CONTACTS
SUBJECTS
VA Medical Records EGA Dilation 110218 Rceived CD Transmittal Medic
2203 -
2203 - ..
2204 - Summary/Objective
2205 -
220501 - Follow up ref SDS 78 0000. ref SDS 74 0000.
220502 -
220503 -
220504 -
220506 - ..
2206 -
2207 -
2208 - Progress
2209 -
220901 - Visited Wilma at ROI Department and received CD with her letter dated
220902 - today on 110520, ref DRT 1 0001, and transmitting VA medical chart
220903 - records for work performing EDG and dilation reported on 110429 1230.
220904 - ref SDS 83 0001
220906 - ..
220907 - CD received from the VA today adds to patient history...
220908 -
220909 - 1. Medical chart received on........... 110520 1537, ref SDS 0 IF7J
220910 - for VA procedure EGD Dilation....... 110429 1230, ref SDS 83 0001
220911 - for VA meeting Cardiology........... 110309 0900, ref SDS 79 OF8F
220912 - for VA Helter Cardiology test....... 110310 0930, ref SDS 80 OF8F
220913 - for VA stress test EKG.............. 110406 1230, ref SDS 81 OF8F
220915 - ..
220916 - 2. Medical chart received on........... 110304 1126, ref SDS 78 125O
220917 - for VA procedure EGD................ 110218 0730, ref SDS 74 SR8M
220919 - ..
220920 - 3. Medical chart received on........... 110114 1309, ref SDS 72 1Y9K
220921 - for VA procedure EGD................ 101210 0930, ref SDS 67 BE44
220922 - for VA meeting Primary Care......... 101223 1030, ref SDS 71 PP8W
220924 - ..
220925 - 4. Medical chart received on........... 101014 1145, ref SDS 52 U455
220926 - for VA procedure on................. 100827 0738, ref SDS 47 0001
220928 - ..
220929 - 5. Medical chart received on........... 100827 1316, ref SDS 48 Y87U
220930 - for VA meeting Primary Care......... 100721 0800, ref SDS 45 PP8W
220932 - ..
220933 - 6. Medical chart received on........... 100312 1119, ref SDS 40 MN4O
220934 - for VA procedure on................. 100305 1000, ref SDS 39 0001
220936 - ..
220937 - VA medical records listed below, ref SDS 0 NX5I, were received today
220938 - transmitted with Wilma's letter, ref DRT 1 0001, and containing VA
220939 - document file saved in patient records....
220940 -
220941 - F:\05\00003\CG\CG\11\05\2001.PDF
220942 -
220943 - ...and in VA records...
220944 -
220945 - F:\05\00441\CG\CG\11\05\2001.PDF
220947 - ..
220948 - Photographs were not received in a separate CD in word.doc files, as
220949 - was done for the procedure on 110218, and reported in the record on
220950 - 110304 1126. ref SDS 78 548L
220952 - ..
220953 - Where are photographs showing findings from EGD, which were presented
220954 - by Doctor Lee post-procedure in recovery, reported on 110429 1230?
220955 - ref SDS 83 MM43 The medical chart says photographs were taken.
220956 - ref DRT 1 0855
220958 - ..
220959 - CD file received today from Wilma shows following....
220960 -
220961 - 1. Wilma's transmittal........................ 110520, ref DRT 1 0001
220963 - ..
220964 - EGD Dilation Evaluate Stricture Dilate Improve Swallowing Nutrition
220965 -
220966 -
220967 - 2. EGD Dilation Procedure..................... 110429, ref DRT 1 0146
220968 -
220969 - 1. Biopsy........Not reported............. 110429,
220971 - ..
220972 - 2. Nurse Pre-proc check list 60439........ 110429, ref DRT 1 PURU
220973 - 1. Vitals............................. 110429, ref DRT 1 PUSW
220974 - 2. NPO solid food 110428 1700......... 110429, ref DRT 1 FC9J
220975 - 3. IV 3 tries not reported............ 110429, ref DRT 1 PVSQ
220976 - 4. Sedation nurse monitor progress.... 110429, ref DRT 1 PVWX
220978 - ..
220979 - Difficulty setting IVs may be important as this problem worsens with
220980 - repeated procedures, based on case study reported, 110429 1230,
220981 - ref SDS 83 UN6K
220983 - ..
220984 - Medical Chart EDG Dilation on 110429 continues...
220985 -
220986 - 3. PACU Record Nursing Recovery....blank.. 110429, ref DRT 1 SE9G
220988 - ..
