CONTACTS
SUBJECTS
Endocrinology Review HDL Failing Rise With Hiking Mileage
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 36 0000. ref SDS 31 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040507 -
040508 -
040510 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Meeting this morning was planned by Doctor Grunfeld during prior
040902 - meeting on 220526 1030. ref SDS 36 0533
040904 - ..
040905 - Did not submit agenda letter, as done for Doctor Grunfeld on 220521
040906 - 1047, ref SDS 34 MJ5I, which guided meeting on 220526 1030.
040907 - ref SDS 36 044K
040908 -
040910 - ..
040911 - Lab this morning on 221104 0730, ref SDS 39 VF7L, shows...
040912 -
040913 - LDL 113 continued to improve after resuming Atorvastatin on
040914 - 220527, see case study on 210101 0643. ref SDS 12 BW6H
040915 -
040916 - HDL 57 lower than expected after resuming hiking on 221020, see
040917 - case study on 200101 0701. ref SDS 8 J3KS
040919 - ..
040920 - Doctor Kim feels LDL is too high.
040922 - ..
040923 - Taking much less opiods to suppress pain, after getting new socks, and
040924 - new shoes, and care in Podiatry has reduced feet injuries, most
040925 - recently on 221025 0900. ref SDS 38 L83K
040927 - ..
040928 - Doctor Kim was familiar with IVUS angiogram findings 0 stenosis on
040929 - 200124 0705, ref SDS 9 5G59, reflecting comments during the procedure,
040930 - also on 200124 0705. ref SDS 9 ME8G
040932 - ..
040933 - Planning IVUS angiogram evaluate plaque with HDL > 50 < 60
040935 - ..
040936 - The doctor indicated that favorable IVUS findings make lab today
040937 - showing LDL 113 less problematic than normally would be based on
040938 - studies that support increasing statin drugs to lower LDL.
040940 - ..
040941 - Doctor Kim is familiar with telomere theory on extended longevity by
040942 - reducing sarcopenia. She does not include this in her practice of
040943 - endocrinology. Doctor Kim will cite some current studies on aging, in
040944 - her progress notes for the meeting today.
040946 - ..
040947 - Bloating issue continues, treating with Simethicone. She has read
040948 - notes on vasodilation diagnosed by Doctor Monto during meeting at
040949 - VAMCSF hospital stay on 200612 0700. ref SDS 10 LY3G She does not have
040950 - ideas to treat bloating in this case, beyond Simethicone.
040952 - ..
040953 - Doctor Kim was familiar with Gen Surgery saying CT 220110 does not
040954 - show diverticulitis, and Vascular Surgery Doctor Innazzie saying the
040955 - CT shows diverticulitis. Doctor Kim has also seen recent CT found no
040956 - evidence diverticulitis, reported on 221025 0815, ref SDS 37 UO40,
040957 - which aligned with MRI on 220425 0830. ref SDS 32 X84P
040959 - ..
040960 - Doctor Kim seems to share Doctor Grunfeld's feeling that recent CT on
040961 - 221025, and CT on 220110 and MRI on 220425 show any possible
040962 - atherosclerosis in blood vessels is stable, i.e., not advancing. She
040963 - feels continuing Atorvastatin resumed during meeting with Doctor
040964 - Grunfeld on 220526 1030, ref SDS 36 YG4K, and after deciding to pause
040965 - statin treatment during prior meeting with Doctor Grunfeld on 220127
040966 - 1100, ref SDS 27 TQ3O, complements hiking at therapeutic levels to
040967 - elevate HDL and EPCs that regresses atherosclerotic plaque.
040969 - ..
040970 - Doctor Kim did not discuss history taking Simvastatin, Rosuvastatin
040971 - and Atovastatin, which all cause side effects, qualifies patient for
040972 - treatment with PCSK9. The PCSK9 treatments require patients to self
040973 - inject the drug daily or weekly.
040975 - ..
040976 - Doctor Kim said Doctor Grunfeld continues research work, while not
040977 - seeing patients. She will say hello.
040979 - ..
040980 - The doctor will be on maternity leave at end of March. She scheduled
040981 - next meeting on...
040982 -
040983 - 230303 0845
040985 - ..
040986 - This conflicts with EGD procedure scheduled with Doctor Lee in GI
040987 - Clinic at VAMC Sacramento on 230303 0830.
040989 - ..
040995 -
040996 -
0410 -
SUBJECTS
Default Null Subject Account for Blank Record
0503 -
050401 - ..
050402 - Progress Notes Meeting Doctor Kim in Endocrinology
050403 -
050404 -
050405 - Downloaded progress notes from VA website...
