620437 - ..
620438 - Units = millimeters of mercury
620439 -
620440 - Systolic Diastolic
620441 - Very 230 135 Very
620442 - severe 220 130 severe
620443 - Stage 4 210 125 Stage 4
620444 - 200 120
620445 - 190 Severe 115
620446 - 180 Stage 3 110
620447 - Moderate 170 105
620448 - Stage 2 160 Requires treatment 100
620449 - Mild 150 Hypertension 95
620450 - Stage 1 140 High blood pressure 90
620451 - 130 High normal 85
620452 - 120 Optimal 80
620453 - 110 After heavy exercise 70
620454 - 100 65
620455 - 90 Low normal 60
620456 - 80 Hypertension low BP 55
620457 - 70 Weak tired 50
620458 - 60 Dizzy fainting 45
620459 - 50 35
620460 - Coma
620461 - Death
620463 - ..
620464 - Sweat (exercise) is the best cardiovascular agent known to
620465 - man... Stanford cardiologist
620466 -
620467 -
620469 - ..
620470 - Diet Optimal Blood Pressure Health
620471 -
620472 - Apples
620473 - Avacado
620474 - Bannana
620475 - Broccoli
620476 - Garlic
620477 - Fish
620478 - Grapes
620479 - Oats
620480 - Orange juice
620481 - water
620482 -
620483 -
620484 -
6205 -
SUBJECTS
Default Null Subject Account for Blank Record
6303 -
630401 - ..
630402 - Hypertension High Blood Pressure Systolic Key Diagnostic
630403 - Paradigm Shift Systolic Critical Diagnostic High Blood Pressure
630404 - Systolic Indicator Hypertension Treatable Disease High Blood Pressure
630405 - Blood Pressure Systolic Main Diagnostic Hypertension Treatable Disease
630406 -
630407 -
630408 - Science Daily
630410 - ..
630411 - Systolic -- Not Diastolic -- Blood-Pressure Reading Should Define
630412 - Hypertension, New NIH Clinical Advisory States
630413 -
630414 - http://www.sciencedaily.com/releases/2000/05/000508082111.htm
630415 -
630416 - Principal Author: Joseph Izzo, M.D.,
630417 - Professor of medicine and pharmacology
630418 - Vice chair of research Department of Medicine
630419 - University at Buffalo
630421 - ..
630422 - May 8, 2000
630423 -
630424 - 1. BUFFALO, N.Y. -- Systolic blood pressure, the first -- or
630425 - higher -- number in a blood-pressure reading, is the important
630426 - factor in determining whether a person has hypertension,
630427 - experts state in a new National Institutes of Health-sponsored
630428 - clinical advisory statement released today (May 4).
630430 - ..
630431 - 2. Traditionally, diastolic blood pressure, the second or lower
630432 - number, was thought to be more important.
630434 - ..
630435 - 3. Joseph Izzo, M.D., professor of medicine and pharmacology at
630436 - the University at Buffalo and vice chair of research for the
630437 - university's Department of Medicine, is the primary author of
630438 - the advisory, which appears in the May issue of Hypertension.
630440 - ..
630441 - 4. The document was developed by the coordinating committee of the
630442 - National High Blood Pressure Education Program, which is part
630443 - of the National Heart, Lung and Blood Institute.
630444 -
630446 - ..
630447 - Heart Disease Hypertension Systolic > 140 Paradigm Shift
630448 -
630449 - 5. Making systolic blood pressure the major criterion for
630450 - diagnosis, staging and therapeutic management of hypertension,
630451 - particularly in middle-aged and older Americans, represents "a
630452 - major paradigm shift," the advisory states. It also calls for
630453 - more vigorous control efforts and for abolishing the use of
630454 - age-adjusted blood-pressure targets.
630456 - ..
630457 - 6. "This shift affects 25 million people in the United States
630458 - whose lives can be improved by the change," Izzo said.
630459 -
630461 - ..
630462 - NIH Standard BP < 140 90 Avoid Heart Damage
630463 -
630464 - 7. Specifically, the new recommendations are:
630465 -
630466 - 1. Systolic blood pressure should become the principal
630467 - clinical endpoint for detection, evaluation and treatment
630468 - of hypertension, especially in middle-aged and older
630469 - Americans
630471 - ..
630472 - 2. Blood pressure should be maintained below 140/90 mmHg
630473 - throughout one's lifetime; above this level, early therapy
630474 - is essential to protect against organ damage.
630476 - ..
630477 - 3. More stringent blood-pressure control is necessary in
630478 - persons with high-risk conditions: hypertensive patients
630479 - with diabetes should keep their blood below 135/85 mmHg and
630480 - persons with renal or heart failure should reduce their
630481 - blood pressure to the lowest level possible.
630483 - ..
630484 - These guidelines are represented as having been derived from clinical
630485 - trials, or other evidenced based process.
630487 - ..
630488 - Article continues...
630489 -
630490 - 4. Age-adjusted blood-pressure targets are inappropriate,
630491 - including the unsubstantiated but persistent clinical
630492 - folklore that "100-+-your-age" is an acceptable systolic
630493 - blood-pressure level.
630495 - ..
630496 - Systolic 140 High Blood Pressure Treatment Lifestyle Change
630497 -
630498 - 8. Systolic blood pressure represents the maximum force exerted
630499 - by the heart against the blood vessels during the heart's
630500 - pumping phase. Diastolic pressure is the resting pressure
630501 - during the heart's relaxation phase. The defining systolic
630502 - number is 140: A higher measurement indicates a need for
630503 - blood-pressure reduction through drugs or lifestyle change.
630505 - ..
630506 - 9. Izzo said much evidence points to systolic pressure as the
630507 - critical factor in determining the risk of heart disease. "For
630508 - example, systolic hypertension is the most prevalent risk
630509 - factor in heart failure, stroke and kidney failure. It is clear
630510 - that lowering systolic pressure is associated with better
630511 - outcomes in cardiovascular and renal disease.
630513 - ..
630514 - 10. "Systolic hypertension interacts with other major risk factors,
630515 - such as high cholesterol and diabetes, which also increase with
630516 - age, to amplify the age-related risk of cardiovascular events."
630518 - ..
630519 - 11. Isolated systolic hypertension is the most common form of
630520 - hypertension and is present in about two-thirds of people over
630521 - the age of 60 with diagnosed high blood pressure, he said.
630522 - Isolated systolic hypertension is defined as systolic pressure
630523 - at or above 140 mm/Hg and diastolic under 90 mm/Hg.
630525 - ..
630526 - 12. Treating isolated systolic hypertension reduces the incidence
630527 - of stroke, heart attack, heart failure and kidney failure, as
630528 - well as reducing overall cardiovascular disease-related
630529 - sickness and death.
630531 - ..
630532 - 13. Using diastolic blood pressure to define hypertension in
630533 - persons middle-aged and older actually misrepresents the risk
630534 - of potential heart problems, Izzo said. "Systolic blood
630535 - pressure increases steadily with age in industrialized Western
630536 - societies, whereas diastolic blood pressure increases until
630537 - about age 55 and then declines. So in older persons, diastolic
630538 - blood pressure is inversely related to cardiovascular risk."
630540 - ..
630541 - 14. Additional authors on the study are Daniel Levy, M.D., director
630542 - of the Framingham Heart Study of the National Heart, Lung and
630543 - Blood Institute, and Henry R. Black, M.D., Roberts Professor
630544 - and chair of the Department of Preventive Medicine, and
630545 - associate vice-president for research at Rush-Presbyterian-St.
630546 - Luke's Medical Center in Chicago.
630547 -
630548 -
630549 -
6306 -
SUBJECTS
Default Null Subject Account for Blank Record
6403 -
640401 - ..
640402 - Pulse Pressure = Systolic - Diastolic Normal 40
640403 -
640404 - Another diagnostic for heart disease also called coronary artery
640405 - disease (CAD) and indicated by hypertension also called high blood
640406 - pressure is something called "pulse pressure," explained in research
640407 - on the Internet...
640408 -
640409 - Wikipedia
640411 - ..
640412 - Pulse pressure
640413 -
640414 - http://en.wikipedia.org/wiki/Pulse_pressure
640415 -
640416 - 1. Pulse Pressure is most easily defined as being the amount of
640417 - pressure required to create the feeling of a pulse. Measured
640418 - in millimeters of mercury (mmHg), the pressure difference
640419 - between the systolic and diastolic pressures give you the
640420 - amount of pressure change to create the pulse, which is the
640421 - pulse pressure. If your resting blood pressure is
640422 - (systolic/diastolic) 120/80 millimeters of mercury (mmHg), your
640423 - pulse pressure is 40 ? which is considered a normal and healthy
640424 - pulse pressure.[1]
640426 - ..
640427 - 2. Calculation
640428 -
640429 - Formally it is the systolic pressure minus the diastolic
640430 - pressure.[2]
640432 - ..
640433 - 3. Theoretically, the systemic pulse pressure can be
640434 - conceptualized as being proportional to stroke volume, or the
640435 - amount of blood ejected from the left ventricle during systole
640436 - and inversely proportional to the compliance of the aorta.[3]
640438 - ..
640439 - 4. The aorta has the highest compliance in the arterial system due
640440 - in part to a relatively greater proportion of elastin fibers
640441 - versus smooth muscle and collagen. This serves the important
640442 - function of dampening the pulsatile output of the left
640443 - ventricle, thereby reducing the pulse pressure. If the aorta
640444 - becomes rigid in conditions such as arteriosclerosis or
640445 - atherosclerosis, the pulse pressure would be very high.
640446 -
640447 - a. systemic pulse pressure = systolic - diastolic
640448 -
640449 - normal = 120 - 80 = 40 mmHg
640450 -
640451 - b. pulmonary pulse pressure = systolic - diastolic
640452 -
640453 - normal = 25 - 10 = 15 mmHg
640454 -
640456 - ..
640457 - 5. Low (Narrow) Pulse Pressure
640458 -
640459 - A pulse pressure is considered abnormally low if it is less
640460 - than 25% of the systolic value. The most common cause of a low
640461 - (narrow) pulse pressure is a drop in left ventricular stroke
640462 - volume. In trauma a low or narrow pulse pressure suggests
640463 - significant blood loss (insufficient preload leading to reduced
640464 - cardiac output).[4]
640466 - ..
640467 - 6. If the pulse pressure is extremely low, i.e. 25 mmHg or less,
640468 - the cause may be low stroke volume, as in Congestive Heart
640469 - Failure and/or shock.
640471 - ..
640472 - 7. A narrow pulse pressure is also caused by aortic valve
640473 - stenosis and cardiac tamponade.
640474 -
640475 -
640477 - ..
640478 - 100 Pulse Pressure During Exercise Healthy Pressue Secret
640479 -
640480 -
640481 - 8. High (Wide) Pulse Pressure
640482 -
640483 - High values during or shortly after exercise
640485 - ..
640486 - Usually, the resting pulse pressure in healthy adults, sitting
640487 - position, is about 30-40 mmHg.
640489 - ..
640490 - The pulse pressure increases with exercise due to increased
640491 - stroke volume,[5] healthy values being up to pulse pressures of
640492 - about 100 mmHg, simultaneously as total peripheral resistance
640493 - drops during exercise.
640495 - ..
640496 - In healthy individuals the pulse pressure will typically return
640497 - to normal within about 10 minutes. For most individuals,
640498 - during aerobic exercise, the systolic pressure progressively
640499 - increases while the diastolic remains about the same. In some
640500 - very aerobically athletic individuals, for example distance
640501 - runners, the diastolic will progressively fall as the systolic
640502 - increases. This behavior facilitates a much greater increase
640503 - in stroke volume and cardiac output at a lower mean arterial
640504 - pressure and enables much greater aerobic capacity and physical
640505 - performance. The diastolic drop reflects a much greater fall
640506 - in total peripheral resistance of the muscle arterioles in
640507 - response to the exercise (a greater proportion of red versus
640508 - white muscle tissue). Individuals with larger BMIs due to
640509 - increased muscle mass (body builders) have also been shown to
640510 - have lower diastolic pressures and larger pulse pressures.[6
640512 - ..
640513 - 9. Consistently high values
640514 -
640515 - If the usual resting pulse pressure is consistently greater
640516 - than 100 mmHg, the most likely basis is stiffness of the major
640517 - arteries, aortic regurgitation (a leak in the aortic valve),
640518 - arteriovenous malformation (an extra path for blood to travel
640519 - from a high pressure artery to a low pressure vein without the
640520 - gradient of a capillary bed), hyperthyroidism or some
640521 - combination. (A chronically increased stroke volume is also a
640522 - technical possibility, but very rare in practice.) While some
640523 - drugs for hypertension have the side effect of increasing
640524 - resting pulse pressure irreversibly, other hypertension drugs,
640525 - such as ACE Inhibitors, have been shown to lower pulse
640526 - pressure.
640528 - ..
640529 - 10. A high resting pulse pressure is harmful and tends to
640530 - accelerate the normal aging of body organs, particularly the
640531 - heart, the brain and kidneys. A high pulse pressure combined
640532 - with bradycardia and an irregular breathing pattern is
640533 - associated with increased intracranial pressure and should be
640534 - reported to a physician immediately. This is known as
640535 - Cushing's triad and can be seen in patients after head trauma
640536 - related to intracranial hemorrhage or edema.
640538 - ..
640539 - Examples: (these are examples of WIDENING pulse pressure
640540 - causes)
640541 -
640543 - ..
640544 - Another article published by...
640546 - ..
640547 - American Heart Association
640549 - ..
640550 - Scientific Contributions
640552 - ..
640553 - Hypertension.........
640555 - ..
640556 - Isolated Systolic Hypertension
640558 - ..
640559 - Prognostic Information Provided by Pulse Pressure
640560 -
640561 - Michael J. Domanski; Barry R. Davis; Marc A^]Pfeffer; Mark
640562 - Kastantin; Gary F. Mitchell
640563 -
640564 - http://hyper.ahajournals.org/content/34/3/375.full
640566 - ..
640567 - This is a technical article with a lot of jargon and mathematics
640568 - required for clinical trial studies.
640570 - ..
640571 - Article does not expressly identify when pulse pressure is
640572 - dangerously high.
