CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 44 0000. ref SDS 43 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040507 -
040508 -
040510 - ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 210607 1428 letter to Doctor Pellegrini references understandings
040902 - from the meeting today, on possible electrical nodes in right atrial
040903 - causing AFL episodes. ref SDS 21 5640
040905 - ..
040906 - On 210607 1428 letter to Doctor Pellegrini lists recurrent AFL
040907 - episodes in right atrial since last ablation on 201210. ref SDS 21
040908 - RF8H
040910 - ..
040911 - On 210824 0845 changed meeting scheduled to meet with Doctor
040912 - Pellegrini on 210825, to 210922 0930, because Kathy had meeting with
040913 - Doctor Hui in sacramento on 210825 1000. ref SDS 23 5M5I This
040914 - followed up letter to Doctor Pellegrini on 210629 1036. ref SDS 22
040915 - TV5L
040917 - ..
040918 - On 210921 0326 letter to Doctor Pellegrini sets agenda for meeting
040919 - today. ref SDS 24 TV5L
040921 - ..
040922 - On 210930 0646 letter to Doctor Pellegrini on results meeting at
040923 - VAMCSF in Cardiology on 210922 0930, ref SDS 26 W44O; ask about letter
040924 - saying another meeting in Cardiology on 210930, ref SDS 26 J463,
040925 - report dates of 5 AFL episodes. ref SDS 26 J534 Review variances in
040926 - blood pressure. ref SDS 26 J53O
040928 - ..
040929 - On 210930 1846 letter to Doctor Pellegrini in Cardiology reports
040930 - another AFL episode. ref SDS 27 BT5N Requests timeline for next
040931 - ablation. ref SDS 27 VU49
040933 - ..
040934 - On 211028 1216 call from Carolyn planning 4th cardiac ablation on
040935 - 211101. ref SDS 31 BT5N
040937 - ..
040938 - On 211029 1002 call from Carolyn planning 4th cardiac ablation
040939 - procedure on 211115. ref SDS 32 BT5N Letter to Doctor Pellegrini
040940 - requests lipids included in lab ordered, and discussing stay in
040941 - hospital overnight after cardiac ablation on 211115, and in order to
040942 - recover from sedation during the procedure. 211029 1002, ref SDS 32
040943 - GD98 Discusses plans for cardiac ablation on 211115 to treat both
040944 - left and right atrials. ref SDS 32 GD97
040946 - ..
040947 - On 211102 0948 letter from Carolyn planning 4th cardiac ablation
040948 - procedure with Doctor Pellegrini. ref SDS 33 BT5N
040949 -
040950 -
040951 -
040952 -
040953 -
040954 -
040955 -
040957 - ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Donald called with Neurosurgery. Scheduled video meeting with
041302 - Neurosurgery clinic at VAMCSF on...
041303 -
041304 - 220418 1600
041306 - ..
041307 - On 220309 10028 Donald called back and changed schedule for meeting
041308 - today on 220425 1400. ref SDS 45 BT5N
041309 -
041311 - ..
041312 - This will review findings of MRI radiology study performed on 220209
041313 - 0845. ref SDS 43 BT5N
041315 - ..
041316 - Findings are listed on 220209 0845. ref SDS 43 UR4H
041318 - ..
041319 - Impressions are listed at 220209 0845, ref SDS 43 629N
041320 -
041321 -
041323 - ..
041324 - Today, Mary Mannix, NP with Neurosurgery at VAMCSF called.
041326 - ..
041327 - Discussed findings in MRI study on 220209 0845. ref SDS 43 BT5N The
041328 - study was initiated during telephone meeting with Doctor Grunfeld on
041329 - 220127 1100. ref SDS 37 VO5O
041330 -
041331 - Impression from MRI are listed. ref SDS 43 629N
041332 -
041333 - 1. Similar multilevel degenerative changes of the cervical
041334 - spine compared to 9/12/2017, with multilevel mild to
041335 - moderate left neural foraminal narrowing. Correlate with
041336 - left-sided radiculopathy.
041338 - ..
041339 - 2. Osseous fusion from C5-C7 with similar mild
041340 - adjacent segment disease at C3-C4, C4-C5, and C7-T1.
041341 -
041343 - ..
041344 - Discussed continuing neck pain that originally seemed to arise from
041345 - car crash on 170905 2230. ref SDS 2 0001 This neck pain resolved
041346 - within 6 months or so. Pain recurred within the past 2 years,
041347 - possibly related to side affects from statin medications, reported to
041348 - Doctor Grunfeld during telephone meeting on 220127 1100. ref SDS 37
041349 - TQ3O
041351 - ..