220989 - 4. Meeting Doctor Lee..................... 110429, ref DRT 1 0491
220990 -
220991 - 1. Consent signature.................. 110429, ref DRT 1 0491
220992 - Dilation proc explained............ 110429, ref DRT 1 PTPY
220994 - ..
220995 - 2. Pre-proc Exam Assmnt 60440......... 110429, ref DRT 1 0264
220996 - 1. Vitals......................... 110429, ref DRT 1 PRSY
220997 - 2. Medications active............. 110429, ref DRT 1 PRWQ
220998 - 3. Sedation plan.................. 110429, ref DRT 1 0457
220999 - 4. Dilation 16.5mm Addendum....... 110429, ref DRT 1 PSRX
221001 - ..
221002 - 3. Procedures......................... 110429, ref DRT 1 PWPS
221003 - 1. Pre-sedation evaluation........ 110429, ref DRT 1 PWPS
221004 - 2. Endoscope equip................ 110429, ref DRT 1 QXSV
221005 - 3. Time Start 1523 End 1546....... 110429, ref DRT 1 0843
221006 - 4. Findings....................... 110429, ref DRT 1 PWTW
221007 - 5. Pictures attached.............. 110429, ref DRT 1 0855
221008 - 6. Dilation 18 mm................. 110429, ref DRT 1 PWVW
221010 - ..
221011 - Addendum later says 16.5 mm............ ref SDS 0 LX5I
221013 - ..
221014 - 7. Injection stricture...3.5mL.... 110429, ref DRT 1 QXXR
221015 - 8. Sedation Med IV................ 110429, ref DRT 1 PWXP
221016 - 9. Kendall signature - no heading. 110429, ref DRT 1 US3I
221018 - ..
221019 - 5. Recovery post-proc nurse note 60251.... 110429, ref DRT 1 0146
221020 - 1. Discharge Instructions............. 110429, ref DRT 1 PPYU,
221021 - 2. Chewing instructions............... 110429, ref DRT 1 0256
221022 - 3. Appt Pendg 3 months dilation....... 110429, ref DRT 1 0256
221023 - 4. Aspirin 81 mg start anytime........ 110429, ref DRT 1 P644
221024 - 5. Omeprazole 40 mg daily............. 110429, ref DRT 1 P644
221026 - ..
221027 - Next meeting in 3 months aligns with planning during the meeting after
221028 - the procedure, reported on 110429 1230, ref SDS 83 LJ6J
221030 - ..
221031 - During the meeting today, asked Wilma about pathology reports on
221032 - biopsies taken during the procedure on 110429?
221034 - ..
221035 - Wilma said there is no record in the medical chart on this case for
221036 - biopsies on 110429.
221038 - ..
221039 - Why no biopsies to assess requirement to continue Omeprazole, and at
221040 - elevated dose, reported in Discharge document for work on 110429 1230.
221041 - ref SDS 83 MM43
221042 -
221044 - ..
221045 - Stress Test Post CABG Cardiology Meetings
221046 - Cardiology Meetings Stress Test Post CABG
221047 -
221048 -
221049 - 3. Cardiology 10501........................... 110415, ref DRT 1 PWYX
221050 -
221051 - 1. Patient profile......................... 110415, ref DRT 1 PXRQ
221052 -
221053 - For some reason this is listed again see below #5.
221054 - ref SDS 0 4P6G
221056 - ..
221057 - 2. Review prior visit 110309............... 110415, ref DRT 1 XH6J
221058 - Cholesterol LDL goal < 70............... 110415, ref DRT 1 XH6J
221060 - ..
221061 - 3. Work Plan............................... 110415, ref DRT 1 4D7H
221062 -
221063 - 1. Aspirin permenantly................. 110415, ref DRT 1 4D7H
221064 - 2. Simvastitan increase 80 mg.......... 110415, ref DRT 1 4D7H
221065 - 3. LDL weight reduce exercise diet..... 110415, ref DRT 1 4D7H
221066 - 4. Holter no evidence afib............. 110415, ref DRT 1 4D7H
221067 - 5. Stress test sets new baseline....... 110415, ref DRT 1 4D7H
221068 - 6. Cardiology follow up after lab July. 110415, ref DRT 1 4D7H
221070 - ..
221071 - 4. Findings/Discussion..................... 110415, ref DRT 1 IJ8O
221072 -
221073 - 1. Doing well post-CABG 4x............. 110415, ref DRT 1 IJ8O
221074 - 2. Aspirin discuss with Doctor Lee..... 110415, ref DRT 1 IJ8O
221075 - 3. Cholesterol LIPID lab in June....... 110415, ref DRT 1 IJ8O
221077 - ..