640573 -
640574 - Abstract
640575 -
640576 - Abstract?Increased arterial stiffness results in increased
640577 - characteristic impedance of the aorta and increased pulse wave
640578 - velocity, which increases systolic and pulse pressures. An
640579 - association between increased pulse pressure and adverse
640580 - cardiovascular events has been found in normotensive and
640581 - hypertensive patient populations. Increased pulse pressure has
640582 - also been associated with thickening of the carotid intima and
640583 - media. However, the relationship between pulse pressure and
640584 - stroke has not previously been evaluated. In this study, we
640585 - examined the hypothesis that pulse pressure is an independent
640586 - predictor of stroke in elderly patients with systolic
640587 - hypertension entered in the Systolic Hypertension in the
640588 - Elderly Program. Differences in baseline characteristics were
640589 - examined by tertiles of pulse pressure. The independent
640590 - prognostic value of pulse pressure and mean arterial pressure
640591 - for predicting either stroke or total mortality was assessed
640592 - with Cox proportional hazards models that included pulse
640593 - pressure, mean arterial pressure, and other variables that were
640594 - significant on univariate analysis. This analysis demonstrated
640595 - an 11% increase in stroke risk and a 16% increase in risk of
640596 - all-cause mortality for each 10-mm Hg increase in pulse
640597 - pressure. Each 10-mm Hg increase in mean arterial pressure was
640598 - independently associated with a 20% increase in the risk of
640599 - stroke and a 14% increase in the risk of all-cause mortality.
640600 - These data provide strong evidence of an association of
640601 - increased conduit vessel stiffness, as indicated by increased
640602 - pulse pressure, with stroke and total mortality, independent of
640603 - the effects of mean arterial pressure, in elderly patients with
640604 - isolated systolic hypertension.
640605 -
640606 -
640607 -
640609 - ..
640610 - Another article published by...
640611 -
640612 - Journal American Medical Association (JAMA)
640613 - Published...................................... May 22-29, 2002
640614 -
640616 - ..
640617 - Pulse Pressure and Cardiovascular Disease Related Mortality
640618 -
640619 - Follow-up Study of the Multiple Risk Factor
640620 - Intervention Trial (MRFIT)
640621 -
640622 - http://jama.ama-assn.org/content/287/20/2677.full.pdf
640623 -
640624 - 1. Context The sixth Joint National Committee (JNC-VI)
640625 - classification system of blood pressure emphasizes both
640626 - systolic blood pressure (SBP) and diastolic blood pressure
640627 - (DBP) for cardiovascular disease risk assessment. Pulse
640628 - pressure may also be a valuable risk assessment tool.
640630 - ..
640631 - 2. Objective To compare relationships of SBP, DBP, and pulse
640632 - pressure, separately and jointly, with cardiovascular
640633 - disease-related mortality in men.
640635 - ..
640636 - 3. Design and Setting Data from the Multiple Risk Factor
640637 - Intervention Trial (MRFIT), which screened men aged 35 to 57
640638 - years from 1973 through 1975 at 22 US centers, was used to
640639 - assess cardiovascular disease-related mortality through 1996.
640641 - ..
640642 - 4. Participants A total of 342815 men without diabetes or a
640643 - history of myocardial infarction were divided into 2 groups
640644 - based on their age at MRFIT screening (35- to 44-year-olds and
640645 - 45- to 57-year olds). Participant blood pressure levels were
640646 - classified into a JNC-VI blood pressure category based on SBP
640647 - and DBP (optimal, normal but not optimal, high normal, stage 1
640648 - hypertension, stage 2-3 hypertension), and pulse pressure was
640649 - calculated.
640651 - ..
640652 - 5. Main Outcome Measure Cardiovascular disease-related mortality.
640654 - ..
640655 - 6. Results There were 25721 cardiovascular disease-related deaths.
640656 - Levels of SBP and DBP were more strongly related to
640657 - cardiovascular disease than pulse pressure. Relationships of
640658 - SBP, DBP, and pulse pressure to cardiovascular disease-related
640659 - mortality varied within JNC-VI category. Concordant elevations
640660 - of SBP and DBP were associated with a greater risk of
640661 - cardiovascular disease-related mortality for both age groups of
640662 - men. Among men aged 45 to 57 years, higher SBP and lower DBP
640663 - (discordant elevations) also yielded a greater risk of
640664 - cardiovascular disease-related mortality.
640666 - ..
640667 - 7. Conclusion In both age groups, cardiovascular disease risk
640668 - assessment was improved by considering both SBP and DBP, not
640669 - just SBP, DBP, or pulse pressure separately.
640671 - ..
640672 - Several tables are presented, which are technical and so
640673 - interpretation is unclear.
640675 - ..
640676 - 8. Table 2 - Relationship of Systolic and Diastolic Blood Pressure
640677 - and Pulse Pressure With Cardiovascular Disease (CVD) Mortality
640678 - Among Men Aged 35 Through 44 Years (n = 148 204)...
640679 -
640680 -
640681 -
640682 - Optimal Blood pressure
640683 -
640684 - 112 (108-116) 72 (69-76) 40 (36-43)
640686 - ..
640687 - Normal Blood pressure
640688 -
640689 - 122 (120-125) 79 (76-82) 43 (38-48)
640690 -
640692 - ..
640693 - High Normal Blood pressure
640694 -
640695 - 130 (126-134) 84 (81-87) 46 (39-52)
640696 -
640698 - ..
640699 - Stage 1 Hypertension Blood Pressure
640700 -
640701 - 138 (131-144) 90 (90-94) 48 (39-56)
640703 - ..
640704 - Stage 2-3 Hypertension Blood Pressure
640705 -
640706 - 154 (143-162) 104 (100-108) 51 (39-60)
640707 -
640709 - ..
640710 - 9. COMMENT
640711 -
640712 - Among men screened for MRFIT, pulse pressure was not as strong
640713 - a predictor of cardiovascular disease-related mortality as SBP
640714 - and DBP. Any combination of 2 of the 3 blood pressure measures
640715 - provided more information about cardiovascular disease risk for
640716 - both age groups than any single measure. Since pulse pressure
640717 - is simply the difference between SBP and DBP, given predictive
640718 - information from SBP and DBP considered together, pulse
640719 - pressure cannot add further information. Also, given the
640720 - various ways a specific pulse pressure can be calculated, it
640721 - was anticipated and was in fact shown to be the weaker
640722 - predictor of cardiovascular disease-related mortality vs SBP.
640723 - For example, a pulse pressure of 70 mm Hg can result from the
640724 - following combinations of SBP and DBP: (1) 120 and 50mmHg; (2)
640725 - 130 and 60mmHg; (3) 140 and 70 mm Hg; or (4) 160 and 90 mm Hg.
640727 - ..
640728 - 10. SBP and DBP for assessing risk is evident from analyses within
640729 - JNC-VI strata. For example, among men aged 35 to 44 years,
640730 - cardiovascular disease risk was greatest for those with
640731 - elevated SBP and DBP levels (concordant). In men aged 45 to 57
640732 - years, in the categories of high normal, stage 1 hypertension,
640733 - and stage 2-3 hypertension, higher cardiovascular disease risk
640734 - was associated with either the discordant pattern of elevated
640735 - SBP and low DBP (highest pulse pressure) or with the concordant
640736 - pattern of elevated SBP and DBP (Figure, B). This pattern of
640737 - risk within JNC-VI strata among older men supports the
640738 - practical inference that in suchmenlowerDBP and higher pulse
640739 - pressure may be markers of end-organ damage. This inference is
640740 - not amenable to testing in this MRFIT data set, since only
640741 - limited assessment was made of target organ status at first
640742 - screening.This limitation aside, it is clear from these data
640743 - that men with elevated SBP who have either low or high DBP (and
640744 - correspondingly have either low or high PP) should be
640745 - vigorously treated.
640747 - ..
640748 - 11. Our results are generally consistent with findings from other
640749 - studies10-28; however, they lead us to broader emphases: from
640750 - age 45 years or older, SBP becomes an increasingly important
640751 - measure of cardiovascular disease risk compared with DBP, but
640752 - both SBP and DBP give information relevant for risk assessment.
640753 - Specifically, in older people with adverse SBP and DBP levels
640754 - (high normal, stage 1 hypertension, and stage 2-3
640755 - hypertension), cardiovascular disease risks are higher for
640756 - individuals with concordant SBP and DBP (high on both, with
640757 - lower pulse pressure) and for individuals with discordant SBP
640758 - and DBP (high SBP and low DBP, with higher pulse pressure).
640759 - For the latter individuals, low DBP and higher pulse pressure
640760 - serve as markers not only of greater cardiovascular disease
640761 - risk, but also of pos- sible end-organ damage related to
640762 - greater cardiovascular disease risk. In summary, our results
640763 - support the conclusion that the expansion in focus in the early
640764 - 1990s from DBP only for cardiovascular disease risk assessment
640765 - to both SBP and DBP8,9,29 was an important and useful advance.
640766 - A broad focus, taking into consideration all blood pressure
640767 - components as predictors, is fully warranted by the findings in
640768 - older people that higher cardiovascular disease risk is
640769 - associated with either elevated SBP and DBP, or elevated SBP
640770 - and low DBP (high pulse pressure).
640771 -
640772 -
640774 - ..
640775 - Isolated Diastolic Hypotension Systolic > 100 Diastolic < 60 Elevated CVD Risk
640776 -
640777 - Another article published by...
640778 -
640779 - Desert News
640780 -
640781 - Low diastolic, high systolic blood pressure a dangerous combination
640783 - ..
640784 - Compiled by Lois M Collins
640785 -
640786 - http://www.deseretnews.com/article/700185266/Low-diastolic-high-systolic-blood-pressure-a-dangerous-combination.html?pg=all
640788 - ..
640789 - Published Wednesday 5 October 2011 1027
640790 -
640791 - 1. High blood pressure has long been linked with bad heart
640792 - outcomes. But research just released from the University of
640793 - Alabama at Birmingham indicates that older adults with a low
640794 - diastolic (the bottom number) and a high upper number face
640795 - greater odds of developing new-onset heart failure.
640797 - ..
640798 - 2. The findings are published in Hypertension, a journal of the
640799 - American Heart Association.
640801 - ..
640802 - 3. The association describes heart failure as a weakened heart
640803 - muscle that can no longer pump hard enough to provide adequate
640804 - blood to the body's cells. It notes that symptoms include
640805 - fatigue and shortness of breath and trouble with everyday
640806 - activities.
640808 - ..
640809 - 4. With heart failure, the heart muscle can't pump adequate blood
640810 - to meet the body's needs for blood and oxygen. It tries to
640811 - compensate by enlarging so it can pump more blood, growing
640812 - thicker muscle mass and pumping faster. The blood vessels try
640813 - to be helpful, too, narrowing to keep blood pressure up. And
640814 - the body diverts blood to the heart and brain, since they are
640815 - the most vital organs, but that shorts the supply needed by
640816 - other tissues and organs. Eventually, it can't mask what's
640817 - happening, but sometimes people do not know for months or even
640818 - years that their hearts are failing because of those masking
640819 - "helps."
640821 - ..
640822 - 5. Blood pressure is a mathematical formula that looks at the
640823 - pressure exerted on vessels when the heart is beating "over"
640824 - the pressure in blood vessels between beats - 120/80 is
640825 - considered optimal.
640827 - ..
640828 - 6. The researchers coined the term "isolated diastolic
640829 - hypotension" to describe a condition where the diastolic or
640830 - between-beat pressure is less than 60 mm Hg and the systolic
640831 - blood pressure is not low, measured at above 100 mm Hg. The
640832 - researchers said it's similar to a condition called isolated
640833 - systolic hypertension, when the systolic blood pressure alone
640834 - is elevated (above 140 mm Hg), but the diastolic is not
640835 - elevated. That is common in older adults and it, too,
640836 - increases the risk one will experience heart failure.
640837 -
640838 - [On 140806 1753 issue of isolated diastolic hypotension
640839 - with diastolic blood pressure below 60 and systolic above
640840 - 100 presented to medical team for evaulation. ref SDS 69
640841 - XF42
640843 - ..
640844 - [On 141029 0900 "isolated diastolic hypotension" with
640845 - diastolic < 60 (e.g., in 50s) and systolic > 100 generally
640846 - referenced in Progress Notes reporting no symptoms, meeting
640847 - with Doctor Egan in Cardiology at VA Martinez Clinic.
640848 - ref SDS 70 M344
640850 - ..
640851 - Typical examples from patient history on diet, medication, exercise
640852 - and vitals include tests mostly after exercise hiking 11 miles, other
640853 - examples are before and after exercise...
640854 -
640855 - 140714 0630......... 120101 0900, ref SDS 68 FN6O
640856 -
640857 - Left Right HR Diff
640858 - 124 58 63 110 50 60 12 8 3
640859 - 102 54 59 111 53 59 -9 1 0
640860 - 108 57 56 100 48 56 8 9 0
640861 - 108 54 54 98 48 55 9 6 -1
640862 -
640863 - 140721 0443.......... 120101 0900, ref SDS 68 ZH4O
640864 -
640865 - 101 55 80 107 60 80 -6 -5 0
640866 - 112 56 84 108 52 82 -9 1 0
640867 - 107 59 78 116 62 76 -9 -3 2
640868 - 114 60 80 114 56 74 0 4 6
640869 -
640870 - 140722 0255........... 120101 0900, ref SDS 68 VY5N
640871 -
640872 - 119 59 56 115 60 56 4 -1 0
640873 - 114 61 56 112 56 56 2 5 0
640874 - 110 59 56 107 54 55 3 5 1
640875 - 110 58 56 106 54 53 4 4 3
640876 -
640877 - 140723 0650........... 120101 0900, ref SDS 68 7Z9K
640878 - 115 61 56 112 51 55 3 10 1
640879 - 112 61 59 118 53 56 -6 8 3
640880 - 118 56 56 116 56 56 2 0 0
640881 - 112 56 57 104 54 56 8 2 1
640882 - 144 65 63 131 54 60 13 11 3
640883 - 133 65 72 129 67 88 4 -2 -16
640884 -
640885 -
640886 - 140428 0752........... 120101 0900, ref SDS 68 CB6N
640887 - 112 65 48 116 59 46 -4 6 2
640888 - 120 62 46 118 57 46 2 5 0
640889 - 120 64 45 115 56 44 4 8 1
640890 - 120 65 47 114 56 46 6 8 1
640891 -
640892 - 118 52 66 103 49 64 15 3 2
640893 - 107 52 62 100 48 62 7 4 0
640894 - 103 54 62 104 48 59 -1 6 3
640895 - 107 59 60 106 50 60 1 9 0
640896 -
640897 -
640898 - 140523 ............... 120101 0900, ref SDS 68 OS9N
640899 - 124 64 45 124 61 46 0 3 -1
640900 - 120 64 46 122 62 47 -2 2 -1
640901 - 124 65 47 124 65 46 0 0 1
640902 - 125 61 47 127 66 46 -2 -5 1
640903 -
640904 - 100 48 77 105 48 77 -5 0 0
640905 - 107 58 84 106 54 82 1 4 2
640906 - 100 59 83 106 57 75 -6 2 8
640907 - 112 59 70 108 52 70 4 7 0
640908 -
640909 - 141107 0615........... 120101 0900, ref SDS 68 LX4N
640910 -
640911 - 120 59 54 114 55 54 6 4 0
640912 - 120 57 53 114 53 52 6 4 1
640913 - 105 54 56 114 54 54 -9 0 2
640914 - 107 56 53 118 58 53 -11 -2 0
640916 - ..
