CONTACTS 

SUBJECTS
Eye Examination Eye Clinic Infection Schedule Referral Scope of Work

0903 -
0903 -    ..
0904 - Summary/Objective
0905 -
090501 - Follow up ref SDS 51 0000. ref SDS 49 0000.
090502 -
090503 - Doctor Sandhu left a staff this morning to make an exigent referral.
090504 - Nurse Sherry was particularly helpful.  Sherry took immediate action
090505 - to facilitate communication, giving the doctor an opportunity to weigh
090506 - investing 5 minutes for referral to provide patient care against staff
090507 - meeting discussion on perpheral matters. ref SDS 0 UF6K  The doctor
090508 - indicated that a letter from the patient facilitated by administrative
090509 - assistant, Terry, helpd decide to take immediate action, rather than
090510 - delay treatment. ref SDS 0 5D50
090511 -
090512 -
090513 -
090514 -
090515 -
090517 -  ..
0906 -
0907 -
0908 - Progress
0909 -
090901 - Referral Prepared by Primary Care Physician for Eye Examination
090902 -
090903 - Follow up ref SDS 51 UF6K, ref SDS 49 OY6M.
090904 -
090905 - Background is reported in the record on 070220. ref SDS 51 UF6K
090907 -  ..
090908 - This morning there was a sign on counter at the Primary Care Clinic
090909 - that said all of the staff were in a meeting until 1000.
090911 -  ..
090912 - Sherry, a nurse, walked through the patient waiting area.  Asked about
090913 - seeing Doctor Sandhu for 5 minutes.  Sherry said everyone is in a
090914 - staff meeting for the next 2 hours, as shown on the sign.  Sherry then
090915 - asked about the scope of the problem.  Explained requirement for
090916 - referral to the Eye Clinic, as set out in the letter to the VA
090917 - yesterday. ref SDS 51 NB6M  Sherry requested patient identification.
090919 -  ..
090920 - About 10 minutes later, Pat came out and said that Doctor Sandhu
090921 - received the letter, ref DIP 6 0001, and will take 5 minutes for a
090922 - consultation.
090924 -  ..
090925 - Pat took vitals.  Was unable to get details on these diagnostics.
090926 - From memory the pulse seemed high at near 80.
090928 -  ..
090929 - Doctor Sandhu said that the letter received from the patient on
090930 - 070220, with a link to the record presenting the scope of the problem,
090931 - ref SDS 51 NB6M, enabled him to determine that referral could be
090932 - prepared in a short enough time to not missed any critical details,
090933 - while the staff discussed matters not affecting his work.
090935 -  ..
090936 - The doctor used an electronic instrument to make a quick examination
090937 - of the left eye.  The doctor confirmed the scope was as presented in
090938 - the record, and not some other matter which would take more time.
090940 -  ..
090941 - The doctor used his computer to make a referral to the eye clinic.
090943 -  ..
090944 - While the doctor prepared referral on his computer, there was an
090945 - article on his desk with a headline about another IBM project to use
090946 - computers for patient case management.
090948 -  ..
090949 - We talked briefly about visiting before long to discuss the VA's
090950 - progress improving patient care with tools for medical management.
090951 -
090952 -        [...later, Doctor Margulies demonstrated how computers are
090953 -        improving health care and medical practice at the VA.
090954 -
090955 -
090956 -
090957 -
090958 -
0910 -

SUBJECTS
Flu Shot at VA Hospital in Martinez Pat

1003 -
1004 - 0850
100501 -  ..
100502 - Flu Shot Annual VA Immunization Service
100503 -
100504 - Follow up ref SDS 33 HP9H.
100505 -
100506 - After meeting with Doctor Sandhu, Pat suggested I get a flu shot.
100507 -
100508 - She said it can be done immediately, and so will not delay other
100509 - work.
100511 -  ..
100512 - Got a flu shot.
100514 -  ..
100515 - Thanked Pat for timely, professional work.  Didn't feel a thing.
100516 -
100517 -
100518 -
100519 -
100520 -
1006 -

