new prescription, because there are 0 refills.
040926 - ..
040927 - Doctor Simpson will order new prescription for Ezetimibe.
040929 - ..
040930 - He mentioned again his recommendation to increase Atorvastatin and
040931 - Ezetimibe.
040933 - ..
040934 - Doctor Simpson ordered refills for Atorvastatin and Ezetimibe.
040935 -
040937 - ..
040938 - 2. Hiking less this year than last year due to pain from rising
040939 - orthopedic and podiatry injuries to feet and knees from hiking.
040940 - This required 7 PRP treatments since the meeting with Doctor
040941 - Simpson last year on 181031.
040942 -
040943 - 191009 1500, ref SDS 93 0001
040944 - 190925 1330, ref SDS 92 0001
040945 - 190816 1100, ref SDS 91 0001
040946 - 190612 1130, ref SDS 90 0001
040947 - 190515 1400, ref SDS 87 0001
040948 - 190403 1000, ref SDS 86 0001
040949 - 181212 1600, ref SDS 80 V54H
040950 - 180824 1530, ref SDS 64 0001
040951 - 180620 1530, ref SDS 61 0001
040952 - 180105 1630. ref SDS 56 0001
040953 - 170816 1400, ref SDS 52 0001
040954 - 170726 1600, ref SDS 51 0001
040956 - ..
040957 - PRP injections were complemented by care for feet and knees in
040958 - VAMCSF Orthopedics by Doctor Thuillier, and further by
040959 - switching to Hoka Bondi 6 Wide shoes and inserts applying
040960 - biomechanics by Mark Wachter at On-the-Run. Strategic use of
040961 - Naproxen pain medication maintained hiking before PRP, and
040962 - after effects of PRP began to wear down again.
040964 - ..
040965 - Need replacement prescription, because Naproxen increases LDL
040966 - and blood pressure. It is an NSAID which reduces effects of
040967 - PRP injection treatments, and so has to be suspended for 1 week
040968 - prior to PRP, and for 6 weeks after PRP treatments.
040970 - ..
040971 - Also need replacement prescription for hydrocodone, because it
040972 - includes acetaminophen, which loweres HDL 30%.
040974 - ..
040975 - This combination of care decreased hiking from 3400 miles last
040976 - year, to over 2,500 miles this year, including Half Dome, see
040977 - spreadsheet...
040978 -
040979 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
040981 - ..
040982 - Decreased hiking occurred from increased PRP treatments, which
040983 - require pausing hiking for rehab.
040985 - ..
040986 - Weight declined from 190 to 183.
040988 - ..
040989 - Blood pressure and heart rate have been mostly steady.
040991 - ..
040992 - HDL declined from 83 to 52, due to reduced hiking and from
040993 - taking hydrocodone with acetaminophen, which reduces HDL 30%.
040995 - ..
040996 - Doctor Simpson said even at HDL 52, this is higher than any other
040997 - patient at this age.
041002 - ..
041003 - The doctor said he takes Gabapentin to supplement hydrocodone for pain
041004 - relief from recent hip replacement redo surgery he had in June.
041005 -
041006 - [On 191107 1338 received prescription for Gabapentin.
041007 - ref SDS 94 888O
041009 - ..
041010 - He ordered Gabapentin to try in my case.
041011 -
041012 - [On 190101 0730 case study reporting 20 mile hike on
041013 - 191205. ref SDS 82 753F
041015 - ..
041016 - After the meeting found Gabapentin is prescribed for shingles. Might
041017 - be helpful for burning sensation in bottom of feet, and for electrical
041018 - shocks in toes that both occur while hiking.
041019 -
041020 -
041021 -
041023 - ..
041024 - 3. Examination
041026 - ..
041027 - The doctor used a stethoscope to examine heart and breathing.
041029 - ..
041030 - He said heart and breathing are normal to excellent, expected for
041031 - hiking 300 miles per month.
041033 - ..
041034 - Doctor Simpson said he detected continuing 2nd sound heart function
041035 - that typically is found in young people. This seems to be a positive
041036 - finding for patient age 74.
041037 -
041038 - [...below on 191030 0830 Doctor Simpson's progress notes
041039 - report under examination: "-hrt M not heard today, nl
041040 - split s2" ref SDS 0 Y45J
041046 - ..