640917 - Article - Low diastolic, high systolic blood pressure a dangerous
640918 - combination - continues...
640919 -
640920 - 7. "Our findings showed that older adults who have low diastolic
640921 - blood pressure but not low systolic blood pressure were more
640922 - likely to develop new-onset heart failure than those with
640923 - higher levels of diastolic blood pressure," said Dr Ali Ahmed,
640924 - study senior investigator, professor of medicine in the
640925 - Division of Gerontology, Geriatrics and Palliative Care and
640926 - also director of Alabama's geriatric heart-failure clinic.
640927 - "Older adults with low diastolic blood pressure also had higher
640928 - risk of death."
640930 - ..
640931 - 8. The researchers found that those who control their high
640932 - systolic blood pressure with medications can also develop
640933 - isolated diastolic hypotension.
640934 -
640935 -
640936 -
640937 -
640938 -
6410 -
SUBJECTS
Heart Rate Pulse Research Vitals Target Maximum Age Resting Exercise
7303 -
730401 - ..
730402 - Heart Rate Pulse Vitals Research
730403 -
730404 - Research finds...
730405 -
730406 - From Wikipedia, the free encyclopedia
730407 -
730408 - http://en.wikipedia.org/wiki/Heart_rate#Measuring_HRmax
730410 - ..
730411 - HRmax is the maximal safe heart rate for an individual. The
730412 - most accurate way of measuring HRmax is via a cardiac stress
730413 - test. In such a test, the subject exercises while being
730414 - monitored by an EKG. During the test, the intensity of
730415 - exercise is periodically increased (if a treadmill is being
730416 - used, through increase in speed or slope of the treadmill),
730417 - continuing until certain changes in heart function are
730418 - detected in the EKG, at which point the subject is directed to
730419 - stop. Typical durations of such a test range from 10 to 20
730420 - minutes.
730422 - ..
730423 - Various formulas are used to estimate individual Maximum Heart
730424 - Rates, based on age, but maximum heart rates vary
730425 - significantly between individuals.
730427 - ..
730428 - The most common formula encountered, with no indication of
730429 - standard deviation, is:
730430 -
730431 - HRmax = 220 - age
730433 - ..
730434 - This is attributed to various sources, often "Fox and
730435 - Haskell," and was devised in 1970 by Dr. William Haskell and
730436 - Dr. Samuel Fox.[2]
730438 - ..
730439 - It gained widespread use through being used by Polar Electro
730440 - in its heart rate monitors,[2] which Dr. Haskell has "laughed
730441 - about",[2] as it "was never supposed to be an absolute guide
730442 - to rule people's training."[2]
730444 - ..
730445 - Despite the widespread publication of this formula, research
730446 - spanning two decades reveals its large inherent error
730447 - (Sxy=7-11 b/min). Consequently, the estimation calculated by
730448 - HRmax=220-age has neither the accuracy nor the scientific
730449 - merit for use in exercise physiology and related fields.[3]
730451 - ..
730452 - Maximum heart rate formulae yield figures that are very much
730453 - averages, and depend greatly on individual physiology and
730454 - fitness. More acceptable formulae include...
730455 -
730456 - 1. HRmax = 205.8 - (0.685 x age)
730458 - ..
730459 - 2. HRmax = 206.3 - (0.711 x age)
730461 - ..
730462 - 3. HRmax = 208 - (0.7 x age)
730464 - ..
730465 - 4. HRmax = 206.9 - (0.67 x age)
730467 - ..
730468 - 5. HRmax = 191.5 - (0.007 x age x age)
730469 -
730471 - ..
730472 - Heart Attack Extended Recovery After Exercise
730473 - Recovery Heart Rate Predictor Heart Attack
730474 -
730475 - This is the heart rate measured at a fixed (or reference)
730476 - period after ceasing activity; typically measured over a 1
730477 - minute period.
730479 - ..
730480 - For death, it has been hypothesized* that a delayed fall in
730481 - the heart rate after exercise might be an important prognostic
730482 - marker. Less than 30 bpm reduction at one minute after
730483 - stopping hard exercise was a predictor of heart attack. More
730484 - than 50 bpm reduction showed reduced risk of heart attack. [6]
730485 -
730487 - ..
730488 - Target Heart Rate Exercise
730489 -
730490 - The Target Heart Rate (THR), or Training Heart Rate, is a
730491 - desired range of heart rate reached during aerobic exercise
730492 - which enables one's heart and lungs to receive the most benefit
730493 - from a workout. This theoretical range varies based on one's
730494 - physical condition, gender, and previous training. Below are
730495 - two ways to calculate one's Target Heart Rate. In each of
730496 - these methods, there is an element called "intensity" which is
730497 - expressed as a percentage. The THR can be calculated as a
730498 - range of 65%-85% intensity. However, it is crucial to derive
730499 - an accurate HRmax to ensure these calculations are meaningful
730500 - (see above). ref SDS 0 QF7R
730501 -
730503 - ..
730504 - Resting Heart Rate Normal 60 - 80 Bradycardia Below 60
730505 -
730506 - Resting heart rate (HRrest) is a person's heart rate when they
730507 - are at rest: awake but lying down, and not having immediately
730508 - exerted themselves. Typical healthy resting heart rate in
730509 - adults is 60-80 bpm,[9] with rates below 60 bpm referred to
730510 - as bradycardia and rates above 100 bpm referred to as
730511 - tachycardia. Note however that conditioned athletes often have
730512 - resting heart rates below 60 bpm. Tour de France cyclist Lance
730513 - Armstrong has a resting HR around 32 bpm, and it is not
730514 - unusual for people doing regular exercise to get below 50 bpm.
730515 - Other cyclists like Miguel Indurain and Alberto Contador have
730516 - reported resting heart rates in the mid-20s.
730518 - ..
730519 - Heart Rate Abnormalities - Tachycardia
730520 - Tachycardia - Heart Rate Abnormalities
730521 -
730522 - Tachycardia is a resting heart rate more than 100 beats per
730523 - minute. This number can vary as smaller people and children
730524 - have faster heart rates than average adults
730525 -
730527 - ..
730528 - Bradycardia
730529 -
730530 - Bradycardia is defined as a heart rate less than 60 beats per
730531 - minute although it is seldom symptomatic until below 50 bpm
730532 - when a human is at total rest. Trained athletes tend to have
730533 - slow resting heart rates, and resting bradycardia in athletes
730534 - should not be considered abnormal if the individual has no
730535 - symptoms associated with it. Again, this number can vary as
730536 - children and small adults tend to have faster heart rates than
730537 - average adults.
730539 - ..
730540 - Miguel Indurain, a Spanish cyclist and five time Tour de
730541 - France winner, had a resting heart rate of 28 beats per
730542 - minute, one of the lowest ever recorded in a healthy
730543 - human.[10]
730544 -
730546 - ..
730547 - Arrhythmia - Palpations
730548 - Palpations - Arrhythmia
730549 -
730550 - Arrhythmias are abnormalities of the heart rate and rhythm
730551 - (sometimes felt as palpitations). They can be divided into two
730552 - broad categories: fast and slow heart rates. Some cause few or
730553 - minimal symptoms. Others produce more serious symptoms of
730554 - lightheadedness, dizziness and fainting.
730555 -
730557 - ..
730558 - Heart Rate Risk Factor
730559 -
730560 - An Australian-led international study of patients with
730561 - cardiovascular disease has shown that heart beat rate is a key
730562 - indicator for the risk of heart attack. The study, published
730563 - in The Lancet (September 2008) studied 11,000 people, across
730564 - 33 countries, who were being treated for heart problems.
730566 - ..
730567 - Heart rate above 70 beats per minute had significantly higher
730568 - incidence of heart attacks, hospital admissions and the need
730569 - for surgery. University of Sydney professor of cardiology Ben
730570 - Freedman from Sydney's Concord hospital, said "If you have a
730571 - high heart rate there was an increase in heart attack, there
730572 - was about a 46 percent increase in hospitalizations for
730573 - non-fatal or fatal heart attack."[11]
730574 -
730575 -
730576 -
7306 -
SUBJECTS
Endoscopy Colonoscopy Test VA Martinez Preparation
9003 -
9004 - 1146
900501 - ..
900502 - Vein IV Needle Puncture Stick Poor Difficult Find Blood Flow
900503 - IV Needle Puncture Stick Difficult Poor Blood Flow Cannot Find Vein
900504 - Needle Puncture Stick IV Difficult Poor Blood Flow Cannot Find Vein
900505 - Needle Stick Puncture IV Difficult Poor Blood Flow Cannot Find Vein
900506 -
900507 - Judith arrives to assist Jennifer by setting IV for anesthetic. She
900508 - does the other patient first.
900510 - ..
900511 - Judith sets IV for anesthetic.
900513 - ..
900514 - She wants to use the vein in the left hand. Since this makes working
900515 - difficult, decide to use left inner elbow.
900517 - ..
900518 - IV seems to be positional. There was initial concern that placement
900519 - failed, reported previously on 091216 0600. ref SDS 36 IG4J Judith
900520 - stuck with it and through massage eventually achieved blood flow to
900521 - complete the work satisfactorily with only one needle puncture.
900523 - ..
900524 - Jennifer read off an assessment check list of medications, allergies,
900525 - physical and medical conditions to evaluate readiness for test
900526 - procedures, and to plan for contingencies.
900527 -
900528 - [...below, nurisng check list. ref SDS 0 VG8F
900529 -
900530 - [...below, medication check list. ref SDS 0 3C5N
900532 - ..
900533 - [...below, logistics check list. ref SDS 0 VR4M
900535 - ..
900536 - [...below, medical condition check list. ref SDS 0 OL3Y
900538 - ..
900539 - [...below, notice to patient explaining procedures and details
900540 - required for knowledgable consent, check list. ref SDS 0 TL3N
900541 -
900543 - ..
900544 - Patient preparation completed.
900546 - ..
900547 - Kim arrives to assist Doctor Lee with the tests.
900549 - ..
900550 - After some discussion, Kim recalled getting email from Rod for the
900551 - medical team, e.g., on 060403 1028. ref SDS 11 UW6J
900552 -
900553 - [On 101108 0929 letter asks Kim to coordinate with Doctor
900554 - Lee on arranging for a driver for EGD test on 101210.
900555 - ref SDS 65 465I
900557 - ..
900558 - Turns out that Kim worked in ICU and Telemetry for the VA Medical
900559 - Center in San Francisco. She lives in Vallejo, and so transferred to
900560 - Martinez 10 years ago to have more time for child care after her
900561 - daughter was born.
900563 - ..
900564 - Kim remembers working with Jan in ICU at the San Francisco Medical
900565 - Center, 10 years ago.
900567 - ..
900568 - Advised that Jan was very helpful after heart surgery in ICU, and in
900569 - Telemetry, reported on 091103 0347. ref SDS 26 PSQU
900571 - ..
900572 - Further related getting excellent care at VA Medical Center in San
900573 - Francisco, reported previously to the medical team on 091104.
900574 - ref SDS 27 PR4V The VA was credited again in a meeting with the Chief
900575 - of Surgery on 091119 1000. ref SDS 30 Q55F Following surgery on
900576 - 091216, to correct achalasia, and while recovering in the hospital,
900577 - commended the VA's work during another meeting with Doctor Ratcliffe.
900578 - reported on 091219 0600, ref SDS 39 Z990 Doctor Stewart was commended
900579 - during a meeting at the VA in San Francisco on 100105 1300.
900580 - ref SDS 48 YD5L
900582 - ..
900583 - Kim said the Medical Center in San Francisco has a good reputation
900584 - throughout the VA, and among patients.
900586 - ..
900587 - At this time, Jennifer was in the room with Kim. Was pleased to
900588 - commend outstanding work by Jennifer, Judith, and of course now Kim.
900589 -
900590 - [...below, after the tests, thanked Doctor Lee for good
900591 - service, and requested a letter transmitting the doctor's
900592 - report for incorporation into patient history. ref SDS 0
900593 - E18F
900595 - ..
900596 - [On 100317 1213 letter to VA commends excellent medical
900597 - services, and confirms understandings that medical tests on
900598 - 100305 made findings of no cancer, and that acid burn has
900599 - occurred only on the flap constructed by Doctor Stewart to
900600 - protect the modified esophgeal sphincter valve from causing
900601 - acid reflux. ref SDS 56 PT6W
900603 - ..
900604 - [On 101108 0929 letter asks Kim to coordinate with Doctor
900605 - Lee on arranging for a driver for EGD test on 101210.
900606 - ref SDS 65 465I
900607 -
900608 -
900610 - ..
9007 -
9008 -
9009 - 1215
9010 -
901001 - Doctor Lee arrives.
901002 -
901003 - The doctor asks about continuing swallowing and vomitting problems.
901005 - ..
901006 - Explained these problems have increased since meeting with the doctor
901007 - last month, reporting swallowing had degraded to 80% with vomitting at
901008 - 20%, shown in the record on 100202 1400. ref SDS 50 PP8W Now
901009 - swallowing may be only 75% or more and vomitting up to 30%.
901010 -
901011 - [...below on 100305 1000 at 1430 LESV dilated from 11-15mm,
901012 - should relieve rising swallowing and vomitting problems.
901013 - ref SDS 0 VC8K
901015 - ..
901016 - The doctor asks about preparation yesterday for colonoscopy today?
901018 - ..
901019 - Reported performance of VA instructions shown in the record on 100304
901020 - 1819. ref SDS 53 PP8W
901022 - ..
901023 - Doctor Lee asks about the taste of...
901024 -
901025 - Golytely
901026 - PEG-3350 and electrolytes for oral solution.
901028 - ..
901029 - Reported there is a salty taste that is palatable.
901031 - ..
