San Francisco, CA
S U M M A R Y
DIARY: December 23, 2010 10:30 AM Thursday;
VA Meeting Doctor Sandhu review cholesterol lab test results.
2...Examination Doctor Prepared Reviewed SDS Record Patient History
3...Simvastatin 40 MG Patient History Consistent Medication Effective
4...Cholesterol Declines Reduces Risk Factor Heart Disease
5...Diabetes Risk Factor Glucose Lab Tests Declines
6...Glucose Blood Sugar Falls Below Diabetes Risk Level
7...Afib Recent Increase Episodes
8...VA Medical Chart for Meeting Today December 23, 2010
9...Myocardial Infarction Heart Disease Risks Reduced Aspirin
10...Aspirin Avoid Heart Attack Side Effects Ulcers Bleeding
11...Aspirin Risks Gastric Ulcers Internal Bleeding Research
........Aspirin (acetylsalicylic acid)
........Coronary and carotid arteries, bypasses and stents
12...Aspirin Conflicts Low Dose Omeprazole Studies Conflicting Results
13...Omeprazole Theoretically Increase Risk Adverse Gastric Effects Aspirin
........Drug interactions between aspirin and Prilosec
........Omeprazole ameliorates aspirin-induced gastroduodenal injury
14...Omeprazole Reduces Side Effects Aspirin
........An Aspirin a Day ... or Not?
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Examination Cholesterol 40% Improvement Heart Disease Risk Declines
2803 - ..
2804 - Summary/Objective
280501 - Follow up ref SDS 41 0000. ref SDS 36 0000.
280506 - ..
2808 - Progess
280901 - Examination Doctor Prepared Reviewed SDS Record Patient History
280903 - Follow up ref SDS 41 PP8W.
280905 - Background reported on 100721 0800. ref SDS 41 5R5H
280907 - ..
280908 - On 101112 0952, Connie schedled meeting today with Doctor Sandhu for
280909 - today. ref SDS 51 PP8W
280911 - ..
280912 - Met with Doctor Sandhu at the VA in Martinez, to follow up meeting on
280913 - 100721, ref SDS 41 PP8W, and as set out in the Medical Chart for that
280914 - meeting, ref DRP 1 PE5J, which was received on 100827 1316,
280915 - ref SDS 44 Y87U9
280917 - ..
280918 - Doctor Sandhu received the letter to the medical team on 101206
280919 - reporting illness with flu-like symptoms. ref SDS 55 7Q4X He seemed
280920 - to say that symptoms were due to excessive exercise over-taxing the
280921 - body helping Ross cut down the Pine 10 trees, reported on 101128 0538.
280922 - ref SDS 54 PU71
280924 - ..
280925 - Doctor Sandhu prescribed another vaccination for flue and H1N1 (swine)
280926 - flue, a combination treatment. This was done at the VA immediately
280927 - after meeting with the doctor, and supplements prior vaccination for
280928 - H1N1 (swine) flue on 100104 0930. ref SDS 36 WR7L
280930 - [...below on 101223 1020 medical chart reports order for
280931 - influenza immunization. ref SDS 0 7X5O
280933 - ..
280934 - Doctor Sandhu received copy of the letter on 101216 1021. ref SDS 59
280935 - K35G, which was sent to the medical team reporting results from
280936 - meeting with Doctor Lee on 101210, to perform EGD and dilation of
280937 - LESV. ref SDS 57 KJ5N Doctor Sandhu advised that he cannot find a
280938 - report in the medical chart for the procedure on 101210.
280940 - [...below on 101223 1020 medical chart says report on EGD
280941 - and dilation procedure on 101210 still pending. ref SDS 0
280942 - RS4J
280944 - ..
280945 - Explained meeting yesterday at the VA with Chris checking progress in
280946 - GI Department on completing the medical chart for work on 101210,
280947 - reported on 101222 0800. ref SDS 61 RR7N
280949 - ..
280950 - Doctor Sandhu asked if swallowing has improved after EGD and dilation
280951 - procedure on 101210?
280953 - ..
280954 - Another letter to the medical team submitted on 101219 reported
280955 - swallowing has improved, ref SDS 60 5N3O, and cites case study on
280956 - 101010, that records swallowing began improving about 5 days after the
280957 - procedure on 101210. ref SDS 46 FS3G
280959 - [...below, on 101223 1030 for some reason the medical chart
280960 - does not cite the record on improved swallowing.
280961 - ref SDS 0 T68T
280963 - ..
280964 - Doctor Sandhu did not ask about severe side effects from Omeprazole
280965 - after doubling the prescription on 101210, and reported to the medical
280966 - team on 101219 1402. ref SDS 60 BE9T
280968 - ..
280969 - The doctor asked about follow up planned for recovering from
280970 - swallowing problems?
280972 - ..
280973 - Letter to the medical team on 101216, reported follow up EGD procedure
280974 - with dialation of lower esophageal sphincter valve (LESV) was
280975 - scheduled by Doctor Lee for 110218 0730, and shown in the record on
280976 - 101216 1021, ref SDS 59 K43W, and further citing letter from the VA
280977 - dated 101210 received on 101214 2330. ref SDS 58 ZG7O
280979 - [...below, on 101223 1030 for some reason the medical chart
280980 - reports follow up procedure as a verbal representation and
280981 - does not cite the record showing next EGD and dilation
280982 - scheduled on 110218. ref SDS 0 T68T
280984 - ..
280985 - After meeting today, called Wilma and said to include meeting with
280986 - Doctor Sandhu in Release of Information CD. She reported that Doctor
280987 - Lee's progress notes are still not available for the meeting on
280988 - 101210. Will notify the GI Clinic to expedite this work, so that
280989 - Wilma can complete ROI request.
280991 - [On 110103 1314 Ray cannot find Progress Notes for meeting
280992 - at VA on 101210 for EGD in VA computer system; Kendal will
280993 - coordinate with Doctor Lee on completing the record.
280994 - ref SDS 62 QP8U
280996 - ..