041047 - The doctor ordered follow up meeting in 1 year.
041048 -
041049 -
041050 -
041051 -
041052 -
041053 -
041054 -
0411 -
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 69 LC5J, ref SDS 54 ME9M.
050407 -
050408 - VA Progress Notes for meeting with health care providers are
050409 - available at...
050410 -
050411 - https://www.myhealth.va.gov/mhv-portal-web/anonymous.portal?_nfpb=true&_nfto=false&_pageLabel=mhvHome
050412 -
050424 -
050426 - ..
050427 - 1. Date/Time: 30 Oct 2019 @ 0928
050428 - Note Title: CARDIOLOGY CLINIC ATTENDING NOTE (MED)
050429 - Location: San Francisco CA VAMC
050430 - Signed By: SIMPSON,PAUL C
050431 - Co-signed By: SIMPSON,PAUL C
050432 - Date/Time Signed: 30 Oct 2019 @ 1447
050433 - -------------------------------------------------------------------------
050435 - ..
050436 - 2. LOCAL TITLE: CARDIOLOGY CLINIC ATTENDING NOTE (MED)
050437 - STANDARD TITLE: CARDIOLOGY ATTENDING NOTE
050438 - DATE OF NOTE: OCT 30, 2019@09:28 ENTRY DATE: OCT 30, 2019@09:28:32
050439 - AUTHOR: SIMPSON,PAUL C EXP COSIGNER:
050440 - URGENCY: STATUS: COMPLETED
050441 -
050446 - ..
050447 - 3. Most Recent VITAL SIGNS:
050448 - Height: 64 in [162.6 cm] (03/01/2019 09:28)
050449 - Weight: 183 lb [83.2 kg] (10/30/2019 08:26)
050450 - BMI: 31.4 (Obesity Level I)
050451 - Temp: 97.4 F [36.3 C] (03/01/2019 09:28)
050452 - Pulse: 63 (10/31/2018 09:28)
050453 - Comments:
050455 - ..
050456 - Resp: 18 (03/01/2019 09:28)
050457 - BP: 130/74 (10/30/2019 08:26)
050458 - O2 Sat: 10/30/19 08:26:03 O98
050460 - ..
050461 - 4. ID/CC:
050462 -
050463 - 74 swm from concord returns for routine f/u CAD sp CABG (2009)
050464 - and to monitor CRFs, esp lipids, since he does not want to take
050465 - high intensity statin.
050467 - ..
050468 - We did a repeat coronary CTA 11-8-18 which showed nicely open
050469 - LIMA and all SVGs. Ca++ score was high as expected about 1400
050470 - same as 2015. Dilated esophagus was c/w achalasia.
050472 - ..
050473 - Last clinic 10-31-18.
050475 - ..
050476 - PHONE (925)849-4745
050477 -
050479 - ..
050480 - 5. ASSESS:
050481 -
050482 - -he is still doing super well, able to hike 6 hours (3-6 hrs
050483 - daily, mostly 6)
050484 - (!!).
050486 - ..
050487 - -2 new things: HDL is not as high as hoped (52) despite the
050488 - extreme ex, and BP post-hike is higher (140s) than usual (90s).
050489 - I don't have a good explanation for either, possibly diet needs
050490 - to change as he gets older, perhaps less sweating w cooler
050491 - weather.
050493 - ..
050494 - -good news, his home BPs at rest are mostly 120s, and weight is
050495 - about 7 lbs down
050497 - ..
050498 - Should submit record on daily diet, exercise and vitals to the
050499 - doctor, so he can incorporate into Progress Notes.
050500 -
050502 - ..
050503 - Progress Notes 191030 Doctor Simpson continue...
050504 -
050505 - from last April.
050507 - ..
050508 - -my main concern is still LDL, and I would like to see it lower
050509 - as we discussed as usual (today 96).
050511 - ..
050512 - -as before PRP is helping knees and feet, but is an expense he
050513 - cannot continue to pay ($1200 to pvt doc in Novato). He is
050514 - hoping VA will cover, but Dr Kim in Ortho was not supportive.
050516 - ..
050517 - Doctor Simpson's comment "-as before..." refers to his examination
050518 - last year on 181031 1000. ref SDS 69 BM86
050520 - ..
