CONTACTS
SUBJECTS
Treadmill Heart Stress Test Schedule 200103 0700 Chest Pain Elevated
2403 -
2403 - ..
2404 - Summary/Objective
2405 -
240501 - Follow up ref SDS F3 0000. ref SDS F1 0000.
240502 -
240503 -
240504 -
240505 -
240507 - ..
2406 -
2407 -
2408 - Background
2409 -
240901 - On 191206 1425 letter to VAMCSF Cardiology Doctor Simpson, ref SDS A7
240902 - NE9N, notify possible afib symptoms. ref SDS A7 N874
240904 - ..
240905 - On 191207 0927 Doctor Simpson to order ECG [...electrocariogram...]
240906 - Zio test for AFib, after he returns to work following several weeks
240907 - out of the office. ref SDS A8 NE9N
240909 - ..
240910 - On 191213 0849 call from Tina - scheduled install Zio equipment for
240911 - heart monitoring test; meeting room 2A16 on 191216 1230. ref SDS A9
240912 - NE9N
240914 - ..
240915 - On 191216 1220 Exmeralda in Cardiology at VAMCSF installed Zio XT
240916 - heart monitor on left chest; she added 2 plastic tapes to secure the
240917 - unit against fall off in shower and perspiration during hiking.
240918 - ref SDS B3 AO7H
240920 - ..
240921 - On 191214 1138 letter to Doctor Simpson in Cardiology at VAMCSF,
240922 - ref SDS B1 NE9N, reports 8 weeks ago increased hiking route with steep
240923 - hills from 11 to 15 miles per day. ref SDS B1 MX58 About a week ago
240924 - increased hiking to 20+ miles per day in order to improve weight
240925 - control and to raise lipids toward HDL 80. ref SDS B1 MX61 Weight
240926 - increased after pausing hiking due to orthopedic pain left knee and
240927 - both feet, which was solved after receiving oxycodone and gabapentin,
240928 - and applying elastic bandage to left knee. ref SDS B1 MX64 Today,
240929 - before hiking felt chest swaying indicating afib. ref SDS B1 MY30
240930 - Research indicates walking can aid recovery from afib; during hike
240931 - today, will reduce level of effort back to 15 miles per day, and avoid
240932 - steeper hills. ref SDS B1 368M Ask about medication to treat afib.
240933 - ref SDS B1 MY38 Offer to walk with Doctor Simpson to assist recovery
240934 - from hip surgery. ref SDS B1 MY41
240936 - ..
240937 - On 191214 1138 at 1324 letter from Doctor Simpson in Cardiology at
240938 - VAMCSF says to do hiking that has led to symptoms. ref SDS B2 0K4L
240940 - ..
240941 - On 191228 1416 letter to Doctor Simpson notify Zio log reports chest
240942 - pain hiking with elastic bandage on left knee. ref SDS B4 NE9N 1st
240943 - episode hiking 12 miles through Golden Gate Park on 191220, chest pain
240944 - mild lasted on ly .25 miles. Occurred again next day hiking 20 miles
240945 - up Crystal Ranch Road. ref SDS B4 B652 Occurred next day on 191222, so
240946 - stopped at mile .75 and removed elastic bandage from left leg, pain
240947 - ended for rest of 20 mile hike and on subsequent hikes 20 mile past 6
240948 - days. ref SDS B4 B655 Today on 191228, chest pain occurred hiking up
240949 - mild hills without elastic bandage on left leg, so ended hike at 7
240950 - miles. ref SDS B4 B658 HR 150 - should be 45 - 55. ref SDS B4 B662
240951 - Seems like bypass saphenous graft failed under elevated load wearing
240952 - elastic bandage on left knee. ref SDS B4 B665 Pause hiking until hear
240953 - from the doctor. ref SDS B4 B668
240955 - ..
240956 - On 191228 1416 at 1534 letter from Doctor Simpson notifies he will
240957 - order treadmill stress test. ref SDS B4 RK6L
240959 - ..
240960 - On 191228 1416 at 1537 letter to Doctor Simpson notifies will submit
240961 - Zio XT device with afib data on Monday, 191230. ref SDS B4 WO6F
240963 - ..
240964 - On 191229 1243 received letter from Doctor Simpson notifies need to
240965 - get ECG test at VAMCSF before they can schedule treadmill stress test.
240966 - ref SDS B5 NE9N Further says to get care in the ER if chest pain
240967 - recurs at rest. ref SDS B5 NH77
240969 - ..