041352 - [On 220517 0800 CT performed in Radiology by Yonas.
041353 - ref SDS 46 NP60
041355 - ..
041356 - Mary said Donald Jones will call to schedule meeting with
041357 - Neurosurgery, and to schedule CT of neck and shoulder. See Mary's
041358 - Plan in progress notes below. ref SDS 0 BY67
041359 -
041360 -
041361 -
041362 -
041363 -
041364 -
041365 -
0414 -
SUBJECTS
Default Null Subject Account for Blank Record
0503 -
050401 - ..
050402 - Progress Notes Telephone Meeting Mary Mannix, NP Neurosurgery
050403 -
050404 - Downloaded progress notes from VA at...
050406 - ..
050407 - VA online Pharmacy...
050408 -
050409 - https://www.myhealth.va.gov/mhv-portal-web/home
050411 - ..
050412 - Customer....
050421 -
050422 -
050423 - Date/Time: 25 Apr 2022 @ 1339
050424 - Note Title: NEUROSURGERY CLINIC CONSULT NOTE
050425 - Location: San Francisco CA VAMC
050426 - Signed By: MANNIX-CANTILLON,ME
050427 - Co-signed By: MANNIX-CANTILLON,ME
050428 - Date/Time Signed: 26 Apr 2022 @ 1429
050429 - ------------------------------------------------------------------------
050431 - ..
050432 - LOCAL TITLE: NEUROSURGERY CLINIC CONSULT NOTE
050433 - STANDARD TITLE: NEUROSURGERY CONSULT
050434 - DATE OF NOTE: APR 25, 2022@13:39 ENTRY DATE: APR 25, 2022@13:40:06
050435 - AUTHOR: MANNIX-CANTILLON,ME EXP COSIGNER:
050436 - URGENCY: STATUS: COMPLETED
050438 - ..
050439 - The attending physician of record for this patient care
050440 - encounter is Grant Gauger
050442 - ..
050443 - This patient encounter was initiated using (Virtual Care
050444 - Manager/VVC) connection between my location and the patient's
050445 - location. However the patient reported that he was unable to
050446 - make the connection despite having 2 computers at home.
050447 - Therefore the visit was converted to telephone visit at the
050448 - patient's request rather than rescheduling his appointment.
050450 - ..
050455 - ..
050456 - Provider: Mary Mannix-Cantillon, MSN, FNP, ANP, CNRN
050457 - Provider affiliation location: SFVA Neurosurgery
050458 - Phone: (415)221-4810 ext. 23237
050460 - ..
050461 - Participants: Mr. Rodney Welch and myself on telephone.
050463 - ..
050464 - CC: worsening neck pain
050466 - ..
050467 - HPI: 77 yo male with hx trauma (MVA 2017) and per the patient
050468 - no hx of cervical spine fusion surgery. His cervical spine MRI
050469 - of 2/9/2022 shows osseous fusion from C5-C7 with similar mild
050470 - adjacent segment disease at C3-C4, C4-C5, and C7- T1.
050472 - ..
050473 - He is very active and hikes approximately 20miles/day and keeps
050474 - a detailed log of his pain level and triggers.
050476 - ..
050477 - Most of the time he has no neck pain at the start of his hikes
050478 - but does occasionally has some sharp pain with turning head
050479 - that radiates from neck across his L>R shoulders. The levels
050480 - are mostly at 1- 2/10 that he notices at the end of his hikes,
050481 - but occasionally as high as 5/10 but this is not often (last
050482 - episode of 5/10 pain occurred in January 2022 according to his
050483 - review of his own recorded log of events. He denies any
050484 - radicular pain in arms or any weakness or stumbling gait.
050486 - ..
050487 - Extract from Case study on 220101 shows for pain issue... Neck left
050488 - side turning head left and right and looking up...