221078 - 5. Patient profile listed again............ 110415, ref DRT 1 DV9O
221079 -
221080 - Seems to repeat above list. ref SDS 0 C39F
221082 - ..
221083 - 6. Medications active...................... 110415, ref DRT 1 NY3H
221085 - ..
221086 - 7. Examination............................. 110415, ref DRT 1 Z44I
221088 - ..
221089 - 8. Labs listed for......................... 110415, ref DRT 1 X55L
221090 -
221091 - Date Spec Chol Trglyc HDL LDL-CHO
221092 - 1. 101207 0917 PLASM 151 41 47 96
221093 - 100721 0854 PLASM 261 87 35 209
221095 - ..
221096 - Date Spec Glucose BUN CREAT NA K CL
221097 - 2. 101207 0917 PLASM 102 8 0.85 137 3.8 104
221098 - 100721 0854 PLASM 117 12 0.89 139 3.9 106
221100 - ..
221101 - Date Spec WBC HGB HTC MCV MCHC PLT
221102 - 3. 101207 0917 Blood 6.7 14.4 43.3 90.7 33.1 310
221103 - 100721 0854 Blood 7.3 14.9 44.0 91.2 33.8 344
221104 -
221106 - ..
221107 - 9. EKG date 091117 1558.................... 110415, ref DRT 1 H96N
221108 -
221109 -
221111 - ..
221112 - 4. Treadmill Stress Test ECG/EKG............... 110406, ref DRT 1 QH7G
221114 - ..
221115 - This part of the record is unclear, doesn't say treadmill stress test;
221116 - content seems to relate details of EKG and diagnostics recorded during
221117 - treadmill stress test on 110406 1230. ref SDS 81 OF8F
221119 - ..
221120 - Medical Chart Stress Test 110406 continues...
221121 -
221122 - 1. Auto Instrument Diagnosis............... 110406, ref DRT 1 ZB7N
221123 -
221124 - Normal sinus rhythm
221125 - Nonspecific T wave abnormality
221126 - Abnormal ECG
221127 - When compared with ECG of 02-NOV-2009 07:43,
221128 - Nonspecific T wave abnormality no longer evident in Inferior leads
221129 - T wave inversion no longer evident in Anterior leads
221130 - Confirmed by URSELL MD, SHANTHA (703) on 11/18/2009 11:51:16 AM
221132 - ..
221133 - This part of the record is unclear; seems to relate historical data,
221134 - but comparison with work on 091102, and 091118, with ECG results on
221135 - 110406 is unclear. There was an EKG test to evaluate for discharge at
221136 - VA Med Center in San Francisco on 091102 0642. ref SDS 18 4Q3H There
221137 - is no actual comparison in this record, and the data for the test on
221138 - 091102, is not evident in the record nor the VA medical chart.
221140 - ..
221141 - There was an EKG at VA Clinic in Martinez on 091117, to prepare for
221142 - meeting with CT team at VA Med Center in San Francisco, and to
221143 - evaluate post-CABG recovery 2 weeks after discharge. ref SDS 21 UH7O
221145 - ..
221146 - Treadmill stress test on 110406, was ordered by Doctor Egan to compare
221147 - with the same test on 090916, cited in the record meeting with the
221148 - doctor on 091002 0900, ref SDS 10 7S8M, and as reported on 110309
221149 - 0900. ref SDS 79 OF8F
221151 - ..
221152 - Recent Treadmill stress test on 110406 shows significant improvement
221153 - compared with the same test on 090916, and reported by Doctor Egan in
221154 - in the meeting on 091002, as showing 11 nodes failed, ref SDS 10 1W5I,
221155 - and confirmed in the medical chart, ref SDS 10 7S8M, assessment
221156 - finding triple vessel disease (TVD), for meeting at the VA on 091002,
221157 - ref SDS 10 8X3G, that led to CABG surgery on 091022.
221159 - ..
221160 - Medical Chart Stress Test 110406 continues...
221161 -
221162 - 2. Auto Instrument Data?................... 110406, ref DRT 1 EO8N
221163 -
221164 - 3. ETT Comments............................ 110406, ref DRT 1 5P4I
221165 - BRUCE protocol 10 min
221166 - Work level Max.METS: 11.70.............. 110406, ref DRT 1 5P4I
221167 - Heart rate 71 to 160 bpm................ 110406, ref DRT 1 NX9N
221168 - 103% max age-predicted heart rate....... 110406, ref DRT 1 PYWQ
221169 - BP 120/86 to 160/82 mmHg................ 110406, ref DRT 1 PYWT
221170 - Completed 10 min Bruce Protocol......... 110406, ref DRT 1 NX4Y
221171 - PAC frequent peak exercise.............. 110406, ref DRT 1 I75J
221173 - ..
