CONTACTS
SUBJECTS
Angiogram Cardiac Catheterization Heart Circulatory Evaluattion Test
1403 -
1403 - ..
1404 - Summary/Objective
1405 -
140501 - Follow up
140502 -
140503 -
140504 -
140505 -
140507 - ..
1406 -
1407 -
1408 - Progress
1409 -
140901 - Met with Doctor James W Egan, MD, Staff Cardiologist.
140902 -
140903 - Doctor Egan reported that treadmill stress test ordered by Doctor Lee,
140904 - on 090908, and performed on 090916, found 10 of 11 test locations
140905 - showed blood circulation problems. Had to end the test after just 7
140906 - minutes due to chest pain.
140908 - ..
140909 - [...below medical chart says 11 of 12 test locations
140910 - positive for CAD. ref SDS 0 0L63
140912 - ..
140913 - [...below, Doctor Eagan applies "evidence-based" medicine
140914 - to assess requirements for cardiology care. ref SDS 0 7S8M
140916 - ..
140917 - [On 101117 0530 Doctor Zimmet commended Doctor Eagan's
140918 - excellent cardiology practice. ref SDS 16 SV3T
140920 - ..
140921 - [On 091021 0716 Doctor Shunk performed angiogram test at VA
140922 - Medical Center in San Francisco, findings severe
140923 - restrictions in at least 2 main arteries to the heart, and
140924 - feels this normally would cause patient severe pain or
140925 - "heart attack" just sitting or with mild effort.
140926 - ref SDS 9 7L6X
140928 - ..
140929 - [On 110406 1230 treadmill stress test performed 2 years
140930 - after heart surgery; initial indications are 100%
140931 - performance, with one node showing possible slight
140932 - irregularity. ref SDS 20 OF8F
140934 - ..
140935 - Doctor Egan asked for patient history on chest pain?
140937 - ..
140938 - Reviewed the record presented to Doctor Lee at the VA on 090908 1130.
140939 - ref SDS 5 MY4N Vigorous pace for daily hikes of 5 - 14 miles the past
140940 - 5 years caused only minor and occasional chest pains going up the
140941 - first big hill at Lafayette Reservoir, and then subsided the rest of
140942 - the 3 mile route on flat terraine, and doing other, more difficult
140943 - hills hiking around the reservoir. On subsequent laps there was no
140944 - pain doing the first hill again. These occasional and temporary pain
140945 - episodes on the first hill were attributed to being out of shape due
140946 - to lack of activity, except tennis, the prior 10 years, so it was
140947 - believed the lungs were expanding on the first lap. Another
140948 - explanation was that cold air initially was felt in the lungs on the
140949 - first lap.
140951 - ..
140952 - This situation changed about 3 days or so before seeing Doctor Lee at
140953 - the VA on 090908. Suddenly, mild chest pain that began going up the
140954 - first hill at the reservoir, did not subside on reaching the flat
140955 - terraine, but rather remained the entire 3 mile route, and continued
140956 - through the 2nd and 3rd laps. Increasing the pace increased
140957 - discomfort. The only way to stop the pain was to slow the pace. The
140958 - next day or so, before seeing Doctor Lee tried hiking slowly, and this
140959 - avoided chest pain even on the steep hills.
140961 - ..
140962 - [On 110309 0900 Doctor Egan asks about patient hiking?
140963 - ref SDS 17 6Z4N
140965 - ..
140966 - [On 131017 1000 meeting Doctor Egan determined that since
140967 - patient is very active phyically, hiking 1200 miles past 5
140968 - months, including Half Dome on 130918, and since the
140969 - patient remain asymptomatic, there is no need to perform
140970 - another treadmill stress test to evaluate for blocked
140971 - arteries due to elevated cholesterol in the lab on 131015.
140972 - ref SDS 23 ZZ6N
140974 - ..
140975 - Presented explanation of technician or doctor who attended the stress
140976 - test a few weeks ago. At that time, a theory was offered for the
140977 - treadmill stress test finding severe blockages in main arteries to the
140978 - heart, but the patient has only recently begun to have continuing
140979 - chest pain during hikes.
140980 -
140981 - [...below, Doctor Eagan's medical chart Progress Notes cite
140982 - chest pain associated with hiking. ref SDS 0 0L9J
140983 - ..
140984 - The VA stress test attendant advised that besides main arteries, blood
140985 - flows to the heart through a great many small collateral and branch
140986 - blood vessels that grow, as primary arteries become blocked with
140987 - plaque. Heavy exercise expands these small capillaries enabling
140988 - increased blood flow to the heart that offsets reduced flow through
140989 - the arteries. Eventually, the amount of flow reduced by restrictions
140990 - in the arteries exceeds the capacity of capillaries to expand. The
140991 - patient then experiences pain, and if not corrected, will suffer heart
140992 - attack.
140994 - ..
140995 - [On 131016 0800 dentist relates artery 100% blockage cannot
140996 - be repaired with stent; heart surgery not prescribed
140997 - because at present capillaries providing sufficient blood
140998 - supply. ref SDS 22 HS6G
141000 - ..