SUBJECTS
Eye Clinic Administration Register for Examination Infection Scope o

1403 -
1404 - 0910
140501 -  ..
140502 - Eye Clinic Examination
140503 -
140504 - Visited the Eye Clinic on the 2nd floor.
140505 -
140506 - The attendant at the patient counter found the referral on the
140507 - computer, created earlier by Doctor Sandhu, per above. ref SDS 0 5D56
140508 - The meeting was recorded in the VA computer with patient
140509 - identification.
140510 -
140512 -  ..
1406 -
1407 -
1408 - 0923
1409 -
140901 - Doctor Margulies came into the patient waiting room and advised that
140902 - she has a hectic schedule with a lot patients today.  Therefore, the
140903 - walk-in meeting arranged by Doctor Sandhu will have to be added to the
140904 - schedule, which may take half-an-hour or so.
140906 -  ..
140907 - This was a very courteous, professional gesture for the doctor to
140908 - personally notify patients about the approximate waiting period to
140909 - start a meeting.  At Kaiser, patients sometimes wait for hours without
140910 - any idea when events will occur, e.g., on 061110. ref SDS 50 SM6M
140911 -
140912 -
140913 -
140914 -
140915 -
140916 -
1410 -

SUBJECTS
Eye Examination Review Record Organizational Memory Patient History

4603 -
4604 - 1013
460501 -  ..
460502 - Doctor Reviews Prior Record Understand Background Current Work
460503 -
460504 - Doctor Margulies reviewed the record of prior work in this case on
460505 - eye examinations.
460507 -  ..
460508 - The doctor found the record for the examination on 060512, and the
460509 - follow up on 060926. ref SDS 49 CH5F  She commented on the technology
460510 - miracle that enables a doctor to find legible reporting on previous
460511 - examinations simply by clicking a few links on the computer screen.
460512 - The doctor feels that increased speed finding legible patient history
460513 - encourages doctors to rely on the record rather than fungible memory
460514 - of patient and doctor alike, and making diagnosis on hunches and
460515 - cursory impressions.
460517 -  ..
460518 - Previously, on 041018 Doctor Benz at UCSF commented that doctor's work
460519 - product in the medical chart are worthless for analysis of patient
460520 - history. ref SDS 12 EN63  An example showing why accurate history is
460521 - critical to health care was reported on 041230. ref SDS 13 XQ84
460523 -  ..
460524 - Earlier today, Doctor Sandhu had an article on his desk that reported
460525 - IBM plans a new project to increase technology support for improving
460526 - care and reducing costs. ref SDS 0 WW6H
460528 -  ..
460529 - Doctor Margulies asked about patient work classification?
460531 -  ..
460532 - Explained the role of intelligence support, set out in NWO.
460533 - ref OF 13 A56M
460535 -  ..
460536 - Doctor Margulies feels that people associate intelligence support with
460537 - national security military work.  She feels people are not ready to
460538 - consider general purpose "intelligence support."
460540 -  ..
460541 - The military has long led the way to new work practices, e.g., command
460542 - control, situational awareness, inventory (logistics), records
460543 - management.  The digital computer, which the doctor feels is so
460544 - helpful today, ref SDS 0 5D88, was developed under military contract
460545 - during World War II.  Then, as now, overcoming resistance to
460546 - improvment was miracle. ref OF 14 YY8M  Today, better technology 60
460547 - years later has reduced the cost of intelligence support for business
460548 - management, medical practice, education, continual learning, science,
460549 - research, contract management, etc., simply by using 8 steps for
460550 - Communication Metrics, listed in POIMS. ref OF 6 685K
460552 -  ..
460553 - The doctor decided to list "management" rather than intelligence
460554 - support for patient work classification.
460556 -  ..
460557 - The doctor said the VA will not transmit the record electronically,
460558 - along with physician comments, which she found was helpful for the
460559 - meeting today. ref SDS 0 5D88  She said patients can go to the 2nd
460560 - floor to get a printed copy, which requires the patient to spend hours
460561 - typing all over again what has already been entered in order to have a
460562 - common understanding of patient history and to have timely access as
460563 - the doctor demonstrated today, and in order to provide feedback to
460564 - refine accuracy of patient history to increase the quality of health
460565 - care.
460567 -  ..
460568 - The doctor displayed findings on her computer screen from prior work
460569 - on 060526, when Doctor Hannum made an eye examination in this case.
460570 - ref SDS 48 UF6K  Doctor Margulies commended thoroughness and quality
460571 - of Doctor Hannum's examination report, which she further noted shows a
460572 - "perfect" condition, with 20 20 vision.  She cited suspect glaucoma
460573 - due to indented optic nerve, observed during examination on 060526,
460574 - ref SDS 48 VU4W, and commented that the VA will continue to monitor
460575 - this issue in the coming years with annual checkups.
460577 -  ..
460578 - The doctor again commented on advantages of relatively instant access
460579 - to legible records on patient history in the VA's electronic medical
460580 - chart.  She feels this is a breakthrough for patients and doctors
460581 - improving the quality of care.
460583 -  ..
460584 - Today, Doctor Margulies performed another vision test.  She magnified
460585 - some of the characters to increase recognition, and advised results
460586 - align with prior findings.  There is no need for glasses or other
460587 - corrective measures at this time.
460588 -
460589 -
460590 -
460591 -
4606 -