050406 -
050407 - https://www.myhealth.va.gov/mhv-portal-web/track-health
050408 -
050421 -
050422 - 1. Date/Time: 04 Nov 2022 @ 2234
050423 - Note Title: ENDOCRINE-METABOLISM CLINIC F/U (MED)
050424 - Location: San Francisco CA VAMC
050425 - Signed By: KIM,TIFFANY Y
050426 - Co-signed By: KIM,TIFFANY Y
050427 - Date/Time Signed: 04 Nov 2022 @ 2341
050428 - -------------------------------------------------------
050429 - LOCAL TITLE: ENDOCRINE-METABOLISM CLINIC F/U (MED)
050430 - STANDARD TITLE: ENDOCRINOLOGY OUTPATIENT NOTE
050431 - DATE OF NOTE: NOV 04, 2022@22:34 ENTRY DATE: NOV 04, 2022@22:34:51
050432 - AUTHOR: KIM,TIFFANY Y EXP COSIGNER:
050433 - URGENCY: STATUS: COMPLETED
050435 - ..
050436 - ENDOCRINE CLINIC NOTE
050438 - ..
050439 - 2. HPI (Hisotory Present Illness)
050440 -
050441 - Rodney Welch is a 77 yo man with a h/o CAD s/p 4VCABG 2009, AF
050442 - s/p ablations, HTN, HL, achlasia, consult for lipid management.
050443 - Previously seen by Drs Diana Alba, Ken Feingold, Carl Grunfeld.
050444 - See note by Dr Grunfeld 5/26/22 for prior history. H/o very
050445 - high LDL, has decreased LDL and increased HDL but interested in
050446 - increasing HDL further.
050448 - ..
050449 - #. ASCVD: CAD s/p 4VCABG 10-22-09 (LIMA, SVG diag, ramus,
050450 - PDA). Carotid US 9-20- 16 sml plaque R bulb, no stenoses. As
050451 - can be seen below, he has aggressively improved his lipid
050452 - profile in the interim. CTAs in 2015 and 2018 with patent
050453 - grafts. Cath Jan 2020 showed all grafts patent with a severe
050454 - 95% stenosis of the rPL branch which had not been bypassed,
050455 - which was stented. 6/10/21 -
050457 - ..
050458 - "Patent" grafts does not identify findings of angiograms that reported
050459 - 0% stenosis on 200124 0705. ref SDS 9 ME8G and progress notes, 200124
050460 - 0705, ref SDS 9 5G59, whereas 70% stenosis qualifies as "patent,"
050461 - reported on 091022 0700. ref SDS 1 RY6H
050463 - ..
050464 - Progress Notes continue...
050465 -
050466 - Reports Platelet rich plasma made a difference.
050468 - ..
050469 - During meeting today, explained history of PRP treatments enabled
050470 - hiking, which in turn increased HDL 30, at time of CABG, to HDL 83 on
050471 - 181112 1720. ref SDS 7 5C7M
050473 - ..
050474 - Progress Notes continue...
050475 -
050476 - Imaging Jan 2022 with aortic atherosclerosis, luminal
050477 - irregularities representing penetrating atherosclerotic
050478 - ulcers/dissection flaps. Vascular surgery recommended 1 year
050479 - f/u imaging. Was hospitalized June 2020 for intermittent
050480 - abdominal pain and bloating, thought to be ischemic colitis,
050481 - although visualized portions of mesenteric vascular were
050482 - patent. Also h/o diverticulae. Seen by gen surg 9/2022,
050484 - ..
050485 - Cannot find record meeting with General Surgery in Sep 2022. Met with
050486 - Doctor Natile Rodriguez and Doctor Kim in Module 2 on 220503 0900.
050487 - ref SDS 33 LW8H - for some reason, progress notes are dated, 220521.
050488 - ref SDS 33 SP4I
050490 - ..
050491 - Progress Notes continue...
050492 -
050493 - thought to have intermittent ischemic colitis with exertion,
050494 - sequaelae of low flow state. Recommended continued GI f/u,
050495 - avoidance of NSAIDS, routine CTA surveillance, medical
050496 - optimization of CV risk factors. Cardiology: Previously
050497 - followed by Dr Paul Simpson, now Dr Cara Pellegrini and NP
050498 - Rettberg.
050500 - ..
050501 - Doctor Monto diagnosed ischemic colitis reported on 200612 0700.
050502 - ref SDS 10 LY3G
050504 - ..
050505 - On 200613 0519 at 1135 discharge instruction progress notes cite
050506 - vasodilation from hiking, together with 4 heart ablation procedures,
050507 - as causing reduced blood flow to heart causing ischemic colitis.
050508 - ref SDS 11 PP9T
050510 - ..
050511 - Progress Notes continue...
050512 -
050513 - #. Dyslipidemia: Many of his early labs were not at the San
050514 - Francisco VA, so may not be available to us. His highest LDL
050515 - here was 243 in 2015. His LDL before 2009 was 192 to 203. His
050516 - HDL before his CABG was 30-32 in 2005-2009. In the years after
050517 - his CABG, his HDL ran in the 40s. His triglycerides are mostly
050518 - below 100. He has trouble with statins but after working with
050519 - Dr Feingold he was able to tolerate atorvastatin 10 mg every
050520 - other day and ezetimibe 10 mg daily. This regimen brought his
050521 - LDL down to the 90s and low 100s.