141001 - [On 200124 0705 follow up Cath angiogram 10 years later
141002 - found bypass grafts completely clear due to hiking that
141003 - raised HDL, ref SDS 24 ME8G; 1 branch vessel had 90%
141004 - stenosis; Doctor did not apply stent, because blockage does
141005 - not affect heart function nor patient health, ref SDS 24
141006 - 5J8O; Harvard Medical article explains when plaque narrows
141007 - an artery that feeds the heart, the body responds by trying
141008 - to bulk up tiny blood vessels in the heart. As these
141009 - so-called collateral vessels grow more muscular and
141010 - interconnected, they begin to reroute some of the blood
141011 - flow around the blockage. Exercise dramatically increases
141012 - blood flow through the coronary arteries. The inner lining
141013 - of the arteries responds to this "stress" much as it does
141014 - to the stress of atherosclerosis, by stimulating collateral
141015 - blood vessels to elongate, widen, and form new connections.
141016 - ref SDS 24 EH96
141018 - ..
141019 - This explains in part why initial mild chest pains go away after
141020 - hiking .5 to 1 mile of the 3 mile route at Lafayette reservoir. It
141021 - also explains why the heart rate (pulse) rises to over 200 when going
141022 - up the hills. The heart has to work harder to force enough blood
141023 - through small capillaries rather than through larger arteries.
141025 - ..
141026 - [...below, Doctor Eagan's medical chart recognizes Doctor
141027 - Lee's assessment, ref SDS 0 0L9J, and work plan to evaluate
141028 - coronary issues before treating achalasia. ref SDS 0 IZ4F
141030 - ..
141031 - [On 091021 0716 Doctor Shunk performed angiogram test at VA
141032 - Medical Center in San Francisco, findings severe stenosis
141033 - restrictions in at least 2 main arteries to the heart, and
141034 - feels this normally would cause patient severe pain or
141035 - "heart attack" just sitting or with mild effort.
141036 - ref SDS 9 7L6X
141038 - ..
141039 - Previously, on 980217 discussed with dentist that dental problems can
141040 - lead to heart failure. ref SDS 1 FV4H
141042 - ..
141043 - Doctor Egan feels current issues are not caused by dental problems.
141045 - ..
141046 - Decided to perform angiogram test (cardiac catheterization) which
141047 - inserts a probe through the groin to test condition of arteries and
141048 - the heart. (see research below, ref SDS 0 V63W)
141049 -
141050 - [On 091007 0021 letter to medical team confirms schedule
141051 - for angiogram test, and asks about cause of pain.
141052 - ref SDS 7 VM9V
141054 - ..
141055 - [On 091007 0818 Doctor Egan did not have time to respond;
141056 - Karen describes symptoms as classic "angina," but does not
141057 - explain what causes pain per se, nor reconcile rising heart
141058 - disease with improving circulation shown by falling blood
141059 - pressure and pulse. ref SDS 8 9E4S
141061 - ..
141062 - [On 091021 0716 angiogram findings multiple vessel disease,
141063 - ref SDS 9 7L43, with recommendation for CABG (coronary
141064 - artery bypass graft). ref SDS 9 7L61
141066 - ..
141067 - Angiogram test work will be performed in San Francisco.
141069 - ..
141070 - If a serious condition is identified and in only 1 - 3 veins, then
141071 - during the procedure, stints might be placed to repair artery damage.
141073 - ..
141074 - If artery damage is widespread involving more than 3 veins, which
141075 - Doctor Eagan suspects, based on stress test results, then heart bypass
141076 - surgery might be required.
141077 -
141078 - [...below medical chart confirms assessment of TVD (triple
141079 - vessel disease], ref SDS 0 8X3G, which will likely require
141080 - heart surgery. ref SDS 0 7S8M
141082 - ..
141083 - [On 091021 0716 Doctor Shunk performed angiogram test at VA
141084 - Medical Center in San Francisco, findings severe
141085 - restrictions in at least 2 main arteries to the heart, and
141086 - feels this normally would cause patient severe pain or
141087 - "heart attack" just sitting or with mild effort.
141088 - ref SDS 9 7L6X
141090 - ..
141091 - [On 091228 1049 notified Doctor Egan in Cardiology at VA in
141092 - Martinez, and also Doctor Sandhu in Primary Care of
141093 - successful heart surgery on 091022. ref SDS 15 JN9X
141095 - ..
141096 - If damage is not severe, which is not expected, then the condition
141097 - might be treated with chrolesterol medication.
141099 - ..
141100 - Should get a call today or tomorrow to schedule the test in about 2 -
141101 - 3 weeks. Doctor recommends not hiking Lafayette reservoir until after
141102 - the test.
141103 -
141104 - [...below medical chart confirms discussion to defer
141105 - further hiking until after review and resolution of
141106 - coronary artery disease. ref SDS 0 RD5F
141108 - ..
141109 - [On 091006 0843 Karen called to schedule work ordered by
141110 - Doctor Egan to perform cardiac catheterization on 091020
141111 - evaluating heart and blood flow. ref SDS 6 1W5I
141113 - ..