240970 - On 191229 1243 at 1256 letter to Doctor Simpson asks where and when to
240971 - get ECG test. ref SDS B5 YH8N Notifies so far chest pain has not
240972 - occurred at rest; has only occurred when hiking. ref SDS B5 YA48
240973 - Notifies of EGD procedure in GI Clinic at VAMC Sacramento on 200107,
240974 - and getting MRI studies on feet and knees at VAMCSF on 200109.
240975 - ref SDS B5 YA51
240977 - ..
240978 - On 191229 1243 at 1420 received letter from Doctor Simpson advising
240979 - ECG is done on 2nd floor building 203, and to arrive about 1000.
240980 - ref SDS B5 LG4J Recommends notifying GI Clinic to delay EGD until
240981 - after resolution of current Cardiology issue. ref SDS B5 6H6G
240983 - ..
240984 - On 191229 1243 at 1538 received letter from Doctor Simpson advising
240985 - ECG was done in this case at the end of Oct, so do not need a new one;
240986 - next step is for VA to schedule stress test. ref SDS B5 E17N
240988 - ..
240989 - On 191229 1243 at 1619 sent letter to Jessica on notifying Doctor Lee
240990 - to delay next EGD scheduled on 200107 0730 for a month until 200204
240991 - 0730. ref SDS B5 4R7J
240993 - ..
240994 - On 191229 1243 at 1700 letter thanks Doctor Simpson for advising ECG
240995 - not needed. ref SDS B5 M48J
240997 - ..
240998 - On 191229 1243 at 1946 letter notifies Doctor Simpson that feet
240999 - elevated on footrest seem swelled. Cellphone reports HR 38. That is
241000 - low for me. Don't feel dizzy or light headed; seems like afib event,
241001 - with chest swaying back and forth. ref SDS B5 MH6N
241003 - ..
241004 - On 191229 1243 at 1946 letter notifies Doctor Simpson Zio device was
241005 - mailed to company a day early on 191229. ref SDS B5 UA47
241007 - ..
241008 - On 191230 0930 received call from Tina in Cardiology at VAMCSF
241009 - scheduled treadmill stress test on 200103, ref SDS B6 NE9N, report
241010 - first at 0700 to ASU on 3rd floor Building 200 for IV, then go to
241011 - Neuclear Medicine on ground floor building 203. ref SDS B6 GE5K
241013 - ..
241014 - On 191230 0930 at 0938 received letter from Doctor Simpson in
241015 - Cardiology explaining symptoms reported last night are okay, since not
241016 - dizzy, until after stress test. ref SDS B6 GF3G
241018 - ..
241019 - On 191230 0930 at 0949 received letter Tina in Cardiology confirming
241020 - schedule for stress test on 200103 0700, and submitting instructions
241021 - to prepare for the test. ref SDS B6 Q76I
241023 - ..
241024 - On 191230 0930 at 1021 letter to Doctor Simpson in Cardiology at
241025 - VAMCSF reporting stress test has been scheduled on 200301 0700.
241026 - ref SDS B6 9W6F Reported mild chest pain at rest for 10 minutes, but
241027 - it resolved while writing the letter. ref SDS B6 JY39
241029 - ..
241030 - On 191230 0930 at 1114 received letter from Lauren, NP and PCP in this
241031 - case; she concurs patient should go to ER if chest pain persists at
241032 - rest, and should have a driver. ref SDS B6 2S4N
241034 - ..
241035 - On 191230 0930 at 1117 received call from Aladin who is Lauren's
241036 - assistent in Medical Practice; he indicated Lauren asked him to call
241037 - and get background on chest pain issue. ref SDS B6 578G Explained
241038 - background is reported in correspondence with Doctor Simpson in
241039 - Cardiology, and this has been copied to Lauren. ref SDS B6 5W6J
241041 - ..
241042 - On 191230 0930 at 1135 responded to Lauren citing call from her
241043 - assistent, Aladin, and reporting background on current issue is
241044 - reported in correspondence with Doctor Simpson in Cardiology, who is
241045 - directing the work, and that Lauren has been copied on all
241046 - correspondence. ref SDS B6 659K
241048 - ..
241049 - On 200227 0800 Lauren called. She will order Tramadol. ref SDS C9
241050 - NE9N Lauren will also order diclofenac topical medication to try
241051 - before ordering naproxen. ref SDS C9 016I She will call back in 2
241052 - weeks to evaluate results trying diclofenac. ref SDS C9 626M
241054 - ..
