CONTACTS
SUBJECTS
VA Cardiology Meeting Examination Object Receive Written Communicati
1603 -
1603 - ..
1604 - Summary/Objective
1605 -
160501 - Follow up ref SDS 18 0000. ref SDS 17 0000.
160502 -
160503 -
160504 - [On 120514 1300 hyperlipidemia LDL 94 declined
160505 - significantly after increasing Rosuvastatin 20 mg and
160506 - increasing hiking. ref SDS 30 X45G
160507 -
160508 -
160510 - ..
1606 -
1607 -
1608 - Progress
1609 -
160901 - Agenda for meeting with Doctor Egan is from prior meeting on 110817
160902 - 1030, ref SDS 18 JE5I, and previously on 110415 0900. ref SDS 10 OF8F
160903 -
160905 - ..
160906 - VA Objects Receiving Written Communication
160907 -
160908 - On 110818 1051 letter to VA reports excellent meeting with Cardiology.
160909 - ref SDS 19 XA5I
160911 - ..
160912 - On 111128 0202 another letter to VA reports lab results and
160913 - implementing work plan to increase Rosuvastatin 20 mg from 10 mg,
160914 - ref SDS 26 EA4V, discussed with the doctor during meeting at the VA
160915 - on, ref SDS 18 JQ54
160917 - ..
160918 - Initially, Doctor Egan objected to the letter on 111128. ref SDS 26
160919 - NP5G The doctor was adament today that all communication with
160920 - Cardiology Department should be conversation in the examination room.
160921 - No writings can be submitted to confirm, clarify, correct, supplement,
160922 - nor commend VA work, including documents, discussion, progress notes,
160923 - and test findings and analysis.
160925 - ..
160926 - [On 120222 1427 received medical chart for work today.
160927 - ref SDS 28 KW5G
160929 - ..
160930 - [On 121206 0900 the doctor reviewed and did not further
160931 - complain nor object to letter with agenda for meeting and
160932 - associated links to analyze lab review. ref SDS 33 TS7I
160933 -
160934 -
160935 -
160936 -
1610 -
SUBJECTS
VA Cardiology Examination Prescribe Hiking 11 Miles Per Day 50 Miles
2903 -
290401 - ..
290402 - Hiking Strengthens Coronary Pulmonary System Reduces Blood Pressure
290403 -
290404 - Follow up ref SDS 18 EL9F.
290405 -
290406 - 1. Review patient history implementing VA guidance to hike for
290407 - recovering from CABG, reported on 101010 0744. ref SDS 5
290408 - 45SU
290410 - ..
290411 - Doctor Egan asked about patient continuing exercise to recover from
290412 - heart surgery and reducing risk factors for CAD patients?
290414 - ..
290415 - Reported hiking increased from August through December 2011; The
290416 - doctor feels that hiking over 180 miles in December, shown in case
290417 - study on 101010 0744, ref SDS 5 1Z4M, reflects strong motivation to
290418 - compliment medical care to maintain good health, and in particular
290419 - lower LDL < 70, discussed during the prior meeting on 110817 1030.
290420 - ref SDS 18 DG36, and originally presented on 110309 0900. ref SDS 8
290421 - ZM98
290423 - ..
290424 - Hiking declined in January to 77 miles, due to weather and mental
290425 - fatigue, and so far in February have hiked only 6 miles, as further
290426 - shown in case study on 101010 0744. ref SDS 5 225O Plan to begin
290427 - hiking again when the weather turns warmer in the spring.
290428 -
290429 - [On 120514 1300 hyperlipidemia LDL 94 declined
290430 - significantly after increasing Rosuvastatin 20 mg and
290431 - increasing hiking. ref SDS 30 X45G
290432 -
290433 -
290434 -
290435 -
290436 -
2905 -
SUBJECTS
VA Cardiology Examination Aspirin Not Prescribed Plateletts Mid Rang
4203 -
420401 - ..
420402 - Aspirin Not Required Platelets at Mid-Range Normal BP and Pulse
420403 -
420404 - Follow up ref SDS 18 IY5O.
420405 -
420406 - There was no discussion of aspirin therapy today following up drop in
420407 - platelets 286 to mid-range for the lab on 110727 1238. ref SDS 13 SL4F
420409 - ..