050521 - Review with Doctor Tang on filing request with Office of Community
050522 - Care for payment of PRP treatment through Veterans Choice program,
050523 - continuing with Doctor Tucker.
050525 - ..
050526 - Review frequent urination causing dry feet and peeling, treated with
050527 - ammonium lactate 12% lotion, reported in case study on 190101 0730.
050528 - ref SDS 81 PVTP
050530 - ..
050531 - PRP treatment before hiking Half Dome on 190911, was performed by
050532 - Doctor Gloria Tucker at her clinic in Novato, CA on 190816 1100.
050533 - ref SDS 91 0001
050535 - ..
050536 - Progress Notes 191030 Doctor Simpson continue...
050537 -
050538 - 6. PLAN:
050539 -
050540 - -refill same meds as needed. Note he gets GI meds from No CA.
050541 -
050542 - -I will add a trial of gabapentin to add to his opioid, which
050543 - might potentiate the analgesia. Dosing handled by Dr Rettberg.
050544 -
050545 - -RV 1 year.
050546 -
050548 - ..
050549 - 7. CARD PROBLEMS:
050550 -
050551 - 1. CAD sp CABG here 10-22-09 (LIMA, SVG diag, ramus, PDA)
050552 - -for angina and severe 3VD
050553 - -last seen CT Surg 11-19-09
050554 - -last TTE here 7-15-16 wnl
050555 - -carotid US 9-20-16 sml plaque R bulb, no stenoses
050556 -
050557 - -cor CTA 10-19-15 all grafts open; reading "Coronary calcium score is
050558 - calculated to be 1360.
050559 -
050560 - No significant calcified plaque is seen in the bypass
050561 - grafts. All the bypass grafts are opacified with
050562 - contrast without evidence for filling defect or wall
050563 - calcifications.
050565 - ..
050566 - No calcification is seen in the aortic wall in the
050567 - visualized portions of the thoracic aorta. No ostial
050568 - calcifications at the origins of great vessels from
050569 - the aortic arch."
050571 - ..
050572 - 04/14/2017 ADDENDUM I re-reviewed his coronary CTA w
050573 - Radiology. They confirmed that his bypass grafts are
050574 - open, w/o significant stenoses. They confirmed that the
050575 - technique cannot rule out atherosclerosis, but can detect
050576 - significant stenoses of = or > 50% vessel diameter.
050577 -
050578 -
050579 - -cor CTA 11-8-18
050580 -
050581 - Calcium score: 1484 compared to 1360 from 10/29/2015
050583 - ..
050584 - Contrast filling left internal mammary artery bypass
050585 - extending to the LAD territory. Contrast filling of 2
050586 - bypass grafts from the anterior aorta to the left
050587 - circumflex territory, Contrast filling of bypass graft
050588 - from the right aortic wall to the territory of the
050589 - right coronary artery.
050591 - ..
050592 - Severe atherosclerotic calcification of native
050593 - coronary arteries.
050595 - ..
050596 - Lungs: Limited evaluation of a portion of the lungs is
050597 - clear.
050599 - ..
050600 - Mediastinum: Dilated esophagus consistent with
050601 - achalasia. No mediastinal lymphadenopathy.
050602 -
050603 -
050604 - 2. hyperlipidemia; LDL varies greatly w extent of statin rx
050605 -
050606 - 3. overwt/obesity (BMI ~30). but very fit. wt coming down
050607 -
050608 - 4. statin SEs: freq urination, dry feet, pain left arm; ok
050609 - on low dose
050611 - ..
050612 - 5. HTN, intermittent
050613 -
050614 - 6. no ASA rx due to achalasia
050615 -
050616 - 7. systolic m (likely flow, nl TTE 2016)
050617 -
050618 - 8. hyperbili, unconjugated, likely Gilberts, per GI/Liver
050619 - 8-2-18, neg abd US 9-
050620 - 27-18.
050621 -
050623 - ..
050624 - 8. OTHER:
050625 -
050626 - 1. achalasia sp ops, frequent egd/dilation
050627 - 2. LLE hematoma w cellulitis sp fall (adm here 9-23 to 9-25-15)
050628 - 3. fx R radius (same fall)
050629 - 4. may16 balance issues possiblky ear, resolved
050630 - 5. stroke-like event at EGD jun16; no recur, brain MRIs wnl,
050631 - possibly periop med-related, Neuro eval 4-11-19 cleared.