280997 - [On 110107 1508 met with Ray at the Control Center for VA
280998 - GI Department in Martinez; Ray advised the doctor has not
280999 - had time to submit progress notes for meeting on 101210 to
281000 - perform EGD procedure; prepared handwritten letter to the
281001 - doctor reporting improved swallowing from excellent work on
281002 - 101210, and requested again the doctor's report on findings
281003 - with biopsy report; submitted copty to Wilma in ROI
281004 - Department. ref SDS 63 XL7K
281006 - ..
281007 - [On 110114 1309 received CD from Wilma transmitting medical
281008 - chart for work at the VA from 101207 - 101223. ref SDS 64
281009 - 1Y9K
281012 - ..
281013 - Simvastatin 40 MG Patient History Consistent Medication Effective
281015 - Follow up ref SDS 41 RP4F.
281017 - In the meeting at the VA on 100721, Doctor Sandhu was disappointed the
281018 - blood test on 100610, reported 100721 0800, ref SDS 41 HY76, showed
281019 - cholesterol had declined very little from the prior test reviewed with
281020 - the doctor on 100104, ref SDS 36 DG4O, and because lab tests on 100610
281021 - showed cholesterol 217, still above the danger level as a risk factor
281022 - for heart disease. ref SDS 41 HY76
281024 - ..
281025 - As a result, the doctor doubled the prescription for Simvastatin to 40
281026 - mg per day. The doctor ordered another lab performed after the
281027 - meeting on 100721. Results received a week later showed dramatic
281028 - worsening of cholesterol from 217 on 100610 to 261 on, reported in the
281029 - record on 100721 0800. ref SDS 41 E19L Assuming this was not an error
281030 - reporting 20% increase in cholesterol over less than 60 days, after
281031 - several years of declining cholesterol, this change presents a rising
281032 - risk factor for heart disease.
281034 - ..
281035 - During the meeting today, Doctor Sandhu indicated he opened the link
281036 - to the case study submitted with the letter to the medical team on
281037 - 101219. ref SDS 60 BE9T The doctor was pleased patient history now
281038 - shows consistent use of prescribed medication, and includes exercise,
281039 - and vitals, beginning on 101010 0744. ref SDS 46 QJ5I The doctor said
281040 - that patient history, including significant decline in cholesterol,
281041 - reported below, ref SDS 0 415H, and refill for Simvastatin on 101104
281042 - 2338, ref SDS 47 5N3O, corrects prior concerns that medication was not
281043 - taken regularly, reported during the meeting at the VA on 100721 0800.
281044 - ref SDS 41 3X4L
281046 - ..
281047 - Doctor Sandhu noted today that patient history in the record on 101010
281048 - showing expanding exercise and vitals improving consistently below
281049 - ranges for cardiovascular risk factors, ref SDS 46 QJ5I, demonstrates
281050 - good recovery from heart surgery at VA Medical Center in San
281051 - Francisco, on 091022, ref SDS 12 PQWU, and later Heller Myotomy
281052 - surgery to relieve achalasia symptoms, also performed at VA in San
281053 - Francisco on 091216. ref SDS 26 KE8T
281055 - [...below on 101223 1020 medical chart reports patient
281056 - recovering well from heart surgery. ref SDS 0 TE49
281058 - ..
281059 - Reporting today that the doctor used the Internet to open SDS records
281060 - on patient history applies VA goals for doctor/patient partnership,
281061 - noted previously for manaqging recovery from heart surgery and later
281062 - the Heller Myotomy procedure to recover from achalasia, discussed on
281063 - 100104 0930. ref SDS 36 YM7N
281066 - ..
281067 - Cholesterol Declines Reduces Risk Factor Heart Disease
281069 - Follow up ref SDS 56 E19L.
281071 - Doctor Sandhu discussed results of blood test on 101207, which was
281072 - ordered on 101108 0929 to prepare for the meeting today for assessing
281073 - effect on lowering cholesterol from doubling medication to Simvastatin
281074 - 40 mg, ref SDS 49 6X8Q
281076 - ..
281077 - Cholesterol declined significantly in the lab on 101207, ref SDS 56
281078 - E19L, and in the VA's report, ref DRP 2 R34M, showing..
281080 - Lab Results
281081 - LIPID PANEL............................ 2010 12 07 0917
281082 - PLASMA Results Units Range
281083 - CHOL 151 mg/dL Ref: <=200
281084 - TRIGLYC 41 mg/dL Ref: <=150
281085 - HDL 47 mg/dL Ref: >=40
281086 - LDL 96 mg/dL Ref: <=160
281088 - ..
281089 - [On 110114 1309 received results for lab on 101207, and
281090 - VA medical chart for meeting with Doctor Lee on 101207,
281091 - and also meeting with Doctor Sandhu on 101223.
281092 - ref SDS 64 GT5K
281094 - ..
281095 - Doctor Sandhu was pleased to see siginficant decline in cholesterol
281096 - that signals reduced risk of arterial coronary (heart) disease,
281097 - following prescription to increase medication with Simvastatin from 20
281098 - to 40 mg per day, and during the meeting on 100721 0800. ref SDS 41
281099 - RP4F The doctor reported favorable trend analysis in the medical
281100 - chart for the meeting today, ref DRP 2 PUWS,
281102 - ..
281103 - Collection DT Spec CHOL TRIGL HDL LDL-CHO
281104 - 12/07/2010 09:17 PLASM 151 41 47 96
281105 - 07/21/2010 08:54 PLASM 261 H 87 35 L 209 H
281106 - 06/10/2010 10:33 PLASM 217 H
281107 - * 12/14/2009 11:10 PLASM 241 H 136 44 170 H
281108 - 08/13/2009 15:09 PLASM 233 H
281109 - 06/16/2006 10:59 PLASM 238 H
281111 - ..
281112 - * Lab at VA San Francisco Medical Center reported on 100928 0706.
281113 - ref SDS 45 VW6J
281115 - ..
