CONTACTS
SUBJECTS
Examination Cholesterol Increase 20 MG to 40 MG Simvastatin Recoveri
1803 -
1803 - ..
1804 - Summary/Objective
1805 -
180501 - Follow up ref SDS 37 0000. ref SDS 34 0000.
180502 -
180503 -
180504 -
180506 - ..
1806 -
1807 -
1808 - Background
1809 -
180901 - On 090908 1130 Doctor Lee prepared work plan, ref SDS 10 BU6W, for
180902 - treating achalasia and including resolving new symptom of chest pains.
180903 - ref SDS 10 FT6M
180905 - ..
180906 - On 091002 met with Doctor Egan, Cardiologist at the VA. The doctor
180907 - advised that 10 of 11 test points in the stress test showed positive
180908 - for circulation problems, and so the doctor ordered angiogram.
180909 - ref SDS 11 1W5I
180911 - ..
180912 - 091021 0716 Meeting at VA to complete angiogram test meeting,
180913 - ref SDS 12 01F9, and perform test. ref SDS 12 025B Results show
180914 - requirement for heart bypass surgery. ref SDS 12 7L47
180916 - ..
180917 - On 091022 0700 Doctor Tseng, Casey and others performed quadruple
180918 - heart bypass surgery at VA in San Francisco. ref SDS 13 01F9
180920 - ..
180921 - On 091031 0730 discussed scheduling surgery to fix achalasia problem
180922 - as essential predicate to maintain nutrition required for recovering
180923 - from heart surgery. ref SDS 16 PW5H
180925 - ..
180926 - On 091103 Paula reported the VA has scheduled a meeting today with
180927 - Doctor Stewart for planning Heller Myotomy surgery to correct
180928 - achalasia problem. ref SDS 18 PS60 On 091104 0718 Medical Chart
180929 - discharge guidance lists meeting with Doctor Stewart 091117 1300,
180930 - which conflicts with patient history today. ref SDS 19 Q03J On 091119
180931 - 1000 Erick confirmed visit with Doctor Stewart on 091208, and is
180932 - reviewing date of surgery scheduled for 091217. ref SDS 21 935H
180934 - ..
180935 - On 091104 0718 discharged from VA recovering from quadruple heart
180936 - bypass surgery, ref SDS 19 PR4V, performed on 091022 0700. ref SDS 13
180937 - PQWU; received medical record with list of medications, also on 091104
180938 - 0718, ref SDS 19 1Q6P, and follow up meetings. ref SDS 19 9T6O
180940 - ..
180941 - On 091208 Doctor Stewart advanced the schedule for surgery one day to
180942 - 091216. ref SDS 23 6E41
180944 - ..
180945 - On 091216 0600 meeting Doctor Stewart for Heller Myotomy surgery to
180946 - correct achalasia; check in at ASU. ref SDS 27 PP8W
180948 - ..
180949 - On 091217 0600 meeting with Joe and Jon on recovring from Heller
180950 - Myotomy surgery; report of complication during surgery on 091216,
180951 - which was repaired, with plan for test to evaluate recovery. reported
180952 - on 091217 0600, ref SDS 28 0042 Doctor Stewart visited and expects
180953 - can start eating after favorable test. ref SDS 28 027A
180955 - ..
180956 - On 091218 0600 xray with gastrogafin to evaluate repair for
180957 - complicaiton during Heller Myotomoy surgery Wednesday, ref SDS 29 PP8W,
180959 - ..
180960 - On 091219 0600 doctor plans discharge tomorrow after evaluating
180961 - progress eating solid food today. ref SDS 30 PP5V Since now eating
180962 - solid food, switched to oral pill medication to replace IV injections;
180963 - this relieved pain that has been increasing using IV catheters set on
180964 - Wednesday, ref SDS 30 PQPX, and also eliminated need to replace IV
180965 - catheters per TCU protocol. ref SDS 30 7Q55 Doctors prescribed hiking
180966 - to recover from Heller Myotomy surgery resolving achalasia.
180967 - ref SDS 30 7Q6P Doctor Ratcliff and Neil visit and discussing doing a
180968 - small business trial to apply SDS technology for upgrading VA and UCSF
180969 - case management. ref SDS 30 0M6S Nurse advises that patient approved
180970 - for moving to a ward for non-critical care, as a predicate to
180971 - discharge, but since there are no rooms available, patient will remain
180972 - in TCU untill a room is available. ref SDS 30 0M8S
180974 - ..
180975 - On 091220 0527 discharge approved from hospital today. ref SDS 31 PP8W
180976 - Left the hospital about 1220. ref SDS 31 HB5O
180978 - ..
180979 - On 091221 1532 Isagani called to schedule meeting with Doctor Stewart
180980 - at VA in San Francisco on 100105. ref SDS 32 PP8W
180982 - ..
180983 - On 091222 1109 letter from Isagana says meeting with Doctor Stewart is
180984 - scheduled on 100112 1400. ref SDS 33 PP8W
180986 - ..
180987 - On 091223 1452 letter came in regular mail scheduling a meeting with
180988 - Doctor Stewart on 100105 1400. ref SDS 34 PP8W
180990 - ..
180991 - On 100104 0930 met with Doctor Sandhu to begin care for heart surgery
180992 - and follow up on Heller Myotomy surgery to recover from achalasia.
180993 - ref SDS 37 PP8W
180995 - ..
180996 - On 100610 1046 went to VA in Martinez for blood draw to evaluate
180997 - cholesterol as a diagnostic of cardiovascular health. ref SDS 38 QV4F
180999 - ..
181000 - On 100721 0800 visit Doctor Sandhu Martinez VA; patient demonstrates
181001 - continuing recovery from heart surgery last October, ref SDS 0 PP8W;
181002 - doctor concerned patient is not listening because Simvastatin
181003 - medication to control cholesterol was not continued after completing
181004 - initial prescription, ref SDS 0 3X4L, shown by lab results cholesterol
181005 - has not declined very much for lab on 100610. ref SDS 0 HY76; doctor
181006 - increased dose of Simvestatin and encourages continuing this
181007 - medication. ref SDS 0 RP4F New lab ordered today shows cholesterol
181008 - reversed long-term decline and increased dramatically in just 30 days,
181009 - suggesting possibly error in lab testing process. ref SDS 0 E19L
181010 -
181011 -
181012 -
181014 - ..
1811 -
1812 -
1813 - Progess
1814 -
181401 - Examination Cholesterol Increase Simvastatin Recover Heart Surgery
181402 -
181403 - Met with Doctor Sandhu at the VA in Martinez, to follow up prior
181404 - meeting this past January, reported on 100104 0930. ref SDS 37 PP8W
181405 -
181406 - [On 100827 1316 received CD with medical records,
181407 - ref SDS 44 Y87U, for meeting with Doctor Sandhu at the VA
181408 - in Martinez on 100721. ref DRP 1 PE5J
181410 - ..
181411 - Doctor Sandhu indicated patient demonstrates continuing good recovery
181412 - from heart surgery at VA Medical Center in San Francisco, on 091022,
181413 - ref SDS 13 PQWU, and later Heller Myotomy surgery to recover from
181414 - achalasia, also performed at VA in San Francisco on 091216.
181415 - ref SDS 27 KE8T
181417 - ..
181418 - Reviewed current medications, listed in discharge medical record
181419 - received from VA on 091220 0527. ref SDS 31 1Q6P
181421 - ..
181422 - Doctor Sandhu checked the computer in the examination room, and
181423 - noticed that treatment with Simvastatin prescribed on release from the
181424 - hospital on 091220, has ended, because the patient has not ordered any
181425 - of 3 refills specified with the original order, reported on 091220,
181426 - ref SDS 31 OX5X,
181428 - ..
181429 - The doctor feels the patient is not listening!
181430 -
181431 - [On 101104 2338 ordered refill prescription Simvastatin.
181432 - ref SDS 45 5N3O
181434 - ..
181435 - Reviewed objectives to control body chemestry, including chelosterol,
181436 - blood pressure, pulse, and temperature through exercise and diet, and
181437 - without reliance on medications.
181439 - ..
181440 - Reported patient history following surgery to correct achalasia on
181441 - 091216, 091216 0600. ref SDS 27 KE8T Convelesence caused reduced
181442 - exercise (hiking only a few miles per day), and eating increased with
181443 - resolution of achalasia. This caused weight gain from about 167 on
181444 - release from the hospital on 091220, ref SDS 31 2V5I, to about 200 #
181445 - again in April. By mid-March was able to resume normal exercise.