050632 - 6. R foot plantart plate tear
050633 - 7. MVA sep17
050634 - 8. LLE hematoma lower left leg resolved in Wound Care Dec 2017
050636 - ..
050637 - Might consider adding...
050638 -
050639 - 9. BPPV - dizziness resolved Audio & Bal continuing care
050640 - 10. Facial abrasions resolved ER
050641 - 11. Right trapezius injury treatment Ortho
050642 - 12. Left shoulder injury
050643 - 13. Right elblw injury
050645 - ..
050646 - Progress Notes 191030 Doctor Simpson continue...
050647 -
050648 - 9. SH: (Social History)
050649 -
050650 - lives concord
050651 - single has gf visits weekends
050652 - wife of many years died of breast ca a few yrs ago
050654 - ..
050655 - Gets up 3-6 am often to walk, on asphalt, bed early am, so not
050656 - much sleep.
050658 - ..
050659 - one meal a day in evening, but healthy (fish, avocados, vegs).
050660 -
050661 - militaray VN clerk
050662 - cigs 0
050663 - drugs
050664 - alcohol
050665 -
050667 - ..
050668 - 10. HPI
050669 -
050670 - super fit
050671 - -3-6 hrs hiking daily
050672 - no cv sxs.
050673 - knees and feet much better after PRP injections
050674 - using Hoka Bondi 6 shoes
050675 -
050677 - ..
050678 - 11. Active Medications:
050679 -
050680 - 1. AMMONIUM LACTATE 12% LOTION APPLY LOTION TOPICALLY
050681 - EVERY DAY AS DIRECTED TO FEET AFTER BATHING FOR DRY
050682 - SKIN
050683 - 2. ATORVASTATIN CALCIUM 20MG TAB TAKE ONE-HALF TABLET
050684 - ORALLY EVERY OTHER DAY FOR CHOLESTEROL **NOTE
050685 - DIRECTIONS**
050686 - 3. CALCIUM CARB 500MG (CA 200MG) CHEW TAB CHEW TWO
050687 - TABLETS ORALLY AT BEDTIME
050688 - 4. EZETIMIDE 10 QOD TAKE ONE TABLE ORALLY EVERY OTHER
050689 - DAY
050690 - 5. HYDROCODONE 5MG/ACETAMINOPHEN 325MG TAB TAKE 1 TABLET
050691 - ORALLY EVERY DAY AS NEEDED FOR PAIN. #28 FOR 28
050692 - DAYS.
050693 - 6. NUTRITION SUPL ENSURE PLUS/VANILLA LIQ TAKE 1
050694 - CONTAINER ORALLY TWICE A DAY
050695 - 7. PEG 400 0.4%/PROP GLYCOL 0.3% OPH SOLN INSTILL 1 DROP
050696 - IN BOTH EYES FOUR TIMES A DAY FOR DRY EYES
050697 - 8. UREA 20% CREAM APPLY CREAM TOPICALLY EVERY MONDAY AS
050698 - NEEDED AS DIRECTED FOR DRY SKIN
050700 - ..
050701 - PANTOPRAZOLE 40 pre-dinner (REMOTE)
050702 - FAMOTIDINE 40 BID (REMOTE)
050703 -
050705 - ..
050706 - Other medications taking...
050708 - ..
050709 - 9. NAPROXEN 250MG TAB TAKE ONE TABLET ORALLY EVERY DAY
050710 - AS NEEDED FOR PAIN
050711 -
050713 - ..
050714 - Progress Notes 191030 Doctor Simpson continue...
050715 -
050716 - 12. Computerized Problem List is the source for the following:
050717 -
050718 - 1. Benign unconjugated bilirubinaemia syndrome 10/31/2018
050719 - GI/Liver clinic 8-2-18
050720 - 2. Metatarsalgia 05/25/2016
050721 - 3. Fall on same level, Onset 00/00/2015 05/25/2016
050722 - 4. History of coronary artery bypass grafting, 10/14/2015
050723 - Onset 10/00/2009
050724 - SFVA LIMA, SVGs diag, ramus, PDA
050725 - 5. Hyperlipidemia 10/14/2015
050726 - 6. Body mass index 30+ - obesity 10/14/2015
050727 - 7. Chronic ischemic heart disease 10/14/2015
050728 - 8. Esophageal stricture (SNOMED CT 63305008) 05/04/2016
050730 - ..