901032 - Doctor Lee asked if half was consumed before noon, and half after
901033 - 1200?
901035 - ..
901036 - Reported completing 1 gallon by OA 1400 drinking 8 oz about every 10
901037 - minutes beginning OA 0630, as prescribed by VA instructions shown in
901038 - the record on 100304 1819, ref SDS 53 6L82
901040 - ..
901041 - Doctor Lee provided a computer instrument with a pen, and requested
901042 - electronic signature to approve getting VA GI tests today.
901044 - ..
901045 - Signed electronic consent.
901046 -
901047 - [...below, VA Progress Notes report explanation of sedation
901048 - plan and risks, which was not actually done, ref SDS 0 9394,
901049 -
901050 - [...below VA Progress Notes Nurses Check List notes consent
901051 - signed. ref SDS 0 K54H
901053 - ..
901054 - [...below VA Progress Notes Nurses Check List notes again
901055 - report patient consent signed. ref SDS 0 W38F
901056 -
901057 -
901058 -
901059 -
9011 -
SUBJECTS
Vaccination Shingles Scheduled
A103 -
A10401 - ..
A10402 - Shingles Vaccination Ordered
A10403 -
A10404 - Reviewed Millie's patient history diagnosed with shingles on 100104.
A10405 - 100104 1115, ref SDS 47 0P9S Asked about shingles vaccination,
A10406 - implementing research on 100104 1115, ref SDS 47 5D3J, and Doctor
A10407 - Johnson's recommendation during the meeting at Kaiser on 100302 0830.
A10408 - ref SDS 52 GS5J
A10410 - ..
A10411 - Doctor Lee was not aware of background risk exposure for shingles, and
A10412 - inquiry about shingles vaccination, reported to the medical team on
A10413 - 100301 0418. ref SDS 51 5T9W
A10415 - ..
A10416 - Doctor Lee will set up vaccination for shingles.
A10417 -
A10419 - ..
A105 -
A106 - 1225
A10701 - ..
A10702 - Doctor Lee reviews medical history to order shingles vaccination,
A10703 - which can be administered in Adult Care before leaving the hospital
A10704 - today.
A10705 -
A10706 - [...below shingles vaccination received. ref SDS 0 GT5G
A10707 -
A10708 -
A10709 -
A10710 -
A10711 -
A108 -
SUBJECTS
Endoscopy Test Acid Burn Esophageal Sphincter Heller Myotomy Surgery
AN03 -
AN04 - 1248
AN0501 - ..
AN0502 - Preparation for GI Procedures
AN0503 -
AN0504 - Taken to OR for procedure.
AN0506 - ..
AN0507 - Kim appologized for delay starting tests at 1248, which were scheduled
AN0508 - for 1000.
AN0510 - ..
AN0511 - Explained there was no lost time working, because the record was
AN0512 - entered and other tasks performed while the team got ready to do the
AN0513 - tests, as shown in this record. ref SDS 0 PP8W
AN0515 - ..
AN0516 - Kim said that not many customers bring computers to the hospital, and
AN0517 - fewer bring them into the OR to collaborate with the medical team.
AN0519 - ..
AN0520 - Kim connected the IV for administering sedation, and said the team is
AN0521 - ready to start work.
AN0523 - ..
AN0524 - Closed the computer, and another attendant placed it beneath the
AN0525 - gurney with other customer affects.
AN0527 - ..
AN0528 - Was given a thick numbing agent substance to initially gargle, and
AN0529 - then swallow. This seemed to immediately numb the throat.
AN0530 -
AN0531 - [On 100827 0738 think the team explained that Lidocaine is
AN0532 - the numbing agent. ref SDS 59 PSQS
AN0534 - ..
AN0535 - Anesthesia administered for tests.
AN0536 -
AN0537 - [...below, VA documentation says medication may effect action
AN0538 - and thinking. ref SDS 0 684M
AN0539 -
AN0540 - [...below, Progress Notes explain sedation. ref SDS 0 W35M
AN0541 -
AN0543 - ..
AN06 -
AN07 -
AN08 - 1430
AN09 -
AN0901 - Endoscopy No Medical Maladies Except Acid Burn Esophageal Sphincter
AN0902 - Acid Burn Esophageal Sphincter Endoscopy No Medical Maladies Except
AN0903 - Swallowing Vomitting Problems Relieved Dilation LESV 11 - 15 MM
AN0904 - Dilation LESV 11 - 15 MM Resolve Swallowing Problems Post Heller Myotomy Surgery
AN0905 -
AN0906 - Follow up ref SDS 50 PP8W, ref SDS 36 KE9U.
AN0908 - ..
AN0909 - Wake up from procedure - meeting with Doctor Lee.
AN0911 - ..
AN0912 - Doctor Lee seemed to say that during EGD procedure the LESV was
AN0913 - dilated from initial condition of 11 mm to maximum of 15 mm during the
AN0914 - procedure today. He feels this will help resolve increased swallowing
AN0915 - and vomitting problems reported earlier today, per above. ref SDS 0
AN0916 - 038F
AN0917 -
AN0918 - [On 100305 1000 Progress Notes for EGD Dilation procedure
AN0919 - do not expressly state dilation of LESV. ref SDS 0 Y65G
AN0921 - ..
AN0922 - [On 100827 0738 at 1333 during post procedure meeting,
AN0923 - Doctor Lee reported condition of LESV is about 11 mm,
AN0924 - unchanged from initial EGD dilation on 100305, when at that
AN0925 - time on 100827, LESV was dilated to 15 MM, so there has
AN0926 - been no evident improvement. ref SDS 60 0466
AN0928 - ..
AN0929 - Doctor Lee showed photographs of throat and stomach from endoscopy.
AN0931 - ..
AN0932 - The doctor indicated finding no evidence of disease from endoscopy
AN0933 - test, except he pointed to a small mark on one picture which indicates
AN0934 - some "acid burn" on the area where Heller Myotomy surgery was
AN0935 - performed. Doctor Lee seemed to explain that "acid burn" occurs only
AN0936 - on the "flap," which Doctor Stewart constructed during surgery on
AN0937 - 091216 0600, ref SDS 36 KE9U, and as explained earlier on 091030 0810.
AN0938 - ref SDS 23 OY64
AN0939 -
AN0940 - [...below endoscopy test findings do not list "acid burn,"
AN0941 - ref SDS 0 Y65V, and photographs are black and white, and do not
AN0942 - clearly identify "acid burn" on "flap" surgically constructed
AN0943 - during Heller Myotomy procedure. ref SDS 0 XI5O
AN0945 - ..
AN0946 - [On 100312 1119 pathology report on biopsies make no findings
AN0947 - of "acid burn," per se, and say simply "Reflux esophagitis,"
AN0948 - and "No intestinal metaplasia (no Barrett's Esophagus)".
AN0949 - ref SDS 55 MX5K
AN0951 - ..
AN0952 - [On 100312 1119 qeustions on scope of test findings of reflux
AN0953 - esophagitis. ref SDS 55 QQ7O
AN0955 - ..
AN0956 - [On 100317 1213 letter to VA commends excellent medical
AN0957 - services, and confirms understandings that medical tests on
AN0958 - 100305 made findings of no cancer, and that acid burn has
AN0959 - occurred only on the flap constructed by Doctor Stewart to
AN0960 - protect the modified esophgeal sphincter valve from causing
AN0961 - acid reflux. ref SDS 56 PT6W
AN0963 - ..
AN0964 - [On 100331 1448 VA letter seems to expand understandings from
AN0965 - meeting on 100305, ref SDS 0 PR6P, and presented in feedback
AN0966 - letter to the VA on 100317 1213. ref SDS 56 PT6W, to relate
AN0967 - test findings of general reflux esophagitis, rather than or in
AN0968 - addition to mere "acid burn" on the flap for the esophageal
AN0969 - sphincter valve. ref SDS 57 YW5S
AN0971 - ..
AN0972 - [On 100827 0738 at 1333 during post procedure meeting, Doctor
AN0973 - Lee reported condition of LESV is about 11 mm, unchanged from
AN0974 - initial EGD dilation on 100305, when at that time on 100827,
AN0975 - LESV was dilated to 15 MM, so there has been no evident
AN0976 - improvement. ref SDS 60 0466
AN0978 - ..
AN0979 - There was no analysis during the meeting of why this one small part of
AN0980 - the stomach shows evidence of acid burn involvement, when the other
AN0981 - 95% of stomach lining has the same exposure.
AN0983 - ..
AN0984 - One reason might reflect that this "flap" component was constructed by
AN0985 - "folding over" existing stomach tissue to prevent backflow, reported
AN0986 - by Doctor Stewart on 091030 0810, ref SDS 23 OY64 Conceivably, this
AN0987 - surgery exposed tissue that was previously shielded from stomach acid,
AN0988 - and so is now showing affects from adjusting to a new condition.
AN0990 - ..
AN0991 - "Acid burn" findings today seem to demonstrate effectiveness of "flap"
AN0992 - preventing acid reflux, accomplighing design goal for Heller Myotomy
AN0993 - surgery planned by Doctor Stewart during the meeting at VA Medical
AN0994 - Center in San Francisco, reported on 091030 0810. ref SDS 23 OY64
AN0995 - Aging process may increases "burping," to relieve acid buildup in the
AN0996 - stomach. This gas relief process of burping focuses acidic stomach
AN0997 - gas of the "flap," causing acid burn.
AN0999 - ..
AN1000 - Results of biopsies from both endoscopy and colonoscopy tests will be
AN1001 - posted in 2 weeks.
AN1003 - ..
AN1004 - The doctor seemed to discuss post-test treatment for acid burn, but
AN1005 - details are hazy due to effects of anesthesia, per above, ref SDS 0
AN1006 - HB4M, and as noted in VA documentation received today. ref SDS 0 684M
AN1008 - ..
AN1009 - The doctor plans follow up examination in 2 months or so to evaluate
AN1010 - "acid burn" issue.
AN1011 -
AN1012 - [...below Progress Notes for endoscopy test findings do not
AN1013 - list "acid burn," medication treatment, nor planning for follow
AN1014 - up test, ref SDS 0 Y65V; photographs are black and white, and
AN1015 - do not clearly identify "acid burn" on "flap" surgically
AN1016 - constructed during Heller Myotomy procedure. ref SDS 0 XI5O
AN1018 - ..
AN1019 - [On 100308 1411 Marcia called to follow up test procedures; and
AN1020 - asked if medication was received for "acid burn?" Advised that
AN1021 - medication was not received, and that GI Discharge document
AN1022 - does not present instructions for use. Marcia indicated Doctor
AN1023 - Lee prescribed Omeprazole medication to treat esophagitis, and
AN1024 - that Progress Notes will explain medication and instructions
AN1025 - for use. ref SDS 54 CH3O Marcia's reference may be to
AN1026 - illegible handwriting in Discharge documentation, show on
AN1027 - 100305, below. ref SDS 0 HC7K
AN1029 - ..
AN1030 - [On 100312 1119 pathology report on biopsies make no findings
AN1031 - of "acid burn," per se, and say simply "Reflux esophagitis,"
AN1032 - and "No intestinal metaplasia (no Barrett's Esophagus)".
AN1033 - ref SDS 55 MX5K
AN1035 - ..
AN1036 - [On 100317 1213 letter to VA reports Omeprazole medication was
AN1037 - received from the VA and started treating esophagitis from acid
AN1038 - reflux. ref SDS 56 PU3W
AN1040 - ..
AN1041 - [On 100810 1530 Doctor Lee asked why meeting to perform follow
AN1042 - up EGD was delayed more than 2 months, ref SDS 58 M18F, planned
AN1043 - in the meeting today, per above, ref SDS 0 HB86, and was
AN1044 - advised there were no instructions on taking Omeprazole, and
AN1045 - Marcia reported on 100308, ref SDS 54 NB7H, that illegible
AN1046 - handwriting in Discharge papers, noted below, ref SDS 0 HC7K,
AN1047 - delayed the VA ordering medication. ref SDS 58 M18K
AN1049 - ..
AN1050 - [On 100827 0738 medical chart presents "Findings" plus
AN1051 - Impressions and Recommendations missing from medical chart for
AN1052 - work today on 100305, for treament with Omeprazole 40 mg,
AN1053 - ref SDS 59 MZ8J, and which doubled dose prescribed today on
AN1054 - 100305, though not listed in the medical chart, nor presented
AN1055 - by the medical team after the procedure, per above, ref SDS 0
AN1056 - HB86; later Marcia called and reported the doctor prescribed
AN1057 - Omeprazole 20 mg per day, which turned out to be illegible
AN1058 - handwriting in the discharge document, per above, ref SDS 0
AN1059 - HC7K, as explained by Marcia on 100308 1411. ref SDS 54 CH3O
AN1061 - ..
AN1062 - [On 100827 0738 VA medical chart for follow up EGD test
AN1063 - reports use of prescribed medication with Omeprazole was
AN1064 - inconsistent, ref SDS 59 JE7X, and again in "Impression"
AN1065 - section, ref SDS 59 JE9J, - clarification note appended on
AN1066 - not getting instructions to use Omeprazole, and illegible
AN1067 - handwriting was vague in Discharge documents. ref SDS 59
AN1068 - JE7X
AN1070 - ..
AN1071 - [On 101210 0930 Doctor Lee prescribes doubling dose again
AN1072 - to Omeprazole 80 mg per day after EGD and dilation found
AN1073 - continuing esophagael sphincter severely restricts
AN1074 - swallowing, ref SDS 66 ZN4M, and shown in medical chart
AN1075 - Recommendations. ref SDS 66 XT5N
AN1077 - ..
AN1078 - Thanked Doctor Lee for excellent work today, including pre-op prep
AN1079 - discussed with Kim, per above. ref SDS 0 QS54 Feel very fortunate
AN1080 - with preliminary findings showing only minimal issues of "acid burn"
AN1081 - on the "flap," ref SDS 0 PR6P, which was surgically constructed by
AN1082 - Doctor Stewart during Heller Myotomy surgery to resolve achalasia
AN1083 - performed at the VA Medical Center in San Francisco on 091216 0600.
AN1084 - ref SDS 36 KE9U
AN1086 - ..
AN1087 - Work today continues excellent health care services for heart surgery,
AN1088 - and later Heller Myotomy surgery to resolve achalasia, discussed with
AN1089 - Doctor Ratcliffe, Chief of Surgery, VA Medical Center San Francisco,
AN1090 - reported on 091219 0600. ref SDS 39 Z990
AN1091 -
AN1092 - [On 100308 1411 Marcia called to follow up test procedures; and
AN1093 - asked about quality of medical services. Strongly commended
AN1094 - Doctor Lee and the VA team for excellent care. ref SDS 54 V55H
AN1095 - S55K
AN1097 - ..