181446 - Currently hiking about 7 miles per day, 5 days a week. Weight has
181447 - finally started coming down again to about 190 # today.
181449 - ..
181450 - Increased hiking causes soreness in lower legs, and some short-lasting
181451 - pain in lower legs climbing longer and steeper hills at Lafayette
181452 - reservoir. There is still shortness of breath climbing hills, which
181453 - did not occur prior to surgery in 2009, and so suggesting that
181454 - dissapating fluid from surgery around the lung area has taken a long
181455 - time and a lot of effort to restore lung capacity
181457 - ..
181458 - Doctor Sandhu was disappointed today by the lab on 100610, which shows
181459 - cholesterol 217 improved from prior test, but is still above minimum
181460 - standards for good health. ref SDS 38 JE4I The doctor said the
181461 - biggest concern is LDL 209 increased from 164, ref SDS 38 5X6U, and so
181462 - increases patient risk for additional artery restrictions that
181463 - required surgery to correct on 091022, ref SDS 13 LO3G, and shown by
181464 - angiogram test the day before on 091021 0716. ref SDS 12 7L43
181465 -
181466 - [...below, lab today shows dramatic worsening of
181467 - cholesterol levels with increase in heart disease risk
181468 - factors, assuming this is not an error in reporting.
181469 - ref SDS 0 E19L
181471 - ..
181472 - [On 101117 1018 Merck announces new drug Anacetrapib shows
181473 - significant improvement in cholesterol; pending further
181474 - clinical trials. ref SDS 48 U75H
181476 - ..
181477 - Doctor Sandhu seemed to indicate during the meeting today that
181478 - cholesteral levels are controlled by...
181479 -
181480 - Diet........................... 10%
181481 - Exercise....................... 10%
181482 - Body chemestry with age........ 80%
181484 - ..
181485 - Therefore, controlling cholesterol at a healthy level is very limited
181486 - with diet and exercise alone, and so in some cases requires continued
181487 - medication with Simvastatin, evidently for life.
181488 -
181490 - ..
181491 - Simvastatin Dose Doubled 40 MG
181492 -
181493 - Follow up ref SDS 37 WR4H.
181494 -
181495 - Doctor Sandhu seemed to say he expects the patient will eventually
181496 - require increasing Simvastatin 20 mg shown in medical chart on 091220
181497 - 0527. ref SDS 31 OX5X, to Simvastatin 40 mg per day. There was
181498 - further consideration of recent lab showing LDL 209 increased, per
181499 - above, ref SDS 0 HY76, and citing the lab on 100610 1046. ref SDS 38
181500 - 5X6U As a result, the doctor decided to increase the dose for
181501 - simvastatin. Doctor Sandhu ordered 3 months supply of simvestatin 40
181502 - mg, and scheduled retest in November.
181503 -
181504 - [...below, lab today shows dramatic worsening of
181505 - cholesterol levels with increase in heart disease risk
181506 - factors, assuming this is not an error in reporting.
181507 - ref SDS 0 E19L
181509 - ..
181510 - [On 101104 2338 ordered refill prescription Simvastatin.
181511 - ref SDS 45 5N3O
181513 - ..
181514 - [On 101108 0929 planning follow up blood draw assess effect
181515 - on lowering cholesterol from increasing Simvastatin 40 mg,
181516 - ref SDS 46 6X8Q
181518 - ..
181519 - [On 101117 1018 Merck announces new drug Anacetrapib shows
181520 - significant improvement in cholesterol; pending further
181521 - clinical trials. ref SDS 48 U75H
181523 - ..
181524 - [On 101207 0906 blood draw for lab to prepare for meeting
181525 - with Doctor Lee on 101210, and Doctor Sandhu on 101223.
181526 - ref SDS 49 PP8W
181528 - ..
181529 - [On 101223 1030 Doctor Sandhu pleased prescription to
181530 - increase Simvistatin yielded very favorable results for the
181531 - first time in many years cholesterol well below level safe
181532 - from arterial coronary disease and heart attack.
181533 - ref SDS 50 415H
181535 - ..
181536 - [On 110817 1030 VA end treatment with Simvastatin, which
181537 - reduced LDL by 50% but LDL 102 on lab 110727, ref SDS 51
181538 - E19L, well above LDL < 70 planned by VA, and Simvastatin
181539 - even if increased to 80 mg cannot further lower LDL, and
181540 - Simvastatin 80 mg has adverse side effects of debilitating
181541 - myopathy; so Doctor Egan prescribed rosuvastatin 10 mg to
181542 - replace Simvastatin, which is more potent and so has the
181543 - chance to reach medical goal LDL < 70. ref SDS 52 DG36
181545 - ..
181546 - Doctor Sandhu listed currently prescribed medications...
181547 -
181548 - 1. OMEPRAZOLE 20MG EC CAP TAKE ONE CAPSULE BY MOUTH ONCE
181549 - ACTIVE DAILY 15 MINUTES BEFORE A MEAL FOR SEVERE ACID
181550 - REFLUX AND ESOPHAGEAL NARROWING. ref DRP 1 DE4S
181551 -
181552 - [On 100827 1316 received CD with Doctor Sandhu's medical
181553 - chart for the meeting today, ref SDS 44 Y87U, and
181554 - including currently prescribed medication. ref DRP 1
181555 - MG9F
181557 - ..
181558 - [On 100827 0738 Doctor Lee increased dose of Omeparazole
181559 - to 20 mg twice a day. ref SDS 43 SG8M
181561 - ..
181562 - 2. SIMVASTATIN 40MG TAB TAKE ONE-HALF TABLET BY MOUTH ACTIVE
181563 - EVERY EVENING - FOR CHOLESTEROL*USE PILL CUTTER* DO NOT
181564 - TAKE WITH GRAPEFRUIT JUICE. ref DRP 1 DE4W
181566 - ..
181567 - Doctor Sandhu ordered full panel lab to supplement blood tests for
181568 - only cholesterol on 100610 1046. ref SDS 38 QV4F
181569 -
181570 - [...below, went to lab for blood draw. ref SDS 0 RP4N
181572 - ..
181573 - Doctor Sandhu provided some documents at the end of the meeting...
181575 - ..
181576 - Pneumococcal Polysaccharide Vaccine
181577 -
181578 - There is a handwritten entry in the top left corner that seems to
181579 - say...
181580 -
181581 - 7/21/10
181582 - L arm
181584 - ..
181585 - This suggests the doctor observed something on the left arm that
181586 - signaled a medical malady.
181588 - ..
181589 - During the meeting there was no discussion of this disease nor patient
181590 - symptoms. Treatment and Medications, however, shows an order for
181591 - Pneumovax, ref SDS 0 7W4K, which research indicates treats
181592 - penumococcal disease.
181594 - ..
181595 - Has penumococcal disease been diagnosed in this case? What symptoms
181596 - support the diagnosis?
181598 - ..
181599 - Is prescribed treatment for prevention, rather than to recover from
181600 - penumococcal disease, suggested by the literature, per below?
181601 - ref SDS 0 HM7H
181603 - ..
181604 - Section 3 indicates patients over 65 years of age, and also patients
181605 - with history of heart disease are both at risk. ref SDS 0 OV4J
181607 - ..
181608 - This therefore seems to be a preventive medicine regimin.
181610 - ..
181611 - Pneumococcal Polysaccharide Vaccine continues
181612 -
181613 - What you need to know
181614 -
181615 - 1. Penumococcal disease
181616 -
181617 - Penumococcal disease is caused by Streptococcus pneumoniae
181618 - bacteria. It is a leading cause of vaccine-preventable
181619 - illness and death in the United States. Anyone can get
181620 - penumococcal disease but some people are at greater risk
181621 - than others:
181623 - ..
181624 - a. People 65 and older
181625 - b. Very young
181626 - c. People with certain health problems
181627 - d. People with weakened immune system
181628 - e. Smokers
181630 - ..
181631 - Penumococcal disease can lead ot serous infections of the
181632 -
181633 - a. Lungs (pneumonia)
181634 - b. Blood (baceteremia), and
181635 - c. Covering of the brain (meningitis)
181637 - ..
181638 - Penumococcal kills about 1 out of 20 people who get it.
181639 - Bacteremia kills about 1 person in 5, adn meningitis about
181640 - 3 people in 10.
181642 - ..
181643 - People with health problems described in Section 3 of this
181644 - statement may be more likely to die from the disease.
181646 - ..