420410 - In the meeting on 110817, Doctor Egan explained platelets elevated
420411 - above mid-range recorded in this case during 2009-2010 can cause blood
420412 - clots that present severe health risks, especially for patients with
420413 - high blood pressure and heart rate and suffering CAD following heart
420414 - surgery (CABG - 4x), as occurred on 091022 0700. ref SDS 2 PQWU At
420415 - that time on 110817, the doctor further advised that the VA prescribes
420416 - aspirin for CAD patients to thin the blood that helps prevent blood
420417 - clots. ref SDS 18 IY5O
420419 - ..
420420 - Platelets were not included in the recent lab on 120209. ref SDS 27
420421 - KK9M
420423 - ..
420424 - Patient history on platelets...
420425 -
420426 - Collection DT PLT Range 130 - 400
420427 - 02/09/2012 11:18 --- ............... ref SDS 27 KK9M
420428 - 11/17/2011 14:27 --- ............... ref SDS 24 KK9M
420429 - 07/27/2011 12:58 286 ............... ref SDS 13 SL4F
420430 - 12/07/2010 09:17 310 ............... ref SDS 6 SL4F
420431 - 07/21/2010 08:54 344 ............... ref SDS 4 OT69
420432 - 08/13/2009 15:09 350 ............... ref SDS 1 075H
420434 - ..
420435 - Platelets at mid-range presents low risk for patients not suffering
420436 - high blood pressure and elevated heart rate, as shown in patient
420437 - history in case study on 101010 0744. ref SDS 5 NQ9F
420438 -
420439 - [On 120509 1108 plateletts 288 steady at mid-range, which
420440 - avoids risk of blood clots that otherwise require aspirin
420441 - treatment. ref SDS 29 RP4N
420443 - ..
420444 - [On 121130 0846 plateletts 254 fall below mid-range,
420445 - ref SDS 32 RP4N; hiking 700 miles and 20 pound weight loss
420446 - over 3 months avoids risk of blood clots without aspirin
420447 - treatment. ref SDS 32 868N
420449 - ..
420450 - [On 140430 0900 discussed concern hiking 11 miles causing
420451 - blood clots due to dehydration; plateletts 303 at
420452 - mid-range, blood pressure and heart rate below normal.
420453 - ref SDS 34 7J7L
420454 -
420455 -
420456 -
420457 -
420458 -
420459 -
4205 -
SUBJECTS
VA Cardiology Examination Bilirubin 1.8 Increased with Rosuvastatin
5303 -
530401 - ..
530402 - Bilirubin Increased with Rosuvastatin 20 MG Cause Peripheral Neuropathy
530403 - Peripheral Neuropathy Cause Bilirubin Increased with Rosuvastatin 20 MG
530404 -
530405 - The lab on 120209 shows Bilirubin 1.8 increased above a healthy range,
530406 - ref SDS 27 KK9M, and nearly 40% higher than prior lab Bilirubin 1.3 on
530407 - 111117 1415. ref SDS 24 KK9M
530408 -
530409 - Collection DT T Bili Range
530410 - 02/09/2012 11:18 1.8 ....0.3 - 1.2.. ref SDS 27 KK9M
530411 - 11/17/2011 14:27 1.3 ............... ref SDS 24 KK9M
530412 - 10/13/2011 14:35 1.3 ............... ref SDS 22 GM65
530413 - 07/27/2011 12:58 2.0 ............... ref SDS 13 GM65
530414 - 12/07/2010 09:17 1.0 ............... ref SDS 6 GM65
530415 - 07/21/2010 08:54 1.3 ............... ref SDS 4 GM65
530416 - 08/13/2009 15:09 1.7 ............... ref SDS 1 VG8R
530418 - ..
530419 - Elevated Bilirubin taking statin drugs like Rosuvastatin may cause
530420 - impaired liver function, shown in research on 111013 1404. ref SDS 22
530421 - LC8J
530422 -
530423 - [On 120514 1300 T bilirubin 2.5 increased 75% causing
530424 - dehydration from frequent dehydration, and peripheral
530425 - neuropathy intermittant severe episodes due to increasing
530426 - Rosuvastation 20 mg causing liver damage. ref SDS 30 3I7G
530428 - ..