SUBJECTS
Eye Left Examination Infection Scope of Work Blood Shot Relieve Pain

4803 -
480401 -  ..
480402 - Examination Left Eye Red Inflammation Infection Painful
480403 - Eye Left Painful Infection Red Inflammation Difficult to Work
480404 -
480405 - The doctor asked about the current problem?
480407 -  ..
480408 - Doctor Margulies could not find the record submitted to Doctor Sandhu
480409 - on 070220 that describes the scope of the problem and background,
480410 - ref SDS 51 NB6M, and which the doctor found helpful for making
480411 - referral this morning, per above. ref SDS 0 5D50
480413 -  ..
480414 - We discussed getting the record on the Internet.  Doctor Margulies
480415 - decided that, while VA policy to protect confidentiallity requires
480416 - patients to spend hours entering VA work product, per above,
480417 - ref SDS 0 QE4N, there wasn't enough time to spend 2 minutes to get an
480418 - accurate record on the scope of the problem, which could then
480419 - transferred electronically (cut and paste) into the VA record.  The
480420 - docter said it would be faster and easier for the patient to try and
480421 - duplicate the prior work, by remembering and verbally explaining
480422 - patient history, while the doctor invested 10 minutes to type into her
480423 - computer again what has already been submitted.
480425 -  ..
480426 - The doctor made a clinical examination.  She used instrumentation to
480427 - examine low levels of detail in the left eye, and compared with the
480428 - right eye.
480430 -  ..
480431 - She referred again to the record of the prior examination, and then
480432 - checked the eye with examination equipment again to verify
480433 - correlations and implications.
480434 -
480435 -
480436 -
480437 -
480438 -
4805 -