181647 - 2. Penumococcal polysaccharide vaccine (PPSV)
181648 -
181649 - Treatment of penumococcal infection with penicillin and
181650 - other drugs used to be more effective. But some strains of
181651 - the disease have become resistant to these drugs. This
181652 - makes prevention of the disease through vaccination, even
181653 - more important.
181655 - ..
181656 - Penumococcal polysaccharide vaccine (PPSV) protects against
181657 - 23 types of penumococcal bacteria, including those most
181658 - likely to cause serious disease.
181660 - ..
181661 - Most healthy adults who get the vaccine develop protection
181662 - to most or all of these types within 2 to 3 weeks of
181663 - getting the shot. Very old people, children under 2 years
181664 - of age, and people with some long-term illnesses might not
181665 - respond as well, or at all.
181667 - ..
181668 - Another type of penumococcal vaccine (penumococcal
181669 - conjugate vaccine, or PCV) is routinely recommended for
181670 - children younger than 5 years of age. PCV is described in
181671 - a seperate Information Statement.
181673 - ..
181674 - 3. Who should get PPSV?
181675 -
181676 - a. All adults 65 years of age and older.
181677 -
181678 - b. Anyone 2 through 64 years of age who has a long-term
181679 - health problem such as...
181681 - ..
181682 - heart disease
181683 - lung disease
181684 - sickle disease
181685 - diabetics
181686 - alcoholism
181687 - cirrhosis
181688 - leaks of cerebrospinal fluid or cochlear implant
181690 - ..
181691 - PPSV may be less effective for some people, especially
181692 - those with lower resistance to infection.
181694 - ..
181695 - But these people should still be vaccinated, because they
181696 - are more likely to have sreious compications if they get
181697 - penumococcal disease.
181699 - ..
181700 - 4. How many doses of PPSV are needed and when?
181701 -
181702 - Usually only one dose of PPSV is needed, butunder some
181703 - circumstances a second dose may be given.
181705 - ..
181706 - When a second dose is given, it should be given 5 years
181707 - after the first dose.
181709 - ..
181710 - Second dose is recommeded for people 65 years and older who
181711 - got their first dose when they were younger than 65 and it
181712 - has been 5 or more years since the first dose.
181714 - ..
181715 - 5. Some people should not get PPSV or should wait.
181717 - ..
181718 - 6. What are risks from PPSV?
181719 -
181720 - About half of people who get PPSV have mild side effects,
181721 - such as redness or pain where the shot is given.
181723 - ..
181724 - Getting a "shot" for PPSV, seems conflicting with VA prescription for
181725 - medication from the Pharmacy, per below. ref SDS 0 7W4K
181727 - ..
181728 - Pneumococcal Polysaccharide Vaccine continues
181729 -
181730 - Less than 1% develop a fever, muscle aches, or more severe
181731 - local reactions.
181733 - ..
181734 - A vaccine, like any medicine, could cause a serious
181735 - reaction. But the risk of a vaccine causig serious harm or
181736 - death is extremely small.
181737 -
181739 - ..
181740 - Treatments and Other Tests
181741 -
181742 - Doctor Sandhu filled out a form that seems to have a check mark next
181743 - to....
181744 -
181745 - Pneumovax
181747 - ..
181748 - Not sure what this is. Need explanation.
181750 - ..
181751 - Research shows Pneumovax is PPSV treatment to prevent penumococcal
181752 - disease, evidently ordered by Doctor Sandhu today, but not discussed
181753 - during the meeting, per above. ref SDS 0 HM7H
181755 - ..
181756 - There seems like a conflict between the doctor's prescription for
181757 - Pneumovax from the pharmacy, and disease literature that describes
181758 - vaccination with a "shot." ref SDS 0 7W4K Is this a self-administered
181759 - vaccination, similar to Neupogen?
181761 - ..
181762 - Treatments and Other Tests Continued...
181763 -
181764 - Lab........... October (scribbled)
181766 - ..
181767 - Not sure but think the doctor ordered follow up lab in October.
181768 -
181769 - Pharmacy
181770 -
181771 - x Medications will be mailed
181773 - ..
181774 - Assume this is simvestatin for cholesterol, per discussion above.
181775 - ref SDS 0 RP4F
181776 -
181777 - Appointments
181778 -
181779 - Call 800 382 8387 in ..... Nov .... for follow up
181780 - meeting with Doctor Sandhu in ..... Dec....
181781 - for ........ 30.... minutes.
181782 -
181783 -
181784 -
181785 -
181786 -
1818 -
SUBJECTS
WBC 7.3 CBC Dramatic Decline 40% Blood Test Conflicts Lab 100610 Sug
3103 -
3104 - 0854
310501 - ..
310502 - Blood Tests Evaluate Health 8 Months After Surgery
310503 -
310504 - Follow up ref SDS 38 QV4F.
310506 - ..
310507 - During the meeting today, Doctor ordered lab, per above. ref SDS 0
310508 - L14K After the meeting, went to the lab for blood draw.
310509 -
310510 - [On 100827 1316 received CD from Patient Records
310511 - Department, ref SDS 44 Y87U, showing results of lab for
310512 - prior tests, and indicating significant changes.
310513 - ref DRP 1 PSQP
310515 - ..
310516 - Date................................. 2010 07 21 0854
310517 -
310518 - CBC
310519 - Blood Results Units Range
310520 - WBC 7.3 K/cmm 4.8 - 10.8
310521 - RBC 4.83 M/cmm 4.7 - 6.1
310522 - HGB 14.9 g/dL 14.0 - 18.0
310523 - HCT 44.0 % 42.0 - 52.0
310524 - MCV 91.2 fL 80.0 - 99.0
310525 - MCH 30.8 uug 27.0 - 34.0
310526 - MCHC 33.8 gm/dL 32.0 - 35.2
310527 - RDW 13.1 % 11.5 - 14.5
310528 - PLT 344 K/cmm 130.0 - 400.0
310529 - MPV 7.5 fL 7.0 - 10.4
310530 - NEUT % 75.6 % 40.0 - 80.0
310531 - LYMPH % L 14.5 % 20.0 - 51.0
310532 - MONO % 7.5 % 2.0 - 13.0
310533 - EOS % 1.7 % 0.5 - 7.0
310534 - BASO % 0.7 % 0.0 - 2.0
310535 - NEUT # 5.5 K/cmm 1.5 - 7.9
310536 - LMYMP # L 1.0 K/cmm 1.2 - 3.4
310537 - MONO # 0.5 K/cmm 0.2 - 1.2
310538 - EOS # 0.1 K/cmm 0.1 - 0.5
310539 - BASO # 0.1 K/cmm 0.0 - 0.2
310540 - ESRmVES Not done mm/hr 0.0 - 10.0
310541 - ESRxCYT Not done mm/hr 2.0 - 10.0
310542 - RETIC % Not done % 0.66 - 2.85
310543 - RETIC # Not done k/uL 27.9 - 121.6
310545 - ..
310546 - a - CBC Rechecked
310547 -
310548 - 5-part diff screening criteria normal. Does not require
310549 - manual dif.
310550 -
310551 - Test performed by VA Martinez, 150 Muir Road, Martinez, CA
310553 - ..
310554 - WBC 7.3 dropping from 12.0 from the prior lab on 091117, reported on
310555 - 091119 1000. ref SDS 21 9S5V
310556 -
310557 -
3106 -
SUBJECTS
Glucose 117 Chem Profile Lab Blood Test Near High Diabetes Signal NA
4503 -
450401 - ..
450402 - Salt Low Sodium NA Healthy Range
450403 - Glucose High End Scale Diabetes Signal Salt Low
450404 - Diabetes Glucose High End Scale Signals Higher Risk
450405 -
450406 -
450407 - Chem Profile
450408 - 2010 07 21 Results Units Range
450409 - Plasma 0854
450410 - GLUCOSE 117 mg/dL 74.0 - 118.0
450411 - GLUfast Not done mg/dL Ref: <= 99.0
450412 - NA (sodium - salt) 139 mmol/L 136.0 - 144.0
450413 - K 3.9 mmol/L 3.4 - 4.8
450414 - CL 106 mmol/L 98.0 - 106.0
450415 - CO2 28 mmol/L 23.0 - 33.0
450416 - BUN 12 mg/dL 8.0 - 26.0
450417 - CREAT 0.89 mg/dL 0.5 - 1.1
450418 - eGFR > 60 mL/min Ref: >= 60.0
450419 - CALCIUM 8.7 mg/dL 8.7 - 10.2
450420 - CA CORR Not done mg/dL 8.7 - 10.2
450421 - PO4 Not done mg/dL 2.4 - 4.5
450422 - ALK PHO H 109 IntUnits/L 37.0 - 107.0
450423 - MG Not done mg/dL 1.8 - 2.5
450424 - T BIL H 1.3 mg/dL 0.3 - 1.2
450425 - D BILI 0.2 mg/dL 0.1 - 0.4
450426 - AST 23 IntUnits/L 8.0 - 42.0
450427 - ALT 24 IntUnits/L 5.0 - 55.0
450428 - ALBUMIN 4.0 g/dL 3.3 - 4.8
450429 - PROTEIN 7.2 g/dL 6.5 - 8.1
450430 - LDH Not done IntUnits/L 90.0 - 208.0
450431 - AMYLASE Not done Units/L 36.0 - 128.0
450432 - LIPASE Not done Units/L 7.0 - 58.0
450433 - NH3 Not done mcmol/L 15.0 - 56.0
450434 - URIC AC Not done mg/dL 4.8 - 8.7
450436 - ..