241055 - On 200312 082309 Lauren called. She does not want to take
241056 - responsibility for ordering naproxen, because it impacts apixaban that
241057 - is a blood thinner to prevent strokes that could occur, while in
241058 - atrial fibrillation. ref SDS D6 955O
241060 - ..
241061 - On 200611 0730 Lauren called with VAMCSF Medical Practice following up
241062 - prior patient review on 200312 0823. ref SDS C8 NE9N During call
241063 - today, explained pausing metoprolol, apixaban and clopidogrel due to
241064 - adverse side effects, reported this morning in case study on 200101
241065 - 0702. ref SDS C9 PQRQ Severe stomach pain occurring in the moment.
241066 - Dizziness, wobbly, staggering during hikes, fainting while working.
241067 - ref SDS E1 NE9N Lauren ordered examination in Urgent Care at VAMCSF.
241068 - ref SDS E1 H64G She wants EKG and labs to support the examination.
241069 - This was scheduled for today at 1400. ref SDS E1 H66H
241070 -
241071 -
241072 -
241073 -
241074 -
241076 - ..
2411 -
2412 -
2413 - Progress
2414 -
241401 - Doctor Simpson called in response to the letter yesterday afternoon,
241402 - reporting low blood pressure (hypotension) after the hike yesterday,
241403 - 200723 1820, ref SDS F4 NE9N, and submitting the record in the case
241404 - study on 200101 0702. ref SDS B9 4T4I
241406 - ..
241407 - [On 200727 0859 submitted this record to Doctor Simpson,
241408 - and requested additions or corrections, ref SDS F6 GT72;
241409 - further requested new prescription for metorpolol succinct,
241410 - because this morning not listed on VA Pharmacy. ref SDS F6
241411 - GT80
241413 - ..
241414 - He seemed to say people feel "light headed", when blood pressure falls
241415 - too low. In some cases people pass out (faint).
241417 - ..
241418 - Asked about a signal to get help before passing out. Generally feel
241419 - light headed after hikes, but BP is > 70 50. Today, had 63 47, so
241420 - just wondered if some remedy should be initated?
241422 - ..
241423 - The doctor explained going to the ER will primarily hydrate with
241424 - saline. Can be done at home with water and juices.
241426 - ..
241427 - Explained always hydrate after hikes with very large amount of juice
241428 - combining small amount of lemon juice, primarily orange juice, and
241429 - small amount of grape juice.
241431 - ..
241432 - Asked about falling heart rate (HR)? The past few weeks HR is often
241433 - below 60, shown in case study on 200101 0701, ref SDS B8 KQ5H; and,
241434 - has fallen below 40 a few times, e.g., HR 39 on 200719. ref SDS B9
241435 - YYWR
241437 - ..
241438 - Doctor Simpson suggested taking metoprolol succinct at night after
241439 - dinner rather than in the morning. If HR is below 60, skip taking
241440 - metoprolol in the evening.
241442 - ..
241443 - This change may improve blurred vision problem that occurs after
241444 - taking metoprolol in the mornings. Becomes difficult to see the
241445 - computer screen, i.e., distinguish characters. When I first log on in
241446 - the morning, can see perfectly. But an hour or so after taking
241447 - metoprolol, charactrs become blurry. Taking metoprolol at night may
241448 - result in blurred vision that aids sleep, and will reduce disruption
241449 - of work.
241451 - ..
241452 - Explained feeling "trapped" with colitis that places a very low limit
241453 - on hiking below vasodilaition that seems to be starting somewhere
241454 - between mile 2 - 7. At that point hiking is just getting started.
241455 - Benefits occur at mile 10+.
241457 - ..
241458 - The doctor cited need to consider reducing reliance on hiking mileage
241459 - for cardiovascular health, as medical maladies increase with age,
241460 - i.e., sarcopenia.
241462 - ..
241463 - Doctor Simpson said he has had to do that now at age 78, noting being
241464 - 3 years older than me. The doctor feels strongly that hiking even 11
241465 - miles per day, the minimum amount I do, is much greater than anybody
241466 - else does, especially people over 70. He expects in the next 5 years,
241467 - mounting medical problems may force cutting back on mileage.
241469 - ..
241470 - Asked the doctor how rehab is going from hip replqcement "redo"
241471 - surgery he underwent last year on June 10, reported in his letter
241472 - received on 190611 1302. ref SDS 95 I46I
241474 - ..