530429 - Additionally, statin drugs, like Rosuvastatin, that sometimes have
530430 - side effects that elevate bilirubin (mostly people above 50), can
530431 - cause fluid loss from increased urination, peripheral neurpoathy, pale
530432 - skin, tingling feeling, reported on 110802 1639, ref SDS 14 QI3K
530434 - ..
530435 - Total Bilirubin 1.8 in recent lab on 120209, rising from 1.3 in prior
530436 - two labs, most recently on 111117, ref SDS 24 KK9M, may reflect
530437 - increasing Rosubastatin 20 mg from 10 mg on 111128, reported in case
530438 - study on patient history on 101010 0744. ref SDS 5 NV7I
530440 - ..
530441 - Bilirubin above healthy range aligns with Rosuvastatin 20 mg begun on
530442 - 111128, shown in case study on 101010 0744, ref SDS 5 NV7I, and
530443 - following lab that measured LDL 200 on 111117 1415, ref SDS 24 IM9N,
530444 - and increased from Rosuvastatin 10 mg prescribed on trial in the
530445 - meeting at the VA on 110817. ref SDS 18 DG36
530446 -
530447 -
530448 -
530449 -
530450 -
5305 -
SUBJECTS
VA Cardiology Examination Resovastatin 20 Mg LDL 228 Significant Ris
6703 -
670401 - ..
670402 - Resovastatin 20 Mg Continue Despite LDL 228 Significant Rise
670403 -
670404 - Follow up ref SDS 18 DG36.
670405 -
670406 - Doctor Egan disappointed interim lab LDL 200, shown in lab on 111117
670407 - 1415, ref SDS 24 IM9N, and that recent lab LDL 228 on 120209 1118.
670408 - ref SDS 27 IM9N
670409 -
670410 - [On 120514 1300 hyperlipidemia LDL 94 declined
670411 - significantly after increasing Rosuvastatin 20 mg and
670412 - increasing hiking. ref SDS 30 X45G
670414 - ..
670415 - Doctor Egan prescribed continuing rosuvastatin 20 mg, implementing
670416 - analysis on 110817, ref SDS 18 FE4H, to increase dose after
670417 - rosuvastatin 10 mg failed to lower LDL cholesterol, and in fact caused
670418 - significant increase in LDL cholesterol, reported in recent lab last
670419 - week on 120209 1118. ref SDS 27 2A4G
670420 -
670421 -
670423 - ..
670424 - Cholesterol Lab 3 Months Evaluate Rosuvastatin Replace Simvastatin
670425 -
670426 - Follow up ref SDS 18 JQ5F.
670427 -
670428 - Doctor Egan ordered another lab in 3 months to evaluate and adjust
670429 - rosuvastatin 20 mg, as required for lowering LDL < 70.
670430 -
670431 -
670432 -
670433 -
670434 -
670435 -
670436 -
6705 -
SUBJECTS
Default Null Subject Account for Blank Record
6803 -
680401 - ..
680402 - Progress Notes Meeting VA Cardiology Department
680403 -
680404 - Follow up
680405 -
680406 - VA file from CD with Progress Notes for meeting on 120514 are stored
680407 - at...
680409 - ..
680410 - F:\05\00003\SM\CC\AGMJ\20120514-083902\welch_052112.pdf
680411 -
680411 - F:\05\00003\SM\CC\AGMJ\20120216-084412\
680411 -
680411 -
680412 - 1. LOCAL TITLE: Cardiology 10501
680413 - STANDARD TITLE: CARDIOLOGY NOTE
680414 - DATE OF NOTE: MAY 14, 2012@08:39
680415 - ENTRY DATE: MAY 14, 2012@08:39:02
680416 - AUTHOR: EGAN,JAMES EXP COSIGNER:
680417 - URGENCY: STATUS: COMPLETED
680422 - ..
680423 - 67 year old MALE followed in Cardiology Clinic for problems
680424 - including
680425 -
680426 - 1. CAD
680427 -
680428 - a) Angina, class II- III 10/2/09
680430 - ..
680431 - b) Abnormal TMST, relatively low work load 9/16/09
680433 - ..
680434 - c) CABGx4v 10/22/09 SFVA (LIMA-->LAD, SVG-->diag,
680435 - SVG-->Ramus,SVG-->PDA).