450437 - Salt - sodium seems still well controlled.
450439 - ..
450440 - Glucose 117 at high end of range for diabetes.
450442 - ..
450443 - HGB1c additional test for diabetes added to lab, and seems in middle
450444 - of range indicating no immediate evidence for diabetes. ref SDS 0 IL4N
450445 -
450446 -
450447 -
450448 -
450449 -
4505 -
SUBJECTS
Cholesterol 261 Lab Dramatic Rise HDL 35 Dramatic Fall Conflicts Lab
6103 -
610401 - ..
610402 - Cholesterol Heart Disease Blood Test Assessment
610403 -
610404 - Follow up ref SDS 38 QV4F.
610405 -
610406 - History of cholesterol lab shown in graph on 090813 1500. ref SDS 9
610407 - 8P5F
610409 - ..
610410 - LIPID Panel Cholesterol
610411 - 2010 07 21 Results Units Range
610412 - Plasma 0854
610413 - CHOLESTEROL H 261 mg/dL Ref: <= 200.0
610414 - TRIGLYC 87 mg/dL Ref: <= 150.0
610415 - HDL L 35 mg/dL Ref: >= 40.0
610416 - LDL H 209 mg/dL Ref: <= 160.0
610417 - LDL Dir Not done mg/dL Ref: <= 160.0
610418 - TRIG NF Not done mg/dL Ref: <= 150.0
610420 - ..
610421 - Comments:
610423 - ..
610424 - a - Test performed by VA Martinez, 150 Muir Road, Martinez, CA
610426 - ..
610427 - Evaluattion for LDL-CHO:
610428 -
610429 - risk category LDL goal
610431 - ..
610432 - CHD and CHD risk equivalents <100 mg/dL
610433 - Multiple (2+) risk factors <130 mg/dL
610434 - 0-1 risk factor <160 mg/dL
610436 - ..
610437 - HD Chol, greater than/equal to 60 mg/dL counts as "negative"
610438 - risk factor; its presence removes 1 risk factor from the total
610439 - count.
610441 - ..
610442 - Ref: Adult Treatment Panel III (ATP IIIa0 JAMA 5/16/01 Vol.
610443 - 285 #19
610445 - ..
6105 -
6106 -
6107 - Analysis
6108 -
610801 - This report indicates substantial worsening from testing last month on
610802 - 100610 1046, ref SDS 38 QV4F, and seems questionable for reversing a
610803 - long-term decline into a steep increase over a very short period of 6
610804 - weeks. During this period diet has been stable, and exercise has
610805 - increased about 30%, from hiking 23 miles a week to more like 30 - 35.
610806 - The doctor notes today that patient continues to benefit from
610807 - Simvastatin for cholesterol, which was ended prior to the lab on
610808 - 100610, per above. ref SDS 0 HY76 It is possible that cholesterol was
610809 - significantly lower in May, when prescription for Simvastatin was not
610810 - re-filled, and so was increasing through 100610, and continuing to the
610811 - test today. Still seems questionable that these blood elements could
610812 - increase so dramatically in just 1 month.
610814 - ..
610815 - [On 101108 0929 planning follow up blood draw assess effect
610816 - on lowering cholesterol from increasing Simvastatin 40 mg,
610817 - ref SDS 46 6X8Q
610819 - ..
610820 - [On 101112 0952 met with Connie at the front desk for VA
610821 - Primary Care at Martinez Clinic, and Connie scheduled
610822 - another full lab as done on 100721, ref SDS 47 4R45
610824 - ..
610825 - [On 101117 1018 Merck announces new drug Anacetrapib shows
610826 - significant improvement in cholesterol; pending further
610827 - clinical trials. ref SDS 48 U75H
610829 - ..
610830 - [On 101207 0906 lab shows cholesterol 151 and related blood
610831 - counts fell 40%, and good cholesterol HDL 47 increased 30%
610832 - after Doctor Sandhu doubled Simvastatin 40 mg per day;
610833 - resulting in significant reduced risk of arterial coronary
610834 - disease and heart attack. ref SDS 49 E19L
610836 - ..
610837 - [On 101223 1030 Doctor Sandhu pleased that doubling the
610838 - prescription for Simvistatin yielded very favorable results
610839 - for the first time in many years cholesterol well below
610840 - level safe from arterial coronary disease and heart attack.
610841 - ref SDS 50 415H
610843 - ..
610844 - [On 111117 1415 Another huge increase LDL cholesterol,
610845 - indicating possible testing errors, ref SDS 53 IM9N, see
610846 - graph. ref SDS 53 7M42
610847 -
610849 - ..
610850 - If stress and tension contribute to cholesterol blood counts,
610851 - then Mil's battle with Kaiser for treatment to live the past
610852 - months may be a factor, reported in draft letter for Kaiser on
610853 - 100719 0522. ref SDS 40 JH7U Later that day, Kaiser continued
610854 - failure for the past year to provide standard of care, 100719
610855 - 1312, ref SDS 41 0X78, and Millie then felt she was cut loose
610856 - to die, also, on 100719 1312, ref SDS 41 RM4N This created
610857 - significant stress to "turn the ship."
610858 -
610859 - [On 100730 0928 Millie died suddenly on 100729; Paula
610860 - called the next day and seemed to indicate a claim by the
610861 - family for wrongful death might be appropriate for good
610862 - faith review of Millie's care that would yield improvements
610863 - for other patients. ref SDS 42 N550
610864 -
610865 -
610866 -
6109 -
SUBJECTS
Anemia B12 302 for 211 911 Low End Range Laboratory Blood Test Indic
7403 -
740401 - ..
740402 - VA Lab Report Continues...
740403 -
740404 - Anemia
740405 - 2010 07 21 Results Units Range
740406 - Plasma 0854
740407 - B12 302 pg/ml 211.0 - 911.0
740408 - FOLATE Not done ng/ml 5.22 - 30.0
740409 - FERRITN Not done ng/ml 22.0 - 415.0
740410 - FE Not done mcg/dL 40.0 - 190.0
740411 - TIBC Not done mcg/dL 260.0 - 420.0
740412 - FE SAT Not done % 11.0 - 46.0
740413 - TRANSFE Not done mg/dL 200.0 - 370.0
740414 - HAPTO Not done mg/dL 34.0 - 200.0
740415 -
740416 - [On 101207 0906 for some reason next lab did not include
740417 - this panel for anemia. ref SDS 49 HE6L
740419 - ..
740420 - Comments:
740422 - ..
740423 - a - Test performed by VA Martinez, 150 Muir Road, Martinez, CA
740424 -
740426 - ..
740427 - This panel seems to indicate nutrition is okay, near the low end of
740428 - the range.
740429 -
740430 -
740431 -
740432 -
740433 -
7405 -
SUBJECTS
Endocrine Thyroid Laboratory Blood Test Normal TSH 2.51 for 1.40 to
8703 -
870401 - ..
870402 - Thyroid Endocrine Test Appears Normal?
870403 -
870404 - Thyroid disorders listed below. ref SDS 0 T640
870406 - ..
870407 - Research indicates range for thyroid disorders should be TSH 0.5 to
870408 - 2.5 or 3.0, not clear. ref SDS 0 UT4M Some authorities call for
870409 - upper limit 2.5. ref SDS 0 HD91 TSH 2.51 in current lab, therefore
870410 - requires review of systems to diagnose need for care.
870411 -
870412 - [On 101207 0906 follow up lab TSH 2.61 slight rise; T4 Free
870413 - not tested; 2.61 continues slightly above new narrower
870414 - range 0.5 - 2.50. ref SDS 49 9677
870416 - ..