281116 - The doctor indicated today that treatment with high dose Simvastatin
281117 - 40 mg per day, should remain until cholesterol falls below 90. The
281118 - medical chart notes that LDL 96 is a goal to be well below target
281119 - range of 160. He wants to increase HDL to above 60, to remove a risk
281120 - factor for good health, cited in "Assessment and Plan" for the medical
281121 - chart today, listed below. ref SDS 0 TE49
281123 - ..
281124 - Doctor Sandhu plans follow up meeting in July to assess continuing
281125 - progress on reducing risk factors for cardiothoracic disease. In May,
281126 - VA will schedule another blood draw in June to be prepared with lab
281127 - report for meeting in July.
281129 - [...below on 101223 1020 medical chart reports cholesterol
281130 - LDL at goal, and continues current high dose of Simvastatin
281131 - until next meeting in June 2011. ref SDS 0 06QW
281133 - ..
281134 - [...below on 101223 1020 medical chart assessment and plan
281135 - for VA to schedule in May another blood draw. ref SDS 0
281136 - TE49
281138 - ..
281139 - [On 110129 2220 ordered refill for Simvastatin.
281140 - ref SDS 65 QS3L
281142 - ..
281143 - [On 110309 0900 Doctor Egan in Cardiology Department VA
281144 - Martinez set target for LDL 70, now at 96, and well below
281145 - 160 shown in VA labs for LDL target range. ref SDS 66 ZM98
281147 - ..
281148 - [On 110429 1230 Connie in primary care scheduled blood draw
281149 - for anytime after 110615; so planning on 110622; and Connie
281150 - confirmed the lab will include Mercury, ordered by Doctor
281151 - Egan. ref SDS 69 UN8N
281153 - ..
281154 - [On 110603 1523 scheduled meeting on 110719 0830, with
281155 - Doctor Sandhu in Primary Care at VA in Martinez; blood draw
281156 - for lab report will be performed a week or so earlier.
281157 - ref SDS 70 6I5H; supports Doctor Egan's work plan to assess
281158 - cholesterol during meeting at VA on 110807. ref SDS 68 MG3I
281160 - ..
281161 - There was no discussion today of report Merck new drug Anacetrapib
281162 - shows significant improvement in cholesterol; pending further clinical
281163 - trials, reported on 101117 1018. ref SDS 53 U75H
Diabetes Risk Declines Gluecose 102 Reduced from 117 Blood Sugar Fal
450401 - ..
450402 - Diabetes Risk Factor Glucose Lab Tests Declines
450403 - Glucose Blood Sugar Falls Below Diabetes Risk Level
450405 - Doctor Sandhu was pleased decline from Glucose 117 to 102, helps
450406 - prevent diabetes, reported in the lab on 101207, ref DRP 2 WW9O,
450407 - showing significant improvement...
450409 - LABS:
450410 - Collection DT Spec GLUCOSE BUN CREAT NA
450411 - 12/07/2010 09:17 PLASMA 102 8 0.85 137
450412 - 07/21/2010 08:54 PLASMA 117 12 0.89 139
450414 - [On 110114 1309 received results for lab on 101207, and
450415 - VA medical chart for meeting with Doctor Lee on 101207,
450416 - and also meeting with Doctor Sandhu on 101223.
450417 - ref SDS 64 GT5K
450419 - ..
450420 - Collection DT Spec K CL CO2
450421 - 12/07/2010 09:17 PLASMA 3.8 104 28
450422 - 07/21/2010 08:54 PLASMA 3.9 106 28
450424 - ..
450425 - Collection DT Spec ALT AST ALK PHO ALBUMIN T BIL
450426 - 12/07/2010 09:17 PLASM 22 26 102 3.9 1.0
450427 - 07/21/2010 08:54 PLASM 24 23 109 H 4.0 1.3 H
450429 - ..
450430 - Collection DT Spec WBC HGB HCT MCV MCHC PLT
450431 - 12/07/2010 09:17 BLOOD 6.7 14.4 43.3 90.7 33.1 310
450432 - 07/21/2010 08:54 BLOOD 7.3 14.9 44.0 91.2 33.8 344
450434 - ..
450435 - SCLU - TSH
450436 - Collection DT Spec Tsh
450437 - 12/07/2010 09:17 SERUM 2.61
450438 - 07/21/2010 08:54 SERUM 2.51
Default Null Subject Account for Blank Record
460401 - ..
460402 - Afib Recent Increase Episodes
460404 - Follow up ref SDS 52 PPWU.
460406 - On 101117 Doctor Jeff Zimmet in Cardiology Department at San Francisco
460407 - Medical Center recommended notifying Primary Care Physician to
460408 - coordinate cardiology review by Doctor Egan of recent increase in afib
460409 - events. ref SDS 52 5B8I
460411 - ..
460412 - During the meeting today, there was not enough time to review notice
460413 - of increased afib events submitted to medical team on 101105 2223.
460414 - ref SDS 48 755I and follow up submitted on 101110 1216. ref SDS 50
460415 - W54S
460417 - [On 110309 0900 Doctor Egan ordered heart monitoring test
460418 - to assess possible afib exosure. ref SDS 66 MY9V
Medical Chart Progress Notes Primary Care Meeting
610401 - ..
610402 - VA Medical Chart for Meeting Today December 23, 2010
610404 - A few weeks later, received Doctor's Sandhu's medical chart with the
610405 - CD submitted by Wilma in ROI Department. ref DRP 2 PTTU
610407 - ..
610408 - 1. LOCAL TITLE: Primary Care Scheduled Visit 60297
610409 - STANDARD TITLE: PRIMARY CARE NOTE
610410 - DATE OF NOTE: DEC 23, 2010@10:40:53 ENTRY DATE: DEC 23, 2010@10:40:53
610411 - AUTHOR: SANDHU,HARKESH S EXP COSIGNER:
610412 - URGENCY: STATUS: COMPLETED
610414 - ..
610415 - 2. 65 yo MALE with medical problems as listed in problem list came
610416 - in for f/u. Pt states he had the egd and it is little better
610417 - and will be going in for redo in february to do more
610418 - dialtation.No f/c/n/v/d/malena.
610420 - ..