680437 - ..
680438 - 2. Hyperlipidemia
680440 - ..
680441 - 3. Achalasia, S/P laparoscopic myotomy with fundoplication at
680442 - the San Francisco VA December 2009. Subsequently recurrent
680443 - stricture, most recent dilatation 3/22/12.
680445 - ..
680446 - 4. PACs with exercise on ETT 4/6/11
680448 - ..
680449 - 2. The patient was last seen in clinic on 2/16/12 , A&P as follow:
680451 - ..
680452 - This part of Progress Notes repeats from prior notes on 120216...
680453 -
680454 - 1. ASSESSMENT:
680455 -
680456 - 1. CAD,stable, asymptomatic
680457 -
680458 - 2. Hyperlipidemia. Paradoxical increase in LDL since changed
680459 - from 40 mg simva to 10-->20 mg rosuva. Accuracy of more
680460 - recent lab in question due to noncompliance. Also note
680461 - increased bilirubin on LFTs, transaminases OK.
680463 - ..
680464 - 3. Achalasia, S/P laparoscopic myotomy with fundoplication at
680465 - the San Francisco VA December 2009. Subsequently recurrent
680466 - stricture.Followed by Dr Lee.
680468 - ..
680469 - 4. PACs with exercise on ETT 4/6/11
680471 - ..
680472 - 2. PLAN:
680473 -
680474 - 1. Current medications reconciled.
680475 -
680476 - 2. Have rewritten rosuvastatin to 20 mg daily.
680477 -
680478 - 3. RTC 3 months with lipids, LFTs, CK one week prior. In the
680479 - interim he will ry to get back to a more regular exercise
680480 - schedule. If LDL remains at this level will have to
680481 - consider change back to simvastatin or increase to 40 mg
680482 - dose rosuva.
680484 - ..
680485 - 3. Clinical Reminders:
680486 -
680487 - LDL >=100 - High Risk Goal <100:
680488 -
680489 - No lipid treatment change is needed based on patient's
680490 - current status.
680492 - ..
680493 - Comment: Ran out of rosuvastatin x 3 weeks prior to lab
680494 - test
680495 -
680496 - 4. /es/ James Egan, MD
680497 - Staff Physician, Cardiology
680498 - Signed: 02/16/2012 10:50
680500 - ..
680501 - Remainder of Progress Notes pertain to meeting today on 120514...
680502 -
680503 - 3. Seen again with his sister-in-law, seems to be doing very well.
680504 - Is hiking more, 40-60 miles weekly, losing some weight. No
680505 - limitation by dyspnea, no sx suggestive of angina. No
680506 - myopathic sx, has some some mild paresthesias of feet which
680507 - seem to be resolving.
680509 - ..
680510 - 4. No history of dizziness, lightheadedness or syncope.
680511 - No palpitations.
680512 - Denies PND, Orthopnea, Edema
680514 - ..
680515 - 5. PAST MEDICAL HISTORY:
680516 -
680517 - 1. Computerized Problem List is the source for the following:
680518 -
680519 - 1. Vitamin D Deficiency 08/03/11 Sandhu, Harkesh
680521 - ..
680522 - 2. Postsurgical Aortocoronary Bypass Status (ICD-9-CM
680523 - V45.81) 03/09/11 Egan, James
680525 - ..
680526 - 3. Esophageal Stricture 03/05/10 LEE,RANDALL E
680528 - ..
680529 - 4. Screening for Malignant Neoplasms of colon 11/15/11
680530 - LEE,RANDALL E (ICD-9-CM V76.51)
680531 -
680532 - 2010 colonoscopy: no polyp. Next screen 2020
680534 - ..
680535 - 5. Coronary Atherosclerosis (unspecified type 02/02/10
680536 - LEE,RANDALL E vessel, native or graft) (ICD-9-CM 41
680538 - ..
680539 - 6. Coronary Artery Bypass using Venous and 01/04/10
680540 - SANDHU,HARKESH Arterial Grafts (Single Vein Graft),
680541 - Onset 10/00/09 done at vasf
680543 - ..
680544 - CABG was performed at VA San Francisco Medical Center on 091022.
680545 - ref SDS 3 PQWU
680547 - ..