870417 - Endocrine Thyroid Health
870418 - 2010 07 21 Results Units Range
870419 - Serum 0854
870420 - * TSH 2.51 uIUnits/mL 1.40 - 5.6
870421 - * T4 FREE 1.02 mg/dL 0.58 - 1.64
870422 - T3 TOT Not done mg/dL 85.0 - 205.0
870423 - T3 TOT Not done
870424 - T3 REV Not done pg/mL 90.0 - 150.0
870425 - T3 FREE Not done pg/mL 2.3 - 4.2
870426 - T3 FREE Not done
870427 - THYROGL Not done ng/mL 0.5 - 55.0
870428 - aTHYROGL Not done IntUnits/mL 0.0 - 40.0
870429 - TPO Ab Not done IntUnits/mL 0.0 - 34.0
870430 - TSI Not done % 0.0 - 139.0
870431 - TshRcAB Not done
870432 - CORT AM Not done mcg/dL 8.7 - 22.4
870433 - CORT PM Not done mcg/dL 0.0 - 10.0
870434 - CORTbas Not done mcg/dL
870435 - CORT 30 Not done mcg/dL 20.0 - 125.0
870436 - CORT 60 Not done mcg/dL 20.0 - 125.0
870438 - ..
870439 - Comments:
870441 - ..
870442 - a - Test performed by VA Martinez, 150 Muir Road, Martinez, CA
870444 - ..
870445 - ** Citations...
870446 -
870447 - TSH - research below. ref SDS 0 454H
870448 -
870449 - T4 Free - research below. ref SDS 0 T98N
870450 -
870451 -
870453 - ..
870454 - Research on the Internet shows...
870455 -
870456 - About.com
870458 - ..
870459 - TSH - Thyroid Stimulating Hormone Test
870460 -
870461 - The TSH Reference Range Wars: What's "Normal?", Who is Wrong,
870462 - Who is Right...
870464 - ..
870465 - Date.............................. June 19, 2006
870466 -
870467 - By Mary Shomon................... ref SDS 0 EX6I
870469 - ..
870470 - 1. Right now, a battle is waging in the endocrinology community
870471 - regarding the so-called "reference range" for the Thyroid
870472 - Stimulating Hormone (TSH) test. The importance of this
870473 - controversy cannot be underestimated. The majority of
870474 - practitioners -- including endocrinologists, the physicians
870475 - who specialize in thyroid disease -- rely solely on the TSH
870476 - test as the primary test, the supposed "gold standard" in
870477 - fact, for diagnosing and managing most thyroid conditions.
870479 - ..
870480 - 2. There is ongoing controversy about whether reliance on the TSH
870481 - test -- to the exclusion of clinical symptoms and other tests
870482 - such as Free T4, Free T3, and antibodies tests -- is medically
870483 - sound. That is a controversy that is unlikely to be decided
870484 - for years. The situation today, however, is that the majority
870485 - of physicians do rely almost exclusively on the TSH test to
870486 - detect thyroid disease, and monitor the effectiveness of
870487 - treatment.
870489 - ..
870490 - 3. Surprisingly, however, while the medical community does rely
870491 - on the TSH test, there is complete disagreement within the
870492 - community as to what constitutes the "normal range.
870494 - ..
870495 - 4. What is a Reference Range?
870496 -
870497 - Reference range is a critical component, and the validity of
870498 - the entire TSH test as diagnostic tool depends on it. A TSH
870499 - reference range is obtained by taking a large group of people
870500 - in the population, measuring their TSH levels, and calculating
870501 - a mean value. Supposedly, these people should be free of
870502 - thyroid disease, so that the level represents the mean TSH of a
870503 - typical thyroid disease-free person in the population. The
870504 - reference range is what determines whether or not thyroid
870505 - disease is even diagnosed at all, much less treated, and when
870506 - it is diagnosed, how it is treated.
870508 - ..
870509 - 5. Currently, at most laboratories in the U.S., the reference
870510 - range for TSH tests is approximately 0.5 to 5.0. Depending on
870511 - the lab, you may seem some variations, i.e., 0.4 to 5.5, or
870512 - 0.6 to 5.7, etc., but generally, 0.5 to 5.0 is considered
870513 - typical of many labs.
870515 - ..
870516 - 6. Typically, doctors interpret levels below 0.5 as indicative of
870517 - hyperthyroidism (an overactive thyroid), and levels above 5.0
870518 - as indicative of hypothyroidism (an underactive thyroid.)
870520 - ..
870521 - 7. Changing the Reference Range
870522 -
870523 - After noticing that patients who had TSH levels in the higher
870524 - end of the normal range tended to go on to develop
870525 - hypothyroidism more often than those in the lower end of the
870526 - spectrum, researchers delved more fully into understanding the
870527 - validity of the reference ranges in use. They found that the
870528 - upper TSH normal range has traditionally included people who
870529 - have mild thyroid disease, and their higher TSH levels skewed
870530 - the standard curve, potentially making the reference range
870531 - wider than it should be, and excluding some people who
870532 - legitimately had a thyroid condition.
870534 - ..
870535 - 8. These findings led to the recommendation in January 2003 by
870536 - the American Association of Clinical Endocrinologists (AACE)
870537 - that doctors "consider treatment for patients who test outside
870538 - the boundaries of a narrower margin based on a target TSH
870539 - level of 0.3 to 3.0. AACE believes the new range will result
870540 - in proper diagnosis for millions of Americans who suffer from
870541 - a mild thyroid disorder, but have gone untreated until now."
870543 - ..
870544 - 9. In a statement from the AACE, Hossein Gharib, MD, FACE, and
870545 - president of AACE at the time, said, "The prevalence of
870546 - undiagnosed thyroid disease in the United States is shockingly
870547 - high...The new TSH range from the AACE guidelines gives
870548 - physicians the information they need to diagnose mild thyroid
870549 - disease before it can lead to more serious effects on a
870550 - patient's health - such as elevated cholesterol, heart disease,
870551 - osteoporosis, infertility, and depression."
870553 - ..
870554 - 10. AACE cited as evidence the guidelines issued by the National
870555 - Academy of Clinical Biochemistry, part of the Academy of the
870556 - American Association for Clinical Chemistry (AACC), and
870557 - presented in their Laboratory Medicine Practice Guidelines for
870558 - the Diagnosis and Monitoring of Thyroid Disease. Late in 2002,
870559 - the group concluded that "it is likely that the current upper
870560 - limit of the population reference range is skewed by the
870561 - inclusion of persons with occult thyroid dysfunction." In their
870562 - guidelines, the National Academy of Clinical Biochemistry
870563 - reported that: "In the future, it is likely that the upper
870564 - limit of the serum TSH euthyroid reference range will be
870565 - reduced to 2.5 mIU/L because 95% of rigorously screened normal
870566 - euthyroid volunteers have serum TSH values between 0.4 and 2.5
870567 - mIU/L." They also stated that "a serum TSH result between 0.5
870568 - and 2.0 mIU/L is generally considered the therapeutic target
870569 - for a standard L-T4 replacement dose for primary
870570 - hypothyroidism."
870572 - ..
870573 - 11. What Would a Narrower Range Mean for Patients?
870574 -
870575 - At the time of the announcement, almost three years ago, AACE
870576 - estimated that the new guidelines would double the number of
870577 - people who have abnormal thyroid function, bringing the total
870578 - to as many as 27 million, up from 13 million thought to have
870579 - the condition under the old guidelines. These new estimates
870580 - would make thyroid disease the most common endocrine disorder
870581 - in North America, far outpacing diabetes.
870583 - ..
870584 - 12. The announcement from AACE was seen by many as a long-overdue
870585 - and much-needed improvement in the level of awareness of
870586 - endocrinologists. After decades of denying that patients
870587 - within the normal range of TSH could in fact have a thyroid
870588 - condition, they were acknowledging what patients and advocates
870589 - had been saying quite vocally for years: that the high and low
870590 - end of the TSH normal range were not, in fact, normal for most
870591 - people.
870592 -
870593 - "...using a TSH upper normal range of 5.0, approximately
870594 - 5% of the population is hypothyroid. However, if the upper
870595 - portion of the normal range was lowered to 3.0,
870596 - approximately 20% of the population would be
870597 - hypothyroid..."
870599 - ..