610421 - Not clear why medical chart relies on impression from what patient
610422 - states, rather than citing the record submitted to the VA, as
610423 - discussed during the meeting, per above. ref SDS 0 LS8J
Afflictions List Case Management Medical Chart Progress Notes Primar
830401 - ..
830402 - VA medical chart continues...
830404 - 3. Computerized Problem List is the source for the following:
830406 - 1. Esophageal Stricture 03/05/10 LEE,RANDALL E.......
830408 - 2. Screening for Malignant Neoplasms of colon 02/02/10
830409 - LEE,RANDALL E (ICD-9-CM V76.51)
830411 - ..
830412 - 3. Coronary Atherosclerosis (unspecified type 02/02/10
830413 - LEE,RANDALL E vessel, native or graft) (ICD-9-CM 41
830415 - ..
830416 - 4. Coronary Artery Bypass using Venous and 01/04/10
830417 - SANDHU,HARKESH Arterial Grafts (Single Vein Graft),
830418 - Onset 10/00/09 done at vasf
830420 - ..
830421 - CABG was performed at VA San Francisco Medical Center on 091022.
830422 - ref SDS 12 PQWU
830424 - ..
830425 - VA medical chart continues...
830427 - 5. Surgical Thoracoscopy with Esophagomyotomy 01/04/10
830428 - SANDHU,HARKESH (Heller Type), Onset 12/16/09 at vasf
830430 - ..
830431 - 6. Hyperlipidemia * (ICD-9-CM 272.4) 10/02/09 EGAN,JAMES
830433 - ..
830434 - 7. Inflamed Seborrheic Keratosis (ICD-9-CM 702.11)
830435 - 03/12/07 LIN,BERTHA
830437 - ..
830438 - 8. Rosacea * (ICD-9-CM 695.3) 03/12/07 LIN,BERTHA
830440 - ..
830441 - 9. Dermatitis * (ICD-9-CM 692.9) 03/12/07 LIN,BERTHA
830443 - ..
830444 - 10. Tinea Unguium * (ICD-9-CM 110.1) 03/12/07 LIN,BERTHA
830446 - ..
830447 - 11. Tinea * (ICD-9-CM 110.9) 03/12/07 LIN,BERTHA
830449 - ..
830450 - 12. Rosacea conjunctivitis (ICD-9-CM 372.31) 03/02/07
830451 - MARGULIES,LINDA
830453 - ..
830454 - 13. Rosacea * (ICD-9-CM 695.3) 03/02/07 MARGULIES,LINDA
830456 - ..
830457 - 14. Blepharitis NOS 02/21/07 MARGULIES,LINDA
830459 - ..
830460 - 15. Achalasia * (ICD-9-CM 530.0) 12/22/05 SANDHU,HARKESH
830462 - ..
830463 - 16. Abn. LFT's 08/16/05 SANDHU,HARKESH
830465 - ..
830466 - 17. Obesity 06/29/05 SANDHU,HARKESH
830468 - ..
830469 - 18. Rosacea 06/29/05 SANDHU,HARKESH
830471 - ..
830472 - 19. Tinea Unguium 06/29/05 SANDHU,HARKESH
Medications Active List VA Medical Chart Progress Notes Primary Care
A10401 - ..
A10402 - 4. Active Outpatient Medications (excluding Supplies):
A10404 - ..
A10405 - Active Outpatient Medications Status
A10406 - =========================================================================
A10408 - 1. OMEPRAZOLE 20MG EC CAP TAKE TWO CAPSULES BY MOUTH
A10409 - ACTIVE
A10411 - TWICE A DAY 15 MINUTES BEFORE A MEAL FOR SEVERE
A10412 - ACID REFLUX AND ESOPHAGEAL NARROWING. **DOSE
A10413 - INCREASE**
A10415 - ..
A10416 - 2. SIMVASTATIN 80MG TAB TAKE ONE-HALF TABLET BY MOUTH ACTIVE
A10417 - EVERY EVENING - FOR CHOLESTEROL*USE PILL CUTTER* DO
A10419 - ..
A10420 - NOT TAKE WITH GRAPEFRUIT JUICE.
Default Null Subject Account for Blank Record
A20401 - ..
A20402 - 5. Physical Examination...
A20404 - 1. Most recent vitals:
A20406 - 1. Temperature: 96.7 F [35.9 C] (12/23/2010 10:36)
A20407 - 2. Pulse: 68 (12/23/2010 10:36)
A20408 - 3. Respirations: 20 (12/23/2010 10:36)
A20409 - 4. B/P: 118/70 (12/23/2010 10:36)
A20410 - 5. Height: 66 in [167.6 cm] (12/10/2010 09:50)
A20411 - 6. Weight: 193.8 lb [88.1 kg] (12/23/2010 10:34)
A20412 - 7. BMI: 31.3
A20413 - 8. Pain: 0 (12/23/2010 10:34)
A20415 - ..
A20416 - 2. HEENT: nc, at, perrl,eomi,no dns,no wax and nl tm
A20418 - ..
A20419 - 3. NECK: no lymph nodes,trachea central,no bruit,no mass
A20420 - and no thyroid enlargment
A20422 - ..
A20423 - 4. LUNGS: clear to auscultation and percussion
A20425 - ..
A20426 - 5. CARDIAC: nl s1s2 no murmur,
A20428 - ..
A20429 - 6. ABDOMEN: Soft, nontender, BS active, no HSM, no masses
A20431 - ..
A20432 - 7. EXT: No cyanosis,clubbing or edema.
A20434 - ..
A20435 - 8. NEURO: alert and oriented x3 , cn 2 -12 intact and
A20436 - no gross motor or sensory abnormality found
Default Null Subject Account for Blank Record
A30401 - ..
A30402 - LABS:
A30403 - Collection DT Spec GLUCOSE BUN CREAT NA K CL CO2
A30404 - 12/07/2010 09:17 PLASMA 102 8 0.85 137 3.8 104 28
A30405 - 07/21/2010 08:54 PLASMA 117 12 0.89 139 3.9 106 28
A30407 - ..
