CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 17 0000. ref SDS 15 0000.
040502 -
040503 -
040504 -
040505 -
040507 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Letter to medical team says...
040902 -
040903 - 1. Subject: LDL 200, Revise Work Plan Welch - SS - 0144
040904 - Date: Mon, 28 Nov 2011 02:22:25 -0800
040913 - ..
040914 - 2. Pleased that Total bilirubin [2] dropped to 1.3 in recent lab
040915 - on 111117 (Nov 17, 2011), after ending treatment with
040916 - simvastatin. ref SDS 17 KK9M [...total bilirubin explained as
040917 - affecting liver function, reported on 111013 1404. ref SDS 14
040918 - LC8J...]
040920 - ..
040921 - 3. Generally, feel very fit with no symptoms of pain or duress;
040922 - blood pressure may be an issue (see below).... ref SDS 0 EA6S
040924 - ..
040925 - 4. Lab on 111117 tested LDL 200, ref SDS 17 IM9N, increased from
040926 - 106 for prior lab on 110727 (July 27, 2011), ref SDS 10 E19L,
040927 - rather than decline below 70.
040929 - ..
040930 - On 111117 1415 research indicates lipid cholesterol tests unreliable
040931 - since 1988, ref SDS 17 PUPU; article published in 2011 by the National
040932 - Health Institute warns testing for LDL cholesterol is still "fraught
040933 - with error." ref SDS 17 N29Y
040935 - ..
040936 - On 111125 2028 CNN television broadcast analysis saying measuring LDL
040937 - cholesterol is not effective for evaluating coronary health risks,
040938 - ref SDS 20 LJ7F, recommends measuring small particle LDL cholesterol
040939 - using coronary calcium san techology. ref SDS 20 LW75
040941 - ..
040942 - Letter to VA continues...
040943 -
040944 - 5. Work plan on 110817 (August 17, 2011), prescribing rosuvastatin
040945 - 10 mg may require increase to 20 mg. ref SDS 11 DG36 Recently,
040946 - ordered refill and so have 20 mg tablets on hand. [...refill
040947 - reported on 111121 1727, ref SDS 18 YU7M, and prescription
040948 - refill for rosuvastatin received from VA on 111125 1338.
040949 - ref SDS 19 Y45J...]
040950 -
040951 - [On 120117 0010 ordered refill rosuvastatin 20 mg.
040952 - ref SDS 22 Y57H
040954 - ..
040955 - 6. Please advise on increasing dose from 10 mg to rosuvastatin 20
040956 - mg?
040957 -
040958 - [...below on 111128 0202 at 1648 letter from the VA advises
040959 - that VA management instructions prevent responding to
040960 - patient communications transmitted with email. ref SDS 0
040961 - E66F
040963 - ..
040964 - [...below on 111128 0202 at 1738 notify medical team will
040965 - implement work plan on 110817 to lower LDL < 70.
040966 - ref SDS 0 AF3H
040968 - ..
040969 - 7. Last year, Doctor Sandhu prescribed simvastatin 20 mg [...
040970 - reported on 100104 0930. ref SDS 4 WR4H, continuing prior
040971 - prescription on 091104 0718. ref SDS 2 IA4H, and which was
040972 - continued a month later on 091220 0527. ref SDS 3 OX5X...] and
040973 - LDL increased [...reported on 100721 0800. ref SDS 5 E19L...],
040974 - as it did in the recent lab [...on 111117 1415. ref SDS 17
040975 - IM9N...]. In [July], he increased the dose to simvastatin 40
040976 - mg [...reported on 100721 0800. ref SDS 5 RP4F...], and my lab
040977 - fell to LDL 96. [...reported on 101207 0906. ref SDS 7 E19L...]
040978 -
040979 -
0410 -
SUBJECTS
Default Null Subject Account for Blank Record
0503 -
050401 - ..
050402 - 8. About that same time [...on 101126...] myopathy in left
050403 - shoulder occurred [...shown in case study on 101010 0744.
050404 - ref SDS 6 6E5I...], and increased through August of this year,
050405 - when you changed prescription to rosuvastatin 10 mg [...
050406 - reported on 110817 1030. ref SDS 11 DG36...], begun on 110823
050407 - ...[reported on 110823 1312. ref SDS 12 UY5G...]. A few weeks
050408 - later, strength and range of motion without pain increased in
050409 - the left shoulder [...reported on 110909 in case study on
050410 - 101010 0744. ref SDS 6 VS8R...]. I recently reported to Doctor
050411 - Sandhu that myopathy has significantly subsided [...reported on
050412 - 111018 0800. ref SDS 16 NP5G...]; can now do push ups again.
050414 - ..
050415 - 9. Other factors that may have influenced unfavorable lab on
050416 - 111117 -- hiking decreased from 40 to 2 miles per week, the
050417 - past 2 months [...shown in case study on 101010 0744.
050418 - ref SDS 6 9C8K...], while doing case management in Southern
050419 - California. I also missed an entire week of treatment the week
050420 - before the lab was performed 111117, due to an error in
050421 - packing, all as shown in patient history case study on 101010.
050422 - ref SDS 6 UT6K
050423 -
050424 -
0505 -
SUBJECTS
Default Null Subject Account for Blank Record
0603 -
060401 - ..