SUBJECTS
Diagnosis Left Eye Ulcerated Cornea Lens Infection Caused by Rosacia

5203 -
520401 -  ..
520402 - Rosacea Treatment Metrogel Tetrycycline Doxycycline
520403 - Corneal Rosacea Ulcerated Cornea Infection Keratitis
520404 - Diagnosis Eye Infection Rosacea Treatment Eye Lid Scrub Antibiotic
520405 -
520406 - The doctor feels there is an infection in one spot on the permimeter
520407 - of the left eye lens.  She called this an ulcerated cornea.  The
520408 - doctor further feels initially this infection is most likely caused by
520409 - rosacea.  She said it is a common association.
520410 -
520411 -           [On 070226 examination shows improvement, treatment
520412 -           continued. ref SDS 52 OY8H
520414 -  ..
520415 - Research on the Internet at...
520416 -
520417 -            http://www.rosacea-ltd.com/ocular.php3
520418 -
520419 - ...shows an article...
520420 -
520421 -            Rosacea-Ltd III
520422 -            Improving the appearance of Ocular Rosacea
520423 -            OCULAR ROSACEA and TREATMENT
520424 -
520425 - ...and says in part...
520427 -         ..
520428 -        50 to 60% of rosacea sufferers have symptoms with their eyes
520429 -        which is known as ocular rosacea.
520431 -         ..
520432 -        Ocular Rosacea is an inflammatory eye condition often
520433 -        associated with acne rosacea.  Symptoms can be persistent
520434 -        burning or gritty feeling in the eyes, inflamed and swollen
520435 -        eyelids with small inflamed bumps, eye lashes that may fall
520436 -        out, compounded by bloodshot eyes (Dr.  Thiboutot).
520438 -         ..
520439 -        Ocular rosacea patients generally have chronically "bloodshot"
520440 -        eyes, dry eyes, and blepharitis (inflammation and debris of the
520441 -        eyelid margins).
520443 -         ..
520444 -        Ophthalmic signs of ocular rosacea include blepharitis,
520445 -        conjunctivitis, iritis, iridocyclitis, hypopyoniritis, and even
520446 -        keratitis. (These conditions will be described in detail
520447 -        below.)
520449 -         ..
520450 -        The most frequent signs, which may never progress to a more
520451 -        severe condition, are chronically inflamed margins of the
520452 -        eyelids with scales and crusts, quite similar to seborrheic
520453 -        dermatitis, with which ocular rosacea is often confused.  Pain
520454 -        and photophobia (abnormal sensitivity to light) may be present.
520455 -        The ocular complications are independent of the severity of
520456 -        facial rosacea (Drs.  Gerd Plewig & Albert M.  Kligman).
520457 -
520459 -         ..
520460 -        Keratitis Corneal Ulceration Infection Can Cause Blindness
520461 -
520462 -        In severe ocular rosacea, there may be corneal ulceration
520463 -        (infection) which, if untreated, may even lead to perforation
520464 -        of the eye. This can be a potentially blinding complication.
520466 -         ..
520467 -        Keratitis ocular conditions of cornea infection.   This may
520468 -        cause severe eye pain, blurry vision and sensitivity to light.
520469 -        Medical evaluation and treatment of keratitis is absolutely
520470 -        essential.  Minor corneal infections are commonly treated with
520471 -        anti-bacterial or anti-fungal eye drops.  If the problem is
520472 -        more severe, a person may receive more intensive antibiotic
520473 -        treatment to eliminate the infection and may even require
520474 -        steroid eye drops to reduce inflammation.
520476 -  ..
520477 - Many of these symptoms are present in this case, including ulderated
520478 - cornea, per examination. ref SDS 0 BM62
520480 -         ..
520481 -        Drinking Water Eases Dry Eyes
520482 -
520483 -        Rosacea causes dehydration.  The body is approximately 65%
520484 -        water while the eye is 96% water.  Increasing water intake
520485 -        increases moisture in the eye (thereby decreasing irritation
520486 -        and dryness).  It has been found that increasing the amount of
520487 -        water consumed daily can ease the symptoms of ocular rosacea
520488 -        for many.
520490 -  ..
520491 - Doctor Margulies prescribed....
520492 -
520493 -    1.  Treatment for rosacia is Doxycycline Hyclate 100 MB capsules to
520494 -        supplement Metrogel.
520495 -
520496 -        Protocol for Metrogel treatment is the same prescribed by
520497 -        Doctor Zipperstein on 940624. ref SDS 1 JP4O  More recently, on
520498 -        050809 Doctor Gallacher at the VA prescribed Metrogel and
520499 -        Tetracycline again, and with the same protocol. ref SDS 23 WH8P
520501 -         ..
520502 -        Protocol for application of Doxycycline Hyclate is swallowing a
520503 -        pill 2 times per day, as well.
520505 -         ..
520506 -        Initially today, Doctor Marguiles considered prescribing
520507 -        Tetracycline, which is already on hand from the prior treatment
520508 -        prescribed on 050809.
520510 -         ..
520511 -        We reviewed challenges swallowing pills that conflict with
520512 -        Achalasia, which constricts swallowing, diagnosed on 051209,
520513 -        ref SDS 33 0001, and which Doctor Lee currently has under
520514 -        review, as reported yesterday. ref SDS 51 5R5R
520516 -         ..
520517 -        Doctor Margulies asked what can be done to manage conflict
520518 -        between requirements for swallowing medication, and delay
520519 -        completing treatment for achalasia to enable swallowing
520520 -        medications.
520522 -         ..
520523 -        Discussed Eye Clinic coordinating with the GI Clinic on
520524 -        interrelated work to complete the plan developed by by Doctor
520525 -        Lee on 060505. ref SDS 47 KU5I
520527 -         ..
520528 -        Doctor Margulies indicated that collaborating between clinics
520529 -        for coordinating treatment is complex.  This aligns with the
520530 -        report from Doctor Sandhu that coordinating the work seems like
520531 -        interference.  It was decided not to contact the GI Clinic to
520532 -        resolve digestion issues in order to facilitate treatment for
520533 -        eye infection.
520535 -         ..
520536 -        The doctor looked in the computer for a liquid form of
520537 -        Tetracycline.  She found this is produced.  The doctor called
520538 -        the pharmacy to verify the VA provides this medication.  The
520539 -        discussion yielded information on complications.  The doctor
520540 -        considered a substitute.  After further research on the VA
520541 -        computer, Doctor Margulies prescribed Docycycline Hyclate 100
520542 -        MG capsules.  Will try this for a week and see what happens.
520544 -             ..
520545 -            [On 070226 problems swallowing Doxycycline Hyclate pills
520546 -            may be managable; continuing this treatment for another
520547 -            cycle. ref SDS 52 HG8J
520549 -             ..
520550 -            [On 070228 examination shows recovery from rosacia.
520551 -            ref SDS 53 4Z7O; prescribed medication treatment will be
520552 -            continued. ref SDS 53 FN5M
520554 -             ..
520555 -            [On 070312 doctor changed prescription to Doxycycline
520556 -            Calcium (Vibramycin) Syrup Oral suspension raspberry apple
520557 -            flavored to solve swallowing problem taking medication for
520558 -            rosacia. ref SDS 54 HB9G
520560 -         ..
520561 -        The doctor indicated that Metrogel provided by the VA in 2005
520562 -        can be tried, also, for a week.  She will consider ordering
520563 -        refill, if needed, shown by follow up examination next week,
520564 -        scheduled below. ref SDS 0 BM6U
520565 -
520566 -            [On 070226 doctor orders prescription refill for Metrogel
520567 -            replacement medication to continue treatment for rosacia.
520568 -            continued. ref SDS 52 H39G
520570 -         ..
520571 -    2.  Eye lid "scrub" washing the location above the eyelash with
520572 -        warm water and soft soap once a day in the morning. (see
520573 -        instructions)
520574 -
520575 -            [On 071128 slightly different explanation for same care.
520576 -            ref SDS 55 3S93
520578 -         ..
520579 -    3.  Bacitracin antibiotic ointment applied at the bottom of the eye
520580 -        4 times a day.   The doctor demonstrated where to apply the
520581 -        treatment by pulling down the skin to expose the bottom of the
520582 -        eye.
520584 -         ..
520585 -        This may relate to the initial theory that rosacia infection
520586 -        in the eyelid is causing the problem to the eye itself.
520587 -
520588 -
520589 -
520590 -
520591 -
5206 -