A30408 - Collection DT Spec ALT AST ALK PHO ALBUMIN T BIL
A30409 - 12/07/2010 09:17 PLASM 22 26 102 3.9 1.0
A30410 - 07/21/2010 08:54 PLASM 24 23 109 H 4.0 1.3 H
A30412 - ..
A30413 - Collection DT Spec WBC HGB HCT MCV MCHC PLT
A30414 - 12/07/2010 09:17 BLOOD 6.7 14.4 43.3 90.7 33.1 310
A30415 - 07/21/2010 08:54 BLOOD 7.3 14.9 44.0 91.2 33.8 344
A30417 - ..
A30418 - SCLU - TSH
A30419 - Collection DT Spec Tsh
A30420 - 12/07/2010 09:17 SERUM 2.61
A30421 - 07/21/2010 08:54 SERUM 2.51
A30423 - ..
A30424 - Collection DT Spec CHOL TRIGL HDL LDL-CHO
A30425 - 12/07/2010 09:17 PLASM 151 41 47 96
A30426 - 07/21/2010 08:54 PLASM 261 H 87 35 L 209 H
Default Null Subject Account for Blank Record
A40401 - ..
A40402 - ASSESSMENT AND PLAN:
A40404 - 1. Cad s/p cabg ; doing well............... ref SDS 0 LW6G
A40406 - ..
A40407 - 2. S/P EGD : report still pending.......... ref SDS 0 4N4O
A40409 - ..
A40410 - 3. Hyperchol ;Ldl at goal. will cont
A40411 - current care. call in
A40412 - may for f/u............................. ref SDS 0 ST6G
A40414 - ..
A40415 - Follow up in May, aligns with understandings from meeting with the
A40416 - doctor this morning, to get a blood draw in June to be prepared for
A40417 - another meeting Primary Care in July. ref SDS 0 9P83
A40419 - [On 110603 1523 scheduled meeting on 110719 0830, with
A40420 - Doctor Sandhu in Primary Care at VA in Martinez; blood draw
A40421 - for lab report will be performed a week or so earlier.
A40422 - ref SDS 70 6I5H; supports Doctor Egan's work plan to assess
A40423 - cholesterol during meeting at VA on 110807. ref SDS 68 MG3I
A40426 - ..
A40427 - Clinical Reminders:
A40429 - 1. Influenza Vaccine Sept 10 - Apr 11:
A40431 - Influenza Immunization ordered.......... ref SDS 0 OR6H
A40434 - ..
A40435 - Myocardial Infarction Heart Disease Risks Reduced Aspirin
A40436 - Aspirin Avoid Heart Attack Side Effects Ulcers Bleeding
A40439 - 2. Consider Aspirin for risk of MI:
A40441 - The patient was educated on the benefits and risks of
A40442 - daily aspirin therapy for the prevention of myocardial
A40443 - infarction in patients at risk. The patient was also
A40444 - informed of the risks of gastric ulcers and bleeding.
A40446 - ..
A40447 - There was no discussion during the meeting today of aspirin and
A40448 - mycardial infarction during the meeting today, nor of gastric ulcers
A40449 - and bleeeding (see research below).
A40451 - [On 110406 1230 discussion in Cardiology on taking aspirin
A40452 - to reduce risk of heart disease and stroke for patients
A40453 - with history of CABG, noted that not all patients take
A40454 - aspirin; and, did not mention that taking aspirin risks
A40455 - side effects that cause gastric ulcers and bleeding.
A40456 - ref SDS 67 5F5J, as noted in the medical chart today, on
A40457 - 101223 1030. ref SDS 0 454F
A40459 - ..
A40460 - There was no discussion of conflicts taking aspirin with Omeprazole,
A40461 - currently prescribed 80 mg per day, reported on 101210 0930.
A40462 - ref SDS 57 HW8H
A40472 - ..
A407 - 1430
A40801 - Aspirin Risks Gastric Ulcers Internal Bleeding Research
A40803 - After the meeting, research on the Internet indicates "myocardial
A40804 - infarction (MI) is another name for heart attack....
A40806 - Wikipedia says in part...
A40808 - ..
A40809 - Myocardial infarction
A40811 - http://en.wikipedia.org/wiki/Myocardial_infarction
A40813 - ..
A40814 - Myocardial infarction (MI) or acute myocardial infarction
A40815 - (AMI), commonly known as a heart attack, is the interruption
A40816 - of blood supply to a part of the heart, causing heart cells to
A40817 - die. This is most commonly due to occlusion (blockage) of a
A40818 - coronary artery following the rupture of a vulnerable
A40819 - atherosclerotic plaque, which is an unstable collection of
A40820 - lipids (fatty acids) and white blood cells (especially
A40821 - macrophages) in the wall of an artery. The resulting ischemia
A40822 - (restriction in blood supply) and oxygen shortage, if left
A40823 - untreated for a sufficient period of time, can cause damage or
A40824 - death (infarction) of heart muscle tissue (myocardium).
A40826 - ..
A40827 - The risk of a recurrent myocardial infarction decreases with
A40828 - strict blood pressure management and lifestyle changes,
A40829 - chiefly smoking cessation, regular exercise, a sensible diet
A40830 - for patients with heart disease, and limitation of alcohol
A40831 - intake.
A40833 - ..
A40834 - Currently, blood pressure is typically below 120/70 with pulse in low
A40835 - 60s upper 50s, and high 40s on waking up in the morning, reported in
A40836 - case study on 101010 0744. ref SDS 46 6Q8N
A40838 - ..
A40839 - Aspirin was taken to reduce symptoms of flu, and this was effective on
A40840 - 101010 0744. ref SDS 46 09AB
A40842 - ..
A40843 - Would help to get evidence for taking aspirin based on diagnostics in
A40844 - the lab, reported on 101207, ref SDS 56 PP8W, and patient history on
A40845 - vitals listed in the record on 101010 0744. ref SDS 46 QJ5I
A40847 - ..