050523 - ..
050524 - Ezetimibe 10 mg is also every other day, taken with Atorvastatin.
050526 - ..
050527 - Progress Notes continue...
050528 -
050529 - He was significantly overweight and began hiking. This raised
050530 - his HDL level so he began hiking more and hikes about 20 miles
050531 - per day many days a week. This hiking regimen brought his HDL
050532 - mostly into the range of high 50s to 60s in our lab.
050534 - ..
050535 - VAMCSF lab reported HDL...
050536 -
050537 - HDL 70............ 150209 1012, ref SDS 4 5C7M
050538 - HDL 69............ 160202 1220, ref SDS 5 5C7M
050540 - ..
050541 - Progress Notes continue...
050542 -
050543 - His HDL has been as high as 83. His HDL was lowered during
050544 - bouts of AF.
050546 - ..
050547 - HDL lowering after onset of AF best seen in spreadsheet...
050548 -
050549 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
050551 - ..
050552 - Progress Notes continue...
050553 -
050554 - He also gets NMR measures of his lipids. He reports that he
050555 - has mostly large fluffy LDL.
050557 - ..
050558 - HDL 83 reported NMR lab at Labcorp on 181112 1720. ref SDS 7 N64J
050560 - ..
050561 - Progress Notes continue...
050562 -
050563 - In the past, he has had elevated CRP: It was as high as 20.6
050564 - in 2016 and during that time it ranged between 3.8 and 5.1.
050565 - When his CRP was 4.5 his sedimentation rate was excellent at 7.
050567 - ..
050568 - He has lost significant weight since then due to his hiking so
050569 - unlikely he has the inflammation of obesity. See note on
050570 - 8/5/21 by Dr Grunfeld:
050572 - ..
050573 - We had a long discussion, in which I explained:
050574 -
050575 - 1) Losing weight was likely the most important factor for
050576 - getting HDL into the 50's and he did that by exercising, so
050577 - exercise is good.
050579 - ..
050580 - Do not recall discussion during the meeting that losing weight
050581 - increases HDL 30 to 50+, per above. ref SDS 0 MJ5I
050583 - ..
050584 - After the meeting, research found...
050586 - ..
050587 - Very Well Health
050588 -
050589 -
050590 - https://www.verywellhealth.com/exercise-and-hdl-cholesterol-1745833
050591 -
050592 - Losing weight: For every 6 pounds lost, HDL may increase
050593 - by 1 mg/dL.Mar 26, 2022
050595 - ..
050596 - Perhaps the most interesting finding from this study is
050597 - the observation that it was the duration of exercise
050598 - sessions and not the frequency or intensity of
050599 - exercise that best correlated with increased HDL levels.
050600 - The investigators reported that in research subjects
050601 - exercising for at least 20 minutes, each additional
050602 - 10-minute increase in exercise duration was associated
050603 - with an additional 1.4 mg/dL of HDL.
050605 - ..
050606 - This aligns with Harvard study reported on
050607 -
050609 - ..
050610 - Progress Notes continues...
050611 -
050612 - 2) Values of HDL are not comparable by different methods
050613 - and hence different laboratories.
050615 - ..
050616 - 3) His values are not significantly different with the
050617 - exercise induced inflammation.
050619 - ..
050620 - 4) So don't focus on levels.
050622 - ..
050623 - 5) He should work on eliminating the inflammation with
050624 - exercise by working with podiatry and consider splitting
050625 - his hikes (which he was thinking of doing).
050626 -
050627 -
050628 -
050629 -
050631 - ..
050632 - He will continue do Platelet rich plasma on his own. In the
050633 - past, has had bad reactions to rosuvastatin and simvastatin:
050634 - shoulder aches, neck aches and worsened. Had worsening
050635 - neuropathy so he stopped atorvastatin, resumed May 2022 b/c his
050636 - athersclerosis was stable while on atorvastatin and while off
050637 - atorvatatin his LDL is too high at 189.
050639 - ..
050640 - Subjective:
050641 - No acute issues. We had a discussion about HDL and LDL, role
050642 - of telomeres in aging. He may be a good candidate for clinical
050643 - studies of aging given his interest. He was disappointed I did
050644 - not have anything to add for abdominal pain.
050646 - ..
050647 - Seems like abdominal pain (bloating) that mostly occurs during
050648 - hiking, but sometimes otherwise, would be an "acute" issue.
050650 - ..
050651 - Progress notes continue...
050652 -
050653 - Reviewed history further after visit, he has been evaluated by
050654 - vascular surgery, general surgery, also GI as per above.
050655 -
050656 -
050657 - Lipid medication:
050658 - Atorvastatin 10 mg QOD
050659 - Ezetimibe 10 mg QOD
050660 -
050661 -
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0507 -