141114 - [On 091007 0021 letter to medical team confirms schedule
141115 - for angiogram test, and asks cause of pain. ref SDS 7 VM9V
141117 - ..
141118 - [On 091021 0716 angiogram positive for multi-vessel
141119 - disease; Doctor Shunk recommends CABG (coronary artery
141120 - bypass graft) surgery. ref SDS 9 S59L
141122 - ..
141123 - [On 091022 0700 quadruple heart bypass surgery performed by
141124 - Doctor Tseng, and her team; took about 8 hours. ref SDS 10
141125 - 01F9
141127 - ..
141128 - Doctor Egan advised that Doctor Lee's plan to perform pneumatic
141129 - dilation to sovle achalasia problem presented on 090908 1130,
141130 - ref SDS 5 BU6W, cannot be performed until after angiogram and other
141131 - measures required to restore heart function are completed.
141132 -
141133 - [On 091030 0810 at 1406 meeting with Doctor Stewart,
141134 - ref SDS 11 KE3B, to discuss plans for Heller Myotomy
141135 - laproscopic surgery to resolve achalasia. ref SDS 11 GM5I
141137 - ..
141138 - [On 091206 1300 meeting at VA Doctor Stewart advances
141139 - Heller Myotomy surgery to 091216. ref SDS 12 PQVQ
141141 - ..
141142 - [On 091216 0600 Heller Myotomy surgery at VA in San
141143 - Francisco to resolve achalasia. ref SDS 13 PQ7S
141145 - ..
141146 - [On 091220 0527 discharged from VA hospital after recovery
141147 - from surgery, with ability to swallow food. ref SDS 14 PP5V
141148 -
141149 -
141150 -
141152 - ..
1412 -
1413 -
1414 - 2251
1415 -
141501 - Research on the Internet shows...
141502 -
141503 - 1. About.com Heart Disease
141504 -
141505 - http://heartdisease.about.com/cs/catheterization/a/cath.htm
141507 - ..
141508 - 2. Cardiac catheterization and angiography
141509 - Heart caths - what you should know
141511 - ..
141512 - 3. By Richard N. Fogoros, M.D., About.com
141513 -
141514 - http://heartdisease.about.com/bio/Richard-N-Fogoros-M-D-6616.htm
141516 - ..
141517 - 4. Updated: November 20, 2008
141519 - ..
141520 - 5. About.com Health's Disease and Condition content is reviewed by
141521 - our Medical Review Board
141522 -
141523 - http://www.about.com/health/review.htm
141525 - ..
141526 - 6. See More About:
141527 -
141528 - coronary artery disease
141529 -
141530 - http://heartdisease.about.com/lr/coronary_artery_disease/89139/1/
141531 -
141532 - cardiac testing
141533 -
141534 - http://heartdisease.about.com/lr/cardiac_testing/89139/2/
141536 - ..
141537 - 7. Cardiac catheterization and angiography are tests in which
141538 - catheters (hollow tubes) are placed into the heart in order to
141539 - evaluate the anatomy and function of the heart and surrounding
141540 - blood vessels. So much useful information can be obtained from
141541 - these tests that they are performed in virtually all patients
141542 - being considered for bypass surgery or angioplasty and
141543 - stenting.
141545 - ..
141546 - Another source says in part...
141547 -
141548 - Cardiologychannel
141549 - Cardiac Catheterization
141550 -
141551 - Original Date of Publication: 01 Jul 2001
141552 - Reviewed by: Stanley J. Swierzewski, III, M.D.
141553 - Last Reviewed: 04 Dec 2007
141554 -
141555 - http://www.cardiologychannel.com/cardiaccath/index.shtml
141557 - ..
141558 - Cardiac catheterization involves passing a catheter (i.e., a
141559 - thin flexible tube) through an artery or a vein to the heart,
141560 - and into a coronary artery. This procedure produces angiograms
141561 - (i.e., x-ray images) of the coronary arteries and the left
141562 - ventricle, the heart's main pumping chamber, and also can be
141563 - used to measure pressures in the pulmonary artery and to
141564 - monitor heart function, usually in critically ill patients
141565 - (called right heart catheterization).
141567 - ..
141568 - In most cases, cardiac catheterization is recommended when a
141569 - partial or complete arterial blockage is suspected. It is used
141570 - to evaluate how well the heart is functioning and to obtain
141571 - information about blockages.
141573 - ..
141574 - Cardiac catheterization is performed in a hospital. Usually,
141575 - the procedure takes 2 to 3 hours to perform and patients are
141576 - required to remain immobile for 4 to 6 hours following cardiac
141577 - catheterization.
141579 - ..
141580 - Cardiac catheterization - what you should know continues...
141581 -
141582 - 8. How is a catheterization performed?
141583 -
141584 - The patient is brought to the catheterization laboratory and
141585 - placed on a special examination table. After local anesthesia
141586 - is given, a catheter is inserted into blood vessels in the
141587 - groin, arm, or neck. (The catheter is inserted either through a
141588 - small incision, or by means of a needle-stick. Sometimes,
141589 - catheters are inserted from more than one site.) The catheter
141590 - is advanced through the blood vessels to the heart.