A40848 - Aspirin was prescribed along with 10 other drugs to recover from heart
A40849 - surgery, reported on 091104 0718. ref SDS 18 1Q6P On 091218, met with
A40850 - cardiothoracic medical team at the VA in San Francisco. At that time,
A40851 - medications were ended with expiration of initial prescriptions,
A40852 - ref SDS 29 Z98L, due to good recovery from heart surgery 2 months
A40853 - earlier on 091022. ref SDS 12 PQWU
A40855 - ..
A40856 - It may turn out that decision to take aspirin is independent of lab
A40857 - tests...
A40859 - ..
A40860 - Angiogram (cardiac catheterization) examination on 091021, discovered
A40861 - very severe stenosis (strictures/blockages) in 3 blood vessels listed
A40862 - in the record recently reviewing the medical chart. 100928 0706,
A40863 - ref SDS 45 H24L During surgery the next day on 091022, a 4th stenosis
A40864 - was found and corrected with bypass, reported in the record on 100928
A40865 - 0706. ref SDS 45 HT9G
A40867 - ..
A40868 - Patient history shows practice of heavy exercise hiking 6 - 14 miles
A40869 - per day 5 days a week, for 5 years leading up to diagnosis of stenosis
A40870 - on 091021. Indeed, stenosis caused chest pain while hiking that led
A40871 - patient to seek medical care, reported on 090908 1130. ref SDS 9 MY4N
A40874 - Wikipedia says in part...
A40876 - ..
A40877 - Aspirin (acetylsalicylic acid)
A40879 - http://en.wikipedia.org/wiki/Aspirin
A40881 - ..
A40882 - Aspirin has an antiplatlet effect inhibiting production of
A40883 - thromboxane, which under normal circumstances binds platelet
A40884 - molecules to create a patch (blood clot) over damaged walls of
A40885 - blood vessels. Because the platelet patch can become too large
A40886 - and also block blood flow, locally and downstream, aspirin is
A40887 - used long-term, at low doses, to help prevent heart attacks,
A40888 - strokes, and blood clot formation in people at high risk for
A40889 - developing blood clots. It has also been established that
A40890 - low doses of aspirin may be given immediately after a heart
A40891 - attack to reduce the risk of another heart attack or death of
A40892 - cardiac tissue.
A40894 - ..
A40895 - Resistance
A40897 - ..
A40898 - For some people, aspirin does not have as strong an effect on
A40899 - platelets as for others, an effect known as aspirin
A40900 - resistanceor insensitivity. One study has suggested women are
A40901 - more likely to be resistant than men, and a different,
A40902 - aggregate study of 2,930 patients found 28% to be
A40903 - resistant. A study in 100 Italian patients found that of
A40904 - the apparent 31% aspirin-resistant subjects, only 5% were truly
A40905 - resistant, and the others were noncompliant
A40907 - ..
A40908 - Side Effects Ulcers and Stomach Bleeding
A40910 - ..
A40911 - The main undesirable side effects of aspirin are
A40912 - gastrointestinal ulcers, stomach bleeding, and tinnitus,
A40913 - especially in higher doses. In children and adolescents,
A40914 - aspirin is no longer used to control flu-like symptoms or the
A40915 - symptoms of chickenpox or other viral illnesses, because of the
A40916 - risk of Reye's syndrome.
A40918 - ..
A40919 - Coronary and carotid arteries, bypasses and stents
A40921 - The coronary arteries supply blood to the heart. Aspirin is
A40922 - recommended for one to six months after placement of stents
A40923 - in the coronary arteries and for years after a coronary artery
A40924 - bypass graft.
A40926 - ..
A40927 - The carotid arteries supply blood to the brain. Patients with
A40928 - mild carotid artery stenosis benefit from aspirin; it is
A40929 - recommended after a carotid endarterectomy or carotid artery
A40930 - stent.
A40932 - ..
A40933 - After vascular surgery of the lower legs using artificial
A40934 - grafts which are sutured to the arteries to improve blood
A40935 - supply, aspirin is used to keep the grafts open.
A40938 - ..
A40939 - Aspirin Conflicts Low Dose Omeprazole Studies Conflicting Results
A40940 - Omeprazole Theoretically Increase Risk Adverse Gastric Effects Aspirin
A40942 - Research on conflicts taking aspirin with Omeprazole currently
A40943 - prescribed at high dose 80 mg per day, reported on 101210 0930.
A40944 - ref SDS 57 HW8H
A40946 - Drugs.com
A40948 - ..
A40949 - Drug interactions between aspirin and Prilosec
A40951 - http://www.drugs.com/drug-interactions/aspirin-with-prilosec-243-0-1750-1118.html
A40953 - ..
A40954 - Coadministration with proton pump inhibitors may decrease the
A40955 - oral bioavailability of aspirin and other salicylates. The
A40956 - interaction has been studied with omeprazole and aspirin,
A40957 - although data are conflicting. In one study, pretreatment with
A40958 - omeprazole (20 mg/day for 2 days) in 11 healthy volunteersled
A40959 - to a significant and progressively greater reduction in the
A40960 - mean serum salicylate level at 30, 60, and 90minutes after
A40961 - administration of aspirin (650 mg single dose). The
A40962 - investigators suggest that acid suppression may reduce the
A40963 - lipophilic nature of aspirin, thereby adversely affecting its
A40964 - absorption from the gastrointestinal tract. Another study
A40965 - found no effect of omeprazole pretreatment (20 mg/day for 4
A40966 - days) on plasma salicylate and aspirin levels, skin bleeding
A40967 - times, or antiplatelet effect of low-dose aspirin (125 mg
A40968 - single dose) in 14 healthy volunteers. However, these results
A40969 - do not exclude the possibility that omeprazole might interfere
A40970 - with the analgesic, antipyretic, oranti-inflammatory effects of
A40971 - aspirin, which has been demonstrated in rats.
A40973 - ..