AN1098 - [On 100317 1213 letter to VA commends excellent medical
AN1099 - services, and confirms understandings that medical tests on
AN1100 - 100305 made findings of no cancer, and that acid burn has
AN1101 - occurred only on the flap constructed by Doctor Stewart to
AN1102 - protect the modified esophgeal sphincter valve from causing
AN1103 - acid reflux. ref SDS 56 PT6W
AN1104 -
AN1105 -
AN1106 -
AN12 -
SUBJECTS
Colonoscopy Test No Polyps No Evident Medical Risks Colorectal Cance
BG03 -
BG0401 - ..
BG0402 - Polyps No Cancer Colorectal Colonoscopy No Evident Medical Risks
BG0403 - Cancer Colorectal No Polyps Colonoscopy No Evident Medical Risks
BG0404 - Colorectal Cancer No Polyps Colonoscopy No Evident Medical Risks
BG0405 - Colonoscopy No Evident Medical Risks Cancer Colorectal No Polyps
BG0406 -
BG0407 - Doctor Lee showed photographs of colonoscopy, and advised findings are
BG0408 - negative for disease or malady of any kind, including polyps and
BG0409 - hemeroids, discussed further below. ref SDS 0 K97H
BG0410 -
BG0411 - [...below colonoscopy test findings report "Normal exam to
BG0412 - terminal ileum." ref SDS 0 SA6O
BG0414 - ..
BG0415 - Research indicates that no findings of polyps indicates reduced risk
BG0416 - of colorectal cancer...
BG0417 -
BG0418 - Webmd
BG0419 - Colorectal Cancer Guide
BG0421 - ..
BG0422 - Colorectal Polyps and Cancer
BG0423 -
BG0424 - http://www.webmd.com/colorectal-cancer/guide/colorectal-polyps-cancer
BG0426 - ..
BG0427 - Colorectal cancer is second leading cause of cancer deaths
BG0428 - among American men and women. These cancers arise from the
BG0429 - lining of the large intestine, also known as the colon. Tumors
BG0430 - may also arise from the lining of the very last part of the
BG0431 - colon, called the rectum.
BG0433 - ..
BG0434 - Unfortunately, most colorectal cancers are "silent" tumors.
BG0435 - They grow slowly and often do not produce symptoms until they
BG0436 - reach a large size. Fortunately, colorectal cancer is
BG0437 - preventable, and curable, if detected early.
BG0439 - ..
BG0440 - Colorectal cancer usually begins as a polyp. The word "polyp"
BG0441 - is a nonspecific term to describe a bump on the surface of the
BG0442 - colon. Polyps can also be bumps of normal colorectal lining
BG0443 - which do not increase the risk of colorectal cancer.
BG0445 - ..
BG0446 - Although most colorectal polyps never become cancer, virtually
BG0447 - all colon and rectal cancers start from these benign growths.
BG0448 -
BG0449 -
BG0450 -
BG0451 -
BG05 -
SUBJECTS
Computer Network Fails Communication Share Information Resist Collab
CP03 -
CP0401 - ..
CP0402 - Computer Network Requires Timely Notice Team Care Communication
CP0403 - Communication Fails Team Care Coordination Nobody Will Notify Anybody
CP0404 - Team Care Coordination Communication Fails Nobody Will Notify Anybody
CP0405 - Coordination Team Care Communication Fails Nobody Will Notify Anybody
CP0406 -
CP0407 - Asked Doctor Lee for a letter presenting results of the meeting today,
CP0408 - including photographs and reports on biopsies. Requested a copy for
CP0409 - feedback to alert Doctor Stewart at VA Medical Center in San Francisco
CP0410 - about acid burn on the "flap" that Doctor Stewart constructed during
CP0411 - Heller Myotomy surgery to correct acalasia on 091216 0600. ref SDS 36
CP0412 - KE9U and citing Doctor Stewart's explaination of the "flap", earlier
CP0413 - on 091030 0810. ref SDS 23 OY64
CP0414 -
CP0415 - [On 100308 1411 Marcia called and discussed planning with
CP0416 - Doctor Lee today on getting the computer file with the report
CP0417 - on work today and for the purpose of efficient case management.
CP0418 - ref SDS 54 ES5O
CP0420 - ..
CP0421 - [On 100308 1411 Marcia presented this issue in Progress Notes
CP0422 - of telecon, ref SDS 54 ES50, received a week later on 100312
CP0423 - 1119. ref SDS 55 MN4O
CP0425 - ..
CP0426 - [On 100312 1119 VA transmittal letter explains patient medical
CP0427 - records are confidential to protect patient from identity
CP0428 - theft, avoid patient embarrassment, and enhance patient
CP0429 - convenience. ref SDS 55 SQ9J
CP0431 - ..
CP0432 - [On 100317 1213 letter to VA commends excellent medical
CP0433 - services, and confirms understandings that medical tests on
CP0434 - 100305 made findings of no cancer, and that acid burn has
CP0435 - occurred only on the flap constructed by Doctor Stewart to
CP0436 - protect the modified esophgeal sphincter valve from causing
CP0437 - acid reflux. ref SDS 56 PT6W
CP0439 - ..
CP0440 - [On 100331 1448 VA letter seems to expand initial
CP0441 - understandings from the meeting on 100305, to relate test
CP0442 - findings of general reflux esophagitis, rather than or in
CP0443 - addition to mere "acid burn" on the flap for the esophageal
CP0444 - sphincter valve. ref SDS 57 YW5S
CP0445 -
CP0447 - ..
CP0448 - Feedback Notice Resisted Reliance Network Passive Access
CP0449 -
CP0450 - Doctor Lee advised that later today he will dictate a report on work
CP0451 - performed today with instructions for the patient. He advised that
CP0452 - patient medical history can be instantly accessed by VA staff anywhere
CP0453 - in the country; but, patients have to get in the car, drive 20 miles
CP0454 - back to the VA and request a printed report, and then drive home and
CP0455 - type it up all over again in order to supporting the doctor/patient
CP0456 - partnership performing case management. This aligns with Doctor
CP0457 - Ratcliffe's concerns on 091219 that HIPAA is misapplied to deny
CP0458 - timely, accurate communication with patients, because doctors are
CP0459 - afraid of accountablity for inadvertant, minor disclosure of patient
CP0460 - medical history to people other than the patient. ref SDS 39 M75F
CP0462 - ..
CP0463 - Doctor Lee emphasized that Doctor Stewart can access the record as
CP0464 - quickly in San Francisco, as the VA team can in Martinez.
CP0466 - ..
CP0467 - Understandings were unclear during the meeting today how Doctor
CP0468 - Stewart will be alerted there is an issue to review, without
CP0469 - affirmative notice that testing today found "acid burn" on the "flap
CP0470 - issue, per above. ref SDS 0 PR6P
CP0472 - ..
CP0473 - Previously, Doctor Sandhu explained that sending notice on issues
CP0474 - affecting patients is resisted, because some doctors feel that being
CP0475 - alerted "interferes" rather than aids their work. Doctors fear
CP0476 - reprisals and accusations of not being a "team player" more than they
CP0477 - fear for the well being of the patient, reported on 060505 0830.
CP0478 - ref SDS 12 P58H More recently, resistance to notice in time to be
CP0479 - effective was reported at Kaiser on 091112 0930. ref SDS 28 B48O Fear
CP0480 - of conflict and retaliation reflects findings that communication is
CP0481 - the biggest risk in enterprise, explained in POIMS, ref OF 4 IE6L,
CP0482 - comprising the biggest cause of medical mistakes.
CP0484 - ..
CP0485 - Experience today indicates that benefits of computer networks can be
CP0486 - significantly leveraged by adding intelligence support using
CP0487 - Communication Metrics for proactive feedback and notice in time to be
CP0488 - effective, explained in POIMS. ref OF 6 1106
CP0489 -
CP0490 - [On 100317 1213 letter to VA commends excellent medical
CP0491 - services, and confirms understandings that medical tests on
CP0492 - 100305 made findings of no cancer, and that acid burn has
CP0493 - occurred only on the flap constructed by Doctor Stewart to
CP0494 - protect the modified esophgeal sphincter valve from causing
CP0495 - acid reflux. ref SDS 56 PT6W
CP0497 - ..
CP0498 - [On 100331 1448 VA letter seems to expand initial
CP0499 - understandings from the meeting on 100305, to relate test
CP0500 - findings of general reflux esophagitis, rather than or in
CP0501 - addition to mere "acid burn" on the flap for the esophageal
CP0502 - sphincter valve. ref SDS 57 YW5S
CP0503 -
CP0504 -
CP0505 -
CP06 -
SUBJECTS
GI Discharge Instructions Illegible Handwriting Follow Up Endoscopy
DF03 -
DF0401 - ..
DF0402 - Discharge Instructions Follow Up Endoscopy Colonoscopy Tests
DF0403 -
DF0404 - Kay submitted and discussed the following document, which is a carbon
DF0405 - copy with handwriting that is difficult to read...
DF0406 -
DF0407 - 1. Department of Veterans Administration
DF0408 - VA Northern California Health Care System
DF0409 - Gastroenterology Department
DF0411 - ..
DF0412 - 2. GI Discharge Instructions
DF0413 -
DF0414 - 1. Do not drive a motor vehicle, operate machinery, or make
DF0415 - important decisions for at least 24 hours after the
DF0416 - procedure. The medication given during the procedure may
DF0417 - effect how you act and think.
DF0419 - ..
DF0420 - 2. You may resume your usual diet after the procedure unless
DF0421 - instructed otherwise.
DF0423 - ..
DF0424 - 3. You may experience some abdominal bloating, cramping or
DF0425 - gas. Walking around the house or drinking warm weak tea or
DF0426 - black coffee may help.
DF0428 - ..
DF0429 - 4. You might have a mild soar throat following an EGD which
DF0430 - can be relieved by gargling with warm salt water.
DF0432 - ..
DF0433 - 5. Continue all medications as directed, and continue new
DF0434 - medications as prescribed.
DF0436 - ..
DF0437 - 6. Do not take aspirin, products containing aspirin, or
DF0438 - anti-inflammatory agents (i.e., Motrin, Advil, etc.) for
DF0439 - the next __________________ days.
DF0441 - ..
DF0442 - 7. Warfarin Coumadin patients
DF0443 -
DF0444 - ___ May resume medication immediately
DF0446 - ..
DF0447 - ___ May resume medication on ______________
DF0449 - ..
DF0450 - 8. If you have any of the following symptoms, please call the
DF0451 - Clinic checked below for advice. ref SDS 0 HC7N
DF0452 -
DF0453 - [On 100308 1411 Marcia called for Doctor Lee and
DF0454 - asked any of these complications have occurred, and
DF0455 - reported there have been no complications.
DF0456 - ref SDS 54 CG6K
DF0458 - ..
DF0459 - A. Passing or vomitting large amount of blood.
DF0461 - ..
DF0462 - B. Passing black or tarry stools.
DF0464 - ..
DF0465 - C. Fever over 100 degrees accompanied or not accompanied
DF0466 - by chills.
DF0468 - ..
DF0469 - D. Severe inflammation at the needle puncture site
DF0471 - ..
DF0472 - E. Severe abdominal or chest pain.
DF0474 - ..
DF0475 - F. Shortness of breath or tightness in your chest.
DF0477 - ..
DF0478 - G. Loss of consciousness or frequent bouts of dizziness.
DF0480 - ..
DF0481 - 3. Please contact the Medical Center between the hours 0800 - 1630
DF0482 - Monday through Friday.
DF0483 -
DF0484 - Martinez...... 925 372 2000 ext 5168
DF0485 - Sacramento.... 916 366 5339
DF0486 - Redding....... 530 226 7555
DF0487 -
DF0488 - [On 100308 1411 Marcia called for Doctor Lee and
DF0489 - asked any of these complications have occurred, and
DF0490 - reported there have been no complications.
DF0491 - ref SDS 54 CG6K
DF0493 - ..
DF0494 - At this point in the form there is illegible handwriting on the
DF0495 - Discharge form.
DF0496 -
DF0497 - [On 100308 1411 Marcia called to follow up test
DF0498 - procedures; and asked if medication was received for
DF0499 - "acid burn?" Advised that medication was not
DF0500 - received, and that GI Discharge document does not
DF0501 - present instructions for use. Marcia indicated
DF0502 - illegible handwriting in the discharge form intends
DF0503 - to convey Doctor Lee prescribed Omeprazole
DF0504 - medication to treat esophagitis, and that Progress
DF0505 - Notes will explain medication and instructions for
DF0506 - use. ref SDS 54 CH3O - appears conflicting with
DF0507 - understandings from discussion with the doctor after
DF0508 - EGD procedure, per above. ref SDS 0 HB86
DF0510 - ..
DF0511 - [On 100317 1213 letter to VA reports Omeprazole
DF0512 - medication was received from the VA and started
DF0513 - treating esophagitis from acid reflux. ref SDS 56
DF0514 - PU3W
DF0516 - ..
DF0517 - [On 100810 1530 Doctor Lee asked why meeting to
DF0518 - perform follow up EGD was delayed more than 2
DF0519 - months, ref SDS 58 M18F, planned in the meeting
DF0520 - today, per above, ref SDS 0 HB86, and was advised
DF0521 - there were no instructions on taking Omeprazole, and
DF0522 - Marcia reported on 100308, ref SDS 54 NB7H, that
DF0523 - illegible handwriting in Discharge papers, noted
DF0524 - above, ref SDS 0 HC7K, delayed the VA ordering
DF0525 - medication. ref SDS 58 M18K
DF0527 - ..
DF0528 - [On 100827 0738 medical chart presents "Findings"
DF0529 - plus Impressions and Recommendations missing from
DF0530 - medical chart for work today on 100305, for treament
DF0531 - with Omeprazole 40 mg, ref SDS 59 MZ8J, and which
DF0532 - doubled dose prescribed today on 100305, though not
DF0533 - listed in the medical chart, nor presented by the
DF0534 - medical team after the procedure, per above,
DF0535 - ref SDS 0 HB86; later Marcia called and reported the
DF0536 - doctor prescribed Omeprazole 20 mg per day, which
DF0537 - turned out to be illegible handwriting in the
DF0538 - discharge document, per above, ref SDS 0 HC7K, as
DF0539 - explained by Marcia on 100308 1411. ref SDS 54 CH3O
DF0541 - ..