141592 - ..
141593 - 9. Once in the heart, the catheter can be maneuvered to various
141594 - locations within the heart, and the pressures within various
141595 - chambers of heart are measured. Blood samples can be withdrawn
141596 - from different locations in order to measure the amount of
141597 - oxygen in the blood (unusual variations in blood oxygen can
141598 - signal a "shunt," or abnormal blood flow within the heart,
141599 - often caused by congenital heart defects.) Finally, by
141600 - injecting dye through the catheter while a series of rapid
141601 - x-ray images is recorded, "movies" can be made of the blood
141602 - flowing through the cardiac chambers, or the through the blood
141603 - vessels surrounding the heart - a procedure know as angiography
141604 - (also called arteriography).
141606 - ..
141607 - 10. Once the procedure is completed, the catheter(s) are removed.
141608 - Bleeding is controlled by placing pressure on the
141609 - catheterization site for 30 - 60 minutes.
141611 - ..
141612 - 11. What kinds of heart disease can catheterization and angiography
141613 - help to evaluate?
141615 - ..
141616 - Cardiac catheterization and angiography can reveal vital
141617 - information about overall cardiac function, about the function
141618 - of the individual cardiac chambers, about the cardiac valves
141619 - (whether they are too narrow (stenosis) or too leaky
141620 - (regurgitation)), congenital heart defects, and about the
141621 - location and severity of blockages in the coronary arteries
141622 - (the arteries that supply blood to the heart muscle).
141624 - ..
141625 - 12. What are some of the variations used with catheterization and
141626 - angiography?
141628 - ..
141629 - Cardiac catheterization is often used therapeutically, that is,
141630 - to deliver treatment for various heart problems. Therapeutic
141631 - catheterizations include procedures to dilate narrowed heart
141632 - valves, procedures to close atrial septal defects (i.e., a hole
141633 - in the wall separating the left and right atria), and of
141634 - course, procedures to relieve blockages in the coronary
141635 - arteries (angioplasty and stent placement).
141637 - ..
141638 - 13. What are the risks of having a catheterization or angiography?
141639 -
141640 - Cardiac catheterization and angiography are relatively safe,
141641 - but because they are invasive procedures involving the heart,
141642 - several complications are possible. Nobody should have a
141643 - cardiac catheterization unless there is a reasonable likelihood
141644 - that the information gained from the procedure will be of
141645 - significant benefit.
141647 - ..
141648 - 14. Minor complications of cardiac catheterization include minor
141649 - bleeding at the site of catheter insertion, temporary heart
141650 - rhythm disturbances caused by the catheter irritating the heart
141651 - muscle, and temporary changes in the blood pressure.
141653 - ..
141654 - 15. More significant complications include perforation of the heart
141655 - wall (causing a life-threatening condition called cardiac
141656 - tamponade), sudden blockage of a coronary artery (leading to a
141657 - heart attack), extensive bleeding, stroke, or an allergic
141658 - reaction to the dye used in angiography.
141659 -
141660 -
1417 -
SUBJECTS
Default Null Subject Account for Blank Record
1503 -
150401 - ..
150402 - Progress Notes Meeting VA Cardiology Department
150403 -
150404 - Doctor Egan's VA report on meeting today...
150405 -
150406 - 1. Local Title: Cardiology Consult 15009
150407 - Standard Title: Cardiology Procedure Consult
150408 - Date of Note................................. 091002 1017
150409 - Entry Date................................... 091002 101714
150410 - Author....................................... James Egan
150411 - Exp Cosigner.................................
150412 - Urgency......................................
150413 - Status....................................... Completed
150414 -
150415 - [On 110309 0900 followed up Progress Notes next meeting
150416 - with Doctor Egan in Cardiology at Martinez Clinic.
150417 - ref SDS 18 S16N
150419 - ..
150424 - ..
150425 - 2. Seen by Doctor Lee 090908 for follow up of chronic
150426 - achalasia/dysphagia and weight loss [see case study patient
150427 - history on 090908 1130. ref SDS 5 FT6M]. A recent history of
150428 - exertional chest discomfort was elicited and ETT requested
150429 - anticiapting EGD with possible pneumatic dilation in the near
150430 - future. ("A relatively new symptoms is that of some exertional
150431 - chest pressure [...see again patient history meeting with
150432 - Doctor Lee on 090908 1130. ref SDS 5 MY4N...]. He has been
150433 - physically active on a regular basis, going on regular hikes
150434 - and over the past week or two he has noticed some pressure-like
150435 - sensaton in his chest after he has been climbing uphill. He
150436 - does not get this sensation when he is on level ground.") [...
150437 - aligns with report to the doctor, per above. ref SDS 0 LF6O...]
150438 -
150439 - [On 110309 0900 Doctor Egan asks about patient hiking?
150440 - ref SDS 17 6Z4N
150442 - ..
