CONTACTS 

SUBJECTS
Examination Cholesterol 40% Improvement Heart Disease Risk Declines

2803 -
2803 -    ..
2804 - Summary/Objective
2805 -
280501 - Follow up ref SDS 41 0000. ref SDS 36 0000.
280502 -
280503 -
280504 -
280506 -  ..
2806 -
2807 -
2808 - Progess
2809 -
280901 - Examination Doctor Prepared Reviewed SDS Record Patient History
280902 -
280903 - Follow up ref SDS 41 PP8W.
280904 -
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
280929 -
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.
280939 -
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
280958 -
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
280978 -
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.
280990 -
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
281010 -
281012 -  ..
281013 - Simvastatin 40 MG Patient History Consistent Medication Effective
281014 -
281015 - Follow up ref SDS 41 RP4F.
281016 -
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
281054 -
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
281064 -
281066 -  ..
281067 - Cholesterol Declines Reduces Risk Factor Heart Disease
281068 -
281069 - Follow up ref SDS 56 E19L.
281070 -
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..
281079 -
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.
281128 -
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
281164 -
281165 -
281166 -
281167 -
2812 -

SUBJECTS
Diabetes Risk Declines Gluecose 102 Reduced from 117 Blood Sugar Fal

4503 -
450401 -  ..
450402 - Diabetes Risk Factor Glucose Lab Tests Declines
450403 - Glucose Blood Sugar Falls Below Diabetes Risk Level
450404 -
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...
450408 -
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
450413 -
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
450439 -
450440 -
450441 -
4505 -

SUBJECTS
Default Null Subject Account for Blank Record

4603 -
460401 -  ..
460402 - Afib Recent Increase Episodes
460403 -
460404 - Follow up ref SDS 52 PPWU.
460405 -
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
460416 -
460417 -            [On 110309 0900 Doctor Egan ordered heart monitoring test
460418 -            to assess possible afib exosure. ref SDS 66 MY9V
460419 -
460420 -
460421 -
4605 -

SUBJECTS
Medical Chart Progress Notes Primary Care Meeting

6103 -
610401 -  ..
610402 - VA Medical Chart for Meeting Today December 23, 2010
610403 -
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
610424 -
610425 -
610426 -
6105 -

SUBJECTS
Afflictions List Case Management Medical Chart Progress Notes Primar

8303 -
830401 -  ..
830402 - VA medical chart continues...
830403 -
830404 -    3.  Computerized Problem List is the source for the following:
830405 -
830406 -             1.  Esophageal Stricture 03/05/10 LEE,RANDALL E.......
830407 -
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...
830426 -
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
830473 -
830474 -
8305 -

SUBJECTS
Medications Active List VA Medical Chart Progress Notes Primary Care

A103 -
A10401 -         ..
A10402 -    4.  Active Outpatient Medications (excluding Supplies):
A10404 -         ..
A10405 -        Active Outpatient Medications                                 Status
A10406 -        =========================================================================
A10407 -
A10408 -             1.  OMEPRAZOLE 20MG EC CAP TAKE TWO CAPSULES BY MOUTH
A10409 -                 ACTIVE
A10410 -
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.
A10421 -
A10422 -
A10423 -
A105 -

SUBJECTS
Default Null Subject Account for Blank Record

A203 -
A20401 -         ..
A20402 -    5.  Physical Examination...
A20403 -
A20404 -        1.  Most recent vitals:
A20405 -
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
A20437 -
A20438 -
A205 -

SUBJECTS
Default Null Subject Account for Blank Record

A303 -
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
A30427 -
A30428 -
A30429 -
A305 -

SUBJECTS
Default Null Subject Account for Blank Record

A403 -
A40401 -         ..
A40402 -        ASSESSMENT AND PLAN:
A40403 -
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
A40418 -
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
A40424 -
A40426 -         ..
A40427 -        Clinical Reminders:
A40428 -
A40429 -             1.  Influenza Vaccine Sept 10 - Apr 11:
A40430 -
A40431 -                 Influenza Immunization ordered.......... ref SDS 0 OR6H
A40432 -
A40434 -  ..
A40435 - Myocardial Infarction Heart Disease Risks Reduced Aspirin
A40436 - Aspirin Avoid Heart Attack Side Effects Ulcers Bleeding
A40437 -
A40438 -
A40439 -             2.  Consider Aspirin for risk of MI:
A40440 -
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).
A40450 -
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
A40463 -
A40464 -
A40469 -
A40470 -
A40472 -  ..
A405 -
A406 -
A407 - 1430
A408 -
A40801 - Aspirin Risks Gastric Ulcers Internal Bleeding Research
A40802 -
A40803 - After the meeting, research on the Internet indicates "myocardial
A40804 - infarction (MI) is another name for heart attack....
A40805 -
A40806 -        Wikipedia says in part...
A40808 -         ..
A40809 -        Myocardial infarction
A40810 -
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
A40872 -
A40873 -
A40874 -        Wikipedia says in part...
A40876 -         ..
A40877 -        Aspirin (acetylsalicylic acid)
A40878 -
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.[2]  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.[3]
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,[69] and a different,
A40902 -        aggregate study of 2,930 patients found 28% to be
A40903 -        resistant.[70]  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
A40920 -
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.
A40936 -
A40938 -  ..
A40939 - Aspirin Conflicts Low Dose Omeprazole Studies Conflicting Results
A40940 - Omeprazole Theoretically Increase Risk Adverse Gastric Effects Aspirin
A40941 -
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
A40945 -
A40946 -        Drugs.com
A40948 -         ..
A40949 -        Drug interactions between aspirin and Prilosec
A40950 -
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.
A40985 -
A40986 -
A40987 -
A40988 -
A40990 -         ..
A40991 -        Deepblue
A40993 -         ..
A40994 -        Omeprazole ameliorates aspirin-induced gastroduodenal injury
A40995 -
A40996 -              http://deepblue.lib.umich.edu/handle/2027.42/44420
A40997 -
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.
A41052 -
A41053 -
A41054 -
A41056 -  ..
A41057 - Omeprazole Reduces Side Effects Aspirin
A41058 -
A41059 -
A41060 -        Medicinenet.com
A41062 -         ..
A41063 -        An Aspirin a Day ... or Not?
A41064 -
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.
A41105 -
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.
A41185 -
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."
A41237 -
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.
A41247 -
A41248 -        c1996-2005 WebMD Inc. All rights reserved.
A41249 -        Last Editorial Review: 1/31/2005 7:05:01 AM
A41250 -
A41251 -
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A413 -