221174 - Research seems to indicate PAC relatively benign condition does not
221175 - require care...
221176 -
221177 - Wikipedia
221179 - ..
221180 - Premature Atrial Contractions (PAC)
221181 - Heart Palpitations PAC Benign Arrhythmia
221182 -
221183 -
221184 - http://en.wikipedia.org/wiki/Premature_atrial_contraction
221186 - ..
221187 - Premature atrial contractions (PACs) are one type
221188 - of premature heartbeat, irregular heart beat, or
221189 - benign arrhythmia. These ectopic beats occur in
221190 - the upper two chambers of the heart, called the
221191 - atria. These beats are not as serious as premature
221192 - ventricular contractions (PVCs) and usually require
221193 - no medical care. Individuals with this condition
221194 - usually report feeling that their heart "stops" or
221195 - misses a beat. Like PVCs, PACs are called heart
221196 - palpitations.
221198 - ..
221199 - Prognosis
221201 - ..
221202 - In rare cases, a PAC, like a PVC, can trigger a
221203 - more serious arrhythmia such as an atrial flutter
221204 - or atrial fibrillation. This is seldom seen in a
221205 - healthy heart but if it does happen medical
221206 - attention should be sought to see what caused the
221207 - problem and what steps can be taken to fix it.
221208 - Unlike PVCs, PACs generally do not compromise the
221209 - hemodynamic system because the conduction
221210 - throughout is via the AV node and the ventricles
221211 - of the heart are activated in a normal sequence.
221213 - ..
221214 - Medical Chart Stress Test 110406 continues...
221215 -
221216 - 4. No ST-T changes with exercise....... 110406, ref DRT 1 FU5M
221217 -
221218 - 5. Myoview study pending............... 110406, ref DRT 1 PYYP
221220 - ..
221221 - Status of pending Myoview study from stress test on 110406?
221223 - ..
221224 - 6. Abnormal atrial arrhythmia exercise. 110406, ref DRT 1 PYYS
221226 - ..
221227 - Doctor Egan cited "abnormal" test findings, in the meeting on 110406,
221228 - and seemed to indicate this is not medically siginficant. 110415 0900,
221229 - ref SDS 82 LY3H
221230 -
221231 - [On 110817 1030 no "Myview" study was performed, so
221232 - no report is pending. ref SDS 84 PM6N
221233 -
221234 -
221236 - ..
221237 - Holter Heart Rate Test Post CABG Cardiology Meetings
221238 - Cardiology Holter Heart Rate Test Post CABG Meetings
221239 - Coronary Heart Function Significantly Stronger Post CABG 4x
221240 -
221241 -
221242 - 5. Holter cardiology test...................... 110310, ref DRT 1 356O
221243 - 1. Raeason for study: PALPITATIONS......... 110310, ref DRT 1 FX4F
221244 - 2. Tape quality good....................... 110310, ref DRT 1 NZ4L
221245 - 3. Heart rate - average 69................. 110310, ref DRT 1 MI5L
221246 - 4. Heart rate - max 152 1123............... 110310, ref DRT 1 MI5L
221247 - 5. Heart rate - min 42 0520............... 110310, ref DRT 1 MI5L
221249 - ..
221250 - On 110310 hiked 2 laps, about 5.5 miles moderate time, reported in
221251 - case study on 101010 0744. ref SDS 50 BT4L "Max heart" rate 152 is
221252 - significantly better than pre-CABG. During years before surgery on
221253 - 091022, heart rate always exceeded 200 hiking hills at Lafayette
221254 - Reservoir. Getting to only max 152 may indicate stronger coronary
221255 - function acheived with CABG 4x, performed on 091022 0700. ref SDS 12
221256 - PQWU
221258 - ..
221259 - Minimum rate 42 at time 0520, further indicates strong heart function
221260 - and aligns with patient history in case study on 101010 0744.
221261 - ref SDS 50 3H6J
221263 - ..
221264 - Medical Chart Cardiology Meeting 110415 continues...
221265 -
221266 - 4. INTERPRETATION:
221267 -
221268 - 1. Predominant rhythm sinus............ 110415, ref DRT 1 206W
221269 - Range 42-152, average 69............ 110415, ref DRT 1 206W,
221270 - Maximum R-R=1.84 seconds............ 110415, ref DRT 1 206W,
221272 - ..