150443 - 3. TMST performed 090916. With treadmill exercise the patient
150444 - sustained chest discomfort and two mm of ST depression in lead
150445 - V5. In the post-exercise period downsloping ST depressions
150446 - and TWIs seen in 11/12 leads (ST elevation in AVR).
150448 - ..
150449 - 4. Doctor Sandhu now requests cardiology guidance on furtrher
150450 - therapy and diagnostic testing.
150452 - ..
150453 - 5. History of hyperlipidemia, prescribed but difficulty taking
150454 - simvastatin, but no prior coronary history.
150456 - ..
150457 - 6. In speaking with the patient today, hx of exertional chest
150458 - discomfor as long as 3 years ago, some respiratory component at
150459 - that time. This seemed to gradually diminish with increasing
150460 - efforts at physical activity. Is an avid hiker, usually at the
150461 - reservoir at Lafayette (hilly). In the last 2-3 months began
150462 - noticing exertional chest discomfort at lower levels of effort.
150463 - The day following TMST even flat walking produced some chest
150464 - pain. Continues to exercise, but has had to decrease pace and
150465 - distance.
150467 - ..
150468 - Aligns with explanation of Doctor Lee's report for meeting on 090908,
150469 - listed above. ref SDS 0 MU4O
150471 - ..
150472 - Doctor Egan's VA report on meeting today continues...
150473 -
150474 - 7. No hx of RF, SF or murmur.
150476 - ..
150477 - No history of dizziness, lightheadedness or syncope. No focal
150478 - neurologic symptoms.
150480 - ..
150481 - No palpitations
150483 - ..
150484 - Denies PND, Orthopnea, Edema
150486 - ..
150487 - 8. Past Medical History
150488 -
150489 - Computerized problem list is the source for the following...
150490 -
150491 - 1. Inflamed Seborrheic Keratosis
150492 - (ICD-9-CM 702.11)............................ 070312 Lin Bertha
150494 - ..
150495 - 2. Rosacia * (ICD-9-CM 695.3)................... 070312 Lin Bertha
150497 - ..
150498 - 3. Dermatitis (ICD-9-CM 692.9).................. 070312 Lin Bertha
150500 - ..
150501 - 4. Tinea Unguium (ICD-9-CM 110.1)............... 070312 Lin Bertha
150503 - ..
150504 - 5. Tinea Unguium (ICD-9-CM 110.9)............... 070312 Lin Bertha
150506 - ..
150507 - 6. Rosacia conjunctivitis
150508 - (ICD-9-CM 372.31)............................ 070312 Margulies, Linda
150510 - ..
150511 - 7. Rosacia * (ICD-9-CM 695.3)................... 070312 Margulies, Linda
150513 - ..
150514 - 8. Blepharitis NOS.............................. 070221 Margulies, Linda
150516 - ..
150517 - 9. Localized supervicial swelling, mas or
150518 - lump (ICD-9-CM 782.21)....................... 051222 Sandhu, Harkesh
150520 - ..
150521 - 10. Achalasia (ICD-9-CM 530.0)................... 051222 Sandhu, Harkesh
150523 - ..
150524 - 11. Abn. LFT's................................... 050816 Sandhu, Harkesh
150526 - ..
150527 - 12. Obesity...................................... 050629 Sandhu, Harkesh
150529 - ..
150530 - 13. Unspecified gastritis and gastroduodenitis
150531 - without mention of hemorrage................. 050629 Sandhu, Harkesh
150533 - ..
150534 - 14. Rosacia...................................... 050629 Margulies, Linda
150536 - ..
150537 - 15. Tinea Unguium................................ 050629 Margulies, Linda
150539 - ..
150540 - 9. Patient has answered NEA
150541 -
150542 - Active Outpatient Medications (including supplies):
150543 -
150544 - 1. Simvastatis 40 MG tab........................ Active
150545 -
150546 - take one-half tablet by mouth every evening - for
150547 - cholesterol * use pill cutter * do not take with grapefruit
150548 - juice.
150550 - ..
150551 - Tablet cutter use devide as directed to split tablets
150553 - ..
150554 - 10. Physical Examination
150555 -
150556 - 091002 0902
150558 - ..
150559 - Temperature.................. 98.5 F (36.9 C)
150560 - Pulse........................ 73
150561 - R............................ 20
150562 - Blood pressure............... 98 58
150563 - Oxygen....................... 97%
150564 - Pain......................... 0 - no pain
150566 - ..
150567 - Head atraumatic, PERRL
150568 - Carotid upstrokes normal, no bruits notes
150569 - Thyroid normal to palpation.
150570 - JVP wnl
150571 - Cor: Regular, no ectopy. Normal intensity and splitting of S!
150572 - S2. No significant mrg noted.
150573 - Lungs clear of rales, ronchi, and wheezes.
150574 - Abdomen supple, no abdominal bruit present.
150575 - Extremeties without cyanosis, clubing or edema.
150577 - ..
150578 - 11. Cholesterol
150579 -
150580 - Collection DT Spec CHOL Target Range
150581 - 090813 1509 PLASM 233 H
150582 - 060616 1059 PLASM 238 H
150584 - ..