870600 - 13. More recently, researchers have looked at an important
870601 - question: If the normal TSH range were narrowed, as has been
870602 - recommended by AACE and the National Academy of Clinical
870603 - Biochemistry, what are the implications? One 2005 study found
870604 - that using a TSH upper normal range of 5.0, approximately 5%
870605 - of the population is hypothyroid. However, if the upper
870606 - portion of the normal range was lowered to 3.0, approximately
870607 - 20% of the population would be hypothyroid! According to
870608 - another study, an additional 12.8 to 16 million people would
870609 - be diagnosed with hypothyroidism if the TSH upper limit was
870610 - 3.0, and an additional 5.4% to 6.3% of the population --- 10.8
870611 - to 12.6 million -- would be diagnosed as hypothyroid if the
870612 - upper range for TSH was 2.5.
870614 - ..
870615 - 14. Clearly, these narrower ranges have huge implications for
870616 - millions of people who are not being diagnosed or treated,
870617 - because their test results are being evaluated according to
870618 - the old reference range.
870620 - ..
870621 - 15. Untreated thyroid disease can severely compromise quality of
870622 - life, and in some cases even be fatal. Untreated thyroid
870623 - disease can cause or contribute to numerous debilitating
870624 - symptoms and conditions, including, among others:
870625 -
870626 - 1. weight problems and obesity
870627 - 2. exhaustion and fatigue
870628 - 3. depression and anxiety disorders
870629 - 4. heart disease
870630 - 5. stroke
870631 - 6. infertility
870632 - 7. miscarriage
870633 - 8. birth defects
870635 - ..
870636 - 16. Some Experts Adopt the New Range
870637 -
870638 - Interestingly, however, in the past three years, most
870639 - laboratories in the U.S., despite what are clear communications
870640 - from both AACE and the Laboratory Medicine Practice Guidelines,
870641 - have not revised their TSH reference range, and remain with the
870642 - 0.5 to 5.0 range as their "normal range."
870644 - ..
870645 - 17. Some practitioners have adopted the new range for diagnostic
870646 - and treatment purposes. Some physicians, who are aware of the
870647 - new guidelines, have, however, chosen not to follow them, and
870648 - remain with the older reference range. Some of them have made
870649 - this decision because they do not agree with the new range,
870650 - medically. Others are attempting to "play it safe" and protect
870651 - themselves because the laboratories have not yet gone with the
870652 - change, and these doctors are reluctant to diagnose a thyroid
870653 - condition unless the printed lab report flags a TSH test result
870654 - as "high" or "low."
870656 - ..
870657 - 18. There are also many doctors, general practitioners and even
870658 - endocrinologists who are still routinely diagnosing and
870659 - treating patients according to the old reference range simply
870660 - because they aren't even aware of the new reference range
870661 - guidelines.
870663 - ..
870664 - 19. Interestingly, some patients who have asked for physicians to
870665 - diagnose and treat them by the new reference range have been
870666 - turned down, told off, or even fired by their physicians. This
870667 - has led to even greater controversy in the medical community,
870668 - as doctors are taking sides in the debate over the old and new
870669 - reference ranges.
870671 - ..
870672 - 20. The Debate Goes Public
870673 -
870674 - In September of 2005, two articles appeared in the Journal of
870675 - Clinical Endocrinology and Metabolism, presenting the two sides
870676 - of the argument.
870678 - ..
870679 - 21. Martin Surks, Gayotri Goswami and Gilbert Daniels argued that
870680 - the reference range should remain the same in their article
870681 - "Controversy in Clinical Endocrinology: The Thyrotropin
870682 - Reference Range Should Remain Unchanged," while Leonard
870683 - Wartofsky and Richard Dickey argued that "The Evidence for a
870684 - Narrower Thyrotropin Reference Range is Compelling."
870686 - ..
870687 - 22. Surks, Goswami and Daniels base their argument on their
870688 - assertion that "because routine levothyroxine treatment is not
870689 - recommended for subclinical hypothyroidism, it is certainly not
870690 - warranted in individuals with upper reference range TSH [TSH
870691 - 2.5 to 4.5]."
870693 - ..
870694 - 23. Doctors Wartofsky and Dickey argue that the previously accepted
870695 - reference ranges are no longer valid because the reference
870696 - populations previously considered normal were "contaminated"
870697 - with individuals with various levels of thyroid disease. They
870698 - argue that the benefits of treatment far outweigh any minimal
870699 - risks.
870701 - ..
870702 - 24. Surks, Goswami and Daniels -- Don't Change the TSH Reference
870703 - Range
870705 - ..
870706 - 25. How these researchers could come to such a definitive
870707 - conclusion that treatment is not warranted for subclinical
870708 - hypothyroidism is inexplicable, given that in the same journal
870709 - where their research is published, an article appeared just a
870710 - few years earlier that demonstrated that treatment of patients
870711 - with subclinical hypothyroidism could help with cholesterol
870712 - levels and potentially reduce cardiovascular mortality risk by
870713 - 31%. ["TSH-controlled L-thyroxine therapy reduces cholesterol
870714 - levels and clinical symptoms in subclinical hypothyroidism: a
870715 - double blind, placebo-controlled trial (Basel Thyroid Study),"
870716 - Journal of Clinical Endocrinology and Metabolism, 2001
870717 - Oct;86(10):4860-6]
870719 - ..
870720 - 26. There is also evidence in the literature that levels above 2.0
870721 - during pregnancy can potentially complicate pregnancy, and
870722 - that upper level normal TSH levels can inhibit fertility. For
870723 - example, in early 2005, Drs. Casey and colleague wrote in the
870724 - journal Obstetrics and Gynecology that "Pregnancies in women
870725 - with subclinical hypothyroidism were 3 times more likely to be
870726 - complicated by placental abruption."
870728 - ..
870729 - 27. There is also a Norwegian study just published in the
870730 - International Journal of Obesity that found that there is a
870731 - positive association between serum TSH within the normal range
870732 - and body mass index, and the higher the TSH level, the higher
870733 - the body mass index and likelihood of overweight or obesity.
870735 - ..
870736 - 28. These are just a few of the many examples of peer-reviewed
870737 - literature in respected medical journals that discredit the
870738 - argument that treatment is not recommended or warranted for
870739 - subclinical hypothyroidism. The authors also state "The only
870740 - documented adverse health outcome for individuals with TSH
870741 - levels between 3.0 and 5.0 is progression to overt
870742 - hypothyroidism. Levothyroxine treatment would clearly prevent
870743 - that outcome, but at what price?"
870745 - ..
870746 - 29. However, it must be asked, why is preventing progression to
870747 - overt hypothyroidism not a desired health objective, given that
870748 - overt hypothyroidism most definitely can contribute to obesity,
870749 - heart disease, depression, infertility, and host of other
870750 - health problems?
870752 - ..
870753 - 30. Prevention of disease is a major focus of much of today's
870754 - medicine, with exercise, diet and medications to prevent heart
870755 - disease, obesity, stroke, and many other conditions. Some of
870756 - these preventative approaches, particularly drug therapies,
870757 - come with some risk factors, but the risks are presented along
870758 - with benefits, so patients can make an informed choice.
870760 - ..
870761 - 31. Even if there is a small risk to treatment of subclinical
870762 - hypothyroidism (and the existence of such a risk is a theory,
870763 - not a proven fact) then why is this same approach not used for
870764 - thyroid patients, who could be given the opportunity to
870765 - prevent overt hypothyroidism, realizing that the prevention
870766 - also comes with some risk?
870768 - ..
870769 - 32. Wartofsky and Dickey: The New Range is More Accurate
870770 -
870771 - Doctors Wartofsky and Dickey defend the shift to the new range,
870772 - with some caveats. They say: "We will probably never have an
870773 - absolutely cutoff value for TSH distinguishing normal from
870774 - abnormal, but recognition that the mean of normal TSH values is
870775 - only between 1.18 and 1.4 mU/liter and that more than 95% of
870776 - the normal population will have a TSH level less than 2.5
870777 - mU/liter clearly imply that anyone with a higher value should
870778 - be carefully assessed for early thyroid failure."
870779 -
870780 - "...the decision as to whether to initiate a trial of
870781 - levothyroxine therapy is based more upon the 'art of
870782 - medicine' at this time than the science."
870784 - ..
870785 - 33. In their article, they point to some key facts, including:
870786 -
870787 - 1. In an iodine-sufficient population, the mean TSH is 1.5
870788 -
870789 - 2. In African-Americans with low incidence of Hashimoto's
870790 - thyroiditis, the mean TSH is 1.18, which suggests that
870791 - "this is close to the true normal mean for a normal
870792 - population"
870794 - ..