050731 - Not clear why achalasia is not listed as a computer problem diagnosed
050732 - OA 2005 07 14 with barrium swallow test. ref SDS 1 Q86F
050734 - ..
050735 - Doctor Lee confimred in direct examination on 051209 1130. ref SDS 2
050736 - 0001
050738 - ..
050739 - Progress Notes 191030 Doctor Simpson continue...
050740 -
050741 - 13. EXAM
050742 -
050743 - -asx, good mood, looks very fit, in shorts as usual, band below left knee
050744 - -vs above OK HR higher than usual, wt down, BP OK.
050745 - -jvp nl, ajr neg
050746 - -car palp no B
050747 - -chest clear
050748 - -hrt M not heard today, nl split s2
050749 - -abd sl fat, no B, no tender
050750 - -ext tanned legs, warm, no edema, band below left knee
050752 - ..
050753 - This section of Progress Notes saying...
050754 -
050755 - -hrt M not heard today, nl split s2
050757 - ..
050758 - Aligns with understandings during meeting that the doctor detected a
050759 - heart diagnostic normal for young people, ref SDS 0 JS83, which shows
050760 - continued good conditioning following examination a year ago on 181031
050761 - 1000. ref SDS 69 JS83
050763 - ..
050764 - Progress Notes 191030 Doctor Simpson continue...
050765 -
050766 - 14. ECG sinus at 70, normal
050768 - ..
050769 - 15. LABS (recent):
050770 -
050771 - Report Released Date/Time: Oct 30, 2019@08:01
050772 - Provider: RETTBERG,LAUREN
050773 - Specimen: URINE. CH 1030 96
050774 - Specimen Collection Date: Oct 30, 2019@07:31
050775 - Test name Result units Ref. range Site Code
050776 - BARBITURATES NEG Ref: NEG [662]
050777 - Eval: Positive barbiturates drug screen results are not confirmed
050778 - Eval: and should not be used for non-medical(legal) purposes.
050779 - Eval: The detection limit for barbiturates is 200 ng/ml in urine.
050780 - AMPHETAMINES NEG Ref: NEG [662]
050781 - Eval: Positive amphetamines drug screen results are not confirmed
050782 - Eval: and should not be used for non-medical (legal) purposes.
050783 - Eval: The detection limit for amphetamines is 1000 ng/ml in urine.
050784 - COCAINE NEG
050785 - Ref: NEG [662]
050786 - Eval: Positive Cocaine&metabolite drug screen results are not confirmed
050787 - Eval: and should not be used for non-medical (legal) purposes.
050788 - Eval: The detection limit for cocaine&metabolite is 300 ng/ml in urine.
050789 - BENZODIAZEPINES NEG Ref: NEG [662]
050790 - Eval: Positive benzodiazepines drug screen results are not confirmed
050791 - Eval: and should not be used for non-medical (legal) purposes.
050792 - Eval: The detection limit for benzodiazepines is 200 ng/ml in urine.
050793 - CANNABINOIDS NEG Ref: NEG [662]
050794 - Eval: Positive cannabinoids drug screen results are not confirmed
050795 - Eval: and should not be used for non-medical (legal) purposes.
050796 - Eval: The detection limit for canabinoids is 50 ng/ml.
050797 - METHADONE NEG Ref: NEG [662]
050798 - Eval: Positive methadone drug screen results are not confirmed
050799 - Eval: and should not be used for non-medical (legal) purposes.
050800 - Eval: The detection limit for methadone is 300 ng/ml in urine.
050801 - OPIATES POS Ref: NEG [662]
050802 - Eval: Positive opiates drug screen results are not confirmed
050803 - Eval: and should not be used for non-medical (legal) purposes.
050804 - Eval: The detection limit for opiates is 300 ng/ml in urine.
050805 - OXYCODONE NEG Ref: NEG [662]
050806 - Eval: Positive Oxycodone drug screen results are not confirmed
050807 - Eval: and should not be used for non-medical (legal) purposes.
050808 - Eval: The detection limit for oxycodone is 300 ng/ml.