150585 - See doctor's assessment of hyperlipidemia, ref SDS 0 YR4S,
150586 - aligned with research below on cholesterol risk factors.
150587 - ref SDS 0 2F8K
150588 -
150589 - TRIGLYC
150590 - 090813 1509 PLASM 118 < 150 normal
150591 - 060616 1059 PLASM 68
150593 - ..
150594 - HDL
150595 - 090813 1509 PLASM 30 L < 40 high risk > 60 low risk
150596 - 060616 1059 PLASM 32 L 192 H
150598 - ..
150599 - LDL-CHO
150600 - 090813 1509 PLASM 179 H < 70 low risk > 190 high risk
150601 - 060616 1059 PLASM 192 H
150603 - ..
150604 - The lab on 060616, is also reported in the record on 060623 0840.
150605 - ref SDS 2 UO6K
150606 -
150607 -
150608 - ---- CHEM PROFILE ---
150610 - ..
150611 - PLASMA 08/13 06/16 08/16 06/29 06/29 Reference
150612 - 2009 2006 2005 2005 2005
150613 - 1509 1059 0859 1114 1114 Units Ranges
150614 -
150615 - -------------------------------------------------------------
150616 - -------------------------------------------------------------
150618 - ..
150619 - 12. Blood Tests
150620 -
150621 - GLUCOSE 98 mg/dL 74 - 118
150622 - GLUfast mg/dL Ref <= 99
150623 - NA 138 mmol/L 136 - 144
150624 - K 3.8 mmol/L 3.4 - 4.8
150625 - CL 108 H mmol/L 98 - 106
150626 - CO2 30 mmol/L 23 - 33
150627 - BUN 11 mg/dL 8 - 26
150628 - CREAT 0.86 mg/dL .5 - 1.1
150629 - eGFR >60 mL/min Ref >= 60
150630 - CALCIUM 8.8 mg/dL 8.7 - 10.2
150631 - CA CORR mg/dL 8.7 - 10.2
150632 - PO4 mg/dL 2.4 - 4.5
150633 - MG mg/dL 1.8 - 2.5
150634 - ALK PHO 102 Int/Units/L 37 - 107
150635 - T BIL 1.7 H mg/dL .3 - 1.2
150636 - D BILI 0.1 mg/dL .1 - .4
150637 - AST 18 Int/Units/L 8 - 42
150638 - ALT 16 Int/Units/L 5 - 55
150639 - ALBUMIN 3.9 g/dL 3.3 - 4.8
150640 - PROTEIN 7.1 g/dL 6.5 - 8.1
150642 - ..
150643 - 13. CBC
150644 -
150645 - Collection DT Spec WBC HGB HCT MCV MCHC PLT
150646 - 090813 1509 BLOOD 10.5 15.7 45.2 87.9 34.8 350
150647 - 060707 0840 BLOOD 10.5 16.0 46.6 88.2 34.3 377
150649 - ..
150650 - 14. EKG Date: 090908 1321
150651 -
150652 - Vent Rate................... 37
150653 - QRS Duration................ 84
150654 - QTC......................... 405
150655 - R Axis...................... -2
150656 - Confirmation Status.........
150657 - PR Interval................. 170
150658 - QT.......................... 416
150659 - P Axis...................... 45
150660 - T Axis...................... 38
150661 - Interpreted By..............
150663 - ..
150664 - Auto Instrument Diagnosis:
150665 - Sinus bradycardia
150666 - Otherwise normal EKG
150667 - No previous ECGs available
150669 - ..
150670 - 15. Stress Test with EKG
150671 -
150672 - Date: 090916
150674 - ..
150675 - Auto Instrument Data?:
150676 - Primary Provider:
150678 - ..
150679 - Comments
150680 -
150681 - 1. The patient exercised according to the BRUCE for 6:59,
150682 - achieving a work level of Max.METS: 8.50.
150684 - ..
150685 - 2. Resting heart rate initially 71 BPM, rose to a maximum
150686 - heart rate of 136 PBM which represents 87% of the maximal
150687 - age-predicted heart rate.
150689 - ..
150690 - 3. Resting blood pressure 130/70 mmHg, rose to a maximum blood
150691 - pressure of 150/80 mmHg.
150693 - ..
150694 - 4. The exercise test was stopped due to CHEST PAIN.
150696 - ..
150697 - 5. Good exercise tolerance.
150699 - ..
150700 - 6. ST depression 2 mm., crescendo angina.
150702 - ..
150703 - 7. Positive exercise tolerence test.
150705 - ..
150706 - 16. Xray Test
150707 -
150708 - Chest 2 views PA & LAT
150709 -
150710 - 1. Examination Date...................... 090908 1314
150711 - Requesting Physician.................. Lee Randall E
150712 - Pat Location:
150713 -
150714 - MTZ MED GI (LEE) (Req'g Loc)
150716 - ..
150717 - 2. Imag Location:
150718 -
150719 - Martinez Radiology
150721 - ..
150722 - 3. Service: Unknown
150724 - ..