DF0542 - [On 100827 0738 VA medical chart for follow up EGD
DF0543 - test reports use of prescribed medication with
DF0544 - Omeprazole was inconsistent, ref SDS 59 JE7X, and
DF0545 - again in "Impression" section, ref SDS 59 JE9J, -
DF0546 - clarification note appended on not getting
DF0547 - instructions to use Omeprazole, and illegible
DF0548 - handwriting was vague in Discharge documents.
DF0549 - ref SDS 59 JE7X
DF0551 - ..
DF0552 - 4. After 1630 on weekends and holidays, please call 800 382 8387
DF0554 - ..
DF0555 - At this point in the form there is a handwritten "*" with the string
DF0556 - "Advice Nurse."
DF0557 -
DF0558 - 5. If you feel there is an emergency, please go to the nearest
DF0559 - hospital or dial 911.
DF0560 -
DF0561 - 9. Additional instructions: (i.e., Sitz Bath, Medications,
DF0562 - etc)
DF0564 - ..
DF0565 - At this point in the form there is more illegible handwriting.
DF0566 -
DF0567 - 10. Follow up with
DF0568 -
DF0569 - A. Primary care provider
DF0570 -
DF0571 - B. GI Clinic
DF0573 - ..
DF0574 - C. Date and Time
DF0576 - ..
DF0577 - At this point in the form there is more illegible handwriting.
DF0578 -
DF0579 -
DF0580 - 6. Nurse Signature
DF0582 - ..
DF0583 - At this point in the form there is more illegible handwriting, may
DF0584 - have been signed by Kay.
DF0585 -
DF0588 - Patient's Signature/Significant others
DF0590 - ..
DF0591 - Date and Time: 100305 1155
DF0593 - ..
DF0594 - 7. My signature indicates that I understand and have received a
DF0595 - copy of these instructions.
DF0597 - ..
DF0598 - 8. Imprint Patient Data Card (name address and social security
DF0599 - number)
DF0606 - ..
DF0607 - 9. Medical Record Nursing Documentation
DF0608 -
DF0609 - VA Form 10-0096
DF0610 -
DF0611 -
DF0612 -
DF0613 -
DF07 -
SUBJECTS
Vaccination Shingles
DP03 -
DP04 - 1517
DP0501 - ..
DP0502 - Shingles Vaccination Performed at VA in Martinez
DP0503 -
DP0504 - Visit Adult Care of 1st floor.
DP0505 -
DP0506 - Evelyn gave vaccination for shingles ordered by Doctor Lee, per above.
DP0507 - ref SDS 0 4O4O
DP0509 - ..
DP0510 - Received following document...
DP0511 -
DP0512 - Shingles Vaccination
DP0514 - ..
DP0515 - This document explains shingles, symptoms, and vaccination, reported
DP0516 - in the record on 100104. ref SDS 47 QP34
DP0518 - ..
DP0519 - Vaccination today for shingles, resolves action item presented to the
DP0520 - medical team on 100301 0418. ref SDS 51 5T9W
DP0521 -
DP0522 - [On 100317 1213 notified medical team vaccinated to reduce risk
DP0523 - of shingles. ref SDS 56 PU7Y
DP0524 -
DP0525 -
DP0526 -
DP0527 -
DP06 -
SUBJECTS
VA Progress Notes Endoscopy Colonoscopy Tests GI Pre-Proc Provider A
EE03 -
EE0401 - ..
EE0402 - Progress Notes GI Pre-Proc Provider Assmnt 60440
EE0403 - Endoscopy and Colonoscopy GI Pre-Proc Provider Assmnt 60440
EE0404 - GI Pre-Proc Provider Assmnt 60440 Progress Notes
EE0405 -
EE0406 - Following VA Progress Notes were not received until several weeks
EE0407 - after the work was performed today.
EE0408 -
EE0409 - [On 100312 1119 drove to VA in Martinez, and received
EE0410 - Release of Information Department the Progress Notes for
EE0411 - work today. ref SDS 55 MN4O
EE0413 - ..
EE0414 - 1. Local Title: GI Pre-Proc Provider Assmnt 60440
EE0415 - Standard Title: Gastroenterology Procedure Note
EE0416 - Date of Note: 2010 MAR 05 1030
EE0417 - Entery Date: 2010 MAR 05 122556
EE0418 - Author
EE0423 - ..
EE0424 - EXP Cosigner
EE0425 - Urgency
EE0426 - Status............................ Completed
EE0428 - ..
EE0429 - 2. Diagnosis: achalasia / screening
EE0431 - ..
EE0432 - 3. Scheduled Procedure: EGD / colonoscopy
EE0434 - ..
EE0435 - 4. Reason for the planned procedure: screening
EE0437 - ..
EE0438 - 5. MD/Dentist/NP Assessment
EE0440 - ..
EE0441 - 6. Past Medical History
EE0442 -
EE0443 - 1. Rosacia
EE0444 - 2. Hypercholesterolemia
EE0445 - 3. CAD s/p CABG 2009
EE0447 - ..
EE0448 - Unclear why history does not list achalasia and Heller Myotomy surger
EE0449 - on 091216.
EE0451 - ..
EE0452 - VA Progress Notes continue...
EE0453 -
EE0454 - 7. Physicial assessment
EE0455 -
EE0456 - a. Vitals - most recent
EE0458 - ..
EE0459 - 1) Temperature...... 97.8 F 36.6 C 2010 MAR 05 1119
EE0460 - 2) Blood Pressure....124 79 2010 MAR 05 1119
EE0461 - 3) Heart Rate........90 2010 MAR 05 1119
EE0462 - 4) Resperation Rate..20 2010 MAR 05 1133
EE0463 - 5) Weight............180 81.8 KG 2010 MAR 05 1119
EE0464 - 6) Height............66 in 167.6 cm 2010 MAR 05 1119
EE0466 - ..
EE0467 - b. Alergies......... Patient has answered NKA
EE0469 - ..
EE0470 - c. Mental Status.... Alert and Oriented x3
EE0472 - ..
EE0473 - d. Airway: can paient open mouth wide...... yes
EE0474 - can paient stick out tongue..... yes
EE0476 - ..
EE0477 - e. Lung................. lungs clear
EE0479 - ..
EE0480 - f. Heart
EE0481 -
EE0482 - Heart is regular and no murmu.
EE0483 -
EE0484 - Sternotomy scar.
EE0486 - ..
EE0487 - Omits reporting scar laprscopic surgery Heller Myotomy resolve
EE0488 - achalasia on 091216.
EE0490 - ..
EE0491 - VA Progress Notes continue...
EE0492 -
EE0493 - g. Abdomen is soft, unremarkable and no masses felt.
EE0495 - ..
EE0496 - h. Medications
EE0497 -
EE0498 - 1) Active outpatient medications (excluding supplies)...
EE0500 - ..
EE0501 - Active Outpatient Medications Status
EE0503 - ..
EE0504 - a) Nitroglycerin (Nitrostat) Active
EE0505 -
EE0506 - 0.4 mg SL TAB disolve one tablet under
EE0507 - the tongue as needed for chest pain. If
EE0508 - no relief in 5 minutes call 911. May
EE0509 - take 1 tablet every 5 minutes (maximum 3
EE0510 - tablets) if needed.
EE0512 - ..
EE0513 - b) Simvastatin Active
EE0514 -
EE0515 - 4.0 MG tablets take one-half tablet
EE0516 - by mouth every evening - for cholesterol.
EE0517 - Use pill cutter. Do not take with
EE0518 - grapefruit juice.
EE0520 - ..
EE0521 - 2) Active Non-VA Medications Status
EE0522 -
EE0523 - a) Metoprolol Tartrate Active
EE0524 -
EE0525 - 25 mg tablets take 12.5 mg by mouth
EE0526 - twice a day.
EE0528 - ..
EE0529 - 3) Total Medications
EE0531 - ..
EE0532 - Unclear about the purpose of this heading - "Total Medications."
EE0533 - Perhaps it signals the end of medication list.
EE0535 - ..
EE0536 - Does this list signal the end for taking aspirin listed on the
EE0537 - discharge report for the record on 091104 0718. ref SDS 27 414R
EE0539 - ..
EE0540 - VA Progress Notes continue...
EE0541 -
EE0542 - i. Is new EKG or CRX Necessary............. no
EE0544 - ..
EE0545 - 8. American Society of Anesthesiologist (ASA) Classification: 2
EE0546 -
EE0547 - I have reviewed the interim history and repeated the relevant
EE0548 - physical exam. There are no significant changes compared to
EE0549 - prior visit.
EE0551 - ..
EE0552 - This part of the report is vague. The medical chart for today should
EE0553 - be linked, or at least cite the prior "visit" for which comparison is
EE0554 - made. Was the work today compared to the meeting with Doctor Lee on
EE0555 - 100202 1400. ref SDS 50 PP8W There were no sedation procedures
EE0556 - performed on 100202.
EE0558 - ..
EE0559 - Patient sedation history shows...
EE0560 -
EE0561 - a) Heller Myotomy surgery at VA Medical
EE0562 - Center in San Francisco............... 091216 0600. ref3SDS 36 KE8T
EE0564 - ..
EE0565 - b) CABG at VA Medical Center San
EE0566 - Francisco............................. 091022 0700, ref2SDS 20 01F9
EE0568 - ..
EE0569 - c) Endoscopy test at VA Clinic
EE0570 - Martinez.............................. 051209 1130, ref8SDS 8 PX3I
EE0572 - ..
EE0573 - VA Progress Notes continue...
EE0574 -
EE0575 - 9. Sedation Plan
EE0576 -
EE0577 - Sedation / Anesthesia options, benefits, and risks were
EE0578 - discussed including: neasua/vomitting, allergic reactions,
EE0579 - unexpected cardiac or pulmonary problems, and cardiac arrest.
EE0580 - Patient expressed understanding and wishes to proceed with
EE0581 - planned secation/anesthesia.
EE0583 - ..
EE0584 - Patient history shows no explanation of sedation plan, nor associated
EE0585 - risks, per above, ref SDS 0 038F; patient signed consent for procedure
EE0586 - to benefit from test results, ref SDS 0 N45K,
EE0587 -
EE0588 - [...below, Sedation Plan presented in Progress Notes
EE0589 - ref SDS 0 W35M, received on 100312, ref SDS 55 FS6V
EE0591 - ..
EE0592 - VA Progress Notes continue...
EE0593 -
EE0594 - Did a family member or companion accompany the patient and
EE0595 - participate in the discussion and Interview? No
EE0597 - ..
EE0598 - VA Progress Notes continue...
EE0599 -
EE0600 - Procedure can proceed with sedation.
EE0602 - ..
EE0603 - Sedation Plan....
EE0604 -
EE0605 - Moderate
EE0607 - ..
EE0608 - /es/ Randall E Lee, MD
EE0609 - Staff Physician, Gastroenterology
EE0610 - Signed: 1010 MAR 05 1229
EE0611 -
EE0612 -
EE0613 -
EE07 -
SUBJECTS
VA Progress Notes Endoscopy Colonoscopy Tests GI Nurse Pre-Proc Chec
F303 -
F30401 - ..
F30402 - Progress Notes Nurse Pre-procedure Checklist Endoscopy Colonoscopy
F30403 - Checklist Endoscopy Colonoscopy Progress Notes Nurse Pre-procedure
F30404 - Endoscopy Checklist Colonoscopy Progress Notes Nurse Pre-procedure
F30405 - Nurse Pre-procedure Checklist Progress Notes Endoscopy Colonoscopy
F30406 -
F30407 - Evidently another document...
F30408 -
F30409 - 1. Local Title: GI Nurse Pre-Proc Checklist...... 60439
F30410 - Standard Title: Gastroenterology Nursing Procedure Note
F30411 - Date of Note: 2010 MAR 05 1136
F30412 - Entery Date: 2010 MAR 05 113617
F30413 - Author
F30418 - ..
F30419 - EXP Cosigner
F30420 - Urgency
F30421 - Status............................ Completed
F30422 -
F30423 - *** GI Nurs Pre-Proc Checklist 60439 has agenda ***
F30425 - ..
F30426 - Adm Time: 2010 MAR 05 @ 1030
F30428 - ..
F30429 - 2. Vitals - most recent
F30430 -
F30431 - 1) Temperature...... 97.8 F 36.6 C 2010 MAR 05 1119
F30432 - 2) Blood Pressure....124 79 2010 MAR 05 1119
F30433 - 3) Heart Rate........90 2010 MAR 05 1119
F30434 - 4) Resperation Rate..20 2010 MAR 05 1133
F30435 - 5) O2 Sat........... 97% RA 2010 MAR 05 1119
F30436 - 6) FBS.............. None
F30437 - 7) Pain............. 0 2010 MAR 05 1119
F30438 - 8) Location......... None
F30440 - ..
F30441 - This "vitals" list copies the list in the first title except height
F30442 - and weight are omitted from this list, and oxygen, FBS, and pain are
F30443 - added to this list compared to the one shown above, ref SDS 0 VG8F,
F30445 - ..
F30446 - VA Progress Notes continue...
F30447 -
F30448 - 3. Comment
F30449 -
F30450 - The patient is here today for screening colonoscopy/EGD. Other
F30451 - history follow up of esophageal achalasia. he has had a known
F30452 - history of esophageal achalasia, with a more than 20 year past
F30453 - history of difficulty swallowing food and drinks, as well as
F30454 - passive regurgitation. Barium esophagram showed a dilated
F30455 - mid-lower esophagus without perisaltic contractions, and a
F30456 - sharp narrowing of the GE junction. EGD and biopsy showed no
F30457 - evidence of maligancy or Barrett's esophausincludes.
F30459 - ..
F30460 - This comment seems to cite the barium test performed at the VA Clinic
F30461 - in Martinez on 050714 1000. ref SDS 6 2I4S
F30463 - ..
F30464 - Helps to list the date of prior procedures, and provide a link for
F30465 - verification.
F30467 - ..
F30468 - 20-year past history of swallowing does not align with the record.
F30469 - Swallowing and digestion problems first reported to primary care
F30470 - physician at VA on 050629 1000. ref SDS 5 K78K During meeting with
F30471 - Doctor Lee, in the GI Department, reported swallowing became difficult
F30472 - over past 5 - 10 years, shown in the record on 051202 1430.
F30473 - ref SDS 7 Q55N
F30475 - ..
F30476 - VA Progress Notes continue...