050809 - BUPRENORPHINE NEG Ref: NEG [662]
050810 - Eval: Positive Buprenorphine drug screen results are not confirmed
050811 - Eval: and should not be used for non-medical (legal) purposes.
050812 - Eval:
050813 - Eval: *Effective 9/1/12019, the detection limit for buprenorphine is
050814 - Eval: 5 ng/mL
050815 - Eval:
050816 - Eval: Effective 2/20/2014, the detection limit for buprenorphine is
050817 - Eval: 10 ng/ml.
050818 - ===============================================================================
050819 -
050821 - ..
050822 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050823 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050825 - ..
050826 - Report Released Date/Time: Oct 30, 2019@07:39
050827 - Provider: SIMPSON,PAUL C
050828 - Specimen: BLOOD. HE 1030 52
050829 - Specimen Collection Date: Oct 30, 2019@07:14
050830 - Test name Result units Ref. range Site Code
050831 - WBC 7.47 K/cmm 4.8 - 10.8 [662]
050832 - RBC 5.19 M/cmm 4.7 - 6.1 [662]
050833 - HEMOGLOBIN 14.6 g/dl 14 - 18 [662]
050834 - HEMATOCRIT 45.7 % 42 - 52 [662]
050835 - MCV 88.1 fL 80 - 100 [662]
050836 - MCH 28.1 pg 27 - 32 [662]
050837 - MCHC 31.9 L gm/dL 32 - 36 [662]
050838 - PLATELET COUNT 311 K/cmm 140 - 450 [662]
050839 - ===============================================================================
050841 - ..
050842 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050843 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050845 - ..
050846 - Report Released Date/Time: Oct 30, 2019@07:58
050847 - Provider: SIMPSON,PAUL C
050848 - Specimen: PLASMA. CH 1030 90
050849 - Specimen Collection Date: Oct 30, 2019@07:14
050850 - Test name Result units Ref. range Site Code
050851 - EGFR 74 mL/min Ref: >=60 [662]
050852 - SODIUM 142 mmol/L 135 - 145 [662]
050853 - POTASSIUM 4.5 mmol/L 3.3 - 4.8 [662]
050854 - CHLORIDE 107 mmol/L 101 - 112 [662]
050855 - CARBON DIOXIDE 27 mmol/L 24 - 32 [662]
050856 - ANION GAP 8 mmol/L 5 - 20 [662]
050857 - UREA NITROGEN 23 mg/dL 10 - 24 [662]
050858 - CREATININE 0.99 mg/dL 0.6 - 1.3 [662]
050859 - GLUCOSE 103 mg/dl 65 - 115 [662]
050860 - CALCIUM 9.2 mg/dL 8.5 - 10.5 [662]
050861 - ALBUMIN 4.3 gm/dL 3.3 - 5.2 [662]
050862 - PROTEIN, TOTAL 6.9 g/dL 6.0 - 8.5 [662]
050863 - ALKALINE PHOSPHATASE 110 U/L 40 - 125 [662]
050864 - SGOT 23 U/L 5 - 35 [662]
050865 - SGPT 18 U/L 7 - 56 [662]
050866 - BILIRUBIN, TOTAL 1.3 H mg/dL 0.1 - 1.2 [662]
050867 - BILIRUBIN, DIRECT 0.2 mg/dL 0.1 - 0.5 [662]
050868 - CHOLESTEROL 172 mg/dl 100 - 240 [662]
050869 - TRIGLYCERIDE 118 mg/dl 10 - 190 [662]
050870 - HIGH DENSITY LIPOPROT (HDL) 52 mg/dl Ref: >=35 [662]
050871 - Eval: HDL <35 is associated with increased risk of CAD.
050872 - LDL CHOL(Calculated) 96 mg/dl Ref: <=131 [662]
050873 - Eval: Desired LDL: <130 mg/dL; evaluate in light of CHD risk factors.
050874 - ===============================================================================
050876 - ..
050877 - Reporting Lab: SAN FRANCISCO VAMC [CLIA# 05D0988226]
050878 - 4150 CLEMENT STREET SAN FRANCISCO, CA 94121-1545
050880 - ..