A40974 - Proton pump inhibitors may enhance the release rate of
A40975 - salicylates from enteric-coated formulations due to premature
A40976 - disruption of the coating and intragastric release of the
A40977 - drugsecondary to an increase in gastric pH. In eight healthy
A40978 - volunteers, omeprazole pretreatment (20 mg/day for 4 days)
A40979 - didnot affect the bioavailability of salicylate from uncoated
A40980 - aspirin tablets but significantly increased the absorption
A40981 - rate of salicylate from enteric-coated sodium salicylate
A40982 - tablets. The clinical significance of this interaction is
A40983 - unknown. Theoretically, it may increase the risk of gastric
A40984 - adverse effects associated with salicylates.
A40990 - ..
A40991 - Deepblue
A40993 - ..
A40994 - Omeprazole ameliorates aspirin-induced gastroduodenal injury
A40996 - http://deepblue.lib.umich.edu/handle/2027.42/44420
A40998 - Authors: Elta, Grace H.
A40999 - Behler, Elizabeth M.
A41000 - Scheiman, James M.
A41001 - Loeffler, Kathryn M.
A41003 - ..
A41004 - Date: Jan - 1994
A41006 - ..
A41007 - Publisher: Kluwer Academic Publishers-Plenum Publishers;
A41008 - Plenum Publishing Corporation ; Springer
A41009 - Science+Business Media
A41011 - ..
A41012 - Abstract...
A41014 - ..
A41015 - Twenty healthy volunteers were randomized to a double-blind,
A41016 - placebo-controlled, crossover study to determine if
A41017 - omeprazole, 40 mg/day prevents gastroduodenal injury due to
A41018 - two weeks of aspirin administration (650 mg four times a day).
A41020 - ..
A41021 - Fourteen of the 20 subjects had less gastric injury during
A41022 - cotherapy with omeprazole.
A41024 - ..
A41025 - All six with no difference received aspirin plus omeprazole in
A41026 - the first treatment period. Omeprazole significantly decreased
A41027 - aspirin-induced gastric mucosal injury ( P <0.001, Wilcoxon
A41028 - signed-rank test).
A41030 - ..
A41031 - Omeprazole protected 85% of subjects from extensive gastric
A41032 - erosions (often associated with evidence of intraluminal
A41033 - bleeding) or ulceration, whereas 70% of the subjects developed
A41034 - aspirin-induced grades 3 and 4 gastric injury on placebo (P
A41035 - <0.01 by X 2 ).
A41037 - ..
A41038 - No subject taking omeprazole developed duodenal injury of any
A41039 - grade, while 50% taking placebo developed erosions and 15% had
A41040 - ulcer ( P <0.001).
A41042 - ..
A41043 - Medication side effects were mild in the majority of subjects.
A41044 - Heartburn occurred in seven subjects on aspirin and placebo vs
A41045 - one on aspirin and omeprazole ( P <0.01). Salicylate levels
A41046 - were 7.39 +or- 4.72 mg/dl (535 +or- 340 umol/liter) inthe
A41047 - placebo group and 6.95 +or- 4.3 mg/dl (503 +or- 311 umol/liter)
A41048 - in the omeprazole group. We conclude that omeprazole, 40
A41049 - mg/day eliminates duodenal injury and markedly ameliorates
A41050 - gastric injury due to administration of aspirin 2600 mg/day.
A41051 - Omeprazole prophylaxis of NSAID injury deserves further study.
A41056 - ..
A41057 - Omeprazole Reduces Side Effects Aspirin
A41060 - Medicinenet.com
A41062 - ..
A41063 - An Aspirin a Day ... or Not?
A41065 - http://www.medicinenet.com/script/main/art.asp?articlekey=52304
A41067 - ..
A41068 - Published Nov. 7, 2003.
A41070 - ..
A41071 - Aspirin's protective powers may now guard against cancer, too.
A41073 - ..
A41074 - By Gina Shaw
A41075 - WebMD Feature
A41077 - ..
A41078 - Reviewed By Brunilda Nazario
A41080 - ..
A41081 - We've long known that aspirin reduces the risk of heart
A41082 - attacks and strokes while increasing your chances of
A41083 - survivingthem. But now this household drug may protect you in
A41084 - other ways, too.
A41086 - ..
A41087 - Newer evidence indicates that aspirin can also reduce the
A41088 - risk of cancer of the colon, esophagus, stomach, rectum, and
A41089 - prostate. And most recently, the humble aspirin has offered
A41090 - the tantalizing possibility that it may help protect against
A41091 - Alzheimer's disease. With all of these potential benefits,
A41092 - why aren't we dumping aspirin in the water as we do with
A41093 - fluoride?
A41095 - ..
A41096 - "Aspirin is the one drug I would take to a desert island with
A41097 - me," says Mark Fendrick, MD, an associate professor of internal
A41098 - medicine at the University of Michigan Medical Schoolin Ann
A41099 - Arbor. "It costs two cents a day and its benefits are amazing.
A41100 - And if it had no side effects at all, we could give it to
A41101 - everybody." But Dr Fendrick worries that the ever-growing list
A41102 - of diseases and disorders that aspirin and other nonsteroidal
A41103 - anti-inflammatory drugs (NSAIDS) seem to combat drowns out
A41104 - information about the risks of this "wonder" drug.
A41106 - "When you take aspirin, the level of stomach protection is
A41107 - decreased and you're more likely to bleed. Thus, people who
A41108 - take aspirin regularly -- even in a buffered or coated form
A41109 - --will have roughly double the likelihood of having a
A41110 - perforated ulcer or bleeding in the GI tract," explains
A41111 - Fendrick. "Relatively little attention is paid to this
A41112 - problem that kills more people in the U.S. each year than
A41113 - asthma or cervical cancer. What we need to do is focus less
A41114 - attention on finding more things that make aspirin look good,
A41115 - we have plenty of those, and think more about focusing on how
A41116 - to minimize risk."
A41118 - ..
A41119 - So how do you decide whether or not a regular, preventive
A41120 - dose of aspirin is right for you? And if it is, how do you
A41121 - lower the risk of side effects? There's no simple formula,
A41122 - unfortunately. "When you're deciding whether someone should
A41123 - take blood pressure medication or diabetes medication, there
A41124 - are clear cutoffs. In the case of aspirin, the decision is
A41125 - multifactorial and requires a lot of thought," Fendrick tells
A41126 - WebMD.