F30477 -
F30478 - 4. Checklist
F30479 -
F30480 - 1) Patient ID: Verbal ID Band. Chart,
F30481 - VA Card.............................................. Yes
F30483 - ..
F30484 - Allergies............................................ NEA
F30486 - ..
F30487 - Patient has answered NEA -
F30489 - ..
F30490 - Allergy information verified......................... Yes
F30492 - ..
F30493 - 2) Legal Guardian, Conservator.......................... No
F30495 - ..
F30496 - 3) Patient has an Advance Directive in medical
F30497 - record............................................... No
F30499 - ..
F30500 - Patient provided us with a copy of Advance
F30501 - Directive today...................................... No
F30503 - ..
F30504 - This part of the record indicating that the patient does not have an
F30505 - Advance Directive on file with the VA appears conflicting with the
F30506 - report on 091023 showing Advance Directive with end-of-life
F30507 - instructions was signed electronically the day after heart surgery at
F30508 - the VA Medical Center in San Francisco. ref SDS 21 WO5Y
F30509 -
F30510 - [On 100928 0706 received CD from VA with medical records
F30511 - showing Advance Directive on file and signed 091023.
F30512 - ref SDS 63 PQ5R
F30514 - ..
F30515 - [On 110218 0730 Iris, lead nurse in GI Department for VA
F30516 - Martinez advised that patient medical records for Advance
F30517 - Directive on file in the San Francisco Medical Center is
F30518 - not available to the VA Clinic in Martinez. ref SDS 67 EE4L
F30520 - ..
F30521 - VA Progress Notes continue...
F30522 -
F30523 - 4) H&P in chart (within 10 days) Read &
F30524 - Reviewed............................................. Yes
F30526 - ..
F30527 - Need explanation for H&P???
F30529 - ..
F30530 - VA Progress Notes Checklist continue...
F30531 -
F30532 - 5) Consent Signed, Dated & Timed (within
F30533 - 10 days) Patient verbally
F30534 - verified............................................. Yes
F30536 - ..
F30537 - Aligns with the record signing consent during meeting with Doctor Lee,
F30538 - per above. ref SDS 0 N45K
F30540 - ..
F30541 - VA Progress Notes Checklist continue...
F30542 -
F30543 - 6) Correct procedure - EGD/Colonoscopy.................. Yes
F30545 - ..
F30546 - 7) NPO Since............................................ Yes
F30547 -
F30548 - Time and Date............ 2010 MAR 04 2200
F30549 - Last Solid Food.......... 2010 MAR 03 1800
F30550 -
F30551 - [...below NPO status applied for immediate pre-sedation
F30552 - evaluation. ref SDS 0 WG66
F30554 - ..
F30555 - 8) Bowel Prep Completed................................. Yes
F30556 -
F30557 - Color of last bowel movement...... clear
F30558 - Fleets enema given................ N/A
F30560 - ..
F30561 - 9) MD Orders. Nursing Assessment Completed............. Yes
F30562 -
F30563 - See Nursing assessment, above. ref SDS 0 RQ3K
F30565 - ..
F30566 - 10) Implants - none...................................... No
F30568 - ..
F30569 - 11) Patient valuables: bedside.......................... Yes
F30571 - ..
F30572 - 12) Patient valuables: bedside.......................... Yes
F30574 - ..
F30575 - 13) Dentures - none...................................... No
F30577 - ..
F30578 - 14) Glasses/Contact Lenses............................... No
F30580 - ..
F30581 - 15) Hearing Aid - none................................... No
F30582 -
F30583 - Jewlery -none........................................ No
F30585 - ..
F30586 - 16) Driver/Escort........................................ Yes
F30588 - ..
F30589 - If yes - name
F30591 - ..
F30594 - ..
F30595 - 17) Post Procedure Instructions Reviewed
F30596 - with patient......................................... Yes
F30598 - ..
F30599 - This may be "GI Discharge Instructions" document, per above.
F30600 - ref SDS 0 5C9H
F30602 - ..
F30603 - VA Progress Notes Checklist continue...
F30604 -
F30605 - 18) NS 500 ml tko #22 to left AC........................ Yes
F30609 - ..
F30610 - Unclear in the record what is being conveyed in this section of the
F30611 - record.
F30613 - ..
F30614 - VA Progress Notes continue...
F30615 -
F30616 - 5. Date of Interview
F30617 -
F30618 - 2010 MAR 05
F30619 -
F30620 - Patient Age..................................... 65
F30622 - ..
F30623 - Physician
F30624 -
F30625 - Randall E Lee, MD
F30627 - ..
F30628 - Procedure.................................... EGD/Colonoscopy
F30630 - ..
F30631 - 6. Checklist
F30632 -
F30633 - 1) Current Medications Taken Today..................... None
F30634 -
F30635 - 2) Are you using Fentanyl patches...................... No
F30636 -
F30637 - 3) Diabetic (IDDM)..................................... No
F30639 - ..
F30640 - 4) Diabetic (NIDDM).................................... No
F30642 - ..
F30643 - 5) ASA................................................. No
F30645 - ..
F30646 - 6) NSAIDS.............................................. No
F30648 - ..
F30649 - 7) Anti-platelets Therapy.............................. No
F30651 - ..
F30652 - 8) Anticoagulation Therapy............................. No
F30654 - ..
F30655 - 9) LOC: AAO........................................... Responsive
F30657 - ..
F30658 - 10) Cognitive Limitations............................... None
F30660 - ..
F30661 - 11) Circ/Perfusion...................................... Warm Dry Normal
F30663 - ..
F30664 - 12) Heart Tones......................................... Normal
F30666 - ..
F30667 - 13) S1 S2............................................... No murmurs
F30669 - ..
F30670 - 14) Resperations........................................ Regular Breath Sounds
F30672 - ..
F30673 - 15) Resperations Regular Breath
F30674 - Sounds.............................................. Clear Bilaterally
F30676 - ..
F30677 - 16) GI Soft Flat Non-tender
F30678 - Bowel Sounds........................................ Present
F30680 - ..
F30681 - 17) GU Voids............................................ Without Problems
F30683 - ..
F30684 - 18) GYN................................................. NA
F30686 - ..
F30687 - 19) Skin................................................ Intact
F30689 - ..
F30690 - 20) Musc / Skeletal / Activity.......................... No abnormal findings
F30692 - ..
F30693 - 21) Mobility............................................ Independent
F30695 - ..
F30696 - 22) Manual Dexterity.................................... Normal
F30698 - ..
F30699 - 23) Behavorial / Emotional Status....................... Calm Cooperative
F30701 - ..
F30702 - 24) Barriars to Learning Functional
F30703 - Assessment.......................................... None
F30705 - ..
F30706 - 25) Vision.............................................. Unimpaired
F30708 - ..
F30709 - 26) Hearing............................................. Unimpaired
F30711 - ..
F30712 - 27) Communication....................................... Normal
F30714 - ..
F30715 - 28) Interpreter Required................................ No
F30717 - ..
F30718 - 29) Nutritional Assessment.............................. No diet restrictions
F30720 - ..
F30721 - 30) Cultural / Religious Preferences.................... None
F30723 - ..
F30724 - 7. Plan of Care - Pre-procedure Sedation
F30726 - ..
F30727 - 8. Knowledge deficit related to impending procedure.
F30728 -
F30729 - 1) Outcomes: Patien has adequate and appropriate information
F30730 - related to pre-procedure, intra-procedure, and
F30731 - post-procedure.
F30733 - ..
F30734 - 2) Instruct patient at initial visit that he/she must arrive
F30735 - with a responsible adult to transport them following the
F30736 - procedure.
F30738 - ..
F30739 - 3) Procedure will be re-scheduled if arrangements not made.
F30741 - ..
F30742 - 4) Explain purpose of pre-procedure sedation.
F30744 - ..
F30745 - 5) Explain how conscious sedation works.
F30747 - ..
F30748 - This is not clear in the record. In this case, patient was entirely
F30749 - unconscious, at least has no memory of the procedure, per above.
F30750 - ref SDS 0 PR6P
F30752 - ..
F30753 - VA Progress Notes continue...
F30754 -
F30755 - 6) Explain monitoring of vital signs, patient pain status
F30756 - throughout procedure.
F30757 -
F30758 - 9. Above actions completed.
F30759 -
F30761 - Nursing Service
F30762 - Signed: 2010 MAR 05 1150
F30764 - ..
F30765 - 10. Addendum................ 2010 MAR 05
F30766 - Status.................. Completed
F30768 - ..
F30769 - H&P and procedural consent for EGD and Colonoscopy with
F30770 - moderate sedation was completed prior to the procedure per
F30773 - ..
F30774 - Aligns with patient history, per above. ref SDS 0 N45K
F30776 - ..
F30777 - The H&P clinic note nursing assessment medications and
F30778 - allergies were reviewed prior to the start of the procedure.
F30780 - ..
F30781 - Aligns with patient history, per above. ref SDS 0 QS51
F30782 -
F30783 -
F30784 -
F308 -
SUBJECTS
Sedation Plan Progress Notes Endoscopy Colonoscopy Tests VA Plan of
FV03 -
FV0401 - ..
FV0402 - Sedation Plan Endoscopy Colonoscopy Tests
FV0403 -
FV0404 - Evidently another document, since there is a signature above, though
FV0405 - there is not new title, as seems to occur for VA Progress Notes
FV0406 - documents, e.g., above. ref SDS 0 RQ3K and, ref SDS 0 P86K
FV0407 -
FV0408 - 1. Plan of Care - Intra-procedure sedation
FV0410 - ..
FV0411 - [...below, sedation plan calls for nurse to give the
FV0412 - patient analgesic, and increase analgesic on orders from
FV0413 - the doctor based on patient showing signs of pain during
FV0414 - the procedure. ref SDS 0 J63X
FV0416 - ..
FV0417 - [On 100827 0738 medical chart for follow up EGD does not
FV0418 - show "sedation plan," but shows implementation of
FV0419 - sedation procedures. ref SDS 59 JE9V
FV0421 - ..
FV0422 - 1) Potential for anxiety related to possible pain during
FV0423 - impending procedure and unfamiliar environment.
FV0425 - ..
FV0426 - 2) Outcomes: Patient shows no signs of anxiety and verbalizes
FV0427 - decreased level of anxiety during procedure.
FV0429 - ..
FV0430 - Not clear if this section refers to verbalizing during procedure while
FV0431 - sedated, or prior to sedation leading to performing test procedures.
FV0433 - ..
FV0434 - Since the patient has no memory of proceedings during sedation, the
FV0435 - record should give examples of what was asked and answered and/or
FV0436 - volunteered by the patient while under sedation.
FV0438 - ..
FV0439 - VA Progress Notes continue...
FV0440 -
FV0441 - 3) Allow private time 1 on 1 with patient to discuss fear or
FV0442 - concerns. Explain monitoring of vital signs / patient pain
FV0443 - status throughout procedure.
FV0444 -
FV0445 - 4) Discuss medications and how patient is monitored.
FV0447 - ..
FV0448 - 5) Ask patient if he / she or someone he / she knows has ever
FV0449 - had an untoward reaction to sedation... encourage
FV0450 - discussion.
FV0452 - ..
FV0453 - 6) Discuss any problems patient may have had with breathing,
FV0454 - airway obstructions in past.
FV0456 - ..
FV0457 - Above actions completed.
FV0459 - ..
FV0460 - The record on these activities is unclear.
FV0461 -
FV0462 - [...this section duplicates and expands Progress Notes above
FV0463 - reporting discussing sedation plan with patient. ref SDS 0
FV0464 - 9394
FV0466 - ..
FV0467 - VA has recent history showing patient has been sedated many times
FV0468 - without incident, e.g., for nearly 24 hours getting heart surgery,
FV0469 - beginning on 091022 0700 at 0930, ref SDS 20 LO3G, and did not awake
FV0470 - until OA 0500 the next day on 091023 0445, ref SDS 21 01F9
FV0472 - ..
FV0473 - Patient suffered significant problems with breathing during sedation
FV0474 - for heart surgery. VA anesthesiologist, Doctor Brezinski, handled the
FV0475 - problem well, reported on 091022 0700. ref SDS 20 JF9K However, the
FV0476 - next day, VA did not handle well patient waking from sedation. 091023
FV0477 - 0445, ref SDS 21 01F9
FV0479 - ..
FV0480 - VA Progress Notes for Endoscopy and Colonoscopy on 100305, reporting
FV0481 - "discussions" with patient on sedation issues, likely appear in VA
FV0482 - Progress Notes for heart surgery, but, like today, did not actually
FV0483 - occur, leading to "panic" suffered by patient.
FV0485 - ..
FV0486 - Patient sedated for Heller Myotomy surgery on 091216 0600 at 0819,
FV0487 - ref SDS 36 KE9U, and did not wake up until 8 hours later on 091216
FV0488 - 0600 at 1650. ref SDS 36 HQ5M
FV0490 - ..
FV0491 - VA Progress Notes continue...
FV0492 -
FV0493 - 2. Potential for risk for altered gas exchange and ineffective
FV0494 - breathing patterns secondary to sedation.
FV0495 -
FV0496 - Outcomes: Patient will exhibit no signs of respiratory
FV0497 - distress and airway will remain pattent throughout the
FV0498 - procedure.
FV0500 - ..
FV0501 - 3. Check List.
FV0502 -
FV0503 - 1) Nurse will assess current allergies and update
FV0504 - documentation of allergies in CPRS.
FV0506 - ..
FV0507 - This seems to have been done per above. ref SDS 0 5L8O and ref SDS 0
FV0508 - VR4M
FV0510 - ..
FV0511 - VA Progress Notes continue...
FV0512 -
FV0513 - 2) Nurse will verify / maintain NPO status.
FV0515 - ..
FV0516 - 3) Nurse will assure that all equipment [is] in close
FV0517 - proximity and in working order prior to procedure.
FV0519 - ..
FV0520 - 4) Nurse administering conscious sedation will keep noise
FV0521 - level to a minimum.
FV0523 - ..
FV0524 - Unclear how nurse can control noise level of doctor, other nurses, and
FV0525 - activity outside OR.
FV0527 - ..
FV0528 - VA Progress Notes continue...
FV0529 -
FV0530 - 5) Nurse will remain alert to subtle changes such as dyspnea,
FV0531 - hyperventilation, cyanosis, shortness of breath or stridor
FV0532 - in breathing patterns and possible drop in oxygen
FV0533 - saturation and/or hypertension keeping physician informed
FV0534 - of patient status during procedure.
FV0536 - ..