050881 - Report Released Date/Time: Oct 30, 2019@07:59
050882 - Provider: RETTBERG,LAUREN
050883 - Specimen: PLASMA. CH 1030 89
050884 - Specimen Collection Date: Oct 30, 2019@07:14
050885 - Test name Result units Ref. range Site Code
050886 - MAGNESIUM 2.3 mg/dL 1.6 - 2.7 [662]
050887 - ===============================================================================
050888 -
050890 - ..
050891 - Time-based coding: total appointment time 60 minutes, more than 50% time spent
050892 - face-to-face counseling the patient on CORONARY ARTERY
050893 - DISEASE management of risk factors, including blood pressure, cholesterol,
050894 - smoking, weight, and activity, on medications, and on
050895 - psychosicial factors important to dealing with the medical issues.
050896 -
050898 - ..
050899 - 16. Clinical Reminder Activity
050900 - MED REC NON PRIMARY CARE:
050901 - MEDICATION RECONCILIATION:
050902 -
050903 - Current medications reviewed with patient/caregiver and reconciliation
050904 - of medications related to today's visit completed, including non-VA
050905 - medications and discrepancies, if identified, were addressed.
050906 - Medication changes and the importance of medication management were
050907 - reviewed with the patient/caregiver today based on individual needs.
050908 - Patient/caregiver acknowledged understanding of instructions as
050909 - stated.
050911 - ..
050912 - An updated list of reconciled medications has been provided to the
050913 - patient/caregiver.
050914 -
050915 - 17. /es/ Paul C. Simpson MD
050916 - Attending MD Cardiology, NPI 1548374093
050917 - Signed: 10/30/2019 14:47
050919 - ..
050920 - Receipt Acknowledged By:
050921 - 10/30/2019 15:29 /es/ LAUREN RETTBERG, MS, MPH, AGNP-BC
050922 - Medical Practice, NPI 1073996773
050923 -
050924 -
050925 -
0510 -
SUBJECTS
Default Null Subject Account for Blank Record
0603 -
060401 - ..
060402 - Flue Immunization Injection
060403 -
060404 - VA Progress Notes for meeting on 191030 are stored in...
060407 -
060408 -
060409 - 1. Date/Time: 30 Oct 2019 @ 0825
060410 - Note Title: IMMUNIZATIONS/SKIN TESTING NOTE
060411 - Location: San Francisco CA VAMC
060412 - Signed By: TONGSON,TERESITA C
060413 - Co-signed By: TONGSON,TERESITA C
060414 - Date/Time Signed: 30 Oct 2019 @ 0828
060416 - ..
060417 - 2. LOCAL TITLE: IMMUNIZATIONS/SKIN TESTING NOTE
060418 - STANDARD TITLE: IMMUNIZATION NOTE
060419 - DATE OF NOTE: OCT 30, 2019@08:25 ENTRY DATE: OCT 30, 2019@08:25:18
060420 - AUTHOR: TONGSON,TERESITA C EXP COSIGNER:
060421 - URGENCY: STATUS: COMPLETED
060423 - ..
060424 - 3. Seasonal Influenza Immunization
060425 - Patients 65 y.o. or older
060426 - The patient received influenza Adjuvanted flu vaccine (Fluad) 0.5 ml
060427 - IM today in
060428 - RIGHT Deltoid.
060429 - Manufacturer: Seqirus
060430 - Lot #: 260390
060431 - Medication Vial Expiration Date: 5/31/20
060432 - Indication: prophylaxis for seasonal influenza.
060433 - Complications: None. No signs or symptoms of adverse reaction
060434 - noted.
060436 - ..
060437 - Patient denies History of Guillain-BarreSyndrome.
060438 - Patient was given instructions about what to do in case
060439 - of reaction and was provided a copy of the Inactivated
060440 - Influenza Vaccine Immunization Statement, current
060441 - edition dated 8/7/2015
060443 - ..
060444 - Patient denies history of anaphylactic reaction to eggs.
060445 - CDC and ACIP recommendations regarding influenza
060446 - vaccination of persons who report allergy to eggs can be
060447 - found at: Influenza Vaccination
060448 -
060449 - /es/ Teresita C. Tongson, RN, MS
060450 - Charge Nurse, Module 1, Specialty Clinics
060451 - Signed: 10/30/2019 08:28
060452 -
060453 -
060454 -
060455 -
060456 -
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060459 -
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0605 -