221273 - 2. Beats tachycardia 10%,
221274 - bradycardia 30%..................... 110415, ref DRT 1 206W,
221276 - ..
221277 - 3. Isolated PVC's, no couplets or runs. 110415, ref DRT 1 206W,
221278 - 4. PAC's with couplets, no runs........ 110415, ref DRT 1 206W,
221280 - ..
221281 - This "interpretation" section and also assessment and plan, indicate
221282 - the medical chart received from VA has commingled events, and now
221283 - shifts back from the Helter heart rate test on 110310, to continue
221284 - Doctor Egan's Progress Notes for the meeting on 110415, per above.
221285 - ref SDS 0 C39F
221287 - ..
221288 - Medical Chart Cardiology Meeting 110415 continues...
221289 -
221290 - 5. ASSESSMENT:
221291 -
221292 - 1. CAD,S/P CABG, asymptomatic.
221293 - Significant improvement in TM
221294 - performance post- CABG.............. 110415, ref DRT 1 PY4K,
221296 - ..
221297 - Asymptomatic commonly describes having no symptoms in this case of
221298 - coronary artery disease (CAD), which aligns with express finding of
221299 - significant improvement in the treadmill stress test, ref SDS 0 PY4K,
221300 - reflects comparing with prior test on 091002, per above. ref SDS 0
221301 - WT8G
221303 - ..
221304 - 2. Hyperlipidemia, target LDL < 70..... 110415, ref DRT 1 PY4K,
221306 - ..
221307 - 3. PACs with exercise on ETT 4/6/11,
221308 - no treatment mandated............... 110415, ref DRT 1 PY4K,
221309 -
221311 - ..
221312 - 6. PLAN:
221313 -
221314 - 1. Current medications reconciled, no
221315 - changes made........................ 110415, ref DRT 1 F55H,
221317 - ..
221318 - 2. To discuss asa use with Dr. Lee..... 110415, ref DRT 1 F55H,
221320 - ..
221321 - 3. F/U Dr Sandhu lipids 1-2 months..... 110415, ref DRT 1 F55H,
221323 - ..
221324 - 4. RTC 4 months........................ 110415, ref DRT 1 F55H,
221326 - ..
221327 - 7. Clinical Reminders...................... 110415, ref DRT 1 G05O,
221328 - 1. Consider Aspirin for risk of MI:
221329 - 2. Aspirin not used or prescribed for this patient:
221330 - 3. Reason -Patient declines despite risk
221331 -
221337 -
221339 - ..
221340 - 6. 04/29/2011 ADDENDUM STATUS: COMPLETED............ ref DRT 1 OK3G
221341 - Discussed use of ASA with patient.
221343 - ..
221344 - I believe he was mistaking the reports of adverse interaction
221345 - between omeprazole and clopidogrel.
221347 - ..
221348 - Doctor Lee cites meeting with patient during EGD Dilation procedure on
221349 - 110429 1230. ref SDS 83 SS8I
221351 - ..
221352 - Doctor Sandhu cites risks of aspirin in the record on 101223 1030.
221353 - ref SDS 71 454F
221355 - ..
221356 - Medical Chart addendum for 110429 Doctor Lee continues...
221357 -
221358 - I have no objection to ASA use for cardioprotection in this
221359 - patient, and I suggested that he start 81mg/day.
221361 - ..
221362 - Doctor Lee addresses Cardiology work plan reported by Doctor Egan
221363 - during the meeting on 110415, as shown in medical chart received
221364 - today, listed above. ref SDS 0 R87H
221366 - ..
221367 - Not clear if Doctor Lee issues addendum to Doctor Egan's report on
221368 - 110415, or to his own report o 110429.
221369 -
221370 - /es/ RANDALL E LEE, MD...................... ref DRT 1 UL4H
221371 - STAFF PHYSICIAN, GASTROENTEROLOGY
221372 - Signed: 04/29/2011 17:09
221374 - ..
221375 - 7. Receipt Acknowledged By:.................... ref DRT 1 G14W
221376 - 05/02/2011 07:57 /es/ Gisela Brunskill, NP
221377 - Nurse Practitioner, Cardiology
221378 - for JAMES EGAN
221379 -
221380 -
221381 -
221382 -
221383 -
221384 -
221385 -
221386 -
221387 -
221388 -
221389 -
221390 -
221391 -
221392 -
221393 -
221394 -