680548 - Onset reported to VA on 090908 1130. ref SDS 2 MY4N
680550 - ..
680551 - VA Progress Notes Cardiology meeting 120514 continue...
680552 -
680553 - 7. Surgical Thoracoscopy with Esophagomyotomy 01/04/10
680554 - SANDHU,HARKESH (Heller Type), Onset 12/16/09 at vasf
680556 - ..
680557 - 8. Hyperlipidemia * (ICD-9-CM 272.4) 10/02/09 EGAN,JAMES
680559 - ..
680560 - 9. Inflamed Seborrheic Keratosis (ICD-9-CM 702.11)
680561 - 03/12/07 LIN,BERTHA
680563 - ..
680564 - 10. Rosacea * (ICD-9-CM 695.3) 03/12/07 LIN,BERTHA
680566 - ..
680567 - 11. Dermatitis * (ICD-9-CM 692.9) 03/12/07 LIN,BERTHA
680569 - ..
680570 - 12. Tinea Unguium * (ICD-9-CM 110.1) 03/12/07 LIN,BERTHA
680572 - ..
680573 - 13. Tinea * (ICD-9-CM 110.9) 03/12/07 LIN,BERTHA
680575 - ..
680576 - 14. Rosacea conjunctivitis (ICD-9-CM 372.31) 03/02/07
680577 - MARGULIES,LINDA
680579 - ..
680580 - 15. Rosacea * (ICD-9-CM 695.3) 03/02/07 MARGULIES,LINDA
680582 - ..
680583 - 16. Blepharitis NOS 02/21/07 MARGULIES,LINDA
680585 - ..
680586 - 17. Achalasia * (ICD-9-CM 530.0) 12/22/05 SANDHU,HARKESH
680588 - ..
680589 - 18. Abn. LFT's 08/16/05 SANDHU,HARKESH
680591 - ..
680592 - 19. Obesity 06/29/05 SANDHU,HARKESH
680594 - ..
680595 - 20. Rosacea 06/29/05 SANDHU,HARKESH
680597 - ..
680598 - 21. Tinea Unguium 06/29/05 SANDHU,HARKESH
680600 - ..
680601 - 2. Patient has answered NKA (no known allergies)
680603 - ..
680604 - 6. Active Outpatient Medications (including Supplies):
680605 -
680606 - 1. OMEPRAZOLE 20MG EC CAP TAKE TWO CAPSULES BY MOUTH TWICE A
680607 - ACTIVE DAY 15 MINUTES BEFORE A MEAL FOR SEVERE ACID REFLUX
680608 - AND ESOPHAGEAL NARROWING. **DOSE INCREASE**
680610 - ..
680611 - 2. ROSUVASTATIN CA 40MG TAB TAKE ONE-HALF TABLET BY MOUTH
680612 - ACTIVE ONCE DAILY - TO LOWER CHOLESTEROL. REPLACES
680613 - SIMVASTATIN *USE PILL CUTTER* (APPROVED)
680615 - ..
680616 - 7. PHYSICAL EXAM - Date: 120514 1306
680617 -
680618 - T....................... 98.0 F (36.7 C)
680619 - P....................... 92
680620 - R....................... 16
680621 - B/P..................... 103/72
680622 - Wt...................... 189.90 (80.68 KG) (ACTUAL STANDING WEIGHT)
680623 - Body Mass Index......... 31*
680624 - Pulse Oximetry.......... 95%
680625 - Pain.................... 0 - No pain
680627 - ..
680628 - 8. Head atraumatic, PERRL.
680629 - Carotid upstrokes normal, no bruits noted
680630 - Thyroid normal to palpation.
680631 - JVP wnl.
680632 - Cor:Regular, no sig mrg.
680633 - Lungs clear of rales, ronchi and wheezes.
680634 - Extremities without cyanosis, clubing or edema.
680636 - ..
680637 - 9. PLASMA 05/09 02/09 11/17 Reference
680638 - 2012 2012 2011
680639 - 11:24 11:56 14:27 Units Ranges
680640 - -------------------------------------------------------------------------------
680641 - CHOL 158 285 H 260 H mg/dL Ref: <=200
680642 - TRIGLYC 76 82 84 mg/dL Ref: <=150
680643 - HDL 49 41 43 mg/dL Ref: >=40
680644 - LDL 94 228 H 200 H mg/dL Ref: <=160
680646 - ..