060402 - 10. Patient history also shows what seems a marked increase in
060403 - blood pressure the past 2 - 4 weeks.[...beginning on 111031,
060404 - shown in case study on 101010 0744. ref SDS 6 9C8K...]. Until
060405 - recently, BP has averaged roughly 115 75 for about a year. The
060406 - past few weeks it seems to have jumped to 135+ 75, there was
060407 - one reading of 150. The past few days BP has trended down
060408 - again, with resumption of normal hiking, but still well above
060409 - 115. Seems like this could reflect blockage of blood flow that
060410 - aligns with rise of LDL.
060412 - ..
060413 - After sending this letter, review of patient history shows research
060414 - indicating Omeprazole causes high blood pressure, reported on 101218
060415 - 1642. ref SDS 8 KI6G
060416 -
060417 - [...below on 111128 0202 at 1648 letter from the VA
060418 - recommends calling advice nurse, drive to the VA for
060419 - Same-Day-Clinic consultaton, or wait and drive to VA for
060420 - scheduled visits. ref SDS 0 KF6L
060422 - ..
060423 - [On 111201 0928 spreadsheet analysis shows average blood
060424 - pressure in the past month has increased 10% compared to
060425 - the prior year from 120 68 55 to 132 74 56. ref SDS 21 GX7N
060427 - ..
060428 - [On 101010 0744 case study on exercise and medications
060429 - shows Omeprazole paused today (111201). ref SDS 6 734L
060431 - ..
060432 - 11. There have been no symptoms of pain, shortness of breath,
060433 - dizziness [...loss of energy - energy and pulmonary function
060434 - seem stronger...] Time hiking 11 mile route and shorter 3 - 6
060435 - mile routes have fallen recently from hiking faster, as shown
060436 - in the study. There has been no chest pain that signaled prior
060437 - coronary issues under similar circumstances. [...reported on
060438 - 090908 1130. ref SDS 1 MY4N...]
060440 - ..
060441 - 12. Should another stress test be considered?
060443 - ..
060444 - 13. Rosuvastatin may have caused side effects of increased
060445 - frequency urinating, and difficulty sleeping. The sleeping
060446 - issue probably predates rosuvastatin. Urination problem seems
060447 - minor, assuming dose increase does not compound the issue.
060449 - ..
060450 - 14. Please advise on increasing the dose to rosuvastatin 20 mg, or
060451 - if some other line of care should be considered.
060452 -
060453 - [...below on 111128 0202 at 1648 letter advises VA
060454 - instructions prevent responding to patient communications
060455 - transmitted with email. ref SDS 0 E66F
060457 - ..
060458 - [...below on 111128 0202 at 1738 notify medical team will
060459 - implement work plan on 110817 to lower LDL < 70.
060460 - ref SDS 0 AF3H
060462 - ..
060463 - 15. Doctor Sandhu has another full lab scheduled in 3 months, so we
060464 - can check for hopefully another turn around in the LDL number.
060466 - ..
060467 - 16. Please advise on meeting to discuss lab results and next steps.
060468 -
060474 -
060475 -
060477 - ..
0605 -
0606 -
0607 - 1648
0608 -
060801 - Received letter from Doctor Egan saying...
060802 -
060803 - 1. Subject: RE: LDL 200, Revise Work Plan Welch - SS - 0144
060804 - Date: Mon, 28 Nov 2011 15:02:39 -0800
060811 - ..
060812 - 2. E-mail is not considered secure and we are instructed not to
060813 - transmit or discuss patient information in this format. [...
060814 - responding to letter on increasing medication to rosuvastatin
060815 - 20 mg, per above. ref SDS 0 NP5G...]
060817 - ..
060818 - 3. If you have immediate concerns you should call the Advice Nurse
060819 - or come in to same-day clinic. Otherwise I will try to cover
060820 - all contingencies during our scheduled visits.
060822 - ..
060823 - Telling the patient to call an Advice Nurse conflicts with the record
060824 - notifying the VA of patient history on rising LDL cholesterol, per
060825 - above, ref SDS 0 EA4V, and possible correlation with rising blood
060826 - pressure. ref SDS 0 EA6S VA duty to provide standard of care requires
060827 - taking appropriate action based on best evidence. In this case, the
060828 - VA has possession of the evidence showing cholesterol lab LDL 200.
060829 -
060830 - [...below on 111128 0202 at 1738 notify medical team will
060831 - implement work plan on 110817 to lower LDL < 70.
060832 - ref SDS 0 AF3H
060833 -
060836 -
060837 -
060839 - ..
0609 -
0610 -
0611 - 1738
0612 -
061201 - Letter to Doctor Egan at Va says...
061202 -
061203 - 1. Subject: Re: LDL 200, Revise Work Plan Welch - SS - 0144
061204 - Date: Mon, 28 Nov 2011 17:44:14 -0800
061211 - ..
061212 - 2. Thanks for your letter today, [...per above, ref SDS 0 O94K,
061213 - responding to letter this morning on increasing medication to
061214 - rosuvastatin 20 mg, in order to correct unfavorable lab showing
061215 - LDL 200, and by reducing this to LDL < 70, per above.
061216 - ref SDS 0 EA4V...]
061218 - ..
061219 - 3. Will implement work plan on 110817, to lower LDL < 70 in next 3
061220 - months. ref SDS 11 DG36 Hope for the best on side effects.
061221 - Please let me know if we need to meet.
061222 -
061228 -
061229 -
061230 -
061231 -
061232 -
061233 -
061234 -
0613 -