150725 - 4. Case 482 Complete
150726 - Chest 2 Views PA & LAT
150727 - RAD Detailed
150728 - CPT: 71020
150730 - ..
150731 - 5. Reason for Study: pre procedural baseline
150733 - ..
150734 - 6. Clinical History
150735 -
150736 - 64 year old man with achalasia. Dilation planned. Request
150737 - preprodedural CXR for baseline comparison.
150739 - ..
150740 - 7. Report status: Verified
150741 - Date Reported......................... 090808
150742 - Date Verified......................... 090808
150743 - Verifier E-Sig ES..................... Jonathan F Barry MD
150745 - ..
150746 - 8. Report
150747 -
150748 - 1. Chest AP and lateral
150749 -
150750 - 2. Comparison: None
150751 -
150752 - 3. History:
150753 -
150754 - Preprodedural chest xray. Patient has a history of
150755 - achalasia.
150757 - ..
150758 - 4. Findings:
150759 -
150760 - There is a large curvilinear density proejcting over
150761 - the spine and projecting to the right of midline. This
150762 - is in the exact position of the markedly dilated
150763 - esophagus identified on the upper GI Exam done on
150764 - 050714. Aorta is normal and the heart is borderline in
150765 - size. The lungs are fully aerated and there is no
150766 - evidence of acute or chronic changes of aspiration or
150767 - other specific parenchymal pathology. The
150768 - hemidiaphragms are visualized and the costophrenic
150769 - angles are clear. Mid and upper mdeiastinum is normal
150770 - and the trachea is in normal position.
150772 - ..
150773 - 5. Impression:
150774 -
150775 - 1. Large dilated esophagus extending to the right of
150776 - midline as described. ref SDS 0 YR4N
150777 -
150778 - 2. No acute or evolving pulmonary pathology.
150780 - ..
150781 - 17. ASSESSMENT
150782 -
150783 - 1. CAD (coronary artery disease)
150784 -
150785 - a. Angina. class II - III with progression in pattern
150786 - within the last two months.
150788 - ..
150789 - b. Abnornal TMST, relatively low work load, multiple lead
150790 - ischemia, suggets TVD (triple vessel disease).
150792 - ..
150793 - 2. Hyperlipidemia
150795 - ..
150796 - Research on Hyperlipidemia
150797 -
150798 - High blood pressure, cholesterol, and triglycerides
150800 - ..
150801 - American Heart Association
150802 -
150803 - http://www.americanheart.org/presenter.jhtml?identifier=4600
150805 - ..
150806 - Hyperlipidemia is an elevation of lipids (fats) in the
150807 - bloodstream. These lipids include cholesterol, cholesterol
150808 - esters (compounds), phospholipids and triglycerides.
150809 - They're transported in the blood as part of large
150810 - molecules called lipoproteins.
150812 - ..
150813 - These are the five major families of blood (plasma)
150814 - lipoproteins:
150815 -
150816 - 1. chylomicrons
150817 - 2. very low-density lipoproteins (VLDL)
150818 - 3. intermediate-density lipoproteins (IDL)
150819 - 4. low-density lipoproteins (LDL)
150820 - 5. high-denisty lipoproteins (HDL)
150822 - ..
150823 - When hyperlipidemia is defined in terms of a class or
150824 - classes of elevated lipoproteins in the blood, the term
150825 - hyperlipoproteinemia is used.
150827 - ..
150828 - Hypercholesterolemia is the term for high cholesterol
150829 - levels in the blood.
150831 - ..
150832 - Hypertriglyceridemia refers to high triglyceride levels in
150833 - the blood.
150835 - ..
150836 - Cholesterol, understanding and controlling...
150837 -
150838 - http://www.americanheart.org/presenter.jhtml?identifier=3046598
150840 - ..
150841 - Cholesterol Levels - What do they mean??
150842 -
150843 - http://www.americanheart.org/presenter.jhtml?identifier=3004817
150844 -
150845 - PDF
150846 -
150847 - http://www.americanheart.org/downloadable/heart/119618151049911%20CholLevels%209_07.pdf
150849 - ..
150850 - 1. HDL Cholesterol
150851 -
150852 - HDL stands for high-density lipoprotein. HDL is "good"
150853 - cholesterol because it seems to lower your risk of
150854 - heart attack and stroke. That means that - unlike
150855 - other cholesterol levels - the higher your HDL
150856 - cholesterol, the better. You can raise your HDL
150857 - cholesterol by quitting smoking, losing excess weight
150858 - and being more active.
150860 - ..
150861 - HDL Cholesterol Levels...
150862 -
150863 - < 40 mg/dL for men = Low HDL (higher risk)
150864 -
150865 - < 50 mg/dL for women = Low HDL (higher risk)
150866 -
150867 - 40 - 49 mg/dL = the higher the better
150868 -
150869 - > 60 mb/dL = high HDL (lower risk)
150870 -
150872 - ..
150873 - 2. LDL Cholesterol
150874 -
150875 - Low-density lipoprotein (LDL) is the main carrier of
150876 - harmful cholesterol in your blood. A high level of LDL
150877 - cholesterol means there's a higher risk of heart
150878 - disease and stroke.