FV0537 - Above actions completed.
FV0539 - ..
FV0540 - 4. Potential for actual pain during procedure.
FV0541 -
FV0542 - Outcome: Patient will verbalize or demonstrate relief of pain
FV0543 - during and post procedure.
FV0545 - ..
FV0546 - Nurse will assess level of pain throughout the procedure and
FV0547 - administer analgesic as needed per order and evaluate
FV0548 - effectiveness.
FV0550 - ..
FV0551 - Above actions completed.
FV0553 - ..
FV0554 - This appears to be the "sedation plan" which is the heading of this
FV0555 - part of the medical chart, per above. ref SDS 0 W35M
FV0557 - ..
FV0558 - Shouldn't the sedation plan say what analgesic will be used and how it
FV0559 - will be applied?
FV0561 - ..
FV0562 - VA Progress Notes continue...
FV0563 -
FV0564 - 5. Immediate Pre-sedation Evaluation
FV0565 -
FV0566 - 1) ASA.......................................... II
FV0567 -
FV0568 - 2) NPO.......................................... Yes
FV0569 -
FV0570 - Last ate: See Nursing Assessment. ref SDS 0 VZ8L
FV0572 - ..
FV0573 - 3) Driver....................................... Yes
FV0575 - ..
FV0576 - 4) Took Meds.................................... No
FV0578 - ..
FV0579 - 5) AM GLU....................................... Not diabetic
FV0581 - ..
FV0582 - 6) Aspirin Off.................................. Yes
FV0584 - ..
FV0585 - 7) NSAID Off.................................... Yes
FV0587 - ..
FV0588 - 8) Vital Signs
FV0590 - ..
FV0591 - Repeats 2 check lists above....
FV0592 -
FV0593 - GI Pre-Proc Provider Assmnt 60440......... ref SDS 0 VG8F
FV0594 - GI Nurse Pre-Proc Checklist 60440,........ ref SDS 0 MJ5T
FV0596 - ..
FV0597 - VA Progress Notes continue...
FV0598 -
FV0599 - 9) Heart Normal S1, S2, RRR, Monitor................. NSR
FV0601 - ..
FV0602 - 10) Lungs: Regular
FV0603 -
FV0604 - Breath sounds clear to auscultation bilaterally.
FV0606 - ..
FV0607 - 11) Implants.......................................... No
FV0609 - ..
FV0610 - 12) Additional comments
FV0611 -
FV0612 - Patient agrees to proceed.
FV0614 - ..
FV0615 - 13) Time Out.......................................... 1254
FV0617 - ..
FV0618 - 14) Verified by
FV0624 - ..
FV0625 - 15) CGRN:
FV0626 -
FV0627 - a) Correct patient.
FV0628 -
FV0629 - b) Correct procedure.
FV0630 -
FV0631 - c) Correct position.
FV0633 - ..
FV0634 - d) Correct physician.
FV0636 - ..
FV0637 - e) Correct equipment required.
FV0639 - ..
FV0640 - f) Correct indication for procedure.
FV0642 - ..
FV0643 - g) Correct ASA
FV0644 -
FV0645 -
FV0646 -
FV07 -
SUBJECTS
Endoscopy Progress Notes EGD Test Procedure 1 Findings No Evidence D
GF03 -
GF0401 - ..
GF0402 - Endoscopy Progress Notes EGD Test Findings No Evidence Disease
GF0403 - Progress Notes Endoscopy EGD Test Findings No Evidence Disease
GF0404 -
GF0405 - Follow up ref SDS 50 PP8W.
GF0406 -
GF0407 - 6. Procedure 1
GF0408 -
GF0409 - EGD wih biopsy and dilation
GF0410 -
GF0411 - [On 100827 0738 VA medical records Progress Notes for
GF0412 - EGD on 100827, cite prior EGD on 100310, but seems to be
GF0413 - referencing work today on 100305. ref SDS 59 JE67
GF0415 - ..
GF0416 - [On 100827 0738 VA medical records for follow up EGD
GF0417 - show section called INTRAVENOUS MEDICATION that is
GF0418 - missing from this test on 100305? ref SDS 59 JE9V
GF0420 - ..
GF0421 - [On 100827 0738 VA medical records for follow up EGD
GF0422 - show thorough explanation and precise details of EGD
GF0423 - procedure. ref SDS 59 JE4S
GF0425 - ..
GF0426 - [On 100827 0738 at 1333 during post procedure meeting,
GF0427 - Doctor Lee reported condition of LESV is about 11 mm,
GF0428 - unchanged from initial EGD dilation on 100305, so there
GF0429 - has been no evident improvement. ref SDS 60 0466
GF0431 - ..
GF0432 - The record seems to indicate that LESV 11 mm at start of procedure
GF0433 - today, and was expanded to 15 mm with balloon dilation, based on
GF0434 - follow up reporting...
GF0436 - ..
GF0437 - [On 100827 0738 Progress Notes seem to report LESV was
GF0438 - expanded with pneumatic (balloon) dilation from initial
GF0439 - condition to 12.9 then again to 14 and finally to 15 mm.
GF0440 - ref SDS 60 JE6X
GF0442 - ..
GF0443 - [On 101210 0930 Progress Notes report LESV was inflated
GF0444 - sequentially to 12, 13, and 14 mm. ref SDS 66 H347
GF0446 - ..
GF0447 - 7. Findings
GF0448 -
GF0449 - 1) Esophageal Stricture. dilated via EGD scope: S/P Nissan
GF0451 - ..
GF0452 - 2) Fundalplication; Esophagitis
GF0454 - ..
GF0455 - Cannot find any research on "Fundalplication Esophagitis" - there is
GF0456 - a lot of reporting on "fundoplication esophagitis."
GF0457 -
GF0458 - [On 100312 1119 pathology report on biopsies make no
GF0459 - findings of "acid burn," per se, and say simply "Reflux
GF0460 - esophagitis," and "No intestinal metaplasia (no
GF0461 - Barrett's Esophagus)". ref SDS 55 MX5K
GF0463 - ..
GF0464 - [On 100331 1448 VA letter seems to expand initial
GF0465 - understandings from the meeting on 100305, to relate
GF0466 - test findings of general reflux esophagitis, rather than
GF0467 - or in addition to mere "acid burn" on the flap for the
GF0468 - esophageal sphincter valve. ref SDS 57 YW5S
GF0470 - ..
GF0471 - [On 100827 0738 medical chart presents "Findings" plus
GF0472 - Impressions and Recommendations missing from medical
GF0473 - chart for work today on 100305, for treament with
GF0474 - Omeprazole 40 mg, ref SDS 59 MZ8J, and which doubled
GF0475 - dose prescribed today on 100305, though not listed in
GF0476 - the medical chart, nor presented by the medical team
GF0477 - after the procedure, per above, ref SDS 0 HB86; later
GF0478 - Marcia called and reported the doctor prescribed
GF0479 - Omeprazole 20 mg per day, which turned out to be
GF0480 - illegible handwriting in the discharge document, per
GF0481 - above, ref SDS 0 HC7K, as explained by Marcia on 100308
GF0482 - 1411. ref SDS 54 CH3O
GF0484 - ..
GF0485 - Research finds...
GF0486 -
GF0487 - Medicinenet.com
GF0488 -
GF0489 - Definition of Fundoplication
GF0490 -
GF0491 - http://www.medterms.com/script/main/art.asp?articlekey=15943
GF0493 - ..
GF0494 - Fundoplication (anti-reflux surgery): A surgical technique
GF0495 - that strengthens the barriar to acid reflux when the lower
GF0496 - esophageal sphincter does not work normally and there is
GF0497 - gastro-esophageal reflux.
GF0499 - ..
GF0500 - Not clear if endoscopy test today diagnosed esophagitis?
GF0502 - ..
GF0503 - Use of a medical term seemingly related to "Fundoplication" aligns
GF0504 - with Heller Myotomy surgery on 091216, which constructed a "flap" to
GF0505 - reduce acid reflux, explained by Doctor Stewart at VA Medical Center
GF0506 - San Francisco during meeting on 091030 0810. ref SDS 23 OY64
GF0508 - ..
GF0509 - During the meeting after endoscopy, the doctor seemed to report
GF0510 - finding "acid burn" on the "flap" constructed by Doctor Stewart, as
GF0511 - part of Heller Myotomy surgery; and this was based on 1 of eight
GF0512 - photographs captured during the endoscopy test, per above. ref SDS 0
GF0513 - PR6P
GF0515 - ..
GF0516 - Why is there no mention of "acid burn" in test findings; there is no
GF0517 - mention of medication prescribed, nor planning for follow up test to
GF0518 - evaluate resolution?
GF0519 -
GF0520 - [On 100308 1411 Marcia advised that Doctor Lee prescribed
GF0521 - medication to recover from "acid burn" to the esophabeal
GF0522 - flap, ref SDS 54 CH3O, and seemed to say that the
GF0523 - prescription including instructions for use are reported in
GF0524 - the Progress Notes. ref SDS 54 CH3O
GF0526 - ..
GF0527 - [On 100312 1119 8 pictures received from VA with Progress
GF0528 - Notes are rendered in black and white, which makes
GF0529 - identifying "acid burn" condition on the esophageal "flap"
GF0530 - in 1 of the 8 pictures difficult to recognize without a
GF0531 - notation of some kind. ref SDS 55 FL5F
GF0533 - ..
GF0534 - [On 100312 1200 pathology report on biopsies seem to find
GF0535 - no evidence for esophagitis, and make no findings of "acid
GF0536 - burn." ref SDS 55 MX5K
GF0538 - ..
GF0539 - Progress Notes should record that "acid burn" on the "flap" that
GF0540 - prevents acid reflux was conveyed to patient as a finding from the
GF0541 - endoscopy test, per above. ref SDS 0 PR6P
GF0543 - ..
GF0544 - VA Progress Notes continue...
GF0545 -
GF0546 - 8. Scope: Olympus GIF-H180 # 3
GF0547 -
GF0548 - 9. Start: 1255 End: 1322
GF0550 - ..
GF0551 - 10. Pictures attached to chart.
GF0553 - ..
GF0554 - There were 8 pictures shown following endoscopy test on 100305, and 1
GF0555 - of these pictures was cited for showing "acid burn" on only the "flap"
GF0556 - surgically constructed by Doctor Stewart during Heller Myotomy to
GF0557 - resolve achalasia. ref SDS 0 PR6P
GF0558 -
GF0559 - [On 100312 1119 8 pictures received from VA with Progress
GF0560 - Notes are rendered in black and white, and do not identify
GF0561 - "acid burn" condition on the esophageal "flap" in 1 of the
GF0562 - 8 pictures difficult to recognize without a notation of
GF0563 - some kind. ref SDS 55 FL5F
GF0565 - ..
GF0566 - 11. Esophageal Dilation
GF0568 - ..
GF0569 - 12. Savory Dilation over 0.038 mm guide wire.
GF0571 - ..
GF0572 - 13. Dilators: 11 mm, 12 mm, and 14 mm
GF0574 - ..
GF0575 - 14. Surgical Pathology
GF0576 -
GF0577 - A. Gastric Biopsies
GF0578 - B. Esophageal Biopsies at 38 cm
GF0579 - C. Esophageal Biopsies at 36 cm
GF0580 - D. Esophageal Biopsies at 34 cm
GF0581 - E. Esophageal Biopsies at 30 cm
GF0582 -
GF0583 - [On 100312 1200 pathology report on biopsies seem to
GF0584 - find no evidence for esophagitis, and do not present
GF0585 - findings of "acid burn," ref SDS 55 MX5K, which was
GF0586 - cited during discussion after the test today, per above.
GF0587 - ref SDS 0 PR6P
GF0589 - ..
GF0590 - [On 100912 1127 received copy of follow up biopsy with
GF0591 - VA transmittal letter, ref SDS 62 1W5I, and Doctor Lee
GF0592 - explaining results of endoscopy EGD test findings, and
GF0593 - biopsy show no cancer, pre-cancerous tissue, nor
GF0594 - infection, but did find acute inflammation, which Doctor
GF0595 - Lee describes as severe acid reflux damage. ref SDS 62
GF0596 - TN80, which aligns with findings shown above on 100827
GF0597 - 0728, ref SDS 59 JF4Q, and previously described in the
GF0598 - biopsy report received on 100312 for the EGD on 100305,
GF0599 - as "reflux esophagitis." ref SDS 55 MX5K
GF0600 -
GF0601 -
GF0602 -
GF0603 -
GF0604 -
GF07 -
SUBJECTS
Colonoscopy Progress Notes Test Procedure 2 VA GI Findings Normal No
GY03 -
GY0401 - ..
GY0402 - Colonoscopy Progress Notes Test Findings No Evidence Disease
GY0403 - Progress Notes Colonoscopy Test Findings No Evidence Disease
GY0404 -
GY0405 -
GY0406 - 15. Procedure 2.
GY0407 -
GY0408 - Colonoscopy to terminal ileum.
GY0410 - ..
GY0411 - 16. Findings
GY0412 -
GY0413 - Normal exam to terminal ileum.
GY0415 - ..
GY0416 - Post-procedure disussion reported finding no evidence of polyps nor
GY0417 - hemorids, ref SDS 0 K97H, which is not presented in Progress Notes on
GY0418 - Findings.
GY0420 - ..
GY0421 - VA Progress Notes continue...
GY0422 -
GY0423 - 17. Scope: Olympus PCF-H180AL # 25
GY0425 - ..
GY0426 - 18. Start: 1338 Cecum: 1343 End: 1355
GY0428 - ..
GY0429 - 19. Pictures attached to chart.
GY0430 -
GY0431 - [On 100312 1119 4 pictures received from VA with Progress
GY0432 - Notes are rendered in black and white. ref SDS 55 ZV42
GY0434 - ..
GY0435 - 20. Procedural Sedation Medications:
GY0436 -
GY0437 - 1. Versed 5 mg IV total
GY0438 -
GY0439 - 2. Fentanyl 250 mcg IV total
GY0440 -
GY0441 - 3. Benadryl 50 mg IV total
GY0443 - ..
GY0444 - 21. Medications given in divided doses for the procedure. See VA
GY0445 - NCHCS Nursing Procedural Sedation & Analgesia Flow Sheet for
GY0446 - times and dowing.
GY0448 - ..
GY0450 - Staff Nurse
GY0451 - Signed: 2010 MAR 05 1356
GY0452 -
GY0453 -
GY0454 -
GY0455 -
GY0456 -
GY0457 -
GY0458 -
GY05 -