241475 - Doctor Simpson indicated having recovered further, and so is doing
241476 - better than when we met 6 months ago in the hospital after
241477 - catherization in my case to place a stent on 200128 0730. ref SDS C5
241478 - 06GC Very good news.
241480 - ..
241481 - Doctor Simpson explained using walking poles for hiking. He
241482 - recommends this for building arm and shoulder strength, and it reduces
241483 - pressure on feet and knees, in addition to aiding balance in difficult
241484 - terrain.
241486 - ..
241487 - Doctor Simpson feels reducing mileage that would reduce HDL, might be
241488 - offset with increased statins to prevent buildup of LDL plaque in
241489 - blood vessels. Adverse side effects, e.g., peripheral neuropathy,
241490 - taking higher dose statins in this case is reported in patient history
241491 - on 200101 0701. ref SDS B8 PXSS
241493 - ..
241494 - The doctor cited catheterization angiogram found 2 blocked collateral
241495 - branch blood vessels into the heart, which he previously discussed on
241496 - 200128 0730. ref SDS C5 AH42 He seemed to feel such blocked vessels
241497 - signal plaque buildup throughout the vascular system. Angiogram
241498 - reported 1 blocked branch into the heart, and further reported 0%
241499 - stenosis in the arteries examined on 200124 0705. ref SDS C4 5G59
241500 - Progress notes for placing a stent to open a 95% blocked branch vessel
241501 - report this did not increase blood flow into the heart, shown in the
241502 - record on 200128 0730, ref SDS C5 QR4M On 180927 1000 ultrasound
241503 - examination of stomach - attendant said there were no indications of
241504 - blockages in the blood vessels. ref SDS 73 656L Progress notes
241505 - report, ref SDS 73 PJ96...
241507 - ..
241508 - Portal vein: Patent, antegrade and normal in size.
241509 - Hepatic veins: Patent, antegrade
241510 - Visualized Inferior Vena Cava: Patent, antegrade,
241512 - ..
241513 - This seems consistent with HL 83, reported on 181112 1720. ref SDS 81
241514 - U45J CCTA test on 181108 0930 found native arteries blocked with
241515 - increased plaque, and bypass grafts were open without evident
241516 - blockages, ref SDS 80 GH4U, similar to 3 years earlier when prior CCTA
241517 - found on 151019 0930. ref SDS 24 SU62...
241518 -
241519 - No significant calcified plaque is seen in the bypass grafts. All
241520 - the bypass grafts are opacified with contrast without evidence
241521 - for filling defect or wall calcifications.
241523 - ..
241524 - No calcification is seen in the aortic wall in the visualized
241525 - portions of the thoracic aorta. No ostial calcifications at the
241526 - origins of great vessels from the aortic arch.
241528 - ..
241529 - MRI on brain made similar findings on 160618 1348. ref SDS 33 HQ5G...
241530 -
241531 - No hemodynamically significant stenosis.
241533 - ..
241534 - IVUS angiogram findings of stenosis 0% on 200124, suggest similarly
241535 - for other blood vessels, since the same HDL blood flows throughout the
241536 - body. Hiking has declined this year due to injuries and disease.
241537 - Notably atrial fibrillation diagnosed on 200103, caused complete pause
241538 - of hiking in January. HDL dropped below 50. Since February HDL has
241539 - been 60 + or -, so there may be some plaque build up. Ablation
241540 - procedures ending on 200511, further curtained hiking, and on 200611,
241541 - stomach pain diagnosed as colitis on 200612, reduced hiking again,
241542 - with the result that HDL may have dipped below 50 again. Now colitis
241543 - symptoms seem to be subsiding. Current efforts are to increase hiking
241544 - to raise HDL > 60, as for the past 6 years.
241546 - ..
241547 - Impending age limitations on physical and neurological function arise
241548 - with exhaustion of telomeres, reported on 160424 1144. ref SDS 30 EU3O
241549 - Some authorities indicate hiking may restore telomeres, reviewed on
241550 - 180111 1143. ref SDS 64 MN6N
241552 - ..
241553 - We have previously considered hiking at theraputic levels that
241554 - elevates HDL and EPCs regresses plaque in blood vessels, shown in
241555 - patient history at...
241556 -
241557 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
241559 - ..