150880 - ..
150881 - Less than 70 mg/dL = Optional goal if you're
150882 - at very high risk of a heart attack or death
150883 - from heart attack.
150885 - ..
150886 - Less than 100 mg/dL = Optimal for people
150887 - with heart disease or diabetes
150889 - ..
150890 - 100 to 129 mg/dL = Near or above optimal
150891 - 130 to 159 mg/dL = Borderline high
150892 - 160 to 189 mg/dL = High
150893 - 190 mg/dL and above = Very High
150895 - ..
150896 - 3. Triglycerides
150897 -
150898 - Triglycerides are the most common type of fat in your
150899 - body. They're also a major energy source. They come
150900 - from food, and your body also makes them. As people
150901 - get older, gain excess weight or both, their
150902 - triglyceride and cholesterol levels tend to rise. Many
150903 - people who have heart disease or diabetes have high
150904 - fasting triglyceride levels. Some studies have shown
150905 - that people with above-normal fasting triglyceride
150906 - levels (150 mg/ dL or higher) have a higher risk of
150907 - heart disease and stroke.
150909 - ..
150910 - Less than 150 mg/dL = Normal
150911 - 150 to 199 mg/dL = Borderline High
150912 - 200 to 499 mg/dL = High
150913 - 500 mg/dL and above = Very High
150914 -
150915 -
150916 -
1510 -
SUBJECTS
Default Null Subject Account for Blank Record
1603 -
160401 - ..
160402 - Doctor Egan's VA report on meeting today continues...
160403 -
160404 - 3. Achalasia
160405 -
160406 - Background on Doctor Lee diagnosing achalasia, reported on
160407 - 090908 1130. ref SDS 5 FT6M
160409 - ..
160410 - 18. Discussion
160411 -
160412 - Given patient's history of exercise ECG [11 of 12 leads
160413 - positive, ref SDS 0 0L63] very little doubt in my mind that his
160414 - symptoms are due to underlying CAD [coronary artery disease].
160415 - ref SDS 0 8X3G We have agreed to cross our fingers that it may
160416 - be amenable to PCI, but I suspect TVD [triple vessel disease]
160417 - +/- LMD [left main coronary artery disease] which will require
160418 - surgery. Explained results of tests and full spectrum of
160419 - possibilities to patient and his wife with good understanding.
160420 - He has ageed with consultation to SFVA for coronary angiography
160421 - with PCI if possible.
160423 - ..
160424 - This is excellent analysis applying "evidence-based medicine" to plan
160425 - the work, reviewed a few months ago on 090725. ref SDS 4 T55W
160427 - ..
160428 - [On 091021 0716 angiogram positive for multi-vessel
160429 - disease; Doctor Shunk recommends CABG (coronary artery
160430 - bypass graft) surgery. ref SDS 9 S59L
160432 - ..
160433 - [On 091021 0716 medical team at VA in San Francisco asks
160434 - for patient history on achalasia and discovery of CAD
160435 - over 10 times, because Doctor Egan's excellent report
160436 - today, cannot be accessed in time to carry on the work.
160437 - ref SDS 9 LJ7L
160439 - ..
160440 - [On 091022 0700 quadruple heart bypass surgery performed
160441 - by Doctor Tseng, and her team; took about 10 hours.
160442 - ref SDS 10 01F9
160444 - ..
160445 - [On 091228 1049 notified Doctor Egan in Cardiology at VA
160446 - in Martinez, and also Doctor Sandhu in Primary Care of
160447 - successful heart surgery on 091022. ref SDS 15 JN9X
160449 - ..
160450 - [On 110309 0900 Progress Notes for next meeting with
160451 - Doctor Egan post CABG surgery. ref SDS 19 S16N
160453 - ..
160454 - 19. PLAN
160455 -
160456 - 1. ASA 325 mg daily if possible. If unable, will try 81 mg
160457 - bid
160458 -
160459 - 2. Continue simvastatin as well as able.
160461 - ..
160462 - 3. Consult SFVA for coronary angiogram.
160464 - ..
160465 - 4. Asked to refrain from hiking until diagnostic studies
160466 - completed because of potential risk for arrhythmia in an
160467 - isolated location. ref SDS 0 W67J
160469 - ..
160470 - 5. Prescription (Rx):
160471 -
160472 - NTG 0.4 mg sl prn cp not responding to a brief period
160473 - of rest. If no relife with one NTG to call 911
160475 - ..
160476 - 6. RTC post cath/intervention
160478 - ..
160479 - 20. CLINICAL REMINDERS
160480 -
160481 - LDL >=160 Goal < 160. ref SDS 0 5X6U
160482 -
160483 - The patient's medication for hyperlipidemia was adjusted.
160485 - ..
160486 - 21. SIGNED
160487 -
160488 - /es/ James Egan MD
160489 - Cardiologist
160490 - Signed: 091002 1019
160491 -
160492 -
160493 -
160494 -
160495 -
160496 -
160497 -
160498 -
1605 -