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0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 21 0000. ref SDS 19 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040507 -
040508 -
040992 -
040994 -  ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Submitted follow up letter to the medical team confirming results of
041302 - meeting at the VA on 091119, and submitting agenda issues for next
041303 - meeting scheduled on 091217...
041304 -
041305 -    1.  Subject: Confirm Planning from Meeting at VA on Nov 19th Recover Heart Surgery
041306 -        Date: Tue, 01 Dec 2009 11:28:35 -0800
041316 -         ..
041317 -    3.  On 091118 an agenda was submitted for discussions the next day
041318 -        on Nov 19th.  Erick led the meeting on the 19th, and advised
041319 -        that he did not get the agenda.  Traffic getting to San
041320 -        Francisco delayed the meeting, so there wasn't enough time to
041321 -        review the record.
041323 -         ..
041324 -    4.  Hopefully today, there will be enough time to make distribution
041325 -        and review.
041327 -         ..
041328 -    5.  Findings from examination on 091118 include...
041330 -             ..
041331 -        1.  Xray at Va in Martinez on 091117 showed reduced and minimal
041332 -            fluid on the lower left lobe of the lungs, reflecting
041333 -            increased hiking that forces deep breathing. ref SDS 21
041334 -            938N
041336 -             ..
041337 -        2.  Vitals showed rising oxygen at 98 up from 94 reported
041338 -            during hospitalization, and further indicating resolution
041339 -            of fluid on the left lung. ref SDS 21 JB56
041341 -             ..
041342 -        3.  Sternum surgery incision healing normally; no evidence of
041343 -            compromise or complications. ref SDS 21 936G
041345 -             ..
041346 -        4.  Incision on right leg and chest healing on schedule.
041347 -            ref SDS 21 IF5F
041349 -             ..
041350 -        5.  Lab report from test at VA in Martinez on 091117, shows WBC
041351 -            remains normal for patient history, and albumin indicates
041352 -            nutrition remains stable and adequate for recovery from
041353 -            heart surgery. ref SDS 21 9S5V
041355 -             ..
041356 -        6.  Follow up review on heart surgery planned for 091217 1030
041357 -            [reported on 091119 1000. ref SDS 21 FW5O same day as
041358 -            surgery to recover from achalasia, also scheduled for
041359 -            091217 according to Paula on 091102. ref SDS 16 PS60
041361 -         ..
041362 -    6.  Interim Progress...
041364 -             ..
041365 -        1.  Hiking has continued to increase.  Have done 2 laps at
041366 -            Lafayette Reservoir several times (6 miles), and on
041367 -            Saturday 091128 did 3 laps, about 9 miles with warm down.
041369 -             ..
041370 -        2.  Improvements from heart surgery seem evident:
041371 -
041372 -            (a)  no chest pain hiking up the tough hills; and
041374 -                  ..
041375 -            (b)  recovery from elevated pulse during hiking now occurs
041376 -                 in about 30 minutes after ending long hikes, rather
041377 -                 than 4 - 6 hours, as occurred previously, prior to
041378 -                 surgery on 091022.
041380 -                  ..
041381 -            (c)  scab on right leg incision fully resolved.
041383 -             ..
041384 -        3.  INR falls below 2.0 despite increasing Coumadin.
041386 -             ..
041387 -            On 091124 INR 1.7 increased slightly from 1.5 a week
041388 -            earlier, so Coumadin was increased from 2 mg to 3 mg per
041389 -            day.
041391 -             ..
041392 -            Today, on 091201 INR still 1.7, so Coumadin increased to
041393 -            4.5 mg 2 days per week, and held at 3 mg for 5 days per
041394 -            week.
041396 -         ..
041397 -    7.  Pending issues...
041399 -             ..
041400 -        1.  Confirm date for surgery on 091217 to resolve achalasia.  A
041401 -            letter was received scheduling a meeting with Doctor
041402 -            Stewart on 091208; however, there is nothing in the record
041403 -            showing surgery is actually scheduled for 091217, as
041404 -            related by  Paula during the meeting on 091103. ref SDS 16
041405 -            PS60
041406 -
041407 -               [On 091208 1300 everything lined up for Heller Myotomy
041408 -               surgery on 091216, advanced from original schedule on
041409 -               091217, to recover from achalasia, and transform
041410 -               negative synergy to make nutrition a postive factor
041411 -               recovery from heart surgery. ref SDS 23 C65G
041413 -             ..
041414 -        2.  Ensure treatment prescribed for nutrition will run out OA
041415 -            091217, the date planned for surgery to resolve achalasia,
041416 -            so that normal eating can resume.  If surgery gets delayed,
041417 -            Ensure prescription may need to be updated to maintain
041418 -            nutrition for recovering from heart surgery.
041420 -             ..
041421 -        3.  Tests for surgery and/or examination on 091217 - if blood
041422 -            work, xrays, etc., are needed can this be scheduled at VA
041423 -            in Martinez a day or so before coming to San Francisco on
041424 -            091217, to facilitate time management, as was done for the
041425 -            meeting on 091119?
041427 -             ..
041428 -        4.  Diana Ruiz, case manager for Coagulation Control at the VA
041429 -            in Martinez presents several questions...
041431 -                 ..
041432 -            a.  Should sonogram test be performed to affirmatively
041433 -                verify resolution of DVT in the right neck; and, if
041434 -                testing shows DVT not resolved, then should Coumadin
041435 -                (warfarin) be continued until testing establishes DVT
041436 -                resolved?
041438 -                 ..
041439 -                Alternatively, should Coumadin be stopped on 091212,
041440 -                per original work plan for 6 week treatment?
041442 -                 ..
041443 -                During the meeting with Erick and Neil on 091119 follow
041444 -                up sonogram test was discussed, with plans for review
041445 -                and determination of this issue.
041446 -
041447 -                    [On 091208 1300 Doctor Stewart ordered sonogram
041448 -                    test to evaluate DVT and need to continue Coumadin
041449 -                    (warfarain) treatments, since these treatments need
041450 -                    to end or be paused at least 5 days prior to
041451 -                    surgery to resolve achalasia scheduled on 091216.
041452 -                    ref SDS 23 C46I
041454 -                 ..
041455 -            b.  If treatment for DVT continues, then Coumadin should be
041456 -                paused for 5 days prior to surgery for achalasia.
041457 -
041458 -                    [On 091208 1300 sonogram test shows DVT resolved,
041459 -                    warfarin (Coumadin) treatments ended. ref SDS 23
041460 -                    D24G
041462 -         ..
041463 -        Looking forward to meeting Doctor Stewart next Tuesday on
041464 -        091208, and to surgery a week later on 091217, at which time,
041465 -        also plan follow up exam with CT surgery team.
041466 -
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0415 -