SUBJECTS
Diagnosis Left Eye Infection Caused by Rosacia Treatment Metrogel Te

5403 -
540401 -  ..
540402 - Schedule Progress Review 5 Days
540403 -
540404 - The doctor initially schedule follow up examination in a week, then
540405 - changed the schedule to next Monday for more timely review.
540406 -
540407 - Scheduled another meeting to review progress on 070226 1330.
540408 -
540410 -  ..
5405 -
5406 -
5407 - 1107
5408 -
540801 - Visited the pharmacy.
540802 -
540803 - The pharmacist called the doctor to clarify the prescription and
540804 - instructions.  The doctor has written "4 days" and intended 4 times
540805 - per day."
540807 -  ..
540808 - The medicine was not available for another 45 mintues.
540810 -  ..
540811 - The pharmacist indicated this could be picked up later today.
540812 -
540813 -
540814 -
540815 -
540816 -
5409 -

SUBJECTS
Notify VA Progress Assistance Effective Facilitating Meeting for Exa

6103 -
6104 - 1517
610501 -  ..
610502 - Letter to VA Reporting Progress and Assistance Effective
610503 -
610504 - Follow up ref SDS 51 416I.
610505 -
610506 - Submitted ref DIT 1 0001 to Kim with a copy to Terry for submission
610507 - to Doctor Sandhu, saying...
610508 -
610509 -    1.  Thanks for communication support yesterday.  Doctor Sandhu
610510 -        expedited review today by Doctor Margulies in the Eye Clinic,
610511 -        who set up a treatment program, as reported in the record
610512 -        today. ref SDS 0 UF6K, ref DIT 1 0001
610514 -         ..
610515 -    2.  As you can see, Doctor Margulies encountered an issue related
610516 -        to Doctor Lee's plans for achalasia surgery, however, this was
610517 -        worked around for the time being. ref SDS 0 J15J, ref DIT 1
610518 -        6C6I
610520 -         ..
610521 -    3.  By copy to Terry (finally found an email address) notifying
610522 -        Doctor Sandhu of work in progress.
610524 -         ..
610525 -    4.  Thanks again for your support.
610526 -
610527 -
610528 -
610529 -
610530 -
610532 -  ..
6106 -
6107 -
6108 - 1604
6109 -
610901 - Visited VA Pharmacy.  Received medications prescribed by Doctor
610902 - Margulies. ref SDS 0 PM52
610904 -  ..
610905 - Began review of instructions.
610906 -
610907 -
610908 -
610909 -
610910 -
610911 -
610912 -
6110 -