241560 - Eliminating plaque in blood vessels, found in this case by Doctor
241561 - Tietjens during IVUS angiogram on 200124 0705, ref SDS C4 ME8G,
241562 - enables high blood flow that optimizes cell regeneration, and thus
241563 - repairs age deficits, e.g., vision, swallowing, back/hip pain, further
241564 - improves strength, vitality, cognition, digestion, immunity, etc.,
241565 - that otherwise decline with advancing age through sarcopenia.
241567 - ..
241568 - Extended endurance exercise hiking long distances is fun, emotionally
241569 - satisfying, and enables periods of extended meditation (focus) for
241570 - solving complex problems with increased blood flow to the brain.
241572 - ..
241573 - Hiking for 3 - 5 hours enables weight control. When hiking there is
241574 - no "grazing" on food that increases weight. Instead there is weight
241575 - loss of 3 - 8 pounds through sweating. This level of effort reduces
241576 - interest in eating after hikes, further aiding weight control.
241578 - ..
241579 - The Welch case has shown these medical benefits can be maintained
241580 - through PRP treatments for repetitive stress injuries to feet, knees
241581 - and hips that can occur hiking at therauptic levels. Like HDL and
241582 - EPCs that proactively regresses plaque and repairs blood vessels, PRP
241583 - is a positive remedy that repairs feet and knee injuries.
241585 - ..
241586 - Discussed Doctor Bob Harrington at Stanford Medical Center, who
241587 - chaired a Cardiology conference in Europe reviewing HDL, reported on
241588 - 131125 0005, ref SDS 17 1J4J
241590 - ..
241591 - Doctor Simpson said he does not know Doctor Harrington. Does not
241592 - recall encountering him at any medical conferences.
241594 - ..
241595 - Doctor Simpson will try to contact Doctor Harington in Cardiology at
241596 - Stanford Medical Center, who also treats patients at the VA Medical
241597 - Center in Palo Alto. He doesn't know him, but may know doctors who
241598 - do, who could explain the purpose of meeting with him, to present
241599 - results hiking 200 - 400 miles per month that raised HDL 30, which
241600 - required CABG x4 on 091022 0700, ref SDS 4 PQWU, to HDL 83, yielding
241601 - stenosis 0, with excellent saphenous veins 11 years later, reported in
241602 - Doctor Tietjens' progress notes on 200124 0705. ref SDS C4 5G59 To
241603 - continue hiking that yields good cardiology results, recommended by
241604 - Doctor Tietjens (see again progress notes, ref SDS C4 5X8N), need PRP
241605 - treatments for repetitive stress injuries to feet and knees. Doctor
241606 - Harrington may have influence with Doctor Chu, who is running PRP
241607 - clinical trial at VAMCPA, and who recommended that VA order PRP
241608 - through Veterans Choice.
241610 - ..
241611 - Discussed HR overnight studies that show brief moments of elevated
241612 - heart rate, where a few beats reach > 150 BPM.
241614 - ..
241615 - Doctor Simpson seemed to say brief spikes in HR during sleep can be
241616 - driven by rapid eye movement (REM), and other factors, rather than
241617 - signal AF recurrence. Polar HR studies during hikes show no
241618 - evidence of AF in that HR profile tracks perfectly changes in terrain
241619 - elevations. HR studies over night show a lot of momentary spikes,
241620 - which hopefully do not signal impending AF...
241659 - ..
241660 - Doctor Simpson noted that at this time, Doctor Pellegrini is the
241661 - attending physician in this case for cardiology, as the leading
241662 - specialist treating atrial fibrillation. This was cited previously in
241663 - his letter on 200714 1351. ref SDS F2 H83G The letter to Doctor
241664 - Simpson and to Doctor Pellegrini reviewed advantages of the current
241665 - medical team, also on 200714 1351. ref SDS F2 JF7W
241666 -
241667 - [On 200724 1108 received call from Carolyn scheduling
241668 - meeting with Doctor Pellegrini on campus at VAMCSF module 1
241669 - on 200826 0830. ref SDS F5 NE9N
241671 - ..
241672 - Considered the role of deliberation discussed in the "New World
241673 - Order..." paper that presents a model of case management based on the
241674 - "locality principal." ref OF 12 I38N Doctor Simpson's experience adds
241675 - perspective that converts daily information into the power of
241676 - knowledge, as seen in the call today. ref SDS 0 PF6O
241678 - ..
241679 - Thanked Doctor Simpson for always being there over the past 6 years
241680 - with timely care and helpful guidance, like today.
241681 -
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