050489 -
050490 - Date PL % of Hike Comment
050491 -
050492 - 220101 3 10 less than yesterday and much less than day before ore
050493 - 220102 3 10 less than yesterday and much less than day before
050494 - 220103 1 20 less than yesterday and much less than day before
050495 - 220104 2 20 more than yesterday and last 5 miles
050496 - 220106 2 20 more than yesterday and last 5 miles
050497 - 220107 0 100
050498 - 220108 2 10
050499 - 220109 5 30
050500 - 220114 5 30
050501 - 220116 1 20
050502 - 220117 2 50
050503 - 220118 1 10
050504 - 220119 2 15
050505 - 220120 1 5
050506 - 220121 1 5
050507 - 220122 1 5
050508 - 220123 1 5
050509 - 220124 1 5
050510 - 220125 1 5
050511 - 220127 1 2
050512 - 220129 3 10
050513 - 220130 2 10
050514 - 220131 1 5
050515 - 220201 0 100
050516 - 220202 2 5
050517 - 220204 1 3
050518 - 220206 1 3
050519 - 220207 1 2
050520 - 220208 1 2
050521 - 220209 1 2
050522 - 220210 1 2
050523 - 220212 3 5
050524 - 220215 1 5
050525 - 220216 1 5
050526 - 220217 1 2
050527 - 220218 1 1
050528 - 220219 0 100 no noticable pain without taking Tramadol
050529 - 220220 1 1
050530 - 220221 1 5
050531 - 220225 1 1
050532 - 220228 0 100
050533 - 220301 2 08 got worse until oxycodone at mile 7
050534 - 220302 0 100
050535 - 220303 0 100
050536 - 220306 0 100
050537 - 220307 0 100
050538 - 220308 1 50
050539 - 220310 1 75
050540 - 220312 1 5
050541 - 220313 1 5
050542 - 220316 0 100
050543 - 220317 0 100
050544 - 220318 0 100
050545 - 220319 0 100
050546 - 220322 0 100
050547 - 220323 0 100
050548 - 220325 0 100
050549 - 220326 0 100
050550 - 220327 1 5 at times, but went away
050551 - 220328 1 5 at times, but went away
050552 - 220329 0 100
050553 - 220330 0 100
050554 - 220401 3 5 no pain if do not turn head
050555 - 220403 0 100
050556 - 220404 0 100
050557 - 220405 0 100
050558 - 220408 0 100
050559 - 220409 2 1 spot occasions when turning head or looking over shoulder, lifting arms
050560 - 220410 0 100
050561 - 220412 6 2 couple times raising either arm so only brief pain
050562 - 220413 4 2 couple times raising either arm so only brief pain
050563 - 220414 0 100
050564 - 220415 0 100
050565 - 220416 0 100
050566 - 220417 0 100
050567 - 220422 1 5 last few miles
050568 - 220423 1 5 last few miles taking Tramadol twice
050569 - 220424 0 100 oxycodone mile 0
050570 - 220425 0 100 Tramadol mile 6 and mile 15
050571 - 220428 0 100 Tramadol mile 0 and mile 17
050572 - 220429 0 100 oxycodone mile 5
050573 - 220430 0 100 oxycodone mile 5 and 15
050574 - 220501 0 100
050575 - 220502 0 100
050576 - 220503 0 100
050577 -
050579 - ..
050580 - VA Progress Notes continue...
050581 -
050582 - Medications:
050583 -
050584 - AMMONIUM LACTATE 12% LOTION APPLY LOTION TOPICALLY EVERY
050585 - ACTIVE
050586 - DAY AS DIRECTED TO FEET AFTER BATHING FOR DRY SKIN
050587 - ATORVASTATIN CALCIUM 20MG TAB TAKE ONE-HALF TABLET ORALLY
050588 - ACTIVE
050589 - EVERY OTHER DAY FOR CHOLESTEROL
050590 - CALCIUM CARB 500MG (CA 200MG) CHEW TAB CHEW TWO TABLETS
050591 - ACTIVE
050592 - ORALLY EVERY DAY AS NEEDED FOR HEARTBURN
050593 - EZETIMIBE 10MG TAB TAKE ONE TABLET ORALLY EVERY OTHER
050594 - DAY ACTIVE
050595 - GABAPENTIN 300MG CAP TAKE ONE CAPSULE ORALLY TWICE A
050596 - DAY ACTIVE
050597 - FOR PAIN RELIEF TO REDUCE OPIOIDS
050598 - MICONAZOLE NITRATE 2% TOP PWDR APPLY POWDER TOPICALLY
050599 - ACTIVE
050600 - EVERY DAY FOR FUNGAL INFECTION. APPLY INSIDE
050601 - SOCKS
050602 - BEFORE WEARING.
050603 - NAPROXEN 250MG TAB TAKE ONE TABLET ORALLY
050604 - TWICE A DAY AS ACTIVE
050605 - NEEDED FOR PAIN OR INFLAMMATION.