870795 - 3. When people with positive antithyroid antibodies or family
870796 - history of autoimmune thyroid disease are excluded from the
870797 - "reference range" cohort, the normal reference range
870798 - becomes .4 to 2.5
870800 - ..
870801 - 34. They argue that physicians are practicing a double standard --
870802 - considering one level the "normal" for treatment, but another
870803 - for diagnosis. The authors write:
870804 -
870805 - We are also befuddled by the practice of supporters of the
870806 - recommendations of the consensus panel [the panel that
870807 - recommended that the reference range not be changed] who
870808 - promote a target TSH range of 1.0-1.5 mU/liter in patients
870809 - already receiving T4 therapy, whereas they refuse to
870810 - accept TSH levels of 3-10 mU/liter as abnormal in patients
870811 - not receiving T4 therapy.
870813 - ..
870814 - 35. According to Wartofsky and Dickey, opponents of the new range
870815 - argue against treatment for subclinical thyroid problems
870816 - because they are concerned about risks of subclinical
870817 - hyperthyroidism due to overtreatment. Wartofsky and Dickey
870818 - argue, however, that there is an equivalent risk of
870819 - undertreatment, and that all of these risks can be minimized by
870820 - educating doctors about the desirable TSH target and teaching
870821 - them how to use various dosages to reach those targets in
870822 - patients. They write:
870823 -
870824 - To us, individual failure on the part of physicians to
870825 - appropriately monitor levothyroxine therapy and adjust
870826 - doses is not a rationale to withhold the indicated therapy.
870827 - We find the reluctance of the consensus panel to consider
870828 - treatment for mild TSH elevations puzzling when it is most
870829 - likely that they would not argue with the wisdom and
870830 - rationale for early therapeutic intervention to mild
870831 - diabetes mellitus with slight, but definite, elevations in
870832 - blood glucose, mild elevations in low-density lipoprotein
870833 - cholesterol, or mild elevations in blood pressure. After
870834 - all, few endocrine disease states appear suddenly in an "on
870835 - or off" or "black and white" manner. Rather, the
870836 - disordered physiology must start at sub-intense level and
870837 - then will have the potential to progress from mild to
870838 - moderate to overt or severe. Just as we have revised
870839 - downward our concept of normal range blood pressure and
870840 - cholesterol, we new now should consider the evidence for
870841 - doing so with TSH. Given the wealth of data on the
870842 - abnormalities present in untreated subclinical
870843 - hypothyroidism or hyperthyroidism and the demonstrated
870844 - benefits of therapy to date, we are not disposed to have
870845 - our hands tied by the deficiencies inherent in analyses of
870846 - this issue by evidence-based medicine and allow our
870847 - patients to continue to be at risk as a consequence."
870849 - ..
870850 - 36. They also conclude their article with what may be the most
870851 - sensible statement of both arguments:
870852 -
870853 - "...the decision as to whether to initiate a trial of
870854 - levothyroxine therapy is based more upon the 'art of
870855 - medicine' at this time than the science."
870857 - ..
870858 - 37. What's Normal, Anyway?
870859 -
870860 - There is also an argument regarding whether or not
870861 - fluctuations with the normal range -- by whichever standard,
870862 - old or new -- represent thyroid dysfunction on an individual
870863 - basis. Danish researchers found that each person tends to have
870864 - what's known as a "set point," a particular level of T4, T3
870865 - and TSH that their body wants to return to automatically. We
870866 - then tend to maintain thyroid levels around that set point,
870867 - within a narrow range -- a range much narrower than the
870868 - "reference range" for normal used by laboratories for testing.
870870 - ..
870871 - 38. Because each of us has a distinct set point for TSH, T3 and T4
870872 - levels, the general population references ranges are in fact
870873 - too broad to detect changes to thyroid function that may
870874 - represent disease in an individual.
870876 - ..
870877 - 39. The Danish researchers concluded that:
870878 -
870879 - The distinction between subclinical and overt thyroid
870880 - disease is somewhat arbitrary because it depends to a
870881 - considerable extent on the position of the patient's
870882 - normal set point for T3 and T4 within the laboratory
870883 - reference range...In conclusion, we found that individual
870884 - reference ranges for serum T3 and T4 are about half the
870885 - width of population-based reference ranges. Hence, a test
870886 - result within the laboratory reference limits is not
870887 - necessarily normal for the individual.
870889 - ..
870890 - 40. What this all means for you is that--
870891 -
870892 - 1. Your doctor probably is still using the old reference range
870893 - of 0.5 to 5.0 for diagnosis and management of your thyroid
870894 - disease
870895 -
870896 - 2. You should not accept the answers "normal," "high" or "low"
870897 - as a report of your blood tests. Instead, ask for the
870898 - actual numbers and ask for the lab's normal range. Better
870899 - yet, ask that a copy of your blood test report be faxed or
870900 - mailed or given to you.
870902 - ..
870903 - 3. If your TSH test levels come in below 0.5, or above
870904 - 2.5-3.0, and your doctor is saying these levels are normal,
870905 - make him or her aware of the AACE and American Association
870906 - for Clinical Chemistry Laboratory Medicine Practice
870907 - Guidelines and their 0.3 to 3.0 new reference range. Ask
870908 - the doctor if he or she will consider a different diagnosis
870909 - and treatment based on this new information.
870911 - ..
870912 - 4. If your doctor refuses to consider your results according
870913 - to the new range, you may want to look for a new doctor who
870914 - is more accepting of change and new evidence, and who will
870915 - in fact be practicing according to the American Association
870916 - of Clinical Endocrinologists new guidelines.
870918 - ..
870919 - 41. Mary Shomon, About.com's Thyroid Guide since 1997, is a
870920 - nationally-known patient advocate and best-selling author of 10
870921 - books on health, including "The Thyroid Diet: Manage Your
870922 - Metabolism for Lasting Weight Loss," "Living Well With
870923 - Hypothyroidism: What Your Doctor Doesn't Tell You...That You
870924 - Need to Know," "Living Well With Graves' Disease and
870925 - Hyperthyroidism," "Living Well With Autoimmune Disease,"
870926 - "Living Well With Chronic Fatigue Syndrome and Fibromyalgia,"
870927 - and the "Thyroid Guide to Fertility, Pregnancy and
870928 - Breastfeeding Success." Click here for more information on Mary
870929 - Shomon.
870930 -
870931 - http://thyroid.about.com/bio/Mary-Shomon-350.htm
870932 -
870934 - ..
870935 - Research on Internet shows...
870936 -
870937 - Lab Tests Online
870938 -
870939 - T4 - Also - Total T4 and Free T4
870940 -
870941 - http://labtestsonline.org/understanding/analytes/t4/tab/test
870943 - ..
870944 - 1. How is it used?
870945 -
870946 - Total T4 and free T4 are two separate tests that can help a
870947 - doctor evaluate thyroid function. The total T4 test has been
870948 - used for many years to help diagnose hyperthyroidism and
870949 - hypothyroidism. It is a useful test but can be affected by the
870950 - amount of protein available in the blood to bind to the
870951 - hormone. The free T4 test is a newer test that is not affected
870952 - by protein levels. Since free T4 is the active form of
870953 - thyroxine, the free T4 test is thought by many to be a more
870954 - accurate reflection of thyroid hormone function and, in most
870955 - cases, its use has replaced that of the total T4 test.
870956 - Whichever thyroxine measurement is ordered, it is usually
870957 - ordered along with or following a TSH test. This helps the
870958 - doctor to determine whether the thyroid hormone feedback system
870959 - is functioning as it should, and the results of the tests help
870960 - to distinguish between different causes of hyperthyroidism and
870961 - hypothyroidism. Sometimes a T3 test will also be ordered to
870962 - give the doctor additional diagnostic information.
870964 - ..
870965 - 2. A T4 and TSH test may be ordered to help evaluate a person with
870966 - a goiter and to aid in the diagnosis of female infertility. If
870967 - a doctor suspects that someone may have an autoimmune-related
870968 - thyroid condition, then thyroid antibodies may be ordered along
870969 - with a T4 test. In those with known thyroid dysfunction, T4
870970 - and/or TSH tests may be ordered to monitor thyroid function.
870972 - ..
870973 - 3. In the United States, newborns are commonly screened for T4
870974 - levels as well as TSH concentrations to check for congenital
870975 - hypothyroidism, which can cause mental retardation if left
870976 - untreated.
870978 - ..
870979 - 4. When is it ordered?