680647 - These valuations align with VA lab on 120509 1108. ref SDS 9 0297
680649 - ..
680650 - VA Progress Notes Cardiology meeting 120514 continue...
680651 -
680652 - 10. ---- CHEM PROFILE ----
680653 - PLASMA 05/09 02/09 11/17 Reference
680654 - 2012 2012 2011
680655 - 11:24 11:56 14:27 Units Ranges
680656 - -------------------------------------------------------------------------------
680657 - GLUCOSE 108 113 108 mg/dL 74 - 118
680658 - GLUfast mg/dL Ref: <=99
680659 - NA 138 142 139 mmol/L 136 - 144
680660 - K 4.2 4.8 4.1 mmol/L 3.4 - 4.8
680661 - CL 105 105 103 mmol/L 98 - 106
680662 - CO2 27 28 30 mmol/L 23 - 33
680663 - BUN 17 17 11 mg/dL 8 - 26
680664 - CREAT 0.94 0.95 0.89 mg/dL .5 - 1.1
680665 - eGFR >60 >60 >60 mL/min Ref: >=60
680666 - CALCIUM 8.7 9.3 9.0 mg/dL 8.7 - 10.2
680667 - CA CORR mg/dL 8.7 - 10.2
680668 - PO4 mg/dL 2.4 - 4.5
680669 - MG mg/dL 1.8 - 2.5
680670 - ALK PHO 86 98 95 IntUnits/L 37 - 107
680671 - T. BIL 2.5 H 1.8 H 1.3 H mg/dL .3 - 1.2
680672 - D. BILI 0.3 0.2 mg/dL .1 - .4
680673 - AST 25 24 25 IntUnits/L 8 - 42
680674 - ALT 21 26 24 IntUnits/L 5 - 55
680675 - ALBUMIN 4.1 4.2 4.4 g/dL 3.3 - 4.8
680676 - PROTEIN 7.1 7.4 7.4 g/dL 6.5 - 8.1
680677 -
680679 - ..
680680 - 11. Collection DT Spec WBC HGB HCT MCV MCHC PLT
680681 - 07/27/2011 12:58 BLOOD 7.5 15.5 46.4 91.2 33.4 286
680682 - 12/07/2010 09:17 BLOOD 6.7 14.4 43.3 90.7 33.1 310
680683 -
680684 -
680685 - 12. ---- CARDIAC ENZYMES ----
680686 - PLASMA 05/09 02/09 11/17 Reference
680687 - 2012 2012 2011
680688 - 11:24 11:56 14:27 Units Ranges
680689 - -------------------------------------------------------------------------------
680690 - CK 152 126 101 IntUnits/L 36 - 340
680692 - ..
680693 - 13. ASSESSMENT:
680694 -
680695 - 1. CAD, stable asymptomatic.
680696 -
680697 - 2. Hyperlipidemia, marked improvement on rosuvastatin 20 mg
680698 - daily.
680700 - ..
680701 - 3. PACs with exercise on ETT 4/6/11
680703 - ..
680704 - 4. Paresthesias, uncertain etiology. Possibly but low
680705 - likelihood realted to rosuvastatin.
680707 - ..
680708 - 5. Hyperbilirubinemia, possible relationship to rosuvastatin
680710 - ..
680711 - 14. PLAN:
680712 -
680713 - 1. Current medications reconciled, no changes made.
680714 -
680715 - 2. Will continue current dose of rosuvastatin but will
680716 - continue to monitor bilirubin.
680718 - ..
680719 - 3. Will discuss hyperbilirubinemia and paresthesias with
680720 - Dr Sandhu at his appointment today.
680722 - ..
680723 - 4. RTC 4 months with lipids, CMP just prior.
680725 - ..
680726 - 5. Encouraged to continue hiking and planned weight loss.
680727 -
680728 - 15. /es/ James Egan, MD
680729 - Staff Physician, Cardiology
680730 - Signed: 05/14/2012 13:38
680731 -
680732 -
680733 -
680734 -
680735 -
680736 -
680737 -
680738 -
680739 -
680740 -
680741 -
680742 -
680743 -
680744 -
680745 -
680746 -
680747 -
6808 -