A41128 - ..
A41129 - Those patients most in need of daily aspirin therapy are easy
A41130 - to identify. If you have a documented personal or family
A41131 - history of heart disease -- including heart attacks, stokes,
A41132 - or angina; if you have diabetes; or if you have multiple
A41133 - risks for the development of heart disease such as have high
A41134 - blood pressure, high cholesterol, or are a smoker, you should
A41135 - most likely take a daily dose of aspirin (but always consult
A41136 - with your physician first). Although the optimal dose of
A41137 - aspirin in prevention of future heart disease is still
A41138 - unclear, doses of 75 milligrams, 100 milligrams, or 325
A41139 - milligrams have been found to be equally effective.
A41141 - ..
A41142 - Studies reviewed by the U.S. Preventive Services Task Force
A41143 - have shown that daily or every-other-day aspirin therapy
A41144 - reduced the risk of coronary heart disease by 28%in persons
A41145 - who had never had a heart attack or stroke, but who were
A41146 - considered high-risk individuals.
A41148 - ..
A41149 - It's also pretty easy to identify those individuals who, in
A41150 - all probability, don't need to take aspirin on a daily basis,
A41151 - Fendrick says. Healthy people in their 20s and 30s, for
A41152 - example, with no cardiac risk factors and no major risk
A41153 - factors for developing the other diseases aspirin can
A41154 - prevent,such as certain cancers, should consider the risks of
A41155 - aspirin therapy to outweigh the benefits.
A41157 - ..
A41158 - But then there's a large group of people that fall into the
A41159 - middle category -- the "probably-should-take" group. For
A41160 - 6. thesepeople, individuals with a strong family history of
A41161 - 7. coloncancer, for example, or dementia, balancing aspirin's
A41162 - potential benefits against its well-documented risks can be a
A41163 - very complicated equation. "The benefits of aspirin for
A41164 - preventing colon cancer, dementia, and heart attacks need to
A41165 - be carefully weighed by a medical professional against the
A41166 - potential for serious complications," says Dr. Fendrick.
A41168 - ..
A41169 - The FDA also provides a fact sheet on deciding whether or not
A41170 - daily aspirin therapy is right for you (it's specific to
A41171 - 8. heartdisease) on its web site.
A41173 - ..
A41174 - More Isn't Always Better
A41176 - ..
A41177 - If you and your doctor decide you should be taking aspirin
A41178 - daily, the next question is, "How much?" In the land of the
A41179 - super-size, is it any wonder that we think that if one pill
A41180 - 9. isgood, two must be better, and if 100 milligrams may help
A41181 - prevent cancer, 200 or 300 milligrams must have twice or
A41182 - 10. threetimes as much cancer-busting power? Stop right there.
A41183 - Medications don't work that way, and especially in the case
A41184 - 11. ofaspirin and other NSAIDs, a little goes a long way.
A41186 - "Low-dose aspirin, a 'baby aspirin' dose of 81 milligrams, is
A41187 - safer and just as effective as the standard adult dose of 325
A41188 - milligrams," says Dr. Fendrick. "When a drug has serious side
A41189 - effects, as aspirin does, you want to give the lowest
A41190 - effective dose. We know now that you don't need 325
A41191 - milligramsin a great majority of circumstances."
A41193 - ..
A41194 - A patient who's having a heart attack right now, for example,
A41195 - should be given a full 325-milligram dose of aspirin, but the
A41196 - person at elevated risk for a heart attack, who's taking
A41197 - daily aspirin as a preventive measure, should stick with the
A41198 - smaller 81-milligram dose.
A41200 - ..
A41201 - Taking low-dose aspirin isn't the only way to maximize the
A41202 - drug's benefits while minimizing its dangers. For people at
A41203 - increased risk of gastrointestinal complications, Fendrick
A41204 - recommends combining any aspirin therapy with a prescribed
A41205 - proton pump inhibitor (PPI) such as Prevacid, Prilosec, or
A41206 - Nexium.
A41208 - ..
A41209 - In a study of people with prior gastrointestinal bleeding,
A41210 - whose doctors felt their chance of having a heart attack was
A41211 - high enough to warrant aspirin therapy despite its
A41212 - gastrointestinal risks, a standard dose of Prevacid reduced
A41213 - their risk of further bleeding by about eight fold.
A41214 - Enteric-coated aspirin or buffered aspirin do not appear to
A41215 - have a reduced risk of bleeding or other adverse events in
A41216 - the stomach.
A41218 - ..
A41219 - Unfortunately, unlike aspirin, these gastroprotective drugs
A41220 - cost a bit more than a couple of cents a day. "If there were
A41221 - no added cost to taking a PPI with a daily aspirin, every
A41222 - aspirin user could benefit from an added level of GI
A41223 - protection," says Fendrick. "But given the current cost of
A41224 - these agents, I only currently recommend gastro protective
A41225 - therapy to those aspirin users who are at increased risk for
A41226 - GI complications."
A41228 - ..
A41229 - That includes people who have had gastrointestinal
A41230 - complications in the past, people who are using high-dose
A41231 - NSAIDs or combining aspirin with other NSAIDs, and people who
A41232 - are taking anticoagulant drugs, among others. "Many older
A41233 - people take aspirin for their heart and then another NSAID
A41234 - fortheir arthritis," says Fendrick. "This is one of those
A41235 - cases in which two rights make a wrong; the aspirin is good,
A41236 - the NSAID is good, but together they can be dangerous."
A41238 - ***************************************************
A41240 - ..
A41241 - SOURCES: Mark Fendrick, MD, associate professor of internal
A41242 - medicine, University of Michigan Medical School. U.S. Food
A41243 - andDrug Administration Center for Drug Evaluation and
A41244 - Research. U.S. Preventive Services Task Force, "Aspirin for
A41245 - the Primary Prevention of Cardiovascular Events," Jan. 14,
A41246 - 2002.
A41248 - c1996-2005 WebMD Inc. All rights reserved.
A41249 - Last Editorial Review: 1/31/2005 7:05:01 AM