870980 -
870981 - A total T4 or free T4 test is primarily ordered in response to
870982 - an abnormal TSH test result. Sometimes the T4 will be ordered
870983 - along with a TSH to give the doctor a more complete evaluation
870984 - of the adequacy of the thyroid hormone feedback system. These
870985 - tests are usually ordered when a person has symptoms of
870986 - hyperthyroidism or hypothyroidism.
870988 - ..
870989 - 5. Signs and symptoms of hyperthyroidism may include:
870990 -
870991 - 1. Increased heart rate
870992 -
870993 - 2. Anxiety
870994 -
870995 - 3. Weight loss
870997 - ..
870998 - 4. Difficulty sleeping
871000 - ..
871001 - 5. Tremors in the hands
871003 - ..
871004 - 6. Weakness
871006 - ..
871007 - 7. Diarrhea (sometimes)
871009 - ..
871010 - 8. Light sensitivity, visual disturbances
871012 - ..
871013 - 9. The eyes may be affected: puffiness around the eyes,
871014 - dryness, irritation, and, in some cases, bulging of the
871015 - eyes.
871017 - ..
871018 - 6. Symptoms of hypothyroidism may include:
871019 -
871020 - 1. Weight gain
871021 - 2. Dry skin
871022 - 3. Constipation
871023 - 4. Cold intolerance
871024 - 5. Puffy skin
871025 - 6. Hair loss
871026 - 7. Fatigue
871027 - 8. Menstrual irregularity in women.
871029 - ..
871030 - 7. Severe untreated hypothyroidism, called myxedema, can lead to
871031 - heart failure, seizures, and coma. In children, hypothyroidism
871032 - can stunt growth and delay sexual development
871034 - ..
871035 - 8. Sometimes they are ordered as screening tests during routine
871036 - blood testing, but expert opinions vary on who can benefit from
871037 - screening and at what age to begin. In those with known
871038 - thyroid disorders, the TSH and sometimes T4 are ordered at
871039 - intervals to monitor the effectiveness of treatment. In
871040 - pregnant women with thyroid disorders, the doctor is likely to
871041 - order thyroid testing early and late in the pregnancy and for a
871042 - time period following delivery to monitor the mother and baby.
871043 - Thyroid hormone screening is commonly performed on newborns in
871044 - the United States as part of newborn screening programs.
871045 -
871046 -
871047 -
871048 -
871049 -
871050 -
8711 -
SUBJECTS
HGBA1C 5.6 for 4.1 to 6.2 Diabetes Negative Laboratory Blood Test Cr
A103 -
A10401 - ..
A10402 - HGB1c Diabetes Blood Test
A10403 - Diabetes Blood Test HGB1c
A10404 -
A10405 -
A10406 - HGBA1c
A10407 - 2010 07 21 Results Units Range
A10408 - Blood 0854
A10409 - Ref range low 4.1
A10410 - Ref range high 6.2
A10411 - %
A10412 - --------------------------------------------------------
A10413 - a 2010 07 21 0854 5.6
A10415 - ..
A10416 - a - Test performed by VA Martinez, 150 Muir Road, Martinez, CA
A10417 -
A10418 - *** For test NGBA1c Normals: 4.1 - 6.0 ***
A10419 - Evaluation for HGBA1c:
A10420 -
A10421 - *** Reference range change effective 2010 06 10. Prev range
A10422 - 4.1 - 6.2.***
A10424 - ..
A10425 - HGB1c seems like additional test to cross check for diabetes, and
A10426 - within mid-range indicates no immediate evidence of diabetes.
A10428 - ..
A10429 - [...above on 100721 0800 Chem Profile lab for glucose 117
A10430 - near top of range for diabetes, ref SDS 0 GM65
A10431 -
A10432 -
A10433 -
A10434 -
A10435 -
A10436 -
A105 -
SUBJECTS
Cancer Markers PSA 1.25 Tumor Marker Low End Scale Signal Negative L
AF03 -
AF0401 - ..
AF0402 - PSA Negative Cancer Markers
AF0403 -
AF0404 -
AF0405 - Tumor Markers
AF0406 - 2010 07 21 Results Units Range
AF0407 - Serum 0854
AF0408 - AFP TM Not done ng/mL 0.0 - 8.0
AF0409 - CEA Not done ng/mL 0.0 - 3.0
AF0410 - PSA (Prostate) 1.25 ng/mL 0.0 - 4.0
AF0411 - CA 125 Not done Units/mL 0.0 - 34.0
AF0412 - CA 15-3 Not done Units/mL 0.0 - 25.0
AF0413 - CA 19-9 Not done Units/mL 0.0 - 37.0
AF0414 -
AF0415 -
AF05 -
SUBJECTS
HIV Aids Lab Blood Test Negative
AQ03 -
AQ0401 - ..
AQ0402 - HIV Aids Negative Lab Blood Test
AQ0403 -
AQ0404 -
AQ0405 - HIV
AQ0406 - 2010 07 21 Results Units Range
AQ0407 - Serum 0854
AQ0408 - HIV old Ref: NEG/NONREACT
AQ0409 - HIV Non Reactive Ref: NONREACT
AQ0410 - GP160
AQ0411 - GP120
AQ0412 - P65
AQ0413 - P55
AQ0414 - P51
AQ0415 - GP41
AQ0416 - P40
AQ0417 - P31
AQ0418 - P24 Ag
AQ0419 - P24
AQ0420 - P18
AQ0421 - Int WB
AQ0423 - ..
AQ0424 - Comments: a
AQ0426 - ..
AQ0427 - a - Performed At: 01
AQ0428 - LabCorp San Diego
AQ0429 - 13112 Evening Creek Dr So Ste 200
AQ0430 - San Diego, CA 921284108
AQ0431 - Index Value: Specimen reactivity relative to the negative
AQ0432 - cutoff
AQ0433 - *** For test HIV Normals: Non Reactive ***
AQ0434 -
AQ0435 -
AQ0436 -
AQ0437 -
AQ0438 -
AQ05 -
SUBJECTS
Urine Lab PH 5.0 for 5.5 to 9.0 Protein Negative Glcose Negative
B103 -
B10401 - ..
B10402 - Urine Glucose Diabetes Lab Negative
B10403 -
B10404 -
B10405 - Urine Dipstick
B10406 - 2010 07 21 Results Units Range
B10407 - Urine 0854
B10408 - PH 5.5 5.0 - 9.0
B10409 - PROTEIN NEG mg/dL NEG - TRACE
B10410 - GLUCOSE NEG mg/dL Ref: NEG
B10411 - KETONES NEG mg/dL Ref: NEG
B10412 - BILI NEG Ref: NEG
B10413 - BILIcnf Ref: NEG
B10414 - BLOOD NEG Ref: NEG
B10415 - NITRITE NEG Ref: NEG
B10416 - UROBILI 0.2 EU/dL 0.1 - 1.0
B10417 - LEU EST NEG Ref: NEG
B10418 - SP.GRAV 1.025 1.003 - 1.035
B10419 - COLOR YELLOW
B10420 - APPEAR CLEAR
B10422 - ..
B10423 - Comments:
B10425 - ..
B10426 - a - Test performed by VA Martinez, 150 Muir Road, Martinez, CA
B10428 - ..
B10429 - Evaluation for SP.GRAV:
B10430 - SG reference range changed from 1.000 - 1.030... 2010 05 10
B10431 -
B10432 -
B105 -
SUBJECTS
HIV Aids Lab Blood Test Negative
BD03 -
BD0401 - ..
BD0402 - Miscellaneous Tests
BD0403 - DATE TIME SPECIMEN TEST VALUE Ref ranges
BD0405 - ..
BD0406 - 2010 07 21 0854 SERUM HivIndx: <1.00 Ref <=1.00
BD0408 - ..
BD0409 - Performed at 01
BD0410 - LabCorp San Diego
BD0411 - 13112 Evening Creek Dr So Ste 200
BD0412 - San Diego, CA 921284108
BD0413 - Index Value: Specimen reactivity relative to the negative
BD0414 - cutoff
BD0415 - ==========================================================
BD0417 - ..
BD0418 - BLOOD BANK
BD0420 - ..
BD0421 - Legacy Vista Blood Bank Report
BD0423 - ..
BD0424 - The following historical information comes from the Legacy
BD0425 - Vista Blood Bank System. It represents data prior to the
BD0426 - installation of VBECS. Some of the information in this report
BD0427 - may be duplicated in the VBECS report above (if available).
BD0429 - ..
BD0430 - Seems to supplement HIV Aids lab, per above. ref SDS 0 F54F
BD0431 -
BD0432 -
BD0433 -
BD0434 -
BD0435 -
BD0436 -
BD0437 -
BD05 -