050606 - NUTRITION SUPL ENSURE PLUS/VANILLA LIQ TAKE 1 CONTAINER ACTIVE
050607 - ORALLY TWICE A DAY
050608 - PEG 400 0.4%/PROP GLYCOL 0.3% OPH SOLN INSTILL 1 DROP IN ACTIVE
050609 - BOTH EYES FOUR TIMES A DAY FOR DRY EYES
050610 - TAPE,MEDIPORE H SOFT 2IN X 10YD 3M#2862 USE TAPE AS ACTIVE
050611 - DIRECTED
050612 - TRAMADOL HCL 50MG TAB TAKE ONE TABLET ORALLY TWICE A DAY ACTIVE
050613 - AS NEEDED FOR PAIN. #56 FOR 28 DAYS
050614 - Non-VA CHONDROITIN/GLUCOSAMINE CAP/TAB 2 TABLESPOONFULS ACTIVE
050615 - ORALLY EVERY DAY
050616 -
050618 - ..
050619 - Allergies: SIMVASTATIN, ROSUVASTATI
050620 -
050622 - ..
050623 - PMH:
050624 -
050625 - 1. Abdominal aortic atherosclerosis 04/12/2022
050626 - 2. Long-term current use of anticoagulant 07/24/2020
050627 - 3. Patient post percutaneous transluminal coronary 01/30/2020
050628 - angioplasty
050629 - 4. CAD - Coronary Artery Disease (SCT 53741008) 01/09/2020
050630 - 5. AF - Paroxysmal atrial fibrillation 01/07/2020
050631 - 6. HTN - Hypertension 10/30/2019
050632 - 7. Benign unconjugated bilirubinaemia syndrome 10/31/2018
050633 - GI/Liver clinic 8-2-18
050634 - 8. Metatarsalgia 05/25/2016
050635 - 9. Fall on same level, Onset 00/00/2015 05/25/2016
050636 - 10. History of coronary artery bypass grafting, 10/14/2015
050637 - Onset 10/00/2009
050638 - SFVA LIMA, SVGs diag, ramus, PDA
050639 - 11. Hyperlipidemia 10/14/2015
050640 - 12. Body mass index 30+ - obesity 10/14/2015
050641 - 13. Chronic ischemic heart disease 10/14/2015
050642 - 14. Esophageal stricture (SNOMED CT 63305008) 05/04/2016
050643 -
050645 - ..
050646 - Exam: limited to telephone conversation
050647 - Gen: AAOx3, speech is fluent, excellent historian
050648 - Affect calm, cooperative, pleasant
050649 - Pul: resp rate even & unlabored, no cough, wheezing heard.
050650 -
050652 - ..
050653 - A/P:
050655 - ..
050656 - 77 yo physically active male with reported worsening neck pain
050657 - with occasional radiation to L>R shoulders. hx MVA 2017, auto
050658 - fusion of C5-7 on recent MRI imaging. Pt provided detailed hx
050659 - of his pain level, and associated times, and triggers (toward
050660 - end of 20 mile daily hikes, and occasionally with lateral
050661 - rotation of head).
050663 - ..
050664 - Plan to have patient come into SFVCAMC Neurosurgery Clinic for
050665 - a face to face visit for a physical exam, and on same day have
050666 - non contrast cervical CT scan as well and flex/neut/ext x-rays
050667 - before the visit to assess the boney anatomy and r/o any
050668 - abnormal motion of cervical spine on flex/ext.
050670 - ..
050671 - Pt stated his agreement with this plan, often asking what
050672 - surgery would be done, I educated him that additional
050673 - information of PE and imaging would be valuable in the review
050674 - of his symptoms to determine what the next intervention if any
050675 - would be recommended.
050676 -
050678 - ..
050679 - RTC face to face visit with cervical spine x-ray and
050680 - non-contrast CT scan on same day.
050681 -
050683 - ..
050684 - Time spent for Telephone encounter: 60 Minutes, including the
050685 - following
050686 - activities on the date of the encounter:
050687 - 1. Preparing to see the patient (e.g., chart review)
050688 - 2. Obtaining and/or reviewing separately obtained history
050689 - 3. Performing a medically appropriate examination limited by telephone
050690 - 4. Counseling and educating the patient.
050691 - 5. Ordering medications, tests, or procedures
050692 - 6. Referring to and communicating with other health care professionals
050693 - 7. Documenting clinical information in the electronic or other health record
050694 - 8. Independently interpreting results (not separately reported) and
050695 - communicating results to the patient.
050696 - 15. Care coordination
050697 -
050699 - ..
050700 - Clinical Reminder Activity.... omitted
050701 -
050702 -
050703 - /es/ Mary MANNIX-CANTILLON
050704 - MSN, NP Neurosurgery, NPI 1629085113
050705 - Signed: 04/26/2022 14:29
050706 -
050707 -
050708 -
050709 -
050710 -
050711 -
050712 -
050713 -
050714 -
050715 -
050716 -
050717 -
050718 -
050719 -
050720 -
0508 -